Orthopedic Shoulder & Elbow Board Prep: Master MCQs

Question 1

A 55-year-old right-hand dominant male presents with acute onset severe right shoulder pain after attempting to lift a heavy box. He describes an audible 'pop' and now has weakness in abduction and external rotation. On examination, he has significant tenderness over the greater tuberosity and a positive painful arc sign. Active abduction is limited to 70 degrees, but passive range of motion is full. Which of the following is the MOST appropriate initial investigation to confirm the diagnosis and guide management?

Explanation

The patient's presentation with an acute 'pop', pain, and weakness in abduction and external rotation strongly suggests an acute rotator cuff tear. While MRI is the gold standard for detailed assessment of rotator cuff integrity, a diagnostic ultrasound is an excellent, cost-effective, and readily available initial investigation to confirm the presence and often the size of a full-thickness rotator cuff tear in the acute setting. It can be performed dynamically and is superior to radiographs for soft tissue assessment. Radiographs rule out fractures or dislocations but provide no information on the rotator cuff. CT scans are primarily for bony pathology. EMG/NCS studies are for nerve entrapment or injury, which is less likely to be the primary acute issue here.

Question 2

A 30-year-old male presents with recurrent anterior shoulder dislocations. He has undergone two previous arthroscopic Bankart repairs, but continues to experience instability, particularly with overhead activities. On examination, he has hyperlaxity and a positive apprehension test in abduction and external rotation. Radiographs show a bony Bankart lesion and a significant Hill-Sachs lesion. Which of the following surgical procedures is MOST appropriate to address his recurrent instability?

Explanation

This patient has failed previous arthroscopic Bankart repairs, indicating persistent instability likely due to significant bone loss (bony Bankart and Hill-Sachs lesions) or generalized hyperlaxity. The Latarjet procedure is highly effective in cases of significant glenoid bone loss (>20-25%) or failed previous stabilization attempts, as it transfers the coracoid process with the attached conjoint tendon to the anterior glenoid, providing both a bone block effect and a sling effect. A repeat arthroscopic Bankart repair is unlikely to succeed given the previous failures and bone loss. Open Bankart with capsular shift is an option for capsular laxity but doesn't directly address significant bone loss. Remplissage alone is for engaging Hill-Sachs lesions without significant glenoid bone loss. Arthroscopic capsular plication addresses generalized laxity but not the underlying bony deficiency.

Question 3

A 68-year-old female presents with severe, constant left shoulder pain, significantly worse at night, and progressive loss of both active and passive range of motion over the past 6 months. She has no history of trauma. On examination, external rotation is severely limited and painful, and she exhibits global stiffness. Radiographs show mild glenohumeral osteoarthritic changes. What is the MOST likely diagnosis?

Explanation

The key features pointing to adhesive capsulitis are the insidious onset of global stiffness, severe pain, and particularly the loss of BOTH active and passive range of motion (especially external rotation). While glenohumeral osteoarthritis can cause stiffness and pain, the primary feature is usually pain and crepitus, and limitation of motion may not be as globally restricted or as progressive in all planes as seen in frozen shoulder. Rotator cuff tendinopathy primarily causes pain with active movement and weakness, often with preserved passive motion. Acute calcific tendinitis presents with sudden, excruciating pain, not progressive stiffness. Subacromial impingement typically involves pain with overhead activities and a painful arc, but generally preserves passive motion.

Question 4

A 45-year-old male sustains a fall directly onto the tip of his right shoulder. He presents with severe pain, a visible deformity, and tenderness over the acromioclavicular (AC) joint. On examination, there is a prominent distal clavicle and positive cross-body adduction test. Radiographs show complete disruption of both the AC and coracoclavicular (CC) ligaments, with significant superior displacement of the clavicle relative to the acromion. Which Rockwood classification type BEST describes this injury?

Explanation

This patient's injury, with complete disruption of both AC and CC ligaments and significant superior displacement of the clavicle, fits the description of a Rockwood Type V AC joint injury. Type I involves a sprain of the AC ligaments with intact CC ligaments. Type II involves disruption of the AC ligaments with intact CC ligaments. Type III involves complete disruption of AC and CC ligaments, with clavicle displacement of 25-100% of the acromion width. Type IV involves posterior displacement of the clavicle into the trapezius muscle. Type V involves severe superior displacement of the clavicle, often 100-300% of the acromion width, through the deltotrapezial fascia. Type VI involves inferior displacement of the clavicle, which is rare.

Question 5

A 12-year-old boy falls off his bicycle, landing on an outstretched arm. He presents with elbow pain, swelling, and an inability to fully extend the elbow. Radiographs show a displaced supracondylar fracture of the humerus. On examination, the radial pulse is diminished, and he has pain with passive extension of the fingers. Which of the following is the MOST appropriate immediate next step in management?

Explanation

The diminished radial pulse and pain with passive finger extension are red flags for potential impending compartment syndrome or vascular compromise (Volkmann's ischaemia), which are serious complications of supracondylar humerus fractures. Immediate closed reduction and percutaneous pinning (CRPP) is indicated for displaced fractures, especially with neurovascular compromise, to restore alignment and relieve pressure on neurovascular structures. Waiting for observation is inappropriate. A CT angiogram is too time-consuming and unnecessary; clinical assessment and immediate reduction are paramount. Fasciotomy is reserved for confirmed compartment syndrome after reduction and observation, not as an initial step. Applying a splint and discharge is completely inappropriate given the vascular compromise.

Question 6

A 70-year-old female presents with a new onset of severe right elbow pain after a fall onto her outstretched hand. She has significant swelling and ecchymosis around the elbow. Radiographs reveal a comminuted fracture of the radial head involving more than one-third of the articular surface, with associated ulnohumeral dislocation and a coronoid fracture. Which of the following describes this complex injury pattern?

Explanation

The described injury pattern – comminuted radial head fracture, ulnohumeral dislocation, and coronoid fracture – is classically known as the 'terrible triad of the elbow'. This is a highly unstable injury with a high risk of chronic instability and stiffness. An Essex-Lopresti lesion involves a radial head fracture with disruption of the interosseous membrane and distal radioulnar joint subluxation/dislocation. Monteggia involves a proximal ulna fracture with radial head dislocation. Galeazzi involves a radial shaft fracture with distal radioulnar joint dislocation. Maissoneuve involves a proximal fibula fracture with distal tibiofibular syndesmosis disruption and medial ankle injury.

Question 7

A 40-year-old male presents with chronic insidious-onset lateral elbow pain, exacerbated by gripping and lifting. Physical examination reveals tenderness over the lateral epicondyle, pain with resisted wrist extension and forearm supination, and a negative neurological examination. Which of the following is the MOST appropriate initial conservative management strategy?

Explanation

The patient's symptoms are classic for lateral epicondylitis (tennis elbow). The vast majority (90-95%) of cases resolve with conservative management. The initial approach should include activity modification (avoiding aggravating activities), NSAIDs for pain and inflammation, and a structured physical therapy program emphasizing eccentric strengthening of the wrist extensors. While corticosteroid injections can provide short-term pain relief, they may be detrimental in the long term by weakening the tendon. PRP injections are considered for refractory cases. Surgical debridement is reserved for failed conservative management (typically >6-12 months). Immobilization is generally not indicated and can lead to stiffness.

Question 8

A 28-year-old competitive weightlifter presents with acute right shoulder pain, swelling, and ecchymosis in the axilla and upper arm after attempting a maximal bench press. He reports an audible 'pop' and now has a visible 'Popeye' deformity in his upper arm. He has weakness with resisted forearm supination. Which structure is MOST likely injured?

Explanation

The clinical picture of acute pain, swelling, ecchymosis in the upper arm/axilla after a powerful lifting maneuver (bench press), an audible 'pop', a 'Popeye' deformity (proximal migration of the muscle belly), and weakness with resisted forearm supination is classic for a complete rupture of the distal biceps tendon from its insertion on the radial tuberosity. A long head of biceps rupture typically causes a 'Popeye' deformity in the mid-arm, but usually results in less functional deficit for elbow flexion and supination as the short head compensates, and the ecchymosis is typically more localized to the anterior shoulder. Pectoralis major tears cause anterior chest wall and axillary pain/ecchymosis, and weakness in adduction/internal rotation. Rotator cuff tears affect abduction/rotation. Triceps tears affect elbow extension.

Question 9

A 60-year-old female with a history of rheumatoid arthritis presents with chronic shoulder pain, crepitus, and limited range of motion, particularly internal rotation and adduction. Radiographs show significant glenohumeral joint space narrowing, humeral head superior migration, and erosion of the glenoid and acromion. She has intact rotator cuff function on ultrasound. What is the MOST appropriate surgical treatment option?

Explanation

The patient has significant glenohumeral arthritis, likely rheumatoid given her history, with glenoid erosion and superior migration of the humeral head. However, the key information is 'intact rotator cuff function'. In the setting of severe glenohumeral arthritis and a functional rotator cuff, anatomic total shoulder arthroplasty (TSA) is the gold standard for pain relief and improved function. Hemiarthroplasty is considered when the glenoid is relatively healthy or in younger, more active patients. Reverse TSA is indicated when the rotator cuff is deficient or irreparable. Shoulder arthrodesis is a salvage procedure for failed arthroplasty or severe deltoid/rotator cuff deficiency. Arthroscopic debridement is for less severe arthritis or as a temporary measure.

Question 10

A 35-year-old male sustains a fall onto his elbow, resulting in an olecranon fracture. Radiographs show a displaced, comminuted intra-articular fracture involving the articular surface, with significant displacement. On examination, he is unable to actively extend his elbow. Which of the following is the MOST appropriate surgical management?

