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Upper Extremity Trauma MCQs

Practice Set 8 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 141

Topic: Upper Extremity Trauma

A 20-year-old collegiate baseball pitcher experiences chronic posteromedial elbow pain during the deceleration phase of throwing. He has a 15-degree flexion contracture. Radiographs show prominent osteophytes on the posteromedial olecranon. The surgeon plans an arthroscopic posteromedial olecranon resection for valgus extension overload. What complication is directly associated with resecting more than 3 mm of the posteromedial olecranon?

. Ulnar collateral ligament (UCL) insufficiency
. Radial nerve palsy
. Heterotopic ossification of the brachialis muscle
. Complete triceps tendon rupture
. Capitellar osteochondritis dissecans

Correct Answer & Explanation

. Ulnar collateral ligament (UCL) insufficiency

Explanation

In valgus extension overload, repetitive impingement of the olecranon into the olecranon fossa causes posteromedial osteophytes. The posteromedial olecranon is an important secondary bony stabilizer to valgus stress. Resecting excessive bone (typically defined as > 2 to 3 mm) from the posteromedial olecranon unmasks underlying Ulnar Collateral Ligament (UCL) insufficiency and transfers excessive valgus stress to the anterior band of the UCL, leading to medial instability.

Question 142

Topic: Upper Extremity Trauma
A 32-year-old male falls directly onto the point of his shoulder while snowboarding. Clinical exam reveals a prominent clavicle, and radiographs show the distal clavicle displaced posteriorly into the trapezius muscle. According to the Rockwood classification of acromioclavicular (AC) joint injuries, what type of injury is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

The Rockwood classification of AC joint injuries is based on the direction and degree of clavicle displacement. Type I: sprain. Type II: AC torn, CC intact. Type III: AC and CC torn, 25-100% superior displacement. Type IV: Posterior displacement of the distal clavicle into the trapezius fascia. Type V: Superior displacement >100%. Type VI: Inferior displacement under the coracoid/acromion.

Question 143

Topic: Upper Extremity Trauma

A 25-year-old mountain biker falls directly onto the point of his shoulder, sustaining an acute high-grade (Type V) acromioclavicular (AC) joint separation.

Surgical reconstruction of the coracoclavicular (CC) ligaments is planned. Biomechanically, which native structure acts as the primary restraint to superior translation of the distal clavicle?

. Acromioclavicular (AC) capsular ligaments
. Trapezoid ligament
. Conoid ligament
. Coracoacromial (CA) ligament
. Superior transverse scapular ligament

Correct Answer & Explanation

. Acromioclavicular (AC) capsular ligaments

Explanation

The coracoclavicular (CC) ligaments provide primary vertical stability to the AC joint. The conoid ligament is the more medial of the two CC ligaments and is the primary restraint to superior translation of the clavicle. The trapezoid ligament is more lateral and provides the primary restraint against axial compression. The AC capsular ligaments primarily provide anteroposterior (horizontal) stability.

Question 144

Topic: Upper Extremity Trauma

A 35-year-old mechanic sustains an Essex-Lopresti injury after falling from a ladder. This injury pattern is characterized by a radial head fracture, disruption of the distal radioulnar joint (DRUJ), and tearing of the interosseous membrane (IOM). If the radial head is completely excised without replacement in this patient, what is the expected biomechanical consequence?

. Proximal migration of the radius, resulting in ulnocarpal impaction and wrist pain
. Distal migration of the radius, resulting in radiocarpal subluxation
. Varus instability of the elbow joint without wrist involvement
. Posterior subluxation of the ulnar head at the DRUJ only
. Anterior subluxation of the radial head remnant

Correct Answer & Explanation

. Proximal migration of the radius, resulting in ulnocarpal impaction and wrist pain

Explanation

An Essex-Lopresti injury involves a longitudinal radioulnar dissociation. The radial head and the interosseous membrane are the primary restraints to proximal migration of the radius. If the radial head is resected in the setting of an IOM tear (Essex-Lopresti lesion), the radius will migrate proximally. This causes positive ulnar variance, leading to severe ulnocarpal impaction, wrist pain, and restricted forearm rotation. Therefore, the radial head must be fixed or replaced with an arthroplasty to restore the longitudinal stability of the forearm.

