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9. Shoulder and Elbow MCQs

Practice Set 53 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 1041

Topic: 9. Shoulder and Elbow

An 18-year-old football player is injured after making a tackle with his left shoulder. He has decreased sensation over the lateral aspect of the left shoulder and radial aspect of the forearm. Motor examination reveals weakness to shoulder abduction and external rotation as well as elbow flexion. He has decreased reflexes of the biceps tendon on the left side but full, nontender range of motion of the cervical spine. What anatomic site has been injured? Review Topic

. Fourth cervical nerve root
. Upper trunk of the brachial plexus
. Middle trunk of the brachial plexus
. Lateral cord of the brachial plexus
. Axillary nerve

Correct Answer & Explanation

. Fourth cervical nerve root

Explanation

The athlete has symptoms referable to the axillary, musculocutaneous, and suprascapular nerves resulting from an injury to the upper trunk of the brachial plexus. This portion of the plexus is formed by contributions of the fourth through sixth cervical nerve roots. This area is often contused or stretched following a tackling maneuver that results in either depression of the shoulder from contact at Erbโ€™s point or traction of the upper plexus from forced stretching of the neck to the contralateral side.

Question 1042

Topic: 9. Shoulder and Elbow
A 25-year-old man injured his dominant shoulder after falling on his outstretched arm 4 months ago. Examination reveals that he cannot lift his arm above 90 degrees, and he has pronounced medial scapular winging. Management should consist of
. spinal accessory nerve exploration with repair.
. long thoracic nerve exploration with repair.
. a sling for comfort, followed by shoulder strengthening exercises.
. scapulothoracic arthrodesis.
. split pectoralis major transfer.

Correct Answer & Explanation

. a sling for comfort, followed by shoulder strengthening exercises.

Explanation

Serratus anterior palsy or long thoracic nerve palsy is usually caused by traction injury to the nerve, blunt injury, or iatrogenic injury. The palsy results in winging of the scapula and medial rotation of the inferior pole of the scapula. A patient with this injury will usually recover in 12 to 18 months. Initial treatment should include observation and shoulder strengthening exercises. Nerve exploration with repair has not proven beneficial in changing the outcome. Many orthopaedic surgeons favor using a split pectoralis major transfer for symptomatic patients. Electrodiagnostic studies are helpful in confirming the diagnosis.

Question 1043

Topic: 9. Shoulder and Elbow

A healthy 64-year-old man just underwent an uncomplicated shoulder arthroplasty for severe glenohumeral osteoarthritis. Intraoperatively, 60 degrees of external rotation was obtained. Postoperatively, he starts on a range-of-motion program. What limitations are recommended? Review Topic

. No external rotation stretching for the first 6 weeks.
. No external rotation stretching for the first 3 weeks.
. Limit external rotation to the side to 60 degrees for the first 6 weeks.
. Limit external rotation to the side to 60 degrees for the first 3 weeks.
. No restrictions on external rotation stretching.

Correct Answer & Explanation

. No external rotation stretching for the first 6 weeks.

Explanation

The patient needs restrictions on his external rotation to allow healing of the subscapularis tendon repair. Limitation to 60 degrees is common if the tendon repair is robust and shows no evidence of tension on range-of-motion testing during thesurgery. Restriction from external rotation stretching for even 3 weeks would compromise his ultimate functional recovery.

Question 1044

Topic: 9. Shoulder and Elbow
In the arthroscopic photograph shown in Figure 5, the structure labeled โ€œAโ€ functions primarily as a restraint to translation of the humeral head in what direction?
. Inferiorly with the arm adducted to the side
. Anteriorly with the arm abducted to 45 degrees and at neutral rotation
. Anteriorly with the arm abducted to 45 degrees and maximally externally rotated
. Anteriorly with the arm abducted to 90 degrees and at neutral rotation
. Anteriorly with the arm abducted to 90 degrees and maximally externally rotated

Correct Answer & Explanation

. Inferiorly with the arm adducted to the side

Explanation

DISCUSSION: The superior glenohumeral ligament identified as โ€œAโ€ in the figure functions primarily as a restraint to inferior glenohumeral translation of the adducted arm. The middle glenohumeral ligament is highly variable and poorly defined in up to 40% of the population and functions to restrain anterior translation of the externally rotated arm in the midrange of abduction. The anterior band of the inferior glenohumeral ligament is the primary restraint to anterior/inferior translation of the head with the shoulder abducted to 90 degrees and in maximum external rotation.

