ABOS Upper Extremity MCQs (Set 2): Shoulder & Elbow

Question 1

A 31-year-old man sustained a closed injury to his arm in a motor vehicle accident 16 months ago. Treatment of the fracture consisted of intramedullary nailing of the humerus. He now reports pain with minimal activities. Clinical examination and laboratory studies suggest no signs of infection. Radiographs are seen in Figures 12a through 12c. Treatment should now consist of

Explanation

The use of locked nailing for the treatment of established nonunion of the humerus has produced poor results. Since humeral nailing has already failed, exchange humeral nailing without bone grafting has an even less change of success. To increase the likelihood of achieving bony union, the treatment of choice is removal of the humeral nail, dynamic compression plating, and bone grafting. Zuckerman J, Giordanno C, Rosen H: Treatment of humeral shaft non-unions, in Bigliani L (ed): Complications of shoulder surgery. Baltimore, MD, William & Wilkins, 1993, pp 173-190.

Question 2

A well-developed college football player reports swelling and a heaviness in the arm after lifting weights. Examination reveals that distal pulses are normal and equal in both arms. A venogram is shown in Figure 13. What is the most likely cause of this condition?

Explanation

The clinical findings indicate venous obstruction without arterial compression, and the venogram reveals occlusion of the subclavian vein, which is most likely the result of thoracic outlet compression. In the developed athlete, scalene muscle hypertrophy (Paget-Schroetter syndrome) causes compression of the subclavian vein. Treatment should consist of thrombolysis followed by decompressive surgery. Angle N, Gelabert HA, Farooq MM, et al: Safety and efficacy of early surgical decompression of the thoracic outlet for Paget-Schroetter syndrome. Ann Vasc Surg 2001;15:37-42.

Question 3

Figure 14 shows the AP radiograph of a patient who underwent prosthetic arthroplasty 8 years ago and has now become symptomatic again over the past 18 months. A WBC count and erythrocyte sedimentation rate are within normal limits, and aspiration of the glenohumeral joint yields a negative Gram stain and cultures. Which of the following procedures will most likely provide the best pain relief and function?

Explanation

Simple removal of the loose glenoid component or removal of the loose component followed by implantation of a new glenoid component are both appropriate treatment choices, depending on the remaining glenoid bone stock. However, removal and reimplantation appears to provide the most predictable pain relief and better function than removal alone. Antuna SA, Sperling JW, Cofield RH, et al: Glenoid revision surgery after total shoulder arthroplasty. J Shoulder Elbow Surg 2001;10:217-224.

Question 4

A 52-year-old woman reports the sudden onset of intense pain in the right shoulder. She denies any history of injury or previous shoulder problems. At a 2-week follow-up examination, she notes that the pain has decreased, but she now has severe weakness of the external rotators and abductors. Her cervical spine and remaining shoulder examination are otherwise unremarkable. Radiographs of the shoulder and neck are normal. What is the most likely diagnosis?

Explanation

Patients with brachial neuritis or Parsonage-Turner syndrome usually report the sudden onset of intense pain that subsides in 1 to 2 weeks, followed by weakness for a period of up to 1 year in the muscle that is supplied by the involved nerve. Calcific tendinitis usually can be diagnosed radiographically, with calcium deposits seen in the rotator cuff. Bursitis and rotator cuff tendinosis usually are seen after an increase in activity, and both decrease with rest and medication. Glenohumeral arthritis is a slow, progressive problem that results in a loss of range of motion. Misamore GW, Lehman DE: Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am 1996;78:1405-1408.

Question 5

What is the most commonly reported complication following elbow arthroscopy?

Explanation

The complication rate following elbow arthroscopy is reported at 5%. The most commonly reported complication is transient neurapraxia, with nerve transection remaining an unfortunate and rare event. While infection remains the most common serious complication, it is uncommon (0.8%). Synovial cutaneous fistula and compartment syndrome, while reported, are the least frequent complications of elbow arthroscopy. Kelly EW, Morrey BF, O'Driscoll SW: Complications of elbow arthroscopy. J Bone Joint Surg Am 2001;83:25-34.

Question 6

When an acute infection of a total elbow arthroplasty is managed with irrigation and debridement, which of the following organisms is associated with the highest risk of persistent infection?

Explanation

Salvage of a total elbow arthroplasty is possible with early aggressive management of acute infection (symptoms for less than 30 days) with serial irrigation and debridement and antibiotic bead placement. This form of treatment is indicated when there are no radiographic or intraoperative signs of loosening. However, successful treatment is largely dependent on the organism. Staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and IV antibiotics. Yamaguchi K, Adams RA, Morrey BF: Infection after total elbow arthroplasty. J Bone Joint Surg Am 1998;80:481-491.

Question 7

A professional baseball player has had intermittent, mild shoulder pain for the past 2 years. Nonsurgical management has consisted of anti-inflammatory drugs. Examination reveals atrophy of the infraspinatus muscle but not the supraspinatus. There is weakness in external rotation with the arm at his side but not at 90 degrees of abduction. He has no weakness or pain with resisted abduction. Electromyography confirms an isolated lesion of the suprascapular nerve branch to the infraspinatus. He is otherwise neurologically intact. An MRI scan of the shoulder shows no cysts but confirms atrophy of the infraspinatus muscle. What is the next most appropriate step in management?

Explanation

Suprascapular nerve injuries are more commonly seen in athletes who participate in overhead activities. When a patient is evaluated for posterior shoulder pain and infraspinatus muscle weakness or atrophy, electrodiagnostic studies are an essential part of the evaluation. In addition, imaging studies are indicated to exclude other diagnoses that can mimic a suprascapular nerve injury. Initial management should consist of cessation of the aggravating activity along with an organized shoulder rehabilitation program. If nonsurgical management fails to provide relief within 6 months to 1 year, surgical exploration of the suprascapular nerve should be considered. Release of the spinoglenoid ligament with resultant suprascapular nerve decompression may result in pain relief and a return of normal shoulder function. In this patient, who has a chronic neuropathy and mild symptoms, surgery is indicated only if nonsurgical management fails to provide relief and he is unable to perform at his position. Cummins CA, Bowen M, Anderson K, et al: Suprascapular nerve entrapment at the spinoglenoid notch in a professional baseball pitcher. Am J Sports Med 1999;27:810-812. Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.

Question 8

A 66-year-old woman who requires a cane for ambulation now notes increasing difficulty in using the cane after undergoing total elbow arthroplasty 3 months ago. AP and lateral radiographs are shown in Figures 15a and 15b. What is the most likely diagnosis?

Explanation

The lateral radiograph reveals a triceps avulsion with a small portion of bone. Triceps weakness and insufficiency can be a symptomatic problem after total elbow arthroplasty and is probably underreported. Ulnar nerve neuritis, aseptic loosening, instability, and infection are all complications of total elbow arthroplasty but would not account for the radiographic findings. Koval K (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orhthopaedic Surgeons, 2002, pp 323-327.

