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Upper Extremity Trauma MCQs

Practice Set 4 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 61

Topic: Upper Extremity Trauma

A patient is 3 months post-operative from a terrible triad repair. They complain of persistent elbow stiffness and a palpable, painful mass around the elbow. Radiographs confirm the presence of mature heterotopic ossification (HO) that is functionally limiting. Which of the following is the most appropriate management strategy for this patient's heterotopic ossification, and what prophylactic measure could have been considered immediately post-operatively?

. Immediate surgical excision of the HO and aggressive passive stretching.
. Non-operative management with NSAIDs and continued physical therapy, with surgical excision considered after maturation if functionally limiting; prophylaxis with Indomethacin or radiation therapy.
. Radiation therapy as a primary treatment for mature HO.
. Manipulation under anesthesia (MUA) to break up the HO.
. Total elbow arthroplasty due to severe stiffness and HO.

Correct Answer & Explanation

. Non-operative management with NSAIDs and continued physical therapy, with surgical excision considered after maturation if functionally limiting; prophylaxis with Indomethacin or radiation therapy.

Explanation

Correct Answer: BThe case, under 'Complications & Management' for Heterotopic Ossification (HO), states: 'Prophylaxis: Indomethacin (for 3-6 weeks post-op) or radiation therapy (single dose within 24-72 hours). Salvage Strategies: Surgical excision after maturation (typically 6-12 months post-onset) if functionally limiting.' Since the HO is mature and functionally limiting, surgical excision is a consideration, but it's important to ensure full maturation and to have considered prophylaxis.Option A (immediate surgical excision) is incorrect because excision should ideally occur after maturation (typically 6-12 months post-onset) to minimize recurrence. Option C (radiation therapy as primary treatment for mature HO) is incorrect; radiation is primarily a prophylactic measure, not a treatment for mature, functionally limiting HO. Option D (MUA) is for stiffness, but not specifically for breaking up mature HO. Option E (total elbow arthroplasty) is a salvage procedure for end-stage arthritis, not the primary treatment for HO.

Question 62

Topic: Upper Extremity Trauma
A 28-year-old male falls onto his adducted shoulder, sustaining an acromioclavicular (AC) joint injury. Radiographs show superior displacement of the clavicle by 150% of the acromion width, with severe disruption of the deltotrapezial fascia. Which Rockwood classification type is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type V

Explanation

Rockwood Type V AC injuries are characterized by 100% to 300% superior displacement of the clavicle relative to the acromion. This severe displacement indicates extensive disruption of the CC ligaments and the deltotrapezial fascia.

Question 63

Topic: Upper Extremity Trauma

When performing an open distal clavicle excision (Mumford procedure), the surgeon must be careful not to resect too much bone to prevent iatrogenic acromioclavicular instability. What is the maximum amount of distal clavicle that should safely be resected?

. 2-4 mm
. 8-10 mm
. 15-20 mm
. 25-30 mm
. 35-40 mm

Correct Answer & Explanation

. 8-10 mm

Explanation

Distal clavicle resection should ideally be limited to 8-10 mm. Resecting more than 1 cm compromises the insertion of the coracoclavicular (CC) ligaments, which can lead to iatrogenic horizontal and superior instability.

Question 64

Topic: Upper Extremity Trauma

What is the primary stabilizing function of the costoclavicular (rhomboid) ligament in the shoulder girdle?

. Restricts anterior translation of the medial clavicle
. Restricts superior translation of the medial clavicle
. Restricts posterior translation of the medial clavicle
. Restricts inferior translation of the lateral clavicle
. Provides dynamic stability to the acromioclavicular joint

Correct Answer & Explanation

. Restricts superior translation of the medial clavicle

Explanation

The costoclavicular ligament is a strong extra-articular ligament that attaches the first rib to the inferior clavicle. It acts as the primary restraint against superior displacement of the medial clavicle, counteracting the upward pull of the sternocleidomastoid muscle.

Question 65

Topic: Upper Extremity Trauma
A 30-year-old cyclist falls onto the point of his shoulder and is diagnosed with a Rockwood Type III acromioclavicular (AC) joint separation. Which of the following accurately describes the status of the supporting ligaments in this injury pattern?
. AC ligaments sprained; CC ligaments intact
. AC ligaments torn; CC ligaments sprained
. AC ligaments torn; CC ligaments torn
. AC ligaments intact; CC ligaments torn
. AC ligaments torn; CC ligaments torn; deltotrapezial fascia torn

Correct Answer & Explanation

. AC ligaments torn; CC ligaments torn

Explanation

In a Rockwood Type III AC separation, both the acromioclavicular (AC) and coracoclavicular (CC) ligaments are completely disrupted, resulting in 25% to 100% superior displacement of the distal clavicle. The deltotrapezial fascia remains intact.

