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9. Shoulder and Elbow MCQs

Practice Set 20 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 381

Topic: 9. Shoulder and Elbow

A patient is 3 weeks post-operative following an acute AC joint reconstruction. During their physical therapy session, the therapist instructs them on pendulum exercises. Which of the following activities, if performed by the patient at this stage, would be considered a violation of the typical Phase One rehabilitation protocol described in the case?

. Active range of motion of the elbow, wrist, and hand.
. Wearing a shoulder sling with an abduction pillow.
. Initiating active shoulder elevation.
. Performing pendulum exercises.
. Avoiding inferior traction on the scapula.

Correct Answer & Explanation

. Performing pendulum exercises.

Explanation

Correct Answer: CThe 'Post Operative Rehabilitation Protocols' section outlines Phase One (Immobilization) from postoperative day zero to four weeks. During this phase, 'The patient is placed in a shoulder sling with an abduction pillow. The sling must support the weight of the arm to prevent inferior traction on the scapula... Active range of motion of the elbow, wrist, and hand is encouraged immediately... Pendulum exercises may be initiated at two weeks, but active shoulder elevation and reaching across the body are strictly prohibited.' Therefore, initiating active shoulder elevation at 3 weeks would be a violation of the protocol.

Question 382

Topic: 9. Shoulder and Elbow

A 32-year-old male presents to the emergency department after a high-energy fall onto an outstretched hand, complaining of severe right shoulder pain and inability to move his arm. Radiographs confirm a displaced greater tuberosity fracture. Which of the following associated injuries is most commonly observed with greater tuberosity fractures?

. Brachial plexus injury
. Humeral shaft fracture
. Anterior glenohumeral dislocation
. Rotator cuff tear (isolated, not part of avulsion)
. Posterior glenohumeral dislocation

Correct Answer & Explanation

. Anterior glenohumeral dislocation

Explanation

Correct Answer: CThe case explicitly states that greater tuberosity fractures are frequently associated with other shoulder injuries, most notably anterior glenohumeral dislocations, occurring in 20-30% of cases. This makes anterior glenohumeral dislocation the most commonly observed associated injury among the options provided. While rotator cuff tears can be concomitant or cause the avulsion, and brachial plexus injuries can occur, they are not as frequently noted as anterior dislocations in the context of GT fractures. Humeral shaft fractures and posterior glenohumeral dislocations are less common associations.

Question 383

Topic: 9. Shoulder and Elbow

A 48-year-old construction worker undergoes open reduction and internal fixation for a 7mm superiorly displaced greater tuberosity fracture. If this fracture had been missed and allowed to heal in its displaced position, what would be the most likely long-term functional consequence?

. Increased risk of avascular necrosis of the humeral head
. Chronic anterior glenohumeral instability
. Mechanical impingement and reduced abduction range of motion
. Isolated external rotation weakness without pain
. Accelerated development of glenohumeral osteoarthritis due to articular incongruity

Correct Answer & Explanation

. Mechanical impingement and reduced abduction range of motion

Explanation

Correct Answer: CThe case explains that a superiorly displaced greater tuberosity fragment can lead to mechanical impingement against the acromion during abduction, causing pain and limiting range of motion. This is a direct biomechanical consequence of the superior migration. While avascular necrosis (AVN) is a concern with humeral head fractures, it is rare for isolated greater tuberosity fractures. Chronic anterior glenohumeral instability is more associated with anterior displacement or recurrent dislocations. Isolated external rotation weakness would be more likely with significant posterior displacement. Accelerated glenohumeral osteoarthritis can be a long-term sequela of chronic impingement and altered kinematics, but mechanical impingement and reduced abduction are the more immediate and direct functional consequences of a superiorly malunited fragment.

Question 384

Topic: 9. Shoulder and Elbow

A 55-year-old active tennis player presents with a greater tuberosity fracture after a fall. CT imaging reveals a single, non-comminuted fragment with 4mm of superior displacement and 2mm of posterior displacement. The patient has no associated glenohumeral dislocation. Based on current guidelines and the patient's activity level, what is the most appropriate management?

. Non-operative management with sling immobilization and early pendulum exercises.
. Immediate arthroscopic debridement and capsular release.
. Open reduction and internal fixation (ORIF) with suture anchors or screws.
. Hemiarthroplasty due to high risk of non-union.
. Delayed ORIF after 6 weeks of observation for spontaneous reduction.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) with suture anchors or screws.

