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9. Shoulder and Elbow MCQs

Practice Set 125 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 2481

Topic: Shoulder Arthroplasty & Arthritis

A 76-year-old right-hand-dominant woman presents with a 4-part proximal humerus fracture following a mechanical fall. She is active and lives independently. Plain radiographs reveal a head-split component with significant osteopenia. She undergoes a reverse total shoulder arthroplasty (RTSA). Compared to hemiarthroplasty for this specific indication, RTSA has been shown to provide which of the following in the literature?

. Increased reliance on tuberosity healing for functional forward elevation
. More consistent restoration of active forward elevation
. Lower rate of overall surgical complications
. Decreased incidence of scapular notching
. Shorter operative time and decreased blood loss

Correct Answer & Explanation

. More consistent restoration of active forward elevation

Explanation

In the treatment of complex proximal humerus fractures in the elderly, reverse total shoulder arthroplasty (RTSA) provides more consistent and reliable restoration of active forward elevation compared to hemiarthroplasty. Hemiarthroplasty relies heavily on anatomic tuberosity healing to provide good functional outcomes; if the tuberosities resorb or fail to heal, patients often develop pseudoparalysis. While RTSA has a slightly higher overall complication rate, its functional predictability makes it the procedure of choice for elderly patients with 4-part fractures and poor bone stock.

Question 2482

Topic: Elbow & Forearm

A 35-year-old male sustains a fall from a height, resulting in a complex elbow injury consisting of a radial head fracture, a type II coronoid fracture, and an elbow dislocation. During surgical reconstruction of this 'terrible triad' injury, what is the recommended sequence of fixation to optimally restore elbow stability?

. Radial head repair/replacement, lateral collateral ligament (LCL) repair, coronoid repair
. LCL repair, coronoid repair, radial head repair/replacement
. Coronoid repair, radial head repair/replacement, LCL repair
. Coronoid repair, LCL repair, radial head repair/replacement
. Medial collateral ligament repair, coronoid repair, LCL repair

Correct Answer & Explanation

. Coronoid repair, radial head repair/replacement, LCL repair

Explanation

The classic 'terrible triad' of the elbow involves an elbow dislocation, radial head fracture, and coronoid fracture. The standard, most reliable surgical sequence to restore stability builds from deep to superficial and medial to lateral: 1) Repair of the coronoid process (often via sutures passed from posterior to anterior or through a specific approach), 2) Repair or replacement of the radial head, and 3) Repair of the lateral ulnar collateral ligament (LUCL) to its origin on the lateral epicondyle.

Question 2483

Topic: 9. Shoulder and Elbow

A 60-year-old diabetic woman presents with a 6-month history of a severely stiff and painful shoulder. She has severely limited active and passive range of motion in all planes, with passive external rotation limited to 5 degrees. Radiographs show a normal glenohumeral joint. She fails 6 months of supervised physical therapy and multiple intra-articular corticosteroid injections. If arthroscopic surgical release is elected, which of the following structures must be released to primarily restore external rotation with the arm at the side?

. Coracoacromial ligament
. Posterior capsule and posterior band of the IGHL
. Rotator interval and coracohumeral ligament
. Supraspinatus tendon
. Pectoralis minor tendon

Correct Answer & Explanation

. Rotator interval and coracohumeral ligament

Explanation

The patient's clinical presentation is classic for recalcitrant adhesive capsulitis (frozen shoulder), which is common in diabetic patients. The primary anatomic structures responsible for the restriction of external rotation with the arm resting at the side are the thickened, contracted coracohumeral ligament and the rotator interval capsule. An arthroscopic capsular release must adequately divide these anterior structures to restore external rotation.

Question 2484

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman undergoes a reverse total shoulder arthroplasty for cuff tear arthropathy. Which of the following glenosphere positioning strategies is most effective in minimizing the risk of scapular notching?

