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Elbow & Forearm MCQs

Practice Set 38 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 741

Topic: Elbow & Forearm

A 45-year-old man falls on an outstretched hand and sustains a posterior elbow dislocation, a comminuted radial head fracture, and a type II coronoid fracture. During the surgical reconstruction of this terrible triad injury of the elbow, what is the generally recommended sequence of repair to best restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical protocol for terrible triad injuries involves repairing structures from deep to superficial, and typically anterior to posterior. Using a lateral or combined approach, the deep anterior structures are addressed first: the coronoid is fixed (often through the fracture defect of the radial head or via a separate medial approach if large), then the radial head is either fixed or replaced to restore the anterior radiocapitellar buttress, and finally, the lateral collateral ligament (LCL) complex is repaired to the lateral epicondyle to restore posterolateral rotatory stability.

Question 742

Topic: Elbow & Forearm

A 38-year-old male undergoes a single-incision anterior approach for repairing a distal biceps tendon rupture. Postoperatively, he notes significant numbness and a tingling sensation along the lateral aspect of his forearm. Which nerve is most likely injured, and what is its anatomical relationship to the operative field?

. Posterior interosseous nerve; it pierces the supinator muscle.
. Lateral antebrachial cutaneous nerve; it courses between the biceps and brachialis muscles.
. Superficial radial nerve; it runs deep to the brachioradialis muscle.
. Medial antebrachial cutaneous nerve; it runs alongside the basilic vein.
. Ulnar nerve; it passes behind the medial epicondyle.

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve; it courses between the biceps and brachialis muscles.

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the terminal sensory branch of the musculocutaneous nerve. It emerges laterally between the biceps and brachialis muscles to pierce the deep fascia and course subcutaneously in the lateral forearm. It is at high risk of stretch or transection during the single-incision anterior approach for distal biceps repair due to retraction. Injury leads to numbness along the lateral forearm.

Question 743

Topic: Elbow & Forearm

A 45-year-old man falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. Which of the following describes the correct surgical sequence to restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury involves a deep-to-superficial approach. This sequence involves fixing the coronoid first, addressing the radial head, and finally repairing the lateral collateral ligament (LCL) complex.

Question 744

Topic: Elbow & Forearm

A 6-year-old child sustains a plastic deformation fracture of the proximal ulna with an anterior dislocation of the radial head. What is the most appropriate management?

. Closed reduction and casting in extension
. Open reduction of the radial head only
. Anatomic reduction and stabilization of the ulna
. Resection of the radial head
. Annular ligament reconstruction

Correct Answer & Explanation

. Anatomic reduction and stabilization of the ulna

Explanation

This describes a Bado Type I Monteggia fracture-dislocation. Restoring the length and anatomic alignment of the ulnar shaft typically results in spontaneous reduction and stability of the radial head.

Question 745

Topic: Elbow & Forearm

In a patient with a chronic radial nerve palsy, which tendon transfer is most commonly utilized to restore active wrist extension?

. Flexor carpi ulnaris to extensor digitorum communis
. Palmaris longus to extensor pollicis longus
. Pronator teres to extensor carpi radialis brevis
. Flexor digitorum superficialis to extensor carpi radialis longus
. Brachioradialis to extensor pollicis longus

Correct Answer & Explanation

. Pronator teres to extensor carpi radialis brevis

Explanation

The pronator teres is routinely transferred to the extensor carpi radialis brevis (ECRB) to restore wrist extension. The ECRB is chosen over the ECRL to maintain central alignment and avoid excessive radial deviation during extension.

Question 746

Topic: Elbow & Forearm

A 40-year-old man presents after a fall onto an outstretched hand. He sustains a posterolateral elbow dislocation with associated fractures of the radial head and coronoid process. After closed reduction, the elbow remains persistently unstable at 45 degrees of extension. In what order should the surgical reconstruction of this 'terrible triad' injury generally proceed?

. Lateral collateral ligament (LCL) repair, followed by radial head fixation, then coronoid fixation
. Coronoid fixation, followed by radial head repair/replacement, then LCL repair
. Radial head repair/replacement, followed by LCL repair, then coronoid fixation
. Medial collateral ligament (MCL) repair, followed by LCL repair, then radial head fixation
. Coronoid fixation, followed by MCL repair, then radial head fixation

Correct Answer & Explanation

. Coronoid fixation, followed by radial head repair/replacement, then LCL repair

Explanation

The standard algorithm for terrible triad injuries is to restore stability from deep to superficial, typically starting with coronoid fixation. This is followed by radial head repair or arthroplasty, and finally reconstruction of the lateral collateral ligament complex.

