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 461
Topic: Elbow & Forearm
A surgeon plans to use a classic two-incision modified Boyd-Anderson approach for the repair of a chronic distal biceps tendon tear. Compared to the single-incision anterior approach, the two-incision technique carries a uniquely increased risk of which of the following complications?
Correct Answer & Explanation
. Radioulnar synostosis
Explanation
The classic two-incision approach exposes both the radius and ulna, significantly increasing the risk of heterotopic ossification and radioulnar synostosis. This risk is minimized by avoiding subperiosteal exposure of the ulna during the posterolateral approach.
Question 462
Topic: 9. Shoulder and Elbow
A 45-year-old laborer elects for nonoperative management of an acute, complete distal biceps tendon rupture. Compared to his uninjured contralateral arm, he is expected to have the greatest percentage of strength deficit in which of the following functional motions?
Correct Answer & Explanation
. Forearm supination
Explanation
Nonoperative management of a complete distal biceps tendon rupture results in an approximate 40-50% loss of sustained forearm supination strength. Loss of elbow flexion strength is comparatively less severe, typically measuring around 30%.
Question 463
Topic: 9. Shoulder and Elbow
A 68-year-old male presents with a 2-year history of progressive right shoulder pain, pseudoparalysis (active elevation to 45 degrees, passive 90 degrees), and significant night pain refractory to NSAIDs and corticosteroid injections. Radiographs demonstrate severe glenohumeral osteoarthritis with superior migration of the humeral head and an acromiohumeral interval of 4mm. What is the most appropriate surgical intervention?
Correct Answer & Explanation
. Reverse total shoulder arthroplasty
Explanation
Correct Answer: CThis patient presents with signs and symptoms consistent with rotator cuff tear arthropathy (RCAT), characterized by chronic shoulder pain, pseudoparalysis, superior migration of the humeral head, and glenohumeral arthritis. In such cases, the deltoid muscle becomes the primary elevator of the arm, and a reverse total shoulder arthroplasty (RTSA) is indicated to medialize and distalize the center of rotation, increasing the deltoid's lever arm and restoring function. Anatomic total shoulder arthroplasty is contraindicated in the presence of an irreparable rotator cuff tear with superior migration as it relies on an intact rotator cuff for stability and function. Arthroscopic repair is not feasible given the chronic nature, pseudoparalysis, and arthritic changes. Hemiarthroplasty alone would not address the deltoid's mechanical disadvantage.
Question 464
Topic: 9. Shoulder and Elbow
In a patient diagnosed with Hypothenar Hammer Syndrome, which of the following angiographic findings is most characteristic of this condition?
Correct Answer & Explanation
. "Corkscrew" appearance, occlusion, or aneurysm of the ulnar artery adjacent to the hamate
Explanation
Angiography in Hypothenar Hammer Syndrome typically demonstrates tortuosity (a "corkscrew" appearance), occlusion, or aneurysm of the ulnar artery at the level of the hook of the hamate. Emboli may also be seen in the digital arteries of the ulnar digits.
Question 465
Topic: Shoulder Pathology
A 45-year-old male smoker presents with ischemic changes in his index and middle fingers. Angiography reveals multiple segmental occlusions in the distal digital arteries of both hands with "corkscrew" collaterals, while the ulnar artery at the wrist is normal. What is the most likely diagnosis?
Correct Answer & Explanation
. Hypothenar hammer syndrome
Explanation
Thromboangiitis obliterans (Buerger's disease) typically presents in young male smokers with bilateral, distal segmental occlusions of medium and small vessels. In contrast, Hypothenar hammer syndrome presents with isolated ulnar artery pathology at the hamate due to repetitive trauma.
Question 466
Topic: 9. Shoulder and Elbow
A 10-year-old boy sustains a traumatic elbow dislocation. Following closed reduction, radiographs reveal an associated medial epicondyle fracture. Which of the following is an absolute indication for operative fixation of the medial epicondyle?
Correct Answer & Explanation
. Incarceration of the epicondyle fragment within the joint
Explanation
Incarceration of the medial epicondyle fragment within the ulnohumeral joint after closed reduction of an elbow dislocation is an absolute indication for open reduction and internal fixation.
