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9. Shoulder and Elbow MCQs

Practice Set 136 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 2701

Topic: 9. Shoulder and Elbow

A 25-year-old male trauma patient presents with massive swelling of the left shoulder girdle, absent radial pulse, and complete flaccidity of the left arm. Chest radiograph reveals marked lateral displacement of the scapula. What is this syndrome, and what specific injury dictates the long-term functional prognosis of the limb?

. Traumatic shoulder dislocation; axillary nerve injury
. Floating shoulder; suprascapular nerve injury
. Scapulothoracic dissociation; brachial plexus injury
. Thoracic outlet syndrome; subclavian artery thrombosis
. Sternoclavicular dislocation; recurrent laryngeal nerve injury

Correct Answer & Explanation

. Scapulothoracic dissociation; brachial plexus injury

Explanation

This is scapulothoracic dissociation, characterized by lateral displacement of the scapula and massive trauma to the shoulder girdle. It is highly associated with subclavian vascular injuries and severe, often complete, brachial plexus avulsions, which ultimately dictate the poor functional prognosis.

Question 2702

Topic: Elbow & Forearm

A 45-year-old woman falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. What is the recommended surgical sequence for reconstructing this injury?

. Radial head, coronoid, lateral collateral ligament (LCL)
. Coronoid, radial head, LCL
. LCL, radial head, coronoid
. Radial head, LCL, coronoid
. Coronoid, LCL, radial head

Correct Answer & Explanation

. Coronoid, radial head, LCL

Explanation

The standard surgical algorithm for terrible triad injuries follows a deep-to-superficial approach. The surgeon should first fix the coronoid, then repair or replace the radial head, and finally reconstruct the lateral ulnar collateral ligament (LUCL/LCL complex).

Question 2703

Topic: 9. Shoulder and Elbow

A 40-year-old man presents with a terrible triad injury of the elbow. During surgical reconstruction, what is the most widely accepted sequence of structural repair to restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad injury follows a deep-to-superficial approach. The coronoid is fixed first, followed by the radial head (fixation or arthroplasty), and finally the lateral collateral ligament (LCL) complex is repaired.

Question 2704

Topic: Elbow & Forearm

A 40-year-old man falls from a height, sustaining a "terrible triad" injury of the elbow. What is the generally recommended sequence of surgical reconstruction to restore stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical protocol for a terrible triad injury proceeds from deep to superficial and medial to lateral. The sequence is typically coronoid fixation, followed by radial head fixation or arthroplasty, and finally lateral collateral ligament (LCL) repair.

Question 2705

Topic: 9. Shoulder and Elbow

A 60-year-old man presents with hand clumsiness and frequent falls. On physical exam, tapping the distal brachioradialis tendon results in spontaneous finger flexion without elbow flexion. This reflex finding localizes the primary pathology to which spinal cord level?

. C3-C4
. C4-C5
. C5-C6
. C6-C7
. C7-T1

Correct Answer & Explanation

. C5-C6

Explanation

The inverted brachioradialis reflex is characterized by finger flexion without normal elbow flexion. This finding indicates a lower motor neuron lesion at the C5 or C6 level and an upper motor neuron lesion below this level.

Question 2706

Topic: Shoulder Pathology

A 28-year-old weightlifter presents with right shoulder pain and weakness. On physical examination, the inferior angle of the right scapula is translated laterally and superiorly when the patient pushes against a wall. Which of the following nerves is most likely injured?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Lateral scapular winging is caused by trapezius muscle paralysis resulting from a spinal accessory nerve injury. Medial winging is caused by serratus anterior paralysis due to a long thoracic nerve injury.

Question 2707

Topic: 9. Shoulder and Elbow

A 72-year-old woman with a history of a massive, retracted, irreparable rotator cuff tear presents with worsening shoulder pain and an inability to actively elevate her arm past 40 degrees. Her passive elevation is 150 degrees. Radiographs show superior migration of the humeral head with an acromiohumeral distance of 3 mm. What is the most reliable surgical option?

. Arthroscopic superior capsule reconstruction
. Latissimus dorsi tendon transfer
. Lower trapezius transfer
. Reverse total shoulder arthroplasty
. Hemiarthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is the most reliable and effective treatment for elderly patients with pseudoparalysis and rotator cuff tear arthropathy. Biologic reconstructions and tendon transfers have high failure rates in this demographic.

Question 2708

Topic: 9. Shoulder and Elbow

A 68-year-old man who underwent an anatomic total shoulder arthroplasty 6 weeks ago reports sudden onset of anterior shoulder pain and increased weakness after reaching for a heavy door. On examination, he has increased passive external rotation and a positive bear-hug test.

Radiographs are unremarkable. What is the most likely diagnosis?

