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9. Shoulder and Elbow MCQs

Practice Set 156 of 197

This practice set contains high-yield board review questions covering key concepts in 9. Shoulder and Elbow. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 3101

Topic: Elbow & Forearm

A 50-year-old female falls onto an outstretched hand and sustains an isolated coronal shear fracture of the capitellum. Radiographs reveal a large osseous fragment consisting of the capitellum and the lateral half of the trochlea without posterior comminution. According to the Dubberley classification, what type of fracture is this?

. Type 1A
. Type 2A
. Type 3A
. Type 1B
. Type 2B

Correct Answer & Explanation

. Type 1A

Explanation

The Dubberley classification of capitellum fractures: Type 1 involves the capitellum only. Type 2 involves the capitellum and trochlea as a single articular fragment. Type 3 involves the capitellum and trochlea as separate fragments. Subtype A lacks posterior wall comminution, whereas Subtype B has posterior condylar comminution. A single fragment with capitellum and trochlea, without posterior comminution, is a Type 2A.

Question 3102

Topic: 9. Shoulder and Elbow

The "terrible triad" of the elbow is a complex instability pattern comprising an elbow dislocation, a radial head fracture, and a coronoid fracture. During open surgical reconstruction of this injury, what is the most widely accepted and biomechanically sound sequence of repair to restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical protocol for a terrible triad injury utilizes an 'inside-out' or 'deep-to-superficial' approach. The widely accepted sequence is: 1) Fixation of the coronoid fracture or repair of the anterior capsule to restore the anterior buttress; 2) Repair or replacement of the radial head to restore the lateral column and anterior structural support; and 3) Repair of the lateral collateral ligament (LCL) complex to the lateral epicondyle to restore posterolateral rotatory stability. The Medial Collateral Ligament (MCL) is typically only addressed if the elbow remains grossly unstable after these three steps are completed.

Question 3103

Topic: 9. Shoulder and Elbow

A 35-year-old female falls on an outstretched hand and presents with elbow pain and instability. Radiographs confirm an elbow dislocation, radial head fracture, and coronoid fracture. Which of the following is the most appropriate sequence of surgical reconstruction for this 'terrible triad' injury?

. 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
. Medial collateral ligament (MCL) repair, radial head fixation, coronoid fixation
. LCL repair, coronoid fixation, radial head replacement

Correct Answer & Explanation

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

Explanation

The standard surgical sequence for a terrible triad injury of the elbow follows a deep-to-superficial (inside-out) approach: 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 collateral ligament (LCL) complex to the lateral epicondyle. MCL repair or hinged external fixation is reserved for cases where the elbow remains unstable after these steps.

Question 3104

Topic: 9. Shoulder and Elbow

The biceps pulley at the superior aspect of the bicipital groove acts to stabilize the long head of the biceps tendon. Which two structures primarily make up this pulley system?

. Superior glenohumeral ligament and supraspinatus tendon
. Superior glenohumeral ligament and coracohumeral ligament
. Middle glenohumeral ligament and coracoacromial ligament
. Coracohumeral ligament and subscapularis tendon
. Transverse humeral ligament and inferior glenohumeral ligament

Correct Answer & Explanation

. Superior glenohumeral ligament and supraspinatus tendon

Explanation

The biceps pulley is composed primarily of the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL), which form a sling around the long head of the biceps tendon to keep it stabilized in the bicipital groove.

Question 3105

Topic: Elbow & Forearm

A 40-year-old weightlifter feels a pop in his elbow while doing heavy curls. Physical examination demonstrates a positive Hook test. When repairing a distal biceps tendon rupture using a single anterior incision approach, which nerve is at highest risk of injury?

. Median nerve
. Ulnar nerve
. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABCN)
. Superficial radial nerve

Correct Answer & Explanation

. Median nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) runs in the subcutaneous tissue over the lateral aspect of the antecubital fossa and is the most commonly injured nerve during a single-incision distal biceps repair. The PIN is more at risk in a two-incision approach or with deep retractor placement.

