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9. Shoulder and Elbow MCQs

Practice Set 103 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 2041

Topic: Shoulder Arthroplasty & Arthritis

A 75-year-old woman with severe osteoporosis sustains a displaced, 4-part proximal humerus fracture. Examination of preoperative imaging suggests severe valgus impaction and poor tuberosity bone stock. Which of the following surgical interventions will provide the most predictable outcome for postoperative functional elevation and pain relief?

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

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) provides more predictable functional outcomes and pain relief than hemiarthroplasty or ORIF in elderly patients with 4-part proximal humerus fractures. It relies on the deltoid rather than a functional rotator cuff, circumventing the issue of non-healing tuberosities.

Question 2042

Topic: Elbow & Forearm

A 45-year-old male weightlifter undergoes surgical repair of an acute distal biceps tendon rupture using a single anterior incision approach. Postoperatively, he complains of numbness and tingling over the anterolateral aspect of his forearm. Which nerve is most likely injured?

. Median nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Superficial radial nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single anterior incision approach for distal biceps repair. Injury typically occurs due to retraction forces or direct damage, as the nerve lies in close proximity to the cephalic vein and the surgical field.

Question 2043

Topic: 9. Shoulder and Elbow

A 70-year-old man presents with chronic, severe shoulder pain and an inability to actively elevate his arm past 40 degrees (pseudoparalysis). Radiographs demonstrate a narrowed acromiohumeral interval of 2 mm and advanced glenohumeral osteoarthritis. What is the most appropriate surgical treatment?

. Arthroscopic superior capsular reconstruction
. Latissimus dorsi tendon transfer
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Hemiarthroplasty

Correct Answer & Explanation

. Arthroscopic superior capsular reconstruction

Explanation

In an elderly patient with rotator cuff tear arthropathy characterized by pseudoparalysis, superior head migration, and glenohumeral arthritis, reverse total shoulder arthroplasty is the treatment of choice. It medializes and distalizes the center of rotation, allowing the deltoid to initiate and maintain elevation.

Question 2044

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate pitcher undergoes ulnar collateral ligament (UCL) reconstruction utilizing a palmaris longus autograft. Which specific bundle of the native UCL is the primary restraint to valgus stress between 30 and 90 degrees of elbow flexion and is the target of this reconstruction?

. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Posterior bundle
. Transverse ligament
. Oblique ligament

Correct Answer & Explanation

. Anterior band of the anterior bundle

Explanation

The anterior bundle of the UCL is the primary stabilizer against valgus stress at the elbow. Specifically, its anterior band is the most important anatomical restraint between 30 and 90 degrees of flexion and is the structure reconstructed during Tommy John surgery.

Question 2045

Topic: Elbow & Forearm

A 35-year-old woman falls on an outstretched hand, sustaining an elbow dislocation, a comminuted radial head fracture, and a Type II coronoid fracture. What is the generally accepted sequence of surgical reconstruction for this "terrible triad" injury?

. Lateral collateral ligament repair -> Coronoid -> Radial head
. Radial head -> Lateral collateral ligament repair -> Coronoid
. Coronoid -> Radial head -> Lateral collateral ligament repair
. Lateral collateral ligament repair -> Radial head -> Coronoid
. Coronoid -> Lateral collateral ligament repair -> Radial head

Correct Answer & Explanation

. Lateral collateral ligament repair -> Coronoid -> Radial head

Explanation

The standard surgical algorithm for fixing a terrible triad injury proceeds from deep to superficial: coronoid fixation first, followed by radial head repair or arthroplasty, and finally lateral collateral ligament (LCL) reconstruction.

Question 2046

Topic: 9. Shoulder and Elbow
A 24-year-old cyclist falls directly onto his shoulder. Clinical examination reveals a prominent distal clavicle. Radiographs demonstrate >100% superior displacement of the clavicle relative to the acromion, with the clavicle penetrating the deltotrapezial fascia. This injury is best classified as a Rockwood Type:
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type V

Explanation

Rockwood Type V injuries involve greater than 100% superior displacement of the distal clavicle and disruption of the deltotrapezial fascia. Surgical reconstruction of the coracoclavicular ligaments is typically indicated for these high-grade injuries.

Question 2047

Topic: Elbow & Forearm

A 38-year-old man falls on an outstretched hand, sustaining an elbow dislocation, a radial head fracture, and a coronoid fracture. Which of the following is the standard recommended surgical sequence for restoring stability in this terrible triad injury?