Question 467
Topic: 9. Shoulder and Elbow
A male newborn, delivered at 40 weeks gestation with shoulder dystocia, presents with his right arm held in an adducted, internally rotated, and pronated position, with absent spontaneous elbow flexion and shoulder abduction. The Moro reflex is absent on the right. This clinical presentation is most consistent with an injury to which of the following brachial plexus components?
Correct Answer & Explanation
. Upper trunk (C5-C6)
Explanation
Correct Answer: CThe clinical presentation described—adducted, internally rotated, and pronated arm (the 'waiter's tip' posture), absent spontaneous elbow flexion, and absent shoulder abduction—is the classic presentation of Erb-Duchenne palsy. This type of brachial plexus birth palsy primarily involves the upper trunk, which is formed by the C5 and C6 nerve roots. These roots are responsible for innervating muscles involved in shoulder abduction (deltoid, supraspinatus), external rotation (infraspinatus, teres minor), and elbow flexion (biceps, brachialis). The absence of the Moro reflex on the affected side further supports a significant motor deficit in these muscle groups. Lower trunk (C8-T1) injuries would typically present with hand weakness and potentially Horner's syndrome. Posterior, medial, and lateral cord injuries are more specific to the divisions of the brachial plexus and would present with more nuanced patterns of weakness, but the overall 'waiter's tip' posture is pathognomonic for upper trunk involvement.
Question 468
Topic: 9. Shoulder and Elbow
Based on the "Pearls & Pitfalls" section of the case, which of the following is considered the most critical prognostic indicator for spontaneous recovery in a newborn with brachial plexus birth palsy, strongly influencing the decision for surgical intervention?
Correct Answer & Explanation
. Absence of antigravity biceps function by 3 months of age.
Explanation
The "Pearls" section of the case explicitly highlights: "Biceps at 3 Months" Rule: The most important prognostic indicator for spontaneous recovery. Absence of antigravity biceps function by 3 months is a strong indication for surgical consideration. Don't wait beyond 6 months for surgical intervention in severe cases. The ability to actively flex the elbow against gravity (biceps function) is a crucial milestone. If this function does not return by 3 months, it indicates a severe injury (likely axonotmesis or neurotmesis) with a low probability of meaningful spontaneous recovery, thus prompting surgical evaluation and intervention within the critical window (3-9 months).
Question 469
Topic: 9. Shoulder and Elbow
During the surgical reconstruction for the patient's Erb-Duchenne palsy, an image similar to the one below might be seen during nerve coaptation. The surgical team performed an Oberlin transfer. What was the primary purpose of this specific nerve transfer?
Correct Answer & Explanation
. To ensure reliable reinnervation of elbow flexion.
Explanation
Correct Answer: CThe case details the surgical reconstruction: "To ensure reliable reinnervation of elbow flexion (biceps), a direct nerve transfer was performed. The medial pectoral nerve... was then coapted to the distal stump of the musculocutaneous nerve (or a specific fascicle leading to biceps)... This 'Oberlin transfer' provides a strong, reliable source of axons to the biceps, prioritizing restoration of active elbow flexion, which is critical for hand-to-mouth function."The Oberlin transfer typically involves transferring a fascicle of the ulnar nerve (or medial pectoral nerve, as described in this case, which is a common variant) to the motor branch of the musculocutaneous nerve that innervates the biceps.Its primary goal is to restore active elbow flexion, a critical function for activities of daily living, particularly hand-to-mouth movements.Other transfers, such as the spinal accessory to suprascapular nerve transfer, are used for shoulder abduction and external rotation.
Question 470
Topic: 9. Shoulder and Elbow
Immediately following the nerve reconstruction surgery for brachial plexus birth palsy, the patient's right arm was placed in an airplane splint. What is the primary purpose of positioning the shoulder abducted to 90 degrees, externally rotated to 30 degrees, and the elbow flexed to 90 degrees?
Correct Answer & Explanation
. To minimize tension on the nerve repair sites.
