Shoulder & Elbow 2016

Question 1

12. Figures 12a and 12b are the postsurgical radiographs of a 22-year-old man who underwent an open coracoid transfer to address recurrent right shoulder instability 5 days ago. He has had an occasional low-grade fever (37.2°C) since surgery. His surgical site is completely benign. Palpation of the axilla shows no fullness. He demonstrates an inability to abduct his shoulder against resistance and decreased sensation on the lateral aspect of his shoulder. He also has decreased sensation along the volar lateral aspect of his ipsilateral forearm. What is the best next step?
13. Continued observation with follow-up in 2 to 3 weeks
14. Urgent electromyography (EMG)/nerve conduction velocity studies of the right

upper extremity

3. CT scan to evaluate for surgical-site hematoma
4. Laboratory studies (erythrocyte sedimentation rate, C-reactive protein, and complete

blood count)

5. Graft position revision and possible neurolysis

Answer 1

1. Continued observation with followup in 2-3 weeks.

RECOMMENDED READINGS

Shah AA, Butler RB, Romanowski J, Goel D, Karadagli D, Warner JJ. Short-term complications of the Latarjet procedure. J Bone Joint Surg Am. 2012 Mar 21;94(6):495-501. doi: 10.2106/JBJS.J.01830. PubMed PMID: 22318222.

Delaney RA, Freehill MT, Janfaza DR, Vlassakov KV, Higgins LD, Warner JJ. 2014 Neer Award Paper: neuromonitoring the Latarjet procedure. J Shoulder Elbow Surg. 2014 Oct;23(10):1473-80. doi: 10.1016/j. jse.2014.04.003. Epub 2014 Jun 18. PubMed PMID: 24950948.

Freehill MT, Srikumaran U, Archer KR, McFarland EG, Petersen SA. The Latarjet coracoid process transfer procedure: alterations in the neurovascular structures. J Shoulder Elbow Surg. 2013 May;22(5):695-700. doi: 10.1016/j.jse.2012.06.003. Epub 2012 Sep 1. PubMed PMID: 22947236.

Boardman ND 3rd, Cofield RH. Neurologic complications of shoulder surgery. Clin Orthop Relat Res. 1999 Nov;(368):44-53. Review. PubMed PMID: 10613152.

Question 2

26.

Figure 26a is the clinical photograph of a 31-year-old recreational athlete who felt a pop in his right shoulder while performing a bench press. Appropriate treatment involves reinsertion of the involved tendon onto the

1. footprint area of the greater tuberosity.
2. lesser tuberosity at the area of avulsion.
3. humeral shaft lateral to the bicipital groove.
4. humeral shaft medial to the bicipital groove.
5. humeral shaft on the inferior edge of the quadrilateral space.

Answer 2

3. Humeral shaft lateral to the bicipital groove.

RECOMMENDED READINGS

Petilon J, Carr DR, Sekiya JK, Unger DV. Pectoralis major muscle injuries: evaluation and management. J Am Acad Orthop Surg. 2005 Jan-Feb;13(1):59-68. Review. PubMed PMID: 15712983.

Butt U, Mehta S, Funk L, Monga P. Pectoralis major ruptures: a review of current management. J Shoulder Elbow Surg. 2015 Apr;24(4):655-62. doi: 10.1016/j.jse.2014.10.024. Epub 2015 Jan 1. Review. PubMed PMID: 25556808.

Question 3

34. Figures 34a through 34c are the radiograph and MR images of a 62-year-old left-hand-dominant woman who has had left shoulder pain for 6 months. The pain bothers her mostly at night. She has been taking nonsteroidal anti-inflammatory drugs (NSAIDs) as needed and received a cortisone injection several years ago in the same shoulder. An examination reveals mildly diminished range of motion in elevation and external rotation, and she reports severe pain with forced shoulder abduction. Her strength in elevation is 4/5 (limited by pain) and external rotation strength is 5/5. What is the most appropriate next step?
35. Ultrasound-guided intra-articular cortisone injection
36. Subacromial cortisone injection followed by formal physical therapy
37. Arthroscopic capsular release with manipulation under anesthesia
38. Arthroscopic subacromial decompression with release of the coracoacromial ligament
39. Arthroscopic takedown of the supraspinatus, followed by repair and decompression

Answer 3

2. Subacromial cortisone injection followed by formal physiotherapy.

RECOMMENDED READINGS

Ketola S, Lehtinen J, Arnala I, Nissinen M, Westenius H, Sintonen H, Aronen P, Konttinen YT, Malmivaara A, Rousi T. Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br. 2009 Oct;91(10):1326-34. doi: 10.1302/0301-620X.91B10.22094. PubMed PMID: 19794168.

