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9. Shoulder and Elbow MCQs

Practice Set 68 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 1341

Topic: 9. Shoulder and Elbow

During the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), which of the following is the generally recommended sequence of reconstruction?

. MCL repair, then coronoid fixation, then radial head repair/replacement
. Radial head repair/replacement, then LCL repair, then coronoid fixation
. Coronoid fixation, then radial head repair/replacement, then LCL repair
. LCL repair, then radial head repair/replacement, then coronoid fixation
. Coronoid fixation, then MCL repair, then radial head repair/replacement

Correct Answer & Explanation

. MCL repair, then coronoid fixation, then radial head repair/replacement

Explanation

The standard 'inside-out' surgical sequence for a terrible triad injury of the elbow is: 1) Fixation of the coronoid fracture (or anterior capsule), 2) Repair or replacement of the radial head, and 3) Repair of the Lateral Collateral Ligament (LCL) complex to the lateral epicondyle. MCL repair is generally only performed if the elbow remains unstable after completing these three steps.

Question 1342

Topic: 9. Shoulder and Elbow

When performing a single-incision anterior approach for a distal biceps tendon repair, which of the following anatomical maneuvers best protects the posterior interosseous nerve (PIN)?

. Pronation of the forearm during retractor placement and drilling
. Supination of the forearm during retractor placement and drilling
. Placement of retractors directly on the ulnar periosteum
. Identifying and retracting the PIN medially
. Keeping the elbow in 90 degrees of flexion throughout the procedure

Correct Answer & Explanation

. Pronation of the forearm during retractor placement and drilling

Explanation

During a single-incision anterior approach for distal biceps repair, supination of the forearm brings the posterior interosseous nerve (PIN) closer to the operative field (anteriorly and medially), increasing the risk of injury. Pronation of the forearm moves the PIN away from the surgical field (laterally and posteriorly), providing maximum protection during retractor placement and drilling of the radial tuberosity.

Question 1343

Topic: 9. Shoulder and Elbow

A 21-year-old collegiate baseball pitcher presents with vague posterior shoulder pain. Physical examination reveals 20 degrees of internal rotation and 130 degrees of external rotation in the throwing shoulder, compared to 60 degrees of internal rotation and 90 degrees of external rotation in the non-throwing shoulder. Total arc of motion is symmetric. What is the primary underlying pathoanatomy for this condition?

. Anterior capsular laxity
. Posterior capsular contracture
. Subscapularis tear
. SLAP lesion type II
. Os acromiale

Correct Answer & Explanation

. Anterior capsular laxity

Explanation

The patient has Glenohumeral Internal Rotation Deficit (GIRD). This is defined as a loss of internal rotation in the throwing shoulder compared to the non-throwing shoulder, usually with a corresponding gain in external rotation, keeping the total arc of motion roughly equal. The primary pathoanatomy is a contracture/thickening of the posteroinferior capsule due to repetitive eccentric loads during the deceleration phase of throwing. Treatment begins with sleeper stretches to stretch the posterior capsule.

Question 1344

Topic: Shoulder Pathology

A 26-year-old female complains of a painful clunking sensation at the superomedial border of her scapula with active elevation of the arm. She has failed 6 months of physical therapy and injections. She is scheduled for arthroscopic bursectomy and partial scapulectomy. Which bursa is most commonly inflamed in this condition?

. Subacromial bursa
. Subdeltoid bursa
. Scapulothoracic (infraserratus) bursa
. Suprascapular bursa
. Coracobrachialis bursa

Correct Answer & Explanation

. Subacromial bursa

Explanation

Snapping scapula syndrome (scapulothoracic crepitus) most commonly involves inflammation of the bursae located between the anterior scapula and the posterior chest wall. The two most prominent bursae are the supraserratus bursa and the infraserratus (scapulothoracic) bursa, which is located between the serratus anterior and the chest wall. The superomedial angle is the most common site of anatomical pathology (e.g., Luschka's tubercle) causing the snapping.

Question 1345

Topic: Elbow & Forearm

A 35-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury to his elbow. Which of the following describes the most appropriate sequence of surgical reconstruction to restore stability?

