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9. Shoulder and Elbow MCQs

Practice Set 170 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 3381

Topic: Elbow & Forearm

A 30-year-old professional baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft. What is the most frequently reported complication following this procedure?

. Graft rupture
. Medial epicondyle fracture
. Ulnar neuropathy
. Heterotopic ossification
. Radial head osteochondritis dissecans

Correct Answer & Explanation

. Graft rupture

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction (Tommy John surgery), occurring in up to 10-15% of cases. Careful handling and potential transposition of the nerve can mitigate this risk.

Question 3382

Topic: Elbow & Forearm

A 50-year-old man presents with persistent elbow pain and lateral-sided snapping. He previously underwent surgery for lateral epicondylitis involving an aggressive release of the common extensor origin. Examination shows varus instability when the elbow is tested in supination. What structure has been iatrogenically compromised?

. Medial collateral ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Biceps tendon

Correct Answer & Explanation

. Medial collateral ligament

Explanation

The lateral ulnar collateral ligament (LUCL) is the primary stabilizer against posterolateral rotatory instability (PLRI). Overly aggressive surgical debridement of the common extensor origin for tennis elbow can iatrogenically injure the underlying LUCL.

Question 3383

Topic: Elbow & Forearm
A 45-year-old mechanic sustains a highly comminuted Mason Type III radial head fracture and an Essex-Lopresti injury. The radial head is deemed unsalvageable. What is the most appropriate management of the radial head?
. Radial head excision alone
. Radial head excision and silastic implant arthroplasty
. Radial head excision and temporary radioulnar pinning
. Radial head arthroplasty with a metallic implant
. Closed reduction and casting

Correct Answer & Explanation

. Radial head arthroplasty with a metallic implant

Explanation

In an Essex-Lopresti injury, there is longitudinal radioulnar instability due to interosseous membrane disruption. Radial head excision alone leads to proximal radial migration; therefore, a rigid metallic radial head arthroplasty is required to maintain longitudinal stability.

Question 3384

Topic: 9. Shoulder and Elbow

Following surgical treatment of a terrible triad injury of the elbow involving radial head replacement, LCL repair, and coronoid fixation, the elbow remains persistently unstable in extension. What is the most appropriate next step in management?

. Cast in 90 degrees of flexion for 6 weeks
. Repair or reconstruct the medial collateral ligament (MCL)
. Place a hinged external fixator
. Revise the radial head to a larger size
. Perform an ulnar nerve transposition

Correct Answer & Explanation

. Cast in 90 degrees of flexion for 6 weeks

Explanation

In terrible triad injuries, if the elbow remains unstable after addressing the coronoid, radial head, and lateral collateral ligament, the medial collateral ligament (MCL) should be repaired to restore coronal stability. A hinged external fixator is reserved for residual instability despite MCL repair.

Question 3385

Topic: 9. Shoulder and Elbow

A 68-year-old male with cuff tear arthropathy and pseudoparalysis of the shoulder is scheduled for a reverse total shoulder arthroplasty. To optimize deltoid function and tension, how does the classic Grammont reverse shoulder design biomechanically alter the center of rotation?

. Moves it laterally and superiorly
. Moves it medially and inferiorly
. Moves it medially and superiorly
. Moves it laterally and inferiorly
. Does not change the center of rotation

Correct Answer & Explanation

. Moves it laterally and superiorly

Explanation

The classic reverse total shoulder arthroplasty design shifts the center of rotation medially and inferiorly. This dramatically increases the deltoid lever arm and resting tension, allowing it to compensate for the absent rotator cuff.

Question 3386

Topic: 9. Shoulder and Elbow

A 12-year-old gymnast sustains an elbow dislocation that is successfully reduced in the emergency department. Post-reduction radiographs show a displaced medial epicondyle fracture. Which of the following is an absolute indication for open reduction and internal fixation?

