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9. Shoulder and Elbow MCQs

Practice Set 189 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 3761

Topic: Shoulder Arthroplasty & Arthritis

To minimize the risk of scapular notching during a Reverse Total Shoulder Arthroplasty (RTSA), how should the glenosphere ideally be positioned?

. Superior tilt and superior translation
. Inferior tilt and inferior translation
. Superior tilt and inferior translation
. Inferior tilt and superior translation

Correct Answer & Explanation

. Inferior tilt and inferior translation

Explanation

Scapular notching occurs when the medial aspect of the humeral component impinges on the inferior scapular neck. This complication is minimized by placing the glenosphere with an inferior tilt and inferior translation, allowing it to overhang the inferior rim of the glenoid.

Question 3762

Topic: Elbow & Forearm

A 35-year-old bodybuilder feels a pop in his anterior elbow during a deadlift. He has a positive hook test. Which intact structure may limit the proximal retraction of the torn distal biceps tendon, potentially masking the cosmetic deformity?

. Brachialis muscle
. Bicipital aponeurosis (Lacertus fibrosus)
. Pronator teres
. Brachioradialis

Correct Answer & Explanation

. Bicipital aponeurosis (Lacertus fibrosus)

Explanation

The bicipital aponeurosis (lacertus fibrosus) expands from the distal biceps tendon to the antebrachial fascia. If it remains intact during a distal biceps rupture, it prevents severe proximal retraction of the muscle belly, sometimes masking the classic 'Popeye' deformity.

Question 3763

Topic: Elbow & Forearm

A patient presents with painful clicking and subjective instability when pushing out of a chair. Posterolateral rotatory instability (PLRI) of the elbow is suspected. The primary deficient structure originates from which anatomic location?

. Lateral epicondyle and inserts on the supinator crest
. Medial epicondyle and inserts on the sublime tubercle
. Lateral epicondyle and inserts on the radial neck
. Capitellum and inserts on the annular ligament

Correct Answer & Explanation

. Lateral epicondyle and inserts on the supinator crest

Explanation

PLRI is caused by incompetence of the lateral ulnar collateral ligament (LUCL). The LUCL originates on the lateral epicondyle and inserts on the supinator crest of the proximal ulna, acting as a crucial secondary stabilizer to varus stress and primary stabilizer to posterolateral rotation.

Question 3764

Topic: 9. Shoulder and Elbow

When performing an open surgical debridement for refractory medial epicondylitis, the procedure primarily targets the pathological origin of which specific muscle?

. Flexor carpi ulnaris
. Pronator teres and flexor carpi radialis
. Flexor digitorum superficialis
. Brachioradialis

Correct Answer & Explanation

. Pronator teres and flexor carpi radialis

Explanation

Medial epicondylitis (golfer's elbow) represents a tendinosis of the common flexor origin. The pathology is most consistently found at the origin of the pronator teres and the flexor carpi radialis (FCR).

Question 3765

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female undergoes reverse total shoulder arthroplasty for cuff tear arthropathy. Which of the following best describes the biomechanical alteration achieved by this prosthesis compared to native anatomy?

. Lateralizes and superiorly translates the center of rotation
. Medializes and inferiorly translates the center of rotation
. Medializes and superiorly translates the center of rotation
. Lateralizes and inferiorly translates the center of rotation
. Maintains the native center of rotation but increases the deltoid moment arm

Correct Answer & Explanation

. Medializes and inferiorly translates the center of rotation

Explanation

Reverse total shoulder arthroplasty medializes and inferiorly translates the center of rotation. This alteration increases the deltoid moment arm and tension, compensating for the deficient rotator cuff to allow active elevation.

Question 3766

Topic: 9. Shoulder and Elbow

A 45-year-old man sustains a terrible triad injury of the elbow. During standard surgical management, after fixing the coronoid process and replacing the comminuted radial head, the elbow remains persistently unstable during varus stress. What is the most appropriate next step in the surgical sequence?

. Repair the medial collateral ligament (MCL)
. Apply a hinged external fixator
. Repair the lateral ulnar collateral ligament (LUCL)
. Perform an olecranon osteotomy to assess the joint
. Cast the elbow in full extension

Correct Answer & Explanation

. Repair the lateral ulnar collateral ligament (LUCL)

Explanation

The standard surgical sequence for a terrible triad injury involves restoring the anterior and lateral bony columns (coronoid and radial head), followed by repairing the LUCL to restore posterolateral stability. Only if the elbow remains unstable after LUCL repair should the MCL be addressed.

Question 3767

Topic: 9. Shoulder and Elbow

A 65-year-old male with primary glenohumeral osteoarthritis is undergoing an anatomic total shoulder arthroplasty. Preoperative CT imaging reveals a B2 glenoid with 20 degrees of retroversion. What is the most critical intraoperative goal regarding glenoid preparation to prevent early component loosening?

