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9. Shoulder and Elbow MCQs

Practice Set 86 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 1701

Topic: 9. Shoulder and Elbow

A 35-year-old male sustains a fall onto an outstretched hand, resulting in a complex elbow injury. Clinical examination reveals gross instability. Radiographs confirm an elbow dislocation, a comminuted radial head fracture, and a coronoid process fracture.

This injury pattern is commonly referred to as the 'terrible triad' of the elbow. Which component of the terrible triad is MOST critical to reconstruct or repair to restore the primary anterior-posterior stability of the elbow joint?

. Radial head reconstruction or replacement.
. Repair of the medial collateral ligament.
. Repair of the lateral collateral ligament.
. Coronoid process repair.
. Capsular plication.

Correct Answer & Explanation

. Coronoid process repair.

Explanation

The terrible triad of the elbow (elbow dislocation, radial head fracture, coronoid fracture) is a complex and highly unstable injury. While all components contribute to overall stability, the coronoid process is the primary anterior buttress against posterior subluxation and dislocation. Repairing or reconstructing the coronoid is therefore MOST critical for restoring the primary anterior-posterior stability of the elbow joint, particularly in the presence of a radial head fracture. The lateral collateral ligament (LCL) complex provides varus and posterolateral rotatory stability, and radial head contributes to both valgus and axial stability. The medial collateral ligament is less commonly injured in pure terrible triads and primarily resists valgus stress.

Question 1702

Topic: Shoulder Arthroplasty & Arthritis

A 48-year-old electrician presents with worsening bilateral shoulder pain and weakness, particularly with overhead activities. He reports chronic symptoms that have been progressive over several years. Physical examination reveals bilateral atrophy of the infraspinatus and supraspinatus muscles, marked weakness in external rotation and abduction, and positive 'horn blower's sign' on the right. MRI of the right shoulder confirms a massive, irreparable rotator cuff tear with significant fatty infiltration and retraction of the supraspinatus and infraspinatus tendons, and superior migration of the humeral head. What is the MOST appropriate surgical management option for this patient?

. Arthroscopic rotator cuff repair with augmentation.
. Reverse total shoulder arthroplasty (RTSA).
. Latissimus dorsi transfer.
. Superior capsular reconstruction.
. Debridement and subacromial decompression.

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (RTSA).

Explanation

The patient presents with chronic, massive, irreparable rotator cuff tears with significant fatty infiltration, retraction, and superior humeral head migration (cuff tear arthropathy). These findings contraindicate a standard rotator cuff repair or augmentation, as the tissue quality and retraction make successful repair highly unlikely, and the superior migration indicates loss of the fulcrum of rotation. The 'horn blower's sign' indicates teres minor dysfunction, often associated with massive irreparable cuff tears, further highlighting the severity.In such cases, particularly in older, low-demand patients or when cuff tear arthropathy is present, Reverse Total Shoulder Arthroplasty (RTSA) is the gold standard. RTSA inverts the ball-and-socket anatomy, medializing and distalizing the center of rotation. This allows the deltoid muscle to become the primary elevator and external rotator of the arm, compensating for the deficient rotator cuff and restoring overhead function and pain relief.Rationale for options:A. Arthroscopic rotator cuff repair with augmentation is typically reserved for large but repairable tears, or when augmentation is needed to reinforce a borderline repair. It is ineffective for massive, irreparable tears with significant fatty infiltration and superior migration.B. Reverse total shoulder arthroplasty (RTSA) is the procedure of choice for massive, irreparable rotator cuff tears with cuff tear arthropathy and pseudoparalysis. It reliably improves pain and function by changing the biomechanics of the shoulder. This is the correct answer.C. Latissimus dorsi transfer is an option for younger, high-demand patients with irreparable posterosuperior rotator cuff tears who do not have significant cuff tear arthropathy, aiming to restore active external rotation and flexion. It's less effective with significant fatty infiltration and superior migration.D. Superior capsular reconstruction is a newer technique for irreparable supraspinatus tears, often using an allograft or autograft, aiming to prevent superior humeral head migration and restore mechanics. While it can be considered, RTSA provides more predictable pain relief and functional improvement in the presence of established cuff tear arthropathy and global dysfunction.E. Debridement and subacromial decompression is a palliative procedure for symptomatic impingement or partial tears but will not restore function in a massive, irreparable tear with superior migration.

