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9. Shoulder and Elbow MCQs

Practice Set 93 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 1841

Topic: Elbow & Forearm

A 35-year-old woman sustains a displaced type I (Hahn-Steinthal) capitellum fracture. What is the most appropriate management?

. Closed reduction and cast immobilization for 4 weeks
. Open reduction and internal fixation with headless compression screws
. Excision of the fracture fragment
. Fragment excision and radial head arthroplasty
. Hinged elbow external fixation

Correct Answer & Explanation

. Open reduction and internal fixation with headless compression screws

Explanation

A Type I (Hahn-Steinthal) capitellum fracture involves a large osseous piece of the capitellum and part of the trochlea. Open reduction and internal fixation, typically using headless compression screws placed from anterior to posterior, is required to restore articular congruity and allow early motion.

Question 1842

Topic: Elbow & Forearm

A 40-year-old man sustains a highly comminuted radial head fracture, an interosseous membrane disruption, and a DRUJ dislocation. What is the most appropriate management strategy?

. Radial head excision and DRUJ pinning
. Radial head arthroplasty and DRUJ stabilization
. Radial head ORIF and Darrach procedure
. Closed reduction of the elbow and wrist casting
. Radial head excision and interosseous membrane reconstruction

Correct Answer & Explanation

. Radial head arthroplasty and DRUJ stabilization

Explanation

This triad of injuries defines an Essex-Lopresti fracture-dislocation. Excision of the radial head without replacement in this setting is strictly contraindicated as it leads to proximal radial migration; treatment requires radial head arthroplasty and stabilization of the DRUJ.

Question 1843

Topic: 9. Shoulder and Elbow

A 45-year-old male laborer experiences a sudden "pop" in his anterior elbow while lifting a heavy box. On exam, the hook test is positive. Which of the following is true regarding nonoperative versus operative management of this injury?

. Nonoperative management results in an approximate 40% loss of supination strength
. Operative management reliably restores 100% of extension strength
. Operative repair via a two-incision technique has a higher rate of lateral antebrachial cutaneous nerve palsy
. Nonoperative management results in a 50% loss of elbow flexion strength
. Early active motion is contraindicated for 6 weeks following anatomic repair

Correct Answer & Explanation

. Nonoperative management results in an approximate 40% loss of supination strength

Explanation

Distal biceps tendon ruptures treated nonoperatively result in approximately a 40-50% loss of supination strength and 20-30% loss of flexion strength. Operative repair is generally recommended for active individuals primarily to restore supination power and endurance.

Question 1844

Topic: Elbow & Forearm

A 45-year-old male falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. During surgical intervention, what is the most appropriate standard sequence of repair?

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

Correct Answer & Explanation

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

Explanation

The standard surgical algorithm for a terrible triad injury works from deep to superficial and medial to lateral: fixation of the coronoid first, followed by radial head repair or replacement, and finally LCL repair. The MCL is typically only addressed if the elbow remains unstable after the lateral-sided repair.

Question 1845

Topic: Shoulder Pathology

A 25-year-old athlete sustains a direct blow to the shoulder and subsequently presents with medial winging of the scapula. Injury to which of the following nerves is the most likely cause?

. Long thoracic nerve
. Spinal accessory nerve
. Dorsal scapular nerve
. Suprascapular nerve
. Axillary nerve

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Medial scapular winging is characteristic of serratus anterior palsy, which is innervated by the long thoracic nerve. Lateral winging is typically associated with trapezius dysfunction due to spinal accessory nerve injury.

Question 1846

Topic: 9. Shoulder and Elbow

A 35-year-old female presents with an elbow injury. Radiographs reveal a coronal shear fracture of the capitellum that includes the lateral trochlear ridge (McKee modification of Bryan and Morrey Type IV). What is the recommended treatment?

. Closed reduction and immobilization in flexion
. Excision of the capitellar fragment
. Open reduction and internal fixation (ORIF)
. Total elbow arthroplasty
. Fragment excision with lateral collateral ligament reconstruction

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF)

Explanation

Type IV capitellum fractures involve the lateral trochlear ridge, making the elbow highly unstable if the fragment is removed. Open reduction and internal fixation (typically with headless compression screws) is required to restore radiocapitellar and ulnohumeral stability.

Question 1847

Topic: Elbow & Forearm

During a single-incision anterior approach for a distal biceps tendon repair, injury to which nerve is the most frequently reported complication?

. Posterior interosseous nerve
. Anterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Superficial radial nerve
. Median nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve is the most commonly injured nerve during the single-incision anterior approach for distal biceps repair. The posterior interosseous nerve (PIN) is more at risk during a two-incision approach.

