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9. Shoulder and Elbow MCQs

Practice Set 112 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 2221

Topic: Shoulder Pathology

When exposing the posterior arch of C1 and the lateral masses of C2 for atlantoaxial fusion, a large neurovascular structure is routinely encountered crossing the posterior aspect of the C1-C2 joint. Which structure must be mobilized caudally or transected to achieve lateral mass exposure?

. C1 nerve root
. C2 nerve root (greater occipital nerve branch)
. Vertebral artery V3 segment
. Vertebral artery V2 segment
. Spinal accessory nerve

Correct Answer & Explanation

. C1 nerve root

Explanation

The C2 nerve root and its dorsal root ganglion exit and course directly posterior to the C1-C2 facet joint. It often obstructs the starting point for C1 lateral mass screws and must be retracted caudally or transected.

Question 2222

Topic: Elbow & Forearm

A 25-year-old female sustains a closed distal humerus fracture involving the capitellum and lateral trochlea extending into the lateral column. Which classification best describes this injury?

. Bryan-Morrey Type I
. Bryan-Morrey Type IV
. Jupiter Type 2
. Milch Type I
. Dubberley Type 3

Correct Answer & Explanation

. Bryan-Morrey Type I

Explanation

The Bryan-Morrey Type IV fracture involves a shear fracture of the capitellum that extends medially to include most of the trochlea. This is also known as a Hahn-Steinthal fracture with lateral trochlear extension.

Question 2223

Topic: 9. Shoulder and Elbow

A 6-year-old child presents with a Bado Type I Monteggia fracture-dislocation (anterior dislocation of the radial head with an anteriorly angulated ulnar fracture). What is the optimal closed reduction maneuver?

. Traction, pronation, and elbow extension
. Traction, supination, and elbow flexion beyond 90 degrees
. Direct pressure on the radial head in full extension
. Hyperpronation and varus stress
. Valgus stress with elbow locked in extension

Correct Answer & Explanation

. Traction, pronation, and elbow extension

Explanation

Bado Type I Monteggia fractures are characterized by anterior bowing of the ulna and anterior radial head dislocation. The standard closed reduction technique involves traction, full supination, and flexing the elbow past 90 degrees to relax the biceps and stabilize the radiocapitellar joint.

Question 2224

Topic: 9. Shoulder and Elbow

A 78-year-old woman with a history of severe osteoporosis sustains a 4-part proximal humerus fracture with significant medial calcar comminution and varus angulation. To optimize her functional outcome and minimize complications, what is the most appropriate surgical treatment?

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

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Reverse total shoulder arthroplasty is indicated for elderly patients with complex 4-part proximal humerus fractures, especially in the setting of poor bone quality or tuberosity comminution. It provides more reliable functional outcomes and pain relief compared to hemiarthroplasty or ORIF in this demographic.

Question 2225

Topic: Elbow & Forearm

A 30-year-old man sustains a Bado Type I Monteggia fracture-dislocation. The ulnar shaft fracture is anatomically reduced and plated, but the radial head remains dislocated anteriorly. What is the most common anatomic structure blocking the reduction of the radial head?

. Biceps tendon
. Annular ligament
. Lateral collateral ligament
. Brachialis muscle
. Median nerve

Correct Answer & Explanation

. Biceps tendon

Explanation

In Monteggia fracture-dislocations, anatomic fixation of the ulna typically reduces the radial head. If the radial head remains unreduced, the most common structure interposed and blocking reduction is the annular ligament.

Question 2226

Topic: Elbow & Forearm

A 45-year-old man presents with a "terrible triad" injury of the elbow following a fall. What is the widely accepted standard sequence for surgical reconstruction of this injury?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury works from deep to superficial: repair the coronoid first, then fix or replace the radial head, and finally repair the lateral ulnar collateral ligament (LUCL). The MCL is only addressed if the elbow remains grossly unstable after lateral-sided repair.

Question 2227

Topic: Elbow & Forearm

A 6-year-old boy presents with a Bado Type I Monteggia fracture-dislocation. Closed reduction of the ulna correctly restores length and alignment, but the radial head remains anteriorly dislocated on radiographs. What is the most common anatomical block to the reduction of the radial head in this scenario?

