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9. Shoulder and Elbow MCQs

Practice Set 173 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 3441

Topic: 9. Shoulder and Elbow

A 28-year-old overhead athlete undergoes repair of a type II SLAP tear. Six months postoperatively, he presents with severe stiffness and a clinically significant loss of external rotation with the arm at the side. Entrapment or overtightening of which capsuloligamentous structure during the anchor placement is most likely responsible?

. Coracohumeral ligament
. Middle glenohumeral ligament
. Anterosuperior labrum and superior glenohumeral ligament
. Posterior band of the inferior glenohumeral ligament
. Subscapularis tendon

Correct Answer & Explanation

. Anterosuperior labrum and superior glenohumeral ligament

Explanation

Loss of external rotation after a SLAP repair is frequently caused by placing anchors too far anteriorly to the biceps root. This inadvertently captures and overtightens the superior glenohumeral ligament (SGHL) and the anterosuperior capsule.

Question 3442

Topic: 9. Shoulder and Elbow

A 70-year-old female with severe rheumatoid arthritis and a massive, irreparable rotator cuff tear undergoes a reverse total shoulder arthroplasty (RTSA). How does the design of the RTSA alter the biomechanics of the glenohumeral joint compared to its native state?

. Moves the center of rotation superiorly and laterally
. Moves the center of rotation inferiorly and medially
. Moves the center of rotation superiorly and medially
. Moves the center of rotation inferiorly and laterally
. Maintains the native center of rotation but increases the joint volume

Correct Answer & Explanation

. Moves the center of rotation inferiorly and medially

Explanation

Reverse total shoulder arthroplasty (RTSA) alters shoulder biomechanics by moving the center of rotation inferiorly and medially. This significantly increases the moment arm of the deltoid muscle, allowing it to substitute for the deficient rotator cuff and initiate shoulder elevation.

Question 3443

Topic: 9. Shoulder and Elbow

A 20-year-old male presents with recurrent anterior shoulder instability. An MRI reveals a classic Bankart lesion. Which specific ligamentous structure is primarily disrupted in this lesion, leading to anterior instability at 90 degrees of abduction?

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

Correct Answer & Explanation

. Anterior band of the inferior glenohumeral ligament

Explanation

A Bankart lesion is an avulsion of the anterior-inferior glenoid labrum along with the attached anterior band of the inferior glenohumeral ligament (IGHL) complex. The anterior band of the IGHL is the primary static restraint to anterior translation of the humeral head when the arm is abducted to 90 degrees and externally rotated.

Question 3444

Topic: Shoulder Pathology

A 35-year-old male presents with the inability to actively raise his right arm above shoulder level following an axillary lymph node dissection 3 months ago. Physical examination reveals prominent medial winging of the scapula that worsens when pushing against a wall. Which nerve is most likely injured?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial scapular winging is caused by paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. This nerve is at risk during axillary dissection. Injury to the spinal accessory nerve causes paralysis of the trapezius, resulting in lateral scapular winging.

Question 3445

Topic: 9. Shoulder and Elbow
A 50-year-old diabetic female complains of 4 months of progressive shoulder stiffness and pain. Radiographs are normal. Examination shows a marked restriction of both active and passive range of motion, with external rotation being the most severely limited. What is the most characteristic histologic finding in the joint capsule of this condition?
. Acute inflammatory infiltrate with neutrophils
. Fibrinoid necrosis and granulomas
. Fibroblastic proliferation with an increased ratio of type III to type I collagen
. Chondroid metaplasia
. Extensive hemosiderin deposition

Correct Answer & Explanation

. Fibroblastic proliferation with an increased ratio of type III to type I collagen

Explanation

The patient has adhesive capsulitis (frozen shoulder). Histologically, it is characterized by a dense, cellular, fibroblastic proliferation of the joint capsule with an increased ratio of type III to type I collagen, closely resembling the pathology seen in Dupuytren's disease. Frank inflammation is minimal or absent.

Question 3446

Topic: 9. Shoulder and Elbow

A 68-year-old male with primary glenohumeral osteoarthritis is undergoing preoperative planning for a total shoulder arthroplasty. His CT scan demonstrates biconcave glenoid wear with posterior subluxation of the humeral head. According to the Walch classification, what type of glenoid morphology is this?

