Shoulder & Elbow 2013 Flashcards
- A 7-month-old infant is evaluated after right brachial plexus birth palsy. Examination reveals scapular winging and no active elbow flexion. Chest radiographs reveal an elevated right hemidiaphragm. The best next step should be
- free functional gracilis muscle transfer.
- observation and re-examination in 3 months.
- therapy to maintain shoulder internal rotation and elevation.
- direct brachial plexus repair with sural nerve grafting if necessary.
- musculocutaneous neurotization from ulnar/median donor fascicles.
- musculocutaneous neurotization from ulnar/median donor fascicles.
RECOMMENDED READINGS
Sedain G, Sharma MS, Sharma BS, Mahapatra AK. Outcome after delayed Oberlin transfer in brachial plexus injury. Neurosurgery. 2011 Oct;69(4):822-7; discussion 827-8. PubMed PMID: 21670719.
- A patient is unable to actively externally rotate the shoulder when the arm is placed into 90 degrees of abduction and neutral rotation. This finding is most consistent with a tear of the
- biceps tendon.
- isolated subscapularis.
- isolated supraspinatus.
- superior and anterior labrum.
- infraspinatus and teres minor.
- infraspinatus and teres minor.
RECOMMENDED READINGS
Walch G, Boulahia A, Calderone S, Robinson AH. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. J Bone Joint Surg Br. 1998 Jul;80(4):624-8. PubMed PMID: 9699824.
Hertel R, Ballmer FT, Lombert SM, Gerber C. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg. 1996 Jul-Aug;5(4):307-13. PubMed PMID: 8872929
- The innervation to the upper portion of the structure noted in Figure 36 arises directly from what aspect of
the brachial plexus?
- Medial cord
- Lateral cord
- Posterior cord
- Upper trunk
- C5-C7 roots
- Posterior cord
RECOMMENDED READINGS
Lyons RP, Green A. Subscapularis tendon tears. J Am Acad Orthop Surg. 2005 Sep;13(5):353-63. Review. PubMed PMID: 16148361.
Kasper JC, Itamura JM, Tibone JE, Levin SL, Stevanovic MV. Human cadaveric study of subscapularis muscle innervation and guidelines to prevent denervation. J Shoulder Elbow Surg. 2008 Jul- Aug;17(4):659-62. Epub 2008 May 12. PubMed PMID: 18472282.
- Figures 41a through 41c are the radiograph and MRI scans of a 76-year-old woman who has intractable left shoulder pain. She was given 2 cortisone injections and oral pain medication without experiencing lasting relief. Examination reveals 60 degrees of active forward elevation (120 degrees passively), 30 degrees of external rotation lag, and a positive Hornblower sign. Pain relief and improved functionality will most likely be achieved with
- continued nonsurgical treatment.
- hemiarthroplasty with partial rotator cuff repair.
- reverse total shoulder arthroplasty with latissimus dorsi transfer.
- rotator cuff repair without acromioplasty, preserving the coracoacromial ligament.
- limited-goals debridement of the rotator cuff and glenohumeral joint without rotator cuff repair.
- reverse total shoulder arthroplasty with latissimus dorsi transfer.
RECOMMENDED READINGS
Gerber C, Pennington SD, Lingenfelter EJ, Sukthankar A. Reverse Delta1III total shoulder replacement combined with latissimus dorsi transfer. A preliminary report. J Bone Joint Surg Am. 2007 May;89(5):940- 7. PubMed PMID: 17473129.
- Figure 53 is the CT scan of a 38-year-old woman who has pain with movement of her right arm and shortness of breath after an assault. She is evaluated in the emergency department and her shoulder radiograph findings are normal. The physician should recomend
- a chest tube.
- a sling and outpatient follow up.
- closed reduction.
- incision and drainage.
- an MRI scan of the shoulder.
- closed reduction.
RECOMMENDED READINGS
Groh GI, Wirth MA. Management of traumatic sternoclavicular joint injuries. J Am Acad Orthop Surg. 2011 Jan;19(1):1-7. Review. PubMed PMID: 21205762.
Glass ER, Thompson JD, Cole PA, Gause TM II, Altman GT. Treatment of sternoclavicular joint dislocations: a systematic review of 251 dislocations in 24 case series. J Trauma. 2011 May;70(5):1294-8. Review. PubMed PMID: 21610444.
