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Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

Orthopedic Surgery Board Review MCQs: Shoulder, Elbow & Trauma | Part 81

23 Apr 2026 145 min read 55 Views
Orthopedic Surgery Board Review MCQs: AAOS Master Bank Part 81

Key Takeaway

This page offers Part 81 of a comprehensive orthopedic surgery board review quiz, featuring 50 high-yield MCQs for AAOS and OITE exam preparation. Designed for orthopedic surgeons and residents, it covers critical topics like shoulder, elbow, trauma, and dislocation with detailed explanations and references.

Orthopedic Surgery Board Review MCQs: Shoulder, Elbow & Trauma | Part 81

Comprehensive 100-Question Exam


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Question 1

A 75-year-old female sustains a displaced 4-part proximal humerus fracture.

Which of the following is the most important biomechanical and clinical factor favoring reverse total shoulder arthroplasty (RTSA) over hemiarthroplasty in this scenario?





Explanation

RTSA is increasingly preferred over hemiarthroplasty for displaced 3- and 4-part proximal humerus fractures in the elderly because forward elevation is driven by the deltoid muscle rather than the rotator cuff. Hemiarthroplasty heavily relies on predictable healing of the greater and lesser tuberosities in their anatomic positions for a good functional outcome; tuberosity nonunion or malunion frequently leads to pseudoparalysis. RTSA circumvents this unpredictability.

Question 2

A 45-year-old male falls on an outstretched hand, sustaining a terrible triad injury of the elbow.

What is the recommended standard sequence of surgical reconstruction to restore concentric stability?





Explanation

The terrible triad of the elbow consists of an elbow dislocation, radial head fracture, and coronoid fracture. The standard surgical sequence works from 'deep to superficial' or 'inside out', starting with coronoid fixation (or anterior capsule repair), followed by radial head fixation or arthroplasty, and finally repair of the lateral ulnar collateral ligament (LUCL) complex to the lateral epicondyle. Medial collateral ligament repair or hinged external fixation is added if the elbow remains unstable after these steps.

Question 3

A 25-year-old male sustains a closed transverse fracture of the middle third of the humeral shaft. Examination reveals an inability to extend the wrist and fingers, as well as loss of sensation in the first dorsal web space. What is the most appropriate initial management?





Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture is typically a neuropraxia or axonotmesis (up to 90% recover spontaneously). The standard of care is nonoperative management of the fracture (e.g., functional brace) and observation of the nerve. If there is no clinical or electromyographic (EMG) evidence of recovery by 3 to 4 months, surgical exploration of the nerve is indicated.

Question 4

A 22-year-old cyclist falls onto his left shoulder and sustains a midshaft clavicle fracture. Which of the following clinical or radiographic findings is a widely accepted relative indication for operative fixation over nonoperative management?





Explanation

Indications for operative fixation of midshaft clavicle fractures include completely displaced fractures with > 2 cm of shortening, severe comminution (Z-deformity), skin tenting posing a risk for open fracture, open fractures, and concomitant vascular or progressive neurologic deficits. Undisplaced or minimally displaced fractures have a very high union rate with nonoperative care.

Question 5

A 30-year-old male bodybuilder feels a pop in his anterior axilla while performing a heavy bench press. Examination reveals an asymmetric chest wall with a loss of the anterior axillary fold contour and weakness in adduction and internal rotation. The rupture most commonly involves which part of the muscle complex and at what location?





Explanation

Pectoralis major ruptures most frequently occur in weightlifters (particularly during the bench press) during eccentric loading. The most common site of rupture is an avulsion of the sternal head tendon from its insertion on the humerus. The sternal head tendon typically twists and inserts deep and superior to the clavicular head tendon, placing it at the greatest biomechanical disadvantage during the lowest part of the bench press.

Question 6

A 40-year-old male is involved in a high-speed motor vehicle collision. Radiographs and CT show an extra-articular scapular body fracture. Which of the following is the most commonly accepted indication for open reduction and internal fixation (ORIF) of an isolated extra-articular scapular fracture?





Explanation

Most extra-articular scapula body and neck fractures are treated nonoperatively with good results. However, indications for surgery include significant displacement, typically defined as medial/lateral displacement > 20 mm, angular deformity > 45 degrees, or a glenopolar angle < 22 degrees. These thresholds aim to prevent altered rotator cuff mechanics and impingement.

Question 7

A 45-year-old manual laborer undergoes a two-incision surgical repair of a distal biceps tendon rupture. Compared to the single anterior incision technique, the two-incision technique is associated with a higher risk of which of the following complications?





Explanation

The classic two-incision technique (Boyd-Anderson or modifications) for distal biceps repair is historically associated with a higher risk of heterotopic ossification and proximal radioulnar synostosis, primarily due to muscle splitting and subperiosteal elevation of the ulna. The single anterior incision technique carries a higher rate of injury to the lateral antebrachial cutaneous nerve (LABCN) and the posterior interosseous nerve (PIN).

Question 8

A 35-year-old female falls onto her outstretched hand and presents with elbow pain. Radiographs demonstrate an isolated fracture of the capitellum with extension into the trochlea (Type IV, McKee modification of Bryan and Morrey). What is the preferred surgical approach for open reduction and internal fixation of this injury?





Explanation

Capitellum and trochlea shear fractures (Type IV) are best addressed via an extended lateral approach. Elevating the extensor origin off the lateral epicondyle and anterior capsule provides excellent visualization of the anterior articular surface of the distal humerus, allowing for anatomical reduction and placement of headless compression screws or anterior-to-posterior screws.

Question 9

A 28-year-old professional volleyball player presents with insidious onset of posterior shoulder pain and weakness. Physical exam reveals isolated atrophy of the infraspinatus with preserved supraspinatus bulk. Weakness is noted in external rotation, but abduction is normal. An MRI is most likely to show a paralabral cyst located in which of the following areas?





Explanation

Isolated atrophy and weakness of the infraspinatus indicate compression of the suprascapular nerve at the spinoglenoid notch, often secondary to a paralabral cyst associated with a posterior or SLAP labral tear. Compression more proximally at the suprascapular notch would affect both the supraspinatus and infraspinatus muscles.

Question 10

A 21-year-old male rugby player has a history of recurrent anterior shoulder dislocations. Imaging demonstrates a 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. He is scheduled for a Latarjet procedure. Which of the following structures is transferred along with the coracoid process to the anterior glenoid?





Explanation

The Latarjet procedure involves the transfer of the coracoid process, along with the attached conjoint tendon (short head of the biceps and coracobrachialis), to the anterior defect of the glenoid. This provides both a bony block and a dynamic 'sling' effect from the conjoint tendon over the subscapularis when the arm is abducted and externally rotated.

Question 11

A 19-year-old male is tackled during an American football game and sustains a posterior sternoclavicular joint dislocation. He complains of mild shortness of breath and dysphagia. What is the most appropriate next step in management?





Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the proximity of vital mediastinal structures (trachea, esophagus, great vessels). Management requires a CT scan to confirm the diagnosis and delineate the relationship to mediastinal structures. Reduction should be performed in the operating room with cardiothoracic surgery backup available, as there is a risk of catastrophic vascular injury during reduction.

Question 12

A 30-year-old male falls directly on his shoulder and is diagnosed with a Type V acromioclavicular (AC) joint separation. He undergoes an anatomic coracoclavicular (CC) ligament reconstruction. Which two ligaments are being reconstructed, and what is their normal anatomic orientation from medial to lateral?





Explanation

The coracoclavicular (CC) ligaments consist of the conoid and the trapezoid. Anatomically, the conoid ligament is medial and posterior, inserting on the conoid tubercle of the clavicle. The trapezoid ligament is lateral and anterior, inserting on the trapezoid line. Anatomic reconstruction aims to recreate these distinct structural bands.

