9. Shoulder and Elbow MCQs

The Grammont design principles for a reverse total shoulder arthroplasty (RTSA) revolutionized the treatment of cuff tear arthropathy. Which of the following statements best describes the primary biomechanical changes achieved by this design compared to normal shoulder anatomy?

A 72-year-old male complains of severe right shoulder pain and an inability to lift his arm above his waist. Examination reveals pseudoparalysis of the shoulder with active forward flexion to 45 degrees, but intact active internal rotation. MRI reveals a massive, fully retracted supraspinatus and infraspinatus tear with grade 4 Goutallier fatty infiltration. The subscapularis and teres minor are intact. Glenohumeral arthritis is absent. What is the most reliable definitive surgical treatment for this patient?

A 5-year-old girl presents with a high-riding left scapula and restricted shoulder abduction. Imaging reveals an omovertebral bone bridging the cervical spine and the scapula. If a Woodward procedure is planned, which of the following structures is most at risk during the release of the superior medial angle of the scapula?

A 35-year-old male presents with a persistent radial nerve palsy following a humerus fracture sustained 12 months ago. He has failed conservative management and is scheduled for tendon transfer surgery. Which of the following describes the most appropriate standard set of tendon transfers to restore wrist, finger, and thumb extension?

In a patient undergoing tendon transfer for a high radial nerve palsy (e.g., standard Jones or Brand transfer), which muscle-tendon unit is universally utilized to restore functional wrist extension?

A 50-year-old male with an irreversible high radial nerve palsy is undergoing tendon transfers. The surgeon elects to perform a Boyes transfer rather than the standard set of tendon transfers. Which of the following specific tendon transfers is a defining feature of the Boyes technique for restoring finger extension?

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. Clinical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinel's sign is positive around the clavicle. Horner's signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion. Diagnosis of the condition is:

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. Clinical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinel's sign is positive around the clavicle. Horner's signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion. The level of lesion is:

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. Clinical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinel's sign is positive around the clavicle. Horner's signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion. The plan of management in this patient 5 months postinjury with no clinical improvement should be:

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle eight weeks prior. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. Clinical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinel's sign is positive around the clavicle. Horner's signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion. The most important function that needs to be restored in this patient is:

A 70-year-old female presents with chronic, severe right shoulder pain and the inability to actively elevate her arm above 60 degrees. Passive range of motion is normal. Radiographs reveal superior migration of the humeral head with articulation against the acromion, and severe glenohumeral osteoarthritis. MRI confirms a massive, retracted, irreparable rotator cuff tear. What is the most reliable surgical treatment for restoring active elevation and relieving pain?

A 28-year-old athlete presents with shoulder weakness. Physical examination reveals prominent medial winging of the scapula when the patient pushes against a wall. Which of the following nerves is most likely injured?

A patient presents with a chronic high radial nerve palsy following a humerus fracture and elects to undergo tendon transfer surgery to restore wrist and finger extension. Which of the following is the most widely accepted standard tendon transfer to restore wrist extension in this scenario?

A 70-year-old female presents with chronic pseudoparalysis of the right shoulder due to massive rotator cuff tear arthropathy. Radiographs show superior migration of the humeral head with acetabularization of the acromion. She is scheduled for a Reverse Total Shoulder Arthroplasty (RTSA). The success of RTSA is most critically dependent on the function of which of the following nerves?

A 25-year-old man sustains a stab wound to the lateral aspect of his chest wall. He subsequently demonstrates winging of the scapula, especially when pushing against a wall. Which of the following muscles is paralyzed?

A 24-year-old motorcyclist sustains a traction injury to his brachial plexus. He exhibits complete loss of shoulder abduction and external rotation, and significant weakness in elbow flexion. Which nerve roots are most likely involved?

A 24-year-old male is brought to the emergency department following a first-time generalized tonic-clonic seizure. He complains of right shoulder pain and an inability to rotate the arm outward. An AP radiograph of the shoulder shows the humeral head overlapping the glenoid with a "lightbulb" sign. What is the next best step in management?

In a patient with a massive, irreparable rotator cuff tear and resultant cuff tear arthropathy, the Hamada classification is used to grade the radiographic severity. What radiographic finding characterizes Hamada Grade 3?

A 60-year-old female presents with chronic shoulder pain and inability to actively elevate her arm above 60 degrees. Radiographs show superior migration of the humeral head and an acromiohumeral interval of 3 mm. Which surgical intervention provides the most reliable restoration of active forward elevation in this patient?

A 40-year-old male sustains a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). During surgical reconstruction, after fixation of the coronoid and replacement of the comminuted radial head, the elbow remains unstable in extension and supination. What is the next most appropriate step in the surgical sequence?