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9. Shoulder and Elbow MCQs

Practice Set 129 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 2561

Topic: Shoulder Arthroplasty & Arthritis

Scapular notching is a recognized complication following reverse total shoulder arthroplasty (RTSA). Which of the following glenosphere placements is most strongly associated with an increased incidence of this complication?

. Superior tilt and medialization
. Inferior tilt and lateralization
. Neutral tilt and inferior translation
. Inferior tilt and medialization
. Posterior tilt and lateralization

Correct Answer & Explanation

. Superior tilt and medialization

Explanation

Scapular notching occurs due to mechanical impingement of the humeral cup on the inferior scapular neck. Superior tilt and medialization of the glenosphere increase the likelihood of this impingement.

Question 2562

Topic: 9. Shoulder and Elbow

A 68-year-old woman presents with persistent pseudoparalysis and severe shoulder pain after a massive irreparable rotator cuff tear. Clinical examination shows an intact deltoid and teres minor, but she has failed conservative treatment.

What is the most appropriate surgical treatment?

. Arthroscopic debridement
. Latissimus dorsi tendon transfer
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is indicated for older patients with massive, irreparable rotator cuff tears and pseudoparalysis, provided the deltoid is functional. It restores tension to the deltoid, allowing for active elevation.

Question 2563

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old man undergoes a reverse total shoulder arthroplasty. At 2-year follow-up, radiographs show grade 2 scapular notching. Which of the following surgical techniques minimizes this complication?

. Superior placement of the glenosphere
. Inferior placement and inferior tilt of the glenosphere
. Medialization of the center of rotation
. Decreasing the size of the glenosphere
. Superior tilt of the glenosphere

Correct Answer & Explanation

. Inferior placement and inferior tilt of the glenosphere

Explanation

Scapular notching in reverse TSA is caused by mechanical impingement of the humeral component against the inferior scapular neck. Inferior placement with an inferior tilt of the glenosphere, as well as lateralization, reduces this risk.

Question 2564

Topic: 9. Shoulder and Elbow

A 78-year-old woman sustains a highly comminuted 4-part proximal humerus fracture. Her history is significant for severe rotator cuff arthropathy and pseudoparalysis of the shoulder prior to the injury. A representative radiograph is similar to

What is the most appropriate surgical treatment?

. Open reduction and internal fixation with locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Intramedullary nailing
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for a 4-part proximal humerus fracture in an elderly patient with pre-existing rotator cuff arthropathy. It provides reliable pain relief and functional restoration without relying on tuberosity healing.

Question 2565

Topic: 9. Shoulder and Elbow

A 19-year-old football player sustains a direct blow to the anteromedial chest. He complains of severe pain at the sternoclavicular joint, dysphagia, and a choking sensation. What is the most critical next step in management?

. Immediate bedside closed reduction without imaging
. AP and axillary shoulder radiographs
. CT scan of the chest and emergent closed reduction in the OR
. MRI of the brachial plexus
. Sling immobilization and outpatient follow-up

Correct Answer & Explanation

. CT scan of the chest and emergent closed reduction in the OR

Explanation

Posterior sternoclavicular dislocations can fatally compress mediastinal structures like the trachea, esophagus, and great vessels. Management requires a CT scan for diagnosis and urgent closed reduction in the operating room with thoracic surgery available.

Question 2566

Topic: 9. Shoulder and Elbow

A 45-year-old woman develops acute, severe right shoulder pain that wakes her from sleep. The pain lasts for two weeks and then subsides, but she subsequently develops profound weakness in shoulder elevation and external rotation. MRI of the shoulder is unremarkable. What is the most likely diagnosis?

. Acute massive rotator cuff tear
. Cervical radiculopathy
. Parsonage-Turner syndrome
. Adhesive capsulitis
. Calcific tendinitis

Correct Answer & Explanation

. Parsonage-Turner syndrome

Explanation

Parsonage-Turner syndrome (brachial neuritis) features an acute onset of severe shoulder pain that resolves, followed by patchy lower motor neuron weakness. Diagnosis is typically confirmed with electromyography (EMG).

Question 2567

Topic: 9. Shoulder and Elbow

A 62-year-old man presents with insidious onset of mild shoulder pain and stiffness 14 months after an anatomic total shoulder arthroplasty. Inflammatory markers are normal, but joint aspiration yields a positive culture after 10 days. What is the most likely causative organism?

. Staphylococcus aureus
. Streptococcus pyogenes
. Cutibacterium acnes
. Pseudomonas aeruginosa
. Escherichia coli

Correct Answer & Explanation

. Cutibacterium acnes

Explanation

Cutibacterium acnes (formerly Propionibacterium acnes) is an indolent, slow-growing anaerobic organism commonly responsible for late periprosthetic shoulder infections. Cultures must be held for at least 14 days to avoid false-negative results.

