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Elbow & Forearm MCQs

Practice Set 15 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 281

Topic: Elbow & Forearm

A 14-year-old female gymnast presents with insidious onset lateral elbow pain, clicking, and a 15-degree extension deficit. Radiographs reveal a radiolucent lesion of the capitellum. Which of the following differentiates capitellar osteochondritis dissecans (OCD) from Panner disease?

. Involvement of the entire capitellum
. Age of onset typically less than 10 years
. Presence of loose bodies or an articular cartilage flap
. Self-limiting nature with no risk of residual deformity
. Primary involvement of the radial head

Correct Answer & Explanation

. Involvement of the entire capitellum

Explanation

Capitellar OCD affects older children (11-17 years) and involves focal subchondral bone changes that can lead to cartilage flaps and loose bodies. Panner disease affects the entire capitellum in younger children (under 10) and is typically self-limiting without loose body formation.

Question 282

Topic: Elbow & Forearm

During an open debridement for recalcitrant lateral epicondylitis (Nirschl procedure), the surgeon must avoid injuring a critical structure located directly beneath the ECRB origin. Which structure is at greatest risk during excessive deep dissection?

. Lateral ulnar collateral ligament (LUCL)
. Radial collateral ligament (RCL)
. Posterior interosseous nerve (PIN)
. Annular ligament
. Superficial radial nerve

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The LUCL lies directly deep to the common extensor origin and ECRB. Excessive deep dissection or over-debridement can violate the LUCL, leading to iatrogenic posterolateral rotatory instability (PLRI) of the elbow.

Question 283

Topic: Elbow & Forearm

On an MRI of a 13-year-old gymnast with an OCD lesion of the capitellum, which finding is the most reliable indicator of lesion instability requiring surgical intervention?

. Bone marrow edema extending to the metaphysis
. High T2 signal interfacing between the fragment and crater
. Subchondral sclerosis around the lesion
. Flattening of the radial head
. Thickening of the radial collateral ligament

Correct Answer & Explanation

. High T2 signal interfacing between the fragment and crater

Explanation

A high T2 signal line indicating fluid between the osteochondral fragment and the underlying bone bed is a classic sign of instability. Once fluid breaches this interface, the lesion is unstable and typically necessitates surgical intervention.

Question 284

Topic: Elbow & Forearm

A 42-year-old tennis player requests a corticosteroid injection for newly diagnosed lateral epicondylitis. What should the physician advise regarding the expected outcomes of a corticosteroid injection compared to physical therapy or observation?

. Superior long-term outcomes at 1 year
. Better short-term relief (at 4-6 weeks) but higher recurrence rates at 1 year
. No difference in short-term pain relief but better long-term function
. Lower risk of tendon rupture compared to platelet-rich plasma (PRP)
. Immediate permanent resolution of symptoms

Correct Answer & Explanation

. Better short-term relief (at 4-6 weeks) but higher recurrence rates at 1 year

Explanation

Corticosteroid injections for lateral epicondylitis provide excellent short-term relief (4-6 weeks) but are associated with worse long-term outcomes at 1 year. They also carry higher recurrence rates compared to physical therapy or watchful waiting.

Question 285

Topic: Elbow & Forearm

A 28-year-old male golfer complains of catching and snapping on the lateral side of his elbow during extension. MRI is negative for loose bodies but shows a thickened band of tissue in the lateral gutter. Which condition most closely mimics lateral loose bodies and lateral epicondylitis in this presentation?

. Posterolateral rotatory instability
. Snapping triceps syndrome
. Symptomatic radiocapitellar synovial plica
. Ulnar nerve subluxation
. Osteoid osteoma of the radial head

Correct Answer & Explanation

. Symptomatic radiocapitellar synovial plica

Explanation

A symptomatic synovial radiocapitellar plica can cause lateral elbow pain, snapping, and mechanical catching. It frequently mimics loose bodies or lateral epicondylitis and is often treated effectively with arthroscopic resection.

