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9. Shoulder and Elbow MCQs

Practice Set 26 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 501

Topic: Elbow & Forearm

A 45-year-old male undergoes an open release for lateral epicondylitis. Postoperatively, he reports a sensation of his elbow giving out when pushing himself out of a chair. Which structure was most likely iatrogenically injured during the procedure?

. Annular ligament
. Anterior bundle of the medial collateral ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament
. Interosseous membrane

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

Excessive posterior and distal dissection during lateral epicondyle release risks injury to the lateral ulnar collateral ligament (LUCL). This complication results in iatrogenic posterolateral rotatory instability (PLRI) of the elbow.

Question 502

Topic: 9. Shoulder and Elbow

A physical therapy protocol is prescribed for a patient with chronic tennis elbow. Which specific type of exercise has the strongest evidence for improving tendinopathy in this condition?

. Concentric wrist flexion
. Concentric wrist extension
. Eccentric wrist extension
. Isometric forearm pronation
. Eccentric forearm supination

Correct Answer & Explanation

. Eccentric wrist extension

Explanation

Eccentric strengthening exercises of the wrist extensors have been shown to stimulate collagen synthesis and organization. They provide superior clinical outcomes for lateral epicondylitis compared to concentric-only exercises.

Question 503

Topic: Elbow & Forearm

When an MRI is obtained to evaluate chronic, atypical lateral epicondylitis, what is the most characteristic imaging finding?

. T1 hyperintensity of the extensor digitorum communis
. T2 hyperintensity and thickening at the ECRB origin
. T2 hypointensity at the ECRL origin
. Significant fluid accumulation in the olecranon bursa
. Complete retraction of the brachioradialis

Correct Answer & Explanation

. T2 hyperintensity and thickening at the ECRB origin

Explanation

MRI in lateral epicondylitis typically demonstrates increased T2 signal intensity, tendon thickening, and occasionally partial-thickness tearing at the origin of the extensor carpi radialis brevis (ECRB).

Question 504

Topic: Elbow & Forearm

During an open surgical approach for recalcitrant lateral epicondylitis, the surgeon incises the extensor aponeurosis. Which structure must be mobilized and retracted anteriorly to expose the diseased ECRB?

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

Correct Answer & Explanation

. Extensor carpi radialis longus (ECRL)

Explanation

The ECRB origin lies deep to the ECRL. During an open approach, the ECRL tendon is typically incised and retracted anteriorly to expose the macroscopic grayish, friable tissue of the diseased ECRB for debridement.

Question 505

Topic: Elbow & Forearm

A patient experiences sharp pain at the lateral epicondyle when resisting extension of the middle finger with the elbow fully extended (Maudsley's test). This maneuver isolates stress primarily on which structures?

. ECRL and brachioradialis
. Extensor indicis proprius
. EDC and ECRB
. Flexor carpi radialis and pronator teres
. Supinator and anconeus

Correct Answer & Explanation

. Extensor indicis proprius

Explanation

Maudsley's test transmits tension through the extensor digitorum communis (EDC) to the lateral epicondyle. This indirectly places stress on the adjacent ECRB origin, reproducing pain in lateral epicondylitis.

Question 506

Topic: 9. Shoulder and Elbow

A patient with 6 months of tennis elbow asks about platelet-rich plasma (PRP) injections. What does current literature conclude regarding PRP compared to corticosteroid injections for this condition?

. Corticosteroids are statistically superior at 12 and 24 months.
. PRP is inferior to corticosteroids at all time points.
. PRP shows greater improvement in pain and function at 1 and 2 years.
. Both modalities have identical efficacy profiles at 2 years.
. PRP has an unacceptably high rate of iatrogenic tendon rupture.

Correct Answer & Explanation

. PRP shows greater improvement in pain and function at 1 and 2 years.

Explanation

Studies comparing PRP and corticosteroid injections for lateral epicondylitis indicate that while steroids may provide better initial relief, PRP yields significantly greater improvements in long-term pain and functional scores at 1 and 2 years.

Question 507

Topic: Elbow & Forearm
Tendinosis in lateral epicondylitis represents a failed healing response. Which extracellular matrix alteration is characteristic of this pathology?
. Decreased ground substance
. Increased proportion of Type I collagen
. Increased proportion of Type III collagen
. Complete absence of resident fibroblasts
. Dense infiltration of polymorphonuclear neutrophils

Correct Answer & Explanation

. Increased proportion of Type III collagen

Explanation

Angiofibroblastic tendinosis features an abortive healing process resulting in disorganized tissue. It is characterized by an increased proportion of immature, structurally weaker Type III collagen relative to normal Type I collagen.

Question 508

Topic: Elbow & Forearm

What is the primary biomechanical rationale for utilizing a counterforce brace (forearm strap) in the conservative management of lateral epicondylitis?

