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Orthopedic Board Prep: Interactive Viva Exam Practice for Trauma & Surgical Cases

Orthopedic Board Prep: Lateral Epicondylitis Clinical Case & Management

23 Apr 2026 70 min read 119 Views
Elbow structured oral examination question 5

Key Takeaway

Initial management for lateral epicondylitis (tennis elbow) is conservative. It prioritizes activity modification and targeted physical therapy, focusing on eccentric strengthening of the extensor carpi radialis brevis (ECRB) origin. This approach addresses the degenerative pathology, promoting long-term healing and functional improvement without immediate surgical intervention.

Comprehensive Exam


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Question 1

A 45-year-old right-hand dominant carpenter presents with two months of worsening left elbow pain, particularly with gripping and lifting. He denies any acute trauma. On examination, he has tenderness over the lateral epicondyle, pain with resisted wrist extension, and a positive Cozen's test. Radiographs are unremarkable. Which of the following is the most appropriate initial management step?





Explanation

The patient presents with classic symptoms of lateral epicondylitis (tennis elbow), which is typically a degenerative process of the ECRB origin rather than an inflammatory one. Initial management is almost always conservative, focusing on activity modification, physical therapy (especially eccentric strengthening of the wrist extensors), bracing, and pain control. Corticosteroid injections can provide short-term relief but have been shown to have worse long-term outcomes and potential adverse effects. Surgery is reserved for failed conservative management (typically after 6-12 months). MRI is usually not indicated unless atypical symptoms, failure to respond to initial conservative treatment, or a suspected different pathology (e.g., intra-articular loose body, osteochondral lesion) are present. NSAIDs can help with pain but don't address the underlying tendinosis, and splinting alone is insufficient.

Question 2

A 32-year-old collegiate baseball pitcher complains of acute, sharp pain in his right elbow after throwing a fastball. He immediately felt a 'pop' and now has difficulty extending his elbow and a feeling of instability. On examination, there is marked tenderness over the medial epicondyle and a positive valgus stress test at 30 degrees of flexion, with increased gapping compared to the contralateral side. Plain radiographs are negative for fracture. What is the most likely diagnosis?





Explanation

The patient's presentation with acute pain, a 'pop,' instability, and a positive valgus stress test in a baseball pitcher is highly characteristic of an acute ulnar collateral ligament (UCL) rupture. This injury is common in overhead athletes due to repetitive valgus stress. While a medial epicondyle avulsion fracture could present similarly, the absence of a fracture on radiographs makes UCL rupture more likely. Olecranon stress fractures cause more chronic pain, and posteromedial olecranon impingement presents with posterior elbow pain. A flexor-pronator mass strain would typically involve less instability and less distinct 'pop' sensation.

Question 3

Following an acute elbow dislocation, what is the most common associated neurovascular complication that must be carefully assessed?





Explanation

While all listed neurovascular structures can be injured during an elbow dislocation, the ulnar nerve is the most commonly affected, particularly with posterior dislocations. Its superficial location posterior to the medial epicondyle makes it vulnerable to stretch or contusion. Radial nerve injury is less common, and median nerve and brachial artery injuries, while serious, are less frequent than ulnar nerve involvement. Anterior interosseous nerve palsy is a specific motor branch of the median nerve and less frequently involved as a standalone primary complication of dislocation.

Question 4

A 68-year-old female sustains a comminuted distal humerus fracture involving both columns. She has no neurological deficits. Given the comminution and her age, surgical fixation is planned. What is the preferred surgical approach for optimal exposure of both columns in a comminuted distal humerus fracture?





Explanation

For comminuted intra-articular distal humerus fractures involving both columns, an olecranon osteotomy is often preferred. This approach provides excellent, extensile exposure of the entire distal humerus articular surface, allowing for anatomical reduction and stable fixation. While paratricipital approaches can be used, they offer more limited visualization of both columns, especially the articular surface. A triceps-splitting approach can damage the triceps muscle and its innervation. The anterolateral approach is primarily for supracondylar fractures and does not provide adequate posterior exposure for bicondylar fractures.

