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Elbow & Forearm MCQs

Practice Set 19 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 361

Topic: Elbow & Forearm
During the anterior approach for repair of a distal biceps tendon rupture, what structure, shown under the scissors in Figure 6, is at risk for injury?
. Brachial artery
. Median nerve
. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Antecubital vein

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

Discussion: The most commonly injured neurovascular structure during an anterior approach for the repair of a distal biceps tendon rupture is the lateral antebrachial cutaneous nerve. This structure is located lateral to the biceps tendon and in a superficial location just deep to the subcutaneous layer.

Question 362

Topic: Elbow & Forearm
A 21-year-old man who underwent repair of a distal biceps tendon rupture using a two-incision approach 4 months ago now reports difficulty gaining rotation of his forearm. Figures 49a and 49b show the AP and lateral radiographs. What is the most likely cause of his problem?
. Inadequate physical therapy
. Exposure of the periosteum of the lateral ulna during surgery
. Inappropriate location of the suture anchor
. Fixation of the tendon with the forearm fully pronated
. Subluxation of the radial head

Correct Answer & Explanation

. Exposure of the periosteum of the lateral ulna during surgery

Explanation

The radiographs show early ectopic bone formation originating between the ulna and the radius. The development of ectopic bone in this area following a two-incision approach for anatomic repair of the distal biceps tendon is thought to be related to exposure of the periosteum of the lateral ulna during surgery. This can be avoided by the use of a muscle-splitting incision between the extensor carpi ulnaris and common extensor muscles. Full pronation of the forearm allows for the necessary exposure of the radial tuberosity during the procedure and for fixation of the tendon at its maximal length.

Question 363

Topic: Elbow & Forearm
A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?
. Radial head resection, open reduction and internal fixation of the coronoid, and medial collateral ligament repair
. Radial head resection and lateral collateral ligament repair
. Radial head arthroplasty alone
. Radial head arthroplasty and lateral collateral ligament repair
. Radial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repair

Correct Answer & Explanation

. Radial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repair

Explanation

DISCUSSION: The combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region. REFERENCES: Ring D, Quintero J, Jupiter JB: Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811-1815. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551. Moro JK, Werier J, MacDermid JC, et al: Arthroplasty with a metal radial head for unreconstructable fractures of the radial head. J Bone Joint Surg Am 2001;83:1201-1211.

Question 364

Topic: Elbow & Forearm
A 39-year-old woman fell onto her flexed elbow and sustained a comminuted displaced radial head and neck fracture. Radiographs confirm concentric reduction of the ulnohumeral joint. Examination reveals pain with compression of the radius and ulna at the wrist. What is the best treatment for the radial head fracture?
. Long arm cast for 2 weeks, followed by range of motion
. Early range of motion
. Metallic radial head arthroplasty
. Silastic radial head arthroplasty
. Excision of the radial head

Correct Answer & Explanation

. Metallic radial head arthroplasty

Explanation

Patients with comminuted radial neck and head fractures and associated wrist pain have a significant injury to the elbow and forearm. Nonsurgical management is an option, but initial casting will result in stiffness and early range of motion is likely to be unsuccessful secondary to pain. Surgical treatment with open reduction and internal fixation, although possible, is technically demanding and results are unpredictable with comminuted fractures. Excision alone in the face of wrist pain may lead to radial shortening. The treatment of choice is excision and metallic radial head arthroplasty. Silastic implants have been associated with synovitis and wear debris.

Question 365

Topic: Elbow & Forearm

Figures 1 and 2 are the MRI scans of a 35-year-old right-hand dominant man who has right elbow pain after trying to lift a large television at home. An examination reveals ecchymosis, an abnormal hook test, and altered biceps muscle contour. What treatment is most likely to result in a satisfactory and predictable outcome?

. Period of immobilization followed by physical therapy
. Local corticosteroid injection
. Surgical repair
. Platelet-rich plasma (PRP)

Correct Answer & Explanation

. Period of immobilization followed by physical therapy

Explanation

Figures 1 and 2 show a full thickness distal biceps tendon rupture with proximal retraction. Edema is seen along the course of the distal biceps tendon, and the axial cut demonstrates the absence of tendon at the radial tuberosity. The sagittal cut demonstrates the stump of the proximally retracted biceps tendon. The biceps muscle contour is abnormal in appearance, demonstrating the classic “popeye” deformity. Nonsurgical treatment options result in predictable loss of supination and elbow flexion strength that is not desirable. A local corticosteroid injection would not improve strength, and there is no evidence to support the use of a PRP injection.

