Menu

9. Shoulder and Elbow MCQs

Practice Set 31 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 601

Topic: 9. Shoulder and Elbow

While reverse shoulder arthroplasty is indicated for rotator cuff tear arthropathy, which of the following conditions would generally be considered a contraindication or a significant relative contraindication for RSA?

. Advanced age (e.g., 80 years old).
. History of previous shoulder surgery.
. Intact and functional rotator cuff.
. Mild glenohumeral osteoarthritis.
. Patient expectation for only pain relief, not improved motion.

Correct Answer & Explanation

. Intact and functional rotator cuff.

Explanation

Correct Answer: CAn intact and functional rotator cuff (Option C) is a contraindication for reverse shoulder arthroplasty (RSA). RSA is specifically designed for patients with a deficient rotator cuff (e.g., massive irreparable tears, rotator cuff tear arthropathy) where a conventional total shoulder arthroplasty (TSA) would fail due to lack of cuff function. If the rotator cuff is intact and functional, a TSA or hemiarthroplasty would typically be preferred for primary glenohumeral osteoarthritis. Advanced age (Option A) is generally not a contraindication if the patient is otherwise fit for surgery. A history of previous shoulder surgery (Option B) is common and not a contraindication. Mild glenohumeral osteoarthritis (Option D) with an intact cuff would be better treated with TSA or hemiarthroplasty. Patient expectation for only pain relief (Option E) is a reasonable goal for RSA, although improved motion is also expected.

Question 602

Topic: 9. Shoulder and Elbow

A 72-year-old female undergoes a reverse total shoulder arthroplasty (RTSA) for rotator cuff tear arthropathy. The biomechanical advantage of this prosthesis relies on medializing the center of rotation and increasing the moment arm of which of the following muscles?

. Supraspinatus
. Pectoralis major
. Deltoid
. Latissimus dorsi
. Subscapularis

Correct Answer & Explanation

. Deltoid

Explanation

RTSA medializes and distalizes the center of rotation of the glenohumeral joint. This significantly increases the moment arm and mechanical advantage of the deltoid, allowing it to compensate for the deficient rotator cuff.

Question 603

Topic: 9. Shoulder and Elbow

A 45-year-old diabetic female presents with global restriction of shoulder active and passive motion. She is diagnosed with adhesive capsulitis. The pathophysiology of this condition is primarily characterized by elevated levels of which of the following cytokines?

. Interleukin-1 (IL-1)
. Tumor necrosis factor-alpha (TNF-a)
. Transforming growth factor-beta (TGF-b)
. Vascular endothelial growth factor (VEGF)
. Fibroblast growth factor (FGF)

Correct Answer & Explanation

. Transforming growth factor-beta (TGF-b)

Explanation

Adhesive capsulitis is characterized by excessive fibroblastic proliferation and capsular fibrosis. Transforming growth factor-beta (TGF-b) is heavily implicated in driving this aberrant fibroproliferative response and collagen deposition.

Question 604

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with pseudoparalysis of her dominant right shoulder. Radiographs show superior migration of the humeral head with an acromiohumeral interval of 3 mm. She has a history of a massive, irreparable rotator cuff tear. Which of the following is an absolute contraindication to a reverse total shoulder arthroplasty (RTSA) in this patient?

. Intact but functionally impaired deltoid muscle
. Axillary nerve palsy
. Prior failed hemiarthroplasty
. Pseudoparalysis with active forward flexion of 45 degrees
. Age greater than 70 years

Correct Answer & Explanation

. Axillary nerve palsy

Explanation

A functioning deltoid is required for a reverse total shoulder arthroplasty to provide the primary force for active elevation. An axillary nerve palsy results in irreversible deltoid dysfunction, making RTSA absolutely contraindicated.

Question 605

Topic: 9. Shoulder and Elbow
A 50-year-old female with type 1 diabetes presents with progressive, severe shoulder pain and stiffness over the past 4 months. She has lost both active and passive range of motion, particularly in external rotation. What is the most characteristic histological finding of the glenohumeral capsule in this condition?
. Heavy infiltration of polymorphonuclear leukocytes
. Abundant giant cells and cholesterol clefts
. Fibroblastic proliferation and dense type III collagen deposition
. Cartilaginous metaplasia of the synovium
. Calcium hydroxyapatite crystal deposition

Correct Answer & Explanation

. Fibroblastic proliferation and dense type III collagen deposition

Explanation

Adhesive capsulitis is characterized histologically by fibroblastic proliferation and dense collagen deposition (initially type III, later maturing to type I). This fibrotic process shares pathophysiological similarities with Dupuytren's contracture.

