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9. Shoulder and Elbow MCQs

Practice Set 10 of 197

This practice set contains high-yield board review questions covering key concepts in 9. Shoulder and Elbow. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 181

Topic: Elbow & Forearm

A 45-year-old female falls on an outstretched hand and sustains a Hahn-Steinthal (Type I) capitellum fracture. Which of the following accurately describes this fracture pattern?

. A large osseous fragment of the capitellum involving a significant portion of the trochlea
. An articular cartilage shear fracture with very little subchondral bone
. A comminuted fracture of the capitellum
. A coronal shear fracture extending into the lateral epicondyle
. An avulsion fracture of the lateral collateral ligament origin

Correct Answer & Explanation

. A large osseous fragment of the capitellum involving a significant portion of the trochlea

Explanation

A Hahn-Steinthal (Type I) fracture involves a large osseous piece of the capitellum and often includes a portion of the lateral trochlea. In contrast, a Kocher-Lorenz (Type II) fracture is an articular cartilage shear with minimal subchondral bone.

Question 182

Topic: Elbow & Forearm

A 30-year-old man falls from a height, sustaining a comminuted radial head fracture and distal radioulnar joint (DRUJ) dislocation. Which of the following management steps is strictly contraindicated?

. Open reduction and internal fixation of the radial head
. Radial head arthroplasty
. Radial head excision alone
. Pinning of the DRUJ in supination
. Repair of the triangular fibrocartilage complex

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

In an Essex-Lopresti injury, the interosseous membrane is disrupted. Excision of the radial head without replacement removes the proximal stabilizing column, leading to severe proximal radial migration and chronic wrist dysfunction.

Question 183

Topic: Elbow & Forearm

What is the recommended sequence for the surgical reconstruction of a 'terrible triad' injury of the elbow (radial head fracture, coronoid fracture, and elbow dislocation)?

. Radial head fixation/replacement, coronoid fixation, LCL repair
. Coronoid fixation, radial head fixation/replacement, LCL repair
. LCL repair, radial head fixation/replacement, coronoid fixation
. Coronoid fixation, MCL repair, radial head fixation
. MCL repair, LCL repair, radial head replacement

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/replacement, LCL repair

Explanation

The standard surgical sequence for a terrible triad injury begins deep-to-superficial: repairing the coronoid first, followed by the radial head, and finally repairing the lateral collateral ligament (LCL) complex. MCL repair is only considered if the elbow remains unstable after these steps.

Question 184

Topic: Elbow & Forearm

A 35-year-old male presents with lateral elbow pain and mechanical clicking when pushing out of a chair. Examination reveals a positive lateral pivot-shift test. Deficiency of which of the following structures is the primary cause of his symptoms?

. Annular ligament
. Lateral ulnar collateral ligament (LUCL)
. Radial collateral ligament
. Medial ulnar collateral ligament
. Biceps tendon

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The patient describes symptoms of posterolateral rotatory instability (PLRI) of the elbow. PLRI is primarily caused by an injury or deficiency of the lateral ulnar collateral ligament (LUCL).

Question 185

Topic: Elbow & Forearm

Compared to a single anterior incision, a two-incision approach for distal biceps tendon repair is associated with a higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve palsy
. Posterior interosseous nerve (PIN) palsy
. Radioulnar synostosis
. Superficial radial nerve injury
. Tendon rerupture

Correct Answer & Explanation

. Radioulnar synostosis

Explanation

The two-incision (Boyd-Anderson) approach historically carries a higher risk of heterotopic ossification and radioulnar synostosis compared to a single-incision anterior approach. Single-incision approaches carry a higher risk of lateral antebrachial cutaneous neuropraxia.

Question 186

Topic: Elbow & Forearm

A 40-year-old sustains an Essex-Lopresti injury with an unreconstructible comminuted radial head fracture, tear of the interosseous membrane, and distal radioulnar joint (DRUJ) dislocation. What is the most appropriate management of the radial head?

. Radial head excision alone
. Radial head arthroplasty
. Silicone radial head replacement
. Fragment excision and delayed reconstruction
. Radiocapitellar fusion

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

In an Essex-Lopresti injury, longitudinal forearm stability is compromised due to the interosseous membrane tear. Radial head arthroplasty is mandatory if the radial head cannot be fixed, to prevent proximal migration of the radius and chronic DRUJ instability.

Question 187

Topic: Elbow & Forearm

A 6-year-old sustains a Bado Type I Monteggia fracture. Closed reduction of the ulnar shaft is achieved perfectly, but the radial head remains dislocated. What is the most common cause of failure to achieve closed reduction of the radiocapitellar joint in this scenario?

