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9. Shoulder and Elbow MCQs

Practice Set 193 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 3841

Topic: 9. Shoulder and Elbow

When interpreting plain radiographs for glenohumeral osteoarthritis, which finding is a strong indicator of an underlying rotator cuff tear arthropathy rather than primary osteoarthritis?

. Presence of large inferior humeral head osteophytes
. Concentric joint space narrowing
. Superior migration of the humeral head
. Subchondral sclerosis
. Small glenoid osteophytes

Correct Answer & Explanation

. Superior migration of the humeral head

Explanation

Superior migration of the humeral head, leading to impingement on the acromion and often erosion of the superior glenoid, is the classic radiographic hallmark of rotator cuff tear arthropathy (RCAT). This occurs because the absence of a functional rotator cuff prevents the humeral head from being centralized in the glenoid during arm elevation. Primary osteoarthritis typically presents with concentric or eccentric (often posterior) joint space narrowing without significant superior migration, unless a massive cuff tear is also present. Large inferior humeral head osteophytes and small glenoid osteophytes can be seen in primary OA. Subchondral sclerosis is a general sign of OA.

Question 3842

Topic: 9. Shoulder and Elbow

A 70-year-old male with severe glenohumeral osteoarthritis is being evaluated for total shoulder arthroplasty. During the examination, you identify a Walch B2 glenoid. What does a Walch B2 glenoid typically imply?

. Minimal glenoid erosion with concentric wear.
. Centralized glenoid erosion without posterior subluxation.
. Posterior glenoid erosion with less than 25 degrees of retroversion and the humeral head centered.
. Posterior glenoid erosion with greater than 25 degrees of retroversion and posterior humeral head subluxation.
. Dysplastic glenoid with severe retroversion greater than 25 degrees.

Correct Answer & Explanation

. Posterior glenoid erosion with greater than 25 degrees of retroversion and posterior humeral head subluxation.

Explanation

The Walch classification system is crucial for preoperative planning of glenohumeral arthroplasty. A Walch B2 glenoid is characterized by posterior glenoid erosion, often described as 'biconcave' wear, where both the anterior and posterior aspects of the glenoid are eroded, and the humeral head is typically posteriorly subluxated. This is usually associated with significant posterior glenoid retroversion, often greater than 25 degrees. Options A and B describe Walch A glenoids (A1 and A2 respectively). Option C describes a Walch B1 glenoid (posterior erosion with less than 25 degrees retroversion). Option E describes a Walch C glenoid (dysplastic, severe retroversion).

Question 3843

Topic: 9. Shoulder and Elbow

When assessing a patient with shoulder pain, which finding during the history or physical examination would make you consider avascular necrosis (AVN) of the humeral head as a differential diagnosis for glenohumeral osteoarthritis?

. Gradual onset of pain with activity, improving with rest.
. Positive Hawkins-Kennedy test.
. History of long-term corticosteroid use or alcohol abuse.
. Palpable crepitus during shoulder motion.
. Stiffness in a capsular pattern.

Correct Answer & Explanation

. History of long-term corticosteroid use or alcohol abuse.

Explanation

A history of long-term corticosteroid use, alcohol abuse, or other conditions like sickle cell disease, lupus, or previous trauma/fracture are well-known risk factors for avascular necrosis (osteonecrosis) of the humeral head. AVN can lead to collapse of the humeral head, secondary osteoarthritis, and severe pain. Gradual onset of pain, crepitus, and a capsular pattern of stiffness can be seen in both OA and AVN. A positive Hawkins-Kennedy test is indicative of impingement. Identifying specific risk factors for AVN is crucial in the history to consider this differential.

Question 3844

Topic: 9. Shoulder and Elbow

A 65-year-old construction worker presents with right shoulder pain that is worse with heavy lifting and overhead work. Examination reveals tenderness over the anterior aspect of the glenohumeral joint and a positive Speed's test. Radiographs show mild concentric joint space narrowing and a small humeral head osteophyte. What is the most likely co-existing pathology in this patient?

