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9. Shoulder and Elbow MCQs

Practice Set 186 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 3701

Topic: 9. Shoulder and Elbow

A 30-year-old male presents with recurrent elbow clicking, snapping, and a sense of giving way when pushing up from a chair. The lateral pivot-shift test of the elbow is positive. This condition is primarily caused by insufficiency of which of the following structures?

. Medial ulnar collateral ligament (anterior bundle)
. Annular ligament
. Lateral ulnar collateral ligament (LUCL)
. Radial collateral ligament
. Quadrate ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily due to insufficiency of the lateral ulnar collateral ligament (LUCL). Patients classically report apprehension or subluxation when the elbow is subjected to an axial load, valgus stress, and supination (e.g., pushing off the armrests of a chair).

Question 3702

Topic: 9. Shoulder and Elbow

A 42-year-old male presents with the sudden onset of severe, unremitting right shoulder pain that woke him from sleep. Two weeks later, the pain spontaneously resolves, but he develops profound weakness in shoulder abduction and external rotation. There is no history of trauma. EMG demonstrates denervation in the supraspinatus, infraspinatus, and deltoid. What is the most likely diagnosis?

. Acute cervical radiculopathy
. Massive rotator cuff tear
. Parsonage-Turner syndrome
. Quadrilateral space syndrome
. Adhesive capsulitis

Correct Answer & Explanation

. Parsonage-Turner syndrome

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) typically presents with an acute phase of severe, unrelenting shoulder/arm pain lasting days to weeks. As the pain subsides, patients develop patchy weakness and atrophy of shoulder girdle muscles (commonly affecting suprascapular, axillary, or long thoracic nerves) due to an inflammatory neuropathy.

Question 3703

Topic: Shoulder Pathology

A 32-year-old carpenter sustained a blunt trauma to his lateral chest wall 6 months ago. He now presents with aching pain around the shoulder and difficulty lifting his arm above shoulder level. On examination, asking the patient to push against a wall with outstretched arms causes prominent medial and superior displacement of the inferior angle of the scapula. Which nerve is most likely injured?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial scapular winging (prominence of the medial border and inferior angle) is typically caused by paralysis of the serratus anterior, which is innervated by the long thoracic nerve. This is accentuated by asking the patient to push against a wall. Lateral winging is caused by trapezius paralysis (spinal accessory nerve injury).

Question 3704

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female presents with progressive shoulder pain and stiffness 5 years after undergoing a Reverse Total Shoulder Arthroplasty (RTSA) for cuff tear arthropathy. Radiographs reveal scapular notching that is classified as Sirveaux Grade 3. Which of the following best describes this radiographic finding?

. Notch limited entirely to the scapular pillar
. Notch reaching the inferior screw of the baseplate
. Notch extending past the inferior screw but not under the baseplate
. Notch extending underneath the baseplate to the central peg
. Notch with associated gross loosening and baseplate migration

Correct Answer & Explanation

. Notch extending underneath the baseplate to the central peg

Explanation

The Sirveaux classification is used to grade scapular notching after RTSA. Grade 1 involves a notch limited to the scapular pillar. Grade 2 is a notch reaching the inferior screw. Grade 3 is a notch that extends past the inferior screw but does not go under the baseplate. Grade 4 is a notch extending under the baseplate, which is highly correlated with baseplate loosening and clinical failure.

Question 3705

Topic: Elbow & Forearm

A 35-year-old male sustains a 'terrible triad' injury of the elbow (dislocation, radial head fracture, and type II coronoid fracture). Surgical intervention is planned. To optimize stability and follow standard principles of reconstruction, what is the most widely accepted sequence for repairing these structures?

. Coronoid fixation, MCL repair, radial head repair, LCL repair
. Radial head repair, LCL repair, coronoid fixation, MCL repair
. Coronoid fixation, radial head repair or replacement, LCL repair, followed by MCL repair only if still unstable
. LCL repair, radial head repair, coronoid fixation, MCL repair
. MCL repair, radial head repair, LCL repair, coronoid fixation

Correct Answer & Explanation

. Coronoid fixation, radial head repair or replacement, LCL repair, followed by MCL repair only if still unstable

Explanation

The standard protocol for treating terrible triad injuries is a 'deep to superficial' or 'inside-out' approach. The sequence is: 1) Fixation of the coronoid process (to restore the anterior buttress), 2) Repair or replacement of the radial head, 3) Repair of the lateral collateral ligament (LCL) complex. The medial collateral ligament (MCL) is typically only repaired if the elbow remains unstable in extension after the first three steps are completed.

Question 3706

Topic: 9. Shoulder and Elbow

A 28-year-old bodybuilder sustains a complete rupture of the pectoralis major tendon at its humeral insertion. He opts for nonoperative management. Which of the following best describes the primary biomechanical deficit he is likely to experience long-term?

