ORTHO MCQS Shoulder and Elbow 019

Shoulder and Elbow Scored and Recorded Self-Assessment Examination 2019

Question 1 of 100 Figures 1 through 3 are the radiographs of a 55-year-old woman who fell on her outstretched right arm, resulting in acute elbow pain and swelling. On examination, she has lateral elbow bruising with mechanical block to supination and pronation. She has no medial tenderness. She is unable to extend her elbow within 60° of full extension. During surgery utilizing a direct lateral approach, the surgeon observes a completely bare lateral epicondyle. After surgical repair, a stable and congruent joint is achieved. Initial postoperative rehabilitation should include

PREFERRED RESPONSE: C DISCUSSION:

Radial head fractures are thought to occur as a result of valgus posterolateral rotary load across the elbow, although the mechanism can certainly vary. Minimally or nondisplaced fractures without any clinical instability or block to motion can often be successfully managed non-surgically. Fractures with >2 mm of displacement or fragments that block motion require surgical repair. A critical aspect during surgery is identifying concomitant injury to the lateral collateral ligament complex (LCL). When encountered, the LCL will be avulsed from its origin from the lateral epicondyle, resulting in a bare area. After the radial head is either reduced and fixed or replaced (Figures 4 and 5), the LCL should be repaired back to its anatomic origin. Postoperatively, the surgeon must communicate to the therapist that elbow extension exercises should be performed with the forearm in pronation as a result of the compromised LCL. Elbow extension exercises in supination and neutral are recommended for compromised medial collateral ligament or combined medial and lateral ligament injury, respectively. Without any medial elbow bruising, swelling, or tenderness, it is unlikely that the patient has an injury to the medial collateral ligament.

 

 Question 2 of 100 A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a comminuted intra-articular distal humerus fracture. What is the best surgical option?

1. Open reduction internal fixation (ORIF) with parallel plates

2. ORIF with orthogonal plates and iliac crest bone grafting

3. Total elbow arthroplasty (TEA)

4. Closed reduction and percutaneous pinning

PREFERRED RESPONSE: C DISCUSSION:

TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower resurgical rate; one- quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again

superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities  that  compromise  bone  stock,  including  osteoporosis  and  oral  corticosteroid  use.  Closed

 reduction and percutaneous pinning studies have not been published on the adult population.

 

 Question 3 of 100 A complication associated with using the Morrey approach (triceps reflecting) to implant  a semiconstrained total elbow arthroplasty is

1. loss of elbow extensor power.

2. implant dislocation.

3. implant malposition.

4. development of heterotopic ossification.

PREFERRED RESPONSE: A DISCUSSION:

Numerous approaches can be used to implant a total elbow arthroplasty. The Morrey approach identifies, transposes, and protects the ulnar nerve, and then subperiosteally reflects the triceps off the ulna. The sleeve of tissue is very thin distally, and the triceps need to be meticulously repaired at the time of closure. Implant dislocation and malposition are less likely with an extensile approach, and dislocation is unlikely with a semiconstrained implant. The development of heterotopic ossification is unrelated to the surgical approach

 used for elbow arthroplasty.

 

 Question 4 of 100 Figures 1 through 4 are the radiographs of a 55-year-old healthy woman who fell down a flight of steps while sleepwalking. When the surgeon replaces the radial head, the elbow dislocates posteriorly at 60° of flexion as it is brought out from full flexion. What is the best next step?

PREFERRED RESPONSE: D DISCUSSION:

The coronoid is important for elbow stability, particularly as the elbow is moved into extension. Repairing the LCL alone after radial head replacement in “terrible triad” injuries may suffice when there is a type 1 coronoid fracture or an anterior capsular avulsion. For more extensive coronoid injuries, live dynamic examination of stability is needed to determine whether repair of the coronoid is needed. For this patient, doing nothing further will lead to immediate postsurgical instability, and repairing the LCL complex alone will not lead to stability.

The posterior band of the MCL will not add to stability. The next step to attain stability is to repair the coronoid

 fracture and re-examine the elbow for stability.

 

 Question 5 of 100 A 45-year-old man falls from a skateboard and dislocates his elbow. After a closed reduction in the emergency department, his elbow is carefully examined. He has positive valgus stress, moving valgus stress, and milking maneuver tests. His elbow appears stable to varus stress and lateral pivot shift tests. What is the most appropriate manner of immobilizing the elbow for this patient?

1. Sling for 3 days, with early active range of motion

2. Posterior splint for 5 to 7 days, forearm in full pronation

3. Posterior splint for 5 to 7 days, forearm in neutral

4. Posterior splint for 5 to 7 days, forearm in full supination

PREFERRED RESPONSE: D DISCUSSION:

Varus posteromedial rotatory instability occurs following a fall onto an outstretched hand with axial loading and a varus stress to the elbow. This injury can result in a rupture of the posterior band of the medial collateral ligament (MCL), fracture of the anteromedial facet of the coronoid, and avulsion of the lateral ulnar collateral ligament (LUCL). Based on the examination findings, this patient has an acute MCL rupture. Furthermore, the LUCL appears intact, as evidence by the stability with varus stress. To protect the reduction in the acute setting, posterior splinting is recommended, but placing the forearm in full supination tightens the structures medially where the MCL is deficient. Splinting in neutral is indicated for valgus posterolateral rotatory instability, where both the LUCL and MCL are ruptured. Splinting in full pronation is indicated for isolated LUCL ruptures. Early active range of motion is not recommended for adults immediately after an acute elbow dislocation, as ligamentous injury or fracture nearly always accompanies the dislocation. In this case, the

 forearm should be splinted in full supination.