. Rotator cuff tear
. Subacromial impingement
. Bicipital tendinopathy
. Adhesive capsulitis
. AC joint osteoarthritis

Correct Answer & Explanation

. Bicipital tendinopathy

Explanation

A positive Speed's test, combined with tenderness over the anterior aspect of the glenohumeral joint (which can include the bicipital groove region), is highly indicative of bicipital tendinopathy or a superior labral anterior-posterior (SLAP) lesion involving the biceps anchor. While mild OA is present, the specific findings point to an additional bicipital issue, which is a common co-existing pathology with glenohumeral OA. Rotator cuff tears would typically manifest with weakness or other specific tests. Subacromial impingement would have positive impingement signs. Adhesive capsulitis would show global stiffness. AC joint OA would have tenderness over the AC joint and a positive cross-body adduction test.

Question 3845

Topic: 9. Shoulder and Elbow

Which of the following is considered a 'secondary' cause of glenohumeral osteoarthritis, distinct from primary (idiopathic) OA?

. Age-related cartilage degeneration
. Genetic predisposition
. Rotator cuff tear arthropathy
. Concentric glenoid wear (Walch A2)
. Generalized joint laxity

Correct Answer & Explanation

. Rotator cuff tear arthropathy

Explanation

Rotator cuff tear arthropathy (RCAT) is a specific, secondary form of glenohumeral osteoarthritis caused by chronic rotator cuff insufficiency leading to biomechanical alterations and degenerative changes. Primary OA is idiopathic, often considered age-related with a genetic component. Concentric glenoid wear describes a pattern of wear that can be seen in both primary and some secondary OA, but doesn't define the etiology itself. Generalized joint laxity can be a risk factor for instability, which can lead to post-traumatic OA, but is not a direct cause of secondary OA itself.

Question 3846

Topic: Shoulder Arthroplasty & Arthritis

Which of the following describes the most common radiographic finding for a Walch Type B1 glenoid?

. Concentric glenoid wear without posterior subluxation.
. Posterior glenoid erosion with less than 25 degrees of retroversion and the humeral head centered.
. Posterior glenoid erosion with greater than 25 degrees of retroversion and posterior humeral head subluxation.
. Biconcave glenoid erosion with significant retroversion.
. Dysplastic glenoid with severe retroversion (>25 degrees).

Correct Answer & Explanation

. Posterior glenoid erosion with less than 25 degrees of retroversion and the humeral head centered.

Explanation

A Walch Type B1 glenoid is characterized by posterior glenoid erosion, but with less than 25 degrees of retroversion, and crucially, the humeral head is still relatively centered on the glenoid, not significantly subluxated posteriorly. The posterior erosion is typically uniconcave. Option A describes a Walch A2. Option C and D describe Walch B2. Option E describes a Walch C.

Question 3847

Topic: 9. Shoulder and Elbow

A 45-year-old patient with a history of recurrent shoulder dislocations and a previous Bankart repair now presents with persistent deep shoulder pain and crepitus. Plain radiographs reveal joint space narrowing, subchondral sclerosis, and osteophytes. What is the most appropriate term for this patient's condition?

. Primary glenohumeral osteoarthritis
. Adhesive capsulitis
. Post-traumatic glenohumeral osteoarthritis
. Rotator cuff tear arthropathy
. Inflammatory arthritis

Correct Answer & Explanation

. Post-traumatic glenohumeral osteoarthritis

Explanation

The patient's history of recurrent shoulder dislocations and a Bankart repair indicates previous trauma to the glenohumeral joint. Such trauma, particularly to the articular cartilage, can accelerate degenerative changes. The described radiographic findings (joint space narrowing, sclerosis, osteophytes) are consistent with osteoarthritis. Therefore, this is classified as post-traumatic glenohumeral osteoarthritis. Primary OA is idiopathic. Adhesive capsulitis is characterized by global stiffness without significant degenerative changes. RCAT involves massive cuff tears and superior humeral head migration. Inflammatory arthritis typically has systemic signs and different radiographic patterns.

Question 3848

Topic: 9. Shoulder and Elbow

Which pain characteristic is most commonly reported by patients with advanced glenohumeral osteoarthritis?

. Sharp, shooting pain radiating down the arm to the fingers.
. Burning pain localized to the lateral deltoid.
. Dull, aching pain aggravated by activity and relieved by rest, often worse at night.
. Sudden, severe pain with 'catching' during specific movements.
. Pain primarily in the anterior shoulder, radiating to the biceps.

Correct Answer & Explanation

. Dull, aching pain aggravated by activity and relieved by rest, often worse at night.

