Elbow Arthroscopy — MCQs
The anterior humeral line and radiocapitellar alignment are most commonly disturbed in -
In elbow, osteochondritis usually involves
In cubital fossa, which structure is the most medial
A 65-year-old lady presented with a swollen and painful knee. On examination, she was found to have grade III osteoarthritic changes. What is the best course of action?
Heller's myotomy is done for
Keinbock's disease is osteochondritis of ?
Which of the following will not take place in a patient with ulnar nerve injury in arm?
Fracture shaft of humerus can cause damage to which of the following nerves?
An athlete sustained an injury around the knee joint with suspected cartilage damage. Which of the following is the investigation of choice?
The joint cavity can be examined in detail with minimal surgical exposure by which procedure?
Elbow Arthroscopy Indian Medical PG Practice Questions and MCQs
Question 1: The anterior humeral line and radiocapitellar alignment are most commonly disturbed in -
- A. Supracondylar Fracture of the humerus (Correct Answer)
- B. Monteggia Fracture dislocation
- C. Fracture of Proximal Radius
- D. Fracture lateral condyle of the humerus
Explanation: ***Supracondylar Fracture of the humerus*** - **Anterior humeral line** passes through the **anterior cortex of the humerus** and should intersect the middle third of the capitellum in a normal elbow. - In supracondylar fractures, particularly those with **posterior displacement**, this line is often displaced **anteriorly or posteriorly**, failing to intersect the capitellum correctly. Additionally, the **radiocapitellar alignment** refers to the relationship between the **radius head** and the **capitellum**. Fractures and displacements around the elbow joint, such as supracondylar fractures, can disrupt this alignment. *Fracture lateral condyle of the humerus* - While a fracture of the lateral condyle can affect the elbow joint, it primarily involves a part of the **articular surface** and not necessarily the overall alignment of the entire distal humerus relative to the capitellum in the same way a supracondylar fracture does. - The **lateral condyle** is a smaller segment, and its fracture may not significantly alter the anterior humeral line **unless there is significant displacement** that indirectly affects the alignment of the capitellum. *Monteggia Fracture dislocation* - A **Monteggia fracture** involves a fracture of the **ulna** with dislocation of the **radial head** at the elbow. - While radiocapitellar alignment is severely disrupted, the **anterior humeral line** itself, which assesses the distal humerus, is typically **unaffected** as the primary injury is in the forearm bones and the radial head. *Fracture of Proximal Radius* - A fracture of the proximal radius (e.g., **radial head or neck fracture**) primarily affects the **radial articular surface** and its alignment with the capitellum. - While **radiocapitellar alignment** would clearly be disturbed, the position of the **distal humerus** relative to the capitellum, which the anterior humeral line evaluates, usually remains intact.
Question 2: In elbow, osteochondritis usually involves
- A. Olecranon
- B. Trochlea
- C. Radial head
- D. Capitulum (Correct Answer)
Explanation: ***Capitulum*** - The **capitulum** of the humerus is the most common site for **osteochondritis dissecans (OCD)** in the elbow, especially in throwing athletes and gymnasts. - This condition involves an avascular necrosis of the subchondral bone leading to a detachment of a cartilage fragment. *Olecranon* - The **olecranon** is part of the ulna and is more commonly affected by **stress fractures** or **bursitis**, not typically osteochondritis. - While it articulates with the trochlea, it does not bear the primary compressive forces that lead to osteochondritis in the same way the capitulum does. *Trochlea* - The **trochlea** of the humerus articulates with the trochlear notch of the ulna and is less frequently involved in primary osteochondritis compared to the capitulum. - Pathologies here are more likely related to **instability** or **fractures**. *Radial head* - The **radial head** articulates with the capitulum and is more prone to **fractures** or degenerative changes like **osteoarthritis**. - While it can be affected by **osteochondral lesions**, the capitulum is the classic site for elbow osteochondritis dissecans.
Question 3: In cubital fossa, which structure is the most medial
- A. Brachial artery
- B. Radial nerve
- C. Median nerve (Correct Answer)
- D. Biceps tendon
Explanation: ***Median nerve*** - The **median nerve** is the most medial structure within the cubital fossa, positioned medial to the brachial artery. - Its medial position is crucial for understanding its vulnerability to injury in this region, especially during venipuncture or supracondylar fractures of the humerus. - It runs along the medial border of the brachial artery throughout its course in the cubital fossa. *Brachial artery* - The **brachial artery** lies lateral to the median nerve and medial to the biceps tendon in the cubital fossa. - It is a major vessel used for blood pressure measurement and is a common site for arterial punctures. - It bifurcates into radial and ulnar arteries at the level of the radial neck. *Radial nerve* - The **radial nerve** is the most lateral structure in the cubital fossa, positioned deep to the brachioradialis muscle. - It divides into deep (posterior interosseous) and superficial branches just distal to the lateral epicondyle. - The deep branch is at risk during surgical approaches to the radial head. *Biceps tendon* - The **biceps tendon** is located centrally within the cubital fossa, lying lateral to the brachial artery. - It inserts into the radial tuberosity and is an important landmark for palpation in the fossa. - The bicipital aponeurosis (lacertus fibrosus) arises from its medial side and protects the median nerve and brachial artery.
