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9. Shoulder and Elbow MCQs

Practice Set 78 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 1541

Topic: Elbow & Forearm

A 40-year-old bodybuilder undergoes a distal biceps tendon repair utilizing a two-incision technique. Compared to a single-incision anterior approach, the two-incision technique carries a uniquely higher risk of which of the following complications?

. Posterior interosseous nerve (PIN) neurapraxia
. Lateral antebrachial cutaneous nerve (LABCN) neurapraxia
. Radioulnar synostosis (heterotopic ossification)
. Recurrent tendon rupture
. Median nerve entrapment

Correct Answer & Explanation

. Radioulnar synostosis (heterotopic ossification)

Explanation

Historically and in comparative studies, the two-incision technique for distal biceps repair has been associated with a higher risk of radioulnar synostosis (heterotopic ossification) because of the subperiosteal dissection near the ulna. Conversely, the single-incision anterior approach places the lateral antebrachial cutaneous nerve (LABCN) and the posterior interosseous nerve (PIN) at higher risk.

Question 1542

Topic: 9. Shoulder and Elbow
A 5-year-old child falls on an outstretched arm and sustains an elbow dislocation. Post-reduction radiographs show an entrapped bony fragment within the medial joint space. Based on the chronologic appearance of elbow ossification centers, which center is most likely incarcerated in the joint, and what is its standard sequence of appearance?
. Capitellum; 1st center to appear
. Medial epicondyle; 3rd center to appear
. Trochlea; 4th center to appear
. Radial head; 2nd center to appear
. Olecranon; 5th center to appear

Correct Answer & Explanation

. Medial epicondyle; 3rd center to appear

Explanation

The ossification centers of the pediatric elbow appear in a predictable sequence represented by the mnemonic CRITOE: Capitellum (1st, ~1 yr), Radial head (2nd, ~3 yrs), Internal/Medial epicondyle (3rd, ~5 yrs), Trochlea (4th, ~7 yrs), Olecranon (5th, ~9 yrs), and External/Lateral epicondyle (6th, ~11 yrs). The medial epicondyle is the 3rd center to appear and is frequently avulsed and incarcerated in the joint during pediatric elbow dislocations.

Question 1543

Topic: Elbow & Forearm

A 35-year-old male requires ligamentous reconstruction for chronic posterolateral rotatory instability (PLRI) of the elbow. During reconstruction of the lateral ulnar collateral ligament (LUCL), where should the femoral tunnel be placed to best approximate the isometric point of the native ligament?

. At the center of the capitellum
. Directly on the lateral epicondyle
. Posterior and superior to the lateral epicondyle
. Anterior and inferior to the lateral epicondyle
. At the isometric center of rotation on the lateral epicondyle

Correct Answer & Explanation

. At the isometric center of rotation on the lateral epicondyle

Explanation

The isometric point for the origin of the lateral ulnar collateral ligament (LUCL) is located at the isometric center of rotation of the capitellum, which corresponds anatomically to the lateral epicondyle. Improper placement, particularly anterior to the axis of rotation, results in the graft being tight in flexion and loose in extension, leading to recurrent instability or loss of motion.

Question 1544

Topic: Elbow & Forearm

A 40-year-old female sustains a fall on an outstretched hand and incurs a complex coronal shear fracture of the distal humerus involving the capitellum and trochlea. Based on the Dubberley classification, what defines a Type 3 capitellum fracture?

. Involvement of the capitellum only
. Involvement of the capitellum and the lateral trochlear ridge
. Fracture extending to the medial epicondyle
. Comminution of the posterior aspect of the lateral condyle
. Fracture extending across the capitellum and the entire trochlea

Correct Answer & Explanation

. Involvement of the capitellum and the lateral trochlear ridge

Explanation

In the Dubberley classification of coronal shear fractures of the distal humerus: Type 1 involves the capitellum with or without the lateral trochlear ridge. Type 2 involves the capitellum and extends medially into the trochlea in a single piece. Type 3 involves fractures extending across the capitellum and the entire trochlea (communited or separate fragments). The addition of 'A' means the posterior condyle is intact, and 'B' means there is posterior condylar comminution.

Question 1545

Topic: Elbow & Forearm

A 45-year-old weightlifter feels a pop in the posterior aspect of his elbow during a heavy bench press. Which of the following physical examination findings is most specific for a complete acute distal triceps tendon rupture?

. Inability to passively extend the elbow
. Loss of active elbow extension against gravity
. Palpable gap in the extensor carpi radialis brevis
. Positive Hook test
. Severe pain with resisted forearm supination

Correct Answer & Explanation

. Loss of active elbow extension against gravity

Explanation

A complete distal triceps rupture typically presents with an inability to actively extend the elbow against gravity (often tested with the arm abducted to 90 degrees). A palpable gap may be felt proximal to the olecranon. The Hook test is used for distal biceps ruptures. Pain with resisted supination is also associated with biceps pathology or lateral epicondylitis.