Question 1045

Topic: 9. Shoulder and Elbow

A 37-year-old recreational athlete has osteoarthritis of the glenohumeral joint. He has failed nonsurgical measures and is interested in surgical intervention but would like to avoid arthroplasty. When performing shoulder arthroscopy for glenohumeral arthritis, which radiographic parameter is most predictive of clinical failure?

. Unipolar arthritis
. >3 mm of glenohumeral joint space
. Walch B2 glenoid morphology
. Small inferior humeral osteophyte

Correct Answer & Explanation

. Unipolar arthritis

Explanation

Multiple studies have evaluated the utility of arthroscopy in the treatment of shoulder arthritis. Despite differing levels of success, a few common characteristics have been shown to lead to a higher probability of clinical failure. Mitchell and associates showed that shoulders with less joint space (1.3 mm vs 2.6 mm) and Walch type B2 and C glenoids were significantly more likely to fail than were Walch types A1, A2, and B1. Additionally, older patients (age >50 years) tended to have worse outcomes. Skelley and associates found that isolated capsular release and debridement had a high failure rate (conversion to total shoulder arthroplasty in 42% within 9 months) and postulated that patients undergoing concomitant procedures, such as biceps tenodesis, may fare better. Van Theil and associates found significant risk factors for failure included the presence of grade 4 bipolar disease, joint space <2 mm, and the presence of large osteophytes. They had a22% conversion to total shoulder arthroplasty at 10.1 months.

Question 1046

Topic: 9. Shoulder and Elbow
A 32-year-old powerlifter who was performing a dead lift 3 days ago noted a sharp pain in the front of his dominant right arm just after beginning to lower the weight. He now reports pain in the anterior aspect of the arm that worsens when he opens a door. Examination reveals moderate ecchymosis and swelling of the forearm and tenderness in the antecubital fossa. The MRI scans are shown in Figures 15a and 15b. If the injury is left unrepaired, the greatest functional deficit will most likely be the loss of
. elbow extension motion.
. elbow flexion strength.
. forearm supination motion.
. forearm pronation strength.
. forearm supination strength.

Correct Answer & Explanation

. forearm supination strength.

Explanation

DISCUSSION: A complete tear of the distal biceps brachii most often occurs from a large, rapid eccentric elbow extension load. A pop or tearing sensation usually occurs, and a palpable defect in the antecubital fossa is often present on examination. The treatment of choice is a direct primary repair by a two-incision technique. If left unrepaired, the most disabling consequence is the loss of forearm supination strength. It is unlikely that significant elbow or forearm motion will be lost if the rupture is left unrepaired and early motion exercises are initiated. Elbow flexion strength tends to return with time, but the loss of forearm supination strength remains problematic.

Question 1047

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

Correct Answer & Explanation

. Lateral ulnar collateral

Explanation

DISCUSSION: 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 1048

Topic: 9. Shoulder and Elbow

A 17-year-old pitcher reports pain over the medial aspect of the elbow that occurs during the acceleration phase of throwing, and it prevents him from throwing at the velocity needed to be competitive. What structure is most likely injured in this patient? Review Topic

. Radial collateral ligament
. Posterior bundle of the ulnar collateral ligament
. Anterior bundle of the ulnar collateral ligament
. Flexor carpi ulnaris
. Pronation teres

Correct Answer & Explanation

. Radial collateral ligament

Explanation

The anterior bundle of the ulnar collateral ligament of the elbow is the primary constraint to valgus force of the elbow. In pitchers and in overhead athletes, injury to this portion of the ligament results in valgus instability. Reconstruction of the anterior band of the ulnar collateral ligament is necessary in many elite athletic throwers to allow them to return to this competitive activity.

