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9. Shoulder and Elbow MCQs

Practice Set 11 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 201

Topic: 9. Shoulder and Elbow
An anxious 25-year-old saleswoman presented with mild shortness of breath on exertion, which had come on gradually over several months. The symptom was intermittent and seemed to get worse in the evening. She had also been on treatment for depression over the previous 2 months. On examination, she has minimal weakness of shoulder abductors and slight weakness of eye closure bilaterally. Deep tendon reflexes are present and symmetrical throughout and plantar responses are flexor. You now have the results of the investigations – FBC, U&E, LFT, electrocardiography, chest X-ray and lung function tests were all normal. What is the most likely diagnosis?
. Angina
. Eaton–Lambert syndrome
. Myasthenia gravis
. Somatisation disorder
. Transient ischaemic attack

Correct Answer & Explanation

. Myasthenia gravis

Explanation

Correct Answer: C - Myasthenia gravis. This young woman has myasthenia gravis, an autoimmune condition. Muscle weakness might not be apparent on a single examination, so the examination should be repeated – most affected are the ocular and shoulder-girdle muscles. Clinical features: Respiratory and proximal lower limb muscles can be involved early in the disease. Breathlessness can develop early and cause sudden death. Swallowing problems, slurred speech and difficulty in chewing can be caused by bulbar involvement. Asymmetrical involvement of an external ocular muscle can mimic cranial nerve palsy but pupillary reflexes are normal. Mild ptosis and weak facial muscles can make patients appear depressed. Thymic enlargement is seen in only 15% of patients.

Question 202

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old man presents with chronic shoulder pain and pseudoparalysis. Radiographs show superior migration of the humeral head and acetabularization of the acromion. He has a functioning deltoid. What is the most appropriate surgical intervention?

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

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

The patient has cuff tear arthropathy with pseudoparalysis but a functioning deltoid. Reverse total shoulder arthroplasty (RTSA) is the treatment of choice, as it medializes and distalizes the center of rotation, maximizing the moment arm of the deltoid.

Question 203

Topic: 9. Shoulder and Elbow
An anxious 22-year-old woman presented with mild shortness of breath on exertion that had come on gradually over several months. Her symptoms are intermittent, but worse in the evening, and her speech becomes slurred during the episodes. She has recently started treatment for anxiety. On examination, she looked depressed but there were no other positive clinical findings. Other than an ESR of 26 mm in the 1st hour, her routine blood results were normal. Chest X-ray, lung function tests, and electrocardiography were all normal. What is the most likely diagnosis?
. Eaton–Lambert syndrome
. Myasthenia gravis
. Somatisation disorder
. Transient ischaemic attack
. Unstable angina

Correct Answer & Explanation

. Myasthenia gravis

Explanation

Correct Answer: B- Myasthenia gravis. This patient presents with symptoms of muscle weakness (slurred speech, breathlessness) that fluctuate and worsen with fatigue, which is characteristic of myasthenia gravis. Ptosis and weak facial muscles can mimic a depressed appearance. Eaton–Lambert syndrome is typically associated with malignancy and is less likely in a young patient with a normal chest X-ray. Somatisation disorder is a diagnosis of exclusion, and the symptoms here are highly suggestive of a neuromuscular junction disorder.

Question 204

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with chronic, intractable shoulder pain and profound weakness in elevation. Radiographs show superior migration of the humeral head with severe glenohumeral osteoarthritis and acetabularization of the coracoacromial arch. What is the most appropriate surgical option?

. Arthroscopic rotator cuff repair
. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Shoulder arthrodesis

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

The patient has cuff tear arthropathy. Reverse total shoulder arthroplasty (RTSA) is the treatment of choice as it medializes and lowers the center of rotation, increasing the deltoid moment arm and allowing it to compensate for the deficient rotator cuff.

Question 205

Topic: 9. Shoulder and Elbow

Which of the following is the seating arrangement recommended for a 5- year-old in a family automobile:

. Lap belt in the middle of the back seat
. Lap and shoulder belt in the back seat
. Lap and shoulder belt and booster seat in back
. Rear-facing child seat in back
. Lap and shoulder belt and booster seat in front

Correct Answer & Explanation

. Lap and shoulder belt and booster seat in back

Explanation

Children ages 4 to 8 (40 lbs to 60 lbs) are at risk for airbag injuries and should not be in the front seat. In addition, they require booster seats to allow proper fitting of the shoulder harness on the upper torso. Rear-facing seats are only appropriate for infants. Children should not be in the front seat until after age 12 and over 100 lbs.

