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9. Shoulder and Elbow MCQs

Practice Set 34 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 661

Topic: 9. Shoulder and Elbow

A 75-year-old female presents with a displaced 4-part proximal humerus fracture. She has a history of severe glenohumeral osteoarthritis and massive rotator cuff tearing. What is the most appropriate surgical intervention?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) is indicated for elderly patients with displaced 4-part proximal humerus fractures, particularly when concurrent rotator cuff arthropathy or severe osteoarthritis is present. RTSA provides superior functional outcomes and more predictable pain relief compared to hemiarthroplasty or ORIF in this demographic.

Question 662

Topic: Shoulder Arthroplasty & Arthritis

Which of the following is considered an absolute indication for Reverse Total Shoulder Arthroplasty (RTSA) over Open Reduction Internal Fixation (ORIF) in the management of an acute proximal humerus fracture?

. A 3-part fracture in a 45-year-old male
. A fracture-dislocation with associated axillary artery transection
. A 4-part fracture in an 80-year-old with a pre-existing massive irreparable rotator cuff tear
. A surgical neck fracture with 15 degrees of valgus impaction
. An isolated greater tuberosity fracture displaced by 1 cm

Correct Answer & Explanation

. A 4-part fracture in an 80-year-old with a pre-existing massive irreparable rotator cuff tear

Explanation

RTSA relies on a functional deltoid rather than an intact rotator cuff to power shoulder elevation. In an elderly patient with a proximal humerus fracture and a pre-existing massive rotator cuff tear (cuff tear arthropathy), ORIF or hemiarthroplasty will fail, making RTSA the absolute treatment of choice.

Question 663

Topic: 9. Shoulder and Elbow

When treating a humeral shaft fracture with functional bracing (Sarmiento brace), what are the maximum acceptable radiographic parameters for angular deformity to ensure a satisfactory functional outcome?

. 10 degrees varus/valgus, 10 degrees AP angulation
. 20 degrees varus/valgus, 20 degrees AP angulation
. 20 degrees AP angulation, 30 degrees varus/valgus
. 30 degrees AP angulation, 20 degrees varus/valgus
. 15 degrees varus/valgus, 15 degrees AP angulation

Correct Answer & Explanation

. 20 degrees AP angulation, 30 degrees varus/valgus

Explanation

Acceptable alignment for humeral shaft fractures treated non-operatively includes up to 20 degrees of anterior/posterior angulation, 30 degrees of varus/valgus angulation, and up to 3 cm of shortening. The extensive range of motion of the shoulder and elbow joints compensates well for these deformities.

Question 664

Topic: Shoulder Arthroplasty & Arthritis

A 75-year-old female with severe osteoporosis sustains a comminuted 4-part proximal humerus fracture with widely displaced tuberosities. Which surgical option is associated with the most predictable restoration of forward elevation and the lowest rate of functional failure in this specific demographic?

. Open reduction internal fixation (ORIF) with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty (RTSA)
. Closed reduction and percutaneous pinning
. Non-operative management with early pendulums

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (RTSA)

Explanation

In elderly patients with 4-part proximal humerus fractures and poor bone quality, RTSA provides more predictable forward elevation and better functional outcomes compared to hemiarthroplasty or ORIF. This is largely because RTSA relies on the deltoid rather than anatomic tuberosity healing, which is often unreliable in this cohort.

Question 665

Topic: Shoulder Arthroplasty & Arthritis

A 75-year-old female with osteoporosis sustains a severe 4-part proximal humerus fracture. A reverse total shoulder arthroplasty (RTSA) is chosen over a hemiarthroplasty. What is the primary functional advantage of RTSA in this specific clinical scenario?

. Decreased risk of postoperative dislocation
. Lower risk of periprosthetic joint infection
. Less reliance on tuberosity healing for overhead forward elevation
. Preservation of the native glenoid bone stock
. Ability to repair the rotator cuff primary without tension

Correct Answer & Explanation

. Less reliance on tuberosity healing for overhead forward elevation

Explanation

RTSA provides a stable, fixed fulcrum for the deltoid muscle, allowing active forward elevation even if the tuberosities (and attached rotator cuff) fail to heal or resorb. This overcomes a major cause of poor outcomes seen in hemiarthroplasty for 4-part fractures.

