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9. Shoulder and Elbow MCQs

Practice Set 87 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 1721

Topic: 9. Shoulder and Elbow

A 25-year-old male sustains a fall directly onto his shoulder during a basketball game. He presents with severe pain and inability to abduct his arm. On examination, the shoulder has lost its rounded contour and there is a palpable void beneath the acromion. Which of the following is the MOST important step PRIOR to attempting reduction?

. Administer intravenous analgesia
. Obtain an MRI scan
. Perform a full neurovascular assessment
. Apply ice to reduce swelling
. Consult orthopedic surgeon for immediate open reduction

Correct Answer & Explanation

. Perform a full neurovascular assessment

Explanation

This patient's presentation is classic for an anterior glenohumeral dislocation. Prior to any attempt at reduction, a thorough neurovascular assessment is paramount. The axillary nerve is the most commonly injured nerve (up to 40% of cases), and brachial plexus or vascular injuries can occur. Documenting baseline neurological and vascular status allows for identification of iatrogenic injury during reduction or confirms pre-existing deficits. While analgesia is important for patient comfort and muscle relaxation, it does not supersede the neurovascular check. MRI is not needed acutely. Ice is secondary. Open reduction is rare for acute anterior dislocations unless irreducible.

Question 1722

Topic: 9. Shoulder and Elbow

A 50-year-old male presents with chronic pain and stiffness in his right elbow after sustaining an elbow dislocation 6 months ago, which was treated non-operatively. He has a flexion contracture of 45 degrees and lacks 30 degrees of full extension. Radiographs show significant heterotopic ossification around the elbow joint. What is the MOST appropriate management?

. Intensified physical therapy and stretching exercises
. Manipulation under anesthesia (MUA)
. Surgical excision of heterotopic ossification and capsular release
. Serial casting to improve extension
. Corticosteroid injection into the joint

Correct Answer & Explanation

. Surgical excision of heterotopic ossification and capsular release

Explanation

The patient has a significant post-traumatic elbow contracture with heterotopic ossification (HO). Once HO is mature (typically 6 months post-injury, indicated by 6 months of symptoms), and non-operative measures have failed, surgical excision of the HO and capsular release is the most effective treatment for restoring elbow range of motion. Intensified physical therapy alone is unlikely to overcome significant HO. Manipulation under anesthesia carries a risk of fracture or re-ossification and is generally not recommended in the presence of extensive HO. Serial casting may be used for milder contractures or as an adjunct. Corticosteroid injections are not indicated for HO.

Question 1723

Topic: 9. Shoulder and Elbow

A 45-year-old male presents with persistent pain and deformity after sustaining a displaced midshaft clavicle fracture treated non-operatively 1 year ago. Radiographs show a sclerotic non-union with significant shortening (2.5 cm). He is unable to perform overhead activities due to pain and weakness. What is the MOST appropriate management?

. Reassurance and continued conservative management
. Electrical stimulation to promote healing
. Open reduction and internal fixation with bone grafting
. Excision of the non-union fragment
. Shoulder arthrodesis

Correct Answer & Explanation

. Open reduction and internal fixation with bone grafting

Explanation

Symptomatic displaced clavicle midshaft non-unions, especially with significant shortening and functional impairment, are best treated surgically with open reduction and internal fixation (ORIF) and often require bone grafting (autograft or allograft) to stimulate healing. Reassurance or electrical stimulation is unlikely to promote healing in a sclerotic non-union with significant displacement. Excision of the fragment would further compromise shoulder girdle integrity. Shoulder arthrodesis is a salvage procedure for glenohumeral joint pathology, not clavicle non-union.

Question 1724

Topic: 9. Shoulder and Elbow

A 60-year-old male with chronic shoulder pain and a massive rotator cuff tear has developed significant glenohumeral osteoarthritis and superior migration of the humeral head. He has minimal active elevation and persistent pain refractory to all conservative measures. He is otherwise healthy. What is the MOST appropriate definitive surgical treatment?

