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9. Shoulder and Elbow MCQs

Practice Set 49 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 961

Topic: 9. Shoulder and Elbow
Which of the following conditions is considered a relative contraindication to interscalene nerve block for patients scheduled to undergo shoulder surgery?
. Prior shoulder surgery
. History of deep venous thrombosis
. Controlled seizure disorder
. Respiratory insufficiency
. Obesity

Correct Answer & Explanation

. Respiratory insufficiency

Explanation

DISCUSSION: A common side effect of interscalene nerve block for shoulder surgery is the blockade of the ipsilateral phrenic nerve. This, in turn, results in paresis of the diaphragm and up to a 30% reduction in pulmonary function volumes. Therefore, interscalene nerve block generally is not recommended for patients whose respiratory function is compromised. Other relative and absolute contraindications for interscalene nerve blocks include allergy to local anesthetics, infection at the injection site, uncontrolled seizure disorder, coagulation abnormality, and preexisting neurologic injury. REFERENCES: Chelly JE: Indications for upper extremity blocks, in Chelly JE (ed): Peripheral Nerve Blocks, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 19-27. Misamore GW, Sallay PI: A prospective analysis of the safety and efficacy of interscalene brachial plexus block anesthesia for shoulder surgery. J Shoulder Elbow Surg 2007;16:e39.

Question 962

Topic: 9. Shoulder and Elbow
A 37-year-old recreational tennis player undergoes surgery for tennis elbow. Following surgery, she describes clicking and popping on the lateral aspect of the elbow. A lateral pivot shift test is positive. What is the most likely cause of her symptoms?
. Injury to the anterior band of the medial collateral ligament
. Injury to the radial nerve
. Injury to the lateral ulnar collateral ligament
. Injury to the lateral radial collateral ligament
. Excessive dissection of the extensor carpi radialis brevis origin

Correct Answer & Explanation

. Injury to the lateral ulnar collateral ligament

Explanation

The patient has a posterolateral rotatory instability (PLRI) of the elbow that is most likely the result of iatrogenic injury to the lateral ulnar collateral ligament, the main ligament implicated in PLRI. The anterior band of the medial collateral ligament is implicated in valgus instability. Injury to the radial nerve is unlikely, and the lateral radial collateral ligament makes less of a contribution to elbow stability than does the ulnar component. While the origin of the extensor carpi radialis brevis may contribute to elbow stability, it is not as important a stabilizer as the lateral ulnohumeral ligament.

Question 963

Topic: 9. Shoulder and Elbow

A 47-year-old woman with no history of trauma has had a painful, stiff shoulder for the past 3 months. Treatment consisting of subacromial injection and nonsteroidal anti-inflammatory drugs has been ineffective. Her active range of motion is painful and is limited to 90 degrees of abduction, 60 degrees of elevation, 30 degrees of external rotation, and internal rotation to the posterior superior iliac spine. Plain radiographs of the cervical spine and shoulder are normal. Management at this time should consist of

. arthroscopic capsular release
. manipulation under anesthesia
. a physical therapy program
. an intra-articular corticosteroid injection
. administration of high-dose oral corticosteroids

Correct Answer & Explanation

. arthroscopic capsular release

Explanation

Idiopathic adhesive capsulitis usually responds to nonoperative therapy or closed manipulation, but shoulder stiffness due to trauma or surgery may necessitate an arthroscopic or an open-release procedure. For most patients, a supervised physical therapy program will be successful in treating adhesive capsulitis.

Question 964

Topic: 9. Shoulder and Elbow

A young gymnast fell awkwardly onto an outstretched hand during a competition. At the time of impact, his forearm was positioned in supination. Axial and posterolateral forces were loaded along the forearm into the elbow and the elbow underwent a significant valgus thrust. What injury pattern is most likely to result from the combination of these forces at the elbow?

