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9. Shoulder and Elbow MCQs

Practice Set 101 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 2001

Topic: 9. Shoulder and Elbow

During surgical management of a 'terrible triad' injury of the elbow, after fixing the coronoid and replacing the radial head, the elbow remains unstable in extension. What is the next most appropriate step?

. Repair the medial collateral ligament
. Repair the lateral ulnar collateral ligament
. Apply a hinged external fixator
. Perform an olecranon osteotomy
. Cast the elbow in 90 degrees of flexion

Correct Answer & Explanation

. Repair the lateral ulnar collateral ligament

Explanation

The standard surgical algorithm for terrible triad injuries involves fixing the coronoid, addressing the radial head, and repairing the lateral ulnar collateral ligament (LUCL). The medial collateral ligament is typically only addressed or an external fixator placed if instability persists after LUCL repair.

Question 2002

Topic: 9. Shoulder and Elbow

A 40-year-old man sustains a severe traction injury to his right arm. Examination reveals massive swelling around the shoulder girdle and absent radial and ulnar pulses. Radiographs show extreme lateral displacement of the scapula. What is the most critical next step in management?

. Immediate brachial plexus exploration
. CT angiography of the upper extremity
. Closed reduction of the shoulder joint
. Application of a shoulder spica cast
. Electromyography (EMG)

Correct Answer & Explanation

. CT angiography of the upper extremity

Explanation

Scapulothoracic dissociation involves a high-energy disruption of the scapulothoracic articulation and is associated with a very high rate of severe subclavian or axillary artery injury. Immediate vascular assessment via CT angiography or formal angiogram is critical to prevent limb loss.

Question 2003

Topic: Elbow & Forearm
A 40-year-old woman falls onto her outstretched hand and presents with lateral elbow pain. A lateral elbow radiograph demonstrates a 'double arc' sign. What specific type of injury does this radiographic finding represent?
. Type I capitellum fracture (Hahn-Steinthal)
. Type II capitellum fracture (Kocher-Lorenz)
. Type III capitellum fracture (Broberg-Morrey)
. Type IV capitellum fracture (McKee modification)
. Radial head fracture with an associated loose body

Correct Answer & Explanation

. Type IV capitellum fracture (McKee modification)

Explanation

The 'double arc' sign on a lateral elbow radiograph represents the displaced subchondral bone of the capitellum and the lateral ridge of the trochlea. This is pathognomonic for a Type IV capitellum fracture (McKee modification), which indicates extension into the trochlea.

Question 2004

Topic: Elbow & Forearm

A 45-year-old weightlifter feels a sudden 'pop' in his anterior elbow during a heavy deadlift. Examination reveals a positive hook test. He undergoes a single-incision anterior approach for distal biceps tendon repair. What is the most common complication associated with this specific surgical approach?

. Lateral antebrachial cutaneous nerve neuropraxia
. Posterior interosseous nerve palsy
. Massive heterotopic ossification
. Tendon re-rupture
. Median nerve transection

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve neuropraxia

Explanation

The single-incision anterior approach for distal biceps tendon repair retracts structures laterally, carrying a high risk of injury to the lateral antebrachial cutaneous nerve. This typically results in transient neuropraxia and numbness over the lateral forearm.

Question 2005

Topic: Elbow & Forearm

A 35-year-old woman undergoes ORIF for a Mason Type II radial head fracture with a mechanical block. To avoid hardware impingement on the proximal radioulnar joint during forearm rotation, plates must be placed within the radial head 'safe zone.' Which clinical landmarks define this safe zone?

. Between the supinator crest and the bicipital tuberosity
. A 90-degree arc defined by projecting the radial styloid and Lister's tubercle proximally with the forearm in neutral
. Directly medial to the bicipital tuberosity
. Posterior to the radial tuberosity
. Directly anterior to the radial neck

Correct Answer & Explanation

. A 90-degree arc defined by projecting the radial styloid and Lister's tubercle proximally with the forearm in neutral

Explanation

The non-articulating 'safe zone' of the radial head is a 90- to 110-degree lateral arc. Intraoperatively, it can be reliably identified by keeping the forearm in neutral rotation and using the proximal projections of the radial styloid and Lister's tubercle as boundaries.

Question 2006

Topic: 9. Shoulder and Elbow

A 35-year-old man sustains a 'terrible triad' injury of the elbow. Intraoperatively, the coronoid fracture is fixed, the comminuted radial head is replaced, and the lateral ulnar collateral ligament (LUCL) is repaired. During range of motion testing, the elbow remains persistently unstable and subluxates in 30 degrees of extension. What is the next most appropriate step?

. Repair the medial collateral ligament (MCL)
. Re-resect the radial head
. Perform a primary ulnohumeral arthrodesis
. Repair the brachialis tendon
. Immobilize the elbow in full extension

Correct Answer & Explanation

. Repair the medial collateral ligament (MCL)

Explanation

The surgical algorithm for terrible triad injuries is: fix the coronoid, fix/replace the radial head, and repair the LCL complex. If the elbow remains unstable after these steps, the MCL should be repaired or a hinged external fixator applied.

