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9. Shoulder and Elbow MCQs

Practice Set 114 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 2261

Topic: Elbow & Forearm

A 42-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. Surgical fixation is planned. To optimize stability and follow standard surgical principles, what is the most appropriate sequence of repair for the injured structures?

. Coronoid fixation, radial head repair or replacement, and lateral ulnar collateral ligament (LUCL) repair
. Radial head replacement, LUCL repair, and coronoid fixation
. LUCL repair, coronoid fixation, and radial head repair
. Coronoid fixation, medial collateral ligament (MCL) repair, and LUCL repair
. Radial head repair, MCL repair, and coronoid fixation

Correct Answer & Explanation

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

Explanation

The terrible triad of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid process fracture. The standard surgical algorithm follows a 'deep to superficial' and 'medial to lateral' approach. The typical sequence is: 1) Coronoid fracture fixation or anterior capsule repair, 2) Radial head repair or replacement, 3) Lateral ulnar collateral ligament (LUCL) repair, and 4) Medial collateral ligament (MCL) repair (only if the elbow remains unstable after the first three steps).

Question 2262

Topic: Shoulder Arthroplasty & Arthritis

You are discussing the biomechanics of a reverse total shoulder arthroplasty (RTSA) with a resident.

Which of the following best describes the primary biomechanical advantage conferred by the medialized and distalized center of rotation typical of a Grammont-style reverse shoulder implant?

. Increases the resting tension and lever arm of the deltoid muscle
. Increases the lever arm of the intact rotator cuff
. Recreates the anatomic center of rotation to restore natural kinematics
. Decreases the shear forces at the glenosphere-baseplate interface
. Enhances the function of the subscapularis for external rotation

Correct Answer & Explanation

. Increases the resting tension and lever arm of the deltoid muscle

Explanation

The key biomechanical principle of the Grammont-style reverse total shoulder arthroplasty is moving the center of rotation medially and distally compared to the native anatomy. This distalization increases the resting tension of the deltoid, while the medialization increases the deltoid's lever arm and recruits more deltoid muscle fibers for forward elevation and abduction, compensating for the absent or deficient rotator cuff. Medialization increases shear forces at the baseplate, which is a known disadvantage counteracted by using inferior tilt or a larger glenosphere.

Question 2263

Topic: Elbow & Forearm

A 38-year-old male weightlifter undergoes repair of a complete distal biceps tendon rupture via a classic two-incision approach. During his postoperative course, what complication is significantly more frequent with this surgical approach compared to a single-incision anterior approach?

. Lateral antebrachial cutaneous nerve neuropraxia
. Proximal radioulnar synostosis
. Posterior interosseous nerve palsy
. Median nerve injury
. Brachial artery injury

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve neuropraxia

Explanation

The two-incision approach for distal biceps repair was historically developed to avoid the radial nerve (PIN) injuries associated with a single anterior incision. However, it carries a significantly higher risk of heterotopic ossification and proximal radioulnar synostosis due to the dissection through the interosseous membrane and around the ulna. The single-incision anterior approach carries a higher risk of lateral antebrachial cutaneous nerve (LABCN) neuropraxia and posterior interosseous nerve (PIN) injury.

Question 2264

Topic: Elbow & Forearm

A 42-year-old male falls from a height and sustains a 'terrible triad' injury of the elbow, which includes an elbow dislocation, a comminuted radial head fracture, and a Type II coronoid fracture. Operative intervention is planned. To optimize stability, what is the most widely accepted surgical sequence for addressing these lesions?

. Lateral collateral ligament repair, radial head replacement, coronoid fixation
. Coronoid fixation, radial head replacement, lateral collateral ligament repair
. Radial head replacement, lateral collateral ligament repair, coronoid fixation
. Medial collateral ligament repair, coronoid fixation, radial head replacement
. Lateral collateral ligament repair, medial collateral ligament repair, radial head replacement

Correct Answer & Explanation

. Lateral collateral ligament repair, radial head replacement, coronoid fixation

Explanation

The 'terrible triad' of the elbow includes an elbow dislocation, radial head fracture, and coronoid fracture. The standard surgical algorithm follows a deep-to-superficial repair sequence to restore stability. First, the anterior capsule and coronoid are fixed to restore the anterior buttress. Second, the radial head is repaired or replaced. Finally, the lateral ulnar collateral ligament (LUCL/LCL complex) is repaired. MCL repair is rarely necessary unless the elbow remains unstable after the standard sequence.

