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9. Shoulder and Elbow MCQs

Practice Set 119 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 2361

Topic: Shoulder Pathology

During a surgical exploration for a closed supraclavicular brachial plexus injury, the surgeon identifies a functioning long thoracic nerve and dorsal scapular nerve, but the suprascapular nerve is non-functional. From which portion of the brachial plexus does the suprascapular nerve directly originate?

. Superior trunk
. Middle trunk
. Inferior trunk
. Lateral cord
. Posterior cord

Correct Answer & Explanation

. Superior trunk

Explanation

The suprascapular nerve arises directly from the superior trunk of the brachial plexus, which is formed by the C5 and C6 roots. The dorsal scapular nerve originates from the C5 root, and the long thoracic nerve arises from the roots of C5, C6, and C7. An intact dorsal scapular and long thoracic nerve with a deficient suprascapular nerve suggests an injury localized to the superior trunk.

Question 2362

Topic: Elbow & Forearm

A 32-year-old female presents with recurrent posterolateral rotatory instability (PLRI) of her right elbow following a traumatic dislocation 6 months ago. Reconstruction of the lateral ulnar collateral ligament (LUCL) is planned. What are the correct anatomical origin and insertion sites for the LUCL?

. Lateral epicondyle to the radial head
. Capitellum to the annular ligament
. Medial epicondyle to the sublime tubercle
. Lateral epicondyle to the supinator crest of the proximal ulna
. Coronoid process to the radial tuberosity

Correct Answer & Explanation

. Lateral epicondyle to the radial head

Explanation

The lateral ulnar collateral ligament (LUCL) is the primary restraint to posterolateral rotatory instability (PLRI) of the elbow. It originates on the lateral epicondyle (blending with the lateral collateral ligament complex) and courses distally and posteriorly to insert on the supinator crest of the proximal ulna. The anterior band of the medial collateral ligament (MCL) originates on the medial epicondyle and inserts on the sublime tubercle of the coronoid.

Question 2363

Topic: Shoulder Pathology

A 42-year-old warehouse worker presents with neurogenic thoracic outlet syndrome that is refractory to physical therapy. Surgical decompression via a supraclavicular approach is planned, which includes an anterior scalenectomy. During dissection of the scalene triangle, what is the correct anatomical relationship of the major neurovascular structures?

. The subclavian vein passes between the anterior and middle scalene muscles.
. The phrenic nerve descends along the anterior surface of the middle scalene muscle.
. The subclavian artery passes posterior to the anterior scalene muscle.
. The trunks of the brachial plexus pass anterior to the anterior scalene muscle.
. The subclavian artery and vein both run posterior to the middle scalene muscle.

Correct Answer & Explanation

. The subclavian vein passes between the anterior and middle scalene muscles.

Explanation

The scalene triangle is bordered by the anterior scalene muscle anteriorly, the middle scalene muscle posteriorly, and the superior border of the first rib inferiorly. The subclavian artery and the roots/trunks of the brachial plexus pass through this triangle (posterior to the anterior scalene). The subclavian vein passes anterior to the anterior scalene muscle, outside the scalene triangle. The phrenic nerve descends along the anterior surface of the anterior scalene muscle.

Question 2364

Topic: 9. Shoulder and Elbow

A 55-year-old woman is noted to have a weakness in the internal rotation and adduction of her shoulder following an extensive axillary node dissection. Injury to the thoracodorsal nerve is suspected. Which of the following best describes the anatomic origin of the thoracodorsal nerve?

. Anterior divisions of the middle and lower trunks
. Posterior cord of the brachial plexus
. Lateral cord of the brachial plexus
. Medial cord of the brachial plexus
. Roots of C5, C6, and C7

Correct Answer & Explanation

. Anterior divisions of the middle and lower trunks

Explanation

The thoracodorsal nerve (also known as the middle subscapular nerve) arises directly from the posterior cord of the brachial plexus. It carries fibers from C6, C7, and C8 nerve roots. It innervates the latissimus dorsi muscle, which functions to extend, adduct, and internally rotate the humerus.

Question 2365

Topic: Elbow & Forearm

A 32-year-old male sustains a Monteggia fracture-dislocation. He undergoes open reduction and internal fixation of the ulna with closed reduction of the radial head. Postoperatively, he is unable to actively extend his thumb and fingers at the metacarpophalangeal joints. Wrist extension is preserved but occurs with radial deviation. Compression or injury to the affected nerve most commonly occurs at which of the following anatomic structures?

