Elbow Arthroplasty — MCQs
Treatment of choice in a 65-year-old female with impacted fracture of the neck of the humerus is:
Open reduction (OR) is not required in which fracture?
The malunion of a supracondylar fracture of the humerus most commonly leads to:
In a functional implant, bone loss seen annually after 1 year is:
Which of the following is NOT a complication of elbow dislocation?
In fracture of upper 1/3 of forearm, it is immobilized in:
The test performed below shows testing of which of the following nerve: (Recent NEET Pattern 2016-17)
The test performed below shows involvement of which of the following nerve?
Which of the following statements is true regarding supracondylar fractures of the humerus?
Fracture shaft of humerus can cause damage to which of the following nerves?
Elbow Arthroplasty Indian Medical PG Practice Questions and MCQs
Question 1: Treatment of choice in a 65-year-old female with impacted fracture of the neck of the humerus is:
- A. Observation
- B. Triangular sling (Correct Answer)
- C. Arthroplasty
- D. Arm chest strapping
Explanation: ***Triangular sling*** - For **impacted fractures** of the humeral neck in elderly patients, non-operative management with a sling is often preferred due to the **stability of the fracture** and the patient's age. - This approach aims for pain control and early mobilization, reducing risks associated with surgery in the elderly. *Observation* - While close monitoring is part of management, simply "observation" without any immobilization like a sling is generally insufficient for a fracture. - It does not provide the initial support needed for fracture healing and pain management. *Arthroplasty* - **Arthroplasty** (joint replacement) is typically reserved for highly **displaced or comminuted fractures** where surgical fixation is not feasible, or in cases of **avascular necrosis**. - It is an **invasive procedure** with higher risks in an elderly patient and is not the first choice for a stable, impacted fracture. *Arm chest strapping* - **Arm chest strapping** is typically used for specific injuries like **rib fractures** or sternal contusions to immobilize the chest wall. - It is **not appropriate** for a humeral neck fracture, as it does not adequately immobilize the shoulder joint and could lead to complications like **shoulder stiffness**.
Question 2: Open reduction (OR) is not required in which fracture?
- A. Fracture of the patella
- B. Fracture of the outer one-third of the radius (Correct Answer)
- C. Displaced fracture of the olecranon
- D. Fracture of the condyle of the humerus
Explanation: ***Fracture of the outer one-third of the radius*** - Fractures of the **outer one-third of the radius** (distal radius fractures) often can be managed with **closed reduction and casting** if stable and adequately reduced. - While some unstable distal radius fractures require OR, many stable patterns, especially those with minimal displacement or good alignment after closed manipulation, do not. *Fracture of the patella* - Many patellar fractures lead to significant **extensor mechanism disruption**, necessitating OR with **tension band wiring** or screw fixation to restore quadriceps function. - Displaced patellar fractures, especially transverse ones, require surgical fixation to prevent extensor lag and **nonunion**. *Displaced fracture of the olecranon* - Displaced olecranon fractures disrupt the **triceps mechanism** and compromise elbow stability, almost always requiring **open reduction and internal fixation (ORIF)**, typically with tension band wiring. - Without surgical repair, a displaced olecranon fracture can lead to significant loss of extension strength and **nonunion**. *Fracture of the condyle of the humerus* - Fractures of the humeral condyle, particularly in children, often require OR due to the risk of **avascular necrosis** (especially lateral condyle) and the need for **precise anatomical reduction** to prevent joint incongruity and cubitus varus/valgus deformities. - Intra-articular and displaced condylar fractures almost invariably require surgical intervention to ensure harmonious joint function and prevent long-term complications like **stiffness and deformity**.
Question 3: The malunion of a supracondylar fracture of the humerus most commonly leads to:
- A. Cubitus varus (Correct Answer)
- B. Cubitus valgus
- C. Extension deformity
- D. Flexion deformity
Explanation: ***Cubitus varus*** - A **supracondylar fracture** malunion often results in posterior and medial displacement of the distal fragment, leading to a **loss of the carrying angle** or even its reversal, known as **cubitus varus** or **gunstock deformity**. - This characteristic deformity is the most common and recognizable long-term complication of improperly healed supracondylar humerus fractures. *Flexion deformity* - While some limitation of extension can occur, a pure **flexion deformity** is not the most common or defining malunion pattern for supracondylar fractures. - The primary angular deformity is typically in the coronal plane (varus) rather than the sagittal plane (flexion/extension). *Cubitus valgus* - **Cubitus valgus** is an increased carrying angle, where the forearm deviates laterally, and is relatively rare after supracondylar fracture malunion. - It is more commonly associated with **lateral condyle fractures** or physeal injuries. *Extension deformity* - An **extension deformity** would imply an increase in the normal extension of the elbow, which is not a common consequence of supracondylar fracture malunion. - The typical angular malunion involves either varus or, less commonly, some degree of flexion contracture.
