Orthopedic Upper Extremity 2026 MCQs: Board Review

Question 1

A 52-year-old man has shoulder pain and stiffness after undergoing a "mini-lateral" rotator cuff repair 6 months ago. Examination reveals that he is afebrile with normal vital signs. There is slight erythema but no drainage from the incision. Range of motion is limited in all planes, and there is weakness with resisted external rotation and abduction. Radiographs show a well-positioned metal implant within the greater tuberosity. Laboratory studies reveal a WBC count of 8,400/mm3 (normal 3,500 to 10,500/mm3) and an erythrocyte sedimentation rate of 63 mm/h (normal up to 20 mm/h). What is the next most appropriate step in management?

Explanation

Deep sepsis of the shoulder following rotator cuff repair is an uncommon problem. Patients with infections of this type typically report persistent pain and are not systemically ill. They may have signs of local wound problems such as erythema, drainage, and dehiscence. Laboratory studies can be helpful in making an accurate diagnosis. Most patients will not show a significant elevation of the WBC count; however, an elevated erythrocyte sedimentation rate is nearly always present and should alert the clinician to the presence of infection. Aspiration of both subacromial and glenohumeral joint spaces is necessary to confirm the diagnosis. The most effective treatment for deep shoulder sepsis following rotator cuff repair involves extensive surgical debridement, removing all suspicious soft tissue as well as implants. Administration of appropriate antibiotic therapy is needed for complete control of the infection. Mirzayan R, Itamura JM, Vangsness CT, et al: Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am 2000;82:1115-1121. Settecerri JJ, Pitnu MA, Rock MG, et al: Infection after rotator cuff repair. J Shoulder Elbow Surg 1994;8:105.

Question 2

A 21-year-old pitcher reports shoulder pain with hard throwing. He notes that the pain occurs in the early acceleration phase of his throw. Given his history, what structures are at greatest risk for injury?

Explanation

Internal impingement in the thrower's shoulder occurs in the abducted, externally rotated position as described by Walch and associates. The injury is thought to occur from repetitive contact between the posterosuperior portion of the labrum and glenoid against the articular side of the rotator cuff and greater tuberosity. Paley KJ, Jobe FW, Pink MM, et al: Arthroscopic findings in the overhand throwing athlete: Evidence for posterior internal impingement of the rotator cuff. Arthroscopy 2000;16:35-40. Jazrawi LM, McCluskey GM III, Andrews JR: Superior labral anterior and posterior lesions and internal impingement in the overhead athlete. Instr Course Lect 2003;52:43-63.

Question 3

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should consist of

Explanation

34b The radiograph shows a valgus impacted four-part fracture. The humeral head is deeply depressed into the metaphysis but is still articulating with the glenoid as seen on the CT scan. Unlike a "classic" four-part fracture in which the head is dislocated out of the glenoid and devoid of any soft-tissue attachments (high risk of osteonecrosis), this valgus impacted head will have a medial soft-tissue hinge with a lower risk of osteonecrosis. It is most amenable to open reduction and internal fixation with minimal soft-tissue stripping techniques. Bone grafting may be necessary on occasion. Nonsurgical management for displaced proximal humeral fractures generally results in a poor outcome. This patient does not have a humeral head defect. A hemiarthroplasty is not indicated. Jakob RP, Miniaci A, Anson PS, et al: Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br 1991;73:295-298.

Question 4

A 22-year-old professional baseball pitcher has had pain in the axillary region of his dominant shoulder for the past several weeks. While throwing a pitch during a game, he notes a sharp pulling sensation with a "pop" in his shoulder. Examination the following day reveals tenderness along the posterior axillary fold and pain and weakness with resisted extension of the shoulder. What is the most likely cause of his symptoms?

Explanation

Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower's shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair. Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower's shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries. Magn Reson Imaging Clin N Am 1999;7:39-49.

Question 5

When comparing the addition of a trough at the greater tuberosity to direct repair of cortical bone, simulated rotator cuff repair in animal models has shown what type of change in the strength of the repair?

Explanation

There was no difference observed in the healing of tendon to bone when comparing healing to cortical bone and to a cancellous trough.

Question 6

Figures 35a and 35b show the radiographs of a 20-year-old man who is unable to rotate his dominant forearm. Examination reveals that the arm is fixed in supination. To regain motion, management should consist of

Explanation

35b The patient has a proximal synostosis; therefore, resection of the synostosis is considered the best option to regain motion. While forearm osteotomy can place the hand in a more functional position, rotation will not be restored. Proximal radial excision can provide forearm rotation; however, this procedure is reserved for patients who have a proximal radioulnar synostosis that is too extensive to allow a safe resection, involves the articular surface, and is associated with an anatomic deformity. Motion will not be restored with dynamic splinting. Kamineni S, Maritz NG, Morrey BF: Proximal radial resection for posttraumatic radioulnar synostosis: A new technique to improve forearm rotation. J Bone Joint Surg Am 2002;84:745-751.

Question 7

A 20-year-old-man sustained a scapular fracture after attempting to grab a beam as he fell through a ceiling at a job site 3 months ago. A clinical photograph is shown in Figure 36. He now reports pain in the anterior shoulder and difficulty with overhead activities. What nerve roots make up the involved peripheral nerve?

Explanation

The patient sustained an injury to the long thoracic nerve, which supplies the serratus anterior. Branches of C5 and C6 enter the scalenus medius, unite in the muscle, and emerge as a single trunk and pass down the axilla. On the surface of the serratus anterior, the long thoracic nerve is joined by the branch from C7 and descends in front of the serratus anterior, providing segmental innervation to the serratus anterior.

Question 8

A 20-year-old collegiate baseball pitcher has persistent deep shoulder pain. Examination reveals normal strength, 130 degrees of external rotation in abduction, 10 degrees of internal rotation in abduction, mild dynamic scapular winging, and equivocal findings on provocative tests for labral tears. Management should consist of

Explanation

Although management of shoulder pain in the throwing athlete is controversial, there are some general principles. Initial management generally includes rest from throwing, restoring normal joint function, specifically motion and strength as well as eliminating pain. In this patient, examination reveals excessive external rotation and decreased internal rotation. This pattern is common in pitchers; however, the total arc of motion should remain close to 180 degrees in abduction. In this patient, the total arc is 140 degrees. Treatment should first focus on restoring a 180-degree arc with posterior scapular stretching, as well as pain control and muscle rehabilitation. Injections and surgery are generally reserved for patients who fail to respond to rest and rehabilitation.

Question 9

Which of the following best describes the most common anatomic variation seen in the glenoid labrum and the middle glenohumeral ligament in the anterosuperior quadrant of the shoulder??

Explanation

Wide variations in the anatomy of the anterosuperior portion of the labrum and the middle glenohumeral ligament have been reported and are more common than previously thought. The labrum attached to the glenoid rim and a flat/broad middle glenohumeral ligament is the most common "normal" variation. A cord-like middle glenohumeral ligament is often associated with the presence of a sublabral hole. An anterosuperior labrum confluent with a cord-like middle glenohumeral ligament and no labral attachment to bone is the configuration of the Buford complex. The prevalence of each variation from one recent study is as follows: #1: 86.6%; #2: 3.3%; #3: 8.6%; and #4: 1.5%. Rao AG, Kim TK, Chronopoulos E, et al: Anatomical variants in the anterosuperior aspect of the glenoid labrum. J Bone Joint Surg Am 2003;85:653-659. Ilahi OA, Labbe MR, Cosculluela P: Variants of the anterosuperior glenoid labrum and associated pathology. Arthroscopy 2002;18:882-886.

Question 10

A 21-year-old hockey player who has recurrent shoulder subluxations undergoes an anterior capsulorrhaphy under general anesthesia, and an interscalene block is used to relieve postoperative pain. At the 1-week follow-up examination, he reports loss of sensation over the lateral region of the shoulder and is unable to actively contract the deltoid muscle. The remainder of the examination is normal. What is the best course of action at this time?

Explanation

The patient has an axillary nerve injury, which is relatively uncommon after surgery for instability. This type of injury generally is the result of a stretch injury rather than transection or a hematoma. Therefore, observation is indicated in the early postoperative period. After approximately 6 weeks, electromyography can be used to confirm and document the point of injury. Interscalene blocks can cause prolonged nerve injury but usually are not limited to the axillary nerve.

Question 11

A 10-year-old boy has had a prominent scapula for the past year. He reports crepitus and aching over the area, but only when he is active. A radiograph and CT scans are shown in Figures 37a through 37c. What is the most likely diagnosis?

Explanation

37b 37c The findings are typical for an osteochondroma. It is found as an outgrowth of bone and cartilage from those bones that arise from enchondral ossification. It may be flat, verrucous, or with a long stalk and cauliflower-like cap. Osteochondromas can become symptomatic secondary to irritation of the adjacent musculature. They cease to proliferate when epiphyseal growth ceases.