Question 5

What anatomical structure provides the primary static restraint to valgus stress in the elbow?





Explanation

The ulnar collateral ligament (UCL), specifically its anterior bundle, is the primary static stabilizer against valgus stress at the elbow, particularly from 30 to 120 degrees of flexion. The radial collateral ligament stabilizes against varus stress. The annular ligament stabilizes the radial head against the ulna. The medial epicondyle is an attachment site for the UCL and flexor-pronator mass but is not a primary static restraint itself. The capitellum is part of the articulation.

Question 6

A 10-year-old boy falls directly onto his elbow and presents with pain, swelling, and limited motion. Radiographs reveal a displaced supracondylar humerus fracture (Gartland Type III). Neurological examination shows weakness in wrist flexion and thumb/index finger flexion, with sensory loss over the palmar aspect of the index and middle fingers. Which nerve is most likely injured?





Explanation

The median nerve is the most commonly injured nerve in supracondylar humerus fractures, especially with posteromedial displacement. Weakness in wrist flexion (flexor carpi radialis), thumb flexion (flexor pollicis longus), and index finger flexion (flexor digitorum profundus to index/middle) along with sensory loss in the palmar aspect of the index and middle fingers and thumb indicates median nerve involvement. The anterior interosseous nerve is a motor branch of the median nerve, but the described sensory loss points to a more proximal median nerve injury. Radial nerve injury typically affects wrist and finger extension, while ulnar nerve injury affects intrinsics and sensation to the little finger and ulnar half of the ring finger.

Question 7

What is the most common complication of a Monteggia fracture-dislocation (ulnar shaft fracture with radial head dislocation)?





Explanation

While all listed are potential complications, malunion of the ulnar fracture (especially in children) leading to persistent radial head dislocation is a significant and common problem if not anatomically reduced and stably fixed. PIN injury is a well-known acute complication (especially with Bado Type I), but persistent radial head dislocation due to inadequate ulnar reduction is arguably the most common and functionally devastating long-term complication if primary fixation is suboptimal. Elbow stiffness is also common but often secondary to the initial trauma and prolonged immobilization or malunion.

Question 8

A 55-year-old male with a history of recurrent gout presents with acute, severe pain and swelling over the posterior aspect of his right elbow. Examination reveals a tense, erythematous, exquisitely tender swelling overlying the olecranon. He is afebrile. Aspirate of the bursa reveals cloudy fluid with uric acid crystals. What is the most appropriate initial treatment?





Explanation

This patient presents with acute olecranon bursitis secondary to gout. While surgical bursectomy is an option for chronic/recurrent cases or septic bursitis unresponsive to other measures, an acute, non-septic gouty flare in the bursa can be effectively treated with aspiration and a corticosteroid injection. This reduces inflammation and provides significant pain relief. Oral antibiotics are indicated for septic bursitis (which this is not, given uric acid crystals and afebrile status). NSAIDs, rest, and cold compresses are conservative measures that may help but are often insufficient for severe gouty flares. Intravenous antibiotics and surgical debridement are for severe septic bursitis.

Question 9

What is the primary function of the anconeus muscle in the elbow?





Explanation

The anconeus muscle is a small muscle located on the posterolateral aspect of the elbow. Its primary function is to assist the triceps in elbow extension and, importantly, to stabilize the ulna during forearm pronation and supination movements. It is not a primary flexor, pronator, or wrist extensor, nor is its main role the stabilization of the radial head (which is primarily the annular ligament).

Question 10

A 28-year-old construction worker presents with chronic elbow pain, stiffness, and catching sensations after a fall onto an outstretched hand two years prior. Radiographs show osteophytes and mild degenerative changes, but no loose bodies are apparent. MRI reveals a large osteochondral defect of the capitellum and multiple intra-articular loose bodies. What is the most appropriate treatment strategy for symptomatic osteochondritis dissecans (OCD) of the capitellum with loose bodies in an adult?





