Menu

9. Shoulder and Elbow MCQs

Practice Set 29 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 561

Topic: Elbow & Forearm

A 42-year-old male with an 18-month history of lateral epicondylitis presents for surgical consultation. He has failed physical therapy, bracing, and a PRP injection. He undergoes an isolated arthroscopic ECRB release. Which of the following best describes the expected postoperative recovery and outcome?

. Immediate return to heavy lifting within 2 weeks with a near 100% success rate
. Requirement for 6 weeks of strict cast immobilization to allow tendon healing
. Gradual return to activities over 3-6 months with an expected success rate of approximately 80%
. Permanent 30% reduction in grip strength is a guaranteed outcome of the release
. High likelihood (>50%) of requiring revision surgery within 2 years due to recurrent tendinosis

Correct Answer & Explanation

. Gradual return to activities over 3-6 months with an expected success rate of approximately 80%

Explanation

Operative treatment for lateral epicondylitis via open or arthroscopic ECRB release yields a good to excellent outcome in 70-85% of properly selected patients. Recovery is progressive, with return to unrestricted heavy activities typically taking 3 to 6 months.

Question 562

Topic: 9. Shoulder and Elbow

A 30-year-old athlete undergoes ORIF for a displaced radial shaft fracture. Postoperatively, the surgeon initiates a rehabilitation protocol. In the early mobilization phase (Weeks 0-2), assuming rigid internal fixation, which of the following activities is the primary focus and which is strictly prohibited?

. A. Primary focus: Progressive strengthening exercises; Strictly prohibited: Gentle, pain-free pronation and supination.
. B. Primary focus: Passive stretching of the forearm musculature; Strictly prohibited: Digital range of motion.
. C. Primary focus: Digital range of motion and gentle, pain-free pronation/supination; Strictly prohibited: Weight-bearing and lifting.
. D. Primary focus: Full, unrestricted weight-bearing; Strictly prohibited: Elbow flexion and extension.
. E. Primary focus: Aggressive manipulation to regain lost motion; Strictly prohibited: Isometric exercises.

Correct Answer & Explanation

. C. Primary focus: Digital range of motion and gentle, pain-free pronation/supination; Strictly prohibited: Weight-bearing and lifting.

Explanation

Correct Answer: CThe teaching case describes Phase I (Early Mobilization, Weeks 0-2) of the rehabilitation protocol: 'Assuming rigid internal fixation has been achieved, early active and active-assisted range of motion (ROM) is initiated within the first few days postoperatively. The primary focus is on digital ROM to prevent tendon adhesions and reduce edema. Gentle, pain-free pronation and supination exercises are commenced, along with elbow flexion and extension. Weight-bearing and lifting are strictly prohibited.'Options A, B, D, and E describe activities that are either incorrect for the early phase (e.g., progressive strengthening, aggressive manipulation, full weight-bearing) or incorrectly prohibited (e.g., digital ROM, elbow flexion/extension).

Question 563

Topic: Elbow & Forearm

A 45-year-old female presents with a comminuted radial head fracture, acute wrist pain, and tenderness along the forearm interosseous membrane following a fall on an outstretched hand. Which of the following treatments is contraindicated in this patient?

. Radial head excision alone
. Radial head arthroplasty
. Open reduction internal fixation of the radial head
. Ulnocarpal shortening osteotomy
. Pinning of the distal radioulnar joint

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

This presentation is classic for an Essex-Lopresti injury (longitudinal radioulnar dissociation). Excision of the radial head without replacement removes the primary remaining stabilizer against proximal radial migration, inevitably leading to severe ulnocarpal impaction.

Question 564

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow, what is the generally accepted and most biomechanically sound sequence of repair?

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

Correct Answer & Explanation

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

Explanation

The standard deep-to-superficial surgical sequence for a terrible triad injury is fixation of the coronoid fracture first, followed by repair or replacement of the radial head, and finally repair of the lateral collateral ligament (LCL) complex.

Question 565

Topic: 9. Shoulder and Elbow

A 38-year-old male falls from a height and sustains a fracture of the anteromedial facet of the coronoid process. If left untreated, this specific fracture pattern most predictably leads to which of the following instability patterns?

. Valgus posterolateral rotatory instability
. Varus posteromedial rotatory instability
. Axial radioulnar dissociation
. Isolated anterior elbow subluxation
. Posterior translation of the radius with intact ulna

Correct Answer & Explanation

. Varus posteromedial rotatory instability

Explanation

Anteromedial facet coronoid fractures are pathognomonic for varus posteromedial rotatory instability (VPMRI) of the elbow. This injury typically involves loss of the anteromedial facet support along with an avulsion of the lateral collateral ligament (LCL) from the lateral epicondyle.