Explanation

Displaced olecranon fractures that disrupt the extensor mechanism (inability to extend the elbow) are surgical indications. While plate and screw fixation is also a viable option, especially for comminuted fractures or those extending into the shaft, tension band wiring is a commonly used and highly effective technique for displaced transverse or oblique olecranon fractures, as it converts the distractive forces of the triceps into compressive forces across the fracture site, promoting healing and allowing early motion. Non-operative treatment is for non-displaced fractures. Excision of the olecranon fragment is typically for small, non-articular fragments or in rare cases of severe comminution with severe osteoporosis in elderly patients where stable fixation is not possible. Radial head replacement is for radial head fractures.

Question 11

A 15-year-old baseball pitcher presents with chronic medial elbow pain, especially during the acceleration phase of throwing. Examination reveals tenderness over the medial epicondyle and a positive valgus stress test. Radiographs show physeal widening of the medial epicondyle. Which of the following is the MOST appropriate initial management strategy?

Explanation

This presentation is classic for 'Little League Elbow', an overuse injury in adolescent throwing athletes, involving stress on the medial epicondylar physis. Physeal widening indicates apophysitis or avulsion. The initial management is non-operative and involves complete rest from throwing to allow the physis to heal, followed by a structured rehabilitation program focusing on strengthening and proper throwing mechanics. Surgical reconstruction of the UCL is reserved for chronic UCL insufficiency in skeletally mature athletes who have failed extensive non-operative management. Medial epicondyle excision is rarely indicated in this age group. Corticosteroid injections are generally contraindicated in growing physes and tendons. Ulnar nerve transposition may be needed if there is symptomatic ulnar nerve compression, but it's not the primary treatment for the bony pathology.

Question 12

A 40-year-old male undergoes arthroscopic rotator cuff repair. Post-operatively, he complains of persistent numbness along the lateral aspect of his shoulder and upper arm. On examination, he has diminished sensation in the 'regimental badge' area. What nerve is MOST likely injured?

Explanation

The 'regimental badge' area is the classic dermatome supplied by the axillary nerve (C5-C6). This nerve is vulnerable during shoulder surgery, particularly during rotator cuff repair, labral repair, or glenohumeral arthroplasty due to its course around the surgical neck of the humerus and close proximity to the inferior capsule. Suprascapular nerve injury would affect sensation in the shoulder joint and cause atrophy of supraspinatus/infraspinatus. Musculocutaneous nerve affects biceps function and lateral forearm sensation. Long thoracic nerve injury causes scapular winging. Radial nerve injury affects posterior arm/forearm sensation and wrist/finger extensors.

Question 13

A 50-year-old female presents with acute pain and swelling in her right shoulder. She is febrile and reports a history of intravenous drug use. On examination, the shoulder is exquisitely tender, erythematous, and warm. She resists all attempts at passive range of motion. Joint aspiration yields purulent fluid. Which of the following is the MOST critical initial step in management, after obtaining cultures?

Explanation

This clinical picture is highly suggestive of septic arthritis of the shoulder. After obtaining Gram stain and cultures from the aspirated fluid, urgent surgical irrigation and debridement is paramount to remove pus and necrotic tissue, reduce bacterial load, and prevent cartilage destruction. This should be combined with appropriate intravenous antibiotics. Oral antibiotics alone are insufficient for septic arthritis. A CT scan may be useful later for osteomyelitis assessment but is not the immediate priority for acute septic arthritis. Ice and immobilization are palliative and do not address the infection. NSAIDs will mask symptoms and do not treat the underlying pathology.

Question 14

A 72-year-old male undergoes a reverse total shoulder arthroplasty for rotator cuff tear arthropathy. Three months post-operatively, he develops sudden severe pain, swelling, and purulent discharge from the incision site. Aspiration confirms a periprosthetic joint infection (PJI). Given the acute nature of the infection and the relatively short time since surgery, what is the MOST appropriate treatment strategy?

Explanation

For acute periprosthetic joint infections (PJI) occurring within 3-4 weeks of surgery, or in early-onset infections (within 3 months) without implant loosening or biofilm maturation, debridement, antibiotics, and implant retention (DAIR) is often a viable option, particularly if the soft tissues are healthy and the organism is susceptible. The goal is to eradicate the infection while preserving the functional implant. Two-stage revision is typically reserved for chronic infections or failed DAIR. Single-stage revision is less common for established infections due to higher failure rates. Long-term suppressive antibiotics are for patients unfit for surgery or with specific organisms. Amputation is a last resort.

Question 15

A 65-year-old active female presents with significant glenohumeral osteoarthritis. She has intact rotator cuff function and no history of shoulder instability. Her pain is refractory to conservative measures, and she desires surgical intervention. What is the MOST appropriate surgical treatment?

Explanation

For severe glenohumeral osteoarthritis with intact rotator cuff function, anatomic total shoulder arthroplasty (TSA) is the gold standard. It involves replacing both the humeral head and the glenoid component, providing excellent pain relief and functional improvement. Hemiarthroplasty replaces only the humeral head and is typically reserved for cases with a healthy glenoid, significant rotator cuff deficiency (but this patient has intact cuff), or younger, more active patients where glenoid wear is less of a concern. Reverse TSA is for rotator cuff tear arthropathy or failed TSA with cuff deficiency. Arthrodesis is a salvage procedure. Arthroscopic debridement is for less severe arthritis or as a temporizing measure.

Question 16

A 30-year-old male sustains a severe traction injury to his right arm after being pulled by a machine. He presents with a flail right arm, absent reflexes, and anesthesia in the entire limb. A Pancoast tumor has been ruled out. Which specific part of the brachial plexus is MOST likely injured?

Explanation

A flail arm with anesthesia in the entire limb after a severe traction injury indicates a complete brachial plexus avulsion, involving all five nerve roots (C5-T1). Upper trunk injuries (Erb's palsy) affect C5-C6 (shoulder abduction, external rotation, elbow flexion). Lower trunk injuries (Klumpke's palsy) affect C8-T1 (intrinsic hand muscles, forearm flexion/extension to some extent). A middle trunk injury is rare in isolation. Isolated nerve to serratus anterior (long thoracic nerve) causes scapular winging but not a flail arm. The description of 'absent reflexes' and 'anesthesia in the entire limb' strongly suggests a pan-plexus injury.

Question 17

A 48-year-old carpenter presents with chronic aching pain and weakness in his right shoulder, particularly with overhead work. On examination, he has atrophy of the supraspinatus and infraspinatus muscles, and weakness with resisted external rotation. Sensation is intact. EMG/NCS confirm denervation of these muscles. What is the MOST likely cause of his symptoms?

Explanation

Atrophy of the supraspinatus and infraspinatus muscles with weakness in external rotation and abduction, but intact sensation, is the classic presentation of suprascapular nerve entrapment. Common sites of entrapment include the suprascapular notch or the spinoglenoid notch. Axillary nerve entrapment would primarily affect the deltoid and teres minor, with sensory loss in the 'regimental badge' area. Long thoracic nerve palsy causes scapular winging (serratus anterior). Spinal accessory nerve injury affects the trapezius, causing shoulder droop and difficulty with arm elevation. Cervical radiculopathy C5-C6 can mimic some symptoms but would typically have dermatomal sensory changes and possibly reflex changes, and often other muscle involvement.

Question 18

A 60-year-old female presents with persistent shoulder pain and limited abduction following a proximal humerus fracture treated non-operatively 6 months ago. Radiographs show a malunited fracture with significant varus angulation and superior migration of the humeral head. Her active abduction is 60 degrees, and passive abduction is 80 degrees. She has significant crepitus with movement. What is the MOST appropriate next step in management?

Explanation

The patient presents with symptomatic malunion of a proximal humerus fracture, leading to pain and reduced range of motion. Given the varus angulation and superior migration, the glenohumeral mechanics are likely significantly altered, leading to impingement and possibly early arthrosis. A CT scan is crucial at this stage to fully characterize the extent of the malunion, assess the articular surface, and rule out avascular necrosis, which is vital for surgical planning. While arthroplasty (hemi or reverse) is a definitive treatment for pain and dysfunction, especially if glenohumeral arthritis has developed, understanding the precise bony anatomy of the malunion is the critical next step before deciding on an irreversible procedure. Continued physical therapy is unlikely to overcome a significant mechanical block from malunion. An osteotomy is a complex procedure, and arthroplasty is often preferred in older patients with significant deformity.

Question 19

A 25-year-old male sustains a direct blow to his right clavicle during a rugby match. He presents with pain, swelling, and a visible deformity in the middle third of his clavicle. Radiographs confirm a displaced midshaft clavicle fracture. Which of the following is an indication for operative management in this acute setting?

Explanation

While most midshaft clavicle fractures can be treated non-operatively, an open fracture is a clear indication for surgical management due to the risk of infection and to ensure proper wound care and reduction. Other relative indications for surgery include significant displacement (>100% cortical apposition loss), significant shortening (>2cm), tenting of skin, associated neurovascular injury, impending skin compromise, and floating shoulder. Shortening of less than 1 cm or displacement less than 50% are typically managed non-operatively. Non-dominant arm injury doesn't contraindicate surgery if other indications exist. Minimal comminution doesn't automatically mean surgical management.

Question 20

A 40-year-old construction worker presents with chronic, diffuse shoulder pain, weakness, and night pain. He denies any acute trauma. On examination, he has a positive Neer and Hawkins impingement sign, and a painful arc of motion. Resisted external rotation is weak but painless. MRI reveals a large, full-thickness supraspinatus tear and severe tendinopathy of the infraspinatus. What is the MOST appropriate surgical intervention?

