S2_L3 Trauma at Elbow

Question 1

Complications

1. Calcification of the collateral ligaments
2. Complex tears of the TFCC
3. Malunion

A. Fractures of distal humerus
B. Fractures of radial head
C. Fractures of proximal ulna
D. Fractures of forearm
E. Dislocation of elbow

Answer 1

1. E
2. B
3. D

Question 2

Complications

1. Capitular osteochondral injuries
2. Intraarticular loose bodies, myositis ossificans, and associated ulnar nerve injury
3. Myositis ossificans specially on brachialis muscle

A. Fractures of distal humerus
B. Fractures of radial head
C. Fractures of proximal ulna
D. Fractures of forearm
E. Dislocation of elbow

Answer 2

1. B
2. A
3. E

Question 3

Complications

1. Distal radioulnar dysfunction (supination & pronation problem)
2. Wrist pain d/t associated interosseus ligament injury
3. Excessive callus formation within the capsule

A. Fractures of distal humerus
B. Fractures of radial head
C. Fractures of proximal ulna
D. Fractures of forearm
E. Dislocation of elbow

Answer 3

1. D
2. B
3. A

Question 4

Complications

1. Radial and median nerve damage
2. LOM with prolonged immobilization, and ulnar or median nerve injuries

A. Fractures of distal humerus
B. Fractures of radial head
C. Fractures of proximal ulna
D. Fractures of forearm
E. Dislocation of elbow

Answer 4

1. D
2. E

Question 5

Complications

Modified TF
A. Loss of motion is a complication of fractures of the distal humerus and proximal ulna, and dislocation of the elbow.
B. Ulnar nerve injuries are complications of fractures of the proximal ulna.

Answer 5

TT

NOTE: For fractures of the distal humerus, up to 20 degrees may be tolerated because of the compensatory movements of the shoulder.
The functional range of the elbow is from 40-130 degrees.

Question 6

Complications

Modified TF
A. Arthritis is a complication of fractures of the proximal ulna.
B. Posttraumatic arthritis can result from fractures of the radial head and fractures of the distal humerus (due to direct trauma or poor joint congruity).

Answer 6

TT

Question 7

Fractures of the Radial Head: Mason Classification System

Displaced fractures with separation, depression, or angulation of the fracture segment. It is treated conservatively or by radial head excision if the articular surface is greatly displaced.

A. Type I
B. Type II
C. Type III
D. Type IV

Answer 7

B. Type II

Question 8

Fractures of the Radial Head: Mason Classification System

Undisplaced fractures, typically treated with immobilization. Management consists of casting only.

A. Type I
B. Type II
C. Type III
D. Type IV

Answer 8

A. Type I

Question 9

Fractures of the Radial Head: Mason Classification System

Comminuted fractures, generally treated by radial head resection.

A. Type I
B. Type II
C. Type III
D. Type IV

Answer 9

C. Type III

Question 10

Fractures of the Radial Head: Mason Classification System

Radial head fractures associated with elbow dislocations. These are treated after reduction based on the amount of displacement or comminution present.

A. Type I
B. Type II
C. Type III
D. Type IV

Answer 10

D. Type IV

Question 11

Fractures of the Forearm

1. Monteggia’s fracture
2. Associated dislocation of the distal radioulnar joint most likely classifies as a Galeazzi’s fracture

A. Radial shaft fracture
B. Ulnar shaft fracture

Answer 11

1. B
2. A

Recall: Monteggia’s fracture is a proximal third fracture of the ulna with dislocation of the radial head.

Question 12

Fractures of the Forearm

1. Usually occurs at the distal 3rd of the shaft
2. Nightstick fracture (defensive/protecting)

A. Radial shaft fracture
B. Ulnar shaft fracture

Answer 12

1. A
2. B

Question 13

Fractures of the Distal Humerus

1. More common in the elderly suffering from osteoporosis
2. Uncommon in adults, more common in children
3. Trochlea or capitulum is involved

A. Supracondylar
B. Transcondylar
C. Intercondylar
D. Condylar
E. Articular
F. Epicondylar

Answer 13

1. B
2. D
3. E

Question 14

Fractures of the Distal Humerus

1. Rare since the fracture fragments are cartilaginous, and they don’t reveal their true size.
2. Usually the result of a direct blow, and may also be avulsion fractures or associated with elbow dislocations

A. Supracondylar
B. Transcondylar
C. Intercondylar
D. Condylar
E. Articular
F. Epicondylar

Answer 14

1. E
2. F

Question 15

Fractures of the Distal Humerus

1. Occurring at the medial or lateral epicondyle
2. Splitting the condyles apart in a T or Y shape
3. Across the condyles at the level of the olecranon fossa

