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 1241
Topic: 9. Shoulder and Elbow
A 55-year-old male returns for follow-up 3 months after reverse shoulder arthroplasty. He reports limited function of his right shoulder but no antecedent trauma. A radiograph of his shoulder is shown in Figure A. All of the following variables are associated with this complication EXCEPT:
Correct Answer & Explanation
. Rheumatoid arthritis
Explanation
Rheumatoid arthritis is not associated with reverse shoulder arthroplasty (RSA) dislocation. RSA dislocation is a known complication of RSA. Risks include proximal humeral bone loss, chronic fracture sequelae with malunited/ununited tuberosities, failed previous arthroplasty, and fixed glenohumeral dislocation preoperatively.
Question 1242
Topic: 9. Shoulder and Elbow
What structure is the primary restraint to inferior translation of the shoulder? Review Topic
Correct Answer & Explanation
. Middle glenohumeral ligament
Explanation
The coracohumeral ligament has been shown to be the primary restraint to inferior translation of the shoulder. Although Bigliani and associates have demonstrated that the inferior capsule and inferior glenohumeral ligaments also play a role, none of the other choices provide primary inferior stability of the shoulder. The coracohumeral ligament is an important structure of the rotator interval of the shoulder (the rotator interval contains the long head of the biceps, the superior glenohumeral ligament, the coracohumeral ligament, and a thin layer of capsule). Harryman and associates demonstrated that an open rotator interval closure via imbrication of the coracohumeral ligament improves inferior stability of the glenohumeral joint.
Question 1243
Topic: Elbow & Forearm
A 51-year-old female sustained a comminuted radial head fracture with 4 fragments and an associated elbow dislocation. She was initially closed reduced and splinted with the elbow joint in a reduced position and presents to the orthopedist's office 10 days later. In response to the patient's question of what treatment offers the best chance for a good outcome, the surgeon should recommend?
Correct Answer & Explanation
. Radial head arthroplasty
Explanation
In a classic article, Ring et al reported that ORIF of radial head fractures with more than 3 fragments has poor results and recommend radial head replacement for these fractures. Metallic implants are the material of choice for radial head replacement. Silicone implants were often used in the past and have many well-documented complications including prosthesis failure, adverse tissue reaction, and poor load transfer. Excision is not appropriate in the setting of a radial head fracture associated with elbow instability.
Question 1244
Topic: 9. Shoulder and Elbow
A fracture of the radial head is surgically exposed using a posterolateral approach to the elbow. Once the radial head is exposed, how should the arm be positioned to best protect the posterior interosseous nerve from injury?
Correct Answer & Explanation
. Forearm pronation
Explanation
As long as the dissection stays proximal to the annular ligament, the posterior interosseous nerve is not at risk for injury. However, to ensure that the nerve is as far removed from the surgical field as possible, the forearm should be placed in pronation. Forearm supination of any degree will bring the nerve toward the surgical field. A neutral position of the forearm or elbow extension with wrist extension will not protect the posterior interosseous nerve.
Question 1245
Topic: 9. Shoulder and Elbow
A 2-year-old girl has had a 2-day history of fever and refuses to move her left shoulder following varicella. Laboratory studies show an erythrocyte sedimentation rate of 75 mm/h and a peripheral WBC count of 18,000/mm³. What is the most common organism in this scenario?
Correct Answer & Explanation
. Group A beta-hemolytic streptococcus
Explanation
The most common bacterial etiologic agent following varicella is group A beta-hemolytic streptococcus. The other organisms are much less common. Staphylococcus aureus is the most common bone infection organism. Staphylococcus epidermidis is increasingly a bone infection organism. Group B streptococcus occurs more commonly in newborns. Kingella kingae is a common joint pathogen but is not as common following varicella.
