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9. Shoulder and Elbow MCQs

Practice Set 69 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 1361

Topic: 9. Shoulder and Elbow

A 55-year-old female with long-standing rheumatoid arthritis presents with severe shoulder pain. Radiographs reveal glenohumeral joint destruction, central glenoid wear, and a high-riding humeral head. MRI confirms a massive, irreparable rotator cuff tear. Which surgical option is most appropriate?

. Anatomic total shoulder arthroplasty
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Glenohumeral arthrodesis
. Arthroscopic debridement

Correct Answer & Explanation

. Anatomic total shoulder arthroplasty

Explanation

In a patient with rheumatoid arthritis who has developed secondary rotator cuff arthropathy (massive irreparable cuff tear with glenohumeral arthritis), a reverse total shoulder arthroplasty is the treatment of choice to restore stability, function, and relieve pain.

Question 1362

Topic: 9. Shoulder and Elbow
What is the most common complication following distal biceps tendon repair?
. Posterior interosseous nerve palsy
. Rerupture of the repair
. Lateral antebrachial cutaneous neuropraxia
. Superficial radial sensory neuropathy

Correct Answer & Explanation

. Lateral antebrachial cutaneous neuropraxia

Explanation

Neuropraxia of the lateral antebrachial cutaneous nerve branch is the most common complication associated with distal biceps repair, with a reported incidence as high as 40%. The nerve branch lies between the biceps and brachialis as it crosses the surgical field in the antecubital fossa. The neuropathy may be related to aggressive retraction, particularly when using the 1-incision technique, and often resolves with time.

Question 1363

Topic: 9. Shoulder and Elbow
A 16-year-old female swimmer reports several episodes of atraumatic glenohumeral instability that occur with different arm positions. Examination reveals generalized ligamentous laxity and a positive sulcus sign, and her shoulder can be subluxated both anteriorly and posteriorly. Initial management should consist of
. A strengthening program for the rotator cuff and scapular muscles.
. Arthroscopic thermal capsulorrhaphy.
. An inferior capsular shift.
. A glenoid osteotomy.
. A Putti-Platt repair.

Correct Answer & Explanation

. A strengthening program for the rotator cuff and scapular muscles.

Explanation

The patient has multidirectional instability (MDI). It has been reported that a high percentage of patients with MDI respond to a properly structured exercise program that is continued for at least 3 to 6 months. If nonsurgical management fails to provide relief, stabilization with an inferior capsular shift procedure has been effective in a high percentage of patients. Unidirectional repairs, such as the Putti-Platt procedure, are unsuitable for correcting MDI. Thermal capsulorrhaphy has been reported to have a very high failure rate (greater than 50%) for treating MDI.

Question 1364

Topic: 9. Shoulder and Elbow
Which of the following best describes the most common anatomic variation seen in the glenoid labrum and the middle glenohumeral ligament in the anterosuperior quadrant of the shoulder?
. Labrum attached to the glenoid rim and a flat/broad middle glenohumeral ligament
. Sublabral hole with the labrum absent and a flat/broad middle glenohumeral ligament
. Sublabral hole with a cord-like labrum and a flat/broad middle glenohumeral ligament
. Anterosuperior labrum confluent with a cord-like middle glenohumeral ligament and no labral attachment to bone
. Anterosuperior labrum confluent with a cord-like middle glenohumeral ligament and glenoid deficiency

Correct Answer & Explanation

. Labrum attached to the glenoid rim and a flat/broad middle glenohumeral ligament

Explanation

Wide variations in the anatomy of the anterosuperior portion of the labrum and the middle glenohumeral ligament have been reported and are more common than previously thought. The labrum attached to the glenoid rim and a flat/broad middle glenohumeral ligament is the most common โ€œnormalโ€ variation. A cord-like middle glenohumeral ligament is often associated with the presence of a sublabral hole. An anterosuperior labrum confluent with a cord-like middle glenohumeral ligament and no labral attachment to bone is the configuration of the Buford complex. The prevalence of each variation from one recent study is as follows: #1: 86.6%; #2: 3.3%; #3: 8.6%; and #4: 1.5%.

Question 1365

Topic: 9. Shoulder and Elbow
What is the structure indicated by the letter โ€œAโ€ in Figure 21?
. Annular ligament
. Lateral ulnar collateral ligament
. Accessory collateral ligament
. Radial collateral ligament
. Transverse ligament

Correct Answer & Explanation

. Radial collateral ligament

Explanation

The ligaments shown are the components of the lateral collateral ligament complex, and the structure indicated by the letter โ€œAโ€ is the radial collateral ligament. The lateral ulnar collateral ligament is the structure indicated by the letter โ€œCโ€ and the annular ligament is indicated by the letter โ€œB.โ€ The transverse ligament is a component of the medial collateral ligament complex.