 

 Question 6 of 100 A  38-year-old  man  sustains  a  terrible  triad  injury consisting of  an  elbow  dislocation, comminuted and displaced radial head fracture, and a type I coronoid fracture. Intraoperative findings after radial head replacement and lateral collateral ligament complex repair reveal persistent instability consisting of medial opening on valgus stress and posteromedial subluxation of the ulnohumeral and radiocapitellar joints. What is the best next step?

1. Medial collateral ligament repair or reconstruction

2. Reconstruction of the radial collateral ligament

3. Resection of the type I coronoid fracture and capsular repair to the remaining coronoid

4. Open reduction and buttress plating of the coronoid fracture

PREFERRED RESPONSE: A DISCUSSION:

Terrible triad injuries of the elbow are common, and the management of type I coronoid tip fractures remains controversial. Type I coronoid fractures result in only small changes in elbow kinematics that have been shown to be uncorrected with suture repair. A type I coronoid tip fracture is not amenable to buttress plate fixation. The radial collateral ligament is a component of the lateral collateral ligament complex and has already been repaired. The persistent medial laxity and posteromedial joint subluxation noted is indicative of ongoing instability. The next step would be repair or reconstruction of the medial collateral ligament, which will

normally correct the medial instability. Articulated versus static external fixation can be considered if

 restoration of the ligamentous constraint of the medial side of the elbow cannot be accomplished surgically. 

 

 Question 7 of 100

When performing an ulnar nerve decompression at the elbow, the surgeon must be aware of the

 

PREFERRED RESPONSE: B DISCUSSION:

The medial antebrachial cutaneous and medial brachial cutaneous are nerves that can be injured during ulnar nerve decompression at the elbow. The medial antebrachial cutaneous nerve crosses the surgical field at an average of 3.1 cm distal to the medial epicondyle. The medial brachial cutaneous nerve crosses the field 7 cm proximal to the medial epicondyle and arborizes into two to three terminal branches. Because the surgical approach involves dissection on the medial side, the posterior antebrachial cutaneous nerve is distant from the exposure. Although the median nerve potentially can be located in the deep dissection of a submuscular

 transposition, it is considered distant to an in situ decompression.

 

 Question 8 of 100

Figures 1 through 3 are the radiographs of a 45-year-old man following acute trauma.

 

Following radial head replacement, the elbow exhibits persistent laxity to valgus stress in extension. What is the best next step to regain stability?

PREFERRED RESPONSE: D DISCUSSION:

Longitudinal forearm instability is an indication for radial head replacement to prevent proximal migration of the  radial  shaft.  Radial  head  replacement  is  indicated  in  radial  head  fractures  involving three  or more

fragments. Younger age is not a contraindication or indication for radial head replacement. Anteromedial coronoid facet fractures usually are associated with a posteromedial rotatory mechanism that does not increase or decrease risk for radial head fractures necessitating replacement. Following restoration of the radial head, a lateral collateral ligament repair would be the next step to restore stability if necessary. MCL repair would restore medial stability if stability persisted following restoration of posterolateral laxity. Repair of type I coronoid fractures does not substantially affect stability. Application of a hinged external fixator can restore stability in severe cases but is usually reserved for refractory instability after ligament repair has been performed and instability persists. Anterior and posterior capsular repair do not significantly affect instability. MCL repair is generally the next step to obtain stability, with application of a hinged external fixator as a last

 step to maintain joint congruity.

 

 Question 9 of 100 A 42-year-old woman sustains a closed posterior elbow dislocation. A closed reduction is performed, and the elbow appears stable under fluoroscopic examination. Initial treatment should consist of

1. early mobilization only.

2. surgical reconstruction of medial and lateral collateral ligaments.

3. active motion in a hinged brace from 30° to 120°.

4. application of hinged external fixator with early mobilization.

PREFERRED RESPONSE: A DISCUSSION:

This is a simple (no associated fracture) elbow dislocation. Such dislocations can be treated with closed reduction followed by mobilization after 5 to 7 days to avoid stiffness, provided the elbow is stable through a full arc of motion at the time of reduction. If the elbow is unstable but has a short arc of stability, then using a hinged brace in the stable arc may be considered. (Note: It may be necessary to splint the elbow in pronation if the medial collateral ligament [MCL] is intact and the lateral collateral ligament [LCL] is disrupted, or in supination if the LCL is intact but the MCL disrupted.) Surgical reconstruction of the LCL and MCL may be required only if the elbow does not have a stable arc at the time of reduction. If unstable after reconstruction,

 application of a hinged external fixator may be considered.

 

 Question 10 of 100 Figures 1 through 3 are the radiographs of a 45-year-old man following acute trauma. Which radiographic finding indicates the likely need for a radial head replacement?