Question 13

A 55-year-old female sustains a transverse olecranon fracture and undergoes tension band wiring. The biomechanical principle of tension band wiring relies on converting which of the following forces at the articular surface into which other force during active elbow extension?





Explanation

The tension band principle relies on placing the implant (wire or suture) on the tension side of a bone (the dorsal/posterior surface of the olecranon). As the triceps pulls and the elbow goes through its range of motion, the tensile forces at the posterior cortex are converted into dynamic compressive forces at the articular surface, promoting stability and healing.

Question 14

A 65-year-old female sustains a comminuted, intra-articular distal humerus fracture (AO/OTA type 13-C3).

During open reduction and internal fixation using dual plating, what is the consensus regarding the biomechanical stability of parallel versus orthogonal plating constructs?





Explanation

For bicolumnar distal humerus fractures, both parallel (plates on the medial and lateral ridges) and orthogonal (one medial, one posterolateral) plating techniques are acceptable. Biomechanical studies and randomized controlled trials have shown that properly applied parallel and orthogonal constructs provide equivalent clinical outcomes and comparable biomechanical stability, provided the principles of stable fixation (maximizing screws in the distal fragments) are met.

Question 15

A 45-year-old male with chronic kidney disease presents after a fall with an inability to actively extend his elbow against gravity. Examination reveals a palpable gap proximal to the olecranon. Radiographs show a small fleck of bone avulsed from the olecranon. What is the most appropriate management?





Explanation

The clinical presentation is classic for a complete triceps tendon rupture, which is highly associated with medical comorbidities like chronic kidney disease, hyperparathyroidism, or anabolic steroid use. The presence of an extensor lag and palpable gap is an indication for surgical repair. Primary repair is typically performed using transosseous tunnels or suture anchors.

Question 16

A 35-year-old male falls onto an outstretched hand. Radiographs reveal a comminuted radial head fracture with 4 distinct articular fragments, none of which are attached to the radial neck (Mason Type III). There is no clinical or radiographic evidence of elbow instability or interosseous membrane injury. What is the most appropriate surgical treatment?





Explanation

For Mason Type III (comminuted) radial head fractures with > 3 fragments that are entirely displaced from the radial neck, open reduction and internal fixation (ORIF) has a high failure rate and risk of nonunion or avascular necrosis. Radial head arthroplasty is the treatment of choice. Excision alone is no longer favored due to the risk of proximal radial migration, even in the absence of frank Essex-Lopresti injuries, and subsequent altered radiocapitellar/ulnocarpal mechanics.

Question 17

A 40-year-old female fell from a height and sustained a comminuted radial head fracture, which was treated with radial head excision. Three months later, she complains of severe ulnar-sided wrist pain. Radiographs demonstrate proximal migration of the radius and a positive ulnar variance. Which of the following is the most appropriate reconstructive option?





Explanation

This clinical scenario describes a longitudinal radioulnar dissociation (Essex-Lopresti injury) unmasked by radial head excision. The proximal radial migration causes ulnocarpal impaction. Treatment for chronic cases requires restoring the lateral column strut with a radial head arthroplasty and performing an ulnar shortening osteotomy to address the positive ulnar variance and unload the ulnocarpal joint.

Question 18

A 30-year-old male sustains a closed fracture of the distal third of the humerus. On examination, he has weak wrist extension and numbness in the first dorsal web space. Which of the following describes the most common mechanism of radial nerve injury in this specific fracture pattern?





Explanation

A spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture) has a high association with radial nerve palsy (up to 22%). As the nerve pierces the lateral intermuscular septum, it is relatively tethered. The most common mechanism of nerve injury in this pattern is direct contusion or entrapment between the fracture fragments, especially during injury or attempted closed reduction.

Question 19

A 35-year-old male is involved in a motorcycle accident and sustains an ipsilateral midshaft clavicle fracture and a scapular neck fracture. This injury pattern ('floating shoulder') disrupts the superior shoulder suspensory complex (SSSC). Which of the following constitutes an indication for operative fixation in this scenario?





Explanation

A 'floating shoulder' represents a double disruption of the superior shoulder suspensory complex (SSSC). Historically considered an absolute indication for surgery, current evidence supports nonoperative management for minimally displaced floating shoulders. Surgery is indicated when there is significant deformity, most commonly evaluated by a glenopolar angle < 22 degrees or marked medialization/displacement, to prevent scapular winging and rotator cuff dysfunction.

Question 20

A 28-year-old male overhead athlete complains of posterior shoulder pain and paresthesias in the lateral aspect of his arm. An MRI reveals atrophy of the teres minor muscle. Angiography shows occlusion of the posterior humeral circumflex artery with shoulder abduction and external rotation. The affected nerve in this syndrome passes through a space bordered by which of the following structures?





Explanation

Quadrilateral space syndrome involves the compression of the axillary nerve and the posterior circumflex humeral artery. The anatomic boundaries of the quadrilateral space are the teres minor (superiorly), teres major (inferiorly), long head of the triceps (medially), and the surgical neck of the humerus (laterally). Compression often leads to teres minor atrophy, deltoid weakness, and lateral arm numbness.

Question 21

A 42-year-old male sustains a severe blunt trauma to his left shoulder in a motor vehicle accident. Radiographs and CT scans reveal a multi-part fracture of the scapular body extending into the glenoid neck. In evaluating the glenoid neck fracture, the glenopolar angle (GPA) is measured. Which of the following statements regarding the glenopolar angle is most accurate?





Explanation

The glenopolar angle (GPA) assesses the rotational malalignment of the glenoid. It is measured on a true AP (Grashey) view or 3D CT. The angle is formed by a line drawn from the highest point of the glenoid cavity to the lowest point, and a second line drawn from the highest point of the glenoid cavity to the most inferior angle of the scapular body. The normal range is 30 to 45 degrees. A decreased GPA (<20-22 degrees) is associated with poor functional outcomes due to altered rotator cuff mechanics and is generally an indication for open reduction and internal fixation.

Question 22

A 38-year-old female presents with a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). Which of the following sequences of surgical repair is currently recommended to maximize elbow stability?





Explanation

The standard recommended sequence for treating a terrible triad injury is to fix from deep to superficial, or inside-out. The typical sequence is: 1) Coronoid fracture fixation (via anterior or anterior-medial aspect through the fracture hematoma or standard approach), 2) Radial head fixation or arthroplasty, 3) Lateral ulnar collateral ligament (LUCL) repair. 4) If the elbow remains unstable after these steps, the Medial Collateral Ligament (MCL) may be repaired or a hinged external fixator applied.

Question 23

A 45-year-old male undergoes a single-incision anterior approach for a distal biceps tendon repair. Postoperatively, he is noted to have a weakness in thumb and finger extension, but normal wrist extension with radial deviation. Sensory examination is completely normal. Which of the following nerves was most likely injured during the procedure?





Explanation

The posterior interosseous nerve (PIN) is at risk during the single-incision anterior approach to the distal biceps, particularly if retractors are placed carelessly around the radial neck or if the elbow is not kept in supination while drilling the radius. Injury results in an inability to extend the fingers at the MCP joints and the thumb. Wrist extension is typically preserved but occurs with radial deviation because the ECRL (innervated by the radial nerve proper before the PIN branches) is intact, whereas the ECU (innervated by the PIN) is denervated. Sensory exam is normal because the PIN is a purely motor nerve.

Question 24

A 28-year-old cyclist falls onto his right shoulder. Radiographs demonstrate a completely displaced, shortened midshaft clavicle fracture. Which of the following represents an absolute indication for open reduction and internal fixation of this acute clavicle fracture?





Explanation

Absolute indications for operative treatment of an acute clavicle fracture include: open fracture, associated neurovascular injury, skin tenting with impending breakdown, and severe polytrauma. Shortening >2 cm, complete displacement, and Z-deformity are relative indications based on increased risk of nonunion and symptomatic malunion, but they are not absolute indications.

