Elbow - RC Q's

Question 1

RC 2011, 2014: Bilat elbow fusion position?<div>45 and 120 degrees<div>65 and 110 degrees</div><div>90 and 120 degrees</div><div>90 and 90 degrees</div></div>

Answer 1

<div>65 and 110</div>

Question 2

RC 2010: what is not true for elbow OA?<div>weakness</div><div>loss of joint space</div><div>tight capsule</div><div>hypertrophic OA</div>

Answer 2

B<div><div>Characterized by the relative preservation of the articular cartilage and maintenance of joint space, but with hypertrophic osteophyte formation and capsular contracture</div></div>

Question 3

<div>RC 2008 - RA and elbow pain, with synovitis and preserved joint space, what is true regarding synovectomy?</div>

1-Improves ROM<div>2-Needs radial head resection</div><div>3-Good pain relief in 80% of patients over 3 years<br></br></div>

Answer 3

Prev answer C, but all seem true. RH excision doesnt seem mandatory<div><br></br></div><div>-Synovectomy with or without radial head excision is well-recognized and accepted form of treatment When done early, may be an effective treatment, lasting >10 years in up to 80% of patients</div><div>-Pain relief is common, but the rate of recurrence increases after 5 years</div><div>-Even in patients with advanced disease, synovectomy and capsular release with or without radial head excision may result in acceptable pain relief and increased elbow ROM<br></br></div>

Question 4

<div>RC 2016 - Nerve injuries in elbow arthroscopy can be common and are devastating. All of the following are ways to minimize this risk, <b><u>except:</u></b></div>

1-Ensuring joint is maximally insufflated with fluid at all times<div>2-Drawing out surface landmarks at start of procedure<div>3-Using a needle to landmark portals prior to making an incision and inserting instruments</div><div>4-Continued use of a tourniquet at all times<br></br></div></div>

Answer 4

4<div>JAAOS: “In every clinical case, the bony anatomy should be drawn on the patient’s elbow, an 18-guage spinal needle should be used to confirm the correct portal location before introducing the trocar and the elbow should be maximally distended at all times to displace the neurovascular structures away from the entering instruments”</div>

Question 5

<div>RC 2017 - Which of these is not a primary stabilizer of the elbow?</div>

Ulnohumeral joint<div>Lateral ulnar collateral ligament</div><div>Anterior band of MCL</div><div>Radiocapitellar joint<br></br></div>

Answer 5

“D. RC joint is a secondary stabilizer<div><img></img><br></br></div>”

Question 6

<div>RC 2010 -45 yr old male with pure ligamentous instability after elbow dislocation on lateral side. What is the management of this elbow?</div>

Answer 6

-Immobilize in 90o with arm in pronation (if purely lateral; but if medial also–> neutral) Think about RH is supination: it will fall out the back!<div>-Follow on weekly basis with radiographs to ensure congruent reduction</div><div>-Hinged elbow brace at 2 weeks with extension blocks -Progressive ROM until full extension</div><div>-Discontinue brace at 6-8 weeks<br></br></div>

Question 7

<div>RC 2014 - Describe the push-up test for PLRI</div>

Answer 7

<ul> <li>Prone, elbows flexed to 90 deg, shoulders abducted, forearms <u>supinated</u></li> <li>Pt attempts elbow extension</li> <li>Positive test is pt apprehension or frank subluxation/dislocation of radial head</li></ul>

Question 8

<div>RC 2013 - What is the most true about elbow dislocations? </div>

Coronoid fractures of 50% height does not increase instability<div>LUCL often tears from the epicondylar origin</div><div>Medial side of elbow fails first<br></br></div>

Answer 8

“2<div><br></br></div><div><img></img><br></br></div>”

Question 9

<div>RC 2013 - What is the most common complication following an elbow dislocation? </div>

Lack of terminal extension<div>Nerve Injury</div><div>Heterotopic ossification</div><div>Late Ligament Instability<br></br></div>

Answer 9

A - 15% rate of stiffness (>30 deg extension lost)<div><br></br></div><div>Recurrence is uncommon (residual instability 2%)</div><div>Myositis Ossificans is uncommon in uncomplicated dislocations (<5%)<br></br></div>

Question 10

RC 2018 All of the following are important contributors to elbow stability EXCEPT<div>Anterior band of ulnar collateral lig</div><div>Posterior band of ulnar collateral lig</div><div>Lateral ulnar collateral lig</div><div>Ulnohumeral articulation<br></br></div>

Answer 10

B.

