Question 1

A 32-year-old male recreational tennis player presents with a 4-week history of progressive activity-related elbow pain in his dominant upper extremity. C linical examination demonstrates marked tenderness at the lateral epicondyle and pain at the lateral epicondyle with resisted wrist extension. No instability is detected on clinical examination. The next step in management is:

Explanation

This patient has lateral epicondylitis. A recent radiographic analysis of lateral epicondylitis showed that radiographs taken at initial presentation did not alter the initial management. Most patients with lateral epicondylitis respond to nonoperative treatment. Surgical treatment should only be considered after failure of a prolonged course (at least 6 months) of nonoperative treatment.

Question 2

During diagnostic elbow arthroscopy, which of the following nerves is at the greatest risk for injury:

Explanation

The radial nerve is at the greatest risk for injury during elbow arthroscopy. Injury usually occurs during creation of the anterolateral portal.

Question 3

Which of the following elbow arthroscopic portals is correctly matched to the nerve at risk during portal creation:

Explanation

Incorrect placement of the anterolateral portal places the radial nerve at risk. Incorrect placement of the anteromedial portal places the median and ulnar nerves at risk. The posterior portal is not associated with neural injury.

Question 4

Which of the following statements is true regarding the use of a two-incision technique vs a single-incision technique for distal biceps repair:

Explanation

Successful treatment of distal biceps tendon tears include dual- and single- incision techniques. The two-incision technique is associated with increased risk of heterotopic ossification, whereas the single-incision technique is associated with an increased risk of nerve injury.

Question 5

Approximately what percentage of supination strength is lost with an unrepaired distal biceps tendon rupture:

Explanation

The biceps provides approximately 40% of supination strength to the forearm.

Question 6

The anterior cruciate ligament is composed of which of the following bundles:

Explanation

The anterior cruciate ligament consists of two bundles. The anteromedial bundle is tight in flexion, and the posterolateral bundle is tight in extension.

Question 7

The anterior cruciate ligament (AC L) provides what percent of the stability to anterior tibial translation with the knee flexed 30°:

Explanation

The AC L functions as the primary stabilizer to anterior tibial translation providing more than 85% of stability with the knee in 30° of flexion.

Question 8

Which of the following positions of knee flexion produces the greatest strain in the anterior cruciate ligament with anterior loading of the tibia:

Explanation

Clinical and biomechanical studies show that anterior loading of the tibia in 30° of knee flexion produces greater strain and elongation of the normal anteromedial bundle than loading in 90° of knee flexion.

Question 9

Anterior cruciate ligament (AC L) injuries are almost _ in women than in their male counterparts in collegiate basketball players:

Explanation

Female collegiate basketball players are almost eight times as likely to sustain AC L injuries as their male counterparts.

Question 10

Which of the following is not considered an intrinsic risk factor for anterior cruciate ligament (AC L) injury:

Explanation

Intrinsic risk factors for AC L injury include a narrow notch width index, a weak or small native AC L, knee joint anteroposterior laxity, malalignment of the lower extremity, pelvic position, navicular drop, and subtalar joint pronation. Male gender is not a risk factor for AC L injury.

Question 11

Anterior cruciate ligament (AC L) injury is most commonly the result of:

Explanation

An AC L injury is commonly the result of a noncontact mechanism. Two common mechanisms that have been described include a valgus force to a flexed knee with the leg in external rotation and knee hyperextension with the leg internally rotated.

Question 12

The incidence of meniscal injury with a concomitant AC L tear is reported to be nearly _, with the __ meniscus more commonly injured in the acute setting:

Explanation

The incidence of meniscal tear after acute anterior cruciate ligament (AC L) injury is reported to be approximately 70%. The lateral meniscus is more often injured in the acute setting, and the medial meniscus is more often injured in the chronically AC L-deficient knee.

Question 13

The healing rate of meniscal repairs in association with acute anterior cruciate ligament (AC L) reconstruction is_ that reported for isolated meniscal repairs:

Explanation

The results with respect to healing of meniscal repairs in the association of an acute AC L injury are reported to be better than in other situations (92% vs 67%).

Question 14

The typical locations for bone contusions as viewed on magnetic resonance imaging after anterior cruciate ligament (AC L) injury are the:

Explanation

The typical locations for bone contusions after an AC L injury are the middle third of the lateral femoral condyle and the posterolateral tibia.

Question 15

The sensitivity of the Lachman test is reported to be up to:

Explanation

Physical examination of the knee includes performing a Lachman test, which has a reported sensitivity of up to 98%.

