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9. Shoulder and Elbow MCQs

Practice Set 110 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 2181

Topic: 9. Shoulder and Elbow

A 72-year-old woman presents with severe shoulder pain and pseudoparalysis. Radiographs demonstrate advanced cuff tear arthropathy with superior migration of the humeral head. She is scheduled for a reverse total shoulder arthroplasty (RTSA).

The stability and primary functional elevation of this implant rely most heavily on the tension and function of which muscle?

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

Correct Answer & Explanation

. Subscapularis

Explanation

A reverse total shoulder arthroplasty medialiizes and distalizes the center of rotation, which increases the moment arm and tension of the deltoid muscle. The deltoid becomes the primary elevator and stabilizer of the shoulder in the absence of a functional rotator cuff.

Question 2182

Topic: 9. Shoulder and Elbow

A 68-year-old man sustains a minimally displaced 2-part surgical neck fracture of the proximal humerus and is treated nonoperatively.

To minimize the risk of adhesive capsulitis while ensuring fracture stability, when is the optimal time to initiate early passive range of motion exercises?

. Immediately (within 24 hours of injury)
. 7 to 14 days post-injury
. 3 to 4 weeks post-injury
. 6 weeks, only after radiographic healing is confirmed
. 8 weeks post-injury

Correct Answer & Explanation

. Immediately (within 24 hours of injury)

Explanation

For minimally displaced proximal humerus fractures, early gentle passive range of motion should typically begin at 7 to 14 days once initial pain subsides. Prolonged immobilization beyond 2-3 weeks significantly increases the risk of severe shoulder stiffness and adhesive capsulitis.

Question 2183

Topic: Shoulder Arthroplasty & Arthritis

A 68-year-old woman sustains a severely displaced 4-part proximal humerus fracture. Radiographic evaluation demonstrates a calcar segment of 4 mm and a completely disrupted medial hinge. According to the Hertel criteria, what is the most reliable management option to ensure a predictable functional recovery given her risk of avascular necrosis?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a locked plate
. Nonoperative management with early pendulums
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Hertel criteria for high risk of humeral head ischemia include a short calcar segment (<8 mm), a disrupted medial hinge, and a basicervical fracture pattern. Reverse total shoulder arthroplasty (RTSA) is favored in elderly patients with 4-part fractures at high risk of AVN to provide reliable functional recovery.

Question 2184

Topic: 9. Shoulder and Elbow

A 78-year-old woman presents with chronic right shoulder pain. Radiographs demonstrate superior migration of the humeral head with "acetabularization" of the coracoacromial arch and advanced glenohumeral osteoarthritis. Which classification system specifically stages these radiographic findings in the setting of rotator cuff arthropathy?

. Neer classification
. Hamada classification
. Goutallier classification
. Patte classification
. Walch classification

Correct Answer & Explanation

. Neer classification

Explanation

The Hamada classification stages the radiographic progression of massive rotator cuff tears. Stage 4a/4b and Stage 5 involve severe glenohumeral arthritis and acetabularization of the acromion, characterizing advanced rotator cuff tear arthropathy.

Question 2185

Topic: 9. Shoulder and Elbow

An 75-year-old female presents with chronic right shoulder pain, limited active elevation to 45 degrees, and a positive hornblower's sign. Radiographs demonstrate superior migration of the humeral head and acetabularization of the acromion.

What is the most appropriate definitive management?

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

Correct Answer & Explanation

. Arthroscopic rotator cuff repair

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for rotator cuff arthropathy with pseudoparalysis, relying on the deltoid to elevate the arm. Hemiarthroplasty is historically an option but provides less predictable functional recovery, and anatomic arthroplasty is contraindicated due to glenoid component rocking (rocking horse effect).

Question 2186

Topic: Shoulder Arthroplasty & Arthritis

In reverse total shoulder arthroplasty (RTSA), moving the center of rotation medially and distally relative to the native joint serves to:

. Increase the tension on the remaining rotator cuff
. Increase the deltoid moment arm
. Decrease the mechanical advantage of the deltoid
. Improve internal rotation strength
. Prevent scapular notching

Correct Answer & Explanation

. Increase the tension on the remaining rotator cuff

Explanation

Medializing and distalizing the center of rotation in an RTSA increases the deltoid moment arm and places the muscle under greater tension. This allows the deltoid to efficiently elevate the arm in the absence of a functioning rotator cuff.

Question 2187

Topic: 9. Shoulder and Elbow

A 75-year-old female sustains a comminuted 4-part proximal humerus fracture. Radiographs and CT show significant osteopenia, severe tuberosity comminution, and a head-split component. What is the most appropriate definitive surgical treatment?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Nonoperative management in a sling

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Reverse total shoulder arthroplasty is the preferred treatment in elderly patients with complex 4-part fractures and head-split components. It relies less on tuberosity healing for functional overhead elevation compared to hemiarthroplasty.