Question 1848

Topic: Elbow & Forearm

A 40-year-old male sustains an Essex-Lopresti injury characterized by a comminuted radial head fracture, interosseous membrane tear, and DRUJ disruption. If the radial head is unreconstructible, what is the most appropriate management?

. Radial head excision alone
. Radial head excision and DRUJ pinning
. Radial head arthroplasty and DRUJ stabilization
. Radial head excision and creation of a one-bone forearm
. Closed management with early range of motion

Correct Answer & Explanation

. Radial head arthroplasty and DRUJ stabilization

Explanation

In an Essex-Lopresti injury, the longitudinal stabilizers of the forearm are compromised. Excision of the radial head is strictly contraindicated as it will lead to proximal radius migration. The appropriate treatment is radial head arthroplasty combined with DRUJ stabilization.

Question 1849

Topic: Elbow & Forearm

A 35-year-old male presents with a 'terrible triad' injury of the elbow after a fall from a ladder. When performing surgical stabilization, what is the generally accepted optimal sequence of repair for the injured structures?

. Lateral collateral ligament (LCL), Coronoid, Radial Head
. Coronoid, Radial Head, Lateral collateral ligament (LCL)
. Radial Head, Lateral collateral ligament (LCL), Coronoid
. Coronoid, Medial collateral ligament (MCL), Radial Head
. Lateral collateral ligament (LCL), Radial Head, Coronoid

Correct Answer & Explanation

. Coronoid, Radial Head, Lateral collateral ligament (LCL)

Explanation

Standard surgical management of terrible triad injuries proceeds from deep to superficial (or anterior to posterior). The accepted sequence is fixation of the coronoid first, followed by the radial head (repair or replace), and finally the LCL complex.

Question 1850

Topic: Elbow & Forearm
A 45-year-old female presents with an Essex-Lopresti injury characterized by a comminuted Mason Type III radial head fracture and distal radioulnar joint (DRUJ) dislocation. Regarding the management of the radial head, which of the following is most appropriate?
. Excision of the radial head alone
. Excision of the radial head and casting in supination
. Radial head arthroplasty
. Closed reduction of the radial head
. Resection of the distal ulna (Darrach procedure)

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

In an Essex-Lopresti injury, the interosseous membrane is disrupted. Excision of the radial head is strictly contraindicated as it will lead to proximal migration of the radius. If the radial head is unreconstructable, a radial head arthroplasty is required.

Question 1851

Topic: 9. Shoulder and Elbow

A 35-year-old female sustains a complex elbow fracture. Radiographs reveal a coronal shear fracture of the capitellum that extends medially to involve the majority of the trochlea.

According to the Bryan and Morrey classification, what type of fracture is this?

. Hahn-Steinthal (Type 1)
. Kocher-Lorenz (Type 2)
. Broberg-Morrey (Type 3)
. McKee modification (Type 4)
. Mason Type 2

Correct Answer & Explanation

. McKee modification (Type 4)

Explanation

The McKee modification (Type 4) of the Bryan and Morrey classification describes a coronal shear fracture of the capitellum that extends to include a significant portion of the trochlea.

Question 1852

Topic: 9. Shoulder and Elbow

In an elderly patient undergoing reverse total shoulder arthroplasty for a 4-part proximal humerus fracture, which of the following factors correlates most strongly with improved postoperative external rotation and overall patient satisfaction?

. Greater tuberosity healing
. Use of a lateralized glenosphere
. Inferior baseplate tilt of 15 degrees
. Humeral stem retroversion of 40 degrees
. Repair of the subscapularis

Correct Answer & Explanation

. Greater tuberosity healing

Explanation

Greater tuberosity healing to the humeral shaft or implant in reverse total shoulder arthroplasty for fractures is associated with significantly improved external rotation and better overall functional outcomes.

Question 1853

Topic: Elbow & Forearm

A 40-year-old male falls from a height and sustains a highly comminuted, unsalvageable radial head fracture, accompanied by distal radioulnar joint (DRUJ) instability. What is the most appropriate management of the radial head?

. Radial head excision alone
. Radial head excision and pinning of the DRUJ
. Radial head arthroplasty
. Silastic radial head replacement
. Open reduction and internal fixation regardless of comminution

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

This patient has an Essex-Lopresti injury (radial head fracture, interosseous membrane disruption, DRUJ instability). Radial head arthroplasty is required to restore longitudinal stability; excision alone leads to proximal radial migration and chronic wrist pain.

Question 1854

Topic: Elbow & Forearm

A 35-year-old female presents with an isolated coronal shear fracture of the capitellum with no posterior comminution. If open reduction and internal fixation with headless compression screws is planned, what is the biomechanically optimal screw trajectory?