Explanation

For symptomatic osteochondritis dissecans (OCD) of the capitellum with loose bodies in an adult, arthroscopic intervention is often indicated. Loose bodies cause mechanical symptoms (catching, locking, pain), and the osteochondral defect contributes to pain and stiffness. Arthroscopy allows for removal of loose bodies and addressing the defect, typically with debridement, drilling, or microfracture to stimulate fibrocartilage formation. Activity modification and NSAIDs are rarely sufficient for mechanical symptoms caused by loose bodies. Proximal ulna osteotomy is for cubitus varus correction. Total elbow arthroplasty is reserved for severe, end-stage degenerative disease, and corticosteroid injections are not curative for mechanical issues.

Question 11

Which of the following describes the 'terrible triad' injury of the elbow?





Explanation

The 'terrible triad' of the elbow refers to a combination of three distinct injuries: an elbow dislocation, a radial head fracture, and a coronoid process fracture. This combination often leads to significant instability and is challenging to manage, with a high risk of stiffness and recurrent instability. Understanding this specific constellation is crucial for diagnosis and treatment planning.

Question 12

A 70-year-old patient with rheumatoid arthritis presents with severe, end-stage elbow destruction, pain, and limited range of motion. She is unable to perform activities of daily living. She has a sedentary lifestyle and minimal manual labor requirements. What is the most appropriate surgical intervention?





Explanation

For severe, end-stage rheumatoid arthritis of the elbow with functional impairment in a low-demand patient, total elbow arthroplasty (TEA) is generally the treatment of choice. It aims to provide pain relief and improve range of motion. Elbow arthrodesis (fusion) results in a stiff elbow, which is poorly tolerated. Interposition arthroplasty (fascia lata, dermis) is historical or reserved for very specific scenarios. Radial head excision helps with pain but doesn't address the entire joint. Debridement arthroplasty provides temporary relief but not long-term solutions for severe destruction.

Question 13

What is the purpose of the 'circle of motion' concept in elbow stability?





Explanation

The 'circle of motion' concept, specifically the 'Horii Circle of Instability,' describes the sequential pattern of soft tissue disruption that leads to elbow dislocation, typically from lateral to medial (LCL complex, then anterior/posterior capsule, then UCL). Understanding this pattern helps predict the stability of the elbow after injury and guides repair strategies, especially in posterolateral rotatory instability.

Question 14

Which of the following is considered the gold standard for diagnosing ulnar collateral ligament (UCL) insufficiency in the elbow?





Explanation

While MRI with contrast can provide excellent anatomical detail of the UCL, and dynamic ultrasound can visualize gapping, the definitive diagnosis of UCL insufficiency often requires elbow arthroscopy. Arthroscopy allows for direct visualization of the ligament, assessment of its integrity, and probing for gapping under valgus stress. Clinical examination with valgus stress testing is highly sensitive but can be limited by patient guarding or pain. Plain radiographs are primarily for bony lesions. Therefore, arthroscopy is considered the gold standard for definitive diagnosis, especially when considering surgical reconstruction.

Question 15

A 16-year-old competitive gymnast presents with chronic posteromedial elbow pain, particularly during hyperextension and weight-bearing activities. Radiographs show an ossicle in the posteromedial olecranon fossa. What is the most likely diagnosis?





Explanation

The patient's symptoms (chronic posteromedial elbow pain with hyperextension/weight-bearing) and radiographic findings (ossicle in the posteromedial olecranon fossa) are characteristic of posteromedial olecranon impingement. This condition is common in athletes involved in activities requiring repetitive elbow extension and valgus stress (e.g., gymnasts, throwers), leading to bone spur formation and impingement. Olecranon stress fractures cause more diffuse posterior pain. Medial epicondyle apophysitis is common in younger throwers but presents with medial epicondyle pain. Ulnar neuropathy presents with neurological symptoms. Flexor-pronator strain causes medial pain, but not typically with impingement symptoms.

Question 16

What is the primary role of the radial head in elbow stability?





