2015 Shoulder and Elbow

Question 1

Question 12 A 72-year-old man with cu tear arthropathy is scheduled for a reverse total shoulder arthroplasty. Which examination nding most strongly indicates the need for a concomitant latissimus dorsi transfer? 1. Pseudoparalysis 2. Anterosuperior escape 3. Positive drop arm sign 4. Positive Hornblower’s test result 5. Passive external rotation to 0 degrees

Answer 1

4. Positive Hornblower’s test result

Question 2

Question 26 An 82-year-old right-hand-dominant man has progressive pain in his left shoulder and loss of overhead function. He underwent a reverse total shoulder arthroplasty for rotator cu –de cient arthritis 30 months ago. Radiographs taken at the current visit are shown in Figures 26a through 26c, and select images from a CT scan are shown in Figures 26d through 26f. Infection workup ndings are negative. Examination reveals 70 degrees of forward elevation with pain with 20 degrees of external rotation. Axillary nerve function is intact. De nitive treatment should consist of 1. retention of the glenoid component with a reverse humeral stem revision. 2. removal of both glenoid and humeral components (“resection arthroplasty”). 3. removal of the glenoid component with humeral stem revision to hemiarthroplasty. 4. in situ placement of the larger glenosphere component with revision reverse humeral stem. 5. revision glenoid baseplate with superiorly placed bone graft with revision reverse humeral stem.

Answer 2

Answer 5. Revision glenoid baseplate with superiorly placed bone graft with revision reverse humeral stem

Question 3

Question 34 Figures 34a and 34b are the radiographs of a 22-year-old woman who sustained an elbow injury after a fall. In the emergency department, her skin is noted to be intact. There is no tenderness over the medial elbow or the distal radioulnar joint. What is the best treatment option? 1. Radial head arthroplasty 2. Long-arm cast for 3 weeks 3. Excision of the fracture fragments 4. Open reduction and internal xation (ORIF) 5. Early motion with a functional brace

Answer 3

4. Open reduction and internal xation (ORIF)

Question 4

Question 41 Video 41 (scan to view) Video 41 is viewed from the posterior portal during shoulder arthroscopy. The instrument is introduced through the anterior portal. Based on these video ndings, which examination maneuver would most likely elicit an abnormality of the indicated structure? 1. Speed test 2. O’Brien test 3. Belly press test 4. Hornblower’s test 5. Cross-body adduction

Answer 4

3. Belly press test

Question 5

Question 53 Figures 53a through 53e are the radiographs and CT scans of a 78-year-old man who is seen in the emergency department with persistent left shoulder pain 3 weeks after a fall. He had full function of his left shoulder prior to the fall. He lives alone, and his medical history includes diabetes and hypertension. Examination reveals pain with any attempted shoulder motion. He is neurovascularly intact in the left upper extremity. What is the best next step? 1. Hemiarthroplasty with biceps tenodesis 2. Unconstrained total shoulder arthroplasty 3. Reverse shoulder arthroplasty with tuberosity repair 4. Percutaneous pinning 5. Open reduction and internal xation with locked plating

Answer 5

3. Reverse shoulder arthroplasty with tuberosity repair

Question 6

Question 66 A 24-year-old man underwent closed reduction for an elbow dislocation 3 months ago. Now, he continues to experience elbow discomfort and feelings of instability. When his forearm is supinated and a valgus force is applied, his pain is recreated as the elbow is brought from exion to extension. He also has di culty getting out of a chair with his forearms supinated. He has completed a course of physical therapy without experiencing improvement. Which soft-tissue structure shown in Figure 66 requires reconstruction? 1. A 2. B 3. C 4. D 5. E

Answer 6

Answer 5. E

Question 7

Question 85 Figure 85a Figure 85b Figures 85a and 85b are the radiographs of a 32-year-old man who had an arthroscopic superior labral repair 5 months ago. Three-suture anchors were used to complete the repair, and all were placed through an anterior rotator interval portal. He has severe posterior shoulder pain with limited overhead elevation and “weakness.” Examination reveals active forward elevation limited to 120 degrees by pain, but he has full passive range of motion, and the belly press test nding is within normal limits. The patient has weakness of external rotation by the side. What is the most likely cause of his symptoms? 1. Rotator cu tear 2. Adhesive capsulitis 3. Axillary nerve injury 4. Suprascapular nerve injury 5. Posttraumatic arthritis

