+967-774203774 [email protected]
Partner Portal Staff Login
العربية
Part of the Master Guide

Glenohumeral Dislocation: Comprehensive Guide to Shoulder Stability

Dislocated Shoulder Exam: Show Answer Show How to Pass

23 Apr 2026 77 min read 232 Views
First image

Key Takeaway

Here are the crucial details you must know about Dislocated Shoulder Exam: Show Answer Show How to Pass. For the 38-year-old woman who fell on her right arm, the diagnosis is an anterior shoulder dislocation, often accompanied by a greater tuberosity fracture. X-rays confirm the humeral head's misalignment, lying anterior and inferior to the glenoid. Management involves reduction of the dislocation and addressing any associated fractures. To show answer show, prompt and precise intervention is crucial for successful recovery and preventing complications.

Comprehensive Exam


00:00

Start Quiz

Question 1

A 24-year-old male presents to the emergency department after a football injury, complaining of severe right shoulder pain. His arm is held in slight abduction and external rotation. On inspection, the anterior aspect of his shoulder appears prominent, and there is a palpable void beneath the acromion. Which of the following physical exam findings is MOST concerning for an associated neurovascular injury in this patient?





Explanation

An absent radial pulse is a critical finding indicating potential compromise of the brachial artery, which is a surgical emergency. While axillary nerve injury (loss of sensation over the lateral deltoid, weakness in abduction) is the most common nerve injury with anterior shoulder dislocations, it is rarely an acute limb-threatening condition unless it's a traction injury without spontaneous recovery. Weakness in wrist extension would suggest radial nerve involvement, which is less common. Ecchymosis is a common finding but not acutely life- or limb-threatening.

Question 2

A 35-year-old patient presents with a history of recurrent anterior shoulder dislocations. During your examination, you perform the Apprehension Test. Which of the following describes a positive test?





Explanation

The Apprehension Test is performed by abducting the shoulder to 90 degrees and slowly externally rotating the arm. A positive test is indicated by the patient's feeling of impending dislocation (apprehension) or significant pain, often due to stretching of the anterior capsule. Options B and C describe findings related to rotator cuff or glenohumeral arthritis. Option D describes the Sulcus Sign, indicative of inferior or multidirectional instability. Option E describes a clunk, which could be related to labral pathology but is not the apprehension test.

Question 3

A 50-year-old patient presents with acute shoulder pain after a seizure. On examination, the arm is held in internal rotation, and the anterior shoulder appears flattened. External rotation is severely restricted. Which radiographic finding on an AP shoulder view is pathognomonic for a posterior shoulder dislocation?





Explanation

The Trough line sign (or reverse Hill-Sachs lesion) is an impaction fracture on the anterior-medial aspect of the humeral head, often seen with posterior dislocations. The other options are incorrect: Hill-Sachs and Bankart lesions are typically associated with anterior dislocations. HAGL lesions are avulsions of the glenohumeral ligaments, often associated with anterior dislocations. Os acromiale is an anatomical variant.

Question 4

During the examination of a patient with suspected shoulder dislocation, you note a sulcus sign. What does this finding MOST commonly indicate?





Explanation

The Sulcus Sign is elicited by applying inferior traction to the arm, causing a dimple or sulcus to appear below the acromion. It is indicative of inferior capsular laxity and is a hallmark of inferior or multidirectional glenohumeral instability. While multidirectional instability often includes an inferior component, the most direct interpretation of a sulcus sign is inferior instability.

Question 5

A 68-year-old woman falls directly onto her shoulder. She presents with severe pain and an inability to move her arm. On exam, the shoulder appears abducted, and a prominent hard mass is palpable inferior to the glenoid, consistent with a Luxatio Erecta. Which neurovascular structure is at highest risk of injury in this type of dislocation?





Explanation

Luxatio Erecta (inferior dislocation) involves extreme abduction, forcing the humeral head inferiorly. The head can impinge upon or stretch the neurovascular bundle in the axilla. The axillary artery is at significant risk due to its proximity and the severe displacement. While the axillary nerve and brachial plexus are also at risk, arterial compromise (axillary artery) is a more acute and limb-threatening complication associated with the extreme force and direction of displacement in luxatio erecta, often leading to intimal tears or thrombosis.

Question 6

Following reduction of an anterior shoulder dislocation, a patient complains of persistent weakness in active shoulder abduction. Sensation over the lateral aspect of the deltoid is intact. Which of the following is the MOST likely cause of this isolated weakness?





