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Elbow & Forearm MCQs

Practice Set 22 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 421

Topic: Elbow & Forearm

A 35-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury to his elbow. Which of the following describes the most appropriate sequence of surgical reconstruction to restore stability?

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

Correct Answer & Explanation

. LUCL repair, radial head fixation/replacement, coronoid fixation

Explanation

The standard inside-out (deep to superficial) sequence for terrible triad reconstruction is: 1) Coronoid fixation (or anterior capsule repair), 2) Radial head fixation or arthroplasty, 3) Lateral ulnar collateral ligament (LUCL) repair, and 4) Optional MCL repair or hinged external fixation if the elbow remains unstable.

Question 422

Topic: Elbow & Forearm

A 45-year-old man requires surgical repair of a chronic distal biceps tendon rupture. A two-incision (Boyd-Anderson) approach is selected to minimize the risk to the lateral antebrachial cutaneous nerve and radial nerve. However, this approach carries a higher risk of which of the following complications compared to a single anterior incision?

. Posterior interosseous nerve (PIN) injury
. Radioulnar synostosis
. Median nerve injury
. Brachial artery pseudoaneurysm
. Recurrent rupture

Correct Answer & Explanation

. Posterior interosseous nerve (PIN) injury

Explanation

The two-incision approach for distal biceps repair was designed to decrease the risk of radial/PIN injury associated with an extensive single anterior exposure. However, dissecting between the radius and ulna to pass the tendon increases the risk of heterotopic ossification and radioulnar synostosis. Using a muscle-splitting approach through the supinator and avoiding subperiosteal elevation on the ulna minimizes this risk.

Question 423

Topic: Elbow & Forearm

A 32-year-old woman sustains a displaced capitellum fracture. Preoperative CT reveals the fracture involves both the capitellum and the lateral trochlear ridge in a single fragment, with significant comminution of the posterior capitellum. According to the Dubberley classification, what type of fracture is this?

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

Correct Answer & Explanation

. Type 1A

Explanation

The Dubberley classification of capitellum and trochlea fractures is based on the extent of articular involvement and the presence of posterior comminution (A = no posterior comminution, B = posterior comminution). Type 1 involves only the capitellum. Type 2 involves the capitellum and the lateral trochlear ridge in a single piece. Type 3 involves separate fragments of the capitellum and trochlea. Because this involves the capitellum and lateral trochlear ridge in a single piece with posterior comminution, it is a Type 2B.

Question 424

Topic: Elbow & Forearm

A 29-year-old male presents with recurrent snapping and pain on the lateral side of his elbow when pushing up from a chair. Physical examination demonstrates a positive lateral pivot-shift test of the elbow. Which structure is fundamentally incompetent in this condition?

. Anterior band of the medial collateral ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Biceps brachii tendon

Correct Answer & Explanation

. Anterior band of the medial collateral ligament

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily caused by insufficiency or a tear of the Lateral Ulnar Collateral Ligament (LUCL). The LUCL is the primary restraint to varus and posterolateral rotatory stress. The pathognomonic sign is a positive lateral pivot-shift test, and patients often describe symptoms when bearing weight on the extended and supinated arm.

Question 425

Topic: Elbow & Forearm

A 45-year-old male undergoes repair of a chronic distal biceps tendon rupture utilizing a single-incision anterior approach. Postoperatively, he notes numbness over the radial aspect of his forearm. Which nerve was most likely injured, and what is the typical mechanism of injury?

. Superficial radial nerve; compression by retractors
. Lateral antebrachial cutaneous nerve; traction during lateral retraction
. Posterior interosseous nerve; direct injury from drill bit
. Medial antebrachial cutaneous nerve; injury during medial dissection
. Musculocutaneous nerve; retraction of the biceps belly

Correct Answer & Explanation

. Superficial radial nerve; compression by retractors

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during the single-incision anterior approach to the distal biceps. It is typically injured via traction or direct compression from retractors placed on the lateral side of the wound.

Question 426

Topic: Elbow & Forearm

During the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture), which of the following represents the generally recommended sequence of structural reconstruction?

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

Correct Answer & Explanation

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

Explanation

The standard surgical approach for a terrible triad injury proceeds from deep to superficial and typically from anterior/medial to lateral. The recommended sequence is first addressing the coronoid fracture (to restore the anterior buttress), followed by the radial head (fixation or arthroplasty to restore the lateral column), and finally repairing the lateral collateral ligament (LCL) complex to the lateral epicondyle to restore rotatory stability.

Question 427

Topic: Elbow & Forearm

A 45-year-old male sustains a terrible triad injury of the elbow. During surgical reconstruction, after fixation of the coronoid and radial head arthroplasty, the elbow remains persistently unstable in extension. What is the next most appropriate step in management?

