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Elbow & Forearm MCQs

Practice Set 36 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 701

Topic: Elbow & Forearm

A 21-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using the docking technique. He is concerned about potential postoperative complications. Which of the following is the most common complication following this procedure?

. Medial epicondyle avulsion fracture
. Graft rupture
. Ulnar neuropathy
. Heterotopic ossification
. Superficial infection

Correct Answer & Explanation

. Ulnar neuropathy

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction, occurring in 5% to 10% of cases depending on the technique used. While modern techniques like the docking approach have helped decrease this incidence compared to historical techniques requiring routine ulnar nerve transposition, transient ulnar neuropraxia remains the most frequently encountered adverse event.

Question 702

Topic: Elbow & Forearm

A 22-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction utilizing a palmaris longus autograft (Tommy John surgery). Which of the following is the most frequent postoperative complication associated with this procedure in overhead throwers?

. Graft rupture
. Ulnar neuropathy
. Medial epicondyle avulsion fracture
. Heterotopic ossification
. Postoperative infection

Correct Answer & Explanation

. Ulnar neuropathy

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction. It can occur due to traction, compression, or ischemia during the procedure, especially if the nerve is handled or transposed. Most cases are transient, but a subset may require secondary neurolysis.

Question 703

Topic: Elbow & Forearm

A 21-year-old collegiate baseball pitcher underwent a right elbow ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft 6 weeks ago. He now presents with persistent tingling in his small and ring fingers, as well as subjective weakness when gripping. Which intraoperative factor or surgical step is most commonly associated with this specific postoperative complication?

. Over-tensioning of the palmaris longus graft during fixation
. Excessive traction and mobilization of the ulnar nerve without transposition
. Drilling of the sublime tubercle bone tunnel for the distal graft insertion
. Medial epicondyle tunnel drilling exiting too anteriorly
. Placement of the graft in a figure-of-eight configuration rather than a docking technique

Correct Answer & Explanation

. Excessive traction and mobilization of the ulnar nerve without transposition

Explanation

Ulnar neuropathy is the most frequent complication following UCL reconstruction (Tommy John surgery). It is most commonly associated with excessive handling, traction, or mobilization of the ulnar nerve during the medial approach. When the nerve is aggressively retracted to expose the sublime tubercle and medial epicondyle but left in situ (or transposed with kinking/devascularization), the risk of postoperative ulnar neuritis increases significantly. Modern techniques emphasize minimal handling and in situ preservation of the nerve, or a meticulous submuscular transposition if the nerve subluxates or is heavily involved in scar tissue.

Question 704

Topic: Elbow & Forearm

A 42-year-old weightlifter feels a sudden pop in his right antecubital fossa while performing a deadlift. On examination, he has weakness in forearm supination and elbow flexion. The 'hook test' is positive. During surgical repair through a single anterior incision, which of the following nerves 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 the most commonly injured nerve during a single-incision anterior approach for distal biceps tendon repair. The radial nerve or posterior interosseous nerve (PIN) is more at risk during a two-incision approach (specifically the posterolateral incision) or if retractors are placed too vigorously on the radial side in a single incision.

Question 705

Topic: Elbow & Forearm

A 14-year-old elite female gymnast presents with lateral elbow pain and catching. Radiographs reveal a radiolucent lesion in the capitellum. MRI demonstrates an osteochondral lesion with a high T2 signal line behind the bone fragment, and an associated loose body in the anterior compartment. What is the most appropriate definitive management?

. Rest and cessation of gymnastics for 3-6 months
. Arthroscopic loose body removal and microfracture of the capitellar lesion
. Open reduction and internal fixation of the capitellar lesion
. Ulnar collateral ligament reconstruction
. Radial head excision

Correct Answer & Explanation

. Arthroscopic loose body removal and microfracture of the capitellar lesion

Explanation

The patient has an unstable osteochondral defect (OCD) of the capitellum, indicated by catching, a high T2 signal line behind the fragment (indicating fluid and instability), and an intra-articular loose body. Conservative management (rest) is indicated for stable lesions with an open capitellar physis. For unstable lesions or those with loose bodies, surgical intervention is required. Arthroscopic loose body removal and debridement/microfracture of the base is the standard of care for fragments that are completely detached or unsuitable for fixation.

Question 706

Topic: Elbow & Forearm

A 14-year-old female gymnast complains of lateral elbow pain, mechanical clicking, and a 15-degree extension deficit. Radiographs and an MRI demonstrate an osteochondritis dissecans (OCD) lesion of the capitellum with an unstable 10 mm osteochondral fragment and fluid tracking behind the lesion. What is the most appropriate next step in management?

