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9. Shoulder and Elbow MCQs

Practice Set 45 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 881

Topic: 9. Shoulder and Elbow
What is the most common contracture deformity of the spastic shoulder secondary to a cerebrovascular accident?
. External rotation, abduction, and extension
. External rotation, adduction, and flexion
. Internal rotation, abduction, and flexion
. Internal rotation, adduction, and extension
. Internal rotation, adduction, and flexion

Correct Answer & Explanation

. Internal rotation, adduction, and flexion

Explanation

DISCUSSION: The resultant spasticity and weakness (paresis) following a cerebrovascular accident leads to muscle imbalance that commonly results in contracture of the shoulder in adduction, internal rotation, and varying degrees of forward flexion. In addition, the elbow is usually flexed and the forearm pronated. REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65. McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient. Instr Course Lect 1975;24:45-55.

Question 882

Topic: 9. Shoulder and Elbow

Which of the following clinical findings is most often seen with the MRI scan findings shown in Figures 19a through 19c? Review Topic

. Atrophy of the lateral shoulder
. Atrophy of the posterior shoulder
. Sensory deficit of the lateral shoulder
. Sensory deficit of the posterior shoulder
. Sensory deficit of the anterior shoulder

Correct Answer & Explanation

. Atrophy of the lateral shoulder

Explanation

The MRI scans show a large superior labral cyst. Impingement of the cyst on the suprascapular nerve is implied by the visible atrophy of the infraspinatus muscle as seen in Figure 19c. Clinically, this is manifested by atrophy of the posterior aspect of the shoulder inferior to the scapular spine. The suprascapular nerve provides only motor function and does not provide any sensory function to the shoulder girdle; therefore, sensory deficits will not be present in this patient.

Question 883

Topic: 9. Shoulder and Elbow
  • Following closed reduction for the injury shown in Figures 69a and 69b, treatment should consist of

. repair or reconstruction of the medial collateral ligament
. repair or reconstruction of the medial
. and lateral collateral ligaments
. immobilization for 5 days or less
. immobilization for 14 days
. immobilization for 25 days

Correct Answer & Explanation

. repair or reconstruction of the medial collateral ligament

Explanation

Repair or reconstruction of the medial collateral ligament-The mechanism of dislocation during a fall on the outstretched hand would involve the body rotating internally on the elbow, which experiences an external rotation/valgus moment as it flexes. Posterior dislocations should therefore be reduced in supination. If valgus stability in pronation is demonstrated, the AMCL can be assumed to be intact, and rehabilitation in a hinged cast-brace with the elbow in full pronation can be commenced immediately.Repair or reconstruction of the medial and lateral collateral ligaments-Acute dislocations can be reduced in supination and tested for valgus stability in pronation. Treatment is determined by the stability following reduction. When there are fractures, the principle is to fix the bones so that the only limitation is the ligaments and then to repair them if the elbow is not stable enough to permit early motion.Immobilization for 14 days-The longer the immobilization had been, the larger the flexion contracture (p less than 0.001) and the more severe the symptoms of pain were. The results indicate that early active motion is the key factor in rehabilitation of the elbow after a dislocation. Simple dislocation of the elbow in the adult. Results afterclosed treatment. Immobilization for 25 days- See above.

Question 884

Topic: 9. Shoulder and Elbow
A 68-year-old woman with serologically proven rheumatoid arthritis underwent an open synovectomy and radial head resection 10 years ago. She now has severe pain that has failed to respond to nonsurgical management. Examination reveals a flexion arc of greater than 90 degrees. Radiographs are shown in Figures 15a and 15b. What is the most appropriate management?
. Semiconstrained total elbow arthroplasty
. Unconstrained total elbow arthroplasty
. Fascial arthroplasty
. Open synovectomy
. Arthroscopic synovectomy

Correct Answer & Explanation

. Semiconstrained total elbow arthroplasty

Explanation

The radiographs reveal severe arthritic changes with no joint space, and the AP view shows a progressive malalignment secondary to the radial head resection. A prosthetic arthroplasty is indicated given the severe arthritis (Larsen grade III). Unconstrained arthroplasties have not performed as well as semiconstrained arthroplasties after previous radial head resections. However, both types of arthroplasties performed better in native elbows. Synovectomies should be reserved for less advanced disease states.

