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9. Shoulder and Elbow MCQs

Practice Set 94 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 1861

Topic: Elbow & Forearm

A 45-year-old female presents with a coronal shear fracture of the capitellum extending into the trochlea (Hahn-Steinthal or Bryan and Morrey Type I).

What is the optimal surgical approach and internal fixation strategy?

. Medial approach with standard compression plates
. Lateral approach with headless compression screws placed posterior-to-anterior
. Lateral approach with headless compression screws placed anterior-to-posterior
. Posterior trans-olecranon approach with K-wires
. Anterior approach with T-plate fixation

Correct Answer & Explanation

. Lateral approach with headless compression screws placed anterior-to-posterior

Explanation

Capitellum fractures are best managed via an extensile lateral approach. Fixation using headless compression screws placed anterior-to-posterior, buried beneath the articular cartilage, provides optimal biomechanical stability.

Question 1862

Topic: 9. Shoulder and Elbow

A 45-year-old male sustains a "terrible triad" injury to his right elbow following a fall. During surgical reconstruction, the coronoid is fixed, the radial head is replaced, and the lateral ulnar collateral ligament (LUCL) is securely repaired to the lateral epicondyle. Intraoperatively, the elbow remains unstable and subluxates in extension. What is the most appropriate next step in management?

. Repair the medial collateral ligament (MCL)
. Perform a flexor-pronator mass advancement
. Apply an articulated external fixator
. Transarticular pinning of the radiocapitellar joint
. Immobilize the elbow in full supination for 6 weeks

Correct Answer & Explanation

. Repair the medial collateral ligament (MCL)

Explanation

The standard surgical algorithm for terrible triad injuries involves fixing the coronoid, restoring the radial head, and repairing the lateral collateral ligament complex. If the elbow remains unstable in extension after these structures are addressed, the next step is to repair the medial collateral ligament (MCL) prior to considering an external fixator.

Question 1863

Topic: 9. Shoulder and Elbow
A healthy 64-year-old man just underwent an uncomplicated shoulder arthroplasty for severe glenohumeral osteoarthritis. Intraoperatively, 60 degrees of external rotation was obtained. Postoperatively, he starts on a range-of-motion program. What limitations are recommended?
. No external rotation stretching for the first 6 weeks.
. No external rotation stretching for the first 3 weeks.
. Limit external rotation to the side to 60 degrees for the first 6 weeks.
. Limit external rotation to the side to 60 degrees for the first 3 weeks.
. No restrictions on external rotation stretching.

Correct Answer & Explanation

. Limit external rotation to the side to 60 degrees for the first 6 weeks.

Explanation

The patient needs restrictions on his external rotation to allow healing of the subscapularis tendon repair. Limitation to 60 degrees is common if the tendon repair is robust and shows no evidence of tension on range-of-motion testing during the surgery. Restriction from external rotation stretching for even 3 weeks would compromise his ultimate functional recovery. Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.

Question 1864

Topic: Elbow & Forearm

A 35-year-old male sustains a terrible triad injury to the elbow after a fall from a ladder. During the standard surgical reconstruction, what is the generally recommended sequence of repair?

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

Correct Answer & Explanation

. Coronoid, radial head, lateral collateral ligament

Explanation

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

Question 1865

Topic: Elbow & Forearm

A 30-year-old female presents with acute wrist and elbow pain after a high-energy fall. She is diagnosed with an Essex-Lopresti injury. What is the appropriate surgical management of the radial head in this scenario?

. Radial head excision and immediate motion
. Radial head excision and prolonged casting
. Radial head internal fixation or arthroplasty
. Closed reduction of the distal radioulnar joint only
. Distal ulna resection (Darrach procedure)

Correct Answer & Explanation

. Radial head internal fixation or arthroplasty

Explanation

Excision of the radial head is strictly contraindicated in Essex-Lopresti injuries due to the concomitant interosseous membrane disruption, which would lead to severe proximal radial migration. The radial head must be stabilized via ORIF or replacement.

Question 1866

Topic: Elbow & Forearm

A 45-year-old woman falls on an outstretched hand and sustains an elbow dislocation, radial head fracture, and coronoid process fracture. She is taken to the operating room for surgical stabilization. What is the most widely accepted sequence for reconstructing the elbow in this 'terrible triad' injury?

. Fixation of the lateral collateral ligament, followed by the radial head, then the coronoid.
. Fixation of the coronoid, followed by the radial head, then the lateral collateral ligament.
. Fixation of the radial head, followed by the lateral collateral ligament, then the coronoid.
. Fixation of the medial collateral ligament, followed by the coronoid, then the radial head.
. Fixation of the coronoid, followed by the lateral collateral ligament, then the radial head.

Correct Answer & Explanation

. Fixation of the coronoid, followed by the radial head, then the lateral collateral ligament.

Explanation

The standard surgical protocol for terrible triad injuries follows a deep-to-superficial approach. Fixation begins with the coronoid and anterior capsule, followed by radial head repair or replacement, and finally repair of the lateral collateral ligament (LCL).