Question 12

In patients who have undergone nonsurgical management for idiopathic adhesive capsulitis, long-term follow-up studies have shown which of the following results?

Explanation

Results have been satisfactory in many patients; however, at long-term follow-up, examination of the affected shoulder often shows some decrease in range of motion compared with the contralateral side. Although range of motion often improves over time, it does not return to normal in 60% of patients. Pain improves but is often increased compared with the contralateral side. Griggs SM, Ahn A, Green A: Idiopathic adhesive capsulitis: A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 2000;82:1398-1407.

Question 13

Which of the following statements best describes the relationship between tissue response to thermal capsulorrhaphy and the type of device used?

Explanation

Although radiofrequency devices and lasers differ fundamentally in the way they generate heat within a tissue, both classes of devices are capable of producing temperatures within the critical temperature range (65 to 75 degrees C) for collagen denaturation and subsequent tissue shrinkage. When it comes to cell viability and tissue response, heat is heat. Once critical temperatures are reached, cells will die at 45 degrees C, collagen will become denatured at 60 degrees C, and tissue ablation will occur at 100 degrees C no matter what the source of thermal energy. Therefore, claims of a better or different type of heat have little bearing on the biologic response of the tissue. Histologic, ultrastructural, and biomaterial alterations induced by laser and radiofrequency energy have been shown to be similar. Arnoczky SP, Aksan A: Thermal modification of connective tissues: Basic science considerations and clinical implications. J Am Acad Orthop Surg 2000;8:305-313. Hayashi K, Markel MD: Thermal modification of joint capsule and ligamentous tissues: The use of thermal energy in sports medicine. Operative Techniques Sports Med 1998;6:120-125.

Question 14

A 35-year-old man has profound deltoid weakness after sustaining a traumatic anterior shoulder dislocation 6 weeks ago. Electromyographic (EMG) studies confirm an axillary nerve injury. Follow-up examination at 3 months reveals no recovery of function. What is the best course of action?

Explanation

Documenting the status of recovery at this time is appropriate; therefore, repeat EMG studies should be conducted to check for early signs of reinnervation. Timing of nerve exploration in this setting is debated, with authors suggesting exploration if there is no sign of recovery at 6 to 9 months. Perlmutter GS: Axillary nerve injury. Clin Orthop 1999;368:28-36. Artico M, Salvati M, D'Andrea V, et al: Isolated lesions of the axillary nerves: Surgical treatment and outcome in twelve cases. Neurosurgery 1991;29:697-700. Vissar CP, Coene LN, Brand R, et al: The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery: A prospective clinical and EMG study. J Bone Joint Surg Br 1999;81:679-685.

Question 15

A 65-year-old woman has had chronic aching discomfort involving her elbow for the past 6 months. Radiographs and a biopsy specimen are shown in Figures 38a through 38c. What is the most likely diagnosis?

Explanation

38b 38c The histologic features of multiple myeloma are distinctive for this lesion. The plasma cells are round or oval and have an eccentric nucleus and prominent nucleolus. These characteristics and a clear area next to the eccentric nucleus representing the prominent Golgi center are pathognomonic for plasma cells. Lymphoma is in the differential diagnosis; the most frequent types that occur in bone are large cell or mixed small and large cell types. The histologic appearance of the specimen is not consistent with the other choices.

Question 16

Which of the following clinical findings is commonly associated with symptomatic partial-thickness rotator cuff tears?

Explanation

In symptomatic partial-thickness rotator cuff tears, a painful arc with active range of motion is common, impingement signs are usually positive, and the lift-off test is normal. Active and passive range of motion measurements are often equal, although active range of motion can be painful. External rotation lag signs are often seen with larger full-thickness tears. Hertel R, Ballmer FT, Lambert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313. McConville OR, Iannotti JP: Partial thickness tears of the rotator cuff: Evaluation and management. J Am Acad Orthop Surg 1999;7:32-43. Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.

Question 17

A 65-year-old woman landed on her nondominant left shoulder in a fall. An AP radiograph is shown in Figure 39. Management should consist of

Explanation

The radiograph reveals a four-part fracture-dislocation of the proximal humerus. Humeral hemiarthroplasty and tuberosity repair is the treatment of choice because the risk of osteonecrosis is high after attempted repair of this injury. Glenoid resurfacing is reserved for acute fractures in which there is significant preexisting glenoid arthrosis, such as in patients with rheumatoid arthritis. Neer CS II: Displaced proximal humeral fractures: II. Treatment of three- and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.

Question 18

To avoid damage to the ascending branch of the anterior humeral circumflex artery during open reduction and internal fixation of a proximal humeral fracture, the blade plate should be placed in what position?

Explanation

The pectoralis major tendon inserts lateral to the biceps tendon, which runs in the bicipital groove. The primary vascular supply of the articular surface of the humeral head is derived from the anterior circumflex humeral artery, which continues into the arcuate artery once it enters the bone. The entry point is on the anterolateral aspect of the humerus just medial to the greater tuberosity within the bicipital groove. To avoid compromising circulation, the blade plate should be placed lateral to the bicipital groove and pectoralis major tendon insertion. Loebenberg M, Plate AM, Zuckerman J: Osteonecrosis of the humeral head. Instr Course Lect 1999;48:349-357.

Question 19

An otherwise healthy 13-year-old boy sustains the fracture shown in Figure 40 while throwing a fastball. Management should consist of

Explanation

Nonsurgical management such as a functional brace, hanging arm cast, or sugar tong splint is the treatment of choice for a fracture of the humeral shaft that is the result of throwing. The fracture surface typically is wide and the degree of displacement is not large; therefore, surgery is not indicated in most patients. Ogawa K, Yoshida A: Throwing fracture of the humeral shaft: An analysis of 90 patients. Am J Sports Med 1998;26:242-246.

Question 20

A 24-year-old man sustains an injury to his right elbow after falling 10 feet. Radiographs are shown in Figures 41a and 41b. Treatment should consist of

Explanation

41b Transolecranon fracture-dislocations are most effectively managed with open reduction and internal fixation, followed by early aggressive range of motion. Concomitant injury to the collateral ligament is rare, and stability is achieved by anatomic reconstruction of the olecranon fracture with rigid fixation. The need for collateral ligament repair or a hinged external fixator is uncommon in this fracture pattern.

Question 21

After closed reduction of the dislocation shown in Figure 42, it is essential to avoid placing the upper extremity in what position for the first 4 to 6 weeks?

Explanation

Acute posterior dislocations occur rarely, accounting for less than 5% of acute dislocations. They are most often the result of falls on an outstretched hand. Reduction can be accomplished with flexion of the arm to 90 degrees and adduction to disimpact the humeral head from the glenoid rim. The arm is then externally rotated until the head has cleared the glenoid rim. Following brace immobilization in neutral to 5 to 10 degrees of external rotation and slight abduction, it is critical to avoid internal rotation for 4 to 6 weeks. Burkhead WZ Jr, Rockwood CA Jr: Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1986;68:724-731.

Question 22

A baseball player has had diffuse scapular soreness for the past 8 weeks. He reports that it began insidiously over several days and gradually has become worse. He denies any history of trauma. Examination reveals drooping of the shoulder, with lateral winging of the scapula at rest. He is otherwise neurologically intact. What is the best course of action?

Explanation

Lateral scapular winging is characteristic of trapezius palsy, whereas medial scapular winging is characteristic of long thoracic nerve palsy. During sports activity, injury to the spinal accessory nerve is rare but may occur with blunt or stretching trauma. Patients often report an asymmetric neckline, drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination. Wiater JM, Bigliani LU: Spinal accessory nerve injury. Clin Orthop 1999;368:5-16. Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop 1999;368:17-27. Mariani PP, Santoriello P, Maresca G: Spontaneous accessory nerve palsy. J Shoulder Elbow Surg 1998;7:545-546. Porter P, Fernandez GN: Stretch-induced spinal accessory nerve palsy: A case report. J Shoulder Elbow Surg 2001;10:92-94.

Question 23

Which of the following best describes the mechanical response of the inferior glenohumeral ligament to repetitive subfailure strains?

Explanation

Repetitive subfailure strains have been shown to affect the mechanical behavior of the inferior glenohumeral ligament, producing dramatic declines in the peak load response and length increases that are largely unrecoverable. In another study, anteroinferior subluxation was found to result in nonrecoverable strain in the anteroinferior capsule, varying from 3% to 7% through a range of joint subluxation. Pollock RG, Wang VM, Bucchieri JS, et al: Effects of repetitive subfailure strains on the mechanical behavior of the inferior glenohumeral ligament. J Shoulder Elbow Surg 2000;9:427-435.