Question 25

A 32-year-old professional volleyball player presents with insidious onset of vague posterior shoulder pain and profound weakness in external rotation. He has full, painless passive range of motion. Examination reveals isolated atrophy of the infraspinatus with a normal-appearing supraspinatus. MRI is most likely to show a cyst in which of the following locations?





Explanation

Isolated atrophy and weakness of the infraspinatus indicate compression of the suprascapular nerve at the spinoglenoid notch (after it has already given off its motor branches to the supraspinatus). This is commonly caused by a paralabral cyst associated with a posterior or SLAP labral tear. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus muscles.

Question 26

A 19-year-old male rugby player presents to the emergency department with acute shortness of breath and right-sided upper chest pain after a pile-up on the field. On examination, there is a visible depression at the right sternoclavicular joint. Which of the following is the most appropriate next step in management?





Explanation

Posterior sternoclavicular dislocations are high-energy injuries that can compromise the trachea, esophagus, and great vessels. A CT scan of the chest is the gold standard imaging modality to evaluate the extent of the dislocation and any associated intrathoracic injuries. Because of the risk of catastrophic vascular injury during reduction, it is strongly recommended that a cardiothoracic surgeon be available, and the reduction is often performed in the operating room.

Question 27

A 40-year-old female sustains a fall on an outstretched hand, resulting in an elbow injury. Radiographs and CT demonstrate a capitellar fracture extending medially to involve the majority of the trochlea, with a separate comminuted fragment of the posterior trochlea. According to the Dubberley classification, what type of fracture is this?





Explanation

The Dubberley classification of capitellum and trochlea fractures is based on the involvement of the trochlea and the presence of posterior condylar comminution. Type 1 involves primarily the capitellum. Type 2 involves the capitellum and trochlea as a single piece. Type 3 involves the capitellum and trochlea as separate fragments. The modifier 'A' indicates no posterior condylar comminution, and 'B' indicates posterior condylar comminution. The scenario describes capitellum and trochlea fractures with a separate posterior trochlea comminuted fragment, making it a Type 3B.

Question 28

A 25-year-old male sustains a closed transverse midshaft humerus fracture and presents with an immediate complete radial nerve palsy. He is treated with a functional brace. At what time point should an EMG/NCS be ordered if there is no clinical evidence of radial nerve recovery?





Explanation

For a closed humerus fracture with an immediate radial nerve palsy, observation is the standard of care as the vast majority are neuropraxias that will recover spontaneously. If there is no clinical evidence of recovery (e.g., return of brachioradialis function or wrist extension) by 12 weeks (3 months), an EMG/NCS should be obtained to evaluate for signs of reinnervation or severe denervation.

Question 29

In a reverse total shoulder arthroplasty (RTSA) performed for cuff tear arthropathy, what is the primary biomechanical advantage conferred by the implant design?





Explanation

The Grammont design of the reverse total shoulder arthroplasty (RTSA) medializes and inferiorizes the center of rotation. Inferiorization increases the resting tension of the deltoid, and medialization increases the deltoid moment arm (specifically the middle and posterior heads) by moving the center of rotation closer to the deltoid tuberosity line of pull. This allows the deltoid to effectively elevate the arm in the absence of a functional rotator cuff.

Question 30

A 55-year-old male presents with shoulder pain and weakness following a fall on an extended arm. On examination, he is able to passively rotate his arm internally behind his back. When the examiner pulls the patient's hand away from the back and asks the patient to maintain this position, the patient's hand falls back against his lumbar spine. What is this test called and what muscle is it testing?





Explanation

The test described is the Internal Rotation Lag Sign (IRLS). The examiner passively brings the patient's hand away from the back (maximal internal rotation) and asks the patient to hold it there. An inability to maintain the hand away from the back (a 'lag') indicates a subscapularis tear. The lift-off test requires the patient to actively push the hand away from the back against resistance, which tests the same muscle but is a different maneuver.

Question 31

A 12-year-old baseball pitcher complains of medial elbow pain that worsens when throwing. Radiographs show widening of the medial epicondyle apophysis. Which of the following is the most appropriate initial management?





Explanation

'Little Leaguer's Elbow' refers to medial epicondyle apophysitis, caused by repetitive valgus stress during throwing. The initial and most appropriate management is strict rest from throwing for 4-6 weeks to allow the inflammation to subside and the apophysis to heal, followed by physical therapy emphasizing core/shoulder strengthening and mechanics, and a gradual return-to-throwing program. Surgery is reserved for acute avulsion fractures of the medial epicondyle that are significantly displaced.

Question 32

A 28-year-old overhead athlete undergoes shoulder arthroscopy. The surgeon identifies a bucket-handle tear of the superior labrum. The biceps anchor remains firmly attached to the glenoid. According to the Snyder classification, what type of SLAP tear is this?





Explanation

According to the Snyder classification of SLAP (Superior Labrum Anterior to Posterior) tears: Type I is fraying of the superior labrum with an intact biceps anchor. Type II is detachment of the superior labrum and biceps anchor from the glenoid. Type III is a bucket-handle tear of the superior labrum with an intact biceps anchor. Type IV is a bucket-handle tear of the superior labrum that extends into the biceps tendon.

Question 33

A 6-year-old boy falls off monkey bars and sustains an injury to his right forearm. Radiographs demonstrate a fracture of the proximal third of the ulna with an anterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this?





Explanation

The Bado classification describes Monteggia fractures based on the direction of the radial head dislocation: Type I: Anterior dislocation of the radial head with fracture of the ulnar diaphysis (most common in children). Type II: Posterior dislocation of the radial head with fracture of the ulnar diaphysis (most common in adults). Type III: Lateral or anterolateral dislocation of the radial head with fracture of the ulnar metaphysis. Type IV: Anterior dislocation of the radial head with fractures of both the radius and ulna at the same level.

Question 34

In patients with idiopathic adhesive capsulitis, which of the following structures is most characteristically thickened and contracted, limiting external rotation with the arm at the side?





Explanation

Adhesive capsulitis is characterized by severe loss of both active and passive range of motion. The earliest and most distinct motion loss is external rotation with the arm at the side, which is primarily restricted by a contracted and thickened coracohumeral ligament (CHL) and the superior glenohumeral ligament. The CHL runs from the coracoid to the greater and lesser tuberosities, bridging the rotator interval. Contracture of the inferior capsule primarily limits abduction.

Question 35

A 35-year-old male presents with severe elbow stiffness 6 months following operative fixation of an elbow fracture-dislocation. Radiographs show mature heterotopic ossification (HO) bridging the medial humerus and ulna. He requests surgical intervention to improve his motion. Which of the following is true regarding surgical excision of HO in this setting?





Explanation

Surgical excision of heterotopic ossification (HO) around the elbow should be performed when the bone is mature to decrease the risk of recurrence. Clinical signs of maturity include normalization of alkaline phosphatase levels and a sharply defined, mature trabecular pattern on radiographs, typically occurring 6 to 9 months post-injury. Postoperative prophylaxis (radiation or indomethacin) is commonly used to prevent recurrence. The ulnar nerve is at high risk and must be carefully identified and often transposed.

Question 36

A 55-year-old smoker presents with persistent arm pain and mobility 9 months after sustaining a midshaft humerus fracture treated nonoperatively. Radiographs confirm an atrophic nonunion. What is the most appropriate surgical management?





Explanation

The treatment of choice for an atrophic humerus shaft nonunion is rigid stabilization and biologic stimulation. Open reduction and internal fixation (ORIF) with plate and screws provides superior compression and stability compared to intramedullary nailing for nonunions. Autologous bone grafting (e.g., iliac crest bone graft) is necessary because it is an atrophic nonunion, providing osteogenic, osteoinductive, and osteoconductive properties.

