Menu

9. Shoulder and Elbow MCQs

Practice Set 14 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 261

Topic: Shoulder Pathology

Weakness is not seen with root avulsion in the:

. Rhomboids
. Serratus anterior
. Supraspinatus
. Trapezius
. Infraspinatus

Correct Answer & Explanation

. Trapezius

Explanation

The trapezius is innervated by spinal accessory nerve and thus will not be involved in a brachial plexus lesion. In the case of a preganglionic lesion, all muscles innervated by the nerve roots will be affected.

Question 262

Topic: Shoulder Pathology

The thoracic outlet syndrome is characterized by:

. The invariable presence of abnormal congenital structures such as cervical ribs or costovertebral synestosis
. Proximal compression of upper extremity neurologic and vascular structures at one of multiple
. A high incidence of vascular symptoms and a low incidence of neurological symptoms
. C ompression of the subclavian vein between the anterior and middle scalene muscles
. A frequently identifiable traumatic precipitant.

Correct Answer & Explanation

. Proximal compression of upper extremity neurologic and vascular structures at one of multiple

Explanation

The thoracic outlet syndrome is a compressive neurovascular disorder of the upper extremity with many possible sites of entrapment. Abnormal congenital structures, macro-, and micro-trauma have all been implicated as possible mechanisms for the process, though none of these factors is an absolute requisite for the disorder. Neurologic symptoms are more common than vascular complaints. The subclavian vein passes anterior to the interscalene interval which contains the subclavian artery and the brachial plexus.C orrect Answer: Proximal compression of upper extremity neurologic and vascular structures at one of multiple

Question 263

Topic: 9. Shoulder and Elbow

Primary treatment of thoracic outlet syndrome should include:

. First rib resection with scalenectomy
. C laviculectomy
. Psychiatric evaluation
. Activity modification and shoulder girdle strengthening
. First rib resection without scalenectomy

Correct Answer & Explanation

. Activity modification and shoulder girdle strengthening

Explanation

Initial treatment of thoracic outlet syndrome is non-operative. Aggravating activities are modified and shoulder girdle strengthening is initiated. Surgery is considered for patients who have failed conservative therapy and suffer intractable pain, and for those who have significant neurologic or vascular deficits. Operative procedures must be tailored to the presumed pathological anatomy; there is no single best procedure.

Question 264

Topic: Shoulder Pathology

Weakness of which of the following muscles is not seen with root avulsion:

. Rhomboids
. Serratus anterior
. Supraspinatus
. Trapezius

Correct Answer & Explanation

. Trapezius

Explanation

Trapezius is innervated by spinal accessory nerve and thus will not be involved in a brachial plexus lesion. In the case of a preganglionic lesion, ALL muscles innervated by the nerve roots will be affected.

Question 265

Topic: 9. Shoulder and Elbow
A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder X-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram. Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of the axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to swing his elbow into flexion. The diagnosis of the boy's condition is:
. Brachial plexus neuropraxia
. Erb's palsy
. Brachial plexus neuritis
. C5, C6 disk herniations

Correct Answer & Explanation

. Erb's palsy

Explanation

The muscles involved have C5, C6 root innervations. There are multiple findings that rule out a preganglionic lesion: positive Tinel sign, functioning rhomboids and serratus anterior, absent Horner syndrome. The electromyogram finding confirms the clinical finding (it does not show subclinical involvement of any other muscle). Neuropraxia usually resolves in 6 weeks and EMG shows fibrillation, both of which are inconsistent with neuropraxia. Brachial plexus neuritis (Parsonage-Turner syndrome) has an acute presentation following a painful episode involving the whole arm. There is significant history of fall from an all-terrain vehicle in this case.

