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9. Shoulder and Elbow MCQs

Practice Set 143 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 2841

Topic: Shoulder Arthroplasty & Arthritis

In the design of a reverse total shoulder arthroplasty (rTSA), moving from a traditional Grammont-style medialized glenosphere to a lateralized glenosphere primarily aims to mitigate which of the following complications?

. Acromial stress fracture
. Glenoid component loosening
. Scapular notching
. Instability
. Deltoid fatigue

Correct Answer & Explanation

. Scapular notching

Explanation

A lateralized glenosphere in rTSA increases the lateral offset, thereby decreasing the risk of inferior scapular notching caused by the humeral component impacting the scapular neck. However, lateralization may increase shear forces at the glenoid baseplate-bone interface.

Question 2842

Topic: Elbow & Forearm

A 45-year-old male sustains a 'terrible triad' injury of the elbow. During surgical reconstruction, what is the most widely accepted sequence of fixation to systematically restore elbow stability?

. LUCL repair, coronoid fixation, radial head fixation
. Radial head fixation, LUCL repair, coronoid fixation
. Coronoid fixation, radial head fixation or replacement, LUCL repair
. MUCL repair, radial head fixation, coronoid fixation
. Coronoid fixation, MUCL repair, radial head replacement

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad injury involves a deep-to-superficial approach: fixing the coronoid first (anterior stability), addressing the radial head (lateral column), and finally repairing the lateral ulnar collateral ligament (LUCL) to restore posterolateral stability.

Question 2843

Topic: Elbow & Forearm

A 38-year-old bodybuilder undergoes a two-incision distal biceps tendon repair. Which of the following complications is significantly more common with this technique compared to a single anterior incision approach?

. Lateral antebrachial cutaneous nerve neuropraxia
. Posterior interosseous nerve palsy
. Heterotopic ossification resulting in radioulnar synostosis
. Rerupture of the distal biceps tendon
. Brachial artery pseudoaneurysm

Correct Answer & Explanation

. Heterotopic ossification resulting in radioulnar synostosis

Explanation

The two-incision technique for distal biceps repair is associated with a higher risk of heterotopic ossification and radioulnar synostosis due to subperiosteal dissection along the ulna. Conversely, the single-incision approach carries a higher risk of lateral antebrachial cutaneous nerve and PIN injuries.

Question 2844

Topic: 9. Shoulder and Elbow

A 45-year-old male sustains a "terrible triad" injury to his elbow. Intraoperatively, after fixation of the radial head and repair of the lateral ulnar collateral ligament (LUCL), the elbow remains persistently subluxated posteriorly at 30 degrees of extension. What is the most appropriate next step in management?

. Application of a hinged external fixator
. Repair of the medial collateral ligament (MCL)
. Resection of the radial head prosthesis
. Release of the extensor origin
. Transarticular pinning in 90 degrees of flexion

Correct Answer & Explanation

. Repair of the medial collateral ligament (MCL)

Explanation

In a terrible triad injury, if the elbow remains unstable after addressing the coronoid, radial head, and LUCL, the MCL should be repaired to restore medial column stability. Hinged external fixation is generally reserved for cases where instability persists despite repair of all essential osseous and ligamentous stabilizers.

Question 2845

Topic: 9. Shoulder and Elbow

A 68-year-old male returns to the clinic 6 weeks after undergoing an anatomic total shoulder arthroplasty (aTSA). He reports a sudden pop and increased pain after reaching for a door handle. On physical examination, he has an increase in passive external rotation compared to his contralateral shoulder and profound weakness with the belly-press test. Which of the following is the most likely cause of his symptoms?

. Glenoid component loosening
. Subscapularis tendon failure
. Axillary nerve neurapraxia
. Anterior glenohumeral dislocation
. Coracoid impingement

Correct Answer & Explanation

. Subscapularis tendon failure

Explanation

Subscapularis failure after an aTSA classically presents with a sudden "pop", weakness in internal rotation (positive belly-press/lift-off tests), and increased passive external rotation. It is a severe complication that compromises anterior stability, often necessitating surgical repair or revision to a reverse total shoulder arthroplasty.

