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9. Shoulder and Elbow MCQs

Practice Set 17 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 321

Topic: Elbow & Forearm
A 4-year-old presents with a Monteggia Type III fracture. After two gentle attempts at closed reduction under sedation, the radial head remains persistently dislocated laterally, as seen in the image. What is the most appropriate next step?
. Repeat closed reduction under general anesthesia with more forceful manipulation
. Proceed with open reduction and internal fixation (ORIF) of the ulna and open reduction of the radial head
. Immobilize in a long-arm cast and re-evaluate in one week
. Order an MRI to identify soft tissue obstruction
. Perform a radial head excision

Correct Answer & Explanation

. Proceed with open reduction and internal fixation (ORIF) of the ulna and open reduction of the radial head

Explanation

If closed reduction attempts for a pediatric Monteggia fracture are unsuccessful after one or, at most, two gentle attempts, further forceful manipulation is not recommended as it can cause iatrogenic damage. The next step is generally open reduction. The most common cause of irreducible radial head dislocation in children is soft tissue interposition, typically the annular ligament or joint capsule, preventing concentric reduction. Open reduction allows for removal of the obstructing tissue and direct reduction of the radial head, often followed by repair of the annular ligament if necessary, and definitive fixation of the ulnar fracture (which may be a greenstick or plastic deformation). An MRI might confirm soft tissue obstruction but usually is not needed if reduction fails; direct surgical exploration is often more efficient. Radial head excision is not indicated in an acute pediatric setting due to potential growth disturbance and long-term wrist issues.

Question 322

Topic: 9. Shoulder and Elbow
A 4-year-old presents with an acute Monteggia Type I fracture. After successful closed reduction of the radial head and stable fixation of the ulna (greenstick fracture) with a long-arm cast, what is the recommended position for immobilization?
. Elbow in 90 degrees flexion, forearm in full pronation
. Elbow in 45 degrees flexion, forearm in neutral rotation
. Elbow in full extension, forearm in supination
. Elbow in 90 degrees flexion, forearm in full supination
. Elbow in 120 degrees flexion, forearm in pronation

Correct Answer & Explanation

. Elbow in 90 degrees flexion, forearm in full supination

Explanation

For a Monteggia Type I fracture (anterior dislocation of the radial head), the radial head is reduced, and the forearm is typically immobilized in full supination with the elbow flexed to 90 degrees. This position helps to tighten the interosseous membrane and the posterior aspect of the annular ligament, creating tension that stabilizes the radial head and prevents its anterior redislocation. For Type III (lateral dislocation), pronation is often used. Full extension is less stable and can compromise circulation. The other options do not provide optimal stability for this specific injury type.

Question 323

Topic: Elbow & Forearm

When evaluating radiographs for a suspected Monteggia fracture, a critical diagnostic rule involves assessing the alignment of the radial head. As illustrated in the image, what is the most definitive radiographic sign to confirm or rule out a radial head dislocation?

. Widening of the radiocapitellar joint space
. Disruption of the radial head-capitellum alignment on all views
. Presence of fat pads in the elbow joint
. Anterior humeral line not intersecting the capitellum
. Increased carrying angle

Correct Answer & Explanation

. Disruption of the radial head-capitellum alignment on all views

Explanation

Correct Answer: BThe definitive radiographic sign of radial head dislocation is the disruption of the radial head-capitellum alignment on all views (AP, lateral, and obliques if needed). A line drawn through the center of the radial shaft should always pass through the center of the capitellum, regardless of elbow flexion or forearm rotation. If this capitellar-radial head line does not intersect the capitellum, the radial head is dislocated. This 'line of sight' rule is crucial for identifying Monteggia fractures, as subtle radial head dislocations can be easily missed. While fat pads indicate an effusion (suggesting injury), and an abnormal anterior humeral line suggests supracondylar or condylar fractures, only direct visualization of the radiocapitellar relationship confirms dislocation of the radial head. Widening of the joint space can be a sign but is less definitive than complete disruption of alignment.

Question 324

Topic: Elbow & Forearm

A 45-year-old female presents with an elbow dislocation, radial head fracture, and coronoid fracture. What is the recommended sequence of surgical reconstruction for this 'terrible triad' injury?