A. Supracondylar
B. Transcondylar
C. Intercondylar
D. Condylar
E. Articular
F. Epicondylar

Answer 15

1. F
2. C
3. B

Question 16

Fractures of the Distal Humerus

1. Complications include gunstock deformity (excessive varus of elbow), peripheral nerve injury, or Volkmann’s ischemia
2. Results from a direct force that causes the wedgelike olecranon to be driven into the distal humeral articulating surface

A. Supracondylar
B. Transcondylar
C. Intercondylar
D. Condylar
E. Articular
F. Epicondylar

Answer 16

1. A
2. C

Question 17

Fractures of the Distal Humerus

1. Most common in children
2. Most common in adults

A. Supracondylar
B. Transcondylar
C. Intercondylar
D. Condylar
E. Articular
F. Epicondylar

Answer 17

1. A
2. C

Question 18

Fractures of the Distal Humerus

Modified TF
A. Epicondylar fracture is more common for the lateral epicondyle.
B. For condylar fractures, fractures of the lateral condyle are most common and are due to a varus force avulsing the condyle (may be due to ligamentous or tendinous influence).

Answer 18

FT

A: Epicondylar fracture is more common for the medial epicondyle.

Question 19

Radiographic Soft Tissue Signs of Trauma

1. May be caused by infections and inflammatory diseases
2. Produced when the effusion distends the capsule enough to displace the fat pad from their normal position

A. Positive fat pad sign
B. Abnormal supinator sign

Answer 19

1. B
2. A (The fat pad moved up and forward relative its usual place)

Question 20

Radiographic Soft Tissue Signs of Trauma

1. It is associated with hemophilia, inflammatory arthritis, infection, intraarticular masses and osteochondritis dissecans
2. Normally seen on the lateral radiograph as a thin lucent line near the radial head

A. Positive fat pad sign
B. Abnormal supinator sign

Answer 20

1. A
2. B

Note: In radial head fractures, the line (abnormal supinator sign) may become elevated, widened or blurred.

Question 21

Fractures of the Proximal Ulna (Olecranon)

1. Most common type
2. Extra-articular and intra-articular fractures of the proximal third of the olecranon
3. Fracture of the distal third of olecranon
4. Fracture of the middle third of olecranon, subdivided into 1 or 2 fracture lines

A. Type I
B. Type II
C. Type III

Answer 21

1. B
2. A
3. C
4. B

Question 22

Treatment of Fractures of the Proximal Ulna

Modified TF:
A. Non-operative treatment consists of immobilization with the arm in flexion with range of motion exercises initiated 4 weeks after injury.
B. Operative treatment comprises open reduction and internal fixation.

Answer 22

FT

A: Non-operative treatment consists of immobilization with the arm in flexion with range of motion exercises initiated 2 weeks after injury.

Question 23

Treatment of Fractures of the Radial Head

Modified TF:
A. Non-operative management consists of sling immobilization and early range of motion exercises.
B. Operative management is for severe displacement or comminution, it includes radial head excision just distal to the annular ligament with/without prosthetic replacement.

Answer 23

TF

B: Operative management is for severe displacement or comminution, it includes radial head excision just proximal to the annular ligament with/without prosthetic replacement.

Question 24

Signs of Osteochondritis Dissecans (Yes or No)

1. Sclerotic rim of subchondral bone adjacent to the articular surface
2. Regular ossification
3. Radiolucency due to hyporemia
4. Bony defect adjacent to the articular surface

Answer 24

1. Yes
2. No (Irregular ossification)
3. No (due to hyperemia)
4. Yes

Question 25

# Dislocation of the Elbow Modified TF A. Dislocations of the elbow may involve only the radius or the ulna, or both. B. The most common (80-90%) type of dislocation of the elbow involves both the radius and ulna.

Answer 25

TT

Question 26

# Dislocation of the Elbow Modified TF: A. Elbow dislocations are most often due to a fall on the outstretched hand that levers the olecranon away from the capitulum. B. The most common elbow dislocation occurs posteriorly or posterolaterally.

Answer 26

FT ## Footnote A: Elbow dislocations are most often due to a fall on the outstretched hand that levers the olecranon away from the **trochlea**.

Question 27

# Treatment of Fractures of the Distal Humerus Modified TF: A. Non operative treatment is for injuries with minimal displacement and or osteopenia; management consists of maintaining the elbow in 90º of elbow flexion for 8 weeks and uses a cast. B. Operative treatment is for cases of open fractures, displaced fractures, and vascular injury.

Answer 27

FT ## Footnote A: Non operative treatment is for injuries with minimal displacement and or osteopenia; management consists of maintaining the elbow in 90º of elbow flexion for **6** weeks and uses a cast.

