Orthopedic Upper Extremity MCQs: 2026 Board Review

Question 1

A 36-year-old woman has pain and swelling of the anterior arm after undergoing arthroscopic shoulder surgery 8 months ago. At the time of the procedure, extensive debridement and synovectomy of the anterior aspect of the joint was performed to remove scar tissue that had formed after an open rotator cuff repair. Examination reveals a golf ball-sized swelling just lateral to the coracoid. The area is not warm and shows no other signs of infection. An MRI scan is shown in Figure 1. Management should now consist of

Explanation

Deficiency of the rotator cuff interval may be acquired or congenital. In this patient, extensive debridement of the rotator cuff interval capsule at the time of arthroscopy most likely is the cause of the defect seen on the MRI scan. Surgical closure of the defect is the treatment of choice. During the repair, the shoulder should be placed in 30 degrees of external rotation to avoid overtightening. Care should be taken to include the leading edge of both the supraspinatus and subscapularis tendons in the repair because the rotator cuff interval capsular tissue is likely to be of poor quality. Cole BJ, Rodeo SA, O'Brien SJ, et al: The anatomy and histology of the rotator interval capsule of the shoulder. Clin Orthop 2001;390:129-137.

Question 2

A 45-year-old recreational tennis player underwent arthroscopic decompression and mini-open repair of a small supraspinatus tendon tear 3 weeks ago after nonsurgical management failed to provide relief. He now has pain, swelling about the wound, erythema, and purulent drainage. The patient is returned to the operating room for irrigation, debridement, and cultures. What is the most common organism causing this infection?

Explanation

In a large series of mini-open rotator cuff repairs, an infection rate of at least 2% was found, with the majority of the infections caused by Propionibacterium acnes. To prevent this complication, the shoulder should be re-prepped before the mini-open incision is made to prevent bacterial contamination from the arthroscopic procedure. Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.

Question 3

A paraplegic 32-year-old man was pulling himself up in bed by grasping the headboard rails when he felt a pop and immediate pain. A radiograph and CT scan are shown in Figures 2a and 2b. Based on these findings, management should consist of

Explanation

2b The coracoid process is an essential component of the superior shoulder suspensory complex and must be maintained. Open reduction and internal fixation is recommended if the fragment is large and displaced more than 1 cm. Froimson AI: Fracture of the coracoid process of the scapula. J Bone Joint Surg Am 1978;60:710-711.

Question 4

A 23-year-old baseball pitcher reports pain in the posterior aspect of his dominant shoulder during the late cocking phase of throwing. With the dominant shoulder positioned in 90 degrees of abduction from the body and with the scapula stabilized, examination reveals 135 degrees of external rotation and 20 degrees of internal rotation. Examination of the opposite shoulder reveals 100 degrees of external rotation and 75 degrees of internal rotation. Both shoulders are stable on examination. Radiographs and MRI scans are unremarkable. What is the primary cause of his pain?

Explanation

Internal impingement of the shoulder is a leading cause of shoulder pain in the throwing athlete. The primary lesion in pathologic internal impingement is excessive tightening of the posterior band of the inferior glenohumeral ligament complex. To obtain an accurate assessment of true glenohumeral rotation, the scapula is stabilized during examination. A loss of 20 degrees or more of internal rotation, as measured with the shoulder positioned in 90 degrees of abduction, indicates excessive tightness of the posterior band of the inferior glenohumeral ligament complex. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420.

Question 5

What is the most common indication for revision following unconstrained elbow arthroplasty?

Explanation

Instability following unconstrained elbow arthroplasty occurs in 10% of patients. Subluxation is twice as common as frank dislocation; however, only 20% of these patients undergo revision. Instability following unconstrained elbow arthroplasty can be caused by component malposition or ligament insufficiency. King GJ, Itoi E, Niebur GL, et al: Motion and laxity of the capitellocondylar total elbow prosthesis. J Bone Joint Surg Am 1994;76:1000-1008.

Question 6

What part of the glenoid labrum has the least vascularity?

Explanation

The glenoid labrum receives its blood supply from the suprascapular, posterior humeral circumflex, and circumflex scapular arteries. The labral vessels arise from the capsular and periosteal vessels that penetrate the periphery of the labrum. The bone does not appear to be a source of vascularity. The posterior/superior and inferior labrum have a fairly robust vascular supply, whereas the anterior/superior labrum has relatively poor vascularity, which may influence the success of superior lateral repairs.

Question 7

One of the serious potential complications of repair of distal biceps tendon ruptures is limited pronation and supination as a result of synostosis. What surgical approach and technique presents the highest risk for development of this complication?

Explanation

The risk of synostosis is imminent with any technique for repairing a distal biceps tendon rupture. However, the risk is quite low for all approaches that avoid exposure of the ulna, including the muscle-splitting two-incision technique.

Question 8

A 25-year-old carpenter falls on his outstretched arm. What physical finding best correlates with the lesion seen on the MRI scan shown in Figure 3?

Explanation

The MRI scan shows disruption of the subscapularis muscle. Subscapularis rupture is associated with weakness in internal rotation as shown with a positive lift-off test as described by Gerber and Krushell. The belly press test also has been shown to be a useful clinical test for this problem. Weakness in external rotation and abduction is more consistent with supraspinatus and infraspinatus tears. Deltoid atrophy is associated with an axillary nerve injury. Loss of biceps contour is associated with rupture of the long head of the biceps. Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.

Question 9

A 72-year-old woman who sustained a cerebrovascular accident 9 months ago now has a fixed elbow flexion contracture of 80 degrees. Management should consist of

Explanation

A flexion contracture of the elbow is commonly seen in hemiplegic patients following cerebrovascular accidents. Spasticity and myostatic contracture of the joint are both causative factors. In patients with a flexion deformity of less than 90 degrees, musculocutaneous neurectomy is recommended, followed by serial casting to treat any residual deformity. At 9 months after injury, physical therapy will not significantly improve motion. Nerve blocks may be used in the early stages of recovery to facilitate therapy and serial casting.

Question 10

A 44-year-old recreational weight lifter reports chronic deep pain in his left shoulder that is aggravated by any pressing exercises. He also notes a painful catch in the shoulder occurring with rotational movements. Physical therapy and nonsteroidal anti-inflammatory drugs for 3 months have failed to provide relief. Examination reveals pain with O'Brien's test but no signs of instability. MRI scans are shown in Figures 4a and 4b. Treatment should now consist of

Explanation

4b The MRI scans show a large paralabral ganglion cyst in the spinoglenoid notch that communicates with an extensive tear of the glenoid labrum. Snyder and associates have classified superior labral tears into several subtypes that reflect the location and extent of the injury. Arthroscopic repair of the labral tear and aspiration of the ganglion cyst is the treatment of choice. Open excision of the cyst does not address the underlying problem of the labral tear. Snyder SJ, Karzel RP, Delpizzo W: SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279. Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch cysts. J Shoulder Elbow Surg 2002;11:600-604. McFarland EG, Kim TK, Savino RM: Clinical assessment of three common tests for superior labral anterior-posterior lesions. Am J Sports Med 2002;30:810-815.