Explanation

Correct Answer: CThe case states that operative management is indicated for displaced fractures, specifically mentioning superior displacement greater than 3-5 mm. With 4mm of superior displacement, this fracture falls within the surgical indication range. Furthermore, the patient is described as an 'active tennis player' with 'high functional demands,' for whom optimal restoration of shoulder mechanics is paramount. Non-operative management is typically reserved for minimally displaced fractures (<3-5mm). Arthroscopic debridement and capsular release are treatments for adhesive capsulitis, not acute fractures. Hemiarthroplasty is an extreme measure for severe, complex fractures or arthrosis, not an isolated GT fracture. Delayed ORIF is generally not recommended as early anatomical reduction is crucial for optimal outcomes.

Question 385

Topic: 9. Shoulder and Elbow

A 60-year-old female undergoes ORIF for a displaced greater tuberosity fracture. Six weeks post-operatively, despite adhering to a protected rehabilitation protocol, she develops progressive, diffuse shoulder pain and a global loss of both active and passive range of motion. Radiographs show satisfactory fracture healing and no hardware issues. What is the most likely diagnosis and the primary management strategy?

. Non-union; revision ORIF with bone grafting.
. Rotator cuff re-tear; revision rotator cuff repair.
. Adhesive capsulitis; aggressive physical therapy.
. Axillary nerve injury; observation and EMG studies.
. Avascular necrosis; hemiarthroplasty.

Correct Answer & Explanation

. Adhesive capsulitis; aggressive physical therapy.

Explanation

Correct Answer: CThe patient's symptoms of progressive, diffuse shoulder pain and a global loss of both active and passive range of motion, despite adherence to rehabilitation and with satisfactory fracture healing, are classic for adhesive capsulitis (frozen shoulder). The case identifies this as a common complication after shoulder trauma and surgery, with aggressive physical therapy being the cornerstone of its management. Non-union would typically present with persistent pain and possibly instability, but not necessarily global loss of passive range of motion if the fracture is healing. A rotator cuff re-tear would cause weakness and pain, but not necessarily global loss of passive motion. Axillary nerve injury would primarily cause deltoid weakness and sensory deficits. Avascular necrosis is rare for isolated GT fractures and presents with progressive pain and stiffness, but the global loss of passive motion points more strongly to adhesive capsulitis.

Question 386

Topic: 9. Shoulder and Elbow

A 35-year-old patient is 3 weeks post-operative following open reduction and internal fixation of a greater tuberosity fracture. The surgeon emphasizes strict adherence to the protection phase of rehabilitation. Which of the following activities is strictly restricted during this initial phase (0-6 weeks)?

. Pendulum exercises (Codman's)
. Passive range of motion (PROM) for the elbow, wrist, and hand
. Gentle isometric scapular retractions
. Active shoulder range of motion (AROM)
. Gravity-assisted passive external rotation to neutral

Correct Answer & Explanation

. Active shoulder range of motion (AROM)

Explanation

Correct Answer: DThe case outlines the 'Protection Phase (0-6 Weeks Post-Op)' of rehabilitation, explicitly stating the restriction: 'NO active shoulder range of motion (AROM).' The goal during this phase is to protect the healing fracture. Pendulum exercises, passive range of motion for adjacent joints (elbow, wrist, hand), gentle isometric scapular retractions, and limited gravity-assisted PROM are generally permitted to prevent stiffness and maintain mobility without stressing the repair. Active shoulder motion would place undue stress on the healing fracture and rotator cuff repair.

Question 387

Topic: 9. Shoulder and Elbow

A patient undergoes ORIF for a Holstein–Lewis fracture with an intact radial nerve. Post-operatively, the surgeon emphasizes early, protected range of motion.

In the immediate post-operative phase (0-2 weeks), which of the following rehabilitation strategies is most appropriate for this patient?

. A. Full active resistance exercises for the elbow to prevent stiffness.
. B. Complete immobilization in a cast for 6 weeks to ensure fracture union.
. C. Gentle active-assisted and passive range of motion (AAROM/PROM) for the elbow (e.g., 30-90 degrees), along with hand/wrist/shoulder exercises.
. D. Unrestricted weight-bearing on the operative extremity to promote bone healing.
. E. Immediate initiation of advanced strengthening exercises for biceps and triceps.

Correct Answer & Explanation

. C. Gentle active-assisted and passive range of motion (AAROM/PROM) for the elbow (e.g., 30-90 degrees), along with hand/wrist/shoulder exercises.

