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Upper Extremity Trauma MCQs

Practice Set 16 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 301

Topic: Upper Extremity Trauma

A 22-year-old collegiate baseball pitcher presents with posterior elbow pain during the deceleration phase of throwing and a progressive loss of terminal extension. Exam shows posteromedial tenderness and pain with forced elbow extension while valgus stress is applied.

Radiographs demonstrate posteromedial olecranon osteophytes. If operative management is chosen, what is a critical technical consideration?

. Performing a generous 10 mm wedge resection of the olecranon to ensure full extension
. Limiting olecranon resection to less than 3 mm to avoid increasing strain on the UCL
. Performing a prophylactic lateral ulnar collateral ligament (LUCL) reconstruction
. Resecting the coronoid tip to decompress the anterior capsule
. Transposing the ulnar nerve subcutaneously in all cases

Correct Answer & Explanation

. Limiting olecranon resection to less than 3 mm to avoid increasing strain on the UCL

Explanation

Valgus extension overload (VEO) results in posteromedial olecranon impingement and osteophyte formation, often coexisting with chronic ulnar collateral ligament (UCL) insufficiency. Resecting more than 3 mm of the posteromedial olecranon removes a secondary bony constraint to valgus stress, which significantly increases strain on the UCL and can unmask or worsen frank valgus instability.

Question 302

Topic: Upper Extremity Trauma

A 26-year-old mountain biker sustains a fall onto his shoulder. Clinical examination reveals a prominent distal clavicle.

Radiographs confirm a Type V acromioclavicular (AC) joint separation. The surgeon plans an anatomic coracoclavicular (CC) ligament reconstruction. To accurately recreate the native anatomy, where should the clavicular tunnel for the conoid ligament be placed?

. 4.5 cm medial to the distal clavicle and centered anterior-to-posterior
. 4.5 cm medial to the distal clavicle and slightly posterior to the midline
. 3.0 cm medial to the distal clavicle and slightly anterior to the midline
. 1.5 cm medial to the distal clavicle and centered anterior-to-posterior
. 1.5 cm medial to the distal clavicle and slightly posterior to the midline

Correct Answer & Explanation

. 4.5 cm medial to the distal clavicle and slightly posterior to the midline

Explanation

Anatomic reconstruction of the CC ligaments requires precise tunnel placement. The native conoid ligament inserts approximately 4.5 cm medial to the distal end of the clavicle and slightly posterior to its midline. The trapezoid ligament inserts approximately 3.0 cm medial to the distal end and slightly anterior. Correct placement optimizes the biomechanical stability of the construct.

Question 303

Topic: Upper Extremity Trauma
A 28-year-old male cyclist falls directly onto his right shoulder. Radiographs show a 150% superior displacement of the distal clavicle relative to the acromion. Physical exam reveals severe soft tissue tenting and pain. According to the Rockwood classification, what is the injury type and most appropriate management?
. Rockwood Type III, nonoperative management
. Rockwood Type II, sling and early physical therapy
. Rockwood Type V, surgical reconstruction of the coracoclavicular ligaments
. Rockwood Type IV, closed reduction and spica casting
. Rockwood Type VI, surgical reconstruction of the acromioclavicular capsule only

Correct Answer & Explanation

. Rockwood Type V, surgical reconstruction of the coracoclavicular ligaments

Explanation

This is a Rockwood Type V acromioclavicular (AC) joint separation, characterized by >100% (typically 100-300%) superior displacement of the distal clavicle into the trapezius fascia, presenting with gross deformity and soft tissue tenting. Surgical reconstruction of the coracoclavicular (CC) ligaments is the indicated treatment for Type V injuries, whereas Type III injuries (up to 100% displacement) often undergo an initial trial of nonoperative management.

Question 304

Topic: Upper Extremity Trauma

A 30-year-old competitive weightlifter feels a sudden 'pop' and tearing sensation in his anterior axilla while performing a heavy bench press. Examination reveals extensive ecchymosis over the medial arm and a loss of the normal anterior axillary fold contour. Weakness is most pronounced with internal rotation and adduction of the arm. Which of the following describes the most common anatomical location of this specific injury?

