151 B 3/11 (3/10 Day &) Daily Mastery Plan

Front 1

Which of the following portals is generally not used during elbow arthroscopy?
1. Antero-lateral
2. Antero-medial
3. Postero-lateral
4. Postero-medial
5. Direct posterior

Back 1

A posterior medial portal is not often used as it would lie very close to, or directly over the ulnar nerve.

In the study by Stothers et al., they found that the proximal approaches (proximal medial and proximal lateral), are safer than the traditional anteromedial and anterolateral approaches.
Ans4

Front 2

A 30-year-old woman falls onto an outstretched arm while rollerblading. She presents to the emergency room with the elbow deformity shown in Figure A. On physical examination she is unable to range her elbow. She is distally neurovascularly intact. Her radiograph is shown in Figure B. What is the next step in management of this patient?
1. Closed reduction, hinged external fixator
2. Closed reduction, acute surgical repair of the lateral collateral ligament complex
3. Open reduction and surgical repair of the lateral collateral ligament complex
4. Closed reduction, splinting & early passive ROM
5. Closed reduction, splinting & early active ROM

Back 2

The clinical presentation is consistent with a simple elbow dislocation. Initial management should include closed reduction, splinting or sling placement for comfort and early active ROM exercises. Simple elbow dislocations should be reduced and treatment guided by the relative stability of the joint during the arc of motion. The elbow should be splinted where it is most stable. After 5-7 days the splint can be discontinued and active ROM started to apply compressive stability to the joint. A hinged brace with an appropriate extension block can facilitate motion through the stable arc.
Incorrect Answers
Answer 1, 2: While use of a hinged external fixator may be appropriate when instability persists after repair/reconstruction of the LCL complex, it is not the first step in the initial management of a simple elbow dislocation.
Answer 3: Open reduction may be warranted if closed reduction is unsuccessful, however an initial attempt at conservative measures should be made.
Answer 4: Closed reduction needs to be followed by splinting to give the tissues a chance to recover from the initial injury; use of ACTIVE range of motion exercises early, will help to provide dynamic compressive stability to the joint.Ans5

Front 3

A 34-year-old male falls from a roof and sustains a right elbow dislocation that is closed reduced in the emergency room. An AP radiograph is shown in Figure A. This injury pattern is at highest risk for which of the following?
1. Anterior interosseous nerve palsy
2. Varus posteromedial rotatory instability
3. Posterior interosseous nerve palsy
4. Valgus posterolateral rotatory instability
5. Elbow instability when pushing oneself up from a seated position in a chair

Back 3

Anteromedial coronoid facet fracture and LCL injury following an elbow dislocation is commonly associated with varus posteromedial rotatory instability. Varus and posteromedial rotation force on the forearm results in rupture of the LCL from its humeral origin. As the LCL ruptures, the medial coronoid process is fractured as it impacts against and under the medial trochlea. Fracture involvement of the sublime tubercle, where the MCL attaches, can lead to more instability. The lateral pivot shift test is similar to pushing oneself up from a seated position in a chair is an indication of valgus posterolateral rotatory instability. Ulnar neuropathy can be seen following this injury pattern but AIN and PIN nerve palsy do not commonly characterize this injury pattern.Ans2

Front 4

What is the most common mode of failure of the lateral ulnar collateral ligament associated with an elbow dislocation?
1. ligament avulsion off the humeral origin
2. ligament avulsion off the ulnar insertion
3. midsubstance rupture
4. bony avulsion of the humeral origin
5. combined proximal and distal ligament avulsions

Back 4

The lateral ulnar collateral ligament (LUCL) is often injured with elbow dislocations, and is most commonly injured at the proximal origin. McKee noted that in 62 consecutive operative elbow dislocations and fracture/dislocations, the LUCL was ruptured in all of the patients, proximally in 32, bony avulsion proximally in 5, midsubstance rupture in 18, ulnar detachment in 3, ulnar bony avulsion in only 1, and combined patterns in 3.Ans1

Front 5

Which of the following structures shares the same attachment site as the tendon that undergoes angiofibroplastic hyperplasia during the pathogenesis of tennis elbow?
1. Brachioradialis
2. Anconeus
3. Annular ligament
4. Flexor carpi ulnaris
5. Palmaris longus