. Fix or replace radial head, fix coronoid, repair lateral collateral ligament (LCL)
. Fix coronoid, fix or replace radial head, repair lateral collateral ligament (LCL)
. Repair lateral collateral ligament (LCL), fix coronoid, fix or replace radial head
. Repair medial collateral ligament (MCL), repair LCL, fix radial head
. Fix coronoid, repair MCL, fix radial head

Correct Answer & Explanation

. Fix coronoid, fix or replace radial head, repair lateral collateral ligament (LCL)

Explanation

The standard surgical algorithm for terrible triad elbow injuries begins with fixing the coronoid to restore deep anterior stability. This is followed by addressing the radial head, and finally repairing the lateral collateral ligament (LCL).

Question 2048

Topic: 9. Shoulder and Elbow

A 74-year-old woman with severe osteoporosis sustains a comminuted 4-part proximal humerus fracture. She undergoes a reverse total shoulder arthroplasty (RTSA). Which of the following describes the primary biomechanical advantage of RTSA in this setting?

. It requires an intact rotator cuff for joint stability
. It medializes and inferiorly displaces the center of rotation
. It lateralizes and superiorly displaces the center of rotation
. It relies on the coracoacromial ligament for superior constraint
. It significantly increases the moment arm of the subscapularis

Correct Answer & Explanation

. It medializes and inferiorly displaces the center of rotation

Explanation

Reverse total shoulder arthroplasty medializes and inferiorly shifts the center of rotation of the glenohumeral joint. This configuration recruits the deltoid muscle more effectively, compensating for the non-functioning or absent rotator cuff.

Question 2049

Topic: 9. Shoulder and Elbow

A 21-year-old collegiate baseball pitcher presents with deep shoulder pain and clicking during the late cocking phase of throwing. MRI arthrography reveals a detachment of the superior labrum and biceps anchor from the glenoid. Which physical examination test is most specific for this pathology?

. Neer impingement sign
. O'Brien active compression test
. Lift-off test
. Belly-press test
. Hawkins-Kennedy test

Correct Answer & Explanation

. O'Brien active compression test

Explanation

The O'Brien active compression test is a sensitive and specific maneuver for detecting Superior Labrum Anterior to Posterior (SLAP) tears. Pain is typically elicited with the arm in internal rotation and relieved when the arm is externally rotated.

Question 2050

Topic: 9. Shoulder and Elbow

A 17-year-old football player sustains a direct blow to the medial shoulder. He presents to the trauma bay with shortness of breath, stridor, and difficulty swallowing. The medial clavicle is not palpable anteriorly. What is the most appropriate next step in management?

. Closed reduction in the emergency department under conscious sedation
. CT scan of the chest and closed reduction in the OR with cardiothoracic standby
. MRI of the brachial plexus to rule out nerve injury
. Sling immobilization and delayed reconstruction
. Immediate open reduction and medial clavicle excision

Correct Answer & Explanation

. CT scan of the chest and closed reduction in the OR with cardiothoracic standby

Explanation

Posterior sternoclavicular dislocations can compress the trachea, esophagus, and great vessels, representing a surgical emergency. Reduction should be performed in the OR with a cardiothoracic surgeon available due to the risk of catastrophic vascular injury.

Question 2051

Topic: 9. Shoulder and Elbow

A 40-year-old weightlifter feels a sudden "pop" in his anterior elbow while attempting a heavy deadlift. On examination, he has marked weakness in forearm supination and elbow flexion. The Hook test is positive. What is the recommended treatment?

. Non-operative management with hinged elbow brace
. Reconstruction using a hamstring autograft
. In situ ulnar nerve decompression
. Primary anatomic repair to the radial tuberosity
. Distal triceps tendon transfer

Correct Answer & Explanation

. Primary anatomic repair to the radial tuberosity

Explanation

Acute distal biceps tendon ruptures in active patients should undergo primary surgical repair to the radial tuberosity to restore supination and flexion strength. Delaying surgery past 3-4 weeks increases the risk of retraction and the need for allograft reconstruction.

Question 2052

Topic: 9. Shoulder and Elbow

A 65-year-old woman who works as a florist has had pain in her right elbow for the past 6 months after lifting a flowerpot. MRI scans are shown in Figures 55a and 55b. The area of increased signal intensity seen in Figure 55b most likely represents which of the following findings?

. Hematoma
. Edema
. Soft-tissue sarcoma
. Antecubital lipoma
. Brachial artery aneurysm

Correct Answer & Explanation

. Hematoma

Explanation

The MRI scans reveal a chronic distal biceps tendinitis. The T1-weighted scan shows the anatomic detail of the biceps tendon, and the T2-weighted scan shows increased signal caused by edema surrounding the tendon. The T1-weighted scan is not consistent with an antecubital lipoma. The chronicity of the lesion makes hematoma unlikely. An aneurysm usually appears with blood flow through the region and is dark on T1- and T2-weighted scans. Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 492-504.

Question 2053

Topic: Shoulder Pathology

Thoracic outlet syndrome commonly involves compression within the interscalene triangle. Which of the following structures pass through the interscalene triangle?

