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Shoulder Pathology MCQs

Practice Set 7 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 121

Topic: Shoulder Pathology

A 22-year-old male cyclist falls onto his left shoulder and sustains a completely displaced midshaft clavicle fracture with 2.5 cm of shortening. He undergoes open reduction and internal fixation (ORIF) with a superiorly placed precontoured locking plate. Which of the following nerves is at greatest risk of injury during the surgical approach?

. Suprascapular nerve
. Axillary nerve
. Spinal accessory nerve
. Supraclavicular nerves
. Long thoracic nerve

Correct Answer & Explanation

. Supraclavicular nerves

Explanation

The supraclavicular nerves (derived from C3, C4) provide sensory innervation over the clavicle and anterosuperior chest wall. They cross superficial to the clavicle and are frequently injured, stretched, or deliberately divided during the surgical approach for clavicle ORIF, resulting in a characteristic numb patch inferior to the incision.

Question 122

Topic: Shoulder Pathology

A 25-year-old motorcyclist sustains a traumatic brachial plexus injury. Examination reveals paralysis of the rhomboids, serratus anterior, and all muscles of the upper extremity, accompanied by ipsilateral ptosis, miosis, and anhidrosis. What does this clinical picture indicate regarding the C8 and T1 nerve roots?

. Postganglionic rupture
. Incomplete neurapraxia
. Axonotmesis
. Preganglionic avulsion
. Intraspinal neuroma

Correct Answer & Explanation

. Preganglionic avulsion

Explanation

In brachial plexus trauma, distinguishing between preganglionic (avulsion) and postganglionic (rupture) injuries is critical for management. Horner syndrome (ptosis, miosis, anhidrosis) indicates disruption of the sympathetic chain, which exits the spinal cord via the T1 root proximally (preganglionic). Additionally, paralysis of the serratus anterior and rhomboids indicates involvement of the long thoracic and dorsal scapular nerves, respectively, which branch off very proximally from the roots. These signs collectively point to a preganglionic avulsion, which carries a poor prognosis for spontaneous recovery and typically requires nerve transfers rather than primary repair or grafting.

Question 123

Topic: Shoulder Pathology

A 25-year-old male presents with medial winging of the scapula after a heavy lifting injury. He is unable to forward elevate his arm past 90 degrees. Injury to which of the following nerves is most likely responsible?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial winging of the scapula is caused by serratus anterior paralysis, innervated by the long thoracic nerve. Lateral winging is associated with trapezius dysfunction secondary to spinal accessory nerve injury.

Question 124

Topic: Shoulder Pathology

Which of the following patient populations has the highest incidence and worst prognosis for developing adhesive capsulitis (frozen shoulder)?

. Patients with hyperthyroidism
. Patients with rheumatoid arthritis
. Patients with Type 1 diabetes mellitus
. Patients with a history of stroke
. Patients with cervical radiculopathy

Correct Answer & Explanation

. Patients with Type 1 diabetes mellitus

Explanation

Diabetes mellitus, particularly Type 1, is a major risk factor for adhesive capsulitis. These patients typically have a more protracted clinical course, severe stiffness, and worse functional outcomes compared to idiopathic cases.

Question 125

Topic: Shoulder Pathology

A 24-year-old pitcher presents with vague shoulder pain and a prominent medial border of the right scapula, especially when performing a wall push-up. EMG confirms an isolated nerve palsy. Which of the following statements regarding the affected nerve is accurate?

. It originates from the posterior cord of the brachial plexus.
. It passes deep to the serratus anterior muscle.
. It is a branch of the upper trunk of the brachial plexus.
. It passes superficial to the serratus anterior muscle.
. It provides sensory innervation to the lateral chest wall.

Correct Answer & Explanation

. It passes superficial to the serratus anterior muscle.

Explanation

Medial scapular winging is caused by a long thoracic nerve palsy. The long thoracic nerve (C5-C7 roots) is unique because it courses superficial to the serratus anterior muscle it innervates, making it susceptible to blunt trauma and traction injuries.

Question 126

Topic: Shoulder Pathology

A 28-year-old overhead athlete undergoes arthroscopic bursectomy for refractory snapping scapula syndrome. Which of the following bursae is most commonly implicated and located between the serratus anterior and the subscapularis?