Question 566

Topic: Elbow & Forearm

A 25-year-old sustains a highly comminuted Essex-Lopresti injury. The radial head is deemed unreconstructible. What is the most appropriate management to prevent proximal migration of the radius?

. Radial head excision alone
. Metallic radial head arthroplasty
. Radial head excision and K-wire pinning of the DRUJ
. Silicone radial head replacement
. Ulnar shortening osteotomy

Correct Answer & Explanation

. Metallic radial head arthroplasty

Explanation

Essex-Lopresti injuries involve a radial head fracture, interosseous membrane tear, and DRUJ disruption. A metallic radial head arthroplasty is required to restore the lateral column and prevent proximal radial migration.

Question 567

Topic: Elbow & Forearm

In the surgical treatment of a Dubberley Type IV capitellum fracture, which surgical approach provides optimal visualization of the capitellum, lateral trochlea, and the posterior aspect of the lateral column?

. Extended lateral (Kocher) approach
. Medial over-the-top approach (Hotchkiss)
. Posterior approach with olecranon osteotomy
. Anterior approach (Henry)
. Boyd approach

Correct Answer & Explanation

. Extended lateral (Kocher) approach

Explanation

The extended lateral (Kocher) approach utilizes the internervous plane between the extensor carpi ulnaris and anconeus, providing excellent exposure of the capitellum, lateral trochlea, and posterior lateral column for rigid fixation.

Question 568

Topic: Elbow & Forearm

A patient presents with a Type I Monteggia fracture-dislocation. Following anatomic open reduction and internal fixation of the ulna, the radial head remains subluxated. What is the most common anatomical structure blocking the reduction of the radial head?

. Interposed annular ligament
. Osteochondral loose body from the capitellum
. Interposed radial nerve
. Inverted anterior joint capsule
. Biceps tendon entrapment

Correct Answer & Explanation

. Interposed annular ligament

Explanation

The annular ligament is the most common structure to become interposed and physically block the reduction of the radial head in Monteggia fracture-dislocations even after ulnar length has been anatomically restored.

Question 569

Topic: Elbow & Forearm

A 38-year-old female presents after a fall on an outstretched hand. Radiographs demonstrate a coronal shear fracture of the distal humerus. The lateral radiograph displays a 'double arc' sign. Based on this radiographic finding, which of the following anatomical structures are involved?

. The capitellum only, with subchondral bone (Hahn-Steinthal)
. The articular cartilage of the capitellum only (Kocher-Lorenz)
. The capitellum and the lateral ridge of the trochlea (McKee modification)
. The capitellum and the lateral epicondyle
. The trochlea and the medial epicondyle

Correct Answer & Explanation

. The capitellum and the lateral ridge of the trochlea (McKee modification)

Explanation

The 'double arc' sign on a lateral radiograph is pathognomonic for a Type IV capitellum fracture (McKee modification). It indicates extension of the coronal shear fracture into the trochlea.

Question 570

Topic: Elbow & Forearm

A 24-year-old male sustained a highly displaced midshaft fracture of the radius. The surgeon elects to use the dorsal Thompson approach. During the deep dissection to expose the proximal half of the radius, the intermuscular interval lies between which of the following muscle bellies?

. Brachioradialis and Flexor Carpi Radialis
. Extensor Carpi Radialis Longus and Brachioradialis
. Extensor Carpi Radialis Brevis and Extensor Digitorum Communis
. Extensor Digitorum Communis and Extensor Carpi Ulnaris
. Supinator and Pronator Teres

Correct Answer & Explanation

. Extensor Carpi Radialis Brevis and Extensor Digitorum Communis

Explanation

The superficial interval of the Thompson approach to the dorsal radius is between the Extensor Carpi Radialis Brevis (ECRB) and the Extensor Digitorum Communis (EDC). The deep dissection requires splitting or elevating the supinator.

Question 571

Topic: Elbow & Forearm

A 42-year-old woman falls from a height and sustains a severely comminuted, unfixable radial head fracture along with acute, severe wrist pain. Clinical exam reveals gross instability of the distal radioulnar joint (DRUJ). Which of the following is the most appropriate management of the proximal injury to prevent chronic disability?

. Radial head excision alone
. Radial head excision with prolonged long-arm casting
. Radial head arthroplasty
. Silicone radial head replacement
. Closed reduction and percutaneous pinning of the radiocapitellar joint

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

This patient has an Essex-Lopresti injury (radial head fracture, interosseous membrane tear, DRUJ dissociation). Radial head arthroplasty (metallic) is mandatory to restore the longitudinal column of the forearm and prevent proximal migration of the radius.

Question 572

Topic: Elbow & Forearm

Restoration of the forearm's axis of rotation is critical during ORIF of both-bone forearm fractures. Anatomically and biomechanically, the normal axis of forearm pronation and supination passes through which of the following landmarks?