Question 2846

Topic: Elbow & Forearm

A surgeon performs a distal biceps tendon repair using a single anterior incision technique. Postoperatively, the patient lacks active MCP joint extension of the fingers and thumb, but wrist extension is preserved with radial deviation. Injury to a nerve during which specific maneuver is the most likely cause?

. Excessive medial retraction against the pronator teres
. Traction on the lateral antebrachial cutaneous nerve
. Plunging the drill through the posterior cortex of the radius
. Dissection superficial to the bicipital aponeurosis
. Splitting the extensor digitorum communis

Correct Answer & Explanation

. Plunging the drill through the posterior cortex of the radius

Explanation

The Posterior Interosseous Nerve (PIN) is at high risk of injury during single-incision distal biceps repairs, particularly when drilling the posterior radius for suspensory cortical button fixation. The PIN wraps around the radial neck within the supinator and can be directly transected by an over-penetrating drill bit.

Question 2847

Topic: Shoulder Pathology

A 35-year-old female presents with shoulder pain, resting downward rotation, and lateral translation of the scapula. The deformity is accentuated by resisted abduction. She underwent a right posterior triangle cervical lymph node biopsy 3 months ago. Which nerve was most likely injured?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Spinal accessory nerve injury denervates the trapezius muscle, leading to lateral scapular winging characterized by downward rotation and lateral translation. This typically occurs iatrogenically after surgical procedures in the posterior triangle of the neck.

Question 2848

Topic: 9. Shoulder and Elbow

A patient presents with a chronic, unreduced posterior shoulder dislocation. What is the MOST likely clinical presentation?

. Arm held in abduction and external rotation with anterior prominence
. Arm held in adduction and internal rotation with significant external rotation block
. Inferior displacement of the humeral head with a prominent acromion
. Pain and instability primarily with overhead activities
. Significant atrophy of the deltoid muscle

Correct Answer & Explanation

. Arm held in adduction and internal rotation with significant external rotation block

Explanation

A chronic posterior shoulder dislocation will maintain the classic position of the acute injury: the arm held in adduction and internal rotation, with a profound block to external rotation. The anterior shoulder will appear flattened, and the coracoid process will be prominent. Option A describes an anterior dislocation. Option C describes an inferior dislocation. Options D and E are less specific to the characteristic presentation of a chronic posterior dislocation.

Question 2849

Topic: 9. Shoulder and Elbow

During your physical exam for shoulder instability, you elicit a positive 'Jerk Test.' What type of instability does this typically indicate?

. Anterior glenohumeral instability
. Inferior glenohumeral instability
. Multidirectional glenohumeral instability
. Posterior glenohumeral instability
. Acromioclavicular joint instability

Correct Answer & Explanation

. Posterior glenohumeral instability

Explanation

The Jerk Test is specifically designed to assess posterior glenohumeral instability. It involves axially loading the arm, which is abducted to 90 degrees and internally rotated, then horizontally adducting the arm across the body. A sudden 'jerk' or clunk as the humeral head subluxates posteriorly over the glenoid rim indicates a positive test. The test may be accompanied by apprehension or pain.

Question 2850

Topic: Shoulder Pathology

Which of the following is the MOST common nerve injury associated with an anterior shoulder dislocation?

. Radial nerve
. Ulnar nerve
. Median nerve
. Axillary nerve
. Long thoracic nerve

Correct Answer & Explanation

. Axillary nerve

Explanation

The axillary nerve is the most commonly injured nerve in anterior shoulder dislocations, occurring in up to 30% of cases, especially in older patients. This is due to its course around the surgical neck of the humerus, making it susceptible to stretch or contusion during dislocation. The radial, ulnar, and median nerves are less commonly affected. The long thoracic nerve is associated with scapular winging but not typically direct dislocation.

Question 2851

Topic: 9. Shoulder and Elbow

Which of the following describes the position of the arm in a typical anterior shoulder dislocation?

. Adducted and internally rotated
. Abducted and externally rotated
. Adducted and externally rotated
. Abducted and internally rotated
. Neutral rotation in resting position

Correct Answer & Explanation

. Abducted and externally rotated

Explanation

In a typical anterior shoulder dislocation, the humeral head rests anteriorly and inferiorly to the glenoid. The arm is consequently held in a position of slight abduction and external rotation, as attempts to internally rotate or adduct the arm cause significant pain and resistance. This is the hallmark clinical presentation.

