2014 Shoulder & Elbow

Question 1

1: In Figure 1, which of the following structures is the primary stabilizer in preventing valgus instability of the elbow?
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1. A
2. B
3. C
4. D
5. E

Answer 1

PREFERRED RESPONSE: 2

DISCUSSION: The anterior bundle of the medial collateral ligament is the prime stabilizer of the medial aspect of the elbow and is indicated by “B” in the figure. When intact, this anterior bundle of the medial collateral ligament is a restraint to valgus instability of the elbow. The posterior bundle is regarded as a secondary stabilizer of the medial elbow (C). The transverse bundle (D), annular ligament (A), and biceps tendon (E) do not play a role in valgus stability of the elbow.

Question 2

2: Figure 2A shows the radiograph of a 20-year-old man who has an injury to the right shoulder. Figure 2B shows an arthroscopic view (posterior portal). The arrow points to a

Fig.

1. rotator cuff tear.
2. bare area.
3. Hill-Sachs defect.
4. Bankart tear.
5. glenoid fracture.

Answer 2

PREFERRED RESPONSE: 3

DISCUSSION: The radiograph shows an anterior dislocation of the shoulder. A frequently encountered sequela of this is a compression fracture of the posterolateral humeral head, commonly referred to as a Hill-Sachs defect. The arthroscopic view of the glenohumeral joint visualizes the posterior aspect of the humeral head. In the image, the area devoid of cartilage to the right is the bare area. The indentation seen to the left is a Hill-Sachs defect.

Question 3

3: A previously asymptomatic 40-year-old man injures his shoulder in a fall. Examination shows that he is unable to lift the hand away from his back while maximally internally rotated. An axial MRI scan of the shoulder is shown in Figure 3. What is the most likely diagnosis?

Figure 3

1. Pectoralis major tendon rupture
2. Supraspinatus rupture
3. Subscapularis rupture
4. Bankart tear
5. Humeral avulsion of the inferior glenohumeral ligament

Answer 3

PREFERRED RESPONSE: 3

DISCUSSION: The MRI scan shows detachment of the subscapularis from its insertion on the lesser tuberosity. The examination finding is consistent with a positive lift-off test, also indicating a tear of the subscapularis.

Question 4

4: Figure 4 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)?

Figure 4

1. Inferior glenohumeral ligament
2. Superior glenohumeral ligament
3. Rotator cuff interval
4. Subscapularis recess
5. Interior recess

Answer 4

PREFERRED RESPONSE: 3

DISCUSSION: The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.

Question 5

5: In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule?

1. A teres minor-splitting approach
2. An infraspinatus-splitting approach
3. Between the infraspinatus and teres minor
4. Between the supraspinatus and infraspinatus
5. In the rotator interval

Answer 5

PREFERRED RESPONSE: 2

DISCUSSION: Using an infraspinatus-splitting incision allows for excellent exposure of the posterior capsule and minimizes the risk of injury to the axillary nerve, which lies inferior to the teres minor in the quadrilateral space.

Question 6

6: Figure 5 shows the MRI scan of a 38-year-old weightlifter. What does the arrow on the MRI scan indicate?

Figure 5

1. Biceps tear
2. Pectoralis minor tear
3. Pectoralis major tear
4. Subscapularis tear
5. Abscess formation

Answer 6

PREFERRED RESPONSE: 3

DISCUSSION: Pectoralis major ruptures typically occur in avid weightlifters (often on supplements) and typically while bench-pressing. Clinically there is significant discoloration/bruising over the pectoralis and into the axilla. MRI helps confirm the diagnosis and may help determine if the tear is in the muscle belly or at the bone-tendon junction.

Question 7

7: Which of the following muscle tendons inserts just lateral to the long head of the biceps tendon on the proximal humerus?

1. Teres major
2. Latissimus dorsi
3. Short head of the biceps
4. Pectoralis major
5. Subscapularis

Answer 7

PREFERRED RESPONSE: 4

DISCUSSION: The pectoralis major insertion is just lateral to the long head of the biceps tendon. Medial to the biceps is the insertion for the teres major and latissimus dorsi. The short head of the biceps originates on the coracoid process. The subscapularis inserts on the lesser tuberosity just medial to the biceps.

Question 8

8: A 68-year-old man had a 3-year history of shoulder pain that failed to respond to nonsurgical management. Examination reveals forward elevation to 120° and external rotation to 30°. True AP and axillary radiographs and an axial CT scan are shown in Figures 6A through 6C. What management option would lead to the best long-term results?

Figure 6

1. Hemiarthroplasty
2. Total shoulder arthroplasty
3. Reverse total shoulder arthroplasty
4. Arthroscopic débridement
5. Glenoid osteotomy and interposition arthroplasty

Answer 8

PREFERRED RESPONSE: 2

DISCUSSION: The radiographs and CT scan reveal osteoarthritis with posterior subluxation and posterior bone loss. Total shoulder arthroplasty with reaming of the high side to neutralize the glenoid surface has been shown to yield better results than hemiarthroplasty. The amount of bone loss in this patient does not require posterior glenoid augmentation. Reverse total shoulder arthroplasty is indicated for rotator cuff tear arthropathy; therefore, it is not applicable. Arthroscopic débridement has yielded poor results with advanced osteoarthritis and posterior subluxation. Results from glenoid osteotomy have been variable, and glenoid osteotomy is not indicated with associated osteoarthritis.