Question 11

A 35-year-old carpenter sustained an injury to his dominant shoulder in a fall. He reports that he felt a sharp tearing sensation as he held on to a scaffold to keep from falling. Examination reveals swelling and ecchymosis down the upper arm, weakness to internal rotation, and deformity of the anterior axilla. He has good strength in external rotation and no apprehension with instability testing. Radiographs are normal. Management should consist of

Explanation

The findings are classic for a pectoralis major tendon avulsion. Deformity of the anterior axillary fold is a classic finding, and ecchymosis down the arm suggests that the injury is at the humeral attachment rather than at the musculotendinous junction. Good external rotation strength indicates that function in the supraspinatus and infraspinatus has been preserved. The treatment of choice for a tendon avulsion in a young individual is early surgical repair. Conversely, if the injury is within the muscle or at the musculotendinous junction, initial nonsurgical management is recommended. If the location of the injury cannot be determined by physical examination, then MRI of the pectoralis major can be helpful. Hanna CM, Glenny AB, Stanley SN, et al: Pectoralis major tears: Comparison of surgical and conservative treatment. Br J Sports Med 2001;35:202-206.

Question 12

A 48-year-old woman with rheumatoid arthritis reports increasing elbow pain for the past 6 months. History reveals that she underwent total elbow arthroplasty 7 years ago. A peripheral WBC count, erythrocyte sedimentation rate, and C-reactive protein studies are normal. An AP radiograph is shown in Figure 5. What is the next most appropriate step in management?

Explanation

Pain relief is excellent after total elbow arthroplasty and is comparable to the results found with hip and knee arthroplasty. The failure of total elbow arthroplasty in the treatment of rheumatoid arthritis can be the result of infection, aseptic loosening, instability, and bearing surface wear. The radiographic findings shown here are consistent with bushing wear in a linked device. The bushings can be changed before continued wear results in osteolysis and implant loosening. If the implants become loose, then reimplantation is necessary. Resection arthroplasty is not indicated if the components are well fixed. Elbow arthrodesis is not indicated in patients with rheumatoid arthritis. Gill DR, Morrey BF: The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: A ten to fifteen-year follow-up study. J Bone Joint Surg Am 1998;80:1327-1335.

Question 13

Figure 6a shows the radiograph of a 50-year-old man who sustained an anterior dislocation of the shoulder. He undergoes closed reduction, and the postreduction radiograph is shown in Figure 6b. Management should now consist of

Explanation

6b Displaced greater tuberosity fractures often will block abduction and/or external rotation by impinging on the underside of the acromion or posterior glenoid. The indications for open reduction and internal fixation are 1 cm of displacement or 45 degrees of rotation of the tuberosity fracture. Surgical treatment has recently been recommended for 0.5 cm of tuberosity displacement. Neer CS II: Displaced proximal humeral fractures: II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.

Question 14

A 42-year-old man sustained a fracture of the distal radius with subsequent stiffness in the ipsilateral shoulder. Despite a 6-month program of range-of-motion exercises, external rotation at the side is limited to 10 degrees. Attempts at closed manipulation are unsuccessful. Treatment should now consist of

Explanation

When external rotation at the side is limited, the most likely diagnosis is contracture of the rotator cuff interval, including the superior glenohumeral and coracohumeral ligaments. Therefore, the treatment of choice is arthroscopic release of the rotator cuff interval.

Question 15

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

Explanation

The MRI scan reveals a large chronic rotator cuff tear with retraction and fatty infiltration atrophy of the supraspinatus and infraspinatus tendons. This tear is responsible for the patient's severe weakness and inability to elevate the arm.

Question 16

A 45-year-old man who underwent an open capsulolabral stabilization procedure 15 years ago now reports pain and has no external rotation on the affected side. Nonsurgical management has failed to provide relief. Examination reveals external rotation to -5 degrees compared with 50 degrees of external rotation on the contralateral side. Radiographs show a small inferior osteophyte and minimal posterior glenoid wear. Which of the following procedures will offer the best chance of restoring motion, decreasing pain, and preserving the native joint?

Explanation

Loss of external rotation following stabilization procedures can result in progressive degenerative joint disease. A tight anterior capsule results in posterior humeral translation and progressive posterior glenoid wear. Patients with early degenerative joint disease and pain can be treated with anterior release to restore more normal glenohumeral biomechanics. This procedure not only improves function but also decreases pain in most patients. Closed manipulation at 15 years after surgery is unlikely to be successful and carries the risk of complications. Acromioplasty, posterior release, and removal of osteophytes do not address the pathology. Arthroscopic releases are favored for intra-articular procedures that have addressed the pathology of instability. Open releases are recommended for nonanatomic extra-articular repairs that include subscapularis tightening procedures. MacDonald PB, Hawkins RJ, Fowler PJ, et al: Release of the subscapularis for internal rotation contracture and pain after anterior repair for recurrent anterior dislocation of the shoulder. J Bone Joint Surg Am 1992;74:734-737.

Question 17

A right-handed 44-year-old construction worker reports pain and limited range of motion in his right elbow that has limited his ability to work for the past year. Examination reveals range of motion from 60 to 90 degrees, and he has pain at the extremes of flexion and extension. Pronation and supination are minimally restricted. Anti-inflammatory drugs have failed to provide relief. A radiograph is shown in Figure 8. Management should now consist of

Explanation

The radiograph reveals primary osteoarthritis of the elbow; therefore, ulnohumeral arthroplasty is the preferred procedure. Patients with severely limited preoperative elbow extension of more than 60 degrees and flexion of less than 100 degrees are at risk for ulnar nerve dysfunction postoperatively and should undergo a concomitant ulnar nerve decompression. Nonsurgical methods are unlikely to improve his chronic condition. Elbow arthroplasty is contraindicated for patients in this age group and with this diagnosis. Antuna SA, Morrey BF, Adams RA, et al: Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: Long-term outcome and complications. J Bone Joint Surg Am 2002;84:2168-2173.

Question 18

Spontaneous recovery of upper extremtiy motor function after a cerebrovascular accident occurs in which of the following predictable patterns?

Explanation

Recovery of upper extremity motor function after a cerebrovascular accident follows a predictable pattern. The greatest amount of recovery is seen within the first 6 weeks. Return of function proceeds from proximal to distal. Shoulder flexion occurs first, followed by return of flexion to the elbow, wrist, and fingers. Return of forearm supination follows the return of finger flexion.