. Type A1
. Type A2
. Type B1
. Type B2
. Type C

Correct Answer & Explanation

. Type B2

Explanation

The Walch B2 glenoid is characterized by an asymmetric biconcave wear pattern with posterior wear and posterior subluxation of the humeral head. It is commonly seen in primary osteoarthritis and poses a challenge for glenoid component placement due to the risk of accelerated loosening if retroversion is not corrected.

Question 3447

Topic: 9. Shoulder and Elbow

A 30-year-old competitive weightlifter feels a sudden 'pop' in his chest while performing a heavy bench press. He subsequently develops severe bruising over the anterior axillary fold and weakness in shoulder adduction and internal rotation. Where does the pectoralis major most commonly rupture in this scenario?

. Sternal head origin
. Clavicular head origin
. Musculotendinous junction
. Tendon insertion on the humerus
. Muscle belly

Correct Answer & Explanation

. Tendon insertion on the humerus

Explanation

Pectoralis major ruptures most commonly occur at the tendinous insertion onto the lateral lip of the bicipital groove of the humerus, particularly in weightlifters performing bench presses. The sternal head fibers, which insert most proximally and posteriorly, are typically the first to tear when the arm is extended and externally rotated under heavy load.

Question 3448

Topic: Shoulder Pathology

A 28-year-old female hair stylist complains of vague aching in her right arm, paresthesias in the ulnar distribution, and fatigue that worsens when working with her arms overhead. Wright's test is positive. If this represents neurogenic thoracic outlet syndrome (TOS), compression of the brachial plexus most commonly occurs within which anatomic space?

. Quadrilateral space
. Triangular interval
. Interscalene triangle
. Spinoglenoid notch
. Guyon's canal

Correct Answer & Explanation

. Interscalene triangle

Explanation

Neurogenic Thoracic Outlet Syndrome (TOS) is most commonly caused by compression of the lower trunk of the brachial plexus (C8-T1) within the interscalene triangle. The boundaries of this triangle are the anterior scalene, middle scalene, and the superior border of the first rib.

Question 3449

Topic: Shoulder Pathology

A 24-year-old male complains of a painful grinding and snapping sensation at the superomedial border of his scapula with arm movement. Physical therapy and multiple steroid injections have failed to provide relief. If operative intervention (bursectomy/partial scapulectomy) is planned, which bursa is the primary target?

. Subacromial bursa
. Subcoracoid bursa
. Subscapularis bursa
. Scapulothoracic bursa (supraserratus/infraserratus)
. Subdeltoid bursa

Correct Answer & Explanation

. Scapulothoracic bursa (supraserratus/infraserratus)

Explanation

Snapping scapula syndrome is caused by periscapular muscle imbalance, bony abnormalities (e.g., Luschka's tubercle, osteochondroma), or inflammation of the scapulothoracic bursae. The two main scapulothoracic bursae located at the superomedial angle are the supraserratus and infraserratus bursae.

Question 3450

Topic: 9. Shoulder and Elbow

A 45-year-old male presents with acute, severe, unrelenting right shoulder pain that started spontaneously and lasted for 2 weeks. As the severe pain begins to subside, he notes profound weakness and noticeable atrophy of his shoulder abductors and external rotators. An MRI of the cervical spine and shoulder is unremarkable. What is the most likely diagnosis?

. Acute massive rotator cuff tear
. Cervical radiculopathy
. Parsonage-Turner syndrome
. Adhesive capsulitis
. Calcific tendinitis

Correct Answer & Explanation

. Parsonage-Turner syndrome

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) is characterized by the sudden onset of severe, unremitting shoulder pain. As the pain resolves over weeks, patients develop striking patchy weakness, denervation, and atrophy in muscles supplied by the brachial plexus, most commonly involving the periscapular, deltoid, or rotator cuff muscles.

Question 3451

Topic: Shoulder Arthroplasty & Arthritis

Which of the following baseplate positions minimizes the risk of scapular notching in Reverse Total Shoulder Arthroplasty (RTSA)?

