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9. Shoulder and Elbow MCQs

Practice Set 8 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 141

Topic: Elbow & Forearm

A 40-year-old man falls on an outstretched hand, sustaining a 'terrible triad' injury of the elbow. Which of the following describes the recommended sequence of surgical reconstruction to restore stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) works deep to superficial: coronoid fixation, then radial head repair or replacement, followed by lateral collateral ligament (LCL) complex repair.

Question 142

Topic: Elbow & Forearm

A 21-year-old collegiate baseball pitcher complains of posteromedial elbow pain occurring primarily during the deceleration phase of throwing. Examination reveals a 15-degree flexion contracture and sharp pain with forced terminal extension. What is the most likely diagnosis?

. Medial epicondylitis
. Ulnar collateral ligament acute rupture
. Valgus extension overload syndrome
. Osteochondritis dissecans of the capitellum
. Cubital tunnel syndrome

Correct Answer & Explanation

. Valgus extension overload syndrome

Explanation

Valgus extension overload in throwers is caused by repetitive impingement of the posteromedial olecranon into the olecranon fossa, often leading to posteromedial osteophytes and pain with forced extension.

Question 143

Topic: 9. Shoulder and Elbow
A 45-year-old woman with type 1 diabetes presents with progressive, painful restriction of both active and passive shoulder motion. During the early 'freezing' phase of this condition, histological analysis of the joint capsule would most likely demonstrate:
. Abundant polymorphonuclear cell infiltration
. Myxoid degeneration of the collagen fibers
. Fibroblastic proliferation with elevated levels of TGF-beta and PDGF
. Granulomatous inflammation with multinucleated giant cells
. Uric acid crystal deposition in the synovium

Correct Answer & Explanation

. Fibroblastic proliferation with elevated levels of TGF-beta and PDGF

Explanation

Adhesive capsulitis is characterized by fibroblastic proliferation and increased type III collagen production. Cytokines such as TGF-beta and PDGF play a central role in driving this fibrotic cascade.

Question 144

Topic: 9. Shoulder and Elbow

A 65-year-old man presents with chronic shoulder pain, significant loss of active elevation (pseudoparalysis), and superior migration of the humeral head on radiographs. If an MRI confirms massive, irreducible tears of the supraspinatus and infraspinatus with grade 4 fatty infiltration, what is the best surgical option to restore function?

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

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is the most reliable treatment for pseudoparalysis in an older patient with an irreparable posterosuperior rotator cuff tear. It medialize and distalizes the center of rotation, increasing the deltoid's moment arm.

Question 145

Topic: 9. Shoulder and Elbow

A 60-year-old female undergoes arthroscopic release for recalcitrant adhesive capsulitis. Which anatomic structure must be released specifically to reliably restore external rotation with the arm at the side?

. Posterior capsule
. Inferior glenohumeral ligament
. Rotator interval and coracohumeral ligament
. Superior labrum
. Middle glenohumeral ligament

Correct Answer & Explanation

. Rotator interval and coracohumeral ligament

Explanation

Contracture of the coracohumeral ligament and the rotator interval is the primary pathology limiting external rotation in the adducted position in patients with adhesive capsulitis.

Question 146

Topic: 9. Shoulder and Elbow

Which of the following radiographic views allows the best visualization of the acromioclavicular (AC ) joint:

. Stryker notch view
. Zanca view
. Garth view
. Serendipity view
. Anteroposterior shoulder view

Correct Answer & Explanation

. Zanca view

Explanation

In addition to standard views, a 10° cephalic tilt (Zanca) view is helpful to evaluate anteroposterior arthritis or distal clavicle osteolysis. This view is taken with approximately half the voltage of a standard anteroposterior shoulder radiograph and allows an unobstructed look at the acromioclavicular joint without soft tissue or bony overlay. The Stryker notch radiograph allows visualization of a Hill-Sachs impression fracture of the posterior humeral head. The glenoid fossa, or Garth view, is a true anteroposterior of the glenohumeral joint with the radiograph beam directed 45° from the plane of the thorax. The Serendipity view is used to evaluate the sternoclavicular joint and is a 40° cephalic tilt view with the patient supine.

Question 147

Topic: 9. Shoulder and Elbow

A 19-year-old collegiate football player experiences a sudden, burning pain radiating down his right arm after a tackle where his neck was laterally flexed to the left and his right shoulder was depressed. The symptoms completely resolve within 5 minutes. This "stinger" most commonly involves which of the following nerve roots?

. C4 and C5
. C5 and C6
. C7 and C8
. C8 and T1
. T1 and T2

Correct Answer & Explanation

. C5 and C6

Explanation

Burners or stingers are transient brachial plexus injuries commonly occurring due to traction or compression. They most frequently involve the upper trunk of the brachial plexus or the C5 and C6 nerve roots.