Question 9

9: A 66-year-old woman who previously underwent hemiarthroplasty 2 years ago for a fracture continues to have severe pain and loss of motion despite undergoing physical therapy. A radiograph is shown in Figure 7. What is the most likely reason that this patient has failed to improve her motion?

Figure 7

1. She was noncompliant in physical therapy.
2. The original surgery should have included resurfacing the glenoid.
3. The humeral head was too large.
4. The humeral component was placed too proud.
5. The tuberosities are malpositioned.

Answer 9

PREFERRED RESPONSE: 5

DISCUSSION: The radiograph shows tuberosity malposition. The effect of improper prosthetic placement has also been associated with poor outcomes. However, the malposition of the tuberosity seen on the radiograph clearly explains loss of motion in this patient. It has been demonstrated that the functional results after hemiarthroplasty for three- and four-part proximal humeral fractures appear to be directly associated with tuberosity osteosynthesis. The most significant factor associated with poor and unsatisfactory postoperative functional results was malposition and/or migration of the tuberosities. Factors associated with a failure of tuberosity osteosynthesis in a recent study were poor initial position of the prosthesis, poor position of the greater tuberosity, and women older than 75 years (most likely with osteopenic bone). Greater tuberosity displacement has been identified by Tanner and Cofield as being the most common complication after prosthetic arthroplasty for proximal humeral fractures. Furthermore, Bigliani and associates examined the causes of failure after prosthetic replacement for proximal humeral fractures and found that although almost all failed cases had multiple causes, the most common single identifiable reason was greater tuberosity displacement.

Question 10

10: A 40-year-old woman underwent an arthroscopic acromioplasty and mini-open rotator cuff repair 4 weeks ago. At follow-up examination, the incision is painful, erythematous, and draining fluid. The patient is febrile and has an elevated white blood cell count. What infectious organism should be under high suspicion of causing this outcome?

1. Escherichia coli
2. Streptococcus viridans
3. Oxalophagus oxalicus
4. Propionibacterium acnes
5. Enterococcus faecalis

Answer 10

PREFERRED RESPONSE: 4

DISCUSSION: Propionibacterium acnes has been a leading cause of indolent shoulder infections. During shoulder arthroscopy, the arthroscopic fluid may actually dilute the shoulder preparation and lead to a higher rate of infection during subsequent mini-open rotator cuff repair surgery. The remaining bacteria listed are rarely associated with shoulder infections after arthroscopy.

Question 11

11: A patient reports persistent anterior shoulder pain following a forceful external rotation injury to the shoulder. An MRI scan is shown in Figure 8. The patient remains symptomatic despite 3 months of nonsurgical management. Treatment should now consist of

Figure 8

1. repair of the superior labrum.
2. isolated supraspinatus repair.
3. biceps recentering.
4. subscapularis repair and biceps tenodesis.
5. subscapularis repair and recentering of the biceps tendon.

Answer 11

PREFERRED RESPONSE: 4

DISCUSSION: The MRI scan reveals a subscapularis tear with a biceps that is out of the groove. Treatment in this patient is most predictable if the subscapularis is repaired. The biceps should either be tenodesed or tenotomized because it is unstable. Recentering of the biceps has been found to be unpredictable. Treatment of these lesions has been shown to have better results if the biceps is either released or tenodesed. This prevents recurrent biceps symptoms that can be source of surgical failure.

Question 12

12: A 78-year-old woman falls onto her nondominant left elbow and sustains the injury shown in Figure 9. What treatment option allows her the shortest recovery time and highest likelihood of good function and range of motion?

Figure 9

1. Total elbow arthroplasty
2. Open reduction and internal fixation
3. Radial head arthroplasty
4. Sling and swathe
5. Bone stimulator

Answer 12

PREFERRED RESPONSE: 1

DISCUSSION: Total elbow arthroplasty has become the treatment of choice for complex, comminuted distal humeral fractures in patients older than 70 years. It yields a faster recovery with more predictable functional outcomes, although limitations of lifting weight of more than 5 lb must be followed to avoid loosening.

Question 13

13: A 45-year-old woman awakens with the acute onset of burning left shoulder pain that radiates toward the axilla. She denies any history of trauma. On examination, she is unable to abduct her arm but has full passive shoulder motion. Her sensation is intact. Cervical spine examination reveals full range of motion and a negative Spurling test. Radiographs and MRI studies are normal for the cervical spine and shoulder. What is the most likely diagnosis?

1. Cervical C6-7 radiculopathy
2. Impingement
3. Rotator cuff tear
4. Brachial neuritis
5. Adhesive capsulitis

Answer 13

PREFERRED RESPONSE: 4

DISCUSSION: The definition of brachial neuritis or Parsonage-Turner syndrome is a rare disorder of unknown etiology that causes pain or weakness of the shoulder and upper extremity. The loss of active motion excludes cervical C6-7 radiculopathy and impingement. A normal MRI scan and full passive motion exclude a rotator cuff tear and adhesive capsulitis, respectively.