. It completely immobilizes the wrist joint to prevent extension.
. It prevents forearm supination during heavy lifting.
. It disperses muscular tensile forces away from the epicondylar origin.
. It applies direct pressure to compress the radial nerve.
. It heals microscopic tendon tears via targeted heat retention.

Correct Answer & Explanation

. It disperses muscular tensile forces away from the epicondylar origin.

Explanation

A counterforce brace compresses the extensor muscle belly distal to the elbow. This essentially creates a new functional origin, dissipating tensile forces away from the degenerative ECRB insertion at the lateral epicondyle.

Question 509

Topic: Elbow & Forearm

When performing an arthroscopic release of the ECRB for lateral epicondylitis, the capsulotomy should be performed carefully to avoid extending too far posterior or distal to protect which structure?

. Ulnar nerve
. Radial nerve
. Posterior interosseous nerve
. Lateral ulnar collateral ligament
. Median nerve

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

During arthroscopic ECRB release, the capsulotomy is performed anterior to the lateral epicondyle and radiocapitellar joint line. Extending the release too far posterior or distal endangers the lateral ulnar collateral ligament (LUCL).

Question 510

Topic: Elbow & Forearm

In recreational tennis players, lateral epicondylitis is most commonly associated with which biomechanical fault?

. Late forehand stroke with excessive top-spin
. Serving with excessive forearm pronation
. Two-handed backhand with rigid footwork
. Single-handed backhand with leading wrist extension
. Overhead smash with a flexed wrist

Correct Answer & Explanation

. Single-handed backhand with leading wrist extension

Explanation

A one-handed backhand executed with poor technique, specifically leading with a rigid extended wrist rather than generating kinetic power from the trunk and legs, places maximal eccentric stress on the ECRB.

Question 511

Topic: Elbow & Forearm

A 45-year-old presents with a 3-month history of localized lateral elbow pain with gripping. The physical examination is classic for lateral epicondylitis without sensory deficits. What is the most appropriate next step in management?

. MRI of the elbow without contrast
. Ultrasound of the common extensor origin
. Electromyography (EMG) of the upper extremity
. Physical therapy, bracing, and NSAIDs
. Immediate surgical debridement of the ECRB

Correct Answer & Explanation

. Physical therapy, bracing, and NSAIDs

Explanation

Lateral epicondylitis is primarily a clinical diagnosis. In a classic presentation without red flags or suspicion of compressive neuropathy, advanced imaging is not required, and initial management consists of conservative measures.

Question 512

Topic: Elbow & Forearm

When using botulinum toxin A injections as a treatment for refractory lateral epicondylitis, what is the most common clinically significant adverse effect?

. Permanent complete radial nerve palsy
. Transient paresis of digit extension
. Permanent skin depigmentation
. Severe localized fat atrophy
. Spontaneous tendon rupture

Correct Answer & Explanation

. Transient paresis of digit extension

Explanation

Botulinum toxin injections can effectively relieve pain but commonly cause temporary diffusion into adjacent extensor muscles. This leads to a transient, mild paresis of finger extension that typically resolves over a few months.

Question 513

Topic: Elbow & Forearm

Following surgical release of the ECRB for refractory lateral epicondylitis, which patient factor is most strongly associated with inferior subjective clinical outcomes and delayed return to function?

. Female sex
. Age greater than 50 years
. Active worker's compensation status
. Dominant arm involvement
. Preoperative duration of symptoms of 6 months

Correct Answer & Explanation

. Active worker's compensation status

Explanation

Worker's compensation claims and active litigation are well-documented independent risk factors for poorer subjective pain scores and delayed return to work following surgical intervention for lateral epicondylitis.

Question 514

Topic: 9. Shoulder and Elbow

Mill's test is a provocative maneuver used to evaluate for lateral epicondylitis. Which of the following accurately describes the performance of this test?

. Resisted wrist extension with the elbow flexed at 90 degrees
. Passive pronation of the forearm, flexion of the wrist, and extension of the elbow
. Resisted supination with the elbow fully extended
. Tapping directly over the radial nerve at the radial neck
. Applying a valgus stress at 30 degrees of elbow flexion

Correct Answer & Explanation

. Passive pronation of the forearm, flexion of the wrist, and extension of the elbow

Explanation

Mill's test involves passive stretching of the extensor origin by fully extending the elbow, pronating the forearm, and flexing the wrist. A positive test reproduces pain at the lateral epicondyle.

Question 515

Topic: 9. Shoulder and Elbow

Ultrasound-guided percutaneous needle tenotomy (barbotage) is utilized for chronic tennis elbow. What is the primary biological goal of this procedure?