 

 

PREFERRED RESPONSE: C

DISCUSSION:

 

Longitudinal forearm instability is an indication for radial head replacement to prevent proximal migration of the radial shaft. Radial head replacement is indicated in radial head fractures involving three or more fragments. Younger age is not a contraindication or indication for radial head replacement. Anteromedial coronoid facet fractures usually are associated with a posteromedial rotatory mechanism that does not increase or decrease risk for radial head fractures necessitating replacement. Following restoration of the radial head, a lateral collateral ligament repair would be the next step to restore stability if necessary. MCL repair would restore medial stability if stability persisted following restoration of posterolateral laxity. Repair of type I coronoid fractures does not substantially affect stability. Application of a hinged external fixator can restore stability in severe cases but is usually reserved for refractory instability after ligament repair has been performed and instability persists. Anterior and posterior capsular repair do not significantly affect instability. MCL repair is generally the next step to obtain stability, with application of a hinged external fixator as a last step to maintain joint congruity.

 

 Question 11 of 100 A 36-year-old right-hand-dominant man falls from his motorcycle and sustains the acute right upper extremity injury seen in Figure 1. At surgery, an open reduction and internal fixation (ORIF) of the ulna is performed along with attempted open reduction of the radiocapitellar joint. However, the radial head is slightly subluxed in flexion and redislocates with elbow extension <90°. What is the most appropriate treatment at this time?

PREFERRED RESPONSE: C DISCUSSION:

This case is a variant of a type I Monteggia fracture according to the Bado classification, with a segmental ulna fracture. In some cases, the radial head subluxation can be subtle, and missing this would lead to a poor outcome. In this case, the anterior radial head dislocation is obvious, but the segmental nature of the ulna fracture makes anatomic reduction difficult. The radial head usually spontaneously reduces once the ulna is anatomically reduced, and no surgical treatment to the lateral side is required. When this is not the case, a

lateral approach and incision of the annular ligament may be required for reduction. If an open reduction of the radial head is unsuccessful, the problem is almost always residual malalignment of the ulna. Therefore, casting and annular ligament repair will not improve reduction. A radial head resection would eliminate the nonconcentric contact between radial head and capitellum but would not be an appropriate treatment for this

 young patient who has an acute, correctable fracture deformity.

 

 Question 12 of 100 A right-hand-dominant 45-year-old man sustains an injury to the anterior aspect of his right elbow while trying to lift a heavy load 3 days ago. He has ecchymosis in the anterior and medial elbow regions and has difficulty with resisted forearm supination with the elbow in a flexed position. A diagnosis of an acute distal biceps tendon rupture is made and surgical treatment is chosen. The anatomic relationship of the distal biceps tendon to the median nerve and recurrent radial artery within the antecubital fossa is such that the biceps tendon travels

1. lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery.

2. lateral (radial) to the median nerve and anterior (superficial) to the recurrent radial artery.

3. medial (ulnar) to the median nerve and posterior (deep) to the recurrent radial artery.

4. medial (ulnar) to the median nerve and anterior (superficial) to the recurrent radial artery.

PREFERRED RESPONSE: A DISCUSSION:

During surgical repair of a distal biceps tendon rupture, regardless of the surgical approach or technique, an understanding of the regional anatomy is important. The tendon passes distally into the antecubital fossa. The antecubital fossa is defined by the brachioradialis radially and the pronator teres ulnarly. A sheath surrounds the biceps tendon as it passes through the antecubital fossa toward its insertion on the radial tuberosity. The lateral antebrachial cutaneous nerve lies superficially in the subcutaneous tissue of the antecubital fossa. The nerve parallels the brachioradialis. While still superficial, the tendon is contiguous with the lacertus fibrosus that becomes confluent medially with the fascia overlying the flexor-pronator mass. The brachial artery lies just beneath the lacertus fibrosus at the level of the elbow flexion crease. The tendon travels just lateral (radial) to the median nerve within the antecubital fossa and passes posterior (deep) to the recurrent radial artery before it attaches to the radial tuberosity. Full forearm supination allows visualization of the tendinous insertion  on

 the radial tuberosity.

 

 Question 13 of 100 A 33-year old man sustains a posterior elbow dislocation after a fall. Attempts at closed reduction result in recurrent instability. What is the most common ligamentous injury found at the time of surgical stabilization?

1. Midsubstance tear of the lateral ulnar collateral ligament

2. Proximal avulsion of the ulnar collateral ligament

3. Proximal avulsion of the lateral ulnar collateral ligament

4. Distal bony avulsion of the ulnar collateral ligament from the sublime tubercle

PREFERRED RESPONSE: C DISCUSSION:

Classic posterior elbow dislocations result from a posterolateral rotatory mechanism, whereby the hand is fixed (typically on the ground) while the weight of the body creates a valgus and external rotation moment on the elbow. This results first in tearing of the lateral collateral ligament that proceeds medially through the anterior and posterior joint capsules, ending with potential involvement of the ulnar collateral ligament (but this is not universal). McKee and associates assessed the lateral soft-tissue injury pattern of elbow dislocations

with and without associated fractures at the time of surgery. Injury to the lateral collateral ligament complex was seen in every case, with avulsion from the distal humerus as the most common finding. Midsubstance

 tears, proximal avulsions, and distal bony avulsions of the ulnar collateral ligament are less common.

 

 Question 14 of 100 Figures 1 and 2 are the radiographs of a 61-year-old woman with a left elbow injury after a fall onto her outstretched hand. She denies any previous injury to her elbow. She undergoes a closed reduction of her elbow in the emergency department. What is the most appropriate next step in definitive management?