Question 14

14: A 72-year-old man who underwent total shoulder arthroplasty 2 years ago slipped on ice and fell on his shoulder 3 weeks ago. Immediately after falling he was unable to elevate his arm. Motor examination reveals deltoid 5-/5, subscapularis 5-/5, external rotation 4-/5, and supraspinatus 2/5. Radiographs are shown in Figures 10A and 10B. What is the most likely diagnosis?

Figure 10

1. Anterior shoulder dislocation
2. Humeral component loosening
3. Glenoid component loosening
4. Glenoid component catastrophic fracture
5. Rotator cuff tear

Answer 14

PREFERRED RESPONSE: 5

DISCUSSION: The patient has a traumatic rotator cuff tear. The history of the fall, the weakness on examination, and normal radiographic findings make a traumatic rotator cuff tear the most likely diagnosis. An MRI scan can be obtained to further evaluate the integrity of the rotator cuff. The axillary radiograph shows a reduced, nondislocated total shoulder arthroplasty. His radiographs show a well-seated humeral stem and no signs of loosening. The glenoid is a cemented all-polyethylene component with no evidence of radiolucent lines surrounding the cemented pegs. The polyethylene glenoid component is radiolucent; however, the space between the metallic humeral head and the glenoid bone is the thickness of the polyethylene glenoid component. If the humeral head were directly against the glenoid bone, then catastrophic fracture of the glenoid would be the working diagnosis.

Question 15

15: A 39-year-old man has had persistent right shoulder pain for the past 6 months. A formal physical therapy program has failed to provide relief, and an injection several months ago provided only short-term relief. Examination reveals a positive Neer and Hawkins test. There is no instability and the neurovascular examination is normal. Arthroscopy reveals a partial rotator cuff tear on the bursal side measuring 60% of the tendon thickness. What is the next most appropriate step in management?

1. Arthroscopic débridement alone of the partial rotator cuff tear
2. Repair of the partial rotator cuff tear and subacromial decompression
3. Arthroscopic débridement combined with subacromial decompression
4. Arthroscopic subacromial decompression
5. Biceps tenotomy

Answer 15

PREFERRED RESPONSE: 2

DISCUSSION: Although arthroscopic débridement with or without subacromial decompression is a reasonable response, the patient has positive impingement signs. Several recent studies regarding the surgical treatment of partial rotator cuff tears have demonstrated good to excellent results after repair of tears involving more than 50% of the tendon thickness. This was shown specifically for bursal-sided tears and joint-side tears. Biceps tenotomy is not indicated in a young patient.

Question 16

16: Figures 11A and 11B show the radiographs of a 47-year-old man who reports pain in both shoulders. He has a history of leukemia that was treated with chemotherapy and high-dose cortisone. What is the most reliable treatment option for pain relief in this patient?

Figure 11

1. Arthroscopic débridement
2. Arthrodesis
3. Resection arthroplasty
4. Hemiarthroplasty
5. Cortisone injection

Answer 16

PREFERRED RESPONSE: 4

DISCUSSION: The radiographs reveal osteonecrosis with collapse. The most reliable and durable treatment for osteonecrosis of the humeral head remains prosthetic shoulder arthroplasty. Osteonecrosis of the humeral head may be seen after the use of steroids, and there is an increasing demand for shoulder arthroplasty in young people because of the use of high-dose steroids in chemotherapy regimens for the treatment of malignant tumors. The indications for most shoulder arthrodeses currently include posttraumatic brachial plexus injury, paralytic disorders in infancy, insufficiency of the deltoid muscle and rotator cuff, chronic infection, failed revision arthroplasty, severe refractory instability, and bone deficiency following resection of a tumor in the proximal aspect of the humerus. Clearly, the role of arthroscopy and related minimally invasive techniques in the treatment of humeral head osteonecrosis remains unknown.

Question 17

17: Figure 12A shows the clinical photograph of a 36-year-old man who has left shoulder pain and dysfunction after undergoing a lymph node biopsy 2 years ago. The appearance of the shoulder during abduction and a wall push-up maneuver is shown in Figures 12B and 12C, respectively. Which of the following procedures provides the best pain relief and function?

Figure 12

1. Direct nerve repair
2. Sural nerve graft
3. Pectoralis major transfer
4. Levator scapula and rhomboid transfer
5. Scapulothoracic fusion

Answer 17

PREFERRED RESPONSE: 4

DISCUSSION: Injury to the spinal accessory nerve can occur after penetrating trauma to the shoulder. Blunt trauma may also cause loss of trapezius function. Most commonly, surgical dissection in the posterior triangle of the neck, such as lymph node biopsy, may expose the nerve to possible damage. Surgical repair of the nerve may be considered up to 1 year after injury; after this time muscle transfer is usually associated with a better functional outcome.

Question 18

18: What is the most common cause of poor outcomes in patients who undergo total shoulder arthroplasty?

1. Loosening of the humeral component
2. Loosening of the glenoid component
3. Infection
4. Brachial plexus injury
5. Rotator cuff tear

Answer 18

PREFERRED RESPONSE: 5

DISCUSSION: In an article in the Journal of Shoulder and Elbow Surgery, 431 total shoulder arthroplasties were performed with a cemented all-polyethylene glenoid component between 1990 and 2000. Follow-up averaged 4.2 years. In total, 53 surgical complications occurred in 53 patients (12%). Of these, 32 were major complications (7.4%), with 17 of these requiring reoperation. Index complications in order of frequency included rotator cuff tearing, postoperative glenohumeral instability, and periprosthetic humeral fracture. Notably, glenoid and humeral component loosening requiring reoperation occurred in only one shoulder. Data from the contemporary patient group suggest that there are fewer complications of shoulder arthroplasty and less need for reoperation. Especially striking is the near-absence of component revision because of loosening or other mechanical factors. Complications involving the brachial plexus have been reported following total shoulder arthroplasty but are not as common of a cause for failure.

