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9. Shoulder and Elbow MCQs

Practice Set 160 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 3181

Topic: 9. Shoulder and Elbow

A 70-year-old male with a massive, chronic rotator cuff tear presents with worsening shoulder pain. An AP radiograph reveals an acromiohumeral interval of 3 mm, acetabularization of the acromion, and significant narrowing of the true glenohumeral joint space.

According to the Hamada classification of rotator cuff tear arthropathy, what is the correct grade for these radiographic findings?

. Grade 1
. Grade 2
. Grade 3
. Grade 4
. Grade 5

Correct Answer & Explanation

. Grade 1

Explanation

The Hamada classification grades rotator cuff tear arthropathy. Grade 1: AHI > 6 mm. Grade 2: AHI < 5 mm. Grade 3: AHI < 5 mm with acetabularization of the acromion. Grade 4: Presence of glenohumeral arthritis (narrowing of the GH joint space) in addition to superior migration. Grade 5: Humeral head collapse (AVN).

Question 3182

Topic: 9. Shoulder and Elbow

A 25-year-old male sustains a neck injury during a wrestling match. Exam shows drooping of the right shoulder, inability to actively abduct the shoulder above 90 degrees, and the medial border of the scapula is translated laterally. Which of the following physical exam findings is most characteristic of this specific nerve injury?

. Winging of the medial border of the scapula accentuated by pushing against a wall
. Winging of the entire scapula with lateral translation, accentuated by resisted shoulder abduction
. Weakness in external rotation with the arm at the side
. Inability to lift the hand off the lower back
. Numbness over the lateral aspect of the shoulder

Correct Answer & Explanation

. Winging of the medial border of the scapula accentuated by pushing against a wall

Explanation

The clinical picture describes a spinal accessory nerve (CN XI) palsy leading to trapezius muscle weakness. The trapezius elevates, retracts, and upwardly rotates the scapula. Its paralysis causes the scapula to translate laterally and rotate downward, leading to 'lateral winging.' This is accentuated by resisted shoulder abduction. Medial winging is caused by serratus anterior (long thoracic nerve) palsy.

Question 3183

Topic: 9. Shoulder and Elbow

In reverse total shoulder arthroplasty (RTSA), moving the center of rotation medially and distally compared to the native glenohumeral joint achieves which of the following biomechanical advantages?

. It increases the tension of the subscapularis, allowing for better internal rotation.
. It recruits more deltoid fibers and increases the deltoid moment arm.
. It increases the sheer forces at the glenoid bone-implant interface.
. It decreases the required deltoid force by decreasing the lever arm.
. It restores the native anatomical offset of the proximal humerus.

Correct Answer & Explanation

. It increases the tension of the subscapularis, allowing for better internal rotation.

Explanation

The Grammont design principles for RTSA include medializing and distalizing the center of rotation (COR). Distalizing the COR increases the resting tension of the deltoid, while medializing the COR increases the deltoid moment arm and recruits more anterior and posterior deltoid fibers for abduction. This effectively converts sheer forces into compressive forces at the glenoid bone-implant interface, enhancing stability.

Question 3184

Topic: Shoulder Arthroplasty & Arthritis

What is the most common radiographic complication specific to the Grammont-style reverse total shoulder arthroplasty, and how is it biomechanically prevented?

. Glenoid loosening; prevented by superior tilt of the glenosphere
. Scapular notching; prevented by inferior overhang and inferior tilt of the glenosphere
. Humeral stem subsidence; prevented by using a larger diaphyseal stem
. Acromial stress fracture; prevented by increased lateralization of the glenosphere
. Coracoid impingement; prevented by medializing the humeral component

Correct Answer & Explanation

. Glenoid loosening; prevented by superior tilt of the glenosphere

Explanation

Scapular notching is the most common radiographic finding/complication in Grammont-style RTSA. It occurs due to impingement of the medial humeral component against the inferior scapular neck during adduction. It is reduced by placing the glenosphere low on the native glenoid (with inferior overhang) and applying an inferior tilt.

Question 3185

Topic: 9. Shoulder and Elbow

A 52-year-old female with type 1 diabetes presents with severe, progressive shoulder stiffness over the last 6 months. She is currently in the 'frozen' phase of adhesive capsulitis. Which of the following anatomical structures is classically the primary site of fibroblastic proliferation and contracture in this condition?

. Subacromial bursa
. Rotator interval and coracohumeral ligament
. Posterior superior capsule
. Inferior glenohumeral ligament complex only
. Coracoacromial ligament

Correct Answer & Explanation

. Subacromial bursa

Explanation

Adhesive capsulitis primarily involves profound thickening and contracture of the rotator interval capsule and the coracohumeral ligament. The inferior capsule also becomes involved, leading to loss of joint volume, but the rotator interval and CHL contracture uniquely cause the profound loss of external rotation with the arm at the side, which is the hallmark of the disease.