Question 2265

Topic: Elbow & Forearm

A 45-year-old competitive weightlifter undergoes surgical repair of a distal biceps tendon rupture using a single-incision anterior approach. On his first postoperative visit, he complains of numbness and tingling along the lateral aspect of his forearm. Motor function of the hand and wrist is completely intact. Which of the following anatomical structures was most likely injured or stretched during the surgical exposure?

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

Correct Answer & Explanation

. Median nerve

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the terminal sensory branch of the musculocutaneous nerve. It exits the deep fascia just lateral to the biceps tendon and is highly vulnerable to traction neuropraxia or transection during a single-incision anterior approach for distal biceps repair. Injury results in numbness along the lateral aspect of the forearm. The posterior interosseous nerve (PIN) is more commonly at risk during a two-incision approach (particularly if the forearm is not kept in supination during the posterolateral exposure) or if retractors are placed too deep radially.

Question 2266

Topic: 9. Shoulder and Elbow

A 72-year-old woman with pseudoparalysis of the shoulder due to massive rotator cuff tear arthropathy is scheduled for a reverse total shoulder arthroplasty (RTSA). Which of the following best describes the fundamental biomechanical advantage conferred by the implant design of an RTSA compared to an anatomic total shoulder arthroplasty?

. Lateralization and superior translation of the center of rotation
. Lateralization and distalization of the center of rotation
. Medialization and superior translation of the center of rotation
. Medialization and distalization of the center of rotation
. Maintenance of the anatomic center of rotation with increased constraint

Correct Answer & Explanation

. Lateralization and superior translation of the center of rotation

Explanation

The fundamental biomechanical principle of the reverse total shoulder arthroplasty (Grammont design) is the medialization and distalization of the glenohumeral center of rotation. Medialization recruits more anterior and posterior deltoid fibers for elevation, while distalization tensions the deltoid and significantly increases its moment arm, allowing the deltoid to compensate for the deficient rotator cuff.

Question 2267

Topic: 9. Shoulder and Elbow

An 18-year-old high school football player is driven into the turf directly onto his lateral shoulder. He presents to the emergency department supporting his injured arm across his chest. He reports worsening shortness of breath, mild dysphagia, and a choking sensation.

A CT scan of the chest confirms a posterior sternoclavicular dislocation. What is the most appropriate initial management of this injury?

. Provide a figure-of-eight brace and observe in the ICU
. Perform a closed reduction in the emergency department using procedural sedation
. Perform a closed reduction in the operating room with a cardiothoracic surgeon readily available
. Immediate open reduction and internal fixation with a hook plate
. Immediate resection of the medial third of the clavicle

Correct Answer & Explanation

. Provide a figure-of-eight brace and observe in the ICU

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies, especially when accompanied by symptoms of mediastinal compression (shortness of breath, dysphagia, venous congestion). Due to the proximity of the great vessels, trachea, and esophagus, reduction should be performed urgently in the operating room under general anesthesia, with a cardiothoracic surgeon available on standby in case of catastrophic hemorrhage or great vessel injury during the reduction maneuver.

Question 2268

Topic: Elbow & Forearm

A 42-year-old male weightlifter feels a sudden pop in his anterior elbow during a heavy deadlift. Clinical examination reveals a positive hook test. He undergoes surgical repair via a single-incision anterior approach. Postoperatively, he complains of numbness and paresthesias over the lateral aspect of his forearm. Which of the following nerves was most likely injured or retracted excessively during the surgical exposure?

. Lateral antebrachial cutaneous nerve
. Radial nerve
. Posterior interosseous nerve
. Median nerve
. Musculocutaneous nerve motor branch

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the sensory continuation of the musculocutaneous nerve. It exits the deep fascia lateral to the biceps tendon and is the most commonly injured nerve during a single-incision anterior approach for distal biceps tendon repair. Injury results in numbness or paresthesias over the lateral forearm.

