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Elbow & Forearm MCQs

Practice Set 21 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 401

Topic: Elbow & Forearm

A 40-year-old male presents with a severely comminuted, non-reconstructable radial head fracture after a fall from a height. He also complains of severe ipsilateral wrist pain. Radiographs reveal a shortened radius and disruption of the distal radioulnar joint (Essex-Lopresti injury). What is the most appropriate management?

. Radial head excision alone
. Radial head excision and DRUJ pinning
. Radial head arthroplasty alone
. Radial head arthroplasty and DRUJ pinning
. Open reduction internal fixation of the radial head

Correct Answer & Explanation

. Radial head arthroplasty and DRUJ pinning

Explanation

An Essex-Lopresti injury involves a radial head fracture, interosseous membrane disruption, and DRUJ dislocation. Radial head excision alone is absolutely contraindicated as it will lead to proximal migration of the radius, resulting in chronic wrist pain and ulnocarpal impingement. The appropriate treatment is restoring the lateral column with a radial head arthroplasty and stabilizing the DRUJ, often with pinning or ligament repair.

Question 402

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture), what is the recommended order of reconstruction to methodically restore joint stability?

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

Correct Answer & Explanation

. Coronoid fixation, radial head fixation, LCL repair

Explanation

The classic 'inside-out' protocol for a terrible triad injury involves: 1) Coronoid fixation or replacement to restore anterior buttress stability; 2) Radial head fixation or arthroplasty to restore the lateral column and valgus stability; 3) Repair of the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle to restore posterolateral rotatory stability. If instability persists, the MCL is repaired or a hinged external fixator is applied.

Question 403

Topic: Elbow & Forearm



A 45-year-old male feels a pop in his elbow while lifting a heavy box. On examination, the examiner's finger cannot hook beneath the tendon in the antecubital fossa from the lateral side. What structure is evaluated by this 'hook test'?

. Triceps tendon
. Brachialis tendon
. Distal biceps tendon
. Pronator teres
. Flexor carpi radialis

Correct Answer & Explanation

. Triceps tendon

Explanation

The 'hook test' evaluates the integrity of the distal biceps tendon. The examiner uses a finger to hook under the tendon from the lateral side with the elbow flexed to 90 degrees and supinated. A positive test (inability to hook the tendon) indicates a complete rupture of the distal biceps tendon.

Question 404

Topic: Elbow & Forearm

Posterolateral rotatory instability (PLRI) of the elbow, which classically presents with a positive pivot-shift test and apprehension when pushing up from a chair, is primarily caused by a deficiency of which ligamentous structure?

. Radial collateral ligament
. Lateral ulnar collateral ligament
. Annular ligament
. Anterior bundle of the medial collateral ligament
. Posterior bundle of the medial collateral ligament

Correct Answer & Explanation

. Radial collateral ligament

Explanation

The lateral ulnar collateral ligament (LUCL) is the primary restraint to posterolateral rotatory instability (PLRI) of the elbow. It originates from the lateral epicondyle and inserts on the supinator crest of the ulna. Insufficiency allows the radial head and proximal ulna to subluxate posterolaterally relative to the capitellum.

Question 405

Topic: Elbow & Forearm
A 35-year-old male sustains a posterior elbow dislocation with an associated Regan-Morrey Type III coronoid fracture. What is the primary biomechanical consequence of failing to fix this specific coronoid fragment?
. Valgus instability
. Varus and posteromedial rotatory instability
. Isolated radioulnar dissociation
. Triceps weakness
. Posterolateral rotatory instability (PLRI)

Correct Answer & Explanation

. Varus and posteromedial rotatory instability

Explanation

The anteromedial facet of the coronoid is critical for resisting varus and posteromedial rotatory instability. Large (Type III) coronoid fractures must be fixed to restore the anterior buttress of the greater sigmoid notch and stabilize the joint.

Question 406

Topic: Elbow & Forearm

During ORIF of a comminuted radial head fracture, the "safe zone" for hardware placement is utilized to prevent impingement. Which anatomical landmarks define this safe zone?

. An arc of 90 degrees between the radial styloid and Lister's tubercle
. An arc of 120 degrees lateral to the bicipital tuberosity when the forearm is neutral
. An arc of 90 degrees defined by the radial collateral ligament footprint
. The non-articular portion bounded by the radial notch of the ulna during full supination and pronation
. The entire anterior half of the radial head

Correct Answer & Explanation

. An arc of 90 degrees between the radial styloid and Lister's tubercle

Explanation

The "safe zone" for radial head plating is a 90-degree arc that does not articulate with the proximal radioulnar joint (radial notch of the ulna) during full forearm rotation. This prevents hardware impingement and loss of pronation/supination.