. Using a highly cross-linked polyethylene cemented peg glenoid without reaming
. Correcting the glenoid retroversion to within 10 degrees of neutral
. Reaming the anterior glenoid extensively to match the posterior wear depth
. Using a keeled glenoid component instead of a pegged one
. Downsizing the humeral head component to reduce joint reaction forces

Correct Answer & Explanation

. Correcting the glenoid retroversion to within 10 degrees of neutral

Explanation

A biconcave B2 glenoid with excessive retroversion (>15 degrees) leads to posterior subluxation and eccentric loading (the rocking horse effect). Correcting this retroversion to less than 10 degrees, often via asymmetric anterior reaming or bone grafting, is critical to prevent early glenoid loosening.

Question 3768

Topic: 9. Shoulder and Elbow

A 52-year-old woman with type 1 diabetes presents with severe left shoulder stiffness. She has equal loss of active and passive range of motion, predominately restricted in external rotation. Contracture of which of the following structures is the pathologic hallmark of this condition?

. Middle glenohumeral ligament
. Coracohumeral ligament and rotator interval
. Posterior band of the inferior glenohumeral ligament
. Transverse humeral ligament
. Acromioclavicular joint capsule

Correct Answer & Explanation

. Coracohumeral ligament and rotator interval

Explanation

Adhesive capsulitis (frozen shoulder) is highly associated with diabetes and is characterized by a global loss of passive and active range of motion. The primary pathoanatomic feature is contracture and fibroplasia of the rotator interval, specifically the coracohumeral ligament.

Question 3769

Topic: Elbow & Forearm

A 45-year-old man undergoes repair of a distal biceps tendon rupture using a single anterior incision approach. Postoperatively, he notes numbness along the lateral aspect of his forearm. Which nerve was most likely injured or retracted excessively during the procedure?

. Superficial radial nerve
. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Medial antebrachial cutaneous nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair due to its superficial course. The posterior interosseous nerve (PIN) is classically more at risk during a two-incision approach.

Question 3770

Topic: Shoulder Arthroplasty & Arthritis

In a reverse total shoulder arthroplasty (RTSA), scapular notching is a well-recognized complication. Which of the following glenosphere positioning strategies is most effective in minimizing the incidence of scapular notching?

. Inferior placement and inferior tilt
. Superior placement and superior tilt
. Neutral placement with superior tilt
. Lateralized placement with superior tilt
. Medialized placement with neutral tilt

Correct Answer & Explanation

. Inferior placement and inferior tilt

Explanation

Inferior placement and inferior tilt of the glenosphere in RTSA are key surgical strategies to prevent impingement of the humeral component against the scapular neck. This configuration reduces the risk of inferior scapular notching.

Question 3771

Topic: Elbow & Forearm

According to standard surgical protocols for a 'terrible triad' injury of the elbow, which of the following represents the most widely accepted sequence of structural repair?

. LCL -> MCL -> Radial head -> Coronoid
. Coronoid -> Radial head -> LCL -> MCL (if needed)
. Radial head -> LCL -> Coronoid -> MCL
. MCL -> Coronoid -> Radial head -> LCL
. LCL -> Coronoid -> Radial head -> Extensor origin

Correct Answer & Explanation

. Coronoid -> Radial head -> LCL -> MCL (if needed)

Explanation

The standard sequence for repairing a terrible triad injury works from deep to superficial: fixing the coronoid first, followed by the radial head (repair or replacement), and then the lateral collateral ligament (LCL). The MCL is only addressed if persistent instability remains after these steps.

Question 3772

Topic: Elbow & Forearm

Posterolateral rotatory instability (PLRI) of the elbow is primarily caused by incompetence of the lateral ulnar collateral ligament (LUCL). What is the exact anatomic insertion of the LUCL on the ulna?

. Coronoid tubercle
. Sublime tubercle
. Olecranon tip
. Supinator crest
. Radial notch

Correct Answer & Explanation

. Supinator crest

Explanation

The LUCL originates from the lateral epicondyle and blends with the annular ligament before inserting on the supinator crest of the proximal ulna. Disruption of this ligament leads to PLRI.

Question 3773

Topic: Elbow & Forearm

A 45-year-old male sustains a severely comminuted, unsalvageable radial head fracture along with a complete tear of the interosseous membrane and distal radioulnar joint disruption. What is the most appropriate management of the proximal radius?

. Radial head excision alone
. Radial head arthroplasty
. Closed reduction and casting
. Open reduction internal fixation of the radial head regardless of comminution
. Resection of the proximal radius to the bicipital tuberosity

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

This patient has an Essex-Lopresti injury. Radial head excision alone is absolutely contraindicated as it will lead to proximal migration of the radius and severe ulnar-sided wrist pain. Radial head arthroplasty is required to maintain longitudinal stability.

