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9. Shoulder and Elbow MCQs

Practice Set 37 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 721

Topic: Elbow & Forearm

Based on high-level clinical evidence, what is the expected long-term outcome (at 1 year) of corticosteroid injection compared to physical therapy for the treatment of lateral epicondylitis?

. Superior pain relief and grip strength recovery
. Equivalent pain relief but significantly higher recurrence rates
. Worse pain scores and higher rates of symptom recurrence
. Decreased risk of eventual surgical intervention
. Accelerated tendon healing on MRI evaluation

Correct Answer & Explanation

. Worse pain scores and higher rates of symptom recurrence

Explanation

Corticosteroid injections for lateral epicondylitis provide excellent short-term relief (at 4-6 weeks) but are associated with worse long-term outcomes (at 1 year) and higher recurrence rates compared to physical therapy or observation.

Question 722

Topic: Elbow & Forearm

During an open release of the extensor carpi radialis brevis (ECRB) for refractory lateral epicondylitis, the surgeon must avoid extending the dissection too posterior and distal. Injury to which structure could result in iatrogenic posterolateral rotatory instability (PLRI)?

. Radial nerve
. Posterior interosseous nerve
. Lateral ulnar collateral ligament
. Annular ligament
. Extensor digitorum communis origin

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The lateral ulnar collateral ligament (LUCL) lies immediately deep and posterior to the common extensor origin. Overzealous debridement or release of the ECRB can compromise the LUCL, leading to PLRI.

Question 723

Topic: Elbow & Forearm

A 7-year-old boy presents with dull, aching lateral elbow pain without mechanical symptoms. Radiographs reveal fragmentation and sclerosis of the entire capitellum. What is the most appropriate initial management?

. Arthroscopic evaluation and microfracture
. Rest and cessation of throwing/weight-bearing activities
. Osteochondral autograft transfer
. Fragment fixation with bioabsorbable pins
. Radial head excision

Correct Answer & Explanation

. Rest and cessation of throwing/weight-bearing activities

Explanation

This clinical presentation is classic for Panner's disease (osteochondrosis of the capitellum), which typically affects children aged 7-10. It is a self-limiting condition that heals completely with rest and avoidance of inciting activities.

Question 724

Topic: Elbow & Forearm

A 42-year-old female presents with lateral elbow and forearm pain. Her pain is maximal 4 to 5 cm distal to the lateral epicondyle. Resisted supination of the forearm with the elbow fully extended significantly exacerbates her symptoms. What is the most likely diagnosis?

. Lateral epicondylitis
. Radial tunnel syndrome
. Pronator syndrome
. Posterolateral rotatory instability
. Capitellar osteochondritis dissecans

Correct Answer & Explanation

. Radial tunnel syndrome

Explanation

Radial tunnel syndrome presents with pain distal to the lateral epicondyle over the mobile wad. Pain exacerbated by resisted supination or resisted middle finger extension (due to the ECRB edge compressing the PIN) distinguishes it from lateral epicondylitis.

Question 725

Topic: 9. Shoulder and Elbow

To optimally visualize a suspected capitellar osteochondritis dissecans lesion on plain radiographs, which specific elbow view is most helpful to profile the typical posterolateral location of the lesion?

. Anteroposterior view in full extension
. Lateral view in 90 degrees of flexion
. Anteroposterior view in 45 degrees of active flexion
. Internal rotation oblique view
. External rotation oblique view

Correct Answer & Explanation

. Anteroposterior view in 45 degrees of active flexion

Explanation

An AP radiograph of the elbow in 45 degrees of active flexion uniquely profiles the posterolateral aspect of the capitellum. This is the classic anatomical location for an OCD lesion, making fragmentation or radiolucencies easier to visualize.

Question 726

Topic: Elbow & Forearm

During a Nirschl procedure for lateral epicondylitis, which of the following describes the most accurate anatomical relationship regarding the posterior interosseous nerve (PIN) to avoid iatrogenic injury?

