Menu

9. Shoulder and Elbow MCQs

Practice Set 121 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 2401

Topic: 9. Shoulder and Elbow

A 34-year-old cyclist is struck by a vehicle and sustains a displaced midshaft clavicle fracture and an ipsilateral displaced fracture of the scapular neck. What is the primary indication for operative fixation of this 'floating shoulder' injury?

. The presence of the ipsilateral scapula fracture regardless of displacement
. Medial displacement of the glenoid fragment greater than 1 cm
. Associated non-displaced rib fractures
. Disruption of the coracoclavicular ligaments and significant medial displacement/angulation of the glenohumeral joint
. Age over 30 years

Correct Answer & Explanation

. Disruption of the coracoclavicular ligaments and significant medial displacement/angulation of the glenohumeral joint

Explanation

A 'floating shoulder' (ipsilateral clavicle and scapular neck fractures) is not an absolute indication for surgery. Operative intervention (typically fixing the clavicle to restore the superior suspensory shoulder complex) is indicated when there is significant displacement of the glenohumeral joint, coracoclavicular ligament disruption, or medialization/angulation of the glenoid neck that fundamentally alters the biomechanics of the shoulder.

Question 2402

Topic: Elbow & Forearm

A 32-year-old patient presents with a sensation of their elbow 'giving way' and clicking when pushing up from a chair with the forearm supinated. Clinical examination reveals a positive lateral pivot-shift test of the elbow. Deficiency of which of the following structures is the primary cause of this condition?

. Radial collateral ligament
. Lateral ulnar collateral ligament
. Annular ligament
. Common extensor origin
. Anterior bundle of the medial collateral ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The patient describes symptoms and exam findings pathognomonic for posterolateral rotatory instability (PLRI) of the elbow. The primary restraint to PLRI is the lateral ulnar collateral ligament (LUCL). Insufficiency of the LUCL allows the radial head to subluxate posterolaterally away from the capitellum, especially during axial loading, valgus stress, and supination.

Question 2403

Topic: Elbow & Forearm

A 40-year-old man falls from a height and sustains a posterolateral elbow dislocation, radial head fracture, and coronoid fracture. Following closed reduction, the joint remains unstable in extension. During operative management, what is the generally recommended sequence of reconstruction to restore elbow stability?

. Lateral collateral ligament (LCL) repair, radial head replacement, coronoid fixation, medial collateral ligament (MCL) repair
. Coronoid fixation, radial head replacement, LCL repair, evaluation for MCL repair or hinged external fixator
. MCL repair, coronoid fixation, radial head replacement, LCL repair
. Radial head replacement, LCL repair, coronoid fixation, MCL repair
. LCL repair, coronoid fixation, radial head replacement, MCL repair

Correct Answer & Explanation

. Coronoid fixation, radial head replacement, LCL repair, evaluation for MCL repair or hinged external fixator

Explanation

The standard surgical protocol for addressing a 'terrible triad' of the elbow (elbow dislocation, radial head fracture, coronoid fracture) typically proceeds from deep to superficial and anterior to posterior: 1. Fixation of the coronoid fracture to restore the anterior buttress, 2. Fixation or replacement of the radial head to restore the lateral column, and 3. Repair of the lateral ulnar collateral ligament (LUCL) complex to the lateral epicondyle. If the elbow remains unstable after these steps (usually assessed in extension), the medial collateral ligament (MCL) may be repaired or a hinged external fixator applied.

Question 2404

Topic: Elbow & Forearm

A 45-year-old competitive weightlifter suffers an acute distal biceps tendon rupture. The surgeon utilizes a two-incision technique (modified Boyd-Anderson) to reattach the tendon to the radial tuberosity. Compared to a single anterior incision technique, the two-incision approach is associated with a higher risk of which of the following postoperative complications?