Question 1867

Topic: 9. Shoulder and Elbow

A 42-year-old woman falls on an outstretched hand and sustains a terrible triad injury of the elbow. Which of the following describes the most appropriate sequence of surgical reconstruction?

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

Correct Answer & Explanation

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

Explanation

The standard sequence for treating a terrible triad injury of the elbow is fixation of the coronoid first, followed by repair or replacement of the radial head, and finally repair of the lateral collateral ligament (LCL) complex. This deep-to-superficial approach systematically restores elbow stability.

Question 1868

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old woman with severe osteoporosis presents with a 4-part proximal humerus fracture after a fall. She has a history of severe rotator cuff arthropathy with pseudo-paralysis of the shoulder prior to the injury. What is the most appropriate surgical intervention?

. Open reduction and internal fixation (ORIF) with a locking plate
. Closed reduction and percutaneous pinning
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for elderly patients with a 4-part proximal humerus fracture and a preexisting massive rotator cuff tear or cuff tear arthropathy. RTSA relies on the deltoid for shoulder elevation and does not depend on tuberosity healing, which is often compromised in osteoporotic bone.

Question 1869

Topic: Elbow & Forearm

A 45-year-old man falls onto an outstretched hand and sustains a 'terrible triad' injury of the elbow.

During surgical reconstruction to restore stability, which of the following represents the most widely accepted standard sequence of repair?

. Lateral ulnar collateral ligament (LUCL) repair, radial head fixation, coronoid fixation
. Coronoid fixation, radial head fixation or arthroplasty, LUCL repair
. Radial head fixation, medial collateral ligament (MCL) repair, coronoid fixation
. LUCL repair, MCL repair, coronoid fixation
. Coronoid fixation, MCL repair, radial head fixation

Correct Answer & Explanation

. Coronoid fixation, radial head fixation or arthroplasty, LUCL repair

Explanation

The standard surgical algorithm for a terrible triad injury proceeds from deep to superficial: coronoid fixation, followed by radial head fixation or replacement, and finally LUCL repair. The MCL is typically only repaired if the elbow remains unstable after the lateral side is secured.

Question 1870

Topic: Elbow & Forearm

A 35-year-old male weightlifter experiences a sudden 'pop' and sharp pain in his dominant anterior elbow while attempting to lift a heavy box. Examination reveals a positive Hook test. If a single-incision anterior surgical approach is chosen for repair, which of the following nerves is at greatest risk of injury?

. Posterior interosseous nerve (PIN)
. Median nerve
. Lateral antebrachial cutaneous nerve (LABCN)
. Superficial radial nerve
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. In contrast, the posterior interosseous nerve (PIN) is at higher risk during a two-incision approach.

Question 1871

Topic: Elbow & Forearm

A 25-year-old gymnast reports clicking, pain, and a feeling of instability in her elbow when pushing herself out of a chair, months after a posterior elbow dislocation. The pivot-shift test of the elbow is positive. Which ligamentous structure is primarily deficient?

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

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The patient's history and symptoms describe posterolateral rotatory instability (PLRI) of the elbow. The essential lesion in PLRI is insufficiency or rupture of the lateral ulnar collateral ligament (LUCL), which normally acts as a primary stabilizer against external rotation and varus stress.

Question 1872

Topic: Elbow & Forearm

A 45-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. What is the most appropriate surgical sequence to effectively restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical protocol for a terrible triad injury involves repairing structures from deep to superficial, or inside-out. The coronoid is fixed first, followed by the radial head (fixation or arthroplasty), and finally the lateral collateral ligament (LCL) complex.

Question 1873

Topic: 9. Shoulder and Elbow

A 38-year-old bodybuilder feels a sudden 'pop' in his anterior arm while deadlifting. Examination reveals a positive hook test and loss of the distal biceps contour. If this injury is managed nonoperatively, which of the following functional deficits is most expected?

. 50% loss of elbow flexion strength
. 40-50% loss of forearm supination strength
. 30% loss of forearm pronation strength
. 70% loss of elbow extension strength
. Complete loss of shoulder forward flexion

Correct Answer & Explanation

. 40-50% loss of forearm supination strength

Explanation

A complete distal biceps tendon rupture results primarily in a significant loss of forearm supination strength (averaging 40% to 50%). Loss of elbow flexion strength is less severe, typically around 30%.

Question 1874

Topic: Elbow & Forearm

A 40-year-old woman reports recurrent clicking and a sense of 'giving way' in her lateral elbow, particularly when she pushes herself out of a chair. What ligament is primarily deficient, and what is the typical mechanism of the initial injury?

. Radial collateral ligament; varus stress
. Lateral ulnar collateral ligament; axial load, valgus, and supination
. Anterior band of the medial collateral ligament; valgus stress
. Annular ligament; axial traction
. Posterior band of the medial collateral ligament; hyperflexion

Correct Answer & Explanation

. Lateral ulnar collateral ligament; axial load, valgus, and supination

Explanation

Posterolateral rotatory instability (PLRI) is caused by deficiency of the lateral ulnar collateral ligament (LUCL). It typically occurs following a traumatic event involving an axial load, a valgus force, and external rotation (supination) of the forearm relative to the humerus.