. It lies directly within the substance of the extensor carpi radialis longus (ECRL)
. It passes between the two heads of the supinator muscle distal to the ECRB origin
. It crosses superficial to the annular ligament at the level of the radial head
. It runs deep to the lateral ulnar collateral ligament
. It courses directly through the common extensor tendon origin

Correct Answer & Explanation

. It passes between the two heads of the supinator muscle distal to the ECRB origin

Explanation

The PIN courses anterior to the radiocapitellar joint and dives between the superficial and deep heads of the supinator muscle (arcade of Frohse). Staying proximal and superior to the supinator during ECRB debridement minimizes the risk of PIN injury.

Question 727

Topic: 9. Shoulder and Elbow

A 45-year-old tennis player presents with chronic lateral elbow pain refractory to 6 months of nonoperative management. He elects to undergo surgical debridement. Histologic examination of the excised tissue from the primary tendon involved would most likely reveal which of the following?

. Acute inflammatory infiltrates with PMNs
. Angiofibroblastic hyperplasia
. Fibrinoid necrosis with giant cells
. Granulomatous inflammation
. Normal tenocyte proliferation

Correct Answer & Explanation

. Angiofibroblastic hyperplasia

Explanation

Lateral epicondylitis is primarily a degenerative tendinosis rather than an inflammatory process. Histology characteristically shows angiofibroblastic hyperplasia, characterized by disorganized collagen, vascular hyperplasia, and an absence of acute inflammatory cells.

Question 728

Topic: Elbow & Forearm

A 14-year-old elite gymnast presents with lateral elbow pain and a 15-degree extension deficit. Radiographs demonstrate a radiolucent lesion of the capitellum. MRI is obtained to evaluate the stability of the osteochondral lesion. Which of the following MRI findings is the most reliable indicator of instability?

. Subchondral sclerosis
. Bone marrow edema in the capitellum
. Intact articular cartilage overlying the lesion
. High T2 signal fluid interposing between the fragment and crater
. Thickening of the radial collateral ligament

Correct Answer & Explanation

. High T2 signal fluid interposing between the fragment and crater

Explanation

In osteochondritis dissecans (OCD) of the capitellum, a high T2 signal (fluid) between the osteochondral fragment and the underlying bone indicates that the lesion is unstable. This fluid line suggests detachment of the fragment from the crater.

Question 729

Topic: Elbow & Forearm

A 9-year-old boy presents with an aching lateral right elbow. He plays Little League baseball but denies any specific injury. Radiographs reveal sclerosis and fragmentation of the entire capitellum without any loose bodies. What is the most appropriate initial management?

. Arthroscopic drilling of the capitellum
. Osteochondral autograft transfer
. Cessation of throwing and symptomatic treatment
. Corticosteroid injection into the radiocapitellar joint
. Ulnar collateral ligament reconstruction

Correct Answer & Explanation

. Cessation of throwing and symptomatic treatment

Explanation

The clinical and radiographic presentation in a child under 10 years old is classic for Panner's disease, a self-limiting osteochondrosis of the capitellum. Treatment consists of rest and avoidance of valgus stress, as the lesion typically resolves spontaneously with re-ossification.

Question 730

Topic: Elbow & Forearm

During open surgical release of the extensor carpi radialis brevis (ECRB) for recalcitrant lateral epicondylitis, an overzealous dissection is performed inferiorly and deep to the tendon origin. Postoperatively, the patient experiences apprehension when pushing up from a chair. Injury to which of the following structures is the most likely cause of this complication?

. Annular ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Posterior interosseous nerve
. Ulnar nerve

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Iatrogenic injury to the lateral ulnar collateral ligament (LUCL) during ECRB debridement can result in posterolateral rotatory instability (PLRI) of the elbow. Patients with PLRI often complain of clicking, snapping, or apprehension when pushing off a chair with the elbow extended and forearm supinated.

Question 731

Topic: 9. Shoulder and Elbow

Which of the following biomechanical forces is the primary contributor to the development of osteochondritis dissecans (OCD) of the capitellum in overhead throwing athletes?

