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9. Shoulder and Elbow MCQs

Practice Set 158 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 3141

Topic: 9. Shoulder and Elbow

A 25-year-old rugby player sustains an acute anterior shoulder dislocation. During the reduction in the emergency department, the physician notes weakness in shoulder abduction and decreased sensation over the lateral deltoid. Which of the following describes the most likely associated nerve injury and its typical prognosis?

. Musculocutaneous nerve; requires immediate surgical exploration
. Axillary nerve; typically a neuropraxia that recovers completely with observation
. Suprascapular nerve; permanent unless the labrum is repaired immediately
. Radial nerve; requires EMG at 1 week to determine intervention
. Long thoracic nerve; typically causes immediate winging of the scapula

Correct Answer & Explanation

. Musculocutaneous nerve; requires immediate surgical exploration

Explanation

The axillary nerve is the most commonly injured nerve during an anterior glenohumeral dislocation. It presents with weakness in the deltoid and teres minor, and sensory loss over the 'regimental badge' area (lateral deltoid). Fortunately, the injury is almost always a neuropraxia (stretching) that resolves spontaneously over weeks to months, and observation is the standard of care.

Question 3142

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate baseball pitcher undergoes an ulnar collateral ligament (UCL) reconstruction using the docking technique. What is the primary anatomical landmark for the accurate placement of the ulnar bone tunnel?

. Coronoid process
. Sublime tubercle
. Supinator crest
. Olecranon tip
. Radial tuberosity

Correct Answer & Explanation

. Coronoid process

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow. It originates on the anterior inferior surface of the medial epicondyle and inserts on the sublime tubercle of the proximal ulna (located at the anteromedial aspect of the coronoid). Therefore, the sublime tubercle is the critical anatomical landmark for ulnar tunnel placement during UCL reconstruction.

Question 3143

Topic: Elbow & Forearm

A 13-year-old male gymnast presents with a 4-month history of lateral elbow pain, locking, and catching. MRI demonstrates an osteochondritis dissecans (OCD) lesion of the capitellum with T2 fluid signal interposing between the osteochondral fragment and the underlying bone. What is the most appropriate next step in management?

. Rest, NSAIDs, and cessation of upper extremity weight-bearing for 3 months
. Arthroscopic evaluation with fragment drilling and potential fixation
. Open osteochondral allograft transplantation
. Ulnar nerve transposition to relieve secondary neuritis
. Resection of the capitellar fragment and radial head excision

Correct Answer & Explanation

. Rest, NSAIDs, and cessation of upper extremity weight-bearing for 3 months

Explanation

The patient has an unstable OCD lesion of the capitellum, as indicated by the presence of locking/catching and the MRI finding of T2 fluid signal behind the fragment (which signifies instability). While stable lesions in patients with open physes can be treated nonoperatively (rest), unstable lesions require surgical intervention. Arthroscopic evaluation to assess stability, followed by drilling (to promote healing) and internal fixation of the salvageable fragment, is the standard of care. Open osteochondral allograft is reserved for large, unsalvageable defects that have failed primary fixation.

Question 3144

Topic: 9. Shoulder and Elbow

A 12-year-old baseball pitcher presents with progressive medial elbow pain and decreased pitch velocity. Radiographs reveal widening and irregularity of the medial epicondyle apophysis. He is diagnosed with 'Little Leaguer's Elbow' (medial epicondyle apophysitis). What is the primary biomechanical force responsible for this condition?

. Valgus overload causing tension on the medial structures
. Varus overload causing compression on the medial structures
. Posterior shear forces during the follow-through phase
. Axial loading during the wind-up phase
. Hyperextension forces causing olecranon impingement

Correct Answer & Explanation

. Valgus overload causing tension on the medial structures

Explanation

During the late cocking and early acceleration phases of throwing, tremendous valgus torque is placed on the elbow. In adults, this force is primarily resisted by the ulnar collateral ligament (UCL). In skeletally immature athletes, the apophyseal growth plate is the weakest link, leading to tension overload and subsequent medial epicondyle apophysitis, commonly known as Little Leaguer's Elbow. It is a tension failure, whereas the lateral side undergoes compression (capitellar OCD).

Question 3145

Topic: Elbow & Forearm

A 19-year-old collegiate baseball pitcher undergoes a modified Jobe ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft. Which of the following represents the most common postoperative complication associated with this specific surgical technique?