Question 2269

Topic: Elbow & Forearm

A 35-year-old man falls from a ladder and sustains an elbow dislocation associated with a radial head fracture and a coronoid fracture. He is taken to the operating room for surgical reconstruction. To optimally restore elbow stability in this 'terrible triad' injury, what is the generally recommended sequence of repair?

. Coronoid fracture, Lateral collateral ligament, Radial head
. Lateral collateral ligament, Radial head, Coronoid fracture
. Coronoid fracture, Radial head, Lateral collateral ligament
. Radial head, Lateral collateral ligament, Coronoid fracture
. Radial head, Coronoid fracture, Lateral collateral ligament

Correct Answer & Explanation

. Coronoid fracture, Lateral collateral ligament, Radial head

Explanation

The standard surgical algorithm for a 'terrible triad' injury of the elbow involves repairing the deep structures first, progressing from medial to lateral and deep to superficial. The typical sequence is: 1) Coronoid fracture fixation or anterior capsule repair, 2) Radial head fixation or replacement, and 3) Lateral collateral ligament (LCL) complex repair.

Question 2270

Topic: 9. Shoulder and Elbow

A 72-year-old female with severe, painful rotator cuff arthropathy and pseudoparalysis of the shoulder undergoes a reverse total shoulder arthroplasty (RTSA). Which of the following best describes the fundamental biomechanical alteration provided by this specific prosthesis compared to native shoulder anatomy?

. Lateralizes the center of rotation and increases the deltoid moment arm
. Medializes and distalizes the center of rotation, increasing the deltoid moment arm
. Medializes and proximalizes the center of rotation, increasing deltoid tension
. Lateralizes and distalizes the center of rotation, decreasing deltoid tension
. Preserves the native center of rotation while constraining the glenohumeral joint

Correct Answer & Explanation

. Lateralizes the center of rotation and increases the deltoid moment arm

Explanation

A reverse total shoulder arthroplasty (RTSA) biomechanically medializes and distalizes the center of rotation of the glenohumeral joint. Medialization recruits more anterior and posterior deltoid fibers for elevation, while distalization tensions the deltoid and increases its moment arm. This allows the deltoid to effectively compensate for the deficient rotator cuff and restores active elevation.

Question 2271

Topic: Elbow & Forearm

A 24-year-old female sustains a severe fall onto an outstretched hand. Imaging reveals a coronal shear fracture of the capitellum that extends medially into the lateral trochlear ridge (Type IV capitellar fracture). She is scheduled for open reduction and internal fixation. Which surgical approach provides the most optimal visualization for addressing this specific fracture pattern?

. Posterior universally (triceps-splitting) approach
. Medial over-the-top approach
. Extensile lateral approach
. Anterior Henry approach
. Standard medial approach

Correct Answer & Explanation

. Posterior universally (triceps-splitting) approach

Explanation

Coronal shear fractures of the distal humerus involving the capitellum and extending into the trochlea (McKee modification Type IV) are best addressed via an extensile lateral approach. This allows excellent exposure of the anterior capitellum and lateral trochlea for placement of headless compression screws from anterior to posterior.

Question 2272

Topic: 9. Shoulder and Elbow

A 32-year-old woman sustains a 'terrible triad' injury to her right elbow. She is taken to the operating room for surgical stabilization. To optimally restore elbow stability, what is the most widely accepted and biomechanically sound sequence of structural reconstruction?

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

Correct Answer & Explanation

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

Explanation

The standard 'inside-out' surgical sequence for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) is: 1) Repair or fixation of the coronoid to restore the anterior buttress, 2) Repair or replacement of the radial head to restore the anterior and valgus buttress, and 3) Repair of the lateral collateral ligament (LCL) complex. Routine MCL repair is generally unnecessary if these structures are adequately stabilized and the elbow is concentrically reduced.

Question 2273

Topic: Elbow & Forearm

A 42-year-old recreational weightlifter undergoes a classic two-incision approach (Boyd-Anderson) for a distal biceps tendon rupture repair. Six months postoperatively, he complains of severe stiffness in forearm rotation. Examination reveals a hard block with only 10 degrees of pronation and 15 degrees of supination. Which of the following technical errors during the index procedure is most likely responsible for this complication?

