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Upper Extremity Trauma MCQs

Practice Set 15 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 281

Topic: Upper Extremity Trauma

A 25-year-old professional hockey player sustains a high-grade acromioclavicular (AC) joint separation and is scheduled for coracoclavicular (CC) ligament reconstruction. To accurately recreate the native anatomy, the surgeon must be aware of the specific insertion footprints of the CC ligaments. Which of the following describes the anatomical insertion of the conoid ligament relative to the trapezoid ligament on the clavicle?

. Medial and posterior
. Medial and anterior
. Lateral and posterior
. Lateral and anterior
. Directly anterior

Correct Answer & Explanation

. Medial and posterior

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid ligament inserts medially and posteriorly on the conoid tubercle of the clavicle, approximately 4.5 cm from the distal end. It is the primary restraint to superior translation of the clavicle. The trapezoid ligament inserts laterally and anteriorly, approximately 3 cm from the distal end, and is the primary restraint to axial compression of the clavicle towards the acromion.

Question 282

Topic: Upper Extremity Trauma

A 25-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate 100% superior displacement of the clavicle relative to the acromion, with the coracoclavicular (CC) distance increased by 50% compared to the contralateral side. A diagnosis of a Type III acromioclavicular (AC) joint separation is made. Which of the following accurately describes the anatomy of the native CC ligaments?

. The conoid is medial and posterior, the trapezoid is lateral and anterior
. The conoid is lateral and anterior, the trapezoid is medial and posterior
. The conoid originates on the acromion, the trapezoid on the coracoid
. The conoid provides primarily anteroposterior stability, the trapezoid provides superior stability
. Both ligaments attach to the medial third of the clavicle

Correct Answer & Explanation

. The conoid is medial and posterior, the trapezoid is lateral and anterior

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid is situated medial and posterior and is the primary restraint to superior displacement of the clavicle. The trapezoid is situated lateral and anterior and is the primary restraint to axial compression (preventing the scapula from moving medially). Understanding this footprint is crucial for anatomic CC ligament reconstruction.

Question 283

Topic: Upper Extremity Trauma

A 25-year-old professional hockey player sustains a direct blow to the point of his shoulder. Radiographs demonstrate an acromioclavicular (AC) joint injury with the clavicle displaced 150% superiorly relative to the acromion. There is palpable trapezius and deltoid fascia stripping. Which of the following is the classification and recommended management for this injury?

. Type II, non-operative management with a sling
. Type III, early surgical reconstruction
. Type III, non-operative management with a sling
. Type V, early surgical reconstruction
. Type V, non-operative management with a sling

Correct Answer & Explanation

. Type V, early surgical reconstruction

Explanation

The injury described is a Type V acromioclavicular (AC) joint separation, characterized by 100% to 300% superior displacement of the clavicle relative to the acromion and extensive stripping of the deltotrapezial fascia. Type III injuries have 25% to 100% displacement and are typically treated non-operatively initially, except in certain high-demand overhead athletes. Type V injuries are highly symptomatic, alter shoulder biomechanics significantly, and generally require early surgical reconstruction of the coracoclavicular ligaments.

Question 284

Topic: Upper Extremity Trauma

A 24-year-old cyclist falls directly onto his shoulder. Clinical examination demonstrates a prominence of the distal clavicle. Radiographs confirm a Type III acromioclavicular (AC) joint separation. Which structure is the primary restraint to anterior-posterior translation of the distal clavicle?

. Coracoacromial ligament
. Acromioclavicular capsular ligaments
. Conoid ligament
. Trapezoid ligament
. Coracohumeral ligament

Correct Answer & Explanation

. Acromioclavicular capsular ligaments

Explanation

The primary stabilizer against anterior-posterior translation of the clavicle relative to the acromion is the acromioclavicular (AC) joint capsule and its intrinsic ligaments (specifically the superior and posterior AC ligaments). The coracoclavicular (CC) ligaments (conoid and trapezoid) are the primary restraints to superior-inferior translation.

