Menu

9. Shoulder and Elbow MCQs

Practice Set 127 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 2521

Topic: Shoulder Pathology

A patient with thoracic outlet syndrome experiences compression of the lower trunk of the brachial plexus. This compression typically occurs in the interscalene triangle. What are the anatomical borders of the interscalene triangle?

. Anterior scalene, middle scalene, and the first rib
. Middle scalene, posterior scalene, and the second rib
. Clavicle, first rib, and subclavius muscle
. Pectoralis minor, coracoid process, and rib cage
. Sternocleidomastoid, anterior scalene, and clavicle

Correct Answer & Explanation

. Anterior scalene, middle scalene, and the first rib

Explanation

The interscalene triangle is bordered anteriorly by the anterior scalene muscle, posteriorly by the middle scalene muscle, and inferiorly by the first rib. The brachial plexus roots and trunks, along with the subclavian artery, pass through this space.

Question 2522

Topic: Shoulder Pathology

A 35-year-old male suffers a traction injury to his brachial plexus following a motorcycle accident. Examination reveals profound winging of the scapula with forward elevation of the arm. The injured nerve originates from which of the following anatomic components?

. C5, C6, C7 nerve roots
. Upper trunk
. Posterior cord
. Medial cord
. C8, T1 nerve roots

Correct Answer & Explanation

. C5, C6, C7 nerve roots

Explanation

Scapular winging indicates paralysis of the serratus anterior, which is innervated by the long thoracic nerve. This nerve originates directly from the ventral rami of the C5, C6, and C7 nerve roots before the formation of the trunks.

Question 2523

Topic: Elbow & Forearm

A 30-year-old gymnast complains of recurrent elbow instability, particularly when pushing out of a chair. Physical examination reveals a positive lateral pivot-shift test, indicating posterolateral rotatory instability (PLRI). The primary structure deficient in this condition originates from the lateral epicondyle and inserts onto which of the following osseous landmarks?

. Radial head
. Radial neck
. Coronoid process of the ulna
. Olecranon
. Supinator crest of the ulna

Correct Answer & Explanation

. Supinator crest of the ulna

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily caused by insufficiency of the lateral ulnar collateral ligament (LUCL). The LUCL is the primary restraint to posterolateral rotatory subluxation. It originates on the lateral epicondyle of the humerus, courses posterior to the radial head, and inserts on the supinator crest of the proximal ulna.

Question 2524

Topic: Shoulder Pathology

Following a motorcycle accident, a 25-year-old male complains of severe shoulder weakness. Physical examination reveals an inability to actively elevate the arm above 90 degrees and prominent medial winging of the scapula when he pushes against a wall. The injured nerve responsible for this clinical presentation originates directly from which anatomical level of the brachial plexus?

. Roots
. Trunks
. Divisions
. Cords
. Branches

Correct Answer & Explanation

. Roots

Explanation

Medial winging of the scapula indicates paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. The long thoracic nerve arises directly from the anterior rami of the C5, C6, and C7 nerve roots. The dorsal scapular nerve (rhomboids) also originates from the root level (C5).

Question 2525

Topic: 9. Shoulder and Elbow

A 45-year-old male laborer presents with a sudden pop and pain in his anterior elbow after lifting a heavy box. An MRI confirms a complete tear of the distal biceps tendon. The surgeon plans an anatomic repair. To properly recreate the native biomechanics for maximal supination strength, where should the biceps tendon be repaired on the radial tuberosity?

. Anterior and proximal
. Anterior and distal
. Posterior and ulnar
. Lateral and proximal
. Volar and radial

Correct Answer & Explanation

. Posterior and ulnar

Explanation

The distal biceps tendon inserts onto the radial tuberosity. The native footprint is located on the posterior-ulnar aspect of the radial tuberosity. Reattaching the tendon to its anatomic posterior-ulnar position is crucial to restore the maximal moment arm for supination. Non-anatomic repair (too anteriorly) significantly decreases supination strength, although flexion strength is generally preserved.

