Menu

9. Shoulder and Elbow MCQs

Practice Set 67 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 1321

Topic: 9. Shoulder and Elbow

A 32-year-old male sustains an elbow injury. CT reveals a fracture of the anteromedial facet of the coronoid. Examination shows instability when the elbow is subjected to a varus stress in flexion. Which of the following ligamentous structures is almost universally injured in this specific fracture pattern?

. Anterior bundle of the medial collateral ligament
. Posterior bundle of the medial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Quadrate ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Anteromedial facet coronoid fractures are pathognomonic for varus posteromedial rotatory instability. This mechanism involves a varus force causing LUCL rupture followed by impaction of the anteromedial coronoid against the medial trochlea.

Question 1322

Topic: Shoulder Arthroplasty & Arthritis

A 75-year-old female sustains a displaced 4-part proximal humerus fracture.

Which of the following is the most important biomechanical and clinical factor favoring reverse total shoulder arthroplasty (RTSA) over hemiarthroplasty in this scenario?

. The presence of an intact and functioning rotator cuff
. The high predictability of greater tuberosity healing with hemiarthroplasty
. The preservation of the coracoacromial arch
. The decreased reliance on tuberosity healing for forward elevation with RTSA
. The inherent risk of axillary nerve neuropraxia with hemiarthroplasty

Correct Answer & Explanation

. The decreased reliance on tuberosity healing for forward elevation with RTSA

Explanation

RTSA is increasingly preferred over hemiarthroplasty for displaced 3- and 4-part proximal humerus fractures in the elderly because forward elevation is driven by the deltoid muscle rather than the rotator cuff. Hemiarthroplasty heavily relies on predictable healing of the greater and lesser tuberosities in their anatomic positions for a good functional outcome; tuberosity nonunion or malunion frequently leads to pseudoparalysis. RTSA circumvents this unpredictability.

Question 1323

Topic: Elbow & Forearm

A 45-year-old male falls on an outstretched hand, sustaining a terrible triad injury of the elbow.

What is the recommended standard sequence of surgical reconstruction to restore concentric stability?

. Lateral collateral ligament (LCL) repair, radial head fixation or replacement, coronoid fixation
. Coronoid fixation, radial head fixation or replacement, LCL repair
. Radial head fixation or replacement, LCL repair, coronoid fixation
. LCL repair, coronoid fixation, radial head fixation or replacement
. Coronoid fixation, LCL repair, radial head fixation or replacement

Correct Answer & Explanation

. Coronoid fixation, radial head fixation or replacement, LCL repair

Explanation

The terrible triad of the elbow consists of an elbow dislocation, radial head fracture, and coronoid fracture. The standard surgical sequence works from 'deep to superficial' or 'inside out', starting with coronoid fixation (or anterior capsule repair), followed by radial head fixation or arthroplasty, and finally repair of the lateral ulnar collateral ligament (LUCL) complex to the lateral epicondyle. Medial collateral ligament repair or hinged external fixation is added if the elbow remains unstable after these steps.

Question 1324

Topic: Elbow & Forearm

A 45-year-old manual laborer undergoes a two-incision surgical repair of a distal biceps tendon rupture. Compared to the single anterior incision technique, the two-incision technique is associated with a higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve neuropraxia
. Superficial radial nerve injury
. Proximal radioulnar synostosis
. Posterior interosseous nerve injury
. Median nerve injury

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

The classic two-incision technique (Boyd-Anderson or modifications) for distal biceps repair is historically associated with a higher risk of heterotopic ossification and proximal radioulnar synostosis, primarily due to muscle splitting and subperiosteal elevation of the ulna. The single anterior incision technique carries a higher rate of injury to the lateral antebrachial cutaneous nerve (LABCN) and the posterior interosseous nerve (PIN).

Question 1325

Topic: 9. Shoulder and Elbow

A 35-year-old female falls onto her outstretched hand and presents with elbow pain. Radiographs demonstrate an isolated fracture of the capitellum with extension into the trochlea (Type IV, McKee modification of Bryan and Morrey). What is the preferred surgical approach for open reduction and internal fixation of this injury?

