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9. Shoulder and Elbow MCQs

Practice Set 90 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 1781

Topic: 9. Shoulder and Elbow

A 40-year-old woman sustains a 'terrible triad' injury of the elbow. During surgical reconstruction, what is the generally accepted sequence of repair to best restore elbow stability?

. Radial head, coronoid, lateral collateral ligament (LCL), medial collateral ligament (MCL)
. Coronoid, LCL, radial head, MCL
. Coronoid, radial head, LCL, MCL (if needed)
. LCL, radial head, coronoid, MCL
. MCL, coronoid, radial head, LCL

Correct Answer & Explanation

. Coronoid, LCL, radial head, MCL

Explanation

The standard surgical protocol for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) typically proceeds from deep to superficial and distal to proximal: Fixation or replacement of the coronoid, followed by the radial head, then repair of the lateral collateral ligament (LCL) complex. The MCL is only repaired if the elbow remains grossly unstable after the lateral side is fixed.

Question 1782

Topic: 9. Shoulder and Elbow

A 60-year-old active male is undergoing arthroscopic rotator cuff repair. A subpectoral biceps tenodesis is planned for a concomitantly degenerative long head of the biceps tendon. What is the primary advantage of subpectoral tenodesis compared to an arthroscopic suprapectoral tenodesis?

. Lower risk of musculocutaneous nerve injury
. Complete removal of the tendon from the bicipital sheath to eliminate groove pain
. Shorter surgical time and fewer incisions
. Decreased risk of postoperative adhesive capsulitis
. Stronger initial biomechanical fixation strength than an interference screw

Correct Answer & Explanation

. Complete removal of the tendon from the bicipital sheath to eliminate groove pain

Explanation

A subpectoral biceps tenodesis places the fixation distal to the bicipital groove. Its primary advantage is the complete removal of the diseased tendon and synovium from the bicipital groove, which is a recognized source of persistent anterior shoulder pain ('groove pain').

Question 1783

Topic: Elbow & Forearm
A 6-year-old boy falls on an outstretched hand and presents with elbow swelling and pain. Radiographs reveal a plastic deformation of the ulna with an anterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this?
. Bado Type I
. Bado Type II
. Bado Type III
. Bado Type IV
. This is an isolated radial head dislocation, not a Monteggia lesion

Correct Answer & Explanation

. Bado Type I

Explanation

A Monteggia fracture-dislocation is an ulnar shaft fracture (or plastic deformation in children) with a radial head dislocation. Bado Type I features anterior dislocation of the radial head. Type II is posterior, Type III is lateral, and Type IV involves fractures of both the radius and ulna with an anterior radial head dislocation.

Question 1784

Topic: Elbow & Forearm

A 42-year-old female falls from a height and sustains a comminuted, irreparable radial head fracture along with severe wrist pain. Examination reveals instability of the distal radioulnar joint (DRUJ) and marked proximal migration of the radius on stress fluoroscopy. Which of the following is the most appropriate surgical management?

. Radial head excision alone
. Radial head excision and DRUJ pinning
. Radial head replacement and DRUJ pinning
. Radial head excision and ulnar shortening osteotomy
. Open reduction and internal fixation of the radial head with DRUJ pinning

Correct Answer & Explanation

. Radial head replacement and DRUJ pinning

Explanation

This is an Essex-Lopresti injury (radial head fracture, interosseous membrane tear, and DRUJ disruption). Excision of the radial head without replacement will lead to unopposed proximal radial migration, ulnocarpal impaction, and chronic wrist pain. Management requires restoration of the radiocapitellar joint (using a radial head arthroplasty if the fracture is irreparable) to restore longitudinal column stability, followed by reduction and stabilization (pinning) of the DRUJ.

Question 1785

Topic: 9. Shoulder and Elbow

A 45-year-old male presents with right arm pain, weakness in elbow extension, and diminished triceps reflex. Sensation is decreased over the long finger. Which cervical nerve root is most likely affected?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

The C7 nerve root supplies the triceps (elbow extension), wrist flexors, and finger extensors. Sensory distribution is classically to the middle finger. The triceps reflex is primarily mediated by the C7 nerve root.

Question 1786

Topic: Elbow & Forearm

A patient with a chronic, irreversible high radial nerve palsy requires tendon transfer surgery to restore wrist and digit extension. What is the most widely utilized and standard tendon transfer to restore wrist extension?

. Flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB)
. Pronator teres (PT) to extensor carpi radialis brevis (ECRB)
. Flexor digitorum superficialis (FDS) to extensor digitorum communis (EDC)
. Palmaris longus (PL) to extensor pollicis longus (EPL)
. Flexor carpi radialis (FCR) to extensor carpi ulnaris (ECU)

Correct Answer & Explanation

. Pronator teres (PT) to extensor carpi radialis brevis (ECRB)

Explanation

The Pronator Teres (PT) to Extensor Carpi Radialis Brevis (ECRB) transfer is the workhorse procedure for restoring wrist extension in radial nerve palsy. The ECRB is preferred over the ECRL because of its more central insertion, which provides balanced dorsiflexion of the wrist without excessive radial deviation.

Question 1787

Topic: 9. Shoulder and Elbow

A 22-year-old overhead athlete presents with recurrent anterior shoulder instability. Magnetic resonance imaging (MRI) reveals a 'J-sign'. This specific radiographic finding corresponds to which of the following anatomical injuries?

. Avulsion of the superior glenohumeral ligament from the glenoid
. Avulsion of the inferior glenohumeral ligament from the anatomic neck of the humerus
. Mid-substance tear of the middle glenohumeral ligament
. Avulsion of the anteroinferior labrum and capsule from the glenoid rim
. Detachment of the biceps anchor from the superior labrum

Correct Answer & Explanation

. Avulsion of the inferior glenohumeral ligament from the anatomic neck of the humerus

Explanation

The 'J-sign' on an MRI (particularly an MR arthrogram) of the shoulder is indicative of a Humeral Avulsion of the Glenohumeral Ligament (HAGL) lesion. This lesion occurs when the inferior glenohumeral ligament (IGHL) is avulsed from its attachment on the anatomic neck of the humerus. Normal anatomy shows a U-shaped axillary pouch; when the humeral attachment is torn, contrast leaks inferiorly, forming a J-shape.

Question 1788

Topic: Elbow & Forearm

In the surgical management of the 'terrible triad' of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), restoring posterolateral rotatory stability is critical. Which ligamentous structure must be meticulously repaired to address this specific instability?

. Anterior bundle of the Medial Collateral Ligament (AMCL)
. Posterior bundle of the Medial Collateral Ligament (PMCL)
. Radial Collateral Ligament (RCL)
. Lateral Ulnar Collateral Ligament (LUCL)
. Quadrate ligament

Correct Answer & Explanation

. Lateral Ulnar Collateral Ligament (LUCL)

Explanation

The Lateral Ulnar Collateral Ligament (LUCL) is the primary restraint to posterolateral rotatory instability (PLRI) of the elbow. In a terrible triad injury, the standard surgical algorithm involves fixing or replacing the radial head, addressing the coronoid/anterior capsule, and rigorously repairing the LUCL to restore lateral stability and prevent subluxation.

Question 1789

Topic: Elbow & Forearm

A 29-year-old male sustains a midshaft humerus fracture and presents with a complete radial nerve palsy. He is managed conservatively in a functional brace. At 12 weeks, there is no clinical or electromyographic (EMG) evidence of nerve recovery. Tendon transfers are planned. Which of the following is the most commonly used donor tendon to restore active wrist extension?

. Flexor carpi ulnaris (FCU)
. Pronator teres (PT)
. Flexor digitorum superficialis (FDS) of the middle finger
. Palmaris longus (PL)
. Flexor carpi radialis (FCR)

Correct Answer & Explanation

. Pronator teres (PT)

Explanation

In standard radial nerve palsy tendon transfers, the pronator teres (PT) is the most commonly used donor muscle to restore wrist extension by transferring it to the extensor carpi radialis brevis (ECRB). The ECRB is chosen as the recipient because its central insertion provides balanced wrist extension without severe radial deviation.

Question 1790

Topic: Elbow & Forearm

A 35-year-old male sustains a "terrible triad" injury of the elbow. Which of the following is the generally recommended surgical sequence for repairing these injuries?

. LCL repair, radial head fixation/replacement, coronoid fixation
. Coronoid fixation, radial head fixation/replacement, LCL repair
. Radial head fixation/replacement, coronoid fixation, LCL repair
. LCL repair, coronoid fixation, radial head fixation/replacement
. Coronoid fixation, LCL repair, radial head fixation/replacement

Correct Answer & Explanation

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

Explanation

The standard inside-out sequence for repairing a terrible triad injury of the elbow is first fixing the coronoid, followed by addressing the radial head (fixation or replacement), and finally repairing the lateral collateral ligament (LCL) complex. MCL repair or hinged external fixation may be added if instability persists.

