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9. Shoulder and Elbow MCQs

Practice Set 132 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 2621

Topic: 9. Shoulder and Elbow

A 58-year-old laborer presents with an irreparable posterosuperior rotator cuff tear. He has profound weakness in external rotation and a positive Hornblower's sign. He has intact forward elevation and no significant glenohumeral arthritis. Which of the following tendon transfers is most appropriate?

. Pectoralis major transfer
. Lower trapezius transfer
. Latissimus dorsi transfer
. Pectoralis minor transfer
. Serratus anterior transfer

Correct Answer & Explanation

. Lower trapezius transfer

Explanation

Lower trapezius transfer (often with an Achilles allograft) is highly effective for restoring external rotation in patients with irreparable posterosuperior cuff tears and a positive Hornblower's sign. It has a more direct line of pull for external rotation compared to the latissimus dorsi.

Question 2622

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman is 3 years status post reverse total shoulder arthroplasty (RTSA) using a Grammont-style prosthesis. Radiographs show a grade 3 inferior scapular notch. Which of the following technical errors during the index procedure most significantly increases the risk of this complication?

. Inferior overhang of the glenosphere
. Superior placement of the baseplate
. Increased lateralization of the glenosphere
. Use of a larger diameter glenosphere
. Inferior tilt of the glenosphere

Correct Answer & Explanation

. Superior placement of the baseplate

Explanation

Superior placement of the baseplate in RTSA increases the risk of scapular notching due to impingement of the humeral tray against the inferior scapular neck. Inferior overhang, inferior tilt, and lateralization are protective against notching.

Question 2623

Topic: 9. Shoulder and Elbow

A 66-year-old man with primary glenohumeral osteoarthritis presents for shoulder arthroplasty. A preoperative CT scan reveals a Walch B2 glenoid with 25 degrees of retroversion and posterior humeral head subluxation. When planning an anatomic total shoulder arthroplasty, what is the best strategy to address the glenoid?

. Concentric reaming to neutral version
. Eccentric anterior reaming to neutralize version
. Placement of a standard keeled component without reaming
. Use of a posteriorly augmented glenoid component or eccentric posterior reaming
. Bone grafting of the anterior glenoid

Correct Answer & Explanation

. Use of a posteriorly augmented glenoid component or eccentric posterior reaming

Explanation

A Walch B2 glenoid is characterized by biconcavity, posterior wear, and retroversion. Management in anatomic TSA requires correcting the retroversion, typically via asymmetric (eccentric) posterior reaming or using a posteriorly augmented glenoid component to prevent premature posterior loosening.

Question 2624

Topic: Shoulder Pathology

A 32-year-old woman develops prominent medial scapular winging three weeks after a severe viral illness. She has weakness in forward elevation but intact external rotation. EMG confirms an isolated nerve palsy. Which nerve-muscle pair is affected?

. Spinal accessory nerve / Trapezius
. Long thoracic nerve / Serratus anterior
. Dorsal scapular nerve / Rhomboids
. Suprascapular nerve / Supraspinatus
. Thoracodorsal nerve / Latissimus dorsi

Correct Answer & Explanation

. Long thoracic nerve / Serratus anterior

Explanation

Medial scapular winging (prominence of the medial border) is classic for serratus anterior paralysis due to long thoracic nerve palsy. Lateral winging is associated with trapezius paralysis from a spinal accessory nerve injury.

Question 2625

Topic: 9. Shoulder and Elbow

A 40-year-old man presents with an acute onset of severe, unremitting right shoulder pain that woke him from sleep. After two weeks, the pain significantly improves, but he notices profound weakness in elevating his arm. MRI of the shoulder is unremarkable. What is the most likely diagnosis?

. Acute massive rotator cuff tear
. Parsonage-Turner Syndrome (Acute Brachial Neuritis)
. Cervical radiculopathy (C5)
. Adhesive capsulitis
. Subacromial bursitis

Correct Answer & Explanation

. Parsonage-Turner Syndrome (Acute Brachial Neuritis)

Explanation

Parsonage-Turner Syndrome classically presents with acute, severe pain followed by patchy weakness and muscle atrophy (often deltoid, rotator cuff, or periscapular muscles) as the pain resolves. It is typically a self-limiting viral or autoimmune neuritis.

Question 2626

Topic: 9. Shoulder and Elbow

A 75-year-old woman with advanced osteoporosis sustains a 4-part proximal humerus fracture with significant comminution of the tuberosities. She is living independently and functionally active. Which of the following treatments provides the most reliable return of active forward elevation?

. Non-operative management with a sling
. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Percutaneous pinning

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In elderly patients with poor bone quality and severely comminuted 4-part proximal humerus fractures, reverse total shoulder arthroplasty provides a more reliable and predictable functional outcome (especially forward elevation) compared to ORIF or hemiarthroplasty, as it relies less on tuberosity healing.