Question 24

A 38-year-old woman who tripped and fell on her outstretched arm reports pain with movement. Examination reveals swelling. AP and lateral radiographs are shown in Figures 43a and 43b. Management should consist of

Explanation

43b The patient has a type I (Hahn-Steinthal) capitellar fracture that is best seen on the lateral radiograph. If a fracture fragment is seen proximal to the radial head, a capitellar fracture is the most likely injury because radial head fractures do not migrate proximally. The fragment is large enough for fixation. Excision is the preferred treatment for small shear osteochondral type II (Kocher-Lorenz) capitellar fractures. Closed reduction usually is not successful because of rotation of the displaced fragment. Mehdian H, McKee M: Management of proximal and distal humerus fractures. Orthop Clin North Am 2000;31:115-127.

Question 25

A 15-year-old girl reports popping and clicking at the sternoclavicular joint and an intermittent asymmetrical prominence of the medial head of the clavicle. She denies any history of trauma or other symptoms. Management should consist of

Explanation

Atraumatic subluxation or dislocation of the sternoclavicular joint typically occurs in individuals with generalized ligamentous laxity. It is generally not painful, has no long-term sequelae, and needs no treatment. In fact, it is more likely to be painful following surgery than if managed nonsurgically. Rockwood CA Jr, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989;71:1280-1288.

Question 26

In a reverse total shoulder arthroplasty (RTSA), the center of rotation is altered compared to the native glenohumeral joint. This specific kinematic alteration achieves which of the following biomechanical advantages?

Explanation

A reverse total shoulder arthroplasty (RTSA) shifts the center of rotation medially and inferiorly. This biomechanical alteration increases the moment arm of the deltoid, allowing it to act as the primary elevator of the shoulder in the absence of a functioning rotator cuff. It also increases deltoid tension and recruits more anterior and posterior deltoid fibers for arm elevation.

Question 27

A 42-year-old woman presents after a fall onto an outstretched hand. She is diagnosed with a 'terrible triad' injury of the elbow. During surgical reconstruction, what is the most widely accepted and appropriate sequence of repair to restore elbow stability?

Explanation

The standard surgical sequence for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) typically proceeds from deep to superficial and anterior to posterior/lateral. The recommended sequence is: 1) Coronoid repair (or anterior capsule reattachment), 2) Radial head repair or replacement, and 3) Lateral collateral ligament (LCL) complex repair. Finally, the elbow is assessed for stability; if valgus or extension instability persists, the medial collateral ligament (MCL) is repaired or a hinged external fixator is applied.

Question 28

A 24-year-old elite volleyball attacker complains of vague posterior shoulder pain and painless weakness over the past 6 months. Physical examination reveals notable atrophy of the infraspinatus fossa but normal bulk of the supraspinatus. She has full strength in shoulder abduction but 3/5 strength in external rotation with the arm at the side. An MRI is obtained, demonstrating a paralabral cyst. Where is the cyst most likely located and which nerve is affected?

Explanation

Isolated infraspinatus weakness and atrophy strongly suggest entrapment of the suprascapular nerve at the spinoglenoid notch. In athletes, particularly overhead throwers and volleyball players, this is often due to a paralabral cyst associated with a posterosuperior labral tear. Entrapment at the suprascapular notch, which is more proximal, would typically denervate both the supraspinatus and infraspinatus muscles.

Question 29

A 65-year-old woman falls and sustains a complex proximal humerus fracture. According to the criteria established by Hertel et al., which combination of radiographic findings is the most reliable predictor of humeral head ischemia?

Explanation

Hertel et al. evaluated the predictors of humeral head ischemia following proximal humerus fractures. The most significant individual predictors include a short posteromedial metaphyseal head extension (calcar segment attached to the articular surface <8 mm), disruption of the medial hinge, and a true anatomic neck fracture. When all three factors are present, the positive predictive value for ischemia is 97%.

Question 30

A 45-year-old man presents with numbness and tingling in his small and ring fingers, along with subjective weakness in his grip. Electromyography confirms isolated ulnar neuropathy at the elbow. During surgical decompression, which of the following structures is identified as the most common primary site of ulnar nerve compression?

Explanation

Cubital tunnel syndrome is the second most common compression neuropathy in the upper extremity. While compression can occur at multiple sites (Arcade of Struthers, medial intermuscular septum, Osborne's ligament, FCU aponeurosis, and deep flexor pronator aponeurosis), the most frequent primary site of compression is at the cubital tunnel retinaculum, also known as Osborne's ligament, which spans between the olecranon and the medial epicondyle.

Question 31

A 22-year-old man falls on an outstretched hand and sustains a minimally displaced fracture of the proximal pole of the scaphoid. He is counseled regarding the high risk for nonunion and avascular necrosis (AVN). Which of the following accurately describes the primary arterial blood supply to the proximal pole of the scaphoid?

Explanation

The scaphoid relies on a tenuous blood supply, predominantly from the radial artery. The major blood supply (70-80%) arises from the dorsal carpal branch of the radial artery, which enters the bone distally at the dorsal ridge (near the waist) and provides retrograde intraosseous flow to the proximal pole. Because of this retrograde flow, fractures of the proximal pole frequently disrupt the blood supply to the proximal fragment, leading to a high rate of avascular necrosis.

Question 32

A 58-year-old woman is evaluated 6 months after open reduction and internal fixation of a distal radius fracture utilizing a volar locking plate. She reports a sudden inability to actively flex the interphalangeal joint of her thumb, which occurred painlessly while wringing out a towel. What is the most likely cause of this complication?

Explanation

Flexor tendon rupture, most notably of the flexor pollicis longus (FPL), is a well-documented complication of volar plating for distal radius fractures. It most commonly occurs when the plate is positioned too distally, beyond the 'watershed line' (the volar margin of the distal radius articular surface). This causes the FPL tendon to rub against the prominent distal edge of the plate or screw heads during active wrist and thumb motion, leading to attritional wear and sudden, often painless, rupture.

Question 33

A 42-year-old tennis player presents with chronic, refractory lateral elbow pain that is exacerbated by wrist extension and gripping. He has failed 8 months of conservative management and is scheduled for surgical debridement. Histologic evaluation of the resected tissue is expected to show angiofibroblastic hyperplasia. The primary pathoanatomic lesion in this condition typically involves the origin of which structure?

Explanation

Lateral epicondylitis (tennis elbow) is primarily a degenerative tendinosis characterized histologically by angiofibroblastic hyperplasia, rather than acute inflammation. The most commonly involved structure is the origin of the extensor carpi radialis brevis (ECRB). While the ECRL and EDC can occasionally be involved, the ECRB is the primary culprit due to its anatomical position overlying the radiocapitellar joint and its mechanical susceptibility to microtrauma during repetitive wrist extension.

Question 34

A 26-year-old professional baseball pitcher undergoes shoulder arthroscopy for a Type II SLAP tear. During dynamic intraoperative testing, the surgeon observes a 'peel-back' mechanism of the superior labrum when the arm is placed in the late-cocking position (abduction and external rotation). This biomechanical phenomenon most directly leads to which of the following secondary shoulder pathologies in overhead athletes?

Explanation

In the overhead throwing athlete, placing the arm in abduction and maximal external rotation (the late cocking phase) shifts the biceps vector posteriorly, creating a 'peel-back' torsional force on the superior labrum. A Type II SLAP tear allows increased posterosuperior translation of the humeral head and increased external rotation. This kinematics shift leads to internal impingement, where the articular surface of the posterosuperior rotator cuff (supraspinatus and infraspinatus) abuts the posterosuperior glenoid labrum, frequently leading to articular-sided 'kissing' lesions of the rotator cuff.

Question 35

A 20-year-old collegiate baseball pitcher is undergoing ulnar collateral ligament (UCL) reconstruction utilizing an autograft. To minimize the risk of postoperative ulnar neuropathy, a common and devastating complication, which of the following intraoperative principles is most critical regarding the handling of the ulnar nerve?

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction. Historically, routine anterior transposition was performed (as in the classic Jobe technique), which carried a high rate of nerve-related complications. Modern techniques (such as the docking technique or muscle-splitting approach) often leave the nerve in situ to preserve its vascularity. When leaving the nerve in situ, it is critical to avoid placing retractors directly on the nerve, to minimize traction, and to release the medial intermuscular septum if there is any tension, thereby preventing tethering or iatrogenic compression.

Question 36

A 45-year-old man presents with chronic, progressive wrist pain 10 years after sustaining an untreated fall on an outstretched hand. Radiographs demonstrate a scaphoid waist nonunion with cystic changes and sclerosis, alongside marked narrowing of the radioscaphoid and capitolunate joint spaces. The radiolunate joint is well-preserved. Which of the following is the most appropriate surgical management?

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 in SNAC/SLAC stage III because it relies on articulating the proximal capitate with the lunate fossa; an arthritic capitate will result in continued pain and failure. Scaphoid excision and four-corner fusion eliminates the arthritic capitolunate and radioscaphoid joints while preserving functional motion through the intact radiolunate joint.

Question 37

Reverse total shoulder arthroplasty (RTSA) is widely utilized to restore function in patients with rotator cuff tear arthropathy. Compared to the native glenohumeral joint, how does RTSA alter the center of rotation to improve active elevation?