Question 266

Topic: 9. Shoulder and Elbow

A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder x-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram. Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to swing his elbow into flexion. What is the level of lesion:

. Postganglionic C 5, C 6
. Preganglionic C 5, C 6
. Posterior cord injury
. Middle trunk

Correct Answer & Explanation

. Postganglionic C 5, C 6

Explanation

The muscles involved have C 5, C 6 root innervations. There are multiple findings that rule out a preganglionic lesion: positive Tinel sign, functioning rhomboids and serratus anterior, absent Horner syndrome. The electromyogram finding confirms the clinical finding (it does not show subclinical involvement of any other muscle). Neuropraxia usually resolves in 6 weeks and EMG shows fibrillation, which is inconsistent with neuropraxia. Brachial plexus neuritis (Parsonage-Turner syndrome) has an acute presentation following a painful episode involving the whole arm. There is significant history of fall from an all terrain vehicle in this case.

Question 267

Topic: 9. Shoulder and Elbow
A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder X-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram. Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of the axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to swing his elbow into flexion. What will be the most important indication for an early exploration in this case?
. Absence of biceps function at 3 months
. Absence of biceps function with return of extensor carpi radialis longus (ECRL) power at 4 months
. Presence of trick movements
. Subluxation of humeral head on X-ray

Correct Answer & Explanation

. Absence of biceps function with return of extensor carpi radialis longus (ECRL) power at 4 months

Explanation

An important indication for early exploration is recovery of a distally supplied muscle (ECRL - C6) in the absence of a proximally supplied muscle (biceps - C5). Trick movements are adaptive movements employed by the patient by recruiting other muscles (use of flexor-pronator as elbow flexors in this patient). Bony deformity is a late sequela and biceps recovery at 3 months is important in obstetric brachial palsy.

Question 268

Topic: 9. Shoulder and Elbow
A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder X-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram. Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of the axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to swing his elbow into flexion. The most important function that needs to be restored in this boy is:
. Shoulder abduction
. Shoulder elevation
. Elbow flexion
. Wrist extension

Correct Answer & Explanation

. Elbow flexion

Explanation

Elbow flexion is central to management of brachial plexus management because it serves the most important function of feeding.

Question 269

Topic: Elbow & Forearm

A 65-year-old female undergoes volar locked plating for a distal radius fracture. During the procedure, the surgeon places a screw in the most ulnar hole of the distal row of the plate. Which tendon is at the highest risk of injury from this specific screw if it penetrates the dorsal cortex?

. Extensor pollicis longus (EPL)
. Extensor carpi radialis brevis (ECRB)
. Extensor digiti minimi (EDM)
. Extensor indicis proprius (EIP)
. Extensor carpi ulnaris (ECU)

Correct Answer & Explanation

. Extensor digiti minimi (EDM)

Explanation

A dorsal prominent screw in the most ulnar hole of the distal row of a volar plate puts the extensor digiti minimi (EDM) tendon at risk within the 5th extensor compartment. The EPL is typically at risk from screws in the 3rd compartment, such as those near the Lister tubercle.

Question 270

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female presents with chronic shoulder pain and pseudoparalysis. Radiographs show superior migration of the humeral head and an acromiohumeral interval of 3 mm. Which treatment provides the best predictable outcomes for this specific condition?

. Arthroscopic rotator cuff repair
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

The patient has rotator cuff tear arthropathy. Reverse total shoulder arthroplasty (RTSA) is the treatment of choice because it establishes a stable center of rotation, allowing the deltoid muscle to efficiently elevate the arm.

Question 271

Topic: 9. Shoulder and Elbow

A 65-year-old man presents with chronic shoulder pain and pseudoparalysis. MRI reveals a massive, retracted tear of the supraspinatus and infraspinatus tendons with severe fatty infiltration (Goutallier stage 4). What is the most appropriate surgical treatment?

. Arthroscopic rotator cuff repair
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty
. Subacromial decompression alone

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In an older patient with an irreparable rotator cuff tear (indicated by Goutallier stage 4 fatty infiltration) and pseudoparalysis, a reverse total shoulder arthroplasty reliably provides pain relief and restores function.

Question 272

Topic: 9. Shoulder and Elbow

A 30-year-old male undergoes successful open reduction and internal fixation of a midshaft humerus fracture with a locking compression plate. The fixation is deemed stable intraoperatively. According to the post-operative rehabilitation protocols outlined in the case, what is the MOST appropriate initial approach to rehabilitation in the immediate post-operative phase (first 1-2 weeks)?