Question 37

A 28-year-old competitive weightlifter feels a sudden 'pop' and sharp pain in his anterior chest while performing a heavy bench press. Examination reveals an asymmetric chest wall with loss of the anterior axillary fold and weakness in internal rotation and adduction. MRI confirms a complete rupture of the pectoralis major. Which tendon tear location is most common and has the best outcomes with surgical repair?





Explanation

Pectoralis major ruptures most commonly occur in young athletic males during weightlifting (particularly bench press). The most common injury pattern is an avulsion of the sternal head (or the entire tendon) from its insertion on the lateral lip of the bicipital groove of the humerus. These injuries are best treated with early surgical repair (suture anchors or bone tunnels), which restores strength and cosmesis more reliably than nonoperative treatment.

Question 38

A 22-year-old motorcyclist is brought to the trauma bay after a high-speed collision. He has massive swelling over his left shoulder and is pulseless in the left upper extremity. Radiographs reveal a completely displaced clavicle fracture, multiple rib fractures, and marked lateral displacement of the scapula relative to the spine. What is the most appropriate initial diagnostic or therapeutic step regarding the vascular injury?





Explanation

The patient has a scapulothoracic dissociation, a highly lethal and devastating injury characterized by complete disruption of the scapulothoracic articulation. It is often accompanied by severe vascular (subclavian or axillary artery) and neurologic (brachial plexus avulsion) injuries. In a hemodynamically stable patient with an ischemic limb, CT angiography or formal angiography is critical to delineate the vascular injury before operative intervention (vascular bypass/repair). Closed reduction of the clavicle will not restore perfusion.

Question 39

A 25-year-old male with recurrent anterior shoulder instability and 25% glenoid bone loss undergoes a Latarjet procedure. Which of the following nerves is at greatest risk of injury during the coracoid osteotomy and transfer?





Explanation

The Latarjet procedure involves the transfer of the coracoid process and its attached conjoint tendon (short head of the biceps and coracobrachialis) to the anterior glenoid neck. The musculocutaneous nerve enters the coracobrachialis muscle typically 3-5 cm distal to the coracoid tip. Retraction of the conjoint tendon or careless dissection medial/distal to the coracoid places this nerve at significant risk during the initial exposure and osteotomy.

Question 40

A 65-year-old female presents with an acute anterior shoulder dislocation. Post-reduction radiographs demonstrate a concentric reduction of the glenohumeral joint, but a greater tuberosity fracture is now identified, displaced superiorly by 8 mm. What is the most appropriate management for this fracture?





Explanation

In the setting of an anterior shoulder dislocation associated with a greater tuberosity fracture, the fragment often reduces anatomically once the joint is relocated. However, if the greater tuberosity remains displaced superiorly by >5 mm (some authors suggest >3 mm in active patients), surgical fixation is indicated. Superior displacement leads to subacromial impingement and alters the biomechanics of the rotator cuff. Therefore, a superiorly displaced greater tuberosity fracture of 8 mm warrants open or arthroscopic reduction and internal fixation.

Question 41

A 35-year-old female presents with elbow pain after a fall. Imaging demonstrates a coronal shear fracture of the capitellum that includes the lateral trochlear ridge. According to the Bryan and Morrey classification, with McKee's modification, what type of fracture is this, and what is the preferred treatment?





Explanation

McKee modified the Bryan and Morrey classification by adding Type IV, which is a coronal shear fracture that involves the capitellum and extends medially to include the lateral trochlear ridge. Due to the extension into the trochlea, these fractures are highly unstable and require Open Reduction and Internal Fixation (ORIF). Type I (Hahn-Steinthal) involves a large osseous piece of capitellum. Type II (Kocher-Lorenz) involves a sleeve of articular cartilage with minimal bone. Type III (Broberg-Morrey) is a comminuted capitellum fracture.

Question 42

A 28-year-old male bodybuilder feels a pop in his anterior axilla while bench-pressing. Physical examination reveals a loss of the normal anterior axillary fold and weakness in internal rotation. Which of the following best describes the anatomical footprint of the torn structure and the recommended treatment?





Explanation

The pectoralis major inserts on the lateral lip of the bicipital groove. In young active patients with complete ruptures (especially at the musculotendinous junction or tendon insertion), early surgical repair is indicated to restore strength, particularly in adduction and internal rotation. The latissimus dorsi inserts on the floor of the groove, and the teres major inserts on the medial lip of the bicipital groove (Lady between two majors).

Question 43

A 45-year-old male sustains a severe closed chest injury with multiple rib fractures and a scapular fracture. Which of the following is considered an absolute indication for operative fixation of a scapular fracture?





Explanation

Absolute indications for operative fixation of a scapula fracture include an intra-articular glenoid fracture with >4-5 mm of step-off, or significant displacement that leads to glenohumeral instability. Scapular body fractures, even with up to 15-20 mm of displacement, are generally treated non-operatively. Glenoid neck fractures are typically treated operatively if angulation exceeds 40 degrees or displacement is >1 cm.

Question 44

A 19-year-old male presents with dyspnea, dysphagia, and right upper chest pain after a rugby tackle. On examination, the medial right clavicle is less prominent than the left. Which of the following is the most appropriate next step in management?





Explanation

The patient has a posterior sternoclavicular (SC) joint dislocation, which is a surgical emergency due to the proximity of the trachea, esophagus, and great vessels. A CT scan of the chest is the gold standard to confirm the diagnosis and assess mediastinal structures. Closed reduction should be attempted in the operating room (not the ED) with cardiothoracic surgery available in case of an acute vascular tear during the reduction maneuver.

Question 45

In a reverse total shoulder arthroplasty (RTSA) performed for cuff tear arthropathy, how does the biomechanical alteration of the center of rotation (COR) optimize the function of the deltoid muscle?





Explanation

RTSA medializes and distalizes the center of rotation (COR) of the glenohumeral joint. Medialization increases the deltoid's moment arm by moving the fulcrum further from the line of pull of the deltoid. Distalization tensions the deltoid, improving its resting length and increasing its ability to recruit muscle fibers to elevate the arm in the absence of a functioning rotator cuff.

Question 46

A 72-year-old female sustains a 4-part proximal humerus fracture. Which of the following radiographic findings (Hertel criteria) is the most reliable predictor of humeral head ischemia?





Explanation

Hertel identified specific radiographic predictors for humeral head ischemia following proximal humerus fractures. The most significant predictors include a posteromedial metaphyseal head extension (calcar length) of <8 mm attached to the articular segment, disruption of the medial hinge >2 mm, and an anatomical neck fracture pattern. A calcar length <8 mm and medial hinge disruption >2 mm are highly predictive of ischemia, as the main blood supply (ascending branch of the anterior humeral circumflex artery) is compromised.

Question 47

A 34-year-old male developed severe heterotopic ossification (HO) following open reduction and internal fixation of a terrible triad elbow injury 6 months ago. He complains of a rigid block to flexion and extension. Serum alkaline phosphatase levels are normal. Radiographs demonstrate mature trabeculated bone bridging the radiocapitellar joint. When is the most appropriate timing for surgical excision of the HO?





Explanation

Historical teaching recommended waiting 12-18 months before excising HO to allow it to "burn out" and prevent recurrence. However, modern evidence suggests that early excision (at 6 months or even earlier, often between 4-6 months) is safe and effective as long as the bone appears radiographically mature (trabeculated) and there is a clear clinical plateau in range of motion. Normalizing alkaline phosphatase or bone scans are no longer strictly required before excision.

Question 48

A 42-year-old male sustains a high-energy fall onto an outstretched hand. He is diagnosed with a comminuted, unsalvageable radial head fracture, an interosseous membrane tear, and distal radioulnar joint (DRUJ) disruption. What is the most appropriate surgical management strategy?





