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9. Shoulder and Elbow MCQs

Practice Set 179 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 3561

Topic: 9. Shoulder and Elbow

What is the primary vascular supply to the anterior compartment of the forearm, distal to the elbow?

. Profunda brachii artery
. Superior ulnar collateral artery
. Brachial artery, dividing into radial and ulnar arteries
. Anterior recurrent ulnar artery
. Posterior interosseous artery

Correct Answer & Explanation

. Brachial artery, dividing into radial and ulnar arteries

Explanation

Distal to the elbow, the brachial artery typically bifurcates into the radial and ulnar arteries. These two major arteries, along with their numerous branches (recurrent arteries, interosseous arteries), provide the primary vascular supply to the entire forearm, including the anterior compartment. The profunda brachii artery is a branch of the brachial artery more proximally in the arm. The superior ulnar collateral artery is a branch in the arm. Recurrent arteries are typically branches of the radial and ulnar arteries themselves, and the posterior interosseous artery is a branch of the common interosseous, which itself is a branch of the ulnar artery.

Question 3562

Topic: Elbow & Forearm

Which muscle is most commonly implicated in medial epicondylitis (golfer's elbow)?

. Extensor carpi radialis brevis
. Supinator
. Pronator teres and flexor carpi radialis
. Biceps brachii
. Triceps brachii

Correct Answer & Explanation

. Pronator teres and flexor carpi radialis

Explanation

Medial epicondylitis, or golfer's elbow, is an overuse injury affecting the common flexor-pronator origin at the medial epicondyle. The pronator teres and flexor carpi radialis are the most commonly involved muscles. The extensor carpi radialis brevis is involved in lateral epicondylitis. Supinator, biceps, and triceps are not primarily implicated in medial epicondylitis.

Question 3563

Topic: Elbow & Forearm
A 25-year-old male sustains a comminuted radial head fracture (Mason Type III) with an associated MCL injury and elbow dislocation (terrible triad). What is the preferred treatment for the radial head component in this active patient?
. Excision of the radial head
. Open reduction and internal fixation (ORIF) of the radial head
. Radial head arthroplasty
. Long-term immobilization
. Percutaneous pinning of the radial head

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

In a terrible triad injury with a comminuted, unreconstructible radial head fracture (Mason Type III) in an active patient, radial head arthroplasty is generally the preferred treatment. Excision of the radial head in the setting of a terrible triad can lead to persistent valgus instability and proximal migration of the radius. ORIF is ideal for reconstructible fractures (Mason Type II), but not for Type III comminution. Long-term immobilization is detrimental for elbow function. Percutaneous pinning is typically for very simple, minimally displaced fractures, not comminuted ones.

Question 3564

Topic: Elbow & Forearm

What is the characteristic radiographic finding in osteochondritis dissecans (OCD) of the capitellum?

. Widening of the trochlear groove
. Sclerosis and fragmentation of the capitellar articular surface
. Prominent osteophytes at the olecranon fossa
. Radial head subluxation
. Medial epicondyle apophysitis

Correct Answer & Explanation

. Sclerosis and fragmentation of the capitellar articular surface

Explanation

Osteochondritis dissecans (OCD) of the capitellum is an idiopathic aseptic necrosis of the subchondral bone, primarily affecting young athletes (e.g., gymnasts, baseball pitchers). Radiographically, it is characterized by sclerosis, fragmentation, and potential loosening of a segment of the capitellar articular surface. Other options describe different pathologies or non-specific findings.

Question 3565

Topic: 9. Shoulder and Elbow

What is the critical range of motion for elbow function in most activities of daily living?

. 0-150 degrees flexion/extension
. 30-130 degrees flexion/extension
. 0-90 degrees flexion/extension
. Full extension to 90 degrees flexion
. 10-100 degrees flexion/extension

Correct Answer & Explanation

. 30-130 degrees flexion/extension

Explanation

The functional arc of motion for the elbow, which allows for most activities of daily living (e.g., eating, personal hygiene, dressing), is generally considered to be 30 to 130 degrees of flexion/extension, with 50 degrees of pronation and 50 degrees of supination. Achieving a full range (0-150) is ideal but not always necessary or achievable. Ranges narrower than 30-130 often lead to significant functional limitations.

Question 3566

Topic: 9. Shoulder and Elbow

Which structure forms the lateral border of the cubital fossa?