Question 285

Topic: Upper Extremity Trauma

A 24-year-old professional baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction utilizing the docking technique. Concurrently, the surgeon addresses concomitant valgus extension overload (VEO) syndrome. To avoid catastrophic failure of the newly reconstructed UCL, the surgeon must exercise extreme caution to prevent which of the following errors?

. Excessive resection of the posteromedial olecranon tip
. Over-tightening of the UCL graft beyond 60 degrees of flexion
. Submuscular anterior transposition of the ulnar nerve
. Inadequate resection of the sublime tubercle
. Debridement of the radiocapitellar articulation

Correct Answer & Explanation

. Excessive resection of the posteromedial olecranon tip

Explanation

Valgus extension overload (VEO) leads to osteophyte formation at the posteromedial olecranon due to abutment in the olecranon fossa. However, the olecranon acts as a critical bony restraint to valgus stress. Resection of more than 3 mm of the posteromedial olecranon drastically alters this bony constraint, significantly increasing the strain transferred to the anterior bundle of the UCL (or the newly placed graft), predisposing the patient to early graft failure and recurrent valgus instability.

Question 286

Topic: Upper Extremity Trauma

A 26-year-old professional mountain biker falls directly onto his right shoulder. Clinical examination reveals an irreducible, posterior displacement of the distal clavicle.

Radiographs confirm a posterior dislocation of the clavicle relative to the acromion on the axillary lateral view. Which Rockwood classification and optimal treatment paradigm applies to this injury?

. Type II; nonoperative management with a sling for 3 weeks
. Type III; immediate open surgical reconstruction of the coracoclavicular ligaments
. Type IV; surgical reduction and stabilization
. Type V; nonoperative management followed by delayed reconstruction if symptomatic
. Type VI; closed reduction under conscious sedation and immobilization

Correct Answer & Explanation

. Type IV; surgical reduction and stabilization

Explanation

This describes a Rockwood Type IV acromioclavicular (AC) joint injury. Type IV injuries are characterized by posterior displacement of the distal clavicle into or through the trapezius muscle fascia. Unlike Types I, II, and many Type III injuries which can be managed nonoperatively, Type IV injuries generally require surgical reduction and stabilization due to the severe soft tissue interposition and static non-reducibility that prevents adequate ligamentous healing.

Question 287

Topic: Upper Extremity Trauma

A 26-year-old mountain biker falls directly onto his shoulder. Clinical examination reveals a prominent distal clavicle. Radiographs demonstrate a 150% superior displacement of the clavicle relative to the acromion, and the coracoclavicular (CC) distance is markedly increased compared to the contralateral side. The deltotrapezial fascia is clinically disrupted. According to the Rockwood classification, what type of injury is this, and what is the standard management approach?

. Type III; initial nonoperative management with a sling
. Type IV; immediate surgical reconstruction of the CC ligaments
. Type V; surgical reduction and reconstruction/fixation
. Type V; initial nonoperative management with a figure-of-eight brace
. Type VI; closed reduction in the emergency department

Correct Answer & Explanation

. Type V; surgical reduction and reconstruction/fixation

Explanation

According to the Rockwood classification of acromioclavicular (AC) joint injuries, a Type V injury is characterized by 100% to 300% superior displacement of the clavicle relative to the acromion, along with severe disruption of the CC ligaments, AC ligaments, and the deltotrapezial fascia. Because of the severe displacement and fascial stripping, Type V injuries are generally treated operatively with surgical reduction and CC ligament reconstruction/fixation.

Question 288

Topic: Upper Extremity Trauma

A 28-year-old mountain biker falls directly onto the point of his shoulder. Clinical examination reveals a prominent distal clavicle with a reducible step-off. Bilateral Zanca view radiographs show that the coracoclavicular (CC) distance on the injured side is 150% greater than the contralateral uninjured side. The acromioclavicular (AC) joint is completely displaced superiorly. What is the Rockwood classification of this injury?

. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type V

Explanation

The Rockwood classification of AC joint separations is based on the direction and degree of clavicular displacement. Type V injuries are characterized by severe superior displacement of the clavicle, with the CC distance increased by 100% to 300% compared to the normal contralateral side. The deltotrapezial fascia is severely stripped from the acromion and clavicle. Type III injuries have a 25% to 100% increase in CC distance.