Back 5

Lateral epidondylitis is classically thought to be caused by histopathologic angiofibroblastic hyperplasia at the origin of the extensor carpi radialis brevis. ECRB originates from the common extensor wad, that also includes ECRL, ED, ECU. The anconeus shares the same attachment site at the lateral epicondyle as the ECRB (as shown in Illustration A).Ans2

Front 6

A 50-year-old carpenter has chronic pain over the lateral aspect of the elbow. He notes pain when using a hammer. On exam, he has pain with resisted wrist extension while the elbow is fully extended. Which muscle attachment is likely to be involved?
1. Distal biceps brachii
2. Brachioradialis
3. Extensor carpi radialis brevis
4. Extensor carpi radialis longus
5. Supinator

Back 6

The clinical presentation is consistent with lateral epicondylitis, which is caused from pathologic changes at the origin of the extensor carpi radialis brevis (ECRB). Physical exam findings consistent with lateral epicondylitis include tenderness over the lateral epicondyle at the origin of the ECRB, and pain that is reproduced with gripping, resisted long finger extension, resisted wrist extension while the elbow is fully extended, and maximum passive wrist flexion. This should be distinguished with the pain with resisted supination with the arm and wrist in extension characteristically seen with radial tunnel syndrome.Ans3

Front 7

A 62-year-old female presents with chronic shoulder pain. She denies any recent or remote history of trauma or infection. A radiograph is provided in Figure A. Which of the following is the most common cause of her findings?
1. Diabetes
2. Syphilis
3. Alcoholism
4. Syringomyelia
5. Uremia

Back 7

The clinical presentation is consistent with Charcot neuroarthropathy of the shoulder. The most common cause of neuropathic arthropathy of the shoulder is syringomyelia, although chronic alcoholism and diabetes have also been reported.
Workup for neuropathic arthropathy of the shoulder includes magnetic resonance images of the cervical spine, to look for a syrinx of the central cord.Ans 4

Front 8

A 50-year-old wheelchair-bound male with a history of traumatic spinal cord injury presents with 6 months of progressive, painless left shoulder weakness and decreased range of motion. He is afebrile and CBC, ESR, and C-reactive protein levels are normal. A radiograph is shown in Figure A. Early management should include:
1. HIV testing
2. cervical spine MRI
3. repeat ESR, C-reactive protein, CBC
4. emergent open reduction and internal fixation
5. emergent irrigation and drainage

Back 8

This patient has a history of spinal cord injury and presents with an upper extremity neuropathic arthropathy, so a syrinx is highly suspected. Figure A demonstrates a Charcot left shoulder. Hatzis et al demonstrated that of 6 patients with Charcot shoulder, 5 of the 6 patients were found to have syrinx on MRI of the spine as the underlying cause. Therefore, all patients with shoulder neuropathic arthropathy should receive an MRI of the cervical spine. Ans2

Front 9

A 12-year-old baseball pitcher describes progressive worsening of medial elbow pain on his throwing side. Examination reveals normal elbow range of motion. He is tender over the medial elbow to palpation. A dynamic ultrasound of his elbow shows no evidence of medial widening with valgus stress. His radiograph is shown in Figure A and an MRI is shown in Figure B. What is the most likely cause of his symptoms?
1. Displaced medial epicondyle avulsion fracture
2. Medial apophysitis
3. Medial ulnar collateral ligament tear
4. Valgus extension overload with olecranon osteophytes
5. Ulnar neuritis

Back 9

The clinical presentation is consistent with Little League Elbow caused by medial apophysitis.
Little League elbow is a general term explaining medial elbow pain in adolescent pitchers. The underlying pathology can include medial epicondyle stress fractures, avulsion fractures of the medial epicondyle, ulnar collateral ligament (UCL) injuries, or medial epicondyle apophysitis. In order to identify the underlying cause it is important to first rule out injury to the MCL by looking for medial widening on stress radiographs or dynamic ultrasound, or valgus instability on physical exam. Radiographs are useful to look for avulsion fractures or subtle physeal widening commonly seen with apophysitis.Ans2

