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9. Shoulder and Elbow MCQs

Practice Set 62 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 1221

Topic: Elbow & Forearm

During a two-incision distal biceps tendon repair, the surgeon develops the posterior plane between the supinator and the extensor carpi radialis brevis. Which nerve is at greatest risk of injury during this posterior exposure if the forearm is not fully pronated?

. Posterior interosseous nerve (PIN)
. Anterior interosseous nerve (AIN)
. Lateral antebrachial cutaneous nerve
. Superficial radial nerve

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The posterior interosseous nerve (PIN) lies within the supinator muscle. Maximally pronating the forearm moves the PIN anteriorly and medially, protecting it during the posterolateral approach of a two-incision distal biceps repair.

Question 1222

Topic: 9. Shoulder and Elbow

A 72-year-old female receives a reverse total shoulder arthroplasty for a 4-part proximal humerus fracture. The surgeon performs a tuberosity repair. Healing of the greater tuberosity is considered most critical for restoring which specific shoulder function?

. Forward elevation
. Internal rotation
. External rotation
. Abduction strength

Correct Answer & Explanation

. Forward elevation

Explanation

The greater tuberosity serves as the attachment for the infraspinatus and teres minor. Healing of the greater tuberosity to the shaft in a reverse total shoulder arthroplasty is essential to restore active external rotation.

Question 1223

Topic: 9. Shoulder and Elbow

In the surgical treatment of a terrible triad injury of the elbow, the coronoid is fixed, the radial head is replaced, and the lateral collateral ligament (LCL) is repaired. However, the elbow remains subluxated and unstable in extension. What is the most appropriate next step?

. Repair the anterior capsule
. Repair the medial collateral ligament (MCL)
. Apply a hinged external fixator immediately
. Immobilize the elbow in 90 degrees of flexion and maximum pronation

Correct Answer & Explanation

. Repair the anterior capsule

Explanation

The standard surgical algorithm for a terrible triad injury proceeds from deep to superficial and lateral to medial. If the elbow remains unstable after coronoid, radial head, and LCL repair, the next step is to repair the MCL.

Question 1224

Topic: Elbow & Forearm

A 15-year-old female gymnast is diagnosed with a capitellar osteochondritis dissecans (OCD) lesion. MRI shows the articular cartilage is intact. Which radiographic view best profiles the capitellum to monitor lesion size and healing during non-operative management?

. Standard AP view
. True lateral view
. Anteroposterior view in 45 degrees of flexion (AP axial view)
. Anteroposterior view in maximum internal rotation

Correct Answer & Explanation

. Standard AP view

Explanation

The capitellum is situated anteriorly on the distal humerus. The AP axial view (taken with the elbow flexed 45 degrees) best profiles the articular surface of the capitellum, clearly demonstrating OCD lesions.

Question 1225

Topic: 9. Shoulder and Elbow
While lifting weights, a patient feels a pop in his arm. He has the deformity shown in Figure 30. If left untreated, the patient will have the greatest deficiency in
. shoulder flexion.
. elbow flexion.
. forearm pronation.
. forearm supination.
. wrist flexion.

Correct Answer & Explanation

. forearm supination.

Explanation

The patient has a distal biceps rupture. While the distal biceps contributes to elbow flexion, its main function is forearm supination.

Question 1226

Topic: 9. Shoulder and Elbow

.Figures 255a through 255c are the radiographs and MRI scan of a 73-year-old man who has severe pain and functional disability of the right shoulder despite receiving several cortisone injections and physical therapy. Examination reveals restricted shoulder range of motion in forward elevation and both internal and external rotation. There is moderately diminished strength and pain with resisted forward elevation.What is the best treatment option?

. Reverse total shoulder arthroplasty
. Unconstrained total shoulder arthroplasty
. Hemiarthroplasty with biologic glenoid resurfacing
. Arthroscopic subacromial decompression
. Arthroscopic capsular release with manipulation under anesthesia

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Question 1227

Topic: Shoulder Pathology

The clinical photograph in Figure 27 shows a palsy of what nerve/associated muscle? Review Topic

. Long thoracic/rhomboid
. Long thoracic/serratus anterior
. Long thoracic/supraspinatus
. Dorsal scapular/trapezius
. Spinal accessory/trapezius

Correct Answer & Explanation

. Long thoracic/rhomboid

Explanation

The clinical picture reveals medial scapular winging, which involves the serratus anterior muscle, potentially due to an injury to the long thoracic nerve that innervates this muscle. Injury to the long thoracic nerve is usually due to closed trauma, direct compression, traction or stretching injury, a direct blow, or, very rarely, viral infectionsuch as Parsonage-Turner syndrome. The nerve is easily injured in surgical dissection of the axilla, and is predisposed to injury due to its relatively long course, it is small in diameter, and it has little surrounding connective tissue. If rehabilitation and time are unsuccessful, both nerve and muscle transfers have been described with mixed results.