Question 11

<div>RC 2018 Regards to testing stability of the ulnar collateral ligament which is true</div>

<div>a.Pivot shift test</div>

<div>b.Posterolaterael drawer</div>

<div>c.End ROM pain</div>

<div>d.Moving valgus stress test</div>

<div></div>

<div><br></br></div>

Answer 11

D<div><br></br></div><div><div>Moving Valgus Stress test O’driscoll AJSM 2005</div>Physical Exam: the examiner applies and maintains a constant moderate valgus torque to the fully flexed elbow and then quickly extends the elbow. The test is positive if the medial elbow pain is reproduced at the medial collateral ligament and is at maximum between 120° and 70° 100% sensitive and 75% specific When compared to MRI evaluation of the elbow, the moving valgus stress test demonstrated a significantly higher sensitivity for MCL insufficiency as determined by operative confirmation<br></br></div>

Question 12

<div>RC 2015 - What is the most common type of elbow instability:</div>

Posterolateral instability<div>Posteromedial varus instability</div><div>Valgus</div><div>Anterior<br></br></div>

Answer 12

<div>A- PLRI - 95%</div>

Question 13

RC 2009 - Elbow dislocation. No fracture. Concentrically reduced, but opens in valgus. Treatment?<div><div>A. Sling</div> <div>B. Splint at 90 with forearm in neutral</div> <div>C. Splint at 90 with forearm in supination</div> <div>D. Splint at 90 with forearm in pronation</div></div>

Answer 13

<div>C. Splint at 90 with forearm in supination</div>

<div>dumb because the muscle masses are probably torn off anyhow.</div>

<div>AAOS - Simple Elbow Dislocation: Point thumb away from injured ligaments<br></br></div>

<div><br></br></div>

<div>if it opened in varus -> LUCL injury (RH goes out the back in supination) --> pronate!</div>

Question 14

<div>RC 2008 - What is the position of the arm when examining for PLRI</div>

Answer 14

“supination, extension, valgus to dislocate, then reduces in flexion<div><img></img><br></br></div>”

Question 15

<div>RC 2014, 2016 Posteromedial rotatory instability:</div>

<div>-assx with radial head fracture</div>

<div>-Rarely have an LCL tear</div>

<div>-Leads to ulnohumeral arthritis</div>

<div>-Anteromedial facet of coronoid is intact</div>

Answer 15

C.<div><br></br></div><div>PMRI - AMCF # and LCL injury leads to <b>rapid</b>UH OA; RH and MCL are often intact</div>

Question 16

<div>RC 2016 All are true regarding an anteromedial coronoid fracture, except:</div>

Lateral collateral ligament disruption<div>Can occur in a terrible triad injury</div><div>Joint dislocation</div><div>A locking plate is recommended<br></br></div>

Answer 16

B.

Question 17

<div>RC 2012 Anteromedial coronoid #, what is true?</div>

Associated with a terrible triad<div>LUCL often ruptured</div><div>Elbow subluxation is common</div><div>Locking plate required<br></br></div>

Answer 17

“B - RH and MCL intact while there is AMCF# and LUCL injury<div>"”This results in an anteromedial facet fracture with associated disruption of the LCL due to a varus force. The radial head is usually not fractured in a varus posteromedial instability pattern, and it is therefore by definition not a true terrible triad injury””</div>”

Question 18

<div>RC 2017 What is the best test for diagnosis of injury to MCL of the elbow?</div>

<ol> <li>Conventional MRI</li> <li>Moving valgus stress test</li> <li>Point tenderness at epicondyle</li> <li>Valgus stress radiographs</li> </ol>

<div></div>

Answer 18

1.

Question 19

<div>RC Which of the following is true about one incision vs two incision technique for distal biceps repair</div>

<ol> <li>Complication rates the same for both</li> <li>< 10% complication rate for both</li> <li>Suture anchors have less failure than trans-osseous tunnel</li></ol>

Answer 19

1. complications: one incision (23.9%) and two incisions (25.7%)<div><br></br></div><div><div>bone tunnel and cortical button methods were significantly safer than the suture anchor and screw methods</div></div>

Question 20

<div>RC 2016 - A patient shows up in your office with an acute distal biceps tendon rupture. He is a big baby and doesn’t want surgery. What would you advise him regarding the non-operative management of distal biceps tendon ruptures?</div>

<ol> <li>Supination strength will decrease 40%</li> <li>Elbow flexion strength will decrease 50%</li> <li>Pronation will be more affected than supination</li> <li>He is at high risk of developing shoulder pain</li></ol>

