Menu

9. Shoulder and Elbow MCQs

Practice Set 50 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 981

Topic: 9. Shoulder and Elbow
A 35-year-old man who is an avid weight lifter competing in local tournaments reports new onset pain and loss of motion in his dominant right shoulder. Examination reveals joint line tenderness, active elevation to 100 degrees, and external rotation to 10 degrees. His contralateral shoulder reveals 170 degrees forward elevation and 50 degrees external rotation. Radiographs are shown in Figures 46a and 46b. What is the next most appropriate step in management?
. Total shoulder arthroplasty
. Hemiarthroplasty with glenoid interposition
. Surface replacement hemiarthroplasty
. Arthroscopic debridement
. Anti-inflammatory drugs and a range-of-motion stretching program

Correct Answer & Explanation

. Anti-inflammatory drugs and a range-of-motion stretching program

Explanation

New onset pain and stiffness in the young arthritic shoulder is a difficult problem to treat. Initial management should be aimed at reducing pain and improving motion in all planes. This patient’s activities and age preclude a shoulder arthroplasty at this time. If nonsurgical management fails to provide relief, then arthroscopic debridement and capsular release may be beneficial.

Question 982

Topic: 9. Shoulder and Elbow

A 67-year-old man with right shoulder osteoarthritis (OA) remains symptomatic despite a course of nonsurgical treatment. A CT scan of the shoulder shows eccentric posterior glenoid wear with 10° of retroversion. What is the appropriate management of this glenoid bone loss during surgery for an anatomic total shoulder arthroplasty?

. In situ glenoid component implantation
. Hemiarthroplasty
. Eccentric reaming of glenoid
. Posterior glenoid bone graft

Correct Answer & Explanation

. Eccentric reaming of glenoid

Explanation

Total shoulder arthroplasty (TSA) is superior to hemiarthroplasty for primary OA. The most common complication of TSA is glenoid loosening and malposition, which are common causes of glenoid failure. Glenoid malposition decreases the glenohumeral contact area and subsequently increases contact pressures. Altering the stem version to accommodate glenoid retroversion does not appropriately address soft-tissue balancing. A retroversion of <12° to 15° can be corrected with eccentric reaming without excessively compromising glenoid bone stock and risking glenoid vault penetration by the glenoid component. Posteriorglenoid bone grafting may be considered for glenoid retroversion >15°.

Question 983

Topic: 9. Shoulder and Elbow
In a patient with a C5-6 herniation, the most likely sensory deficit will be in the
. lateral shoulder.
. radial forearm, thumb, and index finger.
. dorsal forearm and middle finger.
. ulnar forearm, ring finger, and little finger.
. volar forearm and palm.

Correct Answer & Explanation

. radial forearm, thumb, and index finger.

Explanation

DISCUSSION: A C5-6 herniation compresses the C6 root, which innervates the radial forearm, thumb, and index finger. The lateral shoulder is innervated by C5. The dorsal forearm and the middle finger typically are innervated by C7. The ulnar forearm, ring finger, and little finger are innervated by C8. There is no specific nerve associated with the volar forearm and palm.

Question 984

Topic: 9. Shoulder and Elbow

A 53-year-old woman reports a 4-month history of gradual onset diffuse shoulder pain and limited function. She has had no prior treatment, and her medical history is unremarkable. Examination reveals globally painful active range of motion to 120 degrees forward elevation, 25 degrees external rotation with the arm at the side, and internal rotation to the sacrum. Passive range of motion is also limited in comparison with the contralateral shoulder. Radiographs are shown in Figures 31a through 31c. What is the most appropriate management? Review Topic

. Sling immobilization and rest
. Physical therapy for aggressive stretching
. Intra-articular corticosteroid injection and stretching program
. Manipulation of the shoulder under anesthesia
. Arthroscopic subacromial decompression and capsular release

Correct Answer & Explanation

. Sling immobilization and rest

Explanation

The patient has stage II adhesive capsulitis. Patients most commonly affected are women between the ages of 40 and 60, and most cases are considered idiopathic. The preferred method of treatment is an intra-articular corticosteroid injection to decrease inflammation in the joint and allow for a gentle stretching therapy program. Sling immobilization is contraindicated because it likely will promote further joint contracture and prolonged recovery. Aggressive capsular stretching in the early stages of the disease is often counterproductive, unless pain can be adequately controlled with medication or injections. Manipulation under anesthesia and arthroscopic surgical treatment are used when symptoms remain refractory despite initial nonsurgical management.

