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9. Shoulder and Elbow MCQs

Practice Set 35 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 681

Topic: Elbow & Forearm

A 33-year-old male undergoes open reduction and internal fixation of a terrible triad injury of the elbow. The standard surgical sequence involves fixing the coronoid, then the radial head. What is the crucial final step in restoring stability to this elbow?

. Repair of the medial collateral ligament (MCL)
. Repair of the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle
. Transposition of the ulnar nerve
. Application of a hinged external fixator in extension
. Excision of the olecranon tip

Correct Answer & Explanation

. Repair of the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle

Explanation

In a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture), after addressing the coronoid and radial head, the crucial final step to restore posterolateral rotatory stability is the repair of the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle.

Question 682

Topic: Elbow & Forearm

A 2-year-old child presents with a Blauth Type II hypoplastic thumb. Which combination of surgical procedures is most typically indicated for optimal functional restoration?

. Index finger pollicization
. First web space release, opponensplasty, and ulnar collateral ligament reconstruction
. Carpometacarpal joint arthrodesis and web space release
. Flexor digitorum superficialis tendon transfer isolated to the thumb IP joint
. Distal radioulnar joint centralization

Correct Answer & Explanation

. First web space release, opponensplasty, and ulnar collateral ligament reconstruction

Explanation

Blauth Type II thumbs are characterized by first web space narrowing, thenar hypoplasia, and MCP joint instability. Reconstruction involves deepening the web space, an opponensplasty (e.g., Huber transfer), and UCL reconstruction.

Question 683

Topic: 9. Shoulder and Elbow

As Duchenne Muscular Dystrophy progresses into the second decade of life, patients develop significant upper extremity contractures that impair function. What is the classic resting position of the upper extremity due to these contractures?

. Shoulder abduction, elbow extension, wrist extension
. Shoulder adduction, elbow flexion, forearm pronation
. Shoulder abduction, elbow flexion, forearm supination
. Shoulder adduction, elbow extension, forearm pronation
. Shoulder flexion, elbow extension, wrist flexion

Correct Answer & Explanation

. Shoulder adduction, elbow flexion, forearm pronation

Explanation

In advanced DMD, muscle imbalances predictably lead to upper extremity contractures characterized by shoulder adduction and internal rotation, elbow flexion, forearm pronation, and wrist/finger flexion.

Question 684

Topic: 9. Shoulder and Elbow

In the later stages of Duchenne muscular dystrophy, which upper extremity joint typically develops a flexion contracture that most severely interferes with joystick control of a motorized wheelchair?

. Shoulder
. Elbow
. Wrist
. Metacarpophalangeal joints
. Proximal interphalangeal joints

Correct Answer & Explanation

. Elbow

Explanation

Elbow flexion contractures commonly develop in non-ambulatory DMD patients. These contractures can significantly interfere with functional tasks, feeding, and operating the joystick of a powered wheelchair.

Question 685

Topic: 9. Shoulder and Elbow

The examiner asks the candidate to differentiate between Osteochondritis Dissecans (OCD) and osteoarthritis as the cause of the loose body. Which of the following findings from the case most strongly supports OCD over osteoarthritis?

. The patient's current age of 33 years.
. The presence of a single loose body.
. The intermittent painful locking symptoms.
. The history of unexplained painful elbow at age 17.
. The absence of calcification in the muscle or capsule.

Correct Answer & Explanation

. The history of unexplained painful elbow at age 17.

Explanation

Correct Answer: DExplanation:The most compelling finding that differentiates OCD from osteoarthritis in this case is thehistory of unexplained painful elbow at age 17. OCD of the capitellum typically affects adolescents and young adults, often presenting with vague elbow pain, stiffness, or mechanical symptoms. This history strongly suggests an underlying osteochondral lesion that likely progressed to loose body formation. While osteoarthritis can cause loose bodies (osteophytes breaking off), it is less common in a 33-year-old with well-maintained joint space and without a clear history of significant prior trauma or inflammatory conditions. The patient's current age (A) is young for primary osteoarthritis. The presence of a single loose body (B) can occur in both conditions, though multiple loose bodies are more indicative of synovial chondromatosis. Intermittent painful locking (C) is a symptom of any loose body, regardless of etiology. The absence of calcification in the muscle or capsule (E) helps rule out myositis ossificans or synovial sarcoma, but not specifically differentiate OCD from osteoarthritis.

Question 686

Topic: 9. Shoulder and Elbow

When the patient was 17 years old, he experienced unexplained painful elbow for 18 months. If an orthopedic surgeon were consulting him at that time, and MRI was not widely available, what would have been the most appropriate diagnostic imaging study to assess for an osteochondral lesion and its stability?