Question 885

Topic: 9. Shoulder and Elbow
An 18-year-old collegiate football player injures his right shoulder during a tackle. He reports pain and numbness in the shoulder and numbness radiating to his fingers. His symptoms improve within 15 minutes and he has no residual symptoms. This condition is best known as
. acute and transient spinal cord injury.
. central cord syndrome.
. nerve root avulsion.
. Guillain-Barre syndrome.
. stinger/burner.

Correct Answer & Explanation

. stinger/burner.

Explanation

The condition described in this case is known as a stinger or burner. It is caused by stretching the upper trunk of the brachial plexus in the C5 and C6 nerve roots. The symptoms are temporary and last 15 to 20 minutes. There are no residual deficits, unless the patient has had multiple repetitive injuries. Once motor and sensory examination findings and reflexes have normalized, the athlete can return to play. Acute spinal cord injury may cause temporary complete paralysis in the upper and lower extremities with resolution of symptoms within 24 hours. Central cord syndrome affects the upper more than lower extremities and affects mostly elderly patients. Nerve root avulsions lead to permanent deficits and have a poor prognosis for return of function. Guillain-Barre syndrome is an autoimmune disease that presents as an ascending paralysis with weakness in the legs that spreads to the upper limbs and the face along with complete loss of deep tendon reflexes.

Question 886

Topic: 9. Shoulder and Elbow
A 59-year-old man reports moderate shoulder pain and very restricted range of motion after undergoing humeral arthroplasty for osteoarthritis 1 year ago. An AP radiograph is shown in Figure 32. Management should now consist of
. an aggressive program of stretching exercises.
. soft-tissue release and subscapularis lengthening.
. exchange of the modular humeral head to a smaller size, with glenoid arthroplasty.
. revision of the humeral component, re-cutting of the humeral neck, soft-tissue releases, and glenoid arthroplasty.
. glenohumeral arthrodesis.

Correct Answer & Explanation

. revision of the humeral component, re-cutting of the humeral neck, soft-tissue releases, and glenoid arthroplasty.

Explanation

The radiograph reveals that an insufficient amount of the proximal humerus was excised in the index procedure, resulting in malalignment of the humeral component, overstuffing of the glenohumeral joint, and glenoid arthritis. It is unlikely that physical therapy or soft-tissue releases alone will be adequate. Revision of the humeral component, recutting of the proximal humerus to allow a more anatomic alignment of the humeral component, appropriate soft-tissue releases, and glenoid arthroplasty will offer the best chance of improvement in this difficult situation.

Question 887

Topic: Elbow & Forearm
A 20-year-old man sustained an injury to his arm during a tug-of-war contest. An MRI scan is shown in Figure 18. What is the most likely diagnosis?
. Lipoma
. Proximal biceps rupture
. Distal biceps rupture
. Biceps and brachialis rupture
. Biceps brachii transection

Correct Answer & Explanation

. Biceps brachii transection

Explanation

DISCUSSION: The MRI scan reveals a transection of the biceps muscle. The underlying brachialis is intact. This injury can occur as a result of a cord wrapped around the upper arm. Care should be taken to ensure that there is no concurrent vascular injury.

Question 888

Topic: 9. Shoulder and Elbow

Reverse total shoulder arthroplasty improves kinematics in the rotator cuff deficient joint by what directional change to the center of rotation? Review Topic

. Medial
. Lateral
. Posterior
. Proximal

Correct Answer & Explanation

. Medial

Explanation

Surgical indications for reverse total shoulder arthroplasty are expanding. In the setting of rotator cuff tear arthroplasty in which the native humeral head migrates superiorly, these implants impart several kinematic advantages. Implant center of rotation medial to the former joint surface improves glenoid component stability as the resultant force vector passes through the component throughout the arc of motion. A stable and fixed fulcrum for elevation is provided by matched radius of curvature between the glenoid and humeral components. A more distal center of rotation increases resting length and tone of the deltoid muscle, improving its effectiveness as a shoulder elevator. Medialized joint center of rotation increases the moment arm of the deltoid, requiring less muscle force to produce a given torque. This results in decreased articular shear stress.

