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9. Shoulder and Elbow MCQs

Practice Set 176 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 3501

Topic: 9. Shoulder and Elbow

Which of the following radiographic findings is typically considered the earliest sign of primary elbow osteoarthritis?

. Complete loss of joint space
. Subchondral cysts
. Diffuse intra-articular loose bodies
. Peripheral osteophyte formation
. Erosion of articular cartilage

Correct Answer & Explanation

. Peripheral osteophyte formation

Explanation

Peripheral osteophyte formation (e.g., at the tips of the olecranon or coronoid, or around the radial head/capitellum) is often considered one of the earliest and most consistent radiographic signs of developing elbow osteoarthritis. These bony spurs represent the body's attempt to enlarge the joint surface. Complete loss of joint space, subchondral cysts, and diffuse loose bodies are signs of more advanced disease. Erosion of articular cartilage is a pathological finding, often inferred from joint space narrowing on radiographs, but osteophytes are frequently observable early.

Question 3502

Topic: 9. Shoulder and Elbow

What is the primary goal of non-operative management for elbow osteoarthritis?

. To reverse articular cartilage degeneration
. To prevent osteophyte formation
. To eliminate all pain and restore full range of motion
. To manage symptoms, improve function, and delay surgical intervention
. To regenerate damaged subchondral bone

Correct Answer & Explanation

. To manage symptoms, improve function, and delay surgical intervention

Explanation

Non-operative management for elbow osteoarthritis, similar to OA in other joints, aims to manage symptoms (pain, stiffness), improve function, and delay or potentially avoid surgical intervention. It does not reverse articular cartilage degeneration, prevent osteophyte formation, or regenerate damaged bone. While an ideal outcome might be pain elimination and full range of motion, these are often unrealistic expectations for degenerative conditions treated non-operatively. The primary focus is palliation and functional optimization within the constraints of the disease.

Question 3503

Topic: Elbow & Forearm

A 35-year-old active individual develops elbow pain and stiffness. Imaging reveals Panner's disease in the capitellum. Years later, he presents with signs of advanced elbow osteoarthritis. How does Panner's disease predispose to later OA?

. It causes primary synovial inflammation leading to cartilage loss.
. It results in mechanical instability due to ligamentous laxity.
. It leads to chronic ulnar nerve compression, which degrades articular cartilage.
. It causes irregular ossification and potential collapse of the capitellum, altering joint mechanics.
. It directly accelerates Type I collagen breakdown in the cartilage.

Correct Answer & Explanation

. It causes irregular ossification and potential collapse of the capitellum, altering joint mechanics.

Explanation

Panner's disease is an osteochondrosis of the capitellum in children, involving avascular necrosis and subsequent revascularization. This process can lead to an irregular, deformed, or sclerotic capitellum. Even after healing, the altered contour and underlying bone quality can significantly disrupt the normal radiocapitellar joint mechanics, leading to premature and accelerated development of osteoarthritis in adulthood. It does not primarily cause synovial inflammation, ligamentous laxity, ulnar nerve compression, or Type I collagen breakdown. The fundamental issue is the irreversible change in the articular surface contour and underlying subchondral bone, which creates an abnormal stress distribution in the joint.

Question 3504

Topic: 9. Shoulder and Elbow

When considering intra-articular corticosteroid injections for elbow osteoarthritis, which statement is most accurate?

. Corticosteroid injections provide long-term cartilage regeneration and disease modification.
. They are contraindicated in patients with a history of diabetes due to blood sugar elevation.
. The primary benefit is typically short-term pain relief and reduction of inflammation.
. Multiple injections (more than 4 per year) are recommended for maximal efficacy.
. They are less effective than oral NSAIDs for pain control in elbow OA.

Correct Answer & Explanation

. The primary benefit is typically short-term pain relief and reduction of inflammation.

Explanation

Intra-articular corticosteroid injections in elbow osteoarthritis primarily provide short-term pain relief and reduce intra-articular inflammation. They do not regenerate cartilage, modify disease progression long-term, or address mechanical issues like osteophytes or loose bodies. While they can temporarily elevate blood glucose, diabetes is not an absolute contraindication, though caution and monitoring are warranted. Limiting injections to 2-3 per year is generally recommended due to potential risks of cartilage damage and systemic side effects with excessive use. They are often more effective for localized inflammatory pain than systemic oral NSAIDs, especially when applied directly to the joint.

