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9. Shoulder and Elbow MCQs

Practice Set 9 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 161

Topic: Elbow & Forearm

An 8-year-old aspiring baseball pitcher complains of lateral elbow pain. Radiographs reveal flattening and sclerosis of the capitellum. The physis is open. What is the most likely diagnosis?

. Medial epicondyle apophysitis
. Panner disease
. Osteochondritis dissecans (OCD) of the radial head
. Lateral epicondylitis
. Little league elbow

Correct Answer & Explanation

. Panner disease

Explanation

Panner disease is a self-limiting osteochondrosis of the capitellum occurring typically in children under 10 years old. In contrast, osteochondritis dissecans (OCD) of the capitellum usually affects older adolescents and carries a worse prognosis.

Question 162

Topic: 9. Shoulder and Elbow

A 6-year-old child sustains an elbow injury. A lateral radiograph

is obtained to evaluate the anterior humeral line. In a normal pediatric elbow, the anterior humeral line should intersect which portion of the capitellum?

. Anterior third
. Middle third
. Posterior third
. It should pass entirely anterior to the capitellum
. It should pass entirely posterior to the capitellum

Correct Answer & Explanation

. Anterior third

Explanation

On a true lateral radiograph of a normal pediatric elbow, the anterior humeral line should pass through the middle third of the capitellum. In an extension-type supracondylar fracture, it frequently passes anterior to the capitellum.

Question 163

Topic: Elbow & Forearm
A 9-year-old boy sustains a radial neck fracture with 45 degrees of angulation. Closed reduction in the emergency department fails. What is the most appropriate next step in management?
. Open reduction and plate fixation
. Open reduction and cross-pinning
. Closed reduction with percutaneous intramedullary pinning (Métaizeau technique)
. Radial head excision
. Cast immobilization in current position

Correct Answer & Explanation

. Closed reduction with percutaneous intramedullary pinning (Métaizeau technique)

Explanation

For pediatric radial neck fractures with unacceptable angulation (>30 degrees) that fail closed reduction, percutaneous intramedullary pinning (Métaizeau technique) is the treatment of choice. Open reduction is avoided if possible due to the high risk of avascular necrosis.

Question 164

Topic: Elbow & Forearm

A radiograph of a 7-year-old child's forearm

reveals an isolated fracture of the proximal ulna with apex anterior angulation. Which of the following is the most critical next step in evaluating this radiograph?

. Assess for an associated distal radius fracture
. Assess the radiocapitellar alignment to rule out a radial head dislocation
. Check the Baumann angle of the elbow
. Evaluate for a coronoid fracture
. Measure the ulnar variance

Correct Answer & Explanation

. Assess the radiocapitellar alignment to rule out a radial head dislocation

Explanation

An isolated ulnar shaft fracture should immediately raise suspicion for a Monteggia fracture-dislocation. The radiocapitellar line must be evaluated on all views to ensure the radial head is normally aligned with the capitellum.

Question 165

Topic: Shoulder Pathology

The largest available free muscle flap comes from which of the following muscles:

. Gracilis muscle
. Serratus anterior muscle
. Latissimus dorsi muscle
. Rectus abdominis muscle
. Brachialis muscle

Correct Answer & Explanation

. Latissimus dorsi muscle

Explanation

The latissimus dorsi provides the largest available free muscle flap. The gracilis provides a long muscle slip and can be innervated and used for certain innervated muscle transfers. The serratus anterior muscle is thin and can be used when bulk is undesirable.

Question 166

Topic: 9. Shoulder and Elbow

A 12-year-old boy sustained the injury shown (Slide 1, Slide 2, and Slide 3). A postreduction film is also presented (Slide 4). Which of the following treatments is the most likely to produce satisfactory results:

. Accept reduction and continue immobilization for 6 weeks
. Increase pronation of forearm and reapply cast
. Increase elbow extension and reapply cast
. Plate fixation of ulna
. Stabilize radiocapitellar joint with pin

Correct Answer & Explanation

. Plate fixation of ulna

Explanation

This patient has a type 1 (anterior) Monteggia fracture. The radial head is not reduced in the splint. Although supination and flexion may stabilize the radius, the radius remained unstable in this patient because it was dislocated with only a slight offset of the ulna. Plate fixation of the ulna is more likely to stabilize the radius in a patient with this injury. After the ulna is fixed with a plate (Slide 5), the radial head cannot be dislocated. Radiocapitellar pinning should be used only as a final option because of the associated risks of stiffness and breakage.

