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9. Shoulder and Elbow MCQs

Practice Set 82 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 1621

Topic: 9. Shoulder and Elbow

A 19-year-old football player who sustained three traumatic anterior shoulder dislocations underwent surgery to repair a Bankart lesion. Nine months after surgery, examination reveals stability, elevation to 150 degrees, external rotation to 0 degrees with the elbow at his side and to 50 degrees at 90 degrees of abduction, and internal rotation to T12. If his range of motion does not improve, he is at most risk for

. glenohumeral osteoarthritis.
. recurrent posterior subluxation.
. internal impingement syndrome.
. thoracic outlet syndrome.
. subscapularis tendon detachment.

Correct Answer & Explanation

. glenohumeral osteoarthritis.

Explanation

Loss of external rotation can lead to degenerative joint disease following an anterior stabilization procedure. A tight anterior capsule will prevent internal impingement. Risk of thoracic outlet syndrome should not be increased. Subscapularis detachment is a risk following open anterior repair; however, a gain in external rotation would be noted. In time, this patient's shoulder may show increased posterior glenohumeral wear but should not have symptoms of recurrent subluxation unless multidirectional instability is present. Hawkins RJ, Angelo RL: Glenohumeral osteoarthrosis: A late complication of the Putti-Platt repair. J Bone Joint Surg Am 1990;72:1193-1197.

Question 1622

Topic: 9. Shoulder and Elbow

A 78-year-old woman falls onto her nondominant left elbow and sustains the injury shown in Figure 5. What treatment option allows her the shortest recovery time and highest likelihood of good function and range of motion?

Upper Extremity 2008 Practice Questions: Set 1 (Solved) - Figure 11

. Total elbow arthroplasty
. Open reduction and internal fixation
. Radial head arthroplasty
. Sling and swathe
. Bone stimulator

Correct Answer & Explanation

. Total elbow arthroplasty

Explanation

Total elbow arthroplasty has become the treatment of choice for complex, comminuted distal humeral fractures in patients older than age 70 years. It yields a faster recovery with more predictable functional outcomes, although limitations of lifting weight of more than 5 pounds must be followed to avoid loosening. Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am 2004;86:940-947.

Question 1623

Topic: 9. Shoulder and Elbow

Figure 33 shows the CT scan of a 40-year-old man who injured his left shoulder while skiing. What structure is attached to the bony fragment?

Anatomy 2005 Practice Questions: Set 3 (Solved) - Figure 11

. Superior glenohumeral ligament
. Anterior band of the inferior glenohumeral ligament
. Middle glenohumeral ligament
. Subscapularis tendon
. Long head of the biceps tendon

Correct Answer & Explanation

. Anterior band of the inferior glenohumeral ligament

Explanation

The scan reveals a bony Bankart lesion. The anterior band of the inferior glenohumeral ligament is the major restraint to anterior translation of the humeral head and is usually injured with anterior shoulder dislocations. It inserts onto the glenoid labrum at the anteroinferior aspect of the glenoid rim. The labrum most frequently avulses from the glenoid (Bankart lesion), but occasionally the bony attachment is avulsed. O'Brien SJ, Neves MC, Arnoczky SP, et al: The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990;18:449-456.

Question 1624

Topic: 9. Shoulder and Elbow

A 45-year-old woman who recently underwent biopsy of a lymph node in the right posterior cervical triangle now finds it difficult to hold objects overhead and has diffuse aching in the right shoulder region. What is the most likely diagnosis?

. Rotator cuff tear
. Rhomboid paralysis
. Deltoid paralysis
. Triceps paralysis
. Trapezius paralysis

Correct Answer & Explanation

. Trapezius paralysis

Explanation

The trapezius is innervated by the spinal accessory nerve. The nerve is superficial in the area of the posterior cervical triangle and is prone to injury during dissection. Paralysis of the trapezius causes loss of scapular stability when forward flexion or abduction of the shoulder is attempted. Vastamaki M, Solonen KA: Accessory nerve injury. Acta Orthop Scand 1984;55:296-299.