Question 16

The optimal timing for performing anterior cruciate ligament reconstruction after an acute injury is:

Explanation

Shelbourne noted a decrease in the incidence of postoperative stiffness to less than 1% and faster return of strength when surgery is performed after obtaining full knee range of motion including hyperextension of the knee.

Question 17

The most common technical errors when performing anterior cruciate ligament reconstruction are:

Explanation

The most common technical errors involve excessively anterior placement of the tunnels. Anterior tibial tunnel and femoral tunnel placement can result in graft impingement, inability to fully extend the knee, and eventual failure. Excessively anterior femoral tunnel placement can also result in capturing the knee with difficulty in gaining full flexion and eventual stretching or rupture of the graft with attempts at gaining full flexion.

Question 18

All of the following is used to identify the appropriate position for anterior cruciate ligament (AC L) tibial tunnel placement except:

Explanation

Tibial tunnel misplacement can be avoided by using the appropriate landmarks (inner rim of the anterior horn of the lateral meniscus, referencing off of the PC L, the medial tibial spine, and the ACL stump).

Question 19

Adequate bone plug length for interference screw fixation during bone- tendon-bone anterior cruciate ligament reconstruction is:

Explanation

Graft fixation is the weak point in the early postoperative period. Researchers have reported that the optimal bone plug length is at least 1 cm. Bone plugs of shorter lengths have decreased peak load to failure, but bone plugs of greater length did not have significantly increased peak loads to failure.

Question 20

Anterior knee pain was noted in all of the following situations except:

Explanation

Anterior knee pain was reported after patellar tendon and hamstring AC L reconstruction. Although some reports show increased pain with kneeling after patellar tendon AC L reconstruction, it is important to note the development of anterior knee pain in patients with AC L injuries treated nonoperatively. Anterior knee pain after AC L injury with or without reconstruction is not well understood and is likely multifactorial in nature.

Question 21

A 22-year-old collegiate baseball pitcher presents with medial elbow pain. The moving valgus stress test is positive. MRI shows a full-thickness tear of the ulnar collateral ligament (UCL). What is the primary restraint to valgus stress at 90 degrees of elbow flexion?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow, particularly from 30 to 120 degrees of flexion. The posterior bundle acts as a secondary restraint.

Question 22

A 35-year-old woman complains of recurrent clicking and a sensation of her elbow 'giving way' when pushing up from a chair. Physical examination reveals a positive lateral pivot-shift test. Which ligamentous structure is primarily deficient in this condition?

Explanation

Posterolateral rotatory instability (PLRI) is caused by a deficiency of the lateral ulnar collateral ligament (LUCL). This typically presents with locking, snapping, or a giving-way sensation when an axial load, valgus stress, and supination are applied.

Question 23

During elbow arthroscopy, the proximal anteromedial portal is established approximately 2 cm proximal and 1 cm anterior to the medial epicondyle. Which nerve is at greatest risk of injury during the establishment of this portal?

Explanation

The medial antebrachial cutaneous nerve (MACN) is at the greatest risk of injury when establishing the anteromedial and proximal anteromedial portals. The median nerve is further anterior, and the ulnar nerve is posterior to the medial epicondyle.

Question 24

The proximal anterolateral portal is frequently used as an initial viewing portal in elbow arthroscopy. It is established 2 cm proximal and 1 cm anterior to the lateral epicondyle. This portal places which of the following nerves at highest risk?

Explanation

The proximal anterolateral portal places the radial nerve at risk, as it lies an average of 3 to 7 mm from the portal tract. The joint should be distended with fluid prior to portal placement to displace the radial nerve anteriorly.

Question 25

A 14-year-old male gymnast presents with a 4-month history of lateral elbow pain, stiffness, and catching. Radiographs demonstrate a radiolucent lesion of the capitellum with a displaced loose body. What is the most appropriate management?

Explanation

The patient has advanced osteochondritis dissecans (OCD) of the capitellum with a loose body. Surgical management with arthroscopic loose body removal and microfracture or debridement is indicated for unstable lesions or loose bodies.

Question 26

A 25-year-old professional baseball pitcher experiences posterior elbow pain during the deceleration phase of throwing. Imaging reveals posteromedial olecranon osteophytes. If osteophyte excision is performed, what complication is most likely if the resection is overly aggressive?

Explanation

Valgus extension overload syndrome leads to posteromedial olecranon osteophytes. Aggressive resection of the posteromedial olecranon can remove the bony buttress effect, leading to increased strain on the UCL and subsequent valgus instability.

