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Upper Extremity Trauma MCQs

Practice Set 5 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 81

Topic: Upper Extremity Trauma

For the operative treatment of a terrible triad injury, the case describes a specific surgical approach. Which of the following approaches is recommended to gain access to the elbow joint and its surrounding structures?

. A) Anteromedial approach
. B) Direct lateral approach
. C) Utility posterior approach
. D) Medial epicondylar approach
. E) Anterolateral approach

Correct Answer & Explanation

. C) Utility posterior approach

Explanation

Correct Answer: CThe case explicitly states: "I would use the utility posterior approach to the elbow, raising thick flaps." This approach provides excellent visualization of the radial head, coronoid, and both medial and lateral collateral ligament complexes, which is essential for addressing all components of a terrible triad injury.

Question 82

Topic: Upper Extremity Trauma

Prior to initiating the surgical incision for a terrible triad repair, proper patient positioning is crucial. According to the case, what is the recommended patient position for this procedure?

. A) Supine with the arm abducted
. B) Prone with the arm hanging free
. C) Lateral position with the affected arm over a bolster
. D) Beach chair position
. E) Semi-Fowler's position

Correct Answer & Explanation

. C) Lateral position with the affected arm over a bolster

Explanation

Correct Answer: CThe case specifies the patient positioning: "I would position the patient in the lateral position with the affected arm over a bolster." This position allows for gravity-assisted exposure and manipulation of the elbow, providing good access to both medial and lateral aspects of the joint, which is necessary for a comprehensive terrible triad repair.

Question 83

Topic: Upper Extremity Trauma

Following surgical repair of a terrible triad injury of the elbow, the patient is started on early active range of motion. To maximally protect the lateral collateral ligament (LCL) repair during elbow extension, in what position should the forearm be maintained?

. Supination
. Pronation
. Neutral rotation
. Maximal internal rotation
. Maximal external rotation

Correct Answer & Explanation

. Pronation

Explanation

Pronation of the forearm tightens the medial soft tissues and the extensor origin, effectively protecting the LCL repair from varus and posterolateral rotatory stress. Early active motion is typically performed with the forearm in pronation.

Question 84

Topic: Upper Extremity Trauma

During open reduction and internal fixation of a radial head fracture in a terrible triad injury, screws are placed in the 'safe zone' to prevent impingement. Which of the following accurately describes this zone?

. A 90-degree arc directly medial
. A 110-degree arc centered laterally with the forearm in neutral
. A 120-degree arc centered anteriorly
. A 90-degree arc centered posteriorly
. A 180-degree arc corresponding to the entire anterior half

Correct Answer & Explanation

. A 110-degree arc centered laterally with the forearm in neutral

Explanation

The safe zone for radial head hardware placement is a 90 to 110-degree non-articulating arc on the lateral aspect of the radial head. This zone avoids impingement on the lesser sigmoid notch of the ulna during forearm pronation and supination.

Question 85

Topic: Upper Extremity Trauma

Which of the following best describes the typical mechanism of injury resulting in a terrible triad of the elbow?

. Axial load, valgus force, and posterolateral rotation
. Axial load, varus force, and posteromedial rotation
. Direct blow to the posterior olecranon with a flexed elbow
. Hyperflexion with an external rotation moment
. Axial traction with extreme forearm pronation

Correct Answer & Explanation

. Axial load, valgus force, and posterolateral rotation

Explanation

The terrible triad (elbow dislocation, radial head fracture, coronoid fracture) characteristically results from a fall onto an outstretched hand causing an axial load, a valgus force, and posterolateral rotation.

Question 86

Topic: Upper Extremity Trauma

Following a stable and anatomic surgical reconstruction of a terrible triad injury, what is the most widely recommended early rehabilitation protocol?

