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9. Shoulder and Elbow MCQs

Practice Set 76 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 1501

Topic: Shoulder Arthroplasty & Arthritis

A 74-year-old male presents with pseudoparalysis of the shoulder and a massive, irreparable rotator cuff tear involving the supraspinatus, infraspinatus, and teres minor. Clinical exam reveals a positive Hornblower's sign. Which of the following is the most appropriate surgical intervention to optimize his functional outcome?

. Standard reverse total shoulder arthroplasty (RTSA)
. RTSA combined with a latissimus dorsi or lower trapezius tendon transfer
. Anatomic total shoulder arthroplasty with an oversized humeral head
. Arthroscopic superior capsule reconstruction (SCR)
. Hemiarthroplasty with concentric glenoid reaming

Correct Answer & Explanation

. RTSA combined with a latissimus dorsi or lower trapezius tendon transfer

Explanation

A positive Hornblower's sign indicates severe teres minor deficiency. An isolated RTSA will restore forward elevation but not active external rotation; combining RTSA with a latissimus dorsi or lower trapezius transfer is necessary to restore external rotation in these patients.

Question 1502

Topic: Elbow & Forearm

During a radial head arthroplasty for a comminuted radial head fracture, the surgeon inadvertently inserts an implant that is 4 mm too thick. What is the most likely biomechanical consequence of this 'overstuffed' radiocapitellar joint?

. Medial collateral ligament (MCL) laxity and valgus instability
. Increased radiocapitellar joint pressures leading to capitellar cartilage wear and restricted flexion
. Proximal migration of the radius and positive ulnar variance
. Posterolateral rotatory instability (PLRI)
. Spontaneous rupture of the lateral ulnar collateral ligament (LUCL)

Correct Answer & Explanation

. Increased radiocapitellar joint pressures leading to capitellar cartilage wear and restricted flexion

Explanation

Overstuffing the radiocapitellar joint excessively loads the capitellum, causing rapid cartilage wear, lateral elbow pain, and a significant loss of elbow flexion and extension. It artificially tensions the lateral ligamentous complex, rather than causing laxity.

Question 1503

Topic: 9. Shoulder and Elbow

A 62-year-old male with glenohumeral osteoarthritis presents with a Walch B2 glenoid. When performing an anatomic total shoulder arthroplasty (aTSA), what is the most appropriate management of the glenoid to prevent early component failure?

. Eccentric reaming to correct up to 25 degrees of retroversion
. Use of a standard non-augmented peg glenoid component
. Placement of a posteriorly augmented glenoid component
. Anterior capsular plication
. Performing a primary arthrodesis

Correct Answer & Explanation

. Placement of a posteriorly augmented glenoid component

Explanation

Posteriorly augmented glenoids correct retroversion while preserving subchondral bone in Walch B2 glenoids. Eccentric reaming >15 degrees removes excessive subchondral bone and significantly increases the risk of component loosening.

Question 1504

Topic: Shoulder Arthroplasty & Arthritis
A 70-year-old female presents with sudden-onset superior shoulder pain 4 months after a reverse total shoulder arthroplasty (RTSA). Radiographs reveal a Levy type II acromial base fracture. What is the most appropriate initial management?
. Immediate open reduction and internal fixation
. Conservative management with a sling and activity modification
. Revision of the humeral component to a smaller stem
. Revision to an anatomic total shoulder arthroplasty
. Botulinum toxin injection into the deltoid

Correct Answer & Explanation

. Conservative management with a sling and activity modification

Explanation

Acromial stress fractures after RTSA (Levy types I and II) are typically managed non-operatively initially with sling immobilization. Operative fixation is generally reserved for nonunions or severe displacement (Levy type III) that drastically alters deltoid tension.

Question 1505

Topic: Shoulder Arthroplasty & Arthritis

To minimize the risk of inferior scapular notching during a reverse total shoulder arthroplasty (RTSA), how should the glenosphere ideally be positioned?

. With superior tilt and superior translation
. With neutral tilt and flush with the inferior glenoid rim
. With slight inferior tilt and inferior overhang
. With extreme superior overhang
. With 20 degrees of retroversion

Correct Answer & Explanation

. With slight inferior tilt and inferior overhang

Explanation

Inferior overhang (typically 2-4 mm) and a slight inferior tilt of the baseplate shift the center of rotation inferiorly. This minimizes mechanical impingement of the humeral component against the scapular neck during adduction, thus reducing notching.

Question 1506

Topic: Shoulder Arthroplasty & Arthritis

A 65-year-old male undergoes anatomic total shoulder arthroplasty. Six weeks postoperatively, he complains of anterior shoulder pain and weakness in internal rotation. Exam shows a positive belly-press test and increased anterior translation. What is the most reliable definitive management for a confirmed complete avulsion of the subscapularis in this setting?

