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Shoulder Pathology MCQs

Practice Set 10 of 12

This practice set contains high-yield board review questions covering key concepts in Shoulder Pathology. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 181

Topic: Shoulder Pathology

During surgical exploration of the brachial plexus for a traumatic injury, you are evaluating the anatomic structures originating directly from the upper trunk. Which of the following nerves branches exclusively from the upper trunk?

. Dorsal scapular nerve
. Suprascapular nerve
. Long thoracic nerve
. Medial pectoral nerve
. Thoracodorsal nerve

Correct Answer & Explanation

. Suprascapular nerve

Explanation

The suprascapular nerve and the nerve to the subclavius are the only branches that originate directly from the upper trunk of the brachial plexus (formed by C5 and C6 roots). The dorsal scapular (C5) and long thoracic (C5, C6, C7) nerves branch directly from the roots.

Question 182

Topic: Shoulder Pathology

A patient undergoing an anterior cervical discectomy and fusion (ACDF) develops hoarseness postoperatively. Which nerve is most likely to have been injured?

. Phrenic nerve
. Spinal accessory nerve
. Recurrent laryngeal nerve
. Vagus nerve
. Long thoracic nerve

Correct Answer & Explanation

. Recurrent laryngeal nerve

Explanation

Hoarseness after an ACDF is most commonly due to injury or irritation of the recurrent laryngeal nerve, which is closely associated with the surgical field. This nerve innervates most of the intrinsic muscles of the larynx. The phrenic nerve innervates the diaphragm. The spinal accessory nerve innervates the sternocleidomastoid and trapezius muscles. The vagus nerve supplies the recurrent laryngeal nerve, but direct injury to the vagus itself is less common than to its recurrent branch. The long thoracic nerve innervates the serratus anterior muscle.

Question 183

Topic: Shoulder Pathology

What is the most appropriate initial management for acute calcific tendinitis of the rotator cuff?

. Immediate surgical debridement
. Corticosteroid injection and NSAIDs
. Extracorporeal shockwave therapy (ESWT)
. Physical therapy with aggressive strengthening
. Arthroscopic removal of calcium deposits

Correct Answer & Explanation

. Corticosteroid injection and NSAIDs

Explanation

Acute calcific tendinitis is often intensely painful due to an inflammatory reaction around the calcium deposits. The most appropriate initial management is conservative, focusing on pain and inflammation control. This typically involves NSAIDs and often a subacromial corticosteroid injection, which can provide significant pain relief. Surgical debridement or arthroscopic removal of deposits are reserved for chronic, refractory cases. ESWT is often used for chronic calcific tendinitis, not typically for the acute phase. Aggressive strengthening physical therapy is often painful in the acute phase and contraindicated.

Question 184

Topic: Shoulder Pathology

A 45-year-old male presents with right shoulder and arm pain, tingling in the fourth and fifth fingers, and a positive Adson's test. He also complains of intermittent arm swelling and discoloration. Which type of thoracic outlet syndrome is most likely?

. Neurogenic thoracic outlet syndrome.
. Arterial thoracic outlet syndrome.
. Venous thoracic outlet syndrome.
. Mixed neurovascular thoracic outlet syndrome.
. Pancoast tumor-induced TOS.

Correct Answer & Explanation

. Venous thoracic outlet syndrome.

Explanation

The patient's symptoms of pain, tingling in the ulnar nerve distribution (suggesting brachial plexus involvement), a positive Adson's test (indicating compression), combined withintermittent arm swelling and discoloration, are highly indicative of venous thoracic outlet syndrome. This involves compression of the subclavian vein, which can lead to thrombosis (Paget-Schroetter syndrome), edema, and cyanosis. Neurogenic TOS would primarily present with neurological symptoms. Arterial TOS would involve symptoms of ischemia (pallor, coolness, claudication). While there's a neurological component, the vascular signs of swelling and discoloration point specifically to venous compression. Pancoast tumor can mimic TOS but typically causes Horner's syndrome and doesn't usually cause vascular swelling/discoloration.

Question 185

Topic: Shoulder Pathology

During a cervical lymph node biopsy in the posterior triangle of the neck, a patient sustains an iatrogenic nerve injury leading to a laterally winged scapula. Which muscle is predominantly affected by this injury?

