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Elbow & Forearm MCQs

Practice Set 5 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 81

Topic: Elbow & Forearm

A 32-year-old female fell on an outstretched hand and sustained the injury shown in the radiograph.

Assuming this is a "terrible triad" injury of the elbow, which of the following is the standard evidence-based surgical sequence for management?

. MCL repair, radial head fixation, coronoid fixation, LCL repair
. Coronoid fixation, radial head fixation or replacement, LCL repair, MCL repair if needed
. Radial head fixation, LCL repair, coronoid fixation, MCL repair
. LCL repair, coronoid fixation, radial head fixation, MCL repair
. Coronoid fixation, LCL repair, radial head replacement, ulnar nerve transposition

Correct Answer & Explanation

. Coronoid fixation, radial head fixation or replacement, LCL repair, MCL repair if needed

Explanation

The terrible triad of the elbow consists of an elbow dislocation, radial head fracture, and coronoid fracture. The standard surgical approach works deep to superficial: coronoid fixation, radial head repair/replacement, followed by LCL complex repair.

Question 82

Topic: Elbow & Forearm

Extracorporeal shock wave therapy ____ in the treatment of lateral epicondylitis in high-quality trials.

. Is ineffective
. Is beneficial
. Has not been tested
. Improves short-term pain
. Improves function

Correct Answer & Explanation

. Is ineffective

Explanation

Current studies have found no benefit of extracorporeal shock wave therapy in the treatment of lateral epicondylitis.

Question 83

Topic: Elbow & Forearm

Iontophoresis has been effectively used in all of the following EXC EPT:

. C arpal tunnel syndrome
. Wrist arthritis
. Shoulder/rotator cuff tendinitis
. Lateral epicondylitis
. Medial epicondylitis

Correct Answer & Explanation

. Lateral epicondylitis

Explanation

Iontophoresis is effective in soft tissue conditions such as rotator cuff bursitis and lateral epicondylitis.

Question 84

Topic: Elbow & Forearm

Common concomitant intra-articular pathology that can be found and addressed at arthroscopy for lateral epicondylitis include all of the following, except:

. Synovial plica
. Loose body
. Synovitis
. Medial epicondylitis
. Chondral lesion

Correct Answer & Explanation

. Medial epicondylitis

Explanation

While all of the other answers are intra-articular lesions that have been reported in elbow arthroscopies, medial epicondylitis is an extra-articular condition and must be addressed in an open fashion given the proximity of the ulnar nerve.

Question 85

Topic: Elbow & Forearm

A 45-year-old male presents with a terrible triad injury of the elbow after a fall on an outstretched hand.

According to standard surgical protocols, what is the most appropriate sequence of repair to restore elbow stability?

. Fix or replace the radial head, repair the LCL, then address the coronoid
. Fix the coronoid, fix or replace the radial head, then repair the LCL
. Repair the MCL, fix the coronoid, then fix the radial head
. Repair the LCL, fix the coronoid, then fix the radial head
. Fix the coronoid, repair the MCL, then fix the radial head

Correct Answer & Explanation

. Fix the coronoid, fix or replace the radial head, then repair the LCL

Explanation

The standard inside-out surgical sequence for a terrible triad injury is to fix the coronoid first to restore the anterior buttress. This is followed by radial head fixation or replacement, and finally repair of the lateral collateral ligament (LCL) complex.

Question 86

Topic: Elbow & Forearm
According to the Bado classification, a Type III Monteggia fracture-dislocation is characterized by a proximal ulna fracture with which associated radial head displacement?
. Anterior dislocation of the radial head
. Posterior dislocation of the radial head
. Lateral or anterolateral dislocation of the radial head
. Anterior dislocation with a radial head fracture
. Medial dislocation of the radial head

Correct Answer & Explanation

. Lateral or anterolateral dislocation of the radial head

Explanation

In the Bado classification of Monteggia injuries, Type I is anterior, Type II is posterior, Type III is lateral or anterolateral, and Type IV involves fractures of both the radius and ulna with an anterior radial head dislocation.

Question 87

Topic: Elbow & Forearm

A 35-year-old patient falls on an outstretched hand and presents with severe elbow pain and instability. Radiographs confirm a posterior elbow dislocation, a comminuted radial head fracture, and a Type II coronoid fracture.