Explanation

The radial head plays a crucial role as a secondary stabilizer to valgus stress (after the UCL) and is a primary stabilizer against axial compression loads across the humeroradial joint. It also contributes to varus stability. It is not the primary restraint to valgus or varus stress alone. While the annular ligament stabilizes the radial head for pronation/supination, the radial head itself isn't the primary stabilizer of these movements. The common extensor tendon originates from the lateral epicondyle, not the radial head.

Question 17

A 40-year-old diabetic patient presents with a stiff elbow following prolonged immobilization for a forearm fracture. Range of motion is severely limited, with an arc of motion less than 30 degrees. Radiographs show significant heterotopic ossification bridging the joint. What is the most appropriate surgical approach for managing severe elbow stiffness with heterotopic ossification?





Explanation

For severe elbow stiffness with mature heterotopic ossification that significantly limits function, open surgical release with careful excision of the ossification is often necessary. Post-operatively, a structured rehabilitation program, often with continuous passive motion (CPM) or dynamic splinting, and sometimes prophylactic radiation or NSAIDs to prevent recurrence of HO, is critical. Dynamic splinting and serial casting are generally used for less severe stiffness or as adjuncts to surgery. Radiation therapy is primarily prophylactic to prevent HO recurrence, not to treat existing, mature HO. Elbow arthroplasty is for end-stage arthritis, not primarily for stiffness due to HO.

Question 18

Which of the following anatomical structures is most commonly responsible for anterior elbow impingement symptoms?





Explanation

Anterior elbow impingement symptoms, often presenting as pain and limited extension, are most commonly caused by hypertrophy of the coronoid process (or its osteophytes) impinging against the coronoid fossa of the humerus. Olecranon osteophytes cause posterior impingement. Radial head hypertrophy can cause symptoms, but less typically anterior impingement. Medial epicondyle spurs are associated with UCL pathology, and capitellum defects with OCD, not primary anterior impingement.

Question 19

What is the optimal position for immobilization of the elbow following an uncomplicated posterior dislocation in an adult?





Explanation

Following an uncomplicated posterior elbow dislocation, the elbow is typically immobilized in approximately 90 degrees of flexion with the forearm in neutral rotation. This position provides maximum stability and minimizes stress on the healing capsular ligaments. Full extension or full flexion can be unstable or uncomfortable. The duration of immobilization is usually short (1-3 weeks) to prevent stiffness, followed by early controlled range of motion.

Question 20

In a child, what is the most common direction of a supracondylar humerus fracture displacement?





Explanation

The most common type of supracondylar humerus fracture in children is the extension-type injury, resulting from a fall onto an outstretched hand with the elbow extended. This typically leads to posterior and medial displacement of the distal fragment relative to the proximal humerus. Understanding this common displacement pattern is critical for reduction and fixation.

Question 21

What is the most common cause of cubital tunnel syndrome?





Explanation

The most common cause of cubital tunnel syndrome is often considered idiopathic, but repetitive elbow flexion and extension (which increases pressure within the cubital tunnel and stretches the ulnar nerve) is a significant contributing factor and mechanical cause. Other causes include direct trauma, degenerative changes, anconeus epitrochlearis muscle, and a persistent arcade of Struthers, but repetitive motion is a very common mechanism leading to chronic compression or traction neuropathy.

Question 22

Which clinical test is most specific for diagnosing posterolateral rotatory instability (PLRI) of the elbow?





Explanation

The lateral pivot shift test of the elbow (or chair push-up test, posterior drawer test with valgus stress) is the most specific clinical test for diagnosing posterolateral rotatory instability (PLRI). This test reproduces the subluxation and reduction of the radial head and ulna relative to the humerus, which is pathognomonic for PLRI due to insufficiency of the lateral ulnar collateral ligament (LUCL). The valgus and varus stress tests assess the medial and lateral collateral ligaments respectively, while the moving valgus stress test assesses UCL integrity. Cozen's test is for lateral epicondylitis.

Question 23

What is the primary goal of surgical management for a Mason Type II radial head fracture?