. Plain radiographs only
. CT scan of the elbow
. Elbow arthrogram with contrast
. Bone scan
. Ultrasound of the elbow

Correct Answer & Explanation

. Elbow arthrogram with contrast

Explanation

Correct Answer: CExplanation:Given the historical context where MRI was not widely available, anelbow arthrogram with contrastwould have been the most appropriate diagnostic imaging study to assess for an osteochondral lesion and its stability. An arthrogram involves injecting contrast material into the joint, which can then outline the articular cartilage and reveal defects, fissures, or the separation of an osteochondral fragment. This technique was historically used to evaluate the integrity of the articular surface and the stability of OCD lesions before the widespread adoption of MRI. Plain radiographs (A) would likely show subtle or no pathology in early OCD, as noted in the case. A CT scan (B) is excellent for bony detail but less effective for cartilage assessment without intra-articular contrast. A bone scan (D) would show increased metabolic activity but not provide detailed anatomical information about the lesion's stability. Ultrasound (E) has limited utility for deep intra-articular osteochondral lesions.

Question 687

Topic: 9. Shoulder and Elbow

The examiner asks the candidate about the name for OCD of the elbow. The candidate correctly identifies Panner's disease. Which of the following statements best describes Panner's disease?

. It is an osteochondral fracture of the capitellum due to acute trauma.
. It is an avascular necrosis of the capitellar epiphysis in children.
. It is a degenerative condition affecting the entire elbow joint in adults.
. It is a form of primary synovial chondromatosis of the elbow.
. It is a chronic inflammatory condition of the elbow joint.

Correct Answer & Explanation

. It is an avascular necrosis of the capitellar epiphysis in children.

Explanation

Correct Answer: BExplanation:Panner's diseaseis specifically an osteochondrosis (avascular necrosis) of the capitellar epiphysis, typically occurring in children between the ages of 7 and 12 years. It is characterized by fragmentation and necrosis of the capitellar ossification center, often associated with repetitive microtrauma (e.g., in young baseball pitchers or gymnasts). It is distinct from typical osteochondritis dissecans (OCD) of the capitellum, which usually affects older adolescents and young adults (12-18 years) and involves a focal area of subchondral bone necrosis and overlying cartilage damage. While the case uses 'Panner's disease' somewhat broadly for OCD of the elbow, it's important to know the specific definition. Option A describes an acute injury. Option C describes osteoarthritis. Option D describes synovial chondromatosis. Option E describes inflammatory arthritis.

Question 688

Topic: 9. Shoulder and Elbow

The patient's initial presentation at age 17 with unexplained painful elbow was unfortunately discharged from follow-up after a single X-ray showed no obvious pathology. What is the most likely long-term consequence of untreated osteochondritis dissecans of the capitellum that led to the current presentation?

. Spontaneous healing of the lesion without sequelae
. Progressive joint space narrowing and early osteoarthritis
. Formation and detachment of an osteochondral fragment into a loose body
. Development of a chronic inflammatory synovitis
. Increased risk of elbow dislocation

Correct Answer & Explanation

. Formation and detachment of an osteochondral fragment into a loose body

Explanation

Correct Answer: CExplanation:The most likely long-term consequence of untreated osteochondritis dissecans (OCD) of the capitellum, especially if it was unstable, is theformation and detachment of an osteochondral fragment into a loose body. OCD involves a localized area of subchondral bone necrosis and overlying cartilage damage. If the lesion is unstable or progresses, the affected fragment can separate from its bed and become a free-floating loose body within the joint. This loose body then causes mechanical symptoms such as locking, catching, and pain, as seen in the 33-year-old patient. While long-standing OCD can eventually contribute to osteoarthritis (B), the immediate and most direct consequence explaining the current symptoms is the loose body formation. Spontaneous healing (A) is possible for stable, early lesions, but not for those that progress to symptomatic loose bodies. Chronic inflammatory synovitis (D) is not the primary sequela, and increased risk of elbow dislocation (E) is not typically associated with OCD.

Question 689

Topic: 9. Shoulder and Elbow

Considering the examiner's feedback on Candidate 2's performance, which aspect of Candidate 2's approach was most crucial for arriving at a spot-on diagnosis and appropriate management plan?

. Immediately identifying the loose body on radiographs.
. Knowing the specific name 'Panner's disease'.
. Asking about the patient's presenting symptoms.
. Connecting the current findings with the detailed past medical history.
. Suggesting arthroscopic removal of the loose body as treatment.