Question 286

Topic: Elbow & Forearm

A patient develops symptomatic posterolateral rotatory instability (PLRI) following an open release for lateral epicondylitis. Which examination finding confirms this iatrogenic complication?

. Positive moving valgus stress test
. Apprehension during combined axial load, valgus stress, and supination
. Pain with resisted wrist flexion
. Inability to actively extend the thumb
. Paresthesia in the ulnar digits with elbow flexion

Correct Answer & Explanation

. Apprehension during combined axial load, valgus stress, and supination

Explanation

Iatrogenic injury to the LUCL during lateral epicondylitis surgery causes PLRI. This is clinically diagnosed by a positive lateral pivot-shift apprehension test, performed by applying an axial load, valgus stress, and supination as the elbow is flexed.

Question 287

Topic: Elbow & Forearm

According to randomized controlled trials, which orthobiologic injection has demonstrated better long-term pain relief and functional improvement for refractory lateral epicondylitis compared to corticosteroid injections?

. Hyaluronic acid
. Leukocyte-rich platelet-rich plasma (LR-PRP)
. Bone marrow aspirate concentrate (BMAC)
. Botulinum toxin A
. Autologous conditioned serum (ACS)

Correct Answer & Explanation

. Leukocyte-rich platelet-rich plasma (LR-PRP)

Explanation

Multiple studies demonstrate that leukocyte-rich PRP (LR-PRP) offers superior long-term (1-2 years) pain relief and functional improvement for lateral epicondylitis compared to corticosteroids. Corticosteroids typically only offer transient short-term relief.

Question 288

Topic: Elbow & Forearm

The extensor carpi radialis brevis (ECRB) is the primary tendon implicated in lateral epicondylitis. What is its precise anatomical origin relative to the extensor digitorum communis (EDC)?

. Deep and anterior to the EDC
. Superficial and posterior to the EDC
. Distal and posterior to the EDC
. Directly attached to the lateral supracondylar ridge, proximal to the EDC
. Fibers interdigitate superficially over the EDC

Correct Answer & Explanation

. Deep and anterior to the EDC

Explanation

The ECRB origin lies deep and slightly anterior to the extensor digitorum communis (EDC) at the lateral epicondyle. During open surgery for lateral epicondylitis, the EDC is often split or retracted to expose the pathologically altered ECRB tissue.

Question 289

Topic: Elbow & Forearm

A 7-year-old boy presents with a dull, aching pain in his dominant lateral elbow without mechanical locking. Radiographs show fragmentation and sclerosis of the entire capitellum without loose bodies. What is the most appropriate management?

. Arthroscopic debridement and microfracture
. Core decompression of the capitellum
. Symptomatic treatment with rest and avoidance of throwing
. Immobilization in a long arm cast for 12 weeks
. Osteochondral autograft transfer (OATS)

Correct Answer & Explanation

. Symptomatic treatment with rest and avoidance of throwing

Explanation

This presentation is classic for Panner disease, a benign osteochondrosis of the capitellum affecting young children (usually <10 years). It is a self-limiting condition that reliably resolves with conservative management, such as rest and activity modification.

Question 290

Topic: Elbow & Forearm

Microscopic evaluation of tissue excised during surgery for refractory lateral epicondylitis classically demonstrates which of the following?

. Abundant acute inflammatory cells and macrophages
. Angiofibroblastic hyperplasia with disorganized collagen
. Granulomatous inflammation with giant cells
. Synovial hypertrophy with villous proliferation
. Chondroid metaplasia within the tendon substance

Correct Answer & Explanation

. Angiofibroblastic hyperplasia with disorganized collagen

Explanation

The pathologic process in lateral epicondylitis is tendinosis, not an acute tendinitis. Histology characteristically shows angiofibroblastic hyperplasia, disorganized collagen, and an absence of acute inflammatory cells.

Question 291

Topic: Elbow & Forearm

Based on high-level clinical evidence, what is the expected long-term outcome (at 1 year) of corticosteroid injection compared to physical therapy for the treatment of lateral epicondylitis?

