Orthopedic Upper Extremity 2026 MCQs: Review Part 2

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

12b 12c 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

15b 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

16b 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

19b 19c 19d 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 42-year-old woman falls on her outstretched hand and sustains a 'terrible triad' injury to her elbow. Which of the following is the most appropriate sequence of surgical reconstruction to restore elbow stability?

Explanation

The standard surgical protocol for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) proceeds from deep to superficial, or inside-out. The established sequence is: 1) Coronoid process fixation (to restore the anterior buttress), 2) Radial head fixation or replacement (to restore the lateral column), 3) Lateral collateral ligament (LCL) complex repair (typically torn off the lateral epicondyle), and 4) Medial collateral ligament (MCL) repair or application of a hinged external fixator if the elbow remains persistently unstable after the first three steps.

Question 27

A 72-year-old man with cuff tear arthropathy undergoes a reverse total shoulder arthroplasty. By medializing and inferiorly shifting the center of rotation, which of the following is the primary biomechanical advantage achieved?

Explanation

The Grammont principles of reverse total shoulder arthroplasty involve medializing and moving the center of rotation inferiorly relative to the native glenoid. This design significantly increases the deltoid moment arm and recruits more of the anterior and posterior deltoid fibers to assist in forward elevation and abduction. It also lowers the humerus (distalizes), thereby tensioning the deltoid and increasing its mechanical advantage, compensating for the functionally deficient rotator cuff.

Question 28

A 6-year-old boy falls off monkey bars and sustains a significantly displaced extension-type supracondylar humerus fracture. On presentation, the hand is pink and warm, but the radial pulse is nonpalpable. The neurologic examination shows an anterior interosseous nerve palsy. Following closed reduction and percutaneous pinning, the hand remains pink and warm, with a capillary refill of less than 2 seconds, but the radial pulse remains nonpalpable. What is the most appropriate next step in management?

Explanation

The management of the 'pulseless, pink hand' in pediatric supracondylar humerus fractures after acceptable closed reduction and pinning is observation. If the hand remains well-perfused (pink, warm, brisk capillary refill) despite an absent palpable radial pulse, collateral circulation is adequate. Routine vascular exploration or advanced imaging in a well-perfused extremity is not indicated. Exploration is required if the hand becomes cold, pale, and poorly perfused (a pulseless, white hand) after reduction, which implies an arterial injury without sufficient collateral flow.

Question 29

An 80-year-old female with osteoporosis presents with a severely comminuted, intra-articular distal humerus fracture (AO/OTA 13-C3) after a fall from a standing height. She lives independently and uses a walker for ambulation. Which of the following is the primary advantage of total elbow arthroplasty (TEA) compared to open reduction and internal fixation (ORIF) in this patient?

Explanation

In elderly patients with poor bone quality and complex, comminuted intra-articular distal humerus fractures, TEA provides a more predictable and rapid recovery of function and allows for immediate early range of motion compared to ORIF. ORIF in this osteoporotic population is associated with a high rate of hardware failure, nonunion, and stiffness due to the inability to achieve stable enough fixation for early mobilization. However, patients with TEA must abide by a permanent 5- to 10-pound lifting restriction to prevent aseptic loosening and bushing wear. Rates of ulnar neuropathy are similar or slightly higher in TEA.

Question 30

A 35-year-old construction worker falls from a ladder and sustains a comminuted radial head fracture. During evaluation, he complains of wrist pain, and radiographs reveal positive ulnar variance and disruption of the distal radioulnar joint (DRUJ). He is diagnosed with an Essex-Lopresti injury. Which of the following surgical management strategies is most appropriate?

Explanation

An Essex-Lopresti injury consists of a radial head fracture, rupture of the interosseous membrane, and disruption of the DRUJ, leading to longitudinal radioulnar dissociation. Excision of the radial head without replacement is strictly contraindicated, as it will lead to rapid proximal migration of the radius and severe wrist and elbow dysfunction. Management requires restoring the lateral column of the elbow, typically with a radial head arthroplasty (since comminuted fractures are usually unfixable), followed by assessment and stabilization of the DRUJ (which may include TFCC repair and/or pinning the DRUJ in supination).

Question 31

A 12-year-old male baseball pitcher presents with medial elbow pain after a hard throw. Radiographs demonstrate an avulsion fracture of the medial epicondyle with 10 mm of displacement. He wishes to return to competitive throwing. What is the most appropriate management?

Explanation

Medial epicondyle fractures in pediatric and adolescent patients can often be treated non-operatively if minimally displaced. Absolute indications for surgery include entrapment of the fragment in the joint and open fractures. Relative indications, particularly for high-demand overhead athletes with significant displacement (often >5 mm), typically lead to operative management. ORIF with a single cannulated screw or K-wires provides rigid fixation, allowing early range of motion and effectively addresses the valgus instability that is critical for returning to throwing.

Question 32

Following an extensive flexor tendon repair in zone II, a surgeon must release part of the pulley system to allow tendon glide. To prevent significant bowstringing and loss of active flexion mechanics, which pulleys are considered the most critical to preserve?

Explanation

The A2 and A4 pulleys are the major biomechanical pulleys of the digital flexor sheath. They arise from the periosteum of the proximal and middle phalanges, respectively. Loss of both the A2 and A4 pulleys leads to profound bowstringing, mechanical disadvantage, and loss of full active flexion. Preserving or reconstructing the A2 and A4 pulleys remains a fundamental principle in hand surgery to maintain the moment arm of the flexor tendons.

Question 33

A 24-year-old cyclist falls onto his left shoulder and sustains a midshaft clavicle fracture. Which of the following is considered an absolute indication for open reduction and internal fixation?

Explanation

Absolute indications for ORIF of a clavicle fracture include an open fracture, associated neurovascular injury, skin tenting threatening to progress to an open fracture, and 'floating shoulder' in certain scenarios. Relative indications include shortening > 2 cm, 100% displacement, and severe comminution (such as a Z-type fragment). Therefore, an open fracture is the only absolute indication listed.

Question 34

A 6-year-old child presents with an acute Bado type I Monteggia fracture-dislocation (ulnar shaft fracture with anterior dislocation of the radial head). Following closed reduction of the ulnar shaft, the radial head remains anteriorly dislocated. What is the most appropriate next step in management?

Explanation

In a pediatric Monteggia fracture-dislocation, the reduction of the radial head is entirely dependent on achieving anatomical length and alignment of the ulna. If closed reduction of the ulna fails to adequately reduce the radial head, or if the ulna alignment is lost, the next step is anatomic restoration of the ulna via ORIF or intramedullary nailing. Once the ulna is anatomically fixed, the radial head usually reduces spontaneously. Direct open reduction of the radial head is only indicated if it remains dislocated despite a perfectly anatomical ulnar reduction.

Question 35

A 19-year-old male presents to the emergency department after a rugby tackle with severe pain at the base of his neck, difficulty swallowing, and a sensation of shortness of breath. Physical examination reveals an asymmetric chest wall with a depression at the right sternoclavicular joint. A CT scan confirms a posterior sternoclavicular dislocation. Which of the following statements regarding the management of this injury is most accurate?