. Rigid immobilization in full extension for 6 weeks
. Early active range of motion with the forearm in pronation
. Early active range of motion with the forearm in supination
. Immobilization at 90 degrees flexion and full supination for 4 weeks
. Immediate aggressive passive stretching by a therapist

Correct Answer & Explanation

. Early active range of motion with the forearm in pronation

Explanation

Early active motion is crucial to prevent stiffness. Performing exercises with the forearm in pronation tightens the intact medial structures and protects the repaired lateral collateral ligament (LCL) from varus stress.

Question 87

Topic: Upper Extremity Trauma

An adult patient undergoes open reduction and internal fixation of a Bado Type I Monteggia fracture. Intraoperatively, after plating the ulna, the radial head remains anteriorly dislocated. What is the most common cause of this failure of reduction?

. Annular ligament interposition
. A concurrent terrible triad injury
. Malreduction (often shortening or angulation) of the ulnar fracture
. Radial nerve entrapment within the joint
. Undiagnosed Essex-Lopresti lesion

Correct Answer & Explanation

. Malreduction (often shortening or angulation) of the ulnar fracture

Explanation

The radial head follows the alignment of the ulna. If the radial head fails to reduce in a Monteggia fracture, the most common reason is that the ulnar length, alignment, or rotation has not been anatomically restored.

Question 88

Topic: Upper Extremity Trauma

During a radial head replacement in a terrible triad injury, which anatomical landmark is best used to determine the correct proximal-to-distal height of the radial head implant?

. The proximal edge of the lesser sigmoid notch of the ulna
. The inferior pole of the medial epicondyle
. The tip of the olecranon
. The level of the radial styloid
. The sublime tubercle

Correct Answer & Explanation

. The proximal edge of the lesser sigmoid notch of the ulna

Explanation

The articulating margin of the radial head implant should sit level with the proximal edge of the lesser sigmoid notch of the ulna. This ensures proper tracking and avoids overstuffing or under-sizing the joint.

Question 89

Topic: Upper Extremity Trauma

A 40-year-old male requires plate fixation for a comminuted radial head fracture in a terrible triad injury. To prevent impingement on the proximal radioulnar joint during forearm rotation, the plate must be placed within the "safe zone." How is this safe zone defined anatomically?

. A 90-degree arc bordered by the radial styloid and the ulnar styloid
. A 110-degree lateral arc bordered by the radial styloid and Lister's tubercle
. A 90-degree medial arc bordered by the bicipital tuberosity and the supinator crest
. A 120-degree posterior arc directly opposite the bicipital tuberosity
. A 60-degree anterior arc bordered by the coronoid and the radial tuberosity

Correct Answer & Explanation

. A 110-degree lateral arc bordered by the radial styloid and Lister's tubercle

Explanation

The safe zone for radial head plating is approximately a 90 to 110-degree arc on the non-articulating lateral surface of the radial head. It corresponds distally to the area between the radial styloid and Lister's tubercle with the forearm in neutral rotation.

Question 90

Topic: Upper Extremity Trauma

In evaluating a pediatric patient with an isolated, traumatic bowing (plastic deformation) of the ulna and an intact radius, which of the following occult injuries MUST be explicitly ruled out with high-quality radiographs?

. Scapholunate dissociation
. Distal radioulnar joint dislocation (Galeazzi)
. Radial head dislocation (Monteggia variant)
. Supracondylar humerus fracture
. Medial epicondyle avulsion

Correct Answer & Explanation

. Radial head dislocation (Monteggia variant)

Explanation

Traumatic plastic deformation of the ulna in a child effectively shortens the bone and changes its bow. This is a classic Monteggia variant, and the clinician must meticulously assess the radiocapitellar alignment to rule out an occult radial head dislocation.

Question 91

Topic: Upper Extremity Trauma

The coronoid process acts as the primary bony constraint to which of the following forces in the elbow joint?

. Varus stress
. Posterior translation of the ulna
. Anterior translation of the radius
. Distraction of the radiocapitellar joint
. Proximal migration of the radius

Correct Answer & Explanation

. Posterior translation of the ulna

Explanation

The coronoid is the primary bony restraint against posterior translation of the ulna relative to the distal humerus, acting as an anterior buttress. It also provides significant stability against varus stress via its anteromedial facet.

