Menu

9. Shoulder and Elbow MCQs

Practice Set 77 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 1521

Topic: Elbow & Forearm

A 40-year-old male sustained an elbow fracture-dislocation and is diagnosed with posteromedial rotatory instability (PMRI). Which of the following combinations of injury is the hallmark of PMRI?

. Radial head fracture, coronoid tip fracture, and lateral ulnar collateral ligament (LUCL) tear
. Anteromedial facet coronoid fracture and lateral ulnar collateral ligament (LUCL) tear
. Olecranon fracture and medial collateral ligament (MCL) tear
. Capitellum fracture and medial collateral ligament (MCL) tear
. Radial head fracture and complete disruption of the interosseous membrane

Correct Answer & Explanation

. Anteromedial facet coronoid fracture and lateral ulnar collateral ligament (LUCL) tear

Explanation

Posteromedial rotatory instability (PMRI) of the elbow occurs secondary to a varus and posteromedial rotatory force. The hallmark pathoanatomy includes an anteromedial facet fracture of the coronoid process combined with a tear of the lateral collateral ligament complex (specifically the LUCL). Failure to recognize and stabilize the anteromedial coronoid facet leads to rapid development of varus instability and early post-traumatic arthritis.

Question 1522

Topic: Elbow & Forearm

A 25-year-old male sustains an Essex-Lopresti injury characterized by a comminuted radial head fracture, DRUJ dislocation, and interosseous membrane disruption. The radial head is deemed unsalvageable. Radial head excision without replacement is contraindicated in this setting due to the risk of which of the following?

. Proximal migration of the radius and ulnocarpal impaction
. Posterolateral rotatory instability (PLRI) of the elbow
. Heterotopic ossification of the interosseous membrane (synostosis)
. Ulnar nerve entrapment at the cubital tunnel
. Avascular necrosis of the scaphoid

Correct Answer & Explanation

. Proximal migration of the radius and ulnocarpal impaction

Explanation

An Essex-Lopresti injury disrupts the longitudinal radioulnar axis. The radial head is a crucial secondary stabilizer against proximal translation of the radius. If the radial head is excised without prosthetic replacement when the interosseous membrane is torn, the radius will migrate proximally, leading to severe DRUJ incongruity, distal ulna abutment against the carpus (ulnocarpal impaction), and profound wrist pain/dysfunction. A radial head arthroplasty is mandatory.

Question 1523

Topic: Elbow & Forearm

During a single-incision anterior approach for a distal biceps tendon repair, excessive lateral retraction is applied to expose the radial tuberosity. Postoperatively, the patient complains of numbness and paresthesias along the lateral aspect of their volar forearm. Which nerve was most likely injured?

. Superficial radial nerve
. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABCN)
. Medial antebrachial cutaneous nerve (MABCN)
. Palmar cutaneous branch of the median nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

The Lateral Antebrachial Cutaneous Nerve (LABCN), a continuation of the musculocutaneous nerve, exits between the biceps and brachialis and runs laterally in the distal arm and proximal forearm. It is highly susceptible to stretch or transection during the anterior single-incision approach to the distal biceps, particularly with overzealous lateral retraction. It provides sensation to the lateral aspect of the volar forearm.

Question 1524

Topic: Elbow & Forearm

A patient presents with a coronal shear fracture of the distal humerus involving the capitellum and the lateral ridge of the trochlea. According to the Dubberley classification, what specific radiographic feature defines the suffix 'B' in this injury?

. Extension into the medial epicondyle
. Concomitant radial head fracture
. Posterior condylar comminution
. Lateral collateral ligament avulsion
. Anterior cortical impaction

Correct Answer & Explanation

. Posterior condylar comminution

Explanation

In the Dubberley classification of capitellar fractures, Type 1 involves the capitellum, Type 2 involves the capitellum and trochlea, and Type 3 is comminuted. The suffix 'A' indicates an intact posterior condyle, while 'B' indicates posterior condylar comminution, which often necessitates posterior supplemental fixation.

Question 1525

Topic: Elbow & Forearm

A 35-year-old female sustains a highly comminuted capitellum and trochlea fracture extending into the posterior column (Dubberley Type 3B). Which surgical approach provides the most optimal exposure for bicolumnar fixation of this specific injury pattern?

