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9. Shoulder and Elbow MCQs

Practice Set 180 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 3581

Topic: 9. Shoulder and Elbow
The 'acromiohumeral interval' (AHI) is a key measurement on shoulder X-rays. In an 84-year-old female with long-standing shoulder pain, a significantly reduced AHI (e.g., <6mm) is most indicative of:
. Adhesive capsulitis
. Subacromial impingement
. Massive rotator cuff tear with superior humeral head migration
. Glenohumeral osteoarthritis
. Bicipital tendinitis

Correct Answer & Explanation

. Massive rotator cuff tear with superior humeral head migration

Explanation

A severely reduced acromiohumeral interval (distance between the undersurface of the acromion and the superior aspect of the humeral head) is a hallmark radiographic sign of a chronic, massive rotator cuff tear. Without an intact rotator cuff, the unopposed pull of the deltoid muscle causes superior migration of the humeral head. A normal AHI is typically 7-14mm. Impingement can involve spurs, but true superior migration signifies a tear. Adhesive capsulitis has no radiographic findings. GHOA typically causes inferior or concentric narrowing.

Question 3582

Topic: 9. Shoulder and Elbow

On an 84-year-old patient's shoulder X-ray, you observe diffuse, fine, stippled calcifications within the subacromial-subdeltoid bursa. This finding is most likely indicative of:

. Chronic inflammatory bursitis
. Calcium pyrophosphate deposition disease
. Calcific tendinitis
. Synovial osteochondromatosis
. Myositis ossificans

Correct Answer & Explanation

. Chronic inflammatory bursitis

Explanation

Diffuse, stippled calcifications within the subacromial-subdeltoid bursa are characteristic of chronic inflammatory bursitis, often secondary to chronic impingement or irritation. While calcific tendinitis involves tendon calcification, bursal calcification is a distinct entity. CPPD involves articular cartilage. Synovial osteochondromatosis produces numerous loose bodies. Myositis ossificans is heterotopic bone formation within muscle.

Question 3583

Topic: 9. Shoulder and Elbow

An 84-year-old patient presents with their arm fixed in abduction and external rotation, with the humeral head palpable inferiorly. Her X-ray confirms an inferior glenohumeral dislocation. What is the clinical term for this rare type of dislocation?

. Anterior dislocation
. Posterior dislocation
. Luxatio erecta
. Multidirectional instability
. Subluxation

Correct Answer & Explanation

. Luxatio erecta

Explanation

Luxatio erecta is a rare type of inferior glenohumeral dislocation where the humeral head is displaced inferiorly, and the arm is fixed in an abducted and externally rotated position, often above the head. Anterior and posterior dislocations are more common. Subluxation implies partial dislocation. Multidirectional instability is a clinical diagnosis.

Question 3584

Topic: 9. Shoulder and Elbow

An 84-year-old patient with diabetes presents with chronic, low-grade shoulder pain and a discharging sinus. Her X-ray shows periosteal reaction, cortical thickening, and medullary sclerosis in the proximal humerus. These findings are most suggestive of:

. Osteoarthritis
. Rotator cuff arthropathy
. Chronic osteomyelitis
. Calcific tendinitis
. Stress fracture

Correct Answer & Explanation

. Chronic osteomyelitis

Explanation

Periosteal reaction, cortical thickening, and medullary sclerosis (often with a sequestrum or involucrum, though not specified here) are classic radiographic signs of chronic osteomyelitis. This is particularly relevant in patients with predisposing factors like diabetes and a draining sinus. Osteoarthritis and rotator cuff arthropathy are joint diseases. Calcific tendinitis involves tendon calcification. Stress fractures show subtle lucency or sclerosis without such extensive reactive bone changes.

Question 3585

Topic: Shoulder Arthroplasty & Arthritis

An 84-year-old lady has a history of right shoulder replacement. Her current X-ray shows an anatomic total shoulder arthroplasty (TSA). Which components would you expect to see on the X-ray?

