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5. OITE > Shoulder & Elbow 2014 > Flashcards

Shoulder & Elbow 2014 Flashcards

1
Q

Question 12

Figures 12a and 12b are the radiographs of a 75-year-old left-hand-dominant woman with rheumatoid arthritis who is experiencing increasing elbow pain refractory to 6 months of nonsurgical management. Optimal treatment should consist of

  1. cast immobilization.
  2. elbow resection arthroplasty.
  3. linked total elbow arthroplasty.
  4. unlinked total elbow arthroplasty.
  5. open reduction and internal fixation of the nonunion
A
  1. linked total elbow arthroplasty.

RECOMMENDED READINGS

Mansat P, Bonnevialle N, Rongières M, Mansat M, Bonnevialle P.Experience with the Coonrad-Morrey total elbow arthroplasty: 78 consecutive total elbow arthroplasties reviewed with an average 5 years of follow-up. J Shoulder Elbow Surg. 2013 Nov;22(11):1461-8. PMID: 24138820.

Hildebrand KA, Patterson SD, Regan WD, MacDermid JC, King GJ.Functional outcome of semiconstrained total elbow arthroplasty. J Bone Joint Surg Am. 2000 Oct;82-A(10):1379-86. PMID: 11057465.

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2
Q

Question 26

A 31-year-old man who was involved in a motor vehicle collision sustained a displaced glenoid neck fracture with articular discongruity of the glenoid. A posterior approach was used to perform an open reduction and internal fixation. Which internervous interval should be used to expose the posterior glenoid and lateral scapula?

  1. Axially and suprascapular
  2. Axillary and lower subscapular
  3. Upper and lower suprascapular
  4. Suprascapular and upper subscapular
  5. Suprascapular and lower subscapular
A
  1. Axially and suprascapular

RECOMMENDED READINGS

Hoppenfeld S, deBoer P, Buckley R, eds. Surgical Exposures in Orthopedics: The Anatomic Approach. 4th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2009.

Anavian J, Gauger EM, Schroder LK, Wijdicks CA, Cole PA. Surgical and functional outcomes after operative management of complex and displaced intra-articular glenoid fractures. J Bone Joint Surg Am. 2012 Apr 4;94(7):645-53. doi: 10.2106/JBJS.J.00896. PubMed PMID: 22488621.

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3
Q

Question 34

An 18-year-old right-handed baseball pitcher has right-shoulder pain and loss of pitch velocity. His radiograph and MR findings are normal. Examination reveals that his right arm ahs 110 degrees external rotation and 20 degrees of internal rotation with the arm in abduction. His left shoulder has 90 degrees of external rotation and 60 degrees of internal rotation in the abducted position. Therapy primarily should address which pathologic condition?

  1. Rotator interval laxity
  2. Anterior capsule laxity
  3. Anterior capsule tightness
  4. Posterior capsule laxity
  5. Posterior capsule tightness
A
  1. Posterior capsule tightness

RECOMMENDED READINGS

Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 2003 Apr;19(4):404-20. Review. PubMed PMID: 12671624.

Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy. 2003 May-Jun;19(5):531-9. Review. PubMed PMID: 12724684.

Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003 Jul- Aug;19(6):641-61. Review. PubMed PMID: 12861203.

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4
Q

Question 41

Figures 41a through 41e are the radiographs and MR image cuts of a 77-year-old man with severe right shoulder pain. He had a prolonged course of physical therapy and received several cortisone injections for his pain. Examination reveals pseudoparalysis of the right shoulder with a 20-degree external rotation lag with the shoulder adducted. With the shoulder placed in 90 degrees of abduction, he can actively externally rotate his shoulder. Definitive treatment shoudl consist of

  1. latissimus dorsi/teres major tendon transfer.
  2. reverse total shoulder arthroplasty.
  3. arthroscopic debridement of the rotator cuff with biceps tenotomy.
  4. arthroscopic partial rotator cuff repair with subacromial decompression.
  5. unconstrained total shoulder arthroplasty with an inferior tilt to the glenoid polyethylene.
A
  1. reverse total shoulder arthroplasty.

RECOMMENDED READINGS

Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear withoutglenohumeral arthritis. J Bone Joint Surg Am. 2010 Nov 3;92(15):2544-56. doi: 10.2106/JBJS.I.00912. PubMed PMID: 21048173.

Boileau P, Baqué F, Valerio L, Ahrens P, Chuinard C, Trojani C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients withmassive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007 Apr;89(4):747-57. PubMed PMID: 17403796.

