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9. Shoulder and Elbow MCQs

Practice Set 27 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 521

Topic: Elbow & Forearm

During an arthroscopic release of the ECRB for recalcitrant lateral epicondylitis, the surgeon identifies the pathologic tissue. The ECRB origin is typically visualized arthroscopically just anterior and proximal to the midpoint of which of the following structures?

. Coronoid process
. Radiocapitellar joint line
. Lateral ulnar collateral ligament
. Annular ligament
. Biceps tuberosity

Correct Answer & Explanation

. Radiocapitellar joint line

Explanation

In arthroscopic management of lateral epicondylitis, the ECRB origin is located just proximal and anterior to the radiocapitellar joint line. Careful resection in this "safe zone" avoids violating the underlying LUCL.

Question 522

Topic: 9. Shoulder and Elbow

In a patient suspected of having lateral epicondylitis, the examiner resists extension of the third digit with the elbow in extension. This maneuver elicits severe pain at the lateral epicondyle. This clinical test primarily targets which of the following muscles?

. Extensor digiti minimi
. Extensor carpi radialis longus
. Extensor digitorum communis (EDC)
. Extensor indicis proprius
. Supinator

Correct Answer & Explanation

. Extensor digitorum communis (EDC)

Explanation

Maudsley's test involves resisted extension of the middle finger. It selectively places stress on the extensor digitorum communis (EDC) muscle, which shares a common origin at the lateral epicondyle and is often co-involved in the pathology.

Question 523

Topic: Elbow & Forearm

A patient elects to undergo a leukocyte-rich platelet-rich plasma (PRP) injection for chronic lateral epicondylitis. The proposed mechanism of action for PRP in this condition primarily relies on the delivery of high concentrations of which of the following?

. Matrix metalloproteinases
. Transforming growth factor-beta (TGF-b) and platelet-derived growth factor (PDGF)
. Cortisol and dexamethasone
. Hyaluronic acid
. Synoviocytes and chondrocytes

Correct Answer & Explanation

. Transforming growth factor-beta (TGF-b) and platelet-derived growth factor (PDGF)

Explanation

PRP delivers supraphysiologic concentrations of alpha granules containing growth factors like TGF-b, PDGF, and VEGF. These factors are believed to stimulate cellular proliferation, angiogenesis, and collagen synthesis in recalcitrant tendinopathy.

Question 524

Topic: Elbow & Forearm

A 52-year-old male has failed 8 months of non-operative management for lateral epicondylitis, including bracing, NSAIDs, and structured eccentric therapy. MRI reveals a high-grade partial tear of the ECRB origin with surrounding peritendinous edema, but intact collateral ligaments. What is the most appropriate next step in management?

. Ulnar collateral ligament reconstruction
. Percutaneous tenotomy or surgical debridement of the ECRB origin
. Radial head excision
. Extensor carpi ulnaris (ECU) lengthening
. Continued physical therapy for an additional 12 months

Correct Answer & Explanation

. Percutaneous tenotomy or surgical debridement of the ECRB origin

Explanation

Following 6-12 months of failed conservative management with MRI evidence of significant ECRB pathology (such as a high-grade tear or severe tendinosis), surgical intervention via ECRB debridement or release is indicated.

Question 525

Topic: Elbow & Forearm

During arthroscopic evaluation prior to ECRB release for chronic lateral epicondylitis, what is the most commonly identified concurrent intra-articular pathology?

. Medial epicondyle apophysitis
. Loose bodies or radiocapitellar chondromalacia
. Ulnohumeral osteoarthritis
. Radial head fracture nonunion
. Coronoid osteophytes

Correct Answer & Explanation

. Loose bodies or radiocapitellar chondromalacia

Explanation

Arthroscopic management allows for thorough inspection of the radiocapitellar joint. Radiocapitellar chondromalacia, synovial plicae, and loose bodies are frequently identified and can be addressed concurrently with the ECRB release.

Question 526

Topic: Elbow & Forearm

A patient is prescribed a counterforce brace for the management of acute lateral epicondylitis. To maximize its biomechanical effectiveness without causing nerve compression, where should the counterforce strap be optimally positioned?

. Directly over the lateral epicondyle
. 10 cm distal to the lateral epicondyle over the muscle bellies
. 1-2 cm distal to the lateral epicondyle over the extensor muscle mass
. Proximal to the lateral epicondyle over the distal humerus
. Tightly around the wrist to limit wrist extension

Correct Answer & Explanation

. 1-2 cm distal to the lateral epicondyle over the extensor muscle mass

Explanation

A counterforce brace is optimally placed 1-2 cm distal to the lateral epicondyle. It compresses the extensor wad to limit maximal muscular expansion, thereby dispersing tensile forces away from the pathologic ECRB origin.

Question 527

Topic: 9. Shoulder and Elbow

In patients presenting with lateral epicondylitis, which of the following is considered a negative prognostic factor that significantly increases the likelihood of failing conservative management?