Question 2568

Topic: 9. Shoulder and Elbow

A 48-year-old woman presents with agonizing shoulder pain of sudden onset without trauma. Radiographs reveal a homogenous, well-defined radiopacity superior to the greater tuberosity as shown in

Which phase of the disease process is typically the most painful?

. Precalcific phase
. Formative phase
. Resting phase
. Resorptive phase
. Postcalcific phase

Correct Answer & Explanation

. Resorptive phase

Explanation

Calcific tendinitis progresses through precalcific, calcific (formative, resting, resorptive), and postcalcific phases. The resorptive phase is characterized by intense vascular ingrowth and macrophage infiltration, causing extreme pain.

Question 2569

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old man undergoes a reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy. At his 2-year follow-up, radiographs demonstrate inferior scapular notching that extends beyond the inferior screw of the baseplate. According to the Sirveaux classification, what grade of notching is present?

. Grade 1
. Grade 2
. Grade 3
. Grade 4
. Grade 5

Correct Answer & Explanation

. Grade 3

Explanation

According to Sirveaux, Grade 1 is notching confined to the pillar. Grade 2 reaches the inferior screw, Grade 3 extends beyond the inferior screw, and Grade 4 extends under the baseplate.

Question 2570

Topic: Shoulder Arthroplasty & Arthritis

A 74-year-old woman presents with long-standing shoulder pain and inability to elevate her arm past 40 degrees. She has a positive drop arm sign and hornblower's sign. Radiographs demonstrate severe superior migration of the humeral head with articulation against the acromion.

Which of the following is the most reliable surgical option to restore active forward elevation?

. Arthroscopic massive rotator cuff repair
. Latissimus dorsi tendon transfer
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Hemiarthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In an elderly patient with rotator cuff tear arthropathy and pseudoparalysis, a reverse total shoulder arthroplasty (RTSA) provides the most reliable restoration of active forward elevation by utilizing the deltoid muscle.

Question 2571

Topic: 9. Shoulder and Elbow

A 55-year-old woman with type 1 diabetes presents with severe left shoulder pain that is worse at night and progressive stiffness over the past 3 months. Physical exam reveals passive external rotation limited to 10 degrees. Radiographs are normal. What is the initial treatment of choice?

. Arthroscopic capsular release
. Manipulation under anesthesia
. Intra-articular corticosteroid injection and physical therapy
. Oral nonsteroidal anti-inflammatory drugs only
. Open capsulotomy

Correct Answer & Explanation

. Intra-articular corticosteroid injection and physical therapy

Explanation

The patient has adhesive capsulitis (freezing phase). Initial treatment is nonoperative, focusing on gentle, sustained physical therapy stretching and intra-articular corticosteroid injections to decrease pain and inflammation.

Question 2572

Topic: 9. Shoulder and Elbow

A 68-year-old woman presents 3 months after an anatomic total shoulder arthroplasty (TSA) complaining of weakness and a new onset of pain.

Examination reveals passive external rotation of 80 degrees on the operative side compared to 40 degrees on the contralateral side. She has a positive belly-press test. What is the most likely diagnosis?

. Axillary nerve palsy
. Subscapularis failure
. Infraspinatus tear
. Glenoid component loosening
. Adhesive capsulitis

Correct Answer & Explanation

. Subscapularis failure

Explanation

Excessive passive external rotation combined with a positive belly-press test after an anatomic TSA strongly suggests subscapularis failure. This is a known complication following the tenotomy or peel performed during the surgical approach.

Question 2573

Topic: 9. Shoulder and Elbow

A 19-year-old football player sustains a high-energy blow to the medial clavicle. In the emergency department, he complains of shoulder pain, shortness of breath, and difficulty swallowing. Physical exam reveals a palpable depression at the medial end of the clavicle. What is the most appropriate next step in management?

. Discharge with a sling and outpatient orthopedic follow-up
. Immediate closed reduction in the emergency department using traction
. CT scan of the chest and consultation with cardiothoracic surgery
. Open reduction and internal fixation with a hook plate
. Figure-of-eight brace application

Correct Answer & Explanation

. CT scan of the chest and consultation with cardiothoracic surgery

Explanation

This is a posterior sternoclavicular dislocation, a true orthopedic emergency due to potential compression of the trachea, esophagus, and great vessels. A CT scan is required, and reduction should be performed in the OR with cardiothoracic surgery backup.

Question 2574

Topic: Shoulder Pathology

A 26-year-old male presents with winging of his right scapula following a protracted illness.

On physical examination, the medial border of the scapula is prominent, especially when he pushes against a wall. Which nerve is most likely affected?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial scapular winging is caused by serratus anterior paralysis, which is innervated by the long thoracic nerve. Lateral winging is typically due to trapezius dysfunction (spinal accessory nerve).

