Orthopedic Surgery MCQs: Trauma & Shoulder Board Review

Question 1

A 45-year-old bodybuilder feels a sudden 'pop' in his antecubital fossa while lifting weights and presents with weakness in supination. A distal biceps tendon rupture is diagnosed, and surgical repair via a single-incision anterior approach is planned. What is the most common iatrogenic nerve injury associated with this specific surgical approach?

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during the single-incision anterior approach for distal biceps tendon repair. It is at risk during superficial dissection laterally. The posterior interosseous nerve (PIN) is more commonly at risk during the two-incision technique, particularly if retractors are placed aggressively around the radial neck or if the arm is not fully pronated during the posterolateral dissection.

Question 2

A 35-year-old woman sustains a terrible triad injury of the elbow. Intraoperatively, the coronoid fracture is secured with a lasso technique, the radial head is replaced, and the lateral ulnar collateral ligament (LUCL) is primarily repaired to its anatomic footprint on the lateral epicondyle. Upon fluoroscopic stress testing, the elbow readily dislocates at 30 degrees of extension.

What is the next most appropriate step in surgical management?

Explanation

The standard algorithm for treating a terrible triad injury involves restoring osseous stability (coronoid, then radial head) followed by lateral ligamentous stability (LUCL repair). If the elbow remains unstable past 30 degrees of extension after these steps have been completed adequately, the medial collateral ligament (MCL) should be repaired. If instability persists even after MCL repair, a hinged external fixator or cross-pinning may be indicated.

Question 3

A 68-year-old osteoporotic female undergoes open reduction and internal fixation of a 3-part proximal humerus fracture using a locked plate construct. Postoperative follow-up at 6 weeks reveals varus collapse of the humeral head and superior screw cut-out into the glenohumeral joint. To minimize the risk of this specific complication, which of the following surgical maneuvers is most critical during the index procedure?

Explanation

Varus collapse is a common mode of failure in proximal humerus fracture fixation. The placement of medial calcar screws (screws directed into the inferomedial quadrant of the humeral head) provides crucial mechanical support to the medial column, significantly reducing the risk of varus displacement and subsequent secondary screw cut-out into the joint.

Question 4

A 25-year-old male sustains a midshaft clavicle fracture from a bicycle crash. He prefers non-operative management. Which of the following radiographic fracture characteristics is most strongly associated with a higher risk of nonunion if treated non-operatively?

Explanation

Risk factors for nonunion of midshaft clavicle fractures treated non-operatively include 100% displacement (lack of cortical contact), shortening greater than 2 cm (20 mm), advanced age, female sex, and comminution. Complete displacement with no cortical contact is a strong independent predictor of nonunion.

Question 5

A 32-year-old competitive powerlifter experiences a sudden tearing sensation in his anterior chest wall while performing a heavy bench press. Examination reveals a palpable defect and loss of the normal anterior axillary fold contour. MRI confirms a complete rupture of the pectoralis major tendon. Which portion of the muscle is most commonly injured in this mechanism, and what is its normal anatomic insertion relative to the other head?

Explanation

Pectoralis major ruptures most commonly involve the sternocostal head, especially during weightlifting (e.g., bench pressing). The sternocostal head fibers twist 180 degrees before inserting onto the lateral lip of the bicipital groove, such that the inferior fibers of the sternocostal head insert most proximally and deep (posteriorly) relative to the clavicular head.

Question 6

A 40-year-old male is involved in a high-speed motor vehicle collision and sustains multiple injuries, including an isolated fracture of the scapula. Which of the following isolated fracture patterns is an absolute indication for open reduction and internal fixation?

Explanation

Indications for operative fixation of the scapula include intra-articular glenoid fractures with >4-5 mm of step-off or involving >20-25% of the anterior/posterior articular rim (which causes glenohumeral instability). Other relative indications include glenoid neck fractures with >40 degrees angulation or >1 cm translation, or a significantly decreased glenopolar angle (< 22 degrees).

Question 7

A 40-year-old female presents with acute elbow pain after a fall. Radiographs demonstrate a coronal shear fracture of the distal humerus.

Advanced imaging reveals that the fracture includes the capitellum and extends medially to involve the lateral aspect of the trochlea, but leaves the lateral epicondyle intact. According to the Bryan and Morrey classification modified by McKee, what type of fracture is this?

Explanation

In the modified Bryan and Morrey classification of capitellar fractures, Type I (Hahn-Steinthal) involves a large osseous fragment of the capitellum. Type II (Kocher-Lorenz) is an articular cartilage shear with very little subchondral bone. Type III (Broberg-Morrey) is highly comminuted. Type IV, added by McKee, describes a coronal shear fracture that involves the capitellum and extends medially to include the lateral ridge of the trochlea.