Question 3106

Topic: Elbow & Forearm

A 35-year-old male bodybuilder feels a 'pop' in his anterior elbow during a deadlift. Examination reveals a positive hook test. If an anterior single-incision surgical repair using cortical button fixation is chosen, which nerve is at the highest risk of iatrogenic injury?

. Median nerve
. Ulnar nerve
. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABCN)
. Superficial radial nerve

Correct Answer & Explanation

. Median nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair due to its superficial location in the surgical field. PIN injury is more classically associated with the two-incision technique.

Question 3107

Topic: 9. Shoulder and Elbow

A 20-year-old collegiate baseball pitcher reports posteromedial elbow pain specifically during the deceleration phase of throwing. Physical exam reveals a 15-degree lack of terminal extension and pain with forced extension. What is the most likely underlying pathology?

. Medial epicondylitis
. Ulnar collateral ligament acute rupture
. Valgus extension overload syndrome (posteromedial impingement)
. Capitellar osteochondritis dissecans (OCD)
. Flexor-pronator mass avulsion

Correct Answer & Explanation

. Medial epicondylitis

Explanation

Valgus extension overload syndrome results from repetitive valgus stress and olecranon impingement in the posteromedial fossa. It presents with pain during deceleration, loss of terminal extension, and posteromedial osteophytes.

Question 3108

Topic: Elbow & Forearm

A 35-year-old male sustains an acute distal biceps tendon rupture and undergoes surgical repair via a classic two-incision approach. Which of the following complications is more commonly associated with this technique compared to a single anterior incision approach?

. Lateral antebrachial cutaneous nerve palsy
. Proximal radioulnar synostosis
. Posterior interosseous nerve injury
. Median nerve neuropraxia
. Tendon re-rupture

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve palsy

Explanation

The classic two-incision approach for distal biceps repair increases the risk of heterotopic ossification and proximal radioulnar synostosis due to subperiosteal elevation around the ulna. The single anterior incision carries a higher risk of lateral antebrachial cutaneous (LABC) neuropraxia.

Question 3109

Topic: 9. Shoulder and Elbow

During arthroscopic repair of a type II SLAP tear, over-tensioning of the anterior-superior labrum or the middle glenohumeral ligament (MGHL) should be carefully avoided to prevent which of the following postoperative clinical deficits?

. Loss of internal rotation
. Loss of external rotation
. Excessive anterior translation
. Inferior subluxation
. Scapular winging

Correct Answer & Explanation

. Loss of internal rotation

Explanation

Over-tensioning the anterior-superior labrum and associated capsule, particularly incorporating the MGHL during SLAP repair, restricts the capsular tissue. This most commonly results in a significant postoperative loss of external rotation.

Question 3110

Topic: 9. Shoulder and Elbow

A 34-year-old male presents with elbow pain after sustaining a ground level fall 2 weeks ago. An injury radiograph is shown in Figure

A. Which of the following provocative maneuvers will most likely be positive?


. Lateral pivot shift test
. Milking maneuver
. Chair rise test
. Posterior drawer test
. Gravity-assisted varus stress test