. Interposition of the annular ligament
. Biceps tendon subluxation
. Inadequate length restoration of the ulna
. Radial nerve entrapment
. Coronoid fracture fragment

Correct Answer & Explanation

. Interposition of the annular ligament

Explanation

While inadequate ulnar reduction is the most common overall reason for persistent radial head subluxation, if the ulna is anatomically reduced and the radial head remains out, the most common block to reduction is interposition of the torn annular ligament or joint capsule.

Question 188

Topic: 9. Shoulder and Elbow

A 14-year-old boy with multiple palpable bony prominences around his knees and shoulders is diagnosed with Multiple Hereditary Exostoses (MHE). The genetic mutation in this condition directly impairs the synthesis of which substance?

. Hyaluronic acid
. Heparan sulfate
. Type I collagen
. Aggrecan
. Elastin

Correct Answer & Explanation

. Heparan sulfate

Explanation

MHE is caused by mutations in the EXT1 or EXT2 genes, which encode glycosyltransferases essential for the biosynthesis of heparan sulfate. Loss of heparan sulfate leads to abnormal Indian hedgehog (Ihh) signaling and aberrant cartilage growth.

Question 189

Topic: Elbow & Forearm

A 7-year-old girl presents with an acute fracture of her proximal radial metaphysis. Although a line down the shaft of the radius intersects the center of the capitellum, the articular surface of the radial head is angled 20° from the anatomic position as compared with the other elbow. You recommend:

. Observation with follow-up in 1 week
. C losed manipulation with a pronation maneuver
. C losed manipulation with a supination maneuver
. Closed manipulation with a percutaneous K-wire
. Open reduction and internal fixation

Correct Answer & Explanation

. Observation with follow-up in 1 week

Explanation

Proximal radial fractures have excellent remodeling potential, especially if the angulation is less than 30°. Manipulation is not necessary, and the risk of stiffness from any invasive procedure is not worthwhile.

Question 190

Topic: 9. Shoulder and Elbow
A 72-year-old patient presents with severe shoulder pain, pseudoparalysis, and radiographs showing superior migration of the humeral head with "acetabularization" of the acromion. What is the most appropriate surgical treatment?
. Arthroscopic rotator cuff repair
. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Shoulder arthrodesis

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

The clinical and radiographic findings describe severe rotator cuff tear arthropathy (Hamada stage III or higher). Reverse total shoulder arthroplasty is the treatment of choice as it shifts the center of rotation medially and inferiorly, allowing the deltoid to effectively elevate the arm.

Question 191

Topic: Elbow & Forearm

Which of the following is not a common finding in the forearms of patients who have multiple hereditary exostoses:

. Radial head subluxation or dislocation
. Limitation of rotation
. Decreased slope of the distal radial articular surface
. Subluxation of the carpus toward the ulna
. Decreased length of the ulna

Correct Answer & Explanation

. Decreased length of the ulna

Explanation

Multiple hereditary exostosis is characterized by differential growth of the two bones. There is often decreased length of the ulna. This results in increased inclination of the distal radial articular surface, radial head subluxation, and subluxation of the carpus toward the ulna. The exostoses themselves may block rotation.

Question 192

Topic: 9. Shoulder and Elbow

A 3-year-old boy falls from a swing and injures his elbow. Radiographs show posteromedial displacement of the radius and ulna. A small fleck of bone is viewed on the radiograph that does not match the contralateral elbow. The most likely diagnosis is:

. Elbow dislocation
. Salter I disruption of the distal humerus
. Lateral condyle fracture with elbow dislocation
. Supracondylar fracture of the humerus
. Radial head fracture dislocation

Correct Answer & Explanation

. Lateral condyle fracture with elbow dislocation

Explanation

Isolated elbow dislocations are rare in very young children because the epiphysis is mostly cartilaginous. Supracondylar fractures usually occur at an older age and have an obvious fracture line. A Salter I injury does not have an osseous component. A radial head fracture-dislocation would not explain the disruption of the ulna-humerus articulation. A lateral condyle fracture-dislocation is the most likely diagnosis in this patient.

Question 193

Topic: 9. Shoulder and Elbow

A 3-year-old girl is brought to the ED holding her right arm pronated and flexed at the side after her father pulled her up by the wrist. Radiographs are unremarkable. What is the precise anatomic structure involved in this pathology?

. Annular ligament
. Quadrate ligament
. Ulnar collateral ligament
. Radial collateral ligament
. Interosseous membrane

Correct Answer & Explanation

. Annular ligament

Explanation

This presentation is classic for "Nursemaid's elbow," a subluxation of the radial head. It occurs when the annular ligament slips over the radial head and becomes interposed in the radiocapitellar joint.

