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9. Shoulder and Elbow MCQs

Practice Set 154 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 3061

Topic: 9. Shoulder and Elbow

A 50-year-old male undergoes arthroscopic rotator cuff repair. Postoperatively, he develops progressive shoulder stiffness and pain, disproportionate to the expected recovery. He has limited active and passive range of motion, particularly external rotation and abduction. What is the most likely complication, and what is its typical management?

. Re-tear of the rotator cuff; revision surgery.
. Adhesive capsulitis (frozen shoulder); physical therapy and potentially manipulation under anesthesia.
. Infection; surgical debridement and antibiotics.
. Deltoid dehiscence; surgical repair.
. Neurovascular injury; neurosurgical consultation.

Correct Answer & Explanation

. Adhesive capsulitis (frozen shoulder); physical therapy and potentially manipulation under anesthesia.

Explanation

The clinical picture of progressive shoulder stiffness, pain, and limited active and passive range of motion after shoulder surgery is highly suggestive of adhesive capsulitis, commonly known as frozen shoulder. It can occur as a complication of rotator cuff repair or other shoulder procedures. Initial management involves aggressive physical therapy, NSAIDs, and potentially corticosteroid injections. If conservative treatment fails, manipulation under anesthesia (MUA) or arthroscopic capsular release may be considered. A re-tear would typically present with pain and weakness, but usually not profound global stiffness. Infection would present with systemic signs (fever, elevated inflammatory markers) and severe localized pain. Deltoid dehiscence would present with deltoid weakness and possibly a palpable defect. Neurovascular injury would have distinct neurological or vascular signs.

Question 3062

Topic: 9. Shoulder and Elbow

A 35-year-old female presents with chronic lateral elbow pain, worsened by gripping and wrist extension. Examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension and forearm supination. X-rays are normal. What is the most appropriate initial management?

. Corticosteroid injection into the extensor tendon origin.
. Surgical release of the common extensor origin.
. Platelet-rich plasma (PRP) injection.
. Rest, NSAIDs, counterforce bracing, and physical therapy focusing on eccentric strengthening.
. Diagnostic arthroscopy of the elbow.

Correct Answer & Explanation

. Rest, NSAIDs, counterforce bracing, and physical therapy focusing on eccentric strengthening.

Explanation

This is a classic presentation of lateral epicondylitis, also known as 'tennis elbow,' which is a tendinopathy of the common extensor origin (primarily ECRB). The initial management is almost always conservative, focusing on activity modification (rest), non-steroidal anti-inflammatory drugs (NSAIDs), a counterforce brace to offload the tendon, and physical therapy, with a strong emphasis on eccentric strengthening exercises for the wrist extensors. Corticosteroid injections can provide short-term pain relief but have been shown to have worse long-term outcomes and may lead to tendon degeneration. Surgical release is reserved for cases refractory to at least 6-12 months of conservative treatment. PRP is a newer treatment with mixed evidence and is not typically first-line. Diagnostic arthroscopy is not indicated for this diagnosis.

Question 3063

Topic: 9. Shoulder and Elbow

A 62-year-old female presents with chronic shoulder pain and weakness. MRI reveals a massive, irreparable rotator cuff tear with superior migration of the humeral head and glenohumeral arthritis (cuff tear arthropathy). She has limited active elevation but preserved passive range of motion. What is the most appropriate surgical intervention?

. Arthroscopic debridement and partial repair.
. Total shoulder arthroplasty.
. Hemiarthroplasty.
. Reverse total shoulder arthroplasty (rTSA).
. Latissimus dorsi transfer.

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (rTSA).

Explanation

The patient's presentation (massive, irreparable rotator cuff tear, superior humeral head migration, glenohumeral arthritis - cuff tear arthropathy, limited active elevation but preserved passive ROM) is a classic indication for reverse total shoulder arthroplasty (rTSA). rTSA reverses the ball-and-socket anatomy, medializes the center of rotation, and tensions the deltoid, allowing the deltoid to effectively elevate the arm in the absence of a functional rotator cuff. Arthroscopic debridement or partial repair would be ineffective for an irreparable tear with established arthropathy. Total shoulder arthroplasty requires an intact rotator cuff. Hemiarthroplasty might address pain but not active elevation. Latissimus dorsi transfer is an option for younger, active patients with irreparable posterosuperior tears and good deltoid function, but less effective with established arthropathy and superior migration.