Explanation

If sensation over the lateral deltoid (axillary nerve sensory distribution) is intact, persistent isolated weakness in shoulder abduction, especially in an older patient or high-energy trauma, should raise suspicion for an associated rotator cuff tear (supraspinatus or deltoid dysfunction). Axillary nerve neuropraxia would typically present with sensory deficits in addition to motor weakness. Musculocutaneous nerve injury affects biceps and coracobrachialis, and lateral forearm sensation. Long thoracic nerve injury causes scapular winging. Brachial plexus avulsion would present with more widespread neurological deficits.

Question 7

A 22-year-old male presents with his first-time anterior shoulder dislocation. During the initial assessment, which of the following is a critical component of the examination PRIOR to any reduction attempts?





Explanation

A thorough neurovascular examination of the affected extremity, including palpation of pulses and assessment of sensation and motor function, is paramount before any reduction attempts. This establishes a baseline and helps identify any pre-existing or acute neurovascular compromise that could be exacerbated by or misattributed to the reduction maneuver. Analgesia is important but secondary to neurovascular assessment. Contralateral shoulder ROM is not critical pre-reduction. Ice is for comfort. Family history is irrelevant in acute management.

Question 8

You are examining a patient with a suspected posterior shoulder dislocation. Which maneuver is most likely to confirm your suspicion on physical exam?





Explanation

Posterior dislocations classically present with the arm held in internal rotation and adduction, with a significant block to external rotation. The anterior shoulder may appear flattened, and the coracoid process prominent. Apprehension with abduction and external rotation is characteristic of anterior instability. Limited internal rotation with intact external rotation is incorrect. Increased superior translation with anterior force is not directly indicative of posterior dislocation. A palpable defect below the coracoid is more suggestive of anterior dislocation.

Question 9

Which finding on a post-reduction physical exam of an anterior shoulder dislocation indicates successful reduction and suggests stability?





Explanation

Successful reduction is indicated by the restoration of normal shoulder contour (loss of the anterior prominence of the humeral head), relief of severe pain, and the ability to achieve full or near-full passive range of motion without a 'block.' Persistent apprehension or instability signs (like a sulcus sign or continued apprehension with external rotation) suggest potential underlying pathology or incomplete reduction. Crepitus might indicate cartilage damage, and inability to actively abduct could suggest a rotator cuff tear or nerve injury, not necessarily unsuccessful reduction.

Question 10

A 70-year-old male sustains an anterior shoulder dislocation. After reduction, plain radiographs show a concomitant fracture. Which fracture is MOST commonly associated with anterior shoulder dislocation in this age group?





Explanation

While Hill-Sachs and Bankart lesions are very common with anterior dislocations, in older patients, a greater tuberosity fracture is particularly common (up to 30% in some series) due to the weaker bone and the forces involved in the injury. The rotator cuff avulses a piece of the tuberosity during the dislocation. Surgical neck fracture is also possible but less frequent than greater tuberosity in direct association with dislocation. Clavicle fractures are less directly associated with glenohumeral dislocation mechanism.

Question 11

When assessing a patient with a suspected first-time shoulder dislocation, what is the significance of palpating the lateral border of the deltoid muscle?





Explanation

The axillary nerve (C5-C6) provides sensory innervation to the skin over the lateral deltoid (sometimes called the 'regimental badge area'). Assessing sensation in this region is crucial for detecting axillary nerve neuropraxia or injury, which is the most common nerve injury associated with shoulder dislocations. It does not directly assess rotator cuff, AC joint, biceps, or bursa.

Question 12

A patient presents with a chronic, unreduced posterior shoulder dislocation. What is the MOST likely clinical presentation?





Explanation

A chronic posterior shoulder dislocation will maintain the classic position of the acute injury: the arm held in adduction and internal rotation, with a profound block to external rotation. The anterior shoulder will appear flattened, and the coracoid process will be prominent. Option A describes an anterior dislocation. Option C describes an inferior dislocation. Options D and E are less specific to the characteristic presentation of a chronic posterior dislocation.

Question 13

During your physical exam for shoulder instability, you elicit a positive 'Jerk Test.' What type of instability does this typically indicate?