. Lateral antebrachial cutaneous nerve neuropraxia
. Radial nerve palsy
. Proximal radioulnar synostosis
. Posterior interosseous nerve (PIN) injury
. Superficial radial nerve entrapment

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

Operative repair of a distal biceps tendon rupture can be performed via a single anterior incision or a two-incision technique. The single-incision technique carries a higher risk of injury to anterior structures, specifically the lateral antebrachial cutaneous (LABC) nerve and the posterior interosseous nerve (PIN). The two-incision technique was developed to protect these nerves but carries a historically higher risk of proximal radioulnar synostosis (heterotopic ossification bridging the radius and ulna) due to subperiosteal dissection and the potential creation of bone debris in the highly reactive interosseous space.

Question 2405

Topic: 9. Shoulder and Elbow

A 35-year-old man presents with a sense of clicking and instability in his elbow when pushing himself up from a chair. He underwent a lateral epicondylar release for recalcitrant 'tennis elbow' one year ago. On physical examination, with the patient supine and the shoulder flexed, applying an axial load, valgus stress, and supination to the elbow as it is moved from extension to flexion produces a palpable clunk. Deficiency of which of the following structures is most likely responsible for his symptoms?

. Anterior bundle of the medial collateral ligament
. Annular ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament
. Coronoid process

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The patient's history of prior lateral epicondylar surgery and physical examination findings (positive lateral pivot-shift test of the elbow) indicate Posterolateral Rotatory Instability (PLRI). PLRI is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). The LUCL can be iatrogenically injured during a lateral epicondylar release (e.g., Nirschl procedure) if the surgical dissection is carried too far posterior and distal to the extensor carpi radialis brevis (ECRB) origin.

Question 2406

Topic: 9. Shoulder and Elbow

A 72-year-old man with severe pseudoparalysis and glenohumeral osteoarthritis secondary to a massive, irreparable rotator cuff tear is scheduled for a reverse total shoulder arthroplasty (RTSA). Preoperative evaluation demonstrates absent active external rotation with the arm at the side (positive Hornblower's sign and dropped arm sign). In addition to RTSA, what adjunctive procedure is most appropriate to optimize this patient's postoperative ability to perform activities of daily living?

. Pectoralis major transfer
. Latissimus dorsi and/or teres major transfer
. Lower trapezius transfer to the subscapularis
. Coracoacromial ligament release
. Biceps tenodesis to the conjoint tendon

Correct Answer & Explanation

. Latissimus dorsi and/or teres major transfer

Explanation

The patient has a massive rotator cuff tear involving the posterior superior cuff (infraspinatus and teres minor), as evidenced by the lack of active external rotation (positive Hornblower's and drop sign). A reverse total shoulder arthroplasty (RTSA) will restore anterior elevation by utilizing the intact deltoid, but it does not adequately restore active external rotation if the teres minor is nonfunctional. To restore active external rotation and allow the patient to perform essential activities of daily living (like eating, grooming, and reaching the face), an adjunctive latissimus dorsi and/or teres major transfer (L'Episcopo procedure) is frequently performed concurrently with the RTSA.

Question 2407

Topic: 9. Shoulder and Elbow

A 72-year-old male presents with pseudoparalysis of the right shoulder and severe glenohumeral osteoarthritis secondary to massive rotator cuff arthropathy. He is planned for a Grammont-style reverse total shoulder arthroplasty (RTSA). How is the center of rotation biomechanically altered in this implant design compared to the native shoulder?

. Moved laterally and superiorly.
. Moved medially and inferiorly.
. Moved laterally and inferiorly.
. Moved medially and superiorly.
. Remained unchanged, but the joint line is lateralized.

Correct Answer & Explanation

. Moved medially and inferiorly.

Explanation

The classic Grammont-style reverse total shoulder arthroplasty (RTSA) alters the biomechanics by medializing and inferiorizing the center of rotation. Medialization decreases the torque and shear forces on the glenoid component, reducing the risk of loosening, and recruits more deltoid muscle fibers. Inferiorization tensions the deltoid, increasing its lever arm and restoring active elevation in the setting of a deficient rotator cuff.

Question 2408

Topic: 9. Shoulder and Elbow

A 35-year-old male sustains a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). When operating to restore elbow stability, which of the following is the generally accepted sequence of surgical repair?

