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9. Shoulder and Elbow MCQs

Practice Set 184 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 3661

Topic: 9. Shoulder and Elbow

A 45-year-old male with chronic renal failure on hemodialysis presents with severe localized pain above the posterior elbow after lifting a heavy box. He is unable to actively extend his elbow against gravity. A lateral radiograph reveals a 'flake sign.' What is the pathognomonic mechanism of the anatomic injury suggested by this sign?

. Avulsion of the common extensor origin from the lateral epicondyle
. Rupture of the triceps tendon at the musculotendinous junction
. Avulsion of the triceps tendon from its insertion on the olecranon
. Displaced intra-articular fracture of the capitellum
. Avulsion of the medial ulnar collateral ligament

Correct Answer & Explanation

. Avulsion of the triceps tendon from its insertion on the olecranon

Explanation

The 'flake sign' on a lateral elbow radiograph refers to a small avulsed cortical bone fragment from the tip of the olecranon. In the setting of loss of active elbow extension, this is pathognomonic for a triceps tendon avulsion. Risk factors for spontaneous tendon ruptures include chronic kidney disease/secondary hyperparathyroidism, anabolic steroid use, and local corticosteroid injections.

Question 3662

Topic: 9. Shoulder and Elbow

The medial ulnar collateral ligament (MUCL) of the elbow consists of three main bundles. Which specific bundle is considered the primary restraint to valgus stress from 30 to 120 degrees of elbow flexion?

. Anterior bundle
. Posterior bundle
. Transverse bundle (Cooper's ligament)
. Ulnar collateral ligament proper
. Oblique bundle

Correct Answer & Explanation

. Anterior bundle

Explanation

The MUCL complex has an anterior bundle, a posterior bundle, and a transverse bundle. The anterior bundle is the primary restraint to valgus stress throughout the functional arc of motion (30 to 120 degrees of flexion). It is the structure most commonly injured in overhead throwing athletes and is the target of 'Tommy John' reconstruction. The posterior bundle is a secondary restraint, most active at higher degrees of flexion, while the transverse bundle does not cross the joint line and provides no significant stability.

Question 3663

Topic: 9. Shoulder and Elbow

A 32-year-old male presents with severe pain and a cosmetic deformity in his anterior axillary fold after attempting a heavy 1-rep maximum bench press. An MRI confirms a complete rupture of the pectoralis major tendon. What is the most common anatomical site of rupture for the pectoralis major in this demographic?

. Avulsion from the clavicular origin
. Avulsion from the sternal origin
. Rupture at the musculotendinous junction
. Avulsion from the humeral insertion
. Intramuscular tearing of the sternocostal head

Correct Answer & Explanation

. Avulsion from the humeral insertion

Explanation

Pectoralis major ruptures occur most frequently in weightlifters (particularly during the bench press) when the muscle is maximally contracted in an eccentric, stretched position (shoulder extension and external rotation). The most common site of rupture is a direct avulsion from its insertion on the lateral lip of the bicipital groove of the humerus. Due to the significant functional and cosmetic deficits, surgical repair is typically indicated in young, active patients.

Question 3664

Topic: Shoulder Pathology

A 40-year-old female presents with vague shoulder pain, weakness in overhead activities, and a visible deformity of the back 3 months after a lymph node biopsy in the posterior triangle of the neck. Physical examination demonstrates lateral winging of the scapula, which worsens with resisted shoulder abduction. Which muscle is paralyzed?

. Serratus anterior
. Trapezius
. Rhomboid major
. Latissimus dorsi
. Levator scapulae

Correct Answer & Explanation

. Trapezius

Explanation

Lateral winging of the scapula is caused by paralysis of the trapezius muscle, which is innervated by the spinal accessory nerve (cranial nerve XI). This nerve is highly susceptible to iatrogenic injury during procedures in the posterior cervical triangle (e.g., lymph node biopsy). In contrast, medial winging of the scapula is caused by paralysis of the serratus anterior muscle secondary to a long thoracic nerve injury, typically observed when the patient pushes against a wall.

Question 3665

Topic: Elbow & Forearm
A 45-year-old male falls onto an outstretched hand and sustains a coronal shear fracture of the distal humerus. A CT scan reveals a fracture that completely separates the capitellum and the majority of the lateral trochlea from the distal humerus as a single articular piece. According to the Bryan and Morrey classification modified by McKee, how is this fracture classified?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV
. Type V

Correct Answer & Explanation

. Type IV

Explanation

The Bryan and Morrey classification describes capitellum fractures. Type I (Hahn-Steinthal) is a large osseous piece of the capitellum. Type II (Kocher-Lorenz) is a thin shell of articular cartilage with minimal subchondral bone. Type III (Broberg-Morrey) is a severely comminuted capitellum fracture. McKee modified the classification by adding Type IV, which is a coronal shear fracture that involves the capitellum and extends medially to include most or all of the trochlea. It often exhibits a double-arc sign on the lateral radiograph.