Explanation

The patient has symptoms of impingement and a large, full-thickness supraspinatus tear. The most appropriate surgical intervention for a reparable full-thickness rotator cuff tear is rotator cuff repair, often combined with subacromial decompression (acromioplasty) to address impingement and facilitate healing. Subacromial decompression alone will not heal the tear and is insufficient. Arthroscopic debridement is generally reserved for very small, partial tears or irreparable tears where the goal is symptom management, not repair. Superior capsular reconstruction is for irreparable massive cuff tears. Reverse total shoulder arthroplasty is for rotator cuff tear arthropathy where the cuff is irreparable and severe arthritis exists, which is not described here.

Question 21

A 75-year-old female presents with a fall onto her left shoulder. Radiographs show a 4-part displaced proximal humerus fracture. She has a history of severe osteoporosis and multiple comorbidities, making a lengthy surgery high risk. What is the MOST appropriate management strategy?

Explanation

In an elderly patient with a displaced 4-part proximal humerus fracture and comorbidities, non-operative management with a sling is a viable option for those who are frail and have low functional demands, accepting a suboptimal outcome for fracture union and range of motion. While hemiarthroplasty was historically considered, reverse total shoulder arthroplasty (rTSA) has gained favor for displaced 3- and 4-part proximal humerus fractures in elderly, osteoporotic patients, especially those with poor bone quality or who are non-compliant, as it provides more reliable pain relief and functional outcomes than hemiarthroplasty or ORIF in this demographic. ORIF in osteoporotic bone is prone to fixation failure. Arthrodesis is a salvage procedure. The question implies the need for a pragmatic solution considering comorbidities. Given the options, non-operative management is a reasonable choice for very frail patients, but rTSA offers a better functional outcome for suitable candidates.

Question 22

A 22-year-old female presents with chronic shoulder pain and a sensation of the shoulder 'slipping out' during overhead activities. She has generalized ligamentous laxity and a positive sulcus sign bilaterally. Examination reveals positive apprehension and relocation tests, and generalized hypermobility. What is the MOST likely diagnosis?

Explanation

The presence of chronic instability, a sensation of 'slipping out', generalized ligamentous laxity, a positive sulcus sign, and positive apprehension/relocation tests strongly points towards Multidirectional Instability (MDI). MDI is often non-traumatic in origin and associated with generalized ligamentous laxity, affecting anterior, posterior, and inferior directions. Bankart lesions are typically associated with traumatic anterior dislocations. Posterior instability can occur, but MDI encompasses multiple directions. SLAP tears are often associated with overhead activities but typically present with pain and mechanical symptoms rather than global instability. Rotator cuff tendinopathy causes pain and weakness but not instability.

Question 23

A 38-year-old male sustains a fall onto his elbow while snowboarding. He presents with severe elbow pain, swelling, and a visible deformity. Radiographs show a posterior dislocation of the ulna and radius, a comminuted radial head fracture, and a fracture of the coronoid process. What specific surgical fixation is MOST critical to restore elbow stability in this 'terrible triad' injury?

Explanation

The 'terrible triad' of the elbow (elbow dislocation, radial head fracture, coronoid fracture) is a complex and highly unstable injury. To restore stability, all three components need to be addressed. While radial head replacement is crucial for restoring the radial column and ulnar collateral ligament (UCL) repair for medial stability, the MOST critical structure for initial stability after reduction and repair of the coronoid and radial head is often fixation of the coronoid process. The coronoid acts as an anterior buttress to the trochlea, preventing posterior subluxation/dislocation. Without adequate coronoid fixation, the elbow remains inherently unstable, especially after reduction. Ulnar collateral ligament repair is also important, but typically follows bony fixation. Lateral collateral ligament repair is less commonly the primary stabilizer in this posterior dislocation setting. Olecranon osteotomy is an approach, not a fixation.

Question 24

A 50-year-old male presents with chronic insidious onset medial elbow pain, exacerbated by carrying heavy objects and throwing. He denies neurological symptoms. On examination, there is tenderness over the medial epicondyle, and pain with resisted wrist flexion and pronation. Which of the following tendons is MOST commonly implicated in this condition?

Explanation

The symptoms described – chronic medial elbow pain, tenderness over the medial epicondyle, and pain with resisted wrist flexion and pronation – are classic for medial epicondylitis, also known as 'golfer's elbow' or 'thrower's elbow'. This condition involves inflammation and degeneration at the common flexor-pronator origin. The flexor carpi radialis (FCR) tendon is the most commonly affected tendon in medial epicondylitis. The extensor carpi radialis brevis is implicated in lateral epicondylitis. Triceps and biceps are unrelated. Pronator teres can contribute to pain, but FCR is typically the primary tendon involved.

Question 25

A 28-year-old male presents with sudden-onset, excruciating right shoulder pain that woke him from sleep. He denies trauma. On examination, the shoulder is exquisitely tender globally, and all active and passive movements are severely restricted and painful. Radiographs reveal a large, well-defined calcific deposit within the supraspinatus tendon. What is the MOST appropriate initial treatment?

Explanation

This is a classic presentation of acute calcific tendinitis, typically characterized by sudden onset, severe pain, and profound restriction of motion due to the inflammatory response to calcium crystal deposition. The initial management is focused on pain control and reducing inflammation. High-dose oral NSAIDs and potentially a short course of oral corticosteroids are often very effective. A subacromial corticosteroid injection can also provide significant pain relief by reducing inflammation. Physical therapy is not indicated during the acute painful phase. Arthroscopic debridement or needle lavage are options for chronic, refractory cases, but not typically the first-line for acute pain. ESWT is for chronic tendinitis.

Question 26

A 65-year-old female presents with chronic shoulder pain, night pain, and weakness in elevation and external rotation. She reports difficulty lifting her arm above 90 degrees. MRI shows a massive, irreparable rotator cuff tear involving the supraspinatus, infraspinatus, and subscapularis, with significant humeral head superior migration (rotator cuff tear arthropathy). Which of the following procedures is MOST appropriate to restore function and relieve pain?

Explanation

The patient has a massive, irreparable rotator cuff tear leading to rotator cuff tear arthropathy (hamstring sign). In this scenario, with significant superior migration of the humeral head and compromised active elevation, a reverse total shoulder arthroplasty (rTSA) is the procedure of choice. It medializes and distalizes the center of rotation, allowing the deltoid to function as the primary abductor and elevator, thereby compensating for the deficient rotator cuff. Arthroscopic debridement, partial repair, or acromioplasty are inadequate for this condition. Tendon transfers or superior capsular reconstruction are options for massive but reparable or potentially reparable tears, or when rTSA is contraindicated, but rTSA typically yields the most predictable and superior results for established rotator cuff tear arthropathy.

Question 27

A 30-year-old male presents with a fall onto an outstretched hand, resulting in a radial shaft fracture and distal radioulnar joint (DRUJ) dislocation. Which of the following describes this specific injury pattern?

Explanation

A radial shaft fracture with associated distal radioulnar joint (DRUJ) dislocation is classically known as a Galeazzi fracture-dislocation. Monteggia fracture-dislocation involves an ulnar shaft fracture and radial head dislocation. Essex-Lopresti lesion involves a radial head fracture with disruption of the interosseous membrane and DRUJ instability. Colles and Smith fractures are distal radius fractures. Understanding these eponyms is crucial for the FRCS exam.

Question 28

A 6-year-old child presents with elbow pain and refusal to use the arm after being swung by the hand. The elbow is held in slight flexion and pronation. On examination, there is no swelling or ecchymosis, and no tenderness over the bony prominences. Passive supination is painful. What is the MOST likely diagnosis?

Explanation

This classic presentation of a child being swung by the hand, presenting with elbow pain, refusal to use the arm (pseudoparalysis), holding the arm in flexion and pronation, and pain with passive supination without bony tenderness, is characteristic of 'Nursemaid's elbow' (radial head subluxation). This occurs when the annular ligament slips over the radial head. Supracondylar, radial head, and olecranon fractures would typically present with swelling, ecchymosis, and localized bony tenderness. Lateral epicondylitis is an overuse injury not seen in this age group from acute trauma.

Question 29

A 45-year-old female presents with a new onset of severe, aching pain in her right anterior shoulder and proximal arm. She reports no trauma, but describes the pain as having started abruptly a few days ago. On examination, the area around the biceps groove is exquisitely tender, and she has pain with resisted shoulder flexion and forearm supination. Radiographs are normal. What is the MOST likely diagnosis?

Explanation

The described symptoms of acute onset anterior shoulder/proximal arm pain, tenderness in the biceps groove, and pain with resisted shoulder flexion and forearm supination are highly indicative of biceps tendinopathy involving the long head of the biceps. While biceps tendinopathy often coexists with rotator cuff pathology or impingement, the primary symptoms described directly implicate the biceps tendon. Rotator cuff tendinopathy typically presents with weakness and pain in specific directions (abduction, rotation). Subacromial impingement causes pain with overhead activities. Glenohumeral osteoarthritis causes diffuse pain and crepitus. Calcific tendinitis typically causes sudden, excruciating pain with restricted range of motion.

Question 30

A 70-year-old male undergoes reverse total shoulder arthroplasty. Two years post-operatively, he presents with progressive shoulder pain, weakness, and limited elevation. Radiographs show subsidence of the humeral component and glenoid bone loss around the baseplate. The inflammatory markers (ESR, CRP) are mildly elevated. What is the MOST likely cause of his symptoms?

Explanation

Progressive pain, weakness, and limited elevation after a reverse total shoulder arthroplasty, along with radiographic evidence of component subsidence and glenoid bone loss, are classic signs of aseptic loosening. While periprosthetic joint infection (PJI) can also cause pain and loosening, the 'mildly elevated' inflammatory markers are more consistent with aseptic loosening than active infection (where markers are typically significantly elevated). Rotator cuff tears are not relevant after rTSA (the deltoid powers elevation). Impingement syndrome is less common with rTSA geometry. Axillary nerve neuropraxia would typically present earlier post-operatively with deltoid weakness and sensory changes.