Front 10

A 10-year-old little league pitcher has the triad of medial elbow pain in his throwing arm, decreased throwing effectiveness, and decreased throwing distance. What is the pathogenesis of the condition that is most likely to be occuring in this patient?
1. Acute fragmentation of the entire capitellar ossific nucleus
2. Rupture of the anterior band of the anterior bundle of the ulnar collateral ligament
3. Repetitive contraction of the flexor-pronator mass stresses the chondro-osseous origin, leading to apophysitis
4. Microtraumatic vascular insufficiency of the capitellum from chronic compressive and rotatory forces
5. Repetitive triceps contraction during extension

Back 10

This adolescent pitcher's symptoms characterize Little Leaguers elbow. Little League elbow results from repetitive valgus stresses and tension overload of the medial structures. Chen et al presents Level 5 evidence demonstrating that repetitive contraction of the flexor-pronator mass stresses the chondro-osseous origin at the medial epicondyle, leading to inflammation and subsequent apophysitis. Radiographic changes may range from normal to irregular ossification of the medial epicondylar apophysis, followed by accelerated growth, marked by apophyseal enlargement, separation, and eventually fragmentation.Ans3

Front 11

1. what is the #1 most common major joint dislocation
2. What a 2nd most common major joint dislocation in the
3. Was most common direction for an elbow dislocation

Back 11

1. shoulder dislocation
2. Elbow dislocation
3. Posterior lateral dislocation

Front 12

with an elbow dislocation was the 1st structure to fail with the last structure to fail

Back 12

1. 1st – LCL posterior lateral dislocation last – MCL aanterior bundle

Front 13

what is injured with a terrible triad elbow injury

Back 13

1. disruption of the LCL
2. Radial head fracture
3. Coronoid tip fracture
4. Dislocation of the elbow

Front 14

1. patient presents emergency room at this x-ray no signs of compartment syndrome what is the diagnosis AKA
2. What is injured with this type of injury
3. What is the treatment-for simple injury vs complex injury

Back 14

1. elbow dislocation with – terrible triad
2. radial head fracture, coronoid fracture, and LCL rupture

• simple stable– immobilize sling 5-7 days, physical therapy active assist range of motion through stable arc
• simple unstable –extension block brace used 3-4 weeks, light duty at 2 weeks from injury do not immobilize past 2 weeks
• ORIF – coronoid, radial head, LCL repair, MCL repair and postop use a extension block brace do not immobilize past 2 weeks

Front 15

what is the most common sequela of an elbow dislocation

Back 15

loss of motion

Front 16

what is the most common instability after injury to the anterior medial facet of the coronoid and an injury to the LCL

Back 16

varus posterior medial instability – injury LCL and anterior medial facet

Front 17

A 34-year-old male falls from a roof and sustains a right elbow dislocation that is closed reduced in the emergency room. An AP radiograph is shown in Figure A. This injury pattern is at highest risk for which of the following?

1. Anterior interosseous nerve palsy

2. Varus posteromedial rotatory instability

3. Posterior interosseous nerve palsy

4. Valgus posterolateral rotatory instability

5. Elbow instability when pushing oneself up from a seated position in a chair

Back 17

Anteromedial coronoid facet fracture and LCL injury following an elbow dislocation is commonly associated with varus posteromedial rotatory instability. Varus and posteromedial rotation force on the forearm results in rupture of the LCL from its humeral origin. As the LCL ruptures, the medial coronoid process is fractured as it impacts against and under the medial trochlea. Fracture involvement of the sublime tubercle, where the MCL attaches, can lead to more instability. The lateral pivot shift test is similar to pushing oneself up from a seated position in a chair is an indication of valgus posterolateral rotatory instability. Ulnar neuropathy can be seen following this injury pattern but AIN and PIN nerve palsy do not commonly characterize this injury pattern.
ans2

Front 18

1. what physical exam findings and activities of daily living are common with valgus posterior lateral rotary instability
2. What common neuropathies occur with this injury pattern

Back 18

1. lateral pivot shift test
2. Similar to pushing oneself up from a seated position in a chair
3. AIN and PIN nerve palsies

Front 19

was the most common motor failure of the LCL ligament with an elbow dislocation

Back 19

ligament avulsion off the humeral origin

Front 20

what percent of the proximal radial head articulates with the proximal ulna

Back 20

75%

Front 21

1. where does the MCL insert on the ulna
2. what is the primary purpose of the anterior bundle of the MCL in the elbow
3. The anterior medial bundle of the MCL inserts where