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the risk of compression to the mediastinal structures, including the trachea, esophagus, and great vessels. Closed reduction is generally the first line of treatment and is successful in most acute cases. However, due to the proximity of the great vessels, closed reduction must be performed in the operating room under general anesthesia with a cardiothoracic surgeon readily available in case of a catastrophic vascular injury during the reduction maneuver.

Question 36

A 75-year-old woman with a history of severe osteoporosis sustains a 4-part proximal humerus fracture. She is treated with a reverse total shoulder arthroplasty (rTSA). Which of the following tuberosity management strategies during the index procedure is most associated with improved functional outcomes?

Explanation

Reverse total shoulder arthroplasty (rTSA) has become an increasingly popular option for complex proximal humerus fractures in the elderly. While the prosthesis itself confers stability, anatomic healing of the tuberosities (particularly the greater tuberosity) is highly correlated with improved patient-reported outcomes, increased forward elevation, and enhanced external rotation. Nonunion, malunion, or excision of the tuberosities typically leads to poorer functional recovery.

Question 37

A 42-year-old man falls from a height and sustains a 'terrible triad' injury of the elbow. Which of the following best describes the most appropriate sequence of surgical reconstruction?

Explanation

The terrible triad of the elbow involves an elbow dislocation, radial head fracture, and coronoid fracture. The surgical goal is to restore elbow stability to allow early range of motion. The standard treatment algorithm involves an 'inside-out' or deep-to-superficial approach. First, the coronoid is stabilized (often via a suture lasso or screw) to restore the anterior buttress. Next, the radial head is fixed or replaced to restore the radiocapitellar strut. Finally, the lateral collateral ligament (LCL) complex is repaired to the lateral epicondyle. If the elbow remains unstable after these steps, medial collateral ligament (MCL) repair or a hinged external fixator is considered.

Question 38

A 38-year-old man presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with radioscaphoid arthritis and capitolunate arthritis, but the radiolunate joint is anatomically spared. This is consistent with a Stage III SNAC wrist. Which of the following is the most appropriate surgical treatment?

Explanation

The patient has a Stage III Scaphoid Nonunion Advanced Collapse (SNAC) wrist, characterized by radioscaphoid and capitolunate arthritis, but sparing of the radiolunate joint. Proximal row carpectomy (PRC) relies on a preserved proximal capitate articular surface articulating with the lunate fossa; since capitolunate arthritis is present, PRC is contraindicated. A scaphoid excision and four-corner fusion (capitate, hamate, lunate, triquetrum) preserves the normal radiolunate articulation, providing pain relief while maintaining approximately 50% of normal wrist motion.

Question 39

A 45-year-old man undergoes surgical repair of a distal biceps tendon rupture via a single-incision anterior approach using a cortical button. Postoperatively, he reports numbness over the lateral aspect of his forearm. Which of the following nerves is most likely injured during this procedure?

Explanation

The single-incision anterior approach for distal biceps tendon repair places the lateral antebrachial cutaneous nerve (LABCN) at greatest risk. The LABCN runs in the subcutaneous tissue lateral to the biceps tendon and can be injured during superficial dissection or by overzealous retraction. Injury to the posterior interosseous nerve (PIN) is classically associated with the two-incision technique if retractors are placed poorly around the radial neck, or if the tendon is passed through the interosseous membrane incorrectly.

Question 40

A 28-year-old elite volleyball player presents with insidious onset of vague posterior shoulder pain and subjective weakness. Clinical examination reveals isolated atrophy of the infraspinatus muscle with preserved bulk of the supraspinatus. Overhead external rotation strength is decreased. An MRI is obtained. Where is the most likely site of nerve compression?

Explanation

The suprascapular nerve innervates the supraspinatus muscle before traversing the spinoglenoid notch to innervate the infraspinatus. Compression at the spinoglenoid notch, often caused by a paralabral cyst originating from a posterior labral tear, selectively denervates the infraspinatus, leading to isolated atrophy and external rotation weakness. If compression occurred proximally at the suprascapular notch, both the supraspinatus and infraspinatus would be affected.

Question 41

A 65-year-old man sustains a severely comminuted, displaced olecranon fracture extending into the coronoid process. What is the most biomechanically stable construct for fixation of this fracture?

Explanation

Comminuted olecranon fractures, particularly those extending distal to the sublime tubercle or involving the coronoid, are rotationally and axially unstable. Tension band wiring relies on the conversion of tension forces on the posterior cortex into compressive forces at the articular surface, which requires an intact anterior cortex to prevent shortening and collapse. Therefore, in the presence of comminution or associated instability, a posterior pre-contoured locking plate is the most biomechanically stable construct to restore anatomy and permit early range of motion.

Question 42

A 34-year-old male presents with persistent cubital tunnel syndrome despite 6 months of conservative management. He has a history of a childhood supracondylar humerus fracture and presents with a significant cubitus valgus deformity. EMG confirms severe ulnar neuropathy at the elbow. Which of the following surgical interventions is most appropriate?

Explanation

Anterior transposition of the ulnar nerve is indicated for cubital tunnel syndrome in the setting of structural deformities such as cubitus valgus (tardy ulnar palsy from a prior supracondylar fracture), hardware from prior surgeries, nerve instability/subluxation, or a recurrent condition. In situ decompression is a reliable option for idiopathic cases without anatomic distortion, but it is insufficient when bony deformity places chronic tension on the nerve.

Question 43

A 32-year-old manual laborer presents with chronic dorsal wrist pain. Radiographs demonstrate sclerosis and fragmentation of the lunate, with negative ulnar variance. The radioscaphoid angle is normal. What is the most appropriate initial surgical intervention for this patient?

Explanation

Kienbock disease is avascular necrosis of the lunate. In early stages (Lichtman Stage II or IIIA, indicating sclerosis or early fragmentation without carpal collapse) in a patient with negative ulnar variance, a joint-leveling procedure is indicated. A radial shortening osteotomy offloads the radiolunate joint, reducing mechanical stress on the lunate and allowing potential revascularization or cessation of collapse. Proximal row carpectomy or fusions are reserved for advanced stages with carpal collapse and secondary arthritis.

Question 44

A 25-year-old motorcyclist sustains a traumatic brachial plexus injury. Examination reveals paralysis of the rhomboids, serratus anterior, and all muscles of the upper extremity, accompanied by ipsilateral ptosis, miosis, and anhidrosis. What does this clinical picture indicate regarding the C8 and T1 nerve roots?

Explanation

In brachial plexus trauma, distinguishing between preganglionic (avulsion) and postganglionic (rupture) injuries is critical for management. Horner syndrome (ptosis, miosis, anhidrosis) indicates disruption of the sympathetic chain, which exits the spinal cord via the T1 root proximally (preganglionic). Additionally, paralysis of the serratus anterior and rhomboids indicates involvement of the long thoracic and dorsal scapular nerves, respectively, which branch off very proximally from the roots. These signs collectively point to a preganglionic avulsion, which carries a poor prognosis for spontaneous recovery and typically requires nerve transfers rather than primary repair or grafting.

Question 45

A 55-year-old woman undergoes volar locked plating for a displaced distal radius fracture. Six months postoperatively, she suddenly loses the ability to actively flex her thumb interphalangeal joint. What is the most likely cause of this complication?