Question 31

A 40-year-old male sustains a direct fall onto his shoulder, resulting in a displaced fracture of the midshaft of the clavicle. He also has a fracture of the glenoid neck and a significant tear of the rotator cuff. This combination of injuries is referred to as:

Explanation

A 'floating shoulder' injury is characterized by ipsilateral fractures of the clavicle (usually midshaft) and the scapula neck or glenoid (often involving the body). This results in loss of both superior (clavicle) and inferior (scapula) support of the shoulder girdle, making the glenoid 'float'. The associated rotator cuff tear indicates additional soft tissue damage but the bony components define the floating shoulder. Floating elbow is a distal humerus and forearm fracture. Terrible triad of the shoulder is not a recognized eponym. Pellegrini-Stieda syndrome is heterotopic ossification near the medial collateral ligament of the knee. Monteggia equivalent is a variation of Monteggia fracture-dislocation.

Question 32

A 10-year-old boy presents with right elbow pain and limited range of motion following a fall. Radiographs show a minimally displaced Salter-Harris Type II fracture of the distal humerus, with the fracture line extending through the metaphysis and physis. There are no signs of neurovascular compromise. What is the MOST appropriate management?

Explanation

Salter-Harris Type II fractures of the distal humerus, even if minimally displaced, need careful attention. If truly minimally displaced with no neurovascular compromise, closed reduction and long arm cast immobilization is often appropriate. Open reduction and internal fixation is typically reserved for irreducible or significantly displaced fractures, or when neurovascular compromise is present after failed closed reduction. Percutaneous pinning is usually done after closed reduction for unstable fractures. Sling immobilization with early range of motion is for very stable or non-displaced injuries, but not for a true fracture in this age group. Observation alone is risky for growth plate fractures.

Question 33

A 55-year-old female presents with chronic numbness and tingling in the ring and little fingers of her right hand, worse with prolonged elbow flexion. On examination, she has a positive Tinel's sign at the cubital tunnel and mild weakness of intrinsic hand muscles. What is the MOST appropriate initial management?

Explanation

The patient's symptoms are classic for cubital tunnel syndrome (ulnar nerve entrapment at the elbow). Initial management should always be conservative, focusing on activity modification (avoiding prolonged elbow flexion) and night splinting with the elbow in extension to relieve tension on the ulnar nerve. Surgical intervention (cubital tunnel release or anterior transposition) is reserved for cases that fail extensive conservative management, or for severe, progressive neurological deficits. Corticosteroid injections around nerves are generally not recommended due to potential nerve damage. Observation alone is insufficient given the progressive neurological symptoms.

Question 34

A 25-year-old male sustains a fall directly onto his shoulder during a basketball game. He presents with severe pain and inability to abduct his arm. On examination, the shoulder has lost its rounded contour and there is a palpable void beneath the acromion. Which of the following is the MOST important step PRIOR to attempting reduction?

Explanation

This patient's presentation is classic for an anterior glenohumeral dislocation. Prior to any attempt at reduction, a thorough neurovascular assessment is paramount. The axillary nerve is the most commonly injured nerve (up to 40% of cases), and brachial plexus or vascular injuries can occur. Documenting baseline neurological and vascular status allows for identification of iatrogenic injury during reduction or confirms pre-existing deficits. While analgesia is important for patient comfort and muscle relaxation, it does not supersede the neurovascular check. MRI is not needed acutely. Ice is secondary. Open reduction is rare for acute anterior dislocations unless irreducible.

Question 35

A 50-year-old male presents with chronic pain and stiffness in his right elbow after sustaining an elbow dislocation 6 months ago, which was treated non-operatively. He has a flexion contracture of 45 degrees and lacks 30 degrees of full extension. Radiographs show significant heterotopic ossification around the elbow joint. What is the MOST appropriate management?

Explanation

The patient has a significant post-traumatic elbow contracture with heterotopic ossification (HO). Once HO is mature (typically 6 months post-injury, indicated by 6 months of symptoms), and non-operative measures have failed, surgical excision of the HO and capsular release is the most effective treatment for restoring elbow range of motion. Intensified physical therapy alone is unlikely to overcome significant HO. Manipulation under anesthesia carries a risk of fracture or re-ossification and is generally not recommended in the presence of extensive HO. Serial casting may be used for milder contractures or as an adjunct. Corticosteroid injections are not indicated for HO.

Question 36

A 35-year-old male competitive swimmer presents with chronic posterior shoulder pain, worse during the late cocking and early acceleration phases of his stroke. On examination, he has tenderness in the posterior joint line and a positive 'relocation test' for posterior pain. MRI shows a posterior labral tear and some posterior capsular laxity. What is the MOST likely underlying pathology?

Explanation

The symptoms of posterior shoulder pain in an overhead athlete, particularly during late cocking and early acceleration, tenderness in the posterior joint line, and a positive posterior relocation test (relieving posterior pain), are classic for internal impingement (also known as postero-superior impingement). This condition involves impingement of the undersurface of the rotator cuff (supraspinatus/infraspinatus) and posterior labrum against the postero-superior glenoid rim in the abducted, externally rotated, and extended position, common in throwing athletes. Anterior instability, subacromial impingement, and biceps tendinopathy typically present with different pain patterns and examination findings. Adhesive capsulitis presents with global stiffness.

Question 37

A 68-year-old female presents with a fall onto her elbow. Radiographs show an intra-articular comminuted fracture of the distal humerus (C-type according to AO classification). The fracture extends into the articular surface and the metaphysis. Which of the following principles is MOST critical for achieving a successful outcome with surgical management?

Explanation

Distal humerus fractures, especially complex intra-articular ones (AO C-type), require meticulous anatomical reduction of the articular surface and stable internal fixation to allow for early range of motion. Stable fixation is paramount to prevent loss of reduction and allow early motion to minimize post-traumatic stiffness, which is a common and debilitating complication of these injuries. Non-operative management leads to poor outcomes for displaced articular fractures. Radial head replacement is for radial head fractures. Shortening the humerus is not a goal of distal humerus fracture management and would compromise function.

Question 38

A 45-year-old male presents with persistent pain and deformity after sustaining a displaced midshaft clavicle fracture treated non-operatively 1 year ago. Radiographs show a sclerotic non-union with significant shortening (2.5 cm). He is unable to perform overhead activities due to pain and weakness. What is the MOST appropriate management?

Explanation

Symptomatic displaced clavicle midshaft non-unions, especially with significant shortening and functional impairment, are best treated surgically with open reduction and internal fixation (ORIF) and often require bone grafting (autograft or allograft) to stimulate healing. Reassurance or electrical stimulation is unlikely to promote healing in a sclerotic non-union with significant displacement. Excision of the fragment would further compromise shoulder girdle integrity. Shoulder arthrodesis is a salvage procedure for glenohumeral joint pathology, not clavicle non-union.

Question 39

A 58-year-old female presents with a chronic posterior shoulder dislocation that was missed for 3 months. She has limited active external rotation and abduction. Radiographs confirm posterior dislocation with a significant anterior impression fracture of the humeral head (reverse Hill-Sachs lesion). What is the MOST appropriate surgical intervention?

Explanation

Chronic posterior dislocations, especially with a significant reverse Hill-Sachs lesion (anterior humeral head impression fracture), are often irreducible by closed means and require specific surgical approaches. The choice depends on the size of the humeral head defect. For defects involving 25-50% of the articular surface, disimpaction of the humeral head and filling the defect with allograft (e.g., McLaughlin procedure or modified Neer procedure) is a common technique to restore the humeral head contour and improve stability. If the defect is very large (>50%), or if significant glenohumeral arthritis is present, shoulder arthroplasty (hemi or total, or even reverse) may be considered. Closed reduction is unlikely to be successful after 3 months. Latarjet is for anterior instability with glenoid bone loss. Arthroscopic repair is for labral tears without significant bony defects.

Question 40

A 30-year-old male develops numbness and weakness in his intrinsic hand muscles 3 days after undergoing surgery for a complex elbow fracture. He now complains of severe, throbbing pain in his forearm, exacerbated by passive extension of his fingers. His forearm is tense to palpation. What is the MOST appropriate immediate management?

Explanation

The constellation of severe, throbbing pain out of proportion to the injury, pain with passive stretching of muscles (finger extension), paresthesia/numbness, and tense compartment to palpation are the cardinal signs and symptoms of acute forearm compartment syndrome. This is a surgical emergency. The MOST appropriate immediate management is emergency forearm fasciotomy to decompress the compartments and prevent irreversible ischemic damage to muscles and nerves (Volkmann's contracture). Removing the cast and observing is dangerous. Opioids mask symptoms. MRI is too slow and not indicated. Elevating the arm can reduce perfusion and worsen ischemia.

Question 41

A 60-year-old female presents with a painful shoulder and a history of progressive difficulty with external rotation. She denies trauma. On examination, active external rotation is significantly weaker than passive external rotation. She has no instability and full passive range of motion. MRI shows a massive tear of the supraspinatus and infraspinatus, but the subscapularis is intact. What is the MOST appropriate surgical option?

Explanation

This patient has a massive, but potentially reparable, postero-superior rotator cuff tear (supraspinatus and infraspinatus) with an intact subscapularis. Her symptoms indicate functional deficits from this tear. Latissimus dorsi tendon transfer is a recognized surgical option for symptomatic, irreparable postero-superior rotator cuff tears with an intact subscapularis, aiming to restore active external rotation and elevation. Subacromial decompression alone does not address the torn cuff. Repair of a massive tear, while ideal, may not be possible, and the question implies a challenging scenario with 'progressive difficulty'. Reverse total shoulder arthroplasty is typically for rotator cuff tear arthropathy where the cuff is irreparable and severe arthritis is present, or if significant superior migration is already present. Arthrodesis is a salvage procedure.