Explanation
Correct Answer: BThe "Post-Operative Protocol & Rehabilitation" section states: "The patient's right arm was placed in anairplane splintor a long arm cast with the shoulder abducted to 90 degrees, externally rotated to 30 degrees, and the elbow flexed to 90 degrees. This position minimizes tension on the nerve repair sites, particularly the grafted segments and the Oberlin transfer."Nerve repairs, especially grafts and transfers, are delicate and susceptible to tension. Maintaining the limb in a position that approximates the origin and insertion points of the repaired nerves reduces stress on the coaptation sites, promoting healing and preventing disruption.Early active range of motion is contraindicated immediately post-op. While preventing contractures is a long-term goal, the immediate priority is nerve protection. Glenohumeral dysplasia is a long-term complication, not directly prevented by immediate post-op splinting position. Wound care is important but not the primary reason for this specific positioning.
Question 471
Topic: 9. Shoulder and Elbow
A child who underwent nerve reconstruction for Erb-Duchenne palsy, similar to the case patient, presents at 3 years of age with persistent shoulder internal rotation contracture despite extensive physical therapy. Based on the case's "Post-Operative Protocol & Rehabilitation" section, which of the following secondary procedures would most likely be considered to address this specific deformity?
Correct Answer & Explanation
. Humeral derotational osteotomy.
Explanation
The "Post-Operative Protocol & Rehabilitation" section, under "Management of Secondary Procedures," specifically addresses persistent shoulder internal rotation contractures: "Shoulder internal rotation contractures often develop due to persistent muscle imbalance (stronger internal rotators). If conservative measures fail, secondary procedures like Latissimus Dorsi and Teres Major tendon transfers (for external rotation) or subscapularis release may be considered, typically after 2-3 years of age, or once nerve regeneration plateaus. Humeral derotational osteotomy may be necessary in older children with persistent internal rotation deformity and functional deficits." A humeral derotational osteotomy directly corrects the bony rotational deformity of the humerus, which contributes significantly to a fixed internal rotation contracture.
Question 472
Topic: 9. Shoulder and Elbow
A 25-year-old motorcyclist sustains a traumatic brachial plexus injury.
Physical exam reveals intact rhomboid and serratus anterior function, but complete loss of shoulder abduction, elbow flexion, and wrist extension. Horner syndrome is absent. Which roots are most likely involved in this injury?
Correct Answer & Explanation
. C5, C6, C7
Explanation
Intact rhomboids (dorsal scapular nerve, C5) and serratus anterior (long thoracic nerve, C5-C7) suggest the injury is distal to the roots. Loss of shoulder abduction, elbow flexion, and wrist extension indicates involvement of the upper and middle trunks (C5, C6, C7).
Question 473
Topic: Elbow & Forearm
A 35-year-old male presents with a persistent left radial nerve palsy 18 months after a humeral shaft fracture. To optimally restore wrist extension without causing excessive radial deviation, which of the following tendon transfers is most commonly performed?
Correct Answer & Explanation
. Pronator teres (PT) to Extensor carpi radialis brevis (ECRB)
Explanation
In irreversible radial nerve palsy, the standard primary transfer to restore functional wrist extension is the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB). Utilizing the ECRB centralizes wrist extension, avoiding the excessive radial deviation seen if the ECRL were used.
Question 474
Topic: 9. Shoulder and Elbow
A 30-year-old male presents with a persistent C5-C6 upper trunk brachial plexus injury 6 months after a fall. Examination reveals 0/5 strength in elbow flexion and shoulder abduction, but hand function is fully preserved (5/5). Which of the following nerve transfers is most appropriate to restore elbow flexion in this patient?
Correct Answer & Explanation
. Ulnar nerve fascicle to biceps motor branch
Explanation
The Oberlin transfer utilizes a redundant fascicle from the ulnar nerve transferred directly to the motor branch of the biceps to restore elbow flexion. It is highly effective in upper trunk injuries where distal hand function is completely preserved.
Question 475
Topic: 9. Shoulder and Elbow
A 35-year-old female presents with sudden, excruciating pain in her right shoulder that awakened her from sleep. The severe pain lasts for one week and is followed by profound weakness in shoulder abduction and external rotation, though the pain has now largely resolved. What is the most likely diagnosis?
Correct Answer & Explanation
. Parsonage-Turner syndrome
Explanation
Parsonage-Turner syndrome (idiopathic brachial neuritis) classically presents with severe, acute-onset shoulder pain lasting days to weeks. This is typically followed by patchy motor weakness (often upper trunk distribution) and muscle atrophy as the pain subsides.