Question 747

Topic: Elbow & Forearm

A 42-year-old man sustains an isolated fracture of the proximal third of the ulna with an associated anterior dislocation of the radial head. Regarding the definitive management of this specific injury pattern in an adult, which of the following statements is most accurate?

. Closed reduction and casting is the standard of care to prevent stiffness
. Anatomic rigid internal fixation of the ulna usually results in spontaneous reduction of the radial head
. The radial head requires open reduction and annular ligament reconstruction in all cases
. Radial head excision is required due to the high risk of post-traumatic arthrosis
. An external fixator must be applied to maintain length

Correct Answer & Explanation

. Anatomic rigid internal fixation of the ulna usually results in spontaneous reduction of the radial head

Explanation

This is a Bado Type I Monteggia fracture-dislocation. In adults, rigid anatomic internal fixation of the ulnar shaft fracture is required; this typically restores the bony anatomy and length, leading to spontaneous reduction of the radiocapitellar joint without needing open radial head reduction.

Question 748

Topic: Elbow & Forearm

A 48-year-old bodybuilder feels a sudden pop in his antecubital fossa while performing heavy bicep curls. He has weakness in supination and an abnormal Hook test. If the surgeon chooses to repair this injury using a single-incision anterior approach, which nerve is at highest risk of iatrogenic injury?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABCN)
. Medial antebrachial cutaneous nerve (MABCN)
. Anterior interosseous nerve (AIN)
. Ulnar nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

Distal biceps ruptures repaired via a single-incision anterior approach carry the highest risk of injury to the lateral antebrachial cutaneous nerve (LABCN) due to retraction. While the PIN is also at risk, LABCN neurapraxia is the most common complication overall.

Question 749

Topic: Elbow & Forearm

A 38-year-old female falls onto her outstretched hand and sustains a coronal shear fracture of the distal humerus. Radiographs demonstrate a 'double arc' sign on the lateral view. Which of the following best describes the anatomy of this specific fracture pattern (McKee Type IV)?

. Isolated capitellum fracture lacking trochlear extension
. Capitellum and lateral trochlear ridge fracture with an attached lateral epicondyle
. Shear fracture involving the capitellum and most of the trochlea
. Comminuted fracture of the radial head and capitellum
. Transchondral detachment of the articular cartilage from the subchondral bone of the capitellum and trochlea

Correct Answer & Explanation

. Shear fracture involving the capitellum and most of the trochlea

Explanation

The 'double arc' sign on a lateral elbow radiograph represents a type IV coronal shear fracture, which involves the capitellum and extends medially to include most of the trochlea. The two arcs represent the subchondral bone of the capitellum and the lateral ridge of the trochlea.

Question 750

Topic: Elbow & Forearm

A 38-year-old male bodybuilder undergoes a two-incision surgical repair of a complete distal biceps tendon rupture. Compared to a single anterior incision technique, this patient is at an increased risk for which of the following postoperative complications?

. Posterior interosseous nerve (PIN) palsy
. Lateral antebrachial cutaneous nerve palsy
. Heterotopic ossification and radioulnar synostosis
. Median nerve neuropraxia
. Tendon re-rupture

Correct Answer & Explanation

. Heterotopic ossification and radioulnar synostosis

Explanation

The two-incision technique for distal biceps repair was designed to avoid nerve injury but is associated with a significantly higher risk of heterotopic ossification and radioulnar synostosis. In contrast, the single anterior incision approach carries a higher risk of radial or lateral antebrachial cutaneous nerve neuropraxia.

Question 751

Topic: Elbow & Forearm
A 33-year-old woman presents with a severely comminuted radial head fracture involving the entire head and neck, accompanied by a mechanical block to forearm rotation. Radiographs demonstrate a Mason Type III fracture. Intraoperatively, the fracture is deemed completely unreconstructible. What is the most appropriate management?
. Radial head excision alone
. Radial head excision with an anconeus arthroplasty
. Radial head arthroplasty with a metallic prosthesis
. Radial head arthroplasty with a silastic prosthesis
. Resection of the distal ulna

Correct Answer & Explanation

. Radial head arthroplasty with a metallic prosthesis

Explanation

For unreconstructible, comminuted Mason Type III radial head fractures, radial head replacement with a metallic prosthesis is the gold standard. Radial head excision alone is generally avoided due to the high risk of proximal radius migration and longitudinal instability, especially if occult ligamentous injuries exist.

