Upper Limb (2008-2019)

Question 1

1. What are 4 stabilizers of the AC joint? (2014)

Answer 1

JAAOS - AC Joint Injuries:

• Static Stabilizers:
  
  • Joint capsule
  • AC ligaments
  • CC Ligaments
    
    • Conoid ligament (medial)
    • Trapezoid ligament (lateral)
• Dynamic Stabilizers:
  
  • Anterior deltoid muscle
  • Trapezius through fascial insertion on acromion

Question 2

2. What is the best indication for non-operative treatment of a Pec Major injury?
3. If the intimal fascia is intact and attached to the medial antebrachial fascia
4. Proximal tear in the muscle
5. No cosmetic deformity when the muscle is at rest
6. Inferior tear of the tendon because of the spiral orientation

Answer 2

ANSWER: B

2013, 2016

JAAOS – Pectoralis Major Tears

• Investing fascia is continuous with brachium and medial antebrachiam septum  can often be confused for an intact tendon on palpation (not option A)
• Indications for repair:
  
  • Complete tears, myotendinous junction, tendon tears
• ElMaraghy AW (JSES 2011)
  
  • Supports non-operative management of proximal muscle tears
  • Also, two people wrote in to JAAOS after that Pec Major tendon article was published to say they treat all their muscle tears (not avulsions) non-op, including in power lifters, and they have good results

Question 3

3.Which of the following is true about atraumatic SC joint arthritis

1. Common joint involved with RA
2. Elderly people get atraumatic anterior SC dislocations without generalized ligamentous laxity
3. Freidrich’s avascular necrosis produces irregularity and curving of the medial clavicle
4. Carroll will for sure get it because he throws a softball like a girl.

Answer 3

ANSWER: C

2013

JAAOS 2005 - Atraumatic Disorders of the SC Joint

• Rheumatoid arthritis has variable involvement, one study estimated 30%
• Spontaneous anterior subluxation generally occurs in teens or twenties in patients with ligamentous laxity
• Freidrich’s Disease
  
  • Aseptic osteonecrosis of the medial clavicle
  • Discomfort, swelling and crepitus of SC joint
  • Ipsilateral ROM loss

Question 4

4.Patient with hand pustules, acne, pain and swelling at SC joint. What is the diagnosis?

1. condensing osteitis
2. friedrich’s
3. sternal hyperostosis
4. infection

Answer 4

ANSWER: C

2011

JAAOS 2005 - Atraumatic Disorders of the Clavicle

• Sternocostoclavicular Hyperostosis
  
  • Rare disorder of soft-tissue ossification between clavicles associated with severe acne and palmoplantar pustulosis
  • Japanese males in 4-6th decade
•  SAPHO – synovitis, acne, pustulosis, hyperostosis osteomyelitis

Question 5

5.SC joint anterior dislocation. Best treatment?

1. Closed reduction and figure of eight brace
2. Open reduction and suture fixation
3. Do nothing
4. K wire fixation

Answer 5

ANSWER: A (but C is reasonable)

2011

JAAOS 2011 - Management of Traumatic Sternoclavicular Joint Injuries

• Closed reduction is the current treatment of choice, although there is still some controversy regarding management because good long-term results have been reported with nonsurgical management
• Patient under sedation, pressure on medial clavicle, immobilization with figure of eight brace x 6 weeks
• Most unstable after reduction, but if they do stay there is better cosmesis
  
  • Do not recommend open reduction
• Acute – closed reduction
• Chronic – do nothing

Question 6

6.What is the best view for AC joint?

1. Zanca view
2. Stryker notch
3. AP shoulder
4. Oblique View
5. Outlet coracoid view

Answer 6

ANSWER: A

2012

JAAOS 2009 - AC Joint Injuries

• Zanca View visualizes AC joint the best
• Done with beam tilted 10-15o cephalic

Question 7

7.The following are false regarding shoulder imaging, except:

1. West point view is best for imaging a Hill-Sachs lesions – glenoid bone loss
2. Garth view is good for Hill-Sachs and Bankart lesions
3. Xray is sufficient for assessing glenoid bone stock
4. MRI is best for assessing glenoid bone loss

Answer 7

ANSWER: B

2015

• Probably an all are false except
• JAAOS - Hill Sachs
  
  • Modified West Point axillary view –> glenoid bone loss
  • Stryker Notch View best for Hill-Sachs lesion
  • CT is a superior option for bone loss
• JAAOS - Bone Loss
  