Question 366

Topic: Elbow & Forearm
A 30-year-old firefighter sustained a longitudinal pulling injury to the arm while attempting to move a heavy object during a fire. Figure 45 shows an MRI scan of the elbow. Initial management should consist of
. rest and a sling followed by a gradual return to activities.
. physical therapy and extension-block bracing.
. repair of the biceps tendon to the brachialis muscle.
. repair of the common flexor origin.
. anatomic repair of the distal biceps tendon.

Correct Answer & Explanation

. anatomic repair of the distal biceps tendon.

Explanation

DISCUSSION: Because the MRI scan shows a complete rupture of the distal biceps tendon, the preferred treatment is anatomic repair of the tendon to the radial tuberosity either with the use of suture anchors or transosseous sutures through a two-incision technique. Several studies have documented superior results with anatomic repair of the distal biceps tendon when compared with results of nonsurgical management or repair of the tendon by attachment to the brachialis muscle. Patients undergoing anatomic repair of the distal biceps tendon through a two-incision technique typically regain a functional range of motion and nearly normal strength.

Question 367

Topic: Elbow & Forearm
A 55-year-old man sustained an elbow dislocation in a fall. Postreduction radiographs are shown in Figures 40a and 40b. What is the best course of management?
. Closed reduction and casting for 4 weeks
. Closed reduction and bracing with immediate range of motion
. Open reduction, lateral collateral ligament repair, and open reduction and internal fixation or metallic replacement of the radial head
. Open reduction, radial head silastic arthroplasty, and lateral collateral ligament repair
. Open reduction, lateral collateral ligament repair, and radial head excision

Correct Answer & Explanation

. Open reduction, lateral collateral ligament repair, and open reduction and internal fixation or metallic replacement of the radial head

Explanation

The radiographs show an elbow dislocation associated with a comminuted radial head fracture. In the setting of comminution and instability, fractures of the radial head are best managed with an arthroplasty rather than open reduction and internal fixation. Resection of the radial head will worsen the instability and is not recommended. Silastic radial head replacements are contraindicated.

Question 368

Topic: Elbow & Forearm
Figure 2 shows the radiograph of a 26-year-old auto mechanic who injured his right dominant elbow in a fall during a motocross race. Examination reveals pain and catching that limits his range of motion to 45 degrees of supination and 20 degrees of pronation. The interosseous space and distal radioulnar joint are stable. Management should consist of
. splinting for 3 weeks, followed by range-of-motion exercises.
. aspiration of the hemarthrosis, followed by range-of-motion exercises the following day.
. fragment excision.
. open reduction and internal fixation.
. radial head excision.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The radial head is an important secondary stabilizer of the elbow, helping to resist valgus forces. There has been a movement toward open reduction and internal fixation of the radial head when technically feasible, especially in a relatively high-demand athlete or laborer. The examination and radiograph suggest that displacement of the fragment is great enough to create a mechanical block. Extended splinting would only serve to encourage arthrofibrosis. Early range of motion is appropriate if there is minimal displacement of the radial head fragment, it is stable, and there is no mechanical block to motion. Fragments larger than one third of the joint surface should be excised only if it is not possible to reduce and repair the fragment. Primary excision of the radial head should be avoided if possible. Complications after excision of the radial head include muscle weakness, wrist pain, valgus elbow instability, heterotopic ossification, and arthritis.

Question 369

Topic: Elbow & Forearm
A 54-year-old woman sustained an elbow injury 3 months ago that was treated with open reduction and internal fixation. She now reports pain and limited elbow motion. Radiographs are shown in Figures 10a and 10b. Treatment should now consist of
. occupational therapy.
. open reduction of the radial head and annular ligament reconstruction.
. excision of the radial head.
. ulnar osteotomy and closed reduction of the radial head.
. ulnar osteotomy and open reduction of the radial head.

Correct Answer & Explanation

. ulnar osteotomy and open reduction of the radial head.

Explanation

DISCUSSION: Radiographs reveal malunion of a Monteggia fracture-dislocation. Dislocation of the posterior radial head is caused by the malunited ulnar fracture. The deformity includes shortening with an apex posterior angulation. In the acute setting, open reduction of the radial head rarely is necessary; however, in chronic dislocations, open reduction is required. Without ulnar osteotomy, recurrent radial head dislocation is likely.