. Superior pain relief and grip strength recovery
. Equivalent pain relief but significantly higher recurrence rates
. Worse pain scores and higher rates of symptom recurrence
. Decreased risk of eventual surgical intervention
. Accelerated tendon healing on MRI evaluation

Correct Answer & Explanation

. Worse pain scores and higher rates of symptom recurrence

Explanation

Corticosteroid injections for lateral epicondylitis provide excellent short-term relief (at 4-6 weeks) but are associated with worse long-term outcomes (at 1 year) and higher recurrence rates compared to physical therapy or observation.

Question 292

Topic: Elbow & Forearm

During an open release of the extensor carpi radialis brevis (ECRB) for refractory lateral epicondylitis, the surgeon must avoid extending the dissection too posterior and distal. Injury to which structure could result in iatrogenic posterolateral rotatory instability (PLRI)?

. Radial nerve
. Posterior interosseous nerve
. Lateral ulnar collateral ligament
. Annular ligament
. Extensor digitorum communis origin

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The lateral ulnar collateral ligament (LUCL) lies immediately deep and posterior to the common extensor origin. Overzealous debridement or release of the ECRB can compromise the LUCL, leading to PLRI.

Question 293

Topic: Elbow & Forearm

A 7-year-old boy presents with dull, aching lateral elbow pain without mechanical symptoms. Radiographs reveal fragmentation and sclerosis of the entire capitellum. What is the most appropriate initial management?

. Arthroscopic evaluation and microfracture
. Rest and cessation of throwing/weight-bearing activities
. Osteochondral autograft transfer
. Fragment fixation with bioabsorbable pins
. Radial head excision

Correct Answer & Explanation

. Rest and cessation of throwing/weight-bearing activities

Explanation

This clinical presentation is classic for Panner's disease (osteochondrosis of the capitellum), which typically affects children aged 7-10. It is a self-limiting condition that heals completely with rest and avoidance of inciting activities.

Question 294

Topic: Elbow & Forearm

A 42-year-old female presents with lateral elbow and forearm pain. Her pain is maximal 4 to 5 cm distal to the lateral epicondyle. Resisted supination of the forearm with the elbow fully extended significantly exacerbates her symptoms. What is the most likely diagnosis?

. Lateral epicondylitis
. Radial tunnel syndrome
. Pronator syndrome
. Posterolateral rotatory instability
. Capitellar osteochondritis dissecans

Correct Answer & Explanation

. Radial tunnel syndrome

Explanation

Radial tunnel syndrome presents with pain distal to the lateral epicondyle over the mobile wad. Pain exacerbated by resisted supination or resisted middle finger extension (due to the ECRB edge compressing the PIN) distinguishes it from lateral epicondylitis.

Question 295

Topic: Elbow & Forearm

During a Nirschl procedure for lateral epicondylitis, which of the following describes the most accurate anatomical relationship regarding the posterior interosseous nerve (PIN) to avoid iatrogenic injury?

. It lies directly within the substance of the extensor carpi radialis longus (ECRL)
. It passes between the two heads of the supinator muscle distal to the ECRB origin
. It crosses superficial to the annular ligament at the level of the radial head
. It runs deep to the lateral ulnar collateral ligament
. It courses directly through the common extensor tendon origin

Correct Answer & Explanation

. It passes between the two heads of the supinator muscle distal to the ECRB origin

Explanation

The PIN courses anterior to the radiocapitellar joint and dives between the superficial and deep heads of the supinator muscle (arcade of Frohse). Staying proximal and superior to the supinator during ECRB debridement minimizes the risk of PIN injury.

Question 296

Topic: Elbow & Forearm

A 14-year-old elite gymnast presents with lateral elbow pain and a 15-degree extension deficit. Radiographs demonstrate a radiolucent lesion of the capitellum. MRI is obtained to evaluate the stability of the osteochondral lesion. Which of the following MRI findings is the most reliable indicator of instability?