Question 2627

Topic: 9. Shoulder and Elbow
A 55-year-old diabetic woman presents with an 8-month history of a painfully stiff shoulder. She has severely restricted active and passive range of motion in all planes. Radiographs are normal. Which cytokine is most heavily implicated in the pathogenesis of her condition?
. Interleukin-1 (IL-1)
. Transforming Growth Factor-beta (TGF-β)
. Tumor Necrosis Factor-alpha (TNF-α)
. Interleukin-6 (IL-6)
. Vascular Endothelial Growth Factor (VEGF)

Correct Answer & Explanation

. Transforming Growth Factor-beta (TGF-β)

Explanation

Adhesive capsulitis is driven by excessive fibroblastic proliferation and collagen deposition. TGF-β is the primary cytokine responsible for this fibrotic cascade in the joint capsule.

Question 2628

Topic: 9. Shoulder and Elbow

A 38-year-old male presents with chronic anterior shoulder pain. MRI shows a type II SLAP lesion. He undergoes arthroscopic SLAP repair using two suture anchors. Six months postoperatively, he complains of severe stiffness, lacking 30 degrees of external rotation. What is the most likely intraoperative technical error?

. Failure to repair the anterior labrum
. Over-tensioning the repair by capturing the biceps anchor too tightly
. Placing the anchors posterior to the biceps root
. Using bioabsorbable anchors instead of metallic anchors
. Inadequate debridement of the superior glenoid rim

Correct Answer & Explanation

. Over-tensioning the repair by capturing the biceps anchor too tightly

Explanation

Postoperative stiffness, particularly loss of external rotation, is the most common complication of SLAP repairs. It is frequently caused by over-tensioning the anterior-superior labrum or capturing the biceps anchor too tightly, essentially creating a functional capsulorrhaphy.

Question 2629

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female presents with worsening shoulder pain 5 years after undergoing a Reverse Total Shoulder Arthroplasty (RTSA). Radiographs show a radiolucent line under the inferior glenosphere baseplate with associated bone loss (Sirveaux Grade 3 scapular notching). Which surgical factor is most associated with this complication?

. Eccentric reaming of the superior glenoid
. Superior tilt and placement of the glenoid baseplate
. Inferior tilt of the glenoid baseplate
. Use of a lateralized humeral stem
. Repair of the subscapularis tendon

Correct Answer & Explanation

. Superior tilt and placement of the glenoid baseplate

Explanation

Scapular notching is a frequent complication in RTSA caused by mechanical impingement of the humeral component against the inferior scapular neck. Risk factors include superior tilt and superior placement of the glenoid baseplate, whereas inferior placement and tilt are protective.

Question 2630

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Physical examination reveals 25 degrees less internal rotation compared to his contralateral arm, but his total arc of motion is equal bilaterally. What is the most appropriate initial management?

. Arthroscopic anterior capsular release
. Posteroinferior capsular stretching program
. Arthroscopic SLAP repair
. Biceps tenodesis
. Subacromial decompression

Correct Answer & Explanation

. Posteroinferior capsular stretching program

Explanation

This presentation describes Glenohumeral Internal Rotation Deficit (GIRD) with a preserved total arc of motion. The initial and most effective treatment is a physical therapy program emphasizing posteroinferior capsular stretching (e.g., sleeper stretches).

Question 2631

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old female with known severe osteoporosis falls from a standing height. Radiographs reveal a highly displaced 4-part proximal humerus fracture with a head-split component. She is independent and medically fit for surgery. Which of the following treatments provides the most predictable functional outcome?

. Sling immobilization for 6 weeks
. Open reduction and internal fixation (ORIF) with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty (RTSA)
. Closed reduction and percutaneous pinning

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (RTSA)

Explanation

In elderly patients with osteoporotic bone and complex fractures (such as 4-part and head-split), RTSA provides more predictable pain relief and functional restoration than ORIF. Hemiarthroplasty outcomes are highly dependent on tuberosity healing, which is historically unreliable in this age group.

Question 2632

Topic: 9. Shoulder and Elbow

A 65-year-old man with primary glenohumeral osteoarthritis is indicated for an anatomic total shoulder arthroplasty. Preoperative CT imaging reveals a biconcave glenoid with 20 degrees of retroversion and asymmetric posterior wear. According to the Walch classification, which type of glenoid morphology is present?

. Type A1
. Type A2
. Type B1
. Type B2
. Type C

Correct Answer & Explanation

. Type B2

Explanation

A Walch B2 glenoid is characterized by a biconcave surface with posterior wear and retroversion. It often requires asymmetric reaming or bone grafting during anatomic total shoulder arthroplasty to correct the version.

Question 2633

Topic: Shoulder Pathology

A 25-year-old male presents with inability to elevate his right arm past 90 degrees and prominent medial winging of his right scapula, which is exacerbated when he pushes against a wall. He recalls a severe viral illness 3 weeks prior. Which nerve is most likely affected?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial scapular winging is caused by paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. Viral illness or acute brachial neuritis (Parsonage-Turner syndrome) is a common non-traumatic etiology.