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

Correct Answer & Explanation

. Inferior translation and inferior tilt

Explanation

Scapular notching is a frequent complication following reverse total shoulder arthroplasty, caused by mechanical impingement of the humeral component against the inferior scapular neck. Inferior translation of the glenosphere (creating an inferior overhang) and inferior tilt are the most effective surgical strategies to decrease the incidence of scapular notching and improve impingement-free range of motion.

Question 2485

Topic: Elbow & Forearm

A 45-year-old man falls from a ladder and sustains a 'terrible triad' injury to his left elbow. Surgical management is planned. Following standard treatment algorithms, what is the most appropriate sequence of reconstruction?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury (elbow dislocation, coronoid fracture, radial head fracture) follows an inside-out or deep-to-superficial approach. The sequence is typically: 1) Coronoid fixation (or anterior capsule repair if the fragment is too small), 2) Radial head fixation or replacement, 3) Lateral collateral ligament (LCL) complex repair, and 4) Medial collateral ligament (MCL) repair and/or hinged external fixation if the elbow remains unstable after the first three steps.

Question 2486

Topic: Elbow & Forearm

A 30-year-old man has a permanent radial nerve palsy following a severe crush injury to his arm 18 months ago. Tendon transfer surgery is planned to restore wrist, finger, and thumb extension. In a standard flexor carpi radialis (FCR) transfer, which of the following tendon transfers is most commonly used to restore wrist extension?

. Flexor carpi ulnaris (FCU) to extensor carpi radialis longus (ECRL)
. Pronator teres (PT) to extensor carpi radialis brevis (ECRB)
. Flexor digitorum superficialis (FDS) to extensor carpi radialis brevis (ECRB)
. Palmaris longus (PL) to extensor carpi radialis longus (ECRL)
. Flexor carpi radialis (FCR) to extensor carpi ulnaris (ECU)

Correct Answer & Explanation

. Pronator teres (PT) to extensor carpi radialis brevis (ECRB)

Explanation

In the standard tendon transfer for radial nerve palsy, wrist extension is typically restored by transferring the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB). The ECRB is preferred over the ECRL because its central insertion at the base of the third metacarpal provides pure, centralized wrist extension, reducing the risk of strong radial deviation. Finger extension is typically restored via FCR to Extensor Digitorum Communis (EDC), and thumb extension via Palmaris Longus (PL) to Extensor Pollicis Longus (EPL).

Question 2487

Topic: Elbow & Forearm

A 45-year-old man falls on an outstretched hand and sustains a posterior elbow dislocation, a comminuted radial head fracture, and a type II coronoid fracture. During the surgical reconstruction of this terrible triad injury of the elbow, what is the generally recommended sequence of repair to best restore elbow stability?

. Lateral collateral ligament (LCL) repair, radial head fixation/replacement, coronoid fixation
. Coronoid fixation, radial head fixation/replacement, LCL repair
. Radial head fixation/replacement, LCL repair, coronoid fixation
. LCL repair, coronoid fixation, radial head fixation/replacement
. Coronoid fixation, LCL repair, radial head fixation/replacement

Correct Answer & Explanation

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

Explanation

The standard surgical protocol for terrible triad injuries involves repairing structures from deep to superficial, and typically anterior to posterior. Using a lateral or combined approach, the deep anterior structures are addressed first: the coronoid is fixed (often through the fracture defect of the radial head or via a separate medial approach if large), then the radial head is either fixed or replaced to restore the anterior radiocapitellar buttress, and finally, the lateral collateral ligament (LCL) complex is repaired to the lateral epicondyle to restore posterolateral rotatory stability.

Question 2488

Topic: Elbow & Forearm

A 38-year-old male undergoes a single-incision anterior approach for repairing a distal biceps tendon rupture. Postoperatively, he notes significant numbness and a tingling sensation along the lateral aspect of his forearm. Which nerve is most likely injured, and what is its anatomical relationship to the operative field?