  • “MRA studies may suggest the degree of bone loss in the most lateral glenoid cut on the sagittal oblique series. However, the current standard imaging modality for quantifying glenoid bone loss is CT”
  • Garth WP (JBJS 1984) Roentgenographic demonstration of instability of the shoulder: the typical oblique projection. A technical note
  • Showed a cross-sectional projection of the lesion in the posterolateral sector of the humeral head known as the Hill-Sachs lesion. The edge of the anteroinferior margin of the glenoid projecting into that lesion was also shown

Question 8

8. Injury to which nerve is least likely to result in scapular winging?
   a. Upper trunk – dorsal scapular
   b. Nerve to subscapularis
   c. Long thoracic
   d. Spinal accessory

Answer 8

ANSWER: B

2009, 2015

JAAOS - Scapular Winging

• Primary - dysfunction to serratus anterior, trapezius, rhomboids, levator
• Secondary - intra-articular glenohumeral
• Long thoracic = serratus anterior
• Spinal accessory = trapezius

Question 9

9. A man falls off a scaffold and has neck and arm pain with initial x-rays negative in the ER (he has no fractures). He doesn’t get better and shows up in your clinic 3mth later. His exam reveals scapular winging, weak shoulder abduction, numbness on the lateral aspect of the shoulder. What is the most likely diagnosis?
10. Long thoracic nerve palsy
11. C6 nerve root lesion
12. Axillary nerve palsy
13. Upper trunk injury
14. Posterior cord injury

Answer 9

ANSWER: B

2008, 2012, 2016

• Scapular winging = long thoracic nerve, therefore must be at least root
•  •C6 injury – weakness in wrist extension, diminished biceps reflex, sensation lateral forearm, could potentially give winging too via long thoracic nerve.
• Long thoracic nerve – serratus anterior palsy, medial scapular winging. Given off at root level (prior to trunk)
• Posterior cord – gives off upper (subscapularis) & lower (subscapularis & teres major) subscapular nerves, thoracodorsal nerve (latissimus dorsi), axillary and radial nerves. (C5-T1)
• Upper trunk – Lateral antebrachial cutaneous nerve, continuation of musculocutaneous, from lateral cord – sensation to lateral forearm

Question 10

10. What is the first priority during reconstruction of a traumatic brachial plexus injury?
11. Shoulder stability
12. Wrist extension
13. Protective sensation of the hand
14. Elbow flexion

Answer 10

ANSWER: D

2013

JAAOS - Traumatic Brachial Plexus Palsy

Priority of Functional Repairs:

1. Elbow flexion
2. Shoulder abduction and stability
3. Hand sensibility
4. Wrist extension and finger flexion
5. Wrist flexion and finger extension
6. Intrinsic Hand Function

Question 11

11. Most common location of suprascapular nerve compression
12. suprascapular notch
13. spinoglenoid notch
14. quadrilateral space
15. between scalene muscles

Answer 11

ANSWER: A

• 2011
• Operative Techniques in Shoulder and Elbow Surgery
  
  • The most common site is suprascapular notch, where it is compressed by a thickened or ossified transverse scapular ligament
• JBJS 1999 - Entrapment of the suprscapular nerve
  
  • “Most cases of entrapment occur when it courses under the transverse scapular ligament. The nerve then runs obliquely across the supraspinatus fossa toward the rim of the glenoid fossa and enters the infraspinatus fossa around the base of the spine of the scapula coursing beneath the spinoglenoid ligament, which is a much less common site of entrapment.”
  • Their series had 25 suprascapular notch and 7 spinoglenoid notch
  • In overhead athletes the spinoglenoid notch may be more common

Question 12

12. Young swimmer with shoulder pain. All are likely reasons except:
13. Muscle imbalance
14. Subacromial impingement
15. Multidirectional instability
16. Hypovascularity of the supraspinatus

Answer 12

ANSWER: D

2008

JAAOS 2016 - Swimmer’s Shoulder

• The Painful Shoulder
• Subacromial Impingement
• Hyperlaxity
• Scapular Dyskinesis (aka muscle imbalances)
• GIRD (posterosuperior cuff fray/tear)
• Labral Damage
• Suprascapular neuropathy

Question 13

13. Dude with 3 weeks of shoulder pain; no history of trauma. Complains of pain at night and progressive weakness for the last week. MRI is normal except for diffuse edema in the infra and supraspinatus muscles. (2015)

• What is the most likely diagnosis?
• What test would help you determine the diagnosis?

Answer 13

What is the most likely diagnosis?

• Parsonage Turner Syndrome

What test would help you determine the diagnosis?