. Infraserratus bursa
. Supraserratus bursa
. Trapezoid bursa
. Subscapularis bursa
. Subcoracoid bursa

Correct Answer & Explanation

. Supraserratus bursa

Explanation

The supraserratus bursa is located between the deep surface of the subscapularis and the superficial surface of the serratus anterior. Inflammation of this bursa or the infraserratus bursa is a primary cause of snapping scapula syndrome.

Question 127

Topic: Shoulder Pathology

A patient with thoracic outlet syndrome experiences compression of the lower trunk of the brachial plexus. This compression typically occurs in the interscalene triangle. What are the anatomical borders of the interscalene triangle?

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

Correct Answer & Explanation

. Anterior scalene, middle scalene, and the first rib

Explanation

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

Question 128

Topic: Shoulder Pathology

A 35-year-old male suffers a traction injury to his brachial plexus following a motorcycle accident. Examination reveals profound winging of the scapula with forward elevation of the arm. The injured nerve originates from which of the following anatomic components?

. C5, C6, C7 nerve roots
. Upper trunk
. Posterior cord
. Medial cord
. C8, T1 nerve roots

Correct Answer & Explanation

. C5, C6, C7 nerve roots

Explanation

Scapular winging indicates paralysis of the serratus anterior, which is innervated by the long thoracic nerve. This nerve originates directly from the ventral rami of the C5, C6, and C7 nerve roots before the formation of the trunks.

Question 129

Topic: Shoulder Pathology

Following a motorcycle accident, a 25-year-old male complains of severe shoulder weakness. Physical examination reveals an inability to actively elevate the arm above 90 degrees and prominent medial winging of the scapula when he pushes against a wall. The injured nerve responsible for this clinical presentation originates directly from which anatomical level of the brachial plexus?

. Roots
. Trunks
. Divisions
. Cords
. Branches

Correct Answer & Explanation

. Roots

Explanation

Medial winging of the scapula indicates paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. The long thoracic nerve arises directly from the anterior rami of the C5, C6, and C7 nerve roots. The dorsal scapular nerve (rhomboids) also originates from the root level (C5).

Question 130

Topic: Shoulder Pathology

A 45-year-old female undergoes a posterior cervical lymph node biopsy. Several weeks postoperatively, she presents with persistent shoulder aching, weakness with overhead activities, and prominent lateral winging of her scapula on physical examination. Damage to which of the following anatomical structures is most likely responsible for these findings?

. A nerve emerging from C5-C7 that descends on the superficial surface of the serratus anterior
. A nerve passing through the quadrangular space with the posterior circumflex humeral artery
. A cranial nerve that crosses the posterior triangle of the neck superficially
. A nerve piercing the middle scalene to supply the levator scapulae and rhomboids
. A nerve passing through the suprascapular notch beneath the superior transverse scapular ligament

Correct Answer & Explanation

. A cranial nerve that crosses the posterior triangle of the neck superficially

Explanation

The clinical scenario describes a spinal accessory nerve (CN XI) injury, a well-known complication of procedures in the posterior triangle of the neck (such as a lymph node biopsy). CN XI innervates the trapezius muscle. Injury leads to trapezius palsy, presenting as shoulder drooping, weakness in active forward elevation and abduction beyond 90 degrees, and lateral winging of the scapula. Option A describes the long thoracic nerve, injury to which causes medial winging (serratus anterior palsy).

Question 131

Topic: Shoulder Pathology

A 40-year-old woman develops lateral scapular winging after a cervical lymph node biopsy. Which nerve was most likely injured?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Injury to the spinal accessory nerve paralyzes the trapezius, resulting in lateral scapular winging. Medial winging is caused by long thoracic nerve injury (serratus anterior paralysis).

Question 132

Topic: Shoulder Pathology

A 35-year-old woman underwent a cervical lymph node biopsy in the posterior triangle of her neck 6 weeks ago. She now complains of a drooping right shoulder, dull aching pain, and an inability to actively elevate her arm above the horizontal plane. Physical examination reveals lateral winging of the scapula. Which of the following nerves was most likely injured?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Injury to the spinal accessory nerve (CN XI) in the posterior triangle leads to trapezius paralysis. This presents with a drooping shoulder, weakness in overhead elevation, and lateral scapular winging.

Question 133

Topic: Shoulder Pathology

A 25-year-old male presents with pronounced medial winging of his right scapula after sustaining a direct blow to the lateral chest wall during a hockey game. He is unable to perform a wall push-up without the scapula lifting off the thorax. Which muscle and corresponding nerve are primarily affected?