Back 21

1. inserts on the sublime tubercle which is the anterior medial facet of the cornoid specifically 18.4 mm dorsal to the tip of the coronoid process
2. Resistance valgus and posterior medial rotatory instability
3. medial process of the coronoid

Front 22

1. where does the LCL insert on the ulna
2. what is the primary purpose of the LCL in the elbow
3. which part of the ligament

Back 22

1. the LCL inserts on the supinator crest this into the lesser sigmoid notch
2. They resist varus and posterior laterally rotary instability
3. the lateral ulnar collateral ligament

Front 23

patient presents with pain and clicking and locking of the elbow in extension physical exam is varus instability

1. with the diagnosis
2. What the next most appropriate step to confirm the diagnosis
3. With the treatment

Back 23

1. terrible triad – radial head fracture, coronoid fracture, LCL ligament injury
2. CAT scan – evaluate the coronoid fracture
3. ORIF versus arthroplasty radial head, LCL reconstruction, coronoid ORIF

Front 24

1. what position should the arm be placed in postoperatively after fixing a terrible triad of the elbow
2. we'll position should the arm be immobilized if both the MCL and the LCL were repaired

Back 24

1. LCL repair –flex the elbow with the arm in pronation because a provide stability against posterior subluxation
2. both repaired splint in flexion in neutral rotation

Front 25

with the most common complication after repair radial neck fracture

Back 25

failure of internal fixation leading to osteonecrosis and nonunion

Front 26

under what condition showed 1 prophylaxis against heterotopic ossification went along with an elbow dislocation

Back 26

in the setting revision surgery

Front 27

what is a common complication of instability is most likely due to what type of coronoid fracture

Back 27

coronoid fracture type I or 2

Front 28

At the elbow, the anterior bundle of the medial collateral ligament inserts at which site?

1. Radial tuberosity

2. 3mm distal to the tip of the coronoid

3. Anteromedial process of the coronoid

4. Medial border of the olecranon fossa

5. Radial side of ulna at origin of annular ligament

Back 28

The anterior bundle of the medial collateral ligament of the elbow inserts at the anteromedial process of the coronoid, also known as the sublime tubercle. Fractures at this site have been shown to have worse results with nonoperative treatment, due to increased rates of instability and post-traumatic arthrosis.

Front 29

name of 6 muscles intact Lateral Condyle and the Elbow in the one ligament

Back 29

1. extensor carpi radialis brevis
2. Extensor carpi radialis longus
3. extensor carpi ulnaris
4. Extensor digitorum
5. Extensor digiti minimi
6. anconeus
7. LCL

Front 30

avid tennis player presents to the office with pain in the elbow with gripping activities and has noticed a decreased grip strength

1. what is the diagnosis
2. With the next test test to confirm the diagnosis & What is the best provocative test to confirm the diagnosis
3. what the treatment
4. with the surgical treatment

Back 30

1. tennis elbow = inflammation of the ECR B= angiofibroma last hyperplasia
2. , disorganized collagen MRI– increased signal intensity at the ECRB tendon
3. Steroid injections ×3
4. release and debridement of the ECRB origin after 9-12 months of failed conservative treatment

Front 31

1. with the most common complication after surgery leading to instability
2. describe the histology finding of the ECRB tissue

Back 31

1. iatrogenic LCL injury causing posterior lateral instability
2. fibroblastic hyperplasia, disorganized collagen, vascular hyperplasia

Front 32

and involved in angiofibroma plastic hyperplasia of the elbow seen in tennis elbow

Back 32

anconeus muscle

Front 33

A 50-year-old carpenter has chronic pain over the lateral aspect of the elbow. He notes pain when using a hammer. On exam, he has pain with resisted wrist extension while the elbow is fully extended. Which muscle attachment is likely to be involved?

