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9. Shoulder and Elbow MCQs

Practice Set 107 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 2121

Topic: 9. Shoulder and Elbow

According to the Hamada classification of rotator cuff tear arthropathy, what radiographic finding defines Stage 3 disease?

. Acromiohumeral interval < 6 mm
. Acetabularization of the acromion
. Glenohumeral joint space narrowing
. Humeral head collapse (osteonecrosis)
. Normal radiographs with clinical pseudoparalysis

Correct Answer & Explanation

. Acromiohumeral interval < 6 mm

Explanation

In the Hamada classification, Stage 1 is an AHI > 6mm. Stage 2 is an AHI < 6mm. Stage 3 involves "acetabularization" or concave erosion of the acromion undersurface. Stage 4 includes glenohumeral arthritis, and Stage 5 includes humeral head collapse.

Question 2122

Topic: 9. Shoulder and Elbow

A 74-year-old woman presents with severe right shoulder pain and an inability to actively elevate her arm past 40 degrees. Passive elevation is preserved to 150 degrees.

Radiographs show superior migration of the humeral head articulating with the acromion. Which of the following is the most appropriate treatment?

. Arthroscopic rotator cuff repair
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty
. Superior capsular reconstruction

Correct Answer & Explanation

. Arthroscopic rotator cuff repair

Explanation

This patient has rotator cuff arthropathy with pseudoparalysis (inability to actively elevate the arm despite full passive motion). Reverse total shoulder arthroplasty is the treatment of choice as it relies on the deltoid to restore active elevation.

Question 2123

Topic: 9. Shoulder and Elbow

A 60-year-old active man with symptomatic long head of the biceps tendinosis undergoes an arthroscopic biceps tenotomy. Compared to a biceps tenodesis, which of the following outcomes is significantly more likely to occur following a tenotomy?

. Cosmetic Popeye deformity and subjective cramping pain
. Increased postoperative stiffness in external rotation
. Higher risk of superior labral detachment
. Greater loss of grip strength
. Higher rate of failure requiring revision surgery

Correct Answer & Explanation

. Cosmetic Popeye deformity and subjective cramping pain

Explanation

Biceps tenotomy is simpler and has a quicker recovery, but it carries a higher risk of aesthetic "Popeye" deformity and subjective cramping pain in the biceps muscle belly compared to tenodesis. Strength differences (grip or elbow flexion) are generally minimal or not clinically significant.

Question 2124

Topic: Shoulder Arthroplasty & Arthritis

Which of the following best describes the biomechanical alterations achieved by a standard Grammont-style reverse total shoulder arthroplasty?

. Lateralization and superiorization of the center of rotation
. Medialization and inferiorization of the center of rotation
. Medialization and superiorization of the center of rotation
. Lateralization and inferiorization of the center of rotation
. Anatomic restoration of the center of rotation

Correct Answer & Explanation

. Lateralization and superiorization of the center of rotation

Explanation

A Grammont-style reverse total shoulder arthroplasty medializes and inferiorizes the center of rotation. This effectively lengthens the deltoid moment arm and increases its tension, allowing it to compensate for a deficient rotator cuff.

Question 2125

Topic: 9. Shoulder and Elbow

A 72-year-old woman presents with pseudoparalysis of the right shoulder and severe glenohumeral osteoarthritis secondary to a chronic, massive rotator cuff tear. Which of the following is considered an absolute contraindication to performing a reverse total shoulder arthroplasty?

. Intact coracoacromial arch
. Non-functioning deltoid muscle
. Severe superior migration of the humeral head
. Biceps tendon rupture
. Glenoid retroversion of 10 degrees

Correct Answer & Explanation

. Intact coracoacromial arch

Explanation

Reverse total shoulder arthroplasty biomechanically relies on a functioning deltoid muscle to elevate the arm. A non-functioning deltoid (e.g., due to severe axillary nerve palsy) is an absolute contraindication to the procedure.

Question 2126

Topic: 9. Shoulder and Elbow

A 25-year-old baseball pitcher presents with deep shoulder pain during the late cocking phase of throwing. He undergoes shoulder arthroscopy and is diagnosed with a Type II SLAP lesion. Which of the following best describes this pathology?

. Degenerative fraying of the superior labrum with an intact biceps anchor
. Detachment of the superior labrum and biceps anchor from the superior glenoid tubercle
. Bucket-handle tear of the superior labrum with an intact biceps anchor
. Bucket-handle tear of the superior labrum with detachment of the biceps anchor
. Avulsion of the inferior glenohumeral ligament from the glenoid

Correct Answer & Explanation

. Degenerative fraying of the superior labrum with an intact biceps anchor

Explanation

A Type II SLAP lesion is defined by the detachment of both the superior labrum and the origin of the long head of the biceps tendon from the superior glenoid. It is a common cause of pain in overhead athletes and often requires surgical repair.

Question 2127

Topic: 9. Shoulder and Elbow

A 75-year-old man presents with chronic shoulder pain and inability to raise his arm above 60 degrees. Examination demonstrates intact deltoid function but a positive drop arm sign. Radiographs reveal superior migration of the humeral head with articulation against the acromion and severe glenohumeral osteoarthritis.