. Medial collateral ligament (MCL) repair, radial head fixation, coronoid fixation, lateral collateral ligament (LCL) repair.
. LCL repair, radial head fixation, coronoid fixation, MCL repair.
. Coronoid fixation, radial head fixation/replacement, LCL repair, then MCL repair if still unstable.
. Radial head fixation/replacement, LCL repair, coronoid fixation, MCL repair.
. LCL repair, MCL repair, coronoid fixation, radial head replacement.

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/replacement, LCL repair, then MCL repair if still unstable.

Explanation

The standard surgical protocol for a 'terrible triad' of the elbow typically proceeds from deep to superficial, or 'inside-out' through a lateral approach. The sequence is: 1) Fixation of the coronoid fracture (or anterior capsule), 2) Fixation or replacement of the radial head, 3) Repair of the lateral collateral ligament (LCL) complex. After these steps, the elbow is examined for stability. The medial collateral ligament (MCL) is repaired only if the elbow remains grossly unstable in extension after the lateral structures are secured.

Question 2409

Topic: 9. Shoulder and Elbow

A 42-year-old male falls on an outstretched hand and sustains a terrible triad injury of the elbow. Standard surgical protocol dictates repairing structures from deep to superficial to restore elbow stability. Which of the following describes the most appropriate sequence of surgical repair?

. Lateral collateral ligament, radial head, coronoid
. Coronoid, lateral collateral ligament, radial head
. Radial head, coronoid, lateral collateral ligament
. Coronoid, radial head, lateral collateral ligament
. Radial head, lateral collateral ligament, coronoid

Correct Answer & Explanation

. Coronoid, radial head, lateral collateral ligament

Explanation

The standard surgical algorithm for a terrible triad injury of the elbow involves repairing structures from deep to superficial. The classic sequence is coronoid fixation, followed by radial head repair or arthroplasty, and finally lateral collateral ligament (LCL) repair. If the elbow remains unstable after these steps, the medial collateral ligament (MCL) is repaired, or a hinged external fixator is placed.

Question 2410

Topic: 9. Shoulder and Elbow

A 72-year-old female sustains a severe 4-part proximal humerus fracture. She undergoes a reverse total shoulder arthroplasty (RTSA). Which of the following represents the most significant biomechanical advantage of RTSA over an anatomic total shoulder arthroplasty in this specific clinical setting?

. It medializes the center of rotation and increases the deltoid moment arm
. It lateralizes the center of rotation and increases the deltoid moment arm
. It medializes the center of rotation and decreases the deltoid moment arm
. It lateralizes the center of rotation and decreases the supraspinatus moment arm
. It maintains the anatomic center of rotation while relying on the deltoid for elevation

Correct Answer & Explanation

. It medializes the center of rotation and increases the deltoid moment arm

Explanation

Reverse total shoulder arthroplasty (RTSA) is highly effective for 4-part proximal humerus fractures in the elderly, especially when rotator cuff function is compromised or tuberosity healing is unreliable. Biomechanically, RTSA medializes and distalizes the center of rotation of the glenohumeral joint. This significantly increases the moment arm and tension of the deltoid muscle, allowing it to initiate and maintain shoulder elevation without a functioning rotator cuff.

Question 2411

Topic: Elbow & Forearm

A 45-year-old male undergoes surgical repair of an acute distal biceps tendon rupture using a standard 2-incision technique. Postoperatively, he exhibits a specific nerve palsy. Which of the following nerves is at greatest risk during the posterior approach of the 2-incision technique if the forearm is not fully pronated during surgical exposure?

. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Superficial radial nerve
. Anterior interosseous nerve
. Ulnar nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The 2-incision technique for distal biceps tendon repair aims to reduce the risk of lateral antebrachial cutaneous nerve and radial nerve injuries associated with a single anterior incision. However, it places the posterior interosseous nerve (PIN) at risk during the posterior dissection. To protect the PIN, the forearm must be maximally pronated during the posterior approach and retractor placement, as this displaces the PIN anteriorly and medially, away from the surgical field.

Question 2412

Topic: Shoulder Arthroplasty & Arthritis

A 70-year-old woman with advanced rotator cuff tear arthropathy is scheduled for a reverse total shoulder arthroplasty (RTSA). During preoperative templating and intraoperative execution, which of the following glenosphere positioning strategies is most effective in minimizing the risk of scapular notching?

