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Upper Extremity Trauma MCQs

Practice Set 6 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 101

Topic: Upper Extremity Trauma

In evaluating the stability of the acromioclavicular (AC) joint, which of the following structures serves as the primary restraint to anterior-posterior translation of the distal clavicle?

. Acromioclavicular capsule and ligaments
. Coracoacromial ligament
. Conoid ligament
. Trapezoid ligament
. Deltotrapezial fascia

Correct Answer & Explanation

. Acromioclavicular capsule and ligaments

Explanation

The AC joint capsule and its intrinsic ligaments are the primary restraints to anterior-posterior translation. The coracoclavicular ligaments (conoid and trapezoid) primarily resist superior-inferior displacement.

Question 102

Topic: Upper Extremity Trauma

A 28-year-old cyclist falls directly onto his shoulder. Clinical examination reveals a prominent distal clavicle. To accurately diagnose a Rockwood type IV acromioclavicular joint injury, which radiographic view is most critical?

. Anteroposterior (AP) view
. Zanca view
. Axillary lateral view
. Stryker notch view
. West Point view

Correct Answer & Explanation

. Axillary lateral view

Explanation

A Rockwood type IV injury involves posterior displacement of the distal clavicle into or through the trapezius muscle. The axillary lateral view is essential to visualize this posterior horizontal displacement.

Question 103

Topic: Upper Extremity Trauma

A 34-year-old competitive weightlifter complains of a 6-month history of localized right acromioclavicular joint pain, worsened by bench presses. Radiographs reveal widening of the AC joint and subchondral cysts in the distal clavicle. If conservative management fails, what is the most appropriate surgical intervention?

. Coracoclavicular ligament reconstruction
. Weaver-Dunn procedure
. Distal clavicle excision
. Acromioclavicular joint arthrodesis
. Pectoralis major transfer

Correct Answer & Explanation

. Distal clavicle excision

Explanation

Distal clavicle osteolysis (weightlifter's shoulder) presents with localized pain and microcystic changes at the distal clavicle. If rest and activity modifications fail, distal clavicle excision (Mumford procedure) provides excellent pain relief.

Question 104

Topic: Upper Extremity Trauma

The coracoclavicular (CC) ligaments are the primary restraints to superior translation of the distal clavicle. Regarding their anatomy and biomechanics, which of the following statements is true?

. The trapezoid ligament is positioned posteromedial to the conoid ligament.
. The conoid ligament is the primary restraint to anterior-posterior translation.
. The conoid ligament attaches approximately 4.5 cm medial to the distal end of the clavicle.
. The trapezoid ligament provides the primary restraint to superior translation.
. The acromioclavicular (AC) ligaments provide the primary restraint to inferior translation.

Correct Answer & Explanation

. The conoid ligament attaches approximately 4.5 cm medial to the distal end of the clavicle.

Explanation

The conoid ligament attaches roughly 4.5 cm medial to the distal clavicle and is positioned posteromedial to the trapezoid ligament. The conoid is the primary restraint to superior translation, while the AC ligaments primarily resist AP translation.

Question 105

Topic: Upper Extremity Trauma

A 32-year-old cyclist falls directly on his right shoulder and is diagnosed with a Rockwood Type IV acromioclavicular (AC) joint injury. Which of the following best describes the anatomical displacement characteristic of this injury?

. Superior displacement of the clavicle with 100-300% increased coracoclavicular distance.
. Inferior displacement of the clavicle beneath the coracoid process.
. Posterior displacement of the clavicle into or through the trapezius fascia.
. Superior displacement of the clavicle by 25-100% with intact deltotrapezial fascia.
. Sprain of the AC ligaments with intact coracoclavicular ligaments.

Correct Answer & Explanation

. Posterior displacement of the clavicle into or through the trapezius fascia.

Explanation

Rockwood Type IV injuries involve posterior displacement of the distal clavicle into or through the trapezius muscle and fascia. An axillary lateral radiograph is essential to diagnose this posterior displacement.

Question 106

Topic: Upper Extremity Trauma

During surgical reconstruction of a chronic acromioclavicular joint dislocation, a surgeon plans to drill tunnels in the clavicle to recreate the coracoclavicular (CC) ligaments. To accurately reproduce the native anatomy, the medial tunnel (for the conoid) and lateral tunnel (for the trapezoid) should be placed at what respective distances from the distal end of the clavicle?

. 2.0 cm and 1.0 cm
. 3.0 cm and 1.5 cm
. 4.5 cm and 3.0 cm
. 5.5 cm and 4.0 cm
. 6.0 cm and 4.5 cm

Correct Answer & Explanation

. 4.5 cm and 3.0 cm

Explanation

The native footprint of the trapezoid ligament is centered approximately 3.0 cm medial to the distal clavicle. The conoid ligament footprint is centered approximately 4.5 cm medial to the distal clavicle.

