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9. Shoulder and Elbow MCQs

Practice Set 151 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 3001

Topic: 9. Shoulder and Elbow

A 22-year-old professional baseball pitcher presents with pain during the late cocking and early acceleration phases of throwing. MR arthrography reveals a Type II SLAP tear.

What is the widely accepted primary pathomechanical mechanism for this specific injury in overhead throwers?

. Direct axial loading of the adducted and internally rotated arm
. The 'peel-back' mechanism of the biceps anchor during maximal external rotation and abduction
. Eccentric firing of the biceps brachii during the deceleration phase
. Chronic microtrauma to the inferior glenohumeral ligament (IGHL) causing superior migration of the humeral head
. Traction injury from the triceps during the follow-through phase

Correct Answer & Explanation

. The 'peel-back' mechanism of the biceps anchor during maximal external rotation and abduction

Explanation

In overhead throwers, the 'peel-back' mechanism occurs during the late cocking phase of throwing when the shoulder is in maximal abduction and external rotation. This position causes a torsional force at the base of the long head of the biceps tendon, peeling the superior labrum off the posterior glenoid rim.

Question 3002

Topic: 9. Shoulder and Elbow

A 24-year-old professional baseball pitcher requires ulnar collateral ligament (UCL) reconstruction (Tommy John surgery). During the procedure, the surgeon aims to reconstruct the primary restraint to valgus stress at the elbow. Which specific band of the UCL complex is the most critical to reconstruct?

. Posterior bundle
. Transverse ligament (Cooper's ligament)
. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Radial collateral ligament

Correct Answer & Explanation

. Posterior band of the anterior bundle

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow from 30 to 120 degrees of flexion. It is subdivided into the anterior and posterior bands. The anterior band is the primary restraint to valgus stress at lower angles of flexion (up to 90 degrees) and is the most critical component to reconstruct in overhead throwers.

Question 3003

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female undergoes a reverse total shoulder arthroplasty (rTSA) for severe rotator cuff tear arthropathy. Compared to the native anatomic shoulder, which of the following best describes the biomechanical alteration of the center of rotation following a standard Grammont-style rTSA?

. Medialized and superiorized
. Medialized and inferiorized
. Lateralized and superiorized
. Lateralized and inferiorized
. Anatomical center of rotation is maintained exactly

Correct Answer & Explanation

. Medialized and inferiorized

Explanation

The classic Grammont-style reverse total shoulder arthroplasty relies on a medialized and inferiorized (distalized) center of rotation. This biomechanical alteration increases the tension and moment arm of the deltoid muscle, which compensates for the deficient rotator cuff to allow active forward elevation.

Question 3004

Topic: Elbow & Forearm

A 45-year-old male bodybuilder sustains an acute distal biceps tendon rupture and opts for surgical repair via a single-incision anterior approach. Postoperatively, he complains of sensory loss along the lateral aspect of his forearm. Which nerve is most commonly injured during this specific surgical approach?

. Posterior interosseous nerve
. Median nerve
. Superficial radial nerve
. Lateral antebrachial cutaneous nerve
. Medial antebrachial cutaneous nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most frequently injured nerve during a single-incision anterior approach to the distal biceps. It courses between the biceps and brachialis and exits laterally in the subcutaneous tissue, making it vulnerable during superficial dissection and retraction.

Question 3005

Topic: Elbow & Forearm

A 35-year-old male falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. What is the standard algorithmic sequence for surgical fixation of this injury pattern?

. Coronoid fixation, lateral ulnar collateral ligament repair, radial head replacement
. Lateral ulnar collateral ligament repair, coronoid fixation, radial head replacement
. Radial head replacement, coronoid fixation, lateral ulnar collateral ligament repair
. Coronoid fixation, radial head replacement, lateral ulnar collateral ligament repair
. Radial head replacement, lateral ulnar collateral ligament repair, coronoid fixation

Correct Answer & Explanation

. Coronoid fixation, radial head replacement, lateral ulnar collateral ligament repair

Explanation

The standard inside-out surgical algorithm for a terrible triad injury (coronoid fracture, radial head fracture, elbow dislocation) is: 1) Coronoid fixation or repair of the anterior capsule, 2) Radial head fixation or arthroplasty, 3) Lateral ulnar collateral ligament (LUCL) repair. Medial collateral ligament repair is only added if the elbow remains highly unstable after the first three steps.