PREFERRED RESPONSE: C

 DISCUSSION:

 

 Question 15 of 100 A 35-year-old man falls off of a roof and sustains an extra-articular supracondylar elbow fracture. He had normal sensation in all fingers after the injury and before undergoing surgery to repair the fracture. The ulnar nerve was not transposed but was inspected prior to wound closure. Ten days after surgery, the patient has numbness in his small finger and is unable to cross his fingers. His elbow range of motion is 40° to 100°. What is the next appropriate step in management?

1. Elbow splint at 40° for 6 weeks

2. Electromyography (EMG)

3. Exploration of ulnar nerve and transposition

4. Continued observation

PREFERRED RESPONSE: D DISCUSSION:

This patient has an early postsurgical ulnar nerve palsy. The causes of this injury are laceration of the nerve during surgery, entrapment of the nerve in the fracture or hardware, or traction injury during surgery. If the orthopaedic surgeon is sure that the nerve was not lacerated at the end of the case or entrapped in the hardware, then the nerve is probably intact and will recover. Observation is the best treatment in this case because the nerve was checked before wound closure. Elbow splinting has not been shown to help with postsurgical nerve recovery. EMG findings may not be accurate this early following the injury.

 

 

 Question 16 of 100 Figures 1 and 2 are the radiographs of a 64-year-old woman with a history of rheumatoid arthritis (RA) who complains of right elbow pain. She has been treated with tumor necrosis factor-alpha inhibitors and oral corticosteroids for several years. What process is primarily responsible for the radiographic joint destruction?

PREFERRED RESPONSE: D DISCUSSION:

RA is a systemic inflammatory disorder marked by erosive arthritis in multiple joints. Elbow involvement is common. The pathologic lesion in RA is pannus, a hyperplastic synovial proliferation that ultimately results in proteoglycan and collagen digestion. Rheumatoid factor mutations, traumatic insults resulting in complement activation, and osteoblast paracrine signaling are not involved in the pathologic process. The Larsen classification assesses the progression of rheumatoid changes in the elbow. Stage I is characterized by osteopenia without joint space narrowing. Stage II indicates joint space narrowing but a normal joint contour. Stage III is marked by joint space loss. This patient has stage IV disease, as seen by the advanced erosive

 changes with trochlear groove deepening and resulting deformity. Stage V is ankylosis.

 

 Question 17 of 100 Figures 1 through 3 are the radiographs and MRI scan of a 13-year-old girl who has had right   lateral elbow pain and “popping” for 5 months. She has a history of competitive gymnastics for 5 years, which she stopped participating in 2 years ago. She has since been pitching in softball. Her pain is getting worse, and she has not played any sports for the last 2 months. She has undergone a course of physical therapy. On examination, she lacks 5° of elbow extension. What is the next most appropriate step in management?

 

PREFERRED RESPONSE: B

DISCUSSION:

The radiographs and MRI reveal a defect in the capitellum compatible with osteochondritis dissecans (OCD). The initial treatment for an OCD lesion would be cessation of the offending activity with gradual return to the activity over the course of 6 to12 weeks. In the setting of failed nonsurgical treatment, surgical intervention may be considered. The patient has already attempted cessation of sporting activities, as well as physical therapy; as such, a hinged elbow brace would not be of benefit. For the smaller, unstable OCD lesions, arthroscopic debridement and microfracture is the most appropriate treatment option. This would be followed by early protected range-of-motion exercises. The MRI does not show evidence for a lateral collateral ligament injury or lateral epicondylitis. As a result, lateral collateral ligament reconstruction or debridement of the extensor origin would not be indicated for this patient.

 

 Question 18 of 100 A  41-year-old  right-hand-dominant  man  has  been  treated  nonsurgically  for  right  elbow   arthritis.  His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?

1. Inflammatory elbow arthritis

2. A presurgical flexion-extension elbow arc of approximately 50°

3. Retained distal humerus hardware on presurgical radiographs

4. Evidence of presurgical elbow instability

PREFERRED RESPONSE: D DISCUSSION:

End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant  longevity. Soft-tissue interposition arthroplasty does  not  necessitate the same activity and   weight

restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion- extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability upon examination; retained hardware from prior

 surgery was not deemed a contraindication.

 

 Question 19 of 100 Figures 1 and 2 are the radiographs of a 48-year-old right-hand dominant man who has had elbow   pain and stiffness for many years. The patient enjoys recreational softball and weightlifting, and the pain has gotten severe enough that it has begun to interfere with his activities of daily living. On examination, he has a range of motion from 40° to 110°, with pain with terminal extension and flexion, but no pain in the mid-range of motion. He had one corticosteroid injection last year, which temporarily improved his pain but did not improve his motion. What is the most appropriate treatment option for this patient?

PREFERRED RESPONSE: B DISCUSSION:

This patient is relatively young, active, and has evidence of elbow osteoarthritis (OA). Large osteophytes in the anterior and posterior compartments of his elbow are limiting motion. He has failed non-operative treatment, and surgery is indicated. Arthroscopic osteocapsular arthroplasty allows removal of impinging osteophytes and release of hypertrophied capsule and has been shown to be effective at relieving pain and improving motion in patients with OA. Additionally, avoiding prosthetic replacement would allow the patient to continue his active lifestyle. An open elbow release would be another excellent treatment option. Isolated radial head excision would not be indicated, because it would increase contact forces across the ulnohumeral joint and cause little improvement in symptoms. Total elbow arthroplasty is not a good option in a young, active patient. Distal humerus hemiarthroplasty has been described for certain patients with unreconstructable

 distal humerus fractures, but it is not a good option for treatment of OA.

