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Upper Extremity Trauma MCQs

Practice Set 11 of 24

This practice set contains high-yield board review questions covering key concepts in Upper Extremity Trauma. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 201

Topic: Upper Extremity Trauma

During an anatomic reconstruction of the coracoclavicular (CC) ligaments for a chronic Type V acromioclavicular dislocation, accurate footprint placement is crucial. Which of the following describes the normal anatomic orientation of the CC ligaments on the clavicle?

. The conoid is posteromedial, and the trapezoid is anterolateral.
. The conoid is anterolateral, and the trapezoid is posteromedial.
. Both insert centrally along the mechanical axis of the clavicle.
. The conoid inserts 3.0 cm from the distal end, and the trapezoid inserts 4.5 cm from the distal end.
. The trapezoid inserts on the acromion, and the conoid inserts on the clavicle.

Correct Answer & Explanation

. The conoid is posteromedial, and the trapezoid is anterolateral.

Explanation

The conoid ligament inserts posteromedially on the conoid tubercle (roughly 4.5 cm from the distal clavicle). The trapezoid ligament inserts anterolaterally (roughly 3.0 cm from the distal clavicle).

Question 202

Topic: Upper Extremity Trauma

A 25-year-old cyclist falls directly onto his shoulder. Examination reveals skin tenting over a prominent distal clavicle. Radiographs show a 150% superior displacement of the clavicle relative to the acromion. What is the most appropriate management according to the Rockwood classification?

. Sling immobilization for 2 weeks followed by physical therapy
. Figure-of-eight brace
. Open reduction and coracoclavicular ligament reconstruction
. Distal clavicle excision alone
. Closed reduction and percutaneous pinning

Correct Answer & Explanation

. Open reduction and coracoclavicular ligament reconstruction

Explanation

This is a Rockwood Type V acromioclavicular joint dislocation, characterized by >100% superior displacement of the clavicle and disruption of the deltotrapezial fascia. Operative management with CC ligament reconstruction is indicated due to severe displacement and gross instability.

Question 203

Topic: Upper Extremity Trauma

When utilizing an olecranon osteotomy for open reduction and internal fixation of a complex intra-articular distal humerus fracture, which osteotomy configuration is associated with the highest biomechanical stability and lowest risk of articular step-off?

. Transverse osteotomy at the olecranon tip
. Apex-distal chevron osteotomy through the bare area
. Apex-proximal chevron osteotomy through the coronoid process
. Oblique osteotomy from dorsal to volar-distal
. Step-cut osteotomy through the olecranon fossa

Correct Answer & Explanation

. Apex-distal chevron osteotomy through the bare area

Explanation

An apex-distal chevron osteotomy directed through the non-articular bare area of the sigmoid notch provides excellent exposure, maximizes bony contact, and interlocks securely to prevent articular step-off during closure.

Question 204

Topic: Upper Extremity Trauma

A 32-year-old woman falls from a height and sustains a comminuted radial head fracture, which is excised. Postoperatively, she reports persistent, severe wrist pain. Examination reveals tenderness over the distal radioulnar joint (DRUJ) and positive ulnar variance. Which of the following is the most likely diagnosis?

. Monteggia fracture-dislocation
. Galeazzi fracture
. Essex-Lopresti lesion
. Terrible triad injury
. Scapholunate dissociation

Correct Answer & Explanation

. Essex-Lopresti lesion

Explanation

An Essex-Lopresti injury consists of a radial head fracture, rupture of the interosseous membrane, and DRUJ instability. Radial head excision in this setting leads to proximal migration of the radius and severe wrist pain, hence it should be avoided.

Question 205

Topic: Upper Extremity Trauma

Recent quantitative anatomic studies have redefined the primary arterial supply to the articular segment of the proximal humerus. Which vessel provides the majority of the blood supply to the humeral head?

. Anterior humeral circumflex artery
. Posterior humeral circumflex artery
. Thoracoacromial artery
. Subscapular artery
. Suprascapular artery

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

While older literature emphasized the anterior humeral circumflex artery (arcuate branch), recent studies (e.g., Hettrich et al.) demonstrate that the posterior humeral circumflex artery provides approximately 64% of the blood supply to the humeral head.

Question 206

Topic: Upper Extremity Trauma

Which of the following describes the typical mechanism of injury for a 'terrible triad' of the elbow?

. Axial load, valgus stress, and forearm supination
. Axial load, varus stress, and forearm pronation
. Direct blow to the posterior olecranon with the elbow flexed
. Hyperextension with sudden varus stress
. Traction injury with the elbow in extension

Correct Answer & Explanation

. Axial load, valgus stress, and forearm supination

Explanation

A terrible triad injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture) typically occurs from a fall on an outstretched hand resulting in an axial load, valgus stress, and forearm supination. This causes sequential failure of structures from lateral to medial.

Question 207

Topic: Upper Extremity Trauma

During evaluation of a severe shoulder injury, a radiograph

shows superior displacement of the clavicle by 150% relative to the acromion. Which of the following best describes the pathoanatomy of this Rockwood Type V acromioclavicular injury?