. Lateral to medial
. Medial to lateral
. Anterior to posterior
. Posterior to anterior
. Superior to inferior

Correct Answer & Explanation

. Posterior to anterior

Explanation

For isolated capitellar coronal shear fractures, screws placed from posterior to anterior provide superior biomechanical stability compared to anterior-to-posterior screws and avoid articular cartilage penetration.

Question 1855

Topic: Elbow & Forearm

A 45-year-old falls on an outstretched hand and sustains a terrible triad injury of the elbow. Which of the following is the recommended surgical sequence of fixation?

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

Correct Answer & Explanation

. Coronoid fixation, radial head fixation, LCL repair

Explanation

The standard protocol for treating a terrible triad injury of the elbow progresses from deep to superficial structures. This involves coronoid fixation or repair, followed by radial head replacement or fixation, and finally lateral collateral ligament (LCL) repair.

Question 1856

Topic: Elbow & Forearm

A 35-year-old woman sustains a comminuted radial head fracture with more than 3 articular fragments that cannot be anatomically reconstructed. There is an associated disruption of the medial collateral ligament. What is the most appropriate surgical treatment?

. Radial head excision
. Radial head open reduction and internal fixation
. Radial head arthroplasty
. Annular ligament reconstruction
. Closed reduction and early mobilization

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

In the setting of an irreparable radial head fracture with associated elbow instability (such as an MCL tear or interosseous membrane injury), radial head arthroplasty is indicated to restore radiocapitellar stability. Simple excision is contraindicated due to the risk of valgus instability or proximal radial migration.

Question 1857

Topic: 9. Shoulder and Elbow

A 45-year-old male falls from a ladder and sustains an elbow injury. Radiographs reveal a posterior elbow dislocation, a radial head fracture, and a coronoid fracture. During surgical management of this 'terrible triad' injury, what is the generally accepted sequence of repair?

. Lateral collateral ligament (LCL), radial head, coronoid, then medial collateral ligament (MCL)
. Coronoid, radial head, LCL, then MCL if the elbow remains unstable
. Radial head, coronoid, MCL, then LCL
. MCL, coronoid, radial head, then LCL
. Coronoid, MCL, radial head, then LCL

Correct Answer & Explanation

. Coronoid, radial head, LCL, then MCL if the elbow remains unstable

Explanation

The standard surgical sequence for a terrible triad injury is to repair deep to superficial and inside-out: first the coronoid, then the radial head, followed by the LCL complex. The MCL is only addressed if the elbow remains unstable after the lateral side is secured.

Question 1858

Topic: 9. Shoulder and Elbow

In the setting of an acute, simple posterior elbow dislocation, soft tissue disruption classically occurs in a circular progression from lateral to medial (Horii circle). Which structure is typically the FIRST to be injured?

. Lateral ulnar collateral ligament (LUCL)
. Anterior bundle of the medial collateral ligament (AMCL)
. Posterior bundle of the medial collateral ligament (PMCL)
. Common extensor origin
. Brachialis muscle

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

According to the Horii circle of instability, elbow ligamentous disruption progresses from lateral to medial. The lateral collateral ligament complex, specifically the LUCL, is the first structure to fail in a typical posterolateral rotatory mechanism.

Question 1859

Topic: Elbow & Forearm
A 30-year-old male sustains a severely comminuted, unfixable Mason Type III radial head fracture. You plan to perform a radial head excision. This procedure is strictly contraindicated without a radial head replacement in the presence of which concurrent injury?
. Nondisplaced coronoid tip fracture
. Tear of the interosseous membrane (Essex-Lopresti injury)
. Isolated capitellum fracture
. Distal radioulnar joint (DRUJ) arthritis
. Medial epicondyle avulsion

Correct Answer & Explanation

. Tear of the interosseous membrane (Essex-Lopresti injury)

Explanation

Radial head excision without arthroplasty in the setting of a torn interosseous membrane (Essex-Lopresti injury) will lead to proximal migration of the radius, DRUJ dissociation, and severe wrist pain. The radial head must be replaced to maintain longitudinal stability of the forearm.

Question 1860

Topic: Elbow & Forearm

In the O'Driscoll classification of coronoid fractures, an anteromedial facet fracture is most commonly associated with which specific mechanism and injury pattern?

. Valgus stress with acute MCL rupture
. Varus posteromedial rotatory instability (VPMRI)
. Posterolateral rotatory instability (PLRI)
. Isolated anterior elbow dislocation
. Trans-olecranon fracture-dislocation

Correct Answer & Explanation

. Varus posteromedial rotatory instability (VPMRI)

Explanation

Anteromedial facet fractures of the coronoid result from a varus force combined with posteromedial rotation. This causes avulsion of the LCL and compression of the anteromedial coronoid facet against the medial trochlea, leading to VPMRI.

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