Question 1625

Topic: 9. Shoulder and Elbow

A 52-year-old man has pain in the sternal area after landing on his right shoulder in a fall from his bicycle. In addition, he reports that he had difficulty swallowing and breathing immediately after the fall, but the symptoms resolved. A CT scan reveals a posterior sternoclavicular dislocation. Initial management should include

. a snug figure-of-8 splint and observation for spontaneous reduction.
. closed reduction under general anesthesia.
. closed reduction under general anesthesia and percutaneous pinning.
. open reduction and capsuloligamentous repair.
. open reduction and wire stabilization of the joint.

Correct Answer & Explanation

. closed reduction under general anesthesia.

Explanation

Posterior sternoclavicular dislocations require rapid treatment because of the proximity of major neurovascular structures and the airway. Initial management should consist of closed reduction under general anesthesia in the operating room with a chest surgeon available. A successful closed reduction is usually stable. Internal fixation of sternoclavicular injuries should be avoided because of the likelihood of hardware migration and possible injury to the mediastinal structures. If closed reduction is unsuccessful, open reduction is indicated. Treatment following reduction of the sternoclavicular joint includes the application of a figure-of-8 splint and a sling for 6 weeks, followed by stretching and strengthening exercises. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont IL, American Academy of Orthopaedic Surgeons, 1999, pp 287-297.

Question 1626

Topic: 9. Shoulder and Elbow

A 4-year-old boy with arthrogryposis has little active motion of his knees or elbows. Both elbows are in full extension with good triceps strength, but he is unable to bring his hand to his face or feed himself. Management should consist of

. observation.
. serial casting.
. flexion osteotomy of the distal humerus.
. posterior soft-tissue elbow release and anterior triceps transfer.
. adaptive equipment.

Correct Answer & Explanation

. posterior soft-tissue elbow release and anterior triceps transfer.

Explanation

Elbow release and triceps transfer to restore motion can be performed in children who are age 4 years and older. The ability to flex the elbow either actively or passively is of great assistance in activities of daily living. Van Heest A, Waters PM, Simmons BP: Surgical treatment of arthrogrypsosis of the elbow. J Hand Surg Am 1998;23:1063-1070.

Question 1627

Topic: 9. Shoulder and Elbow

Figure 20 shows the MRI scan of a 20-year-old athlete who has a painful shoulder. This pathology is most commonly seen in

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 25

. baseball pitchers.
. downhill skiers.
. football linemen.
. volleyball players.
. tennis players.

Correct Answer & Explanation

. football linemen.

Explanation

The MRI scan reveals a posterior labral detachment. This injury is the result of a posteriorly directed force and is common to football players in blocking positions. Although this injury can occur with trauma in all types of athletes, it is seen with relative frequency in football. Treatment is aimed at labral repair with posterior capsulorrhaphy. Both open and arthroscopic techniques can be used. Misamore GW, Facibene WA: Posterior capsulorrhaphy for the treatment of traumatic recurrent posterior subluxations of the shoulder in athletes. J Shoulder Elbow Surg 2000;9:403-408.

Question 1628

Topic: 9. Shoulder and Elbow

Figure 38 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. To minimize additional trauma to the medial soft tissues, the elbow should be reduced in

Shoulder 2002 Practice Questions: Set 3 (Solved) - Figure 18

. neutral rotation.
. full pronation.
. full supination.
. full extension.
. full flexion.

Correct Answer & Explanation

. full supination.

Explanation

The elbow dislocates by a three-dimensional movement of supination and valgus during flexion. Additional trauma during reduction is minimized by recreating the deformity and reducing the elbow in supination. The actual maneuver includes full supination (actually hypersupination) of the elbow in a valgus position. This is followed by pushing the olecranon distally in line with the long axis of the ulna while swinging the elbow into varus, and then relaxing the supination torque. Postreduction stability is enhanced in pronation, except when the soft-tissue disruption is extensive. O'Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 414.

Question 1629

Topic: 9. Shoulder and Elbow

A 55-year-old man has had progressive right shoulder pain for the past 2 years. Examination reveals active elevation to 120 degrees, external rotation to 20 degrees, and internal rotation to the sacrum. AP and axillary radiographs are shown in Figures 23a and 23b. Which of the following procedures would result in the most predictable long-term pain relief?

