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 281
Topic: Elbow & Forearm
A 10-year-old boy presents with a Monteggia fracture equivalent consisting of an anterior radial head dislocation and plastic deformation of the ulna. Closed reduction under sedation fails to maintain the radial head. What is the most appropriate definitive management?
Correct Answer & Explanation
. Corrective osteotomy of the ulna to restore anatomic alignment, followed by radial head reduction
Explanation
In pediatric Monteggia injuries with ulnar plastic deformation, the radial head will not remain reduced if the ulnar bow is not corrected. Anatomic restoration of the ulnar length and alignment (often requiring an osteotomy) is the critical step to achieve and maintain spontaneous radial head reduction.
Question 282
Topic: 9. Shoulder and Elbow
A 6-year-old boy presents with a painful, swollen elbow after falling from monkey bars. Radiographs demonstrate an anterior dislocation of the radial head and plastic deformation of the ulnar shaft, consistent with a Bado Type I Monteggia variant. What is the most critical initial step in the surgical management of this injury?
Correct Answer & Explanation
. Ulnar osteotomy and restoration of ulnar length and alignment
Explanation
In pediatric Monteggia variants with plastic deformation of the ulna, the ulnar deformity must be anatomically corrected (often via osteotomy) to allow and maintain spontaneous reduction of the radial head.
Question 283
Topic: Elbow & Forearm
A 6-year-old child presents with elbow stiffness 5 months after an unrecognized upper extremity injury. Radiographs demonstrate a malunited proximal third ulnar diaphyseal fracture with persistent anterior dislocation of the radial head. What is the recommended surgical management?
Correct Answer & Explanation
. Ulnar osteotomy with open reduction of the radial head
Explanation
In pediatric patients with chronic missed Monteggia fractures, radial head excision is contraindicated. The standard treatment is an ulnar osteotomy (often with angulation/lengthening) to restore length, coupled with open reduction of the radial head and annular ligament reconstruction.
Question 284
Topic: Elbow & Forearm
A 6-year-old child presents with a Bado Type I Monteggia equivalent lesion featuring a plastic deformation of the ulna and an anterior radial head dislocation. What is the most appropriate initial management?
Correct Answer & Explanation
. Closed reduction of the radial head with application of corrective bending force to the ulna
Explanation
In pediatric Monteggia equivalents with ulnar plastic deformation, it is critical to correct the bowing of the ulna. Applying a corrective bending force to the ulna restores length and alignment, allowing the radial head to spontaneously reduce and remain stable.
Question 285
Topic: Elbow & Forearm
Which of the following physical examination tests is considered most accurate for intraoperative evaluation of syndesmotic instability following internal fixation of a lateral malleolus fracture?
Correct Answer & Explanation
. Cotton test (lateral hook test)
Explanation
The Cotton test (lateral pull on the fibula with a bone hook) is considered the most reliable intraoperative test for assessing syndesmotic instability after the fibula fracture has been provisionally or definitively fixed.
Question 286
Topic: Elbow & Forearm
A 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) vascularized bone graft is utilized for a scaphoid nonunion. Between which two tendons is this pedicle identified?
Correct Answer & Explanation
. Abductor pollicis longus and extensor pollicis brevis
Explanation
The 1,2 ICSRA lies on the surface of the extensor retinaculum between the first dorsal compartment (APL, EPB) and the second dorsal compartment (ECRL, ECRB).
Question 287
Topic: 9. Shoulder and Elbow
The same 29-year-old male presents with suspected pectoralis major muscle rupture. Radiographs of the shoulder were normal. What is the most appropriate next step in management?
Correct Answer & Explanation
. Magnetic resonance imaging (MRI)
Explanation
Correct Answer: CWhile pectoralis major muscle (PMM) injuries are primarily diagnosed clinically, Magnetic Resonance Imaging (MRI) is the imaging modality of choice to evaluate the extent and location of a PMM tendon injury. MRI provides excellent soft tissue detail, allowing for assessment of the tear type (partial vs. complete), location (musculotendinous junction, tendinous insertion, muscle belly), and degree of retraction, which is crucial for surgical planning. Ultrasound is a reasonable alternative, particularly to avoid surgical delay, but it is highly user-dependent and may not provide the comprehensive detail of an MRI. Computed tomography (CT) is not ideal for soft tissue evaluation. Further radiographic evaluation of the humerus or contralateral shoulder is unlikely to provide additional diagnostic information regarding the PMM injury, as initial radiographs of the injured shoulder were already obtained and are often normal in these cases, primarily looking for bony avulsions.
Question 288
Topic: 9. Shoulder and Elbow
After evaluating the MRI, the patient is diagnosed with a complete rupture of the pectoralis major tendon. He is a young, active patient. What is the recommended first step in management?