. Pectoralis major tendon transfer
. Revision to a reverse total shoulder arthroplasty (RTSA)
. Arthroscopic subscapularis repair
. Immobilization in internal rotation for 6 additional weeks
. Latissimus dorsi transfer

Correct Answer & Explanation

. Revision to a reverse total shoulder arthroplasty (RTSA)

Explanation

Complete subscapularis failure post-aTSA leading to anterior instability and superior migration has a very high failure rate with primary repair or isolated tendon transfers. Revision to an RTSA provides the most reliable restoration of joint stability and function.

Question 1507

Topic: 9. Shoulder and Elbow

During implantation of a linked total elbow arthroplasty (TEA) utilizing a Coonrad-Morrey prosthesis, what is the primary biomechanical function of placing bone graft anterior to the anterior flange of the humeral component?

. It prevents anterior dislocation of the ulna
. It resists posteriorly directed rotational torque during elbow extension
. It acts to lateralize the extensor mechanism
. It restores the radiocapitellar joint line
. It provides a platform for triceps reattachment

Correct Answer & Explanation

. It resists posteriorly directed rotational torque during elbow extension

Explanation

The anterior flange of the Coonrad-Morrey humeral component is designed to resist rotational torque and posteriorly directed forces during active elbow extension. Bone grafting anterior to the flange enhances this biomechanical buttress.

Question 1508

Topic: 9. Shoulder and Elbow

Which nerve is most at risk of stretch injury during the lengthening and distalization of the humerus often required to properly tension the deltoid in a reverse total shoulder arthroplasty (RTSA)?

. Musculocutaneous nerve
. Suprascapular nerve
. Axillary nerve
. Radial nerve
. Spinal accessory nerve

Correct Answer & Explanation

. Axillary nerve

Explanation

The axillary nerve runs just inferior to the glenohumeral joint capsule and is highly susceptible to stretch injury when the humerus is excessively lengthened to tension the deltoid in RTSA.

Question 1509

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old male with massive, irreparable posterosuperior rotator cuff tear pseudoparalysis exhibits a positive hornblower's sign and severe drop sign. He is planned for a reverse total shoulder arthroplasty (RTSA). Which adjunctive procedure should be considered to optimize his functional outcome?

. Pectoralis major tendon transfer
. Latissimus dorsi and/or teres major tendon transfer
. Trapezius transfer to the greater tuberosity
. Biceps tenodesis
. Subscapularis advancement

Correct Answer & Explanation

. Latissimus dorsi and/or teres major tendon transfer

Explanation

A positive hornblower's and drop sign indicate severe teres minor deficiency and loss of active external rotation. Combining RTSA with a latissimus dorsi/teres major transfer (L'Episcopo) reliably restores active external rotation.

Question 1510

Topic: Elbow & Forearm
The axis of forearm rotation occurs between what two anatomic points?
. Radial head, radial styloid
. Radial head, ulnar styloid
. Radial head, ulnar head
. Coronoid, sigmoid notch
. Coronoid, radial styloid

Correct Answer & Explanation

. Radial head, ulnar head

Explanation

Forearm rotation results from a complex interaction of osseous articulations and soft tissues including the radiocapitellar articulation, proximal and distal radioulnar joints, the interosseous membrane, and the adjacent forearm muscles. The rotation occurs around a longitudinal forearm axis extending from the center of the radial head proximally through the foveal region of the ulnar head distally.

Question 1511

Topic: 9. Shoulder and Elbow

A 72-year-old female with profound osteoporosis sustains a displaced 4-part proximal humerus fracture. A reverse total shoulder arthroplasty (RTSA) is chosen over hemiarthroplasty. What is the primary biomechanical rationale for utilizing RTSA in this specific patient scenario?

. It medializes and distalizes the center of rotation, allowing the deltoid to initiate elevation without a functional rotator cuff
. It provides a more anatomical restoration of the native glenohumeral center of rotation
. It requires less bony resection from the proximal humeral shaft, preserving bone stock
. It relies entirely on an intact axillary nerve for external rotation of the arm
. It reliably promotes anatomic healing of the greater and lesser tuberosities compared to hemiarthroplasty

Correct Answer & Explanation

. It medializes and distalizes the center of rotation, allowing the deltoid to initiate elevation without a functional rotator cuff

Explanation

In elderly patients with 4-part proximal humerus fractures, the tuberosities (and thus the rotator cuff attachments) frequently fail to heal or resorb. Hemiarthroplasty relies on tuberosity healing for function. RTSA bypasses this need by medializing and distalizing the joint's center of rotation, which increases the deltoid's moment arm and allows it to elevate the arm even in the absence of a functional rotator cuff.