Question 1791

Topic: Elbow & Forearm

In a patient with an irreversible high radial nerve palsy, a standard tendon transfer is planned to restore wrist extension. The Pronator Teres (PT) is most commonly transferred to the Extensor Carpi Radialis Brevis (ECRB) rather than the Extensor Carpi Radialis Longus (ECRL). What is the primary biomechanical rationale for selecting the ECRB?

. ECRB has a significantly longer excursion than ECRL.
. ECRB provides central wrist extension without excessive radial deviation.
. ECRB acts synergistically with digital flexion, unlike ECRL.
. ECRL requires an interposition vein graft to reach the PT insertion.
. ECRB is a physically thicker tendon, providing a biomechanically stronger repair.

Correct Answer & Explanation

. ECRB provides central wrist extension without excessive radial deviation.

Explanation

The ECRB inserts at the base of the third metacarpal, which is centrally located. Therefore, it provides pure wrist extension. The ECRL inserts at the base of the second metacarpal, and utilizing it for wrist extension transfer would result in undesirable radial deviation of the wrist upon extension.

Question 1792

Topic: Elbow & Forearm

A 35-year-old man presents with a permanent low radial nerve palsy after a humerus fracture. A standard Jones tendon transfer procedure is planned. To restore thumb extension, which of the following muscle-tendon transfers is classically utilized in this procedure?

. Pronator teres to extensor carpi radialis brevis
. Flexor carpi radialis to extensor digitorum communis
. Flexor digitorum superficialis to extensor pollicis longus
. Palmaris longus to extensor pollicis longus
. Flexor carpi ulnaris to extensor digitorum communis

Correct Answer & Explanation

. Pronator teres to extensor carpi radialis brevis

Explanation

In the classic Jones transfer for radial nerve palsy, three primary transfers are performed: 1) Pronator teres to ECRB (to restore wrist extension), 2) FCU (or FCR in modified versions) to EDC (to restore finger extension), and 3) Palmaris longus (PL) to EPL (to restore thumb extension).

Question 1793

Topic: 9. Shoulder and Elbow
During arthroscopic evaluation of a shoulder, a surgeon identifies a SLAP (Superior Labrum Anterior to Posterior) lesion. Which type of SLAP lesion is defined by a bucket-handle tear of the superior labrum with the biceps anchor remaining intact?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

According to the Snyder classification of SLAP lesions: Type I is fraying of the superior labrum; Type II is detachment of the superior labrum and biceps anchor from the glenoid; Type III is a bucket-handle tear of the superior labrum with an intact biceps anchor; Type IV is a bucket-handle tear that extends into the biceps tendon.

Question 1794

Topic: Elbow & Forearm

A 35-year-old patient with a high radial nerve palsy secondary to a humerus fracture fails to show nerve recovery at 6 months. In a standard tendon transfer procedure to restore wrist extension, which of the following muscles is most commonly utilized as the motor unit?

. Pronator teres (PT)
. Flexor carpi radialis (FCR)
. Flexor carpi ulnaris (FCU)
. Flexor digitorum superficialis (FDS)
. Palmaris longus (PL)

Correct Answer & Explanation

. Pronator teres (PT)

Explanation

In standard radial nerve tendon transfers (e.g., Boyes, Jones, or modified Green transfers), the Pronator Teres (PT) is the most common muscle transferred to the Extensor Carpi Radialis Brevis (ECRB) to restore wrist extension. It is synergistic and provides excellent excursion and power.

Question 1795

Topic: Elbow & Forearm

A 35-year-old man sustains a 'terrible triad' injury of the elbow following a fall. When performing surgical stabilization, what is the generally accepted and most biomechanically sound sequence of repair?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) works from deep to superficial and typically from medial to lateral: 1) Coronoid repair or fixation, 2) Radial head repair or replacement, 3) Lateral collateral ligament (LCL) repair. If the elbow remains unstable, MCL repair or an external fixator may be considered.

Question 1796

Topic: Elbow & Forearm

A 45-year-old male sustains a 'terrible triad' injury of the elbow following a fall. He is scheduled for operative fixation. What is the standard, biomechanically supported sequence for surgical reconstruction in this injury?