. Subchondral sclerosis
. Bone marrow edema in the capitellum
. Intact articular cartilage overlying the lesion
. High T2 signal fluid interposing between the fragment and crater
. Thickening of the radial collateral ligament

Correct Answer & Explanation

. High T2 signal fluid interposing between the fragment and crater

Explanation

In osteochondritis dissecans (OCD) of the capitellum, a high T2 signal (fluid) between the osteochondral fragment and the underlying bone indicates that the lesion is unstable. This fluid line suggests detachment of the fragment from the crater.

Question 297

Topic: Elbow & Forearm

A 9-year-old boy presents with an aching lateral right elbow. He plays Little League baseball but denies any specific injury. Radiographs reveal sclerosis and fragmentation of the entire capitellum without any loose bodies. What is the most appropriate initial management?

. Arthroscopic drilling of the capitellum
. Osteochondral autograft transfer
. Cessation of throwing and symptomatic treatment
. Corticosteroid injection into the radiocapitellar joint
. Ulnar collateral ligament reconstruction

Correct Answer & Explanation

. Cessation of throwing and symptomatic treatment

Explanation

The clinical and radiographic presentation in a child under 10 years old is classic for Panner's disease, a self-limiting osteochondrosis of the capitellum. Treatment consists of rest and avoidance of valgus stress, as the lesion typically resolves spontaneously with re-ossification.

Question 298

Topic: Elbow & Forearm

During open surgical release of the extensor carpi radialis brevis (ECRB) for recalcitrant lateral epicondylitis, an overzealous dissection is performed inferiorly and deep to the tendon origin. Postoperatively, the patient experiences apprehension when pushing up from a chair. Injury to which of the following structures is the most likely cause of this complication?

. Annular ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Posterior interosseous nerve
. Ulnar nerve

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Iatrogenic injury to the lateral ulnar collateral ligament (LUCL) during ECRB debridement can result in posterolateral rotatory instability (PLRI) of the elbow. Patients with PLRI often complain of clicking, snapping, or apprehension when pushing off a chair with the elbow extended and forearm supinated.

Question 299

Topic: Elbow & Forearm

A 45-year-old woman with lateral epicondylitis asks about corticosteroid injections compared to physical therapy. Based on high-level evidence, what should she be counseled regarding the outcomes of corticosteroid injections for this condition?

. They provide better short-term and long-term relief compared to physical therapy.
. They provide excellent short-term relief but yield worse outcomes at 1 year compared to physical therapy or watchful waiting.
. They are ineffective for short-term relief but provide superior outcomes at 1 year.
. They are associated with a high rate of spontaneous ECRB tendon rupture.
. They cure the underlying angiofibroblastic hyperplasia within 6 weeks.

Correct Answer & Explanation

. They provide excellent short-term relief but yield worse outcomes at 1 year compared to physical therapy or watchful waiting.

Explanation

Level I evidence demonstrates that while corticosteroid injections may provide significant short-term relief (at 4-6 weeks) for lateral epicondylitis, patients often experience high recurrence rates. At 1 year, outcomes are significantly worse compared to physical therapy or a wait-and-see approach.

Question 300

Topic: Elbow & Forearm

When performing an open Nirschl procedure (excision of the angiofibroblastic tissues of the ECRB) for lateral epicondylitis, the surgeon normally approaches the ECRB origin through an interval. Which structure typically overlies the ECRB and must be incised or split to expose the pathologic tissue?

. Extensor carpi ulnaris
. Extensor digiti minimi
. Extensor carpi radialis longus (ECRL) and Extensor digitorum communis (EDC) aponeurosis
. Brachioradialis
. Anconeus

Correct Answer & Explanation

. Extensor carpi radialis longus (ECRL) and Extensor digitorum communis (EDC) aponeurosis

Explanation

The ECRB origin lies deep to the extensor carpi radialis longus (ECRL) and the extensor digitorum communis (EDC). The surgical approach classically involves splitting the ECRL-EDC interval or splitting the EDC to expose the underlying degenerated ECRB tendon.

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