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43 Cards in this Set
- Front
- Back
Which of the following portals is generally not used during elbow arthroscopy? |
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 |
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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 |
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 |
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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 |
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
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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 |
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
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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 |
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
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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 |
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
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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 |
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 |
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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 |
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
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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 |
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 |
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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? |
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
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with an elbow dislocation was the 1st structure to fail with the last structure to fail |
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what is injured with a terrible triad elbow injury |
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what is the most common sequela of an elbow dislocation |
loss of motion |
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what is the most common instability after injury to the anterior medial facet of the coronoid and an injury to the LCL |
varus posterior medial instability – injury LCL and anterior medial facet |
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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 |
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. |
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was the most common motor failure of the LCL ligament with an elbow dislocation |
ligament avulsion off the humeral origin |
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what percent of the proximal radial head articulates with the proximal ulna |
75% |
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patient presents with pain and clicking and locking of the elbow in extension physical exam is varus instability
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with the most common complication after repair radial neck fracture |
failure of internal fixation leading to osteonecrosis and nonunion |
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under what condition showed 1 prophylaxis against heterotopic ossification went along with an elbow dislocation |
in the setting revision surgery |
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what is a common complication of instability is most likely due to what type of coronoid fracture |
coronoid fracture type I or 2 |
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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 |
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. |
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name of 6 muscles intact Lateral Condyle and the Elbow in the one ligament |
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avid tennis player presents to the office with pain in the elbow with gripping activities and has noticed a decreased grip strength
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and involved in angiofibroma plastic hyperplasia of the elbow seen in tennis elbow |
anconeus muscle |
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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 |
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 |
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patient presents to the emergency room with elbow pain in limited use of the upper extremity
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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 |
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 |
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what is the most common associated condition with pictures elbow |
cubital tunnel syndrome |
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professional player presents pain with forced elbow extension he is tender medially
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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 |
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 |
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patient presents with painless loss of function of the shoulder exam reveals warm swollen erythematous joint
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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
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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. |