Explanation

Correct Answer: CThe 'Post-Operative Rehabilitation Protocols' section for Phase 1 (0-2 Weeks) outlines the following: 'Gentle active-assisted ROM (AAROM) and passive ROM (PROM) of the elbow, typically 30-90 degrees of flexion/extension, initiated as soon as pain allows and dictated by surgical stability.' It also specifies 'Active and passive range of motion (ROM) exercises for the wrist, hand, and fingers' and 'Pendulum exercises, active-assisted shoulder flexion, extension, abduction, and rotation (within pain limits) to prevent shoulder stiffness.' It explicitly states 'No active biceps/triceps contractions against resistance' and 'Non-weight-bearing (NWB) for the operative extremity.'Option A and E are incorrect as active resistance and advanced strengthening are contraindicated in the immediate post-operative phase to protect the fixation. Option B (complete immobilization for 6 weeks) is incorrect as early, protected motion is crucial to prevent elbow stiffness. Option D (unrestricted weight-bearing) is incorrect as the limb must be non-weight-bearing in this phase.

Question 388

Topic: Shoulder Pathology

During an open distal clavicle excision (Mumford procedure) for AC joint osteoarthritis, the surgeon meticulously resects the distal clavicle. Resecting more than 10-12 mm of the distal clavicle increases the risk of which iatrogenic complication?

. Rotator cuff tear
. Adhesive capsulitis
. Anterior-posterior instability of the clavicle
. Coracoid impingement
. Suprascapular nerve palsy

Correct Answer & Explanation

. Anterior-posterior instability of the clavicle

Explanation

Resection of greater than 1 cm of the distal clavicle can compromise the superior and posterior AC capsular ligaments, leading to anterior-posterior (horizontal) instability. Care must be taken to preserve these capsular structures during excision.

Question 389

Topic: 9. Shoulder and Elbow

A 50-year-old female presents with a non-displaced greater tuberosity fracture after a ground-level fall. She is treated non-operatively and immobilized in a sling for 4 weeks. At her 3-month follow-up, radiographs confirm complete fracture union, but she complains of significant, globally restricted active and passive shoulder range of motion. What is the most likely diagnosis?

. Rotator cuff tear
. Axillary nerve palsy
. Adhesive capsulitis
. Osteonecrosis of the humeral head
. Subacromial impingement

Correct Answer & Explanation

. Adhesive capsulitis

Explanation

Adhesive capsulitis (shoulder stiffness) is the most common complication following non-operative management of isolated, non-displaced greater tuberosity fractures. Early implementation of passive and active-assisted range of motion is crucial to prevent this.

Question 390

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old male with severe osteoporosis and a history of a massive, irreparable rotator cuff tear presents with a highly comminuted four-part proximal humerus fracture after a fall. He is physiologically fit for surgery and desires to regain as much function as possible. Based on the current literature and guidelines, which surgical option is MOST likely to provide predictable pain relief and functional improvement in this specific patient?

. Open reduction and internal fixation (ORIF) with a locking plate and suture augmentation.
. Hemiarthroplasty with tuberosity repair.
. Non-operative management with sling immobilization.
. Reverse total shoulder arthroplasty (RTSA).
. Intramedullary nailing.

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (RTSA).

Explanation

Correct Answer: DThe patient presents with a 'highly comminuted four-part proximal humerus fracture,' 'severe osteoporosis,' and a 'massive, irreparable rotator cuff tear' in an 'elderly' patient. The text explicitly states: 'Reverse Total Shoulder Arthroplasty (RTSA) has gained significant traction, especially in elderly patients with complex PHFs, pre-existing rotator cuff dysfunction, or severe osteopenia. Multiple studies demonstrate more predictable pain relief and functional outcomes with RTSA compared to hemiarthroplasty or ORIF in this specific demographic, as it bypasses the need for tuberosity healing and relies on the deltoid for elevation.' This perfectly matches the patient's profile and desired outcome.ORIF with a locking plate (A) would be highly challenging and likely to fail given the severe comminution, severe osteoporosis, and irreparable rotator cuff tear. The ability to achieve stable fixation and tuberosity healing would be severely compromised.Hemiarthroplasty (B) has historically been an option for complex fractures in older patients, but the text notes 'outcomes can be variable, often limited by tuberosity healing and rotator cuff function.' Given the irreparable rotator cuff tear and severe osteoporosis, hemiarthroplasty would likely yield poor functional results.Non-operative management (C) for a highly comminuted four-part fracture in a patient desiring function would likely result in significant pain, malunion, and very poor function.Intramedullary nailing (E) is less common for complex PHFs and is generally not indicated for four-part fractures, especially with severe osteoporosis and rotator cuff compromise, due to difficulty controlling head rotation and potential for AVN.