. Extended lateral approach (Kocher interval)
. Universal posterior approach with olecranon osteotomy
. Anterolateral approach
. Medial over-the-top approach
. Extensile volar approach

Correct Answer & Explanation

. Universal posterior approach with olecranon osteotomy

Explanation

While an extended lateral approach is common for isolated capitellar fractures, Dubberley Type 3 fractures involving both the capitellum and trochlea with posterior comminution often require a posterior approach with an olecranon osteotomy for adequate visualization and stable bicolumnar fixation.

Question 1526

Topic: Elbow & Forearm

A 40-year-old male falls from a height and sustains a comminuted, unsalvageable radial head fracture. During examination, he reports severe pain at the ipsilateral wrist, and the distal radioulnar joint (DRUJ) is grossly unstable. What is the most appropriate management?

. Radial head excision alone
. Radial head arthroplasty, pinning of the DRUJ, and immobilization in supination
. Radial head excision and ulnar shortening osteotomy
. Open reduction internal fixation of the radial head despite comminution
. Silicone radial head replacement and early mobilization

Correct Answer & Explanation

. Radial head arthroplasty, pinning of the DRUJ, and immobilization in supination

Explanation

This patient has an Essex-Lopresti injury, consisting of a radial head fracture, interosseous membrane tear, and DRUJ disruption. Radial head excision is contraindicated as it leads to proximal radial migration; treatment requires rigid radial head arthroplasty and DRUJ stabilization.

Question 1527

Topic: Elbow & Forearm

A surgeon is planning a distal biceps tendon repair using a two-incision technique (modified Boyd-Anderson). Which complication is specifically increased with the two-incision technique compared to a single anterior incision approach?

. Lateral antebrachial cutaneous nerve neuropraxia
. Radial nerve transection
. Heterotopic ossification (radioulnar synostosis)
. Posterior interosseous nerve injury
. Rerupture of the biceps tendon

Correct Answer & Explanation

. Heterotopic ossification (radioulnar synostosis)

Explanation

The two-incision technique was historically associated with a higher risk of radioulnar synostosis, especially if the interosseous membrane is violated or muscle planes are not respected. The single-incision technique carries a higher risk of lateral antebrachial cutaneous nerve (LABC) injury.

Question 1528

Topic: 9. Shoulder and Elbow

A 45-year-old man falls on an outstretched hand and sustains a terrible triad injury of the elbow. Intraoperatively, after fixation of the radial head and repair of the lateral ulnar collateral ligament (LUCL), the elbow remains unstable in extension. What is the most appropriate next step?

. Repair of the medial collateral ligament (MCL)
. Fixation of the coronoid fracture
. Application of a hinged external fixator
. Casting in 90 degrees of flexion
. Resection of the radial head

Correct Answer & Explanation

. Fixation of the coronoid fracture

Explanation

In a terrible triad injury, the coronoid fracture should be addressed if the elbow remains unstable after radial head fixation and LUCL repair. The coronoid is a primary restraint to posterior translation of the ulna, and stabilizing it restores the anterior buttress.

Question 1529

Topic: 9. Shoulder and Elbow

A 68-year-old woman with osteopenia falls and sustains a comminuted, displaced intra-articular distal humerus fracture. Due to severe comminution and poor bone quality, total elbow arthroplasty (TEA) is planned. Which of the following is a strict contraindication to acute TEA in this setting?

. Age younger than 70 years
. Coronal shear fracture of the capitellum
. Complete loss of the lateral column
. Non-functioning triceps muscle
. Active elbow joint infection

Correct Answer & Explanation

. Active elbow joint infection

Explanation

Active joint infection is an absolute contraindication to any total joint arthroplasty, including the elbow. Triceps dysfunction is a relative contraindication or requires a triceps-sparing approach, but active infection precludes immediate arthroplasty entirely.

Question 1530

Topic: Elbow & Forearm

What is the recommended sequence of surgical reconstruction for a "terrible triad" injury of the elbow?

. MCL repair, LCL repair, radial head, coronoid
. Coronoid, radial head, LCL repair
. Radial head, coronoid, MCL repair
. LCL repair, coronoid, radial head, MCL repair
. Radial head, LCL repair, coronoid

Correct Answer & Explanation

. Coronoid, radial head, LCL repair

Explanation

The standard surgical sequence for a terrible triad injury of the elbow (radial head fracture, coronoid fracture, and elbow dislocation) is fixation of the coronoid, followed by the radial head, and finally repair of the lateral collateral ligament (LCL).