Which of the following is the most appropriate surgical treatment?

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

Correct Answer & Explanation

. Arthroscopic rotator cuff repair

Explanation

This patient has rotator cuff tear arthropathy with pseudoparalysis. A reverse total shoulder arthroplasty (RTSA) is the treatment of choice as it relies on the intact deltoid to elevate the arm by medializing the center of rotation and increasing the deltoid moment arm.

Question 2128

Topic: 9. Shoulder and Elbow

A 28-year-old weightlifter feels a sudden 'pop' and sharp pain in his anterior shoulder during a heavy bench press. Examination reveals loss of the anterior axillary fold contour and significant weakness with resisted internal rotation and adduction. What is the recommended treatment for optimal return of strength?

. Immobilization in a sling for 6 weeks followed by physical therapy
. Surgical repair of the pectoralis major tendon to the humerus
. Surgical repair of the pectoralis major muscle belly
. Cortisone injection into the bicipital groove
. Arthroscopic subacromial decompression

Correct Answer & Explanation

. Immobilization in a sling for 6 weeks followed by physical therapy

Explanation

Pectoralis major ruptures commonly occur at the humeral insertion during heavy eccentric loading (e.g., bench press). Surgical repair to the humeral shaft provides the best outcomes for strength and cosmetic restoration in young, active patients.

Question 2129

Topic: 9. Shoulder and Elbow

A 55-year-old diabetic woman complains of insidious onset of severe right shoulder pain and progressive loss of motion over the past 4 months. Examination shows significant limitations in both active and passive range of motion in forward flexion, abduction, and external rotation. Radiographs are unremarkable. What is the primary pathophysiologic mechanism of this condition?

. Degeneration of the supraspinatus tendon
. Contracture of the coracohumeral ligament and rotator interval
. Labral fraying and superior glenohumeral ligament tear
. Osteophyte formation at the acromioclavicular joint
. Denervation of the deltoid muscle

Correct Answer & Explanation

. Degeneration of the supraspinatus tendon

Explanation

This patient has adhesive capsulitis (frozen shoulder), highly associated with diabetes. The hallmark is global loss of both active and passive motion due to fibroblastic proliferation and contracture, specifically involving the coracohumeral ligament and rotator interval.

Question 2130

Topic: 9. Shoulder and Elbow

A 24-year-old powerlifter presents with an insidious onset of pain on top of his left shoulder. The pain is exacerbated by bench pressing and dips. Examination shows localized tenderness over the acromioclavicular (AC) joint and pain with cross-body adduction. Radiographs reveal widening of the AC joint and subchondral cysts in the lateral clavicle. What is the most likely diagnosis?

. Type III AC joint separation
. Distal clavicle osteolysis
. Glenohumeral osteoarthritis
. Os acromiale
. Coracoclavicular ligament sprain

Correct Answer & Explanation

. Type III AC joint separation

Explanation

Distal clavicle osteolysis ('weightlifter's shoulder') is caused by repetitive microtrauma to the AC joint, commonly seen in young male athletes who lift heavy weights. Radiographs classicially show resorption and microcystic changes of the distal clavicle.

Question 2131

Topic: Shoulder Pathology

A 22-year-old football player sustains a blunt injury to the posterolateral neck and subsequently develops classic medial winging of the scapula. The injured nerve originates directly from which of the following neural structures?

. Ventral rami of C5, C6, C7
. Upper trunk of the brachial plexus
. Lateral cord of the brachial plexus
. Posterior cord of the brachial plexus
. Ventral rami of C8, T1

Correct Answer & Explanation

. Ventral rami of C5, C6, C7

Explanation

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

Question 2132

Topic: 9. Shoulder and Elbow

An orthopaedic surgeon evaluates an MRI of the shoulder for a suspected biceps pathology. The radiologist notes an abnormality within the rotator interval. Which of the following structures is considered a normal anatomic component or boundary of this specific space?

. Teres minor
. Superior glenohumeral ligament
. Inferior glenohumeral ligament
. Short head of the biceps tendon
. Coracoacromial ligament

Correct Answer & Explanation

. Teres minor

Explanation

The rotator interval is a triangular anatomic space defined by the subscapularis anteriorly, supraspinatus superiorly, and the base of the coracoid medially. Its contents include the long head of the biceps tendon, the superior glenohumeral ligament, and the coracohumeral ligament.

Question 2133

Topic: Shoulder Pathology

A 52-year-old woman presents with isolated medial scapular winging that is significantly accentuated when she pushes against a wall with her arms forward. She has a history of an axillary lymph node dissection. Injury to which of the following nerves is the primary cause of her deficit?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Medial scapular winging is classically caused by serratus anterior muscle paralysis due to long thoracic nerve injury. Lateral winging is typically caused by trapezius paralysis secondary to spinal accessory nerve injury.