Question 19

A 65-year-old woman sustained an axial load on the arm followed by an abduction injury after falling on ice. Treatment in the emergency department consisted of reduction of an anterior dislocation. She now has a positive drop arm sign and a positive lift-off test. An MRI scan is shown in Figure 9. Based on these findings, management should consist of

Explanation

Dislocation of the long head of the biceps tendon is the result of a defect in the region of the rotator cuff interval, coracohumeral ligament-superior glenohumeral ligament pulley, or an associated tear of the medial insertion of the subscapularis tendon. In the case of an intra-articular dislocation of the long head of the biceps tendon associated with a tear of the subscapularis tendon, stabilization of the biceps tendon is difficult in this situation; therefore, biceps release or tenodesis and repair of the subscapularis tendon is the treatment of choice. Eakin CL, Faber KJ, Hawkins RJ, et al: Biceps tendon disorders in athletes. J Am Acad Orthop Surg 1999;7:300-310. Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654.

Question 20

What type of nerve palsy is most common following elbow arthroscopy?

Explanation

Transient ulnar nerve palsy is the most common palsy following elbow arthroscopy. The ulnar nerve is most frequently affected, followed by the radial nerve. Injury to the other nerves has been reported but less frequently. Kelly EW, Morrey BF, O'Driscoll SW: Complications of elbow arthroscopy. J Bone Joint Surg Am 2001;83:25-34.

Question 21

A 72-year-old man injured his right shoulder after tripping over a chair leg. Radiographs obtained in the emergency department reveal an isolated anterior dislocation. After successful closed reduction, the patient has recurrent anterior instability and is unable to elevate the arm. What is the most likely cause of the recurrent instability?

Explanation

A rotator cuff tear is the most common cause of recurrent instability following a first-time dislocation in patients older than age 40 years. Dislocations occur through a posterior mechanism rather than by an isolated labral avulsion or a Bankart lesion as seen in younger patients. Nevaiser RJ, Nevaiser TJ: Recurrent instability of the shoulder after age 40. J Shoulder Elbow Surg 1995;4:416-418.

Question 22

A 54-year-old woman sustained an elbow injury 3 months ago that was treated with open reduction and internal fixation. She now reports pain and limited elbow motion. Radiographs are shown in Figures 10a and 10b. Treatment should now consist of

Explanation

10b Radiographs reveal malunion of a Monteggia fracture-dislocation. Dislocation of the posterior radial head is caused by the malunited ulnar fracture. The deformity includes shortening with an apex posterior angulation. In the acute setting, open reduction of the radial head rarely is necessary; however, in chronic dislocations, open reduction is required. Without ulnar osteotomy, recurrent radial head dislocation is likely.

Question 23

Ulnohumeral distraction interposition arthroplasty is considered the most appropriate treatment for which of the following patients?

Explanation

Distraction interposition arthroplasty is indicated for the treatment of both rheumatoid and posttraumatic arthritis and is reserved for younger patients who are not suitable candidates for total elbow arthroplasty. Although less reliable than prosthetic replacement, distraction interposition arthroplasty is a useful option in the treatment of young, high-demand patients with elbow arthritis. It is rarely indicated in the presence of polyarticular inflammatory arthritis but may be of value in those patients in whom the disease is limited primarily to the elbow. Isolated radiocapitellar arthritis can be successfully treated with radial head resection, although caution should be exercised if there is evidence of instability. Osteoarthritis is best treated with ulnohumeral arthroplasty. Cheng SL, Morrey BF: Treatment of the mobile, painful arthritic elbow by distraction interposition arthroplasty. J Bone Joint Surg Br 2000;82:233-238.

Question 24

A 57-year-old man with type I diabetes mellitus has had a tender, erythematous right sternoclavicular joint for the past 2 weeks. Radiographs reveal mild osteolysis without arthritic changes, within normal limits. Management should consist of

Explanation

Sternoclavicular joint sepsis is a rare condition that is most often restricted to patients who are immunocompromised, diabetic, or IV drug abusers. Examination commonly reveals a tender, painful, and possibly swollen sternoclavicular joint. If suspicion remains high following a thorough history, physical examination, radiographs, and routine blood tests, joint aspiration should be performed prior to incision and drainage or administration of antibiotics. Bremner RA: Monarticular noninfected subacute arthritis of the sternoclavicular joint. J Bone Joint Surg Br 1959;41:749-753.

Question 25

A 58-year-old man has persistent pain and weakness of his right shoulder after undergoing primary rotator cuff repair 1 year ago. A clinical photograph is shown in Figure 11. Which of the following factors might make functional improvement problematic with revision rotator cuff surgery?

Explanation

Functional improvement after revision rotator cuff surgery is most likely to occur in patients with an intact deltoid, good-quality rotator cuff tissue, preoperative active elevation alone to 90 degrees, and only one prior rotator cuff repair. In this patient, the compromised deltoid origin might make functional improvement less likely. Djurasovic M, Marra G, Arroyo JS, et al: Revision rotator cuff repair: Factors influencing results. J Bone Joint Surg Am 2001;83:1849-1855. Bigliani LU, Cordasco FA, McIlveen SJ, et al: Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am 1992;74:1505-1515.

Question 26

A 72-year-old woman undergoes a reverse total shoulder arthroplasty for rotator cuff tear arthropathy. Postoperatively, she develops a grade 3 scapular notch. Which of the following implant configurations is most strongly associated with preventing this complication?

Explanation

Scapular notching is a common complication of reverse TSA caused by mechanical impingement. Inferior placement and inferior tilt of the glenosphere, along with lateralization of the center of rotation, help prevent impingement of the humeral component on the scapular neck.

Question 27

A 25-year-old professional baseball pitcher presents with medial elbow pain during the late cocking phase of throwing. MRI arthrogram reveals a high-grade partial tear of the ulnar collateral ligament. If surgical reconstruction is chosen, the most isometric point of origin for the graft on the medial epicondyle is located:

Explanation

The native UCL anterior bundle originates slightly posterior to the epicondylar axis. However, for reconstruction, placing the graft origin at the exact axis of rotation provides the most isometric and biomechanically stable construct.

Question 28

A 38-year-old man fell onto an outstretched arm and sustained a terrible triad injury of the elbow. During surgical management, the standard step-wise approach to restoring elbow stability typically begins with fixation or replacement of which structure?

Explanation

The standard inside-out surgical sequence for a terrible triad injury involves fixation of the coronoid process first. This is followed by radial head repair or replacement, and finally lateral ulnar collateral ligament (LUCL) repair.

Question 29

A 55-year-old woman presents with sudden loss of active thumb interphalangeal joint flexion 9 months after volar plate fixation of a distal radius fracture. Radiographs show the plate is positioned volar to the watershed line. Which of the following describes the most likely pathogenesis of her current condition?

Explanation

Plate placement distal to the watershed line (Soong grade 2) significantly increases the risk of flexor pollicis longus (FPL) tendon attrition and rupture. Prompt plate removal is recommended if early signs of tenosynovitis occur.

Question 30

A 32-year-old male bodybuilder feels a sudden pop in his anterior axilla while performing a heavy bench press. Examination reveals loss of the anterior axillary fold and weakness in internal rotation. In a complete rupture of the pectoralis major, which anatomical segment is most commonly torn from its humeral insertion?