Question 19

19: A 49-year-old woman with serologically proven rheumatoid arthritis has Larsen grade II radiographic changes in the elbow. Examination reveals a preoperative arc of flexion of less than 90° and there is no instability. Nonsurgical management has failed to provide relief. What is the best treatment option?

1. Semiconstrained total elbow arthroplasty
2. Unlinked total elbow arthroplasty
3. Fascial arthroplasty
4. Open synovectomy
5. Arthroscopic synovectomy

Answer 19

PREFERRED RESPONSE: 5

DISCUSSION: Larsen grade I and II rheumatoid arthritis is best treated with synovectomy with arthroplasty reserved for later stages, especially in younger patients. Open synovectomy with or without a radial head excision has yielded good results for pain and function, with arthroscopic synovectomies yielding similar results. Arthroscopic synovectomy has been shown to be more effective in restoring function in patients with a flexion arc of less than 90°.

Question 20

20: A 68-year-old woman with serologically proven rheumatoid arthritis underwent an open synovectomy and radial head resection 10 years ago. She now has severe pain that has failed to respond to nonsurgical management. Examination reveals a flexion arc of greater than 90°. Radiographs are shown in Figures 13A and 13B. What is the most appropriate management?

Figure 13

1. Semiconstrained total elbow arthroplasty
2. Unconstrained total elbow arthroplasty
3. Fascial arthroplasty
4. Open synovectomy
5. Arthroscopic synovectomy

Answer 20

PREFERRED RESPONSE: 1

DISCUSSION: The radiographs reveal severe arthritic changes with no joint space, and the AP view shows a progressive malalignment secondary to the radial head resection. A prosthetic arthroplasty is indicated given the severe arthritis (Larsen grade III). Unconstrained arthroplasties have not performed as well as semiconstrained arthroplasties after previous radial head resections. However, both types of arthroplasties performed better in native elbows. Synovectomies should be reserved for less advanced disease states.

Question 21

21: A football player sustains a traumatic anterior-inferior dislocation of the shoulder in the last game of the season. It is reduced 20 minutes later in the locker room. The patient is neurologically intact and has regained motion. If the patient undergoes arthroscopic evaluation, what finding is seen most consistently?

1. Superior labral detachment
2. Engaging Hill-Sachs lesion
3. Large glenoid rim fracture
4. Avulsion of the inferior glenohumeral ligament from the humerus
5. Avulsion of the anterior inferior glenoid labrum

Answer 21

PREFERRED RESPONSE: 5

DISCUSSION: In an acute first-time dislocation, arthroscopy has been shown to reveal a Bankart lesion in most shoulders. The classic finding of labral detachment from the anterior inferior glenoid along with occasional hemorrhage within the inferior glenohumeral ligament is the most common sequelae of a traumatic anterior inferior dislocation. Acute treatment, if chosen, is repair of the labral tissue back to the glenoid plus or minus any capsular plication to address potential plastic deformation of the glenohumeral ligament. Acute treatment of a patient sustaining a first-time dislocation remains controversial. The potential indications may be patients whose dislocation occurs at the end of a season and when the desire to minimize risk of future instability outweighs the risks of surgical intervention.

Question 22

22: A 42-year-old patient undergoes resection of the medial clavicle for painful sternoclavicular degenerative joint disease. The postoperative course is complicated by an increase in symptoms, a medial bump, and subjective tingling in the digits. A clinical photograph and radiograph are shown in Figures 14A and 14B. What is the most appropriate procedure at this time?

Figure 14

1. Semitendinosus figure-of-8 graft
2. Subclavius tendon transfer
3. Medial clavicular osteotomy
4. Medial clavicular resection
5. Sternoclavicular arthrodesis

Answer 22

PREFERRED RESPONSE: 1

DISCUSSION: Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-8 pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability.

Question 23

23: A 32-year-old woman sustained an elbow dislocation, and management consisted of early range of motion. Examination at the 3-month follow-up appointment reveals that she has regained elbow motion but has a weak pinch. A clinical photograph is shown in Figure 15. What is the most likely diagnosis?

Figure 15

1. Flexor pollicis longus rupture
2. Median nerve palsy
3. Ulnar nerve palsy
4. Anterior interosseous nerve palsy
5. Posterior interosseous nerve palsy

Answer 23

PREFERRED RESPONSE: 4

DISCUSSION: The photograph shows the characteristic attitude of the hand when an anterior interosseous nerve palsy is present. The patient is unable to flex the interphalangeal joint to the joint of the thumb. Anterior interosseous nerve palsies are often misdiagnosed as tendon ruptures.

Question 24

24: What are the proposed biomechanical advantages of the Grammont reverse total shoulder arthroplasty when compared to a standard shoulder arthroplasty?

