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Elbow & Forearm MCQs

Practice Set 4 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 61

Topic: Elbow & Forearm

What is the recommended sequence for the surgical reconstruction of a 'terrible triad' injury of the elbow (radial head fracture, coronoid fracture, and elbow dislocation)?

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

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad injury begins deep-to-superficial: repairing the coronoid first, followed by the radial head, and finally repairing the lateral collateral ligament (LCL) complex. MCL repair is only considered if the elbow remains unstable after these steps.

Question 62

Topic: Elbow & Forearm

A 35-year-old male presents with lateral elbow pain and mechanical clicking when pushing out of a chair. Examination reveals a positive lateral pivot-shift test. Deficiency of which of the following structures is the primary cause of his symptoms?

. Annular ligament
. Lateral ulnar collateral ligament (LUCL)
. Radial collateral ligament
. Medial ulnar collateral ligament
. Biceps tendon

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The patient describes symptoms of posterolateral rotatory instability (PLRI) of the elbow. PLRI is primarily caused by an injury or deficiency of the lateral ulnar collateral ligament (LUCL).

Question 63

Topic: Elbow & Forearm

Compared to a single anterior incision, a two-incision approach for distal biceps tendon repair is associated with a higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve palsy
. Posterior interosseous nerve (PIN) palsy
. Radioulnar synostosis
. Superficial radial nerve injury
. Tendon rerupture

Correct Answer & Explanation

. Radioulnar synostosis

Explanation

The two-incision (Boyd-Anderson) approach historically carries a higher risk of heterotopic ossification and radioulnar synostosis compared to a single-incision anterior approach. Single-incision approaches carry a higher risk of lateral antebrachial cutaneous neuropraxia.

Question 64

Topic: Elbow & Forearm

A 40-year-old sustains an Essex-Lopresti injury with an unreconstructible comminuted radial head fracture, tear of the interosseous membrane, and distal radioulnar joint (DRUJ) dislocation. What is the most appropriate management of the radial head?

. Radial head excision alone
. Radial head arthroplasty
. Silicone radial head replacement
. Fragment excision and delayed reconstruction
. Radiocapitellar fusion

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

In an Essex-Lopresti injury, longitudinal forearm stability is compromised due to the interosseous membrane tear. Radial head arthroplasty is mandatory if the radial head cannot be fixed, to prevent proximal migration of the radius and chronic DRUJ instability.

Question 65

Topic: Elbow & Forearm

A 6-year-old sustains a Bado Type I Monteggia fracture. Closed reduction of the ulnar shaft is achieved perfectly, but the radial head remains dislocated. What is the most common cause of failure to achieve closed reduction of the radiocapitellar joint in this scenario?

. Interposition of the annular ligament
. Biceps tendon subluxation
. Inadequate length restoration of the ulna
. Radial nerve entrapment
. Coronoid fracture fragment

Correct Answer & Explanation

. Interposition of the annular ligament

Explanation

While inadequate ulnar reduction is the most common overall reason for persistent radial head subluxation, if the ulna is anatomically reduced and the radial head remains out, the most common block to reduction is interposition of the torn annular ligament or joint capsule.

Question 66

Topic: Elbow & Forearm

A 7-year-old girl presents with an acute fracture of her proximal radial metaphysis. Although a line down the shaft of the radius intersects the center of the capitellum, the articular surface of the radial head is angled 20° from the anatomic position as compared with the other elbow. You recommend:

. Observation with follow-up in 1 week
. C losed manipulation with a pronation maneuver
. C losed manipulation with a supination maneuver
. Closed manipulation with a percutaneous K-wire
. Open reduction and internal fixation

Correct Answer & Explanation

. Observation with follow-up in 1 week

Explanation

Proximal radial fractures have excellent remodeling potential, especially if the angulation is less than 30°. Manipulation is not necessary, and the risk of stiffness from any invasive procedure is not worthwhile.

Question 67

Topic: Elbow & Forearm

Which of the following is not a common finding in the forearms of patients who have multiple hereditary exostoses:

. Radial head subluxation or dislocation
. Limitation of rotation
. Decreased slope of the distal radial articular surface
. Subluxation of the carpus toward the ulna
. Decreased length of the ulna

Correct Answer & Explanation

. Decreased length of the ulna

Explanation

Multiple hereditary exostosis is characterized by differential growth of the two bones. There is often decreased length of the ulna. This results in increased inclination of the distal radial articular surface, radial head subluxation, and subluxation of the carpus toward the ulna. The exostoses themselves may block rotation.

Question 68

Topic: Elbow & Forearm

A patient with an irreparable high radial nerve palsy requires tendon transfers to restore wrist and finger extension. Which muscle is most commonly transferred to the extensor carpi radialis brevis (ECRB) to restore wrist extension?

. Pronator teres
. Flexor carpi ulnaris
. Palmaris longus
. Flexor digitorum superficialis
. Brachioradialis

Correct Answer & Explanation

. Pronator teres

Explanation

The pronator teres is the standard donor muscle transferred to the ECRB to restore strong and synergistic wrist extension in radial nerve palsy.