Question 391

Topic: Shoulder Arthroplasty & Arthritis

A 75-year-old female with a history of severe osteoporosis sustains a displaced four-part proximal humerus fracture. The greater and lesser tuberosities are severely comminuted. To provide the most reliable restoration of active forward elevation, which surgical option is preferred?

. Nonoperative management in a sling
. Open reduction and internal fixation with a locked plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Percutaneous pinning

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for elderly patients with complex three- or four-part proximal humerus fractures and poor bone quality. RTSA provides more reliable pain relief and functional overhead elevation compared to hemiarthroplasty, which depends heavily on tuberosity healing.

Question 392

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old female with severe rotator cuff tear arthropathy is scheduled for a reverse total shoulder arthroplasty (RTSA) via the deltopectoral approach. The surgical team positions her in the beach chair position. Which of the following is a recognized disadvantage or potential complication specifically associated with the beach chair position for this procedure?

. A. Increased risk of brachial plexus injury due to gravity working against exposure.
. B. Higher incidence of deep vein thrombosis in the operative arm.
. C. Potential for cerebral hypoperfusion, requiring meticulous blood pressure monitoring.
. D. Difficulty in achieving adequate glenoid exposure due to the patient's upright posture.
. E. Increased risk of ulnar nerve palsy in the non-operative arm due to excessive abduction.

Correct Answer & Explanation

. C. Potential for cerebral hypoperfusion, requiring meticulous blood pressure monitoring.

Explanation

Correct Answer: CThe case study explicitly lists 'Risk of Cerebral Hypoperfusion' as a disadvantage of the beach chair position, emphasizing that 'Careful monitoring of blood pressure is essential.' This is due to the patient's elevated head position, which can reduce cerebral blood flow if systemic blood pressure is not adequately maintained. Option A is incorrect; gravity typically assists exposure in the beach chair position, and brachial plexus injury is more related to improper head/neck positioning or arm traction, not directly 'gravity working against exposure.' Option B is incorrect; the beach chair position is not specifically associated with an increased risk of DVT in the operative arm compared to other positions. Option D is incorrect; the case states, 'Gravity Assists Exposure: The arm hangs naturally, facilitating humeral head dislocation and glenoid exposure,' which is an advantage, not a disadvantage. Option E is a general risk of improper arm positioning, but not a unique disadvantage of the beach chair position itself, and the non-operative arm is typically tucked, not excessively abducted.

Question 393

Topic: 9. Shoulder and Elbow

A 68-year-old female presents with a highly comminuted 4-part proximal humerus fracture, deemed unsuitable for ORIF due to severe osteopenia. A reverse total shoulder arthroplasty (RTSA) is planned via the deltopectoral approach. Which of the following conditions would be a relative contraindication to proceeding with the deltopectoral approach in a different patient scenario?

. A. A history of well-controlled hypertension.
. B. Extensive scarring from previous surgeries in the deltopectoral interval.
. C. Mild glenohumeral osteoarthritis in the contralateral shoulder.
. D. A small, partial-thickness supraspinatus tear.
. E. A patient requiring an interscalene block for post-operative pain control.

Correct Answer & Explanation

. B. Extensive scarring from previous surgeries in the deltopectoral interval.

Explanation

Correct Answer: BThe case study lists 'Extensive Scarring/Prior Surgery' as a contraindication, stating, 'Significant scarring from previous surgeries in the deltopectoral interval can obliterate the plane, making dissection difficult and increasing the risk of iatrogenic injury.' This directly addresses the scenario in Option B. Option A (well-controlled hypertension) is a common comorbidity and not a contraindication. Option C (mild osteoarthritis in the contralateral shoulder) is irrelevant to the operative shoulder. Option D (small, partial-thickness supraspinatus tear) is a common finding and not a contraindication to the deltopectoral approach for other pathologies. Option E (requiring an interscalene block) is a beneficial pre-operative measure, not a contraindication.

Question 394

Topic: Shoulder Arthroplasty & Arthritis

A 65-year-old male presents with increased weakness in internal rotation and a positive bear-hug test 6 months after an anatomic total shoulder arthroplasty via a deltopectoral approach. What is the most likely cause of his symptoms?

. Axillary nerve injury
. Glenoid component loosening
. Subscapularis tendon failure
. Suprascapular nerve entrapment
. Coracoid impingement

Correct Answer & Explanation

. Subscapularis tendon failure

Explanation

Subscapularis failure is a known complication after anatomic TSA performed via a deltopectoral approach. It typically presents with increased external rotation, weakness in internal rotation, and positive lift-off or bear-hug tests.