Question 145

Topic: Upper Extremity Trauma

A 25-year-old cyclist falls directly onto his right shoulder. He complains of severe pain at the top of the shoulder. Radiographs show a 200% superior displacement of the distal clavicle relative to the acromion.

Which ligaments are disrupted in this Rockwood Type V injury?

. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Acromioclavicular and coracoacromial ligaments
. Acromioclavicular and coracoclavicular ligaments, and detachment of the deltotrapezial fascia
. Coracoclavicular and coracoacromial ligaments

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular ligaments, and detachment of the deltotrapezial fascia

Explanation

In a Rockwood Type V acromioclavicular (AC) joint injury, there is complete disruption of both the AC ligaments and the coracoclavicular (CC) ligaments, along with gross disruption of the deltotrapezial fascia. This extensive soft tissue stripping allows severe superior displacement of the clavicle (100-300% compared to the contralateral side).

Question 146

Topic: Upper Extremity Trauma

A 35-year-old man undergoes surgical release for post-traumatic elbow stiffness following a terrible triad injury 1 year ago. To prevent recurrence due to heterotopic ossification (HO), which of the following is the most standard prophylactic regimen?

. Indomethacin 75 mg SR daily for 3-6 weeks
. High-dose oral corticosteroids for 2 weeks
. Single-fraction radiation therapy (700-800 cGy)
. Methotrexate weekly for 4 weeks
. Celecoxib 200 mg daily for 5 days

Correct Answer & Explanation

. Indomethacin 75 mg SR daily for 3-6 weeks

Explanation

Prophylaxis for heterotopic ossification (HO) around the elbow typically involves either nonsteroidal anti-inflammatory drugs (NSAIDs) such as Indomethacin (e.g., 75 mg sustained release daily or 25 mg TID for 3-6 weeks) or a single fraction of low-dose radiation therapy (700-800 cGy) administered within 24 to 48 hours before or after surgery. Corticosteroids and methotrexate are not standard HO prophylaxis.

Question 147

Topic: Upper Extremity Trauma

Recent quantitative perfusion studies have redefined the vascularity of the proximal humerus. According to these studies, which artery provides the predominant blood supply to the humeral head?

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

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

Historically, the anterior humeral circumflex artery (via the arcuate artery) was thought to provide the main blood supply to the humeral head. However, recent studies (e.g., Hettrich et al.) demonstrate that the posterior humeral circumflex artery supplies approximately 64% of the humeral head.

Question 148

Topic: Upper Extremity Trauma

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

. Disruption of the AC ligaments with intact coracoclavicular (CC) ligaments
. Disruption of AC and CC ligaments with 100% to 300% superior displacement of the clavicle
. Posterior displacement of the clavicle into the trapezius muscle
. Inferior displacement of the clavicle under the coracoid process
. Disruption of AC and CC ligaments with less than 25% displacement

Correct Answer & Explanation

. Disruption of AC and CC ligaments with 100% to 300% superior displacement of the clavicle

Explanation

A Rockwood Type V injury involves complete disruption of both the AC and CC ligaments along with the deltotrapezial fascia. This extensive soft tissue failure leads to severe superior displacement (100% to 300%) of the distal clavicle relative to the acromion.

Question 149

Topic: Upper Extremity Trauma
A 28-year-old male cyclist falls directly onto his right shoulder. Clinical examination and radiographs confirm a Type III acromioclavicular (AC) joint dislocation. He is counseled on operative versus non-operative treatment. According to the current orthopedic literature, what is the expected outcome if he chooses non-operative management compared to surgical reconstruction?
. Higher rate of returning to his pre-injury level of sport
. Lower risk of chronic cosmetic deformity
. No significant difference in long-term shoulder functional outcome scores
. Significantly decreased shoulder strength in internal rotation
. Higher rate of delayed neurologic deficit

Correct Answer & Explanation

. No significant difference in long-term shoulder functional outcome scores

Explanation

For Type III AC joint dislocations, the literature generally demonstrates no significant difference in long-term functional outcome scores (e.g., DASH, Constant scores) between operative and non-operative management. Non-operative management avoids surgical complications and allows an earlier return to work and sports, though it is associated with a higher likelihood of persistent cosmetic deformity. Internal rotation strength is generally not significantly affected.