Question 752

Topic: Elbow & Forearm

A 45-year-old weightlifter undergoes a single-incision anterior approach repair of a distal biceps tendon rupture. Postoperatively, he notes numbness along the lateral aspect of his volar forearm. Which nerve was most likely injured during the superficial exposure and retraction?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

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

Question 753

Topic: Elbow & Forearm

A 30-year-old gymnast complains of recurrent elbow instability, particularly when pushing out of a chair. Physical examination reveals a positive lateral pivot-shift test, indicating posterolateral rotatory instability (PLRI). The primary structure deficient in this condition originates from the lateral epicondyle and inserts onto which of the following osseous landmarks?

. Radial head
. Radial neck
. Coronoid process of the ulna
. Olecranon
. Supinator crest of the ulna

Correct Answer & Explanation

. Supinator crest of the ulna

Explanation

Posterolateral rotatory instability (PLRI) of the elbow is primarily caused by insufficiency of the lateral ulnar collateral ligament (LUCL). The LUCL is the primary restraint to posterolateral rotatory subluxation. It originates on the lateral epicondyle of the humerus, courses posterior to the radial head, and inserts on the supinator crest of the proximal ulna.

Question 754

Topic: Elbow & Forearm

A 22-year-old collegiate baseball pitcher presents with posteromedial elbow pain and a noticeable decrease in throwing velocity over the last two months. He describes a severe 'catching' and 'locking' sensation specifically in the deceleration phase of throwing. Physical examination reveals a 15-degree flexion contracture and sharp pain in the posteromedial olecranon fossa when forced terminal extension is applied concurrently with a valgus stress. The milking maneuver is negative. What is the most likely diagnosis?

. Medial epicondylitis
. Acute ulnar collateral ligament anterior bundle rupture
. Valgus extension overload syndrome
. Ulnar neuritis
. Osteochondritis dissecans of the capitellum

Correct Answer & Explanation

. Valgus extension overload syndrome

Explanation

Valgus extension overload (VEO) syndrome in overhead athletes results from chronic, repetitive valgus stress and extension forces. This leads to posterior radiocapitellar compression and traction/shear forces on the medial olecranon tip as it impinges within the olecranon fossa. Patients characteristically present with posteromedial pain, a flexion contracture, and pain on forced terminal extension with valgus stress (the moving valgus stress test may also be positive, but specifically terminal extension pain points to impingement/osteophytes). The 'catching' in the deceleration phase is classic for VEO, often secondary to posteromedial olecranon osteophytes or loose bodies.

Question 755

Topic: Elbow & Forearm

A 9-year-old male baseball pitcher complains of lateral right elbow pain and stiffness that worsens with throwing. Examination shows a 15-degree flexion contracture. Radiographs reveal diffuse sclerosis and fragmentation involving the entire capitellum, with no loose bodies or localized subchondral bone defects. What is the most appropriate management?

. Arthroscopic microfracture of the capitellum
. Open osteochondral autograft transfer (OATS)
. Rest, activity modification, and symptomatic treatment
. Ulnar collateral ligament reconstruction
. Drilling of the capitellum to promote revascularization

Correct Answer & Explanation

. Rest, activity modification, and symptomatic treatment

Explanation

The clinical presentation and radiographic findings in a child under 10 years old are characteristic of Panner's disease (osteochondrosis of the capitellum). Unlike osteochondritis dissecans (OCD) of the capitellum, which typically occurs in older adolescents (12-15 years), involves a focal defect, and may lead to loose bodies, Panner's disease is self-limiting, involves the entire ossific nucleus, and uniformly responds to nonoperative treatment consisting of rest and avoidance of throwing until symptoms resolve and radiographic healing occurs.

Question 756

Topic: Elbow & Forearm

A 20-year-old collegiate baseball pitcher complains of medial elbow pain and diminished pitching velocity for 6 weeks. A moving valgus stress test reproduces his pain.

An MR arthrogram confirms a partial tear of the anterior bundle of the ulnar collateral ligament (UCL). What is the most appropriate initial management?