Correct Answer & Explanation
. Sling immobilization in adducted and internally rotated position, cold compression, analgesics, and plan for surgical repair in 4 to 8 weeks
Explanation
Correct Answer: AFor a young, active patient with a complete pectoralis major muscle (PMM) rupture, surgical repair is generally indicated to restore strength and function. However, immediate surgical intervention is not typically required. The first step in management, regardless of the definitive treatment plan, should be rest, ice, compression, and pain control (RICE). Sling immobilization in an adducted and internally rotated position helps to minimize tension on the torn tendon and prevent further retraction. While there is no absolute consensus on the ideal timing for repair, delaying surgery for 4 to 8 weeks allows for the acute swelling and ecchymosis to subside, which can facilitate surgical dissection and reduce complications. Options B and D risk further tendon retraction. Option C represents a nonoperative protocol, which is generally reserved for elderly or low-demand patients, or partial/muscle belly ruptures. Option E, immediate surgery, is usually not necessary and can be complicated by acute swelling and bleeding.
Question 289
Topic: Shoulder Pathology
The patient's symptoms fail to improve after 6 months of conservative management. Radiographs and a three-dimensional CT scan were obtained, revealing an anterior โhorn-likeโ projection at the superomedial angle of the scapula. Surgical intervention is planned using a modified mini-open approach with arthroscopy-assisted bursectomy. Portals are placed 3 cm medial to the medial scapular border.
Which structure(s) are avoided with this portal placement?
Correct Answer & Explanation
. Dorsal scapular artery and nerve
Explanation
Correct Answer: CThe dorsal scapular artery and nerve are critical structures that run beneath the rhomboid minor and major muscles, approximately 1 to 2 cm medial to the medial scapular border. Therefore, placing portals 3 cm medial to the medial scapular border is a technique designed to safely avoid injury to these neurovascular structures. The long thoracic nerve is located more laterally and is rarely endangered unless dissection extends too far laterally. The suprascapular nerve and spinal accessory nerve are typically at risk if portals are placed superior to the scapular spine. The deep branch of the transverse cervical artery becomes the dorsal scapular artery, so avoiding the dorsal scapular artery also implies avoiding its direct precursor in this region.
Question 290
Topic: Shoulder Pathology
A superomedial scapular resection as well as bursectomy is performed. While dissecting laterally, the suprascapular notch becomes visible in the operative field. What structure runs superficial to the transverse scapular ligament?
Correct Answer & Explanation
. Suprascapular nerve
Explanation
Correct Answer: DThis is a classic anatomical relationship tested in orthopedic surgery. The suprascapular artery runs superficial (or over) the transverse scapular ligament, while the suprascapular nerve travels deep (or under) the ligament, through the suprascapular notch. This anatomical arrangement is often remembered by the mnemonic 'Army over Navy' (Artery over Nerve). The transverse cervical artery is a more proximal vessel, and its deep branch becomes the dorsal scapular artery, which is not directly associated with the suprascapular notch in this manner. The spinal accessory nerve and long thoracic nerve are not closely associated with the transverse scapular ligament or suprascapular notch.
Question 291
Topic: 9. Shoulder and Elbow
The 42-year-old female with an early post-traumatic intrinsic joint contracture of the elbow, 3 months post-radial head fracture, has limited flexion/extension (80 to 50 degrees). What is the preferred first line of treatment at this time?
Correct Answer & Explanation
. Daily supervised physical therapy with static or dynamic progressive splinting
Explanation
Correct Answer: CFor most cases of post-traumatic elbow stiffness, especially within the early timeframe (first 6 months), daily supervised physical therapy combined with static or dynamic progressive splinting is the preferred first line of treatment. Significant gains in elbow motion can be achieved within the first 3 to 6 months of initiating this conservative regimen, and improvement can continue for up to a year. If the contracture is primarily due to capsular tightness, operative management may not even be required. Manipulation under anesthesia (A) or surgical releases (B, D) are typically reserved for cases that fail an adequate trial of conservative therapy. Serial casting (E) can be part of conservative management but is often combined with or follows intensive physical therapy.
Question 292
Topic: Shoulder Pathology
Considering the patient's age (45-year-old) and high functional demands, the orthopedic surgeon decides on open reduction and internal fixation (ORIF) with a locking plate. Which of the following is a primary rationale for recommending surgical intervention over non-operative management in this specific patient, as discussed in the case?
Correct Answer & Explanation
. C. To achieve the best functional outcome and avoid potentially painful mal- or non-union.