Answer 20

A. With nonoperative management, a 40% to 50% reduction in supination strength, 30% reduction in flexion strength, and 15% reduction in grip strength can be expected

Question 21

<div>RC 2013 - Both 1 and 2 incision techniques for distal biceps tendon repair have been described. Which is NOT true</div>

<div>PIN can be injured in both</div>

<div>1 incision leads to 20% less supination strength</div>

<div>Two incision has a higher rate of HO</div>

<div>One incision has higher LACN injury<br></br></div>

<div></div>

Answer 21

B - equivalent strength<div><br></br></div><div>No difference in supination/pronation strength</div><div>10% increase in flexion strength in double incision (104% vs 94%)</div><div>More LACN injury with single incision (19 vs 3)</div><div><div>Single incision repair techniques are more likely to be complicated by a transient neurapraxia (LABCN), while dual-incision repair techniques are more likely to be complicated by heterotopic ossification and stiffness</div></div>

Question 22

<div>RC 2012 - What is the most common nerve injury in a two incision distal biceps tendon reconstruction? (LACN NOT an option)</div>

<ol> <li>MCNF</li> <li>Median nerve</li> <li>PIN </li> <li>AIN</li></ol>

Answer 22

“3.<div>incidence: LABC>SRN>PIN</div><div><br></br></div><div>note: single incision has more nerve injury - labc, pin</div><div><br></br></div><div><ul> <li>Complications equivalent between single and dual incision (RC EXAM)</li> <li>Single incision repair techniques are more likely to be complicated by a transient neurapraxia (LABCN), while dual-incision repair techniques are more likely to be complicated by heterotopic ossification and stiffness</li></ul></div><div><br></br></div><div><img></img><br></br></div>”

Question 23

<div>RC 2014,16 - What is true regarding the biceps tendon insertion on the radial tuberosity?</div>

<ol> <li>The short head is more lateral and the long head is more medial.</li> <li>The short head is more medial and the long head is more lateral.</li> <li>The long head is more proximal and the short head is more distal.</li> <li>The long head is more distal and the short head is more proximal.</li></ol>

Answer 23

“<div>C</div><div><br></br></div>Proximal: LHB<div>Distal: Short Head</div><div><img></img><br></br></div>”

Question 24

RC 2008 - 50 yo construction worker has 4 months shoulder pain, then pop! Now he has a lump in his distal bicep. What to do? <ol> <li>Repair </li> <li>Transfer coracobrachialis</li> <li>Physio for strengthening</li> <li>Physio for shoulder / elbow ROM</li></ol>

Answer 24

D.

Question 25

<div>RC 2015 - What is true regarding triceps tendon rupture:</div>

<ol> <li>More common in younger women than older women</li> <li>Typically avulses from the bony insertion</li> <li>Will have weakness of flexion and extension</li> <li>A complete tear will result in complete loss of extension</li></ol>

Answer 25

“2.<div><br></br></div><div>JAAOS</div><div><ul> <li>Most common in young men</li> <li>May have elbow extension despite complete tear</li> <li>Weakness of extension, not flexion</li> <li>"”regardless of the mechanism of injury, triceps tendon ruptures are usually seen at the osseous insertion””</li></ul></div>”

Question 26

<div>RC 2008 Which ligament is the main stabilizer during early acceleration?</div>

<ol> <li>Posterior band of MCL</li> <li>Anterior band of MCL</li> <li>LCL</li> <li>Flexor pronator mass</li></ol>

Answer 26

“2<div>.<img></img></div>”

Question 27

<div>RC 2009 Question about acceleration phases of throwing. What had tensile forces, and what had compressive forces</div>

<ol> <li>tension force across ulna/troch and tension across radio-cap</li> <li>tension across radio-cap and compression across ulna/troch</li> <li>compression force across ulna/troch and compression across radio-cap</li> <li>Tension across ulnotrochlear and compression across radiocapitellar joint</li></ol>

Answer 27

“D.<div><img></img><br></br></div>”

Question 28

<div>RC 2013, 2015 What is not a cause of medial elbow pain in a throwing athlete:</div>

<ol> <li>Ulnohumeral arthritis</li> <li>Cubital tunnel syndrome</li> <li>Valgus extension overload</li> <li>Flexor-pronator tendonitis</li> </ol>