Question 107

Topic: Upper Extremity Trauma

A patient undergoes a Weaver-Dunn procedure for a chronic Type V acromioclavicular (AC) joint separation. This procedure involves detaching a ligament from its native insertion and transferring it to the distal clavicle. Which ligament is transferred, and how does its biomechanical strength compare to the intact native coracoclavicular (CC) ligaments?

. Coracoacromial (CA) ligament; it is stronger than the native CC ligaments.
. Coracoacromial (CA) ligament; it is approximately 20-30% as strong as the native CC ligaments.
. Conjoined tendon; it is stronger than the native CC ligaments.
. Acromioclavicular (AC) ligament; it is approximately 50% as strong as the native CC ligaments.
. Coracohumeral ligament; it is biomechanically equivalent to the native CC ligaments.

Correct Answer & Explanation

. Coracoacromial (CA) ligament; it is approximately 20-30% as strong as the native CC ligaments.

Explanation

The Weaver-Dunn procedure transfers the CA ligament to the distal clavicle. The transferred CA ligament possesses only about 20% to 30% of the ultimate load to failure compared to the native intact CC ligaments.

Question 108

Topic: Upper Extremity Trauma

When performing elbow arthroscopy, it is often necessary to evaluate the posterior compartment. When entering the posterior compartment of the elbow, what are the two safest and most commonly used portals? Review Topic

. The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps
. The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps
. The posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps and the posterior lateral portal created 3 cm from the tip of the olecranon and lateral to the triceps
. The posterior medial portal created 3 cm from the tip of the olecranon and the lateral portal made through the anconeus
. The posterior portal created at the tip of olecranon and the posterior medial portal just medial to the triceps

Correct Answer & Explanation

. The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps

Explanation

The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps are the "workhorse" portals of the posterior compartment and although relatively safe, risks exist. The radial nerve proximity averages 4.8 mm (3 to 8 mm) from the posterolateral portal. The central posterior portal is close to 20 mm from the ulnar nerve.

Question 109

Topic: Upper Extremity Trauma
A 27-year-old professional baseball pitcher who underwent arthroscopic olecranon debridement continues to have medial-sided elbow pain during late cocking. Physical examination reveals laxity and pain with valgus stress testing. What is the most likely cause of his pain?
. Ulnar neuritis
. Excessive olecranon resection
. Osteochondritis dissecans of the capitellum
. Olecranon stress fracture
. Valgus extension overload

Correct Answer & Explanation

. Excessive olecranon resection

Explanation

DISCUSSION: Both the medial collateral ligament and the olecranon contribute to valgus stability of the elbow. Excessive olecranon resection increases the demand placed on the medial collateral ligament in resisting valgus forces during throwing. Bone removal from the olecranon should be limited to osteophytes.

Question 110

Topic: Upper Extremity Trauma
Which of the following is considered an advantage of arthroscopic distal clavicle excision compared with open distal clavicle excision?
. Fewer complications
. Lower infection rate
. Evaluation of the glenohumeral joint
. Preservation of the inferior acromioclavicular ligament
. Decreased surgical time

Correct Answer & Explanation

. Evaluation of the glenohumeral joint

Explanation

DISCUSSION: Arthroscopic versus open distal clavicle excision has the advantage of allowing evaluation of the glenohumeral joint arthroscopically prior to moving into the subclavicular and subacromial space to perform the distal clavicle excision. This can be of value in both confirming the diagnosis as well as avoiding diagnostic errors. Berg and Ciullo showed that in 20 patients who underwent open distal clavicle excision that resulted in failure, 15 of those patients had a superior labral anterior posterior (SLAP) lesion. Of these 15 patients who had the lesion treated surgically, 9 went on to a good to excellent result after the surgery was performed arthroscopically. Fewer complications, lower infection rate, and decreased surgical time have not been documented in the literature. Arthroscopic technique sacrifices the inferior acromioclavicular ligament and preserves the superior acromioclavicular ligament.

Question 111

Topic: Upper Extremity Trauma

The use of a screw between the clavicle and the coracoid process to maintain the clavicle and acromioclavicular (AC) joint in a reduced position is a treatment option for AC joint separations. Screw removal is generally recommended after soft-tissue healing. What effect does this rigid coracoclavicular fixation have on shoulder kinematics?

