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9. Shoulder and Elbow MCQs

Practice Set 130 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 2581

Topic: Shoulder Pathology

A 65-year-old man presents with an inability to actively elevate his arm above 60 degrees. Passive elevation is full. An intra-articular injection of local anesthetic completely restores his active elevation to 150 degrees. This clinical finding most likely indicates:

. True pseudoparalysis due to an irreparable massive rotator cuff tear
. Axillary nerve palsy
. Pseudoparesis secondary to pain inhibition
. Adhesive capsulitis
. Cervical radiculopathy

Correct Answer & Explanation

. Pseudoparesis secondary to pain inhibition

Explanation

True pseudoparalysis implies a mechanical inability to elevate the arm that does not improve with pain relief. Restoration of active motion after a local anesthetic injection confirms pseudoparesis driven by pain inhibition.

Question 2582

Topic: 9. Shoulder and Elbow

A 35-year-old man presents to the emergency department after experiencing a grand mal seizure. He holds his right arm internally rotated and is unable to actively or passively externally rotate it. An AP radiograph demonstrates the "lightbulb sign." What is the most appropriate initial management?

. Immediate operative open reduction
. Closed reduction under conscious sedation
. CT scan of the shoulder to quantify bone loss
. MRI of the shoulder to assess the rotator cuff
. Application of a shoulder spica cast

Correct Answer & Explanation

. Closed reduction under conscious sedation

Explanation

The clinical presentation (locked internal rotation) and radiographic "lightbulb sign" are classic for a posterior shoulder dislocation. Initial management involves prompt closed reduction under conscious sedation or general anesthesia.

Question 2583

Topic: 9. Shoulder and Elbow

A 55-year-old diabetic woman presents with a 4-month history of severe, diffuse shoulder pain that is progressively worsening, especially at night. Her range of motion is globally decreased but pain is the primary limiting factor. She is currently in which phase of adhesive capsulitis?

. Freezing phase
. Frozen phase
. Thawing phase
. Resolution phase
. Prodromal phase

Correct Answer & Explanation

. Freezing phase

Explanation

The freezing phase (lasting 2-9 months) is characterized by severe, progressive pain and a gradual loss of motion. The subsequent frozen phase involves less pain but profound, unyielding stiffness.

Question 2584

Topic: Shoulder Pathology

A 26-year-old manual laborer complains of painful crepitus and a loud snapping sensation at the superomedial border of his scapula with movement. Following failure of extensive nonoperative management, surgical intervention is planned. Which structure is most commonly targeted for resection?

. Subacromial bursa
. Subdeltoid bursa
. Subscapularis bursa
. Scapulothoracic bursa and superomedial scapular angle
. Coracobrachial bursa

Correct Answer & Explanation

. Scapulothoracic bursa and superomedial scapular angle

Explanation

Snapping scapula syndrome is frequently caused by an inflamed scapulothoracic bursa and/or a prominent superomedial scapular angle. Operative treatment typically consists of bursectomy and resection of the superomedial angle.

Question 2585

Topic: 9. Shoulder and Elbow

Compared to native shoulder anatomy, a traditional Grammont-style reverse total shoulder arthroplasty alters the biomechanics by doing which of the following?

. Lateralizing the center of rotation and superiorly displacing the humerus
. Medializing the center of rotation and inferiorly displacing the humerus
. Lateralizing the center of rotation and inferiorly displacing the humerus
. Medializing the center of rotation and superiorly displacing the humerus
. Preserving the anatomic center of rotation while increasing the deltoid moment arm

Correct Answer & Explanation

. Medializing the center of rotation and superiorly displacing the humerus

Explanation

The traditional Grammont-style reverse shoulder arthroplasty medializes the center of rotation to the glenoid face and inferiorly displaces the humerus. This design tensions the deltoid and increases its moment arm, allowing it to elevate the arm without a functioning rotator cuff.

Question 2586

Topic: Shoulder Arthroplasty & Arthritis

According to the Walch classification, a B2 glenoid is characterized by which of the following?

. Central wear with concentric bone loss
. Asymmetric posterior wear with a biconcave shape and posterior humeral subluxation
. Dysplastic glenoid with severe retroversion
. Superior migration of the humeral head due to rotator cuff deficiency
. Asymmetric anterior wear with anterior subluxation

Correct Answer & Explanation

. Asymmetric posterior wear with a biconcave shape and posterior humeral subluxation

Explanation

A Walch B2 glenoid is characterized by a biconcave articular surface with asymmetric posterior wear and posterior subluxation of the humeral head. It poses a high risk for glenoid component loosening if not addressed during anatomic total shoulder arthroplasty.

