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9. Shoulder and Elbow MCQs

Practice Set 57 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 1121

Topic: 9. Shoulder and Elbow

Figure 83a shows an axillary radiograph and Figures 83b and 83c show axial MR arthrograms of a 20-year-old collegiate offensive lineman who has shoulder pain while pass-blocking. He sustained a shoulder injury 3 months earlier when he "jammed it." Prior to this injury, he denies any pain or instability in either shoulder. Despite undergoing rehabilitation with a physical therapist and trainer and abstaining from playing for 6 weeks, he is currently unable to play because of his symptoms. Examination reveals full active range of motion, a positive jerk test which reproduces his symptoms, and a grade 2 posterior translation of the humeral head with load and shift testing which also reproduces his symptoms. What is the best management option to allow him to return to his pre-injury function next season? Review Topic

. Arthroscopic posterior capsulolabral repair
. Thermal capsulorrhaphy
. Open anterior capsulorrhaphy
. Intra-articular injection of corticosteroid
. Immobilization for 6 weeks in external rotation

Correct Answer & Explanation

. Arthroscopic posterior capsulolabral repair

Explanation

Arthroscopic posterior capsulolabral repair is most likely to return him to competitive athletics. The patient has symptomatic posterior instability that is preventing him from performing high-level athletic activities. Posterior subluxation of the humeral head is seen on the axillary radiograph and a posterior labral tear is seen on the axial MR arthrograms. Because nonsurgical management has failed to provide relief, treatment should consist of posterior capsulolabral repair. This can be performed either arthroscopically or open with similar excellent results. An intra-articular injection may help his pain but will not likely allow him to return to his pre-injury functional level. Thermal capsulorrhaphy has limited use in the shoulder because of the high rate of complications reported, and anterior capsulorrhaphy will not correct the posterior instability. Whereas a trial of immobilization in external rotation may have benefitted him with the acute injury, it is unlike to help with this recurrent instability.

Question 1122

Topic: Elbow & Forearm
A 21-year-old man who underwent repair of a distal biceps tendon rupture using a two-incision approach 4 months ago now reports difficulty gaining rotation of his forearm. Figures 49a and 49b show the AP and lateral radiographs. What is the most likely cause of his problem?
. Inadequate physical therapy
. Exposure of the periosteum of the lateral ulna during surgery
. Inappropriate location of the suture anchor
. Fixation of the tendon with the forearm fully pronated
. Subluxation of the radial head

Correct Answer & Explanation

. Exposure of the periosteum of the lateral ulna during surgery

Explanation

The radiographs show early ectopic bone formation originating between the ulna and the radius. The development of ectopic bone in this area following a two-incision approach for anatomic repair of the distal biceps tendon is thought to be related to exposure of the periosteum of the lateral ulna during surgery. This can be avoided by the use of a muscle-splitting incision between the extensor carpi ulnaris and common extensor muscles. Full pronation of the forearm allows for the necessary exposure of the radial tuberosity during the procedure and for fixation of the tendon at its maximal length.

Question 1123

Topic: 9. Shoulder and Elbow
Osteonecrosis of the humeral head is a rare complication seen after dislocation of the glenohumeral joint in skeletally immature patients. When this complication is encountered, treatment should consist of
. humeral head arthroplasty.
. observation.
. arthroscopic capsular release.
. grafting of the humeral head defect.
. electrical stimulation.

Correct Answer & Explanation

. observation.

Explanation

DISCUSSION: This rare complication occurs after fracture-dislocation and has been seen after surgical stabilization in the adolescent. In most reported cases, prolonged observation has been shown to result in revascularization.

Question 1124

Topic: 9. Shoulder and Elbow
A 22-year-old patient underwent successful reduction of a posterolateral elbow dislocation. Management should now consist of
. splinting for 5 weeks.
. active range-of-motion exercises after 1 to 3 days.
. delayed passive stretching at 2 weeks.
. open medial collateral ligament reconstruction.
. open lateral collateral ligament reconstruction.

Correct Answer & Explanation

. active range-of-motion exercises after 1 to 3 days.