Question 9

The mother of a healthy 8-month-old boy reports that her son refuses to use his left arm. Examination reveals that the arm hangs limp at his side in an adducted and internally rotated position, and the affected shoulder subluxates posteriorly. Passive external rotation measures 15 degrees. Management should consist of

Explanation

Injury to the upper trunk of the brachial plexus during birth (Erb's palsy) occurs in approximately 1 in 3,000 births. In a complete lesion, paralysis of the deltoid, supraspinatus, infraspinatus, teres minor, biceps, and brachioradialis results in the findings described above. Spontaneous recovery may occur for up to 2 years. Passive exercises administered daily by the parents are the initial recommended treatment at this age. If significant contracture results in posterior dislocation, surgical correction may be considered. Neer CS: Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990, pp 452-454. Pearl ML: Arthroscopy release of shoulder contracture secondary to birth palsy: An early report on findings and surgical technique. Arthroscopy 2003;19:577-582.

Question 10

During shoulder motion with the elbow controlled in a brace, electromyographic studies of the supraspinatus show significant activity with all range-of-motion testing. Concurrent electromyographic studies of the long head of the biceps will most likely show

Explanation

During electromyographic studies, the long head of the biceps has been shown to have little activity throughout a wide range of shoulder motion as long as the elbow is immobilized. The supraspinatus is active throughout the range of shoulder motion. Rotator cuff tears do not influence biceps activity as long as the elbow is controlled. Yamaguchi K, Riew KD, Galutz LM, et al: Biceps activity during shoulder motion: An electromyographic analysis. Clin Orthop 1997;336:122-129.

Question 11

A right-handed 24-year-old professional baseball player injured his left shoulder 6 weeks ago when he dove forward and landed hard with the arm extended. He reports that the shoulder "slipped out" and "went back in." The shoulder did not need to be reduced. He now reports deep pain in the front of the shoulder when batting on either side and is hesitant to raise his left arm up over his head to catch a ball. Examination reveals no obvious deformities of the shoulder and a somewhat guarded, limited range of motion in all planes. Provocative tests for the rotator cuff and labrum are equivocal. MRI scans are shown in Figures 16a and 16b. What is the best course of action?

Explanation

A hard fall on an outstretched arm often results in injury to the glenoid labrum. A significant tear of the anterior/inferior labrum often leads to instability, pain, and mechanical symptoms of the shoulder. The MRI scan shows no obvious labral tear or Hill-Sachs lesion to suggest an anterior dislocation. Recent clinical studies have suggested that early stabilization of initial anterior dislocations may lead to better results than nonsurgical management in young, athletic patients. However, there are no data to support early surgery for anterior labral tears resulting from traumatic subluxation without dislocation. Initial treatment should consist of a short period of rest and immobilization, followed by a physical therapy rehabilitation program designed to restore motion, strength, and dynamic stability to the shoulder. If the athlete cannot return to play following nonsurgical management, surgical repair of the labrum, either through an open or arthroscopic approach, is indicated. There is no role for immediate thermal capsular shift in this setting. Abrams JS, Savoie FH III, Tauro JC, et al: Recent advances in the evaluation and treatment of shoulder instability: Anterior, posterior and multidirectional. Arthroscopy 2002;18:1-13.

Question 12

A 35-year-old woman dislocated her right shoulder in a fall from a step stool several months ago. She now reports several painful recurrences. Examination reveals anterior and inferior apprehension that reproduces her symptoms. An MRI scan is shown in Figure 17. Management should consist of

Explanation

The MRI findings reveal a disruption of the humeral insertion of the glenohumeral ligaments and joint capsule (humeral avulsion of the glenohumeral ligament). This lesion has been reported to account for an 8% rate of recurrent dislocation in a subset of patients who are typically older than those with the more common lesions of the glenoid labrum (Bankart lesion). Open repairs have been reported to be successful in the prevention of recurrent instability. Since there is no Bankart lesion, open or arthroscopic labral repairs are not indicated. Nonsurgical management is possible if the patient does not want to undergo surgery; however, the recurrence rate is very high. Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607. Bokor DJ. Conboy VB. Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96.

Question 13

A 20-year-old man sustained an injury to his arm during a tug-of-war contest. An MRI scan is shown in Figure 18. What is the most likely diagnosis?

Explanation

The MRI scan reveals a transection of the biceps muscle. The underlying brachialis is intact. This injury can occur as a result of a cord wrapped around the upper arm. Care should be taken to ensure that there is no concurrent vascular injury. A posterior subcutaneous lipoma appears as a well-encapsulated mass on T2-weighted images. Heckman JD, Levine MI: Traumatic closed transection of the biceps brachii in the military parachutist. J Bone Joint Surg Am 1978;60:369-372.

Question 14

When the elbow is extended and an axial load is applied, what percent of stress distribution occurs across the ulnohumeral and radiohumeral articular surface, respectively?

Explanation

When load is applied to the wrist, most of the stress is absorbed by the radius. As the load is transferred through the forearm, the interosseous membrane transfers some of the load from the radius to the ulna. The load at the elbow is distributed with 40% at the ulnohumeral articulation and 60% at the radiohumeral articulation. Halls AA, Travill R: Transmission of pressure across the elbow joint. Anat Rec 1964;150:243.

Question 15

Which of the following is most frequently associated with heterotopic ossification about the shoulder?

Explanation

Multiple attempts at closed reduction, delayed surgery for proximal humeral fractures, and associated closed head injury all have been associated with a higher incidence of heterotopic ossification. Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, p 291.

Question 16

A 55-year-old woman with a 15-year history of systemic lupus erythematosus has had left shoulder pain for the past 3 months. She reports that the pain has grown progressively worse over the past few months, and her shoulder function is severely limited. She is presently being treated with azathioprine and has used corticosteroids in the past. AP and axillary radiographs are shown in Figures 19a and 19b, and MRI scans are shown in Figures 19c and 19d. Which of the following forms of management will yield the most predictable pain relief and return of shoulder function?

Explanation

Prosthetic shoulder arthroplasty has been shown to provide predictable results for treating stage III and stage IV osteonecrosis of the humeral head. The decision to resurface the glenoid (total shoulder arthroplasty versus humeral hemiarthroplasty) usually is made based on the radiographic and intraoperative appearance of the glenoid. Core decompression of the humeral head has been reported to be effective for earlier stages (pre collapse) but would not be appropriate for a patient with stage IV disease. Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Results of replacement. J Shoulder Elbow Surg 2000;9:177-182. L'Insalata JC, Pagnani MJ, Warren RF, et al: Humeral head osteonecrosis: Clinical course and radiographic predictors of outcome. J Shoulder Elbow Surg 1996;5:355-361.

Question 17

A 45-year-old man sustains an acute closed posterolateral elbow dislocation. The elbow is reduced, and examination reveals that the elbow dislocates posteriorly at 35 degrees with the forearm placed in supination. What is the best course of action?