Question 407

Topic: Elbow & Forearm

A 45-year-old tennis player presents with refractory lateral epicondylitis despite 12 months of conservative treatment. Surgical debridement is planned. Which tendon is the primary pathological structure targeted during this procedure?

. Extensor carpi radialis longus (ECRL)
. Extensor carpi radialis brevis (ECRB)
. Extensor digitorum communis (EDC)
. Extensor carpi ulnaris (ECU)
. Brachioradialis

Correct Answer & Explanation

. Extensor carpi radialis longus (ECRL)

Explanation

The Extensor Carpi Radialis Brevis (ECRB) tendon is the primary site of angiofibroblastic hyperplasia in lateral epicondylitis. Surgical treatment involves careful excision and debridement of this specific pathological tissue at its origin on the lateral epicondyle.

Question 408

Topic: Elbow & Forearm
A 40-year-old female presents with acute elbow pain after a fall. Radiographs demonstrate a coronal shear fracture of the distal humerus. Advanced imaging reveals that the fracture includes the capitellum and extends medially to involve the lateral aspect of the trochlea, but leaves the lateral epicondyle intact. According to the Bryan and Morrey classification modified by McKee, what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV (McKee)
. Type V

Correct Answer & Explanation

. Type IV (McKee)

Explanation

In the modified Bryan and Morrey classification of capitellar fractures, Type I (Hahn-Steinthal) involves a large osseous fragment of the capitellum. Type II (Kocher-Lorenz) is an articular cartilage shear with very little subchondral bone. Type III (Broberg-Morrey) is highly comminuted. Type IV, added by McKee, describes a coronal shear fracture that involves the capitellum and extends medially to include the lateral ridge of the trochlea.

Question 409

Topic: Elbow & Forearm

A 30-year-old female undergoes open reduction and internal fixation for a displaced Mason type II radial head fracture that caused a mechanical block to forearm rotation. To avoid impingement of the hardware on the proximal radioulnar joint during pronation and supination, the plate must be placed within the radial head 'safe zone'. Which of the following accurately describes this anatomic safe zone?

. A 90-degree arc from the radial styloid to the Lister tubercle
. A 110-degree arc on the lateral margin of the radial head, directly opposite the radial tuberosity
. A 90-degree arc extending laterally from the coronoid process
. A 120-degree arc centered directly over the radial tuberosity
. A 180-degree arc on the volar surface of the radial head

Correct Answer & Explanation

. A 110-degree arc on the lateral margin of the radial head, directly opposite the radial tuberosity

Explanation

The 'safe zone' for placing hardware on the radial head to prevent impingement in the lesser sigmoid notch of the ulna during forearm rotation is an approximately 110-degree arc. This zone is located on the lateral aspect of the radial head when the forearm is in neutral rotation and is anatomically directly opposite the radial tuberosity.

Question 410

Topic: Elbow & Forearm
A 6-year-old boy falls off the monkey bars. Radiographs demonstrate an anterior bowing (plastic deformation) of the ulnar shaft and an anterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this, and what is the preferred initial management?
. Bado Type I; immediate open reduction of the radial head and plating of the ulna
. Bado Type I; closed reduction of the ulnar deformity and the radial head, followed by casting
. Bado Type II; long arm cast in full extension
. Bado Type III; flexible intramedullary nailing of the radius and ulna
. Bado Type IV; open reduction and internal fixation of the ulna with an external fixator

Correct Answer & Explanation

. Bado Type I; closed reduction of the ulnar deformity and the radial head, followed by casting

Explanation

Anterior dislocation of the radial head with anterior angulation or plastic deformation of the ulna is a Bado Type I Monteggia fracture-dislocation. It is the most common type in children. Unlike in adults (where ORIF is mandatory), the preferred initial management in pediatric patients is closed reduction of the ulnar bowing, which typically allows spontaneous reduction of the radial head, followed by long arm casting.