Question 666

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old female with osteoporosis presents with a highly comminuted, 4-part proximal humerus fracture. There is significant disruption of the medial hinge and tuberosity osteopenia. Which surgical intervention offers the most reliable functional outcome for this patient?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a locking plate
. Hemiarthroplasty
. Reverse total shoulder arthroplasty (rTSA)
. Nonoperative management with a sling

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (rTSA)

Explanation

In elderly patients with complex 4-part fractures and poor bone quality, rTSA provides more reliable pain relief and functional restoration compared to ORIF or hemiarthroplasty. It relies on the deltoid for motion, bypassing the frequently compromised rotator cuff and tuberosity healing issues.

Question 667

Topic: Elbow & Forearm

A 40-year-old female undergoes open reduction and internal fixation of a Type IV (Dubberley) capitellum fracture via an extensile lateral approach. Which associated soft tissue injury is frequently encountered and must be addressed to restore elbow stability?

. Medial ulnar collateral ligament tear
. Lateral ulnar collateral ligament (LUCL) tear
. Biceps tendon rupture
. Annular ligament avulsion
. Brachialis muscle avulsion

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL) tear

Explanation

Complex capitellum and trochlea shear fractures are frequently associated with injury to the lateral collateral ligament complex, specifically the lateral ulnar collateral ligament (LUCL). Repairing the LUCL is crucial to prevent posterolateral rotatory instability.

Question 668

Topic: 9. Shoulder and Elbow

A 19-year-old male sustains a 'floating elbow' injury consisting of a displaced midshaft humerus fracture and ipsilateral displaced both-bone forearm fractures. What is the standard of care for the humeral component of this injury?

. Functional bracing
. Coaptation splinting
. Operative fixation
. Skeletal traction
. Shoulder spica casting

Correct Answer & Explanation

. Operative fixation

Explanation

A 'floating elbow' (ipsilateral humerus and forearm fractures) is an absolute indication for operative fixation of both the humerus and forearm. Stabilization is required to allow early mobilization and prevent severe joint stiffness.

Question 669

Topic: Elbow & Forearm

A 40-year-old construction worker presents with chronic, severe lateral epicondylitis refractory to 9 months of conservative management, including rest, NSAIDs, physical therapy, and multiple steroid injections. Clinical examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension. Imaging confirms degenerative changes at the ECRB origin. Which surgical approach is indicated for debridement of the degenerative tissue and release of the ECRB origin?

. A. Kocher posterior approach.
. B. Medial epicondyle approach.
. C. Kaplan anterolateral approach.
. D. Direct anterior approach.
. E. Posteromedial approach.

Correct Answer & Explanation

. C. Kaplan anterolateral approach.

Explanation

Correct Answer: CExplanation:The text clearly states under 'Kaplan Anterolateral Approach - Indications' that it is used for 'Lateral Epicondylitis: Refractory cases requiring debridement of degenerative tissue or release of the ECRB origin.' This directly matches the clinical scenario described.A. Kocher posterior approach:This approach is for posterior pathologies like distal humerus fractures, olecranon fractures, and total elbow arthroplasty, not lateral epicondylitis.B. Medial epicondyle approach:This approach would be used for medial epicondylitis or ulnar nerve issues, not lateral epicondylitis.D. Direct anterior approach:This is not a standard approach for lateral epicondylitis.E. Posteromedial approach:This is not a standard approach for lateral epicondylitis.

Question 670

Topic: Elbow & Forearm

A 50-year-old male undergoes ORIF of a radial head fracture via the Kaplan anterolateral approach. The surgeon carefully identifies the internervous plane between the ECRB and EDC. Deep to these muscles, the supinator is encountered. To safely expose the radial head and neck while protecting the Posterior Interosseous Nerve (PIN), which of the following deep dissection techniques is described as the safest method?