1. Lateralization of the center of rotation, lengthening the deltoid, and decreasing the deltoid moment arm
2. Lateralization of the center of rotation, shortening the deltoid, and decreasing acromial stress
3. Lateralization of the center of rotation, lengthening the deltoid, and increasing the transverse force couple
4. Medialization of the center of rotation, lengthening the deltoid, and increasing the deltoid moment arm
5. Medialization of the center of rotation, shortening the deltoid, and decreasing acromial stress

Answer 24

PREFERRED RESPONSE: 4

DISCUSSION: The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid.

Question 25

25: A 74-year-old woman with rheumatoid arthritis reports shoulder pain that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 16A and 16B. Examination reveals active forward elevation to 120° and external rotation to 30°. What treatment option results in the most predictable pain relief and function?

Figure 16

1. Hemiarthroplasty
2. Arthroscopic débridement
3. Total shoulder arthroplasty with a cemented all-polyethylene glenoid component
4. Reverse total shoulder arthroplasty
5. Total shoulder arthroplasty with a metal-backed glenoid component

Answer 25

PREFERRED RESPONSE: 3

DISCUSSION: Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared to hemiarthroplasty in patients with rheumatoid arthritis. Although rotator cuff tears are more common in this patient population, this patient has good forward elevation and no significant superior migration of the humeral head; therefore, a reverse arthroplasty is not indicated. The arthritis is too advanced in this patient to consider arthroscopy, but in less advanced cases it can improve range of motion and decrease pain. Metal-backed glenoid components have shown higher rates of loosening.

Question 26

26: A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan?

1. Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.
2. Maintain sling immobilization for 3 weeks, and then begin a global range-of-motion program.
3. Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
4. Immediately begin a passive range-of-motion program for forward elevation only; no external rotation is allowed for 6 weeks.
5. Immediately begin active range of motion in forward elevation and external rotation to the side with a progression to full rotator cuff strengthening in 3 weeks.

Answer 26

PREFERRED RESPONSE: 3

DISCUSSION: The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Because she has a good-quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.

Question 27

27: A 22-year-old man who is right-handed fell off his motorcycle onto the tip of his right shoulder 2 weeks ago now and reports pain and difficulty raising his right arm. Examination reveals tenderness and gross movement over the lateral scapular spine and severe weakness during resisted abduction. A radiograph and three-dimensional CT scan are shown in Figures 17A and 17B. What is the next most appropriate step in management?

Figure 17

1. Open reduction and internal fixation
2. External bone stimulator
3. 90° abduction splint
4. Arthroscopic acromioplasty
5. Fragment excision

Answer 27

PREFERRED RESPONSE: 1

DISCUSSION: The patient has a displaced scapular spine fracture that has resulted in shoulder weakness from a poor deltoid lever arm. The downward tilt may lead to subacromial impingement and rotator cuff dysfunction. Open reduction and internal fixation would best allow normal deltoid and shoulder function. Bone stimulators and abduction bracing may lead to healing but in a malunited position. Arthroscopic acromioplasty and fragment excision should be avoided.

Question 28

28: A 20-year-old man who plays minor league baseball has a symptomatic torn ulnar collateral ligament (UCL) in his pitching elbow. Nonsurgical management consisting of rest and physical therapy aimed at elbow strengthening has failed to provide relief. He has concomitant cubital tunnel symptoms that worsen while throwing. What is his best surgical option?

1. UCL repair and nighttime elbow extension splinting
2. UCL repair with ulnar nerve decompression in situ
3. Allograft UCL reconstruction with interference screws
4. Autograft UCL reconstruction with ulnar nerve transposition
5. Autograft UCL reconstruction using a docking technique

Answer 28

PREFERRED RESPONSE: 4

DISCUSSION: High-level pitchers with symptomatic UCL tears require reconstruction, with autograft being the best studied graft selection. With concomitant ulnar nerve symptoms, a simultaneous ulnar nerve transposition provides good results. Ligament “repairs” and allograft reconstructions have not shown good long-term results.

Question 29

29: A patient who underwent open reduction and internal fixation of an olecranon fracture 2 months ago now reports painless limitation of motion. Examination reveals a well-healed incision and a flexion-extension arc from 40° to 80°. The patient has been performing home exercises. Radiographs are shown in Figures 18A and 18B. What is the most appropriate treatment?

Figure 18

1. Continued observation and home therapy
2. Radiation therapy, followed by aggressive range-of-motion exercises
3. Formal physical therapy and static progressive splinting
4. Revision open reduction and internal fixation and capsular release
5. Manipulation under anesthesia

Answer 29

PREFERRED RESPONSE: 3

DISCUSSION: The radiographs do not show an articular malunion. Treatment is directed at the soft-tissue contracture and should begin with formal physical therapy and static progressive splinting. Radiation therapy is effective in the perioperative period and is indicated when ectopic bone formation is a concern.

Question 30

30: A 23-year-old patient who is a professional baseball pitcher reports shoulder pain and decreased velocity while pitching. Physical examination reveals a side-to-side internal rotation deficit of 25 degrees. The O’Brien sign is negative; Neer and Hawkins signs are negative. Rotator cuff strength is full. Radiographs are unremarkable. What is the next step in management?