Question 1366

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female undergoes a reverse total shoulder arthroplasty (rTSA). To minimize the risk of inferior scapular notching, how should the glenosphere baseplate be optimally positioned?

. Superior tilt and superior translation
. Superior tilt and inferior translation
. Inferior tilt and inferior translation
. Neutral tilt and superior translation
. Inferior tilt and superior translation

Correct Answer & Explanation

. Inferior tilt and inferior translation

Explanation

Scapular notching is a common complication of rTSA, particularly with Grammont-style implants, where the humeral component abuts the inferior scapular neck. To minimize this, biomechanical and clinical studies recommend placing the baseplate (glenosphere) with inferior translation (overhanging the inferior glenoid rim by 2-4mm) and inferior tilt (approximately 10-15 degrees). This allows the humeral cup to clear the inferior scapular neck during adduction.

Question 1367

Topic: Shoulder Pathology

A 19-year-old male undergoes open reduction and internal fixation of a displaced midshaft clavicle fracture using a superiorly applied pre-contoured plate. Postoperatively, he complains of a numb patch of skin over his anterior chest wall. Which nerve was most likely injured during the surgical approach?

. Suprascapular nerve
. Supraclavicular nerve
. Axillary nerve
. Long thoracic nerve
. Spinal accessory nerve

Correct Answer & Explanation

. Supraclavicular nerve

Explanation

The supraclavicular nerves (C3-C4 roots from the superficial cervical plexus) branch outward over the clavicle to provide sensation to the anterior chest wall. They are frequently encountered and are at high risk of iatrogenic injury or entrapment during superior plating of midshaft clavicle fractures, resulting in a predictable area of anterior chest numbness.

Question 1368

Topic: Shoulder Pathology

A 40-year-old female presents with shoulder pain, inability to actively abduct the arm beyond 90 degrees, and lateral scapular winging following a posterior triangle cervical lymph node biopsy. Which of the following tendon transfers (Eden-Lange procedure) is classically indicated for her condition?

. Transfer for long thoracic nerve palsy
. Transfer for spinal accessory nerve palsy
. Transfer for suprascapular nerve palsy
. Transfer for axillary nerve palsy
. Transfer for musculocutaneous nerve palsy

Correct Answer & Explanation

. Transfer for long thoracic nerve palsy

Explanation

Injury to the spinal accessory nerve during posterior triangle neck surgery results in trapezius palsy, characterized clinically by lateral scapular winging and loss of active abduction. The Eden-Lange procedure is the classic tendon transfer used to treat this condition; it involves transferring the levator scapulae to the acromion, and the rhomboids major and minor to the infraspinatus fossa to replicate the absent force vectors of the trapezius.

Question 1369

Topic: 9. Shoulder and Elbow

A 70-year-old male is 3 weeks post-anatomic total shoulder arthroplasty. He reports a sudden pop and increased pain after reaching backward for a door. Examination reveals increased passive external rotation compared to the contralateral side and profound weakness in internal rotation. What is the most likely diagnosis?

. Glenoid component aseptic loosening
. Acromion stress fracture
. Subscapularis tendon failure
. Axillary nerve neurapraxia
. Coracoid process fracture

Correct Answer & Explanation

. Glenoid component aseptic loosening

Explanation

Subscapularis failure after anatomic TSA presents with anterior shoulder pain, weak internal rotation, and increased passive external rotation. It typically occurs early postoperatively due to excessive external rotation or forceful extension before the tendon has healed.

Question 1370

Topic: Shoulder Arthroplasty & Arthritis

A 70-year-old male presents 3 months after an anatomic total shoulder arthroplasty with an acute loss of active internal rotation and anterior instability. Imaging confirms a complete, retracted subscapularis failure. What is the most reliable definitive surgical treatment?

. Direct primary repair of the subscapularis
. Pectoralis major tendon transfer
. Revision to reverse total shoulder arthroplasty
. Achilles tendon allograft reconstruction
. Arthroscopic superior capsule reconstruction

Correct Answer & Explanation

. Direct primary repair of the subscapularis

Explanation

Complete subscapularis failure after anatomic TSA leads to anterior instability and significant dysfunction. Revision to a reverse total shoulder arthroplasty (rTSA) provides the most reliable outcome, as direct repairs or tendon transfers in this setting have unacceptably high failure rates.

Question 1371

Topic: Shoulder Arthroplasty & Arthritis

Which of the following intraoperative modifications is most effective at preventing scapular notching during a reverse total shoulder arthroplasty?

. Superior translation of the glenosphere
. Superior tilt of the glenosphere
. Medialization of the glenosphere
. Inferior translation and inferior tilt of the glenosphere
. Decreasing the glenosphere diameter

Correct Answer & Explanation

. Superior translation of the glenosphere

Explanation

Scapular notching is a frequent complication in reverse total shoulder arthroplasty (rTSA). It is caused by mechanical impingement of the humeral cup against the inferior scapular neck during adduction. Placing the glenosphere with an inferior translation (overhanging the inferior rim) and an inferior tilt minimizes this impingement.

