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9. Shoulder and Elbow MCQs

Practice Set 56 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 1101

Topic: 9. Shoulder and Elbow
Figures 4a and 4b show the radiographs of a 53-year-old woman who was injured in a fall. After initial closed reduction, what is the preferred treatment for this fracture?
. Open reduction and internal fixation of the radial head and immobilization
. Medial collateral ligament repair
. Radial head replacement, ulnar nerve transposition, and external fixation
. Coronoid repair, radial head replacement, and lateral ligamentous repair
. Nonsurgical management in a hinged elbow brace

Correct Answer & Explanation

. Coronoid repair, radial head replacement, and lateral ligamentous repair

Explanation

DISCUSSION: This elbow fracture-dislocation involves a radial head fracture, coronoid fracture, and ulnohumeral dislocation (terrible triad). Several algorithms exist for treatment; surgical treatment is indicated. The treatment should address the radial head. Studies have shown replacement to be superior to repair in comminuted fractures. The coronoid may be addressed in unstable cases at the time of radial head excision and replacement. Lateral ligamentous repair is carried out during closure of the lateral elbow capsule.

Question 1102

Topic: 9. Shoulder and Elbow

The right shoulder exercise seen in Figure A will put the LEAST amount of stretch on which structure? Review Topic

. Inferior glenohumeral ligament
. Coracohumeral ligament
. Anterior-superior capsule
. Superior glenohumeral ligament
. Posterior capsule

Correct Answer & Explanation

. Posterior capsule

Explanation

Shoulder wand exercises, as shown in Figure A, are used to increase external range of motion of the shoulder. With the arm adducted and the elbow flexed, this exercise will put the LEAST amount of stretch on the posterior capsule.External rotation shoulder wand exercises are commonly used for the treatment of adhesive capsulitis. Adhesive capsulitis is most commonly caused by contracture of the rotator interval. The rotator interval includes the anterior-superior capsule, superior glenohumeral ligament, coracohumeral ligament and long head biceps tendon. The structure most commonly contracted is the anterior-superior capsule, which limits external rotation when the arm is adducted.Kuhn et al. showed that in the neutral position, each ligament except the posterior capsule significantly affected the torque required for external rotation. The greatest effect on resisting external rotation at 0 degrees of abduction was the entire inferior glenohumeral ligament > coracohumeral ligament > anterior band of the inferior glenohumeral ligament > superior and middle glenohumeral ligament.Harryman et al. looked at the role of the rotator interval capsule in passive motion and stability of the shoulder. They found operative alteration of this capsular interval was found to affect flexion, extension, external rotation, and adduction of the humerus with respect to the scapula. Limitation of external motion was increased by operative imbrication of the rotator interval and decreased by sectioning of the rotator interval capsule.Kim et al. reviewed shoulder MRIs to determine if abnormalities of the rotator interval were correlated with chronic shoulder instability. They found a significantly larger rotator interval height, rotator interval area, and rotator interval index in patients with chronic anterior shoulder instability compared to patients without instability.Figure A shows a patient performing an exercise to increase right shoulder external rotation with a wand/stick. The right arm is fully adducted by her side, and her elbow flexed at 90 degrees.Incorrect Answers:

Question 1103

Topic: 9. Shoulder and Elbow

A 75-year-old man who is right-hand dominant has had a painful right shoulder for the past 6 months, with no improvement with nonsurgical management. Examination reveals an active motion of 60 degrees of forward flexion and abduction, with severe crepitus and pain. Radiographs reveal a high-riding humeral head with severe glenohumeral arthritic changes. What is the most appropriate treatment? Review Topic

. Humeral head resurfacing
. Humeral head arthroplasty
. Reverse shoulder arthroplasty
. Total shoulder arthroplasty
. Arthroscopic shoulder debridement

Correct Answer & Explanation

. Reverse shoulder arthroplasty

Explanation

In an older age group, the most predictable outcome is obtained with a reverse shoulder arthroplasty. Treatment with a standard hemiarthroplasty is more unpredictable in that the pain relief is typically good to excellent in 75% of patients, but the function is poor in most patients. A total shoulder arthroplasty is contraindicated as a result of the significant shearing forces that the glenoid would experience as a result of the rotator cuff deficiency. Arthroscopic lavage and debridement is ineffective in such advanced cases.