. Serratus anterior
. Trapezius
. Rhomboid major
. Levator scapulae
. Latissimus dorsi

Correct Answer & Explanation

. Serratus anterior

Explanation

The posterior triangle of the neck contains the spinal accessory nerve (CN XI), which innervates the trapezius muscle. Injury leads to lateral winging of the scapula (the scapula is displaced laterally and inferiorly). Medial winging, in contrast, is caused by injury to the long thoracic nerve, which innervates the serratus anterior.

Question 186

Topic: Shoulder Pathology

A 35-year-old female presents with pain, weakness, and paresthesias affecting the medial aspect of her forearm and the ring and small fingers of her hand. True neurogenic thoracic outlet syndrome is suspected. Compression of which part of the brachial plexus is most characteristic of this presentation?

. Upper trunk
. Middle trunk
. Lower trunk
. Lateral cord
. Posterior cord

Correct Answer & Explanation

. Upper trunk

Explanation

True neurogenic thoracic outlet syndrome typically involves compression of the lower trunk of the brachial plexus (C8-T1). This leads to sensory symptoms in the distribution of the medial antebrachial cutaneous nerve and ulnar nerve, and motor weakness in intrinsic hand muscles supplied by the lower trunk.

Question 187

Topic: Shoulder Pathology

A patient presents with shoulder weakness and pain two months after a radical neck dissection for squamous cell carcinoma. Examination reveals winging of the scapula with lateral translation of the inferior pole. Which muscle is denervated, and what is its primary motor nerve?

. Serratus anterior / Long thoracic nerve
. Trapezius / Spinal accessory nerve
. Rhomboid major / Dorsal scapular nerve
. Latissimus dorsi / Thoracodorsal nerve
. Levator scapulae / Cervical plexus

Correct Answer & Explanation

. Serratus anterior / Long thoracic nerve

Explanation

Lateral winging of the scapula is characteristic of trapezius palsy, which is innervated by the spinal accessory nerve (CN XI). Medial winging is typically caused by serratus anterior paralysis due to long thoracic nerve injury.

Question 188

Topic: Shoulder Pathology

In patients with neurogenic thoracic outlet syndrome, compression most commonly occurs within the interscalene triangle. What are the anatomical borders of this triangle?

. Anterior scalene, middle scalene, and clavicle
. Anterior scalene, middle scalene, and first rib
. Sternocleidomastoid, anterior scalene, and first rib
. Clavicle, first rib, and subclavius muscle
. Pectoralis minor, coracoid process, and ribs 2-4

Correct Answer & Explanation

. Anterior scalene, middle scalene, and clavicle

Explanation

The interscalene triangle is bordered anteriorly by the anterior scalene, posteriorly by the middle scalene, and inferiorly by the first rib. The brachial plexus trunks and the subclavian artery pass through this triangle.

Question 189

Topic: Shoulder Pathology

A 22-year-old motorcyclist presents after a high-speed collision. He has a mangled, pulseless left upper extremity with massive swelling over the shoulder and chest wall. Radiographs show lateral displacement of the scapula with a widened sternoclavicular joint. What is the most likely neurologic injury associated with this pattern?

. Complete brachial plexus avulsion
. Axillary nerve transection
. Spinal accessory nerve palsy
. Long thoracic nerve neurapraxia
. Isolated ulnar nerve injury

Correct Answer & Explanation

. Complete brachial plexus avulsion

Explanation

Scapulothoracic dissociation is a high-energy injury characterized by complete disruption of the scapulothoracic articulation. It is associated with severe neurovascular injuries, most notably complete brachial plexus avulsion (which occurs in up to 80% of cases) and subclavian/axillary artery disruption. The presentation typically involves a pulseless, flail upper extremity and lateral displacement of the scapula on chest X-ray.

Question 190

Topic: Shoulder Pathology

A 25-year-old military recruit presents with aching shoulder pain and notable medial prominence of his right scapula (medial winging) when asked to perform a wall push-up. Which nerve is most likely injured?