Question 476
Topic: Shoulder Pathology
A 29-year-old female presents with vague right arm paresthesias, subjective weakness, and coldness in her hand, particularly when reaching overhead. Adson's test is positive, and cervical spine radiographs reveal an accessory cervical rib. Compression of which specific neurovascular structures is most likely responsible for her clinical presentation?
Correct Answer & Explanation
. Lower trunk and subclavian artery
Explanation
Neurogenic thoracic outlet syndrome most commonly involves compression of the lower trunk (C8, T1) of the brachial plexus, producing ulnar-sided symptoms. Arterial thoracic outlet syndrome involves compression of the subclavian artery, often caused by a cervical rib or anomalous first rib.
Question 477
Topic: 9. Shoulder and Elbow
When harvesting the reverse radial forearm flap, what is the correct handling of the proximal radial artery to ensure mobility and survival of the flap?
Correct Answer & Explanation
. It is ligated and divided just distal to the radial recurrent artery takeoff to allow distal pivoting
Explanation
For a reverse-flow flap, the proximal radial artery and its venae comitantes must be ligated and divided (typically just distal to the radial recurrent artery). This allows the flap to pivot distally, relying entirely on retrograde blood flow from the palmar arches.
Question 478
Topic: 9. Shoulder and Elbow
A 48-year-old tennis player presents with chronic lateral elbow pain, exacerbated by gripping and wrist extension. On examination, maximal tenderness is consistently localized to an area just distal and anterior to the lateral epicondyle. Which specific structure is most likely the primary source of pathology?
Correct Answer & Explanation
. Origin of the Extensor Carpi Radialis Brevis (ECRB) tendon
Explanation
Correct Answer: CThe most common site of pathology in lateral epicondylitis (tennis elbow) is the origin of the Extensor Carpi Radialis Brevis (ECRB) tendon, specifically its deep fibers, just distal and anterior to the lateral epicondyle. While the common extensor origin is affected, the ECRB is the primary culprit. The anconeus muscle is more posterior and not typically the primary pain generator. The lateral collateral ligament complex is associated with elbow instability. The radial nerve proper is rarely the direct source of pain but can be entrapped in radial tunnel syndrome, which is a differential diagnosis, but the precise localization points strongly to the ECRB.
Question 479
Topic: 9. Shoulder and Elbow
During your physical examination for suspected lateral epicondylitis, you perform Cozen's test. Which maneuver constitutes a positive Cozen's test?
Correct Answer & Explanation
. Pain with resisted wrist extension while the elbow is extended, the forearm is pronated, and the wrist is radially deviated.
Explanation
Correct Answer: CCozen's test involves the examiner palpating the lateral epicondyle while the patient makes a fist, pronates the forearm, radially deviates the wrist, and then extends the wrist against resistance. A positive test is reproduction of pain at the lateral epicondyle. Option C accurately describes this maneuver. Option B describes a component but misses the critical elbow extension and forearm pronation. Option D describes Mill's test, which is passive. Option E describes Maudsley's test.
Question 480
Topic: Elbow & Forearm
A 55-year-old accountant presents with lateral elbow pain that started insidiously. He denies any acute trauma but notes pain with typing and lifting objects, especially with his palm down. Which of the following findings on examination would be MOST specific for lateral epicondylitis rather than a radial tunnel syndrome?
Correct Answer & Explanation
. Pain elicited by passive wrist flexion with the elbow extended.
Explanation
Correct Answer: CPain elicited by passive wrist flexion with the elbow extended (Mill's test) is a classic maneuver that stretches the common extensor origin, particularly the ECRB, and is highly suggestive of lateral epicondylitis. While Maudsley's test (resisted long finger extension) is also positive in lateral epicondylitis, it can sometimes be positive in radial tunnel syndrome due to irritation of the nerve passing beneath the ECRB. Tenderness over the supinator muscle and pain with resisted forearm supination are more indicative of radial tunnel syndrome. Normal sensation in the superficial radial nerve distribution is common in both, as PIN entrapment is a motor neuropathy. Therefore, Mill's test specifically targets the common extensor origin's stretch sensitivity.
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