. Posterior interosseous nerve; it pierces the supinator muscle.
. Lateral antebrachial cutaneous nerve; it courses between the biceps and brachialis muscles.
. Superficial radial nerve; it runs deep to the brachioradialis muscle.
. Medial antebrachial cutaneous nerve; it runs alongside the basilic vein.
. Ulnar nerve; it passes behind the medial epicondyle.

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve; it courses between the biceps and brachialis muscles.

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the terminal sensory branch of the musculocutaneous nerve. It emerges laterally between the biceps and brachialis muscles to pierce the deep fascia and course subcutaneously in the lateral forearm. It is at high risk of stretch or transection during the single-incision anterior approach for distal biceps repair due to retraction. Injury leads to numbness along the lateral forearm.

Question 2489

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 (RTSA).

Which of the following best describes the fundamental biomechanical alteration achieved by RTSA that restores active arm elevation?

. Superior translation of the center of rotation, increasing the deltoid moment arm.
. Lateralization of the center of rotation, restoring the anatomic force couple.
. Medialization and inferiorization of the center of rotation, increasing the deltoid moment arm.
. Medialization and superiorization of the center of rotation, increasing tension on the remaining rotator cuff.
. Lateralization and inferiorization of the center of rotation, increasing tension on the coracobrachialis.

Correct Answer & Explanation

. Medialization and inferiorization of the center of rotation, increasing the deltoid moment arm.

Explanation

A reverse total shoulder arthroplasty functions by medializing and inferiorizing the center of rotation of the glenohumeral joint compared to native anatomy. This medialization recruits more deltoid muscle fibers (anterior and posterior) for elevation, while the inferiorization tensions the deltoid, drastically increasing its moment arm. This allows the deltoid to act as the primary elevator of the arm in the absence of a functional supraspinatus.

Question 2490

Topic: 9. Shoulder and Elbow
A 34-year-old female falls on an outstretched hand and presents with elbow pain. Radiographs reveal a fracture of the capitellum with a distinct, separate fracture extension into the lateral trochlear ridge. According to the Bryan and Morrey classification (as modified by McKee), what type of fracture does this represent, and what is the preferred treatment?
. Type I (Hahn-Steinthal); closed reduction and short-arm casting.
. Type II (Kocher-Lorenz); arthroscopic excision of the fragment.
. Type III (Broberg-Morrey); primary total elbow arthroplasty.
. Type IV (McKee modification); open reduction and internal fixation.
. Type I (Hahn-Steinthal); open reduction and internal fixation.

Correct Answer & Explanation

. Type IV (McKee modification); open reduction and internal fixation.

Explanation

The Bryan and Morrey classification describes capitellar fractures: Type I (Hahn-Steinthal) is a large osseous fragment, Type II (Kocher-Lorenz) is an articular cartilage shear, and Type III is comminuted. The McKee modification added Type IV, which is a capitellar shear fracture that extends medially to include the lateral trochlear ridge. Recognizing Type IV is crucial because the lateral trochlear ridge provides significant coronal stability to the elbow. Non-operative treatment or excision leads to instability; therefore, open reduction and internal fixation (ORIF) is the preferred treatment.

Question 2491

Topic: 9. Shoulder and Elbow

A 35-year-old male falls from a height and sustains a complex elbow injury. Radiographs reveal a posterior elbow dislocation, a comminuted radial head fracture, and a type II coronoid fracture.

To optimally restore elbow stability, what is the generally recommended sequence of surgical reconstruction for this 'terrible triad' injury?