Question 2007

Topic: Elbow & Forearm
A 40-year-old woman falls on an outstretched hand and sustains a comminuted, unfixable Mason type III radial head fracture combined with distal radioulnar joint instability (Essex-Lopresti lesion). What is the most appropriate management of the radial head?
. Radial head excision alone
. Open reduction and internal fixation with a mini-fragment plate
. Radial head arthroplasty
. Closed reduction and casting in supination
. Radial head excision with immediate silastic spacer replacement

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

In an Essex-Lopresti injury, the interosseous membrane is disrupted, leading to longitudinal radioulnar instability. Radial head excision is absolutely contraindicated; radial head arthroplasty is required to restore longitudinal stability.

Question 2008

Topic: 9. Shoulder and Elbow

A 19-year-old football player presents with shortness of breath, dysphagia, and a choking sensation after a direct blow to the medial aspect of his shoulder. Plain radiographs of the shoulder and clavicle are inconclusive. What is the most appropriate next diagnostic step?

. Ultrasound of the sternoclavicular joint
. MRI of the brachial plexus
. CT scan of the chest and sternoclavicular joints
. Repeat AP, lateral, and axillary radiographs of the shoulder
. Diagnostic arthroscopy of the sternoclavicular joint

Correct Answer & Explanation

. CT scan of the chest and sternoclavicular joints

Explanation

The patient's symptoms (dysphagia, shortness of breath) strongly suggest a posterior sternoclavicular dislocation, which can compress the trachea and great vessels. A CT scan is the gold standard imaging modality to definitively diagnose and evaluate the direction of sternoclavicular dislocations.

Question 2009

Topic: 9. Shoulder and Elbow

According to the O'Driscoll classification of coronoid fractures, an isolated fracture of the anteromedial facet of the coronoid is pathognomonic for which specific instability pattern of the elbow?

. Terrible triad of the elbow
. Varus posteromedial rotatory instability
. Valgus extension overload syndrome
. Posterolateral rotatory instability
. Isolated radial head longitudinal instability

Correct Answer & Explanation

. Varus posteromedial rotatory instability

Explanation

Anteromedial facet fractures of the coronoid result from varus posteromedial rotatory forces. This injury pattern typically involves disruption of the lateral collateral ligament complex and can lead to rapid arthrosis if the facet is not stabilized.

Question 2010

Topic: Elbow & Forearm

A 35-year-old man falls from a height and sustains a 'terrible triad' injury to his elbow. When proceeding with operative management, what is the most accepted sequence of surgical repair to restore elbow stability?

. Lateral collateral ligament, radial head, coronoid
. Coronoid, lateral collateral ligament, radial head
. Coronoid, radial head, lateral collateral ligament
. Radial head, coronoid, lateral collateral ligament
. Radial head, lateral collateral ligament, coronoid

Correct Answer & Explanation

. Coronoid, radial head, lateral collateral ligament

Explanation

The classic sequence for repairing a terrible triad injury proceeds from deep to superficial. The coronoid is addressed first, followed by the radial head, and finally the lateral collateral ligament complex.

Question 2011

Topic: Elbow & Forearm

A 40-year-old woman presents with elbow pain after a fall on an outstretched hand. The lateral radiograph reveals a 'double arc' sign. Which of the following is the most likely diagnosis?

. Type II radial head fracture
. Type IV capitellum fracture
. Coronoid process fracture
. Olecranon fracture
. Supracondylar humerus fracture

Correct Answer & Explanation

. Type IV capitellum fracture

Explanation

The 'double arc' sign on a lateral elbow radiograph represents the subchondral bone of the capitellum and the lateral trochlear ridge. It is pathognomonic for a Type IV (McKee modification) capitellum fracture that extends medially into the trochlea.

Question 2012

Topic: Elbow & Forearm

A 30-year-old manual laborer sustains a comminuted radial head fracture, wrist pain, and distal radioulnar joint (DRUJ) instability. If the radial head is excised and not replaced, what is the most likely long-term complication?

. Cubitus varus deformity
. Proximal migration of the radius and ulnocarpal impaction
. Median nerve palsy
. Heterotopic ossification of the wrist
. Posterior interosseous nerve palsy

Correct Answer & Explanation

. Proximal migration of the radius and ulnocarpal impaction

Explanation

This presentation describes an Essex-Lopresti injury, which involves a radial head fracture, interosseous membrane tear, and DRUJ disruption. Excision of the radial head without replacement leads to proximal radial migration and severe ulnocarpal impaction.

Question 2013

Topic: 9. Shoulder and Elbow

Following a closed reduction of a simple posterolateral elbow dislocation in a 40-year-old male, the elbow is noted to be stable in pronation and flexion but subluxates in full extension. What is the best rehabilitation protocol?

. Cast immobilization in 90 degrees of flexion for 6 weeks
. Cast immobilization in full extension for 3 weeks
. Early active range of motion in a hinged brace with an extension block
. Immediate unconstrained aggressive passive stretching
. Static splinting in supination and extension

Correct Answer & Explanation

. Early active range of motion in a hinged brace with an extension block

Explanation

Early active range of motion with an extension block prevents stiffness while protecting the healing collateral ligaments. Active muscle contraction also provides dynamic stability to the joint during rehabilitation.

