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9. Shoulder and Elbow MCQs

Practice Set 162 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 3221

Topic: 9. Shoulder and Elbow

A 40-year-old female sustains a 'terrible triad' injury of the elbow following a fall onto an outstretched hand. Open reduction and internal fixation are planned. According to standard evidence-based protocols, which of the following represents the most appropriate surgical sequence to restore elbow stability?

. Fixation of the coronoid fracture, followed by fixation or replacement of the radial head, followed by repair of the lateral collateral ligament (LCL) complex.
. Repair of the lateral collateral ligament (LCL) complex, followed by fixation of the radial head, followed by coronoid fixation.
. Replacement of the radial head, followed by medial collateral ligament (MCL) repair, followed by coronoid fixation.
. Fixation of the coronoid fracture, followed by medial collateral ligament (MCL) repair, followed by lateral collateral ligament (LCL) repair.
. Radial head fixation, followed by coronoid fixation, followed by medial collateral ligament (MCL) repair.

Correct Answer & Explanation

. Fixation of the coronoid fracture, followed by fixation or replacement of the radial head, followed by repair of the lateral collateral ligament (LCL) complex.

Explanation

The 'terrible triad' of the elbow consists of an elbow dislocation, radial head fracture, and coronoid process fracture. The classic surgical algorithm established by Pugh et al. dictates an 'inside-out' or deep-to-superficial approach. The recommended sequence is: 1) Fixation or repair of the coronoid to restore the anterior buttress; 2) Fixation or arthroplasty of the radial head to restore the lateral column and anterior restraint; 3) Repair of the lateral ulnar collateral ligament (LUCL) to restore posterolateral rotatory stability. The MCL is typically only repaired if the elbow remains unstable after the first three steps and application of a hinged external fixator is not preferred.

Question 3222

Topic: Elbow & Forearm

A 35-year-old bodybuilder undergoes a two-incision technique for repair of a distal biceps tendon rupture. Six months postoperatively, he presents with severely restricted forearm pronation and supination, though elbow flexion and extension are normal. What is the most likely complication he developed from this specific surgical approach?

. Posterior interosseous nerve (PIN) entrapment
. Proximal radioulnar synostosis
. Medial collateral ligament insufficiency
. Recurrent distal biceps rupture
. Capitellar osteochondritis dissecans

Correct Answer & Explanation

. Posterior interosseous nerve (PIN) entrapment

Explanation

The two-incision technique (modified Boyd-Anderson) for distal biceps repair was developed to reduce the risk of posterior interosseous nerve (PIN) injury associated with the extensile single anterior incision. However, muscle splitting and subperiosteal dissection between the radius and ulna during the posterior approach increases the risk of heterotopic ossification, specifically proximal radioulnar synostosis. This complication leads to profound loss of forearm rotation (pronation/supination). Careful technique to avoid exposing the ulna or breaching the interosseous membrane is critical.

Question 3223

Topic: 9. Shoulder and Elbow

When performing a reverse total shoulder arthroplasty (RTSA) using the classic Grammont design for a patient with cuff tear arthropathy, how does the prosthesis biomechanically alter the center of rotation (COR) of the glenohumeral joint compared to the native anatomy?

. It medializes and distalizes the center of rotation.
. It medializes and proximalizes the center of rotation.
. It lateralizes and distalizes the center of rotation.
. It lateralizes and proximalizes the center of rotation.
. It restores the anatomic center of rotation.

Correct Answer & Explanation

. It medializes and distalizes the center of rotation.

Explanation

The classic Grammont design for a reverse total shoulder arthroplasty (RTSA) biomechanically medializes and distalizes the center of rotation. Medialization decreases the torque on the glenoid component (minimizing the 'rocking horse' effect and risk of baseplate loosening). Distalization tensions the deltoid and significantly increases its moment arm, allowing the deltoid to effectively elevate the arm in the absence of a functional rotator cuff.