Question 3505

Topic: 9. Shoulder and Elbow

A patient with elbow osteoarthritis presents with a severe flexion contracture of 45 degrees. Radiographs show significant osteophytes in both fossae. During surgical debridement, which of the following is most critical to address to improve elbow extension?

. Excision of the radial head
. Release of the medial collateral ligament
. Removal of posterior osteophytes and posterior capsular release
. Removal of anterior osteophytes and anterior capsular release
. Ulnar nerve transposition

Correct Answer & Explanation

. Removal of posterior osteophytes and posterior capsular release

Explanation

A severe flexion contracture (loss of extension) is primarily caused by posterior impingement from olecranon osteophytes and tightening/scarring of the posterior capsule. Therefore, removal of posterior osteophytes (from the olecranon tip and olecranon fossa) and a thorough posterior capsular release are the most critical steps to improve elbow extension. Excision of the radial head primarily addresses radiocapitellar pain and pronation/supination. Release of the medial collateral ligament would lead to instability and is not indicated for a flexion contracture. Removal of anterior osteophytes and anterior capsular release primarily improve flexion. Ulnar nerve transposition addresses nerve symptoms, not directly elbow extension.

Question 3506

Topic: 9. Shoulder and Elbow

The Mayo Elbow Performance Score (MEPS) is commonly used to assess outcomes after surgical treatment for elbow osteoarthritis. Which component of the MEPS contributes the most points to the overall score?

. Pain
. Range of Motion
. Stability
. Function
. Strength

Correct Answer & Explanation

. Pain

Explanation

The Mayo Elbow Performance Score (MEPS) is composed of four subscales: Pain (45 points), Range of Motion (20 points), Stability (10 points), and Function (25 points). Pain contributes the most points (45 out of a possible 100), highlighting its importance in patient-reported outcomes for elbow pathology. Strength is not directly a component of the MEPS.

Question 3507

Topic: 9. Shoulder and Elbow

A 50-year-old male with severe elbow osteoarthritis is undergoing total elbow arthroplasty. During the procedure, significant bone loss is noted in the distal humerus, compromising implant stability. What is the most appropriate intraoperative management strategy to address this?

. Switch to an unlinked implant design
. Perform a radial head excision to offload the joint
. Utilize long-stemmed humeral and/or ulnar components with cement augmentation
. Proceed with a conventional short-stemmed implant and rely solely on soft tissue tension
. Convert to an interposition arthroplasty immediately

Correct Answer & Explanation

. Utilize long-stemmed humeral and/or ulnar components with cement augmentation

Explanation

Significant bone loss in the distal humerus during TEA requires enhanced fixation. Utilizing long-stemmed humeral components, often with cement augmentation, is the most appropriate strategy to achieve stable fixation in cases of poor bone stock. Long stems provide a greater surface area for fixation, bypassing areas of compromised bone, and cement ensures a robust interface. Switching to an unlinked implant would be detrimental as it relies on good bone and ligamentous support, which is lacking. Radial head excision would not address the humeral bone loss for a TEA. Relying solely on soft tissue tension with short stems is insufficient and prone to early loosening. Converting to an interposition arthroplasty is a different surgical strategy and not an immediate fix for bone loss during a planned TEA.

Question 3508

Topic: 9. Shoulder and Elbow

Which of the following is an absolute contraindication for elbow arthroscopy?

. Body mass index (BMI) > 35 kg/m2
. Previous elbow fracture with malunion
. Severe capsular contracture resulting in bony ankylosis
. Mild ulnar nerve symptoms
. Concurrent lateral epicondylitis

Correct Answer & Explanation

. Severe capsular contracture resulting in bony ankylosis

Explanation

Severe capsular contracture resulting in bony ankylosis (complete fusion of the joint) is an absolute contraindication for elbow arthroscopy. If the joint is completely fused by bone, there is no joint space to distend or operate within arthroscopically. While previous malunited fractures, high BMI, and mild ulnar nerve symptoms can make arthroscopy more challenging or increase risks, they are not absolute contraindications. Concurrent lateral epicondylitis is a separate issue that can be treated independently or sometimes simultaneously addressed, but does not contraindicate arthroscopy for OA.

Question 3509

Topic: Elbow & Forearm

Which of the following is a recognized complication specifically associated with radial head excision for radiocapitellar osteoarthritis?

