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Upper Extremity Trauma MCQs

Practice Set 18 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 341

Topic: Upper Extremity Trauma

A 30-year-old cyclist falls directly onto his right shoulder. Radiographs demonstrate 150% superior displacement of the distal clavicle relative to the acromion, and the coracoclavicular distance is more than doubled compared to the contralateral side. What is the most appropriate management for this Rockwood Type V acromioclavicular (AC) joint injury?

. Sling immobilization for 2 weeks followed by physical therapy
. Distal clavicle excision alone
. Coracoclavicular (CC) ligament reconstruction or operative fixation
. Acromionectomy
. Corticosteroid injection into the AC joint

Correct Answer & Explanation

. Coracoclavicular (CC) ligament reconstruction or operative fixation

Explanation

Rockwood Type V injuries involve severe superior displacement (>100%) due to disruption of both the AC and CC ligaments, along with stripping of the deltotrapezial fascia. Operative intervention (CC ligament reconstruction/fixation) is generally indicated for Type V injuries to restore mechanics and alleviate pain.

Question 342

Topic: Upper Extremity Trauma

In a severe acromioclavicular (AC) joint separation, the coracoclavicular (CC) ligaments are disrupted. Which of the following accurately describes the relative anatomy and function of the intact CC ligaments?

. The conoid is lateral to the trapezoid and resists horizontal translation
. The trapezoid is medial to the conoid and resists horizontal translation
. The conoid is medial to the trapezoid and resists superior translation
. The trapezoid is medial to the conoid and resists superior translation
. The conoid is lateral to the trapezoid and resists superior translation

Correct Answer & Explanation

. The conoid is medial to the trapezoid and resists superior translation

Explanation

The conoid ligament is situated medial to the trapezoid ligament and provides the primary restraint against superior translation of the clavicle. The trapezoid provides primary restraint to axial compression.

Question 343

Topic: Upper Extremity Trauma

A 25-year-old male weightlifter complains of superior shoulder pain localized to the AC joint during bench press. Radiographs reveal subchondral cysts and osteopenia of the distal clavicle. If 6 months of conservative management fails, what is the most appropriate surgical intervention?

. Weaver-Dunn procedure
. Coracoclavicular ligament reconstruction
. Distal clavicle excision
. Acromioclavicular joint fusion
. Subacromial decompression

Correct Answer & Explanation

. Distal clavicle excision

Explanation

Distal clavicle osteolysis commonly affects weightlifters. If nonoperative treatment (rest, NSAIDs, injections) fails, arthroscopic or open distal clavicle excision provides reliable symptomatic relief.

Question 344

Topic: Upper Extremity Trauma



During an anatomic coracoclavicular (CC) ligament reconstruction for a chronic Type V acromioclavicular joint separation, the surgeon drills tunnels in the clavicle to recreate the conoid and trapezoid ligaments. To accurately replicate native anatomy, the conoid tunnel should be placed approximately:

. 25 mm medial to the distal clavicle and anterior
. 25 mm medial to the distal clavicle and posterior
. 45 mm medial to the distal clavicle and posterior
. 45 mm medial to the distal clavicle and anterior
. 15 mm medial to the distal clavicle and central

Correct Answer & Explanation

. 45 mm medial to the distal clavicle and posterior

Explanation

The conoid ligament inserts approximately 45 mm medial to the distal end of the clavicle on its posterior aspect. The trapezoid ligament inserts more laterally (approximately 25 mm medial) and anteriorly.

Question 345

Topic: Upper Extremity Trauma

A 14-year-old elite Little League pitcher presents with progressive, insidious-onset throwing arm shoulder pain. Radiographs demonstrate widening and irregularity of the proximal humeral physis compared to the contralateral side. What is the standard of care for this condition?

. Surgical pinning of the epiphysis
. Arthroscopic SLAP repair
. Corticosteroid injection into the subacromial space
. Absolute cessation of throwing for 3 months followed by a progressive return
. Immediate physical therapy emphasizing aggressive internal rotation stretching

Correct Answer & Explanation

. Absolute cessation of throwing for 3 months followed by a progressive return

Explanation

Little League shoulder is an epiphysiolysis of the proximal humerus caused by repetitive torsional stress. It is managed nonoperatively with complete cessation of throwing (typically 3 months) until symptoms resolve and radiographs normalize.