Question 1531

Topic: Elbow & Forearm
A 40-year-old female presents with a displaced fracture of the capitellum that includes the lateral trochlear ridge. According to the Bryan and Morrey classification, what type of fracture is this, and what is the preferred treatment?
. Type I; closed reduction and casting
. Type II; fragment excision
. Type III; nonoperative management
. Type IV; open reduction and internal fixation
. Type I; open reduction and internal fixation

Correct Answer & Explanation

. Type IV; open reduction and internal fixation

Explanation

A Type IV Bryan and Morrey capitellum fracture involves the capitellum and extends medially to include the lateral trochlear ridge. Open reduction and internal fixation is indicated to restore joint congruity and elbow stability.

Question 1532

Topic: Elbow & Forearm

A 38-year-old female falls on an outstretched hand and sustains a comminuted radial head fracture. On examination, she complains of severe wrist pain and has tenderness over the distal radioulnar joint (DRUJ). Which of the following treatments is contraindicated?

. Open reduction and internal fixation of the radial head
. Radial head arthroplasty
. Radial head excision alone
. Closed reduction and casting of the forearm
. Fixation of the radial head with DRUJ pinning

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

The patient has an Essex-Lopresti injury, characterized by a radial head fracture, interosseous membrane disruption, and DRUJ dislocation. Radial head excision alone is contraindicated as it will lead to proximal migration of the radius and chronic wrist pain.

Question 1533

Topic: 9. Shoulder and Elbow

A 45-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. He undergoes operative management. To restore elbow stability, what is the most widely accepted sequence of surgical reconstruction for this specific injury pattern?

. Radial head, coronoid, lateral collateral ligament (LCL)
. Coronoid, radial head, lateral collateral ligament (LCL)
. Lateral collateral ligament (LCL), radial head, coronoid
. Medial collateral ligament (MCL), coronoid, radial head
. Coronoid, medial collateral ligament (MCL), lateral collateral ligament (LCL)

Correct Answer & Explanation

. Coronoid, radial head, lateral collateral ligament (LCL)

Explanation

The standard surgical sequence for a terrible triad injury is fixation of the coronoid first, followed by repair or replacement of the radial head, and finally repair of the lateral collateral ligament. Medial collateral ligament repair or hinged external fixation is only added if the elbow remains unstable after these steps.

Question 1534

Topic: Elbow & Forearm

A 35-year-old female presents with a highly comminuted distal humerus fracture after a fall. Imaging identifies a type IV capitellum fracture according to the McKee modification of the Bryan and Morrey classification. What specific finding defines this fracture type?

. Pure articular cartilage shear fracture without subchondral bone
. Comminuted fracture strictly isolated to the capitellar articular surface
. Coronal shear fracture extending laterally to the epicondyle
. Large osseous piece of the capitellum without any trochlear involvement
. Coronal shear fracture involving the capitellum and the majority of the trochlea

Correct Answer & Explanation

. Coronal shear fracture involving the capitellum and the majority of the trochlea

Explanation

A Type IV capitellum fracture involves a coronal shear fracture that propagates medially to include the capitellum and a large portion of the trochlea. This often produces the classic 'double-arc sign' on a lateral radiograph.

Question 1535

Topic: 9. Shoulder and Elbow

Which of the following statements regarding the use of thermal shrinkage during arthroscopic shoulder surgery is most accurate? Review Topic

. The amount of shrinkage is fixed for a given peak temperature, irrespective of the time of application.
. Denatured capsular tissue does not undergo a healing response.
. The capsule is typically found to be thick and fibrotic in revision cases following thermal shrinkage.
. Patients with good results at 1 year are unlikely to develop recurrent instability in the future.
. High failure rates have been reported in its use for anterior, posterior, and multidirectional instability.

Correct Answer & Explanation

. High failure rates have been reported in its use for anterior, posterior, and multidirectional instability.

Explanation

Reports of clinical results at 2- and 5-year follow-up indicate much higher failure rates than traditional stabilization techniques for all common instability patterns. The degree of capsular shrinkage is dependent on the total amount of thermal energy delivered, as well as the rate of delivery. Denatured tissue undergoes a healing response. The capsule typically encountered in revision cases is thin and patulous, rather than thick and fibrotic.

Question 1536

Topic: 9. Shoulder and Elbow

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture), what is the most widely accepted sequential protocol to restore elbow stability?

