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Upper Extremity Trauma MCQs

Practice Set 9 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 161

Topic: Upper Extremity Trauma
A 28-year-old male laborer sustains an acromioclavicular (AC) joint injury. Radiographs reveal 100% superior displacement of the clavicle relative to the acromion, with the coracoclavicular distance increased but less than 100% compared to the normal side (Rockwood Type III). What is the preferred initial management?
. Nonoperative management with a brief period of sling immobilization followed by physical therapy
. Arthroscopic coracoclavicular ligament reconstruction
. Immediate open reduction and internal fixation with a hook plate
. Primary distal clavicle excision
. Acromioclavicular joint fusion

Correct Answer & Explanation

. Immediate open reduction and internal fixation with a hook plate

Explanation

Rockwood Type III AC joint separations are initially treated nonoperatively with a brief sling and early physical therapy. Surgical intervention is generally reserved for patients who remain symptomatic after an exhausted trial of conservative management, or occasionally for high-demand overhead athletes.

Question 162

Topic: Upper Extremity Trauma
A 25-year-old male falls directly onto his right shoulder during a cycling accident. Radiographs reveal an acromioclavicular (AC) joint injury. According to the Rockwood classification, which of the following specific radiographic and anatomic findings distinguishes a Type V injury from a Type III injury?
. Complete disruption of the AC ligaments with intact coracoclavicular (CC) ligaments
. Superior displacement of the clavicle by 25% to 100% of the normal joint space
. Posterior displacement of the distal clavicle into the trapezius muscle
. Superior translation of the distal clavicle by 100% to 300% with extensive stripping of the deltotrapezial fascia
. Inferior displacement of the clavicle under the coracoid process

Correct Answer & Explanation

. Superior translation of the distal clavicle by 100% to 300% with extensive stripping of the deltotrapezial fascia

Explanation

In the Rockwood classification of AC joint separations, a Type III injury involves disruption of both the AC and CC ligaments, resulting in up to 100% superior displacement of the clavicle relative to the acromion. A Type V injury is a much more severe form of Type III, characterized by 100% to 300% superior displacement, along with severe disruption/stripping of the deltotrapezial fascia, resulting in a dramatic clinical deformity.

Question 163

Topic: Upper Extremity Trauma
A 14-year-old boy who is right-handed reports right shoulder pain. Radiographs show a lucent lesion of the proximal humeral epiphysis with a narrow zone of transition. Results of an open biopsy confirm the presence of a chondroblastoma. Based on these findings, the next most appropriate step in management should consist of:
. Intralesional curettage and bone grafting
. Intra-articular resection of the proximal humerus and endoprosthetic replacement
. Intra-articular resection of the proximal humerus and osteoarticular allograft reconstruction
. Extra-articular resection of the proximal humerus and allograft arthrodesis of the shoulder
. Observation and serial radiographs

Correct Answer & Explanation

. Intralesional curettage and bone grafting

Explanation

DISCUSSION: The patient has a chondroblastoma of the proximal humerus; therefore, the treatment of choice is curettage and bone grafting. Surgical resection of the proximal humerus is not indicated in the initial treatment of an intraosseous chondroblastoma.

Question 164

Topic: Upper Extremity Trauma
A 25-year-old mountain biker falls directly onto his shoulder point. Radiographs show a significantly displaced distal clavicle. The injury is classified as a Rockwood Type III acromioclavicular (AC) joint dislocation. Which of the following describes the status of the stabilizing soft tissues in this specific injury grade?
. Acromioclavicular ligaments disrupted, coracoclavicular ligaments intact
. Coracoclavicular ligaments disrupted, acromioclavicular ligaments intact
. Both AC and CC ligaments disrupted, deltotrapezial fascia intact
. Both AC and CC ligaments disrupted, deltotrapezial fascia disrupted
. Isolated disruption of the coracoacromial ligament

Correct Answer & Explanation

. Both AC and CC ligaments disrupted, deltotrapezial fascia intact

Explanation

In a Rockwood Type III injury, both the acromioclavicular (AC) and coracoclavicular (CC) ligaments are completely torn, leading to superior displacement of the clavicle by 25-100% compared to the normal side. The deltotrapezial fascia remains intact. If the deltotrapezial fascia is disrupted, allowing severe subcutaneous displacement, it is classified as a Type V injury.