Question 148

Topic: Shoulder Pathology

Histological studies comparing multifidus muscle integrity after open versus minimally invasive lumbar fusion demonstrate significantly less muscle atrophy in the MIS group. What is the primary mechanism of multifidus injury prevented by the MIS tubular approach?

. Direct thermal necrosis from electrocautery
. Ischemic necrosis due to prolonged static retractor pressure
. Denervation via transection of the primary ventral rami
. Traction injury to the spinal accessory nerve
. Laceration of the segmental lumbar arteries

Correct Answer & Explanation

. Direct thermal necrosis from electrocautery

Explanation

Traditional open midline approaches require prolonged static retraction of the paraspinal muscles, causing elevated intramuscular pressure and subsequent ischemic necrosis. MIS tubular retractors split the muscle fibers and significantly reduce this ischemic burden.

Question 149

Topic: 9. Shoulder and Elbow

If the C 5 cervical spine nerve root is injured during a decompression of the cervical spine, then sensation is lost over which of the following areas:

. The lateral aspect of the arm from the shoulder to the elbow
. The medial aspect of the arm from the shoulder to the elbow
. The lateral border of the forearm including the thumb
. The middle finger
. The medial border of the forearm including the little finger

Correct Answer & Explanation

. The lateral aspect of the arm from the shoulder to the elbow

Explanation

The C 5 cervical spine nerve root supplies sensation from the lateral aspect of the arm from the shoulder to the elbow. C5 Lateral aspect of the arm from the shoulder to the elbow C6 Lateral border of the forearm including the thumb C7 Middle finger C8 Medial border of the forearm including the little finger T1 Medial aspect of the arm from the shoulder to the elbow

Question 150

Topic: 9. Shoulder and Elbow

If the C 7 cervical spine nerve root is injured during a posterior decompression of the cervical spine, then sensation is lost in which of the following areas:

. The lateral aspect of the arm from the shoulder to the elbow
. The medial aspect of the arm from the shoulder to the elbow
. The lateral border of the forearm including the thumb
. The middle finger
. The medial border of the forearm including the little finger

Correct Answer & Explanation

. The lateral aspect of the arm from the shoulder to the elbow

Explanation

The C7 cervical spine nerve root supplies sensation to the skin over the volar aspect of the middle finger. C 5 Lateral aspect of the arm from the shoulder to the elbow C 6 Lateral border of the forearm including the thumb C 7 Middle finger C 8 Medial border of the forearm including the little finger T1 Medial aspect of the arm from the shoulder to the elbow

Question 151

Topic: 9. Shoulder and Elbow

If the C 8 cervical spine nerve root is injured during a posterior spinal decompression, then sensation is lost over which of the following areas:

. The lateral aspect of the arm from the shoulder to the elbow
. The medial aspect of the arm from the shoulder to the elbow
. The lateral border of the forearm including the thumb
. The middle finger
. The medial border of the forearm including the little finger

Correct Answer & Explanation

. The lateral aspect of the arm from the shoulder to the elbow

Explanation

The C8 cervical spine nerve root supplies sensation to the medial border of the forearm including the little finger. C5 Lateral aspect of the arm from the shoulder to the elbow C 6 Lateral border of the forearm including the thumb C7 Middle finger C8 Medial border of the forearm including the little finger T1 Medial aspect of the arm from the shoulder to the elbow

Question 152

Topic: 9. Shoulder and Elbow

A patient develops a C8 nerve root palsy following a posterior cervical foraminotomy. Which of the following motor deficits is most likely to be observed on clinical examination?

. Weakness in shoulder abduction
. Weakness in elbow flexion
. Weakness in wrist extension
. Weakness in finger flexion
. Weakness in finger abduction

Correct Answer & Explanation

. Weakness in finger flexion

Explanation

The C8 nerve root supplies the flexor digitorum profundus and superficialis, controlling finger flexion. Finger abduction is primarily innervated by T1, while wrist extension is mediated by C6.

Question 153

Topic: Shoulder Pathology

A 45-year-old female undergoes an anterior transthoracic discectomy at the T1-T2 level. Postoperatively, she is noted to have unilateral ptosis, miosis, and anhidrosis on the ipsilateral side. Which structure was most likely compromised during the exposure?

. Recurrent laryngeal nerve
. Phrenic nerve
. Stellate ganglion
. Vagus nerve
. Long thoracic nerve

Correct Answer & Explanation

. Stellate ganglion

Explanation

The clinical presentation describes Horner's syndrome, caused by disruption of the sympathetic chain. During upper thoracic anterior approaches, the stellate ganglion, located anterior to the neck of the first rib, is at high risk of iatrogenic injury.