Question 2634

Topic: 9. Shoulder and Elbow

Which of the following best describes the biomechanical alteration achieved by a Grammont-style reverse total shoulder arthroplasty compared to the native shoulder joint?

. The center of rotation is moved laterally and superiorly.
. The center of rotation is moved medially and inferiorly.
. The center of rotation remains unchanged.
. The center of rotation is moved medially and superiorly.
. The center of rotation is moved laterally and inferiorly.

Correct Answer & Explanation

. The center of rotation is moved medially and inferiorly.

Explanation

A reverse total shoulder arthroplasty medializes and inferiorizes the center of rotation. This dramatically increases the deltoid moment arm and tension, allowing it to elevate the arm in the absence of a functional rotator cuff.

Question 2635

Topic: 9. Shoulder and Elbow
During the 'freezing' phase of adhesive capsulitis, which of the following is the predominant histologic finding in the glenohumeral joint capsule?
. Fibroblastic proliferation and dense type III collagen deposition
. Capsular thinning with mucinous degeneration
. Chondrocyte hypertrophy and metaplasia
. Abundant macrophage infiltration with necrosis
. Avascular necrosis of the underlying labrum

Correct Answer & Explanation

. Fibroblastic proliferation and dense type III collagen deposition

Explanation

Adhesive capsulitis is characterized by dense fibroblastic proliferation and increased expression of cytokines leading to capsular fibrosis, particularly involving the coracohumeral ligament and rotator interval.

Question 2636

Topic: 9. Shoulder and Elbow

A 40-year-old female presents to the ER with excruciating, acute-onset right shoulder pain with no history of trauma. Radiographs reveal a fluffy, ill-defined calcific deposit in the supraspinatus tendon. The patient's intense pain is most characteristic of which phase of calcific tendinitis?

. Pre-calcific phase
. Formative phase
. Resorptive phase
. Post-calcific phase
. Resting phase

Correct Answer & Explanation

. Resorptive phase

Explanation

The resorptive phase of calcific tendinitis is intensely painful due to aggressive vascular infiltration, edema, and macrophage-mediated resorption of the calcium deposit under pressure.

Question 2637

Topic: 9. Shoulder and Elbow

A 75-year-old woman presents with severe shoulder pain and inability to actively elevate her arm past 40 degrees (pseudoparalysis). Radiographs reveal severe glenohumeral osteoarthritis, superior migration of the humeral head (Hamada Grade 3), and acetabularization of the coracoacromial arch. What is the gold standard surgical treatment?

. Shoulder hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic superior capsular reconstruction
. Latissimus dorsi tendon transfer

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for rotator cuff tear arthropathy with pseudoparalysis, as it relies on the deltoid muscle to restore active elevation.

Question 2638

Topic: 9. Shoulder and Elbow

A 45-year-old man develops severe, spontaneous right shoulder pain that lasts continuously for 2 weeks. As the pain finally begins to subside, he notices profound, painless weakness in his shoulder, specifically unable to abduct or externally rotate the arm. Examination reveals deltoid and periscapular atrophy. What is the most likely diagnosis?

. Cervical radiculopathy (C5-C6)
. Acute massive rotator cuff tear
. Parsonage-Turner syndrome
. Adhesive capsulitis
. Thoracic outlet syndrome

Correct Answer & Explanation

. Parsonage-Turner syndrome

Explanation

Parsonage-Turner syndrome (acute brachial neuritis) classically presents with severe, unprovoked shoulder pain lasting weeks, followed by painless muscle weakness and atrophy as the pain resolves.

Question 2639

Topic: 9. Shoulder and Elbow

What is the primary biomechanical advantage of the baseplate and glenosphere design in a standard reverse total shoulder arthroplasty?

. It medializes and distalizes the center of rotation, increasing the deltoid moment arm.
. It lateralizes and superiorizes the center of rotation, restoring native rotator cuff tension.
. It medializes the center of rotation while shifting the joint line superiorly.
. It lateralizes the center of rotation to increase the tension on the intact subscapularis.
. It maintains the anatomic center of rotation but limits glenohumeral translation.

Correct Answer & Explanation

. It medializes and distalizes the center of rotation, increasing the deltoid moment arm.

Explanation

Reverse total shoulder arthroplasty typically medializes and distalizes the center of rotation. This increases the moment arm and tension of the deltoid, allowing it to efficiently elevate the arm in the presence of a deficient rotator cuff.

Question 2640

Topic: 9. Shoulder and Elbow

A 68-year-old man presents with severe shoulder pain and restricted motion due to primary osteoarthritis. Axial CT imaging reveals a biconcave glenoid with 22 degrees of retroversion and asymmetric posterior wear. The humeral head is subluxated posteriorly. According to the Walch classification, which type of glenoid morphology does this represent?

. Type A1
. Type A2
. Type B1
. Type B2
. Type C

Correct Answer & Explanation

. Type B2

Explanation

The Walch B2 classification characterizes a glenoid with a biconcave surface, asymmetric posterior wear, and posterior subluxation of the humeral head. It is a critical finding that dictates specific glenoid management during shoulder arthroplasty.

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