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Elbow & Forearm MCQs

Practice Set 13 of 57

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

Question 241

Topic: Elbow & Forearm

A surgeon is reviewing the literature on terrible triad injuries. The case mentions that the need for Medial Collateral Ligament (MCL) repair in TTI is debated, as it is typically spared in the primary injury. According to the provided case material, under what specific circumstance would an acute repair of the MCL typically be indicated in a terrible triad injury?

. If the MCL is found to be avulsed from its humeral origin during the initial lateral approach.
. If gross valgus instability persists after stabilization of the LUCL, coronoid, and radial head.
. Prophylactically in all terrible triad injuries to enhance overall stability.
. Only if the patient develops chronic valgus instability after initial surgery.
. If the coronoid fracture involves the sublime tubercle, regardless of other stability.

Correct Answer & Explanation

. If gross valgus instability persists after stabilization of the LUCL, coronoid, and radial head.

Explanation

Correct Answer: BThe case, under 'Medial Collateral Ligament (MCL) Assessment', states: 'Though less commonly injured primarily in TTI, the MCL should be dynamically stressed after the lateral structures are stabilized.If gross valgus instability persists after LUCL, coronoid, and radial head stabilization, an acute repair of the MCL (typically the anterior bundle) is indicated.' This highlights the specific intra-operative finding that would necessitate MCL repair.Option A is incorrect because the MCL is on the medial side and would not be visualized during a standard lateral approach. Option C (prophylactic repair) is not supported by the case, which states its role is debated. Option D (chronic instability) would be a delayed presentation, whereas the question asks about acute repair. Option E (coronoid fracture involving the sublime tubercle) is important because the sublime tubercle is the attachment site for the MCL, and its fracture can compromise MCL stability. However, the case specifies that MCL repair is indicated ifgross valgus instability persistsafter addressing all other components, implying a dynamic assessment of overall stability, not just the presence of a specific fracture pattern.

Question 242

Topic: Elbow & Forearm

Surgical management of the 'terrible triad' of the elbow traditionally follows a specific sequence to sequentially restore stability. After addressing the coronoid and radial head fractures, what is the next most critical ligamentous structure to repair?

. Medial collateral ligament (MCL)
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Interosseous membrane
. Anterior band of the MCL

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The terrible triad of the elbow includes fractures of the radial head and coronoid with elbow dislocation. Surgical management prioritizes fixing the coronoid, then the radial head, followed by repair of the lateral ulnar collateral ligament (LUCL) to restore posterolateral rotatory stability.

Question 243

Topic: Elbow & Forearm

A 40-year-old female presents with a highly comminuted radial head fracture and significant distal radioulnar joint (DRUJ) pain following a fall. If this injury is incorrectly managed with isolated radial head excision, what is the most likely long-term complication?

. Elbow stiffness in extension
. Heterotopic ossification of the triceps insertion
. Proximal migration of the radius and ulnocarpal impaction
. Varus posteromedial rotatory instability
. Avascular necrosis of the capitellum

Correct Answer & Explanation

. Proximal migration of the radius and ulnocarpal impaction

Explanation

An Essex-Lopresti injury consists of a radial head fracture, DRUJ disruption, and an interosseous membrane tear. Radial head excision is strictly contraindicated as it leads to proximal radial migration and debilitating ulnocarpal impaction; a radial head arthroplasty is required.

Question 244

Topic: Elbow & Forearm

A 25-year-old male sustains an elbow dislocation. A post-reduction CT scan demonstrates an isolated fracture of the anteromedial facet of the coronoid process. What specific ligamentous injury is pathognomonic for this fracture pattern?

. Lateral collateral ligament (LCL) complex disruption
. Isolated medial collateral ligament (MCL) tear
. Annular ligament avulsion
. Distal biceps tendon rupture
. Ulnar collateral ligament anterior band tear

Correct Answer & Explanation

. Lateral collateral ligament (LCL) complex disruption

Explanation

Fractures of the anteromedial facet of the coronoid are pathognomonic for a varus posteromedial rotatory instability mechanism. This injury pattern typically involves a rupture of the lateral collateral ligament (LCL) complex, allowing the anteromedial facet to impact the trochlea.

Question 245

Topic: Elbow & Forearm

A patient presents with a capitellum fracture classified as a Dubberley type 3B. What defining characteristic of this specific fracture type often necessitates structural bone grafting or a posterior approach?