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5
Q

Question 53

Figures 53a through 53e are the radiographs and CT arthrograms of a 70-year-old woman who has had progressively worsening right shoulder pain with overhead activities for 6 months even though she has recieved physical therapy and has been taking anti-inflammatory medications. She underwent an uncomplicated right total shoulder arthroplasty 5 years ago. Examination reveals 60 degrees of active for deltoid fires well. An infection workup is ward elevation and 150 degrees of passive elevation. Her negative. What is the most appropriate surgical option?

  1. Revision to resection arthroplasty
  2. Revision to reverse shoulder arthroplasty
  3. Revision of the glenoid component to a pegged component
  4. Open rotator cuff repair with retention of the prosthesis
  5. Removal of the glenoid component and glenoid bone grafting
A
  1. Revision to reverse shoulder arthroplasty

RECOMMENDED READINGS

Patel DN, Young B, Onyekwelu I, Zuckerman JD, Kwon YW. Reverse total shoulder arthroplasty for failed shoulder arthroplasty. J Shoulder Elbow Surg. 2012 Nov;21(11):1478-83. doi: 10.1016/j. jse.2011.11.004. Epub 2012 Feb 22. PubMed PMID: 22361717.

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6
Q

Question 66

Figures 66a through 66c are the radiographs and 3-dimensional CT reconstructed image of a 38-year-old man who is seen in the emergency department after falling from a ladder. Examination reveals significant swelling about the elbow and crepitus with attempted range of motion. He is distally neurovascularly intact. Definitive treatment should include

  1. application of a long-arm cast with delayed mobilization.
  2. placement of a hinged external fixator with radial head excision
  3. closed reduction and percutaneous fixation of the radial head
  4. open reduction and internal fixation with radial head replacement
  5. ulnohumeral interpositional arthroplasty with radial head replacement.
A
  1. open reduction and internal fixation with radial head replacement

RECOMMENDED READINGS

Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002Apr;84-A(4):547-51. PubMed PMID: 11940613.

Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004 Jun;86-A(6):1122-30. PubMed PMID: 15173283.

Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg Am. 2004;May;86-A(5):975-82. PubMed PMID: 15118040.

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7
Q

Question 85

A 24-year-old woman with elbow stiffness resulting from a previous nondisplaced radial head fracture refractory to nonsurgical treatment is undergoing surgical elbow release. She has range of motion between 50 and 100 degrees and pain in her ringa nd small fingers with forced flexion. Which 2 structures must be addressed to restore flexion

  1. Anterior capsule and ulnar nerve
  2. Anterior bundle of the medial collateral ligament (MCL) and the olecranon
  3. Posterior bundle of the MCL and ulnar nerve
  4. Posterior bundle of the MCL and the olecranon
  5. Lateral ulnar collateral ligament and posterior bundle of the MCL
A
  1. Posterior bundle of the MCL and ulnar nerve

RECOMMENDED READINGS

Williams BG, Sotereanos DG, Baratz ME, Jarrett CD, Venouziou AI, Miller MC. The contracted elbow: is ulnar nerve release necessary? J Shoulder Elbow Surg. 2012 Dec;21(12):1632-6. doi: 10.1016/j. jse.2012.04.007. Epub 2012 Jun 26. PubMed PMID: 22743068.

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8
Q

Question 89

A 20-year-old man has right shoulder pain and weakness after a fall from a height 4 months ago. Examination, which reveals medial scapula winging, otherwise is unremarkable. Radiographs and MR arthrogram findings are normal. Which nerve most likely is injured?

  1. Axillary
  2. Long thoracic
  3. Dorsal scapular
  4. Suprascapular
  5. Spinal accessory
A
  1. Long thoracic

RECOMMENDED READINGS

Camp SJ, Birch R. Injuries to the spinal accessory nerve: a lesson to surgeons. J Bone Joint Surg Br. 2011 Jan;93(1):62-7. doi:10.1302/0301-620X.93B1.24202. PubMed PMID: 21196545.

Pikkarainen V, Kettunen J, Vastamäki M. The natural course of serratus palsy at 2 to 31 years. Clin Orthop Relat Res. 2013 May;471(5):1555-63. doi:10.1007/s11999-012-2723-7. Epub 2012 Dec 1. PubMed PMID: 23208124; PubMed Central PMCID: PMC3613528.