. Acute onset of symptoms related to a specific traumatic injury
. Female gender with manual labor occupations
. Age less than 30 years
. Presence of a concurrent focal nerve entrapment such as cubital tunnel syndrome
. Central sensitization and co-existing neck/shoulder pain

Correct Answer & Explanation

. Central sensitization and co-existing neck/shoulder pain

Explanation

Patients with central sensitization, co-existing neck or shoulder pain (e.g., cervical radiculopathy), and those involved in repetitive heavy manual labor have higher rates of recalcitrant lateral epicondylitis and poorer responses to non-operative care.

Question 528

Topic: 9. Shoulder and Elbow

A 14-year-old elite gymnast presents with lateral elbow pain exacerbated by weight-bearing activities on her hands. Examination reveals a lack of 15 degrees of terminal extension and lateral elbow tenderness, but no pain with resisted wrist extension. What is the most likely diagnosis?

. Lateral epicondylitis
. Radial tunnel syndrome
. Osteochondritis dissecans of the capitellum
. Panner's disease
. Little Leaguer's elbow

Correct Answer & Explanation

. Osteochondritis dissecans of the capitellum

Explanation

In an adolescent athlete presenting with lateral elbow pain during weight-bearing, loss of terminal extension, and no pain on resisted wrist extension, capitellar osteochondritis dissecans (OCD) is the most likely diagnosis. True lateral epicondylitis is rare in this age group.

Question 529

Topic: 9. Shoulder and Elbow

During an extended open approach for lateral epicondyle release and extensor wad debridement, the surgeon must be careful to avoid injuring the posterior interosseous nerve (PIN). The PIN typically enters the supinator muscle beneath which anatomical structure?

. Arcade of Struthers
. Arcade of Frohse
. Lacertus fibrosus
. Ligament of Struthers
. Mobile wad of Henry

Correct Answer & Explanation

. Arcade of Frohse

Explanation

The PIN travels distal to the radiocapitellar joint and enters the supinator muscle beneath a fibrous arch known as the Arcade of Frohse. It must be protected during extensive distal exposures of the lateral elbow.

Question 530

Topic: Elbow & Forearm

Physical therapy emphasizing eccentric strengthening is a cornerstone of non-operative management for lateral epicondylitis. What is the primary theoretical benefit of eccentric exercises in managing this tendinopathy?

. They selectively cause hypertrophy of type IIx muscle fibers.
. They completely immobilize the musculotendinous junction to prevent micro-tears.
. They promote collagen fiber cross-linking and stimulate tenocyte mechanotransduction.
. They reduce local blood flow to decrease chronic inflammation.
. They induce an acute inflammatory response that resorbs calcifications.

Correct Answer & Explanation

. They promote collagen fiber cross-linking and stimulate tenocyte mechanotransduction.

Explanation

Eccentric exercises are thought to stimulate mechanotransduction in tenocytes. This process promotes the production and organized cross-linking of type I collagen, gradually remodeling the disorganized angiofibroblastic matrix.

Question 531

Topic: 9. Shoulder and Elbow

A 38-year-old woman receives her third corticosteroid injection for lateral epicondylitis within a 6-month period. She returns 4 weeks later with a new cosmetic complaint over the lateral elbow. What is the most likely examination finding?

. Hypertrophic keloid scar formation
. Subcutaneous fat atrophy and hypopigmentation
. Dense hyperpigmentation and localized hair growth
. Superficial venous thrombosis
. Formation of a painful rheumatoid nodule

Correct Answer & Explanation

. Subcutaneous fat atrophy and hypopigmentation

Explanation

Subcutaneous fat atrophy and skin hypopigmentation are well-documented, potentially permanent complications of superficial or repeated local corticosteroid injections around the lateral epicondyle.

Question 532

Topic: Elbow & Forearm

During the Nirschl surgical technique for lateral epicondylitis, after incising the extensor aponeurosis, the surgeon excises the pathological ECRB origin. To stimulate a healing response, which adjunctive step is routinely performed at the anatomic footprint?

. Drilling or decortication of the lateral epicondyle
. Implantation of a suture anchor for ECRB reattachment
. Resection of the entire lateral epicondyle
. Osteotomy of the radial head
. Excision of the annular ligament

Correct Answer & Explanation

. Drilling or decortication of the lateral epicondyle

Explanation

In the classic Nirschl technique, after excising the degenerative angiofibroblastic tissue, the underlying lateral epicondyle is typically decorticated or drilled. This creates a bleeding bone bed to stimulate a vascular healing response.

Question 533

Topic: Elbow & Forearm

What is the classic histologic finding associated with chronic lateral epicondylitis?

. Acute inflammatory infiltrate with dense neutrophils
. Angiofibroblastic tendinosis with disorganized collagen
. Granulomatous inflammation with multinucleated giant cells
. Chondroid metaplasia with diffuse calcification
. Fibrinoid necrosis of the local microvasculature

Correct Answer & Explanation

. Angiofibroblastic tendinosis with disorganized collagen

Explanation

Chronic lateral epicondylitis is a degenerative process rather than an acute inflammatory one. Histology classically demonstrates angiofibroblastic hyperplasia, disorganized collagen fibers, and an absence of acute inflammatory cells.