Explanation

This is an Essex-Lopresti injury. The interosseous membrane (IOM) and DRUJ are disrupted, leading to longitudinal radioulnar dissociation. Radial head resection alone is contraindicated, as it will lead to proximal migration of the radius, ulnar positive variance, and chronic wrist pain. The correct management is radial head replacement to restore the primary stabilizer against proximal radial migration, followed by assessment of the DRUJ. If the DRUJ is unstable, it should be pinned (typically in supination) or the TFCC repaired.

Question 49

A 25-year-old male sustains a closed mid-distal third spiral fracture of the humerus (Holstein-Lewis). At presentation, he has normal wrist and finger extension. Following closed reduction and splinting in the emergency department, he is unable to extend his wrist or fingers. What is the most appropriate management?





Explanation

A secondary radial nerve palsy (a deficit that develops after closed reduction or manipulation) is a widely accepted indication for immediate surgical exploration and fracture fixation. Primary radial nerve palsies (present on initial examination before manipulation) are generally observed. A Holstein-Lewis fracture is a spiral fracture of the distal third of the humerus, which carries a higher risk of radial nerve entrapment as the nerve pierces the lateral intermuscular septum.

Question 50

A 50-year-old female is being evaluated for nonoperative treatment of a midshaft clavicle fracture. Which of the following factors has the highest predictive value for the development of a nonunion?





Explanation

Displacement >100% (i.e., complete lack of cortical contact) is the single most significant predictive factor for nonunion in midshaft clavicle fractures treated nonoperatively. Other factors like advanced age, female gender, smoking, and comminution also increase the risk, but profound displacement (often combined with shortening >1.5 to 2 cm) has the strongest correlation with nonunion, making it a relative indication for ORIF.

Question 51

A 65-year-old male with a massive, irreparable posterosuperior rotator cuff tear presents with pseudoparalysis of the shoulder (active elevation <90 degrees). He has intact subscapularis function and minimal glenohumeral arthritis (Hamada Grade 1). What is the most reliable surgical option to restore active forward elevation?





Explanation

In older patients with a massive, irreparable rotator cuff tear and pseudoparalysis (inability to actively elevate the arm past 90 degrees), Reverse Total Shoulder Arthroplasty (RTSA) is the most reliable procedure to restore forward elevation. Tendon transfers (latissimus dorsi, lower trapezius) or SCR generally require a shoulder that is not pseudoparalytic to function optimally and are typically reserved for younger patients without pseudoparalysis.

Question 52

A 12-year-old boy falls on an outstretched hand and presents with a dislocated elbow and an associated medial epicondyle fracture. Following closed reduction of the elbow joint, radiographs show the medial epicondyle fragment is incarcerated within the joint space. What is the most appropriate definitive management?





Explanation

Incarceration of the medial epicondyle fragment within the elbow joint after closed reduction of an elbow dislocation is an absolute indication for Open Reduction and Internal Fixation (ORIF) or surgical extraction. If left inside, it will cause severe articular damage and mechanical block. While extraction techniques (valgus stress, wrist/finger extension, and supination) can occasionally free the fragment, ORIF provides definitive management for a fragment that was incarcerated, ensuring joint clearance and stability.

Question 53

During the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), which of the following is the generally recommended sequence of reconstruction?





Explanation

The standard 'inside-out' surgical sequence for a terrible triad injury of the elbow is: 1) Fixation of the coronoid fracture (or anterior capsule), 2) Repair or replacement of the radial head, and 3) Repair of the Lateral Collateral Ligament (LCL) complex to the lateral epicondyle. MCL repair is generally only performed if the elbow remains unstable after completing these three steps.

Question 54

When performing a single-incision anterior approach for a distal biceps tendon repair, which of the following anatomical maneuvers best protects the posterior interosseous nerve (PIN)?





Explanation

During a single-incision anterior approach for distal biceps repair, supination of the forearm brings the posterior interosseous nerve (PIN) closer to the operative field (anteriorly and medially), increasing the risk of injury. Pronation of the forearm moves the PIN away from the surgical field (laterally and posteriorly), providing maximum protection during retractor placement and drilling of the radial tuberosity.

Question 55

A 21-year-old collegiate baseball pitcher presents with vague posterior shoulder pain. Physical examination reveals 20 degrees of internal rotation and 130 degrees of external rotation in the throwing shoulder, compared to 60 degrees of internal rotation and 90 degrees of external rotation in the non-throwing shoulder. Total arc of motion is symmetric. What is the primary underlying pathoanatomy for this condition?





Explanation

The patient has Glenohumeral Internal Rotation Deficit (GIRD). This is defined as a loss of internal rotation in the throwing shoulder compared to the non-throwing shoulder, usually with a corresponding gain in external rotation, keeping the total arc of motion roughly equal. The primary pathoanatomy is a contracture/thickening of the posteroinferior capsule due to repetitive eccentric loads during the deceleration phase of throwing. Treatment begins with sleeper stretches to stretch the posterior capsule.

Question 56

A 26-year-old female complains of a painful clunking sensation at the superomedial border of her scapula with active elevation of the arm. She has failed 6 months of physical therapy and injections. She is scheduled for arthroscopic bursectomy and partial scapulectomy. Which bursa is most commonly inflamed in this condition?





Explanation

Snapping scapula syndrome (scapulothoracic crepitus) most commonly involves inflammation of the bursae located between the anterior scapula and the posterior chest wall. The two most prominent bursae are the supraserratus bursa and the infraserratus (scapulothoracic) bursa, which is located between the serratus anterior and the chest wall. The superomedial angle is the most common site of anatomical pathology (e.g., Luschka's tubercle) causing the snapping.

Question 57

A 22-year-old male undergoes diagnostic shoulder arthroscopy for recurrent anterior instability. The surgeon visualizes an avulsion of the anterior labroligamentous complex from the glenoid, but notes that the labrum is medially displaced and healed to the medial scapular neck with intact anterior scapular periosteum. What is the correct term for this lesion?





Explanation

An ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion) lesion occurs when the anterior labrum is avulsed but the periosteum remains intact, allowing the labrum to roll medially and heal in a displaced position on the anterior glenoid neck. A classic Bankart involves a complete tear of the labrum and periosteum. A Perthes lesion is a nondisplaced tear of the labrum with an intact strip of periosteum. GLAD is a Glenolabral Articular Disruption. HAGL is a Humeral Avulsion of the Glenohumeral Ligament.

Question 58

A 35-year-old trauma patient presents with an ipsilateral midshaft clavicle fracture and a fracture of the scapular neck. This 'floating shoulder' disrupts the superior shoulder suspensory complex (SSSC). Which of the following best describes the anatomical components of the SSSC?





Explanation

The Superior Shoulder Suspensory Complex (SSSC) is a bone-and-soft-tissue ring that secures the upper extremity to the axial skeleton. It is composed of the glenoid, the coracoid process, the coracoclavicular (CC) ligaments, the distal clavicle, the acromioclavicular (AC) joint, and the acromion process. A 'floating shoulder' typically involves double disruptions of this ring (e.g., fractures of the surgical neck of the scapula and the clavicle).

Question 59

A 78-year-old female with a history of severe osteoporosis and rheumatoid arthritis sustains a heavily comminuted, intra-articular distal humerus fracture (AO/OTA 13-C3). Based on current evidence, how does primary total elbow arthroplasty (TEA) compare to open reduction and internal fixation (ORIF) in this patient demographic?





Explanation

In elderly patients with severe osteopenia/osteoporosis and complex, comminuted intra-articular distal humerus fractures, primary Total Elbow Arthroplasty (TEA) has been shown to provide more reliable early and midterm functional outcomes with fewer complications and reoperations compared to ORIF. ORIF in osteoporotic bone is fraught with hardware failure, nonunion, and stiffness. TEA does restrict lifting to 5-10 lbs for life, which must be considered.

