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9. Shoulder and Elbow MCQs

Practice Set 40 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 781

Topic: Elbow & Forearm

When repairing the lateral ulnar collateral ligament (LUCL) during a terrible triad reconstruction, anatomic placement of the suture anchor on the humerus is crucial. What is the correct anatomic origin of the LUCL?

. The medial epicondyle, anterior to the flexor pronator mass
. The lateral epicondyle, at the isometric center of capitellar rotation
. The supinator crest of the proximal ulna
. The lateral supracondylar ridge, proximal to the ECRL origin
. The radial tuberosity, deep to the biceps tendon

Correct Answer & Explanation

. The lateral epicondyle, at the isometric center of capitellar rotation

Explanation

The LUCL originates on the lateral epicondyle at the isometric point corresponding to the center of capitellar rotation. It inserts distally onto the supinator crest of the ulna.

Question 782

Topic: Elbow & Forearm

A surgeon approaches a complex proximal ulna fracture with radial head dislocation using the Boyd approach. Which of the following complications is historically highly associated with the extensive muscle stripping required by this approach?

. Superficial radial nerve neuroma
. Triceps avulsion
. Proximal radioulnar synostosis
. Ulnar nerve palsy
. Avascular necrosis of the capitellum

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

The Boyd approach exposes the proximal ulna and radius by elevating the supinator and anconeus off the ulna. This extensive subperiosteal stripping in the region of the interosseous membrane carries a notoriously high risk of developing proximal radioulnar synostosis.

Question 783

Topic: Elbow & Forearm

A 28-year-old male undergoes surgical treatment for a terrible triad injury. Postoperatively, what forearm position is theoretically most protective of the repaired lateral ulnar collateral ligament (LUCL) during early range of motion exercises?

. Full supination
. Full pronation
. Neutral rotation with varus stress
. Neutral rotation with forced extension
. Supination with valgus stress

Correct Answer & Explanation

. Full pronation

Explanation

Forearm pronation tensions the medial soft tissues and the intact medial hinge, thereby crossing the radius over the ulna and protecting the repaired lateral side (LUCL) from varus stress and subluxation during early rehabilitation.

Question 784

Topic: Elbow & Forearm

You are templating a radial head arthroplasty for an irreparable radial head fracture in a terrible triad injury. What intraoperative landmark is most reliable for determining the correct height of the radial head prosthesis?

. The proximal edge of the lesser sigmoid notch of the ulna
. The distal tip of the coronoid process
. The center of the capitellum
. The insertion of the biceps tendon on the radial tuberosity
. The superior margin of the annular ligament

Correct Answer & Explanation

. The proximal edge of the lesser sigmoid notch of the ulna

Explanation

To avoid overstuffing the joint, the articular surface of the radial head prosthesis should sit flush with, or up to 1-2 mm proximal to, the proximal edge of the lesser sigmoid notch of the ulna when the elbow is reduced.

Question 785

Topic: 9. Shoulder and Elbow

During the reduction of a terrible triad injury, the surgeon performs the 'hanging arm test' under fluoroscopy. What is the primary purpose of this maneuver?

. To assess for ulnar nerve subluxation
. To evaluate the competence of the medial collateral ligament (MCL) after LCL repair
. To confirm the size of the radial head prosthesis
. To check for dynamic posterior interosseous nerve (PIN) entrapment
. To test for isolated radioulnar syndesmosis disruption

Correct Answer & Explanation

. To evaluate the competence of the medial collateral ligament (MCL) after LCL repair

Explanation

The hanging arm test places the elbow in extension to allow gravity to provide a valgus stress. It is used after coronoid, radial head, and LCL fixation to assess the competence of the MCL and determine if further stabilization is needed.

Question 786

Topic: Elbow & Forearm

A 45-year-old male sustains a terrible triad injury of the elbow. Operative management is planned. To optimize biomechanical stability, what is the most widely accepted sequence of structural repair?