Explanation

The Jerk Test is specifically designed to assess posterior glenohumeral instability. It involves axially loading the arm, which is abducted to 90 degrees and internally rotated, then horizontally adducting the arm across the body. A sudden 'jerk' or clunk as the humeral head subluxates posteriorly over the glenoid rim indicates a positive test. The test may be accompanied by apprehension or pain.

Question 14

A patient describes a sensation of the shoulder 'slipping out' when reaching across the body to perform a task like fastening a seatbelt. This mechanism is suggestive of which type of instability?





Explanation

Reaching across the body (horizontal adduction and internal rotation) is a classic position for posterior subluxation or dislocation. Anterior instability typically occurs with abduction and external rotation. Inferior instability is less position-specific but involves inferior translation. Multidirectional instability would involve multiple directions. Rotator cuff impingement causes pain with certain movements but not a 'slipping out' sensation.

Question 15

Which of the following is the MOST common nerve injury associated with an anterior shoulder dislocation?





Explanation

The axillary nerve is the most commonly injured nerve in anterior shoulder dislocations, occurring in up to 30% of cases, especially in older patients. This is due to its course around the surgical neck of the humerus, making it susceptible to stretch or contusion during dislocation. The radial, ulnar, and median nerves are less commonly affected. The long thoracic nerve is associated with scapular winging but not typically direct dislocation.

Question 16

A patient with a dislocated shoulder presents with wrist drop. Which nerve is most likely injured?





Explanation

Wrist drop, characterized by the inability to extend the wrist and fingers, is a classic sign of radial nerve palsy. While other nerves can be injured in severe shoulder trauma or brachial plexus injuries, radial nerve compression or stretch is the most direct cause of wrist drop. This is a less common injury with isolated shoulder dislocation but can occur with associated humeral shaft fractures or severe traction.

Question 17

In assessing a patient for multidirectional instability (MDI), which of the following signs would be most indicative?





Explanation

Multidirectional instability (MDI) implies instability in at least two, but typically three, directions (anterior, posterior, and inferior). Therefore, a patient with MDI would likely exhibit positive findings on tests for anterior instability (Apprehension Test), posterior instability (Jerk Test), and inferior instability (Sulcus Sign). Generalized ligamentous laxity (e.g., Beighton score) often predisposes to MDI. Isolated pain with resisted internal rotation suggests rotator cuff pathology.

Question 18

Which of the following describes the position of the arm in a typical anterior shoulder dislocation?





Explanation

In a typical anterior shoulder dislocation, the humeral head rests anteriorly and inferiorly to the glenoid. The arm is consequently held in a position of slight abduction and external rotation, as attempts to internally rotate or adduct the arm cause significant pain and resistance. This is the hallmark clinical presentation.

Question 19

A patient presents with a superior labral anterior-posterior (SLAP) lesion. Which physical exam maneuver is MOST likely to elicit pain?





Explanation

Speed's Test (or Biceps Load Test II) is specifically designed to test for SLAP lesions, assessing pain with resisted shoulder flexion while the elbow is extended and forearm supinated. Neer and Hawkins-Kennedy are for impingement, Empty Can for supraspinatus, and Cross-Body Adduction for AC joint pathology. While impingement tests can sometimes be positive with SLAP, Speed's test is more specific for biceps/labral irritation.

Question 20

What is the primary purpose of obtaining an axillary view radiograph in a patient with a suspected shoulder dislocation?





Explanation

The axillary view (or Velpeau view if unable to abduct) is crucial for differentiating between anterior and posterior dislocations, as it provides a true lateral view of the glenohumeral joint and shows the relationship of the humeral head to the glenoid. An AP view alone can sometimes be misleading, especially with posterior dislocations. While it can also show bony Bankart lesions, its primary utility is differentiation of dislocation type. Hill-Sachs can be seen on AP or West Point axillary. It does not directly evaluate rotator cuff tears or measure the critical shoulder angle (which is for impingement/arthritis risk).

Question 21

A patient reports a 'dead arm' sensation and transient weakness after a forceful abduction-external rotation injury to the shoulder. This symptom complex is most suggestive of:





Explanation

The 'dead arm' syndrome, characterized by transient numbness, tingling, and weakness after a high-energy injury in abduction and external rotation, is a classic presentation of a transient brachial plexopathy or neurapraxia, often seen with shoulder subluxation or dislocation. It implies transient stretch injury to the brachial plexus. While other injuries may cause pain, the 'dead arm' sensation is distinctively neurological.

Question 22

When performing the Load and Shift test, what does excessive posterior translation of the humeral head indicate?