Explanation

Pectoralis major ruptures typically occur during eccentric loading. The sternal head, which inserts deep and proximal to the clavicular head on the humerus, is placed under maximal tension during a bench press and is most commonly torn.

Question 31

A 22-year-old competitive rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals 26% anterior glenoid bone loss. Which of the following is the most appropriate definitive surgical management?

Explanation

Anterior glenoid bone loss greater than 20-25% is a critical threshold where arthroscopic Bankart soft-tissue repair has an unacceptably high failure rate. An open Latarjet (coracoid transfer) procedure is the treatment of choice.

Question 32

A 45-year-old manual laborer undergoes arthroscopic evaluation for a type II SLAP tear. He also has a full-thickness supraspinatus tear. What is the most appropriate management of the biceps labral complex in this patient demographic?

Explanation

In patients older than 40 years, especially those with concomitant rotator cuff tears, biceps tenodesis yields superior functional outcomes and lower complication rates compared to SLAP repair. SLAP repair in older individuals is highly associated with postoperative stiffness.

Question 33

A 42-year-old man undergoes a single-incision anterior approach for repair of an acute distal biceps tendon rupture. Postoperatively, he notes numbness along the lateral aspect of his forearm. Which nerve is most likely injured?

Explanation

The lateral antebrachial cutaneous (LABC) nerve is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. Injury typically occurs due to excessive lateral retraction.

Question 34

A 25-year-old male presents with medial winging of the scapula after a heavy lifting injury. He is unable to forward elevate his arm past 90 degrees. Injury to which of the following nerves is most likely responsible?

Explanation

Medial winging of the scapula is caused by serratus anterior paralysis, innervated by the long thoracic nerve. Lateral winging is associated with trapezius dysfunction secondary to spinal accessory nerve injury.

Question 35

A 35-year-old male suffers a closed, midshaft humeral fracture. He has a complete radial nerve palsy on initial presentation. What is the most appropriate initial management?

Explanation

Primary radial nerve palsy with a closed humeral shaft fracture is managed nonoperatively initially, as 70-90% resolve spontaneously. Surgical exploration is indicated for open fractures, vascular injury, or palsy developing after closed reduction.

Question 36

A 68-year-old female presents with a displaced 4-part proximal humerus fracture with significant comminution of the tuberosities and osteopenic bone. What is the most reliable surgical option to restore active forward elevation?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for complex 4-part proximal humerus fractures in older patients with poor bone quality. It provides more predictable functional outcomes and forward elevation compared to hemiarthroplasty.

Question 37

A 40-year-old female undergoes volar locking plate fixation for a distal radius fracture. Six months postoperatively, she suddenly loses the ability to actively flex the interphalangeal joint of her thumb. Which of the following is the most likely cause?

Explanation

Flexor pollicis longus (FPL) rupture is a known complication of volar plating if the plate is placed distal to the watershed line. The prominent edge of the plate causes attritional wear and subsequent tendon rupture.

Question 38

A 45-year-old man falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. Which of the following describes the correct surgical sequence to restore elbow stability?

Explanation

The standard surgical algorithm for a terrible triad injury involves a deep-to-superficial approach. This sequence involves fixing the coronoid first, addressing the radial head, and finally repairing the lateral collateral ligament (LCL) complex.

Question 39

A 28-year-old male sustains a scaphoid waist fracture that progresses to a scaphoid nonunion advanced collapse (SNAC) pattern. Radiographs reveal degenerative changes limited to the radioscaphoid joint. What stage of SNAC wrist does this represent?

Explanation

SNAC Stage I involves arthritis localized to the radioscaphoid joint. Stage II involves the scaphocapitate joint, and Stage III progresses to involve the capitolunate joint.

Question 40

A 38-year-old bodybuilder undergoes a single-incision anterior approach repair for a distal biceps tendon rupture. Postoperatively, he complains of numbness and tingling along the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior distal biceps repair. The posterior interosseous nerve is more commonly at risk with a two-incision approach.

Question 41

Which of the following patient populations has the highest incidence and worst prognosis for developing adhesive capsulitis (frozen shoulder)?

Explanation

Diabetes mellitus, particularly Type 1, is a major risk factor for adhesive capsulitis. These patients typically have a more protracted clinical course, severe stiffness, and worse functional outcomes compared to idiopathic cases.

Question 42

A 22-year-old football player sustains an acromioclavicular (AC) joint injury. Radiographs show posterior displacement of the distal clavicle into the trapezius fascia. What is the correct classification and recommended treatment?

Explanation

Posterior displacement of the distal clavicle into the trapezius characterizes a Type IV AC joint injury. It is generally an absolute indication for surgical reconstruction due to significant pain and functional impairment.

Question 43

A 20-year-old rugby player has recurrent anterior shoulder instability. CT scan reveals 25% anterior glenoid bone loss. A Latarjet procedure is planned. Which nerve is at greatest risk during the coracoid transfer?

Explanation

The musculocutaneous nerve enters the coracobrachialis approximately 3-8 cm distal to the coracoid process tip. It is at significant risk of traction or direct injury during coracoid osteotomy and transfer during the Latarjet procedure.

Question 44

A 6-year-old child sustains a plastic deformation fracture of the proximal ulna with an anterior dislocation of the radial head. What is the most appropriate management?

Explanation

This describes a Bado Type I Monteggia fracture-dislocation. Restoring the length and anatomic alignment of the ulnar shaft typically results in spontaneous reduction and stability of the radial head.

Question 45

A 50-year-old male presents with weakness of pinch grip and numbness in the small finger, extending to the dorsal ulnar aspect of the hand. Examination reveals weakness of the first dorsal interosseous muscle and a positive Froment sign. What is the most likely diagnosis?

Explanation

The combination of sensory symptoms in the ulnar digits and weakness in ulnar-innervated intrinsic muscles suggests ulnar neuropathy. Sensation loss over the dorsal ulnar hand localizes the compression proximal to Guyon's canal, pointing to cubital tunnel syndrome.

Question 46

In a patient with a chronic radial nerve palsy, which tendon transfer is most commonly utilized to restore active wrist extension?

Explanation

The pronator teres is routinely transferred to the extensor carpi radialis brevis (ECRB) to restore wrist extension. The ECRB is chosen over the ECRL to maintain central alignment and avoid excessive radial deviation during extension.

Question 47

A 30-year-old construction worker presents with chronic wrist pain and decreased grip strength. Radiographs reveal sclerosis of the lunate with negative ulnar variance, but no carpal collapse. What is the most appropriate surgical treatment?

Explanation

Early-stage Kienbock disease associated with negative ulnar variance is best treated with a joint leveling procedure, such as a radial shortening osteotomy. This decreases load transmission across the avascular lunate.

Question 48

A 40-year-old man presents after a fall onto an outstretched hand. He sustains a posterolateral elbow dislocation with associated fractures of the radial head and coronoid process. After closed reduction, the elbow remains persistently unstable at 45 degrees of extension. In what order should the surgical reconstruction of this 'terrible triad' injury generally proceed?