Question 2188

Topic: 9. Shoulder and Elbow

On a coronal T2-weighted MRI of the shoulder in a patient with recurrent instability, the normal U-shaped axillary pouch is disrupted and appears as a 'J-sign'. This finding is pathognomonic for which of the following lesions?

. Bankart lesion
. ALPSA lesion
. HAGL lesion
. GLAD lesion
. Perthes lesion

Correct Answer & Explanation

. Bankart lesion

Explanation

The 'J-sign' on a coronal MRI indicates a Humeral Avulsion of the Glenohumeral Ligament (HAGL) lesion. The normal axillary recess loses its U-shape due to the capsular avulsion from the humeral neck.

Question 2189

Topic: 9. Shoulder and Elbow

In a patient with cuff tear arthropathy, what radiographic feature characterizes Hamada Stage 3 disease?

. Acromiohumeral distance > 6 mm
. Acetabularization of the acromion and femoralization of the humeral head
. Glenohumeral joint space narrowing
. Humeral head collapse/osteonecrosis
. Isolated anterior humeral head subluxation

Correct Answer & Explanation

. Acromiohumeral distance > 6 mm

Explanation

According to the Hamada classification for cuff tear arthropathy, Stage 3 is characterized by 'acetabularization' of the coracoacromial arch (acromion) and 'femoralization' of the humeral head without true glenohumeral arthritis.

Question 2190

Topic: Shoulder Arthroplasty & Arthritis

A 71-year-old man presents with an inability to actively elevate his right arm above 40 degrees. Passive elevation is full. MRI reveals a massive, retracted tear of the supraspinatus and infraspinatus tendons with Goutallier stage 4 fatty infiltration. His deltoid function is intact. What is the most appropriate surgical intervention?

. Arthroscopic complete rotator cuff repair
. Arthroscopic partial repair with margin convergence
. Superior capsular reconstruction
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Arthroscopic complete rotator cuff repair

Explanation

Pseudoparalysis (inability to actively elevate >90 degrees with full passive ROM) in an elderly patient with a massive, irreparable rotator cuff tear (Goutallier stage 3 or 4) is the classic indication for a reverse total shoulder arthroplasty. Anatomic TSA is contraindicated due to the deficient cuff.

Question 2191

Topic: 9. Shoulder and Elbow

A 31-year-old competitive weightlifter felt a 'pop' in his anterior axilla while performing a heavy bench press. Examination shows loss of the normal anterior axillary contour and weakness in internal rotation and adduction. MRI confirms a complete avulsion of the pectoralis major tendon from its humeral insertion. Surgical repair is most likely to restore strength in which of the following motions?

. Shoulder flexion
. Shoulder abduction
. Shoulder adduction and internal rotation
. Elbow flexion and supination
. Scapular protraction

Correct Answer & Explanation

. Shoulder flexion

Explanation

The pectoralis major functions primarily to adduct and internally rotate the humerus. Early surgical repair of sternocostal head ruptures at the humeral insertion reliably restores strength in adduction and internal rotation for high-demand athletes.

Question 2192

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with chronic severe shoulder pain and an inability to actively elevate her arm above 40 degrees, despite full passive range of motion. Radiographs demonstrate severe glenohumeral osteoarthritis with superior migration of the humeral head articulating with the acromion. Which of the following is the most reliable surgical option?

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

Correct Answer & Explanation

. Arthroscopic rotator cuff repair

Explanation

Reverse total shoulder arthroplasty is the gold standard for rotator cuff tear arthropathy with pseudoparalysis. It medializes and distalizes the center of rotation, significantly increasing the deltoid moment arm to compensate for the deficient rotator cuff.

Question 2193

Topic: 9. Shoulder and Elbow

A 70-year-old woman presents with severe shoulder pain and an inability to actively elevate her arm past 45 degrees. Radiographs demonstrate superior migration of the humeral head and glenohumeral osteoarthritis. MRI confirms a massive, retracted, and fatty-infiltrated rotator cuff tear. What is the most appropriate surgical treatment?

. Arthroscopic rotator cuff repair
. Hemiarthroplasty
. Reverse total shoulder arthroplasty (RTSA)
. Superior capsule reconstruction
. Latissimus dorsi transfer

Correct Answer & Explanation

. Arthroscopic rotator cuff repair

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for rotator cuff tear arthropathy in older patients with pseudoparalysis. It relies on the deltoid to elevate the arm by medializing and distalizing the center of rotation.

Question 2194

Topic: 9. Shoulder and Elbow

A 76-year-old right-hand-dominant woman sustains a highly comminuted 4-part proximal humerus fracture with splitting of the humeral head. The tuberosities are widely displaced. What is the most reliable surgical option to restore active elevation?

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

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Reverse total shoulder arthroplasty provides more predictable pain relief and functional restoration in elderly patients with complex 4-part fractures and poor bone quality. It is less reliant on tuberosity healing compared to hemiarthroplasty.

Question 2195

Topic: 9. Shoulder and Elbow

A 55-year-old diabetic woman presents with insidious onset of progressive shoulder stiffness and pain over the last 4 months. Passive and active ROM are equally restricted, with external rotation at 0 degrees and forward elevation at 80 degrees. Radiographs are normal. What is the primary pathophysiologic process?