. Sprain of AC ligaments, intact CC ligaments
. Torn AC ligaments, sprained CC ligaments
. Torn AC and CC ligaments, intact deltotrapezius fascia
. Torn AC and CC ligaments, stripped deltotrapezius fascia
. Inferior dislocation of the clavicle under the coracoid

Correct Answer & Explanation

. Torn AC and CC ligaments, stripped deltotrapezius fascia

Explanation

A Rockwood Type V injury involves tearing of the acromioclavicular (AC) and coracoclavicular (CC) ligaments, along with extensive stripping of the deltotrapezius fascia, leading to severe superior displacement of the distal clavicle.

Question 208

Topic: Upper Extremity Trauma

A 25-year-old rugby player sustains an acromioclavicular (AC) joint injury. Radiographs reveal 150% superior displacement of the clavicle relative to the acromion. Which of the following ligaments are disrupted in this Rockwood Type V injury?

. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Acromioclavicular and coracoclavicular ligaments, with stripping of the deltotrapezial fascia
. Acromioclavicular ligaments and coracoacromial ligaments
. Coracohumeral ligaments

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular ligaments, with stripping of the deltotrapezial fascia

Explanation

Rockwood Type V injuries involve severe superior displacement of the clavicle (100-300%). This requires disruption of the AC ligaments, CC ligaments, and significant stripping or detachment of the deltotrapezial fascia.

Question 209

Topic: Upper Extremity Trauma
A 28-year-old rugby player sustains a Type III acromioclavicular (AC) joint separation. Which ligaments are structurally disrupted in this specific injury pattern?
. The acromioclavicular ligaments only
. The coracoclavicular ligaments only
. Both the acromioclavicular and coracoclavicular ligaments
. The coracoacromial and acromioclavicular ligaments
. The sternoclavicular and coracoclavicular ligaments

Correct Answer & Explanation

. Both the acromioclavicular and coracoclavicular ligaments

Explanation

A Rockwood Type III AC joint separation involves complete tearing of both the acromioclavicular ligaments and the coracoclavicular (conoid and trapezoid) ligaments. The clavicle is typically elevated 25-100% relative to the acromion.

Question 210

Topic: Upper Extremity Trauma

A 32-year-old motorcyclist is involved in a high-speed collision.

Chest radiographs demonstrate marked lateral displacement of the left scapula. The patient's left upper extremity is flaccid. What is the most critical next step in management?

. Immediate open reduction of the acromioclavicular joint
. CT angiography of the chest and upper extremity
. EMG and nerve conduction studies
. Application of a shoulder spica cast
. MRI of the brachial plexus

Correct Answer & Explanation

. CT angiography of the chest and upper extremity

Explanation

Scapulothoracic dissociation is a high-energy injury characterized by lateral scapular displacement and is highly associated with catastrophic neurovascular injuries. CT angiography is the most critical initial step to evaluate for a limb- or life-threatening subclavian or axillary artery disruption.

Question 211

Topic: Upper Extremity Trauma

A 29-year-old weightlifter feels a tearing sensation in his chest while performing a heavy bench press. Examination reveals bruising and loss of the normal anterior axillary fold contour. What is the most common anatomic location for a pectoralis major rupture?

. Muscle belly
. Musculotendinous junction
. Clavicular head origin
. Sternal head origin
. Tendinous insertion onto the proximal humerus

Correct Answer & Explanation

. Tendinous insertion onto the proximal humerus

Explanation

Pectoralis major ruptures most frequently occur in weightlifters (especially during the bench press) at the tendinous insertion onto the lateral lip of the bicipital groove of the proximal humerus.

Question 212

Topic: Upper Extremity Trauma
A 26-year-old hockey player sustains a direct downward blow to his shoulder. Radiographs demonstrate superior displacement of the clavicle relative to the acromion by approximately 200%. The coracoclavicular distance is more than twice that of the uninjured side. According to the Rockwood classification, what type of acromioclavicular injury is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type V

Explanation

A Rockwood Type V acromioclavicular dislocation involves severe superior displacement of the clavicle (100% to 300%) relative to the acromion, accompanied by significant stripping of the deltotrapezial fascia. Type III involves up to 100% displacement, and Type IV is displaced posteriorly into the trapezius.

Question 213

Topic: Upper Extremity Trauma

During a coracoclavicular (CC) ligament reconstruction for a chronic Type V acromioclavicular joint separation, the surgeon must recreate the anatomical footprints. Which of the following accurately describes the native CC ligament anatomy?

. The conoid ligament is anterolateral to the trapezoid ligament
. The trapezoid ligament inserts approximately 4.5 cm from the distal clavicle
. The conoid ligament is located posteromedial to the trapezoid ligament
. The trapezoid ligament inserts into the base of the coracoid process
. Both ligaments merge into a single insertion on the acromion

Correct Answer & Explanation

. The conoid ligament is located posteromedial to the trapezoid ligament

Explanation

The conoid ligament is located posteromedial to the trapezoid ligament and inserts approximately 4.5 cm medial to the distal end of the clavicle. The trapezoid is anterolateral and inserts approximately 3 cm medial to the distal clavicle.

