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Upper Extremity Trauma MCQs

Practice Set 2 of 24

This practice set contains high-yield board review questions covering key concepts in Upper Extremity Trauma. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 21

Topic: Upper Extremity Trauma
A 35-year-old businessman sustains a type III acromioclavicular (AC) separation of his dominant shoulder. Preferred treatment should be:
. Open subacromial decompression with distal clavicle resection
. Arthroscopic subacromial decompression
. Repair of coracoacromial ligament and fixation with a Bosworth screw
. Symptomatic treatment followed by return to activities as tolerated
. Reduction of the AC joint and stabilization with pins

Correct Answer & Explanation

. Symptomatic treatment followed by return to activities as tolerated

Explanation

Long-term outcome studies have demonstrated good and excellent results following symptomatic, nonsurgical treatment of grade I-III acromioclavicular separations. Surgical treatment may lead to complications (especially with the use of transfixing smooth pins), loss of reduction, and chronic pain due to joint instability.

Question 22

Topic: Upper Extremity Trauma

Which of the following combinations correctly describes the contributions of the acromioclavicular ligaments and coracoclavicular ligaments in stabilizing the acromioclavicular joint:

. Horizontal stability is controlled by the coracoacromial ligament.
. Vertical stability is controlled by the acromioclavicular ligament.
. Horizontal stability is controlled by the coracoclavicular ligament and vertical stability is controlled by the acromioclavicular ligament.
. Horizontal stability is controlled by the coracoacromial ligament and vertical stability is controlled by the acromioclavicular ligament.
. Horizontal stability is controlled by the acromioclavicular ligament and vertical stability is controlled by the coracoclavicular ligament.

Correct Answer & Explanation

. Horizontal stability is controlled by the coracoacromial ligament.

Explanation

Fuduka and colleagues have studied the individual ligamentous contributions to acromioclavicular stability by performing load displacement tests on sectioned cadaveric models. These experiments led to the conclusion that the horizontal stability of the acromioclavicular joint is controlled by the acromioclavicular ligament and vertical stability is controlled by the coracoclavicular ligament.

Question 23

Topic: Upper Extremity Trauma

According to the Rockwood classification of acromioclavicular (AC) joint injuries, what defines a Type V injury?

. Sprain of the AC ligaments with intact coracoclavicular ligaments
. Disruption of the AC ligaments and sprain of the coracoclavicular ligaments
. Disruption of both AC and CC ligaments with 25% to 100% superior displacement
. Posterior displacement of the clavicle into the trapezius muscle
. Greater than 100% superior displacement of the clavicle with extensive stripping of the deltotrapezial fascia

Correct Answer & Explanation

. Greater than 100% superior displacement of the clavicle with extensive stripping of the deltotrapezial fascia

Explanation

A Type V AC joint injury involves disruption of the AC and CC ligaments with >100% (often 100-300%) superior displacement of the distal clavicle and severe stripping of the deltotrapezial fascia from the clavicle and acromion.

Question 24

Topic: Upper Extremity Trauma

A 28-year-old bodybuilder feels a sudden pop in his anterior chest while performing a bench press. Examination reveals loss of the anterior axillary fold and weakness in shoulder adduction and internal rotation. What is the most common anatomical site of this rupture?

. Avulsion of the sternal head from the humeral insertion
. Mid-substance tear of the clavicular head
. Musculotendinous junction of the sternal head
. Avulsion of the clavicular head from the clavicle
. Mid-substance tear of the sternal head

Correct Answer & Explanation

. Avulsion of the sternal head from the humeral insertion

Explanation

Pectoralis major ruptures most commonly occur as avulsions of the sternal head from its insertion on the proximal humerus, typically occurring during eccentric loading such as the downward phase of a bench press.

Question 25

Topic: Upper Extremity Trauma
A 25-year-old cyclist falls directly onto his shoulder. Radiographs show a 100% superior displacement of the distal clavicle relative to the acromion. The coracoclavicular distance is increased by 50% compared to the contralateral side. What is the generally accepted initial management?
. Open reduction and hook plate fixation
. Arthroscopic coracoclavicular ligament reconstruction
. Non-operative management with a sling and early range of motion
. Distal clavicle excision
. Primary acromioclavicular joint arthrodesis

Correct Answer & Explanation

. Non-operative management with a sling and early range of motion

Explanation

This is a Rockwood Type III acromioclavicular joint separation. Most literature supports initial non-operative management for Type III injuries, as functional outcomes are typically equivalent to surgery without the associated surgical risks.