Correct Answer & Explanation

. Lateral pivot shift test

Explanation

Figure A demonstrates a fracture of the anteromedial coronoid. Patients with this injury pattern will have feelings of instability with the gravity-assisted varus stress test.Varus posteromedial rotatory instability (VPMRI) of the elbow is caused by a varus and posteromedial rotation force, resulting in rupture of the lateral collateral ligament (LCL) from its humeral origin. The medial coronoid process is subsequently forced against the medial trochlea, which results in fracture of the anteromedial portion. The most sensitive test is the gravity-assisted varus stress test. The arm is abducted to 90° and the patient is asked to flex and extend the elbow. The test is positive for pain, grinding, or instability during range of motion, as the ulnohumeral joint is closed medially by the lack of the buttress from the anteromedial coronoid. Treatment involves surgically addressing the anteromedial facet of the coronoid and repairing the LCL.Steinmann performed a review of coronoid process fractures. He reports that with an anteromedial coronoid fracture, the anteroposterior (AP) radiograph of the elbow will demonstrate progressive narrowing of the joint space from lateral to medial. They conclude that an important determinant of stability is the involvement of the sublime tubercle (insertion point of the MCL). When the sublime tubercle is involved, medial elbow instability is likely.Doornberg et al. performed a retrospective review of coronoid fracture patterns. They found that large fractures of the coronoid were involved with anterior and posterior olecranon fracture/dislocations, small transverse fractures were involved with terrible triad injuries, and anteromedial facet fractures were associated with VPMRI.Doornberg et al. performed a retrospective review of patients with fracture of the anteromedial facet of the coronoid. They report that if the fracture is not specifically treated, patients ultimately developed arthrosis. They report that the coronoid fracture may be secured with a plate, screw, or sutures. They conclude that secure fixation of the coronoid usually restores good elbow function.Figure A is an AP radiograph of the elbow demonstrating a fracture of the anteromedial facet of the coronoid. Illustration A is a fluoroscopic stress view demonstrating ulnohumeral instability due to an associated LCL injury.Illustration B is an AP radiograph demonstrating plate and screw fixation of the coronoid and suture anchor repair of the LCL.Incorrect Answers:Answer 1: The lateral pivot shift test is performed with the patient supine with the affected arm overhead. The forearm is supinated and valgus stress is applied while flexing the elbow. Subluxation constitutes a positive finding and is seen in valgus posterolateral rotatory instability of the elbow.Answer 2: The milking maneuver is performed by creating valgus stress by pulling the patient's thumb with the forearm supinated and elbow flexed to 90°. Subluxation constitutes a positive finding and is seen in valgus posterolateral rotatory instability of the elbow.Answer 3: The chair rise test is performed by asking the patient to push off from a seated position in a chair. Subluxation when transitioning to elbow extension constitutes a positive finding and is seen in valgus posterolateral rotatory instability of the elbow.Answer 4: The posterior drawer test is performed with the patient in a seated position with the elbow flexed to 90°. The clinician stabilizes the humerus and gives a superior and inferior force to the forearm. Subluxation constitutes apositive finding and is seen in valgus posterolateral rotatory instability of the elbow.

Question 3111

Topic: 9. Shoulder and Elbow

You are planning operative treatment of the injury shown in figure A. If the MCL is intact, in what position should the elbow and

forearm be splinted at the end of the case?

. extension and pronation
. extension and supination
. extension and neutral rotation
. flexion and pronation
. flexion and supination

Correct Answer & Explanation

. extension and pronation

Explanation

A terrible triad elbow injury consists of an elbow dislocation with fractures of the radial head and coronoid. After surgical repair, splinting in flexion and pronation is felt to help ensure reduction and aid stability. Flexion adds to the bony congruity of the elbow and the elbow is more stable in increasing degrees of flexion. Pronation tightens the medial ulnar collateral complex which acts like a sling to keep the radio-capitellar joint reduced.Neale et al (Presentation at the 23rd Annual Meeting of the American Society of Biomechanics, University of Pittsburgh; October 21-23, 1999) showed that the coronoid is clearly a primary stabilizer of the elbow, with the radial head being a secondary stabilizer. When the elbow was slowly brought into extension to find the point at which it becomes unstable, the degree of flexion needed to maintain stability was greater with progessive loss of coronoid and with loss of the radial head. Therefore, the elbow is more stable in flexion due to the support provided by the coronoid and radial head.Dunning et al investigated the contribution of forearm position to the stability of a lateral collateral ligament deficient elbow. They determined that varus and valgus laxity was significantly less with the forearm in pronation than in supination. They speculated that the internal rotation torque applied to thewrist to maintain the forearm in pronation may cause the ulna to pivot about the intact soft tissues on the medial side of the elbow and close the gap on the lateral side. The most stable position is flexion with forearm pronation.If both the MCL and LCL are repaired, newer recommendations from Mathew et al. are for splinting in flexion and neutral rotation.