. Extension-type supracondylar fracture
. Flexion-type supracondylar fracture
. Anterior olecranon fracture dislocation
. Coronoid fracture, olecranon fracture and elbow dislocation
. Coronoid fracture, radial head fracture and elbow dislocation

Correct Answer & Explanation

. Extension-type supracondylar fracture

Explanation

The combination of valgus, axial, and posterolateral rotatory forces (forearm supination) can result in a "terrible triad" injury of the elbow.The key features of a terrible triad injury include a radial head fracture, coronoid fracture, and dislocation of the elbow. Disruption of the lateral collateral ligament complex often concomitantly occurs. While restoration of the bony anatomy is important for static stability, the key primary stabilizer that needs to be addressed is the lateral collateral ligament complex. In acute injuries LCL repair may be possible. In chronic injury, LCL reconstruction would need to be considered.O'Driscoll et al. 1991, examined 5 patients with recurrent posterolateral rotatory instability of the elbow. They showed that by applying supination of the forearm with a valgus moment and an axial compression force to the elbow while it is flexed from full extension, this can demonstrate posterolateral rotatory instability of the elbow. The elbow is reduced in full extension and must be subluxated as it is flexed in order to obtain a positive test result (a sudden reduction of the subluxation).O'Driscoll et al. 1992 looked at a cadaveric study of the elbow. They showed that external rotation and valgus moments with axial forces resulted in posterior dislocations in 12 of the 13 specimens when the anterior medial collateral ligament (AMCL) remained intact. Clinically, it valgus stability in pronation is demonstrated, the AMCL can be assumed to be intact.Illustration A and B shows radiographs of a terrible triad injury. There is posterolateral dislocation of the elbow with associated radial head fracture, coronoid fracture.Incorrect Answers:

Question 965

Topic: Elbow & Forearm

What is the most common complication associated with the treatment of the distal biceps ruptures as shown in Figures 79a and 79b? Review Topic

. Re-rupture
. Radioulnar synostosis
. Posterior interosseous nerve injury
. Lateral antebrachial cutaneous nerve irritation
. Radial fracture

Correct Answer & Explanation

. Re-rupture

Explanation

The patient shown underwent distal biceps repair with a button technique. Among the reports in the literature, the most commonly noted complication associated with this technique is lateral antebrachial cutaneous nerve irritation. Re-rupture, radioulnar synostosis, and posterior interosseous nerve injury can occur, but are not as common as lateral antebrachial cutaneous nerve injury.

Question 966

Topic: 9. Shoulder and Elbow

Which of the following characteristics is seen in patients with osteochondritis dissecans of the elbow? Review Topic

. MRI reveals separation of cartilage from the capitellum and chondral fissuring
. Fragmentation of the entire capitellar ossific nucleus
. Normal capitellar regrowth with no late sequelae
. Age younger than 10 years
. Medial ulnar collateral ligament laxity

Correct Answer & Explanation

. MRI reveals separation of cartilage from the capitellum and chondral fissuring

Explanation

Osteochondritis dissecans occurs in the older child or adolescent (typically older than age 13 years). It involves the lateral compartment. The etiology is felt to be microtraumatic vascular insufficiency from repetitive rotatory and compressive forces. MRI typically shows separation of cartilage from the capitellum and chondral fissuring. Pannerโ€™s disease is usually seen in children younger than age 10 years, involves the entire capitellar ossific nucleus, and resolves typically with no residual deformity or late sequelae. There is no evidence of ligamentous injury.

Question 967

Topic: 9. Shoulder and Elbow
A 25-year-old man sustains a left brachial plexus injury from a fall while rock climbing. Examination reveals poor intrinsic function of the hand, ptosis, and miosis. He is able to abduct and forward flex his shoulder with full strength. This combination of physical findings is most suggestive of what pattern of nerve injury?
. C5-C6 postganglionic injury
. C8-T1 preganglionic injury
. C5 through C7 preganglionic injury
. C8-T1 postganglionic injury

Correct Answer & Explanation

. C8-T1 preganglionic injury

Explanation

A preganglionic lesion occurs proximal to the spinal foramen, whereas a postganglionic lesion occurs distal to the spinal foramen in the root, trunk, division, cord, or branches of the brachial plexus. The Horner sign, which is characterized by miosis, ptosis, anhydrosis, and enophthalmos, results from an injury to the sympathetic ganglion, which lies in close proximity to the T1 root level. The presence of a Horner sign is highly suggestive of a T1 preganglionic injury. Other physical examination indicators of a preganglionic injury include atrophy of the parascapular muscles (injury to the dorsal rami of the cervical spinal nerve roots), winged scapula (injury to the long thoracic nerve) and hemidiaphragmatic paralysis (phrenic nerve injury). The lack of intrinsic hand function in this patient is also suggestive of an injury at the level of C8-T1. Preservation of shoulder abduction and forward flexion would not typically be seen with an injury to the C5-C6 roots or the upper trunk.