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

Correct Answer & Explanation

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

Explanation

The standard protocol for terrible triad reconstruction follows an 'inside-out' approach: coronoid fixation first, followed by radial head repair or arthroplasty, and finally lateral collateral ligament (LCL) repair. This sequence systematically restores the anterior buttress, lateral column, and lateral ligamentous stability.

Question 325

Topic: 9. Shoulder and Elbow

In the surgical management of a terrible triad injury, an unrepairable comminuted radial head fracture is treated with arthroplasty. If the implanted radial head is 'overstuffed' (too thick), what is the most likely clinical consequence?

. Loss of elbow flexion and extension
. Loss of pronation and supination
. Ulnar nerve palsy
. Instability in terminal extension
. Recurrent posterolateral rotatory instability

Correct Answer & Explanation

. Loss of elbow flexion and extension

Explanation

Overstuffing the radial head causes increased radiocapitellar joint pressures, leading to restricted elbow flexion and extension. It also artificially distracts the joint, which can cause gapping of the medial joint line and persistent lateral elbow pain.

Question 326

Topic: 9. Shoulder and Elbow

Following standard surgical reconstruction of a terrible triad injury (coronoid ORIF, radial head replacement, LCL repair), the elbow remains unstable in 30 degrees of extension during the intraoperative 'drop sign' test. What is the next most appropriate step?

. Apply a hinged external fixator immediately
. Repair the medial collateral ligament (MCL)
. Revise the radial head to a larger size
. Place the arm in a cast at 90 degrees of flexion for 6 weeks
. Perform an olecranon osteotomy to tighten the triceps

Correct Answer & Explanation

. Repair the medial collateral ligament (MCL)

Explanation

If the elbow remains unstable or subluxates in extension after addressing the coronoid, radial head, and LCL, the MCL should be evaluated and repaired to restore medial column stability. If instability persists despite MCL repair, a hinged external fixator is indicated.

Question 327

Topic: Elbow & Forearm

An 8-year-old boy sustains a Bado Type I Monteggia fracture. After closed reduction and casting of the ulnar shaft, radiographs show the radial head remains dislocated. What is the most common structure blocking closed reduction of the radial head in this scenario?

. Biceps tendon
. Brachialis muscle
. Annular ligament
. Median nerve
. Quadrate ligament

Correct Answer & Explanation

. Annular ligament

Explanation

In pediatric Monteggia injuries, failure to achieve closed reduction of the radial head after anatomically aligning the ulna is most commonly due to interposition of the annular ligament or joint capsule. Open reduction is required to remove the interposed tissue and allow concentric reduction.

Question 328

Topic: Elbow & Forearm

During surgery for a terrible triad injury, the coronoid fracture is identified as an O'Driscoll Type II (anteromedial facet). Which of the following best describes the pathomechanics of this specific coronoid fracture type?

. Varus posteromedial rotational force
. Valgus posterolateral rotational force
. Direct axial load in hyperpronation
. Hyperextension with radial deviation
. Pure anterior shear force

Correct Answer & Explanation

. Varus posteromedial rotational force

Explanation

O'Driscoll anteromedial facet fractures of the coronoid are typically caused by a varus posteromedial rotational force. This mechanism usually disrupts the lateral collateral ligament (LCL) and causes varus instability, distinguishing it from the standard posterolateral rotatory instability (PLRI) mechanism.

Question 329

Topic: Elbow & Forearm

A 42-year-old female sustains a terrible triad injury of the elbow following a fall. During operative management, what is the generally accepted and most mechanically sound sequence of surgical reconstruction?

. Coronoid fixation, lateral ulnar collateral ligament repair, radial head reconstruction
. Radial head reconstruction, coronoid fixation, lateral ulnar collateral ligament repair
. Coronoid fixation, radial head reconstruction, lateral ulnar collateral ligament repair
. Lateral ulnar collateral ligament repair, radial head reconstruction, coronoid fixation
. Coronoid fixation, medial collateral ligament repair, radial head reconstruction

Correct Answer & Explanation

. Coronoid fixation, radial head reconstruction, lateral ulnar collateral ligament repair

Explanation

The standard inside-out surgical sequence for a terrible triad injury involves addressing the deep/medial structures first. Fixation proceeds sequentially with the coronoid (and anterior capsule), followed by the radial head (fixation or arthroplasty), and finally repair of the lateral ulnar collateral ligament (LUCL).

