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9. Shoulder and Elbow MCQs

Practice Set 88 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 1741

Topic: 9. Shoulder and Elbow

A 72-year-old female with severe rotator cuff tear arthropathy undergoes a reverse total shoulder arthroplasty (RTSA). Which of the following best describes the primary biomechanical advantage of this implant design compared to native shoulder anatomy?

. Medializes and distalizes the center of rotation, increasing the deltoid moment arm
. Lateralizes and distalizes the center of rotation, increasing rotator cuff tension
. Medializes and proximalizes the center of rotation, maximizing abduction strength
. Lateralizes and proximalizes the center of rotation, preventing scapular notching
. Maintains the anatomic center of rotation while constraining the glenohumeral joint

Correct Answer & Explanation

. Medializes and distalizes the center of rotation, increasing the deltoid moment arm

Explanation

Reverse total shoulder arthroplasty shifts the center of rotation medially and distally compared to the native joint. This recruits more deltoid fibers and significantly increases its moment arm, allowing the deltoid to compensate for the absent rotator cuff during elevation.

Question 1742

Topic: Elbow & Forearm

A 45-year-old male falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. He undergoes operative management. Which of the following is the most widely accepted sequence of structural repair to systematically restore elbow stability?

. Lateral ulnar collateral ligament, radial head, coronoid
. Coronoid, radial head, lateral ulnar collateral ligament
. Radial head, coronoid, lateral ulnar collateral ligament
. Lateral ulnar collateral ligament, coronoid, radial head
. Coronoid, lateral ulnar collateral ligament, radial head

Correct Answer & Explanation

. Coronoid, radial head, lateral ulnar collateral ligament

Explanation

The standard inside-out surgical sequence for a terrible triad elbow injury is fixation of the coronoid first, followed by radial head repair or replacement, and finally lateral ulnar collateral ligament (LUCL) repair. This progressive stabilization restores the anterior buttress before addressing the lateral column.

Question 1743

Topic: Elbow & Forearm

A 38-year-old bodybuilder undergoes surgical repair of a distal biceps tendon rupture using a traditional two-incision technique. Compared to a single-incision anterior approach, this patient is at a statistically higher risk for which of the following postoperative complications?

. Lateral antebrachial cutaneous nerve neurapraxia
. Posterior interosseous nerve palsy
. Radioulnar synostosis
. Radial nerve complete transection
. Early tendon re-rupture

Correct Answer & Explanation

. Radioulnar synostosis

Explanation

The two-incision technique for distal biceps repair carries a higher risk of heterotopic ossification and radioulnar synostosis compared to the single-incision approach. Conversely, single-incision approaches carry a higher risk of lateral antebrachial cutaneous (LABC) nerve injury.

Question 1744

Topic: 9. Shoulder and Elbow

A 65-year-old male is 4 weeks post-operative from an anatomic total shoulder arthroplasty (TSA) utilizing a lesser tuberosity osteotomy. He reports a sudden 'pop' and severe anterior shoulder pain while reaching for a door. Examination reveals significantly increased passive external rotation and a positive belly-press test. What is the most appropriate next step in management?

. MRI of the shoulder without contrast
. Immediate open revision and repair of the lesser tuberosity
. CT scan of the shoulder to assess glenoid component version
. Aggressive physical therapy focusing on anterior deltoid compensation
. Immobilization in internal rotation for 6 weeks

Correct Answer & Explanation

. Immediate open revision and repair of the lesser tuberosity

Explanation

Acute failure of the subscapularis or lesser tuberosity osteotomy following anatomic TSA is a surgical emergency requiring prompt open repair. Nonoperative management typically leads to catastrophic anterior instability, component wear, and poor functional outcomes.

Question 1745

Topic: 9. Shoulder and Elbow

A 35-year-old female complains of recurrent lateral elbow pain, clicking, and a subjective sense of instability when pushing off from a chair with her arms. Which of the following ligamentous structures is most likely deficient in this patient?

. Annular ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament
. Anterior bundle of the medial collateral ligament
. Posterior bundle of the medial collateral ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily caused by insufficiency of the lateral ulnar collateral ligament (LUCL). Patients typically describe apprehension or subluxation when the elbow is axially loaded, supinated, and extended, such as pushing up from a chair.