Question 8

An 82-year-old low-demand nursing home resident sustains an isolated, displaced, transverse olecranon fracture after a ground-level fall. Due to severe medical comorbidities, non-operative management with early mobilization is chosen. Based on current literature, what is the most likely functional outcome and complication profile for this patient?

Explanation

Studies evaluating the non-operative treatment of displaced olecranon fractures in elderly, low-demand patients (e.g., Duckworth et al.) have consistently shown that while the radiographic nonunion rate is very high (often >70%), clinical outcomes are excellent. Patients typically achieve a functional range of motion, experience minimal pain, and report high satisfaction without the risks associated with surgery in frail patients.

Question 9

A 35-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture) following an arm-wrestling match. On initial examination in the emergency department, he exhibits an inability to extend his wrist and fingers, with loss of sensation over the dorsal first web space. What is the most appropriate initial management?

Explanation

A primary radial nerve palsy associated with a closed humeral shaft fracture, even a Holstein-Lewis type (distal third spiral fracture), is initially managed conservatively (non-operatively) with a coaptation splint or functional brace. The vast majority of these injuries are neuropraxias that will spontaneously recover. Indications for immediate exploration include open fractures, penetrating trauma, or a secondary nerve palsy that develops after a closed reduction attempt.

Question 10

A 28-year-old male cyclist falls directly onto his right shoulder. Clinical examination and radiographs confirm a Type III acromioclavicular (AC) joint dislocation. He is counseled on operative versus non-operative treatment. According to the current orthopedic literature, what is the expected outcome if he chooses non-operative management compared to surgical reconstruction?

Explanation

For Type III AC joint dislocations, the literature generally demonstrates no significant difference in long-term functional outcome scores (e.g., DASH, Constant scores) between operative and non-operative management. Non-operative management avoids surgical complications and allows an earlier return to work and sports, though it is associated with a higher likelihood of persistent cosmetic deformity. Internal rotation strength is generally not significantly affected.

Question 11

A 42-year-old male presents to the emergency department after a seizure. He complains of right shoulder pain and an inability to externally rotate the arm. Radiographs reveal a posterior shoulder dislocation.

A CT scan is obtained after closed reduction and demonstrates an anteromedial impaction fracture of the humeral head (reverse Hill-Sachs lesion) involving 25% of the articular surface. Which of the following is the most appropriate surgical treatment?

Explanation

The size of the reverse Hill-Sachs lesion dictates treatment. Defects < 20% are often stable and can be managed non-operatively or with a soft-tissue transfer (McLaughlin procedure). Defects between 20% and 40% typically require structural fill, most commonly via transfer of the lesser tuberosity with the attached subscapularis tendon (Modified McLaughlin procedure) or osteochondral allograft. Defects > 40-50% in a younger patient may require massive allograft, but often necessitate arthroplasty.

Question 12

A 30-year-old female undergoes open reduction and internal fixation for a displaced Mason type II radial head fracture that caused a mechanical block to forearm rotation. To avoid impingement of the hardware on the proximal radioulnar joint during pronation and supination, the plate must be placed within the radial head 'safe zone'. Which of the following accurately describes this anatomic safe zone?

Explanation

The 'safe zone' for placing hardware on the radial head to prevent impingement in the lesser sigmoid notch of the ulna during forearm rotation is an approximately 110-degree arc. This zone is located on the lateral aspect of the radial head when the forearm is in neutral rotation and is anatomically directly opposite the radial tuberosity.

Question 13

A 45-year-old polytrauma patient presents with an ipsilateral midshaft clavicle fracture and a displaced scapular neck fracture (floating shoulder). The surgeon considers operative fixation of the scapula rather than the clavicle alone. Which of the following radiographic findings is a primary indication for surgical fixation of the scapular fracture in this scenario?

Explanation

A glenopolar angle (GPA) of less than 20 to 22 degrees indicates significant rotational malalignment of the glenoid and is associated with poor functional outcomes. In the setting of a floating shoulder, a decreased GPA is a primary indication for surgical fixation of the scapula, as fixing the clavicle alone may not adequately correct the glenoid version and tilt.

Question 14

A 26-year-old male sustains an elbow dislocation that is reduced in the emergency department.

A subsequent CT scan reveals an isolated fracture of the anteromedial facet of the coronoid process. What specific mechanism of injury and associated ligamentous disruption is most characteristic of this particular fracture pattern?