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9
Q

Question 101

The medial side of the elbow experiences the most valgus stress during which phase of the baseball throwing motion?

  1. Wind-up
  2. Acceleration
  3. Early cocking
  4. Follow-through
  5. Tensile stress is equal throughout the entire motion
A
  1. Acceleration

RECOMMENDED READINGS

Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF: Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med. 1995;23(2):233-239. PMID: 7778711.

Safran MR. Nonacute medial elbow injuries. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009: 47-57.

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10
Q

Question 116

Figures 116a and 116b are the radiographs and MR images of a 14-year-old right-hand-dominant gymnast who has had left elbow pain for 2 days. She twisted her elbow while performing a vault. Initial management should include

  1. return to gymnastics as tolerated.
  2. arthroscopic debridement of the elbow joint.
  3. surgical repair of the torn ulnar collateral ligament.
  4. surgical fixation of the medial epicondyle avulsion fracture
  5. a short period of immobilization and physical therapy.
A
  1. a short period of immobilization and physical therapy.

RECOMMENDED READINGS

Chen FS, Diaz VA, Loebenberg M, Rosen JE. Shoulder and elbow injuries in the skeletally immature athlete. J Am Acad Orthop Surg. 2005 May-Jun;13(3):172-85. Review. PubMed PMID: 15938606.

Murthi AM, Keener JD, Armstrong AD, Getz CL. The recurrent unstable elbow: diagnosis and treatment. J Bone Joint Surg Am. 2010 Jul 21;92(8):1794-804. PubMed PMID: 20660245.

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11
Q

Question 131

The nerve most commonly injured during a distal biceps repair arises from the

  1. lower trunk.
  2. medial cord.
  3. lateral cord.
  4. posterior cord.
  5. medial and lateral cords.
A
  1. lateral cord.

RECOMMENDED READINGS

Cain RA, Nydick JA, Stein MI, Williams BD, Polikandriotis JA, Hess AV: Complications following distal biceps repair. J Hand Surg Am. 2012 Oct;37(10):2112-7. doi: 10.1016/j.jhsa.2012.06.022. PMID: 22938802.

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12
Q

Question 149

Figures 149a and 149b are the radiographs of a 79-year-old right-hand-dominant man who has had longterm right shoulder pain. His symptoms have been treated with injections, physical therapy, nonsteroidal anti-inflammatory drugs, and oral analgesics. He is experiencing a recent, substantial increase in pain with overhead activities and now takes oral narcotics to help sleep at night. Examination reveals 120 degrees of forward elevation, 20 degrees of external rotation, and internal rotation to the sacrum. His shoulder has good abduction and external rotation strength. What is the best next step?

  1. Hemiarthroplasty
  2. Total shoulder arthroplasty
  3. Reverse shoulder arthroplasty
  4. Arthroscopic debridement and contracture release
  5. CT-guided aspiration of the joint and humeral biopsy
A
  1. Total shoulder arthroplasty

RECOMMENDED READINGS

Edwards TB, Kadakia NR, Boulahia A, Kempf JF, Boileau P, Némoz C, Walch G. A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study. J Shoulder Elbow Surg. 2003 May-Jun;12(3):207-13. PubMed PMID: 12851570.

Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. Neer Award 2005: The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg. 2006 Sep-Oct;15(5):527-40. PubMed PMID: 16979046.

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13
Q

Question 167

The structure indicated by the asterisk (*) shown in Figure 167 receives its innervation from which portion of the brachial plexus?

  1. Lateral cord
  2. Medial cord
  3. Posterior cord
  4. Upper trunk
  5. C5-C7 nerve roots
A
  1. Posterior cord

RECOMMENDED READINGS

Friend J, Francis S, McCulloch J, Ecker J, Breidahl W, McMenamin P. Teres minor innervation in the context of isolated muscle atrophy. Surg Radiol Anat. 2010 Mar;32(3):243-9. doi: 10.1007/s00276-009- 0605-9. Epub 2009 Dec 18. PubMed PMID: 20020125.

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14
Q

Question 178

Figures 178a through 178i are the images of a 21-year-old right-hand-dominant man who injured his right shoulder in a bicycle collision 3 days ago. His dislocation was placed into a sling after closed reduction in the emergency department. What is the most appropriate treatment at this time?