. Prosthetic joint infection
. Glenoid component loosening
. Subscapularis tendon rupture
. Axillary nerve palsy
. Anterior dislocation

Correct Answer & Explanation

. Subscapularis tendon rupture

Explanation

Sudden pain, increased passive external rotation, and weakness in internal rotation (positive bear-hug test) in the early postoperative period after TSA are classic signs of subscapularis failure. This requires prompt diagnostic imaging and likely surgical repair.

Question 2709

Topic: 9. Shoulder and Elbow

A 55-year-old man presents with severe glenohumeral osteoarthritis. CT scan shows a Walch type B2 glenoid with 20 degrees of retroversion and posterior humeral head subluxation. What is the most appropriate strategy for addressing the glenoid deformity if an anatomic total shoulder arthroplasty is planned?

. Eccentric anterior reaming to neutralize version entirely
. Concentric reaming to native version only
. Asymmetric reaming to correct version up to 10 degrees, utilizing an augmented glenoid component or bone graft for the remainder
. Implantation of a standard component in 20 degrees of retroversion
. Reverse total shoulder arthroplasty

Correct Answer & Explanation

. Asymmetric reaming to correct version up to 10 degrees, utilizing an augmented glenoid component or bone graft for the remainder

Explanation

For a B2 glenoid with >15 degrees of retroversion, excessive asymmetric reaming removes critical subchondral bone, increasing the risk of component subsidence. The preferred strategy is partial correction (up to 10 degrees) paired with a posteriorly augmented component or bone graft.

Question 2710

Topic: 9. Shoulder and Elbow

A 22-year-old collegiate baseball pitcher presents with vague posterior right shoulder pain. Physical examination reveals glenohumeral internal rotation of 25 degrees and external rotation of 135 degrees on the right, compared to 65 degrees of internal rotation and 95 degrees of external rotation on the left. Radiographs are normal. What is the most appropriate initial management?

. Arthroscopic posterior capsular release
. Arthroscopic superior labral repair
. Physical therapy focusing on posterior capsular stretching
. Physical therapy focusing on anterior capsular stretching
. Corticosteroid injection into the subacromial space

Correct Answer & Explanation

. Physical therapy focusing on posterior capsular stretching

Explanation

This patient exhibits Glenohumeral Internal Rotation Deficit (GIRD). The initial treatment of choice is a dedicated physical therapy program focusing on posteroinferior capsular stretching, such as the sleeper stretch.

Question 2711

Topic: Shoulder Arthroplasty & Arthritis

In reverse total shoulder arthroplasty (RTSA), changing the center of rotation alters the biomechanical advantage of the deltoid muscle. Which of the following best describes the kinematic changes associated with a Grammont-style RTSA design compared to the native shoulder?

. Lateralization and superior translation of the center of rotation
. Lateralization and inferior translation of the center of rotation
. Medialization and superior translation of the center of rotation
. Medialization and inferior translation of the center of rotation
. No change in the center of rotation, but an increase in the deltoid moment arm

Correct Answer & Explanation

. Medialization and inferior translation of the center of rotation

Explanation

The Grammont-style RTSA medializes and distalizes (inferiorly translates) the center of rotation. This increases the deltoid moment arm, recruiting more deltoid fibers to power forward elevation.

Question 2712

Topic: 9. Shoulder and Elbow

A 70-year-old woman presents with persistent shoulder pain 1 year after a reverse total shoulder arthroplasty.

Radiographs show inferior scapular notching. What is the most critical factor during baseplate implantation to minimize this complication?

. Superior tilt of the glenosphere
. Medialization of the glenosphere
. Inferior overhang of the glenosphere
. Use of a larger humeral tray
. Decreasing the neck-shaft angle of the humeral stem

Correct Answer & Explanation

. Inferior overhang of the glenosphere

Explanation

Inferior overhang of the glenosphere beyond the inferior glenoid rim and an inferior tilt help minimize scapular notching in reverse total shoulder arthroplasty. Medialization and superior tilt increase the risk of this complication.

Question 2713

Topic: Shoulder Pathology

A 24-year-old male presents with right shoulder pain and weakness after carrying a heavy backpack during a 3-week hike. On exam, he has medial scapular winging when pushing against a wall. Which of the following nerve-muscle combinations is affected?

. Spinal accessory nerve / Trapezius
. Long thoracic nerve / Serratus anterior
. Dorsal scapular nerve / Rhomboids
. Suprascapular nerve / Supraspinatus
. Axillary nerve / Deltoid

Correct Answer & Explanation

. Long thoracic nerve / Serratus anterior

Explanation

Medial scapular winging is caused by paralysis of the serratus anterior, which is innervated by the long thoracic nerve. Trapezius palsy secondary to spinal accessory nerve injury typically causes lateral winging.

Question 2714

Topic: 9. Shoulder and Elbow

Glenohumeral internal rotation deficit (GIRD) in overhead athletes is typically accompanied by which of the following capsular adaptations?

