Orthopedic Upper Extremity MCQs: 2026 Board Review

Question 1

A 60-year-old right hand-dominant women fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management?

Explanation

In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate step in management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography. Stayner LR, Cumming J, Andersen J, et al: Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231-239.

Question 2

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

Explanation

14b Comminuted, displaced radial head fractures (Hotchkiss type 3) require anatomic metallic radial head arthroplasty to regain function. Radial head excision has led to catastrophic sequelae including chronic wrist pain, elbow instability, and proximal radius migration. Immobilization, internal fixation, or anconeus arthroplasty are not recommended at this time because of the potentially poorer outcomes. Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

Question 3

A 68-year-old woman with serologically proven rheumatoid arthritis underwent an open synovectomy and radial head resection 10 years ago. She now has severe pain that has failed to respond to nonsurgical management. Examination reveals a flexion arc of greater than 90 degrees. Radiographs are shown in Figures 15a and 15b. What is the most appropriate management?

Explanation

15b The radiographs reveal severe arthritic changes with no joint space, and the AP view shows a progressive malalignment secondary to the radial head resection. A prosthetic arthroplasty is indicated given the severe arthritis (Larsen grade III). Unconstrained arthroplasties have not performed as well as semiconstrained arthroplasties after previous radial head resections. However, both types of arthroplasties performed better in native elbows. Synovectomies should be reserved for less advanced disease states. Whaley A, Morrey BF, Adams R: Total elbow arthroplasty after previous resection of the radial head and synovectomy. J Bone Joint Surg Br 2005;87:47-53. Maenpaa HM, Kuusela PP, Kaarela KK, et al: Reoperation rate after elbow synovectomy in rheumatoid arthritis. J Shoulder Elbow Surg 2003;12:480-483.

Question 4

Which of the following conditions is associated with palmoplantar pustulosis?

Explanation

Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis. Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 608-609.

Question 5

A 38-year-old left hand-dominant bodybuilder reports ecchymosis in the left axilla and anterior brachium after sustaining an injury while bench pressing 3 weeks ago. Coronal and axial MRI scans are shown in Figures 16a and 16b. What treatment method yields the best long-term results?

Explanation

16b The MRI scans show a rupture of the sternocostal portion of the pectoralis major tendon. This is the most common site of rupture and bench pressing is the most common etiology. Surgical repair yields better functional outcomes and patient satisfaction for tears not only at the tendon/bone interface but also at the myotendinous junction. Bak K, Cameron EA, Henderson IJ: Rupture of the pectoralis major: A meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8:113-119.

Question 6

A patient sustained a sharp laceration to the base of his left, nondominant thumb 4 months ago. Examination reveals no active flexion but full passive motion of the interphalangeal joint. What is the best treatment option?

Explanation

The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation. Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.

Question 7

A 17-year-old javelin thrower reports medial-sided elbow pain and diminished grip strength while throwing. He has decreased sensation in the little and ring fingers of his throwing hand only while throwing. The sensory deficits resolve at rest. Examination of the elbow reveals no instability and full motion. He has a positive Tinel's sign over the cubital tunnel and a positive elbow flexion test. Radiographs are normal. What is the next most appropriate step in management?

Explanation

The patient's symptoms and examination findings are consistent with ulnar neuritis/cubital tunnel syndrome, most probably exacerbated by javelin throwing. The first step includes rest and extension splinting. Surgical intervention should only be considered after failure of nonsurgical management. Posner MA: Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-317.

Question 8

What are the most likely symptoms and examination findings related to the mass in zone 2 of Guyon's canal seen in Figure 17?

Explanation

The lesion lies in zone II of the ulnar tunnel. In that zone the deep motor branch of the ulnar nerve is susceptible to compression. Distal to the hook of the hamate, the motor branch of the ulnar nerve dives deep to innervate the interossei as it begins to move from an ulnar to radial direction. Because of its course, it has little or no give in response to a mass effect from the floor of Guyon's canal. Ganglions are the most common cause of ulnar nerve entrapment in the wrist. Lesions in zone I can affect both sensory and motor aspects of the ulnar nerve as well as the motor innervation of the hypothenar muscles. Lesions at the elbow or mid-to-proximal forearm are associated with dorsal hand numbness and tingling. Kuschner SH, Gelberman RH, Jennings C: Ulnar nerve compression at the wrist. J Hand Surg Am 1988;13:577-580.

Question 9

A football player sustains a traumatic anterior inferior dislocation of the shoulder in the last game of the season. It is reduced 20 minutes later in the locker room. The patient is neurologically intact and has regained motion. If the patient undergoes arthroscopic evaluation, what finding is seen most consistently?

Explanation

In an acute first-time dislocation, arthroscopy has been shown to reveal a Bankart lesion in most shoulders. The classic finding of labral detachment from the anterior inferior glenoid along with occasional hemorrhage within the inferior glenohumeral ligament is the most common sequelae of a traumatic anterior inferior dislocation. Acute treatment, if chosen, is repair of the labral tissue back to the glenoid plus or minus any capsular plication to address potential plastic deformation of the glenohumeral ligament. Acute treatment of a patient sustaining a first-time dislocation remains controversial. The potential indications may be patients whose dislocation occurs at the end of a season and when the desire to minimize risk of future instability outweighs the risks of surgical intervention. Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311. DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.

Question 10

Examination of a hand with compartment syndrome is most likely to reveal which of the following?

Explanation

In a study of 19 patients with compartment syndrome of the hand, all had tense swollen hands with elevated compartment pressures. Most patients were neurologically compromised so pain with passive stretch may be difficult to illicit. Arterial inflow is present in the arch and thus pallor is not present. The typical posture of the hand is not clenched, rather it is an intrinsic minus posture of metacarpophalangeal joint extension and flexion of the proximal and distal interphalangeal joints. Oullette EA, Kelly R: Compartment syndromes of the hand. J Bone Joint Surg Am 1996;78:1515-1522.

Question 11

A cord-like middle glenohumeral ligament and absent anterosuperior labrum complex can be a normal anatomic capsulolabral variant. If this normal variation is repaired during arthroscopy, it will cause

Explanation

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur. Williams MM, Snyder SJ, Buford D Jr: The Buford complex - the "cord-like" middle glenohumeral ligament and absent anterosuperior labrum complex: A normal anatomic capsulolabral variant. Arthroscopy 1994;10:241-247.

Question 12

Figures 18a through 18c show the clinical photograph, radiograph, and CT scan of a 21-year-old man who reports persistent pain after injuring his right shoulder 4 months ago. What is the most likely factor associated with this patient's diagnosis?

Explanation

18b 18c The more severe the trauma, the higher the rate of subsequent clavicular nonunion. Neither duration nor type of immobilization has been clearly demonstrated to be a causative factor in the development of nonunion. Similarly, closed reduction has not been found to alter the healing course in midshaft clavicular fractures. Lazarus MD, Seon C: Fractures of the clavicle, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, vol 2, pp 1241-1242.

Question 13

A 72-year-old woman with diabetes mellitus who underwent a total shoulder arthroplasty for degenerative arthritis 5 years ago now reports the sudden onset of shoulder pain following recent hospitalization for pneumonia. Laboratory values show a WBC count of 11,400/mm3 and an erythrocyte sedimentation rate of 52mm/h. What is the most appropriate action?

Explanation

The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism's susceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time. Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 953-954.

Question 14

The usual presentation of traumatic subscapularis tears is most often seen after forced

Explanation

The typical mechanism of injury is a fall and the patient grasps something to prevent the fall. This maneuver forces the arm into external rotation against resistance. Kreuz PC, Remiger A, Erggelet C, et al: Isolated and combined tears of the subscapularis tendon. Am J Sports Med 2005;33:1831-1837.

Question 15

A 25-year-old left hand-dominant man has severe left shoulder pain after being involved in a high-speed motor vehicle accident. Examination reveals that he is unable to move the left shoulder. His neurovascular status is intact in the entire left upper extremity. A radiograph is shown in Figure 19. What is the most appropriate surgical management of this injury?

Explanation

In this young patient, every attempt must be made to retain the native proximal humerus; therefore, open reduction and internal fixation should be attempted of both the articular segment and tuberosities to the humeral shaft. This is best accomplished through an open approach. Shoulder arthroplasty should be reserved for the elderly and for failed internal fixation. Ko JY, Yamamoto R: Surgical treatment of complex fractures of the proximal humerus. Clin Orthop Relat Res 1996;327:225-237.

Question 16

A 42-year-old patient undergoes resection of the medial clavicle for painful sternoclavicular degenerative joint disease. The postoperative course is complicated by an increase in symptoms, a medial bump, and subjective tingling in the digits. A clinical photograph and radiograph are shown in Figures 20a and 20b. What is the most appropriate procedure at this time?

Explanation

20b Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-eight pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability. Rockwood CA, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 608-609.

Question 17

Patients who have osteonecrosis of the humeral head and who have the best prognosis are those with which of the following conditions?

Explanation

The natural history of nontraumatic osteonecrosis varies greatly, so it is difficult to predict which patients will have severe arthrosis develop. Patients with sickle cell disease tend to have the most benign course. The most commonly reported cause of nontraumatic osteonecrosis is corticosteroid therapy. Fortunately, the incidence of osteonecrosis among patients treated with long-term systemic corticosteroids has fallen from more than 25% to less than 5% in recent years, owning to judicious steroid use and dosing. The interval between corticosteroid administration and the onset of shoulder symptoms is also variable, ranging from 6 to 18 months in one large series. This is comparable to the interval leading up to the onset of hip symptoms, which ranges from 6 months to 3 years or longer. The incidence of humeral head involvement has not been shown to vary with the underlying indication for steroid use. Hasan SS, Romeo AA: Nontraumatic osteonecrosis of the humeral head. J Shoulder Elbow Surg 2002;11:281-298.