. Superior translation and superior tilt
. Superior translation and inferior tilt
. Inferior translation and superior tilt
. Inferior translation and inferior tilt
. Neutral translation and neutral tilt

Correct Answer & Explanation

. Superior translation and inferior tilt

Explanation

Scapular notching is a common complication of RTSA. To minimize impingement of the humeral component against the inferior scapular neck, the glenosphere baseplate should be placed with inferior translation (overhanging the inferior glenoid margin by 2-4 mm) and inferior tilt. This improves the impingement-free arc of motion and mechanical advantage of the deltoid.

Question 3452

Topic: Elbow & Forearm

Which of the following is a recognized difference in complication profiles between the single-incision anterior approach and the two-incision (modified Boyd-Anderson) approach for distal biceps tendon repair?

. The single-incision approach has a higher rate of radioulnar synostosis.
. The two-incision approach has a higher rate of lateral antebrachial cutaneous nerve (LABCN) injury.
. The single-incision approach has a higher rate of lateral antebrachial cutaneous nerve (LABCN) injury.
. The two-incision approach has a higher rate of posterior interosseous nerve (PIN) injury.
. There is no difference in the rate of neurovascular injuries between the two approaches.

Correct Answer & Explanation

. The single-incision approach has a higher rate of lateral antebrachial cutaneous nerve (LABCN) injury.

Explanation

The single-incision anterior approach requires deeper retraction, resulting in a higher risk of neurapraxia to the lateral antebrachial cutaneous nerve (LABCN) and radial nerve. Conversely, the two-incision approach (modified Boyd-Anderson) historically carries a higher risk of heterotopic ossification and radioulnar synostosis, although modern muscle-splitting techniques have mitigated this risk.

Question 3453

Topic: Shoulder Pathology

A 42-year-old patient presents with lateral scapular winging following a posterior cervical lymph node biopsy. The scapula is translated laterally, with the inferior pole rotated laterally. Which of the following procedures is most appropriate for a symptomatic, refractory case?

. Split pectoralis major transfer
. Eden-Lange procedure
. Modified Weaver-Dunn procedure
. Latarjet procedure
. Latissimus dorsi transfer

Correct Answer & Explanation

. Eden-Lange procedure

Explanation

Lateral scapular winging is caused by a spinal accessory nerve (CN XI) palsy leading to trapezius paralysis. The Eden-Lange procedure involves transferring the levator scapulae to the acromion, and the rhomboid major and minor to the infraspinatus fossa, restoring the suspensory function of the paralyzed trapezius.

Question 3454

Topic: Elbow & Forearm

During the surgical management of a 'terrible triad' injury of the elbow, what is the generally accepted sequence of repair to restore joint stability?

. LCL repair -> radial head fixation/replacement -> coronoid fixation
. Radial head fixation/replacement -> coronoid fixation -> LCL repair
. Coronoid fixation -> radial head fixation/replacement -> LCL repair
. LCL repair -> coronoid fixation -> radial head fixation/replacement
. Coronoid fixation -> LCL repair -> radial head fixation/replacement

Correct Answer & Explanation

. Coronoid fixation -> radial head fixation/replacement -> LCL repair

Explanation

The standard surgical sequence for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) works deep to superficial and medial to lateral (from a lateral approach): 1) Fixation of the coronoid process or anterior capsule repair, 2) Fixation or replacement of the radial head, and 3) Repair of the lateral collateral ligament (LCL) complex. The MCL is usually only repaired if instability persists after these steps.

Question 3455

Topic: 9. Shoulder and Elbow

A 29-year-old weightlifter feels a 'pop' in his anterior shoulder while performing a heavy bench press. Examination reveals an asymmetric axillary fold. If surgical repair is undertaken, which of the following describes the correct anatomic insertion of the torn tendon fibers most commonly injured in this mechanism?

. The clavicular head inserts deep and proximal to the sternal head
. The sternal head inserts deep and proximal to the clavicular head
. The sternal head inserts superficial and distal to the clavicular head
. The sternal head inserts directly onto the coracoid process
. The clavicular head inserts directly onto the lesser tuberosity

Correct Answer & Explanation

. The sternal head inserts deep and proximal to the clavicular head

Explanation

Pectoralis major ruptures usually involve the sternal head, often failing at the insertion during eccentric loading (e.g., bench press). The sternal head fibers twist such that they insert deep and proximal to the clavicular head fibers on the lateral lip of the bicipital groove.