. Significant limitation of humeral elevation
. Significant limitation of shoulder abduction
. Significant loss of motion in all directions
. Little to no limitation of shoulder range of motion
. Limitation of humeral rotation

Correct Answer & Explanation

. Significant limitation of humeral elevation

Explanation

DISCUSSION: This issue has been debated since Inman published his classic study on clavicular rotation in 1944.ย  Subsequently, it has been shown by several authors that the clinical evaluation of patients with either coracoclavicular screws in place or with arthrodesis of the coracoclavicular reveals little to no loss of shoulder motion.ย  This is most likely the result of synchronous motion of the scapula and clavicle in shoulder movements.REFERENCES: Flatow EL: The biomechanics of the acromioclavicular, sternoclavicular, and scapulothoracic joints. Instr Course Lect 1993;42:237-245.Kenedy JC, Cameron H: Complete dislocation of the acromioclavicular joint.ย  J Bone Joint Surg Br 1954;36:202-208.Rockwood CA Jr, Williams GR, Young CD: Disorders of the acromioclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.ย  Philadelphia, PA, WB Saunders, 1998, vol 1, pp 483-553.Inman VT, Saunders JB, Abbott LC: Observations of the function of the shoulder joint.ย  Clin Orthop 1996;330:3-12.

Question 112

Topic: Upper Extremity Trauma

Persistent symptoms and decreased function following distal clavicle resection, coracoacromial ligament transfer, and augmentation (modified Weaver-Dunn) are most likely related to Review Topic

. anterior-posterior translation.
. superior-inferior translation.3inadequate resection of the distal clavicle.
. excessive reduction of the clavicle relative to the coracoid.
. unrecognized instability of the sternoclavicular joint.

Correct Answer & Explanation

. anterior-posterior translation.

Explanation

Although multiple studies have reported good clinical results with the modified Weaver-Dunn reconstruction, others have suggested that the reconstruction does not restore the native stability to the acromioclavicular joint. In particular, persistent horizontal (anterior to posterior) instability may cause persistent symptoms following reconstruction. Anatomic repair and reconstruction techniques that preserve the distal clavicle may offer patients less risk of horizontal instability.

Question 113

Topic: Upper Extremity Trauma

A 26-year-old weight lifter has had increasing pain in his left shoulder for 4 months. His symptoms do not improve with nonsurgical treatment that included activity modification, anti-inflammatory medication, and corticosteroid injections. He undergoes arthroscopic distal clavicle excision with resection of the distal 2.5 cm of clavicle. Three months after surgery, he reports persistent pain and popping in his shoulder. An examination demonstrates anterior and posterior instability of the distal clavicle without gross deformity. Radiographs are unremarkable. What is the most likely cause of distal clavicle instability after surgery?

. Release of the coracoacromial ligament
. Use of an arthroscopic rather than open technique
. Overresection of the distal clavicle
. Treatment with corticosteroid injections before surgery

Correct Answer & Explanation

. Overresection of the distal clavicle

Explanation

DISCUSSIONOverresection of the distal clavicle can result in disruption of the acromioclavicular ligamentous complex, which inserts at an average of 22.9 mm from the distal clavicle. A comparison of arthroscopic and open distal clavicle excision demonstrated less pain in the arthroscopic group, with no difference in patient satisfaction or shoulder function between groups. Injuries to the conoid and trapezoid ligaments occur with high-grade acromioclavicular separations, resulting in superior migration of the distal clavicle relative to the acromion. Release of the coracoacromial ligament typically is not performed during distal clavicle excision.

Question 114

Topic: Upper Extremity Trauma
A 26-year-old weightlifter has increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication, corticosteroid injections, and rest fails to alleviate his symptoms. He undergoes an arthroscopic distal clavicle resection with excision of the distal 8 mm of clavicle (Mumford procedure). Three months after surgery, he reports mild pain and popping by his clavicle. His clavicle demonstrates mild posterior instability on examination without any obvious deformity on his radiographs. What structures were compromised during his excision?
. Anterior and superior acromioclavicular joint ligaments
. Posterior and superior acromioclavicular joint ligaments
. Conoid ligament
. Trapezoid ligament

Correct Answer & Explanation

. Posterior and superior acromioclavicular joint ligaments

Explanation

The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the preferred response and prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.

Question 115

Topic: Upper Extremity Trauma
A 26-year-old weightlifter had increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication failed. Which of the following structures must be preserved during a Mumford procedure to prevent posterior translation of the acromioclavicular joint?
. Anterior and superior acromioclavicular joint ligaments
. Posterior and superior acromioclavicular joint ligaments
. Conoid ligament
. Trapezoid ligament

Correct Answer & Explanation

. Posterior and superior acromioclavicular joint ligaments

Explanation

The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the preferred response and prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.

