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 3861
Topic: 9. Shoulder and Elbow
Which of the following is an early radiographic sign of glenohumeral osteoarthritis?
Correct Answer & Explanation
. Marginal osteophytes at the inferior humeral head and glenoid
Explanation
Marginal osteophytes, particularly at the inferior aspect of the humeral head and glenoid, along with subtle joint space narrowing, are typically among the earliest radiographic signs of glenohumeral osteoarthritis. Complete obliteration of the joint space, large subchondral cysts, significant superior migration, and severe glenoid retroversion are indicative of more advanced stages of the disease or specific subtypes like RCAT (superior migration) or Walch B/C glenoids (retroversion).
Question 3862
Topic: Shoulder Arthroplasty & Arthritis
A 62-year-old male presents with chronic shoulder pain. MRI findings include extensive chondral delamination, subchondral bone cysts, and full-thickness supraspinatus tear with retraction. What is the most appropriate long-term management consideration for this patient?
Correct Answer & Explanation
. Reverse total shoulder arthroplasty (rTSA).
Explanation
The combination of extensive chondral delamination, subchondral bone cysts (advanced OA features), and a retracted full-thickness supraspinatus tear indicates rotator cuff tear arthropathy (RCAT) with significant articular destruction. In such cases, standard rotator cuff repair is often not feasible or durable due to tissue quality and retraction, and the arthritis component is significant. Reverse total shoulder arthroplasty (rTSA) is typically the most effective surgical treatment for RCAT, as it provides stability and restores function by bypassing the deficient rotator cuff. Physical therapy, debridement alone, or subacromial decompression/cuff repair are generally inadequate for this advanced pathology. Long-term NSAIDs are palliative but not curative for such advanced disease.
Question 3863
Topic: 9. Shoulder and Elbow
Which finding during a systemic review of symptoms would be most concerning for an inflammatory component to a patient's shoulder arthritis?
Correct Answer & Explanation
. Constitutional symptoms such as prolonged fatigue, unintentional weight loss, and low-grade fever.
Explanation
Constitutional symptoms such as prolonged fatigue, unintentional weight loss, and low-grade fever are red flags that point towards a systemic inflammatory process (e.g., rheumatoid arthritis, systemic lupus erythematosus, polymyalgia rheumatica, or even infection/malignancy) rather than isolated, non-inflammatory osteoarthritis. Morning stiffness lasting less than 30 minutes is more characteristic of OA. Unilateral involvement and pain worse with activity can be seen in OA. Absence of warmth or erythema does not rule out all inflammatory conditions, and localized warmth can be seen in flare-ups of OA.
Question 3864
Topic: 9. Shoulder and Elbow
A 55-year-old tennis player presents with shoulder pain. Examination reveals tenderness over the AC joint, pain with cross-body adduction, and osteophytes on plain radiographs of the AC joint. What is the most likely referred pain pattern from this pathology that might mimic glenohumeral OA?
Correct Answer & Explanation
. Deep, diffuse pain in the anterior and superior shoulder region.
Explanation
Pain from the acromioclavicular (AC) joint commonly refers to the superior, anterior, and often diffuse shoulder region, making it challenging to distinguish from true glenohumeral pain or even rotator cuff pathology. The AC joint often refers pain broadly to the 'top' of the shoulder. While it can radiate a bit towards the neck, a deep, diffuse pain in the anterior and superior shoulder is a very common presentation that can be confused with other shoulder pathologies. Pain down the posterior arm or biceps groove is less typical. Sharp pain with internal rotation is not specific.
Question 3865
Topic: 9. Shoulder and Elbow
In a patient with suspected glenohumeral osteoarthritis, the presence of isolated tenderness to palpation in the bicipital groove, without significant limitation of glenohumeral motion, would suggest:
Correct Answer & Explanation
. Bicipital tendinopathy or superior labrum anterior-posterior (SLAP) lesion.
Explanation
Isolated tenderness to palpation in the bicipital groove, especially if exacerbated by specific tests like Speed's test or Yergason's test, and without significant glenohumeral motion restriction, is highly indicative of bicipital tendinopathy or a SLAP lesion involving the biceps anchor. While these can coexist with OA, they are distinct pathologies. Advanced OA would have widespread pain and motion loss. Adhesive capsulitis would have global motion restriction. Rotator cuff tears would have weakness and specific tests. AC joint arthritis has superior AC joint tenderness.
Question 3866
Topic: 9. Shoulder and Elbow
A 67-year-old retired manual laborer presents with severe, chronic shoulder pain. On physical examination, there is marked crepitus and pain with all shoulder movements. Radiographs show significant joint space narrowing, subchondral sclerosis, and large osteophytes. The patient is considering surgical intervention. Which of the following is an absolute contraindication to anatomic total shoulder arthroplasty (TSA) in this patient?