Explanation

The standard algorithm for terrible triad injuries is to restore stability from deep to superficial, typically starting with coronoid fixation. This is followed by radial head repair or arthroplasty, and finally reconstruction of the lateral collateral ligament complex.

Question 49

A 55-year-old male presents with severe anterior shoulder pain and increased passive external rotation compared to the contralateral side. He exhibits a positive lift-off test and belly-press test. If this patient undergoes arthroscopy, what is the most likely associated pathology found in conjunction with his primary tendon injury?

Explanation

The clinical examination indicates an isolated subscapularis tear. Because the subscapularis and the coracohumeral ligament stabilize the long head of the biceps, a complete subscapularis tear frequently leads to medial subluxation or dislocation of the biceps tendon.

Question 50

A 28-year-old carpenter lacerates his index finger at the level of the proximal phalanx, completely severing both the FDS and FDP tendons (Zone II). Which of the following factors has the most direct correlation with the tensile strength of the primary flexor tendon repair, allowing for an early active motion protocol?

Explanation

The initial tensile strength of a flexor tendon repair is directly proportional to the number of core suture strands crossing the repair site. A 4- or 6-strand repair provides sufficient strength to withstand the forces of early active motion rehabilitation.

Question 51

A 35-year-old man presents with chronic, progressive wrist pain and stiffness 5 years after an untreated wrist injury. Radiographs reveal advanced sclerosis and collapse of the scaphoid with radioscaphoid arthritis. The radiolunate and midcarpal joints remain preserved. What is the most appropriate surgical management for this stage of Scaphoid Nonunion Advanced Collapse (SNAC)?

Explanation

In advanced SNAC (Stage II/III) where the radiolunate joint is spared but midcarpal or radioscaphoid arthritis is present, a scaphoid excision and four-corner fusion is indicated. Proximal row carpectomy is generally contraindicated if significant capitate head arthritis is present, which frequently accompanies advanced stages.

Question 52

A 76-year-old female sustains a 4-part proximal humerus fracture after a mechanical fall. Radiographs demonstrate severe valgus impaction, disruption of the medial hinge, and metaphyseal extension less than 8 mm. Which surgical option is shown to provide the most predictable improvement in functional outcome and pain relief in this specific demographic?

Explanation

RTSA is increasingly preferred for elderly patients with 4-part proximal humerus fractures due to reliable pain relief and functional outcomes, bypassing the need for tuberosity healing which frequently fails in hemiarthroplasty or ORIF. The described fracture pattern carries a very high risk of humeral head avascular necrosis.

Question 53

A 45-year-old typist complains of numbness in his ring and small fingers, and weakness in his hand. Examination reveals a positive Froment's sign when attempting to pinch a piece of paper. Which muscle is compensating for the primary motor deficit during this maneuver?

Explanation

Froment's sign demonstrates compensatory interphalangeal joint flexion by the flexor pollicis longus (innervated by the anterior interosseous nerve) during pinch grip. This compensates for the weakness of the adductor pollicis, which is paralyzed due to ulnar nerve compression (cubital or Guyon's canal).

Question 54

A 22-year-old collegiate baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. Examination shows a glenohumeral internal rotation deficit (GIRD) of 25 degrees compared to the contralateral shoulder. What is the primary underlying pathophysiology driving this specific impingement pattern?

Explanation

Internal impingement in overhead throwers is driven by posteroinferior capsular contracture (leading to GIRD). This contracture alters glenohumeral kinematics, shifting the humeral head posterosuperiorly during maximum external rotation and pinching the rotator cuff against the posterosuperior glenoid.

Question 55

A 28-year-old construction worker complains of dorsal central wrist pain. Radiographs reveal ulnar negative variance and sclerosis of the lunate without collapse. MRI confirms diffuse avascular necrosis of the lunate. What is the most appropriate initial surgical intervention to offload the radiolunate joint?

Explanation

In early-stage Kienbock's disease (stage I or II) with ulnar negative variance, a radial shortening osteotomy is the treatment of choice. It levels the joint and decreases the mechanical load transmitted through the lunate, potentially allowing for revascularization.

Question 56

A 30-year-old male sustains a severe high-energy wrist hyperextension injury. Lateral radiograph demonstrates the capitate resting dorsally to the lunate, while the lunate maintains its normal alignment with the distal radius. The patient exhibits acute numbness in the thumb, index, and middle fingers. What is the most appropriate initial step in management?

Explanation

The scenario describes a dorsal perilunate dislocation causing acute median nerve compression. Emergent closed reduction is required to relieve pressure on the median nerve, followed by definitive surgical stabilization (ORIF) typically performed semi-electively.

Question 57

A 42-year-old man sustains an isolated fracture of the proximal third of the ulna with an associated anterior dislocation of the radial head. Regarding the definitive management of this specific injury pattern in an adult, which of the following statements is most accurate?

Explanation

This is a Bado Type I Monteggia fracture-dislocation. In adults, rigid anatomic internal fixation of the ulnar shaft fracture is required; this typically restores the bony anatomy and length, leading to spontaneous reduction of the radiocapitellar joint without needing open radial head reduction.

Question 58

A 34-year-old man presents to the emergency department after a first-time generalized tonic-clonic seizure. His shoulder is locked in internal rotation and he cannot actively or passively externally rotate. An axillary radiograph confirms a posterior glenohumeral dislocation with an anteromedial humeral head impaction fracture involving 30% of the articular surface. What is the most appropriate surgical treatment?

Explanation

The patient has a posterior dislocation with a significant reverse Hill-Sachs lesion (between 20-40% of the articular surface). The modified McLaughlin procedure (transfer of the lesser tuberosity/subscapularis into the defect) stabilizes the joint and prevents engagement of the defect on the posterior glenoid rim.

Question 59

A 48-year-old bodybuilder feels a sudden pop in his antecubital fossa while performing heavy bicep curls. He has weakness in supination and an abnormal Hook test. If the surgeon chooses to repair this injury using a single-incision anterior approach, which nerve is at highest risk of iatrogenic injury?

Explanation

Distal biceps ruptures repaired via a single-incision anterior approach carry the highest risk of injury to the lateral antebrachial cutaneous nerve (LABCN) due to retraction. While the PIN is also at risk, LABCN neurapraxia is the most common complication overall.

Question 60

A 62-year-old female with advanced basal joint arthritis undergoes a ligament reconstruction and tendon interposition (LRTI) procedure using the flexor carpi radialis (FCR) tendon. This procedure is specifically designed to reconstruct which primary stabilizing ligament of the trapeziometacarpal joint to prevent proximal metacarpal subsidence?

Explanation

The anterior oblique ligament (AOL) is the primary volar stabilizer of the thumb carpometacarpal joint. The LRTI procedure utilizes a tendon slip (most commonly FCR) routed through the base of the first metacarpal to reconstruct the AOL and prevent proximal migration.

