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9. Shoulder and Elbow MCQs

Practice Set 192 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 3821

Topic: 9. Shoulder and Elbow

A 55-year-old male presents with progressive right shoulder pain, weakness, and difficulty with overhead activities for 6 months. Physical examination reveals significant deltoid atrophy, an absent acromial-humeral interval on radiographs, and a positive external rotation lag sign. He has intact sensation and deltoid function. What is the most appropriate surgical treatment?

. Arthroscopic rotator cuff repair
. Debridement and subacromial decompression
. Latissimus dorsi transfer
. Reverse total shoulder arthroplasty
. Hemiarthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

The clinical presentation (deltoid atrophy, absent acromial-humeral interval on radiographs, positive external rotation lag sign) strongly suggests rotator cuff arthropathy, which is advanced glenohumeral arthritis associated with a massive, irreparable rotator cuff tear. In such cases, a reverse total shoulder arthroplasty is the treatment of choice, as it medializes and distalizes the center of rotation, allowing the deltoid muscle to function more efficiently and restore active elevation. Rotator cuff repair is not feasible for massive, irreparable tears with cuff arthropathy. Debridement is palliative. Latissimus dorsi transfer is used for isolated irreparable posterosuperior tears, often in younger patients without significant arthropathy. Hemiarthroplasty alone would not address the cuff deficiency.

Question 3822

Topic: 9. Shoulder and Elbow

What is the most common direction of glenohumeral dislocation?

. Anterior
. Posterior
. Inferior
. Superior
. Multidirectional

Correct Answer & Explanation

. Anterior

Explanation

Anterior dislocations are by far the most common direction of glenohumeral dislocation, accounting for over 95% of cases. This typically occurs due to an injury with the arm in abduction and external rotation. Posterior dislocations are much rarer (2-4%), often associated with seizures or electrocution. Inferior and superior dislocations are extremely rare. Multidirectional instability is a different clinical entity, often without a specific traumatic event.

Question 3823

Topic: 9. Shoulder and Elbow
A 21-year-old collegiate pitcher presents with chronic shoulder pain that has failed to improve with rest and physical therapy. An arthroscopic view from the posterior portal is shown. Probing reveals fraying of the superior labrum, but the biceps anchor is firmly attached to the superior glenoid tubercle. Which of the following best describes the Snyder classification and the most appropriate management for this lesion?
. Type I; arthroscopic debridement
. Type II; arthroscopic repair
. Type III; excision of the bucket-handle tear
. Type IV; biceps tenodesis
. Type I; biceps tenotomy

Correct Answer & Explanation

. Type I; arthroscopic debridement

Explanation

The arthroscopic image demonstrates a Type I SLAP (Superior Labrum Anterior and Posterior) lesion, which is characterized by fraying and degeneration of the superior labrum with an intact biceps anchor. The appropriate treatment for a Type I SLAP lesion is simple arthroscopic debridement. Biceps tenodesis or tenotomy is not indicated because the biceps anchor is stable. Type II lesions involve detachment of the superior labrum and biceps anchor and are typically treated with repair. Type III lesions are bucket-handle tears of the labrum with an intact biceps anchor, and Type IV lesions are bucket-handle tears that extend into the biceps tendon.

Question 3824

Topic: 9. Shoulder and Elbow

A 52-year-old former baseball pitcher presents with pain at the extremes of elbow flexion and extension. A radiograph is provided. Which of the following is the most appropriate surgical intervention if nonoperative management fails?

. Total elbow arthroplasty
. Ulnar nerve transposition
. Excision of osteophytes and loose bodies with capsular release
. Radial head excision
. Medial ulnar collateral ligament reconstruction

Correct Answer & Explanation

. Excision of osteophytes and loose bodies with capsular release

Explanation

Correct Answer: Excision of osteophytes and loose bodies with capsular releaseThe radiograph and history are classic for primary degenerative arthritis of the elbow, characterized by osteophytes on the coronoid and olecranon, and loose bodies. Treatment consists of removal of loose bodies and impinging osteophytes along with capsular release. Total elbow arthroplasty is generally contraindicated in younger, active patients who wish to maintain heavy use of the extremity.

Question 3825

Topic: 9. Shoulder and Elbow

A 24-year-old recreational weightlifter presents with vague anterior shoulder pain. An arthroscopic image from the posterior portal is shown. Probing reveals fraying of the superior labrum, but the biceps anchor is firmly attached to the superior glenoid tubercle. Which of the following is the most appropriate management?