Question 3064

Topic: 9. Shoulder and Elbow

A 50-year-old male presents with chronic cough, weight loss, and severe right shoulder pain. Radiographs of the shoulder are unremarkable, but a chest X-ray shows an apical mass. What is the most likely diagnosis causing his shoulder pain?

. Rotator cuff tear.
. Adhesive capsulitis.
. Bicipital tendinitis.
. Pancoast tumor.
. Cervical radiculopathy.

Correct Answer & Explanation

. Pancoast tumor.

Explanation

This is a classic presentation of a Pancoast tumor, which is an apical lung tumor. It can invade the brachial plexus, leading to severe shoulder and arm pain (often mimicking musculoskeletal shoulder pathology or cervical radiculopathy), and can also cause Horner's syndrome if the sympathetic chain is involved. The chronic cough and weight loss are systemic symptoms of lung cancer. The key here is the apical mass seen on chest X-ray in conjunction with shoulder pain. The other conditions are primarily musculoskeletal or neurological and would not explain the lung mass or systemic symptoms.

Question 3065

Topic: Shoulder Pathology

A 45-year-old male presents with right shoulder and arm pain, tingling in the fourth and fifth fingers, and a positive Adson's test. He also complains of intermittent arm swelling and discoloration. Which type of thoracic outlet syndrome is most likely?

. Neurogenic thoracic outlet syndrome.
. Arterial thoracic outlet syndrome.
. Venous thoracic outlet syndrome.
. Mixed neurovascular thoracic outlet syndrome.
. Pancoast tumor-induced TOS.

Correct Answer & Explanation

. Venous thoracic outlet syndrome.

Explanation

The patient's symptoms of pain, tingling in the ulnar nerve distribution (suggesting brachial plexus involvement), a positive Adson's test (indicating compression), combined withintermittent arm swelling and discoloration, are highly indicative of venous thoracic outlet syndrome. This involves compression of the subclavian vein, which can lead to thrombosis (Paget-Schroetter syndrome), edema, and cyanosis. Neurogenic TOS would primarily present with neurological symptoms. Arterial TOS would involve symptoms of ischemia (pallor, coolness, claudication). While there's a neurological component, the vascular signs of swelling and discoloration point specifically to venous compression. Pancoast tumor can mimic TOS but typically causes Horner's syndrome and doesn't usually cause vascular swelling/discoloration.

Question 3066

Topic: 9. Shoulder and Elbow

A 55-year-old painter presents with chronic right shoulder pain, worse with overhead activities. Examination reveals pain with resisted abduction and external rotation, and a positive Neer's and Hawkins' sign. Plain radiographs are unremarkable. Which of the following is the most likely diagnosis?

. Adhesive capsulitis
. Glenohumeral osteoarthritis
. Subacromial impingement syndrome with possible rotator cuff tendinopathy
. Bicipital tendinopathy
. Acromioclavicular (AC) joint arthritis

Correct Answer & Explanation

. Subacromial impingement syndrome with possible rotator cuff tendinopathy

Explanation

The patient's age, occupation, pain with overhead activities, and positive impingement signs (Neer's, Hawkins') are highly suggestive of subacromial impingement syndrome, which often involves rotator cuff tendinopathy (especially supraspinatus). Adhesive capsulitis presents with global range of motion restriction. Glenohumeral OA would show joint space narrowing on X-ray. Bicipital tendinopathy typically causes anterior shoulder pain, and AC joint arthritis pain is localized to the AC joint.

Question 3067

Topic: 9. Shoulder and Elbow

A 45-year-old construction worker presents with insidious onset, aching pain in his right elbow, aggravated by gripping and wrist extension. Physical examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension with the elbow extended. What is the most likely diagnosis?

. Medial epicondylitis (Golfer's elbow)
. Olecranon bursitis
. Lateral epicondylitis (Tennis elbow)
. Ulnar nerve entrapment
. Radial head fracture

Correct Answer & Explanation

. Lateral epicondylitis (Tennis elbow)

Explanation

The symptoms (pain over the lateral epicondyle, aggravated by gripping and resisted wrist extension) are classic for lateral epicondylitis, commonly known as Tennis elbow. This is an overuse tendinopathy affecting the common extensor origin. Medial epicondylitis involves the common flexor origin. Olecranon bursitis involves swelling over the olecranon. Ulnar nerve entrapment would present with paresthesia in the small finger and ulnar half of the ring finger. A radial head fracture would have an acute traumatic onset.

