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9. Shoulder and Elbow MCQs

Practice Set 32 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 621

Topic: 9. Shoulder and Elbow

Following reduction of an anterior shoulder dislocation, a patient complains of persistent weakness in active shoulder abduction. Sensation over the lateral aspect of the deltoid is intact. Which of the following is the MOST likely cause of this isolated weakness?

. Persistent axillary nerve neuropraxia
. Associated rotator cuff tear
. Musculocutaneous nerve injury
. Long thoracic nerve injury
. Brachial plexus avulsion

Correct Answer & Explanation

. Associated rotator cuff tear

Explanation

Correct Answer: BIf sensation over the lateral deltoid (axillary nerve sensory distribution) is intact, persistent isolated weakness in shoulder abduction, especially in an older patient or high-energy trauma, should raise suspicion for an associated rotator cuff tear (supraspinatus or deltoid dysfunction). Axillary nerve neuropraxia would typically present with sensory deficits in addition to motor weakness. Musculocutaneous nerve injury affects biceps and coracobrachialis, and lateral forearm sensation. Long thoracic nerve injury causes scapular winging. Brachial plexus avulsion would present with more widespread neurological deficits.

Question 622

Topic: 9. Shoulder and Elbow

A 22-year-old male presents with his first-time anterior shoulder dislocation. During the initial assessment, which of the following is a critical component of the examination PRIOR to any reduction attempts?

. Administration of intravenous analgesia
. Detailed assessment of range of motion in the contralateral shoulder
. Neurovascular examination of the affected extremity
. Application of ice pack to the affected shoulder
. Obtaining a detailed family history of orthopedic conditions

Correct Answer & Explanation

. Neurovascular examination of the affected extremity

Explanation

Correct Answer: CA thorough neurovascular examination of the affected extremity, including palpation of pulses and assessment of sensation and motor function, is paramount before any reduction attempts. This establishes a baseline and helps identify any pre-existing or acute neurovascular compromise that could be exacerbated by or misattributed to the reduction maneuver. Analgesia is important but secondary to neurovascular assessment. Contralateral shoulder ROM is not critical pre-reduction. Ice is for comfort. Family history is irrelevant in acute management.

Question 623

Topic: 9. Shoulder and Elbow

You are examining a patient with a suspected posterior shoulder dislocation. Which maneuver is most likely to confirm your suspicion on physical exam?

. Pain and apprehension with passive shoulder abduction and external rotation
. Limited internal rotation and abduction with intact external rotation
. Inability to externally rotate the shoulder past neutral, with the arm held in internal rotation
. Increased superior translation of the humeral head with anterior directed force
. A palpable defect below the coracoid process

Correct Answer & Explanation

. Inability to externally rotate the shoulder past neutral, with the arm held in internal rotation

Explanation

Correct Answer: CPosterior dislocations classically present with the arm held in internal rotation and adduction, with a significant block to external rotation. The anterior shoulder may appear flattened, and the coracoid process prominent. Apprehension with abduction and external rotation is characteristic of anterior instability. Limited internal rotation with intact external rotation is incorrect. Increased superior translation with anterior force is not directly indicative of posterior dislocation. A palpable defect below the coracoid is more suggestive of anterior dislocation.

Question 624

Topic: Shoulder Arthroplasty & Arthritis

A 75-year-old female with osteoporosis presents with a severely displaced 4-part proximal humerus fracture. The decision is made to proceed with a reverse total shoulder arthroplasty (RTSA) rather than a hemiarthroplasty. Which of the following is the primary biomechanical advantage of RTSA over hemiarthroplasty in this specific clinical scenario?

. Decreased risk of scapular notching
. Lower long-term revision rate for polyethylene wear
. Better preservation of external rotation
. Less dependence on tuberosity healing for forward elevation
. Lower risk of postoperative dislocation

Correct Answer & Explanation

. Less dependence on tuberosity healing for forward elevation

Explanation

RTSA provides a semi-constrained articulation that relies on the deltoid for elevation, shifting the center of rotation medially and inferiorly. This makes forward elevation less dependent on anatomic tuberosity healing, which is often compromised in elderly osteoporotic patients with 4-part fractures.