Question 1746

Topic: Elbow & Forearm

A 45-year-old female falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. Radiographs and CT show a posterior elbow dislocation, a comminuted radial head fracture, and a Type II coronoid fracture. During surgical reconstruction, what is the most widely accepted sequence of repair to restore elbow stability?

. Fixation of the coronoid, followed by radial head replacement or fixation, and finally lateral collateral ligament (LCL) repair.
. Repair of the lateral collateral ligament (LCL), followed by radial head fixation, and finally coronoid fixation.
. Radial head replacement, followed by medial collateral ligament (MCL) repair, and finally lateral collateral ligament (LCL) repair.
. Fixation of the coronoid, followed by medial collateral ligament (MCL) repair, and finally lateral collateral ligament (LCL) repair.
. Medial collateral ligament (MCL) repair, followed by coronoid fixation, and finally radial head replacement.

Correct Answer & Explanation

. Fixation of the coronoid, followed by radial head replacement or fixation, and finally lateral collateral ligament (LCL) repair.

Explanation

The standard protocol for terrible triad injuries involves an inside-out or deep-to-superficial repair sequence. The coronoid is addressed first, followed by the radial head, and finally the lateral collateral ligament complex to restore joint kinematics.

Question 1747

Topic: 9. Shoulder and Elbow

A 72-year-old female with severe osteoporosis sustains a 4-part proximal humerus fracture. The decision is made to proceed with a reverse total shoulder arthroplasty (rTSA). Successful healing of the greater tuberosity to the proximal humerus shaft most directly impacts which postoperative functional outcome?

. Active forward elevation
. Active external rotation
. Active internal rotation
. Implant survivorship
. Prevention of acromial stress fracture

Correct Answer & Explanation

. Active external rotation

Explanation

In reverse total shoulder arthroplasty for trauma, healing of the greater tuberosity is critical for restoring active external rotation and shoulder contour. Forward elevation is primarily restored by the deltoid tensioning inherent to the semi-constrained reverse implant design.

Question 1748

Topic: Shoulder Pathology

A 24-year-old weightlifter presents with a dull ache in his right shoulder and noticeable lateral scapular winging. Examination reveals weakness in shoulder abduction, but normal forward elevation. Which nerve has most likely been injured?

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

Correct Answer & Explanation

. Spinal accessory nerve

Explanation

Lateral scapular winging is classically caused by trapezius muscle paralysis due to a spinal accessory nerve injury. Medial winging, by contrast, is associated with serratus anterior palsy from a long thoracic nerve injury.

Question 1749

Topic: Elbow & Forearm

A 38-year-old male undergoes a single-incision anterior approach for a distal biceps tendon rupture repair. Postoperatively, he notes numbness along the radial-volar aspect of his forearm. Which nerve was most likely injured during the exposure?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABC)
. Ulnar nerve
. Anterior interosseous nerve (AIN)
. Superficial radial nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABC)

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior approach to the distal biceps. The two-incision technique decreases this nerve risk but carries a higher risk of radioulnar synostosis.

Question 1750

Topic: 9. Shoulder and Elbow

A 55-year-old active male presents with a massive, irreparable posterosuperior rotator cuff tear. His subscapularis is intact. He demonstrates a severe external rotation lag but has preserved active forward elevation. Radiographs show minimal glenohumeral arthritis. What is the most appropriate surgical option?

. Reverse total shoulder arthroplasty
. Latissimus dorsi tendon transfer
. Lower trapezius tendon transfer
. Pectoralis major tendon transfer
. Arthroscopic superior capsule reconstruction

Correct Answer & Explanation

. Lower trapezius tendon transfer

Explanation

For an isolated irreparable posterosuperior cuff tear with external rotation weakness in a younger patient without arthritis, lower trapezius transfer is highly effective. It better restores external rotation kinematics due to its more anatomical line of pull compared to the latissimus dorsi.

Question 1751

Topic: Elbow & Forearm

Which of the following structures is most commonly affected in 'tennis elbow' (lateral epicondylitis)?

. Flexor Carpi Radialis
. Extensor Carpi Radialis Brevis
. Extensor Carpi Ulnaris
. Brachioradialis
. Biceps Brachii

Correct Answer & Explanation

. Extensor Carpi Radialis Brevis

Explanation

Lateral epicondylitis, or 'tennis elbow,' is a degenerative tendinopathy (not purely inflammatory) primarily affecting the origin of the extensor carpi radialis brevis (ECRB) tendon at the lateral epicondyle. While other extensors can be involved, ECRB is consistently the most affected. The other muscles listed are either flexors, other extensors, or not primarily involved.