Question 4: A 65-year-old lady presented with a swollen and painful knee. On examination, she was found to have grade III osteoarthritic changes. What is the best course of action?
- A. Conservative management
- B. Total knee replacement (Correct Answer)
- C. Arthroscopic washing
- D. Partial knee replacement
Explanation: ***Total knee replacement*** - For **grade III osteoarthritis** in a 65-year-old, a total knee replacement is the most definitive and effective treatment to relieve pain and restore function in a severely damaged joint. - This procedure addresses widespread cartilage loss and structural changes typical of advanced osteoarthritis. *Conservative management* - This approach is typically favored for **mild to moderate osteoarthritis**, involving physical therapy, NSAIDs, and lifestyle modifications. - For **grade III changes** with significant pain and swelling, conservative measures are unlikely to provide sufficient relief or halt disease progression effectively. *Arthroscopic washing* - **Arthroscopic lavage** and debridement are rarely recommended for osteoarthritis as they have not shown sustained benefits for pain or function. - It is sometimes used for specific mechanical symptoms, but it does not address the underlying cartilage loss and structural damage in severe osteoarthritis. *Partial knee replacement* - A **partial knee replacement** is suitable when osteoarthritis is confined to a single compartment of the knee, and the other compartments are healthy. - Given the indication of "grade III osteoarthritic changes" without specifying a single compartment, a total knee replacement is generally more appropriate for widespread disease.
Question 5: Heller's myotomy is done for
- A. Zenker's diverticulum
- B. Achalasia cardia (Correct Answer)
- C. Hiatus hernia
- D. Diffuse esophageal spasm
Explanation: ***Achalasia cardia*** - **Heller's myotomy** (esophagomyotomy) is the definitive surgical treatment for **achalasia cardia** - The procedure involves cutting the circular muscle fibers of the **lower esophageal sphincter (LES)** to relieve the functional obstruction - It addresses the primary pathology of achalasia: **failure of LES relaxation** and absence of esophageal peristalsis - Often combined with a partial fundoplication (Dor or Toupet) to prevent postoperative reflux *Zenker's diverticulum* - This is a **pharyngeal pouch** that develops at the pharyngoesophageal junction (Killian's triangle) - Treated with **diverticulectomy or diverticulopexy** with cricopharyngeal myotomy - Involves the upper esophageal sphincter, not the LES targeted by Heller's myotomy *Diffuse esophageal spasm* - A primary esophageal motility disorder characterized by **simultaneous, non-peristaltic contractions** - While esophageal myotomy may occasionally be considered in refractory cases, it is not the standard procedure - Management is primarily **medical** (calcium channel blockers, nitrates) rather than surgical *Hiatus hernia* - Involves herniation of the stomach through the esophageal hiatus of the diaphragm - Treated with **fundoplication** (Nissen or partial fundoplication) to reinforce the LES and repair the hiatus - Does not involve cutting the LES muscle as in Heller's myotomy
Question 6: Keinbock's disease is osteochondritis of ?
- A. Scaphoid
- B. Lunate (Correct Answer)
- C. Calcaneum
- D. Tibial tuberosity
Explanation: ***Lunate*** - **Keinbock's disease** is characterized by avascular necrosis of the **lunate bone** in the wrist. - This condition leads to pain, stiffness, and eventual collapse of the lunate, affecting wrist function. *Scaphoid* - Avascular necrosis of the scaphoid is referred to as **Preiser's disease**, not Keinbock's disease. - The scaphoid is more commonly associated with **fractures** due to its precarious blood supply. *Calcaneum* - The calcaneum (heel bone) is affected by **Sever's disease**, which is osteochondrosis of the calcaneal apophysis, typically seen in children. - This condition is not related to osteonecrosis of a carpal bone. *Tibial tuberosity* - The tibial tuberosity is associated with **Osgood-Schlatter disease**, which is an inflammation of the patellar ligament at its insertion point on the tibia, common in adolescents. - This is an apophysitis, not an osteochondrosis affecting a carpal bone.
Question 7: Which of the following will not take place in a patient with ulnar nerve injury in arm?