1. MRI-arthrogram to evaluate the rotator cuff
2. Rotator cuff strengthening program
3. Posterior capsular stretching program
4. Shoulder arthroscopy with superior labrum anterior to posterior repair
5. Shoulder arthroscopy with posterior capsular release

Answer 30

PREFERRED RESPONSE: 3

DISCUSSION: Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients who do not respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.

Question 31

31: A 72-year-old woman who is right-handed has severe pain in the right shoulder that has failed to respond to nonsurgical management. She reports night pain and significant disability. Examination reveals 30° of active forward elevation. An AP radiograph is shown in Figure 19. Which of the following treatment options will provide the best functional improvement?

Figure 19

1. Arthroscopic débridement
2. Arthroscopic rotator cuff repair
3. Hemiarthroplasty with rotator cuff repair
4. Total shoulder arthroplasty
5. Reverse shoulder arthroplasty

Answer 31

PREFERRED RESPONSE: 5

DISCUSSION: The patient has end-stage rotator cuff tear arthropathy. The radiograph shows complete proximal humeral migration (acromiohumeral interval of 0 mm), severe glenohumeral arthritis, and acetabularization of the acromion. In addition, she has pseudoparalysis with active elevation of only 30°. Reverse shoulder arthroplasty affords her the best opportunity for pain relief and functional improvement. The other procedures have mixed results but typically are better for pain relief than they are for functional gains.

Question 32

32: A 64-year-old man who was involved in a high-speed motor vehicle accident 6 weeks ago has been in the intensive care unit with a closed head injury. Examination reveals that his range of motion for external rotation to the side is –30°. Radiographs are shown in Figures 20A and 20B. What is the most likely diagnosis?

Figure 20

1. Adhesive capsulitis
2. Calcific tendinitis
3. Anterior shoulder dislocation
4. Posterior shoulder dislocation
5. Glenohumeral osteoarthritis

Answer 32

PREFERRED RESPONSE: 4

DISCUSSION: The patient has a posterior shoulder dislocation. The AP radiograph shows overlapping of the humeral head on the glenoid. The scapular Y view shows his humeral articular surface posterior to the glenoid. The posterior shoulder dislocation is frequently missed because the patient is comfortable in the “sling” position with the arm adducted and internally rotated across the abdomen. The marked restriction in external rotation on examination raises the suspicion of a posterior dislocation, adhesive capsulitis, or glenohumeral osteoarthritis. The posterior dislocation is diagnosed based on the radiographic findings. An axillary view or CT is recommended to better evaluate the dislocation.

Question 33

33: A football lineman who sustained a traumatic injury while blocking during a game now reports that his shoulder is slipping while pass blocking. Examination reveals no apprehension in abduction and external rotation; however, he reports pain with posterior translation of the shoulder. He has full strength in external rotation, internal rotation, and supraspinatus testing. What is the pathology most likely responsible for his symptoms?

1. Anterior glenoid rim fracture tear
2. Anterior inferior labral tear
3. Posterior labral tear
4. Total capsular laxity
5. Osteochondral defect of the humeral head

Answer 33

PREFERRED RESPONSE: 3

DISCUSSION: Traumatic posterior instability is a common finding in football players, especially in the blocking positions as well as in the defensive linemen and linebackers. A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Rarely do these patients have true dislocations that require reduction; however, recurrent episodes of subluxation or pain are not uncommon. Posterior repair has been shown to be successful in the treatment of traumatic instability.

Question 34

34: A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management?

1. Immobilization in a sling and swathe
2. Open capsular shift
3. Arthroscopic capsular plication
4. Thermal capsulorrhaphy
5. Physical therapy and home exercises

Answer 34

PREFERRED RESPONSE: 5

DISCUSSION: Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury.

Question 35

35: A previously healthy 65-year-old woman has a closed fracture of the right clavicle after falling down the basement stairs. Examination reveals good capillary refill in the digits of her right hand. Radial and ulnar pulses are 1+ at the right wrist compared with 2+ on the opposite side. In the arteriogram shown in Figure 21, the arrow is pointing at which of the following arteries?

Figure 21

1. Brachiocephalic
2. Innominate
3. Subclavian
4. Axillary
5. Circumflex scapular

Answer 35

PREFERRED RESPONSE: 4

DISCUSSION: The axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.

Question 36

36: An adult patient has a closed humeral fracture that was treated nonsurgically and a concomitant radial nerve injury. Six weeks after injury, electromyography shows no evidence of recovery. Management should now consist of

1. exploration and neurolysis/repair.
2. MRI of the arm.
3. functional electrical stimulation.
4. radial nerve tendon transfers.
5. observation.

Answer 36

PREFERRED RESPONSE: 5

DISCUSSION: In patients with radial nerve injuries with closed humeral fractures, it has been reported that 85% to 95% spontaneously recover. Based on this premise, most surgeons favor expectant management of these injuries. Even if there is no evidence of recovery at 6 weeks, repeat electromyography at 12 weeks is advocated. If there are no clinical or electromyographic signs of recovery at 6 months, exploration is recommended. If the nerve is in continuity at the time of exploration, nerve action potentials are useful in helping determine the need for neurolysis, excision, and grafting, or if excision and repair is the best option.