. Lateral collateral ligament (LCL), radial head, coronoid, medial collateral ligament (MCL)
. Coronoid, radial head, LCL, MCL (if needed)
. Radial head, coronoid, MCL, LCL
. MCL, coronoid, radial head, LCL
. Radial head, LCL, coronoid, MCL

Correct Answer & Explanation

. Coronoid, radial head, LCL, MCL (if needed)

Explanation

The standard sequence of repair in a terrible triad injury proceeds from deep to superficial: coronoid fixation, radial head repair or replacement, and LCL repair. MCL repair or a hinged external fixator is only added if the elbow remains persistently unstable after the lateral side is reconstructed.

Question 787

Topic: 9. Shoulder and Elbow

During surgery for a terrible triad injury, a severely comminuted radial head is replaced with a modular prosthesis. Postoperatively, radiographs reveal a widened medial joint clear space, and the patient lacks full elbow flexion and extension. What is the most likely cause?

. Under-sizing the radial head prosthesis
. Failure to repair the medial collateral ligament
. Overstuffing the radiocapitellar joint
. Nonunion of the coronoid process
. Heterotopic ossification

Correct Answer & Explanation

. Overstuffing the radiocapitellar joint

Explanation

Overstuffing the joint with a radial head prosthesis that is too long "cams" the joint open medially, causing a widened medial clear space. This increases joint contact pressures and significantly restricts the range of motion.

Question 788

Topic: Elbow & Forearm

A 50-year-old male undergoes open reduction and internal fixation for a Bado Type II Monteggia fracture. Following rigid plate fixation of the ulna, the radial head remains subluxated posteriorly. What is the most critical next step in management?

. Open reduction of the radial head and annular ligament reconstruction
. Resection of the radial head
. Application of a hinged external fixator
. Assessment and revision of the ulnar reduction and fixation
. Closed reduction and casting in full extension

Correct Answer & Explanation

. Assessment and revision of the ulnar reduction and fixation

Explanation

In Monteggia fractures, the key to reducing the radial head is anatomic restoration of the ulna's length and alignment. Persistent radial head subluxation after ulnar plating indicates ulnar malreduction, which must be addressed first.

Question 789

Topic: 9. Shoulder and Elbow

A patient with an elbow fracture-dislocation is found to have an O'Driscoll anteromedial facet fracture of the coronoid. If left untreated, this specific fracture pattern is most likely to result in which of the following complications?

. Posterolateral rotatory instability (PLRI)
. Valgus instability in extension
. Varus posteromedial rotatory instability
. Isolated radiocapitellar arthritis
. Ulnar nerve subluxation

Correct Answer & Explanation

. Varus posteromedial rotatory instability

Explanation

The anteromedial facet of the coronoid is critical for resisting varus forces. Failure to fix these fractures typically leads to varus posteromedial rotatory instability and rapid onset of elbow arthrosis.

Question 790

Topic: Elbow & Forearm

When evaluating pediatric forearm radiographs for a suspected Monteggia equivalent injury, which radiographic line is most reliable to confirm a reduced radiocapitellar joint?

. The anterior humeral line should bisect the middle third of the capitellum.
. The radiocapitellar line should bisect the capitellum in all radiographic views.
. Baumann's angle should measure less than 75 degrees.
. The coronoid line should intersect the radial neck.
. The radioulnar line must be parallel to the interosseous membrane.

Correct Answer & Explanation

. The radiocapitellar line should bisect the capitellum in all radiographic views.

Explanation

The radiocapitellar line is drawn through the center of the radial shaft and neck. To rule out a radial head dislocation, this line must intersect the center of the capitellum on every radiographic view, regardless of the elbow's flexion angle.

Question 791

Topic: Elbow & Forearm

During the lateral reconstruction phase of a terrible triad injury, the LCL complex must be reattached to its anatomic footprint to ensure isometric stability. Where is the precise isometric origin of the LCL on the humerus?

. Base of the lateral epicondyle, at the center of capitellar curvature
. Anterior and distal to the lateral epicondyle
. Posterior and proximal to the lateral epicondyle
. At the supracondylar ridge
. Directly on the articular margin of the capitellum

Correct Answer & Explanation

. Base of the lateral epicondyle, at the center of capitellar curvature

Explanation

The isometric point for the LCL (specifically the lateral ulnar collateral ligament, LUCL) is located at the center of rotation of the capitellum. This corresponds to the base of the lateral epicondyle.