Question 1512

Topic: 9. Shoulder and Elbow

During surgical management of a terrible triad injury of the elbow, the coronoid is fixed, the radial head is replaced, and the lateral ulnar collateral ligament (LUCL) is repaired. On intraoperative fluoroscopic examination, the elbow persistently subluxates posteriorly when extended past 30 degrees. What is the most appropriate next step in management?

. Cast the elbow in 90 degrees of flexion and pronation to heal
. Perform a medial approach to repair the anterior bundle of the medial collateral ligament (MCL)
. Remove the radial head arthroplasty and insert a larger spacer to tension the ligaments
. Perform an olecranon osteotomy to alter the joint reaction forces
. Perform a tenotomy of the brachialis tendon to reduce flexion contracture forces

Correct Answer & Explanation

. Perform a medial approach to repair the anterior bundle of the medial collateral ligament (MCL)

Explanation

In terrible triad injuries, the standard protocol involves fixing the coronoid, restoring the radial head, and repairing the lateral collateral ligament complex. If the elbow remains unstable in extension after these steps, it indicates medial collateral ligament (MCL) insufficiency. The current standard of care is to proceed with repair of the MCL (or application of a hinged external fixator). Leaving the elbow subluxated or merely casting it risks chronic instability and post-traumatic arthritis.

Question 1513

Topic: Elbow & Forearm

A 6-year-old boy presents for follow-up 6 weeks after closed reduction and casting of a Monteggia equivalent lesion. Radiographs reveal that the radial head is dislocated anteriorly, and the proximal ulna fracture has healed in apex-anterior angulation. What is the most appropriate management?

. Continued observation as the radial head will spontaneously reduce with remodeling
. Closed reduction of the radial head and application of a Muenster cast
. Open reduction of the radial head and annular ligament reconstruction alone
. Proximal ulna osteotomy with open reduction of the radial head
. Resection of the radial head

Correct Answer & Explanation

. Proximal ulna osteotomy with open reduction of the radial head

Explanation

A missed or chronic Monteggia fracture-dislocation in a child invariably stems from malreduction (angulation or length loss) of the ulna. The radial head cannot maintain reduction if the ulna length and alignment are not restored. Treatment requires a corrective osteotomy of the proximal ulna, combined with open reduction of the radial head. Radial head resection is contraindicated in children due to subsequent growth disturbances and wrist issues.

Question 1514

Topic: Elbow & Forearm
A 42-year-old man falls from a ladder, sustaining a comminuted, un-reconstructible radial head fracture. Intraoperatively, after radial head excision, he is noted to have significant longitudinal translation of the radius. Examination of the wrist reveals dorsal prominence and gross instability of the distal ulna. What is the most appropriate definitive management of the elbow and wrist?
. Radial head replacement and pinning of the DRUJ in supination
. Radial head replacement and Darrach procedure of the distal ulna
. Radial head resection alone with early active motion
. Radial head replacement and Sauvé-Kapandji procedure
. Radial head resection and reconstruction of the interosseous membrane

Correct Answer & Explanation

. Radial head replacement and pinning of the DRUJ in supination

Explanation

This is a classic Essex-Lopresti injury, characterized by a radial head fracture, tear of the interosseous membrane, and disruption of the distal radioulnar joint (DRUJ). Because the central band of the IOM is incompetent, the radial head acts as the primary constraint to proximal migration of the radius. Radial head resection alone is strictly contraindicated as it leads to severe proximal migration of the radius and ulnocarpal impaction. Treatment mandates radial head replacement to restore longitudinal stability and stabilization of the DRUJ (usually by pinning the wrist in supination for 4-6 weeks).

Question 1515

Topic: 9. Shoulder and Elbow

A 35-year-old male falls from a height and sustains a 'terrible triad' injury of the elbow. According to standard biomechanical principles and accepted surgical protocols, what is the most appropriate sequence of surgical reconstruction?

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

Correct Answer & Explanation

. Radial head fixation/replacement, LCL repair, coronoid fixation

Explanation

The standard surgical protocol for a terrible triad injury (elbow dislocation, radial head fracture, and coronoid fracture) involves a deep-to-superficial repair sequence. The most accepted sequence is to stabilize the coronoid first (restoring anterior stability), followed by the radial head (either ORIF or arthroplasty to restore the lateral column), and finally the lateral collateral ligament (LCL) complex. The MCL is typically only repaired if the elbow remains unstable after these three steps.

Question 1516

Topic: Elbow & Forearm

A 28-year-old patient sustained a midshaft humerus fracture with an associated radial nerve palsy that shows no clinical or electromyographic signs of recovery at 6 months. For restoration of functional wrist extension, what is the most common and reliable tendon transfer?