Question 3068

Topic: 9. Shoulder and Elbow

A 22-year-old male sustains a traumatic anterior shoulder dislocation. After successful closed reduction, which of the following is the most important instruction to give the patient to prevent recurrence?

. Avoid lifting heavy objects for 6 weeks
. Keep the arm in an abducted and externally rotated position
. Perform aggressive range of motion exercises immediately
. Immobilize the arm in a sling for 3-4 weeks, avoiding abduction and external rotation
. Undergo immediate surgical stabilization

Correct Answer & Explanation

. Immobilize the arm in a sling for 3-4 weeks, avoiding abduction and external rotation

Explanation

After a traumatic anterior shoulder dislocation, especially in younger patients who have a high risk of recurrence, immobilization in a sling (typically for 3-4 weeks) is crucial to allow the labral-ligamentous structures to heal. Avoiding positions of abduction and external rotation (the 'at-risk' position for anterior dislocation) during the healing phase is paramount. Immediate surgical stabilization is not indicated for a first-time dislocation in most cases. Aggressive range of motion or maintaining the arm in the 'at-risk' position would promote recurrence.

Question 3069

Topic: 9. Shoulder and Elbow

A 60-year-old patient presents with pain and deformity of the proximal humerus following a fall. Radiographs reveal a 3-part proximal humerus fracture. Which of the following factors is most important in determining whether to proceed with surgical fixation versus shoulder arthroplasty (hemiarthroplasty or reverse total shoulder arthroplasty)?

. Patient's hand dominance.
. Age and bone quality.
. Presence of an associated rotator cuff tear.
. Risk of avascular necrosis of the humeral head.
. Time from injury to presentation.

Correct Answer & Explanation

. Age and bone quality.

Explanation

For complex proximal humerus fractures (e.g., 3- or 4-part), the decision between fixation (ORIF) and arthroplasty is multifactorial, butage and bone qualityare consistently among the most important determinants. In younger, active patients with good bone stock, ORIF is generally attempted. In elderly, osteoporotic patients with comminuted fractures where stable fixation is unlikely or bone healing is compromised, arthroplasty (hemiarthroplasty or reverse TSA) is often preferred. Risk of AVN is a consideration with fixation, but poor bone quality often precludes successful fixation in the first place. Rotator cuff tears are often associated and influence the choice between hemiarthroplasty and reverse TSA, but age and bone quality are more fundamental for the initial fixation vs. replacement decision.

Question 3070

Topic: 9. Shoulder and Elbow

A 40-year-old female presents with chronic lateral elbow pain, exacerbated by gripping and lifting. She has tenderness over the lateral epicondyle and reproduces pain with resisted wrist extension and forearm supination. Which of the following is the most likely diagnosis?

. Medial epicondylitis ('golfer's elbow').
. Olecranon bursitis.
. Cubital tunnel syndrome.
. Lateral epicondylitis ('tennis elbow').
. Distal biceps tendon rupture.

Correct Answer & Explanation

. Lateral epicondylitis ('tennis elbow').

Explanation

The symptoms (chronic lateral elbow pain, tenderness over the lateral epicondyle, pain with resisted wrist extension and forearm supination) 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 tendon. Medial epicondylitis (golfer's elbow) involves the common flexor origin. Olecranon bursitis is swelling over the olecranon tip. Cubital tunnel syndrome is ulnar nerve compression. Distal biceps rupture causes weakness in supination and flexion with a visible deformity.

Question 3071

Topic: 9. Shoulder and Elbow

A 45-year-old male sustains a complete tear of the distal biceps tendon. He has significant weakness in forearm supination and elbow flexion. Which of the following is the most appropriate management for this injury in an otherwise healthy and active individual?

. Conservative management with a sling and physical therapy.
. Percutaneous repair with sutures.
. Delayed surgical repair after 6 weeks of rest.
. Open surgical repair with reattachment to the radial tuberosity.
. Activity modification and NSAIDs.

Correct Answer & Explanation

. Open surgical repair with reattachment to the radial tuberosity.

Explanation

For active individuals with a complete rupture of the distal biceps tendon, open surgical repair with reattachment to the radial tuberosity is the gold standard. This restores supination strength and elbow flexion power, which are significantly compromised with non-operative management. Conservative management leads to permanent weakness. Percutaneous repair can be less robust than open repair. Delayed repair after 6 weeks becomes more challenging due to tendon retraction and scarring. Activity modification and NSAIDs are not treatments for a complete rupture.

