Shoulder Arthroscopy — MCQs

10 questions

The contraindication to internal fixation -

The image shows a highlighted region on the dorsal aspect of the hand (anatomical snuffbox). Which of the following anatomical structures form the boundaries or floor of this region?

Complications of sling procedures (TVT) for USI are all except:

Which of the following techniques is appropriate for the reduction of the shoulder?

Which statement considering the relations of nerves to the humerus is the most accurate?

Preparation of the shoulder in an anterior tooth is done with:

Heller's myotomy is done for

Hill-Sach's lesion is seen in:

A 52-year-old female complains of increasing pain in the right shoulder. She is also finding it increasingly difficult to do overhead abduction of the affected joint. She had been diagnosed as a diabetic 20 years back and is on treatment since then. What is the most likely cause of her clinical condition?

Q10

With reference to frozen shoulder, consider the following statements: 1. It is associated with diabetes and heart disease. 2. It may follow minor trauma. 3. Its differential diagnosis are infection and fractures. 4. Treatment of choice is surgery. Which of the statements given above are correct?

Shoulder Arthroscopy Indian Medical PG Practice Questions and MCQs

Question 1: The contraindication to internal fixation -

A. Fracture dislocation
B. Intraarticular fracture
C. Physeal injury
D. Active infection (Correct Answer)

Explanation: ***Active infection*** - **Active infection** is a strong contraindication to internal fixation because introducing foreign material (implants) into an infected area can spread the infection, make it chronic, and lead to implant failure, osteomyelitis, or sepsis. - The presence of bacteria can colonize the implant surface, forming **biofilms** that are highly resistant to antibiotics and host immune responses, severely complicating treatment. *Fracture dislocation* - **Fracture dislocations** are often a strong *indication* for internal fixation to achieve anatomical reduction and stable fixation, allowing for early mobilization and preventing avascular necrosis or persistent instability. - The goal is to restore joint congruity and maintain reduction, which is difficult to achieve and maintain with non-operative methods. *Intraarticular fracture* - **Intraarticular fractures** are frequently *managed with* internal fixation to restore articular surface congruity, minimize post-traumatic arthritis, and allow for early range of motion. - Precise reduction and stable fixation are crucial to prevent long-term complications such as joint stiffness and osteoarthritis. *Physeal injury* - **Physeal injuries** (growth plate fractures) are often *treated with* surgical fixation, particularly unstable or displaced fractures, to ensure anatomical reduction and prevent growth disturbances. - The fixation technique must be chosen carefully to avoid damaging the physis itself, often using smooth pins or screws that do not cross the growth plate.

Question 2: The image shows a highlighted region on the dorsal aspect of the hand (anatomical snuffbox). Which of the following anatomical structures form the boundaries or floor of this region?

A. Abductor pollicis longus muscle.
B. Styloid process of the radius.
C. Extensor pollicis longus muscle.
D. All of the above anatomical structures. (Correct Answer)

Explanation: ***All of the above anatomical structures.*** - The image highlights the **anatomical snuffbox**, a triangular depression on the radial dorsal aspect of the hand. Its boundaries are formed by the tendons of the **extensor pollicis longus muscle** (ulnar side), and the **abductor pollicis longus** and **extensor pollicis brevis muscles** (radial side). - The **styloid process of the radius** forms the floor of the anatomical snuffbox along with the scaphoid and trapezium bones. All the options listed are key anatomical features associated with this region. *Extensor pollicis longus muscle.* - This muscle forms the **ulnar (medial) border** of the anatomical snuffbox. - Its tendon can be palpated during **thumb extension** and contributes to the overall structure of the highlighted area. *Abductor pollicis longus muscle.* - This muscle, along with the extensor pollicis brevis, forms the **radial (lateral) border** of the anatomical snuffbox. - Its tendon is visible and palpable on the radial side of the highlighted region when the thumb is abducted. *Styloid process of the radius.* - This bony prominence is located at the **distal end of the radius** on the radial side of the wrist. - It forms part of the **proximal floor** of the anatomical snuffbox, contributing to its definition.

Question 3: Complications of sling procedures (TVT) for USI are all except:

A. Obturator nerve injury is about 10% (Correct Answer)
B. Overactive bladder in about 7% cases
C. Injury to bladder and wound haematoma
D. Sling erosion particularly with polytetrafluoroethylene (Goretex)

Explanation: ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.

Question 4: Which of the following techniques is appropriate for the reduction of the shoulder?

