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9. Shoulder and Elbow MCQs

Practice Set 89 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 1761

Topic: Elbow & Forearm

A 45-year-old carpenter presents with a chronic, unretractable rupture of the extensor pollicis longus (EPL) tendon, which occurred 3 months following a non-operative distal radius fracture. The surgeon plans a tendon transfer to restore thumb extension. Which of the following is the most appropriate and commonly used donor tendon for this procedure?

. Extensor carpi radialis longus (ECRL)
. Extensor carpi radialis brevis (ECRB)
. Extensor digitorum communis (EDC) to the index finger
. Extensor indicis proprius (EIP)
. Palmaris longus (PL)

Correct Answer & Explanation

. Extensor indicis proprius (EIP)

Explanation

The Extensor Indicis Proprius (EIP) is the gold standard donor tendon for restoring EPL function. It has an appropriate line of pull, sufficient excursion, and its harvest leaves the index finger with independent extension via the intact EDC tendon.

Question 1762

Topic: 9. Shoulder and Elbow

A 42-year-old male undergoes surgery for a "terrible triad" injury of the elbow. The radial head is replaced, the coronoid fracture is fixed with a suture lasso, and the lateral ulnar collateral ligament (LUCL) is repaired. Intraoperative fluoroscopic testing reveals the elbow persistently subluxates when extended past 30 degrees of flexion. What is the most appropriate next step in management?

. Apply a hinged external fixator
. Repair the medial collateral ligament (MCL)
. Revise the radial head to a larger size
. Place the arm in a cast at 90 degrees of flexion
. Perform an olecranon osteotomy

Correct Answer & Explanation

. Repair the medial collateral ligament (MCL)

Explanation

The standard surgical sequence for a terrible triad injury is coronoid fixation, radial head repair or replacement, followed by LUCL repair. If the elbow remains unstable in extension after these steps, the next appropriate action is exploration and repair of the MCL. A hinged external fixator is reserved for persistent instability even after the MCL has been addressed.

Question 1763

Topic: Elbow & Forearm

You are discussing the 'terrible triad' of the elbow in a Trauma viva. Which of the following best represents the standard surgical sequence for reconstructing this injury pattern?

. MCL repair, LCL repair, radial head fixation, coronoid fixation
. Radial head fixation, coronoid fixation, MCL repair, LCL repair
. Coronoid fixation, radial head fixation/replacement, LCL repair, MCL repair (if needed)
. LCL repair, radial head fixation, coronoid fixation, MCL repair
. Coronoid fixation, MCL repair, radial head fixation, LCL repair

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/replacement, LCL repair, MCL repair (if needed)

Explanation

The standard surgical algorithm for a terrible triad (coronoid fracture, radial head fracture, elbow dislocation) restores stability from deep to superficial: fix the coronoid, fix/replace the radial head, then repair the LCL. The MCL is only repaired if the elbow remains unstable.

Question 1764

Topic: 9. Shoulder and Elbow

A 72-year-old female with massive, irreparable rotator cuff arthropathy and pseudoparalysis of the shoulder undergoes a reverse total shoulder arthroplasty (RTSA). Which biomechanical alteration is responsible for restoring her active forward elevation?

. Lateralization and superior translation of the center of rotation
. Medialization and inferior translation of the center of rotation
. Restoration of the native anatomical center of rotation
. Medialization and superior translation of the center of rotation
. Lateralization and inferior translation of the center of rotation

Correct Answer & Explanation

. Medialization and inferior translation of the center of rotation

Explanation

RTSA medializes and inferiorly translates the center of rotation of the glenohumeral joint. This increases the lever arm and resting tension of the deltoid, allowing it to initiate and maintain forward elevation even in the absence of a functional rotator cuff.

Question 1765

Topic: Elbow & Forearm

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

. Lateral collateral ligament repair, coronoid fixation, radial head fixation/replacement
. Radial head fixation, coronoid fixation, lateral collateral ligament repair
. Coronoid fixation, radial head fixation/replacement, lateral collateral ligament repair
. Lateral collateral ligament repair, radial head fixation, coronoid fixation
. Coronoid fixation, lateral collateral ligament repair, radial head fixation/replacement

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/replacement, lateral collateral ligament repair

Explanation

The standard surgical sequence for a terrible triad injury of the elbow begins with deep to superficial repair: 1. Fixation of the coronoid fracture (or anterior capsule), 2. Fixation or replacement of the radial head, and 3. Repair of the lateral collateral ligament (LCL) complex.