Sudden onset pain, followed by flaccid paralysis

MRI:

• Early - increased T2/edema in muscles innervated by nerves affected
• Late - increased T1 signal –> fatty atrophy and infiltration

EMG:

• 96% abnormal
• Acute denervation with PSW and fibrillations at 3-4 weeks
• May see chronic denervation at 3-4 months

Suprascapular nerve block

Question 14

14. What are 3 local biologic or anatomic features predictive of non-healing after rotator cuff repair? (2016)

Answer 14

• JAAOS 2014 - Rehabilitation following arthroscopic Rotator Cuff Repair
• “The re-tear rate is related to patient factors such as:
  
  • Age
  • Tear size
  • Tissue quality
  • Fatty infiltration
  • And medical comorbidities
  • …as well as to surgical factors”
• From Jess’ CSES 2017 notes from lectures/small groups
  
  • Age >65 (this is not a local/anatomic factor)
  • Tear size (full thickness and involvement of >1 tendon)
  • Atrophy/fatty infiltration (Goutallier grade 3 or 4) / Tangent sign (if supra below)
  • Degree of muscle retraction (i.e. lateral tendon at level of glenoid)
  • Severely hooked acromion (type III)

Question 15

15. Excluding medical co-morbidities, what are 4 patient factors (not tear characteristics) that predict poor rotator cuff healing post operatively? (2013)

Answer 15

OKU 10

• Age older than 65 years
• Female sex
• Smoking
• Duration of symptoms
• Medical comorbidities
• Inability to elevate >100o
• Weak elevation and external rotation

Question 16

16. What predicts poor outcome following rotator cuff tear?
17. Pain with resisted external rotation
18. Acromiohumeral distance of 1cm
19. Small tear size
20. Weakness in forward elevation

Answer 16

ANSWER: D

2008, 2014, 2016

JAAOS 1994 - Iannotti

• Significant weakness of external rotation and significant muscular atrophy are associated with larger chronic full thickness tears
• “A less favorable prognosis for functional recovery following surgery also should be anticipated in patients with the constellation of large chronic rotator cuff defects, chronic rupture of the long head of the biceps tendon, marked weakness of forward flexion, chronic atrophy of the deltoid and cephalic migration of the humeral head when active elevation of the arm is attempted”
• Ellman H (JBJS 1986) Repair of the rotator cuff. End-result study of factors influencing reconstruction
• The strength of abduction and of external rotation before repair was of prognostic value: the greater the weakness, the poorer the result. The poorest results were in patients with strength ratings of grade 3 or less. Limitation of active motion preoperatively was also of prognostic value: in patients who were unable to abduct the shoulder beyond 100o preoperatively, there was an increased risk of a poor result. An acromiohumeral distance of 7mm or less suggested a larger tear and likelihood that there would be less strength in flexion, less active motion, and lower scores”

Question 17

17. Benefit of double-row repair for rotator cuff tear:
18. Better in large tears
19. No difference in biomechanical outcomes
20. No difference in clinical outcomes
21. No difference in costs

Answer 17

ANSWER: C

2015

• JAAOS 2014 - single-row versus double-row rotator cuff repairs
  
  • “double-row repair configurations for rotator cuff tears provide a superior biomechanical construct and improved footprint coverage. However, clinical studies are needed to determine whether double-row repairs provides substantially better structural healing or functional outcomes than does single-row repair”
  • “…justify the increased surgical time and expense of double row repair”
• (JBJS 2010) Outcomes of Single Row and Double Row Arthroscopic Rotator Cuff Repair
  
  • No difference in clinical outcomes
  • One study shows double row better for massive tears (>3cm) compared to small-medium tears

Question 18

18. What is the main disadvantage of using absorbable suture anchors for rotator cuff repair?
19. Infection
20. Reduced pull-out strength
21. Biological reaction
22. Modulus of elasticity?

Answer 18

ANSWER: C

2016

JAAOS 2012 - Tissue Anchor Use in Arthroscopic Glenohumeral Surgery

• Comparisons of the mechanical strength of bio absorbable and metal anchors have yielded mixed results; some studies report inferior biomechanical characteristics, whereas others report equivalent profiles”
• “additional evidence of inflammatory response to bio absorbable anchors, which may lead to bone osteolysis, chondral damage and significant morbidity has also been reported”

Question 19

19. What is true about tendon transfers for massive rotator cuff tears?
20. Pectoralis major transfer can be used for subscapularis deficiency
21. A latissimus dorsi transfer is indicated for supraspinatus, infraspinatus and subscapularis deficiency
22. When doing a pec major transfer, it should pass above the conjoint tendon

Answer 19

ANSWER: A

C also right

2016

• Latissimus dorsi transfer for irreparable subscapularis tendon tears – MUN 2018 JSES
  