Question 20 of 100 A 32-year-old man sustains elbow trauma in a motor vehicle collision and has medial elbow  pain, swelling, and   bruising.   A   3D-CT   scan   with   representative   images   are   shown   in   Figures   1   and           2.

 

What function does the ligamentous structure attached to the ulnar fracture fragment provide?

PREFERRED RESPONSE: B DISCUSSION:

The medial collateral ligament of the elbow inserts into the sublime tubercle, which is shown as a fracture fragment on the 3D-CT scan. The medial collateral ligament is the primary restraint to valgus stress of the elbow. Secondary restraints to elbow instability are the radiohumeral articulation, the common flexor-pronator tendon, the common extensor tendon, and the elbow capsule. The primary restraint to posterolateral rotatory instability is the lateral collateral ligament that originates on the lateral epicondyle and inserts on the crista supinatoris of the ulna. There are no described "tertiary" restraints to the ulnohumeral joint. The anteromedial coronoid facet is part of the coronoid, which extends more lateral and anterior than the anteromedial facet. The anteromedial facet represents the critical weight-bearing portion of the ulnohumeral joint. Damage to this structure causes posteromedial subluxation that often results in severe progressive arthritis. The coronoid is the larger structure of which the anteromedial coronoid facet is a portion. The posteromedial coronoid facet does not appear to be critical in weight bearing. The radial notch is not associated with increased stress with weight bearing. The treatment of displaced fractures of this structure is ORIF utilizing buttress plating. Closed treatment  is  acceptable  only for nondisplaced  fractures  with  appropriate  radiographic  follow-up. Suture

 fixation is not advocated because of inadequate strength.

 

 Question 21 of 100 A 23-year-old collegiate gymnast sustains a rupture of his medial collateral ligament of the elbow    when he falls off the parallel bars. On physical examination, he has instability to valgus stress and tenderness along the medial elbow. Radiographs show no fracture. Which component of the medial collateral ligament of the elbow is the dominant restraint to valgus stress?

1. Transverse ligament

2. Anterior band of the medial collateral ligament

3. Posterior band of the medial collateral ligament

4. Posterior capsule PREFERRED RESPONSE: B

DISCUSSION:

The anterior bundle of the medial collateral ligament is the prime stabilizer against valgus stress. The posterior bundle, which originates on the medial epicondyle and inserts broadly along the medial edge of the trochlea from the sublime tubercle posteriorly, has stress only in elbow flexion. The transverse band, which originates on the posteromedial olecranon and inserts on the sublime tubercle, deepens the trochlea, but neither the band nor the posterior capsule provides significant restraint. The lateral collateral ligament, which originates from the lateral epicondyle and inserts on the crista supinatoris of the ulna, is the prime stabilizer of varus stress and posterolateral rotatory subluxation.

 Question 22 of 100 A 13-year-old pitcher reports the immediate onset of medial elbow pain after throwing a pitch. Upon examination, the patient is tender to palpation at the medial epicondyle and has pain and instability with valgus testing of the elbow. If the patient were a college pitcher with a similar clinical presentation and physical examination, what anatomic structure would most likely be injured?

1. Ulnar collateral ligament (UCL)

2. Pronator teres

3. Ligament of Struthers

4. Lateral collateral ligament

PREFERRED RESPONSE: A DISCUSSION:

The patient has an acute avulsion fracture of the medial epicondyle, which can occur in response to the valgus load placed on the elbow while throwing. Diagnosis is confirmed by radiograph, with comparison views of the uninjured elbow to evaluate for physeal closure versus injury. In older pitchers, the UCL fails rather than the bone of the medial epicondyle. Advanced imaging may be necessary to confirm the diagnosis of an UCL

injury and/or bony injury.

 Question 23 of 100 A 55-year-old woman develops posttraumatic arthritis in the elbow following a distal humerus fracture. What is the most likely mid-term (5-10 years after surgery) complication following semiconstrained total elbow arthroplasty (TEA)?

1. Bushing wear

2. Infection

3. Aseptic component loosening

4. Component fracture

PREFERRED RESPONSE: A DISCUSSION:

TEA has been described for posttraumatic arthritis of the elbow and typically involves a young patient population with multiple previous operations on the affected elbow. Morrey and Schneeberger found aseptic component loosening to be uncommon (<10% of patients) and usually occurring >10 years after surgery. Prosthetic fracture, usually of the ulnar component, is also a late-term finding. Infection is the most common mode of early failure but usually occurs within the first 5 years and has an overall rate of approximately 5%. Bushing wear has been reported as the most common cause of mechanical TEA failure in this population   at

 intermediate-term follow-up.

 

 Question 24 of 100 A 13-year-old pitcher reports the immediate onset of medial elbow pain after throwing a pitch. Upon examination, the patient is tender to palpation at the medial epicondyle and has pain and instability with valgus

testing of the elbow. The diagnostic modality selected in the prior question would be most useful to evaluate for

 

PREFERRED RESPONSE: A DISCUSSION:

The patient has an acute avulsion fracture of the medial epicondyle, which can occur in response to the valgus load placed on the elbow while throwing. Diagnosis is confirmed by radiograph, with comparison views of the uninjured elbow to evaluate for physeal closure versus injury. In older pitchers, the UCL fails rather than the bone of the medial epicondyle. Advanced imaging may be necessary to confirm the diagnosis of an UCL

 injury and/or bony injury.