Question 1766

Topic: Elbow & Forearm

During the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), repair of the lateral ulnar collateral ligament (LUCL) is a critical step to restore stability. What are the correct anatomical origin and insertion of the LUCL?

. Lateral epicondyle to the radial neck
. Lateral epicondyle to the supinator crest of the ulna
. Capitellum to the annular ligament
. Lateral epicondyle to the coronoid process
. Radial head to the supinator crest of the ulna

Correct Answer & Explanation

. Lateral epicondyle to the supinator crest of the ulna

Explanation

The lateral ulnar collateral ligament (LUCL) is the primary restraint to posterolateral rotatory instability. It originates on the lateral epicondyle of the humerus and inserts distally onto the supinator crest of the proximal ulna.

Question 1767

Topic: 9. Shoulder and Elbow

A 19-year-old female collegiate swimmer presents with bilateral shoulder pain and a feeling of the shoulders 'slipping.' Examination shows a positive sulcus sign bilaterally that does not decrease with external rotation, and a positive apprehension test. Initial management with 6 months of targeted physical therapy has failed. If surgery is performed, which anatomical structure is the primary target for plication or shift?

. Superior glenohumeral ligament (SGHL)
. Middle glenohumeral ligament (MGHL)
. Rotator interval
. Inferior glenohumeral ligament (IGHL) complex
. Coracoacromial ligament

Correct Answer & Explanation

. Inferior glenohumeral ligament (IGHL) complex

Explanation

The patient has Multidirectional Instability (MDI) of the shoulder, characterized by generalized laxity and a sulcus sign that persists in external rotation. When extensive conservative management fails, the surgical procedure of choice is an inferior capsular shift. The target of this shift is the redundant inferior capsular pouch, formed by the inferior glenohumeral ligament (IGHL) complex, which is the primary restraint to inferior translation in abduction.

Question 1768

Topic: 9. Shoulder and Elbow

A 65-year-old male presents with indolent pain and stiffness 2 years after a primary anatomic total shoulder arthroplasty. His inflammatory markers (ESR, CRP) are within normal limits, but an aspirate is suspicious for infection. Intraoperative tissue cultures are sent. Which organism is classically associated with this type of insidious periprosthetic shoulder infection?

. Staphylococcus aureus
. Streptococcus pyogenes
. Pseudomonas aeruginosa
. Cutibacterium acnes
. Escherichia coli

Correct Answer & Explanation

. Cutibacterium acnes

Explanation

Cutibacterium acnes (formerly Propionibacterium acnes) is a slow-growing, anaerobic, Gram-positive bacillus that resides in the sebaceous glands, predominantly around the shoulder. It is the classic organism responsible for insidious, culture-negative or late-presenting periprosthetic joint infections of the shoulder. Cultures must be held for up to 14 days to detect it.

Question 1769

Topic: Elbow & Forearm

During surgical management of a 'terrible triad' injury of the elbow (coronoid fracture, radial head fracture, elbow dislocation), what is the most widely accepted sequence of repair according to the standard surgical algorithm?

. LCL -> Radial Head -> Coronoid -> MCL
. Coronoid -> Radial Head -> LCL -> MCL (if needed)
. Radial Head -> LCL -> Coronoid -> MCL
. MCL -> Coronoid -> Radial Head -> LCL
. Coronoid -> MCL -> Radial Head -> LCL

Correct Answer & Explanation

. Coronoid -> Radial Head -> LCL -> MCL (if needed)

Explanation

The standard surgical algorithm for a terrible triad injury emphasizes a deep-to-superficial repair from the lateral side. The sequence is typically: 1) Repair or fix the coronoid (to restore anterior stability), 2) Repair or replace the radial head, 3) Repair the lateral collateral ligament (LCL) complex. The medial collateral ligament (MCL) is only repaired if the elbow remains unstable after the lateral-sided and osseous repairs are complete.

Question 1770

Topic: Elbow & Forearm

In a standard Boyes tendon transfer for a high radial nerve palsy, which muscle is transferred to the extensor carpi radialis brevis to restore wrist extension?