. Associated radial head fracture
. Anterior capsular tearing
. Posterior capitellar comminution
. Medial epicondyle avulsion
. Coronoid process fracture

Correct Answer & Explanation

. Posterior capitellar comminution

Explanation

The Dubberley classification for capitellum fractures incorporates the presence of posterior capitellar comminution (Type B). Because Type B fractures lack a stable posterior bony buttress, they often require structural bone grafting or more extensive posterior fixation strategies.

Question 246

Topic: Elbow & Forearm

An adult patient undergoes plate fixation for a Bado type II Monteggia fracture (posterior dislocation of the radial head with an apex-posterior ulnar diaphyseal fracture). Intraoperatively, after the ulnar plate is applied, the radial head remains dislocated. What is the most appropriate next step in management?

. Open reduction of the radial head and annular ligament repair
. Reconstruction of the annular ligament with a triceps slip
. Revision of the ulnar fixation to restore appropriate length and alignment
. Excision of the radial head
. Pinning of the radiocapitellar joint

Correct Answer & Explanation

. Revision of the ulnar fixation to restore appropriate length and alignment

Explanation

In Monteggia fracture-dislocations, failure to achieve or maintain radial head reduction is almost invariably due to malreduction (often malalignment or shortening) of the ulnar fracture. The ulnar fixation must be revised before addressing the radiocapitellar joint directly.

Question 247

Topic: Elbow & Forearm

A 38-year-old female presents with a 'terrible triad' injury of the elbow consisting of a dislocation, a comminuted radial head fracture, and a type II coronoid fracture. Following closed reduction, the joint remains unstable. What is the most appropriate biomechanical sequence of surgical reconstruction?

. LCL repair, radial head replacement, coronoid fixation
. Radial head replacement, coronoid fixation, LCL repair
. Coronoid fixation, radial head replacement, LCL repair
. MCL repair, coronoid fixation, radial head replacement
. Coronoid fixation, LCL repair, radial head replacement

Correct Answer & Explanation

. Coronoid fixation, radial head replacement, LCL repair

Explanation

Surgical management of terrible triad injuries classically proceeds from deep to superficial, starting with fixation of the coronoid. This is followed by radial head repair or replacement to restore the anterior buttress, and finally repair of the lateral collateral ligament (LCL) complex.

Question 248

Topic: Elbow & Forearm

A 35-year-old female presents with a 'terrible triad' injury of the elbow after a fall onto an outstretched hand.

If surgical intervention is undertaken using a standard lateral approach, what is the generally recommended sequence of reconstruction?

. Repair the lateral ulnar collateral ligament (LUCL), then fix the radial head, then fix the coronoid
. Fix the coronoid, then fix or replace the radial head, then repair the LUCL
. Fix or replace the radial head, then repair the LUCL, then fix the coronoid
. Repair the medial collateral ligament (MCL), fix the coronoid, then fix the radial head
. Repair the LUCL, fix the coronoid, then repair the MCL

Correct Answer & Explanation

. Fix the coronoid, then fix or replace the radial head, then repair the LUCL

Explanation

The standard "inside-out" surgical sequence for a terrible triad injury involves first fixing the coronoid to restore the anterior buttress. This is followed by radial head repair or replacement, and finally LUCL repair to restore posterolateral stability.

Question 249

Topic: Elbow & Forearm

A 40-year-old female sustains a fall onto an outstretched hand resulting in a capitellum fracture. Radiographic evaluation and subsequent surgical exploration classify the injury as a Kocher-Lorenz (Type II) fracture. Which of the following best describes this specific fracture type?

. A large osseous fragment of the capitellum with attached articular cartilage
. A thin fragment of articular cartilage with very little attached subchondral bone
. A comminuted fracture involving both the capitellum and the trochlea
. A coronal shear fracture that extends medially to involve the lateral epicondyle
. An isolated fracture of the lateral epicondyle sparing the capitellar articular surface

Correct Answer & Explanation

. A thin fragment of articular cartilage with very little attached subchondral bone

Explanation

A Kocher-Lorenz fracture (Type II) involves predominantly articular cartilage with minimal attached subchondral bone, often making it difficult to secure with standard internal fixation. In contrast, a Hahn-Steinthal (Type I) involves a large osseous piece of the capitellum.

Question 250

Topic: Elbow & Forearm

A 40-year-old female sustains a Mason Type II radial head fracture. On examination in the emergency department, she has a reproducible mechanical block to forearm rotation despite aspiration of the hematoma and intra-articular local anesthetic injection. What is the most appropriate management?

. Immobilization in a sling for 3 weeks followed by physical therapy
. Radial head excision alone
. Primary radial head arthroplasty
. Open reduction and internal fixation (ORIF)
. Total elbow arthroplasty

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF)

Explanation

A Mason Type II injury is a displaced partial articular fracture of the radial head. When associated with a mechanical block to rotation that persists after hematoma block, ORIF is indicated to restore joint congruency and allow early motion.