Question 60

A 45-year-old carpenter presents with a 2-week history of a swollen, erythematous, and exquisitely tender bursa over his left olecranon. He denies fever, but the overlying skin is warm, and he has extreme pain with any degree of passive elbow flexion. Aspiration yields 5 cc of turbid fluid with a WBC count of 85,000 cells/mm3. What is the most appropriate initial management?





Explanation

The presentation (warmth, erythema, severe pain with motion, and a bursal aspirate WBC > 50,000 cells/mm3) is highly suggestive of septic olecranon bursitis. The initial management consists of prompt administration of antibiotics (intravenous for severe cases). If the condition does not improve or worsens within 24-48 hours of appropriate antibiotic therapy, or if there is impending skin necrosis, surgical excision of the bursa (bursectomy) is indicated. Corticosteroid injections are strictly contraindicated in the presence of infection.

Question 61

A 35-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury to his elbow. Which of the following describes the most appropriate sequence of surgical reconstruction to restore stability?





Explanation

The standard inside-out (deep to superficial) sequence for terrible triad reconstruction is: 1) Coronoid fixation (or anterior capsule repair), 2) Radial head fixation or arthroplasty, 3) Lateral ulnar collateral ligament (LUCL) repair, and 4) Optional MCL repair or hinged external fixation if the elbow remains unstable.

Question 62

A 42-year-old man presents to the ER with his arm locked in hyperabduction over his head after a fall. Radiographs show an inferior glenohumeral dislocation (luxatio erecta). What is the most frequently injured neurovascular structure in this specific dislocation pattern?





Explanation

Luxatio erecta is a rare inferior shoulder dislocation. The axillary nerve is the most commonly injured neurovascular structure (up to 60% of cases). While axillary artery injuries have the highest rate of occurrence in luxatio erecta compared to other dislocation directions, nerve injuries (specifically the axillary nerve) remain overall more frequent.

Question 63

A 30-year-old competitive weightlifter feels a 'pop' in his anterior chest while performing a bench press. Examination reveals an asymmetric axillary fold. MRI confirms a rupture of the pectoralis major. Which head of the pectoralis major is most commonly injured in this mechanism, and where does it normally insert?





Explanation

In a bench press injury, the sternal head is most commonly ruptured. The pectoralis major tendon undergoes a 180-degree twist before inserting on the lateral lip of the bicipital groove. Because of this twist, the sternal head inserts deep and proximal to the clavicular head. Thus, it is under maximal tension when the arm is extended and externally rotated (the bottom of the bench press).

Question 64

A 22-year-old collegiate baseball pitcher complains of vague posterior shoulder pain and a loss of velocity. Physical exam shows a Glenohumeral Internal Rotation Deficit (GIRD) of 25 degrees compared to the contralateral side. What is the primary anatomic structure responsible for this clinical finding?





Explanation

GIRD in overhead throwing athletes is primarily caused by contracture and thickening of the posterior capsule, specifically the posterior band of the inferior glenohumeral ligament (PBIGHL). This alters glenohumeral kinematics, driving the humeral head posterosuperiorly during late cocking and increasing shear stress on the SLAP complex (peel-back mechanism).

Question 65

A 19-year-old man sustains a closed, highly displaced midshaft clavicle fracture from a motorcycle accident. He has diminished radial and ulnar pulses with pallor of the hand. CT angiogram shows an intimal tear of the subclavian artery. At what anatomical location does the subclavian artery typically pass in relation to the scalene muscles?





Explanation

The subclavian artery and the brachial plexus pass through the interscalene triangle, which is bordered anteriorly by the anterior scalene muscle, posteriorly by the middle scalene muscle, and inferiorly by the first rib. The subclavian vein passes anterior to the anterior scalene.

Question 66

A 65-year-old woman is undergoing open reduction and internal fixation (ORIF) of a 3-part proximal humerus fracture. The surgeon is careful to avoid varus malreduction. Which of the following surgical techniques best prevents postoperative varus collapse?





Explanation

In the surgical management of proximal humerus fractures, restoring medial column support is critical to prevent varus collapse and screw cut-out. This can be achieved by anatomic reduction of the medial cortex, use of an intramedullary fibular strut allograft, or precise placement of inferomedial locking screws (calcar screws) into the inferomedial quadrant of the humeral head.

Question 67

A 45-year-old man requires surgical repair of a chronic distal biceps tendon rupture. A two-incision (Boyd-Anderson) approach is selected to minimize the risk to the lateral antebrachial cutaneous nerve and radial nerve. However, this approach carries a higher risk of which of the following complications compared to a single anterior incision?





Explanation

The two-incision approach for distal biceps repair was designed to decrease the risk of radial/PIN injury associated with an extensive single anterior exposure. However, dissecting between the radius and ulna to pass the tendon increases the risk of heterotopic ossification and radioulnar synostosis. Using a muscle-splitting approach through the supinator and avoiding subperiosteal elevation on the ulna minimizes this risk.

Question 68

A 28-year-old motorcyclist is brought in after a high-speed collision. He has massive swelling over his left shoulder, an ipsilateral clavicle fracture, and an acromioclavicular separation. His arm is completely flail and pulseless. Chest radiograph reveals lateral displacement of the scapula compared to the contralateral side. What is the most critical initial step in management?





Explanation

Scapulothoracic dissociation is a devastating, high-energy injury characterized by complete disruption of the scapulothoracic articulation. It is highly associated with massive vascular injuries (subclavian/axillary artery) and complete brachial plexus avulsions. Due to the high mortality rate from exsanguination, emergent vascular assessment (CT angiography) and life-saving hemorrhage control in conjunction with vascular surgery is the most critical initial step.

Question 69

A 32-year-old woman sustains a displaced capitellum fracture. Preoperative CT reveals the fracture involves both the capitellum and the lateral trochlear ridge in a single fragment, with significant comminution of the posterior capitellum. According to the Dubberley classification, what type of fracture is this?





Explanation

The Dubberley classification of capitellum and trochlea fractures is based on the extent of articular involvement and the presence of posterior comminution (A = no posterior comminution, B = posterior comminution). Type 1 involves only the capitellum. Type 2 involves the capitellum and the lateral trochlear ridge in a single piece. Type 3 involves separate fragments of the capitellum and trochlea. Because this involves the capitellum and lateral trochlear ridge in a single piece with posterior comminution, it is a Type 2B.

Question 70

A 25-year-old man sustains a closed, middle-third humeral shaft fracture. On presentation, he has a complete primary radial nerve palsy. He is managed non-operatively in a functional brace. At 12 weeks follow-up, there is radiographic evidence of bridging callus, but the patient still has 0/5 wrist extension, 0/5 finger extension, and absent brachioradialis function. EMG shows no evidence of reinnervation. What is the most appropriate next step?





Explanation

For a closed humeral shaft fracture with a primary radial nerve palsy, observation is the standard of care because 70-90% will spontaneously recover. Recovery usually begins by 3-4 months. If there is no clinical or electromyographic (EMG) evidence of recovery by 12 weeks (3 months), surgical exploration of the nerve is indicated. Since the fracture is healing, concurrent ORIF is not necessary.

Question 71



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





Explanation

Hertel described reliable predictors of humeral head ischemia. The most important predictors for AVN in proximal humerus fractures include a short metaphyseal head extension (< 8 mm of calcar attached to the articular segment), disruption of the medial hinge (> 2 mm of displacement between the shaft and head), and an anatomic neck fracture pattern. An intact medial hinge and a calcar segment > 8 mm protect the blood supply (anterior and posterior circumflex humeral arteries).

