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Elbow & Forearm MCQs

Practice Set 29 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 561

Topic: Elbow & Forearm

A 30-year-old female presents with acute wrist and elbow pain after a high-energy fall. She is diagnosed with an Essex-Lopresti injury. What is the appropriate surgical management of the radial head in this scenario?

. Radial head excision and immediate motion
. Radial head excision and prolonged casting
. Radial head internal fixation or arthroplasty
. Closed reduction of the distal radioulnar joint only
. Distal ulna resection (Darrach procedure)

Correct Answer & Explanation

. Radial head internal fixation or arthroplasty

Explanation

Excision of the radial head is strictly contraindicated in Essex-Lopresti injuries due to the concomitant interosseous membrane disruption, which would lead to severe proximal radial migration. The radial head must be stabilized via ORIF or replacement.

Question 562

Topic: Elbow & Forearm

A 45-year-old woman falls on an outstretched hand and sustains an elbow dislocation, radial head fracture, and coronoid process fracture. She is taken to the operating room for surgical stabilization. What is the most widely accepted sequence for reconstructing the elbow in this 'terrible triad' injury?

. Fixation of the lateral collateral ligament, followed by the radial head, then the coronoid.
. Fixation of the coronoid, followed by the radial head, then the lateral collateral ligament.
. Fixation of the radial head, followed by the lateral collateral ligament, then the coronoid.
. Fixation of the medial collateral ligament, followed by the coronoid, then the radial head.
. Fixation of the coronoid, followed by the lateral collateral ligament, then the radial head.

Correct Answer & Explanation

. Fixation of the coronoid, followed by the radial head, then the lateral collateral ligament.

Explanation

The standard surgical protocol for terrible triad injuries follows a deep-to-superficial approach. Fixation begins with the coronoid and anterior capsule, followed by radial head repair or replacement, and finally repair of the lateral collateral ligament (LCL).

Question 563

Topic: Elbow & Forearm

A 45-year-old man falls onto an outstretched hand and sustains a 'terrible triad' injury of the elbow.

During surgical reconstruction to restore stability, which of the following represents the most widely accepted standard sequence of repair?

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

Correct Answer & Explanation

. Coronoid fixation, radial head fixation or arthroplasty, LUCL repair

Explanation

The standard surgical algorithm for a terrible triad injury proceeds from deep to superficial: coronoid fixation, followed by radial head fixation or replacement, and finally LUCL repair. The MCL is typically only repaired if the elbow remains unstable after the lateral side is secured.

Question 564

Topic: Elbow & Forearm

A 35-year-old male weightlifter experiences a sudden 'pop' and sharp pain in his dominant anterior elbow while attempting to lift a heavy box. Examination reveals a positive Hook test. If a single-incision anterior surgical approach is chosen for repair, which of the following nerves is at greatest risk of injury?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. In contrast, the posterior interosseous nerve (PIN) is at higher risk during a two-incision approach.

Question 565

Topic: Elbow & Forearm

A 25-year-old gymnast reports clicking, pain, and a feeling of instability in her elbow when pushing herself out of a chair, months after a posterior elbow dislocation. The pivot-shift test of the elbow is positive. Which ligamentous structure is primarily deficient?

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

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The patient's history and symptoms describe posterolateral rotatory instability (PLRI) of the elbow. The essential lesion in PLRI is insufficiency or rupture of the lateral ulnar collateral ligament (LUCL), which normally acts as a primary stabilizer against external rotation and varus stress.

Question 566

Topic: Elbow & Forearm

A 45-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. What is the most appropriate surgical sequence to effectively restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical protocol for a terrible triad injury involves repairing structures from deep to superficial, or inside-out. The coronoid is fixed first, followed by the radial head (fixation or arthroplasty), and finally the lateral collateral ligament (LCL) complex.

Question 567

Topic: Elbow & Forearm

A 40-year-old woman reports recurrent clicking and a sense of 'giving way' in her lateral elbow, particularly when she pushes herself out of a chair. What ligament is primarily deficient, and what is the typical mechanism of the initial injury?

. Radial collateral ligament; varus stress
. Lateral ulnar collateral ligament; axial load, valgus, and supination
. Anterior band of the medial collateral ligament; valgus stress
. Annular ligament; axial traction
. Posterior band of the medial collateral ligament; hyperflexion

Correct Answer & Explanation

. Lateral ulnar collateral ligament; axial load, valgus, and supination

Explanation

Posterolateral rotatory instability (PLRI) is caused by deficiency of the lateral ulnar collateral ligament (LUCL). It typically occurs following a traumatic event involving an axial load, a valgus force, and external rotation (supination) of the forearm relative to the humerus.

Question 568

Topic: Elbow & Forearm

A 32-year-old man falls from a height onto his outstretched hands, sustaining a highly comminuted radial head fracture, diffuse forearm pain, and distal radioulnar joint (DRUJ) instability. To prevent longitudinal radioulnar dissociation, what is the most appropriate surgical management for the radial head?

