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9. Shoulder and Elbow MCQs

Practice Set 153 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 3041

Topic: Elbow & Forearm

A 50-year-old female presents with a 'Terrible Triad' injury of the elbow (coronoid fracture, radial head fracture, and elbow dislocation). During surgical reconstruction, what is the generally accepted optimal sequence of repair to restore elbow stability?

. Repair the lateral ulnar collateral ligament (LUCL), fix the radial head, fix the coronoid
. Fix the radial head, repair the medial collateral ligament (MCL), fix the coronoid
. Fix or replace the radial head, fix the coronoid, repair the LUCL
. Fix the coronoid, fix or replace the radial head, repair the LUCL
. Repair the MCL, repair the LUCL, fix the coronoid

Correct Answer & Explanation

. Fix the coronoid, fix or replace the radial head, repair the LUCL

Explanation

The standard surgical algorithm for a Terrible Triad injury progresses from deep to superficial and typically from medial/anterior to lateral. The accepted sequence is: 1) Fix the coronoid (to restore the anterior buttress), 2) Fix or replace the radial head (to restore the lateral column/anterior buttress), 3) Repair the lateral collateral ligament complex (LUCL) to the lateral epicondyle. The MCL is only repaired if the elbow remains grossly unstable after these steps.

Question 3042

Topic: Elbow & Forearm

A posterolateral (Kocher) approach is performed on the elbow for radial head replacement.

Which ligament is most at risk of iatrogenic injury if the origin of the extensor mass on the lateral epicondyle is aggressively elevated anteriorly?

. Annular ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Medial ulnar collateral ligament
. Quadrate ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The lateral ulnar collateral ligament (LUCL) originates on the lateral epicondyle and inserts on the supinator crest of the ulna. It acts as the primary restraint to posterolateral rotatory instability (PLRI) of the elbow. If the dissection is taken too far anteriorly or distally off the lateral epicondyle, the LUCL can be severed, leading to iatrogenic PLRI.

Question 3043

Topic: Shoulder Pathology

During surgical exploration of the brachial plexus for a traumatic injury, you are evaluating the anatomic structures originating directly from the upper trunk. Which of the following nerves branches exclusively from the upper trunk?

. Dorsal scapular nerve
. Suprascapular nerve
. Long thoracic nerve
. Medial pectoral nerve
. Thoracodorsal nerve

Correct Answer & Explanation

. Suprascapular nerve

Explanation

The suprascapular nerve and the nerve to the subclavius are the only branches that originate directly from the upper trunk of the brachial plexus (formed by C5 and C6 roots). The dorsal scapular (C5) and long thoracic (C5, C6, C7) nerves branch directly from the roots.

Question 3044

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old female sustains a comminuted 4-part proximal humerus fracture. The surgeon elects to perform a reverse total shoulder arthroplasty (RTSA). To minimize the risk of post-operative external rotation weakness and optimize functional outcome, the surgeon must prioritize the healing of which specific bony fragment?

. Lesser tuberosity
. Greater tuberosity
. Both tuberosities equally
. Deltoid tuberosity
. Anatomic neck fragment

Correct Answer & Explanation

. Greater tuberosity

Explanation

In RTSA performed for proximal humerus fractures, while the implant design compensates for rotator cuff arthropathy by relying on the deltoid, healing of the greater tuberosity is strongly correlated with improved active external rotation and significantly better overall patient functional scores (e.g., ASES scores). Therefore, meticulous repair of the greater tuberosity is prioritized.

Question 3045

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with a 4-part proximal humerus fracture featuring medial calcar comminution and significant lateral head displacement. She has a known history of severe, symptomatic rotator cuff arthropathy. Which surgical option is most appropriate?

. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty with greater and lesser tuberosity repair
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty
. Closed reduction and percutaneous pinning

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is indicated for elderly patients with complex 4-part proximal humerus fractures, especially those with pre-existing rotator cuff arthropathy, as it relies on deltoid function and bypasses the high risk of head AVN and tuberosity nonunion.

Question 3046

Topic: Elbow & Forearm
A 40-year-old female presents with an isolated coronal shear fracture of the capitellum involving a large segment of subchondral bone. How is this fracture classified according to the Bryan and Morrey system?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV (McKee)
. Type V (Osborne-Cotterill)

Correct Answer & Explanation

. Type I (Hahn-Steinthal)

Explanation

A Bryan and Morrey Type I fracture, also known as a Hahn-Steinthal fracture, involves a large coronal shear fracture of the capitellum that includes a significant portion of subchondral bone. Type II (Kocher-Lorenz) involves an articular cartilage sleeve with very little bone.