1- Closed reduction under anesthesia

2- Arthroscopic repair of the humeral avulsion of the glenohumeral ligament lesion

3- Arthroscopic repair of the bony Bankart lesion

4- Open surgical repair witha modified McLaughlin procedure

5- Sling for 2 weeks followed by physical therapy

A

3- Arthroscopic repair of the bony Bankart lesion

RECOMMENDED READINGS

Porcellini G, Paladini P, Campi F, Paganelli M. Long-term outcome of acute versus chronic bony Bankart lesions managed arthroscopically. Am J Sports Med. 2007 Dec;35(12):2067-72. Epub 2007 Oct 31. PubMed PMID: 17978001.

Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA 3rd. Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):317-28. doi: 10.1016/j. jse.2008.10.013. Review. PubMed PMID: 19218054.

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15
Q

Question 185

Figure 185 is the radiograph of a 53-year-old man who fell and injured his right elbow. He also has wrist pain and is tender over the medial aspect of his elbow. Wrist radiographs are negative for bony injury. What is the best treatment option?

  1. Radial head excision
  2. Radial head arthroplasty
  3. Nonsurgical management
  4. Internal fixation of the coranoid only
  5. Open reduction and internal fixation of the radial head and coranoid
A
  1. Radial head arthroplasty

RECOMMENDED READINGS

Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ: Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am. 2001; 83-A:1201-11. PMID: 115071291.

Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and xcoronoid. J Bone Joint Surg Am. 2002 Apr;84-A(4):547-51. PMID: 11940613.

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16
Q

Question 202

Figures 202a and 202b are the MR images of a 47-year-old right-hand-dominant man who has had right shoulder problems since using a jackhammer at a worksite. His severe pain, weakness, and limited range of motion began the morning after his injury. When he arrives for an examination 6 weeks later, most of his pain has resolved but the weakness persists. Range-of-motion testing reveals active forward elevation of 150 degrees with a mildly painful arc. He has shoulder external rotation weakness with his arm by his side. An abdominal compression test result is within normal limits. Radiographs are unremarkable. What is the best treatment option?

  1. EMG/NCV
  2. Physical therapy
  3. Oral corticosteroids
  4. Arthroscopic labral repair
  5. Arthroscopic rotator cuff repair
A
  1. Physical therapy

RECOMMENDED READINGS

Yanny S, Toms AP. MR patterns of denervation around the shoulder. AJR Am J Roentgenol. 2010 Aug;195(2):W157-63. doi: 10.2214/AJR.09.4127. Review. PubMed PMID: 20651176.

Sumner AJ. Idiopathic brachial neuritis. Neurosurgery. 2009 Oct;65(4 Suppl):A150-2. doi: 10.1227/01. NEU.0000345355.59438.D1. Review. PubMed PMID: 19927060.

17
Q

Question 215

Figures 215a and 215b are the radiographs of a 65-year-old woman who underwent a right shoulder hemiarthroplasty for a comminuted proximal humerus fracture 10 months ago. She has significant pain and limited active range of motion. Examination reveals active forward elevation of 30 degrees that is scapulothoracic in nature. She is unable to actively externally rotate her arm when the arm is held in the abducted position. Both her C-reactive protein and erythrocyte sedimentation levels are within normal limits. What is the best next treatment option?

  1. Shoulder fusion
  2. Latissimus dorsi transfer with retention of the original implant
  3. Conversion to an anatomic total shoulder arthroplasty
  4. Conversion to a reverse total shoulder arthroplasty with a latissimus dorsi transfer
  5. Explantation of hemiarthroplasty and implantation of an antibiotic-laden cement spacer
A
  1. Conversion to a reverse total shoulder arthroplasty with a latissimus dorsi transfer

RECOMMENDED READINGS

Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The Reverse Shoulder Prosthesis for glenohumerual arthritis associated with severe rotator cuff deficiency. A minimum two-year followup study of sixty patients. J Bone Joint Surg Am. 2005 Aug;87(8):1697-705. PubMed PMID: 16085607.

18
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Question 221

Figure 221 is an MR image of a 25-year-old swimmer who has had posterior shoulder pain for 3 to 4 months. She denies any discrete injury and has painful clicking with shoulder range of motion. Examination reveals symmetric range of motion in all planes. She has some mild external rotation weakness by her side when compared to the contralateral shoulder. Anterior apprehension and sulcus signs are negative. What is the best treatment option?