. Displacement greater than 5 mm
. Valgus instability at 30 degrees of flexion
. Entrapment of the medial epicondyle fragment within the joint space
. Presence of an ulnar nerve palsy
. Patient demand for early return to gymnastics

Correct Answer & Explanation

. Displacement greater than 5 mm

Explanation

Entrapment of the medial epicondyle within the ulnohumeral joint is an absolute indication for operative intervention to prevent joint destruction and restore range of motion. Displacement >5 mm and athletic demands are considered relative indications.

Question 3387

Topic: Elbow & Forearm

In a patient with a high radial nerve palsy, which of the following is the most standard tendon transfer utilized to restore wrist extension?

. Flexor carpi ulnaris (FCU) to Extensor digitorum communis (EDC)
. Pronator teres (PT) to Extensor carpi radialis brevis (ECRB)
. Flexor digitorum superficialis (FDS) to Extensor pollicis longus (EPL)
. Palmaris longus (PL) to Extensor pollicis brevis (EPB)
. Flexor carpi radialis (FCR) to Abductor pollicis longus (APL)

Correct Answer & Explanation

. Flexor carpi ulnaris (FCU) to Extensor digitorum communis (EDC)

Explanation

The classic and most reliable tendon transfer to restore wrist extension in a radial nerve palsy is transferring the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB). The ECRB is chosen over the ECRL because of its more central insertion, which limits radial deviation during wrist extension.

Question 3388

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow, what is the standard algorithmic sequence of anatomic reconstruction?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad (elbow dislocation with radial head and coronoid fractures) is to proceed from deep to superficial: coronoid fixation or anterior capsular repair, followed by radial head repair or replacement, and finally lateral collateral ligament (LCL) repair. The MCL is typically only repaired if the elbow remains grossly unstable after these steps.

Question 3389

Topic: Elbow & Forearm
A distal humerus fracture consists of a coronal shear fracture involving the entire capitellum and the lateral portion of the trochlea, but leaves the lateral epicondyle intact. According to the McKee modification of the Bryan and Morrey classification, what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV (McKee)
. Type V

Correct Answer & Explanation

. Type IV (McKee)

Explanation

The McKee modification added Type IV to the Bryan and Morrey classification. Type I is a large osseous capitellar piece. Type II is a thin articular cartilage sleeve. Type III is comminuted. Type IV (McKee) is a coronal shear fracture that involves both the capitellum and the lateral half of the trochlea.

Question 3390

Topic: Elbow & Forearm

A patient presents with a "terrible triad" injury of the elbow following a fall onto an outstretched hand. During operative management, what is the standard recommended sequence of surgical reconstruction to restore stability?

. MCL repair, LCL repair, radial head fixation, coronoid fixation
. Radial head fixation, coronoid fixation, LCL repair, MCL repair
. Coronoid fixation, radial head fixation/replacement, LCL repair, MCL repair (if needed)
. LCL repair, coronoid fixation, radial head fixation, MCL repair
. Coronoid fixation, MCL repair, radial head fixation, LCL repair

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury begins deep and moves superficial: fixation of the coronoid first, followed by the radial head, then repair of the lateral collateral ligament (LCL) complex. MCL repair is only performed if the elbow remains unstable after these steps.

Question 3391

Topic: 9. Shoulder and Elbow

A 30-year-old motorcyclist presents after a high-speed collision with massive swelling over the shoulder and an entirely flail, pulseless upper extremity. A chest radiograph reveals a significantly laterally displaced scapula compared to the contralateral side. What is the most critical initial step in the evaluation of this patient?

. Emergent MRI of the brachial plexus
. CT angiography of the chest and upper extremity
. Immediate forequarter amputation
. Application of a shoulder spica cast
. EMG to confirm complete brachial plexus avulsion

Correct Answer & Explanation

. Emergent MRI of the brachial plexus

Explanation

Scapulothoracic dissociation is a devastating closed injury analogous to a forequarter amputation and carries a very high incidence of life-threatening subclavian or axillary vascular disruption. Urgent vascular evaluation via CT angiography or direct surgical exploration is critical for hemorrhage control.

Question 3392

Topic: 9. Shoulder and Elbow

When surgically managing a 'terrible triad' injury of the elbow, which of the following represents the most accepted standard sequence of repair to restore elbow stability?