Question 26

Topic: Upper Extremity Trauma
A 30-year-old male sustains an acute, high-energy acromioclavicular joint separation. Radiographs demonstrate >100% superior displacement of the clavicle relative to the acromion, with significant posterior displacement into the trapezius fascia. What is the correct classification of this injury?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

In the Rockwood classification, a Type IV AC joint separation is characterized by posterior displacement of the distal clavicle into or through the trapezius fascia, which requires surgical intervention.

Question 27

Topic: Upper Extremity Trauma

Which shape of the olecranon apophysis correlates most closely with closure of the triradiate cartilage of the hips:

. Formation of initial ossification center
. Initial appearance of two ossification centers
. Formation of a curved single ossification center
. Formation of a rectangular ossification center
. Closure of the olecranon ossification center

Correct Answer & Explanation

. Formation of a rectangular ossification center

Explanation

The olecranon ossifies from two centers that merge and form one banana- shaped ossification center. When the ossificaiton center is rectangular in shape, it correlates with closure of the triradiate cartilage of the pelvis.

Question 28

Topic: Upper Extremity Trauma

An 11-year-old elite baseball pitcher presents with insidious onset of right shoulder pain during the late cocking phase of throwing. Radiographs demonstrate widening and demineralization of the proximal humeral physis. What is the best initial management for this condition?

. Physical therapy focusing exclusively on rotator cuff strengthening
. Intra-articular corticosteroid injection
. Complete rest from throwing for 3 to 6 months
. Surgical pinning of the proximal humerus physis
. Arthroscopic labral debridement

Correct Answer & Explanation

. Complete rest from throwing for 3 to 6 months

Explanation

Little League Shoulder is an epiphysiolysis of the proximal humerus caused by repetitive rotational microtrauma. The foundation of treatment is complete rest from throwing for typically 3 to 6 months until symptoms resolve and radiographs normalize.

Question 29

Topic: Upper Extremity Trauma

A 14-year-old left-handed boy suffers an avulsion of the medial epicondyle of the distal humerus when landing from a fall. The epicondyle is displaced 7 mm. His physical demands include swimming and lifting boxes. The recommended treatment for this injury is:

. Open reduction and internal fixation
. Manipulation and percutaneous fixation
. Percutaneous fixation in situ
. Splint for 1 week
. Excision of the fragment with reattachment of muscle to bone

Correct Answer & Explanation

. Splint for 1 week

Explanation

Unless the fragment is entrapped or significant valgus loading is anticipated, nonoperative treatment is indicated. Range of motion should be started within 1 week. Open reduction is only indicated, if the epicondyle was entrapped in the joint, or if significant valgus loading was anticipated. The results of nonoperative treatment are just as good as any invasive treatment. Excision of the fragment is only indicated, if operative treatment is indicated, and the epicondyle is fragmented.

Question 30

Topic: Upper Extremity Trauma

Which of the following statements is true about the medial humeral epicondyle:

. The medial humeral epicondyle is the first center to ossify in the distal humerus.
. The medial humeral epicondyle usually fuses to the distal humerus at age twelve.
. The medial humeral epicondyle is located anteromedially on the distal humerus.
. The medial humeral epicondyle is the origin of the wrist extensor muscles.
. The medial humeral epicondyle may ossify from several centers.

Correct Answer & Explanation

. The medial humeral epicondyle may ossify from several centers.

Explanation

The medial epicondyle may have several ossification centers. The medial epicondyle is the third center to ossify, beginning at age 4 to 6 years old. The medial epicondyle usually fuses near skeletal maturity, at approximately age 15. The medial epicondyle is located posteromedially. The medial epicondyle is the origin of the flexor-pronator muscles.

Question 31

Topic: Upper Extremity Trauma

During an open reduction and internal fixation of a complex, intra-articular distal humerus fracture (OTA 13C3), an olecranon osteotomy is planned. At which specific anatomical location should the osteotomy be directed to minimize articular damage?

. Distal to the sublime tubercle
. Through the center of the coronoid process
. Through the bare area of the sigmoid notch
. Directly through the olecranon fossa
. At the insertion of the triceps tendon

Correct Answer & Explanation

. Through the bare area of the sigmoid notch

Explanation

An olecranon osteotomy for distal humerus exposure is classically a chevron-type osteotomy directed through the "bare area" of the greater sigmoid notch. This area has devoid articular cartilage, minimizing postoperative articular incongruity and arthritis.

Question 32

Topic: Upper Extremity Trauma

During a transverse osteotomy of the olecranon for access to a complex distal humerus fracture, which specific anatomical location is targeted to minimize damage to the articular cartilage of the greater sigmoid notch?