Question 1104

Topic: 9. Shoulder and Elbow

A 19-year-old college pitcher reports posterior shoulder discomfort that started recently with pitching. He is able to throw with normal velocity and control, but his pain in the early acceleration phase of throwing is getting worse. Examination reveals symmetric rotator cuff strength and no increased anterior or posterior translation of either shoulder. He has some discomfort with his shoulder in abduction and external rotation. Supine range of motion of the right shoulder in 90 degrees of abduction reveals external rotation to 100 degrees and internal rotation to 25 degrees. His left shoulder has 95 degrees of external rotation and 45 degrees of internal rotation. He is not playing the next 2 weeks and requests some exercises that he can do on his own. Which of the following exercises will most likely improve his shoulder symptoms? Review Topic

. Standard and low rowing exercises
. Lying on his side with the shoulder abducted 90 degrees, elbow flexed 90 degrees, and pushing his forearm toward the table
. Humeral head depressions while holding a ball against a wall
. Scapularpunchesin many directions
. Putting a rolled towel between his shoulder blades while lying supine and having a teammate push posteriorly on the shoulders

Correct Answer & Explanation

. Standard and low rowing exercises

Explanation

The patient has a glenohumeral internal rotation deficit of 20 degrees. Posterior capsular stretching would be beneficial. A sleeper stretch is a common way for patients to stretch the posterior capsule on their own. It involves lying on the side with the shoulder abducted 90 degrees and the elbow flexed 90 degrees and trying to push the forearm toward the table. Closed-chain rotator cuff exercises, such as humeral head depressions while holding a ball against a wall, pectoralis minor stretching, such as lying on a rolled towel and pushing posteriorly on the shoulders, scapularprotraction, such as punches, and scapular retraction, such as row exercises, can all be helpful for the disabled throwing shoulder, but they will not restore the decreased internal rotation.

Question 1105

Topic: 9. Shoulder and Elbow
Acute redislocation of the glenohumeral joint is a complication that occurs following a first-time dislocation. This is most often seen with
. subglenoid dislocation.
. subcoracoid dislocation.
. fracture of the greater tuberosity.
. fracture of the greater tuberosity and glenoid rim.
. pediatric-age patients.

Correct Answer & Explanation

. fracture of the greater tuberosity and glenoid rim.

Explanation

DISCUSSION: Redislocation following acute dislocation occurs in approximately 3% of patients. This redislocation tends to occur in middle-aged and elderly patients. A higher incidence of redislocation occurs when there are accompanying fractures of the glenoid rim and the greater tuberosity. REFERENCES: Robinson CM, Kelly M, Wakefield AE: Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: Risk factors and results of treatment. J Bone Joint Surg Am 2002;84:1552-1559. Bigliani LU, Newton PM, Steinmann SP, et al: Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. J Sports Med 1998;26:41-45.

Question 1106

Topic: 9. Shoulder and Elbow
What is the most common complication following arthroscopic capsular release in a patient with adhesive capsulitis of the shoulder?
. Wound infection
. Failure to maintain range of motion
. Instability
. Axillary nerve injury
. Impingement syndrome

Correct Answer & Explanation

. Failure to maintain range of motion

Explanation

DISCUSSION: Although all of the above are potential complications after arthroscopic capsular release for adhesive capsulitis, the most common problem is the failure to regain normal glenohumeral motion. An immediate physical therapy program is critical to prevent this complication. REFERENCES: Ghalambor N, Warner JJP: Arthroscopic capsular release: Evolution of the technique and its applications. Tech Shoulder Elbow Surg 2000;1:52-60. Pollock RG, Duralde XA, Flatow EL, Bigliani LU: The use of arthroscopy in the treatment of resistant frozen shoulder. Clin Orthop 1994;304:30-36.