Explanation

The biomechanical advantage of the reverse total shoulder arthroplasty (RTSA) is achieved by medializing and inferiorly shifting the center of rotation. Medialization increases the moment arm of the deltoid, while inferiorization tensions the deltoid and recruits more of its anterior and posterior fibers to assist with forward elevation and abduction, effectively compensating for the deficient rotator cuff.

Question 38

A 35-year-old woman is undergoing surgery for a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). Intraoperatively, the coronoid has been securely fixed, the radial head has been replaced, and the lateral collateral ligament (LCL) complex has been repaired to the lateral epicondyle. Upon testing range of motion, the elbow remains unstable and subluxates in terminal extension. What is the next most appropriate step in management?

Explanation

The surgical algorithm for terrible triad injuries includes: 1) establishing a stable anterior base via coronoid fixation or capsular repair, 2) radial head fixation or replacement, and 3) LCL complex repair. If the elbow remains unstable after these steps (often subluxating in extension), the next step is to address the medial side by repairing the medial collateral ligament (MCL). If instability persists despite MCL repair, a hinged external fixator is indicated.

Question 39

A 62-year-old woman presents with the sudden inability to bend the tip of her thumb. Twelve months prior, she underwent open reduction and internal fixation of a distal radius fracture with a volar locking plate. Lateral radiographs show the plate is positioned prominent and distal to the watershed line. Given the likely diagnosis, what is the most appropriate surgical treatment?

Explanation

The patient has a flexor pollicis longus (FPL) tendon rupture, a known complication of prominent volar hardware placed distal to the watershed line of the distal radius. Chronic attrition leads to rupture with retracted and degenerated tendon ends, precluding direct repair. The standard treatment is hardware removal and tendon transfer, most commonly utilizing the flexor digitorum superficialis (FDS) of the ring finger.

Question 40

A 42-year-old mechanic complains of clumsiness, weakness in his grip, and numbness in his small and ring fingers. During physical examination, the examiner asks the patient to hold a piece of paper laterally between his thumb and index finger. As the examiner pulls the paper away, the patient strongly flexes the interphalangeal (IP) joint of his thumb. Which muscle is compensating to produce this clinical sign?

Explanation

This describes a positive Froment's sign, which tests for ulnar nerve palsy. The primary muscle for key pinch is the adductor pollicis (innervated by the ulnar nerve). When the adductor pollicis is weak, the patient compensates by hyperflexing the thumb interphalangeal (IP) joint using the flexor pollicis longus (FPL), which is innervated by the anterior interosseous nerve (AIN), a branch of the median nerve.

Question 41

A 74-year-old female sustains a displaced 3-part proximal humerus fracture with varus impaction of the head. Bone density testing indicates significant osteoporosis. If the surgeon decides to proceed with open reduction and internal fixation (ORIF) using a locked plate rather than arthroplasty, what is the most common complication she is at risk for postoperatively?

Explanation

Intra-articular screw penetration (screw cut-out) is the most frequent complication following locked plating of proximal humerus fractures, particularly in elderly patients with osteoporotic bone and varus-pattern fractures. It occurs due to varus collapse of the humeral head fragment, causing the screws to breach the articular surface. Medial calcar support is critical to minimize this risk.

Question 42

A 45-year-old male bodybuilder undergoes a single-incision anterior approach for the repair of a complete distal biceps tendon rupture. Postoperatively, he complains of numbness over the radial aspect of his forearm. Which nerve was most likely injured or stretched during the surgical exposure?

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. It runs superficially in the subcutaneous tissues on the lateral aspect of the anterior elbow and provides sensation to the radial forearm. The posterior interosseous nerve (PIN) is at higher risk during a two-incision approach or with deep retractor placement on the radial neck.

Question 43

A 32-year-old male presents with chronic dorsal wrist pain and weakened grip strength. Radiographs reveal sclerosis, cystic changes, and early fragmentation of the lunate, consistent with Kienböck's disease (Lichtman Stage IIIA). Ulnar variance is measured at -3 mm. MRI confirms the articular cartilage of the radiocarpal and midcarpal joints remains intact. What is the most appropriate surgical intervention?

Explanation

In Kienböck's disease with negative ulnar variance and intact carpal articular cartilage (Stage I to IIIA), joint-leveling procedures are indicated to mechanically unload the lunate. Radial shortening osteotomy is the gold standard and most reliable method to achieve this in the setting of ulnar minus variance. Capitate shortening is reserved for patients with neutral or positive ulnar variance.

Question 44

A 22-year-old motorcyclist sustains a traumatic brachial plexus injury following a high-speed collision. He presents with a completely flail and insensate right upper extremity. Physical examination reveals right-sided ptosis, miosis, and anhidrosis. What does this constellation of signs definitively indicate regarding his nerve injury?

Explanation

Ptosis, miosis, and anhidrosis describe Horner's syndrome, which indicates disruption of the sympathetic chain. In the context of a severe brachial plexus injury, this suggests a preganglionic nerve root avulsion of the lower roots (C8 and T1), as the sympathetic fibers exit the spinal cord at T1. A preganglionic avulsion represents a proximal injury that cannot be directly repaired or grafted, indicating a poor prognosis for spontaneous recovery of hand function.

Question 45

A 28-year-old professional tennis player presents with posterior shoulder pain and selective weakness in external rotation. An MRI of the shoulder reveals a multi-lobulated paralabral cyst located strictly within the spinoglenoid notch. Based on this isolated compression, which of the following clinical findings would most likely be observed on physical examination?

Explanation

The suprascapular nerve supplies motor innervation to the supraspinatus before passing through the spinoglenoid notch to innervate the infraspinatus. Compression of the nerve at the spinoglenoid notch (often caused by a paralabral cyst associated with a posterior labral tear) results in isolated denervation, weakness, and subsequent atrophy of the infraspinatus muscle. Compression more proximally at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 46

A 22-year-old male presents with a proximal pole scaphoid fracture after a fall. Operative fixation is planned. Which of the following is true regarding the surgical approach and relevant anatomy for this specific fracture pattern?

Explanation

Proximal pole scaphoid fractures are best approached dorsally. The blood supply to the scaphoid enters the dorsal ridge at the waist and flows in a retrograde fashion to the proximal pole. A dorsal approach, when done carefully, does not compromise this blood supply. More importantly, it provides direct access to the proximal pole, allowing for a screw trajectory that is parallel to the central axis of the scaphoid and perpendicular to the fracture plane, which maximizes biomechanical compression.

Question 47

A 60-year-old woman sustained a nondisplaced distal radius fracture treated in a short arm cast. Six weeks later, she develops a sudden inability to actively extend her thumb interphalangeal joint. What is the most likely pathomechanism of this complication?

Explanation

Extensor pollicis longus (EPL) rupture is a known complication of nondisplaced distal radius fractures. The EPL tendon takes a sharp turn around Lister's tubercle and passes through a tight third extensor compartment. In nondisplaced fractures, the extensor retinaculum remains intact; combined with fracture hematoma, this increases the pressure within the compartment, leading to ischemic necrosis and mechanical attrition of the tendon. Treatment typically involves an extensor indicis proprius (EIP) to EPL tendon transfer.

Question 48

A 72-year-old woman undergoes reverse total shoulder arthroplasty for cuff tear arthropathy. At her 2-year follow-up, radiographs show inferior scapular notching. Which of the following component positionings is most strongly associated with this radiographic finding?

Explanation

Scapular notching is a frequent complication following reverse total shoulder arthroplasty, caused by mechanical impingement of the medial humeral metaphysis against the inferior scapular neck during adduction. Superior placement and medialization of the glenosphere significantly increase the risk of notching. Conversely, surgical techniques and implant designs utilizing inferior placement, inferior tilt, and lateralization of the glenosphere help mitigate this impingement.

Question 49

A 45-year-old man undergoes repair of a distal biceps tendon rupture via a dorsal and volar two-incision technique. Postoperatively, he is unable to actively extend his fingers and thumb, but wrist extension is preserved with radial deviation. Which nerve is most likely injured, and what is its anatomic relationship in the forearm?

Explanation

The posterior interosseous nerve (PIN) is highly susceptible to injury during a two-incision distal biceps repair, particularly during the dorsal dissection or through injudicious retractor placement. The PIN enters the arcade of Frohse and travels between the superficial and deep heads of the supinator muscle. A PIN injury results in the inability to extend the fingers and thumb. Wrist extension is preserved but deviates radially because the extensor carpi radialis longus (ECRL) is innervated by the radial nerve proper proximal to the PIN branch.

Question 50

A 35-year-old man falls from a ladder and sustains a 'terrible triad' injury of the elbow. Which of the following lists the sequence of structures typically addressed during surgical management, from deep to superficial?