Question 194

Topic: 9. Shoulder and Elbow

A 72-year-old woman presents with severe shoulder pain, pseudoparalysis, and inability to actively elevate her arm above 90 degrees. Radiographs show superior migration of the humeral head and advanced glenohumeral osteoarthritis. MRI confirms a massive, retracted rotator cuff tear. What is the most appropriate surgical treatment?

. Anatomic total shoulder arthroplasty
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic rotator cuff repair
. Latissimus dorsi tendon transfer

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is indicated for cuff tear arthropathy. It bypasses the deficient rotator cuff by medialiszing and lowering the center of rotation, allowing the deltoid to effectively elevate the arm.

Question 195

Topic: Elbow & Forearm

A patient with an irreparable high radial nerve palsy requires tendon transfers to restore wrist and finger extension. Which muscle is most commonly transferred to the extensor carpi radialis brevis (ECRB) to restore wrist extension?

. Pronator teres
. Flexor carpi ulnaris
. Palmaris longus
. Flexor digitorum superficialis
. Brachioradialis

Correct Answer & Explanation

. Pronator teres

Explanation

The pronator teres is the standard donor muscle transferred to the ECRB to restore strong and synergistic wrist extension in radial nerve palsy.

Question 196

Topic: 9. Shoulder and Elbow

A 72-year-old man presents with chronic right shoulder pain and pseudoparalysis. Radiographs demonstrate severe superior migration of the humeral head with an acromiohumeral distance of 2 mm and glenohumeral osteoarthritis (Hamada grade 4). What is the most reliable surgical option?

. Arthroscopic rotator cuff repair
. Latissimus dorsi tendon transfer
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Shoulder hemiarthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for older patients with massive rotator cuff tear arthropathy and pseudoparalysis. It medializes and distalizes the center of rotation, allowing the deltoid muscle to effectively elevate the arm without a functional rotator cuff.

Question 197

Topic: 9. Shoulder and Elbow

A 55-year-old manual laborer presents with right shoulder pain and weakness, particularly with external rotation. MRI reveals a massive, retracted tear of the supraspinatus and infraspinatus tendons with severe fatty infiltration (Goutallier stage 4). He has intact deltoid function. What is the most appropriate surgical option?

. Arthroscopic rotator cuff repair
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty
. Subacromial decompression alone

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In older or relatively low-demand patients with a massive, irreparable rotator cuff tear and severe fatty infiltration, a reverse total shoulder arthroplasty is indicated. It provides excellent pain relief and restores active elevation by utilizing the intact deltoid muscle.

Question 198

Topic: 9. Shoulder and Elbow

A 75-year-old man presents with chronic, intractable right shoulder pain and an inability to actively elevate his arm beyond 40 degrees (pseudoparalysis). Radiographs reveal a massive, retracted rotator cuff tear with superior migration of the humeral head articulating with the acromion. What is the most reliable surgical option?

. Arthroscopic rotator cuff repair
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Latissimus dorsi tendon transfer
. Shoulder hemiarthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In the setting of rotator cuff arthropathy with pseudoparalysis, a reverse total shoulder arthroplasty is the treatment of choice. It alters the center of rotation, allowing the deltoid to effectively elevate the arm without a functioning rotator cuff.

Question 199

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with severe shoulder pain and pseudoparalysis. Radiographs reveal a high-riding humeral head and severe glenohumeral osteoarthritis. She has a massive, irreparable rotator cuff tear. What is the most appropriate surgical treatment?

. Arthroscopic rotator cuff repair
. Latissimus dorsi tendon transfer
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Hemiarthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is indicated for rotator cuff tear arthropathy with pseudoparalysis. It relies on the deltoid muscle for elevation, bypassing the deficient rotator cuff and restoring overhead function.

Question 200

Topic: Elbow & Forearm

A patient sustained a mid-shaft humerus fracture and subsequently developed a complete radial nerve palsy. Three months later, there is no clinical or EMG evidence of recovery. Which muscle is most commonly transferred to the Extensor Carpi Radialis Brevis (ECRB) to restore wrist extension?

. Flexor carpi radialis (FCR)
. Pronator teres (PT)
. Palmaris longus (PL)
. Flexor carpi ulnaris (FCU)
. Flexor digitorum superficialis (FDS)

Correct Answer & Explanation

. Pronator teres (PT)

Explanation

In standard radial nerve palsy tendon transfers, the Pronator Teres (innervated by the median nerve) is transferred to the ECRB to effectively restore wrist extension.

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