. Superior placement with superior tilt
. Inferior placement with inferior tilt
. Superior placement with neutral tilt
. Medialization of the center of rotation with superior tilt
. Neutral placement with superior tilt

Correct Answer & Explanation

. Inferior placement with inferior tilt

Explanation

Scapular notching is a common and highly recognized complication of reverse total shoulder arthroplasty (RTSA). It occurs due to mechanical impingement of the humeral polyethylene cup against the inferior scapular neck during arm adduction. Inferior placement of the baseplate along with inferior tilt of the glenosphere, and lateralization of the center of rotation, have been proven to significantly decrease the incidence of scapular notching by increasing the impingement-free range of motion.

Question 2413

Topic: Elbow & Forearm

A 34-year-old man presents with recurrent clicking, apprehension, and a sensation of 'giving way' in his right elbow, particularly when attempting to push himself out of a chair. Physical examination reveals a positive lateral pivot-shift test of the elbow. Which of the following ligamentous structures is primarily deficient in this specific instability pattern?

. Annular ligament
. Radial collateral ligament
. Anterior band of the medial collateral ligament
. Lateral ulnar collateral ligament
. Posterior band of the medial collateral ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The patient describes symptoms and demonstrates physical exam signs consistent with posterolateral rotatory instability (PLRI) of the elbow. PLRI is primarily caused by insufficiency of the lateral ulnar collateral ligament (LUCL), which acts as the main restraint to varus and posterolateral rotatory stress. The pathognomonic mechanism that reproduces symptoms involves a combination of axial load, valgus stress, and external rotation (supination) of the forearm.

Question 2414

Topic: 9. Shoulder and Elbow

A 68-year-old female sustains a 3-part anterior fracture-dislocation of her right proximal humerus after a mechanical fall. Upon presentation in the emergency department, she exhibits decreased sensation over the lateral aspect of her shoulder. Which of the following physical examination findings would most likely accompany this isolated neurological deficit once the fracture is stabilized?

. Inability to actively internally rotate the shoulder against resistance
. Weakness in active elbow flexion and forearm supination
. Weakness in active shoulder abduction beyond 15 degrees
. Inability to actively extend the wrist and digits
. Winging of the scapula with forward elevation

Correct Answer & Explanation

. Weakness in active shoulder abduction beyond 15 degrees

Explanation

Decreased sensation over the lateral aspect of the shoulder (the territory of the superior lateral brachial cutaneous nerve) strongly indicates an axillary nerve injury. The axillary nerve is the most commonly injured nerve in anterior shoulder dislocations and proximal humerus fracture-dislocations. It provides motor innervation to the deltoid and teres minor. Because the supraspinatus (suprascapular nerve) initiates the first 15 degrees of shoulder abduction, an isolated axillary nerve injury will present clinically as profound weakness in active shoulder abduction beyond those initial 15 degrees.

Question 2415

Topic: 9. Shoulder and Elbow

A 42-year-old male weightlifter feels a sudden 'pop' in his anterior elbow while performing heavy eccentric bicep curls. He presents with ecchymosis in the antecubital fossa and a positive 'hook test.' To restore maximum functional strength, surgical repair should anatomically reattach the tendon to which of the following structures?

. Ulnar tuberosity
. Coronoid process
. Bicipital aponeurosis
. Brachialis muscle belly
. Radial tuberosity

Correct Answer & Explanation

. Radial tuberosity

Explanation

The patient has sustained a rupture of the distal biceps tendon, indicated by the mechanism of injury, ecchymosis, and a positive hook test (inability to hook the finger under the intact biceps tendon from the lateral side). The distal biceps tendon anatomically inserts onto the radial tuberosity. The primary function of the biceps brachii at the elbow is robust forearm supination, followed by elbow flexion. Anatomic repair to the radial tuberosity is mandatory to restore full supination torque, which is otherwise permanently decreased by roughly 40% if left unrepaired or repaired non-anatomically (e.g., to the brachialis).