Question 150

Topic: Upper Extremity Trauma

A 48-year-old male presents with acute weakness in elbow extension after attempting a heavy overhead triceps extension. MRI confirms a complete avulsion of the distal triceps tendon from the olecranon. During surgical repair using a transosseous cruciate technique, understanding the anatomic footprint is crucial. What is the most accurate description of the triceps tendon insertion on the olecranon to guide anatomic repair?

. It inserts exclusively on the sharp proximal tip of the olecranon
. It inserts over a broad area on the proximal olecranon dome, beginning slightly distal to the tip and extending 1 to 2 cm distally
. It inserts predominantly on the medial aspect of the proximal ulna, blending with the sublime tubercle
. It inserts as a narrow, pencil-like footprint 3 cm distal to the olecranon tip
. It inserts bilaterally on the epicondyles with a central aponeurosis over the olecranon

Correct Answer & Explanation

. It inserts over a broad area on the proximal olecranon dome, beginning slightly distal to the tip and extending 1 to 2 cm distally

Explanation

The anatomic footprint of the distal triceps tendon is broad and covers the proximal portion of the olecranon (the dome). It typically begins a few millimeters distal to the articular tip of the olecranon and extends distally for approximately 1 to 2 cm. Reattaching the tendon specifically to the tip without covering the dome can lead to altered biomechanics and an extension lag.

Question 151

Topic: Upper Extremity Trauma
A 28-year-old manual laborer requires surgical reconstruction for a chronic Type III acromioclavicular (AC) joint separation. The reconstruction will target the coracoclavicular (CC) ligaments. Which of the following best describes the anatomical orientation of the native CC ligaments?
. The conoid is medial and posterior; the trapezoid is lateral and anterior.
. The conoid is lateral and anterior; the trapezoid is medial and posterior.
. The conoid is medial and anterior; the trapezoid is lateral and posterior.
. The conoid is lateral and posterior; the trapezoid is medial and anterior.
. Both ligaments run parallel with no distinct anteroposterior separation.

Correct Answer & Explanation

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

Explanation

The coracoclavicular ligament complex consists of the conoid and trapezoid ligaments. The conoid is situated medial and posterior, while the trapezoid is lateral and anterior. Anatomic reconstruction techniques aim to reproduce this specific footprint.

Question 152

Topic: Upper Extremity Trauma

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?

. Conoid is medial, Trapezoid is lateral
. Trapezoid is medial, Conoid is lateral
. Coracoacromial is medial, Conoid is lateral
. Conoid is medial, Coracoacromial is lateral
. Trapezoid is medial, Coracoacromial is lateral

Correct Answer & Explanation

. Conoid is medial, Trapezoid is 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 153

Topic: Upper Extremity Trauma

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?

. Wait at least 12 months from the injury regardless of radiographic appearance
. Wait at least 18 months to ensure complete metabolic inactivity
. Proceed with excision now, as the bone appears mature radiographically and clinically
. Perform immediate manipulation under anesthesia
. Proceed with a total elbow arthroplasty

Correct Answer & Explanation

. Wait at least 12 months from the injury regardless of radiographic appearance

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 154

Topic: Upper Extremity Trauma

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?

. Compressive wrapping and oral NSAIDs
. Corticosteroid injection into the bursa
. Intravenous antibiotics, and surgical bursectomy if no improvement in 24-48 hours
. Immediate arthroscopic synovectomy of the elbow joint
. Observation and warm compresses

Correct Answer & Explanation

. Compressive wrapping and oral NSAIDs

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 155

Topic: Upper Extremity Trauma

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?

. Single simple suture
. Figure-of-eight suture alone
. Krackow locking stitch with transosseous cruciate configuration
. Anchor fixation without transosseous sutures
. Mattress suture

Correct Answer & Explanation

. Single simple suture

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 156

Topic: Upper Extremity Trauma

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?