Question 251

Topic: Elbow & Forearm

A 45-year-old female falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. Radiographs and CT demonstrate a posterior elbow dislocation, a comminuted radial head fracture, and a Regan-Morrey Type II coronoid fracture. During surgical reconstruction, what is the most widely accepted sequence of fixation to reliably restore elbow stability?

. Radial head, coronoid, lateral collateral ligament (LCL)
. Coronoid, radial head, lateral collateral ligament (LCL)
. Lateral collateral ligament (LCL), coronoid, radial head
. Medial collateral ligament (MCL), radial head, lateral collateral ligament (LCL)
. Radial head, lateral collateral ligament (LCL), coronoid

Correct Answer & Explanation

. Coronoid, radial head, lateral collateral ligament (LCL)

Explanation

The standard surgical sequence for terrible triad injuries aims to reconstruct from deep to superficial structures: coronoid fixation or anterior capsule repair, followed by radial head repair or arthroplasty, and finally LCL repair. This systematic approach effectively restores the anterior and lateral bony and ligamentous buttresses.

Question 252

Topic: Elbow & Forearm

When performing open reduction and internal fixation (ORIF) of a radial head fracture, what is the ideal placement for fixation screws to minimize impingement with the capitellum during forearm rotation?

. Anterior aspect of the radial head
. Posterior aspect of the radial head
. Inferior aspect of the radial head
. Superior aspect of the radial head
. The 'safe zone' between 90 degrees of supination and 90 degrees of pronation, typically the non-articulating portion corresponding to the posterolateral quadrant when the forearm is in neutral rotation.

Correct Answer & Explanation

. The 'safe zone' between 90 degrees of supination and 90 degrees of pronation, typically the non-articulating portion corresponding to the posterolateral quadrant when the forearm is in neutral rotation.

Explanation

Correct Answer: ETo avoid impingement of hardware against the capitellum, screws and plates should ideally be placed in the 'safe zone' of the radial head. This zone is typically defined as the non-articulating portion of the radial head that does not articulate with the capitellum through a full range of forearm rotation. This zone is generally considered to be a 110-degree arc on the radial head, typically in the posterolateral quadrant when the forearm is in neutral rotation, or approximately between 90 degrees of supination and 90 degrees of pronation. Placing hardware in the anterior, posterior, or superior articulating zones is prone to impingement and pain.

Question 253

Topic: Elbow & Forearm

Which of the following ligaments is most commonly injured in a 'terrible triad' injury of the elbow?

. Medial collateral ligament (MCL)
. Annular ligament
. Lateral ulnar collateral ligament (LUCL)
. Oblique cord
. Radiocapitellar ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Correct Answer: CThe 'terrible triad' of the elbow consists of a posterior elbow dislocation, a radial head fracture, and a coronoid process fracture. The most consistently injured ligament in this complex is the lateral ulnar collateral ligament (LUCL), which is crucial for posterolateral rotatory stability of the elbow. MCL injury can also occur, but the LUCL is the key structure disrupting posterolateral stability in this injury pattern. The annular ligament is injured as part of the radial head fracture, but the LUCL is the primary stabilizer injured in the dislocation component.

Question 254

Topic: Elbow & Forearm

A 40-year-old gymnast falls from a height and sustains an anteromedial facet fracture of the coronoid process. If left untreated, this specific fracture pattern most predictably leads to which of the following instability patterns?

. Valgus posterolateral rotatory instability
. Posterolateral rotatory instability (PLRI) with isolated LCL insufficiency
. Varus posteromedial rotatory instability (VPMRI)
. Straight anterior instability
. Isolated radioulnar divergence

Correct Answer & Explanation

. Varus posteromedial rotatory instability (VPMRI)

Explanation

Anteromedial facet coronoid fractures typically occur from an axial load coupled with varus and posteromedial rotation. They are highly associated with lateral collateral ligament (LCL) injuries, resulting in varus posteromedial rotatory instability (VPMRI).

Question 255

Topic: Elbow & Forearm

A 50-year-old male sustains a terrible triad injury of the elbow consisting of an elbow dislocation, radial head fracture, and coronoid fracture. According to standard treatment algorithms, what is the most appropriate sequence of surgical repair?