. LUCL repair, radial head fixation/replacement, coronoid fixation
. Coronoid fixation, radial head fixation/replacement, LUCL repair
. Radial head fixation/replacement, LUCL repair, coronoid fixation
. LUCL repair, coronoid fixation, radial head fixation/replacement
. Coronoid fixation, LUCL repair, radial head fixation/replacement

Correct Answer & Explanation

. LUCL repair, radial head fixation/replacement, coronoid fixation

Explanation

The standard inside-out (deep to superficial) sequence for terrible triad reconstruction is: 1) Coronoid fixation (or anterior capsule repair), 2) Radial head fixation or arthroplasty, 3) Lateral ulnar collateral ligament (LUCL) repair, and 4) Optional MCL repair or hinged external fixation if the elbow remains unstable.

Question 1346

Topic: 9. Shoulder and Elbow
A 22-year-old collegiate baseball pitcher complains of vague posterior shoulder pain and a loss of velocity. Physical exam shows a Glenohumeral Internal Rotation Deficit (GIRD) of 25 degrees compared to the contralateral side. What is the primary anatomic structure responsible for this clinical finding?
. Anterior band of the inferior glenohumeral ligament
. Posterior band of the inferior glenohumeral ligament
. Superior glenohumeral ligament
. Subscapularis tendon
. Coracohumeral ligament

Correct Answer & Explanation

. Posterior band of the inferior glenohumeral ligament

Explanation

GIRD in overhead throwing athletes is primarily caused by contracture and thickening of the posterior capsule, specifically the posterior band of the inferior glenohumeral ligament (PBIGHL). This alters glenohumeral kinematics, driving the humeral head posterosuperiorly during late cocking and increasing shear stress on the SLAP complex (peel-back mechanism).

Question 1347

Topic: Elbow & Forearm

A 45-year-old man requires surgical repair of a chronic distal biceps tendon rupture. A two-incision (Boyd-Anderson) approach is selected to minimize the risk to the lateral antebrachial cutaneous nerve and radial nerve. However, this approach carries a higher risk of which of the following complications compared to a single anterior incision?

. Posterior interosseous nerve (PIN) injury
. Radioulnar synostosis
. Median nerve injury
. Brachial artery pseudoaneurysm
. Recurrent rupture

Correct Answer & Explanation

. Posterior interosseous nerve (PIN) injury

Explanation

The two-incision approach for distal biceps repair was designed to decrease the risk of radial/PIN injury associated with an extensive single anterior exposure. However, dissecting between the radius and ulna to pass the tendon increases the risk of heterotopic ossification and radioulnar synostosis. Using a muscle-splitting approach through the supinator and avoiding subperiosteal elevation on the ulna minimizes this risk.

Question 1348

Topic: Elbow & Forearm

A 32-year-old woman sustains a displaced capitellum fracture. Preoperative CT reveals the fracture involves both the capitellum and the lateral trochlear ridge in a single fragment, with significant comminution of the posterior capitellum. According to the Dubberley classification, what type of fracture is this?

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

Correct Answer & Explanation

. Type 1A

Explanation

The Dubberley classification of capitellum and trochlea fractures is based on the extent of articular involvement and the presence of posterior comminution (A = no posterior comminution, B = posterior comminution). Type 1 involves only the capitellum. Type 2 involves the capitellum and the lateral trochlear ridge in a single piece. Type 3 involves separate fragments of the capitellum and trochlea. Because this involves the capitellum and lateral trochlear ridge in a single piece with posterior comminution, it is a Type 2B.

Question 1349

Topic: Elbow & Forearm

A 29-year-old male presents with recurrent snapping and pain on the lateral side of his elbow when pushing up from a chair. Physical examination demonstrates a positive lateral pivot-shift test of the elbow. Which structure is fundamentally incompetent in this condition?

. Anterior band of the medial collateral ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Biceps brachii tendon

Correct Answer & Explanation

. Anterior band of the medial collateral ligament

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily caused by insufficiency or a tear of the Lateral Ulnar Collateral Ligament (LUCL). The LUCL is the primary restraint to varus and posterolateral rotatory stress. The pathognomonic sign is a positive lateral pivot-shift test, and patients often describe symptoms when bearing weight on the extended and supinated arm.