Explanation

Patients with advanced glenohumeral osteoarthritis typically report a dull, aching pain that is aggravated by activity and often relieved by rest. Night pain, particularly when lying on the affected side, is also a very common and bothersome symptom due to chronic inflammation and lack of distraction. Sharp, shooting pain to the fingers suggests radiculopathy. Burning pain in the lateral deltoid might indicate referred pain from subacromial pathology. Sudden, severe pain with 'catching' is more indicative of mechanical issues like labral tears or loose bodies. Pain radiating to the biceps suggests biceps pathology.

Question 3849

Topic: 9. Shoulder and Elbow

Which of the following is NOT a typical radiographic finding associated with glenohumeral osteoarthritis?

. Joint space narrowing
. Subchondral sclerosis
. Marginal osteophyte formation
. Subchondral cysts (geodes)
. Periarticular osteopenia

Correct Answer & Explanation

. Periarticular osteopenia

Explanation

Periarticular osteopenia (decreased bone density around the joint) is more characteristic of inflammatory arthropathies (e.g., rheumatoid arthritis) or prolonged disuse, not typically primary glenohumeral osteoarthritis, which tends to feature subchondral sclerosis (increased bone density). The other options – joint space narrowing, subchondral sclerosis, marginal osteophyte formation, and subchondral cysts – are all classic radiographic signs of osteoarthritis.

Question 3850

Topic: 9. Shoulder and Elbow

In a patient presenting with shoulder pain and suspected glenohumeral osteoarthritis, involvement of other peripheral joints (e.g., metacarpophalangeal joints, wrists) should prompt further investigation for:

. Polymyalgia rheumatica
. Systemic lupus erythematosus
. Gout
. Rheumatoid arthritis or other inflammatory arthropathy
. Regional pain syndrome

Correct Answer & Explanation

. Rheumatoid arthritis or other inflammatory arthropathy

Explanation

Involvement of other peripheral joints, especially in a symmetrical pattern (e.g., metacarpophalangeal joints, wrists, small joints of the hands and feet), is a hallmark of systemic inflammatory arthropathies such as rheumatoid arthritis, psoriatic arthritis, or other spondyloarthropathies. While osteoarthritis can occur in multiple joints, it typically presents differently and without the systemic inflammatory signs. Polymyalgia rheumatica primarily affects the shoulder and pelvic girdles but without joint destruction. Gout usually presents as acute mono- or oligoarthritis. Systemic lupus erythematosus can cause arthralgias but less commonly destructive arthritis as a primary presentation. Regional pain syndrome is a diagnosis of exclusion with distinct features.

Question 3851

Topic: 9. Shoulder and Elbow
A 68-year-old female presents with severe, chronic left shoulder pain. Radiographs reveal advanced glenohumeral osteoarthritis with Walch B2 glenoid morphology. What is the primary surgical implication of a Walch B2 glenoid in total shoulder arthroplasty?
. It typically allows for standard anatomic total shoulder arthroplasty with minimal glenoid reaming.
. It often requires an eccentric reaming technique or augmentation of the posterior glenoid for anatomic total shoulder arthroplasty, or consideration of reverse total shoulder arthroplasty.
. It indicates suitability for hemiarthroplasty only.
. It suggests a high risk of intraoperative humeral fracture.
. It mandates an open surgical approach due to complexity.

Correct Answer & Explanation

. It often requires an eccentric reaming technique or augmentation of the posterior glenoid for anatomic total shoulder arthroplasty, or consideration of reverse total shoulder arthroplasty.

Explanation

A Walch B2 glenoid signifies significant posterior glenoid erosion with associated retroversion and often posterior subluxation of the humeral head. This complex morphology presents challenges for anatomic total shoulder arthroplasty (TSA), as it necessitates addressing the posterior bone loss to achieve proper glenoid component seating and avoid excessive retroversion. Options often include eccentric reaming, posterior glenoid augmentation (wedges), or a decision to proceed with a reverse total shoulder arthroplasty (RSA) which is less dependent on glenoid version. It does not imply suitability for hemiarthroplasty only, or a high risk of humeral fracture, or mandate an open approach.

Question 3852

Topic: 9. Shoulder and Elbow

Which clinical scenario is most likely to lead to an erroneous diagnosis of primary glenohumeral osteoarthritis?

. A 70-year-old with chronic shoulder pain, crepitus, and a capsular pattern of restriction.
. A 60-year-old with sudden onset severe shoulder pain after a fall, limited motion, and tenderness over the greater tuberosity.
. A 65-year-old with progressive shoulder stiffness, night pain, and a positive shrug sign.
. A 55-year-old with deep, aching shoulder pain worse with overhead activity, improved with rest, and mild joint space narrowing on X-ray.
. A 72-year-old with pain on passive external rotation, limited active elevation, and negative impingement signs.