. Avulsion of the clavicular head from its humeral insertion
. Avulsion of the sternal head from its humeral insertion
. Tear of the sternal head at the musculotendinous junction
. Tear of the clavicular head at the musculotendinous junction
. Mid-substance rupture of the combined muscle belly

Correct Answer & Explanation

. Avulsion of the sternal head from its humeral insertion

Explanation

The patient has sustained a pectoralis major rupture, classically occurring during the eccentric phase of a bench press. The most common site of injury is an avulsion of the sternal head from its insertion on the proximal humerus, lateral to the bicipital groove. Because the sternal head inserts deep and proximal to the clavicular head, extreme tension is placed selectively on the inferior (sternal) fibers when the arm is extended and externally rotated, making it highly susceptible to isolated tearing or avulsion.

Question 305

Topic: Upper Extremity Trauma

A 28-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate a type V acromioclavicular (AC) joint separation, indicating that the coracoclavicular (CC) ligaments are ruptured. Which specific ligaments comprise the CC complex?

. Superior and inferior AC ligaments
. Conoid and trapezoid ligaments
. Coracoacromial and coracohumeral ligaments
. Transverse scapular and spinoglenoid ligaments
. Costoclavicular and sternoclavicular ligaments

Correct Answer & Explanation

. Conoid and trapezoid ligaments

Explanation

The coracoclavicular (CC) ligaments consist of the conoid (medial) and trapezoid (lateral) ligaments, which act as the primary vertical stabilizers of the acromioclavicular joint.

Question 306

Topic: Upper Extremity Trauma
A 26-year-old cyclist sustains a type III acromioclavicular (AC) joint separation. Biomechanical studies indicate that the primary restraint to superior translation of the distal clavicle is the:
. Acromioclavicular ligament
. Coracoacromial ligament
. Conoid ligament
. Trapezoid ligament
. Coracobrachialis tendon

Correct Answer & Explanation

. Conoid ligament

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid ligament is the primary restraint to superior translation of the clavicle, while the trapezoid is the primary restraint to axial compression.

Question 307

Topic: Upper Extremity Trauma

A 28-year-old weightlifter presents with acute right axillary pain and weakness after performing a heavy bench press.

Physical examination reveals significant ecchymosis and a loss of the anterior axillary fold contour. Which of the following is the most appropriate surgical management for a complete rupture in this demographic?

. Repair of the tendon directly to the sternum
. Repair of the tendon to the clavicle
. Repair of the tendon to the proximal humerus lateral to the bicipital groove
. Repair of the tendon to the humerus medial to the bicipital groove
. Nonoperative management with early mobilization in a sling

Correct Answer & Explanation

. Repair of the tendon to the proximal humerus lateral to the bicipital groove

Explanation

Pectoralis major ruptures most commonly occur at the humeral insertion (sternocostal head) in weightlifters performing bench presses. Anatomic repair is recommended for active individuals, which involves reattaching the tendon at its native footprint on the proximal humerus, located lateral to the bicipital groove.

Question 308

Topic: Upper Extremity Trauma
A 30-year-old cyclist falls directly onto his shoulder. A Zanca view radiograph shows superior displacement of the distal clavicle measuring 200% compared to the contralateral side. The axillary view demonstrates the distal clavicle displaced posteriorly into the trapezius fascia. What is the Rockwood classification and appropriate treatment?
. Type III, conservative management
. Type IV, operative stabilization
. Type V, conservative management
. Type V, operative stabilization
. Type VI, operative stabilization

Correct Answer & Explanation

. Type IV, operative stabilization

Explanation

Posterior displacement of the distal clavicle into or through the trapezius fascia defines a Rockwood Type IV acromioclavicular (AC) joint injury. Type IV injuries are universally recommended for operative stabilization.

Question 309

Topic: Upper Extremity Trauma
A 30-year-old downhill mountain biker crashes onto his shoulder. Radiographs reveal a 150% superior displacement of the distal clavicle relative to the acromion, with a significantly widened coracoclavicular interval. What is the correct Rockwood classification for this injury?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type V

Explanation

A Rockwood Type V acromioclavicular separation involves disruption of the AC and CC ligaments along with the deltotrapezial fascia, leading to >100% to 300% superior displacement of the clavicle.