  1. Posterior bone block
  2. Arthroscopic Bankart repair
  3. Arthroscopic posterior labral repair
  4. Physical therapy and activity modification
  5. Osteoarticular allograft to the humeral head
A
  1. Arthroscopic posterior labral repair

RECOMMENDED READINGS

Bottoni CR, Franks BR, Moore JH, DeBerardino TM, Taylor DC, Arciero RA. Operative stabilization of posterior shoulder instability. Am J Sports Med. 2005 Jul;33(7):996-1002. Epub 2005 May 11. PubMed PMID: 15890637.

Kim SH, Ha KI, Yoo JC, Noh KC. Kim’s lesion: an incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthroscopy. 2004 Sep;20(7):712-20. Review. PubMed PMID: 15346113.

19
Q

Question 234

Figures 234a and 234b are the radiographs of a 35-year-old otherwise healthy woman who slipped and fell on the ice and landed on her outstretched left hand. Although clinicians emphasized early active motion and pain control, she returns at 10 weeks with her sling still in place. Examination reveals an arc of elbow flexion/extension from 35 degrees to 100 degrees. After 6 weeks of physical therapy, her arc of motion does not improve. Follow-up radiographs reveal normal osseous anatomy. What is the best next step?

  1. Manipulation under anesthesia
  2. Static progressive elbow splinting
  3. Open elbow release via the lateral column approach
  4. Arthroscopic elbow capsular release with ulnar nerve release
  5. Continued sling use for 6 more weeks followed by aggressive range-of-motion exercises
A
  1. Static progressive elbow splinting

RECOMMENDED READINGS

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. doi: 10.2106/JBJS.J.01761. PubMed PMID: 22517385.

20
Q

Question 242

Figures 242a and 242b are the radiographs of a 28-year-old man who has a stiff elbow 3 years after undergoing open reduction and internal fixation of a distal humerus fracture. Range-of motion testing reveals he lacks 50 degrees of extension and has 85 degrees of flexion. He denies pain during mid range of motion but has pain at terminal flexion and extension. He has normal distal motor function and sensation. What is the preferred treatment option?

  1. Open capsular release
  2. Arthroscopic capsular release
  3. Hardware removal only
  4. Total elbow arthroplasty
  5. Interposition arthroplasty
A
  1. Open capsular release

RECOMMENDED READINGS

Sears BW, Puskas GJ, Morrey ME, Sanchez-Sotelo J, Morrey BF. Posttraumatic elbow arthritis in the young adult: evaluation and management. J Am Acad Orthop Surg. 2012 Nov;20(11):704-14. doi: 10.5435/JAAOS-20-11-704. Review. PubMed PMID: 23118136.

21
Q

Question 253

A 66-year-old right-hand-dominant woman with rheumatoid arthritis underwent total elbow arthroplasty with a triceps-reflecting approach. Which immediate postsurgical therapy most likely will injure the repaired elbow?

  1. Sling to be worn at all times
  2. Long-arm cast immobilization
  3. Supine extension against gravity
  4. Seated active flexion with active extension
  5. Intermittant immobilization with an anterior splint in full extension
A
  1. Supine extension against gravity

RECOMMENDED READINGS

Maloney WJ, Schurman DJ. Cast immobilization after total elbow arthroplasty. A safe cost-effective method of initial postoperative care. Clin Orthop Relat Res. 1989http://www.ncbi.nlm.nih.gov/ pubmed/8478378Aug;(245):117-22. PubMed PMID: 2752611.

Smith J, Morrey BF. Principles of elbow rehabilitation. In: Morrey BF, Sanchez-Sotelo J, eds. The Elbow and Its Disorders. 4th ed. Philadelphia, PA: WB Saunders; 2008:152-9.

22
Q

Question 272

Figures 272a and 272b are the radiographs of a 40-year-old roofer who is seen in the emergency department for shoulder pain following a fall from a ladder. What is the most appropriate treatment at this time?

  1. Repeat the evaluation in 1 week
  2. Order outpatient MR images
  3. Prescribe empiric physical therapy
  4. Obtain orthogonal shoulder radiographs
  5. Perform a diagnostic subacromial injection
A
  1. Obtain orthogonal shoulder radiographs

RECOMMENDED READINGS

Millett PJ, Clavert P, Hatch GF 3rd, Warner JJ. Recurrent posterior shoulder instability. J Am Acad Orthop Surg. 2006 Aug;14(8):464-76. Review. PubMed PMID: 16885478.

Robinson CM, Aderinto J. Posterior shoulder dislocations and fracture-dislocations. J Bone Joint Surg Am. 2005 Mar;87(3):639-50. Review.PubMed PMID: 15741636.

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