A patient with a transverse femur fracture undergoes statically locked antegrade intramedullary nailing. Postoperatively, the patient appears to have a

Defend the case because despite there being an error, the error was corrected and there were little or no damages compared with expected outcomes.

Which of the following findings is most prognostic for the ability of a young child with cerebral palsy to walk? Review Topic

Ability to sit independently by age 2 years

Figure 30 shows the radiograph of a 38-year-old man who reports persistent pain laterally and plantarly about the fifth metatarsal head. Examination reveals calluses dorsolaterally and plantarly about the fifth metatarsal head. Nonsurgical management

oblique mid-diaphyseal osteotomy of the fifth metatarsal.

Examination of a 7-year-old girl with myelomeningocele reveals calcaneal deformities of both feet. She ambulates on both extremities wearing ankle-foot orthoses and has no upper extremity aids. She has grade 5/5 motor strength to the tibialis anterio

transfer of the anterior tibial tendon to the calcaneus.

Figures 39a through 39c show a clinical photograph and the radiographs of a 32-year-old woman who has been unable to actively extend her dominant ring and small finger for the past two weeks. She has no history of trauma and has minimal pain. Examina

Darrach distal ulna resection, dorsal tenosynosynovectomy, and tendon transfers

A 4-year-old child sustains a spiral fracture to the tibia in an unwitnessed fall. History reveals three other fractures to long bones, and the parents are vague about the etiology of each. There is no family history of bone disease. The parents ask

notification of child protective services and hospital admission.

Shoulder and Elbow Review: MCQ Quiz by Dr. Hutaif

Shoulder And Elbow: Review | Dr Hutaif Shoulder & Elbow -...

Comprehensive 100-Question Exam

00:00

Start Quiz

Question 1

A 72-year-old female undergoes a reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy. By what biomechanical mechanism does RTSA primarily restore active forward elevation in a patient with a massive, irreparable rotator cuff tear?

Explanation

Reverse total shoulder arthroplasty (RTSA), based on Grammont's principles, medializes and distalizes the center of rotation of the glenohumeral joint. This biomechanical alteration increases the moment arm of the deltoid muscle, specifically tensioning the anterior and middle fibers, thereby allowing the deltoid to effectively substitute for the deficient rotator cuff to provide active forward elevation.

Question 2

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture), what is the most widely accepted sequence of reconstruction from a standard lateral approach to optimize joint stability?

Explanation

The standard surgical protocol for a terrible triad injury addresses structures from deep to superficial through a lateral approach. The correct sequence is: (1) Fixation of the coronoid fracture or repair of the anterior capsule (often facilitated through the defect left by the displaced radial head); (2) Fixation or replacement of the radial head; and (3) Repair of the lateral ulnar collateral ligament (LUCL/LCL complex) back to the lateral epicondyle.

Question 3

A 45-year-old manual laborer undergoes surgical repair of a distal biceps tendon rupture using a single-incision anterior approach. Postoperatively, he reports numbness along the lateral aspect of his forearm. Which nerve is most likely injured, and what is the typical path of this nerve relative to the biceps tendon?

Explanation

The lateral antebrachial cutaneous nerve (LABC), which is the terminal sensory branch of the musculocutaneous nerve, is the most commonly injured structure during a single-incision anterior approach for distal biceps repair. It emerges from between the biceps and brachialis muscles and courses just lateral to the distal biceps tendon. Forceful lateral retraction easily neuropraxias or transects this nerve, resulting in lateral forearm numbness.

Question 4

A 35-year-old male presents with recurrent lateral elbow pain and a sensation of clicking when pushing himself up from a chair. Physical examination reveals a positive lateral pivot-shift test. This condition is primarily due to insufficiency of which structure, and where does this structure insert?

Explanation

The patient is presenting with posterolateral rotatory instability (PLRI) of the elbow. The primary restraint to PLRI is the lateral ulnar collateral ligament (LUCL). The LUCL originates on the lateral epicondyle and inserts on the supinator crest of the proximal ulna.

Question 5

According to Hertel's criteria, which combination of radiographic findings in an acute proximal humerus fracture yields the highest positive predictive value for the development of avascular necrosis (AVN) of the humeral head?

Explanation

Hertel et al. described reliable predictors for humeral head ischemia. The highest positive predictive value for AVN occurs when there is an anatomic neck fracture (disrupting intraosseous blood supply), a short metaphyseal head extension (calcar segment <8 mm), and disruption of the medial hinge (>2 mm displacement), which compromises the ascending branch of the anterior humeral circumflex artery.

Question 6

A 22-year-old rugby player has recurrent anterior shoulder instability. CT evaluation reveals anterior glenoid bone loss. The glenoid width measures 30 mm, and the anterior defect measures 6 mm. According to the glenoid track concept, what is the calculated width of this patient's glenoid track?

Explanation

The width of the glenoid track is calculated as 83% of the inferior glenoid diameter (D), minus the width of the anterior bone defect (d). Formula: Glenoid track = (0.83 * D) - d. Given D = 30 mm and d = 6 mm. First, 0.83 * 30 = 24.9 mm. Then, 24.9 - 6 = 18.9 mm. The glenoid track width is 18.9 mm.

Question 7

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

Explanation

The musculocutaneous nerve typically enters the coracobrachialis muscle approximately 5 to 8 cm distal to the tip of the coracoid process (though this can be variable). Medial and aggressive retraction of the conjoined tendon during the Latarjet procedure places significant traction on this nerve, making it the most vulnerable structure during this specific step of the operation.

Question 8

A 28-year-old weightlifter feels a 'pop' in his anterior chest wall while performing a bench press. MRI confirms a complete tear of the pectoralis major tendon at its insertion. Regarding the normal anatomy of the pectoralis major insertion, which of the following statements is true?

Explanation

The pectoralis major tendon undergoes a 180-degree twist before inserting onto the lateral lip of the bicipital groove. Because of this twist, the lower fibers of the muscle (sternal/abdominal head) become the posterior lamina and insert highest (most proximal) and deep. The upper fibers (clavicular head) form the anterior lamina and insert more inferiorly (distal) and superficial.

Question 9

A 31-year-old elite volleyball player presents with insidious onset of posterior shoulder pain and weakness. Physical examination demonstrates normal external rotation strength in adduction, but profound weakness in external rotation with the arm abducted. Muscle atrophy is noted exclusively in the infraspinatus fossa. Where is the most likely location of a paralabral cyst in this patient?

Explanation

Isolated atrophy and weakness of the infraspinatus indicate compression of the suprascapular nerve at the spinoglenoid notch. At this level, the nerve has already given off its motor branches to the supraspinatus (which occurs more proximally at the suprascapular notch). Spinoglenoid cysts are highly associated with posterior SLAP tears.

Question 10

A 40-year-old male presents with cubital tunnel syndrome. During surgical decompression, the surgeon explores potential sites of ulnar nerve compression. Which of the following anatomic structures is located approximately 8 cm proximal to the medial epicondyle?

Explanation

The Arcade of Struthers is a fascial band extending from the medial head of the triceps to the medial intermuscular septum, located approximately 8 cm proximal to the medial epicondyle. It is a known potential site of ulnar nerve compression, especially if the nerve is transposed anteriorly without adequate proximal release. Osborne's ligament is at the level of the epicondyle (spanning the two heads of FCU).

Question 11

A 26-year-old cyclist falls directly onto his shoulder and sustains a distal clavicle fracture. Radiographs show a fracture line situated between the coracoclavicular ligaments. The proximal fragment is displaced superiorly. Surgical exploration reveals the conoid ligament is torn from the proximal fragment, but the trapezoid ligament remains intact and attached to the distal fragment. How is this fracture classified according to the Neer classification?

Explanation

Neer Type II distal clavicle fractures are unstable due to loss of the coracoclavicular (CC) ligamentous restraint to the proximal fragment. Type IIA fractures occur medial to the CC ligaments (ligaments remain attached to the distal fragment). Type IIB fractures occur between the CC ligaments; the conoid ligament is ruptured, allowing the proximal fragment to displace superiorly, while the trapezoid remains intact on the distal fragment.

Question 12

When planning a total elbow arthroplasty (TEA) for a patient with advanced rheumatoid arthritis, the surgeon considers whether to use a linked (semi-constrained) or unlinked implant. What is an absolute prerequisite for using an unlinked TEA design?

Explanation

Unlinked (unconstrained) total elbow arthroplasty relies heavily on the patient's native soft tissues for stability. Therefore, competent medial and lateral collateral ligaments, as well as an intact anterior capsule, are an absolute prerequisite to prevent dislocation. Linked (semi-constrained) implants are used when ligaments are incompetent, or in cases of severe bone loss and trauma.

Question 13

A 65-year-old man presents with pseudoparalysis of the shoulder, an inability to actively externally rotate, and a positive hornblower's sign. Imaging reveals a massive, retracted, irreducible tear of the supraspinatus, infraspinatus, and teres minor. The subscapularis is fully intact. He wishes to undergo a tendon transfer. Which of the following tendon transfers is most appropriate for restoring his external rotation and forward elevation?

Explanation

Latissimus dorsi or lower trapezius tendon transfers are the preferred surgical options for younger, active patients with massive, irreparable posterosuperior rotator cuff tears (supraspinatus and infraspinatus/teres minor) who have an intact subscapularis. An intact subscapularis is a vital prerequisite for a successful latissimus dorsi transfer to provide an anterior counterforce (force couple) for overhead function. Pectoralis major transfers are used for irreparable subscapularis tears.

Question 14

During the physical examination of a patient with a suspected rotator cuff tear, you wish to isolate the function of the inferior (lower) portion of the subscapularis muscle. Which of the following provocative tests is most specific for assessing the lower subscapularis?

Explanation

The subscapularis has distinct functional zones. The superior portion is primarily tested by the belly-press and bear-hug tests. The lift-off test (Gerber's test) requires internal rotation behind the back, which biomechanically isolates the inferior (lower) portion of the subscapularis. An inability to lift the hand off the lumbar spine indicates a tear involving the lower subscapularis.

Question 15

A 24-year-old professional baseball pitcher complains of right shoulder pain during the late cocking phase of throwing. He exhibits a significant Glenohumeral Internal Rotation Deficit (GIRD). If diagnostic arthroscopy is performed for suspected internal impingement, what is the most characteristic pattern of pathology observed?

Explanation

Internal impingement in overhead throwing athletes occurs during the late cocking phase (abduction and maximum external rotation). In this position, the articular surface of the posterosuperior rotator cuff (supraspinatus/infraspinatus interval) abuts against the posterosuperior glenoid labrum. This pathologic contact leads to 'kissing lesions': articular-sided cuff tears and posterosuperior labral tears.

Question 16

According to the O'Driscoll classification of coronoid fractures, an anteromedial facet fracture is highly associated with varus posteromedial rotatory instability. What is the classic mechanism of injury that produces this specific fracture pattern?

Explanation

Anteromedial facet fractures of the coronoid are the hallmark of varus posteromedial rotatory instability of the elbow. The mechanism of injury is a varus stress combined with an axial load. As the elbow subluxates posteromedially, the anteromedial facet of the coronoid shears off against the medial trochlea, and the lateral collateral ligament (LCL) complex typically tears.