Question 3047

Topic: Shoulder Pathology

A patient undergoing an anterior cervical discectomy and fusion (ACDF) develops hoarseness postoperatively. Which nerve is most likely to have been injured?

. Phrenic nerve
. Spinal accessory nerve
. Recurrent laryngeal nerve
. Vagus nerve
. Long thoracic nerve

Correct Answer & Explanation

. Recurrent laryngeal nerve

Explanation

Hoarseness after an ACDF is most commonly due to injury or irritation of the recurrent laryngeal nerve, which is closely associated with the surgical field. This nerve innervates most of the intrinsic muscles of the larynx. The phrenic nerve innervates the diaphragm. The spinal accessory nerve innervates the sternocleidomastoid and trapezius muscles. The vagus nerve supplies the recurrent laryngeal nerve, but direct injury to the vagus itself is less common than to its recurrent branch. The long thoracic nerve innervates the serratus anterior muscle.

Question 3048

Topic: 9. Shoulder and Elbow

A 60-year-old female presents with severe pain and progressive stiffness in her shoulder, limiting both active and passive range of motion. Radiographs show diffuse osteopenia but no acute fracture or significant degenerative changes. What is the most likely diagnosis?

. Rotator cuff tear
. Glenohumeral osteoarthritis
. Adhesive capsulitis (Frozen Shoulder)
. Biceps tendinopathy
. Calcific tendinitis

Correct Answer & Explanation

. Adhesive capsulitis (Frozen Shoulder)

Explanation

The key features pointing to adhesive capsulitis (frozen shoulder) are severe pain and a progressive global limitation ofboth active and passiverange of motion. Rotator cuff tears primarily limit active range of motion, often with preserved passive motion (unless severe chronic tear leading to stiffness). Glenohumeral osteoarthritis would show significant joint space narrowing and osteophytes on radiographs. Biceps tendinopathy and calcific tendinitis are usually more localized and less restrictive of global motion, though they cause significant pain.

Question 3049

Topic: 9. Shoulder and Elbow

A 40-year-old male presents with lateral elbow pain exacerbated by gripping and resisted wrist extension. Examination reveals tenderness over the lateral epicondyle and pain with Cozen's test. What is the most likely diagnosis?

. Medial epicondylitis
. Olecranon bursitis
. Radial tunnel syndrome
. Lateral epicondylitis (Tennis Elbow)
. Biceps tendinopathy

Correct Answer & Explanation

. Lateral epicondylitis (Tennis Elbow)

Explanation

The symptoms (lateral elbow pain, exacerbated by gripping and resisted wrist extension) and examination findings (tenderness over the lateral epicondyle, positive Cozen's test - pain with resisted wrist extension with the elbow extended) are classic for lateral epicondylitis, commonly known as 'tennis elbow.' This condition involves degeneration of the common extensor origin, primarily the extensor carpi radialis brevis. Medial epicondylitis ('golfer's elbow') involves the common flexor origin. Olecranon bursitis involves the bursa. Radial tunnel syndrome involves compression of the posterior interosseous nerve, causing more vague forearm pain. Biceps tendinopathy causes pain in the anterior elbow/shoulder.

Question 3050

Topic: Shoulder Pathology

What is the most appropriate initial management for acute calcific tendinitis of the rotator cuff?

. Immediate surgical debridement
. Corticosteroid injection and NSAIDs
. Extracorporeal shockwave therapy (ESWT)
. Physical therapy with aggressive strengthening
. Arthroscopic removal of calcium deposits

Correct Answer & Explanation

. Corticosteroid injection and NSAIDs

Explanation

Acute calcific tendinitis is often intensely painful due to an inflammatory reaction around the calcium deposits. The most appropriate initial management is conservative, focusing on pain and inflammation control. This typically involves NSAIDs and often a subacromial corticosteroid injection, which can provide significant pain relief. Surgical debridement or arthroscopic removal of deposits are reserved for chronic, refractory cases. ESWT is often used for chronic calcific tendinitis, not typically for the acute phase. Aggressive strengthening physical therapy is often painful in the acute phase and contraindicated.

Question 3051

Topic: 9. Shoulder and Elbow

What is the most common direction of shoulder dislocation?

. Inferior
. Superior
. Anterior
. Posterior
. Luxatio erecta

Correct Answer & Explanation

. Anterior

Explanation

Anterior shoulder dislocation is by far the most common type of glenohumeral dislocation, accounting for over 95% of cases. It typically occurs due to an abduction-external rotation force. Posterior dislocations are much less common and often associated with seizures or electrocution. Inferior and superior dislocations are rare. Luxatio erecta is a specific type of inferior dislocation.