Question 27

A 45-year-old man undergoes a single-incision anterior repair for an acute distal biceps tendon rupture. Postoperatively, he notes numbness over the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision anterior approach to the distal biceps. It courses between the biceps and brachialis.

Question 28

A 40-year-old sustains a terrible triad injury of the elbow after a fall on an outstretched hand. According to standard surgical protocols, what is the recommended sequence of structural reconstruction?

Explanation

The standard surgical protocol for a terrible triad injury is to repair from deep to superficial, generally starting with the coronoid, followed by the radial head (repair or replacement), and finally the LUCL.

Question 29

A 30-year-old sustains an isolated anteromedial facet fracture of the coronoid. This specific fracture pattern is most closely associated with which mechanism and concomitant ligamentous injury?

Explanation

Anteromedial facet fractures of the coronoid are pathognomonic for varus posteromedial rotatory instability. This injury pattern typically involves a concomitant tear of the lateral collateral ligament (LCL) complex.

Question 30

In a patient undergoing surgical debridement for recalcitrant medial epicondylitis, which muscular origins are most commonly involved in the pathologic tendinosis?

Explanation

Medial epicondylitis primarily involves the origin of the pronator teres and the flexor carpi radialis. Surgical management involves excision of the angiofibroblastic tissue at this origin.

Question 31

A 9-year-old boy presents with lateral elbow pain and stiffness. Radiographs show sclerosis, fragmentation, and flattening of the entire capitellum without loose bodies. What is the most likely diagnosis?

Explanation

Panner disease is an osteochondrosis of the capitellum that affects younger children (usually under 10 years old), involves the entire capitellum, and is typically self-limiting. OCD affects older children and typically involves localized lesions.

Question 32

The capitellum is prone to osteochondritis dissecans due to a tenuous vascular supply. The dominant intraosseous vascular supply to the capitellum enters from which direction?

Explanation

The primary blood supply to the capitellum comes from posteriorly via end-arteries. This makes the anterior and lateral portions susceptible to avascular necrosis and OCD under repetitive stress.

Question 33

A 42-year-old mechanic presents with chronic lateral elbow pain radiating down the dorsal forearm. Pain is severe with resisted middle finger extension. Tenderness is noted 4 cm distal to the lateral epicondyle. What is the most likely site of nerve compression?

Explanation

The clinical picture describes Radial Tunnel Syndrome. The most common site of compression of the posterior interosseous nerve (PIN) in the radial tunnel is the Arcade of Frohse (the proximal edge of the superficial head of the supinator).

Question 34

During a two-incision distal biceps repair, a muscle-splitting approach is utilized to reach the radial tuberosity. To best protect the posterior interosseous nerve (PIN) during this posterior approach, the forearm should be placed in which position?

Explanation

During the posterior approach in a two-incision distal biceps repair, keeping the forearm in full pronation pulls the PIN medially and distally, moving it away from the surgical field and reducing the risk of injury.

Question 35

When creating the standard anteromedial portal for elbow arthroscopy, the ulnar nerve is located at what approximate average distance from the correct portal placement?

Explanation

The standard anteromedial portal is typically placed 2 cm distal and 2 cm anterior to the medial epicondyle. At this location, the ulnar nerve is safely posterior, an average of 22 to 25 mm away from the portal.

Question 36

A 35-year-old male developed severe heterotopic ossification (HO) following an elbow fracture-dislocation, leading to profound stiffness. When is the optimal time for surgical excision of the HO?

Explanation

Surgical excision of heterotopic ossification should be delayed until the bone is mature to prevent recurrence. This is indicated by sharp, distinct margins on radiographs and normalization of serum alkaline phosphatase levels (usually 6-9 months).

Question 37

A patient is diagnosed with compression of the median nerve at the ligament of Struthers. This pathology is invariably associated with an anomalous bony spur located on which of the following structures?

Explanation

The ligament of Struthers connects an anomalous supracondylar process (located on the anteromedial aspect of the distal humerus) to the medial epicondyle, which can compress the median nerve and brachial artery.

Question 38

During the throwing motion of a baseball pitcher, peak valgus stress at the elbow, which places the maximal strain on the ulnar collateral ligament, occurs during which phase?

Explanation

Peak valgus stress on the elbow occurs during the late cocking and early acceleration phases of throwing. This is when the UCL is subjected to maximum tension and is most susceptible to injury.

Question 39

A patient presents with a 45-degree flexion contracture of the elbow 6 months after a simple dislocation. Non-operative management has failed. During an open arthrolysis, which structure is the primary restraint that must be released to achieve full extension?