Question 606

Topic: 9. Shoulder and Elbow

A 22-year-old collegiate wrestler sustains a traumatic anterior shoulder dislocation. After reduction, an MRI arthrogram reveals an avulsion of the anterior-inferior glenoid labrum. Which ligamentous structure, attached to this torn labral fragment, acts as the primary restraint to anterior translation at 90 degrees of shoulder abduction and maximum external rotation?

. Middle glenohumeral ligament
. Superior glenohumeral ligament
. Anterior band of the inferior glenohumeral ligament
. Coracohumeral ligament
. Posterior band of the inferior glenohumeral ligament

Correct Answer & Explanation

. Anterior band of the inferior glenohumeral ligament

Explanation

The anterior band of the inferior glenohumeral ligament (IGHL) is the primary static restraint to anterior and inferior translation of the humeral head when the shoulder is positioned in 90 degrees of abduction and externally rotated.

Question 607

Topic: Shoulder Pathology

The examiner describes the thoraco-abdominal (Hodgson's) approach for excising a hemivertebra. During this procedure, after incising the skin and fat, serratus anterior, external oblique, and latissimus dorsi, and removing the 10th rib subperiosteally, what is the critical next anatomical step to gain access to the retroperitoneum?

. Ligation of the segmental vessels at the level of the hemivertebra.
. Division of the parietal pleura to expose the lung and diaphragm.
. Splitting the costal cartilage to enter the retroperitoneum.
. Excision of the discs above and below the hemivertebra.
. Sweeping away retroperitoneal fascia with swabs.

Correct Answer & Explanation

. Splitting the costal cartilage to enter the retroperitoneum.

Explanation

Correct Answer: CThe case explicitly describes the Hodgson's approach: 'A key step in this procedure is splitting the costal cartilage to enter the retroperitoneum.' This step allows access to the retroperitoneal space where the spine is located, without entering the peritoneal cavity directly.Option A is incorrectbecause ligation of segmental vessels occurs later, after the retroperitoneum is accessed and the discs are excised, to prepare for vertebral excision.Option B is incorrectbecause the parietal pleura is incisedbeforesplitting the costal cartilage, exposing the lung and diaphragm. The question asks for the stepafterthese initial muscle and rib excisions, specifically to enter the retroperitoneum.Option D is incorrectbecause excision of the discs above and below the hemivertebra occurs after the retroperitoneum is accessed and the diaphragm is divided, as part of the vertebral excision process.Option E is incorrectbecause sweeping away retroperitoneal fascia with swabs occursafterentering the retroperitoneum, to clear the surgical field and expose the vertebral column.

Question 608

Topic: Elbow & Forearm

When performing open reduction and internal fixation (ORIF) of a radial head fracture, what is the ideal placement for fixation screws to minimize impingement with the capitellum during forearm rotation?

. Anterior aspect of the radial head
. Posterior aspect of the radial head
. Inferior aspect of the radial head
. Superior aspect of the radial head
. The 'safe zone' between 90 degrees of supination and 90 degrees of pronation, typically the non-articulating portion corresponding to the posterolateral quadrant when the forearm is in neutral rotation.

Correct Answer & Explanation

. The 'safe zone' between 90 degrees of supination and 90 degrees of pronation, typically the non-articulating portion corresponding to the posterolateral quadrant when the forearm is in neutral rotation.

Explanation

Correct Answer: ETo avoid impingement of hardware against the capitellum, screws and plates should ideally be placed in the 'safe zone' of the radial head. This zone is typically defined as the non-articulating portion of the radial head that does not articulate with the capitellum through a full range of forearm rotation. This zone is generally considered to be a 110-degree arc on the radial head, typically in the posterolateral quadrant when the forearm is in neutral rotation, or approximately between 90 degrees of supination and 90 degrees of pronation. Placing hardware in the anterior, posterior, or superior articulating zones is prone to impingement and pain.

Question 609

Topic: Elbow & Forearm

Which of the following ligaments is most commonly injured in a 'terrible triad' injury of the elbow?

. Medial collateral ligament (MCL)
. Annular ligament
. Lateral ulnar collateral ligament (LUCL)
. Oblique cord
. Radiocapitellar ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Correct Answer: CThe 'terrible triad' of the elbow consists of a posterior elbow dislocation, a radial head fracture, and a coronoid process fracture. The most consistently injured ligament in this complex is the lateral ulnar collateral ligament (LUCL), which is crucial for posterolateral rotatory stability of the elbow. MCL injury can also occur, but the LUCL is the key structure disrupting posterolateral stability in this injury pattern. The annular ligament is injured as part of the radial head fracture, but the LUCL is the primary stabilizer injured in the dislocation component.

