Deck 18: The Elbow and Forearm Complex

Question 1

Your goal is to increase end-range elbow flexion using joint-mobilization techniques.Which of the following techniques is appropriate?

A) Stabilize the distal humerus and apply a proximal glide of the ulna
B) Apply a valgus stress at the elbow
C) Stabilize the humerus and apply a dorsal glide to the head of the radius
D) Stabilize the distal humerus and apply an ulnar (lateral)glide of the ulna

Answer 1

D

Question 2

You are modifying a home-exercise program for a patient recovering from an episode of medial epicondylitis.Although pain has subsided,there is evidence of mild limitation of motion and pain when the involved muscle-tendon unit is placed on a stretch and overpressure is applied at the end of the available ROM.To fully lengthen the muscle-tendon unit typically involved in medial epicondylitis,have the patient perform a self-stretch by using the opposite hand to:

A) Flex and ulnarly deviate the wrist and flex the fingers while the elbow is extended and the forearm is pronated.
B) Flex and radially deviate the wrist and flex the fingers while the elbow is extended and the forearm is supinated.
C) Extend and ulnarly deviate the wrist and extend the fingers while the elbow is extended and the forearm is pronated.
D) Extend and radially deviate the wrist and extend the fingers while the elbow is extended and the forearm is supinated.

Answer 2

D

Question 3

When a period of continuous immobilization of the elbow is required after trauma or surgery,the elbow often is positioned in only a moderate amount of flexion (20 ^$\circ$ to 30 ^$\circ$ )rather than 90 ^$\circ$ of flexion.This position is selected to:

A) Decrease the risk of ulnar neuropathy from compression of the ulnar nerve in the cubital tunnel.
B) Decrease the risk of radial neuropathy from compression of the radial nerve in the cubital tunnel.
C) Decrease the risk of median nerve neuropathy from compression in the cubital tunnel.
D) Decrease the risk of overstretching the lateral collateral ligament complex of the elbow that could cause posterior translation of the radial head.

Answer 3

Decrease the risk of ulnar neuropathy from compression of the ulnar nerve in the cubital tunnel.

Question 4

Using a handheld weight as the source of resistance,which of the following positions to strengthen the elbow extensors begins with the long head of the triceps brachii fully lengthened?

A) Have the patient assume a prone-lying position with the shoulder in 90 ^$\circ$ abduction,the upper arm supported on the table,and the elbow flexed to 90 ^$\circ$
B) Have the patient assume the supine position with the shoulder flexed to 90 ^$\circ$ and the elbow flexed so the handheld weight touches the opposite shoulder.
C) With the patient standing or sitting in a chair,begin with the elbow fully flexed and the arm elevated overhead and stabilized to maintain the shoulder in as much flexion as possible.
D) While the patient is in a standing position and the hips are flexed to 90 ^$\circ$ ,begin with the shoulder in hyperextension.

Question 5

You are educating your patient about returning to functional activities following a radial head resection with an implant.What should you tell her about returning to high-demand,high-impact activities?

A) Avoid these activities on a permanent basis.
B) Because she had a radial head implant,she may return to these activities after 6 months.
C) She may return to heavy lifting after 6 months,but not high-impact (tennis or golf)activities due to the ballistic force these activities create.
D) She should have had a total elbow arthroplasty if she wanted to return to these activities.

Question 6

Tennis elbow may involve all of the following structures except the:

A) Extensor carpi radialis brevis
B) Extensor communis
C) Pronator teres
D) Annular ligament

Question 7

Which of the following is true about myositis ossificans (heterotopic bone formation)in the elbow region?

A) The muscle most often affected in the elbow region is the biceps brachii.
B) It is distinguished from traumatic arthritis of the humeroulnar joint in that passive extension is more limited than flexion.
C) After the acute inflammatory period,heterotopic bone is laid down within muscle fibers and within the joint.
D) Before the bony mass in the muscle has matured,the muscle should be stretched and massaged regularly to prevent a contracture.

Question 8

To strengthen the elbow extensors in a closed chain,you have the patient perform push-ups,using body weight as the source of resistance.Which of the following variations of push-ups provides the greatest amount of resistance to the elbow extensors?