Question 17

Six weeks after undergoing an uncomplicated anatomic total shoulder arthroplasty (TSA) through a standard deltopectoral approach, a 68-year-old female experiences a sudden 'pop' while pushing open a heavy door. She now presents with increased passive external rotation compared to her uninjured side, weakness in internal rotation, and anterior shoulder pain. What is the most likely complication?

Explanation

Failure of the subscapularis repair is a well-known and devastating complication following anatomic total shoulder arthroplasty utilizing a deltopectoral approach. It classically presents in the early postoperative period with anterior pain, weakness in internal rotation (positive belly-press/lift-off), and noticeably increased passive external rotation due to the loss of the anterior soft-tissue restraint.

Question 18

A 42-year-old female falls onto an outstretched hand and sustains a distal humerus fracture. CT imaging reveals a coronal shear fracture that involves the capitellum and extends medially to include the majority of the trochlea, maintaining them as a single continuous osteochondral fragment. According to the McKee modification of the Bryan and Morrey classification, what type of fracture is this?

Explanation

In the Bryan and Morrey classification of capitellum fractures, Type I is a large osseous piece of the capitellum (Hahn-Steinthal), Type II is an articular cartilage shear with minimal bone (Kocher-Lorenz), and Type III is comminuted. McKee introduced the Type IV fracture, which is a coronal shear fracture that extends medially to include the capitellum and the lateral ridge/bulk of the trochlea as a single fragment.

Question 19

A 38-year-old female presents to the clinic with shoulder pain and visible shoulder asymmetry 3 months after a cervical lymph node biopsy. On physical examination, her affected shoulder droops, she has an inability to actively abduct the arm past 90 degrees, and there is prominent lateral winging of the scapula. Which nerve was most likely injured?

Explanation

Injury to the spinal accessory nerve (CN XI) denervates the trapezius muscle, leading to a drooping shoulder, weakness in forward elevation/abduction, and lateral winging of the scapula (the scapula is translated laterally and rotated downward). This classically occurs after posterior triangle neck surgeries (like lymph node biopsies). Conversely, medial winging is caused by serratus anterior paralysis (long thoracic nerve).

Question 20

A surgeon plans to perform tension band wiring for a displaced, transverse olecranon fracture. Biomechanically, for the tension band principle to function successfully and convert tensile distraction forces into articular compression during active elbow flexion, which of the following prerequisites MUST be met?

Explanation

The tension band principle relies on placing a device (like a wire loop) on the tension side of a bone (the posterior cortex of the olecranon). As the elbow flexes, the triceps pulls on the proximal fragment, and the tension band converts this distracting tensile force into compressive forces at the opposite (articular) side. This biomechanical conversion absolutely requires an intact or anatomically reduced opposing cortex (the anterior articular surface) to act as a solid buttress for compression. If the anterior cortex is comminuted or absent, tension band wiring will fail and the fracture will collapse.

Question 21

In the surgical evaluation for a Superior Capsular Reconstruction (SCR) in a patient with a massive, irreparable posterosuperior rotator cuff tear, which of the following preoperative findings is considered an absolute contraindication to the procedure?

Explanation

Superior Capsular Reconstruction (SCR) is indicated for massive, irreparable posterosuperior rotator cuff tears in patients without advanced arthritis. Advanced glenohumeral osteoarthritis (Hamada grade 4 or 5) is an absolute contraindication to SCR; these patients are better served with a reverse total shoulder arthroplasty (rTSA). An intact subscapularis is actually preferred for SCR success.

Question 22

A 72-year-old female presents with sudden onset of superior shoulder pain 4 months after a reverse total shoulder arthroplasty (rTSA). Radiographs reveal a Levy type II acromial stress fracture (involving the base of the acromion posterior to the acromioclavicular joint). What is the most appropriate initial management?

Explanation

Acromial stress fractures after rTSA are a known complication due to the increased tension placed on the deltoid and acromion (increased mechanical advantage). The vast majority of Levy type I and II fractures are initially managed nonoperatively with sling immobilization and activity modification for 4-6 weeks. Surgery is reserved for severely displaced fractures or nonunions that fail conservative management.

Question 23

A 35-year-old female presents with shoulder weakness and a cosmetic deformity following a cervical lymph node biopsy. Physical examination demonstrates lateral winging of the scapula that worsens with shoulder abduction. If conservative management fails, which of the following surgical procedures is most appropriate?

Explanation

Lateral scapular winging following a posterior triangle neck biopsy is classically due to iatrogenic injury to the spinal accessory nerve, resulting in trapezius palsy. The Eden-Lange procedure (transfer of the levator scapulae, rhomboid major, and rhomboid minor to the lateral scapula) is the standard surgical reconstruction for chronic, symptomatic trapezius palsy.

Question 24

Which of the following physical examination findings is the pathognomonic hallmark of posterolateral rotatory instability (PLRI) of the elbow?

Explanation

PLRI is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). The lateral pivot-shift test of the elbow reproduces the instability: as the supinated forearm is axially loaded and extended from a flexed position while applying a valgus force, the radial head subluxates posteriorly. Upon further flexion, the radial head reduces with a palpable clunk.

Question 25

A 22-year-old collegiate baseball pitcher undergoes Ulnar Collateral Ligament (UCL) reconstruction. The surgeon opts for the 'docking technique' rather than the classic modified Jobe figure-of-eight technique. What is the primary biomechanical and anatomical advantage of the docking technique?

Explanation

The docking technique utilizes a single socket in the medial epicondyle into which the two ends of the graft are 'docked' and tied over a bone bridge via smaller exit punctures. This significantly decreases the number of large converging tunnels in the medial epicondyle compared to the traditional Jobe figure-of-eight technique, thereby reducing the risk of iatrogenic medial epicondyle fracture.

Question 26

When comparing the single-incision anterior approach to the two-incision (Boyd-Anderson) approach for distal biceps tendon repair, the two-incision approach is historically associated with a higher risk of which of the following complications?

Explanation

The classic two-incision approach (developed to avoid radial nerve injury seen in extensive single anterior incisions) carries a higher risk of heterotopic ossification and proximal radioulnar synostosis, especially if the interosseous membrane is breached or if bone debris is left in the plane between the radius and ulna. Single-incision techniques have a higher risk of LABCN injury.

Question 27

A 40-year-old male develops severe elbow stiffness secondary to heterotopic ossification (HO) following a terrible triad injury. When planning surgical excision of the HO to restore motion, what is the most reliable clinical and radiographic indicator that the ectopic bone is mature enough for safe resection?

Explanation

Historically, alkaline phosphatase and bone scans were used to determine HO maturity, but these have been shown to be unreliable. The current gold standard for timing surgical excision is clinical (cessation of progressive stiffness) and radiographic (appearance of sharp, distinct trabecular margins indicating mature bone on plain radiographs).

Question 28

A 28-year-old male sustains a direct blow to the anterior shoulder and is diagnosed with an Ogawa Type I coracoid process fracture. According to this classification, an Ogawa Type I fracture involves a fracture line located:

Explanation

The Ogawa classification divides coracoid fractures based on their relationship to the coracoclavicular (CC) ligaments. Type I fractures occur proximal to the CC ligaments (meaning the CC ligaments remain attached to the distal fragment). Type II fractures occur distal to the CC ligaments.

Question 29

During a Latarjet procedure, the coracoid bone block is secured to the anterior glenoid neck with two screws. If the screws are directed too far medially (e.g., greater than 15 degrees medial to the glenoid articular surface), which neurologic structure is at the greatest risk of iatrogenic injury from the prominent screw tips posteriorly?

Explanation

Screws directed excessively medial during a Latarjet procedure can breach the posterior glenoid neck and enter the spinoglenoid notch. The suprascapular nerve courses through this notch to innervate the infraspinatus and is at high risk of injury from prominent or misdirected hardware.

Question 30

In the Dubberley classification of coronal shear fractures of the capitellum and trochlea, what specific anatomic feature distinguishes a Type B fracture from a Type A fracture?

Explanation

The Dubberley classification defines Type 1 (capitellum +/- lateral trochlear ridge), Type 2 (capitellum and trochlea in one fragment), and Type 3 (capitellum and trochlea in separate fragments). The modifier A indicates no posterior comminution, whereas the modifier B indicates the presence of posterior condylar comminution, which alters surgical fixation strategy.

Question 31

A 32-year-old bodybuilder ruptures his pectoralis major tendon at its insertion during a heavy bench press. Which of the following accurately describes the anatomical orientation of the normal pectoralis major tendon at its insertion on the proximal humerus?

Explanation

The pectoralis major tendon consists of two main heads: clavicular and sternocostal. As the tendon courses laterally to insert on the lateral lip of the bicipital groove, it twists 180 degrees. The clavicular head inserts proximally and superficially, while the sternocostal head twists such that its most inferior fibers insert the most superiorly (proximally) and deep to the clavicular head.

Question 32

When evaluating a displaced proximal humerus fracture for the risk of avascular necrosis (AVN) of the humeral head, which of the following criteria described by Hertel is considered a strong predictor of ischemia?

Explanation

Hertel described several criteria predicting ischemia (and thus AVN) of the humeral head after proximal humerus fractures. The strongest predictors include a metaphyseal head extension (calcar length) of less than 8 mm, disruption of the medial hinge (> 2 mm displacement), and an anatomic neck fracture line.

Question 33

A 20-year-old collegiate baseball pitcher presents with symptomatic Glenohumeral Internal Rotation Deficit (GIRD). Which of the following anatomic changes is considered the primary driver of GIRD in the overhead throwing athlete?

Explanation

In overhead throwing athletes, repetitive microtrauma during the deceleration phase of throwing leads to hypertrophy, thickening, and contracture of the posteroinferior capsule. This contracture shifts the glenohumeral contact point posterosuperiorly in maximum external rotation and is the primary soft-tissue driver of GIRD.

Question 34

A 45-year-old male presents with severe, unremitting right shoulder pain that awoke him from sleep. The acute pain subsided after two weeks, but he now has profound weakness in forward elevation and external rotation. If an MRI is obtained, what is the most likely finding?

Explanation

The clinical presentation is classic for Parsonage-Turner Syndrome (neuralgic amyotrophy / acute brachial neuritis). Following the acute painful phase, patients develop profound weakness. MRI typically reveals denervation edema (increased T2 signal) in the affected muscles (commonly supraspinatus, infraspinatus, or deltoid) with structurally intact rotator cuff tendons.

Question 35

A 35-year-old female undergoes surgical fixation for a 'terrible triad' injury of the elbow. Following standard principles of elbow reconstruction, what is the recommended sequential order of structural repair?

Explanation

The standard surgical algorithm for a terrible triad injury follows a 'deep to superficial' and 'medial to lateral' progression through a lateral approach. The sequence is: 1) Coronoid fracture fixation (often through the defect left by the fractured radial head), 2) Radial head repair or replacement, and 3) LCL complex repair to the lateral epicondyle.

Question 36

In the surgical management of anterior shoulder instability, a 'remplissage' procedure involves tenodesis of the infraspinatus tendon and posterior capsule into a humeral head defect. Which of the following is the most appropriate indication for performing a remplissage in conjunction with an arthroscopic Bankart repair?