. Interposition of the annular ligament
. Incarceration of the median nerve
. Interposition of the biceps tendon
. An unrecognized osteochondral fragment from the capitellum
. Subluxation of the distal radioulnar joint

Correct Answer & Explanation

. Interposition of the annular ligament

Explanation

In Bado Type I Monteggia injuries where the ulna is anatomically reduced but the radial head remains dislocated, the most common block to reduction is interposition of the annular ligament or joint capsule. Open reduction of the radiocapitellar joint is required to clear the interposed tissue.

Question 2228

Topic: 9. Shoulder and Elbow

A 40-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. Which of the following best describes the typical sequence of surgical repair to restore stability?

. LCL repair, radial head fixation/replacement, coronoid fixation
. Coronoid fixation, radial head fixation/replacement, LCL repair
. Radial head fixation, LCL repair, MCL repair
. Coronoid fixation, MCL repair, LCL repair
. LCL repair, MCL repair, coronoid fixation

Correct Answer & Explanation

. LCL repair, radial head fixation/replacement, coronoid fixation

Explanation

Surgical management of terrible triad elbow injuries traditionally proceeds from deep to superficial, or 'inside-out'. The standard sequence is fixation of the coronoid fracture, followed by radial head repair or replacement, and finally repair of the lateral collateral ligament (LCL).

Question 2229

Topic: Elbow & Forearm

A 45-year-old female falls onto an outstretched hand and sustains a 'terrible triad' injury of the elbow. Which of the following represents the most accepted surgical sequence for reconstructing this injury?

. Fixation of the coronoid, followed by radial head repair/replacement, then lateral collateral ligament (LCL) repair
. Radial head repair/replacement, followed by LCL repair, then coronoid fixation
. LCL repair, followed by coronoid fixation, then radial head replacement
. Medial collateral ligament (MCL) repair, LCL repair, then radial head repair
. Coronoid fixation, MCL repair, then radial head replacement

Correct Answer & Explanation

. Fixation of the coronoid, followed by radial head repair/replacement, then lateral collateral ligament (LCL) repair

Explanation

The standard surgical sequence for a terrible triad injury works deep to superficial from lateral to medial. It involves fixing the coronoid first, addressing the radial head (repair or replacement), and finally repairing the lateral ulnar collateral ligament (LUCL).

Question 2230

Topic: 9. Shoulder and Elbow

A 62-year-old sedentary patient presents with chronic, intractable shoulder pain and weakness, particularly with overhead activities. MRI reveals a massive, irreparable rotator cuff tear involving the supraspinatus, infraspinatus, and subscapularis, with significant retraction and fatty infiltration (Goutallier Grade 3-4) and superior migration of the humeral head with glenohumeral arthritis (Hamada Stage 4). She has failed extensive non-operative management. What is the MOST appropriate surgical intervention?

. Arthroscopic rotator cuff repair
. Superior capsular reconstruction
. Latissimus dorsi transfer
. Reverse total shoulder arthroplasty
. Partial rotator cuff repair with debridement

Correct Answer & Explanation

. Arthroscopic rotator cuff repair

Explanation

The patient's presentation of a massive, irreparable rotator cuff tear with significant fatty infiltration and retraction, combined with glenohumeral arthritis and superior humeral head migration (rotator cuff arthropathy, Hamada Stage 4), indicates a condition best managed by reverse total shoulder arthroplasty (rTSA). rTSA is designed for situations where the rotator cuff is deficient, allowing the deltoid to power shoulder elevation and rotation. Arthroscopic repair or partial repair would be futile due to the irreparable nature and significant fatty infiltration. Superior capsular reconstruction is typically reserved for younger, active patients with irreparable tears but without significant glenohumeral arthritis. Latissimus dorsi transfer is an option for irreparable posterosuperior tears, often in younger patients, to restore external rotation and elevation, but it does not address the underlying glenohumeral arthritis. For this patient with established rotator cuff arthropathy, rTSA provides the most reliable pain relief and functional improvement.

Question 2231

Topic: 9. Shoulder and Elbow

A 70-year-old female presents with severe, chronic pain and crepitus in her right shoulder. Radiographs show significant glenohumeral osteoarthritis with concentric wear and an intact rotator cuff confirmed on MRI. She is active and wishes to return to gardening and light sports. What is the MOST appropriate surgical option?

. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty
. Arthroscopic debridement
. Shoulder fusion

Correct Answer & Explanation

. Hemiarthroplasty

Explanation

The patient presents with severe glenohumeral osteoarthritis with concentric wear and an intact rotator cuff, and has failed conservative management. For this scenario, anatomic total shoulder arthroplasty (TSA) is the gold standard. It replaces both the humeral head and glenoid surface, providing excellent pain relief and functional restoration in patients with an intact, functional rotator cuff. Hemiarthroplasty is typically considered for younger patients with glenohumeral arthritis and a good rotator cuff, but where glenoid replacement is deferred (e.g., due to concerns about glenoid wear or activity level), or for certain humeral head fractures. Reverse total shoulder arthroplasty is indicated when the rotator cuff is deficient (rotator cuff arthropathy). Arthroscopic debridement offers only temporary relief for severe arthritis. Shoulder fusion is a salvage procedure providing pain relief at the expense of motion, typically for failed arthroplasty or severe infection/paralysis.

Question 2232

Topic: Elbow & Forearm

A professional baseball pitcher presents with chronic medial elbow pain and decreased throwing velocity. He describes a "pop" during a pitch several months ago. Examination reveals tenderness over the medial epicondyle, a positive valgus stress test at 30 degrees of elbow flexion, and a positive moving valgus stress test. Radiographs show no acute fractures but reveal subtle calcification within the medial collateral ligament. What is the MOST likely diagnosis and definitive treatment?

. Medial epicondylitis; PRP injection
. Ulnar nerve entrapment; Cubital tunnel release
. Ulnar collateral ligament (UCL) insufficiency; UCL reconstruction (Tommy John surgery)
. Flexor-pronator strain; Rest and physical therapy
. Olecranon stress fracture; Immobilization

Correct Answer & Explanation

. Medial epicondylitis; PRP injection

Explanation

The presentation is classic for ulnar collateral ligament (UCL) insufficiency in an overhead athlete: acute "pop" during throwing, chronic medial elbow pain, decreased velocity, tenderness over the UCL, and positive valgus stress tests (both static and moving). Subtle calcification within the ligament supports chronic injury. Medial epicondylitis (golfer's elbow) typically causes pain with resisted wrist flexion/pronation and is less associated with acute instability or a 'pop'. Ulnar nerve entrapment would present with paresthesias in the ring/small fingers. Flexor-pronator strain is possible but less likely to cause instability on valgus stress. Olecranon stress fractures cause pain primarily with extension. For a professional athlete with symptomatic UCL insufficiency, UCL reconstruction (Tommy John surgery) is the definitive treatment to restore stability and allow return to high-level throwing.

Question 2233

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old female sustains a Neer three-part proximal humerus fracture after a fall. She is relatively active for her age but has significant comorbidities including diabetes and cardiac disease. Radiographs show significant displacement of the greater tuberosity and surgical neck, but the articular segment appears well-preserved. What is the MOST appropriate initial management strategy?

. Sling immobilization for 6 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF)
. Reverse total shoulder arthroplasty (rTSA)
. Hemiarthroplasty

Correct Answer & Explanation

. Sling immobilization for 6 weeks

Explanation

A Neer three-part proximal humerus fracture involves displacement of the surgical neck and either the greater or lesser tuberosity. While conservative management (sling) is often considered for minimally displaced or two-part fractures in older patients, and hemiarthroplasty/rTSA for very comminuted or four-part fractures in older patients, a three-part fracture, especially with displacement of the tuberosities, often benefits from surgical intervention to restore anatomy and function. Given the patient's relative activity level and "well-preserved articular segment," ORIF with locking plates is often preferred in patients with good bone quality and a reconstructible fracture. This aims to restore tuberosity position, which is crucial for rotator cuff function and prevents impingement. Reverse TSA is typically reserved for four-part fractures, head split fractures, or patients with rotator cuff deficiency, particularly in the elderly. Hemiarthroplasty is an option for four-part fractures or head split fractures in good bone stock. Closed reduction and pinning is less stable for this degree of displacement.

Question 2234

Topic: 9. Shoulder and Elbow

A 55-year-old active laborer presents with a massive, irreparable posterosuperior rotator cuff tear with significant retraction (Sugaya Type V). He has no signs of glenohumeral arthritis. He experiences significant pain and inability to elevate his arm above 90 degrees. He desires to return to work. What is the MOST appropriate surgical option to improve function and pain?