Question 610

Topic: 9. Shoulder and Elbow

A 55-year-old patient presents with an olecranon fracture. Standard AP and lateral radiographs show a transverse, displaced fracture. What additional radiographic view is *most beneficial* for further characterization, particularly to assess comminution and articular involvement?

. Radial head-capitellum view
. Oblique views (internal and external)
. Axillary view
. Stress views
. Contralateral elbow comparison view

Correct Answer & Explanation

. Oblique views (internal and external)

Explanation

Correct Answer: BWhile standard AP and lateral views are essential, oblique views (B) provide additional perspectives that can be invaluable. They help to better delineate the fracture pattern, identify comminution not clearly seen on orthogonal views, and assess the extent of articular involvement (e.g., small intra-articular fragments or subtle step-offs). This detailed information is crucial for surgical planning. Radial head-capitellum view (A) is for radial head fractures. Axillary view (C) is typically for shoulder dislocations. Stress views (D) assess ligamentous instability. Contralateral views (E) are for comparing anatomical variations or growth plate status in children.

Question 611

Topic: Elbow & Forearm

A 40-year-old gymnast falls from a height and sustains an anteromedial facet fracture of the coronoid process. If left untreated, this specific fracture pattern most predictably leads to which of the following instability patterns?

. Valgus posterolateral rotatory instability
. Posterolateral rotatory instability (PLRI) with isolated LCL insufficiency
. Varus posteromedial rotatory instability (VPMRI)
. Straight anterior instability
. Isolated radioulnar divergence

Correct Answer & Explanation

. Varus posteromedial rotatory instability (VPMRI)

Explanation

Anteromedial facet coronoid fractures typically occur from an axial load coupled with varus and posteromedial rotation. They are highly associated with lateral collateral ligament (LCL) injuries, resulting in varus posteromedial rotatory instability (VPMRI).

Question 612

Topic: Elbow & Forearm

A 50-year-old male sustains a terrible triad injury of the elbow consisting of an elbow dislocation, radial head fracture, and coronoid fracture. According to standard treatment algorithms, what is the most appropriate sequence of surgical repair?

. Fixation of the coronoid, followed by radial head repair/replacement, followed by LCL repair
. LCL repair, followed by radial head repair/replacement, followed by coronoid fixation
. Radial head repair/replacement, followed by LCL repair, followed by coronoid fixation
. MCL repair, followed by coronoid fixation, followed by LCL repair
. Fixation of the coronoid, followed by MCL repair, followed by radial head repair/replacement

Correct Answer & Explanation

. Fixation of the coronoid, followed by radial head repair/replacement, followed by LCL repair

Explanation

The standard inside-out protocol for terrible triad injuries begins with deep and medial structures, repairing the coronoid first, followed by the radial head (repair or arthroplasty), and finally the lateral collateral ligament (LCL) complex.

Question 613

Topic: 9. Shoulder and Elbow

During surgery for a highly comminuted radial head fracture, the surgeon decides to place a radial head arthroplasty. If the implanted prosthesis is excessively long (overstuffed), what is the most likely clinical and biomechanical consequence?

. Increased varus instability
. Capitellar cartilage wear and a mechanical block to terminal flexion
. Proximal radioulnar joint (PRUJ) diastasis
. Increased valgus laxity and ulnar nerve traction
. Excessive supination contracture

Correct Answer & Explanation

. Capitellar cartilage wear and a mechanical block to terminal flexion

Explanation

Overstuffing the radiocapitellar joint increases contact pressures, leading to accelerated wear of the capitellar articular cartilage. It also alters joint kinematics, frequently causing a mechanical block to elbow flexion.

Question 614

Topic: Elbow & Forearm

During surgical reconstruction of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), which of the following represents the most widely accepted sequence of structural repair to restore stability?

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

Correct Answer & Explanation

. Coronoid fixation, followed by radial head fixation/replacement, followed by LCL repair

Explanation

The standard surgical sequence for a terrible triad injury progresses from deep to superficial and anterior to posterior: coronoid (and anterior capsule) fixation first, followed by radial head repair or replacement, and finally lateral collateral ligament (LCL) repair. The MCL is only repaired if the elbow remains unstable after these steps.

Question 615

Topic: 9. Shoulder and Elbow

A 22-year-old motorcyclist presents with severe lateral displacement of the scapula on a chest radiograph and massive shoulder swelling (scapulothoracic dissociation). Which vascular structure is most commonly injured in this specific severe trauma pattern?