Question 889

Topic: 9. Shoulder and Elbow
The essential lesion responsible for posterolateral rotatory instability of the elbow is disruption of the:
. lateral ulnar collateral ligament.
. medial collateral ligament.
. radial collateral ligament.
. annular ligament.
. posterolateral capsule.

Correct Answer & Explanation

. lateral ulnar collateral ligament.

Explanation

Posterolateral rotatory instability (PLRI) of the elbow represents a three-dimensional injury pattern of rotational displacement of the ulna from the trochlea and the radius from the capitellum. The ulna supinates (externally rotates) past its normal limit and the radiocapitellar joint subluxates posterolaterally, permitting the coronoid process to slide beneath the trochlea. In cadaver studies, the lateral ulnar collateral ligament has been shown to be the essential lesion responsible for PLRI. The medial collateral ligament (of which the anterior bundle is the most important) is the primary restraint to valgus instability. The posterolateral capsule and radial collateral ligament may be disrupted in a complete posterolateral dislocation but are not essential injuries for PLRI. The primary function of the annular ligament is to stabilize the proximal radioulnar joint.

Question 890

Topic: Shoulder Pathology
  • A 32-year-old has diffuse pain, weakness, and limited overhead motion in the shoulder as a result of falling on his outstretched arm 2 months ago. Examination reveals medial scapular winging, and an electromyogram shows denervation of the long thoracic nerve. Management should consist of
. scapulothoracic fusion
. strengthening of the periscapular muscles
. pectoralis minor-fascia lata graft transfer to the scapula
. pectoralis major-fascia lata graft transfer to the scapula
. exploration of the long thoracic nerve, with sural nerve graft

Correct Answer & Explanation

. pectoralis major-fascia lata graft transfer to the scapula

Explanation

Most cases of isolated serratus anterior palsy resolve spontaneously, usually within 6 to 9 months after traumatic injury and within 2 years after an infectious cause. Pectoralis major-fascia lata graft is an effective treatment for persistent winging.

Question 891

Topic: 9. Shoulder and Elbow

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral Review Topic

. abduction and external rotation.
. abduction and internal rotation.
. adduction and external rotation.
. adduction and internal rotation.
. external rotation and forward flexion.

Correct Answer & Explanation

. abduction and external rotation.

Explanation

Nonsurgical management is considered for proximal tears as well as partial tears in some individuals. Surgical management is often not appropriate in older or sedentary patients. However, patients treated nonsurgically will have a significant cosmetic defect, as well as weakness in adduction and internal rotation.

Question 892

Topic: 9. Shoulder and Elbow

A 43-year-old woman has a 2-week history of right shoulder pain. She denies any injury to initiate her symptoms but states that she has shoulder pain with range of motion and lifting objects. Examination reveals mild pain with abduction, empty can testing, and with the Neer and Hawkins impingement tests. Her range of motion with the right shoulder reveals passive forward flexion to 90 degrees, abduction to 90 degrees, external rotation at the side to 15 degrees, and internal rotation to her buttock. The uninvolved left shoulder has forward flexion to 160 degrees, abduction to 150 degrees, external rotation at the side to 60 degrees, and internal rotation to T6. Radiographs of the shoulder are normal. What is the next most appropriate step in management? Review Topic

. Home exercise program
. Sling at all times until her pain decreases
. Closed manipulation under anesthesia
. Arthroscopic rotator cuff repair
. Arthroscopic anterior and posterior capsular release

Correct Answer & Explanation

. Home exercise program

Explanation

The patient has the recent onset of adhesive capsulitis, which is characterized by loss of both active and passive range of motion. A home exercise program is as helpful as organized therapy to improve her range of motion. While a sling might be appropriate for comfort, continuous use might increase her shoulder stiffness. Surgical treatments, such as a manipulation under anesthesia or arthroscopic capsular release, might be necessary if her motion cannot be restored with physical therapy and home exercises. However, the natural history of idiopathic adhesive capsulitis is self limited and does not usually require surgery. An arthroscopic rotator cuff repair is not indicated because she does not have a rotator cuff tear.