Question 3224

Topic: Elbow & Forearm

A 32-year-old female falls onto her outstretched hand and sustains a fracture of the anteromedial facet of the coronoid process of the ulna. Based on this specific fracture pattern, what is the underlying mechanism of injury and the associated ligamentous pathology?

. Valgus extension overload; rupture of the anterior bundle of the MCL.
. Posterolateral rotatory instability; rupture of the LUCL and anterior capsule.
. Varus posteromedial rotatory instability; rupture of the LCL complex and preservation of the anterior bundle of the MCL.
. Direct axial loading in hyperflexion; rupture of both MCL and LCL complexes.
. Olecranon shear force; isolated rupture of the posterior band of the MCL.

Correct Answer & Explanation

. Valgus extension overload; rupture of the anterior bundle of the MCL.

Explanation

Anteromedial facet fractures of the coronoid are the hallmark of Varus Posteromedial Rotatory Instability (VPMRI). This injury pattern is caused by a varus stress applied to the elbow, combined with axial load and posteromedial rotation of the ulna. This forces the anteromedial coronoid facet to impact the trochlea, causing a fracture. The lateral collateral ligament (LCL) complex is classically avulsed or torn, leading to the varus instability. The anterior bundle of the medial collateral ligament (MCL) usually remains intact or is only partially injured.

Question 3225

Topic: 9. Shoulder and Elbow

A 22-year-old collegiate baseball pitcher presents with medial elbow pain and decreased pitching velocity. Examination demonstrates pain with the moving valgus stress test. He is diagnosed with an ulnar collateral ligament (UCL) tear. Which distinct portion of the UCL complex serves as the primary restraint to valgus stress between 30 and 120 degrees of elbow flexion?

. Posterior bundle of the UCL
. Anterior bundle of the UCL
. Transverse ligament (Cooper's ligament)
. Medial ulnar collateral capsular reflection
. Flexor-pronator aponeurosis

Correct Answer & Explanation

. Posterior bundle of the UCL

Explanation

The ulnar collateral ligament (UCL) is composed of three bundles: anterior, posterior, and transverse. The anterior bundle is the primary stabilizer against valgus stress at the elbow throughout the functional range of motion (from roughly 30 to 120 degrees of flexion). The posterior bundle acts as a secondary restraint, specifically functioning in higher degrees of elbow flexion (>90 degrees). The transverse bundle has no significant role in elbow stability, as it originates and inserts on the same bone (ulna).

Question 3226

Topic: 9. Shoulder and Elbow

A 65-year-old male with an isolated, massive, irreparable posterosuperior rotator cuff tear presents with persistent shoulder pain, preserved forward elevation, but a profound external rotation lag sign (positive Hornblower's sign). He is deemed unsuitable for a reverse total shoulder arthroplasty due to lack of glenohumeral arthritis. Which tendon transfer provides the most biomechanically synergistic line of pull to restore active external rotation in this patient?

. Pectoralis major transfer
. Lower trapezius transfer
. Pectoralis minor transfer
. Latissimus dorsi transfer
. Levator scapulae transfer

Correct Answer & Explanation

. Pectoralis major transfer

Explanation

For an irreparable posterosuperior cuff tear with severe external rotation weakness (positive Hornblower's), a lower trapezius transfer is highly favored. The lower trapezius muscle fibers are aligned perfectly with the native infraspinatus, providing a synergistic, in-phase line of pull to restore external rotation. While the latissimus dorsi transfer has historically been used for this indication, it is an internal rotator and adductor out-of-phase with external rotation, requiring extensive cortical re-education and providing a less optimal biomechanical vector.

Question 3227

Topic: Elbow & Forearm
According to the McKee modification of the Bryan and Morrey classification for capitellum fractures, what describes a Type IV injury?
. An isolated osteochondral shear fracture of the capitellum (Hahn-Steinthal).
. A fracture involving the capitellum and a thin sleeve of cartilage (Kocher-Lorenz).
. A highly comminuted fracture of the capitellum (Broberg-Morrey).
. A coronal shear fracture that includes the capitellum and the majority of the trochlea.
. A fracture of the capitellum extending proximally into the lateral epicondyle.

