Shoulder and Elbow Scored and Recorded Self-
Assessment Examination 2019
,Question 1 of 100
Figures 1 through 3 are the radiographs of a 55-year-old woman who fell on her outstretched right arm,
resulting in acute elbow pain and swelling. On examination, she has lateral elbow bruising with mechanical
block to supination and pronation. She has no medial tenderness. She is unable to extend her elbow within 60°
of full extension. During surgery utilizing a direct lateral approach, the surgeon observes a completely bare
lateral epicondyle. After surgical repair, a stable and congruent joint is achieved. Initial postoperative
rehabilitation should include
A. 3 weeks of cast immobilization.
B. elbow extension exercises with the forearm supinated.
C. elbow extension exercises with the forearm pronated.
D. elbow extension exercises with the forearm in neutral rotation.
PREFERRED RESPONSE: C
DISCUSSION:
Radial head fractures are thought to occur as a result of valgus posterolateral rotary load across the elbow,
although the mechanism can certainly vary. Minimally or nondisplaced fractures without any clinical
instability or block to motion can often be successfully managed non-surgically. Fractures with >2 mm of
displacement or fragments that block motion require surgical repair. A critical aspect during surgery is
identifying concomitant injury to the lateral collateral ligament complex (LCL). When encountered, the LCL
will be avulsed from its origin from the lateral epicondyle, resulting in a bare area. After the radial head is
either reduced and fixed or replaced (Figures 4 and 5), the LCL should be repaired back to its anatomic origin.
Postoperatively, the surgeon must communicate to the therapist that elbow extension exercises should be
performed with the forearm in pronation as a result of the compromised LCL. Elbow extension exercises in
supination and neutral are recommended for compromised medial collateral ligament or combined medial and
lateral ligament injury, respectively. Without any medial elbow bruising, swelling, or tenderness, it is unlikely
that the patient has an injury to the medial collateral ligament.
Question 2 of 100
A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a
comminuted intra-articular distal humerus fracture. What is the best surgical option?
A. Open reduction internal fixation (ORIF) with parallel plates
B. ORIF with orthogonal plates and iliac crest bone grafting
C. Total elbow arthroplasty (TEA)
D. Closed reduction and percutaneous pinning
PREFERRED RESPONSE: C
DISCUSSION:
TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial
comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and
more predictable outcomes compared with ORIF. TEA was also likely to result in a lower resurgical rate; one-
quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and
associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again
,superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with
comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed
reduction and percutaneous pinning studies have not been published on the adult population.
Question 3 of 100
A complication associated with using the Morrey approach (triceps reflecting) to implant a semiconstrained
total elbow arthroplasty is
A. loss of elbow extensor power.
B. implant dislocation.
C. implant malposition.
D. development of heterotopic ossification.
PREFERRED RESPONSE: A
DISCUSSION:
Numerous approaches can be used to implant a total elbow arthroplasty. The Morrey approach identifies,
transposes, and protects the ulnar nerve, and then subperiosteally reflects the triceps off the ulna. The sleeve
of tissue is very thin distally, and the triceps need to be meticulously repaired at the time of closure. Implant
dislocation and malposition are less likely with an extensile approach, and dislocation is unlikely with a
semiconstrained implant. The development of heterotopic ossification is unrelated to the surgical approach
used for elbow arthroplasty.
Question 4 of 100
Figures 1 through 4 are the radiographs of a 55-year-old healthy woman who fell down a flight of steps while
sleepwalking. When the surgeon replaces the radial head, the elbow dislocates posteriorly at 60° of flexion as
it is brought out from full flexion. What is the best next step?
A. Only repair the lateral collateral ligament (LCL).
B. Do nothing further and place the elbow in 90° of flexion.
C. Repair the posterior band of the medial collateral ligament (MCL).
D. Repair the coronoid and reassess for stability.
PREFERRED RESPONSE: D
DISCUSSION:
The coronoid is important for elbow stability, particularly as the elbow is moved into extension. Repairing the
LCL alone after radial head replacement in “terrible triad” injuries may suffice when there is a type 1 coronoid
fracture or an anterior capsular avulsion. For more extensive coronoid injuries, live dynamic examination of
stability is needed to determine whether repair of the coronoid is needed. For this patient, doing nothing further
will lead to immediate postsurgical instability, and repairing the LCL complex alone will not lead to stability.
, The posterior band of the MCL will not add to stability. The next step to attain stability is to repair the coronoid
fracture and re-examine the elbow for stability.
Question 5 of 100
A 45-year-old man falls from a skateboard and dislocates his elbow. After a closed reduction in the emergency
department, his elbow is carefully examined. He has positive valgus stress, moving valgus stress, and milking
maneuver tests. His elbow appears stable to varus stress and lateral pivot shift tests. What is the most
appropriate manner of immobilizing the elbow for this patient?