Pedowitz RA, Yamaguchi K, Ahmad CS, Burks RT, Flatow EL, Green A, Iannotti JP, Miller BS, Tashjian RZ, Watters WC 3rd, Weber K, Turkelson CM, Wies JL, Anderson S, St Andre J, Boyer K, Raymond L, Sluka P, McGowan R; American Academy of Orthopaedic Surgeons. Optimizing the management of rotator cuff problems. J Am Acad Orthop Surg. 2011 Jun;19(6):368-79. PubMed PMID: 21628648.

Ketola S, Lehtinen J, Rousi T, Nissinen M, Huhtala H, Konttinen YT, Arnala I. No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial. Bone Joint Res. 2013 Jul 1;2(7):132-9. doi: 10.1302/2046- 3758.27.2000163. Print 2013. PubMed PMID: 23836479.

Question 4

41. Video 41 features a 45-year-old man who has long-standing right shoulder pain that is refractory to physical therapy. The figure provides intraoperative arthroscopic images taken while viewing from the lateral portal in the beach-chair position. After undergoing this isolated procedure, which upper extremity motion should be avoided during the initial 2 weeks following surgery?
42. Supine passive shoulder-forward elevation
43. Supine active abduction and external rotation of the shoulder
44. Seated active shoulder internal rotation
45. Seated active forearm supination with the elbow flexed 90 degrees
46. Seated active forearm pronation with the elbow flexed 90 degrees

Answer 4

4. Seated active foreamr supination with elbow flexed 90 degrees

RECOMMENDED READINGS

Shank JR, Singleton SB, Braun S, Kissenberth MJ, Ramappa A, Ellis H, Decker MJ, Hawkins RJ, Torry MR. A comparison of forearm supination and elbow flexion strength in patients with long head of the biceps tenotomy or tenodesis. Arthroscopy. 2011 Jan;27(1):9-16. doi: 10.1016/j.arthro.2010.06.022. Epub 2010 Oct 29. PubMed PMID: 21035992.

Levy AS, Kelly BT, Lintner SA, Osbahr DC, Speer KP. Function of the long head of the biceps at the shoulder: electromyographic analysis. J Shoulder Elbow Surg. 2001 May-Jun;10(3):250-5. PubMed PMID: 11408907.

Yamaguchi K, Riew KD, Galatz LM, Syme JA, Neviaser RJ. Biceps activity during shoulder motion: an electromyographic analysis. Clin Orthop Relat Res. 1997 Mar;(336):122-9. PubMed PMID: 9060495.

Question 5

53. The condition seen in Figures 53a through 53c likely represents progression of
54. unrecognized Propionibacterium acnes (P. acnes) infection.
55. an untreated rotator cuff tear with a long-head biceps tendon rupture.
56. inflammatory synovitis associated with rheumatoid arthritis.
57. joint breakdown secondary to acquired hemophilia.
58. chronic hypertrophic nonunion of a proximal humeral fracture.

Answer 5

2. Untreated rotator cuff tear with a long-head biceps tendon rupture.

RECOMMENDED READINGS

Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am Acad Orthop Surg. 2007 Jun;15(6):340-9. Review. PubMed PMID: 17548883.

Feeley BT, Gallo RA, Craig EV. Cuff tear arthropathy: current trends in diagnosis and surgical management. J Shoulder Elbow Surg. 2009 May-Jun;18(3):484-94. doi: 10.1016/j.jse.2008.11.003. Epub 2009 Feb 8. Review. PubMed PMID: 19208484.

Question 6

78. A 78-year-old man has a 4-part fracture of the proximal humerus. He is scheduled for a reverse total shoulder arthroplasty (TSA). Objective improvement in active external rotation will most consistently be achieved with which surgical technique?
79. Inferior placement of the baseplate
80. Increased retroversion of the humeral stem
81. Placement of a thicker polyethylene insert
82. Suture fixation of the greater tuberosity
83. Use of a more valgus neck-shaft angled stem

Answer 6

4. Suture fixation of the greater tuberosity

RECOMMENDED READINGS

Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg. 2015 Mar;23(3):190-201. doi: 10.5435/JAAOS-D-13-00190. Epub 2015 Jan 28. Review. PubMed PMID: 25630370.