Question 985

Topic: 9. Shoulder and Elbow

A 45-year-old tennis player undergoes surgery for chronic lateral epicondylitis. After returning to play, he notes increasing lateral elbow pain with mechanical catching and locking. Examination shows positive supine posterolateral rotatory instability. What ligament has been injured? Review Topic

. Annular
. Anterior band of the medial collateral
. Lateral orbicular
. Lateral radial collateral
. Lateral ulnar collateral

Correct Answer & Explanation

. Annular

Explanation

The patient has sustained an iatrogenic injury to the lateral ulnar collateral ligament. This injury has been reported after lateral approaches to the elbow. The orbicular, annular, and lateral radial collateral ligaments have a much less important role in lateral elbow stability. The anterior band of the ulnar collateral ligament is on the medial side of the elbow and is important for valgus stability.

Question 986

Topic: 9. Shoulder and Elbow

A 4-month-old infant is unable to flex her elbow as a result of an obstetrical brachial plexus palsy. This most likely illustrates a predominate injury to what structure? Review Topic

. C4
. Upper trunk
. Posterior cord
. Lateral cord
. Musculocutaneous nerve

Correct Answer & Explanation

. C4

Explanation

Erb’s palsy is the most common form of obstetrical plexus palsy resulting in C5, C6, or upper trunk deficits. This causes loss of shoulder abduction and elbow flexion. The biceps muscle and the brachialis muscles are predominately responsible for flexion of the elbow. Each of these muscles is innervated by individual branches of the musculocutaneous nerve which are supplied predominately by axons from the C6 nerve root and the upper trunk of the brachial plexus

Question 987

Topic: 9. Shoulder and Elbow
A 55-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing left shoulder pain for the past 2 years despite nonsurgical management. No focal weakness is noted. Treatment should consist of:
. arthroscopic synovectomy.
. humeral arthroplasty.
. unconstrained total shoulder arthroplasty.
. constrained total shoulder arthroplasty with a fixed-fulcrum prosthesis.
. glenohumeral arthrodesis.

Correct Answer & Explanation

. unconstrained total shoulder arthroplasty.

Explanation

Unconstrained total shoulder arthroplasty has been found to yield satisfactory results in a high percentage of patients with rheumatoid involvement of the glenohumeral joint. Pain relief has been more predictable with total shoulder arthroplasty than humeral arthroplasty, and a glenoid component is favored when there is sufficient glenoid bone stock and an intact rotator cuff.

Question 988

Topic: 9. Shoulder and Elbow
A 36-year-old man reports the insidious onset of pain in the right shoulder. What is the most appropriate description of the acromial morphology shown on the MRI?
. Type I acromion
. Type III acromion
. Meso os acromiale
. Meta os acromiale
. Pre os acromiale

Correct Answer & Explanation

. Meso os acromiale

Explanation

The MRI scans reveal a meso os acromiale with edema at the site in a skeletally mature patient.

Question 989

Topic: Shoulder Arthroplasty & Arthritis

The best candidate for a reverse total shoulder arthroplasty is a patient with rotator cuff tear arthropathy with Review Topic

. anterior superior escape.
. rheumatoid arthritis.
. an acromial stress fracture.
. a centered head and an external rotation lag sign of 50 degrees.
. active forward elevation of 130 degrees.

Correct Answer & Explanation

. anterior superior escape.

Explanation

Reverse total shoulder arthroplasty is relatively contraindicated in patients with acromial stress fractures and rheumatoid arthritis. A patient with active forward elevation to 130 degrees is better treated with a hemiarthroplasty because the motion already exceeds the average forward elevation attained in most studies using the reverse prosthesis. A centered case of rotator cuff tear arthropathy is also better treated with a hemiarthroplasty, especially in patients with a large external rotation lag sign because the reverse prosthesis has been shown to decrease active external rotation. However, hemiarthroplasties have not performed well in patients with anterior superior escape and in this group of patients, the reverse prosthesis is best.

