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9. Shoulder and Elbow MCQs

Practice Set 36 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 701

Topic: Elbow & Forearm

To avoid posterolateral rotatory instability (PLRI) during surgical debridement of the lateral epicondyle, the surgeon must preserve the lateral ulnar collateral ligament (LUCL). The LUCL originates from the lateral epicondyle at which position relative to the ECRB origin?

. Posterior and deep
. Anterior and superior
. Distal and superficial
. Anterior and superficial
. Proximal and anterior

Correct Answer & Explanation

. Posterior and deep

Explanation

The LUCL origin lies on the lateral epicondyle posterior and deep to the common extensor origin (specifically the ECRB). Careless or overly aggressive deep dissection during lateral epicondylitis surgery risks compromising this crucial stabilizing structure.

Question 702

Topic: Elbow & Forearm

A 40-year-old plumber with chronic lateral epicondylitis is prescribed a counterforce brace. To be mechanically effective and properly offload the diseased tendon, where should the brace be positioned relative to the lateral epicondyle?

. Directly over the lateral epicondyle
. 2 to 3 cm proximal to the lateral epicondyle
. 2 to 3 cm distal to the lateral epicondyle
. Over the radial styloid
. Tightly around the mid-biceps

Correct Answer & Explanation

. 2 to 3 cm distal to the lateral epicondyle

Explanation

A counterforce brace should be placed approximately 2 to 3 cm distal to the lateral epicondyle. This disperses the muscular forces away from the diseased ECRB origin during wrist and finger extension.

Question 703

Topic: Elbow & Forearm

The susceptibility of the capitellum to osteochondritis dissecans in adolescent throwers is largely attributed to its tenuous blood supply. Which of the following best describes the vascular anatomy of the capitellum?

. It receives rich collateral flow from the radial recurrent artery
. It is supplied by multiple anterior and posterior perforating vessels
. It is supplied by 1 or 2 isolated end-arteries entering posteriorly
. It receives blood exclusively from the interosseous membrane plexus
. It is avascular and relies solely on synovial fluid diffusion

Correct Answer & Explanation

. It is supplied by 1 or 2 isolated end-arteries entering posteriorly

Explanation

The capitellum relies on a tenuous blood supply consisting of 1 or 2 isolated end-arteries that enter posteriorly and do not anastomose with neighboring vessels. This lack of collateral flow predisposes it to ischemia and osteochondritis dissecans from repetitive microtrauma.

Question 704

Topic: 9. Shoulder and Elbow

A 28-year-old tennis player complains of lateral elbow snapping and painful catching during terminal extension. MRI is negative for loose bodies or OCD, but reveals a thickened band of tissue in the radiocapitellar joint. What is the most likely diagnosis?

. Annular ligament tear
. Symptomatic synovial plica
. Loose body of the olecranon fossa
. Biceps tendinitis
. Triceps snapping syndrome

Correct Answer & Explanation

. Symptomatic synovial plica

Explanation

A symptomatic synovial plica in the elbow typically presents as lateral-sided elbow pain with mechanical snapping or catching, often mimicking a loose body or lateral epicondylitis. Diagnosis is confirmed by MRI showing a thickened radiocapitellar plica band.

Question 705

Topic: Elbow & Forearm

A 15-year-old baseball pitcher presents with pain in the posterior aspect of the elbow during the deceleration phase of throwing. He denies lateral pain. Exam shows a flexion contracture of 15 degrees and tenderness over the posteromedial olecranon. What is the most likely diagnosis?

. Capitellar osteochondritis dissecans
. Lateral epicondylitis
. Valgus extension overload syndrome
. Medial epicondyle avulsion
. Radial head stress fracture

Correct Answer & Explanation

. Valgus extension overload syndrome

Explanation

Valgus extension overload syndrome occurs due to impingement of the posteromedial olecranon in the olecranon fossa during the repetitive valgus stress and extension of throwing. It is critical to differentiate this posterior/posteromedial pain from the lateral pain characteristic of capitellar OCD.