<div></div>

<div><br></br></div>

Answer 28

<div></div>

<div>ANSWER: A>b</div>

<div><br></br></div>

Question 29

<div>RC 2018 Which portal for elbow arthroscopy has the highest risk of nerve injury?</div>

<div>a.Anteromedial</div>

<div>b.Posteromedial</div>

<div>c.Posterolateral</div>

<div>d.Anterolateral</div>

<div></div>

<div><br></br></div>

Answer 29

Answer: D<div><br></br></div><div>might be anteromedial (for MABC)</div>

Question 30

<div>RC 2010 - Patient sustained an elbow dislocation that was reduced but remained unstable at 45 degrees with posterolateral instability.</div>

<div>(1) list 3 stabilizers to posterolateral instability?</div>

<div>(2) most important structure?</div>

Answer 30

(1) LUCL, RH, coronoid<div>(2) LUCL</div>

Question 31

<div>RC 2018, 2015 - Regarding elbow dislocation, what is true:</div>

<ol> <li>An LCL injury should be rehabilitated in supination</li> <li>Should be immobilized for at least 3 weeks</li> <li>Often associated with posterior capitellar impaction</li> <li>Instability is a common complication</li></ol>

Answer 31

C.<div><ul> <li>Supination shortens extensor-supination mass –> want to elongate this to provide stability that LCL is lacking</li> <li>3 weeks too long for immobilization, generally only 1-2 weeks</li> <li>Stiffness more common than instability</li></ul></div>

Question 32

RC 2017 - Elbow dislocation with no fracture. Unstable in valgus stress? What is the best management? <ol> <li>hinged external fixation to protect the ligament and allow early ROM.</li> <li>splint at 90 in supination for 1-2 weeks</li> <li>splint at 90 in supination for 3-4 weeks</li> <li>fix mcl</li></ol>

Answer 32

B.<div><br></br></div><div><br></br></div>

Question 33

<div>RC 2008 - What is the position of the arm when examining for PLRI</div>

<ol> <li>Extension, valgus and supination</li> <li>Flexion, varus and pronation</li> <li>Extension, valgus and pronation</li> <li>Flexion, varus and supination</li></ol>

Answer 33

A.<div><br></br></div><div><br></br></div>

Question 34

<div>RC 2008 - All are true except:</div>

<ol> <li>Radio capitellar joint bears 20% of the load through elbow</li> <li>radial head fractures account for 2-4% of all fractures</li> <li>Radio capitellar joint is only a secondary stabilizer to valgus stress (exact wording!)</li></ol>

Answer 34

A<div><br></br></div><div><ul> <li>JAAOS 2008 - Radial Head Arthroplasty</li> <li>Anterior bundle of the MCL is the primary stabilizer to valgus force across the elbow</li> <li>Radial head fractures represent 5.4% of all fractures</li> </ul> <div></div> <ul> <li>JAAOS 2007 - Radial Head Fractures</li> <li>Radius bears 80% of load at wrist, but load sharing ratio equalizes at the elbow</li> </ul> <ul> <li>Radiocapitellar articular accounts for as much as 60% of load transfer across the elbow</li></ul></div>

Question 35

<div>RC 2012 What is true about a comminuted distal humerus fracture in an elderly patient? </div>

<div>A. TEA has improved outcome over ORIF at 1 year </div>

<div>B. Patient functional outcomes for TEA are better at 1 year </div>

<div>C. Re-operation rates for ORIF are significantly higher at 1 yr </div>

<div>D. It is “almost impossible” to do a quality ORIF with poor bone</div>

Answer 35

B.<div><div>Mckee JSES TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF, based on the MEPS. DASH scores were better in the TEA group in the short term but were not statistically different at 2 years’ follow-up. TEA may result in decreased reoperation rates, considering that 25% of fractures randomized to ORIF were not amenable to internal fixation. TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients have an increased baseline DASH score and appear to accommodate to objective limitations in function with time. </div> <div></div></div>

Question 36

X-ray and CT of a large coronoid fracture. What approach would you use? (RC 2019)<div>A. Kocher</div><div>B. Direct anterior</div><div>C. Flexor-pronator split</div><div>D. Boyd</div>