Answer 7

4. Suprascapular nerve injury

Question 8

Question 89 Figure 89 is the clinical photograph of a 42-year-old woman who has had gradual-onset atraumatic elbow pain for 2 months. She has pain with daily activities and especially when her elbow is extended. Her elbow is tender to palpation in the area shown in the photograph, but elbow radiograph ndings are normal. What is the best next step? 1. Elbow immobilization 2. Cortisone injection 3. Ligament reconstruction 4. Tendon repair 5. Tendon gliding exercises

Answer 8

5. Tendon gliding exercises

Question 9

Question 101 A 52-year-old otherwise healthy woman elects to undergo an arthroscopic right shoulder rotator cu repair with decompression in the beach chair position. She receives an uncomplicated interscalene regional block using nerve stimulation localization that is supplemented with laryngeal mask airway. Twenty minutes into surgery, the anesthesiologist informs you that the patient has become hypotensive (mean arterial pressure 40-60 mm Hg) and tachycardic despite repeated use of vasopressors. Decreased breath sounds are noted in the upper lung elds on the right. In addition to halting the surgery, the most appropriate next step is a 1. CT angiogram. 2. venous duplex ultrasound. 3. portable chest radiograph. 4. critical care consultation. 5. transesophageal echocardiogram.

Answer 9

3. portable chest radiograph.

Question 10

Question 116 During arthroscopic evaluation of a 44-year-old mechanic’s shoulder, the pathology noted in Figure 116 is seen. What is the best treatment option? 1. Labral repair 2. Biceps tenodesis 3. Rotator cu repair 4. Rotator cu debridement 5. Subacromial decompression

Answer 10

3. Rotator cuff repair

Question 11

Question 131 The examination nding demonstrated in Video 131 is consistent with a tear of which structure? 1. Infraspinatus 2. Subscapularis 3. Pectoralis major 4. Superior labrum 5. Long head of the biceps

Answer 11

1. Infraspinatus

Question 12

Question 149 Figures 149a through 149e are the radiographs and MR images of a 78-year-old woman who has pain in her left shoulder. The pain is worse at night and seems to “come and go”. She has functional restrictions for simple activities of daily living. Her treatment to date has consisted of occasional acetaminophen, which temporarily eases the pain. Examination reveals 140 degrees of overhead elevation and 30 degrees of external rotation with a 10-degree external rotation lag. There is moderate pain at the extremes of motion and weakness to resistance. What is the best next step? 1. Injection of corticosteroids followed by physical therapy 2. Trial of immobilization with referral to pain management 3. Reverse total shoulder arthroplasty with latissimus dorsi transfer 4. Arthroscopic capsular release with manipulation under anesthesia 5. Arthroscopic partial rotator cu repair with concomitant interpositional allograft

Answer 12

1. Injection of corticosteroids followed by physical therapy

Question 13

Question 167 Figure 167 is an intraoperative view from the accessory anterolateral portal of a 31-year-old man who underwent arthroscopic surgery on his right shoulder. The surgery was performed in the lateral decubitus position. During the rst 3 weeks after surgery, the repair will be protected by avoiding repetitive passive 1. abduction to 90 degrees in the scapular plane. 2. internal rotation with the shoulder adducted. 3. adduction with the shoulder exed at shoulder level. 4. external rotation with the shoulder adducted. 5. external rotation to 45 degrees with the shoulder abducted.

Answer 13

3. adduction with the shoulder exed at shoulder level.

Question 14

Figures 178a and 178b are the plain radiographs of a 36-year-old woman who has right elbow sti ness. She sustained an injury to her right elbow 7 months ago. Injury radiographs are shown in Figures 178c and 178d. She underwent a protracted course of occupational therapy that included use of a static splint. Examination reveals elbow range of motion from 15 degrees of extension and exion of 90 degrees. There is no pain in the midrange of her motion arc, but there is pain at the extremes. During an open release of her elbow to restore elbow exion, release of which structure is necessary? 1. Posterior oblique band of the medial collateral ligament 2. Triceps tendon insertion 3. Lateral ulnar collateral ligament 4. Anterior capsule 5. Anterior band of the medial collateral ligament