. Olecranon tip
. Sublime tubercle of the coronoid process
. Radial neck
. Annular ligament
. Brachialis tendon insertion

Correct Answer & Explanation

. Olecranon tip

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 157

Topic: Upper Extremity Trauma

Recent quantitative vascular studies assessing the blood supply to the proximal humerus have challenged historical anatomical teachings. Which artery is now recognized as providing the predominant blood supply (up to 64%) to the humeral head?

. Anterior circumflex humeral artery
. Arcuate artery of Laing
. Posterior circumflex humeral artery
. Thoracoacromial artery
. Profunda brachii artery

Correct Answer & Explanation

. Posterior circumflex humeral artery

Explanation

Historically, the anterior circumflex humeral artery was thought to be the main vascular supply to the humeral head. However, recent studies demonstrate that the posterior circumflex humeral artery provides the majority of the blood supply to the proximal humerus.

Question 158

Topic: Upper Extremity Trauma

In the surgical reconstruction of a chronic Type V acromioclavicular (AC) joint dislocation, anatomic reconstruction of the coracoclavicular (CC) ligaments is planned. What are the precise anatomical insertion sites of the conoid and trapezoid ligaments on the clavicle relative to the distal clavicle tip?

. Conoid is approximately 4.5 cm medial, and trapezoid is 3.0 cm medial
. Conoid is approximately 3.0 cm medial, and trapezoid is 4.5 cm medial
. Both insert conjointly at exactly 2.5 cm medial
. Conoid is approximately 1.5 cm medial, and trapezoid is 3.0 cm medial
. Conoid is approximately 4.5 cm medial on the anterior edge, and trapezoid is 3.0 cm medial on the posterior edge

Correct Answer & Explanation

. Conoid is approximately 4.5 cm medial, and trapezoid is 3.0 cm medial

Explanation

Anatomic studies of the coracoclavicular (CC) ligaments have demonstrated that the trapezoid inserts anterolaterally on the clavicle, averaging 3.0 cm medial to the distal tip. The conoid inserts posteromedially, averaging 4.5 cm medial to the distal tip. Knowledge of these footprints is crucial for anatomical CC ligament reconstruction.

Question 159

Topic: Upper Extremity Trauma

Recent quantitative anatomical studies of humeral head perfusion (e.g., Hettrich et al.) have challenged traditional teaching regarding the primary blood supply to the proximal humerus. Based on current evidence, which vessel provides the majority of the blood supply to the humeral head?

. Anterior humeral circumflex artery (arcuate branch)
. Posterior humeral circumflex artery
. Suprascapular artery
. Thoracoacromial artery
. Profunda brachii artery

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

Historically, the arcuate branch of the anterior humeral circumflex artery was taught as the primary blood supply to the humeral head. However, landmark modern quantitative studies (e.g., Hettrich et al., JBJS 2010) demonstrated that the posterior humeral circumflex artery actually provides the vast majority (approximately 64%) of the blood supply to the humeral head. This is frequently tested on OITE and ABOS exams.

Question 160

Topic: Upper Extremity Trauma
A 24-year-old cyclist falls directly onto his shoulder. Clinical examination reveals a prominent distal clavicle. An axillary radiograph demonstrates the distal clavicle is displaced posteriorly, penetrating into the trapezius fascia. According to the Rockwood classification, what is the appropriate injury type and generally accepted management?
. Type III; nonoperative management
. Type IV; surgical reconstruction
. Type V; surgical reconstruction
. Type IV; nonoperative management
. Type VI; urgent surgical reduction

Correct Answer & Explanation

. Type IV; surgical reconstruction

Explanation

The Rockwood classification of acromioclavicular (AC) joint injuries defines a Type IV injury as posterior displacement of the distal clavicle into or through the trapezius fascia. This injury is extremely painful, often irreducible closed, and fundamentally disrupts the deltotrapezial fascia. Because of the persistent disability and irreducible nature, Rockwood Type IV, V, and VI injuries are generally treated with surgical reduction and reconstruction.

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