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9. Shoulder and Elbow MCQs

Practice Set 187 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 3721

Topic: 9. Shoulder and Elbow

A 35-year-old male presents with sudden onset of severe, unremitting right shoulder and periscapular pain that began 2 weeks ago without any antecedent trauma. Over the last 48 hours, the severe pain has rapidly subsided, but he has now noticed profound weakness in overhead elevation and external rotation. An MRI of the shoulder is unremarkable. What is the most likely diagnosis?

. Acute massive rotator cuff tear
. Cervical radiculopathy (C5-C6)
. Parsonage-Turner syndrome
. Adhesive capsulitis (Freezing phase)
. Subscapularis tendon rupture

Correct Answer & Explanation

. Parsonage-Turner syndrome

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) is characterized by the sudden onset of severe, burning shoulder and arm pain that typically lasts for 1 to 2 weeks. As the pain subsides, profound weakness, atrophy, and paralysis of the affected shoulder girdle musculature become evident. It most commonly affects the suprascapular nerve, long thoracic nerve, or anterior interosseous nerve. Diagnosis is clinical and can be confirmed with EMG.

Question 3722

Topic: Elbow & Forearm

A 9-year-old Little League baseball pitcher presents with a 3-month history of lateral elbow pain, stiffness, and occasional swelling. Radiographs reveal sclerosis, fragmentation, and rarefaction of the entire capitellar ossific nucleus. The capitellar physis remains wide open. What is the most appropriate management for this condition?

. Arthroscopic debridement and microfracture of the capitellum
. Cessation of throwing activities and symptomatic observation
. Ulnar collateral ligament reconstruction
. Open reduction and internal fixation of the capitellum
. Radial head excision

Correct Answer & Explanation

. Cessation of throwing activities and symptomatic observation

Explanation

This clinical and radiographic picture is characteristic of Panner's disease, an osteochondrosis of the capitellum that affects younger children (typically boys aged 7-10 years) with an open capitellar physis. It involves the entire capitellum and has an excellent prognosis, almost always resolving with nonoperative management (rest and cessation of throwing). This distinguishes it from osteochondritis dissecans (OCD) of the capitellum, which occurs in older adolescents (12-15 years), involves focal defects, and may result in loose bodies requiring surgery.

Question 3723

Topic: Elbow & Forearm

A patient with a chronic high radial nerve palsy is scheduled for a standard Boyes tendon transfer procedure to restore hand function. In a classic Boyes transfer, which of the following muscles is transferred to restore thumb extension?

. Palmaris longus
. Flexor carpi radialis (FCR)
. Flexor digitorum superficialis (FDS) of the middle finger
. Flexor carpi ulnaris (FCU)
. Brachioradialis

Correct Answer & Explanation

. Flexor digitorum superficialis (FDS) of the middle finger

Explanation

In the Boyes tendon transfer for radial nerve palsy, the FDS of the middle finger is transferred to the Extensor Digitorum Communis (EDC) to restore finger extension, and the FDS of the ring finger is transferred to the Extensor Pollicis Longus (EPL) and Extensor Indicis Proprius (EIP) to restore thumb and index extension. The Pronator Teres (PT) is transferred to the Extensor Carpi Radialis Brevis (ECRB) for wrist extension. Note that in a standard FCR or FCU transfer (not Boyes), the Palmaris longus is typically transferred to the EPL.

Question 3724

Topic: Elbow & Forearm

In a patient undergoing tendon transfers for an irreparable high radial nerve palsy, the Pronator Teres (PT) is typically transferred to the Extensor Carpi Radialis Brevis (ECRB) rather than the Extensor Carpi Radialis Longus (ECRL). What is the primary biomechanical advantage of selecting the ECRB?

. It provides significantly greater excursion than the ECRL.
. It prevents radial deviation of the wrist during active extension.
. It preserves the functional integrity of the dart-thrower's motion.
. It requires a shorter routing path, reducing the risk of tendon adhesions.
. It acts as a synergistic muscle, eliminating the need for postoperative motor re-education.