Question 706

Topic: Elbow & Forearm

What is the primary histological finding in the extensor carpi radialis brevis (ECRB) tendon in a patient with chronic lateral epicondylitis?

. Acute inflammatory infiltrate with neutrophils
. Angiofibroblastic hyperplasia
. Fibrinoid necrosis of the tendon sheath
. Granulomatous inflammation with giant cells
. Calcific tendinopathy with hydroxyapatite deposition

Correct Answer & Explanation

. Angiofibroblastic hyperplasia

Explanation

Chronic lateral epicondylitis is characterized by angiofibroblastic hyperplasia (tendinosis) rather than acute inflammation. This involves disorganized collagen, immature fibroblasts, and non-functional microvascularity without an acute inflammatory infiltrate.

Question 707

Topic: Elbow & Forearm

A 14-year-old female gymnast presents with insidious onset lateral elbow pain, clicking, and a 15-degree extension deficit. Radiographs reveal a radiolucent lesion of the capitellum. Which of the following differentiates capitellar osteochondritis dissecans (OCD) from Panner disease?

. Involvement of the entire capitellum
. Age of onset typically less than 10 years
. Presence of loose bodies or an articular cartilage flap
. Self-limiting nature with no risk of residual deformity
. Primary involvement of the radial head

Correct Answer & Explanation

. Involvement of the entire capitellum

Explanation

Capitellar OCD affects older children (11-17 years) and involves focal subchondral bone changes that can lead to cartilage flaps and loose bodies. Panner disease affects the entire capitellum in younger children (under 10) and is typically self-limiting without loose body formation.

Question 708

Topic: Elbow & Forearm

During an open debridement for recalcitrant lateral epicondylitis (Nirschl procedure), the surgeon must avoid injuring a critical structure located directly beneath the ECRB origin. Which structure is at greatest risk during excessive deep dissection?

. Lateral ulnar collateral ligament (LUCL)
. Radial collateral ligament (RCL)
. Posterior interosseous nerve (PIN)
. Annular ligament
. Superficial radial nerve

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The LUCL lies directly deep to the common extensor origin and ECRB. Excessive deep dissection or over-debridement can violate the LUCL, leading to iatrogenic posterolateral rotatory instability (PLRI) of the elbow.

Question 709

Topic: 9. Shoulder and Elbow

Which physical examination maneuver is most specific for diagnosing lateral epicondylitis by isolating the extensor carpi radialis brevis (ECRB)?

. Resisted wrist extension with the elbow flexed at 90 degrees
. Resisted extension of the middle finger with the elbow extended
. Resisted forearm supination with the elbow flexed
. Pain with passive wrist extension and forearm supination
. Resisted pronation with the elbow extended

Correct Answer & Explanation

. Resisted extension of the middle finger with the elbow extended

Explanation

Resisted extension of the long (middle) finger with the elbow fully extended isolates stress on the ECRB muscle. This maneuver, known as Maudsley's test, reproduces the pain of lateral epicondylitis at its origin.

Question 710

Topic: 9. Shoulder and Elbow

A 38-year-old man presents with decreased elbow range of motion and mechanical catching. Radiographs reveal over 30 uniform, small, calcified loose bodies within the elbow joint space. What is the most likely underlying pathophysiology?

. Metaplasia of the synovial membrane
. Repetitive valgus overload leading to osteophyte fragmentation
. Avascular necrosis of the capitellum
. Crystalline deposition in the joint capsule
. Untreated capitellar Panner disease

Correct Answer & Explanation

. Metaplasia of the synovial membrane

Explanation

Primary synovial chondromatosis is a benign neoplastic process characterized by cartilaginous metaplasia of the synovial membrane. It produces multiple uniform cartilaginous nodules that can detach and calcify as joint loose bodies.