Explanation

Most closed simple dislocations are best managed with early range of motion. Posterior dislocation typically occurs through a posterolateral rotatory mechanism. When placed in pronation, the elbow has greater stability when the medial ligamentous structures are intact. In traumatic dislocations, MRI rarely provides additional information that will affect treatment. In elbows that remain unstable, primary repair is preferred over ligament reconstruction. Cast immobilization increases the risk of arthrofibrosis.

Question 18

Figure 20 shows the MRI scan of a 20-year-old athlete who has a painful shoulder. This pathology is most commonly seen in

Explanation

The MRI scan reveals a posterior labral detachment. This injury is the result of a posteriorly directed force and is common to football players in blocking positions. Although this injury can occur with trauma in all types of athletes, it is seen with relative frequency in football. Treatment is aimed at labral repair with posterior capsulorrhaphy. Both open and arthroscopic techniques can be used. Misamore GW, Facibene WA: Posterior capsulorrhaphy for the treatment of traumatic recurrent posterior subluxations of the shoulder in athletes. J Shoulder Elbow Surg 2000;9:403-408.

Question 19

Figure 21 shows the radiograph of an 18-year-old man who was brought to the emergency department with shoulder pain following a rollover accident on an all-terrain vehicle. Examination reveals a fracture with massive swelling; however, the skin is intact and not tented over the fracture. Based on these findings, initial management should consist of

Explanation

The radiographic and clinical findings suggest a scapulothoracic dissociation with a widely displaced clavicular fracture and a laterally displaced scapula. These injuries have a high association with neurovascular injuries to the brachial plexus and subclavian artery. Emergent vascular evaluation with arteriography and possible vascular repair are indicated. This repair can be combined with open reduction and internal fixation of the clavicle to improve stability. Delay in treatment of these vascular injuries can be devastating. Iannotti JP, Williams GR (eds): Disorders of the Shoulder. Philadelphia, PA, Lippincott, 1999, pp 632-635.

Question 20

A 55-year-old man reports increasing weakness in his arms that has progressed to his lower limbs, resulting in frequent tripping and falling. Examination reveals weakness in shoulder abduction and external and internal rotation bilaterally. Fasciculation is noted. He also has weakness in elbow flexion and extension bilaterally, and his grip strength is diminished. An electromyogram and nerve conduction velocity studies show decreased amplitude of compound motor action potential, slightly slowed motor conduction velocity, and denervation signs with decreased recruitment in all extremities. The sensory study is normal. Based on these findings, what is the most likely diagnosis?

Explanation

The major determinant of ALS (Lou Gehrig disease) is progressive loss of motor neurons. The loss usually begins in one area, is asymmetrical, and later becomes evident in other areas. The first signs of ALS may include either upper or lower motor neuron loss. Recognition of upper motor neuron involvement depends on clinical signs, but electromyography and nerve conduction velocity studies can help identify lower motor neuron involvement. Electrodiagnostic abnormalities in three or more areas are required to make a definitive diagnosis. The motor unit potentials (MUPs) changes in ALS include impaired MUPs recruitment, unstable MUPs, and abnormal MUPs size and configuration. A number of abnormal spontaneous discharges can occur with ALS, especially fibrillation potentials and fasciculation potentials. In ALS, the motor nerve conduction study will be abnormal, but a co-existing normal sensory study is definitive for this disease. de Carvalho M, Johnsen B, Fuglsang-Frederiksen A: Medical technology assessment: Electrodiagnosis in motor neuron diseases and amyotrophic lateral sclerosis. Neurophysiol Clin 2001;31:341-348. Daube JR: Electrodiagnostic studies in amyotrophic lateral sclerosis and other motor neuron disorders. Muscle Nerve 2000;23:1488-1502.

Question 21

Which of the following positions of immobilization has been shown to best approximate the anterior labrum against the glenoid rim following anterior dislocation of the shoulder?

Explanation

Following anterior dislocation of the shoulder, the affected arm is typically placed in a sling with the shoulder in adduction and internal rotation. A recent study has shown that placement in this position actually results in laxity of the anterior supporting structures of the shoulder, allowing the postinjury hemarthrosis to push the labrum and capsular ligaments away from the anterior glenoid rim. Thus, immobilization in this position may actually impede healing of these structures. Alternatively, resting the arm in a position of adduction and external rotation allows the anterior supporting structures to abut against the anterior glenoid rim by forcing the hemarthrosis posteriorly. Placing the arm in this position following anterior dislocation is believed to allow for better healing of the anterior labrum and ligaments.

Question 22

What is the most common complication following arthroscopic capsular release in a patient with adhesive capsulitis of the shoulder?

Explanation

Although all of the above are potential complications after arthroscopic capsular release for adhesive capsulitis, the most common problem is the failure to regain normal glenohumeral motion. An immediate physical therapy program is critical to prevent this complication. Ghalambor N, Warner JJP: Arthroscopic capsular release: Evolution of the technique and its applications. Tech Shoulder Elbow Surg 2000;1:52-60.

Question 23

What is the most common complication following surgical fixation of a distal humeral fracture?

Explanation

In most series, elbow stiffness is the most common complication and can be overcome by achieving stable fixation and initiating early motion after surgery. All of the other complications are seen but to a lesser degree than elbow stiffness. Sanders RA, Raney EM, Pipkin S: Operative treatment of bicondylar intra-articular fractures of the distal humerus. Orthopedics 1992;15:159-163.

Question 24

A 16-year-old female swimmer reports several episodes of atraumatic glenohumeral instability that occur with different arm positions. Examination reveals generalized ligamentous laxity and a positive sulcus sign, and her shoulder can be subluxated both anteriorly and posteriorly. Initial management should consist of

Explanation

The patient has multidirectional instability (MDI). It has been reported that a high percentage of patients with MDI respond to a properly structured exercise program that is continued for at least 3 to 6 months. If nonsurgical management fails to provide relief, stabilization with an inferior capsular shift procedure has been effective in a high percentage of patients. Unidirectional repairs, such as the Putti-Platt procedure, are unsuitable for correcting MDI. Thermal capsulorrhaphy has been reported to have a very high failure rate (greater than 50%) for treating MDI. Burkhead WZ Jr, Rockwood CA Jr: Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1992;74:890-896. Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908. Pollock RG, Owens JM, Flatow EL, et al: Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am 2000;82:919-928.

Question 25

A 13-year-old boy has a mild deformity of the left sternoclavicular joint after being involved in a rollover accident while riding an all-terrain vehicle. Examination in the emergency department reveals that he is hemodynamically stable, and his neurovascular examination is normal. The CT scan shown in Figure 22 was obtained because radiographs were inconclusive. Management should consist of

Explanation

The CT scan reveals a completely displaced physeal fracture of the medial clavicle with marked posterior displacement of the distal fragment. This fracture pattern is associated with potential injury to the vascular structures of the mediastinum. Reduction should be performed for this fracture and generally can be done closed with shoulder retraction and upward pull on the clavicle with a towel clip. Once reduced, the fracture is relatively stable and typically will heal in good position. Reduction should be performed in the operating room in the event that a vascular injury is detected once compression is removed from the clavicle. Open reduction may be necessary if closed reduction is not possible; however, pinning or ligament reconstruction usually is not necessary. Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, p 581.