Question 37

37: A 55-year-old man who works as a carpenter reports chronic right anterior shoulder pain and weakness. Examination reveals 90° of external rotation (with the arm at the side) compared to 45° on the left side. His lift-off examination is positive, along with a positive belly press finding. An MRI scan reveals a chronic, retracted atrophied subscapularis tendon. What is the most appropriate management of his shoulder pain and weakness?

1. Shoulder fusion
2. Arthroscopic subscapularis repair
3. Intra-articular corticosteroid injection
4. Open subscapularis repair
5. Pectoralis major transfer

Answer 37

PREFERRED RESPONSE: 5

DISCUSSION: Chronic subscapularis tendon ruptures preclude primary repair. In such instances, subcoracoid pectoralis major tendon transfers may improve function and diminish pain. The subcoracoid position of the transfer allows redirection of the pectoralis major in a direction re-creating the vector of the subscapularis tendon. Shoulder fusion is a salvage procedure, and corticosteroid injection may reduce pain but will not improve function.

Question 38

38: With the arm abducted 90° and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus?

1. Coracohumeral
2. Superior glenohumeral
3. Middle glenohumeral
4. Anterior band of the inferior glenohumeral ligament complex
5. Posterior band of the inferior glenohumeral ligament complex

Answer 38

PREFERRED RESPONSE: 4

DISCUSSION: With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45°. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated.

Question 39

39: Figure 22 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment?

Figure 22

1. Reverse shoulder arthroplasty
2. Hemiarthroplasty
3. Resurfacing of the humeral head
4. Arthroscopic débridement
5. Shoulder fusion

Answer 39

PREFERRED RESPONSE: 1

DISCUSSION: The authors of several studies conducted in Europe have reported promising results in the short- and medium-term with use of a reversed or inverted shoulder implant. The most recent investigation, a multicenter study in Europe in which 77 patients (80 shoulders) with glenohumeral osteoarthritis and a massive rupture of the rotator cuff were treated with the Delta III prosthesis, described an improvement in the mean constant score of 42 points, an increase of 65° in forward elevation, and minimal or no pain in 96% of the patients. Hemiarthroplasty, the “nonconstrained” option, has long been the standard of care for rotator cuff tear arthropathy. However, careful examination of the literature reveals that the results have not been uniform.

Question 40

40: A 55-year-old man sustained an elbow dislocation during a fall. Postreduction radiographs are shown in Figures 23A and 23B. What is the best course of management?

Figure 23

1. Closed reduction and casting for 4 weeks
2. Closed reduction and bracing with immediate range of motion
3. Open reduction, lateral collateral ligament repair, and open reduction and internal fixation or metallic replacement of the radial head
4. Open reduction, radial head Silastic arthroplasty, and lateral collateral ligament repair
5. Open reduction, lateral collateral ligament repair, and radial head excision

Answer 40

PREFERRED RESPONSE: 3

DISCUSSION: The radiographs show an elbow dislocation associated with a comminuted radial head fracture. In the setting of comminution and instability, factures of the radial head are best managed with an arthroplasty rather than open reduction and internal fixation. Resection of the radial head will worsen the instability and is not recommended. Silastic radial head replacements are contraindicated.

Question 41

41: Osteochondritis dissecans of the capitellum is a source of elbow pain and most commonly occurs in what patient population?

1. Swimmers and divers
2. Football lineman
3. Rugby players
4. Gymnasts and throwing athletes
5. Cyclists

Answer 41

PREFERRED RESPONSE: 4

DISCUSSION: The etiology of osteochondritis dissecans of the capitellum is somewhat unclear. However, trauma has been implicated in this disease process. Gymnasts who load their upper extremities during tumbling, and throwing athletes with repetitive trauma during the throwing motion are common patient subgroups in which osteochondritis dissecans of the elbow is seen. This often occurs in the adolescent age population.

Question 42

42: What are the two terminal branches of the lateral cord of the brachial plexus?

1. Musculocutaneous and median
2. Musculocutaneous and axillary
3. Median and axillary
4. Ulnar and median
5. Ulnar and medial pectoral

Answer 42

PREFERRED RESPONSE: 1

DISCUSSION: The lateral cord divides into the musculocutaneous and median nerves. The posterior cord terminates into the axillary and radial nerves. The medial cord divides into the ulnar and median nerves.

Question 43

43: A 32-year-old patient reports progressively increasing pain and stiffness after undergoing arthroscopic shoulder stabilization 1 year ago. The stabilization procedure was a Bankart repair with anchor fixation and supplemented with the heat probe. Radiographs are shown in Figures 24A and 24B. What is the most likely diagnosis?

Figure 24

1. Subscapularis failure
2. Frozen shoulder
3. Recurrent instability
4. Loose body
5. Chondrolysis

Answer 43

PREFERRED RESPONSE: 5

DISCUSSION: Postshoulder stabilization chondrolysis is a rare but devastating complication. It has been implicated with the use of the radiofrequency heat probe in some patients.

Question 44

44: Acute redislocation of the glenohumeral joint is a complication that occurs following a first-time dislocation. This is most often seen with

1. subglenoid dislocation.
2. subcoracoid dislocation.
3. fracture of the greater tuberosity.
4. fracture of the greater tuberosity and glenoid rim.
5. pediatric patients.