Question 310

Topic: Upper Extremity Trauma

A 28-year-old mountain biker falls directly onto his shoulder and sustains a type V acromioclavicular (AC) joint separation. Which of the following best describes the structural disruption seen in this specific injury pattern?

. AC ligaments only
. Coracoclavicular ligaments only
. AC ligaments, coracoclavicular ligaments, and deltotrapezial fascia
. AC ligaments and partial disruption of the coracoacromial ligament
. Sternoclavicular ligaments and AC ligaments

Correct Answer & Explanation

. AC ligaments, coracoclavicular ligaments, and deltotrapezial fascia

Explanation

A Rockwood Type V AC joint injury involves complete disruption of the AC ligaments, the coracoclavicular (CC) ligaments, and extensive tearing of the deltotrapezial fascia. This results in greater than 100% superior displacement of the clavicle.

Question 311

Topic: Upper Extremity Trauma

A 28-year-old elite weightlifter complains of superior shoulder pain aggravated by dips and the bench press. Radiographs reveal widening of the acromioclavicular joint and subchondral cystic changes of the distal clavicle. If conservative management fails, what is the treatment of choice?

. Coracoacromial ligament release
. Arthroscopic distal clavicle excision
. Acromioclavicular joint reconstruction
. Proximal biceps tenodesis
. Subacromial decompression

Correct Answer & Explanation

. Arthroscopic distal clavicle excision

Explanation

Distal clavicle osteolysis commonly affects weightlifters. When nonoperative treatments fail, arthroscopic distal clavicle excision (Mumford procedure) provides excellent pain relief.

Question 312

Topic: Upper Extremity Trauma

A 32-year-old bodybuilder feels a sudden, painful 'pop' in his anterior chest while performing a heavy bench press. Examination reveals an asymmetric anterior axillary fold and significant ecchymosis over the medial arm. Which of the following describes the most common anatomical site of this rupture?

. Intramuscular muscle belly of the pectoralis major
. Musculotendinous junction of the clavicular head
. Sternal head avulsion at the humeral insertion
. Clavicular head avulsion at the humeral insertion
. Origin of the sternal head at the sternum

Correct Answer & Explanation

. Sternal head avulsion at the humeral insertion

Explanation

Pectoralis major ruptures most commonly occur as an avulsion of the sternocostal head from its insertion on the proximal humerus, typically occurring during eccentric loading such as the downward phase of a bench press.

Question 313

Topic: Upper Extremity Trauma
A 35-year-old mountain biker falls directly onto the point of his shoulder. Radiographs show a 100% superior displacement of the clavicle relative to the acromion, with an increased coracoclavicular distance. What ligaments are ruptured?
. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Both acromioclavicular and coracoclavicular ligaments
. Coracoacromial ligament
. Sternoclavicular ligaments

Correct Answer & Explanation

. Both acromioclavicular and coracoclavicular ligaments

Explanation

A Type III acromioclavicular (AC) joint injury involves complete rupture of both the acromioclavicular and coracoclavicular (conoid and trapezoid) ligaments. This results in superior translation of the clavicle by 25% to 100%.

Question 314

Topic: Upper Extremity Trauma

A 28-year-old professional rugby player sustains an acute type V acromioclavicular (AC) joint separation. He is scheduled for an anatomic coracoclavicular (CC) ligament reconstruction. To accurately recreate the native anatomy, the surgeon must place the grafts based on the anatomic insertions. Which of the following statements regarding the CC ligaments is true?

. The conoid is lateral and anterior to the trapezoid
. The conoid is medial and posterior to the trapezoid
. The trapezoid inserts on the medial base of the coracoid
. The conoid provides primary restraint to horizontal translation
. The trapezoid is the stronger of the two ligaments

Correct Answer & Explanation

. The conoid is medial and posterior to the trapezoid

Explanation

The conoid ligament is located medial and posterior to the trapezoid ligament and inserts on the conoid tubercle. The conoid is the primary restraint to superior translation, while the trapezoid primarily resists horizontal/axial compression.