Question 26

A 45-year-old mechanic presents with chronic radial-sided wrist pain. Imaging shows a scaphoid waist nonunion with radioscaphoid and capitolunate arthritis. The radiolunate joint is entirely spared. What is the most appropriate surgical treatment?

Explanation

In SNAC stage III, arthritis involves the radioscaphoid and capitolunate joints but spares the radiolunate joint. Scaphoid excision and four-corner fusion is indicated, whereas proximal row carpectomy is contraindicated due to the presence of capitolunate arthritis.

Question 27

A 35-year-old weightlifter undergoes a single-incision anterior repair of a distal biceps tendon rupture using suture anchors. Postoperatively, he exhibits weakness in thumb and finger extension, but normal wrist flexion. Wrist extension is weak and deviates radially. Which nerve was most likely injured during the procedure?

Explanation

The posterior interosseous nerve (PIN) is at risk during the single-incision anterior approach for distal biceps repair, especially with excessive lateral retraction. PIN injury presents with weakness in finger/thumb extension and weak, radially-deviated wrist extension (due to ECRL preservation via the radial nerve proper).

Question 28

A 22-year-old rugby player has recurrent anterior shoulder instability. CT scan demonstrates 25% glenoid bone loss and a large, engaging Hill-Sachs lesion. What is the most appropriate definitive management?

Explanation

For recurrent anterior shoulder instability with critical glenoid bone loss (typically >20-25%), an arthroscopic soft tissue repair is insufficient. The Latarjet procedure (coracoid transfer) is indicated to restore the glenoid arc and provide a dynamic sling effect.

Question 29

A 28-year-old carpenter sustains a laceration to the volar index finger at the proximal phalanx, completely dividing the FDP and FDS tendons. He undergoes primary 6-strand core repair. Which rehabilitation protocol provides the best combination of tendon glide and prevention of rupture?

Explanation

Modern 4- and 6-strand core suture techniques for Zone II flexor tendon repairs are strong enough to allow early active motion protocols. This approach minimizes peritendinous adhesions and improves functional excursion compared to strict immobilization or passive-only protocols.

Question 30

Six weeks after closed reduction and casting of a nondisplaced distal radius fracture, a 65-year-old woman presents with the sudden inability to actively extend her thumb interphalangeal joint. What is the most appropriate surgical management?

Explanation

Extensor pollicis longus (EPL) tendon rupture is a known complication of nondisplaced distal radius fractures due to ischemia or attrition in the third dorsal compartment. Because the tendon ends are typically retracted and degenerated, EIP to EPL transfer is the preferred and most reliable treatment.

Question 31

A 42-year-old woman undergoing hemodialysis for end-stage renal disease presents with severe, bilateral carpal tunnel syndrome that has failed conservative management. During open carpal tunnel release, thick, brownish tenosynovial tissue is noted. What is the most likely composition of this tissue?

Explanation

Dialysis-related amyloidosis is caused by the accumulation of Beta-2-microglobulin, which is not adequately cleared by standard hemodialysis membranes. It frequently deposits in the osteoarticular system, commonly causing severe carpal tunnel syndrome and destructive arthropathy.

Question 32

A 45-year-old man falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. Which of the following is the standard recommended sequence of surgical reconstruction?

Explanation

The standard surgical algorithm for a terrible triad injury begins with restoring deep to superficial and anterior to posterior structures. This typically involves coronoid fixation first, followed by radial head fixation or replacement, and finally LCL complex repair.

Question 33

A 72-year-old woman with rotator cuff tear arthropathy and pseudoparalysis undergoes a reverse total shoulder arthroplasty (RTSA). Which of the following muscles provides the primary motive force for active elevation postoperatively?

Explanation

Reverse total shoulder arthroplasty medializes and distalizes the center of rotation, increasing the moment arm and resting tension of the deltoid muscle. This allows the deltoid to effectively compensate for the deficient rotator cuff to provide active anterior elevation.

Question 34

The spiral cord in Dupuytren's disease causes central and superficial displacement of the digital neurovascular bundle, placing it at high risk during fasciectomy. Which of the following normal anatomical structures is NOT a component of the spiral cord?

Explanation

The spiral cord is formed by the pathologic contracture of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. Cleland's ligament is located dorsal to the neurovascular bundle and is typically spared in Dupuytren's disease.

Question 35

A 30-year-old manual laborer presents with dorsal wrist pain. Radiographs show sclerosis and fragmentation of the lunate, with a negative ulnar variance of 3 mm. There is no radiocarpal arthritis. What is the most appropriate initial surgical intervention?

Explanation

In early-stage Kienböck's disease (Stage II or IIIA) associated with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. This decreases the mechanical load transmitted across the radiolunate joint, potentially allowing for revascularization of the lunate.

Question 36

A 6-year-old boy sustains a Bado Type I Monteggia fracture-dislocation. Closed reduction of the ulna fracture is achieved and stabilized with an intramedullary wire, but the radial head remains anteriorly dislocated. What is the most appropriate next step in management?

Explanation

In pediatric Monteggia fractures, the radial head dislocation almost always reduces once the ulnar fracture is anatomically reduced and aligned. If the radial head remains dislocated, the surgeon must first critically evaluate the ulnar reduction (ruling out plastic deformation) before attempting open reduction of the radiocapitellar joint.

Question 37

A 45-year-old construction worker falls from a ladder and sustains an elbow dislocation. Radiographs reveal a posterior elbow dislocation associated with a radial head fracture and a coronoid fracture. During surgical reconstruction of this 'terrible triad' injury, what is the standard sequence of repair?

Explanation

The standard surgical sequence for a terrible triad injury proceeds from deep/medial to superficial/lateral. The coronoid is fixed first to restore anterior stability, followed by radial head repair or replacement, and finally the LCL complex is repaired.

Question 38

A 24-year-old man presents with a 9-month history of wrist pain after a fall. MRI shows a scaphoid nonunion with avascular necrosis (AVN) of the proximal pole. What is the most appropriate surgical management?

Explanation

Proximal pole AVN with nonunion is an indication for vascularized bone grafting (e.g., 1,2 ICSRA pedicled graft). Non-vascularized grafts have an unacceptably high failure rate when the proximal pole is ischemic.

Question 39

A 72-year-old female presents with chronic right shoulder pain and pseudoparalysis, unable to actively elevate her arm past 40 degrees. Radiographs show severe glenohumeral arthritis with superior migration of the humeral head articulating with the acromion. Which procedure provides the most predictable improvement in function?

Explanation

Rotator cuff tear arthropathy complicated by pseudoparalysis is best treated with a reverse total shoulder arthroplasty. This design lateralizes and distalizes the center of rotation, recruiting the deltoid to restore forward elevation.