Correct Answer & Explanation

. It prevents radial deviation of the wrist during active extension.

Explanation

The ECRB inserts centrally at the base of the third metacarpal, whereas the ECRL inserts more radially at the base of the second metacarpal. Transferring the PT to the ECRB provides balanced, centralized wrist extension, thereby preventing the unwanted radial deviation that would occur if the ECRL were used.

Question 3725

Topic: Elbow & Forearm

A patient with an isolated low radial nerve palsy undergoes tendon transfer surgery. To restore thumb extension, which of the following is the most classic and widely utilized donor tendon transfer?

. Palmaris longus (PL) to Extensor pollicis longus (EPL)
. Brachioradialis (BR) to Extensor pollicis longus (EPL)
. Flexor digitorum superficialis (FDS) to Extensor pollicis longus (EPL)
. Flexor carpi radialis (FCR) to Extensor pollicis longus (EPL)
. Pronator teres (PT) to Extensor pollicis longus (EPL)

Correct Answer & Explanation

. Palmaris longus (PL) to Extensor pollicis longus (EPL)

Explanation

In a standard set of tendon transfers for low radial nerve palsy, the Palmaris Longus (PL) is rerouted to the Extensor Pollicis Longus (EPL) to restore thumb extension. The standard Boyes or FCR transfer sets both utilize PL to EPL. Other components typically include PT to ECRB (for wrist extension) and FCR or FDS to EDC (for finger extension).

Question 3726

Topic: Elbow & Forearm

In a standard Boyes tendon transfer for a high radial nerve palsy, which muscle is transferred to restore wrist extension?

. Pronator teres
. Flexor carpi ulnaris
. Flexor digitorum superficialis
. Flexor carpi radialis
. Palmaris longus

Correct Answer & Explanation

. Pronator teres

Explanation

In virtually all classic radial nerve palsy tendon transfers (including Boyes, Jones, and Smith), the pronator teres (PT) is transferred to the extensor carpi radialis brevis (ECRB) to predictably restore wrist extension.

Question 3727

Topic: Elbow & Forearm

A 26-year-old elite rower presents with pain, swelling, and distinct crepitus approximately 4 cm proximal to Lister's tubercle on the dorsal forearm. The pain is exacerbated by repetitive wrist flexion and extension. This condition represents an inflammatory friction syndrome between which of the following extensor compartments?

. First and second compartments
. Second and third compartments
. Third and fourth compartments
. First and third compartments
. Fourth and fifth compartments

Correct Answer & Explanation

. First and second compartments

Explanation

Intersection syndrome is characterized by tenosynovitis at the crossing point of the first dorsal compartment muscles (APL and EPB) over the second dorsal compartment muscles (ECRL and ECRB) in the distal forearm.

Question 3728

Topic: Elbow & Forearm

A 35-year-old male presents with a high radial nerve palsy following a humerus fracture. He is planned for a Boyes tendon transfer to restore wrist and finger extension. Which of the following describes the standard Boyes transfer for restoring finger extension?

. Flexor carpi radialis to extensor digitorum communis
. Flexor digitorum superficialis of the middle finger to extensor digitorum communis
. Pronator teres to extensor carpi radialis brevis
. Flexor carpi ulnaris to extensor digitorum communis
. Palmaris longus to extensor pollicis longus

Correct Answer & Explanation

. Flexor digitorum superficialis of the middle finger to extensor digitorum communis

Explanation

In the Boyes transfer for radial nerve palsy, the FDS of the middle finger is routed through the interosseous membrane to the EDC to restore finger extension. Pronator teres to ECRB is utilized for wrist extension, and FCR to EDC is characteristic of the Brand transfer.