. Trapezius innervated by the spinal accessory nerve
. Serratus anterior innervated by the long thoracic nerve
. Rhomboids innervated by the dorsal scapular nerve
. Latissimus dorsi innervated by the thoracodorsal nerve
. Levator scapulae innervated by C3-C4 branches

Correct Answer & Explanation

. Serratus anterior innervated by the long thoracic nerve

Explanation

Medial winging of the scapula is characteristic of serratus anterior dysfunction, which is caused by an injury to the long thoracic nerve.

Question 134

Topic: Shoulder Pathology

A 26-year-old male presents with winging of his right scapula following a protracted illness.

On physical examination, the medial border of the scapula is prominent, especially when he pushes against a wall. Which nerve is most likely affected?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial scapular winging is caused by serratus anterior paralysis, which is innervated by the long thoracic nerve. Lateral winging is typically due to trapezius dysfunction (spinal accessory nerve).

Question 135

Topic: Shoulder Pathology

A 65-year-old man presents with an inability to actively elevate his arm above 60 degrees. Passive elevation is full. An intra-articular injection of local anesthetic completely restores his active elevation to 150 degrees. This clinical finding most likely indicates:

. True pseudoparalysis due to an irreparable massive rotator cuff tear
. Axillary nerve palsy
. Pseudoparesis secondary to pain inhibition
. Adhesive capsulitis
. Cervical radiculopathy

Correct Answer & Explanation

. Pseudoparesis secondary to pain inhibition

Explanation

True pseudoparalysis implies a mechanical inability to elevate the arm that does not improve with pain relief. Restoration of active motion after a local anesthetic injection confirms pseudoparesis driven by pain inhibition.

Question 136

Topic: Shoulder Pathology

A 26-year-old manual laborer complains of painful crepitus and a loud snapping sensation at the superomedial border of his scapula with movement. Following failure of extensive nonoperative management, surgical intervention is planned. Which structure is most commonly targeted for resection?

. Subacromial bursa
. Subdeltoid bursa
. Subscapularis bursa
. Scapulothoracic bursa and superomedial scapular angle
. Coracobrachial bursa

Correct Answer & Explanation

. Scapulothoracic bursa and superomedial scapular angle

Explanation

Snapping scapula syndrome is frequently caused by an inflamed scapulothoracic bursa and/or a prominent superomedial scapular angle. Operative treatment typically consists of bursectomy and resection of the superomedial angle.

Question 137

Topic: Shoulder Pathology

A 28-year-old man presents with dull, aching shoulder pain and prominent medial scapular winging that worsens when pushing against a wall. Examination reveals weakness of the serratus anterior. Injury to which nerve is the most likely cause?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial scapular winging is caused by serratus anterior paralysis due to long thoracic nerve injury. It is classically accentuated by having the patient push forward against a wall.

Question 138

Topic: Shoulder Pathology

A 45-year-old woman presents with shoulder pain and difficulty lifting her arm after a lymph node biopsy in the posterior cervical triangle. On examination, the superior angle of the scapula is displaced laterally, and winging worsens with arm abduction. What is the most likely diagnosis?

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

Correct Answer & Explanation

. Spinal accessory nerve palsy

Explanation

Spinal accessory nerve palsy (often iatrogenic from neck procedures) paralyzes the trapezius, causing lateral scapular winging. Long thoracic nerve palsy paralyzes the serratus anterior, resulting in medial scapular winging.

Question 139

Topic: Shoulder Pathology

A 28-year-old man presents with persistent shoulder pain and weakness 4 months after a blunt trauma to his right neck and shoulder region. On examination, forward elevation of the arm against resistance exacerbates the prominence of the medial border of the scapula. Which of the following nerves is most likely injured?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Prominence of the medial border of the scapula with forward elevation indicates medial winging, which is caused by serratus anterior weakness. The serratus anterior is innervated by the long thoracic nerve.

Question 140

Topic: Shoulder Pathology

A 24-year-old male sustains a traction injury to his shoulder and presents with lateral scapular winging. Which of the following nerve-muscle combinations is most likely injured?

. Long thoracic nerve, serratus anterior
. Spinal accessory nerve, trapezius
. Dorsal scapular nerve, rhomboids
. Suprascapular nerve, infraspinatus
. Axillary nerve, deltoid

Correct Answer & Explanation

. Spinal accessory nerve, trapezius

Explanation

Lateral scapular winging is typically caused by injury to the spinal accessory nerve, resulting in trapezius palsy. Medial winging is caused by long thoracic nerve injury, leading to serratus anterior palsy.

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