Explanation

The Load and Shift test assesses glenohumeral translation in anterior and posterior directions. Excessive posterior translation indicates posterior capsular laxity, a hallmark of posterior glenohumeral instability. Anterior capsular laxity would manifest as excessive anterior translation. Inferior glenohumeral ligament incompetence would contribute to inferior instability. Labral or rotator cuff tears are structural injuries, not directly measured by generalized capsular laxity translation tests.

Question 23

Which of the following historical elements is MOST indicative of a posterior shoulder dislocation?





Explanation

Posterior shoulder dislocations are often caused by direct trauma to the anterior shoulder, forcing the humeral head posteriorly, or by violent muscle contractions as seen in seizures or electrocution. Anterior dislocations typically result from falls on an outstretched arm with abduction/external rotation. Luxatio Erecta results from traction. Repetitive overhead activities are linked to overuse injuries or anterior instability. Insidious onset suggests degenerative conditions.

Question 24

In a patient presenting with an acute shoulder dislocation, a palpable clunk or grind during gentle rotation of the arm post-reduction could indicate:





Explanation

A palpable clunk or grind post-reduction, especially with specific movements, can indicate an intra-articular loose body (e.g., osteochondral fragment, bony Bankart fragment) or a labral tear (e.g., Bankart lesion). It suggests continued pathology within the joint despite reduction. Successful reduction implies smooth, pain-free motion. Recurrence would be a complete dislocation. Nerve recovery/injury is unrelated to mechanical clunking.

Question 25

When examining a patient with recurrent anterior shoulder instability, what is the significance of a 'Bankart lesion'?





Explanation

A Bankart lesion is a specific injury to the anterior-inferior glenoid labrum and the attached inferior glenohumeral ligament, caused by the humeral head forcefully impacting the glenoid rim during an anterior dislocation. It is a critical lesion contributing to recurrent anterior instability. Option A describes a Hill-Sachs lesion. Options C, D, and E describe other distinct injuries.

Question 26

A patient with a dislocated shoulder is noted to have significant ecchymosis extending down the arm, and the skin appears stretched and tense. Which imaging modality is indicated NEXT if routine radiographs confirm dislocation but you suspect a severe soft tissue injury or vascular compromise?





Explanation

Significant ecchymosis and tense skin, especially with an abnormal pulse exam (though not specified here, it's implied by 'vascular compromise'), demand immediate investigation for vascular injury. A CT angiogram is the most appropriate imaging study to evaluate the integrity of the axillary or brachial artery quickly and accurately in an acute setting. MRI and plain CT are better for soft tissue/bone detail but not for urgent vascular assessment. Ultrasound can be used but CTA is more definitive in this setting. Nerve conduction studies are for chronic nerve assessment, not acute vascular emergency.

Question 27

What physical exam finding is MOST characteristic of a traumatic posterior shoulder dislocation?





Explanation

Traumatic posterior shoulder dislocations classically present with the arm held in adduction and internal rotation, with a hallmark inability to externally rotate the shoulder beyond neutral. The anterior shoulder may appear flattened, and the coracoid prominent. Option A is characteristic of anterior dislocation. Option B is incorrect. Option C is less specific than restricted external rotation. Option D is characteristic of anterior dislocation.

Question 28

During the physical exam, a patient with a history of recurrent anterior dislocations expresses apprehension when you gently attempt to externally rotate their arm with the shoulder abducted to 90 degrees. What is the next logical step to confirm instability?





Explanation

If the Apprehension Test is positive (patient feels apprehension), the next step is often to perform the Relocation Test (also known as the Fulcrum Test or Jobe Relocation Test). By applying a posterior force to the humeral head while maintaining the abducted and externally rotated position, if the apprehension or pain decreases, it confirms anterior instability. This sequence differentiates true instability from generalized shoulder pain. Reducing the shoulder is premature. Sulcus sign tests inferior instability. MRI is an imaging study, not an immediate physical exam confirmation. Cervical spine ROM is not directly related to shoulder instability confirmation.

Question 29

Which finding during a physical exam for shoulder instability suggests generalized ligamentous laxity?





Explanation

Generalized ligamentous laxity is often assessed using criteria like the Beighton score. Specific signs include elbow hyperextension (>10 degrees), knee hyperextension (>10 degrees), thumb-to-forearm apposition, and excessive spinal or wrist flexibility. O'Brien's and Speed's tests are for labral and biceps pathology respectively. Pain with passive ER/Abduction is for anterior instability. Scapular winging indicates long thoracic nerve or serratus anterior weakness.

