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9. Shoulder and Elbow MCQs

Practice Set 185 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 3681

Topic: Elbow & Forearm

A 45-year-old manual laborer undergoes surgical repair of a distal biceps tendon rupture using a single-incision anterior approach. Postoperatively, he reports numbness along the lateral aspect of his forearm. Which nerve is most likely injured, and what is the typical path of this nerve relative to the biceps tendon?

. Posterior interosseous nerve; runs lateral to the biceps tendon within the supinator muscle.
. Superficial radial nerve; runs medial to the biceps tendon alongside the brachial artery.
. Medial antebrachial cutaneous nerve; crosses superficial to the biceps tendon.
. Lateral antebrachial cutaneous nerve; courses between the biceps and brachialis muscles, emerging lateral to the distal biceps tendon.
. Musculocutaneous nerve; terminates immediately proximal to the biceps tendon insertion.

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve; courses between the biceps and brachialis muscles, emerging lateral to the distal biceps tendon.

Explanation

The lateral antebrachial cutaneous nerve (LABC), which is the terminal sensory branch of the musculocutaneous nerve, is the most commonly injured structure during a single-incision anterior approach for distal biceps repair. It emerges from between the biceps and brachialis muscles and courses just lateral to the distal biceps tendon. Forceful lateral retraction easily neuropraxias or transects this nerve, resulting in lateral forearm numbness.

Question 3682

Topic: Elbow & Forearm

A 35-year-old male presents with recurrent lateral elbow pain and a sensation of clicking when pushing himself up from a chair. Physical examination reveals a positive lateral pivot-shift test. This condition is primarily due to insufficiency of which structure, and where does this structure insert?

. Radial collateral ligament; inserts on the annular ligament.
. Lateral ulnar collateral ligament (LUCL); inserts on the supinator crest of the proximal ulna.
. Lateral ulnar collateral ligament (LUCL); inserts on the sublime tubercle of the ulna.
. Annular ligament; inserts on the radial notch of the ulna.
. Ulnar collateral ligament (MCL); inserts on the medial epicondyle.

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL); inserts on the supinator crest of the proximal ulna.

Explanation

The patient is presenting with posterolateral rotatory instability (PLRI) of the elbow. The primary restraint to PLRI is the lateral ulnar collateral ligament (LUCL). The LUCL originates on the lateral epicondyle and inserts on the supinator crest of the proximal ulna.

Question 3683

Topic: 9. Shoulder and Elbow

According to the O'Driscoll classification of coronoid fractures, an anteromedial facet fracture is highly associated with varus posteromedial rotatory instability. What is the classic mechanism of injury that produces this specific fracture pattern?

. Valgus stress with elbow hyperextension.
. Direct blow to the anterior elbow.
. Axial load applied to the forearm in supination.
. Varus stress combined with an axial load.
. Sudden violent triceps contraction with the elbow flexed.

Correct Answer & Explanation

. Varus stress combined with an axial load.

Explanation

Anteromedial facet fractures of the coronoid are the hallmark of varus posteromedial rotatory instability of the elbow. The mechanism of injury is a varus stress combined with an axial load. As the elbow subluxates posteromedially, the anteromedial facet of the coronoid shears off against the medial trochlea, and the lateral collateral ligament (LCL) complex typically tears.

Question 3684

Topic: 9. Shoulder and Elbow

Six weeks after undergoing an uncomplicated anatomic total shoulder arthroplasty (TSA) through a standard deltopectoral approach, a 68-year-old female experiences a sudden 'pop' while pushing open a heavy door. She now presents with increased passive external rotation compared to her uninjured side, weakness in internal rotation, and anterior shoulder pain. What is the most likely complication?

. Dislocation of the long head of the biceps.
. Subscapularis tendon failure.
. Supraspinatus tendon rupture.
. Aseptic loosening of the glenoid component.
. Anterior deltoid dehiscence.

Correct Answer & Explanation

. Subscapularis tendon failure.

Explanation

Failure of the subscapularis repair is a well-known and devastating complication following anatomic total shoulder arthroplasty utilizing a deltopectoral approach. It classically presents in the early postoperative period with anterior pain, weakness in internal rotation (positive belly-press/lift-off), and noticeably increased passive external rotation due to the loss of the anterior soft-tissue restraint.