Question 1752

Topic: Elbow & Forearm

A 40-year-old male presents with acute pain and swelling at the base of his thumb, worse with movement. Examination reveals tenderness localized to the extensor pollicis longus (EPL) tendon where it crosses the extensor carpi radialis longus (ECRL) and brevis (ECRB) tendons. What is the most likely diagnosis?

. De Quervain's Tenosynovitis
. Intersection Syndrome
. Flexor Carpi Radialis Tenosynovitis
. Thumb CMC Osteoarthritis
. Wartenberg's Syndrome

Correct Answer & Explanation

. Intersection Syndrome

Explanation

Intersection Syndrome (also known as 'squeaker's wrist' or 'oarsman's wrist') is an inflammatory condition affecting the crossing point of the first dorsal compartment tendons (APL, EPB) and the second dorsal compartment tendons (ECRL, ECRB). The pain described in the question, however, is at the crossing point of the third dorsal compartment tendon (EPL) over the second dorsal compartment tendons (ECRL, ECRB), which is known asproximalintersection syndrome (or sometimes referred to as intersection syndrome if referring to the more common distal intersection of APL/EPB over ECRL/ECRB is not the case). The question specified EPL over ECRL/ECRB. De Quervain's affects the first dorsal compartment (APL, EPB). The scenario describes a variant of intersection syndrome. Given the options, Intersection Syndrome is the best fit, despite the nuance of the specific tendons mentioned (often 'distal' intersection syndrome is what is implied, involving APL/EPB crossing ECRL/ECRB more proximally). Proximal Intersection syndrome involves EPL crossing ECRL/ECRB tendons.

Question 1753

Topic: 9. Shoulder and Elbow

A 62-year-old female with long-standing rheumatoid arthritis reports a sudden inability to actively flex the interphalangeal joint of her right thumb. Which of the following is the most likely etiology of her condition (Mannerfelt-Norman syndrome)?

. Rupture of the flexor pollicis longus (FPL) over a palmar scaphoid osteophyte
. Rupture of the extensor pollicis longus (EPL) over Lister's tubercle
. Subluxation of the extensor tendons into the ulnar gutters
. Posterior interosseous nerve (PIN) entrapment by a rheumatoid elbow cyst
. Ischemic necrosis of the flexor digitorum profundus (FDP)

Correct Answer & Explanation

. Rupture of the flexor pollicis longus (FPL) over a palmar scaphoid osteophyte

Explanation

Mannerfelt-Norman syndrome specifically refers to the spontaneous rupture of the flexor pollicis longus (FPL) tendon in patients with rheumatoid arthritis. This attrition rupture occurs secondary to a bony spur located on the palmar aspect of the scaphoid.

Question 1754

Topic: Elbow & Forearm

A patient with a high radial nerve palsy requires tendon transfers to restore wrist, finger, and thumb extension. The standard Boyes transfer is planned. Which muscle is typically transferred to the Extensor Carpi Radialis Brevis (ECRB) to restore wrist extension?

. Flexor Carpi Radialis (FCR)
. Flexor Carpi Ulnaris (FCU)
. Palmaris Longus (PL)
. Pronator Teres (PT)
. Flexor Digitorum Superficialis (FDS)

Correct Answer & Explanation

. Pronator Teres (PT)

Explanation

In classic tendon transfers for radial nerve palsy, the Pronator Teres (PT) is transferred to the ECRB to restore strong wrist extension. The FCR or FCU is typically used for finger extension (to EDC), and PL is used for thumb extension (to EPL).

Question 1755

Topic: 9. Shoulder and Elbow

A 4-year-old child presents with a 'pulled elbow' after being swung by his arm. He refuses to use his arm, which is held in flexion and pronation. Which of the following maneuvers is most likely to reduce the subluxation?

. Supination and flexion of the forearm.
. Pronation and extension of the forearm.
. Traction and direct pressure on the radial head.
. Supination and extension of the forearm.
. Flexion and internal rotation of the arm.

Correct Answer & Explanation

. Supination and flexion of the forearm.

Explanation

A 'pulled elbow' or nursemaid's elbow is a radial head subluxation, typically caused by longitudinal traction on the pronated and extended arm. The classic reduction maneuver involves supination and then flexion of the forearm. This maneuver attempts to reduce the annular ligament back into its normal position around the radial head. Pronation and extension, supination and extension, or traction and direct pressure are not the primary successful maneuvers and may even worsen the subluxation. Flexion and internal rotation are not indicated.