. Radial head excision alone
. Radial head excision and DRUJ pinning
. Metallic radial head arthroplasty
. Radial head excision and acute interosseous membrane reconstruction
. Silastic radial head replacement

Correct Answer & Explanation

. Metallic radial head arthroplasty

Explanation

This patient has an Essex-Lopresti injury. Radial head excision is absolutely contraindicated as it will lead to proximal migration of the radius. A metallic radial head arthroplasty is required to restore the lateral column and longitudinal stability.

Question 569

Topic: Elbow & Forearm

A 40-year-old man falls on an outstretched hand and sustains a posterior elbow dislocation, a radial head fracture, and a coronoid fracture. During surgical management, what is the standard recommended sequence of repair to restore elbow stability?

. Lateral collateral ligament repair, coronoid fixation, radial head fixation
. Coronoid fixation, radial head repair or replacement, lateral collateral ligament repair
. Radial head replacement, medial collateral ligament repair, coronoid fixation
. Medial collateral ligament repair, coronoid fixation, radial head repair
. Coronoid fixation, medial collateral ligament repair, lateral collateral ligament repair

Correct Answer & Explanation

. Coronoid fixation, radial head repair or replacement, lateral collateral ligament repair

Explanation

The standard sequence for terrible triad injuries is to build from deep to superficial and medial to lateral: fix the coronoid, address the radial head (fixation or arthroplasty), and finally repair the lateral ulnar collateral ligament (LUCL). The medial collateral ligament is generally only addressed if the elbow remains unstable after the lateral side is stabilized.

Question 570

Topic: Elbow & Forearm

A 35-year-old male undergoes a two-incision surgical repair of a distal biceps tendon rupture. Postoperatively, he presents with an inability to extend his thumb and fingers at the metacarpophalangeal joints, but his wrist extension is preserved with radial deviation. Which nerve was most likely injured?

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

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is particularly at risk during the posterolateral muscle-splitting approach of a two-incision distal biceps repair. Injury results in loss of finger and thumb extension, while wrist extension is preserved (with radial deviation) due to an intact extensor carpi radialis longus.

Question 571

Topic: Elbow & Forearm

A 65-year-old woman fell onto her outstretched right arm and immediately had pain. She has a history of osteoporosis. Examination of the right arm reveals lateral arm swelling, ecchymosis, and she is unable to move the elbow due to pain. Her neurovascular status is intact. Radiographs are shown in Figures 14a and 14b. Appropriate treatment should include

. splint immobilization and early range-of-motion exercises.
. radial head excision.
. anatomic metallic radial head arthroplasty.
. radial head open reduction and internal fixation.
. anconeus interposition arthroplasty.

Correct Answer & Explanation

. anatomic metallic radial head arthroplasty.

Explanation

Comminuted, displaced radial head fractures (Hotchkiss type 3) require anatomic metallic radial head arthroplasty to regain function. Radial head excision has led to catastrophic sequelae including chronic wrist pain, elbow instability, and proximal radius migration. Immobilization, internal fixation, or anconeus arthroplasty are not recommended at this time because of the potentially poorer outcomes. Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

Question 572

Topic: Elbow & Forearm

A 45-year-old man sustains a terrible triad injury of the elbow. During surgical reconstruction, what is the generally recommended sequence of repair?

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

Correct Answer & Explanation

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

Explanation

The standard sequence for terrible triad reconstruction is deep to superficial. This means coronoid fixation first, followed by radial head fixation or replacement, and finally LCL repair.

Question 573

Topic: Elbow & Forearm

A 35-year-old woman sustains a highly comminuted radial head fracture and reports right wrist pain. Examination reveals tenderness over the distal radioulnar joint (DRUJ). If the radial head is deemed unreconstructible, what is the most appropriate management?

. Radial head resection and early range of motion
. Radial head resection and DRUJ pinning
. Radial head arthroplasty and DRUJ stabilization
. Silicone radial head replacement
. Radial head arthroplasty alone

Correct Answer & Explanation

. Radial head arthroplasty and DRUJ stabilization

Explanation

This is an Essex-Lopresti injury characterized by a radial head fracture and DRUJ disruption. Radial head resection alone leads to proximal radial migration, requiring radial head arthroplasty and DRUJ stabilization.

Question 574

Topic: Elbow & Forearm

A 42-year-old bodybuilder feels a pop in his anterior elbow while lifting weights. Examination reveals an abnormal hook test and weakness in supination. During a single-incision anterior repair of the distal biceps tendon, which nerve is at greatest risk of injury?

. Median nerve
. Ulnar nerve
. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is at highest risk during the anterior single-incision approach to the distal biceps. This is due to its superficial location in the surgical field.

Question 575

Topic: Elbow & Forearm

A 35-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. To optimally restore elbow stability, which of the following sequences is recommended during surgical reconstruction?