Question 395

Topic: Shoulder Arthroplasty & Arthritis

The design of a Grammont-style reverse total shoulder arthroplasty alters shoulder biomechanics to compensate for rotator cuff deficiency by:

. Lateralizing and superiorly displacing the center of rotation
. Medializing and distalizing the center of rotation
. Medializing and superiorly displacing the center of rotation
. Lateralizing and distalizing the center of rotation
. Maintaining the anatomic center of rotation

Correct Answer & Explanation

. Medializing and distalizing the center of rotation

Explanation

A Grammont-style RTSA medializes and distalizes the center of rotation. This increases the deltoid lever arm and resting tension, allowing it to initiate and maintain abduction without a functioning rotator cuff.

Question 396

Topic: 9. Shoulder and Elbow

A 62-year-old male with primary glenohumeral osteoarthritis has a Walch B2 glenoid with 25 degrees of retroversion. If an anatomic total shoulder arthroplasty is planned, which of the following is the most appropriate management of the glenoid deformity?

. Standard concentric reaming
. Eccentric anterior reaming
. Posterior augmented glenoid component
. Placement of a reverse total shoulder arthroplasty
. Hemiarthroplasty alone

Correct Answer & Explanation

. Posterior augmented glenoid component

Explanation

For a B2 glenoid with excessive retroversion (>15-20 degrees), correcting version with eccentric anterior reaming removes excessive subchondral bone. A posterior augmented glenoid component preserves bone stock and restores version.

Question 397

Topic: 9. Shoulder and Elbow

Which of the following technical modifications during baseplate fixation in a reverse total shoulder arthroplasty most effectively decreases the incidence of scapular notching?

. Superior placement with superior tilt
. Central placement with neutral tilt
. Inferior placement with inferior tilt
. Superior placement with inferior tilt
. Lateralized glenosphere with superior tilt

Correct Answer & Explanation

. Inferior placement with inferior tilt

Explanation

Scapular notching is caused by mechanical impingement of the humeral component against the scapular neck. Placing the baseplate inferiorly (creating an overhang) and with an inferior tilt minimizes this impingement.

Question 398

Topic: 9. Shoulder and Elbow

A 65-year-old male develops insidious onset of shoulder stiffness and vague pain 1 year after an anatomic TSA. Inflammatory markers are mildly elevated. Aspiration yields no growth at 3 days. What is the most likely causative organism and the required culture duration for diagnosis?

. Staphylococcus aureus, 7 days
. Staphylococcus epidermidis, 14 days
. Cutibacterium acnes, 14 days
. Pseudomonas aeruginosa, 7 days
. Streptococcus pneumoniae, 14 days

Correct Answer & Explanation

. Cutibacterium acnes, 14 days

Explanation

Cutibacterium acnes is a common, slow-growing, indolent pathogen in shoulder arthroplasty infections. Cultures must be held for at least 14 days to ensure reliable detection of this anaerobic organism.

Question 399

Topic: Shoulder Arthroplasty & Arthritis

When utilizing a reverse total shoulder arthroplasty for an acute 4-part proximal humerus fracture in an elderly patient, healing of the greater tuberosity is associated with which of the following clinical outcomes?

. Improved forward elevation but worse internal rotation
. Improved external rotation and patient satisfaction
. Increased risk of scapular notching
. Higher rate of glenoid baseplate loosening
. No significant difference in functional outcomes

Correct Answer & Explanation

. Improved external rotation and patient satisfaction

Explanation

In RTSA for proximal humerus fractures, anatomic healing of the greater tuberosity to the shaft is highly correlated with improved postoperative external rotation and superior overall patient-reported outcomes.

Question 400

Topic: Shoulder Arthroplasty & Arthritis

During a reverse total shoulder arthroplasty, the surgeon must restore adequate tension to the deltoid. Which clinical assessment is best used intraoperatively to confirm appropriate deltoid tension?

. The conjoint tendon should be tight and rigid
. The conjoint tendon should exhibit an elastic bounce
. The acromiohumeral distance should be less than 5 mm
. The subscapularis must easily reach the lesser tuberosity without tension
. The arm should spontaneously rest in 30 degrees of abduction

Correct Answer & Explanation

. The conjoint tendon should exhibit an elastic bounce

Explanation

Intraoperative assessment of proper deltoid tension in RTSA involves checking the conjoint tendon, which should have a firm but elastic "bounce". Overtensioning leads to a rigid tendon and increases the risk of acromial stress fracture.

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