Question 2852

Topic: 9. Shoulder and Elbow

A patient reports a 'dead arm' sensation and transient weakness after a forceful abduction-external rotation injury to the shoulder. This symptom complex is most suggestive of:

. Rotator cuff impingement
. Acute brachial plexopathy
. Glenohumeral ligament sprain
. Acromioclavicular joint sprain
. Cervical radiculopathy

Correct Answer & Explanation

. Acute brachial plexopathy

Explanation

The 'dead arm' syndrome, characterized by transient numbness, tingling, and weakness after a high-energy injury in abduction and external rotation, is a classic presentation of a transient brachial plexopathy or neurapraxia, often seen with shoulder subluxation or dislocation. It implies transient stretch injury to the brachial plexus. While other injuries may cause pain, the 'dead arm' sensation is distinctively neurological.

Question 2853

Topic: 9. Shoulder and Elbow

Which of the following historical elements is MOST indicative of a posterior shoulder dislocation?

. Fall on an outstretched arm with abduction and external rotation
. Direct blow to the anterior shoulder, or seizure/electrocution
. Traction injury to the arm, causing inferior displacement
. Repetitive overhead throwing activities
. Insidious onset of pain and stiffness

Correct Answer & Explanation

. Direct blow to the anterior shoulder, or seizure/electrocution

Explanation

Posterior shoulder dislocations are often caused by direct trauma to the anterior shoulder, forcing the humeral head posteriorly, or by violent muscle contractions as seen in seizures or electrocution. Anterior dislocations typically result from falls on an outstretched arm with abduction/external rotation. Luxatio Erecta results from traction. Repetitive overhead activities are linked to overuse injuries or anterior instability. Insidious onset suggests degenerative conditions.

Question 2854

Topic: 9. Shoulder and Elbow

A patient with a dislocated shoulder is noted to have significant ecchymosis extending down the arm, and the skin appears stretched and tense. Which imaging modality is indicated NEXT if routine radiographs confirm dislocation but you suspect a severe soft tissue injury or vascular compromise?

. MRI of the shoulder
. Ultrasound of the shoulder
. CT angiogram
. Plain CT scan of the shoulder
. Nerve conduction studies

Correct Answer & Explanation

. CT angiogram

Explanation

Significant ecchymosis and tense skin, especially with an abnormal pulse exam (though not specified here, it's implied by 'vascular compromise'), demand immediate investigation for vascular injury. A CT angiogram is the most appropriate imaging study to evaluate the integrity of the axillary or brachial artery quickly and accurately in an acute setting. MRI and plain CT are better for soft tissue/bone detail but not for urgent vascular assessment. Ultrasound can be used but CTA is more definitive in this setting. Nerve conduction studies are for chronic nerve assessment, not acute vascular emergency.

Question 2855

Topic: 9. Shoulder and Elbow

What physical exam finding is MOST characteristic of a traumatic posterior shoulder dislocation?

. A prominent anterior deltoid contour
. Inability to internally rotate the arm
. Loss of the normal rounded contour of the posterior shoulder
. Arm held in abduction and external rotation
. Restricted external rotation with the arm held in internal rotation

Correct Answer & Explanation

. Restricted external rotation with the arm held in internal rotation

Explanation

Traumatic posterior shoulder dislocations classically present with the arm held in adduction and internal rotation, with a hallmark inability to externally rotate the shoulder beyond neutral. The anterior shoulder may appear flattened, and the coracoid prominent. Option A is characteristic of anterior dislocation. Option B is incorrect. Option C is less specific than restricted external rotation. Option D is characteristic of anterior dislocation.

Question 2856

Topic: 9. Shoulder and Elbow

Which finding during a physical exam for shoulder instability suggests generalized ligamentous laxity?

. A positive O'Brien's test
. A positive Speed's test
. Elbow hyperextension beyond 10 degrees and thumb-to-forearm apposition
. Pain with passive external rotation and abduction
. Scapular winging

Correct Answer & Explanation

. Elbow hyperextension beyond 10 degrees and thumb-to-forearm apposition

Explanation

Generalized ligamentous laxity is often assessed using criteria like the Beighton score. Specific signs include elbow hyperextension (>10 degrees), knee hyperextension (>10 degrees), thumb-to-forearm apposition, and excessive spinal or wrist flexibility. O'Brien's and Speed's tests are for labral and biceps pathology respectively. Pain with passive ER/Abduction is for anterior instability. Scapular winging indicates long thoracic nerve or serratus anterior weakness.