Explanation

The 'terrible triad' of the elbow involves a coronoid fracture, a radial head fracture, and a lateral collateral ligament (LCL) tear, leading to posterolateral rotatory instability. The standard surgical protocol dictates repairing structures from deep/anterior to superficial/lateral. The typical sequence is: 1) fixation of the coronoid to restore the anterior buttress, 2) fixation or replacement of the radial head, and 3) repair of the LCL complex to the lateral epicondyle to restore lateral stability. The medial collateral ligament is typically only addressed if gross instability persists after these steps.

Question 51

A 55-year-old manual laborer presents with chronic, progressively worsening radial-sided wrist pain. Radiographs demonstrate advanced narrowing of the radioscaphoid joint and capitulolunate joint, with a preserved radiolunate joint. Which of the following is the most appropriate surgical treatment?

Explanation

The patient has Stage III Scapholunate Advanced Collapse (SLAC) wrist, characterized by radioscaphoid and midcarpal (capitolunate) arthritis, while characteristically sparing the radiolunate joint. A proximal row carpectomy (PRC) is contraindicated in Stage III SLAC because the capitate head is arthritic and cannot smoothly articulate with the lunate fossa. Therefore, scaphoid excision with four-corner (capitate, hamate, lunate, triquetrum) arthrodesis is the most appropriate motion-preserving surgical treatment.

Question 52

A 65-year-old woman sustains an intra-articular distal humerus fracture (AO type 13-C3). Open reduction and internal fixation is performed with dual plating. Which of the following statements regarding the biomechanical stability of plating configurations is most accurate?

Explanation

According to extensive biomechanical studies (such as those by O'Driscoll and others), both parallel plating (medial and lateral plates) and orthogonal plating (medial and posterolateral plates) provide sufficient and comparable biomechanical stability for the fixation of intra-articular distal humerus fractures. The choice between the two constructs largely depends on the specific fracture pattern and surgeon preference, provided that basic principles of fracture fixation and interdigitation of screws are strictly followed.

Question 53

A 28-year-old carpenter presents with dorsal wrist pain. MRI confirms osteonecrosis of the lunate. Radiographs demonstrate lunate sclerosis and fragmentation, but the carpal height ratio is preserved and there is no radioscaphoid arthritis. Ulnar variance is -3mm. Which of the following is the most appropriate operative intervention?

Explanation

This patient has Lichtman Stage IIIa Kienböck's disease (lunate fragmentation without fixed scaphoid rotation or carpal collapse). In the presence of ulnar minus variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. This procedure unloads the lunate by shifting compressive forces to the ulnocarpal joint, preventing further collapse. Ulnar lengthening is associated with higher nonunion rates. Salvage procedures like PRC or intercarpal fusions are reserved for Stage IIIb or IV disease.

Question 54

A 45-year-old diabetic man presents with persistent ulnar neuropathy 6 months after an in situ ulnar nerve decompression at the cubital tunnel. EMG shows active denervation in the abductor digiti minimi. During revision surgery, the nerve is embedded in dense scar tissue and subluxates anteriorly with elbow flexion. Which of the following is the most appropriate next step?

Explanation

In the setting of revision cubital tunnel surgery, especially when the ulnar nerve is embedded in scar tissue and demonstrating subluxation, a submuscular transposition is widely considered the procedure of choice. It moves the nerve out of the scarred, poorly vascularized primary surgical bed and places it in a healthy, well-vascularized environment deep to the flexor-pronator mass, simultaneously correcting the dynamic subluxation.

Question 55

A 22-year-old collegiate baseball pitcher presents with deep shoulder pain and decreased throwing velocity. He has a positive O'Brien test and dynamic labral shear test. MRI arthrogram shows a type II SLAP tear. Following 3 months of failed physical therapy, what is the most appropriate surgical treatment?

Explanation

In a young, high-demand overhead athlete (such as a collegiate pitcher) with a symptomatic type II SLAP tear that has failed conservative management, arthroscopic SLAP repair is the preferred surgical treatment. Restoring the anatomy of the superior labrum and the tension of the biceps anchor is critical for the 'peel-back' mechanism and maintaining normal shoulder kinematics required for high-velocity overhead throwing. Biceps tenodesis is increasingly favored in older, non-overhead athletes due to a lower risk of postoperative stiffness, but it alters throwing mechanics in elite pitchers.

Question 56

A 68-year-old woman presents with persistent shoulder pain and pseudoparalysis. MRI reveals a massive rotator cuff tear involving the supraspinatus and infraspinatus. Which of the following MRI findings is the strongest contraindication to a primary arthroscopic repair?

Explanation

Goutallier stage 3 or 4 fatty infiltration represents irreversible muscle degeneration. It strongly correlates with poor functional outcomes and high retear rates following rotator cuff repair, making it a major contraindication to primary arthroscopic repair.

Question 57

A 32-year-old man sustained a closed midshaft humerus fracture and presents with an inability to extend his wrist or fingers. He is treated nonoperatively with a functional brace. At 3 months, his fracture shows progressive healing, but there is no clinical or electromyographic (EMG) evidence of radial nerve recovery. What is the most appropriate next step in management?

Explanation

Observation of primary radial nerve palsy in closed humerus fractures is standard, as most resolve spontaneously. However, the lack of clinical or EMG signs of recovery by 3 to 4 months warrants surgical exploration to assess the nerve and perform neurolysis or repair as indicated.

Question 58

A 45-year-old woman falls on an outstretched hand and sustains an acute 'terrible triad' injury of the elbow.

During surgical reconstruction, after fixation of the coronoid and radial head fractures and repair of the lateral collateral ligament (LCL) complex, the elbow remains persistently unstable in extension. What is the next most appropriate step in surgical management?

Explanation

The standard sequence of treating terrible triad injuries includes repairing the coronoid, restoring the radial head, and repairing the LCL complex. If the elbow remains unstable in extension after these steps, the MCL should be repaired. Hinged external fixation is reserved for residual instability after all primary capsuloligamentous structures have been addressed.

Question 59

A 75-year-old right-hand-dominant woman sustains a 4-part proximal humerus fracture. She has a history of severe osteoporosis and advanced osteoarthritis of the glenohumeral joint. Which of the following surgical options will provide the most reliable pain relief and functional improvement?

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for elderly patients with 4-part proximal humerus fractures, especially in the setting of concurrent glenohumeral arthritis or poor tuberosity bone quality. RTSA provides more predictable functional outcomes and forward elevation compared to hemiarthroplasty, which relies heavily on tuberosity healing.

Question 60

A 22-year-old male cyclist falls onto his left shoulder and sustains a completely displaced midshaft clavicle fracture with 2.5 cm of shortening. He undergoes open reduction and internal fixation (ORIF) with a superiorly placed precontoured locking plate. Which of the following nerves is at greatest risk of injury during the surgical approach?

Explanation

The supraclavicular nerves (derived from C3, C4) provide sensory innervation over the clavicle and anterosuperior chest wall. They cross superficial to the clavicle and are frequently injured, stretched, or deliberately divided during the surgical approach for clavicle ORIF, resulting in a characteristic numb patch inferior to the incision.

Question 61

A 40-year-old male weightlifter feels a sudden 'pop' in his anterior elbow while performing a heavy bicep curl. On examination, he has weakness in forearm supination and elbow flexion. He undergoes a single-incision anterior approach for distal biceps tendon repair. Which of the following complications is most specifically associated with this single-incision approach?

Explanation

The single-incision anterior approach for distal biceps repair is associated with a higher risk of LABCN neuropraxia due to the required superficial radial-sided retraction. Radioulnar synostosis is a complication more classically associated with the two-incision approach.

Question 62

A 24-year-old man falls on an outstretched hand. Initial radiographs are negative, but an MRI obtained 2 weeks later confirms a non-displaced proximal pole scaphoid fracture. Due to the high risk of nonunion, surgical fixation is recommended. The blood supply to the proximal pole of the scaphoid is primarily derived from branches of which of the following arteries?

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters at the waist and courses in a retrograde fashion to the proximal pole. Fractures of the proximal pole disrupt this delicate supply, placing it at a high risk for avascular necrosis and nonunion.

Question 63

A 19-year-old male presents to the emergency department with severe chest pain, shortness of breath, and dysphagia after being tackled during a rugby match. Examination reveals a depression at the right sternoclavicular joint. A CT scan confirms a posterior sternoclavicular dislocation. What is the most appropriate initial management?

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the risk of compression of mediastinal structures (trachea, esophagus, major vessels). Attempts at closed reduction should be performed in the operating room with a cardiothoracic surgeon readily available on standby due to the life-threatening risk of major vascular injury during the reduction maneuver.

Question 64

A 55-year-old male manual laborer undergoes an open subpectoral biceps tenodesis for partial tearing of the long head of the biceps tendon. Which of the following represents a known advantage of open subpectoral biceps tenodesis compared to an arthroscopic suprapectoral tenodesis?