Question 3729

Topic: Elbow & Forearm

A 45-year-old construction worker presents with the inability to actively extend his thumb, index, and middle fingers after sustaining a midshaft humerus fracture 6 months ago. EMG shows no evidence of reinnervation. A decision is made to proceed with tendon transfers. If the Pronator Teres (PT) is transferred to the Extensor Carpi Radialis Brevis (ECRB) to restore wrist extension, which of the following combinations is most commonly used to restore finger and thumb extension?

. Flexor Carpi Radialis (FCR) to Extensor Digitorum Communis (EDC); Palmaris Longus (PL) to Extensor Pollicis Longus (EPL)
. Flexor Carpi Ulnaris (FCU) to EDC; FCR to EPL
. Flexor Digitorum Superficialis (FDS) of the ring finger to EDC; FDS of the middle finger to EPL
. Brachioradialis (BR) to EDC; PL to EPL
. FCR to EPL; PL to EDC

Correct Answer & Explanation

. Flexor Carpi Radialis (FCR) to Extensor Digitorum Communis (EDC); Palmaris Longus (PL) to Extensor Pollicis Longus (EPL)

Explanation

The most common tendon transfers for a high radial nerve palsy are the PT to ECRB (to restore wrist extension), the FCR to the EDC (to restore finger extension), and the PL to the EPL (to restore thumb extension). The FCR is generally preferred over the FCU for finger extension to preserve the FCU's critical role in the dart-throwing motion and strong grip.

Question 3730

Topic: Elbow & Forearm

A 32-year-old male presents with a high radial nerve palsy following a humeral shaft fracture 8 months ago. He has no clinically detectable nerve recovery. For restoration of wrist extension, finger extension, and thumb extension, which set of tendon transfers represents the classic Brand transfer?

. Pronator teres to extensor carpi radialis brevis, flexor carpi radialis to extensor digitorum communis, palmaris longus to extensor pollicis longus
. Pronator teres to extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum communis, palmaris longus to extensor pollicis longus
. Flexor carpi ulnaris to extensor carpi radialis brevis, flexor carpi radialis to extensor digitorum communis, palmaris longus to extensor pollicis longus
. Pronator teres to extensor carpi radialis longus, flexor carpi radialis to extensor digitorum communis, palmaris longus to extensor pollicis longus
. Brachioradialis to extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum communis, palmaris longus to extensor pollicis longus

Correct Answer & Explanation

. Pronator teres to extensor carpi radialis brevis, flexor carpi radialis to extensor digitorum communis, palmaris longus to extensor pollicis longus

Explanation

The classic Brand tendon transfer for high radial nerve palsy utilizes the pronator teres for wrist extension (ECRB), the flexor carpi radialis for finger extension (EDC), and the palmaris longus for thumb extension (EPL). Transferring to the ECRB rather than the ECRL prevents an unacceptable radial deviation during wrist extension.

Question 3731

Topic: Shoulder Arthroplasty & Arthritis

A 70-year-old female with chronic rotator cuff arthropathy (cuff tear arthropathy) presents with severe shoulder pain and loss of active elevation. Radiographs show superior migration of the humeral head and glenoid erosion. She has failed conservative management. What is the most appropriate surgical treatment?

. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic debridement
. Rotator cuff repair

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (rTSA) is the gold standard surgical treatment for rotator cuff arthropathy. This condition is characterized by a massive, irreparable rotator cuff tear leading to superior migration of the humeral head, glenoid erosion, and pseudoparalysis. By reversing the ball-and-socket configuration, rTSA medializes and inferiorizes the center of rotation, allowing the deltoid muscle to function effectively even in the absence of a functional rotator cuff, thereby restoring active elevation and alleviating pain. Anatomic total shoulder arthroplasty requires an intact or reparable rotator cuff, which is not the case here.