Question 2134

Topic: Elbow & Forearm

A 35-year-old male presents with posterolateral rotatory instability (PLRI) of the elbow following a dislocation. Which of the following describes the origin and insertion of the primary ligamentous restraint involved in this condition?

. Lateral epicondyle to the radial head
. Lateral epicondyle to the supinator crest of the ulna
. Medial epicondyle to the sublime tubercle
. Medial epicondyle to the coronoid process
. Radial styloid to the scaphoid

Correct Answer & Explanation

. Lateral epicondyle to the radial head

Explanation

The lateral ulnar collateral ligament (LUCL) is the primary restraint to PLRI of the elbow. It originates on the lateral epicondyle and inserts distally on the supinator crest of the ulna.

Question 2135

Topic: Shoulder Pathology

A patient presents with winging of the scapula characterized by medial translation of the inferior pole during active wall push-ups. Which nerve is most likely injured, and what is its segmental origin?

. Long thoracic nerve (C5, C6, C7)
. Spinal accessory nerve (CN XI)
. Dorsal scapular nerve (C5)
. Suprascapular nerve (C5, C6)
. Thoracodorsal nerve (C6, C7, C8)

Correct Answer & Explanation

. Long thoracic nerve (C5, C6, C7)

Explanation

Medial winging of the scapula is caused by paralysis of the serratus anterior, which is innervated by the long thoracic nerve (roots C5, C6, C7). Lateral winging is typically associated with spinal accessory nerve (trapezius) injury.

Question 2136

Topic: Shoulder Pathology

A patient presents with a winged scapula, and physical examination demonstrates isolated weakness of the serratus anterior muscle. Injury to the long thoracic nerve is suspected. Which nerve roots contribute to the formation of this nerve?

. C3, C4
. C4, C5, C6
. C5, C6, C7
. C7, C8, T1
. C8, T1

Correct Answer & Explanation

. C3, C4

Explanation

The long thoracic nerve innervates the serratus anterior muscle and is formed by branches from the C5, C6, and C7 nerve roots. Injury leads to medial winging of the scapula.

Question 2137

Topic: 9. Shoulder and Elbow

The rotator interval is a critical anatomic space in the anterior shoulder involved in glenohumeral stability. Which of the following structures is NOT found within or bordering the rotator interval?

. Coracohumeral ligament
. Superior glenohumeral ligament
. Long head of the biceps tendon
. Subscapularis tendon
. Inferior glenohumeral ligament

Correct Answer & Explanation

. Coracohumeral ligament

Explanation

The rotator interval is bordered by the subscapularis and supraspinatus tendons and contains the coracohumeral ligament, superior glenohumeral ligament, and the long head of the biceps tendon. The inferior glenohumeral ligament is located lower in the capsule and is not part of this interval.

Question 2138

Topic: Elbow & Forearm

Posterolateral rotatory instability (PLRI) of the elbow presents with a clunk during extension and supination. This condition is primarily caused by insufficiency of which ligamentous structure?

. Annular ligament
. Lateral ulnar collateral ligament (LUCL)
. Radial collateral ligament
. Anterior bundle of the medial collateral ligament
. Posterior bundle of the medial collateral ligament

Correct Answer & Explanation

. Annular ligament

Explanation

PLRI occurs due to deficiency of the lateral ulnar collateral ligament (LUCL). The LUCL serves as a primary restraint preventing posterior subluxation of the radial head relative to the capitellum.

Question 2139

Topic: 9. Shoulder and Elbow

A 45-year-old woman is undergoing shoulder arthroscopy for adhesive capsulitis. The surgeon plans a release of the rotator interval. Which of the following structures are the primary contents of the rotator interval?

. Coracoacromial ligament and long head of the biceps tendon
. Coracohumeral ligament, superior glenohumeral ligament, and long head of the biceps tendon
. Middle glenohumeral ligament and subscapularis tendon
. Inferior glenohumeral ligament complex and joint capsule
. Transverse humeral ligament and short head of the biceps tendon

Correct Answer & Explanation

. Coracoacromial ligament and long head of the biceps tendon

Explanation

The rotator interval is a triangular space bounded by the supraspinatus superiorly, subscapularis inferiorly, and the coracoid base medially. Its primary contents are the coracohumeral ligament, the superior glenohumeral ligament (SGHL), and the intra-articular portion of the long head of the biceps tendon.

Question 2140

Topic: 9. Shoulder and Elbow
A 10-year-old boy falls on his outstretched hand. Radiographs of the elbow reveal a displaced fracture of a secondary ossification center. Based on the typical sequence of elbow ossification, which of the following centers is the last to fuse to the adjacent bone?
. Capitellum
. Radial head
. Medial epicondyle
. Trochlea
. Lateral epicondyle

Correct Answer & Explanation

. Medial epicondyle

Explanation

While the medial epicondyle is the third ossification center to appear (following the mnemonic CRITOE: Capitellum, Radius, Internal/Medial epicondyle, Trochlea, Olecranon, External/Lateral epicondyle), it is the last ossification center to fuse, typically doing so around age 15-18.

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