Question 289

Topic: Upper Extremity Trauma

A 32-year-old competitive weightlifter feels a sudden tear in his chest while performing a heavy bench press. Examination reveals extensive ecchymosis over the anterior arm and chest, a palpable defect in the anterior axillary fold, and profound weakness with resisted shoulder internal rotation and adduction. Which of the following accurately describes the most common location of a pectoralis major rupture and the optimal timing for surgical repair in an athlete?

. Musculotendinous junction; conservative management is preferred
. Sternal head avulsion from the humerus; repair within 6 weeks
. Clavicular head avulsion from the humerus; repair after 3 months
. Intramuscular belly tear; acute repair within 2 weeks
. Sternal head avulsion from the sternum; acute repair within 1 week

Correct Answer & Explanation

. Sternal head avulsion from the humerus; repair within 6 weeks

Explanation

The most common mechanism for a pectoralis major rupture is an eccentric load during a bench press. The vast majority of these tears involve an avulsion of the sternal head tendon from its insertion on the proximal humerus, while the clavicular head remains intact. Early surgical repair (typically within the first 6 weeks before significant retraction and scarring occur) yields significantly better functional outcomes, peak torque recovery, and cosmetic satisfaction compared to delayed repair or nonoperative management in athletic populations.

Question 290

Topic: Upper Extremity Trauma

A 28-year-old cyclist falls directly onto his right shoulder. Clinical examination reveals a prominent distal clavicle. Radiographs demonstrate an acromioclavicular (AC) joint separation with 150% superior displacement of the distal clavicle relative to the acromion. Which of the following ligamentous structures are completely disrupted in this injury?

. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Acromioclavicular and coracoclavicular ligaments
. Coracoacromial ligament only
. Sternoclavicular ligaments

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular ligaments

Explanation

Displacement of the distal clavicle superiorly by more than 100% relative to the acromion classifies the injury as at least a Rockwood Type III AC joint separation. Type III (and above) injuries involve the complete rupture of both the acromioclavicular (AC) ligaments and the coracoclavicular (CC) ligaments (conoid and trapezoid).

Question 291

Topic: Upper Extremity Trauma

A 28-year-old male falls directly onto the point of his shoulder. Radiographs demonstrate a Rockwood Type V acromioclavicular (AC) joint separation, characterized by >100% superior displacement of the clavicle relative to the acromion. Operative stabilization is planned. Which of the following ligaments are primarily targeted for reconstruction to restore vertical stability to the distal clavicle?

. Acromioclavicular and coracoacromial ligaments
. Conoid and trapezoid ligaments
. Superior and inferior acromioclavicular ligaments
. Coracohumeral and superior glenohumeral ligaments
. Sternoclavicular ligaments

Correct Answer & Explanation

. Conoid and trapezoid ligaments

Explanation

Vertical stability of the distal clavicle is primarily provided by the coracoclavicular (CC) ligaments, which consist of the conoid (medial) and trapezoid (lateral) ligaments. The acromioclavicular (AC) ligaments primarily provide anteroposterior (horizontal) stability. Surgical reconstruction of high-grade AC joint separations (Types IV, V, VI) focuses on repairing or reconstructing the CC ligaments to reduce the distal clavicle back to the coracoid process.

Question 292

Topic: Upper Extremity Trauma

A 22-year-old male motorcyclist is struck by a car and presents with massive swelling over his left shoulder girdle and a completely flail, pulseless left upper extremity. A chest radiograph demonstrates a laterally displaced scapula, a widened acromioclavicular joint, and an intact clavicle. What is the most critical immediate priority in the management of this specific injury?