Question 1246
Topic: Shoulder Pathology
During an arthroscopic SLAP (Superior Labrum Anterior to Posterior) repair on a right shoulder, the surgeon prepares to place a suture anchor at the 1 o'clock position on the glenoid rim. Deep drill penetration past the far cortex at this specific location places which of the following neurovascular structures at greatest risk of injury?
Correct Answer & Explanation
. Axillary nerve
Explanation
The suprascapular nerve courses through the suprascapular notch and winds around the spinoglenoid notch. It passes dangerously close (often within 1 cm) to the base of the coracoid process and the anterosuperior glenoid neck. Anteriorly placed anchors for SLAP repairs (1 to 2 o'clock position) that penetrate too deeply place the suprascapular nerve at high risk.
Question 1247
Topic: 9. Shoulder and Elbow
A 22-year-old collegiate baseball pitcher is scheduled for an ulnar collateral ligament (UCL) reconstruction using an autograft. Which specific bundle of the UCL is the primary restraint to valgus stress during the late cocking and early acceleration phases of throwing, and is thus the primary structure reconstructed in this procedure?
Correct Answer & Explanation
. Posterior bundle
Explanation
The anterior bundle of the medial ulnar collateral ligament is the primary restraint to valgus stress at the elbow from approximately 30 to 120 degrees of flexion. It is the structure most susceptible to microtrauma and rupture during overhead throwing and is the focus of UCL ('Tommy John') reconstruction.
Question 1248
Topic: 9. Shoulder and Elbow
A 65-year-old male presents with chronic right shoulder pain and an inability to actively elevate his arm above 45 degrees (pseudoparalysis). Passive forward elevation is 160 degrees. MRI demonstrates a massive, retracted tear of the supraspinatus and infraspinatus with Goutallier stage 4 fatty infiltration. The subscapularis and teres minor are intact. What is the most appropriate, definitive surgical intervention to restore active forward elevation?
Correct Answer & Explanation
. Arthroscopic primary repair of the rotator cuff
Explanation
This patient has pseudoparalysis of the shoulder secondary to a massive, irreparable rotator cuff tear (Goutallier stage 4 fatty infiltration indicates irreversibility). Reverse total shoulder arthroplasty (RTSA) is the gold standard for restoring active forward elevation in older patients with pseudoparalysis, as it medializes and distalizes the center of rotation, recruiting the deltoid to initiate and maintain forward elevation.
Question 1249
Topic: 9. Shoulder and Elbow
A 32-year-old competitive bodybuilder presents with acute anterior shoulder pain and a visible deformity in his axillary fold after attempting a max-weight bench press. MRI confirms a complete rupture of the pectoralis major tendon at its humeral insertion. During open repair, understanding the normal anatomy is crucial. Relative to the clavicular head, where does the sternal head of the pectoralis major tendon anatomically insert on the humerus?
Correct Answer & Explanation
. Superficial and proximal
Explanation
The pectoralis major tendon undergoes a 180-degree twist as it courses from the chest wall to its insertion on the lateral lip of the bicipital groove of the humerus. Due to this twist, the sternal head (inferior fibers) rotates to insert deep (posterior) and proximal to the clavicular head (superior fibers). The sternal head is under the most tension when the arm is extended and externally rotated (the bottom of a bench press), making it the most frequently injured component.
Question 1250
Topic: Elbow & Forearm
A 22-year-old elite basketball player undergoes open surgical debridement of the inferior pole of the patella for chronic, refractory 'jumper’s knee' (patellar tendinopathy). Which of the following describes the most likely classic histologic findings in the excised pathologic tendon tissue?
Correct Answer & Explanation
. Disorganized collagen, mucoid ground substance, and angiofibroblastic hyperplasia without acute inflammatory cells
Explanation
Chronic patellar tendinopathy (jumper's knee), like lateral epicondylitis and Achilles tendinopathy, is histologically a 'tendinosis' rather than a true 'tendinitis'. Pathologic evaluation of the diseased tendon demonstrates a lack of active acute inflammatory cells. Instead, the tissue exhibits angiofibroblastic hyperplasia, mucoid (myxoid) degeneration, disorganized collagen architecture (increased Type III collagen relative to Type I), and increased cellularity of poorly differentiated fibroblasts. This process represents a failed healing response rather than an active inflammatory cascade.