. Reverse total shoulder arthroplasty
. Latissimus dorsi tendon transfer
. Superior capsular reconstruction (SCR)
. Partial repair and debridement
. Total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

This patient has an irreparable posterosuperior rotator cuff tear without glenohumeral arthritis, and desires functional improvement to return to work. While latissimus dorsi transfer is a historical option for posterior cuff deficiency, superior capsular reconstruction (SCR) has emerged as a viable option for irreparable massive rotator cuff tears in younger, active patients without significant arthritis. SCR aims to restore the superior capsule's function in preventing superior migration of the humeral head, thereby improving deltoid mechanics and often pain and active elevation. Reverse total shoulder arthroplasty is indicated for rotator cuff arthropathy (arthritis with cuff deficiency), which this patient does not have. Partial repair and debridement offers limited functional improvement for massive tears. Total shoulder arthroplasty is for glenohumeral arthritis with an intact cuff. The key here is an irreparable tearwithoutarthritis.

Question 2235

Topic: 9. Shoulder and Elbow

A 32-year-old male falls on an outstretched arm and sustains an elbow injury. Radiographs reveal a comminuted radial head fracture, a coronoid process fracture, and posterior dislocation of the elbow. Which of the following is NOT typically part of the initial surgical management for this "terrible triad" injury?

. Radial head replacement or ORIF
. Repair or reconstruction of the lateral ulnar collateral ligament (LUCL)
. Repair of the medial collateral ligament (MCL)
. Coronoid process repair or fixation
. Temporary transarticular pinning of the elbow

Correct Answer & Explanation

. Radial head replacement or ORIF

Explanation

The "terrible triad" of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid process fracture. This injury pattern typically involves disruption of the lateral ulnar collateral ligament (LUCL), making the elbow highly unstable. The goals of surgical management are to restore stability and allow early motion. This involves: 1) repairing or replacing the radial head, 2) repairing or fixing the coronoid process, and 3) repairing or reconstructing the LUCL. Temporary transarticular pinning may be used to maintain stability, especially if there are concerns about early redislocation. The medial collateral ligament (MCL) is usually intact in terrible triad injuries, or it is stretched but not the primary stabilizer that needs repair. The LUCL is the key posterolateral stabilizer disrupted. Therefore, repairing the MCL is NOT typically part of the initial surgical management for a terrible triad injury.

Question 2236

Topic: 9. Shoulder and Elbow

An 80-year-old frail female with a history of a massive rotator cuff tear presents with severe shoulder pain, pseudoparalysis (inability to actively elevate the arm), and limited range of motion. Radiographs show superior migration of the humeral head and glenohumeral arthritis. She has significant medical comorbidities. What is the MOST appropriate treatment strategy to improve her quality of life?

. Conservative management with pain medication and physical therapy
. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Arthrodesis

Correct Answer & Explanation

. Conservative management with pain medication and physical therapy

Explanation

This patient presents with rotator cuff arthropathy (superior humeral head migration with glenohumeral arthritis) and pseudoparalysis, meaning she cannot actively elevate her arm despite an intact deltoid. For this condition, especially in the elderly, reverse total shoulder arthroplasty (rTSA) is the treatment of choice. rTSA alters the biomechanics of the shoulder, making the deltoid muscle more efficient in elevating the arm, thereby providing pain relief and restoring active elevation in the absence of a functional rotator cuff. Conservative management might temporarily relieve pain but will not restore function. Hemiarthroplasty and anatomic total shoulder arthroplasty rely on an intact rotator cuff, which this patient lacks. Arthrodesis is a salvage procedure that sacrifices motion and is generally not preferred for improving quality of life unless other options have failed or are contraindicated.

Question 2237

Topic: 9. Shoulder and Elbow

A 50-year-old diabetic female presents with diffuse, severe shoulder pain and progressive loss of active and passive range of motion in all planes over the past 3 months. She denies any injury. Radiographs are normal. What is the MOST appropriate initial management?

. Arthroscopic capsular release
. Corticosteroid injection into the glenohumeral joint
. Aggressive manipulation under anesthesia
. Reverse total shoulder arthroplasty
. Shoulder fusion

Correct Answer & Explanation

. Arthroscopic capsular release

Explanation

This patient presents with classic signs and symptoms of adhesive capsulitis (frozen shoulder), particularly in a patient with diabetes, which is a known risk factor. The "freezing" phase is characterized by severe pain and progressive loss of motion. The initial management is typically conservative and focuses on pain control and maintaining motion. A corticosteroid injection into the glenohumeral joint is highly effective for reducing pain and inflammation in the "freezing" phase, which then facilitates physical therapy. Aggressive manipulation under anesthesia and arthroscopic capsular release are reserved for patients who fail conservative management and are in the "frozen" or "thawing" phases with persistent stiffness. Reverse total shoulder arthroplasty and shoulder fusion are inappropriate for adhesive capsulitis.