Question 92

Topic: Upper Extremity Trauma

During the postoperative rehabilitation of a successfully reconstructed terrible triad injury (coronoid, radial head, and LCL repaired), immediate active-assisted range of motion is initiated. To maximally protect the LCL repair during elbow flexion and extension, the forearm should be held in what position?

. Full supination
. Full pronation
. Neutral rotation
. Alternating pronation and supination
. Forced valgus

Correct Answer & Explanation

. Full pronation

Explanation

Pronation of the forearm positions the intact or repaired medial structures to act as a hinge, relaxing the LCL complex and protecting the lateral repair from varus stress during early range of motion.

Question 93

Topic: Upper Extremity Trauma
A 25-year-old male presents to the emergency department after a direct fall onto the superior aspect of his right shoulder during a rugby match. He reports immediate severe pain and inability to lift his arm. On examination, there is marked superior displacement of the distal clavicle, significant tenting of the skin, and a palpable gap between the clavicle and acromion. The deltoid and trapezius muscles appear extensively stripped from the distal clavicle. Based on the clinical presentation and the provided image, which Rockwood classification best describes this injury?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type V

Explanation

The patient's presentation, including a direct fall, marked superior displacement of the distal clavicle, significant skin tenting, and extensive stripping of the deltoid and trapezius muscles, is characteristic of a Rockwood Type V AC joint separation. Type V represents a severe injury with complete tears of AC and CC ligaments, marked superior displacement of the clavicle (typically >100% of its height), and extensive stripping of the deltoid and trapezius from the distal clavicle.

Question 94

Topic: Upper Extremity Trauma
A 40-year-old male presents with a painful right shoulder after falling directly onto his acromion. Radiographs reveal complete tears of both the acromioclavicular (AC) and coracoclavicular (CC) ligaments. The distal clavicle is superiorly displaced by approximately 75% of its height relative to the acromion, but an axillary lateral view confirms it remains within the sagittal contour of the acromion. The deltoid and trapezius muscle attachments appear largely intact. Which Rockwood classification best describes this injury?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type III

Explanation

The description of complete tears of both AC and CC ligaments, with the clavicle superiorly displaced by 25% to 100% of its height and remaining within the sagittal contour of the acromion, is the classic definition of a Rockwood Type III AC joint separation.

Question 95

Topic: Upper Extremity Trauma

A surgeon is performing an AC joint reconstruction using a suture-button system for coracoclavicular ligament reconstruction, as shown in the intraoperative image below. After achieving anatomical reduction of the clavicle, the sutures are tensioned and secured. What is the primary biomechanical principle by which this suture-button construct provides vertical stability to the AC joint?

. It directly repairs the torn acromioclavicular ligaments.
. It provides rigid bony fixation between the clavicle and acromion.
. It compresses the AC joint articular surfaces, promoting fusion.
. It approximates the clavicle to the coracoid process, functionally replacing the CC ligaments.
. It acts as a scaffold for the coracoacromial ligament transfer.

Correct Answer & Explanation

. It approximates the clavicle to the coracoid process, functionally replacing the CC ligaments.

Explanation

Correct Answer: DThe suture-button system for coracoclavicular (CC) ligament reconstruction works by passing strong suture tapes through tunnels drilled in the clavicle and coracoid. When tensioned, these sutures pull the clavicle inferiorly towards the coracoid process, thereby approximating the two structures and functionally replacing the torn CC ligaments. This restores vertical stability to the AC joint.Option A:While AC joint capsular repair may be performed concurrently, the suture-button construct itself is primarily for CC ligament reconstruction and vertical stability, not direct AC ligament repair.Option B:Suture-button systems provide dynamic stability, allowing for some micromotion, rather than rigid bony fixation between the clavicle and acromion. Rigid fixation between the clavicle and acromion alone has largely been abandoned due to high failure rates.Option C:The goal is to restore the normal anatomical relationship and stability, not to compress the articular surfaces for fusion. Fusion is not a desired outcome for acute AC joint reconstruction.Option E:While some historical techniques (e.g., Weaver-Dunn) involved coracoacromial ligament transfer, the suture-button system is a distinct method for CC ligament reconstruction and does not primarily act as a scaffold for other ligament transfers.