Question 3456

Topic: 9. Shoulder and Elbow

A 24-year-old patient with recurrent anterior glenohumeral instability undergoes an MRI arthrogram, which demonstrates extravasation of contrast into the axillary pouch creating a 'J sign'. The labrum appears intact. What is the most likely diagnosis?

. Bankart lesion
. ALPSA lesion
. GLAD lesion
. HAGL lesion
. Perthes lesion

Correct Answer & Explanation

. HAGL lesion

Explanation

A HAGL (Humeral Avulsion of the Glenohumeral Ligament) lesion involves the avulsion of the inferior glenohumeral ligament from the anatomic neck of the humerus. On MRI arthrogram, contrast leaks inferiorly through the axillary pouch, transforming the normal U-shaped pouch into a 'J sign'.

Question 3457

Topic: Elbow & Forearm
A 40-year-old female sustains a coronal shear fracture of the distal humerus involving the capitellum. Radiographs and CT show a large fracture fragment consisting of articular cartilage and a thick layer of subchondral bone, with no extension into the trochlea. What is the correct Bryan and Morrey classification?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV (McKee)
. Type V

Correct Answer & Explanation

. Type I (Hahn-Steinthal)

Explanation

In the Bryan and Morrey classification: Type I (Hahn-Steinthal) is a large osseous articular fragment of the capitellum. Type II (Kocher-Lorenz) is a purely articular cartilage fragment with minimal subchondral bone. Type III (Broberg-Morrey) is a comminuted capitellum fracture. Type IV (McKee) involves a coronal shear fracture extending into the trochlea.

Question 3458

Topic: Elbow & Forearm

Posterolateral rotatory instability (PLRI) of the elbow typically results from an injury to the lateral ulnar collateral ligament (LUCL). What is the anatomic insertion of the LUCL?

. Lateral epicondyle
. Annular ligament
. Supinator crest of the ulna
. Radial tuberosity
. Coronoid process

Correct Answer & Explanation

. Supinator crest of the ulna

Explanation

The Lateral Ulnar Collateral Ligament (LUCL) is the primary restraint to posterolateral rotatory instability (PLRI). It originates on the lateral epicondyle and inserts distally on the supinator crest of the proximal ulna, acting as a supportive sling for the radial head.

Question 3459

Topic: Elbow & Forearm

A 45-year-old male sustains a comminuted, unsalvageable radial head fracture. Intraoperatively, marked proximal translation of the radius is noted when a longitudinal traction force is applied. Which of the following is the most appropriate management?

. Radial head excision alone
. Radial head excision and ulnar shortening osteotomy
. Radial head arthroplasty and distal radioulnar joint (DRUJ) stabilization
. Open reduction internal fixation of the radial head regardless of comminution
. Silicone radial head replacement

Correct Answer & Explanation

. Radial head arthroplasty and distal radioulnar joint (DRUJ) stabilization

Explanation

This patient has an Essex-Lopresti lesion (radial head fracture, interosseous membrane tear, and DRUJ disruption). Radial head excision alone is contraindicated as it will lead to proximal radial migration and chronic wrist pain. The correct treatment is a rigid metallic radial head arthroplasty to restore the longitudinal column, along with stabilization/pinning of the DRUJ.

Question 3460

Topic: Elbow & Forearm

A 14-year-old female gymnast presents with insidious onset of lateral elbow pain, clicking, and a 15-degree extension deficit. Radiographs demonstrate a radiolucent defect in the capitellum with a sclerotic margin and a loose body in the joint space. What is the most critical factor distinguishing this condition from Panner's disease?

. Involvement of the radial head
. Age of the patient and presence of loose bodies
. Association with medial epicondylitis
. History of acute macrotrauma
. Presence of ulnar neuropathy

Correct Answer & Explanation

. Age of the patient and presence of loose bodies

Explanation

This patient has Osteochondritis Dissecans (OCD) of the capitellum. It is crucial to distinguish OCD from Panner's disease (osteochondrosis of the capitellum). Panner's disease occurs in younger children (usually under 10 years old), is self-limiting, and does not form loose bodies. Capitellar OCD occurs in adolescents (typically 12-15 years old) and frequently results in loose body formation and long-term mechanical symptoms requiring surgery.

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