Question 968

Topic: Elbow & Forearm
A 13-year-old gymnast has had recurrent right elbow pain for the past year. She denies any history of trauma. Rest and anti-inflammatory drugs have failed to provide relief. Examination reveals no localized tenderness and only slight loss of both flexion and extension (10 degrees). What is the most likely diagnosis?
. Recurrent valgus overload (medial collateral ligament sprain)
. Posterior lateral rotatory instability
. Biceps tendinitis
. Medial epicondylitis
. Osteochondritis of the capitellum

Correct Answer & Explanation

. Osteochondritis of the capitellum

Explanation

Osteochondritis of the capitellum is characterized by pain, swelling, and limited motion. Catching, clicking, and giving way also can occur. It commonly affects athletes who participate in competitive sports with high stresses, such as pitching or gymnastics.

Question 969

Topic: Shoulder Pathology
Figure 17 shows the clinical photograph of a 45-year-old female tennis player who has right arm pain and weakness with elevation after undergoing a cervical biopsy several months ago. The cause of her shoulder weakness is damage to the:
. spinal accessory nerve, causing shoulder elevation with the scapula translated and the inferior angle rotated medially.
. spinal accessory nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.
. long thoracic nerve, causing shoulder elevation with the scapula translated medially and the inferior angle rotated medially.
. long thoracic nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.
. thoracodorsal nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.

Correct Answer & Explanation

. spinal accessory nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.

Explanation

DISCUSSION: The patient has primary scapulotrapezius winging caused by surgical damage to the spinal accessory nerve during a lymph node biopsy. Other causes include blunt trauma, traction, and penetrating injuries. With spinal accessory palsy, the shoulder appears depressed and laterally translated because of unopposed serratus anterior muscle function. With primary serratus anterior winging that is the result of long thoracic nerve palsy, the scapula assumes a position of elevation and medial translation with the inferior angle rotated medially. The thoracodorsal nerve innervates the latissimus dorsi and is not associated with scapular winging. REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325. Wright TA: Accessory spinal nerve injury. Clin Orthop 1975;109:15-18.

Question 970

Topic: 9. Shoulder and Elbow

If the structure marked by the tip of the probe in Figure 94 is repaired to the bony glenoid with suture anchors during an arthroscopic stabilization procedure, what is the most likely result? Review Topic

. Loss of external rotation with the glenohumeral joint abducted 90 degrees
. Loss of external rotation with the arm at the side of the body
. Loss of internal rotation with the glenohumeral joint abducted 90 degrees
. Loss of internal rotation up the back
. Loss of flexion

Correct Answer & Explanation

. Loss of external rotation with the arm at the side of the body

Explanation

The probe is on the middle glenohumeral ligament (MGHL), which, in this case, is a cord-like and robust structure, commonly known as a Buford complex. The space between the bony glenoid and the MGHL (in this case, a cord-like Buford complex) is a normal variant and should not be repaired or tightened to the bony glenoid with a soft-tissue anchor or other repair. If this structure is inadvertently repaired, the most common scenario is loss of external rotation with the arm at the side, as the MGHL/Buford complex becomes tight with the arm in this position. The loss of external rotation is more pronounced with the arm at the side than abducted at 90 degrees as the MGHL/Buford complex becomes tighter with the arm at the side than abducted.

Question 971

Topic: 9. Shoulder and Elbow

An MRI arthrogram of the elbow is shown in Figure 6. Based on these findings, what is the most likely diagnosis? Review Topic

. Rupture of the medial collateral ligament
. Rupture of the lateral collateral ligament
. Intra-articular loose body
. Flexor-pronator injury
. Extensor origin avulsion

Correct Answer & Explanation

. Rupture of the medial collateral ligament

Explanation

Carrino JA, Morrison WB, Zou KH, et al: Noncontrast MR imaging and MR arthrography of the ulnar collateral ligament of the elbow: Prospective evaluation of two-dimensional pulse sequences for detection of complete tears. Skeletal Radiol 2001;30:625-632.