Question 206

Topic: Elbow & Forearm

A 45-year-old falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. During surgical reconstruction, what is the most appropriate sequence of repair to restore elbow stability?

. Coronoid fixation, lateral ulnar collateral ligament (LUCL) repair, radial head repair/replacement
. Radial head repair/replacement, coronoid fixation, LUCL repair
. LUCL repair, coronoid fixation, radial head repair/replacement
. Coronoid fixation, radial head repair/replacement, LUCL repair
. Radial head repair/replacement, LUCL repair, coronoid fixation

Correct Answer & Explanation

. Coronoid fixation, lateral ulnar collateral ligament (LUCL) repair, radial head repair/replacement

Explanation

The standard surgical sequence for a terrible triad injury is to reconstruct from deep to superficial: coronoid fixation first, followed by radial head repair or replacement, and finally LUCL repair. If the elbow remains unstable, the medial collateral ligament may be addressed last.

Question 207

Topic: 9. Shoulder and Elbow

Which of the following is considered a critical element in surgically correcting posttraumatic elbow flexion contractures in adolescents:

. Lengthening of the biceps muscle
. Lengthening of the triceps muscle
. Perioperative indomethacin
. Pre- or postoperative radiation
. Postoperative continuous passive motion and physical therapy

Correct Answer & Explanation

. Postoperative continuous passive motion and physical therapy

Explanation

Bae and Waters have shown that adolescents with significant posttraumatic elbow flexion contractures can gain an average of 54° of motion with surgical release. They believe postoperative physical therapy and continuous passive motion are considered critical to success of surgical release. Lengthening of the biceps or triceps is not recommended. Measures to prevent postoperative heterotopic ossification did not influence the outcome.

Question 208

Topic: 9. Shoulder and Elbow

In which region is direct anatomical extension from the metaphysis of a long bone to the adjacent joint not anatomically possible in the child:

. Shoulder
. Elbow
. Hip
. Knee
. Ankle

Correct Answer & Explanation

. Knee

Explanation

The metaphysis of the proximal humerus lies partially within the shoulder joint; similarly, that of the proximal radius lies within the elbow. The metaphysis of the proximal femur lies within the hip joint and that of the distal lateral tibia within the ankle joint. There is no intra-articular metaphysis about the knee, however.

Question 209

Topic: 9. Shoulder and Elbow
Anterior elbow release in children with cerebral palsy is likely to result in which of the following outcomes:
. Decreased flexion posture during use
. Decreased flexion contracture
. Increased use during bimanual activity
. Increased strength of elbow flexion
. Increased grip strength

Correct Answer & Explanation

. Decreased flexion posture during use

Explanation

Anterior elbow release consists of lengthening of the lacertus fibrosus and the brachialis fascia. It may or may not include lengthening of the biceps tendon itself. Anterior elbow release effectively decreases the excessive flexion posture of the elbow during use, which one author has termed the 'flexion posture angle.' It does not result in decreased (or increased) strength of elbow flexion if the biceps tendon is preserved. Unfortunately, increased use during bimanual activity and increased grip strength are usually not observed.

Question 210

Topic: 9. Shoulder and Elbow

A newborn girl is noted to have decreased movement in the right upper extremity. She was large (10 lbs) at birth and was delivered vaginally with shoulder dystocia. She does not have elbow flexion, external shoulder rotation, or abduction. She has had weak finger flexion for 3 months. At 4-months-old, she regains the ability to flex her elbow. Recommended treatment includes:

. Magnetic resonance imaging of the shoulder
. Tendon transfers of the teres major and latissimus
. Physical therapy
. Microvascular repair of the brachial plexus
. Open reduction of the glenohumeral joint

Correct Answer & Explanation

. Physical therapy

Explanation

Conservative therapy is predicted to bring a good result because biceps are returning at four months of age. However, stretching of the shoulder is indicated to maintain a range of external rotation and abduction. Magnetic resonance imaging is only indicated if there is a need to consider microvascular repair. Tendon transfers are performed later (at several years of age), if shoulder abduction and external rotation are significantly limited. Microvascular repair is mainly considered in patients who do not have return of biceps function by five months. Open reduction is indicated later (if the shoulder joint is subluxated or severely contracted) after motor recovery has reached a plateau.