Question 4: In a functional implant, bone loss seen annually after 1 year is:
- A. 1 to 1.5 mm
- B. Less than 0.1 mm (Correct Answer)
- C. 1 to 2 mm
- D. 1.5 to 2 mm
Explanation: ***Less than 0.1 mm*** - In a functional implant, **crestal bone loss** after the first year of initial healing is expected to be minimal. - This minimal bone loss indicates successful **osseointegration** and long-term stability of the implant. *1 to 1.5 mm* - This amount of annual bone loss is generally considered **excessive** and may indicate issues such as peri-implantitis or improper loading. - Such bone loss could compromise the **long-term prognosis** and stability of the dental implant. *1 to 2 mm* - An annual bone loss in this range would be deemed **unacceptable** for a healthy, functional implant. - This level of bone loss suggests significant **peri-implant inflammation** or biomechanical overload, requiring intervention. *1.5 to 2 mm* - This degree of bone loss is a clear sign of significant **implant pathology** and would likely lead to implant failure if not addressed. - It is far beyond the clinically acceptable limits for bone remodeling around a **stable implant**.
Question 5: Which of the following is NOT a complication of elbow dislocation?
- A. Vascular injury
- B. Median nerve injury
- C. Myositis ossificans
- D. Radial nerve injury (Correct Answer)
Explanation: ***Radial nerve injury*** - The **radial nerve** is rarely injured in an elbow dislocation due to its anatomical course, which is less exposed to the shearing forces involved in this type of injury. - While other nerves like the ulnar and median nerves are more susceptible, significant stretching or compression of the radial nerve is **uncommon** in typical elbow dislocations. *Vascular injury* - The **brachial artery** runs in close proximity to the elbow joint and can be torn or compressed during a dislocation, leading to **ischemia** if not promptly recognized and treated. - This complication can result in **Volkmann's ischemic contracture** if perfusion is not restored. *Median nerve injury* - The **median nerve** passes anterior to the elbow joint and is vulnerable to injury from stretching or direct compression during dislocation. - Injury can manifest as **sensory deficits** in the distribution of the median nerve and **weakness** of forearm pronation and thumb flexion/opposition. *Myositis ossificans* - This is a common chronic complication of elbow dislocations, particularly in cases of **delayed reduction** or aggressive physical therapy. - It involves the **abnormal ossification** of soft tissues around the joint, commonly in the brachialis muscle, leading to **pain and restricted range of motion**.
Question 6: In fracture of upper 1/3 of forearm, it is immobilized in:
- A. Supination (Correct Answer)
- B. Pronation
- C. Any position
- D. Mid prone
Explanation: ***Supination*** - In a fracture of the **proximal third of the forearm**, the **biceps brachii** and **supinator muscles**, which are still attached to the proximal fragment, will cause it to **supinate**. - To align the distal fragment with the proximal fragment and ensure proper healing, the forearm must be immobilized in **full supination**. *Pronation* - **Pronation** would cause malalignment of the fracture fragments, as the proximal fragment would remain supinated while the distal fragment is pronated. - This position is only used for fractures of the **distal third of the forearm** where the **pronator quadratus** and **pronator teres** dominate. *Any position* - Immobilizing in **any position** would risk **malunion** or nonunion due to the unopposed muscle forces acting on the proximal and distal fragments. - Correct anatomical alignment is crucial for restoring function and preventing long-term complications. *Mid prone* - The **mid-prone** position is typically used for fractures of the **middle third of the forearm**, where the pronator and supinator muscle forces are more balanced. - In a proximal third fracture, the stronger supinator muscles would still pull the proximal fragment into supination, causing misalignment in the mid-prone position.