. Arthroscopic debridement of the glenohumeral joint
. Open subscapularis lengthening and cheilectomy
. Humeral hemiarthroplasty
. Bipolar humeral hemiarthroplasty
. Total shoulder arthroplasty

Correct Answer & Explanation

. Total shoulder arthroplasty

Explanation

Total shoulder arthroplasty yields excellent pain relief and function in patients with osteoarthritis. It is favored over humeral arthroplasty, especially when there is asymmetric posterior glenoid wear and posterior humeral subluxation as shown on the axillary radiograph. Arthroscopic debridement of the glenohumeral joint may be helpful in delaying the need for arthroplasty when the arthritic changes are mild to moderate but is not indicated for advanced osteoarthritis. Cofield RH, Frankle MA, Zuckerman JD: Humeral head replacement for glenohumeral arthritis. Semin Arthroplasty 1995;6:214-221. Levine WN, Djurasovic M, Glasson JM, Pollock RG, Flatow EL, Bigliani LU: Hemiarthroplasty for glenohumeral osteoarthritis: Results correlated to degree of glenoid wear. J Shoulder Elbow Surg 1997;6:449-454.

Question 1630

Topic: 9. Shoulder and Elbow

Figures 23a and 23b show the AP and lateral radiographs of the elbow of a 30-year-old professional pitcher. The pathology shown in these studies is most consistent with which of the following conditions?

. Insertional triceps tendinitis
. Valgus extension overload
. Medial epicondylitis
. Stress fracture of the olecranon
. Chronic olecranon bursitis

Correct Answer & Explanation

. Valgus extension overload

Explanation

The radiographs show the osteophytic build-up of the posteromedial corner of the elbow that occurs with valgus extension overload in the pitching elbow. This is the result of excessive valgus forces during the acceleration and deceleration phases of throwing. These forces, coupled with medial elbow stresses, cause a wedging of the olecranon into the medial wall of the olecranon fossa. Valgus instability of the elbow may further stimulate osteophyte formation. Repetitive impact of a spur within the olecranon fossa may cause fragmentation and eventual formation of loose bodies. Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers. Oper Tech Sports Med 1996;4:91-99. Field LD, Savoie FJ: Common elbow injuries in sport. Sports Med 1988;26:193-205.

Question 1631

Topic: 9. Shoulder and Elbow

A 55-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing left shoulder pain for the past 2 years despite nonsurgical management. No focal weakness is noted during examination of the shoulder. AP and axillary radiographs are shown in Figures 47a and 47b. Treatment should consist of

. arthroscopic synovectomy.
. humeral arthroplasty.
. unconstrained total shoulder arthroplasty.
. constrained total shoulder arthroplasty with a fixed-fulcrum prosthesis.
. glenohumeral arthrodesis.

Correct Answer & Explanation

. unconstrained total shoulder arthroplasty.

Explanation

Unconstrained total shoulder arthroplasty has been found to yield satisfactory results in a high percentage of patients with rheumatoid involvement of the glenohumeral joint. Pain relief has been more predictable with total shoulder arthroplasty than humeral arthroplasty, and a glenoid component is favored when there is sufficient glenoid bone stock and an intact rotator cuff. Constrained or fixed-fulcrum devices have an unacceptably high failure rate because of loosening. Glenohumeral arthrodesis is avoided when the deltoid or rotator cuff is functioning because the functional results after arthroplasty are superior when compared with results of arthrodesis. Arthroscopic synovectomy may be helpful in early stages of the disease before extensive cartilage damage has occurred. Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.

Question 1632

Topic: 9. Shoulder and Elbow

A 13-year-old girl who competes in gymnastics reports the insidious onset of lateral left elbow pain over the past 6 months. She also notes occasional catching episodes in the elbow; however, she denies any history of trauma. Examination reveals tenderness over the lateral epicondyle and extensor muscle origin. The elbow is stable and has full flexion, but lacks 10 degrees of full extension. An AP plain radiograph and an MRI scan are shown in Figures 17a and 17b. Management of the elbow should consist of

. open excision of the radial head.
. a cortisone injection into the extensor muscle origin.
. a tennis elbow release.
. arthroscopic removal of loose bodies and microfracture of the crater.
. rest, physical therapy, pulsed electromagnetic therapy, and no further gymnastic activities.

Correct Answer & Explanation

. arthroscopic removal of loose bodies and microfracture of the crater.

