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9. Shoulder and Elbow MCQs

Practice Set 122 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 2421

Topic: Elbow & Forearm

A 33-year-old carpenter falls from a ladder, sustaining a comminuted radial head fracture. Following radial head excision at an outside facility, he develops chronic wrist pain and proximal migration of the radius. This complication is a result of the undiagnosed disruption of which of the following structures?

. Triangular fibrocartilage complex (TFCC)
. Medial collateral ligament of the elbow
. Interosseous membrane (IOM) of the forearm
. Annular ligament
. Lateral ulnar collateral ligament

Correct Answer & Explanation

. Interosseous membrane (IOM) of the forearm

Explanation

The patient is presenting with a longitudinal radioulnar dissociation (Essex-Lopresti injury), characterized by a radial head fracture, tear of the forearm interosseous membrane (IOM), and disruption of the distal radioulnar joint (DRUJ). If the radial head is excised without recognizing the IOM injury, the radius will migrate proximally, leading to chronic wrist pain and ulnar-sided abutment. Management requires restoring radial length and stability, typically with radial head arthroplasty.

Question 2422

Topic: Elbow & Forearm

A 45-year-old male weightlifter felt a sudden pop in his anterior elbow while performing heavy bicep curls. He presents with local ecchymosis and weakness in forearm supination. Which of the following clinical tests has the highest sensitivity and specificity for diagnosing a complete rupture of the distal biceps tendon?

. Speed's test
. Yergason's test
. Hook test
. O'Brien's active compression test
. Cozen's test

Correct Answer & Explanation

. Hook test

Explanation

The Hook test involves having the patient flex the elbow to 90 degrees and actively supinate the forearm. The examiner attempts to hook an index finger under the lateral edge of the intact distal biceps tendon. It has a reported sensitivity and specificity approaching 100% for diagnosing complete distal biceps tendon ruptures.

Question 2423

Topic: Elbow & Forearm

A 34-year-old man sustains a "terrible triad" injury of the elbow after falling from a ladder. What three anatomic injuries characterize this condition, and what is the standard recommended surgical repair sequence?

. Elbow dislocation, olecranon fracture, coronoid fracture; repair sequence: olecranon, coronoid, lateral collateral ligament.
. Elbow dislocation, radial head fracture, coronoid fracture; repair sequence: coronoid, radial head, lateral collateral ligament.
. Elbow dislocation, capitellum fracture, radial head fracture; repair sequence: capitellum, radial head, lateral collateral ligament.
. Elbow dislocation, radial head fracture, coronoid fracture; repair sequence: lateral collateral ligament, radial head, coronoid.
. Elbow dislocation, radial neck fracture, medial epicondyle fracture; repair sequence: medial epicondyle, radial neck, ulnar collateral ligament.

Correct Answer & Explanation

. Elbow dislocation, radial head fracture, coronoid fracture; repair sequence: coronoid, radial head, lateral collateral ligament.

Explanation

The 'terrible triad' of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid fracture. The classic surgical protocol described by Pugh et al. involves a deep-to-superficial repair approach: first fix or reconstruct the coronoid (often accessed through the radial head defect), then fix or replace the radial head, and finally repair the lateral collateral ligament (LCL) complex to restore posterolateral rotatory stability.

Question 2424

Topic: Elbow & Forearm

A 42-year-old male undergoes a two-incision technique for repair of a ruptured distal biceps tendon. Postoperatively, he is noted to have a new-onset nerve deficit characterized by the inability to actively extend his thumb and fingers at the metacarpophalangeal joints. When he attempts to extend his wrist, it deviates radially. Injury to which of the following nerves is the most likely cause?

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

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is at high risk during the two-incision technique for distal biceps repair, particularly if the forearm is not fully pronated during the posterior dissection or through aggressive retraction. The PIN supplies the ECU, EDC, EDM, APL, EPB, EPL, and EIP. Injury results in the inability to actively extend the fingers and thumb. Because the extensor carpi radialis longus and brevis (ECRL, ECRB) are innervated by the radial nerve proper prior to its bifurcation, wrist extension is preserved but occurs with strong radial deviation due to the loss of the counterbalancing ECU.

Question 2425

Topic: 9. Shoulder and Elbow

In a reverse total shoulder arthroplasty (RTSA), the center of rotation is altered compared to the native glenohumeral joint. This specific kinematic alteration achieves which of the following biomechanical advantages?