. Emergent open reduction and internal fixation of the scapula
. MRI of the brachial plexus to assess for nerve root avulsions
. CT angiography of the upper extremity and vascular surgery consultation
. Immediate forequarter amputation to prevent crush syndrome
. Application of a shoulder spica cast and strict elevation

Correct Answer & Explanation

. CT angiography of the upper extremity and vascular surgery consultation

Explanation

The clinical and radiographic presentation describes a scapulothoracic dissociation, a severe, high-energy injury characterized by complete disruption of the scapulothoracic articulation. It is often likened to a 'closed forequarter amputation'. It is highly associated with massive, potentially life-threatening hemorrhage from subclavian or axillary artery disruption, as well as severe brachial plexus avulsions. Because of the immediate threat to life and limb from vascular injury, CT angiography and vascular surgery evaluation are the most critical immediate priorities.

Question 293

Topic: Upper Extremity Trauma
A 22-year-old football player sustains an acromioclavicular (AC) joint injury. Radiographs show posterior displacement of the distal clavicle into the trapezius fascia. What is the correct classification and recommended treatment?
. Type III, nonoperative management
. Type IV, surgical reconstruction
. Type V, nonoperative management
. Type II, surgical reconstruction
. Type VI, surgical reconstruction

Correct Answer & Explanation

. Type IV, surgical reconstruction

Explanation

Posterior displacement of the distal clavicle into the trapezius characterizes a Type IV AC joint injury. It is generally an absolute indication for surgical reconstruction due to significant pain and functional impairment.

Question 294

Topic: Upper Extremity Trauma

During an anatomic reconstruction of the coracoclavicular (CC) ligaments for an acromioclavicular joint separation, the surgeon must replicate the natural orientation of the conoid and trapezoid ligaments. What is the spatial relationship of the conoid ligament relative to the trapezoid ligament?

. Anteromedial
. Anterolateral
. Posteromedial
. Posterolateral
. Directly inferior

Correct Answer & Explanation

. Posteromedial

Explanation

The coracoclavicular ligaments consist of the conoid and trapezoid. The conoid ligament is positioned posteromedial to the trapezoid ligament and provides the primary restraint to superior clavicular translation.

Question 295

Topic: Upper Extremity Trauma

In the setting of an Essex-Lopresti injury, longitudinal stability of the forearm is compromised due to a radial head fracture and disruption of the interosseous membrane (IOM). Which anatomical component of the IOM provides the greatest resistance to proximal migration of the radius?

. Distal oblique bundle
. Proximal oblique cord
. Dorsal oblique accessory cord
. Central band
. Volar radioulnar ligament

Correct Answer & Explanation

. Central band

Explanation

The central band is the thickest and most biomechanically robust component of the interosseous membrane. It originates on the radius and inserts distally on the ulna (running in a distal-ulnarward direction), acting as the primary soft-tissue restraint to longitudinal radioulnar translation.

Question 296

Topic: Upper Extremity Trauma

A 31-year-old male presents with a suspected Essex-Lopresti injury after a fall on an outstretched hand. He has pain at the elbow and wrist. Which portion of the interosseous membrane of the forearm is the primary stabilizer against longitudinal radioulnar translation?

. Distal oblique bundle
. Central band
. Proximal oblique cord
. Dorsal oblique accessory cord
. Triangular fibrocartilage complex

Correct Answer & Explanation

. Central band

Explanation

The central band of the interosseous membrane (IOM) is the thickest and most critical portion for providing longitudinal stability to the forearm, transferring force from the radius to the ulna. In an Essex-Lopresti injury, which consists of a radial head fracture, disruption of the DRUJ, and a longitudinal tear of the IOM, the central band is disrupted, leading to proximal migration of the radius if the radial head is not reconstructed or replaced.

Question 297

Topic: Upper Extremity Trauma

A 28-year-old cyclist sustains a severe type V acromioclavicular (AC) joint separation after being thrown over the handlebars. He fails conservative management and undergoes an anatomic coracoclavicular (CC) ligament reconstruction. To accurately recreate the biomechanics of the native ligaments, the surgeon must drill the clavicular tunnels mimicking the anatomic footprints. Which of the following accurately describes the anatomic orientation of the conoid and trapezoid ligaments?