Question 3666

Topic: 9. Shoulder and Elbow

A 35-year-old falls on an outstretched hand, sustaining a varus posteromedial rotatory instability (PMRI) injury of the elbow. Imaging shows a fracture of the anteromedial facet of the coronoid process. What ligamentous injury is most predictably associated with this specific fracture pattern?

. Anterior bundle of the medial collateral ligament (AMCL)
. Posterior bundle of the medial collateral ligament (PMCL)
. Lateral ulnar collateral ligament (LUCL)
. Radial collateral ligament
. Annular ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Fractures of the anteromedial facet of the coronoid are the hallmark of posteromedial rotatory instability (PMRI) of the elbow. The mechanism involves a varus force that first disrupts the lateral collateral ligament complex (specifically the LUCL), followed by the anteromedial coronoid facet fracturing against the medial trochlea. The AMCL typically remains intact, maintaining a medial hinge.

Question 3667

Topic: Shoulder Arthroplasty & Arthritis

Which of the following design modifications or surgical techniques in a reverse total shoulder arthroplasty (RTSA) most effectively decreases the incidence of inferior scapular notching?

. Superior placement of the baseplate on the glenoid
. Superior tilt of the glenosphere
. Inferior translation of the baseplate with inferior tilt
. Medialization of the center of rotation
. Decreasing the glenosphere diameter

Correct Answer & Explanation

. Inferior translation of the baseplate with inferior tilt

Explanation

Inferior scapular notching in RTSA is caused by mechanical impingement of the humeral component against the scapular neck during adduction. To minimize this, the baseplate should be placed inferiorly (flush or slightly overhanging the inferior glenoid rim) and tilted inferiorly. Lateralizing the center of rotation and using a larger glenosphere also reduce notching.

Question 3668

Topic: Shoulder Pathology

A 40-year-old patient undergoes a radical neck dissection. Postoperatively, he notes shoulder weakness and an inability to abduct the arm above 90 degrees. Examination shows lateral winging of the scapula at rest, which worsens with attempted shoulder abduction. Injury to which nerve is most likely?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Injury to the spinal accessory nerve (CN XI) causes trapezius palsy, leading to lateral winging of the scapula (the scapula translates laterally and rotates inferiorly). This is a known complication of neck dissections. Medial winging is caused by serratus anterior palsy (long thoracic nerve injury) and is accentuated by forward elevation or wall push-ups.

Question 3669

Topic: 9. Shoulder and Elbow

A 29-year-old male bodybuilder feels a pop in his anterior axilla while bench pressing. Examination reveals loss of the anterior axillary fold and weakness in shoulder internal rotation. Which anatomical portion of the pectoralis major tendon is most commonly torn, and what is its normal insertion pattern on the humerus?

. Clavicular head; inserts deep and proximal to the sternal head
. Clavicular head; inserts superficial and distal to the sternal head
. Sternal head; inserts deep and proximal to the clavicular head
. Sternal head; inserts superficial and distal to the clavicular head
. Costal head; inserts directly into the intertubercular groove

Correct Answer & Explanation

. Sternal head; inserts deep and proximal to the clavicular head

Explanation

Pectoralis major ruptures most commonly involve the sternal head during heavy eccentric loading (bench press). As the muscle inserts onto the lateral lip of the bicipital groove, the tendon twists 180 degrees such that the inferior (sternal) head inserts deep (posterior) and proximal to the superior (clavicular) head.

Question 3670

Topic: Elbow & Forearm

A 32-year-old male sustains a comminuted radial head fracture from a high-energy fall. During examination, he reports severe ipsilateral wrist pain. Radiographs suggest disruption of the distal radioulnar joint (DRUJ). What is the most appropriate management of the radial head to prevent long-term proximal radial migration?

. Radial head excision alone
. Radial head excision combined with immediate wrist arthroscopy
. Radial head arthroplasty
. Nonoperative management of the elbow in a long arm cast
. Closed reduction and pinning of the radiocapitellar joint

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

The patient has an Essex-Lopresti injury: radial head fracture, interosseous membrane tear, and DRUJ disruption. Radial head excision is absolutely contraindicated as it will result in severe proximal migration of the radius, ulnocarpal impaction, and chronic wrist pain. Radial head replacement (arthroplasty) is required to restore longitudinal forearm stability.