Explanation

The radiograph and MRI scan show osteochondritis dissecans of the capitellum, and the patient's history suggests a loose body. The treatment of choice is arthroscopic removal of the loose body and microfracture of the crater. Excision of the radial head, a cortisone injection, or tennis elbow release does not treat the pathology in the capitellum. Nonsurgical treatment would not relieve the mechanical symptoms of the loose body or promote healing in the crater. Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520-530. Jackson DW, Silvino N, Reiman P: Osteochondritis in the female gymnast's elbow. Arthroscopy 1989;5:129-136.

Question 1633

Topic: 9. Shoulder and Elbow

A 61-year-old woman with a long-standing history of rheumatoid arthritis reports progressive elbow pain for the past 12 months. She denies any recent trauma to the elbow; however, she notes increasing pain and decreased joint motion that are now compromising her function. Radiographs are shown in Figures 57a and 57b. What is the most appropriate treatment at this time?

. Physical therapy for restoration of motion
. Elbow arthroscopy, removal of loose bodies, excision of osteophytes, and capsular release (osteocapsulectomy)
. Elbow arthroscopy and synovectomy
. Constrained total elbow arthroplasty
. Semiconstrained total elbow arthroplasty

Correct Answer & Explanation

. Semiconstrained total elbow arthroplasty

Explanation

The patient has end-stage arthritis of the elbow with advanced joint destruction. At this point, nonsurgical management is unlikely to provide much relief of symptoms. Arthroscopic procedures can provide relief, but it is likely to be incomplete and unpredictable. The most reliable surgical option is total elbow arthroplasty. Currently, semiconstrained components are generally preferred because constrained components have been associated with a high rate of early prosthetic loosening. Little CP, Graham AJ, Karatzas G, et al: Outcomes of total elbow arthroplasty for rheumatoid arthritis: Comparative study of three implants. J Bone Joint Surg Am 2005;87:2439-2448.

Question 1634

Topic: 9. Shoulder and Elbow
A 68-year-old woman with serologically proven rheumatoid arthritis underwent an open synovectomy and radial head resection 10 years ago. She now has severe pain that has failed to respond to nonsurgical management. Examination reveals a flexion arc of greater than 90 degrees. Radiographs are shown in Figures 15a and 15b. What is the most appropriate management?
. Semiconstrained total elbow arthroplasty
. Unconstrained total elbow arthroplasty
. Fascial arthroplasty
. Open synovectomy
. Arthroscopic synovectomy

Correct Answer & Explanation

. Semiconstrained total elbow arthroplasty

Explanation

The radiographs reveal severe arthritic changes with no joint space, and the AP view shows a progressive malalignment secondary to the radial head resection. A prosthetic arthroplasty is indicated given the severe arthritis (Larsen grade III). Unconstrained arthroplasties have not performed as well as semiconstrained arthroplasties after previous radial head resections. Synovectomies should be reserved for less advanced disease states.

Question 1635

Topic: 9. Shoulder and Elbow

What structure provides the most static stability for valgus restraint in the elbow?

. Posterior band of the ulnar collateral ligament
. Anterior band of the ulnar collateral ligament
. Transverse band of the ulnar collateral ligament
. Annular ligament
. Flexor/pronator mass

Correct Answer & Explanation

. Anterior band of the ulnar collateral ligament

Explanation

The anterior band of the ulnar collateral ligament provides the greatest restraint to valgus stress in the elbow. The posterior band is taut in flexion and resists stress between 60 degrees and full flexion. The annular ligament stabilizes the radial head. The flexor/pronator mass are important dynamic stabilizers of the medial elbow. Ahmad CS, ElAttrache NS: Elbow valgus instability in the throwing athlete. J Am Acad Orthop Surg 2006;14:693-700. Regan WD, Korinek SL, Morrey BF, et al: Biomechanical study of ligaments around the elbow joint. Clin Orthop Relat Res 1991;271:170-179.

Question 1636

Topic: Elbow & Forearm

A 38-year-old woman who tripped and fell on her outstretched arm reports pain with movement. Examination reveals swelling. AP and lateral radiographs are shown in Figures 43a and 43b. Management should consist of

. excision of the fracture fragment.
. radial head replacement.
. closed reduction and cast immobilization.
. open reduction and internal fixation of the radial head.
. open reduction and internal fixation of the capitellum.