Question 1703

Topic: Elbow & Forearm

A 6-year-old male is evaluated for a progressively worsening left upper extremity deformity and functional limitation. He was born with a congenitally short ulna and radial head dislocation. Clinical examination reveals significant forearm bowing, restricted elbow and wrist motion, and instability of the radial head. Radiographs confirm severe ulnar hypoplasia, radial bowing, and a dislocated radial head. Which of the following is the MOST appropriate surgical management strategy for this patient?

. Early radial head excision.
. Ulnar lengthening with bone grafting and radial osteotomy.
. Forearm osteotomy to correct radial bowing and stabilize radial head.
. Distal radioulnar joint (DRUJ) fusion.
. Observation with serial radiographs until skeletal maturity.

Correct Answer & Explanation

. Ulnar lengthening with bone grafting and radial osteotomy.

Explanation

The patient presents with a severe congenital forearm deformity characterized by ulnar hypoplasia, radial bowing, and radial head dislocation, often referred to as congenital radioulnar synostosis or a severe form of radial club hand spectrum with ulnar involvement. This condition causes progressive deformity and functional limitation.The management aims to improve forearm alignment and elbow/wrist function. Early radial head excision is generally contraindicated in skeletally immature patients as it can lead to further deformity (progressive ulnar deviation of the wrist) and loss of distal radial support. DRUJ fusion is not indicated here.For this complex deformity, a multi-stage approach is often required. The primary goals are to restore forearm alignment and length. Ulnar lengthening (often with an external fixator) combined with a radial osteotomy to correct the bowing can improve forearm length and alignment. This may indirectly help in reducing the radial head or improving the conditions for a stable reduction if attempted. Bone grafting may be necessary to augment lengthening.Rationale for options:A. Early radial head excision in a growing child is generally contraindicated because it can lead to progressive proximal migration of the radius and severe radial deviation of the wrist, worsening the deformity and function.B. Ulnar lengthening with bone grafting and radial osteotomy to correct bowing is the most comprehensive and appropriate surgical strategy for this severe congenital forearm deformity. It addresses the fundamental issues of ulnar deficiency and radial bowing, aiming to restore overall forearm length and alignment. This is the correct answer.C. Forearm osteotomy to correct radial bowing and stabilize radial head may be part of the treatment, but without addressing the ulnar hypoplasia (length discrepancy), the deformity will likely recur or persist. Stabilization of the radial head can be very difficult with severe ulnar hypoplasia.D. Distal radioulnar joint (DRUJ) fusion is not indicated as the primary issue is the radial head dislocation and overall forearm length/alignment, not an isolated DRUJ problem.E. Observation is inappropriate for a progressively worsening, severe deformity in a young, growing child, as it will likely lead to irreversible functional loss.

Question 1704

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), which of the following sequences is the standard recommended approach for reconstruction to restore stability?

. MCL repair, coronoid fixation, radial head fixation, LCL repair.
. Radial head fixation, coronoid fixation, LCL repair, MCL repair.
. Coronoid fixation, radial head repair or replacement, LCL repair, and MCL repair only if persistently unstable.
. LCL repair, radial head fixation, coronoid fixation.
. Coronoid fixation, MCL repair, radial head fixation.

Correct Answer & Explanation

. Coronoid fixation, radial head repair or replacement, LCL repair, and MCL repair only if persistently unstable.

Explanation

The classic, systematic approach to a terrible triad injury works from deep to superficial and typically from lateral to medial if a standard lateral approach is used. The sequence is: 1) fix the coronoid (restores the anterior buttress and capsule), 2) repair or replace the radial head (restores anterior and valgus buttress), and 3) repair the lateral collateral ligament (LCL) to the lateral epicondyle (restores posterolateral rotatory stability). The MCL is only addressed if the elbow remains persistently unstable after these primary steps.