. Pronator teres
. Flexor carpi ulnaris
. Flexor carpi radialis
. Flexor digitorum superficialis
. Palmaris longus

Correct Answer & Explanation

. Pronator teres

Explanation

In standard tendon transfer algorithms for radial nerve palsy (such as the Boyes or Jones transfers), wrist extension is restored by transferring the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB). The PT is an ideal donor because of its synergistic action and adequate excursion.

Question 1771

Topic: 9. Shoulder and Elbow

During arthroscopic evaluation of a baseball pitcher's shoulder, a Type II SLAP (Superior Labrum Anterior and Posterior) tear is identified. The 'peel-back' mechanism, which dynamically exacerbates this lesion during the throwing motion, occurs primarily in which of the following shoulder positions?

. Abduction and maximum internal rotation
. Flexion and maximum internal rotation
. Adduction and maximum external rotation
. Abduction and maximum external rotation
. Extension and maximum internal rotation

Correct Answer & Explanation

. Abduction and maximum external rotation

Explanation

The 'peel-back' mechanism describes the dynamic shift of the biceps vector during the late cocking phase of throwing, which places the shoulder in abduction and maximum external rotation. This force peels the superior labrum off the posterior glenoid rim.

Question 1772

Topic: 9. Shoulder and Elbow

Which of the following structures is classically the last to be addressed or repaired during the step-wise surgical reconstruction of a 'terrible triad' injury of the elbow?

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

Correct Answer & Explanation

. Medial collateral ligament (MCL)

Explanation

The standard surgical algorithm for a terrible triad of the elbow (elbow dislocation, radial head fracture, and coronoid fracture) proceeds from deep to superficial and typically from lateral to medial (or via a single lateral approach). The sequence is: 1) Coronoid fixation, 2) Radial head fixation or replacement, 3) LUCL repair. The Medial Collateral Ligament (MCL) is only repaired (or augmented with an external fixator) if the elbow remains unstable in extension after the first three steps are completed.

Question 1773

Topic: 9. Shoulder and Elbow

The 'peel-back' mechanism is a well-described etiology for creating SLAP (Superior Labrum Anterior to Posterior) lesions in overhead athletes. In which specific shoulder position does this mechanism maximally tension the long head of the biceps anchor?

. Flexion and internal rotation
. Extension and internal rotation
. Abduction and maximal external rotation
. Adduction and external rotation
. Forward elevation and supination

Correct Answer & Explanation

. Abduction and maximal external rotation

Explanation

The 'peel-back' mechanism occurs primarily during the late cocking phase of throwing, where the shoulder is positioned in abduction and maximal external rotation. In this position, the vector of the long head of the biceps shifts posteriorly, creating a torsional force that 'peels' the superior labrum off the posterior-superior glenoid rim.

Question 1774

Topic: Elbow & Forearm

In a patient with a permanent high radial nerve palsy, a standard Boyes tendon transfer is planned. To restore thumb extension (extensor pollicis longus), which of the following muscles is most classically transferred?

. Flexor carpi ulnaris (FCU)
. Flexor digitorum superficialis (FDS) of the ring finger
. Palmaris longus (PL)
. Pronator teres (PT)
. Brachioradialis (BR)

Correct Answer & Explanation

. Pronator teres (PT)

Explanation

In standard tendon transfers for radial nerve palsy (e.g., Jones or Boyes), the Pronator Teres (PT) is transferred to the Extensor Carpi Radialis Brevis (ECRB) for wrist extension. For thumb extension, the Palmaris Longus (PL) is most commonly transferred to the Extensor Pollicis Longus (EPL). Finger extension is usually restored by transferring FCU or FDS to the EDC.

Question 1775

Topic: 9. Shoulder and Elbow

A 22-year-old collegiate baseball pitcher is undergoing ulnar collateral ligament (UCL) reconstruction ('Tommy John' surgery) of the elbow. Which specific anatomical component of the UCL complex serves as the primary restraint to valgus stress at 90 degrees of elbow flexion?

. Posterior bundle
. Transverse ligament (Cooper's ligament)
. Anterior bundle
. Annular ligament
. Radial collateral ligament

Correct Answer & Explanation

. Anterior bundle

Explanation

The Ulnar Collateral Ligament (UCL) complex consists of three components: the anterior bundle, the posterior bundle, and the transverse ligament. Biomechanical studies have proven that the anterior bundle is the primary restraint to valgus stress of the elbow throughout the functional range of motion, particularly at 90 degrees of flexion.