Question 165

Topic: Upper Extremity Trauma

During a surgical reconstruction for a chronic Type V acromioclavicular (AC) joint separation, the surgeon aims to reconstruct the coracoclavicular ligaments. What is the approximate anatomic distance from the distal clavicle to the normal insertion of the conoid ligament?

. 1.5 cm
. 3.0 cm
. 4.5 cm
. 6.0 cm
. 7.5 cm

Correct Answer & Explanation

. 4.5 cm

Explanation

The conoid ligament inserts approximately 4.5 cm medial to the distal articular end of the clavicle, while the trapezoid ligament inserts approximately 3.0 cm medial to it. Knowledge of this anatomy is crucial for accurate tunnel placement during reconstruction.

Question 166

Topic: Upper Extremity Trauma

During reconstruction of the acromioclavicular joint, a graft is used to recreate the conoid and trapezoid ligaments. Which of the following best describes the anatomic footprint and biomechanical role of the conoid ligament?

. Inserts on the anterolateral clavicle and resists posterior translation
. Inserts on the posteromedial clavicle and primarily resists superior translation
. Inserts on the posterolateral clavicle and primarily resists anterior translation
. Inserts on the anteromedial clavicle and resists inferior translation
. Inserts on the distal clavicle and acts as the primary restraint to axial rotation

Correct Answer & Explanation

. Inserts on the posteromedial clavicle and primarily resists superior translation

Explanation

The conoid ligament inserts on the posteromedial aspect of the distal clavicle and is the primary restraint to superior translation. The trapezoid ligament inserts anterolaterally and resists posterior translation.

Question 167

Topic: Upper Extremity Trauma

When performing an open or arthroscopic distal clavicle excision for osteolysis, what is the maximum amount of bone that should be resected to preserve the acromioclavicular (AC) ligaments and prevent anterior-posterior instability?

. 2 to 3 mm
. 5 to 8 mm
. 10 to 12 mm
. 15 to 20 mm
. 25 to 30 mm

Correct Answer & Explanation

. 5 to 8 mm

Explanation

Distal clavicle resection typically aims for 5 to 8 mm of bone removal. Resecting more than 10 mm risks compromising the superior and posterior AC capsular ligaments, leading to iatrogenic horizontal (AP) instability.

Question 168

Topic: Upper Extremity Trauma

In the setting of an acromioclavicular (AC) joint dislocation, which of the following ligaments provides the primary restraint to superior translation of the distal clavicle?

. Acromioclavicular ligament
. Coracoacromial ligament
. Trapezoid ligament
. Conoid ligament
. Superior transverse scapular ligament

Correct Answer & Explanation

. Conoid ligament

Explanation

The conoid ligament is the primary restraint to superior translation of the distal clavicle. The trapezoid ligament primarily resists axial compression to the shoulder.

Question 169

Topic: Upper Extremity Trauma

A 42-year-old bodybuilder feels a pop in his posterior elbow during a heavy bench press. Examination reveals a palpable gap and loss of active elbow extension against gravity. Surgical repair of the distal triceps tendon is planned. Based on biomechanical studies, which repair construct provides the highest load to failure and restores the largest anatomic footprint?

. Single-row repair using suture anchors at the articular margin
. Transtendinous running suture with a single intramedullary anchor
. Cruciate repair using transosseous tunnels in a double-row equivalent
. Bio-tenodesis screw in the proximal ulna diaphysis
. Direct end-to-end suture to the anconeus fascia

Correct Answer & Explanation

. Cruciate repair using transosseous tunnels in a double-row equivalent

Explanation

Biomechanical studies have shown that a cruciate double-row or anatomic transosseous cruciate repair technique provides the highest load to failure, minimizes gap formation, and optimally restores the broad anatomic footprint of the distal triceps tendon on the olecranon, compared to single-row suture anchor repairs or simple transosseous knots.

