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9. Shoulder and Elbow MCQs

Practice Set 92 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 1821

Topic: 9. Shoulder and Elbow

A 45-year-old man falls on an outstretched hand, sustaining a 'terrible triad' injury of the elbow. To optimally restore elbow kinematics and stability, which of the following represents the most widely accepted surgical sequence?

. Fix the lateral collateral ligament (LCL), fix the coronoid, fix the radial head
. Fix the coronoid, fix the radial head, repair the LCL
. Fix the radial head, repair the LCL, fix the coronoid
. Repair the medial collateral ligament (MCL), fix the radial head, fix the coronoid
. Fix the coronoid, repair the MCL, fix the LCL

Correct Answer & Explanation

. Fix the coronoid, fix the radial head, repair the LCL

Explanation

The standard inside-out surgical sequence for a terrible triad injury is fixation of the coronoid first, followed by the radial head, and finally the LCL complex. This systematically builds stability from the deep anterior structures to the lateral stabilizers.

Question 1822

Topic: 9. Shoulder and Elbow

A 35-year-old sustains a comminuted radial head fracture, a torn interosseous membrane, and distal radioulnar joint (DRUJ) instability. If the surgeon erroneously performs a radial head excision without arthroplasty, what is the most likely long-term complication?

. Proximal radial migration with ulnocarpal impaction
. Heterotopic ossification of the interosseous membrane
. Posterior interosseous nerve palsy
. Recurrent posterior elbow dislocation
. Progressive varus elbow instability

Correct Answer & Explanation

. Proximal radial migration with ulnocarpal impaction

Explanation

This patient has an Essex-Lopresti injury. Excision of the radial head without replacement in the setting of a disrupted interosseous membrane leads to uninhibited proximal migration of the radius, causing severe ulnocarpal impaction and wrist pain.

Question 1823

Topic: Elbow & Forearm

A 45-year-old female sustains a fall on an outstretched hand resulting in an elbow dislocation, a comminuted radial head fracture, and a Type II coronoid fracture. During surgical management of this 'terrible triad' injury, what is the most widely accepted sequence of repair?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for terrible triad injuries proceeds from deep to superficial. This involves coronoid fixation or anterior capsular repair, followed by radial head repair or replacement, and finally LCL complex repair.

Question 1824

Topic: Elbow & Forearm

A 60-year-old female requires open reduction and internal fixation for a Type IV coronal shear fracture of the capitellum that extends into the trochlea (Dubberley Type 3B). Extensive posterior dissection is performed. What is the most significant risk associated with this surgical approach?

. Avascular necrosis of the capitellum
. Transection of the ulnar nerve
. Posterolateral rotatory instability
. Radial nerve palsy
. Nonunion of an olecranon osteotomy

Correct Answer & Explanation

. Avascular necrosis of the capitellum

Explanation

Extensive posterior dissection and stripping of the lateral column to address coronal shear fractures disrupt the tenuous intraosseous blood supply, significantly increasing the risk of avascular necrosis of the capitellum.

Question 1825

Topic: 9. Shoulder and Elbow

A 30-year-old male weightlifter feels a sudden 'pop' and tearing sensation in his chest while performing a heavy bench press. Examination reveals loss of the anterior axillary fold contour and weakness in shoulder internal rotation. Where is the most common anatomic location for this specific rupture?

. The mid-substance of the muscle belly
. The musculotendinous junction
. The sternal origin
. Avulsion of the tendon from its insertion on the humerus
. The clavicular origin

Correct Answer & Explanation

. Avulsion of the tendon from its insertion on the humerus

Explanation

Pectoralis major ruptures almost exclusively occur in young, active males engaged in weightlifting. The most common site of injury is an avulsion of the tendon directly from its insertion on the lateral lip of the bicipital groove of the humerus.

Question 1826

Topic: Elbow & Forearm

A 33-year-old female sustains a highly comminuted radial head fracture. During examination, she complains of severe wrist pain, and radiographs show proximal migration of the radius. Which of the following treatments is absolutely contraindicated?

. Radial head excision alone
. Radial head arthroplasty with DRUJ pinning
. Open reduction and internal fixation of the radial head
. Reconstruction of the interosseous membrane
. Ulnar shortening osteotomy

Correct Answer & Explanation

. Radial head arthroplasty with DRUJ pinning

Explanation

This patient has an Essex-Lopresti lesion, consisting of a radial head fracture, interosseous membrane tear, and DRUJ disruption. Radial head excision alone is contraindicated as it leads to unchecked proximal migration of the radius and severe ulnocarpal impaction.

Question 1827

Topic: Elbow & Forearm

Following surgical repair of a terrible triad elbow injury (radial head replacement, coronoid fixation, and LCL repair), a patient is noted to have a persistent block to forearm pronation. Which of the following is the most likely cause?