Explanation

A flexion contracture limits extension. The anterior capsule becomes contracted and thickened, making it the primary soft tissue restraint to elbow extension that must be released during arthrolysis.

Question 40

A 38-year-old female presents with aching pain in the volar proximal forearm and paresthesias in the thumb, index, and middle fingers. Symptoms are worsened by resisted forearm pronation, but not by wrist flexion. Which nerve is compressed, and at what structure?

Explanation

The patient has Pronator Syndrome, characterized by median nerve compression in the proximal forearm. Pain with resisted pronation specifically implicates the two heads of the pronator teres as the site of compression.

Question 41

A 13-year-old female gymnast presents with insidious onset lateral elbow pain. Examination reveals a 15-degree extension deficit. Radiographs show a radiolucent lesion with a sclerotic margin over the capitellum. MRI demonstrates subchondral fluid underneath the lesion but no loose bodies. What is the most appropriate initial management?

Explanation

The patient has a stable osteochondritis dissecans (OCD) of the capitellum, indicated by the absence of loose bodies or articular collapse. Initial management for stable lesions in adolescents is non-operative, focusing on rest and activity modification.

Question 42

In a patient diagnosed with refractory medial epicondylitis, which of the following tendinous structures is most commonly targeted during surgical debridement?

Explanation

Medial epicondylitis primarily involves microtearing and tendinosis at the origin of the flexor carpi radialis (FCR) and the pronator teres. Surgical intervention specifically targets these tendinous origins for debridement.

Question 43

A 22-year-old collegiate baseball pitcher reports acute medial elbow pain accompanied by a "pop" during a pitch. Examination reveals pain and laxity with valgus stress at 30 degrees of elbow flexion. Injury to which of the following structures is the primary cause of this instability?

Explanation

The anterior bundle of the medial collateral ligament (MCL) is the primary restraint to valgus stress at the elbow. It is most effectively evaluated with valgus stress applied at 30 degrees of elbow flexion to unlock the olecranon from its fossa.

Question 44

A 45-year-old falls onto an outstretched hand and sustains a "terrible triad" injury of the elbow. Which of the following describes the standard recommended sequence of surgical repair for this injury?

Explanation

The standard surgical sequence for a terrible triad injury involves repairing structures from deep to superficial. This typically means addressing the coronoid fracture first, followed by the radial head, and finally the lateral collateral ligament (LCL).

Question 45

A 35-year-old woman complains of recurrent elbow clicking and a feeling that the elbow will "give way" when pushing up from a chair. On examination, a pivot-shift test is positive. This condition is most likely caused by insufficiency of which of the following ligaments?

Explanation

Posterolateral rotatory instability (PLRI) classically presents with apprehension or giving way when an axial load, valgus force, and supination are applied. It is primarily caused by an insufficiency of the lateral ulnar collateral ligament (LUCL).

Question 46

During a single-incision anterior approach for a distal biceps tendon repair, the patient develops postoperative numbness over the lateral aspect of the forearm. Which nerve was most likely injured during the procedure?

Explanation

The lateral antebrachial cutaneous nerve (LABCN) exits the deep fascia laterally between the biceps and brachialis muscles. It is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair.

Question 47

When establishing the proximal anteromedial portal during elbow arthroscopy, the joint should be distended and the elbow flexed to 90 degrees. This specific portal places which of the following nerves at the greatest risk of injury?

Explanation

The proximal anteromedial portal is created approximately 2 cm proximal and 2 cm anterior to the medial epicondyle. It places the medial antebrachial cutaneous nerve (MABCN) at highest risk, as the nerve lies an average of 1-2 mm from the portal tract.

Question 48

A 7-year-old boy presents with a 3-month history of dull, aching lateral elbow pain without a specific injury. Radiographs reveal fragmentation and sclerosis of the entire capitellum. What is the most likely diagnosis?

Explanation

Panner's disease is an osteochondrosis of the capitellum that typically affects children younger than 10 years old and involves the entire ossific nucleus. It is a self-limiting condition treated with symptomatic rest, unlike OCD which occurs in older adolescents.

Question 49

A 45-year-old bodybuilder feels a sudden snap in the back of his elbow while performing heavy bench presses. He has a palpable gap proximal to the olecranon and marked weakness in active elbow extension against resistance. What is the most common mechanism of this specific tendon rupture?

Explanation

Triceps tendon ruptures typically occur due to an eccentric load on a contracting triceps muscle, such as decelerating a heavy weight or falling onto an outstretched hand. Immediate surgical repair is indicated for complete ruptures to restore extension strength.