If operative intervention is indicated, what is the most widely accepted surgical sequence for addressing this 'terrible triad' injury?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury follows an 'inside-out' approach. This sequence involves fixing the coronoid first, followed by the radial head (fixation or arthroplasty), and finally repairing the lateral collateral ligament.

Question 88

Topic: Elbow & Forearm
When performing open reduction and internal fixation of radial neck fractures, the plate should be placed:
. In the "nonarticular safe-zone" comprising 120° of the 360° radial head circumference
. Forearm in pronation with plate posterior
. Forearm in supination with plate anterior
. Forearm in supination with plate posterior
. Forearm in neutral with plate anterior

Correct Answer & Explanation

. Forearm in supination with plate posterior

Explanation

The "nonarticular safe-zone" comprising only 90° of the radial head circumference is achieved by placing the plate posterior with the arm in supination.

Question 89

Topic: Elbow & Forearm

During the surgical repair of a "terrible triad" injury of the elbow, which of the following sequences is the standard algorithm for reconstruction?

. Repair coronoid, fix or replace radial head, repair LCL
. Repair LCL, fix radial head, repair coronoid
. Fix radial head, repair LCL, repair coronoid
. Repair MCL, repair coronoid, fix radial head
. Repair LCL, repair MCL, fix radial head

Correct Answer & Explanation

. Repair coronoid, fix or replace radial head, repair LCL

Explanation

The standard surgical algorithm for a terrible triad injury works deep to superficial: repair the coronoid first, then fix or replace the radial head, and finally repair the lateral ulnar collateral ligament (LUCL).

Question 90

Topic: Elbow & Forearm
The most common forearm deformity in patients with hereditary multiple osteochondromatosis is:
. Ulnar shortening
. Radial shortening
. Radial head dislocation
. Madelung's deformity
. Translocation of carpus

Correct Answer & Explanation

. Radial head dislocation

Explanation

Ulnar involvement and shortening frequently occur in patients with hereditary multiple osteochondromatosis because the distal ulnar growth plate is smaller than that of the radius; consequently, its length is affected more. The ulnar shortening causes radial bowing or radial head dislocation.

Question 91

Topic: Elbow & Forearm

A 65-year-old female undergoes volar locked plating for a distal radius fracture. During the procedure, the surgeon places a screw in the most ulnar hole of the distal row of the plate. Which tendon is at the highest risk of injury from this specific screw if it penetrates the dorsal cortex?

. Extensor pollicis longus (EPL)
. Extensor carpi radialis brevis (ECRB)
. Extensor digiti minimi (EDM)
. Extensor indicis proprius (EIP)
. Extensor carpi ulnaris (ECU)

Correct Answer & Explanation

. Extensor digiti minimi (EDM)

Explanation

A dorsal prominent screw in the most ulnar hole of the distal row of a volar plate puts the extensor digiti minimi (EDM) tendon at risk within the 5th extensor compartment. The EPL is typically at risk from screws in the 3rd compartment, such as those near the Lister tubercle.

Question 92

Topic: Elbow & Forearm

A 38-year-old construction worker sustains a Bado Type II Monteggia fracture-dislocation after a fall from a height. During surgical planning, the orthopedic surgeon reviews the relevant anatomy. Which of the following structures is considered the primary stabilizer of the radial head within the radial notch of the ulna?

. Medial Collateral Ligament (MCL)
. Lateral Ulnar Collateral Ligament (LUCL)
. Annular Ligament
. Interosseous Membrane (IOM)
. Biceps tendon

Correct Answer & Explanation

. Annular Ligament

Explanation

Correct Answer: CThe case explicitly states, 'The annular ligament is the primary stabilizer of the radial head within the radial notch of the ulna. It forms a fibrous ring encircling the radial head and neck, attaching to the anterior and posterior margins of the radial notch.' Its integrity is crucial for maintaining the proximal radioulnar joint (PRUJ) stability.Option A (Medial Collateral Ligament - MCL):The MCL provides valgus stability to the elbow and is not the primary stabilizer of the radial head within the radial notch.Option B (Lateral Ulnar Collateral Ligament - LUCL):The LUCL is part of the lateral collateral ligament complex and is critical for posterolateral rotatory stability of the elbow, but not the primary stabilizer of the radial head within the radial notch.Option D (Interosseous Membrane - IOM):The IOM connects the ulna and radius, transmitting axial loads and contributing to overall forearm stability, but it is not the primary direct stabilizer of the radial head within the radial notch.Option E (Biceps tendon):The biceps tendon primarily functions in elbow flexion and forearm supination. While it crosses the elbow joint, it does not directly stabilize the radial head within the radial notch.