Question 30

A 45-year-old male sustains a fall onto his abducted arm. Radiographs confirm an anterior shoulder dislocation. Which associated fracture is most likely due to impaction of the posterior-superior humeral head against the anterior glenoid rim?





Explanation

A Bony Bankart lesion is an avulsion fracture of the anterior-inferior glenoid rim, occurring when the humeral head dislocates anteriorly and impacts the glenoid. A Reverse Hill-Sachs lesion is associated with posterior dislocations. Greater tuberosity and surgical neck fractures are also associated but are different mechanisms. Clavicle fractures are less directly associated with the dislocation mechanism itself.

Question 31

What is the primary significance of a 'Hill-Sachs lesion' in the context of shoulder dislocation?





Explanation

A Hill-Sachs lesion is an impaction fracture on the posterior-superior aspect of the humeral head, caused when the humeral head impacts against the anterior glenoid rim during an anterior dislocation. It is a key indicator of prior anterior dislocation and contributes to recurrent instability. Reverse Hill-Sachs is for posterior. Greater tuberosity is a separate fracture. Rotator cuff tears and labral tears are distinct injuries.

Question 32

When assessing for posterior instability with the patient supine, which test involves applying an axial load while horizontally adducting and internally rotating the arm?





Explanation

The Jerk Test (also known as the Posterior Clunk Test or Load and Shift with specific movements) is performed with the patient supine, arm abducted to 90 degrees, and internally rotated. An axial load is applied through the humerus, and the arm is then moved into horizontal adduction. A sudden 'jerk' or clunk as the humeral head subluxates posteriorly indicates a positive test for posterior instability. Apprehension and Relocation tests are for anterior. Sulcus Sign is for inferior. Lift-Off Test is for subscapularis.

Question 33

A patient with a suspected first-time shoulder dislocation is unable to move their arm. Which finding on a pre-reduction X-ray would be a contraindication to closed reduction in the emergency department?





Explanation

A displaced fracture of the surgical neck of the humerus is generally a contraindication to closed reduction in the emergency department, as reduction maneuvers could further displace the fracture or cause neurovascular injury. Such cases often require orthopedic consultation for potential open reduction or different reduction strategies. Hill-Sachs, bony Bankart, and greater tuberosity fractures, while associated, are not absolute contraindications to closed reduction unless they are very large or complex. Minor calcification is irrelevant for acute dislocation management.

Question 34

The 'Drop Arm Test' is positive in a patient with a dislocated shoulder. What associated injury does this MOST likely indicate?





Explanation

The Drop Arm Test assesses the integrity of the rotator cuff, particularly the supraspinatus. A positive test, where the patient cannot smoothly lower their arm from abduction or the arm 'drops,' suggests a complete rotator cuff tear. While axillary nerve palsy can also cause abduction weakness, the specific 'dropping' often points to the rotator cuff. Labral avulsion, biceps rupture, and AC joint separation have different specific tests.

Question 35

What is the expected physical exam finding for a patient with a 'Luxatio Erecta' dislocation?





Explanation

Luxatio Erecta is an inferior dislocation where the arm is held in sustained and forceful abduction, often with the elbow flexed and hand behind the head. The humeral head is typically palpable in the axilla. Options A and D describe posterior dislocations. Option B describes anterior dislocation. Option E is non-specific.

Question 36

When evaluating a patient for shoulder instability, what is the purpose of assessing the 'apprehension' rather than just pain?





Explanation

In the context of the Apprehension Test, 'apprehension' refers to the patient's subjective feeling of the shoulder 'going out' or impending dislocation, often accompanied by muscle guarding. This is a more specific indicator of true glenohumeral instability (especially anterior) than pain alone, as pain can arise from various shoulder pathologies. A positive apprehension indicates that the position reproduces the sensation of instability, which is distinct from mere pain.

Question 37

A 19-year-old male presents with recurrent anterior shoulder dislocations. On examination, he is found to have a positive 'Kim Test.' What does this test evaluate?