Question 50

A 50-year-old typist presents with medial elbow pain radiating to the ring and small fingers. Examination shows a positive Tinel's sign at the cubital tunnel and a positive Froment's sign. Which structure is the most common site of compression for this pathology?

Explanation

Cubital tunnel syndrome is the most common ulnar nerve entrapment neuropathy at the elbow. The most frequent site of compression is at the cubital tunnel retinaculum, also known as Osborne's ligament.

Question 51

A 42-year-old mechanic complains of chronic, aching pain over the dorsal aspect of the proximal forearm. Pain is exacerbated by resisted extension of the middle finger with the elbow extended, but there is no motor weakness. What is the most likely site of neural compression?

Explanation

The presentation is classic for radial tunnel syndrome, a compressive neuropathy of the deep branch of the radial nerve causing pain without motor loss. The Arcade of Frohse (the proximal edge of the superficial supinator muscle) is the most common site of compression.

Question 52

A 28-year-old carpenter experiences deep, aching forearm pain that worsens with activity. He notes occasional numbness in his thumb, index, and middle fingers, but specifically denies night pain. Examination reveals pain with resisted forearm pronation. This presentation is characteristic of compression of which nerve?

Explanation

Pronator syndrome involves compression of the median nerve in the proximal forearm, leading to aching pain exacerbated by resisted pronation. It is distinguished clinically from carpal tunnel syndrome by the absence of night pain.

Question 53

A patient sustains an anteromedial facet fracture of the coronoid process. If left untreated, this specific fracture pattern is highly associated with which type of elbow instability?

Explanation

Anteromedial facet fractures of the coronoid result from a varus load combined with axial compression. This injury pattern disrupts the essential bony buttress of the coronoid, leading to varus posteromedial rotatory instability if not anatomically fixed.

Question 54

A 16-year-old elite baseball pitcher presents with posterior elbow pain during the deceleration phase of throwing. Examination demonstrates an extension deficit and pain with forced extension. Radiographs show osteophytes at the posteromedial olecranon tip. What is the underlying pathophysiology?

Explanation

Valgus extension overload (VEO) syndrome occurs in throwers due to repetitive impingement of the posteromedial olecranon into the olecranon fossa. It is driven by the extreme valgus forces and rapid extension during the throwing motion.

Question 55

During a surgical approach to the radial head, the surgeon decides to use the Kocher interval to access the joint. This interval utilizes the internervous plane between which two muscles?

Explanation

The Kocher approach to the lateral elbow utilizes the internervous plane between the anconeus (innervated by the radial nerve) and the extensor carpi ulnaris (innervated by the posterior interosseous nerve). This provides safe exposure to the radial head and neck.

Question 56

A 30-year-old patient falls onto an outstretched arm and sustains a Mason type II radial head fracture. There is a 3 mm displaced fragment involving 25% of the articular surface, but no mechanical block to rotation is noted on examination after intra-articular local anesthetic injection. What is the most appropriate management?

Explanation

Mason type II fractures with no mechanical block and minimal displacement can generally be successfully managed non-operatively. Early active range of motion is crucial to prevent long-term elbow stiffness.

Question 57

A 40-year-old female presents with recurrent elbow clicking and a sensation of giving way when pushing up from a chair. Physical examination reveals apprehension with axial load, supination, and valgus stress applied to the elbow. Which of the following structures is most likely deficient?

Explanation

Posterolateral rotatory instability (PLRI) is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). The classic mechanism of provocation is axial load, supination, and valgus stress, mimicking pushing off a chair.

Question 58

A 22-year-old collegiate baseball pitcher reports medial elbow pain during the late cocking and early acceleration phases of throwing. On physical examination, pain is reproduced when a valgus stress is applied to the elbow while rapidly extending it from 120 to 30 degrees of flexion. This test is most sensitive for evaluating which of the following structures?

Explanation

The moving valgus stress test is highly sensitive and specific for insufficiency of the anterior bundle of the ulnar collateral ligament (UCL). Pain is typically maximal between 120 and 70 degrees of elbow flexion.

Question 59

A 13-year-old male gymnast complains of insidious onset, progressive lateral elbow pain and catching. Radiographs demonstrate a radiolucent defect in the capitellum with a sclerotic margin. MRI reveals a detached osteochondral fragment. What is the most appropriate definitive management?

Explanation

Osteochondritis dissecans of the capitellum with an unstable or detached fragment requires surgical intervention. Fragment excision, loose body removal, and marrow stimulation (microfracture) of the base are indicated for symptomatic detached lesions.