Question 411

Topic: Elbow & Forearm

A surgeon plans to repair a retracted distal biceps tendon rupture using a two-incision (modified Boyd-Anderson) approach. This approach was historically developed to minimize the risk to the posterior interosseous nerve (PIN). However, compared to the single-incision anterior approach, the two-incision technique carries a higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve palsy
. Median nerve injury
. Radioulnar synostosis
. Brachial artery pseudoaneurysm
. Recurrent rupture

Correct Answer & Explanation

. Radioulnar synostosis

Explanation

The two-incision approach protects the PIN and LABCN but has historically been associated with a higher risk of heterotopic ossification and radioulnar synostosis, especially if the interosseous membrane is violated during the procedure.

Question 412

Topic: Elbow & Forearm

A 45-year-old female presents with a highly comminuted radial head fracture, acute wrist pain, and distal radioulnar joint (DRUJ) instability. A diagnosis of an Essex-Lopresti injury is made. If the radial head is simply excised and not replaced, what is the most likely biomechanical consequence?

. Distal migration of the radius leading to radiocapitellar impingement
. Proximal migration of the radius leading to ulnocarpal impingement
. Varus instability of the elbow
. Posterolateral rotatory instability of the elbow
. Isolated loss of forearm supination

Correct Answer & Explanation

. Proximal migration of the radius leading to ulnocarpal impingement

Explanation

An Essex-Lopresti injury involves a radial head fracture, interosseous membrane rupture, and DRUJ disruption. Excision of the radial head without prosthetic replacement eliminates the proximal stabilizer, leading to proximal radial migration and severe ulnocarpal impingement.

Question 413

Topic: Elbow & Forearm

During the surgical reconstruction of a "terrible triad" injury of the elbow, the surgeon follows a standard protocol to restore elbow stability. After addressing the deep articular structures, which of the following represents the most appropriate sequence of repair?

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

Correct Answer & Explanation

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

Explanation

The standard sequence for treating a terrible triad injury works from deep to superficial and medial to lateral (if approached laterally). Fixation begins with the coronoid, followed by the radial head (repair or replacement), and finally the lateral ulnar collateral ligament (LUCL).

Question 414

Topic: Elbow & Forearm

A 45-year-old male falls on an outstretched hand, sustaining a terrible triad injury of the elbow.

What is the recommended standard sequence of surgical reconstruction to restore concentric stability?

. Lateral collateral ligament (LCL) repair, radial head fixation or replacement, coronoid fixation
. Coronoid fixation, radial head fixation or replacement, LCL repair
. Radial head fixation or replacement, LCL repair, coronoid fixation
. LCL repair, coronoid fixation, radial head fixation or replacement
. Coronoid fixation, LCL repair, radial head fixation or replacement

Correct Answer & Explanation

. Coronoid fixation, radial head fixation or replacement, LCL repair

Explanation

The terrible triad of the elbow consists of an elbow dislocation, radial head fracture, and coronoid fracture. The standard surgical sequence works from 'deep to superficial' or 'inside out', starting with coronoid fixation (or anterior capsule repair), followed by radial head fixation or arthroplasty, and finally repair of the lateral ulnar collateral ligament (LUCL) complex to the lateral epicondyle. Medial collateral ligament repair or hinged external fixation is added if the elbow remains unstable after these steps.

Question 415

Topic: Elbow & Forearm

A 45-year-old manual laborer undergoes a two-incision surgical repair of a distal biceps tendon rupture. Compared to the single anterior incision technique, the two-incision technique is associated with a higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve neuropraxia
. Superficial radial nerve injury
. Proximal radioulnar synostosis
. Posterior interosseous nerve injury
. Median nerve injury

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

The classic two-incision technique (Boyd-Anderson or modifications) for distal biceps repair is historically associated with a higher risk of heterotopic ossification and proximal radioulnar synostosis, primarily due to muscle splitting and subperiosteal elevation of the ulna. The single anterior incision technique carries a higher rate of injury to the lateral antebrachial cutaneous nerve (LABCN) and the posterior interosseous nerve (PIN).

Question 416

Topic: Elbow & Forearm

A 40-year-old female fell from a height and sustained a comminuted radial head fracture, which was treated with radial head excision. Three months later, she complains of severe ulnar-sided wrist pain. Radiographs demonstrate proximal migration of the radius and a positive ulnar variance. Which of the following is the most appropriate reconstructive option?