Anakwenze OA, Zoller S, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for acute proximal humerus fractures: a systematic review. J Shoulder Elbow Surg. 2014 Apr;23(4):e73-80. doi: 10.1016/j. jse.2013.09.012. Epub 2014 Jan 7. Review. PubMed PMID: 24406120.

Gallinet D, Adam A, Gasse N, Rochet S, Obert L. Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2013 Jan;22(1):38-44. doi: 10.1016/j.jse.2012.03.011. Epub 2012 Jun 15. PubMed PMID: 22705317.

Question 7

85. A 45-year-old laborer has pain and stiffness of his dominant right elbow that has gradually worsened for 6 months. He has received several injections, experienced diminishing success, and is now taking narcotic pain medication to relieve his symptoms. He is still working despite the pain and reports that he cannot take much time off from work or he will lose his job. An examination reveals full strength with extension of 30 degrees, flexion of 120 degrees, pronation of 90 degrees, and supination of 85 degrees. He has mild crepitus with motion. Radiographs reveal moderate osteoarthritis with osteophytes of the humerus and ulna. His radiocapitellar joint has minimal arthritic change. What is the best option for treatment?
86. Substitution of narcotic pain medication for prescription nonsteroidal anti-inflammatory

drugs (NSAIDs)

2. Injection of the ulnohumeral joint with corticosteroids followed by intense physical therapy
3. Arthroscopic fenestration of the olecranon fossa and osteophyte debridement
4. Open debridement of osteophytes on the humerus and ulna with radial head resection
5. Total elbow arthroplasty with preservation of the nonarthritic native radial head using a linked

ulnar prosthesis

Answer 7

3. Arthroscopic fenestration of the olecranon fossa and osteophyte debridement.

RECOMMENDED READINGS

Beingessner DM, Dunning CE, Gordon KD, Johnson JA, King GJ. The effect of radial head excision and arthroplasty on elbow kinematics and stability. J Bone Joint Surg Am. 2004 Aug;86-A(8):1730-9. PubMed PMID: 15292422.

Krishnan SG, Harkins DC, Pennington SD, Harrison DK, Burkhead WZ. Arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in patients under fifty years of age. J Shoulder Elbow Surg. 2007 Jul-Aug;16(4):443-8. Epub 2007 Jan 24. PubMed PMID: 17254810.

Question 8

89. When performing a primary anatomic total shoulder arthroplasty for glenohumeral osteoarthritis, reproducing the center of rotation of the glenohumeral joint is important to achieve symmetric joint balancing. Relative to the center of the humeral intramedullary canal, the offset of the humeral head center of rotation (COR) generally lies
90. 8 mm posterior and 4 mm medial.
91. 8 mm posterior and 4 mm lateral.
92. 8 mm anterior and 4 mm lateral.
93. 4 mm anterior and 4 mm medial.
94. 4 mm medial only.

Answer 8

1. 8mm posterior and 4mm medial

RECOMMENDED READINGS

Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br. 1997 Sep;79(5):857-65. PubMed PMID: 9331050.

Robertson DD, Yuan J, Bigliani LU, Flatow EL, Yamaguchi K. Three-dimensional analysis of the proximal part of the humerus: relevance to arthroplasty. J Bone Joint Surg Am. 2000 Nov;82-A(11):1594-602. PubMed PMID: 11097450.

Question 9

101. A 45-year-old woman underwent arthroscopic capsular release for recalcitrant adhesive capsulitis. Release of the tissue using cautery as shown in Video 101 results primarily in increased
102. external rotation with the shoulder abducted 90 degrees.
103. terminal internal rotation of the humeral head.
104. inferior translation of the humeral head in neutral rotation.
105. posterior translation of the shoulder forward flexed and internally rotated.
106. anterior translation with the shoulder abducted 45 degrees.

Answer 9

3. inferior translation of the humeral head in neutral rotation.

