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Upper Extremity Trauma MCQs

Practice Set 7 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 121

Topic: Upper Extremity Trauma

During an ulnar collateral ligament (UCL) reconstruction using the docking technique in a baseball pitcher, the surgeon aims to anatomically restore the anterior bundle of the UCL. What is the anatomic insertion site of this anterior bundle on the ulna?

. The supinator crest
. The tip of the olecranon
. The sublime tubercle
. The base of the coronoid process, lateral to the brachialis insertion
. The radial notch

Correct Answer & Explanation

. The supinator crest

Explanation

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

Question 122

Topic: Upper Extremity Trauma

A 30-year-old cyclist undergoes surgical reconstruction for a severe Type V acromioclavicular (AC) joint separation. To accurately restore the native anatomy of the coracoclavicular ligaments, the surgeon must account for their respective insertions. Which of the following is true regarding the conoid and trapezoid ligaments?

. The conoid inserts anterolaterally and the trapezoid inserts posteromedially on the clavicle.
. The conoid inserts posteromedially and the trapezoid inserts anterolaterally on the clavicle.
. Both ligaments insert strictly on the anterior margin of the clavicle.
. The trapezoid is the primary restraint to superior translation of the clavicle.
. The conoid is the primary restraint to anterior-posterior translation of the clavicle.

Correct Answer & Explanation

. The conoid inserts anterolaterally and the trapezoid inserts posteromedially on the clavicle.

Explanation

The conoid ligament inserts more posteromedially on the conoid tubercle of the clavicle and serves as the primary restraint to superior translation. The trapezoid ligament inserts more anterolaterally on the trapezoid line and is the primary restraint to axial compression (anterior-posterior translation).

Question 123

Topic: Upper Extremity Trauma

A 24-year-old professional baseball pitcher presents with posterior elbow pain during the deceleration phase of throwing and loss of terminal extension. He is diagnosed with valgus extension overload syndrome. Where is the characteristic osteophyte located in this condition?

. Anteromedial coronoid process
. Posterolateral olecranon tip
. Anterolateral capitellum
. Radial head
. Posteromedial tip of the olecranon

Correct Answer & Explanation

. Anteromedial coronoid process

Explanation

Valgus extension overload (VEO) syndrome in overhead athletes results from repetitive valgus stress and extreme extension forces. It leads to impingement of the olecranon in the olecranon fossa, characteristically producing an osteophyte at the posteromedial tip of the olecranon.

Question 124

Topic: Upper Extremity Trauma

The coracoclavicular (CC) ligaments are the primary restraints to superior translation of the clavicle relative to the acromion. In normal anatomy, the footprint of the conoid ligament on the undersurface of the clavicle is located in what position relative to the footprint of the trapezoid ligament?

. Posteromedial
. Posterolateral
. Anteromedial
. Anterolateral
. Directly superior

Correct Answer & Explanation

. Posteromedial

Explanation

The CC ligament complex consists of the conoid and trapezoid ligaments. The conoid is located posteromedial to the trapezoid. It attaches to the conoid tubercle of the clavicle and is the primary restraint to superior/inferior translation. The trapezoid is situated anterolateral to the conoid and primarily resists axial compression to the acromioclavicular joint.

Question 125

Topic: Upper Extremity Trauma

When performing an anatomic coracoclavicular (CC) ligament reconstruction for an acromioclavicular joint separation, proper clavicular tunnel placement is critical. The footprint of the conoid ligament is typically located at what distance medial to the distal clavicular articular margin?

. 10 mm
. 25 mm
. 45 mm
. 60 mm
. 75 mm

Correct Answer & Explanation

. 10 mm

Explanation

The normal anatomic insertion of the conoid ligament on the clavicle is approximately 45 mm medial to the distal clavicular articular margin. The trapezoid ligament inserts more laterally, approximately 25 mm medial to the joint.

Question 126

Topic: Upper Extremity Trauma

During an ulnar collateral ligament (UCL) reconstruction using the docking technique, an ulnar tunnel is created based on the footprint of the native anterior bundle. Where does the anterior bundle of the UCL primarily insert?

. Sublime tubercle
. Olecranon tip
. Coronoid tip
. Radial tuberosity
. Supinator crest

Correct Answer & Explanation

. Sublime tubercle

Explanation

The anterior bundle is the primary restraint to valgus stress at the elbow. It originates on the anterior undersurface of the medial epicondyle and inserts on the sublime tubercle of the proximal medial ulna.