. A. Splitting the supinator muscle longitudinally along its fibers.
. B. Detaching the anconeus and LUCL from the lateral epicondyle.
. C. Performing a subperiosteal dissection of the supinator from the lateral aspect of the radius, elevating it as a sleeve.
. D. Reflecting the superficial head of the supinator anteriorly after sharply incising its ulnar attachment.
. E. Direct incision through the joint capsule without addressing the supinator.

Correct Answer & Explanation

. C. Performing a subperiosteal dissection of the supinator from the lateral aspect of the radius, elevating it as a sleeve.

Explanation

Correct Answer: CExplanation:Under 'Detailed Surgical Approach / Technique - Kaplan Anterolateral Approach - Deep Dissection & PIN Protection,' the text states: 'The safest method is to perform a subperiosteal dissection of the supinator from the lateral aspect of the radius, elevating it anteriorly and posteriorly as a sleeve, thereby protecting the PIN which remains deep to the supinator.' This directly identifies the safest technique.A. Splitting the supinator muscle longitudinally along its fibers:The text mentions this 'carries a higher risk of PIN injury,' making it less safe than subperiosteal elevation.B. Detaching the anconeus and LUCL from the lateral epicondyle:This describes the Kocher lateral approach to the radial head, which is a variation, but the Kaplan approach aims to preserve the LUCL.D. Reflecting the superficial head of the supinator anteriorly after sharply incising its ulnar attachment:This is described as 'Another option,' but the text explicitly calls subperiosteal dissection the 'safest method.'E. Direct incision through the joint capsule without addressing the supinator:The supinator muscle overlies the radial neck and proximal radius, so it must be addressed to expose the radial head and neck.

Question 671

Topic: 9. Shoulder and Elbow

A 60-year-old male undergoes ORIF of a complex distal humerus fracture via a Kocher posterior approach. Post-operatively, the surgeon emphasizes early controlled motion to prevent stiffness. However, the rehabilitation protocol must balance this with protecting the surgical repair. In Phase I (Weeks 0-6) of rehabilitation for this approach, which of the following is a key principle?

. A. Immediate, aggressive passive range of motion to full extension and flexion.
. B. Complete immobilization in a cast for the entire 6-week period.
. C. Gentle, gravity-assisted passive range of motion within a stable, protected arc, avoiding stress on the triceps repair/osteotomy site.
. D. Initiation of heavy resistance strengthening exercises for elbow flexors and extensors.
. E. Full weight-bearing on the operative extremity as tolerated.

Correct Answer & Explanation

. C. Gentle, gravity-assisted passive range of motion within a stable, protected arc, avoiding stress on the triceps repair/osteotomy site.

Explanation

Correct Answer: CExplanation:Under 'Post-Operative Rehabilitation Protocols - Kocher Posterior Approach - Phase I: Immobilization and Early Protected Motion (Weeks 0-6),' the text states: 'Motion: Passive Range of Motion (PROM): Gentle, gravity-assisted flexion/extension and pronation/supination, within the stable arc defined by the surgeon (e.g., 30-90 degrees initially). Avoid forceful manipulation. Avoid stressing the triceps repair/osteotomy site.' This aligns perfectly with the correct answer.A. Immediate, aggressive passive range of motion to full extension and flexion:This is too aggressive and risks compromising fixation, as the text advises 'avoid forceful manipulation' and 'avoid stressing the triceps repair/osteotomy site.'B. Complete immobilization in a cast for the entire 6-week period:While some initial immobilization may occur, the text emphasizes 'Early Controlled Motion' as the 'cornerstone of modern elbow rehabilitation' and that 'Immobilization is typically minimized to prevent stiffness.'D. Initiation of heavy resistance strengthening exercises for elbow flexors and extensors:The text states 'Strengthening: None during this phase for the elbow.'E. Full weight-bearing on the operative extremity as tolerated:The text specifies 'Weight Bearing: Non-weight bearing for the operative extremity' during Phase I.