Question 60

During an elbow arthroscopy, the surgeon establishes the proximal anteromedial portal. This portal is typically placed 2 cm proximal and 1 cm anterior to the medial epicondyle. Which nerve is at greatest risk during the establishment of this portal if the scalpel is plunged too deeply?

Explanation

The medial antebrachial cutaneous nerve (MABC) is the most superficial structure at risk when establishing the anteromedial and proximal anteromedial portals. The median nerve is also at risk but is situated deeper and more laterally.

Question 61

A 24-year-old professional baseball pitcher presents with posterior elbow pain during the deceleration phase of throwing. He complains of an inability to fully extend his elbow and occasionally feels catching. Radiographs demonstrate posteromedial olecranon osteophytes. What is the most likely diagnosis?

Explanation

Valgus extension overload (VEO) occurs in overhead throwing athletes due to repetitive valgus stress, leading to impingement of the posteromedial olecranon in the olecranon fossa. It classically presents with posterior elbow pain during the deceleration phase and posteromedial osteophytes.

Question 62

A 45-year-old heavy laborer felt a pop in his anterior elbow while lifting a heavy box. Examination reveals weakness in forearm supination and elbow flexion, with a positive hook test. If an anterior single-incision surgical repair is planned using suture anchors, which of the following nerves is at greatest risk if retractors are placed aggressively on the radial neck?

Explanation

The posterior interosseous nerve (PIN) is at risk during a single-incision anterior approach to the distal biceps, especially with aggressive lateral retraction or over-penetration of the radius.

Question 63

A 35-year-old male falls from a ladder and sustains a terrible triad injury of the elbow. He undergoes open reduction and internal fixation. What is the recommended sequence of surgical repair for this injury pattern?

Explanation

The classic algorithm for treating a terrible triad injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture) starts deep/medial and works superficial/lateral. The recommended sequence is repairing the coronoid, followed by the radial head, and finally the lateral ulnar collateral ligament (LUCL).

Question 64

A 48-year-old avid golfer presents with chronic medial elbow pain. Examination reveals point tenderness just distal to the medial epicondyle and pain with resisted wrist flexion and pronation. Non-operative management has failed. Surgical intervention for this condition primarily involves debridement of the origin of which muscle?

Explanation

Medial epicondylitis (golfer's elbow) is characterized by tendinosis and microtearing of the flexor-pronator mass. The pronator teres and flexor carpi radialis (FCR) are the most commonly involved structures requiring debridement.

Question 65

A 38-year-old female presents with a 6-month history of lateral forearm pain that worsens with repetitive supination. She has no weakness in finger or wrist extension, but tenderness is maximal 4-5 cm distal to the lateral epicondyle. Which of the following is the most frequent site of nerve compression in this condition?

Explanation

Radial tunnel syndrome is a compressive neuropathy of the posterior interosseous nerve characterized by pain without significant motor weakness. The most common site of compression is the Arcade of Frohse, the proximal fibrous edge of the supinator muscle.

Question 66

A 29-year-old male sustains an elbow subluxation. CT scan demonstrates an anteromedial facet fracture of the coronoid process. Which specific ligamentous structure inserts onto the anteromedial facet and must be addressed to restore stability?

Explanation

The anteromedial facet of the coronoid is critical for varus and posteromedial rotatory stability. The anterior bundle of the medial ulnar collateral ligament (AMCL) inserts onto the sublime tubercle, which is located on the anteromedial facet.

Question 67

A 12-year-old baseball pitcher presents with medial elbow pain, decreased throwing velocity, and localized tenderness over the medial epicondyle. Radiographs reveal widening of the medial epicondyle apophysis compared to the contralateral side. What is the initial treatment of choice?

Explanation

Little League elbow typically presents as medial epicondylar apophysitis in skeletally immature throwing athletes. The cornerstone of initial treatment is absolute rest from throwing for 4 to 6 weeks, followed by a gradual return-to-throwing program.

Question 68

During an in situ ulnar nerve decompression for severe cubital tunnel syndrome, an anomalous muscle is found crossing the ulnar nerve from the medial olecranon to the medial epicondyle. What is the name of this anomalous muscle?

Explanation

The anconeus epitrochlearis is an anomalous muscle present in up to 11% of the population. It spans from the medial epicondyle to the olecranon, replacing the Osborne ligament, and can be a cause of cubital tunnel syndrome.

Question 69

A 25-year-old female falls on her outstretched hand and presents with elbow pain. Radiographs and CT show an articular cartilage shear fracture of the capitellum with very little attached subchondral bone. According to the Bryan and Morrey classification, what type of fracture is this?