. The exact center of the trochlear notch
. The coronoid process base
. The bare area between the olecranon and coronoid articular surfaces
. The sublime tubercle
. The radioulnar articulation

Correct Answer & Explanation

. The bare area between the olecranon and coronoid articular surfaces

Explanation

An olecranon osteotomy (typically an apex-distal chevron) is directed toward the 'bare area' (transverse groove) of the greater sigmoid notch. This area is devoid of articular cartilage, thereby minimizing intra-articular damage during the osteotomy.

Question 33

Topic: Upper Extremity Trauma

A surgeon plans a posterior extensile approach with an olecranon osteotomy to treat an intra-articular distal humerus fracture. To minimize articular disruption and facilitate anatomic reduction, the apex of the chevron osteotomy should be directed toward which structure?

. The coronoid tip
. The bare area of the sigmoid notch
. The olecranon fossa
. The radial notch of the ulna
. The sublime tubercle

Correct Answer & Explanation

. The bare area of the sigmoid notch

Explanation

A chevron-type olecranon osteotomy should be directed at the "bare area" of the sigmoid notch. This specific area is naturally devoid of articular cartilage, which minimizes damage to the articular surface.

Question 34

Topic: Upper Extremity Trauma
An 8-year-old boy presents after a fall. Radiographs demonstrate a fracture of the ulnar diaphysis and a displaced fracture of the radial neck, but the radiocapitellar articulation remains intact without true dislocation. Which of the following best describes this injury pattern?
. Bado Type I Monteggia
. Bado Type III Monteggia
. Monteggia equivalent lesion
. Galeazzi equivalent lesion
. Essex-Lopresti injury

Correct Answer & Explanation

. Monteggia equivalent lesion

Explanation

A Monteggia equivalent lesion involves an ulnar shaft fracture associated with a radial neck fracture, epiphyseal separation, or radial head fracture, rather than a classic true dislocation of the radial head.

Question 35

Topic: Upper Extremity Trauma
A 30-year-old male sustains an isolated grade III acromioclavicular (AC) joint separation. Which of the following ligaments are primarily responsible for preventing superior translation of the distal clavicle?
. Acromioclavicular ligaments
. Coracoacromial ligament
. Conoid and trapezoid ligaments
. Coracohumeral ligament
. Superior glenohumeral ligament

Correct Answer & Explanation

. Conoid and trapezoid ligaments

Explanation

The coracoclavicular (CC) ligaments, composed of the conoid and trapezoid, provide vertical stability to the AC joint. The AC ligaments primarily provide anteroposterior stability.

Question 36

Topic: Upper Extremity Trauma

Current anatomical and perfusion studies dictate that the primary blood supply to the articular segment (humeral head) in the proximal humerus is derived mainly from which of the following vessels?

. Anterior circumflex humeral artery
. Posterior circumflex humeral artery
. Suprascapular artery
. Thoracoacromial artery
. Profunda brachii artery

Correct Answer & Explanation

. Posterior circumflex humeral artery

Explanation

While historically the anterior circumflex humeral artery was thought to be the primary supply, recent anatomical studies demonstrate that the posterior circumflex humeral artery provides the majority (up to 64%) of the blood supply to the humeral head.

Question 37

Topic: Upper Extremity Trauma
A 35-year-old manual laborer sustains a Type III acromioclavicular (AC) joint separation. The coracoclavicular (CC) ligaments are completely ruptured. Which of the following describes the correct anatomic orientation of the native CC ligaments?
. The conoid is lateral and anterior, the trapezoid is medial and posterior
. The conoid is medial and posterior, the trapezoid is lateral and anterior
. The conoid and trapezoid both originate from the acromion
. The coracoacromial ligament is the primary vertical stabilizer
. The conoid is lateral and posterior, the trapezoid is medial and anterior

Correct Answer & Explanation

. The conoid is medial and posterior, the trapezoid is lateral and anterior

Explanation

The coracoclavicular ligaments consist of the conoid and trapezoid. The conoid is situated medial and posterior, while the trapezoid is located lateral and anterior.

Question 38

Topic: Upper Extremity Trauma

A 40-year-old patient undergoes surgical repair of a terrible triad injury. Postoperatively, the patient develops significant elbow stiffness, limiting both flexion/extension and pronation/supination. Which of the following factors is most commonly associated with the development of postoperative elbow stiffness after a terrible triad injury repair?

. A. Early, aggressive passive range of motion exercises.
. B. Prolonged immobilization of the elbow joint.
. C. Inadequate repair of the medial collateral ligament.
. D. Overstuffing of the radial head prosthesis.
. E. Failure to decompress the ulnar nerve during surgery.

