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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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