Question 18

A 26-year-old right hand-dominant man has had right shoulder pain for the past 6 months. History reveals that he was the starting pitcher for his high school team. Activity modification, physical therapy, cortisone injection, and anti-inflammatory drugs have failed to improve his symptoms. He has a positive O'Brien's active compression test. What is the next most appropriate step in the diagnosis of this patient?

Explanation

MRI-arthrography has been shown to be an accurate technique for assessing the glenoid labrum in patients with suspected labral tears. Often standard MRI technique will not identify labral lesions. The use of MRI-arthrography with an intra-articular injection of gadolinium provides improved visualization of labral lesions. Bencardino and associates demonstrated a sensitivity of 89%, a specificity of 91%, and an accuracy of 90% in detecting labral lesions. SLAP lesions can be visualized on coronal oblique sequences as a deep cleft between the superior labrum and the glenoid that extends well around and below the biceps anchor. Often, contrast will diffuse into the labral fragment, causing it to appear ragged or indistinct. Applegate GR, Hewitt M, Snyder SJ, et al: Chronic labral tears: Value of magnetic resonance arthrography in evaluating the glenoid labrum and labral-bicipital complex. Arthroscopy 2004;20:959-963. Bencardino JT, Beltran J, Rosenberg ZS, et al: Superior labrum anterior-posterior lesions: Diagnosis with MR arthrography of the shoulder. Radiology 2000;214:267-271.

Question 19

A 32-year-old woman sustained an elbow dislocation, and management consisted of early range of motion. Examination at the 3-month follow-up appointment reveals that she has regained elbow motion but has a weak pinch. A clinical photograph is shown in Figure 21. What is the most likely diagnosis?

Explanation

The photograph shows the characteristic attitude of the hand when an anterior interosseous nerve palsy is present. The patient is unable to flex the interphalangeal joint to the joint of the thumb. Anterior interosseous nerve palsies are often misdiagnosed as tendon ruptures. Schantz K, Reigels-Nielsen P: The anterior interosseous nerve syndrome. J Hand Surg Br 1992;17:510-512.

Question 20

A 59-year-old man underwent interposition arthroplasty for osteoarthritis of the elbow 9 years ago. Over the past year the patient has had increasing pain and elbow instability. There is no clinical evidence of infection, and radiographs show no new bony process. What is the best option for this patient?

Explanation

In a series reported by Blaine and associates, 12 patients were converted from interposition to total elbow arthroplasty. This procedure was successful in 10 out of 12 patients. Blaine TA, Adams R, Morrey BF: Total elbow arthroplasty after interposition arthroplasty for elbow arthritis. J Bone Joint Surg Am 2005;87;286-292.

Question 21

What are the proposed biomechanical advantages of the Grammont reverse total shoulder arthroplasty when compared to a standard shoulder arthroplasty?

Explanation

The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid. Werner CM, Steinmann PA, Gilbert M: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.

Question 22

A 17-year-old high school football player reports wrist pain after being tackled. Radiographs are shown in Figures 22a through 22c. What is the recommended intervention?

Explanation

22b 22c The patient has an acute fracture of the proximal pole. A 100% healing rate has been reported for open reduction and internal fixation of proximal pole fractures via a dorsal approach. This allows for direct viewing of the fracture line, facilitates reduction, and bone grafting can be done through the same incision if necessary. A vascularized or corticocancellous graft is reserved for nonunions. Proximal fractures are very slow to heal with a cast, if they heal at all. As a small fragment, percutaneous fixation is very difficult and has been reported for waist fractures. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.

Question 23

A 74-year-old woman with rheumatoid arthritis reports shoulder pain that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 23a and 23b. Examination reveals active forward elevation to 120 degrees and external rotation to 30 degrees. What treatment option results in the most predictable pain relief and function?

Explanation

23b Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared to hemiarthroplasty in patients with rheumatoid arthritis. Although rotator cuff tears are more common in this patient population, this patient has good forward elevation and no significant superior migration of the humeral head; therefore, a reverse arthroplasty is not indicated. The arthritis is too advanced in this patient to consider arthroscopy, but in less advanced cases it can improve range of motion and decrease pain. Metal-backed glenoid components have shown higher rates of loosening. Collin DN, Harryman DT II, Wirth MA: Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am 2004;86:2489-2496. Baumgarten KM, Lashgari CM, Yamaguchi K: Glenoid resurfacing in shoulder arthroplasty: Indications and contraindications. Instr Course Lect 2004;53:3-11.

Question 24

A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan?

Explanation

The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal. Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.

Question 25

A 27-year-old woman reports the acute atraumatic onset of burning pain in her right shoulder followed a week later by significant weakness and the inability to abduct her shoulder. One week prior to this incident she had recovered from a flu-like syndrome. Examination reveals full passive motion of the shoulder and the inability to actively raise the arm. Sensation in the right upper extremity is normal. Cervical spine examination is normal. Radiographs of the shoulder and cervical spine are normal. What is the most likely diagnosis?

Explanation

The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely. Turner JW, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis). Lancet 1957;2:209-212.

Question 26

A 68-year-old man presents with anterior shoulder pain and subjective weakness 6 weeks after undergoing an anatomic total shoulder arthroplasty (TSA) via a standard deltopectoral approach. On physical examination, he demonstrates significantly increased passive external rotation compared to the contralateral normal shoulder and a positive belly-press test. Anteroposterior and axillary radiographs demonstrate a well-fixed, appropriately positioned glenoid and humeral implant without loosening or dislocation. What is the most likely diagnosis?

Explanation

Subscapularis failure is a known complication after anatomic total shoulder arthroplasty using a deltopectoral approach, where the tendon is typically taken down and repaired. Clinical signs include an unexpected increase in passive external rotation (loss of the anterior tether), internal rotation weakness, and positive specialized tests such as the belly-press, lift-off, or bear-hug tests. Axillary nerve palsy would typically present with deltoid weakness and sensory changes laterally, not isolated internal rotation weakness with increased external rotation.

Question 27

A 55-year-old woman returns to the clinic 1 year after volar locking plate fixation of a distal radius fracture. She reports suddenly losing the ability to flex the interphalangeal (IP) joint of her thumb while lifting a moderately heavy pan. Radiographs demonstrate a well-healed distal radius fracture with the volar plate positioned palmar to the watershed line. Assuming the distal segment of the ruptured tendon is not amenable to primary repair, which of the following is the most appropriate surgical management?

Explanation

Attritional rupture of the flexor pollicis longus (FPL) tendon is a well-recognized complication of volar distal radius plates placed distal to the watershed line (the prominent distal palmar rim of the radius). Due to chronic attrition and tendon retraction, primary repair is usually impossible. The standard of care for restoring FPL function in this setting is a tendon transfer using the ring or middle finger flexor digitorum superficialis (FDS) tendon or an interposition tendon graft. EIP is traditionally used for extensor pollicis longus (EPL) ruptures.

Question 28

A 42-year-old man sustains a fall from a ladder, resulting in a terrible triad injury of the right elbow. Intraoperatively, following secure fixation of the coronoid process fracture, a metallic radial head arthroplasty, and robust repair of the lateral collateral ligament (LCL) complex, the elbow is taken through a range of motion. On fluoroscopic examination, the ulnohumeral joint remains persistently subluxated posteriorly when extended beyond 30 degrees. What is the most appropriate next step in surgical management?

Explanation

The standard surgical algorithm for terrible triad injuries involves repairing deep to superficial, typically starting with coronoid fixation, followed by radial head replacement or repair, and then LCL repair. If the elbow remains persistently unstable (e.g., subluxates in extension) after these three elements have been addressed, the next step in the algorithm is to explore and repair the medial collateral ligament (MCL). A hinged external fixator is reserved for residual instability after the MCL has been repaired or if the MCL repair is inadequate.

Question 29

A 72-year-old woman with a history of a massive, irreparable rotator cuff tear and pseudoparalysis undergoes a reverse total shoulder arthroplasty (RTSA). Biomechanically, how does the RTSA restore active forward elevation in the setting of a deficient rotator cuff?

Explanation

The reverse total shoulder arthroplasty (RTSA) functions by altering the biomechanics of the shoulder. Grammont's original design medializes and distalizes the center of rotation relative to the native shoulder. Medialization recruits more deltoid muscle fibers for elevation, while distalization tensions the deltoid, increasing its resting tone and effectively lengthening its moment arm, which compensates for the absent rotator cuff.

Question 30

A 45-year-old male bodybuilder undergoes a single-incision anterior approach for the repair of an acute distal biceps tendon rupture. Postoperatively, he complains of numbness, tingling, and paresthesias over the anterolateral aspect of his forearm. Injury to which of the following structures is the most likely cause of his current symptoms?

Explanation

The lateral antebrachial cutaneous nerve (LABCN), which is the terminal sensory branch of the musculocutaneous nerve, exits deep to the biceps and courses subcutaneously on the lateral forearm. It is the most commonly injured nerve during a single-incision anterior approach to the distal biceps. Injury results in lateral forearm paresthesias. The posterior interosseous nerve (PIN) is more commonly at risk during a two-incision approach.