Question 1705

Topic: 9. Shoulder and Elbow

While most scapular fractures are treated non-operatively, surgical fixation of a scapular neck fracture is typically indicated when the glenopolar angle (GPA) falls below which of the following thresholds?

. 45 degrees
. 35 degrees
. 22 degrees
. 10 degrees
. 0 degrees

Correct Answer & Explanation

. 22 degrees

Explanation

A normal glenopolar angle is between 30 and 45 degrees. A severely decreased glenopolar angle of less than 20-22 degrees alters glenohumeral biomechanics significantly and is a standard indication for operative fixation.

Question 1706

Topic: Shoulder Arthroplasty & Arthritis

A 75-year-old female undergoes a reverse total shoulder arthroplasty (RTSA) for rotator cuff tear arthropathy. Six months postoperatively, she presents with persistent shoulder pain, weakness, and a positive 'drop arm' sign. X-rays show no signs of loosening or infection. Physical examination reveals impaired active external rotation. What is the MOST likely cause of her persistent symptoms and functional deficit?

. Acromial stress fracture
. Deltoid dysfunction
. Baseplate loosening
. Axillary nerve neuropraxia
. Impingement of the greater tuberosity on the inferior glenosphere

Correct Answer & Explanation

. Deltoid dysfunction

Explanation

The combination of persistent pain, weakness, a positive 'drop arm' sign, and impaired active external rotation after RTSA, with normal X-rays, strongly points towards deltoid dysfunction. The deltoid muscle is the primary motor for abduction and elevation after RTSA, and its integrity and function are critical. Dysfunction can arise from fatty infiltration, scarring, denervation (e.g., axillary nerve injury), or disinsertion from the acromion. While acromial stress fracture (option A) causes pain and weakness, the 'drop arm' sign specifically points to a functional issue with the deltoid. Baseplate loosening (option C) would typically be evident on X-rays and cause more diffuse pain. Axillary nerve neuropraxia (option D) would typically manifest earlier post-operatively and also affect deltoid function, but 'deltoid dysfunction' encompasses a broader range of etiologies leading to the observed clinical picture. Impingement (option E) typically restricts motion rather than causing isolated weakness and a drop arm sign.

Question 1707

Topic: 9. Shoulder and Elbow

A 68-year-old female presents with severe, constant left shoulder pain, significantly worse at night, and progressive loss of both active and passive range of motion over the past 6 months. She has no history of trauma. On examination, external rotation is severely limited and painful, and she exhibits global stiffness. Radiographs show mild glenohumeral osteoarthritic changes. What is the MOST likely diagnosis?

. Rotator cuff tendinopathy
. Glenohumeral osteoarthritis
. Adhesive capsulitis (Frozen Shoulder)
. Acute calcific tendinitis
. Subacromial impingement syndrome

Correct Answer & Explanation

. Adhesive capsulitis (Frozen Shoulder)

Explanation

The key features pointing to adhesive capsulitis are the insidious onset of global stiffness, severe pain, and particularly the loss of BOTH active and passive range of motion (especially external rotation). While glenohumeral osteoarthritis can cause stiffness and pain, the primary feature is usually pain and crepitus, and limitation of motion may not be as globally restricted or as progressive in all planes as seen in frozen shoulder. Rotator cuff tendinopathy primarily causes pain with active movement and weakness, often with preserved passive motion. Acute calcific tendinitis presents with sudden, excruciating pain, not progressive stiffness. Subacromial impingement typically involves pain with overhead activities and a painful arc, but generally preserves passive motion.

Question 1708

Topic: 9. Shoulder and Elbow

A 40-year-old male presents with chronic insidious-onset lateral elbow pain, exacerbated by gripping and lifting. Physical examination reveals tenderness over the lateral epicondyle, pain with resisted wrist extension and forearm supination, and a negative neurological examination. Which of the following is the MOST appropriate initial conservative management strategy?