Question 127

Topic: Upper Extremity Trauma
A 50-year-old man fell from a ladder onto his left shoulder and sustained the injury shown in the radiographs in Figures 71a and 71b. He underwent surgery with repair of the coracoclavicular ligaments and deltotrapezial fascia with coracoclavicular screw placement. Which of the following statements regarding postoperative complications is most accurate?
. Hardware migration is more likely than with acromioclavicular pinning.
. Failure of fixation is usually at the level of the clavicle.
. Hardware removal is avoided to prevent late displacement.
. Neurologic injury most likely involves the axillary nerve.
. Acromioclavicular arthritis is more likely than with nonsurgical management.

Correct Answer & Explanation

. Acromioclavicular arthritis is more likely than with nonsurgical management.

Explanation

Whereas pain and functional disturbance may persist with nonsurgical management, the lack of articular surface contact prevents arthritic symptoms from developing. Cartilage injury caused by trauma and any persistent joint incongruity following repair would contribute to posttraumatic arthritis. Pinning across the acromioclavicular joint has a high incidence of hardware migration and potential catastrophic consequences. Most cases of lost fixation of coracoclavicular screws are at the level of the thread purchase in the coracoid. Routine hardware removal at 8 to 12 weeks is recommended to avoid screw breakage because of natural movement between the clavicle and scapula. The axillary nerve passes around the inferior edge of the subscapularis and is anatomically distant to the coracoid. The musculocutaneous nerve would have the closest anatomic position to the coracoid.

Question 128

Topic: Upper Extremity Trauma
A patient with an acromioclavicular dislocation has a very prominent distal clavicle. Examination reveals that the deformity increases rather than reduces with an isometric shoulder shrug. Which of the following structures is most likely intact?
. Trapezoid ligament
. Conoid ligament
. Acromioclavicular ligament
. Deltoid muscle origin
. Trapezius muscle insertion

Correct Answer & Explanation

. Trapezius muscle insertion

Explanation

Severely displaced acromioclavicular injuries disrupt the deltotrapezial fascia and muscular origin in addition to the ligaments (acromioclavicular and coracoclavicular or trapezoid and conoid). When the deltoid is still attached to the clavicle, an isometric shoulder shrug will tend to reduce the displacement. When the deltoid is detached but the trapezius is attached, this maneuver will increase the deformity and surgery may be indicated.

Question 129

Topic: Upper Extremity Trauma
A 46-year-old woman fell from her bicycle and sustained the injury shown in Figure 24. Which of the following ligaments has been disrupted?
. Acromioclavicular
. Acromioclavicular and coracoclavicular
. Coracoclavicular
. Coracoacromial and sternoclavicular
. Sternoclavicular

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular

Explanation

DISCUSSION: The radiograph shows a type V acromioclavicular joint injury. Type V injuries involve disruption of the acromioclavicular and coracoclavicular ligaments. Type I injuries involve a sprain of the acromioclavicular joint ligaments. Type II injuries involve disruption of the acromioclavicular joint ligaments; the coracoclavicular ligaments are partially injured. Sternoclavicular ligaments stabilize the medial clavicle and the sternum; they are not damaged with acromioclavicular joint dislocations. REFERENCES: Fukuda K, Craig EV, An KN, et al: Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg Am 1986;68:434-439. Bosworth B: Complete acromioclavicular dislocation. N Engl J Med 1949;241:221-225.

Question 130

Topic: Upper Extremity Trauma
Osteophyte formation at the posteromedial olecranon and olecranon articulation in high-caliber throwing athletes is most often the result of underlying
. anterior capsular tears.
. forearm pronator and flexor muscle weakness.
. biceps or brachialis muscle weakness.
. ulnar collateral ligament insufficiency.
. radial collateral ligament insufficiency.

Correct Answer & Explanation

. ulnar collateral ligament insufficiency.

Explanation

DISCUSSION: During the late acceleration phase of throwing, the triceps forcibly contracts, extending the elbow as the ball is released. Normally, this force is absorbed by the anterior capsule and the brachialis and biceps muscles. However, if the ulnar collateral ligament is insufficient, the elbow will be in a subluxated position during extension and cause impaction of the olecranon and the olecranon fossa posteromedially. Over time, osteophyte formation is likely to occur. REFERENCES: Conway JE, Jobe FW, Glousman RE, Pink M: Medial instability of the elbow in throwing athletes: Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am 1992;74:67-83. Wilson FD, Andrews JR, Blackburn TA, McCluskey G: Valgus extension overload in the pitching elbow. Am J Sports Med 1983;11:83-88.