Question 3186

Topic: 9. Shoulder and Elbow
A 45-year-old female presents to the emergency department with acute, excruciating right shoulder pain of 2 days duration. She has no history of trauma. Radiographs reveal a cloudy, poorly defined, 'toothpaste-like' radiopacity adjacent to the greater tuberosity. Which phase of calcific tendinitis is she most likely experiencing, and what is the underlying pathophysiology of the pain?
. Formative phase; deposition of calcium hydroxyapatite crystals
. Resting phase; mechanical impingement of the hardened calcium deposit
. Resorptive phase; vascular invasion, phagocytosis, and intense acute inflammation
. Post-calcific phase; remodeling of the tendon defect with type III collagen
. Pre-calcific phase; fibrocartilaginous metaplasia of the tenocytes

Correct Answer & Explanation

. Resorptive phase; vascular invasion, phagocytosis, and intense acute inflammation

Explanation

Calcific tendinitis is most painful during the resorptive phase. In this phase, the calcium deposit changes from a chalk-like consistency to a toothpaste-like, cloudy appearance on x-ray. Macrophages and multi-nucleated giant cells invade the area to resorb the calcium, causing intense vascularization, edema, and a severe acute inflammatory response, which results in excruciating pain.

Question 3187

Topic: 9. Shoulder and Elbow

A 28-year-old female complains of a painful grating sensation and audible snapping at the superomedial border of her scapula with active shoulder movement. Radiographs reveal a bony prominence on the superomedial aspect of the anterior scapula. What is the eponymous name for this bony variant?

. Hill-Sachs lesion
. Luschka's tubercle
. Sprengel's deformity
. Os acromiale
. Coracoclavicular exostosis

Correct Answer & Explanation

. Hill-Sachs lesion

Explanation

Snapping scapula syndrome involves crepitus between the anterior scapula and the posterior thoracic wall. It can be caused by bursitis (scapulothoracic bursa), osteochondromas, or an anatomical bony prominence at the superomedial angle of the scapula known as Luschka's tubercle. Initial treatment is conservative (PT), but surgical excision is an option for refractory cases.

Question 3188

Topic: Elbow & Forearm

A 32-year-old gymnast falls from a height and presents with an elbow dislocation, a comminuted radial head fracture, and a Type II coronoid fracture. According to established biomechanical principles for treating the 'terrible triad' of the elbow, what is the most widely recommended surgical sequence?

. Fixation of the radial head, repair of the lateral ulnar collateral ligament (LUCL), followed by coronoid fixation
. Fixation of the coronoid, fixation/replacement of the radial head, followed by repair of the LUCL
. Repair of the LUCL, fixation of the coronoid, followed by radial head replacement
. Repair of the medial collateral ligament (MCL), fixation of the radial head, followed by the coronoid
. Fixation of the radial head, repair of the MCL, followed by the LUCL

Correct Answer & Explanation

. Fixation of the radial head, repair of the lateral ulnar collateral ligament (LUCL), followed by coronoid fixation

Explanation

The standard surgical algorithm for a terrible triad injury works from 'deep to superficial' or 'inside out'. The typical sequence is: 1) Fixation of the coronoid (to restore the anterior buttress), 2) Fixation or arthroplasty of the radial head (to restore the radiocapitellar anterior restraint), 3) Repair of the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle. Repair of the MCL is usually only indicated if the elbow remains unstable after the first three steps.

Question 3189

Topic: 9. Shoulder and Elbow

A motorcyclist is ejected and sustains a closed, pulseless, completely flail upper extremity. Chest radiographs demonstrate severe lateral displacement of the scapula. What is the most commonly associated vascular injury in this condition?

. Axillary artery
. Subclavian artery
. Brachial artery
. Thoracoacromial artery

Correct Answer & Explanation

. Axillary artery

Explanation

Scapulothoracic dissociation is a devastating traction injury to the shoulder girdle. The subclavian artery and the brachial plexus are the most commonly injured neurovascular structures due to severe lateral traction.

Question 3190

Topic: Elbow & Forearm

A 35-year-old male sustained a midshaft humerus fracture resulting in a permanent radial nerve palsy. He is undergoing tendon transfer surgery to restore function. To restore functional and balanced wrist extension without inducing significant radial deviation, which of the following is the most preferred tendon transfer?

. Flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB)
. Flexor carpi radialis (FCR) to extensor digitorum communis (EDC)
. Pronator teres (PT) to extensor carpi radialis brevis (ECRB)
. Pronator teres (PT) to extensor carpi radialis longus (ECRL)
. Palmaris longus (PL) to extensor pollicis longus (EPL)

Correct Answer & Explanation

. Flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB)

Explanation

The most widely accepted and reliable tendon transfer to restore wrist extension in a radial nerve palsy is the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB). The ECRB is chosen over the ECRL because its insertion is more central (base of the 3rd metacarpal), which provides pure wrist extension without the radial deviation that occurs when using the ECRL.

