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9. Shoulder and Elbow MCQs

Practice Set 52 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 1021

Topic: 9. Shoulder and Elbow
It is important to avoid which of the following exercises in the immediate postoperative period after humeral head replacement for an acute four-part fracture?
. Pendulum exercises
. External rotation with a stick
. Passive forward elevation
. Active forward elevation
. Active range of motion of the elbow, wrist, and hand

Correct Answer & Explanation

. Active forward elevation

Explanation

DISCUSSION: It is critical to withhold active range of motion of the shoulder within the first 6 weeks after arthroplasty for acute fracture to prevent tuberosity avulsion. When radiographic and clinical findings show that the tuberosities are healed, active motion may be instituted, usually at 6 to 8 weeks. Immediate passive range-of-motion exercises, including external rotation with a stick, pendulum, and passive elevation, should begin within the limits of the repair on the day of surgery to prevent stiffness.

Question 1022

Topic: Elbow & Forearm

A young, healthy male undergoes a distal biceps repair and sustains an iatrogenic nerve injury during the procedure. Which of the following clinical findings are most likely to be seen in this circumstance? Review Topic

. Inability to extend the thumb
. Lateral volar forearm numbness
. Inability to flex the middle finger
. Medial volar forearm numbness
. Dorsal thumb numbness

Correct Answer & Explanation

. Inability to extend the thumb

Explanation

The most commonly injured nerve during a distal biceps repair is the lateral antebrachial cutaneous nerve (LABCN). Injury to this nerve would result in lateral volar forearm numbness.Distal biceps avulsions can be partial or complete. Indications for surgical management include young, healthy patients who do not wish to sacrifice function, as well as partial biceps avulsions that do not respond to conservative management. Repair of a distal biceps avulsion can be approached through either an anterior one-incision technique or a two-incision technique (Boyd-Anderson). The one-incision technique uses the interval between the brachioradialis (radial nerve) and pronator teres (median nerve), while the two-incision technique uses this same interval in addition to a second posterolateral elbow incision. The lateral antebrachial cutaneous nerve is the most common nerve injured during either approach.Kelly et al. retrospectively reviewed 74 distal biceps tendon repairs, and found five sensory nerve paresthesias. The lateral antebrachial cutaneous nerve was most commonly injured, followed by the superficial radial nerve.Cain et al. retrospectively reviewed 198 distal biceps tendon repairs, and found a 36% complication rate. Lateral antebrachial cutaneous nerve paresthesias were found in 26%, while radial sensory nerve paresthesias were found in 6%, and posterior interosseous nerve (PIN) injury in 4%.Illustration A shows the close relationship between the lateral antebrachial cutaneous nerve (LABCN) and the distal biceps. Illustration B shows the sensory nerves of the upper extremity and their respective areas of innervation.Incorrect Answers:

Question 1023

Topic: 9. Shoulder and Elbow

A 15-year-old right-handed pitcher reports shoulder pain after throwing. His symptoms have been present for 3 months and have been getting progressively worse. Clinical examination shows no atrophy of the shoulder muscles, but he has pain with resisted motion of the shoulder, especially internal rotation. Radiographs are shown in Figures 73a and 73b. What is the next step in the evaluation and treatment of his shoulder pain? Review Topic

. MRI/arthrogram of the right shoulder
. CT of the right proximal humerus
. Bone biopsy of the right proximal humerus
. Cessation of throwing for 6 to 8 weeks, followed by a progressive throwing program
. Arthroscopic evaluation of the right shoulder

Correct Answer & Explanation

. MRI/arthrogram of the right shoulder

Explanation

The patient has proximal humeral epiphyseolysis, otherwise known as "Little League shoulder." This is an overuse injury of the shoulder in the skeletally immature overhead throwing athlete. Most frequently seen in pitchers, it usually develops after an increase in the amount or intensity of throwing activity. Initial treatment involves cessation of throwing activities so the proximal humeral growth plate injury can heal, followed by a gradual return to throwing.