Correct Answer & Explanation

. A coronal shear fracture that includes the capitellum and the majority of the trochlea.

Explanation

The Bryan and Morrey classification divides capitellar fractures into three primary types: Type I (Hahn-Steinthal, large osseous fragment), Type II (Kocher-Lorenz, primarily articular cartilage with a thin layer of bone), and Type III (Broberg-Morrey, comminuted). McKee later modified this classification by adding Type IV, which is a coronal shear fracture that involves not only the capitellum but extends medially to include the majority of the trochlea. Identifying a Type IV fracture is critical, as it requires fixation of both the capitellum and the trochlear fragment to restore elbow biomechanics.

Question 3228

Topic: Elbow & Forearm

A 45-year-old female presents with severe lateral elbow pain exacerbated by lifting objects with the forearm pronated. She is diagnosed with lateral epicondylitis. Histopathologic examination of the affected tissue typically reveals angiofibroblastic hyperplasia rather than acute inflammation. Which tendon is considered the primary site of pathology in this condition?

. Extensor digitorum communis
. Extensor carpi radialis longus
. Extensor carpi radialis brevis
. Extensor carpi ulnaris
. Brachioradialis

Correct Answer & Explanation

. Extensor digitorum communis

Explanation

Lateral epicondylitis (tennis elbow) is a tendinopathy (angiofibroblastic tendinosis) primarily involving the origin of the extensor carpi radialis brevis (ECRB) tendon. The ECRB lies deep to the extensor carpi radialis longus (ECRL) and extensor digitorum communis (EDC). The chronic microtrauma at its origin on the lateral epicondyle leads to tissue degeneration rather than active inflammatory cells. The ECRL and EDC can be secondarily involved, but the ECRB is the hallmark site of pathology.

Question 3229

Topic: Elbow & Forearm
A 50-year-old female undergoes a radial head arthroplasty for a comminuted, irreparable radial head fracture (Mason Type III). During the procedure, the surgeon inadvertently implants a prosthesis that is 4 mm too thick. What is the most likely clinical and radiographic consequence of this technical error?
. Valgus instability with attenuation of the medial collateral ligament.
. Medial joint line narrowing and accelerated trochlear wear.
. Asymmetric widening of the lateral ulnohumeral joint with capitellar wear.
. Proximal radioulnar synostosis with blocked supination.
. Posterolateral rotatory instability from stretching the LUCL.

Correct Answer & Explanation

. Asymmetric widening of the lateral ulnohumeral joint with capitellar wear.

Explanation

Overstuffing the radiocapitellar joint by inserting a radial head prosthesis that is too long causes altered elbow kinematics. It exerts excessive pressure on the capitellum, leading to rapid cartilage wear and subchondral osteolysis. Radiographically, this manifests as asymmetric widening of the ulnohumeral joint (specifically opening of the lateral aspect of the ulnohumeral articulation, creating a 'gap') because the radius is pushing the humerus away from the ulna. It also leads to a severe loss of elbow flexion and extension.

Question 3230

Topic: Shoulder Pathology

A 28-year-old male presents with right shoulder asymmetry. On examination, having the patient perform a wall push-up causes the medial border of the right scapula to become excessively prominent and translate superiorly and medially. Injury to which of the following nerves is responsible for this classic presentation?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

This is a classic presentation of medial scapular winging, which is caused by paralysis of the serratus anterior muscle due to long thoracic nerve palsy. The serratus anterior normally protracts and upwardly rotates the scapula, keeping the medial border closely applied to the thorax. When it is paralyzed, the medial border lifts off the chest wall (wings medially) and the scapula translates superiorly and medially. This is differentiated from lateral winging (spinal accessory nerve / trapezius palsy), where the scapula translates inferiorly and laterally.