Question 10

116. Figures 116a and 116b are the radiographs of a 71-year-old man who underwent uncomplicated right total shoulder arthroplasty for glenohumeral osteoarthritis 1 year ago. He now reports the sudden onset of severe pain in his right shoulder over the weekend and says that he feels somewhat “feverish.” He cannot move his arm without a substantial increase in pain, and he is having trouble sleeping and with activities of daily living. He denies nausea, vomiting, or specific trauma to his shoulder and is worried that his shoulder is infected (he also reports attending a recent family reunion and getting food poisoning). Radiograph findings are negative, and laboratory values include a normal white blood count, C-reactive protein of 1.2 mg/L (rr, 0.08-3.1 mg/L), and erythrocyte sedimentation rate of 17 mm/h (rr, 0-20 mm/h). Treatment will likely involve
117. reassurance and observation.
118. diagnostic arthroscopy with lavage and 48 hours of intravenous antibiotics.
119. immediate aspiration with a fluid culture.
120. open reduction and internal fixation (ORIF).
121. revision shoulder arthroplasty.

Answer 10

5. Revision shoulder arthroplasty

Pinkas D, Wiater B, Wiater JM. The Glenoid Component in Anatomic Shoulder Arthroplasty. J Am Acad Orthop Surg. 2015 May;23(5):317-326. Epub 2015 Mar 31. Review. PubMed PMID: 25829449.

Papadonikolakis A, Neradilek MB, Matsen FA 3rd. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013 Dec 18;95(24):2205-12. doi: 10.2106/JBJS.L.00552. Review. PubMed PMID: 24352774.

Question 11

131. Figure 131a is the radiograph of a 60-year-old right-hand-dominant woman who has persistent right shoulder pain. She has received several cortisone injections to the shoulder, which helped temporarily. Physical therapy has exacerbated her pain. An examination reveals 120 degrees of active forward elevation with scapulothoracic substitution and 15 degrees of external rotation. Her strength in elevation is 4/5, and external rotation strength is 5/5. MR images are shown in Figures 131b through 131d. What is the most appropriate surgical intervention?
132. Arthroscopic capsular release with debridement of the glenohumeral joint
133. Arthroscopic rotator cuff repair with biceps tenotomy
134. Hemiarthroplasty with an enlarged prosthetic humeral head
135. Unconstrained total shoulder arthroplasty (TSA) with rotator cuff repair
136. Reverse (TSA)

Answer 11

5. Reverse TSA

RECOMMENDED READINGS

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. PubMed PMID: 20511443.

Edwards TB, Boulahia A, Kempf JF, Boileau P, Nemoz C, Walch G. The influence of rotator cuff disease on the results of shoulder arthroplasty for primary osteoarthritis: results of a multicenter study. J Bone Joint Surg Am. 2002 Dec;84-A(12):2240-8. PubMed PMID: 12473715.

Question 12

149. A 46-year-old woman sustained a simple elbow dislocation with no fracture after a fall. After undergoing closed reduction, she has substantial pain and does not want to move her arm because it “hurts too much.” Together, you and the patient agree to pursue a course of directed physical therapy. What is the best recommendation for the therapist regarding her rehabilitation protocol?
150. Use aggressive passive stretching into extension to prevent flexion contracture from

prolonged immobilization.

2. Encourage early, gentle active range of motion to improve stabilizing compressive forces

across the joint.

3. Encourage early strengthening of the flexor wad musculature to prevent atrophy and

recurrent instability.

4. Allow only passive range of motion by the therapist to decrease risk for recurrent posterior

dislocation of the joint through active firing of the triceps.

5. After a 4-week period of immobilization to allow for bony healing, allow both passive

and active range of motion in a hinged brace to protect the joint followed by an early

progression to strengthening.

Answer 12

2. Encourage early, getle active range of motion to improve stabilizing compressive forces across the joint.

RECOMMENDED READINGS

Seiber K, Gupta R, McGarry MH, Safran MR, Lee TQ. The role of the elbow musculature, forearm rotation, and elbow flexion in elbow stability: an in vitro study. J Shoulder Elbow Surg. 2009 Mar- Apr;18(2):260-8. doi: 10.1016/j.jse.2008.08.004. Epub 2008 Nov 30. PubMed PMID: 19046641.

Wyrick JD, Dailey SK, Gunzenhaeuser JM, Casstevens EC. Management of Complex Elbow Dislocations: A Mechanistic Approach. J Am Acad Orthop Surg. 2015 May;23(5):297-306. Review. PubMed PMID: 25911662.