Question 28

# Fractures of the Proximal Ulna Modified TF A. Fractures of the proximal ulna that disrupt the trochlear notch have the potential to impair both flexion and extension mobility and mediolateral stability of the elbow. B. The humeroulnar joint provides the main mechanism for flexion and extension of elbow.

Answer 28

TT

Question 29

# Treatment of Dislocation of Elbow Modified TF: A. Treatment consists of open reduction under sedation and anesthesia followed by short term sling immobilization with early active range of motion exercises. B. Operative management is required for bony or soft tissue entrapment.

Answer 29

FT ## Footnote A: Treatment consists of **closed** reduction under sedation and anesthesia followed by short term sling immobilization with early active range of motion exercises. NOTE: Recovery of motion may require 3-6 months.

Question 30

# Imaging Evaluation for Epicondylitis / Epicondylalgia Modified TF A. MRI is recommended when radiographs are nondiagnostic and the patient does not respond to conservative management. B. MRI can rule out associated disorders, e.g., collateral ligament tears, and identify degenerative tissue.

Answer 30

TT

Question 31

TRUE OR FALSE: After a fracture has healed, the final clinical result may not coincide with the final radiographic appearance.

Answer 31

True

Question 32

# Trauma at the Elbow Modified TF A. Fractures of the proximal ulna are well demonstrated on routine radiographs (AP and lateral views). B. Likewise, dislocation of the elbow is readily diagnosed on routine AP and lateral radiographs.

Answer 32

TT ## Footnote NOTE: Radiographs of the forearm and wrist are included in imaging for dislocation of the elbow.

Question 33

# Osteochondritis dissecans imaging Modified TF A. Routine radiographs are commonly used, and lateral radiographs may show flattening of the trochlea. B. On the other hand, MRI is useful for early detection via the T1 weighted sequence.

Answer 33

FF ## Footnote A: Routine radiographs are commonly used, and lateral radiographs may show flattening of the **capitulum**. B: On the other hand, MRI is useful for early detection via the **T2** weighted sequence.

Question 34

# Osteochondritis dissecans Modified TF A. It is a localized joint injury that involves a separation of a segment of cartilage and subchondral bone from the articular surface. B. Loose bodies may form within the joint due to the separation.

Answer 34

TT

Question 35

# Epicondylitis / Epicondylalgia Overuse Injuries Modified TF A. Lateral epicondylitis is also referred to as Golfer’s/Little Leaguer’s Elbow. B. Tennis Elbow is another name for medial epicondylitis.

Answer 35

FF ## Footnote A: **Medial** epicondylitis is also referred to as Golfer’s/Little Leaguer’s Elbow. B. Tennis Elbow is another name for **lateral** epicondylitis. NOTE: The underlying collateral ligaments and capsule may be implicated in epicondylitis.

Question 36

# Epicondylitis/Epicondylalgia Modified TF A. In epicondylitis, tendinosis develops due to repetitive stress which prevents the tendon from healing normally. B. Radiographs are used to rule out intra-articular loose bodies, bony avulsions, arthritis, or calcifications in the tendons involved.

Answer 36

TT

Question 37

# Fractures of the Distal Humerus Modified TF A. Treatment and rehabilitation goals include restoration of normal ROM, joint surfaces, articular congruity, and muscle strength at the elbow, forearm, and wrist. B. Other joints connected to an affected joint may also be affected.

Answer 37

TT

Question 38

# Fractures of the forearm TRUE OR FALSE: Fractures of both the radius and ulna are usually displaced fractures due to the severity of the force necessary to injure both bones.

Answer 38

True

Question 39

# Fractures of the forearm treatment Modified TF A. Treatment will often require performing open reduction and internal fixation. B. However, if only the radial shaft was fractured, non-operative treatment will be done.

Answer 39

TT ## Footnote NOTE: Fracture dislocations require operative treatment.

Question 40

# Trauma of the Elbow TRUE OR FALSE: Residual pain, deformities, loss of motion, and posttraumatic arthritic changes are common following fractures, dislocations, or subluxations of the elbow.

Answer 40

True

Question 41

Classification of fractures of the distal humerus usually come with complications such as gunstock deformity, peripheral nerve injuries, and Volkmann's ischemia. A. Supracondylar B. Transcondylar C. Intercondylar D. None

Answer 41

A. Supracondylar

Question 42

TRUE OR FALSE: Monteggia's fracture is an example of a radial shaft fracture.

Answer 42

False

Question 43

TRUE OR FALSE: Positive fat pad signs are associated with hemophilia and inflammatory arthritis.

Answer 43

True