Explanation

Volar locking plates have become the gold standard for many displaced distal radius fractures. However, if the plate is placed too distally (beyond the watershed line), the flexor tendons, most notably the flexor pollicis longus (FPL), can rub against the prominent distal edge of the plate. Over time, this attrition can lead to a sudden, painless rupture of the FPL tendon, presenting as a loss of active thumb interphalangeal joint flexion. Extensor tendon ruptures are more commonly associated with prominent dorsal screws protruding through the dorsal cortex.

Question 46

A 45-year-old construction worker presents with chronic radial-sided wrist pain. Radiographs demonstrate a scaphoid nonunion with advanced degenerative changes involving the radioscaphoid and capitolunate joints. The radiolunate joint is well preserved. Which of the following is the most appropriate surgical treatment?

Explanation

The patient has Scaphoid Nonunion Advanced Collapse (SNAC) stage III, which is characterized by arthritis at the radioscaphoid and capitolunate joints with sparing of the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in this setting because it requires a pristine capitate head to articulate with the lunate fossa of the radius. Because the capitolunate joint (and thus the capitate head) is arthritic, a PRC would result in continued pain. Scaphoid excision and four-corner fusion (capitate, lunate, hamate, triquetrum) is the standard of care as it preserves the unaffected radiolunate joint and removes the arthritic articulations.

Question 47

A 70-year-old woman presents with anterior shoulder pain and a sensation of instability 6 months after undergoing an anatomic total shoulder arthroplasty via a deltopectoral approach. Physical examination reveals a positive belly-press test, increased passive external rotation compared to the contralateral side, and profound weakness in internal rotation. Radiographs demonstrate anterior subluxation of the humeral head. What is the most appropriate and reliable surgical management?

Explanation

This patient has suffered a postoperative subscapularis failure after anatomic total shoulder arthroplasty, presenting with a positive belly-press test, increased passive external rotation, and anterior instability. In an older patient with secondary anterior instability following TSA, primary repair and tendon transfers (such as pectoralis major transfer) have high failure rates and less predictable outcomes. Revision to a reverse total shoulder arthroplasty (rTSA) provides a semiconstrained articulation that restores stability and function, making it the most reliable salvage procedure in this setting.

Question 48

A 40-year-old man undergoes a single-incision anterior approach for a distal biceps tendon repair using cortical button fixation. Postoperatively, he notes numbness and tingling over the lateral aspect of his forearm but demonstrates normal strength in wrist and finger extension. Which structure was most likely injured during the procedure, and during which step of the surgery does this typically occur?

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. The LABC, which is the terminal sensory branch of the musculocutaneous nerve, exits laterally between the biceps and brachialis muscles and travels superficially in the lateral forearm. It is highly susceptible to injury or traction neuropraxia during the initial subcutaneous dissection and superficial retraction.

Question 49

A 35-year-old woman falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow, consisting of a posterior elbow dislocation, a comminuted radial head fracture, and a coronoid fracture. Which of the following ligamentous structures is the primary restraint to posterolateral rotatory instability (PLRI) and is invariably torn in this injury pattern?

Explanation

The terrible triad of the elbow results from a valgus, axial, and posterolateral rotatory force that causes sequential failure of the lateral and medial soft tissue constraints, along with fractures of the radial head and coronoid. The lateral ulnar collateral ligament (LUCL) is the primary restraint to posterolateral rotatory instability (PLRI). It is invariably torn in a terrible triad injury and must be securely repaired to the lateral epicondyle to restore elbow stability.

Question 50

A 55-year-old woman undergoes volar locked plating for a comminuted, intra-articular fracture of the distal radius. Six months later, she returns to the clinic reporting a sudden inability to actively flex the interphalangeal joint of her thumb. Radiographs demonstrate an anatomically healed fracture. What is the most likely cause of this complication?

Explanation

The patient has experienced an attritional rupture of the flexor pollicis longus (FPL) tendon. The FPL tendon runs in close proximity to the volar cortex of the distal radius. If a volar plate is placed too distally (at or beyond the watershed line), the hardware prominence causes friction and attritional wear on the tendon during wrist motion, eventually leading to FPL rupture.

Question 51

A 22-year-old competitive rugby player presents with recurrent anterior shoulder instability following 4 traumatic dislocations. A CT scan with 3D reconstruction demonstrates 28% anterior glenoid bone loss. Which of the following is the most appropriate surgical management to prevent recurrence?

Explanation

In the setting of anterior shoulder instability, critical glenoid bone loss is generally considered to be greater than 20-25%. Soft tissue stabilization alone (e.g., arthroscopic or open Bankart repair) is contraindicated due to unacceptably high recurrence rates. A bony augmentation procedure, such as the Latarjet procedure (transfer of the coracoid process with the attached conjoint tendon to the anterior glenoid), is required to restore the articular arc and provide the dynamic 'sling' effect of the conjoint tendon.

Question 52

A 78-year-old woman with a history of severe osteoporosis falls and sustains a highly comminuted, intra-articular fracture of the distal humerus (AO/OTA type 13-C3). She is a community ambulator and lives independently. Intraoperatively, open reduction and internal fixation (ORIF) is attempted but deemed technically impossible due to severe 'eggshell' comminution and poor bone quality. What is the most appropriate alternative surgical option to maximize her functional recovery?

Explanation

Total elbow arthroplasty (TEA) is the treatment of choice for severely comminuted intra-articular distal humerus fractures in elderly patients with poor bone quality where ORIF is not feasible. TEA allows for immediate postoperative range of motion, providing rapid and reliable pain relief and functional restoration compared to prolonged immobilization or attempts at fixing osteoporotic bone which frequently fail.

Question 53

A 30-year-old manual laborer presents with chronic dorsal wrist pain. Radiographs demonstrate sclerosis and early fragmentation of the lunate, with normal carpal alignment and a negative ulnar variance of -3 mm. There is no evidence of radiocarpal or midcarpal arthritis. MRI confirms avascular necrosis of the lunate. Which of the following is the most appropriate initial surgical management?

Explanation

The patient has Lichtman Stage II or early Stage IIIA Kienbock's disease (avascular necrosis of the lunate) with ulnar negative variance. In the absence of carpal collapse and arthritis, joint-leveling procedures are indicated to mechanically unload the lunate. A radial shortening osteotomy is the preferred procedure, as it reliably unloads the radiolunate joint and is associated with fewer complications (e.g., nonunion) than ulnar lengthening.

Question 54

When performing a reverse total shoulder arthroplasty (rTSA), placing the glenosphere with an inferior tilt and slight inferior overhang relative to the native glenoid margin is done primarily to minimize the risk of which of the following postoperative complications?

Explanation

Scapular notching is a well-known complication of reverse total shoulder arthroplasty, characterized by mechanical impingement of the medial humeral polyethylene cup against the inferior scapular neck during arm adduction. To minimize this, the glenosphere should be positioned with an inferior tilt and an inferior overhang past the inferior margin of the glenoid to prevent direct contact of the humeral component with the scapular pillar.

Question 55

A 45-year-old carpenter complains of progressive numbness in the small and ring fingers of his right hand, along with weakness in grip strength. Examination shows intrinsic muscle wasting and a positive Tinel's sign at the cubital tunnel. EMG reveals severe ulnar neuropathy at the elbow. During surgical exploration for ulnar nerve decompression, the ulnar nerve is observed to subluxate anteriorly over the medial epicondyle during elbow flexion. Which of the following is the most appropriate surgical procedure?

