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9. Shoulder and Elbow MCQs

Practice Set 22 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 421

Topic: 9. Shoulder and Elbow

A 55-year-old patient is found to have an L-shaped rotator cuff tear during arthroscopy. The surgeon notes that one leg of the L is a mobile, less retracted crescent-shaped tear, while the other leg is a less mobile, more retracted U-shaped tear. To achieve a successful repair, what is the initial and most critical step for addressing the retracted portion of this L-shaped tear?

. Direct repair of the crescent-shaped portion to the greater tuberosity.
. Performing an anterior interval slide to mobilize the entire tear.
. Utilizing marginal convergence on the U-shaped portion of the tear.
. Employing a Krackow stitch for enhanced tendon-to-bone fixation.
. Considering a reverse total shoulder arthroplasty immediately.

Correct Answer & Explanation

. Utilizing marginal convergence on the U-shaped portion of the tear.

Explanation

Correct Answer: CThe discussion describes L-shaped tears as having both a mobile, less retracted crescent-shaped part and a less mobile, more retracted U-shaped part. It explicitly states: 'The retracted U-shaped part, like a normal U-shaped tear, must be repaired using marginal convergence. Then the remaining crescent-shaped part, like a normal crescent-shaped tear, can be mobilized laterally and repaired to bone.' Therefore, the initial and most critical step for addressing the retracted U-shaped portion is marginal convergence. The image (Figure 2-15) illustrates the application of marginal convergence to an L-shaped tear. Direct repair of the crescent-shaped portion (Option A) would be done after the U-shaped portion is addressed. Anterior interval slide (Option B) is for specific massive, immobile tears, not the primary technique for L-shaped tears. A Krackow stitch (Option D) is a type of suture, not a tear-conversion technique. Reverse total shoulder arthroplasty (Option E) is a salvage procedure for irreparable tears, not a repair technique for an L-shaped tear that can be converted.

Question 422

Topic: Shoulder Arthroplasty & Arthritis

A 62-year-old female undergoes reverse total shoulder arthroplasty (RSA) for rotator cuff arthropathy. In the original Grammont design, what is the primary biomechanical advantage conferred by the placement and design of the glenosphere?

. It lateralizes the center of rotation to increase the tension on the remaining rotator cuff
. It medializes and distalizes the center of rotation to recruit more deltoid fibers and increase their moment arm
. It places the center of rotation exactly at the anatomical native joint line
. It primarily relies on an intact coracoacromial arch for superior stability
. It increases sheer forces at the glenoid bone-implant interface to promote osseointegration

Correct Answer & Explanation

. It medializes and distalizes the center of rotation to recruit more deltoid fibers and increase their moment arm

Explanation

The Grammont reverse shoulder arthroplasty design medializes and distalizes the center of rotation. This increases the moment arm of the deltoid, recruits more anterior and posterior deltoid fibers for elevation, and converts shear forces into compressive forces at the glenoid.

Question 423

Topic: 9. Shoulder and Elbow

A complication unique to reverse total shoulder arthroplasty (RSA) is scapular notching. According to the Sirveaux classification, which of the following intraoperative techniques is most effective in preventing inferior scapular notching?

. Superior placement of the glenosphere baseplate
. Neutral or superior tilt of the glenosphere
. Inferior placement and inferior tilt of the glenosphere with overhang past the inferior glenoid rim
. Using a smaller diameter glenosphere to reduce impingement
. Decreasing the humeral neck-shaft angle to 135 degrees without altering glenosphere position

Correct Answer & Explanation

. Inferior placement and inferior tilt of the glenosphere with overhang past the inferior glenoid rim

Explanation

Scapular notching occurs when the medial aspect of the humeral tray impinges on the inferior scapular neck. It is best prevented by placing the baseplate low on the glenoid, using an inferior tilt, and ensuring the glenosphere overhangs the inferior rim.

Question 424

Topic: 9. Shoulder and Elbow

A 65-year-old male with primary glenohumeral osteoarthritis is indicated for an anatomic total shoulder arthroplasty. Preoperative CT scan reveals a Walch B2 glenoid morphology. What defines a Walch B2 glenoid?

. Concentric wear with central bone loss
. A biconcave glenoid with asymmetric posterior wear and posterior subluxation of the humeral head
. Severe medialization of the joint line beyond the base of the coracoid
. Dysplastic retroversion of the glenoid of more than 25 degrees without localized wear
. Anterior subluxation with severe anterior rim wear

Correct Answer & Explanation

. A biconcave glenoid with asymmetric posterior wear and posterior subluxation of the humeral head

Explanation

In the Walch classification for glenoid morphology in osteoarthritis, a B2 glenoid is characterized by a biconcave surface with asymmetric posterior bone loss and posterior subluxation of the humeral head. Failure to correct the retroversion can lead to early posterior instability and implant failure.