. Lateral ulnar collateral ligament (LUCL) repair -> coronoid fixation -> radial head fixation
. Radial head fixation -> LUCL repair -> coronoid fixation
. Coronoid fixation -> radial head repair or replacement -> LUCL repair
. LUCL repair -> radial head repair -> coronoid fixation
. Medial collateral ligament (MCL) repair -> radial head replacement -> LUCL repair

Correct Answer & Explanation

. Coronoid fixation -> radial head repair or replacement -> LUCL repair

Explanation

The standard surgical sequence for a terrible triad injury works from deep to superficial, or inside-out. This involves fixing the coronoid first, followed by repairing or replacing the radial head, and finally repairing the lateral ulnar collateral ligament (LUCL).

Question 576

Topic: Elbow & Forearm

A 40-year-old man sustains a Bado Type I Monteggia fracture-dislocation. Intraoperatively, following rigid plate fixation of the ulna fracture, the radial head remains anteriorly dislocated. What is the most appropriate next step in management?

. Proceed directly to annular ligament reconstruction
. Perform closed reduction of the elbow and cast in extension
. Inspect the ulnar reduction for residual malalignment or shortening
. Perform an immediate radial head excision
. Open the radiocapitellar joint to forcefully reduce the radial head

Correct Answer & Explanation

. Inspect the ulnar reduction for residual malalignment or shortening

Explanation

In Monteggia fractures, the radial head should spontaneously reduce once the ulnar length and alignment are anatomically restored. If the radial head remains dislocated after ulnar fixation, the surgeon must first assume that the ulnar reduction is imperfect and address any residual angulation or shortening.

Question 577

Topic: Elbow & Forearm
A Bryan and Morrey Type I (Hahn-Steinthal) fracture of the capitellum is best described radiographically and anatomically as:
. A thin shell of articular cartilage separated from subchondral bone
. A large fracture fragment comprising substantial subchondral bone and articular cartilage
. A highly comminuted capitellar fracture
. A coronal shear fracture extending medially to involve most of the trochlea
. An isolated osteochondral fracture of the lateral epicondyle

Correct Answer & Explanation

. A large fracture fragment comprising substantial subchondral bone and articular cartilage

Explanation

The Hahn-Steinthal (Type I) fracture involves a large osseous fragment of the capitellum containing a significant amount of subchondral bone. Type II (Kocher-Lorenz) is a thin articular cartilage shell, Type III is comminuted, and Type IV (McKee modification) involves the trochlea.

Question 578

Topic: Elbow & Forearm

A 45-year-old man falls from a ladder and sustains a 'terrible triad' injury to his elbow. Which of the following represents the most widely accepted surgical sequence for reconstructing this injury to restore stability?

. Repair lateral collateral ligament, fix/replace radial head, fix coronoid
. Fix coronoid, fix/replace radial head, repair lateral collateral ligament
. Repair medial collateral ligament, fix/replace radial head, repair lateral collateral ligament
. Fix/replace radial head, fix coronoid, repair lateral collateral ligament
. Fix coronoid, repair lateral collateral ligament, fix/replace radial head

Correct Answer & Explanation

. Fix coronoid, fix/replace radial head, repair lateral collateral ligament

Explanation

The standard deep-to-superficial approach for a terrible triad injury involves fixing the coronoid first, followed by the radial head, and finally repairing the lateral ulnar collateral ligament (LUCL).

Question 579

Topic: Elbow & Forearm

A 35-year-old woman presents with severe elbow and wrist pain after a fall. Radiographs demonstrate a comminuted radial head fracture. On examination, she has marked tenderness and instability over the distal radioulnar joint (DRUJ). Which of the following treatments is absolutely contraindicated?

. Radial head excision alone
. Radial head open reduction and internal fixation
. Radial head arthroplasty
. Ulnar shortening osteotomy
. Closed reduction and casting of the wrist

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

This patient has an Essex-Lopresti injury (radial head fracture, interosseous membrane tear, and DRUJ disruption). Radial head excision alone is contraindicated as it will lead to proximal migration of the radius and chronic wrist pain.

Question 580

Topic: Elbow & Forearm

A 42-year-old man sustains a fracture of the proximal third of the ulna with an associated radial head dislocation. During operative management, the ulna is anatomically reduced and rigidly plated, but the radial head remains dislocated. What is the most appropriate next step?

. Radial head resection
. Radial head arthroplasty
. Exploration of the radiocapitellar joint for interposed soft tissue
. Blind percutaneous pinning of the radiocapitellar joint
. Perform an ulnar lengthening osteotomy

Correct Answer & Explanation

. Exploration of the radiocapitellar joint for interposed soft tissue

Explanation

In a Monteggia fracture-dislocation, if the radial head fails to reduce after anatomic fixation of the ulna, soft tissue interposition (such as the annular ligament or joint capsule) blocking reduction must be suspected and openly explored.

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