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Elbow & Forearm MCQs

Practice Set 54 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 1061

Topic: Elbow & Forearm

In the surgical management of recalcitrant lateral epicondylitis (tennis elbow), debridement is primarily targeted at the macroscopic degenerative tissue (angiofibroblastic hyperplasia) found within the origin of which muscle?

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

Correct Answer & Explanation

. Extensor carpi radialis brevis (ECRB)

Explanation

Lateral epicondylitis is characterized by angiofibroblastic tendinosis primarily involving the origin of the extensor carpi radialis brevis (ECRB). During surgical release/debridement, the ECRB origin is located deep to the extensor digitorum communis (EDC) aponeurosis at the lateral epicondyle.

Question 1062

Topic: Elbow & Forearm

A 40-year-old female sustains a coronal shear fracture of the capitellum and lateral trochlea. CT scan reveals extensive posterior comminution of the lateral condyle. According to the Dubberley classification, what is the surgical implication of this posterior comminution?

. It necessitates a purely medial surgical approach
. It precludes the use of isolated anterior-to-posterior headless compression screws
. It indicates an obligate concurrent radial head fracture
. It is an absolute indication for total elbow arthroplasty
. It signifies an intact lateral ulnar collateral ligament

Correct Answer & Explanation

. It precludes the use of isolated anterior-to-posterior headless compression screws

Explanation

The Dubberley classification of capitellum fractures distinguishes between Type A (no posterior comminution) and Type B (posterior comminution). Type B fractures lack a stable posterior buttress. Therefore, anterior-to-posterior headless compression screws alone will fail due to lack of posterior support. These require a posterior buttress plate to prevent displacement.

Question 1063

Topic: Elbow & Forearm

A 45-year-old male sustains a 'terrible triad' injury of the elbow (dislocation, radial head fracture, and coronoid fracture) requiring operative fixation. What is the classic, biomechanically recommended sequence of surgical reconstruction for this injury complex?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury involves an inside-out approach: 1) Fixation of the coronoid process (to restore the anterior buttress), 2) Fixation or replacement of the radial head (to restore the anterior and lateral column), and 3) Repair of the lateral collateral ligament (LCL) complex to the lateral epicondyle. The MCL is only repaired if gross instability remains after these steps.

Question 1064

Topic: Elbow & Forearm

A 22-year-old collegiate baseball pitcher undergoes medial ulnar collateral ligament (MUCL) reconstruction using a palmaris longus autograft via the modified Jobe (figure-of-eight) technique. Postoperatively, what is the most frequently reported complication specific to this procedure?

. Graft rupture
. Radiocapitellar arthritis
. Ulnar neuropathy
. Heterotopic ossification
. Medial epicondyle nonunion

Correct Answer & Explanation

. Ulnar neuropathy

Explanation

Ulnar neuropathy is the most common complication following medial ulnar collateral ligament (MUCL) reconstruction (Tommy John surgery). It can occur due to traction, compression during exposure, or issues related to ulnar nerve transposition (if performed). While modern techniques (like the docking technique) have reduced this rate by minimizing nerve handling, it remains the leading complication.

Question 1065

Topic: Elbow & Forearm

A 35-year-old male presents with recurrent catching and clicking in his right elbow, particularly when pushing himself up from a seated position. Physical examination reveals apprehension with axial compression, supination, and valgus stress applied to the elbow during flexion. Which of the following structures is most likely deficient?

. Medial ulnar collateral ligament (MUCL)
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Anterior joint capsule
. Radial collateral ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The clinical scenario and provocative maneuver (lateral pivot-shift test of the elbow) are classic for Posterolateral Rotatory Instability (PLRI). PLRI is the most common pattern of chronic elbow instability and is caused by an insufficiency of the lateral ulnar collateral ligament (LUCL). The LUCL serves as the primary restraint to posterolateral rotatory forces. It originates on the lateral epicondyle and inserts on the supinator crest of the ulna.

