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9. Shoulder and Elbow MCQs

Practice Set 42 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 821

Topic: Elbow & Forearm
Based on the expected chronological appearance of secondary ossification centers in the pediatric elbow (CRITOE), which center should be radiographically visible in a normal 6-year-old child, while the subsequent center is not yet visible?
. Capitellum
. Radial head
. Medial epicondyle
. Trochlea
. Olecranon

Correct Answer & Explanation

. Trochlea

Explanation

The CRITOE mnemonic dictates the appearance of ossification centers: Capitellum (1 year), Radius (3 years), Internal/Medial epicondyle (5 years), Trochlea (7 years), Olecranon (9 years), and External epicondyle (11 years). At 6 years old, the medial epicondyle is visible, but the trochlea is not.

Question 822

Topic: 9. Shoulder and Elbow

A 2-year-old girl is brought to the emergency department refusing to move her right arm after her father lifted her by the wrist to step onto a curb. Her elbow is held in slight flexion and the forearm is pronated. What is the pathophysiology of this condition?

. Subluxation of the annular ligament over the radial head
. Rupture of the ulnar collateral ligament
. Avulsion fracture of the medial epicondyle
. Complete dislocation of the ulnohumeral joint
. Plastic deformation of the ulna

Correct Answer & Explanation

. Subluxation of the annular ligament over the radial head

Explanation

This is a classic presentation of 'nursemaid's elbow' (radial head subluxation). It is caused by axial traction on a pronated forearm, leading to the annular ligament slipping over the radial head and becoming interposed in the radiocapitellar joint.

Question 823

Topic: 9. Shoulder and Elbow

A 9-year-old girl falls onto her outstretched arm and sustains an acute posterior elbow dislocation. Following closed reduction in the emergency department, post-reduction radiographs demonstrate a medial epicondyle fracture with the avulsed fragment located inside the ulnohumeral joint. What is the most appropriate management?

. Long arm casting for 3 weeks followed by progressive range of motion
. Immediate active range of motion to spontaneously extract the fragment
. Open reduction and internal fixation or extraction of the incarcerated fragment
. Closed reduction and percutaneous pinning without joint exploration
. Excision of the fragment and ulnar collateral ligament reconstruction

Correct Answer & Explanation

. Open reduction and internal fixation or extraction of the incarcerated fragment

Explanation

An incarcerated medial epicondyle fragment within the elbow joint after reduction of a dislocation is an absolute indication for surgical intervention. Open reduction and internal fixation is performed to remove the fragment from the joint and restore stability.

Question 824

Topic: Elbow & Forearm

A 32-year-old competitive rower presents with pain and swelling on the dorsal radial aspect of his distal forearm. Examination reveals palpable crepitus approximately 4 to 6 cm proximal to Lister's tubercle during active wrist extension. This condition is caused by friction between which of the following extensor compartments?

. 1st and 2nd dorsal compartments
. 2nd and 3rd dorsal compartments
. 1st and 3rd dorsal compartments
. 3rd and 4th dorsal compartments
. 4th and 5th dorsal compartments

Correct Answer & Explanation

. 2nd and 3rd dorsal compartments

Explanation

Intersection syndrome occurs at the site where the muscle bellies of the 1st dorsal compartment (APL and EPB) cross over the tendons of the 2nd dorsal compartment (ECRL and ECRB), typically 4-6 cm proximal to Lister's tubercle.

Question 825

Topic: Elbow & Forearm
When interpreting pediatric elbow radiographs, understanding the chronologic appearance of secondary ossification centers is crucial. Which of the following sequences represents the normal order of ossification center appearance in a growing child?
. Capitellum, Radial head, Medial epicondyle, Trochlea, Olecranon, Lateral epicondyle
. Capitellum, Medial epicondyle, Radial head, Trochlea, Olecranon, Lateral epicondyle
. Radial head, Capitellum, Medial epicondyle, Olecranon, Trochlea, Lateral epicondyle
. Capitellum, Radial head, Trochlea, Medial epicondyle, Olecranon, Lateral epicondyle
. Medial epicondyle, Capitellum, Radial head, Trochlea, Olecranon, Lateral epicondyle

Correct Answer & Explanation

. Capitellum, Radial head, Medial epicondyle, Trochlea, Olecranon, Lateral epicondyle

Explanation

The mnemonic CRITOE (Capitellum, Radial head, Internal/Medial epicondyle, Trochlea, Olecranon, External/Lateral epicondyle) accurately describes the sequential appearance of the secondary ossification centers of the pediatric elbow.

Question 826

Topic: 9. Shoulder and Elbow

A 12-year-old boy sustains a posterior elbow dislocation during a wrestling match. After a closed reduction in the emergency department, post-reduction radiographs show a slightly widened medial joint space and an absent medial epicondyle on the AP view. The lateral view shows a bony fragment within the ulnohumeral joint. What is the most appropriate management?