A. Sling for 3 days, with early active range of motion
B. Posterior splint for 5 to 7 days, forearm in full pronation
C. Posterior splint for 5 to 7 days, forearm in neutral
D. Posterior splint for 5 to 7 days, forearm in full supination
PREFERRED RESPONSE: D
DISCUSSION:
Varus posteromedial rotatory instability occurs following a fall onto an outstretched hand with axial loading
and a varus stress to the elbow. This injury can result in a rupture of the posterior band of the medial collateral
ligament (MCL), fracture of the anteromedial facet of the coronoid, and avulsion of the lateral ulnar collateral
ligament (LUCL). Based on the examination findings, this patient has an acute MCL rupture. Furthermore,
the LUCL appears intact, as evidence by the stability with varus stress. To protect the reduction in the acute
setting, posterior splinting is recommended, but placing the forearm in full supination tightens the structures
medially where the MCL is deficient. Splinting in neutral is indicated for valgus posterolateral rotatory
instability, where both the LUCL and MCL are ruptured. Splinting in full pronation is indicated for isolated
LUCL ruptures. Early active range of motion is not recommended for adults immediately after an acute elbow
dislocation, as ligamentous injury or fracture nearly always accompanies the dislocation. In this case, the
forearm should be splinted in full supination.
Question 6 of 100
A 38-year-old man sustains a terrible triad injury consisting of an elbow dislocation, comminuted and
displaced radial head fracture, and a type I coronoid fracture. Intraoperative findings after radial head
replacement and lateral collateral ligament complex repair reveal persistent instability consisting of medial
opening on valgus stress and posteromedial subluxation of the ulnohumeral and radiocapitellar joints. What
is the best next step?
A. Medial collateral ligament repair or reconstruction
B. Reconstruction of the radial collateral ligament
C. Resection of the type I coronoid fracture and capsular repair to the remaining coronoid
D. Open reduction and buttress plating of the coronoid fracture
PREFERRED RESPONSE: A
DISCUSSION:
Terrible triad injuries of the elbow are common, and the management of type I coronoid tip fractures remains
controversial. Type I coronoid fractures result in only small changes in elbow kinematics that have been shown
to be uncorrected with suture repair. A type I coronoid tip fracture is not amenable to buttress plate fixation.
The radial collateral ligament is a component of the lateral collateral ligament complex and has already been
repaired. The persistent medial laxity and posteromedial joint subluxation noted is indicative of ongoing
instability. The next step would be repair or reconstruction of the medial collateral ligament, which will
Assessment Examination 2019
,Question 1 of 100
Figures 1 through 3 are the radiographs of a 55-year-old woman who fell on her outstretched right arm,
resulting in acute elbow pain and swelling. On examination, she has lateral elbow bruising with mechanical
block to supination and pronation. She has no medial tenderness. She is unable to extend her elbow within 60°
of full extension. During surgery utilizing a direct lateral approach, the surgeon observes a completely bare
lateral epicondyle. After surgical repair, a stable and congruent joint is achieved. Initial postoperative
rehabilitation should include
A. 3 weeks of cast immobilization.
B. elbow extension exercises with the forearm supinated.
C. elbow extension exercises with the forearm pronated.
D. elbow extension exercises with the forearm in neutral rotation.
PREFERRED RESPONSE: C
DISCUSSION:
Radial head fractures are thought to occur as a result of valgus posterolateral rotary load across the elbow,
although the mechanism can certainly vary. Minimally or nondisplaced fractures without any clinical
instability or block to motion can often be successfully managed non-surgically. Fractures with >2 mm of
displacement or fragments that block motion require surgical repair. A critical aspect during surgery is
identifying concomitant injury to the lateral collateral ligament complex (LCL). When encountered, the LCL
will be avulsed from its origin from the lateral epicondyle, resulting in a bare area. After the radial head is
either reduced and fixed or replaced (Figures 4 and 5), the LCL should be repaired back to its anatomic origin.
Postoperatively, the surgeon must communicate to the therapist that elbow extension exercises should be
performed with the forearm in pronation as a result of the compromised LCL. Elbow extension exercises in
supination and neutral are recommended for compromised medial collateral ligament or combined medial and
lateral ligament injury, respectively. Without any medial elbow bruising, swelling, or tenderness, it is unlikely
that the patient has an injury to the medial collateral ligament.
Question 2 of 100
A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a
comminuted intra-articular distal humerus fracture. What is the best surgical option?
A. Open reduction internal fixation (ORIF) with parallel plates
B. ORIF with orthogonal plates and iliac crest bone grafting
C. Total elbow arthroplasty (TEA)
D. Closed reduction and percutaneous pinning
PREFERRED RESPONSE: C
DISCUSSION:
TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial
comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and
more predictable outcomes compared with ORIF. TEA was also likely to result in a lower resurgical rate; one-
quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and
associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again
,superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with
comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed
reduction and percutaneous pinning studies have not been published on the adult population.