Question 170

Topic: Upper Extremity Trauma
A 29-year-old mountain biker falls directly onto the point of his shoulder. Radiographs reveal an acromioclavicular (AC) joint dislocation. He is diagnosed with a Rockwood Type V injury. Which of the following best describes the specific anatomical disruption and radiographic appearance that defines a Type V injury?
. Sprain of the AC ligaments with intact coracoclavicular (CC) ligaments and normal AC joint space
. Rupture of the AC ligaments and sprain of the CC ligaments, with <25% superior displacement of the clavicle
. Complete rupture of AC and CC ligaments with 25-100% superior displacement of the clavicle relative to the acromion
. Complete rupture of AC and CC ligaments with posterior displacement of the clavicle into the trapezius fascia
. Complete rupture of AC and CC ligaments, disruption of the deltotrapezial fascia, with 100-300% superior displacement of the clavicle

Correct Answer & Explanation

. Complete rupture of AC and CC ligaments with 25-100% superior displacement of the clavicle relative to the acromion

Explanation

The Rockwood classification of AC joint injuries is based on the degree and direction of distal clavicle displacement. Type I is a sprain; Type II involves AC rupture and CC sprain; Type III is complete rupture of AC and CC ligaments with 25-100% superior displacement. Type IV is posterior displacement into or through the trapezius. Type V is severe superior displacement (>100% and up to 300%) due to disruption of the AC ligaments, CC ligaments, and the deltotrapezial fascial attachments.

Question 171

Topic: Upper Extremity Trauma
A 25-year-old male falls onto his shoulder apex, sustaining a Type III acromioclavicular (AC) joint dislocation. He is curious about the ruptured ligaments. Which of the following statements correctly pairs the coracoclavicular (CC) ligament bundles with their primary biomechanical restraint function?
. The conoid ligament primarily resists horizontal (anterior-posterior) translation
. The trapezoid ligament primarily resists superior translation of the clavicle
. The conoid ligament primarily resists superior translation of the clavicle
. The coracoacromial ligament primarily resists superior translation of the clavicle
. The acromioclavicular ligaments primarily resist superior translation of the clavicle

Correct Answer & Explanation

. The conoid ligament primarily resists superior translation of the clavicle

Explanation

The CC ligaments consist of the medial conoid and the lateral trapezoid. Biomechanical studies have shown that the conoid ligament is the primary restraint against superior translation of the clavicle. The trapezoid ligament primarily resists axial compression (horizontal loading) into the acromion. The AC ligaments provide primary restraint to anterior-posterior translation.

Question 172

Topic: Upper Extremity Trauma

A 28-year-old professional motocross rider sustains a Type V acromioclavicular (AC) joint dislocation. He undergoes surgical reconstruction of the coracoclavicular (CC) ligaments. Which of the following accurately describes the native anatomy and biomechanics of the CC ligaments being reconstructed?

. The conoid ligament is lateral to the trapezoid ligament and provides primary restraint against anterior translation.
. The trapezoid ligament is medial to the conoid ligament and provides primary restraint against posterior translation.
. The conoid ligament attaches to the posteromedial clavicle and is the primary restraint to superior clavicular translation.
. The trapezoid ligament attaches to the posteromedial clavicle and is the primary restraint to superior clavicular translation.
. Both ligaments insert on the anterior aspect of the clavicle and act equally to resist inferior translation.

Correct Answer & Explanation

. The conoid ligament attaches to the posteromedial clavicle and is the primary restraint to superior clavicular translation.