Explanation

Open subpectoral tenodesis completely removes the long head of the biceps tendon from the bicipital groove. This effectively eliminates the groove as a potential source of persistent anterior shoulder pain, which can occur from tenosynovitis or hidden tendon lesions that might remain if a suprapectoral tenodesis is performed.

Question 65

A 50-year-old woman with type 1 diabetes mellitus presents with insidious onset of progressive shoulder pain and stiffness over the last 4 months. She denies any preceding trauma. Examination shows equal limitation in both active and passive range of motion, with significant restriction in external rotation. Radiographs are normal. What is the underlying pathophysiological hallmark of her condition?

Explanation

The patient's clinical presentation is classic for adhesive capsulitis (frozen shoulder), which is strongly associated with diabetes. Its pathophysiological hallmark is fibroblastic proliferation, capsular thickening, and contracture. This predominantly involves the rotator interval, consisting of the coracohumeral ligament and superior glenohumeral ligament, leading to the characteristic early loss of external rotation.

Question 66

A 72-year-old woman with a massive, irreparable rotator cuff tear and pseudoparalysis undergoes a reverse total shoulder arthroplasty. During glenoid baseplate preparation, which of the following positioning strategies is most effective in minimizing the risk of scapular notching?

Explanation

In reverse total shoulder arthroplasty, scapular notching is a common complication caused by mechanical impingement of the humeral component against the inferior scapular neck. Positioning the glenosphere with an inferior translation (overhang) and an inferior tilt has been biomechanically and clinically shown to effectively reduce the incidence and severity of scapular notching.

Question 67

A 45-year-old recreational weightlifter presents with deep, anterior shoulder pain exacerbated by bench pressing. He has a positive O'Brien test and a positive Speed's test. MRI reveals a type II SLAP tear. Nonoperative management has failed. Which of the following surgical interventions provides the most reliable return to his pre-injury activity level?

Explanation

In patients older than 35-40 years or those who are not overhead throwing athletes, biceps tenodesis provides more reliable pain relief and return to function compared to SLAP repair. SLAP repair in this demographic has a higher rate of persistent pain, stiffness, and subsequent revision surgery. Biceps tenodesis provides excellent functional outcomes without the cramping and 'Popeye' deformity risks seen with tenotomy.

Question 68

A 32-year-old man falls from a ladder and sustains an elbow dislocation associated with a radial head fracture and a coronoid fracture. Following closed reduction of the elbow, he is taken to the operating room. What is the standard recommended sequence of surgical reconstruction for this injury?

Explanation

The classic 'terrible triad' of the elbow consists of an elbow dislocation, radial head fracture, and coronoid fracture. The standard surgical sequence works from deep to superficial: first repairing or replacing the coronoid (to restore the anterior buttress), then fixing or replacing the radial head (to restore the anterior and valgus buttress), and finally repairing the lateral ulnar collateral ligament (LUCL) to restore posterolateral rotatory stability.

Question 69

A 24-year-old man falls on an outstretched hand and sustains a fracture of the scaphoid. The fracture line passes through the proximal pole. He is at high risk for avascular necrosis due to the unique blood supply of the scaphoid. The predominant blood supply to the proximal pole is derived from a retrograde flow pattern originating from which of the following vessels?

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters the bone distally at the dorsal ridge and supplies the proximal 70-80% of the bone via retrograde flow. A fracture through the proximal pole disrupts this retrograde supply, placing the proximal fragment at a very high risk of avascular necrosis and nonunion.

Question 70

A 21-year-old collegiate baseball pitcher presents with medial elbow pain and decreased pitching velocity. Physical examination demonstrates pain and laxity with the moving valgus stress test. An MRI arthrogram confirms a tear of the ulnar collateral ligament (UCL). Which specific bundle of the UCL is the primary restraint to valgus stress from 30 to 120 degrees of elbow flexion?

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow, particularly between 30 and 120 degrees of flexion. It originates from the anteroinferior medial epicondyle and inserts on the sublime tubercle of the coronoid. The posterior bundle is a secondary restraint, and the transverse bundle provides no significant stability.

Question 71

A 28-year-old motorcyclist is involved in a high-speed collision and sustains a severe traction injury to his right upper extremity. On examination, he has a flail, insensate right arm. He also exhibits right-sided ptosis, miosis, and anhidrosis. The presence of these ocular and facial symptoms strongly suggests an injury at which of the following levels?

Explanation

The patient has Horner's syndrome (ptosis, miosis, anhidrosis), which indicates disruption of the sympathetic chain. The sympathetic fibers to the head and neck exit the spinal cord at T1. Therefore, Horner's syndrome in the setting of a brachial plexus injury strongly points to a preganglionic avulsion of the lower roots (C8-T1). Preganglionic injuries have a poor prognosis for spontaneous recovery and are generally not amenable to direct nerve repair or grafting.

Question 72

A 55-year-old woman presents with sudden inability to actively flex the interphalangeal joint of her right thumb. She underwent open reduction and internal fixation of a right distal radius fracture with a volar locking plate 4 years ago. Radiographs show the plate is positioned distally, overriding the watershed line. Which of the following is the most appropriate definitive management for her current condition?

Explanation

The patient has a rupture of the Flexor Pollicis Longus (FPL) tendon, a known complication of volar plating of the distal radius when the plate is placed distal to the watershed line, leading to attrition over the hardware. Because the rupture often presents late with tendon retraction and poor tissue quality, primary repair is usually impossible. The standard treatment is hardware removal and a tendon transfer, most commonly using the Flexor Digitorum Superficialis (FDS) of the ring or middle finger to restore FPL function.

Question 73

A 42-year-old carpenter presents with chronic lateral elbow pain that worsens with gripping and resisted wrist extension. Nonoperative management over the past 12 months has failed, and he is scheduled for surgical debridement. The pathologic tissue in lateral epicondylitis most commonly involves the origin of which of the following muscles?

Explanation

Lateral epicondylitis (tennis elbow) is a tendinosis characterized by angiofibroblastic hyperplasia. The most commonly and primarily affected structure is the origin of the extensor carpi radialis brevis (ECRB) tendon. While the extensor digitorum communis can sometimes be involved, the ECRB is considered the primary site of pathology.

Question 74

A 35-year-old man sustains a closed spiral fracture of the distal third of the humeral shaft following an arm-wrestling match. On initial presentation in the emergency department, he is unable to actively extend his wrist or fingers, and he has decreased sensation over the dorsal first web space. Radiographs confirm a Holstein-Lewis fracture. What is the most appropriate initial management?

Explanation

Radial nerve palsy associated with a closed humeral shaft fracture (including Holstein-Lewis fractures) is typically a neuropraxia or axonotmesis. The most appropriate initial management is nonoperative treatment of the fracture (e.g., coaptation splint followed by a functional brace) and observation of the nerve palsy. Spontaneous recovery occurs in the vast majority of cases. Surgical exploration is indicated if the fracture is open, if there is an associated vascular injury, or if a nerve palsy develops AFTER a closed reduction attempt.

Question 75

A 28-year-old mechanic complains of an inability to pinch objects using his right thumb and index finger. On examination, when asked to make an 'OK' sign, he compensates by using the pulps of his thumb and index finger rather than the tips, resulting in a flat pinch. Sensation in the hand is completely normal. Which of the following muscles is most likely paralyzed?

Explanation

The patient's clinical presentation is classic for Anterior Interosseous Nerve (AIN) syndrome, characterized by a pure motor palsy. The AIN innervates the flexor pollicis longus (FPL), the radial half of the flexor digitorum profundus (FDP), and the pronator quadratus. Paralysis of the FPL and FDP to the index finger leads to an inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger, resulting in the characteristic abnormal 'OK' sign (positive Kiloh-Nevin sign). Sensation is spared because the AIN carries no cutaneous sensory fibers.

Question 76

A 65-year-old right-hand-dominant woman presents after a fall onto an outstretched hand. Radiographs demonstrate a displaced intra-articular distal radius fracture with a volar marginal shear fragment.

Which of the following approaches and fixation constructs is most appropriate to prevent carpal subluxation?

Explanation

Volar Barton fractures (volar marginal shear fractures of the distal radius) represent a fracture-dislocation of the radiocarpal joint. The radiocarpal ligaments remain attached to the volar fragment, causing the carpus to subluxate volarly. Nonoperative management or isolated external fixation often fails to maintain reduction due to shear forces. The most appropriate management is open reduction via a volar approach and application of a volar buttress plate.

Question 77

A 45-year-old man falls from a ladder and sustains an elbow dislocation. After closed reduction in the emergency department, radiographs are obtained as shown in the provided figure.

A subsequent CT scan confirms a type II coronoid fracture and a comminuted radial head fracture. During surgical intervention, what is the most appropriate sequence of repair to restore elbow stability?