Question 1066

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), standard surgical principles dictate a specific sequence of repair. Which of the following represents the most widely accepted sequence of structural reconstruction?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury generally progresses from deep to superficial and from anterior to posterior if performed through a single lateral approach, though modern techniques often utilize a dual incision. The accepted structural sequence is to establish the anterior buttress first by repairing or fixing the coronoid, followed by restoring the radiocapitellar contact via radial head fixation or arthroplasty, and finally restoring lateral stability by repairing the LUCL. Medial collateral ligament repair or hinged external fixation is reserved for residual instability.

Question 1067

Topic: Elbow & Forearm
A 45-year-old male falls onto an outstretched hand and sustains a coronal shear fracture of the distal humerus. A CT scan reveals a fracture that completely separates the capitellum and the majority of the lateral trochlea from the distal humerus as a single articular piece. According to the Bryan and Morrey classification modified by McKee, how is this fracture classified?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV
. Type V

Correct Answer & Explanation

. Type IV

Explanation

The Bryan and Morrey classification describes capitellum fractures. Type I (Hahn-Steinthal) is a large osseous piece of the capitellum. Type II (Kocher-Lorenz) is a thin shell of articular cartilage with minimal subchondral bone. Type III (Broberg-Morrey) is a severely comminuted capitellum fracture. McKee modified the classification by adding Type IV, which is a coronal shear fracture that involves the capitellum and extends medially to include most or all of the trochlea. It often exhibits a double-arc sign on the lateral radiograph.

Question 1068

Topic: Elbow & Forearm

A 32-year-old male sustains a comminuted radial head fracture from a high-energy fall. During examination, he reports severe ipsilateral wrist pain. Radiographs suggest disruption of the distal radioulnar joint (DRUJ). What is the most appropriate management of the radial head to prevent long-term proximal radial migration?

. Radial head excision alone
. Radial head excision combined with immediate wrist arthroscopy
. Radial head arthroplasty
. Nonoperative management of the elbow in a long arm cast
. Closed reduction and pinning of the radiocapitellar joint

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

The patient has an Essex-Lopresti injury: radial head fracture, interosseous membrane tear, and DRUJ disruption. Radial head excision is absolutely contraindicated as it will result in severe proximal migration of the radius, ulnocarpal impaction, and chronic wrist pain. Radial head replacement (arthroplasty) is required to restore longitudinal forearm stability.

Question 1069

Topic: Elbow & Forearm

In a patient with a suspected acute distal biceps tendon rupture, the O'Driscoll Hook Test is performed. The examiner attempts to hook an index finger under the intact biceps tendon. Which structure can yield a false-negative Hook test by remaining intact despite a complete avulsion of the main distal biceps tendon?

. Brachialis tendon
. Lacertus fibrosus (bicipital aponeurosis)
. Pronator teres origin
. Brachioradialis fascia
. Coracobrachialis

Correct Answer & Explanation

. Lacertus fibrosus (bicipital aponeurosis)

Explanation

The lacertus fibrosus (bicipital aponeurosis) can remain intact even when the primary distal biceps tendon is completely avulsed from the radial tuberosity. An intact lacertus fibrosus limits proximal retraction of the muscle belly and can simulate an intact tendon on palpation, potentially leading to a false-negative Hook test.

Question 1070

Topic: Elbow & Forearm

A 42-year-old female sustains a 'terrible triad' injury to her elbow. Surgical intervention is planned. Which of the following describes the most widely accepted sequence of surgical repair to predictably restore stability?

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

Correct Answer & Explanation

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

Explanation

The classic, widely accepted sequence for repairing a terrible triad of the elbow follows a deep-to-superficial (or inside-out) approach: 1) Coronoid fracture fixation or capsular repair, 2) Radial head fixation or arthroplasty, and 3) Lateral collateral ligament (LCL) complex repair. The MCL is typically only explored if gross instability remains after these three steps.

Question 1071

Topic: Elbow & Forearm

A 9-year-old male gymnast presents with lateral elbow pain and stiffness. Radiographs show sclerosis and fragmentation of the entire capitellum without a discrete osteochondral defect or loose body. What is the most likely diagnosis, and what is the expected outcome with rest?