Correct Answer & Explanation

. open reduction and internal fixation of the capitellum.

Explanation

The patient has a type I (Hahn-Steinthal) capitellar fracture that is best seen on the lateral radiograph. If a fracture fragment is seen proximal to the radial head, a capitellar fracture is the most likely injury because radial head fractures do not migrate proximally. The fragment is large enough for fixation. Excision is the preferred treatment for small shear osteochondral type II (Kocher-Lorenz) capitellar fractures. Closed reduction usually is not successful because of rotation of the displaced fragment. Mehdian H, McKee M: Management of proximal and distal humerus fractures. Orthop Clin North Am 2000;31:115-127.

Question 1637

Topic: Shoulder Pathology

A 56-year-old woman who underwent axillary node dissection 4 months ago now reports shoulder pain, weakness of forward elevation, and obvious winging of the scapula. What structure has been injured?

. Long thoracic nerve
. Spinal accessory nerve
. Thoracodorsal nerve
. Lower trunk of the brachial plexus
. Posterior cord of the brachial plexus

Correct Answer & Explanation

. Long thoracic nerve

Explanation

The long thoracic nerve, which innervates the serratus anterior, is prone to injury because of its superficial location along the chest wall. The long thoracic nerve is derived from the roots of C5, C6, and C7. The spinal accessory nerve innervates the trapezius, and the thoracodorsal nerve innervates the latissimus dorsi. The posterior cord of the brachial plexus provides the axillary and the radial nerves. Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, pp 259-340.

Question 1638

Topic: 9. Shoulder and Elbow

Figures 5a and 5b show the radiographs of a 45-year-old patient. What is the most likely diagnosis?

. Glenoid dysplasia
. Rheumatoid arthritis with centralization
. Osteoarthritis with posterior glenoid wear
. Posterior scapular fracture deformity
. Traumatic posterior subluxation of the shoulder

Correct Answer & Explanation

. Glenoid dysplasia

Explanation

Glenoid dysplasia is an uncommon anomaly that usually has a benign course but may result in shoulder pain, arthritis, or multidirectional instability. Shoulder pain and instability often improve with shoulder strengthening exercises. Wirth MA, Lyons FR, Rockwood CA Jr: Hypoplasia of the glenoid: A review of sixteen patients. J Bone Joint Surg Am 1993;75:1175-1184.

Question 1639

Topic: 9. Shoulder and Elbow

A 42-year-old patient has had painful inferior subluxation of the glenohumeral joint following a recent cerebrovascular accident (CVA). Figure 34 shows the AP radiograph of the shoulder. Management should consist of

Shoulder 2002 Practice Questions: Set 3 (Solved) - Figure 11

. closed reduction.
. symptomatic sling support and range-of-motion exercises.
. arthroscopic thermal capsulorrhaphy.
. an open anterior-inferior capsular shift.
. a Laterjet procedure.

Correct Answer & Explanation

. symptomatic sling support and range-of-motion exercises.

Explanation

Following a CVA and with the resumption of upright posture, downward subluxation of the glenohumeral joint may occur. Although usually painless, some patients may report pain secondary to stretching of the brachial plexus. This is the result of flaccid paralysis of the deltoid muscle, and it will persist until some motor tone or spasticity returns to the shoulder girdle musculature. Early sling support and range-of-motion exercises to prevent contracture will provide the best relief. Surgical procedures are not indicated. Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.

Question 1640

Topic: 9. Shoulder and Elbow

An MRI arthrogram of the elbow is shown in Figure 6. Based on these findings, what is the most likely diagnosis?

Upper Extremity 2008 Practice Questions: Set 1 (Solved) - Figure 12

. Rupture of the medial collateral ligament
. Rupture of the lateral collateral ligament
. Intra-articular loose body
. Flexor-pronator injury
. Extensor origin avulsion

Correct Answer & Explanation

. Rupture of the medial collateral ligament

Explanation

MRI arthrography is the imaging study of choice for evaluation of medial collateral ligament injuries. Carrino JA, Morrison WB, Zou KH, et al: Noncontrast MR imaging and MR arthrography of the ulnar collateral ligament of the elbow: Prospective evaluation of two-dimensional pulse sequences for detection of complete tears. Skeletal Radiol 2001;30:625-632.

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