Explanation

DISCUSSION: The elbow usually is stable after reduction in most elbow dislocations. Ross and associates reported that supervised motion begun immediately after reduction was effective in uncomplicated dislocations. The elbow will become stiff if immobilization is applied for an extended period of time. Immediate open treatment is not indicated for a simple elbow dislocation. REFERENCES: Ross G, McDevitt ER, Chronister R, et al: Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308-311. Oโ€™Driscoll SW, Jupiter JB, King GJ, et al: The unstable elbow. J Bone Joint Surg Am 2000;82:724-738.

Question 1125

Topic: 9. Shoulder and Elbow

An extended head hemiarthroplasty (rotator cuff tear arthropathy head) has what theoretic advantage when compared to a standard hemiarthroplasty? Review Topic

. Improved superior stability
. Fixed fulcrum kinematics
. Creates a metal-to-bone articulation with the acromion
. Increased deltoid moment arm
. Increased glenohumeral offset

Correct Answer & Explanation

. Creates a metal-to-bone articulation with the acromion

Explanation

The theoretic advantage of a metal-to-bone articulation with the acromion is that there is a greater arc in which a smooth metal surface contacts the glenoid and acromion. This may improve pain and function, but no studies have evaluated this to date. One study showed results comparable to that of a standard hemiarthroplasty. There are no other biomechanic advantages.

Question 1126

Topic: Elbow & Forearm
A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?
. Radial head resection, open reduction and internal fixation of the coronoid, and medial collateral ligament repair
. Radial head resection and lateral collateral ligament repair
. Radial head arthroplasty alone
. Radial head arthroplasty and lateral collateral ligament repair
. Radial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repair

Correct Answer & Explanation

. Radial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repair

Explanation

DISCUSSION: The combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region. REFERENCES: Ring D, Quintero J, Jupiter JB: Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811-1815. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551. Moro JK, Werier J, MacDermid JC, et al: Arthroplasty with a metal radial head for unreconstructable fractures of the radial head. J Bone Joint Surg Am 2001;83:1201-1211.

Question 1127

Topic: 9. Shoulder and Elbow

A 10-day-old girl has decreased active motion of the left upper extremity. The mother reports a difficult vaginal delivery with presumed shoulder dystocia. Examination shows full passive range of motion of the shoulder, elbow, and wrist but only active flexion of the fingers and wrist. Factors predictive of a good outcome include which of the following?

. Breech delivery
. Absence of an ipsilateral clavicle fracture
. Horner's sign and an APGAR score of 10 at 1 minute
. Return of active biceps before 3 months and preservation of full passive shoulder range of motion
. Absent Moro and Babinski reflexes

Correct Answer & Explanation

. Return of active biceps before 3 months and preservation of full passive shoulder range of motion

Explanation

Return of active biceps before 3 months and preservation of full passive shoulder range of motion are predictors of a good outcome. Breech delivery is usually associated with preganglionic injury. Preganglionic injury can result in a Horner's sign, which includes ptosis, myosis, and anhydrosis. Preganglionic injuries are unlikely to recover. The Moro reflex is elicited by dropping a baby's head a short distance and observing active elbow extension and fanning of the fingers, followed by elbow flexion and crying. Absence of the Moro reflex suggests a poor prognosis.

Question 1128

Topic: 9. Shoulder and Elbow
A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?
. Inflammatory elbow arthritis
. A presurgical flexion-extension elbow arc of approximately 50ยฐ
. Retained distal humerus hardware on presurgical radiographs
. Evidence of presurgical elbow instability

Correct Answer & Explanation

. Evidence of presurgical elbow instability

Explanation

End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey reported worse results and elevated incidence of complications for patients with presurgical elbow instability upon examination; retained hardware from prior surgery was not deemed a contraindication.

Question 1129

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? Review Topic

. 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

. Lateralization of the center of rotation, lengthening the deltoid, and decreasing the deltoid moment arm

Explanation

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 1130

Topic: Elbow & Forearm
A 39-year-old woman fell onto her flexed elbow and sustained a comminuted displaced radial head and neck fracture. Radiographs confirm concentric reduction of the ulnohumeral joint. Examination reveals pain with compression of the radius and ulna at the wrist. What is the best treatment for the radial head fracture?
. Long arm cast for 2 weeks, followed by range of motion
. Early range of motion
. Metallic radial head arthroplasty
. Silastic radial head arthroplasty
. Excision of the radial head

Correct Answer & Explanation

. Metallic radial head arthroplasty

Explanation

Patients with comminuted radial neck and head fractures and associated wrist pain have a significant injury to the elbow and forearm. Nonsurgical management is an option, but initial casting will result in stiffness and early range of motion is likely to be unsuccessful secondary to pain. Surgical treatment with open reduction and internal fixation, although possible, is technically demanding and results are unpredictable with comminuted fractures. Excision alone in the face of wrist pain may lead to radial shortening. The treatment of choice is excision and metallic radial head arthroplasty. Silastic implants have been associated with synovitis and wear debris.