. Arthroscopic debridement and partial repair
. Open rotator cuff repair with augmentation
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Shoulder arthrodesis

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

This patient presents with rotator cuff tear arthropathy (massive irreparable cuff tear + glenohumeral osteoarthritis + superior humeral head migration). The gold standard for symptomatic rotator cuff tear arthropathy in a suitable patient is a reverse total shoulder arthroplasty (rTSA). rTSA re-establishes the center of rotation and allows the deltoid to effectively abduct and elevate the arm, providing significant pain relief and functional improvement. The other options are inadequate for this advanced pathology. Arthroscopic debridement, open repair, or tendon transfers are for lesser degrees of cuff pathology or when rTSA is contraindicated. Arthrodesis is a salvage procedure.

Question 1725

Topic: Shoulder Pathology

A 35-year-old male presents with a visible 'winging' of his right scapula, particularly when he pushes against a wall. He reports difficulty with overhead activities. What nerve is MOST likely injured?

. Axillary nerve
. Suprascapular nerve
. Long thoracic nerve
. Spinal accessory nerve
. Dorsal scapular nerve

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Winged scapula, particularly with pushing against a wall (scapular protraction), is a classic sign of long thoracic nerve palsy, which innervates the serratus anterior muscle. The serratus anterior is responsible for holding the scapula against the thoracic wall and for upward rotation during abduction. Axillary nerve injury affects deltoid and teres minor. Suprascapular nerve affects supraspinatus and infraspinatus. Spinal accessory nerve affects the trapezius. Dorsal scapular nerve affects rhomboids and levator scapulae.

Question 1726

Topic: Shoulder Pathology

A 40-year-old female presents with a progressive inability to elevate her arm overhead. On examination, she has severe atrophy of the deltoid muscle, and sensory loss over the lateral aspect of the shoulder (regimental badge area). What is the MOST likely nerve injury?

. Long thoracic nerve
. Spinal accessory nerve
. Suprascapular nerve
. Axillary nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Axillary nerve

Explanation

Atrophy of the deltoid and sensory loss over the 'regimental badge' area (lateral aspect of the shoulder) are the hallmark signs of axillary nerve injury. The axillary nerve innervates the deltoid and teres minor muscles and provides sensation to the inferior lateral shoulder. Long thoracic nerve injury causes scapular winging. Spinal accessory nerve injury affects the trapezius. Suprascapular nerve injury affects supraspinatus and infraspinatus. Musculocutaneous nerve injury affects biceps and brachialis, and sensation to the lateral forearm.

Question 1727

Topic: 9. Shoulder and Elbow

A 40-year-old female presents with chronic, diffuse pain around her elbow, which she describes as an 'aching' sensation, without specific tenderness. She has limited extension and flexion, but no instability. Radiographs show early degenerative changes with osteophytes. What is the MOST appropriate initial conservative management?

. Diagnostic arthroscopy
. Surgical osteophyte excision and debridement
. Activity modification, NSAIDs, and physical therapy focused on range of motion and strengthening
. Immobilization in a long arm cast
. Corticosteroid injections into the joint

Correct Answer & Explanation

. Activity modification, NSAIDs, and physical therapy focused on range of motion and strengthening

Explanation

The patient's presentation of chronic diffuse elbow pain, limited range of motion, and early degenerative changes suggests elbow osteoarthritis. The initial management for elbow osteoarthritis, like most degenerative conditions, is conservative. This includes activity modification, NSAIDs for pain and inflammation, and a physical therapy program focused on improving range of motion and maintaining strength. Surgical interventions (arthroscopy, osteophyte excision) are reserved for cases that fail conservative management. Immobilization is generally detrimental, leading to stiffness. Corticosteroid injections may provide temporary relief but are not a long-term solution and have potential risks.

Question 1728

Topic: Elbow & Forearm

A 28-year-old male presents with persistent elbow pain after a fall, particularly with forearm rotation and direct compression of the radial head. Radiographs show a Mason Type II radial head fracture (non-displaced, involving 30% of the articular surface). There is no mechanical block to motion. What is the MOST appropriate initial management?