Question 2857

Topic: 9. Shoulder and Elbow

What is the expected physical exam finding for a patient with a 'Luxatio Erecta' dislocation?

. Arm held in adduction and internal rotation, unable to externally rotate
. Arm held in abduction and external rotation, anterior prominence
. Arm held in sustained abduction, elbow flexed, humeral head palpable in the axilla
. Arm held in internal rotation, flattened posterior shoulder
. Significant pain with resisted shoulder flexion

Correct Answer & Explanation

. Arm held in sustained abduction, elbow flexed, humeral head palpable in the axilla

Explanation

Luxatio Erecta is an inferior dislocation where the arm is held in sustained and forceful abduction, often with the elbow flexed and hand behind the head. The humeral head is typically palpable in the axilla. Options A and D describe posterior dislocations. Option B describes anterior dislocation. Option E is non-specific.

Question 2858

Topic: 9. Shoulder and Elbow

Which of the following describes the correct interpretation of a 'positive' O'Brien's Test for a SLAP lesion?

. Pain with the thumb down (internal rotation) that is relieved with the thumb up (external rotation) during resisted flexion
. Pain with the thumb up (external rotation) that is relieved with the thumb down (internal rotation) during resisted flexion
. Pain with passive external rotation and abduction at 90 degrees
. Pain with resisted external rotation in neutral
. Pain with palpation over the AC joint

Correct Answer & Explanation

. Pain with the thumb down (internal rotation) that is relieved with the thumb up (external rotation) during resisted flexion

Explanation

O'Brien's Test (also known as the Active Compression Test) is performed with the patient's arm flexed to 90 degrees, adducted 10-15 degrees, and the elbow extended. The test is performed first with the thumb pointing down (internal rotation) and then with the palm up (external rotation), resisting downward force. A positive test for a SLAP lesion is pain felt deep within the shoulder during internal rotation (thumb down) that is decreased or abolished with external rotation (thumb up). This difference indicates labral pathology. Other options describe different tests or findings.

Question 2859

Topic: 9. Shoulder and Elbow
A patient presents with an acute, painful shoulder after a fall. On examination, the patient resists any movement and exhibits significant muscle spasm. Which is the most appropriate initial step in management before attempting reduction?
. Immediate surgical consultation
. Aggressive manipulation to overcome spasm
. Administration of adequate analgesia and muscle relaxation
. Application of a shoulder sling without further assessment
. Ordering an MRI to rule out associated injuries

Correct Answer & Explanation

. Administration of adequate analgesia and muscle relaxation

Explanation

In the acute setting, severe pain and muscle spasm make reduction difficult and potentially more traumatic. Administering adequate analgesia (e.g., opioids) and muscle relaxation (e.g., benzodiazepines) is crucial to facilitate a gentle, successful closed reduction and minimize patient distress and potential for iatrogenic injury. Immediate surgery is rarely needed for uncomplicated dislocations. Aggressive manipulation is contraindicated. A sling is for post-reduction. MRI is not an acute pre-reduction step unless neurovascular compromise is suspected and requires specific advanced imaging.

Question 2860

Topic: 9. Shoulder and Elbow

Which statement regarding shoulder dislocations in children is TRUE?

. Glenohumeral dislocations are the most common shoulder injury in children.
. Children rarely sustain associated fractures with shoulder dislocations.
. Physeal injuries (epiphyseal fractures) are more common than glenohumeral dislocations in younger children.
. Neurovascular injuries are almost never seen in pediatric shoulder dislocations.
. Recurrence rates are typically lower than in adults due to faster healing.

Correct Answer & Explanation

. Physeal injuries (epiphyseal fractures) are more common than glenohumeral dislocations in younger children.

Explanation

In younger children (pre-adolescent), physeal injuries (fractures through the growth plate of the proximal humerus) are much more common than true glenohumeral dislocations because the physis is weaker than the ligaments and capsule. True glenohumeral dislocations become more prevalent in adolescence. Recurrence rates in adolescents are often very high, similar to young adults. While less common than in adults, neurovascular injuries can occur.

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