. Superior and lateral shift of the center of rotation, increasing the deltoid moment arm
. Inferior and medial shift of the center of rotation, increasing the deltoid moment arm
. Superior and medial shift of the center of rotation, decreasing the deltoid moment arm
. Inferior and lateral shift of the center of rotation, increasing the deltoid moment arm
. Inferior and medial shift of the center of rotation, decreasing the deltoid moment arm

Correct Answer & Explanation

. Inferior and medial shift of the center of rotation, increasing the deltoid moment arm

Explanation

A reverse total shoulder arthroplasty (RTSA) shifts the center of rotation medially and inferiorly. This biomechanical alteration increases the moment arm of the deltoid, allowing it to act as the primary elevator of the shoulder in the absence of a functioning rotator cuff. It also increases deltoid tension and recruits more anterior and posterior deltoid fibers for arm elevation.

Question 2426

Topic: 9. Shoulder and Elbow

A 42-year-old woman presents after a fall onto an outstretched hand. She is diagnosed with a 'terrible triad' injury of the elbow. During surgical reconstruction, what is the most widely accepted and appropriate sequence of repair to restore elbow stability?

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

Correct Answer & Explanation

. Coronoid repair, radial head repair/replacement, LCL repair, MCL repair (if still unstable)

Explanation

The standard surgical sequence for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) typically proceeds from deep to superficial and anterior to posterior/lateral. The recommended sequence is: 1) Coronoid repair (or anterior capsule reattachment), 2) Radial head repair or replacement, and 3) Lateral collateral ligament (LCL) complex repair. Finally, the elbow is assessed for stability; if valgus or extension instability persists, the medial collateral ligament (MCL) is repaired or a hinged external fixator is applied.

Question 2427

Topic: Elbow & Forearm

A 42-year-old tennis player presents with chronic, refractory lateral elbow pain that is exacerbated by wrist extension and gripping. He has failed 8 months of conservative management and is scheduled for surgical debridement. Histologic evaluation of the resected tissue is expected to show angiofibroblastic hyperplasia. The primary pathoanatomic lesion in this condition typically involves the origin of which structure?

. Extensor carpi radialis longus (ECRL)
. Extensor carpi radialis brevis (ECRB)
. Extensor digitorum communis (EDC)
. Extensor carpi ulnaris (ECU)
. Supinator muscle

Correct Answer & Explanation

. Extensor carpi radialis brevis (ECRB)

Explanation

Lateral epicondylitis (tennis elbow) is primarily a degenerative tendinosis characterized histologically by angiofibroblastic hyperplasia, rather than acute inflammation. The most commonly involved structure is the origin of the extensor carpi radialis brevis (ECRB). While the ECRL and EDC can occasionally be involved, the ECRB is the primary culprit due to its anatomical position overlying the radiocapitellar joint and its mechanical susceptibility to microtrauma during repetitive wrist extension.

Question 2428

Topic: 9. Shoulder and Elbow

Reverse total shoulder arthroplasty (RTSA) is widely utilized to restore function in patients with rotator cuff tear arthropathy. Compared to the native glenohumeral joint, how does RTSA alter the center of rotation to improve active elevation?

. Lateralizes and superiorly shifts the center of rotation
. Medializes and inferiorly shifts the center of rotation
. Medializes and superiorly shifts the center of rotation
. Lateralizes and inferiorly shifts the center of rotation
. Maintains the native center of rotation but increases the deltoid lever arm

Correct Answer & Explanation

. Medializes and inferiorly shifts the center of rotation

Explanation

The biomechanical advantage of the reverse total shoulder arthroplasty (RTSA) is achieved by medializing and inferiorly shifting the center of rotation. Medialization increases the moment arm of the deltoid, while inferiorization tensions the deltoid and recruits more of its anterior and posterior fibers to assist with forward elevation and abduction, effectively compensating for the deficient rotator cuff.

Question 2429

Topic: 9. Shoulder and Elbow

A 35-year-old woman is undergoing surgery for a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). Intraoperatively, the coronoid has been securely fixed, the radial head has been replaced, and the lateral collateral ligament (LCL) complex has been repaired to the lateral epicondyle. Upon testing range of motion, the elbow remains unstable and subluxates in terminal extension. What is the next most appropriate step in management?

. Repair the medial collateral ligament (MCL)
. Apply a hinged external fixator
. Downsize the radial head arthroplasty implant
. Release the brachialis muscle
. Perform a definitive ulnohumeral arthrodesis

Correct Answer & Explanation

. Repair the medial collateral ligament (MCL)

Explanation

The surgical algorithm for terrible triad injuries includes: 1) establishing a stable anterior base via coronoid fixation or capsular repair, 2) radial head fixation or replacement, and 3) LCL complex repair. If the elbow remains unstable after these steps (often subluxating in extension), the next step is to address the medial side by repairing the medial collateral ligament (MCL). If instability persists despite MCL repair, a hinged external fixator is indicated.

