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9. Shoulder and Elbow MCQs

Practice Set 30 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 581

Topic: Elbow & Forearm
A surgeon is addressing a terrible triad injury in a 60-year-old patient. The radial head is found to be severely comminuted (Mason Type IV) and unreconstructible, making ORIF unfeasible. Referring to the intra-operative field shown and the principles outlined in the case, which of the following is the preferred management strategy for this radial head fracture in the context of a terrible triad injury?
. Radial head excision to decompress the joint and prevent impingement.
. Open reduction and internal fixation with multiple mini-screws.
. Radial head arthroplasty to restore radial length and provide a buttress against valgus stress.
. Non-operative management with early range of motion, as the coronoid and LUCL repairs will provide sufficient stability.
. External fixation across the elbow joint to stabilize the radial head.

Correct Answer & Explanation

. Radial head arthroplasty to restore radial length and provide a buttress against valgus stress.

Explanation

Radial head arthroplasty is the preferred option for severely comminuted or unreconstructible Mason Type III or IV fractures. Implants can be metal or pyrocarbon. The goal is to restore the correct radial length and provide a buttress against valgus stress. Radial head excision is generally contraindicated in TTI due to profound loss of valgus and axial stability.

Question 582

Topic: Elbow & Forearm

Following successful repair of the coronoid and radial head in a terrible triad injury, the surgeon proceeds to address the lateral ulnar collateral ligament (LUCL). The LUCL is found to be avulsed from its humeral origin at the lateral epicondyle, with good tissue quality.

Based on the typical surgical sequence and the principles outlined in the case, which of the following best describes the next step for LUCL repair and its appropriate tensioning?

. Direct repair using suture anchors into the lateral epicondyle, with the forearm in supination and elbow in full extension.
. Direct repair using suture anchors into the lateral epicondyle, with the forearm in pronation and elbow flexed to 60-90 degrees.
. Reconstruction using a palmaris longus autograft, tensioned in full extension.
. Excision of the avulsed ligament and reliance on capsular repair for stability.
. Non-operative management, as the coronoid and radial head repairs provide sufficient stability.

Correct Answer & Explanation

. Direct repair using suture anchors into the lateral epicondyle, with the forearm in pronation and elbow flexed to 60-90 degrees.

Explanation

Correct Answer: BThe case, under 'Lateral Ulnar Collateral Ligament (LUCL) Repair/Reconstruction', states: 'If the tissue quality is good and the ligament can be reapproximated to its anatomic origin on the lateral epicondyle, suture anchors (typically 2-3) are placed into the epicondyle. Non-absorbable sutures are passed through the avulsed ligamentous tissue and tied down with the forearm inpronation and the elbow flexed to 60-90 degrees to tension the LUCL appropriately.' The image shows a post-operative radiograph consistent with internal fixation and likely ligamentous repair, supporting the surgical approach.Option A is incorrect because the forearm should be in pronation and the elbow flexed to tension the LUCL correctly, not supination and full extension. Option C (reconstruction) is for severely damaged or chronic LUCL tissue, not good quality tissue. Option D (excision) and Option E (non-operative management) are incorrect as LUCL repair is crucial for posterolateral rotatory stability and is a core component of TTI management.

Question 583

Topic: Elbow & Forearm

A patient has undergone successful surgical repair of a terrible triad injury, including coronoid fixation, radial head arthroplasty, and LUCL repair. Post-operatively, the elbow is initially immobilized in a posterior splint. In the immediate post-operative protective phase (Weeks 0-6), which of the following rehabilitation principles is most critical for optimizing outcomes while protecting the surgical repairs?

. Aggressive passive range of motion into full extension to prevent contracture.
. Immediate full weight-bearing and strengthening exercises.
. Early, controlled active-assisted range of motion within a stable arc, often favoring pronation.
. Complete immobilization for 6 weeks to ensure ligamentous healing.
. Manipulation under anesthesia (MUA) at 2 weeks post-op to break adhesions.