Question 1024

Topic: 9. Shoulder and Elbow
A 40-year-old right hand-dominant construction worker has had a 6-month history of aching left shoulder pain that is worse after working a long day. Examination reveals limited range of motion and good strength when compared to his asymptomatic right arm. He has not had any orthopaedic intervention to date. Radiographs are shown in Figures 43a and 43b. What is the most appropriate treatment?
. Nonsteroidal anti-inflammatory drugs, cortisone injection, and physical therapy
. Total shoulder arthroplasty
. Shoulder fusion
. Arthroscopic debridement and capsular release
. Humeral head resurface arthroplasty

Correct Answer & Explanation

. Nonsteroidal anti-inflammatory drugs, cortisone injection, and physical therapy

Explanation

DISCUSSION: The patient is a young laborer with osteoarthritis. Initial treatment should begin with nonsurgical management that may include anti-inflammatory drugs, cortisone injections, and physical therapy to diminish pain and improve motion. The other choices may eventually be necessary but should only follow a course of nonsurgical management.

Question 1025

Topic: 9. Shoulder and Elbow
Figure 38 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. To minimize additional trauma to the medial soft tissues, the elbow should be reduced in
. neutral rotation.
. full pronation.
. full supination.
. full extension.
. full flexion.

Correct Answer & Explanation

. full supination.

Explanation

DISCUSSION: The elbow dislocates by a three-dimensional movement of supination and valgus during flexion. Additional trauma during reduction is minimized by recreating the deformity and reducing the elbow in supination. The actual maneuver includes full supination (actually hypersupination) of the elbow in a valgus position. This is followed by pushing the olecranon distally in line with the long axis of the ulna while swinging the elbow into varus, and then relaxing the supination torque. Postreduction stability is enhanced in pronation, except when the soft-tissue disruption is extensive. REFERENCES: O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 414. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.

Question 1026

Topic: 9. Shoulder and Elbow

A 45-year-old male laborer injured his right elbow trying to catch a heavy object. He has antecubital pain and forearm ecchymosis. MRI scans are shown in Figures 4a and 4b. Nonsurgical management of this injury is most associated with the loss of Review Topic

. forearm supination strength.
. forearm pronation strength.
. elbow flexion strength.
. elbow extension strength.
. wrist extension strength.

Correct Answer & Explanation

. forearm supination strength.

Explanation

Complete ruptures of the distal biceps typically occur at the radial tuberosity. Proximal retraction causes visible deformity and is associated with both pain and weakness in the acute setting. Due to the presence of the brachialis, elbow flexion strength returns to near normal. However, forearm supination strength remains weak with nonsurgical management. With surgical management, iatrogenic injury to the posterior interosseous nerve is a concern during exposure of the radial tuberosity. This complication would result in weakness on wrist extension.

Question 1027

Topic: 9. Shoulder and Elbow
A 70-year-old man seen in the emergency department has had left shoulder pain and a fever of 101.5°F (38.6°C) for the past 3 days. He denies any history of trauma. Examination reveals tenderness anterosuperiorly and at the posterior glenohumeral joint line. He has very limited range of motion (passive and active). Laboratory studies show a WBC count of 12,000/mm³ and an erythrocyte sedimentation rate of 48 mm/h. Initial management should consist of:
. an oral cephalosporin antibiotic and discharge home.
. IV oxacillin and gentamicin.
. arthroscopic drainage of the glenohumeral joint.
. open irrigation and drainage of the glenohumeral joint.
. aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.

Correct Answer & Explanation

. aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.

Explanation

DISCUSSION: It appears that the patient has septic arthritis of the glenohumeral joint; therefore, initial management should consist of aspiration of the glenohumeral joint and subacromial space separately, followed by Gram stain and culture of the fluid. Based on the findings, broad-spectrum IV antibiotics should be started. If the diagnosis of septic arthritis is confirmed, then arthroscopic or open surgical drainage usually is indicated. REFERENCES: Sawyer JR, Esterhai JL Jr: Shoulder infections, in Warner JJ, Iannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, PA, Lippincott-Raven, 1997. Leslie BM, Harris JM, Driscoll D: Septic arthritis of the shoulder in adults. J Bone Joint Surg Am 1989;71:1516-1522.

Question 1028

Topic: 9. Shoulder and Elbow

An 18-month-old boy with obstetric brachial plexus palsy is being evaluated for limited right shoulder motion. Physical therapy for the past 6 months has failed to result in improvement of the contracture. Which of the following studies is necessary prior to any shoulder reconstruction? Review Topic

. Electromyography
. MRI of the shoulder joint
. MRI of the brain
. Radiograph of the elbow
. Aspiration of the right shoulder

Correct Answer & Explanation

. MRI of the shoulder joint

Explanation

The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful.