Question 131

Topic: Upper Extremity Trauma

What adaptations occur in the dominant shoulder of throwers compared to their nondominant shoulder? Review Topic

. Humeral anteversion with a normal total arc of motion
. Tight posterior capsule with a normal total arc of motion
. Lengthening of the anterior capsule with a decreased total arc of motion
. Increased external rotation with a decreased total arc of motion
. Decreased internal rotation with an increased total arc of motion

Correct Answer & Explanation

. Humeral anteversion with a normal total arc of motion

Explanation

Pitchers change rotation during adolescent growth with external rotation of the proximal humerus. The result is increased external rotation and decreased internal rotation, resulting in a normal total arc of motion. External rotation lengthens the arc of acceleration, resulting in increased velocity. The shorter arc of internal rotation, associated with a tight posterior capsule, makes deceleration of the arm more difficult, which may lead to overuse injuries.

Question 132

Topic: Upper Extremity Trauma
A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of:
. an arm sling.
. nonsteroidal anti-inflammatory drugs and a rapid return to activity.
. arthroscopic partial claviculectomy.
. acromioclavicular joint reduction and stabilization.
. acromionectomy.

Correct Answer & Explanation

. acromioclavicular joint reduction and stabilization.

Explanation

Type V acromioclavicular dislocations are characterized by elevation of the clavicle of 100% to 300% and involve extensive soft-tissue stripping. The treatment of choice is surgical reduction of the acromioclavicular joint and some type of stabilization. Treatment of type III injuries is controversial.

Question 133

Topic: Upper Extremity Trauma

A 46-year-old woman fell from her bicycle and sustained the injury shown in Figure 24. Which of the following ligaments has been disrupted? Review Topic

. Acromioclavicular
. Acromioclavicular and coracoclavicular
. Coracoclavicular
. Coracoacromial and sternoclavicular
. Sternoclavicular

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular

Explanation

The radiograph shows a type V acromioclavicular joint injury. Type V injuries involve disruption of the acromioclavicular and coracoclavicular ligaments. Type I injuries involve a sprain of the acromioclavicular joint ligaments. Type II injuries involve disruption of the acromioclavicular joint ligaments; the coracoclavicular ligaments are partially injured. Sternoclavicular ligaments stabilize the medial clavicle and the sternum; they are not damaged with acromioclavicular joint dislocations.

Question 134

Topic: Upper Extremity Trauma

During anatomic reconstruction of a chronic type V acromioclavicular (AC) joint separation, the surgeon reconstructs the coracoclavicular (CC) ligaments. To accurately reproduce the biomechanics of the native joint, where should the conoid and trapezoid reconstruction tunnels be placed relative to the distal clavicle?

. Conoid 25 mm medial, Trapezoid 45 mm medial
. Conoid 45 mm medial, Trapezoid 25 mm medial
. Conoid 15 mm medial, Trapezoid 30 mm medial
. Conoid 30 mm medial, Trapezoid 15 mm medial
. Both at 35 mm medial

Correct Answer & Explanation

. Conoid 25 mm medial, Trapezoid 45 mm medial

Explanation

The trapezoid ligament is positioned more anteriorly and laterally, inserting approximately 2.5 cm (25 mm) medial to the distal clavicle. The conoid ligament is positioned more posteromedially, inserting on the conoid tubercle approximately 4.5 cm (45 mm) medial to the distal clavicle.

Question 135

Topic: Upper Extremity Trauma

During a coracoclavicular (CC) ligament reconstruction for a high-grade acromioclavicular joint separation, the surgeon passes grafts to recreate the native ligaments. Which of the following accurately describes the anatomic relationship of the native CC ligaments?

. The conoid ligament is medial and posterior; the trapezoid ligament is lateral and anterior.
. The conoid ligament is lateral and anterior; the trapezoid ligament is medial and posterior.
. The conoid ligament is medial and anterior; the trapezoid ligament is lateral and posterior.
. The conoid ligament is lateral and posterior; the trapezoid ligament is medial and anterior.
. Both ligaments attach to the medial aspect of the coracoid process with the trapezoid lying strictly superior.

Correct Answer & Explanation

. The conoid ligament is medial and posterior; the trapezoid ligament is lateral and anterior.

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid ligament is located medial and posterior (inserting on the conoid tubercle of the clavicle), and it acts as the primary restraint to superior/inferior translation. The trapezoid ligament is lateral and anterior (inserting on the trapezoid line), acting as the primary restraint to axial compression.