 

 Question 25 of 100 A 26-year-old mixed martial arts fighter sustains a posterolateral elbow dislocation. The   primary stabilizers of the elbow joint are the

1. radiocapitellar joint, the posterior band of the medial collateral ligament, and the annular ligament.

2. ulnohumeral joint, the anterior band of the medial collateral ligament, and the lateral ulnar collateral ligament.

3. radiocapitellar joint, the anterior band of the medial collateral ligament, and the radial collateral ligament.

4. ulnohumeral joint, the anterior band of the medial collateral ligament, and the posterior band of the medial collateral ligament.

PREFERRED RESPONSE: B DISCUSSION:

The primary stabilizers of the elbow are the ulnohumeral joint, the lateral collateral ligament (lateral epicondyle to the crista supinatoris), and the anterior band of the medial collateral ligament (anterior inferior medial epicondyle to the sublime tubercle). Secondary stabilizers are the radial head, the common flexor and

 extensor origins, and the joint capsule. The muscles that cross the elbow joint act as dynamic stabilizers.        

 

 Question 26 of 100 A 51-year-old butcher has an 18-month history of recalcitrant medial elbow pain, which is affecting his occupational demands. He describes the pain as mainly anterior and distal to the medial epicondyle. His symptoms are exacerbated with resisted wrist flexion and forearm pronation. On examination, he is also found to have a positive Tinel’s sign at the elbow with weakness of intrinsic strength. He has attempted physical therapy, activity modification, bracing, and anti-inflammatory medication without any significant improvement. Presurgical counseling should include the understanding that

1. concomitant ulnar neuropathy is a potential poor prognostic factor.

2. a change in occupation will likely be required after surgery.

3. weakness in wrist flexion strength will result postoperatively.

4. prior corticosteriod injections are a potential poor prognostic factor.

PREFERRED RESPONSE: A DISCUSSION:

Although less common in comparison with lateral elbow tendinopathy, medial elbow tendinopathy remains a significant cause of elbow disability. Fortunately, most patients can anticipate resolution of symptoms with nonsurgical management. For patients with recalcitrant symptoms, surgical intervention should be discussed as a treatment alternative. The literature reports successful results with surgical intervention via debridement

of pathologic tissue, release of the flexor carpi radialis - pronator teres origin, and/or repair of the flexor carpi radialis - pronator teres origin. Several authors have raised concern of the impact of concomitant ulnar neuropathy on results following surgical treatment for medial epicondylitis. Kurvers and Verhaar and Gabel and Morrey, among others, have reported a statistically significant association between concomitant ulnar neuropathy and worse outcomes following surgery. Most patients can anticipate a return to prior activity levels after surgery without any consistently reported loss of flexor/pronator strength. Prior corticosteroid injections

 have not been found to impact results.

 

 Question 27 of 100 A 17-year-old girl develops chronic posterolateral rotatory instability (PLRI) of the elbow   following closed treatment of an elbow dislocation. Advanced imaging reveals incompetence of the lateral collateral ligament complex, and ligament reconstruction is planned. Examination under anesthesia is performed with the forearm in maximal supination and valgus force applied to the elbow, demonstrated in Video 1(The pivot shift test) As the elbow is brought through a range of motion assessment, the radial head is

 

PREFERRED RESPONSE: A DISCUSSION:

PLRI of the elbow is the most common form of chronic elbow instability. The mechanism occurs following a fall onto an outstretched hand, where a valgus force is applied to the elbow and the forearm rotates into progressive supination. This allows the radial head to translate posterior to the capitellum, with progressive injury from lateral to medial sides of the elbow. The pivot shift test is a useful examination maneuver to confirm the presence of PLRI. With the forearm in maximal supination and valgus stress applied to the elbow, the radial head is forced posterior to the capitellum as the elbow is brought into progressive extension, revealing a dimple on the lateral aspect of the elbow. This typically occurs at roughly 30⁰ of flexion. As  the

 elbow is flexed, the radial head reduces.

 

 Question 28 of 100 A 13-year-old pitcher reports the immediate onset of medial elbow pain after throwing a pitch. Upon examination, the patient is tender to palpation at the medial epicondyle and has pain and instability with valgus testing of the elbow. What would be the most appropriate initial diagnostic test for this patient?

1. MRI arthrogram

2. CT scan with 3-dimensional reconstructions

3. Plain radiographs of both elbows

4. Ultrasonography

PREFERRED RESPONSE: C DISCUSSION:

The patient has an acute avulsion fracture of the medial epicondyle, which can occur in response to the valgus load placed on the elbow while throwing. Diagnosis is confirmed by radiograph, with comparison views of the uninjured elbow to evaluate for physeal closure versus injury. In older pitchers, the UCL fails rather than the bone of the medial epicondyle. Advanced imaging may be necessary to confirm the diagnosis of an UCL

 injury and/or bony injury.

Question 29 of 100 A 45-year-old construction worker sees a surgeon 23 days after sustaining an eccentric injury to his dominant right elbow. An MRI demonstrates a distal biceps tendon rupture with 5 cm of proximal retraction. In the operating room, the surgeon encounters good tissue quality but finds that primary repair can only be performed with the elbow hyperflexed to 70°. What is the best next step?

