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9. Shoulder and Elbow MCQs

Practice Set 95 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 1881

Topic: 9. Shoulder and Elbow

A 45-year-old woman falls on an outstretched hand, sustaining a terrible triad injury of the elbow. During surgical reconstruction, what is the most appropriate sequence of repair to restore elbow stability?

. Lateral collateral ligament (LCL) repair, radial head fixation, coronoid fixation
. Coronoid fixation, radial head fixation or replacement, LCL repair
. Radial head replacement, medial collateral ligament (MCL) repair, coronoid fixation
. MCL repair, LCL repair, coronoid fixation
. Coronoid fixation, MCL repair, radial head replacement

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad injury is to build stability from deep to superficial, typically starting with coronoid fixation. This is followed by radial head fixation or arthroplasty, and finally, repair of the lateral collateral ligament (LCL) complex.

Question 1882

Topic: Elbow & Forearm

A 35-year-old male undergoes a two-incision surgical repair of a distal biceps tendon rupture. Postoperatively, he presents with an inability to extend his thumb and fingers at the metacarpophalangeal joints, but his wrist extension is preserved with radial deviation. Which nerve was most likely injured?

. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Median nerve
. Anterior interosseous nerve
. Superficial radial nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is particularly at risk during the posterolateral muscle-splitting approach of a two-incision distal biceps repair. Injury results in loss of finger and thumb extension, while wrist extension is preserved (with radial deviation) due to an intact extensor carpi radialis longus.

Question 1883

Topic: 9. Shoulder and Elbow

A 72-year-old woman presents with severe shoulder pain and an inability to raise her arm above 40 degrees of forward elevation. Radiographs show an acromiohumeral interval of 3 mm and severe glenohumeral osteoarthritis. If she undergoes the most appropriate arthroplasty procedure, what is its primary biomechanical advantage?

. Medialization and inferiorization of the center of rotation
. Lateralization and superiorization of the center of rotation
. Anatomic restoration of the glenohumeral joint line
. Reconstruction of the superior capsular restraints
. Obliteration of the deltoid moment arm to reduce tension

Correct Answer & Explanation

. Medialization and inferiorization of the center of rotation

Explanation

This patient has rotator cuff tear arthropathy with pseudoparalysis, which is best treated with a reverse total shoulder arthroplasty (rTSA). The rTSA medializes and inferiorizes the center of rotation, lengthening the deltoid moment arm and allowing it to initiate forward elevation without a functioning rotator cuff.

Question 1884

Topic: 9. Shoulder and Elbow

A 32-year-old female presents with lateral elbow pain after a fall. Imaging reveals a displaced coronal shear fracture of the capitellum with extension into the lateral trochlear ridge. What is the preferred surgical approach and fixation strategy?

. Medial approach with tension band wiring
. Posterior approach with triceps-splitting exposure and bridging plate
. Extended lateral approach with headless compression screws placed anterior-to-posterior
. Anterior approach with Herbert screws placed posterior-to-anterior
. Lateral approach with simple excision of the capitellar fragment

Correct Answer & Explanation

. Extended lateral approach with headless compression screws placed anterior-to-posterior

Explanation

Displaced coronal shear fractures of the capitellum are best managed with an extended lateral approach (Kocher or Kaplan). Headless compression screws placed from anterior-to-posterior provide stable fixation while countersinking below the articular cartilage to prevent joint impingement.

Question 1885

Topic: Elbow & Forearm

A 65-year-old woman fell onto her outstretched right arm and immediately had pain. She has a history of osteoporosis. Examination of the right arm reveals lateral arm swelling, ecchymosis, and she is unable to move the elbow due to pain. Her neurovascular status is intact. Radiographs are shown in Figures 14a and 14b. Appropriate treatment should include

. splint immobilization and early range-of-motion exercises.
. radial head excision.
. anatomic metallic radial head arthroplasty.
. radial head open reduction and internal fixation.
. anconeus interposition arthroplasty.

Correct Answer & Explanation

. anatomic metallic radial head arthroplasty.

Explanation

Comminuted, displaced radial head fractures (Hotchkiss type 3) require anatomic metallic radial head arthroplasty to regain function. Radial head excision has led to catastrophic sequelae including chronic wrist pain, elbow instability, and proximal radius migration. Immobilization, internal fixation, or anconeus arthroplasty are not recommended at this time because of the potentially poorer outcomes. Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

Question 1886

Topic: Elbow & Forearm

A 45-year-old man sustains a terrible triad injury of the elbow. During surgical reconstruction, what is the generally recommended sequence of repair?

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

Correct Answer & Explanation

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

Explanation

The standard sequence for terrible triad reconstruction is deep to superficial. This means coronoid fixation first, followed by radial head fixation or replacement, and finally LCL repair.

Question 1887

Topic: Elbow & Forearm

A 35-year-old woman sustains a highly comminuted radial head fracture and reports right wrist pain. Examination reveals tenderness over the distal radioulnar joint (DRUJ). If the radial head is deemed unreconstructible, what is the most appropriate management?