Question 1049

Topic: 9. Shoulder and Elbow
A 20-year-old collegiate pitcher sustains a medial collateral ligament (MCL) rupture of his throwing elbow for which surgical reconstruction is necessary. The goal of surgery is anatomic restoration of the MCL. Which statement best describes the kinematics of the native MCL?
. The posterior bundle demonstrates the greatest change in tension from flexion to extension.
. The posterior bundle is isometric.
. The anterior bundle becomes tight in flexion and lax in extension.
. The anterior and posterior bundles are isometric.

Correct Answer & Explanation

. The posterior bundle demonstrates the greatest change in tension from flexion to extension.

Explanation

The posterior bundle of the MCL demonstrates the most change in length from extension to flexion of all the elbow ligaments. The anterior bundle is the primary restraint to valgus stress and remains taut throughout the full range of flexion due to a CAM effect.

Question 1050

Topic: 9. Shoulder and Elbow
A healthy 65-year-old woman undergoes anatomic total shoulder arthroplasty to address osteoarthritis (OA). The surgery is uncomplicated. What is the most common indication for future revision?
. Deep infection
. Periprosthetic fracture
. Glenoid component loosening
. Rotator cuff tear

Correct Answer & Explanation

. Glenoid component loosening

Explanation

The most common reason for revision surgery following unconstrained shoulder arthroplasty for glenohumeral OA is loosening of an implant. In most studies that distinguish glenoid from humeral loosening, it appears the glenoid is the problem. Comprehensive systematic reviews have found that radiographic glenoid loosening can comprise nearly 30% to 40% of all complications following shoulder arthroplasty for non-inflammatory arthritis. Infections, periprosthetic fractures, and rotator cuff tears are uncommon. In the population-based study by Matsen and associates, 10% of the revisions were performed for loosening versus 7% for infection and 7% for rotator cuff tearing.

Question 1051

Topic: 9. Shoulder and Elbow
Figures 87a and 87b are sagittal and coronal MR images of the affected elbow of a 36-year-old man who has a history of painful mechanical symptoms in his dominant arm when extending his elbow in full supination. What is the most likely cause of his painful snapping?
. Lacertus fibrosis contracture
. Intra-articular loose bodies
. Olecranon fossa impingement
. Radiocapitellar plica

Correct Answer & Explanation

. Radiocapitellar plica

Explanation

DISCUSSION: The MRI studies show a radiocapitellar plica. This anomalous structure has been associated with symptomatic snapping. Lacertus fibrosis contracture will not cause painful snapping. An intra-articular pathology such as loose bodies is not present on these imaging studies. Olecranon fossa impingement causes posterior pain in extension and is not shown in the images.

Question 1052

Topic: Elbow & Forearm
An 8-year-old girl injures her elbow playing soccer. After attempted reduction in the emergency department, radiographs of the elbow are shown in Figures 35a through 35c. What is the next most appropriate step in treatment?
. Cast immobilization for 2 weeks followed by early motion
. Minimal treatment for this congenital radial head dislocation
. Open reduction and internal fixation
. Annular ligament reconstruction
. Attempt a repeat closed reduction

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

DISCUSSION: Ninety percent of injuries to the proximal radius in children are radial neck fractures, and 50% of these fractures are through the metaphyseal bone. The remaining 50% are Salter-Harris type I or II fractures. These radiographs show a fracture of the radial head and subluxation of the radius anteriorly. Most congenital radial head dislocations are posterior lateral. Nonsurgical treatment modalities are unlikely to be successful due to the wide displacement of the fracture fragments, as well as dislocation of the radial head.

Question 1053

Topic: 9. Shoulder and Elbow
Based on the MR arthrogram of the elbow shown in Figure 8, which of the following structures is torn?
. Common flexor tendon
. Anconeus
. Radial collateral ligament
. Ulnar collateral ligament
. Lateral ulnar collateral ligament

Correct Answer & Explanation

. Ulnar collateral ligament

Explanation

Based on the MR arthrogram in which gadolinium was injected into the joint space prior to imaging, the study shows a tear of the anterior band of the ulnar collateral ligament (UCL). The disruption in the distal end of the UCL is outlined by contrast. A small collection of contrast extravasation into the flexor musculature further confirms the presence of a tear. Most UCL tears occur distally at the ulnar (coronoid) attachment.