. Injury to the lateral antebrachial cutaneous nerve
. Entrapment of the posterior interosseous nerve (PIN)
. Overtensioning of the biceps tendon during cortical button fixation
. Subperiosteal stripping and exposure of the proximal ulna
. Failure to repair the lacertus fibrosus

Correct Answer & Explanation

. Injury to the lateral antebrachial cutaneous nerve

Explanation

The patient has developed a proximal radioulnar synostosis (heterotopic ossification bridging the radius and ulna), which is a devastating complication of the two-incision distal biceps repair. This typically occurs due to subperiosteal stripping or inappropriate exposure of the ulna during the posterior approach, leading to bleeding and cross-union. Modern modifications (such as Morrey's muscle-splitting approach) specifically avoid exposing the ulna to prevent this complication.

Question 2274

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old man undergoes a reverse total shoulder arthroplasty (rTSA) for massive, irreparable rotator cuff tear arthropathy. Two years later, routine follow-up radiographs reveal grade 3 scapular notching. Which of the following surgical techniques or implant choices would have most likely decreased the incidence of this specific complication?

. Superior placement of the glenosphere baseplate
. Inferior translation of the glenosphere to overhang the inferior glenoid rim
. Using a smaller diameter glenosphere
. Medialization of the glenosphere baseplate
. Increasing the humeral stem neck-shaft angle to 155 degrees

Correct Answer & Explanation

. Superior placement of the glenosphere baseplate

Explanation

Scapular notching is a frequent complication after reverse total shoulder arthroplasty, caused by mechanical impingement of the medial humeral metaphysis against the inferior scapular neck during arm adduction. Techniques proven to decrease scapular notching include: inferior translation of the glenosphere (creating an overhang over the inferior rim), inferior tilt of the glenosphere, lateralization of the center of rotation (e.g., BIO-RSA or lateralized baseplates), and using a larger diameter glenosphere.

Question 2275

Topic: Elbow & Forearm

A 6-year-old boy presents to the emergency department after falling off playground equipment. Radiographs demonstrate an isolated plastic deformation of the ulnar shaft and an anteriorly dislocated radial head. Which of the following is the most critical step in the initial management to ensure a stable reduction of the radial head?

. Closed reduction and casting of the elbow in full extension
. Immediate open reduction of the radial head followed by ulnar plating
. Closed reduction of the ulna with complete restoration of its anatomic bow
. Surgical reconstruction of the annular ligament
. Immobilization in 120 degrees of flexion without manipulating the ulna

Correct Answer & Explanation

. Closed reduction and casting of the elbow in full extension

Explanation

This is a Bado Type I Monteggia equivalent fracture (plastic deformation of the ulna with anterior radial head dislocation). In pediatric patients, the absolute key to reducing and maintaining the radial head is restoring the exact anatomic length and alignment (the normal bow) of the ulna. If the ulnar plastic deformity is not corrected, the radial head will remain unstable or completely irreducible. Annular ligament reconstruction is rarely needed in acute pediatric cases.

Question 2276

Topic: Elbow & Forearm

A 45-year-old woman falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. She undergoes operative management. During the procedure, the surgeon decides to repair the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle using a suture anchor. Where is the precise isometric origin of the LUCL on the lateral epicondyle?

. At the center of the capitellum axis of rotation
. Just anterior to the center of the capitellum axis
. Just posterior to the center of the capitellum axis
. Distal to the center of the capitellum axis
. Proximal to the center of the capitellum axis

Correct Answer & Explanation

. At the center of the capitellum axis of rotation

Explanation

The isometric point for LUCL reconstruction or repair on the lateral epicondyle is located at the center of the axis of rotation of the capitellum. Placing the anchor or graft at this exact point ensures uniform tension on the ligament throughout the elbow's full range of motion, which is crucial for restoring posterolateral rotatory stability in a terrible triad injury.