Correct Answer & Explanation
. Active shoulder infection.
Explanation
Active infection in the joint is an absolute contraindication to implanting any prosthetic device, including a total shoulder arthroplasty. Attempting arthroplasty in the presence of infection would almost certainly lead to prosthetic joint infection, requiring removal of components and a two-stage revision. A Walch B2 glenoid is arelativecontraindication or a significant challenge that may necessitate a reverse total shoulder arthroplasty or complex reconstruction, but not an absolute contraindication toanyform of arthroplasty. Age and activity level are factors for patient selection and type of arthroplasty, but not absolute contraindications. Moderate deltoid atrophy can be addressed or is a consideration for RSA, but not an absolute contraindication.
Question 3867
Topic: 9. Shoulder and Elbow
In evaluating shoulder osteoarthritis, which type of glenoid morphology, as per the Walch classification, is typically associated with a dysplastic glenoid and severe retroversion (greater than 25 degrees) without significant posterior erosion?
Correct Answer & Explanation
. Type C
Explanation
Walch Type C glenoid is characterized by a dysplastic glenoid with severe retroversion, typically greater than 25 degrees, and is not primarily due to erosion. This congenital or developmental abnormality presents unique challenges for total shoulder arthroplasty. A1 and A2 are concentric wear patterns. B1 and B2 involve posterior erosion and retroversion, which are acquired changes due to wear, distinct from the developmental retroversion of a Type C glenoid.
Question 3868
Topic: Elbow & Forearm
A 10-year-old boy with Hereditary Multiple Exostoses (HME) presents with progressive forearm deformity and loss of pronation. Which of the following is the characteristic pattern of forearm dysplasia typically seen in HME?
Correct Answer & Explanation
. Ulnar shortening, radial bowing, and radial head subluxation
Explanation
In HME, the distal ulna contributes significantly to longitudinal growth and is disproportionately affected by osteochondromas. This results in relative ulnar shortening, secondary radial bowing, and eventual radial head subluxation.
Question 3869
Topic: 9. Shoulder and Elbow
A 72-year-old male presents with pseudoparalysis of the right shoulder. MRI demonstrates a massive, retracted, and fatty-infiltrated rotator cuff tear involving the supraspinatus and infraspinatus. Radiographs show severe glenohumeral osteoarthritis with superior migration of the humeral head (Hamada Grade 4). What is the most appropriate surgical treatment?
Correct Answer & Explanation
. Reverse total shoulder arthroplasty
Explanation
Reverse total shoulder arthroplasty relies on the deltoid muscle to power the shoulder and is the treatment of choice for rotator cuff tear arthropathy (massive irreparable tear with glenohumeral arthritis).
Question 3870
Topic: 9. Shoulder and Elbow
Which joint is most frequently affected by primary synovial chondromatosis?
Correct Answer & Explanation
. Knee
Explanation
The knee is by far the most commonly affected joint in primary synovial chondromatosis, accounting for approximately 50-70% of cases. It is followed in frequency by the hip, elbow, and shoulder.
Question 3871
Topic: Elbow & Forearm
A 14-year-old boy with a known diagnosis of Multiple Hereditary Exostoses (MHE) presents with a progressive deformity of his left forearm. Which of the following is the most typical pattern of forearm deformity expected in this condition?
Correct Answer & Explanation
. Ulnar shortening, radial bowing, and potential radial head dislocation
Explanation
Correct Answer: Ulnar shortening, radial bowing, and potential radial head dislocationIn Multiple Hereditary Exostoses (Osteochondromatosis), forearm deformities are common due to the presence of osteochondromas affecting the distal physes. The distal ulnar physis contributes a larger percentage to the overall length of the ulna compared to the radius. Therefore, an osteochondroma here disproportionately retards ulnar growth, leading to relative ulnar shortening. The continued growth of the tethered radius results in radial bowing, increased ulnar variance (negative), and eventually radial head subluxation or dislocation (Masada classification).
Question 3872
Topic: Elbow & Forearm
A 10-year-old boy with multiple osteochondromas presents with a progressive forearm deformity. Which of the following is the classic pattern of forearm deformity expected in this patient due to the anarchic development of bone constituents?
Correct Answer & Explanation
. Ulnar shortening, radial bowing, ulnar deviation of the hand, and potential radial head dislocation
Explanation
Correct Answer: Ulnar shortening, radial bowing, ulnar deviation of the hand, and potential radial head dislocationMultiple Hereditary Exostoses (MHE), also known as diaphyseal aclasis, is characterized by the anarchic development of cartilage-capped bony outgrowths. In the forearm, the distal ulna is disproportionately affected because it contributes a large percentage of the bone's overall longitudinal growth and has a small cross-sectional area. This leads to relative ulnar shortening. The radius continues to grow, resulting in radial bowing to accommodate the length discrepancy. The tethering effect leads to ulnar deviation of the carpus and can eventually cause dislocation of the radial head (usually posterolaterally).