Correct Answer & Explanation

. Early, controlled active-assisted range of motion within a stable arc, often favoring pronation.

Explanation

Correct Answer: CThe case, under 'Post-Operative Rehabilitation Protocols', emphasizes 'Early Motion: Initiate controlled range of motion as soon as possible to prevent adhesion formation and stiffness.' Specifically, for the Protective Phase (Weeks 0-6): 'Active-assisted and gentle passive ROM: Initiated within the first few days to a week. The brace's range of motion is progressively increased... Forearm Rotation: Gentle pronation/supination within comfort and stability limits, often favoring pronation initially to protect the LUCL.'Option A (aggressive passive ROM into full extension) is incorrect as it risks stressing the LUCL repair and causing instability. Option B (immediate full weight-bearing and strengthening) is too aggressive and would jeopardize the repairs. Option D (complete immobilization for 6 weeks) is incorrect as it would lead to severe stiffness, which is a common complication. Option E (MUA at 2 weeks) is a treatment for acute stiffness, not a routine part of immediate post-operative rehabilitation.

Question 584

Topic: Elbow & Forearm

A surgeon is reviewing the literature on terrible triad injuries. The case mentions that the need for Medial Collateral Ligament (MCL) repair in TTI is debated, as it is typically spared in the primary injury. According to the provided case material, under what specific circumstance would an acute repair of the MCL typically be indicated in a terrible triad injury?

. If the MCL is found to be avulsed from its humeral origin during the initial lateral approach.
. If gross valgus instability persists after stabilization of the LUCL, coronoid, and radial head.
. Prophylactically in all terrible triad injuries to enhance overall stability.
. Only if the patient develops chronic valgus instability after initial surgery.
. If the coronoid fracture involves the sublime tubercle, regardless of other stability.

Correct Answer & Explanation

. If gross valgus instability persists after stabilization of the LUCL, coronoid, and radial head.

Explanation

Correct Answer: BThe case, under 'Medial Collateral Ligament (MCL) Assessment', states: 'Though less commonly injured primarily in TTI, the MCL should be dynamically stressed after the lateral structures are stabilized.If gross valgus instability persists after LUCL, coronoid, and radial head stabilization, an acute repair of the MCL (typically the anterior bundle) is indicated.' This highlights the specific intra-operative finding that would necessitate MCL repair.Option A is incorrect because the MCL is on the medial side and would not be visualized during a standard lateral approach. Option C (prophylactic repair) is not supported by the case, which states its role is debated. Option D (chronic instability) would be a delayed presentation, whereas the question asks about acute repair. Option E (coronoid fracture involving the sublime tubercle) is important because the sublime tubercle is the attachment site for the MCL, and its fracture can compromise MCL stability. However, the case specifies that MCL repair is indicated ifgross valgus instability persistsafter addressing all other components, implying a dynamic assessment of overall stability, not just the presence of a specific fracture pattern.

Question 585

Topic: Elbow & Forearm

Surgical management of the 'terrible triad' of the elbow traditionally follows a specific sequence to sequentially restore stability. After addressing the coronoid and radial head fractures, what is the next most critical ligamentous structure to repair?

. Medial collateral ligament (MCL)
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Interosseous membrane
. Anterior band of the MCL

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The terrible triad of the elbow includes fractures of the radial head and coronoid with elbow dislocation. Surgical management prioritizes fixing the coronoid, then the radial head, followed by repair of the lateral ulnar collateral ligament (LUCL) to restore posterolateral rotatory stability.

Question 586

Topic: Elbow & Forearm

A 40-year-old female presents with a highly comminuted radial head fracture and significant distal radioulnar joint (DRUJ) pain following a fall. If this injury is incorrectly managed with isolated radial head excision, what is the most likely long-term complication?

