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9. Shoulder and Elbow MCQs

Practice Set 161 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 3201

Topic: Elbow & Forearm

A 45-year-old male sustains a 'terrible triad' injury of the elbow after a fall on an outstretched hand. Which of the following represents the most widely accepted sequence of surgical reconstruction to restore elbow stability?

. LCL repair, coronoid fixation, radial head replacement
. Coronoid fixation, radial head replacement or fixation, LCL repair
. Radial head replacement, LCL repair, coronoid fixation
. MCL repair, coronoid fixation, radial head replacement, LCL repair
. Radial head replacement, MCL repair, coronoid fixation

Correct Answer & Explanation

. LCL repair, coronoid fixation, radial head replacement

Explanation

The standard surgical protocol for a terrible triad of the elbow (elbow dislocation, radial head fracture, coronoid fracture) typically proceeds from deep to superficial: 1) Coronoid fixation or anterior capsule repair, 2) Radial head fixation or arthroplasty, and 3) Lateral ulnar collateral ligament (LUCL) repair. If the elbow remains unstable after these steps, the MCL may be repaired or an external fixator applied.

Question 3202

Topic: Elbow & Forearm

A 32-year-old female sustains an Essex-Lopresti injury. She undergoes radial head excision without prosthetic replacement. Which of the following is the most likely late complication?

. Distal radioulnar joint (DRUJ) ankylosis
. Ulnar nerve palsy
. Proximal migration of the radius and ulnar impaction syndrome
. Avascular necrosis of the capitellum
. Cubitus varus deformity

Correct Answer & Explanation

. Distal radioulnar joint (DRUJ) ankylosis

Explanation

An Essex-Lopresti injury consists of a radial head fracture, tear of the interosseous membrane, and disruption of the DRUJ. If the radial head is excised without being replaced, the radius will migrate proximally due to the loss of the stabilizing interosseous membrane and radial head. This leads to positive ulnar variance and severe ulnar impaction syndrome.

Question 3203

Topic: Shoulder Pathology

A 30-year-old female presents with true neurogenic thoracic outlet syndrome (TOS). She requires surgical decompression. The most common site of nerve compression in this syndrome involves the interscalene triangle. What are the anatomic borders of this triangle?

. Clavicle, first rib, and subclavius muscle
. Pectoralis minor, coracoid process, and ribs
. Anterior scalene, middle scalene, and first rib
. Sternocleidomastoid, anterior scalene, and clavicle
. Middle scalene, posterior scalene, and second rib

Correct Answer & Explanation

. Clavicle, first rib, and subclavius muscle

Explanation

The interscalene triangle is the most common site of compression in neurogenic thoracic outlet syndrome. Its borders are the anterior scalene muscle anteriorly, the middle scalene muscle posteriorly, and the superior border of the first rib inferiorly. The brachial plexus trunks and the subclavian artery pass through this triangle (the subclavian vein runs anterior to the anterior scalene and is not within the triangle).

Question 3204

Topic: Elbow & Forearm

A 42-year-old female sustains a terrible triad injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). During surgical reconstruction, what is the most appropriate standard sequence of repair?

. Coronoid fixation, LCL repair, radial head fixation, MCL repair
. Radial head fixation, coronoid fixation, LCL repair, MCL repair
. Coronoid fixation, radial head fixation, LCL repair, common extensor origin repair
. LCL repair, radial head fixation, coronoid fixation, common extensor repair
. Coronoid fixation, LCL repair, radial head excision, MCL repair

Correct Answer & Explanation

. Coronoid fixation, LCL repair, radial head fixation, MCL repair

Explanation

The standard sequence for reconstructing a terrible triad injury is working deep to superficial: coronoid fixation, radial head fixation or replacement, followed by lateral collateral ligament (LCL) and extensor origin repair.

Question 3205

Topic: 9. Shoulder and Elbow

A 50-year-old diabetic female complains of progressive right shoulder stiffness and pain over 4 months. She has profound restriction in both active and passive external rotation. Radiographs are normal. What is the most appropriate initial management?