Question 1251
Topic: Shoulder Pathology
A 50-year-old man reports left shoulder pain and weakness after undergoing a lymph node biopsy in his neck 2 years ago. Examination reveals winging of the left scapula. Electromyography shows denervation of the trapezius. Surgical treatment for this condition involves:
Correct Answer & Explanation
. lateral transfer of the levator scapulae and rhomboid minor and major.
Explanation
DISCUSSION: The muscle transfer procedure most commonly performed for trapezius paralysis is the Eden-Lange procedure. Trapezius paralysis in this patient is secondary to iatrogenic injury to the spinal accessory nerve during lymph node biopsy. In this procedure, the levator scapulae and rhomboid minor and major muscles are transferred laterally. Pectoralis transfer to the inferior border of the scapula is used as a dynamic transfer for serratus anterior winging. REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325. Langenskiold A, Ryoppy S: Treatment of paralysis of the trapezius muscle by Eden-Lange operation. Acta Orthop Scand 1973;44:383-388. Romero J, Gerber C: Levator scapulae and rhomboid transfer for paralysis of trapezius: The Eden-Lange procedure. J Bone Joint Surg Br 2003;85:1141-1145.
Question 1252
Topic: Elbow & Forearm
A 62-year-old man slips on ice and sustains an elbow dislocation. Post-reduction imaging reveals a highly comminuted radial head fracture and coronoid fracture through its base. What is the most appropriate treatment?
Correct Answer & Explanation
. Radial head replacement, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed
Explanation
DISCUSSION: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and/or stiffness from prolonged immobilization. Therefore, radial head replacement and open reduction internal fixation of the coronoid is the most appropriate treatment. Pugh et al reported their experiences with this difficult population. Their protocol consisted of ORIF or replacement of the radial head, ORIF of the coronoid fracture, repair of the LCL and capsule, and repair of the MCL and/or hinged external fixation. Of the 36 cases, the outcome was graded as 28 excellent to good, 7 fair, and 1 poor. 8 cases required re-operation. The authors concluded that their surgical protocol restored sufficient elbow stability to allow early motion post-op, thereby enhancing the functional outcome. In fracture dislocation of the elbow with radial head and coronoid fracture, the radial head must be fixed or replaced to restore stability. The ORIF of coronoid fracture and radial head restores some valgus stability, therefore MCL repair may not be needed. However, the varus stability must be restored by LCL repair.
Question 1253
Topic: 9. Shoulder and Elbow
Reverse total shoulder arthroplasty with a latissimus dorsi transfer would be the most appropriate treatment for which of the following patients? Review Topic
Correct Answer & Explanation
. Previous shoulder arthrodesis and complete brachial plexus injury
Explanation
Reverse total shoulder arthroplasty with a latissimus dorsi transfer would be most appropriate in a patient with failed shoulder hemiarthroplasty and the inability to perform active external rotation with the arm abductedR-TSA has become the mainstay treatment for rotator cuff arthropathy. In the presence of severe loss of active elevation and external rotation, combined latisimus dorsi transfer and reverse total shoulder arthroplasty can restore elevation and external rotation, respectively. This may be used in the primary or revision setting.Frankle et al. report the results of sixty patients with rotator cuff deficiency and glenohumeral arthritis who were followed for a minimum of two years. All weretreated with R-TSA. Their study showed that forward flexion increased from 55 to105 degrees, and abduction increased from 41 to 102 degrees.Boileau et al. followed 45 patients with severe cuff tear arthropathy and advanced atrophy/fatty infiltration of the infraspinatus or teres minor muscles. All patients were treated with R-TSA and a modified L'Episcopo procedure (latissimus dorsi and teres major transfer). Mean active elevation increased from 74 degrees preoperatively to149 postoperatively, and external rotation increased from -21 to 13 degrees.Illustrations A and B show the classic findings of rotator cuff arthropathy. There is significant acromial acetabularization and femoralization of humeral head. Other features include: asymmetric superior glenoid wear, osteopenia, "snowcap sign" due to subchondral sclerosis and anterosuperior escape. Illustration C shows a left shoulder after conversion from hemiarthroplasty to reverse total shoulder arthropathy.Incorrect Answers:
Question 1254
Topic: 9. Shoulder and Elbow
A 55-year-old man has had progressive right shoulder pain for the past 2 years. Examination reveals active elevation to 120 degrees, external rotation to 20 degrees, and internal rotation to the sacrum. AP and axillary radiographs are shown in Figures 23a and 23b. Which of the following procedures would result in the most predictable long-term pain relief?