- A 40-year-old man with a history of a nondisplaced radial head fracture was initially treated with cast immobilization for 3 weeks followed by a course of physical therapy. Six months later, he has limited elbow range of motion. Examination reveals he lacks 30 degrees of extension and has flexion to only 90 degrees. To restore flexion, which structure must be released?
- Triceps tendon
- Anterior capsule
- Ulnar part of the lateral collateral ligament
- Anterior bundle of the medial collateral ligament
- Posteromedial bundle of the medial collateral ligament
- Posteromedial bundle of the medial collateral ligament
RECOMMENDED READINGS
Wada T, Ishii S, Usui M, Miyano S. The medial approach for operative release of post-traumatic contracture of the elbow. J Bone Joint Surg Br. 2000 Jan;82(1):68-73. PubMed PMID: 10697317.
Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983 Sep-Oct;11(5):315-9. PubMed PMID: 6638246.
Regan WD, Korinek SL, Morrey BF, An KN. Biomechanical study of ligaments around the elbow joint. Clin Orthop Relat Res. 1991 Oct;(271):170-9. PubMed PMID: 1914292.
- Figures 89a and 89b are the radiographs of an 18-year-old woman who has had elbow pain after falling on an outstretched hand. She is evaluated 5 days after the injury. Examination reveals the wrist is normal and her elbow has a limited arc of motion of 30 to 90 degrees of flexion/extension and 20 to 20 degrees of pronation and supination, with tenderness isolated to the lateral side of the elbow. What is the most appropriate treatment option?
- Cast for 2 weeks
- Initiate mobilization
- Radial head excision
- Radial head replacement
- Open reduction and internal fixation
- Initiate mobilization
RECOMMENDED READINGS
Paschos NK, Mitsionis GI, Vasiliadis HS, Georgoulis AD. Comparison of early mobilization protocols in radial head fractures. A prospective randomized controlled study. The effect of fracture characteristics on outcome. J Orthop Trauma. 2012 Jul 11. PubMed PMID: 22576643.
Tejwani NC, Mehta H. Fractures of the radial head and neck: current concepts in management. J Am Acad Orthop Surg. 2007 Jul;15(7):380-7. Review. PubMed PMID: 17602027
- Figures 101a and 101b are the radiographs of a 50-year-old who has difficulty with overahd work following a superior labrum anterior to posterior (SLAP) repair 12 months ago. He had no early postsurgical complications and was in therapy for 9 months after surgery. Examination of the shoulder reveals 110 and 45 degrees of active elevation and active external rotation with his arm at his side, respectively. His passive range of motion is symmetric to his active range of motion. What is the best treatment option?
- Arthroplasty
- Acromioplasty
- Continue therapy
- Revision SLAP repair
- Arthroscopic capsular release
- Arthroscopic capsular release
RECOMMENDED READINGS
Katz LM, Hsu S, Miller SL, Richmond JC, Khetia E, Kohli N, Curtis AS. Poor outcomes after SLAP repair: descriptive analysis and prognosis. Arthroscopy. 2009 Aug;25(8):849-55. Erratum in: Arthroscopy. 2009 Nov;25(11):1361. Ketia, Eric [corrected to Khetia, Eric]. PubMed PMID: 19664504.
Holloway GB, Schenk T, Williams GR, Ramsey ML, Iannotti JP. Arthroscopic capsular release for the treatment of refractory postoperative or post-fracture shoulder stiffness. J Bone Joint Surg Am. 2001 Nov;83-A(11):1682-7. PubMed PMID: 11701791.
- A 45-year-old woman has elbow stiffness 3 months after treatment of an elbow dislocation consisting of self-directed exercises. Examination reveals that her elbow is stable. Range-of-motion testing reveals a 35-degree flexion contracture, full flexion, and 80 degrees of both pronation and supination. What is the best next treatment step?
- Hinged elbow brace
- Open contracture release
- Arthroscopic debridement and release
- Supervised therapy with splinting
- Examination under anesthesia and manipulation
- Supervised therapy with splinting
RECOMMENDED READINGS
Doornberg JN, Ring D, Jupiter JB. Static progressive splinting for posttraumatic elbow stiffness. J Orthop Trauma. 2006 Jul;20(6):400-4. PubMed PMID: 16825965.