. Ligament of Struthers
. Lacertus fibrosus
. Arcade of Frohse
. Osborne's ligament
. Between the two heads of the pronator teres

Correct Answer & Explanation

. Ligament of Struthers

Explanation

The patient is exhibiting symptoms of a posterior interosseous nerve (PIN) palsy. The PIN innervates the finger and thumb extensors and the extensor carpi ulnaris (ECU). Because the extensor carpi radialis longus (ECRL) and brevis (ECRB) are often innervated by the radial nerve proximal to the PIN branch, wrist extension is preserved but deviates radially. The most common site of PIN compression is the Arcade of Frohse, which is the thickened proximal tendinous edge of the superficial head of the supinator muscle.

Question 2366

Topic: 9. Shoulder and Elbow

The anterior bundle of the ulnar collateral ligament (UCL) of the elbow is the primary restraint to valgus stress. How do the distinct bands of the anterior bundle function during elbow range of motion?

. The anterior band is taut in extension and the posterior band is taut in flexion
. The anterior band is taut in flexion and the posterior band is taut in extension
. Both bands are uniformly taut throughout the entire arc of motion
. Both bands are lax in extension and taut in flexion
. The anterior band is taut in supination only

Correct Answer & Explanation

. The anterior band is taut in extension and the posterior band is taut in flexion

Explanation

The anterior bundle consists of two bands: the anterior band is primarily tight in elbow extension, while the posterior band tightens progressively as the elbow is flexed.

Question 2367

Topic: 9. Shoulder and Elbow

During a standard deltopectoral approach to the shoulder, the cephalic vein is typically identified and retracted in which direction to best preserve its primary venous drainage?

. Medially with the pectoralis major
. Superiorly with the coracoid process
. Inferiorly with the long head of the biceps
. It is routinely ligated and not retracted
. Laterally with the deltoid

Correct Answer & Explanation

. Medially with the pectoralis major

Explanation

The cephalic vein is typically retracted laterally with the deltoid to preserve its major venous tributaries from the deltoid muscle. If injured or ligated, patients may experience increased postoperative swelling of the shoulder.

Question 2368

Topic: Shoulder Pathology

A 40-year-old patient undergoes a lymph node biopsy in the posterior cervical triangle. Postoperatively, she cannot abduct her shoulder beyond 90 degrees and has lateral scapular winging. Which of the following muscles is primarily denervated?

. Serratus anterior
. Trapezius
. Rhomboid major
. Levator scapulae
. Latissimus dorsi

Correct Answer & Explanation

. Serratus anterior

Explanation

The spinal accessory nerve (CN XI) courses through the posterior cervical triangle and innervates the trapezius. Iatrogenic injury causes lateral scapular winging and an inability to actively abduct the shoulder above 90 degrees.

Question 2369

Topic: Shoulder Pathology

A patient undergoing arthroscopic rotator cuff repair receives an interscalene nerve block and subsequently develops transient hemidiaphragmatic paresis. The affected nerve shares its primary segmental root origin with which of the following nerves?

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

Correct Answer & Explanation

. Dorsal scapular nerve

Explanation

Hemidiaphragmatic paresis is caused by block of the phrenic nerve, which originates from roots C3, C4, and C5. The long thoracic nerve originates from the C5, C6, and C7 nerve roots, sharing the C5 root with the phrenic nerve.

Question 2370

Topic: Elbow & Forearm

A 21-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using the docking technique. He is concerned about potential postoperative complications. Which of the following is the most common complication following this procedure?

. Medial epicondyle avulsion fracture
. Graft rupture
. Ulnar neuropathy
. Heterotopic ossification
. Superficial infection

Correct Answer & Explanation

. Ulnar neuropathy

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction, occurring in 5% to 10% of cases depending on the technique used. While modern techniques like the docking approach have helped decrease this incidence compared to historical techniques requiring routine ulnar nerve transposition, transient ulnar neuropraxia remains the most frequently encountered adverse event.

Question 2371

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate pitcher undergoes ulnar collateral ligament (UCL) reconstruction utilizing a palmaris longus autograft. Which of the following technical factors is most critical for successfully restoring the normal kinematics and stability of the elbow?

. Reconstruction of the transverse ligament of the elbow
. Routine submuscular transposition of the ulnar nerve to prevent postoperative neuropathy
. Tensioning the graft in full elbow extension
. Anatomic placement of the graft at the sublime tubercle and medial epicondyle
. Re-creating the posterior bundle of the UCL instead of the anterior bundle

Correct Answer & Explanation

. Anatomic placement of the graft at the sublime tubercle and medial epicondyle

Explanation

The anterior band of the anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. In UCL reconstruction (e.g., Tommy John surgery), anatomic placement of the graft tunnels at the native footprintsโ€”the sublime tubercle on the proximal ulna and the anteroinferior aspect of the medial epicondyleโ€”is the most critical factor for restoring kinematics. Non-anatomic placement leads to graft stretching or loss of motion due to lack of isometry. Ulnar nerve transposition is not routinely required unless there are preoperative nerve symptoms.

