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9. Shoulder and Elbow MCQs

Practice Set 96 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 1901

Topic: 9. Shoulder and Elbow

A 75-year-old woman with severe glenohumeral osteoarthritis and a known massive irreducible rotator cuff tear sustains a severely displaced 3-part proximal humerus fracture. What is the most appropriate surgical treatment?

. Open reduction and internal fixation with a locking plate.
. Hemiarthroplasty.
. Reverse total shoulder arthroplasty.
. Closed reduction and percutaneous pinning.
. Nonoperative management with a sling.

Correct Answer & Explanation

. Reverse total shoulder arthroplasty.

Explanation

Reverse total shoulder arthroplasty is indicated for complex proximal humerus fractures in elderly patients with pre-existing rotator cuff arthropathy or massive rotator cuff tears. It relies on the deltoid for overhead function, bypassing the deficient rotator cuff.

Question 1902

Topic: Elbow & Forearm

A 45-year-old man undergoes volar locked plating for a displaced distal radius fracture. Six months later, he presents with an inability to actively extend his thumb interphalangeal joint. This complication is most likely due to rupture of which structure?

. Extensor pollicis longus (EPL).
. Flexor pollicis longus (FPL).
. Extensor carpi radialis brevis (ECRB).
. Extensor indicis proprius (EIP).
. Posterior interosseous nerve (PIN).

Correct Answer & Explanation

. Extensor pollicis longus (EPL).

Explanation

Prominent dorsal screws extending past the dorsal cortex in a volar plate construct are a common cause of extensor tendon irritation and EPL rupture. The EPL is particularly vulnerable as it curves around Lister's tubercle.

Question 1903

Topic: Elbow & Forearm

A 28-year-old woman falls from a height, sustaining a highly comminuted, unsalvageable radial head fracture and positive ulnar variance at the wrist with distal radioulnar joint (DRUJ) instability. What is the most appropriate management of the radial head in this setting?

. Radial head excision alone.
. Radial head excision with distal radioulnar joint pinning.
. Radial head arthroplasty.
. Radial head arthroplasty and distal radioulnar joint pinning.
. Open reduction and internal fixation.

Correct Answer & Explanation

. Radial head arthroplasty and distal radioulnar joint pinning.

Explanation

This is an Essex-Lopresti injury involving longitudinal radioulnar dissociation. Excision of the radial head without replacement leads to proximal radial migration; therefore, radial head arthroplasty combined with DRUJ stabilization is required.

Question 1904

Topic: Elbow & Forearm

A 40-year-old woman falls on her outstretched hand and sustains a capitellum fracture. Radiographs show a large anterior osteochondral fragment that includes the capitellum and the lateral half of the trochlea. This describes which type of fracture pattern?

. Hahn-Steinthal (Type 1).
. Kocher-Lorenz (Type 2).
. Broberg-Morrey (Type 3).
. Type 4 (McKee modification).
. Osborne-Cotterill.

Correct Answer & Explanation

. Type 4 (McKee modification).

Explanation

A Type 4 capitellum fracture (McKee modification of the Bryan and Morrey classification) involves a coronal shear fracture that includes the capitellum and the lateral half of the trochlea. It often requires stable anatomic fixation to prevent post-traumatic arthrosis.

Question 1905

Topic: 9. Shoulder and Elbow

A 75-year-old right-hand-dominant woman presents with a 4-part proximal humerus fracture after a ground-level fall. Radiographs demonstrate significant osteopenia and a severely comminuted calcar. She has a documented history of severe rotator cuff arthropathy in the affected shoulder. What is the most appropriate surgical management?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a locked plate
. Reverse total shoulder arthroplasty
. Hemiarthroplasty
. Nonoperative management with early pendulums

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for elderly patients with 4-part proximal humerus fractures and pre-existing rotator cuff dysfunction. It provides more predictable functional outcomes compared to hemiarthroplasty when tuberosity healing is uncertain.

Question 1906

Topic: 9. Shoulder and Elbow

A 42-year-old male sustains a severely displaced fracture of the scapular body and neck following a high-speed motor vehicle collision. Which of the following radiographic findings represents an absolute indication for surgical intervention?

. Scapular body comminution
. Medialization of the glenoid of 15 mm
. Glenohumeral instability
. Angulation of the glenoid neck of 20 degrees
. Articular step-off of 2 mm

Correct Answer & Explanation

. Glenohumeral instability

Explanation

Glenohumeral instability or subluxation is an absolute indication for operative fixation of scapula fractures. Articular step-off >4 mm, medialization >20 mm, and angulation >45 degrees are generally considered relative indications.