Question 93

Topic: Elbow & Forearm

A 55-year-old female presents with a Bado Type I Monteggia fracture-dislocation. The surgical team is preparing for operative management. Based on the biomechanical principles outlined in the case, which of the following statements represents the cornerstone of successful treatment for this injury?

. Primary open reduction and repair of the annular ligament to stabilize the radial head.
. Achieving concentric reduction of the radial head first, followed by ulnar fixation.
. Anatomic reduction and rigid internal fixation of the ulna to restore forearm stability and facilitate spontaneous radial head reduction.
. Application of an external fixator to the elbow joint to maintain radial head reduction.
. Early aggressive range of motion exercises to prevent stiffness, even before definitive ulnar fixation.

Correct Answer & Explanation

. Anatomic reduction and rigid internal fixation of the ulna to restore forearm stability and facilitate spontaneous radial head reduction.

Explanation

Correct Answer: CThe case explicitly states, 'The key biomechanical principle in treating Monteggia injuries is that the ulna dictates the stability of the entire forearm and the radial head. Anatomic reduction and rigid internal fixation of the ulna are prerequisites for successful radial head reduction and maintaining its concentric alignment with the capitellum.' This principle is reiterated multiple times throughout the text, emphasizing that restoring the ulna's length, rotation, and alignment is paramount.Option A (Primary open reduction and repair of the annular ligament):While annular ligament repair may be necessary if the radial head remains unstable after ulnar fixation, it is not the primary cornerstone. The ulna's stability is the prerequisite.Option B (Achieving concentric reduction of the radial head first):This is incorrect. The radial head's position is dictated by the ulna. Attempting to reduce the radial head first without addressing the ulnar fracture will likely be unsuccessful or unstable.Option D (Application of an external fixator):While external fixation might be used temporarily in severe open fractures or for damage control, it is not the definitive treatment for adult Monteggia fracture-dislocations, which almost universally require open reduction and internal fixation (ORIF) of the ulna.Option E (Early aggressive range of motion exercises):Early motion is important post-operatively, but it must be controlled and initiatedafterstable fixation of the ulna and concentric reduction of the radial head. Aggressive motion before definitive fixation would destabilize the injury.

Question 94

Topic: Elbow & Forearm

A 40-year-old male undergoes open reduction and internal fixation for a Bado Type I Monteggia fracture-dislocation. The surgeon has successfully achieved anatomical reduction and rigid internal fixation of the ulnar fracture using a locking compression plate, as depicted in the provided image. What is the immediate next critical step in the surgical procedure, according to the case's detailed surgical technique?

. Perform a thorough neurovascular assessment of the limb.
. Initiate aggressive range of motion exercises for the elbow.
. Assess the radial head for spontaneous concentric reduction and stability under fluoroscopy.
. Proceed with layered wound closure and apply a splint.
. Directly repair the torn annular ligament.

Correct Answer & Explanation

. Assess the radial head for spontaneous concentric reduction and stability under fluoroscopy.

Explanation

Correct Answer: CThe case outlines the step-by-step surgical technique, stating under 'Radial Head Assessment': 'Once the ulna is rigidly fixed, the radial head should spontaneously reduce into its concentric position relative to the capitellum. Confirm with fluoroscopy in AP and lateral views, ensuring the radial head bisects the capitellum in all positions of elbow flexion and forearm rotation.' This is the immediate and critical next step after ulnar fixation.Option A (Perform a thorough neurovascular assessment):While a neurovascular assessment is crucial, it is typically performed at the end of the procedure (Final Stability Check) and also pre-operatively, but not as theimmediatenext step after ulnar fixation before confirming radial head reduction.Option B (Initiate aggressive range of motion exercises):This is incorrect. Early aggressive motion is contraindicated at this stage and could destabilize the repair. Controlled motion begins post-operatively during rehabilitation.Option D (Proceed with layered wound closure and apply a splint):Wound closure and splint application are final steps, performed only after all reductions and fixations are confirmed stable and neurovascular status is checked.Option E (Directly repair the torn annular ligament):Annular ligament repair is only indicated if the radial headdoes notspontaneously reduce or remains unstableafteranatomical ulnar fixation. It is not an automatic next step.