Question 3006

Topic: Shoulder Pathology

A 24-year-old male presents with right shoulder pain and weakness after a blunt trauma to his upper back. Physical examination reveals pronounced medial winging of the scapula that worsens when the patient is asked to perform a wall push-up. Which nerve and corresponding muscle are injured?

. 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 winging (where the medial border of the scapula translates medially and prominently away from the thorax) is caused by paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. Lateral winging is characteristically due to trapezius palsy (spinal accessory nerve).

Question 3007

Topic: 9. Shoulder and Elbow
A 65-year-old male with a massive, retracted rotator cuff tear undergoes radiographic evaluation. According to the Hamada classification for rotator cuff tear arthropathy, what specific radiographic finding defines a Stage 3 arthropathy?
. Acromiohumeral interval greater than 6 mm
. Acromiohumeral interval less than or equal to 5 mm
. Acetabularization of the coracoacromial arch
. Glenohumeral joint osteoarthritis with joint space narrowing
. Humeral head collapse or osteonecrosis

Correct Answer & Explanation

. Acromiohumeral interval less than or equal to 5 mm

Explanation

In the Hamada classification: Stage 1 = normal AHI (>6 mm); Stage 2 = narrowed AHI (≤5 mm); Stage 3 = acetabularization (concave erosion) of the undersurface of the acromion/coracoacromial arch; Stage 4 = glenohumeral joint space narrowing (arthritis); Stage 5 = humeral head collapse.

Question 3008

Topic: 9. Shoulder and Elbow

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow. It is subdivided into distinct bands. Which of the following accurately describes the tensioning pattern of these bands during elbow range of motion?

. The anterior band is taut in extension and the posterior band is taut in deeper flexion
. The anterior band is taut in flexion and the posterior band is taut in extension
. Both bands remain equally taut throughout the entire arc of motion
. The anterior band is isometric while the posterior band dynamically lengthens in pronation
. The posterior band provides valgus stability exclusively in full extension

Correct Answer & Explanation

. The anterior band is taut in flexion and the posterior band is taut in extension

Explanation

The anterior bundle of the UCL consists of anterior and posterior bands that insert onto the sublime tubercle. Reciprocal tension occurs during elbow motion: the anterior band is primarily taut in extension, while the posterior band becomes taut in deeper degrees of elbow flexion.

Question 3009

Topic: Shoulder Pathology

A 50-year-old diabetic female presents with an insidious onset of severe shoulder pain and progressive stiffness over the last 4 months. Which of the following physical examination findings is considered pathognomonic for idiopathic adhesive capsulitis?

. Loss of internal rotation at 90 degrees of abduction
. Significant loss of passive external rotation with the arm at the side
. A painful arc of motion strictly between 60 and 120 degrees of elevation
. Complete loss of active forward flexion with entirely preserved passive external rotation
. Increased passive external rotation compared to the unaffected contralateral side

Correct Answer & Explanation

. Significant loss of passive external rotation with the arm at the side

Explanation

The hallmark and pathognomonic physical exam finding in adhesive capsulitis (frozen shoulder) is a marked reduction in passive external rotation with the patient's arm resting at their side. This specific restriction is primarily caused by contracture and thickening of the coracohumeral ligament and the rotator interval.

Question 3010

Topic: Shoulder Arthroplasty & Arthritis

Scapular notching is a well-recognized complication following Reverse Total Shoulder Arthroplasty (RTSA). Based on modern biomechanical principles and implant design modifications, which of the following component positioning strategies is most effective in minimizing the risk of inferior scapular notching?