. 50% loss of peak torque during shoulder abduction
. 30-50% loss of peak torque during shoulder adduction and internal rotation
. Complete loss of active shoulder internal rotation
. 50% loss of peak torque during shoulder forward flexion
. No measurable objective loss of peak torque, but subjective fatigue

Correct Answer & Explanation

. 30-50% loss of peak torque during shoulder adduction and internal rotation

Explanation

While patients with complete pectoralis major ruptures can regain a nearly normal range of motion and function for activities of daily living without surgery, high-demand individuals experience a significant decrease in power. Biomechanical studies (e.g., Bak et al.) demonstrate a permanent 30% to 50% decrease in peak torque and work during isokinetic adduction and internal rotation if left un-repaired.

Question 3707

Topic: Elbow & Forearm

A patient is scheduled for open reduction and internal fixation of a capitellar fracture classified as Dubberley type 3B. In the Dubberley classification system, what specific anatomic finding distinguishes a 'type B' lesion from a 'type A' lesion?

. Involvement of the lateral epicondyle
. Extension of the fracture into the trochlea
. Presence of posterior condylar comminution
. Concomitant radial head fracture
. Associated disruption of the lateral ulnar collateral ligament

Correct Answer & Explanation

. Presence of posterior condylar comminution

Explanation

The Dubberley classification for capitellum and trochlea fractures is highly relevant for surgical planning. Type 1 is a capitellum-only fracture; Type 2 involves the capitellum and trochlea in a single piece; Type 3 involves the capitellum and trochlea as separate fragments. The modifier 'A' indicates no posterior comminution, whereas 'B' indicates posterior comminution. Type B fractures are more complex, often requiring posterior structural grafting or total elbow arthroplasty in older patients.

Question 3708

Topic: 9. Shoulder and Elbow

During the late cocking phase of throwing, a baseball pitcher's elbow is flexed to approximately 90 to 120 degrees and subjected to massive valgus stress. Which specific bundle of the ulnar collateral ligament (UCL) acts as the primary restraint to valgus opening at this specific degree of flexion?

. Posterior bundle of the UCL
. Transverse bundle of the UCL
. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Radial collateral ligament

Correct Answer & Explanation

. Posterior band of the anterior bundle

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. It is subdivided into the anterior and posterior bands. The anterior band is tightest in extension up to roughly 90 degrees of flexion. The posterior band becomes the primary restraint tightest from 90 to 120 degrees of flexion, which corresponds to the late cocking phase of throwing.

Question 3709

Topic: Elbow & Forearm

A 48-year-old man undergoes a two-incision (Boyd-Anderson) repair of a distal biceps tendon rupture. To minimize the specific complication of postoperative proximal radioulnar synostosis, which of the following surgical techniques is most critical?

. Using a cortical button rather than suture anchors for fixation
. Avoiding subperiosteal elevation and limiting exposure of the ulnar periosteum
. Maintaining the forearm strictly in pronation during the entire procedure
. Performing a complete excision of the bicipitoradial bursa
. Using a single-incision anterior approach instead

Correct Answer & Explanation

. Avoiding subperiosteal elevation and limiting exposure of the ulnar periosteum

Explanation

Proximal radioulnar synostosis is a devastating complication historically associated with the two-incision approach for distal biceps repair. The risk is significantly reduced by limiting subperiosteal dissection of the ulna during the posterolateral exposure and by thoroughly irrigating bone debris to prevent an osteogenic bridge between the radius and ulna.

Question 3710

Topic: 9. Shoulder and Elbow

A 14-year-old elite female gymnast presents with lateral elbow pain. Radiographs and MRI confirm osteochondritis dissecans (OCD) of the capitellum. Under which of the following circumstances is operative intervention explicitly indicated rather than nonoperative management?

. Open distal humeral physis with a stable lesion
. Lesion localized exclusively to the central capitellum
. Loss of 5 degrees of terminal elbow extension
. Presence of a detached loose body or fluid behind the osteochondral fragment on MRI
. Mild associated radiocapitellar plica hypertrophy

Correct Answer & Explanation

. Presence of a detached loose body or fluid behind the osteochondral fragment on MRI

Explanation

Indications for surgical management of capitellar OCD include unstable lesions. Signs of instability include a loose body, articular cartilage fracture, or MRI findings of a fluid cleft behind the fragment. Nonoperative management (rest from gymnastics) is indicated for stable lesions, particularly in patients with open physes. A mild loss of terminal extension (<20 degrees) is common and not an absolute surgical indication.