Question 1228

Topic: 9. Shoulder and Elbow
What three structures are considered the primary constraints necessary for elbow stability?
. Coronoid, ulnar part of the lateral collateral ligament, capsule
. Capsule, anterior band of the medial collateral ligament, radial head
. Radial head, ulnar part of the lateral collateral ligament, capsule
. Anterior band of the medial collateral ligament, coronoid, radial head
. Ulnar part of the lateral collateral ligament, anterior band of the medial collateral ligament, coronoid

Correct Answer & Explanation

. Ulnar part of the lateral collateral ligament, anterior band of the medial collateral ligament, coronoid

Explanation

DISCUSSION: The three primary constraints necessary for elbow stability in all directions are the ulnar part of the lateral collateral ligament (also called the lateral ulnar collateral ligament), the anterior band of the medial collateral ligament, and the coronoid. The radial head and capsule are secondary constraints to elbow instability. REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.

Question 1229

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
. 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

. loss of external rotation.

Explanation

DISCUSSION: If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur. REFERENCES: Williams MM, Snyder SJ, Buford D Jr: The Buford complex - the “cord-like” middle glenohumeral ligament and absent anterosuperior labrum complex: A normal anatomic capsulolabral variant. Arthroscopy 1994;10:241-247. Cooper DE, Arnoczky SP, O’Brien SJ, et al: Anatomy, histology, and vascularity of the glenoid labrum: An anatomical study. J Bone Joint Surg Am 1992;74:46-52.

Question 1230

Topic: 9. Shoulder and Elbow
Figure 31 shows the AP and lateral radiographs of the elbow of a 56-year-old man with chronic polyarticular rheumatoid arthritis. His function continues to be limited by pain with activities of daily living. Examination shows that his total arc of motion is 110 degrees. Nonsurgical management has failed to provide relief. Treatment should now consist of
. elbow fusion with a contoured dynamic compression plate.
. radial head excision and synovectomy.
. distraction arthroplasty with interpositional tissue.
. total elbow replacement with an unconstrained prosthesis.
. total elbow replacement with a semiconstrained prosthesis.

Correct Answer & Explanation

. total elbow replacement with a semiconstrained prosthesis.

Explanation

DISCUSSION: A semiconstrained prosthesis can provide excellent results in carefully selected patients. Because the radiographs show extensive joint destruction with loss of the capitellum and trochlea, a capitellocondylar total elbow (unconstrained) prosthesis is contraindicated. Elbow fusion is poorly accepted, and the radiographs show too much articular destruction for a radial head excision, synovectomy, or interposition arthroplasty to be effective. REFERENCES: Ewald FC, Simmons ED Jr, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. J Bone Joint Surg Am 1993;75:498-507. Morrey BF, Adams RA: Capitellocondylar total elbow replacement in rheumatoid arthritis. J Bone Joint Surg Am 1992;74:479-490.

Question 1231

Topic: 9. Shoulder and Elbow
A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow. The most substantial functional deficit that may develop if no surgical treatment is provided is
. elbow flexion strength.
. elbow supination strength.
. lack of terminal extension at the elbow.
. decrease of elbow pronation strength.

Correct Answer & Explanation

. elbow supination strength.

Explanation

This patient had an eccentric muscle contraction of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding. The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of the other elbow flexors (brachioradialis and brachialis).

Question 1232

Topic: 9. Shoulder and Elbow
Treatment of adhesive capsulitis has a high failure rate when the underlying cause is
. idiopathic.
. traumatic.
. diabetes mellitus.
. hypothyroidism.
. hyperthyroidism.

Correct Answer & Explanation

. diabetes mellitus.