Question 2416

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman is 3 years post Reverse Total Shoulder Arthroplasty (RTSA). Radiographs show Grade 3 scapular notching. Which of the following surgical techniques or implant designs would most effectively minimize the risk of this complication?

. Superior baseplate positioning
. A 155-degree humeral neck-shaft angle
. Medialization of the glenosphere
. Inferior baseplate positioning with inferior tilt
. Decreased glenosphere diameter

Correct Answer & Explanation

. Inferior baseplate positioning with inferior tilt

Explanation

Scapular notching is a well-known complication of RTSA caused by mechanical impingement of the humeral component against the inferior scapular neck during adduction. Factors that decrease the risk of scapular notching include inferior placement of the glenoid baseplate, inferior tilt of the baseplate, lateralization of the glenosphere, use of a larger glenosphere, and a lower humeral neck-shaft angle (e.g., 135 degrees vs 155 degrees).

Question 2417

Topic: Elbow & Forearm

A 22-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft via the docking technique. What is the most common complication following this procedure?

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

Correct Answer & Explanation

. Ulnar neuropathy

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction, occurring in up to 10-15% of patients depending on the surgical technique (muscle-splitting vs. detachment) and whether routine ulnar nerve transposition is performed. Symptoms are often transient but can be persistent and may require later neurolysis.

Question 2418

Topic: Elbow & Forearm

A 45-year-old male falls on an outstretched hand, sustaining a 'terrible triad' injury of the elbow. Intraoperatively, after secure fixation of the coronoid process and stable radial head arthroplasty, the elbow remains unstable and tends to subluxate posteriorly in extension. What is the next most appropriate step in management?

. Application of a hinged external fixator
. Repair of the medial collateral ligament (MCL)
. Repair of the lateral ulnar collateral ligament (LUCL)
. Cross-pinning of the radiocapitellar joint
. Dynamic distraction splinting

Correct Answer & Explanation

. Repair of the lateral ulnar collateral ligament (LUCL)

Explanation

The standard surgical algorithm for a terrible triad injury involves: 1) Coronoid fixation or anterior capsule repair, 2) Radial head fixation or replacement, and 3) LCL (specifically LUCL) repair. If the elbow remains unstable after LUCL repair, the MCL may then be repaired, or an external fixator applied. Since the LUCL has not yet been addressed in this scenario, repairing it is the critical next step to restore lateral column stability.

Question 2419

Topic: Elbow & Forearm

A 38-year-old weightlifter undergoes a single-incision anterior approach for distal biceps tendon repair using suture anchors. Postoperatively, he notes a new onset of numbness along the radial aspect of his volar forearm. Which of the following nerves is most likely injured, and what is its motor innervation?

. Posterior interosseous nerve; innervates extensor digitorum communis
. Lateral antebrachial cutaneous nerve; provides no motor innervation
. Superficial radial nerve; provides no motor innervation
. Medial antebrachial cutaneous nerve; provides no motor innervation
. Anterior interosseous nerve; innervates flexor pollicis longus

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve; provides no motor innervation

Explanation

The lateral antebrachial cutaneous nerve (LABCN), the terminal sensory branch of the musculocutaneous nerve, is the most commonly injured nerve during a single-incision anterior distal biceps repair due to vigorous lateral retraction. It provides sensation to the radial/lateral aspect of the forearm and has strictly sensory function, thus providing no motor innervation.

Question 2420

Topic: Shoulder Pathology

A 55-year-old man presents with a chronic, massive, irreparable posterosuperior rotator cuff tear. He has preserved forward elevation but a severe lack of active external rotation with a positive Hornblower's sign. He undergoes a lower trapezius tendon transfer prolonged with an Achilles tendon allograft. Which of the following nerves must be carefully protected during the harvest and mobilization of the lower trapezius?

. Thoracodorsal nerve
. Long thoracic nerve
. Spinal accessory nerve
. Suprascapular nerve
. Axillary nerve

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

The lower trapezius is innervated by the spinal accessory nerve (CN XI). During its harvest and mobilization for a tendon transfer to restore external rotation, meticulous care must be taken to identify and protect the spinal accessory nerve and the transverse cervical artery, which course on the deep surface of the muscle.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page