. Varus overload in the acceleration phase
. Valgus extension overload in the deceleration phase
. Radiocapitellar compression during the late cocking and early acceleration phases
. Olecranon impingement in the follow-through phase
. Distraction forces at the medial epicondyle

Correct Answer & Explanation

. Radiocapitellar compression during the late cocking and early acceleration phases

Explanation

In overhead throwers, enormous valgus forces at the elbow result in tension medially and compression laterally. This radiocapitellar compression, combined with repetitive microtrauma to the tenuous blood supply of the capitellum, leads to OCD.

Question 732

Topic: 9. Shoulder and Elbow

A 40-year-old carpenter presents with lateral elbow pain. Provocative testing reveals pain at the lateral epicondyle when the patient extends his wrist against resistance with the elbow fully extended. Which tendon is the primary pathological structure isolated by this maneuver?

. Extensor digitorum communis (EDC)
. Extensor carpi ulnaris (ECU)
. Extensor carpi radialis longus (ECRL)
. Extensor carpi radialis brevis (ECRB)
. Brachioradialis

Correct Answer & Explanation

. Extensor carpi radialis brevis (ECRB)

Explanation

Lateral epicondylitis primarily involves the origin of the extensor carpi radialis brevis (ECRB). Resisted wrist extension with the elbow in full extension (Cozen's test) optimally isolates and loads the ECRB, reproducing the patient's pain.

Question 733

Topic: Elbow & Forearm

A 45-year-old woman with lateral epicondylitis asks about corticosteroid injections compared to physical therapy. Based on high-level evidence, what should she be counseled regarding the outcomes of corticosteroid injections for this condition?

. They provide better short-term and long-term relief compared to physical therapy.
. They provide excellent short-term relief but yield worse outcomes at 1 year compared to physical therapy or watchful waiting.
. They are ineffective for short-term relief but provide superior outcomes at 1 year.
. They are associated with a high rate of spontaneous ECRB tendon rupture.
. They cure the underlying angiofibroblastic hyperplasia within 6 weeks.

Correct Answer & Explanation

. They provide excellent short-term relief but yield worse outcomes at 1 year compared to physical therapy or watchful waiting.

Explanation

Level I evidence demonstrates that while corticosteroid injections may provide significant short-term relief (at 4-6 weeks) for lateral epicondylitis, patients often experience high recurrence rates. At 1 year, outcomes are significantly worse compared to physical therapy or a wait-and-see approach.

Question 734

Topic: Elbow & Forearm

When performing an open Nirschl procedure (excision of the angiofibroblastic tissues of the ECRB) for lateral epicondylitis, the surgeon normally approaches the ECRB origin through an interval. Which structure typically overlies the ECRB and must be incised or split to expose the pathologic tissue?

. Extensor carpi ulnaris
. Extensor digiti minimi
. Extensor carpi radialis longus (ECRL) and Extensor digitorum communis (EDC) aponeurosis
. Brachioradialis
. Anconeus

Correct Answer & Explanation

. Extensor carpi radialis longus (ECRL) and Extensor digitorum communis (EDC) aponeurosis

Explanation

The ECRB origin lies deep to the extensor carpi radialis longus (ECRL) and the extensor digitorum communis (EDC). The surgical approach classically involves splitting the ECRL-EDC interval or splitting the EDC to expose the underlying degenerated ECRB tendon.

Question 735

Topic: 9. Shoulder and Elbow

Regarding the vascular anatomy of the capitellum, which of the following best explains its susceptibility to osteochondrosis and osteochondritis dissecans?

. It receives an abundant blood supply from the recurrent radial artery.
. Its blood supply depends entirely on the intra-osseous anastomosis of the medial epicondyle.
. It is supplied by end arteries that enter posteriorly without significant collateral circulation.
. The intra-articular pressure of the elbow prevents adequate venous drainage.
. It is supplied by a single anterior vessel that is easily compressed during elbow extension.

Correct Answer & Explanation

. It is supplied by end arteries that enter posteriorly without significant collateral circulation.

Explanation

The capitellum is supplied by a single end-arterial supply consisting of 1 to 2 vessels entering posteriorly. The lack of collateral circulation renders the capitellum highly susceptible to avascular necrosis and osteochondritis dissecans from repetitive microtrauma.