. Medial approach
. Extended lateral approach (Kocher or Kaplan)
. Posterior approach with olecranon osteotomy
. Anterior approach (Henry)
. Posterior approach with triceps-splitting

Correct Answer & Explanation

. Extended lateral approach (Kocher or Kaplan)

Explanation

Capitellum and trochlea shear fractures (Type IV) are best addressed via an extended lateral approach. Elevating the extensor origin off the lateral epicondyle and anterior capsule provides excellent visualization of the anterior articular surface of the distal humerus, allowing for anatomical reduction and placement of headless compression screws or anterior-to-posterior screws.

Question 1326

Topic: Elbow & Forearm

A 40-year-old female fell from a height and sustained a comminuted radial head fracture, which was treated with radial head excision. Three months later, she complains of severe ulnar-sided wrist pain. Radiographs demonstrate proximal migration of the radius and a positive ulnar variance. Which of the following is the most appropriate reconstructive option?

. Ulnar shortening osteotomy and radial head arthroplasty
. Darrach procedure
. Suave-Kapandji procedure
. Distal radioulnar joint (DRUJ) arthrodesis
. Interosseous membrane reconstruction alone

Correct Answer & Explanation

. Ulnar shortening osteotomy and radial head arthroplasty

Explanation

This clinical scenario describes a longitudinal radioulnar dissociation (Essex-Lopresti injury) unmasked by radial head excision. The proximal radial migration causes ulnocarpal impaction. Treatment for chronic cases requires restoring the lateral column strut with a radial head arthroplasty and performing an ulnar shortening osteotomy to address the positive ulnar variance and unload the ulnocarpal joint.

Question 1327

Topic: 9. Shoulder and Elbow
A 35-year-old male is involved in a motorcycle accident and sustains an ipsilateral midshaft clavicle fracture and a scapular neck fracture. This injury pattern ('floating shoulder') disrupts the superior shoulder suspensory complex (SSSC). Which of the following constitutes an indication for operative fixation in this scenario?
. The presence of the floating shoulder injury pattern itself, regardless of displacement
. Medialization of the glenoid > 5 mm
. Glenopolar angle less than 22 degrees
. Concomitant rib fractures
. Scapular neck fracture with 2 mm of step-off

Correct Answer & Explanation

. Glenopolar angle less than 22 degrees

Explanation

A 'floating shoulder' represents a double disruption of the superior shoulder suspensory complex (SSSC). Historically considered an absolute indication for surgery, current evidence supports nonoperative management for minimally displaced floating shoulders. Surgery is indicated when there is significant deformity, most commonly evaluated by a glenopolar angle < 22 degrees or marked medialization/displacement, to prevent scapular winging and rotator cuff dysfunction.

Question 1328

Topic: Elbow & Forearm

A 38-year-old female presents with a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). Which of the following sequences of surgical repair is currently recommended to maximize elbow stability?

. Radial head fixation/replacement, coronoid fixation, LUCL repair, MCL repair (if needed)
. Coronoid fixation, radial head fixation/replacement, LUCL repair, MCL repair (if needed)
. LUCL repair, coronoid fixation, radial head fixation/replacement, hinged external fixation
. MCL repair, radial head fixation, coronoid fixation, LUCL repair
. Coronoid fixation, LUCL repair, radial head fixation/replacement, hinged external fixation

Correct Answer & Explanation

. Radial head fixation/replacement, coronoid fixation, LUCL repair, MCL repair (if needed)

Explanation

The standard recommended sequence for treating a terrible triad injury is to fix from deep to superficial, or inside-out. The typical sequence is: 1) Coronoid fracture fixation (via anterior or anterior-medial aspect through the fracture hematoma or standard approach), 2) Radial head fixation or arthroplasty, 3) Lateral ulnar collateral ligament (LUCL) repair. 4) If the elbow remains unstable after these steps, the Medial Collateral Ligament (MCL) may be repaired or a hinged external fixator applied.