Explanation

A remplissage is indicated to address an 'off-track' (engaging) Hill-Sachs lesion in the setting of subcritical glenoid bone loss. If critical glenoid bone loss (>20-25%) is present, a bony augmentation procedure (e.g., Latarjet) is required regardless of the Hill-Sachs lesion.

Question 37

A 42-year-old female presents with acute, excruciating right shoulder pain. Radiographs demonstrate a fluffy, ill-defined radiopacity at the supraspinatus insertion. According to the Uhthoff classification of calcific tendinitis, during which phase does the patient typically experience the most severe, acute pain?

Explanation

Calcific tendinitis progresses through three main stages: pre-calcific, calcific (which includes formative, resting, and resorptive phases), and post-calcific. The most severe, acute pain is typically experienced during the resorptive phase, when the calcific deposit becomes toothpaste-like, vascular channels invade, and macrophages mount an intense inflammatory response to resorb the calcium.

Question 38

When performing open reduction and internal fixation of a radial head fracture, the hardware must be placed within the 'safe zone' to prevent impingement on the proximal radioulnar joint (PRUJ) during forearm rotation. Which of the following accurately describes this safe zone?

Explanation

The safe zone of the radial head represents the non-articulating portion that does not impinge on the lesser sigmoid notch of the ulna during pronation and supination. It corresponds to an arc of approximately 90 to 110 degrees located laterally, directly opposite the radial tuberosity.

Question 39

Idiopathic adhesive capsulitis is characterized by an inflammatory, fibrotic process of the glenohumeral capsule. Molecular studies of the contracted capsular tissue most consistently demonstrate an upregulation of which of the following cytokines, driving the fibrotic cascade?

Explanation

The pathophysiology of adhesive capsulitis involves an initial inflammatory response followed by dense fibrosis. Molecular analysis of capsular biopsies from affected patients demonstrates high levels of cytokines driving fibroblast proliferation and extracellular matrix deposition, most notably Transforming growth factor-beta (TGF-beta), platelet-derived growth factor (PDGF), and basic fibroblast growth factor (bFGF).

Question 40

The biomechanical design of a standard Grammont-style reverse total shoulder arthroplasty (rTSA) optimizes the mechanical advantage of the deltoid muscle. Which of the following best describes the intentional shift in the center of rotation of the glenohumeral joint following a Grammont rTSA?

Explanation

The Grammont principles of reverse total shoulder arthroplasty include medializing and inferiorizing the center of rotation. Medialization increases the abductor moment arm of the deltoid (recruiting more anterior and posterior fibers) and decreases torque at the glenoid bone-implant interface. Inferiorization tensions the deltoid, restoring its resting length and optimizing function in the absence of a rotator cuff.

Question 41

A 24-year-old rugby player undergoes a Latarjet procedure. Postoperatively, he has weakness in elbow flexion and decreased sensation over the lateral forearm. Improper retractor placement under which of the following structures is the most likely cause of this complication?

Explanation

The musculocutaneous nerve typically enters the conjoint tendon (coracobrachialis) 3-8 cm distal to the coracoid tip. Retractors placed too medially, deeply, or forcefully under the conjoint tendon during the Latarjet procedure can cause neuropraxia of the musculocutaneous nerve, leading to biceps weakness and lateral antebrachial cutaneous nerve sensory deficits.

Question 42

In reverse total shoulder arthroplasty (RTSA), altering the center of rotation (COR) is critical for restoring forward elevation in the setting of rotator cuff arthropathy. Compared to the native anatomic shoulder, how is the COR modified in a classic Grammont-style RTSA?

Explanation

The Grammont-style RTSA moves the center of rotation medially and inferiorly. Medialization recruits more deltoid fibers (especially anterior and posterior) by increasing their moment arms, while inferiorization tensions the deltoid, improving its biomechanical efficiency for forward elevation without a functioning rotator cuff.

Question 43

A 40-year-old female sustains a terrible triad injury to her elbow. During surgical reconstruction, after fixing the coronoid fracture and replacing the irreparable radial head, the elbow remains unstable in extension and supination. What is the next most appropriate step in management?

Explanation

The standard surgical algorithm for a terrible triad injury of the elbow involves restoring the anterior buttress (coronoid), restoring the lateral column (radial head), and then repairing the lateral structures (LUCL). If the elbow remains unstable after LUCL repair, the MUCL may be explored/repaired or a hinged external fixator applied.

Question 44

A 62-year-old male laborer presents with profound weakness in shoulder external rotation and a positive Hornblower's sign. MRI reveals a massive, retracted, and irreparable tear of the supraspinatus, infraspinatus, and teres minor. The subscapularis is intact. Which of the following tendon transfers provides the most biomechanically advantageous line of pull to restore external rotation?

Explanation

For irreparable posterosuperior rotator cuff tears with profound external rotation weakness (infraspinatus/teres minor deficit), the lower trapezius transfer (often augmented with an Achilles tendon allograft) closely matches the physiological line of pull of the infraspinatus. This makes it biomechanically superior to the latissimus dorsi transfer, which has an inferior-to-superior vector.

Question 45

A 35-year-old female falls on an outstretched hand and sustains a coronal shear fracture of the distal humerus. CT scan demonstrates a fracture extending medially to involve the entire capitellum and the majority of the trochlea, with a separate fragment of the posterior trochlea. Based on the Bryan and Morrey classification (modified by McKee), what type of fracture is this?

Explanation

McKee modified the Bryan and Morrey classification of capitellum fractures by adding the Type 4 fracture. This is a coronal shear fracture involving the capitellum that extends medially to include most or all of the trochlea, creating a complete articular shear.

Question 46

A 28-year-old elite volleyball player complains of vague posterior shoulder pain and isolated weakness in external rotation. Forward elevation and internal rotation strength are normal. MRI reveals a paralabral cyst. Where is this cyst most likely located?

Explanation

A cyst at the spinoglenoid notch compresses the suprascapular nerve after it has already given off its motor branches to the supraspinatus, resulting in isolated denervation and weakness of the infraspinatus (manifesting as an external rotation deficit). Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 47

A 45-year-old male undergoes a distal biceps tendon repair utilizing a single-incision anterior approach with cortical button fixation. Two weeks postoperatively, he complains of numbness over the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?

Explanation

The lateral antebrachial cutaneous nerve (LABCN), the terminal sensory branch of the musculocutaneous nerve, is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. It runs between the biceps and brachialis and courses superficially in the lateral forearm.

Question 48

A 30-year-old male presents with recurrent elbow clicking, snapping, and a sense of giving way when pushing up from a chair. The lateral pivot-shift test of the elbow is positive. This condition is primarily caused by insufficiency of which of the following structures?

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily due to insufficiency of the lateral ulnar collateral ligament (LUCL). Patients classically report apprehension or subluxation when the elbow is subjected to an axial load, valgus stress, and supination (e.g., pushing off the armrests of a chair).

Question 49

A 19-year-old football player presents to the emergency department after a direct blow to the anteromedial clavicle. He complains of chest pain, difficulty swallowing (dysphagia), and a choking sensation. Clinical exam reveals a sunken appearance of the medial clavicle. What is the most appropriate next step in management?

Explanation

The patient has a posterior sternoclavicular dislocation, which is an orthopedic emergency due to the risk of compression to the trachea, esophagus, and great vessels. An urgent CT assesses the mediastinum. Reduction should be performed in the operating room with a cardiothoracic surgeon available in case of a catastrophic vascular tear during reduction.

Question 50

A 22-year-old collegiate baseball pitcher presents with vague shoulder pain and decreased throwing velocity. Physical examination reveals a 25-degree loss of glenohumeral internal rotation compared to the contralateral side, but total arc of motion is symmetric. What is the primary pathophysiologic cause of this internal rotation deficit?

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead athletes is classically caused by contracture and thickening of the posteroinferior capsule. This forces the humeral head posterosuperiorly during the late cocking phase, predisposing the athlete to internal impingement and SLAP tears. Sleeper stretches are the mainstay of initial treatment.

Question 51

A 30-year-old male bodybuilder feels a sudden 'pop' in his anterior axilla while performing heavy bench press exercises. Examination reveals ecchymosis, swelling, and loss of the normal anterior axillary fold. If surgical repair is pursued, understanding the anatomy of the pectoralis major footprint is critical. Which of the following statements regarding the sternal head insertion is accurate?

Explanation

At its humeral footprint, the pectoralis major tendon undergoes a 180-degree twist. The clavicular head descends to insert anteriorly (superficial) and distally. The sternal head twists behind it to insert posteriorly (deep) and proximally. Tears most commonly involve the sternal head failing during eccentric contraction.

Question 52

A 68-year-old female with severe rheumatoid arthritis undergoes a primary linked semi-constrained total elbow arthroplasty (TEA). At 7-year follow-up, she complains of gradually worsening elbow pain. Radiographs show radiolucent lines >2 mm around both the humeral and ulnar stems without signs of fracture. What is the most common long-term complication leading to revision in this procedure?

Explanation

Aseptic loosening is the most common long-term complication and the leading cause of revision in total elbow arthroplasty, particularly in linked (semi-constrained) designs. These designs transmit significant stresses to the bone-cement interface.

Question 53

During elbow arthroscopy, the proximal anteromedial portal is established 2 cm proximal to the medial epicondyle, just anterior to the medial intermuscular septum. Which of the following nerves is at the greatest risk of injury during the establishment of this portal?

Explanation

The proximal anteromedial portal places the medial antebrachial cutaneous nerve (MACN) at greatest risk as it courses through the subcutaneous tissue. The ulnar nerve is posterior to the medial intermuscular septum and is protected provided the portal remains anterior to the septum.

Question 54

A 42-year-old male presents with the sudden onset of severe, unremitting right shoulder pain that woke him from sleep. Two weeks later, the pain spontaneously resolves, but he develops profound weakness in shoulder abduction and external rotation. There is no history of trauma. EMG demonstrates denervation in the supraspinatus, infraspinatus, and deltoid. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) typically presents with an acute phase of severe, unrelenting shoulder/arm pain lasting days to weeks. As the pain subsides, patients develop patchy weakness and atrophy of shoulder girdle muscles (commonly affecting suprascapular, axillary, or long thoracic nerves) due to an inflammatory neuropathy.

Question 55

In an overhead throwing athlete, a Type II SLAP tear is often generated by the 'peel-back' mechanism. During which phase of the throwing motion does the maximal peel-back force occur on the superior labrum?

Explanation

The 'peel-back' mechanism occurs primarily during the late cocking phase of throwing, when the shoulder reaches maximum abduction and external rotation. In this position, the long head of the biceps vector shifts posteriorly and transmits a strong torsional force to the superior labral anchor, leading to labral detachment.

Question 56

A 28-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate a displaced acromioclavicular (AC) joint injury. The clavicle is displaced superiorly by 150% of the normal joint space relative to the acromion. The deltotrapezial fascia is clinically disrupted. Which Rockwood classification type best describes this injury?

Explanation

Rockwood Type V AC joint separations are characterized by complete tearing of the AC and CC ligaments, severe disruption of the deltotrapezial fascia, and severe superior displacement of the distal clavicle by >100% (often up to 300%) compared to the normal contralateral side.

Question 57

In the medial ulnar collateral ligament (MUCL) complex of the elbow, which structural component provides the primary restraint to valgus stress between 30 and 90 degrees of flexion?