Question 425

Topic: 9. Shoulder and Elbow

Six months after a reverse total shoulder arthroplasty, a 70-year-old female presents with sudden onset lateral shoulder pain and decreased active elevation after lifting a moderately heavy box. Radiographs reveal a stress fracture at the base of the acromion (Levy Type II). What is the primary underlying biomechanical cause of this specific complication?

. Avascular necrosis of the acromion from circumflex humeral artery damage
. Over-lengthening of the humerus resulting in excessive deltoid tension
. Failure of the glenosphere baseplate fixation
. Undetected preoperative rotator cuff tear extending into the deltoid fascia
. Excessive superior tilt of the glenosphere causing direct bony impingement

Correct Answer & Explanation

. Over-lengthening of the humerus resulting in excessive deltoid tension

Explanation

Acromial stress fractures after RSA are primarily caused by increased deltoid tension, often due to over-lengthening and distalization of the humerus. This increased resting tension and moment arm place significant stress on the acromion, predisposing it to fatigue failure.

Question 426

Topic: 9. Shoulder and Elbow

A 72-year-old patient with severe glenohumeral osteoarthritis and a massive, retracted rotator cuff tear presents with active forward elevation of 40 degrees and a 'shrug' sign. They have no pain relief after conservative management. In determining the appropriate arthroplasty option, why is an anatomic total shoulder arthroplasty (TSA) contraindicated in this patient?

. The deltoid is likely too atrophied to support an anatomic TSA
. Anatomic TSA relies on the rotator cuff for dynamic stability, and its absence will result in superior migration and eccentric glenoid loosening
. The patient's age precludes the use of a polyethylene glenoid component
. Anatomic TSA will tension the remaining cuff, causing intractable postoperative pain
. The humeral head will subluxate anteriorly due to intact subscapularis overpull

Correct Answer & Explanation

. Anatomic TSA relies on the rotator cuff for dynamic stability, and its absence will result in superior migration and eccentric glenoid loosening

Explanation

Anatomic TSA requires a functioning rotator cuff to provide a compressive force couple. Without it, the humeral head migrates superiorly ('rocking horse' phenomenon), leading to rapid, eccentric loosening of the glenoid component.

Question 427

Topic: 9. Shoulder and Elbow

When evaluating a patient for a shoulder arthroplasty, assessing the status of the axillary nerve is critical. If a patient requires a reverse shoulder arthroplasty but is found to have profound, irreversible axillary nerve palsy with a completely atrophic deltoid, what is the most appropriate management?

. Proceed with reverse total shoulder arthroplasty using a larger glenosphere
. Perform an anatomic total shoulder arthroplasty with an oversized humeral head
. Perform a latissimus dorsi and teres major transfer along with a reverse total shoulder arthroplasty
. Perform a shoulder arthrodesis
. Perform a hemiarthroplasty with concentric reaming of the glenoid

Correct Answer & Explanation

. Perform a shoulder arthrodesis

Explanation

A functional deltoid is an absolute prerequisite for a reverse total shoulder arthroplasty. In the setting of an absent or completely non-functional deltoid (e.g., profound axillary nerve palsy), RSA is contraindicated, and shoulder arthrodesis is the salvage procedure of choice.

Question 428

Topic: Shoulder Arthroplasty & Arthritis

In a patient undergoing reverse total shoulder arthroplasty (rTSA) for cuff tear arthropathy, how does the prosthesis alter the biomechanics of the shoulder to restore active elevation?

. Lateralizes and superiorly translates the center of rotation
. Lateralizes and inferiorly translates the center of rotation
. Medializes and distalizes the center of rotation
. Medializes and superiorly translates the center of rotation
. Maintains the anatomic center of rotation while increasing the moment arm

Correct Answer & Explanation

. Medializes and distalizes the center of rotation

Explanation

Reverse total shoulder arthroplasty (rTSA) medializes and distalizes (inferiorly translates) the center of rotation. This effectively recruits more deltoid muscle fibers and increases the deltoid's moment arm, compensating for the absent rotator cuff.

Question 429

Topic: Shoulder Arthroplasty & Arthritis

A 65-year-old female is undergoing anatomic total shoulder arthroplasty (TSA) for primary osteoarthritis. Preoperative CT planning demonstrates a B2 glenoid. What defines a Walch B2 glenoid deformity?