. Complete mechanical detachment of the ECRB from the epicondyle
. Aspiration of symptomatic calcium hydroxyapatite deposits
. Conversion of a chronic avascular tendinosis into an acute inflammatory healing response
. Selective chemical denervation of the posterior interosseous nerve
. Mechanical ablation of the radial nerve articular branches

Correct Answer & Explanation

. Conversion of a chronic avascular tendinosis into an acute inflammatory healing response

Explanation

Percutaneous needle tenotomy repeatedly fenestrates the degenerative tendon to break up scar tissue and induce localized bleeding. This biologically converts chronic, avascular tendinosis into an acute, healing inflammatory cascade.

Question 516

Topic: Elbow & Forearm

Histological evaluation of surgical specimens from patients with chronic lateral epicondylitis most classically demonstrates which of the following?

. Acute inflammatory infiltrates with neutrophils
. Angiofibroblastic tendinosis with disorganized collagen
. Granulomatous inflammation with giant cells
. Chondroid metaplasia with calcification
. Extensive necrosis with ghost cells

Correct Answer & Explanation

. Angiofibroblastic tendinosis with disorganized collagen

Explanation

Lateral epicondylitis is primarily a degenerative tendinosis, not an acute inflammatory process. Histology typically shows angiofibroblastic hyperplasia, disorganized collagen, and an absence of acute inflammatory cells.

Question 517

Topic: Elbow & Forearm

During an open surgical release for recalcitrant lateral epicondylitis, the surgeon isolates the primary pathologic tendon. What is the normal anatomic position of this specific structure relative to the lateral epicondyle and adjacent tendons?

. Deep to the extensor carpi radialis longus (ECRL) and anterior to the extensor digitorum communis (EDC)
. Superficial to the ECRL and posterior to the EDC
. Deep to the supinator and anterior to the brachioradialis
. Superficial to the anconeus and posterior to the extensor carpi ulnaris (ECU)
. Intra-articular origin on the radial collateral ligament

Correct Answer & Explanation

. Deep to the extensor carpi radialis longus (ECRL) and anterior to the extensor digitorum communis (EDC)

Explanation

The primary tendon involved in lateral epicondylitis is the extensor carpi radialis brevis (ECRB). The ECRB originates from the lateral epicondyle deep to the ECRL and anterior to the EDC.

Question 518

Topic: Elbow & Forearm

A 45-year-old recreational athlete is diagnosed with lateral epicondylitis. In discussing non-operative treatment options, what does current high-level evidence indicate regarding the use of corticosteroid injections compared to physical therapy at 1-year follow-up?

. Corticosteroid injections provide superior long-term pain relief and lower recurrence rates.
. Corticosteroid injections demonstrate a higher recurrence rate and worse outcomes at 1 year.
. Physical therapy is inferior to corticosteroid injections at both 6 weeks and 1 year.
. Watchful waiting has the highest rate of progression to surgical intervention.
. Corticosteroid injections combined with NSAIDs show synergistic long-term efficacy.

Correct Answer & Explanation

. Corticosteroid injections demonstrate a higher recurrence rate and worse outcomes at 1 year.

Explanation

Multiple studies demonstrate that while corticosteroid injections may provide short-term relief, they are associated with higher recurrence rates and worse outcomes at 1 year compared to physical therapy or watchful waiting.

Question 519

Topic: Elbow & Forearm

A 50-year-old man undergoes an open ECRB release for chronic lateral epicondylitis. Postoperatively, he complains of mechanical clicking and a feeling of the elbow "giving way" when pushing up from a chair. Which structure was most likely inadvertently injured during the surgical procedure?

. Annular ligament
. Radial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Interosseous membrane
. Extensor carpi ulnaris origin

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

Iatrogenic injury to the LUCL during an overly aggressive posterior/inferior ECRB release can lead to posterolateral rotatory instability (PLRI). This manifests as clicking or giving way during activities that load the elbow in supination, axial loading, and valgus.

Question 520

Topic: 9. Shoulder and Elbow

Which of the following elbow positions and wrist movements places maximal tension on the extensor carpi radialis brevis (ECRB) origin, thereby exacerbating the symptoms of lateral epicondylitis during a provocation test?

. Elbow flexion with wrist extension and forearm supination
. Elbow extension with wrist flexion and forearm pronation
. Elbow flexion with wrist flexion and forearm pronation
. Elbow extension with wrist extension and forearm pronation
. Elbow extension with wrist flexion and forearm supination

Correct Answer & Explanation

. Elbow extension with wrist flexion and forearm pronation

Explanation

Mill's test places maximal tension on the ECRB by passively extending the elbow, pronating the forearm, and fully flexing the wrist. This stretch reliably reproduces pain at the lateral epicondyle in affected patients.

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