. Radial head fixation/replacement, followed by LCL repair, then coronoid fixation
. Coronoid fixation, followed by radial head fixation/replacement, then LCL complex repair
. LCL complex repair, followed by radial head fixation, then coronoid fixation
. MCL repair, followed by coronoid fixation, then radial head replacement
. Coronoid fixation, followed by MCL repair, then radial head fixation

Correct Answer & Explanation

. Coronoid fixation, followed by radial head fixation/replacement, then LCL complex repair

Explanation

The terrible triad of the elbow consists of a coronoid fracture, radial head fracture, and LCL tear. The standard surgical sequence works from deep to superficial: first repairing the coronoid (to restore the anterior buttress), then fixing or replacing the radial head (lateral buttress), and finally repairing the lateral collateral ligament (LCL) complex. MCL repair or hinged external fixation is reserved for residual instability.

Question 1797

Topic: 9. Shoulder and Elbow
A 22-year-old collegiate baseball pitcher reports deep anterior shoulder pain. An MR arthrogram demonstrates a bucket-handle tear of the superior labrum that extends directly into the long head of the biceps tendon. According to the Snyder classification of SLAP lesions, what type is this?
. Type I
. Type II
. Type III
. Type V
. Type IV

Correct Answer & Explanation

. Type II

Explanation

In the Snyder classification of SLAP lesions: Type I is fraying of the superior labrum; Type II is detachment of the labrum and biceps anchor from the superior glenoid; Type III is a bucket-handle tear of the superior labrum with an intact biceps anchor; Type IV is a bucket-handle tear of the superior labrum that extends into the long head of the biceps tendon.

Question 1798

Topic: 9. Shoulder and Elbow

A 68-year-old female presents with chronic severe right shoulder pain and an inability to actively elevate her arm past 40 degrees (pseudoparalysis). Radiographs demonstrate superior migration of the humeral head with an acromiohumeral interval of 3 mm and severe glenohumeral osteoarthritis (Hamada Grade 4). What is the most appropriate surgical treatment?

. Arthroscopic rotator cuff repair
. Superior capsular reconstruction
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Latissimus dorsi tendon transfer

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

This patient has cuff tear arthropathy (CTA) with pseudoparalysis and severe glenohumeral arthritis. Reverse total shoulder arthroplasty (RTSA) is the gold standard treatment, as it medializes and distalizes the center of rotation, allowing the deltoid to effectively elevate the arm and compensating for the absent rotator cuff. Anatomic TSA is contraindicated due to the deficient cuff, which would lead to eccentric loading and early glenoid loosening.

Question 1799

Topic: 9. Shoulder and Elbow

A 'terrible triad' injury of the elbow involves a posterior elbow dislocation, radial head fracture, and coronoid fracture. During the standard surgical reconstruction via a single lateral approach, what is the generally recommended sequence of fixation to restore elbow stability?

. MCL repair, coronoid fixation, radial head repair/replacement, LCL repair
. Radial head repair/replacement, coronoid fixation, LCL repair, MCL repair
. Coronoid fixation, radial head repair/replacement, LCL repair, and MCL repair if still unstable
. LCL repair, radial head repair/replacement, coronoid fixation, MCL repair
. Coronoid fixation, LCL repair, MCL repair, radial head repair/replacement

Correct Answer & Explanation

. Coronoid fixation, radial head repair/replacement, LCL repair, and MCL repair if still unstable

Explanation

The standard surgical algorithm for a terrible triad injury involves working deep to superficial from the lateral side. First, the coronoid fracture (or anterior capsule) is repaired. Next, the radial head is either fixed or replaced. Then, the lateral collateral ligament (LCL) complex is repaired to the lateral epicondyle. The medial collateral ligament (MCL) is only addressed if the elbow remains grossly unstable after these three steps.

Question 1800

Topic: Shoulder Arthroplasty & Arthritis

A 60-year-old man has a massive, irreparable posterosuperior rotator cuff tear. He has intact subscapularis and teres minor function. He complains primarily of an inability to actively elevate his arm above 40 degrees but has minimal pain (pseudoparalysis). Which of the following is the most appropriate surgical treatment?

. Latissimus dorsi tendon transfer
. Lower trapezius tendon transfer
. Reverse total shoulder arthroplasty
. Superior capsular reconstruction
. Arthroscopic debridement and biceps tenotomy

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

In older patients with a massive, irreparable posterosuperior rotator cuff tear and pseudoparalysis (inability to actively elevate >90 degrees), a reverse total shoulder arthroplasty (RTSA) provides a stable, fixed fulcrum and restores active elevation by maximizing the mechanical advantage of the deltoid muscle.

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