. The conoid is medial and posterior; the trapezoid is lateral and anterior
. The conoid is medial and anterior; the trapezoid is lateral and posterior
. The conoid is lateral and posterior; the trapezoid is medial and anterior
. The conoid is lateral and anterior; the trapezoid is medial and posterior
. Both ligaments insert symmetrically along the midline of the clavicle

Correct Answer & Explanation

. The conoid is medial and posterior; the trapezoid is lateral and anterior

Explanation

The coracoclavicular (CC) ligament complex consists of the conoid and trapezoid ligaments, which are the primary vertical restraints of the AC joint. The conoid ligament is cone-shaped and attaches to the conoid tubercle on the posteromedial aspect of the inferior clavicle. The trapezoid ligament is broad and attaches anterolaterally to the trapezoid ridge. Therefore, relative to each other, the conoid is medial and posterior, while the trapezoid is lateral and anterior. Recreating this footprint is essential during anatomic CC reconstructions.

Question 298

Topic: Upper Extremity Trauma

A 30-year-old competitive weightlifter feels a sudden 'pop' in his anterior chest while performing a heavy bench press, followed by immediate weakness and ecchymosis over the anterior axillary fold. He is diagnosed with a complete rupture of the pectoralis major tendon. During surgical repair, a thorough understanding of the insertional anatomy is essential. How does the sternocostal head insert relative to the clavicular head on the lateral lip of the bicipital groove?

. Distal and anterior
. Distal and posterior
. Proximal and anterior
. Proximal and posterior
. Co-joined and indistinguishable

Correct Answer & Explanation

. Distal and posterior

Explanation

The pectoralis major has a complex twisted insertion on the proximal humerus. The clavicular head inserts anteriorly and distally, while the sternocostal head twists 180 degrees upon itself such that its inferior-most fibers insert most proximally and posteriorly (deep) to the clavicular head. The sternocostal head is placed under maximum tension during the eccentric phase of a bench press and is the most commonly ruptured segment.

Question 299

Topic: Upper Extremity Trauma
A 25-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate 150% superior displacement of the distal clavicle relative to the acromion. Physical examination notes a severe clinical deformity and the MRI shows disruption of the deltotrapezial fascia along with torn acromioclavicular and coracoclavicular ligaments. According to the Rockwood classification, what type of injury is this and what is the generally recommended treatment?
. Type III; conservative management with a sling
. Type III; surgical reconstruction
. Type V; conservative management with a sling
. Type V; surgical reconstruction
. Type IV; surgical reconstruction

Correct Answer & Explanation

. Type V; surgical reconstruction

Explanation

This is a Rockwood Type V acromioclavicular (AC) joint injury. It is characterized by 100-300% superior displacement of the clavicle, complete rupture of the AC and CC ligaments, and gross disruption of the deltotrapezial fascia resulting in severe soft tissue stripping. Type V injuries are generally treated with surgical reconstruction to restore shoulder biomechanics. Type III injuries have up to 100% displacement and are often managed conservatively, whereas Type IV injuries involve posterior displacement of the clavicle into or through the trapezius.

Question 300

Topic: Upper Extremity Trauma
A 31-year-old male cyclist falls directly onto his right shoulder. Clinical examination reveals a prominent distal clavicle. Radiographs demonstrate 150% superior displacement of the distal clavicle relative to the acromion, with a significantly increased coracoclavicular distance. Which of the following structures must be completely disrupted to result in this radiographic appearance?
. Acromioclavicular ligaments only
. Acromioclavicular and coracoclavicular ligaments with an intact deltotrapezial fascia
. Acromioclavicular and coracoclavicular ligaments with disruption of the deltotrapezial fascia
. Coracoacromial ligament and coracoclavicular ligaments
. Sternoclavicular ligaments and costoclavicular ligaments

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular ligaments with disruption of the deltotrapezial fascia

Explanation

Superior displacement of the distal clavicle between 100% and 300% relative to the acromion represents a Rockwood Type V acromioclavicular (AC) joint separation. This severe degree of displacement is only biomechanically possible when there is a complete disruption of the acromioclavicular ligaments, the coracoclavicular ligaments (conoid and trapezoid), and the deltotrapezial fascia. A Type III injury (up to 100% displacement) retains an intact deltotrapezial fascia.

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