  • LD transfer resulted in pain relief and restoration of shoulder range of motion and function. LD transfer could be considered an effective and safe salvage treatment for irreparable subscapularis tears.
• JAAOS - Tendon Transfers for Irreparable Rotator Cuff Tears
  
  • Latissimus for irreparable posterosuperior tears –> wouldn’t reach subscap
  • Subcoracoid pectoralis major transfer better approximately the force vector originally provided by the subscap
  • The pec major tendon gets transferred under the conjoined tendon for the transfer. If there is not enough space under the conjoined tendon, only a partial pec major tendon transfer can be done. The location of musculocutaneous nerve must be known because the pec major tendon should lie superficial to it (i.e. in a tunnel between the deep musc n. and the superficial conjoined tendon)

Question 20

20. During an extensive rotator cuff repair, the subscapularis is released using the following releases EXCEPT
21. Superior margin released from coracoid
22. Posterior surface is released from anterior capsule, superior glenoid neck, plexus
23. Inferior border released from axillary nerve and circumflex vessels
24. Anterior surface released from conjoint tendon

Answer 20

ANSWER: B

2008

JAAOS - Subscapularis Tears 2005

360o release

• Superior margin from coracoid
• Posterior surface from anterior capsule and scapular neck
• Inferior border from axillary nerve and circumflex vessels
• Anterior surface from conjoined tendon

Question 21

21. What are 3 ways in which a Laterjet procedure through a split subscapularis stabilizes the glenohumeral joint? (2014, 2015)

Answer 21

JAAOS 2009 - Glenoid Bone Deficiency

• Increased glenoid bone stock
• Capsulolabral repair (may be augmented by attachments of the released coracoacromial ligaments to the labrum)
• Dynamic sling via transfer of conjoined tendon

Question 22

22. Acute posterior shoulder dislocation with large anterior humeral bone defect? What are the most appropriate surgical treatment options (2010, 2012, 2014, 2015)?

Answer 22

JAAOS 2012 Hill Sachs Lesion/JAAOS 2014 Acute Traumatic Posterior Dislocation

• Disimpaction (must be <3 weeks old)
• McLaughlin - isolated subscap transfer into defect
• Modified McLaughlin - subscap transfer with LT
• Osteochondral allograft (i.e. from cadaver humeral head usually)
• Hemiarthroplasty/TSA
• Humeral head re-surfacing
• Rotationplasty (historical)

Question 23

23. Flexion, Adduction and internal rotation of the shoulder. Which structure is primarily responsible for posterior stability?
24. Superior Glenohumeral and Coracohumeral
25. Middle glenohumeral
26. Teres minor and infraspinatus
27. Posterior inferior glenohumeral ligament and posterior labrum

Answer 23

ANSWER: D

2013

Charles and Clay: 45-90 of GH elevation = posterior IGHL vs Arm on side (0 GH elevation) = SGHL

• Jerk test evaluates posterior band of IGHL and posterior labrum and simulates this position
• AAOS Comprehensive Review
  
  • The posterior IGHL is a primary static restraint against postero-inferior translation in internal rotation and adduction
• Miller’s Orthopedics - Table 4-8
  
  • SGHL/CHL –> Forward flexion/abduction/IR –> stabilizes posterior translation
• JAAOS 2014 - Acute Traumatic Posterior Dislocation
  
  • Coracohumeral ligament and superior glenohuemral ligament provide little anterior resistance, but help prevent posterior translation in the flexed, adducted, and internally rotated shoulder
  • Inferior glenohumeral ligament is the main stabilizer against posterior dislocation
  • The posterior band of the inferior glenohumeral ligament restricts posterior displacement with the arm in abduction
• JBJS Current Concepts Review 2015 - Posterior Instability
• The posterior band of the IGHL is the most important stabilizer in adduction, flexion and internal rotation

Question 24

24. What is the main stabilizer to posterior shoulder translation when the shoulder is in flexion, abduction, and internal rotation? REPEAT
25. SGHL and Coracohumeral ligament
26. MGHL and Arcuate ligament
27. IGHL – Posterior Band
28. Infraspinatus and teres minor

Answer 24

ANSWER: C

2012

• Miller’s Orthopedics - Table 4-8
  
  • SGHL/CHL –> Forward flexion/abduction/IR –> stabilizes posterior translation
• JAAOS 2014 - Acute Traumatic Posterior Dislocation
  