Question 1329

Topic: 9. Shoulder and Elbow

A 45-year-old male undergoes a single-incision anterior approach for a distal biceps tendon repair. Postoperatively, he is noted to have a weakness in thumb and finger extension, but normal wrist extension with radial deviation. Sensory examination is completely normal. Which of the following nerves was most likely injured during the procedure?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The posterior interosseous nerve (PIN) is at risk during the single-incision anterior approach to the distal biceps, particularly if retractors are placed carelessly around the radial neck or if the elbow is not kept in supination while drilling the radius. Injury results in an inability to extend the fingers at the MCP joints and the thumb. Wrist extension is typically preserved but occurs with radial deviation because the ECRL (innervated by the radial nerve proper before the PIN branches) is intact, whereas the ECU (innervated by the PIN) is denervated. Sensory exam is normal because the PIN is a purely motor nerve.

Question 1330

Topic: 9. Shoulder and Elbow

A 19-year-old male rugby player presents to the emergency department with acute shortness of breath and right-sided upper chest pain after a pile-up on the field. On examination, there is a visible depression at the right sternoclavicular joint. Which of the following is the most appropriate next step in management?

. Immediate closed reduction in the emergency department with procedural sedation
. CT scan of the chest and consultation with cardiothoracic surgery prior to reduction attempt
. Routine AP and lateral chest radiographs followed by discharge in a sling
. MRI of the right shoulder and sternoclavicular joint
. Open reduction and internal fixation with a hook plate

Correct Answer & Explanation

. CT scan of the chest and consultation with cardiothoracic surgery prior to reduction attempt

Explanation

Posterior sternoclavicular dislocations are high-energy injuries that can compromise the trachea, esophagus, and great vessels. A CT scan of the chest is the gold standard imaging modality to evaluate the extent of the dislocation and any associated intrathoracic injuries. Because of the risk of catastrophic vascular injury during reduction, it is strongly recommended that a cardiothoracic surgeon be available, and the reduction is often performed in the operating room.

Question 1331

Topic: Elbow & Forearm

A 40-year-old female sustains a fall on an outstretched hand, resulting in an elbow injury. Radiographs and CT demonstrate a capitellar fracture extending medially to involve the majority of the trochlea, with a separate comminuted fragment of the posterior trochlea. According to the Dubberley classification, what type of fracture is this?

. Type 1A
. Type 2B
. Type 3A
. Type 3B
. Type 4

Correct Answer & Explanation

. Type 3B

Explanation

The Dubberley classification of capitellum and trochlea fractures is based on the involvement of the trochlea and the presence of posterior condylar comminution. Type 1 involves primarily the capitellum. Type 2 involves the capitellum and trochlea as a single piece. Type 3 involves the capitellum and trochlea as separate fragments. The modifier 'A' indicates no posterior condylar comminution, and 'B' indicates posterior condylar comminution. The scenario describes capitellum and trochlea fractures with a separate posterior trochlea comminuted fragment, making it a Type 3B.

Question 1332

Topic: Shoulder Arthroplasty & Arthritis

In a reverse total shoulder arthroplasty (RTSA) performed for cuff tear arthropathy, what is the primary biomechanical advantage conferred by the implant design?

. Medialization and inferiorization of the center of rotation, which increases the deltoid moment arm
. Lateralization and superiorization of the center of rotation, which tension the remaining rotator cuff
. Medialization and superiorization of the center of rotation to restore the anatomic joint line
. Lateralization and inferiorization of the center of rotation to increase the subacromial space
. Preservation of the anatomic center of rotation while constraining the joint

Correct Answer & Explanation

. Medialization and inferiorization of the center of rotation, which increases the deltoid moment arm

Explanation

The Grammont design of the reverse total shoulder arthroplasty (RTSA) medializes and inferiorizes the center of rotation. Inferiorization increases the resting tension of the deltoid, and medialization increases the deltoid moment arm (specifically the middle and posterior heads) by moving the center of rotation closer to the deltoid tuberosity line of pull. This allows the deltoid to effectively elevate the arm in the absence of a functional rotator cuff.