Question 672

Topic: Elbow & Forearm

During the surgical management of a terrible triad injury of the elbow (radial head fracture, coronoid fracture, and elbow dislocation), what is the most widely accepted sequential order of repair to systematically restore elbow stability?

. Lateral collateral ligament complex, coronoid process, radial head
. Radial head, lateral collateral ligament complex, coronoid process
. Coronoid process, radial head, lateral collateral ligament complex
. Coronoid process, lateral collateral ligament complex, radial head
. Radial head, coronoid process, lateral collateral ligament complex

Correct Answer & Explanation

. Coronoid process, radial head, lateral collateral ligament complex

Explanation

The standard surgical algorithm for terrible triad injuries builds stability from deep to superficial. This typically begins with fixation or reconstruction of the coronoid, followed by the radial head, and finally repair of the lateral collateral ligament (LCL) complex to the lateral epicondyle.

Question 673

Topic: 9. Shoulder and Elbow

A 72-year-old male with a history of hypertension and coronary artery disease is scheduled for a reverse total shoulder arthroplasty via the deltopectoral approach. The surgical team opts for the beach chair position. Which of the following is a significant disadvantage of this positioning that requires meticulous monitoring?

. Increased risk of brachial plexus compression from shoulder retraction.
. Difficulty in achieving adequate glenoid exposure due to gravity.
. Elevated risk of cerebral hypoperfusion.
. Limited intraoperative assessment of range of motion.
. Increased blood loss due to venous pooling in the operative limb.

Correct Answer & Explanation

. Elevated risk of cerebral hypoperfusion.

Explanation

Correct Answer: CExplanation:The case lists the disadvantages of the beach chair position: "Risk of Cerebral Hypoperfusion:Careful monitoring of blood pressure is essential.Potential for Air Embolism:Rare, but a serious complication.Neck and Head Positioning:Requires careful padding and stabilization to prevent nerve palsy (e.g., brachial plexus, ulnar nerve) or pressure injuries." Therefore, the elevated risk of cerebral hypoperfusion is a significant disadvantage requiring meticulous monitoring.A. Increased risk of brachial plexus compression from shoulder retraction:While nerve palsies are a risk in beach chair, they are typically due to neck/head positioning or direct pressure, not primarily from shoulder retraction itself. Brachial plexus stretch can occur with improper head positioning.B. Difficulty in achieving adequate glenoid exposure due to gravity:This is an advantage of the beach chair position, not a disadvantage. The case states: "Gravity Assists Exposure:The arm hangs naturally, facilitating humeral head dislocation and glenoid exposure."D. Limited intraoperative assessment of range of motion:The beach chair position allows for excellent, unrestricted intraoperative assessment of range of motion because the arm is draped free.E. Increased blood loss due to venous pooling in the operative limb:The beach chair position, especially with hypotensive anesthesia, typically leads toreducedblood loss, not increased, due to lower extremity venous pooling and reduced hydrostatic pressure in the upper extremity.

Question 674

Topic: 9. Shoulder and Elbow

A 40-year-old male presents with a chronic, high-grade acromioclavicular (AC) joint dislocation (Rockwood Type V) and significant pain and dysfunction. He is otherwise healthy. Which of the following is an absolute contraindication to proceeding with an elective AC joint reconstruction via the deltopectoral approach?

. History of prior shoulder surgery in the same limb.
. Patient's desire for a rapid return to contact sports.
. Active infection in the surgical field.
. Concomitant partial-thickness supraspinatus tear.
. Mild glenohumeral osteoarthritis.

Correct Answer & Explanation

. Active infection in the surgical field.