Question 211

Topic: Elbow & Forearm

A 50-year-old woman has chronic lateral elbow pain exacerbated by resisted wrist extension and forearm supination. She has failed a year of conservative treatment, and surgery is planned. Which structure is the primary site of pathology being targeted?

. Extensor carpi radialis longus
. Extensor carpi radialis brevis
. Extensor digitorum communis
. Brachioradialis
. Supinator

Correct Answer & Explanation

. Extensor carpi radialis brevis

Explanation

Lateral epicondylitis (tennis elbow) is primarily characterized by angiofibroblastic tendinosis of the origin of the extensor carpi radialis brevis (ECRB) tendon. Surgical intervention focuses on debridement or release of the ECRB.

Question 212

Topic: Elbow & Forearm

A 45-year-old woman falls on her outstretched arm and sustains a 'terrible triad' injury of the elbow. During surgical reconstruction, after addressing the radial head fracture, the lateral ulnar collateral ligament (LUCL) must be repaired. What is the primary anatomical origin and insertion of the LUCL?

. Originates on the lateral epicondyle and inserts on the radial tuberosity
. Originates on the lateral epicondyle and inserts on the supinator crest of the ulna
. Originates on the medial epicondyle and inserts on the coronoid process
. Originates on the capitellum and inserts on the annular ligament
. Originates on the lateral epicondyle and inserts on the sublime tubercle of the ulna

Correct Answer & Explanation

. Originates on the lateral epicondyle and inserts on the supinator crest of the ulna

Explanation

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

Question 213

Topic: Elbow & Forearm

A 7-year-old boy falls and suffers a Salter type IV fracture of the proximal radius. The size of the displaced fragment is 40% of the radial head, and it is translated distally by 2 mm. The optimum treatment is:

. Immobilization for 2 weeks with early range of motion
. Immobilization for 6 weeks with early range of motion
. Percutaneous fixation in situ to prevent further displacement
. Excision of the radial head fragment
. Open reduction, internal fixation

Correct Answer & Explanation

. Open reduction, internal fixation

Explanation

Because the displacement is likely to be >2 mm, open reduction may lessen the risk of problems with growth and mobility. This is suggested by clinical series. The displacement is likely to be greater than the radiograph shows, and growth disturbance is likely. Range of motion at two weeks is too early. Percutaneous fixation in situ would still carry a risk of growth disturbance, because the displacement is likely to be more than the plain radiographs show due to the largely cartilaginous nature of the radial head. Excision of a fragment this large is likely to produce incongruity of the radio-capitellar joint.

Question 214

Topic: 9. Shoulder and Elbow

The most common structure to be injured in conjunction with an elbow dislocation is:

. The ulnar nerve
. The median nerve
. The radial nerve
. The brachial artery
. The biceps tendon

Correct Answer & Explanation

. The ulnar nerve

Explanation

With an injury rate of approximately 6%, the ulnar nerve is the most common injured structure in an elbow dislocation. Median nerve injuries are rare with elbow dislocation. Such injuries may be due to nerve entrapment. If chronic, this may produce the Matev sign of a groove in the distal humerus. The radial nerve and biceps tendon are not commonly injured with an elbow dislocation. The brachial artery is rarely injured with an elbow dislocation.

Question 215

Topic: Elbow & Forearm

A 4-year-old girl is brought in for examination by her mother because of a bump on the lateral side of her elbow. The girl is unable to extend her elbow. She falls as much as any child, but no particular injury to the elbow is recalled. Radiographs show a dislocated, enlarged radial head that is convex proximally. There is a proximal radioulnar synostosis. Recommended treatment includes:

. Radial head excision
. Open reduction of the radial head and annular ligament reconstruction
. Open reduction of the radial head and ulnar lengthening osteotomy
. Silastic radial head arthroplasty
. No treatment

Correct Answer & Explanation

. No treatment

Explanation

This child has a congenital dislocation of the radial head, and no treatment is indicated unless the forearm is fixed in a position of extreme malrotation. Radial head excision should only be performed if there is pain and the child is skeletally mature. Silastic radial head arthroplasty has a significant risk of particulate synovitis.