A) Bilateral push-ups while in a fully prone position on the floor with weight on the hands and toes
B) Bilateral wall push-ups while in a standing position and leaning into and pushing away from the wall
C) Bilateral push-ups while standing and leaning on the hands on a kitchen countertop
D) Bilateral push-ups in a prone position with weight on the hands and knees

Question 9

Your patient,a 19-year-old college student,sustained a nondisplaced fracture of the distal humerus,which was managed by closed reduction and 6 weeks of immobilization in a cast.Yesterday the cast was removed and the patient is to begin exercises to improve ROM and strength of the elbow.Your examination reveals significant limitation of elbow flexion/extension and forearm pronation/supination as well as reduced joint play at the elbow.The patient describes her elbow as feeling "very stiff," but pain occurs only when overpressure is applied at the end of the available ranges.One of the goals in this patient's treatment plan is to increase elbow ROM.Which of the following techniques should you begin with to increase ROM?

A) Cross-fiber massage of the tendons inserting at the elbow
B) Joint-mobilization techniques to stretch the restricted joints (grade III sustained glide or grade IV oscillation techniques)after evaluating the reactivity of the elbow joints with grade II sustained glides
C) Manual passive stretching to lengthen muscles that cross the elbow
D) Passive ROM within pain-free ranges

Question 10

Which of the following is true about total elbow arthroplasty (TEA)?

A) A semiconstrained,linked prosthesis allows flexion and extension of the elbow but not varus,valgus,or rotational motions.
B) The typical method of fixation of the implants is all-cementless (all-biological)fixation.
C) The surgical approach most often used leaves the triceps tendon intact.
D) One of the more common,long-term complications after TEA is joint instability,particularly with unlinked implants or if the patient previously underwent excision of the radial head.

Question 11

Current research shows that the "survival rate" for total elbow arthroplasty (TEA)is:

A) 30% over a 10-year period.
B) Greater for patients with RA than for those with traumatic arthritis or OA.
C) Highly correlated with the type of implant (prosthesis).
D) 82% over a 5.5-year period.

Question 12

Each of the following is a precaution that should be taken after total elbow arthroplasty involving a triceps-reflecting or triceps-splitting approach except:

A) Limit assisted elbow flexion to about 90 ^$\circ$ to 100 ^$\circ$ for the first 3 to 4 weeks postoperatively.
B) For about the first 3 to 4 weeks,perform active elbow flexion/extension only while lying in the supine position.
C) Postpone elbow extension against manual resistance or light weights for 6 weeks or longer.
D) Avoid pushing motions with the operated upper extremity during functional activities,such as pushing up from a chair,for at least 6 weeks.

Question 13

A person with a long history of polyarticular rheumatoid arthritis is experiencing severe,dominant-side elbow pain that is interfering with personal grooming,light housework,and work-related responsibilities as a computer programmer.In addition to pain,physical findings include persistent synovitis despite ongoing medical management,limited elbow ROM,and complete loss of the joint space of the humeroulnar (HU)and humeroradial (HR)joints.Given these findings,this person is most likely a candidate for which of the following surgical procedures to relieve pain and improve daily function?

A) Synovectomy
B) Excision of the radial head coupled with prosthetic implant
C) Total elbow arthroplasty
D) Arthrodesis of the elbow

Question 14

In an adult,a displaced fracture of the radial head typically is managed surgically by reduction and internal fixation of the fracture site or excision of the radial head with or without a prosthetic implant.Which of the following is incorrect about the indications,advantages,or disadvantages of these two procedures?

A) Resection of the radial head coupled with prosthetic implant is typically performed arthroscopically,allowing a rapid postoperative recovery.
B) Open or arthroscopically assisted reduction and internal fixation is typically the procedure of choice if the patient is young and active.
C) Early postoperative motion is permissible after open reduction and internal fixation unless extensive repair of elbow ligaments was required.
D) Excision of the radial head is the only option if the fracture is severely comminuted.

Question 15

You place your patient's wrist in a splint because he is experiencing an acute episode of lateral epicondylitis.Which of the following is the least appropriate intervention while the inflamed soft tissue is healing?

A) Have the patient wear a splint to immobilize the wrist continuously for at least 2 weeks or until there is no pain.
B) Have the patient remove the splint several times each day and perform active or self-assisted ROM of the wrist within pain-free ranges.
C) Have the patient remove the splint several times a day and perform gentle muscle-setting exercises,elongating the involved muscle-tendon unit slightly after each contraction but not beyond the pain-free ranges.
D) Apply cross-fiber massage at the site of the lesion.