Explanation
Correct Answer: CThe case explicitly states the rationale for surgery: "I would tell the patient that surgery is generally safe and is likely to give him the best functional outcome and to avoid potentially painful mal- or non-union." This directly addresses the benefits of surgery for an active, younger patient with high functional demands, aiming for a more reliable and optimal recovery.Option A (To minimize the risk of infection):Infection is a risk of surgery, not something surgery prevents compared to non-operative treatment.Option B (To ensure a faster return to work):While surgery might facilitate an earlier start to rehabilitation, a faster return to work is not the primary stated rationale for choosing surgery over non-operative treatment in the case. The focus is on the quality of the functional outcome.Option D (To reduce the overall cost of treatment):Surgical treatment is generally more expensive than non-operative treatment.Option E (To prevent the development of adhesive capsulitis):Shoulder stiffness (adhesive capsulitis) is listed as a potential risk of surgery, not something surgery prevents. Both operative and non-operative management can lead to stiffness.
Question 293
Topic: 9. Shoulder and Elbow
A 78-year-old sedentary female with low functional demands presents with a similar displaced three-part proximal humerus fracture. She has significant comorbidities, including severe osteoporosis and poorly controlled diabetes. Based on the principles discussed in the case, what would be the most appropriate initial management consideration for this patient?
Correct Answer & Explanation
. C. Non-operative treatment with sling immobilization and early gentle pendulum exercises.
Explanation
Correct Answer: CThe case contrasts the management of an active, younger patient with that of a patient with lower demands: "It is possible that for a patient with very low functional demands, non-operative treatment may allow healing with a functional result..." For an elderly, sedentary patient with low functional demands and significant comorbidities (osteoporosis, diabetes), the risks of surgery (infection, fixation failure in osteoporotic bone, general anesthesia risks) often outweigh the potential benefits. Non-operative management, focusing on pain control and early gentle motion to prevent stiffness, is often the preferred approach, aiming for a functional rather than perfect anatomical outcome.Option A (Open reduction and internal fixation with a locking plate):While an option for some, the severe osteoporosis and comorbidities in an elderly, low-demand patient make fixation challenging and prone to failure, and the surgical risks are higher.Option B (Hemiarthroplasty of the shoulder):Hemiarthroplasty is a significant surgical procedure, usually reserved for more complex fractures (e.g., four-part, head-splitting) or failed ORIF, and still carries substantial risks for a patient with multiple comorbidities.Option D (Reverse total shoulder arthroplasty):Reverse total shoulder arthroplasty is typically considered for very complex fractures in older patients, especially with rotator cuff deficiency, or as a salvage procedure. While it might be considered in some elderly patients with complex fractures, for a three-part fracture in a low-demand patient with comorbidities, non-operative treatment is often the safer initial choice.Option E (Immediate referral for complex reconstructive surgery):This is too aggressive for an initial management consideration in a patient who might benefit from non-operative care.
Question 294
Topic: 9. Shoulder and Elbow
A 45-year-old active male undergoes ORIF of his displaced three-part proximal humerus fracture with a locking plate. During the post-operative period, he develops persistent pain, crepitus, and progressive loss of shoulder motion despite adherence to physical therapy. Radiographs show evidence of hardware loosening and partial collapse of the humeral head. Which of the following complications, mentioned in the case, is most likely occurring?
Correct Answer & Explanation
. D. Failure of fixation
Explanation
Correct Answer: DThe case lists "failure of fixation" as a specific risk of the operation. The symptoms described โ persistent pain, crepitus, progressive loss of motion, and radiographic evidence of hardware loosening and humeral head collapse โ are classic signs of fixation failure. This can occur due to poor bone quality, inadequate reduction, improper plate placement, or early aggressive rehabilitation.Option A (Neurovascular injury):While a risk, neurovascular injury would typically present with immediate post-operative neurological deficits (e.g., axillary nerve palsy) or vascular compromise, not progressive pain and hardware issues.Option B (Infection):Infection is a risk, but it would typically present with signs like fever, redness, warmth, purulent drainage, and elevated inflammatory markers, which are not described as the primary issue here.Option C (Shoulder stiffness):Shoulder stiffness is a risk, but the description of hardware loosening and humeral head collapse points to a structural failure rather than just soft tissue contracture. While stiffness can result from fixation failure, it's a symptom, not the underlying primary complication described.Option E (Adhesive capsulitis):Adhesive capsulitis is a form of shoulder stiffness, but the radiographic findings of hardware loosening and collapse indicate a mechanical failure of the construct, which is distinct from primary adhesive capsulitis.
Question 295
Topic: 9. Shoulder and Elbow
The case highlights the importance of patient counseling regarding the risks of surgery for proximal humerus fractures. When discussing the risk of shoulder stiffness with a patient undergoing ORIF, which of the following statements is most accurate?
Correct Answer & Explanation
. B. Stiffness is a common complication, and while early motion is important, some degree of stiffness can occur despite optimal management.