Question 95

Topic: Elbow & Forearm

A 32-year-old male undergoes ORIF for a Bado Type I Monteggia fracture-dislocation. Post-operatively, despite what the surgeon believes was rigid internal fixation of the ulna, fluoroscopy reveals persistent subluxation of the radial head. Based on the case, what is the most common reason for persistent radial head dislocation or subluxation after ulnar fixation, and what is the appropriate next step?

. An irreparable annular ligament tear; proceed with radial head replacement.
. Inadequate anatomical reduction or unstable fixation of the ulna; re-evaluate and revise ulnar fixation.
. Interposition of the biceps tendon; perform an open reduction of the radial head to clear the obstruction.
. Associated coronoid process fracture; fix the coronoid fracture.
. Posterior interosseous nerve impingement; perform neurolysis.

Correct Answer & Explanation

. Inadequate anatomical reduction or unstable fixation of the ulna; re-evaluate and revise ulnar fixation.

Explanation

Correct Answer: BThe case clearly states under 'Complications and Management' and 'Persistent Radial Head Dislocation/Subluxation': 'This is the most common and critical complication. It's almost always due to inadequate anatomical reduction or unstable fixation of the ulna (malreduction, malalignment, shortening, or rotation).' The management is to 're-establish anatomical reduction and rigid fixation of the ulna.'Option A (An irreparable annular ligament tear; proceed with radial head replacement):While an annular ligament tear can contribute to instability, it is rarely theprimaryreason for persistent dislocation if the ulna is anatomically reduced. Radial head replacement is generally discouraged in acute Monteggia for unreconstructible radial head fractures, and even less so for an isolated annular ligament issue.Option C (Interposition of the biceps tendon):While soft tissue interposition can occur, the case emphasizes that inadequate ulnar reduction is themost commonreason. If soft tissue interposition is suspected after optimal ulnar fixation, open reduction of the radial head would be performed, but the primary focus remains the ulna.Option D (Associated coronoid process fracture):Coronoid fractures can destabilize the elbow, but the most common reason for persistent radial head dislocation in a Monteggia is still inadequate ulnar reduction. If a coronoid fracture was significant enough to cause persistent instability, it should have been addressed during the initial fixation.Option E (Posterior interosseous nerve impingement):PIN impingement causes neurological symptoms (wrist drop) but does not directly cause persistent radial head dislocation. Neurolysis would be for nerve recovery, not joint stability.

Question 96

Topic: Elbow & Forearm

A 35-year-old male sustains a Monteggia fracture-dislocation with an associated severely comminuted radial head fracture that is deemed unreconstructible. The ulnar fracture has been anatomically reduced and rigidly fixed. Based on the current literature and guidelines discussed in the case, what is the generally discouraged approach for managing the unreconstructible radial head fracture in this acute setting, especially in a younger, active adult?

. Radial head arthroplasty to restore mechanical stability.
. Primary radial head excision.
. Open reduction of the radial head to clear any interposed soft tissue.
. Annular ligament reconstruction if the radial head remains unstable.
. Temporary K-wire stabilization of the radial head.

Correct Answer & Explanation

. Primary radial head excision.