Question 3685

Topic: Elbow & Forearm
A 42-year-old female falls onto an outstretched hand and sustains a distal humerus fracture. CT imaging reveals a coronal shear fracture that involves the capitellum and extends medially to include the majority of the trochlea, maintaining them as a single continuous osteochondral fragment. According to the McKee modification of the Bryan and Morrey classification, what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV
. Type V

Correct Answer & Explanation

. Type IV

Explanation

In the Bryan and Morrey classification of capitellum fractures, Type I is a large osseous piece of the capitellum (Hahn-Steinthal), Type II is an articular cartilage shear with minimal bone (Kocher-Lorenz), and Type III is comminuted. McKee introduced the Type IV fracture, which is a coronal shear fracture that extends medially to include the capitellum and the lateral ridge/bulk of the trochlea as a single fragment.

Question 3686

Topic: 9. Shoulder and Elbow

A 38-year-old female presents to the clinic with shoulder pain and visible shoulder asymmetry 3 months after a cervical lymph node biopsy. On physical examination, her affected shoulder droops, she has an inability to actively abduct the arm past 90 degrees, and there is prominent lateral winging of the scapula. Which nerve was most likely injured?

. Long thoracic nerve
. Dorsal scapular nerve
. Spinal accessory nerve (CN XI)
. Suprascapular nerve
. Axillary nerve

Correct Answer & Explanation

. Spinal accessory nerve (CN XI)

Explanation

Injury to the spinal accessory nerve (CN XI) denervates the trapezius muscle, leading to a drooping shoulder, weakness in forward elevation/abduction, and lateral winging of the scapula (the scapula is translated laterally and rotated downward). This classically occurs after posterior triangle neck surgeries (like lymph node biopsies). Conversely, medial winging is caused by serratus anterior paralysis (long thoracic nerve).

Question 3687

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female presents with sudden onset of superior shoulder pain 4 months after a reverse total shoulder arthroplasty (rTSA). Radiographs reveal a Levy type II acromial stress fracture (involving the base of the acromion posterior to the acromioclavicular joint). What is the most appropriate initial management?

. Immediate open reduction and internal fixation with a tension band construct
. Immobilization in a sling for 4 to 6 weeks
. Revision to a standard anatomic total shoulder arthroplasty
. Exchange of the glenosphere to a larger size to increase deltoid tension
. Botulinum toxin injection to the deltoid to prevent fracture displacement

Correct Answer & Explanation

. Immobilization in a sling for 4 to 6 weeks

Explanation

Acromial stress fractures after rTSA are a known complication due to the increased tension placed on the deltoid and acromion (increased mechanical advantage). The vast majority of Levy type I and II fractures are initially managed nonoperatively with sling immobilization and activity modification for 4-6 weeks. Surgery is reserved for severely displaced fractures or nonunions that fail conservative management.

Question 3688

Topic: 9. Shoulder and Elbow

A 35-year-old female presents with shoulder weakness and a cosmetic deformity following a cervical lymph node biopsy. Physical examination demonstrates lateral winging of the scapula that worsens with shoulder abduction. If conservative management fails, which of the following surgical procedures is most appropriate?

. Split pectoralis major transfer
. Eden-Lange procedure
. Scapulothoracic arthrodesis
. Split latissimus dorsi transfer
. Pectoralis minor release

Correct Answer & Explanation

. Eden-Lange procedure

Explanation

Lateral scapular winging following a posterior triangle neck biopsy is classically due to iatrogenic injury to the spinal accessory nerve, resulting in trapezius palsy. The Eden-Lange procedure (transfer of the levator scapulae, rhomboid major, and rhomboid minor to the lateral scapula) is the standard surgical reconstruction for chronic, symptomatic trapezius palsy.

Question 3689

Topic: 9. Shoulder and Elbow

Which of the following physical examination findings is the pathognomonic hallmark of posterolateral rotatory instability (PLRI) of the elbow?

. Apprehension with the elbow fully flexed and valgus stress applied
. A palpable clunk during elbow extension from a flexed position with forearm supination and valgus/axial stress
. Pain over the medial epicondyle with resisted wrist flexion
. Inability to actively extend the elbow against gravity
. Medial joint gap opening on varus stress test at 30 degrees of flexion

Correct Answer & Explanation

. A palpable clunk during elbow extension from a flexed position with forearm supination and valgus/axial stress

Explanation

PLRI is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). The lateral pivot-shift test of the elbow reproduces the instability: as the supinated forearm is axially loaded and extended from a flexed position while applying a valgus force, the radial head subluxates posteriorly. Upon further flexion, the radial head reduces with a palpable clunk.

Question 3690

Topic: Elbow & Forearm

When comparing the single-incision anterior approach to the two-incision (Boyd-Anderson) approach for distal biceps tendon repair, the two-incision approach is historically associated with a higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve (LABCN) neuropraxia
. Radial nerve palsy
. Proximal radioulnar synostosis
. Rerupture of the tendon
. Anterior interosseous nerve (AIN) palsy

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

The classic two-incision approach (developed to avoid radial nerve injury seen in extensive single anterior incisions) carries a higher risk of heterotopic ossification and proximal radioulnar synostosis, especially if the interosseous membrane is breached or if bone debris is left in the plane between the radius and ulna. Single-incision techniques have a higher risk of LABCN injury.