Explanation

While in situ decompression is an effective treatment for many cases of primary cubital tunnel syndrome, a nerve that subluxates anteriorly over the medial epicondyle during elbow flexion after decompression is at high risk for friction neuritis and recurrent symptoms. Therefore, the presence of dynamic nerve subluxation is a direct indication to perform an anterior transposition (subcutaneous, intramuscular, or submuscular) of the ulnar nerve to stabilize it in an anterior position.

Question 56

A 76-year-old right-hand-dominant woman presents with a 4-part proximal humerus fracture following a mechanical fall. She is active and lives independently. Plain radiographs reveal a head-split component with significant osteopenia. She undergoes a reverse total shoulder arthroplasty (RTSA). Compared to hemiarthroplasty for this specific indication, RTSA has been shown to provide which of the following in the literature?

Explanation

In the treatment of complex proximal humerus fractures in the elderly, reverse total shoulder arthroplasty (RTSA) provides more consistent and reliable restoration of active forward elevation compared to hemiarthroplasty. Hemiarthroplasty relies heavily on anatomic tuberosity healing to provide good functional outcomes; if the tuberosities resorb or fail to heal, patients often develop pseudoparalysis. While RTSA has a slightly higher overall complication rate, its functional predictability makes it the procedure of choice for elderly patients with 4-part fractures and poor bone stock.

Question 57

A 22-year-old collegiate rugby player presents with his third anterior shoulder dislocation this season. Advanced imaging shows a 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following is the most appropriate definitive management to prevent recurrent instability and allow a return to contact sports?

Explanation

In a young, high-demand collision athlete with significant anterior glenoid bone loss (>20-25%), an arthroscopic Bankart repair is associated with an unacceptably high failure rate. A bony augmentation procedure, such as the Latarjet (coracoid transfer), is indicated to restore the glenoid arc and provide a dynamic 'sling' effect from the conjoint tendon. Remplissage can address an engaging Hill-Sachs lesion but does not treat the critical anterior glenoid bone loss.

Question 58

A 45-year-old man presents with a sudden inability to flex the interphalangeal joint of his right thumb. He sustained a distal radius fracture 8 weeks ago that was treated with volar locked plating. Radiographs demonstrate the fracture is healing in good alignment, but the plate is positioned prominent and distal to the watershed line. Which of the following is the most likely etiology of his current deficit?

Explanation

Volar plates placed distal to the watershed line of the distal radius can impinge on the flexor tendons. The flexor pollicis longus (FPL) tendon lies directly over the volar-ulnar aspect of the radius and is the most susceptible to attrition and rupture from prominent hardware. The patient's inability to actively flex the thumb interphalangeal joint is classic for an iatrogenic FPL rupture, which typically requires plate removal and tendon reconstruction (e.g., tendon transfer or graft).

Question 59

A 35-year-old male sustains a fall from a height, resulting in a complex elbow injury consisting of a radial head fracture, a type II coronoid fracture, and an elbow dislocation. During surgical reconstruction of this 'terrible triad' injury, what is the recommended sequence of fixation to optimally restore elbow stability?

Explanation

The classic 'terrible triad' of the elbow involves an elbow dislocation, radial head fracture, and coronoid fracture. The standard, most reliable surgical sequence to restore stability builds from deep to superficial and medial to lateral: 1) Repair of the coronoid process (often via sutures passed from posterior to anterior or through a specific approach), 2) Repair or replacement of the radial head, and 3) Repair of the lateral ulnar collateral ligament (LUCL) to its origin on the lateral epicondyle.

Question 60

A 28-year-old male bodybuilder reports vague, deep posterior shoulder pain and weakness with external rotation. He denies any history of trauma. Physical examination reveals isolated atrophy of the infraspinatus with normal bulk of the supraspinatus. Forward elevation and internal rotation strength are normal. MRI of the shoulder is most likely to show which of the following?

Explanation

Isolated infraspinatus atrophy with normal supraspinatus function is the classic presentation for suprascapular nerve compression at the spinoglenoid notch. In young, athletic patients, this is most commonly caused by a paralabral cyst forming as a result of a posterior labral tear. Compression at the suprascapular notch would present earlier in the nerve's course, affecting both the supraspinatus and infraspinatus muscles. Quadrilateral space syndrome involves the axillary nerve, leading to teres minor and deltoid atrophy.

Question 61

A 55-year-old manual laborer presents with progressive wrist pain, stiffness, and diminished grip strength over the past 2 years. He had a scaphoid fracture 10 years ago that was treated nonoperatively. Radiographs show a scaphoid nonunion with narrowing of the radioscaphoid joint and midcarpal joint, but sparing of the radiolunate joint. What is the most appropriate surgical treatment for this patient?

Explanation

The patient has a Scaphoid Nonunion Advanced Collapse (SNAC) wrist. Radiographs reveal involvement of the midcarpal joint (capitolunate joint), consistent with a Stage 3 SNAC wrist. In a high-demand manual laborer with capitate involvement, scaphoid excision and four-corner fusion is the treatment of choice. Proximal row carpectomy (PRC) relies on a pristine capitate head; since the midcarpal joint is arthritic, PRC is contraindicated. Total wrist arthrodesis is a salvage procedure, and total wrist arthroplasty is contraindicated in heavy laborers.

Question 62

A 34-year-old man presents with weakness of finger and thumb extension after sustaining a closed humerus shaft fracture initially treated with a functional brace. His neurological exam at the time of injury was intact, but 3 weeks post-injury he developed a complete wrist drop. Electrodiagnostic testing at 12 weeks shows no motor unit potentials or signs of reinnervation in the brachioradialis or extensor digitorum communis. What is the most appropriate next step in management?

Explanation

A radial nerve palsy that develops AFTER a closed reduction (a secondary palsy) or one that fails to show any clinical or electromyographic signs of recovery by 3 to 4 months (12-16 weeks) is an absolute indication for surgical exploration of the radial nerve. While many primary radial nerve palsies associated with humerus fractures (e.g., Holstein-Lewis) resolve spontaneously, the lack of EMG recovery at 12 weeks requires direct visualization to address potential entrapment, laceration, or neuroma formation.

Question 63

A 42-year-old right-hand-dominant male undergoes a single-incision anterior repair of an acute complete distal biceps tendon rupture using cortical button fixation. Two weeks postoperatively, he complains of profound numbness over the lateral aspect of his forearm. His motor examination is completely intact. Which of the following nerves was most likely injured or compressed during the surgical exposure?

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the terminal sensory branch of the musculocutaneous nerve. It exits the deep fascia lateral to the biceps tendon in the distal arm. It is the most commonly injured structure during a single-anterior-incision approach for distal biceps repair, leading to numbness along the lateral forearm. Injury to the posterior interosseous nerve (PIN) is classically associated with the two-incision approach and results in motor weakness of finger and thumb extension.

Question 64

A 27-year-old healthy male sustains an isolated, completely displaced, and 2.5 cm shortened midshaft clavicle fracture. He is counseled on operative versus nonoperative treatment. Compared to nonoperative management with a sling, operative fixation with plate and screws is associated with which of the following?