Explanation

The anterior bundle of the MUCL is the primary stabilizer against valgus stress at the elbow. Specifically, the anterior band of the anterior bundle is taut in early flexion (up to 90 degrees) and is the primary restraint in this arc, while the posterior band of the anterior bundle becomes tighter in greater flexion (>90 degrees).

Question 58

A 13-year-old male baseball pitcher complains of gradually worsening shoulder pain in his throwing arm over the last two months. Examination reveals pain with resisted internal rotation and tenderness over the proximal humerus. Radiographs show widening and sclerosis of the proximal humeral physis. What is the most appropriate initial management?

Explanation

The presentation is classic for 'Little Leaguer's shoulder,' which is a proximal humeral epiphysiolysis caused by repetitive rotational stress across the open physis. The gold standard of treatment is complete rest from throwing (usually a minimum of 3 months) until symptoms resolve and radiographic healing is noted, followed by physical therapy and a structured return-to-throw program.

Question 59

A 26-year-old weightlifter presents with medial elbow pain and a snapping sensation when flexing and extending the elbow beyond 90 degrees. Examination demonstrates a reproducible palpable 'snap' over the medial epicondyle, accompanied by paresthesias radiating into the ring and small fingers. Which two structures are most likely translocating over the medial epicondyle?

Explanation

Snapping triceps syndrome occurs when the ulnar nerve and the medial edge of the medial head of the triceps recurrently dislocate anteriorly over the medial epicondyle during dynamic elbow flexion, causing a palpable double snap and symptoms of ulnar neuritis.

Question 60

A 32-year-old carpenter sustained a blunt trauma to his lateral chest wall 6 months ago. He now presents with aching pain around the shoulder and difficulty lifting his arm above shoulder level. On examination, asking the patient to push against a wall with outstretched arms causes prominent medial and superior displacement of the inferior angle of the scapula. Which nerve is most likely injured?

Explanation

Medial scapular winging (prominence of the medial border and inferior angle) is typically caused by paralysis of the serratus anterior, which is innervated by the long thoracic nerve. This is accentuated by asking the patient to push against a wall. Lateral winging is caused by trapezius paralysis (spinal accessory nerve injury).

Question 61

A 72-year-old female presents with progressive shoulder pain and stiffness 5 years after undergoing a Reverse Total Shoulder Arthroplasty (RTSA) for cuff tear arthropathy. Radiographs reveal scapular notching that is classified as Sirveaux Grade 3. Which of the following best describes this radiographic finding?

Explanation

The Sirveaux classification is used to grade scapular notching after RTSA. Grade 1 involves a notch limited to the scapular pillar. Grade 2 is a notch reaching the inferior screw. Grade 3 is a notch that extends past the inferior screw but does not go under the baseplate. Grade 4 is a notch extending under the baseplate, which is highly correlated with baseplate loosening and clinical failure.

Question 62

A 35-year-old male sustains a 'terrible triad' injury of the elbow (dislocation, radial head fracture, and type II coronoid fracture). Surgical intervention is planned. To optimize stability and follow standard principles of reconstruction, what is the most widely accepted sequence for repairing these structures?

Explanation

The standard protocol for treating terrible triad injuries is a 'deep to superficial' or 'inside-out' approach. The sequence is: 1) Fixation of the coronoid process (to restore the anterior buttress), 2) Repair or replacement of the radial head, 3) Repair of the lateral collateral ligament (LCL) complex. The medial collateral ligament (MCL) is typically only repaired if the elbow remains unstable in extension after the first three steps are completed.

Question 63

A 28-year-old bodybuilder sustains a complete rupture of the pectoralis major tendon at its humeral insertion. He opts for nonoperative management. Which of the following best describes the primary biomechanical deficit he is likely to experience long-term?

Explanation

While patients with complete pectoralis major ruptures can regain a nearly normal range of motion and function for activities of daily living without surgery, high-demand individuals experience a significant decrease in power. Biomechanical studies (e.g., Bak et al.) demonstrate a permanent 30% to 50% decrease in peak torque and work during isokinetic adduction and internal rotation if left un-repaired.

Question 64

A 24-year-old weightlifter presents with medial elbow pain, intermittent tingling in the ring and small fingers, and a distinct 'popping' sensation over the medial elbow when actively extending the elbow from a flexed position. Ultrasound dynamically visualizes a structure snapping over the medial epicondyle, dislocating the ulnar nerve. Which anatomic structure is the primary cause of this phenomenon?

Explanation

Snapping triceps syndrome occurs when the medial margin of the medial head of the triceps dislocates over the medial epicondyle during elbow flexion and snaps back during extension. This dynamic impingement frequently causes secondary friction and subluxation of the ulnar nerve, leading to cubital tunnel symptoms.

Question 65

A 40-year-old female sustains a high-energy fall, resulting in an acute, highly comminuted, irreparable radial head fracture and severe wrist pain. Examination reveals a positive ulnar variance and distal radioulnar joint (DRUJ) instability. What is the most appropriate initial surgical management?

Explanation

This is an acute Essex-Lopresti injury (longitudinal radioulnar dissociation). The essential management involves restoring the radiocapitellar contact to prevent proximal migration of the radius. This is achieved via radial head replacement (as the head is irreparable). The DRUJ must also be stabilized, often with temporary pinning in supination or TFCC repair. Excision of the radial head is contraindicated as it leads to progressive, debilitating proximal radial migration.

Question 66

During an arthroscopic suprascapular nerve release for entrapment at the suprascapular notch, the surgeon must identify the transverse scapular ligament. To avoid vascular injury, the surgeon must be aware of the anatomic relationship of the neurovascular structures at this site. Which statement is correct?

Explanation

At the suprascapular notch, the transverse scapular ligament bridges the notch. The suprascapular artery passes over (superior to) the ligament, while the suprascapular nerve passes under (inferior to) the ligament through the notch. The classic mnemonic is 'Army (Artery) goes over the bridge, Navy (Nerve) goes under the bridge'.

Question 67

A patient is scheduled for open reduction and internal fixation of a capitellar fracture classified as Dubberley type 3B. In the Dubberley classification system, what specific anatomic finding distinguishes a 'type B' lesion from a 'type A' lesion?

Explanation

The Dubberley classification for capitellum and trochlea fractures is highly relevant for surgical planning. Type 1 is a capitellum-only fracture; Type 2 involves the capitellum and trochlea in a single piece; Type 3 involves the capitellum and trochlea as separate fragments. The modifier 'A' indicates no posterior comminution, whereas 'B' indicates posterior comminution. Type B fractures are more complex, often requiring posterior structural grafting or total elbow arthroplasty in older patients.

Question 68

A latissimus dorsi tendon transfer is being considered for a 55-year-old male with a massive, irreparable posterosuperior rotator cuff tear. Which of the following preoperative findings is considered an absolute contraindication to performing this specific tendon transfer?

Explanation

A latissimus dorsi transfer depends heavily on an intact anterior force couple to dynamically stabilize the humeral head in the glenoid during arm elevation. Therefore, an irreparable subscapularis tear is considered an absolute contraindication, as the joint will remain uncoupled and unbalanced, leading to inevitable failure of the transfer.

Question 69

A 45-year-old man with a history of seizures presents with a chronic, locked posterior shoulder dislocation. A modified McLaughlin procedure is planned. During this procedure, which anatomic structure is transferred into the reverse Hill-Sachs defect to provide stability?

Explanation

The original McLaughlin procedure involves detaching the subscapularis tendon and transferring it into the reverse Hill-Sachs (anteromedial humeral head) defect to prevent it from engaging the posterior glenoid rim. The modified McLaughlin procedure, popularized by Neer, involves an osteotomy of the lesser tuberosity with the subscapularis attached, transferring the bone block into the defect for superior bone-to-bone healing.

Question 70

A 30-year-old male developed severe heterotopic ossification (HO) restricting elbow motion following a complex distal humerus fracture treated with ORIF. When timing the surgical excision of the HO, what is currently considered the most reliable clinical indicator that the HO is 'mature' and safe to resect with a minimized risk of recurrence?

Explanation

Historically, serum alkaline phosphatase and bone scans were used to determine HO maturity, but these have proven unreliable. Currently, the most reliable indicator for mature HO safe for resection is the plain radiographic appearance, characterized by distinct trabecular patterns and sharp, well-defined cortical margins. Excision is typically performed when this maturity is evident, often around 6 months post-injury.

Question 71

During the late cocking phase of throwing, a baseball pitcher's elbow is flexed to approximately 90 to 120 degrees and subjected to massive valgus stress. Which specific bundle of the ulnar collateral ligament (UCL) acts as the primary restraint to valgus opening at this specific degree of flexion?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. It is subdivided into the anterior and posterior bands. The anterior band is tightest in extension up to roughly 90 degrees of flexion. The posterior band becomes the primary restraint tightest from 90 to 120 degrees of flexion, which corresponds to the late cocking phase of throwing.

Question 72

A 48-year-old man undergoes a two-incision (Boyd-Anderson) repair of a distal biceps tendon rupture. To minimize the specific complication of postoperative proximal radioulnar synostosis, which of the following surgical techniques is most critical?

Explanation

Proximal radioulnar synostosis is a devastating complication historically associated with the two-incision approach for distal biceps repair. The risk is significantly reduced by limiting subperiosteal dissection of the ulna during the posterolateral exposure and by thoroughly irrigating bone debris to prevent an osteogenic bridge between the radius and ulna.

Question 73

A lower trapezius tendon transfer is performed in a young laborer for a massive, irreparable posterosuperior rotator cuff tear. What is the primary kinematic function this transfer aims to restore, and what graft is most commonly used to bridge the interval to the greater tuberosity?

Explanation

The lower trapezius transfer was developed by Elhassan to restore active external rotation in patients with irreparable posterosuperior cuff tears (supraspinatus/infraspinatus). Because the lower trapezius tendon cannot reach the greater tuberosity, an interposition graft—most commonly an Achilles tendon allograft or fascia lata—is required to bridge the gap.

Question 74

A 29-year-old overhead athlete complains of vague posterior shoulder pain and early fatigue when pitching. Physical exam demonstrates weakness in external rotation with the arm abducted to 90 degrees. MRI shows isolated fatty infiltration and severe atrophy of the teres minor muscle. What is the most likely diagnosis?

Explanation

Quadrilateral space syndrome results from compression of the posterior branch of the axillary nerve and the posterior humeral circumflex artery within the quadrilateral space (often by fibrous bands). This classically presents as isolated atrophy and fatty infiltration of the teres minor on MRI, accompanied by poorly localized posterior shoulder pain.

Question 75

A 14-year-old elite female gymnast presents with lateral elbow pain. Radiographs and MRI confirm osteochondritis dissecans (OCD) of the capitellum. Under which of the following circumstances is operative intervention explicitly indicated rather than nonoperative management?

Explanation

Indications for surgical management of capitellar OCD include unstable lesions. Signs of instability include a loose body, articular cartilage fracture, or MRI findings of a fluid cleft behind the fragment. Nonoperative management (rest from gymnastics) is indicated for stable lesions, particularly in patients with open physes. A mild loss of terminal extension (<20 degrees) is common and not an absolute surgical indication.