. Complete immobilization in a cast for 6 weeks to ensure fracture stability.
. Initiate immediate full active range of motion (ROM) for the shoulder and elbow to prevent stiffness.
. A sling for comfort and protection, with early gentle active-assisted and passive ROM for the shoulder and elbow, avoiding heavy lifting.
. Aggressive isometric strengthening exercises for the deltoid and biceps muscles.
. No weight-bearing or lifting, but unrestricted active rotation of the shoulder and elbow.

Correct Answer & Explanation

. A sling for comfort and protection, with early gentle active-assisted and passive ROM for the shoulder and elbow, avoiding heavy lifting.

Explanation

Correct Answer: CThe case material states under 'Immediate Post-Operative Phase': "Immobilization:Initially, a sling or shoulder immobilizer for comfort and protection, especially for the first 1-2 weeks. For highly stable fixation (e.g., well-locked plate, IM nail with good purchase), early gentle active-assisted and passive ROM can begin within days." It also specifies: "Weight-Bearing:No weight-bearing or lifting with the affected arm." This aligns perfectly with Option C.Option A (Complete immobilization in a cast for 6 weeks)is incorrect. While immobilization is initially used, prolonged casting is generally avoided after stable operative fixation to prevent joint stiffness, especially in the humerus where early motion is encouraged.Option B (Initiate immediate full active range of motion)is incorrect. While early motion is encouraged, 'full active ROM' immediately post-op is too aggressive and could jeopardize the healing fracture or fixation. It should be gentle and active-assisted/passive initially.Option D (Aggressive isometric strengthening exercises)is incorrect. Isometric strengthening is introduced in the 'Early Healing and Strengthening Phase,' not immediately post-op. Aggressive exercises could disrupt the healing process.Option E (Unrestricted active rotation)is incorrect. While early ROM is encouraged, 'unrestricted active rotation' is too aggressive, especially for the shoulder, and the case specifically advises: "Caution is advised with rotation, especially in early IM nailing where rotational stability may be limited." Even with plate fixation, unrestricted active rotation is not typically allowed immediately.

Question 273

Topic: Elbow & Forearm

A 38-year-old construction worker sustains a Bado Type II Monteggia fracture-dislocation after a fall from a height. During surgical planning, the orthopedic surgeon reviews the relevant anatomy. Which of the following structures is considered the primary stabilizer of the radial head within the radial notch of the ulna?

. Medial Collateral Ligament (MCL)
. Lateral Ulnar Collateral Ligament (LUCL)
. Annular Ligament
. Interosseous Membrane (IOM)
. Biceps tendon

Correct Answer & Explanation

. Annular Ligament

Explanation

Correct Answer: CThe case explicitly states, 'The annular ligament is the primary stabilizer of the radial head within the radial notch of the ulna. It forms a fibrous ring encircling the radial head and neck, attaching to the anterior and posterior margins of the radial notch.' Its integrity is crucial for maintaining the proximal radioulnar joint (PRUJ) stability.Option A (Medial Collateral Ligament - MCL):The MCL provides valgus stability to the elbow and is not the primary stabilizer of the radial head within the radial notch.Option B (Lateral Ulnar Collateral Ligament - LUCL):The LUCL is part of the lateral collateral ligament complex and is critical for posterolateral rotatory stability of the elbow, but not the primary stabilizer of the radial head within the radial notch.Option D (Interosseous Membrane - IOM):The IOM connects the ulna and radius, transmitting axial loads and contributing to overall forearm stability, but it is not the primary direct stabilizer of the radial head within the radial notch.Option E (Biceps tendon):The biceps tendon primarily functions in elbow flexion and forearm supination. While it crosses the elbow joint, it does not directly stabilize the radial head within the radial notch.

Question 274

Topic: Elbow & Forearm

A 55-year-old female presents with a Bado Type I Monteggia fracture-dislocation. The surgical team is preparing for operative management. Based on the biomechanical principles outlined in the case, which of the following statements represents the cornerstone of successful treatment for this injury?