Question 1029

Topic: 9. Shoulder and Elbow

A 41-year-old woman with diabetes mellitus fell onto her outstretched arm and sustained an injury to the right elbow. Radiographs are shown in Figures 53a and 53b. What is the most appropriate management?

. Open reduction and internal fixation
. MRI of the elbow to assess the integrity of the collateral ligaments
. Immobilization in a long arm cast for 3 weeks
. Short-term immobilization in a splint, followed by early motion exercises
. Radial head replacement

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

The radiographs reveal a capitellum fracture with anterior displacement. To regain concentric and stable joint motion, this fragment requires reduction and stabilization. Without a joint dislocation, the ligaments are unlikely to be damaged and do not require further assessment with MRI. Closed reduction may be considered, but is unlikely to be successful. Without anatomic reduction of the fracture fragment, immobilization in either a long arm cast or a splint will not provide optimal outcomes. Based on the radiographs, the radial head is intact and does not require replacement.

Question 1030

Topic: 9. Shoulder and Elbow
Which of the following structures is most commonly involved in lateral epicondylitis?
. Anconeus
. Extensor digitorum communis
. Extensor carpi radialis longus
. Extensor carpi radialis brevis
. Extensor carpi ulnaris

Correct Answer & Explanation

. Extensor carpi radialis brevis

Explanation

DISCUSSION: The most common specific site of involvement is the origin of the extensor carpi radialis brevis. It is usually caused by overuse activities, such as the eccentric overload exhibited during a backhand in tennis. In most patients, the characteristic friable, grayish tissue described as angiofibroblastic hyperplasia or hyaline degeneration is seen at the extensor carpi radialis brevis origin. REFERENCES: Nirschl RP: Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11:851-870. Regan W, Wold LE, Coonrad R, Morrey BF: Microscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med 1992;20:746-749.

Question 1031

Topic: 9. Shoulder and Elbow

Compared with surgically treated patients, patients with extra-articular distal third humeral shaft fractures that are treated nonsurgically with functional bracing can be expected to show which of the following findings?

. Similar loss of elbow motion
. Greater loss of elbow extension
. Higher rate of varus malalignment
. Higher rate of functionally limiting malalignment
. Significantly better shoulder motion

Correct Answer & Explanation

. Similar loss of elbow motion

Explanation

In a retrospective review of patients with extra-articular distal humeral shaft fractures treated surgically versus nonsurgically, the authors found that the amount of motion loss was not different between the treatment groups. Of 21 patients in the nonsurgical group, one lost 20 degrees of extension, one lost 30 degrees of extension, and one patient lost 15 degrees of flexion. Of the 19 patients in the surgical group, two patients lost 5 degrees of extension, and one each lost 10, 15, and 20 degrees of extension, respectively. One patient lost 5 degrees of flexion and one lost 15 degrees of flexion. The average loss of motion in the surgical group was 3 degrees, compared with 6 degrees in the nonsurgical group, but this difference was not significant. One hundred percent of the nonsurgically treated fractures healed. Both groups of patients regained shoulder motion within 10 degrees of normal. In the nonsurgically treated group, 10 healed with less than 10 degrees of malalignment, 6 healed with 11 to 20 degrees of malalignment, and three healed with greater than 30 degrees of malalignment, but the authors did not report any functional problems due to these deformities.

Question 1032

Topic: 9. Shoulder and Elbow
What are the proposed biomechanical advantages of the Grammont reverse total shoulder arthroplasty when compared to a standard shoulder arthroplasty?
. Lateralization of the center of rotation, lengthening the deltoid, and decreasing the deltoid moment arm
. Lateralization of the center of rotation, shortening the deltoid, and decreasing acromial stress
. Lateralization of the center of rotation, lengthening the deltoid, and increasing the transverse force couple
. Medialization of the center of rotation, lengthening the deltoid, and increasing the deltoid moment arm
. Medialization of the center of rotation, shortening the deltoid, and decreasing acromial stress

Correct Answer & Explanation

. Medialization of the center of rotation, lengthening the deltoid, and increasing the deltoid moment arm

Explanation

DISCUSSION: The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid.