. Radial head resection and early range of motion
. Radial head resection and DRUJ pinning
. Radial head arthroplasty and DRUJ stabilization
. Silicone radial head replacement
. Radial head arthroplasty alone

Correct Answer & Explanation

. Radial head arthroplasty and DRUJ stabilization

Explanation

This is an Essex-Lopresti injury characterized by a radial head fracture and DRUJ disruption. Radial head resection alone leads to proximal radial migration, requiring radial head arthroplasty and DRUJ stabilization.

Question 1888

Topic: 9. Shoulder and Elbow

A 40-year-old man sustains an anterior shoulder dislocation with an associated displaced greater tuberosity fracture. Following successful closed reduction of the glenohumeral joint, radiographs show the greater tuberosity is displaced 8 mm superiorly. What is the most appropriate next step?

. Sling immobilization for 4 weeks
. Physical therapy for early range of motion
. Open reduction and internal fixation of the greater tuberosity
. Arthroscopic Bankart repair
. Reverse total shoulder arthroplasty

Correct Answer & Explanation

. Open reduction and internal fixation of the greater tuberosity

Explanation

Following shoulder reduction, greater tuberosity fractures displaced >5 mm in active patients generally require surgical fixation. This prevents subacromial impingement and restores rotator cuff function.

Question 1889

Topic: Elbow & Forearm

A 42-year-old bodybuilder feels a pop in his anterior elbow while lifting weights. Examination reveals an abnormal hook test and weakness in supination. During a single-incision anterior repair of the distal biceps tendon, which nerve is at greatest risk of injury?

. Median nerve
. Ulnar nerve
. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is at highest risk during the anterior single-incision approach to the distal biceps. This is due to its superficial location in the surgical field.

Question 1890

Topic: 9. Shoulder and Elbow
A 30-year-old woman presents with elbow pain after a fall. Imaging reveals a capitellum fracture consisting primarily of articular cartilage with very little subchondral bone. How is this fracture classified?
. Hahn-Steinthal (Type I)
. Kocher-Lorenz (Type II)
. Broberg-Morrey (Type III)
. McKee (Type IV)
. Dubberley Type A

Correct Answer & Explanation

. Kocher-Lorenz (Type II)

Explanation

A Kocher-Lorenz (Type II) capitellum fracture involves an articular cartilage shear fragment with minimal attached subchondral bone. Hahn-Steinthal (Type I) involves a large piece of subchondral bone.

Question 1891

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman with severe osteoporosis presents with a closed, displaced 3-part proximal humerus fracture involving the surgical neck and greater tuberosity. The humeral head is varus and severely retroverted. What is the most appropriate surgical treatment?

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

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (RTSA)

Explanation

Reverse total shoulder arthroplasty (RTSA) provides more reliable outcomes and improved active elevation compared to ORIF or hemiarthroplasty for displaced 3- and 4-part fractures in elderly patients with poor bone quality. It mitigates the risk of fixation failure and relies less on tuberosity healing for overhead function.

Question 1892

Topic: Elbow & Forearm

A 35-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. To optimally restore elbow stability, which of the following sequences is recommended during surgical reconstruction?

. Lateral ulnar collateral ligament (LUCL) repair -> coronoid fixation -> radial head fixation
. Radial head fixation -> LUCL repair -> coronoid fixation
. Coronoid fixation -> radial head repair or replacement -> LUCL repair
. LUCL repair -> radial head repair -> coronoid fixation
. Medial collateral ligament (MCL) repair -> radial head replacement -> LUCL repair

Correct Answer & Explanation

. Coronoid fixation -> radial head repair or replacement -> LUCL repair

Explanation

The standard surgical sequence for a terrible triad injury works from deep to superficial, or inside-out. This involves fixing the coronoid first, followed by repairing or replacing the radial head, and finally repairing the lateral ulnar collateral ligament (LUCL).

Question 1893

Topic: Elbow & Forearm

A 40-year-old man sustains a Bado Type I Monteggia fracture-dislocation. Intraoperatively, following rigid plate fixation of the ulna fracture, the radial head remains anteriorly dislocated. What is the most appropriate next step in management?

. Proceed directly to annular ligament reconstruction
. Perform closed reduction of the elbow and cast in extension
. Inspect the ulnar reduction for residual malalignment or shortening
. Perform an immediate radial head excision
. Open the radiocapitellar joint to forcefully reduce the radial head

Correct Answer & Explanation

. Inspect the ulnar reduction for residual malalignment or shortening

Explanation

In Monteggia fractures, the radial head should spontaneously reduce once the ulnar length and alignment are anatomically restored. If the radial head remains dislocated after ulnar fixation, the surgeon must first assume that the ulnar reduction is imperfect and address any residual angulation or shortening.