Question 76

A surgeon performs an anatomic coracoclavicular (CC) ligament reconstruction for a chronic Type V acromioclavicular joint separation. To accurately reproduce the native biomechanics, drill holes are placed in the clavicle corresponding to the native footprints of the conoid and trapezoid ligaments. What are the approximate distances of these insertions from the distal aspect of the clavicle?

Explanation

The native footprints of the CC ligaments are critical for anatomic reconstruction. The conoid ligament is positioned more medial and slightly posterior, inserting approximately 45 mm from the distal clavicle. The trapezoid ligament is more lateral and anterior, inserting approximately 25 to 30 mm from the distal clavicle.

Question 77

A 79-year-old female with severe rheumatoid arthritis sustains a highly comminuted, intra-articular distal humerus fracture (AO type 13-C3). Which of the following is the primary advantage of performing a Total Elbow Arthroplasty (TEA) over Open Reduction Internal Fixation (ORIF) in this specific patient?

Explanation

In elderly patients with poor bone quality (e.g., rheumatoid arthritis) and complex intra-articular distal humerus fractures, TEA offers a more reliable and immediate stable construct. This allows for early mobilization, leading to a more predictable return of functional range of motion compared to ORIF, which carries a high risk of fixation failure and stiffness. However, TEA necessitates a permanent 5-10 lb lifetime lifting restriction.

Question 78

A 21-year-old rugby player presents to the trauma bay after a pile-up. He complains of severe medial chest pain and difficulty swallowing. Exam reveals a palpable depression over the medial left clavicle. He is hemodynamically stable. What is the most appropriate next step in management?

Explanation

The patient has a posterior sternoclavicular (SC) joint dislocation, evidenced by the palpable depression and dysphagia (compression of the esophagus/mediastinal structures). Because of the proximity of the brachiocephalic vessels, reduction (whether closed or open) carries a high risk of catastrophic hemorrhage. Therefore, reduction must be performed in the OR with cardiothoracic surgery readily available.

Question 79

A 45-year-old mechanic felt a sudden 'pop' in the back of his elbow while forcefully tightening a bolt. Which of the following physical examination findings is most specific for a complete rupture of the distal triceps tendon?

Explanation

A complete rupture of the distal triceps tendon results in loss of the extensor mechanism of the elbow. This is best tested using the modified Thompson test for the triceps, or by asking the patient to extend the elbow against gravity with the shoulder abducted to 90 degrees or positioned overhead. A positive hook test evaluates the distal biceps tendon, not the triceps.

Question 80

A 32-year-old male sustains a closed, mid-shaft humerus fracture. On initial presentation, his neurovascular exam is completely normal. A closed reduction is performed and a coaptation splint is applied. Immediately following the reduction, the patient is noted to have a complete wrist drop and inability to extend his fingers. What is the most appropriate next step in management?

Explanation

While an initial (primary) radial nerve palsy in a closed humerus fracture is generally treated with observation, a secondary radial nerve palsy that develops immediately after a closed reduction attempt strongly suggests that the nerve has become entrapped or lacerated within the fracture site during the manipulation. This is a classic indication for immediate surgical exploration and internal fixation.

Question 81

A 45-year-old female presents with severe right shoulder weakness 6 months after undergoing a radical neck dissection for squamous cell carcinoma. On physical examination, her right shoulder droops, she is unable to actively abduct her arm past 90 degrees, and there is noticeable lateral winging of the scapula when she pushes against a wall. Which of the following nerves has most likely been injured?

Explanation

The clinical presentation is classic for a spinal accessory nerve (CN XI) injury, a known complication of cervical lymph node biopsies or radical neck dissections. The spinal accessory nerve innervates the trapezius muscle. Paralysis of the trapezius leads to drooping of the shoulder, weakness in forward elevation and abduction, and lateral winging of the scapula. This is distinguished from medial winging, which is caused by a long thoracic nerve injury (serratus anterior palsy).

Question 82

A 24-year-old gymnast sustains a fall onto an outstretched hand and presents with elbow pain. Radiographs reveal a fracture of the capitellum. Intraoperative findings demonstrate a large fracture fragment consisting of articular cartilage and a substantial portion of the underlying subchondral bone. According to the Bryan and Morrey classification, what type of capitellar fracture is this?

Explanation

The Bryan and Morrey classification describes capitellum fractures. Type I (Hahn-Steinthal) is a shear fracture in the coronal plane involving a large piece of osseous subchondral bone and articular cartilage. Type II (Kocher-Lorenz) involves an articular cartilage sleeve with minimal subchondral bone. Type III (Broberg-Morrey) is a highly comminuted fracture. Type IV, added by McKee, involves a shear fracture that extends medially to include the lateral trochlear ridge.

Question 83

In the preoperative planning for a total shoulder arthroplasty in a patient with primary glenohumeral osteoarthritis, a CT scan is obtained. The axial images show a biconcave glenoid with significant posterior wear and static posterior subluxation of the humeral head. According to the Walch classification, what type of glenoid morphology is present?

Explanation

The Walch classification describes glenoid morphology in primary osteoarthritis. Type A glenoids have concentric wear (A1 = minor, A2 = major central cupping). Type B glenoids involve posterior subluxation of the humeral head; B1 has narrowing of the posterior joint space without biconcavity, while B2 is characterized by a biconcave appearance with posterior wear and posterior subluxation of the humeral head. Type C is dysplastic with >15 degrees of retroversion and is not primarily caused by wear.

Question 84

A 32-year-old male bodybuilder feels a 'pop' in his anterior chest while performing a heavy bench press. MRI confirms a complete rupture of the pectoralis major tendon at its insertion. Which of the following best describes the anatomic insertion of the pectoralis major tendon?

Explanation

The pectoralis major inserts onto the lateral lip of the bicipital groove. The tendon is unique because it undergoes a 180-degree twist as it approaches the humerus. The clavicular head forms the anterior (superficial) lamina and inserts distally. The sternal/abdominal head forms the posterior (deep) lamina, twisting such that its lowest fibers insert most superiorly (proximally). Therefore, the sternal head inserts deep and proximal to the clavicular head.

Question 85

A 45-year-old man undergoes anatomic repair of a distal biceps tendon rupture via a single-incision anterior approach. Postoperatively, he reports altered sensation along the radial aspect of his proximal forearm. Which nerve is most likely injured?

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is a terminal branch of the musculocutaneous nerve and provides sensation to the radial aspect of the forearm. It is the most commonly injured nerve during a single-incision anterior approach to the distal biceps due to its proximity to the surgical field and superficial position. The posterior interosseous nerve (PIN) is more at risk with deep dissection or retractors placed around the radial neck, or classically during the posterolateral exposure of a two-incision technique.

Question 86

During an elbow arthroscopy for the removal of loose bodies, the surgeon establishes the standard anteromedial portal. Which of the following neurological structures is at greatest risk of iatrogenic injury during the creation of this specific portal?

Explanation

The medial antebrachial cutaneous nerve (MABC) is the structure at greatest risk during the establishment of the anteromedial portal. It runs very close to the standard anteromedial portal site (typically 2 cm distal and 2 cm anterior to the medial epicondyle). The median nerve is also at risk if the portal is placed too far anteriorly. The radial nerve is primarily at risk during the creation of the anterolateral portal.

Question 87

A 35-year-old male presents with recurrent episodes of a 'popping' sensation over the medial aspect of his elbow during active flexion and extension. He also reports intermittent numbness in his ring and small fingers. Physical examination reveals two distinct palpable 'snaps' over the medial epicondyle as the elbow is flexed from 0 to 120 degrees. What is the most likely diagnosis?

Explanation

Snapping triceps syndrome occurs when both the ulnar nerve and the medial head of the triceps subluxate over the medial epicondyle during elbow flexion. The presence of two distinct snaps—one from the ulnar nerve and the second from the medial head of the triceps—is pathognomonic for snapping triceps syndrome. Isolated ulnar nerve subluxation would typically produce only a single snap.

Question 88

A 40-year-old construction worker falls from a ladder, sustaining a highly comminuted radial head fracture. The treating surgeon elects to perform a radial head resection alone. Six months later, the patient presents with severe ulnar-sided wrist pain and grip weakness. Radiographs demonstrate proximal migration of the radius. This complication is the hallmark of an unrecognized injury to which of the following structures?

Explanation

The clinical scenario describes an Essex-Lopresti injury, which involves a radial head fracture with concomitant disruption of the interosseous membrane (IOM) and the distal radioulnar joint (DRUJ), leading to longitudinal radioulnar dissociation. Excision of the radial head in this setting removes the secondary stabilizer to proximal radial migration, resulting in severe ulnocarpal impaction. Treatment mandates radial head replacement (not excision) and DRUJ pinning.

Question 89

A 28-year-old male sustains a 'terrible triad' injury of the elbow (radial head fracture, coronoid fracture, and elbow dislocation). Operative management is planned. According to standardized treatment protocols, which of the following represents the optimal surgical sequence for addressing this injury?

Explanation

The standard surgical sequence for a terrible triad injury of the elbow (Pugh et al.) begins deep and works superficial, usually from a lateral or dual approach: 1) Fixation of the coronoid fracture to restore the anterior buttress, 2) Fixation or replacement of the radial head to restore the anterior column/valgus buttress, and 3) Repair of the lateral collateral ligament (LCL/LUCL) complex. The MCL is typically only repaired if the elbow remains grossly unstable after these steps.

Question 90

A 70-year-old male with a massive chronic rotator cuff tear presents with worsening shoulder pain. Anteroposterior (AP) radiographs demonstrate an acromiohumeral interval of 3 mm, 'acetabularization' (concave remodeling) of the acromion, and narrowing of the true glenohumeral joint space. According to the Hamada classification of rotator cuff arthropathy, what grade is this patient's condition?

Explanation

The Hamada classification stages rotator cuff arthropathy: Grade 1 is AHI >6 mm (normal is 7-14 mm). Grade 2 is AHI <= 5 mm. Grade 3 involves acetabularization (remodeling of the acromion) without glenohumeral arthritis. Grade 4 is characterized by the addition of glenohumeral arthritis (joint space narrowing). Grade 5 includes osteonecrosis or humeral head collapse. Because this patient has narrowing of the glenohumeral joint space, it is Grade 4.

Question 91

A reverse total shoulder arthroplasty (RTSA) is performed using the original Grammont biomechanical principles. Which of the following best describes the intended alteration of the glenohumeral center of rotation compared to the native anatomy?

Explanation

The Grammont design principles for reverse total shoulder arthroplasty (RTSA) rely on moving the center of rotation medial and inferior relative to the native glenohumeral joint. Medialization decreases the torque on the glenoid component (reducing loosening risk) and recruits more deltoid fibers. Inferiorization tensions the deltoid, increasing its lever arm to compensate for the absent rotator cuff.

Question 92

A 55-year-old male with end-stage renal disease on hemodialysis presents with a sudden inability to actively extend his elbow after a fall onto a flexed arm. A lateral radiograph of the elbow reveals a small osseous avulsion fragment situated proximal to the olecranon fossa. What is this radiographic finding commonly called, and what does it signify?