. Humeral head prosthesis only
. Humeral stem and glenoid cup only
. Humeral stem with a modular head component, and a polyethylene glenoid component cemented into a metallic glenoid baseplate
. Humeral stem with a reverse ball component and a glenoid socket
. A prosthetic ball cemented to the glenoid and a prosthetic cup on the humerus

Correct Answer & Explanation

. Humeral stem with a modular head component, and a polyethylene glenoid component cemented into a metallic glenoid baseplate

Explanation

An anatomic Total Shoulder Arthroplasty (TSA) aims to replicate normal anatomy. It consists of a humeral component (stem with a modular head, typically metal) and a glenoid component (a polyethylene liner usually cemented into a metallic baseplate that is fixated to the glenoid bone). Option A is hemiarthroplasty. Option D is a reverse TSA. Option E describes a reverse TSA setup with components flipped. Option B is incomplete.

Question 3586

Topic: Shoulder Arthroplasty & Arthritis

On the X-ray of an 84-year-old lady with a Reverse Total Shoulder Arthroplasty (rTSA), what is the key radiographic characteristic differentiating it from an anatomic TSA?

. A larger humeral head prosthesis
. A metallic glenosphere fixed to the scapula and a humeral socket
. Absence of a humeral stem
. A smaller glenoid component
. The presence of a polyethylene humeral head

Correct Answer & Explanation

. A metallic glenosphere fixed to the scapula and a humeral socket

Explanation

In a reverse total shoulder arthroplasty (rTSA), the 'ball' (glenosphere) is fixed to the glenoid bone, and the 'socket' (humeral cup/liner) is on the humeral side, effectively reversing the native anatomy. This allows the deltoid to act as the primary elevator, compensating for a deficient rotator cuff. An anatomic TSA has the ball on the humerus and socket on the glenoid.

Question 3587

Topic: Shoulder Arthroplasty & Arthritis

Which radiographic finding is a common long-term complication specifically associated with Reverse Total Shoulder Arthroplasty (rTSA)?

. Instability of the humeral head in the glenoid
. Scapular notching
. Resorption of the greater tuberosity
. Dislocation of the metal humeral head
. Avascular necrosis of the glenoid

Correct Answer & Explanation

. Scapular notching

Explanation

Scapular notching is a common and specific complication of reverse total shoulder arthroplasty, occurring when the medial aspect of the humeral implant impinges on the inferior scapular neck during adduction and internal rotation, leading to bony erosion. Instability of the humeral head in the glenoid is for anatomic TSA. Resorption of the greater tuberosity is more relevant to proximal humerus fractures or hemiarthroplasty. Dislocation of the metal humeral head is for anatomic TSA. Avascular necrosis of the glenoid is rare.

Question 3588

Topic: Shoulder Arthroplasty & Arthritis

What is the primary radiographic feature used to diagnose scapular notching in an X-ray of an rTSA patient?

. Glenoid component subsidence
. Erosion of the inferior scapular neck by the humeral component
. Fracture of the coracoid process
. Increased joint space
. Periprosthetic osteolysis around the humeral stem

Correct Answer & Explanation

. Erosion of the inferior scapular neck by the humeral component

Explanation

Scapular notching is precisely defined as the erosion of the inferior scapular neck by the humeral component of the rTSA, specifically the polyethylene liner impacting the bone during certain movements. It's a progressive, visually distinct radiographic finding. Glenoid subsidence is different, and the other options are not directly related to notching.

Question 3589

Topic: 9. Shoulder and Elbow

On an AP shoulder X-ray, you observe calcification in the soft tissues superior to the coracoid process, possibly within the coracoclavicular ligaments. This finding could indicate:

. Normal aging variant
. Prior AC joint dislocation with calcification
. Coracoid impingement
. Ossification of the coracoclavicular ligaments
. Subcoracoid bursitis

Correct Answer & Explanation

. Ossification of the coracoclavicular ligaments

Explanation

Calcification or ossification of the coracoclavicular ligaments (conoid and trapezoid) can occur, sometimes post-traumatically (e.g., after an AC joint injury where the ligaments were stretched or torn) or as an idiopathic process. It's not a normal aging variant. While it might be associated with prior AC dislocation, 'ossification of the coracoclavicular ligaments' directly describes the radiographic finding. Coracoid impingement is more about morphology. Subcoracoid bursitis typically doesn't calcify in this manner.