Correct Answer & Explanation
. Total shoulder arthroplasty
Explanation
Total shoulder arthroplasty yields excellent pain relief and function in patients with osteoarthritis. It is favored over humeral arthroplasty, especially when there is asymmetric posterior glenoid wear and posterior humeral subluxation as shown on the axillary radiograph. Arthroscopic debridement of the glenohumeral joint may be helpful in delaying the need for arthroplasty when the arthritic changes are mild to moderate but is not indicated for advanced osteoarthritis.
Question 1255
Topic: 9. Shoulder and Elbow
A 20-year-old collegiate volleyball player has vague left, nondominant elbow pain. Five years ago, he sustained a dislocation of the same joint and, while he could participate in his sport, he notes that the elbow 'never felt quite right.The pain is not severe but prevents him from playing sports and he cannot localize the pain to any specific location. Occasionally he will perceive a catching when pushing himself out of a chair but the elbow never locks in one position. Examination reveals full passive and active range of motion in flexion, extension, supination, and pronation. There is tenderness of the lateral elbow during elbow extension with the forearm supinated and a momentary painfulclunk` is noted. Radiographs and MRI scans are normal. What is the most likely instability? Review Topic
Correct Answer & Explanation
. Varus
Explanation
Posterolateral rotatory instability of the elbow is seen in athletes and frequently follows a previous injury such as a dislocation where the lateral ulnar collateral ligament becomes weakened and attenuated. The ulna supinates away from the humerus and the radius subluxates posteriorly on the capitellum with the forearm supinated and the elbow in extension. Posteromedial rotatory instability is more often seen in association with fracture of the coronoid process following a varus stress to the elbow. Valgus instability occurs due to an injury to the medial ulnar collateral ligament seen most commonly in throwers from overuse. Varus instability is rare but results in lateral gapping of the elbow. Longitudinal forearm instability is seen after an Essex-Lopresti injury.
Question 1256
Topic: 9. Shoulder and Elbow
A 70-year-old female with severe rotator cuff tear arthropathy undergoes a reverse total shoulder arthroplasty (RTSA). How does this implant design alter the biomechanics of her shoulder to restore active elevation?
Correct Answer & Explanation
. Lateralizes and superiorly displaces the center of rotation, tightening the remaining rotator cuff.
Explanation
The reverse total shoulder arthroplasty functions by medializing and inferiorly displacing the center of rotation of the glenohumeral joint. This significantly increases the lever arm and tension of the deltoid muscle, allowing it to initiate and power arm elevation in the absence of a functional rotator cuff.
Question 1257
Topic: 9. Shoulder and Elbow
A 23-year-old baseball pitcher reports pain in the posterior aspect of his dominant shoulder during the late cocking phase of throwing. With the dominant shoulder positioned in 90 degrees of abduction from the body and with the scapula stabilized, examination reveals 135 degrees of external rotation and 20 degrees of internal rotation. Examination of the opposite shoulder reveals 100 degrees of external rotation and 75 degrees of internal rotation. Both shoulders are stable on examination. Radiographs and MRI scans are unremarkable. What is the primary cause of his pain?