. Arthroscopic capsular release
. Manipulation under anesthesia
. Subacromial corticosteroid injection and physical therapy
. Intra-articular corticosteroid injection and physical therapy
. Biceps tenodesis

Correct Answer & Explanation

. Arthroscopic capsular release

Explanation

The patient has adhesive capsulitis (frozen shoulder), highly correlated with diabetes. Initial treatment is an intra-articular glenohumeral corticosteroid injection combined with a stretching program.

Question 3206

Topic: 9. Shoulder and Elbow

A 72-year-old female sustains a 4-part proximal humerus fracture. She has a history of severe osteoporosis and known advanced glenohumeral osteoarthritis. Which of the following treatments provides the most reliable functional outcome with the lowest rate of revision?

. Nonoperative management with a sling
. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Nonoperative management with a sling

Explanation

In an elderly patient with a 4-part fracture, poor bone stock, and preexisting osteoarthritis, a reverse total shoulder arthroplasty provides reliable pain relief and functional restoration without relying on tuberosity healing.

Question 3207

Topic: Shoulder Pathology

A 28-year-old athlete undergoes an isolated arthroscopic SLAP repair. Postoperatively, he experiences profound, isolated weakness in external rotation of the shoulder, with normal deltoid function and internal rotation. Suture anchor placement most likely injured which nerve?

. Axillary nerve
. Suprascapular nerve
. Musculocutaneous nerve
. Spinal accessory nerve
. Long thoracic nerve

Correct Answer & Explanation

. Axillary nerve

Explanation

The suprascapular nerve passes through the spinoglenoid notch near the posterosuperior glenoid. Misplaced posterosuperior suture anchors can tether or injure this nerve, causing isolated infraspinatus weakness.

Question 3208

Topic: 9. Shoulder and Elbow

A 45-year-old female presents after a fall on an outstretched hand with a 'terrible triad' injury of the elbow. To properly restore elbow stability, what is the most widely accepted sequence of surgical repair?

. Repair the lateral collateral ligament (LCL), then the radial head, then the coronoid
. Repair the coronoid, then the radial head, then the lateral collateral ligament (LCL)
. Repair the radial head, then the LCL, then the coronoid
. Repair the medial collateral ligament (MCL), then the coronoid, then the radial head
. Repair the coronoid, then the MCL, then the LCL

Correct Answer & Explanation

. Repair the lateral collateral ligament (LCL), then the radial head, then the coronoid

Explanation

The standard surgical algorithm for a terrible triad injury is to start deep and work outward: fix or replace the coronoid first, then address the radial head, and finally repair the LCL complex to restore lateral stability.

Question 3209

Topic: 9. Shoulder and Elbow

A 22-year-old male athlete presents with recurrent anterior shoulder instability. MRI reveals an anterior capsulolabral avulsion (Bankart lesion). Which of the following glenohumeral ligaments is the primary restraint to anterior translation of the humeral head at 90 degrees of abduction?

. Superior glenohumeral ligament
. Middle glenohumeral ligament
. Inferior glenohumeral ligament
. Coracohumeral ligament
. Transverse humeral ligament

Correct Answer & Explanation

. Superior glenohumeral ligament

Explanation

The anterior band of the inferior glenohumeral ligament (IGHL) is the primary static restraint against anterior translation of the humeral head when the shoulder is abducted to 90 degrees and externally rotated.

Question 3210

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with chronic pseudoparalysis of the shoulder. Radiographs demonstrate severe glenohumeral osteoarthritis with superior migration of the humeral head articulating with the acromion. What is the most appropriate surgical intervention?

. Anatomic total shoulder arthroplasty
. Hemiarthroplasty
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Arthroscopic massive cuff repair

Correct Answer & Explanation

. Anatomic total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for rotator cuff tear arthropathy. It medializes and distalizes the center of rotation, allowing the deltoid to effectively elevate the arm.