Question 3052

Topic: 9. Shoulder and Elbow

A 55-year-old painter presents with chronic right shoulder pain, especially with overhead activities and at night. He has significant weakness with abduction and external rotation. On examination, a positive Neer's and Hawkins' sign are present, and he has a painful arc of motion. What is the MOST likely diagnosis?

. Adhesive capsulitis
. Bicipital tendonitis
. Glenohumeral osteoarthritis
. Rotator cuff tear
. Acromioclavicular (AC) joint arthritis

Correct Answer & Explanation

. Rotator cuff tear

Explanation

The combination of chronic shoulder pain, pain with overhead activities, night pain, and weakness in abduction and external rotation is highly suggestive of a rotator cuff tear, particularly involving the supraspinatus and infraspinatus. Positive Neer's and Hawkins' signs indicate impingement, which often precedes or coexists with cuff tears. Adhesive capsulitis presents with global stiffness. Bicipital tendonitis is anterior shoulder pain. Glenohumeral OA causes diffuse pain and stiffness but often with crepitus. AC joint arthritis causes pain localized to the superior aspect of the shoulder, exacerbated by adduction across the chest.

Question 3053

Topic: 9. Shoulder and Elbow

A 2-year-old child presents with refusal to use her left arm after being pulled up by the hand. The arm is held in slight flexion and pronation. There is no swelling or ecchymosis. What is the MOST likely diagnosis and treatment?

. Distal radius fracture; casting
. Clavicle fracture; sling immobilization
. Nursemaid's elbow (radial head subluxation); closed reduction
. Elbow dislocation; urgent open reduction
. Septic elbow arthritis; urgent aspiration

Correct Answer & Explanation

. Nursemaid's elbow (radial head subluxation); closed reduction

Explanation

This is a classic presentation of Nursemaid's elbow, or radial head subluxation, common in young children after a sudden pull on the arm. The typical presentation is a child holding the arm in slight flexion and pronation, unwilling to use it. The treatment is a simple closed reduction maneuver (either supination-flexion or hyperpronation technique), which is usually successful and immediately relieves symptoms. The other options are incorrect based on the mechanism and presentation.

Question 3054

Topic: 9. Shoulder and Elbow

A 30-year-old male presents to the emergency department after falling directly onto his shoulder. His arm is held in slight abduction and external rotation, and there is a palpable void beneath the acromion. What is the MOST likely type of shoulder dislocation?

. Anterior
. Posterior
. Inferior (Luxatio erecta)
. Superior
. Acromioclavicular

Correct Answer & Explanation

. Anterior

Explanation

The classic presentation of an anterior glenohumeral dislocation (the most common type, accounting for >95%) is the arm held in slight abduction and external rotation, with a palpable anterior shoulder prominence and a 'square shoulder' deformity (void under the acromion). Posterior dislocations typically present with the arm internally rotated and adducted. Luxatio erecta is rare with the arm locked overhead. AC joint dislocation is at the AC joint, not glenohumeral.

Question 3055

Topic: 9. Shoulder and Elbow

A 40-year-old tennis player complains of lateral elbow pain that radiates down his forearm, exacerbated by gripping and lifting objects. Examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension. What is the MOST likely diagnosis?

. Medial epicondylitis
. Olecranon bursitis
. Radial tunnel syndrome
. Lateral epicondylitis (Tennis Elbow)
. Ulnar nerve entrapment

Correct Answer & Explanation

. Lateral epicondylitis (Tennis Elbow)

Explanation

This presentation is classic for lateral epicondylitis, commonly known as 'Tennis Elbow.' It is a tendinopathy of the common extensor origin at the lateral epicondyle, primarily involving the extensor carpi radialis brevis (ECRB) tendon. Pain with resisted wrist extension is a hallmark sign. Medial epicondylitis (Golfer's Elbow) affects the common flexor origin. Radial tunnel syndrome is nerve entrapment, not typically isolated to the epicondyle. Olecranon bursitis is swelling at the tip of the elbow. Ulnar nerve entrapment causes medial elbow pain and small finger numbness.

Question 3056

Topic: 9. Shoulder and Elbow

A 70-year-old patient with severe osteoarthritis of the shoulder presents with chronic pain and limited range of motion, significantly impacting daily activities. Rotator cuff function is intact. What is the MOST appropriate surgical treatment?