Explanation

The 'fleck sign' on a lateral elbow radiograph refers to a small avulsion fracture of the olecranon tip. In a patient with loss of active elbow extension, this is highly suggestive of a triceps tendon rupture. Triceps ruptures are rare but are strongly associated with systemic risk factors such as chronic kidney disease, hyperparathyroidism, and anabolic steroid or fluoroquinolone use.

Question 93

To diagnose posterolateral rotatory instability (PLRI) of the elbow, a pivot-shift test can be performed. The test aims to subluxate the radial head posteriorly relative to the capitellum. Which of the following combinations of forces must the examiner apply to the patient's arm during elbow flexion to successfully elicit this subluxation?

Explanation

Posterolateral rotatory instability (PLRI) is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). To elicit the pivot-shift sign, the examiner starts with the elbow in extension and applies an axial load, valgus stress, and forearm supination. As the elbow is flexed, the radial head subluxates posterolaterally, typically clunking back into place around 40 degrees of flexion as triceps tension increases.

Question 94

A 19-year-old rugby player presents to the emergency department after a direct blow to the medial aspect of his clavicle. He complains of severe pain and exhibits shortness of breath, mild stridor, and venous engorgement of his right upper extremity. A CT scan confirms a posterior sternoclavicular joint dislocation. What is the most appropriate next step in management?

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies if there are signs of mediastinal compression (dyspnea, dysphagia, stridor, venous congestion). Because the great vessels, trachea, and esophagus lie directly posterior to the medial clavicle, attempted closed reduction carries a risk of life-threatening hemorrhage if a vessel has been lacerated but tamponaded by the clavicle. Therefore, reduction must be performed in the operating room with a cardiothoracic surgeon on standby.

Question 95

A 52-year-old diabetic female presents with an insidious onset of severe shoulder pain and progressive restriction of both active and passive range of motion. The physical exam is notable for a profound loss of passive external rotation with the arm resting at the side. Pathologic thickening and contracture of which of the following capsuloligamentous structures is most directly responsible for this specific motion deficit?

Explanation

The patient's presentation is classic for adhesive capsulitis (frozen shoulder). The hallmark of this condition is a loss of active and passive range of motion, particularly external rotation with the arm at the side. This specific restriction is biomechanically caused by profound thickening and contracture of the coracohumeral ligament (CHL) and the structures within the rotator interval.

Question 96

A 35-year-old male presents with sudden onset of severe, unremitting right shoulder and periscapular pain that began 2 weeks ago without any antecedent trauma. Over the last 48 hours, the severe pain has rapidly subsided, but he has now noticed profound weakness in overhead elevation and external rotation. An MRI of the shoulder is unremarkable. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) is characterized by the sudden onset of severe, burning shoulder and arm pain that typically lasts for 1 to 2 weeks. As the pain subsides, profound weakness, atrophy, and paralysis of the affected shoulder girdle musculature become evident. It most commonly affects the suprascapular nerve, long thoracic nerve, or anterior interosseous nerve. Diagnosis is clinical and can be confirmed with EMG.

Question 97

A 28-year-old elite volleyball player presents with insidious onset of right shoulder weakness. Physical examination reveals normal forward elevation and abduction, but isolated weakness in external rotation. There is prominent atrophy of the infraspinatus fossa, while the supraspinatus fossa is well-preserved. An MRI reveals a paralabral cyst. Where is the cyst most likely located?

Explanation

The suprascapular nerve innervates both the supraspinatus and the infraspinatus muscles. The motor branch to the supraspinatus takes off after the nerve passes through the suprascapular notch but before it reaches the spinoglenoid notch. Entrapment of the nerve at the spinoglenoid notch (often due to a paralabral cyst associated with a posterior labral tear) results in isolated denervation of the infraspinatus, sparing the supraspinatus.

Question 98

A 9-year-old Little League baseball pitcher presents with a 3-month history of lateral elbow pain, stiffness, and occasional swelling. Radiographs reveal sclerosis, fragmentation, and rarefaction of the entire capitellar ossific nucleus. The capitellar physis remains wide open. What is the most appropriate management for this condition?

Explanation

This clinical and radiographic picture is characteristic of Panner's disease, an osteochondrosis of the capitellum that affects younger children (typically boys aged 7-10 years) with an open capitellar physis. It involves the entire capitellum and has an excellent prognosis, almost always resolving with nonoperative management (rest and cessation of throwing). This distinguishes it from osteochondritis dissecans (OCD) of the capitellum, which occurs in older adolescents (12-15 years), involves focal defects, and may result in loose bodies requiring surgery.

Question 99

A 26-year-old male cyclist falls directly onto his right shoulder. Radiographs demonstrate a fracture of the distal third of the clavicle. The fracture line is located just medial to the coracoclavicular (CC) ligaments, which remain attached entirely to the distal fracture fragment. The proximal fragment is significantly displaced superiorly. According to the Neer classification, what type of distal clavicle fracture is this, and what is its clinical significance?

Explanation

According to the Neer classification for distal clavicle fractures, a Type II fracture occurs when the fracture is at the level of the CC ligaments. The ligaments are either torn (IIA) or intact but attached to the distal fragment (IIB), leaving the proximal fragment devoid of CC ligamentous restraint. The trapezius pulls the proximal fragment superiorly, while the weight of the arm pulls the distal fragment inferiorly. This loss of stability leads to a high rate of nonunion (up to 30-45%) if treated nonoperatively, frequently necessitating surgical fixation.

Question 100

A 45-year-old male presents with anterior shoulder pain characterized by a positive 'coracoid impingement test' (pain elicited with the arm in forward flexion, internal rotation, and adduction). Advanced imaging measures the coracohumeral distance to be 4 mm. Pathology involving which of the following structures is most highly associated with subcoracoid impingement?

Split pectoralis major transfer
Eden-Lange procedure
Scapulothoracic arthrodesis
Split latissimus dorsi transfer
Pectoralis minor release

Correct Answer: Eden-Lange procedure

Explanation:

Question 24:

Which of the following physical examination findings is the pathognomonic hallmark of posterolateral rotatory instability (PLRI) of the elbow?

Options:

Apprehension with the elbow fully flexed and valgus stress applied
A palpable clunk during elbow extension from a flexed position with forearm supination and valgus/axial stress
Pain over the medial epicondyle with resisted wrist flexion
Inability to actively extend the elbow against gravity
Medial joint gap opening on varus stress test at 30 degrees of flexion

Correct Answer: A palpable clunk during elbow extension from a flexed position with forearm supination and valgus/axial stress

Explanation:

Question 25:

Options:

It completely avoids the need to manage or mobilize the ulnar nerve
It uses an interference screw in the ulna, eliminating the need for bone tunnels
It decreases the number of holes drilled in the medial epicondyle, reducing the risk of epicondylar fracture
It requires a shorter graft length, allowing for isolated use of the plantaris tendon
It avoids detachment of the flexor-pronator mass origin

Correct Answer: It decreases the number of holes drilled in the medial epicondyle, reducing the risk of epicondylar fracture

Explanation:

Question 26:

Options:

Lateral antebrachial cutaneous nerve (LABCN) neuropraxia
Radial nerve palsy
Proximal radioulnar synostosis
Rerupture of the tendon
Anterior interosseous nerve (AIN) palsy

Correct Answer: Proximal radioulnar synostosis

Explanation:

Question 27:

Options:

Exactly 6 months of elapsed time from the injury
Normalization of serum alkaline phosphatase levels
Cold uptake on a technetium-99m bone scan
Sharp, distinct trabecular margins seen on plain radiographs with cessation of ROM changes
Resolution of all soft tissue swelling

Correct Answer: Sharp, distinct trabecular margins seen on plain radiographs with cessation of ROM changes

Explanation:

Question 28:

Options:

Distal to the coracoclavicular (CC) ligaments
Through the tip of the coracoid involving only the conjoined tendon origin
Proximal to the coracoclavicular (CC) ligaments
Through the base extending into the suprascapular notch without CC involvement
Isolated to the medial border of the coracoid

Correct Answer: Proximal to the coracoclavicular (CC) ligaments

Explanation:

Question 29:

Options:

Axillary nerve
Musculocutaneous nerve
Suprascapular nerve
Subscapular nerve
Radial nerve

Correct Answer: Suprascapular nerve

Explanation:

Question 30:

In the Dubberley classification of coronal shear fractures of the capitellum and trochlea, what specific anatomic feature distinguishes a Type B fracture from a Type A fracture?

Options:

Extension of the fracture into the lateral epicondyle
Involvement of the trochlea
Presence of posterior condylar comminution
Associated radial head fracture
Articular cartilage impaction

Correct Answer: Presence of posterior condylar comminution

Explanation:

Question 31:

Options:

The clavicular head inserts deep and proximal to the sternal head
The sternal head twists 180 degrees so its lowest fibers insert highest (proximal) and deep to the clavicular head
Both heads blend completely, making it impossible to distinguish layers at the footprint
The clavicular head inserts deep and distal to the sternal head
The sternal head inserts superficial and distal to the clavicular head

Correct Answer: The sternal head twists 180 degrees so its lowest fibers insert highest (proximal) and deep to the clavicular head

Explanation:

Question 32:

Options:

Metaphyseal head extension (calcar length) less than 8 mm
Greater tuberosity displacement greater than 5 mm
Integrity of the medial hinge with less than 2 mm displacement
Angulation of the surgical neck greater than 30 degrees
Subcapital fracture line above the equator of the head

Correct Answer: Metaphyseal head extension (calcar length) less than 8 mm

Explanation:

Question 33:

Options:

Anterior capsular laxity
Hypertrophy of the anterior band of the inferior glenohumeral ligament (IGHL)
Contracture and thickening of the posteroinferior capsule
Subscapularis tendon shortening
Osseous retroversion of the humeral head

Correct Answer: Contracture and thickening of the posteroinferior capsule

Explanation:

Question 34:

Options:

Massive full-thickness tear of the supraspinatus and infraspinatus with acute retraction
Increased T2 signal (denervation edema) in the supraspinatus and infraspinatus muscle bellies without tendon disruption
An isolated paralabral cyst in the spinoglenoid notch causing nerve compression
Severe fatty infiltration (Goutallier Grade 4) of the subscapularis
Thickening and hyperintensity of the coracohumeral ligament characteristic of adhesive capsulitis

Correct Answer: Increased T2 signal (denervation edema) in the supraspinatus and infraspinatus muscle bellies without tendon disruption

Explanation:

Question 35:

Options:

Coronoid fixation, followed by radial head repair/replacement, followed by lateral collateral ligament (LCL) repair
Radial head repair/replacement, followed by coronoid fixation, followed by lateral collateral ligament (LCL) repair
Lateral collateral ligament (LCL) repair, followed by radial head repair/replacement, followed by coronoid fixation
Coronoid fixation, followed by medial collateral ligament (MCL) repair, followed by radial head repair/replacement
Radial head repair/replacement, followed by lateral collateral ligament (LCL) repair, followed by coronoid fixation

Correct Answer: Coronoid fixation, followed by radial head repair/replacement, followed by lateral collateral ligament (LCL) repair

Explanation:

Question 36:

Options:

Subcritical glenoid bone loss (<15%) with an off-track (engaging) Hill-Sachs lesion
Critical glenoid bone loss (>25%) regardless of the Hill-Sachs lesion size
An on-track Hill-Sachs lesion with an intact anterior capsule
Concomitant HAGL (humeral avulsion of the glenohumeral ligament) lesion
Revision setting after a failed open Latarjet procedure