Question 972

Topic: 9. Shoulder and Elbow
A 16-year-old cheerleader reports an ache in the right shoulder and arm that is worse after activity. She denies any history of acute trauma. Examination reveals a positive sulcus sign and an AP glide test with a posterior and anterior apprehension sign. To confirm a diagnosis of multidirectional instability, which of the following imaging studies is most appropriate?
. Ultrasound
. CT
. Bone scan
. Scapular Y-view of the shoulder
. Stress views of the shoulder

Correct Answer & Explanation

. Stress views of the shoulder

Explanation

DISCUSSION: Multidirectional instability is a common finding in young female athletes. The anatomic structures are all intact but are hypermobile; therefore, CT and bone scans and scapular Y-views are often normal. Obtaining a weighted or AP stress view while applying downward traction on the arm will document instability and hypermobility of the joint. MRI generally is not indicated in this condition. Ultrasound is used primarily for rotator cuff pathology. REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908. Warner JJ, Johnson D, Miller M, Caborn DN: Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability. J Shoulder Elbow Surg 1995;4:352-364.

Question 973

Topic: 9. Shoulder and Elbow
A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a โ€œpop.โ€ He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow. Which type of contraction of the involved muscle most likely resulted in this lineman's injury?
. Eccentric
. Concentric
. Isometric
. Isokinetic

Correct Answer & Explanation

. Eccentric

Explanation

This patient had an eccentric muscle contraction (muscle lengthening while contracting) of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps muscle belly). Eccentric contractions have the highest potential for building strength but also are at highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle length with contraction), and isokinetic (constant velocity of muscle contraction with a variable force) do not describe the mechanism detailed.

Question 974

Topic: 9. Shoulder and Elbow
Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral
. Abduction and external rotation
. Abduction and internal rotation
. Adduction and external rotation
. Adduction and internal rotation
. External rotation and forward flexion

Correct Answer & Explanation

. Adduction and internal 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 975

Topic: 9. Shoulder and Elbow
A 45-year-old man reports that he awoke 2 weeks ago with severe pain in his right arm. Examination reveals weakness in the biceps, brachialis, and wrist extensors. There is decreased sensation in the thumb and index finger and a diminished brachioradialis reflex. Assuming this patient has a posterolateral herniated nucleus pulposus, what level is involved?
. C2-3
. C3-4
. C4-5
. C5-6
. C6-7

Correct Answer & Explanation

. C5-6

Explanation

This is a classic C6 nerve injury, and it is most likely the result of a herniated nucleus pulposus at C5-6. The C5 nerve root controls the elbow flexors, shoulder abductors, and external rotators. The C7 nerve root controls the elbow extensors, wrist pronators, and the triceps reflex.

Question 976

Topic: Elbow & Forearm

A 34-year-old man presents to clinic with 4 months of right elbow pain. He began going to the gym and playing squash about 3 months ago. On exam, he is tender over the lateral aspect of the elbow and has pain with resisted wrist extension. Which of the following choices lists the correct compartment of the muscle typically involved in this disease and then lists its antagonist muscle? Review Topic

. posterior; flexor carpi radialis
. posterior; flexor carpi ulnaris
. posterior; flexor digitorum superficialis to the long finger
. mobile wad; flexor carpi radialis
. mobile wad; flexor carpi ulnaris

Correct Answer & Explanation

. mobile wad; flexor carpi ulnaris

Explanation

The patient presents with lateral epicondylitis, which typically involves the origin of the extensor carpi radialis brevis (ECRB). ECRB is in the mobile wad compartment and its antagonist muscle is flexor carpi ulnaris.Lateral epicondylitis is an overuse injury, typically secondary to repetitive pronation and supination motion in extension, that leads to inflammation of the ECRB origin at the elbow. Histological analysis typically shows vascular hyperplasia and disorganized collagen. Clinically, patients will have pain over the lateral elbow exacerbated by resisted wrist extension. ECRB, the most commonly involved muscle origin, is innervated by the deep branch of the radial nerve and inserts on the base of the 3rd metacarpal. As it is radial wrist extensor, its antagonist is the ulnar sided wrist flexor.Brummel et al. reviewed the clinical presentation and management options for lateral epicondylitis. They report acute symptoms in younger patients and chronic symptoms in older patients. NSAIDs, extensor stretching and activity modification are the mainstay of nonsurgical treatment.Bunata et al. studies 85 cadavar elbows to determine anatomic factors contributing to tennis elbow. They found that the ECRB undersurface rubs against the lateral capitellium in elbow extension leading to tendinosis.Illustration A is cross-sectional diagram of the forearm with muscle bellies labeled. Notice the location of ECRB in the mobile wad. Illustration B is a coronal T2 MRI showing fluid signal and undersurface tearing near the extensor origin as can be seen in lateral epicondylitis.Incorrect Answers:1-4: The ECRB is in the mobile wad and its antagonist is flexor carpi ulnaris. All other answers are incorrect.