Question 315

Topic: Upper Extremity Trauma

Recent anatomic injection studies and quantitative MRI analyses have challenged traditional teaching regarding the vascular supply of the proximal humerus. According to current literature, which vessel provides the predominant blood supply to the articular segment of the humeral head?

. Ascending branch of the anterior humeral circumflex artery
. Posterior humeral circumflex artery
. Thoracoacromial artery
. Suprascapular artery
. Subscapular artery

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

Recent studies demonstrate that the posterior humeral circumflex artery provides the dominant blood supply to the humeral head, supplying up to 64% of the articular segment, refuting the traditional belief that the anterior humeral circumflex was primary.

Question 316

Topic: Upper Extremity Trauma
A 25-year-old cyclist falls directly onto his shoulder apex. Radiographs reveal 100% superior displacement of the distal clavicle relative to the acromion. The coracoclavicular distance is increased by 50% compared to the uninjured side. The deltotrapezial fascia remains intact. This represents what type of acromioclavicular (AC) joint injury?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type III

Explanation

A Type III AC joint separation involves complete rupture of both the AC and CC ligaments, resulting in 25-100% superior displacement of the clavicle. Type V involves >100% displacement with disruption of the overlying deltotrapezial fascia.

Question 317

Topic: Upper Extremity Trauma

A 28-year-old male construction worker falls directly onto his right shoulder. Radiographs demonstrate an acromioclavicular (AC) joint injury with the distal clavicle displaced superiorly by 150% of the normal AC joint distance. What is the most appropriate management?

. Sling immobilization and early range of motion
. Corticosteroid injection and physical therapy
. Arthroscopic distal clavicle excision
. Surgical AC and coracoclavicular (CC) ligament reconstruction
. Open reduction and rigid plate fixation of the clavicle to the acromion

Correct Answer & Explanation

. Surgical AC and coracoclavicular (CC) ligament reconstruction

Explanation

A Type V AC joint separation is characterized by greater than 100% superior displacement of the distal clavicle with detachment of the deltotrapezial fascia. Operative reconstruction of the CC ligaments is indicated to restore normal shoulder mechanics.

Question 318

Topic: Upper Extremity Trauma
A 25-year-old manual laborer falls directly onto his shoulder. Radiographs show a Rockwood type III acromioclavicular (AC) joint separation. What is the current consensus regarding the initial management of this injury?
. Immediate open reduction and hook plate fixation
. Arthroscopic coracoclavicular ligament reconstruction
. Nonoperative management with a sling and early rehabilitation
. Primary distal clavicle excision
. Figure-of-eight bracing for 6 weeks

Correct Answer & Explanation

. Nonoperative management with a sling and early rehabilitation

Explanation

Most Rockwood type III AC joint separations are managed nonoperatively initially, yielding good functional outcomes comparable to surgery but with fewer complications. Surgery may be considered later for chronic pain or specific high-demand needs.

Question 319

Topic: Upper Extremity Trauma
A 24-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate a complete dislocation of the acromioclavicular (AC) joint with the clavicle displaced superiorly by 200% compared to the contralateral side. The deltotrapezial fascia is completely stripped from the distal clavicle. Which Rockwood classification best describes this injury?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type V

Explanation

A Type V AC joint injury features superior displacement of the distal clavicle by 100% to 300% relative to the acromion, accompanied by severe stripping of the deltotrapezial fascia. This degree of displacement and fascial compromise generally warrants operative intervention.

Question 320

Topic: Upper Extremity Trauma

Recent quantitative anatomical studies investigating the arterial supply to the proximal humerus have redefined classic teachings. Based on these contemporary studies, which artery provides the majority of the blood supply to the humeral head?

. Ascending branch of the anterior humeral circumflex artery
. Posterior humeral circumflex artery
. Suprascapular artery
. Thoracoacromial artery
. Circumflex scapular artery

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

Recent studies (e.g., Hettrich et al.) demonstrated that the posterior humeral circumflex artery supplies approximately 64% of the blood to the humeral head. This contradicts older literature which emphasized the anterolateral ascending branch of the anterior humeral circumflex artery.

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