. Superior translation of the glenosphere
. Superior tilt of the glenosphere
. Inferior tilt and inferior translation of the glenosphere
. Medialization of the center of rotation with a flush baseplate
. Increasing the humeral neck-shaft angle to 155 degrees

Correct Answer & Explanation

. Inferior tilt and inferior translation of the glenosphere

Explanation

Inferior scapular notching occurs due to mechanical impingement of the humeral component against the scapular neck during adduction. Inferior translation (placing the baseplate low on the glenoid) and inferior tilt of the glenosphere help to clear the inferior scapular pillar, thereby reducing the incidence of notching. Lateralization of the center of rotation and using a smaller humeral neck-shaft angle (e.g., 135-145 degrees) also decrease notching.

Question 3011

Topic: Elbow & Forearm

A 45-year-old man requires operative repair of a complete acute distal biceps tendon rupture. The surgeon must choose between a single-incision anterior approach and a two-incision approach. Compared to the single-incision technique, the two-incision approach has a historically higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve (LABCN) neurapraxia
. Posterior interosseous nerve (PIN) palsy
. Radioulnar synostosis
. Rerupture of the repaired tendon
. Superficial radial nerve injury

Correct Answer & Explanation

. Radioulnar synostosis

Explanation

The two-incision approach (modified Boyd-Anderson) was developed to limit radial nerve injury, but dissection between the radius and ulna significantly increases the risk of heterotopic ossification and radioulnar synostosis compared to a single anterior incision. The single-incision approach has a higher rate of lateral antebrachial cutaneous nerve (LABCN) neuropraxia due to anterior retraction.

Question 3012

Topic: Elbow & Forearm

A 30-year-old patient presents with a 'terrible triad' injury of the elbow following a fall onto an outstretched hand. The injury involves an elbow dislocation, a radial head fracture, and a coronoid process fracture. According to standard surgical protocols, what is the most widely accepted sequence of structural repair to restore elbow stability?

. Medial collateral ligament (MCL) repair -> Radial head fixation/replacement -> Coronoid fixation -> Lateral collateral ligament (LCL) repair
. Radial head fixation/replacement -> LCL repair -> Coronoid fixation -> MCL repair
. Coronoid fixation -> Radial head fixation/replacement -> LCL repair -> MCL repair (if still unstable)
. LCL repair -> Coronoid fixation -> Radial head fixation/replacement -> MCL repair
. MCL repair -> LCL repair -> Coronoid fixation -> Radial head fixation/replacement

Correct Answer & Explanation

. Radial head fixation/replacement -> LCL repair -> Coronoid fixation -> MCL repair

Explanation

The standard inside-out surgical sequence for a terrible triad injury of the elbow is: 1. Fixation of the coronoid fracture (or reattachment of the anterior capsule), 2. Fixation or replacement of the radial head, 3. Repair of the lateral collateral ligament (LUCL) to the lateral epicondyle. The medial collateral ligament (MCL) is only repaired or a hinged external fixator applied if the elbow remains unstable in extension after the lateral side is secured.

Question 3013

Topic: 9. Shoulder and Elbow

A 21-year-old collegiate baseball pitcher undergoes Medial Ulnar Collateral Ligament (MUCL) reconstruction (Tommy John surgery). The surgeon must anatomically restore the primary restraint to valgus stress at the elbow. Which bundle of the MUCL is being reconstructed, and what is its role in elbow kinematics?

. Posterior bundle; primary restraint to valgus stress from 0 to 30 degrees of flexion
. Anterior bundle; primary restraint to valgus stress from 30 to 120 degrees of flexion
. Transverse bundle; dynamically stabilizes the ulnar nerve during flexion
. Anterior bundle; primary restraint to valgus stress from 0 to 30 degrees of flexion
. Posterior bundle; primary restraint to valgus stress in terminal extension

Correct Answer & Explanation

. Anterior bundle; primary restraint to valgus stress from 30 to 120 degrees of flexion

Explanation

The anterior bundle of the MUCL originates on the anteroinferior surface of the medial epicondyle and inserts on the sublime tubercle of the ulna. It is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion. The posterior bundle is a secondary restraint, and the transverse (Cooper's) ligament contributes little to elbow stability.