Question 1546

Topic: Elbow & Forearm

A 35-year-old male falls on an outstretched hand and sustains a fracture of the anteromedial facet of the coronoid process. Which of the following injury mechanisms and associated ligamentous injuries is most classically associated with this fracture pattern?

. Posterolateral rotatory instability with lateral ulnar collateral ligament (LUCL) tear
. Varus posteromedial rotatory instability with lateral ulnar collateral ligament (LUCL) tear
. Valgus overload with medial ulnar collateral ligament (MUCL) anterior bundle tear
. Axial compression with radial head fracture and interosseous membrane tear
. Posterior dislocation with complete anterior capsule avulsion

Correct Answer & Explanation

. Varus posteromedial rotatory instability with lateral ulnar collateral ligament (LUCL) tear

Explanation

Fractures of the anteromedial facet of the coronoid process are the hallmark of varus posteromedial rotatory instability (VPMRI) of the elbow. The mechanism involves an axial load combined with varus and posteromedial rotatory forces. This causes the anteromedial coronoid facet to impact the medial trochlea, resulting in a fracture, and invariably causes rupture of the lateral collateral ligament (LCL) complex, including the LUCL. Failure to recognize and treat the LUCL injury and the facet fracture can lead to rapid post-traumatic arthrosis and chronic subluxation.

Question 1547

Topic: Elbow & Forearm

A patient demonstrates posterolateral rotatory instability (PLRI) of the elbow. The primary pathomechanical lesion involves the avulsion of the lateral ulnar collateral ligament (LUCL) from which specific anatomic structure?

. Coronoid process
. Radial head
. Lateral epicondyle of the humerus
. Supinator crest of the ulna
. Olecranon tip

Correct Answer & Explanation

. Lateral epicondyle of the humerus

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily caused by an insufficiency of the lateral ulnar collateral ligament (LUCL). The LUCL originates on the lateral epicondyle of the humerus and inserts on the supinator crest of the ulna. The most common site of avulsion or disruption resulting in PLRI is at its humeral origin on the lateral epicondyle.

Question 1548

Topic: 9. Shoulder and Elbow

A 28-year-old gymnast sustains an elbow injury. CT imaging reveals a fracture of the anteromedial facet of the coronoid. This specific fracture pattern is most closely associated with which mechanism of injury and corresponding ligamentous disruption?

. Posterolateral rotatory instability; lateral ulnar collateral ligament (LUCL) isolated rupture
. Varus posteromedial rotatory instability; lateral collateral ligament (LCL) complex rupture
. Valgus extension overload; anterior bundle of the ulnar collateral ligament (UCL) rupture
. Axial loading; interosseous membrane tear
. Terrible triad injury; isolated anterior capsule avulsion

Correct Answer & Explanation

. Varus posteromedial rotatory instability; lateral collateral ligament (LCL) complex rupture

Explanation

Anteromedial facet coronoid fractures occur via a mechanism of varus force coupled with posteromedial rotation (Varus Posteromedial Rotatory Instability, VPMRI). As the elbow subluxates, the anteromedial facet of the coronoid impacts the medial trochlea, causing the fracture. This mechanism inherently involves rupture of the lateral collateral ligament (LCL) complex, which must be addressed surgically to restore stability.

Question 1549

Topic: Elbow & Forearm
A 42-year-old female falls onto an outstretched hand and sustains an elbow fracture. The lateral radiograph demonstrates a 'double-arc' sign. According to the Bryan and Morrey classification modified by McKee, what does this radiographic sign pathognomonically represent?
. A Type I (Hahn-Steinthal) fracture with isolated large osseous capitellum fragment
. A Type II (Kocher-Lorenz) cartilaginous shear fracture
. A Type III comminuted capitellum fracture
. A Type IV fracture involving the capitellum and extending medially to include the lateral trochlear ridge
. Associated posterior dislocation of the radial head

Correct Answer & Explanation

. A Type IV fracture involving the capitellum and extending medially to include the lateral trochlear ridge

Explanation

The 'double-arc' sign on a lateral elbow radiograph is pathognomonic for a McKee modification Type IV coronal shear fracture. The two arcs represent the subchondral bone of the capitellum and the lateral ridge of the trochlea, which are fractured and displaced as a single unit. It is critical to recognize this, as it indicates a more extensive medial extension of the fracture that requires adequate surgical exposure and fixation to restore the radiocapitellar and ulnohumeral articulations.

Question 1550

Topic: 9. Shoulder and Elbow

A 13-year-old elite baseball pitcher presents with chronic medial elbow pain and decreased pitching velocity. Radiographs demonstrate widening of the medial epicondyle apophysis. Which phase of the throwing motion is associated with the highest valgus stress on the medial elbow structures, exacerbating this condition?