Question 625

Topic: 9. Shoulder and Elbow

A 22-year-old rugby player presents to the emergency department with dyspnea, hoarseness, and a prominent medial clavicle defect after a direct blow to the medial shoulder. Imaging confirms a posterior sternoclavicular dislocation. If closed reduction under general anesthesia is planned, which of the following is a strict prerequisite in the operating room?

. Availability of a rigid bronchoscope
. Availability of an intra-aortic balloon pump
. Presence of a cardiothoracic surgery team on standby
. Routine pre-reduction angiography
. Availability of extracorporeal membrane oxygenation (ECMO)

Correct Answer & Explanation

. Presence of a cardiothoracic surgery team on standby

Explanation

Posterior sternoclavicular dislocations can compress or injure the trachea, esophagus, and great vessels. Closed reduction must be performed in the OR with cardiothoracic surgery backup readily available due to the risk of life-threatening great vessel injury during the reduction maneuver.

Question 626

Topic: 9. Shoulder and Elbow

A 35-year-old male sustains an anterior shoulder dislocation with an associated anterior intra-articular glenoid fracture (Ideberg Type Ia). Closed reduction of the joint is successful. Which of the following criteria is an accepted indication for open reduction and internal fixation of the glenoid fragment?

. A 1 mm articular step-off
. Fragment involving 10% of the anterior surface with a stable joint
. Fragment involving 15% of the anterior surface with no subluxation
. Fragment involving > 25% of the anterior surface with persistent shoulder instability
. Presence of a concurrent nondisplaced coracoid fracture

Correct Answer & Explanation

. Fragment involving > 25% of the anterior surface with persistent shoulder instability

Explanation

Operative fixation of an anterior glenoid rim fracture is typically indicated if the fragment involves greater than 25% of the articular surface, if there is an articular step-off > 5 mm, or if there is persistent glenohumeral instability after reduction.

Question 627

Topic: 9. Shoulder and Elbow

A 19-year-old rugby player presents with shortness of breath and right shoulder pain after a direct blow to the anterior chest. Examination reveals a palpable depression at the right sternoclavicular joint. What is the MOST appropriate next step in management?

. Immediate closed reduction in the emergency department
. CT scan of the chest to evaluate mediastinal structures
. MRI of the sternoclavicular joint
. Sling immobilization and outpatient orthopedic follow-up
. Immediate open reduction via a median sternotomy

Correct Answer & Explanation

. CT scan of the chest to evaluate mediastinal structures

Explanation

Posterior sternoclavicular dislocations can cause life-threatening compression of mediastinal structures. A CT scan of the chest is critical to evaluate the position of the medial clavicle relative to these structures prior to reduction.

Question 628

Topic: Shoulder Arthroplasty & Arthritis

In an active 78-year-old female with a highly comminuted 4-part proximal humerus fracture and poor bone quality, what is the primary advantage of a reverse total shoulder arthroplasty (RTSA) compared to a hemiarthroplasty?

. Higher rate of tuberosity healing
. Decreased risk of postoperative dislocation
. More predictable restoration of active forward elevation
. Preservation of native glenoid bone stock
. Shorter operative time

Correct Answer & Explanation

. More predictable restoration of active forward elevation

Explanation

RTSA provides more predictable restoration of active forward elevation and functional outcomes in the elderly with 4-part proximal humerus fractures, as its function does not rely on anatomical tuberosity healing.

Question 629

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old female sustains a 4-part proximal humerus fracture with severe tuberosity comminution. Which of the following is the primary biomechanical advantage of choosing a reverse total shoulder arthroplasty (RTSA) over a hemiarthroplasty in this patient?

. It relies heavily on tuberosity healing to restore active elevation.
. It lateralizes the center of rotation to increase the subscapularis moment arm.
. It requires an intact rotator cuff for joint stability.
. It medializes and distalizes the center of rotation to recruit the deltoid.
. It preserves the native glenoid bone stock completely.

Correct Answer & Explanation

. It medializes and distalizes the center of rotation to recruit the deltoid.

Explanation

RTSA is preferred for elderly patients with 4-part fractures because it does not rely on tuberosity healing for forward elevation. The design medializes and distalizes the center of rotation, significantly increasing the deltoid moment arm to compensate for a deficient rotator cuff.

Question 630

Topic: 9. Shoulder and Elbow

A 45-year-old avid tennis player falls directly onto his shoulder. Imaging reveals an isolated, closed fracture of the greater tuberosity that is displaced 6 mm superiorly and posteriorly. What is the most appropriate management to optimize functional outcome and prevent mechanical impingement?