Correct Answer & Explanation

. Connecting the current findings with the detailed past medical history.

Explanation

Correct Answer: DExplanation:Candidate 2's most crucial contribution to a spot-on diagnosis and appropriate management plan wasconnecting the current findings with the detailed past medical history. While identifying the loose body (A) is a basic radiographic interpretation, and knowing Panner's disease (B) is specific knowledge, and asking about presenting symptoms (C) is good clinical practice, it was the specific inquiry into 'any problem with this elbow in the past' and then linking the 'unexplained painful elbow at age 17' to the current loose body that allowed Candidate 2 to correctly deduce the diagnosis of OCD. This demonstrates a higher-order clinical reasoning skill of synthesizing historical data with current findings. Suggesting arthroscopic removal (E) is the correct treatment, but it follows from the correct diagnosis, which was enabled by the historical connection.

Question 690

Topic: Elbow & Forearm

Which muscle is most commonly implicated in the pathology of lateral epicondylitis?

. Extensor Digitorum Communis (EDC)
. Extensor Carpi Ulnaris (ECU)
. Extensor Carpi Radialis Longus (ECRL)
. Extensor Carpi Radialis Brevis (ECRB)
. Supinator

Correct Answer & Explanation

. Extensor Carpi Radialis Brevis (ECRB)

Explanation

Correct Answer: DThe Extensor Carpi Radialis Brevis (ECRB) is almost universally accepted as the primary muscle/tendon involved in lateral epicondylitis. Its origin on the lateral epicondyle is the most common site of tendinopathic changes. While other extensors (ECRL, EDC, ECU) also originate from the common extensor tendon, the ECRB is most consistently implicated due to its anatomical position and biomechanical loading characteristics, especially with wrist extension and radial deviation combined with gripping.

Question 691

Topic: Elbow & Forearm

During surgical debridement for refractory lateral epicondylitis, the surgeon must identify and excise the pathologic tissue. Which of the following muscles is the primary site of pathology in this condition?

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

Correct Answer & Explanation

. Extensor carpi radialis brevis

Explanation

Lateral epicondylitis is primarily characterized by tendinosis of the extensor carpi radialis brevis (ECRB) origin. Surgical management involves excising the diseased portion of the ECRB while protecting the lateral collateral ligament complex.

Question 692

Topic: Elbow & Forearm

A 45-year-old female undergoes open debridement for lateral epicondylitis. Postoperatively, she reports a new clicking sensation and elbow instability when attempting to push herself off a chair. Iatrogenic injury to which structure is most likely responsible for this complication?

. Radial collateral ligament
. Lateral ulnar collateral ligament
. Annular ligament
. Extensor carpi radialis longus
. Interosseous membrane

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The lateral ulnar collateral ligament (LUCL) is the primary restraint to posterolateral rotatory instability (PLRI) of the elbow. Iatrogenic injury to the LUCL, which lies posterior and deep to the ECRB origin, can occur during overly aggressive surgical debridement for lateral epicondylitis.

Question 693

Topic: 9. Shoulder and Elbow

A 7-year-old male baseball player presents with lateral elbow pain and stiffness. Radiographs demonstrate fragmentation and sclerosis of the entire capitellum without a localized defect or loose body. What is the most appropriate initial management?

. Arthroscopic microfracture
. Osteochondral autograft transfer
. Rest and avoidance of throwing until symptoms resolve
. Corticosteroid injection
. Surgical fixation of the fragment

Correct Answer & Explanation

. Rest and avoidance of throwing until symptoms resolve

Explanation

This presentation is characteristic of Panner's disease, an osteochondrosis of the capitellum affecting children typically under age 10. It is a self-limiting condition that resolves with rest and activity modification.

Question 694

Topic: 9. Shoulder and Elbow

A 14-year-old female gymnast presents with lateral elbow pain. Radiographs reveal a radiolucent lesion in the capitellum. MRI is obtained to evaluate the lesion's stability. Which of the following MRI findings most strongly indicates an unstable osteochondritis dissecans (OCD) lesion that may necessitate surgical intervention?

. Bone marrow edema surrounding the lesion
. Intact overlying articular cartilage
. Subchondral cyst formation measuring 2 mm
. High T2 signal fluid completely surrounding the osteochondral fragment
. Thickening of the radial collateral ligament

Correct Answer & Explanation

. High T2 signal fluid completely surrounding the osteochondral fragment

Explanation

A rim of high T2 signal fluid completely surrounding the osteochondral fragment on MRI indicates detachment and instability of the lesion. Unstable capitellar OCD lesions in adolescents typically require surgical intervention.