Explanation

The Kim Test is a specific maneuver used to detect a posterior-inferior labral avulsion, which is associated with posterior shoulder instability. It involves the examiner holding the patient's elbow and applying an axial load while elevating the arm to 90 degrees and applying a posteroinferior force to the humeral head. A positive test elicits posterior pain and a clunk. Anterior labral tears (Bankart) are assessed with other tests (e.g., Apprehension/Relocation). SLAP lesions (superior labral) are assessed with tests like Speed's or O'Brien's.

Question 38

Which of the following describes the correct interpretation of a 'positive' O'Brien's Test for a SLAP lesion?





Explanation

O'Brien's Test (also known as the Active Compression Test) is performed with the patient's arm flexed to 90 degrees, adducted 10-15 degrees, and the elbow extended. The test is performed first with the thumb pointing down (internal rotation) and then with the palm up (external rotation), resisting downward force. A positive test for a SLAP lesion is pain felt deep within the shoulder during internal rotation (thumb down) that is decreased or abolished with external rotation (thumb up). This difference indicates labral pathology. Other options describe different tests or findings.

Question 39

A patient with a dislocated shoulder has a suspected Axillary nerve injury. Which muscle should you test to assess its motor function?





Explanation

The axillary nerve innervates the deltoid and teres minor muscles. Therefore, testing the deltoid (e.g., resisted shoulder abduction) is the primary way to assess the motor function of the axillary nerve. Supraspinatus and Infraspinatus are innervated by the suprascapular nerve. Biceps brachii by the musculocutaneous nerve. Subscapularis by the upper and lower subscapular nerves.

Question 40

A patient presents with a chronic, unreduced posterior shoulder dislocation. Which associated complication is MOST likely to lead to poor long-term outcomes even after successful reduction?





Explanation

Chronic posterior dislocations often lead to a large reverse Hill-Sachs lesion (an impaction fracture on the anterior-medial humeral head). If this defect involves a significant portion of the humeral head articular surface (e.g., >25-40%), it can prevent stable reduction and lead to persistent pain, arthritis, and recurrent instability, even after surgical intervention, significantly impacting long-term outcomes. Axillary nerve neuropraxia often recovers. Small Bankart lesions are associated with anterior instability. Generalized laxity is a predisposing factor but not a direct complication of chronic dislocation. Greater tuberosity fractures are associated with anterior dislocations and are typically managed acutely.

Question 41

In the acute assessment of a dislocated shoulder, what is the MOST reliable way to differentiate between an anterior and posterior dislocation on a single, well-centered AP radiograph, if other views are unavailable?





Explanation

While several signs can suggest a posterior dislocation on an AP view, the 'light bulb sign' is considered the most reliable. This refers to the appearance of the humeral head as uniformly rounded and internally rotated, obscuring the normal profile of the humeral head (the 'handshake sign' or half-moon sign). Hill-Sachs and Bankart lesions are associated with anterior dislocations. The rim sign (widening of the glenohumeral interval) and trough line sign are also for posterior, but the 'light bulb sign' is a common and distinctive feature on AP. Degree of external rotation is usually lost in posterior, but 'light bulb' describes the specific head shape due to fixed internal rotation.

Question 42

Which test is used to assess the integrity of the subscapularis tendon in a patient with a suspected rotator cuff injury accompanying a dislocation?





Explanation

Both the Internal Rotation Lag Sign (which is essentially the Lift-Off Test performed with resistance) and the Belly Press Test are used to assess the subscapularis tendon. The Lift-Off Test is performed with the hand behind the back, asking the patient to lift it off their back against resistance. The Belly Press Test involves the patient pressing their hand into their belly with internal rotation force. Empty Can Test is for supraspinatus. External Rotation Lag Sign is for infraspinatus and teres minor.

Question 43

A patient presents with an acute, painful shoulder after a fall. On examination, the patient resists any movement and exhibits significant muscle spasm. Which is the MOST appropriate initial step in management BEFORE attempting reduction?





Explanation

In the acute setting, severe pain and muscle spasm make reduction difficult and potentially more traumatic. Administering adequate analgesia (e.g., opioids) and muscle relaxation (e.g., benzodiazepines) is crucial to facilitate a gentle, successful closed reduction and minimize patient distress and potential for iatrogenic injury. Immediate surgery is rarely needed for uncomplicated dislocations. Aggressive manipulation is contraindicated. A sling is for post-reduction. MRI is not an acute pre-reduction step unless neurovascular compromise is suspected and requires specific advanced imaging.