A. Spinal anesthesia
B. Interscalene block (Correct Answer)
C. Axillary brachial block
D. Bier block

Explanation: ***Interscalene block*** - An **interscalene block** targets the brachial plexus at the level of the neck, providing excellent anesthesia for shoulder procedures. - This technique effectively blocks the nerves innervating the shoulder joint, allowing for **muscle relaxation** and pain control necessary for reduction. *Spinal anesthesia* - **Spinal anesthesia** provides anesthesia to the lower body and is primarily used for procedures below the waist. - It does not provide adequate **analgesia or muscle relaxation** for a shoulder reduction. *Axillary brachial block* - An **axillary brachial block** anesthetizes the distal arm and hand, but it often spares the more proximal shoulder innervation. - While useful for forearm and hand surgery, it typically does not provide sufficient **anesthesia for the shoulder** joint itself. *Bier block* - A **Bier block**, or intravenous regional anesthesia, is suitable for procedures on the distal extremities, such as the hand or foot. - It involves tourniquet inflation and intravenous injection of local anesthetic, making it **unsuitable for shoulder reduction** due to the large muscle mass and proximal location.

Question 5: Which statement considering the relations of nerves to the humerus is the most accurate?

A. Deltoid may atrophy following shoulder dislocation. (Correct Answer)
B. The median nerve runs in the spiral groove.
C. The axillary nerve runs around the anatomical neck.
D. Mid-shaft humeral fractures will usually result in complete paralysis of triceps.

Explanation: **Deltoid may atrophy following shoulder dislocation.** - **Shoulder dislocations**, particularly anterior dislocations, frequently injure the **axillary nerve** due to its close proximity to the humeral head and surgical neck. - Damage to the axillary nerve, which innervates the **deltoid muscle**, can lead to deltoid paralysis and subsequent **atrophy**, resulting in a flattened shoulder contour and impaired abduction. *The median nerve runs in the spiral groove.* - The **radial nerve**, not the median nerve, runs in the **spiral groove** (radial groove) of the humerus [1]. - The median nerve travels more anteriorly in the arm, alongside the brachial artery. *The axillary nerve runs around the anatomical neck.* - The **axillary nerve** wraps around the **surgical neck** of the humerus, not the anatomical neck. - The surgical neck is a common site for fractures, making the axillary nerve vulnerable to injury in such cases. *Mid-shaft humeral fractures will usually result in complete paralysis of triceps.* - Mid-shaft humeral fractures primarily risk damage to the **radial nerve**, which innervates the lateral and medial heads of the triceps [1]. - However, the **long head of the triceps** is innervated by the radial nerve more proximally and may remain partially functional, preventing complete paralysis of the entire triceps muscle.

Question 6: Preparation of the shoulder in an anterior tooth is done with:

A. Invested cone bur
B. Plain fissure bur
C. Cross cut fissure bur
D. End cutting bur (Correct Answer)

Explanation: ***End cutting bur*** - An **end-cutting bur** is specifically designed to create a **flat floor or shoulder margin** with a sharp internal angle, which is essential for certain crown preparations in anterior teeth. - Its design allows for shaping the shoulder while minimizing the risk of inadvertently cutting the axial walls. *Invested cone bur* - An **inverted cone bur** is primarily used to create **undercuts** and broaden the pulpal floor in cavity preparations. - It is not suitable for creating a distinct shoulder margin for crown preparations. *Plain fissure bur* - A **plain fissure bur (straight fissure)** is used for creating parallel-sided preparations and defining axial walls. - It is not ideal for creating a precise, flat shoulder margin due to its side-cutting nature. *Cross cut fissure bur* - A **cross-cut fissure bur** is designed for efficient cutting of tooth structure, often used for creating or extending preparations with parallel walls. - Like the plain fissure bur, it is not specialized for forming a sharp, flat shoulder margin.

Question 7: Heller's myotomy is done for

A. Zenker's diverticulum
B. Achalasia cardia (Correct Answer)
C. Hiatus hernia
D. Diffuse esophageal spasm

Explanation: ***Achalasia cardia*** - **Heller's myotomy** (esophagomyotomy) is the definitive surgical treatment for **achalasia cardia** - The procedure involves cutting the circular muscle fibers of the **lower esophageal sphincter (LES)** to relieve the functional obstruction - It addresses the primary pathology of achalasia: **failure of LES relaxation** and absence of esophageal peristalsis - Often combined with a partial fundoplication (Dor or Toupet) to prevent postoperative reflux *Zenker's diverticulum* - This is a **pharyngeal pouch** that develops at the pharyngoesophageal junction (Killian's triangle) - Treated with **diverticulectomy or diverticulopexy** with cricopharyngeal myotomy - Involves the upper esophageal sphincter, not the LES targeted by Heller's myotomy *Diffuse esophageal spasm* - A primary esophageal motility disorder characterized by **simultaneous, non-peristaltic contractions** - While esophageal myotomy may occasionally be considered in refractory cases, it is not the standard procedure - Management is primarily **medical** (calcium channel blockers, nitrates) rather than surgical *Hiatus hernia* - Involves herniation of the stomach through the esophageal hiatus of the diaphragm - Treated with **fundoplication** (Nissen or partial fundoplication) to reinforce the LES and repair the hiatus - Does not involve cutting the LES muscle as in Heller's myotomy