Question 31

A 35-year-old manual laborer presents with chronic, progressive, dorsal wrist pain. Radiographs demonstrate significant sclerosis and early fragmentation of the lunate, confirming Kienbock's disease. Measurements reveal a negative ulnar variance of 3 mm. There is no fixed scaphoid rotary subluxation and no evidence of radiocarpal or midcarpal arthritis (Lichtman Stage IIIA). Which of the following is the most appropriate surgical treatment?

Explanation

For Lichtman Stage IIIA Kienbock's disease (lunate sclerosis and fragmentation, but normal carpal alignment without fixed scaphoid rotation) in a patient with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is the treatment of choice. This unloads the lunate and redistributes forces across the radiocarpal joint. Salvage procedures like proximal row carpectomy or arthrodesis are reserved for more advanced stages (IIIB and IV) where carpal collapse or arthritis has ensued.

Question 32

When repairing an acute flexor tendon laceration in Zone II, early active motion protocols are utilized to minimize adhesions and optimize glide. To safely allow an early active motion protocol, what is the generally accepted minimum number of core suture strands required across the repair site?

Explanation

The ultimate tensile strength of a flexor tendon repair is directly proportional to the number of core suture strands crossing the repair site. Biomechanical and clinical studies have demonstrated that a 2-strand repair is typically insufficient to withstand the forces of early active motion and is prone to gap formation or rupture. A minimum of 4 core strands is required to provide adequate strength and stiffness to safely implement an early active motion rehabilitation protocol.

Question 33

A 52-year-old man presents with chronic, progressive wrist pain and stiffness. He sustained a fall onto his outstretched hand 15 years ago but never sought medical treatment. Current radiographs reveal a chronic scaphoid waist nonunion with advanced degenerative changes involving both the radioscaphoid and capitolunate joints. The radiolunate articulation is entirely spared. What stage of Scaphoid Nonunion Advanced Collapse (SNAC) does this represent, and what is the preferred surgical salvage procedure?

Explanation

SNAC wrist progression occurs predictably: Stage I involves the radial styloid; Stage II involves the entire radioscaphoid joint; Stage III involves the capitolunate joint; and Stage IV involves the entire carpus (often sparing the radiolunate joint initially). Because the capitolunate joint is arthritic (Stage III), a proximal row carpectomy (PRC) is contraindicated, as PRC relies on a pristine capitate head articulating with the lunate fossa. Therefore, scaphoid excision and four-corner arthrodesis is the preferred motion-preserving salvage procedure for SNAC Stage III.

Question 34

A 24-year-old healthy male sustains a completely displaced, 100% translated, midshaft clavicle fracture. After thoroughly discussing operative and nonoperative management, he chooses nonoperative management with a sling. Based on current high-level prospective evidence (such as the Canadian Orthopaedic Trauma Society trials), which of the following is true regarding his expected outcome compared to operative fixation?

Explanation

Current high-level evidence, including RCTs and meta-analyses, demonstrates that nonoperative management of displaced midshaft clavicle fractures carries a higher risk of nonunion and symptomatic malunion compared to ORIF. However, at long-term follow-up (1-2 years and beyond), there is no clinically significant difference in patient-reported functional outcome scores (e.g., DASH, Constant scores) between the operative and nonoperative groups. Secondary surgical intervention rates are often similar due to the high rate of symptomatic hardware removal in the operative group.

Question 35

During a posterior approach with an olecranon osteotomy for open reduction and internal fixation of a comminuted intra-articular distal humerus fracture (AO/OTA type 13C3), which of the following osteotomy configurations is recommended to optimize stability upon repair and minimize articular step-off?

Explanation

When performing an olecranon osteotomy for distal humerus exposure, a chevron-shaped osteotomy with the apex directed distally (V-shape pointing toward the diaphysis) is recommended. The cut should be made in the center of the 'bare area' (the non-articular portion of the greater sigmoid notch). The distally directed apex provides maximal inherent stability against medial-lateral and rotational translation when compressed, facilitating anatomic restoration and rigid fixation at closure.

Question 36

A 24-year-old man presents with chronic wrist pain after a fall 2 years ago. He is diagnosed with a scaphoid nonunion. Radiographs reveal a humpback deformity with a radiolunate angle of 20 degrees. MRI shows avascular necrosis of the proximal pole without radioscaphoid arthritis. What is the most appropriate surgical treatment?

Explanation

In the presence of a scaphoid nonunion with a humpback deformity and an avascular proximal pole, a structurally sound vascularized bone graft is indicated. The medial femoral condyle (MFC) free vascularized bone graft provides both structural support to correct the humpback deformity and robust vascularity to heal the avascular proximal pole. Distal radius vascularized grafts (e.g., 1,2-ICSRA) typically lack the structural integrity to correct a significant humpback deformity. Proximal row carpectomy and four-corner fusion are salvage procedures reserved for advanced cases with radiocarpal arthritis (SNAC wrist).

Question 37

During the surgical management of a 'terrible triad' injury of the elbow, the surgeon fixes the coronoid fracture, replaces the comminuted radial head, and repairs the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle. Upon intraoperative testing, the elbow demonstrates persistent instability and subluxates during extension past 30 degrees. What is the next most appropriate step in management?

Explanation

The classic treatment protocol for terrible triad elbow injuries (elbow dislocation, radial head fracture, coronoid fracture) involves sequentially restoring the stabilizers from deep to superficial: coronoid fixation, radial head fixation or replacement, and LUCL repair. If the elbow remains unstable following these steps, the medial ulnar collateral ligament (MUCL) should be evaluated and repaired. If instability persists even after MUCL repair, a hinged external fixator or cross-pinning is indicated.

Question 38

A 55-year-old woman is seen 8 weeks after a nondisplaced distal radius fracture treated with cast immobilization. She reports a sudden inability to extend her thumb at the interphalangeal joint, which occurred while lifting a light pan. Examination reveals full passive extension of the thumb IP joint but a complete lack of active extension. Radiographs show a healed distal radius fracture. What is the most appropriate management?

Explanation

The patient has experienced a spontaneous rupture of the extensor pollicis longus (EPL) tendon, a well-known complication of nondisplaced or minimally displaced distal radius fractures. The rupture is thought to be secondary to ischemia and attrition within the third dorsal compartment. Because the tendon ends typically retract and degenerate, primary repair is usually not feasible. The standard treatment of choice is a tendon transfer utilizing the extensor indicis proprius (EIP) to the EPL, which provides an in-phase transfer with predictable and excellent functional results.

Question 39

A 76-year-old woman with a history of severe osteoporosis sustains a 4-part proximal humerus fracture after a mechanical fall. Radiographs demonstrate severe comminution of the tuberosities and a valgus-impacted head with varus collapse. She is functionally active and desires to return to her previous daily activities. Which surgical intervention is associated with the most predictable restoration of active forward elevation in this patient profile?

Explanation

Reverse total shoulder arthroplasty (RTSA) has become the preferred surgical treatment for displaced 3- and 4-part proximal humerus fractures in elderly patients with poor bone quality. Compared to hemiarthroplasty and ORIF, RTSA provides more predictable pain relief and restoration of active forward elevation because its function relies on the deltoid muscle rather than anatomic tuberosity healing. Hemiarthroplasty outcomes are notoriously unreliable in this population due to the high rate of tuberosity nonunion or resorption in osteoporotic bone.

Question 40

A 48-year-old carpenter complains of numbness and tingling in his small and ring fingers of the right hand. He also notes weakness in grip strength. Examination reveals a positive Froment's sign and intrinsic muscle wasting. Electrodiagnostic studies confirm severe ulnar neuropathy at the elbow. Which of the following clinical or anatomic findings is an absolute indication for an anterior transposition of the ulnar nerve rather than a simple in situ decompression?

Explanation

In situ decompression and anterior transposition of the ulnar nerve have shown similar overall clinical outcomes for idiopathic cubital tunnel syndrome. However, specific absolute indications exist for anterior transposition. These include a significant valgus deformity of the elbow (which increases tension on the nerve), a history of prior failed in situ decompression (revision surgery), a subluxating ulnar nerve (either preoperatively or post-decompression), and the presence of a space-occupying lesion. Intrinsic muscle wasting indicates severe disease but does not anatomically mandate a transposition over an in situ decompression.

Question 41

A 22-year-old collegiate baseball pitcher presents with vague anterior shoulder pain and a 'dead arm' sensation during the late cocking phase of throwing. MRI arthrogram reveals a type II SLAP (superior labrum anterior and posterior) lesion. He has failed a 4-month course of physical therapy focusing on periscapular stabilization and posterior capsular stretching. What is the most appropriate surgical management to optimize his return to elite throwing?

Explanation

A type II SLAP tear involves detachment of the superior labrum and the origin of the long head of the biceps tendon from the glenoid. In a young, high-demand overhead athlete (such as a collegiate pitcher), arthroscopic repair of the SLAP lesion is the standard of care to restore the anchor of the biceps and maintain the kinetic chain of the shoulder during the throwing motion. While biceps tenodesis is increasingly favored for older patients or non-throwers due to excellent pain relief and lower complication rates, anatomic repair remains the first-line surgical treatment for young, elite overhead throwers.

Question 42

A 40-year-old bodybuilder feels a sudden 'pop' in his anterior elbow while performing heavy preacher curls. Examination reveals a palpable defect in the distal biceps tendon, weakness in supination, and proximal retraction of the muscle belly. He undergoes a single-incision distal biceps tendon repair using a cortical button and an interference screw. Postoperatively, he notes weakness in extending his thumb and fingers, though wrist extension is preserved with radial deviation. Which nerve is most likely injured, and what is the mechanism?