Question 2526

Topic: Shoulder Pathology

A 45-year-old female undergoes a posterior cervical lymph node biopsy. Several weeks postoperatively, she presents with persistent shoulder aching, weakness with overhead activities, and prominent lateral winging of her scapula on physical examination. Damage to which of the following anatomical structures is most likely responsible for these findings?

. A nerve emerging from C5-C7 that descends on the superficial surface of the serratus anterior
. A nerve passing through the quadrangular space with the posterior circumflex humeral artery
. A cranial nerve that crosses the posterior triangle of the neck superficially
. A nerve piercing the middle scalene to supply the levator scapulae and rhomboids
. A nerve passing through the suprascapular notch beneath the superior transverse scapular ligament

Correct Answer & Explanation

. A cranial nerve that crosses the posterior triangle of the neck superficially

Explanation

The clinical scenario describes a spinal accessory nerve (CN XI) injury, a well-known complication of procedures in the posterior triangle of the neck (such as a lymph node biopsy). CN XI innervates the trapezius muscle. Injury leads to trapezius palsy, presenting as shoulder drooping, weakness in active forward elevation and abduction beyond 90 degrees, and lateral winging of the scapula. Option A describes the long thoracic nerve, injury to which causes medial winging (serratus anterior palsy).

Question 2527

Topic: Elbow & Forearm

A 22-year-old collegiate baseball pitcher presents with posteromedial elbow pain and a noticeable decrease in throwing velocity over the last two months. He describes a severe 'catching' and 'locking' sensation specifically in the deceleration phase of throwing. Physical examination reveals a 15-degree flexion contracture and sharp pain in the posteromedial olecranon fossa when forced terminal extension is applied concurrently with a valgus stress. The milking maneuver is negative. What is the most likely diagnosis?

. Medial epicondylitis
. Acute ulnar collateral ligament anterior bundle rupture
. Valgus extension overload syndrome
. Ulnar neuritis
. Osteochondritis dissecans of the capitellum

Correct Answer & Explanation

. Valgus extension overload syndrome

Explanation

Valgus extension overload (VEO) syndrome in overhead athletes results from chronic, repetitive valgus stress and extension forces. This leads to posterior radiocapitellar compression and traction/shear forces on the medial olecranon tip as it impinges within the olecranon fossa. Patients characteristically present with posteromedial pain, a flexion contracture, and pain on forced terminal extension with valgus stress (the moving valgus stress test may also be positive, but specifically terminal extension pain points to impingement/osteophytes). The 'catching' in the deceleration phase is classic for VEO, often secondary to posteromedial olecranon osteophytes or loose bodies.

Question 2528

Topic: 9. Shoulder and Elbow

A 22-year-old collegiate baseball pitcher reports severe medial elbow pain and a recent drop in his fast pitch velocity. He experiences sharp pain during the late cocking and early acceleration phases of throwing. The moving valgus stress test is markedly positive. An MRI arthrogram demonstrates a high-grade partial tear of the ulnar collateral ligament (UCL). If conservative management fails and surgical reconstruction is planned, which anatomic bundle of the UCL must be targeted as it is the primary restraint to valgus stress at 90 degrees of flexion?

. Anterior bundle
. Posterior bundle
. Transverse bundle
. Oblique bundle
. Lateral ulnar collateral ligament

Correct Answer & Explanation

. Anterior bundle

Explanation

The ulnar collateral ligament (UCL) of the elbow consists of anterior, posterior, and transverse bundles. The anterior bundle is the primary restraint to valgus stress of the elbow between 30 and 120 degrees of flexion, which includes the critical 90-degree position during the throwing motion. Consequently, it is the anterior bundle that is the primary focus of reconstruction during a 'Tommy John' surgery. The posterior bundle is a secondary restraint, and the transverse bundle contributes little to valgus stability.