Question 2372

Topic: 9. Shoulder and Elbow

A 23-year-old collegiate baseball pitcher requires an ulnar collateral ligament (UCL) reconstruction after suffering a complete rupture of the anterior bundle. During reconstruction using the docking technique, the surgeon aims to anatomically recreate the primary restraint to valgus stress. To which specific anatomic footprints must the graft be secured to accurately recreate the anterior bundle of the UCL?

. The lateral epicondyle to the radial head
. The medial epicondyle to the sublime tubercle of the proximal ulna
. The medial epicondyle to the coronoid process of the ulna
. The lateral epicondyle to the supinator crest of the ulna
. The medial epicondyle to the tip of the olecranon

Correct Answer & Explanation

. The medial epicondyle to the sublime tubercle of the proximal ulna

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow, particularly between 30 and 120 degrees of flexion. It originates on the anteroinferior surface of the medial epicondyle and inserts distally on the sublime tubercle of the proximal ulna. Anatomic UCL reconstruction techniques specifically target these footprints to restore native elbow kinematics and stability.

Question 2373

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate baseball pitcher presents with medial elbow pain that occurs predominantly during the late cocking and early acceleration phases of throwing. On physical examination, the moving valgus stress test is markedly positive. Magnetic resonance imaging confirms a high-grade partial tear of the ulnar collateral ligament (UCL), and he elects to undergo UCL reconstruction. Which bundle of the UCL is the primary restraint to valgus stress, and what is its true anatomic footprint?

. Posterior bundle; inserts on the sublime tubercle
. Anterior bundle; inserts on the sublime tubercle
. Anterior bundle; inserts on the olecranon
. Transverse bundle; originates on the medial epicondyle
. Posterior bundle; inserts on the coronoid process

Correct Answer & Explanation

. Anterior bundle; inserts on the sublime tubercle

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress of the elbow between 30 and 120 degrees of flexion. It originates on the anterior undersurface of the medial epicondyle and inserts on the sublime tubercle of the anteromedial facet of the coronoid process. The posterior bundle forms the floor of the cubital tunnel and is only a secondary restraint to valgus stress at higher degrees of flexion.

Question 2374

Topic: Elbow & Forearm

A 22-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction utilizing a palmaris longus autograft (Tommy John surgery). Which of the following is the most frequent postoperative complication associated with this procedure in overhead throwers?

. Graft rupture
. Ulnar neuropathy
. Medial epicondyle avulsion fracture
. Heterotopic ossification
. Postoperative infection

Correct Answer & Explanation

. Ulnar neuropathy

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction. It can occur due to traction, compression, or ischemia during the procedure, especially if the nerve is handled or transposed. Most cases are transient, but a subset may require secondary neurolysis.

Question 2375

Topic: 9. Shoulder and Elbow

A 21-year-old collegiate baseball pitcher reports medial elbow pain and decreased velocity during the late cocking and early acceleration phases of throwing. An MRI is shown in Figure 15.

He undergoes an ulnar collateral ligament (UCL) reconstruction using a docking technique. During the surgical exposure, the surgeon utilizes a muscle-splitting approach through the flexor-pronator mass. Care must be taken to identify and protect which of the following cutaneous nerves to prevent painful neuroma formation?

. Lateral antebrachial cutaneous nerve
. Medial antebrachial cutaneous nerve
. Posterior interosseous nerve
. Anterior interosseous nerve
. Superficial branch of the radial nerve

Correct Answer & Explanation

. Medial antebrachial cutaneous nerve

Explanation

During the medial approach to the elbow for UCL reconstruction, branches of the medial antebrachial cutaneous (MABC) nerve frequently cross the operative field. They lie superficial to the flexor-pronator mass. Injury to the MABC can cause numbness over the medial forearm or a painful neuroma, which is a significant complication for a throwing athlete. The ulnar nerve is deeper and must be managed (either protected in situ or transposed), but the MABC is the specific superficial cutaneous nerve at high risk.

Question 2376

Topic: Elbow & Forearm

A 21-year-old collegiate baseball pitcher underwent a right elbow ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft 6 weeks ago. He now presents with persistent tingling in his small and ring fingers, as well as subjective weakness when gripping. Which intraoperative factor or surgical step is most commonly associated with this specific postoperative complication?