Question 44

A 55-year-old patient with an anterior shoulder dislocation complains of a new onset 'pins and needles' sensation in the lateral forearm. Which nerve injury is MOST likely responsible?





Explanation

The musculocutaneous nerve provides sensory innervation to the lateral forearm via its terminal branch, the lateral antebrachial cutaneous nerve. While less common than axillary nerve injury, a musculocutaneous nerve injury could occur with shoulder dislocation, especially with traction or compression. Axillary nerve injury affects the lateral deltoid sensation. Radial nerve affects posterior arm/forearm and dorsum of hand. Ulnar nerve affects medial forearm and hand. Median nerve affects volar hand and fingertips.

Question 45

When evaluating the stability of a reduced shoulder, what is the 'Recurrence Rate' primarily influenced by?





Explanation

The patient's age at the time of the first dislocation is the single most significant risk factor for recurrent instability. Younger patients (e.g., teenagers and those in their early 20s) have significantly higher recurrence rates (up to 90%) compared to older patients, largely due to higher activity levels and stronger collagen which makes soft tissue healing less robust compared to bone in younger patients, leading to persistent laxity. While other factors contribute, age at first dislocation is paramount. Presence of a Hill-Sachs lesion increases the risk too, but age at first dislocation is the primary driver of recurrence rates.

Question 46

A patient with a dislocated shoulder is suspected of having an associated Bankart lesion. Which imaging study is BEST for visualizing this injury?





Explanation

A Bankart lesion is a soft tissue injury (labral avulsion). While a bony Bankart lesion (with a bone fragment) can be seen on plain radiographs or CT, a pure soft tissue Bankart lesion is best visualized with an MR arthrogram. The intra-articular contrast distends the joint capsule and outlines the labrum and glenohumeral ligaments, making tears and avulsions much more apparent than on a standard MRI or CT. Ultrasound has limited utility for labral assessment.

Question 47

Which statement regarding shoulder dislocations in children is TRUE?





Explanation

In younger children (pre-adolescent), physeal injuries (fractures through the growth plate of the proximal humerus) are much more common than true glenohumeral dislocations because the physis is weaker than the ligaments and capsule. True glenohumeral dislocations become more prevalent in adolescence. Recurrence rates in adolescents are often very high, similar to young adults. While less common than in adults, neurovascular injuries can occur.

Question 48

A patient reports a 'grinding' or 'catching' sensation in their shoulder, particularly when moving their arm overhead. Which labral injury is MOST likely based on this symptom?





Explanation

A 'grinding' or 'catching' sensation, particularly with overhead activities, is a common symptom of a superior labral anterior-posterior (SLAP) lesion, as the biceps anchor (which is part of the superior labrum) can be unstable or irritated. While other labral tears can also cause similar symptoms, SLAP lesions are specifically associated with overhead activity and sometimes 'popping' or 'catching.' Bankart and posterior labral tears are more commonly associated with instability or clunking during specific movements. HAGL and glenoid rim fractures are also distinct pathologies.

Question 49

What is the typical mechanism of injury for a traumatic anterior shoulder dislocation?





Explanation

The classic mechanism for a traumatic anterior shoulder dislocation is an indirect force, such as a fall on an outstretched arm, which drives the humeral head anteriorly and inferiorly, especially when the arm is in abduction and external rotation. Direct blows to the posterior shoulder, seizures/electrocution are mechanisms for posterior dislocation. Direct fall onto the adducted arm is less specific and could lead to other injuries. Repeated heavy lifting is more associated with overuse injuries or rotator cuff pathology.

Question 50

Which finding during an examination for shoulder instability is MOST consistent with a large Hill-Sachs lesion?





Explanation

A large Hill-Sachs lesion, which is an impaction fracture on the posterior-superior humeral head, can 'engage' or 'lock' against the anterior glenoid rim during abduction and external rotation. This engagement contributes significantly to recurrent anterior instability. A palpable defect on the anterior glenoid rim would suggest a Bankart lesion. Pain with resisted elbow flexion suggests biceps pathology. Scapular dyskinesis is a pattern of abnormal scapular movement. Increased internal rotation ROM is generally not associated with Hill-Sachs; rather, limited ER due to engagement.

Question 51

A patient is unable to initiate shoulder abduction against gravity. Which nerve is MOST likely injured?