Correct Answer & Explanation

. A 60-year-old with sudden onset severe shoulder pain after a fall, limited motion, and tenderness over the greater tuberosity.

Explanation

A sudden onset of severe shoulder pain after a fall, limited motion, and tenderness over the greater tuberosity is highly suggestive of an acute rotator cuff tear or fracture, not typically the gradual onset of primary glenohumeral osteoarthritis. While OA can coexist, the acute presentation with trauma points strongly away from a primary OA diagnosis being the sole or primary issue. The other scenarios describe clinical pictures highly consistent with or supportive of a primary OA diagnosis or rotator cuff arthropathy (shrug sign).

Question 3853

Topic: 9. Shoulder and Elbow

During the physical examination of a shoulder with suspected osteoarthritis, which finding is most specific to pathology of the glenohumeral joint capsule rather than the articular cartilage itself?

. Crepitus with rotation
. Pain with axial compression
. Limited passive range of motion in a capsular pattern
. Subchondral sclerosis on X-ray
. Tenderness over the bicipital groove

Correct Answer & Explanation

. Limited passive range of motion in a capsular pattern

Explanation

A limited passive range of motion in a capsular pattern (ER > ABD > IR restriction) is characteristic of a contracture or inflammation of the glenohumeral joint capsule, which occurs in both adhesive capsulitis and glenohumeral osteoarthritis. While crepitus and pain with axial compression indicate articular cartilage damage, the capsular pattern points specifically to the capsule. Subchondral sclerosis is a radiographic sign of bony response to cartilage loss. Tenderness over the bicipital groove indicates biceps pathology.

Question 3854

Topic: 9. Shoulder and Elbow

A 72-year-old patient with long-standing rheumatoid arthritis presents with progressive, severe shoulder pain. Radiographs show symmetric joint space narrowing, humeral head superior migration, and significant osteopenia. What is the most likely diagnosis for her shoulder condition?

. Primary glenohumeral osteoarthritis
. Rotator cuff tear arthropathy
. Rheumatoid arthritis of the glenohumeral joint
. Post-traumatic arthritis
. Avascular necrosis

Correct Answer & Explanation

. Rheumatoid arthritis of the glenohumeral joint

Explanation

Long-standing rheumatoid arthritis can directly affect the glenohumeral joint, leading to a specific pattern of arthritis. The findings of symmetric joint space narrowing (due to pannus erosion of cartilage), humeral head superior migration (often from rotator cuff involvement secondary to inflammation), and significant osteopenia (characteristic of RA and steroid use) are all consistent with rheumatoid arthritis affecting the glenohumeral joint. While RCAT also has superior migration, the symmetric narrowing and generalized osteopenia with a history of RA point strongly to inflammatory arthritis as the primary cause. Primary OA typically has asymmetric narrowing and sclerosis, not osteopenia.

Question 3855

Topic: 9. Shoulder and Elbow

Which of the following historical details is crucial for assessing potential factors contributing to secondary glenohumeral osteoarthritis?

. Dietary habits
. History of previous shoulder trauma, surgery, or instability
. Family history of knee osteoarthritis
. Current medication list for hypertension
. Occupation as an accountant

Correct Answer & Explanation

. History of previous shoulder trauma, surgery, or instability

Explanation

A history of previous shoulder trauma (e.g., fracture, dislocation), prior surgeries, or chronic instability (e.g., recurrent dislocations) are significant risk factors for developing secondary glenohumeral osteoarthritis due to direct damage to articular cartilage and altered joint mechanics. These are crucial historical details for determining the etiology of the OA. While other factors might influence general health, they are not direct contributors to secondary shoulder OA. Family history of knee OA is less specific for shoulder, and occupation as an accountant typically involves less direct shoulder stress than, for example, a manual laborer.

Question 3856

Topic: 9. Shoulder and Elbow

In the context of glenohumeral osteoarthritis, a 'geode' refers to which specific radiographic finding?

. A large marginal osteophyte
. A subchondral cyst
. A loose body within the joint
. A region of subchondral sclerosis
. A calcified intra-articular body

Correct Answer & Explanation

. A subchondral cyst

Explanation

In orthopedic radiology, 'geode' is an alternative term for a subchondral cyst. These are cystic lesions that form within the subchondral bone, typically adjacent to areas of cartilage loss and increased stress, and are a characteristic radiographic finding in osteoarthritis. They are not osteophytes, loose bodies, or sclerosis.