Question 3873
Topic: Elbow & Forearm
A 10-year-old boy with multiple hereditary exostoses (MHE) presents with a progressive forearm deformity. Which of the following is the most characteristic pattern of forearm deformity seen in this condition?
Correct Answer & Explanation
. Ulnar shortening, radial bowing, ulnar deviation of the carpus, and radial head dislocation
Explanation
Correct Answer: Ulnar shortening, radial bowing, ulnar deviation of the carpus, and radial head dislocationThe classic forearm deformity in Multiple Hereditary Exostoses (MHE) is driven by the disproportionate shortening of the ulna. Because the ulna contributes less to the distal growth plate than the radius, osteochondromas at the distal ulna severely tether its growth. This leads to ulnar shortening, secondary bowing of the radius (which continues to grow but is tethered to the short ulna), ulnar deviation of the carpus (due to lack of ulnar support), and eventual dislocation of the radial head.
Question 3874
Topic: 9. Shoulder and Elbow
Which joint is most frequently affected by primary synovial chondromatosis, and what is the typical patient demographic?
Correct Answer & Explanation
. Knee; middle-aged males
Explanation
Primary synovial chondromatosis most commonly affects the knee joint (accounting for over 50% of cases). It typically presents in males during their 3rd to 5th decades of life.
Question 3875
Topic: 9. Shoulder and Elbow
A 45-year-old man presents with painless, massive swelling and instability of his right shoulder. Radiographs demonstrate severe glenohumeral destruction with osseous debris. Physical exam reveals a loss of pain and temperature sensation in both upper extremities. What is the most likely underlying diagnosis?
Correct Answer & Explanation
. Syringomyelia
Explanation
Syringomyelia commonly causes neuropathic (Charcot) arthropathy in the upper extremities, particularly the shoulder. This occurs due to central cord cavity expansion disrupting the spinothalamic tracts, eliminating protective pain and temperature sensation.
Question 3876
Topic: 9. Shoulder and Elbow
A 55-year-old female with poorly controlled diabetes mellitus presents with severe global restriction of active and passive shoulder motion. She is diagnosed with idiopathic frozen shoulder. Contracture of which of the following structures is considered the primary anatomical restraint to external rotation in the early stages of this condition?
Correct Answer & Explanation
. Coracohumeral ligament and rotator interval
Explanation
Correct Answer: BIn frozen shoulder or adhesive capsulitis (Index 15.3.4), the earliest and most profound motion loss is typically external rotation with the arm at the side. This is primarily due to contracture, thickening, and fibroplasia of the coracohumeral ligament and the structures within the rotator interval.
Question 3877
Topic: 9. Shoulder and Elbow
A 10-year-old girl is evaluated for multiple painless bony prominences around her knees and shoulders. Radiographs demonstrate multiple sessile and pedunculated lesions growing away from the physes. Genetic testing reveals an EXT1 mutation. The pathophysiology of her condition is directly related to a defect in the synthesis of which of the following?
Correct Answer & Explanation
. Heparan sulfate
Explanation
Multiple hereditary exostoses (MHE) is caused by mutations in the EXT1 or EXT2 genes. These genes encode glycosyltransferases essential for the synthesis of heparan sulfate, a critical regulator of chondrocyte proliferation.
Question 3878
Topic: 9. Shoulder and Elbow
What is the most common functional limitation observed in patients with an untreated, severe Sprengel's deformity?
Correct Answer & Explanation
. Decreased shoulder abduction and forward elevation
Explanation
Due to the tethering of the scapula and altered biomechanics of the shoulder girdle, patients with Sprengel's deformity classically have restricted shoulder abduction and forward elevation.
Question 3879
Topic: 9. Shoulder and Elbow
A patient with untreated Sprengel's deformity will most likely exhibit limited range of motion in which of the following shoulder movements?
Correct Answer & Explanation
. Abduction
Explanation
The scapula in Sprengel's deformity is elevated, hypoplastic, and medially rotated, leading to a significant restriction in scapulothoracic motion. This most notably limits active shoulder abduction.
Question 3880
Topic: 9. Shoulder and Elbow
A 5-year-old boy presents with a high-riding left scapula and restricted left shoulder abduction. A clinical image is evaluated:
At what embryonic stage does the normal descent of the scapula usually occur, failing which results in this deformity?
Correct Answer & Explanation
. 9-12 weeks gestation
Explanation
The scapula normally develops in the cervical region at about 5 weeks of gestation and descends to its definitive thoracic position by the 9th to 12th week. Failure of this descent results in Sprengel's deformity.
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