Question 167

Topic: 9. Shoulder and Elbow

A 2-year-old child presents with a sudden onset of refusal to use the right arm after being pulled by the wrist. The arm is held in extension and pronation. Radiographs are normal. What is the most appropriate management?

. Cast immobilization for 3 weeks
. MRI of the elbow
. Supination-flexion maneuver
. Open reduction of the radial head
. Analgesia and observation

Correct Answer & Explanation

. Supination-flexion maneuver

Explanation

Nursemaid's elbow (radial head subluxation) is treated with a closed reduction maneuver involving supination and flexion, or hyperpronation, yielding immediate relief.

Question 168

Topic: 9. Shoulder and Elbow

A neonate is born with internally rotated shoulders, extended elbows, flexed wrists, dislocated hips, and rigid equinovarus foot deformities bilaterally. Sensation and intelligence are normal. Muscle biopsy would most likely show:

. Dystrophin deficiency
. Fibrofatty replacement of muscle fibers
. Inflammatory infiltrates
. Central core myopathy
. Glycogen accumulation

Correct Answer & Explanation

. Fibrofatty replacement of muscle fibers

Explanation

The clinical picture is classic for Amyoplasia, the most common form of Arthrogryposis Multiplex Congenita. The primary pathology is a failure of muscle development due to anterior horn cell deficiency, leading to fibrofatty replacement of muscle and rigid joint contractures.

Question 169

Topic: 9. Shoulder and Elbow
Which of the following conditions is represented by this radiograph of an infant's elbow?
. Salter I fracture of distal humerus
. Elbow dislocation
. Type 2 Monteggia's fracture dislocation
. Septic elbow
. Proximal radioulnar synostosis

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

This patient has a proximal radioulnar synostosis. Patients with proximal radioulnar synostosis often have dysplasia of the proximal ulna, maldirection of the proximal radius, and cortical continuity of the ulna and radius.

Question 170

Topic: 9. Shoulder and Elbow
In a type 1 Monteggia fracture, the position of reduction is:
. Flexion of the elbow and supination of the forearm
. Flexion of the elbow and pronation of the forearm
. Extension of the elbow and pronation of the forearm
. Extension of the elbow and supination of the forearm
. Extension of the elbow and midposition of the forearm

Correct Answer & Explanation

. Flexion of the elbow and supination of the forearm

Explanation

Type 1 Monteggia fracture is associated with an anterior dislocation of the radial head and an apex anterior fracture of the ulna. Type 1 Monteggia fracture is best treated by flexion and supination. The same maneuvers that reduce the ulna will also stabilize the radial head.

Question 171

Topic: Elbow & Forearm

Which of the following aspects of reconstruction of chronic posttraumatic dislocation of the radial head has not been shown to improve the success rate:

. Apex-posterior angulation
. Rigid fixation
. Slight lengthening
. Early range of motion
. Radiocapitellar pin fixation

Correct Answer & Explanation

. Apex-posterior angulation

Explanation

Reconstruction with an ulnar osteotomy with apex-posterior angulation and slight lengthening with rigid fixation to allow early range of motion have been shown to improve results. Radiocapitellar pin fixation may cause arthrosis, breakage, and infection so it is not routinely recommended.

Question 172

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow, which of the following sequences of repair is generally recommended to best restore stability?

. Lateral collateral ligament (LCL), radial head, coronoid
. Coronoid, LCL, radial head
. Coronoid, radial head, LCL
. Radial head, LCL, coronoid
. LCL, coronoid, radial head

Correct Answer & Explanation

. Coronoid, radial head, LCL

Explanation

Standard protocol for terrible triad reconstruction proceeds from deep to superficial and typically from anterior to posterior. The sequence is fixing the coronoid, then repairing or replacing the radial head, and finally repairing the lateral collateral ligament (LCL).

Question 173

Topic: Elbow & Forearm

A 35-year-old female sustains a Dubberley Type 3B capitellum fracture. What specific anatomical feature distinguishes a Type B from a Type A in the Dubberley classification?

. Involvement of the lateral epicondyle
. Extension into the trochlea
. Presence of posterior condylar comminution
. Associated radial head fracture
. Associated lateral collateral ligament tear

Correct Answer & Explanation

. Presence of posterior condylar comminution

Explanation

The Dubberley classification divides capitellum fractures based on the presence (Type B) or absence (Type A) of posterior condylar comminution. This is critical because Type B fractures lack posterior cortical support and often require specific fixation strategies.