Question 61

A 25-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). On initial presentation in the emergency department, he is noted to have a complete radial nerve palsy. After closed reduction and splinting, his radial nerve palsy persists but is unchanged. What is the most appropriate management regarding the radial nerve?

Explanation

Primary radial nerve palsy associated with a closed humeral shaft fracture is typically a neurapraxia and managed observationally. Immediate exploration is only indicated for open fractures, severe vascular injury, or a secondary palsy that appears only after closed reduction attempts.

Question 62

A 55-year-old woman with poorly controlled type II diabetes presents with an insidious onset of diffuse shoulder pain and profound restriction of both active and passive range of motion. Radiographs are unremarkable. Which specific anatomic structure is primarily responsible for the loss of external rotation observed in this condition?

Explanation

In adhesive capsulitis, fibroblastic proliferation and contracture heavily involve the rotator interval. Contracture of the coracohumeral ligament, a primary component of the rotator interval, is specifically responsible for the marked loss of passive external rotation.

Question 63

A 38-year-old female falls onto her outstretched hand and sustains a coronal shear fracture of the distal humerus. Radiographs demonstrate a 'double arc' sign on the lateral view. Which of the following best describes the anatomy of this specific fracture pattern (McKee Type IV)?

Explanation

The 'double arc' sign on a lateral elbow radiograph represents a type IV coronal shear fracture, which involves the capitellum and extends medially to include most of the trochlea. The two arcs represent the subchondral bone of the capitellum and the lateral ridge of the trochlea.

Question 64

A 40-year-old mechanic presents with a swollen, erythematous index finger held in slight flexion. He reports severe pain when the examiner passively extends the digit. He has exquisite tenderness along the volar aspect of the digit. If left untreated, what is the most significant consequence of the increased pressure within the flexor tendon sheath?

Explanation

The patient exhibits Kanavel's signs for acute purulent flexor tenosynovitis. Prompt surgical irrigation and debridement are critical because increased pressure within the closed flexor tendon sheath causes ischemia, leading to rapid tendon necrosis and irreversible functional loss.

Question 65

A 26-year-old competitive volleyball player undergoes arthroscopic repair of a posterior labral tear. The surgeon places suture anchors extensively along the posteroinferior and posterosuperior glenoid rim. Postoperatively, the patient experiences isolated, profound weakness in external rotation despite a pain-free joint. What is the most likely iatrogenic cause of this complication?

Explanation

The suprascapular nerve passes through the spinoglenoid notch approximately 1 to 2 cm medial to the posterior glenoid rim. Placement of anchors or sutures too deeply or too far medially along the posterior/posterosuperior glenoid can easily entrap the nerve, causing denervation of the infraspinatus.

Question 66

A 60-year-old woman requires open reduction and internal fixation for a volar Barton's fracture of the distal radius. The surgeon utilizes a standard volar Henry approach. During distal dissection, which structure must be carefully retracted ulnarly to protect the median nerve while maintaining the plane between the FCR and radial artery?

Explanation

In the standard volar Henry approach to the distal radius, the interval is between the flexor carpi radialis (FCR) and the radial artery. Retracting the FCR tendon ulnarly protects the median nerve, including its palmar cutaneous branch, which lies ulnar to the FCR.

Question 67

A 24-year-old gymnast presents with persistent ulnar-sided wrist pain and clicking upon pronation and supination. Examination reveals gross instability of the distal radioulnar joint (DRUJ) and a positive foveal sign. MRI confirms a complete avulsion of the triangular fibrocartilage complex (TFCC). Which specific fibers must be reattached to restore DRUJ stability?

Explanation

The deep fibers of the TFCC (ligamentum subcruentum), which insert into the fovea at the base of the ulnar styloid, are the primary stabilizers of the DRUJ. Failure to repair these deep fibers results in persistent DRUJ instability.

Question 68

A 70-year-old woman undergoes a reverse total shoulder arthroplasty for rotator cuff tear arthropathy. To minimize the risk of postoperative scapular notching, which of the following intraoperative techniques regarding glenosphere placement is most appropriate?

Explanation

Scapular notching in reverse total shoulder arthroplasty is caused by mechanical impingement of the humeral cup against the inferior scapular neck. Inferior translation and inferior tilt of the glenosphere have been shown to significantly reduce this risk by clearing the inferior scapular pillar.

Question 69

A 42-year-old man falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. During surgical reconstruction, after stable fixation of the coronoid and radial head, the elbow remains persistently unstable in extension. What is the next most appropriate step in management?

Explanation

The standard surgical protocol for terrible triad injuries follows an inside-out or outside-in approach, but definitively requires fixing the coronoid, then the radial head, followed by repairing the LUCL. If the elbow remains unstable after LUCL repair, MUCL repair or hinged external fixation may then be considered.

Question 70

A 38-year-old male bodybuilder undergoes a two-incision surgical repair of a complete distal biceps tendon rupture. Compared to a single anterior incision technique, this patient is at an increased risk for which of the following postoperative complications?

Explanation

The two-incision technique for distal biceps repair was designed to avoid nerve injury but is associated with a significantly higher risk of heterotopic ossification and radioulnar synostosis. In contrast, the single anterior incision approach carries a higher risk of radial or lateral antebrachial cutaneous nerve neuropraxia.

Question 71

A 25-year-old cyclist sustains a midshaft clavicle fracture after a high-speed crash. Which of the following radiographic findings is considered the strongest relative indication for operative fixation over nonoperative management in this patient?

Explanation

Shortening of greater than 20 mm (or 2 cm) in midshaft clavicle fractures is a well-recognized relative indication for surgical fixation. This degree of shortening is associated with increased rates of symptomatic nonunion, malunion, and decreased shoulder muscle endurance.

Question 72

A 31-year-old competitive weightlifter feels a tearing sensation in his anterior chest while performing a heavy bench press. Examination reveals extensive ecchymosis and loss of the anterior axillary fold. MRI confirms a complete rupture of the pectoralis major. Which portion of the musculotendinous unit is most commonly injured in this mechanism?

Explanation

Pectoralis major ruptures almost exclusively occur during weightlifting (e.g., bench press) when the muscle is eccentrically loaded. The tear most frequently involves the sternocostal head avulsing directly from its insertion site on the lateral lip of the bicipital groove of the humerus.

Question 73

A 45-year-old man presents with chronic wrist pain. Radiographs demonstrate a chronic scaphoid nonunion with radioscaphoid arthritis, but the capitolunate joint and midcarpal joints are perfectly preserved. What stage of Scaphoid Nonunion Advanced Collapse (SNAC) does this represent, and what is an appropriate surgical option?

Explanation

SNAC Stage II involves arthritis extending to the entire radioscaphoid joint while sparing the midcarpal joint. Proximal row carpectomy (PRC) or scaphoid excision with four-corner fusion are standard motion-preserving surgical treatments for Stage II SNAC.