Question 2529

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate pitcher undergoes a flexor-pronator splitting approach for ulnar collateral ligament (UCL) reconstruction. During the initial subcutaneous dissection over the medial epicondyle, a nerve is encountered and carefully protected. Injury to this nerve would result in a sensory deficit to which of the following areas?

. Palmar aspect of the small finger
. Medial aspect of the forearm
. Dorsal aspect of the thumb web space
. Lateral aspect of the forearm
. Medial aspect of the upper arm

Correct Answer & Explanation

. Medial aspect of the forearm

Explanation

The medial antebrachial cutaneous nerve (MABC) courses superficially over the medial elbow and is highly at risk during the surgical approach to the medial elbow, such as during a UCL reconstruction. It provides sensation to the medial aspect of the forearm. Neuroma formation or transection of the MABC is a common and troublesome complication in elbow surgery.

Question 2530

Topic: 9. Shoulder and Elbow

A 62-year-old man presents with a chronic, massive, irreparable posterosuperior rotator cuff tear. He has active forward elevation to 130 degrees but severe pain. He is considered for an arthroscopic Superior Capsular Reconstruction (SCR). Which of the following is considered an absolute contraindication for this procedure?

. Hamada stage 2 arthropathy
. Pseudoparalysis with active forward elevation < 90 degrees
. Advanced glenohumeral osteoarthritis (Hamada stage 4 or 5)
. Goutallier stage 2 fatty infiltration of the infraspinatus
. Concomitant biceps tenosynovitis

Correct Answer & Explanation

. Advanced glenohumeral osteoarthritis (Hamada stage 4 or 5)

Explanation

Superior capsular reconstruction (SCR) is indicated for massive, irreparable rotator cuff tears in patients who have an intact or repairable subscapularis, preserved deltoid function, and minimal glenohumeral arthritis. Advanced glenohumeral arthritis (Hamada stage 4 or 5) is an absolute contraindication for SCR; a reverse total shoulder arthroplasty (RTSA) is the preferred and most predictable treatment in this setting.

Question 2531

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate baseball pitcher reports progressive medial elbow pain and decreased pitching velocity. Examination reveals pain with the moving valgus stress test and maximal tenderness slightly distal to the medial epicondyle. MRI shows a high-grade partial tear of the ulnar collateral ligament (UCL). Which of the following bundles of the UCL provides the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion?

. Anterior bundle
. Posterior bundle
. Transverse bundle
. Radial collateral ligament
. Lateral ulnar 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 on the anteroinferior surface of the medial epicondyle and inserts on the sublime tubercle of the ulna. The posterior bundle acts as a secondary restraint, and the transverse bundle provides no significant stability to valgus stress.

Question 2532

Topic: 9. Shoulder and Elbow

A 19-year-old collegiate baseball pitcher reports medial elbow pain and a noticeable decline in throwing velocity over the past month. Physical examination reveals tenderness just distal to the medial epicondyle and localized pain with valgus stress testing at 30 degrees of elbow flexion. Which structure is the primary restraint to valgus stress during the late cocking and early acceleration phases of throwing, and what is its correct anatomic distal insertion?

. Posterior bundle of the UCL; sublime tubercle
. Posterior bundle of the UCL; olecranon
. Anterior bundle of the UCL; sublime tubercle
. Anterior bundle of the UCL; coronoid tip
. Transverse bundle of the UCL; sublime tubercle

Correct Answer & Explanation

. Anterior bundle of the UCL; sublime tubercle

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress between 30 and 120 degrees of elbow flexion, which corresponds to the late cocking and early acceleration phases of throwing. It originates from the anteroinferior surface of the medial epicondyle and inserts distally on the sublime tubercle of the anteromedial coronoid process of the ulna.