Question 977

Topic: 9. Shoulder and Elbow

A 45-year-old construction worker sees a surgeon 23 days after sustaining an eccentric injury to his dominant right elbow. An MRI demonstrates a distal biceps tendon rupture with 5 cm of proximal retraction. In the operating room, the surgeon encounters good tissue quality but finds that primary repair can only be performed with the elbow hyperflexed to 70ยฐ. What is the best next step?

. Proceed with primary repair with the elbow hyperflexed
. Use interposition allograft to reconstruct with elbow in extension
. Tenodese distal biceps tendon to underlying brachialis muscle
. Forego primary repair, but perform stump debridement

Correct Answer & Explanation

. Proceed with primary repair with the elbow hyperflexed

Explanation

Distal biceps ruptures, although relatively less common in comparison with other upper extremity tendon injuries, still garner considerable attention in the orthopaedic literature. The mechanism of injury typically results from an eccentric extension load to a flexed elbow. A biceps-deficient arm can result in up to 40% loss of supination strength and up to 80% loss of supination endurance. A delay in diagnosis can compromise the ability to reduce the tendon back to its anatomic insertion without having to hyperflex the elbow. Current literature confirms the ability to safely proceed with primary repair even with the elbow flexed up to 100ยฐ without fear of developing a flexion contracture. With time, patients can anticipate restoration of full elbow extension. An interposition graft should be used for a poor residual tendon quality stump <4 cm in length and in cases of delay to surgery of >6 weeks. Biceps to brachialis tendon transfer does not restore supinationstrength. Isolated debridement of the distal tendon would not be an appropriate treatment.

Question 978

Topic: 9. Shoulder and Elbow
With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus?
. Coracohumeral
. Superior glenohumeral
. Middle glenohumeral
. Anterior band of the inferior glenohumeral ligament complex
. Posterior band of the inferior glenohumeral ligament complex

Correct Answer & Explanation

. Anterior band of the inferior glenohumeral ligament complex

Explanation

With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45 degrees. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated.

Question 979

Topic: 9. Shoulder and Elbow

A 22-year-old man reports that he initially dislocated his shoulder while playing basketball 2 years ago and was subsequently treated with an arthroscopic Bankart repair. Despite appropriate rehabilitation, the patient continues to report recurrent instability. An axillary view radiograph and CT scan are shown in Figures 57a and 57b. What is the most appropriate management at this time? Review Topic

. Supervised physical therapy
. Arthroscopic capsulorrhaphy and labral repair
. Open shoulder capsulorrhaphy and labral repair
. Open shoulder capsulorrhaphy and bone block
. Shoulder arthrodesis

Correct Answer & Explanation

. Supervised physical therapy

Explanation

Although the changes are subtle on the radiograph, an anterior inferior glenoid bone defect is clearly evident on the CT scan. With loss of greater than 20% to 25% of the glenoid width, patients may experience persistent instability despite appropriate labral repair and capsulorrhaphy. Therefore, nonsurgical management with supervised therapy or surgical treatments that do not address the bony defect, such as arthroscopic or open labral repair and capsulorrhaphy, are not likely to stabilize the joint. An open shoulder stabilization procedure with a bone block should address the defect and stabilize the joint. Shoulder arthrodesis is not warranted in this patient at this time because the shoulder is likely salvageable.

Question 980

Topic: 9. Shoulder and Elbow
A baseball player has had diffuse scapular soreness for the past 8 weeks. He reports that it began insidiously over several days and gradually has become worse. He denies any history of trauma. Examination reveals drooping of the shoulder, with lateral winging of the scapula at rest. He is otherwise neurologically intact. What is the best course of action?
. Immediate MRI of the brain
. Electromyography and nerve conduction velocity studies
. Physical therapy and observation
. Lyme titer
. Psychiatric consultation

Correct Answer & Explanation

. Electromyography and nerve conduction velocity studies

Explanation

Lateral scapular winging is characteristic of trapezius palsy, whereas medial scapular winging is characteristic of long thoracic nerve palsy. During sports activity, injury to the spinal accessory nerve is rare but may occur with blunt or stretching trauma. Patients often report an asymmetric neckline, drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination.

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