Question 3072

Topic: 9. Shoulder and Elbow

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

. Surgical excision of the calcific deposit.
. Corticosteroid injection into the subacromial space.
. Physical therapy focusing on strengthening exercises.
. Aggressive massage and heat therapy.
. Immediate arthroscopic debridement.

Correct Answer & Explanation

. Corticosteroid injection into the subacromial space.

Explanation

Acute calcific tendinitis of the shoulder can be exquisitely painful. Initial management often involves conservative measures such as rest, NSAIDs, and a subacromial corticosteroid injection, which can effectively reduce inflammation and pain. Surgical excision is reserved for chronic, refractory cases. Physical therapy for strengthening is not appropriate in the acute painful phase. Aggressive massage and heat can exacerbate symptoms. Arthroscopic debridement is a surgical intervention for failed conservative care.

Question 3073

Topic: 9. Shoulder and Elbow

Which of the following is a classic indication for surgical repair of a full-thickness rotator cuff tear?

. Chronic, asymptomatic tear in an elderly patient.
. Partial-thickness tear with minimal pain.
. Small, full-thickness tear in a highly active, younger patient with functional deficits.
. Large, irreparable tear in a patient with glenohumeral arthritis.
. Any rotator cuff tear, regardless of symptoms.

Correct Answer & Explanation

. Small, full-thickness tear in a highly active, younger patient with functional deficits.

Explanation

Surgical repair of a full-thickness rotator cuff tear is typically indicated for highly active, younger patients (under 60-65 years) who experience significant pain, weakness, or functional deficits that have failed conservative management, even for smaller tears, to prevent progression and restore function. Asymptomatic tears, partial tears with minimal symptoms, or irreparable tears in patients with advanced arthritis are generally managed conservatively or with alternative procedures (e.g., reverse total shoulder arthroplasty for cuff tear arthropathy).

Question 3074

Topic: 9. Shoulder and Elbow

A 60-year-old female presents with progressive difficulty with overhead activities and external rotation of her left shoulder. She reports chronic dull pain exacerbated by movement. On examination, she has severe pain and weakness with resisted external rotation and abduction. What is the most likely diagnosis?

. Adhesive capsulitis
. Subacromial impingement syndrome
. Rotator cuff tear
. Biceps tendinopathy
. Glenohumeral osteoarthritis

Correct Answer & Explanation

. Rotator cuff tear

Explanation

The combination of progressive difficulty with overhead activities, weakness with resisted external rotation and abduction, and chronic pain is highly suggestive of a rotator cuff tear, particularly affecting the supraspinatus and/or infraspinatus. Adhesive capsulitis presents with global restriction of both active and passive range of motion. Subacromial impingement syndrome typically causes pain with overhead activities but not necessarily profound weakness in resisted movements. Biceps tendinopathy causes pain in the anterior shoulder. Glenohumeral osteoarthritis would present with crepitus and restricted passive range of motion, often with significant pain.

Question 3075

Topic: Elbow & Forearm

Which tendon is most commonly involved in 'tennis elbow' (lateral epicondylitis)?

. Flexor carpi radialis
. Flexor carpi ulnaris
. Extensor carpi ulnaris
. Extensor carpi radialis brevis
. Brachioradialis

Correct Answer & Explanation

. Extensor carpi radialis brevis

Explanation

Lateral epicondylitis, or 'tennis elbow,' is a degenerative condition affecting the common extensor origin at the lateral epicondyle, with the Extensor Carpi Radialis Brevis (ECRB) tendon being most commonly involved. Repetitive wrist extension and supination contribute to its development. The other tendons listed are either flexors or less commonly involved in this specific condition.

Question 3076

Topic: 9. Shoulder and Elbow

After a Colles fracture has been surgically stabilized with a volar locking plate, what is the recommended immediate post-operative rehabilitation protocol for finger motion?

. Full immobilization of all digits for 6 weeks to ensure fracture healing.
. Immediate, active and passive range of motion exercises for the fingers and thumb.
. Gentle passive range of motion of fingers, avoiding active motion.
. Active range of motion only for the shoulder and elbow.
. Splinting of the fingers in extension.

Correct Answer & Explanation

. Immediate, active and passive range of motion exercises for the fingers and thumb.

Explanation

A significant advantage of stable surgical fixation with a volar locking plate is the ability to initiate immediate, active and passive range of motion exercises for the fingers and thumb. This helps prevent stiffness, tendon adhesions, and reduces the risk of CRPS. The wrist itself may be protected initially with a removable splint, but finger motion is encouraged from day one. Full immobilization of digits is detrimental. Restricted passive motion is less beneficial than active.