Question 2575

Topic: 9. Shoulder and Elbow

A 20-year-old elite collegiate tennis player presents with shoulder pain during the serve. Physical examination reveals glenohumeral internal rotation deficit (GIRD) of 25 degrees compared to the contralateral side, and 15 degrees of increased external rotation. The underlying pathophysiology of GIRD is most directly related to contracture of which structure?

. Anterior band of the inferior glenohumeral ligament
. Posterior band of the inferior glenohumeral ligament
. Coracohumeral ligament
. Superior glenohumeral ligament
. Middle glenohumeral ligament

Correct Answer & Explanation

. Posterior band of the inferior glenohumeral ligament

Explanation

GIRD in overhead athletes is primarily caused by contracture and thickening of the posterior capsule and the posterior band of the inferior glenohumeral ligament (IGHL) resulting from repetitive microtrauma during the deceleration phase of throwing.

Question 2576

Topic: Shoulder Arthroplasty & Arthritis

A 70-year-old woman is 6 months status post a reverse total shoulder arthroplasty (RTSA) for massive rotator cuff tear. She was doing well until she experienced a sudden onset of superior shoulder pain without any distinct trauma.

Radiographs indicate an acromial stress fracture. Which biomechanical alteration inherent to RTSA most directly contributes to this complication?

. Medialization of the center of rotation causing increased deltoid tension
. Superior migration of the center of rotation
. Decreased lever arm of the middle deltoid
. Excessive retroversion of the glenosphere
. Failure to repair the subscapularis

Correct Answer & Explanation

. Medialization of the center of rotation causing increased deltoid tension

Explanation

RTSA medializes and distalizes the center of rotation, which significantly increases the tension and lever arm of the deltoid. This increased load can lead to acromial or scapular spine stress fractures.

Question 2577

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman presents with lateral shoulder pain 2 years after undergoing a reverse total shoulder arthroplasty (RTSA). Radiographs reveal grade 3 scapular notching. Which of the following surgical technique modifications during the index procedure would have best minimized this complication?

. Superior placement of the glenosphere
. Superior tilt of the glenosphere
. Inferior placement of the glenosphere with inferior overhang
. Increasing the neck-shaft angle to 155 degrees
. Using a smaller glenosphere diameter

Correct Answer & Explanation

. Inferior placement of the glenosphere with inferior overhang

Explanation

Scapular notching in RTSA is best minimized by placing the glenosphere inferiorly with a slight inferior overhang and a neutral or inferior tilt. This biomechanical adjustment prevents impingement of the medial humeral component on the inferior scapular neck during arm adduction.

Question 2578

Topic: 9. Shoulder and Elbow
A 55-year-old woman with type 1 diabetes mellitus presents with progressive, severe shoulder stiffness and pain over the past 6 months. Examination demonstrates equal restriction of both active and passive range of motion. What is the classic histologic finding in the joint capsule of patients with this condition?
. Dense infiltration of polymorphonuclear leukocytes
. Granulomatous inflammation with multinucleated giant cells
. Proliferation of fibroblasts and myofibroblasts with dense type III collagen
. Amyloid deposition in the subsynovial layer
. Extensive chondroid metaplasia

Correct Answer & Explanation

. Proliferation of fibroblasts and myofibroblasts with dense type III collagen

Explanation

Adhesive capsulitis (frozen shoulder) is a fibroproliferative condition rather than an acute inflammatory one. Histologic analysis of the capsule classically demonstrates a dense matrix of type III collagen populated by a high number of fibroblasts and myofibroblasts without significant acute inflammatory cells.

Question 2579

Topic: 9. Shoulder and Elbow

An 82-year-old woman sustains a displaced 4-part proximal humerus fracture. She has a documented history of severe osteoarthritis and a massive rotator cuff tear prior to the injury. What is the most appropriate surgical treatment?

. Open reduction and internal fixation
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty
. Nonoperative management with early passive motion

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for elderly patients with 4-part proximal humerus fractures and pre-existing rotator cuff arthropathy or massive cuff tears, as it utilizes the deltoid for shoulder elevation.

Question 2580

Topic: Shoulder Arthroplasty & Arthritis

In reverse total shoulder arthroplasty (rTSA), which of the following component positioning strategies is most effective in minimizing the risk of scapular notching?

. Superior placement of the glenosphere
. Inferior tilt and translation of the glenosphere
. Increased retroversion of the humeral component
. Decreased lateral offset of the glenosphere
. Using a smaller diameter glenosphere

Correct Answer & Explanation

. Inferior tilt and translation of the glenosphere

Explanation

Inferior translation and inferior tilt of the glenosphere, along with increased lateral offset, are crucial strategies to reduce scapular notching in rTSA. This prevents abutment of the humeral tray against the scapular neck during adduction.

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