Question 96

Topic: Upper Extremity Trauma
A 35-year-old mountain biker falls off his bike and sustains a shoulder injury. Examination reveals a painful, non-reducible distal clavicle that is impaled posteriorly into the trapezius fascia. According to the Rockwood classification, what type of injury is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

A Rockwood Type IV AC joint injury involves posterior displacement of the distal clavicle into or through the trapezius fascia. It generally requires surgical reduction due to the irreducible nature of the clavicle.

Question 97

Topic: Upper Extremity Trauma

The classic Weaver-Dunn procedure for chronic AC joint instability involves resection of the distal clavicle and transfer of which ligament to the distal clavicle?

. Coracohumeral ligament
. Superior acromioclavicular ligament
. Coracoacromial (CA) ligament
. Conoid ligament
. Trapezoid ligament

Correct Answer & Explanation

. Coracoacromial (CA) ligament

Explanation

The Weaver-Dunn procedure transfers the coracoacromial (CA) ligament from its acromial attachment to the resected end of the distal clavicle. It is often augmented because the CA ligament is weaker than native CC ligaments.

Question 98

Topic: Upper Extremity Trauma

A 28-year-old professional hockey player undergoes coracoclavicular (CC) ligament reconstruction for a chronic Type V acromioclavicular (AC) joint separation. To anatomically recreate the CC ligaments, the surgeon must place drill holes in the clavicle. Which of the following best describes the anatomic location of the conoid and trapezoid ligaments?

. Conoid is anterolateral, 4.5 cm from the distal clavicle; Trapezoid is posteromedial, 3.0 cm from the distal clavicle.
. Conoid is posteromedial, 4.5 cm from the distal clavicle; Trapezoid is anterolateral, 3.0 cm from the distal clavicle.
. Conoid is anterolateral, 3.0 cm from the distal clavicle; Trapezoid is posteromedial, 4.5 cm from the distal clavicle.
. Conoid is posteromedial, 3.0 cm from the distal clavicle; Trapezoid is anterolateral, 4.5 cm from the distal clavicle.
. Conoid and trapezoid both originate 4.5 cm from the distal clavicle in a single bundled footprint.

Correct Answer & Explanation

. Conoid is posteromedial, 4.5 cm from the distal clavicle; Trapezoid is anterolateral, 3.0 cm from the distal clavicle.

Explanation

The conoid ligament inserts posteromedially on the clavicle approximately 4.5 cm from the distal end. The trapezoid ligament inserts anterolaterally approximately 3.0 cm from the distal end.

Question 99

Topic: Upper Extremity Trauma
A 45-year-old male falls directly on his shoulder and presents with intense pain. The axillary lateral radiograph reveals that the distal clavicle is displaced posteriorly into the trapezius muscle. Which Rockwood classification type is this injury?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

A Rockwood Type IV AC joint separation is characterized by posterior displacement of the distal clavicle into or through the trapezius muscle fascia. This injury requires operative intervention.

Question 100

Topic: Upper Extremity Trauma

While testing the stability of the acromioclavicular joint, you note significant anterior-posterior (A-P) translation but normal superior-inferior stability. Which ligamentous structure is primarily injured?

. Conoid ligament
. Trapezoid ligament
. Superior AC ligament
. Coracoacromial ligament
. Coracohumeral ligament

Correct Answer & Explanation

. Superior AC ligament

Explanation

The superior AC ligament, a thickening of the joint capsule, is the thickest and strongest AC ligament. It provides the primary restraint to anterior-posterior translation of the distal clavicle.

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