. Medial epicondyle fracture.
. Graft rupture.
. Ulnar neuropathy.
. Heterotopic ossification of the ulnohumeral joint.
. Deep space infection.

Correct Answer & Explanation

. Medial epicondyle fracture.

Explanation

Ulnar neuropathy is the most frequent complication following UCL reconstruction, particularly with techniques like the modified Jobe that involve routine ulnar nerve transposition. Modern techniques, such as the docking procedure, minimize nerve handling and have significantly reduced this risk.

Question 3146

Topic: 9. Shoulder and Elbow

An 82-year-old female with severe osteopenia falls from a standing height, sustaining a 4-part valgus-impacted proximal humerus fracture, as shown in the image below. She has limited pre-injury shoulder function due to long-standing rotator cuff arthropathy and a low demand lifestyle.

What is the most appropriate surgical treatment option for this patient?

. Open reduction internal fixation (ORIF) with a locking plate
. Intramedullary nailing
. Hemiarthroplasty
. Reverse total shoulder arthroplasty (RTSA)
. Non-operative management with a sling and early rehabilitation

Correct Answer & Explanation

. Open reduction internal fixation (ORIF) with a locking plate

Explanation

For elderly patients with complex 3- or 4-part proximal humerus fractures, especially in the setting of osteopenia and pre-existing rotator cuff dysfunction or rotator cuff arthropathy, reverse total shoulder arthroplasty (RTSA) has shown superior functional outcomes and lower reoperation rates compared to ORIF or hemiarthroplasty. ORIF has high failure rates in osteopenic bone, and hemiarthroplasty relies on a functional rotator cuff for optimal results, which is often compromised in this demographic. Non-operative management would likely lead to poor functional recovery in a displaced 4-part fracture.

Question 3147

Topic: 9. Shoulder and Elbow
A 45-year-old male sustains a fall onto an outstretched hand, resulting in a complex elbow injury. Radiographs confirm a posterior elbow dislocation, a Mason Type III radial head fracture, and a Regan-Morrey Type II coronoid fracture. Which of the following represents the most appropriate sequence and combination of surgical interventions for this 'terrible triad' injury?
. Radial head excision, coronoid ORIF, LCL repair, followed by MCL repair if instability persists.
. ORIF of coronoid, radial head replacement, LCL repair, and if necessary, MCL repair.
. ORIF of radial head, coronoid excision, LCL repair, then MCL repair.
. Elbow arthrodesis to ensure stability and pain relief.
. Closed reduction, long-arm casting for 6 weeks, then gradual range of motion.

Correct Answer & Explanation

. ORIF of coronoid, radial head replacement, LCL repair, and if necessary, MCL repair.

Explanation

The 'terrible triad' injury involves an elbow dislocation, radial head fracture, and coronoid fracture. Surgical management aims to restore stability and congruity. The preferred approach involves: 1) ORIF of the coronoid fracture (essential for elbow stability), 2) radial head replacement for Mason Type III fractures (ORIF if simple and reconstructible, but replacement is common for comminuted injuries), 3) repair of the lateral collateral ligament (LCL) complex (the primary varus and posterolateral stabilizer), and 4) repair of the medial collateral ligament (MCL) if significant instability persists after the initial repairs. Radial head excision alone can lead to valgus instability and wrist pain. Arthrodesis is a salvage procedure, not primary treatment. Closed reduction and casting alone are insufficient for such complex unstable injuries.

Question 3148

Topic: 9. Shoulder and Elbow

A 68-year-old male presents with chronic severe right shoulder pain and significant weakness, limiting his active abduction to 60 degrees. MRI imaging, similar to the one shown, confirms a massive, irreparable posterosuperior rotator cuff tear with significant superior migration of the humeral head and Goutallier Grade 3 fatty infiltration of the infraspinatus.

Given these findings and his age, what is the most appropriate surgical intervention?