Explanation

Correct Answer: CExplanation:The case lists "Contraindications" and explicitly states: "Active Infection in the Surgical Field:An absolute contraindication for elective procedures." An AC joint reconstruction is an elective procedure. While in acute septic arthritis, surgical debridement via this approach may be indicated, it is not an elective procedure.A. History of prior shoulder surgery in the same limb:This is listed as a potential challenge or relative contraindication ("Extensive Scarring/Prior Surgery"), as it can make dissection difficult, but it is not an absolute contraindication.B. Patient's desire for a rapid return to contact sports:This is a patient expectation and a factor in surgical planning and rehabilitation, but not an anatomical or medical contraindication to the approach itself.D. Concomitant partial-thickness supraspinatus tear:This is a separate pathology that may or may not require treatment, but it is not an absolute contraindication to performing an AC joint reconstruction via the deltopectoral approach.E. Mild glenohumeral osteoarthritis:This is a separate, often conservatively managed condition that does not preclude an AC joint reconstruction.

Question 675

Topic: 9. Shoulder and Elbow

A 65-year-old female presents with chronic, debilitating shoulder pain and weakness, severely limiting her activities of daily living. Physical examination reveals pseudoparalysis, a positive shoulder shrug sign, and severe limitations in active range of motion, particularly elevation and external rotation. Radiographs show severe glenohumeral osteoarthritis and superior migration of the humeral head with complete absence of the rotator cuff. She has failed extensive conservative management. Which surgical option is most appropriate?

. Anatomic total shoulder arthroplasty
. Hemiarthroplasty of the shoulder
. Reverse total shoulder arthroplasty
. Arthroscopic debridement and rotator cuff repair
. Shoulder fusion

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Correct Answer: CThe constellation of severe glenohumeral osteoarthritis, superior migration of the humeral head, pseudoparalysis, and complete absence of the rotator cuff (referred to as 'rotator cuff arthropathy') are classic indications for a reverse total shoulder arthroplasty (rTSA). Anatomic total shoulder arthroplasty relies on an intact rotator cuff for function and stability. Hemiarthroplasty might address pain but would not restore function in the setting of pseudoparalysis. Arthroscopic debridement and rotator cuff repair are not feasible for a complete, irreparable cuff tear with arthropathy. Shoulder fusion is a salvage procedure for younger, higher-demand patients or failed arthroplasty, and would severely limit motion.

Question 676

Topic: 9. Shoulder and Elbow

Following successful surgical repair of the ulnar collateral ligament, the patient enters the acute immobilization phase (0-2 weeks). Which of the following instructions is most critical for the patient during this initial postoperative period?

. A. Begin gentle active abduction exercises of the thumb MCP joint to prevent stiffness.
. B. Maintain strict elevation of the operative extremity and perform active range of motion of the thumb interphalangeal joint.
. C. Initiate passive valgus stress testing of the thumb MCP joint to assess repair integrity.
. D. Remove the splint daily for wound care and light activities of daily living.
. E. Start progressive strengthening exercises with therapeutic putty to restore pinch strength.

Correct Answer & Explanation

. B. Maintain strict elevation of the operative extremity and perform active range of motion of the thumb interphalangeal joint.

Explanation

Correct Answer: BThe case outlines the acute immobilization phase: 'The patient is instructed to maintain strict elevation of the operative extremity above the level of the heart to mitigate swelling. Active range of motion of the shoulder, elbow, and non-involved digits is strongly encouraged to prevent stiffness and promote venous return. The interphalangeal joint of the involved thumb must be actively flexed and extended multiple times daily to prevent tethering of the flexor pollicis longus tendon.'Option A is incorrectbecause active abduction would place direct stress on the healing UCL repair and is strictly contraindicated in the early phase.Option C is incorrectbecause passive valgus stress testing would risk disrupting the fresh repair and is not part of the early rehabilitation protocol.Option D is incorrectbecause the splint is typically removed by a therapist at the 2-week mark, and strict immobilization is crucial for protection during the initial healing phase.Option E is incorrectbecause progressive strengthening exercises are initiated much later, typically at 6 weeks postoperatively, after initial ligament-to-bone healing has occurred.

