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9. Shoulder and Elbow MCQs

Practice Set 38 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 741

Topic: 9. Shoulder and Elbow

When initiating your answer to an oral examination question about a patient presenting with shoulder pain, what is the most crucial element to establish first to demonstrate a systematic approach?

. Your provisional diagnosis.
. The patient's age and dominant arm.
. The duration and mechanism of injury.
. The patient's full medical history and social context.
. A comprehensive list of differential diagnoses.

Correct Answer & Explanation

. The patient's full medical history and social context.

Explanation

Correct Answer: DWhile age, mechanism, and duration are vital historical elements, starting with a comprehensive patient history, including relevant medical comorbidities, medications, allergies, social history, and previous treatments, establishes a foundational understanding. This holistic approach demonstrates a thorough, patient-centered, and systematic thought process, which is highly valued in oral examinations. Jumping to a diagnosis or differential without context is premature.

Question 742

Topic: 9. Shoulder and Elbow

An examiner asks you to discuss the differential diagnosis for a 55-year-old active male presenting with atraumatic, insidious onset shoulder pain, worse with overhead activities. Which of the following conditions is LEAST likely to be a primary consideration in this demographic?

. Rotator cuff tendinopathy/partial tear.
. Subacromial impingement syndrome.
. Glenohumeral osteoarthritis.
. Adhesive capsulitis.
. Recurrent anterior glenohumeral instability.

Correct Answer & Explanation

. Recurrent anterior glenohumeral instability.

Explanation

Correct Answer: ERecurrent anterior glenohumeral instability, while possible, is far less common to present de novo as atraumatic, insidious onset pain in a 55-year-old male compared to younger, more active populations. Rotator cuff pathology (tendinopathy/tear), subacromial impingement, glenohumeral osteoarthritis, and adhesive capsulitis are all very common causes of atraumatic, insidious shoulder pain in this age group and should be primary considerations.

Question 743

Topic: 9. Shoulder and Elbow

You are discussing a case of suspected adhesive capsulitis with an examiner. Which of the following physical examination findings is most characteristic and crucial to highlight?

. Positive Neer and Hawkins signs.
. Severe pain with passive abduction beyond 90 degrees.
. Loss of passive external rotation, often greater than 50% compared to the contralateral side.
. Apprehension with anterior loading.
. Pain with resisted shoulder flexion.

Correct Answer & Explanation

. Loss of passive external rotation, often greater than 50% compared to the contralateral side.

Explanation

Correct Answer: CThe hallmark of adhesive capsulitis is a significant global restriction of both active and passive range of motion, with passive external rotation being the most consistently and severely limited motion. A loss of passive external rotation often exceeding 50% compared to the unaffected side is highly characteristic. Neer and Hawkins signs are indicative of impingement, apprehension for instability, and resisted flexion for biceps/impingement.

Question 744

Topic: 9. Shoulder and Elbow

When outlining your management plan for a patient with acute calcific tendinitis, what is the most appropriate initial non-operative treatment strategy to propose?

. Immediate surgical excision of calcium deposits.
. Corticosteroid injection into the glenohumeral joint.
. High-dose oral NSAIDs, rest, and physical therapy with gentle range of motion.
. Extracorporeal Shock Wave Therapy (ESWT).
. Manipulation under anesthesia.

Correct Answer & Explanation

. High-dose oral NSAIDs, rest, and physical therapy with gentle range of motion.

Explanation

Correct Answer: CAcute calcific tendinitis can be excruciating. A comprehensive initial non-operative strategy typically includes high-dose oral NSAIDs for pain and inflammation, rest from aggravating activities, and physical therapy with gentle range of motion exercises to maintain mobility. While a subacromial corticosteroid injection can provide rapid pain relief and is often considered, option B specifies a 'glenohumeral joint' injection, which is incorrect for subacromial calcific tendinitis. Therefore, a structured regimen of NSAIDs, rest, and PT is the most appropriate initialstrategyamong the given choices. Surgical excision is reserved for refractory cases, and ESWT is a secondary option. Manipulation is not indicated.

Question 745

Topic: 9. Shoulder and Elbow

An examiner presents a radiograph showing significant glenohumeral osteoarthritis in a 70-year-old patient with intact rotator cuff. When discussing surgical options, what would be your primary recommendation?

. Reverse Total Shoulder Arthroplasty (RTSA).
. Hemiarthroplasty.
. Arthroscopic debridement and lavage.
. Total Shoulder Arthroplasty (TSA).
. Arthrodesis.

Correct Answer & Explanation

. Total Shoulder Arthroplasty (TSA).