Explanation
Correct Answer: BThe case lists "shoulder stiffness" as a risk inherent with the operation. Shoulder stiffness (including adhesive capsulitis) is a common complication following both operative and non-operative treatment of proximal humerus fractures. While early, controlled rehabilitation is crucial to prevent severe stiffness, some degree of stiffness can still occur due to the initial trauma, prolonged immobilization, or inflammatory response, even with optimal surgical fixation and rehabilitation. It's important to set realistic expectations for patients.Option A (Shoulder stiffness is a rare complication that can be entirely prevented with early aggressive physical therapy):Stiffness is not rare, and while therapy helps, it cannot entirely prevent it in all cases. Aggressive therapy too early can also compromise fixation.Option C (Stiffness is primarily caused by neurovascular injury during surgery and is usually temporary):Stiffness is not primarily caused by neurovascular injury; it's more related to soft tissue healing, inflammation, and immobilization.Option D (The locking plate prevents stiffness by providing rigid fixation, allowing immediate full range of motion):While locking plates provide stable fixation, they do not prevent stiffness, and immediate full range of motion is typically not allowed due to the risk of fixation failure and compromise of fracture healing.Option E (Stiffness is only a concern in non-operative management and not after surgical fixation):This is incorrect. Stiffness is a concern in both operative and non-operative management of shoulder fractures.
Question 296
Topic: 9. Shoulder and Elbow
A 45-year-old male sustains a fall onto an outstretched hand, resulting in a radial head fracture. Radiographs show a displaced, comminuted fracture involving 40% of the articular surface with a 3mm step-off, but no mechanical block to forearm rotation. Which Mason-Johnston classification best describes this injury?
Correct Answer & Explanation
. Type III
Explanation
Mason-Johnston Type III fractures are characterized by significant comminution and/or displacement, often involving more than 30% of the articular surface and/or displacement of more than 2mm, or with mechanical block. While a Type II involves a single displaced fragment, a Type III implies more extensive disruption, typically precluding successful closed reduction and often requiring surgical intervention.
Question 297
Topic: Elbow & Forearm
A 62-year-old female presents with a Mason-Johnston Type II radial head fracture with 2mm displacement and a palpable block to terminal forearm pronation. There is no associated elbow dislocation or other obvious ligamentous injury. What is the most appropriate initial management strategy?
Correct Answer & Explanation
. Open reduction and internal fixation (ORIF)
Explanation
A Mason-Johnston Type II fracture with a mechanical block to forearm rotation is a strong indication for surgical intervention, typically ORIF. The mechanical block signifies impingement of the displaced fragment, which will prevent full range of motion and lead to chronic dysfunction if not addressed.
Question 298
Topic: Elbow & Forearm
A 55-year-old painter presents with a Mason-Johnston Type III radial head fracture with 4 fragments, involving 60% of the articular surface. He is very active and desires a full return to function. There is no associated elbow dislocation. What is the preferred surgical option to restore function and stability?
Correct Answer & Explanation
. Radial head replacement
Explanation
For highly comminuted (Mason-Johnston Type III or IV) radial head fractures, particularly in active patients where restoration of articular congruity and preservation of radial length are critical, radial head replacement is often the preferred surgical option.
Question 299
Topic: 9. Shoulder and Elbow
What is the primary concern when considering radial head excision for a comminuted radial head fracture in a young, active patient?
Correct Answer & Explanation
. Proximal migration of the radius and DRUJ instability
Explanation
Correct Answer: DThe primary concern with radial head excision, especially in younger, active patients, is the loss of longitudinal stability of the forearm, leading to proximal migration of the radius and subsequent distal radio-ulnar joint (DRUJ) instability. This can cause significant wrist pain and dysfunction. While elbow stiffness and heterotopic ossification are potential complications of any elbow trauma or surgery, proximal migration and DRUJ issues are specific and major drawbacks of radial head excision.
Question 300
Topic: 9. Shoulder and Elbow
A 28-year-old male sustains a Mason-Johnston Type IV radial head fracture with a posterior elbow dislocation. After successful closed reduction of the elbow, radiographs show significant comminution of the radial head. What is the most appropriate next step in management?
Correct Answer & Explanation
. Radial head replacement with concurrent assessment of elbow stability
Explanation
Correct Answer: CA Mason-Johnston Type IV fracture with elbow dislocation (often part of a 'terrible triad' if coronoid and LCL are also injured) requires careful management. After reduction of the dislocation, the radial head injury needs to be addressed to restore stability and function. Given significant comminution in an active 28-year-old, radial head replacement is often the best option to restore radial length and provide buttress to the lateral elbow, preventing recurrent instability. Concurrently, the elbow's stability, especially regarding the LCL and potentially MCL, must be assessed. ORIF would be challenging with significant comminution. Excision is contraindicated due to the high risk of instability. Non-operative management or casting would not address the inherent instability caused by the radial head comminution in this severe injury.
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