. Avascular necrosis of the capitellum
. Distal radioulnar joint (DRUJ) instability
. Nonunion of the olecranon
. Medial collateral ligament insufficiency
. Heterotopic ossification

Correct Answer & Explanation

. Distal radioulnar joint (DRUJ) instability

Explanation

Radial head excision removes the primary stabilizer of the proximal radius. While generally well-tolerated for isolated radiocapitellar OA, a recognized complication is proximal migration of the radius and subsequent distal radioulnar joint (DRUJ) instability, particularly if the interosseous membrane is compromised or the forearm axis is altered. Avascular necrosis of the capitellum is more associated with trauma or conditions like Panner's. Nonunion of the olecranon relates to osteotomy. Medial collateral ligament insufficiency is usually a primary pathology or complication of trauma/surgery that destabilizes the ulnohumeral joint. Heterotopic ossification can occur with any elbow surgery but is not specifically unique to radial head excision compared to other elbow procedures.

Question 3510

Topic: 9. Shoulder and Elbow

In the context of elbow osteoarthritis, what role does hyaluronic acid injection play?

. It is a proven disease-modifying agent that regenerates hyaline cartilage.
. It provides superior long-term pain relief compared to corticosteroids.
. Its efficacy in the elbow is well-established and routinely recommended.
. It acts as a viscoelastic supplement to improve joint lubrication and shock absorption.
. It is an FDA-approved treatment for elbow osteoarthritis.

Correct Answer & Explanation

. It acts as a viscoelastic supplement to improve joint lubrication and shock absorption.

Explanation

Hyaluronic acid (viscosupplementation) is believed to act by improving joint lubrication and shock absorption, and potentially having anti-inflammatory effects. However, its efficacy for elbow osteoarthritis is not as well-established or consistently proven as for knee OA, and it is not routinely recommended or FDA-approved specifically for the elbow. It does not regenerate hyaline cartilage or modify disease progression long-term, and its superiority to corticosteroids in the elbow is not definitively proven. Therefore, its role is primarily as a viscoelastic supplement, but its clinical utility in the elbow is considered less robust than in other joints.

Question 3511

Topic: 9. Shoulder and Elbow

What is the primary reason for performing a capsular release in conjunction with osteophyte excision for elbow osteoarthritis?

. To prevent heterotopic ossification
. To address intrinsic joint stiffness from capsular contracture
. To decompress the ulnar nerve prophylactically
. To improve stability of the ulnohumeral joint
. To facilitate radial head replacement

Correct Answer & Explanation

. To address intrinsic joint stiffness from capsular contracture

Explanation

Capsular release is performed in conjunction with osteophyte excision primarily to address intrinsic joint stiffness caused by a contracted and thickened joint capsule. While osteophyte removal addresses bony impingement, a tight capsule can independently restrict motion. Releasing the capsule allows for greater range of motion, particularly at the terminal ends of flexion and extension. It does not prevent heterotopic ossification (though HO can complicate motion), decompress the ulnar nerve, improve ulnohumeral stability (it can potentially decrease it if over-released), or facilitate radial head replacement directly.

Question 3512

Topic: 9. Shoulder and Elbow

A 45-year-old male presents with elbow pain and loss of motion. Radiographs show early tricompartmental osteoarthritis. He reports pain at the extremes of flexion and extension, but no mechanical locking. Which non-operative treatment modality has the strongest evidence for providing short-term pain relief in elbow OA?

. Glucosamine and chondroitin sulfate supplements
. Platelet-rich plasma (PRP) injections
. Physical therapy focusing on strengthening exercises
. Intra-articular corticosteroid injections
. Acupuncture

Correct Answer & Explanation

. Intra-articular corticosteroid injections

Explanation

For short-term pain relief in osteoarthritis, intra-articular corticosteroid injections have the strongest evidence base. They act by reducing local inflammation within the joint. While physical therapy is crucial for improving motion and strength, its primary role is not acute pain relief. Glucosamine/chondroitin and PRP have limited or inconclusive evidence for elbow OA, and acupuncture lacks strong scientific backing for definitive short-term pain relief in this context. Therefore, corticosteroid injections are typically considered the most effective short-term intervention when pain is a predominant symptom.

Question 3513

Topic: 9. Shoulder and Elbow

What is the primary concern when performing a radial head excision in a patient with rheumatoid arthritis and advanced elbow destruction?