Question 1033

Topic: 9. Shoulder and Elbow

A 74-year-old patient is seen for follow-up 6 weeks after undergoing a total shoulder arthroplasty for glenohumeral osteoarthritis. The patient missed the 2-week follow-up appointment and is currently wearing a sling. The incision is well healed with no signs of breakdown. Examination reveals that passive range of motion is forward elevation of 90 degrees, external rotation at the side 0 degrees, and internal rotation up the back is to the level of the greater trochanter. A radiograph shows no signs of fracture or dislocation. What is the next most appropriate management for this patient? Review Topic

. Physical therapy for range-of-motion exercises
. Aspiration for possible infection
. MRI to evaluate for possible rotator cuff tear
. Sling immobilization and reevaluation in 4 weeks
. Duplex ultrasound for possible upper extremity deep venous thrombosis

Correct Answer & Explanation

. Physical therapy for range-of-motion exercises

Explanation

The patient has a postoperative stiff shoulder. The patient missed follow-up appointments and has not been participating in physical therapy for stretching. Based on normal radiographic findings, the shoulder is not dislocated; therefore, physical therapy should begin immediately. Continued sling immobilization will further worsen the stiffness. There is no indication of an infection or rotator cuff tear. Deep venous thrombosis would present with abnormal swelling and pain.

Question 1034

Topic: Shoulder Pathology
In the most common condition causing a winged scapula, which of the following nerves is affected?
. Long thoracic nerve
. Spinal accessory nerve
. Suprascapular nerve
. Dorsal scapular nerve
. Thoracodorsal nerve

Correct Answer & Explanation

. Long thoracic nerve

Explanation

DISCUSSION: A winged scapula is most often associated with Parsonage-Turner syndrome, a condition thought to be due to an inflammatory or immune-mediated mechanism. Certain muscles are predisposed, particularly the serratus anterior muscle innervated by the long thoracic nerve. Other less common nerve lesions (e.g., the spinal accessory and dorsal scapular nerves) may also cause winged scapulae. REFERENCES: Kline DG, Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments and Tumors. Philadelphia, PA, WB Saunders, 1995. van Alfen N, van Engelen BG: The clinical spectrum of neuralgic amyotrophy in 246 cases. Brain 2006;129:438-450.

Question 1035

Topic: Elbow & Forearm
A 38-year-old woman who tripped and fell on her outstretched arm reports pain with movement. Examination reveals swelling. AP and lateral radiographs are shown in Figures 43a and 43b. Management should consist of
. excision of the fracture fragment.
. radial head replacement.
. closed reduction and cast immobilization.
. open reduction and internal fixation of the radial head.
. open reduction and internal fixation of the capitellum.

Correct Answer & Explanation

. open reduction and internal fixation of the capitellum.

Explanation

DISCUSSION: The patient has a type I (Hahn-Steinthal) capitellar fracture that is best seen on the lateral radiograph. If a fracture fragment is seen proximal to the radial head, a capitellar fracture is the most likely injury because radial head fractures do not migrate proximally. The fragment is large enough for fixation. Excision is the preferred treatment for small shear osteochondral type II (Kocher-Lorenz) capitellar fractures. Closed reduction usually is not successful because of rotation of the displaced fragment. REFERENCES: Mehdian H, McKee M: Management of proximal and distal humerus fractures. Orthop Clin North Am 2000;31:115-127. Ring D, Jupiter J, Gulotta L: Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 2003;85:232-238.

Question 1036

Topic: 9. Shoulder and Elbow
After performing an open distal clavicle excision and resecting 15 mm of distal clavicle, which potential concern for shoulder function could result?
. Persistent pain attributable to inadequate resection
. Complex regional pain syndrome
. Fracture
. AC joint instability

Correct Answer & Explanation

. AC joint instability

Explanation

AC joint arthritis often is marked by pain along the anterior and superior aspects of the shoulder. It can occasionally radiate into the trapezius and the anterolateral neck region. A patient may have tenderness to palpation directly at the AC joint or pain with the cross-body adduction stress test and the O'Brien active compression test. Persistent pain is the most common complication following distal clavicle excision. Although the exact amount of distal clavicle that should be resected is a topic of debate, resection of 10 mm or more of the distal clavicle may lead to instability of the AC joint, especially if the AC capsule is sectioned.