Question 3671

Topic: Elbow & Forearm

In a patient with a suspected acute distal biceps tendon rupture, the O'Driscoll Hook Test is performed. The examiner attempts to hook an index finger under the intact biceps tendon. Which structure can yield a false-negative Hook test by remaining intact despite a complete avulsion of the main distal biceps tendon?

. Brachialis tendon
. Lacertus fibrosus (bicipital aponeurosis)
. Pronator teres origin
. Brachioradialis fascia
. Coracobrachialis

Correct Answer & Explanation

. Lacertus fibrosus (bicipital aponeurosis)

Explanation

The lacertus fibrosus (bicipital aponeurosis) can remain intact even when the primary distal biceps tendon is completely avulsed from the radial tuberosity. An intact lacertus fibrosus limits proximal retraction of the muscle belly and can simulate an intact tendon on palpation, potentially leading to a false-negative Hook test.

Question 3672

Topic: 9. Shoulder and Elbow

A 21-year-old collegiate baseball pitcher presents with right shoulder pain. Examination reveals 25 degrees of internal rotation and 130 degrees of external rotation on the right, compared to 60 degrees of internal rotation and 95 degrees of external rotation on the left. The total arc of motion is symmetric. What is the most appropriate primary treatment?

. Anterior capsulolabral reconstruction
. Arthroscopic SLAP repair
. Physical therapy with sleeper stretch exercises
. Surgical posterior capsular release
. Arthroscopic subacromial decompression

Correct Answer & Explanation

. Physical therapy with sleeper stretch exercises

Explanation

This pitcher exhibits Glenohumeral Internal Rotation Deficit (GIRD) with a preserved total arc of motion (155 degrees bilaterally). This is a physiologic adaptation in throwers caused by posteroinferior capsular contracture. The primary treatment is nonoperative, focusing on posteroinferior capsular stretching (sleeper stretches, cross-body adduction).

Question 3673

Topic: Elbow & Forearm

A 42-year-old female sustains a 'terrible triad' injury to her elbow. Surgical intervention is planned. Which of the following describes the most widely accepted sequence of surgical repair to predictably restore stability?

. LCL repair, followed by radial head fixation/replacement, then coronoid fixation
. Coronoid fixation, followed by radial head fixation/replacement, then LCL repair
. Radial head fixation/replacement, followed by LCL repair, then coronoid fixation
. MCL repair, followed by radial head fixation, then LCL repair
. Coronoid fixation, followed by MCL repair, then radial head fixation

Correct Answer & Explanation

. Coronoid fixation, followed by radial head fixation/replacement, then LCL repair

Explanation

The classic, widely accepted sequence for repairing a terrible triad of the elbow follows a deep-to-superficial (or inside-out) approach: 1) Coronoid fracture fixation or capsular repair, 2) Radial head fixation or arthroplasty, and 3) Lateral collateral ligament (LCL) complex repair. The MCL is typically only explored if gross instability remains after these three steps.

Question 3674

Topic: Elbow & Forearm

A 9-year-old male gymnast presents with lateral elbow pain and stiffness. Radiographs show sclerosis and fragmentation of the entire capitellum without a discrete osteochondral defect or loose body. What is the most likely diagnosis, and what is the expected outcome with rest?

. Osteochondritis dissecans; high likelihood of requiring surgery
. Panner's disease; spontaneous resolution
. Capitellar shear fracture; nonunion if untreated
. Lateral epicondylitis; chronic tendinosis
. Little league elbow; medial instability

Correct Answer & Explanation

. Panner's disease; spontaneous resolution

Explanation

Panner's disease is an osteochondrosis of the capitellum affecting children (usually <10 years old). It involves the entire capitellum, presents with lateral elbow pain, and almost always resolves spontaneously with rest. In contrast, Osteochondritis Dissecans (OCD) of the capitellum affects older adolescents (12-16) and has a much higher rate of loose body formation requiring surgery.

Question 3675

Topic: 9. Shoulder and Elbow

A 25-year-old male with a complete, irreversible flail arm from a brachial plexus injury is planned for a glenohumeral arthrodesis to provide a stable proximal strut for eventual hand positioning (following distal reconstruction). What is the currently recommended optimal position for shoulder arthrodesis?