Question 893

Topic: 9. Shoulder and Elbow
What is the most common complication after distal biceps tendon repair at the elbow?
. Lateral antebrachial cutaneous neuritis
. Radial sensory neuritis
. Symptomatic heterotopic ossification
. Rupture of the repair

Correct Answer & Explanation

. Lateral antebrachial cutaneous neuritis

Explanation

Cain and associates retrospectively reviewed 198 consecutive surgical repairs of the biceps and noted a 36% overall complication rate, including 26% paresthesia of the lateral antebrachial cutaneous nerve, 6% paresthesia of the sensory branch of the radial nerve, 2% superficial infection, 4% injury to the posterior interosseous nerve, 3% symptomatic heterotopic ossification, and 2% rerupture.

Question 894

Topic: 9. Shoulder and Elbow

A 74-year-old man underwent a hemiarthroplasty with acromioplasty for rotator cuff tear arthropathy 2 years ago. Despite continued therapy, he is still unable to elevate his arm beyond 40 degrees. Attempted elevation is painful and demonstrates bulging in the anterosuperior aspect of his shoulder. Radiographs show a well-positioned hemiarthroplasty without signs of loosening. What is the most appropriate treatment for this patient? Review Topic

. Conversion to a total shoulder arthroplasty
. Conversion to a reverse shoulder arthroplasty
. Continued physical therapy
. Cortisone injection
. Anti-inflammatory medication

Correct Answer & Explanation

. Conversion to a total shoulder arthroplasty

Explanation

The patient is experiencing anterosuperior escape with attempted shoulder elevation. A conversion to a reverse shoulder arthroplasty will provide the stability to allow active elevation without subluxation. Further physical therapy, cortisone injection, or anti-inflammatory medication will not resolve this instability. A total shoulder arthroplasty is contraindicated because of the anterosuperior escape.

Question 895

Topic: 9. Shoulder and Elbow
What is the most common complaint in patients with a developmental radial head dislocation?
. Pain
. Recurrent elbow subluxation
. Limitation of extension
. Cosmetic deformity
. Locking

Correct Answer & Explanation

. Cosmetic deformity

Explanation

DISCUSSION: Developmental dislocation of the radial head most frequently presents as a painless mass over the posterior aspect of the elbow. Patients do not have feelings of elbow subluxation but may report pain or clicking. Limitation of motion is most frequently found in the pronation and supination arc rather than in flexion and extension.

Question 896

Topic: 9. Shoulder and Elbow
Patients who have osteonecrosis of the humeral head and who have the best prognosis are those with which of the following conditions?
. Sickle cell disease
. Associated malunion
. Alcoholic-induced disease
. Previously received high-dose steroids
. Postradiation necrosis

Correct Answer & Explanation

. Sickle cell disease

Explanation

DISCUSSION: The natural history of nontraumatic osteonecrosis varies greatly, so it is difficult to predict which patients will have severe arthrosis develop. Patients with sickle cell disease tend to have the most benign course. The most commonly reported cause of nontraumatic osteonecrosis is corticosteroid therapy.

Question 897

Topic: Elbow & Forearm
Rupture of the structure shown in the axial cross and the sagittal sections in Figures 100a and 100b causes weakness in
. extension and supination.
. pronation.
. flexion and pronation.
. flexion and supination.

Correct Answer & Explanation

. flexion and supination.

Explanation

The structure identified is the distal biceps tendon. Rupture of this tendon causes weakness in both flexion and supination. The biceps tendon does not affect extension or pronation.

Question 898

Topic: 9. Shoulder and Elbow
When the elbow is extended and an axial load is applied, what percent of stress distribution occurs across the ulnohumeral and radiohumeral articular surface, respectively?
. 20% and 80%
. 40% and 60%
. 50% and 50%
. 60% and 40%
. 80% and 20%

Correct Answer & Explanation

. 40% and 60%

Explanation

When load is applied to the wrist, most of the stress is absorbed by the radius. As the load is transferred through the forearm, the interosseous membrane transfers some of the load from the radius to the ulna. The load at the elbow is distributed with 40% at the ulnohumeral articulation and 60% at the radiohumeral articulation.