Explanation

A Mason Type II radial head fracture is a displaced, but not comminuted, fracture. The primary goal of surgical management for a Mason Type II fracture, especially if it blocks motion or causes mechanical symptoms, is anatomical reduction and stable internal fixation. This preserves the radial head, which is crucial for elbow and forearm stability and kinematics. Radial head excision is generally reserved for unreconstructible fractures (Type III) or specific contexts. Replacement is for Type III fractures or concomitant ligamentous injuries. Total elbow arthroplasty and arthrodesis are for end-stage conditions.

Question 24

In a complete tear of the distal biceps tendon, which muscle primarily provides elbow flexion power?





Explanation

In a complete tear of the distal biceps tendon, the brachialis muscle becomes the primary elbow flexor. The brachialis inserts on the coronoid process and ulnar tuberosity, acting as a pure elbow flexor regardless of forearm rotation. The brachioradialis also contributes to flexion, especially in neutral rotation, but the brachialis is more powerful. The triceps extends the elbow. The flexor carpi ulnaris and pronator teres are forearm muscles with different primary actions.

Question 25

What is the most common cause of post-traumatic elbow stiffness?





Explanation

While heterotopic ossification (HO) is a significant cause of post-traumatic elbow stiffness, the most common cause of restricted motion is contracture of the anterior capsule, often combined with posterior capsule contracture. The anterior capsule limits extension, and the posterior capsule limits flexion. HO often complicates these capsular contractures but is not universally present or the sole cause. Loss of articular congruity certainly contributes but is an underlying bony issue, not solely a soft tissue contracture.

Question 26

A patient undergoing an ulnar nerve transposition procedure should be counseled about potential for injury to which nearby structure if dissection is not meticulous?





Explanation

During ulnar nerve transposition (subcutaneous, intramuscular, or submuscular), the medial antebrachial cutaneous nerve (MABCN) is consistently in the surgical field and is at high risk of injury. It provides sensation to the medial forearm. Injury can lead to a painful neuroma or numbness in its distribution. The other listed nerves and artery are generally not in the immediate vicinity of the ulnar nerve transposition, assuming proper surgical technique.

Question 27

In the setting of a Type II open distal humerus fracture, what is the initial management priority after wound debridement and stabilization?





Explanation

For any open fracture, the initial priority after wound debridement and stabilization (usually with temporary external fixation) is the administration of broad-spectrum intravenous antibiotics to prevent infection. This should be done as soon as possible. Vascular exploration would only be an initial priority if there were signs of active ischemia. Definitive fixation is performed after the soft tissue envelope has improved and infection risk is minimized. Early range of motion is for stable, closed fractures. Delayed primary closure is appropriate for open fractures, but antibiotics precede it.

Question 28

Which compartment of the forearm is primarily affected in Volkmann's ischemic contracture after an elbow injury?





Explanation

Volkmann's ischemic contracture typically affects the deep anterior (flexor) compartment of the forearm. This compartment contains the critical flexor muscles (like FDP, FPL) and the median and ulnar nerves, which are highly susceptible to ischemia due to their position and limited space. Compartment syndrome in this region leads to muscle necrosis and subsequent contracture if not treated promptly with fasciotomy.

Question 29

A 5-year-old child presents with a 'pulled elbow' (nursemaid's elbow). What is the underlying pathological lesion?





Explanation

A 'pulled elbow' or nursemaid's elbow is a subluxation of the radial head. The annular ligament slips over the radial head and becomes trapped in the radiocapitellar joint, preventing full reduction. It is not a true dislocation of the entire elbow joint, a fracture, or a ligament sprain in the traditional sense, but rather an interposition of the annular ligament.

Question 30

What is the most common nerve injured in a proximal ulnar shaft fracture with associated radial head dislocation (Monteggia fracture-dislocation)?





Explanation

The posterior interosseous nerve (PIN) is the most commonly injured nerve in Monteggia fracture-dislocations, especially Bado Type I (anterior radial head dislocation). The PIN is a purely motor branch of the radial nerve, and it can be stretched or entrapped around the radial head or the supinator muscle during the dislocation. While radial nerve proper injury is also possible, PIN is more specific to this injury pattern.

Question 31

In an adult with acute, unstable elbow dislocation, what is the typical initial treatment after closed reduction?