. Strict cessation of gymnastics for 3 months and NSAIDs
. Intra-articular corticosteroid injection
. Surgical fragment fixation or excision with microfracture
. Ulnar collateral ligament reconstruction
. Radial head excision

Correct Answer & Explanation

. Surgical fragment fixation or excision with microfracture

Explanation

In adolescent overhead athletes or gymnasts, OCD of the capitellum can cause significant morbidity. Nonoperative management is indicated for stable lesions with an open capitellar physis. However, the presence of mechanical symptoms (clicking), an extension deficit, and MRI findings of instability (fluid tracking behind the fragment) are indications for surgical intervention. Treatment involves either fixation of the fragment (if viable and adequately sized) or excision with microfracture/marrow stimulation for smaller, non-viable fragments.

Question 707

Topic: Elbow & Forearm

A 35-year-old male is involved in a high-speed motor vehicle collision and sustains a 'terrible triad' injury of the elbow. Which of the following describes the most appropriate sequence of surgical reconstruction to restore stability?

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

Correct Answer & Explanation

. Coronoid fixation, radial head repair/replacement, lateral collateral ligament (LCL) repair

Explanation

The standard sequence for addressing a terrible triad injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture) typically proceeds from deep to superficial and medial to lateral (when approached laterally). The optimal sequence is coronoid fixation first, followed by radial head repair or arthroplasty, and finally LCL complex repair.

Question 708

Topic: Elbow & Forearm

A 35-year-old woman falls onto an outstretched hand and presents with a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid process fracture). Which of the following describes the most universally accepted surgical sequence for reconstructing this injury?

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

Correct Answer & Explanation

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

Explanation

The standard surgical protocol for a terrible triad injury of the elbow follows an 'inside-out' or deep-to-superficial approach. First, the coronoid is fixed (or the anterior capsule is repaired) to restore anterior stability. Second, the radial head is repaired or replaced to restore the anterior radiocapitellar buttress and valgus stability. Finally, the lateral ulnar collateral ligament (LUCL/LCL complex) is repaired to restore posterolateral rotatory stability. If the elbow remains unstable after these steps, medial collateral ligament (MCL) repair or a hinged external fixator is considered.

Question 709

Topic: Elbow & Forearm

A 44-year-old woman falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. Operative intervention is planned. To restore concentric stability of the elbow joint, which of the following represents the most appropriate and widely accepted sequence of surgical reconstruction?

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

Correct Answer & Explanation

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

Explanation

A terrible triad injury of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid fracture. The standard surgical treatment algorithm dictates a 'deep to superficial' or 'inside-out' approach, typically beginning anteriorly and laterally. The recommended sequence is: 1) Fixation of the coronoid fracture to restore the anterior buttress; 2) Fixation or replacement of the radial head to restore the lateral column; and 3) Repair of the lateral ulnar collateral ligament (LUCL/LCL complex) to restore posterolateral rotatory stability. The medial collateral ligament (MCL) is typically only repaired if the elbow remains grossly unstable after these steps.

Question 710

Topic: Elbow & Forearm

A 32-year-old patient presents with a sensation of their elbow 'giving way' and clicking when pushing up from a chair with the forearm supinated. Clinical examination reveals a positive lateral pivot-shift test of the elbow. Deficiency of which of the following structures is the primary cause of this condition?

. Radial collateral ligament
. Lateral ulnar collateral ligament
. Annular ligament
. Common extensor origin
. Anterior bundle of the medial collateral ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The patient describes symptoms and exam findings pathognomonic for posterolateral rotatory instability (PLRI) of the elbow. The primary restraint to PLRI is the lateral ulnar collateral ligament (LUCL). Insufficiency of the LUCL allows the radial head to subluxate posterolaterally away from the capitellum, especially during axial loading, valgus stress, and supination.

Question 711

Topic: Elbow & Forearm

A 40-year-old man falls from a height and sustains a posterolateral elbow dislocation, radial head fracture, and coronoid fracture. Following closed reduction, the joint remains unstable in extension. During operative management, what is the generally recommended sequence of reconstruction to restore elbow stability?