Question 1350

Topic: 9. Shoulder and Elbow
A 40-year-old man sustains a 'floating shoulder' injury, defined by ipsilateral fractures of the clavicle and the scapular neck. According to the Goss classification, a double disruption of the superior shoulder suspensory complex (SSSC) requires surgical fixation. Which two structures primarily comprise the SSSC struts connecting the ring to the axial skeleton and appendicular skeleton?
. Clavicle and glenoid face
. Clavicle and acromial process
. Clavicle and coracoid process (via CC ligaments)
. Coracoid process and glenoid face
. Middle clavicle and lateral scapular body/spine

Correct Answer & Explanation

. Middle clavicle and lateral scapular body/spine

Explanation

The Superior Shoulder Suspensory Complex (SSSC) is a bone-and-soft-tissue ring. The superior and inferior struts that connect this ring to the axial skeleton and the rest of the appendicular skeleton are the middle clavicle and lateral scapular body/spine, respectively. A floating shoulder classically involves disruptions of the SSSC in two places, destabilizing the suspensory mechanism.

Question 1351

Topic: 9. Shoulder and Elbow

A 16-year-old rugby player falls directly onto his posterolateral shoulder and presents with severe pain, shortness of breath, and dysphagia. Examination shows an absent medial clavicular prominence on the affected side. A CT scan confirms a posterior sternoclavicular dislocation. After a failed closed reduction in the operating room under general anesthesia, what is the safest next step in management?

. Discharge with a figure-of-eight brace
. Open reduction with cardiothoracic surgery available on standby
. Resection of the medial clavicle
. Sternoclavicular arthrodesis
. Percutaneous pinning of the SC joint

Correct Answer & Explanation

. Discharge with a figure-of-eight brace

Explanation

Posterior sternoclavicular dislocations can be life-threatening due to compression of the mediastinal structures (trachea, esophagus, great vessels). If closed reduction fails or if the patient remains highly symptomatic (dyspnea, dysphagia), open reduction is indicated. Because of the immediate proximity to the great vessels, this must be performed with a cardiothoracic surgeon on standby in case of catastrophic hemorrhage.

Question 1352

Topic: Shoulder Pathology

A 35-year-old carpenter presents with a dull ache in his shoulder and weakness with overhead activities after carrying heavy beams over his right shoulder for several weeks. On physical examination, lateral winging of the scapula is noted, which worsens when the patient attempts to abduct the arm. Which nerve is most likely injured, and which muscle is affected?

. Long thoracic nerve; Serratus anterior
. Spinal accessory nerve; Trapezius
. Dorsal scapular nerve; Rhomboids
. Suprascapular nerve; Infraspinatus
. Axillary nerve; Deltoid

Correct Answer & Explanation

. Long thoracic nerve; Serratus anterior

Explanation

Lateral winging of the scapula (the scapula translates laterally and the superior angle rotates laterally) is classically caused by a trapezius palsy due to injury to the spinal accessory nerve (CN XI). Medial winging is caused by serratus anterior palsy due to injury to the long thoracic nerve. Direct pressure from carrying heavy loads on the shoulder is a classic mechanism for spinal accessory neuropraxia.

Question 1353

Topic: 9. Shoulder and Elbow

A 42-year-old male is involved in a high-speed motorcycle crash and sustains an isolated scapula fracture. Which of the following parameters is considered a relative indication for open reduction and internal fixation of a scapular body/neck fracture?

. 5 mm of medial translation of the glenoid fragment
. 15 degrees of glenohumeral angulation
. Glenopolar angle (GPA) of 20 degrees
. 15% involvement of the posterior glenoid without subluxation
. Intra-articular step-off of 2 mm

Correct Answer & Explanation

. 5 mm of medial translation of the glenoid fragment

Explanation

A glenopolar angle (GPA) of less than 22 degrees alters the biomechanics of the shoulder significantly and is associated with poor functional outcomes if treated non-operatively, making it a relative indication for surgery. Other operative indications include >40 degrees of angulation, >1-2 cm of medial translation, and intra-articular step-off >4-5 mm.

Question 1354

Topic: 9. Shoulder and Elbow

A 65-year-old female presents with persistent shoulder pain and weakness 9 months after a 2-part surgical neck proximal humerus fracture treated conservatively. Radiographs demonstrate a surgical neck nonunion. There is no evidence of avascular necrosis of the humeral head, and joint spaces are preserved. What is the most appropriate surgical management?

. Reverse total shoulder arthroplasty
. Hemiarthroplasty
. Open reduction and internal fixation with a locking plate and intramedullary fibular strut allograft
. Intramedullary nailing
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

For a proximal humerus surgical neck nonunion with adequate humeral head bone stock, no AVN, and no glenohumeral arthritis, joint preservation is the preferred approach. ORIF with locking plates augmented by an intramedullary fibular strut allograft provides necessary biomechanical stability and biological support for healing.