Question 72

A 29-year-old male presents with recurrent snapping and pain on the lateral side of his elbow when pushing up from a chair. Physical examination demonstrates a positive lateral pivot-shift test of the elbow. Which structure is fundamentally incompetent in this condition?





Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily caused by insufficiency or a tear of the Lateral Ulnar Collateral Ligament (LUCL). The LUCL is the primary restraint to varus and posterolateral rotatory stress. The pathognomonic sign is a positive lateral pivot-shift test, and patients often describe symptoms when bearing weight on the extended and supinated arm.

Question 73

A 40-year-old man sustains a 'floating shoulder' injury, defined by ipsilateral fractures of the clavicle and the scapular neck. According to the Goss classification, a double disruption of the superior shoulder suspensory complex (SSSC) requires surgical fixation. Which two structures primarily comprise the SSSC struts connecting the ring to the axial skeleton and appendicular skeleton?





Explanation

The Superior Shoulder Suspensory Complex (SSSC) is a bone-and-soft-tissue ring. The superior and inferior struts that connect this ring to the axial skeleton and the rest of the appendicular skeleton are the middle clavicle and lateral scapular body/spine, respectively. A floating shoulder classically involves disruptions of the SSSC in two places, destabilizing the suspensory mechanism.

Question 74



An orthopedic surgeon is planning an olecranon osteotomy approach for open reduction and internal fixation of an AO type 13-C3 distal humerus fracture. To optimize the repair of the osteotomy at the end of the procedure and minimize articular step-off, what type of osteotomy is recommended?





Explanation

For a transolecranon approach to the distal humerus, a chevron (V-shaped) osteotomy with the apex directed distally is preferred. The osteotomy is directed into the 'bare area' (a region devoid of articular cartilage) of the greater sigmoid notch. This shape provides rotational stability and interdigitation upon repair, decreasing the risk of malunion and articular step-off.

Question 75

A 16-year-old rugby player falls directly onto his posterolateral shoulder and presents with severe pain, shortness of breath, and dysphagia. Examination shows an absent medial clavicular prominence on the affected side. A CT scan confirms a posterior sternoclavicular dislocation. After a failed closed reduction in the operating room under general anesthesia, what is the safest next step in management?





Explanation

Posterior sternoclavicular dislocations can be life-threatening due to compression of the mediastinal structures (trachea, esophagus, great vessels). If closed reduction fails or if the patient remains highly symptomatic (dyspnea, dysphagia), open reduction is indicated. Because of the immediate proximity to the great vessels, this must be performed with a cardiothoracic surgeon on standby in case of catastrophic hemorrhage.

Question 76

A 35-year-old carpenter presents with a dull ache in his shoulder and weakness with overhead activities after carrying heavy beams over his right shoulder for several weeks. On physical examination, lateral winging of the scapula is noted, which worsens when the patient attempts to abduct the arm. Which nerve is most likely injured, and which muscle is affected?





Explanation

Lateral winging of the scapula (the scapula translates laterally and the superior angle rotates laterally) is classically caused by a trapezius palsy due to injury to the spinal accessory nerve (CN XI). Medial winging is caused by serratus anterior palsy due to injury to the long thoracic nerve. Direct pressure from carrying heavy loads on the shoulder is a classic mechanism for spinal accessory neuropraxia.

Question 77

A 55-year-old manual laborer has a massive, irreparable posterosuperior rotator cuff tear (supraspinatus and infraspinatus). He has preserved forward elevation but severe weakness in external rotation (Hornblower's sign positive). He has no glenohumeral arthritis. Which of the following is the classic tendon transfer utilized to restore active external rotation in this specific scenario?





Explanation

For massive irreparable posterosuperior cuff tears with isolated loss of active external rotation and an intact subscapularis, the latissimus dorsi transfer (LDT) has historically been the workhorse to restore active external rotation and depress the humeral head. The latissimus (normally an internal rotator) is redirected to the greater tuberosity to function as an external rotator.

Question 78



A 65-year-old osteoporotic female sustains a highly comminuted, intra-articular distal humerus fracture (AO type 13-C3) that cannot be anatomically reconstructed. The surgeon opts for a Total Elbow Arthroplasty (TEA). Which of the following is an absolute contraindication to primary TEA for a distal humerus fracture?





Explanation

Total elbow arthroplasty (TEA) is an excellent option for elderly patients with unreconstructible, comminuted distal humerus fractures. Osteoporosis and rheumatoid arthritis are indications or favorable conditions for TEA over ORIF. Active infection or inadequate soft-tissue coverage are absolute contraindications to joint arthroplasty due to the unacceptable risk of deep periprosthetic joint infection.

Question 79

A 42-year-old bodybuilder feels a pop in his posterior elbow during heavy triceps extensions. He has loss of active elbow extension against resistance. MRI confirms a complete avulsion of the triceps tendon from the olecranon. During surgical repair, passing sutures through transosseous drill holes in the olecranon is planned. Which configuration provides the strongest biomechanical repair for triceps avulsion?





Explanation

Biomechanical studies have demonstrated that a modified Krackow locking stitch in the triceps tendon passed through transosseous drill holes in a cruciate (crossed) configuration provides superior construct strength and minimizes gap formation compared to simple, mattress, or figure-of-eight configurations.

Question 80

A 35-year-old male presents with severe elbow stiffness 6 months after a complex fracture-dislocation. Radiographs demonstrate extensive heterotopic ossification (HO) bridging the radiocapitellar and ulnohumeral joints. His inflammatory markers are normal. The surgeon plans an open arthrolysis and excision of the HO. What is the most effective postoperative prophylaxis regimen to prevent recurrence of HO in this high-risk patient?





Explanation

Patients requiring surgical excision of extensive heterotopic ossification around the elbow are at extremely high risk for recurrence. The most effective prophylactic regimen is a combination of localized single-dose radiation therapy (typically 700 cGy administered within 24-48 hours postoperatively) and a nonsteroidal anti-inflammatory drug (NSAID) such as indomethacin for 3-6 weeks.

Question 81

A 42-year-old male is involved in a high-speed motorcycle crash and sustains an isolated scapula fracture. Which of the following parameters is considered a relative indication for open reduction and internal fixation of a scapular body/neck fracture?





Explanation

A glenopolar angle (GPA) of less than 22 degrees alters the biomechanics of the shoulder significantly and is associated with poor functional outcomes if treated non-operatively, making it a relative indication for surgery. Other operative indications include >40 degrees of angulation, >1-2 cm of medial translation, and intra-articular step-off >4-5 mm.

Question 82

A 19-year-old rugby player sustains a posterior sternoclavicular (SC) joint dislocation. Closed reduction is planned in the operating room. Which of the following ligamentous structures is the most critical stabilizer resisting both anterior and posterior translation of the SC joint?





Explanation

Biomechanical studies have demonstrated that the posterior sternoclavicular ligament is the most important stabilizer against both anterior and posterior translation of the medial clavicle. Its complete disruption is necessary for an anterior or posterior SC joint dislocation to occur.

Question 83

A 65-year-old female presents with persistent shoulder pain and weakness 9 months after a 2-part surgical neck proximal humerus fracture treated conservatively. Radiographs demonstrate a surgical neck nonunion. There is no evidence of avascular necrosis of the humeral head, and joint spaces are preserved. What is the most appropriate surgical management?





Explanation

For a proximal humerus surgical neck nonunion with adequate humeral head bone stock, no AVN, and no glenohumeral arthritis, joint preservation is the preferred approach. ORIF with locking plates augmented by an intramedullary fibular strut allograft provides necessary biomechanical stability and biological support for healing.

Question 84

A 45-year-old male undergoes repair of a chronic distal biceps tendon rupture utilizing a single-incision anterior approach. Postoperatively, he notes numbness over the radial aspect of his forearm. Which nerve was most likely injured, and what is the typical mechanism of injury?





Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during the single-incision anterior approach to the distal biceps. It is typically injured via traction or direct compression from retractors placed on the lateral side of the wound.

Question 85

A 24-year-old weightlifter complains of a snapping sensation and medial elbow pain during triceps extensions. Examination reveals a snapping structure over the medial epicondyle during elbow flexion. Ultrasound demonstrates ulnar nerve subluxation as well as an additional snapping muscular structure. What is the most likely diagnosis?





Explanation

Snapping triceps syndrome involves the subluxation of the medial head of the triceps over the medial epicondyle during active elbow flexion. It is frequently associated with concurrent ulnar nerve subluxation and can cause ulnar neuritis.

Question 86

A 72-year-old female presents with chronic shoulder pain. Radiographs show a massive rotator cuff tear, an acromiohumeral interval of 3 mm, and 'acetabularization' of the acromion, but no significant glenohumeral cartilage loss. According to the Hamada classification, what stage is this?





Explanation

In the Hamada classification for rotator cuff arthropathy: Stage 1 = AHI > 6 mm; Stage 2 = AHI < 5 mm; Stage 3 = AHI < 5 mm with acetabularization of the acromion; Stage 4 = Glenohumeral arthritis; Stage 5 = Humeral head collapse.

Question 87

To optimize deltoid function in a patient undergoing reverse total shoulder arthroplasty, the design of the prosthesis alters the center of rotation of the glenohumeral joint. In which directions is the center of rotation shifted compared to the native anatomy?





Explanation

A reverse total shoulder arthroplasty medializes and inferiorizes the center of rotation. This increases the moment arm of the deltoid muscle and recruits more of its fibers (especially anterior and posterior fibers) to compensate for the absent rotator cuff during arm elevation.

Question 88

A 35-year-old female sustains a coronal shear fracture of the distal humerus involving the capitellum that extends medially to include the majority of the trochlea. Which classification applies to this fracture pattern?





Explanation

McKee's modification (Type IV) to the Bryan and Morrey classification describes a coronal shear fracture of the capitellum that extends medially to involve most or all of the trochlea. Type I is a large osseous capitellar fragment. Type II is a cartilaginous shell. Type III is comminuted.

Question 89

In a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), the coronoid fracture typically corresponds to which pattern according to the O'Driscoll classification?





Explanation

Terrible triad injuries of the elbow typically feature a transverse fracture of the coronoid tip (O'Driscoll Type 1). Anteromedial facet fractures are associated with varus posteromedial rotatory instability, and base fractures are often seen in anterior olecranon fracture-dislocations.

Question 90

A 40-year-old male with a conservatively treated midshaft clavicle fracture 5 years ago presents with arm fatigue, numbness, and tingling in the ulnar digits when working overhead. Imaging reveals a hypertrophic nonunion of the clavicle. Which structure is most likely being directly compressed by the callus?





Explanation

Hypertrophic callus or nonunion of the middle third of the clavicle can impinge upon the underlying neurovascular structures in the thoracic outlet. The medial cord of the brachial plexus (which contributes to the ulnar nerve) and the subclavian vessels are at greatest risk.

Question 91

A 30-year-old male with a severe elbow fracture-dislocation treated with ORIF 8 months ago has a stiff elbow with a 30-degree arc of motion. Radiographs show mature heterotopic ossification (HO) blocking motion. Serum alkaline phosphatase is normal. What is the most appropriate next step?





Explanation

Modern literature indicates that early excision of elbow heterotopic ossification (typically around 6 months post-injury) is safe and effective once the bone appears radiographically mature and alkaline phosphatase levels have normalized. Waiting 18 months or for a cold bone scan is no longer strictly necessary.

Question 92

A 13-year-old elite baseball pitcher presents with anterior shoulder pain worsening with throwing. Examination shows proximal humerus tenderness but normal ROM. Radiographs reveal widening of the proximal humeral physis. What is the most appropriate initial management?





Explanation

'Little Leaguer's shoulder' is a stress fracture (epiphysiolysis) of the proximal humeral physis due to repetitive rotational torque. Treatment is strictly non-operative, requiring complete rest from throwing (usually 3 months) until clinical and radiographic resolution, followed by a structured return-to-throwing protocol.

Question 93

A 28-year-old male sustains a closed transverse midshaft humerus fracture with an immediate complete radial nerve palsy. He is treated with a functional brace. At 12 weeks post-injury, the fracture is healing, but there is no clinical or EMG evidence of radial nerve recovery. What is the most appropriate next step?





Explanation

Most radial nerve palsies associated with closed humeral shaft fractures are neuropraxias or axonotmesis that resolve spontaneously within 3 to 4 months. If there are no clinical or electromyographic signs of recovery by 12 weeks, surgical exploration of the nerve is indicated.

Question 94

According to the Bado classification, a Monteggia fracture-dislocation characterized by a metaphyseal fracture of the proximal ulna with a posterior dislocation of the radial head is classified as:





Explanation

In the Bado classification of Monteggia injuries: Type I involves anterior dislocation of the radial head; Type II involves posterior dislocation; Type III involves lateral dislocation; Type IV involves fractures of both the radius and ulna with anterior radial head dislocation.

Question 95

During anatomic total shoulder arthroplasty, excessive retroversion of the glenoid component significantly increases the risk of which complication?





Explanation

Excessive retroversion of the glenoid component shifts the contact point posteriorly, leading to posterior humeral subluxation, edge loading, and early glenoid component loosening or posterior instability.

Question 96

The anterior bundle of the ulnar collateral ligament (UCL) of the elbow originates from the anteroinferior surface of the medial epicondyle and inserts onto which structure?





Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. It originates on the medial epicondyle and inserts on the sublime tubercle, which is located on the medial aspect of the coronoid process.

Question 97

Scapulothoracic dissociation is a high-energy injury characterized by complete disruption of the scapulothoracic articulation. Which neurovascular injury is most commonly associated with this condition and dictates limb viability?





Explanation

Scapulothoracic dissociation is often considered a 'closed forequarter amputation'. It is highly associated with severe traction injuries to the brachial plexus and tears of the subclavian or axillary artery. The status of these structures dictates whether the limb can be salvaged or requires amputation.

Question 98

A 55-year-old female with long-standing rheumatoid arthritis presents with severe shoulder pain. Radiographs reveal glenohumeral joint destruction, central glenoid wear, and a high-riding humeral head. MRI confirms a massive, irreparable rotator cuff tear. Which surgical option is most appropriate?





Explanation

In a patient with rheumatoid arthritis who has developed secondary rotator cuff arthropathy (massive irreparable cuff tear with glenohumeral arthritis), a reverse total shoulder arthroplasty is the treatment of choice to restore stability, function, and relieve pain.

Question 99

A 35-year-old male sustained a seizure and presents with a locked posterior shoulder dislocation. CT shows a reverse Hill-Sachs lesion involving 35% of the humeral head articular surface. Which of the following is the most appropriate surgical treatment?





Explanation

For locked posterior dislocations with an anteromedial humeral head defect (reverse Hill-Sachs) involving 20-40% of the articular surface, a modified McLaughlin procedure (transfer of the subscapularis and lesser tuberosity into the defect) or osteochondral allografting is recommended to prevent engagement and recurrent instability.

Question 100

A 28-year-old overhead athlete is diagnosed with a Type IV SLAP lesion following an MRI arthrogram. Which of the following accurately describes a Type IV SLAP tear?





Explanation

According to Snyder's classification of SLAP tears: Type I is fraying; Type II is detachment of the superior labrum and biceps anchor; Type III is a bucket-handle tear of the labrum with an intact biceps anchor; Type IV is a bucket-handle tear of the labrum that extends into the biceps tendon.

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Dr. Mohammed Hutaif
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