Question 990

Topic: 9. Shoulder and Elbow
Which of the following ligaments is most commonly involved in posterolateral rotatory instability of the elbow?
. Annular
. Lateral ulnar collateral
. Anterior band of the medial collateral
. Radial part of the lateral collateral
. Posterior capsular

Correct Answer & Explanation

. Lateral ulnar collateral

Explanation

Recurrent posterolateral rotatory instability of the elbow is difficult to diagnose. Such instability can be demonstrated only by the lateral pivot-shift test. The cause for this condition is laxity of the ulnar part of the lateral collateral ligament, which allows a transient rotatory subluxation of the ulnohumeral joint and a secondary dislocation of the radiohumeral joint. The annular ligament remains intact, so the radioulnar joint does not dislocate. Treatment consists of surgical reconstruction of the lax ulnar part of the lateral collateral ligament. The anterior band is the most important part of the medial collateral which is lax in valgus instability of the elbow.

Question 991

Topic: 9. Shoulder and Elbow
A 35-year-old active woman with rheumatoid arthritis experiences right shoulder pain following an extended course of corticosteroids (Figures 96a and 96b).
. Humeral head resurfacing/shoulder hemiarthroplasty
. Anatomic total shoulder arthroplasty (TSA)
. Reverse total shoulder arthroplasty (rTSA)
. Rotator cuff repair
. Open reduction and internal fixation (ORIF)

Correct Answer & Explanation

. Humeral head resurfacing/shoulder hemiarthroplasty

Explanation

The indications for hemiarthroplasty continue to narrow, but it is still a consideration for young patients with unipolar shoulder degeneration. In this 35-year-old patient, her MR image shows avascular necrosis in the humeral head, and her arthroscopy suggests arthritic change only on the humeral side with an uncompromised glenoid. To best treat young and active patients, a hemiarthroplasty that articulates with healthy glenoid cartilage can provide good pain relief and functional outcomes.

Question 992

Topic: Elbow & Forearm

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

. Resisted forearm pronation and wrist flexion with a clenched fist
. Resisted forearm supination and wrist extension with a clenched fist
. Dynamic valgus stress test
. Milking maneuver
. Pinch grip test

Correct Answer & Explanation

. Resisted forearm pronation and wrist flexion with a clenched fist

Explanation

A provocative test for medial epicondylitis can be elicited by applying resistance to a patient with their fist clenched, wrist flexed and pronated.Medial epicondylitis is an overuse syndrome of the flexor-pronator mass. The pronator teres (PT) and flexor carpi radialis (FCR) are thought to be most affected with this condition. It is most common in the dominant arm and occurs with activities that require repetitive wrist flexion/forearm pronation. Patients are most tender over the origin of PT and FCR at the medial epicondyle. Resisting a patient with their fist clenched, wrist flexed and pronated can cause worsening of their pain. This maneuver can be used as a provocative test for this condition.Cain et al. reviewed elbow injuries in throwing athletes. They comment that the common flexor-pronator muscle origin provides dynamic support to valgus stress in the throwing elbow, especially during early arm acceleration and help produce wrist flexion during ball release.Amin et al. reviewed the evaluation and management of medial epicondylitis. They report that medial epicondylitis typically occurs in the fourth through sixth decades of life, the peak working years, and equally affects men and women. Physical therapy and rehabilitation is the main aspect of recovery from medial epicondylitis, once acute symptoms have been alleviated.Illustration A shows a video of this provocative test for medial epicondylitis. Incorrect Answers:

Question 993

Topic: 9. Shoulder and Elbow
Which of the following best describes the mechanical response of the inferior glenohumeral ligament to repetitive subfailure strains?
. Decreased peak load response and length decreases
. Decreased peak load response and recoverable length increases
. Decreased peak load response and unrecoverable length increases
. Increased peak load response and recoverable length increases
. Increased peak load response and unrecoverable length increases

Correct Answer & Explanation

. Decreased peak load response and unrecoverable length increases

Explanation

DISCUSSION: Repetitive subfailure strains have been shown to affect the mechanical behavior of the inferior glenohumeral ligament, producing dramatic declines in the peak load response and length increases that are largely unrecoverable. In another study, anteroinferior subluxation was found to result in nonrecoverable strain in the anteroinferior capsule, varying from 3% to 7% through a range of joint subluxation. REFERENCES: Pollock RG, Wang VM, Bucchieri JS, et al: Effects of repetitive subfailure strains on the mechanical behavior of the inferior glenohumeral ligament. J Shoulder Elbow Surg 2000;9:427-435. Malicky DM, Kuhn JE, Frisancho JC, et al: Nonrecoverable strain fields of the anteroinferior glenohumeral capsule under subluxation. J Shoulder Elbow Surg 2002;11:529-540.