Question 3112

Topic: Elbow & Forearm
A 6-year-old girl sustained a Gartland III supracondylar humerus fracture that was managed non-operatively. She develops a severe malunion. If a persistent cubitus varus deformity (gunstock deformity) remains, what is the most significant long-term clinical consequence aside from the cosmetic appearance?
. Ulnar neuropathy and tardy posterolateral rotatory instability (PLRI)
. Median neuropathy and tardy posteromedial rotatory instability (PMRI)
. Recurrent radial nerve entrapment
. High incidence of recurrent supracondylar fractures
. Avascular necrosis of the trochlea

Correct Answer & Explanation

. Ulnar neuropathy and tardy posterolateral rotatory instability (PLRI)

Explanation

Cubitus varus is historically considered a largely cosmetic issue with minimal functional deficit in childhood. However, in adulthood, it alters the triceps vector, causing chronic lateral ulnar collateral ligament (LUCL) attenuation, leading to tardy posterolateral rotatory instability (PLRI) and snapping of the medial head of the triceps, which can cause ulnar neuritis/neuropathy.

Question 3113

Topic: Elbow & Forearm

A 35-year-old male sustains a midshaft humerus fracture. Examination reveals an inability to extend the wrist and digits. He is diagnosed with a radial nerve palsy. If tendon transfers are required due to lack of recovery, which of the following combinations is the classic Boyes transfer for radial nerve palsy?

. Pronator teres to ECRB; FCU to EDC; Palmaris longus to EPL
. Pronator teres to ECRB; FDS of ring finger to EPL; FDS of middle finger to EDC; FCR to APL/EPB
. Pronator teres to ECRB; FCR to EDC; Palmaris longus to EPL
. FCU to ECRB; FCR to EDC; FDS to EPL
. Brachioradialis to ECRB; FCR to EDC; Palmaris longus to EPL

Correct Answer & Explanation

. Pronator teres to ECRB; FCU to EDC; Palmaris longus to EPL

Explanation

The Boyes transfer utilizes the Pronator Teres (PT) to Extensor Carpi Radialis Brevis (ECRB) for wrist extension, Flexor Digitorum Superficialis (FDS) of the middle finger to Extensor Digitorum Communis (EDC) for finger extension, FDS of the ring finger to Extensor Pollicis Longus (EPL) for thumb extension, and Flexor Carpi Radialis (FCR) to Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB). In contrast, the more common standard (Jones) transfer uses PT to ECRB, FCU to EDC, and Palmaris Longus to EPL.

Question 3114

Topic: Elbow & Forearm

A patient sustained a humerus fracture resulting in a persistent high radial nerve palsy. When planning a standard set of tendon transfers to restore function, which muscle is typically transferred to the extensor carpi radialis brevis (ECRB) to restore wrist extension?

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

Correct Answer & Explanation

. Pronator teres

Explanation

In a standard radial nerve palsy tendon transfer (e.g., Jones transfer), the pronator teres is transferred to the ECRB to restore wrist extension. The FCU or FCR is typically transferred to the EDC for finger extension.

Question 3115

Topic: Elbow & Forearm

In a patient undergoing tendon transfers for a high radial nerve palsy, the pronator teres (PT) is typically transferred to restore wrist extension. Why is the extensor carpi radialis brevis (ECRB) preferred as the recipient tendon over the extensor carpi radialis longus (ECRL)?

. The ECRB has a longer excursion than the ECRL.
. The ECRB is functionally stronger due to a larger cross-sectional area.
. The ECRB is innervated by the posterior interosseous nerve.
. The ECRB provides centralized wrist extension without excessive radial deviation.
. The ECRB tendon is located more superficially, easing the transfer.

Correct Answer & Explanation

. The ECRB has a longer excursion than the ECRL.

Explanation

The ECRB inserts at the base of the third metacarpal, allowing for centralized wrist extension. Transferring to the ECRL, which inserts on the second metacarpal, would cause excessive radial deviation during wrist extension.

Question 3116

Topic: Elbow & Forearm

A patient with a chronic, irreparable high radial nerve palsy is undergoing tendon transfers to restore wrist, finger, and thumb extension. The surgeon plans to transfer the Pronator Teres to the Extensor Carpi Radialis Brevis (PT to ECRB) for wrist extension, and the Flexor Carpi Radialis to the Extensor Digitorum Communis (FCR to EDC) for finger extension. What is the standard tendon transfer utilized in this set to restore thumb extension (EPL)?