Question 330

Topic: Elbow & Forearm

A 6-year-old boy presents with an isolated anterior radial head dislocation without obvious fracture lines on standard radiographs. To prevent chronic radial head instability, which of the following occult injuries must be meticulously evaluated?

. Plastic deformation of the radius
. Plastic deformation of the ulna
. Distal radioulnar joint disruption
. Lateral ulnar collateral ligament tear
. Coronoid process avulsion

Correct Answer & Explanation

. Plastic deformation of the ulna

Explanation

An isolated radial head dislocation in a child should be treated as a Monteggia equivalent until proven otherwise. Plastic deformation (ulnar bow) of the ulna is the most common occult injury and must be addressed to allow anatomic reduction of the radial head.

Question 331

Topic: Elbow & Forearm

During surgery for a terrible triad injury, the radial head is found to have four highly comminuted articular fragments. Which of the following is the most appropriate management for the radial head to optimize elbow biomechanics and stability?

. Excision of the radial head alone
. Open reduction and internal fixation with a mini-fragment plate
. Radial head arthroplasty
. Excision and delayed radial head reconstruction
. Suture anchor repair of the osteochondral fragments

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

In a terrible triad injury, the radial head is a critical secondary stabilizer to valgus stress. When there are 3 or more fragments making rigid fixation impossible, radial head arthroplasty is indicated to prevent post-operative instability.

Question 332

Topic: Elbow & Forearm

A 35-year-old male sustains a Bado Type I Monteggia fracture. Following rigid internal fixation of the ulnar shaft with a compression plate, the radial head remains persistently anteriorly subluxated. What is the most appropriate next step in management?

. Perform a radial head excision
. Revise the ulnar fixation to restore anatomic length and bow
. Immobilize the arm in forced supination for 6 weeks
. Proceed to primary annular ligament reconstruction
. Perform a radial head arthroplasty

Correct Answer & Explanation

. Revise the ulnar fixation to restore anatomic length and bow

Explanation

In adult Monteggia fractures, persistent subluxation of the radial head after ulnar fixation is almost always due to malreduction of the ulna. The immediate next step is to take down the plate and revise the ulnar fixation to restore perfect length and the anatomic ulnar bow.

Question 333

Topic: Elbow & Forearm

In the setting of a terrible triad injury of the elbow, the lateral ulnar collateral ligament (LUCL) is almost universally disrupted. From which anatomical attachment site is the LUCL most commonly avulsed in this injury pattern?

. The radial head
. The supinator crest of the ulna
. The lateral epicondyle of the humerus
. The coronoid process
. The anterior band of the medial collateral ligament

Correct Answer & Explanation

. The lateral epicondyle of the humerus

Explanation

In terrible triad injuries, the lateral ulnar collateral ligament (LUCL) typically avulses from its humeral origin at the lateral epicondyle. Repair involves reattaching the ligament to the isometric point on the lateral epicondyle using suture anchors.

Question 334

Topic: 9. Shoulder and Elbow

During surgical reconstruction of a terrible triad injury, an oversized radial head prosthesis is inadvertently inserted, resulting in a prosthesis that is 4 mm too thick (overstuffed). Which of the following radiographic or clinical findings is the primary consequence of this technical error?

. Asymmetric widening of the medial ulnohumeral joint space
. Increased arc of elbow flexion
. Iatrogenic varus instability
. Posterior interosseous nerve palsy
. Attentuation of the annular ligament

Correct Answer & Explanation

. Asymmetric widening of the medial ulnohumeral joint space

Explanation

Overstuffing the radial joint space with a prosthesis that is too thick alters radiocapitellar tracking and forcefully hinges the medial joint open. This results in asymmetric widening of the medial ulnohumeral joint space, lateral elbow pain, and early capitellar wear.

Question 335

Topic: Elbow & Forearm

A 7-year-old boy presents with a missed Bado Type I Monteggia fracture-dislocation that occurred 6 months ago. The radial head remains anteriorly dislocated, and the ulnar fracture is malunited. What is the most appropriate and successful surgical management at this stage?