  • Coracohumeral ligament and superior glenohuemral ligament provide little anterior resistance, but help prevent posterior translation in the flexed, adducted, and internally rotated shoulder
  • Inferior glenohumeral ligament is the main stabilizer against posterior dislocation
  • The posterior band of the inferior glenohumeral ligament restricts posterior displacement with the arm in abduction

Question 25

25.  What is a static restraint of the GH joint?
    a. CH ligament
    b. CA ligament
    c. biceps
    d. negative intra-articular pressure

Answer 25

ANSWER: D

2015

Miller’s Orthopedics (p. 320)

• Static Restraints:
  
  • Glenoid labrum, articular version, articular conformity, negative pressure, capsule, capsuloligamentous structures
• Dynamic Restraints:
  
  • Joint concavity compression by cuff
• Pagnani MJ (JSES 1994) Stabilizers of the glenohumeral joint
  
  • The coracohumeral ligament appeared to have no significant suspensory role

Question 26

26. What is not a risk factor for redislocation following Bankart repair:
27. Contact sport
28. Hill Sachs visible on external rotation x ray
29. Age >40yrs
30. Ligamentous hyperlaxity

Answer 26

ANSWER: C

2015

JAAOS 2014 - Anterior Glenohumeral Instability

Risk Factors for failure of arthroscopic capsulolabral repair:

• Ligamentous laxity
• Hill-Sachs > 250mm3
• Immobilization <4 weeks
• <28 years old
• Glenoid bone loss > 15%
• Contact sports

ISIS score components

• Age at surgery < 20
• Competitive sports
• Contact or forced overhead sports
• Shoulder hyperlaxity
• Hill-Sachs visible on ER A/P radiograph
• Glenoid loss of contour on AP radiograph

Question 27

27. Regarding a Hill-Sachs lesion following anterior shoulder dislocation, which of the following is true?
28. Located in the posterolateral aspect of the humeral head
29. Is the most common cause of recurrent dislocation
30. Best seen on AP view
31. Best seen on the AP view with the humerus in maximal external rotation

Answer 27

ANSWER: A

2012, 2014

• The Hill-Sachs lesion: diagnosis, classification, and management. JAAOS. 2012
  
  • “The Hill-Sachs lesion is a compression fracture of the posterosuperolateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint.”
  • Stryker notch view is most specific for evaluating a Hill-Sachs lesion - adduction and internal rotation view brings posterolateral aspect of humeral head into view
  • Lesions <20% of humeral head are of no clinical significance; lesions >40% are nearly always clinically significant and can result in recurrent anterior instability - basis of classification system (Flatow & Warner)
  • Consider all GH anatomy when planning treatment - small HS lesions can be clinically significant in the setting of large glenoid bone loss
  • Address primary problem prior to addressing HS lesion = Bankart or glenoid bone loss
  • Surgical options for HS lesions include auto/allograft, soft tissue filling (remplissage), disimpaction, hemiarthroplasty/resurfacing
• Note: the ISIS score looks at whether the Hill-Sachs is visible on an AP view with the shoulder in maximal ER but this is NOT the best way to see it. IR is best, but they used ER for their score because they found that if the lesion was seen on a maximal ER view then it was located more superior on the head and therefore more likely to be engaging and associated with instability.

Question 28

28. Patient with a Hill Sachs lesion. All of the following are choices for surgical treatment, except:
29. Lesser Tuberosity transfer into defect
30. Infraspinatus transfer into the defect
31. Allograft humeral head to fill the defect
32. Remplissage

Answer 28

ANSWER: A

2013

• JAAOS – The Hill Sachs Lesions
• Surgical management:
  
  • Capsular Shift
  • Glenoid bone augmentation
  • Humeral head bone augmentation
    
    • Autograft, fresh or frozen allograft or synthetic
  • Tissue Filling (Replissage)
  • Connolly procedure = open procedure involving transfer of the infraspinatus and portion of GT into defect
  • Remplissage:
    
    • Converted to extra-articular defect with soft-tissue coverage
    • Arthroscopic posterior capsulodesis and infraspinatus tenodesis with fixation to the surface of the Hill sachs defect
  • Disimpaction
  • Resurfacing/Prosthesis
• Posterior Instability:
  
  • McLaughlin = open transfer of the subscap tendon and LT to fill humeral head defect

Question 29

29. What is true about recurrent traumatic shoulder dislocation?
30. Females have more recurrent traumatic shoulder dislocation
31. More likely if Glenoid fracture

Answer 29

ANSWER: B

2016

Question 30

30. All the following are components of the rotator cuff interval EXCEPT?
31. CHL
32. SGHL
33. Glenohumeral joint capsule
34. Short head of biceps tendon