Question 116

Topic: Upper Extremity Trauma

The MRI scan shown in Figure 33 reveals the sequelae of an acute traumatic anteroinferior shoulder dislocation. The image reveals the typical separation of what two commonly injured structures? Review Topic

. Anteroinferior labrum from the bony glenoid
. Anteroinferior labrum from the cartilaginous surface of the glenoid
. Biceps tendon from its origin on the supraglenoid tubercle
. Anterior capsule from the proximal humerus
. Posteroinferior labrum from the bony glenoid

Correct Answer & Explanation

. Anteroinferior labrum from the bony glenoid

Explanation

The MRI scan reveals the sequelae of an anteroinferior dislocation, specifically separation of the anteroinferior labrum from the bony glenoid. The separation does not classically occur only at the cartilage-labral junction, but extends to the bony surface of the medial glenoid neck. Separation of the biceps tendon from its origin on the supraglenoid tubercle (SLAP lesion) or separation of the anterior capsule with the proximal humerus (HAGL lesion) may occur but are not the most common sequelae and are not demonstrated in this MRI image. Anteroinferior shoulder dislocations normally do not affect the posterior labral structures. In their landmark study, Rowe and associates noted that this demonstrated lesion was the most common lesion, present in 85% of their series.

Question 117

Topic: Upper Extremity Trauma
Figure 7 shows the radiograph of an 18-year-old hockey player who sustained a shoulder injury during a fall into the side boards. Examination reveals a significant prominence at the acromioclavicular joint. Management should consist of
. a figure-of-8 clavicle strap.
. a sling for comfort, followed by early range-of-motion and strengthening exercises.
. open reduction and stabilization.
. immobilization in a spica cast.
. resection of the distal clavicle.

Correct Answer & Explanation

. open reduction and stabilization.

Explanation

The radiograph shows a type V acromioclavicular separation with greater than 100% superior elevation of the clavicle. This finding implies detachment of the deltoid and trapezius from the distal clavicle. Because of severe compromise of function and potential compromise to the overlying skin, surgery is the treatment of choice for type V acromioclavicular separations. During reduction and repair, meticulous repair of the deltotrapezial fascia will also aid in securing the repair.

Question 118

Topic: Upper Extremity Trauma
A 58-year-old man has a painful, warm, erythematous, and fluctuant area over his left olecranon. An aspiration would be most likely to reveal:
. Staphylococcus aureus.
. Streptococcus pyogenes.
. Enterococcus faecalis.
. Pseudomonas aeruginosa.

Correct Answer & Explanation

. Staphylococcus aureus.

Explanation

DISCUSSION: Staphylococcus aureus is the most common causative organism in septic bursitis, making up 80% or more of cases of culture-proven septic bursitis. Staphylococcus aureus was the most frequent pathogen (217 out of 256 or 85%), followed by Streptococcus pyogenes (16), other streptococci (15), Enterococcus faecalis (4), and coagulase-negative staphylococci (2).

Question 119

Topic: Upper Extremity Trauma

A 27-year-old professional baseball pitcher who underwent arthroscopic olecranon debridement continues to have medial-sided elbow pain during late cocking. Physical examination reveals laxity and pain with valgus stress testing. What is the most likely cause of his pain? Review Topic

. Ulnar neuritis
. Excessive olecranon resection
. Osteochondritis dissecans of the capitellum
. Olecranon stress fracture
. Valgus extension overload

Correct Answer & Explanation

. Ulnar neuritis

Explanation

Both the medial collateral ligament and the olecranon contribute to valgus stability of the elbow. Excessive olecranon resection increases the demand placed on the medial collateral ligament in resisting valgus forces during throwing. Bone removal from the olecranon should be limited to osteophytes.

Question 120

Topic: Upper Extremity Trauma
When performing elbow arthroscopy, it is often necessary to evaluate the posterior compartment. When entering the posterior compartment of the elbow, what are the two safest and most commonly used portals?
. The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps
. The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps
. The posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps and the posterior lateral portal created 3 cm from the tip of the olecranon and lateral to the triceps
. The posterior medial portal created 3 cm from the tip of the olecranon and the lateral portal made through the anconeus
. The posterior portal created at the tip of olecranon and the posterior medial portal just medial to the triceps

Correct Answer & Explanation

. The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps

Explanation

DISCUSSION: The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps are the โ€œworkhorseโ€ portals of the posterior compartment and although relatively safe, risks exist. The radial nerve proximity averages 4.8 mm (3 to 8 mm) from the posterolateral portal. The central posterior portal is close to 20 mm from the ulnar nerve.

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