Question 69

Topic: Elbow & Forearm

A patient sustained a mid-shaft humerus fracture and subsequently developed a complete radial nerve palsy. Three months later, there is no clinical or EMG evidence of recovery. Which muscle is most commonly transferred to the Extensor Carpi Radialis Brevis (ECRB) to restore wrist extension?

. Flexor carpi radialis (FCR)
. Pronator teres (PT)
. Palmaris longus (PL)
. Flexor carpi ulnaris (FCU)
. Flexor digitorum superficialis (FDS)

Correct Answer & Explanation

. Pronator teres (PT)

Explanation

In standard radial nerve palsy tendon transfers, the Pronator Teres (innervated by the median nerve) is transferred to the ECRB to effectively restore wrist extension.

Question 70

Topic: Elbow & Forearm

A 45-year-old falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. During surgical reconstruction, what is the most appropriate sequence of repair to restore elbow stability?

. Coronoid fixation, lateral ulnar collateral ligament (LUCL) repair, radial head repair/replacement
. Radial head repair/replacement, coronoid fixation, LUCL repair
. LUCL repair, coronoid fixation, radial head repair/replacement
. Coronoid fixation, radial head repair/replacement, LUCL repair
. Radial head repair/replacement, LUCL repair, coronoid fixation

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad injury is to reconstruct from deep to superficial: coronoid fixation first, followed by radial head repair or replacement, and finally LUCL repair. If the elbow remains unstable, the medial collateral ligament may be addressed last.

Question 71

Topic: Elbow & Forearm

A 50-year-old woman has chronic lateral elbow pain exacerbated by resisted wrist extension and forearm supination. She has failed a year of conservative treatment, and surgery is planned. Which structure is the primary site of pathology being targeted?

. Extensor carpi radialis longus
. Extensor carpi radialis brevis
. Extensor digitorum communis
. Brachioradialis
. Supinator

Correct Answer & Explanation

. Extensor carpi radialis brevis

Explanation

Lateral epicondylitis (tennis elbow) is primarily characterized by angiofibroblastic tendinosis of the origin of the extensor carpi radialis brevis (ECRB) tendon. Surgical intervention focuses on debridement or release of the ECRB.

Question 72

Topic: Elbow & Forearm

A 45-year-old woman falls on her outstretched arm and sustains a 'terrible triad' injury of the elbow. During surgical reconstruction, after addressing the radial head fracture, the lateral ulnar collateral ligament (LUCL) must be repaired. What is the primary anatomical origin and insertion of the LUCL?

. Originates on the lateral epicondyle and inserts on the radial tuberosity
. Originates on the lateral epicondyle and inserts on the supinator crest of the ulna
. Originates on the medial epicondyle and inserts on the coronoid process
. Originates on the capitellum and inserts on the annular ligament
. Originates on the lateral epicondyle and inserts on the sublime tubercle of the ulna

Correct Answer & Explanation

. Originates on the lateral epicondyle and inserts on the supinator crest of the ulna

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 of the humerus and inserts distally on the supinator crest of the proximal ulna.

Question 73

Topic: Elbow & Forearm

A 7-year-old boy falls and suffers a Salter type IV fracture of the proximal radius. The size of the displaced fragment is 40% of the radial head, and it is translated distally by 2 mm. The optimum treatment is:

. Immobilization for 2 weeks with early range of motion
. Immobilization for 6 weeks with early range of motion
. Percutaneous fixation in situ to prevent further displacement
. Excision of the radial head fragment
. Open reduction, internal fixation

Correct Answer & Explanation

. Open reduction, internal fixation

Explanation

Because the displacement is likely to be >2 mm, open reduction may lessen the risk of problems with growth and mobility. This is suggested by clinical series. The displacement is likely to be greater than the radiograph shows, and growth disturbance is likely. Range of motion at two weeks is too early. Percutaneous fixation in situ would still carry a risk of growth disturbance, because the displacement is likely to be more than the plain radiographs show due to the largely cartilaginous nature of the radial head. Excision of a fragment this large is likely to produce incongruity of the radio-capitellar joint.

Question 74

Topic: Elbow & Forearm

A 4-year-old girl is brought in for examination by her mother because of a bump on the lateral side of her elbow. The girl is unable to extend her elbow. She falls as much as any child, but no particular injury to the elbow is recalled. Radiographs show a dislocated, enlarged radial head that is convex proximally. There is a proximal radioulnar synostosis. Recommended treatment includes:

. Radial head excision
. Open reduction of the radial head and annular ligament reconstruction
. Open reduction of the radial head and ulnar lengthening osteotomy
. Silastic radial head arthroplasty
. No treatment

Correct Answer & Explanation

. No treatment

Explanation

This child has a congenital dislocation of the radial head, and no treatment is indicated unless the forearm is fixed in a position of extreme malrotation. Radial head excision should only be performed if there is pain and the child is skeletally mature. Silastic radial head arthroplasty has a significant risk of particulate synovitis.

