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Shoulder Pathology MCQs

Practice Set 12 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 221

Topic: Shoulder Pathology

A 45-year-old woman presents with a 'drooping' right shoulder and weakness in overhead activities three months after undergoing a posterior triangle lymph node biopsy. On physical examination, her right scapula demonstrates lateral winging when she is asked to abduct her arm against resistance. Which nerve has most likely been injured?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

The spinal accessory nerve (CN XI) innervates the trapezius. Injury, often iatrogenic during procedures in the posterior triangle of the neck, causes a drooping shoulder and lateral scapular winging. In contrast, injury to the long thoracic nerve causes paralysis of the serratus anterior and medial scapular winging.

Question 222

Topic: Shoulder Pathology

Which of the following bony anatomical variants of the scapula is most strongly associated with the development of snapping scapula syndrome?

. Os acromiale
. Coracoid hypoplasia
. Glenoid retroversion
. Bipartite glenoid
. Luschka's tubercle

Correct Answer & Explanation

. Luschka's tubercle

Explanation

Snapping scapula syndrome is caused by a disruption of the smooth gliding motion between the anterior scapula and the posterior chest wall. Luschka's tubercle is an abnormal, bony enlargement at the superomedial angle of the scapula that can cause friction, bursitis, and symptomatic crepitus (snapping).

Question 223

Topic: Shoulder Pathology

A 32-year-old patient presents with lateral winging of the scapula. The scapula is translated laterally, rotated downward, and the deformity is accentuated by resisted shoulder abduction. Which nerve is most likely injured in this patient?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Lateral winging is characteristic of trapezius muscle paralysis, which is innervated by the spinal accessory nerve (CN XI). Medial winging (accentuated by pushing against a wall) is caused by serratus anterior weakness due to long thoracic nerve palsy.

Question 224

Topic: Shoulder Pathology

A patient presents with a winged scapula following a posterior triangle lymph node biopsy. The injured nerve is derived from which roots of the brachial plexus?

. C5, C6
. C5, C6, C7
. C6, C7, C8
. C8, T1
. C7, C8, T1

Correct Answer & Explanation

. C5, C6

Explanation

Winging of the scapula with medial deviation is typically due to a long thoracic nerve injury resulting in serratus anterior paralysis. The long thoracic nerve is formed directly by the ventral rami of C5, C6, and C7 before they form the trunks of the brachial plexus.

Question 225

Topic: Shoulder Pathology

A patient with HME presents with an osteochondroma in the scapula. What unique functional impairment might be caused by this specific location?

. Genu valgum
. Radial nerve palsy
. Scapular winging or limited shoulder range of motion
. Foot drop
. Limb length discrepancy

Correct Answer & Explanation

. Scapular winging or limited shoulder range of motion

Explanation

Osteochondromas in the scapula or periscapular region can cause significant functional impairment, including mechanical obstruction leading to scapular winging, limited shoulder range of motion (especially abduction and rotation), pain, and snapping scapula syndrome. Genu valgum and foot drop are lower extremity issues. Radial nerve palsy is an upper extremity nerve compression but less typical for scapular lesions compared to direct mechanical restriction.

Question 226

Topic: Shoulder Pathology

A 28-year-old male sustains blunt trauma to his right posterolateral neck and shoulder. He subsequently presents with medial winging of his scapula, which worsens when he pushes against a wall. Which nerve is most likely injured, and what is its segmental origin?

. Spinal accessory nerve; Cranial Nerve XI
. Long thoracic nerve; C5, C6, C7
. Dorsal scapular nerve; C5
. Suprascapular nerve; C5, C6
. Thoracodorsal nerve; C6, C7, C8

Correct Answer & Explanation

. Long thoracic nerve; C5, C6, C7

Explanation

Medial scapular winging is caused by paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. The long thoracic nerve arises from the ventral rami of the C5, C6, and C7 nerve roots.

Question 227

Topic: Shoulder Pathology

A 40-year-old female presents with vague shoulder pain, weakness in overhead activities, and a visible deformity of the back 3 months after a lymph node biopsy in the posterior triangle of the neck. Physical examination demonstrates lateral winging of the scapula, which worsens with resisted shoulder abduction. Which muscle is paralyzed?

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

Correct Answer & Explanation

. Trapezius

Explanation

Lateral winging of the scapula is caused by paralysis of the trapezius muscle, which is innervated by the spinal accessory nerve (cranial nerve XI). This nerve is highly susceptible to iatrogenic injury during procedures in the posterior cervical triangle (e.g., lymph node biopsy). In contrast, medial winging of the scapula is caused by paralysis of the serratus anterior muscle secondary to a long thoracic nerve injury, typically observed when the patient pushes against a wall.

Question 228

Topic: Shoulder Pathology

A 40-year-old patient undergoes a radical neck dissection. Postoperatively, he notes shoulder weakness and an inability to abduct the arm above 90 degrees. Examination shows lateral winging of the scapula at rest, which worsens with attempted shoulder abduction. Injury to which nerve is most likely?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Injury to the spinal accessory nerve (CN XI) causes trapezius palsy, leading to lateral winging of the scapula (the scapula translates laterally and rotates inferiorly). This is a known complication of neck dissections. Medial winging is caused by serratus anterior palsy (long thoracic nerve injury) and is accentuated by forward elevation or wall push-ups.

Question 229

Topic: Shoulder Pathology

A 32-year-old carpenter sustained a blunt trauma to his lateral chest wall 6 months ago. He now presents with aching pain around the shoulder and difficulty lifting his arm above shoulder level. On examination, asking the patient to push against a wall with outstretched arms causes prominent medial and superior displacement of the inferior angle of the scapula. Which nerve is most likely injured?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial scapular winging (prominence of the medial border and inferior angle) is typically caused by paralysis of the serratus anterior, which is innervated by the long thoracic nerve. This is accentuated by asking the patient to push against a wall. Lateral winging is caused by trapezius paralysis (spinal accessory nerve injury).