. Flexor carpi ulnaris (FCU) to Extensor digitorum communis (EDC)
. Flexor digitorum superficialis (FDS) to Extensor pollicis longus (EPL)
. Brachioradialis (BR) to Extensor carpi radialis brevis (ECRB)
. Pronator teres (PT) to Extensor carpi radialis brevis (ECRB)
. Palmaris longus (PL) to Extensor carpi ulnaris (ECU)

Correct Answer & Explanation

. Pronator teres (PT) to Extensor carpi radialis brevis (ECRB)

Explanation

The standard set of tendon transfers for a high radial nerve palsy includes transferring the Pronator Teres (PT) (innervated by the median nerve) to the Extensor Carpi Radialis Brevis (ECRB) to restore wrist extension. The ECRB is preferred over the ECRL because its central location prevents radial deviation during active wrist extension.

Question 1517

Topic: 9. Shoulder and Elbow

A 42-year-old woman sustains a shear fracture of the capitellum and lateral trochlea. CT imaging reveals significant posterior coronal comminution. According to the Dubberley classification, what is the significance of this posterior comminution?

. It classifies the injury as Type A, making it amenable to closed reduction.
. It classifies the injury as Type B, indicating a high risk of failure with isolated anterior-to-posterior screw fixation.
. It indicates involvement of the medial epicondyle.
. It necessitates primary total elbow arthroplasty.
. It suggests an intact lateral collateral ligament.

Correct Answer & Explanation

. It classifies the injury as Type B, indicating a high risk of failure with isolated anterior-to-posterior screw fixation.

Explanation

In the Dubberley classification of capitellum/trochlea fractures, Type A fractures lack posterior comminution, while Type B fractures have posterior condylar comminution. Type B fractures lack a posterior bony buttress, making them biomechanically unstable with isolated anterior-to-posterior screws. They typically require a posterior approach (or extensile lateral approach) with supplemental posterior plating to prevent fixation failure.

Question 1518

Topic: Elbow & Forearm

A surgeon chooses to perform a distal biceps tendon repair using a two-incision technique rather than a single anterior incision. The two-incision technique historically carries a higher risk of which of the following complications compared to the single-incision technique?

. Lateral antebrachial cutaneous (LABC) nerve palsy
. Proximal radioulnar synostosis
. Median nerve palsy
. Brachial artery transection
. Posterior interosseous nerve (PIN) palsy

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

The two-incision technique for distal biceps repair exposes the patient to a higher risk of heterotopic ossification and proximal radioulnar synostosis because it dissects the interosseous membrane between the radius and ulna. In contrast, the single anterior incision approach carries a significantly higher risk of injury to the Lateral Antebrachial Cutaneous (LABC) nerve.

Question 1519

Topic: 9. Shoulder and Elbow

A 45-year-old female presents with a closed elbow injury after a fall. Plain radiographs show a capitellum fracture. The lateral radiograph demonstrates a classic 'double arc sign.' Which of the following statements is true regarding this specific fracture pattern?

. It represents a Bryan and Morrey Type I fracture and can be treated with simple excision.
. It indicates a coronal shear fracture that extends medially to involve the trochlear ridge.
. The primary mechanism of injury is direct posterior trauma to a flexed elbow.
. It represents a purely osteochondral shear fragment (Kocher-Lorenz) with minimal subchondral bone.
. Nonoperative management is preferred due to the high risk of avascular necrosis.

Correct Answer & Explanation

. It indicates a coronal shear fracture that extends medially to involve the trochlear ridge.

Explanation

The 'double arc sign' on a true lateral radiograph of the elbow is pathognomonic for a coronal shear fracture of the distal humerus that involves both the capitellum and the lateral trochlear ridge (McKee modification Type IV capitellum fracture). One arc represents the capitellum, and the second arc represents the trochlear ridge. These are highly unstable and typically require open reduction and internal fixation (ORIF), often via an extensile lateral or dual-incision approach, using headless compression screws.

Question 1520

Topic: 9. Shoulder and Elbow

Following a traumatic 'terrible triad' injury of the elbow, a 35-year-old patient undergoes ORIF of the coronoid and radial head with LCL repair. Which of the following is the most commonly reported complication after surgical management of this injury?

. Recurrent elbow instability
. Nonunion of the radial head
. Post-traumatic elbow stiffness
. Ulnar neuropathy
. Heterotopic ossification

Correct Answer & Explanation

. Post-traumatic elbow stiffness

Explanation

While heterotopic ossification, ulnar neuropathy, and recurrent instability can occur, post-traumatic elbow stiffness is by far the most common complication following the surgical treatment of a terrible triad injury (elbow dislocation, radial head fracture, and coronoid fracture). Early postoperative mobilization is critical to mitigate this risk once a stable joint construct is achieved.

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