Question 3211

Topic: Elbow & Forearm

A 40-year-old male is undergoing a two-incision approach for a distal biceps tendon repair. Compared to a single anterior incision approach, which of the following complications occurs at a higher rate with the two-incision technique?

. Heterotopic ossification (radioulnar synostosis)
. Lateral antebrachial cutaneous nerve palsy
. Radial nerve palsy
. Tendon re-rupture
. Median nerve injury

Correct Answer & Explanation

. Heterotopic ossification (radioulnar synostosis)

Explanation

The two-incision approach (modified Boyd-Anderson) carries a higher risk of heterotopic ossification and radioulnar synostosis due to muscle dissection, whereas the single anterior incision has a higher risk of lateral antebrachial cutaneous nerve neuropraxia.

Question 3212

Topic: 9. Shoulder and Elbow

A newborn presents with an asymmetric Moro reflex. The right arm is held internally rotated, the elbow is extended, the forearm is pronated, and the wrist is flexed ('waiter's tip' posture). Which primary brachial plexus nerve roots are injured?

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

Correct Answer & Explanation

. C5 and C6

Explanation

Erb-Duchenne palsy is an upper trunk brachial plexus injury involving the C5 and C6 nerve roots. It paralyzes the shoulder abductors/external rotators, elbow flexors, and forearm supinators, resulting in the classic 'waiter's tip' posture.

Question 3213

Topic: Elbow & Forearm

A 35-year-old female fell on her outstretched hand.

Radiographs show a radial head fracture with 3 mm of articular step-off. On examination, there is a distinct mechanical block to forearm pronation and supination. What is the most appropriate treatment?

. Open reduction and internal fixation (ORIF) of the radial head
. A sling for 3 days followed by early active motion
. Long-arm cast immobilization for 4 weeks
. Complete radial head resection
. Radial head arthroplasty

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) of the radial head

Explanation

A displaced radial head fracture (Mason Type II) that causes a mechanical block to forearm rotation is an indication for surgical intervention, typically ORIF if the fragment is large enough and amenable to fixation.

Question 3214

Topic: Shoulder Pathology

A 50-year-old female presents with severe shoulder stiffness and pain, characterized by globally restricted active and passive range of motion. Which of the following systemic comorbidities has the strongest established association with the development of adhesive capsulitis?

. Hypertension
. Diabetes mellitus
. Hypothyroidism
. Rheumatoid arthritis
. Chronic kidney disease

Correct Answer & Explanation

. Hypertension

Explanation

Diabetes mellitus has a strong, well-documented association with adhesive capsulitis (frozen shoulder). Diabetic patients have a higher incidence of the disease, and it is often more severe and refractory to treatment.

Question 3215

Topic: Elbow & Forearm

A 32-year-old gymnast falls from a height and sustains a 'terrible triad' injury of the elbow. Operative intervention is planned. To properly restore elbow stability in a step-wise fashion, what is the accepted standard sequence of surgical repair?

. Lateral collateral ligament (LCL) -> Radial head -> Coronoid
. Radial head -> Coronoid -> Medial collateral ligament (MCL)
. Medial collateral ligament (MCL) -> Radial head -> Coronoid
. Coronoid -> Lateral collateral ligament (LCL) -> Radial head
. Coronoid -> Radial head -> Lateral collateral ligament (LCL)

Correct Answer & Explanation

. Lateral collateral ligament (LCL) -> Radial head -> Coronoid

Explanation

The standard surgical algorithm for a terrible triad injury follows an 'inside-out' approach. The deep anterior structures (coronoid) are repaired first, followed by the radial head, and finally the lateral collateral ligament (LCL) complex.

Question 3216

Topic: 9. Shoulder and Elbow

A 72-year-old female sustains a 4-part proximal humerus fracture. She has a history of severe osteoporosis and osteoarthritis of the glenohumeral joint. Which of the following is the most appropriate surgical treatment?