. Sling immobilization for 6 weeks followed by passive range of motion
. Closed reduction and application of a shoulder spica cast
. Operative fixation with suture anchors or screws
. Primary reverse total shoulder arthroplasty
. Physical therapy focusing exclusively on internal rotation stretching

Correct Answer & Explanation

. Operative fixation with suture anchors or screws

Explanation

Greater tuberosity fractures displaced >5 mm in active individuals (or >3 mm in overhead athletes) are indications for operative fixation. Unrecognized or untreated superior/posterior displacement predictably leads to subacromial impingement and a block to external rotation/abduction.

Question 631

Topic: 9. Shoulder and Elbow

A 76-year-old right-hand-dominant female sustains a severely comminuted, head-splitting proximal humerus fracture. Her history is significant for severe, long-standing rotator cuff arthropathy with pseudo-paralysis of the right shoulder prior to her fall. What is the MOST appropriate surgical intervention?

. Open reduction and internal fixation with a locked plate
. Hemiarthroplasty with meticulous tuberosity repair
. Reverse total shoulder arthroplasty
. Closed reduction and percutaneous pinning
. Non-operative management with early passive motion

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In an elderly patient with a highly comminuted/head-splitting fracture and pre-existing rotator cuff arthropathy, ORIF and hemiarthroplasty will likely fail due to poor bone quality and lack of a functional rotator cuff. Reverse total shoulder arthroplasty is the procedure of choice as it relies on the deltoid for elevation.

Question 632

Topic: 9. Shoulder and Elbow

When reviewing the shoulder X-ray of an elderly patient, you note an apparent non-union of the acromion. Which specific view would be most crucial to confirm an os acromiale and differentiate it from an acute fracture?

. AP internal rotation
. Axillary view
. Outlet view
. Zanca view
. Transthoracic view

Correct Answer & Explanation

. Outlet view

Explanation

Correct Answer: CThe outlet view (or supraspinatus outlet view) is optimal for evaluating the acromial morphology, including the presence of an os acromiale, by projecting the acromion en face. An os acromiale is a developmental failure of fusion of the acromial apophyses. While other views might incidentally show it, the outlet view provides the best profile. The Zanca view is specific for the AC joint. Axillary view is for glenohumeral congruity. Transthoracic is for humeral shaft.

Question 633

Topic: 9. Shoulder and Elbow

Reverse total shoulder arthroplasty (RTSA) is highly effective for restoring active elevation in patients with massive, irreparable rotator cuff tears. Which of the following best describes the primary biomechanical alteration achieved by this prosthesis?

. Lateralization and superior translation of the center of rotation
. Medialization and distalization of the center of rotation
. Medialization and superior translation of the center of rotation
. Lateralization and distalization of the center of rotation
. Direct preservation of the anatomic center of rotation

Correct Answer & Explanation

. Medialization and distalization of the center of rotation

Explanation

RTSA medially and distally shifts the glenohumeral center of rotation. This change lengthens the deltoid moment arm and recruits more deltoid fibers, allowing it to substitute for the deficient rotator cuff during arm elevation.

Question 634

Topic: Shoulder Arthroplasty & Arthritis

A 65-year-old male is scheduled for an anatomic total shoulder arthroplasty. Preoperative CT scanning classifies the glenoid morphology as a Walch B2 type. Which of the following best describes a Walch B2 glenoid?

. Concentric wear with central erosion
. Biconcave joint surface with posterior bone wear and retroversion
. Dysplastic retroverted glenoid without focal wear
. Severe anterior glenoid wear with subluxation
. A monoconcave retroverted glenoid with excessive medial wear

Correct Answer & Explanation

. Biconcave joint surface with posterior bone wear and retroversion

Explanation

The Walch B2 classification describes a biconcave glenoid with significant asymmetric posterior wear and retroversion. It is highly associated with posterior humeral head subluxation and poses a significant risk for early glenoid component loosening if not corrected.

Question 635

Topic: 9. Shoulder and Elbow

A 45-year-old laborer undergoes shoulder arthroscopy for chronic anterior shoulder pain and a positive belly-press test. Upon visualizing the rotator interval, the surgeon notes a 'comma sign'. Which structures primarily comprise this anatomical landmark?