. Osteochondritis dissecans; high likelihood of requiring surgery
. Panner's disease; spontaneous resolution
. Capitellar shear fracture; nonunion if untreated
. Lateral epicondylitis; chronic tendinosis
. Little league elbow; medial instability

Correct Answer & Explanation

. Panner's disease; spontaneous resolution

Explanation

Panner's disease is an osteochondrosis of the capitellum affecting children (usually <10 years old). It involves the entire capitellum, presents with lateral elbow pain, and almost always resolves spontaneously with rest. In contrast, Osteochondritis Dissecans (OCD) of the capitellum affects older adolescents (12-16) and has a much higher rate of loose body formation requiring surgery.

Question 1072

Topic: Elbow & Forearm

A 45-year-old male sustains a 'terrible triad' injury of the elbow. What is the generally recommended surgical sequence for reconstructing this injury pattern?

. Coronoid fixation, radial head repair/replacement, LCL repair, MCL repair (if needed)
. MCL repair, LCL repair, coronoid fixation, radial head fixation
. Radial head repair/replacement, coronoid fixation, MCL repair, LCL repair
. LCL repair, coronoid fixation, radial head replacement, MCL repair
. Coronoid fixation, MCL repair, LCL repair, radial head repair

Correct Answer & Explanation

. Coronoid fixation, radial head repair/replacement, LCL repair, MCL repair (if needed)

Explanation

The standard surgical sequence for a terrible triad is deep-to-superficial: coronoid fixation first, followed by radial head repair or replacement, and then lateral collateral ligament (LCL) repair. The MCL is only repaired if the elbow remains unstable after these steps.

Question 1073

Topic: Elbow & Forearm

When performing a two-incision distal biceps tendon repair, how should the forearm be positioned during the posterolateral muscle-splitting approach to the radial tuberosity to maximally protect the posterior interosseous nerve (PIN)?

. Full supination
. Neutral rotation
. 90 degrees of flexion and supination
. Full extension and neutral rotation
. Full pronation

Correct Answer & Explanation

. Full pronation

Explanation

During the posterior approach to the radial tuberosity, the forearm must be placed in full pronation. This shifts the posterior interosseous nerve (PIN) anteriorly, moving it safely away from the operative field.

Question 1074

Topic: Elbow & Forearm

A patient with posterolateral rotatory instability (PLRI) of the elbow demonstrates a positive pivot-shift test. Which essential ligamentous structure is deficient in this condition?

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

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Posterolateral rotatory instability (PLRI) is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). Reconstruction of the LUCL is required to restore posterolateral stability to the elbow.

Question 1075

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture), what is the most widely accepted sequence of reconstruction from a standard lateral approach to optimize joint stability?

. LCL repair, followed by radial head fixation, then coronoid fixation.
. Radial head fixation/replacement, followed by LCL repair, then coronoid fixation.
. Coronoid fixation or anterior capsule repair, followed by radial head fixation/replacement, then LCL repair.
. 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 or anterior capsule repair, followed by radial head fixation/replacement, then LCL repair.

Explanation

The standard surgical protocol for a terrible triad injury addresses structures from deep to superficial through a lateral approach. The correct sequence is: (1) Fixation of the coronoid fracture or repair of the anterior capsule (often facilitated through the defect left by the displaced radial head); (2) Fixation or replacement of the radial head; and (3) Repair of the lateral ulnar collateral ligament (LUCL/LCL complex) back to the lateral epicondyle.

Question 1076

Topic: Elbow & Forearm

A 45-year-old manual laborer undergoes surgical repair of a distal biceps tendon rupture using a single-incision anterior approach. Postoperatively, he reports numbness along the lateral aspect of his forearm. Which nerve is most likely injured, and what is the typical path of this nerve relative to the biceps tendon?

. Posterior interosseous nerve; runs lateral to the biceps tendon within the supinator muscle.
. Superficial radial nerve; runs medial to the biceps tendon alongside the brachial artery.
. Medial antebrachial cutaneous nerve; crosses superficial to the biceps tendon.
. Lateral antebrachial cutaneous nerve; courses between the biceps and brachialis muscles, emerging lateral to the distal biceps tendon.
. Musculocutaneous nerve; terminates immediately proximal to the biceps tendon insertion.