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

Correct Answer & Explanation

. Open reduction and internal fixation with a locking plate

Explanation

In elderly patients with 4-part proximal humerus fractures, poor bone quality, and preexisting glenohumeral osteoarthritis, reverse total shoulder arthroplasty provides superior and more predictable functional outcomes than ORIF or hemiarthroplasty.

Question 3217

Topic: Elbow & Forearm

A 45-year-old female sustains a 'terrible triad' injury to the elbow. During surgical reconstruction, after fixing the coronoid and radial head, the elbow remains persistently unstable in extension. What is the next most appropriate step?

. Repair the medial collateral ligament (MCL)
. Apply a hinged external fixator
. Repair the lateral ulnar collateral ligament (LUCL) origin to the lateral epicondyle
. Resect the radial head
. Immobilize in 90 degrees of flexion for 6 weeks

Correct Answer & Explanation

. Repair the medial collateral ligament (MCL)

Explanation

The standard surgical algorithm for a terrible triad injury involves fixation of the coronoid and radial head, followed by repair of the lateral ulnar collateral ligament (LUCL). This restores posterolateral rotatory stability.

Question 3218

Topic: Shoulder Arthroplasty & Arthritis
A 65-year-old female sustains a proximal humerus fracture. Radiographs and CT show a 4-part fracture with complete lateral hinge disruption and a short calcar segment (<8 mm). What is the most appropriate definitive surgical management?
. Non-operative management in a sling
. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Percutaneous pinning

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In elderly patients with a 4-part proximal humerus fracture, especially with strong predictors of humeral head ischemia (disrupted medial hinge, short calcar <8mm, disrupted anatomic neck), reverse total shoulder arthroplasty (RTSA) provides more predictable outcomes and better forward elevation than ORIF or hemiarthroplasty. RTSA relies on the deltoid and does not depend on tuberosity healing for basic overhead function, though tuberosity repair improves rotation.

Question 3219

Topic: 9. Shoulder and Elbow

A motorcyclist presents after a severe accident with massive swelling around the shoulder girdle, a pulseless ipsilateral upper extremity, and a profoundly widened scapulothoracic articulation on a chest radiograph. What associated injury in this specific injury pattern carries the highest immediate mortality rate?

. Complete brachial plexus avulsion
. Subclavian or axillary artery disruption
. Massive tension pneumothorax
. Ipsilateral flail chest
. Traumatic brain injury

Correct Answer & Explanation

. Complete brachial plexus avulsion

Explanation

The clinical presentation describes a scapulothoracic dissociation, which is characterized by complete disruption of the scapulothoracic articulation. The most life-threatening complication associated with this severe traction injury is a massive hemorrhage resulting from the disruption of the subclavian or axillary artery, leading to rapid exsanguination if not identified and treated emergently.

Question 3220

Topic: Elbow & Forearm

A 'terrible triad' injury of the elbow involves an elbow dislocation, a radial head fracture, and a coronoid process fracture. When undertaking surgical repair, which of the following represents the standard, sequential order of fixation to progressively restore elbow stability?

. Coronoid fixation, followed by Radial head fixation/replacement, followed by Lateral collateral ligament (LCL) repair
. Radial head fixation/replacement, followed by Coronoid fixation, followed by LCL repair
. LCL repair, followed by Coronoid fixation, followed by Radial head fixation
. Coronoid fixation, followed by Medial collateral ligament (MCL) repair, followed by Radial head fixation
. LCL repair, followed by Radial head fixation, followed by Medial collateral ligament repair

Correct Answer & Explanation

. Coronoid fixation, followed by Radial head fixation/replacement, followed by Lateral collateral ligament (LCL) repair

Explanation

The standard surgical protocol for a terrible triad injury involves a systematic approach working deep to superficial and typically from medial (via deep exposure through lateral side) to lateral. The order is: 1) Coronoid fixation or capsular repair, 2) Radial head fixation or arthroplasty, and 3) Lateral collateral ligament (LUCL) complex repair to the lateral epicondyle.

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