Question 3191

Topic: 9. Shoulder and Elbow

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), standard algorithmic principles dictate a specific sequence of repair. Following surgical approach, which of the following is the generally recommended sequence for reconstruction?

. Lateral collateral ligament (LCL) repair -> radial head fixation/replacement -> coronoid fixation
. Coronoid fixation -> radial head fixation/replacement -> LCL repair
. Radial head fixation/replacement -> LCL repair -> coronoid fixation
. LCL repair -> coronoid fixation -> radial head fixation/replacement
. Coronoid fixation -> LCL repair -> radial head fixation/replacement

Correct Answer & Explanation

. Lateral collateral ligament (LCL) repair -> radial head fixation/replacement -> coronoid fixation

Explanation

The standard surgical algorithm for a terrible triad of the elbow proceeds from deep to superficial, or medial/anterior to lateral, via a lateral approach. The correct sequence is: 1) Coronoid fracture fixation (or anterior capsule repair if the fragment is too small), 2) Radial head fixation or arthroplasty, and 3) LCL complex repair to the lateral epicondyle. If the elbow remains unstable after this sequence, MCL repair or a hinged external fixator is considered.

Question 3192

Topic: 9. Shoulder and Elbow

During the late cocking phase of throwing, a baseball pitcher experiences significant torsional forces at the superior labrum-biceps anchor complex. The biomechanical shift of the biceps vector posteriorly, creating a direct torsional force that detached the labrum, is known as the 'peel-back' mechanism. In a Type II SLAP tear resulting from this mechanism, what is the most significant biomechanical consequence for the glenohumeral joint?

. Increased anterior translation of the humeral head in abduction and external rotation
. Increased inferior translation of the humeral head in neutral position
. Obligate internal rotation during forward elevation
. Decreased posterior capsule tightness
. Rupture of the transverse humeral ligament

Correct Answer & Explanation

. Increased anterior translation of the humeral head in abduction and external rotation

Explanation

The superior labrum and the biceps anchor serve as important stabilizers of the glenohumeral joint. A Type II SLAP tear (detachment of the superior labrum and biceps anchor) secondary to the peel-back mechanism results in loss of this stabilization. Biomechanically, this leads to significantly increased anterior translation (strain on the anterior band of the inferior glenohumeral ligament) when the arm is in the abducted, externally rotated (late cocking) position.

Question 3193

Topic: Elbow & Forearm

A fracture involving the capitellum and the lateral half of the trochlea in a single piece, with associated posterior condylar comminution, is evaluated on a CT scan.

According to the Dubberley classification, this is classified as:

. Type 1A
. Type 2A
. Type 2B
. Type 3A
. Type 3B

Correct Answer & Explanation

. Type 1A

Explanation

The Dubberley classification evaluates coronal shear fractures of the distal humerus. Type 1: primarily capitellum. Type 2: capitellum and lateral half of trochlea in a single fragment. Type 3: capitellum and trochlea as separate fragments. Modifiers A and B indicate the absence (A) or presence (B) of posterior condylar comminution. Thus, Type 2B involves the capitellum and trochlea as one piece with posterior comminution.

Question 3194

Topic: Elbow & Forearm

A 40-year-old female presents after falling on an outstretched hand, sustaining a "terrible triad" injury of the elbow.

Which of the following accurately describes the typical sequence of surgical repair for this injury?

. Medial collateral ligament (MCL) repair, coronoid fixation, radial head fixation, lateral collateral ligament (LCL) repair.
. Radial head fixation, LCL repair, coronoid fixation, MCL repair.
. Coronoid fixation, radial head fixation or replacement, LCL repair, followed by MCL repair if the elbow remains unstable.
. LCL repair, radial head replacement, coronoid fixation, MCL repair.
. Coronoid fixation, MCL repair, radial head fixation, LCL repair.

Correct Answer & Explanation

. Medial collateral ligament (MCL) repair, coronoid fixation, radial head fixation, lateral collateral ligament (LCL) repair.

Explanation

The standard surgical algorithm for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) typically proceeds deep to superficial, or anterior to posterior. It involves fixing the coronoid first (if accessible/indicated), followed by the radial head, and then repairing the lateral ulnar collateral ligament (LUCL/LCL complex). The MCL is generally only repaired if gross instability persists.

Question 3195

Topic: Elbow & Forearm

During the surgical approach for a terrible triad injury of the elbow, what is the generally recommended sequence of reconstruction to restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard protocol for a terrible triad injury involves a deep-to-superficial repair sequence. This entails fixation of the coronoid first, followed by radial head repair or arthroplasty, and finally repair of the lateral collateral ligament complex.