. Center of the radial head proximally to the radial styloid distally
. Lateral epicondyle proximally to the ulnar styloid distally
. Center of the radial head proximally to the fovea of the ulnar head distally
. Center of the olecranon proximally to the center of the distal radius distally
. Coronoid process proximally to the distal radioulnar joint volar ligaments distally

Correct Answer & Explanation

. Center of the radial head proximally to the fovea of the ulnar head distally

Explanation

The longitudinal axis of rotation of the forearm runs obliquely from the center of the radial head proximally to the center of the ulnar head (fovea) distally.

Question 573

Topic: Elbow & Forearm

A 31-year-old female presents with a 'terrible triad' injury of the elbow. Surgical management is planned. According to standard treatment algorithms for this injury pattern, what is the most widely accepted sequence of reconstruction to restore elbow stability?

. Lateral collateral ligament (LCL) repair, followed by coronoid fixation, then radial head fixation
. Radial head fixation, followed by LCL repair, then coronoid fixation
. Coronoid fixation, followed by LCL repair, then radial head fixation
. Coronoid fixation/replacement, followed by radial head fixation/replacement, then LCL repair
. MCL repair, followed by radial head replacement, then coronoid fixation

Correct Answer & Explanation

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

Explanation

The standard sequence of reconstruction for a terrible triad injury proceeds from deep to superficial: fixation or replacement of the coronoid first, followed by the radial head, and finally repair of the lateral collateral ligament (LCL) complex.

Question 574

Topic: Elbow & Forearm

A 42-year-old female presents with a Bado Type I Monteggia fracture-dislocation. She undergoes anatomic rigid plate fixation of the ulnar shaft, but intraoperatively the radial head remains anteriorly dislocated. What is the most appropriate next step in management?

. Closed reduction and pinning of the radiocapitellar joint
. Radial head excision
. Open reduction of the radial head and annular ligament repair
. Loosen the ulnar plate and reassess ulnar reduction and length
. Perform a corrective osteotomy of the proximal radius

Correct Answer & Explanation

. Loosen the ulnar plate and reassess ulnar reduction and length

Explanation

In a Monteggia fracture, the radial head typically reduces spontaneously once the ulna is anatomically restored in length and alignment. If the radial head remains dislocated, the surgeon must suspect ulnar malreduction and reassess the ulnar fixation before attempting open reduction of the radial head.

Question 575

Topic: Elbow & Forearm

During ORIF of a middle-third diaphyseal fracture of the radius using a dorsal (Thompson) approach, the surgeon must identify and protect the posterior interosseous nerve (PIN). The PIN typically exits the supinator muscle and runs distally between which two muscle bellies in the proximal forearm?

. Brachioradialis and ECRL
. ECRB and EDC
. EDC and EDM
. ECU and Anconeus
. Pronator teres and FCR

Correct Answer & Explanation

. ECRB and EDC

Explanation

During the dorsal (Thompson) approach to the proximal radius, the PIN is at risk. It courses out of the distal edge of the supinator muscle and travels distally in the intermuscular plane between the extensor carpi radialis brevis (ECRB) and the extensor digitorum communis (EDC).

Question 576

Topic: Elbow & Forearm
A 60-year-old female sustains a coronal shear fracture of the distal humerus involving the capitellum and extending medially to include the lateral trochlear ridge. According to the Bryan and Morrey classification modified by McKee, 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

A Type IV Bryan-Morrey fracture (McKee's modification) is a coronal shear fracture that involves the capitellum and extends medially to include the majority of the trochlea (lateral trochlear ridge). This extension requires rigorous internal fixation to prevent joint subluxation.

Question 577

Topic: Elbow & Forearm

A 38-year-old male presents to the emergency department after a fall onto an outstretched hand with his forearm supinated, experiencing an axial load and valgus stress on his elbow. Clinical examination and imaging confirm a terrible triad injury. Based on the described mechanism, which of the following structures is most likely the *initial* ligamentous injury to occur in this sequential pattern?

. Anterior bundle of the Medial Collateral Ligament (MCL)
. Posterior bundle of the Medial Collateral Ligament (MCL)
. Lateral Ulnar Collateral Ligament (LUCL)
. Radial Collateral Ligament (RCL)
. Annular ligament

Correct Answer & Explanation

. Lateral Ulnar Collateral Ligament (LUCL)

Explanation

Correct Answer: CThe case explicitly states that the terrible triad injury (TTI) typically results from a fall onto an outstretched hand with the forearm supinated, leading to an axial load, valgus stress, and external rotation moment. This mechanism initiates a sequential pattern of soft tissue and bony injury,beginning with the LUCL complex, progressing to the radial head, and finally involving the coronoid. The LUCL is the primary stabilizer against posterolateral rotatory subluxation and is invariably disrupted in TTI.Options A and B are incorrect because the MCL complex is typically spared in a primary TTI, although its integrity must always be assessed. Options D and E are components of the lateral collateral ligament complex, but the LUCL is specifically identified as the primary stabilizer against posterolateral rotatory subluxation and the initial structure to fail in this injury pattern.