Question 3774

Topic: Elbow & Forearm

When performing a distal biceps tendon repair, which of the following complications is most specifically associated with a two-incision technique compared to a single anterior incision approach?

. Lateral antebrachial cutaneous nerve neuropraxia
. Posterior interosseous nerve injury
. Radioulnar synostosis
. Rerupture of the tendon
. Superficial radial nerve injury

Correct Answer & Explanation

. Radioulnar synostosis

Explanation

The two-incision technique for distal biceps repair carries a higher risk of heterotopic ossification and radioulnar synostosis due to violation of the interosseous membrane. The single-incision technique has a higher risk of lateral antebrachial cutaneous nerve (LABC) injury.

Question 3775

Topic: Shoulder Pathology

A 45-year-old woman presents with isolated lateral scapular winging following a posterior cervical triangle lymph node biopsy. Which nerve was most likely injured, and what muscle does it innervate?

. Long thoracic nerve; serratus anterior
. Dorsal scapular nerve; rhomboids
. Spinal accessory nerve; trapezius
. Suprascapular nerve; supraspinatus
. Axillary nerve; deltoid

Correct Answer & Explanation

. Spinal accessory nerve; trapezius

Explanation

The spinal accessory nerve (CN XI) innervates the trapezius and is vulnerable to iatrogenic injury during procedures in the posterior cervical triangle. Injury results in lateral winging of the scapula.

Question 3776

Topic: 9. Shoulder and Elbow

Anteromedial facet fractures of the coronoid process are classically associated with which of the following specific patterns of elbow instability?

. Posterolateral rotatory instability
. Varus posteromedial rotatory instability
. Valgus posterolateral rotatory instability
. Anterior instability
. Pure valgus instability

Correct Answer & Explanation

. Varus posteromedial rotatory instability

Explanation

Anteromedial facet fractures of the coronoid usually occur via a varus and posteromedial rotatory force. This mechanism causes a loss of the anterior medial buttress and often involves LCL disruption, leading to varus posteromedial rotatory instability.

Question 3777

Topic: 9. Shoulder and Elbow

A 58-year-old man presents with persistent deep shoulder pain. MRI confirms an isolated Type II SLAP lesion. What is the most reliable surgical intervention for this specific patient population if conservative measures fail?

. Arthroscopic SLAP repair with suture anchors
. Arthroscopic debridement of the labrum only
. Open anterior capsulo-labral reconstruction
. Biceps tenodesis
. Coracoid transfer

Correct Answer & Explanation

. Biceps tenodesis

Explanation

In patients over the age of 40-50, arthroscopic SLAP repairs have a high rate of stiffness and clinical failure. Biceps tenodesis is the preferred and more reliable surgical treatment in this demographic.

Question 3778

Topic: Elbow & Forearm

The primary pathologic process underlying lateral epicondylitis is best described histologically as which of the following?

. Angiofibroblastic tendinosis
. Acute neutrophilic inflammation
. Granulomatous inflammation
. Fibrinoid necrosis
. Chondroid metaplasia

Correct Answer & Explanation

. Angiofibroblastic tendinosis

Explanation

Lateral epicondylitis is a degenerative condition of the extensor carpi radialis brevis (ECRB) origin, not an acute inflammatory process. Histologically, it is characterized by angiofibroblastic tendinosis (hyperplasia of fibroblasts and disorganized collagen).

Question 3779

Topic: 9. Shoulder and Elbow

A 35-year-old male presents with acute, severe, unremitting unilateral shoulder pain lasting two weeks, which has recently subsided but left him with profound weakness in forward elevation and external rotation. MRI of the shoulder is unremarkable. What is the most likely diagnosis?

. Cervical radiculopathy
. Parsonage-Turner syndrome (brachial neuritis)
. Acute massive rotator cuff tear
. Adhesive capsulitis
. Thoracic outlet syndrome

Correct Answer & Explanation

. Parsonage-Turner syndrome (brachial neuritis)

Explanation

Parsonage-Turner syndrome classically presents with acute, severe shoulder pain that resolves after a few weeks, followed by patchy weakness of the shoulder girdle musculature (often involving the suprascapular or axillary nerves).

Question 3780

Topic: 9. Shoulder and Elbow

In a patient with idiopathic adhesive capsulitis, physical examination typically reveals a significant loss of external rotation with the arm at the side. Contracture of which specific structure is primarily responsible for this clinical finding?

. Inferior glenohumeral ligament
. Middle glenohumeral ligament
. Superior glenohumeral ligament
. Coracohumeral ligament
. Posterior capsule

Correct Answer & Explanation

. Coracohumeral ligament

Explanation

The coracohumeral ligament (CHL) lies in the rotator interval. Its contracture is the primary anatomic reason for the hallmark loss of external rotation with the arm adducted to the side in adhesive capsulitis.

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