. Primary open reduction and repair of the annular ligament to stabilize the radial head.
. Achieving concentric reduction of the radial head first, followed by ulnar fixation.
. Anatomic reduction and rigid internal fixation of the ulna to restore forearm stability and facilitate spontaneous radial head reduction.
. Application of an external fixator to the elbow joint to maintain radial head reduction.
. Early aggressive range of motion exercises to prevent stiffness, even before definitive ulnar fixation.

Correct Answer & Explanation

. Anatomic reduction and rigid internal fixation of the ulna to restore forearm stability and facilitate spontaneous radial head reduction.

Explanation

Correct Answer: CThe case explicitly states, 'The key biomechanical principle in treating Monteggia injuries is that the ulna dictates the stability of the entire forearm and the radial head. Anatomic reduction and rigid internal fixation of the ulna are prerequisites for successful radial head reduction and maintaining its concentric alignment with the capitellum.' This principle is reiterated multiple times throughout the text, emphasizing that restoring the ulna's length, rotation, and alignment is paramount.Option A (Primary open reduction and repair of the annular ligament):While annular ligament repair may be necessary if the radial head remains unstable after ulnar fixation, it is not the primary cornerstone. The ulna's stability is the prerequisite.Option B (Achieving concentric reduction of the radial head first):This is incorrect. The radial head's position is dictated by the ulna. Attempting to reduce the radial head first without addressing the ulnar fracture will likely be unsuccessful or unstable.Option D (Application of an external fixator):While external fixation might be used temporarily in severe open fractures or for damage control, it is not the definitive treatment for adult Monteggia fracture-dislocations, which almost universally require open reduction and internal fixation (ORIF) of the ulna.Option E (Early aggressive range of motion exercises):Early motion is important post-operatively, but it must be controlled and initiatedafterstable fixation of the ulna and concentric reduction of the radial head. Aggressive motion before definitive fixation would destabilize the injury.

Question 275

Topic: Elbow & Forearm

A 40-year-old male undergoes open reduction and internal fixation for a Bado Type I Monteggia fracture-dislocation. The surgeon has successfully achieved anatomical reduction and rigid internal fixation of the ulnar fracture using a locking compression plate, as depicted in the provided image. What is the immediate next critical step in the surgical procedure, according to the case's detailed surgical technique?

. Perform a thorough neurovascular assessment of the limb.
. Initiate aggressive range of motion exercises for the elbow.
. Assess the radial head for spontaneous concentric reduction and stability under fluoroscopy.
. Proceed with layered wound closure and apply a splint.
. Directly repair the torn annular ligament.

Correct Answer & Explanation

. Assess the radial head for spontaneous concentric reduction and stability under fluoroscopy.

Explanation

Correct Answer: CThe case outlines the step-by-step surgical technique, stating under 'Radial Head Assessment': 'Once the ulna is rigidly fixed, the radial head should spontaneously reduce into its concentric position relative to the capitellum. Confirm with fluoroscopy in AP and lateral views, ensuring the radial head bisects the capitellum in all positions of elbow flexion and forearm rotation.' This is the immediate and critical next step after ulnar fixation.Option A (Perform a thorough neurovascular assessment):While a neurovascular assessment is crucial, it is typically performed at the end of the procedure (Final Stability Check) and also pre-operatively, but not as theimmediatenext step after ulnar fixation before confirming radial head reduction.Option B (Initiate aggressive range of motion exercises):This is incorrect. Early aggressive motion is contraindicated at this stage and could destabilize the repair. Controlled motion begins post-operatively during rehabilitation.Option D (Proceed with layered wound closure and apply a splint):Wound closure and splint application are final steps, performed only after all reductions and fixations are confirmed stable and neurovascular status is checked.Option E (Directly repair the torn annular ligament):Annular ligament repair is only indicated if the radial headdoes notspontaneously reduce or remains unstableafteranatomical ulnar fixation. It is not an automatic next step.