Explanation

Correct Answer: DFor primary glenohumeral osteoarthritis with an intact rotator cuff, Total Shoulder Arthroplasty (TSA) is the gold standard surgical treatment, providing excellent pain relief and restoration of function. RTSA is indicated for rotator cuff deficient arthropathy. Hemiarthroplasty is considered for younger, active patients, those with inflammatory arthritis, or when the glenoid is irreparable. Arthroscopic debridement is generally palliative for early OA. Arthrodesis is a salvage procedure.

Question 746

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female with massive, irreparable rotator cuff tear and pseudoparalysis is undergoing a reverse total shoulder arthroplasty (RTSA). During component positioning, which of the following modifications is most effective at decreasing the risk of postoperative scapular notching?

. Superior tilt of the glenoid baseplate
. Inferior tilt and inferior placement of the glenosphere
. Medialization of the center of rotation
. Decreasing the size of the glenosphere
. Superior translation of the humerus

Correct Answer & Explanation

. Inferior tilt and inferior placement of the glenosphere

Explanation

Scapular notching is a common complication of RTSA caused by impingement of the humeral component against the inferior scapular neck. Inferior positioning and inferior tilt of the baseplate, along with lateralization, significantly reduce this risk.

Question 747

Topic: Shoulder Pathology

A 30-year-old male presents with dull aching pain in his right shoulder and difficulty lifting overhead. On examination, having the patient perform a wall push-up demonstrates pronounced prominence of the medial border of the scapula. An injury to which of the following nerves is the most likely cause?

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

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Prominence of the medial border of the scapula with forward elevation or wall push-ups indicates medial winging, caused by paralysis of the serratus anterior muscle which is innervated by the long thoracic nerve.

Question 748

Topic: Shoulder Pathology

A 35-year-old female undergoes a posterior cervical lymph node biopsy. Postoperatively, she complains of shoulder weakness and is noted to have lateral winging of the scapula with the shoulder drooping. Which nerve was most likely injured, and which muscle is primarily affected?

. Long thoracic nerve; serratus anterior
. Spinal accessory nerve; trapezius
. Suprascapular nerve; supraspinatus
. Dorsal scapular nerve; rhomboids
. Axillary nerve; deltoid

Correct Answer & Explanation

. Spinal accessory nerve; trapezius

Explanation

Injury to the spinal accessory nerve (often during posterior triangle neck biopsies) causes trapezius palsy, leading to lateral winging of the scapula. Long thoracic nerve injury causes medial winging due to serratus anterior weakness.

Question 749

Topic: 9. Shoulder and Elbow

A 30-year-old competitive weightlifter feels a sudden "pop" in his anterior shoulder while performing a heavy bench press. He presents with ecchymosis and loss of the anterior axillary fold. If surgical repair is pursued, which of the following describes the most common anatomic location of the tear?

. Clavicular head at the musculotendinous junction
. Sternal head avulsion from the humeral insertion
. Clavicular head avulsion from the humeral insertion
. Mid-substance tear of the sternal head
. Avulsion of the origin at the sternum

Correct Answer & Explanation

. Sternal head avulsion from the humeral insertion

Explanation

Pectoralis major ruptures most commonly occur during eccentric loading, such as the bench press. The majority of these injuries involve avulsion of the sternal head from its insertion on the humerus.

Question 750

Topic: 9. Shoulder and Elbow

A 70-year-old male with a chronic massive rotator cuff tear presents with pseudoparalysis and severe glenohumeral osteoarthritis. Radiographs show superior migration of the humeral head with acetabularization of the coracoacromial arch (Hamada Grade 3). Which of the following is the most appropriate definitive surgical management?

. Arthroscopic rotator cuff repair
. Latissimus dorsi tendon transfer
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Hemiarthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for rotator cuff arthropathy with pseudoparalysis. Anatomic TSA is contraindicated due to the deficient rotator cuff, which would lead to superior eccentric wear and early glenoid loosening.

Question 751

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with severe right shoulder pain, limited active elevation to 45 degrees, and an intact deltoid. Radiographs reveal severe glenohumeral osteoarthritis with superior migration of the humeral head. An MRI confirms a massive, retracted, and irreducible tear of the supraspinatus and infraspinatus tendons with grade 4 fatty infiltration. What is the most appropriate surgical intervention?

. Arthroscopic rotator cuff repair with patch augmentation
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Latissimus dorsi tendon transfer
. Shoulder arthrodesis

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty relies on the deltoid to elevate the arm, moving the center of rotation medially and inferiorly. It is the treatment of choice for patients with cuff tear arthropathy and pseudoparalysis.