Question 2238

Topic: Elbow & Forearm

A 45-year-old male bodybuilder experiences a sudden, sharp pain in his elbow while lifting a heavy weight. He notices a "pop" and immediate weakness in elbow flexion and forearm supination. Examination reveals a palpable defect in the distal biceps tendon, ecchymosis in the antecubital fossa, and a positive "hook test". What is the MOST appropriate management?

. Conservative management with sling immobilization
. Repair of the distal biceps tendon to the radial tuberosity
. Reattachment of the biceps tendon to the brachialis muscle
. Debridement of the ruptured tendon
. Corticosteroid injection for pain relief

Correct Answer & Explanation

. Conservative management with sling immobilization

Explanation

The patient's presentation is classic for an acute distal biceps tendon rupture (sudden pain, "pop," weakness in flexion and supination, palpable defect, positive hook test). For active individuals, especially those involved in heavy lifting, surgical repair is the gold standard treatment to restore strength and endurance in elbow flexion and forearm supination. The repair involves reattaching the ruptured tendon to its anatomical insertion on the radial tuberosity. Conservative management leads to significant functional deficits. Reattachment to the brachialis is not anatomically correct and will not restore supination strength. Debridement is insufficient. Corticosteroid injections are contraindicated as they can weaken tendons and increase rupture risk.

Question 2239

Topic: 9. Shoulder and Elbow

A 60-year-old male develops severe elbow stiffness with a functional arc of motion of only 30-70 degrees (flexion-extension) after sustaining a distal humerus fracture treated with ORIF 6 months ago. Radiographs show heterotopic ossification around the elbow joint. He has failed extensive physical therapy. What is the MOST appropriate surgical intervention?

. Loose body removal
. Capsular release with excision of heterotopic ossification
. Radial head replacement
. Ulnar nerve transposition
. Elbow arthrodesis

Correct Answer & Explanation

. Loose body removal

Explanation

The patient presents with severe post-traumatic elbow stiffness and heterotopic ossification (HO) following a distal humerus fracture, limiting his functional arc of motion. When conservative management (physical therapy, dynamic splinting) fails, surgical intervention is indicated. This typically involves an arthroscopic or open capsular release to address contractures of the anterior and posterior capsules, combined with excision of the heterotopic ossification. This procedure aims to restore functional range of motion. Loose body removal might be part of it but is not the sole solution for widespread stiffness and HO. Radial head replacement is for radial head fractures or arthritis. Ulnar nerve transposition might be done concomitantly if the nerve is entrapped, but it doesn't address stiffness. Elbow arthrodesis is a salvage procedure for a painful, unsalvageable joint, not for restoring motion in a stiff but otherwise preserved joint.

Question 2240

Topic: 9. Shoulder and Elbow

A 38-year-old tennis player complains of chronic lateral elbow pain, which is exacerbated by gripping and forearm supination. He has no numbness or tingling. Examination reveals tenderness over the mobile wad of Henry (specifically the supinator muscle) and pain with resisted middle finger extension (Maudeley's test). Resisted wrist extension is not particularly painful. What is the MOST likely diagnosis?

. Lateral epicondylitis (tennis elbow)
. Ulnar nerve entrapment
. Radial tunnel syndrome
. Distal biceps tendinopathy
. Olecranon bursitis

Correct Answer & Explanation

. Lateral epicondylitis (tennis elbow)

Explanation

The patient's symptoms are highly suggestive of radial tunnel syndrome, which is compression of the posterior interosseous nerve (PIN), a branch of the radial nerve, within the radial tunnel. Key features include chronic lateral elbow pain exacerbated by gripping and supination, tenderness over the supinator, and pain with resisted middle finger extension (which stresses the extensor digitorum communis, innervated by PIN). Importantly, there is no numbness/tingling (as PIN is purely motor) and resisted wrist extension is not the primary pain generator, differentiating it from classic lateral epicondylitis. Lateral epicondylitis involves pain with resisted wrist extension and palpation of the lateral epicondyle. Ulnar nerve entrapment affects the medial side. Distal biceps tendinopathy involves the anterior elbow. Olecranon bursitis is posterior.

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