Question 792

Topic: Elbow & Forearm

A 6-year-old child presents with an isolated plastic deformation of the ulna and an anterior radial head dislocation that occurred 3 weeks ago. Closed reduction attempts in the emergency department fail. What is the most appropriate management?

. Open reduction of the radial head with annular ligament reconstruction
. Osteotomy of the ulna to correct the bowing, followed by radial head reduction
. Excision of the radial head
. Observation until skeletal maturity
. Application of a hinged elbow brace

Correct Answer & Explanation

. Osteotomy of the ulna to correct the bowing, followed by radial head reduction

Explanation

Plastic deformation of the ulna acts as a Bado Type I Monteggia equivalent. Failure to correct the ulnar bowing prevents stable reduction of the radial head; therefore, an ulnar osteotomy is required.

Question 793

Topic: 9. Shoulder and Elbow

After completing rigid internal fixation of the coronoid and radial head, and repairing the LCL in a terrible triad injury, the elbow drops out of joint when extended past 30 degrees. What is the most appropriate next step?

. Apply a splint in 90 degrees of flexion and avoid early motion.
. Perform a medial collateral ligament (MCL) repair or place a hinged external fixator.
. Revise the LCL repair using a larger suture anchor.
. Resect the radial head to decompress the joint.
. Release the anterior capsule.

Correct Answer & Explanation

. Perform a medial collateral ligament (MCL) repair or place a hinged external fixator.

Explanation

If the elbow remains unstable in extension after addressing the coronoid, radial head, and LCL, it indicates severe capsuloligamentous injury involving the MCL. The next step is MCL repair or a hinged external fixator to allow early range of motion.

Question 794

Topic: Elbow & Forearm

Which of the following characteristics is most closely associated with a Bado Type II Monteggia fracture-dislocation compared to other Bado types?

. It is the most common pattern in pediatric patients.
. It is frequently associated with radial head and coronoid fractures.
. It typically presents with a high radial nerve palsy.
. The radial head dislocates anteriorly.
. It is optimally treated with closed reduction and casting in adults.

Correct Answer & Explanation

. It is frequently associated with radial head and coronoid fractures.

Explanation

Bado Type II involves posterior dislocation of the radial head and a posterior angulated ulnar fracture. It is highly associated with elbow fracture-dislocations, including concomitant radial head and coronoid fractures.

Question 795

Topic: Elbow & Forearm
A Bado Type III Monteggia fracture-dislocation is radiographically defined by which of the following features?
. Anterior dislocation of the radial head with middle-third ulnar fracture
. Posterior dislocation of the radial head with proximal ulnar fracture
. Lateral or anterolateral dislocation of the radial head with proximal ulnar metaphyseal fracture
. Anterior dislocation of the radial head with a concomitant radial shaft fracture
. Isolated dislocation of the distal radioulnar joint (DRUJ)

Correct Answer & Explanation

. Lateral or anterolateral dislocation of the radial head with proximal ulnar metaphyseal fracture

Explanation

Bado Type III injuries feature a lateral or anterolateral dislocation of the radial head combined with a fracture of the proximal ulnar metaphysis. This pattern is primarily seen in pediatric patients.

Question 796

Topic: Elbow & Forearm

When performing open reduction and internal fixation of the radial head using a plate, the hardware must be placed within the "safe zone" to prevent impingement on the proximal radioulnar joint (PRUJ). This safe zone corresponds to an arc of approximately how many degrees?

. 45 degrees
. 90 degrees
. 180 degrees
. 270 degrees
. 360 degrees

Correct Answer & Explanation

. 90 degrees

Explanation

The "safe zone" for radial head hardware placement spans approximately 90 to 110 degrees on the non-articulating lateral aspect of the radial head. It is defined by an arc from the radial styloid to Lister's tubercle with the forearm in neutral rotation.

Question 797

Topic: Elbow & Forearm

Which of the following structures must be preserved or carefully repaired during the Boyd approach to the proximal ulna to prevent a debilitating complication in Monteggia fracture management?