. Lateral collateral ligament (LCL) repair, radial head replacement, coronoid fixation, medial collateral ligament (MCL) repair
. Coronoid fixation, radial head replacement, LCL repair, evaluation for MCL repair or hinged external fixator
. MCL repair, coronoid fixation, radial head replacement, LCL repair
. Radial head replacement, LCL repair, coronoid fixation, MCL repair
. LCL repair, coronoid fixation, radial head replacement, MCL repair

Correct Answer & Explanation

. Coronoid fixation, radial head replacement, LCL repair, evaluation for MCL repair or hinged external fixator

Explanation

The standard surgical protocol for addressing a 'terrible triad' of the elbow (elbow dislocation, radial head fracture, coronoid fracture) typically proceeds from deep to superficial and anterior to posterior: 1. Fixation of the coronoid fracture to restore the anterior buttress, 2. Fixation or replacement of the radial head to restore the lateral column, and 3. Repair of the lateral ulnar collateral ligament (LUCL) complex to the lateral epicondyle. If the elbow remains unstable after these steps (usually assessed in extension), the medial collateral ligament (MCL) may be repaired or a hinged external fixator applied.

Question 712

Topic: Elbow & Forearm

A 45-year-old competitive weightlifter suffers an acute distal biceps tendon rupture. The surgeon utilizes a two-incision technique (modified Boyd-Anderson) to reattach the tendon to the radial tuberosity. Compared to a single anterior incision technique, the two-incision approach is associated with a higher risk of which of the following postoperative complications?

. Lateral antebrachial cutaneous nerve neuropraxia
. Radial nerve palsy
. Proximal radioulnar synostosis
. Posterior interosseous nerve (PIN) injury
. Superficial radial nerve entrapment

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

Operative repair of a distal biceps tendon rupture can be performed via a single anterior incision or a two-incision technique. The single-incision technique carries a higher risk of injury to anterior structures, specifically the lateral antebrachial cutaneous (LABC) nerve and the posterior interosseous nerve (PIN). The two-incision technique was developed to protect these nerves but carries a historically higher risk of proximal radioulnar synostosis (heterotopic ossification bridging the radius and ulna) due to subperiosteal dissection and the potential creation of bone debris in the highly reactive interosseous space.

Question 713

Topic: Elbow & Forearm

A 45-year-old male undergoes surgical repair of an acute distal biceps tendon rupture using a standard 2-incision technique. Postoperatively, he exhibits a specific nerve palsy. Which of the following nerves is at greatest risk during the posterior approach of the 2-incision technique if the forearm is not fully pronated during surgical exposure?

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

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The 2-incision technique for distal biceps tendon repair aims to reduce the risk of lateral antebrachial cutaneous nerve and radial nerve injuries associated with a single anterior incision. However, it places the posterior interosseous nerve (PIN) at risk during the posterior dissection. To protect the PIN, the forearm must be maximally pronated during the posterior approach and retractor placement, as this displaces the PIN anteriorly and medially, away from the surgical field.

Question 714

Topic: Elbow & Forearm

A 34-year-old man presents with recurrent clicking, apprehension, and a sensation of 'giving way' in his right elbow, particularly when attempting to push himself out of a chair. Physical examination reveals a positive lateral pivot-shift test of the elbow. Which of the following ligamentous structures is primarily deficient in this specific instability pattern?

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

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The patient describes symptoms and demonstrates physical exam signs consistent with posterolateral rotatory instability (PLRI) of the elbow. PLRI is primarily caused by insufficiency of the lateral ulnar collateral ligament (LUCL), which acts as the main restraint to varus and posterolateral rotatory stress. The pathognomonic mechanism that reproduces symptoms involves a combination of axial load, valgus stress, and external rotation (supination) of the forearm.

Question 715

Topic: Elbow & Forearm

A 22-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft via the docking technique. What is the most common complication following this procedure?

. Ulnar neuropathy
. Graft rupture
. Medial epicondyle fracture
. Heterotopic ossification
. Superficial infection

Correct Answer & Explanation

. Ulnar neuropathy

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction, occurring in up to 10-15% of patients depending on the surgical technique (muscle-splitting vs. detachment) and whether routine ulnar nerve transposition is performed. Symptoms are often transient but can be persistent and may require later neurolysis.

Question 716

Topic: Elbow & Forearm

A 45-year-old male falls on an outstretched hand, sustaining a 'terrible triad' injury of the elbow. Intraoperatively, after secure fixation of the coronoid process and stable radial head arthroplasty, the elbow remains unstable and tends to subluxate posteriorly in extension. What is the next most appropriate step in management?