Question 3590

Topic: 9. Shoulder and Elbow

What constitutes an 'adequate' shoulder X-ray series for an initial evaluation of trauma in an 84-year-old lady?

. Single AP view
. AP external rotation and internal rotation views only
. AP, Scapular Y, and Axillary views
. AP and Outlet views
. Bilateral AP views

Correct Answer & Explanation

. AP, Scapular Y, and Axillary views

Explanation

An adequate shoulder trauma series typically includes at least three views: an AP view (often a Grashey true AP is preferred), a Scapular Y view (for assessing dislocation direction and scapular body), and an Axillary view (crucial for glenohumeral congruity, anterior/posterior dislocation, and glenoid rim pathology). These three views provide a comprehensive initial assessment.

Question 3591

Topic: 9. Shoulder and Elbow

An 84-year-old lady presents with chronic shoulder pain. Her X-ray shows diffuse periarticular osteopenia, concentric joint space narrowing, and marginal erosions in both glenohumeral joints. These findings are highly characteristic of:

. Primary glenohumeral osteoarthritis
. Rotator cuff arthropathy
. Rheumatoid arthritis
. Septic arthritis
. Calcium pyrophosphate deposition disease

Correct Answer & Explanation

. Rheumatoid arthritis

Explanation

Bilateral, symmetrical, concentric joint space narrowing, periarticular osteopenia, and marginal erosions are classic radiographic features of rheumatoid arthritis. Primary OA is typically asymmetric, with osteophytes and sclerosis. Rotator cuff arthropathy involves superior migration. Septic arthritis is usually unilateral and rapidly destructive. CPPD involves chondrocalcinosis.

Question 3592

Topic: 9. Shoulder and Elbow

An 84-year-old female presents with acute severe pain and limited range of motion after a minor trauma. Her X-ray shows marked periarticular osteopenia, joint space narrowing, and a 'pressure erosion' on the posterior aspect of the humeral head. This combination is highly suggestive of:

. Osteoarthritis
. Rotator cuff tear arthropathy
. Neuropathic (Charcot) arthropathy
. Post-traumatic arthritis
. Adhesive capsulitis

Correct Answer & Explanation

. Neuropathic (Charcot) arthropathy

Explanation

Neuropathic (Charcot) arthropathy in the shoulder, though rare, can present with marked periarticular osteopenia, joint space narrowing, fragmentation, and 'pressure erosions' or 'resorption' of the humeral head and glenoid, often with associated soft tissue swelling and instability. This occurs due to loss of proprioception and pain sensation. Post-traumatic arthritis would have a clear history and signs of prior trauma. Other options do not typically cause such rapid, severe destruction with pressure erosions.

Question 3593

Topic: 9. Shoulder and Elbow

When evaluating a shoulder X-ray, the presence of 'vacuum phenomenon' within the glenohumeral joint space (gas shadows) is typically seen in:

. Acute septic arthritis
. Chronic inflammatory arthritis
. Degenerative joint disease (osteoarthritis)
. Acute shoulder dislocation
. Calcium pyrophosphate deposition disease

Correct Answer & Explanation

. Degenerative joint disease (osteoarthritis)

Explanation

The vacuum phenomenon (presence of gas within the joint space) is a common finding in degenerative joint disease (osteoarthritis). It is believed to be due to nitrogen gas released from synovial fluid into areas of negative pressure within the joint, often during traction or joint manipulation. It is generally not seen in inflammatory or septic conditions.

Question 3594

Topic: 9. Shoulder and Elbow

An 84-year-old lady presents with chronic, diffuse shoulder pain. Her X-ray shows diffuse osteopenia, narrowing of the glenohumeral joint space, and evidence of mild subchondral erosions without significant osteophyte formation. What systemic condition should be considered in the differential diagnosis?