Explanation

Fractures of the anteromedial facet of the coronoid process are pathognomonic for a varus posteromedial rotatory instability (VPMRI) mechanism. This injury pattern typically involves a varus force that causes failure of the lateral collateral ligament (LCL) complex, followed by impaction of the anteromedial coronoid facet against the medial trochlea, often sparing the medial collateral ligament.

Question 15

A 19-year-old collegiate football player sustains a direct blow to the anteromedial aspect of his shoulder. He presents to the trauma bay with severe pain, a feeling of fullness in his neck, dysphagia, and mild stridor. Imaging confirms a posterior sternoclavicular (SC) joint dislocation. A closed reduction in the operating room under general anesthesia is planned. Which surgical specialist must be immediately available on standby during the reduction?

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the proximity of the displaced medial clavicle to vital mediastinal structures, including the trachea, esophagus, and great vessels (e.g., brachiocephalic veins and artery). Because of the high risk of catastrophic vascular injury either from the initial trauma or during the reduction maneuver, a cardiothoracic surgeon should be available on standby.

Question 16

A 48-year-old male presents with acute weakness in elbow extension after attempting a heavy overhead triceps extension. MRI confirms a complete avulsion of the distal triceps tendon from the olecranon. During surgical repair using a transosseous cruciate technique, understanding the anatomic footprint is crucial. What is the most accurate description of the triceps tendon insertion on the olecranon to guide anatomic repair?

Explanation

The anatomic footprint of the distal triceps tendon is broad and covers the proximal portion of the olecranon (the dome). It typically begins a few millimeters distal to the articular tip of the olecranon and extends distally for approximately 1 to 2 cm. Reattaching the tendon specifically to the tip without covering the dome can lead to altered biomechanics and an extension lag.

Question 17

A 6-year-old boy falls off the monkey bars. Radiographs demonstrate an anterior bowing (plastic deformation) of the ulnar shaft and an anterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this, and what is the preferred initial management?

Explanation

Anterior dislocation of the radial head with anterior angulation or plastic deformation of the ulna is a Bado Type I Monteggia fracture-dislocation. It is the most common type in children. Unlike in adults (where ORIF is mandatory), the preferred initial management in pediatric patients is closed reduction of the ulnar bowing, which typically allows spontaneous reduction of the radial head, followed by long arm casting.

Question 18

A 45-year-old female who smokes 1 pack of cigarettes a day presents 9 months after sustaining a midshaft humerus fracture that was treated non-operatively in a functional brace. She reports persistent pain and gross motion at the fracture site. Radiographs demonstrate smooth, sclerotic fracture ends with no bridging callus. Which of the following represents the gold standard surgical management for this condition?

Explanation

The patient has an atrophic nonunion of the humeral shaft (indicated by motion at 9 months and sclerotic ends with no callus). The gold standard treatment for atrophic humeral shaft nonunions is open reduction and internal fixation (ORIF) with rigid compression plating combined with autologous bone grafting (typically from the iliac crest) to provide both mechanical stability and biological stimulation.

Question 19

A 65-year-old female sustains an AO/OTA 13-C3 comminuted intra-articular fracture of the distal humerus. The surgeon elects to perform an olecranon osteotomy for optimal articular visualization during open reduction and internal fixation. To maximize stability and minimize the risk of subsequent osteotomy nonunion, what is the preferred geometry and location of the osteotomy?

Explanation

A chevron-shaped (V-shaped) osteotomy with the apex pointing distally is preferred over a transverse cut because it provides greater surface area for healing and inherent rotational stability, aiding in anatomic reduction. It should be performed at the 'bare area' (the non-articular groove in the center of the greater sigmoid notch) to minimize damage to the articular cartilage.

Question 20

A 55-year-old man presents with a complex elbow injury following a fall from a height. Radiographs demonstrate a comminuted fracture of the olecranon. The distal radius and ulna, along with the radial head and coronoid, are displaced anteriorly relative to the distal humerus. However, the proximal radioulnar joint (PRUJ) remains anatomically congruent. What is the key pathomechanical feature of this 'trans-olecranon fracture-dislocation' that distinguishes it from an anterior Monteggia fracture-dislocation?

Explanation

In a true trans-olecranon fracture-dislocation, the injury energy is dissipated through the bone (the olecranon fracture) rather than the ligaments. Consequently, the proximal radioulnar joint (PRUJ) and the collateral ligament complexes usually remain intact. The radius and ulna dislocate as a single unit anteriorly relative to the humerus. This contrasts with a Monteggia fracture, where the PRUJ is disrupted as the radial head dislocates independently of the proximal ulna.