Question 13

167. An 82-year-old woman underwent an uncomplicated reverse total shoulder arthroplasty performed under general anesthesia. Her history includes diabetes and hypertension, both controlled by oral medication, as well as renal insufficiency. On the second postsurgical day, she is conversant when evaluated on rounds, but she appears more tired than she was at baseline. She has been prescribed 2.5 mg of oxycodone every 4 hours as needed. A review of her visual analog scores since surgery reveal a range between 9/10 and 10/10, and her vital signs include tachycardia in the 90s. Her complete blood count findings are similar to her baseline values. The most appropriate next step is to
168. reassure the patient and provide follow-up later that afternoon.
169. proceed with discharge and expedite outpatient orthopaedic follow-up.
170. perform repeat shoulder radiographs.
171. consult with the geriatric service for medical co-management.
172. initiate intravenous meperidine patient-controlled analgesia

Answer 13

4. Consult with geratric service for medical co-managment.

RECOMMENDED READINGS

American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg. 2015 Feb;220(2):136-48.e1. doi: 10.1016/j.jamcollsurg.2014.10.019. Epub 2014 Nov 14. PubMed PMID: 25535170.

Mendelson DA, Friedman SM. Principles of comanagement and the geriatric fracture center. Clin Geriatr Med. 2014 May;30(2):183-9. doi: 10.1016/j.cger.2014.01.016. Epub 2014 Mar 14. Review. PubMed PMID: 24721359.

Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes. Arch Intern Med. 2009 Oct 12;169(18):1712-7. doi: 10.1001/ archinternmed.2009.321. PubMed PMID: 19822829.

Question 14

178. A morbidly obese 63-year-old man sustained a fall and fractured his right shoulder and right ankle. His history included diabetes, hypertension, coronary artery disease, peripheral vascular disease, and gastroesophageal reflux. His medications include verapamil, insulin, metformin, hydrochlorothiazide, and omeprazole. Simultaneous open reduction and internal fixation (ORIF) of the ankle in the supine position and ORIF with bone grafting of the shoulder in the beach-chair position (BCP) under general anesthesia with supplemental regional blocks were performed as shown in Figures 178a and 178b. After surgery, he has a sense of severe burning and tingling in his right leg. An examination reveals diminished light-touch sensation in the proximal lateral right thigh but full strength with challenge of hip flexion and knee extension. What is the most likely cause of his symptoms?
179. Undiagnosed pelvic fracture resulting from the initial fall
180. Neurologic complication from the lower extremity regional block
181. Failure to appropriately cushion the lateral abdominal support post during positioning
182. Exacerbation of preexisting diabetic peripheral neuropathy
183. Interaction of halothane (used for general anesthesia) with verapamil and hydrochlorothiazide

Answer 14

3. Failure to appropriately cushion the lateral abdominal support post during positioning.

RECOMMENDED READINGS

Guss D, Bhattacharyya T. Perioperative management of the obese orthopaedic patient. J Am Acad Orthop Surg. 2006 Jul;14(7):425-32. Review. PubMed PMID: 16822890.

Moen TC, Rudolph GH, Caswell K, Espinoza C, Burkhead WZ Jr, Krishnan SG. Complications of shoulder arthroscopy. J Am Acad Orthop Surg. 2014 Jul;22(7):410-9. doi: 10.5435/JAAOS-22-07-410. Review. PubMed PMID: 24966247.

Question 15

185. A 19-year-old man sustained an anterior shoulder dislocation during a wrestling match and undergoes surgical repair of the injury. At arthroscopy, you encounter the finding shown in Figure 185a and perform the repair shown in Figure 185b. These images are taken from the posterior portal with the patient in the lateral decubitus position. Failure to completely evaluate the extent of damage to the structure marked as 1 will result in
186. recurrent anterior instability with repair failure.
187. excess tightening and stiffness.
188. subluxation of the long head of the biceps.
189. subscapularis insufficiency.
190. symptomatic posterior subluxation when lifting weight.

Answer 15

1. Recurrent anterior instability with repair failure.

RECOMMENDED READINGS

Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill- Sachs lesion. Arthroscopy. 2000 Oct;16(7):677-94. PubMed PMID: 11027751.

Bushnell BD, Creighton RA, Herring MM. Bony instability of the shoulder. Arthroscopy. 2008 Sep;24(9):1061-73. doi: 10.1016/j.arthro.2008.05.015. Epub 2008 Jun 30. Review. PubMed PMID: 18760215.