Question 276

Topic: Elbow & Forearm

A 32-year-old male undergoes ORIF for a Bado Type I Monteggia fracture-dislocation. Post-operatively, despite what the surgeon believes was rigid internal fixation of the ulna, fluoroscopy reveals persistent subluxation of the radial head. Based on the case, what is the most common reason for persistent radial head dislocation or subluxation after ulnar fixation, and what is the appropriate next step?

. An irreparable annular ligament tear; proceed with radial head replacement.
. Inadequate anatomical reduction or unstable fixation of the ulna; re-evaluate and revise ulnar fixation.
. Interposition of the biceps tendon; perform an open reduction of the radial head to clear the obstruction.
. Associated coronoid process fracture; fix the coronoid fracture.
. Posterior interosseous nerve impingement; perform neurolysis.

Correct Answer & Explanation

. Inadequate anatomical reduction or unstable fixation of the ulna; re-evaluate and revise ulnar fixation.

Explanation

Correct Answer: BThe case clearly states under 'Complications and Management' and 'Persistent Radial Head Dislocation/Subluxation': 'This is the most common and critical complication. It's almost always due to inadequate anatomical reduction or unstable fixation of the ulna (malreduction, malalignment, shortening, or rotation).' The management is to 're-establish anatomical reduction and rigid fixation of the ulna.'Option A (An irreparable annular ligament tear; proceed with radial head replacement):While an annular ligament tear can contribute to instability, it is rarely theprimaryreason for persistent dislocation if the ulna is anatomically reduced. Radial head replacement is generally discouraged in acute Monteggia for unreconstructible radial head fractures, and even less so for an isolated annular ligament issue.Option C (Interposition of the biceps tendon):While soft tissue interposition can occur, the case emphasizes that inadequate ulnar reduction is themost commonreason. If soft tissue interposition is suspected after optimal ulnar fixation, open reduction of the radial head would be performed, but the primary focus remains the ulna.Option D (Associated coronoid process fracture):Coronoid fractures can destabilize the elbow, but the most common reason for persistent radial head dislocation in a Monteggia is still inadequate ulnar reduction. If a coronoid fracture was significant enough to cause persistent instability, it should have been addressed during the initial fixation.Option E (Posterior interosseous nerve impingement):PIN impingement causes neurological symptoms (wrist drop) but does not directly cause persistent radial head dislocation. Neurolysis would be for nerve recovery, not joint stability.

Question 277

Topic: Elbow & Forearm

A 35-year-old male sustains a Monteggia fracture-dislocation with an associated severely comminuted radial head fracture that is deemed unreconstructible. The ulnar fracture has been anatomically reduced and rigidly fixed. Based on the current literature and guidelines discussed in the case, what is the generally discouraged approach for managing the unreconstructible radial head fracture in this acute setting, especially in a younger, active adult?

. Radial head arthroplasty to restore mechanical stability.
. Primary radial head excision.
. Open reduction of the radial head to clear any interposed soft tissue.
. Annular ligament reconstruction if the radial head remains unstable.
. Temporary K-wire stabilization of the radial head.

Correct Answer & Explanation

. Primary radial head excision.

Explanation

Correct Answer: BThe case states under 'Summary of Key Literature and Guidelines' and 'Radial Head Fractures': 'Unreconstructible radial head fractures in the context of an acute Monteggia are challenging. While historically radial head excision was considered, it is now generally discouraged in the acute setting due to the risk of severe valgus instability and proximal radial migration, especially in younger, active adults.'Option A (Radial head arthroplasty):The case mentions that 'Radial head arthroplasty may be considered in selected cases to restore mechanical stability, particularly in older patients with low demand, but its role inacuteMonteggia is not universally accepted compared to its use in terrible triad injuries.' While not universally accepted for acute Monteggia, it is a consideration for stability, unlike excision.Option C (Open reduction of the radial head to clear any interposed soft tissue):This is a necessary step if the radial head cannot be reduced, regardless of whether it's fractured or not, to clear obstructions. This is not discouraged.Option D (Annular ligament reconstruction):If the radial head remains unstable after ulnar fixation and any necessary radial head management, annular ligament reconstruction is a valid and often necessary step to maintain stability. This is not discouraged.Option E (Temporary K-wire stabilization):Temporary K-wire stabilization can be considered in highly unstable cases to maintain reduction, although it limits early motion. This is a recognized technique, not generally discouraged.