Question 8: Hill-Sach's lesion is seen in:

A. Anterior dislocation of hip
B. Posterior dislocation of hip
C. Recurrent dislocation of shoulder (Correct Answer)
D. Posterior dislocation of shoulder

Explanation: ***Recurrent dislocation of shoulder*** - A **Hill-Sach's lesion** is a **compression fracture** of the posterolateral part of the humeral head, occurring as the humeral head impacts the anterior rim of the glenoid during **anterior shoulder dislocation**. - It is particularly associated with **recurrent anterior shoulder dislocations** due to repeated impaction. *Anterior dislocation of hip* - This condition involves the femoral head moving anteriorly out of the acetabulum and is not associated with a Hill-Sach's lesion. - While it causes significant pain and immobility, the specific bone lesion known as Hill-Sach's involves the humerus, not the femur. *Posterior dislocation of hip* - A posterior hip dislocation involves the femoral head moving posteriorly out of the acetabulum and is not linked to a Hill-Sach's lesion. - This type of injury is often seen in high-impact trauma, such as car accidents, and can be associated with acetabular fractures or sciatic nerve injury. *Posterior dislocation of shoulder* - This involves the humeral head dislocating posteriorly relative to the glenoid, and while bone lesions can occur, they are typically **reverse Hill-Sach's lesions** (on the anterior aspect of the humeral head) or **bony Bankart lesions** of the posterior glenoid. - A standard Hill-Sach's lesion specifically refers to the posterolateral humeral head defect seen in **anterior dislocations**.

Question 9: A 52-year-old female complains of increasing pain in the right shoulder. She is also finding it increasingly difficult to do overhead abduction of the affected joint. She had been diagnosed as a diabetic 20 years back and is on treatment since then. What is the most likely cause of her clinical condition?

A. Frozen shoulder (Correct Answer)
B. Bacterial arthritis
C. Osteoarthritis
D. Rotator cuff tear

Explanation: ***Frozen shoulder*** - The patient's presentation with **increasing pain** and **difficulty with overhead abduction** of the shoulder, especially in the context of long-standing **diabetes**, is highly characteristic of **adhesive capsulitis** (frozen shoulder). - This condition is marked by **progressive stiffness** and **restricted range of motion** in the shoulder joint due to inflammation and fibrosis of the joint capsule. *Bacterial arthritis* - **Bacterial arthritis** typically presents with an **acutely painful**, **swollen**, and **erythematous joint**, often accompanied by systemic symptoms like **fever** and **malaise**. - The chronic, progressive nature of the patient's symptoms and the absence of acute inflammatory signs or fever make bacterial arthritis less likely. *Osteoarthritis* - While **osteoarthritis** can cause shoulder pain and stiffness, it usually presents with **pain that worsens with activity** and is relieved by rest, often with **crepitus** and a more gradual loss of range of motion. - The pronounced restriction in **overhead abduction** in this patient, particularly given the diabetic history, points away from primary osteoarthritis as the most likely cause. *Rotator cuff tear* - A **rotator cuff tear** typically presents with pain and weakness, especially during **abduction** or **external rotation**, and may have a specific mechanism of injury. - While abduction can be difficult, the classic presentation of a frozen shoulder with severe, global restriction of both active and passive range of motion is a stronger fit for the described symptoms.

Question 10: With reference to frozen shoulder, consider the following statements: 1. It is associated with diabetes and heart disease. 2. It may follow minor trauma. 3. Its differential diagnosis are infection and fractures. 4. Treatment of choice is surgery. Which of the statements given above are correct?

A. 1 and 2 only
B. 3 and 4 only
C. 1, 2 and 3 (Correct Answer)
D. 2, 3 and 4

Explanation: ***1, 2 and 3*** - **Frozen shoulder** (adhesive capsulitis) has a higher incidence in individuals with **diabetes mellitus** and **cardiovascular diseases**, indicating systemic associations. - It can be triggered by minor trauma or surgery, but often it has **no identifiable cause** (idiopathic). - The differential diagnoses for shoulder pain and restricted motion include serious conditions like **infection (septic arthritis)** and **fractures**, which must be ruled out. *1 and 2 only* - This option correctly identifies the association with diabetes and heart disease, and the possibility of minor trauma. - However, it incorrectly excludes the importance of considering infection and fractures in the differential diagnosis. *3 and 4 only* - This option correctly identifies the importance of differential diagnosis (infection and fractures). - However, **surgery is generally not the first-line treatment for frozen shoulder**; it is reserved for severe cases unresponsive to conservative measures. - It also fails to acknowledge the associations with diabetes and heart disease, or the role of minor trauma. *2, 3 and 4* - This option correctly notes that frozen shoulder can follow minor trauma and that infection and fractures are important differential diagnoses. - However, it incorrectly states that **surgery is the treatment of choice**, when **conservative management is usually first-line**. - It also misses the crucial association with **diabetes and heart disease**.

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