Explanation

This patient has a terrible triad injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). The standard surgical sequence for restoring stability involves deep to superficial and medial to lateral (if approached laterally). The accepted sequence is: 1) Coronoid fixation or anterior capsule repair, 2) Radial head replacement or fixation, 3) Lateral ulnar collateral ligament (LUCL) repair. If the elbow remains unstable after these steps, the medial collateral ligament (MCL) is repaired or a hinged external fixator is applied.

Question 78

A 72-year-old woman sustains a shoulder injury after a mechanical fall.

Assuming this is a severely comminuted 4-part proximal humerus fracture with varus impaction and severe osteoporosis, which of the following is the strongest predictor of postoperative complications if treated with open reduction and internal fixation (ORIF) utilizing a locked plate?

Explanation

In the surgical treatment of proximal humerus fractures using locking plates, restoration or presence of medial calcar support is critical to prevent varus collapse and secondary screw cutout. Loss of medial support leads to significantly higher failure rates. Other risk factors for failure include initial severe varus angulation, poor bone quality, and inadequate superior screw placement into the humeral head.

Question 79

A 28-year-old laborer presents with progressive dorsal radial wrist pain 3 years after a fall. He did not seek medical attention initially. Radiographs and an MRI confirm a scaphoid waist nonunion with radioscaphoid arthritis and capitolunate arthritis, but the radiolunate joint is preserved.

What is the most appropriate surgical treatment?

Explanation

The clinical scenario describes Scaphoid Nonunion Advanced Collapse (SNAC) stage III, which involves arthritis of the radioscaphoid and capitolunate joints with a preserved radiolunate joint. Proximal row carpectomy (PRC) is contraindicated when there is significant arthritis of the capitate head (capitolunate joint). Therefore, the most appropriate salvage procedure is scaphoid excision and four-corner (capitate, lunate, hamate, triquetrum) arthrodesis, which relies on the preserved radiolunate articulation to maintain functional wrist motion.

Question 80

A 55-year-old male complains of numbness and tingling in his small and ring fingers that awakens him at night. Examination shows a positive Tinel's sign at the elbow and a positive Froment's sign. He has clinically palpable snapping over the medial epicondyle during elbow flexion. Electrodiagnostic studies confirm severe ulnar neuropathy at the elbow. He fails a 6-month trial of conservative management.

What is the primary indication for choosing an anterior transposition of the ulnar nerve over an in situ decompression in this patient?

Explanation

Randomized controlled trials have generally shown no significant difference in clinical outcomes between simple in situ decompression and anterior transposition for the treatment of primary cubital tunnel syndrome. However, anterior transposition is specifically indicated in patients with a subluxating ulnar nerve, a valgus deformity of the elbow, or post-traumatic stiffness requiring a tension-free route. In this patient, the palpable snapping over the medial epicondyle indicates nerve subluxation, dictating an anterior transposition to prevent ongoing mechanical irritation.

Question 81

A 22-year-old elite collegiate baseball pitcher presents with vague posterior shoulder pain during the late cocking and early acceleration phases of throwing.

Physical examination reveals a loss of 25 degrees of internal rotation in the throwing arm compared to the contralateral side. He has a positive apprehension test that is relieved by a relocation maneuver. What is the most likely underlying pathophysiology of his pain?

Explanation

The athlete presents with Glenohumeral Internal Rotation Deficit (GIRD) and signs of internal impingement. Repetitive throwing leads to contracture of the posterior capsule and the posterior band of the inferior glenohumeral ligament (IGHL). This results in a posterosuperior shift of the glenohumeral contact point during maximum external rotation and abduction (late cocking phase), causing impingement of the undersurface of the rotator cuff and superior labrum between the greater tuberosity and the posterosuperior glenoid.

Question 82

A 35-year-old mechanic presents with chronic, progressive dorsal wrist pain and decreased grip strength.

Imaging demonstrates sclerosis and fragmentation of the lunate with negative ulnar variance, but no fixed carpal collapse (Lichtman Stage IIIA). What is the most appropriate initial surgical intervention?

Explanation

The presentation is classic for Kienböck's disease (avascular necrosis of the lunate). For Lichtman Stage II or IIIA (fragmentation without fixed scaphoid rotation or carpal collapse) associated with negative ulnar variance, joint-leveling procedures are the treatment of choice. A radial shortening osteotomy unloads the lunate by shifting compressive forces to the ulnocarpal articulation, potentially halting disease progression in the early stages.

Question 83

A 75-year-old woman with long-standing rheumatoid arthritis presents with debilitating right shoulder pain and an inability to lift her arm above 60 degrees.

Radiographs show severe glenohumeral osteoarthritis with massive superior migration of the humeral head, articulating with the acromion. She has an intact deltoid muscle but a massive, irreparable rotator cuff tear. What is the most appropriate definitive management?

Explanation

The patient has severe rotator cuff tear arthropathy (Hamada stage III/IV) with pseudoparalysis and an intact deltoid. Reverse total shoulder arthroplasty (RTSA) is the gold standard for this condition. It medializes and distalizes the center of rotation, increasing the lever arm of the deltoid, thereby allowing it to substitute for the deficient rotator cuff and restore forward elevation. Anatomic total shoulder arthroplasty is contraindicated because eccentric superior loading by the uncontained humeral head would lead to early glenoid component loosening (rocking horse phenomenon).

Question 84

A 29-year-old male cyclist falls directly onto his left shoulder. He presents with severe pain and a prominent distal clavicle.

Radiographs demonstrate a 150% superior displacement of the distal clavicle relative to the acromion, with the clavicle visibly protruding and tenting the trapezius fascia on clinical exam. What is the diagnosis and recommended treatment?

Explanation

The scenario describes a Type V acromioclavicular (AC) joint injury, characterized by 100-300% superior displacement of the clavicle, severe disruption of the coracoclavicular (CC) ligaments, and stripping of the deltotrapezial fascia. Type IV injuries involve posterior displacement into the trapezius muscle. Due to the profound biomechanical dysfunction and marked clinical deformity with soft-tissue compromise, Type V injuries generally require surgical intervention for CC ligament reconstruction and joint reduction.

Question 85

A 6-year-old boy falls from the monkey bars and presents with a swollen, painful forearm.

Radiographs reveal a plastic deformation and fracture of the proximal ulnar shaft accompanied by an anterior dislocation of the radial head. Which of the following nerves is at greatest risk of injury with this specific fracture pattern?

Explanation

The patient has sustained a Bado Type I Monteggia fracture-dislocation (anterior dislocation of the radial head with an anteriorly angulated fracture or plastic deformation of the ulnar diaphysis). The posterior interosseous nerve (PIN), a deep motor branch of the radial nerve, wraps around the radial neck and is tethered by the arcade of Frohse. It is uniquely susceptible to stretch, compression, or contusion injuries from the anteriorly displaced radial head in this specific fracture configuration.

Question 86

A 72-year-old woman presents 3 years after a reverse total shoulder arthroplasty with progressive shoulder pain. Radiographs are shown in Figure 1. What factor most contributes to the complication seen (scapular notching)?

Explanation

Scapular notching is a frequent complication of reverse total shoulder arthroplasty (RTSA), particularly with Grammont-style prostheses. Risk factors include superior tilt of the baseplate, high placement on the glenoid, and a medialized center of rotation. In contrast, inferior tilt, lateralization, and the use of a larger glenosphere can reduce the incidence of notching by increasing the distance between the humerus and the scapular neck during adduction.

Question 87

A 45-year-old man falls onto his outstretched hand and sustains the injury shown in Figure 2. Which of the following is the most appropriate surgical sequence for managing this injury?

Explanation

The patient has sustained a terrible triad injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). The standard surgical sequence generally progresses from deep to superficial: fixing the coronoid first (or placing the suture lasso), followed by the radial head (fixation or arthroplasty), then the lateral collateral ligament (LCL) repair. The medial collateral ligament (MCL) is only repaired if the elbow remains unstable in extension after the lateral side and bony structures have been addressed.

Question 88

A 65-year-old woman sustains a distal radius fracture. The lateral radiograph (Figure 3) demonstrates a volarly displaced fracture fragment of the lunate facet ("volar teardrop"). Failure to adequately stabilize this specific fragment is most likely to result in which of the following complications?

Explanation

The volar lunate facet fragment ("volar teardrop") is a critical stabilizing structure of the radiocarpal joint because the short radiolunate ligament originates from this fragment. Failure to capture and stabilize this fragment (often requiring fragment-specific fixation if standard volar plates do not securely capture it) can lead to volar subluxation of the carpus.

Question 89

A 24-year-old man sustains a scaphoid waist fracture. The vascular supply to the proximal pole of the scaphoid relies primarily on retrograde flow from vessels entering which aspect of the bone?

Explanation

The scaphoid receives its primary blood supply from branches of the radial artery. The major blood supply enters via the dorsal ridge (accounting for 70-80% of the intraosseous vascularity) and supplies the proximal pole in a retrograde fashion. A secondary volar supply enters the distal tubercle. Because of this retrograde blood supply, proximal pole fractures have a notoriously high rate of avascular necrosis and nonunion.