1. Distal biceps brachii

2. Brachioradialis

3. Extensor carpi radialis brevis

4. Extensor carpi radialis longus

5. Supinator

Back 33

The clinical presentation is consistent with lateral epicondylitis, which is caused from pathologic changes at the origin of the extensor carpi radialis brevis (ECRB).ans3

Front 34

patient presents to the emergency room with elbow pain in limited use of the upper extremity

1. what is the diagnosis
2. what position is the child's arm in?
3. what is the reduction maneuver

Back 34

1. nursemaid elbow radial head subluxation with interposition of the annual ligament
2. the arm is flexed and the forearm is pronated
3. Supinate the forearm and flex the elbow past 90°

Front 35

A 2-year-old is brought to the emergency room with reports of elbow pain and limited use of the left upper extremity. The patient is neurovascularly intact, but examination is limited secondary to pain. AP and lateral radiographs are shown in Figures A and B. What is the next best step in management

1. Observation

2. MRI

3. Supination alone

4. Supination reduction maneuver with long arm casting

5. Pronation reduction maneuver with long arm casting

Back 35

Based on clinical findings and radiographs provided, the patient should undergo a supination maneuver without casting to acutely treat this radial head subluxation or “nursemaid’s elbow”.ans3

Front 36

1. what phase of the patient is most likely affected with pictures elbow
2. with the diagnosis
3. With the treatment

Back 36

1. deceleration phase
2. Pitcher's elbow elbow= valgus extension overload
3. Debridement of the posterior medial osteophytessheer forces of the olecranon generated from rubbing on the medial aspect of the

Front 37

what is the most common associated condition with pictures elbow

Back 37

cubital tunnel syndrome

Front 38

professional player presents pain with forced elbow extension he is tender medially

1. With the diagnosis
2. which imaging finding or help confirm the diagnosis
3. With the treatment

Back 38

1. valgus extension overload pictures elbow
2. X-rays – osteophytes nposterior medial olecranon fossa MRI – osteophytes and rule out partial MCL tear
3. Resection of posterior medial osteophytes

Front 39

In valgus extension overload of the elbow, which letter in Figure A corresponds to the typical location of osteophytes formation?

1. A

2. B

3. C

4. D

5. E

Back 39

Valgus extension overload syndrome of the elbow occurs in throwing athletes. The mechanism is thought to be valgus stress on the elbow during acceleration, especially with insufficiency of the medial ulnar collateral ligament. Over time, the continuous impaction of the posterior-medial olecranon in the olecranon fossa can lead to chondromalacia and osteophyte formation. ans4

Front 40

1. most common etiology of neuropathic arthropathy in the upper extremity
2. what is syringobulbia
3. what is the most common cause of neuropathy in the foot

Back 40

1. syringomyeliaa fluid-filled cavity within the spinal cord that expands progressively at least an neurologic deficits
2. a syrinx within the brainstem and leads to neurologic symptoms– tong weakness and atrophy – cranial nerve XII: Sternocleidomastoid and trapezius muscle weakness – cranial nerve XI: Dysphagia and dysrhythmia – cranial nerve IX and X: Facial palsy – cranial nerves VII
3. Cranial nerve – 12, 11, 9, 10, 7
4. diabetes

Front 41

patient presents with painless loss of function of the shoulder exam reveals warm swollen erythematous joint

1. What is the diagnosis
2. with the next best diagnostic study to confirm the diagnosis
3. Was a treatment
4. What test is helpful to rule out infection of the shoulder

Back 41

1. Charcot arthropathy of the shoulder
2. MRI cervical spine – rule out syrinx Syria syringomyelia
3. Sling, arthrodesis only in stage III, contraindicated - total joint replacement
4. Indium WBC scan rule out osteomyelitis

Front 42

1. describe the histology was a diagnosis
2. For procedure is contraindicated with this diagnosis
3. Was a treatment with this diagnosis

Back 42

1. synovial hypertrophy and detritic synovitis= cartilage and bone distribution in synovium
2. total joint replacement is contraindicated
3. arthrodesis only in stage III

Front 43

A 50-year-old wheelchair-bound male with a history of traumatic spinal cord injury presents with 6 months of progressive, painless left shoulder weakness and decreased range of motion. He is afebrile and CBC, ESR, and C-reactive protein levels are normal. A radiograph is shown in Figure A. Early management should include:

1. HIV testing

2. cervical spine MRI

3. repeat ESR, C-reactive protein, CBC

4. emergent open reduction and internal fixation

5. emergent irrigation and drainage

Back 43

This patient has a history of spinal cord injury and presents with an upper extremity neuropathic arthropathy, so a syrinx is highly suspected. Figure A demonstrates a Charcot left shoulder.
ans2