. Coronoid fixation, radial head repair or replacement, lateral collateral ligament (LCL) repair, and medial collateral ligament (MCL) repair if necessary
. Radial head replacement, coronoid fixation, LCL repair, and MCL repair if necessary
. LCL repair, radial head replacement, coronoid fixation, and MCL repair if necessary
. MCL repair, coronoid fixation, radial head replacement, and LCL repair
. LCL repair, MCL repair, coronoid fixation, and radial head replacement

Correct Answer & Explanation

. Coronoid fixation, radial head repair or replacement, lateral collateral ligament (LCL) repair, and medial collateral ligament (MCL) repair if necessary

Explanation

The standard surgical sequence for a 'terrible triad' of the elbow (elbow dislocation, radial head fracture, coronoid fracture) is designed to rebuild the elbow from deep to superficial, or inside-out. The recommended sequence is: 1) Coronoid fixation or anterior capsule reattachment; 2) Radial head repair or replacement; 3) LCL complex repair to the lateral epicondyle; 4) Re-evaluation of stability; and 5) MCL repair or cross-pinning only if the elbow remains grossly unstable after the first three steps.

Question 2492

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman is 4 years status-post a reverse total shoulder arthroplasty (RTSA) for severe rotator cuff tear arthropathy. Routine follow-up radiographs reveal a localized radiolucent line and bony defect at the inferior aspect of the scapular neck. Which of the following prosthesis design modifications or surgical techniques has been shown to most effectively reduce the incidence of this specific radiographic finding?

. Superior placement of the glenosphere
. Decreased lateralization of the center of rotation
. Inferior tilt and inferior overhang of the glenosphere
. Increasing the neck-shaft angle of the humeral component to 155 degrees
. Using a purely medialized glenoid and medialized humeral design

Correct Answer & Explanation

. Inferior tilt and inferior overhang of the glenosphere

Explanation

The radiographic finding described is 'scapular notching,' a well-known complication of RTSA caused by mechanical impingement of the medial aspect of the humeral implant against the inferior scapular neck during arm adduction. Surgical techniques and design modifications that minimize scapular notching include inferior placement of the glenosphere (creating inferior overhang), inferior tilt of the baseplate, lateralization of the glenosphere, and decreasing the humeral neck-shaft angle (e.g., to 135 or 145 degrees).

Question 2493

Topic: 9. Shoulder and Elbow

A 48-year-old male bodybuilder presents with anterior elbow pain and weakness in forearm supination. He reports feeling a 'pop' 8 weeks ago while lifting heavy weights but initially deferred evaluation. On examination, the hook test is abnormal. Magnetic resonance imaging (MRI) reveals a complete rupture of the distal biceps tendon with 6 cm of proximal retraction. During surgery, the tendon cannot be mobilized to reach the radial tuberosity without placing the elbow in 60 degrees of flexion. What is the most appropriate intraoperative management?

. Tenodesis of the biceps tendon stump to the brachialis muscle belly
. Tendon reconstruction utilizing an allograft or autograft
. Primary repair to the radial tuberosity and casting the elbow in 60 degrees of flexion
. Resection of the distal biceps stump and closure
. V-Y lengthening of the biceps aponeurosis to gain excursion

Correct Answer & Explanation

. Tendon reconstruction utilizing an allograft or autograft

Explanation

This patient has a chronic, retracted distal biceps tendon rupture. Primary repair is generally contraindicated if the elbow cannot be extended past 30 to 45 degrees of flexion with the tendon opposed to the tuberosity, as this significantly increases the risk of a permanent flexion contracture or repair failure. In such cases where adequate length cannot be obtained through mobilization, tendon reconstruction utilizing an allograft (e.g., Achilles, semitendinosus) or autograft (e.g., fascia lata, hamstring) is the standard of care to bridge the gap and restore supination and flexion strength.

Question 2494

Topic: 9. Shoulder and Elbow

A 35-year-old male sustains a fall resulting in a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid process fracture). During surgery, the radial head is replaced and the coronoid fracture is fixed securely. Upon completion of these steps, the elbow remains persistently unstable to varus and valgus stress in extension. What is the next most appropriate step in the standard surgical algorithm?