. Immediate long-arm casting for 3 weeks followed by physical therapy
. Open reduction and internal fixation to extract and secure the incarcerated fragment
. Closed manipulation with a valgus stress to unlock the fragment, followed by splinting
. CT scan to assess articular cartilage damage before planning conservative care
. Arthroscopic excision of the medial epicondyle fragment

Correct Answer & Explanation

. Open reduction and internal fixation to extract and secure the incarcerated fragment

Explanation

Incarceration of the medial epicondyle within the joint after reduction of an elbow dislocation is an absolute indication for surgery. Open reduction and internal fixation are required to extract the fragment, restore joint congruity, and reattach the medial collateral ligament origin.

Question 827

Topic: 9. Shoulder and Elbow

Which of the following clinical tests is used to diagnose medial instability of the elbow? Review Topic

. Posterolateral rotatory drawer test
. Lateral pivot-shift test
. Moving valgus stress test
. Chair test (apprehension or dislocation on terminal extension of the supinated forearm when rising from a seated position)
. Pushup sign

Correct Answer & Explanation

. Moving valgus stress test

Explanation

The moving valgus stress test is used in the diagnosis of medial collateral ligament instability of the elbow. The other tests apply a varus force to the elbow and are used to diagnose lateral ulnar collateral insufficiency.

Question 828

Topic: 9. Shoulder and Elbow

A 42-year-old woman sustains a closed posterior elbow dislocation. A closed reduction is performed, and the elbow appears stable under fluoroscopic examination. Initial treatment should consist of

. early mobilization only.
. surgical reconstruction of medial and lateral collateral ligaments.
. active motion in a hinged brace from 30° to 120°.
. application of hinged external fixator with early mobilization.

Correct Answer & Explanation

. early mobilization only.

Explanation

This is a simple (no associated fracture) elbow dislocation. Such dislocations can be treated with closed reduction followed by mobilization after 5 to 7 days to avoid stiffness, provided the elbow is stable through a full arc of motion at the time of reduction. If the elbow is unstable but has a short arc of stability, then using a hinged brace in the stable arc may be considered. (Note: It may be necessary to splint the elbow in pronation if the medial collateral ligament [MCL] is intact and the lateral collateral ligament [LCL] is disrupted, or in supination if the LCL is intact but the MCL disrupted.) Surgical reconstruction of the LCL and MCL may be required only if the elbow does not have a stable arc at the time of reduction. If unstable after reconstruction,application of a hinged external fixator may be considered.

Question 829

Topic: 9. Shoulder and Elbow
Figure 38 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment?
. Reverse shoulder arthroplasty
. Hemiarthroplasty
. Resurfacing of the humeral head
. Arthroscopic debridement
. Shoulder fusion

Correct Answer & Explanation

. Reverse shoulder arthroplasty

Explanation

DISCUSSION: The authors of several studies conducted in Europe have reported promising results in the short- and medium-term with use of a reversed or inverted shoulder implant. The most recent investigation, a multicenter study in Europe in which 77 patients (80 shoulders) with glenohumeral osteoarthritis and a massive rupture of the rotator cuff were treated with the Delta III prosthesis, described an improvement in the mean constant score of 42 points, an increase of 65 degrees in forward elevation, and minimal or no pain in 96% of the patients. Hemiarthroplasty, the “nonconstrained” option, has long been the standard of care for rotator cuff tear arthropathy. However, careful examination of the literature reveals that the results have not been uniform. REFERENCES: Favard L, Lautmann S, Sirveaux F, et al: Hemiarthroplasty versus reverse arthroplasty in the treatment of osteoarthritis with massive rotator cuff tear, in Walch G, Boileau P, Mole D (eds): 2000 Shoulder Prosthesis Two to Ten Year Follow-Up. Montpellier, France, Sauramps Medical, 2001, pp 261-268. Frankle M, Siegal S, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am 2005;87:1697-1705. Werner CM, Steinmann PA, Gilbart M, et al: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.

Question 830

Topic: 9. Shoulder and Elbow
A 34-year-old woman has had painful snapping and popping in the elbow since falling while in-line skating 6 months ago. The popping also occurs when she pushes off with her hands to rise from a seated position. Initial radiographs were normal, and she was told that she had sprained her elbow. Examination reveals few findings except that she is very apprehensive when the forearm is forcefully supinated with the elbow extended or partially flexed. A radiograph taken in that position is shown in Figure 24. Treatment should consist of
. arthroscopic loose body removal.
. arthroscopic debridement and loose body removal for osteochondritis dissecans of the capitellum.
. annular ligament reconstruction for posttraumatic posterior subluxation of the radial head.
. radial head resection for congenital type II dislocation of the radial head.
. lateral collateral ligament reconstruction for posterolateral rotatory instability.