. Application of a hinged external fixator
. Repair of the medial collateral ligament (MCL)
. Repair of the lateral ulnar collateral ligament (LUCL)
. Cross-pinning of the radiocapitellar joint
. Dynamic distraction splinting

Correct Answer & Explanation

. Repair of the lateral ulnar collateral ligament (LUCL)

Explanation

The standard surgical algorithm for a terrible triad injury involves: 1) Coronoid fixation or anterior capsule repair, 2) Radial head fixation or replacement, and 3) LCL (specifically LUCL) repair. If the elbow remains unstable after LUCL repair, the MCL may then be repaired, or an external fixator applied. Since the LUCL has not yet been addressed in this scenario, repairing it is the critical next step to restore lateral column stability.

Question 717

Topic: Elbow & Forearm

A 38-year-old weightlifter undergoes a single-incision anterior approach for distal biceps tendon repair using suture anchors. Postoperatively, he notes a new onset of numbness along the radial aspect of his volar forearm. Which of the following nerves is most likely injured, and what is its motor innervation?

. Posterior interosseous nerve; innervates extensor digitorum communis
. Lateral antebrachial cutaneous nerve; provides no motor innervation
. Superficial radial nerve; provides no motor innervation
. Medial antebrachial cutaneous nerve; provides no motor innervation
. Anterior interosseous nerve; innervates flexor pollicis longus

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve; provides no motor innervation

Explanation

The lateral antebrachial cutaneous nerve (LABCN), the terminal sensory branch of the musculocutaneous nerve, is the most commonly injured nerve during a single-incision anterior distal biceps repair due to vigorous lateral retraction. It provides sensation to the radial/lateral aspect of the forearm and has strictly sensory function, thus providing no motor innervation.

Question 718

Topic: Elbow & Forearm

A 33-year-old carpenter falls from a ladder, sustaining a comminuted radial head fracture. Following radial head excision at an outside facility, he develops chronic wrist pain and proximal migration of the radius. This complication is a result of the undiagnosed disruption of which of the following structures?

. Triangular fibrocartilage complex (TFCC)
. Medial collateral ligament of the elbow
. Interosseous membrane (IOM) of the forearm
. Annular ligament
. Lateral ulnar collateral ligament

Correct Answer & Explanation

. Interosseous membrane (IOM) of the forearm

Explanation

The patient is presenting with a longitudinal radioulnar dissociation (Essex-Lopresti injury), characterized by a radial head fracture, tear of the forearm interosseous membrane (IOM), and disruption of the distal radioulnar joint (DRUJ). If the radial head is excised without recognizing the IOM injury, the radius will migrate proximally, leading to chronic wrist pain and ulnar-sided abutment. Management requires restoring radial length and stability, typically with radial head arthroplasty.

Question 719

Topic: Elbow & Forearm

A 45-year-old male weightlifter felt a sudden pop in his anterior elbow while performing heavy bicep curls. He presents with local ecchymosis and weakness in forearm supination. Which of the following clinical tests has the highest sensitivity and specificity for diagnosing a complete rupture of the distal biceps tendon?

. Speed's test
. Yergason's test
. Hook test
. O'Brien's active compression test
. Cozen's test

Correct Answer & Explanation

. Hook test

Explanation

The Hook test involves having the patient flex the elbow to 90 degrees and actively supinate the forearm. The examiner attempts to hook an index finger under the lateral edge of the intact distal biceps tendon. It has a reported sensitivity and specificity approaching 100% for diagnosing complete distal biceps tendon ruptures.

Question 720

Topic: Elbow & Forearm

A 34-year-old man sustains a "terrible triad" injury of the elbow after falling from a ladder. What three anatomic injuries characterize this condition, and what is the standard recommended surgical repair sequence?

. Elbow dislocation, olecranon fracture, coronoid fracture; repair sequence: olecranon, coronoid, lateral collateral ligament.
. Elbow dislocation, radial head fracture, coronoid fracture; repair sequence: coronoid, radial head, lateral collateral ligament.
. Elbow dislocation, capitellum fracture, radial head fracture; repair sequence: capitellum, radial head, lateral collateral ligament.
. Elbow dislocation, radial head fracture, coronoid fracture; repair sequence: lateral collateral ligament, radial head, coronoid.
. Elbow dislocation, radial neck fracture, medial epicondyle fracture; repair sequence: medial epicondyle, radial neck, ulnar collateral ligament.

Correct Answer & Explanation

. Elbow dislocation, radial head fracture, coronoid fracture; repair sequence: coronoid, radial head, lateral collateral ligament.

Explanation

The 'terrible triad' of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid fracture. The classic surgical protocol described by Pugh et al. involves a deep-to-superficial repair approach: first fix or reconstruct the coronoid (often accessed through the radial head defect), then fix or replace the radial head, and finally repair the lateral collateral ligament (LCL) complex to restore posterolateral rotatory stability.

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