Question 40

A 45-year-old manual laborer presents with persistent shoulder pain. MRI confirms a Type II SLAP tear. After failing conservative management, surgical intervention is planned. To minimize the risk of post-operative stiffness and reoperation in this demographic, what is the preferred procedure?

Explanation

In patients older than 40, primary biceps tenodesis yields better clinical outcomes, higher satisfaction, and lower reoperation rates compared to arthroscopic SLAP repair for Type II lesions.

Question 41

A 30-year-old man sustains a closed midshaft humerus fracture. Initial examination shows intact radial nerve function. A closed reduction is performed, and a coaptation splint is applied. Immediately after reduction, the patient is unable to extend his wrist or fingers. What is the most appropriate next step?

Explanation

A secondary radial nerve palsy that occurs immediately after a closed reduction attempt of a closed humeral shaft fracture is an absolute indication for surgical exploration. The nerve may be entrapped in the fracture site.

Question 42

A 35-year-old carpenter has central dorsal wrist pain. Radiographs reveal sclerosis and a coronal fracture of the lunate, without carpal collapse (Lichtman Stage IIIa). Ulnar variance is neutral. What is the most appropriate joint-leveling procedure to unload the lunate?

Explanation

For Kienböck disease stage I-IIIa with neutral or negative ulnar variance, a joint-leveling procedure like radial shortening osteotomy is indicated. It decreases the mechanical load on the lunate to prevent progressive collapse.

Question 43

A 42-year-old male undergoes a two-incision surgical repair of a distal biceps tendon rupture. Compared to a single-incision anterior approach, the two-incision technique carries a historically higher risk of which of the following complications?

Explanation

The classic two-incision technique for distal biceps repair is associated with a higher risk of radioulnar synostosis (heterotopic ossification). Single-incision approaches carry a higher risk of injury to the lateral antebrachial cutaneous nerve.

Question 44

A 25-year-old cyclist sustains a displaced fracture of the distal third of the clavicle. Radiographs show superior displacement of the medial fragment, while the coracoclavicular (CC) ligaments remain attached to the distal fragment. What is the recommended management?

Explanation

Neer Type II distal clavicle fractures involve detachment of the medial segment from the CC ligaments. Because of the high nonunion rate (up to 50%) with nonoperative management, operative fixation is indicated.

Question 45

Following a primary repair of a Zone II flexor digitorum profundus (FDP) laceration in the index finger, which post-operative rehabilitation protocol most reliably decreases adhesion formation while protecting the repair?

Explanation

Early active motion protocols, such as 'place and hold', have been shown to significantly reduce tendon adhesions and improve ultimate excursion in Zone II repairs, providing superior functional outcomes compared to passive protocols.

Question 46

A 65-year-old patient presents with a highly comminuted olecranon fracture that exits distal to the coronoid process (trans-olecranon fracture-dislocation pattern). What is the most appropriate method of internal fixation?

Explanation

Tension band wiring relies on anterior cortical contact to convert tensile forces to compressive forces; it is contraindicated in comminuted fractures or fractures distal to the coronoid. Plate and screw fixation is required to maintain the dimensions of the greater sigmoid notch.

Question 47

A 28-year-old male sustained a wrist hyperextension injury 3 weeks ago. Radiographs demonstrate a scapholunate interval of 4mm and a 'signet ring' sign of the scaphoid. What is the most appropriate surgical intervention?

Explanation

Acute or subacute (< 4 weeks) scapholunate dissociation with a reparable ligament is best treated with direct open repair of the dorsal scapholunate ligament, typically augmented with a dorsal capsulodesis or pinning to protect the repair.

Question 48

An 80-year-old female with severe osteoporosis presents with a closed 4-part proximal humerus fracture. The humeral head is completely split into two segments and is displaced from the glenoid. What is the most appropriate surgical treatment?

Explanation

In elderly patients with poor bone quality and non-reconstructible 4-part fractures (especially head-splitting variants), reverse shoulder arthroplasty provides more predictable functional outcomes and pain relief compared to ORIF or hemiarthroplasty.

Question 49

A 50-year-old male with severe cubital tunnel syndrome presents with intrinsic muscle atrophy and clawing of the small and ring fingers. He previously underwent a simple in-situ ulnar nerve release 2 years ago, with initial relief followed by recurrence. What is the most appropriate next surgical step?

Explanation

For recurrent cubital tunnel syndrome after a failed in-situ release, or in severe cases with deformity/atrophy, anterior transposition (submuscular or subfascial) is recommended to place the nerve in a pristine, well-vascularized bed away from the scar tissue.

Question 50

A 22-year-old competitive rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals 28% bone loss of the anterior/inferior glenoid. Which surgical procedure is most appropriate?

Explanation

Anterior glenoid bone loss greater than 20-25% (critical bone loss) is an indication for a bony augmentation procedure, such as the Latarjet procedure. Soft tissue repairs alone have an unacceptably high failure rate in this setting.

Question 51

A 40-year-old manual laborer presents with Stage II SLAC (Scapholunate Advanced Collapse) wrist. Radiographs show osteoarthritis at the radioscaphoid joint, but the radiolunate and midcarpal joints are spared. If he desires a motion-preserving salvage procedure, which of the following is acceptable?

Explanation

Proximal row carpectomy (PRC) is a motion-preserving option for SLAC stage II, provided the capitate head and lunate fossa cartilage are intact. It offers comparable outcomes to four-corner fusion with slightly better range of motion.

Question 52

A 45-year-old manual laborer presents with a massive, irreparable posterosuperior rotator cuff tear. Examination reveals an intact subscapularis and deltoid, but he has significant weakness in active external rotation and forward elevation. Which of the following tendon transfers is the most appropriate surgical treatment to restore function?

Explanation

Latissimus dorsi transfer is indicated for young, active patients with massive, irreparable posterosuperior cuff tears (supraspinatus and infraspinatus) who have an intact subscapularis and deltoid. It helps restore active external rotation and forward elevation.

Question 53

A 35-year-old male falls on an outstretched hand and sustains a 'terrible triad' injury to the elbow. Operative management is planned. Following a standard deep-to-superficial surgical approach, what is the accepted sequence of structural repair to restore elbow stability?

Explanation

The standard sequence of repair for a terrible triad injury addresses structures from deep to superficial: first the coronoid, followed by the radial head, and finally the lateral ulnar collateral ligament (LUCL).

Question 54

A 55-year-old man presents with chronic wrist pain and weakness. Radiographs demonstrate scapholunate advanced collapse (SLAC) stage III, defined by capitatolunate arthritis with a preserved radiolunate joint. Which of the following is the most appropriate surgical management?

Explanation

SLAC stage III involves the capitatolunate joint. Proximal row carpectomy is contraindicated because it relies on a preserved proximal capitate articular surface. Four-corner fusion with scaphoid excision is the standard of care for SLAC stage III.