Question 3711

Topic: 9. Shoulder and Elbow

A 45-year-old mechanic felt a sudden 'pop' in the back of his elbow while forcefully tightening a bolt. Which of the following physical examination findings is most specific for a complete rupture of the distal triceps tendon?

. Inability to actively extend the elbow against gravity, particularly when the arm is positioned overhead
. Inability to passively extend the elbow to zero degrees
. Weakness with elbow flexion when the forearm is fully supinated
. A positive hook test
. Tingling in the small and ring fingers during elbow flexion

Correct Answer & Explanation

. Inability to actively extend the elbow against gravity, particularly when the arm is positioned overhead

Explanation

A complete rupture of the distal triceps tendon results in loss of the extensor mechanism of the elbow. This is best tested using the modified Thompson test for the triceps, or by asking the patient to extend the elbow against gravity with the shoulder abducted to 90 degrees or positioned overhead. A positive hook test evaluates the distal biceps tendon, not the triceps.

Question 3712

Topic: Shoulder Pathology

A 45-year-old female presents with severe right shoulder weakness 6 months after undergoing a radical neck dissection for squamous cell carcinoma. On physical examination, her right shoulder droops, she is unable to actively abduct her arm past 90 degrees, and there is noticeable lateral winging of the scapula when she pushes against a wall. Which of the following nerves has most likely been injured?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

The clinical presentation is classic for a spinal accessory nerve (CN XI) injury, a known complication of cervical lymph node biopsies or radical neck dissections. The spinal accessory nerve innervates the trapezius muscle. Paralysis of the trapezius leads to drooping of the shoulder, weakness in forward elevation and abduction, and lateral winging of the scapula. This is distinguished from medial winging, which is caused by a long thoracic nerve injury (serratus anterior palsy).

Question 3713

Topic: 9. Shoulder and Elbow

In the preoperative planning for a total shoulder arthroplasty in a patient with primary glenohumeral osteoarthritis, a CT scan is obtained. The axial images show a biconcave glenoid with significant posterior wear and static posterior subluxation of the humeral head. According to the Walch classification, what type of glenoid morphology is present?

. Type A1
. Type A2
. Type B1
. Type B2
. Type C

Correct Answer & Explanation

. Type B2

Explanation

The Walch classification describes glenoid morphology in primary osteoarthritis. Type A glenoids have concentric wear (A1 = minor, A2 = major central cupping). Type B glenoids involve posterior subluxation of the humeral head; B1 has narrowing of the posterior joint space without biconcavity, while B2 is characterized by a biconcave appearance with posterior wear and posterior subluxation of the humeral head. Type C is dysplastic with >15 degrees of retroversion and is not primarily caused by wear.

Question 3714

Topic: Elbow & Forearm

A 45-year-old man undergoes anatomic repair of a distal biceps tendon rupture via a single-incision anterior approach. Postoperatively, he reports altered sensation along the radial aspect of his proximal forearm. Which nerve is most likely injured?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is a terminal branch of the musculocutaneous nerve and provides sensation to the radial aspect of the forearm. It is the most commonly injured nerve during a single-incision anterior approach to the distal biceps due to its proximity to the surgical field and superficial position. The posterior interosseous nerve (PIN) is more at risk with deep dissection or retractors placed around the radial neck, or classically during the posterolateral exposure of a two-incision technique.

Question 3715

Topic: Elbow & Forearm

A 40-year-old construction worker falls from a ladder, sustaining a highly comminuted radial head fracture. The treating surgeon elects to perform a radial head resection alone. Six months later, the patient presents with severe ulnar-sided wrist pain and grip weakness. Radiographs demonstrate proximal migration of the radius. This complication is the hallmark of an unrecognized injury to which of the following structures?

. Distal radioulnar joint (DRUJ) ligaments and interosseous membrane
. Triangular fibrocartilage complex (TFCC) alone
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Proximal radioulnar joint capsule

Correct Answer & Explanation

. Distal radioulnar joint (DRUJ) ligaments and interosseous membrane

Explanation

The clinical scenario describes an Essex-Lopresti injury, which involves a radial head fracture with concomitant disruption of the interosseous membrane (IOM) and the distal radioulnar joint (DRUJ), leading to longitudinal radioulnar dissociation. Excision of the radial head in this setting removes the secondary stabilizer to proximal radial migration, resulting in severe ulnocarpal impaction. Treatment mandates radial head replacement (not excision) and DRUJ pinning.

Question 3716

Topic: Elbow & Forearm

A 28-year-old male sustains a 'terrible triad' injury of the elbow (radial head fracture, coronoid fracture, and elbow dislocation). Operative management is planned. According to standardized treatment protocols, which of the following represents the optimal surgical sequence for addressing this injury?