. Pronator teres muscle
. Brachioradialis muscle
. Biceps tendon
. Medial epicondyle
. Lateral epicondyle

Correct Answer & Explanation

. Biceps tendon

Explanation

The cubital fossa is a triangular space located anterior to the elbow joint. Its boundaries are: superiorly by an imaginary line connecting the medial and lateral epicondyles; medially by the pronator teres muscle; and laterally by the brachioradialis muscle. The floor is formed by the brachialis and supinator muscles, and the roof by the bicipital aponeurosis and skin. The biceps tendon passes through it. The epicondyles are superior landmarks.

Question 3567

Topic: 9. Shoulder and Elbow

A 35-year-old male presents with persistent elbow pain and inability to fully extend his elbow following a fall. Radiographs show heterotopic ossification (HO) in the anterior compartment. What is the most effective prophylactic measure against recurrent HO after surgical excision?

. Prolonged immobilization in extension
. High-dose oral corticosteroids for 6 weeks
. Indomethacin or radiation therapy post-operatively
. Physical therapy focusing solely on passive range of motion
. Intra-articular hyaluronic acid injections

Correct Answer & Explanation

. Indomethacin or radiation therapy post-operatively

Explanation

After surgical excision of heterotopic ossification (HO) in the elbow, the most effective prophylactic measures against recurrence are post-operative radiation therapy (typically a single low dose) or a course of non-steroidal anti-inflammatory drugs (NSAIDs) like indomethacin. Early, active range of motion is also crucial. Prolonged immobilization can worsen stiffness and potentially exacerbate HO. Corticosteroids are not a standard prophylactic. Hyaluronic acid injections are for joint lubrication.

Question 3568

Topic: Elbow & Forearm

Which structure provides the most significant secondary stability to the elbow, particularly in valgus stress, when the primary stabilizer (AMCL) is compromised?

. Radial head and capitellum articulation
. Common extensor origin
. Triceps tendon insertion
. Joint capsule (anterior and posterior)
. Anconeus muscle

Correct Answer & Explanation

. Radial head and capitellum articulation

Explanation

The radial head and capitellum articulation provide significant secondary stability to the elbow, especially against valgus stress, once the primary stabilizer (anterior bundle of the medial collateral ligament) is compromised. This is why excision of the radial head in the setting of valgus instability (e.g., terrible triad) can exacerbate the instability. The other options contribute less directly or significantly to static valgus stability.

Question 3569

Topic: 9. Shoulder and Elbow

What is the primary function of the annular ligament of the elbow?

. Primary restraint to valgus stress
. Primary restraint to varus stress
. Stabilizes the radial head in the radial notch of the ulna
. Connects the olecranon to the medial epicondyle
. Limits hyperextension of the elbow

Correct Answer & Explanation

. Stabilizes the radial head in the radial notch of the ulna

Explanation

The annular ligament encircles the radial head, holding it firmly in the radial notch of the ulna. This allows for pronation and supination of the forearm while preventing displacement of the radial head. It is not a primary restraint to varus or valgus stress, nor does it limit hyperextension, nor connect the olecranon to the medial epicondyle.

Question 3570

Topic: 9. Shoulder and Elbow
In the setting of a complex elbow dislocation, what is the significance of a Type III coronoid fracture (O'Driscoll classification)?
. It is a small, non-displaced tip avulsion and does not affect stability.
. It indicates involvement of less than 10% of the coronoid height, managed non-operatively.
. It involves greater than 50% of the coronoid height, significantly compromising ulnohumeral stability.
. It suggests associated radial head injury requiring radial head excision.
. It is an extra-articular fracture with no impact on elbow kinematics.

Correct Answer & Explanation

. It involves greater than 50% of the coronoid height, significantly compromising ulnohumeral stability.

Explanation

O'Driscoll Type III coronoid fractures involve a large portion (greater than 50%) of the coronoid height. Such extensive involvement significantly compromises the ulnohumeral articulation, leading to gross instability of the elbow, especially in posterior dislocations. These fractures almost always require surgical fixation to restore stability. Type I is a tip avulsion, Type II is intermediate (10-50%).

Question 3571

Topic: 9. Shoulder and Elbow

What is the most common complication following distal biceps tendon repair?

. Re-rupture
. Ulnar nerve palsy
. Heterotopic ossification
. Loss of elbow flexion
. Posterior interosseous nerve palsy

Correct Answer & Explanation

. Heterotopic ossification

Explanation

Heterotopic ossification (HO) is the most common complication following distal biceps tendon repair, particularly with two-incision approaches or extensive dissection. Careful surgical technique, atraumatic handling, and post-operative prophylaxis (e.g., NSAIDs or radiation) can reduce its incidence. Re-rupture is uncommon with good repair. Ulnar and PIN palsies are less common than HO but can occur with nerve retraction or direct injury. Loss of elbow flexion is rare if repair is done correctly.