Question 90

A 22-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft. To minimize the risk of postoperative ulnar neuropathy, which of the following techniques or principles is recommended during the surgical approach?

Explanation

A muscle-splitting approach through the flexor carpi ulnaris (FCU) provides excellent exposure to the sublime tubercle and the native UCL while minimizing trauma to the ulnar nerve. Routine transposition of the ulnar nerve is not recommended unless there are preoperative ulnar nerve symptoms or the nerve subluxates during surgery, as transposition can paradoxically increase the risk of postoperative ulnar neuropathy.

Question 91

A 28-year-old professional volleyball player complains of vague posterior shoulder pain and weakness with external rotation. An MRI (Figure 4) demonstrates a paralabral cyst in the spinoglenoid notch. Which of the following physical examination findings is most likely present?

Explanation

A cyst at the spinoglenoid notch compresses the suprascapular nerve distal to the motor branches supplying the supraspinatus. Consequently, it causes isolated denervation of the infraspinatus muscle, leading to isolated weakness in external rotation and infraspinatus atrophy. Entrapment at the suprascapular notch (more proximally) would affect both the supraspinatus and infraspinatus.

Question 92

A 60-year-old man undergoes arthroscopic rotator cuff repair. A Popeye deformity is a known potential outcome of biceps tenotomy. Compared to arthroscopic biceps tenodesis, which of the following is true regarding biceps tenotomy?

Explanation

Biceps tenotomy and tenodesis both provide excellent pain relief for pathology of the long head of the biceps. Tenotomy is associated with a higher incidence of the 'Popeye' deformity and subjective cramping pain in the biceps muscle belly compared to tenodesis. However, there are no significant differences in functional outcome scores, overall patient satisfaction, elbow flexion, supination strength, or rotator cuff healing rates.

Question 93

A 78-year-old woman with severe rheumatoid arthritis presents with a comminuted, intra-articular distal humerus fracture. Due to the severe osteopenia and joint destruction, she undergoes a total elbow arthroplasty (TEA). Which of the following is a recognized absolute contraindication for TEA in the setting of trauma?

Explanation

Active local or systemic infection is an absolute contraindication to total joint arthroplasty, including total elbow arthroplasty (TEA). A lifetime lifting restriction (usually 5-10 lbs) is a relative contraindication if the patient is expected to be non-compliant. Severe RA and older age are standard indications for TEA in complex distal humerus fractures, particularly when the columns are non-reconstructable.

Question 94

A 13-year-old elite baseball pitcher presents with a 4-week history of gradual-onset shoulder pain during the cocking and early acceleration phases of pitching. Radiographs (Figure 5) reveal widening and irregularity of the proximal humeral physis. What is the most appropriate initial management for this patient?

Explanation

The patient has 'Little League Shoulder' (proximal humeral epiphysiolysis), a stress injury to the proximal humeral physis caused by repetitive rotational torque during throwing. The standard treatment is complete cessation of throwing (rest), usually for 3 months or until symptoms resolve and radiographic healing is evident. This is followed by a structured physical therapy and progressive return-to-throwing program. Surgery is not indicated.

Question 95

A 29-year-old competitive weightlifter feels a 'pop' in his anterior axilla while performing a heavy bench press. Examination reveals bruising over the anterior arm and axilla, and weakness with adduction and internal rotation. He is diagnosed with a pectoralis major rupture. Which portion of the pectoralis major tendon is under the greatest tension during the eccentric phase of the bench press, making it most susceptible to injury?

Explanation

The pectoralis major tendon twists 180 degrees before inserting on the humerus. The inferior fibers (sternocostal head) insert most proximally on the humerus, while the superior fibers (clavicular head) insert distally. During the eccentric phase of a bench press (arm extended, abducted, and externally rotated), the inferior fibers are stretched disproportionately and are under the greatest tension, making them the most frequently ruptured portion.

Question 96

A 35-year-old manual laborer presents with chronic radial-sided wrist pain that is exacerbated by heavy lifting. He reports a history of falling onto an outstretched hand 2 years ago, for which he did not seek medical attention. Radiographs reveal a scaphoid nonunion with advanced degenerative changes at both the radioscaphoid and capitolunate joints. The radiolunate joint space is well preserved. What is the most appropriate surgical management for this patient?

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III, which is characterized by arthritic changes extending to the capitolunate joint, while sparing the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in SNAC Stage III because successful PRC requires a pristine capitate head to articulate with the lunate fossa of the radius. Therefore, scaphoid excision and four-corner (capitate, lunate, hamate, triquetrum) arthrodesis is the most appropriate management. Radial styloidectomy is reserved for SNAC Stage I, and total wrist arthrodesis is indicated for SNAC Stage IV (pancarpal arthritis).

Question 97

A 42-year-old woman sustains a highly unstable elbow injury after falling from a height. Radiographs demonstrate a posterolateral elbow dislocation associated with a comminuted radial head fracture and a type II coronoid fracture. Operative intervention is undertaken. After securely fixing the coronoid fracture and replacing the radial head with an arthroplasty component, the elbow remains unstable when brought into extension. What is the next most appropriate step in the surgical management?

Explanation

The patient has sustained a 'terrible triad' injury of the elbow. The standard, reliable surgical algorithm for this injury addresses structures from deep to superficial. The typical sequence is: 1) fixation of the coronoid fracture, 2) fixation or replacement of the radial head, and 3) repair of the lateral collateral ligament (LCL) complex, specifically the lateral ulnar collateral ligament (LUCL). If the elbow remains persistently unstable or subluxated in extension after these three steps are completed, then repair of the medial collateral ligament (MCL) or application of a hinged external fixator is indicated. In this scenario, the LUCL has not yet been addressed, making it the definitive next step.

Question 98

A 28-year-old elite volleyball player complains of vague, deep-seated posterior shoulder pain and weakness with overhead activities. Examination demonstrates marked atrophy of the infraspinatus fossa but normal bulk and tone of the supraspinatus. Significant weakness is noted in external rotation with the arm at the side, but abduction strength is symmetrically intact. MRI of the shoulder reveals a paralabral cyst. Based on the physical examination, where is the cyst most likely located?

Explanation

The clinical presentation is classic for suprascapular nerve entrapment at the spinoglenoid notch. The suprascapular nerve provides motor innervation to the supraspinatus and then passes through the spinoglenoid notch to innervate the infraspinatus. Compression at the suprascapular notch (proximal) would result in atrophy and weakness of both the supraspinatus and infraspinatus. Compression at the spinoglenoid notch (distal) affects only the infraspinatus, presenting as isolated external rotation weakness and isolated infraspinatus atrophy. Paralabral cysts in this location are frequently associated with posterior or SLAP labral tears.

Question 99

A 45-year-old mechanic presents with a 6-month history of numbness and tingling in his ring and small fingers, which worsens when he keeps his elbow flexed during telephone calls. Examination shows a strongly positive Tinel's sign over the posteromedial elbow and a positive Froment's sign. Electromyography confirms severe ulnar neuropathy isolated to the elbow. During a surgical ulnar nerve release, the primary site of compression is identified between the humeral and ulnar heads of the flexor carpi ulnaris (FCU). What anatomical structure forms the roof of this specific compression site?

Explanation

The ulnar nerve can be compressed at several distinct sites around the elbow, most commonly at the cubital tunnel. The cubital tunnel itself is bordered by the medial epicondyle anteriorly, the olecranon laterally, and the two heads of the flexor carpi ulnaris (FCU) distally. The roof of the tunnel, which connects the humeral and ulnar heads of the FCU, is formed by Osborne's ligament (or Osborne's fascia). The Arcade of Struthers is a fascial band proximal to the medial epicondyle. The Ligament of Struthers and the Lacertus fibrosus are associated with median nerve compression.

Question 100

A 72-year-old woman undergoes a reverse total shoulder arthroplasty (RTSA) for severe rotator cuff tear arthropathy. The design of the prosthesis fundamentally alters the biomechanics of the glenohumeral joint to compensate for the absent rotator cuff. According to the original Grammont design principles, how is the center of rotation (COR) of the glenohumeral joint altered compared to the native anatomic state?

Explanation

The Grammont design for reverse total shoulder arthroplasty relies on moving the center of rotation (COR) medially and inferiorly. Medializing the COR decreases the torque at the glenoid component-bone interface, reducing the risk of baseplate failure, and increases the number of deltoid fibers recruited for elevation. Inferiorizing the COR properly tensions the deltoid muscle, thereby increasing its resting tone and mechanical advantage, allowing the deltoid to effectively elevate the arm in the absence of a functioning supraspinatus.

General Orthopedics 2026 Practice Questions: Set 13 (Solved)

Orthopedic Upper Extremity 2026 MCQs: Board Review Questions & Answers (Part 4)

Key Takeaway

Orthopedic Upper Extremity 2026 MCQs: Board Review Questions & Answers (Part 4)

Chapter Index