. Biceps tenodesis
. Arthroscopic debridement of the frayed labrum
. Suture anchor repair of the superior labrum
. Biceps tenotomy
. Open capsulorraphy

Correct Answer & Explanation

. Arthroscopic debridement of the frayed labrum

Explanation

Correct Answer: BThe image and clinical description are consistent with a Type I SLAP lesion, which is characterized by degenerative fraying of the superior labrum with an intact biceps anchor. The appropriate treatment for a Type I SLAP lesion is simple arthroscopic debridement of the frayed tissue. Repair or tenodesis is not indicated because the biceps anchor remains stable and intact.

Question 3826

Topic: 9. Shoulder and Elbow

A 55-year-old male heavy laborer complains of progressive loss of elbow extension and pain at the extremes of motion. A lateral radiograph is shown. Which of the following surgical interventions is most appropriate for this patient if conservative management fails?

. Total elbow arthroplasty
. Ulnar nerve transposition
. Excision of osteophytes, loose body removal, and capsular release
. Radial head excision
. Medial collateral ligament reconstruction

Correct Answer & Explanation

. Excision of osteophytes, loose body removal, and capsular release

Explanation

Correct Answer: CThe patient has primary degenerative arthritis of the elbow, characterized by osteophytes on the coronoid and olecranon, loose bodies, and pain at terminal extension. The most appropriate surgical treatment for a high-demand patient (such as a heavy laborer) is the removal of loose bodies, excision of impinging osteophytes, and capsular release (performed either open or arthroscopically). Total elbow arthroplasty is contraindicated in heavy laborers due to strict permanent lifting restrictions.

Question 3827

Topic: 9. Shoulder and Elbow

Understanding Glenohumeral Osteoarthritis

A 68-year-old male presents with chronic, progressive right shoulder pain over the past 3 years. He reports difficulty with overhead activities, dressing, and often experiences a grinding sensation with movement. Night pain has become increasingly bothersome. On examination, active forward elevation is 90 degrees, and external rotation is 20 degrees, with significant pain at the end ranges. Passive range of motion is similar. Which of the following physical examination findings is most characteristic of primary glenohumeral osteoarthritis?

. Significant internal rotation deficit with an intact external rotation
. Greater restriction in passive range of motion compared to active range of motion
. A capsular pattern of restriction, with external rotation being the most restricted
. Relief of pain with subacromial injection of local anesthetic
. Prominent scapular dyskinesis with compensatory shoulder shrug

Correct Answer & Explanation

. A capsular pattern of restriction, with external rotation being the most restricted

Explanation

The classic capsular pattern for the glenohumeral joint involves the greatest restriction in external rotation, followed by abduction, and then internal rotation. This pattern is indicative of true glenohumeral joint pathology, such as osteoarthritis or adhesive capsulitis. While pain and limited range of motion are present, the specific order of restriction is key. Option A is incorrect as external rotation is typically the most restricted. Option B is characteristic of a rotator cuff tear or impingement where active motion may be more limited than passive due to pain or weakness, but in advanced OA, passive and active motion are often similarly restricted. Option D would be more characteristic of subacromial impingement or bursitis rather than intrinsic glenohumeral OA. Option E can be seen in various shoulder pathologies but is not the most specific characteristic of glenohumeral OA itself.

Question 3828

Topic: 9. Shoulder and Elbow
Regarding the radiographic assessment of glenohumeral osteoarthritis, which view is most crucial for evaluating glenoid version and posterior erosion, particularly when considering total shoulder arthroplasty?
. Anteroposterior (AP) view in external rotation
. Anteroposterior (AP) view in internal rotation
. Scapular Y view
. Axillary lateral view
. Zanca view

Correct Answer & Explanation

. Axillary lateral view

Explanation

The axillary lateral view is indispensable for evaluating glenoid morphology, including glenoid version (anteversion or retroversion) and the presence and extent of posterior erosion. This information is critical for pre-operative planning in total shoulder arthroplasty (TSA) to ensure proper component placement and prevent malalignment. AP views (external and internal rotation) are excellent for assessing joint space narrowing, osteophytes, and subchondral sclerosis but offer limited information on glenoid version. The Scapular Y view is primarily used to assess the relationship of the humeral head to the glenoid, often for dislocations or fractures. The Zanca view is specific for the AC joint.

Question 3829

Topic: 9. Shoulder and Elbow

Types and Etiology of GHOA

A 72-year-old patient presents with end-stage glenohumeral osteoarthritis. During physical examination, you note significant superior migration of the humeral head on the glenoid, along with associated atrophy of the deltoid and rotator cuff muscles. Radiographs confirm marked joint space narrowing, subchondral sclerosis, and large superior osteophytes, but also show a full-thickness rotator cuff tear. What specific type of glenohumeral osteoarthritis is most likely present?