. Flexor carpi ulnaris (FCU) to EPL
. Palmaris longus (PL) to EPL
. Flexor digitorum superficialis (FDS) of ring finger to EPL
. Brachioradialis (BR) to EPL
. Extensor indicis proprius (EIP) to EPL

Correct Answer & Explanation

. Flexor carpi ulnaris (FCU) to EPL

Explanation

The standard set of tendon transfers for a high radial nerve palsy (the Boyes or standard Jones transfer set variations) commonly uses the Pronator Teres (PT) to ECRB for wrist extension, the Flexor Carpi Radialis (FCR) or Flexor Carpi Ulnaris (FCU) to the EDC for finger extension, and the Palmaris Longus (PL) rerouted to the Extensor Pollicis Longus (EPL) to restore thumb extension.

Question 3117

Topic: Elbow & Forearm

A 35-year-old male sustained a mid-shaft humerus fracture resulting in an irreparable radial nerve palsy. He is undergoing a classic 'standard' (Jones) tendon transfer to restore function. In this specific transfer arrangement, which muscle is most commonly transferred to the extensor pollicis longus (EPL) to restore thumb extension?

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

Correct Answer & Explanation

. Flexor carpi radialis (FCR)

Explanation

In the standard (Jones) tendon transfer for radial nerve palsy, the palmaris longus (PL) is transferred to the EPL to restore thumb extension. The pronator teres (PT) is transferred to the ECRB to restore wrist extension, and the flexor carpi radialis (FCR) is transferred to the EDC to restore digit extension.

Question 3118

Topic: 9. Shoulder and Elbow

A 25-year-old male sustains a C5-C6 brachial plexus root avulsion injury. He has absent shoulder abduction and elbow flexion, but normal hand function. A nerve transfer is planned to restore elbow flexion. Which of the following nerve transfers is most appropriate for this specific deficit?

. Spinal accessory nerve to suprascapular nerve
. Ulnar nerve fascicle to biceps motor branch (Oberlin transfer)
. Intercostal nerves to musculocutaneous nerve
. Sural nerve graft to lateral cord
. Radial nerve branch to triceps to axillary nerve

Correct Answer & Explanation

. Spinal accessory nerve to suprascapular nerve

Explanation

The Oberlin transfer involves taking a redundant fascicle from the ulnar nerve (often the FCU fascicle) and transferring it directly to the motor branch of the biceps. This is an excellent option to restore elbow flexion in upper trunk injuries (C5-C6) when distal hand function (ulnar nerve) is completely intact.

Question 3119

Topic: Elbow & Forearm

In a patient with a high radial nerve palsy undergoing tendon transfers, the pronator teres (PT) is most commonly transferred to which of the following tendons to restore functional wrist extension?

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

Correct Answer & Explanation

. Extensor carpi radialis brevis (ECRB)

Explanation

In standard tendon transfer operations for radial nerve palsy (such as the Jones, Boyes, or Brand transfers), the pronator teres is transferred to the ECRB. The ECRB is preferred over the ECRL because its central location provides more balanced wrist extension without excessive radial deviation.

Question 3120

Topic: Elbow & Forearm

A 32-year-old male presents with an irreversible high radial nerve palsy following a humerus fracture. To restore wrist extension, which tendon transfer is most commonly utilized and provides the best biomechanical advantage?

. Flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB)
. Pronator teres (PT) to extensor carpi radialis brevis (ECRB)
. Flexor digitorum superficialis (FDS) to extensor digitorum communis (EDC)
. Palmaris longus (PL) to extensor pollicis longus (EPL)
. Flexor carpi radialis (FCR) to extensor carpi radialis longus (ECRL)

Correct Answer & Explanation

. Flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB)

Explanation

The pronator teres to ECRB transfer is the gold standard for restoring wrist extension in radial nerve palsy. The ECRB is preferred over the ECRL as it provides more central wrist extension and avoids excessive radial deviation.

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