Question 1372

Topic: 9. Shoulder and Elbow

Which of the following describes the fundamental biomechanical alteration created by a reverse total shoulder arthroplasty (rTSA) that enables elevation of the arm in a patient with a massive, irreparable rotator cuff tear?

. It shifts the center of rotation laterally and superiorly, increasing the tension on the remaining rotator cuff.
. It shifts the center of rotation medially and inferiorly, increasing the moment arm of the deltoid.
. It shifts the center of rotation laterally and inferiorly, isolating the function of the supraspinatus.
. It primarily acts by tenodesing the long head of the biceps to provide superior stability.
. It increases the offset of the humerus to recruit the pectoralis major for forward flexion.

Correct Answer & Explanation

. It shifts the center of rotation medially and inferiorly, increasing the moment arm of the deltoid.

Explanation

The design of the reverse total shoulder arthroplasty (rTSA) shifts the glenohumeral center of rotation medially and inferiorly relative to the native shoulder. This biomechanical shift significantly increases the moment arm of the deltoid muscle and recruits more of its anterior and posterior fibers, allowing the deltoid to effectively elevate the arm even in the absence of a functional rotator cuff.

Question 1373

Topic: 9. Shoulder and Elbow

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), what is the generally accepted sequence of surgical repair to predictably restore elbow stability?

. Repair of the LCL, followed by radial head fixation, then coronoid fixation
. Coronoid fixation or capsule repair, followed by radial head fixation/replacement, then LCL repair
. Radial head fixation/replacement, followed by LCL repair, then coronoid fixation
. MCL repair, followed by radial head fixation, then LCL repair
. Coronoid fixation, followed by MCL repair, then radial head fixation

Correct Answer & Explanation

. Coronoid fixation or capsule repair, followed by radial head fixation/replacement, then LCL repair

Explanation

The classic, systematic 'inside-out' approach to repairing a terrible triad injury involves starting deep/medially and working laterally. The standard sequence is: 1) Fixation of the coronoid fracture or repair of the anterior capsule to restore the anterior buttress; 2) Fixation or prosthetic replacement of the radial head to restore the lateral column; 3) Repair of the lateral collateral ligament (LCL) complex to the lateral epicondyle. The medial collateral ligament (MCL) is generally only addressed if the elbow remains grossly unstable after these steps.

Question 1374

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female undergoes a reverse total shoulder arthroplasty (rTSA) for cuff tear arthropathy. The surgeon decides to use a lateralized glenosphere rather than a traditional medialized Grammont-style design. Which of the following biomechanical effects is most likely to result from this design choice?

. Decreased deltoid moment arm and decreased joint reactive forces
. Increased risk of inferior scapular notching
. Increased external rotation and decreased risk of scapular notching
. Decreased shear stress at the baseplate-glenoid interface
. Medialization of the center of rotation improving the tension of the remaining rotator cuff

Correct Answer & Explanation

. Increased external rotation and decreased risk of scapular notching

Explanation

Lateralized glenospheres in rTSA shift the center of rotation laterally compared to traditional medialized designs. This lateralization improves the resting tension of the remaining posterior rotator cuff (improving active external rotation), improves the overall contour of the shoulder, and decreases the incidence of inferior scapular notching. However, it does increase the shear stress at the glenoid baseplate interface compared to medialized designs.

Question 1375

Topic: Shoulder Pathology

A 32-year-old male presents with shoulder pain and weakness 6 weeks after a blunt trauma to the posterolateral neck. Physical examination reveals prominent medial winging of the scapula when the patient pushes against a wall. Which muscle and associated nerve have most likely been injured?

. Serratus anterior / Long thoracic nerve
. Trapezius / Spinal accessory nerve
. Rhomboids / Dorsal scapular nerve
. Latissimus dorsi / Thoracodorsal nerve
. Supraspinatus / Suprascapular nerve

Correct Answer & Explanation

. Serratus anterior / Long thoracic nerve

Explanation

Medial winging of the scapula is caused by dysfunction of the serratus anterior muscle, which is innervated by the long thoracic nerve. The serratus anterior normally holds the medial border of the scapula against the thoracic wall. In contrast, injury to the spinal accessory nerve results in trapezius dysfunction, causing lateral winging of the scapula.

Question 1376

Topic: 9. Shoulder and Elbow

Superior capsular reconstruction (SCR) using a dermal allograft is being considered for a 60-year-old laborer with a massive, irreparable posterosuperior rotator cuff tear. Which of the following is considered an absolute contraindication to performing this procedure?