Explanation

After closed reduction of an uncomplicated, stable elbow dislocation in an adult, the initial treatment typically involves a brief period of immobilization (1-3 weeks) followed by early controlled range of motion with a hinged brace. Prolonged immobilization can lead to severe stiffness. Immediate surgical stabilization is reserved for unstable dislocations after reduction, irreducible dislocations, or those with associated fractures requiring fixation. Dynamic external fixation is for complex unstable dislocations. Corticosteroid injection is not indicated.

Question 32

Which type of nonunion is typically treated with intramedullary nailing in the ulna?





Explanation

Intramedullary nailing is a viable option for midshaft ulnar hypertrophic nonunion, especially in cases where previous plate fixation has failed or when the bone defect is minimal. It provides good stability and biological stimulation. For atrophic nonunions with bone loss, bone grafting is usually required. Olecranon and coronoid nonunions typically require plate/screw fixation or tension band wiring. Distal ulna hypertrophic nonunion may also be amenable to plating or non-operative management if asymptomatic.

Question 33

What is the most common complication following surgical fixation of an intra-articular distal humerus fracture?





Explanation

The most common and challenging complication following surgical fixation of an intra-articular distal humerus fracture is post-traumatic arthritis and elbow stiffness. While nonunion, infection, ulnar nerve palsy, and loss of reduction can occur, stiffness and eventual degenerative changes are almost universal to some degree, often requiring extensive rehabilitation or further intervention. The complexity of the joint and the extensive soft tissue dissection contribute to this.

Question 34

Which nerve is at greatest risk during an anterior capsular release for elbow flexion contracture?





Explanation

During an anterior capsular release, particularly if performed from a medial approach, the median nerve is at greatest risk. It lies anterior to the elbow joint and crosses the anterior capsule. The brachial artery is also in close proximity. The ulnar nerve is typically protected posteriorly. The radial nerve is lateral. PIN and AIN are distal branches.

Question 35

A 12-year-old throws a baseball with a valgus force. He experiences medial elbow pain during acceleration phase of throwing. Physical examination reveals tenderness over the medial epicondyle. Radiographs show widening of the physis around the medial epicondyle. What is the most likely diagnosis?





Explanation

The patient's age (12-year-old growing athlete), throwing mechanism with valgus stress, medial elbow pain, tenderness over the medial epicondyle, and radiographic finding of widening of the physis are all classic signs of Little Leaguer's elbow, which is synonymous with medial epicondyle apophysitis. This is an overuse injury due to repetitive traction on the medial epicondyle apophysis. A medial epicondyle avulsion fracture is a more acute, complete separation and would usually show more displacement. UCL tear is less likely with open physes. Olecranon stress fracture is posterior pain. Flexor-pronator strain is a muscle injury.

Question 36

Which surgical technique is most commonly used for repair of a distal biceps tendon rupture?





Explanation

Both single-incision anterior approach and double-incision approaches are commonly used for distal biceps tendon repair. However, the single-incision anterior approach with cortical button or suture anchors has become increasingly popular due to its excellent cosmetic results and strong fixation. The double-incision approach traditionally used a transosseous tunnel but has fallen out of favor for some surgeons due to concerns about heterotopic ossification and cosmesis. Posterior, medial, or lateral approaches are not suitable for distal biceps repair.

Question 37

What is the primary stabilizer of the proximal radioulnar joint?





Explanation

The annular ligament is the primary stabilizer of the proximal radioulnar joint. It encircles the radial head, holding it in firm apposition with the radial notch of the ulna, thereby allowing pronation and supination while preventing proximal migration or subluxation of the radial head. The interosseous membrane and oblique cord are distal to this joint and provide stability to the forearm generally. The quadrate ligament also contributes to PRUJ stability but is secondary to the annular ligament. The radial collateral ligament stabilizes the humeroradial joint.

Question 38

A 75-year-old female presents with severe pain and inability to move her elbow after a fall. Radiographs show a comminuted fracture of the olecranon. She has osteoporosis. What surgical fixation method is generally preferred for comminuted olecranon fractures in osteoporotic bone?