Question 994

Topic: Shoulder Pathology
A 38-year-old man has winging of the ipsilateral scapula after undergoing a transaxillary resection of the first rib 3 weeks ago. What is the most likely cause of this finding?
. Persistent thoracic outlet syndrome
. Injury to the upper trunk of the brachial plexus
. Injury to the long thoracic nerve
. Injury to the lower trunk of the brachial plexus
. Injury to the spinal accessory nerve

Correct Answer & Explanation

. Injury to the long thoracic nerve

Explanation

During transaxillary resection of the first rib, the long thoracic nerve is at risk as it passes either through or posterior to the middle scalene muscle. Injury to this nerve may occur as the result of overly aggressive retraction of the middle scalene during the procedure.

Question 995

Topic: 9. Shoulder and Elbow

Figures 51a and 51b show the AP and lateral radiographs of the elbow of a 26-year-old man who fell. Closed reduction was performed in the emergency department, and management consisted of immobilization for 3 weeks prior to the initiation of motion. At 12 weeks after injury, he reports continued feelings of instability and catching in his elbow when using his arms to rise from a chair. Which of the following procedures needs to be performed, at a minimum, to reestablish stability of the elbow? Review Topic

. Medial collateral ligament repair
. Medial collateral ligament reconstruction
. Hinged external fixation
. Lateral collateral ligament repair
. Lateral collateral ligament reconstruction

Correct Answer & Explanation

. Medial collateral ligament repair

Explanation

The patient has chronic posterolateral instability of the elbow following dislocation. The lateral collateral ligament complex is responsible for maintaining stability of the elbow. Because of the chronicity of the injury, the ligamentous tissues are frequently attenuated and not amenable to simple repair; while the native ligament can be imbricated, reconstruction with allograft or autograft is recommended. Medial collateral ligament reconstruction or hinged external fixation is needed only if restoration of the lateral ligamentous complex does not restore elbow stability; however, these procedures are rarely required. Lateral elbow pain when rising from a chair is equivalent to a positive pivot shift test.

Question 996

Topic: 9. Shoulder and Elbow
Figures 14a and 14b show the initial radiographs of an 18-year-old man who fell while snowboarding. Figures 14c and 14d show the radiographs obtained following closed reduction. Examination reveals that the elbow is stable with range of motion. Management should now consist of
. immediate return to unrestricted activity.
. a posterior long arm splint for 7 to 10 days, followed by elbow range-of-motion exercises.
. a long arm cast for 4 weeks.
. immediate surgical repair of the collateral ligaments.
. immediate surgical repair of the collateral ligaments and placement of a hinged external fixator.

Correct Answer & Explanation

. a posterior long arm splint for 7 to 10 days, followed by elbow range-of-motion exercises.

Explanation

DISCUSSION: The initial radiographs reveal a simple elbow dislocation without associated fractures. After successful closed reduction, the range of stability should be assessed. If the elbow is stable, nonsurgical management should consist of a short period of immobilization followed by range-of-motion exercises. Immobilization for more than 3 weeks results in significant elbow stiffness. Surgical repair is indicated for dislocations that are irreducible, have associated fractures, or where stability cannot be maintained with closed treatment.

Question 997

Topic: 9. Shoulder and Elbow

A 45-year-old right-hand dominant woman falls onto an outstretched left hand. Imaging shows a complex elbow dislocation. The postreduction CT scan demonstrates a reduced joint, comminuted radial head fracture, and type I coronoid fracture. Surgical intervention is recommended to address the involved structures. Which component of the intervention adds the most rotational stability?

. ixation of the coronoid fragment
. Radial head arthroplasty
. Repair or reconstruction of the lateral collateral ligament (LCL) complex
. Repair or reconstruction of the medial collateral ligament (MCL)This represents a terrible triad injury, with elbow dislocation, radial head fracture, and coronoid fracture. The LCL complex is typically disrupted in this injury pattern. Repair or reconstruction of this structure provides the greatest increase in rotational stability of the elbow.