Correct Answer & Explanation
. Posterior capsular tightness
Explanation
Internal impingement of the shoulder is a leading cause of shoulder pain in the throwing athlete. The primary lesion in pathologic internal impingement is excessive tightening of the posterior band of the inferior glenohumeral ligament complex. To obtain an accurate assessment of true glenohumeral rotation, the scapula is stabilized during examination. A loss of 20 degrees or more of internal rotation, as measured with the shoulder positioned in 90 degrees of abduction, indicates excessive tightness of the posterior band of the inferior glenohumeral ligament complex.
Question 1258
Topic: 9. Shoulder and Elbow
A 62-year-old man complains of shoulder pain for 2 years. He has had 1 course of intra-articular sodium hyaluronate and 6 weeks of physical therapy with little relief. Examination reveals diminished arm flexion and abduction secondary to pain. Radiographs of his shoulder are shown in Figures A and B. According to the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, what is the next best step? Review Topic
Correct Answer & Explanation
. Humeral head replacement arthroplasty
Explanation
This patient has end-stage glenohumeral osteoarthritis (GH OA). According to the AAOS CPG, total shoulder arthroplasty (TSA) is recommended using an all-polyethylene cemented glenoid component.TSA is indicated for cases of end-stage GH OA. It is preferred to hemiarthroplasty. It is contraindicated in cases with insufficient glenoid bone stock (glenoid wear to the level of the coracoid), rotator cuff arthropathy or irreparable cuff tears and deltoid dysfunction. It provides good pain relief and has good survival at 10 years (>90%).Radnay et al. performed a systematic review involving 1952 patients comparing TSA with humeral head replacement (HHR). They found that TSR provided greater pain relief, range of motion, patient satisfaction, and had lower revision rates. They recommend TSA over HHR for GH OA.Izquierdo et al. described the AAOS Clinical Practice Guidelines (CPG) regarding treatment of GH OA. This is summarized in Illustration A.Figures A and B show end-stage GH OA with large osteophytes and subchondral sclerosis. There is significant glenoid wear and posterior subluxation (Walch B glenoid deformity). Illustration A is a table summarizing the AAOS CPG on treatment of GH OA. Illustration B shows a CTA humeral component. It is not paired with a glenoid component.Incorrect Answers:
Question 1259
Topic: 9. Shoulder and Elbow
A 24-year-old athlete sustains an anterior shoulder dislocation during a rugby tackle.
After successful closed reduction, he is noted to have decreased sensation over the lateral aspect of his deltoid. Which of the following physical examination findings is most specifically associated with this nerve injury?
Correct Answer & Explanation
. Weakness of shoulder abduction from 15 to 90 degrees.
Explanation
The axillary nerve is the most commonly injured nerve in anterior shoulder dislocations. It innervates the deltoid and teres minor muscles. The deltoid acts as the primary abductor of the shoulder from 15 to 90 degrees. Initiation of abduction (0-15 degrees) is primarily a function of the supraspinatus (suprascapular nerve). External rotation at the side is primarily driven by the infraspinatus (suprascapular nerve).
Question 1260
Topic: Shoulder Pathology
A 40-year-old motorcyclist presents after a high-speed crash with massive soft tissue swelling over the left shoulder. Radiographs demonstrate lateral displacement of the scapula, an intact but widened acromioclavicular joint, and a severely displaced clavicle fracture. Radial pulses are diminished. Which nerve injury is most common in this scenario?
Correct Answer & Explanation
. Isolated axillary nerve palsy
Explanation
This clinical and radiographic picture defines a scapulothoracic dissociation, which acts as a closed forequarter amputation. It is highly associated with catastrophic subclavian vascular disruption and complete brachial plexus avulsions, carrying a dismal functional prognosis.
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