Question 3857

Topic: 9. Shoulder and Elbow

A 50-year-old female presents with shoulder pain and limited abduction. On examination, the active and passive range of motion are equally restricted, with a painful 'end-feel'. Radiographs show mild joint space narrowing. Which of the following is most likely to be the primary diagnosis?

. Full-thickness rotator cuff tear
. Subacromial impingement
. Adhesive capsulitis
. Bicipital tendinopathy
. Acromioclavicular joint osteoarthritis

Correct Answer & Explanation

. Adhesive capsulitis

Explanation

When both active and passive ranges of motion are equally and significantly restricted, especially with a painful 'end-feel', this is highly suggestive of adhesive capsulitis (frozen shoulder) or glenohumeral osteoarthritis. Given the age and only mild joint space narrowing, adhesive capsulitis is often a more acute or subacute presentation with this level of global restriction. A full-thickness rotator cuff tear would typically show greater active than passive restriction due to weakness. Subacromial impingement or bicipital tendinopathy would have specific positive tests and usually less global restriction. AC joint OA causes pain primarily at the AC joint and with cross-body adduction.

Question 3858

Topic: 9. Shoulder and Elbow

Which of the following statements about pain assessment in glenohumeral osteoarthritis is true?

. Pain is typically sharp and well-localized to the deltoid insertion.
. Pain is usually constant and unaffected by activity.
. Night pain is a rare symptom and not indicative of severity.
. Pain is often described as a deep, aching sensation, exacerbated by activity and relieved by rest in early stages.
. Pain radiating past the elbow is always indicative of cervical spine pathology.

Correct Answer & Explanation

. Pain is often described as a deep, aching sensation, exacerbated by activity and relieved by rest in early stages.

Explanation

The most common and accurate description of pain in glenohumeral osteoarthritis is a deep, aching sensation. It is typically exacerbated by activity and relieved by rest in the earlier stages, though it becomes more constant and bothersome at night as the disease progresses. Night pain is a common and often debilitating symptom, indicative of disease progression. Pain past the elbow can be referred from the shoulder, but is more suspicious for cervical spine pathology and warrants further investigation, but it's notalwaysindicative. Sharp, localized pain and constant pain unaffected by activity are atypical.

Question 3859

Topic: 9. Shoulder and Elbow

What is the primary diagnostic utility of the anteroposterior (AP) view of the shoulder with the humerus in external rotation when evaluating glenohumeral osteoarthritis?

. To visualize the subacromial space for impingement.
. To better assess the bicipital groove.
. To clearly visualize the true glenohumeral joint space without humeral head overlap.
. To identify posterior glenoid erosion.
. To evaluate the acromioclavicular joint.

Correct Answer & Explanation

. To clearly visualize the true glenohumeral joint space without humeral head overlap.

Explanation

The AP view of the shoulder in external rotation (often called the 'Grashey view' when the patient is obliqued 30-45 degrees) is used to obtain a 'true' AP view of the glenohumeral joint. This projection helps to open up the joint space by removing the overlap of the humeral head with the glenoid, allowing for the most accurate assessment of the glenohumeral joint space narrowing, osteophytes, and subchondral changes. Other views are better for the subacromial space, bicipital groove, or AC joint.

Question 3860

Topic: 9. Shoulder and Elbow

A 60-year-old male with a history of multiple shoulder surgeries for instability now has chronic shoulder pain and limited range of motion. Radiographs demonstrate severe glenohumeral osteoarthritis. His current presentation is best categorized as:

. Primary (idiopathic) osteoarthritis
. Rheumatoid arthritis
. Post-traumatic osteoarthritis
. Rotator cuff tear arthropathy
. Osteonecrosis

Correct Answer & Explanation

. Post-traumatic osteoarthritis

Explanation

A history of multiple shoulder surgeries for instability indicates significant prior trauma and surgical interventions that directly alter joint mechanics and cartilage integrity. This leads to accelerated degenerative changes, classifying the resulting osteoarthritis as post-traumatic. Primary OA is idiopathic. Rheumatoid arthritis is systemic. RCAT involves massive cuff tears and superior migration. Osteonecrosis has specific radiographic findings and risk factors.

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