. Corticosteroid injection into the extensor carpi radialis brevis origin
. Surgical debridement of the extensor origin
. Activity modification, NSAIDs, and physical therapy focused on eccentric strengthening
. Immobilization in a long arm cast for 6 weeks
. Platelet-rich plasma (PRP) injection

Correct Answer & Explanation

. Activity modification, NSAIDs, and physical therapy focused on eccentric strengthening

Explanation

The patient's symptoms are classic for lateral epicondylitis (tennis elbow). The vast majority (90-95%) of cases resolve with conservative management. The initial approach should include activity modification (avoiding aggravating activities), NSAIDs for pain and inflammation, and a structured physical therapy program emphasizing eccentric strengthening of the wrist extensors. While corticosteroid injections can provide short-term pain relief, they may be detrimental in the long term by weakening the tendon. PRP injections are considered for refractory cases. Surgical debridement is reserved for failed conservative management (typically >6-12 months). Immobilization is generally not indicated and can lead to stiffness.

Question 1709

Topic: 9. Shoulder and Elbow

A 28-year-old competitive weightlifter presents with acute right shoulder pain, swelling, and ecchymosis in the axilla and upper arm after attempting a maximal bench press. He reports an audible 'pop' and now has a visible 'Popeye' deformity in his upper arm. He has weakness with resisted forearm supination. Which structure is MOST likely injured?

. Long head of biceps tendon at the glenoid origin
. Distal biceps tendon at the radial tuberosity
. Pectoralis major tendon at the humeral insertion
. Rotator cuff (supraspinatus) tendon
. Triceps tendon at the olecranon

Correct Answer & Explanation

. Distal biceps tendon at the radial tuberosity

Explanation

The clinical picture of acute pain, swelling, ecchymosis in the upper arm/axilla after a powerful lifting maneuver (bench press), an audible 'pop', a 'Popeye' deformity (proximal migration of the muscle belly), and weakness with resisted forearm supination is classic for a complete rupture of the distal biceps tendon from its insertion on the radial tuberosity. A long head of biceps rupture typically causes a 'Popeye' deformity in the mid-arm, but usually results in less functional deficit for elbow flexion and supination as the short head compensates, and the ecchymosis is typically more localized to the anterior shoulder. Pectoralis major tears cause anterior chest wall and axillary pain/ecchymosis, and weakness in adduction/internal rotation. Rotator cuff tears affect abduction/rotation. Triceps tears affect elbow extension.

Question 1710

Topic: 9. Shoulder and Elbow

A 60-year-old female with a history of rheumatoid arthritis presents with chronic shoulder pain, crepitus, and limited range of motion, particularly internal rotation and adduction. Radiographs show significant glenohumeral joint space narrowing, humeral head superior migration, and erosion of the glenoid and acromion. She has intact rotator cuff function on ultrasound. What is the MOST appropriate surgical treatment option?

. Hemiarthroplasty
. Anatomic total shoulder arthroplasty (TSA)
. Reverse total shoulder arthroplasty (rTSA)
. Shoulder arthrodesis
. Arthroscopic debridement and synovectomy

Correct Answer & Explanation

. Anatomic total shoulder arthroplasty (TSA)

Explanation

The patient has significant glenohumeral arthritis, likely rheumatoid given her history, with glenoid erosion and superior migration of the humeral head. However, the key information is 'intact rotator cuff function'. In the setting of severe glenohumeral arthritis and afunctionalrotator cuff, anatomic total shoulder arthroplasty (TSA) is the gold standard for pain relief and improved function. Hemiarthroplasty is considered when the glenoid is relatively healthy or in younger, more active patients. Reverse TSA is indicated when the rotator cuff is deficient or irreparable. Shoulder arthrodesis is a salvage procedure for failed arthroplasty or severe deltoid/rotator cuff deficiency. Arthroscopic debridement is for less severe arthritis or as a temporary measure.

Question 1711

Topic: 9. Shoulder and Elbow

A 40-year-old male undergoes arthroscopic rotator cuff repair. Post-operatively, he complains of persistent numbness along the lateral aspect of his shoulder and upper arm. On examination, he has diminished sensation in the 'regimental badge' area. What nerve is MOST likely injured?