Question 3231

Topic: Shoulder Arthroplasty & Arthritis

A 65-year-old female undergoes a reverse total shoulder arthroplasty for severe cuff tear arthropathy. Postoperatively, radiographs reveal scapular notching. According to the Sirveaux classification, what defines a Grade 3 notch?

. Notching confined to the scapular pillar
. Notching extending to the inferior screw
. Notching extending over and past the inferior screw
. Notching extending to the baseplate central peg
. Notching extending entirely through the glenoid vault

Correct Answer & Explanation

. Notching confined to the scapular pillar

Explanation

In the Sirveaux classification for scapular notching, Grade 1 is confined to the pillar, Grade 2 reaches the inferior screw, Grade 3 extends over the inferior screw, and Grade 4 reaches the central peg. Inferior positioning and eccentric inferior overhang of the glenosphere help prevent this complication.

Question 3232

Topic: Elbow & Forearm

A 30-year-old male presents with elbow pain and a mechanical click during extension and forearm supination following a fall. Examination reveals a positive lateral pivot-shift test. Which ligamentous structure is primarily deficient?

. Anterior bundle of the medial collateral ligament
. Lateral ulnar collateral ligament
. Annular ligament
. Radial collateral ligament
. Quadrate ligament

Correct Answer & Explanation

. Anterior bundle of the medial collateral ligament

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). The lateral pivot-shift test dynamically reproduces the characteristic subluxation and reduction of the radiocapitellar joint.

Question 3233

Topic: 9. Shoulder and Elbow
A 45-year-old poorly controlled diabetic female presents with globally restricted passive and active shoulder range of motion. Radiographs demonstrate no joint space narrowing. What is the characteristic histologic and structural finding in the joint capsule of this specific condition?
. Chondroid metaplasia with loose body formation
. Acute neutrophilic infiltration with purulence
. Fibroblastic proliferation and thickening of the coracohumeral ligament
. Extensive amyloid deposition in the subacromial bursa
. Monosodium urate crystal deposition in the rotator interval

Correct Answer & Explanation

. Fibroblastic proliferation and thickening of the coracohumeral ligament

Explanation

Adhesive capsulitis is histologically characterized by profound fibroblastic proliferation and type III collagen deposition. Macroscopically, the coracohumeral ligament and the rotator interval capsule become severely thickened and contracted.

Question 3234

Topic: Shoulder Pathology

A 22-year-old boxer complains of prominent medial winging of his right scapula that worsens when doing push-ups against a wall. He sustained a direct blow to his lateral chest wall three months ago. Which nerve was most likely injured, and which muscle is consequently paralyzed?

. Long thoracic nerve / Serratus anterior
. Spinal accessory nerve / Trapezius
. Dorsal scapular nerve / Rhomboids
. Thoracodorsal nerve / Latissimus dorsi
. Axillary nerve / Deltoid

Correct Answer & Explanation

. Long thoracic nerve / Serratus anterior

Explanation

Medial scapular winging is the classic presentation of serratus anterior paralysis, which is innervated by the long thoracic nerve. In contrast, lateral scapular winging is associated with trapezius paralysis from a spinal accessory nerve injury.

Question 3235

Topic: 9. Shoulder and Elbow

A 68-year-old male with a massive, irreparable rotator cuff tear and pseudoparalysis presents for evaluation. Radiographs demonstrate superior migration of the humeral head, acromial acetabularization, but preserved glenohumeral joint space (Hamada grade 3). A Reverse Total Shoulder Arthroplasty (RTSA) is planned. In RTSA, what is the primary biomechanical advantage conferred by the implant design?

. Medializes and inferiorizes the center of rotation
. Lateralizes and superiorizes the center of rotation
. Decreases the deltoid lever arm
. Requires an intact coracoacromial ligament for stability
. Restores the normal anatomic center of rotation

Correct Answer & Explanation

. Medializes and inferiorizes the center of rotation

Explanation

RTSA medializes and inferiorizes the center of rotation, which increases the lever arm and resting tension of the deltoid. This allows the deltoid to effectively compensate for the deficient rotator cuff.