Question 230

Topic: Shoulder Pathology

A 45-year-old female presents with severe right shoulder weakness 6 months after undergoing a radical neck dissection for squamous cell carcinoma. On physical examination, her right shoulder droops, she is unable to actively abduct her arm past 90 degrees, and there is noticeable lateral winging of the scapula when she pushes against a wall. Which of the following nerves has most likely been injured?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

The clinical presentation is classic for a spinal accessory nerve (CN XI) injury, a known complication of cervical lymph node biopsies or radical neck dissections. The spinal accessory nerve innervates the trapezius muscle. Paralysis of the trapezius leads to drooping of the shoulder, weakness in forward elevation and abduction, and lateral winging of the scapula. This is distinguished from medial winging, which is caused by a long thoracic nerve injury (serratus anterior palsy).

Question 231

Topic: Shoulder Pathology

Which of the following muscles acts to elevate the clavicle, and its integrity is specifically compromised in Rockwood Type V AC joint injuries?

. Pectoralis major
. Serratus anterior
. Latissimus dorsi
. Trapezius
. Rhomboid major

Correct Answer & Explanation

. Trapezius

Explanation

The trapezius muscle, along with the deltoid, attaches to the distal clavicle. In Rockwood Type V AC joint injuries, there is extensive stripping of the deltoid and trapezius muscles from the distal clavicle, contributing to the severe superior displacement. The trapezius muscle is a primary elevator of the clavicle, and its detachment further exacerbates the superior migration.

Question 232

Topic: Shoulder Pathology

A 45-year-old woman presents with isolated lateral scapular winging following a posterior cervical triangle lymph node biopsy. Which nerve was most likely injured, and what muscle does it innervate?

. Long thoracic nerve; serratus anterior
. Dorsal scapular nerve; rhomboids
. Spinal accessory nerve; trapezius
. Suprascapular nerve; supraspinatus
. Axillary nerve; deltoid

Correct Answer & Explanation

. Spinal accessory nerve; trapezius

Explanation

The spinal accessory nerve (CN XI) innervates the trapezius and is vulnerable to iatrogenic injury during procedures in the posterior cervical triangle. Injury results in lateral winging of the scapula.

Question 233

Topic: Shoulder Pathology

A 5-year-old girl presents with a high-riding left scapula and restricted shoulder abduction. Imaging reveals an omovertebral bone bridging the cervical spine and the scapula. If a Woodward procedure is planned, which of the following structures is most at risk during the release of the superior medial angle of the scapula?

. Spinal accessory nerve
. Dorsal scapular nerve
. Suprascapular nerve
. Long thoracic nerve
. Brachial plexus

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

During a Woodward procedure for Sprengel deformity, the spinal accessory nerve is at risk when detaching the trapezius from the scapula, especially at the superomedial angle where the omovertebral bone typically attaches.

Question 234

Topic: Shoulder Pathology

A 28-year-old athlete presents with shoulder weakness. Physical examination reveals prominent medial winging of the scapula when the patient pushes against a wall. Which of the following nerves is most likely injured?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial winging of the scapula is caused by paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. Lateral winging is caused by trapezius dysfunction, innervated by the spinal accessory nerve.

Question 235

Topic: Shoulder Pathology

A 25-year-old man sustains a stab wound to the lateral aspect of his chest wall. He subsequently demonstrates winging of the scapula, especially when pushing against a wall. Which of the following muscles is paralyzed?

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

Correct Answer & Explanation

. Serratus anterior

Explanation

Winging of the scapula, particularly prominent with forward pushing, is the classic sign of paralysis of the serratus anterior muscle. This muscle is innervated by the long thoracic nerve (C5, C6, C7), which courses superficially along the lateral chest wall, making it vulnerable to penetrating trauma or surgical injury.

Question 236

Topic: Shoulder Pathology

A 25-year-old motorcyclist sustains a traction injury to his right brachial plexus. Clinical examination shows a flail right arm, Horner syndrome (ptosis, miosis, anhidrosis), and paralysis of the rhomboids and serratus anterior. These findings strongly suggest an injury at which specific anatomical level?

. Post-ganglionic nerve roots
. Pre-ganglionic nerve roots
. Upper trunk
. Posterior cord
. Medial cord

Correct Answer & Explanation

. Pre-ganglionic nerve roots

Explanation

Horner syndrome (indicating T1 sympathetic ganglion involvement) and paralysis of muscles innervated by root-level branches (dorsal scapular and long thoracic nerves) indicate a severe pre-ganglionic root avulsion injury. This level of injury is typically not amenable to direct nerve repair.

Question 237

Topic: Shoulder Pathology

When performing a Woodward procedure for a severe Sprengel's deformity, which neurovascular structure is at highest risk during the caudal relocation of the scapula?

. Axillary nerve
. Spinal accessory nerve
. Brachial plexus
. Suprascapular nerve
. Long thoracic nerve

Correct Answer & Explanation

. Brachial plexus

Explanation

The brachial plexus is at significant risk of stretch injury during the distal relocation of the scapula. Clavicle osteotomy is often performed concurrently in severe cases to shorten the distance and protect the plexus.

Question 238

Topic: Shoulder Pathology

During the Woodward procedure for Sprengel's deformity, the origins of specific muscles are detached from the spinous processes to allow inferior mobilization of the scapula. Which nerve is most directly at risk of injury during the mobilization of the trapezius muscle?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

The spinal accessory nerve (CN XI) innervates the trapezius and is at risk during its detachment and mobilization in the Woodward procedure. Careful dissection is required to avoid causing a winged scapula.

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