. The superficial branch of the radial nerve
. The lateral ulnar collateral ligament (LUCL)
. The medial antebrachial cutaneous nerve
. The recurrent interosseous artery
. The anconeus insertion

Correct Answer & Explanation

. The lateral ulnar collateral ligament (LUCL)

Explanation

The Boyd approach reflects the supinator and anconeus off the proximal ulna. If dissection proceeds too far anteriorly or distally without protecting the lateral ligamentous complex, the LUCL can be compromised, resulting in iatrogenic posterolateral rotatory instability (PLRI).

Question 798

Topic: Shoulder Pathology

During an open reduction and internal fixation of a Rockwood Type V AC joint separation, the surgeon is carefully dissecting to expose the coracoid process for coracoclavicular ligament reconstruction. The anatomical illustration below highlights the relevant structures.

Which critical neurovascular structure is at the highest risk of iatrogenic injury if dissection is not meticulously performed, particularly when drilling tunnels through the base of the coracoid?

. Axillary nerve
. Suprascapular nerve
. Brachial plexus and subclavian vessels
. Cephalic vein
. Long thoracic nerve

Correct Answer & Explanation

. Brachial plexus and subclavian vessels

Explanation

Correct Answer: CThe case explicitly states that 'The brachial plexus and subclavian vessels lie inferior and medial to the coracoid process. Extreme caution is required during surgical dissection and drilling around the coracoid to avoid iatrogenic injury.' These structures are immediately adjacent to the coracoid base, making them highly vulnerable during tunnel drilling or aggressive dissection.Option A:The axillary nerve is typically located more inferiorly and posteriorly, wrapping around the surgical neck of the humerus, and is less directly at risk during coracoid exposure for AC joint reconstruction.Option B:The suprascapular nerve passes through the suprascapular notch and is at risk during procedures involving the scapular neck or glenoid, but not typically during coracoid exposure.Option D:The cephalic vein is located more laterally in the deltopectoral groove and, while needing protection, is generally less critical than the major neurovascular bundle medial to the coracoid.Option E:The long thoracic nerve runs along the medial border of the scapula and is at risk during procedures involving the chest wall or scapular dissection, not typically during coracoid exposure.

Question 799

Topic: 9. Shoulder and Elbow
A 29-year-old patient is 4 weeks post-operative from an AC joint reconstruction with a suture-button system. They are currently in Phase I (Protection & Early Motion) of their rehabilitation protocol. Which of the following activities is strictly contraindicated at this stage to protect the healing repair?
. Gentle pendulum exercises for the shoulder.
. Active range of motion exercises for the elbow, wrist, and hand.
. Passive shoulder flexion to 90 degrees under therapist guidance.
. Active cross-body adduction of the operative arm.
. Gentle scapular retraction exercises (non-weight bearing).

Correct Answer & Explanation

. Active cross-body adduction of the operative arm.

Explanation

Correct Answer: D. Phase I of rehabilitation (4-6 weeks post-op) is focused on protecting the healing repair and maintaining passive range of motion. The guidelines explicitly state to 'avoid cross-body adduction or AC joint compression' and 'No lifting, pushing, pulling, or active shoulder movements against resistance.' Active cross-body adduction directly stresses the AC joint and could jeopardize the repair. Option A: Gentle pendulum exercises are initiated around 1-2 weeks post-op and are appropriate for Phase I. Option B: Active range of motion exercises for the elbow, wrist, and hand should begin immediately post-op to prevent stiffness. Option C: Gentle passive shoulder flexion (0-90 degrees) may be initiated around 2-3 weeks under therapist guidance, making it an appropriate activity for Phase I. Option E: Gentle scapular retraction and protraction exercises (non-weight bearing) are encouraged to maintain scapulothoracic mobility.

Question 800

Topic: 9. Shoulder and Elbow

A 35-year-old male falls on the point of his shoulder. Clinical examination suggests an AC joint injury, but standard AP views of the shoulder show overlapping structures. Which radiographic view is most appropriate to isolate and evaluate the AC joint without scapular spine superimposition?

. Stryker notch view
. West Point axillary view
. Zanca view
. Garth view
. Serendipity view

Correct Answer & Explanation

. Zanca view

Explanation

The Zanca view is performed with a 10-15 degree cephalad tilt of the X-ray beam. This removes the superimposition of the scapular spine, allowing clear visualization of the AC joint.

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