Question 174

Topic: Elbow & Forearm

When surgically reconstructing a terrible triad injury of the elbow, which of the following represents the most accepted and standard sequence of repair?

. LCL repair, followed by coronoid fixation, then radial head arthroplasty
. Coronoid fixation, followed by radial head repair/arthroplasty, then LCL repair
. Radial head arthroplasty, followed by coronoid fixation, then LCL repair
. Radial head arthroplasty, followed by LCL repair, then coronoid fixation
. Coronoid fixation, followed by LCL repair, then radial head repair

Correct Answer & Explanation

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

Explanation

The standard inside-out sequence for repairing a terrible triad injury is coronoid fixation first, followed by radial head replacement or fixation, and finally LCL repair. This restores the deep skeletal stabilizers before reconstructing the lateral ligamentous constraints.

Question 175

Topic: Elbow & Forearm

A patient presents with a Dubberley Type 3B fracture of the capitellum. In this classification system, what does the suffix "B" specifically denote?

. Trochlear involvement
. Posterior articular comminution
. Medial column extension
. Associated radial head fracture
. Anterior cortical comminution

Correct Answer & Explanation

. Posterior articular comminution

Explanation

In the Dubberley classification of capitellum fractures, Type 3 denotes comminution. The addition of the suffix "B" indicates posterior articular comminution, which implies a lack of a bony buttress and often necessitates bone grafting or excision.

Question 176

Topic: 9. Shoulder and Elbow

Which of the following ligamentous structures is the primary restraint to valgus stress at the elbow during the throwing motion (between 30 and 120 degrees of flexion)?

. Anterior bundle of the ulnar collateral ligament
. Posterior bundle of the ulnar collateral ligament
. Transverse bundle of the ulnar collateral ligament
. Lateral ulnar collateral ligament
. Annular ligament

Correct Answer & Explanation

. Anterior bundle of the ulnar collateral ligament

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus instability at the elbow. It is most taut from 30 to 120 degrees of flexion, making it a critical stabilizer for throwing athletes.

Question 177

Topic: Elbow & Forearm

The lateral ulnar collateral ligament (LUCL) is the primary stabilizing structure preventing posterolateral rotatory instability (PLRI) of the elbow. Where does this ligament distally insert?

. Radial neck
. Annular ligament
. Supinator crest of the ulna
. Coronoid process
. Olecranon tip

Correct Answer & Explanation

. Supinator crest of the ulna

Explanation

The lateral ulnar collateral ligament (LUCL) acts as a sling supporting the radial head and prevents PLRI. It originates on the lateral epicondyle and inserts on the supinator crest of the proximal ulna.

Question 178

Topic: Elbow & Forearm

In the surgical management of a "terrible triad" injury of the elbow, which of the following sequences of reconstruction provides the most biomechanically stable construct?

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

Correct Answer & Explanation

. Coronoid, LCL, radial head

Explanation

Standard protocol for terrible triad reconstruction generally proceeds from deep to superficial. This involves fixing or replacing the coronoid first, followed by the radial head, and finally repairing the lateral collateral ligament (LCL) complex.

Question 179

Topic: Elbow & Forearm

A 35-year-old patient presents with recurrent clicking and giving way of the elbow when pushing up from a chair. The lateral ulnar collateral ligament (LUCL) is suspected to be deficient. Which physical exam test is most specific for this condition?

. Milking maneuver
. Moving valgus stress test
. Pivot shift test of the elbow
. Hook test
. Tinel's sign at the cubital tunnel

Correct Answer & Explanation

. Pivot shift test of the elbow

Explanation

The lateral pivot shift test of the elbow specifically evaluates for posterolateral rotatory instability (PLRI) caused by LUCL insufficiency. It involves applying an axial load, valgus stress, and supination while flexing the elbow.

Question 180

Topic: Elbow & Forearm

A 6-year-old boy sustains a Bado Type I Monteggia fracture-dislocation. Closed reduction of the ulna is achieved, but the radial head remains anteriorly dislocated. What is the most common anatomical block to reduction of the radial head in this scenario?

. Interposed annular ligament
. Biceps tendon entrapment
. Median nerve entrapment
. Osteochondral fragment from the capitellum
. Brachialis muscle belly

Correct Answer & Explanation

. Interposed annular ligament

Explanation

The annular ligament is the most common structure that becomes interposed and blocks closed reduction of the radial head in a pediatric Monteggia fracture-dislocation. Open reduction is frequently required to extricate the ligament.

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