. Elbow stiffness in extension
. Heterotopic ossification of the triceps insertion
. Proximal migration of the radius and ulnocarpal impaction
. Varus posteromedial rotatory instability
. Avascular necrosis of the capitellum

Correct Answer & Explanation

. Proximal migration of the radius and ulnocarpal impaction

Explanation

An Essex-Lopresti injury consists of a radial head fracture, DRUJ disruption, and an interosseous membrane tear. Radial head excision is strictly contraindicated as it leads to proximal radial migration and debilitating ulnocarpal impaction; a radial head arthroplasty is required.

Question 587

Topic: Elbow & Forearm

A 25-year-old male sustains an elbow dislocation. A post-reduction CT scan demonstrates an isolated fracture of the anteromedial facet of the coronoid process. What specific ligamentous injury is pathognomonic for this fracture pattern?

. Lateral collateral ligament (LCL) complex disruption
. Isolated medial collateral ligament (MCL) tear
. Annular ligament avulsion
. Distal biceps tendon rupture
. Ulnar collateral ligament anterior band tear

Correct Answer & Explanation

. Lateral collateral ligament (LCL) complex disruption

Explanation

Fractures of the anteromedial facet of the coronoid are pathognomonic for a varus posteromedial rotatory instability mechanism. This injury pattern typically involves a rupture of the lateral collateral ligament (LCL) complex, allowing the anteromedial facet to impact the trochlea.

Question 588

Topic: Elbow & Forearm

A patient presents with a capitellum fracture classified as a Dubberley type 3B. What defining characteristic of this specific fracture type often necessitates structural bone grafting or a posterior approach?

. Associated radial head fracture
. Anterior capsular tearing
. Posterior capitellar comminution
. Medial epicondyle avulsion
. Coronoid process fracture

Correct Answer & Explanation

. Posterior capitellar comminution

Explanation

The Dubberley classification for capitellum fractures incorporates the presence of posterior capitellar comminution (Type B). Because Type B fractures lack a stable posterior bony buttress, they often require structural bone grafting or more extensive posterior fixation strategies.

Question 589

Topic: Elbow & Forearm

An adult patient undergoes plate fixation for a Bado type II Monteggia fracture (posterior dislocation of the radial head with an apex-posterior ulnar diaphyseal fracture). Intraoperatively, after the ulnar plate is applied, the radial head remains dislocated. What is the most appropriate next step in management?

. Open reduction of the radial head and annular ligament repair
. Reconstruction of the annular ligament with a triceps slip
. Revision of the ulnar fixation to restore appropriate length and alignment
. Excision of the radial head
. Pinning of the radiocapitellar joint

Correct Answer & Explanation

. Revision of the ulnar fixation to restore appropriate length and alignment

Explanation

In Monteggia fracture-dislocations, failure to achieve or maintain radial head reduction is almost invariably due to malreduction (often malalignment or shortening) of the ulnar fracture. The ulnar fixation must be revised before addressing the radiocapitellar joint directly.

Question 590

Topic: Elbow & Forearm

A 38-year-old female presents with a 'terrible triad' injury of the elbow consisting of a dislocation, a comminuted radial head fracture, and a type II coronoid fracture. Following closed reduction, the joint remains unstable. What is the most appropriate biomechanical sequence of surgical reconstruction?

. LCL repair, radial head replacement, coronoid fixation
. Radial head replacement, coronoid fixation, LCL repair
. Coronoid fixation, radial head replacement, LCL repair
. MCL repair, coronoid fixation, radial head replacement
. Coronoid fixation, LCL repair, radial head replacement

Correct Answer & Explanation

. Coronoid fixation, radial head replacement, LCL repair

Explanation

Surgical management of terrible triad injuries classically proceeds from deep to superficial, starting with fixation of the coronoid. This is followed by radial head repair or replacement to restore the anterior buttress, and finally repair of the lateral collateral ligament (LCL) complex.

Question 591

Topic: 9. Shoulder and Elbow



A 40-year-old female presents with a Dubberley type 3B capitellum fracture, characterized by capitellar and trochlear involvement with severe posterior condylar comminution. What is the optimal fixation strategy via a lateral approach?