Answer 44

PREFERRED RESPONSE: 4

DISCUSSION: Redislocation following acute dislocation occurs in approximately 3% of patients. This redislocation tends to occur in middle-aged and elderly patients. A higher incidence of redislocation occurs when there are accompanying fractures of the glenoid rim and the greater tuberosity.

Question 45

45: A 51-year-old woman is seen for evaluation of chronic supraspinatus and infraspinatus tendon tears. Three years ago, in an attempted repair the surgeon was unable to repair the supraspinatus and infraspinatus tendon tears. Currently, the patient has a marked amount of pain, reduced range of motion, and weakness. Examination reveals anterosuperior escape. Radiographs show no signs of arthritic changes. You are considering a latissimus dorsi tendon transfer. During the discussion, you mention that

1. she can expect to have good pain relief following surgery.
2. active forward elevation and external rotation are reliably obtained postoperatively.
3. with her current anterosuperior escape, she is likely to have a poor surgical result.
4. postoperatively, significant muscular atrophy in the latissimus dorsi commonly occurs.
5. no advancement in glenohumeral arthritic changes should occur following surgery.

Answer 45

PREFERRED RESPONSE: 3

DISCUSSION: Latissimus dorsi tendon transfer is considered a surgical option for treatment in patients with chronic supraspinatus and infraspinatus tendon tears. Preoperative subscapularis function is necessary for good clinical results. Additionally, men with active elevation to shoulder level and active external rotation to 20° have predictably good results. Women with active shoulder elevation limited to below chest level have poor results from this procedure and should not be considered candidates. Postoperatively they lack pain control, active elevation, and active external rotation. Muscular atrophy in the latissimus dorsi does not occur, and glenohumeral arthritic changes frequently develop postoperatively.

Question 46

46: A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 25A and 25B, respectively. Which of the following best explains the 8-week postinjury clinical findings seen in Figure 25C?

Figure 25

1. Axillary nerve palsy
2. Spinal accessory nerve palsy
3. Deltoid avulsion
4. Rotator cuff tear
5. Unreduced posterior glenohumeral dislocation

Answer 46

PREFERRED RESPONSE: 4

DISCUSSION: Patients older than 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.

Question 47

47: Which of the following has been associated with a decreased rate of glenoid component radiolucent lines?

1. A curve-backed pegged cemented polyethylene glenoid component
2. A curve-backed keeled cemented polyethylene glenoid component design
3. A flat-backed keeled cemented polyethylene glenoid component
4. An oversized pegged cemented glenoid component
5. A superiorly placed pegged glenoid component

Answer 47

PREFERRED RESPONSE: 1

DISCUSSION: According to a recent study, cemented pegged glenoid components had fewer radiolucent lines initially and at 2-year follow-up when compared to a cemented keeled design. Curve-backed designs have also shown fewer radiolucent lines when compared to flat-backed designs. Oversizing the glenoid can lead to impaired rotator cuff function and decreased range of motion. An off-centered glenoid can lead to early loosening.

Question 48

48: Figure 26 shows the radiograph of a 42-year-old man who is a construction worker and who has pain and limited motion in his dominant elbow. Management consisting of NSAIDs and cortisone has failed to provide relief. What is the next most appropriate step in treatment?

1. Unlinked elbow arthroplasty
2. Linked elbow arthroplasty
3. Interposition arthroplasty
4. Arthroscopic or open débridement
5. Radial head excision

Answer 48

PREFERRED RESPONSE: 4

DISCUSSION: The patient has symptomatic primary osteoarthritis of the elbow with multiple loose bodies. Given his age and occupation, an elbow arthroplasty is not an option. Arthroscopic débridement and removal of loose bodies has been shown to be effective for osteoarthritis of the elbow.

Question 49

49: A 61-year-old woman with a long-standing history of rheumatoid arthritis reports progressive elbow pain for the past 12 months. She denies any recent trauma to the elbow; however, she notes increasing pain and decreased joint motion that are now compromising her function. Radiographs are shown in Figures 27A and 27B. What is the most appropriate treatment at this time?
1. Physical therapy for restoration of motion
2. Elbow arthroscopy, removal of loose bodies, excision of osteophytes, and capsular release (osteocapsulectomy)
3. Elbow arthroscopy and synovectomy
4. Constrained total elbow arthroplasty
5. Semiconstrained total elbow arthroplasty

Answer 49

PREFERRED RESPONSE: 5

DISCUSSION: The patient has end-stage arthritis of the elbow with advanced joint destruction. At this point, nonsurgical management is unlikely to provide much relief of symptoms. Arthroscopic procedures can provide relief, but it is likely to be incomplete and unpredictable. The most reliable surgical option is total elbow arthroplasty. Currently, semiconstrained components are generally preferred because constrained components have been associated with a high rate of early prosthetic loosening.

Question 50

50: What neurovascular structure is at greatest risk when creating a proximal anterolateral elbow arthroscopy portal?

1. Lateral antebrachial cutaneous nerve
2. Radial nerve
3. Posterior interosseous nerve
4. Median nerve
5. Brachial artery

Answer 50

PREFERRED RESPONSE: 2

DISCUSSION: The radial nerve is 4 to 7 mm from the anterolateral portal, which is placed 1 cm anterior and 3 cm proximal to the lateral epicondyle. The posterior interosseous nerve can lie 1 to 14 mm from the portal site.