Question 214

Topic: Upper Extremity Trauma

A 40-year-old man underwent excision of a comminuted radial head fracture 6 weeks ago. He now presents with progressive ulnar-sided wrist pain and weakness. Radiographs demonstrate proximal migration of the radius. This complication is a result of an unrecognized injury to which structure?

. Triangular fibrocartilage complex (TFCC)
. Interosseous membrane
. Annular ligament
. Lateral ulnar collateral ligament
. Scapholunate interosseous ligament

Correct Answer & Explanation

. Interosseous membrane

Explanation

Proximal migration of the radius following radial head excision indicates an unrecognized disruption of the interosseous membrane, known as an Essex-Lopresti lesion. This results in longitudinal radioulnar dissociation and requires radial head replacement.

Question 215

Topic: Upper Extremity Trauma
In an unreduced Type III acromioclavicular (AC) joint separation, which of the following ligaments provides the primary restraint against superior translation of the clavicle?
. Acromioclavicular ligaments
. Coracoacromial ligament
. Conoid ligament
. Trapezoid ligament
. Coracohumeral ligament

Correct Answer & Explanation

. Conoid ligament

Explanation

The conoid and trapezoid comprise the coracoclavicular (CC) ligaments. The conoid ligament is located posteromedially and acts as the primary restraint to superior translation of the clavicle.

Question 216

Topic: Upper Extremity Trauma

The anterior bundle of the medial collateral ligament (AMCL) of the elbow is the primary restraint to valgus stress. Where is its primary insertion on the proximal ulna?

. Olecranon tip
. Sublime tubercle
. Supinator crest
. Coronoid tip
. Radial notch

Correct Answer & Explanation

. Sublime tubercle

Explanation

The anterior bundle of the elbow MCL originates on the anteroinferior aspect of the medial epicondyle and inserts on the sublime tubercle of the proximal ulna.

Question 217

Topic: Upper Extremity Trauma

During reconstruction of the coracoclavicular (CC) ligaments for an acromioclavicular joint separation, anatomic placement is crucial. Which of the following best describes the normal anatomic orientation of the CC ligaments?

. The conoid ligament is lateral and anterior to the trapezoid ligament
. The conoid ligament is medial and posterior to the trapezoid ligament
. The trapezoid ligament is medial and posterior to the conoid ligament
. The trapezoid ligament is medial and anterior to the conoid ligament
. The conoid and trapezoid ligaments share a single footprint on the clavicle

Correct Answer & Explanation

. The conoid ligament is medial and posterior to the trapezoid ligament

Explanation

The conoid ligament attaches posteromedially on the clavicle at the conoid tubercle, acting primarily to resist superior displacement. The trapezoid ligament attaches anterolaterally on the trapezoid line and resists axial compression.

Question 218

Topic: Upper Extremity Trauma

Superior capsular reconstruction (SCR) is considered for younger patients with massive, irreparable posterosuperior rotator cuff tears. The primary biomechanical goal of this procedure is to prevent which of the following?

. Anterior translation of the humeral head
. Superior migration of the humeral head
. Posterior subluxation of the humeral head
. Acromioclavicular joint arthritis
. Inferior displacement of the glenoid

Correct Answer & Explanation

. Superior migration of the humeral head

Explanation

Superior capsular reconstruction utilizes a graft to replace the deficient superior capsule. The primary biomechanical goal is to depress the humeral head, preventing superior migration and restoring normal glenohumeral kinematics to allow the deltoid to function effectively.

Question 219

Topic: Upper Extremity Trauma
A 25-year-old cyclist falls directly onto his shoulder. Radiographs show a 150% superior displacement of the clavicle relative to the acromion. This injury represents a complete tear of which of the following?
. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Acromioclavicular and coracoclavicular ligaments
. Coracoacromial ligament
. Sternoclavicular ligaments

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular ligaments

Explanation

This is a Type III (or higher) acromioclavicular joint injury. It is characterized by complete disruption of both the acromioclavicular (AC) and coracoclavicular (CC) ligaments, leading to significant superior displacement of the clavicle.

Question 220

Topic: Upper Extremity Trauma

A 26-year-old weightlifter feels a tearing sensation in his anterior chest while performing a heavy bench press.

Examination reveals loss of the anterior axillary fold. Where does the pectoralis major tendon most commonly rupture in this demographic?

. At the sternoclavicular origin
. At the musculotendinous junction
. Mid-substance of the muscle belly
. At its insertion on the humerus
. At the coracoid process

Correct Answer & Explanation

. At its insertion on the humerus

Explanation

In young, active weightlifters performing bench press exercises, pectoralis major ruptures most frequently occur as avulsions at or near the tendinous insertion onto the proximal humerus.

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