Correct Answer & Explanation

. B. Prolonged immobilization of the elbow joint.

Explanation

Correct Answer: BProlonged immobilization of the elbow joint is a well-known risk factor for postoperative stiffness after any elbow trauma or surgery, including terrible triads. While some period of immobilization is necessary for soft tissue and bone healing, excessive or prolonged immobilization can lead to capsular contracture, adhesions, and heterotopic ossification, all contributing to stiffness. The goal of terrible triad repair is to achieve stability sufficient for early, controlled range of motion.Option A (Early, aggressive passive range of motion exercises)is incorrect. While overly aggressive or uncontrolled motion can sometimes lead to complications, early, controlled range of motion is generally encouraged to prevent stiffness, not cause it, once stability is achieved.Option C (Inadequate repair of the medial collateral ligament)is incorrect. Inadequate MCL repair would primarily lead to valgus instability, not necessarily stiffness. While instability can indirectly lead to guarding and stiffness, it's not the most direct cause of stiffness compared to immobilization.Option D (Overstuffing of the radial head prosthesis)is correct in that it can cause stiffness and pain, but the question asks for the 'most commonly associated' factor. While overstuffing is a significant cause of stiffness and pain, prolonged immobilization is a more pervasive and common cause of stiffness across various elbow injuries and surgeries.Option E (Failure to decompress the ulnar nerve during surgery)is incorrect. Failure to decompress the ulnar nerve would primarily lead to ulnar neuropathy symptoms (pain, numbness, weakness), not directly to global elbow stiffness.

Question 39

Topic: Upper Extremity Trauma

A 60-year-old patient with a terrible triad injury undergoes successful surgical repair. During the immediate postoperative period, the patient is placed in a hinged elbow brace. What is the primary biomechanical rationale for using a hinged elbow brace in the early rehabilitation phase following a terrible triad repair?

. A. To completely immobilize the elbow joint to allow for maximal soft tissue healing.
. B. To prevent heterotopic ossification by limiting joint motion.
. C. To allow controlled range of motion while protecting the repaired ligaments from excessive stress.
. D. To provide continuous passive motion (CPM) without patient effort.
. E. To reduce swelling and inflammation around the elbow joint.

Correct Answer & Explanation

. C. To allow controlled range of motion while protecting the repaired ligaments from excessive stress.

Explanation

Correct Answer: CThe primary rationale for a hinged elbow brace is to allow controlled range of motion (flexion and extension) within a safe arc, while simultaneously protecting the repaired ligaments (especially the LCL and potentially MCL) from excessive varus, valgus, or rotatory stresses. This balance promotes healing, prevents stiffness, and maintains joint congruity.Option A (To completely immobilize the elbow joint to allow for maximal soft tissue healing)is incorrect. A hinged brace allows motion, it does not completely immobilize. Complete immobilization is generally avoided in terrible triads due to the high risk of stiffness.Option B (To prevent heterotopic ossification by limiting joint motion)is incorrect. While limiting motion can sometimes be part of a strategy to prevent HO, the primary mechanism for a hinged brace is controlled motion, not strict limitation for HO prevention. Early motion is often thought to help prevent HO.Option D (To provide continuous passive motion (CPM) without patient effort)is incorrect. A hinged brace allows active or passive motion within its set limits, but it does not provide CPM automatically. CPM machines are separate devices.Option E (To reduce swelling and inflammation around the elbow joint)is incorrect. While a brace might offer some compression, its primary role is mechanical protection and controlled motion, not direct management of swelling or inflammation.

Question 40

Topic: Upper Extremity Trauma

A 42-year-old male underwent ORIF of a terrible triad injury 6 months ago. He now lacks 45 degrees of extension and is limited to 100 degrees of flexion. Radiographs show mature heterotopic ossification (HO) bridging the lateral collateral ligament complex. What is the best management strategy?

. Immediate surgical excision of the HO followed by radiation
. Wait until HO matures (typically 18-24 months) before surgical excision
. Perform surgical excision of the mature HO and consider prophylaxis
. Indomethacin for 6 weeks, then reassess
. Physical therapy with aggressive passive stretching

Correct Answer & Explanation

. Perform surgical excision of the mature HO and consider prophylaxis

Explanation

Heterotopic ossification is a recognized complication after terrible triad injuries. Surgical excision is indicated to restore motion once the HO is fully mature (indicated by sharp radiographic borders and normal inflammatory markers, typically 6-12 months post-injury), usually combined with radiation or indomethacin prophylaxis.

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