. Application of an external fixator across the elbow
. Repair of the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle
. Reconstruction of the anterior bundle of the medial collateral ligament
. Excision of the radial head arthroplasty and placement of a larger component
. Release of the common extensor origin to reduce tension

Correct Answer & Explanation

. Repair of the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle

Explanation

The standard surgical algorithm for a terrible triad injury includes fixing the coronoid, restoring the radial head, and repairing the LUCL. If instability persists after addressing the anterior osseous structures, the LUCL must be repaired to the lateral epicondyle to restore lateral stability.

Question 428

Topic: Elbow & Forearm

A 35-year-old female presents with severe elbow pain after falling onto an outstretched hand. The lateral elbow radiograph demonstrates a 'double-arc sign.' What does this classic radiographic finding indicate regarding the distal humerus fracture pattern?

. Isolated capitellum fracture
. Concomitant fracture of the capitellum and the lateral epicondyle
. Extension of a capitellum fracture into the trochlea
. Associated displaced radial head fracture
. Associated type II coronoid process fracture

Correct Answer & Explanation

. Extension of a capitellum fracture into the trochlea

Explanation

The 'double-arc sign' on a lateral radiograph of the elbow is pathognomonic for a capitellum fracture that extends medially to include a significant portion of the trochlea (McKee modification Type IV). The two arcs represent the subchondral bone of the capitellum and the lateral ridge of the trochlea. Identifying this requires adequate surgical approach and fixation of both articular segments.

Question 429

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow, which of the following sequences represents the generally accepted standard protocol for reconstruction?

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

Correct Answer & Explanation

. Radial head fixation/replacement, coronoid fixation, LCL repair

Explanation

The standard surgical sequence for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) is: 1. Fixation or replacement of the radial head. 2. Fixation of the coronoid (or anterior capsule). 3. Repair of the lateral collateral ligament (LCL) complex. MCL repair or external fixation is reserved for cases of residual instability after the primary lateral protocol is complete.

Question 430

Topic: Elbow & Forearm

A 35-year-old female sustains a "terrible triad" injury of the elbow. Operative intervention is planned to restore stability. According to standard biomechanical principles and established protocols, what is the most appropriate sequence of surgical reconstruction?

. Radial head fixation/arthroplasty, lateral ulnar collateral ligament (LUCL) repair, coronoid fixation
. Coronoid fixation, radial head fixation/arthroplasty, lateral ulnar collateral ligament (LUCL) repair
. Medial collateral ligament (MCL) repair, coronoid fixation, radial head fixation/arthroplasty
. Lateral ulnar collateral ligament (LUCL) repair, radial head fixation/arthroplasty, coronoid fixation
. Coronoid fixation, medial collateral ligament (MCL) repair, radial head fixation/arthroplasty

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/arthroplasty, lateral ulnar collateral ligament (LUCL) repair

Explanation

The standard surgical algorithm for a terrible triad injury proceeds from deep to superficial and inside to outside. The typical sequence is fixing the coronoid first, followed by the radial head (fixation or replacement), and finally repairing the LUCL.

Question 431

Topic: Elbow & Forearm

A 35-year-old patient sustains a 'terrible triad' injury of the elbow. Standard surgical protocol dictates a specific order of repair to restore stability. Which of the following represents the most accepted surgical sequence?

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

Correct Answer & Explanation

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

Explanation

The standard sequence for treating a terrible triad injury is to fix from deep to superficial. This involves restoring the anterior column (coronoid) first, followed by the radial head, and finally the lateral collateral ligament (LCL) complex.

Question 432

Topic: Elbow & Forearm
A 40-year-old woman falls on an outstretched hand and sustains a coronal shear fracture of the distal humerus. CT imaging reveals that the fracture fragment includes the capitellum and extends medially to include the majority of the trochlea. According to the McKee modification of the Bryan and Morrey classification, what type of fracture is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type IV

Explanation

The Bryan and Morrey classification describes capitellum fractures. Type I (Hahn-Steinthal) is a large capitellar fragment with substantial subchondral bone. Type II (Kocher-Lorenz) involves articular cartilage with minimal subchondral bone. Type III (Broberg-Morrey) is comminuted. McKee added Type IV, which is a coronal shear fracture that involves the capitellum and extends medially to include most or all of the trochlea.

Question 433

Topic: Elbow & Forearm

A patient complains of elbow clicking and a sense of giving way when pushing out of a chair. The lateral pivot-shift test of the elbow reproduces the symptoms. This instability pattern (PLRI) is primarily caused by insufficiency of which of the following structures?

. Anterior bundle of the medial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Radial collateral ligament
. Annular ligament
. Anterior joint capsule

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is the most common pattern of chronic elbow instability. It is classically caused by insufficiency or rupture of the lateral ulnar collateral ligament (LUCL). The LUCL serves as the primary restraint to posterolateral subluxation of the radial head and proximal ulna relative to the humerus.

Question 434

Topic: Elbow & Forearm

A 45-year-old male sustains an acute distal biceps tendon rupture while lifting a heavy box. A double-incision (modified Boyd-Anderson) repair technique is chosen. Compared to a single-incision anterior approach, the double-incision technique carries a statistically higher risk of which of the following specific complications?