Question 346

Topic: Upper Extremity Trauma
A 28-year-old cyclist falls directly onto his shoulder. Radiographs reveal 100% superior displacement of the clavicle relative to the acromion, with the clavicle displaced posteriorly into the trapezius fascia on the axillary lateral view. What is the Rockwood classification and optimal management for this injury?
. Type III; nonoperative management
. Type IV; surgical reconstruction
. Type V; nonoperative management
. Type VI; surgical reconstruction
. Type II; nonoperative management

Correct Answer & Explanation

. Type IV; surgical reconstruction

Explanation

A Rockwood Type IV AC joint separation involves posterior displacement of the distal clavicle into or through the trapezius fascia. Because it is highly symptomatic and functionally limiting, it generally requires surgical reduction and stabilization.

Question 347

Topic: Upper Extremity Trauma

A 25-year-old cyclist falls directly onto the point of his right shoulder. Clinical examination reveals profound tenting of the skin over the AC joint. Radiographs show the distal clavicle is displaced superiorly by 150% of the acromion width. The coracoclavicular distance is 28 mm (normal 11-13 mm). According to the Rockwood classification, what is the best treatment option?

. Sling immobilization for 2 weeks followed by range of motion
. Figure-of-eight brace for 6 weeks
. Corticosteroid injection into the AC joint
. Distal clavicle excision (Mumford procedure)
. Operative reconstruction of the coracoclavicular ligaments

Correct Answer & Explanation

. Operative reconstruction of the coracoclavicular ligaments

Explanation

A Rockwood Type V acromioclavicular joint injury involves >100% superior displacement of the clavicle with stripping of the deltopectoral fascia. Due to the severe instability, it typically requires operative intervention with coracoclavicular (CC) ligament reconstruction.

Question 348

Topic: Upper Extremity Trauma

A 25-year-old cyclist falls directly onto the point of his shoulder. Radiographs show a type V acromioclavicular (AC) joint dislocation with 150% superior displacement of the clavicle relative to the acromion. What is the most appropriate management?

. Sling for 1-2 weeks followed by early range of motion
. Corticosteroid injection into the AC joint
. Distal clavicle excision
. Operative AC joint reconstruction
. Figure-of-eight bracing

Correct Answer & Explanation

. Operative AC joint reconstruction

Explanation

Type V AC joint injuries involve severe superior displacement of the clavicle due to disruption of the AC and coracoclavicular ligaments and the deltotrapezial fascia. They are typically treated with operative reconstruction.

Question 349

Topic: Upper Extremity Trauma

During an anatomic reconstruction of a high-grade acromioclavicular joint separation, the surgeon targets the coracoclavicular ligaments. Which of the following statements regarding the native anatomy is correct?

. The conoid ligament inserts anterolateral to the trapezoid ligament
. The trapezoid ligament inserts posteromedial to the conoid ligament
. The conoid ligament inserts posteromedial to the trapezoid ligament
. Both ligaments insert at the exact same medial-lateral location on the clavicle
. The trapezoid is a cone-shaped ligament providing primary resistance to superior displacement

Correct Answer & Explanation

. The conoid ligament inserts posteromedial to the trapezoid ligament

Explanation

The conoid ligament is cone-shaped and inserts posteromedial to the trapezoid on the conoid tubercle. The trapezoid inserts anterolaterally and acts as the primary restraint to axial compression.

Question 350

Topic: Upper Extremity Trauma

A 35-year-old sustains an Essex-Lopresti injury, characterized by a radial head fracture, distal radioulnar joint dislocation, and rupture of the interosseous membrane (IOM). In the anatomical position, what is the correct orientation of the fibers of the central band of the forearm IOM?

. Proximal-radial to distal-ulnar
. Distal-ulnar to proximal-radial
. Transversely from radius to ulna
. Distal-radial to proximal-ulnar
. Obliquely from the radial styloid to the coronoid process

Correct Answer & Explanation

. Proximal-radial to distal-ulnar

Explanation

The central band of the interosseous membrane is the primary stabilizer against longitudinal migration of the radius. Its fibers run obliquely from proximal on the radius to distal on the ulna.

Question 351

Topic: Upper Extremity Trauma

A collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction. The anterior bundle of the UCL is the primary restraint to valgus stress. Where is the precise anatomical footprint of this bundle on the ulna?

. Olecranon tip
. Coronoid process at the sublime tubercle
. Radial notch
. Supinator crest
. Ulnar styloid

Correct Answer & Explanation

. Coronoid process at the sublime tubercle

Explanation

The anterior bundle of the MUCL originates on the anteroinferior surface of the medial epicondyle and inserts on the sublime tubercle at the medial margin of the coronoid process.

Question 352

Topic: Upper Extremity Trauma

During surgical reconstruction of the coracoclavicular (CC) ligaments for a high-grade acromioclavicular joint separation, anatomic placement of the drill holes is critical. Relative to the distal clavicle tip, what is the normal anatomic location of the CC ligament insertions?