. Fibroblastic proliferation of the coracohumeral ligament and joint capsule
. Myxoid degeneration of the supraspinatus tendon
. Hypertrophy of the acromioclavicular joint
. Chondral thinning of the glenohumeral joint
. Retraction of the subscapularis

Correct Answer & Explanation

. Fibroblastic proliferation of the coracohumeral ligament and joint capsule

Explanation

Adhesive capsulitis (frozen shoulder) is characterized by fibroblastic proliferation and thickening of the joint capsule, particularly involving the coracohumeral ligament and the rotator interval.

Question 2196

Topic: Shoulder Arthroplasty & Arthritis

A 75-year-old female presents with a severely comminuted, valgus-impacted 4-part proximal humerus fracture with profound osteopenia. The tuberosities are extensively fragmented. What is the most reliable surgical option to restore active elevation in this patient?

. Nonoperative management in a sling
. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Closed reduction and percutaneous pinning

Correct Answer & Explanation

. Nonoperative management in a sling

Explanation

In elderly patients with 4-part proximal humerus fractures, poor bone quality, and severely comminuted tuberosities, Reverse Total Shoulder Arthroplasty (RTSA) provides more reliable outcomes and function. Hemiarthroplasty heavily relies on tuberosity healing, which is unpredictable in this population.

Question 2197

Topic: 9. Shoulder and Elbow

An 18-year-old football player is tackled directly onto his lateral shoulder and presents with severe pain, shortness of breath, and dysphagia. Examination suggests a posterior sternoclavicular joint dislocation. After securing the airway, what is the gold-standard imaging modality to evaluate this injury?

. Serendipity view radiograph
. Hobo view radiograph
. Non-contrast MRI of the chest
. Contrast-enhanced CT of the chest
. Doppler ultrasound of the neck

Correct Answer & Explanation

. Serendipity view radiograph

Explanation

Posterior sternoclavicular joint dislocations are orthopedic emergencies due to the proximity of vital mediastinal structures (trachea, esophagus, great vessels). A contrast-enhanced CT scan is the gold standard to accurately evaluate the joint and simultaneously assess for vascular injury.

Question 2198

Topic: 9. Shoulder and Elbow

A 68-year-old male who underwent an anatomic total shoulder arthroplasty 5 years ago presents with new-onset shoulder pain and clicking. Radiographs reveal superior migration of the humeral head and an asymmetric radiolucent line around the glenoid component, suggestive of the 'rocking horse' phenomenon. What is the primary etiology of this finding?

. Excessive initial glenoid retroversion
. Uncorrected superior migration of the humeral head due to late rotator cuff failure
. Use of a pegged rather than keeled glenoid component
. Subclinical infection with Propionibacterium acnes
. Over-stuffing the joint with an oversized humeral head component

Correct Answer & Explanation

. Excessive initial glenoid retroversion

Explanation

The 'rocking horse' phenomenon in anatomic total shoulder arthroplasty refers to early glenoid component loosening caused by eccentric loading. This most commonly results from late failure of the rotator cuff, causing superior migration of the humeral head and subsequent asymmetric superior loading on the glenoid.

Question 2199

Topic: 9. Shoulder and Elbow

A 68-year-old man presents with severe shoulder pain and an inability to actively elevate his arm past 45 degrees, though passive motion is full. MRI reveals a massive, retracted, and fatty-infiltrated tear of the supraspinatus and infraspinatus. The subscapularis and teres minor are intact. Radiographs show no significant glenohumeral osteoarthritis. What is the most reliable surgical option to restore active elevation?

. Arthroscopic superior capsule reconstruction (SCR)
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic debridement and partial repair
. Latissimus dorsi tendon transfer

Correct Answer & Explanation

. Arthroscopic superior capsule reconstruction (SCR)

Explanation

Reverse total shoulder arthroplasty is indicated for patients with massive, irreparable rotator cuff tears associated with pseudoparalysis, especially in older patients. It restores elevation by increasing the deltoid moment arm, regardless of the presence of advanced arthritis.

Question 2200

Topic: 9. Shoulder and Elbow

During the late cocking phase of a throwing motion, the shoulder is in maximum abduction and external rotation. In this specific position, which capsuloligamentous structure provides the primary static restraint to anterior translation of the humeral head?

. Coracohumeral ligament (CHL)
. Superior glenohumeral ligament (SGHL)
. Middle glenohumeral ligament (MGHL)
. Anterior band of the inferior glenohumeral ligament (AB-IGHL)
. Posterior band of the inferior glenohumeral ligament (PB-IGHL)

Correct Answer & Explanation

. Coracohumeral ligament (CHL)

Explanation

Biomechanical studies have demonstrated that the anterior band of the inferior glenohumeral ligament (AB-IGHL) is the primary restraint to anterior and inferior humeral translation when the shoulder is positioned in 90 degrees of abduction and maximum external rotation.

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