Question 736

Topic: 9. Shoulder and Elbow

A 68-year-old male presents with profound weakness in shoulder elevation and external rotation. MRI reveals a massive, retracted, and fatty-infiltrated tear of the supraspinatus and infraspinatus with an intact subscapularis and normal articular cartilage. He has active forward flexion to only 45 degrees but a negative hornblower's sign. Which of the following is the most appropriate surgical option?

. Total shoulder arthroplasty
. Arthroscopic marginal convergence repair
. Superior capsular reconstruction (SCR)
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

This patient has pseudoparalysis with an irreparable posterosuperior rotator cuff tear without advanced glenohumeral arthritis. A reverse total shoulder arthroplasty (RTSA) is highly effective at reversing pseudoparalysis in the setting of massive irreparable tears. Superior capsular reconstruction is less reliable when significant pseudoparalysis is present.

Question 737

Topic: 9. Shoulder and Elbow

A 35-year-old manual laborer presents with chronic, severe shoulder pain and weakness in external rotation. Imaging reveals a massive, retracted, and irreparable tear of the supraspinatus and infraspinatus with advanced fatty infiltration, but an intact subscapularis and teres minor. He has no significant glenohumeral arthritis. What is the most appropriate surgical intervention?

. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty
. Latissimus dorsi tendon transfer
. Pectoralis major tendon transfer
. Arthroscopic subacromial decompression and debridement

Correct Answer & Explanation

. Latissimus dorsi tendon transfer

Explanation

Latissimus dorsi transfer is indicated for young, active patients with massive, irreparable posterosuperior rotator cuff tears, an intact subscapularis, and no arthritis. Reverse total shoulder arthroplasty is generally avoided in this age group if tendon transfer is viable.

Question 738

Topic: 9. Shoulder and Elbow

A 24-year-old minor league baseball pitcher presents with vague, deep shoulder pain and clicking. MRI arthrogram shows a Type II Superior Labrum Anterior and Posterior (SLAP) tear. The "peel-back" mechanism precipitating this injury occurs maximally in which arm position during throwing?

. Abduction and maximum external rotation
. Flexion and maximum internal rotation
. Adduction and maximum internal rotation
. Extension and neutral rotation
. Forward flexion during the follow-through phase

Correct Answer & Explanation

. Abduction and maximum external rotation

Explanation

The peel-back mechanism occurs during the late cocking phase of throwing when the arm is in abduction and maximum external rotation. This position causes the biceps vector to shift posteriorly, placing torsional stress on the superior labral anchor.

Question 739

Topic: 9. Shoulder and Elbow

A 68-year-old female presents with primary glenohumeral osteoarthritis. A CT scan of the shoulder reveals significant posterior glenoid wear, causing biconcavity and retroversion of the glenoid face. Based on the Walch classification, what type of glenoid morphology does she have?

. Type A1
. Type B2
. Type C
. Type B1
. Type A2

Correct Answer & Explanation

. Type B2

Explanation

A Walch B2 glenoid is characterized by asymmetric posterior wear resulting in a biconcave surface and posterior subluxation of the humeral head. Correctly recognizing this is critical, as it requires specific surgical strategies (e.g., asymmetric reaming, augmented components) during total shoulder arthroplasty.

Question 740

Topic: 9. Shoulder and Elbow

A 72-year-old male undergoes a reverse total shoulder arthroplasty. At his 2-year follow-up, radiographs demonstrate inferior scapular notching. Which of the following surgical technique modifications during the index procedure would have most effectively reduced the risk of this complication?

. Superior baseplate tilt
. Medialization of the glenosphere
. Inferior baseplate placement with inferior tilt
. Decreasing the glenosphere size
. Retaining the anterior deltoid origin

Correct Answer & Explanation

. Inferior baseplate placement with inferior tilt

Explanation

Scapular notching is a common complication of reverse total shoulder arthroplasty. Placing the baseplate inferiorly with an inferior tilt, lateralizing the center of rotation, and using a larger glenosphere can reduce the incidence of inferior scapular impingement.

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