Question 1894

Topic: Elbow & Forearm
A Bryan and Morrey Type I (Hahn-Steinthal) fracture of the capitellum is best described radiographically and anatomically as:
. A thin shell of articular cartilage separated from subchondral bone
. A large fracture fragment comprising substantial subchondral bone and articular cartilage
. A highly comminuted capitellar fracture
. A coronal shear fracture extending medially to involve most of the trochlea
. An isolated osteochondral fracture of the lateral epicondyle

Correct Answer & Explanation

. A large fracture fragment comprising substantial subchondral bone and articular cartilage

Explanation

The Hahn-Steinthal (Type I) fracture involves a large osseous fragment of the capitellum containing a significant amount of subchondral bone. Type II (Kocher-Lorenz) is a thin articular cartilage shell, Type III is comminuted, and Type IV (McKee modification) involves the trochlea.

Question 1895

Topic: 9. Shoulder and Elbow

A 45-year-old man felt a sudden 'pop' in his anterior elbow while lifting a heavy box. On examination, a positive Hook test is noted. Which of the following physical examination findings is most functionally characteristic of this specific injury?

. Significant weakness in active elbow extension
. Significant weakness in active forearm pronation
. Significant weakness in active forearm supination
. Inability to actively flex the shoulder
. Paresthesias in the median nerve sensory distribution

Correct Answer & Explanation

. Significant weakness in active forearm supination

Explanation

A positive Hook test indicates a complete distal biceps tendon rupture. The biceps brachii is the primary supinator of the forearm, especially with the elbow flexed, so its rupture results in profound weakness in supination, along with mild-to-moderate weakness in elbow flexion.

Question 1896

Topic: Elbow & Forearm

A 45-year-old man falls from a ladder and sustains a 'terrible triad' injury to his elbow. Which of the following represents the most widely accepted surgical sequence for reconstructing this injury to restore stability?

. Repair lateral collateral ligament, fix/replace radial head, fix coronoid
. Fix coronoid, fix/replace radial head, repair lateral collateral ligament
. Repair medial collateral ligament, fix/replace radial head, repair lateral collateral ligament
. Fix/replace radial head, fix coronoid, repair lateral collateral ligament
. Fix coronoid, repair lateral collateral ligament, fix/replace radial head

Correct Answer & Explanation

. Fix coronoid, fix/replace radial head, repair lateral collateral ligament

Explanation

The standard deep-to-superficial approach for a terrible triad injury involves fixing the coronoid first, followed by the radial head, and finally repairing the lateral ulnar collateral ligament (LUCL).

Question 1897

Topic: Elbow & Forearm

A 35-year-old woman presents with severe elbow and wrist pain after a fall. Radiographs demonstrate a comminuted radial head fracture. On examination, she has marked tenderness and instability over the distal radioulnar joint (DRUJ). Which of the following treatments is absolutely contraindicated?

. Radial head excision alone
. Radial head open reduction and internal fixation
. Radial head arthroplasty
. Ulnar shortening osteotomy
. Closed reduction and casting of the wrist

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

This patient has an Essex-Lopresti injury (radial head fracture, interosseous membrane tear, and DRUJ disruption). Radial head excision alone is contraindicated as it will lead to proximal migration of the radius and chronic wrist pain.

Question 1898

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old woman with a history of severe osteoporosis sustains a displaced 4-part proximal humerus fracture. She lives independently and is active. What surgical option provides the most predictable return of forward elevation and is least dependent on tuberosity healing?

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

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (RTSA)

Explanation

RTSA relies on deltoid function rather than an intact rotator cuff. It provides more predictable functional outcomes for forward elevation in elderly patients with 4-part fractures, even if the tuberosities fail to heal.

Question 1899

Topic: Elbow & Forearm

A 42-year-old man sustains a fracture of the proximal third of the ulna with an associated radial head dislocation. During operative management, the ulna is anatomically reduced and rigidly plated, but the radial head remains dislocated. What is the most appropriate next step?

. Radial head resection
. Radial head arthroplasty
. Exploration of the radiocapitellar joint for interposed soft tissue
. Blind percutaneous pinning of the radiocapitellar joint
. Perform an ulnar lengthening osteotomy

Correct Answer & Explanation

. Exploration of the radiocapitellar joint for interposed soft tissue

Explanation

In a Monteggia fracture-dislocation, if the radial head fails to reduce after anatomic fixation of the ulna, soft tissue interposition (such as the annular ligament or joint capsule) blocking reduction must be suspected and openly explored.

Question 1900

Topic: Elbow & Forearm

A 35-year-old man falls on his outstretched arm, sustaining an elbow dislocation with associated radial head and coronoid process fractures. After operative restoration of the coronoid and radial head, the elbow remains unstable in extension. What is the most appropriate next step in management?

. Repair the lateral ulnar collateral ligament (LUCL).
. Repair the medial collateral ligament (MCL).
. Apply an external fixator.
. Perform a common extensor origin repair.
. Cross-pin the radiocapitellar joint.

Correct Answer & Explanation

. Repair the lateral ulnar collateral ligament (LUCL).

Explanation

The standard surgical sequence for a terrible triad injury involves coronoid fixation, radial head repair or replacement, and LUCL repair. If the elbow remains unstable after these steps, MCL repair or a hinged external fixator may be considered.

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