Question 3732

Topic: 9. Shoulder and Elbow

A 55-year-old female presents with persistent pain and decreased range of motion in her right shoulder. She describes weakness with overhead activities and difficulty sleeping on the affected side. Physical examination reveals tenderness over the greater tuberosity, a positive Neer's and Hawkins' impingement sign, and weakness with active abduction and external rotation against resistance. She has a positive 'drop arm' test. Radiographs show superior migration of the humeral head relative to the glenoid. What is the most likely diagnosis?

. Adhesive capsulitis (frozen shoulder)
. Calcific tendinitis
. Rotator cuff tendinopathy
. Massive, irreparable rotator cuff tear
. Glenohumeral osteoarthritis

Correct Answer & Explanation

. Massive, irreparable rotator cuff tear

Explanation

The combination of chronic pain, weakness with overhead activities, positive impingement signs, a positive 'drop arm' test (indicating inability to hold the arm in abduction), and superior migration of the humeral head on radiographs are highly suggestive of a massive, irreparable rotator cuff tear. Adhesive capsulitis primarily presents with global stiffness. Calcific tendinitis typically has acute, severe pain. Rotator cuff tendinopathy would not typically have superior humeral head migration or a positive drop arm sign. Glenohumeral osteoarthritis would show joint space narrowing and osteophytes, which are not the primary findings described here, although it can be secondary to chronic massive cuff tears (rotator cuff arthropathy).

Question 3733

Topic: 9. Shoulder and Elbow

A 45-year-old male presents with chronic lateral elbow pain, worsened by gripping and lifting. He is a carpenter and reports increased pain with using a hammer or screwdriver. Examination reveals tenderness over the lateral epicondyle and pain elicited by resisted wrist extension and resisted forearm supination. Radiographs are normal. What is the most effective initial non-surgical treatment?

. Corticosteroid injection into the lateral epicondyle
. Platelet-rich plasma (PRP) injection
. Activity modification, NSAIDs, and physical therapy focusing on eccentric strengthening of the wrist extensors
. Surgical debridement of the extensor origin
. Shockwave therapy

Correct Answer & Explanation

. Activity modification, NSAIDs, and physical therapy focusing on eccentric strengthening of the wrist extensors

Explanation

The patient's symptoms and signs are classic for lateral epicondylitis (tennis elbow). The most effective initial non-surgical treatment typically involves activity modification, NSAIDs for pain relief, and a structured physical therapy program emphasizing eccentric strengthening of the wrist extensor muscles (e.g., extensor carpi radialis brevis). While corticosteroid injections can provide short-term pain relief, they have been shown to have worse long-term outcomes and potential for tendon degeneration. PRP and shockwave therapy are second-line treatments with variable evidence. Surgical debridement is reserved for refractory cases that fail prolonged conservative management.

Question 3734

Topic: 9. Shoulder and Elbow

Which of the following describes a key biomechanical advantage of reverse total shoulder arthroplasty (rTSA) in patients with rotator cuff arthropathy?

. It restores the normal glenohumeral center of rotation
. It reconstructs the torn rotator cuff tendons
. It medializes and distalizes the center of rotation, increasing the deltoid moment arm
. It reduces stress on the glenoid component by offloading the deltoid
. It improves external rotation by tensioning the infraspinatus

Correct Answer & Explanation

. It medializes and distalizes the center of rotation, increasing the deltoid moment arm

Explanation

The primary biomechanical advantage of the reverse total shoulder arthroplasty (rTSA) in rotator cuff arthropathy is that it medializes and distalizes the center of rotation of the shoulder joint. This significantly increases the deltoid muscle's moment arm, allowing the deltoid to compensate for the absent or dysfunctional rotator cuff and effectively elevate the arm. Anatomic TSA restores the normal center of rotation. rTSA does not reconstruct the torn rotator cuff. It increases, rather than reduces, the deltoid's role. It does not improve external rotation by tensioning the infraspinatus, which is absent/non-functional; rather, external rotation can be limited.

Question 3735

Topic: Elbow & Forearm

A 6-month-old infant is found to have an irreducible, complete dislocation of the radial head. The forearm is in pronation and flexion, and there is limited supination. Radiographs confirm radial head dislocation and an abnormal radial head configuration. The child has no other obvious deformities. What is the most likely underlying condition?