Question 55

A 25-year-old rugby player presents with an inability to actively flex the distal interphalangeal (DIP) joint of his ring finger after grabbing an opponent's jersey. Radiographs reveal a large bony avulsion fragment volar to the DIP joint. According to the Leddy-Packer classification, what type of flexor digitorum profundus (FDP) avulsion is this?

Explanation

A Leddy-Packer Type III injury represents a large bony avulsion of the FDP tendon that gets caught at the A4 pulley, preventing proximal retraction into the palm. Type I retracts to the palm, and Type II retracts to the PIP joint.

Question 56

A 22-year-old competitive rugby player with a history of recurrent anterior shoulder dislocations undergoes advanced imaging. A 3D CT scan reveals a 28% anterior glenoid bone defect. What is the most appropriate definitive surgical intervention?

Explanation

In collision athletes with critical glenoid bone loss (typically > 20-25%), isolated soft-tissue stabilization (Bankart repair) has unacceptably high failure rates. A bone-block procedure, such as the Latarjet (coracoid transfer), is the standard of care.

Question 57

A 42-year-old bodybuilder feels a 'pop' in his anterior elbow while doing heavy biceps curls. MRI confirms a complete distal biceps tendon rupture. If a single anterior incision technique is chosen for the repair, which nerve is at the highest risk of iatrogenic injury?

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single anterior incision approach for distal biceps repair. The PIN is at higher risk during a two-incision technique.

Question 58

A 65-year-old woman with advanced rheumatoid arthritis presents with a massive, irreparable rotator cuff tear, severe glenohumeral osteoarthritis, and pseudoparalysis of the shoulder. Physical exam confirms an intact and functioning deltoid muscle.

Which of the following is the most appropriate definitive management?

Explanation

Reverse total shoulder arthroplasty is the procedure of choice for cuff tear arthropathy with pseudoparalysis, provided the deltoid and axillary nerve are intact. Anatomic total shoulder arthroplasty is contraindicated due to the deficient rotator cuff.

Question 59

A 28-year-old gymnast presents with chronic ulnar-sided wrist pain. Examination reveals a positive foveal sign. MRI arthrogram demonstrates a peripheral tear of the triangular fibrocartilage complex (TFCC) with an avulsion from the fovea of the ulna. This corresponds to which Palmer classification, and what is the preferred treatment?

Explanation

A peripheral tear of the TFCC involving the foveal attachment is classified as Palmer 1B. Because the peripheral TFCC has excellent blood supply, these tears are highly amenable to open or arthroscopic surgical repair.

Question 60

During the surgical management of a distal radius fracture with a volar locking plate, the surgeon ensures the plate is placed proximal to the watershed line. This anatomic guideline is primarily utilized to prevent which of the following complications?

Explanation

The watershed line is a critical anatomic landmark on the volar distal radius. Placing a volar plate distal to this line significantly increases the risk of flexor tendon irritation and subsequent rupture, most commonly the flexor pollicis longus (FPL).

Question 61

A 30-year-old male sustains a Bennett fracture. Radiographs show a fracture at the base of the thumb metacarpal where the volar ulnar intra-articular fragment retains its anatomic position. The metacarpal shaft is displaced proximally, dorsally, and radially. Which muscle is the primary deforming force responsible for this characteristic shaft displacement?

Explanation

In a Bennett fracture, the anterior oblique ligament anchors the small volar ulnar fragment in place. The main shaft of the metacarpal is pulled proximally, dorsally, and radially primarily by the abductor pollicis longus (APL) tendon.

Question 62

A patient with a severe ulnar nerve transection at the level of the elbow initially presents with weakness of intrinsic hand muscles but minimal clawing of the ring and small fingers. Three months following nerve repair at the elbow, pronounced clawing of these digits develops. This phenomenon is known as:

Explanation

The Ulnar paradox occurs in high ulnar nerve lesions where the flexor digitorum profundus (FDP) to the ring and small fingers is paralyzed, preventing prominent clawing. As the nerve regenerates and reinnervates the FDP, active flexion returns and clawing becomes pronounced.

Question 63

A 35-year-old male sustains a closed diaphyseal fracture of the humerus. On initial evaluation, he is unable to actively extend his wrist or fingers. He undergoes closed reduction and functional bracing. At 12 weeks, there is no clinical or electromyographic (EMG) evidence of radial nerve recovery. What is the most appropriate next step in management?

Explanation

Observation of a closed humerus fracture with a radial nerve palsy is standard up to 12 weeks. If there is no clinical or EMG evidence of recovery by 3 months (12 weeks), surgical exploration of the radial nerve is indicated.

Question 64

A 40-year-old patient with Kienböck's disease is evaluated radiographically. Images reveal lunate sclerosis and fragmentation, fixed scaphoid rotation, and established osteoarthritis in the capitolunate joint. According to the Lichtman classification, this is Stage IV Kienböck's. Which of the following procedures is contraindicated in this setting?

Explanation

Radial shortening osteotomy (a joint-leveling procedure) relies on preserving carpal kinematics and is contraindicated in Stage IV Kienböck's disease, where there is extensive carpal collapse and secondary osteoarthritis. Salvage procedures like PRC or wrist fusion are indicated instead.

Question 65

A 19-year-old collegiate baseball pitcher presents with medial elbow pain during the late cocking phase of throwing. MRI arthrogram confirms a high-grade ulnar collateral ligament (UCL) tear. During UCL reconstruction (e.g., using the docking technique), the graft is primarily designed to replicate which specific structure?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow, particularly from 30 to 120 degrees of flexion. UCL reconstruction techniques are designed to recreate the biomechanical function of this specific bundle.

Question 66

A 50-year-old diabetic female presents with a locking thumb that is refractory to corticosteroid injections. During surgical release of the A1 pulley, the surgeon must be particularly careful to protect a nerve that courses obliquely over the flexor sheath near the metacarpophalangeal flexion crease. Which nerve is this?

Explanation

The radial digital nerve of the thumb is particularly vulnerable during A1 pulley release because it crosses obliquely from ulnar to radial directly over the flexor tendon sheath at the level of the MCP flexion crease.

Question 67

A 28-year-old cyclist sustains a mid-shaft clavicle fracture after going over the handlebars.

According to established orthopedic guidelines, which of the following is considered an ABSOLUTE indication for acute operative fixation of a clavicle fracture?

Explanation

Absolute indications for operative fixation of a clavicle fracture include an open fracture, associated neurovascular injury, or skin tenting with progressive ischemia. Displacement and shortening > 2 cm are relative indications.

Question 68

A 68-year-old osteoporotic woman sustains a displaced 3-part proximal humerus fracture. Open reduction and internal fixation with a locking plate is planned. To maximize biomechanical stability and prevent postoperative varus collapse of the humeral head, which of the following must be achieved intraoperatively?

Explanation

Restoration of the medial hinge (calcar) and the insertion of inferomedial calcar screws are critical steps in locking plate fixation of proximal humerus fractures to prevent varus collapse and secondary screw cutout.