Question 1875

Topic: Elbow & Forearm

A 32-year-old man falls from a height onto his outstretched hands, sustaining a highly comminuted radial head fracture, diffuse forearm pain, and distal radioulnar joint (DRUJ) instability. To prevent longitudinal radioulnar dissociation, what is the most appropriate surgical management for the radial head?

. Radial head excision alone
. Radial head excision and DRUJ pinning
. Metallic radial head arthroplasty
. Radial head excision and acute interosseous membrane reconstruction
. Silastic radial head replacement

Correct Answer & Explanation

. Metallic radial head arthroplasty

Explanation

This patient has an Essex-Lopresti injury. Radial head excision is absolutely contraindicated as it will lead to proximal migration of the radius. A metallic radial head arthroplasty is required to restore the lateral column and longitudinal stability.

Question 1876

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old man with a chronic massive rotator cuff tear presents with pseudoparalysis. Radiographs show severe superior migration of the humeral head and acetabularization of the acromion. If a reverse total shoulder arthroplasty is performed, the center of rotation is altered in which direction compared to the native anatomy?

. Lateralized and superior
. Medialized and inferior
. Medialized and superior
. Lateralized and inferior
. Unchanged

Correct Answer & Explanation

. Medialized and inferior

Explanation

The Grammont design principles for reverse total shoulder arthroplasty involve medializing and inferiorizing the center of rotation. This optimizes the deltoid's moment arm and resting tension, allowing it to substitute for the deficient rotator cuff.

Question 1877

Topic: Elbow & Forearm

A 40-year-old man falls on an outstretched hand and sustains a posterior elbow dislocation, a radial head fracture, and a coronoid fracture. During surgical management, what is the standard recommended sequence of repair to restore elbow stability?

. Lateral collateral ligament repair, coronoid fixation, radial head fixation
. Coronoid fixation, radial head repair or replacement, lateral collateral ligament repair
. Radial head replacement, medial collateral ligament repair, coronoid fixation
. Medial collateral ligament repair, coronoid fixation, radial head repair
. Coronoid fixation, medial collateral ligament repair, lateral collateral ligament repair

Correct Answer & Explanation

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

Explanation

The standard sequence for terrible triad injuries is to build from deep to superficial and medial to lateral: fix the coronoid, address the radial head (fixation or arthroplasty), and finally repair the lateral ulnar collateral ligament (LUCL). The medial collateral ligament is generally only addressed if the elbow remains unstable after the lateral side is stabilized.

Question 1878

Topic: 9. Shoulder and Elbow

A 45-year-old man undergoes a two-incision technique for repair of a distal biceps tendon rupture. Six months postoperatively, he complains of a severe progressive loss of forearm rotation, though his elbow flexion arc is fully preserved. What is the most likely complication he has developed?

. Posterior interosseous nerve (PIN) entrapment
. Heterotopic ossification with radioulnar synostosis
. Re-rupture of the biceps tendon
. Complex regional pain syndrome
. Lateral antebrachial cutaneous neuroma

Correct Answer & Explanation

. Heterotopic ossification with radioulnar synostosis

Explanation

The two-incision technique for distal biceps repair carries a higher risk of heterotopic ossification and radioulnar synostosis compared to a single-incision anterior approach. This complication severely limits forearm pronation and supination due to bone bridging between the radius and ulna.

Question 1879

Topic: 9. Shoulder and Elbow

A 22-year-old collegiate baseball pitcher presents with right shoulder pain. Physical examination shows a 25-degree loss of internal rotation compared to the contralateral side, with an equivalent increase in external rotation. Which of the following anatomic structures is most likely contracted?

. Coracohumeral ligament
. Posterior band of the inferior glenohumeral ligament
. Middle glenohumeral ligament
. Superior glenohumeral ligament
. Anterior capsule

Correct Answer & Explanation

. Posterior band of the inferior glenohumeral ligament

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead throwing athletes is primarily caused by contracture and thickening of the posteroinferior capsule, specifically the posterior band of the inferior glenohumeral ligament. Treatment centers on posterior capsular stretching programs.

Question 1880

Topic: 9. Shoulder and Elbow

A 42-year-old carpenter presents with chronic lateral elbow pain exacerbated by lifting objects with the forearm pronated. Nonoperative management has failed after 12 months. He undergoes surgical debridement. Histologic examination of the excised pathological tissue is most likely to show which of the following?

. Acute inflammatory infiltrates with neutrophils
. Granulomatous inflammation with giant cells
. Angiofibroblastic hyperplasia
. Fibrinoid necrosis with palisading histiocytes
. Myxoid degeneration with calcium pyrophosphate crystals

Correct Answer & Explanation

. Angiofibroblastic hyperplasia

Explanation

Lateral epicondylitis (tennis elbow) is a degenerative tendinosis rather than an acute inflammatory process. Histologically, it is characterized by angiofibroblastic hyperplasia, disorganized collagen, and a distinct absence of acute inflammatory cells.

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