Question 1907

Topic: Elbow & Forearm

A 35-year-old female presents with a 'terrible triad' injury of the elbow consisting of an elbow dislocation, radial head fracture, and coronoid fracture. What is the standard sequence of repair during surgical reconstruction?

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

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for terrible triad injuries addresses structures from deep to superficial: coronoid fixation first, followed by radial head repair or replacement, and finally lateral ulnar collateral ligament (LUCL) repair.

Question 1908

Topic: 9. Shoulder and Elbow

A 72-year-old woman presents with severe shoulder pain and pseudoparalysis. Radiographs demonstrate severe glenohumeral osteoarthritis with superior migration of the humeral head articulating with the acromion.

Which of the following relies on the deltoid to restore active elevation in this setting?

. Total shoulder arthroplasty
. Hemiarthroplasty
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Arthroscopic superior capsule reconstruction

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty medializes and distalizes the center of rotation, which tensions the deltoid. This allows the deltoid to act as the primary elevator in the setting of rotator cuff tear arthropathy.

Question 1909

Topic: Elbow & Forearm

A 40-year-old weightlifter undergoes an anterior single-incision repair of a distal biceps tendon rupture. Postoperatively, he reports numbness over the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?

. Superficial radial nerve
. Median nerve
. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve
. Medial antebrachial cutaneous nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LACN) is the terminal sensory branch of the musculocutaneous nerve and courses near the cephalic vein in the lateral forearm. It is the most commonly injured nerve during a single-incision anterior distal biceps repair.

Question 1910

Topic: Elbow & Forearm

A 35-year-old man falls on an outstretched hand, sustaining a 'terrible triad' injury of the elbow. During surgical reconstruction, what is the generally recommended sequence of repair to restore elbow stability?

. Lateral collateral ligament complex, then radial head, then coronoid
. Coronoid, then radial head, then lateral collateral ligament complex
. Radial head, then lateral collateral ligament complex, then coronoid
. Medial collateral ligament, then coronoid, then radial head
. Coronoid, then medial collateral ligament, then radial head

Correct Answer & Explanation

. Coronoid, then radial head, then lateral collateral ligament complex

Explanation

The standard surgical sequence for a terrible triad injury is repairing deep to superficial. This involves addressing the coronoid first, followed by the radial head (repair or replace), and finally the lateral collateral ligament complex.

Question 1911

Topic: 9. Shoulder and Elbow

A 21-year-old collegiate baseball pitcher complains of vague posterior shoulder pain. Exam reveals 20 degrees of internal rotation and 130 degrees of external rotation. Which anatomic structure is most likely pathologically contracted?

. Anterior band of the inferior glenohumeral ligament
. Posterior band of the inferior glenohumeral ligament
. Coracohumeral ligament
. Subscapularis tendon
. Superior glenohumeral ligament

Correct Answer & Explanation

. Posterior band of the inferior glenohumeral ligament

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead throwing athletes is primarily caused by a contracture of the posteroinferior capsule. Specifically, the posterior band of the inferior glenohumeral ligament is tightened.

Question 1912

Topic: 9. Shoulder and Elbow

A 50-year-old woman with type 1 diabetes mellitus presents with recalcitrant adhesive capsulitis. After 9 months of failed physical therapy and intra-articular corticosteroid injections, she elects for surgery. What is the most appropriate next step in management?

. Manipulation under anesthesia alone
. Arthroscopic capsular release
. Open capsular release
. Biceps tenodesis
. Total shoulder arthroplasty

Correct Answer & Explanation

. Arthroscopic capsular release

Explanation

Arthroscopic capsular release (often combined with manipulation) is the treatment of choice for refractory adhesive capsulitis. Diabetic patients have a higher rate of recalcitrant disease and often require comprehensive release of the rotator interval and coracohumeral ligament.

Question 1913

Topic: 9. Shoulder and Elbow

A 72-year-old female presents with chronic right shoulder pain and an inability to actively raise her arm above 60 degrees. Radiographs, similar to those seen in advanced rotator cuff tear arthropathy, demonstrate superior migration of the humeral head with articulation at the acromion.

What is the most appropriate surgical intervention to restore functional elevation in this patient?

. Hemiarthroplasty
. Total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic rotator cuff repair
. Glenohumeral arthrodesis

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty relies on the deltoid to restore elevation in patients with a deficient rotator cuff. It medializes and distalizes the center of rotation, increasing the deltoid's moment arm and improving function.

Question 1914

Topic: Elbow & Forearm

In the surgical management of a "terrible triad" injury of the elbow, which of the following represents the most accepted sequence of repair after exposing the joint?