Question 3 of 100
A complication associated with using the Morrey approach (triceps reflecting) to implant a semiconstrained
total elbow arthroplasty is
A. loss of elbow extensor power.
B. implant dislocation.
C. implant malposition.
D. development of heterotopic ossification.
PREFERRED RESPONSE: A
DISCUSSION:
Numerous approaches can be used to implant a total elbow arthroplasty. The Morrey approach identifies,
transposes, and protects the ulnar nerve, and then subperiosteally reflects the triceps off the ulna. The sleeve
of tissue is very thin distally, and the triceps need to be meticulously repaired at the time of closure. Implant
dislocation and malposition are less likely with an extensile approach, and dislocation is unlikely with a
semiconstrained implant. The development of heterotopic ossification is unrelated to the surgical approach
used for elbow arthroplasty.
Question 4 of 100
Figures 1 through 4 are the radiographs of a 55-year-old healthy woman who fell down a flight of steps while
sleepwalking. When the surgeon replaces the radial head, the elbow dislocates posteriorly at 60° of flexion as
it is brought out from full flexion. What is the best next step?
A. Only repair the lateral collateral ligament (LCL).
B. Do nothing further and place the elbow in 90° of flexion.
C. Repair the posterior band of the medial collateral ligament (MCL).
D. Repair the coronoid and reassess for stability.
PREFERRED RESPONSE: D
DISCUSSION:
The coronoid is important for elbow stability, particularly as the elbow is moved into extension. Repairing the
LCL alone after radial head replacement in “terrible triad” injuries may suffice when there is a type 1 coronoid
fracture or an anterior capsular avulsion. For more extensive coronoid injuries, live dynamic examination of
stability is needed to determine whether repair of the coronoid is needed. For this patient, doing nothing further
will lead to immediate postsurgical instability, and repairing the LCL complex alone will not lead to stability.
, The posterior band of the MCL will not add to stability. The next step to attain stability is to repair the coronoid
fracture and re-examine the elbow for stability.
Question 5 of 100
A 45-year-old man falls from a skateboard and dislocates his elbow. After a closed reduction in the emergency
department, his elbow is carefully examined. He has positive valgus stress, moving valgus stress, and milking
maneuver tests. His elbow appears stable to varus stress and lateral pivot shift tests. What is the most
appropriate manner of immobilizing the elbow for this patient?
A. Sling for 3 days, with early active range of motion
B. Posterior splint for 5 to 7 days, forearm in full pronation
C. Posterior splint for 5 to 7 days, forearm in neutral
D. Posterior splint for 5 to 7 days, forearm in full supination
PREFERRED RESPONSE: D
DISCUSSION:
Varus posteromedial rotatory instability occurs following a fall onto an outstretched hand with axial loading
and a varus stress to the elbow. This injury can result in a rupture of the posterior band of the medial collateral
ligament (MCL), fracture of the anteromedial facet of the coronoid, and avulsion of the lateral ulnar collateral
ligament (LUCL). Based on the examination findings, this patient has an acute MCL rupture. Furthermore,
the LUCL appears intact, as evidence by the stability with varus stress. To protect the reduction in the acute
setting, posterior splinting is recommended, but placing the forearm in full supination tightens the structures
medially where the MCL is deficient. Splinting in neutral is indicated for valgus posterolateral rotatory
instability, where both the LUCL and MCL are ruptured. Splinting in full pronation is indicated for isolated
LUCL ruptures. Early active range of motion is not recommended for adults immediately after an acute elbow
dislocation, as ligamentous injury or fracture nearly always accompanies the dislocation. In this case, the
forearm should be splinted in full supination.
Question 6 of 100
A 38-year-old man sustains a terrible triad injury consisting of an elbow dislocation, comminuted and
displaced radial head fracture, and a type I coronoid fracture. Intraoperative findings after radial head
replacement and lateral collateral ligament complex repair reveal persistent instability consisting of medial
opening on valgus stress and posteromedial subluxation of the ulnohumeral and radiocapitellar joints. What
is the best next step?
A. Medial collateral ligament repair or reconstruction
B. Reconstruction of the radial collateral ligament
C. Resection of the type I coronoid fracture and capsular repair to the remaining coronoid
D. Open reduction and buttress plating of the coronoid fracture
PREFERRED RESPONSE: A
DISCUSSION:
Terrible triad injuries of the elbow are common, and the management of type I coronoid tip fractures remains
controversial. Type I coronoid fractures result in only small changes in elbow kinematics that have been shown
to be uncorrected with suture repair. A type I coronoid tip fracture is not amenable to buttress plate fixation.
The radial collateral ligament is a component of the lateral collateral ligament complex and has already been
repaired. The persistent medial laxity and posteromedial joint subluxation noted is indicative of ongoing
instability. The next step would be repair or reconstruction of the medial collateral ligament, which will