Lindenhovius AL, Doornberg JN, Brouwer KM, Jupiter JB, Mudgal CS, Ring D. A prospective randomized controlled trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness. J Bone Joint Surg Am. 2012 Apr 18;94(8):694-700. PubMed PMID: 22517385.
- A 22-year-old collegiate baseball pitcher has had posterior shoulder pain with decreased throwing velocity and accuracy over the past several months. Examination of the abducted shoulder in the supine position reveals 120 degrees of external rotation, 40 degrees of internal rotation on the throwing side, 100 degrees of external rotation, and 70 degrees of internal rotation on the nonthrowing side. The remainder of the clinical examination is unremarkable. An MRI scan shows a small partial articular-sided infraspinatus tear. Initial treatment should consist of
- arthroscopic rotator cuff repair.
- arthroscopic anterior capsulorrhaphy.
- arthroscopic selective posterior capsular release.
- selective posterior rotator cuff strengthening.
- posterior capsular stretching with scapular stabilization.
- posterior capsular stretching with scapular stabilization.
RECOMMENDED READINGS
Heyworth BE, Williams RJ 3rd. Internal impingement of the shoulder. Am J Sports Med. 2009 May;37(5):1024-37. Epub 2008 Dec 4. PubMed PMID: 19059895.
Tyler TF, Nicholas SJ, Lee SJ, Mullaney M, McHugh MP. Correction of posterior shoulder tightness is associated with symptom resolution in patients with internal impingement. Am J Sports Med. 2010 Jan;38(1):114-9. Epub 2009 Dec 4. PubMed PMID: 19966099.
- Which factor is associated with an increased risk for the complication shown in Figure 166 following reverse total shoulder arthroplasty?
- Failed previous arthroplasty
- Anterosuperior approach
- Complete repair of the subscapularis
- Inferior inclination of the glenosphere baseplate
- Humeral stem placement in 10 degrees’ retroversion
- Failed previous arthroplasty
RECOMMENDED READINGS
Trappey GJ 4th, O’Connor DP, Edwards TB. What are the instability and infection rates after reverse shoulder arthroplasty? Clin Orthop Relat Res. 2011 Sep;469(9):2505-11. PubMed PMID: 21104354.
Favre P, Sussmann PS, Gerber C. The effect of component positioning on intrinsic stability of the reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2010 Jun;19(4):550-6. Epub 2010 Mar 23. PubMed PMID: 20335055.
- Figures 174a through 174d are the radiographs and selected MRI sequences of a 35-year-old man with a history of alcoholism. He has right shoulder pain that has been progressively worsening over the past several years. Examination reveals active forward elevation of 150 degrees, external rotation of 50 degrees with his arm by his side, and internal rotation to the T-12 vertebral level. He had a cortisone injection, but experienced no relief. What is the best treatment option?
- Hemiarthroplasty
- Core decompression
- Arthroscopy and capsular release
- Intra-articular hyaluronate injections
- Physical therapy and nonsteroidal anti-inflamatory medication
- Core decompression
RECOMMENDED READINGS
LaPorte DM, Mont MA, Mohan V, Pierre-Jacques H, Jones LC, Hungerford DS. Osteonecrosis of the humeral head treated by core decompression. Clin Orthop Relat Res. 1998 Oct;(355):254-60. PubMed PMID: 9917611.
- Figures 194a and 194b are the radiographs of a 59-year-old right-hand-dominant woman who has pain in her dominant shoulder following a fall 1 day ago. Examination reveals tenderness over the proximal humerus and ecchymosis about the midarm. She is distally neurovascularly intact. What is the most appropriate treatment option?
- Hemiarthroplasty
- Reverse total shoulder arthroplasty
- Open reduction and internal fixation
- Sling immobilization for 6 weeks followed by passive range of motion
- Symptomatic sling use followed by early active range-of-motion exercises
- Open reduction and internal fixation
RECOMMENDED READINGS
Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am. 2009 Jul;91(7):1689-97. PubMed PMID: 19571092.
Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg. 2007 Jan;15(1):12-26. Review. PubMed PMID: 17213379
- A woman who underwent an unconstrained total shoulder arthroplasty fell 6 weeks after surgery. She now has a documented anterior shoulder dislocation and undergoes closed reduction. All 3 heads of the deltoid contract, passive elevation is limited by pain to 30 degrees, and her internal rotation is to the side and her passive external rotation is 80 degrees. At the 2-week postsurgical visit, her elevation is 60 degrees, external rotation is 10 degrees, and internal rotation is to the side. Radiographs reveal no loosening, fractures, or dislocations. Further evaluation should consist of
- an indium scan.
- C-reactive protein.
- electromyography.
- aspiration of the shoulder.
- ultrasound of the shoulder.
- ultrasound of the shoulder.
RECOMMENDED READINGS
Miller BS, Joseph TA, Noonan TJ, Horan MP, Hawkins RJ. Rupture of the subscapularis tendon after shoulder arthroplasty: diagnosis, treatment, and outcome. J Shoulder Elbow Surg. 2005 Sep- Oct;14(5):492-6. PubMed PMID: 16194740.
Westhoff B, Wild A, Werner A, Schneider T, Kahl V, Krauspe R. The value of ultrasound after shoulder arthroplasty. Skeletal Radiol. 2002 Dec;31(12):695- 701. Epub 2002 Oct 25. PubMed PMID: 12483430.
- A fall onto an outstretched arm places an axial load on the wrist and forearm. What other combination of forces at the elbow leads to a terrible triad of radial head fracture, coronoid fracture, and lateral collateral ligament injury?
- Forearm supination and varus thrust
- Forearm pronation and varus thrust
- Forearm supination and valgus thrust
- Forearm pronation and valgus thrust
- No rotational forces, only axial loading
- Forearm supination and valgus thrust
RECOMMENDED READINGS
O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991 Mar;73(3):440-6. PubMed PMID: 2002081.
O’Driscoll SW, Morrey BF, Korinek S, An KN. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res. 1992 Jul;(280):186-97. PubMed PMID: 1611741.
- Figures 255a through 255c are the radiographs and MRI scan of a 73-year-old man who has severe pain and functional disability of the right shoulder despite receiving several cortisone injections and physical therapy. Examination reveals restricted shoulder range of motion in forward elevation and both internal and external rotation. There is moderately diminished strength and pain with resisted forward elevation. What is the best treatment option?
- Reverse total shoulder arthroplasty
- Unconstrained total shoulder arthroplasty
- Hemiarthroplasty with biologic glenoid resurfacing
- Arthroscopic subacromial decompression
- Arthroscopic capsular release with manipulation under anesthesia
- Unconstrained total shoulder arthroplasty
RECOMMENDED READINGS
Radnay CS, Setter KJ, Chambers L, Levine WN, Bigliani LU, Ahmad CS. Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review. J Shoulder Elbow Surg. 2007 Jul-Aug;16(4):396-402. Epub 2007 Jun 20. Review. PubMed PMID: 17582789.
Izquierdo R, Voloshin I, Edwards S, Freehill MQ, Stanwood W, Wiater JM, Watters WC 3rd, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Anderson S, Boyer K, Raymond L, Sluka P; American Academy of Orthopedic Surgeons. Treatment of glenohumeral osteoarthritis. J Am Acad Orthop Surg. 2010 Jun;18(6):375-82. PubMedPMID: 20511443.
- Figure 266 is the anteroposterior radiograph of a 6-year-old boy who sustained an injury to his left elbow after a fall. Examination of his elbow reveals intact skin. There is tenderness over the radial head, but he is nontender elsewhere, including his wrist. His distal neurovascular examination is unremarkable. A closed reduction was attempted; however, there was no improvement in position. What is the best next treatment option?
- Radial head arthroplasty
- Long-arm cast for 4 weeks
- Open reduction and plate fixation
- Immediate range of motion and physical therapy
- Percutaneous Kirschner wire-assisted reduction and casting
- Percutaneous Kirschner wire-assisted reduction and casting
RECOMMENDED READINGS
Ursei M, Sales de Gauzy J, Knorr J, Abid A, Darodes P, Cahuzac JP. Surgical treatment of radial neck fractures in children by intramedullary pinning. Acta Orthop Belg. 2006 Apr;72(2):131-7. PubMed PMID: 16768254.
Eilert RE, Erickson MA. Fractures of the proximal radius and ulna. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:443-490.