. Over-tightening of the medial collateral ligament
. An oversized radial head arthroplasty prosthesis
. Heterotopic ossification of the brachialis muscle
. Unrecognized capitellum fracture
. Malunion of the coronoid process

Correct Answer & Explanation

. An oversized radial head arthroplasty prosthesis

Explanation

An oversized (overstuffed) radial head prosthesis after a terrible triad injury causes excessive radiocapitellar pressure. This leads to a mechanical block in forearm rotation, most commonly pronation, as well as limited flexion.

Question 1828

Topic: Elbow & Forearm

A 7-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 appropriate next step?

. Perform an open reduction of the radiocapitellar joint and repair the annular ligament
. Accept the alignment and cast in 90 degrees of flexion
. Improve the reduction of the ulnar shaft fracture
. Perform a radial head excision
. Perform an osteotomy of the proximal radius

Correct Answer & Explanation

. Improve the reduction of the ulnar shaft fracture

Explanation

In pediatric Monteggia fractures, the radial head dislocation is almost always secondary to the ulnar deformity. If the radial head remains dislocated, it usually means ulnar length or bow is not adequately restored, so improving the ulnar reduction is the critical next step.

Question 1829

Topic: Elbow & Forearm

A 38-year-old female sustains a fracture of the capitellum that extends medially to include the lateral aspect of the trochlea, with a separate posterior comminuted fragment. According to the Dubberley classification, what type of fracture is this?

. Type 1A
. Type 2A
. Type 3A
. Type 3B
. Type 4B

Correct Answer & Explanation

. Type 3B

Explanation

The Dubberley classification distinguishes capitellar fractures based on trochlear extension. Type 3 involves both the capitellum and the trochlea. The "B" modifier indicates posterior condylar comminution.

Question 1830

Topic: 9. Shoulder and Elbow
A 28-year-old female presents with an elbow injury. Radiographs and CT reveal a coronal shear fracture of the capitellum that extends medially to include the lateral trochlear ridge. According to the modified Bryan-Morrey classification, what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV (McKee)
. Type V

Correct Answer & Explanation

. Type IV (McKee)

Explanation

A Bryan-Morrey Type IV fracture, as described by McKee, involves a coronal shear fracture of the capitellum extending to include the lateral trochlear ridge. This fragment creates significant articular instability and typically requires operative fixation.

Question 1831

Topic: 9. Shoulder and Elbow

An anteromedial facet fracture of the coronoid process typically results from varus posteromedial rotatory instability (VPMRI) of the elbow. Which ligamentous structure is most commonly ruptured in this specific injury pattern?

. Lateral ulnar collateral ligament (LUCL)
. Medial ulnar collateral ligament (MUCL)
. Annular ligament
. Radial collateral ligament
. Anterior band of the MUCL

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

VPMRI is caused by a varus force on the elbow, leading to rupture of the lateral collateral ligament complex (specifically the LUCL) and a shearing fracture of the anteromedial facet of the coronoid. Treatment requires addressing both the bony and ligamentous instability.

Question 1832

Topic: Elbow & Forearm
A 40-year-old female falls on an outstretched hand and sustains a coronal shear fracture of the distal humerus that involves the capitellum and extends medially to include the majority of the trochlea. According to the Bryan and Morrey classification with McKee's modification, what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broghter)
. Type IV (McKee modification)
. Type V (Bicolumnar shear)

Correct Answer & Explanation

. Type IV (McKee modification)

Explanation

The McKee modification added the Type IV fracture to the Bryan and Morrey classification. A Type IV lesion represents a coronal shear fracture that involves the capitellum and extends medially to include the majority of the trochlea, often necessitating separate medial and lateral internal fixation.

Question 1833

Topic: 9. Shoulder and Elbow

In the context of elbow trauma, the anteromedial facet of the coronoid is critical for resisting varus posteromedial rotatory instability. Which ligamentous structure attaches directly to the sublime tubercle on the anteromedial facet?

. Lateral ulnar collateral ligament (LUCL)
. Anterior bundle of the medial ulnar collateral ligament (MUCL)
. Posterior bundle of the medial ulnar collateral ligament (MUCL)
. Annular ligament
. Radial collateral ligament

Correct Answer & Explanation

. Anterior bundle of the medial ulnar collateral ligament (MUCL)

Explanation

The anterior bundle of the medial ulnar collateral ligament (MUCL) inserts onto the sublime tubercle, which is located on the anteromedial facet of the coronoid process. Fractures involving this facet compromise the MUCL insertion, leading to varus posteromedial rotatory instability of the elbow.

Question 1834

Topic: 9. Shoulder and Elbow

A 45-year-old male falls from a ladder and sustains a complex elbow injury. Radiographs reveal a posterior elbow dislocation, a comminuted radial head fracture, and a Type II coronoid fracture. Operative intervention is planned. What is the recommended sequence of surgical reconstruction to restore elbow stability?