. Increased risk of heterotopic ossification
. Exacerbation of ulnar nerve symptoms
. Proximal migration of the radius leading to severe elbow instability
. Development of new-onset lateral epicondylitis
. Difficulty with wound healing due to immunosuppression

Correct Answer & Explanation

. Proximal migration of the radius leading to severe elbow instability

Explanation

In patients with rheumatoid arthritis (RA), the elbow joint often suffers from widespread soft tissue and ligamentous destruction, including potential insufficiency of the medial collateral ligament and interosseous membrane. Removing the radial head in this setting can further destabilize the elbow, leading to significant proximal migration of the radius and severe elbow instability, particularly a disabling valgus instability and potentially carpal collapse. While heterotopic ossification and ulnar nerve symptoms can occur, the primary and most severe concern is the potential for profound instability due to already compromised soft tissues. Wound healing can be an issue due to RA medications but is not the primary concern specific to radial head excision itself. Lateral epicondylitis is unlikely to be caused by radial head excision.

Question 3514

Topic: 9. Shoulder and Elbow

A 58-year-old male with chronic elbow pain and stiffness is diagnosed with primary elbow osteoarthritis. He is considering surgical intervention. Which of the following is a primary indication for open debridement and osteophyte excision?

. Extensive tricompartmental cartilage loss requiring joint resurfacing
. History of active elbow infection within the last 6 months
. Persistent mechanical symptoms (e.g., locking, catching) despite conservative care
. Significant elbow instability requiring ligamentous reconstruction
. Severe osteoporosis contraindicating bone-implant interface

Correct Answer & Explanation

. Persistent mechanical symptoms (e.g., locking, catching) despite conservative care

Explanation

Open debridement and osteophyte excision are primarily indicated for patients with elbow osteoarthritis who experience persistent mechanical symptoms (locking, catching, restricted range of motion) due to osteophytes or loose bodies, and who have failed conservative management. This procedure aims to remove mechanical blocks and restore motion. Extensive tricompartmental cartilage loss would favor arthroplasty. Active elbow infection is a contraindication to elective surgery. Significant instability would require ligamentous reconstruction, not just debridement. Severe osteoporosis is a concern for implant fixation in arthroplasty, not necessarily an indication for debridement.

Question 3515

Topic: 9. Shoulder and Elbow

What is the most common radiographic finding in early primary elbow osteoarthritis?

. Subchondral cysts
. Ankylosis
. Joint space narrowing
. Osteophyte formation
. Erosion

Correct Answer & Explanation

. Osteophyte formation

Explanation

Osteophyte formation, particularly at the olecranon tip, coronoid, and radial head, is generally considered the earliest and most prevalent radiographic sign of primary elbow osteoarthritis. These bony spurs often precede significant joint space narrowing or subchondral cyst formation. Ankylosis is a late-stage complication, and erosion is more typical of inflammatory arthropathies. Joint space narrowing follows the formation of osteophytes as cartilage degrades.

Question 3516

Topic: 9. Shoulder and Elbow

In the context of elbow osteoarthritis, what is the significance of heterotopic ossification (HO) and how is it often managed?

. HO is a protective mechanism that improves joint stability and range of motion.
. It is a rare complication of elbow surgery, typically requiring no intervention.
. HO can cause pain and restrict range of motion, often requiring prophylaxis and sometimes excision.
. It is always a sign of infection and mandates immediate antibiotic treatment.
. Prophylaxis for HO is only indicated after total elbow arthroplasty, not debridement.

Correct Answer & Explanation

. HO can cause pain and restrict range of motion, often requiring prophylaxis and sometimes excision.

Explanation

Heterotopic ossification (HO) is the abnormal formation of bone in soft tissues where bone does not normally exist. It is a recognized complication of elbow trauma and surgery, particularly for stiffness. HO can cause pain, restrict range of motion, and severely limit functional outcomes. Prophylaxis, often with NSAIDs (e.g., indomethacin) or radiation therapy, is indicated in high-risk patients or after certain procedures (like contracture release). If significant and symptomatic, HO may require surgical excision after maturation. HO is not protective, not always rare, and is not a sign of infection. Prophylaxis is indicated for any elbow surgery that places the patient at high risk for HO, not just TEA.