Question 1107

Topic: 9. Shoulder and Elbow
Figure 22 shows the radiographs of a 16-year-old boy who injured his elbow in a fall 1 year ago. Although he has no pain, he reports restricted forearm rotation and elbow flexion. What is the most likely diagnosis?
. Posttraumatic soft-tissue contractures
. Congenital dislocation of the radial head
. Chronic posttraumatic dislocation of the radial head
. Combined annular and lateral collateral ligament injury
. An unrecognized Monteggia variant type of injury

Correct Answer & Explanation

. Congenital dislocation of the radial head

Explanation

DISCUSSION: Congenital dislocation of the radial head is often confused with posttraumatic dislocation. The distinguishing feature here is the dome-shaped radial head. Some patients with congenital anomalies fail to recognize their limitations until an injury occurs. Soft-tissue contractures do not cause radial head dislocation nor do they usually cause this pattern of motion restriction (mainly flexion and rotation without significant loss of extension). There is no deformity of the ulna to suggest an old Monteggia lesion. REFERENCES: Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 196. Bell SN, Morrey BF, Bianco AJ Jr: Chronic posterior subluxation and dislocation of the radial head. J Bone Joint Surg Am 1991;73:392-396.

Question 1108

Topic: 9. Shoulder and Elbow
Figure 93 is the radiograph of a 72-year-old woman. Treatment includes fixation of the ulna. What options are recommended for the radius?
. Radial head replacement to restore radiocapitellar contact
. Radial head excision because there is no risk for posterolateral instability
. Percutaneous fixation to avoid the risk for stiffness after surgery
. Allograft reconstruction to prevent capitellar erosion

Correct Answer & Explanation

. Radial head replacement to restore radiocapitellar contact

Explanation

Discussion: Prosthetic replacement is an appropriate option in cases of a nonreconstructable fracture to restore the radiocapitellar contact. Most complex fractures are associated with instability; therefore, it is advisable to consider open reduction and internal fixation or radial head replacement when the injury involves a dislocation or fracture of the ulna. Simple radial head excision may be a viable option for a comminuted fracture without instability or associated ulnar fracture. When the radial head is replaced, caution must be exercised to avoid overstuffing the joint because this can lead to stiffness from impingement, capitellar erosion, loss of flexion, or synovitis.

Question 1109

Topic: 9. Shoulder and Elbow

A 47-year-old male with a history of a Putti-Platt procedure 20 years ago presents with right shoulder pain with decreased range-of-motion. Radiograph is shown in Figure A. What is the most accurate diagnosis? Review Topic

. Primary osteoarthritis
. Post-capsulorrhaphy arthropathy
. Post-traumatic arthritis
. Arthritis from poor placement of coracoid transfer
. Avascular necrosis

Correct Answer & Explanation

. Post-capsulorrhaphy arthropathy

Explanation

With a history of a Putti-Platt procedure with the radiograph, the patient most likely has post-capsulorrhaphy arthropathy.Post-stabilization procedure arthritis is thought to occur due to changes in contact loading in the shoulder joint due to fixing the joint in an incongruent posistion. It can be severe and debilitating, and lead to arthroplasty as a salvage procedure. The Putti-Platt procedure involves a division of the subscapularis tendon and anterior capsule, and realignment of the lateral tendon stump and capsule sewn into the anterior glenoid neck capsular insertion. The "pants-over-vest" style of repair is then finished by sewing the medial tendon stump into the tuberosity, so that external rotation is significantly limited by the soft tissue imbrication. There is no coracoid transfer for this stabilization procedure.Bigliani et al. reported on a series of similar patients who developed arthritis following surgery for recurrent glenohumeral dislocation. Authors have theorized that instability repair may excessively tighten the joint in one direction and cause a fixed subluxation in the direction opposite from the side of repair, leading to severe degenerative arthritis due to inappropriate contact loading. 77% of patients following arthroplasty after post-capsulorrhaphy arthropathy had an excellent or satisfactory outcome, with improved pain and range of motion.Figure A demonstrates severe osteoarthrosis of the affected shoulder, with significant joint space narrowing, periarticular osteophyte formation, and subchondral sclerosis.Incorrect Answers:performed for traumatic dislocation, but the best answer choice for this stem is Answer 2.

Question 1110

Topic: 9. Shoulder and Elbow

A 45-year-old coach sustains a complete distal biceps tendon rupture at the elbow. Surgical repair is most indicated to Review Topic

. restore full supination strength.
. restore full elbow flexion strength.
. restore full range of motion.
. improve cosmesis.
. prevent degenerative changes of the elbow.

Correct Answer & Explanation

. restore full supination strength.