Answer 30

ANSWER: D

2014

• OKU Shoulder and elbow 4
  
  • Rotator interval is the area of the capsule between the supraspinatus and subscapularis, includes the…
    
    • SGHL
    • Coracohumeral ligament
    • Long head of biceps
  • Contracture common in adhesive capsulitis, should release if treating arthroscopically
  • Laxity in instability, tightening is controversial

Question 31

31. 50 M fell and had anterior dislocation of shoulder. Reduced in ER 1 hour after dislocation. Presents to office 1 week later with full passive ROM but weak Abduction. Why?
32. RTC tear
33. Axillary nerve injury
34. Frozen Shoulder
35. C6 root injury

Answer 31

ANSWER: A

2011

• Neviaser RJ (JBJS 1988) Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient
  
  • 31 patients unable to abduct arm after reduction of primary dislocation
  • All patients older than 35
  • 29 presumed to have axillary nerve injury –> only 1/24 positive on EMG
  • 7.8% axillary nerve injury, 100% rotator cuff tear

Question 32

32. Mechanism of action for posterior should dislocation
33. Abduction, ER
34. Abduction, IR
35. Elevation, ER
36. Elevation, IR

Answer 32

ANSWER: D

2008

Question 33

33. Posterior shoulder instability. All are true EXCEPT
34. Dislocation is more common than subluxation
35. Non operative treatment is usually satisfactory
36. Posterior Bankart is unusual
37. Commonly associated with multidirectional subluxation

Answer 33

ANSWER: A

2008

 

Question 34

34. Posterior shoulder dislocation is associated with. All of the following except:
35. Pts can voluntarily dislocate their own shoulder
36. Glenoid osteotomy is no longer indicated
37. Surgery is often helpful
38. Subluxation is more common than dislocation

Answer 34

ANSWER: B

2009

JAAOS 2017 – Posterior GH instability: Evidence based treatment

Question 35

35. Give the 4 types of SLAP tears. (2011)

Answer 35

Snyder Classification:

1. Labral fraying
2. Fraying with detached biceps tendon anchor
3. Bucket handle tear, intact biceps tendon anchor
4. Bucket hand with detached biceps anchor (bucket extends up biceps)

Question 36

36. What are 3 mechanisms of injury for a SLAP tear? (2010, 2013, 2015)

Answer 36

JAAOS 2009 - Superior Labral Tears of the Shoulder

• Forceful traction injury to the arm
• Direct compression load/blow
• Repetitive overhead throwing activities (peel back)

Question 37

37. List 4 ways to determine the correct height of a humeral prosthesis in a hemiarthroplasty performed for a 3-4 part fracture (2016)

Answer 37

JAAOS 2012- Hemiarthroplasty for three and four part proximal humerus fractures

• Top of prosthesis should be 5.6cm from upper border of pec major
• GT 10mm below articular surface
• GT/LT fragments reduce without tension
• GT superomedial corner 4.2cm above the pec major insertion
• (GT should be between 10-16mm from superior margin of the humeral head, over or under reduction correlated with poor results)

Side note: should be in 20-30deg retroversion as measured from the epicondylar axis.

Can be done by placing lateral fin of prosthesis 30deg posterior to posterior edge of bicipital groove’

CORR Course:

Size/template other side

Intra-operative fluoro

Question 38

38. All of the following are true in patients with Adhesive Capsulitis, except ?
39. Associated with thyroid disease
40. Relief with corticosteroid injection
41. Favorable natural history for resolution
42. Impingement test will be positive

Answer 38

ANSWER: D

2010, 2012

JAAOS Adhesive Capsulitis

• Associated Conditions:
  
  • Cardiovascular disease
  • Thyroid dysfunction/ACTH deficiency
  • Breast cancer treatment
  • Risk factors –> CVA, MI, DM
  • DM has worse prognosis
  • Minor trauma to limb
  • Heart Disease, cardiac surgery
  • Parkinsonism
  • Malignancy
  • Hyperlipidemia
  • Drugs –> MMP inhibitors (glaucoma), antiretroviral, pneumococcal/influenza vaccine, fluoroquinolones
  • Dupuytren’s contracture
• Transient pain relief with corticosteroid injections
• Natural resolution of symptoms with mild treatment

Question 39

39. 18 year-old female presents to you complaining of her shoulder going “in and out” when swimming or playing volleyball. Never had a traumatic dislocation. Which of the following is the best option for treatment of her instability?
40. Bankart repair
41. Magnuson-Stack procedure
42. Inferior capsular shift
43. Putti-Platt procedure