. Conoid is lateral (approx 30mm), Trapezoid is medial (approx 45mm)
. Trapezoid is lateral (approx 25mm), Conoid is medial (approx 45mm)
. Conoid and Trapezoid insert at the exact same location (approx 30mm)
. Trapezoid is anterior, Conoid is posterior at 35mm
. Conoid is lateral (approx 45mm), Trapezoid is medial (approx 25mm)

Correct Answer & Explanation

. Trapezoid is lateral (approx 25mm), Conoid is medial (approx 45mm)

Explanation

The trapezoid ligament inserts more laterally on the clavicle, approximately 25 mm from the distal clavicle tip. The conoid ligament inserts more medially, approximately 45 mm from the distal tip.

Question 353

Topic: Upper Extremity Trauma

A 60-year-old male with chronic tophaceous gout presents with a large, draining mass over his olecranon.

Which of the following is an absolute indication for surgical excision of a gouty tophus?

. An asymptomatic tophus measuring less than 1 cm
. A tophus causing local skin necrosis and recurrent secondary infection
. The initial presentation of any tophus prior to medical therapy
. Persistently high serum uric acid levels > 10 mg/dL
. Concomitant radiographic evidence of chondrocalcinosis

Correct Answer & Explanation

. A tophus causing local skin necrosis and recurrent secondary infection

Explanation

Medical therapy is the first-line treatment for gouty tophi. Surgical excision is indicated when the tophus causes severe mechanical block, neurovascular compression, skin ulceration, or recurrent secondary infection.

Question 354

Topic: Upper Extremity Trauma

A 55-year-old man undergoes excision of a large, chalky white mass overlying his olecranon. The surgeon suspects a gouty tophus. To accurately preserve the diagnostic crystals for histopathological examination, the specimen should be fixed in which of the following solutions?

. 10% Neutral buffered formalin
. Glutaraldehyde
. Absolute alcohol
. Bouin's solution
. Normal saline

Correct Answer & Explanation

. Absolute alcohol

Explanation

Monosodium urate crystals are water-soluble and will dissolve if placed in standard aqueous fixatives like 10% neutral buffered formalin. The specimen must be placed in absolute alcohol (ethanol) to preserve the crystals for visualization under polarized light microscopy.

Question 355

Topic: Upper Extremity Trauma
A 28-year-old male presents after a high-speed motorcycle collision with severe shoulder pain. Radiographs demonstrate an acromioclavicular (AC) joint separation with the clavicle displaced superiorly by 200% relative to the acromion. Based on the Rockwood classification, this is a Type V injury. Which of the following best describes the anatomical disruption in this specific injury type?
. Rupture of the AC ligaments with intact coracoclavicular (CC) ligaments.
. Rupture of the AC ligaments and CC ligaments, with an intact deltotrapezial fascia.
. Rupture of the AC ligaments and CC ligaments, with stripping of the deltotrapezial fascia from the distal clavicle.
. Inferior dislocation of the clavicle under the coracoid process.
. Posterior dislocation of the clavicle into the trapezius muscle.

Correct Answer & Explanation

. Rupture of the AC ligaments and CC ligaments, with stripping of the deltotrapezial fascia from the distal clavicle.

Explanation

The Rockwood classification categorizes AC joint injuries based on the degree and direction of displacement and the involved anatomical structures. A Type III injury involves rupture of both the AC and CC (conoid and trapezoid) ligaments, resulting in 25-100% superior displacement, but the deltotrapezial fascia remains largely intact. A Type V injury is a more severe variant characterized by >100% (often 100-300%) superior displacement of the clavicle. This extreme displacement is only possible because, in addition to the AC and CC ligament ruptures, there is extensive stripping and disruption of the deltotrapezial fascia from the distal clavicle. Type IV is posterior displacement into the trapezius. Type VI is inferior displacement under the coracoid.

Question 356

Topic: Upper Extremity Trauma

A 28-year-old male sustains a Type V acromioclavicular (AC) joint separation during a rugby match. The surgeon plans an open reduction and anatomical reconstruction of the coracoclavicular (CC) ligaments using a tendon allograft. To accurately recreate the native biomechanics, the surgeon must understand the anatomical footprints of the CC ligaments. Which of the following best describes the anatomical footprint of the conoid ligament relative to the trapezoid ligament on the undersurface of the clavicle?

. Medial and posterior.
. Medial and anterior.
. Lateral and posterior.
. Lateral and anterior.
. Directly inferior and central.

Correct Answer & Explanation

. Medial and posterior.