Question 1355

Topic: Elbow & Forearm

A 45-year-old male undergoes repair of a chronic distal biceps tendon rupture utilizing a single-incision anterior approach. Postoperatively, he notes numbness over the radial aspect of his forearm. Which nerve was most likely injured, and what is the typical mechanism of injury?

. Superficial radial nerve; compression by retractors
. Lateral antebrachial cutaneous nerve; traction during lateral retraction
. Posterior interosseous nerve; direct injury from drill bit
. Medial antebrachial cutaneous nerve; injury during medial dissection
. Musculocutaneous nerve; retraction of the biceps belly

Correct Answer & Explanation

. Superficial radial nerve; compression by retractors

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during the single-incision anterior approach to the distal biceps. It is typically injured via traction or direct compression from retractors placed on the lateral side of the wound.

Question 1356

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with chronic shoulder pain. Radiographs show a massive rotator cuff tear, an acromiohumeral interval of 3 mm, and 'acetabularization' of the acromion, but no significant glenohumeral cartilage loss. According to the Hamada classification, what stage is this?

. Stage 1
. Stage 2
. Stage 3
. Stage 4
. Stage 5

Correct Answer & Explanation

. Stage 1

Explanation

In the Hamada classification for rotator cuff arthropathy: Stage 1 = AHI > 6 mm; Stage 2 = AHI < 5 mm; Stage 3 = AHI < 5 mm with acetabularization of the acromion; Stage 4 = Glenohumeral arthritis; Stage 5 = Humeral head collapse.

Question 1357

Topic: 9. Shoulder and Elbow

To optimize deltoid function in a patient undergoing reverse total shoulder arthroplasty, the design of the prosthesis alters the center of rotation of the glenohumeral joint. In which directions is the center of rotation shifted compared to the native anatomy?

. Superiorly and laterally
. Superiorly and medially
. Inferiorly and medially
. Inferiorly and laterally
. Directly medially

Correct Answer & Explanation

. Superiorly and laterally

Explanation

A reverse total shoulder arthroplasty medializes and inferiorizes the center of rotation. This increases the moment arm of the deltoid muscle and recruits more of its fibers (especially anterior and posterior fibers) to compensate for the absent rotator cuff during arm elevation.

Question 1358

Topic: 9. Shoulder and Elbow

A 30-year-old male with a severe elbow fracture-dislocation treated with ORIF 8 months ago has a stiff elbow with a 30-degree arc of motion. Radiographs show mature heterotopic ossification (HO) blocking motion. Serum alkaline phosphatase is normal. What is the most appropriate next step?

. Immediate surgical excision of the HO
. Delay surgery until 18 months post-injury
. Aggressive manipulation under anesthesia
. Wait for a bone scan to turn 'cold'
. Radiation therapy followed by delayed excision

Correct Answer & Explanation

. Immediate surgical excision of the HO

Explanation

Modern literature indicates that early excision of elbow heterotopic ossification (typically around 6 months post-injury) is safe and effective once the bone appears radiographically mature and alkaline phosphatase levels have normalized. Waiting 18 months or for a cold bone scan is no longer strictly necessary.

Question 1359

Topic: 9. Shoulder and Elbow

During anatomic total shoulder arthroplasty, excessive retroversion of the glenoid component significantly increases the risk of which complication?

. Anterior instability
. Posterior instability
. Superior humeral migration
. Coracoid impingement
. Acromial stress fracture

Correct Answer & Explanation

. Anterior instability

Explanation

Excessive retroversion of the glenoid component shifts the contact point posteriorly, leading to posterior humeral subluxation, edge loading, and early glenoid component loosening or posterior instability.

Question 1360

Topic: Shoulder Pathology

Scapulothoracic dissociation is a high-energy injury characterized by complete disruption of the scapulothoracic articulation. Which neurovascular injury is most commonly associated with this condition and dictates limb viability?

. Subclavian/Axillary artery and brachial plexus
. Axillary artery and musculocutaneous nerve
. Suprascapular nerve and artery
. Thoracodorsal artery and nerve
. Long thoracic nerve and lateral thoracic artery

Correct Answer & Explanation

. Subclavian/Axillary artery and brachial plexus

Explanation

Scapulothoracic dissociation is often considered a 'closed forequarter amputation'. It is highly associated with severe traction injuries to the brachial plexus and tears of the subclavian or axillary artery. The status of these structures dictates whether the limb can be salvaged or requires amputation.

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