. Primary (idiopathic) osteoarthritis
. Post-traumatic osteoarthritis
. Inflammatory osteoarthritis
. Rotator cuff tear arthropathy (RCAT)
. Osteonecrosis of the humeral head

Correct Answer & Explanation

. Rotator cuff tear arthropathy (RCAT)

Explanation

The key features described are superior migration of the humeral head, a full-thickness rotator cuff tear, and glenohumeral osteoarthritis. This combination is pathognomonic for rotator cuff tear arthropathy (RCAT), also known as cuff tear arthropathy or 'Milwaukee shoulder'. In RCAT, the chronic absence of a functioning rotator cuff leads to superior migration of the humeral head, abnormal contact stresses, and eventual degenerative changes of the glenohumeral joint. While primary OA can have similar degenerative changes, the superior migration and confirmed rotator cuff tear differentiate RCAT. Post-traumatic OA would typically have a history of significant trauma, and osteonecrosis would show specific radiographic changes like collapse and sclerosis of the humeral head, often without the superior migration seen in RCAT. Inflammatory arthritis would typically involve systemic symptoms and specific serological markers.

Question 3830

Topic: 9. Shoulder and Elbow
When performing a physical examination for suspected glenohumeral osteoarthritis, which maneuver is least likely to elicit pain specifically localized to the glenohumeral joint itself?
. Passive external rotation at 0 degrees abduction
. Active forward elevation with overpressure at the end range
. Palpation of the subacromial space
. Compression-rotation test (grinding test) of the glenohumeral joint
. Passive internal rotation with the arm abducted to 90 degrees

Correct Answer & Explanation

. Palpation of the subacromial space

Explanation

Palpation of the subacromial space is most likely to elicit pain in conditions affecting the subacromial bursa or rotator cuff tendons (e.g., impingement, bursitis, rotator cuff tendinopathy/tear), rather than directly from the glenohumeral joint articular cartilage itself. The other options, passive external rotation, active forward elevation with overpressure, compression-rotation testing, and passive internal rotation with abduction, all involve moving or compressing the glenohumeral joint, which would typically reproduce pain in a patient with glenohumeral osteoarthritis. The 'grinding test' (compression-rotation) is particularly useful for reproducing crepitus and pain originating from the joint surfaces.

Question 3831

Topic: 9. Shoulder and Elbow

A 55-year-old male presents with severe pain and limited range of motion in his dominant right shoulder. Radiographs demonstrate significant concentric joint space narrowing, subchondral sclerosis, and osteophyte formation globally around the glenohumeral joint. There is no evidence of superior migration of the humeral head. According to the Walch classification for glenoid morphology, which type would these radiographic findings most likely represent?

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

Correct Answer & Explanation

. Type A2

Explanation

The Walch classification categorizes glenoid morphology, primarily based on the presence and location of wear and retroversion. Type A glenoids are characterized by centralized wear without significant posterior erosion. A1 has minimal or no glenoid erosion, while A2 has centralized erosion (concentric joint space narrowing) but no posterior subluxation. The description of 'significant concentric joint space narrowing' without superior migration or posterior subluxation fits Walch A2. B1 and B2 involve posterior erosion and retroversion, often with posterior subluxation of the humeral head. Type C indicates severe glenoid dysplasia with retroversion greater than 25 degrees.

Question 3832

Topic: 9. Shoulder and Elbow

During the medical history of a patient with suspected shoulder osteoarthritis, which of the following is the most sensitive indicator for diagnosing primary glenohumeral osteoarthritis versus other shoulder pathologies?

. History of night pain
. Presence of crepitus during active motion
. Difficulty reaching overhead
. Stiffness, particularly 'start-up' pain or stiffness after rest
. Pain radiating down the arm to the hand

Correct Answer & Explanation

. Stiffness, particularly 'start-up' pain or stiffness after rest

Explanation

While night pain, crepitus, and difficulty reaching overhead can be present in various shoulder conditions, stiffness, especially 'start-up' pain or stiffness after periods of rest, is a highly characteristic symptom of degenerative arthritis in any joint, including the glenohumeral joint. This stiffness typically improves with activity but may recur with prolonged rest. Night pain can be seen in many inflammatory or degenerative conditions. Crepitus is indicative but not exclusive to OA. Pain radiating to the hand is more suggestive of cervical radiculopathy, though severe shoulder pathology can occasionally refer pain distally.