Explanation

DISCUSSION: Diabetes mellitus has been associated with resistant cases of adhesive capsulitis. With other causes of onset, adhesive capsulitis frequently responds to nonsurgical management such as stretching exercises or, when this fails, manipulation under anesthesia and/or arthroscopic release. Manipulation is rarely successful for the treatment of adhesive capsulitis associated with diabetes mellitus, and arthroscopic release may be preferred.

Question 1233

Topic: 9. Shoulder and Elbow

A 27-year-old right hand dominant construction worker falls off a scaffold onto his outstretched arm. Figure A exhibits the radiograph taken at a local emergency room. Following treatment, he is placed in a sling and follows up at your office two weeks later. He complains of a feeling that his arm is going to 'pop out'. Which specific physical examination finding is likely to be present? Review Topic

. Hornblower's Test
. Jobe's Test
. Apprehension Sign with shoulder abducted and externally rotated
. Speed's Test
. Kim's Test

Correct Answer & Explanation

. Hornblower's Test

Explanation

The patient suffered a posterior shoulder dislocation, likely injuring the posterior capsule and/or labrum. Out of all the answer choices, Kim's test assesses posterior structures. Thus, Kim's test is the physical examination finding most likely to be present.Posterior dislocations occur less frequently than anterior dislocations, and are often missed. Following closed reduction, persistent instability can occur, usually associated with posterior capsular or labral pathology. Posteriorly directed provocative maneuvers, such as the Kim test can be positive.Robinson et al. performed an epidemiologic analysis on 120 posterior dislocations. Recurrent instability occurred at a rate of 17.7%. Risk factors for recurrent instability included age less than 40-years-old, dislocation during seizure, and a large reverse Hill-sachs (>1.5 cm3).Kim et al. describe the Kim lesion, a separation between the posteroinferior labrum and the articular cartilage without complete detachment of the labrum, which cause persistent posterior instability.Figure A depicts a posterior dislocation on xray. Illustration A depicts the Kim test, which is performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45° forward flexion while simultaneously applying axial load on the elbow and posterior-inferior force on the upper humerus. The test is positive when there is pain. Video 1 depicts the proper way to perform a Kim Test.Incorrect answers:

Question 1234

Topic: Shoulder Pathology

A 47-year-old man undergoes a posterior cervical procedure for a benign tumor. Postoperatively, severe dysfunction with decreased forward elevation and abduction develops and he has lateral winging of the scapula. What is the recommended treatment to best restore motion and function? Review Topic

. Rhomboids and levator transfer
. Split pectoralis major transfer
. Long head of triceps transfer
. Scapulothoracic fusion
. Infraspinatus transfer

Correct Answer & Explanation

. Rhomboids and levator transfer

Explanation

The patient has sustained a permanent injury to the spinal accessory nerve and has resultant scapular winging (lateral winging) because of trapezius palsy with weakness in abduction and forward elevation. The modified Eden-Lange procedure (transfer of the rhomboid minor, major, and levator scapulae) has been shown to reliably restore range of motion and function. Split pectoralis major transfer is performed to restore serratus anterior function. The long head of the triceps and infraspinatus tendon transfers are rarely used for any shoulder muscle transfer. A scapulothoracic fusion can also be performed for this problem, but the results are not as effective as the Eden-Lange procedure.

Question 1235

Topic: 9. Shoulder and Elbow

-What is the most likely deficit in elbow function resulting from an isolated lesion of the ulnar nerve above the elbow?

. No elbow deficit
. Weakness of elbow flexion
. Weakness of elbow extension
. Weakness of forearm pronation
. Weakness of forearm supination

Correct Answer & Explanation

. No elbow deficit

Explanation

Question 1236

Topic: 9. Shoulder and Elbow
A 52-year-old woman reports the sudden onset of intense pain in the right shoulder. She denies any history of injury or previous shoulder problems. At a 2-week follow-up examination, she notes that the pain has decreased, but she now has severe weakness of the external rotators and abductors. Her cervical spine and remaining shoulder examination are otherwise unremarkable. Radiographs of the shoulder and neck are normal. What is the most likely diagnosis?
. Calcific tendinitis
. Rotator cuff tendinosis
. Bursitis
. Brachial neuritis
. Glenohumeral arthritis

Correct Answer & Explanation

. Brachial neuritis

Explanation

Patients with brachial neuritis or Parsonage-Turner syndrome usually report the sudden onset of intense pain that subsides in 1 to 2 weeks, followed by weakness for a period of up to 1 year in the muscle that is supplied by the involved nerve. Calcific tendinitis usually can be diagnosed radiographically, with calcium deposits seen in the rotator cuff. Bursitis and rotator cuff tendinosis usually are seen after an increase in activity, and both decrease with rest and medication. Glenohumeral arthritis is a slow, progressive problem that results in a loss of range of motion.