Question 2533

Topic: Elbow & Forearm

A 9-year-old male baseball pitcher complains of lateral right elbow pain and stiffness that worsens with throwing. Examination shows a 15-degree flexion contracture. Radiographs reveal diffuse sclerosis and fragmentation involving the entire capitellum, with no loose bodies or localized subchondral bone defects. What is the most appropriate management?

. Arthroscopic microfracture of the capitellum
. Open osteochondral autograft transfer (OATS)
. Rest, activity modification, and symptomatic treatment
. Ulnar collateral ligament reconstruction
. Drilling of the capitellum to promote revascularization

Correct Answer & Explanation

. Rest, activity modification, and symptomatic treatment

Explanation

The clinical presentation and radiographic findings in a child under 10 years old are characteristic of Panner's disease (osteochondrosis of the capitellum). Unlike osteochondritis dissecans (OCD) of the capitellum, which typically occurs in older adolescents (12-15 years), involves a focal defect, and may lead to loose bodies, Panner's disease is self-limiting, involves the entire ossific nucleus, and uniformly responds to nonoperative treatment consisting of rest and avoidance of throwing until symptoms resolve and radiographic healing occurs.

Question 2534

Topic: Elbow & Forearm

A 20-year-old collegiate baseball pitcher complains of medial elbow pain and diminished pitching velocity for 6 weeks. A moving valgus stress test reproduces his pain.

An MR arthrogram confirms a partial tear of the anterior bundle of the ulnar collateral ligament (UCL). What is the most appropriate initial management?

. Immediate UCL reconstruction (Tommy John surgery)
. UCL repair with internal brace augmentation
. Rest from throwing, NSAIDs, and a flexor-pronator mass rehabilitation program
. Corticosteroid injection into the UCL origin
. Arthroscopic debridement of the radiocapitellar joint

Correct Answer & Explanation

. Rest from throwing, NSAIDs, and a flexor-pronator mass rehabilitation program

Explanation

The standard of care for an initial partial tear of the UCL in a throwing athlete is nonoperative management. This involves a period of absolute rest from throwing (typically 6-12 weeks), followed by a progressive rehabilitation program focused on strengthening the dynamic medial stabilizers (flexor-pronator mass) and optimizing throwing mechanics. Corticosteroid injections are contraindicated due to the risk of inducing complete ligament rupture. Surgery is reserved for complete tears or failed prolonged nonoperative treatment.

Question 2535

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate baseball pitcher has medial elbow pain during the late cocking and early acceleration phases of throwing. MRI shows a high-grade tear of the ulnar collateral ligament (UCL) anterior bundle. Which of the following best describes the biomechanical property of the anterior bundle of the UCL?

. It is the primary restraint to varus stress in full extension
. It is the primary restraint to valgus stress from 30 to 120 degrees of flexion
. It acts as a secondary restraint to posterolateral rotatory instability
. The posterior band of the anterior bundle is most taut in full extension
. It is the primary restraint to valgus stress in terminal extension only

Correct Answer & Explanation

. It is the primary restraint to valgus stress from 30 to 120 degrees of flexion

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion. It consists of an anterior band (taut in extension up to roughly 90 degrees) and a posterior band (taut from 60 to 120 degrees). The anterior bundle is the most critical ligamentous stabilizer for the throwing athlete.

Question 2536

Topic: 9. Shoulder and Elbow

A 68-year-old male presents with persistent right shoulder pain and pseudoparalysis. Radiographs

show superior migration of the humeral head with an acromiohumeral distance of 4 mm. MRI reveals a massive, retracted tear of the supraspinatus and infraspinatus with Goutallier grade 4 fatty infiltration. He has preserved deltoid function and an intact teres minor. Which of the following is the most appropriate surgical treatment?

. Arthroscopic rotator cuff repair
. Superior capsular reconstruction
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In an older patient with a massive, irreparable rotator cuff tear (indicated by pseudoparalysis, proximal humeral migration, and severe Goutallier grade 4 fatty infiltration), reverse total shoulder arthroplasty (RTSA) is the gold standard. RTSA alters the center of rotation and relies on the deltoid muscle to elevate the arm, overcoming the superior migration and reliably restoring function.