Question 3572

Topic: 9. Shoulder and Elbow

What is the primary role of the common extensor origin in elbow stability?

. It is a primary dynamic stabilizer against valgus stress.
. It acts as a primary static restraint to varus stress.
. It provides secondary static stability against varus stress, particularly when the radial collateral ligament complex is deficient.
. It is involved in preventing posterior subluxation of the ulna.
. It has no significant role in elbow stability, only muscle function.

Correct Answer & Explanation

. It provides secondary static stability against varus stress, particularly when the radial collateral ligament complex is deficient.

Explanation

The common extensor origin, along with the other soft tissues of the lateral elbow, provides secondary static stability against varus stress. When the radial collateral ligament (RCL) complex is deficient, these tendinous origins can contribute to preventing excessive varus gapping. The LUCL is the primary static restraint to varus. It is not a dynamic stabilizer against valgus stress.

Question 3573

Topic: Elbow & Forearm

What is the primary concern when managing a displaced lateral condyle fracture of the humerus in a 6-year-old child?

. Radial nerve entrapment
. Ulnar nerve palsy
. Nonunion and cubitus valgus deformity
. Brachial artery injury
. Posterolateral rotatory instability

Correct Answer & Explanation

. Nonunion and cubitus valgus deformity

Explanation

Displaced lateral condyle fractures in children are prone to nonunion, especially if not adequately fixed. A nonunion of the lateral condyle can lead to a progressive cubitus valgus deformity, which can then cause a delayed ulnar nerve palsy (tardy ulnar palsy). Therefore, preventing nonunion and subsequent deformity is a primary concern. Nerve and vascular injuries are less common than with supracondylar fractures. PLRI is associated with LUCL injury.

Question 3574

Topic: 9. Shoulder and Elbow

A 50-year-old male with chronic lateral epicondylitis fails extensive conservative management. Surgical options include open release or arthroscopic debridement. What is the main benefit of arthroscopic over open release for this condition?

. Less painful post-operative recovery
. Superior long-term outcomes
. Allows for concomitant treatment of intra-articular pathologies
. Lower risk of nerve injury
. Faster return to sport

Correct Answer & Explanation

. Allows for concomitant treatment of intra-articular pathologies

Explanation

The main benefit of arthroscopic treatment for lateral epicondylitis over open release is the ability to diagnose and treat concomitant intra-articular pathologies, such as plica, synovitis, loose bodies, or chondral lesions, which can contribute to persistent elbow pain. While some patients may experience a less invasive feeling, long-term outcomes are generally comparable, and the risk of nerve injury can actually be higher with arthroscopy if not performed meticulously. Recovery speed varies.

Question 3575

Topic: Shoulder Arthroplasty & Arthritis

For an 84-year-old lady with a comminuted 4-part proximal humerus fracture, which radiographic feature is most indicative of a potential need for reverse total shoulder arthroplasty (rTSA) over open reduction internal fixation (ORIF)?

. Presence of an intact lesser tuberosity
. Minimal metaphyseal comminution
. Head split component
. Valgus-impacted fracture pattern
. Intact rotator cuff tendons (inferred)

Correct Answer & Explanation

. Head split component

Explanation

A head split component (fracture extending through the articular surface of the humeral head) or significant articular damage makes anatomical reduction difficult or impossible, often leading to poor outcomes with ORIF. In the elderly, especially with osteoporotic bone, rTSA is often preferred for complex 3- and 4-part fractures, particularly when articular comminution or displacement suggests avascular necrosis risk or inability to achieve stable fixation with ORIF. Valgus-impacted fractures are generally more stable. Intact tuberosities or minimal comminution would favor ORIF. Intact rotator cuff tendons would be important for an anatomic TSA, but rTSA bypasses a non-functional cuff.

Question 3576

Topic: 9. Shoulder and Elbow

Which radiographic finding in an 84-year-old's shoulder X-ray, weeks after a surgical neck fracture treated non-operatively, would raise the greatest concern for delayed union or non-union?

. Persistent fracture line with surrounding lucency
. Early callus formation
. Absence of new displacement
. Mild soft tissue swelling
. Maintained glenohumeral joint space

Correct Answer & Explanation

. Persistent fracture line with surrounding lucency

Explanation

Persistent fracture line with surrounding lucency (resorption) and lack of bridging callus formation at the fracture site are classic radiographic signs of delayed union or non-union. Early callus formation indicates healing. Absence of new displacement is a good sign. Soft tissue swelling is expected post-injury. Maintained glenohumeral joint space is unrelated to fracture healing.