Answer 39

ANSWER: C

2012

JAAOS - Management of Multidirectional Instability of the Shoulder

Reconstructive techniques include glenoid osteotomy, labral augmentation, capsuloligamentous reconstruction

Open Inferior Capsular Shift

Question 40

40. Most common cause of upper extremity neuropathic arthropathy(charcot)?
41. Syringomyelia
42. Diabetes
43. Syphilis
44. Multiple Sclerosis
45. Hansen - leprosy

Answer 40

ANSWER: A

2012

JAAOS 1996 - Neuropathic Arthropathy + Millers 8th edition p.40

• Neuropathy in the shoulder (upper extremity) is most commonly associated with syringomyelia
• Second most common charcot upper extremity arthropathy is Hansen-Leprosy

 

Question 41

41. Lady with mild trauma, no pain, not wearing a splint, xray shows destroyed distal radius. How do you make the diagnosis. No constitutional symptoms.
42. EMG
43. ESR/CRP
44. MRI C Spine
45. HbA1c

Answer 41

ANSWER: C (first to r/o syrinx then DM2)

2008

• Jackson et al. 2012. Charcot arthropathy of the wrist associated with cervical spondylotic myelopathy.
• The most frequently cited cause of Charcot arthropathy of the upper extremity is syringomyelia, and magnetic resonance imaging of the cervical spine should be obtained at presentation.

Question 42

42. What is not true about internal impingement of the shoulder in a throwing athlete?
43. Results in full-thickness RC tear
44. Treatment with sleeper stretches
45. Tight posterior capsule
46. Associated with mild shoulder instability

Answer 42

ANSWER: A

2014, 2016

JAAOS 2007 - Understanding Shoulder and Elbow Injuries in Baseball

• Internal impingement has been through to have the following etiologies contributing: traction on biceps tendon, laxity of anterior band of IGHL caused by excessive external rotation stretch, posterior capsular tightness and scapular dyskinesia

JAAOS - Posterior Capsular Contracture of the Shoulder:

• Non-operative treatment includes sleeper stretches
• Micro-instability is associated

OKU Shoulder and Elbow:

• Regardless of their etiology, injuries to the throwing shoulder share many final sequelae, including superior labrum anterior to posterior (SLAP) tears, proximal biceps pathology, partial thickness rotator cuff tears, and scapular dyskinesia
• “Full thickness tears are uncommon, but partial thickness articular sided tears are almost ubiquitous in throwing athletes”

Question 43

  43. Regarding thoracic outlet syndrome. Which of the following is true:

1. Compression between the anterior scaline and SCM
2. Positive Watson test
3. Elevation of the scapula
4. More common in males
5. Adson Test +

Answer 43

Answer: E.

• C is false: depression
• D is false: women more common
• B is false: SL instability
• A is false: anterior and middle scalene

2008, 2014 (confirmed McGill)

2008 question has female gender which I like best

• JAAOS 2015 - Thoracic Outlet Syndrome
  
  • Thoracic outlet is interval from supraclavicular fossa to axilla (between clavicle and first rib)
  • Typical patient is young, thin, female with a long neck and drooping shoulders
  • Compression:
  • Inter-scalene -anterior scalene, middle scalene, first rib
    
    • Subclavian artery, trunks of brachial plexus
  • Costo-clavicular - clavicle, subclavius, costocorocoid ligament
    
    • Subclavian vessels, divisions of brachial plexus
  • Retro-pectoralis - inferior to coracoid process
    
    • Brachial plexus, axillary artery and vein
• Provocative Tests:
  
  • Wright - decrease in pulse with hyper-abduction and ER with head on opposite side
  • Adson - extension with head towards side + deep breath
  • Roos - 90o abduction, elbows 90o + hand open/close

“Nonsurgical management is reported to be less successful in obese patients, in patients who are on workers’ compensation, and in patients with double-crush neurologic pathology involving the carpal or cubital tunnels.”

Question 44

44. Thoracic outlet syndrome, which is false?
45. Vascular cause accounts for 5%
46. Adson’s is sensitive but not very specific
47. Can be tested my abducting arm and internally rotating shoulder
48. Cervical rib is most common X ray finding

Answer 44

ANSWER: C

2010

• Wright test is symptoms with abduction an EXTERNAL rotation
• Tests are neither sensitive nor specific (50-70% range)
• ” Gergoudis et al1challenged the clinical utility of this test by showing that 66 of 130 normal persons (51%) had a diminished pulse with the Adson maneuver.” (JAAOS)
• “In a series by Gillard et al. the specificity for the Adson test and for the Roos test was 76% and 30%, respectively; however, when both tests were positive, specificity increased to 82%.”
•  