. 60 degrees abduction, 60 degrees forward flexion, 60 degrees external rotation
. 30 degrees abduction, 30 degrees forward flexion, 30 degrees internal rotation
. 15 degrees abduction, 15 degrees forward flexion, 45 degrees internal rotation
. 45 degrees abduction, 45 degrees forward flexion, neutral rotation
. 90 degrees abduction, 30 degrees forward flexion, neutral rotation

Correct Answer & Explanation

. 30 degrees abduction, 30 degrees forward flexion, 30 degrees internal rotation

Explanation

Modern recommendations for shoulder arthrodesis advocate for a position of 20-30 degrees of abduction, 20-30 degrees of forward flexion, and 20-30 degrees of internal rotation. This minimizes disabling scapular winging at rest while allowing the hand to reach the mouth. Historical positions with higher abduction led to severe pain and winging.

Question 3676

Topic: Elbow & Forearm

A 45-year-old male sustains a 'terrible triad' injury of the elbow. What is the generally recommended surgical sequence for reconstructing this injury pattern?

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

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad is deep-to-superficial: coronoid fixation first, followed by radial head repair or replacement, and then lateral collateral ligament (LCL) repair. The MCL is only repaired if the elbow remains unstable after these steps.

Question 3677

Topic: Elbow & Forearm

When performing a two-incision distal biceps tendon repair, how should the forearm be positioned during the posterolateral muscle-splitting approach to the radial tuberosity to maximally protect the posterior interosseous nerve (PIN)?

. Full supination
. Neutral rotation
. 90 degrees of flexion and supination
. Full extension and neutral rotation
. Full pronation

Correct Answer & Explanation

. Full pronation

Explanation

During the posterior approach to the radial tuberosity, the forearm must be placed in full pronation. This shifts the posterior interosseous nerve (PIN) anteriorly, moving it safely away from the operative field.

Question 3678

Topic: Elbow & Forearm

A patient with posterolateral rotatory instability (PLRI) of the elbow demonstrates a positive pivot-shift test. Which essential ligamentous structure is deficient in this condition?

. Radial collateral ligament
. Annular ligament
. Anterior bundle of the medial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Oblique cord

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Posterolateral rotatory instability (PLRI) is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). Reconstruction of the LUCL is required to restore posterolateral stability to the elbow.

Question 3679

Topic: 9. Shoulder and Elbow

A 72-year-old female undergoes a reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy. By what biomechanical mechanism does RTSA primarily restore active forward elevation in a patient with a massive, irreparable rotator cuff tear?

. Lateralization and superiorization of the center of rotation, increasing tension on the remaining rotator cuff.
. Medialization and distalization of the center of rotation, increasing the deltoid moment arm and tension.
. Medialization and superiorization of the center of rotation, increasing the mechanical advantage of the coracobrachialis.
. Lateralization and distalization of the center of rotation, isolating the anterior deltoid fibers.
. Restoration of the anatomic center of rotation, allowing the deltoid to act solely as an abductor.

Correct Answer & Explanation

. Medialization and distalization of the center of rotation, increasing the deltoid moment arm and tension.

Explanation

Reverse total shoulder arthroplasty (RTSA), based on Grammont's principles, medializes and distalizes the center of rotation of the glenohumeral joint. This biomechanical alteration increases the moment arm of the deltoid muscle, specifically tensioning the anterior and middle fibers, thereby allowing the deltoid to effectively substitute for the deficient rotator cuff to provide active forward elevation.

Question 3680

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture), what is the most widely accepted sequence of reconstruction from a standard lateral approach to optimize joint stability?

. LCL repair, followed by radial head fixation, then coronoid fixation.
. Radial head fixation/replacement, followed by LCL repair, then coronoid fixation.
. Coronoid fixation or anterior capsule repair, followed by radial head fixation/replacement, then LCL repair.
. MCL repair, followed by LCL repair, then radial head fixation.
. Coronoid fixation, followed by MCL repair, then radial head fixation.

Correct Answer & Explanation

. Coronoid fixation or anterior capsule repair, followed by radial head fixation/replacement, then LCL repair.

Explanation

The standard surgical protocol for a terrible triad injury addresses structures from deep to superficial through a lateral approach. The correct sequence is: (1) Fixation of the coronoid fracture or repair of the anterior capsule (often facilitated through the defect left by the displaced radial head); (2) Fixation or replacement of the radial head; and (3) Repair of the lateral ulnar collateral ligament (LUCL/LCL complex) back to the lateral epicondyle.

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