Question 534

Topic: Elbow & Forearm

During surgical release for lateral epicondylitis, the primary pathological tissue is typically found at the origin of which specific muscle?

. Extensor carpi radialis longus
. Extensor digitorum communis
. Extensor carpi radialis brevis
. Brachioradialis
. Extensor carpi ulnaris

Correct Answer & Explanation

. Extensor carpi radialis brevis

Explanation

The extensor carpi radialis brevis (ECRB) origin is the primary site of pathology in lateral epicondylitis. It attaches to the lateral epicondyle just distal to the ECRL.

Question 535

Topic: Elbow & Forearm

A patient develops a positive pivot-shift test of the elbow and complains of recurrent clicking and giving way 6 months after an open release for lateral epicondylitis. Which structure was most likely inadvertently injured during surgery?

. Annular ligament
. Lateral ulnar collateral ligament
. Radial collateral ligament
. Interosseous membrane
. Quadrate ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The lateral ulnar collateral ligament (LUCL) lies deep and slightly posterior to the ECRB origin. Iatrogenic injury during deep dissection for lateral epicondyle release can lead to posterolateral rotatory instability (PLRI).

Question 536

Topic: Elbow & Forearm

Which of the following physical examination maneuvers involves resisted extension of the middle finger to specifically isolate the extensor carpi radialis brevis and reproduce lateral epicondylitis pain?

. Cozen's test
. Mill's test
. Maudsley's test
. Chair test
. Hook test

Correct Answer & Explanation

. Maudsley's test

Explanation

Maudsley's test consists of resisted extension of the middle finger with the elbow extended. This maneuver places stress directly on the extensor digitorum communis and the ECRB, reliably reproducing lateral elbow pain.

Question 537

Topic: Elbow & Forearm

A 42-year-old mechanic presents with chronic lateral elbow and proximal forearm pain. Which finding is most indicative of radial tunnel syndrome rather than lateral epicondylitis?

. Maximal tenderness directly on the lateral epicondyle
. Pain reproduced by resisted wrist extension
. Tenderness 4 to 5 cm distal to the lateral epicondyle over the mobile wad
. Pain during passive wrist flexion with the elbow extended
. Complete resolution of symptoms following a local corticosteroid injection at the ECRB origin

Correct Answer & Explanation

. Tenderness 4 to 5 cm distal to the lateral epicondyle over the mobile wad

Explanation

Radial tunnel syndrome is characterized by maximal tenderness over the radial nerve approximately 4 to 5 cm distal to the lateral epicondyle. In contrast, pain directly over the epicondyle is the hallmark of lateral epicondylitis.

Question 538

Topic: Elbow & Forearm

Which of the following is the most accurate statement regarding the use of corticosteroid injections for the treatment of lateral epicondylitis based on current high-level evidence?

. They provide superior long-term outcomes at 1 year compared to physical therapy.
. They are associated with a higher rate of recurrence and worse long-term outcomes than physical therapy or observation.
. They promote tendon healing by reversing angiofibroblastic hyperplasia.
. They are indicated only after 6 months of failed conservative management.
. They are equally effective as platelet-rich plasma (PRP) at 52 weeks.

Correct Answer & Explanation

. They are associated with a higher rate of recurrence and worse long-term outcomes than physical therapy or observation.

Explanation

High-level evidence demonstrates corticosteroid injections provide short-term pain relief but result in higher recurrence rates and worse outcomes at 1 year compared to physical therapy or watchful waiting. They are believed to delay intrinsic tendon healing.

Question 539

Topic: Elbow & Forearm

A 45-year-old male with refractory lateral elbow pain undergoes an MRI. Which MRI finding is most consistent with severe, chronic lateral epicondylitis?

. Bone marrow edema isolated to the capitellum
. Thickening and increased T2 signal intensity at the common extensor origin
. Complete tear of the lateral ulnar collateral ligament with a pristine common extensor
. Loculated fluid within the olecranon bursa
. Hypertrophy and increased signal of the anconeus muscle

Correct Answer & Explanation

. Thickening and increased T2 signal intensity at the common extensor origin

Explanation

On MRI, lateral epicondylitis is characterized by thickening and increased T2 signal intensity at the common extensor origin, specifically the ECRB. These findings correspond to myxoid degeneration and angiofibroblastic tendinosis.

Question 540

Topic: Elbow & Forearm

During an open approach for debridement of the ECRB in lateral epicondylitis, care must be taken to protect the posterior interosseous nerve (PIN). The PIN typically passes between the two heads of which muscle?

. Pronator teres
. Flexor carpi ulnaris
. Extensor carpi radialis brevis
. Supinator
. Extensor digitorum communis

Correct Answer & Explanation

. Supinator

Explanation

The posterior interosseous nerve (PIN) passes under the arcade of Frohse and between the superficial and deep heads of the supinator muscle. It is at risk during extensive deep dissection in the proximal forearm.

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