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve; courses between the biceps and brachialis muscles, emerging lateral to the distal biceps tendon.

Explanation

The lateral antebrachial cutaneous nerve (LABC), which is the terminal sensory branch of the musculocutaneous nerve, is the most commonly injured structure during a single-incision anterior approach for distal biceps repair. It emerges from between the biceps and brachialis muscles and courses just lateral to the distal biceps tendon. Forceful lateral retraction easily neuropraxias or transects this nerve, resulting in lateral forearm numbness.

Question 1077

Topic: Elbow & Forearm

A 35-year-old male presents with recurrent lateral elbow pain and a sensation of clicking when pushing himself up from a chair. Physical examination reveals a positive lateral pivot-shift test. This condition is primarily due to insufficiency of which structure, and where does this structure insert?

. Radial collateral ligament; inserts on the annular ligament.
. Lateral ulnar collateral ligament (LUCL); inserts on the supinator crest of the proximal ulna.
. Lateral ulnar collateral ligament (LUCL); inserts on the sublime tubercle of the ulna.
. Annular ligament; inserts on the radial notch of the ulna.
. Ulnar collateral ligament (MCL); inserts on the medial epicondyle.

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL); inserts on the supinator crest of the proximal ulna.

Explanation

The patient is presenting with posterolateral rotatory instability (PLRI) of the elbow. The primary restraint to PLRI is the lateral ulnar collateral ligament (LUCL). The LUCL originates on the lateral epicondyle and inserts on the supinator crest of the proximal ulna.

Question 1078

Topic: Elbow & Forearm
A 42-year-old female falls onto an outstretched hand and sustains a distal humerus fracture. CT imaging reveals a coronal shear fracture that involves the capitellum and extends medially to include the majority of the trochlea, maintaining them as a single continuous osteochondral fragment. According to the McKee modification of the Bryan and Morrey classification, what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV
. Type V

Correct Answer & Explanation

. Type IV

Explanation

In the Bryan and Morrey classification of capitellum fractures, Type I is a large osseous piece of the capitellum (Hahn-Steinthal), Type II is an articular cartilage shear with minimal bone (Kocher-Lorenz), and Type III is comminuted. McKee introduced the Type IV fracture, which is a coronal shear fracture that extends medially to include the capitellum and the lateral ridge/bulk of the trochlea as a single fragment.

Question 1079

Topic: Elbow & Forearm

When comparing the single-incision anterior approach to the two-incision (Boyd-Anderson) approach for distal biceps tendon repair, the two-incision approach is historically associated with a higher risk of which of the following complications?

. Lateral antebrachial cutaneous nerve (LABCN) neuropraxia
. Radial nerve palsy
. Proximal radioulnar synostosis
. Rerupture of the tendon
. Anterior interosseous nerve (AIN) palsy

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

The classic two-incision approach (developed to avoid radial nerve injury seen in extensive single anterior incisions) carries a higher risk of heterotopic ossification and proximal radioulnar synostosis, especially if the interosseous membrane is breached or if bone debris is left in the plane between the radius and ulna. Single-incision techniques have a higher risk of LABCN injury.

Question 1080

Topic: Elbow & Forearm

In the Dubberley classification of coronal shear fractures of the capitellum and trochlea, what specific anatomic feature distinguishes a Type B fracture from a Type A fracture?

. Extension of the fracture into the lateral epicondyle
. Involvement of the trochlea
. Presence of posterior condylar comminution
. Associated radial head fracture
. Articular cartilage impaction

Correct Answer & Explanation

. Presence of posterior condylar comminution

Explanation

The Dubberley classification defines Type 1 (capitellum +/- lateral trochlear ridge), Type 2 (capitellum and trochlea in one fragment), and Type 3 (capitellum and trochlea in separate fragments). The modifier A indicates no posterior comminution, whereas the modifier B indicates the presence of posterior condylar comminution, which alters surgical fixation strategy.

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