. Coronoid fixation, followed by radial head arthroplasty or fixation, then lateral collateral ligament complex repair
. Lateral collateral ligament repair, followed by radial head arthroplasty, then coronoid fixation
. Radial head arthroplasty, followed by lateral collateral ligament repair, then coronoid fixation
. Medial collateral ligament repair, followed by radial head arthroplasty, then coronoid fixation
. Coronoid fixation, followed by medial collateral ligament repair, then radial head arthroplasty

Correct Answer & Explanation

. Coronoid fixation, followed by radial head arthroplasty or fixation, then lateral collateral ligament complex repair

Explanation

The terrible triad of the elbow requires a systematic deep-to-superficial (inside-out) approach. The standard sequence is coronoid fixation, followed by radial head replacement or fixation, and finally lateral collateral ligament complex repair.

Question 1835

Topic: 9. Shoulder and Elbow

A 32-year-old male with a history of seizure disorder presents to the emergency department with severe shoulder pain and an inability to externally rotate his arm. An anteroposterior (AP) radiograph demonstrates a symmetrically rounded appearance of the humeral head. What is the most likely diagnosis?

. Posterior shoulder dislocation
. Anterior shoulder dislocation
. Inferior shoulder dislocation (luxatio erecta)
. Massive rotator cuff tear
. Adhesive capsulitis

Correct Answer & Explanation

. Posterior shoulder dislocation

Explanation

The lightbulb sign on an AP radiograph represents a posterior shoulder dislocation, commonly seen following seizures or electrocution. The humeral head is locked in internal rotation, creating a symmetrical rounded appearance.

Question 1836

Topic: Elbow & Forearm

A 45-year-old man falls on an outstretched hand and sustains a terrible triad injury of the elbow. What is the recommended surgical sequence for repairing these injuries?

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

Correct Answer & Explanation

. Coronoid fixation, radial head fixation, LCL repair

Explanation

The standard surgical sequence for a terrible triad injury is to address deep to superficial structures. Fixation progresses from the coronoid, then the radial head, and finally the lateral collateral ligament (LCL) complex to restore stability from the inside out.

Question 1837

Topic: Elbow & Forearm

A 45-year-old man sustains a terrible triad injury of the elbow consisting of an elbow dislocation, radial head fracture, and coronoid fracture. What is the generally recommended surgical sequence of reconstruction?

. Radial head fixation, coronoid fixation, LCL repair
. Coronoid fixation, radial head repair or replacement, LCL repair
. LCL repair, radial head repair or replacement, coronoid fixation
. Coronoid fixation, LCL repair, radial head repair or replacement
. MCL repair, radial head repair or replacement, LCL repair

Correct Answer & Explanation

. Coronoid fixation, LCL repair, radial head repair or replacement

Explanation

The classic inside-out sequence of surgical reconstruction for a terrible triad injury begins deep with the coronoid. This is followed by radial head fixation or arthroplasty, and finally repair of the lateral collateral ligament (LCL) complex to restore stability.

Question 1838

Topic: Elbow & Forearm

A 45-year-old man sustains a terrible triad injury to his elbow. During surgical reconstruction, what is the recommended sequence of repair to restore elbow stability?

. LUCL, radial head, coronoid
. Coronoid, radial head, LUCL
. Radial head, LUCL, coronoid
. Coronoid, LUCL, radial head
. LUCL, coronoid, radial head

Correct Answer & Explanation

. Coronoid, radial head, LUCL

Explanation

Standard surgical protocol for a terrible triad injury involves repairing structures from deep to superficial: the coronoid first, followed by the radial head, and finally the lateral ulnar collateral ligament (LUCL).

Question 1839

Topic: 9. Shoulder and Elbow

A 45-year-old man falls on his outstretched hand and sustains a terrible triad injury of the elbow.

During the standard lateral surgical approach, which of the following structures is typically repaired last to restore elbow stability?

. Coronoid process
. Lateral collateral ligament (LCL) complex
. Radial head
. Medial collateral ligament (MCL)
. Common extensor origin

Correct Answer & Explanation

. Coronoid process

Explanation

The standard surgical approach for a terrible triad injury involves addressing structures from deep to superficial. The coronoid is addressed first, followed by radial head fixation or arthroplasty, and finally the lateral collateral ligament complex is repaired. The MCL is typically only addressed if the elbow remains unstable after restoring the lateral-sided structures.

Question 1840

Topic: Elbow & Forearm

A 42-year-old man falls on an outstretched hand and sustains a "terrible triad" injury to his elbow. During surgical reconstruction, what is the recommended sequence of repair to restore elbow stability?

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

Correct Answer & Explanation

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

Explanation

The standard surgical protocol for terrible triad injuries is a deep-to-superficial approach. The anterior column (coronoid) is fixed first, followed by the lateral column (radial head fixation or arthroplasty), and finally the LCL complex is repaired to the lateral epicondyle.

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