Question 75

Topic: Elbow & Forearm

A 7-year-old girl is seen because of a persistent anterior dislocation of the radial head that occurred 2 months ago with an ulna fracture. The ulna has healed but has 25° of angulation. Her family would like to have this fixed to remove the prominence in the hope of preventing future joint degeneration. The recommended treatment is:

. Closed reduction of the radial head
. Open reduction and pin fixation of the radial head
. Open reduction and annular ligament reconstruction
. Open reduction, annular ligament reconstruction, and ulnar osteotomy
. Open reduction, radial shortening, and annular ligament reconstruction

Correct Answer & Explanation

. Open reduction, annular ligament reconstruction, and ulnar osteotomy

Explanation

The combination of open reduction, annular ligament reconstruction, and ulnar osteotomy should correct all of the components of the deformity. Closed reduction is not successful beyond 1-2 weeks after injury. Because of the 25° ulnar bow, recurrence is likely, and ulnar osteotomy is indicated. An ulnar osteotomy should be included to prevent recurrence.

Question 76

Topic: Elbow & Forearm

A 6-year-old patient has an acute proximal ulnar fracture with an apex posteriorly, as well as a radial head dislocation. Treatment at this stage should consist of:

. Closed reduction and immobilization in supination and flexion more than 90° in a long arm cast
. Closed reduction and immobilization in extension in a long arm cast
. Closed reduction and intramedullary rod fixation of the ulna
. Open reduction of the radial head and plate fixation of the ulna
. Open reduction of the radial head and annular ligament reconstruction

Correct Answer & Explanation

. Closed reduction and immobilization in extension in a long arm cast

Explanation

Extension will reduce the dislocation and the fracture. This type II Monteggia proximal fracture is best immobilized in extension. An intramedullary rod is indicated only if closed treatment fails. Open reduction of the radial head and plate fixation of the ulna are indicated only if closed treatment fails. Annular ligament reconstruction is indicated only if the dislocation is unreduced for more than 1 to 2 weeks.

Question 77

Topic: Elbow & Forearm
A 12-year-old girl sustains a closed type III Monteggia fracture. One week after closed reduction, the radial head resubluxates and the ulna bows. The next step of treatment is:
. Repeat closed reduction and a long arm cast
. Reconstruct the annular ligament using a strip of triceps fascia
. Reduce and internally fix the ulna and close-reduce the radial head
. Reduce and internally fix the ulna and open-reduce the radial head
. Reduce and pin the radial head

Correct Answer & Explanation

. Reduce and internally fix the ulna and close-reduce the radial head

Explanation

Once the ulna is predictably reduced, the radial head has a good chance of staying reduced. Repeat closed reduction and a long arm cast has a significant chance of redisplacement. If further time passes, radial head reduction will be difficult. Annular ligament reconstruction is only indicated if there is late subluxation (after several weeks) that does not reduce with closed means. Once the ulna is realigned and fixed, closed reduction of the radius must be tried next.

Question 78

Topic: Elbow & Forearm

A 9-year-old child presents one year after a supracondylar humerus fracture is healed. The elbow is in 15° more varus than the other side. Which of the following statements to the family is true:

. This is likely to be due to growth plate damage in the distal humerus.
. This is likely to correct fully before the end of growth.
. The deformity is probably due to hyperemia and overgrowth of the capitellum.
. The deformity is likely due to malposition of the fracture during healing.
. The varus will likely lead to an increased likelihood of degenerative joint disease.

Correct Answer & Explanation

. The deformity is likely due to malposition of the fracture during healing.

Explanation

Fracture malalignment is the most common cause of cubitus varus. Physeal damage is rare after supracondylar fractures. Angular malalignment corrects slowly and incompletely in the distal humerus, especially in the coronal plane. There is no reason for selective hyperemia of the capitellum in this fracture. There is no evidence of predisposition to degenerative joint disease in cubitus varus.

Question 79

Topic: Elbow & Forearm

A patient with refractory lateral epicondylitis undergoes open surgical debridement. The primary pathological tissue targeted during this procedure is the origin of which of the following structures?

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

Correct Answer & Explanation

. Extensor carpi radialis brevis (ECRB)

Explanation

Lateral epicondylitis primarily involves angiofibroblastic hyperplasia of the origin of the Extensor Carpi Radialis Brevis (ECRB). Surgical management focuses on excising this degenerative tissue while sparing the overlying ECRL.

Question 80

Topic: Elbow & Forearm

A 45-year-old male presents with recurrent posterolateral rotatory instability (PLRI) of the elbow. During surgical reconstruction of the lateral ulnar collateral ligament (LUCL), the isometric point on the lateral epicondyle must be identified for graft placement. Where is this point anatomically located?

. At the center of the capitellum axis of rotation
. Posterior and distal to the lateral epicondyle
. Anterior and proximal to the lateral epicondyle
. Directly on the supracondylar ridge
. At the radial notch of the ulna

Correct Answer & Explanation

. At the center of the capitellum axis of rotation

Explanation

The isometric point for LUCL reconstruction is located on the lateral epicondyle at the center of the capitellum's axis of rotation. Improper graft placement here leads to laxity or stiffness during different arcs of elbow motion.

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