Question 711

Topic: Elbow & Forearm

On an MRI of a 13-year-old gymnast with an OCD lesion of the capitellum, which finding is the most reliable indicator of lesion instability requiring surgical intervention?

. Bone marrow edema extending to the metaphysis
. High T2 signal interfacing between the fragment and crater
. Subchondral sclerosis around the lesion
. Flattening of the radial head
. Thickening of the radial collateral ligament

Correct Answer & Explanation

. High T2 signal interfacing between the fragment and crater

Explanation

A high T2 signal line indicating fluid between the osteochondral fragment and the underlying bone bed is a classic sign of instability. Once fluid breaches this interface, the lesion is unstable and typically necessitates surgical intervention.

Question 712

Topic: Elbow & Forearm

A 42-year-old tennis player requests a corticosteroid injection for newly diagnosed lateral epicondylitis. What should the physician advise regarding the expected outcomes of a corticosteroid injection compared to physical therapy or observation?

. Superior long-term outcomes at 1 year
. Better short-term relief (at 4-6 weeks) but higher recurrence rates at 1 year
. No difference in short-term pain relief but better long-term function
. Lower risk of tendon rupture compared to platelet-rich plasma (PRP)
. Immediate permanent resolution of symptoms

Correct Answer & Explanation

. Better short-term relief (at 4-6 weeks) but higher recurrence rates at 1 year

Explanation

Corticosteroid injections for lateral epicondylitis provide excellent short-term relief (4-6 weeks) but are associated with worse long-term outcomes at 1 year. They also carry higher recurrence rates compared to physical therapy or watchful waiting.

Question 713

Topic: Elbow & Forearm

A 28-year-old male golfer complains of catching and snapping on the lateral side of his elbow during extension. MRI is negative for loose bodies but shows a thickened band of tissue in the lateral gutter. Which condition most closely mimics lateral loose bodies and lateral epicondylitis in this presentation?

. Posterolateral rotatory instability
. Snapping triceps syndrome
. Symptomatic radiocapitellar synovial plica
. Ulnar nerve subluxation
. Osteoid osteoma of the radial head

Correct Answer & Explanation

. Symptomatic radiocapitellar synovial plica

Explanation

A symptomatic synovial radiocapitellar plica can cause lateral elbow pain, snapping, and mechanical catching. It frequently mimics loose bodies or lateral epicondylitis and is often treated effectively with arthroscopic resection.

Question 714

Topic: Elbow & Forearm

A patient develops symptomatic posterolateral rotatory instability (PLRI) following an open release for lateral epicondylitis. Which examination finding confirms this iatrogenic complication?

. Positive moving valgus stress test
. Apprehension during combined axial load, valgus stress, and supination
. Pain with resisted wrist flexion
. Inability to actively extend the thumb
. Paresthesia in the ulnar digits with elbow flexion

Correct Answer & Explanation

. Apprehension during combined axial load, valgus stress, and supination

Explanation

Iatrogenic injury to the LUCL during lateral epicondylitis surgery causes PLRI. This is clinically diagnosed by a positive lateral pivot-shift apprehension test, performed by applying an axial load, valgus stress, and supination as the elbow is flexed.

Question 715

Topic: Elbow & Forearm

According to randomized controlled trials, which orthobiologic injection has demonstrated better long-term pain relief and functional improvement for refractory lateral epicondylitis compared to corticosteroid injections?

. Hyaluronic acid
. Leukocyte-rich platelet-rich plasma (LR-PRP)
. Bone marrow aspirate concentrate (BMAC)
. Botulinum toxin A
. Autologous conditioned serum (ACS)

Correct Answer & Explanation

. Leukocyte-rich platelet-rich plasma (LR-PRP)

Explanation

Multiple studies demonstrate that leukocyte-rich PRP (LR-PRP) offers superior long-term (1-2 years) pain relief and functional improvement for lateral epicondylitis compared to corticosteroids. Corticosteroids typically only offer transient short-term relief.