. Spinal accessory nerve
. Suprascapular nerve
. Long thoracic nerve
. Dorsal scapular nerve
. Axillary nerve

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Medial scapular winging is caused by serratus anterior paralysis due to long thoracic nerve palsy. Lateral winging is associated with trapezius dysfunction from spinal accessory nerve injury.

Question 191

Topic: Shoulder Pathology

A 25-year-old tennis player complains of shoulder weakness and a prominent shoulder blade following a viral illness. On physical examination, forward elevation of the arm against resistance demonstrates pronounced medial winging of the scapula. An injury to which of the following nerves is the most likely cause of this clinical presentation?

. Spinal accessory nerve
. Long thoracic nerve
. Dorsal scapular nerve
. Suprascapular nerve
. Axillary nerve

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Medial winging of the scapula is caused by serratus anterior paralysis, which is innervated by the long thoracic nerve. Lateral winging is typically associated with spinal accessory nerve palsies affecting the trapezius.

Question 192

Topic: Shoulder Pathology

A 28-year-old female presents with a dull ache around her shoulder and medial scapular winging that noticeably worsens when pushing against a wall. Which nerve and muscle are most likely affected?

. Spinal accessory nerve - Trapezius
. Long thoracic nerve - Serratus anterior
. Dorsal scapular nerve - Rhomboids
. Suprascapular nerve - Supraspinatus
. Axillary nerve - Deltoid

Correct Answer & Explanation

. Spinal accessory nerve - Trapezius

Explanation

Medial scapular winging is classically caused by serratus anterior paralysis, which is innervated by the long thoracic nerve. It is often accentuated by having the patient push against a wall. In contrast, lateral winging is typically caused by trapezius paralysis (spinal accessory nerve).

Question 193

Topic: Shoulder Pathology

A 34-year-old female presents with paresthesias and pain in the medial aspect of her right forearm and hand, particularly with overhead activities. On examination, the Adson test is positive. Plain radiographs show large bilateral cervical ribs. Electromyography reveals decreased conduction velocity in the ulnar nerve distribution. Which of the following anatomical triangles is most commonly implicated in this form of Thoracic Outlet Syndrome?

. Between the anterior scalene, middle scalene, and first rib
. Between the pectoralis minor, coracoid, and rib cage
. Between the clavicle, first rib, and subclavius muscle
. Between the sternocleidomastoid, anterior scalene, and clavicle
. Between the latissimus dorsi, teres major, and humerus

Correct Answer & Explanation

. Between the anterior scalene, middle scalene, and first rib

Explanation

Neurogenic Thoracic Outlet Syndrome most commonly occurs at the interscalene triangle, which is bordered anteriorly by the anterior scalene muscle, posteriorly by the middle scalene muscle, and inferiorly by the first rib. The presence of a cervical rib narrows this space further, predisposing to brachial plexus compression.

Question 194

Topic: Shoulder Pathology

A 30-year-old female presents with true neurogenic thoracic outlet syndrome (TOS). She requires surgical decompression. The most common site of nerve compression in this syndrome involves the interscalene triangle. What are the anatomic borders of this triangle?

. Clavicle, first rib, and subclavius muscle
. Pectoralis minor, coracoid process, and ribs
. Anterior scalene, middle scalene, and first rib
. Sternocleidomastoid, anterior scalene, and clavicle
. Middle scalene, posterior scalene, and second rib

Correct Answer & Explanation

. Clavicle, first rib, and subclavius muscle

Explanation

The interscalene triangle is the most common site of compression in neurogenic thoracic outlet syndrome. Its borders are the anterior scalene muscle anteriorly, the middle scalene muscle posteriorly, and the superior border of the first rib inferiorly. The brachial plexus trunks and the subclavian artery pass through this triangle (the subclavian vein runs anterior to the anterior scalene and is not within the triangle).

Question 195

Topic: Shoulder Pathology

A 28-year-old athlete undergoes an isolated arthroscopic SLAP repair. Postoperatively, he experiences profound, isolated weakness in external rotation of the shoulder, with normal deltoid function and internal rotation. Suture anchor placement most likely injured which nerve?