Explanation

Correct Answer: Medial and posterior.The coracoclavicular (CC) ligaments are the primary restraints to superior and posterior translation of the clavicle relative to the acromion. They consist of two distinct bands: the conoid and the trapezoid. The conoid ligament is the more medial and posterior of the two. It originates from the posteromedial base of the coracoid process and inserts onto the conoid tubercle on the posteromedial undersurface of the distal clavicle. The trapezoid ligament is located lateral and anterior to the conoid. It originates from the superior aspect of the coracoid process and inserts onto the trapezoid line on the anterolateral undersurface of the distal clavicle. Understanding this spatial relationship is critical for anatomical CC ligament reconstruction techniques.

Question 357

Topic: Upper Extremity Trauma

A 21-year-old collegiate baseball pitcher presents with medial elbow pain and diminished throwing velocity. MRI arthrogram demonstrates an avulsion of the anterior bundle of the medial ulnar collateral ligament (MUCL). At which anatomic landmark does this critical stabilizing structure insert?

. Coronoid process of the ulna
. Medial epicondyle of the humerus
. Sublime tubercle of the proximal ulna
. Olecranon process
. Radial notch of the ulna

Correct Answer & Explanation

. Sublime tubercle of the proximal ulna

Explanation

The anterior bundle of the MUCL is the primary restraint to valgus stress at the elbow during throwing. It originates on the anterior undersurface of the medial epicondyle and inserts on the sublime tubercle of the anteromedial coronoid facet.

Question 358

Topic: Upper Extremity Trauma

During an anatomic coracoclavicular (CC) ligament reconstruction for a chronic Type V acromioclavicular joint separation, the surgeon aims to accurately recreate the insertions of the conoid and trapezoid ligaments on the clavicle. Which of the following best describes the anatomic footprints of these ligaments?

. The conoid inserts anterolaterally and the trapezoid inserts posteromedially
. The conoid inserts posteromedially and the trapezoid inserts anterolaterally
. Both ligaments insert on the anterior border of the distal clavicle
. The conoid inserts on the superior clavicle and the trapezoid inserts on the inferior clavicle
. The conoid and trapezoid share a single conjoined insertion 10 mm medial to the AC joint

Correct Answer & Explanation

. The conoid inserts posteromedially and the trapezoid inserts anterolaterally

Explanation

In the native anatomy of the coracoclavicular ligaments, the conoid ligament footprint is located posteromedially on the conoid tubercle, approximately 45 mm from the distal clavicle. The trapezoid ligament footprint is located more anterolaterally, approximately 25 mm from the distal clavicle.

Question 359

Topic: Upper Extremity Trauma

A patient presents with a symptomatic proximal humerus locking plate, experiencing shoulder impingement due to hardware prominence. Which factor is most commonly implicated in this complication?

. Excessive screw length causing penetration of the articular surface.
. Over-tightening of the locking screws, leading to plate deformation.
. Improper plate contouring, especially at the superior aspect of the greater tuberosity.
. Inadequate number of screws used in the humeral head, leading to construct failure.
. Placement of the plate too far anterior on the humeral shaft.

Correct Answer & Explanation

. Improper plate contouring, especially at the superior aspect of the greater tuberosity.

Explanation

Hardware prominence, particularly at the superior aspect of the greater tuberosity, is a common complication with proximal humerus locking plates. This often occurs if the plate is positioned too high or if its contour does not precisely match the complex anatomy of the proximal humerus, leading to irritation or impingement of the deltoid or rotator cuff tendons. While articular screw penetration is also a serious complication, plate prominence causing impingement is frequently observed due to the plate's position relative to the surrounding soft tissues and acromion. Over-tightening of locking screws is not typically an issue due to the fixed-angle nature, and screw number relates to stability, not impingement.

Question 360

Topic: Upper Extremity Trauma

A surgeon is considering the use of a low-profile plate for a subcutaneous bone like the clavicle or distal ulna. What is the primary advantage of a low-profile plate in these locations?

. Increased biomechanical strength due to reduced material volume.
. Facilitates easier removal due to a smaller footprint.
. Minimizes soft tissue irritation and hardware prominence.
. Allows for better visualization during fluoroscopy.
. Promotes faster bone healing by increasing local vascularity.

Correct Answer & Explanation

. Minimizes soft tissue irritation and hardware prominence.

Explanation

In subcutaneous locations (e.g., clavicle, olecranon, distal ulna, distal tibia), hardware prominence is a very common cause of patient discomfort, pain, and irritation, often necessitating plate removal. Low-profile plates are specifically designed to have a thinner and flatter contour to minimize this issue, thus improving patient comfort and potentially reducing the need for subsequent hardware removal. They do not offer increased strength (often less so), faster healing, or better fluoroscopy (can be harder to see if very thin).

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