. Suprascapular nerve
. Axillary nerve
. Musculocutaneous nerve
. Long thoracic nerve
. Radial nerve

Correct Answer & Explanation

. Axillary nerve

Explanation

The 'regimental badge' area is the classic dermatome supplied by the axillary nerve (C5-C6). This nerve is vulnerable during shoulder surgery, particularly during rotator cuff repair, labral repair, or glenohumeral arthroplasty due to its course around the surgical neck of the humerus and close proximity to the inferior capsule. Suprascapular nerve injury would affect sensation in the shoulder joint and cause atrophy of supraspinatus/infraspinatus. Musculocutaneous nerve affects biceps function and lateral forearm sensation. Long thoracic nerve injury causes scapular winging. Radial nerve injury affects posterior arm/forearm sensation and wrist/finger extensors.

Question 1712

Topic: 9. Shoulder and Elbow

A 65-year-old active female presents with significant glenohumeral osteoarthritis. She has intact rotator cuff function and no history of shoulder instability. Her pain is refractory to conservative measures, and she desires surgical intervention. What is the MOST appropriate surgical treatment?

. Shoulder hemiarthroplasty
. Total shoulder arthroplasty (TSA)
. Reverse total shoulder arthroplasty (rTSA)
. Shoulder arthrodesis
. Arthroscopic debridement

Correct Answer & Explanation

. Total shoulder arthroplasty (TSA)

Explanation

For severe glenohumeral osteoarthritis with intact rotator cuff function, anatomic total shoulder arthroplasty (TSA) is the gold standard. It involves replacing both the humeral head and the glenoid component, providing excellent pain relief and functional improvement. Hemiarthroplasty replaces only the humeral head and is typically reserved for cases with a healthy glenoid, significant rotator cuff deficiency (but this patient has intact cuff), or younger, more active patients where glenoid wear is less of a concern. Reverse TSA is for rotator cuff tear arthropathy or failed TSA with cuff deficiency. Arthrodesis is a salvage procedure. Arthroscopic debridement is for less severe arthritis or as a temporizing measure.

Question 1713

Topic: 9. Shoulder and Elbow

A 30-year-old male sustains a severe traction injury to his right arm after being pulled by a machine. He presents with a flail right arm, absent reflexes, and anesthesia in the entire limb. A Pancoast tumor has been ruled out. Which specific part of the brachial plexus is MOST likely injured?

. Upper trunk (C5-C6)
. Middle trunk (C7)
. Lower trunk (C8-T1)
. All five nerve roots (C5-T1)
. Isolated nerve to serratus anterior

Correct Answer & Explanation

. All five nerve roots (C5-T1)

Explanation

A flail arm with anesthesia in the entire limb after a severe traction injury indicates a complete brachial plexus avulsion, involving all five nerve roots (C5-T1). Upper trunk injuries (Erb's palsy) affect C5-C6 (shoulder abduction, external rotation, elbow flexion). Lower trunk injuries (Klumpke's palsy) affect C8-T1 (intrinsic hand muscles, forearm flexion/extension to some extent). A middle trunk injury is rare in isolation. Isolated nerve to serratus anterior (long thoracic nerve) causes scapular winging but not a flail arm. The description of 'absent reflexes' and 'anesthesia in the entire limb' strongly suggests a pan-plexus injury.

Question 1714

Topic: Shoulder Pathology

A 48-year-old carpenter presents with chronic aching pain and weakness in his right shoulder, particularly with overhead work. On examination, he has atrophy of the supraspinatus and infraspinatus muscles, and weakness with resisted external rotation. Sensation is intact. EMG/NCS confirm denervation of these muscles. What is the MOST likely cause of his symptoms?

. Axillary nerve entrapment
. Suprascapular nerve entrapment
. Long thoracic nerve palsy
. Spinal accessory nerve injury
. Cervical radiculopathy C5-C6

Correct Answer & Explanation

. Suprascapular nerve entrapment

Explanation

Atrophy of the supraspinatus and infraspinatus muscles with weakness in external rotation and abduction, but intact sensation, is the classic presentation of suprascapular nerve entrapment. Common sites of entrapment include the suprascapular notch or the spinoglenoid notch. Axillary nerve entrapment would primarily affect the deltoid and teres minor, with sensory loss in the 'regimental badge' area. Long thoracic nerve palsy causes scapular winging (serratus anterior). Spinal accessory nerve injury affects the trapezius, causing shoulder droop and difficulty with arm elevation. Cervical radiculopathy C5-C6 can mimic some symptoms but would typically have dermatomal sensory changes and possibly reflex changes, and often other muscle involvement.