Question 74

A 28-year-old professional volleyball player presents with vague posterior shoulder pain and weakness with external rotation. Examination reveals isolated atrophy of the infraspinatus with normal supraspinatus bulk and strength. An MRI reveals a paralabral cyst. Where is the cyst most likely located to produce these exact findings?

Explanation

A cyst at the spinoglenoid notch compresses the suprascapular nerve after it has already given off its motor branches to the supraspinatus muscle. This results in isolated infraspinatus weakness and atrophy, which is a classic finding in overhead athletes with posterior labral tears.

Question 75

A 65-year-old woman sustains a highly comminuted fracture of the olecranon that extends distally to involve the coronoid process. Which of the following internal fixation constructs is most appropriate for this specific fracture pattern?

Explanation

While tension band wiring is appropriate for simple, transverse olecranon fractures, it is strictly contraindicated in comminuted fractures or those extending to the coronoid (Monteggia variants) due to the risk of collapse and shortening. Plate fixation provides the rigid stabilization necessary for comminuted patterns.

Question 76

During shoulder arthroscopy on a 25-year-old throwing athlete, you identify a superior labrum anterior-posterior (SLAP) lesion. The superior labrum is completely detached, and the tear extends into the substance of the long head of the biceps tendon, creating a bucket-handle tear. How is this lesion classified according to the Snyder classification?

Explanation

A Type IV SLAP tear is characterized by a bucket-handle tear of the superior labrum that extends into the long head of the biceps tendon. Treatment depends on the extent of biceps involvement and may include labral repair with or without biceps tenodesis.

Question 77

A 45-year-old carpenter presents with persistent numbness in his small and ring fingers, accompanied by intrinsic hand muscle weakness. He is diagnosed with severe cubital tunnel syndrome. During surgical decompression, which structure represents the most common site of ulnar nerve compression at the elbow?

Explanation

Osborne's ligament, also known as the cubital tunnel retinaculum, spans between the olecranon and the medial epicondyle and is the most frequent site of ulnar nerve compression. The ligament of Struthers is associated with median nerve compression in the distal humerus.

Question 78

A 78-year-old woman sustains a severely comminuted 4-part proximal humerus fracture. Her history is notable for severe osteoporosis and chronic, massive rotator cuff tearing. Which surgical option is most likely to provide her with reliable forward elevation and the best functional outcome?

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for elderly patients with complex 4-part proximal humerus fractures in the setting of rotator cuff arthropathy or poor bone quality. RTSA provides much more predictable forward elevation and functional recovery compared to hemiarthroplasty or ORIF in this demographic.

Question 79

A 33-year-old woman presents with a severely comminuted radial head fracture involving the entire head and neck, accompanied by a mechanical block to forearm rotation. Radiographs demonstrate a Mason Type III fracture. Intraoperatively, the fracture is deemed completely unreconstructible. What is the most appropriate management?

Explanation

For unreconstructible, comminuted Mason Type III radial head fractures, radial head replacement with a metallic prosthesis is the gold standard. Radial head excision alone is generally avoided due to the high risk of proximal radius migration and longitudinal instability, especially if occult ligamentous injuries exist.

Question 80

A 22-year-old rugby player undergoes diagnostic arthroscopy for recurrent anterior shoulder instability. The surgeon notes a Bankart lesion and an "engaging" Hill-Sachs lesion that drops over the anterior glenoid rim in abduction and external rotation. Assuming no significant glenoid bone loss, what adjunctive soft-tissue procedure should be performed alongside the Bankart repair?

Explanation

An "engaging" Hill-Sachs lesion significantly increases the risk of recurrent anterior dislocation if only a Bankart repair is performed. Arthroscopic remplissage (insetting the infraspinatus tendon into the humeral defect) combined with a Bankart repair effectively converts the intra-articular defect into an extra-articular one, preventing engagement.

Question 81

A 25-year-old chef lacerates his index finger flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons in Zone II. He undergoes an uncomplicated primary repair using a 4-strand core suture and an epitendinous repair. What is the most appropriate postoperative rehabilitation protocol?

Explanation

Modern flexor tendon rehabilitation following a robust repair (at least a 4-strand core plus epitendinous suture) emphasizes early active motion within a dorsal blocking splint. This protocol enhances tendon excursion, minimizes adhesion formation, and yields better functional outcomes than traditional passive-only protocols.

Question 82

A 29-year-old man falls backward onto his extended wrist and complains of severe dorsal radial wrist pain. Radiographs demonstrate a widened scapholunate interval of 5 mm and a "cortical ring sign" of the scaphoid. The patient is scheduled for surgical repair of the scapholunate ligament. Which portion of the scapholunate interosseous ligament is the strongest and most critical to repair for carpal stability?

Explanation

The scapholunate interosseous ligament consists of three distinct regions: the volar band, the proximal membranous portion, and the dorsal band. The dorsal band is the thickest, strongest, and acts as the primary restraint to palmar flexion of the scaphoid, making its anatomic repair critical.

Question 83

A 42-year-old man falls from a ladder and sustains a 'terrible triad' injury to his elbow. During surgical reconstruction, after addressing the coronoid and replacing the radial head, the elbow remains unstable. Repair of the lateral collateral ligament (LCL) complex is performed. The primary isometric stabilizer of the LCL complex originates from the lateral epicondyle and inserts on which of the following structures?

Explanation

The lateral ulnar collateral ligament (LUCL) is the primary isometric stabilizer of the posterolateral elbow. It originates on the lateral epicondyle and inserts on the supinator crest of the proximal ulna.

Question 84

A 24-year-old male presents with persistent wrist pain 12 weeks after falling on an outstretched hand. MRI confirms a proximal pole scaphoid nonunion with avascular necrosis. Which of the following surgical options offers the most reliable rate of union in this specific scenario?

Explanation

For a proximal pole scaphoid nonunion complicated by avascular necrosis, a vascularized bone graft (such as the 1,2 ICSRA graft) is indicated to restore blood supply and promote healing. Non-vascularized grafts have a high failure rate in the presence of AVN.

Question 85

A 45-year-old weightlifter undergoes a single-incision anterior approach repair of a distal biceps tendon rupture. Postoperatively, he notes numbness along the lateral aspect of his volar forearm. Which nerve was most likely injured during the superficial exposure and retraction?

Explanation

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

Question 86

Which of the following best describes the biomechanical rationale for utilizing a reverse total shoulder arthroplasty in a patient with massive, irreparable rotator cuff tear arthropathy?

Explanation

A reverse total shoulder arthroplasty medializes and inferiorly translates the center of rotation of the glenohumeral joint. This biomechanical alteration lengthens the deltoid, increasing its moment arm and allowing it to compensate for the deficient rotator cuff.

Question 87

A 58-year-old woman presents with progressive wrist pain 10 years after an untreated wrist injury. A radiograph is shown in Figure 60.

Assuming the typical progressive arthritic pattern seen in Scapholunate Advanced Collapse (SLAC), which articulation is characteristically spared from degenerative changes even in late stages?