. Anterior-to-posterior headless compression screws only
. Posterior-to-anterior headless compression screws only
. Excision of the capitellar fragment and LCL repair
. Anterior-to-posterior headless compression screws with a posterior buttress plate
. Total elbow arthroplasty

Correct Answer & Explanation

. Anterior-to-posterior headless compression screws with a posterior buttress plate

Explanation

Dubberley type 3B fractures lack an intact posterior buttress due to posterior condylar comminution. Fixation solely with anterior-to-posterior screws is insufficient; supplemental posterior buttress plating is required to prevent displacement.

Question 592

Topic: Elbow & Forearm

A 35-year-old female presents with a 'terrible triad' injury of the elbow after a fall onto an outstretched hand.

If surgical intervention is undertaken using a standard lateral approach, what is the generally recommended sequence of reconstruction?

. Repair the lateral ulnar collateral ligament (LUCL), then fix the radial head, then fix the coronoid
. Fix the coronoid, then fix or replace the radial head, then repair the LUCL
. Fix or replace the radial head, then repair the LUCL, then fix the coronoid
. Repair the medial collateral ligament (MCL), fix the coronoid, then fix the radial head
. Repair the LUCL, fix the coronoid, then repair the MCL

Correct Answer & Explanation

. Fix the coronoid, then fix or replace the radial head, then repair the LUCL

Explanation

The standard "inside-out" surgical sequence for a terrible triad injury involves first fixing the coronoid to restore the anterior buttress. This is followed by radial head repair or replacement, and finally LUCL repair to restore posterolateral stability.

Question 593

Topic: Elbow & Forearm

A 40-year-old female sustains a fall onto an outstretched hand resulting in a capitellum fracture. Radiographic evaluation and subsequent surgical exploration classify the injury as a Kocher-Lorenz (Type II) fracture. Which of the following best describes this specific fracture type?

. A large osseous fragment of the capitellum with attached articular cartilage
. A thin fragment of articular cartilage with very little attached subchondral bone
. A comminuted fracture involving both the capitellum and the trochlea
. A coronal shear fracture that extends medially to involve the lateral epicondyle
. An isolated fracture of the lateral epicondyle sparing the capitellar articular surface

Correct Answer & Explanation

. A thin fragment of articular cartilage with very little attached subchondral bone

Explanation

A Kocher-Lorenz fracture (Type II) involves predominantly articular cartilage with minimal attached subchondral bone, often making it difficult to secure with standard internal fixation. In contrast, a Hahn-Steinthal (Type I) involves a large osseous piece of the capitellum.

Question 594

Topic: Elbow & Forearm

A 40-year-old female sustains a Mason Type II radial head fracture. On examination in the emergency department, she has a reproducible mechanical block to forearm rotation despite aspiration of the hematoma and intra-articular local anesthetic injection. What is the most appropriate management?

. Immobilization in a sling for 3 weeks followed by physical therapy
. Radial head excision alone
. Primary radial head arthroplasty
. Open reduction and internal fixation (ORIF)
. Total elbow arthroplasty

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF)

Explanation

A Mason Type II injury is a displaced partial articular fracture of the radial head. When associated with a mechanical block to rotation that persists after hematoma block, ORIF is indicated to restore joint congruency and allow early motion.

Question 595

Topic: Elbow & Forearm

A 45-year-old female falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. Radiographs and CT demonstrate a posterior elbow dislocation, a comminuted radial head fracture, and a Regan-Morrey Type II coronoid fracture. During surgical reconstruction, what is the most widely accepted sequence of fixation to reliably restore elbow stability?

. Radial head, coronoid, lateral collateral ligament (LCL)
. Coronoid, radial head, lateral collateral ligament (LCL)
. Lateral collateral ligament (LCL), coronoid, radial head
. Medial collateral ligament (MCL), radial head, lateral collateral ligament (LCL)
. Radial head, lateral collateral ligament (LCL), coronoid

Correct Answer & Explanation

. Coronoid, radial head, lateral collateral ligament (LCL)

Explanation

The standard surgical sequence for terrible triad injuries aims to reconstruct from deep to superficial structures: coronoid fixation or anterior capsule repair, followed by radial head repair or arthroplasty, and finally LCL repair. This systematic approach effectively restores the anterior and lateral bony and ligamentous buttresses.