Question 216

Topic: Elbow & Forearm

A 7-year-old girl is seen because of a persistent anterior dislocation of the radial head that occurred 2 months ago with an ulna fracture. The ulna has healed but has 25° of angulation. Her family would like to have this fixed to remove the prominence in the hope of preventing future joint degeneration. The recommended treatment is:

. Closed reduction of the radial head
. Open reduction and pin fixation of the radial head
. Open reduction and annular ligament reconstruction
. Open reduction, annular ligament reconstruction, and ulnar osteotomy
. Open reduction, radial shortening, and annular ligament reconstruction

Correct Answer & Explanation

. Open reduction, annular ligament reconstruction, and ulnar osteotomy

Explanation

The combination of open reduction, annular ligament reconstruction, and ulnar osteotomy should correct all of the components of the deformity. Closed reduction is not successful beyond 1-2 weeks after injury. Because of the 25° ulnar bow, recurrence is likely, and ulnar osteotomy is indicated. An ulnar osteotomy should be included to prevent recurrence.

Question 217

Topic: Elbow & Forearm

A 6-year-old patient has an acute proximal ulnar fracture with an apex posteriorly, as well as a radial head dislocation. Treatment at this stage should consist of:

. Closed reduction and immobilization in supination and flexion more than 90° in a long arm cast
. Closed reduction and immobilization in extension in a long arm cast
. Closed reduction and intramedullary rod fixation of the ulna
. Open reduction of the radial head and plate fixation of the ulna
. Open reduction of the radial head and annular ligament reconstruction

Correct Answer & Explanation

. Closed reduction and immobilization in extension in a long arm cast

Explanation

Extension will reduce the dislocation and the fracture. This type II Monteggia proximal fracture is best immobilized in extension. An intramedullary rod is indicated only if closed treatment fails. Open reduction of the radial head and plate fixation of the ulna are indicated only if closed treatment fails. Annular ligament reconstruction is indicated only if the dislocation is unreduced for more than 1 to 2 weeks.

Question 218

Topic: 9. Shoulder and Elbow

A 5-year-old patient sustains a fracture of the ulna with apex anteriorly, as well as an anterior dislocation of the radial head. The recommended treatment is:

. Closed reduction with elbow flexed at least 90° and somewhat supinated
. Closed reduction with the elbow in extension
. Closed reduction with the elbow flexed and the forearm in maximal pronation
. Closed reduction of the radial head and intramedullary rod of the ulna
. Open reduction of the radial head, annular ligament repair, and closed reduction of the ulna

Correct Answer & Explanation

. Closed reduction with elbow flexed at least 90° and somewhat supinated

Explanation

Flexion to at least 90° helps redirect the radial head, as does partial supination. Extension of the elbow will increase the tendency to dislocate. Pronation of the forearm will increase the tendency to dislocate. An intramedullary rod is needed only if closed treatment fails. Open reduction is required only if closed treatment fails.

Question 219

Topic: Elbow & Forearm
A 12-year-old girl sustains a closed type III Monteggia fracture. One week after closed reduction, the radial head resubluxates and the ulna bows. The next step of treatment is:
. Repeat closed reduction and a long arm cast
. Reconstruct the annular ligament using a strip of triceps fascia
. Reduce and internally fix the ulna and close-reduce the radial head
. Reduce and internally fix the ulna and open-reduce the radial head
. Reduce and pin the radial head

Correct Answer & Explanation

. Reduce and internally fix the ulna and close-reduce the radial head

Explanation

Once the ulna is predictably reduced, the radial head has a good chance of staying reduced. Repeat closed reduction and a long arm cast has a significant chance of redisplacement. If further time passes, radial head reduction will be difficult. Annular ligament reconstruction is only indicated if there is late subluxation (after several weeks) that does not reduce with closed means. Once the ulna is realigned and fixed, closed reduction of the radius must be tried next.

Question 220

Topic: Elbow & Forearm

A 9-year-old child presents one year after a supracondylar humerus fracture is healed. The elbow is in 15° more varus than the other side. Which of the following statements to the family is true:

. This is likely to be due to growth plate damage in the distal humerus.
. This is likely to correct fully before the end of growth.
. The deformity is probably due to hyperemia and overgrowth of the capitellum.
. The deformity is likely due to malposition of the fracture during healing.
. The varus will likely lead to an increased likelihood of degenerative joint disease.

Correct Answer & Explanation

. The deformity is likely due to malposition of the fracture during healing.

Explanation

Fracture malalignment is the most common cause of cubitus varus. Physeal damage is rare after supracondylar fractures. Angular malalignment corrects slowly and incompletely in the distal humerus, especially in the coronal plane. There is no reason for selective hyperemia of the capitellum in this fracture. There is no evidence of predisposition to degenerative joint disease in cubitus varus.

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