Question 2430

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman undergoes reverse total shoulder arthroplasty for cuff tear arthropathy. At her 2-year follow-up, radiographs show inferior scapular notching. Which of the following component positionings is most strongly associated with this radiographic finding?

. Superior placement of the glenosphere.
. Inferior tilt of the glenosphere.
. Increased lateralization of the glenosphere.
. Decreased neck-shaft angle of the humeral component.
. Increased retroversion of the humeral component.

Correct Answer & Explanation

. Superior placement of the glenosphere.

Explanation

Scapular notching is a frequent complication following reverse total shoulder arthroplasty, caused by mechanical impingement of the medial humeral metaphysis against the inferior scapular neck during adduction. Superior placement and medialization of the glenosphere significantly increase the risk of notching. Conversely, surgical techniques and implant designs utilizing inferior placement, inferior tilt, and lateralization of the glenosphere help mitigate this impingement.

Question 2431

Topic: Elbow & Forearm

A 35-year-old man falls from a ladder and sustains a 'terrible triad' injury of the elbow. Which of the following lists the sequence of structures typically addressed during surgical management, from deep to superficial?

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

Correct Answer & Explanation

. Coronoid, lateral collateral ligament complex, radial head.

Explanation

The 'terrible triad' of the elbow involves a coronoid fracture, a radial head fracture, and a lateral collateral ligament (LCL) tear, leading to posterolateral rotatory instability. The standard surgical protocol dictates repairing structures from deep/anterior to superficial/lateral. The typical sequence is: 1) fixation of the coronoid to restore the anterior buttress, 2) fixation or replacement of the radial head, and 3) repair of the LCL complex to the lateral epicondyle to restore lateral stability. The medial collateral ligament is typically only addressed if gross instability persists after these steps.

Question 2432

Topic: 9. Shoulder and Elbow

A 75-year-old right-hand-dominant woman sustains a 4-part proximal humerus fracture. She has a history of severe osteoporosis and advanced osteoarthritis of the glenohumeral joint. Which of the following surgical options will provide the most reliable pain relief and functional improvement?

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

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for elderly patients with 4-part proximal humerus fractures, especially in the setting of concurrent glenohumeral arthritis or poor tuberosity bone quality. RTSA provides more predictable functional outcomes and forward elevation compared to hemiarthroplasty, which relies heavily on tuberosity healing.

Question 2433

Topic: Shoulder Pathology

A 22-year-old male cyclist falls onto his left shoulder and sustains a completely displaced midshaft clavicle fracture with 2.5 cm of shortening. He undergoes open reduction and internal fixation (ORIF) with a superiorly placed precontoured locking plate. Which of the following nerves is at greatest risk of injury during the surgical approach?

. Suprascapular nerve
. Axillary nerve
. Spinal accessory nerve
. Supraclavicular nerves
. Long thoracic nerve

Correct Answer & Explanation

. Supraclavicular nerves

Explanation

The supraclavicular nerves (derived from C3, C4) provide sensory innervation over the clavicle and anterosuperior chest wall. They cross superficial to the clavicle and are frequently injured, stretched, or deliberately divided during the surgical approach for clavicle ORIF, resulting in a characteristic numb patch inferior to the incision.

Question 2434

Topic: 9. Shoulder and Elbow

A 40-year-old male weightlifter feels a sudden 'pop' in his anterior elbow while performing a heavy bicep curl. On examination, he has weakness in forearm supination and elbow flexion. He undergoes a single-incision anterior approach for distal biceps tendon repair. Which of the following complications is most specifically associated with this single-incision approach?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN) neuropraxia

Explanation

The single-incision anterior approach for distal biceps repair is associated with a higher risk of LABCN neuropraxia due to the required superficial radial-sided retraction. Radioulnar synostosis is a complication more classically associated with the two-incision approach.

Question 2435

Topic: 9. Shoulder and Elbow

A 50-year-old woman with type 1 diabetes mellitus presents with insidious onset of progressive shoulder pain and stiffness over the last 4 months. She denies any preceding trauma. Examination shows equal limitation in both active and passive range of motion, with significant restriction in external rotation. Radiographs are normal. What is the underlying pathophysiological hallmark of her condition?