Explanation

Large randomized controlled trials have demonstrated that operative fixation of completely displaced, shortened midshaft clavicle fractures significantly decreases the rates of nonunion and symptomatic malunion compared to nonoperative treatment. However, operative fixation does not clearly provide superior long-term (2+ years) functional outcomes. Furthermore, operative treatment is associated with a higher rate of subsequent surgeries, primarily for symptomatic hardware removal.

Question 65

A 60-year-old diabetic woman presents with a 6-month history of a severely stiff and painful shoulder. She has severely limited active and passive range of motion in all planes, with passive external rotation limited to 5 degrees. Radiographs show a normal glenohumeral joint. She fails 6 months of supervised physical therapy and multiple intra-articular corticosteroid injections. If arthroscopic surgical release is elected, which of the following structures must be released to primarily restore external rotation with the arm at the side?

Explanation

The patient's clinical presentation is classic for recalcitrant adhesive capsulitis (frozen shoulder), which is common in diabetic patients. The primary anatomic structures responsible for the restriction of external rotation with the arm resting at the side are the thickened, contracted coracohumeral ligament and the rotator interval capsule. An arthroscopic capsular release must adequately divide these anterior structures to restore external rotation.

Question 66

A 72-year-old woman undergoes a reverse total shoulder arthroplasty for cuff tear arthropathy. Which of the following glenosphere positioning strategies is most effective in minimizing the risk of scapular notching?

Explanation

Scapular notching is a frequent complication following reverse total shoulder arthroplasty, caused by mechanical impingement of the humeral component against the inferior scapular neck. Inferior translation of the glenosphere (creating an inferior overhang) and inferior tilt are the most effective surgical strategies to decrease the incidence of scapular notching and improve impingement-free range of motion.

Question 67

A 45-year-old man falls from a ladder and sustains a 'terrible triad' injury to his left elbow. Surgical management is planned. Following standard treatment algorithms, what is the most appropriate sequence of reconstruction?

Explanation

The standard surgical algorithm for a terrible triad injury (elbow dislocation, coronoid fracture, radial head fracture) follows an inside-out or deep-to-superficial approach. The sequence is typically: 1) Coronoid fixation (or anterior capsule repair if the fragment is too small), 2) Radial head fixation or replacement, 3) Lateral collateral ligament (LCL) complex repair, and 4) Medial collateral ligament (MCL) repair and/or hinged external fixation if the elbow remains unstable after the first three steps.

Question 68

A 32-year-old male sustains a volar shear fracture of the distal radius (volar Barton fracture). During open reduction and internal fixation via a classic Henry approach, which of the following structures must be carefully protected to preserve the primary volar stabilizer of the radiocarpal joint?

Explanation

The radioscaphocapitate (RSC) ligament is a critical volar stabilizer of the wrist, preventing ulnar translation of the carpus. During a volar approach to the distal radius (e.g., Henry approach), dissection distal to the watershed line must be minimized to avoid damaging the stout volar radiocarpal ligaments (RSC, long radiolunate, short radiolunate).

Question 69

A 42-year-old manual laborer presents with chronic right wrist pain. Radiographs reveal a scaphoid nonunion with arthritic changes at the radioscaphoid joint and the scaphocapitate joint, but the radiolunate joint is spared. This is consistent with Stage II Scaphoid Nonunion Advanced Collapse (SNAC). Which of the following is the most appropriate surgical treatment?

Explanation

Stage II SNAC wrist involves arthritis of the radioscaphoid and scaphocapitate joints with preservation of the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated if there is capitate arthritis (which is present in Stage II SNAC) because the capitate must articulate directly with the lunate fossa in a PRC. Therefore, scaphoid excision and four-corner arthrodesis (capitate, hamate, lunate, triquetrum) is the preferred motion-preserving salvage procedure.

Question 70

An 6-year-old boy presents to the emergency department after falling off monkey bars. Radiographs reveal a Gartland Type III extension supracondylar humerus fracture with posteromedial displacement of the distal fragment. Which of the following neurologic deficits is most likely to be observed on physical examination?

Explanation

In an extension-type supracondylar fracture of the humerus, the distal fragment is displaced posteriorly. If the distal fragment is displaced posteromedially, the proximal fragment acts as a lateral spike, which puts the radial nerve at the highest risk of injury. A radial nerve palsy presents with the inability to extend the wrist and metacarpophalangeal joints. Posterolateral displacement of the distal fragment puts the median nerve (particularly the anterior interosseous nerve) and brachial artery at risk due to the medial spike of the proximal fragment.

Question 71

A 28-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture) following a wrestling injury. On examination, he has a wrist drop and inability to extend his fingers, which was not present immediately after the injury but developed after a closed reduction and splinting attempt in the emergency department. What is the most appropriate next step in management?

Explanation

A secondary (post-reduction) radial nerve palsy in the setting of a humeral shaft fracture, particularly a Holstein-Lewis fracture (distal third spiral fracture), is an absolute indication for immediate surgical exploration. The nerve is at high risk of having become entrapped within the fracture site or the lateral intermuscular septum during reduction maneuvers. Observation is appropriate primarily for primary radial nerve palsies present before manipulation.

Question 72

A 45-year-old female presents with aching pain in her proximal forearm and paresthesias in the thumb, index, and middle fingers. Phalen's test and Tinel's sign at the wrist are negative. Which of the following physical examination findings best distinguishes Pronator Syndrome from Carpal Tunnel Syndrome?

Explanation

Pronator syndrome is a compressive neuropathy of the median nerve in the proximal forearm. It shares sensory symptoms in the median nerve distribution with Carpal Tunnel Syndrome (CTS). However, the palmar cutaneous branch of the median nerve, which provides sensation to the thenar eminence, branches off proximal to the carpal tunnel and travels superficial to the transverse carpal ligament. Therefore, sensation over the thenar eminence is preserved in CTS but frequently decreased in Pronator Syndrome.

Question 73

A 30-year-old man has a permanent radial nerve palsy following a severe crush injury to his arm 18 months ago. Tendon transfer surgery is planned to restore wrist, finger, and thumb extension. In a standard flexor carpi radialis (FCR) transfer, which of the following tendon transfers is most commonly used to restore wrist extension?

Explanation

In the standard tendon transfer for radial nerve palsy, wrist extension is typically restored by transferring the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB). The ECRB is preferred over the ECRL because its central insertion at the base of the third metacarpal provides pure, centralized wrist extension, reducing the risk of strong radial deviation. Finger extension is typically restored via FCR to Extensor Digitorum Communis (EDC), and thumb extension via Palmaris Longus (PL) to Extensor Pollicis Longus (EPL).

Question 74

A 38-year-old diabetic male presents with a severely swollen, erythematous left thumb that he holds in a flexed posture. He reports severe pain with passive extension. Over the next 24 hours, he develops similar swelling, pain, and flexed posture in his little finger, while the index, middle, and ring fingers remain relatively asymptomatic. This classic spread of infection occurs through which of the following anatomical spaces?