Question 3014

Topic: 9. Shoulder and Elbow

A 48-year-old man presents with painful swelling at the posterior aspect of both elbows and inability to actively extend against resistance. He reports a sudden 'tearing' sensation bilaterally while attempting to break a fall. MRI confirms bilateral triceps tendon ruptures. Which of the following systemic medical conditions is classically most associated with bilateral spontaneous triceps tendon ruptures?

. Rheumatoid arthritis
. Systemic lupus erythematosus
. Secondary hyperparathyroidism (renal osteodystrophy)
. Diabetes mellitus type 2
. Gouty arthropathy

Correct Answer & Explanation

. Secondary hyperparathyroidism (renal osteodystrophy)

Explanation

While unilateral triceps ruptures are generally traumatic (e.g., weightlifting), bilateral simultaneous triceps tendon ruptures are rare and highly associated with underlying systemic conditions that weaken the tendon. The classic board-tested association for bilateral spontaneous triceps rupture is secondary hyperparathyroidism (renal osteodystrophy), which causes pathologic changes at the bone-tendon junction. Other risks include chronic corticosteroid use, anabolic steroids, and fluoroquinolones.

Question 3015

Topic: Shoulder Pathology
A 52-year-old female with poorly controlled type 1 diabetes presents with severe restriction of active and passive range of motion of her right shoulder, consistent with adhesive capsulitis (frozen shoulder). Pathophysiologically, the joint capsule in this condition demonstrates dense fibroblastic proliferation. Which of the following cytokines/growth factors is most heavily implicated in driving the fibrogenic cascade in adhesive capsulitis?
. Tumor Necrosis Factor-alpha (TNF-alpha)
. Transforming Growth Factor-beta (TGF-beta)
. Interleukin-1 (IL-1)
. Fibroblast Growth Factor (FGF)
. Platelet-Derived Growth Factor (PDGF)

Correct Answer & Explanation

. Transforming Growth Factor-beta (TGF-beta)

Explanation

Adhesive capsulitis is characterized by chronic inflammation leading to dense capsular fibrosis. Cytokine profiling of the capsule in patients with frozen shoulder shows significantly elevated levels of Transforming Growth Factor-beta (TGF-beta) and Platelet-Derived Growth Factor (PDGF). TGF-beta is considered the primary driver of the fibrotic response, stimulating fibroblasts to produce type I and type III collagen.

Question 3016

Topic: Elbow & Forearm

A 34-year-old female sustains a coronal shear fracture of the distal humerus. Imaging demonstrates that the fracture involves both the capitellum and the lateral half of the trochlea in a single contiguous articular fragment. According to the Dubberley classification, this represents a Type 3 injury. What specific radiographic feature differentiates a Dubberley Type 3B from a Type 3A injury?

. Involvement of the lateral trochlear ridge
. Complete articular separation from the humeral shaft
. Presence of posterior condylar comminution
. Extension into the medial epicondyle
. Disruption of the lateral collateral ligament complex

Correct Answer & Explanation

. Presence of posterior condylar comminution

Explanation

The Dubberley classification of coronal shear fractures divides them by extent: Type 1 involves the capitellum only, Type 2 includes the capitellum and the lateral trochlear ridge, and Type 3 involves the capitellum and trochlea as a single piece. The modifier A or B is added based on the absence (A) or presence (B) of posterior condylar comminution, which is critical because Type B injuries lack posterior cortical buttressing and often require specialized plating.

Question 3017

Topic: Elbow & Forearm

A 28-year-old male describes a sensation of his elbow 'clicking and giving way' when he tries to push himself up from an armchair. Physical exam reveals apprehension and a clunk with a supination, valgus, and axial compression load applied to the elbow as it is moved from extension to flexion. What is the primary ligamentous restraint that is deficient, and what is its anatomic insertion on the ulna?

. Radial collateral ligament; annular ligament
. Lateral ulnar collateral ligament; supinator crest of the ulna
. Lateral ulnar collateral ligament; sublime tubercle
. Annular ligament; radial neck
. Anterior band of the medial collateral ligament; sublime tubercle

Correct Answer & Explanation

. Lateral ulnar collateral ligament; supinator crest of the ulna

Explanation

The patient is presenting with Posterolateral Rotatory Instability (PLRI) of the elbow. The primary deficient structure is the Lateral Ulnar Collateral Ligament (LUCL). The LUCL originates from the lateral epicondyle, blends with the annular ligament, and inserts on the supinator crest of the proximal ulna. Its incompetence allows the radial head and proximal ulna to subluxate posterolaterally away from the humerus.