Explanation

The biceps is primarily responsible for supination of the forearm. The brachialis muscle is primarily repsonsible for elbow flexion strength. Failure to repair the distal biceps tendon will result in loss of 40% supination strength and 10% loss in flexion strength. Therefore, surgical repair of a complete distal biceps tendon rupture is most indicated to maximize supination strength. Improved cosmesis should not be the primary indication for surgical repair. Degenerative changes of the elbow have no bearing on whether the distal biceps is repaired or not. Loss of terminal extension is common in distal biceps tendon repairs.

Question 1111

Topic: 9. Shoulder and Elbow
Glenohumeral inferior stability in the adducted shoulder position is primarily a function of the:
. rotator cuff.
. posterior glenohumeral ligament.
. long head of the biceps tendon.
. inferior glenohumeral ligament complex.
. superior glenohumeral ligament.

Correct Answer & Explanation

. superior glenohumeral ligament.

Explanation

DISCUSSION: When the arm is adducted, the superior structures, including the superior glenohumeral ligament, are responsible for limiting inferior translation. With the arm abducted, the inferior glenohumeral ligament complex is responsible for limiting inferior subluxation. Rotator cuff activity can actually depress the humeral head and does not play a role in preventing inferior subluxation. The long head of the biceps and the posterior glenohumeral ligament do not play a role in protecting the shoulder from inferior instability.

Question 1112

Topic: 9. Shoulder and Elbow

Glenohumeral disarticulation often leads to which of the following changes?

. Hiking of the shoulder girdle
. Hypertrophy of the amputated shoulder girdle
. Improvement in thoracic spinal deformity
. Protraction of the shoulder
. Winging of the scapula

Correct Answer & Explanation

. Hiking of the shoulder girdle

Explanation

Postural abnormalities are common after high upper extremity amputation. Normally the weight of the upper extremity and the shoulder girdle muscles keep the shoulder balanced. When the arm is amputated and the scapula remains, the shoulder girdle muscles are unopposed, resulting in upward movement often called "hiking" of the shoulder girdle. In a growing child, removal of the entire upper limb can result in scoliosis of the spine due to muscle imbalance. Abnormal shoulder elevation can often be minimized by corrective exercises and wearing a shoulder prosthesis.

Question 1113

Topic: 9. Shoulder and Elbow

A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test. What phase of the throwing cycle most likely will reproduce his symptoms? Review Topic

. Early cocking
. Late cocking
. Acceleration
. Deceleration

Correct Answer & Explanation

. Early cocking

Explanation

This patient is experiencing soreness over his medial (ulnar) collateral ligament. Valgus overload is likely to reproduce his symptoms and is most pronounced during the late cocking phase of the throwing cycle. In wind up, very little elbow torque is required. In early cocking, the arm is getting loaded and maximum valgus is not yet achieved at the elbow. In acceleration and deceleration, more force is generated at the level of the shoulder joint.

Question 1114

Topic: 9. Shoulder and Elbow

A cord-like middle glenohumeral ligament and absent anterosuperior labrum complex can be a normal anatomic capsulolabral variant. If this normal variation is repaired during arthroscopy, it will cause Review Topic

. anterior translation of the humeral head.
. loss of external rotation.
. excessive tightening of the biceps tendon.
. superior migration of the humeral head.
. no excessive changes

Correct Answer & Explanation

. anterior translation of the humeral head.

Explanation

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur.

Question 1115

Topic: 9. Shoulder and Elbow
Figure 38 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment?
. Reverse shoulder arthroplasty
. Hemiarthroplasty
. Resurfacing of the humeral head
. Arthroscopic debridement
. Shoulder fusion

Correct Answer & Explanation

. Reverse shoulder arthroplasty

Explanation

The authors of several studies conducted in Europe have reported promising results in the short- and medium-term with use of a reversed or inverted shoulder implant for patients with glenohumeral osteoarthritis and a massive rupture of the rotator cuff. Hemiarthroplasty, the โ€œnonconstrainedโ€ option, has long been the standard of care for rotator cuff tear arthropathy, but results have not been uniform.

Question 1116

Topic: 9. Shoulder and Elbow
Figure 6 shows the radiograph of a 14-year-old baseball player who felt a pop and had an immediate onset of pain in his elbow after a hard throw from the outfield. The best course of action should be to
. obtain stress radiographs of the elbow.
. obtain an MRI scan of the elbow.
. apply a splint and initiate early range-of-motion exercises.
. apply a cast in 90ยฐ of flexion for 4 weeks.
. perform open reduction and internal fixation.