Explanation

This clinical presentation describes a 'horseshoe abscess,' resulting from pyogenic flexor tenosynovitis. The radial bursa (which surrounds the flexor pollicis longus tendon sheath) and the ulnar bursa (which contains the flexor tendons of the little finger) communicate in the distal forearm via the Space of Parona in approximately 50-80% of individuals. This anatomical connection allows an infection to spread rapidly from the thumb to the little finger (or vice versa), sparing the central digits.

Question 75

A 22-year-old competitive cyclist presents with a closed, isolated midshaft clavicle fracture after a fall. Radiographs demonstrate 100% displacement and 2.5 cm of shortening. Which of the following represents the most scientifically supported rationale for choosing open reduction and internal fixation (ORIF) over nonoperative management in this specific patient?

Explanation

For completely displaced midshaft clavicle fractures with significant shortening (>2 cm), multiple prospective randomized controlled trials have demonstrated that operative fixation (ORIF) significantly decreases the rate of nonunion and symptomatic malunion compared to nonoperative treatment. While cosmetic deformity is improved and early functional return may be faster, the ultimate range of motion at 1 year is generally comparable between both groups. The most compelling evidence-based reason for surgery in highly displaced/shortened midshaft fractures is the significant reduction in nonunion risk.

Question 76

A 45-year-old man falls on an outstretched hand and sustains a posterior elbow dislocation, a comminuted radial head fracture, and a type II coronoid fracture. During the surgical reconstruction of this terrible triad injury of the elbow, what is the generally recommended sequence of repair to best restore elbow stability?

Explanation

The standard surgical protocol for terrible triad injuries involves repairing structures from deep to superficial, and typically anterior to posterior. Using a lateral or combined approach, the deep anterior structures are addressed first: the coronoid is fixed (often through the fracture defect of the radial head or via a separate medial approach if large), then the radial head is either fixed or replaced to restore the anterior radiocapitellar buttress, and finally, the lateral collateral ligament (LCL) complex is repaired to the lateral epicondyle to restore posterolateral rotatory stability.

Question 77

A 38-year-old male undergoes a single-incision anterior approach for repairing a distal biceps tendon rupture. Postoperatively, he notes significant numbness and a tingling sensation along the lateral aspect of his forearm. Which nerve is most likely injured, and what is its anatomical relationship to the operative field?

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the terminal sensory branch of the musculocutaneous nerve. It emerges laterally between the biceps and brachialis muscles to pierce the deep fascia and course subcutaneously in the lateral forearm. It is at high risk of stretch or transection during the single-incision anterior approach for distal biceps repair due to retraction. Injury leads to numbness along the lateral forearm.

Question 78

A 72-year-old woman with a massive, irreparable rotator cuff tear and pseudoparalysis undergoes a reverse total shoulder arthroplasty (RTSA).

Which of the following best describes the fundamental biomechanical alteration achieved by RTSA that restores active arm elevation?

Explanation

A reverse total shoulder arthroplasty functions by medializing and inferiorizing the center of rotation of the glenohumeral joint compared to native anatomy. This medialization recruits more deltoid muscle fibers (anterior and posterior) for elevation, while the inferiorization tensions the deltoid, drastically increasing its moment arm. This allows the deltoid to act as the primary elevator of the arm in the absence of a functional supraspinatus.

Question 79

A 65-year-old woman sustains a 3-part proximal humerus fracture. Open reduction and internal fixation with a locking plate is planned. To minimize the risk of avascular necrosis of the humeral head and promote fracture healing, preservation of which of the following vascular structures is most critical during the surgical approach and dissection?

Explanation

Historically, the anterolateral ascending branch of the anterior humeral circumflex artery was thought to provide the main blood supply to the humeral head. However, modern anatomical injection studies have demonstrated that the posterior humeral circumflex artery provides the predominant blood supply (approximately 64% of the humeral head). Preservation of the posteromedial capsular hinge and the posterior humeral circumflex vessels is critical to minimizing the risk of avascular necrosis.

Question 80

A 28-year-old elite volleyball player presents with an insidious onset of vague posterior shoulder pain and weakness with external rotation. Clinical examination reveals isolated atrophy of the infraspinatus with a normal bulk and strength of the supraspinatus.

The most likely site of nerve compression is the:

Explanation

The suprascapular nerve provides motor innervation to both the supraspinatus and infraspinatus muscles. Compression at the suprascapular notch affects both muscles. However, compression at the spinoglenoid notch occurs distal to the motor branch for the supraspinatus, resulting in isolated weakness and atrophy of the infraspinatus muscle. This is classically seen in overhead athletes or in association with a posterior paralabral cyst.

Question 81

A 19-year-old male is brought to the trauma bay after a rugby tackle, complaining of severe pain in his medial clavicle, shortness of breath, and dysphagia. Examination shows a palpable depression over the medial clavicle on the affected side. Which of the following is the most appropriate next step in management?

Explanation

The clinical presentation (depression of the medial clavicle, shortness of breath, and dysphagia) is highly suspicious for a posterior sternoclavicular (SC) joint dislocation. This is an orthopedic emergency due to the potential for compression or injury to mediastinal structures (trachea, esophagus, great vessels). An urgent CT scan is the gold standard to confirm the direction of dislocation and assess for mediastinal structure compromise prior to any reduction attempt. Reduction should ideally be performed in the operating room with a thoracic surgeon available.

Question 82

An 82-year-old woman with severe rheumatoid arthritis and advanced osteopenia sustains a comminuted, intra-articular distal humerus fracture (AO/OTA type 13-C3). Compared to open reduction and internal fixation (ORIF), primary total elbow arthroplasty (TEA) for this specific patient is most likely associated with:

Explanation

In elderly, low-demand patients with complex, comminuted intra-articular distal humerus fractures (especially those with osteopenia or pre-existing inflammatory arthritis), primary total elbow arthroplasty (TEA) provides a more predictable functional outcome, allows for immediate postoperative mobilization, and has lower rates of reoperation compared to ORIF. ORIF in this osteoporotic population is associated with high rates of hardware failure, nonunion, and stiffness.

Question 83

A 34-year-old female falls on an outstretched hand and presents with elbow pain. Radiographs reveal a fracture of the capitellum with a distinct, separate fracture extension into the lateral trochlear ridge.

According to the Bryan and Morrey classification (as modified by McKee), what type of fracture does this represent, and what is the preferred treatment?

Explanation

The Bryan and Morrey classification describes capitellar fractures: Type I (Hahn-Steinthal) is a large osseous fragment, Type II (Kocher-Lorenz) is an articular cartilage shear, and Type III is comminuted. The McKee modification added Type IV, which is a capitellar shear fracture that extends medially to include the lateral trochlear ridge. Recognizing Type IV is crucial because the lateral trochlear ridge provides significant coronal stability to the elbow. Non-operative treatment or excision leads to instability; therefore, open reduction and internal fixation (ORIF) is the preferred treatment.

Question 84

A 25-year-old man sustains a closed, transverse mid-shaft humerus fracture in a motor vehicle collision. On initial examination in the emergency department, his distal pulses are intact, but he is unable to actively extend his wrist or digits, and has decreased sensation in the first dorsal web space. Which of the following represents the most appropriate initial management for the nerve injury?