Question 42

A 28-year-old male sustains a fall onto his elbow. Radiographs show a fracture of the ulnar shaft and an associated anterior dislocation of the radial head. What is the appropriate eponymous classification for this injury?

Explanation

A Monteggia fracture-dislocation is defined by a fracture of the ulnar shaft associated with a dislocation of the radial head. The dislocation can be anterior, posterior, or lateral. Galeazzi fracture is a radial shaft fracture with DRUJ dislocation. Essex-Lopresti lesion is a radial head fracture with interosseous membrane disruption and DRUJ dislocation. Barton's and Colles fractures are types of distal radius fractures.

Question 43

A 60-year-old male with chronic shoulder pain and a massive rotator cuff tear has developed significant glenohumeral osteoarthritis and superior migration of the humeral head. He has minimal active elevation and persistent pain refractory to all conservative measures. He is otherwise healthy. What is the MOST appropriate definitive surgical treatment?

Explanation

This patient presents with rotator cuff tear arthropathy (massive irreparable cuff tear + glenohumeral osteoarthritis + superior humeral head migration). The gold standard for symptomatic rotator cuff tear arthropathy in a suitable patient is a reverse total shoulder arthroplasty (rTSA). rTSA re-establishes the center of rotation and allows the deltoid to effectively abduct and elevate the arm, providing significant pain relief and functional improvement. The other options are inadequate for this advanced pathology. Arthroscopic debridement, open repair, or tendon transfers are for lesser degrees of cuff pathology or when rTSA is contraindicated. Arthrodesis is a salvage procedure.

Question 44

A 30-year-old male presents with chronic anterior shoulder pain, clicking, and a sensation of 'catching' with overhead activities. He is a keen tennis player. On examination, O'Brien's test (active compression test) is positive, and he has pain with resisted supination of the forearm while the elbow is flexed (Speed's test). MRI confirms a superior labrum anterior posterior (SLAP) tear. What type of SLAP lesion is MOST likely given his symptoms?

Explanation

The symptoms of chronic pain, clicking, catching with overhead activities, positive O'Brien's, and Speed's test are highly suggestive of a SLAP tear. Type II SLAP lesions are the most common type and involve detachment of the superior labrum and the biceps anchor from the glenoid, making the biceps unstable. Type I is fraying/degeneration of the superior labrum. Type III involves a bucket-handle tear of the superior labrum with an intact biceps anchor. Type IV involves a bucket-handle tear of the superior labrum extending into the biceps tendon. Type V is a Type II SLAP tear extending into an anterior Bankart lesion.

Question 45

A 70-year-old female presents with severe pain and limited motion of her right shoulder after a fall. Radiographs show a severely comminuted fracture of the humeral head involving the articular surface, with four distinct fragments. Which of the following classifications is MOST commonly used for proximal humerus fractures?

Explanation

The Neer classification is the most commonly used system for classifying proximal humerus fractures, particularly in the English-speaking world. It categorizes fractures based on the number of 'parts' (humeral head, greater tuberosity, lesser tuberosity, shaft) that are displaced by >1cm or >45 degrees angulation. Gustilo-Anderson is for open fractures. AO/OTA is a comprehensive alphanumeric system. Salter-Harris is for physeal fractures in children. Rockwood classification is for AC joint injuries.

Question 46

A 35-year-old male presents with a visible 'winging' of his right scapula, particularly when he pushes against a wall. He reports difficulty with overhead activities. What nerve is MOST likely injured?

Explanation

Winged scapula, particularly with pushing against a wall (scapular protraction), is a classic sign of long thoracic nerve palsy, which innervates the serratus anterior muscle. The serratus anterior is responsible for holding the scapula against the thoracic wall and for upward rotation during abduction. Axillary nerve injury affects deltoid and teres minor. Suprascapular nerve affects supraspinatus and infraspinatus. Spinal accessory nerve affects the trapezius. Dorsal scapular nerve affects rhomboids and levator scapulae.

Question 47

A 20-year-old competitive swimmer presents with chronic shoulder pain, particularly during the pull-through phase of his stroke. He has a positive Jobe's test and Empty Can test. Which muscle/tendon unit is MOST likely involved?

Explanation

The Jobe's test (Empty Can test) specifically assesses the integrity and strength of the supraspinatus muscle-tendon unit. A positive test indicates weakness or pain originating from the supraspinatus, which is a common cause of shoulder pain and impingement, especially in overhead athletes. Subscapularis is tested with Lift-off or Belly-press. Teres minor and infraspinatus are tested with resisted external rotation. Long head of biceps is assessed with Speed's or Yergason's test.

Question 48

A 6-year-old boy presents with a displaced supracondylar humerus fracture. After successful closed reduction and percutaneous pinning, he develops a palpable mass in the antecubital fossa which gradually ossifies over several weeks. He now has a severe elbow flexion contracture. What is the MOST likely complication?

Explanation

Myositis ossificans is the most likely complication. It is the heterotopic formation of bone in soft tissues, commonly seen after trauma around the elbow, especially supracondylar fractures. Risk factors include repeated trauma, vigorous manipulation, and head injuries. It presents as a palpable mass and progressive loss of motion, leading to a flexion contracture. Non-union is a different issue. Compartment syndrome is an acute ischemic event. Volkmann's ischemic contracture is a severe ischemic contracture resulting from unaddressed compartment syndrome. Ulnar nerve entrapment might occur but wouldn't typically present with a palpable ossified mass and a severe flexion contracture as the primary problem.

Question 49

A 40-year-old female presents with a progressive inability to elevate her arm overhead. On examination, she has severe atrophy of the deltoid muscle, and sensory loss over the lateral aspect of the shoulder (regimental badge area). What is the MOST likely nerve injury?

Explanation

Atrophy of the deltoid and sensory loss over the 'regimental badge' area (lateral aspect of the shoulder) are the hallmark signs of axillary nerve injury. The axillary nerve innervates the deltoid and teres minor muscles and provides sensation to the inferior lateral shoulder. Long thoracic nerve injury causes scapular winging. Spinal accessory nerve injury affects the trapezius. Suprascapular nerve injury affects supraspinatus and infraspinatus. Musculocutaneous nerve injury affects biceps and brachialis, and sensation to the lateral forearm.

Question 50

A 62-year-old male with a history of recurrent anterior shoulder dislocations now presents with chronic pain and instability. Radiographs reveal significant glenoid bone loss (estimated at 30%) and a large engaging Hill-Sachs lesion. Which of the following procedures is MOST appropriate to address his instability?

Explanation

For recurrent anterior shoulder instability with significant glenoid bone loss (typically >20-25%), the Latarjet procedure is the procedure of choice. It involves transferring the coracoid process with the attached conjoint tendon to the anterior glenoid, providing a bone block effect, a sling effect from the conjoint tendon, and re-tensioning of the anterior capsule. Arthroscopic Bankart repair is typically ineffective with significant bone loss. Open Bankart repair might be considered for isolated soft tissue lesions but not extensive bone loss. Remplissage addresses an engaging Hill-Sachs lesion but not the glenoid bone loss. SLAP repair is for superior labral pathology.

Question 51

A 40-year-old female presents with chronic, diffuse pain around her elbow, which she describes as an 'aching' sensation, without specific tenderness. She has limited extension and flexion, but no instability. Radiographs show early degenerative changes with osteophytes. What is the MOST appropriate initial conservative management?

Explanation

The patient's presentation of chronic diffuse elbow pain, limited range of motion, and early degenerative changes suggests elbow osteoarthritis. The initial management for elbow osteoarthritis, like most degenerative conditions, is conservative. This includes activity modification, NSAIDs for pain and inflammation, and a physical therapy program focused on improving range of motion and maintaining strength. Surgical interventions (arthroscopy, osteophyte excision) are reserved for cases that fail conservative management. Immobilization is generally detrimental, leading to stiffness. Corticosteroid injections may provide temporary relief but are not a long-term solution and have potential risks.

Question 52

A 25-year-old male presents with a persistent feeling of arm 'heaviness' and fatigue, swelling, and discoloration of his right upper extremity, particularly after overhead activities. He also reports numbness in his ring and little fingers. A venous Doppler confirms subclavian vein thrombosis. What is the MOST likely underlying condition?

Explanation

The combination of arm heaviness, fatigue, swelling, discoloration, and subclavian vein thrombosis (Paget-Schroetter syndrome) in a young, active individual (often related to repetitive overhead activity) is highly characteristic of Venous Thoracic Outlet Syndrome (TOS). This results from compression of the subclavian vein in the costoclavicular space. Cervical radiculopathy causes nerve symptoms but not venous thrombosis. Cubital tunnel syndrome affects the ulnar nerve at the elbow. Brachial plexus injury can cause neurological deficits but typically not venous thrombosis. A Pancoast tumor is a malignancy in the lung apex causing TOS, but typically arterial or neurological, and less common in a young patient.

Question 53

A 50-year-old female undergoes arthroscopic rotator cuff repair. During the procedure, the posterior portal is placed too medially. Post-operatively, she develops weakness in abduction and external rotation, along with atrophy of the supraspinatus and infraspinatus muscles. Sensation is intact. What nerve is MOST likely injured?