Correct Answer & Explanation

. perform open reduction and internal fixation.

Explanation

DISCUSSION: The valgus stress at the elbow caused by throwing strains the medial collateral ligament. The medial epicondyle, on which the ligament inserts, is the last ossification center to fuse to the distal humerus, and acute avulsion of the medial epicondyle can occur in adolescents. If the elbow is allowed to heal in a displaced position, valgus instability and loss of elbow extension may result. Valgus instability is especially problematic for the throwing athlete. Surgical treatment with rigid internal fixation is the treatment of choice for displaced medial epicondyle avulsion fractures. Valgus instability is prevented, and the rigid fixation allows for early range of motion. REFERENCES: Case SL, Hennrikus WL: Surgical treatment of displaced medial epicondyle fractures in adolescent athletes. Am J Sports Med 1997;25:682-686. Woods GW, Tullos HS: Elbow instability and medial epicondyle fractures. Am J Sports Med 1977;5:23-30.

Question 1117

Topic: 9. Shoulder and Elbow

During the cocking and acceleration phases of the overhand throw (pitch), there are several static and dynamic restraints to provide medial elbow support and prevent valgus instability. The dynamic structures found to be most important during these phases of the overhand throw are the flexor digitorum Review Topic

. profundus and extensor carpi radialis longus.
. profundus and extensor carpi radialis brevis.
. superficialis and extensor carpi radialis longus.
. superficialis and flexor carpi ulnaris.
. superficialis and flexor carpi radialis.

Correct Answer & Explanation

. profundus and extensor carpi radialis longus.

Explanation

Biomechanical analysis has demonstrated that local dynamic stability of the elbow is provided by the flexor digitorum superficialis and the flexor carpi ulnaris, especially during the cocking and acceleration phases of the overhand throw. This provides dynamic joint compression across the elbow joint and may be protective to the static restraints such as the ulnar collateral ligament. It also emphasizes the need to strengthen distant muscles in the forearm to assist with elbow biomechanics and potentially prevent injury.

Question 1118

Topic: 9. Shoulder and Elbow
What range of motion parameters are required for a patient with posttraumatic elbow stiffness to accomplish all the normal activities of daily living?
. Flexion and extension of 10 degrees to 110 degrees, pronation of 50 degrees, and supination of 50 degrees
. Flexion and extension of 10 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees
. Flexion and extension of 30 degrees to 110 degrees, pronation of 60 degrees, and supination of 30 degrees
. Flexion and extension of 30 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees
. Flexion and extension of 30 degrees to 130 degrees, pronation of 60 degrees, and supination of 30 degrees

Correct Answer & Explanation

. Flexion and extension of 30 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees

Explanation

Discussion: Activities of daily living such as dressing, eating, and bathing can all be performed with elbow motion through a 100-degree arc of flexion and extension (30 degrees to 130 degrees) and a 100-degree arc of forearm rotation (50 degrees pronation, 50 degrees supination). Some patients can accomplish these activities of daily living with 10 degrees less motion at each end point. This is referred to as the functional arc of motion.

Question 1119

Topic: 9. Shoulder and Elbow
Intraoperative frozen section analysis reveals 10 neutrophils per high-power field and a positive gram stain result. What is the best next step?
. Implant removal, irrigation and debridement, and resection arthroplasty
. Implant removal, irrigation and debridement, and rTSA
. Implant removal, irrigation and debridement, and revision hemiarthroplasty
. Implant removal, irrigation and debridement, and antibiotic cement spacer placement

Correct Answer & Explanation

. Implant removal, irrigation and debridement, and antibiotic cement spacer placement

Explanation

In the event that frozen section analysis and positive gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate.

Question 1120

Topic: Elbow & Forearm
During the anterior approach for repair of a distal biceps tendon rupture, what structure, shown under the scissors in Figure 6, is at risk for injury?
. Brachial artery
. Median nerve
. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Antecubital vein

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

Discussion: The most commonly injured neurovascular structure during an anterior approach for the repair of a distal biceps tendon rupture is the lateral antebrachial cutaneous nerve. This structure is located lateral to the biceps tendon and in a superficial location just deep to the subcutaneous layer.

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