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

Correct Answer & Explanation

. Coronoid fixation, LCL repair, radial head repair

Explanation

Standard protocol for the terrible triad includes coronoid fixation, radial head repair or replacement, followed by lateral collateral ligament (LCL) repair. This inside-out sequence restores anterior skeletal stability before addressing the lateral ligamentous restraints.

Question 1915

Topic: 9. Shoulder and Elbow

A 45-year-old patient with type 1 diabetes mellitus presents with gradual onset of shoulder stiffness. Examination reveals a significant loss of active and passive external rotation with the arm at the side. What is the primary pathologic mechanism?

. Hypertrophy of the middle glenohumeral ligament
. Contracture of the rotator interval and coracohumeral ligament
. Capsular redundancy in the axillary pouch
. Fibrosis of the subscapularis tendon
. Ossification of the coracoacromial ligament

Correct Answer & Explanation

. Contracture of the rotator interval and coracohumeral ligament

Explanation

Adhesive capsulitis is characterized by severe loss of both active and passive range of motion, specifically external rotation. The primary pathology is fibroblastic proliferation and contracture of the rotator interval and the coracohumeral ligament.

Question 1916

Topic: 9. Shoulder and Elbow

A 70-year-old man presents with an inability to actively raise his right arm above 40 degrees, despite intact passive range of motion. Radiographs reveal superior migration of the humeral head with articulation against the acromion and severe glenohumeral osteoarthritis.

Which of the following surgical options is the most appropriate management for this patient?

. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Latissimus dorsi tendon transfer
. Superior capsular reconstruction

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty is indicated for rotator cuff arthropathy with pseudoparalysis. It medializes and distalizes the center of rotation, increasing the deltoid moment arm to restore elevation.

Question 1917

Topic: Elbow & Forearm

A 35-year-old woman sustains a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). Surgical fixation is planned. What is the generally accepted sequence of repair to restore stability?

. MCL repair -> Coronoid -> Radial head -> LCL
. Coronoid -> Radial head -> LCL -> MCL (if needed)
. Radial head -> LCL -> Coronoid -> MCL
. LCL -> Radial head -> Coronoid -> MCL
. Radial head -> Coronoid -> MCL -> LCL

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury proceeds from deep to superficial: coronoid fixation first, followed by the radial head, and finally the lateral collateral ligament (LCL) complex. MCL repair is only considered if the elbow remains grossly unstable after these steps.

Question 1918

Topic: 9. Shoulder and Elbow
A 45-year-old female with poorly controlled diabetes mellitus presents with a 4-month history of severe shoulder pain and progressively restricted active and passive range of motion. Radiographs are normal. What is the classic pathologic finding associated with this condition?
. Fibroblastic proliferation in the subacromial bursa
. Fibroblastic proliferation and thickening of the coracohumeral ligament and rotator interval
. Granulomatous inflammation of the inferior glenohumeral ligament
. Degeneration and delamination of the articular cartilage
. Calcific deposits within the supraspinatus tendon

Correct Answer & Explanation

. Fibroblastic proliferation and thickening of the coracohumeral ligament and rotator interval

Explanation

This patient has adhesive capsulitis, which is strongly associated with diabetes. Pathology demonstrates dense fibroblastic proliferation and type III collagen deposition, primarily affecting the rotator interval and coracohumeral ligament.

Question 1919

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate baseball pitcher is diagnosed with a full-thickness tear of the ulnar collateral ligament (UCL) of the elbow. Reconstruction is planned to restore valgus stability. Which specific ligamentous band must be reconstructed?

. Posterior bundle of the UCL
. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Transverse ligament of Cooper
. Lateral ulnar collateral ligament

Correct Answer & Explanation

. Anterior band of the anterior bundle

Explanation

The anterior band of the anterior bundle of the UCL is the primary restraint to valgus stress at the elbow during the throwing motion. Surgical reconstruction (Tommy John surgery) focuses on restoring this specific anatomical structure.

Question 1920

Topic: 9. Shoulder and Elbow

A 74-year-old woman presents with severe right shoulder pain and an inability to raise her arm above shoulder level. Radiographs reveal superior migration of the humeral head with an acromiohumeral distance of 4 mm. MRI confirms a massive, retracted rotator cuff tear involving the supraspinatus and infraspinatus with advanced fatty infiltration. What is the most appropriate surgical treatment?

. Arthroscopic rotator cuff repair
. Latissimus dorsi tendon transfer
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Reverse total shoulder arthroplasty (RTSA) is the gold standard for rotator cuff tear arthropathy and massive, irreparable tears with pseudoparalysis in the elderly. It medializes and distalizes the center of rotation, recruiting the deltoid to elevate the arm.

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