Question 154

Topic: Elbow & Forearm
The parents of a 12-year-old boy notice an abnormal shape on their son's forearm. He states that he does not feel any pain. Based on his radiograph (Slide), the most likely diagnosis is:
. Congenital dislocation of the radial head
. Unrecognized traumatic dislocation of the radial head
. Osteogenesis imperfecta
. Fibrous dysplasia
. Multiple exostoses

Correct Answer & Explanation

. Multiple exostoses

Explanation

This patient has multiple exostoses. Multiple exostoses, which result from a mutation on one of three EXT genes, cause a growth disturbance of affected limb segments. This effect is most pronounced in the two-bone segments (forearm and lower leg). The bone with the exostoses grows less in length and often develops angulation. The less-affected bone often develops secondary deformity, such as the radial head dislocation in this patient. Fibrous dysplasia and osteogenesis imperfecta may lead to developmental dislocation of the radial head as well, but the associated bony changes allow correct diagnosis of each of these conditions.

Question 155

Topic: Elbow & Forearm
In a lateral radiograph of a child's elbow, the anterior humeral line should be located:
. Anterior to the capitellum
. In the anterior one-third of the capitellum
. In the middle-third of the capitellum
. In the posterior-third of the capitellum
. Posterior to the capitellum

Correct Answer & Explanation

. In the middle-third of the capitellum

Explanation

In a child's elbow, the anterior humeral line should be located in the middle-third of the capitellum.

Question 156

Topic: Elbow & Forearm

Based on the elbow radiograph of a 5-year-old child presenting with acute trauma (

), what is the most significant long-term complication if a widely displaced lateral condyle fracture goes entirely unrecognized and develops into a nonunion?

. Cubitus varus
. Tardy ulnar nerve palsy
. Radial nerve palsy
. Avascular necrosis of the radial head
. Heterotopic ossification

Correct Answer & Explanation

. Tardy ulnar nerve palsy

Explanation

A nonunion of the lateral condyle typically leads to progressive cubitus valgus deformity. Over time, the valgus stretch causes a tardy ulnar nerve palsy.

Question 157

Topic: 9. Shoulder and Elbow

A 3-year-old toddler is pulled by the arm by a sibling and subsequently refuses to use the right upper extremity, holding it in slight flexion and pronation. Which anatomic structure is primarily interposed in the joint in this condition?

. Lateral collateral ligament
. Quadrate ligament
. Annular ligament
. Biceps tendon
. Brachialis muscle

Correct Answer & Explanation

. Annular ligament

Explanation

Nursemaid's elbow (radial head subluxation) occurs when axial traction allows the annular ligament to slip over the radial head and become incarcerated in the radiocapitellar joint.

Question 158

Topic: Elbow & Forearm

A 14-year-old boy with a known diagnosis of Multiple Hereditary Exostoses (MHE) presents with a progressive forearm deformity. Which of the following describes the most classic forearm deformity seen in these patients?

. Radial lengthening and ulnar bowing
. Ulnar shortening and radial bowing
. Bilateral radioulnar synostosis
. Madelung-type dorsal radial bowing
. Proximal radial head hypertrophy

Correct Answer & Explanation

. Ulnar shortening and radial bowing

Explanation

The classic MHE forearm deformity involves relative ulnar shortening (due to distal ulnar osteochondromas tethering growth) and consequent radial bowing. This often leads to radial head subluxation or dislocation.

Question 159

Topic: Elbow & Forearm

A 4-year-old sustains a trauma to the forearm. Radiographs demonstrate an accentuated bowing of the ulna without an obvious cortical breach, and an anterior dislocation of the radial head. The initial step in the reduction maneuver for the ulnar plastic deformation should involve:

. Application of continuous traction only
. Immobilization in a Muenster cast without manipulation
. Application of a corrective bending force opposite to the deformity
. Immediate open osteotomy
. Percutaneous intramedullary nailing

Correct Answer & Explanation

. Application of a corrective bending force opposite to the deformity

Explanation

Plastic deformation of the ulna must be actively reduced by applying a constant corrective bending force (often over an apex like the surgeon's knee) for several minutes. Failing to correct the ulnar bow will prevent stable reduction of the radial head.

Question 160

Topic: Elbow & Forearm

A 3-year-old girl is brought to the clinic because she keeps her right elbow partially flexed and pronated. Her father reports he pulled her up by the hand onto a sidewalk step. What is the pathophysiology of her suspected condition?

. Subluxation of the radial head with interposition of the annular ligament
. Avulsion of the biceps tendon from the radial tuberosity
. Subluxation of the ulnohumeral joint with collateral ligament sprain
. Osteochondral defect of the capitellum
. Traction injury to the lower trunk of the brachial plexus

Correct Answer & Explanation

. Subluxation of the radial head with interposition of the annular ligament

Explanation

The clinical picture describes "nursemaid's elbow" (radial head subluxation). It occurs from an axial traction force on an extended and pronated forearm, causing the annular ligament to slip over the radial head and become interposed in the joint.

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