Question 596

Topic: 9. Shoulder and Elbow

A 76-year-old left-handed fit gentleman presents with difficulties in overhead activities. An anteroposterior shoulder X-ray is obtained.

Which of the following findings is MOST indicative of rotator cuff arthropathy on this radiograph?

. Normal glenohumeral joint space.
. Sclerosis of the undersurface of the acromion.
. Proximal migration of the humeral head.
. Absence of acromioclavicular joint arthritis.
. Presence of osteophytes on the humeral head.

Correct Answer & Explanation

. Proximal migration of the humeral head.

Explanation

Correct Answer: CProximal migration of the humeral head is the hallmark radiographic sign of rotator cuff tear arthropathy (RCAT). It indicates the loss of the superior stabilizing force of the rotator cuff, allowing the deltoid to pull the humeral head superiorly. This superior migration leads to abnormal articulation between the humeral head and the acromion, causing characteristic degenerative changes. While subacromial narrowing and sclerosis of the undersurface of the acromion (Option B) are often present due to impingement and chronic cuff pathology, they are not as specific for established arthropathy as proximal migration. Normal glenohumeral joint space (Option A) and absence of AC joint arthritis (Option D) are findings that rule out other pathologies but do not specifically point to RCAT. Osteophytes on the humeral head (Option E) are more characteristic of primary glenohumeral osteoarthritis, which typically presents with concentric joint space narrowing, rather than the superior erosion seen in RCAT.

Question 597

Topic: 9. Shoulder and Elbow

A 76-year-old left-handed fit gentleman presents with difficulties in overhead activities. The anteroposterior shoulder X-ray shows proximal migration of the humeral head and narrowing of the subacromial space. An ultrasound reveals torn subscapularis and supraspinatus with massive retraction. Given these findings, what is the MOST appropriate initial diagnosis?

. Primary glenohumeral osteoarthritis.
. Calcific tendinitis of the rotator cuff.
. Rotator cuff tear arthropathy (RCAT).
. Adhesive capsulitis.
. Subacromial impingement syndrome.

Correct Answer & Explanation

. Rotator cuff tear arthropathy (RCAT).

Explanation

Correct Answer: CThe combination of proximal humeral migration on X-ray, massive rotator cuff tears (subscapularis and supraspinatus) with retraction on ultrasound, and difficulties with overhead activities in a 76-year-old gentleman strongly points to Rotator Cuff Tear Arthropathy (RCAT). RCAT is a specific form of degenerative arthritis characterized by superior migration of the humeral head due to a massive, irreparable rotator cuff tear, leading to erosion of the glenoid and humeral head. Primary glenohumeral osteoarthritis (Option A) typically involves concentric joint space narrowing and osteophyte formation, without significant proximal migration. Calcific tendinitis (Option B) is a distinct entity involving calcium deposits within tendons. Adhesive capsulitis (Option D) presents with global loss of range of motion, often without significant radiographic changes or massive cuff tears. While subacromial impingement syndrome (Option E) is often a precursor, the presence of massive tears and proximal migration indicates a more advanced stage, specifically RCAT.

Question 598

Topic: 9. Shoulder and Elbow

If this 76-year-old gentleman had a massive rotator cuff tear but without radiographic evidence of proximal humeral migration or established arthropathy, what would be the MOST appropriate initial non-operative management strategy?

. Immediate surgical repair of the rotator cuff.
. Subacromial steroid injection followed by physical therapy.
. Glenohumeral steroid injection to reduce pain.
. Activity modification and observation only.
. Referral for shoulder fusion.

Correct Answer & Explanation

. Subacromial steroid injection followed by physical therapy.