Question 1131

Topic: 9. Shoulder and Elbow

MRI results are shown in Figure 1 for a 22-year-old, right-hand dominant collegiate athlete who reports a 6-month history of progressive weakness in his right arm. He denies any specific traumatic event. He has altered his weight-lifting activities and tried over-the-counter ibuprofen without benefit. No appreciable deformity or atrophy is found on examination of the upper extremities. He demonstrates full active shoulder range of motion, and there is no weakness with abduction in the plane of the scapula. Belly press test findings are normal, but weakness is seen in external rotation with the arm in adduction. He does not demonstrate anterior apprehension, and there is no instability with load and shift testing. Radiographs are unremarkable. What is the best surgical option?

. Arthroscopic labral debridement and biceps tenodesis
. Shoulder arthroscopy with undersurface cuff debridement and acromioplasty
. Cyst decompression at the spinoglenoid notch with possible labral repair
. Cyst decompression at the suprascapular notch with possible labral repairThis patientโ€™s clinical and MRI findings are consistent with a posterior paralabral cyst with compression of the suprascapular nerve, specifically at the spinoglenoid notch. Compression of the suprascapular nerve can occur at either the suprascapular or spinoglenoid notch. Compression of the nerve at the suprascapular notch affects innervation to both the supraspinatus and infraspinatus muscles, resulting in weakness in both shoulder abduction and external rotation. However, compression at the spinoglenoid notch only affects innervation to the infraspinatus muscle, resulting in isolated weakness in external rotation.Compression at the spinoglenoid notch often is seen in overhead athletes, and studies have shown associated posterior labral tears (Piatt and associates). Several studies have addressed nonsurgical and surgical treatment options. The treatment decision should focus on the underlying cause (Martin and associates)โ€”in this patient, the cyst. Nonsurgical treatment in the presence of a known lesion has been associated with a higher failure rate than addressing the lesion, which can result in functional improvement (Chen and associates, Cummins and associates). The best response in this scenario is decompression of the cyst at the spinoglenoid notch with possible labral repair.

Correct Answer & Explanation

. Arthroscopic labral debridement and biceps tenodesis

Explanation

A 45-year-old woman diagnosed with lateral epicondylitis undergoes an open debridement of the extensor carpi radialis brevis. During surgery, resection extends posterior to the equator of the radiocapitellar joint. Postoperatively, she complains of persistent pain, despite appropriate rehabilitation. What other physical examination finding is she likely to have?A. Pain with elbow extension in forearm pronationB. Mechanical symptoms when rising from a chairC. Valgus instabilityD. Tenderness over the medial collateral ligament (MCL)Excessive resection of the common extensor origin posterior to the equator of the radiocapitellar joint may lead to iatrogenic lateral collateral ligament (LCL) injury, causing posterior lateral rotatory instability (PLRI). Patients may present with lateral elbow pain, a positive lateral pivot shift test, or mechanical symptoms/subjective instability when pushing up from a chair (positive chair rise test). PLRI is often provoked with combined elbow extension and forearm supination, as the posterior support for the radiocapitellar joint has been lost. Therefore, placing the forearm in pronation during elbow extension places the radiocapitellar joint in a more stable position and is less likely to induce pain or mechanical symptoms. Valgus instability and MCL tenderness would be associated with an MCL injury.56- A 75-year-old man presents with complaints of shoulder pain, bruising, and weakness following a fall onto his outstretched hand. He underwent an uncomplicated anatomic total shoulder arthroplasty 5 years prior with good range of motion and strength. His current radiographs are shown in Figures 1 and 2. What is the most appropriate next step to restore this patientโ€™s function?