. Repair of the coronoid, followed by the radial head, then the lateral collateral ligament (LCL)
. Repair of the LCL, followed by the radial head, then the coronoid
. Repair of the radial head, followed by the coronoid, then the LCL
. Repair of the medial collateral ligament (MCL), followed by the coronoid, then the radial head
. Repair of the coronoid, followed by the LCL, then the radial head

Correct Answer & Explanation

. Repair of the coronoid, followed by the radial head, then the lateral collateral ligament (LCL)

Explanation

The standard surgical protocol for a terrible triad injury, popularized by Pugh et al., involves fixing structures from deep to superficial, typically starting anterior to posterior or inside-out. The sequence is: 1) Coronoid fracture fixation or anterior capsule repair, 2) Radial head fixation or replacement, 3) LCL repair to the lateral epicondyle. If the elbow remains unstable after these steps, the MCL is repaired or a hinged external fixator is applied.

Question 1537

Topic: Elbow & Forearm

When comparing the single anterior incision to the two-incision technique for distal biceps tendon repair, the single anterior incision is associated with a higher risk of injury to which of the following nerves?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABCN)
. Superficial radial nerve
. Ulnar nerve
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

The single-incision anterior approach for distal biceps repair is associated with a higher risk of neurapraxia to the lateral antebrachial cutaneous nerve (LABCN), which is often retracted laterally during the exposure. The two-incision technique historically carries a higher risk of heterotopic ossification and potential injury to the posterior interosseous nerve (PIN) during the posterior exposure if the forearm is not fully pronated.

Question 1538

Topic: Elbow & Forearm
A 35-year-old female sustains a coronal shear fracture of the distal humerus. Intraoperative findings reveal the fracture involves the capitellum and the lateral half of the trochlea as a single articular piece. Which classification best describes this specific fracture pattern?
. Bryan and Morrey Type I (Hahn-Steinthal)
. Bryan and Morrey Type II (Kocher-Lorenz)
. Bryan and Morrey Type III (Brogdon)
. Bryan and Morrey Type IV (McKee modification)
. Jupiter Type I

Correct Answer & Explanation

. Bryan and Morrey Type IV (McKee modification)

Explanation

The McKee modification to the Bryan and Morrey classification added the Type IV fracture, which describes a coronal shear fracture involving the capitellum and a large portion of the lateral trochlea as a single fragment. Type I is a large osseous capitellum fragment (Hahn-Steinthal), Type II is a thin articular cartilage fragment with minimal bone (Kocher-Lorenz), and Type III is a comminuted capitellum fracture.

Question 1539

Topic: 9. Shoulder and Elbow

During the late cocking and early acceleration phases of pitching, the ulnar collateral ligament (UCL) of the elbow experiences maximal stress. Which specific structure is the primary restraint to valgus stress at 30, 60, and 90 degrees of elbow flexion?

. Posterior band of the anterior bundle
. Anterior band of the anterior bundle
. Transverse band of the UCL
. Oblique band of the UCL
. Accessory band of the anterior bundle

Correct Answer & Explanation

. Anterior band of the anterior bundle

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. Within the anterior bundle, the anterior band is tense throughout the range of motion and provides the primary restraint up to 90 degrees of flexion, whereas the posterior band becomes taut and contributes more at flexion angles greater than 90 degrees (up to 120 degrees).

Question 1540

Topic: 9. Shoulder and Elbow

A 45-year-old man falls from a ladder and sustains a 'terrible triad' injury of the elbow. He undergoes operative management via a single lateral incision. According to standard treatment protocols for this injury, what is the most appropriate sequence of repair?

. Fixation of the coronoid, fixation or replacement of the radial head, and repair of the lateral collateral ligament (LCL) complex.
. Repair of the medial collateral ligament (MCL), fixation of the radial head, and fixation of the coronoid.
. Fixation of the radial head, repair of the MCL, and repair of the LCL complex.
. Repair of the LCL complex, fixation of the coronoid, and fixation of the radial head.
. Fixation of the radial head, repair of the LCL complex, and fixation of the coronoid.

Correct Answer & Explanation

. Fixation of the radial head, repair of the LCL complex, and fixation of the coronoid.

Explanation

The standard protocol for treating a terrible triad injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture) via a single lateral approach involves working deep to superficial. The sequence is: 1) Coronoid fixation or capsular repair, 2) Radial head fixation or arthroplasty, and 3) LCL complex repair. The MCL is typically only repaired if the elbow remains unstable after these three steps are completed and a hinged external fixator is not preferred.

Test Yourself

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

On this Page