Question 3577

Topic: 9. Shoulder and Elbow

An 84-year-old lady complains of pain localized to the superior aspect of her shoulder, exacerbated by overhead activities. Her X-ray series includes a Zanca view. Which radiographic findings would be most consistent with symptomatic acromioclavicular (AC) joint osteoarthritis?

. Superior migration of the humeral head
. Subacromial spurring
. Joint space narrowing, osteophytes, and subchondral sclerosis of the AC joint
. Erosions of the distal clavicle
. Glenohumeral joint space narrowing

Correct Answer & Explanation

. Joint space narrowing, osteophytes, and subchondral sclerosis of the AC joint

Explanation

AC joint osteoarthritis, like other degenerative arthropathies, is characterized by joint space narrowing, osteophyte formation, and subchondral sclerosis, specifically affecting the articulation between the distal clavicle and the acromion. A Zanca view is a specialized AP projection with cephalic tilt to optimally visualize the AC joint. Superior migration of the humeral head points to rotator cuff arthropathy. Subacromial spurring is associated with impingement, not directly AC joint OA. Erosions of the distal clavicle can be seen in inflammatory arthritis (e.g., RA, CPPD) or osteolysis, but OA predominantly shows sclerosis and osteophytes. Glenohumeral joint narrowing is GHOA.

Question 3578

Topic: 9. Shoulder and Elbow

A 84-year-old female's shoulder X-ray shows glenohumeral joint space narrowing, subchondral sclerosis, and, notably, linear calcifications within the hyaline cartilage. This specific calcification pattern is highly suggestive of:

. Calcium hydroxyapatite deposition disease (CHADD)
. Rotator cuff calcific tendinitis
. Gout
. Calcium pyrophosphate deposition disease (CPPD) / Chondrocalcinosis
. Septic arthritis

Correct Answer & Explanation

. Calcium pyrophosphate deposition disease (CPPD) / Chondrocalcinosis

Explanation

Linear or punctate calcifications within the joint cartilage (hyaline or fibrocartilage) are the hallmark radiographic sign of calcium pyrophosphate deposition disease (CPPD), also known as chondrocalcinosis. CHADD or calcific tendinitis involves calcifications within tendons or bursae, usually amorphous. Gout causes erosions with overhanging edges, often without joint space calcification. Septic arthritis involves rapid joint destruction.

Question 3579

Topic: 9. Shoulder and Elbow

In differentiating chronic inflammatory arthritis (e.g., rheumatoid arthritis) from osteoarthritis on a shoulder X-ray of an 84-year-old, which finding would be most characteristic of rheumatoid arthritis?

. Inferior glenohumeral osteophytes
. Concentric joint space narrowing with marginal erosions
. Subchondral sclerosis
. Superior migration of the humeral head without erosions
. Unilateral involvement

Correct Answer & Explanation

. Concentric joint space narrowing with marginal erosions

Explanation

Rheumatoid arthritis in the shoulder is characterized by concentric joint space narrowing (affecting all aspects of the joint equally), marginal erosions (particularly at the bare areas), and often periarticular osteopenia. In later stages, it can also lead to rotator cuff tears and superior migration. Osteoarthritis typically causes asymmetrical joint space narrowing (inferomedial for GHOA), prominent osteophytes, and subchondral sclerosis, usually without true erosions. Superior migration without erosions is more classic for rotator cuff arthropathy. RA is often bilateral.

Question 3580

Topic: 9. Shoulder and Elbow

A 84-year-old man presents with acute, severe shoulder pain. His X-ray shows soft tissue swelling and a lytic lesion with an overhanging edge near the greater tuberosity. While rare in the shoulder, these findings are most suggestive of:

. Acute calcific tendinitis
. Osteoarthritis flare
. Gouty arthritis
. Stress fracture
. Septic arthritis

Correct Answer & Explanation

. Gouty arthritis

Explanation

Although less common in the shoulder than in the foot, gout can affect any joint. The characteristic radiographic signs of chronic gout are soft tissue swelling due to tophi, 'punched-out' lytic lesions (erosions) with sclerotic margins, and often a classic 'overhanging edge' (Martel sign). Acute calcific tendinitis presents with amorphous calcifications. OA flare is typically joint space narrowing and osteophytes. Stress fractures are subtle cortical breaks. Septic arthritis leads to rapid joint destruction and effusion.

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