Question 3236

Topic: 9. Shoulder and Elbow

A 45-year-old female with diabetes presents with severe shoulder pain and profound loss of active and passive external rotation for 4 months. She is diagnosed with the 'freezing' stage of adhesive capsulitis. Which cytokine or growth factor is most heavily implicated in the pathogenesis of this condition?

. Tumor Necrosis Factor-alpha (TNF-alpha)
. Interleukin-1 (IL-1)
. Transforming Growth Factor-beta (TGF-beta)
. Fibroblast Growth Factor (FGF)
. Platelet-Derived Growth Factor (PDGF)

Correct Answer & Explanation

. Tumor Necrosis Factor-alpha (TNF-alpha)

Explanation

TGF-beta is a major driver of fibrosis and plays a central role in the pathogenesis of adhesive capsulitis. It promotes robust fibroblast proliferation and excessive collagen production within the joint capsule.

Question 3237

Topic: Elbow & Forearm

A 14-year-old elite baseball pitcher presents with lateral elbow pain, clicking, and a 15-degree extension deficit. Radiographs reveal a radiolucent lesion of the capitellum with a sclerotic margin and a visible loose body in the joint. What is the most appropriate management?

. Rest and cessation of throwing for 6 weeks
. Arthroscopic debridement, loose body removal, and marrow stimulation
. Open reduction internal fixation of the capitellum
. Ulnar collateral ligament reconstruction
. Radial head excision

Correct Answer & Explanation

. Rest and cessation of throwing for 6 weeks

Explanation

In an adolescent with capitellar osteochondritis dissecans (OCD) presenting with a loose body and mechanical symptoms (indicating an unstable lesion), surgical intervention is required. Arthroscopic loose body removal and marrow stimulation (microfracture) is the standard of care.

Question 3238

Topic: Elbow & Forearm

A 21-year-old collegiate pitcher undergoes a Tommy John surgery (UCL reconstruction). Which specific bundle of the Ulnar Collateral Ligament is the primary restraint to valgus stress at 90 degrees of flexion and is the primary target for this reconstruction?

. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Posterior bundle
. Transverse ligament
. Oblique band

Correct Answer & Explanation

. Anterior band of the anterior bundle

Explanation

The anterior bundle of the UCL, specifically the anterior band, is the primary restraint to valgus stress between 30 and 120 degrees of elbow flexion. It is the critical structure reconstructed in Tommy John surgery.

Question 3239

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female with osteoporosis sustains a severely displaced 4-part proximal humerus fracture. She lives independently and is functionally active. Which surgical intervention provides the most predictable functional outcome and pain relief in this demographic?

. Percutaneous pinning
. Intramedullary nailing
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Non-operative management in a sling

Correct Answer & Explanation

. Percutaneous pinning

Explanation

Reverse total shoulder arthroplasty (RTSA) provides more predictable functional outcomes and better pain relief than ORIF or hemiarthroplasty for displaced 4-part proximal humerus fractures in the elderly. This is because RTSA relies on deltoid function rather than tuberosity healing for overhead elevation.

Question 3240

Topic: Shoulder Pathology

A 30-year-old male presents with medial scapular winging and inability to actively elevate his arm past 90 degrees following a heavy traction injury. EMG confirms a complete long thoracic nerve palsy. After 1 year of strict conservative management with no recovery, what is the treatment of choice?

. Eden-Lange procedure
. Pectoralis major transfer
. Split pectoralis minor transfer
. Rhomboid transfer
. Modified Eden-Lange procedure

Correct Answer & Explanation

. Eden-Lange procedure

Explanation

Pectoralis major transfer (using fascia lata autograft or direct transfer to the inferior angle of the scapula) is the standard surgical treatment for chronic, irrecoverable serratus anterior palsy causing medial winging.

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