. Wind-up
. Early cocking
. Late cocking and early acceleration
. Deceleration
. Follow-through

Correct Answer & Explanation

. Late cocking and early acceleration

Explanation

Little League elbow (medial epicondyle apophysitis) is caused by repetitive valgus overload. During the throwing motion, the late cocking and early acceleration phases generate the maximum valgus torque on the elbow. This results in tremendous tensile stress across the medial elbow structures (UCL, medial epicondyle apophysis, flexor-pronator mass) and compressive forces laterally (radiocapitellar joint).

Question 1551

Topic: Elbow & Forearm

Following an ulnar collateral ligament (UCL) reconstruction ('Tommy John' surgery) using a palmaris longus autograft via the docking technique, what is the most frequent postoperative complication reported in the literature?

. Palmaris longus graft rupture
. Medial epicondyle avulsion fracture
. Ulnar neuropathy
. Superficial wound infection
. Heterotopic ossification of the medial collateral ligament

Correct Answer & Explanation

. Ulnar neuropathy

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction, reported in approximately 5-10% of cases. The ulnar nerve lies in the cubital tunnel immediately posterior to the UCL and is at high risk of irritation, traction, or compression during surgical exposure and tunnel drilling. Modern techniques, such as the docking technique with meticulous handling of the nerve or formal transposition when indicated, have helped minimize, but not eliminate, this risk.

Question 1552

Topic: 9. Shoulder and Elbow

A 45-year-old male feels a sudden 'pop' in his anterior elbow while lifting a heavy box. Clinical examination demonstrates a positive 'hook test.' If this patient opts for non-operative management of his distal biceps tendon rupture, which functional deficit will be most pronounced?

. Elbow flexion strength
. Elbow extension strength
. Forearm pronation strength
. Forearm supination strength
. Wrist flexion strength

Correct Answer & Explanation

. Forearm supination strength

Explanation

A complete distal biceps tendon rupture leads to significant deficits in both forearm supination and elbow flexion. However, the loss of supination strength is much more pronounced (typically 40-50% loss) compared to the loss of elbow flexion strength (typically 30% loss) because the brachialis remains an intact and powerful elbow flexor.

Question 1553

Topic: Elbow & Forearm

A 35-year-old female presents after a fall onto an outstretched hand. She is diagnosed with a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). According to standard protocols, what is the recommended surgical sequence for repairing these injuries?

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

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/replacement, lateral collateral ligament (LCL) repair

Explanation

The standard protocol for treating a terrible triad injury follows an 'inside-out' approach. The deep anterior structures are addressed first (coronoid fixation), followed by the lateral column (radial head fixation or replacement), and finally the lateral capsuloligamentous structures (LCL repair). The MCL is generally only repaired if the elbow remains grossly unstable after the lateral side is fixed.

Question 1554

Topic: Elbow & Forearm

A 28-year-old male sustains a 'terrible triad' injury of the elbow. Intraoperatively, after definitive internal fixation of the coronoid fracture and replacement of a highly comminuted radial head, the elbow exhibits persistent posterolateral rotatory instability. What is the most appropriate next step in management?

. Repair the anterior bundle of the medial collateral ligament (MCL)
. Apply a hinged external fixator
. Repair the lateral ulnar collateral ligament (LUCL)
. Immobilize the elbow in 90 degrees of flexion and full supination
. Perform an olecranon osteotomy to assess the trochlea

Correct Answer & Explanation

. Repair the lateral ulnar collateral ligament (LUCL)

Explanation

The standard algorithm for treating a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) involves restoring the anterior buttress (coronoid), restoring the lateral buttress (radial head repair or replacement), and then repairing the lateral ligamentous complex (specifically the LUCL) to the lateral epicondyle. If instability persists after LUCL repair, the MCL may be repaired or an external fixator applied.

Question 1555

Topic: 9. Shoulder and Elbow

A 72-year-old female undergoes a reverse total shoulder arthroplasty for cuff tear arthropathy. How does this implant design alter the biomechanics of the glenohumeral joint compared to native anatomy?

. Lateralizes and superiorly translates the center of rotation
. Medializes and inferiorly translates the center of rotation
. Medializes and superiorly translates the center of rotation
. Lateralizes and inferiorly translates the center of rotation
. Maintains anatomic center of rotation but increases the deltoid lever arm

Correct Answer & Explanation

. Medializes and inferiorly translates the center of rotation

Explanation

Reverse total shoulder arthroplasty (based on the Grammont design principles) medializes and inferiorly translates the center of rotation of the glenohumeral joint. This alteration significantly increases the lever arm of the deltoid muscle, allowing it to recruit more fibers for arm elevation in the absence of a functioning rotator cuff. It also decreases torque on the glenoid component.