Question 136

Topic: Upper Extremity Trauma

During an open release for severe post-traumatic elbow stiffness via a lateral column approach, the anterior capsule is excised, which improves flexion. However, extension remains severely limited. What is the most appropriate next step in the surgical sequence?

. Release the posterior bundle of the medial collateral ligament
. Release the anterior bundle of the medial collateral ligament
. Resect the olecranon tip and release the posterior capsule
. Release the common extensor origin

Correct Answer & Explanation

. Resect the olecranon tip and release the posterior capsule

Explanation

When elbow extension remains limited after anterior capsular release, the next step is to address the posterior impingement. This involves excising the posterior capsule and frequently resecting the tip of the olecranon.

Question 137

Topic: Upper Extremity Trauma

A 30-year-old male is undergoing reconstruction of a Type V acromioclavicular (AC) joint separation using a free tendon graft. To accurately recreate the native anatomy of the coracoclavicular ligaments, where should the conoid and trapezoid insertions be targeted relative to the distal clavicle?

. Conoid 45 mm medial, Trapezoid 25 mm medial
. Conoid 25 mm medial, Trapezoid 45 mm medial
. Conoid 15 mm medial, Trapezoid 30 mm medial
. Conoid 30 mm medial, Trapezoid 15 mm medial

Correct Answer & Explanation

. Conoid 45 mm medial, Trapezoid 25 mm medial

Explanation

The conoid ligament inserts more medially (approximately 45 mm from the distal clavicle), whereas the trapezoid inserts more laterally (approximately 25 mm from the distal clavicle). Restoring this footprint optimizes the biomechanics of the AC joint.

Question 138

Topic: Upper Extremity Trauma
A 28-year-old hockey player has a shoulder deformity after being checked into the boards. Examination reveals that swelling has improved, but there is tenderness along the distal clavicle. Radiographs reveal a grade II acromioclavicular joint separation. Initial management should consist of
. a sling, ice, and isometric exercises.
. a glenohumeral cortisone injection.
. surgical repair of the coracoclavicular ligaments.
. chin-ups and latissimus pull-down exercises.
. cross-chest stretches.

Correct Answer & Explanation

. a sling, ice, and isometric exercises.

Explanation

DISCUSSION: The most common shoulder injury in hockey players is to the acromioclavicular joint. Early rest and control of pain and inflammation is the preferred management. Surgery is reserved for patients with significant coracoclavicular disruption that has failed to respond to nonsurgical management. Cross-chest stretches and overhead exercises may increase symptoms. A cortisone injection within the glenohumeral joint will have little effect.

Question 139

Topic: Upper Extremity Trauma
A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of
. an arm sling.
. nonsteroidal anti-inflammatory drugs and a rapid return to activity.
. arthroscopic partial claviculectomy.
. acromioclavicular joint reduction and stabilization.
. acromionectomy.

Correct Answer & Explanation

. acromioclavicular joint reduction and stabilization.

Explanation

Type V acromioclavicular dislocations are characterized by elevation of the clavicle of 100% to 300% and involve extensive soft-tissue stripping. The treatment of choice is surgical reduction of the acromioclavicular joint and some type of stabilization. Treatment of type III injuries is controversial.

Question 140

Topic: Upper Extremity Trauma
Figure 17 shows the radiograph of a 25-year-old professional football player who has superior shoulder pain that prevents him from sports participation. History reveals that he sustained a shoulder injury that was treated with closed reduction and temporary pinning 3 years ago. The best course of action should be
. no further participation in contact sports.
. open reduction of the acromioclavicular joint and coracoclavicular screw stabilization.
. open repair of the coracoclavicular ligaments.
. Weaver-Dunn reconstruction and coracoclavicular reconstruction.
. excision of the distal clavicle.

Correct Answer & Explanation

. Weaver-Dunn reconstruction and coracoclavicular reconstruction.

Explanation

The radiograph shows a complete acromioclavicular separation. Because the patient is a professional athlete who is unable to participate, surgery is indicated. Chronic separations, especially those with previous trauma from joint pinning, should be treated with resection of the distal clavicle and stabilization to the coracoid. Some type of biologic reconstruction of the coracoclavicular ligaments is generally recommended. Open repair of the ligaments is generally not possible in such a delayed fashion. Screw fixation alone will not provide a lasting solution as the screws usually need to be removed, leaving no fixation in place. Reconstruction using the coracoacromial ligament is generally recommended with coracoclavicular fixation to protect the repair while it heals.

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