Question 899

Topic: 9. Shoulder and Elbow

A 22-year-old javelin thrower reports that he has had increasing discomfort in his right elbow and loss of distance from his throws for the past 3 months. Examination reveals tenderness over the medial elbow. Application of valgus torque to the elbow through a passive range of motion elicits pain from 70 degrees to 120 degrees of flexion, with no pain at the limits of extension. What structure is primarily responsible for the patient's symptoms? Review Topic

. Anterior bundle of the medial collateral ligament (MCL)
. Posterior bundle of the MCL
. Annular ligament
. Triceps insertion
. Olecranon osteophytes

Correct Answer & Explanation

. Anterior bundle of the medial collateral ligament (MCL)

Explanation

The MCL is divided into anterior and posterior bundles; the anterior bundle is subdivided into anterior and posterior bands. Sectioning studies showed that the anterior band of the anterior bundle is the primary restraint to valgus stress at 30 degrees, 60 degrees, and 90 degrees; the posterior band of the anterior bundle is the primary restraint at 120 degrees. Medial elbow pathology in a throwing athlete can present with pain, instability, loss of velocity or control, or with ulnar nerve symptoms. Differentiating between different causes of disability can be largely accomplished through physical examination. The moving valgus stress test is performed by applying a valgus stress to a maximally flexed elbow, then passively extending the elbow. Reproduction of the patient's symptoms in the mid arc of flexion suggests MCL insufficiency. Pain at the end point of extension suggests posterior compartment symptoms, which were not present in this patient. The posterior bundleis a secondary stabilizer at 30 degrees of flexion, and not susceptible to valgus load when the anterior bundle is intact. The annular ligament and triceps insertion are not involved with medial instability of the elbow. Olecranon osteophytes likely cause pain in terminal extension of the elbow.

Question 900

Topic: Elbow & Forearm

A 25-year-old athlete presents with symptoms attributed to injury to ligament D in Figure A. Which of the following symptoms and signs is characteristic of this injury? Review Topic

. Pain during late cocking and acceleration; milking maneuver.
. Painful clicking during pushoff from armrests of a chair; milking maneuver.
. Painful clicking during pushoff from armrests of a chair; lateral pivot shift.
. Pain during late cocking and acceleration; lateral pivot shift.
. Painful clicking during pushoff from armrests of a chair; moving valgus stress test.

Correct Answer & Explanation

. Pain during late cocking and acceleration; milking maneuver.

Explanation

This patient has rupture of the lateral ulnar collateral ligament (LUCL), producing posterolateral rotatory instability (PLRI). This is best demonstrated with a positive lateral pivot shift test.PLRI can be diagnosed using the lateral pivot shift or posterolateral drawer. According to O’Driscoll, the elbow dislocates in 3 stages from lateral to medial (circle of Horii). Stage 1 involves disruption of the LUCL and partial/total disruption of the LCL complex (creating PLRI). Patients have pain with varus stress. Stage 2 includes disruption of the anterior capsule from incomplete elbow posterolateral dislocation. Stage 3 is divided into:(a) Disruption of all soft tissues surrounding/ including the posterior MCL except for the anterior bundle. This bundle forms the pivot around which the elbow dislocates in a posterior direction by way of a posterolateral rotatory mechanism; and (b) complete disruption of the MCL.O'Driscoll et al. describe PLRI diagnosed in 5 patients who had elbow dislocation using the posterolateral rotatory instability test, which they describe as being analogous to the test for lateral rotatory instability of the knee after ACL rupture. They believed the condition was laxity of the LUCL, which allowed transient rotatory subluxation of the ulnohumeral joint and secondary dislocation of the radiohumeral joint, without radio-ulnar joint dislocation. They recommended repair of the LUCL to eliminate PLRI.Sanchez-Sotelo et al. retrospectively described 12 cases of direct repair and 33 ligamentous reconstructions for PLRI. 86% were satisfied with the procedure. Better results were obtained with patients with post-traumatic etiology, instability at presentation, and those with augmented reconstruction with tendon graft (compared with ligament repair alone).Figure A shows structures on the lateral side of the elbow. The corresponding labels are seen in Illustration A. Illustration B shows the lateral pivot shift (also known as the posterolateral rotatory instability test).Incorrect Answers:

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