. Open reduction and internal fixation
. Radial head excision
. Immobilization in a long arm cast for 6 weeks
. Sling immobilization for comfort with early active range of motion
. Radial head replacement

Correct Answer & Explanation

. Sling immobilization for comfort with early active range of motion

Explanation

A Mason Type II radial head fracture that is non-displaced and involves less than 30% of the articular surface without a mechanical block is typically managed non-operatively. The mainstay of treatment is sling immobilization for comfort, followed by early active range of motion exercises to prevent stiffness. Open reduction and internal fixation is for displaced or mechanically blocking fractures. Radial head excision is generally reserved for comminuted fractures not amenable to fixation, particularly in older individuals. Long arm cast immobilization can lead to significant stiffness and is generally avoided. Radial head replacement is for severely comminuted or unreconstructable fractures, especially in unstable elbows (e.g., terrible triad).

Question 1729

Topic: 9. Shoulder and Elbow

A 30-year-old female presents with an anterior shoulder dislocation. After successful closed reduction, which of the following is the MOST appropriate duration for initial immobilization in a sling for a first-time traumatic dislocation to minimize the risk of recurrence?

. No immobilization; immediate range of motion
. 1 week
. 3 weeks
. 6 weeks
. 12 weeks

Correct Answer & Explanation

. 3 weeks

Explanation

For a first-time traumatic anterior shoulder dislocation in a young, active individual, initial immobilization in a sling for approximately 3 weeks is a common recommendation. This allows for initial soft tissue healing (e.g., Bankart lesion) and can reduce the risk of early recurrence compared to shorter immobilization periods. However, prolonged immobilization (e.g., 6+ weeks) offers no additional benefit in reducing recurrence and increases the risk of stiffness, particularly in older patients. For older patients, early mobilization is favored to prevent frozen shoulder. The specific position of immobilization (internal vs. external rotation) is also debated, but a conventional sling holds the arm in internal rotation.

Question 1730

Topic: 9. Shoulder and Elbow

A 55-year-old male presents with chronic shoulder pain. He has a history of multiple previous surgeries for rotator cuff tears and impingement. On examination, he has significant weakness in external rotation and abduction, a positive lag sign for external rotation, and significant atrophy of the infraspinatus and supraspinatus. MRI shows a massive, irreparable posterior-superior rotator cuff tear. He has no significant glenohumeral arthritis. Which of the following is the MOST appropriate treatment option to restore active external rotation and improve function?

. Subacromial decompression and biceps tenodesis
. Reverse total shoulder arthroplasty
. Latissimus dorsi tendon transfer
. Superior capsular reconstruction
. Shoulder arthrodesis

Correct Answer & Explanation

. Latissimus dorsi tendon transfer

Explanation

This patient has a massive, irreparable postero-superior rotator cuff tear without significant glenohumeral arthritis. In this scenario, a latissimus dorsi tendon transfer is a recognized and effective procedure to improve active external rotation and overall function. The latissimus dorsi is transferred to the greater tuberosity to augment external rotation and depression of the humeral head. Reverse total shoulder arthroplasty is indicated when there is rotator cuff tear arthropathy (i.e., significant arthritis). Superior capsular reconstruction is for superior migration of the humeral head in an irreparable tear. Subacromial decompression and biceps tenodesis are insufficient. Arthrodesis is a salvage procedure.

Question 1731

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with a spontaneous, acute rupture of her right pectoralis major tendon while gardening. On examination, she has ecchymosis in the anterior axilla and upper arm, and a visible defect in the anterior axillary fold. She has weakness with resisted adduction and internal rotation of the arm. What is the MOST appropriate management?

. Non-operative management with sling and physical therapy
. Surgical repair of the pectoralis major tendon
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Shoulder arthrodesis

Correct Answer & Explanation

. Surgical repair of the pectoralis major tendon

Explanation

Acute, complete tears of the pectoralis major tendon, especially in active individuals, are generally indications for surgical repair to restore strength in adduction and internal rotation and improve cosmesis. While the injury was 'spontaneous' in this patient, it implies a true rupture requiring surgical intervention to regain function. Non-operative management leads to persistent weakness and deformity. Latissimus dorsi transfer is for irreparable rotator cuff tears. Reverse TSA and arthrodesis are for glenohumeral joint pathology.