Question 21

A 42-year-old male sustains a closed, isolated scapula fracture in an MVC. Non-operative management is generally indicated for most scapula fractures; however, surgical fixation is recommended when certain criteria are met. Which of the following radiographic parameters is a widely accepted indication for open reduction and internal fixation of the scapula?

Explanation

A glenopolar angle of less than 22 degrees indicates severe angular deformity of the scapular neck and is a widely accepted indication for surgery. Other operative indications include medialization greater than 20 mm, angulation greater than 45 degrees, and an intra-articular glenoid step-off greater than 4 mm.

Question 22

A 42-year-old male presents with a traumatic elbow injury. Radiographs and CT scan reveal a fracture of the anteromedial facet of the coronoid process. On examination, the elbow demonstrates instability when a varus stress is applied. Which of the following ligamentous structures is almost invariably disrupted in this specific injury pattern?

Explanation

Fractures of the anteromedial facet of the coronoid are the hallmark of varus posteromedial rotatory instability (VPMRI). This injury pattern invariably involves disruption of the lateral collateral ligament (LCL) complex, specifically the LUCL, requiring surgical repair of the ligament and buttress plating of the coronoid.

Question 23

A 55-year-old female sustains a completely displaced, comminuted midshaft clavicle fracture. She opts for non-operative management. Which of the following radiographic or demographic factors is most strongly predictive of nonunion in this patient?

Explanation

Risk factors for nonunion of midshaft clavicle fractures include advanced age, female gender, complete displacement (100%), comminution, and fracture shortening of greater than 2 cm. Shortening > 2 cm is a strong relative indication for operative fixation.

Question 24

Historically, the arcuate artery (a branch of the anterior humeral circumflex artery) was thought to provide the main blood supply to the humeral head. However, recent quantitative cadaveric studies have demonstrated that the principal blood supply to the humeral head is derived from which of the following vessels?

Explanation

Recent studies (e.g., Hettrich et al.) demonstrated that the posterior humeral circumflex artery provides the majority (approximately 64%) of the blood supply to the humeral head, challenging the historical belief that the anterior humeral circumflex was the primary supply.

Question 25

A surgeon plans to repair a retracted distal biceps tendon rupture using a two-incision (modified Boyd-Anderson) approach. This approach was historically developed to minimize the risk to the posterior interosseous nerve (PIN). However, compared to the single-incision anterior approach, the two-incision technique carries a higher risk of which of the following complications?

Explanation

The two-incision approach protects the PIN and LABCN but has historically been associated with a higher risk of heterotopic ossification and radioulnar synostosis, especially if the interosseous membrane is violated during the procedure.

Question 26

A 35-year-old male with a history of poorly controlled seizures presents with a locked internal rotation deformity of his right shoulder. A CT scan confirms a posterior shoulder dislocation with an impaction fracture of the anterior humeral head (reverse Hill-Sachs lesion) involving 35% of the articular surface. The dislocation is <3 weeks old. What is the most appropriate surgical management?

Explanation

For a reverse Hill-Sachs lesion involving 20% to 40% of the articular surface, the modified McLaughlin procedure (transfer of the lesser tuberosity and subscapularis tendon into the defect) is the recommended treatment to restore stability.

Question 27

A 22-year-old male presents to the emergency department after a high-speed motor vehicle collision. He complains of chest pain, shortness of breath, and pain in the right medial clavicle region. Examination shows a posterior sternoclavicular dislocation. What is the most appropriate next step in management?

Explanation

Posterior sternoclavicular dislocations can compress mediastinal structures (trachea, esophagus, great vessels). Due to the high risk of catastrophic vascular injury during reduction, it must be performed in the OR with a cardiothoracic surgeon on standby after a CT scan evaluates the mediastinum.

Question 28

A 40-year-old patient sustains a severely comminuted fracture of the scapular body after falling from a roof. Measurement of the glenopolar angle (GPA) is obtained to evaluate the need for surgical intervention. What is the normal range of the GPA, and at what threshold is surgical fixation generally recommended?

Explanation

The normal glenopolar angle is between 30 and 45 degrees. A GPA of less than 22 degrees indicates severe rotational malalignment of the glenoid and is a widely accepted indication for open reduction and internal fixation.