Correct Answer & Explanation

. lateral collateral ligament reconstruction for posterolateral rotatory instability.

Explanation

DISCUSSION: The radiograph reveals posterolateral rotatory subluxation of the radiohumeral and ulnohumeral joints. The space between the ulna and trochlea is enlarged, particularly posteriorly at the olecranon. These findings are diagnostic of posterolateral rotatory instability, which causes recurrent subluxation and reduction as the elbow is flexed from an extended and supinated position with valgus load. The posterolateral rotatory instability apprehension test was performed on this patient and the result was positive. The lateral pivot-shift test causes a clunk as the elbow reduces but is more difficult to perform, even under general anesthesia. The patient does not have isolated subluxation of the radial head, although these findings can be mistakenly diagnosed as such. The radial head is normally shaped and does not represent a congenital dislocation. There are no findings here to suggest osteochondritis dissecans or loose bodies. REFERENCES: O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446. Burgess RC, Sprague HH: Post-traumatic posterior radial head subluxation: Two case reports. Clin Orthop 1984;186:192-194. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.

Question 831

Topic: 9. Shoulder and Elbow

What is the most important stabilizing mechanism in the midrange of motion of the glenohumeral joint? Review Topic

. Concavity compression
. Isometric articular ligaments
. Increased tensile force of the capsule
. Biceps tendon
. Deltoid contraction

Correct Answer & Explanation

. Concavity compression

Explanation

Concavity compression is a stabilizing mechanism by which muscular compression of the humeral head into the glenoid fossa stabilizes the glenohumeral joint against shear forces. This is dependent on the depth of the concavity and the magnitude of the compressive force.

Question 832

Topic: 9. Shoulder and Elbow

A 78-year-old woman falls onto her nondominant left elbow and sustains the injury shown in Figure A. What treatment option allows her the shortest recovery time and highest likelihood of good function and range of motion? Review Topic

. Total elbow arthroplasty
. Open reduction and internal fixation
. Radial head arthroplasty
. Sling and swathe
. Bone stimulator

Correct Answer & Explanation

. Total elbow arthroplasty

Explanation

Total elbow arthroplasty has become the treatment of choice for complex, comminuted distal humeral fractures in patients older than age 70 years. It yields a faster recovery with more predictable functional outcomes, although limitations of lifting weight of more than 5 pounds must be followed to avoid loosening.

Question 833

Topic: 9. Shoulder and Elbow

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

. Prior shoulder joint infection
. Pseudoparalysis
. Prior partial acromioplasty
. Absent glenohumeral joint space narrowing
. Axillary neuropathy

Correct Answer & Explanation

. Pseudoparalysis

Explanation

The reverse total shoulder arthroplasty depends on a functional deltoid muscle which is innervated by the axillary nerve to restore elevation for the patient. Pseudoparalysis is an indication for a reverse shoulder arthroplasty. Acromioplasty has not been correlated with poor results with a reverse shoulder arthroplasty. As long as the patient does not have an active infection, prior infections are not a contraindication. Patients can still have pain and pseudoparalysis from a chronic rotator cuff tear, despite having normal cartilage, and they will still benefit from a reverse total shoulder arthroplasty if other treatments have failed.

Question 834

Topic: 9. Shoulder and Elbow

A 25-year-old woman returns for her first postoperative visit after arthroscopic thermal capsulorrhaphy for recurrent multidirectional instability. Examination reveals that the portals are healed, there is no swelling; and passive range of motion is within the normal range. However, she is unable to actively raise her arm. Shoulder radiographs are normal. What is the most likely cause of these findings? Review Topic

. Adhesive capsulitis
. Sling immobilization
. Thermal chondrolysis
. Subacromial impingement
. Axillary nerve injury

Correct Answer & Explanation

. Axillary nerve injury

Explanation

Treatment of shoulder instability with thermal devices has lead to numerous complications including recurrent instability, chondrolysis, stiffness, and capsular necrosis. This patient’s findings are consistent with a heat-induced axillary nerve injury. Normal radiographs exclude extensive chondrolysis.

Question 835

Topic: 9. Shoulder and Elbow
Figures 42a and 42b show the radiographs of a 52-year-old man who sustained a fall from a motorcycle 6 months ago and now reports pain and stiffness in his left shoulder. What is the most reliable treatment to improve function and comfort of the shoulder?
. Vigorous physical therapy
. Manipulation under anesthesia
. Arthroscopic capsular release
. Hemiarthroplasty
. Arthroscopic capsular plication

Correct Answer & Explanation

. Hemiarthroplasty

Explanation

DISCUSSION: Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult. REFERENCES: Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382. Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652. Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527. Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18. McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584-590.