Question 1715

Topic: 9. Shoulder and Elbow

A 75-year-old female presents with a fall onto her left shoulder. Radiographs show a 4-part displaced proximal humerus fracture. She has a history of severe osteoporosis and multiple comorbidities, making a lengthy surgery high risk. What is the MOST appropriate management strategy?

. Open reduction and internal fixation (ORIF)
. Hemiarthroplasty
. Reverse total shoulder arthroplasty (rTSA)
. Non-operative management with sling immobilization
. Shoulder arthrodesis

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (rTSA)

Explanation

In an elderly patient with a displaced 4-part proximal humerus fracture and comorbidities, non-operative management with a sling is a viable option for those who are frail and have low functional demands, accepting a suboptimal outcome for fracture union and range of motion. While hemiarthroplasty was historically considered, reverse total shoulder arthroplasty (rTSA) has gained favor for displaced 3- and 4-part proximal humerus fractures in elderly, osteoporotic patients, especially those with poor bone quality or who are non-compliant, as it provides more reliable pain relief and functional outcomes than hemiarthroplasty or ORIF in this demographic. ORIF in osteoporotic bone is prone to fixation failure. Arthrodesis is a salvage procedure. The question implies the need for a pragmatic solution considering comorbidities. Given the options, non-operative management is a reasonable choice for very frail patients, but rTSA offers a better functional outcome for suitable candidates.

Question 1716

Topic: 9. Shoulder and Elbow

A 38-year-old male sustains a fall onto his elbow while snowboarding. He presents with severe elbow pain, swelling, and a visible deformity. Radiographs show a posterior dislocation of the ulna and radius, a comminuted radial head fracture, and a fracture of the coronoid process. What specific surgical fixation is MOST critical to restore elbow stability in this 'terrible triad' injury?

. Radial head replacement
. Ulnar collateral ligament repair
. Lateral collateral ligament repair
. Coronoid process fixation
. Olecranon osteotomy for exposure

Correct Answer & Explanation

. Coronoid process fixation

Explanation

The 'terrible triad' of the elbow (elbow dislocation, radial head fracture, coronoid fracture) is a complex and highly unstable injury. To restore stability, all three components need to be addressed. While radial head replacement is crucial for restoring the radial column and ulnar collateral ligament (UCL) repair for medial stability, the MOST critical structure for initial stability after reduction and repair of the coronoid and radial head is often fixation of the coronoid process. The coronoid acts as an anterior buttress to the trochlea, preventing posterior subluxation/dislocation. Without adequate coronoid fixation, the elbow remains inherently unstable, especially after reduction. Ulnar collateral ligament repair is also important, but typically follows bony fixation. Lateral collateral ligament repair is less commonly the primary stabilizer in this posterior dislocation setting. Olecranon osteotomy is an approach, not a fixation.

Question 1717

Topic: 9. Shoulder and Elbow

A 50-year-old male presents with chronic insidious onset medial elbow pain, exacerbated by carrying heavy objects and throwing. He denies neurological symptoms. On examination, there is tenderness over the medial epicondyle, and pain with resisted wrist flexion and pronation. Which of the following tendons is MOST commonly implicated in this condition?

. Extensor carpi radialis brevis
. Flexor carpi radialis
. Triceps brachii
. Biceps brachii
. Pronator teres

Correct Answer & Explanation

. Flexor carpi radialis

Explanation

The symptoms described – chronic medial elbow pain, tenderness over the medial epicondyle, and pain with resisted wrist flexion and pronation – are classic for medial epicondylitis, also known as 'golfer's elbow' or 'thrower's elbow'. This condition involves inflammation and degeneration at the common flexor-pronator origin. The flexor carpi radialis (FCR) tendon is the most commonly affected tendon in medial epicondylitis. The extensor carpi radialis brevis is implicated in lateral epicondylitis. Triceps and biceps are unrelated. Pronator teres can contribute to pain, but FCR is typically the primary tendon involved.