Question 16

202. Figures 202a and 202b are the anteroposterior and lateral radiographs of an obese 58-year-old woman who sustained an elbow injury after a fall. What is the best course of treatment for the radial head component of this injury?
203. Open reduction and internal fixation (ORIF)
204. Open fragment excision and lateral ligament repair
205. Radial head arthroplasty
206. Radial head excision
207. Arthroscopic fragment excision

Answer 16

3. Radial Head Arthroplasty

RECOMMENDED READINGS

Acevedo DC, Paxton ES, Kukelyansky I, Abboud J, Ramsey M. Radial Head Arthroplasty: State of the Art. J Am Acad Orthop Surg. 2014 Oct;22(10):633-642. Review. PubMed PMID: 25281258.

Beingessner DM, Dunning CE, Gordon KD, Johnson JA, King GJ. The effect of radial head excision and arthroplasty on elbow kinematics and stability. J Bone Joint Surg Am. 2004 Aug;86-A(8):1730-9. PubMed PMID: 15292422.

Question 17

213. Figures 213a through 213e are the MR images of a 42-year-old man who underwent right shoulder arthroscopy for recalcitrant shoulder pain 6 months ago. He received 2 subacromial cortisone injections that provided temporary pain relief and underwent physical therapy. While arthroscopically viewing from the posterior portal, the material shown in Video 213f was encountered. What is the most appropriate next step?
214. Arthroscopic debridement alone with a specimen for culture and sensitivity
215. Arthroscopic debridement alone with administration of intravenous colchicine
216. Arthroscopic debridement of the lesion with concomitant rotator cuff repair
217. Conversion to open excision of the lesion with drain placement
218. Immediate wound closure and referral to orthopaedic oncology

Answer 17

3. Arthroscopic debridmeent of lesion with concomittant rotator cuff repair.

RECOMMENDED READINGS

Suzuki K, Potts A, Anakwenze O, Singh A. Calcific Tendinitis of the Rotator Cuff: Management Options. J Am Acad Orthop Surg. 2014 Nov;22(11):707-717. Review. PubMed PMID: 25344596.

El Shewy MT. Arthroscopic removal of calcium deposits of the rotator cuff: a 7-year follow-up. Am J Sports Med. 2011 Jun;39(6):1302-5. doi: 10.1177/0363546510396320. Epub 2011 Feb 24. PubMed PMID: 21350066.

Question 18

221. Figures 221a and 221b are the current radiographs of a 43-year-old right-hand-dominant man who has severe left shoulder pain 2 years after undergoing left shoulder hemiarthroplasty with biological resurfacing of the glenoid. An examination reveals 130 degrees of painful elevation and 30 degrees of external rotation. Elevation and external rotation strength are both 5/5. The best next step is
222. intra-articular cortisone injection with manipulation under anesthesia.
223. arthroscopic capsular release and lysis of adhesions.
224. revision shoulder hemiarthroplasty with Achilles allograft resurfacing.
225. revision to unconstrained total shoulder arthroplasty (TSA).
226. revision to reverse TSA.

Answer 18

4. Revision to unconstrained total shoulder arthroplasty (TSA).

RECOMMENDED READINGS

Lee BK, Vaishnav S, Rick Hatch GF 3rd, Itamura JM. Biologic resurfacing of the glenoid with meniscal allograft: long-term results with minimum 2-year follow-up. J Shoulder Elbow Surg. 2013 Feb;22(2):253- 60. doi: 10.1016/j.jse.2012.04.019. Epub 2012 Aug 25. PubMed PMID: 22929583.

Hammond LC, Lin EC, Harwood DP, Juhan TW, Gochanour E, Klosterman EL, Cole BJ, Nicholson GP, Verma NN, Romeo AA. Clinical outcomes of hemiarthroplasty and biological resurfacing in patients aged younger than 50 years. J Shoulder Elbow Surg. 2013 Oct;22(10):1345-51. doi: 10.1016/j.jse.2013.04.015. Epub 2013 Jun 22. PubMed PMID: 23796385.

Bois AJ, Whitney IJ, Somerson JS, Wirth MA. Humeral Head Arthroplasty and Meniscal Allograft Resurfacing of the Glenoid: A Concise Follow-up of a Previous Report and Survivorship Analysis. J Bone Joint Surg Am. 2015 Oct 7;97(19):1571-7. doi: 10.2106/JBJS.N.01079. PubMed PMID: 26446964.