Question 3018

Topic: 9. Shoulder and Elbow

A 26-year-old man suffered a severe pan-brachial plexus avulsion injury 2 years ago and has no functional recovery of shoulder or elbow musculature, though he has undergone successful distal nerve transfers to restore rudimentary hand grip. He is scheduled for a shoulder arthrodesis to provide a stable proximal platform to aid in hand-to-mouth function. According to modern recommendations, what is the ideal position for glenohumeral fusion?

. 15 degrees of flexion, 15 degrees of abduction, 15 degrees of external rotation
. 30 degrees of flexion, 30 degrees of abduction, 30 degrees of internal rotation
. 45 degrees of flexion, 45 degrees of abduction, 45 degrees of internal rotation
. 30 degrees of flexion, 30 degrees of abduction, 30 degrees of external rotation
. 0 degrees of flexion, 30 degrees of abduction, 0 degrees of internal rotation

Correct Answer & Explanation

. 30 degrees of flexion, 30 degrees of abduction, 30 degrees of internal rotation

Explanation

The currently recommended, standard functional position for shoulder arthrodesis is approximately 30 degrees of flexion, 30 degrees of abduction, and 30 degrees of internal rotation (the '30-30-30' rule). This position allows the hand to reach the midline and mouth for feeding while enabling the arm to rest comfortably at the side when relaxed. Older recommendations (Rowe position) used more internal rotation and less abduction, but the 30-30-30 position optimizes modern activities of daily living.

Question 3019

Topic: Elbow & Forearm

A 45-year-old female falls on her outstretched hand. Radiographs confirm an elbow dislocation, a comminuted radial head fracture, and a Type II coronoid fracture.

According to standard surgical protocols for this 'terrible triad' injury, what is the most appropriate sequence of repair to restore elbow stability?

. Lateral ulnar collateral ligament (LUCL) repair, radial head fixation/replacement, coronoid fixation
. Coronoid fixation/capsular repair, radial head fixation/replacement, LUCL repair
. Radial head fixation/replacement, medial collateral ligament (MCL) repair, LUCL repair
. LUCL repair, medial collateral ligament (MCL) repair, coronoid fixation
. Coronoid fixation, MCL repair, radial head fixation/replacement

Correct Answer & Explanation

. Coronoid fixation/capsular repair, radial head fixation/replacement, LUCL repair

Explanation

The classic 'terrible triad' of the elbow includes an elbow dislocation, radial head fracture, and coronoid fracture. The widely accepted surgical protocol described by Pugh and McKee recommends repairing structures from deep to superficial, typically starting anteriorly: 1) Coronoid fixation or anterior capsule repair to restore the anterior buttress, 2) Radial head ORIF or arthroplasty, 3) LUCL repair to the lateral epicondyle, and 4) MCL repair or application of a hinged external fixator if the elbow remains unstable after the first three steps.

Question 3020

Topic: Elbow & Forearm

When performing a lateral ulnar collateral ligament (LUCL) reconstruction for posterolateral rotatory instability (PLRI) of the elbow, accurate graft placement is critical. Where is the precise isometric origin of the LUCL on the lateral epicondyle to ensure stability and uniform tension throughout the elbow's range of motion?

. At the geometric center of the capitellum's axis of rotation
. Proximal and posterior to the lateral epicondyle
. Directly on the lateral supracondylar ridge
. Distal and anterior to the lateral epicondyle
. At the supinator crest of the ulna

Correct Answer & Explanation

. At the geometric center of the capitellum's axis of rotation

Explanation

The isometric point for the origin of the lateral ulnar collateral ligament (LUCL) on the humerus is located at the center of the capitellum's axis of rotation. Placing the humeral tunnel at this exact point ensures that the reconstructed ligament maintains consistent tension and provides stability across the full arc of elbow flexion and extension.

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