Answer 36

“Ans: C<div><div><span>REF: Medial Elbow Exposure for Coronoid Fractures: FCU-Split Versus Over-the-Top – JOT Dec 2013</span></div><ul><li><div><span>FCU split provides best medial access to anteromedial coronoid</span> and proximal ulna (more so than Hotchkiss over-the-top)</div></li><li><div>Kocher and Boyd are both lateral</div></li><li><div>Anterior useful for biceps tendon</div></li></ul><br></br><div><span>Ref: JAAOS 2013</span></div><ul><li><div>Anteromedial facet fractures of the coronoid are addressed through a medial approach to the joint, but the skin incision can be either medial or posterior.</div></li><li><div>Ulnar nerve is identified and can be released in situ for posterior retraction to avoid postoperative neuropathies.</div></li><li><div>The flexor-pronator muscle group is detached from the medial epicondyle using an L-shaped distal-to-proximal incision, preserving the MCL attachment.</div></li><li><div>An opening of the joint capsule permits excellent visibility for anatomic fixation with screws and, when possible, a buttress plate).</div></li><li><div>Alternatively, a flexor-pronator split, anterior to the ulnar nerve, can be used.</div></li></ul></div>”

Question 37

What is true regarding distal biceps repair (RC 2019)<div>A. One incision has shorter OR times</div><div>B. Two incision has more HO resulting in stiffness</div><div>C. One incision has less transient nerve injury</div><div>D. Single has better patient satisfaction/functional outcomes at 1 year</div>

Answer 37

“<div>Answer: B<br></br><br></br></div><div><span>Ref: JAAOS 2010</span></div><ul><li><div><span>2 incision has more HO and stiffness.</span> Although with smaller incisions and better handling, its not as bad as historical levels.<span><br></br><br></br></span></div></li></ul><div><span>REF: One- Versus Two-Incision Technique for Distal Biceps Tendon Repair – HSS journal Oct 2008</span></div><div> Retrospective review</div><ul><li><div>HO – 3 in 2-incision approach, 1 in single-incision approach</div></li><li><div>LABC parasthesias – 1 patient in single-incision approach</div></li><li><div>Patient satisfaction and functional outcomes <span>same </span>in single/two incision approaches</div></li><li><div>ROM outcomes equivalent</div></li><li><div>Nothing about timing of surgery</div></li></ul><br></br><div><span>REF: Single Versus Double-Incision Technique for the Repair of Acute Distal Biceps Tendon Ruptures – JBJS 2012</span></div><ul><li><div>Low risk of HO, but both groups received prophylaxis</div></li><li><div>Nothing about timing of surgery</div></li></ul><br></br><div><span>REF: Complications of Distal Biceps Tendon Repair A Meta-analysis of Single-Incision Versus Double-Incision Surgical Technique OJSM 2016.</span></div><ul><li><div>2 incision technique</div></li><ul><li><div>Higher risk of HO (7.2%)</div></li></ul><li><div>Single incision technique</div></li><ul><li><div>Higher risk of LABC neuropraxia (9.8%)</div></li><li><div>PIN palsy 1.9% risk</div></li></ul></ul>”

Question 38

<div>Elbow physical exam - all are true except?</div>

<ol><li><div>Tennis elbow symptoms can be elicited with resisted long finger extension</div></li><li><div>NPV of Milking manoeuvre is poor</div></li><li><div>Chair Push-up test more sensitive that pivot shift</div></li><li><div>Moving valgus stress test is sensitive</div></li></ol>

Answer 38

“Ans: 1<div><br></br></div><div><div>9. Elbow physical - all are true except?</div><ol><li><div>Tennis elbow symptoms can be elicited with resisted long finger extension</div></li><li><div>NPV of Milking manoeuvre is poor</div></li><li><div>Chair Push-up test more sensitive that pivot shift</div></li><li><div>Moving valgus stress test is sensitive</div></li></ol><div>Answer: B</div><br></br><div><span>Ref: JAAOS 2018 26(19):678</span></div><ul><li><div><span>Resisted middle finger extension recruits ECRB</span> which can cause pain from lateral epicondylitis as well as radial tunnel syndrome</div></li></ul><ul><li><div><span>Special tests:</span></div></li><ul><li><div>Manual valgus stress test: sensitivity 19%, specificity 100%</div></li><li><div>Moving valgus stress test: sensitivity 100%, specificity 75%</div></li><li><div>Chair push up test: sensitivity 87.5%</div></li><li><div>Pivot shift test: sensitivity 37.5%</div></li><ul><li><div>When performed under anesthesia = ~100% sensitive</div></li></ul></ul></ul><ul><li><div>Milking maneuver: sensitivity 87.5%,<span> </span><span>NPV 100%</span><br></br><br></br></div></li></ul>Most SENSITIVE:<span> </span><span>Moving valgus stress test</span><br></br></div>”