. Fixation of the coronoid, followed by radial head repair/replacement, followed by LCL repair
. LCL repair, followed by radial head repair/replacement, followed by coronoid fixation
. Radial head repair/replacement, followed by LCL repair, followed by coronoid fixation
. MCL repair, followed by coronoid fixation, followed by LCL repair
. Fixation of the coronoid, followed by MCL repair, followed by radial head repair/replacement

Correct Answer & Explanation

. Fixation of the coronoid, followed by radial head repair/replacement, followed by LCL repair

Explanation

The standard inside-out protocol for terrible triad injuries begins with deep and medial structures, repairing the coronoid first, followed by the radial head (repair or arthroplasty), and finally the lateral collateral ligament (LCL) complex.

Question 256

Topic: Elbow & Forearm

During surgical reconstruction of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), which of the following represents the most widely accepted sequence of structural repair to restore stability?

. Radial head fixation/replacement, followed by LCL repair, followed by coronoid fixation
. LCL repair, followed by coronoid fixation, followed by radial head fixation/replacement
. Coronoid fixation, followed by radial head fixation/replacement, followed by LCL repair
. MCL repair, followed by coronoid fixation, followed by radial head fixation/replacement
. Coronoid fixation, followed by MCL repair, followed by radial head fixation/replacement

Correct Answer & Explanation

. Coronoid fixation, followed by radial head fixation/replacement, followed by LCL repair

Explanation

The standard surgical sequence for a terrible triad injury progresses from deep to superficial and anterior to posterior: coronoid (and anterior capsule) fixation first, followed by radial head repair or replacement, and finally lateral collateral ligament (LCL) repair. The MCL is only repaired if the elbow remains unstable after these steps.

Question 257

Topic: Elbow & Forearm
A 6-year-old boy sustains a Bado Type III Monteggia equivalent lesion. Which of the following defines this injury pattern and its most common associated neurological complication?
. Anterior radial head dislocation with median nerve palsy
. Posterior radial head dislocation with ulnar nerve palsy
. Lateral radial head dislocation with posterior interosseous nerve (PIN) palsy
. Anterior radial head dislocation with anterior interosseous nerve (AIN) palsy
. Posterior radial head dislocation with musculocutaneous nerve palsy

Correct Answer & Explanation

. Lateral radial head dislocation with posterior interosseous nerve (PIN) palsy

Explanation

A Bado Type III Monteggia fracture involves a lateral dislocation of the radial head with an ulnar metaphyseal/diaphyseal fracture. It is predominantly seen in children and has the highest association with posterior interosseous nerve (PIN) palsy.

Question 258

Topic: Elbow & Forearm

A 34-year-old male falls on an outstretched hand, sustaining a comminuted radial head fracture and severe wrist pain. Clinical exam reveals distal radioulnar joint (DRUJ) instability. What surgical intervention is absolutely contraindicated in the management of this specific injury pattern?

. Closed reduction and long arm casting
. Radial head excision without replacement
. Radial head arthroplasty
. Open reduction and internal fixation of the radial head
. Percutaneous pinning of the DRUJ

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

This patient has an Essex-Lopresti injury (longitudinal radioulnar dissociation). Radial head excision is absolutely contraindicated as it removes the proximal stabilizer, leading to catastrophic proximal migration of the radius and chronic wrist pain.

Question 259

Topic: Elbow & Forearm

A 6-year-old boy presents with an anteriorly displaced radial head dislocation and a midshaft ulnar fracture. Following closed reduction of the ulna, the radial head remains irreducible. What is the most likely anatomic structure blocking reduction?

. Biceps tendon
. Brachialis muscle
. Annular ligament
. Quadrate ligament
. Interosseous membrane

Correct Answer & Explanation

. Annular ligament

Explanation

In pediatric Monteggia fractures, the radial head usually reduces once the ulna is out to length. If it remains irreducible, the annular ligament or joint capsule is the most common interposing structure requiring open extraction.

Question 260

Topic: Elbow & Forearm

A 45-year-old male falls from a ladder, sustaining a highly comminuted radial head fracture, proximal radius shaft migration, and acute wrist pain. Radiographs demonstrate distal radioulnar joint (DRUJ) widening. The radial head is deemed unreconstructible. What is the most appropriate surgical management?

. Radial head excision and immediate active range of motion
. Radial head excision and DRUJ percutaneous pinning
. Radial head arthroplasty and DRUJ stabilization
. Silastic radial head replacement and long arm casting
. Radial head excision and open TFCC repair

Correct Answer & Explanation

. Radial head arthroplasty and DRUJ stabilization

Explanation

This patient has an Essex-Lopresti injury, characterized by a radial head fracture, interosseous membrane disruption, and DRUJ dislocation. Radial head excision alone is strictly contraindicated as it leads to proximal radial migration; a rigid radial head arthroplasty is required to restore length and stability.

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