. Concentric wear with central erosion
. Biconcave glenoid with asymmetric posterior wear and posterior subluxation
. Monoconcave glenoid with severe posterior wear and >15 degrees of retroversion
. Dysplastic glenoid with severe retroversion
. Superior wear secondary to massive rotator cuff tear

Correct Answer & Explanation

. Biconcave glenoid with asymmetric posterior wear and posterior subluxation

Explanation

In the Walch classification, a B2 glenoid is characterized by a biconcave surface with asymmetric posterior wear and posterior subluxation of the humeral head. A B3 glenoid is monoconcave with posterior wear, and B1 indicates posterior subluxation without significant bony deformity.

Question 430

Topic: Shoulder Arthroplasty & Arthritis

Scapular notching is a recognized complication of reverse total shoulder arthroplasty (rTSA). Which technical modification of the glenosphere most effectively reduces the incidence of this complication?

. Superior placement with superior tilt
. Superior placement with inferior tilt
. Inferior placement with superior tilt
. Inferior placement with inferior tilt
. Neutral placement with neutral tilt

Correct Answer & Explanation

. Inferior placement with inferior tilt

Explanation

Scapular notching occurs when the humeral component impinges on the inferior scapular neck. Inferior placement of the glenosphere (with or without an inferior tilt) overhangs the bone edge and helps prevent impingement and subsequent notching.

Question 431

Topic: 9. Shoulder and Elbow

A 60-year-old male presents with pseudo-paralysis of his right shoulder and a massive, irreparable posterosuperior rotator cuff tear. Glenohumeral cartilage is intact. He undergoes a superior capsular reconstruction (SCR). Which of the following is an absolute contraindication for an SCR?

. Intact subscapularis
. Mild acromioclavicular arthritis
. Hamada Grade 4 glenohumeral arthritis
. Previous biceps tenodesis
. Age greater than 55

Correct Answer & Explanation

. Hamada Grade 4 glenohumeral arthritis

Explanation

Superior capsular reconstruction is indicated for massive irreparable posterosuperior cuff tears without significant glenohumeral arthritis. Hamada Grade 4 implies severe glenohumeral arthritis (narrowing of the joint space), making rTSA the appropriate treatment, not SCR.

Question 432

Topic: 9. Shoulder and Elbow

A 35-year-old weightlifter presents with acute anterior shoulder pain after a heavy bench press. MRI confirms an isolated full-thickness rupture of the pectoralis major tendon at its insertion. In surgical repair, where should the tendon be anatomically reattached?

. Medial lip of the bicipital groove
. Lateral lip of the bicipital groove
. Coracoid process
. Lesser tuberosity
. Superior facet of the greater tuberosity

Correct Answer & Explanation

. Lateral lip of the bicipital groove

Explanation

The pectoralis major inserts onto the lateral lip of the bicipital groove. Surgical repair of an acute, complete rupture at the insertion involves securing the tendon back to this anatomic footprint, usually utilizing suture anchors or bone tunnels.

Question 433

Topic: 9. Shoulder and Elbow

A 45-year-old manual laborer presents with an irreparable, massive posterosuperior rotator cuff tear. He has intact subscapularis function, a functioning deltoid, and preserved glenohumeral articular cartilage without arthritis. Which of the following is the most appropriate surgical option?

. Reverse total shoulder arthroplasty
. Total shoulder arthroplasty
. Latissimus dorsi tendon transfer
. Pectoralis major tendon transfer
. Debridement and biceps tenotomy

Correct Answer & Explanation

. Latissimus dorsi tendon transfer

Explanation

A latissimus dorsi or lower trapezius tendon transfer is indicated for young, active patients with irreparable posterosuperior rotator cuff tears, intact subscapularis function, and no glenohumeral arthritis. Reverse shoulder arthroplasty is generally reserved for older patients or those with pseudoparalysis and arthritis.

Question 434

Topic: Shoulder Arthroplasty & Arthritis

In reverse total shoulder arthroplasty (RSA), moving the center of rotation medially and distally compared to the native joint achieves which of the following biomechanical advantages?

. Increases the moment arm of the rotator cuff
. Decreases the moment arm of the deltoid
. Increases the tension and moment arm of the deltoid
. Decreases shear forces on the glenoid baseplate
. Restores the anatomic joint line

Correct Answer & Explanation

. Increases the tension and moment arm of the deltoid

Explanation

The Grammont principles of RSA involve medializing and distalizing the center of rotation. This increases the tension and moment arm of the deltoid muscle, allowing it to compensate for the deficient rotator cuff.

Question 435

Topic: Shoulder Arthroplasty & Arthritis

A 70-year-old female is 2 years status-post reverse total shoulder arthroplasty for cuff tear arthropathy. Radiographs reveal erosive changes on the inferior scapular neck extending beyond the inferior screw of the baseplate, but not reaching the central peg. According to the Sirveaux classification, what grade of scapular notching is present?