Question 370

Topic: Elbow & Forearm

A 35-year-old male presents with recurrent clicking and apprehension when pushing up from a chair 6 months after an elbow dislocation. Which ligament is primarily deficient, and what is the typical path of subluxation?

. Anterior bundle of the medial collateral ligament; radius translates anteriorly
. Lateral ulnar collateral ligament; radius and ulna subluxate posterolaterally away from the humerus
. Radial collateral ligament; ulna subluxates posteromedially
. Annular ligament; radius translates inferiorly
. Lateral ulnar collateral ligament; ulna hinges on the intact MCL

Correct Answer & Explanation

. Anterior bundle of the medial collateral ligament; radius translates anteriorly

Explanation

Posterolateral rotatory instability (PLRI) is caused by a deficiency of the lateral ulnar collateral ligament (LUCL). During provocative maneuvers (like pushing off a chair), the radius and ulna supinate and subluxate posterolaterally away from the humerus as a single unit.

Question 371

Topic: Elbow & Forearm

During surgical reconstruction of a 'terrible triad' injury of the elbow, what is the standard recommended sequence of repair to progressively restore stability?

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

Correct Answer & Explanation

. Radial head, coronoid, lateral collateral ligament (LCL)

Explanation

The standard sequence for terrible triad repair is deep to superficial, anterior to posterior. The coronoid is addressed first (via suture lasso, screw, or plate), followed by radial head fixation or arthroplasty, and finally LCL repair to the lateral epicondyle.

Question 372

Topic: Elbow & Forearm
A 42-year-old female sustains an elbow injury. Radiographs reveal a type IV Bryan and Morrey capitellum fracture. What is the defining characteristic of this fracture pattern?
. Complete articular shear fracture of the capitellum with little or no extension into the trochlea
. A thin shell of articular cartilage separated from the capitellum
. Comminuted fracture of the capitellum
. Coronal shear fracture involving the capitellum and extending medially to involve the majority of the trochlea
. Fracture of the capitellum extending into the lateral epicondyle

Correct Answer & Explanation

. Coronal shear fracture involving the capitellum and extending medially to involve the majority of the trochlea

Explanation

In the Bryan and Morrey classification of capitellar fractures: Type I (Hahn-Steinthal) is a large osseous segment. Type II (Kocher-Lorenz) is an articular cartilage shell. Type III is comminuted. Type IV (McKee modification) is a coronal shear fracture that involves both the capitellum and a significant portion of the trochlea.

Question 373

Topic: Elbow & Forearm

A 9-year-old boy presents with a cubitus varus deformity 3 years after a supracondylar humerus fracture. He is asymptomatic, but if left uncorrected, what is the most significant potential late functional complication of this deformity?

. Median nerve palsy
. Tardy ulnar nerve palsy
. Posterolateral rotatory instability (PLRI)
. Valgus extension overload
. Ulnar collateral ligament attenuation

Correct Answer & Explanation

. Median nerve palsy

Explanation

While initially a cosmetic issue, the mechanical axis deviation in cubitus varus causes the triceps to pull in a medially displaced vector. Over years, this repetitive eccentric loading stretches the lateral ulnar collateral ligament (LUCL) complex, eventually predisposing the patient to tardy posterolateral rotatory instability (PLRI) and ulnar neuropathy. Tardy ulnar nerve palsy is classically associated with cubitus valgus.

Question 374

Topic: Elbow & Forearm

A 38-year-old bodybuilder undergoes distal biceps tendon repair using a single anterior incision technique. Postoperatively, he exhibits weakness in extending the wrist and fingers, though wrist drop is incomplete. The affected nerve most likely runs between which two muscle bellies near the level of the radial neck?

. Brachialis and Brachioradialis
. Supinator and Extensor Carpi Radialis Brevis
. Superficial and deep heads of the Supinator
. Flexor Carpi Ulnaris and Flexor Digitorum Profundus
. Pronator Teres and Flexor Carpi Radialis

Correct Answer & Explanation

. Brachialis and Brachioradialis

Explanation

The posterior interosseous nerve (PIN) is at risk during a single-incision distal biceps repair, particularly with aggressive lateral retraction. The PIN enters the arcade of Frohse and travels through the supinator muscle, specifically between its superficial and deep heads.

Question 375

Topic: Elbow & Forearm

A 34-year-old male falls on an outstretched arm and sustains an elbow injury. Examination reveals varus posteromedial rotatory instability (VPMRI). Which of the following injury patterns is most classically associated with this specific physical examination finding?