. Lateral antebrachial cutaneous (LABC) nerve palsy
. Posterior interosseous nerve (PIN) palsy
. Proximal radioulnar synostosis
. Re-rupture of the tendon
. Median nerve entrapment

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

The double-incision approach was developed to avoid the radial nerve and lateral antebrachial cutaneous (LABC) nerve injuries associated with the single anterior incision. However, it requires dissection through the interosseous membrane or around the ulna, which carries a higher risk of heterotopic ossification and proximal radioulnar synostosis compared to a single-incision approach. Single-incision approaches have a higher rate of LABC nerve neuropraxia.

Question 435

Topic: Elbow & Forearm

A 35-year-old female complains of recurrent elbow clicking and a sense of instability when pushing up from a chair. Examination reveals a positive lateral pivot-shift test of the elbow. This condition is most directly caused by insufficiency of which of the following structures?

. Radial collateral ligament
. Lateral ulnar collateral ligament
. Annular ligament
. Anterior bundle of the medial collateral ligament
. Extensor carpi radialis brevis origin

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

Posterolateral rotatory instability (PLRI) is the most common form of recurrent elbow instability. It is caused by insufficiency of the lateral ulnar collateral ligament (LUCL), which allows the radial head to subluxate posterolaterally.

Question 436

Topic: Elbow & Forearm

A 40-year-old male undergoes a two-incision distal biceps tendon repair. Compared to a single-incision anterior approach, the two-incision technique is historically associated with a higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve palsy
. Posterior interosseous nerve palsy
. Radioulnar synostosis
. Median nerve neuropraxia
. Re-rupture of the repaired tendon

Correct Answer & Explanation

. Radioulnar synostosis

Explanation

The two-incision (modified Boyd-Anderson) approach was developed to decrease radial nerve injuries but is associated with a higher risk of heterotopic ossification and radioulnar synostosis due to subperiosteal dissection near the ulna. Single-incision repairs carry a higher risk to the lateral antebrachial cutaneous nerve (LABCN).

Question 437

Topic: Elbow & Forearm

A 32-year-old gymnast reports recurrent clicking and catching in her lateral elbow when pushing up from a chair. The lateral pivot-shift test of the elbow is positive. Which ligamentous structure is primarily incompetent?

. Annular ligament
. Anterior bundle of the medial collateral ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Oblique cord

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). The patient typically presents with symptoms during axial loading, supination, and valgus stress (e.g., pushing off a chair).

Question 438

Topic: Elbow & Forearm

A 40-year-old female presents with an elbow injury. Lateral radiographs show the "double-arc" sign. Which of the following best describes this fracture pattern?

. Radial head fracture with a posterior elbow dislocation
. Isolated fracture of the articular cartilage of the capitellum (Kocher-Lorenz)
. Coronal shear fracture involving both the capitellum and the lateral ridge of the trochlea (McKee type)
. Supracondylar humerus fracture with anterior displacement
. Fracture of the olecranon extending into the coronoid

Correct Answer & Explanation

. Coronal shear fracture involving both the capitellum and the lateral ridge of the trochlea (McKee type)

Explanation

The "double-arc" sign on a lateral elbow radiograph is pathognomonic for a Type IV (McKee) coronal shear fracture, indicating involvement of both the capitellum and the lateral trochlear ridge. Anatomic reduction and rigid internal fixation are required.

Question 439

Topic: Elbow & Forearm

In a Dubberley Type 3B fracture of the capitellum, what specific anatomic characteristic dictates the need for a more complex reconstructive strategy compared to a Type 3A fracture?

. The presence of posterior capitellar comminution
. Involvement of the radial head
. Disruption of the lateral ulnar collateral ligament
. Associated fracture of the coronoid process
. Avulsion of the triceps insertion

Correct Answer & Explanation

. The presence of posterior capitellar comminution

Explanation

The Dubberley classification differentiates capitellar/trochlear fractures based on the presence (Type B) or absence (Type A) of posterior capitellar comminution. Type B fractures lack a stable posterior bony buttress, often requiring structural bone grafting or specialized posterior to anterior fixation to prevent collapse.

Question 440

Topic: Elbow & Forearm

During surgical reconstruction of the lateral ulnar collateral ligament (LUCL) for posterolateral rotatory instability of the elbow, accurate placement of the humeral tunnel is critical. Where is the optimal isometric point for the humeral attachment?

. Anterior and proximal to the lateral epicondyle
. At the center of curvature of the capitellum
. Directly at the insertion of the extensor carpi radialis brevis
. On the supracondylar ridge 2 cm proximal to the joint line
. At the sublime tubercle

Correct Answer & Explanation

. At the center of curvature of the capitellum

Explanation

The isometric point for LUCL reconstruction on the humerus is located at the center of curvature of the capitellum, which typically lies just distal and anterior to the lateral epicondyle tip. Non-isometric placement will result in graft stretching or restricted range of motion.

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