Question 3517

Topic: 9. Shoulder and Elbow

A 70-year-old patient with end-stage elbow osteoarthritis and significant triceps insufficiency is being considered for surgical intervention. Which procedure would be LEAST appropriate given the triceps insufficiency?

. Total elbow arthroplasty (TEA)
. Open debridement with osteophyte excision
. Interposition arthroplasty
. Arthrodesis
. Radial head excision

Correct Answer & Explanation

. Total elbow arthroplasty (TEA)

Explanation

Significant triceps insufficiency is a relative contraindication for total elbow arthroplasty (TEA), especially for linked designs. The triceps muscle is crucial for elbow extension and dynamic stability, and its compromise can lead to extensor lag, poor functional outcomes, and increased risk of implant failure or instability after TEA. Open debridement, interposition arthroplasty, and radial head excision would not necessarily be compromised by triceps insufficiency to the same degree as TEA, as they do not rely as heavily on the integrity of the surrounding musculature for implant stability. Arthrodesis, while leading to a fused joint, would provide stability independent of the triceps function.

Question 3518

Topic: 9. Shoulder and Elbow

When interpreting radiographs for elbow osteoarthritis, which view is most important for assessing posterior olecranon osteophytes?

. Anteroposterior (AP) view
. Lateral view
. Oblique views
. External rotation view
. Axial view of the capitellum

Correct Answer & Explanation

. Lateral view

Explanation

The lateral view of the elbow is essential for assessing posterior olecranon osteophytes and the olecranon fossa, as well as anterior coronoid osteophytes and the coronoid fossa. These structures are best visualized in profile on a true lateral projection. The AP view primarily shows the width of the joint space and medial/lateral osteophytes. Oblique views can provide additional information but are not primary for posterior osteophytes. External rotation views and axial views target specific other pathologies.

Question 3519

Topic: 9. Shoulder and Elbow

A patient with elbow osteoarthritis undergoes arthroscopic debridement. Postoperatively, she develops a common complication known as 'arthrofibrosis,' leading to persistent stiffness. Which of the following is the most effective approach to prevent this complication?

. Aggressive, early passive range of motion (CPM) immediately post-op.
. Strict immobilization for 6 weeks to allow soft tissue healing.
. High-dose systemic corticosteroids for 2 weeks post-op.
. Prophylactic low-dose radiation therapy post-op.
. Avoidance of any physical therapy for the first month.

Correct Answer & Explanation

. Aggressive, early passive range of motion (CPM) immediately post-op.

Explanation

Arthrofibrosis is a major concern after elbow surgery. While a multifactorial issue, aggressive, early, and sustained range of motion (often with the aid of continuous passive motion, CPM, or immediate therapist-supervised exercises) is crucial in preventing and managing postoperative stiffness and arthrofibrosis after elbow debridement. Strict immobilization is generally avoided as it promotes stiffness. High-dose systemic corticosteroids are not a standard prophylactic measure for arthrofibrosis and carry significant side effects. Prophylactic low-dose radiation therapy is primarily used to prevent heterotopic ossification, not generalized arthrofibrosis. Avoiding physical therapy would exacerbate stiffness.

Question 3520

Topic: 9. Shoulder and Elbow

A 60-year-old male presents with advanced elbow osteoarthritis primarily affecting the ulnohumeral joint. He desires pain relief but wants to avoid a total elbow arthroplasty due to his active lifestyle. His radiographs show good bone stock and minimal involvement of the radiocapitellar joint. Which surgical option would be most suitable?

. Isolated radial head excision
. Interposition arthroplasty of the ulnohumeral joint
. Elbow arthrodesis
. Arthroscopic capsular release without debridement
. TEA

Correct Answer & Explanation

. Interposition arthroplasty of the ulnohumeral joint

Explanation

For advanced ulnohumeral osteoarthritis in an active patient desiring to avoid TEA and preserve motion, an interposition arthroplasty of the ulnohumeral joint is a suitable option. This involves resurfacing the joint with autologous (e.g., fascia lata) or allogenic tissue to provide a gliding surface and cushion, preserving bone stock. Isolated radial head excision would not address the ulnohumeral pain. Elbow arthrodesis would eliminate motion, which is usually undesirable for active patients unless pain is intractable and stability is paramount. Arthroscopic capsular release alone is insufficient for advanced cartilage loss. TEA is being avoided by the patient.

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