Question 3691

Topic: Elbow & Forearm

In the Dubberley classification of coronal shear fractures of the capitellum and trochlea, what specific anatomic feature distinguishes a Type B fracture from a Type A fracture?

. Extension of the fracture into the lateral epicondyle
. Involvement of the trochlea
. Presence of posterior condylar comminution
. Associated radial head fracture
. Articular cartilage impaction

Correct Answer & Explanation

. Presence of posterior condylar comminution

Explanation

The Dubberley classification defines Type 1 (capitellum +/- lateral trochlear ridge), Type 2 (capitellum and trochlea in one fragment), and Type 3 (capitellum and trochlea in separate fragments). The modifier A indicates no posterior comminution, whereas the modifier B indicates the presence of posterior condylar comminution, which alters surgical fixation strategy.

Question 3692

Topic: Elbow & Forearm

A 35-year-old female undergoes surgical fixation for a 'terrible triad' injury of the elbow. Following standard principles of elbow reconstruction, what is the recommended sequential order of structural repair?

. Coronoid fixation, followed by radial head repair/replacement, followed by lateral collateral ligament (LCL) repair
. Radial head repair/replacement, followed by coronoid fixation, followed by lateral collateral ligament (LCL) repair
. Lateral collateral ligament (LCL) repair, followed by radial head repair/replacement, followed by coronoid fixation
. Coronoid fixation, followed by medial collateral ligament (MCL) repair, followed by radial head repair/replacement
. Radial head repair/replacement, followed by lateral collateral ligament (LCL) repair, followed by coronoid fixation

Correct Answer & Explanation

. Coronoid fixation, followed by radial head repair/replacement, followed by lateral collateral ligament (LCL) repair

Explanation

The standard surgical algorithm for a terrible triad injury follows a 'deep to superficial' and 'medial to lateral' progression through a lateral approach. The sequence is: 1) Coronoid fracture fixation (often through the defect left by the fractured radial head), 2) Radial head repair or replacement, and 3) LCL complex repair to the lateral epicondyle.

Question 3693

Topic: 9. Shoulder and Elbow

A 42-year-old female presents with acute, excruciating right shoulder pain. Radiographs demonstrate a fluffy, ill-defined radiopacity at the supraspinatus insertion. According to the Uhthoff classification of calcific tendinitis, during which phase does the patient typically experience the most severe, acute pain?

. Pre-calcific phase
. Formative phase
. Resting phase
. Resorptive phase
. Post-calcific phase

Correct Answer & Explanation

. Resorptive phase

Explanation

Calcific tendinitis progresses through three main stages: pre-calcific, calcific (which includes formative, resting, and resorptive phases), and post-calcific. The most severe, acute pain is typically experienced during the resorptive phase, when the calcific deposit becomes toothpaste-like, vascular channels invade, and macrophages mount an intense inflammatory response to resorb the calcium.

Question 3694

Topic: Elbow & Forearm

When performing open reduction and internal fixation of a radial head fracture, the hardware must be placed within the 'safe zone' to prevent impingement on the proximal radioulnar joint (PRUJ) during forearm rotation. Which of the following accurately describes this safe zone?

. An arc of 90 degrees centered over the anteromedial quadrant of the radial head
. An arc of 90 to 110 degrees on the lateral aspect of the radial head, directly opposite the radial tuberosity
. An arc of 180 degrees encompassing the entire lateral half of the radial head
. The area between the coronoid process and the tip of the olecranon
. Directly over the bicipital tuberosity

Correct Answer & Explanation

. An arc of 90 to 110 degrees on the lateral aspect of the radial head, directly opposite the radial tuberosity

Explanation

The safe zone of the radial head represents the non-articulating portion that does not impinge on the lesser sigmoid notch of the ulna during pronation and supination. It corresponds to an arc of approximately 90 to 110 degrees located laterally, directly opposite the radial tuberosity.

Question 3695

Topic: 9. Shoulder and Elbow

Idiopathic adhesive capsulitis is characterized by an inflammatory, fibrotic process of the glenohumeral capsule. Molecular studies of the contracted capsular tissue most consistently demonstrate an upregulation of which of the following cytokines, driving the fibrotic cascade?