Explanation

Correct Answer: BFor a massive rotator cuff tearwithoutestablished arthropathy, initial management often involves non-operative approaches to alleviate symptoms and improve function. A subacromial steroid injection (Option B) can help reduce inflammation and pain, facilitating participation in physical therapy to strengthen remaining cuff muscles and periscapular stabilizers. Immediate surgical repair (Option A) is often considered for younger, active patients or those who fail non-operative management, but it's not always theinitialstep, especially in older patients or those with lower demands. Glenohumeral steroid injection (Option C) is less commonly used for cuff tears and more for primary glenohumeral arthritis. Activity modification and observation (Option D) alone may not be sufficient for symptomatic relief or functional improvement. Shoulder fusion (Option E) is a salvage procedure for severe, painful, irreparable conditions, not an initial management for a massive tear without arthropathy.

Question 599

Topic: 9. Shoulder and Elbow

The first candidate suggests a subacromial steroid injection, followed by arthroscopic debridement and subacromial decompression after 8 weeks of failed conservative treatment. Why is this management plan inappropriate for a patient with established rotator cuff tear arthropathy?

. Subacromial decompression is contraindicated in patients over 70 years old.
. Steroid injections are ineffective for any type of shoulder pain.
. These procedures do not address the underlying biomechanical instability and massive, irreparable cuff tear characteristic of RCAT.
. Arthroscopic debridement increases the risk of infection in elderly patients.
. The patient's symptoms of difficulty with overhead activities are not amenable to surgical intervention.

Correct Answer & Explanation

. These procedures do not address the underlying biomechanical instability and massive, irreparable cuff tear characteristic of RCAT.

Explanation

Correct Answer: CThe first candidate's plan is inappropriate because subacromial steroid injections, arthroscopic debridement, and subacromial decompression primarily address impingement and inflammation, or debride torn tissue. In established rotator cuff tear arthropathy (RCAT), the underlying problem is a massive, irreparable rotator cuff tear leading to superior migration of the humeral head and subsequent degenerative changes. These procedures do not restore the lost superior stability or the function of the massively torn cuff, and therefore will not significantly improve the patient's symptoms or function. Subacromial decompression is not contraindicated by age alone (Option A). Steroid injections can be effective for some shoulder pain (Option B), but not for the underlying structural problem of RCAT. While infection risk is a concern in any surgery, it's not the primary reason this plan is inappropriate (Option D). The patient's symptomsareamenable to surgical intervention, but a different type (Option E).

Question 600

Topic: 9. Shoulder and Elbow

Given the diagnosis of rotator cuff tear arthropathy in this 76-year-old fit gentleman who desires reasonable ability to abduct his shoulder for painting and has failed conservative management, what is the MOST appropriate surgical intervention?

. Rotator cuff repair.
. Hemiarthroplasty.
. Total shoulder arthroplasty (TSA).
. Reverse shoulder arthroplasty (RSA).
. Arthrodesis.

Correct Answer & Explanation

. Reverse shoulder arthroplasty (RSA).

Explanation

Correct Answer: DFor a 76-year-old fit gentleman with established rotator cuff tear arthropathy (RCAT), failed conservative management, and a desire for improved abduction, a reverse shoulder arthroplasty (RSA) is the most appropriate surgical intervention. Rotator cuff repair (Option A) is not possible due to the established arthropathy and likely irreparable nature of the massive tear. Hemiarthroplasty (Option B) would replace only the humeral head, but without a functional rotator cuff, the superior migration would persist, leading to poor outcomes and continued glenoid erosion. Total shoulder arthroplasty (TSA) (Option C) relies on an intact rotator cuff for stability and function, making it contraindicated in RCAT. Arthrodesis (Option E) is a salvage procedure that sacrifices motion for pain relief and stability, which would not meet the patient's desire for abduction for painting. RSA, by medializing and distalizing the center of rotation, allows the deltoid to function as the primary abductor, providing predictable pain relief and improved active range of motion, especially abduction.

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