Explanation

A primary radial nerve palsy associated with a closed humeral shaft fracture is predominantly a neurapraxia or axonotmesis. The standard of care is conservative management of both the fracture and the nerve, utilizing a coaptation splint or functional brace, along with close clinical observation. More than 85% of primary palsies spontaneously recover. Immediate exploration is only indicated for open fractures, associated vascular injuries requiring repair, or secondary nerve palsies that develop after a closed reduction attempt.

Question 85

A 22-year-old collegiate baseball pitcher presents with vague anterior shoulder pain during the late cocking and early acceleration phases of throwing. Examination shows a 25-degree loss of internal rotation and a 15-degree gain in external rotation in the symptomatic shoulder compared to the contralateral side. Which of the following pathological changes is most closely associated with the development of this specific glenohumeral internal rotation deficit (GIRD)?

Explanation

Glenohumeral internal rotation deficit (GIRD) is classically associated with contracture and thickening of the posteroinferior capsule, commonly seen in overhead throwing athletes due to repetitive eccentric loads during the deceleration phase of throwing. This contracture shifts the glenohumeral center of rotation posterosuperiorly during the cocking phase, predisposing the athlete to SLAP tears and internal impingement. Treatment involves physical therapy focused on posterior capsule stretching (e.g., sleeper stretches).

Question 86

A 45-year-old manual laborer presents with chronic, severe right shoulder pain and an inability to actively elevate his arm above 40 degrees. He has a positive drop sign and a positive hornblower's sign. MRI demonstrates a massive, retracted supraspinatus and infraspinatus tear with Goutallier grade 4 fatty infiltration. The subscapularis tendon is completely intact. After failure of conservative management, what is the most appropriate surgical tendon transfer to restore active external rotation and function in this patient?

Explanation

A Latissimus dorsi transfer (or lower trapezius transfer) is indicated for younger patients with a massive, irreparable posterosuperior rotator cuff tear (supraspinatus and infraspinatus) who have an intact or repairable subscapularis and preserved deltoid function. The positive drop and hornblower's signs indicate profound external rotation weakness and infraspinatus/teres minor deficiency. Pectoralis major transfer is indicated for massive, irreparable subscapularis tears.

Question 87

A 35-year-old male falls from a height and sustains a complex elbow injury. Radiographs reveal a posterior elbow dislocation, a comminuted radial head fracture, and a type II coronoid fracture.

To optimally restore elbow stability, what is the generally recommended sequence of surgical reconstruction for this 'terrible triad' injury?

Explanation

The standard surgical sequence for a 'terrible triad' of the elbow (elbow dislocation, radial head fracture, coronoid fracture) is designed to rebuild the elbow from deep to superficial, or inside-out. The recommended sequence is: 1) Coronoid fixation or anterior capsule reattachment; 2) Radial head repair or replacement; 3) LCL complex repair to the lateral epicondyle; 4) Re-evaluation of stability; and 5) MCL repair or cross-pinning only if the elbow remains grossly unstable after the first three steps.

Question 88

A 52-year-old man presents with chronic, progressive wrist pain and weakness 15 years after a fall on an outstretched hand. Radiographs demonstrate a chronic scaphoid waist nonunion with severe degenerative changes between the distal scaphoid fragment and the radial styloid, as well as narrowing of the capitolunate joint space. The radiolunate joint is widely preserved. What is the most appropriate surgical procedure for this patient?

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III arthritis. In SNAC III, arthritis involves the radioscaphoid and capitolunate joints, while the radiolunate articulation is classically preserved. Proximal row carpectomy (PRC) is contraindicated because the procedure relies on a healthy capitate head to articulate with the lunate fossa of the radius; in SNAC III, the capitolunate joint (and thus the capitate head) is arthritic. Therefore, a scaphoid excision and four-corner fusion is the best motion-preserving salvage option. Total wrist arthrodesis is typically reserved for pan-carpal arthritis (SNAC IV).

Question 89

A 24-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture) following a wrestling injury. In the emergency department, his initial neurologic exam reveals intact wrist and finger extension. Following closed reduction and application of a coaptation splint, the patient immediately demonstrates a complete inability to extend his wrist, thumb, and metacarpophalangeal joints. What is the most appropriate next step in management?

Explanation

A secondary radial nerve palsy (one that develops after closed reduction or splint application) in the setting of a humeral shaft fracture is a classic, absolute indication for immediate surgical exploration and fracture fixation. The primary concern is that the radial nerve has become entrapped or lacerated within the fracture site during the reduction maneuver. Primary radial nerve palsies (present on initial presentation before manipulation) are generally observed.

Question 90

A 66-year-old female with long-standing rheumatoid arthritis reports a sudden inability to flex the interphalangeal (IP) joint of her right thumb. She denies any preceding trauma or acute pain. On physical examination, she is unable to actively flex the thumb IP joint. Passive extension of the wrist does not produce passive flexion of the thumb IP joint. Flexion of the index and long fingers is normal. What is the most likely etiology of her deficit?

Explanation

The patient has a Mannerfelt lesion, which is an attritional rupture of the flexor pollicis longus (FPL) tendon as it tracks over a bony spur (osteophyte) on the volar scaphoid in patients with rheumatoid arthritis. The critical distinguishing factor on physical exam between an FPL tendon rupture and an Anterior Interosseous Nerve (AIN) palsy is the tenodesis test. In AIN palsy, the tendon is intact, so passive wrist extension will cause the thumb IP joint to flex (positive tenodesis effect). In an FPL rupture, the tenodesis effect is absent.

Question 91

A 72-year-old woman is 4 years status-post a reverse total shoulder arthroplasty (RTSA) for severe rotator cuff tear arthropathy. Routine follow-up radiographs reveal a localized radiolucent line and bony defect at the inferior aspect of the scapular neck. Which of the following prosthesis design modifications or surgical techniques has been shown to most effectively reduce the incidence of this specific radiographic finding?

Explanation

The radiographic finding described is 'scapular notching,' a well-known complication of RTSA caused by mechanical impingement of the medial aspect of the humeral implant against the inferior scapular neck during arm adduction. Surgical techniques and design modifications that minimize scapular notching include inferior placement of the glenosphere (creating inferior overhang), inferior tilt of the baseplate, lateralization of the glenosphere, and decreasing the humeral neck-shaft angle (e.g., to 135 or 145 degrees).

Question 92

A 21-year-old collegiate cyclist sustains an isolated, closed, midshaft clavicle fracture. Radiographs demonstrate completely displaced fracture fragments with 2.8 cm of shortening and z-deformity. The overlying skin is intact but tented. If the surgeon elects for open reduction and internal fixation (ORIF) over nonoperative management, the patient should be counseled that ORIF will most likely result in which of the following?

Explanation

In young, active patients with completely displaced midshaft clavicle fractures with significant shortening (>2 cm), operative fixation (ORIF) significantly decreases the rate of nonunion (approximately 1-2% compared to 15% for nonoperative management) and improves early functional outcomes (DASH and Constant scores) compared to nonoperative treatment. However, ORIF carries surgical risks, including a higher rate of hardware irritation requiring secondary removal.

Question 93

A 48-year-old male bodybuilder presents with anterior elbow pain and weakness in forearm supination. He reports feeling a 'pop' 8 weeks ago while lifting heavy weights but initially deferred evaluation. On examination, the hook test is abnormal. Magnetic resonance imaging (MRI) reveals a complete rupture of the distal biceps tendon with 6 cm of proximal retraction. During surgery, the tendon cannot be mobilized to reach the radial tuberosity without placing the elbow in 60 degrees of flexion. What is the most appropriate intraoperative management?