Question 578

Topic: Elbow & Forearm

A terrible triad injury involves a combination of radial head fracture, coronoid process fracture, and disruption of the lateral ulnar collateral ligament (LUCL) complex. Each of these components contributes to elbow stability. Which of the following bony structures is described as a key anterior stabilizer, primarily resisting posterior displacement of the ulna relative to the humerus?

. Radial head
. Olecranon process
. Coronoid process
. Lateral epicondyle
. Capitellum

Correct Answer & Explanation

. Coronoid process

Explanation

Correct Answer: CThe case states under 'Surgical Anatomy & Biomechanics' that the 'Coronoid process is a key anterior stabilizer, resisting posterior displacement of the ulna relative to the humerus. Fractures of the coronoid significantly compromise this inherent bony stability.' This highlights its crucial role in preventing posterior dislocation of the elbow.The radial head (Option A) contributes to valgus stability and resistance to axial loading. The olecranon process (Option B) forms the posterior part of the trochlear notch but is not the primary anterior buttress. The lateral epicondyle (Option D) is an origin for ligaments and muscles, not a primary anterior bony stabilizer. The capitellum (Option E) is part of the distal humerus and articulates with the radial head, but it is not an anterior stabilizer of the ulna.

Question 579

Topic: Elbow & Forearm

A 55-year-old patient presents with a suspected terrible triad injury after a fall. Initial plain radiographs confirm an elbow dislocation and a comminuted radial head fracture. The surgeon is planning for operative intervention.

Based on the provided image and the case description, which imaging modality is *absolutely essential* for comprehensive pre-operative planning in this case, and what specific information does it provide?

. Magnetic Resonance Imaging (MRI) to assess the integrity of the medial collateral ligament (MCL) and capsule.
. Ultrasound to evaluate for associated neurovascular compromise and fluid collections.
. Computed Tomography (CT) scan with 3D reconstructions to detail coronoid and radial head fracture morphology.
. Stress radiographs to dynamically confirm posterolateral rotatory instability.
. Arthrography to delineate capsular tears and articular cartilage damage.

Correct Answer & Explanation

. Computed Tomography (CT) scan with 3D reconstructions to detail coronoid and radial head fracture morphology.

Explanation

Correct Answer: CThe case explicitly states under 'Diagnostic Workup' that a 'Computed Tomography (CT) Scan:Absolutely essential.A high-resolution CT scan with 3D reconstructions provides invaluable information regarding: Coronoid fracture morphology (size, comminution, displacement, and involvement of the sublime tubercle); Radial head fracture pattern (number of fragments, displacement, articular step-off, and associated impaction); Humerus and ulna integrity; Congruity of reduction.' The image provided is an example of such a CT scan, further emphasizing its importance.Option A (MRI) can provide detailed information about ligamentous injuries but is not routinely required acutely and is described as supplementary. Option B (Ultrasound) is useful for soft tissue and vascular assessment but does not provide the detailed bony architecture needed for surgical planning of complex fractures. Option D (Stress radiographs) can confirm instability but does not provide the detailed fracture morphology. Option E (Arthrography) is rarely used acutely for TTI and is less informative than CT for bony injuries.

Question 580

Topic: Elbow & Forearm
A 42-year-old patient presents with an elbow dislocation, a Mason Type III radial head fracture, and an O'Driscoll Type II coronoid fracture involving 15% of the coronoid height. After closed reduction, the elbow remains grossly unstable through a 30-130 degree arc of motion with gentle valgus and rotational stress. The patient is medically fit for surgery. Based on the case description, what is the most appropriate management strategy?
. Non-operative management with a hinged elbow brace and early controlled range of motion.
. Radial head excision and LUCL repair, followed by immobilization.
. Open reduction internal fixation (ORIF) of the radial head, coronoid repair, and LUCL repair.
. Dynamic external fixation without internal fixation of the fractures.
. Immediate total elbow arthroplasty due to the severity of the injury.

Correct Answer & Explanation

. Open reduction internal fixation (ORIF) of the radial head, coronoid repair, and LUCL repair.

Explanation

The case states that all terrible triad injuries, by definition, involve a combination of radial head fracture, coronoid fracture, and LUCL disruption leading to gross elbow instability, necessitating surgical stabilization. It further specifies operative indications for Mason Type III radial head fractures and O'Driscoll Type II coronoid fractures (especially if >10-15% of coronoid height is involved), and the necessity of LUCL repair. The description of gross instability after reduction is a definitive indication for surgery.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page