Explanation

For comminuted olecranon fractures, especially in osteoporotic bone, plate and screw fixation is generally preferred over tension band wiring. Tension band wiring is more suitable for simple, transverse, or oblique fractures but can fail in comminuted or osteoporotic bone due to inadequate bone purchase. Excision of fragments and triceps advancement is usually reserved for very small, non-reconstructible fragments in low-demand patients. Intramedullary nailing is not typically used for comminuted olecranon fractures. External fixation is reserved for open fractures, severe soft tissue compromise, or temporary stabilization.

Question 39

Which of the following conditions is most likely to result in a 'gunstock deformity' (cubitus varus)?





Explanation

Cubitus varus, or 'gunstock deformity,' is most commonly caused by malunion of a supracondylar humerus fracture in a child. This typically occurs when the distal fragment rotates internally, leading to a varus angulation of the elbow in extension. The other conditions do not typically lead to this specific deformity.

Question 40

What is the most common elbow fracture in adults?





Explanation

Radial head fractures are the most common elbow fracture in adults, accounting for approximately one-third of all elbow fractures. They typically result from a fall onto an outstretched hand, transmitting axial load through the radial head. Olecranon and distal humerus fractures are also common but less frequent than radial head fractures.

Question 41

A patient presents with a chronically painful, stiff elbow with a fixed flexion deformity of 30 degrees and an arc of motion of 70 degrees. Radiographs show diffuse degenerative changes. What is the main indication for interposition arthroplasty of the elbow?





Explanation

Interposition arthroplasty (e.g., using fascia lata, dermis, or allograft) is generally reserved for younger, active patients with end-stage elbow arthritis where a total elbow arthroplasty (TEA) is contraindicated or carries too high a risk of failure due to the patient's activity level. It aims to provide a pain-relieving, albeit often limited motion, functional joint. TEA is preferred for older, low-demand patients. It's not a primary treatment for acute trauma or stiffness without arthritis, nor is it the primary revision strategy for failed TEA in most cases.

Question 42

Which imaging modality is most sensitive for detecting early osteochondral lesions of the capitellum in an athlete?





Explanation

MRI with contrast is the most sensitive imaging modality for detecting early osteochondral lesions of the capitellum, as it can visualize cartilage integrity, subchondral bone changes, and marrow edema, which are not well seen on plain radiographs or CT. Ultrasound is useful for soft tissues but limited for articular cartilage and bone. A bone scan can show increased metabolic activity but is not specific for an OCD lesion.

Question 43

What is the common mechanism of injury for a medial epicondyle avulsion fracture in a pediatric athlete?





Explanation

Medial epicondyle avulsion fractures in pediatric athletes commonly occur due to repetitive valgus stress during the acceleration phase of throwing. The strong pull of the flexor-pronator mass and the tension on the ulnar collateral ligament complex avulse the unfused medial epicondyle physis. Direct blows or falls can cause fractures, but this specific mechanism is highly associated with throwing athletes.

Question 44

When performing an ulnar nerve anterior transposition, what is a common complication specific to placing the nerve subcutaneously?





Explanation

When the ulnar nerve is transposed subcutaneously, a common specific complication is persistent pain from its superficial positioning, making it susceptible to direct trauma or pressure. The nerve can also sometimes subluxate back over the epicondyle, although this is less common with proper soft tissue release and fixation. Compression by the arcade of Struthers (proximal to the cubital tunnel) is a cause of compression that needs to be released, not a specific complication of subcutaneous transposition. PIN injury is not related. Brachial artery injury is also not a specific complication of subcutaneous transposition, although always a general risk.

Question 45

What is the primary function of the medial collateral ligament (MCL) complex of the elbow?





Explanation

The medial collateral ligament (MCL) complex, specifically the anterior bundle of the ulnar collateral ligament (UCL), is the primary static stabilizer that resists valgus stress at the elbow. The lateral collateral ligament (LCL) complex resists varus stress and posterolateral rotatory instability.