. Hamada Grade 1 radiographic changes
. Intact subscapularis tendon
. Pseudoparalysis with active forward elevation to 45 degrees, but intact deltoid function
. Advanced glenohumeral osteoarthritis (Hamada Grade 4 or 5)
. Mild fatty infiltration (Goutallier stage 1) of the teres minor

Correct Answer & Explanation

. Advanced glenohumeral osteoarthritis (Hamada Grade 4 or 5)

Explanation

Superior capsular reconstruction (SCR) is indicated for massive, irreparable posterosuperior rotator cuff tears in patients with an intact or repairable subscapularis, a functioning deltoid, and minimal arthritis. Advanced glenohumeral osteoarthritis (Hamada Grade 4 or 5) is an absolute contraindication for SCR; these patients are better served with a reverse total shoulder arthroplasty (rTSA). Pseudoparalysis is a relative contraindication, though some studies suggest SCR can reverse it if the deltoid is functional, but rTSA is often preferred in severe pseudoparalysis.

Question 1377

Topic: 9. Shoulder and Elbow

A 72-year-old female undergoes a reverse total shoulder arthroplasty (RTSA) for severe rotator cuff tear arthropathy. Compared to the native anatomic shoulder, how is the center of rotation biomechanically altered in a traditional Grammont-style reverse shoulder prosthesis?

. Medialized and distalized
. Medialized and proximalized
. Lateralized and distalized
. Lateralized and proximalized
. Unchanged

Correct Answer & Explanation

. Medialized and distalized

Explanation

The traditional Grammont-style reverse total shoulder arthroplasty is designed to medialize and distalize the center of rotation. Medialization decreases the torque on the glenoid component, reducing the risk of loosening, while simultaneously recruiting more anterior and posterior deltoid fibers for elevation. Distalization tensions the deltoid, thereby increasing its moment arm and improving the mechanical advantage for active shoulder elevation in a rotator cuffโ€“deficient shoulder.

Question 1378

Topic: Shoulder Pathology

A 29-year-old female presents with shoulder weakness and aching pain following a posterior triangle neck lymph node biopsy. On examination, the resting position of her scapula is translated laterally and rotated downwardly. Attempted shoulder abduction results in the medial border of the scapula becoming less prominent (lateral winging). What is the most likely injured nerve?

. Long thoracic nerve
. Suprascapular nerve
. Spinal accessory nerve
. Dorsal scapular nerve
. Axillary nerve

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Injury to the spinal accessory nerve (CN XI), commonly occurring during biopsies in the posterior triangle of the neck, denervates the trapezius. This leads to 'lateral winging' of the scapula, characterized by a resting posture that is depressed, laterally translated, and downwardly rotated. Medial winging (prominence of the medial border with the scapula translated medially and superiorly) is caused by serratus anterior denervation secondary to long thoracic nerve injury.

Question 1379

Topic: 9. Shoulder and Elbow

A 68-year-old male with a history of an anatomic total shoulder arthroplasty presents with progressive pain and decreased elevation. Radiographs demonstrate superior migration of the humeral head with eccentric superior wear and gross loosening of the glenoid component. What is the biomechanical mechanism primarily responsible for this specific mode of failure?

. Cam-impingement
. The 'rocking horse' phenomenon
. Edge-loading of the inferior glenoid
. Galvanic corrosion of the trunnion
. Polyethylene oxidation from gamma irradiation in air

Correct Answer & Explanation

. The 'rocking horse' phenomenon

Explanation

The 'rocking horse' phenomenon occurs in anatomic total shoulder arthroplasty when an unrecognized or progressive rotator cuff tear leads to superior migration of the humeral head. The unconstrained humeral head applies eccentric, unbalanced superomedial forces on the superior rim of the glenoid component. This eccentric loading creates a rocking motion that inevitably leads to catastrophic early loosening and failure of the cemented glenoid component.

Question 1380

Topic: 9. Shoulder and Elbow

A 28-year-old motorcyclist is brought to the trauma bay after a high-speed collision. The chest radiograph reveals a laterally displaced left scapula with a widened scapulothoracic distance. Examination reveals an insensate, flail left upper extremity and an absent radial pulse. Which of the following is the most appropriate next step in management?

. Immediate brachial plexus exploration and nerve grafting
. Emergent CT angiography of the upper extremity
. Closed reduction of the scapula and shoulder spica casting
. Forequarter amputation
. Open reduction and internal fixation of the clavicle

Correct Answer & Explanation

. Emergent CT angiography of the upper extremity

Explanation

The clinical picture indicates a scapulothoracic dissociation, defined by lateral scapular displacement, devastating brachial plexus injury, and often subclavian or axillary artery injury. Given the absent pulse, emergent vascular imaging (CT angiography) or immediate surgical vascular intervention is required to address limb-threatening ischemia prior to any orthopedic fixation or nerve reconstruction.

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