Question 1237

Topic: Shoulder Arthroplasty & Arthritis

What prosthetic factor has the most impact on decreasing the rate of scapular notching in a Grammont-style reverse total shoulder arthroplasty? Review Topic

. Posterior tilt of the glenoid component
. Inferior tilt of the glenoid component
. Inferior positioning of the glenoid component
. Use of a cemented humeral component
. Use of locking screws in the glenoid component

Correct Answer & Explanation

. Posterior tilt of the glenoid component

Explanation

A low position of the glenoid base plate has been shown to have the greatest effect on decreasing scapular notching with a Grammont-style prosthesis. Scapular notching is the phenomena seen after reverse total shoulder arthroplasty when bone along the inferior scapular neck is lost. It is thought to be the result of repeated contact between the humeral component and the bone. The Grammont-style reverse total shoulder arthroplasty has a medialized center of rotation that decreases strain at the glenoid component but has less space for the humerus to clear the scapula. Scapular notching was seen least in components that are placed low on the glenoid. Posterior and inferior tilt has minimal effect on scapular notching and may even increase notching by bringing the humerus closer to the scapula. The use of locking screws and a cemented humeral stem had no influence on notching.

Question 1238

Topic: 9. Shoulder and Elbow

Which of the following is considered a contraindication to elbow arthroscopy? Review Topic

. Osteonecrosis of the elbow (Panner disease)
. Loose body in the ulnohumeral joint
. Status post open reduction and internal fixation of a radial head fracture
. Ulnar neuropathy with prior submuscular ulnar nerve transposition
. Elbow stiffness

Correct Answer & Explanation

. Osteonecrosis of the elbow (Panner disease)

Explanation

Neurovascular complications are the most common complications reported with elbow arthroscopy. Any distortion in the anatomy of the elbow, especially when it involves neurovascular structures, such as a prior ulnar nerve transposition, increases the risk of neurovascular injury and is generally considered a contraindication to elbow arthroscopy. The other answers listed are either indications for arthroscopy or are not contraindications for the procedure.

Question 1239

Topic: Elbow & Forearm
A 10-year-old girl has a right elbow deformity that is the result of trauma 5 years ago. She has no pain despite the arm deformity. The radiographs in Figures 42a and 42b show complete healing. This radiographic appearance demonstrates what complication?
. Growth arrest of the medial trochlear physis
. Varus malunion of a supracondylar humeral fracture
. Valgus malunion of a lateral condylar fracture
. Posterior and lateral dislocation of the radial head
. Osteonecrosis of the capitellum

Correct Answer & Explanation

. Varus malunion of a supracondylar humeral fracture

Explanation

Cubitus varus is a common complication of displaced supracondylar humeral fractures that are treated with closed reduction and cast immobilization. Treatment with closed reduction and percutaneous pinning decreases the incidence of this complication. Cubitus varus also can occur in minimally displaced fractures when unrecognized collapse of the medial column of the distal humerus is not corrected with manipulation. This can be detected on physical examination of the carrying angle or on radiographs measuring Baumann’s angle, both in comparison to the opposite side. Cubitus varus may result in unacceptable cosmesis and may predispose the patient to fractures of the lateral condyle. The lateral radiograph demonstrates the crescent sign from overlap of the distal humerus with the olecranon seen in patients with cubitus varus.

Question 1240

Topic: 9. Shoulder and Elbow
With increasing abduction in the scapular plane, maintaining neutral rotation, contact area, and contact pressure per unit area between the humeral head and glenoid follows what pattern if the total load across the joint is held constant?
. Contact area and contact pressure both decrease.
. Contact area and contact pressure both increase.
. Contact area and contact pressure both remain the same.
. Contact area increases and contact pressure decreases.
. Contact area decreases and contact pressure increases.

Correct Answer & Explanation

. Contact area increases and contact pressure decreases.

Explanation

The glenohumeral joint becomes more congruent at higher levels of abduction. As a consequence, contact area increases. As the load is spread more evenly across the joint, contact pressure per unit area decreases as long as the total load across the joint is held constant.

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