Question 677

Topic: Elbow & Forearm

A 35-year-old male requires surgical intervention for a chronic thumb UCL injury that occurred 6 months ago. Intraoperatively, the native UCL tissue is found to be deficient and cannot be primarily repaired. What is the most appropriate surgical technique?

. UCL reconstruction using a free tendon graft (e.g., palmaris longus)
. Primary repair using non-absorbable sutures
. MCP joint arthroplasty
. Transfer of the extensor pollicis brevis tendon
. Adductor pollicis advancement

Correct Answer & Explanation

. UCL reconstruction using a free tendon graft (e.g., palmaris longus)

Explanation

In chronic UCL injuries where the native ligament is attenuated or deficient, ligament reconstruction using a free tendon graft (most commonly palmaris longus) is the standard of care to restore stability.

Question 678

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with acute, severe, intractable pain in her right shoulder following a fall. She has significant medical comorbidities including atrial fibrillation on anticoagulation, poorly controlled diabetes, and severe osteoporosis. X-rays reveal a displaced 3-part fracture of the proximal humerus. She has limited active and passive range of motion. What is the most appropriate surgical management option?

. Open reduction and internal fixation with locking plate.
. Reverse total shoulder arthroplasty (rTSA).
. Hemiarthroplasty.
. Non-operative management with a sling and early motion.
. Total shoulder arthroplasty.

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (rTSA).

Explanation

Correct Answer: BIn an elderly patient with severe osteoporosis, a 3-part displaced proximal humerus fracture, significant comorbidities, and likely poor bone quality, reverse total shoulder arthroplasty (rTSA) has emerged as a favorable option. ORIF often has high complication rates (screw cut-out, avascular necrosis) in this population. Hemiarthroplasty can lead to glenoid erosion and pain. Non-operative management is typically reserved for non-displaced or minimally displaced fractures, or very low-demand patients, and is unlikely to provide adequate pain relief or function for a severe displaced fracture. Total shoulder arthroplasty is not indicated for fracture care in this setting due to rotator cuff compromise.

Question 679

Topic: 9. Shoulder and Elbow
A 30-year-old male sustains a high-energy impaction injury to his elbow. Radiographs show a comminuted fracture of the radial head with significant displacement and involvement of the coronoid process (Mason Type III, Regan-Morrey Type II coronoid). He has associated elbow instability. Which of the following is the most appropriate management strategy?
. Excision of the radial head and immobilization
. Open reduction and internal fixation of the radial head and coronoid with lateral collateral ligament repair
. Radial head arthroplasty with coronoid fixation and lateral collateral ligament repair
. Radial head arthroplasty alone
. Closed reduction and casting for 6 weeks

Correct Answer & Explanation

. Radial head arthroplasty with coronoid fixation and lateral collateral ligament repair

Explanation

This patient has a 'terrible triad' injury of the elbow: comminuted radial head fracture, coronoid fracture, and associated elbow dislocation/instability. For Mason Type III radial head fractures with instability and coronoid involvement, radial head arthroplasty is often preferred over ORIF, especially if the radial head is irreparable, to restore stability and maintain length. Concomitant repair of the coronoid process (if a significant fragment) and the lateral collateral ligament complex is crucial for restoring elbow stability. Excision of the radial head alone in the presence of elbow instability and coronoid fracture can lead to persistent instability and proximal migration of the radius. ORIF of a comminuted radial head often fails. Closed reduction and casting are inadequate for such a complex, unstable injury.

Question 680

Topic: 9. Shoulder and Elbow

A 78-year-old osteoporotic female sustains a 4-part proximal humerus fracture with varus impaction and head ischemia. She has significant shoulder osteoarthritis. What is the most reliable surgical option to predictably restore elevation and provide pain relief?

. Open reduction and internal fixation with a locking plate
. Closed reduction and percutaneous pinning
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for elderly patients with complex 4-part proximal humerus fractures and poor bone quality or pre-existing osteoarthritis. RTSA relies on the deltoid for elevation and is less dependent on tuberosity healing compared to hemiarthroplasty.

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