Question 46

A 22-year-old weightlifter presents with chronic anterior elbow pain, particularly with heavy biceps curls. Examination reveals a painful 'pop' with resisted elbow flexion. MRI shows a partial tear of the distal biceps tendon. What is the most appropriate initial management?





Explanation

For a partial tear of the distal biceps tendon, especially in the chronic setting and without complete avulsion, initial management is typically conservative. This includes rest, activity modification (avoiding aggravating activities like heavy lifting), NSAIDs for pain, and a structured physical therapy program focusing on eccentric strengthening. Surgical repair is generally reserved for complete ruptures or failed conservative management of symptomatic partial tears. Injections are generally not recommended for partial tendon tears due to the risk of further degeneration or rupture. Cast immobilization is overly restrictive and can lead to stiffness.

Question 47

What is the key to preventing recurrent posterolateral rotatory instability (PLRI) after operative repair?





Explanation

Posterolateral rotatory instability (PLRI) is caused by insufficiency of the lateral ulnar collateral ligament (LUCL). Therefore, the key to preventing recurrent instability after operative treatment is the anatomical repair or reconstruction of the LUCL. Other elements like good rehabilitation are important, but addressing the underlying ligamentous pathology is paramount. Aggressive early range of motion without adequate stability can lead to recurrence. Strict immobilization can lead to stiffness. Medial collateral ligament reconstruction is for valgus instability, and radial head excision can actually worsen stability.

Question 48

In the context of a terrible triad injury, which fracture component is most critical to anatomical reduction for elbow stability?





Explanation

In a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture), the coronoid process fracture is considered the most critical component to anatomically reduce and fix. The coronoid is a key anterior buttress of the ulna against the trochlea and provides significant anterior stability. Inadequate fixation of the coronoid often leads to persistent instability and recurrent dislocation, even if the radial head and ligaments are addressed. While the radial head is also important for stability, the coronoid is often described as the 'gatekeeper' of stability in this injury.

Question 49

A patient with chronic, recalcitrant lateral epicondylitis has failed 6 months of conservative management, including physical therapy, bracing, and a single corticosteroid injection. What is the next most appropriate step?





Explanation

After 6-12 months of failed comprehensive conservative management for chronic lateral epicondylitis, surgical intervention, typically open or arthroscopic debridement of the degenerative ECRB origin, is considered the next most appropriate step. Repeating corticosteroid injections is not recommended due to potential long-term negative effects. PRP injections have shown mixed results and are still considered experimental or second-line. MRI of the cervical spine is relevant if radiculopathy is suspected, but in a classic presentation with localized tenderness, surgical treatment of the elbow is more indicated. Further observation is unlikely to lead to resolution after extensive failed conservative care.

Question 50

Which of the following describes the anatomical structure known as the 'arcade of Struthers'?





Explanation

The arcade of Struthers is a fibrous band or ligamentous structure that extends from the medial head of the triceps to the medial intermuscular septum. It is a potential site of ulnar nerve compression, located approximately 8 cm proximal to the medial epicondyle. It is distinct from the pronator teres arch (median nerve), the arcade of Frohse (PIN), or the annular ligament.

Question 51

What is the significance of the radiocapitellar view on plain radiographs for elbow trauma?





Explanation

The radiocapitellar (or oblique) view is a crucial radiographic view for elbow trauma. It helps to better visualize the radial head and neck, allowing for the detection of non-displaced radial head fractures or subtle fractures that may be missed on standard AP and lateral views. It also aids in identifying subtle joint effusions (e.g., 'fat pad sign') by displacing the anterior fat pad. It does not directly visualize ligaments or the olecranon fossa as well as other views.

Question 52

What is the primary role of the posterior bundle of the ulnar collateral ligament (UCL)?





Explanation

The posterior bundle of the ulnar collateral ligament (UCL) is a fan-shaped structure that becomes taut in full elbow flexion. Its primary role is to act as a secondary stabilizer against valgus stress in flexion and to limit full elbow flexion. The anterior bundle is the primary valgus stabilizer, particularly between 30 and 120 degrees of flexion. The posterior bundle is distinct from the primary valgus stabilizers.

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