Question 29

A 30-year-old male weightlifter felt a sudden "tearing" sensation in his chest while performing a heavy bench press. Examination reveals loss of the anterior axillary fold contour and weakness in internal rotation. Operative repair of the pectoralis major is planned. Which anatomical statement correctly describes the insertion of the most commonly ruptured portion of this muscle?

Explanation

The pectoralis major tendon undergoes a 180-degree twist before inserting on the lateral lip of the bicipital groove. This causes the inferior (sternal) fibers to insert deep and proximal to the superior (clavicular) fibers. The sternal head is the most commonly ruptured.

Question 30

A 28-year-old manual laborer requires surgical reconstruction for a chronic Type III acromioclavicular (AC) joint separation. The reconstruction will target the coracoclavicular (CC) ligaments. Which of the following best describes the anatomical orientation of the native CC ligaments?

Explanation

The coracoclavicular ligament complex consists of the conoid and trapezoid ligaments. The conoid is situated medial and posterior, while the trapezoid is lateral and anterior. Anatomic reconstruction techniques aim to reproduce this specific footprint.

Question 31

A 45-year-old female presents with a highly comminuted radial head fracture, acute wrist pain, and distal radioulnar joint (DRUJ) instability. A diagnosis of an Essex-Lopresti injury is made. If the radial head is simply excised and not replaced, what is the most likely biomechanical consequence?

Explanation

An Essex-Lopresti injury involves a radial head fracture, interosseous membrane rupture, and DRUJ disruption. Excision of the radial head without prosthetic replacement eliminates the proximal stabilizer, leading to proximal radial migration and severe ulnocarpal impingement.

Question 32

A 34-year-old female presents with elbow pain after a fall. Radiographs and CT demonstrate a coronal shear fracture of the capitellum that extends medially to include the majority of the trochlea, with a separate comminuted fracture of the posterior trochlea. According to the Dubberley classification, what is the most appropriate surgical approach for open reduction and internal fixation of this Type 3B injury?

Explanation

Dubberley Type 3B fractures involve the capitellum and trochlea with significant posterior articular comminution. A universal posterior approach with an olecranon osteotomy is required to adequately visualize and rigidly fix the articular surface while managing the posterior comminution.

Question 33

A 17-year-old male sustains a direct blow to the medial chest wall during a football game. He presents with severe chest pain, shortness of breath, and dysphagia. Examination reveals a palpable depression at the medial end of the clavicle. What is the most appropriate next step in management?

Explanation

Posterior sternoclavicular dislocations can cause life-threatening compression of mediastinal structures, leading to dyspnea and dysphagia. A CT angiogram of the chest is critical to evaluate the great vessels, and cardiothoracic surgery must be available during reduction in case of sudden vascular injury.

Question 34

A 28-year-old sustains a closed, isolated midshaft transverse humerus fracture after a direct blow. On initial examination in the emergency department, he is noted to have a complete absence of wrist extension, finger extension, and decreased sensation over the dorsal first web space. What is the most appropriate initial management for this neurologic finding?

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture is typically a neuropraxia and should be managed with closed reduction, splinting, and observation. Surgical exploration is generally indicated only if the palsy occurs after a closed reduction attempt or in open fractures.

Question 35

A 24-year-old cyclist sustains a highly displaced midshaft clavicle fracture. Which of the following is considered an absolute indication for acute open reduction and internal fixation?

Explanation

Absolute indications for operative treatment of clavicle fractures include open fractures, vascular injury, and severe skin tenting with impending necrosis. Displacement and shortening >2 cm are relative indications based on the increased risk of symptomatic nonunion.

Question 36

During the surgical reconstruction of a "terrible triad" injury of the elbow, the surgeon follows a standard protocol to restore elbow stability. After addressing the deep articular structures, which of the following represents the most appropriate sequence of repair?

Explanation

The standard sequence for treating a terrible triad injury works from deep to superficial and medial to lateral (if approached laterally). Fixation begins with the coronoid, followed by the radial head (repair or replacement), and finally the lateral ulnar collateral ligament (LUCL).

Question 37

A 32-year-old male sustains an elbow injury. CT reveals a fracture of the anteromedial facet of the coronoid. Examination shows instability when the elbow is subjected to a varus stress in flexion. Which of the following ligamentous structures is almost universally injured in this specific fracture pattern?

Explanation

Anteromedial facet coronoid fractures are pathognomonic for varus posteromedial rotatory instability. This mechanism involves a varus force causing LUCL rupture followed by impaction of the anteromedial coronoid against the medial trochlea.

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Key Takeaway

Orthopedic Surgery MCQs: Trauma, Shoulder & Elbow Board Review | Part 83

Chapter Index