. Application of a static external fixator
. Repair of the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle
. Reconstruction of the anterior bundle of the medial collateral ligament (MCL)
. Transarticular pinning of the ulnohumeral joint
. Fascia lata autograft reconstruction of the annular ligament

Correct Answer & Explanation

. Repair of the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle

Explanation

The surgical management of a terrible triad injury of the elbow follows a standardized deep-to-superficial algorithm to systematically restore stability. The accepted protocol dictates: 1) fixation or replacement of the radial head, 2) fixation of the coronoid fracture or anterior capsule, and 3) repair of the lateral collateral ligament complex, specifically the lateral ulnar collateral ligament (LUCL), to the lateral epicondyle. If the elbow remains persistently unstable after the lateral side is addressed, only then should the medial collateral ligament (MCL) be repaired or a hinged external fixator applied.

Question 2495

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman undergoes a reverse total shoulder arthroplasty for rotator cuff tear arthropathy. Postoperatively, she develops a grade 3 scapular notch. Which of the following implant configurations is most strongly associated with preventing this complication?

. Superior glenosphere placement
. Increased humeral neck-shaft angle
. Inferior eccentric tilt of the glenosphere
. Medialization of the center of rotation
. Decreased glenosphere size

Correct Answer & Explanation

. Inferior eccentric tilt of the glenosphere

Explanation

Scapular notching is a common complication of reverse TSA caused by mechanical impingement. Inferior placement and inferior tilt of the glenosphere, along with lateralization of the center of rotation, help prevent impingement of the humeral component on the scapular neck.

Question 2496

Topic: 9. Shoulder and Elbow

A 25-year-old professional baseball pitcher presents with medial elbow pain during the late cocking phase of throwing. MRI arthrogram reveals a high-grade partial tear of the ulnar collateral ligament. If surgical reconstruction is chosen, the most isometric point of origin for the graft on the medial epicondyle is located:

. Anterior and inferior to the medial epicondyle center
. On the sublime tubercle
. Posterior to the axis of rotation
. Directly on the medial intermuscular septum
. At the medial epicondyle axis of rotation

Correct Answer & Explanation

. At the medial epicondyle axis of rotation

Explanation

The native UCL anterior bundle originates slightly posterior to the epicondylar axis. However, for reconstruction, placing the graft origin at the exact axis of rotation provides the most isometric and biomechanically stable construct.

Question 2497

Topic: 9. Shoulder and Elbow

A 38-year-old man fell onto an outstretched arm and sustained a terrible triad injury of the elbow. During surgical management, the standard step-wise approach to restoring elbow stability typically begins with fixation or replacement of which structure?

. Radial head
. Lateral ulnar collateral ligament
. Coronoid process
. Medial ulnar collateral ligament
. Anterior capsule

Correct Answer & Explanation

. Coronoid process

Explanation

The standard inside-out surgical sequence for a terrible triad injury involves fixation of the coronoid process first. This is followed by radial head repair or replacement, and finally lateral ulnar collateral ligament (LUCL) repair.

Question 2498

Topic: Shoulder Pathology

A 25-year-old male presents with medial winging of the scapula after a heavy lifting injury. He is unable to forward elevate his arm past 90 degrees. Injury to which of the following nerves is most likely responsible?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial winging of the scapula is caused by serratus anterior paralysis, innervated by the long thoracic nerve. Lateral winging is associated with trapezius dysfunction secondary to spinal accessory nerve injury.

Question 2499

Topic: 9. Shoulder and Elbow

A 68-year-old female presents with a displaced 4-part proximal humerus fracture with significant comminution of the tuberosities and osteopenic bone. What is the most reliable surgical option to restore active forward elevation?

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

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for complex 4-part proximal humerus fractures in older patients with poor bone quality. It provides more predictable functional outcomes and forward elevation compared to hemiarthroplasty.

Question 2500

Topic: Elbow & Forearm

A 45-year-old man falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. Which of the following describes the correct surgical sequence to restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury involves a deep-to-superficial approach. This sequence involves fixing the coronoid first, addressing the radial head, and finally repairing the lateral collateral ligament (LCL) complex.

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