. Over-tensioning of the palmaris longus graft during fixation
. Excessive traction and mobilization of the ulnar nerve without transposition
. Drilling of the sublime tubercle bone tunnel for the distal graft insertion
. Medial epicondyle tunnel drilling exiting too anteriorly
. Placement of the graft in a figure-of-eight configuration rather than a docking technique

Correct Answer & Explanation

. Excessive traction and mobilization of the ulnar nerve without transposition

Explanation

Ulnar neuropathy is the most frequent complication following UCL reconstruction (Tommy John surgery). It is most commonly associated with excessive handling, traction, or mobilization of the ulnar nerve during the medial approach. When the nerve is aggressively retracted to expose the sublime tubercle and medial epicondyle but left in situ (or transposed with kinking/devascularization), the risk of postoperative ulnar neuritis increases significantly. Modern techniques emphasize minimal handling and in situ preservation of the nerve, or a meticulous submuscular transposition if the nerve subluxates or is heavily involved in scar tissue.

Question 2377

Topic: Elbow & Forearm

A 42-year-old weightlifter feels a sudden pop in his right antecubital fossa while performing a deadlift. On examination, he has weakness in forearm supination and elbow flexion. The 'hook test' is positive. During surgical repair through a single anterior incision, which of the following nerves is at greatest risk of injury?

. Median nerve
. Ulnar nerve
. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision anterior approach for distal biceps tendon repair. The radial nerve or posterior interosseous nerve (PIN) is more at risk during a two-incision approach (specifically the posterolateral incision) or if retractors are placed too vigorously on the radial side in a single incision.

Question 2378

Topic: Elbow & Forearm

A 14-year-old elite female gymnast presents with lateral elbow pain and catching. Radiographs reveal a radiolucent lesion in the capitellum. MRI demonstrates an osteochondral lesion with a high T2 signal line behind the bone fragment, and an associated loose body in the anterior compartment. What is the most appropriate definitive management?

. Rest and cessation of gymnastics for 3-6 months
. Arthroscopic loose body removal and microfracture of the capitellar lesion
. Open reduction and internal fixation of the capitellar lesion
. Ulnar collateral ligament reconstruction
. Radial head excision

Correct Answer & Explanation

. Arthroscopic loose body removal and microfracture of the capitellar lesion

Explanation

The patient has an unstable osteochondral defect (OCD) of the capitellum, indicated by catching, a high T2 signal line behind the fragment (indicating fluid and instability), and an intra-articular loose body. Conservative management (rest) is indicated for stable lesions with an open capitellar physis. For unstable lesions or those with loose bodies, surgical intervention is required. Arthroscopic loose body removal and debridement/microfracture of the base is the standard of care for fragments that are completely detached or unsuitable for fixation.

Question 2379

Topic: 9. Shoulder and Elbow

A 19-year-old collegiate baseball pitcher presents with medial elbow pain during the late cocking and early acceleration phases of throwing.

Based on the history, physical exam, and imaging, a decision is made to perform a Ulnar Collateral Ligament (UCL) reconstruction using the docking technique. What is the primary biomechanical and surgical advantage of the docking technique compared to the classic figure-of-eight (Jobe) technique?

. Decreased risk of ulnar nerve neuropraxia due to avoidance of anterior transposition
. Avoidance of a flexor-pronator mass splitting approach
. Minimization of bone removal and fewer drill holes in the medial epicondyle
. Significantly earlier return to competitive throwing
. Elimination of the need for an autograft

Correct Answer & Explanation

. Minimization of bone removal and fewer drill holes in the medial epicondyle

Explanation

The docking technique for UCL reconstruction involves securing the two ends of the graft into a single bony tunnel in the medial epicondyle. This minimizes the amount of bone removed and reduces the number of drill holes required compared to the classic figure-of-eight (Jobe) technique, which requires multiple intersecting tunnels. This substantially reduces the risk of iatrogenic medial epicondyle fracture while providing excellent biomechanical fixation.

Question 2380

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate baseball pitcher is undergoing an ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft (Tommy John surgery).

During the preparation of the tunnels, where is the optimal location for the femoral (humeral) tunnel to best recreate the native anatomy and isometry of the anterior bundle of the UCL?

. At the center of the sublime tubercle
. Just posterior to the sublime tubercle
. On the anterior-inferior aspect of the medial epicondyle
. On the posterior-superior aspect of the medial epicondyle
. At the base of the coronoid process

Correct Answer & Explanation

. On the anterior-inferior aspect of the medial epicondyle

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. Its native humeral origin is located on the anterior-inferior aspect of the medial epicondyle. Recreating this anatomic origin is critical for maintaining graft isometry throughout the elbow's range of motion during UCL reconstruction. The sublime tubercle is the anatomical insertion site on the ulna, not the humerus.

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