. Radial head excision to improve forearm rotation
. In situ annular ligament reconstruction without ulnar intervention
. Ulnar lengthening/angulation osteotomy with open reduction of the radial head
. Radial shortening osteotomy to decompress the radiocapitellar joint
. Observation and physical therapy until skeletal maturity

Correct Answer & Explanation

. Ulnar lengthening/angulation osteotomy with open reduction of the radial head

Explanation

The treatment of a chronic, missed pediatric Monteggia fracture requires an ulnar osteotomy to correct the angulation and restore length. This addresses the primary bone deformity, allowing for reduction of the radial head, often supplemented by annular ligament reconstruction.

Question 336

Topic: 9. Shoulder and Elbow

A 42-year-old female presents with an elbow fracture-dislocation consistent with a terrible triad injury. During surgical reconstruction, what is the generally accepted sequence of repair to best restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical protocol for terrible triad injuries involves first repairing the coronoid, followed by the radial head, and finally the lateral collateral ligament (LCL) complex. Medial collateral ligament (MCL) repair is usually reserved for persistent instability after the primary lateral and anterior structures are addressed.

Question 337

Topic: 9. Shoulder and Elbow

During the surgical management of a terrible triad elbow injury, the radial head has been replaced, the coronoid fixed, and the LCL repaired. Intraoperative fluoroscopy under valgus stress reveals 30 degrees of medial joint opening. What is the most appropriate next step?

. Application of a hinged external fixator
. Repair or reconstruction of the medial collateral ligament (MCL)
. Immobilization in a cast at 90 degrees of flexion for 4 weeks
. Revision of the radial head arthroplasty to a larger size
. Re-evaluating the LCL repair tension

Correct Answer & Explanation

. Repair or reconstruction of the medial collateral ligament (MCL)

Explanation

If significant valgus or extension instability persists after addressing the coronoid, radial head, and LCL, the MCL should be evaluated and repaired. Persistent gross instability is the primary indication for acute MCL repair in terrible triad injuries.

Question 338

Topic: 9. Shoulder and Elbow

A 42-year-old female falls from a ladder and sustains a terrible triad injury of the elbow. Which of the following best describes the classic mechanism and kinematics that result in this specific injury pattern?

. Axial load combined with varus force and forearm pronation
. Direct posterior blow to the flexed proximal ulna
. Axial load combined with a valgus force and forearm supination
. Hyperextension injury with forced radial deviation
. Traction injury with sudden extension and pronation

Correct Answer & Explanation

. Axial load combined with a valgus force and forearm supination

Explanation

The terrible triad of the elbow is primarily driven by a posterolateral rotatory instability (PLRI) mechanism. This typically involves a combination of an axial load, valgus force, and forearm supination as the patient falls onto an outstretched hand.

Question 339

Topic: Elbow & Forearm

When performing surgical reconstruction for a terrible triad injury of the elbow, what is the generally recommended, step-wise sequence to restore joint stability?

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

Correct Answer & Explanation

. Coronoid fixation, radial head fixation or replacement, lateral collateral ligament repair

Explanation

The standard surgical algorithm for a terrible triad injury follows a 'deep to superficial' or 'inside-out' approach. Reconstruction proceeds by first addressing the coronoid, then fixing or replacing the radial head, and finally repairing the lateral collateral ligament (LCL) complex.

Question 340

Topic: 9. Shoulder and Elbow

During surgery for a terrible triad injury, you have rigidly fixed the coronoid, replaced the comminuted radial head, and repaired the lateral collateral ligament to the lateral epicondyle. Intraoperatively, the elbow is stable in extension, but you note gross residual valgus instability at 30 degrees of flexion. What is the most appropriate next step in management?

. Apply a dynamic hinged external fixator
. Downsize the radial head prosthesis
. Release the common extensor origin
. Explore and repair the Medial Collateral Ligament (MCL)
. Cast the elbow in 90 degrees of flexion and pronation

Correct Answer & Explanation

. Explore and repair the Medial Collateral Ligament (MCL)

Explanation

In the surgical treatment of a terrible triad, the medial collateral ligament (MCL) is typically not addressed initially. However, if persistent gross instability (especially valgus) remains after the coronoid, radial head, and LCL have been restored, MCL repair is indicated.

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