Explanation

The coracoclavicular (CC) ligament complex consists of the conoid and trapezoid ligaments. The conoid ligament is located medial and posterior to the trapezoid ligament. It is cone-shaped and acts as the primary restraint against superior translation of the clavicle relative to the acromion. The trapezoid ligament is located anterolateral to the conoid and is the primary restraint against axial compression (driving the acromion medial towards the clavicle).

Question 173

Topic: Upper Extremity Trauma

During surgical reconstruction of a severe acromioclavicular (AC) joint separation, precise knowledge of the coracoclavicular (CC) ligament insertions is required. Which of the following best describes the normal anatomic footprint of the CC ligaments on the clavicle?

. The conoid ligament inserts on the anterolateral clavicle, approximately 2.5 cm from the distal end.
. The trapezoid ligament inserts on the posteromedial clavicle, approximately 4.5 cm from the distal end.
. The conoid ligament inserts on the posteromedial aspect of the distal clavicle, approximately 4.5 cm from the AC joint.
. The trapezoid ligament inserts on the posteromedial aspect of the distal clavicle, approximately 3.0 cm from the AC joint.
. Both ligaments blend together and insert at the exact same footprint on the inferior clavicle, 1.0 cm from the AC joint.

Correct Answer & Explanation

. The conoid ligament inserts on the posteromedial aspect of the distal clavicle, approximately 4.5 cm from the AC joint.

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid is medial and posterior, inserting approximately 4.5 cm from the distal end of the clavicle. The trapezoid is lateral and anterior, inserting approximately 3.0 cm from the distal clavicle. Mnemonic: 'Conoid is Cone-shaped, medial, and posterior.' Accurate tunnel placement requires knowing these distances.

Question 174

Topic: Upper Extremity Trauma
A 22-year-old male falls directly onto his shoulder tip. Radiographs demonstrate 100% superior displacement of the clavicle relative to the acromion. Based on the Rockwood classification for acromioclavicular (AC) joint injuries, a Type III separation involves complete rupture of which ligaments?
. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Both the acromioclavicular and coracoclavicular ligaments
. Acromioclavicular, coracoclavicular, and coracoacromial ligaments
. Coracoacromial and coracoclavicular ligaments

Correct Answer & Explanation

. Both the acromioclavicular and coracoclavicular ligaments

Explanation

In the Rockwood classification: Type I is an AC ligament sprain; Type II is an AC ligament tear with a CC ligament sprain; Type III is a complete rupture of both the AC ligaments and the CC ligaments (conoid and trapezoid), resulting in superior displacement of the clavicle between 25% and 100%.

Question 175

Topic: Upper Extremity Trauma

Recent quantitative anatomic studies evaluating the vascularity of the proximal humerus have challenged historical teachings regarding the primary blood supply to the humeral head. Based on contemporary understanding (e.g., Hertel et al.), which artery provides the predominant blood supply to the humeral head?

. Anterior humeral circumflex artery
. Posterior humeral circumflex artery
. Thoracoacromial artery
. Subscapular artery
. Profunda brachii artery

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

Historically, the arcuate artery (a branch of the ascending branch of the anterior humeral circumflex artery) was thought to be the principal blood supply to the humeral head. However, modern cadaveric studies using advanced perfusion techniques have definitively demonstrated that the posterior humeral circumflex artery provides the vast majority (up to 64%) of the robust intraosseous blood supply to the humeral head.

Question 176

Topic: Upper Extremity Trauma

A 50-year-old weightlifter presents with an inability to actively extend his elbow against gravity following a sudden pop. MRI shows a complete avulsion of the triceps tendon from the olecranon. During surgical repair, an anatomic reattachment is planned. Where is the true anatomic footprint of the triceps tendon located on the olecranon?

. Directly at the proximal tip of the olecranon process
. Approximately 1-2 cm distal to the tip on the posterior surface
. 3 cm distal to the tip on the lateral border
. Intra-articularly along the sublime tubercle
. Medial to the ulnar nerve groove

Correct Answer & Explanation

. Approximately 1-2 cm distal to the tip on the posterior surface

Explanation

The triceps footprint is located approximately 1 to 2 cm distal to the very tip of the olecranon on the posterior surface. Reattaching it too proximally (at the very tip) can cause mechanical impingement in the olecranon fossa during extension, leading to a loss of full terminal extension.