Question 1732

Topic: 9. Shoulder and Elbow

A 40-year-old male presents with chronic shoulder pain, worse with overhead activities. He has a positive Neer and Hawkins impingement sign. Radiographs are normal. MRI shows no rotator cuff tear but significant subacromial bursitis. Which of the following conditions is MOST likely responsible for his symptoms?

. Frozen shoulder
. Calcific tendinitis
. Subacromial impingement syndrome
. Glenohumeral osteoarthritis
. AC joint arthritis

Correct Answer & Explanation

. Subacromial impingement syndrome

Explanation

The patient's symptoms (chronic pain, worse overhead, positive impingement signs, subacromial bursitis on MRI) are classic for subacromial impingement syndrome. This is a common diagnosis where the rotator cuff tendons and subacromial bursa are compressed between the humeral head and the undersurface of the acromion. Frozen shoulder presents with global stiffness. Calcific tendinitis causes acute, severe pain with a calcific deposit. Glenohumeral osteoarthritis causes joint line pain and crepitus. AC joint arthritis causes pain localized to the AC joint, often worse with cross-body adduction.

Question 1733

Topic: 9. Shoulder and Elbow

A 65-year-old female presents with chronic shoulder pain and inability to actively abduct her arm beyond 70 degrees. She has significant atrophy of the supraspinatus and infraspinatus. MRI shows a massive, irreparable rotator cuff tear and severe superior migration of the humeral head. Her pain is severe and refractory to conservative treatment. She is not a candidate for a reverse total shoulder arthroplasty due to medical comorbidities. What is the MOST appropriate salvage procedure to provide pain relief and improve function?

. Subacromial decompression and debridement
. Latissimus dorsi tendon transfer
. Superior capsular reconstruction
. Shoulder arthrodesis
. Hemiarthroplasty

Correct Answer & Explanation

. Shoulder arthrodesis

Explanation

In a patient with a massive, irreparable rotator cuff tear, severe superior migration of the humeral head (rotator cuff tear arthropathy), severe pain, and who is not a candidate for rTSA due to comorbidities, shoulder arthrodesis is a definitive salvage procedure. While it sacrifices motion, it provides excellent pain relief and a stable platform for a functional range of motion (typically 30-40 degrees of abduction and flexion) by relying on scapulothoracic motion. Subacromial decompression/debridement and hemiarthroplasty are unlikely to provide lasting relief or function. Latissimus dorsi transfer and superior capsular reconstruction are typically for patients where rTSA is not indicated but some active motion is desired, and the patient's condition allows for a more involved procedure. Given the 'salvage' nature and comorbidities, arthrodesis is a strong consideration.

Question 1734

Topic: Elbow & Forearm

A 35-year-old male presents with persistent elbow pain and a sensation of clunking after a fall onto an outstretched hand. He has pain with forearm supination and extension of the elbow, and a positive pivot shift test. What is the MOST likely pathology?

. Medial epicondylitis
. Radial head fracture
. Posterolateral rotatory instability (PLRI)
. Ulnar collateral ligament (UCL) injury
. Olecranon bursitis

Correct Answer & Explanation

. Posterolateral rotatory instability (PLRI)

Explanation

The symptoms of elbow pain, a sensation of clunking, pain with forearm supination and extension, and a positive pivot shift test are highly characteristic of posterolateral rotatory instability (PLRI) of the elbow. This injury results from insufficiency of the lateral ulnar collateral ligament (LUCL) complex, allowing the radial head to subluxate posteriorly and externally rotate relative to the ulna. Medial epicondylitis causes medial pain. Radial head fracture would have localized tenderness. UCL injury would cause medial instability. Olecranon bursitis is superficial swelling and inflammation.