Question 66

Topic: Upper Extremity Trauma

When evaluating a standard anteroposterior chest radiograph for a suspected scapulothoracic dissociation, which finding is most diagnostic of this condition?

. Widening of the acromioclavicular joint space greater than 5 mm
. A scapular index greater than 1.5
. Overlapping of the sternoclavicular joints
. Significantly increased distance from the spinous processes to the medial border of the scapula
. A decreased glenopolar angle

Correct Answer & Explanation

. Significantly increased distance from the spinous processes to the medial border of the scapula

Explanation

Scapulothoracic dissociation is defined by massive lateral displacement of the scapula. Radiographically, this is measured as a significantly increased distance from the thoracic spinous processes to the medial border of the scapula compared to the contralateral side.

Question 67

Topic: Upper Extremity Trauma
The concept of a 'floating shoulder' involves a double disruption of the Superior Shoulder Suspensory Complex (SSSC). Which of the following anatomic structures correctly defines the osseoligamentous ring of the SSSC?
. Glenoid, coracoid process, acromion, distal clavicle, acromioclavicular joint, and coracoclavicular ligaments
. Proximal humerus, glenoid, labrum, and inferior glenohumeral ligament
. Clavicle, sternum, sternoclavicular joint, and first rib
. Scapular body, spine, acromion, and trapezius insertion
. Coracoid process, conjoint tendon, pectoralis minor, and short head of biceps

Correct Answer & Explanation

. Glenoid, coracoid process, acromion, distal clavicle, acromioclavicular joint, and coracoclavicular ligaments

Explanation

The SSSC is an osseoligamentous ring consisting of the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion. A double disruption of this ring (e.g., ipsilateral clavicle and scapular neck fractures) creates a 'floating shoulder'.

Question 68

Topic: Upper Extremity Trauma
A 28-year-old female accountant sustains a Type III acromioclavicular (AC) joint separation (100% displacement of the distal clavicle) after falling on her shoulder. What is the most appropriate initial management for this patient?
. Acute Hook plate fixation
. Acute coracoclavicular ligament reconstruction
. Nonoperative management with a brief period of sling immobilization and early range of motion
. Weaver-Dunn procedure
. Primary AC joint arthrodesis

Correct Answer & Explanation

. Nonoperative management with a brief period of sling immobilization and early range of motion

Explanation

Type III AC separations in most patients, especially non-laborers, are initially treated nonoperatively with a sling for comfort and early range of motion. Surgical reconstruction is typically reserved for those who fail conservative management or specific high-demand overhead laborers/athletes.

Question 69

Topic: Upper Extremity Trauma

A 45-year-old mountain biker falls directly onto his shoulder and sustains an acromioclavicular (AC) joint injury. Radiographs show 150% superior displacement of the clavicle relative to the acromion. Which of the following represents the optimal management?

. Broad arm sling for 6 weeks
. Figure-of-eight brace
. Surgical reconstruction of the coracoclavicular ligaments
. Mumford procedure (distal clavicle excision)
. Primary arthrodesis of the AC joint

Correct Answer & Explanation

. Surgical reconstruction of the coracoclavicular ligaments

Explanation

A Type V AC joint injury involves greater than 100% superior displacement of the distal clavicle and disruption of the deltotrapezial fascia. Operative reconstruction of the coracoclavicular (CC) ligaments is indicated.

Question 70

Topic: Upper Extremity Trauma

A 25-year-old cyclist falls directly onto his shoulder and sustains a Type V acromioclavicular (AC) joint separation. During surgical reconstruction, the surgeon aims to reconstruct the primary restraint to superior translation of the distal clavicle. Which ligament serves this function?

. Acromioclavicular ligament
. Trapezoid ligament
. Conoid ligament
. Coracoacromial ligament
. Transverse humeral ligament

Correct Answer & Explanation

. Conoid ligament

Explanation

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

Question 71

Topic: Upper Extremity Trauma

A surgeon is performing a coracoclavicular ligament reconstruction for a chronic Type V acromioclavicular (AC) joint separation. To anatomically restore the ligaments, the surgeon must understand their native footprints. Which of the following accurately describes the anatomy of the coracoclavicular ligaments?