Explanation

In SLAC wrist, the spherical shape of the lunate maintains a congruent and load-sharing articulation with the lunate fossa of the distal radius. Therefore, the radiolunate joint is characteristically spared from arthritis, which allows for salvage procedures like a four-corner fusion.

Question 88

During a Latarjet procedure for recurrent anterior shoulder instability, the coracoid process is osteotomized and transferred to the anterior glenoid. Which nerve is at the greatest risk of injury during the mobilization and transfer of the conjoined tendon?

Explanation

The musculocutaneous nerve penetrates the coracobrachialis muscle typically 3 to 8 cm distal to the coracoid process. It is uniquely tethered to the conjoined tendon, making it highly susceptible to stretch or transection during the Latarjet procedure.

Question 89

A 62-year-old woman returns to the clinic 8 months after undergoing volar plate fixation for a distal radius fracture. She reports a sudden inability to actively flex the interphalangeal joint of her thumb. Radiographs reveal the hardware is intact but positioned distal to the watershed line. Which of the following is the most appropriate surgical management?

Explanation

Rupture of the FPL tendon post-volar plating is due to chronic attrition over the prominent plate and cannot be reliably repaired primarily. An EIP to FPL tendon transfer is the standard and most reliable method to restore thumb interphalangeal flexion.

Question 90

A 22-year-old rugby player sustained a hyperextension injury to his ring finger while grasping an opponent's jersey. He cannot actively flex the distal interphalangeal (DIP) joint. Examination reveals tenderness localized to the palm. According to the Leddy and Packer classification, what is the appropriate management for this injury?

Explanation

This is a Type I Jersey finger (FDP avulsion) where the tendon retracts into the palm, disrupting both the vincular blood supply and the tendon's nutritional pathways. It requires early surgical repair within 7 to 10 days to prevent permanent tendon retraction and necrosis.

Question 91

A 40-year-old carpenter presents with numbness and tingling in his small and ring fingers. He also notes clumsiness when handling small nails. Nerve conduction studies confirm ulnar neuropathy at the elbow. Which of the following is the most common site of ulnar nerve compression in this condition?

Explanation

Cubital tunnel syndrome is most commonly caused by compression of the ulnar nerve at Osborne's ligament (the cubital tunnel retinaculum) which connects the humeral and ulnar heads of the flexor carpi ulnaris.

Question 92

A patient presents with an inability to extend their fingers at the metacarpophalangeal (MCP) joints following a penetrating injury to the proximal forearm. When asked to extend the wrist, it strongly deviates radially. This clinical presentation is most consistent with an injury to which nerve?

Explanation

PIN palsy causes weakness in finger extension and extensor carpi ulnaris (ECU), but spares the extensor carpi radialis longus (ECRL) which is innervated by the radial nerve proper. This selective weakness results in strong radial deviation during active wrist extension.

Question 93

A 32-year-old bodybuilder feels a pop in his anterior chest while performing a heavy bench press. Examination reveals bruising and a loss of the anterior axillary fold contour. MRI confirms a complete pectoralis major rupture. Which portion of the muscle is most commonly injured in this classic mechanism?

Explanation

Pectoralis major ruptures typically occur at the insertion of the sternal head onto the humerus during forced eccentric contraction, such as the lowering phase of a bench press.

Question 94

A 24-year-old pitcher presents with vague shoulder pain and a prominent medial border of the right scapula, especially when performing a wall push-up. EMG confirms an isolated nerve palsy. Which of the following statements regarding the affected nerve is accurate?

Explanation

Medial scapular winging is caused by a long thoracic nerve palsy. The long thoracic nerve (C5-C7 roots) is unique because it courses superficial to the serratus anterior muscle it innervates, making it susceptible to blunt trauma and traction injuries.

Question 95

A 35-year-old manual laborer presents with dorsal wrist pain and decreased grip strength. Radiographs reveal sclerosis and fragmentation of the lunate with a negative ulnar variance of 3 mm. The radioscaphoid joint appears entirely normal. What is the most appropriate surgical intervention?

Explanation

This patient has Kienbock's disease (Stage IIIa) with negative ulnar variance. A joint-leveling procedure, such as a radial shortening osteotomy, offloads the radiolunate joint and halts disease progression before widespread carpal collapse occurs.

Question 96

A 29-year-old volleyball player has an isolated weakness of external rotation in her dominant shoulder. Atrophy is noted over the infraspinatus fossa, while the supraspinatus muscle belly appears normal. MRI reveals a paralabral cyst. Where is the cyst most likely located?

Explanation

A cyst at the spinoglenoid notch compresses the terminal branch of the suprascapular nerve, resulting in isolated denervation of the infraspinatus. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 97

A 48-year-old avid cyclist presents with profound intrinsic muscle weakness in his hand, manifesting as a positive Wartenberg sign and an inability to cross his fingers. Sensation on both the volar and dorsal aspects of the hand is completely normal. Compression of the ulnar nerve is most likely occurring in which anatomical zone of Guyon's canal?

Explanation

Guyon's canal Zone 2 contains only the deep motor branch of the ulnar nerve. Compression here (often due to a hook of hamate fracture or ganglion) causes isolated motor deficits without sensory abnormalities.

Question 98

A 19-year-old football player presents to the emergency department after a high-impact collision. He complains of severe pain at the base of his neck, difficulty swallowing, and a feeling of fullness in his throat. What is the most appropriate initial imaging modality to confirm the suspected diagnosis?

Explanation

The patient is presenting with signs of a posterior sternoclavicular joint dislocation, a surgical emergency due to proximity to mediastinal structures. A CT scan is the gold standard imaging modality to definitively evaluate sternoclavicular displacement and mediastinal compromise.

Question 99

When performing a primary repair of a severed flexor tendon in Zone II, which biomechanical factor contributes most significantly to the ultimate tensile strength of the repair during the early postoperative rehabilitation phase?

Explanation

The ultimate tensile strength of a flexor tendon repair is directly proportional to the number of core suture strands that cross the repair site. Modern protocols typically recommend at least a 4-strand (and increasingly 6-strand) core repair to permit early active motion.

Question 100

A 55-year-old woman with type 1 diabetes mellitus presents with progressively worsening, severe shoulder pain that awakens her at night. Active and passive range of motion are moderately restricted globally. Intra-articular corticosteroid injections are being considered. She is currently in the classic 'freezing' phase of adhesive capsulitis. What is the predominant histological characteristic of the joint capsule during this phase?

Explanation

The 'freezing' phase (Stage II) of adhesive capsulitis is characterized by severe pain and early stiffness. Histologically, it demonstrates hypervascular, hypertrophic synovitis with a marked perivascular inflammatory infiltrate before progressing to dense fibrosis in the later stages.

General Orthopedics 2026 Practice Questions: Set 13 (Solved)

Orthopedic Upper Extremity 2026 MCQs: Board Review Questions & Answers (Part 1)

Key Takeaway

Orthopedic Upper Extremity 2026 MCQs: Board Review Questions & Answers (Part 1)

Chapter Index