Question 1054

Topic: 9. Shoulder and Elbow
A 20-year-old male lacrosse player sustains an anterior dislocation of the shoulder. He is extremely concerned about recurrent dislocations. Which of the following treatments has been shown to reduce the risk of recurrent dislocation?
. Functional rehabilitation and return to play when he has pain-free range of motion
. Immobilization in internal rotation for 6 weeks
. Immobilization in internal rotation for 3 weeks, followed by 3 weeks of supervised rehabilitation
. Immobilization with the arm in neutral rotation
. Immobilization with the arm in 30 degrees of external rotation

Correct Answer & Explanation

. Immobilization with the arm in 30 degrees of external rotation

Explanation

DISCUSSION: Recent evidence has shown that the position of immobilization of the shoulder after a dislocation influences the reduction of the Bankart lesion. In an MRI study in patients who sustained an anterior dislocation, the Bankart lesion was reduced to the glenoid anatomically with the arm in 30 degrees of external rotation. Subsequently, a clinical follow-up study has shown a reduction in recurrence rates when the arm is immobilized in external rotation compared to internal rotation. REFERENCES: Itoi E, Hatakeyama Y, Kido T, et al: A new method of immobilization after traumatic anterior dislocation of the shoulder: A preliminary study. J Shoulder Elbow Surg 2003;12:413-415. Itoi E, Sashi R, Minagawa H, et al: Position of immobilization after dislocation of the glenohumeral joint: A study with use of magnetic resonance imaging. J Bone Joint Surg Am 2001;83:661-667.

Question 1055

Topic: 9. Shoulder and Elbow
A 58-year-old woman with a history of severe asthma and long-term prednisone use reports a progression of chronic shoulder pain for the past 6 months. Radiographs and MRI scans are shown in Figures 30a through 30d. What is the most likely diagnosis?
. Osteonecrosis of the humeral head
. Partial-thickness supraspinatus tendon tear
. Full-thickness supraspinatus tendon tear
. Glenohumeral septic arthritis
. Rheumatoid arthritis

Correct Answer & Explanation

. Osteonecrosis of the humeral head

Explanation

DISCUSSION: The patient has osteonecrosis of the humeral head. The radiographs show increased density in the superior subchondral region of the humeral head. The MRI scans reveal a central collapse of the humeral head. The patientโ€™s history of severe asthma and long-term prednisone use predisposes her to this condition. The MRI scans show no evidence of a full- or partial-thickness rotator cuff tear. Without a history of fevers, chills, or other systemic signs or symptoms, there is no indication of septic arthritis. The radiographs do not reveal periarticular erosions, commonly seen in rheumatoid arthritis. REFERENCES: Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 871-874. Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Results of replacement. J Shoulder Elbow Surg 2000;9:177-182.

Question 1056

Topic: 9. Shoulder and Elbow
A 72-year-old active man has shoulder pain after undergoing an explantation of an anatomic shoulder arthroplasty 6 months prior with an antibiotic cement spacer placed. The patient has 60ยฐ of forward flexion, 40ยฐ of external rotation, and a positive belly press with limited internal rotation. A recent work-up for continued infection is negative, and a follow-up MRI reveals grade 2 atrophy of the supraspinatus and grade 3 atrophy of the subscapularis with tendon retraction to the glenoid rim. What is the best next step in definitive management?
. Revision anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Hemiarthroplasty with latissimus dorsi transfer
. Resection arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

This patient has a previously failed total shoulder arthroplasty for which he underwent placement of an antibiotic spacer, and now has continued shoulder pain. The recent MRI demonstrates a likely irreparable subscapularis tendon, making revision with an anatomic shoulder arthroplasty contraindicated. Use of a hemiarthroplasty is unlikely to restore function in this older patient with underlying rotator cuff disease, though it may be helpful for pain relief. Furthermore, a latissimus dorsi transfer is also contraindicated in the setting of a chronic subscapularis tear. A reverse shoulder arthroplasty offers the most reliable clinical outcome. Given that the preoperative infection work-up was negative, resection arthroplasty is not indicated for this otherwise active patient.