Question 752

Topic: 9. Shoulder and Elbow
A 50-year-old female with poorly controlled Type II diabetes mellitus presents with insidious onset of progressive shoulder stiffness and pain, consistent with adhesive capsulitis. Histologic analysis of the affected capsular tissue is most likely to demonstrate which of the following?
. Acute neutrophilic infiltration with necrosis
. Abundant synovial hypertrophy with villous projections
. Fibroblastic proliferation primarily involving the coracohumeral ligament and rotator interval
. Granulomatous inflammation with multinucleated giant cells
. Chondroid metaplasia within the inferior glenohumeral ligament

Correct Answer & Explanation

. Fibroblastic proliferation primarily involving the coracohumeral ligament and rotator interval

Explanation

Adhesive capsulitis is characterized histologically by dense fibroblastic proliferation and type III collagen deposition. This contracture primarily affects the rotator interval capsule and the coracohumeral ligament.

Question 753

Topic: 9. Shoulder and Elbow

In the biomechanical design of a reverse total shoulder arthroplasty (RTSA), moving the center of rotation medially and inferiorly achieves which of the following mechanical advantages?

. It decreases the tension on the remaining rotator cuff musculature.
. It increases the deltoid moment arm and recruits more deltoid fibers for elevation.
. It restores normal glenohumeral joint kinematics to match the native shoulder.
. It prevents inferior scapular notching.
. It increases the moment arm of the subscapularis for internal rotation.

Correct Answer & Explanation

. It increases the deltoid moment arm and recruits more deltoid fibers for elevation.

Explanation

RTSA medialize and inferiorize the center of rotation. This dramatically increases the moment arm of the deltoid and tension on the muscle, allowing it to functionally elevate the arm in the absence of a competent rotator cuff.

Question 754

Topic: 9. Shoulder and Elbow

The examiner asks how to remove the cemented femoral component. The candidate describes several steps. What is the *initial critical step* in removing a well-fixed cemented femoral component to prevent complications such as a greater trochanter fracture or obstruction of stem removal?

. A. Using cement splitters to remove cement radially
. B. Performing an extended trochanteric osteotomy (ETO)
. C. Clearing the shoulder of the prosthesis by removing any overhanging cement or bone
. D. Utilizing ultrasonic tools to disrupt the cement
. E. Applying flexible osteotomes to disrupt the cement/implant interface

Correct Answer & Explanation

. C. Clearing the shoulder of the prosthesis by removing any overhanging cement or bone

Explanation

Correct Answer: CExplanation:The case describes the femoral component removal process: 'It is important to clear the shoulder of the prosthesis removing any cement or bone overhanging the proximal aspect of the greater trochanter as either stem removal will be obstructed or a greater trochanter fracture will occur with stem removal.'A. Using cement splitters to remove cement radially:Cement splitters are used later in the process to break up the cement mantle, but not as the initial critical step to prevent proximal complications.B. Performing an extended trochanteric osteotomy (ETO):While an ETO 'will greatly simplify implant and cement removal,' it is a major surgical step and not theinitial critical stepfor preventing immediate complications during stem removal itself. The ETO is a method of access and removal, not a preparatory step for the stem removal itself.C. Clearing the shoulder of the prosthesis by removing any overhanging cement or bone:This is explicitly stated as the 'important' initial step to prevent 'stem removal will be obstructed or a greater trochanter fracture will occur with stem removal.' This is crucial for safe and effective stem extraction.D. Utilizing ultrasonic tools to disrupt the cement:Ultrasonic tools are used to disrupt cement, but this comes after the initial clearance of the proximal shoulder and often in conjunction with other tools.E. Applying flexible osteotomes to disrupt the cement/implant interface:Flexible osteotomes are used to further disrupt the cement/implant interface, but this is doneafterthe initial clearance of the shoulder.

Question 755

Topic: 9. Shoulder and Elbow

During the operative treatment of a terrible triad injury, the primary objective is to restore stability to the elbow joint. According to the case description, which specific joint stability is the most critical to restore?

. A) Radiocapitellar joint stability
. B) Proximal radioulnar joint stability
. C) Ulnohumeral joint stability
. D) Distal radioulnar joint stability
. E) Scapulothoracic joint stability

Correct Answer & Explanation

. C) Ulnohumeral joint stability

Explanation

Correct Answer: CThe case explicitly states: "Since this is an inherently unstable injury, I would advise operative treatment to restore ulnohumeral joint stability by reducing the dislocation and repairing the coronoid fracture." While the radial head replacement contributes to overall elbow stability, the primary goal is to restore the stability of the main articulation of the elbow, the ulnohumeral joint, which is disrupted by the dislocation and coronoid fracture.

Question 756

Topic: Elbow & Forearm

During radial head replacement in the context of a terrible triad injury, the surgeon must be meticulous to avoid a common complication that can lead to persistent instability or stiffness. What specific intraoperative pitfall is emphasized in the case description regarding radial head replacement?