Question 3077

Topic: 9. Shoulder and Elbow

A 60-year-old sedentary female presents with chronic shoulder pain, primarily with overhead activities. Physical examination reveals a positive Neer's and Hawkins' sign, but full active and passive range of motion. Strength is 5/5 in all planes. Radiographs show acromial spurring and mild AC joint arthrosis. Initial non-operative management has failed. What is the most likely diagnosis?

. Rotator cuff tear
. Adhesive capsulitis
. Glenohumeral osteoarthritis
. Subacromial impingement syndrome
. Biceps tendinopathy

Correct Answer & Explanation

. Subacromial impingement syndrome

Explanation

The clinical picture of chronic shoulder pain with overhead activities, positive impingement signs (Neer's and Hawkins'), full range of motion, and normal strength points strongly towards subacromial impingement syndrome. Acromial spurring on radiographs further supports this. A rotator cuff tear would typically present with weakness, especially with active range of motion. Adhesive capsulitis (frozen shoulder) involves significant global loss of both active and passive range of motion. Glenohumeral osteoarthritis would show significant radiographic changes and painful loss of passive motion. Biceps tendinopathy could be a component but impingement is the overarching diagnosis for these symptoms and signs.

Question 3078

Topic: 9. Shoulder and Elbow

A 35-year-old male presents with chronic pain and instability of the elbow. Radiographs show osteochondritis dissecans (OCD) of the capitellum, with a loose body. Which of the following is the most appropriate treatment?

. Sling immobilization and rest.
. NSAIDs and physical therapy.
. Arthroscopic debridement and loose body removal.
. Radial head excision.
. Elbow arthroplasty.

Correct Answer & Explanation

. Arthroscopic debridement and loose body removal.

Explanation

Osteochondritis dissecans (OCD) of the capitellum, especially with a symptomatic loose body, requires surgical intervention. Arthroscopic debridement and removal of the loose body are the most appropriate treatment to relieve mechanical symptoms (pain, locking) and prevent further articular damage. If the fragment is large and potentially salvageable, internal fixation may be attempted. Conservative management is for stable lesions without loose bodies or in the early stages. Radial head excision is for radial head fractures or severe arthritis. Elbow arthroplasty is a salvage procedure for end-stage arthritis.

Question 3079

Topic: 9. Shoulder and Elbow

A 50-year-old construction worker presents with insidious onset of right elbow pain, particularly exacerbated by gripping and lifting. Examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension. What is the most appropriate initial management?

. Corticosteroid injection
. Surgical debridement of extensor origin
. PRP injection
. Activity modification, NSAIDs, physical therapy, counterforce brace
. Immobilization in a long arm cast

Correct Answer & Explanation

. Activity modification, NSAIDs, physical therapy, counterforce brace

Explanation

The symptoms are classic for lateral epicondylitis (tennis elbow). The initial management is overwhelmingly conservative, focusing on activity modification, NSAIDs (for pain relief, not primary treatment of the tendinosis), physical therapy (stretching, strengthening, eccentric exercises), and use of a counterforce brace. Corticosteroid injections provide short-term relief but can be detrimental long-term. PRP is an emerging therapy but not initial. Surgery is reserved for recalcitrant cases failing extensive conservative treatment. Immobilization is generally not indicated and can lead to stiffness.

Question 3080

Topic: 9. Shoulder and Elbow

A 58-year-old male undergoes arthroscopic rotator cuff repair. Postoperatively, he develops sudden, severe anterior shoulder pain and inability to actively abduct or externally rotate the shoulder. On examination, he has a positive 'drop arm' sign. What is the most likely cause of this acute decline?

. Adhesive capsulitis
. Recurrent rotator cuff tear
. Postoperative infection
. Axillary nerve injury
. Subdeltoid impingement

Correct Answer & Explanation

. Recurrent rotator cuff tear

Explanation

The sudden onset of severe anterior shoulder pain, inability to actively abduct or externally rotate the shoulder, and a positive 'drop arm' sign after rotator cuff repair are highly suggestive of an acute recurrent rotator cuff tear. Adhesive capsulitis typically develops gradually with progressive stiffness. Infection would present with systemic signs and increasing pain but not usually acute inability to move. Axillary nerve injury would primarily affect deltoid function (abduction). Subdeltoid impingement would cause pain but not typically complete inability to move or a positive drop arm sign post-repair.

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