Question 1037

Topic: 9. Shoulder and Elbow

A 31-year-old right handed pitcher felt a pop in his throwing elbow during a game. He is diagnosed with a rupture to the medial ulnar collateral ligament complex of the elbow. During which phase of the overhead throwing cycle did this pitcher most likely sustain his injury? Review Topic

. Wind-up
. Early cocking
. Early acceleration
. Ball release
. Follow-through

Correct Answer & Explanation

. Wind-up

Explanation

The medial ulnar collateral ligament is subjected to the greatest tensile stress during the late cocking/early acceleration phase of throwing.The medial ulnar collateral ligament, or medial collateral ligament of the elbow, is composed of three bundles: an anterior bundle, a posterior bundle, and a variable transverse oblique bundle. During late cocking and early acceleration phases of the overhead throw, the medial UCL is subjected to the greatest amount of valgus stress to the elbow. During this phase, the forearm lags behind the upper arm and generates valgus stress while the elbow is primarily dependent on the anterior band of the UCL for stability. This puts the ligament at greatest risk of injury during this phase.Fleisig et al. examined the kinetics of baseball pitching and the implications on injury mechanisms. They showed that the UCL contributes to 54% of the varus torque that is generated during the early acceleration of throwing. The position of greatest load occurred when the arm was flexed to 95 +/-14 degrees with an applied valgus load.Illustration A shows a diagram of the medial ulnar collateral ligament ligament bundles.Incorrect Answers:

Question 1038

Topic: 9. Shoulder and Elbow
A 65-year-old woman fell onto her outstretched right arm and immediately had pain. She has a history of osteoporosis. Examination of the right arm reveals lateral arm swelling, ecchymosis, and she is unable to move the elbow due to pain. Her neurovascular status is intact. Radiographs are shown in Figures 14a and 14b. Appropriate treatment should include
. splint immobilization and early range-of-motion exercises.
. radial head excision.
. anatomic metallic radial head arthroplasty.
. radial head open reduction and internal fixation.
. anconeus interposition arthroplasty.

Correct Answer & Explanation

. anatomic metallic radial head arthroplasty.

Explanation

Comminuted, displaced radial head fractures (Hotchkiss type 3) require anatomic metallic radial head arthroplasty to regain function. Radial head excision has led to catastrophic sequelae including chronic wrist pain, elbow instability, and proximal radius migration. Immobilization, internal fixation, or anconeus arthroplasty are not recommended at this time because of the potentially poorer outcomes.

Question 1039

Topic: 9. Shoulder and Elbow
A 40-year-old man who is an avid weight lifter has had chronic pain in the proximal anterior shoulder for the past year. He denies any history of trauma. Examination reveals tenderness at the intertubercular groove, a positive Speed test, and a positive Neer impingement sign. Nonsurgical management has failed to provide relief, and he is now considering surgery. Arthroscopic findings in the glenohumeral joint are shown in Figure 31. Based on these findings, treatment should consist of
. debridement of the biceps tendon.
. debridement of the rotator cuff tear.
. repair of the biceps pulley system.
. repair of the rotator cuff tear.
. tenodesis of the biceps tendon.

Correct Answer & Explanation

. tenodesis of the biceps tendon.

Explanation

The arthroscopic image shows a tear through more than 50% of the biceps tendon; therefore, treatment should consist of tenodesis or tenotomy of the tendon. However, because this patient is relatively young and active, the treatment of choice is tenodesis of the biceps tendon.

Question 1040

Topic: 9. Shoulder and Elbow

A 68-year-old man had a 3-year history of shoulder pain that failed to respond to nonsurgical management. Examination reveals forward elevation to 120 degrees and external rotation to 30 degrees. True AP and axillary radiographs and an axial CT scan are shown in Figures 1a through 1c. What management option would lead to the best long-term results? Review Topic

. Hemiarthroplasty
. Total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic debridement
. Glenoid osteotomy and interposition arthroplasty

Correct Answer & Explanation

. Hemiarthroplasty

Explanation

The radiographs and CT scan reveal osteoarthritis with posterior subluxation and posterior bone loss. Total shoulder arthroplasty with reaming of the high side to neutralize the glenoid surface has been shown to yield better results than hemiarthroplasty. The amount of bone loss in this patient does not require posterior glenoid augmentation. Reverse total shoulder arthroplasty is indicated for rotator cuff tear arthropathy; therefore, it is not applicable. Arthroscopic debridement has yielded poor results with advanced osteoarthritis and posterior subluxation. Results from glenoid osteotomy have been variable and glenoid osteotomy is not indicated with associated osteoarthritis.

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