. Coronoid fixation, radial head repair/replacement, lateral collateral ligament repair
. Lateral collateral ligament repair, radial head repair/replacement, coronoid fixation
. Radial head repair/replacement, coronoid fixation, lateral collateral ligament repair
. Medial collateral ligament repair, coronoid fixation, lateral collateral ligament repair
. Coronoid fixation, medial collateral ligament repair, radial head replacement

Correct Answer & Explanation

. Coronoid fixation, radial head repair/replacement, lateral collateral ligament repair

Explanation

The standard surgical algorithm for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) proceeds from deep to superficial: first addressing the coronoid, then repairing or replacing the radial head, and finally repairing the lateral collateral ligament (LCL) complex. The MCL is typically only repaired if the elbow remains persistently unstable after these lateral and anterior structures are restored.

Question 3393

Topic: Elbow & Forearm
A 34-year-old female falls onto an outstretched hand and sustains a capitellum fracture. Radiographs and CT show a coronal shear fracture that involves the capitellum and extends medially to include the majority of the trochlea. According to the Bryan-Morrey classification (incorporating the McKee modification), what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV (McKee modification)
. Type V

Correct Answer & Explanation

. Type IV (McKee modification)

Explanation

The McKee modification of the Bryan-Morrey classification adds Type IV, which describes a coronal shear fracture involving the capitellum that extends medially to include most or all of the trochlea, often referred to as a capitellotrochlear fracture.

Question 3394

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female presents with chronic shoulder pseudoparalysis and severe pain. Radiographs show superior migration of the humeral head with articulation against the acromion, and acetabularization of the coracoacromial arch (Hamada Stage 3). An MRI confirms a massive, irreparable rotator cuff tear. What is the most appropriate surgical intervention?

. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Superior capsular reconstruction
. Latissimus dorsi tendon transfer

Correct Answer & Explanation

. Hemiarthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for rotator cuff tear arthropathy with pseudoparalysis in older patients. It relies on the deltoid muscle to elevate the arm by medializing and distalizing the center of rotation, which increases the deltoid's moment arm. Anatomic TSA is contraindicated due to the deficient rotator cuff leading to early eccentric glenoid failure (the 'rocking horse' phenomenon).

Question 3395

Topic: 9. Shoulder and Elbow

A 40-year-old male sustains a 'terrible triad' injury of the elbow after a fall on an outstretched hand. During surgical reconstruction, what is the classically recommended sequence of repair to restore elbow stability?

. Radial head, coronoid, LCL
. LCL, radial head, coronoid
. Coronoid, radial head, LCL
. Coronoid, LCL, radial head
. LCL, coronoid, radial head

Correct Answer & Explanation

. Radial head, coronoid, LCL

Explanation

The classic surgical sequence for a terrible triad injury of the elbow (coronoid fracture, radial head fracture, LCL tear) is to repair from deep to superficial: the coronoid fracture is addressed first, followed by the radial head (fixation or arthroplasty), and finally the lateral collateral ligament (LCL) complex. MCL repair or external fixation is reserved for persistent instability after these steps.

Question 3396

Topic: 9. Shoulder and Elbow

A 28-year-old female overhead athlete complains of arm fatigue, numbness in the ulnar digits, and vague shoulder pain when pitching. Provocative testing is positive when her shoulder is abducted and externally rotated, causing a loss of the radial pulse. EMG/NCS is normal. Which anatomic structure is the most common site of compression in this specific variant of the syndrome?

. Between the anterior and middle scalene muscles
. Between the clavicle and first rib
. Beneath the pectoralis minor tendon at the coracoid process
. At the level of the cervical rib
. In the spiral groove of the humerus

Correct Answer & Explanation

. Between the anterior and middle scalene muscles

Explanation

The clinical presentation and positive hyperabduction test (Wright's maneuver) are indicative of Thoracic Outlet Syndrome compression in the subcoracoid space (beneath the pectoralis minor tendon). This variant is often called pectoralis minor syndrome or hyperabduction syndrome. Adson's test evaluates the interscalene triangle, while the costoclavicular maneuver evaluates the costoclavicular space.