Question 1718

Topic: Shoulder Arthroplasty & Arthritis

A 65-year-old female presents with chronic shoulder pain, night pain, and weakness in elevation and external rotation. She reports difficulty lifting her arm above 90 degrees. MRI shows a massive, irreparable rotator cuff tear involving the supraspinatus, infraspinatus, and subscapularis, with significant humeral head superior migration (rotator cuff tear arthropathy). Which of the following procedures is MOST appropriate to restore function and relieve pain?

. Arthroscopic debridement and partial repair
. Tendon transfer (e.g., latissimus dorsi)
. Superior capsular reconstruction
. Reverse total shoulder arthroplasty (rTSA)
. Acromioplasty and debridement

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (rTSA)

Explanation

The patient has a massive, irreparable rotator cuff tear leading to rotator cuff tear arthropathy (hamstring sign). In this scenario, with significant superior migration of the humeral head and compromised active elevation, a reverse total shoulder arthroplasty (rTSA) is the procedure of choice. It medializes and distalizes the center of rotation, allowing the deltoid to function as the primary abductor and elevator, thereby compensating for the deficient rotator cuff. Arthroscopic debridement, partial repair, or acromioplasty are inadequate for this condition. Tendon transfers or superior capsular reconstruction are options for massive but reparable or potentially reparable tears, or when rTSA is contraindicated, but rTSA typically yields the most predictable and superior results for established rotator cuff tear arthropathy.

Question 1719

Topic: 9. Shoulder and Elbow

A 6-year-old child presents with elbow pain and refusal to use the arm after being swung by the hand. The elbow is held in slight flexion and pronation. On examination, there is no swelling or ecchymosis, and no tenderness over the bony prominences. Passive supination is painful. What is the MOST likely diagnosis?

. Supracondylar humerus fracture
. Radial head fracture
. Olecranon fracture
. Nursemaid's elbow (radial head subluxation)
. Lateral epicondylitis

Correct Answer & Explanation

. Nursemaid's elbow (radial head subluxation)

Explanation

This classic presentation of a child being swung by the hand, presenting with elbow pain, refusal to use the arm (pseudoparalysis), holding the arm in flexion and pronation, and pain with passive supination without bony tenderness, is characteristic of 'Nursemaid's elbow' (radial head subluxation). This occurs when the annular ligament slips over the radial head. Supracondylar, radial head, and olecranon fractures would typically present with swelling, ecchymosis, and localized bony tenderness. Lateral epicondylitis is an overuse injury not seen in this age group from acute trauma.

Question 1720

Topic: 9. Shoulder and Elbow

A 45-year-old female presents with a new onset of severe, aching pain in her right anterior shoulder and proximal arm. She reports no trauma, but describes the pain as having started abruptly a few days ago. On examination, the area around the biceps groove is exquisitely tender, and she has pain with resisted shoulder flexion and forearm supination. Radiographs are normal. What is the MOST likely diagnosis?

. Rotator cuff tendinopathy
. Biceps tendinopathy (long head)
. Subacromial impingement syndrome
. Glenohumeral osteoarthritis
. Calcific tendinitis

Correct Answer & Explanation

. Biceps tendinopathy (long head)

Explanation

The described symptoms of acute onset anterior shoulder/proximal arm pain, tenderness in the biceps groove, and pain with resisted shoulder flexion and forearm supination are highly indicative of biceps tendinopathy involving the long head of the biceps. While biceps tendinopathy often coexists with rotator cuff pathology or impingement, the primary symptoms described directly implicate the biceps tendon. Rotator cuff tendinopathy typically presents with weakness and pain in specific directions (abduction, rotation). Subacromial impingement causes pain with overhead activities. Glenohumeral osteoarthritis causes diffuse pain and crepitus. Calcific tendinitis typically causes sudden, excruciating pain with restricted range of motion.

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