Question 7: The test performed below shows testing of which of the following nerve: (Recent NEET Pattern 2016-17)
- A. Median nerve
- B. Ulnar nerve (Correct Answer)
- C. Radial nerve
- D. Axillary nerve
Explanation: ***Ulnar nerve*** - The image shows a patient with inability to adequately flex the **ring and little fingers**, a classic sign of **ulnar nerve palsy**. This is known as the **"ulnar claw"** when the patient attempts to make a fist or extend the fingers. - The ulnar nerve innervates most of the **intrinsic hand muscles**, including the **interossei** and the **medial two lumbricals (ring and little fingers)**, which are responsible for flexion at the metacarpophalangeal joints and extension at the interphalangeal joints of these digits. *Median nerve* - **Median nerve injury** typically results in inability to **oppose the thumb** (ape hand deformity) and sensory loss over the radial three and a half digits. - It affects the **flexor muscles of the forearm** and the **thenar muscles**, not primarily the ring and little finger flexion shown. *Radial nerve* - **Radial nerve injury** causes **wrist drop** and **finger drop** due to paralysis of the extensors of the wrist and fingers. - It primarily affects **extension** of the wrist and fingers, rather than the intrinsic hand function of flexion shown in the image. *Axillary nerve* - The **axillary nerve** primarily innervates the **deltoid muscle** and **teres minor**, responsible for shoulder abduction and external rotation. - Injury to the axillary nerve would result in **shoulder weakness** and sensory loss over the lateral shoulder, with no direct impact on hand or finger function.
Question 8: The test performed below shows involvement of which of the following nerve?
- A. Radial nerve
- B. Axillary nerve
- C. Median nerve (Correct Answer)
- D. Ulnar nerve
Explanation: ***Median nerve*** - The image depicts the **Phalen's test**, where prolonged forced wrist flexion compresses the **median nerve** within the **carpal tunnel**. - The lightning bolt symbol indicates the characteristic **paresthesia** (tingling, numbness) experienced in the distribution of the median nerve, affecting the **thumb, index finger, middle finger, and radial half of the ring finger**. *Radial nerve* - The **radial nerve** primarily innervates the **extensor muscles** of the forearm and hand and provides sensation to the posterior aspect of the forearm and hand, as well as the dorsal side of the lateral 3.5 digits; it is not compressed by Phalen's maneuver. - Injury to the radial nerve typically causes **wrist drop** and sensory loss in a different distribution. *Axillary nerve* - The **axillary nerve** innervates the **deltoid** and **teres minor** muscles and provides sensation over the lateral shoulder. - It is not involved in conditions affecting the wrist or hand tested by maneuvers like Phalen's. *Ulnar nerve* - The **ulnar nerve** provides sensation to the **little finger** and **ulnar half of the ring finger**, and innervates most of the intrinsic hand muscles. - Compression of the ulnar nerve is typically tested by **Tinel's sign** at the **cubital tunnel** or Guyon's canal, not Phalen's test.
Question 9: Which of the following statements is true regarding supracondylar fractures of the humerus?
- A. Extension type most common (Correct Answer)
- B. Flexion type is less common than extension type
- C. Both types are equally common
- D. More common in adults
Explanation: **Extension type most common** - **Extension-type supracondylar fractures** account for the vast majority (about 95%) of all supracondylar humerus fractures. - This type typically results from a fall on an **outstretched hand** with the elbow in extension, forcing the distal fragment posteriorly. *More common in adults* - **Supracondylar fractures of the humerus** are predominantly observed in children, especially between 5 and 10 years of age. - They are the **most common elbow fracture in children**, making this statement incorrect. *Flexion type is less common than extension type* - While flexion-type fractures do occur, they are significantly less common, representing only about 5% of all supracondylar fractures. - This type typically results from a direct blow to the posterior aspect of the elbow, with the distal fragment displaced anteriorly. *Both types are equally common* - As established, extension-type fractures are far more prevalent than flexion-type fractures, making them not equally common. - The significant disparity in incidence confirms that this statement is incorrect.
Question 10: Fracture shaft of humerus can cause damage to which of the following nerves?
- A. Ulnar nerve
- B. Radial nerve (Correct Answer)
- C. Axillary nerve
- D. Median nerve
Explanation: ***Radial nerve*** - The **radial nerve** runs in the **spiral groove** along the posterior aspect of the humerus shaft, making it highly susceptible to injury during a fracture in this region. - Damage can lead to **wrist drop** and impaired sensation over the posterior forearm and hand. *Ulnar nerve* - The **ulnar nerve** primarily runs along the medial epicondyle of the humerus, making it more vulnerable to injuries around the **elbow joint**, not typically the humeral shaft. - Injury to the ulnar nerve results in a characteristic **"claw hand"** deformity and sensory loss over the medial aspect of the hand. *Axillary nerve* - The **axillary nerve** wraps around the surgical neck of the humerus and is most commonly injured with **shoulder dislocations** or fractures involving the surgical neck, not the shaft. - Damage to the axillary nerve causes weakness in **deltoid abduction** and sensory loss over the lateral shoulder (regimental badge area). *Median nerve* - The **median nerve** travels more anteriorly and medially in the arm and is generally protected from direct injury in a mid-shaft humeral fracture. - Injury to the median nerve can cause a **"ape hand" deformity** and sensory loss over the radial aspect of the palm.
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