Question 695

Topic: Elbow & Forearm

A 50-year-old male undergoes surgical excision of diseased tissue for chronic, refractory lateral epicondylitis. Histopathological examination of the excised tissue is most likely to demonstrate which of the following?

. Acute inflammatory infiltrate with abundant neutrophils
. Angiofibroblastic hyperplasia and disorganized collagen
. Granulomatous inflammation with multinucleated giant cells
. Dense regular connective tissue with minimal cellularity
. Extensive chondroid metaplasia and calcification

Correct Answer & Explanation

. Angiofibroblastic hyperplasia and disorganized collagen

Explanation

Lateral epicondylitis is a tendinosis, not a true inflammatory tendinitis. Histology classically shows angiofibroblastic hyperplasia, characterized by disorganized collagen, vascular proliferation, and fibroblast hypertrophy without acute inflammatory cells.

Question 696

Topic: Elbow & Forearm

When evaluating a patient for suspected lateral epicondylitis, the examiner performs provocative testing. Resisted extension of which digit is most specific for stressing and isolating the extensor carpi radialis brevis (ECRB) origin?

. Thumb
. Index finger
. Middle finger
. Ring finger
. Small finger

Correct Answer & Explanation

. Middle finger

Explanation

Resisted extension of the middle finger places selective stress on the ECRB tendon due to its anatomical insertion at the base of the third metacarpal. Exacerbation of lateral elbow pain during this test is highly indicative of lateral epicondylitis.

Question 697

Topic: 9. Shoulder and Elbow

A 13-year-old male baseball pitcher complains of lateral elbow pain. Routine anteroposterior (AP) and lateral elbow radiographs appear normal. Suspecting early capitellar osteochondritis dissecans, which specific radiographic view should be ordered next to best visualize the capitellum?

. AP view with the elbow in full extension
. Lateral view with 90 degrees of flexion
. 45-degree flexion AP view
. Cubital tunnel view
. Radial head-capitellum view

Correct Answer & Explanation

. 45-degree flexion AP view

Explanation

The 45-degree flexion AP view profiles the posterior, weight-bearing aspect of the capitellum where OCD lesions most commonly occur. Standard views may miss early or posteriorly located lesions.

Question 698

Topic: Elbow & Forearm

A 42-year-old tennis player presents with lateral epicondylitis and is considering a corticosteroid injection versus physical therapy. Based on randomized controlled trials, what is the most likely long-term (1 year) outcome of corticosteroid injection compared to physical therapy or watchful waiting?

. Superior pain relief and grip strength
. Lower recurrence rates of pain
. Higher rates of symptom recurrence and poorer overall outcomes
. Complete resolution of tendinosis on MRI
. Accelerated progression to surgical intervention

Correct Answer & Explanation

. Higher rates of symptom recurrence and poorer overall outcomes

Explanation

While corticosteroid injections provide excellent short-term relief (4-6 weeks) for lateral epicondylitis, long-term follow-up at 1 year shows higher recurrence rates and worse outcomes compared to physical therapy or wait-and-see approaches.

Question 699

Topic: Elbow & Forearm

During open surgery for lateral epicondylitis, the surgeon defines the interval between the extensor carpi radialis longus (ECRL) and the extensor digitorum communis (EDC) to access the ECRB. Where is the origin of the ECRL located relative to the lateral epicondyle?

. Directly on the lateral epicondyle
. On the lateral supracondylar ridge of the humerus
. On the radial head
. On the lateral aspect of the olecranon
. On the lateral intermuscular septum

Correct Answer & Explanation

. On the lateral supracondylar ridge of the humerus

Explanation

The ECRL originates primarily on the lateral supracondylar ridge, proximal to the lateral epicondyle. Identifying this anatomy is crucial to locate the interval between the ECRL and EDC to expose the underlying ECRB.

Question 700

Topic: 9. Shoulder and Elbow

A 14-year-old gymnast presents with lateral elbow pain. The examiner supinates the patient's forearm, flexes the elbow to 15 degrees, and applies a valgus stress while passively extending the elbow, eliciting a painful catch. What does this test evaluate?

. Valgus extension overload
. Posterolateral rotatory instability (Pivot-shift test)
. Medial epicondyle apophysitis
. Active radiocapitellar compression
. Cubital tunnel syndrome

Correct Answer & Explanation

. Posterolateral rotatory instability (Pivot-shift test)

Explanation

The lateral pivot-shift test for posterolateral rotatory instability (PLRI) involves supination, valgus stress, and axial load while bringing the elbow from flexion to extension. PLRI can mimic or occur alongside lateral elbow pathology.

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