. Interleukin-10 (IL-10)
. Transforming growth factor-beta (TGF-beta)
. Bone morphogenetic protein-2 (BMP-2)
. Insulin-like growth factor-1 (IGF-1)
. Tumor necrosis factor-beta (TNF-beta)

Correct Answer & Explanation

. Transforming growth factor-beta (TGF-beta)

Explanation

The pathophysiology of adhesive capsulitis involves an initial inflammatory response followed by dense fibrosis. Molecular analysis of capsular biopsies from affected patients demonstrates high levels of cytokines driving fibroblast proliferation and extracellular matrix deposition, most notably Transforming growth factor-beta (TGF-beta), platelet-derived growth factor (PDGF), and basic fibroblast growth factor (bFGF).

Question 3696

Topic: 9. Shoulder and Elbow

The biomechanical design of a standard Grammont-style reverse total shoulder arthroplasty (rTSA) optimizes the mechanical advantage of the deltoid muscle. Which of the following best describes the intentional shift in the center of rotation of the glenohumeral joint following a Grammont rTSA?

. Superior and lateral
. Superior and medial
. Inferior and medial
. Inferior and lateral
. It remains unchanged compared to the native joint

Correct Answer & Explanation

. Inferior and medial

Explanation

The Grammont principles of reverse total shoulder arthroplasty include medializing and inferiorizing the center of rotation. Medialization increases the abductor moment arm of the deltoid (recruiting more anterior and posterior fibers) and decreases torque at the glenoid bone-implant interface. Inferiorization tensions the deltoid, restoring its resting length and optimizing function in the absence of a rotator cuff.

Question 3697

Topic: Shoulder Arthroplasty & Arthritis

In reverse total shoulder arthroplasty (RTSA), altering the center of rotation (COR) is critical for restoring forward elevation in the setting of rotator cuff arthropathy. Compared to the native anatomic shoulder, how is the COR modified in a classic Grammont-style RTSA?

. Moved superiorly and laterally
. Moved inferiorly and laterally
. Moved inferiorly and medially
. Moved superiorly and medially
. Remains unchanged but becomes highly constrained

Correct Answer & Explanation

. Moved inferiorly and medially

Explanation

The Grammont-style RTSA moves the center of rotation medially and inferiorly. Medialization recruits more deltoid fibers (especially anterior and posterior) by increasing their moment arms, while inferiorization tensions the deltoid, improving its biomechanical efficiency for forward elevation without a functioning rotator cuff.

Question 3698

Topic: 9. Shoulder and Elbow

A 40-year-old female sustains a terrible triad injury to her elbow. During surgical reconstruction, after fixing the coronoid fracture and replacing the irreparable radial head, the elbow remains unstable in extension and supination. What is the next most appropriate step in management?

. Application of a hinged external fixator
. Repair of the lateral ulnar collateral ligament (LUCL)
. Repair of the medial ulnar collateral ligament (MUCL)
. Open reduction and internal fixation of the olecranon
. Fascia lata autograft reconstruction of the annular ligament

Correct Answer & Explanation

. Repair of the lateral ulnar collateral ligament (LUCL)

Explanation

The standard surgical algorithm for a terrible triad injury of the elbow involves restoring the anterior buttress (coronoid), restoring the lateral column (radial head), and then repairing the lateral structures (LUCL). If the elbow remains unstable after LUCL repair, the MUCL may be explored/repaired or a hinged external fixator applied.

Question 3699

Topic: Elbow & Forearm

A 35-year-old female falls on an outstretched hand and sustains a coronal shear fracture of the distal humerus. CT scan demonstrates a fracture extending medially to involve the entire capitellum and the majority of the trochlea, with a separate fragment of the posterior trochlea. Based on the Bryan and Morrey classification (modified by McKee), what type of fracture is this?

. Type 1 (Hahn-Steinthal)
. Type 2 (Kocher-Lorenz)
. Type 3 (Broberg-Morrey)
. Type 4
. Type 5

Correct Answer & Explanation

. Type 4

Explanation

McKee modified the Bryan and Morrey classification of capitellum fractures by adding the Type 4 fracture. This is a coronal shear fracture involving the capitellum that extends medially to include most or all of the trochlea, creating a complete articular shear.

Question 3700

Topic: Elbow & Forearm

A 45-year-old male undergoes a distal biceps tendon repair utilizing a single-incision anterior approach with cortical button fixation. Two weeks postoperatively, he complains of numbness over the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABCN)
. Medial antebrachial cutaneous nerve (MACN)
. Superficial radial nerve
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

The lateral antebrachial cutaneous nerve (LABCN), the terminal sensory branch of the musculocutaneous nerve, is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. It runs between the biceps and brachialis and courses superficially in the lateral forearm.

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