. Contracture of the anterior band of the inferior glenohumeral ligament
. Contracture of the posteroinferior capsule
. Contracture of the superior glenohumeral ligament
. Laxity of the coracohumeral ligament
. Contracture of the rotator interval

Correct Answer & Explanation

. Contracture of the posteroinferior capsule

Explanation

GIRD is associated with a contracture of the posteroinferior capsule, which alters glenohumeral kinematics by pushing the humeral head posterosuperiorly during cocking. This increases stress on the superior labrum and posterior cuff.

Question 2715

Topic: 9. Shoulder and Elbow
A 52-year-old woman with poorly controlled type 2 diabetes presents with progressive shoulder stiffness and pain. Physical exam shows restricted active and passive motion in all planes. Which of the following is the most consistent histological finding in the affected tissue?
. Proliferation of myofibroblasts and type III collagen
. Necrotizing granulomas
. Abundant polymorphonuclear leukocytes
. Amyloid deposition
. Cartilage metaplasia

Correct Answer & Explanation

. Proliferation of myofibroblasts and type III collagen

Explanation

Adhesive capsulitis (frozen shoulder) is characterized by fibroplasia. Histology demonstrates a dense proliferation of myofibroblasts and predominantly type III collagen deposition in the joint capsule, particularly at the rotator interval.

Question 2716

Topic: 9. Shoulder and Elbow

A 68-year-old man presents with vague shoulder pain 2 years after an anatomic total shoulder arthroplasty. Inflammatory markers (CRP, ESR) are normal, and aspiration yields no growth at 3 days. What is the most appropriate next step in diagnosing a potential Cutibacterium acnes infection?

. Perform a 99mTc bone scan
. Hold cultures for a minimum of 14 days
. Immediately revise the arthroplasty components
. Start empiric oral antibiotics for 6 weeks
. Perform a PET scan

Correct Answer & Explanation

. Hold cultures for a minimum of 14 days

Explanation

Cutibacterium acnes is an indolent, slow-growing anaerobic organism commonly responsible for late shoulder arthroplasty infections. Cultures must be held for at least 14 to 21 days to maximize detection yield.

Question 2717

Topic: Shoulder Pathology

A 35-year-old motorcyclist is involved in a high-speed collision.

He presents with a massive shoulder hematoma, absent radial pulse, and a completely flail extremity. Chest radiograph shows lateral displacement of the scapula. What is the most common neurologic injury associated with this condition?

. Isolated axillary nerve palsy
. Complete brachial plexus avulsion
. Isolated radial nerve palsy
. Long thoracic nerve palsy
. Spinal accessory nerve palsy

Correct Answer & Explanation

. Complete brachial plexus avulsion

Explanation

Scapulothoracic dissociation involves complete disruption of the scapulothoracic articulation. It is a high-energy trauma highly associated with devastating injuries, most commonly a complete brachial plexus avulsion and vascular disruption.

Question 2718

Topic: 9. Shoulder and Elbow

A 42-year-old man presents with sudden onset of severe, unrelenting right shoulder pain lasting for 2 weeks, followed by profound weakness in overhead elevation and external rotation as the pain subsides.

MRI of the shoulder is unremarkable. What is the most likely diagnosis?

. Acute rotator cuff tear
. Cervical radiculopathy
. Parsonage-Turner syndrome (idiopathic brachial neuritis)
. Quadrilateral space syndrome
. Suprascapular notch cyst

Correct Answer & Explanation

. Parsonage-Turner syndrome (idiopathic brachial neuritis)

Explanation

Parsonage-Turner syndrome typically presents with an acute phase of severe, debilitating shoulder pain. This is followed by a painless phase characterized by patchy weakness and profound atrophy of shoulder girdle muscles due to brachial neuritis.

Question 2719

Topic: Shoulder Pathology

A 26-year-old female presents with a painful clunking sensation at the superomedial angle of her scapula during arm elevation. Nonoperative management has failed. Which bony structure may need resection to relieve her symptoms?

. Coracoid process
. Acromion
. Superomedial angle of the scapula
. Inferior angle of the scapula
. Clavicle

Correct Answer & Explanation

. Superomedial angle of the scapula

Explanation

Snapping scapula syndrome often involves bursitis or bony abnormalities at the superomedial border of the scapula. If prolonged conservative treatment fails, partial resection of the superomedial angle provides significant relief.

Question 2720

Topic: Shoulder Arthroplasty & Arthritis

To minimize the risk of scapular notching following a reverse total shoulder arthroplasty (RTSA), how should the glenosphere component optimally be positioned on the baseplate?

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

Correct Answer & Explanation

. Inferior tilt and inferior translation

Explanation

Scapular notching in RTSA is caused by the humeral component impinging on the inferior scapular neck. Inferior tilt and inferior positioning (or eccentric offset) of the glenosphere move the center of rotation downward, reducing this mechanical impingement.

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