- A. Claw hand
- B. Weakness of flexor carpi ulnaris
- C. Sensory loss over medial aspect of hand
- D. Weakness of flexor digitorum profundus to index finger (Correct Answer)
Explanation: ***Weakness of flexor digitorum profundus to index finger*** - The **flexor digitorum profundus** muscle has dual innervation: the ulnar half (to the ring and little fingers) is supplied by the ulnar nerve, but the radial half (to the index and middle fingers) is supplied by the **median nerve**. - Therefore, an ulnar nerve injury would not affect the function of the flexor digitorum profundus to the index finger. *Claw hand* - A low ulnar nerve injury (at the wrist) typically results in **ulnar claw hand**, where the 4th and 5th digits are hyperextended at the MCP joints and flexed at the IP joints. - This is due to paralysis of the **lumbricals** to the 4th and 5th digits, leading to unopposed action of the extensor digitorum and flexor digitorum profundus. *Weakness of flexor carpi ulnaris* - The **flexor carpi ulnaris** is innervated exclusively by the ulnar nerve. - An ulnar nerve injury in the arm would therefore lead to weakness or paralysis of this muscle, affecting wrist flexion and ulnar deviation. *Sensory loss over medial aspect of hand* - The ulnar nerve provides sensory innervation to the **medial 1 and 1/2 fingers** (little finger and medial half of the ring finger) as well as the corresponding palmar and dorsal aspects of the hand. - An ulnar nerve injury would result in sensory deficits in this distribution.
Question 8: 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.
Question 9: An athlete sustained an injury around the knee joint with suspected cartilage damage. Which of the following is the investigation of choice?
- A. X-ray
- B. Clinical examination
- C. Arthroscopy (Correct Answer)
- D. Arthrotomy
Explanation: **Explanation:** The investigation of choice for suspected intra-articular cartilage damage is **Arthroscopy**. It is considered the **"Gold Standard"** because it allows for direct visualization of the articular surfaces, menisci, and ligaments under magnification. Unlike imaging, it provides a dynamic assessment of the tissue's integrity and allows the surgeon to perform immediate therapeutic interventions (e.g., debridement or chondroplasty). **Analysis of Options:** * **X-ray (Option A):** X-rays are excellent for visualizing bony injuries or fractures but are poor at showing soft tissues like cartilage or menisci. They are usually the first-line screening tool but are not definitive for cartilage damage. * **Clinical Examination (Option B):** While essential for initial diagnosis (e.g., McMurray’s or Lachman tests), clinical exams are subjective and can be limited by pain, swelling, or muscle guarding in an acute athlete injury. * **Arthrotomy (Option D):** This involves a large surgical incision to open the joint. It is highly invasive and has been largely replaced by arthroscopy due to higher morbidity and longer recovery times. **Clinical Pearls for NEET-PG:** * **MRI vs. Arthroscopy:** While MRI is the investigation of choice for *non-invasive* screening of soft tissue injuries, **Arthroscopy** remains the overall "Gold Standard" for definitive diagnosis and treatment. * **Triad of O'Donoghue:** Often seen in athletes, involving injury to the ACL, MCL, and Medial Meniscus. * **Arthroscopy Media:** Normal saline or Ringer’s Lactate is used to distend the joint during the procedure. * **Common Portals:** The anterolateral portal is the most common primary portal used in knee arthroscopy.
Question 10: The joint cavity can be examined in detail with minimal surgical exposure by which procedure?
- A. Sialography
- B. Arthroscopy (Correct Answer)
- C. Biopsy
- D. Endoscopy
Explanation: **Explanation:** **Arthroscopy** is the correct answer because it is a minimally invasive surgical procedure used to visualize, diagnose, and treat problems inside a joint. It involves inserting a fiber-optic camera (arthroscope) through a small "portal" or stab incision. This allows for a detailed examination of the joint cavity (articular cartilage, ligaments, and synovium) with significantly less morbidity, faster recovery, and minimal surgical exposure compared to traditional open arthrotomy. **Analysis of Incorrect Options:** * **Sialography (A):** This is a radiographic examination of the salivary glands and ducts using a contrast medium. It is unrelated to joint pathology. * **Biopsy (C):** While a biopsy can be performed *during* an arthroscopy, the term refers to the removal of tissue for histological examination. It is a diagnostic technique, not a procedure designed for the comprehensive visualization of a joint cavity. * **Endoscopy (D):** This is a broad umbrella term for looking inside the body using an endoscope. While arthroscopy is technically a type of endoscopy, "Arthroscopy" is the specific and most appropriate clinical term for joint visualization. **High-Yield Clinical Pearls for NEET-PG:** * **Triangulation:** The fundamental skill in arthroscopy where the scope and the surgical instrument meet at a specific point within the joint to perform a task. * **Distension Media:** Normal saline or Ringer’s Lactate is used to expand the joint space for better visualization. * **Common Sites:** The **knee** is the most common joint examined via arthroscopy, followed by the shoulder and ankle. * **Complications:** Although rare, the most common complication of arthroscopy is **hemarthrosis** (bleeding into the joint).
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