Question 836

Topic: 9. Shoulder and Elbow

A 21-year-old basketball player reports increased left shoulder pain with all lifting and overhead activities. He denies any history of dislocations. Axial MRI arthrogram images are seen in Figures 34a and 34b. An expected finding on physical examination of the shoulder would be positive findings for which of the following tests? Review Topic

. O'Brien's test
. Speed's test
. Jerk test
. Neer impingement test
. Apprehension test

Correct Answer & Explanation

. Jerk test

Explanation

An MRI arthrogram is a sensitive imaging study used to identify intra-articular shoulder pathology, especially abnormalities of the labrum. Posterior labral tears, although generally less common than anterior tears, can cause significant morbidity, especially in the athlete. Pain, grinding, or gross subluxation often can be elicited with a "jerk" test of the involved shoulder. This test consists of placing an axial load through the humerus, with the shoulder forward flexed to 90 degrees. The shoulder isthen abducted, while maintaining the axial load, and the patient's subjective and objective response is observed. Comparison to the contralateral shoulder is important, especially if painless subluxation is noted, to determine potential evidence of generalized joint laxity.

Question 837

Topic: 9. Shoulder and Elbow
A 42-year-old patient undergoes resection of the medial clavicle for painful sternoclavicular degenerative joint disease. The postoperative course is complicated by an increase in symptoms, a medial bump, and subjective tingling in the digits. A clinical photograph and radiograph are shown in Figures 20a and 20b. What is the most appropriate procedure at this time?
. Semitendinosis figure-of-eight graft
. Subclavius tendon transfer
. Medial clavicular osteotomy
. Medial clavicular resection
. Sternoclavicular arthrodesis

Correct Answer & Explanation

. Semitendinosis figure-of-eight graft

Explanation

Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-eight pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability.

Question 838

Topic: 9. Shoulder and Elbow
Figures 34a through 34c show the radiographs of a 51-year-old woman who injured her elbow in a fall from standing height. Examination reveals that elbow range of motion is limited by pain only. Management should consist of
. open reduction and internal fixation.
. excision of the radial head.
. excision of the radial head and prosthetic arthroplasty.
. a long arm cast.
. a sling and early range-of-motion exercises.

Correct Answer & Explanation

. a sling and early range-of-motion exercises.

Explanation

DISCUSSION: The radiographs show a small minimally displaced radial head fracture that is amenable to nonsurgical management. Early range-of-motion exercises will best restore function and minimize stiffness. A long arm cast for any length of time will result in severe elbow stiffness. REFERENCES: Morrey BF: Radial head fracture, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 341-364. Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

Question 839

Topic: 9. Shoulder and Elbow

A 20-year-old minor league baseball pitcher is diagnosed with a symptomatic torn ulnar collateral ligament (UCL) in his pitching elbow. Nonsurgical management consisting of rest and physical therapy aimed at elbow strengthening has

. UCL repair and nighttime elbow extension splinting
. UCL repair with ulnar nerve decompression in situ
. Allograft UCL reconstruction with interference screws
. Autograft UCL reconstruction with ulnar nerve transposition
. Autograft UCL reconstruction using a docking technique

Correct Answer & Explanation

. Autograft UCL reconstruction with ulnar nerve transposition

Explanation

High-level pitchers with symptomatic UCL tears require reconstruction, with autograft being the best studied graft selection. With concomitant ulnar nerve symptoms, a simultaneous ulnar nerve transposition provides good results. Ligament “repairs” and allograft reconstructions have not shown good long-term results.

Question 840

Topic: 9. Shoulder and Elbow
What is the most common complication associated with scalene regional anesthesia for shoulder procedures?
. Cardiovascular collapse
. Block failure
. Seizure secondary to intravascular injection
. Phrenic nerve injury
. Laryngeal nerve injury

Correct Answer & Explanation

. Block failure

Explanation

DISCUSSION: Failure of the scalene block, necessitating general anesthesia or the immediate administration of narcotic medications, is the most common complication, occurring in 3% to 18% of patients. Cardiac arrest or cardiovascular collapse has been reported in anecdotal occurrences. Seizure that is the result of intravascular injection of local anesthetic is a rare complication, with an incidence reported of 0% to 6%. Neurologic complications, including laryngeal and phrenic nerve injuries, are rare although paresthesias lasting up to 2 weeks have been reported in up to 3% of patients. REFERENCES: Weber SC, Jain R: Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk. J Bone Joint Surg Am 2002;84:775-779. Conn RA, Colfield RH, Byer DE, Lindstromberg JW: Interscalene block anesthesia for shoulder surgery. Clin Orthop 1987;216:94-98.

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