Question 2587

Topic: Shoulder Pathology

A 28-year-old man presents with dull, aching shoulder pain and prominent medial scapular winging that worsens when pushing against a wall. Examination reveals weakness of the serratus anterior. Injury to which nerve is the most likely cause?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial scapular winging is caused by serratus anterior paralysis due to long thoracic nerve injury. It is classically accentuated by having the patient push forward against a wall.

Question 2588

Topic: 9. Shoulder and Elbow

A 45-year-old woman presents with acute, severe shoulder pain that awakens her from sleep. Radiographs show a fluffy, ill-defined calcific deposit in the supraspinatus tendon. During which phase of calcific tendinitis does a patient typically experience the most severe pain?

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

Correct Answer & Explanation

. Resorptive phase

Explanation

Calcific tendinitis is most painful during the resorptive phase. During this time, the calcific deposit has a toothpaste-like consistency and elicits a vigorous vascular and inflammatory response.

Question 2589

Topic: 9. Shoulder and Elbow

Which of the following structures is NOT a component of the rotator interval of the shoulder?

. Coracohumeral ligament
. Superior glenohumeral ligament
. Long head of the biceps tendon
. Joint capsule
. Middle glenohumeral ligament

Correct Answer & Explanation

. Middle glenohumeral ligament

Explanation

The rotator interval is a triangular space bordered by the supraspinatus superiorly, subscapularis inferiorly, and the coracoid process medially. It contains the coracohumeral ligament, superior glenohumeral ligament, joint capsule, and the long head of the biceps tendon, but not the middle glenohumeral ligament.

Question 2590

Topic: 9. Shoulder and Elbow

A 50-year-old woman with diabetes mellitus presents with worsening shoulder stiffness and pain. Arthroscopy reveals hypervascularity and proliferative synovitis without significant capsular fibrosis. This represents which stage of adhesive capsulitis, and what is the typical duration of this stage?

. Stage 1; 0 to 3 months
. Stage 2 (Freezing); 3 to 9 months
. Stage 3 (Frozen); 9 to 15 months
. Stage 4 (Thawing); 15 to 24 months
. Stage 1; 3 to 9 months

Correct Answer & Explanation

. Stage 2 (Freezing); 3 to 9 months

Explanation

Stage 2 of adhesive capsulitis (the "freezing" stage) typically lasts from 3 to 9 months. It is characterized by intense pain, progressive loss of motion, and arthroscopic findings of hypertrophic, hypervascular synovitis with early scar formation.

Question 2591

Topic: 9. Shoulder and Elbow

A 30-year-old weightlifter feels a "pop" in his anterior axilla while performing a bench press. Examination reveals an ecchymotic swelling and loss of the anterior axillary fold. MRI confirms a complete rupture of the pectoralis major at its humeral insertion. Which of the following is the most appropriate treatment to restore maximum strength?

. Nonoperative management with a sling
. Physical therapy focusing on adductor strengthening
. Surgical repair of the tendon to the humerus
. Pectoralis minor tendon transfer
. Coracobrachialis tendon transfer

Correct Answer & Explanation

. Surgical repair of the tendon to the humerus

Explanation

In young athletic patients seeking to return to high-level activity, surgical repair of a complete pectoralis major rupture at the humeral insertion is indicated. Operative treatment reliably restores peak torque in shoulder adduction and internal rotation.

Question 2592

Topic: Shoulder Arthroplasty & Arthritis

In reverse total shoulder arthroplasty (RTSA), which of the following glenosphere design modifications or placements is most effective in decreasing the incidence of inferior scapular notching?

. Medialization of the center of rotation
. Superior translation of the glenosphere
. Inferior translation of the glenosphere over the scapular neck
. Increasing the neck-shaft angle of the humeral component
. Decreasing the diameter of the glenosphere

Correct Answer & Explanation

. Inferior translation of the glenosphere over the scapular neck

Explanation

Inferior translation (overhang) of the glenosphere and lateralization of the center of rotation help prevent mechanical impingement of the humeral component on the inferior scapular neck. This significantly reduces the risk of scapular notching.

Question 2593

Topic: 9. Shoulder and Elbow

A 65-year-old woman is planning to undergo total shoulder arthroplasty (TSA) for primary osteoarthritis. Preoperative CT imaging reveals a Walch B2 glenoid. What is the recommended strategy to address this specific deformity during primary TSA to prevent early glenoid component loosening?

. Use of a standard concentric glenoid component with posterior capsular plication
. Anterior eccentric reaming to restore neutral version without component adjustment
. Posterior augmented glenoid component or asymmetric reaming
. Use of a standard hemiarthroplasty without glenoid resurfacing
. Superior capsular reconstruction to balance forces

Correct Answer & Explanation

. Posterior augmented glenoid component or asymmetric reaming

Explanation

A Walch B2 glenoid is characterized by biconcavity and posterior subluxation of the humeral head. Addressing the pathologic retroversion with a posterior augmented glenoid or asymmetric reaming is critical to prevent eccentric loading and early loosening of the component.