. Subacromial bursal hypertrophy
. Fatty infiltration of the rotator cuff muscles
. Fibroblastic proliferation and contracture of the rotator interval
. Chondral wear of the humeral head
. Tearing of the superior labrum from anterior to posterior (SLAP)

Correct Answer & Explanation

. Fibroblastic proliferation and contracture of the rotator interval

Explanation

The patient's clinical presentation is classic for adhesive capsulitis (frozen shoulder), which is strongly associated with diabetes. Its pathophysiological hallmark is fibroblastic proliferation, capsular thickening, and contracture. This predominantly involves the rotator interval, consisting of the coracohumeral ligament and superior glenohumeral ligament, leading to the characteristic early loss of external rotation.

Question 2436

Topic: 9. Shoulder and Elbow

A 72-year-old woman with a massive, irreparable rotator cuff tear and pseudoparalysis undergoes a reverse total shoulder arthroplasty. During glenoid baseplate preparation, which of the following positioning strategies is most effective in minimizing the risk of scapular notching?

. Superior translation and superior tilt
. Inferior translation and inferior tilt
. Anterior translation and superior tilt
. Posterior translation and superior tilt
. Neutral translation and superior tilt

Correct Answer & Explanation

. Inferior translation and inferior tilt

Explanation

In reverse total shoulder arthroplasty, scapular notching is a common complication caused by mechanical impingement of the humeral component against the inferior scapular neck. Positioning the glenosphere with an inferior translation (overhang) and an inferior tilt has been biomechanically and clinically shown to effectively reduce the incidence and severity of scapular notching.

Question 2437

Topic: Elbow & Forearm

A 32-year-old man falls from a ladder and sustains an elbow dislocation associated with a radial head fracture and a coronoid fracture. Following closed reduction of the elbow, he is taken to the operating room. What is the standard recommended sequence of surgical reconstruction for this injury?

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

Correct Answer & Explanation

. Radial head fixation/replacement, coronoid fixation, lateral collateral ligament repair

Explanation

The classic 'terrible triad' of the elbow consists of an elbow dislocation, radial head fracture, and coronoid fracture. The standard surgical sequence works from deep to superficial: first repairing or replacing the coronoid (to restore the anterior buttress), then fixing or replacing the radial head (to restore the anterior and valgus buttress), and finally repairing the lateral ulnar collateral ligament (LUCL) to restore posterolateral rotatory stability.

Question 2438

Topic: 9. Shoulder and Elbow

A 21-year-old collegiate baseball pitcher presents with medial elbow pain and decreased pitching velocity. Physical examination demonstrates pain and laxity with the moving valgus stress test. An MRI arthrogram confirms a tear of the ulnar collateral ligament (UCL). Which specific bundle of the UCL is the primary restraint to valgus stress from 30 to 120 degrees of elbow flexion?

. Anterior bundle
. Posterior bundle
. Transverse bundle
. Oblique bundle
. Radial collateral ligament

Correct Answer & Explanation

. Anterior bundle

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 from the anteroinferior medial epicondyle and inserts on the sublime tubercle of the coronoid. The posterior bundle is a secondary restraint, and the transverse bundle provides no significant stability.

Question 2439

Topic: Elbow & Forearm

A 42-year-old carpenter presents with chronic lateral elbow pain that worsens with gripping and resisted wrist extension. Nonoperative management over the past 12 months has failed, and he is scheduled for surgical debridement. The pathologic tissue in lateral epicondylitis most commonly involves the origin of which of the following muscles?

. Extensor carpi radialis longus
. Extensor carpi radialis brevis
. Extensor digitorum communis
. Brachioradialis
. Extensor carpi ulnaris

Correct Answer & Explanation

. Extensor carpi radialis brevis

Explanation

Lateral epicondylitis (tennis elbow) is a tendinosis characterized by angiofibroblastic hyperplasia. The most commonly and primarily affected structure is the origin of the extensor carpi radialis brevis (ECRB) tendon. While the extensor digitorum communis can sometimes be involved, the ECRB is considered the primary site of pathology.

Question 2440

Topic: Elbow & Forearm

A 45-year-old man falls from a ladder and sustains an elbow dislocation. After closed reduction in the emergency department, radiographs are obtained as shown in the provided figure.

A subsequent CT scan confirms a type II coronoid fracture and a comminuted radial head fracture. During surgical intervention, what is the most appropriate sequence of repair to restore elbow stability?

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

Correct Answer & Explanation

. Coronoid, radial head, lateral collateral ligament, medial collateral ligament

Explanation

This patient has a terrible triad injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). The standard surgical sequence for restoring stability involves deep to superficial and medial to lateral (if approached laterally). The accepted sequence is: 1) Coronoid fixation or anterior capsule repair, 2) Radial head replacement or fixation, 3) Lateral ulnar collateral ligament (LUCL) repair. If the elbow remains unstable after these steps, the medial collateral ligament (MCL) is repaired or a hinged external fixator is applied.

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