Answer 14

1. Posterior oblique band of the medial collateral ligament

Question 15

Figures 185a through 185d are the radiographs and MR image of a 55-year-old man who had arthroscopic repair of an acute, traumatic, massive 2-tendon rotator cu tear involving the supraspinatus and infraspinatus 4 months ago. He did well initially with formal physical therapy, but during the last month has noted increasing shoulder pain and decreasing range of motion. Examination reveals he has active forward elevation of about 100 degrees. He has well-preserved passive range of motion, weakness of external rotation by his side, and positive impingement signs. Hornblower’s and belly press test ndings are normal, and an infection workup is negative. What is the best next step? 1. Revision rotator cu repair 2. Continued physical therapy 3. Hemiarthroplasty 4. Latissimus dorsi transfer 5. Reverse total shoulder arthroplasty

Answer 15

1. Revision rotator cuff repair

Question 16

Question 202 An active 65-year-old woman slipped on ice, fell down 2 steps, and injured her right shoulder. Prior to the injury her shoulder “was normal,” and she denies any history of shoulder pain or injury. She sustained a distal radius fracture 1 year ago after sustaining a simple mechanical fall, which was treated with cast immobilization. Examination reveals that her skin is intact and the deltoid contracts well. Radiographs demonstrate a displaced 4-part proximal humeral fracture with a fracture through the anatomic neck that has a 2-mm posteromedial metaphyseal extension. The head fragment is in 90 degrees of varus. What is the best treatment option? 1. Hemiarthroplasty 2. Percutaneous pinning 3. Unconstrained total shoulder arthroplasty 4. Open reduction and internal xation (ORIF) 5. Sling immobilization and physical therapy

Answer 16

1. Hemiarthroplasty

Question 17

Question 213 Which diagnosis most favorably in uences implant survivorship among patients who undergo total elbow arthroplasty? 1. Rheumatoid arthritis 2. Posttraumatic arthritis 3. Primary osteoarthritis 4. Distal humeral nonunion 5. Acute distal humeral fracture

Answer 17

1. Rheumatoid arthritis

Question 18

Question 215 Under the Physician Payments Sunshine Act, what is the annual monetary value limit for items given to physicians by orthopaedic implant companies? (These companies must report this type of activity to the Centers for Medicare and Medicaid Services.) 1. $10 2. $25 3. $50 4. $100 5. $200

Answer 18

1. $10

Question 19

Question 221 A 55-year-old woman has had pain in her left shoulder for 3 months with no preceding trauma. Examination reveals substantial reduction in her left shoulder motion, both actively and passively. MR imaging reveals space reduction in the axillary recess. Which comorbidity is associated with a much worse prognosis and poorer outcomes of both nonsurgical and surgical treatment? 1. Diabetes mellitus 2. Crohn’s disease 3. Renal disease 4. Congestive obstructive pulmonary disease 5. Breast cancer

Answer 19

1. Diabetes mellitus

Question 20

Question 234 A 55-year-old woman had successful reduction of an anterior shoulder dislocation 2 weeks ago. Examination reveals she is unable to actively elevate her arm. Her passive range of motion is equal to uninjured shoulder motion. What is the function of the structure that is most likely injured? 1. Scapular protraction and inferior rotation 2. Scapular elevation and superior rotation 3. Flexion and supination of the forearm 4. Extension of the humerus 5. Compression of the humeral head against the glenoid

Answer 20

5. Compression of the humeral head against the glenoid

Question 21

Question 242 A 45-year-old man has a painful shoulder after a fall and di culty elevating his arm above waist level. Shoulder radiograph ndings are normal. His belly press sign is positive, but there is no external rotation lag. His deltoid contracts strongly. Which other examination nding would most likely be positive? 1. Neer test 2. Lift-o test 3. Apprehension test 4. Hornblower’s test 5. Increased passive internal rotation

Answer 21

2. Lift-of test

Question 22

What is the most likely risk factor for recurrent shoulder instability after arthroscopic anterior shoulder stabilization? 1. Female gender 2. Athletic throwing activity 3. Age older than 20 years 4. Unidirectional instability 5. Attritional glenoid bone loss

Answer 22

5. Attritional glenoid bone loss

Question 23

When performing a primary anatomic total shoulder arthroplasty for glenohumeral osteoarthritis, selecting an appropriately sized humeral head component is important to avoid either overstu ng the joint or leaving it too lax. Which relationship between thickness of the humeral head and radius of the curvature most closely replicates normal anatomy? 1. Approximately 30% radius of curvature 2. Approximately 40% radius of curvature 3. Approximately 50% radius of curvature 4. Approximately 70% radius of curvature 5. Approximately 90% radius of curvature

Answer 23

4. Approximately 70% radius of curvature