Question 2537

Topic: 9. Shoulder and Elbow

A 25-year-old rugby player undergoes an MRI arthrogram of the shoulder following a traumatic anterior dislocation. The images demonstrate extravasation of contrast material inferiorly down the humeral shaft, producing a characteristic 'J' sign. Which of the following is the most likely diagnosis?

. Bankart lesion
. Anterior labroligamentous periosteal sleeve avulsion (ALPSA)
. Glenolabral articular disruption (GLAD)
. Humeral avulsion of the glenohumeral ligament (HAGL)
. Perthes lesion

Correct Answer & Explanation

. Humeral avulsion of the glenohumeral ligament (HAGL)

Explanation

A Humeral Avulsion of the Glenohumeral Ligament (HAGL) occurs when the inferior glenohumeral ligament is torn from its humeral attachment rather than its glenoid attachment. On an MRI arthrogram, contrast leaks inferiorly through the defect into the axillary pouch and tracks down the humeral neck, forming the characteristic 'J' sign. Identifying a HAGL lesion is critical, as it requires specific surgical repair; addressing only a presumed Bankart lesion will result in persistent instability.

Question 2538

Topic: Elbow & Forearm

A 14-year-old female gymnast complains of lateral elbow pain, clicking, and a 15-degree flexion contracture. Radiographs reveal a radiolucency in the capitellum. MRI demonstrates a 12 mm osteochondral defect of the capitellum. Which of the following MRI findings is the strongest absolute indication for surgical intervention?

. Extensive bone marrow edema within the capitellum
. Intact overlying articular cartilage
. High T2 signal (fluid) extending behind the osteochondral fragment
. Lesion size less than 10 mm in the coronal plane
. Subchondral sclerosis surrounding the lesion

Correct Answer & Explanation

. High T2 signal (fluid) extending behind the osteochondral fragment

Explanation

Osteochondritis dissecans (OCD) of the capitellum is common in young gymnasts and overhead athletes. The stability of the lesion dictates treatment. Non-operative management is appropriate for stable lesions with open physes. However, high T2 signal (synovial fluid) interposing behind the osteochondral fragment or a break in the articular cartilage signifies an unstable lesion. Unstable lesions are unlikely to heal with rest alone and are an absolute indication for surgical intervention (e.g., drilling, fixation, or fragment excision with microfracture).

Question 2539

Topic: 9. Shoulder and Elbow

A 21-year-old collegiate baseball pitcher reports medial elbow pain and decreased velocity. Valgus stress testing is positive. Which specific bundle of the ulnar collateral ligament (UCL) acts as the primary restraint to valgus stress during the late cocking phase of throwing?

. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Posterior bundle
. Transverse bundle
. Annular ligament

Correct Answer & Explanation

. Anterior band of the anterior bundle

Explanation

The anterior band of the anterior bundle of the UCL is the primary restraint to valgus stress from 30 to 120 degrees of elbow flexion, which is critical during the throwing motion.

Question 2540

Topic: 9. Shoulder and Elbow

A 14-year-old female gymnast complains of chronic lateral elbow pain. Radiographs and MRI reveal an osteochondritis dissecans (OCD) lesion of the capitellum. Which of the following is an absolute indication for operative management?

. An open capitellar physis
. Intact articular cartilage overlying the lesion on MRI
. Presence of a mechanical intra-articular loose body
. A flexion contracture of exactly 5 degrees
. Complete pain relief following 3 weeks of strict rest

Correct Answer & Explanation

. Presence of a mechanical intra-articular loose body

Explanation

Surgical indications for capitellar OCD lesions include detached or unstable lesions, the presence of intra-articular loose bodies, failed conservative treatment in a compliant patient, or skeletal maturity.

Test Yourself

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

On this Page