Question 1735

Topic: 9. Shoulder and Elbow

A 60-year-old patient presents with chronic pain and stiffness in their elbow. Radiographs show significant joint space narrowing, osteophyte formation, and loose bodies. The primary goal of surgical management for this patient with elbow osteoarthritis is to:

. Achieve full range of motion immediately post-op
. Replace the entire elbow joint (total elbow arthroplasty)
. Debride osteophytes, remove loose bodies, and improve range of motion while preserving stability
. Arthrodese the elbow joint
. Perform a radial head excision only

Correct Answer & Explanation

. Debride osteophytes, remove loose bodies, and improve range of motion while preserving stability

Explanation

For symptomatic elbow osteoarthritis, particularly with mechanical symptoms (locking, catching) due to osteophytes and loose bodies, the primary surgical goal is to debride the osteophytes, remove loose bodies, and perform a capsular release to improve the range of motion while preserving the inherent stability of the joint. Total elbow arthroplasty is reserved for severe, disabling arthritis, often in older, low-demand patients, or those with inflammatory arthritis. Arthrodesis leads to severe functional deficits. Radial head excision is for radial head fractures or isolated radiocapitellar arthritis. Full range of motion is rarely achievable or necessary for a good outcome; a functional arc of motion (30-130 degrees) is usually the goal.

Question 1736

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old female undergoes a reverse total shoulder arthroplasty for rotator cuff tear arthropathy. Postoperatively, what glenosphere positioning modification most effectively decreases the risk of scapular notching?

. Superior translation and superior tilt
. Superior translation and inferior tilt
. Inferior translation and inferior tilt
. Medialization and superior tilt
. Medialization and neutral tilt

Correct Answer & Explanation

. Superior translation and inferior tilt

Explanation

Scapular notching is a common complication of reverse total shoulder arthroplasty. Placing the glenosphere with inferior translation and inferior tilt helps clear the inferior scapular neck and prevents mechanical impingement by the humeral cup.

Question 1737

Topic: 9. Shoulder and Elbow

A 45-year-old male sustains a 'terrible triad' injury of the elbow. During surgical reconstruction, what is the most appropriate sequence of repair to restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad injury works from deep to superficial: fixation or replacement of the coronoid, followed by the radial head, and finally repair of the lateral collateral ligament (LCL) complex.

Question 1738

Topic: Shoulder Pathology

A 28-year-old male presents with a dull ache in his right shoulder and difficulty lifting his arm above shoulder level after blunt trauma to the posterior neck. Examination reveals lateral winging of the scapula. Which nerve is most likely injured?

. Long thoracic nerve
. Spinal accessory nerve
. Suprascapular nerve
. Axillary nerve
. Dorsal scapular nerve

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Lateral winging of the scapula is caused by trapezius muscle paralysis due to a spinal accessory nerve injury. Medial winging, in contrast, is associated with long thoracic nerve palsy affecting the serratus anterior.

Question 1739

Topic: 9. Shoulder and Elbow

A 42-year-old male undergoes a two-incision repair for an acute distal biceps tendon rupture. Postoperatively, he has limited forearm rotation but full elbow flexion and extension. Radiographs show abnormal bone formation between the radius and ulna. What is the most common cause of this specific complication?

. Posterior interosseous nerve palsy
. Heterotopic ossification due to subperiosteal dissection of the ulna
. Over-tensioning of the biceps tendon
. Medial antebrachial cutaneous nerve neuroma
. Radiohumeral joint arthritis

Correct Answer & Explanation

. Heterotopic ossification due to subperiosteal dissection of the ulna

Explanation

The two-incision technique for distal biceps repair carries a higher risk of radioulnar synostosis (heterotopic ossification) compared to the single-incision approach. This is primarily due to subperiosteal exposure and bleeding involving the ulnar footprint.

Question 1740

Topic: 9. Shoulder and Elbow

A 52-year-old male presents with severe glenohumeral osteoarthritis. A preoperative axial CT scan shows a biconcave glenoid with 25 degrees of retroversion and posterior subluxation of the humeral head. According to the Walch classification, what type of glenoid morphology is this?

. Type A1
. Type A2
. Type B1
. Type B2
. Type C

Correct Answer & Explanation

. Type B2

Explanation

In the Walch classification, a B2 glenoid is characterized by a biconcave surface with posterior wear, posterior subluxation of the humeral head, and increased retroversion. This is a critical consideration for implant positioning in total shoulder arthroplasty.

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