Explanation

In the Bryan and Morrey classification, a Type II (Kocher-Lorenz) fracture is an articular cartilage shear fracture of the capitellum with minimal subchondral bone. A Type I (Hahn-Steinthal) involves a large fragment of subchondral bone.

Question 70

A 9-year-old gymnast presents with lateral elbow pain and stiffness. Radiographs demonstrate sclerosis and fragmentation of the entire capitellum without a localized loose body or distinct crater. Given her age and radiographic findings, what is the most likely diagnosis?

Explanation

Panner's disease is an osteochondrosis of the capitellum typically affecting children under 10 years old, involving the entire ossific nucleus. Unlike OCD, it does not typically produce loose bodies and usually resolves completely with conservative management.

Question 71

A 48-year-old bodybuilder experiences a painful snap in his posterior elbow while performing heavy bench presses. Physical exam shows a palpable gap proximal to the olecranon and inability to actively extend the elbow against gravity. When performing a primary repair of this acute injury, where is the optimal site for reattachment of the tendon?

Explanation

The normal footprint of the triceps tendon is broad and inserts slightly distal (approx. 1-2 cm) to the tip of the olecranon. Reattaching the tendon anatomically to its footprint provides optimal biomechanical strength and prevents an extension block.

Question 72

Which bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow during late cocking and early acceleration phases of throwing?

Explanation

The anterior bundle of the medial UCL is the primary restraint to valgus stress at the elbow from 30 to 120 degrees of flexion. It is the most frequently injured ligament in throwing athletes.

Question 73

To minimize the risk of injury to the posterior interosseous nerve (PIN) when establishing the anterolateral portal during elbow arthroscopy, the elbow should be positioned in:

Explanation

Positioning the elbow in 90 degrees of flexion and forearm pronation moves the PIN further anterior and medially. Distending the joint with fluid also increases the safety margin away from the anterolateral portal.

Question 74

A 45-year-old woman complains of elbow clicking and a sense of instability when pushing off from a chair. The underlying pathology primarily involves deficiency of which of the following structures?

Explanation

Posterolateral rotatory instability (PLRI) is caused by incompetence of the lateral ulnar collateral ligament (LUCL). Patients typically report apprehension or mechanical symptoms when the arm is supinated, valgus-stressed, and loaded in extension.

Question 75

When performing a two-incision distal biceps tendon repair, which of the following structures is at the highest risk of injury during the creation of the posterolateral approach through the extensor mass?

Explanation

In a two-incision technique for distal biceps repair, creating the posterolateral approach requires dissecting through the extensor musculature. The posterior interosseous nerve (PIN) is at significant risk if the forearm is not fully pronated during this step.

Question 76

A 22-year-old collegiate baseball pitcher presents with posterior elbow pain during the deceleration phase of throwing. Imaging reveals loose bodies and osteophytes in the posteromedial olecranon fossa. What is the most likely underlying pathophysiology?

Explanation

Valgus extension overload is typically secondary to chronic attenuation of the anterior bundle of the medial UCL. This leads to excessive valgus laxity, causing impingement of the posteromedial olecranon against the medial wall of the olecranon fossa.

Question 77

A 14-year-old male gymnast presents with lateral elbow pain and mechanical catching. MRI demonstrates fluid behind a loose osteochondral fragment in the capitellum. What is the most appropriate initial management?

Explanation

In osteochondritis dissecans (OCD) of the capitellum, an unstable lesion indicated by mechanical symptoms and fluid behind the fragment on MRI warrants surgical intervention. Arthroscopic fragment excision and marrow stimulation (microfracture) is standard for smaller defects.

Question 78

A 45-year-old golfer presents with severe medial elbow pain that worsens with resisted forearm pronation and wrist flexion. Nonoperative management has failed. Surgical debridement targets the origin of which of the following muscle pairs?

Explanation

Medial epicondylitis involves tendinosis of the common flexor origin. The primary structures affected are the pronator teres and the flexor carpi radialis (FCR).

Question 79

An 11-year-old Little League pitcher complains of medial elbow pain. Radiographs demonstrate widening of the medial epicondylar apophysis. Which of the following statements is most accurate regarding this condition?

Explanation

Medial epicondylar apophysitis (Little League Elbow) is caused by repetitive valgus tension forces on the growing apophysis. It is managed conservatively with complete cessation of throwing, followed by physical therapy and a structured return-to-throw program.

Question 80

During medial ulnar collateral ligament (UCL) reconstruction via the docking technique, where is the precise isometric point for the ulnar tunnel placement?