Question 1132

Topic: 9. Shoulder and Elbow
A 15-year-old boy falls from his bicycle and sustains an injury to his elbow. Prereduction radiographs are shown in Figure 12a. Closed reduction is performed without difficulty and postreduction radiographs are shown in Figure 12b. What is the next most appropriate step in treatment?
. Conversion to cast immobilization for 6 weeks
. Application of an articulated external fixator
. Begin early motion as soon as pain resolves
. Open reduction
. MRI to assess ligament integrity

Correct Answer & Explanation

. Open reduction

Explanation

Elbow dislocations in children are rare injuries and usually result from a fall on an outstretched arm. In adolescent patients, simple elbow dislocations are treated with splint immobilization and the initiation of physical therapy once comfortable. The practitioner must be aware of structures that may get caught in the joint on reduction. These include the median nerve as well as the medial epicondyle. In this patient, the radiographs reveal a medial epicondyle fracture. Postreduction radiographs show the joint to be incongruous secondary to intra-articular displacement. At this point, the most appropriate treatment is to perform an open reduction and repair of the medial epicondyle fragment.

Question 1133

Topic: 9. Shoulder and Elbow

Figure 72 is the MRI scan of a 61-year-old man who had left shoulder pain with a massive rotator cuff tear. Active forward elevation was 120 degrees. Arthroscopic examination revealed that the rotator cuff tear was irreparable. The articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment option? Review Topic

. Biceps tenotomy
. Loose body removal
. Latissimus dorsi transfer
. Reverse total shoulder arthroplasty

Correct Answer & Explanation

. Biceps tenotomy

Explanation

The MRI scan shows medial subluxation of the biceps tendon. Biceps tenotomy has been an effective treatment option for patients with large to massive rotator cuff tears when the tear is irreparable and pain is the main symptom. The MRI scan does not show a loose body. Patients with severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer. Reverse total shoulder arthroplasty is an option in patients with cuff tear arthropathy and pseudoparalysis.

Question 1134

Topic: 9. Shoulder and Elbow
Figures 37a and 37b show radiographs of a right-handed, 78-year-old man who had painful glenohumeral arthritis, moderate limitation of motion, and good strength prior to replacement of the humeral head 2 years ago. At the time of treatment, the rotator cuff was intact. He now has limited motion, weakness, and persistent pain in the shoulder. What is the most likely diagnosis?
. Infection
. Tear of the rotator cuff
. Loosening of the humeral component
. Arthritis of the glenoid
. Arthritis of the AC joint

Correct Answer & Explanation

. Infection

Explanation

The referenced text states that the most frequent complications in shoulder hemiarthroplasty are due to rotator cuff and tuberosity problems or postoperative instability. Return of motion is expected to be two-thirds to three-fourths of pre-operative. 80-90% of patients undergoing hemiarthroplasty experience pain relief. Of the 10-20% who fail to get relief, conversion to total shoulder arthroplasty should be considered. The point strongly emphasized in the article was that for those patients requiring conversion to TSA, strongly suspect infection.

Question 1135

Topic: 9. Shoulder and Elbow

Which of the following is helpful on physical examination to diagnose a fixed posterior shoulder dislocation? Review Topic

. Apprehension sign
. Jobe relocation test
. Sulcus sign
. Jerk test
. Lack of external rotation

Correct Answer & Explanation

. Apprehension sign

Explanation

The apprehension sign and Jobe relocation test are helpful for the diagnosis of anterior shoulder instability. The sulcus sign provides information on the status of the rotator interval. The jerk test is helpful for the diagnosis of posterior instability, but a fixed posterior shoulder dislocation is associated with loss of external rotation. Since an AP radiograph may miss this diagnosis, an axillary view should be obtained on patients with a shoulder injury.

Question 1136

Topic: 9. Shoulder and Elbow

A 74-year-old woman with rheumatoid arthritis reports shoulder pain that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 23a and 23b. Examination reveals active forward elevation to 120 degrees and external rotation to 30 degrees. What treatment option results in the most predictable pain relief and function? Review Topic

. Hemiarthroplasty
. Arthroscopic debridement
. Total shoulder arthroplasty with a cemented all-polyethelene glenoid component
. Reverse total shoulder arthroplasty
. Total shoulder arthroplasty with a metal-backed glenoid component

Correct Answer & Explanation

. Hemiarthroplasty

Explanation

Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared to hemiarthroplasty in patients with rheumatoid arthritis. Although rotator cuff tears are more common in this patient population, this patient has good forward elevation and no significant superior migration of the humeral head; therefore, a reverse arthroplasty is not indicated. The arthritis is too advanced in this patient to consider arthroscopy, but in less advanced cases it can improve range of motion and decrease pain. Metal-backed glenoid components have shown higher rates of loosening.