. Middle glenohumeral ligament and long head of the biceps
. Superior glenohumeral ligament and coracohumeral ligament
. Inferior glenohumeral ligament complex and subscapularis tendon
. Coracoacromial ligament and short head of the biceps
. Transverse humeral ligament and subscapularis tendon

Correct Answer & Explanation

. Superior glenohumeral ligament and coracohumeral ligament

Explanation

The arthroscopic 'comma sign' is seen in full-thickness upper subscapularis tears. It is formed by the avulsed superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL) as they remain attached to the superolateral corner of the retracted subscapularis tendon.

Question 636

Topic: 9. Shoulder and Elbow

A 52-year-old female with poorly controlled type 2 diabetes presents with gradual onset of severe, diffuse shoulder pain and significantly restricted active and passive range of motion. Radiographs show no degenerative changes. Which of the following is the most appropriate initial management?

. Arthroscopic capsular release
. Manipulation under anesthesia
. Physical therapy focusing on stretching and intra-articular corticosteroid injection
. Oral nonsteroidal anti-inflammatory drugs only
. Immediate subacromial decompression

Correct Answer & Explanation

. Physical therapy focusing on stretching and intra-articular corticosteroid injection

Explanation

The clinical presentation is classic for adhesive capsulitis, which is strongly associated with diabetes. Initial management is nonoperative, consisting of a supervised stretching program and intra-articular corticosteroid injections to rapidly reduce inflammation and improve ROM.

Question 637

Topic: 9. Shoulder and Elbow

A 58-year-old active male presents with an irreparable posterosuperior rotator cuff tear. He has an intact subscapularis, a functioning deltoid, and no glenohumeral arthritis. He wishes to return to heavy lifting at work. What is the most appropriate joint-preserving surgical option?

. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Lower trapezius tendon transfer
. Superior capsule reconstruction
. Arthroscopic suprascapular nerve release

Correct Answer & Explanation

. Superior capsule reconstruction

Explanation

Superior capsule reconstruction (SCR) using a dermal or fascial graft is indicated for massive, irreparable posterosuperior cuff tears in active patients without arthritis and with an intact subscapularis. It prevents superior humeral head migration and restores glenohumeral kinematics.

Question 638

Topic: 9. Shoulder and Elbow

A 72-year-old female undergoes a reverse total shoulder arthroplasty (RTSA) for massive rotator cuff tear arthropathy. Which of the following best describes the biomechanical alteration of the glenohumeral center of rotation achieved by this prosthesis?

. Lateralizes and proximalizes the center of rotation
. Medializes and proximalizes the center of rotation
. Medializes and distalizes the center of rotation
. Lateralizes and distalizes the center of rotation
. Maintains the anatomic center of rotation while increasing constraint

Correct Answer & Explanation

. Medializes and distalizes the center of rotation

Explanation

RTSA medializes and distalizes the center of rotation of the glenohumeral joint. This increases the moment arm and resting tension of the deltoid, allowing it to initiate and maintain abduction in the absence of a functional rotator cuff.

Question 639

Topic: Shoulder Pathology

A 35-year-old woman complains of shoulder pain and weakness 3 months after a cervical lymph node biopsy. On physical exam, there is lateral winging of the scapula that worsens with resisted shoulder abduction. Which nerve is most likely injured?

. Long thoracic nerve
. Spinal accessory nerve
. Dorsal scapular nerve
. Suprascapular nerve
. Axillary nerve

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

The spinal accessory nerve (CN XI) innervates the trapezius, and its injury results in lateral scapular winging. This classically occurs after posterior triangle neck surgery, such as a lymph node biopsy.

Question 640

Topic: 9. Shoulder and Elbow

A 75-year-old man presents with chronic shoulder pain and inability to elevate his arm above 40 degrees. X-rays reveal severe superior migration of the humeral head, 'acetabularization' of the coracoacromial arch, and severe glenohumeral osteoarthritis.

What is the definitive surgical treatment of choice?

. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Superior capsular reconstruction
. Latissimus dorsi tendon transfer

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

The clinical and radiographic presentation describes severe rotator cuff tear arthropathy (Hamada Stage 4/5) with pseudoparalysis. Reverse total shoulder arthroplasty is the gold standard treatment, providing a stable fulcrum for the deltoid to restore elevation.

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