. Primary Osteoarthritis
. Gout
. Psoriatic Arthritis
. Rheumatoid Arthritis
. Polymyalgia Rheumatica

Correct Answer & Explanation

. Rheumatoid Arthritis

Explanation

Diffuse osteopenia, joint space narrowing (often concentric), and mild subchondral erosions without prominent osteophytes are characteristic features of inflammatory arthropathies, particularly Rheumatoid Arthritis, which can affect the shoulder. Primary osteoarthritis typically presents with subchondral sclerosis and prominent osteophytes. Gout would show punched-out erosions with overhanging edges. Psoriatic arthritis might show periostitis or 'pencil-in-cup' deformity, but is less common in the shoulder. Polymyalgia Rheumatica is a clinical diagnosis without specific radiographic findings.

Question 3595

Topic: 9. Shoulder and Elbow

On an AP X-ray of an 84-year-old patient, you notice small, well-defined, ring-like calcifications within the soft tissues of the shoulder, not clearly associated with tendons or bursae. These findings might be suggestive of:

. Acute calcific tendinitis
. Vascular calcifications
. Synovial osteochondromatosis
. Pneumarthrosis
. Foreign body

Correct Answer & Explanation

. Synovial osteochondromatosis

Explanation

Synovial osteochondromatosis is a metaplastic condition where the synovial membrane forms cartilaginous nodules that can detach and grow, leading to multiple, small, often ring-like or amorphous calcified loose bodies within the joint space or bursae. Acute calcific tendinitis has amorphous calcifications within tendons. Vascular calcifications follow vessel paths. Pneumarthrosis is gas. Foreign bodies are usually solitary.

Question 3596

Topic: 9. Shoulder and Elbow

An X-ray of an 84-year-old patient's shoulder demonstrates severe degenerative changes in the glenohumeral joint, including joint space narrowing, subchondral sclerosis, and large osteophytes. Notably, there is also evidence of osteolysis affecting the distal clavicle. This combination of findings should prompt consideration of:

. Primary glenohumeral osteoarthritis only
. Rotator cuff tear arthropathy
. Distal clavicular osteolysis in conjunction with degenerative arthritis (e.g., from prior trauma or overuse)
. Septic arthritis of both joints
. Systemic lupus erythematosus

Correct Answer & Explanation

. Distal clavicular osteolysis in conjunction with degenerative arthritis (e.g., from prior trauma or overuse)

Explanation

Osteolysis of the distal clavicle can occur as an isolated condition, often due to repetitive microtrauma (e.g., weightlifting) or prior AC joint injury. When seen in conjunction with severe glenohumeral osteoarthritis in an elderly patient, it suggests a multifactorial etiology, likely degenerative arthritis affecting multiple shoulder joints, possibly exacerbated by previous trauma or chronic stress. While septic arthritis could cause osteolysis, affecting both GH and AC joints with typical OA signs is less common for infection. SLE is a possibility but osteolysis of the distal clavicle is not a hallmark. RCA would show superior migration, not necessarily distal clavicle osteolysis.

Question 3597

Topic: 9. Shoulder and Elbow

On an 84-year-old lady's shoulder X-ray, you observe a well-defined, radiolucent lesion within the humeral head. This lucency, especially if it is expansile and cortically thinned, should raise concern for which type of underlying bone pathology?

. Subchondral sclerosis
. Blastic metastasis
. Osteophyte formation
. Lytic lesion (e.g., enchondroma, metastasis)
. Calcific tendinitis

Correct Answer & Explanation

. Lytic lesion (e.g., enchondroma, metastasis)

Explanation

A well-defined radiolucent lesion ('lucency') in bone indicates an area of decreased bone density, often representing a lytic lesion. In an 84-year-old, this could range from benign entities like an enchondroma (especially if well-defined and expansile) or a simple bone cyst to more concerning pathologies like a lytic metastasis or multiple myeloma. Cortical thinning and expansion would further increase suspicion for a space-occupying lesion. Sclerosis and osteophytes are increased density. Blastic metastasis is increased density. Calcific tendinitis involves calcification, not lucency.