. Ulnar shortening osteotomy and radial head arthroplasty
. Darrach procedure
. Suave-Kapandji procedure
. Distal radioulnar joint (DRUJ) arthrodesis
. Interosseous membrane reconstruction alone

Correct Answer & Explanation

. Ulnar shortening osteotomy and radial head arthroplasty

Explanation

This clinical scenario describes a longitudinal radioulnar dissociation (Essex-Lopresti injury) unmasked by radial head excision. The proximal radial migration causes ulnocarpal impaction. Treatment for chronic cases requires restoring the lateral column strut with a radial head arthroplasty and performing an ulnar shortening osteotomy to address the positive ulnar variance and unload the ulnocarpal joint.

Question 417

Topic: Elbow & Forearm

A 38-year-old female presents with a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture). Which of the following sequences of surgical repair is currently recommended to maximize elbow stability?

. Radial head fixation/replacement, coronoid fixation, LUCL repair, MCL repair (if needed)
. Coronoid fixation, radial head fixation/replacement, LUCL repair, MCL repair (if needed)
. LUCL repair, coronoid fixation, radial head fixation/replacement, hinged external fixation
. MCL repair, radial head fixation, coronoid fixation, LUCL repair
. Coronoid fixation, LUCL repair, radial head fixation/replacement, hinged external fixation

Correct Answer & Explanation

. Radial head fixation/replacement, coronoid fixation, LUCL repair, MCL repair (if needed)

Explanation

The standard recommended sequence for treating a terrible triad injury is to fix from deep to superficial, or inside-out. The typical sequence is: 1) Coronoid fracture fixation (via anterior or anterior-medial aspect through the fracture hematoma or standard approach), 2) Radial head fixation or arthroplasty, 3) Lateral ulnar collateral ligament (LUCL) repair. 4) If the elbow remains unstable after these steps, the Medial Collateral Ligament (MCL) may be repaired or a hinged external fixator applied.

Question 418

Topic: Elbow & Forearm

A 40-year-old female sustains a fall on an outstretched hand, resulting in an elbow injury. Radiographs and CT demonstrate a capitellar fracture extending medially to involve the majority of the trochlea, with a separate comminuted fragment of the posterior trochlea. According to the Dubberley classification, what type of fracture is this?

. Type 1A
. Type 2B
. Type 3A
. Type 3B
. Type 4

Correct Answer & Explanation

. Type 3B

Explanation

The Dubberley classification of capitellum and trochlea fractures is based on the involvement of the trochlea and the presence of posterior condylar comminution. Type 1 involves primarily the capitellum. Type 2 involves the capitellum and trochlea as a single piece. Type 3 involves the capitellum and trochlea as separate fragments. The modifier 'A' indicates no posterior condylar comminution, and 'B' indicates posterior condylar comminution. The scenario describes capitellum and trochlea fractures with a separate posterior trochlea comminuted fragment, making it a Type 3B.

Question 419

Topic: Elbow & Forearm
A 6-year-old boy falls off monkey bars and sustains an injury to his right forearm. Radiographs demonstrate a fracture of the proximal third of the ulna with an anterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type I

Explanation

The Bado classification describes Monteggia fractures based on the direction of the radial head dislocation: Type I: Anterior dislocation of the radial head with fracture of the ulnar diaphysis (most common in children). Type II: Posterior dislocation of the radial head with fracture of the ulnar diaphysis (most common in adults). Type III: Lateral or anterolateral dislocation of the radial head with fracture of the ulnar metaphysis. Type IV: Anterior dislocation of the radial head with fractures of both the radius and ulna at the same level.

Question 420

Topic: Elbow & Forearm
A 35-year-old female presents with elbow pain after a fall. Imaging demonstrates a coronal shear fracture of the capitellum that includes the lateral trochlear ridge. According to the Bryan and Morrey classification, with McKee's modification, what type of fracture is this, and what is the preferred treatment?
. Type I; Nonoperative treatment
. Type II; Excision of the fragment
. Type III; ORIF
. Type IV; ORIF
. Type IV; Radial head arthroplasty

Correct Answer & Explanation

. Type IV; ORIF

Explanation

McKee modified the Bryan and Morrey classification by adding Type IV, which is a coronal shear fracture that involves the capitellum and extends medially to include the lateral trochlear ridge. Due to the extension into the trochlea, these fractures are highly unstable and require Open Reduction and Internal Fixation (ORIF). Type I (Hahn-Steinthal) involves a large osseous piece of capitellum. Type II (Kocher-Lorenz) involves a sleeve of articular cartilage with minimal bone. Type III (Broberg-Morrey) is a comminuted capitellum fracture.

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