Question 3833

Topic: 9. Shoulder and Elbow
A 65-year-old female presents with bilateral shoulder pain. On examination, you notice tenderness over the bilateral acromioclavicular (AC) joints, with pain exacerbated by cross-body adduction. Radiographs confirm severe osteoarthritis of both AC joints, but also show mild glenohumeral joint space narrowing. What is the most common cause of pain referral to the glenohumeral joint region that originates from AC joint pathology?
. Direct neural communication via the axillary nerve
. Inflammatory mediators spilling from the AC joint capsule
. Referred pain patterns from the supraclavicular nerves
. Overuse of the rotator cuff due to AC joint instability
. Local irritation of the deltoid and trapezius muscles

Correct Answer & Explanation

. Inflammatory mediators spilling from the AC joint capsule

Explanation

The AC joint shares innervation with the shoulder region (suprascapular nerve, lateral pectoral nerve, and axillary nerve contributions). Pain from the AC joint often refers locally to the superior shoulder and can mimic glenohumeral pain. Additionally, degenerative changes in the AC joint, particularly osteophytes projecting inferiorly, can contribute to subacromial impingement, which secondarily irritates the rotator cuff and bursa, leading to more diffuse shoulder pain, including pain perceived within the glenohumeral region. While direct neural communication exists, the most common cause of pain referral in this context relates to its proximity and the shared local innervation/irritation patterns that can be perceived more broadly in the shoulder, affecting surrounding musculature and capsules.

Question 3834

Topic: 9. Shoulder and Elbow

Which of the following special tests, if positive, would most strongly suggest an alternative or co-existing diagnosis to primary glenohumeral osteoarthritis in a patient presenting with shoulder pain?

. Pain with active forward elevation
. Crepitus on circumduction of the arm
. Pain on passive external rotation
. Positive Hawkins-Kennedy impingement test
. Limited passive range of motion in a capsular pattern

Correct Answer & Explanation

. Positive Hawkins-Kennedy impingement test

Explanation

The Hawkins-Kennedy impingement test is designed to detect subacromial impingement, which affects the rotator cuff tendons or bursa, not primarily the glenohumeral joint articular cartilage. While glenohumeral osteoarthritis can coexist with impingement, a positive impingement sign would suggest a distinct or co-existing pathology in the subacromial space. Pain with active forward elevation, crepitus on circumduction, pain on passive external rotation, and a limited capsular pattern of motion are all consistent findings in primary glenohumeral osteoarthritis, indicating intrinsic joint pathology.

Question 3835

Topic: 9. Shoulder and Elbow

When assessing a patient with suspected glenohumeral osteoarthritis, which characteristic feature on plain radiographs is most indicative of early disease progression?

. Extensive subchondral cysts
. Marked glenoid erosion (Walch B2 or C)
. Generalized osteopenia
. Subchondral sclerosis
. Asymmetric joint space narrowing

Correct Answer & Explanation

. Asymmetric joint space narrowing

Explanation

Asymmetric joint space narrowing, often superior or posterior, is one of the earliest and most consistent radiographic signs of glenohumeral osteoarthritis, reflecting the focal loss of articular cartilage in areas of high stress. Subchondral sclerosis and osteophyte formation typically follow or occur concurrently with early joint space narrowing. Extensive subchondral cysts and marked glenoid erosion (Walch B2 or C) represent more advanced stages of the disease. Generalized osteopenia is more characteristic of inflammatory arthritis or disuse, not typically primary OA.

Question 3836

Topic: 9. Shoulder and Elbow

A 62-year-old male with a history of recurrent anterior shoulder dislocations now presents with chronic shoulder pain and crepitus. Radiographs demonstrate joint space narrowing, marginal osteophytes, and subchondral sclerosis. What is the most appropriate classification for this patient's glenohumeral osteoarthritis?

. Primary osteoarthritis
. Rotator cuff tear arthropathy
. Post-traumatic osteoarthritis
. Inflammatory osteoarthritis
. Dysplastic osteoarthritis

Correct Answer & Explanation

. Post-traumatic osteoarthritis

Explanation

A history of recurrent anterior shoulder dislocations, which cause trauma to the articular cartilage and supporting structures, is a direct cause of secondary osteoarthritis. This is classified as post-traumatic osteoarthritis. Primary osteoarthritis is idiopathic. Rotator cuff tear arthropathy would involve superior migration of the humeral head due to a massive cuff tear. Inflammatory osteoarthritis would involve systemic disease. Dysplastic osteoarthritis refers to congenital abnormalities in joint development.