Explanation

The posterior interosseous nerve (PIN) is highly vulnerable during single-incision anterior approaches for distal biceps repair. The PIN wraps around the radial neck and can be injured by overly aggressive retractor placement on the radial side, or by the drill/pin exiting the posterior (far) cortex of the radius when creating the bone tunnel for a cortical button. The clinical presentation of weakness in finger and thumb extension, while maintaining wrist extension (as ECRL is innervated by the radial nerve proximal to the PIN branch), confirms a PIN neuropathy.

Question 43

A 32-year-old carpenter presents with an 8-month history of dorsal wrist pain and decreased grip strength. Radiographs show sclerosis and early collapse of the lunate with a negative ulnar variance of 3 mm. There is no evidence of radiocarpal osteoarthritis. MRI confirms avascular necrosis of the lunate. Based on the Lichtman classification (Stage IIIA), what is the most appropriate surgical intervention?

Explanation

This patient has Lichtman Stage IIIA Kienböck disease (lunate collapse without scaphoid rotation or secondary arthritis) combined with a negative ulnar variance. Joint-leveling procedures are indicated in this setting to mechanically unload the lunate and shift compressive forces to the radioscaphoid joint. A radial shortening osteotomy is the most reliable and commonly performed joint-leveling procedure. Ulnar lengthening osteotomies have a significantly higher rate of nonunion and hardware complications. Proximal row carpectomy and four-corner fusions are salvage procedures reserved for later stages (Stage IV) with established radiocarpal arthritis.

Question 44

A 72-year-old man underwent a reverse total shoulder arthroplasty (RTSA) for massive rotator cuff tear arthropathy 2 years ago. He now complains of progressive lateral shoulder pain and a 'clunking' sensation. Radiographs demonstrate severe scapular notching that extends beyond the inferior screw of the baseplate. What is the primary modifiable surgical risk factor for scapular notching in RTSA?

Explanation

Scapular notching in reverse total shoulder arthroplasty (RTSA) is caused by mechanical impingement of the medial edge of the humeral cup against the inferior scapular neck during adduction. The most significant surgeon-controlled risk factor for notching is a superiorly placed glenosphere. To minimize notching, the baseplate and glenosphere should be placed inferiorly on the glenoid, often flush with or slightly overhanging the inferior rim, and with a slight inferior tilt. Lateralizing the center of rotation also helps to decrease scapular notching by increasing the clearance between the humerus and the scapular neck.

Question 45

A 60-year-old man of Northern European descent presents with progressive flexion contractures of his ring and small fingers. He is diagnosed with Dupuytren's disease. Which of the following normal anatomic fascial structures is the primary precursor to the pseudo-cord responsible for contracture at the proximal interphalangeal (PIP) joint?

Explanation

In Dupuytren's disease, normal fascial bands hypertrophy and become pathological cords. The proximal interphalangeal (PIP) joint contracture is most commonly caused by the spiral cord. The spiral cord originates from the pathological involvement of four normal structures: the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. The pretendinous band primarily causes metacarpophalangeal (MCP) joint contractures. Cleland's ligament is located dorsal to the neurovascular bundle and is typically spared in Dupuytren's disease. The natatory ligament is responsible for web space contractures.

Question 46

A 78-year-old woman with a history of severe rheumatoid arthritis and osteoporosis sustains a 4-part proximal humerus fracture with head-splitting extension after a fall. Radiographs demonstrate significant displacement of the tuberosities and advanced glenohumeral joint space narrowing. Which of the following treatments provides the most reliable outcome for pain relief and functional restoration?

Explanation

In an elderly patient with poor bone quality, pre-existing glenohumeral arthritis, and a complex 4-part/head-split fracture, Reverse Total Shoulder Arthroplasty (RTSA) is the most reliable option. Hemiarthroplasty outcomes are heavily dependent on tuberosity healing, which is unpredictable in osteoporotic bone. Total shoulder arthroplasty is contraindicated due to rotator cuff dysfunction associated with 4-part displaced fractures.

Question 47

A 45-year-old man sustains a fall on an outstretched hand, resulting in a 'terrible triad' injury of the elbow. Intraoperatively, the coronoid is found to have a small tip fracture, which is treated with anterior capsular repair. A radial head arthroplasty is performed for a comminuted radial head fracture. Following these steps, the elbow remains persistently unstable in extension and supinates when extended. Which of the following is the most appropriate next step in management?

Explanation

The standard surgical algorithm for a terrible triad injury involves restoring the anterior column (coronoid), the lateral column (radial head), and the lateral stabilizing structures (LCL complex, specifically the LUCL). If the elbow remains unstable after addressing the coronoid and radial head, the LUCL must be repaired. MUCL repair or hinged external fixation is generally reserved for cases where the elbow remains unstable despite a secure LUCL repair.

Question 48

A 38-year-old male manual laborer complains of right wrist pain 5 years after a fall. Radiographs demonstrate a scaphoid nonunion with radioscaphoid joint space narrowing and capitolunate arthritis. The radiolunate joint space is preserved. What 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 with sparing of the radiolunate joint. Because the proximal pole of the capitate is arthritic, a Proximal Row Carpectomy (PRC) is contraindicated. A scaphoid excision combined with a four-corner (capitate, lunate, hamate, triquetrum) arthrodesis is the treatment of choice to provide pain relief while preserving functional wrist motion.

Question 49

A 40-year-old male felt a pop in his antecubital fossa while lifting a heavy box. An MRI confirms a complete avulsion of the distal biceps tendon from the radial tuberosity. He elects to undergo surgical repair using a single-incision anterior approach. Which of the following neurological complications is most frequently encountered with this specific surgical approach?

Explanation

The single-incision anterior approach for distal biceps repair carries a higher risk of injury to the lateral antebrachial cutaneous nerve (LABC) due to its proximity to the superficial surgical interval, often resulting in temporary neurapraxia. The two-incision approach classically has a higher risk of heterotopic ossification and radioulnar synostosis, while minimizing LABC injury but introducing a potential risk to the posterior interosseous nerve if retractors are poorly placed dorsally.

Question 50

A 75-year-old woman with advanced rheumatoid arthritis presents with a severely comminuted intra-articular distal humerus fracture (AO/OTA 13-C3) after a low-energy fall. She is functionally independent but relies on a walker for ambulation. What is the most appropriate surgical intervention to optimize early functional recovery?

Explanation

In an elderly, low-demand patient with inflammatory arthritis, poor bone quality, and a highly comminuted distal humerus fracture, Total Elbow Arthroplasty (TEA) provides reliable pain relief and allows for immediate post-operative range of motion. ORIF in this setting has a high failure rate due to the inability to achieve stable fixation in osteoporotic bone.

Question 51

A 58-year-old female sustains a nondisplaced distal radius fracture treated with cast immobilization. Six weeks later, the cast is removed, and radiographs confirm a healed fracture. Two weeks following cast removal, she reports a sudden inability to actively extend the interphalangeal joint of her thumb. She is unable to lift her thumb off the table when the hand is placed flat. Which of the following is the most appropriate surgical management?

Explanation

The patient has sustained a delayed spontaneous rupture of the extensor pollicis longus (EPL) tendon, a known complication following both displaced and nondisplaced distal radius fractures due to vascular watershed ischemia or mechanical attrition within the third extensor compartment. Primary repair is generally not possible due to tendon retraction and poor tissue quality. An EIP to EPL tendon transfer is the gold standard for restoring thumb extension.

Question 52

A 62-year-old woman undergoes open reduction and internal fixation of a distal radius fracture with a volar locking plate. Four months postoperatively, she presents with volar wrist pain and a new-onset inability to actively flex the interphalangeal joint of her thumb. Radiographs demonstrate fracture union, but the volar plate is positioned distal to the watershed line. Which of the following is the most likely etiology of her condition?

Explanation

Placement of a volar locking plate distal to the watershed line of the distal radius places the flexor tendons, particularly the flexor pollicis longus (FPL), at high risk for mechanical irritation and eventual rupture. The delayed inability to actively flex the IP joint of the thumb strongly points to FPL tendon rupture due to attrition against the prominent distal hardware.

Question 53

A 50-year-old male carpenter presents with a 6-month history of numbness and tingling in his ring and small fingers, accompanied by grip weakness. Nerve conduction studies confirm compression of the ulnar nerve across the elbow. During a surgical in situ decompression, the nerve is traced from proximal to distal. Which of the following structures is the most common site of ulnar nerve compression in this region?

Explanation

Cubital tunnel syndrome is the second most common compression neuropathy in the upper extremity. The most common site of ulnar nerve compression at the elbow is beneath Osborne's ligament (the cubital tunnel retinaculum), which spans between the medial epicondyle and the olecranon. The Arcade of Struthers is a less common, more proximal site. The Ligament of Struthers is associated with median nerve compression, and the Arcade of Frohse with PIN compression.

Question 54

A 21-year-old collegiate baseball pitcher presents with chronic right shoulder pain that occurs primarily during the late cocking and early acceleration phases of throwing. He has failed a 4-month course of physical therapy. Physical exam reveals a positive O'Brien's active compression test and a positive dynamic labral shear test. MRI arthrogram demonstrates a Type II SLAP (Superior Labrum Anterior to Posterior) tear. What is the most appropriate surgical treatment for this athlete?

Explanation

In a young, high-demand overhead athlete (such as a baseball pitcher) with a symptomatic Type II SLAP tear that has failed conservative management, arthroscopic SLAP repair is traditionally considered the primary surgical option. While biceps tenodesis is increasingly utilized for SLAP tears in older individuals or non-overhead athletes, labral repair remains the standard intended to restore normal anatomy and overhead mechanics in young competitive throwers.