Question 2594

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old right-hand-dominant woman sustains a 4-part proximal humerus fracture with severe varus collapse and significant comminution of the tuberosities. She lives independently and is medically optimized. What is the most appropriate surgical treatment?

. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty with tuberosity repair
. Percutaneous pinning
. Reverse total shoulder arthroplasty
. Intramedullary nailing

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In elderly patients with complex, comminuted 4-part proximal humerus fractures, reverse total shoulder arthroplasty (RTSA) provides more predictable functional outcomes and pain relief. It relies less on tuberosity healing compared to ORIF or hemiarthroplasty.

Question 2595

Topic: 9. Shoulder and Elbow

A 52-year-old woman with a 10-year history of poorly controlled type 1 diabetes presents with severe, progressive shoulder stiffness and pain for 4 months. She has profound loss of active and passive external rotation. Which of the following best describes the underlying pathophysiology of her condition?

. Myxoid degeneration of the rotator cuff tendons
. Fibroblastic proliferation and capsular fibrosis with elevated cytokines
. Chondral full-thickness cartilage loss on the glenoid
. Avascular necrosis of the humeral head
. Denervation atrophy of the deltoid

Correct Answer & Explanation

. Fibroblastic proliferation and capsular fibrosis with elevated cytokines

Explanation

Adhesive capsulitis (frozen shoulder) is strongly associated with diabetes mellitus. It is characterized by fibroblastic proliferation, capsular fibrosis, and contracture, driven by inflammatory cytokines and altered collagen metabolism.

Question 2596

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman undergoes a reverse total shoulder arthroplasty (RTSA). At 2-year follow-up, radiographs show inferior scapular notching. Which of the following implant positioning strategies most effectively reduces the risk of this complication?

. Superior placement of the glenosphere
. Inferior tilt and inferior placement of the glenosphere
. Increased medialization of the glenosphere
. Decreasing the glenosphere diameter
. Superior tilt of the glenosphere

Correct Answer & Explanation

. Inferior tilt and inferior placement of the glenosphere

Explanation

Scapular notching in RTSA is caused by mechanical impingement of the humeral cup against the inferior scapular neck. Inferior translation and inferior tilt of the glenosphere, along with lateralization, decrease the risk of notching.

Question 2597

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old woman sustains a 4-part proximal humerus fracture with head splitting and osteopenia. She lives independently and is a community ambulator. What is the most reliable surgical option to predictably restore forward elevation?

. Open reduction internal fixation with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Closed reduction and percutaneous pinning
. Nonoperative management with early range of motion

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In elderly patients with complex 4-part or head-splitting proximal humerus fractures, RTSA provides more predictable pain relief and functional restoration (especially forward elevation) compared to ORIF or hemiarthroplasty, bypassing the need for tuberosity healing.

Question 2598

Topic: Shoulder Pathology

A 45-year-old woman presents with shoulder pain and difficulty lifting her arm after a lymph node biopsy in the posterior cervical triangle. On examination, the superior angle of the scapula is displaced laterally, and winging worsens with arm abduction. What is the most likely diagnosis?

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

Correct Answer & Explanation

. Spinal accessory nerve palsy

Explanation

Spinal accessory nerve palsy (often iatrogenic from neck procedures) paralyzes the trapezius, causing lateral scapular winging. Long thoracic nerve palsy paralyzes the serratus anterior, resulting in medial scapular winging.

Question 2599

Topic: 9. Shoulder and Elbow

A 60-year-old man with primary glenohumeral osteoarthritis is planned for a total shoulder arthroplasty. A 3D CT scan reveals a Walch B2 glenoid with 20 degrees of retroversion. To prevent early glenoid component loosening, which of the following is the most appropriate management strategy?

. Standard concentric reaming preserving version
. Asymmetric anterior reaming to neutralize version
. Implantation of a standard pegged glenoid without version correction
. Use of an augmented glenoid component or bone grafting
. Proceeding with a hemiarthroplasty

Correct Answer & Explanation

. Use of an augmented glenoid component or bone grafting

Explanation

A Walch B2 glenoid features biconcave wear and significant retroversion. Correcting retroversion to less than 10-15 degrees is critical to prevent eccentric loading and early component failure, achieved via augmented glenoids or structural bone grafting.

Question 2600

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman undergoes a reverse total shoulder arthroplasty for cuff tear arthropathy. To minimize the risk of scapular notching, which of the following is the optimal positioning strategy for the glenoid baseplate?

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

Correct Answer & Explanation

. Inferior tilt and inferior translation

Explanation

Scapular notching occurs when the humeral component impinges on the inferior scapular neck during adduction. Placing the glenoid baseplate with an inferior tilt and inferior translation decreases this impingement risk.

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