. Grade 1
. Grade 2
. Grade 3
. Grade 4
. Grade 5

Correct Answer & Explanation

. Grade 4

Explanation

In the Sirveaux classification for scapular notching: Grade 1 is confined to the pillar, Grade 2 contacts the inferior screw, Grade 3 extends beyond the inferior screw, and Grade 4 extends to the central peg of the baseplate.

Question 436

Topic: 9. Shoulder and Elbow

A 62-year-old male presents with advanced osteoarthritis of the right shoulder. CT imaging reveals a biconcave glenoid with 20 degrees of retroversion and posterior subluxation of the humeral head. According to the Walch classification, what type of glenoid morphology is present?

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

Correct Answer & Explanation

. Type B2

Explanation

The Walch classification describes glenoid morphology in osteoarthritis. A Type B2 glenoid is defined by a biconcave surface with posterior subluxation of the humeral head and posterior wear, often presenting a significant challenge in shoulder arthroplasty.

Question 437

Topic: 9. Shoulder and Elbow

Three years after undergoing an anatomic total shoulder arthroplasty, a 65-year-old male develops progressive shoulder stiffness and pain. Inflammatory markers are normal. Aspiration yields fluid with a normal leukocyte count, but intraoperative tissue cultures eventually grow an organism at 11 days. What is the most likely responsible pathogen?

. Staphylococcus aureus
. Staphylococcus epidermidis
. Cutibacterium acnes
. Pseudomonas aeruginosa
. Streptococcus pyogenes

Correct Answer & Explanation

. Cutibacterium acnes

Explanation

Cutibacterium acnes (formerly Propionibacterium acnes) is a slow-growing, anaerobic, gram-positive rod frequently implicated in indolent periprosthetic shoulder infections. It requires extended culture times of up to 14 days for detection.

Question 438

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female undergoes a reverse total shoulder arthroplasty (rTSA) for severe rotator cuff tear arthropathy. Compared to the native anatomic shoulder, which of the following best describes the biomechanical alteration achieved by the classic Grammont-style reverse shoulder implant?

. Lateralizes the center of rotation and distalizes the humerus.
. Medializes the center of rotation and distalizes the humerus.
. Medializes the center of rotation and proximalizes the humerus.
. Lateralizes the center of rotation and proximalizes the humerus.
. Maintains the anatomic center of rotation while increasing deltoid tension.

Correct Answer & Explanation

. Medializes the center of rotation and distalizes the humerus.

Explanation

The Grammont design of an rTSA medializes the center of rotation, which increases the deltoid's moment arm and recruits more muscle fibers for elevation. It also distalizes the humerus, tensioning the deltoid and allowing it to effectively function without a rotator cuff.

Question 439

Topic: Shoulder Arthroplasty & Arthritis

A 75-year-old male is evaluated 3 years after a reverse total shoulder arthroplasty. He is asymptomatic, but a standard AP radiograph shows bone resorption at the inferior scapular neck that extends medially, progressing just past the inferior screw of the glenoid baseplate. According to the Sirveaux classification, what grade of scapular notching does this represent?

. Grade 1
. Grade 2
. Grade 3
. Grade 4
. Grade 5

Correct Answer & Explanation

. Grade 2

Explanation

Scapular notching is a well-known complication of rTSA graded by Sirveaux. Grade 1 involves the scapular pillar only; Grade 2 extends to the inferior screw; Grade 3 extends past the inferior screw; and Grade 4 extends to the central peg of the baseplate.

Question 440

Topic: 9. Shoulder and Elbow

A 52-year-old male presents to the clinic 3 days after feeling a "pop" in his right elbow while lifting a heavy box. He reports immediate pain, followed by bruising and weakness. On examination, a palpable defect is noted in the distal arm, and he demonstrates weakness with resisted elbow flexion and supination. The image below shows the clinical appearance of his arm.

. Ecchymosis in the cubital fossa
. Weakness with resisted elbow flexion
. Inability to "hook" the distal biceps tendon
. Palpable defect in the distal arm
. Increased prominence of the biceps muscle belly proximally

Correct Answer & Explanation

. Inability to "hook" the distal biceps tendon

Explanation

Correct Answer: CThe case explicitly states under 'Pre-Operative Planning & Patient Positioning' that the"Hook Test" is highly sensitive and specific: inability to hook a finger under the intact distal biceps tendon from the lateral side of the cubital fossa is indicative of a complete rupture.While ecchymosis, weakness with resisted elbow flexion, a palpable defect, and the 'Popeye' sign (increased prominence of the biceps muscle belly proximally, as seen in the image) are all important clinical findings suggestive of a distal biceps tendon rupture, the Hook Test provides the most definitive clinical confirmation due to its high sensitivity and specificity.

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