Question 55

A 55-year-old female presents with persistent numbness, tingling, and pain in her thumb, index, and long fingers, waking her up at night. She underwent an open carpal tunnel release 6 months ago by an outside surgeon. Nerve conduction studies confirm severe median neuropathy across the carpal tunnel. Exploration of the carpal tunnel is performed. What is the most common intraoperative finding responsible for recurrent or persistent carpal tunnel syndrome?

Explanation

The most common cause of persistent carpal tunnel syndrome after a primary surgical release is the incomplete transection of the transverse carpal ligament (flexor retinaculum), particularly its distal portion. While other factors like perineural scarring, anomalous structures, or severe tenosynovitis can cause recurrence, incomplete release is the most frequently identified technical error leading to failed primary surgery.

Question 56

A 55-year-old manual laborer presents with chronic right wrist pain. Radiographs demonstrate advanced joint space narrowing of the radioscaphoid and capitolunate joints, while the radiolunate joint is well preserved. Based on these findings, which of the following is the most appropriate surgical treatment?

Explanation

This patient presents with Stage III scapholunate advanced collapse (SLAC) wrist, which is characterized by degenerative changes extending to the capitolunate joint while sparing the radiolunate joint. Proximal row carpectomy (PRC) relies on an intact proximal capitate articular surface to articulate with the lunate fossa; therefore, it is contraindicated in Stage III SLAC due to capitate wear. The gold standard surgical management for Stage III SLAC wrist is a scaphoid excision and four-corner (capitate, lunate, triquetrum, hamate) arthrodesis.

Question 57

A 62-year-old woman is 6 months status post volar locked plating of a comminuted distal radius fracture. She reports a sudden inability to flex her thumb interphalangeal joint. Radiographs show a well-healed fracture, but the distal margin of the plate is positioned directly on the watershed line. Which tendon is most likely ruptured?

Explanation

Volar plates placed at or distal to the watershed line of the distal radius are associated with a high risk of flexor tendon irritation and subsequent attrition rupture. The flexor pollicis longus (FPL) tendon is most commonly affected due to its intimate anatomical proximity to the prominent volar hardware near the watershed line. The extensor pollicis longus (EPL) is at risk from prominent dorsal screws, not volar plate positioning.

Question 58

A 45-year-old man sustains a fall from a height and presents with a 'terrible triad' injury of the elbow. Which of the following correctly describes the typical deep surgical sequence for operative repair of this injury?

Explanation

The terrible triad of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid fracture. The standard 'inside-out' protocol for surgical management involves: 1) repairing or fixing the coronoid fracture to restore the anterior buttress, 2) fixing or replacing the radial head to restore the anterior and valgus buttress, and 3) repairing the lateral ulnar collateral ligament (LUCL) to restore posterolateral rotatory stability. The medial collateral ligament is only addressed if profound instability persists after the standard sequence.

Question 59

A 35-year-old bodybuilder undergoes a two-incision (modified Boyd-Anderson) repair of a distal biceps tendon rupture. Compared to a single anterior incision approach, he is at an increased risk for which of the following complications?

Explanation

The two-incision technique for distal biceps tendon repair was developed to decrease the risk of posterior interosseous nerve (PIN) injury, which was a historic concern with the single anterior incision approach. However, the two-incision approach carries a significantly higher risk of heterotopic ossification (specifically radioulnar synostosis), especially if the interosseous membrane is heavily breached or muscle bellies are traumatized. The single anterior incision is most commonly associated with lateral antebrachial cutaneous (LABC) nerve neurapraxia.

Question 60

A 72-year-old man presents with chronic right shoulder pain and weakness. On physical examination, he has active forward elevation to 45 degrees, which improves to 160 degrees passively. He has a positive external rotation lag sign. Radiographs show a humeroacromial interval of 2 mm and severe glenohumeral osteoarthritis (Hamada grade 4). What is the most appropriate definitive management?

Explanation

This patient presents with rotator cuff tear arthropathy and pseudoparalysis (the inability to actively elevate the arm past 90 degrees despite preserved passive motion). In the setting of severe glenohumeral osteoarthritis combined with pseudoparalysis, a reverse total shoulder arthroplasty (RTSA) is the gold standard treatment. RTSA shifts the center of rotation medially and inferiorly, allowing the deltoid to effectively elevate the arm in the absence of a functional rotator cuff. Superior capsular reconstruction is typically reserved for massive irreparable rotator cuff tears without significant glenohumeral arthritis.

Question 61

A 40-year-old man presents with sudden, severe, non-traumatic right shoulder pain that awakened him from sleep. The severe pain persisted for 2 weeks and has now begun to rapidly subside; however, he has noticed profound weakness in overhead activities. Examination reveals significant atrophy of the supraspinatus and infraspinatus. Passive shoulder range of motion is full and painless. MRI of the shoulder and cervical spine are unremarkable. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) classically presents with the acute onset of severe shoulder girdle pain, often occurring at night, followed by profound weakness, muscle atrophy, and flaccidity as the intense pain subsides. It most commonly affects the long thoracic, suprascapular, or axillary nerves. The normal passive range of motion and negative MRI findings reliably rule out structural causes like a full-thickness rotator cuff tear or adhesive capsulitis.

Question 62

An 82-year-old woman with severe osteoporosis presents with a closed, highly comminuted intra-articular fracture of the distal humerus following a fall. She lives independently and manages all activities of daily living. Examination shows intact neurovascular status. Radiographs demonstrate multi-fragmentary articular involvement with poor bone stock that is not amenable to stable internal fixation. Which of the following is the most appropriate surgical treatment to allow early range of motion?

Explanation

Total elbow arthroplasty (TEA) is an excellent and highly reliable treatment option for comminuted, intra-articular distal humerus fractures in elderly patients with poor bone quality. It provides immediate stability and allows for early range of motion, which is crucial for preventing severe elbow stiffness. Studies demonstrate that in patients over 65 with complex distal humerus fractures, TEA offers more predictable functional outcomes and lower reoperation rates compared to open reduction and internal fixation (ORIF).

Question 63

A 30-year-old mechanic presents with a swollen, painful index finger 3 days after sustaining a minor puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of pyogenic flexor tenosynovitis?

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: 1) fusiform (sausage-like) swelling of the entire digit, 2) resting flexed posture of the digit, 3) exquisite tenderness along the course of the flexor tendon sheath, and 4) excruciating pain with passive extension of the digit. Erythema extending proximally to the wrist is not a cardinal sign and may instead indicate spreading cellulitis or a proximal space infection.

Question 64

A 22-year-old woman falls on an outstretched hand and presents with lateral elbow pain. Radiographs reveal a displaced shear fracture of the capitellum with extension medially to include the lateral trochlear ridge. According to the Bryan and Morrey classification (with McKee modification), what type of fracture is this?

Explanation

Capitellum fractures are classified by Bryan and Morrey into three main types: Type I (Hahn-Steinthal) involves a large osseous fragment; Type II (Kocher-Lorenz) involves an articular cartilage sleeve with minimal subchondral bone; and Type III (Broberg-Morrey) is highly comminuted. McKee added a Type IV modification, which is a capitellar shear fracture that extends medially to include the lateral trochlear ridge. Recognizing the Type IV pattern is critical because it introduces significant elbow instability and requires fixation of the trochlear component.

Question 65

A 45-year-old avid cyclist presents with a 3-month history of numbness and tingling in his right ring and small fingers. He also notes weakness in spreading his fingers apart. Tinel's sign is positive over the ulnar aspect of the wrist, but negative at the elbow. Sensation over the dorsoulnar aspect of the hand is completely normal. Where is the most likely site of nerve compression?

Explanation

The patient has ulnar neuropathy at the wrist (Guyon's canal), as evidenced by normal sensation to the dorsoulnar hand (supplied by the dorsal ulnar sensory branch, which branches off proximal to the wrist). Guyon's canal is divided into three zones. Zone I is proximal to the bifurcation of the ulnar nerve; compression here yields mixed motor and volar sensory deficits. Zone II encompasses the deep branch and yields isolated motor deficits. Zone III encompasses the superficial branch and yields isolated sensory deficits. Because this patient has both motor (weakness in finger abduction) and volar sensory (numbness in ring/small fingers) deficits, the compression must be in Zone I.

Question 66

A 45-year-old man presents with chronic, progressive wrist pain and limited range of motion. He recalls falling on his outstretched hand several years ago but did not seek medical attention at the time. Radiographs reveal a scaphoid nonunion with advanced arthritic changes at the radioscaphoid and capitolunate joints, while the radiolunate joint is entirely preserved. Based on these findings, which of the following is the most appropriate surgical treatment?

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) stage III, characterized by radioscaphoid and capitolunate arthritis with a spared radiolunate joint. Proximal row carpectomy (PRC) is contraindicated because it relies on a pristine capitate proximal pole to articulate with the lunate fossa of the radius. Therefore, scaphoid excision and four-corner fusion (capitate, hamate, lunate, triquetrum) is the preferred treatment, as it eliminates the arthritic capitolunate joint while preserving some wrist motion through the pristine radiolunate joint.

Question 67

A 74-year-old woman with a history of osteoporosis and severe glenohumeral osteoarthritis sustains a highly comminuted, displaced 3-part proximal humerus fracture after a mechanical fall. Which of the following surgical interventions is associated with the most predictable pain relief and functional improvement in this specific patient profile?