. Subclavian vein and brachial plexus
. Subclavian artery and brachial plexus
. Subclavian artery, subclavian vein, and brachial plexus
. Subclavian vein and phrenic nerve
. Subclavian artery and vagus nerve

Correct Answer & Explanation

. Subclavian vein and brachial plexus

Explanation

The interscalene triangle is bordered by the anterior scalene, middle scalene, and the first rib. It contains the subclavian artery and the roots/trunks of the brachial plexus. The subclavian vein runs anterior to the anterior scalene muscle.

Question 2054

Topic: Shoulder Pathology

A patient presents with shoulder weakness after a superficial lymph node biopsy in the posterior triangle of the neck. Examination shows a prominent medial border of the scapula with lateral translation and an inability to abduct the arm past 90 degrees. Which nerve was most likely injured?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

The spinal accessory nerve (CN XI) runs superficially in the posterior triangle of the neck and is vulnerable during minor procedures. Injury paralyzes the trapezius, causing lateral winging of the scapula and difficulty elevating the arm past 90 degrees.

Question 2055

Topic: Elbow & Forearm

During an anterior approach to the proximal radius (Henry approach), the posterior interosseous nerve (PIN) is at risk. What structure represents the most common site of PIN compression in radial tunnel syndrome?

. Leash of Henry
. Arcade of Frohse
. Distal edge of the supinator
. Fibrous edge of the ECRB
. Lacertus fibrosus

Correct Answer & Explanation

. Leash of Henry

Explanation

The Arcade of Frohse, which is the proximal fibrous edge of the superficial head of the supinator muscle, is the most common site of posterior interosseous nerve compression. Other sites include the leash of Henry and the fibrous edge of the ECRB.

Question 2056

Topic: Shoulder Pathology

A 45-year-old patient presents with lateral winging of the scapula and inability to shrug the shoulder following a lymph node biopsy in the posterior triangle of the neck. Which of the following muscles has most likely been denervated?

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

Correct Answer & Explanation

. Serratus anterior

Explanation

The spinal accessory nerve (CN XI) courses through the posterior triangle of the neck to innervate the trapezius muscle. Injury to this nerve causes lateral scapular winging and weakness in shoulder elevation.

Question 2057

Topic: Shoulder Pathology

In a patient with neurogenic thoracic outlet syndrome caused by a cervical rib, the lower trunk of the brachial plexus is commonly compressed. This lower trunk is formed by the union of which nerve roots?

. C8 and T1
. C5 and C6
. C7 only
. C6, C7, and C8
. C5, C6, and C7

Correct Answer & Explanation

. C8 and T1

Explanation

The lower trunk of the brachial plexus is formed by the union of the C8 and T1 ventral rami. Compression of the lower trunk typically yields ulnar-sided hand symptoms and intrinsic muscle wasting.

Question 2058

Topic: Shoulder Pathology

A 45-year-old woman presents with shoulder pain and an inability to elevate her arm above 90 degrees following a lymph node biopsy in the posterior cervical triangle. Examination reveals lateral winging of the scapula. Which of the following muscles is primarily denervated?

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

Correct Answer & Explanation

. Serratus anterior

Explanation

The spinal accessory nerve (CN XI) innervates the trapezius and is at risk during procedures in the posterior cervical triangle. Injury leads to lateral winging of the scapula and profound difficulty with overhead elevation.

Question 2059

Topic: Elbow & Forearm

A patient has posterolateral rotatory instability (PLRI) of the elbow. Reconstruction of the lateral ulnar collateral ligament (LUCL) is planned. The LUCL normally originates on the lateral epicondyle and inserts on which of the following structures?

. Radial head
. Radial neck
. Coronoid process
. Supinator crest of the ulna
. Olecranon

Correct Answer & Explanation

. Radial head

Explanation

The lateral ulnar collateral ligament (LUCL) originates on the lateral epicondyle and inserts on the supinator crest of the proximal ulna. It acts as the primary restraint against posterolateral rotatory instability of the elbow.

Question 2060

Topic: 9. Shoulder and Elbow

During a standard deltopectoral approach to the shoulder, the cephalic vein is identified in the interval. The vein is classically retracted in which direction, and for what anatomic reason?

. Medially, to protect its primary tributaries from the pectoralis major
. Medially, to protect its primary tributaries from the deltoid
. Laterally, to protect its primary tributaries from the pectoralis major
. Laterally, to protect its primary tributaries from the deltoid
. Superiorly, to protect the thoracoacromial axis

Correct Answer & Explanation

. Medially, to protect its primary tributaries from the pectoralis major

Explanation

The cephalic vein is typically retracted laterally to protect the major venous tributaries that drain into it from the deltoid muscle, reducing the risk of bleeding and preserving venous drainage.

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