Correct Answer & Explanation

. ixation of the coronoid fragment

Explanation

A 68-year-old right-hand dominant woman has experienced progressive right elbow pain and loss of motion for several years. She has failed nonsurgical treatment and elects to undergo a total elbow arthroplasty (TEA). In comparison to a linked prosthesis, an unlinked prosthesis has which reported distinction with extended follow-up?A. Improved longevity in comparison to the linked prosthesisB. A significantly larger flexion-extension arcC. A higher incidence of postsurgical instabilityD. Lower frequency of ulnar nerve dysfunctionTEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.

Question 998

Topic: 9. Shoulder and Elbow

Which of the following statements is true regarding the posterior oblique portion of the medial collateral ligament of the elbow? Review Topic

. Can be released to gain flexion in patients with post-traumatic contracture
. Has the highest tensile strength of any elbow ligament
. Is reconstructed in the Tommy John procedure
. Is the primary ligamentous restraint to valgus force during throwing
. Is responsible for the pivot shift of the elbow

Correct Answer & Explanation

. Can be released to gain flexion in patients with post-traumatic contracture

Explanation

Addressing flexion in a post-traumatic contracture of the elbow requires releasing the posterior oblique ligament (or band) of the medial ulnar collateral complex.The medial ulnar collateral ligament is one of the primary static stabilizers of the elbow and is composed of three parts: anterior, posterior and transverse. The MCL provides resistance to valgus and distractive stresses. The anterior oblique fibers (of the anterior bundle) are the most important against valgus stresses. The posterior bundle is involved elbow contractures and releasing it can yield significant flexion gains, without creating valgus instability.Morrey et al. performed a pilot study on 4 specimens and found the valgus stability is equally divided among the medial collateral ligament complex, anterior capsule, and bony articulation in full extension; whereas, at 90 degrees of flexion the contribution of the anterior capsule is assumed by the medial collateral ligament which provides approximately 55% of the stabilizing contribution to valgus stress.Regan et al. was a subsequent study by the same group that found the posterior medial collateral ligament (PMCL) was taut only when the elbow was in a flexed position. Among the collateral ligaments, the anterior (AMCL) was the strongest and stiffest. (Of note, using present terminology these would be referred to as posterior oblique and anterior oblique portions of the medial ulnar collateral complex).Wada et al. reported a series of open medial releases for post-traumatic elbow contracture and found scarring on the posterior oblique bundle in all cases. Large increases in flexion were achieved by releasing this structure and the capsule without the need for a lateral incision in most cases.Illustrations A and B show the posterior oblique portion of the medial collateral ligament. Illustration C shows the most recent terminology and identifies the area to be resected for stiffness.Incorrect Answers:

Question 999

Topic: 9. Shoulder and Elbow
A 12-year-old boy has severe left shoulder pain after being struck by an automobile. A chest radiograph, AP and lateral radiographs, and a CT scan with three-dimensional reconstruction of the scapula are shown in Figures 38a through 38d. Management should consist of
. closed reduction and a shoulder spica cast.
. open reduction and internal fixation.
. an abduction orthosis.
. sling immobilization.
. a figure-of-8 splint.

Correct Answer & Explanation

. sling immobilization.

Explanation

DISCUSSION: Scapular body fractures in children are rare and are often associated with other injuries of the chest and thorax. Management is generally nonsurgical, unless the injury is open, and usually consists of support with a sling and gentle range-of-motion exercises to minimize shoulder stiffness. REFERENCES: Green N, Swiontkowski M: Skeletal Trauma in Children, ed 2. Philadelphia, PA, WB Saunders, 1998, vol 3, pp 319-341. Curtis RJ Jr, Rockwood CA Jr: Fractures and dislocations of the shoulder in children, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, vol 2, pp 991-1032.

Question 1000

Topic: Elbow & Forearm
Which of the following structures may help maintain radial length after a radial head fracture?
. Triangular fibrocartilage complex
. Medial ulnar collateral ligament
. Lateral ulnar collateral ligament
. Annular ligament
. Coronoid

Correct Answer & Explanation

. Triangular fibrocartilage complex

Explanation

DISCUSSION: Essex-Lopresti injuries affect axial stability of the forearm. Injury to the interosseous membrane or the triangular fibrocartilage complex can result in proximal migration of the radius. REFERENCES: Morrey BF, Chao EY, Hui FC: Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am 1979;61:63-68. Coleman DA, Blair WF, Shurr D: Resection of the radial head for fracture of the radial head: Long-term follow-up of seventeen cases. J Bone Joint Surg Am 1987;69:385-392.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page