Explanation

Reverse total shoulder arthroplasty (RTSA) is increasingly recognized as the treatment of choice for elderly patients with complex (3- or 4-part) proximal humerus fractures, especially in the setting of preexisting glenohumeral osteoarthritis, poor bone quality, or an unreliable rotator cuff. RTSA provides more predictable functional outcomes and forward elevation compared to hemiarthroplasty or ORIF, which have high rates of tuberosity nonunion and fixation failure in osteoporotic bone.

Question 68

A 38-year-old construction worker falls from a ladder and sustains a 'terrible triad' injury of the elbow. He is taken to the operating room for surgical stabilization. To optimize stability and functional outcomes, what is the most widely accepted sequence for repairing the injured structures?

Explanation

The terrible triad of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid fracture. The standard surgical protocol dictates a 'deep to superficial' approach. The sequence begins with restoring the anterior column by fixing the coronoid fracture or anterior capsule, followed by restoring the lateral column by fixing or replacing the radial head, and finally repairing the lateral collateral ligament (LCL) complex to the lateral epicondyle.

Question 69

A 32-year-old manual laborer presents with an insidious onset of dorsal wrist pain and weakened grip strength. Radiographs reveal sclerosis, cystic changes, and early fragmentation of the lunate, consistent with Lichtman Stage IIIA Kienböck disease. Wrist films also demonstrate a negative ulnar variance of 3 mm. There are no signs of carpal collapse or secondary osteoarthritis. Which of the following is the most appropriate management?

Explanation

In early to intermediate Kienböck disease (Lichtman Stage II or IIIA) in a patient with negative ulnar variance, joint-leveling procedures are indicated to mechanically unload the radiolunate joint and revascularize the lunate. A radial shortening osteotomy is the most common and reliable method. Salvage procedures like proximal row carpectomy or STT fusion are reserved for more advanced stages (Stage IIIB or IV) where carpal collapse or secondary osteoarthritis has occurred.

Question 70

A 45-year-old weightlifter feels a sudden 'pop' in his anterior elbow during a heavy biceps curl. Examination demonstrates a positive hook test. He undergoes a single-incision distal biceps tendon repair. Which of the following is the most commonly reported complication specifically associated with this surgical approach?

Explanation

The single-incision anterior approach for distal biceps tendon repair is most commonly associated with neuropraxia of the lateral antebrachial cutaneous nerve (LABCN) due to its proximity to the superficial surgical dissection. The two-incision approach has a historically higher risk of radioulnar synostosis and heterotopic ossification. While PIN injury can occur with both approaches, it is less frequent than LABCN injury in the single-incision technique.

Question 71

A 28-year-old man sustained a closed, midshaft humerus fracture and an isolated, complete radial nerve palsy at the time of injury. He was treated in a functional fracture brace. Twelve weeks after the injury, the humerus demonstrates clinical and radiographic evidence of union, but the patient continues to have a complete wrist drop. Electromyography (EMG) shows no evidence of reinnervation of the brachioradialis or extensor carpi radialis longus. What is the most appropriate next step in management?

Explanation

Most radial nerve palsies associated with closed humerus fractures represent a neuropraxia or axonotmesis and will recover spontaneously. However, if there is no clinical or electromyographic (EMG) evidence of recovery by 12 weeks (3 to 4 months), surgical exploration of the nerve is indicated to evaluate for entrapment, scarring, or transection that may require neurolysis, primary repair, or nerve grafting.

Question 72

A 40-year-old active man complains of persistent shoulder pain and a palpable 'clunking' 8 months after sustaining a midshaft clavicle fracture treated nonoperatively in a sling. Radiographs demonstrate an atrophic nonunion with 2.5 cm of shortening. What is the most appropriate surgical treatment?

Explanation

Atrophic nonunions lack adequate biological activity and require both mechanical stability and biological stimulation to heal. The gold standard for treating a symptomatic, atrophic midshaft clavicle nonunion is open reduction and internal fixation (ORIF) with a plate and screws supplemented with autologous bone graft (often from the iliac crest) to stimulate osteogenesis.

Question 73

A 62-year-old woman is treated with a volar locking plate for a comminuted intra-articular distal radius fracture. Eight weeks postoperatively, she presents to the clinic complaining that she suddenly lost the ability to actively flex the interphalangeal joint of her thumb. Passive thumb interphalangeal joint motion is full and painless. What is the most likely etiology of her current presentation?

Explanation

Volar locking plates placed distal to the 'watershed line' of the distal radius can irritate the overlying flexor tendons. The flexor pollicis longus (FPL) tendon is the most commonly injured flexor tendon due to attrition against prominent hardware, leading to delayed spontaneous rupture. Extensor tendon ruptures (like EPL) are more commonly associated with nonoperative treatment or prominent dorsal screws piercing the dorsal cortex.

Question 74

A 52-year-old man presents with chronic numbness and tingling in his small and ring fingers. Physical examination reveals a positive Tinel's sign over the cubital tunnel and weak interosseous muscles. Nerve conduction studies confirm severe ulnar neuropathy at the elbow. During surgical decompression, the surgeon must evaluate all potential sites of ulnar nerve entrapment. From proximal to distal, which of the following represents the most proximal potential site of compression?

Explanation

The ulnar nerve can be compressed at several distinct sites around the elbow. From proximal to distal, these potential sites are: the Arcade of Struthers (a fascial band extending from the medial head of the triceps to the medial intermuscular septum), the medial intermuscular septum, the medial epicondyle, the cubital tunnel proper (roofed by Osborne's ligament), and the deep aponeurosis of the flexor carpi ulnaris (FCU).

Question 75

A 70-year-old man presents with an inability to actively lift his right arm above 45 degrees, though passive motion is full. Radiographs show superior migration of the humeral head, acetabularization of the acromion, and severe glenohumeral joint space narrowing. An MRI confirms massive, retracted tears of the supraspinatus and infraspinatus with Goutallier stage 4 fatty infiltration. What is the most definitive and reliable surgical option for this patient?

Explanation

This patient has classic rotator cuff tear arthropathy (CTA) with pseudoparalysis and severe fatty infiltration. A reverse total shoulder arthroplasty (RTSA) is the treatment of choice. RTSA medializes and distalizes the center of rotation of the shoulder joint, increasing the lever arm of the deltoid muscle, which compensates for the deficient rotator cuff to restore active forward elevation. Anatomic total shoulder arthroplasty is contraindicated in the setting of a massive, irreparable rotator cuff tear due to the risk of eccentric glenoid wear and early 'rocking horse' loosening.

Question 76

A 45-year-old man falls on his outstretched hand and sustains a terrible triad injury of the elbow. He undergoes operative management to restore elbow stability. Assuming a standard lateral approach is utilized, which of the following is the recommended sequence of surgical reconstruction?

Explanation

The standard recommended surgical sequence for a terrible triad injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture) is repairing deep to superficial. The classic sequence is coronoid fixation first, followed by radial head repair or replacement, and finally lateral collateral ligament (LCL) complex repair to restore posterolateral rotatory stability. If residual instability exists after these three steps, medial collateral ligament (MCL) repair or the application of a hinged external fixator may be considered.

Question 77

A 55-year-old man presents with chronic anterior shoulder pain and weakness. On physical examination, he demonstrates increased passive external rotation compared to the contralateral side. He tests positive for both the lift-off and belly-press tests. An MRI demonstrates a complete, retracted tear of the subscapularis tendon. Which of the following structures is most likely to be concomitantly injured or destabilized in this patient?

Explanation

The subscapularis tendon provides anterior stability to the glenohumeral joint and acts as a vital medial restraint for the long head of the biceps tendon (LHBT). A complete tear of the subscapularis, especially involving the superior portion, often disrupts the biceps reflection pulley (composed of the coracohumeral ligament and superior glenohumeral ligament), leading to medial subluxation or dislocation of the LHBT. Therefore, the long head of the biceps is the structure most frequently injured or destabilized in this setting.

Question 78

A 32-year-old manual laborer presents with an 8-month history of central dorsal wrist pain. Radiographs demonstrate sclerosis and early fragmentation of the lunate, but the carpal height is maintained and there is no capitate migration. Radiographic measurements reveal a negative ulnar variance of 3 mm. Which of the following is the most appropriate surgical treatment?

Explanation

The patient has Kienböck disease (avascular necrosis of the lunate) stage IIIA (fragmentation, but preserved carpal height without carpal collapse), with a negative ulnar variance. Joint-leveling procedures, such as a radial shortening osteotomy, are indicated in earlier stages of Kienböck disease (Stages I, II, IIIA) with negative ulnar variance. This procedure offloads the lunate by shifting mechanical compressive forces to the radiocarpal joint. Salvage procedures like proximal row carpectomy or limited carpal arthrodesis are reserved for more advanced stages with carpal collapse (Stage IIIB) or secondary osteoarthritis (Stage IV).

Question 79

A 42-year-old male bodybuilder sustains an acute distal biceps tendon rupture and undergoes surgical repair using a dual-incision (modified Boyd-Anderson) technique. Postoperatively, he reports difficulty extending his fingers and thumb. Examination reveals absent digit extension at the metacarpophalangeal joints, but wrist extension is preserved albeit with radial deviation. Sensation over the dorsum of the hand and lateral forearm is completely intact. Which of the following nerves was most likely injured during the procedure?