. Arthroscopic debridement
. Reverse total shoulder arthroplasty
. Total shoulder arthroplasty (Anatomic TSA)
. Resection arthroplasty (Girdlestone)
. Partial humeral head resurfacing

Correct Answer & Explanation

. Total shoulder arthroplasty (Anatomic TSA)

Explanation

For severe glenohumeral osteoarthritis with an intact rotator cuff, Anatomic Total Shoulder Arthroplasty (TSA) is the gold standard surgical treatment. It involves replacing both the humeral head and the glenoid with prosthetic components, offering excellent pain relief and restoration of function. Reverse TSA is indicated for rotator cuff deficient arthropathy. Arthroscopic debridement is for less severe cases. Resection arthroplasty is for salvage or infection. Partial resurfacing is for very early-stage disease.

Question 3057

Topic: 9. Shoulder and Elbow

A 60-year-old female presents with severe pain and progressive stiffness in her left shoulder. She has significantly limited active and passive range of motion in all planes, with radiographs showing only mild degenerative changes. What is the MOST likely diagnosis?

. Rotator cuff tear
. Glenohumeral osteoarthritis
. Adhesive capsulitis (Frozen Shoulder)
. Calcific tendonitis
. Acromioclavicular joint arthritis

Correct Answer & Explanation

. Adhesive capsulitis (Frozen Shoulder)

Explanation

The hallmark of adhesive capsulitis, or 'frozen shoulder,' is a global restriction of both active and passive range of motion, often severe, with radiographs that are typically normal or show only mild changes. Rotator cuff tears usually have intact passive range of motion. Glenohumeral osteoarthritis would show significant degenerative changes on X-ray. Calcific tendonitis is acute and painful but doesn't cause global stiffness. AC joint arthritis pain is localized superiorly and not global stiffness.

Question 3058

Topic: 9. Shoulder and Elbow

Which of the following ligaments is critical for providing primary valgus stability to the elbow joint?

. Radial collateral ligament
. Lateral ulnar collateral ligament
. Annular ligament
. Medial ulnar collateral ligament (UCL)
. Oblique cord

Correct Answer & Explanation

. Medial ulnar collateral ligament (UCL)

Explanation

The Medial Ulnar Collateral Ligament (UCL), specifically its anterior bundle, is the primary static stabilizer of the elbow against valgus stress. Injuries to the UCL are common in overhead throwing athletes (e.g., 'Tommy John' injury). The radial collateral ligament complex provides varus and posterolateral rotatory stability. The annular ligament stabilizes the radial head. The oblique cord has a minor role.

Question 3059

Topic: 9. Shoulder and Elbow

What is the most common direction of glenohumeral instability?

. Anterior
. Posterior
. Inferior
. Multidirectional
. Superior

Correct Answer & Explanation

. Anterior

Explanation

Anterior glenohumeral instability (dislocation or subluxation) is by far the most common direction of shoulder instability, accounting for over 95% of cases. This is due to the inherent anatomy of the glenohumeral joint, with less anterior bony constraint and the typical mechanism of injury involving abduction and external rotation. Posterior and inferior instability are less common, and multidirectional instability involves instability in multiple directions.

Question 3060

Topic: 9. Shoulder and Elbow

A 70-year-old male with a history of congestive heart failure and chronic hyponatremia (baseline Na+ 128 mEq/L) is scheduled for elective shoulder surgery. His current medications include Furosemide. What is the most appropriate management of his hyponatremia perioperatively?

. Administer 3% hypertonic saline pre-operatively to normalize sodium
. Discontinue Furosemide pre-operatively and restrict fluids
. Continue Furosemide and monitor sodium closely
. Administer oral sodium tablets pre-operatively
. Delay surgery until hyponatremia is completely resolved

Correct Answer & Explanation

. Discontinue Furosemide pre-operatively and restrict fluids

Explanation

This patient has hypervolemic hyponatremia due to congestive heart failure and loop diuretic use. Furosemide, a loop diuretic, can contribute to hyponatremia, though less commonly than thiazides. For chronic, asymptomatic hyponatremia, the goal is often to prevent further drops and avoid overcorrection. Discontinuing the diuretic (if medically safe) and implementing judicious fluid restriction can help improve sodium balance. Administering 3% hypertonic saline is reserved for severe, symptomatic hyponatremia. Continuing Furosemide without other interventions would likely perpetuate the hyponatremia. Oral sodium tablets would exacerbate fluid retention. Delaying surgery for mild, chronic, asymptomatic hyponatremia may not be necessary if managed appropriately.

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