Question 1756

Topic: Elbow & Forearm

A 28-year-old male sustains an open Monteggia fracture-dislocation (ulnar shaft fracture with radial head dislocation). Which of the following is the most important principle of surgical management?

. Closed reduction and long arm cast immobilization.
. Fixation of the ulnar shaft fracture and assessment of radial head reduction.
. Immediate radial head excision.
. External fixation of both the ulna and radius.
. Primary elbow arthrodesis.

Correct Answer & Explanation

. Fixation of the ulnar shaft fracture and assessment of radial head reduction.

Explanation

A Monteggia fracture-dislocation (ulnar shaft fracture with associated radial head dislocation) is an unstable injury. The key principle of surgical management in adults is to anatomically reduce and stably fix the ulnar shaft fracture (typically with a plate and screws). Once the ulnar length and alignment are restored, the radial head dislocation usually reduces spontaneously. The radial head reduction must then be confirmed both clinically and radiographically. If the radial head remains dislocated after ulnar fixation, soft tissue interposition or annular ligament injury may require further exploration. Closed reduction and casting are rarely successful in adults. Radial head excision is generally avoided in younger patients. External fixation is reserved for severe open injuries. Primary elbow arthrodesis is a salvage procedure.

Question 1757

Topic: 9. Shoulder and Elbow

An active 75-year-old female presents with a closed 4-part proximal humerus fracture. The humeral head is split, the tuberosities are severely displaced, and radiographs reveal underlying severe glenohumeral osteoarthritis. What is the best definitive surgical management?

. Non-operative management with a sling
. ORIF with a proximal humerus locking plate
. Cemented hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In elderly patients with poor bone quality, 4-part fractures, and pre-existing osteoarthritis, a Reverse Total Shoulder Arthroplasty (RTSA) provides the most reliable functional recovery. It relies on the deltoid for elevation, mitigating the poor outcomes associated with tuberosity nonunion seen in hemiarthroplasty.

Question 1758

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old right-hand-dominant female presents with a severely displaced Neer 4-part proximal humerus fracture. Which of the following is the strongest indication to perform a Reverse Total Shoulder Arthroplasty (RTSA) rather than a Hemiarthroplasty?

. An intact rotator cuff
. Unpredictable tuberosity healing
. Concomitant axillary nerve palsy
. Age younger than 65 years
. Associated proximal diaphyseal fracture

Correct Answer & Explanation

. Unpredictable tuberosity healing

Explanation

RTSA provides more predictable functional outcomes in the elderly with 4-part fractures because its function does not depend on tuberosity healing. Hemiarthroplasty outcomes are historically poor if the greater tuberosity fails to heal or malunions.

Question 1759

Topic: Elbow & Forearm

In the surgical management of the 'terrible triad' of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), standard treatment algorithms suggest addressing structures from deep to superficial. Which structure is typically repaired last, and only if residual instability persists?

. Coronoid process
. Radial head
. Lateral ulnar collateral ligament (LUCL)
. Medial collateral ligament (MCL)
. Common extensor origin

Correct Answer & Explanation

. Coronoid process

Explanation

The standard sequence is fixing the coronoid, then addressing the radial head, followed by the LUCL. The MCL is typically only repaired if the elbow remains grossly unstable in extension after the anterior and lateral structures are stabilized.

Question 1760

Topic: 9. Shoulder and Elbow

A reverse total shoulder arthroplasty (RTSA) is performed for a 75-year-old patient with severe rotator cuff tear arthropathy. How does the biomechanical design of the RTSA primarily restore active forward elevation?

. It medializes and distalizes the center of rotation, increasing the deltoid moment arm
. It lateralizes and superiorly shifts the center of rotation, increasing the deltoid moment arm
. It medializes the center of rotation and decreases the deltoid moment arm
. It lateralizes the center of rotation and decreases the deltoid moment arm
. It relies purely on the intact subscapularis to act as an elevator

Correct Answer & Explanation

. It medializes and distalizes the center of rotation, increasing the deltoid moment arm

Explanation

The RTSA design medializes and distalizes the glenohumeral joint's center of rotation. This recruits more deltoid muscle fibers and significantly increases the deltoid's moment arm, allowing it to substitute for the deficient supraspinatus.

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