. Immediate UCL reconstruction (Tommy John surgery)
. UCL repair with internal brace augmentation
. Rest from throwing, NSAIDs, and a flexor-pronator mass rehabilitation program
. Corticosteroid injection into the UCL origin
. Arthroscopic debridement of the radiocapitellar joint

Correct Answer & Explanation

. Rest from throwing, NSAIDs, and a flexor-pronator mass rehabilitation program

Explanation

The standard of care for an initial partial tear of the UCL in a throwing athlete is nonoperative management. This involves a period of absolute rest from throwing (typically 6-12 weeks), followed by a progressive rehabilitation program focused on strengthening the dynamic medial stabilizers (flexor-pronator mass) and optimizing throwing mechanics. Corticosteroid injections are contraindicated due to the risk of inducing complete ligament rupture. Surgery is reserved for complete tears or failed prolonged nonoperative treatment.

Question 757

Topic: Elbow & Forearm

A 14-year-old female gymnast complains of lateral elbow pain, clicking, and a 15-degree flexion contracture. Radiographs reveal a radiolucency in the capitellum. MRI demonstrates a 12 mm osteochondral defect of the capitellum. Which of the following MRI findings is the strongest absolute indication for surgical intervention?

. Extensive bone marrow edema within the capitellum
. Intact overlying articular cartilage
. High T2 signal (fluid) extending behind the osteochondral fragment
. Lesion size less than 10 mm in the coronal plane
. Subchondral sclerosis surrounding the lesion

Correct Answer & Explanation

. High T2 signal (fluid) extending behind the osteochondral fragment

Explanation

Osteochondritis dissecans (OCD) of the capitellum is common in young gymnasts and overhead athletes. The stability of the lesion dictates treatment. Non-operative management is appropriate for stable lesions with open physes. However, high T2 signal (synovial fluid) interposing behind the osteochondral fragment or a break in the articular cartilage signifies an unstable lesion. Unstable lesions are unlikely to heal with rest alone and are an absolute indication for surgical intervention (e.g., drilling, fixation, or fragment excision with microfracture).

Question 758

Topic: Elbow & Forearm

A 14-year-old gymnast complains of lateral elbow pain, clicking, and mechanical catching. Radiographs reveal a radiolucent lesion in the capitellum. MRI demonstrates fluid behind an osteochondral fragment, with an associated loose body. What is the recommended management?

. Strict cessation of gymnastics for 6 months and NSAIDs
. Drilling of the capitellum in situ with a retrograde approach
. Fragment excision, removal of loose bodies, and microfracture of the bed
. Open reduction and internal fixation of the capitellum only
. Total elbow arthroplasty

Correct Answer & Explanation

. Fragment excision, removal of loose bodies, and microfracture of the bed

Explanation

Unstable osteochondritis dissecans (OCD) lesions of the capitellum (indicated by fluid behind the lesion or loose bodies) in throwing athletes or gymnasts require surgical intervention. Excision of the fragment with microfracture of the bed is the standard treatment for smaller lesions.

Question 759

Topic: Elbow & Forearm

A 14-year-old male competitive gymnast presents with lateral elbow pain and mechanical catching. Radiographs show a radiolucent lesion of the capitellum. An MRI demonstrates a 12 mm osteochondral defect with a rim of high T2 signal fluid tracking completely behind the lesion. What is the recommended treatment?

. Cessation of gymnastics and observation for 3 months
. Arthroscopic drilling of the intact lesion
. Surgical fixation or osteochondral autograft transfer (OATS)
. Radial head excision
. Ulnar collateral ligament reconstruction

Correct Answer & Explanation

. Surgical fixation or osteochondral autograft transfer (OATS)

Explanation

The presence of fluid tracking completely behind an osteochondral lesion of the capitellum on a T2-weighted MRI indicates an unstable fragment. Since the patient is symptomatic and the lesion is structurally unstable, surgical intervention (fixation or OATS) is required.

Question 760

Topic: Elbow & Forearm

A 40-year-old weightlifter requires a distal biceps tendon repair. If the surgeon opts for a traditional two-incision (Boyd-Anderson) technique rather than a single anterior extensile approach, the patient is at a relatively higher risk for which of the following complications?

. Lateral antebrachial cutaneous nerve injury
. Posterior interosseous nerve (PIN) injury
. Radioulnar synostosis
. Median nerve palsy
. Brachial artery transection

Correct Answer & Explanation

. Radioulnar synostosis

Explanation

The two-incision technique was historically designed to minimize injury to the lateral antebrachial cutaneous nerve commonly seen with the single-incision approach. However, the muscle-splitting dissection significantly increases the risk of heterotopic ossification and radioulnar synostosis.

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