. Axillary nerve
. Suprascapular nerve
. Musculocutaneous nerve
. Spinal accessory nerve
. Long thoracic nerve

Correct Answer & Explanation

. Axillary nerve

Explanation

The suprascapular nerve passes through the spinoglenoid notch near the posterosuperior glenoid. Misplaced posterosuperior suture anchors can tether or injure this nerve, causing isolated infraspinatus weakness.

Question 196

Topic: Shoulder Pathology

A 50-year-old female presents with severe shoulder stiffness and pain, characterized by globally restricted active and passive range of motion. Which of the following systemic comorbidities has the strongest established association with the development of adhesive capsulitis?

. Hypertension
. Diabetes mellitus
. Hypothyroidism
. Rheumatoid arthritis
. Chronic kidney disease

Correct Answer & Explanation

. Hypertension

Explanation

Diabetes mellitus has a strong, well-documented association with adhesive capsulitis (frozen shoulder). Diabetic patients have a higher incidence of the disease, and it is often more severe and refractory to treatment.

Question 197

Topic: Shoulder Pathology

A 28-year-old male presents with right shoulder asymmetry. On examination, having the patient perform a wall push-up causes the medial border of the right scapula to become excessively prominent and translate superiorly and medially. Injury to which of the following nerves is responsible for this classic presentation?

. Long thoracic nerve
. Spinal accessory nerve
. Dorsal scapular nerve
. Suprascapular nerve
. Axillary nerve

Correct Answer & Explanation

. Long thoracic nerve

Explanation

This is a classic presentation of medial scapular winging, which is caused by paralysis of the serratus anterior muscle due to long thoracic nerve palsy. The serratus anterior normally protracts and upwardly rotates the scapula, keeping the medial border closely applied to the thorax. When it is paralyzed, the medial border lifts off the chest wall (wings medially) and the scapula translates superiorly and medially. This is differentiated from lateral winging (spinal accessory nerve / trapezius palsy), where the scapula translates inferiorly and laterally.

Question 198

Topic: Shoulder Pathology

A 22-year-old boxer complains of prominent medial winging of his right scapula that worsens when doing push-ups against a wall. He sustained a direct blow to his lateral chest wall three months ago. Which nerve was most likely injured, and which muscle is consequently paralyzed?

. Long thoracic nerve / Serratus anterior
. Spinal accessory nerve / Trapezius
. Dorsal scapular nerve / Rhomboids
. Thoracodorsal nerve / Latissimus dorsi
. Axillary nerve / Deltoid

Correct Answer & Explanation

. Long thoracic nerve / Serratus anterior

Explanation

Medial scapular winging is the classic presentation of serratus anterior paralysis, which is innervated by the long thoracic nerve. In contrast, lateral scapular winging is associated with trapezius paralysis from a spinal accessory nerve injury.

Question 199

Topic: Shoulder Pathology

A 30-year-old male presents with medial scapular winging and inability to actively elevate his arm past 90 degrees following a heavy traction injury. EMG confirms a complete long thoracic nerve palsy. After 1 year of strict conservative management with no recovery, what is the treatment of choice?

. Eden-Lange procedure
. Pectoralis major transfer
. Split pectoralis minor transfer
. Rhomboid transfer
. Modified Eden-Lange procedure

Correct Answer & Explanation

. Eden-Lange procedure

Explanation

Pectoralis major transfer (using fascia lata autograft or direct transfer to the inferior angle of the scapula) is the standard surgical treatment for chronic, irrecoverable serratus anterior palsy causing medial winging.

Question 200

Topic: Shoulder Pathology

A 26-year-old female presents with shoulder weakness 4 months after a cervical lymph node biopsy. On exam, her scapula is laterally translated and wings when she attempts to abduct the arm against resistance. The medial border is depressed. Which nerve was most likely injured?

. Long thoracic nerve
. Spinal accessory nerve
. Suprascapular nerve
. Axillary nerve
. Dorsal scapular nerve

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Lateral scapular winging with an inability to actively abduct the arm beyond 90 degrees is a hallmark of trapezius paralysis due to spinal accessory nerve injury. Procedures in the posterior cervical triangle, such as lymph node biopsies, carry a high risk for this complication.

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