Explanation

The patient exhibits a posterior interosseous nerve (PIN) palsy, characterized by the inability to extend the digits at the metacarpophalangeal joints and the thumb, but with preserved wrist extension. Wrist extension is maintained because the extensor carpi radialis longus (ECRL) is innervated by the radial nerve proximal to the branching of the PIN. However, the wrist deviates radially during extension because the extensor carpi ulnaris (ECU) is paralyzed. The PIN can be injured during distal biceps repair due to over-retraction on the lateral side or deep dissection around the radial tuberosity. The lack of sensory deficits distinguishes an isolated PIN injury from a more proximal radial nerve injury.

Question 80

A 28-year-old male professional volleyball player presents with progressive right shoulder weakness and vague posterior shoulder pain. Examination reveals visible atrophy of the infraspinatus fossa but normal bulk of the supraspinatus. He has isolated weakness in external rotation with the arm at his side. Forward elevation and abduction strength are normal. An MRI of the shoulder is most likely to show a paralabral cyst in which of the following locations?

Explanation

The patient presents with isolated infraspinatus atrophy and weakness, which points to suprascapular nerve compression at the spinoglenoid notch. The suprascapular nerve innervates the supraspinatus muscle before passing through the spinoglenoid notch to innervate the infraspinatus. Therefore, compression at the suprascapular notch (transverse scapular ligament) would typically affect both the supraspinatus and infraspinatus muscles. Paralabral cysts located in the spinoglenoid notch are often associated with posterior superior labral tears and predominantly compress the motor branch to the infraspinatus.

Question 81

A 45-year-old man presents with chronic radial-sided wrist pain 10 years after a fall on his outstretched hand. Radiographs demonstrate a scaphoid waist fracture nonunion with sclerosis and cystic changes. There is joint space narrowing and osteophyte formation between the distal scaphoid fragment and the radial styloid. The radiolunate and midcarpal joints are well preserved. What is the diagnosis and the most appropriate surgical management?

Explanation

The patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage I, defined by osteoarthritis isolated to the articulation between the distal scaphoid fragment and the radial styloid. The proximal scaphoid fragment, tethered to the lunate, retains its normal cartilaginous articulation with the radius. Management for SNAC Stage I typically involves radial styloidectomy to address the arthritic portion of the joint, combined with scaphoid nonunion takedown, bone grafting, and internal fixation to heal the underlying fracture. SNAC Stage II involves the scaphocapitate joint, and SNAC Stage III involves the capitolunate joint, for which salvage procedures like proximal row carpectomy or four-corner fusion are indicated.

Question 82

A 68-year-old woman with severe glenohumeral osteoarthritis undergoes an anatomic total shoulder arthroplasty (TSA). During the procedure, the subscapularis tendon is peeled from the lesser tuberosity and subsequently repaired. Six months postoperatively, she presents with anterior shoulder pain and sudden weakness in internal rotation after lifting a heavy pot. Radiographs show a well-fixed prosthesis with normal implant position. Which of the following physical examination findings would most likely be positive in this patient?

Explanation

The clinical scenario describes a postoperative failure of the subscapularis repair after an anatomic total shoulder arthroplasty, a known complication that leads to anterior shoulder pain, instability, and internal rotation weakness. The bear-hug test, belly-press test, and lift-off test are specific physical examination maneuvers used to evaluate the integrity and strength of the subscapularis tendon. Hornblower's sign evaluates the teres minor. Jobe's test evaluates the supraspinatus. O'Brien's test evaluates for SLAP lesions or AC joint pathology. Speed's test evaluates the long head of the biceps tendon.

Question 83

A 55-year-old woman is seen in the clinic 6 weeks after sustaining a nondisplaced distal radius fracture treated conservatively in a short arm cast. The cast is removed, and radiographs show early healing with maintained alignment. Two weeks later, she returns reporting a sudden inability to actively extend her thumb at the interphalangeal joint. She denies any new trauma. What is the most appropriate management for this complication?

Explanation

The patient has sustained a delayed spontaneous rupture of the extensor pollicis longus (EPL) tendon, a classic complication occurring weeks after a nondisplaced or minimally displaced distal radius fracture. The rupture is typically ischemic in nature, secondary to hematoma and swelling within the tight third dorsal compartment, or due to attrition over fracture callus. Because the tendon ends are usually degenerated, frayed, and retracted, a primary end-to-end repair is rarely feasible. The standard and most reliable surgical treatment is a tendon transfer, with the extensor indicis proprius (EIP) to EPL transfer being the procedure of choice as it provides similar vector, excursion, and expendability without significant donor-site morbidity.

Question 84

A 72-year-old man undergoes a reverse total shoulder arthroplasty (RTSA) for massive rotator cuff tear arthropathy. According to Grammont's original biomechanical principles, how does the RTSA prosthesis alter the center of rotation and the deltoid moment arm compared to the native anatomic shoulder?

Explanation

Grammont's biomechanical principles for reverse total shoulder arthroplasty (RTSA) involve medializing and inferiorizing the center of rotation of the glenohumeral joint relative to the native anatomy. Medializing the center of rotation recruits more deltoid muscle fibers and significantly increases the deltoid moment arm, making it a more efficient elevator of the arm. Inferiorizing the center of rotation essentially lengthens and tensions the deltoid muscle, compensating for the lack of a functional rotator cuff. This altered biomechanics allows the deltoid to initiate and maintain forward elevation without the superior migration of the humeral head typical of cuff tear arthropathy.

Question 85

A 35-year-old man sustains a closed spiral fracture of the distal third of his right humeral shaft in a motor vehicle collision (Holstein-Lewis fracture). In the emergency department, he is entirely unable to extend his wrist or digits, and has decreased sensation over the dorsal first web space. His radial and ulnar pulses are 2+ and capillary refill is brisk. A closed reduction is performed, and a coaptation splint is applied. Post-reduction radiographs show acceptable alignment, but his neurologic deficit remains completely unchanged. What is the most appropriate next step in management?

Explanation

The patient presents with a Holstein-Lewis fracture (spiral fracture of the distal third of the humeral shaft) complicated by a primary radial nerve palsy. The incidence of radial nerve palsy with humeral shaft fractures is approximately 11-18%, and the vast majority represent neuropraxia or axonotmesis that will recover spontaneously over 3 to 4 months. The standard of care for a closed humeral shaft fracture with a primary radial nerve palsy is conservative management with observation and supportive splinting of the wrist and digits. Surgical exploration is generally not immediately indicated for a primary palsy following a closed fracture unless the fracture itself requires surgery for other indications (e.g., open fracture, vascular injury, polytrauma), or it fails to show clinical or electromyographic (EMG) signs of recovery by 3 to 4 months. Since his palsy was present before reduction and remained unchanged, observation is the correct next step. An EMG is typically obtained at 6 weeks to establish a baseline or check for early signs of reinnervation if clinical improvement is absent.

Question 86

A 75-year-old female with severe shoulder pseudoparalysis and cuff tear arthropathy undergoes a reverse total shoulder arthroplasty (RTSA). Postoperative radiographs taken 1 year later demonstrate inferior scapular notching. Which of the following surgical technique modifications during the index procedure would have most effectively minimized the risk of this complication?

Explanation

Scapular notching is a well-recognized complication of Grammont-style (medialized) reverse total shoulder arthroplasty, often caused by impingement of the humeral cup against the inferior scapular neck during adduction. Techniques to minimize scapular notching include inferior placement of the baseplate, inferior tilt (not superior), and lateralization of the center of rotation (e.g., using a lateralized glenosphere or bony BIO-RSA). Medialization of the humerus and smaller glenospheres generally increase the risk of notching.

Question 87

A 45-year-old male falls from a height and sustains a traumatic elbow dislocation, radial head fracture, and a type II coronoid fracture. During surgical reconstruction, the radial head is replaced, the coronoid is stabilized, and the lateral collateral ligament (LCL) complex is repaired to the lateral epicondyle. Upon intraoperative testing, the elbow remains persistently unstable in extension. What is the most appropriate next step in management?

Explanation

The standard surgical algorithm for the 'terrible triad' of the elbow includes restoring the anterior bony buttress (coronoid fixation if possible/necessary), restoring the lateral bony column (radial head fixation or replacement), and repairing the LCL complex. If the elbow remains unstable after these steps (often tested from 30 degrees of flexion to full extension), the next step is to address medial-sided instability by repairing the medial collateral ligament (MCL). If the elbow is still unstable after MCL repair, application of a hinged external fixator is indicated.

Question 88

A 28-year-old mechanic presents with chronic wrist pain 2 years after falling onto an outstretched hand. Radiographs demonstrate a scaphoid waist nonunion with advanced osteoarthritis of the radioscaphoid and capitolunate joints. The radiolunate joint is well preserved. What is the most appropriate surgical treatment?

Explanation

This patient has Stage III scaphoid nonunion advanced collapse (SNAC). SNAC III is characterized by arthritis involving the radioscaphoid and capitolunate joints, while the radiolunate joint is typically spared. A proximal row carpectomy (PRC) is contraindicated in SNAC III because it relies on a pristine head of the capitate articulating with the lunate fossa; advanced capitolunate arthritis precludes this. Therefore, a four-corner fusion (capitate, hamate, lunate, triquetrum) with scaphoid excision is the preferred motion-preserving salvage procedure.

Question 89

A 60-year-old woman undergoes volar locked plating for a comminuted distal radius fracture. Six months postoperatively, she presents to the clinic with an inability to actively flex the interphalangeal joint of her thumb. Which of the following technical errors during the index procedure is most likely responsible for this complication?