Question 278

Topic: 9. Shoulder and Elbow

A 28-year-old professional athlete undergoes ORIF of a displaced proximal humerus fracture via a deltopectoral approach. Post-operatively, he is placed in a sling. At the 3-week follow-up, he reports mild pain but is eager to begin aggressive rehabilitation. Based on the provided rehabilitation protocol, which of the following activities is most appropriate for this patient during the immediate post-operative phase (0-6 weeks)?

. A. Active shoulder abduction against light resistance with a Theraband.
. B. Active-assistive range of motion (AAROM) for shoulder flexion up to 150 degrees.
. C. Gentle passive external rotation of the shoulder to 0-30 degrees.
. D. Full active range of motion (AROM) exercises for the shoulder to prevent stiffness.
. E. Weight-bearing through the affected arm to promote early bone healing.

Correct Answer & Explanation

. C. Gentle passive external rotation of the shoulder to 0-30 degrees.

Explanation

Correct Answer: CThe case content, under 'Phase 1 Immediate Post-operative Phase 0-6 Weeks' for Proximal Humerus (Deltopectoral Approach), states: 'Passive Range of Motion (PROM): Pendulum exercises (gentle, gravity-assisted distraction and rotation), supine passive external rotation (to 0-30 degrees), passive forward flexion (up to 90-120 degrees depending on stability), passive internal rotation.' It also lists 'No active shoulder abduction or external rotation against resistance' as a precaution.Option A (Active shoulder abduction against light resistance with a Theraband):This is explicitly contraindicated in Phase 1. 'No active shoulder abduction or external rotation against resistance' is a precaution.Option B (Active-assistive range of motion (AAROM) for shoulder flexion up to 150 degrees):AAROM is typically initiated in Phase 2 (6-12 weeks). While PROM for flexion up to 90-120 degrees is allowed, 150 degrees is likely too aggressive for the immediate phase, and AAROM is not the primary focus yet.Option D (Full active range of motion (AROM) exercises for the shoulder to prevent stiffness):AROM is generally initiated in Phase 2. Phase 1 focuses on PROM to protect the healing fracture.Option E (Weight-bearing through the affected arm to promote early bone healing):This is explicitly contraindicated. 'No weight-bearing through the arm' is a precaution in Phase 1.

Question 279

Topic: Elbow & Forearm
A 30-year-old male presents with a complex elbow injury. Radiographs show a coronal shear fracture of the distal humerus that involves both the capitellum and a significant portion of the trochlea. According to the Bryan and Morrey classification (with McKee modification), what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV (McKee modification)
. Type V

Correct Answer & Explanation

. Type IV (McKee modification)

Explanation

A Type IV capitellum fracture (McKee modification to the Bryan-Morrey classification) describes a coronal shear fracture that extends medially to involve the majority of the trochlea. A Type I (Hahn-Steinthal) involves a large osseous piece of the capitellum without significant trochlear extension.

Question 280

Topic: Elbow & Forearm
A 29-year-old male presents with a Bado Type III Monteggia fracture-dislocation. Which of the following best describes the classical presentation of a Bado Type III injury?
. Anterior dislocation of the radial head with anterior angulation of the ulnar diaphysis
. Posterior dislocation of the radial head with posterior angulation of the ulnar diaphysis
. Lateral or anterolateral dislocation of the radial head with an ulnar metaphyseal fracture
. Anterior dislocation of the radial head with fractures of both the radius and ulna shafts
. Isolated dislocation of the radial head without an associated ulnar fracture

Correct Answer & Explanation

. Lateral or anterolateral dislocation of the radial head with an ulnar metaphyseal fracture

Explanation

A Bado Type III Monteggia fracture is characterized by a lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysis. This pattern is primarily seen in children and frequently presents with an associated posterior interosseous nerve (PIN) palsy.

Test Yourself

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

On this Page