. Axillary artery
. Subclavian artery
. Brachial artery
. Suprascapular artery
. Internal thoracic artery

Correct Answer & Explanation

. Subclavian artery

Explanation

Scapulothoracic dissociation is a severe closed traction injury to the forequarter. The subclavian artery and the brachial plexus are frequently injured, carrying a high risk of amputation and mortality.

Question 616

Topic: 9. Shoulder and Elbow

A 24-year-old motorcyclist sustains a severe traction injury to his right shoulder, presenting with a flail, insensate arm. Physical examination reveals right-sided ptosis, miosis, and anhidrosis. This specific constellation of clinical findings indicates an injury at which level?

. C5 root avulsion
. C6 root avulsion
. Upper trunk rupture
. Posterior cord injury
. C8-T1 root avulsion

Correct Answer & Explanation

. C8-T1 root avulsion

Explanation

Horner syndrome (ptosis, miosis, anhidrosis) indicates a proximal injury (pre-ganglionic root avulsion) to the T1 nerve root. This occurs due to disruption of the sympathetic ganglion chain located near the C8-T1 levels.

Question 617

Topic: Shoulder Pathology

A 45-year-old male sustains a high-energy traction injury to his right arm. Physical examination reveals massive swelling and marked lateral displacement of the scapula. An angiogram demonstrates a right subclavian artery occlusion. What concomitant neurologic injury is most frequently associated with this diagnosis?

. Isolated axillary nerve palsy
. Complete brachial plexus avulsion
. Isolated musculocutaneous nerve palsy
. Spinal accessory nerve palsy
. Long thoracic nerve palsy

Correct Answer & Explanation

. Complete brachial plexus avulsion

Explanation

The clinical picture describes scapulothoracic dissociation. This devastating closed forequarter amputation equivalent is highly associated with complete brachial plexus avulsions and subclavian vascular injuries.

Question 618

Topic: 9. Shoulder and Elbow

What is the most common indirect mechanism of injury leading to a posterior sternoclavicular joint dislocation?

. A fall onto an outstretched hand with the arm extended
. Forceful superior traction on an abducted arm
. A direct, blunt impact to the anterior sternum
. A compressive force applied to the posterolateral aspect of the shoulder
. An axial load applied to a flexed elbow

Correct Answer & Explanation

. A compressive force applied to the posterolateral aspect of the shoulder

Explanation

The most common indirect mechanism for a posterior SC joint dislocation involves a compressive force applied to the posterolateral shoulder, which hinges the medial aspect of the clavicle posteriorly behind the sternum.

Question 619

Topic: 9. Shoulder and Elbow

A 35-year-old patient presents with a history of recurrent anterior shoulder dislocations. During your examination, you perform the Apprehension Test. Which of the following describes a positive test?

. Pain and apprehension when the shoulder is passively abducted and externally rotated
. Pain and crepitus with passive internal and external rotation in adduction
. Reproduction of pain with resisted shoulder abduction
. Superior translation of the humeral head with inferior traction on the arm
. A palpable clunk with shoulder adduction and internal rotation from an abducted and externally rotated position

Correct Answer & Explanation

. Pain and apprehension when the shoulder is passively abducted and externally rotated

Explanation

Correct Answer: AThe Apprehension Test is performed by abducting the shoulder to 90 degrees and slowly externally rotating the arm. A positive test is indicated by the patient's feeling of impending dislocation (apprehension) or significant pain, often due to stretching of the anterior capsule. Options B and C describe findings related to rotator cuff or glenohumeral arthritis. Option D describes the Sulcus Sign, indicative of inferior or multidirectional instability. Option E describes a clunk, which could be related to labral pathology but is not the apprehension test.

Question 620

Topic: 9. Shoulder and Elbow

During the examination of a patient with suspected shoulder dislocation, you note a sulcus sign. What does this finding MOST commonly indicate?

. Anterior glenohumeral instability
. Posterior glenohumeral instability
. Inferior glenohumeral instability
. Acromioclavicular joint separation
. Rotator cuff tear

Correct Answer & Explanation

. Inferior glenohumeral instability

Explanation

Correct Answer: CThe Sulcus Sign is elicited by applying inferior traction to the arm, causing a dimple or sulcus to appear below the acromion. It is indicative of inferior capsular laxity and is a hallmark of inferior or multidirectional glenohumeral instability. While multidirectional instability often includes an inferior component, the most direct interpretation of a sulcus sign is inferior instability.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page