Question 1057

Topic: 9. Shoulder and Elbow
Which of the following ligaments is the primary static restraint against inferior translation of the arm when the shoulder is in 0 degrees of abduction?
. Middle glenohumeral
. Inferior glenohumeral
. Coracoacromial
. Coracoclavicular
. Coracohumeral

Correct Answer & Explanation

. Coracohumeral

Explanation

DISCUSSION: The superior glenohumeral ligament (SGHL) and coracohumeral ligament serve as primary static restraints against inferior translation of the arm when the shoulder is in 0 degrees of abduction. Of these, the coracohumeral ligament has been shown to have a greater cross-sectional area, greater stiffness, and greater ultimate load than the SGHL. The inferior glenohumeral ligament plays a greater stabilizing role with increasing abduction of the arm. The coracoacromial ligament may help provide superior stability, especially when the rotator cuff is deficient. The coracoclavicular ligaments stabilize the acromioclavicular joint. REFERENCES: Boardman ND, Debski RE, Warner JJ, et al: Tensile properties of the superior glenohumeral and coracohumeral ligaments. J Shoulder Elbow Surg 1996;5:249-254. Warner JJ, Deng XH, Warren RF, Torzilli PA: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.

Question 1058

Topic: 9. Shoulder and Elbow
A 15-year-old girl reports popping and clicking at the sternoclavicular joint and an intermittent asymmetrical prominence of the medial head of the clavicle. She denies any history of trauma or other symptoms. Management should consist of:
. figure-of-8 splinting to maintain the clavicle in a reduced position.
. an exercise program to stabilize the joint in a reduced position.
. elective reconstruction of the sternoclavicular joint ligaments.
. reassurance and local symptomatic treatment.
. closed reduction and temporary pin fixation to stabilize the joint.

Correct Answer & Explanation

. reassurance and local symptomatic treatment.

Explanation

DISCUSSION: Atraumatic subluxation or dislocation of the sternoclavicular joint typically occurs in individuals with generalized ligamentous laxity. It is generally not painful, has no long-term sequelae, and needs no treatment. In fact, it is more likely to be painful following surgery than if managed nonsurgically. REFERENCES: Rockwood CA Jr, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989;71:1280-1288. Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, p 583.

Question 1059

Topic: 9. Shoulder and Elbow
Figure 42 is a transverse MRI scan of the left shoulder. The arrow points to which of the following structures?
. Anterior labrum
. Long head of the biceps tendon
. Middle glenohumeral ligament
. Lower glenohumeral ligament
. Axillary nerve

Correct Answer & Explanation

. Long head of the biceps tendon

Explanation

The figure shows an axial image of the shoulder immediately inferior to the coracoid process. The subscapularis tendon, which can be traced from the myotendinous junction, is torn and detached from its lesser tuberosity attachment on the humerus. Lateral to the lesser tuberosity, the bicipital groove is empty. The arrow points to the subluxated biceps tendon. Superficial fibers of the subscapularis tendon are contiguous with the biceps retinaculum, which covers the bicipital groove and holds the biceps tendon in place. The vast majority of subscapularis tendon tears result in disruption of the biceps retinaculum with resultant subluxation of the tendon.

Question 1060

Topic: 9. Shoulder and Elbow
Spontaneous recovery of upper extremity motor function after a cerebrovascular accident occurs in which of the following predictable patterns?
. Shoulder flexion, elbow flexion, wrist flexion, finger flexion
. Shoulder flexion, forearm supination, wrist flexion, finger flexion
. Shoulder extension, elbow extension, wrist extension, finger extension
. Finger flexion, wrist extension, elbow flexion, shoulder flexion
. Finger flexion, wrist flexion, elbow flexion, shoulder flexion

Correct Answer & Explanation

. Shoulder flexion, elbow flexion, wrist flexion, finger flexion

Explanation

Recovery of upper extremity motor function after a cerebrovascular accident follows a predictable pattern. The greatest amount of recovery is seen within the first 6 weeks. Return of function proceeds from proximal to distal. Shoulder flexion occurs first, followed by return of flexion to the elbow, wrist, and fingers. Return of forearm supination follows the return of finger flexion.

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