Question 1333

Topic: 9. Shoulder and Elbow

A 12-year-old baseball pitcher complains of medial elbow pain that worsens when throwing. Radiographs show widening of the medial epicondyle apophysis. Which of the following is the most appropriate initial management?

. Immediate open reduction and internal fixation of the medial epicondyle
. Ulnar collateral ligament reconstruction (Tommy John surgery)
. Complete cessation of throwing for 4 to 6 weeks, followed by a gradual return-to-throwing program
. Corticosteroid injection into the medial epicondyle
. Continuation of throwing with a strict pitch count and NSAIDs

Correct Answer & Explanation

. Complete cessation of throwing for 4 to 6 weeks, followed by a gradual return-to-throwing program

Explanation

'Little Leaguer's Elbow' refers to medial epicondyle apophysitis, caused by repetitive valgus stress during throwing. The initial and most appropriate management is strict rest from throwing for 4-6 weeks to allow the inflammation to subside and the apophysis to heal, followed by physical therapy emphasizing core/shoulder strengthening and mechanics, and a gradual return-to-throwing program. Surgery is reserved for acute avulsion fractures of the medial epicondyle that are significantly displaced.

Question 1334

Topic: Elbow & Forearm
A 6-year-old boy falls off monkey bars and sustains an injury to his right forearm. Radiographs demonstrate a fracture of the proximal third of the ulna with an anterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type I

Explanation

The Bado classification describes Monteggia fractures based on the direction of the radial head dislocation: Type I: Anterior dislocation of the radial head with fracture of the ulnar diaphysis (most common in children). Type II: Posterior dislocation of the radial head with fracture of the ulnar diaphysis (most common in adults). Type III: Lateral or anterolateral dislocation of the radial head with fracture of the ulnar metaphysis. Type IV: Anterior dislocation of the radial head with fractures of both the radius and ulna at the same level.

Question 1335

Topic: 9. Shoulder and Elbow

In patients with idiopathic adhesive capsulitis, which of the following structures is most characteristically thickened and contracted, limiting external rotation with the arm at the side?

. Inferior glenohumeral ligament
. Coracohumeral ligament
. Posterior capsule
. Middle glenohumeral ligament
. Superior labrum

Correct Answer & Explanation

. Coracohumeral ligament

Explanation

Adhesive capsulitis is characterized by severe loss of both active and passive range of motion. The earliest and most distinct motion loss is external rotation with the arm at the side, which is primarily restricted by a contracted and thickened coracohumeral ligament (CHL) and the superior glenohumeral ligament. The CHL runs from the coracoid to the greater and lesser tuberosities, bridging the rotator interval. Contracture of the inferior capsule primarily limits abduction.

Question 1336

Topic: 9. Shoulder and Elbow

A 65-year-old female presents with an acute anterior shoulder dislocation. Post-reduction radiographs demonstrate a concentric reduction of the glenohumeral joint, but a greater tuberosity fracture is now identified, displaced superiorly by 8 mm. What is the most appropriate management for this fracture?

. Sling immobilization for 6 weeks followed by physical therapy
. Immediate open reduction and internal fixation of the greater tuberosity
. Closed reduction of the greater tuberosity under fluoroscopy
. Reverse total shoulder arthroplasty
. Excision of the greater tuberosity fragment

Correct Answer & Explanation

. Sling immobilization for 6 weeks followed by physical therapy

Explanation

In the setting of an anterior shoulder dislocation associated with a greater tuberosity fracture, the fragment often reduces anatomically once the joint is relocated. However, if the greater tuberosity remains displaced superiorly by >5 mm (some authors suggest >3 mm in active patients), surgical fixation is indicated. Superior displacement leads to subacromial impingement and alters the biomechanics of the rotator cuff. Therefore, a superiorly displaced greater tuberosity fracture of 8 mm warrants open or arthroscopic reduction and internal fixation.