Correct Answer: Subcritical glenoid bone loss (<15%) with an off-track (engaging) Hill-Sachs lesion

Explanation:

Question 37:

Options:

Pre-calcific phase
Formative phase
Resting phase
Resorptive phase
Post-calcific phase

Correct Answer: Resorptive phase

Explanation:

Question 38:

Options:

An arc of 90 degrees centered over the anteromedial quadrant of the radial head
An arc of 90 to 110 degrees on the lateral aspect of the radial head, directly opposite the radial tuberosity
An arc of 180 degrees encompassing the entire lateral half of the radial head
The area between the coronoid process and the tip of the olecranon
Directly over the bicipital tuberosity

Correct Answer: An arc of 90 to 110 degrees on the lateral aspect of the radial head, directly opposite the radial tuberosity

Explanation:

Question 39:

Options:

Interleukin-10 (IL-10)
Transforming growth factor-beta (TGF-beta)
Bone morphogenetic protein-2 (BMP-2)
Insulin-like growth factor-1 (IGF-1)
Tumor necrosis factor-beta (TNF-beta)

Correct Answer: Transforming growth factor-beta (TGF-beta)

Explanation:

Question 40:

Options:

Superior and lateral
Superior and medial
Inferior and medial
Inferior and lateral
It remains unchanged compared to the native joint

Correct Answer: Inferior and medial

Explanation:

Question 41:

Options:

Coracoacromial ligament
Conjoint tendon
Pectoralis minor
Subscapularis
Long head of the biceps

Correct Answer: Conjoint tendon

Explanation:

Question 42:

Options:

Moved superiorly and laterally
Moved inferiorly and laterally
Moved inferiorly and medially
Moved superiorly and medially
Remains unchanged but becomes highly constrained

Correct Answer: Moved inferiorly and medially

Explanation:

Question 43:

Options:

Application of a hinged external fixator
Repair of the lateral ulnar collateral ligament (LUCL)
Repair of the medial ulnar collateral ligament (MUCL)
Open reduction and internal fixation of the olecranon
Fascia lata autograft reconstruction of the annular ligament

Correct Answer: Repair of the lateral ulnar collateral ligament (LUCL)

Explanation:

Question 44:

Options:

Pectoralis major transfer
Latissimus dorsi transfer
Lower trapezius transfer
Rhomboid major transfer
Pectoralis minor transfer

Correct Answer: Lower trapezius transfer

Explanation:

Question 45:

Options:

Type 1 (Hahn-Steinthal)
Type 2 (Kocher-Lorenz)
Type 3 (Broberg-Morrey)
Type 4
Type 5

Correct Answer: Type 4

Explanation:

Question 46:

Options:

Quadrilateral space
Suprascapular notch
Spinoglenoid notch
Spiral groove
Triangular interval

Correct Answer: Spinoglenoid notch

Explanation:

Question 47:

Options:

Posterior interosseous nerve (PIN)
Lateral antebrachial cutaneous nerve (LABCN)
Medial antebrachial cutaneous nerve (MACN)
Superficial radial nerve
Anterior interosseous nerve (AIN)

Correct Answer: Lateral antebrachial cutaneous nerve (LABCN)

Explanation:

Question 48:

Options:

Medial ulnar collateral ligament (anterior bundle)
Annular ligament
Lateral ulnar collateral ligament (LUCL)
Radial collateral ligament
Quadrate ligament

Correct Answer: Lateral ulnar collateral ligament (LUCL)

Explanation:

Question 49:

Options:

Immediate closed reduction under procedural sedation in the ED
Urgent CT scan of the chest and formal closed reduction in the OR with cardiothoracic surgery available
Discharge with a sling and outpatient orthopedic follow-up
Immediate open reduction and internal fixation with a hook plate
Figure-of-eight brace and admission for observation

Correct Answer: Urgent CT scan of the chest and formal closed reduction in the OR with cardiothoracic surgery available

Explanation:

Question 50:

Options:

Anterior capsular laxity
Posterior capsular contracture
Subscapularis tear
Acromioclavicular osteoarthritis
Biceps anchor fraying

Correct Answer: Posterior capsular contracture

Explanation:

Question 51:

Options:

It inserts deep and proximal to the clavicular head
It inserts superficial and distal to the clavicular head
It inserts superficial and proximal to the clavicular head
It inserts deep and distal to the clavicular head
It merges completely with the clavicular head prior to insertion, making them indistinguishable

Correct Answer: It inserts deep and proximal to the clavicular head

Explanation:

Question 52:

Options:

Deep infection
Aseptic loosening
Ulnar component fracture
Triceps avulsion
Periprosthetic joint dislocation

Correct Answer: Aseptic loosening

Explanation:

Question 53:

Options:

Ulnar nerve
Median nerve
Medial antebrachial cutaneous nerve (MACN)
Musculocutaneous nerve
Radial nerve

Correct Answer: Medial antebrachial cutaneous nerve (MACN)

Explanation:

Question 54:

Options:

Acute cervical radiculopathy
Massive rotator cuff tear
Parsonage-Turner syndrome
Quadrilateral space syndrome
Adhesive capsulitis

Correct Answer: Parsonage-Turner syndrome

Explanation:

Question 55:

Options:

Wind-up
Early cocking
Late cocking
Acceleration
Deceleration

Correct Answer: Late cocking

Explanation:

Question 56:

Options:

Type II
Type III
Type IV
Type V
Type VI

Correct Answer: Type V

Explanation:

Question 57:

In the medial ulnar collateral ligament (MUCL) complex of the elbow, which structural component provides the primary restraint to valgus stress between 30 and 90 degrees of flexion?

Options:

Posterior bundle of the MUCL
Transverse ligament (Cooper's ligament)
Anterior band of the anterior bundle of the MUCL
Posterior band of the anterior bundle of the MUCL
Radiocapitellar joint

Correct Answer: Anterior band of the anterior bundle of the MUCL

Explanation:

Question 58:

Options:

Corticosteroid injection into the subacromial space
Diagnostic shoulder arthroscopy
Immediate cessation of throwing for 3 months followed by physical therapy
Surgical pinning of the physis
Sleeper stretch program while continuing to throw through the pain

Correct Answer: Immediate cessation of throwing for 3 months followed by physical therapy

Explanation:

Question 59:

Options:

Median nerve and flexor carpi radialis
Ulnar nerve and medial head of the triceps
Ulnar nerve and anconeus epitrochlearis
Medial antebrachial cutaneous nerve and pronator teres
Ulnar nerve and long head of the triceps

Correct Answer: Ulnar nerve and medial head of the triceps

Explanation:

Question 60:

Options:

Spinal accessory nerve
Dorsal scapular nerve
Long thoracic nerve
Suprascapular nerve
Axillary nerve

Correct Answer: Long thoracic nerve

Explanation:

Question 61:

Options:

Notch limited entirely to the scapular pillar
Notch reaching the inferior screw of the baseplate
Notch extending past the inferior screw but not under the baseplate
Notch extending underneath the baseplate to the central peg
Notch with associated gross loosening and baseplate migration

Correct Answer: Notch extending past the inferior screw but not under the baseplate

Explanation:

Question 62:

Options:

Coronoid fixation, MCL repair, radial head repair, LCL repair
Radial head repair, LCL repair, coronoid fixation, MCL repair
Coronoid fixation, radial head repair or replacement, LCL repair, followed by MCL repair only if still unstable
LCL repair, radial head repair, coronoid fixation, MCL repair
MCL repair, radial head repair, LCL repair, coronoid fixation

Correct Answer: Coronoid fixation, radial head repair or replacement, LCL repair, followed by MCL repair only if still unstable

Explanation:

Question 63:

Options:

50% loss of peak torque during shoulder abduction
30-50% loss of peak torque during shoulder adduction and internal rotation
Complete loss of active shoulder internal rotation
50% loss of peak torque during shoulder forward flexion
No measurable objective loss of peak torque, but subjective fatigue

Correct Answer: 30-50% loss of peak torque during shoulder adduction and internal rotation

Explanation:

Question 64:

Options:

Osborne's ligament
Arcade of Struthers
Medial head of the triceps
Flexor carpi ulnaris fascial band
Anconeus epitrochlearis

Correct Answer: Medial head of the triceps

Explanation:

Question 65:

Options:

Radial head excision alone and casting in supination
Radial head replacement with acute ulnar shortening osteotomy
Radial head replacement and pinning or stabilization of the DRUJ
Reconstruction of the interosseous membrane with a synthetic graft alone
Closed reduction of the DRUJ with pronation casting

Correct Answer: Radial head replacement and pinning or stabilization of the DRUJ

Explanation:

Question 66:

Options:

Both the suprascapular artery and nerve pass inferior to the ligament
The suprascapular artery passes superior to the ligament, and the nerve passes inferior to it
Both the suprascapular artery and nerve pass superior to the ligament
The suprascapular nerve passes superior to the ligament, and the artery passes inferior to it
The artery is deep to the nerve, and both pierce the ligament directly

Correct Answer: The suprascapular artery passes superior to the ligament, and the nerve passes inferior to it

Explanation:

Question 67:

Options:

Involvement of the lateral epicondyle
Extension of the fracture into the trochlea
Presence of posterior condylar comminution
Concomitant radial head fracture
Associated disruption of the lateral ulnar collateral ligament

Correct Answer: Presence of posterior condylar comminution

Explanation:

Question 68:

Options:

Severe atrophy and fatty infiltration of the teres minor
Irreparable subscapularis tendon tear
Hamada grade 2 radiographic changes
Inability to actively externally rotate the shoulder beyond neutral
Age greater than 50 years

Correct Answer: Irreparable subscapularis tendon tear

Explanation:

Question 69:

Options:

Subscapularis tendon alone
Lesser tuberosity with the attached subscapularis tendon
Coracoid process with the conjoined tendon
Pectoralis major tendon
Long head of the biceps tendon

Correct Answer: Lesser tuberosity with the attached subscapularis tendon

Explanation:

The original McLaughlin procedure involves detaching the subscapularis tendon and transferring it into the reverse Hill-Sachs (anteromedial humeral head) defect to prevent it from engaging the posterior glenoid rim. The *modified* McLaughlin procedure, popularized by Neer, involves an osteotomy of the lesser tuberosity with the subscapularis attached, transferring the bone block into the defect for superior bone-to-bone healing.