. Radial head fracture with medial ulnar collateral ligament tear
. Coronoid tip fracture with anterior capsule avulsion
. Anteromedial facet coronoid fracture with lateral collateral ligament tear
. Olecranon fracture with distal biceps rupture
. Capitellum fracture with lateral ulnar collateral ligament tear

Correct Answer & Explanation

. Radial head fracture with medial ulnar collateral ligament tear

Explanation

Varus posteromedial rotatory instability (VPMRI) is caused by an axial load combined with a varus force. It classically presents with a fracture of the anteromedial facet of the coronoid and an associated avulsion or tear of the lateral collateral ligament (LCL) complex. This contrasts with posterolateral rotatory instability (PLRI) which involves radial head/coronoid tip fractures (terrible triad).

Question 376

Topic: Elbow & Forearm

A 14-year-old elite gymnast presents with lateral elbow pain and catching. Radiographs reveal a radiolucent lesion in the capitellum. The pathogenesis of this condition is most directly related to which of the following?

. Traction apophysitis of the lateral epicondyle
. Repetitive valgus overload causing tensile failure of the lateral collateral ligament
. Repetitive compressive/shear forces acting on the precarious end-arterial blood supply of the capitellum
. A primary inflammatory arthropathy affecting the radiocapitellar joint
. Anomalous insertion of the extensor carpi radialis brevis

Correct Answer & Explanation

. Repetitive compressive/shear forces acting on the precarious end-arterial blood supply of the capitellum

Explanation

Osteochondritis dissecans (OCD) of the capitellum is predominantly seen in adolescent throwing athletes and gymnasts. It is caused by repetitive valgus compression and shear forces at the radiocapitellar joint. The capitellum is particularly vulnerable due to its tenuous, end-arterial blood supply.

Question 377

Topic: Elbow & Forearm

A 45-year-old male sustains a terrible triad injury of the elbow following a fall. Intraoperatively, the surgeon decides on a single lateral approach. What is the recommended sequence of anatomical repair to systematically restore elbow stability?

. Lateral ulnar collateral ligament, coronoid process, radial head
. Coronoid process, radial head, lateral ulnar collateral ligament
. Radial head, coronoid process, lateral ulnar collateral ligament
. Coronoid process, lateral ulnar collateral ligament, radial head
. Radial head, lateral ulnar collateral ligament, coronoid process

Correct Answer & Explanation

. Coronoid process, radial head, lateral ulnar collateral ligament

Explanation

Standard management of terrible triad injuries proceeds from deep to superficial. The coronoid (and anterior capsule) is repaired first, followed by the radial head (repair or arthroplasty), and finally the lateral ulnar collateral ligament.

Question 378

Topic: Elbow & Forearm

A 45-year-old male undergoes a single-incision anterior repair of a distal biceps tendon rupture. Postoperatively, he is unable to actively extend his fingers or thumb, but wrist extension is partially preserved with a radial deviation bias. Which nerve was injured during the approach?

. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Superficial radial nerve
. Median nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is at risk during single-incision anterior distal biceps repairs, especially with vigorous radial retraction. PIN injury causes finger/thumb extension loss, but radial wrist extension remains via the ECRL (innervated by the radial nerve proper).

Question 379

Topic: Elbow & Forearm

A 40-year-old female presents with posterolateral rotatory instability (PLRI) of the elbow. During the lateral pivot-shift test of the elbow, at what degree of flexion does maximal subluxation of the radial head typically occur?

. 0 to 10 degrees
. 40 to 50 degrees
. 70 to 80 degrees
. 90 to 100 degrees
. 110 to 120 degrees

Correct Answer & Explanation

. 40 to 50 degrees

Explanation

In PLRI, the lateral ulnar collateral ligament (LUCL) is deficient. During the pivot-shift test, the radial head maximally subluxates posteriorly at approximately 40 to 50 degrees of flexion before reducing as flexion increases.

Question 380

Topic: Elbow & Forearm

During a two-incision distal biceps tendon repair, the surgeon develops the posterior plane between the supinator and the extensor carpi radialis brevis. Which nerve is at greatest risk of injury during this posterior exposure if the forearm is not fully pronated?

. Posterior interosseous nerve (PIN)
. Anterior interosseous nerve (AIN)
. Lateral antebrachial cutaneous nerve
. Superficial radial nerve

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The posterior interosseous nerve (PIN) lies within the supinator muscle. Maximally pronating the forearm moves the PIN anteriorly and medially, protecting it during the posterolateral approach of a two-incision distal biceps repair.

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