Explanation

The suprascapular nerve is vulnerable during arthroscopic shoulder surgery, particularly during posterior portal placement if it's placed too medially and inferiorly, or during extensive debridement in the suprascapular or spinoglenoid notch. Injury to the suprascapular nerve results in weakness and atrophy of the supraspinatus (abduction) and infraspinatus (external rotation) muscles, typically without sensory deficits, as the nerve is primarily motor. Axillary nerve injury affects the deltoid and teres minor, with sensory loss in the regimental badge area. Musculocutaneous affects biceps. Long thoracic affects serratus anterior. Radial nerve affects wrist/finger extensors.

Question 54

A 14-year-old female presents with a progressive, painless deformity of her right shoulder, characterized by elevation and medial rotation of the scapula, and a short, thick neck. She has limited abduction of the shoulder. What is the MOST likely diagnosis?

Explanation

This clinical description is classic for Sprengel's deformity, which is congenital elevation and hypoplasia of the scapula. It is characterized by a high-riding scapula that is medially rotated, often associated with a short, thick neck, and limited shoulder abduction due to the abnormal position of the scapula and potential omovertebral bone. Klippel-Feil syndrome is congenital fusion of cervical vertebrae. Poland syndrome involves absence of the pectoralis major and often hand abnormalities. Congenital pseudoarthrosis of the clavicle is a distinct clavicular anomaly. Congenital muscular torticollis involves sternocleidomastoid contracture.

Question 55

A 28-year-old male presents with persistent elbow pain after a fall, particularly with forearm rotation and direct compression of the radial head. Radiographs show a Mason Type II radial head fracture (non-displaced, involving 30% of the articular surface). There is no mechanical block to motion. What is the MOST appropriate initial management?

Explanation

A Mason Type II radial head fracture that is non-displaced and involves less than 30% of the articular surface without a mechanical block is typically managed non-operatively. The mainstay of treatment is sling immobilization for comfort, followed by early active range of motion exercises to prevent stiffness. Open reduction and internal fixation is for displaced or mechanically blocking fractures. Radial head excision is generally reserved for comminuted fractures not amenable to fixation, particularly in older individuals. Long arm cast immobilization can lead to significant stiffness and is generally avoided. Radial head replacement is for severely comminuted or unreconstructable fractures, especially in unstable elbows (e.g., terrible triad).

Question 56

A 30-year-old female presents with an anterior shoulder dislocation. After successful closed reduction, which of the following is the MOST appropriate duration for initial immobilization in a sling for a first-time traumatic dislocation to minimize the risk of recurrence?

Explanation

For a first-time traumatic anterior shoulder dislocation in a young, active individual, initial immobilization in a sling for approximately 3 weeks is a common recommendation. This allows for initial soft tissue healing (e.g., Bankart lesion) and can reduce the risk of early recurrence compared to shorter immobilization periods. However, prolonged immobilization (e.g., 6+ weeks) offers no additional benefit in reducing recurrence and increases the risk of stiffness, particularly in older patients. For older patients, early mobilization is favored to prevent frozen shoulder. The specific position of immobilization (internal vs. external rotation) is also debated, but a conventional sling holds the arm in internal rotation.

Question 57

A 55-year-old male presents with chronic shoulder pain. He has a history of multiple previous surgeries for rotator cuff tears and impingement. On examination, he has significant weakness in external rotation and abduction, a positive lag sign for external rotation, and significant atrophy of the infraspinatus and supraspinatus. MRI shows a massive, irreparable posterior-superior rotator cuff tear. He has no significant glenohumeral arthritis. Which of the following is the MOST appropriate treatment option to restore active external rotation and improve function?

Explanation

This patient has a massive, irreparable postero-superior rotator cuff tear without significant glenohumeral arthritis. In this scenario, a latissimus dorsi tendon transfer is a recognized and effective procedure to improve active external rotation and overall function. The latissimus dorsi is transferred to the greater tuberosity to augment external rotation and depression of the humeral head. Reverse total shoulder arthroplasty is indicated when there is rotator cuff tear arthropathy (i.e., significant arthritis). Superior capsular reconstruction is for superior migration of the humeral head in an irreparable tear. Subacromial decompression and biceps tenodesis are insufficient. Arthrodesis is a salvage procedure.

Question 58

A 30-year-old construction worker presents with chronic pain and weakness in his right shoulder, specifically with heavy lifting and forceful internal rotation. He describes an audible 'pop' during a lifting incident 6 months ago. On examination, he has tenderness over the anterior aspect of the shoulder, and weakness with resisted internal rotation (positive 'belly press' and 'lift-off' tests). What structure is MOST likely injured?

Explanation

The symptoms of anterior shoulder pain, weakness with resisted internal rotation, and positive 'belly press' and 'lift-off' tests are highly suggestive of a subscapularis tendon tear. The subscapularis is the largest and most powerful rotator cuff muscle, primarily responsible for internal rotation and anterior stability. Supraspinatus is tested with abduction (Jobe's test). Infraspinatus and Teres minor are tested with external rotation. Long head of biceps tendinopathy causes pain in the bicipital groove and with resisted elbow flexion/forearm supination.

Question 59

A 70-year-old female presents with persistent pain, limited range of motion, and a visible step-off deformity at her right acromioclavicular (AC) joint following a fall 3 months ago. Radiographs show a Rockwood Type III AC joint injury. She has significant discomfort with overhead activities and reaching across her body. What is the MOST appropriate management?

Explanation

For symptomatic chronic Rockwood Type III AC joint injuries that have failed conservative management, surgical reconstruction of the coracoclavicular ligaments (often combined with AC ligament repair or reconstruction) is the most appropriate treatment to restore stability and reduce pain. This aims to restore the anatomical relationship and kinematics. Continued non-operative management is unlikely to resolve chronic symptoms in this active patient. Corticosteroid injections are temporary. AC joint arthrodesis is an option but less common than reconstruction. Distal clavicle excision (Mumford procedure) addresses AC joint pain from arthritis or impingement but does not restore stability to a Type III injury.

Question 60

A 55-year-old patient undergoes an open Bankart repair for recurrent anterior shoulder instability. Post-operatively, he develops difficulty with elbow flexion and sensation along the lateral forearm. What nerve is MOST likely injured?

Explanation

The musculocutaneous nerve innervates the biceps brachii and brachialis muscles (primary elbow flexors) and provides sensory innervation to the lateral forearm (lateral cutaneous nerve of the forearm). It is at risk during anterior shoulder approaches, particularly with excessive retraction of the conjoined tendon (coracobrachialis and short head of biceps), which lies close to this nerve. Axillary nerve injury would affect deltoid and teres minor. Radial nerve affects wrist/finger extensors. Ulnar nerve affects intrinsic hand muscles and medial forearm sensation. Median nerve affects forearm pronation, thumb, and index/middle finger flexion, and sensation to the thumb/index/middle fingers.

Question 61

A 72-year-old female presents with a spontaneous, acute rupture of her right pectoralis major tendon while gardening. On examination, she has ecchymosis in the anterior axilla and upper arm, and a visible defect in the anterior axillary fold. She has weakness with resisted adduction and internal rotation of the arm. What is the MOST appropriate management?

Explanation

Acute, complete tears of the pectoralis major tendon, especially in active individuals, are generally indications for surgical repair to restore strength in adduction and internal rotation and improve cosmesis. While the injury was 'spontaneous' in this patient, it implies a true rupture requiring surgical intervention to regain function. Non-operative management leads to persistent weakness and deformity. Latissimus dorsi transfer is for irreparable rotator cuff tears. Reverse TSA and arthrodesis are for glenohumeral joint pathology.

Question 62

A 25-year-old male sustains a direct blow to the lateral aspect of his elbow, resulting in a displaced fracture of the radial head. He also presents with severe wrist pain and instability of the distal radioulnar joint (DRUJ). Which of the following describes this complex injury pattern?

Explanation

An Essex-Lopresti lesion is a triad of radial head fracture, rupture of the interosseous membrane (connecting radius and ulna), and dislocation or subluxation of the distal radioulnar joint (DRUJ). This injury typically occurs from a fall onto an outstretched hand with a pronated forearm. Monteggia is ulnar fracture with radial head dislocation. Galeazzi is radial shaft fracture with DRUJ dislocation. Terrible triad is elbow dislocation + radial head fracture + coronoid fracture. Barton's is a distal radius fracture.

Question 63

A 7-year-old boy presents with left elbow pain and swelling following a fall from a monkey bar. Radiographs reveal a Gartland Type II supracondylar humerus fracture. His radial pulse is palpable and strong, and he has no neurological deficits. What is the MOST appropriate initial management?

Explanation

A Gartland Type II supracondylar humerus fracture is displaced posteriorly with an intact posterior cortex, making it inherently unstable. Given the displacement, closed reduction and percutaneous pinning (CRPP) is the treatment of choice. This provides stable fixation while preserving the biology and allows for early mobilization to prevent stiffness. Closed reduction and casting in hyperflexion is an older technique with risks of neurovascular compromise and redisplacement. ORIF is reserved for irreducible fractures or those with open wounds. Sling immobilization is for non-displaced fractures (Type I). Observation is inappropriate for a displaced fracture.

Question 64

A 40-year-old male presents with chronic shoulder pain, worse with overhead activities. He has a positive Neer and Hawkins impingement sign. Radiographs are normal. MRI shows no rotator cuff tear but significant subacromial bursitis. Which of the following conditions is MOST likely responsible for his symptoms?

Explanation

The patient's symptoms (chronic pain, worse overhead, positive impingement signs, subacromial bursitis on MRI) are classic for subacromial impingement syndrome. This is a common diagnosis where the rotator cuff tendons and subacromial bursa are compressed between the humeral head and the undersurface of the acromion. Frozen shoulder presents with global stiffness. Calcific tendinitis causes acute, severe pain with a calcific deposit. Glenohumeral osteoarthritis causes joint line pain and crepitus. AC joint arthritis causes pain localized to the AC joint, often worse with cross-body adduction.