Explanation

This patient has a chronic, retracted distal biceps tendon rupture. Primary repair is generally contraindicated if the elbow cannot be extended past 30 to 45 degrees of flexion with the tendon opposed to the tuberosity, as this significantly increases the risk of a permanent flexion contracture or repair failure. In such cases where adequate length cannot be obtained through mobilization, tendon reconstruction utilizing an allograft (e.g., Achilles, semitendinosus) or autograft (e.g., fascia lata, hamstring) is the standard of care to bridge the gap and restore supination and flexion strength.

Question 94

A 39-year-old female presents with persistent ulnar-sided wrist pain that is exacerbated by gripping, pronation, and ulnar deviation. Conservative measures including splinting and NSAIDs have failed. Radiographs reveal 3.5 mm of positive ulnar variance. An MRI arthrogram demonstrates a degenerative, central perforation of the triangular fibrocartilage complex (TFCC) and corresponding chondromalacia on the proximal ulnar aspect of the lunate. What is the most appropriate surgical intervention?

Explanation

This patient's presentation is classic for ulnar impaction syndrome with a Palmer Class 2C degenerative TFCC tear. The underlying biomechanical issue is excessive ulnar length (positive ulnar variance), leading to increased load transmission across the ulnocarpal joint. The most appropriate treatment for symptomatic ulnar impaction syndrome with ulnar variance >2 mm that has failed conservative care is an ulnar shortening osteotomy. This extra-articular procedure unloads the ulnocarpal joint and typically tightens the ulnocarpal ligaments. An arthroscopic wafer procedure may be considered if variance is <2 mm.

Question 95

A 6-year-old boy sustains a lateral condyle fracture of the humerus. Radiographs show a Milch Type II fracture pattern with 4 mm of displacement. The family refuses surgery and the patient is treated in a cast. Six months later, the patient returns and radiographs demonstrate an established nonunion of the lateral condyle. If left untreated, this child is at highest risk for developing which of the following long-term complications?

Explanation

Nonunion is a known complication of displaced, nonoperatively treated pediatric lateral condyle fractures. Because the lateral column fails to grow normally while the medial column continues to grow, the patient progressively develops a cubitus valgus deformity. Over time, this valgus angulation stretches the ulnar nerve behind the medial epicondyle, classically leading to a tardy ulnar nerve palsy years or even decades later. Cubitus varus is the classic complication of supracondylar humerus malunions.

Question 96

A 42-year-old man undergoes surgical repair of a complete distal biceps tendon rupture using a single-incision anterior approach. Postoperatively, he cannot actively extend his thumb or the metacarpophalangeal joints of his fingers, but wrist extension is maintained with noticeable radial deviation. Sensation in the hand and forearm is entirely intact. Which of the following is the most likely cause of this complication?

Explanation

The clinical scenario describes a posterior interosseous nerve (PIN) palsy, characterized by the inability to extend the fingers and thumb at the MCP joints. Wrist extension is preserved but deviates radially because the extensor carpi radialis longus (ECRL) is innervated by the radial nerve proper proximal to the PIN bifurcation, while the extensor carpi ulnaris (ECU) is denervated. In a single-incision anterior approach to the distal biceps, the PIN is highly vulnerable, most commonly due to vigorous lateral retraction of the brachioradialis and supinator, or by placing retractors directly on the radial neck.

Question 97

A 60-year-old carpenter presents with progressive right wrist pain over the past two years. Radiographs reveal advanced joint space narrowing, sclerosis, and osteophyte formation of the entire radioscaphoid articulation. The radiolunate and midcarpal (capitolunate) joints appear completely preserved with no evidence of arthritis. What is the most appropriate surgical treatment for this patient?

Explanation

The patient has Stage II Scapholunate Advanced Collapse (SLAC), which is characterized by arthritis extending to the entire radioscaphoid joint, while sparing the radiolunate and midcarpal (capitolunate) joints. Proximal row carpectomy (PRC) or scaphoid excision combined with a four-corner fusion are the mainstays of surgical treatment. Because the cartilage on the head of the capitate and the lunate fossa of the radius is preserved, PRC is an excellent option that provides good pain relief and maintains a functional arc of motion.

Question 98

A 35-year-old male sustains a fall resulting in a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid process fracture). During surgery, the radial head is replaced and the coronoid fracture is fixed securely. Upon completion of these steps, the elbow remains persistently unstable to varus and valgus stress in extension. What is the next most appropriate step in the standard surgical algorithm?

Explanation

The surgical management of a terrible triad injury of the elbow follows a standardized deep-to-superficial algorithm to systematically restore stability. The accepted protocol dictates: 1) fixation or replacement of the radial head, 2) fixation of the coronoid fracture or anterior capsule, and 3) repair of the lateral collateral ligament complex, specifically the lateral ulnar collateral ligament (LUCL), to the lateral epicondyle. If the elbow remains persistently unstable after the lateral side is addressed, only then should the medial collateral ligament (MCL) be repaired or a hinged external fixator applied.

Question 99

A 72-year-old female with long-standing, medically managed rheumatoid arthritis sustains a closed, highly comminuted intra-articular fracture of the distal humerus (AO/OTA 13-C3) following a mechanical fall. Her bone quality is evaluated as markedly osteopenic. What is the most appropriate definitive surgical intervention that prioritizes early mobilization and functional recovery?

Explanation

In elderly patients with highly comminuted intra-articular distal humerus fractures, particularly those with compromised bone quality and pre-existing inflammatory arthropathy (such as rheumatoid arthritis), total elbow arthroplasty (TEA) provides more predictable outcomes. Studies show that TEA offers superior pain relief and allows for immediate postoperative mobilization compared to open reduction and internal fixation (ORIF), which carries a high rate of hardware failure, nonunion, and post-traumatic stiffness in this specific demographic.

Question 100

A 29-year-old elite volleyball player presents with an 8-month history of deep, aching posterior shoulder pain and a noted decrease in serving velocity. Physical examination reveals noticeable atrophy of the infraspinatus fossa, while the supraspinatus fossa appears completely normal. She demonstrates 5/5 strength in forward elevation but 3/5 strength in external rotation with the arm resting at her side. What is the most likely anatomic location of the neural compression?

Explanation

The clinical presentation is classic for suprascapular nerve entrapment at the spinoglenoid notch. Because the suprascapular nerve gives off its motor branches to the supraspinatus muscle proximal to the spinoglenoid notch, entrapment at this distal location results in isolated infraspinatus atrophy and weakness (manifesting as weakness in external rotation). This condition is commonly seen in overhead athletes and is frequently associated with a paralabral cyst arising from a posterior SLAP or labral tear. Entrapment at the more proximal suprascapular notch would typically affect both the supraspinatus and infraspinatus.

General Orthopedics 2026 Practice Questions: Set 13 (Solved)

Orthopedic Upper Extremity 2026 MCQs: Board Review Questions & Answers (Part 2)

Key Takeaway

Orthopedic Upper Extremity 2026 MCQs: Board Review Questions & Answers (Part 2)

Chapter Index