Question 1137

Topic: 9. Shoulder and Elbow
Figure 37 shows the radiograph of a 23-year-old football player who sustained a blow to the anterior aspect of his shoulder. Examination reveals pain and limited rotation. He is unable to flex the arm above the shoulder. Management should include which of the following studies?
. Axillary radiograph
. Arthrogram
. Electromyogram
. Bone scan
. Arteriogram

Correct Answer & Explanation

. Axillary radiograph

Explanation

The patient has a posterior dislocation. The radiograph reveals marked internal rotation, but fails to show whether the humeral head is posteriorly displaced. Therefore, an axillary radiograph should be obtained to help confirm the diagnosis.

Question 1138

Topic: 9. Shoulder and Elbow

To prevent injury to the posterior interosseous nerve during the approach for reduction and fixation of a fracture of the radial head, anterior retraction should be performed with the forearm

. Maximally pronated and elbow extended
. Maximally pronated and the elbow flexed
. Maximally supinated and the elbow flexed
. Maximally supinated and the elbow extended
. In neutral rotation, with the elbow extended

Correct Answer & Explanation

. Maximally pronated and elbow extended

Explanation

Position of the patient-Place supine on the operating table, with the affected arm positioned over the chest. Pronate the forearm.Deep surgical dissection-Fully pronate the forearm to move the posterior interosseous nerve away from the operative field. Incise the capsule of the elbow joint longitudinally to reveal the underlying capitulum, the radial head, and the annular ligament. Do not incise the capsule too far anteriorly; the radial nerve runs over the front of the anterolateral portion of the elbow capsule. Do not continue their dissection below the annular ligament or retract vigorously, distally, or anteriorly, because the posterior interosseous nerve lies within the substance of the supinator muscle and is vunerable to injury.Dangers: Nerves-The posterior interosseous nerve is in no danger as long as the dissection remains proximal to the annular ligament. Pronation of the forearm keeps the nerve as far from the operative field as it possible can be. To ensure the safety of the nerve, take great care to place the retractors directly on the bone and be careful in their placement. Because the posterior interosseous nerve actually may touch the bone of the radial neck, directly opposite the bicipital tuberosity, placing retractors behind it poses a risk.

Question 1139

Topic: Elbow & Forearm

Figures 1 and 2 are the MRI scans of a 35-year-old right-hand dominant man who has right elbow pain after trying to lift a large television at home. An examination reveals ecchymosis, an abnormal hook test, and altered biceps muscle contour. What treatment is most likely to result in a satisfactory and predictable outcome?

. Period of immobilization followed by physical therapy
. Local corticosteroid injection
. Surgical repair
. Platelet-rich plasma (PRP)

Correct Answer & Explanation

. Period of immobilization followed by physical therapy

Explanation

Figures 1 and 2 show a full thickness distal biceps tendon rupture with proximal retraction. Edema is seen along the course of the distal biceps tendon, and the axial cut demonstrates the absence of tendon at the radial tuberosity. The sagittal cut demonstrates the stump of the proximally retracted biceps tendon. The biceps muscle contour is abnormal in appearance, demonstrating the classic โ€œpopeyeโ€ deformity. Nonsurgical treatment options result in predictable loss of supination and elbow flexion strength that is not desirable. A local corticosteroid injection would not improve strength, and there is no evidence to support the use of a PRP injection.

Question 1140

Topic: 9. Shoulder and Elbow

The sublime tubercle of the elbow serves as the insertion site of the Review Topic

. anterior bundle of the medial collateral ligament.
. posterior bundle of the medial collateral ligament.
. transverse bundle of the medial collateral ligament.
. annular ligament.
. lateral collateral ligament.

Correct Answer & Explanation

. anterior bundle of the medial collateral ligament.

Explanation

The anterior bundle originates on the anteroinferior medial humeral epicondyle and inserts on the medial portion of the coronoid, known as the sublime tubercle.

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