Question 1556

Topic: Elbow & Forearm

During surgical approach and debridement for refractory lateral epicondylitis, care must be taken to avoid iatrogenic injury to the lateral ulnar collateral ligament (LUCL). What is the anatomic location of the LUCL origin relative to the extensor carpi radialis brevis (ECRB) origin?

. Anterior and superficial
. Anterior and deep
. Posterior and deep
. Superior and superficial
. Distal and anterior

Correct Answer & Explanation

. Posterior and deep

Explanation

The lateral ulnar collateral ligament (LUCL) originates on the lateral epicondyle posterior and deep to the origin of the extensor carpi radialis brevis (ECRB) and the common extensor tendon. It then traverses distally to insert on the supinator crest of the ulna. Overzealous deep and posterior surgical release of the ECRB can result in iatrogenic posterolateral rotatory instability (PLRI) of the elbow.

Question 1557

Topic: 9. Shoulder and Elbow

Based on the Grammont principles of Reverse Total Shoulder Arthroplasty (rTSA), how does the implant biomechanically alter the glenohumeral joint's center of rotation compared to the native anatomy?

. Medializes and inferiorizes the center of rotation
. Lateralizes and superiorizes the center of rotation
. Medializes and superiorizes the center of rotation
. Lateralizes and inferiorizes the center of rotation
. Maintains the native anatomic center of rotation

Correct Answer & Explanation

. Medializes and inferiorizes the center of rotation

Explanation

The classical Grammont design for Reverse Total Shoulder Arthroplasty (rTSA) medializes and inferiorizes the center of rotation. Medialization increases the deltoid moment arm and recruits more anterior and posterior deltoid fibers for elevation. Inferiorization tensions the deltoid, compensating for an absent or non-functional rotator cuff.

Question 1558

Topic: 9. Shoulder and Elbow

A 68-year-old male presents with chronic shoulder pain and inability to actively elevate his arm above 40 degrees (pseudoparalysis). MRI shows a massive, retracted, fatty-infiltrated rotator cuff tear involving the supraspinatus and infraspinatus. Radiographs display severe superior migration of the humeral head with acetabularization of the acromion (Hamada Stage 4). What is the most appropriate surgical intervention?

. Arthroscopic rotator cuff repair
. Latissimus dorsi tendon transfer
. Superior capsular reconstruction
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for an elderly patient with rotator cuff tear arthropathy (Hamada Stage 4) and pseudoparalysis. It relies on the deltoid to restore elevation while addressing glenohumeral arthritis.

Question 1559

Topic: 9. Shoulder and Elbow
A 16-year-old high school student undergoes a routine preparticipation physical examination at the beginning of the school year. Examination reveals marked laxity of both shoulders but only mild generalized laxity in other joints. The load and shift test allows for anterior humeral translation to the glenoid rim and posterior humeral translation beyond the glenoid rim. The sulcus sign is present. What is the next most appropriate step in management?
. Inform the student that participation in sports is prohibited.
. Order MRI of the shoulders to evaluate for labral tears.
. Consider arthroscopic thermal capsulorraphy to tighten the shoulders.
. Consider open capsular shift procedures to stabilize the shoulders.
. Recommend a program of shoulder strengthening exercises and allow participation in sports.

Correct Answer & Explanation

. Recommend a program of shoulder strengthening exercises and allow participation in sports.

Explanation

This patient has shoulder laxity without apprehension. Because there is a wide range of normal laxity in asymptomatic shoulders, the physician should inform the student of these findings, recommend shoulder strengthening exercises, and allow unrestricted sports participation unless symptoms develop.

Question 1560

Topic: 9. Shoulder and Elbow
Which of the following ligaments are the primary static restraints to inferior translation of the arm when the shoulder is in 0 degrees of abduction and neutral rotation?
. Inferior and middle glenohumeral
. Middle and superior glenohumeral
. Superior glenohumeral and coracohumeral
. Coracohumeral and coracoclavicular
. Coracoacromial and coracoclavicular

Correct Answer & Explanation

. Superior glenohumeral and coracohumeral

Explanation

DISCUSSION: Biomechanical ligament sectioning studies have implicated both the superior glenohumeral and coracohumeral ligaments as restraints to inferior translation when the shoulder is in 0 degrees of abduction and neutral rotation. Although there is controversy over the significance of each ligament, both are involved to some degree. The middle glenohumeral ligament is more important in the midranges of abduction, and the inferior ligament is more important at 90 degrees of abduction. The coracoacromial and coracoclavicular ligaments play no role in glenohumeral restraint. REFERENCES: Warner JJ, Deng XH, Warren RF, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685. Jost B, Koch PP, Gerber C: Anatomy and function of the rotator interval. J Shoulder Elbow Surg 2000;9:336-341.

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