Question 3837

Topic: 9. Shoulder and Elbow

Which aspect of the physical examination is most valuable for differentiating between glenohumeral osteoarthritis and adhesive capsulitis (frozen shoulder) in its early stages?

. Presence of night pain
. Severity of pain with movement
. Global restriction of active and passive range of motion
. Identification of crepitus during range of motion
. Tenderness over the bicipital groove

Correct Answer & Explanation

. Identification of crepitus during range of motion

Explanation

While both conditions present with pain and stiffness, the presence of crepitus is a key differentiator. Crepitus, a grating sensation, is a hallmark of articulating surfaces with damaged cartilage, as seen in osteoarthritis. Adhesive capsulitis, by contrast, involves fibrosis and thickening of the joint capsule and typically does not produce crepitus unless there's concomitant articular damage. Night pain, severity of pain, and global restriction of motion can be present in both. Tenderness over the bicipital groove indicates biceps pathology, which can coexist but is not specific to distinguishing between these two conditions.

Question 3838

Topic: 9. Shoulder and Elbow

In the context of shoulder osteoarthritis, what is the significance of tenderness to palpation over the posterior glenohumeral joint line?

. It is a reliable indicator of concomitant rotator cuff impingement.
. It typically points to biceps tendinopathy.
. It suggests posterior glenohumeral joint involvement, often associated with posterior labral pathology or early posterior glenohumeral OA.
. It is pathognomonic for adhesive capsulitis.
. It signifies an associated AC joint arthritis.

Correct Answer & Explanation

. It suggests posterior glenohumeral joint involvement, often associated with posterior labral pathology or early posterior glenohumeral OA.

Explanation

Tenderness to palpation over the posterior glenohumeral joint line specifically indicates pathology within or around the posterior aspect of the glenohumeral joint. This can be associated with posterior glenohumeral osteoarthritis, posterior labral pathology, or capsular irritation. It is not specifically indicative of rotator cuff impingement (which typically has anterior or superior tenderness), biceps tendinopathy (anterior tenderness), adhesive capsulitis (diffuse tenderness, no specific joint line finding), or AC joint arthritis (superior tenderness over AC joint).

Question 3839

Topic: 9. Shoulder and Elbow

A 60-year-old male presents with shoulder pain. On clinical examination, he exhibits a 'shrug sign' during active forward elevation. Radiographs show superior migration of the humeral head and superior glenoid wear. What does the 'shrug sign' primarily indicate in this context?

. Inflammatory synovitis
. Acromioclavicular joint pathology
. Compensatory mechanism for deficient rotator cuff function
. Primary adhesive capsulitis
. Bicipital tendinopathy

Correct Answer & Explanation

. Compensatory mechanism for deficient rotator cuff function

Explanation

The 'shrug sign' (or 'shoulder hike') is a compensatory mechanism where the patient elevates the scapula and shoulder girdle to achieve overhead motion when the glenohumeral joint motion is restricted, often due to significant pain, stiffness, or, crucially, deficient rotator cuff function. In the context of superior humeral head migration and superior glenoid wear, this strongly suggests rotator cuff arthropathy, where the rotator cuff is unable to depress and rotate the humeral head, leading to compensatory scapular motion. It is not specific for synovitis, AC joint pathology, adhesive capsulitis (though it can be present there), or bicipital tendinopathy.

Question 3840

Topic: 9. Shoulder and Elbow

What is the primary role of plain radiographs in the initial evaluation of suspected glenohumeral osteoarthritis?

. To definitively diagnose soft tissue abnormalities like rotator cuff tears.
. To determine the precise amount of articular cartilage loss.
. To identify characteristic bony changes and assess joint space narrowing.
. To rule out inflammatory arthritis requiring serological testing.
. To evaluate neural compression causing referred pain.

Correct Answer & Explanation

. To identify characteristic bony changes and assess joint space narrowing.

Explanation

Plain radiographs are the initial and primary imaging modality for diagnosing and assessing glenohumeral osteoarthritis. They are excellent for identifying characteristic bony changes such as joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts (geodes), and changes in humeral head position (e.g., superior migration). While they can hint at soft tissue pathology (e.g., superior migration suggesting cuff tear), they cannot definitively diagnose soft tissue lesions or precisely quantify cartilage loss. Inflammatory arthritis requires clinical correlation and serological tests. Neural compression is better evaluated clinically and with advanced imaging if indicated.

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