Explanation

Correct Answer: BThe case states under 'Summary of Key Literature and Guidelines' and 'Radial Head Fractures': 'Unreconstructible radial head fractures in the context of an acute Monteggia are challenging. While historically radial head excision was considered, it is now generally discouraged in the acute setting due to the risk of severe valgus instability and proximal radial migration, especially in younger, active adults.'Option A (Radial head arthroplasty):The case mentions that 'Radial head arthroplasty may be considered in selected cases to restore mechanical stability, particularly in older patients with low demand, but its role inacuteMonteggia is not universally accepted compared to its use in terrible triad injuries.' While not universally accepted for acute Monteggia, it is a consideration for stability, unlike excision.Option C (Open reduction of the radial head to clear any interposed soft tissue):This is a necessary step if the radial head cannot be reduced, regardless of whether it's fractured or not, to clear obstructions. This is not discouraged.Option D (Annular ligament reconstruction):If the radial head remains unstable after ulnar fixation and any necessary radial head management, annular ligament reconstruction is a valid and often necessary step to maintain stability. This is not discouraged.Option E (Temporary K-wire stabilization):Temporary K-wire stabilization can be considered in highly unstable cases to maintain reduction, although it limits early motion. This is a recognized technique, not generally discouraged.

Question 97

Topic: Elbow & Forearm
A 30-year-old male presents with a complex elbow injury. Radiographs show a coronal shear fracture of the distal humerus that involves both the capitellum and a significant portion of the trochlea. According to the Bryan and Morrey classification (with McKee modification), what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV (McKee modification)
. Type V

Correct Answer & Explanation

. Type IV (McKee modification)

Explanation

A Type IV capitellum fracture (McKee modification to the Bryan-Morrey classification) describes a coronal shear fracture that extends medially to involve the majority of the trochlea. A Type I (Hahn-Steinthal) involves a large osseous piece of the capitellum without significant trochlear extension.

Question 98

Topic: Elbow & Forearm
A 29-year-old male presents with a Bado Type III Monteggia fracture-dislocation. Which of the following best describes the classical presentation of a Bado Type III injury?
. Anterior dislocation of the radial head with anterior angulation of the ulnar diaphysis
. Posterior dislocation of the radial head with posterior angulation of the ulnar diaphysis
. Lateral or anterolateral dislocation of the radial head with an ulnar metaphyseal fracture
. Anterior dislocation of the radial head with fractures of both the radius and ulna shafts
. Isolated dislocation of the radial head without an associated ulnar fracture

Correct Answer & Explanation

. Lateral or anterolateral dislocation of the radial head with an ulnar metaphyseal fracture

Explanation

A Bado Type III Monteggia fracture is characterized by a lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysis. This pattern is primarily seen in children and frequently presents with an associated posterior interosseous nerve (PIN) palsy.

Question 99

Topic: Elbow & Forearm

A 10-year-old boy presents with a Monteggia fracture equivalent consisting of an anterior radial head dislocation and plastic deformation of the ulna. Closed reduction under sedation fails to maintain the radial head. What is the most appropriate definitive management?

. Open reduction of the radial head and annular ligament reconstruction
. Closed reduction and percutaneous pinning of the radiocapitellar joint
. Corrective osteotomy of the ulna to restore anatomic alignment, followed by radial head reduction
. Resection of the radial head
. Application of a hinged elbow external fixator

Correct Answer & Explanation

. Corrective osteotomy of the ulna to restore anatomic alignment, followed by radial head reduction

Explanation

In pediatric Monteggia injuries with ulnar plastic deformation, the radial head will not remain reduced if the ulnar bow is not corrected. Anatomic restoration of the ulnar length and alignment (often requiring an osteotomy) is the critical step to achieve and maintain spontaneous radial head reduction.

Question 100

Topic: Elbow & Forearm

A 6-year-old child presents with elbow stiffness 5 months after an unrecognized upper extremity injury. Radiographs demonstrate a malunited proximal third ulnar diaphyseal fracture with persistent anterior dislocation of the radial head. What is the recommended surgical management?

. Radial head excision
. Ulnar osteotomy with open reduction of the radial head
. In situ ulnar plating without addressing the radial head
. Closed reduction of the radial head alone
. Ulnar lengthening with a circular external fixator

Correct Answer & Explanation

. Ulnar osteotomy with open reduction of the radial head

Explanation

In pediatric patients with chronic missed Monteggia fractures, radial head excision is contraindicated. The standard treatment is an ulnar osteotomy (often with angulation/lengthening) to restore length, coupled with open reduction of the radial head and annular ligament reconstruction.

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