Question 1337

Topic: Elbow & Forearm
A 35-year-old female presents with elbow pain after a fall. Imaging demonstrates a coronal shear fracture of the capitellum that includes the lateral trochlear ridge. According to the Bryan and Morrey classification, with McKee's modification, what type of fracture is this, and what is the preferred treatment?
. Type I; Nonoperative treatment
. Type II; Excision of the fragment
. Type III; ORIF
. Type IV; ORIF
. Type IV; Radial head arthroplasty

Correct Answer & Explanation

. Type IV; ORIF

Explanation

McKee modified the Bryan and Morrey classification by adding Type IV, which is a coronal shear fracture that involves the capitellum and extends medially to include the lateral trochlear ridge. Due to the extension into the trochlea, these fractures are highly unstable and require Open Reduction and Internal Fixation (ORIF). Type I (Hahn-Steinthal) involves a large osseous piece of capitellum. Type II (Kocher-Lorenz) involves a sleeve of articular cartilage with minimal bone. Type III (Broberg-Morrey) is a comminuted capitellum fracture.

Question 1338

Topic: 9. Shoulder and Elbow

In a reverse total shoulder arthroplasty (RTSA) performed for cuff tear arthropathy, how does the biomechanical alteration of the center of rotation (COR) optimize the function of the deltoid muscle?

. It lateralizes and superiorizes the COR to increase deltoid tension
. It medializes and distalizes the COR to recruit more anterior deltoid fibers
. It medializes and distalizes the COR to increase the deltoid moment arm
. It lateralizes and distalizes the COR to increase the supraspinatus moment arm
. It medializes and superiorizes the COR to decrease joint reaction forces

Correct Answer & Explanation

. It lateralizes and superiorizes the COR to increase deltoid tension

Explanation

RTSA medializes and distalizes the center of rotation (COR) of the glenohumeral joint. Medialization increases the deltoid's moment arm by moving the fulcrum further from the line of pull of the deltoid. Distalization tensions the deltoid, improving its resting length and increasing its ability to recruit muscle fibers to elevate the arm in the absence of a functioning rotator cuff.

Question 1339

Topic: 9. Shoulder and Elbow
A 65-year-old male with a massive, irreparable posterosuperior rotator cuff tear presents with pseudoparalysis of the shoulder (active elevation <90 degrees). He has intact subscapularis function and minimal glenohumeral arthritis (Hamada Grade 1). What is the most reliable surgical option to restore active forward elevation?
. Arthroscopic superior capsular reconstruction (SCR)
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty (RTSA)
. Arthroscopic partial repair and biceps tenotomy
. Lower trapezius tendon transfer

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (RTSA)

Explanation

In older patients with a massive, irreparable rotator cuff tear and pseudoparalysis (inability to actively elevate the arm past 90 degrees), Reverse Total Shoulder Arthroplasty (RTSA) is the most reliable procedure to restore forward elevation. Tendon transfers (latissimus dorsi, lower trapezius) or SCR generally require a shoulder that is not pseudoparalytic to function optimally and are typically reserved for younger patients without pseudoparalysis.

Question 1340

Topic: 9. Shoulder and Elbow

A 12-year-old boy falls on an outstretched hand and presents with a dislocated elbow and an associated medial epicondyle fracture. Following closed reduction of the elbow joint, radiographs show the medial epicondyle fragment is incarcerated within the joint space. What is the most appropriate definitive management?

. Long arm cast in 90 degrees of flexion and pronation
. Closed manipulation utilizing the 'milking' maneuver and valgus stress
. Open reduction and internal fixation of the medial epicondyle
. Excision of the medial epicondyle fragment and flexor-pronator mass repair
. Observation and early active range of motion

Correct Answer & Explanation

. Long arm cast in 90 degrees of flexion and pronation

Explanation

Incarceration of the medial epicondyle fragment within the elbow joint after closed reduction of an elbow dislocation is an absolute indication for Open Reduction and Internal Fixation (ORIF) or surgical extraction. If left inside, it will cause severe articular damage and mechanical block. While extraction techniques (valgus stress, wrist/finger extension, and supination) can occasionally free the fragment, ORIF provides definitive management for a fragment that was incarcerated, ensuring joint clearance and stability.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page