. Arthroscopic debridement and biceps tenodesis
. Superior capsular reconstruction (SCR)
. Reverse total shoulder arthroplasty (RTSA)
. Partial rotator cuff repair with augmentation
. Latissimus dorsi tendon transfer

Correct Answer & Explanation

. Arthroscopic debridement and biceps tenodesis

Explanation

For an elderly patient with a massive, irreparable rotator cuff tear, significant superior humeral head migration (rotator cuff arthropathy), fatty infiltration of the rotator cuff muscles, and poor active elevation, reverse total shoulder arthroplasty (RTSA) is the gold standard. RTSA bypasses the need for a functional rotator cuff by medializing the center of rotation and tensioning the deltoid, leading to predictable pain relief and improved active elevation. Debridement and biceps tenodesis are palliative and unlikely to restore function. SCR is typically considered in younger, active patients with irreparable tears but without significant glenohumeral arthritis or superior migration. Partial repair or augmentation may be attempted in younger patients with less severe muscle atrophy and without significant cuff tear arthropathy. Latissimus dorsi transfer is an option for irreparable posterosuperior tears, particularly in younger, active patients without advanced arthropathy.

Question 3149

Topic: Elbow & Forearm

A 45-year-old male presents with acute anterior elbow pain and a palpable defect after feeling a 'pop' while lifting a heavy couch. The Hook test is positive. If the surgeon elects to perform a single-incision anterior approach for anatomic repair, which of the following nerves is at highest risk of iatrogenic injury?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. The posterior interosseous nerve is at higher risk with a two-incision approach.

Question 3150

Topic: Shoulder Pathology

A 25-year-old military recruit presents with aching shoulder pain and notable medial prominence of his right scapula (medial winging) when asked to perform a wall push-up. Which nerve is most likely injured?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Medial scapular winging is caused by serratus anterior paralysis due to long thoracic nerve palsy. Lateral winging is associated with trapezius dysfunction from spinal accessory nerve injury.

Question 3151

Topic: Elbow & Forearm

A patient presents with a 'terrible triad' of the elbow, which includes a posterior dislocation, radial head fracture, and coronoid fracture. When performing surgical reconstruction for this injury complex, what is the standard, biomechanically validated sequence of fixation?

. Coronoid, then radial head, then lateral collateral ligament (LCL)
. Radial head, then coronoid, then medial collateral ligament (MCL)
. LCL, then radial head, then coronoid
. MCL, then LCL, then coronoid
. Coronoid, then MCL, then radial head

Correct Answer & Explanation

. Coronoid, then radial head, then lateral collateral ligament (LCL)

Explanation

The standard surgical algorithm for the terrible triad works deep to superficial and anterior to posterior: fix the coronoid first, replace or fix the radial head second, and finally repair the LCL complex.

Question 3152

Topic: Elbow & Forearm

A 42-year-old male bodybuilder feels a 'pop' in his antecubital fossa while performing heavy deadlifts. Clinical examination reveals a positive hook test. If a single-incision anterior surgical approach is chosen for repair, which structure is at the greatest risk of iatrogenic injury?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous (LABC) nerve is the most commonly injured structure during a single-incision anterior approach for distal biceps repair. In contrast, the posterior interosseous nerve (PIN) is at higher risk during a two-incision approach if retractors are improperly placed.

Question 3153

Topic: 9. Shoulder and Elbow

Reverse total shoulder arthroplasty (RTSA) is indicated for a 72-year-old with pseudoparalysis secondary to a massive irreparable rotator cuff tear. How does RTSA alter the shoulder biomechanics to allow the deltoid to initiate abduction?

. Lateralizes and superiorly translates the center of rotation
. Medializes and distalizes the center of rotation
. Medializes and superiorly translates the center of rotation
. Lateralizes and distalizes the center of rotation
. Maintains the anatomic center of rotation but increases deltoid tension

Correct Answer & Explanation

. Lateralizes and superiorly translates the center of rotation

Explanation

RTSA medializes and distalizes the center of rotation of the glenohumeral joint. This increases the lever arm of the deltoid and recruits more deltoid fibers, allowing it to initiate and power abduction in a cuff-deficient shoulder.

Question 3154

Topic: 9. Shoulder and Elbow

A 50-year-old diabetic female presents with 'frozen shoulder'. She has significant limitation of passive external rotation with the arm at the side. Contracture of which of the following structures is primarily responsible for this specific physical exam finding?

. Coracohumeral ligament
. Anterior band of the inferior glenohumeral ligament
. Posterior capsule
. Middle glenohumeral ligament
. Superior glenohumeral ligament

Correct Answer & Explanation

. Coracohumeral ligament

Explanation

Contracture of the coracohumeral ligament within the rotator interval is the primary restrictor of passive external rotation when the arm is adducted at the patient's side.