Question 65

A 65-year-old female presents with chronic shoulder pain and inability to actively abduct her arm beyond 70 degrees. She has significant atrophy of the supraspinatus and infraspinatus. MRI shows a massive, irreparable rotator cuff tear and severe superior migration of the humeral head. Her pain is severe and refractory to conservative treatment. She is not a candidate for a reverse total shoulder arthroplasty due to medical comorbidities. What is the MOST appropriate salvage procedure to provide pain relief and improve function?

Explanation

In a patient with a massive, irreparable rotator cuff tear, severe superior migration of the humeral head (rotator cuff tear arthropathy), severe pain, and who is not a candidate for rTSA due to comorbidities, shoulder arthrodesis is a definitive salvage procedure. While it sacrifices motion, it provides excellent pain relief and a stable platform for a functional range of motion (typically 30-40 degrees of abduction and flexion) by relying on scapulothoracic motion. Subacromial decompression/debridement and hemiarthroplasty are unlikely to provide lasting relief or function. Latissimus dorsi transfer and superior capsular reconstruction are typically for patients where rTSA is not indicated but some active motion is desired, and the patient's condition allows for a more involved procedure. Given the 'salvage' nature and comorbidities, arthrodesis is a strong consideration.

Question 66

A 35-year-old male presents with persistent elbow pain and a sensation of clunking after a fall onto an outstretched hand. He has pain with forearm supination and extension of the elbow, and a positive pivot shift test. What is the MOST likely pathology?

Explanation

The symptoms of elbow pain, a sensation of clunking, pain with forearm supination and extension, and a positive pivot shift test are highly characteristic of posterolateral rotatory instability (PLRI) of the elbow. This injury results from insufficiency of the lateral ulnar collateral ligament (LUCL) complex, allowing the radial head to subluxate posteriorly and externally rotate relative to the ulna. Medial epicondylitis causes medial pain. Radial head fracture would have localized tenderness. UCL injury would cause medial instability. Olecranon bursitis is superficial swelling and inflammation.

Question 67

A 40-year-old male presents with shoulder pain, clicking, and a 'dead arm' sensation after a forceful throw. He has a positive apprehension test and pain during the late cocking phase of throwing. MRI reveals a Bankart lesion and a significant Hill-Sachs lesion. Which of the following is the MOST appropriate surgical intervention?

Explanation

The patient has a traumatic anterior shoulder instability with a Bankart lesion (anterior labral tear) and a significant Hill-Sachs lesion (compression fracture of the posterior humeral head). For traumatic anterior instability with a Bankart lesion, an open Bankart repair with capsular shift (if capsular laxity is also present) is a common and effective surgical intervention. Arthroscopic Bankart repair is typically preferred for isolated Bankart lesions without significant bone loss. The Latarjet procedure is usually reserved for cases with significant glenoid bone loss (>20-25%) or failed previous stabilization. Remplissage alone is for engaging Hill-Sachs lesions without significant glenoid bone loss or instability. SLAP repair is for superior labral tears.

Question 68

A 60-year-old patient presents with chronic pain and stiffness in their elbow. Radiographs show significant joint space narrowing, osteophyte formation, and loose bodies. The primary goal of surgical management for this patient with elbow osteoarthritis is to:

Explanation

For symptomatic elbow osteoarthritis, particularly with mechanical symptoms (locking, catching) due to osteophytes and loose bodies, the primary surgical goal is to debride the osteophytes, remove loose bodies, and perform a capsular release to improve the range of motion while preserving the inherent stability of the joint. Total elbow arthroplasty is reserved for severe, disabling arthritis, often in older, low-demand patients, or those with inflammatory arthritis. Arthrodesis leads to severe functional deficits. Radial head excision is for radial head fractures or isolated radiocapitellar arthritis. Full range of motion is rarely achievable or necessary for a good outcome; a functional arc of motion (30-130 degrees) is usually the goal.

Question 69

A 72-year-old female undergoes a reverse total shoulder arthroplasty for rotator cuff tear arthropathy. Postoperatively, what glenosphere positioning modification most effectively decreases the risk of scapular notching?

Explanation

Scapular notching is a common complication of reverse total shoulder arthroplasty. Placing the glenosphere with inferior translation and inferior tilt helps clear the inferior scapular neck and prevents mechanical impingement by the humeral cup.

Question 70

A 45-year-old male sustains a 'terrible triad' injury of the elbow. During surgical reconstruction, what is the most appropriate sequence of repair to restore elbow stability?

Explanation

The standard surgical sequence for a terrible triad injury works from deep to superficial: fixation or replacement of the coronoid, followed by the radial head, and finally repair of the lateral collateral ligament (LCL) complex.

Question 71

A 32-year-old competitive weightlifter feels a sudden 'pop' in his anterior chest while performing a bench press. He presents with bruising and weakness in shoulder internal rotation. If a complete pectoralis major rupture is present, which anatomical location is most commonly involved?

Explanation

Pectoralis major ruptures most frequently occur at the tendinous insertion of the sternal head onto the proximal humerus, particularly during eccentric loading exercises like the bench press.

Question 72

A 28-year-old male presents with a dull ache in his right shoulder and difficulty lifting his arm above shoulder level after blunt trauma to the posterior neck. Examination reveals lateral winging of the scapula. Which nerve is most likely injured?

Explanation

Lateral winging of the scapula is caused by trapezius muscle paralysis due to a spinal accessory nerve injury. Medial winging, in contrast, is associated with long thoracic nerve palsy affecting the serratus anterior.

Question 73

A 31-year-old elite volleyball player complains of vague posterior shoulder pain and isolated weakness in external rotation. MRI reveals a paralabral cyst in the spinoglenoid notch. Which of the following exam findings is most expected?

Explanation

A cyst at the spinoglenoid notch specifically compresses the distal branches of the suprascapular nerve, resulting in isolated denervation and atrophy of the infraspinatus muscle. The supraspinatus is spared because its nerve supply branches off proximal to the notch.

Question 74

A 42-year-old male undergoes a two-incision repair for an acute distal biceps tendon rupture. Postoperatively, he has limited forearm rotation but full elbow flexion and extension. Radiographs show abnormal bone formation between the radius and ulna. What is the most common cause of this specific complication?

Explanation

The two-incision technique for distal biceps repair carries a higher risk of radioulnar synostosis (heterotopic ossification) compared to the single-incision approach. This is primarily due to subperiosteal exposure and bleeding involving the ulnar footprint.

Question 75

A 52-year-old male presents with severe glenohumeral osteoarthritis. A preoperative axial CT scan shows a biconcave glenoid with 25 degrees of retroversion and posterior subluxation of the humeral head. According to the Walch classification, what type of glenoid morphology is this?

Explanation

In the Walch classification, a B2 glenoid is characterized by a biconcave surface with posterior wear, posterior subluxation of the humeral head, and increased retroversion. This is a critical consideration for implant positioning in total shoulder arthroplasty.

Question 76

A 72-year-old female with severe rotator cuff tear arthropathy undergoes a reverse total shoulder arthroplasty (RTSA). Which of the following best describes the primary biomechanical advantage of this implant design compared to native shoulder anatomy?

Explanation

Reverse total shoulder arthroplasty shifts the center of rotation medially and distally compared to the native joint. This recruits more deltoid fibers and significantly increases its moment arm, allowing the deltoid to compensate for the absent rotator cuff during elevation.

Question 77

A 45-year-old male falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. He undergoes operative management. Which of the following is the most widely accepted sequence of structural repair to systematically restore elbow stability?

Explanation

The standard inside-out surgical sequence for a terrible triad elbow injury is fixation of the coronoid first, followed by radial head repair or replacement, and finally lateral ulnar collateral ligament (LUCL) repair. This progressive stabilization restores the anterior buttress before addressing the lateral column.

Question 78

A 38-year-old bodybuilder undergoes surgical repair of a distal biceps tendon rupture using a traditional two-incision technique. Compared to a single-incision anterior approach, this patient is at a statistically higher risk for which of the following postoperative complications?

Explanation

The two-incision technique for distal biceps repair carries a higher risk of heterotopic ossification and radioulnar synostosis compared to the single-incision approach. Conversely, single-incision approaches carry a higher risk of lateral antebrachial cutaneous (LABC) nerve injury.

Question 79

A 28-year-old professional volleyball player presents with isolated atrophy and weakness of the infraspinatus. An MRI reveals a paralabral cyst located in the spinoglenoid notch. This finding is most highly associated with which of the following concomitant intra-articular pathologies?

Explanation

Paralabral cysts at the spinoglenoid notch are strongly associated with posterior superior labral (SLAP) tears, which create a one-way valve allowing joint fluid to accumulate. Compression at the spinoglenoid notch selectively affects the suprascapular nerve branches to the infraspinatus, sparing the supraspinatus.

Question 80

A 65-year-old male is 4 weeks post-operative from an anatomic total shoulder arthroplasty (TSA) utilizing a lesser tuberosity osteotomy. He reports a sudden 'pop' and severe anterior shoulder pain while reaching for a door. Examination reveals significantly increased passive external rotation and a positive belly-press test. What is the most appropriate next step in management?

Explanation

Acute failure of the subscapularis or lesser tuberosity osteotomy following anatomic TSA is a surgical emergency requiring prompt open repair. Nonoperative management typically leads to catastrophic anterior instability, component wear, and poor functional outcomes.

Question 81

A 35-year-old female complains of recurrent lateral elbow pain, clicking, and a subjective sense of instability when pushing off from a chair with her arms. Which of the following ligamentous structures is most likely deficient in this patient?