Question 3397

Topic: Elbow & Forearm

During surgical management of a 'terrible triad' injury of the elbow, what is the recommended sequence of reconstruction to restore concentric stability?

. MCL repair, radial head fixation, coronoid fixation, LCL repair
. Coronoid fixation, radial head fixation or arthroplasty, LCL repair, and lastly MCL repair if still unstable
. Radial head fixation, LCL repair, coronoid fixation, MCL repair
. LCL repair, coronoid fixation, radial head fixation, MCL repair
. MCL repair, coronoid fixation, radial head arthroplasty, LCL repair

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) typically works from deep to superficial: 1) Coronoid fixation (restores anterior buttress), 2) Radial head fixation or replacement (restores lateral column), 3) LCL complex repair (restores posterolateral rotatory stability). MCL repair is generally only performed if the elbow remains grossly unstable in extension after the first three steps are completed.

Question 3398

Topic: Elbow & Forearm

During a single-incision anterior approach for distal biceps tendon repair, the forearm is held in full supination while passing sutures and reattaching the tendon to the radial tuberosity. Which nerve is at greatest risk of injury if retractors are placed too deeply on the lateral aspect of the proximal radius?

. Lateral antebrachial cutaneous nerve
. Superficial radial nerve
. Posterior interosseous nerve (PIN)
. Anterior interosseous nerve (AIN)
. Median nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The posterior interosseous nerve (PIN) wraps around the radial neck within the supinator muscle. Retractors placed blindly or deeply on the lateral side of the radius can compress or stretch the PIN. Keeping the forearm in supination moves the PIN further laterally and posteriorly, protecting it during the anterior approach, but deep radial retractor placement still poses the greatest risk to this structure.

Question 3399

Topic: 9. Shoulder and Elbow

In the design and biomechanics of a reverse total shoulder arthroplasty (rTSA), moving the center of rotation medially and distally compared to the native shoulder achieves which of the following mechanical advantages?

. Increases the tension on the remaining rotator cuff tendons
. Decreases the deltoid moment arm, requiring more force to abduct the arm
. Increases the deltoid moment arm and recruits more deltoid fibers for elevation
. Restores the anatomic force couple between the subscapularis and infraspinatus
. Increases shear forces at the glenosphere-baseplate interface

Correct Answer & Explanation

. Increases the tension on the remaining rotator cuff tendons

Explanation

The fundamental biomechanical principle of the Grammont reverse total shoulder arthroplasty is medializing and distalizing the center of rotation. This lengthens the deltoid (increasing its tension) and increases the deltoid moment arm, allowing it to act as the primary elevator of the shoulder in the absence of a functioning rotator cuff. It recruits more of the anterior and posterior deltoid fibers to assist the middle deltoid in abduction and elevation.

Question 3400

Topic: Shoulder Pathology

A 34-year-old female presents with chronic numbness and tingling in the ulnar distribution of her right hand, accompanied by intrinsic muscle weakness. She has a positive Roos test and a positive Adson maneuver. A cervical radiograph reveals bilateral cervical ribs. Electromyography (EMG) shows decreased SNAP amplitude in the ulnar nerve and denervation in the abductor pollicis brevis. What is the most likely diagnosis?

. Vascular thoracic outlet syndrome
. True neurogenic thoracic outlet syndrome
. Disputed neurogenic thoracic outlet syndrome
. C8-T1 cervical radiculopathy
. Cubital tunnel syndrome

Correct Answer & Explanation

. Vascular thoracic outlet syndrome

Explanation

The clinical picture describes 'true neurogenic thoracic outlet syndrome' (tnTOS). It is rare but classically associated with a structural anomaly like a cervical rib causing compression of the lower trunk of the brachial plexus (C8-T1). It is characterized by objective findings: thenar atrophy (Gilliatt-Sumner hand), weakness in intrinsic muscles, and objective EMG/NCS changes. 'Disputed' or 'symptomatic' neurogenic TOS lacks objective EMG findings.

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