Question 70:

Options:

Normalization of serum alkaline phosphatase levels
Decreased radiotracer uptake on a three-phase technetium bone scan
Radiographic appearance showing distinct trabecular markings and sharp, well-defined cortical margins
A minimum of 18 months elapsed since the initial trauma
Resolution of clinical pain at rest

Correct Answer: Radiographic appearance showing distinct trabecular markings and sharp, well-defined cortical margins

Explanation:

Question 71:

Options:

Posterior bundle of the UCL
Transverse bundle of the UCL
Anterior band of the anterior bundle
Posterior band of the anterior bundle
Radial collateral ligament

Correct Answer: Posterior band of the anterior bundle

Explanation:

Question 72:

Options:

Using a cortical button rather than suture anchors for fixation
Avoiding subperiosteal elevation and limiting exposure of the ulnar periosteum
Maintaining the forearm strictly in pronation during the entire procedure
Performing a complete excision of the bicipitoradial bursa
Using a single-incision anterior approach instead

Correct Answer: Avoiding subperiosteal elevation and limiting exposure of the ulnar periosteum

Explanation:

Question 73:

Options:

Internal rotation; Gracilis autograft
External rotation; Fascia lata or Achilles allograft
Forward elevation; Hamstring autograft
Abduction; Synthetic mesh graft
Internal rotation; Fascia lata autograft

Correct Answer: External rotation; Fascia lata or Achilles allograft

Explanation:

Question 74:

Options:

Parsonage-Turner syndrome
Suprascapular nerve entrapment at the spinoglenoid notch
Quadrilateral space syndrome
Traction injury to the lower subscapular nerve
C5 cervical radiculopathy

Correct Answer: Quadrilateral space syndrome

Explanation:

Question 75:

Options:

Open distal humeral physis with a stable lesion
Lesion localized exclusively to the central capitellum
Loss of 5 degrees of terminal elbow extension
Presence of a detached loose body or fluid behind the osteochondral fragment on MRI
Mild associated radiocapitellar plica hypertrophy

Correct Answer: Presence of a detached loose body or fluid behind the osteochondral fragment on MRI

Explanation:

Question 76:

Options:

Conoid at 15 mm, Trapezoid at 30 mm
Conoid at 25 mm, Trapezoid at 15 mm
Conoid at 45 mm, Trapezoid at 25 mm
Conoid at 25 mm, Trapezoid at 45 mm
Both tunnels placed symmetrically at exactly 30 mm

Correct Answer: Conoid at 45 mm, Trapezoid at 25 mm

Explanation:

Question 77:

Options:

Elimination of a permanent lifting restriction
Immediate allowance for weight-bearing through the upper extremity
A more predictable and rapid return of functional elbow range of motion
Decreased incidence of postoperative ulnar neuropathy
Lower lifetime probability of reoperation for aseptic loosening

Correct Answer: A more predictable and rapid return of functional elbow range of motion

Explanation:

Question 78:

Options:

Immediate closed reduction in the emergency department using anterior traction
Observation and application of a figure-of-eight brace
Open or closed reduction in the operating room with cardiothoracic surgery on standby
Resection of the medial third of the clavicle
Application of an arm sling and outpatient orthopedic follow-up

Correct Answer: Open or closed reduction in the operating room with cardiothoracic surgery on standby

Explanation:

Question 79:

Options:

Inability to actively extend the elbow against gravity, particularly when the arm is positioned overhead
Inability to passively extend the elbow to zero degrees
Weakness with elbow flexion when the forearm is fully supinated
A positive hook test
Tingling in the small and ring fingers during elbow flexion

Correct Answer: Inability to actively extend the elbow against gravity, particularly when the arm is positioned overhead

Explanation:

Question 80:

Options:

Clinical observation for 3 to 4 months followed by EMG if no recovery is noted
Immediate surgical exploration of the radial nerve and rigid fracture fixation
Immediate electromyography (EMG) and nerve conduction studies
Switching from a coaptation splint to a Sarmiento functional fracture brace
Administration of high-dose intravenous corticosteroids

Correct Answer: Immediate surgical exploration of the radial nerve and rigid fracture fixation

Explanation:

While an initial (primary) radial nerve palsy in a closed humerus fracture is generally treated with observation, a secondary radial nerve palsy that develops *immediately after* a closed reduction attempt strongly suggests that the nerve has become entrapped or lacerated within the fracture site during the manipulation. This is a classic indication for immediate surgical exploration and internal fixation.

Question 81:

Options:

Long thoracic nerve
Spinal accessory nerve
Dorsal scapular nerve
Suprascapular nerve
Axillary nerve

Correct Answer: Spinal accessory nerve

Explanation:

Question 82:

Options:

Type I (Hahn-Steinthal)
Type II (Kocher-Lorenz)
Type III (Broberg-Morrey)
Type IV (McKee)
Type V

Correct Answer: Type I (Hahn-Steinthal)

Explanation:

Question 83:

Options:

Type A1
Type A2
Type B1
Type B2
Type C

Correct Answer: Type B2

Explanation:

Question 84:

Options:

The sternal head inserts superficial and proximal to the clavicular head on the lateral lip of the bicipital groove.
The sternal head twists such that its lower fibers insert deep and proximal to the clavicular head on the lateral lip of the bicipital groove.
The clavicular head inserts deep and proximal to the sternal head on the medial lip of the bicipital groove.
The two heads merge to form a single untwisted tendon that inserts on the medial lip of the bicipital groove.
The sternal head inserts onto the lesser tuberosity, while the clavicular head inserts onto the greater tuberosity.

Correct Answer: The sternal head twists such that its lower fibers insert deep and proximal to the clavicular head on the lateral lip of the bicipital groove.

Explanation:

Question 85:

Options:

Posterior interosseous nerve (PIN)
Superficial radial nerve
Lateral antebrachial cutaneous nerve (LABCN)
Medial antebrachial cutaneous nerve (MACN)
Anterior interosseous nerve (AIN)

Correct Answer: Lateral antebrachial cutaneous nerve (LABCN)

Explanation:

Question 86:

Options:

Radial nerve
Ulnar nerve
Median nerve
Medial antebrachial cutaneous nerve (MABC)
Posterior interosseous nerve

Correct Answer: Medial antebrachial cutaneous nerve (MABC)

Explanation:

Question 87:

Options:

Isolated ulnar nerve subluxation
Medial epicondylitis
Snapping triceps syndrome
Cubital tunnel syndrome from an anconeus epitrochlearis
Ulnar collateral ligament insufficiency

Correct Answer: Snapping triceps syndrome

Explanation:

Question 88:

Options:

Distal radioulnar joint (DRUJ) ligaments and interosseous membrane
Triangular fibrocartilage complex (TFCC) alone
Lateral ulnar collateral ligament (LUCL)
Annular ligament
Proximal radioulnar joint capsule

Correct Answer: Distal radioulnar joint (DRUJ) ligaments and interosseous membrane

Explanation:

Question 89:

Options:

Radial head fixation/replacement, LCL repair, Coronoid fixation
LCL repair, Coronoid fixation, Radial head fixation/replacement
Coronoid fixation, Radial head fixation/replacement, LCL repair
Radial head fixation/replacement, Coronoid fixation, MCL repair
Coronoid fixation, MCL repair, Radial head fixation/replacement

Correct Answer: Coronoid fixation, Radial head fixation/replacement, LCL repair

Explanation:

Question 90:

Options:

Grade 1
Grade 2
Grade 3
Grade 4
Grade 5

Correct Answer: Grade 4

Explanation:

Question 91:

Options:

Lateralized and superior
Lateralized and inferior
Medialized and inferior
Medialized and superior
Anatomic location is maintained

Correct Answer: Medialized and inferior

Explanation:

Question 92:

Options:

Fat pad sign; occult radial head fracture
Fleck sign; acute triceps tendon rupture
Terry Thomas sign; scapholunate dissociation
Teardrop sign; intra-articular effusion
Gull-wing sign; erosive osteoarthritis

Correct Answer: Fleck sign; acute triceps tendon rupture

Explanation:

Question 93:

Options:

Axial load, varus stress, and forearm pronation
Axial load, varus stress, and forearm supination
Axial load, valgus stress, and forearm pronation
Axial load, valgus stress, and forearm supination
Traction, valgus stress, and forearm pronation

Correct Answer: Axial load, valgus stress, and forearm supination

Explanation:

Question 94:

Options:

Immediate closed reduction in the emergency department using traction and a figure-of-eight brace
Open reduction and internal fixation with K-wires across the sternoclavicular joint
Closed reduction in the operating room with a cardiothoracic surgeon available on standby
Observation and sling immobilization as these typically remodel in young patients
Resection arthroplasty of the medial clavicle

Correct Answer: Closed reduction in the operating room with a cardiothoracic surgeon available on standby

Explanation:

Question 95:

Options:

Inferior glenohumeral ligament (IGHL)
Coracohumeral ligament (CHL)
Middle glenohumeral ligament (MGHL)
Superior glenohumeral ligament (SGHL)
Transverse humeral ligament

Correct Answer: Coracohumeral ligament (CHL)

Explanation:

Question 96:

Options:

Acute massive rotator cuff tear
Cervical radiculopathy (C5-C6)
Parsonage-Turner syndrome
Adhesive capsulitis (Freezing phase)
Subscapularis tendon rupture

Correct Answer: Parsonage-Turner syndrome

Explanation:

Question 97:

Options:

Suprascapular notch
Spinoglenoid notch
Quadrilateral space
Rotator interval
Triangular space

Correct Answer: Spinoglenoid notch

Explanation:

Question 98:

Options:

Arthroscopic debridement and microfracture of the capitellum
Cessation of throwing activities and symptomatic observation
Ulnar collateral ligament reconstruction
Open reduction and internal fixation of the capitellum
Radial head excision

Correct Answer: Cessation of throwing activities and symptomatic observation

Explanation:

Question 99:

Options:

Type I; high rate of nonunion
Type I; typically heals well with a sling
Type II; high rate of nonunion due to deforming forces
Type III; high risk of late acromioclavicular arthritis
Type IV; common in children due to periosteal sleeve avulsion

Correct Answer: Type II; high rate of nonunion due to deforming forces

Explanation:

Question 100:

Options:

Supraspinatus tendon
Subscapularis tendon
Infraspinatus tendon
Teres minor tendon
Long head of the triceps tendon

Correct Answer: Subscapularis tendon

Shoulder And Elbow: Review | Dr Hutaif Shoulder & Elbow -...

Quick Medical Answer

Shoulder And Elbow: Review | Dr Hutaif Shoulder & Elbow -...

Detailed Chapters & Topics

Acute Total Elbow Arthroplasty for Comminuted Distal Humerus Fractures: A Masterclass

Shoulder And Elbow Free Review | Dr Hutaif Shoulder & E -...

Shoulder And Elbow: And Emqs A Review | Dr Hutaif Shoul -...

Orthopedic Board Prep: Lateral Epicondylitis Clinical Case & Management

Orthopedic Shoulder And Review | Dr Hutaif Shoulder & E -...

Orthopedic Upper Limb Review | Dr Hutaif General Orthop -...

Orthopedic With Answer Sh Review | Dr Hutaif General Or -...

Orthopedic With Answer Upper L Review | Dr Hutaif Gener -...

Orthopedic Ob Shoulder And Elb Review | Dr Hutaif Shoul -...

Ortho Shoulder And Elbow Review | Dr Hutaif Shoulder & - ...

Ortho Shoulder And Elbow Review | Dr Hutaif Shoulder & - ...

Elbow Osteoarthritis: Comprehensive Guide to Epidemiology, Anatomy & Clinical Insights

Elbow Calcific Tendonitis: Comprehensive Diagnosis, Clinical Presentation & Phases

Elbow Capitellar Osteochondritis Dissecans: Epidemiology, Biomechanics & Comprehensive Management

AAOS Shoulder Board Review MCQs (Set 2): Rotator Cuff, Instability & Proximal Humerus Fractures

Guide Overview