Question 2014

Topic: Elbow & Forearm

A 45-year-old man falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. Which of the following is the standard recommended sequence of surgical reconstruction?

. MCL repair, radial head fixation, coronoid fixation, LCL repair
. Coronoid fixation, radial head fixation/replacement, LCL repair, MCL repair (if needed)
. Radial head replacement, LCL repair, coronoid fixation, MCL repair
. LCL repair, coronoid fixation, radial head replacement
. MCL repair, coronoid fixation, radial head replacement

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/replacement, LCL repair, MCL repair (if needed)

Explanation

The standard surgical algorithm for a terrible triad injury begins with restoring deep to superficial and anterior to posterior structures. This typically involves coronoid fixation first, followed by radial head fixation or replacement, and finally LCL complex repair.

Question 2015

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman with rotator cuff tear arthropathy and pseudoparalysis undergoes a reverse total shoulder arthroplasty (RTSA). Which of the following muscles provides the primary motive force for active elevation postoperatively?

. Supraspinatus
. Subscapularis
. Deltoid
. Pectoralis major
. Teres minor

Correct Answer & Explanation

. Deltoid

Explanation

Reverse total shoulder arthroplasty medializes and distalizes the center of rotation, increasing the moment arm and resting tension of the deltoid muscle. This allows the deltoid to effectively compensate for the deficient rotator cuff to provide active anterior elevation.

Question 2016

Topic: Elbow & Forearm

A 6-year-old boy sustains a Bado Type I Monteggia fracture-dislocation. Closed reduction of the ulna fracture is achieved and stabilized with an intramedullary wire, but the radial head remains anteriorly dislocated. What is the most appropriate next step in management?

. Open reduction of the radial head and annular ligament reconstruction
. Resection of the radial head
. Critically assess and correct the ulnar reduction
. Application of a hinged external fixator
. Radial head pinning to the capitellum

Correct Answer & Explanation

. Critically assess and correct the ulnar reduction

Explanation

In pediatric Monteggia fractures, the radial head dislocation almost always reduces once the ulnar fracture is anatomically reduced and aligned. If the radial head remains dislocated, the surgeon must first critically evaluate the ulnar reduction (ruling out plastic deformation) before attempting open reduction of the radiocapitellar joint.

Question 2017

Topic: Elbow & Forearm

A 45-year-old construction worker falls from a ladder and sustains an elbow dislocation. Radiographs reveal a posterior elbow dislocation associated with a radial head fracture and a coronoid fracture. During surgical reconstruction of this 'terrible triad' injury, what is the standard sequence of repair?

. Lateral collateral ligament (LCL), coronoid, radial head
. Radial head, coronoid, LCL
. Coronoid, radial head, LCL
. LCL, radial head, coronoid
. Coronoid, LCL, radial head

Correct Answer & Explanation

. Coronoid, radial head, LCL

Explanation

The standard surgical sequence for a terrible triad injury proceeds from deep/medial to superficial/lateral. The coronoid is fixed first to restore anterior stability, followed by radial head repair or replacement, and finally the LCL complex is repaired.

Question 2018

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with chronic right shoulder pain and pseudoparalysis, unable to actively elevate her arm past 40 degrees. Radiographs show severe glenohumeral arthritis with superior migration of the humeral head articulating with the acromion. Which procedure provides the most predictable improvement in function?

. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic superior capsular reconstruction
. Arthroscopic massive rotator cuff repair

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Rotator cuff tear arthropathy complicated by pseudoparalysis is best treated with a reverse total shoulder arthroplasty. This design lateralizes and distalizes the center of rotation, recruiting the deltoid to restore forward elevation.

Question 2019

Topic: 9. Shoulder and Elbow

A 42-year-old male undergoes a two-incision surgical repair of a distal biceps tendon rupture. Compared to a single-incision anterior approach, the two-incision technique carries a historically higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve injury
. Heterotopic ossification (radioulnar synostosis)
. Median nerve injury
. Posterior interosseous nerve injury
. Loss of terminal elbow extension

Correct Answer & Explanation

. Heterotopic ossification (radioulnar synostosis)

Explanation

The classic two-incision technique for distal biceps repair is associated with a higher risk of radioulnar synostosis (heterotopic ossification). Single-incision approaches carry a higher risk of injury to the lateral antebrachial cutaneous nerve.

Question 2020

Topic: 9. Shoulder and Elbow

An 80-year-old female with severe osteoporosis presents with a closed 4-part proximal humerus fracture. The humeral head is completely split into two segments and is displaced from the glenoid. What is the most appropriate surgical treatment?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Primary shoulder arthrodesis

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In elderly patients with poor bone quality and non-reconstructible 4-part fractures (especially head-splitting variants), reverse shoulder arthroplasty provides more predictable functional outcomes and pain relief compared to ORIF or hemiarthroplasty.

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