. Nursemaid's elbow
. Congenital radial head dislocation
. Monteggia fracture-dislocation
. Madelung's deformity
. Olecranon fracture

Correct Answer & Explanation

. Congenital radial head dislocation

Explanation

The description of an irreducible, complete radial head dislocation with an abnormal radial head configuration in a 6-month-old infant, without history of trauma (implying congenital), is characteristic of congenital radial head dislocation. Nursemaid's elbow is a subluxation of the radial head that is usually reducible and occurs after a pull injury. A Monteggia fracture-dislocation involves a fracture of the ulna with radial head dislocation, typically traumatic. Madelung's deformity involves dorsal subluxation of the distal ulna with premature physeal closure of the distal radius. Olecranon fracture is a traumatic elbow injury.

Question 3736

Topic: 9. Shoulder and Elbow

A 65-year-old male with severe shoulder pain and crepitus undergoes a total shoulder arthroplasty. Intraoperatively, the surgeon notes significant glenoid bone loss and a deficient rotator cuff. Which type of glenoid component is contraindicated in this scenario?

. All-polyethylene pegged glenoid component
. All-polyethylene keeled glenoid component
. Metallic-backed glenoid component
. Reverse total shoulder arthroplasty glenosphere
. Resurfacing glenoid component

Correct Answer & Explanation

. Metallic-backed glenoid component

Explanation

In anatomic total shoulder arthroplasty, a metallic-backed glenoid component (with a polyethylene liner) requires robust glenoid bone stock for long-term fixation and stability. Its use is contraindicated in cases of significant glenoid bone loss, as seen with severe glenoid erosion from osteoarthritis or in patients with deficient rotator cuffs, where superior migration of the humeral head can lead to eccentric loading and early failure. All-polyethylene pegged or keeled components are more commonly used in patients with good bone stock. For significant glenoid bone loss and deficient rotator cuff, a reverse total shoulder arthroplasty is typically indicated, which uses a metallic glenosphere. Resurfacing components are for limited indications.

Question 3737

Topic: 9. Shoulder and Elbow

In a written exam question on total shoulder arthroplasty, which aspect of the pre-operative workup is most vital to include for a comprehensive answer that scores well?

. Only requesting a basic shoulder X-ray.
. Focusing solely on the patient's age.
. Detailed clinical assessment including range of motion, rotator cuff integrity, and neurovascular status; advanced imaging (CT for bone stock, MRI for soft tissues); and assessment of patient expectations and functional goals.
. Assuming all patients are candidates for total shoulder arthroplasty.
. Only considering a reverse total shoulder arthroplasty.

Correct Answer & Explanation

. Detailed clinical assessment including range of motion, rotator cuff integrity, and neurovascular status; advanced imaging (CT for bone stock, MRI for soft tissues); and assessment of patient expectations and functional goals.

Explanation

A comprehensive pre-operative workup for total shoulder arthroplasty extends beyond basic imaging. It necessitates a thorough clinical assessment (ROM, strength, neurovascular status), specialized imaging to assess bone stock (CT) and rotator cuff integrity (MRI), and crucially, understanding patient expectations and functional goals to tailor the implant choice (anatomic vs. reverse) and manage post-operative outcomes. This integrated approach is essential for high marks.

Question 3738

Topic: Shoulder Arthroplasty & Arthritis

When presenting a surgical procedure (e.g., reverse total shoulder arthroplasty), what is the most important biomechanical principle to articulate for scoring highly?

. The length of the humeral stem.
. The material of the glenosphere.
. Medialization of the center of rotation and distalization of the humerus, which increases the deltoid lever arm, allowing the deltoid to compensate for a dysfunctional rotator cuff.
. The number of screws used.
. The type of anesthesia.