Explanation

The patient has sustained an iatrogenic rupture of the Flexor Pollicis Longus (FPL) tendon, which is the most common flexor tendon complication following volar plating of the distal radius. This typically occurs due to placement of the plate distal to the watershed line of the distal radius, leading to prominence of the plate edge and attritional wear of the tendon. Penetration of the dorsal cortex would put the extensor tendons at risk.

Question 90

A 72-year-old female sustains a 4-part proximal humerus fracture after a mechanical fall. Which of the following radiographic findings is considered the most reliable predictor of subsequent avascular necrosis (AVN) of the humeral head?

Explanation

According to Hertel's criteria, the best radiographic predictors for ischemia (and subsequent AVN) of the humeral head in proximal humerus fractures include a short metaphyseal head extension (calcar length) of < 8 mm, disruption of the medial (not lateral) periosteal hinge, and an anatomic neck fracture pattern. Valgus impacted fractures generally have a lower rate of AVN compared to displaced anatomic neck or varus angulated fractures.

Question 91

A 25-year-old man presents with chronic dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate without fixed scaphoid rotation or carpal height collapse. Ulnar variance is measured at negative 3 mm. What is the most appropriate initial surgical management?

Explanation

The patient has Kienbock's disease (avascular necrosis of the lunate) classified as Lichtman Stage IIIA (fragmentation/collapse of the lunate but normal carpal alignment/height). Because the patient has ulnar negative variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated to decompress the radiolunate joint and redistribute loads across the wrist. PRC or total wrist fusion are salvage procedures reserved for more advanced stages (Stage IV) with diffuse carpal arthritis.

Question 92

A 45-year-old male undergoes a single-incision anterior repair of a distal biceps tendon rupture. Postoperatively, he is noted to have profound weakness in finger and thumb extension, but his wrist extension is preserved with radial deviation. Sensation over the hand and forearm is entirely intact. Which nerve was most likely injured, and what is its anatomic path near the surgical site?

Explanation

The patient presents with an isolated motor deficit of the extensor digitorum communis (EDC), extensor pollicis longus (EPL), and other digital extensors, with preserved ECRL (radial nerve innervated before the PIN branches) causing radial deviation during wrist extension. This is the classic presentation of a Posterior Interosseous Nerve (PIN) injury. The PIN wraps around the radial neck and passes through the arcade of Frohse between the two heads of the supinator muscle. It is at particular risk during anterior single-incision distal biceps repair due to lateral retraction.

Question 93

A 55-year-old male undergoes surgery for severe cubital tunnel syndrome. During the planned in situ decompression, the ulnar nerve is observed to subluxate completely anterior to the medial epicondyle during passive elbow flexion. What is the most appropriate next step in surgical management?

Explanation

While an in situ ulnar nerve decompression is a highly successful treatment for standard cubital tunnel syndrome, intraoperative nerve instability (subluxation anterior to the medial epicondyle during flexion) is a primary indication for anterior transposition (subcutaneous, intramuscular, or submuscular). Leaving a subluxating nerve in situ after decompression can lead to chronic friction neuritis and 'snapping triceps/nerve' symptoms, leading to failure of the procedure.

Question 94

A 22-year-old female competitive swimmer presents with right arm fatigue, heaviness, and numbness in the medial forearm that worsens with overhead activities. Wright's and Roos provocative tests are positive. Symptoms have been refractory to 6 months of physical therapy, and surgical decompression is planned. Which of the following structures form the borders of the space where the compression most commonly occurs in this condition?

Explanation

The patient's presentation is consistent with neurogenic Thoracic Outlet Syndrome (TOS), which most commonly involves compression of the lower trunk of the brachial plexus. The most common site of compression is within the scalene triangle. The boundaries of the scalene triangle are the anterior scalene muscle (anteriorly), the middle scalene muscle (posteriorly), and the first rib (inferiorly). The subclavian artery also passes through this triangle, while the subclavian vein passes anterior to the anterior scalene.

Question 95

A 34-year-old man falls on an outstretched hand and sustains a coronal shear fracture of the capitellum that extends medially to include the majority of the trochlea (McKee modification Type IV). Which surgical approach and fixation strategy is considered most appropriate for direct visualization and anatomic reconstruction of this specific fracture pattern?

Explanation

Capitellar and trochlear shear fractures (Bryan and Morrey types, including the McKee modification Type IV) are articular fractures requiring anatomic reduction and rigid fixation. An extensile lateral approach (e.g., extended Kocher or Kaplan) provides excellent visualization of the capitellum and lateral trochlea. Fixation is classically achieved using headless compression screws placed from anterior to posterior, burying the heads beneath the articular cartilage to allow early range of motion without impinging on the radial head.

Question 96

A 42-year-old man falls on an outstretched hand and sustains a posterior elbow dislocation, a radial head fracture, and a coronoid process fracture. During the surgical reconstruction of this "terrible triad" injury, what is the generally recommended sequence of repair to restore elbow stability?

Explanation

The standard surgical sequence for treating a terrible triad injury of the elbow typically proceeds from deep to superficial, or "inside-out." The recommended sequence is fixation of the coronoid (to restore the anterior buttress), followed by repair or replacement of the radial head (to address anterior and lateral stability), and finally repair of the lateral ulnar collateral ligament (LUCL) complex. If the elbow remains unstable after these steps, the medial collateral ligament (MCL) may be repaired or a hinged external fixator applied.

Question 97

A 68-year-old man presents with chronic right shoulder pain and profound weakness in forward elevation. He is unable to actively elevate his arm above 45 degrees, though passive range of motion is full. MRI demonstrates massive, retracted tears of the supraspinatus and infraspinatus with Goutallier grade 4 fatty infiltration. An anteroposterior radiograph shows severe superior migration of the humeral head with acetabularization of the acromion and an acromiohumeral interval of 2 mm. He has an intact subscapularis and teres minor, but mild glenohumeral osteoarthritis is present. Which of the following is the most appropriate definitive surgical management?

Explanation

This patient presents with a massive, irreparable rotator cuff tear resulting in pseudoparalysis, superior humeral migration (cuff tear arthropathy), and early glenohumeral osteoarthritis. In an older patient with pseudoparalysis and proximal migration of the humerus, a reverse total shoulder arthroplasty (RTSA) is the most reliable treatment to restore elevation and relieve pain. Superior capsular reconstruction and latissimus dorsi transfers are generally contraindicated in the setting of true pseudoparalysis and established cuff tear arthropathy. Anatomic total shoulder arthroplasty is contraindicated due to the "rocking horse" phenomenon caused by a deficient rotator cuff, which leads to early glenoid loosening.

Question 98

A 55-year-old woman is seen 6 weeks after sustaining a non-displaced distal radius fracture treated conservatively in a cast. The cast was removed 2 weeks ago, and she began physical therapy. She now reports a sudden, painless inability to actively extend her thumb interphalangeal joint. On examination, she has full passive thumb extension, but cannot actively lift the thumb off the table when the hand is placed flat. Radiographs show a healed distal radius fracture. What is the most appropriate surgical management for this patient's new deficit?

Explanation

The patient has sustained a delayed rupture of the extensor pollicis longus (EPL) tendon, a well-known complication following distal radius fractures, particularly those that are non-displaced. The rupture is secondary to ischemia and mechanical attrition at the level of Lister's tubercle. Because of tendon retraction and substance loss, direct primary repair is typically impossible. The gold standard treatment for chronic or attritional EPL ruptures is a tendon transfer utilizing the extensor indicis proprius (EIP). The EIP provides a synergistic transfer with appropriate excursion, leaving the extensor digitorum communis to the index finger intact to maintain independent index finger extension.

Question 99

A 35-year-old man sustains a severe, closed proximal third humeral shaft fracture with extension into the surgical neck. He undergoes open reduction and internal fixation using a long proximal humeral locking plate via a standard deltopectoral approach. During the surgical approach and lateral plate placement, the surgeon must be particularly mindful of avoiding iatrogenic nerve injury. The axillary nerve is most at risk in which of the following anatomic locations?

Explanation

The axillary nerve exits the quadrangular space and wraps around the posterior and lateral aspects of the surgical neck of the humerus. Anatomically, from the lateral edge of the acromion, the axillary nerve is located approximately 5 to 7 cm distally. When placing a lateral locking plate for a proximal humerus fracture, especially during minimally invasive plate osteosynthesis (MIPO) or when extending a deltopectoral approach distally, the nerve is at significant risk as it crosses the lateral humerus horizontally deep to the deltoid muscle.

Question 100

A 40-year-old male bodybuilder undergoes a single-incision anterior approach for repairing an acute distal biceps tendon rupture using cortical button fixation. Six weeks postoperatively, he complains of weakness in his hand and difficulty extending his fingers. On physical examination, he demonstrates a lack of active metacarpophalangeal (MCP) joint extension of all four fingers and thumb extension. Wrist extension is preserved but occurs with radial deviation. Sensation over the hand and forearm is normal. Which of the following nerves was most likely injured during the surgical procedure?

Explanation

The patient presents with classic signs of a posterior interosseous nerve (PIN) palsy. The PIN (the deep motor branch of the radial nerve) innervates the extensors of the fingers and thumb, as well as the extensor carpi ulnaris (ECU). Injury results in a loss of active MCP joint and thumb extension. Wrist extension is preserved (due to the intact ECRL innervated by the radial nerve proximal to the PIN bifurcation) but occurs with radial deviation because of the paralyzed ECU. Sensation remains normal since the PIN is a purely motor nerve. The PIN is at risk during the single-incision anterior approach to the distal biceps, particularly if retractors are placed aggressively on the lateral side of the radius (supinator muscle) or if the forearm is inadvertently pronated during drilling.

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