1. Proceed with primary repair with the elbow hyperflexed

2. Use interposition allograft to reconstruct with elbow in extension

3. Tenodese distal biceps tendon to underlying brachialis muscle

4. Forego primary repair, but perform stump debridement

PREFERRED RESPONSE: A DISCUSSION:

Distal biceps ruptures, although relatively less common in comparison with other upper extremity tendon injuries, still garner considerable attention in the orthopaedic literature. The mechanism of injury typically results from an eccentric extension load to a flexed elbow. A biceps-deficient arm can result in up to 40% loss of supination strength and up to 80% loss of supination endurance. A delay in diagnosis can compromise the ability to reduce the tendon back to its anatomic insertion without having to hyperflex the elbow. Current literature confirms the ability to safely proceed with primary repair even with the elbow flexed up to 100° without fear of developing a flexion contracture. With time, patients can anticipate restoration of full elbow extension. An interposition graft should be used for a poor residual tendon quality stump <4 cm in length and in cases of delay to surgery of >6 weeks. Biceps to brachialis tendon transfer does not restore supination

 strength. Isolated debridement of the distal tendon would not be an appropriate treatment.

 

 Question 30 of 100 A 45-year-old construction worker has right elbow pain and swelling following a fall from a step ladder onto his outstretched hand. Figures 1 and 2 are his radiograph and 3D-CT scan. Examination under anesthesia reveals widening of the radiocapitellar joint space with varus stress. Surgical intervention is undertaken for open reduction internal fixation (ORIF) of the coronoid fragment. Following fixation, the elbow remains unstable with persistent varus laxity. What is the best next step?

PREFERRED RESPONSE: D

DISCUSSION:

Posteromedial rotatory instability of the elbow is typically associated with a fall backwards onto an outstretched arm, resulting in varus stress across the elbow and progressive pronation of the forearm. As the coronoid translates posterior to the trochlea, the anteromedial facet is often fractured. The lateral ulnar collateral ligament is frequently compromised as a result of the varus force. The degree of elbow instability relates to both the size of the coronoid fragment and the associated soft-tissue injuries about the elbow. The images reveal a displaced O’Driscoll type 2 coronoid fracture that is amenable to ORIF. If this fails to restore stability to the elbow, the next most appropriate intervention is to repair the lateral collateral ligament complex, an injury that is suggested by the widened radiocapitellar joint space on preoperative evaluation. A dynamic external fixator can be used in the setting of grossly unstable elbows, but all correctible instability lesions should be addressed before determining if this is necessary. Immobilization or temporary transarticular

 pinning would be unlikely to adequately restore stability to the elbow.

 

 Question 31 of 100 Figure 1 is the MRI scan of a 25-year-old left-hand dominant minor league pitcher who has elbow pain during pitching that has gotten worse for the past several months. He fails nonoperative treatment and undergoes surgery to address the problem. What is the most common complication of this procedure?

 

PREFERRED RESPONSE: A DISCUSSION

The MRI scan shows evidence of a medial collateral ligament (MCL) injury. In a patient with a chronic MCL injury that has failed non-operative treatment, MCL reconstruction would be indicated. Initial MCL reconstruction technique involved routine transposition of the ulnar nerve and detachment of the flexor- pronator mass. Subsequent modification of surgical techniques has been made to attempt to minimize complications by avoiding routine ulnar nerve transposition and performing a muscle-splitting approach. Regardless, transient ulnar nerve neuropraxia remains the most common complication, and patients should be counseled about its occurrence. Flexor pronator mass avulsion is more likely with a muscle-detaching approach  but  is  not  more  common  than  ulnar  nerve  neuropraxia.  Posterolateral  rotatory instability is a

complication  of  lateral  collateral  ligament  repair  or  reconstruction,   not  medial  collateral        ligament

 reconstruction. Symptomatic hardware is not a common complication.

 

 Question 32 of 100 A 32-year-old man sustains elbow trauma in a motor vehicle collision and has medial elbow  pain, swelling, and bruising. A 3D-CT scan with representative images are shown in Figures 1 and 2.Definitive treatment of this fracture should consist of

 

PREFERRED RESPONSE: C DISCUSSION

The medial collateral ligament of the elbow inserts into the sublime tubercle, which is shown as a fracture fragment on the 3D-CT scan. The medial collateral ligament is the primary restraint to valgus stress of the elbow. Secondary restraints to elbow instability are the radiohumeral articulation, the common flexor-pronator tendon, the common extensor tendon, and the elbow capsule. The primary restraint to posterolateral rotatory instability is the lateral collateral ligament that originates on the lateral epicondyle and inserts on the crista supinatoris of the ulna. There are no described "tertiary" restraints to the ulnohumeral joint. The anteromedial coronoid facet is part of the coronoid, which extends more lateral and anterior than the anteromedial facet. The anteromedial facet represents the critical weight-bearing portion of the ulnohumeral joint. Damage to this structure causes posteromedial subluxation that often results in severe progressive arthritis. The coronoid is the larger structure of which the anteromedial coronoid facet is a portion. The posteromedial coronoid facet does not appear to be critical in weight bearing. The radial notch is not associated with increased stress with weight bearing. The treatment of displaced fractures of this structure is ORIF utilizing buttress plating. Closed treatment  is  acceptable  only for nondisplaced  fractures  with  appropriate  radiographic  follow-up. Suture

 fixation is not advocated because of inadequate strength.