Question 177

Topic: Upper Extremity Trauma
A 26-year-old cyclist falls directly onto his right shoulder. Radiographs reveal superior displacement of the distal clavicle. The axillary view clearly demonstrates the distal clavicle displaced posteriorly into the trapezius muscle fascia. What is the Rockwood classification of this acromioclavicular injury?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

Rockwood classification: Type I (sprain), Type II (AC torn, CC sprained), Type III (AC and CC torn, clavicle superiorly displaced up to 100%), Type IV (clavicle displaced posteriorly into or through the trapezius muscle), Type V (clavicle displaced superiorly >100-300%), Type VI (clavicle displaced inferiorly under the coracoid or acromion). The posterior displacement into the trapezius defines a Type IV injury.

Question 178

Topic: Upper Extremity Trauma

A 50-year-old weightlifter with recalcitrant, isolated acromioclavicular (AC) joint osteoarthritis is undergoing an arthroscopic distal clavicle excision. To prevent postoperative iatrogenic anteroposterior instability of the clavicle, the surgeon must be careful to preserve which of the following structures during the resection?

. The superior and posterior AC capsular ligaments
. The conoid ligament
. The trapezoid ligament
. The coracoacromial ligament
. The coracoclavicular fascia

Correct Answer & Explanation

. The superior and posterior AC capsular ligaments

Explanation

During a distal clavicle excision (Mumford procedure), it is crucial to resect an adequate amount of bone to prevent impingement (usually 5-8 mm) but not so much that the stabilizing ligaments are compromised. The superior and posterior AC ligaments are the primary restraints to anteroposterior translation of the distal clavicle. Excessive resection (>10-15 mm) risks disrupting these capsular ligaments, leading to AP instability. The coracoclavicular (conoid and trapezoid) ligaments prevent superior translation and are located further medially.

Question 179

Topic: Upper Extremity Trauma
A 42-year-old female presents with a highly comminuted, displaced radial head fracture (Mason Type III) and an associated tear of the medial ulnar collateral ligament, causing elbow instability. Which of the following is the most appropriate surgical treatment?
. Open reduction and internal fixation of the radial head
. Radial head excision alone
. Radial head excision with prosthetic replacement
. Closed reduction and casting for 6 weeks
. Distal humerus replacement

Correct Answer & Explanation

. Radial head excision with prosthetic replacement

Explanation

In a Mason Type III (comminuted) radial head fracture with associated ligamentous instability (e.g., Essex-Lopresti, terrible triad, or MUCL tear), radial head excision alone is contraindicated because the radial head is a crucial secondary stabilizer to valgus stress and longitudinal forearm stability. If ORIF is not possible due to severe comminution, radial head excision with prosthetic replacement is the treatment of choice to restore stability.

Question 180

Topic: Upper Extremity Trauma

A 28-year-old hockey player has a shoulder deformity after being checked into the boards. Examination reveals that swelling has improved, but there is tenderness along the distal clavicle. Radiographs reveal a grade II acromioclavicular joint separation. Initial management should consist of

. a sling, ice, and isometric exercises.
. a glenohumeral cortisone injection.
. surgical repair of the coracoclavicular ligaments.
. chin-ups and latissimus pull-down exercises.
. cross-chest stretches.

Correct Answer & Explanation

. a sling, ice, and isometric exercises.

Explanation

The most common shoulder injury in hockey players is to the acromioclavicular joint. Early rest and control of pain and inflammation is the preferred management. Surgery is reserved for patients with significant coracoclavicular disruption that has failed to respond to nonsurgical management. Cross-chest stretches and overhead exercises may increase symptoms. A cortisone injection within the glenohumeral joint will have little effect. Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.

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