Question 716

Topic: 9. Shoulder and Elbow

A 55-year-old manual laborer presents with progressive elbow stiffness, painful terminal extension, and multiple large loose bodies in the coronoid and olecranon fossae. The joint space is globally narrowed. What is the most appropriate surgical intervention for durable relief of mechanical symptoms?

. Open loose body removal and Outerbridge-Kashiwagi (OK) procedure
. Arthroscopic microfracture of the capitellum
. Total elbow arthroplasty
. Radial head arthroplasty
. Ulnar nerve transposition

Correct Answer & Explanation

. Open loose body removal and Outerbridge-Kashiwagi (OK) procedure

Explanation

In a middle-aged laborer with primary elbow osteoarthritis and a mechanical block from loose bodies and osteophytes, an ulnohumeral arthroplasty (OK procedure) or comprehensive arthroscopic debridement is indicated. Total elbow arthroplasty is contraindicated due to lifelong lifting restrictions.

Question 717

Topic: Elbow & Forearm

The extensor carpi radialis brevis (ECRB) is the primary tendon implicated in lateral epicondylitis. What is its precise anatomical origin relative to the extensor digitorum communis (EDC)?

. Deep and anterior to the EDC
. Superficial and posterior to the EDC
. Distal and posterior to the EDC
. Directly attached to the lateral supracondylar ridge, proximal to the EDC
. Fibers interdigitate superficially over the EDC

Correct Answer & Explanation

. Deep and anterior to the EDC

Explanation

The ECRB origin lies deep and slightly anterior to the extensor digitorum communis (EDC) at the lateral epicondyle. During open surgery for lateral epicondylitis, the EDC is often split or retracted to expose the pathologically altered ECRB tissue.

Question 718

Topic: Elbow & Forearm

A 7-year-old boy presents with a dull, aching pain in his dominant lateral elbow without mechanical locking. Radiographs show fragmentation and sclerosis of the entire capitellum without loose bodies. What is the most appropriate management?

. Arthroscopic debridement and microfracture
. Core decompression of the capitellum
. Symptomatic treatment with rest and avoidance of throwing
. Immobilization in a long arm cast for 12 weeks
. Osteochondral autograft transfer (OATS)

Correct Answer & Explanation

. Symptomatic treatment with rest and avoidance of throwing

Explanation

This presentation is classic for Panner disease, a benign osteochondrosis of the capitellum affecting young children (usually <10 years). It is a self-limiting condition that reliably resolves with conservative management, such as rest and activity modification.

Question 719

Topic: Elbow & Forearm

Microscopic evaluation of tissue excised during surgery for refractory lateral epicondylitis classically demonstrates which of the following?

. Abundant acute inflammatory cells and macrophages
. Angiofibroblastic hyperplasia with disorganized collagen
. Granulomatous inflammation with giant cells
. Synovial hypertrophy with villous proliferation
. Chondroid metaplasia within the tendon substance

Correct Answer & Explanation

. Angiofibroblastic hyperplasia with disorganized collagen

Explanation

The pathologic process in lateral epicondylitis is tendinosis, not an acute tendinitis. Histology characteristically shows angiofibroblastic hyperplasia, disorganized collagen, and an absence of acute inflammatory cells.

Question 720

Topic: 9. Shoulder and Elbow

Which of the following physical examination maneuvers is most specific for isolating the extensor carpi radialis brevis (ECRB) in a patient suspected of having lateral epicondylitis?

. Resisted wrist flexion with the elbow extended
. Resisted middle finger extension with the elbow extended
. Resisted forearm pronation
. Resisted wrist ulnar deviation
. Passive wrist extension with elbow flexed

Correct Answer & Explanation

. Resisted middle finger extension with the elbow extended

Explanation

Resisted extension of the middle finger places isolated stress on the ECRB. This specifically reproduces pain at its origin on the lateral epicondyle in patients with lateral epicondylitis.

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