Question 2277

Topic: Shoulder Arthroplasty & Arthritis

A 70-year-old woman undergoes reverse total shoulder arthroplasty (RTSA) for massive cuff tear arthropathy. Postoperatively, she has active forward elevation to 135 degrees but reports difficulty eating, drinking, and washing her opposite shoulder. Examination reveals a positive hornblower's sign. Which of the following muscles is most likely deficient and responsible for her functional limitations?

. Subscapularis
. Supraspinatus
. Teres minor
. Latissimus dorsi
. Pectoralis major

Correct Answer & Explanation

. Subscapularis

Explanation

A positive hornblower's sign indicates a deficiency of the teres minor. In patients undergoing RTSA, an intact teres minor is critical for providing the external rotation necessary for activities of daily living that require bringing the hand to the mouth or face (e.g., eating, drinking) while the arm is elevated in space. If the teres minor is irreparably damaged or absent, a latissimus dorsi transfer combined with the RTSA may be indicated to restore external rotation.

Question 2278

Topic: Elbow & Forearm

A 32-year-old woman sustains a coronal shear fracture of the distal humerus extending medially to include the lateral aspect of the trochlea (McKee modification of Bryan and Morrey Type IV). She is scheduled for open reduction and internal fixation. Which of the following structures is most commonly injured with this fracture pattern and must be carefully evaluated for repair during surgery?

. Ulnar nerve
. Medial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Distal biceps tendon

Correct Answer & Explanation

. Ulnar nerve

Explanation

Coronal shear fractures of the distal humerus that extend medially to include the lateral trochlea (McKee modification of a Type IV capitellum fracture) are frequently associated with injuries to the lateral collateral ligament complex, particularly the LUCL. The extensor origin and LUCL may be avulsed from the lateral epicondyle by the trauma itself or may need to be elevated to adequately access and fix the fracture. Repairing the LUCL at the conclusion of the case is critical to prevent posterolateral rotatory instability.

Question 2279

Topic: Shoulder Pathology

A 29-year-old female presents with right shoulder pain and weakness after a prolonged backpacking trip. On examination, medial winging of the scapula is prominent when she performs a wall push-up. EMG confirms a severe, isolated long thoracic nerve injury. After 15 months of physical therapy and observation, there is no clinical or electromyographic improvement. Which of the following tendon transfers is the most appropriate surgical option?

. Latissimus dorsi transfer to the greater tuberosity
. Split pectoralis major transfer to the lower pole of the scapula
. Eden-Lange procedure (levator scapulae and rhomboids transfer)
. Pectoralis minor transfer to the coracoid
. Lower trapezius transfer to the infraspinatus

Correct Answer & Explanation

. Latissimus dorsi transfer to the greater tuberosity

Explanation

Medial winging of the scapula is caused by paralysis of the serratus anterior muscle, innervated by the long thoracic nerve. When nonoperative management fails after a period of 12 to 24 months, the gold standard surgical procedure is the transfer of the sternal head of the pectoralis major (often utilizing a fascia lata autograft extension) to the lower pole of the scapula. The Eden-Lange procedure is indicated for lateral winging caused by a spinal accessory nerve palsy (trapezius deficiency).

Question 2280

Topic: Elbow & Forearm

A 42-year-old male heavy laborer feels a 'pop' in his anterior elbow while lifting a 50-lb box. Clinical examination demonstrates a reverse Popeye deformity and weakness in forearm supination. He undergoes an anatomic single-incision repair of the distal biceps tendon using a cortical button. Which of the following nerve complications is most classically associated with the anterior single-incision approach to the distal biceps?

. Anterior interosseous nerve neuropraxia
. Lateral antebrachial cutaneous nerve neuropraxia
. Posterior interosseous nerve (PIN) palsy
. Ulnar nerve entrapment
. Median nerve transection

Correct Answer & Explanation

. Anterior interosseous nerve neuropraxia

Explanation

The single-incision anterior approach for distal biceps repair is most commonly associated with lateral antebrachial cutaneous nerve (LABCN) neuropraxia due to the nerve's superficial location crossing the surgical field near the cephalic vein. While posterior interosseous nerve (PIN) injury can occur with aggressive radial retraction, LABCN injury is the most frequent neurologic complication. Heterotopic ossification and radioulnar synostosis are historically more common with the two-incision (Boyd-Anderson) approach.

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