Explanation

The supraspinatus muscle, primarily innervated by the suprascapular nerve, is responsible for initiating the first 15-30 degrees of shoulder abduction. While the deltoid (axillary nerve) takes over for further abduction, the inability to initiate abduction strongly points to the supraspinatus/suprascapular nerve. Axillary nerve injury would cause deltoid weakness in later abduction. Long thoracic affects serratus anterior. Median and radial nerves are distal to the shoulder.

Question 52

After reduction of a shoulder dislocation, which of the following is MOST important to assess to ensure adequate blood supply to the hand?





Explanation

Capillary refill is a quick and reliable indicator of peripheral perfusion and adequate blood supply to the extremity, including the hand. Diminished or delayed capillary refill suggests potential arterial compromise, which is critical to identify post-reduction. Sensation, motor function, and specific muscle strengths assess nerve integrity but not directly arterial blood flow to the hand.

Question 53

A patient with known Ehlers-Danlos Syndrome presents with recurrent, atraumatic shoulder dislocations. Which type of instability is MOST likely in this patient?





Explanation

Ehlers-Danlos Syndrome is a connective tissue disorder characterized by generalized ligamentous laxity. Patients with such systemic laxity are prone to atraumatic, recurrent dislocations in multiple directions, classifying it as atraumatic multidirectional instability. Traumatic unidirectional instabilities are typically associated with specific injury mechanisms. Voluntary dislocation can be part of MDI but MDI describes the underlying instability.

Question 54

Which of the following is considered a 'red flag' during the initial assessment of a shoulder dislocation, mandating immediate senior orthopedic review?





Explanation

An absent radial pulse combined with signs of ischemia (cool, pale hand) indicates acute limb-threatening vascular compromise (e.g., axillary artery injury), which is a surgical emergency and mandates immediate senior orthopedic and often vascular surgery review. First-time dislocation, Hill-Sachs, and seizure-induced dislocation are common scenarios. While pain control is important, it is not a 'red flag' signaling immediate limb threat like vascular compromise.

Question 55

What is the primary goal of physical examination after reduction of a shoulder dislocation?





Explanation

After reduction, the primary goals of the physical exam are to confirm that the shoulder is stably reduced (checking for smooth, pain-free range of motion) and to meticulously re-assess neurovascular status to ensure no new compromise has occurred during the reduction maneuver. Hill-Sachs is an pre-existing bony lesion. Long-term prognosis and arthritis are not immediate post-reduction concerns. Immediate aggressive rehab is not typical.

Question 56

A patient presents with a locked anterior shoulder dislocation that has been unreduced for 3 days. What is the MOST appropriate imaging study prior to attempted reduction?





Explanation

For a chronic or 'locked' dislocation, particularly one unreduced for several days, there is an increased risk of significant associated bony lesions (e.g., large Hill-Sachs, bony Bankart, surgical neck fracture, or glenoid rim fracture) that can complicate reduction or make closed reduction impossible. A CT scan provides excellent bony detail to assess the size and location of these lesions, which is crucial for planning the safest and most effective reduction strategy. While MRI shows soft tissue, bony detail is paramount here. Plain films may miss subtle but significant fractures. Ultrasound and bone scan are not indicated.

Question 57

Which of the following signs on physical exam is most indicative of a pectoralis major rupture?





Explanation

Pectoralis major rupture, especially of the sternal head, leads to a loss of the normal axillary fold contour and significant weakness in shoulder adduction and internal rotation. Option B describes anterior dislocation. Options C and D relate to rotator cuff or nerve injuries, respectively. Option E is non-specific.

Question 58

When assessing a patient who has sustained a fall onto the lateral aspect of their shoulder, leading to a suspected dislocated shoulder, which of the following anatomical landmarks should be carefully palpated for tenderness and deformity, specifically ruling out an AC joint injury?





Explanation

A fall onto the lateral aspect of the shoulder can cause an AC joint separation, which must be differentiated from or recognized in addition to a glenohumeral dislocation. Palpating the acromion and distal clavicle for tenderness, deformity, and assessing the step-off at the AC joint is crucial for diagnosing an AC injury. The other landmarks relate more to the glenohumeral joint or specific tendons.

Previous ChapterSuperior Glenohumeral Dislocation: A Comprehensive Guide to… Next Chapter Clinical Evaluation and History in Recurrent Shoulder Insta…
Dr. Mohammed Hutaif
Medically Verified Content by
Prof. Dr. Mohammed Hutaif
Consultant Orthopedic & Spine Surgeon
Chapter Index
    Back to Master Guide