Question 69

A 24-year-old male sustains a posterior elbow dislocation. After closed reduction, the elbow is stable in 90 degrees of flexion but immediately subluxates when extended with the forearm in supination. This specific pattern of instability indicates insufficiency of which of the following structures?

Explanation

Posterolateral rotatory instability (PLRI) occurs due to insufficiency of the lateral ulnar collateral ligament (LUCL). It typically manifests as subluxation or dislocation when the elbow is extended, supinated, and subjected to an axial load or valgus force.

Question 70

A 32-year-old carpenter suffers a clean guillotine amputation of his index finger at the level of the proximal phalanx. Replantation is attempted. To maximize venous outflow and ensure the best survival rate of the replanted digit, what is the optimal ratio of veins to arteries that should be anastomosed?

Explanation

During digital replantation, venous congestion is a primary cause of failure. The standard microsurgical principle is to attempt to repair two veins for every one artery anastomosed to ensure adequate venous outflow.

Question 71

A 26-year-old chef sustains a deep laceration to the volar aspect of his index finger over the middle phalanx, cleanly transecting both the FDS and FDP tendons (Zone II). Primary repair is planned. According to biomechanical studies, the strength of the flexor tendon repair is most directly proportional to which of the following factors?

Explanation

The ultimate tensile strength of a repaired flexor tendon is most directly proportional to the number of core suture strands crossing the repair site (e.g., a 4-strand or 6-strand repair is significantly stronger than a 2-strand repair).

Question 72

A 72-year-old woman presents with chronic right shoulder pain and an inability to raise her arm above the horizontal plane. Physical examination reveals active forward elevation to 40 degrees and passive elevation to 150 degrees. Radiographs demonstrate superior migration of the humeral head with articulation against the acromion

. Which of the following is the most appropriate surgical treatment?

Explanation

This patient has rotator cuff arthropathy with pseudoparalysis (active elevation less than 90 degrees with preserved passive motion). Reverse total shoulder arthroplasty is the treatment of choice as it shifts the center of rotation medially and inferiorly, allowing the deltoid to effectively elevate the arm.

Question 73

A 35-year-old man presents with chronic wrist pain and stiffness 2 years after a fall. Imaging reveals a scaphoid nonunion with radioscaphoid arthritis and preservation of the midcarpal joint. The proximal pole of the capitate demonstrates no arthritic changes. Which of the following procedures is most appropriate?

Explanation

In Scaphoid Nonunion Advanced Collapse (SNAC) stage II with a preserved proximal capitate and lunate fossa, proximal row carpectomy (PRC) is highly effective. While four-corner fusion is an option, PRC is favored when capitate cartilage is pristine as it avoids nonunion risks and allows earlier rehabilitation.

Question 74

A 42-year-old woman falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. Which of the following structures is the primary restraint to posterolateral rotatory instability (PLRI) and must be meticulously repaired or reconstructed during surgery?

Explanation

The lateral ulnar collateral ligament (LUCL) is the primary restraint to posterolateral rotatory instability. In a terrible triad injury, the LUCL is typically avulsed from the lateral epicondyle and must be repaired to restore elbow stability.

Question 75

A 28-year-old carpenter presents with acute finger pain, swelling, and a flexed posture of the index finger 48 hours after a penetrating injury. Which of the following is NOT one of Kanavel's cardinal signs of acute suppurative flexor tenosynovitis?

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are fusiform swelling, flexed resting posture, tenderness along the flexor sheath, and pain on passive extension. Erythema extending proximally is not one of these specific signs, though it may indicate tracking cellulitis.

Question 76

A 21-year-old collegiate wrestler has experienced multiple anterior shoulder dislocations. A recent CT scan indicates 30% anterior glenoid bone loss. What is the most appropriate surgical intervention to prevent recurrent instability?

Explanation

Anterior glenoid bone loss exceeding 20-25% is a strict contraindication for isolated soft-tissue procedures like a Bankart repair. A bony augmentation procedure, such as the Latarjet (coracoid transfer), is required to restore the glenoid articular arc.

Question 77

A 29-year-old construction worker complains of progressive dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate without carpal collapse. Measurements demonstrate 3 mm of negative ulnar variance. What is the most appropriate surgical treatment?

Explanation

This patient has Lichtman Stage II/IIIA Kienböck's disease with negative ulnar variance. A joint-leveling procedure, typically a radial shortening osteotomy, unloads the lunate and can successfully halt disease progression and relieve pain.

Question 78

A 45-year-old man complains of elbow pain and a "clunking" sensation when pushing himself out of a chair. On examination, a positive pivot-shift test of the elbow is elicited. Which mechanism of injury is most commonly associated with this specific condition?

Explanation

The patient has posterolateral rotatory instability (PLRI) due to lateral ulnar collateral ligament (LUCL) insufficiency. The classic mechanism of injury is a fall on the outstretched hand resulting in axial load, valgus stress, and forearm supination.

Question 79

A 32-year-old woman undergoes primary repair of a lacerated flexor digitorum profundus (FDP) tendon in Zone II. To optimize healing and minimize adhesions, which of the following postoperative rehabilitation protocols is most strongly supported by current evidence?

Explanation

Early active motion protocols for Zone II flexor tendon repairs have been shown to significantly decrease tendon adhesions while maintaining repair strength. This is typically performed within the safety constraints of a dorsal blocking splint.

Question 80

A 38-year-old bicyclist falls directly onto his shoulder. Clinical examination and standing X-rays demonstrate a Type V acromioclavicular (AC) joint separation, with the distal clavicle elevated 150% above the acromion. Which ligaments are completely disrupted in this injury pattern?

Explanation

A Type V AC joint separation involves severe superior displacement of the clavicle due to complete disruption of both the acromioclavicular (AC) and coracoclavicular (conoid and trapezoid) ligaments, along with disruption of the deltotrapezial fascia.

Question 81

A 62-year-old woman presents with debilitating pain at the base of her right thumb. Examination shows a positive grind test. Radiographs demonstrate severe joint space narrowing and osteophytes at the trapeziometacarpal joint, but the scaphotrapezial joint is spared. Following failed conservative management, what is the gold standard surgical treatment?

Explanation

Trapeziectomy with or without LRTI is the gold standard surgical treatment for advanced thumb carpometacarpal (CMC) arthritis. Outcomes between simple trapeziectomy and trapeziectomy with LRTI are highly comparable in long-term studies.

Question 82

A 44-year-old weightlifter sustained an acute complete distal biceps tendon rupture and underwent surgical repair using a two-incision technique. Postoperatively, he has profound restriction of forearm pronation and supination but full elbow flexion and extension. What is the most likely complication responsible for his restricted motion?

Explanation

The two-incision technique for distal biceps tendon repair has historically carried a higher risk of radioulnar synostosis (heterotopic ossification bridging the radius and ulna) compared to the single-incision technique. This complication directly causes profound loss of forearm rotation.