Question 19

234. Figures 234a through 234d are the radiographs and CT scans of an 86-year-old woman who fell and sustained a left elbow fracture. She has considerable pain in her elbow, an inability to flex or extend her elbow, and numbness and tingling in the ring and small fingers of her left hand. She lives in an assisted living facility and reports no problems with her elbow before the fall. Her history includes mild chronic lung disease, hypertension, diabetes, hyperlipidemia, peripheral neuropathy, gout, cardiomyopathy, renal failure, and a heart attack. What is the best treatment option to maximize function?
235. Observation with early mobilization
236. A 6- to 8-week casting period to allow the fracture to heal, followed by isolated ulnar nerve

transposition if the patient is still symptomatic

3. Open reduction and internal fixation (ORIF) with ulnar nerve transposition
4. Radial head excision with lateral ligamentous reconstruction and ulnar nerve transposition
5. Total elbow arthroplasty (TEA) with ulnar nerve transposition

Answer 19

5. Total elbow arthroplasty (TEA) with ulnar nerve transposition.

RECOMMENDED READINGS

Choo A, Ramsey ML. Total elbow arthroplasty: current options. J Am Acad Orthop Surg. 2013 Jul;21(7):427-37. doi: 10.5435/JAAOS-21-07-427. Review. PubMed PMID: 23818030.

Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg. 2010 Jan;18(1):20-30. Review. PubMed PMID: 20044489.

Question 20

253. During an anterior approach to the shoulder for a reverse total shoulder arthroplasty (TSA) with a concomitant latissimus dorsi/teres major transfer, retractors are placed along the superficial surface of the latissimus dorsi. Which nerve is most at risk during exposure?
254. Musculocutaneous
255. Axillary
256. Radial
257. Median
258. Ulnar

Answer 20

3. Radial

RECOMMENDED READINGS

Pearle AD, Kelly BT, Voos JE, Chehab EL, Warren RF. Surgical technique and anatomic study of latissimus dorsi and teres major transfers. J Bone Joint Surg Am. 2006 Jul;88(7):1524-31. PubMed PMID: 16818978.

Morelli M, Nagamori J, Gilbart M, Miniaci A. Latissimus dorsi tendon transfer for massive irreparable cuff tears: an anatomic study. J Shoulder Elbow Surg. 2008 Jan-Feb;17(1):139-43. PubMed PMID: 18069017.

Question 21

272. Figures 272a through 272e are the clinical photograph, radiograph, and MR images of a 40-year-old right-hand-dominant man who has severe pain in his right shoulder that began acutely 3 days ago while he was arm wrestling. He is an avid weight trainer and has a history of an open instability repair on the left and an arthroscopic instability repair on the right. He has been taking anti-inflammatory drugs, experiencing minimal pain relief. An examination reveals his active and passive motion above shoulder level is markedly restricted by pain, and rotator cuff strength testing is not tolerated. The most appropriate next step is
273. referral to pain management with continued sling use for 6 weeks.
274. referral to physical therapy for immediate shoulder mobilization.
275. arthroscopic subscapularis tendon repair.
276. open repair of the sternal head of the pectoralis major.
277. subpectoral long head biceps tenodesis.

Answer 21

4. Open repair of the sternal head of the pectoralis major.

RECOMMENDED READINGS

Petilon J, Carr DR, Sekiya JK, Unger DV. Pectoralis major muscle injuries: evaluation and management. J Am Acad Orthop Surg. 2005 Jan-Feb;13(1):59-68. Review. PubMed PMID: 15712983.

de Castro Pochini A, Andreoli CV, Belangero PS, Figueiredo EA, Terra BB, Cohen C, Andrade Mdos S, Cohen M, Ejnisman B. Clinical considerations for the surgical treatment of pectoralis major muscle ruptures based on 60 cases: a prospective study and literature review. Am J Sports Med. 2014 Jan;42(1):95-102. doi: 10.1177/0363546513506556. Epub 2013 Nov 5. Review. PubMed PMID: 24192390.

Lee J, Brookenthal KR, Ramsey ML, Kneeland JB, Herzog R. MR imaging assessment of the pectoralis major myotendinous unit: an MR imaging-anatomic correlative study with surgical correlation. AJR Am J Roentgenol. 2000 May;174(5):1371-5. PubMed PMID: 10789797.