. A) Incorrect sizing of the radial head implant
. B) Failure to adequately debride the joint
. C) 'Overstuffing' the joint with the radial head prosthesis
. D) Damage to the posterior interosseous nerve
. E) Inadequate cementation of the prosthesis

Correct Answer & Explanation

. C) 'Overstuffing' the joint with the radial head prosthesis

Explanation

Correct Answer: CThe case specifically warns against this pitfall: "The next step would be to prepare and place a radial head replacement, taking care not to 'overstuff' the joint." Overstuffing the joint can lead to increased joint reactive forces, stiffness, pain, and even persistent instability by preventing full reduction or proper tracking of the ulnohumeral joint. While other options are important considerations, 'overstuffing' is explicitly mentioned as a critical point to avoid.

Question 757

Topic: 9. Shoulder and Elbow

Following the initial fixation of the coronoid, radial head replacement, and LCL repair in a terrible triad injury, the elbow still demonstrates residual instability. According to the case, what are the two primary options to address this persistent instability?

. A) Immediate conversion to total elbow arthroplasty or prolonged immobilization.
. B) Revision of radial head replacement or early range of motion.
. C) Separate repair of the medial collateral ligament or application of an external fixator.
. D) Bone grafting of the coronoid or nerve decompression.
. E) Arthroscopic debridement or steroid injection.

Correct Answer & Explanation

. C) Separate repair of the medial collateral ligament or application of an external fixator.

Explanation

Correct Answer: CThe case clearly outlines the management for residual instability: "If residual instability persists following fixation, I would consider a separate repair of the medial collateral ligament, or alternatively, I would consider augmenting the fixation by applying an external fixator across the elbow." These two options are crucial for achieving stability when the initial repairs are insufficient.

Question 758

Topic: Elbow & Forearm

In the described operative sequence for a terrible triad injury, which of the following steps is performed first to facilitate access to deeper structures like the coronoid and anterior capsule?

. A) Repair of the lateral collateral ligament
. B) Placement of the radial head replacement
. C) Excision of the radial head fragments
. D) Reduction and fixation of the coronoid fracture
. E) Repair of the medial collateral ligament

Correct Answer & Explanation

. C) Excision of the radial head fragments

Explanation

Correct Answer: CThe case clearly outlines the initial steps: "I would excise the radial head fragments first, which would give me access to the coronoid and anterior capsule." Removing the radial head fragments provides an unobstructed view and working space for addressing the coronoid fracture and anterior capsule repair, which are crucial for ulnohumeral stability.

Question 759

Topic: Elbow & Forearm

Which radiographic sign is most indicative of a radial head dislocation in the context of an ulnar fracture?

. Widening of the radiocapitellar joint space
. Disruption of the radial head-capitellum alignment on all views
. Presence of fat pads in the elbow joint
. Anterior humeral line not intersecting the capitellum
. Increased carrying angle

Correct Answer & Explanation

. Disruption of the radial head-capitellum alignment on all views

Explanation

Correct Answer: BThe definitive radiographic sign of radial head dislocation is thedisruption of the radial head-capitellum alignment on all views(AP, lateral, and obliques if needed). A line drawn through the center of the radial shaft should always pass through the center of the capitellum, regardless of elbow flexion or forearm rotation. If this capitellar-radial head line does not intersect the capitellum, radial head dislocation is present. While fat pads indicate an effusion (suggesting injury), and an abnormal anterior humeral line suggests supracondylar or condylar fractures, only direct visualization of the radiocapitellar relationship confirms dislocation of the radial head. Widening of the joint space can be a sign but is less definitive than complete disruption of alignment.

Question 760

Topic: 9. Shoulder and Elbow
A 4-year-old presents with a Monteggia Type III fracture. After closed reduction, the radial head appears concentrically reduced on fluoroscopy. What is the appropriate post-reduction immobilization?
. Long-arm cast with elbow in 90 degrees flexion and forearm in full pronation
. Short-arm cast with elbow in 90 degrees flexion and forearm in supination
. Long-arm cast with elbow in 45 degrees flexion and forearm in neutral rotation
. Long-arm cast with elbow in 90 degrees flexion and forearm in full supination
. Sling only, encouraging early motion

Correct Answer & Explanation

. Long-arm cast with elbow in 90 degrees flexion and forearm in full pronation

Explanation

For Monteggia Type III fractures (lateral/anterolateral radial head dislocation with ulnar metaphyseal fracture), the forearm is immobilized in pronation to maintain reduction. This maneuver tightens the interosseous membrane and helps stabilize the radial head against lateral displacement. The elbow is typically flexed to 90 degrees.

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