Question 83

A 26-year-old male falls from a height and presents with a markedly swollen and painful wrist. The lateral radiograph demonstrates the "spilled teacup" sign with the lunate displaced volarly. During physical examination, which nerve distribution should be most meticulously evaluated?

Explanation

A volar lunate dislocation (indicated by the "spilled teacup" sign on a lateral radiograph) occupies space within the carpal tunnel. This often causes acute compression of the median nerve, leading to acute carpal tunnel syndrome.

Question 84

A 55-year-old woman presents with a 6-month history of progressive, severe, global loss of both active and passive shoulder range of motion. She denies any preceding trauma. Which of the following systemic conditions is most strongly associated with the development and refractoriness of her most likely diagnosis?

Explanation

This patient has idiopathic adhesive capsulitis (frozen shoulder). Diabetes mellitus is the strongest known systemic risk factor, associated with a higher incidence, bilateral involvement, and increased resistance to conservative treatments.

Question 85

A 72-year-old female presents with severe right shoulder pain and an inability to actively elevate her arm above 40 degrees. Radiographs demonstrate superior migration of the humeral head with an acromiohumeral distance of 3 mm. Examination reveals intact deltoid function but positive lag signs. What is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for rotator cuff tear arthropathy in an elderly patient with intact deltoid function. The prosthesis medializes and distalizes the center of rotation, allowing the deltoid to effectively elevate the arm despite a deficient rotator cuff.

Question 86

A 42-year-old male presents with a "terrible triad" injury of the elbow following a fall onto an outstretched hand. When performing the surgical reconstruction, what is the most widely accepted sequence of repair?

Explanation

The terrible triad of the elbow involves an elbow dislocation with concomitant radial head and coronoid process fractures. The standard surgical sequence proceeds from deep to superficial: fixing the coronoid first, followed by the radial head, and finally repairing the lateral collateral ligament (LCL).

Question 87

A 45-year-old male presents with chronic wrist pain and a history of a scaphoid fracture 15 years ago. Radiographs demonstrate advanced radioscaphoid arthritis and scaphocapitate arthritis, but the radiolunate joint is completely spared (SNAC Stage III). What is the most appropriate definitive surgical intervention?

Explanation

In Scaphoid Nonunion Advanced Collapse (SNAC) Stage III, there is arthritic involvement of both the radioscaphoid and midcarpal (scaphocapitate) joints. Proximal row carpectomy is contraindicated when the capitate is arthritic, making four-corner arthrodesis the procedure of choice.

Question 88

A 28-year-old carpenter lacerates the volar surface of his index finger over the middle phalanx (Zone II). A primary flexor tendon repair is planned. To safely implement an early active motion protocol postoperatively, what is the minimum recommended number of core strands across the repair site?

Explanation

Early active motion protocols after flexor tendon repairs require a biomechanically robust construct to prevent gap formation or rupture. A minimum of a 4-strand core repair, often augmented with an epitendinous suture, is recommended to safely withstand the forces of active digital flexion.

Question 89

A 21-year-old collegiate rugby player with a history of multiple recurrent anterior shoulder dislocations undergoes evaluation. A CT scan with 3D reconstruction reveals a 28% anterior glenoid bone loss. What is the most appropriate surgical intervention?

Explanation

Critical glenoid bone loss (typically > 20-25%) is a direct contraindication to an isolated soft-tissue Bankart repair due to unacceptably high recurrence rates. The Latarjet procedure (coracoid transfer) is the gold standard, effectively restoring the bony arc and providing a dynamic soft-tissue sling.

Question 90

A 35-year-old bodybuilder feels a sudden pop in his anterior elbow during a heavy bicep curl. The hook test is positive. The surgeon utilizes a single-incision anterior approach to repair the distal biceps tendon. Which of the following nerves is at highest risk of iatrogenic injury with this specific approach?

Explanation

The lateral antebrachial cutaneous nerve (LABCN) courses superficially in the lateral aspect of the antecubital fossa near the cephalic vein. It is the most commonly injured nerve during a single-incision anterior approach for distal biceps tendon repair, resulting in lateral forearm paresthesias.

Question 91

A 26-year-old male falls from a ladder onto an outstretched hand. An AP radiograph of the wrist reveals a "piece of pie" sign, while the lateral radiograph demonstrates a "spilled teacup" sign. Which nerve is most commonly acutely injured in this specific clinical setting?

Explanation

The "piece of pie" and "spilled teacup" radiographic signs indicate a lunate dislocation. As the lunate is displaced volarly into the carpal tunnel, it frequently compresses the median nerve, leading to acute acute carpal tunnel syndrome requiring urgent reduction.

Question 92

During a regional fasciectomy for severe Dupuytren's disease, the surgeon carefully dissects a spiral cord to avoid neurovascular injury. How does the spiral cord typically displace the digital neurovascular bundle?

Explanation

In Dupuytren's contracture, the spiral cord originates from the pretendinous band, passing dorsal to the neurovascular bundle before spiraling volarly. This pathognomonic contracture displaces the neurovascular bundle volarly and centrally (toward the midline), placing it at severe risk during surgical release.

Question 93

A 30-year-old right-hand-dominant construction worker sustains a Type III acromioclavicular (AC) joint separation following a direct blow to the shoulder. What is the most widely accepted initial management for this patient?

Explanation

Acute Type III AC joint separations (complete tear of the AC and CC ligaments) are generally treated nonoperatively with a sling and early rehabilitation. Multiple studies have shown that clinical outcomes of nonoperative management are comparable to surgery, with lower complication rates.

Question 94

A 45-year-old female sustains a coronal shear fracture of the capitellum that extends medially to include the majority of the trochlea (McKee modification Type IV). Open reduction and internal fixation with headless compression screws is planned. What is the most common complication following surgical management of this injury?

Explanation

Coronal shear fractures of the distal humerus involve significant intra-articular disruption and require extensive surgical exposure for accurate reduction. Consequently, post-traumatic elbow stiffness (loss of terminal extension) is the most frequently encountered postoperative complication.

Question 95

A 24-year-old gymnast complains of ulnar-sided wrist pain and clicking. Examination reveals severe distal radioulnar joint (DRUJ) instability in both supination and pronation. MRI confirms a foveal avulsion of the triangular fibrocartilage complex (TFCC). What is the primary biomechanical function of the foveal attachment of the TFCC?

Explanation

The deep foveal attachment of the TFCC inserts into the base of the ulnar styloid and constitutes the primary stabilizing restraint to distal radioulnar joint (DRUJ) translation. Tears at this location (Type 1B) reliably result in DRUJ instability and often require open or arthroscopic repair.

100 High-Yield Orthopedic MCQs: Shoulder & Elbow | Mock Exam 251

Upper Extremity Orthopedic MCQs (Set 2): Shoulder, Elbow, Wrist & Hand | ABOS & AAOS Board Review

Key Takeaway

Upper Extremity Orthopedic MCQs (Set 2): Shoulder, Elbow, Wrist & Hand | ABOS & AAOS Board Review

Chapter Index