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily caused by insufficiency of the lateral ulnar collateral ligament (LUCL). Patients typically describe apprehension or subluxation when the elbow is axially loaded, supinated, and extended, such as pushing up from a chair.

Question 82

A 55-year-old male sustains a severely displaced 4-part proximal humerus fracture. Based on modern quantitative perfusion studies, injury to which of the following vessels places the humeral head at the greatest risk for avascular necrosis?

Explanation

Historically, the anterior humeral circumflex artery (arcuate branch) was thought to be the main blood supply to the humeral head. However, modern cadaveric perfusion studies demonstrate that the posterior humeral circumflex artery actually provides the predominant blood supply to the articular segment.

Question 83

A 32-year-old male weightlifter feels a tearing sensation in his anterior axilla while performing a heavy bench press. He has an obvious loss of the anterior axillary fold contour and weakness in internal rotation. MRI reveals a pectoralis major rupture located entirely within the musculotendinous junction. What is the most appropriate management?

Explanation

Pectoralis major ruptures at the musculotendinous junction or within the muscle belly itself are generally treated nonoperatively because the muscle tissue holds sutures poorly. Operative repair is primarily indicated for avulsions of the tendon from its insertion on the humeral shaft in active patients.

Question 84

A 42-year-old female requires open reduction and internal fixation of a Dubberley Type 2B coronal shear fracture of the capitellum extending into the trochlea. An extensile lateral approach (Kocher interval) is utilized. Distal extension of this exposure places which of the following neurologic structures at greatest risk?

Explanation

The extensile lateral approach utilizes the Kocher or Kaplan interval. Distal extension of this exposure risks injury to the posterior interosseous nerve (PIN) as it courses within the supinator muscle. Supination of the forearm helps move the PIN further anteriorly and away from the surgical field.

Question 85

A 24-year-old cyclist crashes directly onto the point of his shoulder. Radiographs demonstrate a Type V acromioclavicular (AC) joint injury with 150% superior displacement of the distal clavicle relative to the acromion. Which of the following describes the status of the stabilizing ligaments?

Explanation

A Type V acromioclavicular joint injury is characterized by greater than 100% superior displacement of the distal clavicle into the trapezius fascia. This severe displacement is biomechanically impossible without complete rupture of both the acromioclavicular and coracoclavicular (conoid and trapezoid) ligaments.

Question 86

A 21-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction via the docking technique after failing nonoperative management for a full-thickness anterior bundle tear. What is the most critical anatomical consideration when creating the ulnar tunnel to ensure proper biomechanics?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. Recreating its nearly isometric origin on the anteroinferior surface of the medial epicondyle is the most critical technical step to restore stable, physiologic elbow kinematics throughout the arc of motion.

Question 87

A 25-year-old elite overhead thrower presents with chronic posterior shoulder pain during the late cocking phase of throwing. Examination reveals a significant Glenohumeral Internal Rotation Deficit (GIRD) and a positive posterior impingement test. Diagnostic arthroscopy is most likely to reveal which of the following?

Explanation

Internal impingement in overhead athletes occurs when the posterosuperior rotator cuff is pinched between the greater tuberosity and the posterosuperior glenoid labrum during extreme abduction and external rotation. This repetitive trauma predictably leads to articular-sided cuff fraying and posterosuperior labral pathology.

Question 88

A 45-year-old female falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. Radiographs and CT show a posterior elbow dislocation, a comminuted radial head fracture, and a Type II coronoid fracture. During surgical reconstruction, what is the most widely accepted sequence of repair to restore elbow stability?

Explanation

The standard protocol for terrible triad injuries involves an inside-out or deep-to-superficial repair sequence. The coronoid is addressed first, followed by the radial head, and finally the lateral collateral ligament complex to restore joint kinematics.

Question 89

A 72-year-old female with severe osteoporosis sustains a 4-part proximal humerus fracture. The decision is made to proceed with a reverse total shoulder arthroplasty (rTSA). Successful healing of the greater tuberosity to the proximal humerus shaft most directly impacts which postoperative functional outcome?

Explanation

In reverse total shoulder arthroplasty for trauma, healing of the greater tuberosity is critical for restoring active external rotation and shoulder contour. Forward elevation is primarily restored by the deltoid tensioning inherent to the semi-constrained reverse implant design.

Question 90

A 24-year-old weightlifter presents with a dull ache in his right shoulder and noticeable lateral scapular winging. Examination reveals weakness in shoulder abduction, but normal forward elevation. Which nerve has most likely been injured?

Explanation

Lateral scapular winging is classically caused by trapezius muscle paralysis due to a spinal accessory nerve injury. Medial winging, by contrast, is associated with serratus anterior palsy from a long thoracic nerve injury.

Question 91

A 22-year-old collegiate baseball pitcher complains of deep shoulder pain during the late cocking phase of throwing. MRI arthrogram shows a Type II SLAP tear. After failing 6 months of targeted physical therapy, what is the most appropriate surgical intervention?

Explanation

In a young overhead athlete with a Type II SLAP tear failing conservative treatment, arthroscopic SLAP repair is the preferred surgical option to maintain the biceps anchor and normal shoulder kinematics. Biceps tenodesis is typically reserved for older patients, laborers, or revision settings.

Question 92

A 38-year-old male undergoes a single-incision anterior approach for a distal biceps tendon rupture repair. Postoperatively, he notes numbness along the radial-volar aspect of his forearm. Which nerve was most likely injured during the exposure?

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior approach to the distal biceps. The two-incision technique decreases this nerve risk but carries a higher risk of radioulnar synostosis.

Question 93

An 18-year-old football player is tackled onto his lateral shoulder and presents with severe sternoclavicular pain, shortness of breath, and hoarseness. The medial clavicle is not palpable. What is the most appropriate next step in management?

Explanation

Posterior sternoclavicular dislocations can compress mediastinal structures, causing life-threatening respiratory distress or vascular compromise. CT angiography of the chest is critical to evaluate the position of the medial clavicle relative to the great vessels before a cardiothoracic-backed reduction is attempted.

Question 94

A 40-year-old male sustained a highly comminuted radial head fracture from a fall. He underwent isolated radial head excision. Three months later, he presents with severe ulnar-sided wrist pain and radiographs demonstrate proximal migration of the radius. Injury to which anatomic structure was missed initially?

Explanation

The patient has an Essex-Lopresti lesion, consisting of a radial head fracture, interosseous membrane disruption, and distal radioulnar joint instability. Radial head excision in the setting of an unrecognized interosseous membrane tear leads to catastrophic proximal radial migration.

Question 95

A 32-year-old male felt a pop in his anterior axillary fold while bench pressing. Examination reveals loss of the anterior axillary contour and weakness in internal rotation. MRI shows rupture of the sternoclavicular head of the pectoralis major. What is the most common mechanism for this injury?

Explanation

Pectoralis major tendon ruptures classically occur during eccentric contraction with the arm extended and externally rotated. This places maximum tension on the sternoclavicular head, which is usually the first to fail during the eccentric phase of a bench press.

Question 96

A 55-year-old active male presents with a massive, irreparable posterosuperior rotator cuff tear. His subscapularis is intact. He demonstrates a severe external rotation lag but has preserved active forward elevation. Radiographs show minimal glenohumeral arthritis. What is the most appropriate surgical option?

Explanation

For an isolated irreparable posterosuperior cuff tear with external rotation weakness in a younger patient without arthritis, lower trapezius transfer is highly effective. It better restores external rotation kinematics due to its more anatomical line of pull compared to the latissimus dorsi.

Question 97

A 68-year-old female with advanced rheumatoid arthritis undergoes a primary linked Total Elbow Arthroplasty (TEA). To ensure implant longevity, which of the following is a mandatory permanent postoperative restriction?

Explanation

To prevent catastrophic aseptic loosening and polyethylene wear, patients with a Total Elbow Arthroplasty are strictly advised to adhere to a lifetime lifting restriction. This is typically limited to 1 pound repetitively and 5 to 10 pounds for single events.

Question 98

A 28-year-old female falls onto her extended arm. Radiographs and CT show a capitellum fracture extending into the lateral trochlear ridge with significant posterior comminution (Dubberley Type 3B). What is the most appropriate surgical approach to achieve stable fixation?

Explanation

Dubberley Type 3 fractures involve both the capitellum and trochlea, and the presence of posterior comminution (Type B) frequently necessitates a lateral or combined approach. A lateral approach with posterior extension allows adequate visualization to address both anterior and posterior articular surfaces securely.

Question 99

A 20-year-old collegiate pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft. Which functional bundle of the UCL is the primary restraint to valgus stress and is the primary target of this reconstruction?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. The anterior band is taut in extension, while the posterior band is taut in flexion; reconstructions primarily focus on restoring the stabilizing properties of the anterior bundle.

Question 100

A 45-year-old male sustains a traumatic right shoulder injury. He exhibits increased passive external rotation, a positive lift-off test, and a positive belly-press test. MRI confirms an isolated full-thickness tear of the subscapularis tendon. Which associated pathology must be carefully evaluated and addressed during surgical repair?

Explanation

The subscapularis tendon contributes to the medial wall of the bicipital groove and the transverse humeral ligament. A full-thickness tear of the subscapularis is highly associated with medial subluxation or dislocation of the long head of the biceps tendon.

AAOS & ABOS Upper Extremity MCQs (Set 4): Shoulder, Elbow, Wrist, Hand & Nerve Review | 2025-2026 Boards

Orthopedic Shoulder & Elbow Board Prep MCQs: Master Your Exams

Key Takeaway

Orthopedic Shoulder & Elbow Board Prep MCQs: Master Your Exams

Chapter Index