Question 3196

Topic: Elbow & Forearm

A 40-year-old male presents with a Terrible Triad injury of the elbow.

Surgical management is planned. What is the generally accepted sequence of repair to restore elbow stability?

. LCL repair, radial head fixation/arthroplasty, coronoid fixation
. Coronoid fixation, radial head fixation/arthroplasty, LCL repair
. Radial head fixation/arthroplasty, coronoid fixation, MCL repair
. LCL repair, coronoid fixation, radial head fixation/arthroplasty
. Coronoid fixation, MCL repair, radial head fixation/arthroplasty

Correct Answer & Explanation

. LCL repair, radial head fixation/arthroplasty, coronoid fixation

Explanation

The standard surgical algorithm for a terrible triad injury progresses from deep to superficial and medial to lateral: 1) Coronoid fixation to restore the anterior buttress, 2) Radial head fixation or replacement to restore the lateral column, and 3) Lateral ulnar collateral ligament (LUCL/LCL complex) repair. The MCL is only addressed if the elbow remains unstable after these steps.

Question 3197

Topic: Elbow & Forearm

A 42-year-old tennis player undergoes surgical debridement for refractory lateral epicondylitis. Histologic examination of the excised tissue from the extensor carpi radialis brevis (ECRB) origin will most typically demonstrate which of the following?

. Acute inflammatory infiltrates with neutrophils
. Angiofibroblastic hyperplasia
. Granulomatous inflammation
. Fibrinoid necrosis
. Normal tendon architecture

Correct Answer & Explanation

. Acute inflammatory infiltrates with neutrophils

Explanation

Lateral epicondylitis (tennis elbow) is fundamentally a tendinosis, not an acute tendinitis. Histologic examination classically shows angiofibroblastic hyperplasia, characterized by disorganized collagen, fibroblasts, and poorly formed blood vessels, with an absence of acute inflammatory cells.

Question 3198

Topic: Elbow & Forearm

A 45-year-old bodybuilder feels a pop in his anterior elbow during a heavy deadlift. Clinical exam shows a positive Hook test. A single-incision anterior approach is planned to repair the avulsed distal biceps tendon. During this approach, which nerve is at greatest risk of iatrogenic injury?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABCN)
. Medial antebrachial cutaneous nerve (MABCN)
. Ulnar nerve
. Median nerve

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The lateral antebrachial cutaneous nerve (LABCN) runs superficially in the lateral aspect of the antecubital fossa and is the most commonly injured nerve during the anterior single-incision approach to the distal biceps. The posterior interosseous nerve (PIN) is at higher risk during a two-incision approach or with deep, overzealous lateral retraction.

Question 3199

Topic: Elbow & Forearm

A 45-year-old male feels a sudden 'pop' in his right elbow while attempting to lift a heavy box. On examination, he has a positive hook test and a visible proximal retraction of the biceps muscle belly. A single anterior incision approach is planned for distal biceps tendon repair. Which of the following nerves is at the greatest risk of iatrogenic injury during this specific surgical approach?

. Radial nerve
. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Ulnar nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

The lateral antebrachial cutaneous nerve (LABC), which is the terminal sensory branch of the musculocutaneous nerve, exits lateral to the biceps tendon and is highly susceptible to neuropraxia or transection during the single-incision anterior approach to the distal biceps. The posterior interosseous nerve (PIN) is more at risk when exposing the radial tuberosity, particularly if retractors are placed too far laterally or distally, and is the classic nerve injured in a two-incision approach if the muscle splitting is incorrect, but the most frequently injured nerve overall in the single anterior incision is the LABC.

Question 3200

Topic: 9. Shoulder and Elbow

A macrosomic newborn is noted to have a flaccid right upper extremity immediately after a difficult vaginal delivery involving shoulder dystocia. On examination, the infant has an absent grasp reflex and an ipsilateral ptosis and miosis. However, shoulder abduction and elbow flexion are spontaneous and intact. Which nerve roots are predominantly injured in this pattern of brachial plexus birth palsy?

. C5, C6
. C5, C6, C7
. C7, C8
. C8, T1
. C5 through T1

Correct Answer & Explanation

. C5, C6

Explanation

The patient's presentation is classic for Klumpke's palsy, which is a rare lower brachial plexus injury involving roots C8 and T1. It results in absent hand and wrist function (absent grasp reflex) but preserved proximal muscle function (shoulder abduction/elbow flexion, supplied by C5/C6). The presence of Horner's syndrome (ptosis, miosis, anhidrosis) indicates avulsion of the T1 root, which carries sympathetic fibers to the superior cervical ganglion. Erb's palsy (C5, C6) presents with the classic 'waiter's tip' posture and intact hand grasp.

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