Question 3598

Topic: Elbow & Forearm

When performing Maudsley's test, which specific finding indicates a positive result and points towards lateral epicondylitis?

. Pain over the medial epicondyle with resisted wrist flexion.
. Pain over the lateral epicondyle with resisted supination.
. Pain over the lateral epicondyle with resisted extension of the third digit (middle finger).
. Pain over the dorsal aspect of the wrist with resisted wrist flexion.
. Pain in the biceps groove with resisted forearm supination.

Correct Answer & Explanation

. Pain over the lateral epicondyle with resisted extension of the third digit (middle finger).

Explanation

Maudsley's test, also known as the 'middle finger extension test,' specifically assesses the extensor digitorum communis (EDC) which has a common origin with the ECRB. A positive test involves pain over the lateral epicondyle with resisted extension of the third digit (middle finger). This test places direct stress on the common extensor origin. Options A, B, D, and E describe tests for medial epicondylitis, radial tunnel, wrist pain, or biceps pathology respectively.

Question 3599

Topic: 9. Shoulder and Elbow

A 40-year-old administrative assistant complains of insidious onset lateral elbow pain. She states her pain is worse when lifting a coffee cup or using a computer mouse. On physical exam, you find tenderness over the lateral epicondyle and a positive Mill's test. She has full, pain-free elbow range of motion. What is the most appropriate initial management strategy?

. Immediate surgical debridement of the ECRB origin.
. Prescription of oral corticosteroids for 6 weeks.
. Referral for an MRI to confirm tendon tear.
. Activity modification, NSAIDs, and physical therapy focused on eccentric strengthening.
. Corticosteroid injection into the common extensor origin.

Correct Answer & Explanation

. Activity modification, NSAIDs, and physical therapy focused on eccentric strengthening.

Explanation

For initial presentation of lateral epicondylitis, conservative management is almost always indicated. This includes activity modification (avoiding aggravating activities), NSAIDs for pain relief, and physical therapy focusing on pain-free eccentric strengthening of the wrist extensors. Surgery is reserved for chronic, recalcitrant cases (typically >6-12 months of failed non-operative treatment). Oral corticosteroids are generally not used due to systemic side effects and limited long-term efficacy. An MRI is not necessary for initial diagnosis in a classic presentation. While corticosteroid injections can provide short-term relief, they are often considered after an initial trial of activity modification, NSAIDs, and PT, and their long-term benefit is debated compared to other non-operative treatments.

Question 3600

Topic: 9. Shoulder and Elbow

A 28-year-old overhead athlete presents with chronic lateral elbow pain and occasional clicking, particularly with pronation and supination. Examination reveals tenderness over the radial head and capitellum, along with some crepitus during elbow rotation. Resisted wrist extension is mildly painful. What is the most important differential diagnosis to consider in this patient?

. Lateral epicondylitis
. Radial tunnel syndrome
. Capitellar osteochondritis dissecans (OCD)
. Posterior interosseous nerve entrapment
. Triceps tendinopathy

Correct Answer & Explanation

. Capitellar osteochondritis dissecans (OCD)

Explanation

Given the patient's age (28, though OCD is more common in adolescents), overhead athlete status, chronic lateral elbow pain, clicking, tenderness over the radial head/capitellum, and crepitus with rotation, Capitellar Osteochondritis Dissecans (OCD) is a critical differential. While lateral epicondylitis can cause lateral elbow pain, the mechanical symptoms (clicking, crepitus, tenderness specifically over the joint line) in an athlete should raise suspicion for intra-articular pathology like OCD or early radiohumeral arthritis. Radial tunnel and PIN entrapment are less likely to cause mechanical joint symptoms. Triceps tendinopathy causes posterior elbow pain.

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