Explanation

The anterior bundle of the UCL inserts distally at the sublime tubercle of the anteromedial coronoid. Tunnel placement at this exact location reproduces the native isometric biomechanics of the UCL.

Question 81

A patient presents with volar forearm pain and an inability to form an 'OK' sign, demonstrating an extended thumb IP joint and index finger DIP joint. Sensation in the hand is strictly normal. Which structure is most likely compressed?

Explanation

Anterior interosseous nerve (AIN) syndrome is a pure motor neuropathy affecting the flexor pollicis longus, flexor digitorum profundus of the index finger, and pronator quadratus. This results in the characteristic inability to pinch using the fingertips.

Question 82

In the surgical management of a 'terrible triad' injury of the elbow, which of the following represents the standard sequence of repair to restore stability?

Explanation

The standard surgical protocol for a terrible triad injury proceeds from deep to superficial: coronoid fixation first, followed by radial head repair or arthroplasty, and finally restoration of the lateral ulnar collateral ligament (LUCL).

Question 83

During a single-incision anterior approach for a distal biceps tendon repair, aggressive lateral retraction of the soft tissues places which of the following nerves at the highest risk?

Explanation

The lateral antebrachial cutaneous nerve (LABCN) runs superficially in the lateral aspect of the antecubital fossa. It is highly susceptible to neurapraxia or transection from excessive lateral retraction during single-incision biceps repairs.

Question 84

Which of the following anatomic structures is the most common site of compression in radial tunnel syndrome?

Explanation

The Arcade of Frohse, formed by the proximal aponeurotic edge of the superficial head of the supinator muscle, is the most frequent site of posterior interosseous nerve compression in radial tunnel syndrome.

Question 85

Following severe elbow trauma, a patient undergoes open contracture release via a lateral column approach. Which of the following nerves must be protected anteriorly when elevating the brachialis off the joint capsule?

Explanation

During the lateral column procedure for elbow release, the radial nerve courses anterior to the radiocapitellar joint. It must be carefully protected as the brachialis muscle is elevated off the anterior capsule.

Question 86

A 35-year-old weightlifter feels a sudden pop in the posterior elbow during a heavy bench press. MRI confirms a complete triceps tendon rupture. During surgical repair, anatomical reattachment should target the normal footprint located:

Explanation

The anatomic footprint of the triceps tendon is a broad area on the posterior olecranon process, inserting approximately 1 to 2 cm distal to the proximal tip, which is itself covered by a bursa.

Question 87

A 28-year-old manual laborer presents with medial elbow pain and a snapping sensation during flexion and extension, accompanied by intermittent numbness in his ring and small fingers. Ultrasonography is most likely to demonstrate subluxation of the ulnar nerve along with which other structure?

Explanation

Snapping triceps syndrome occurs when the medial head of the triceps subluxates over the medial epicondyle during elbow flexion. It frequently displaces the ulnar nerve concurrently, precipitating cubital tunnel symptoms.

Question 88

During surgical decompression for cubital tunnel syndrome, the ulnar nerve is traced distally into the proximal forearm. Which structure bridges the two heads of the flexor carpi ulnaris (FCU) and represents a common site of deep compression?

Explanation

Osborne's ligament (the cubital tunnel retinaculum) forms the roof of the cubital tunnel, bridging the humeral and ulnar heads of the flexor carpi ulnaris. It is a primary site of entrapment for the ulnar nerve.

Question 89

When creating the posteromedial portal for elbow arthroscopy, the portal is typically placed superior to the olecranon tip and medial to the triceps tendon. Which nerve is at the greatest risk of injury during the establishment of this portal?

Explanation

The ulnar nerve resides posterior to the medial epicondyle. The posteromedial portal must be created carefully with a 'nick and spread' technique, remaining close to the olecranon to avoid ulnar nerve injury.

Question 90

The most common major complication following ulnar collateral ligament (UCL) reconstruction of the elbow is:

Explanation

Postoperative ulnar neuropathy is the most frequent complication following UCL reconstruction. It may result from excessive traction, fluid extravasation, or handling during nerve transposition.

Question 91

A 7-year-old boy presents with dull, aching lateral elbow pain without a history of significant trauma. Radiographs show sclerosis and fragmentation of the capitellum without loose bodies. What is the most likely diagnosis?

Explanation

Panner disease is an osteochondrosis of the capitellum typically affecting boys aged 7 to 10 years. Unlike osteochondritis dissecans seen in adolescents, Panner disease generally heals completely with conservative treatment and rest.

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 49

Orthopedic Prometric MCQs - Chapter 3 Part 49

Chapter Index