Correct Answer & Explanation

. Medialization of the center of rotation and distalization of the humerus, which increases the deltoid lever arm, allowing the deltoid to compensate for a dysfunctional rotator cuff.

Explanation

For Reverse Total Shoulder Arthroplasty (RTSA), understanding its unique biomechanical principles is essential for high marks. The key is to explain how it medializes the center of rotation and distalizes the humerus, thereby increasing the deltoid's lever arm. This biomechanical alteration allows the deltoid muscle to effectively compensate for a deficient or irreparable rotator cuff, enabling active elevation. This demonstrates a deep understanding beyond just the surgical steps.

Question 3739

Topic: Shoulder Arthroplasty & Arthritis

You are describing the technique for a total shoulder arthroplasty. The examiner abruptly asks, 'What is the most common and often devastating complication unique to reverse total shoulder arthroplasty (rTSA) compared to anatomic TSA, and how do you mitigate it?'

. Aseptic loosening of the humeral component, mitigated by cementing the stem.
. Axillary nerve palsy due to surgical dissection, mitigated by careful nerve identification.
. Scapular notching, caused by impingement of the humeral polyethylene liner on the inferior glenoid neck. It is mitigated by appropriate glenosphere lateralization, inferior placement, and proper soft tissue tensioning.
. Infection, mitigated by strict sterile technique and perioperative antibiotics.
. Rotator cuff failure, mitigated by preserving the subscapularis.

Correct Answer & Explanation

. Scapular notching, caused by impingement of the humeral polyethylene liner on the inferior glenoid neck. It is mitigated by appropriate glenosphere lateralization, inferior placement, and proper soft tissue tensioning.

Explanation

Scapular notching is a complication unique and relatively common to reverse total shoulder arthroplasty, where the humeral polyethylene liner impinges on the inferior aspect of the scapular neck during adduction and internal rotation, leading to erosion of the bone. It can lead to pain, reduced range of motion, and implant loosening. Mitigation strategies include lateralizing the glenosphere, inferomedial placement of the glenosphere, and achieving appropriate soft tissue tension. Axillary nerve palsy (B) can occur in both, but scapular notching is unique to rTSA. Aseptic loosening (A) is a general arthroplasty complication, not unique. Infection (D) is also a general complication. Rotator cuff failure (E) is thereasonfor rTSA in many cases, not a unique complicationofrTSA in the context of anatomic TSA comparison.

Question 3740

Topic: 9. Shoulder and Elbow

You are discussing the management of a patient with chronic lateral epicondylitis (tennis elbow) who has failed extensive conservative management. The examiner asks, 'What is the most appropriate next step in management for this patient?'

. A course of oral steroids to reduce inflammation.
. Immediate surgical release of the extensor carpi radialis brevis origin.
. Further comprehensive re-evaluation to confirm diagnosis, rule out alternative pathology, and consider advanced conservative options (e.g., PRP injections, dry needling, focused extracorporeal shockwave therapy) before considering surgery.
. Referral to a chronic pain specialist for opioid management.
. Complete cessation of all arm activities indefinitely.

Correct Answer & Explanation

. Further comprehensive re-evaluation to confirm diagnosis, rule out alternative pathology, and consider advanced conservative options (e.g., PRP injections, dry needling, focused extracorporeal shockwave therapy) before considering surgery.

Explanation

For chronic lateral epicondylitis refractory to initial conservative care, the most appropriate next step is a comprehensive re-evaluation to confirm the diagnosis and rule out other causes of lateral elbow pain (e.g., radial tunnel syndrome, cervical radiculopathy). Following this, advanced conservative options such as platelet-rich plasma (PRP) injections, dry needling, or focused extracorporeal shockwave therapy can be considered, as evidence supports their use in some cases. Surgical release (B) is usually a last resort after exhausting all non-operative options. Oral steroids (A) have limited long-term benefit. Opioid management (D) is inappropriate. Complete cessation (E) is rarely practical or beneficial long-term.

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