Question 3155

Topic: Elbow & Forearm
A 55-year-old female presents with base of thumb pain. Radiographs reveal Eaton-Littler Stage III basal joint arthritis. She is scheduled for a ligament reconstruction and tendon interposition (LRTI). Which tendon is most commonly harvested for this procedure?
. Flexor carpi radialis (FCR)
. Abductor pollicis longus (APL)
. Extensor carpi radialis brevis (ECRB)
. Palmaris longus
. Extensor pollicis brevis (EPB)

Correct Answer & Explanation

. Flexor carpi radialis (FCR)

Explanation

The flexor carpi radialis (FCR) is the most frequently harvested tendon for an LRTI procedure to stabilize the thumb metacarpal base after trapeziectomy, reconstructing the beak ligament.

Question 3156

Topic: 9. Shoulder and Elbow

A 22-year-old collegiate baseball pitcher reports medial elbow pain during the late cocking and early acceleration phases of throwing. On examination, he has valgus laxity when the elbow is flexed between 30 and 120 degrees. Which specific anatomical structure is most likely compromised?

. Posterior bundle of the ulnar collateral ligament
. Transverse bundle of the ulnar collateral ligament
. Anterior bundle of the ulnar collateral ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament

Correct Answer & Explanation

. Posterior bundle of the ulnar collateral ligament

Explanation

The anterior bundle of the ulnar collateral ligament is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion, which is critical during the throwing motion.

Question 3157

Topic: Shoulder Pathology

A 25-year-old tennis player complains of shoulder weakness and a prominent shoulder blade following a viral illness. On physical examination, forward elevation of the arm against resistance demonstrates pronounced medial winging of the scapula. An injury to which of the following nerves is the most likely cause of this clinical presentation?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Medial winging of the scapula is caused by serratus anterior paralysis, which is innervated by the long thoracic nerve. Lateral winging is typically associated with spinal accessory nerve palsies affecting the trapezius.

Question 3158

Topic: Elbow & Forearm

During an anterior single-incision surgical repair of a distal biceps tendon rupture, the patient is at highest risk for injury to a specific peripheral nerve. Injury to this nerve typically results in which of the following clinical deficits?

. Weakness in thumb extension
. Numbness over the lateral aspect of the forearm
. Inability to flex the distal interphalangeal joint of the index finger
. Numbness over the dorsal web space between the thumb and index finger
. Weakness in spreading the fingers against resistance

Correct Answer & Explanation

. Weakness in thumb extension

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision distal biceps repair. Injury results in numbness over the lateral (radial) aspect of the forearm.

Question 3159

Topic: 9. Shoulder and Elbow

A 72-year-old male presents with severe shoulder pain and an inability to actively elevate his arm above 40 degrees. Deltoid function is intact. Radiographs reveal advanced glenohumeral arthritis with severe superior migration of the humeral head (acetabularization of the coracoacromial arch).

What is the most appropriate definitive management?

. Arthroscopic superior capsule reconstruction
. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic debridement and biceps tenodesis

Correct Answer & Explanation

. Arthroscopic superior capsule reconstruction

Explanation

The patient has classic rotator cuff arthropathy with pseudoparalysis. Reverse total shoulder arthroplasty (RTSA) is the treatment of choice as it alters the center of rotation, allowing the intact deltoid to initiate and maintain shoulder elevation.

Question 3160

Topic: 9. Shoulder and Elbow

A 30-year-old male with a severe traumatic brain injury sustains an elbow dislocation. He subsequently develops severe heterotopic ossification (HO) bridging the radiocapitellar joint, causing a rigid block to forearm rotation. When is the optimal time for surgical excision of the HO?

. Immediately upon radiographic appearance
. After 3 months, only if the serum alkaline phosphatase normalizes
. When radiographic margins are sharp and trabecular patterns are visible, typically 4-6 months
. Strictly after 18 months to prevent any recurrence
. Concomitant with prophylactic radiation therapy at 2 weeks post-injury

Correct Answer & Explanation

. Immediately upon radiographic appearance

Explanation

Modern guidelines suggest HO excision can be safely performed once it is radiographically mature (sharp margins, distinct trabecular pattern), typically around 4-6 months. A normal alkaline phosphatase level is no longer considered a strict prerequisite.

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