. Radial head fixation/replacement, LCL repair, Coronoid fixation
. LCL repair, Coronoid fixation, Radial head fixation/replacement
. Coronoid fixation, Radial head fixation/replacement, LCL repair
. Radial head fixation/replacement, Coronoid fixation, MCL repair
. Coronoid fixation, MCL repair, Radial head fixation/replacement

Correct Answer & Explanation

. Coronoid fixation, Radial head fixation/replacement, LCL repair

Explanation

The standard surgical sequence for a terrible triad injury of the elbow (Pugh et al.) begins deep and works superficial, usually from a lateral or dual approach: 1) Fixation of the coronoid fracture to restore the anterior buttress, 2) Fixation or replacement of the radial head to restore the anterior column/valgus buttress, and 3) Repair of the lateral collateral ligament (LCL/LUCL) complex. The MCL is typically only repaired if the elbow remains grossly unstable after these steps.

Question 3717

Topic: 9. Shoulder and Elbow

A 70-year-old male with a massive chronic rotator cuff tear presents with worsening shoulder pain. Anteroposterior (AP) radiographs demonstrate an acromiohumeral interval of 3 mm, 'acetabularization' (concave remodeling) of the acromion, and narrowing of the true glenohumeral joint space. According to the Hamada classification of rotator cuff arthropathy, what grade is this patient's condition?

. Grade 1
. Grade 2
. Grade 3
. Grade 4
. Grade 5

Correct Answer & Explanation

. Grade 4

Explanation

The Hamada classification stages rotator cuff arthropathy: Grade 1 is AHI >6 mm (normal is 7-14 mm). Grade 2 is AHI <= 5 mm. Grade 3 involves acetabularization (remodeling of the acromion) without glenohumeral arthritis. Grade 4 is characterized by the addition of glenohumeral arthritis (joint space narrowing). Grade 5 includes osteonecrosis or humeral head collapse. Because this patient has narrowing of the glenohumeral joint space, it is Grade 4.

Question 3718

Topic: 9. Shoulder and Elbow

A reverse total shoulder arthroplasty (RTSA) is performed using the original Grammont biomechanical principles. Which of the following best describes the intended alteration of the glenohumeral center of rotation compared to the native anatomy?

. Lateralized and superior
. Lateralized and inferior
. Medialized and inferior
. Medialized and superior
. Anatomic location is maintained

Correct Answer & Explanation

. Medialized and inferior

Explanation

The Grammont design principles for reverse total shoulder arthroplasty (RTSA) rely on moving the center of rotation medial and inferior relative to the native glenohumeral joint. Medialization decreases the torque on the glenoid component (reducing loosening risk) and recruits more deltoid fibers. Inferiorization tensions the deltoid, increasing its lever arm to compensate for the absent rotator cuff.

Question 3719

Topic: Elbow & Forearm

To diagnose posterolateral rotatory instability (PLRI) of the elbow, a pivot-shift test can be performed. The test aims to subluxate the radial head posteriorly relative to the capitellum. Which of the following combinations of forces must the examiner apply to the patient's arm during elbow flexion to successfully elicit this subluxation?

. Axial load, varus stress, and forearm pronation
. Axial load, varus stress, and forearm supination
. Axial load, valgus stress, and forearm pronation
. Axial load, valgus stress, and forearm supination
. Traction, valgus stress, and forearm pronation

Correct Answer & Explanation

. Axial load, valgus stress, and forearm supination

Explanation

Posterolateral rotatory instability (PLRI) is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). To elicit the pivot-shift sign, the examiner starts with the elbow in extension and applies an axial load, valgus stress, and forearm supination. As the elbow is flexed, the radial head subluxates posterolaterally, typically clunking back into place around 40 degrees of flexion as triceps tension increases.

Question 3720

Topic: 9. Shoulder and Elbow

A 52-year-old diabetic female presents with an insidious onset of severe shoulder pain and progressive restriction of both active and passive range of motion. The physical exam is notable for a profound loss of passive external rotation with the arm resting at the side. Pathologic thickening and contracture of which of the following capsuloligamentous structures is most directly responsible for this specific motion deficit?

. Inferior glenohumeral ligament (IGHL)
. Coracohumeral ligament (CHL)
. Middle glenohumeral ligament (MGHL)
. Superior glenohumeral ligament (SGHL)
. Transverse humeral ligament

Correct Answer & Explanation

. Coracohumeral ligament (CHL)

Explanation

The patient's presentation is classic for adhesive capsulitis (frozen shoulder). The hallmark of this condition is a loss of active and passive range of motion, particularly external rotation with the arm at the side. This specific restriction is biomechanically caused by profound thickening and contracture of the coracohumeral ligament (CHL) and the structures within the rotator interval.

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