Question 1776

Topic: 9. Shoulder and Elbow

A 35-year-old male sustains a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). According to standard surgical principles for restoring elbow stability, which of the following is the recommended sequence of surgical reconstruction?

. Radial head fixation/replacement, coronoid fixation, LCL repair, MCL repair
. Coronoid fixation, radial head fixation/replacement, LCL repair, MCL repair (if needed)
. LCL repair, radial head fixation/replacement, coronoid fixation, MCL repair
. MCL repair, coronoid fixation, radial head fixation/replacement, LCL repair
. Coronoid fixation, LCL repair, radial head fixation/replacement, MCL repair

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/replacement, LCL repair, MCL repair (if needed)

Explanation

The standard surgical protocol for a terrible triad injury, established by Pugh et al., involves a deep-to-superficial repair from the inside out: (1) Fixation of the coronoid process, (2) Fixation or replacement of the radial head, (3) Repair of the lateral collateral ligament (LCL) complex to the lateral epicondyle. Repair of the medial collateral ligament (MCL) or application of an external fixator is reserved for cases where the elbow remains unstable after the first three steps.

Question 1777

Topic: 9. Shoulder and Elbow

In the biomechanical design of a Grammont-style reverse total shoulder arthroplasty, how is the center of rotation altered compared to the native glenohumeral joint?

. Moved medially and inferiorly
. Moved laterally and inferiorly
. Moved medially and superiorly
. Moved laterally and superiorly
. Remains unchanged but constrained

Correct Answer & Explanation

. Moved medially and inferiorly

Explanation

The Grammont design medializes and distalizes (inferiorizes) the center of rotation. This alteration increases the deltoid lever arm, recruits more deltoid fibers, and improves resting tension, compensating for the absent rotator cuff.

Question 1778

Topic: 9. Shoulder and Elbow

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture), what is the generally recommended sequence of repair to restore elbow stability?

. Lateral collateral ligament (LCL), radial head, coronoid
. Coronoid, radial head, Lateral collateral ligament (LCL)
. Radial head, coronoid, Medial collateral ligament (MCL)
. Medial collateral ligament (MCL), coronoid, radial head
. LCL, coronoid, radial head

Correct Answer & Explanation

. Coronoid, radial head, Lateral collateral ligament (LCL)

Explanation

The standard surgical algorithm for a terrible triad injury involves restoring structures from deep to superficial, moving from anterior/medial to lateral: 1) Repair or fix the coronoid (or anterior capsule) to restore the anterior buttress, 2) Replace or fix the radial head, 3) Repair the lateral collateral ligament (LCL) complex. MCL repair is only considered if the elbow remains grossly unstable after the first three steps.

Question 1779

Topic: 9. Shoulder and Elbow

During reconstruction of the ulnar collateral ligament (UCL) of the elbow in a throwing athlete, which bundle is the primary restraint to valgus stress and the primary anatomic target for reconstruction?

. Posterior bundle
. Transverse bundle
. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Accessory collateral ligament

Correct Answer & Explanation

. Anterior band of the anterior bundle

Explanation

The ulnar collateral ligament (UCL) complex consists of anterior, posterior, and transverse bundles. The anterior bundle is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion. Specifically, the anterior band of the anterior bundle is the most critical structure and is the primary target recreated during a 'Tommy John' reconstruction.

Question 1780

Topic: 9. Shoulder and Elbow
Which of the following scenarios represents an absolute indication for operative fixation of a 'floating shoulder' (ipsilateral fractures of the clavicle and scapular neck)?
. Medial clavicle displacement of 1 cm
. Scapular neck angulation of 10 degrees
. Disruption of the superior shoulder suspensory complex (SSSC) with >1 cm glenoid medialization and 40 degrees of angular deformity
. Presence of a concomitant non-displaced ipsilateral rib fracture
. Intact coracoclavicular (CC) ligaments on MRI

Correct Answer & Explanation

. Disruption of the superior shoulder suspensory complex (SSSC) with >1 cm glenoid medialization and 40 degrees of angular deformity

Explanation

A floating shoulder does not mandate surgery by default. Operative fixation is indicated when there is severe displacement threatening the Superior Shoulder Suspensory Complex (SSSC). Glenoid medialization > 1-2 cm and severe angular deformity (>40 degrees) alter glenohumeral biomechanics and rotator cuff function, warranting internal fixation.

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