Question 45

45. Thoracic outlet, all of the following true except
46. 50% vascular
47. Occurs in females more often
48. Can present with C8-T1 nerve symptoms
49. First event can present with thrombosis

Answer 45

ANSWER: A

2008

JAAOS 2015 - Thoracic Outlet Syndrome

• Vascular causes rare (3-5% venous, <1% arterial)
• Females are more common
• Neurogenic (90%)
• Lower and combined plexus presentation is more common (85-90%)
• Arterial cases –> can develop and aneurysm, thrombosis and limb threatening ischemia

Question 46

46. Rate of return to play at same level following SLAP repair:
47. 5%
48. 20%
49. 50%
50. 80%

Answer 46

ANSWER: C

2015

• Brockmeier SF (JBJS 2009) Outcomes after arthroscopic repair of type II SLAP lesions
  
  • 47 patients at 2 years following arthroscopic SLAP repair with suture anchors
  • Return to sport (same level) = 74%
• Neuman BJ (AJSM 2011) Results of arthroscopic repair of type II SLAP in overhead athletes
  
  • 30 patients at 3.5 years
  • 84% return to preinjury level of function

Question 47

47. What is a cause of glenoid loosening in total shoulder arthroplasty in rotator cuff arthropathy?
    a. superior eccentric wear
    b. concentric wear
    c. posterior eccentric wear

Answer 47

ANSWER: A

2015

JAAOS 2007 - Rotator Cuff Tear Arthropathy

• “Patients with cuff deficiency demonstrated significantly greater superior migration of the humeral prosthesis on the glenoid component compared with patients with no rotator cuff deficiency. The investigators suggested that this superior displacement of the humeral head on the glenoid led to loosening of the glenoid component and a “rocking horse” phenomenon of glenoid loosening”
• Matsen, F (JBJS 2008) Glenoid component failure in total shoulder arthroplasty
• As a special type of glenohumeral instability, the superior subluxation seen with massive rotator cuff deficiency is an important cause of eccentric loading, creating the risk of rocking-horse loosening of the glenoid component

Question 48

48. Most common cause of anterior shoulder instability after TSA?
49. humeral anteversion
50. glenoid anteversion
51. subscap repair failure
52. Posterior capsule not released

Answer 48

ANSWER: C

2011

Bohsali KI (JBJS 2006) Complications of TSA

• Anterior and superior instability accounted for 80% of instability cases
• Anterior instability is associated with humeral component malrotation, anterior glenoid deficiency, anterior deltoid muscle dysfunction, failure of the subscapularis tendon and anterior aspect of the capsule

Moeckel (JBJS 1993)

• 100% of shoulders with anterior dislocation had subscap insufficiency (granted only 7 shoulders)

Question 49

49. What is a cause of poor outcomes for shoulder hemiarthroplasty?
50. Rotator Cuff Tear
51. Non concentric wear on glenoid
52. Eburnated bone on glenoid
53. Circumferential capsular release

Answer 49

ANSWER: B

2008

• Levine WN (JSES 1997) Hemiarthroplasty for glenohumeral osteoarthritis: Results correlated to degree of glenoid wear
  
  • 31 shoulders
  • 86% satisfaction with concentric shoulders, 63% with non-concentric glenoids
• Ianotti JP (JBJS 2003) Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis
  
  • 128 shoulders at 46 months
  • 10% had supraspinatus tear - no effect on ASES, decrease in pain or satisfaction
  • Patients with posterior subluxation of humeral head had worse outcomes
• Levine WN (JBJS 2012) long term follow up of shoulder hemiarthroplastyfor glenohumeral osteoarthritis
  
  • 25% satisfaction at 17 years
  • Concentric glenoids and primary OA do better than non-concentric glenoids and secondary arthritis

Question 50

50. What is not a cause of medial elbow pain in a throwing athlete:
51. Ulnohumeral arthritis
52. Cubital tunnel syndrome
53. Valgus extension overload
54. Flexor-pronator tendonitis

Answer 50

ANSWER: A

2013, 2015

JAAOS 2001 - Medial Elbow Problems in the Over-head Throwing Athlete

• Valgus instability
• Valgus Extension Overload
• Medial Epicondylitis (flexor-pronator mass)
• Ulnar Neuropathy:
  
  • “athletes with ulnar neuropathy usually present with intermittent medial elbow pain that may occasionally radiate down the medial aspect of the forearm into the hand”

Question 51

51. Which ligament is the main stabilizer during early acceleration?
52. Posterior band of MCL
53. Anterior band of MCL
54. LCL
55. Flexor pronator mass

Answer 51

ANSWER: B

2008