. The conoid ligament inserts anterolateral to the trapezoid ligament on the clavicle
. The conoid ligament inserts posteromedial to the trapezoid ligament on the clavicle
. Both ligaments insert on the superior aspect of the coracoid process identically
. The trapezoid ligament is the primary restraint to superior translation
. The conoid ligament originates from the base of the coracoid and inserts laterally on the acromion

Correct Answer & Explanation

. The conoid ligament inserts posteromedial to the trapezoid ligament on the clavicle

Explanation

The coracoclavicular complex consists of the conoid and trapezoid ligaments. The conoid ligament inserts posteromedial to the trapezoid on the clavicle and acts as the primary restraint to superior translation.

Question 72

Topic: Upper Extremity Trauma
A 24-year-old manual laborer sustains a Grade III acromioclavicular (AC) joint separation. Biomechanical studies indicate that the primary restraint to superior translation of the distal clavicle is provided by which of the following structures?
. Superior AC ligament
. Inferior AC ligament
. Trapezoid ligament
. Conoid ligament
. Coracoacromial ligament

Correct Answer & Explanation

. Conoid ligament

Explanation

The conoid ligament is the primary restraint to superior translation of the distal clavicle. The trapezoid ligament provides the primary restraint to axial compression, while the AC ligaments provide horizontal stability.

Question 73

Topic: Upper Extremity Trauma

A 22-year-old collegiate pitcher presents with posteromedial elbow pain and lack of full extension. Radiographs show loose bodies in the posteromedial compartment and an olecranon osteophyte. What associated pathology must be carefully evaluated before proceeding with arthroscopic loose body removal and olecranon debridement?

. Ulnar collateral ligament (UCL) insufficiency
. Lateral ulnar collateral ligament (LUCL) tear
. Radial nerve entrapment
. Posterior interosseous nerve syndrome
. Capitellar osteonecrosis

Correct Answer & Explanation

. Ulnar collateral ligament (UCL) insufficiency

Explanation

Valgus extension overload causes posteromedial osteophytes and loose bodies due to repetitive impingement. Aggressive olecranon debridement without addressing concurrent UCL insufficiency can unmask and exacerbate severe medial instability.

Question 74

Topic: Upper Extremity Trauma

In a 55-year-old heavy laborer with primary osteoarthritis of the elbow, loose bodies and osteophytes are most commonly symptomatic and surgically addressed in which of the following elbow compartments?

. Anterior (coronoid/radial fossa) and posterior (olecranon fossa)
. Radiocapitellar joint
. Medial gutter
. Proximal radioulnar joint
. Posterolateral gutter

Correct Answer & Explanation

. Anterior (coronoid/radial fossa) and posterior (olecranon fossa)

Explanation

Primary elbow osteoarthritis in laborers typically presents with terminal extension and flexion loss. This is driven by osteophyte impingement and loose body formation in the olecranon fossa (posteriorly) and coronoid fossa (anteriorly), respectively.

Question 75

Topic: Upper Extremity Trauma
A 45-year-old cyclist falls directly onto his shoulder. Clinical examination reveals a prominent clavicle, and radiographs show an acromioclavicular (AC) joint dislocation with 150% superior displacement of the clavicle relative to the acromion. Which of the following describes the injured structures in a Type III AC separation?
. Acromioclavicular ligaments torn, coracoclavicular ligaments intact
. Acromioclavicular ligaments intact, coracoclavicular ligaments torn
. Both acromioclavicular and coracoclavicular ligaments torn, with deltotrapezial fascia stripping
. Both acromioclavicular and coracoclavicular ligaments torn, deltotrapezial fascia intact
. Clavicle displaced inferiorly under the coracoid process

Correct Answer & Explanation

. Both acromioclavicular and coracoclavicular ligaments torn, deltotrapezial fascia intact

Explanation

In a Type III AC separation, both the AC and CC ligaments are completely torn, but the deltotrapezial fascia remains intact, allowing for 25-100% superior displacement. A Type V separation involves tearing of the AC, CC, and the deltotrapezial fascia, resulting in >100% superior displacement of the clavicle.

Question 76

Topic: Upper Extremity Trauma

A 30-year-old male weightlifter feels a pop in his anterior chest while performing a bench press. Examination reveals an asymmetric axillary fold and weakness with resisted adduction and internal rotation. Where does the pectoralis major most commonly tear in this mechanism?

. At the musculotendinous junction
. At the tendinous insertion on the humerus
. At the sternal origin
. At the clavicular origin
. Mid-substance of the muscle belly

Correct Answer & Explanation

. At the tendinous insertion on the humerus

Explanation

Pectoralis major ruptures most commonly occur in weightlifters (specifically during bench press) and almost exclusively happen at the tendinous insertion onto the proximal humerus. The sternal head, which inserts deep and superiorly, is typically injured first as it stretches maximally during the eccentric phase of the lift.

Question 77

Topic: Upper Extremity Trauma

A 33-year-old professional overhead laborer falls directly onto his acromion, sustaining an acromioclavicular (AC) joint injury. Radiographs show superior displacement of the clavicle by 150% compared to the acromion, with an increased coracoclavicular distance. What is the most appropriate management for this Type V AC joint injury?

. Sling immobilization for 6 weeks followed by progressive therapy
. Surgical reconstruction of the coracoclavicular (CC) ligaments
. Distal clavicle excision alone
. Primary repair of the AC capsule without CC ligament stabilization
. Figure-of-eight bracing for 12 weeks

Correct Answer & Explanation

. Surgical reconstruction of the coracoclavicular (CC) ligaments

Explanation

Type V AC joint injuries involve severe superior displacement (>100%) due to disruption of both the AC and CC ligaments, along with deltotrapezial fascial stripping. Surgical reconstruction is generally indicated, especially in laborers and active patients.

Question 78

Topic: Upper Extremity Trauma
A 28-year-old male sustains a Grade III acromioclavicular (AC) joint separation. If non-operative management fails and reconstruction is required, the surgeon must focus on reconstructing the primary stabilizers to superior translation of the distal clavicle. Which structures are these?
. Acromioclavicular ligaments
. Coracoclavicular ligaments
. Coracoacromial ligament
. Superior transverse scapular ligament
. Glenohumeral joint capsule

Correct Answer & Explanation

. Coracoclavicular ligaments

Explanation

The coracoclavicular (CC) ligaments, consisting of the conoid and trapezoid, act as the primary stabilizers against superior translation of the distal clavicle. The AC ligaments primarily restrict anterior-posterior translation.

Question 79

Topic: Upper Extremity Trauma
A 24-year-old male cyclist falls directly onto the point of his shoulder. Radiographs show a 100% superior displacement of the distal clavicle relative to the acromion, with a coracoclavicular distance increased by 50% compared to the contralateral side. The deltotrapezial fascia is intact on physical exam. What is the most appropriate initial management?
. Immediate open reduction and coracoclavicular ligament reconstruction
. Hook plate fixation
. Sling immobilization, ice, and early range of motion as tolerated
. Arthroscopic Mumford procedure
. Figure-of-eight bracing for 6 weeks

Correct Answer & Explanation

. Sling immobilization, ice, and early range of motion as tolerated

Explanation

This represents a Type III acromioclavicular (AC) joint separation. Nonoperative management with a sling and early ROM yields excellent functional outcomes and is the standard initial treatment for uncomplicated Type III injuries.

Question 80

Topic: Upper Extremity Trauma

A 55-year-old patient presents with an elbow injury following a fall onto an outstretched hand. Radiographs reveal an elbow dislocation, a comminuted radial head fracture, and a coronoid fracture. Based on the provided case, which of the following soft tissue structures is most consistently injured in this "terrible triad" pattern?

. A) Medial collateral ligament (MCL)
. B) Triceps tendon
. C) Lateral collateral ligament (LCL)
. D) Biceps tendon
. E) Posterior capsule

Correct Answer & Explanation

. C) Lateral collateral ligament (LCL)

Explanation

Correct Answer: CThe case explicitly states that with a terrible triad injury, soft tissue stabilizers of the elbow, such as the lateral collateral ligament, the anterior capsule of the elbow joint in association with the coronoid fracture, and possibly the medial collateral ligament, are expected to be injured. The LCL is a critical stabilizer against posterolateral rotatory instability, which is the common mechanism for terrible triad injuries. While the MCL can be involved, it is not as consistently injured as the LCL and anterior capsule in the initial injury pattern. The triceps tendon, biceps tendon, and posterior capsule are not typically considered primary structures injured in the terrible triad pattern.

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