 

 Question 33 of 100 A 53-year-old man complains of recurrent lateral elbow pain.    He was surgically treated approximately one year ago with some improvement in his direct lateral elbow pain. He now reports new-onset discomfort at the posterolateral elbow, as well as difficulty when pushing himself up from a chair. On examination, he has a well-healed 6-cm incision over the lateral epicondyle with full active and passive range of motion. He has

pain with palpation along the posterior lateral elbow and a positive posterior drawer test. Radiographs are unremarkable. What is the best next step?

1. Platelet-rich plasma

2. Physical therapy

3. Lateral epicondyle debridement

4. Lateral collateral ligament reconstruction

PREFERRED RESPONSE: D DISCUSSION

Lateral elbow tendinopathy remains a frequently encountered pathology of the elbow. Open or arthroscopic lateral epicondyle debridement can be considered for patients with refractory symptoms. With either technique, the lateral collateral ligament complex of the elbow is at risk for compromise, with excessive debridement distal and posterior to the center of rotation of the capitellum. When injured, patients often complain of pain around the posterior lateral elbow, which is commonly misdiagnosed as recurrent lateral epicondylitis. The push-up test (apprehension using the supinated forearm to push up from a chair) is a typical examination finding, along with a positive posterior drawer test. Patients may also develop posterior   lateral

 instability of the elbow, for which the recommended treatment is lateral collateral ligament reconstruction.    

 

 Question 34 of 100 A 32-year-old man sustains elbow trauma in a motor vehicle collision and has medial elbow  pain, swelling, and bruising. A 3D-CT scan with representative images are shown in Figures 1 and 2.The critical weight- bearing portion of the elbow joint that is damaged in this fracture is the

 

PREFERRED RESPONSE: A DISCUSSION

The medial collateral ligament of the elbow inserts into the sublime tubercle, which is shown as a fracture fragment on the 3D-CT scan. The medial collateral ligament is the primary restraint to valgus stress of the elbow. Secondary restraints to elbow instability are the radiohumeral articulation, the common flexor-pronator tendon, the common extensor tendon, and the elbow capsule. The primary restraint to posterolateral rotatory instability is the lateral collateral ligament that originates on the lateral epicondyle and inserts on the crista supinatoris of the ulna. There are no described "tertiary" restraints to the ulnohumeral joint. The anteromedial coronoid facet is part of the coronoid, which extends more lateral and anterior than the anteromedial facet. The anteromedial facet represents the critical weight-bearing portion of the ulnohumeral joint. Damage to this

structure causes posteromedial subluxation that often results in severe progressive arthritis. The coronoid is the larger structure of which the anteromedial coronoid facet is a portion. The posteromedial coronoid facet does not appear to be critical in weight bearing. The radial notch is not associated with increased stress with weight bearing. The treatment of displaced fractures of this structure is ORIF utilizing buttress plating. Closed treatment  is  acceptable  only for nondisplaced  fractures  with  appropriate  radiographic  follow-up. Suture

 fixation is not advocated because of inadequate strength.

 

 Question 35 of 100 A 54-year-old woman undergoes an interposition arthroplasty that fails and requires conversion to a total elbow arthroplasty. She has progressive elbow pain and radiographic loosening. Erythrocyte sedimentation rate and C-reactive protein are normal. Joint aspiration is positive for Staphylococcus epidermidis. What surgical treatment would best optimize function and decrease risk of recurrence?

1. Resection arthroplasty

2. Single-stage revision total elbow arthroplasty

3. Two-stage revision elbow arthroplasty

4. Aggressive arthroscopic debridement and retention of components

PREFERRED RESPONSE: C DISCUSSION

The most reliable surgical option in this case for eradicating a deep infection following a total elbow arthroplasty is a two-stage revision. One study, however, reported that staged reimplantation of an infected total elbow replacement could be successful in the setting of organisms other than S epidermidis. Arthroscopic debridement is not a viable option with poorly fixed or loose components. A single-stage revision, while considered an option in hip and knee arthroplasty, has not been definitively proven to be an option for revision total elbow arthroplasty. Single-stage revision has shown moderate success in the setting of Staphylococcus aureus infections, although with only short-term follow-up. A resection arthroplasty would likely be successful in managing the deep infection but would not optimize the functional result. Resection arthroplasty

 is best reserved for low-demand or infirm patients.

 

 Question 36 of 100 Figures 1 and 2 are the radiographs of a 47-year-old right-hand-dominant active man with a   10-year history of progressive right elbow pain associated with stiffness. He previously underwent collateral ligament reconstruction. He has pain throughout his range-of-motion arc, which currently measures 20° of extension to 80° of flexion. Initial treatment with nonsteroidal anti-inflammatory medication, physical therapy, cortisone injections, and arthroscopic debridement has failed to provide relief of his symptoms and improvement in function. What is the most appropriate treatment if instability is present at the time of evaluation?

 

 

PREFERRED RESPONSE: A DISCUSSION

The radiographs reveal ulnohumeral arthrosis with relative sparing of the radiocapitellar articulation secondary to underlying osteoarthritis. Arthrosis of the elbow joint in this young and active patient presents a treatment dilemma for the surgeon. Interposition arthroplasty allows for improved function with pain relief and no weight-lifting restrictions, as required with TEA. This option is an intermediate procedure that preserves bone stock and allows for conversion to a TEA if necessary. Conventional TEA would provide pain relief with improved range of motion, but activity limitation and lifetime weight restrictions make this an undesirable option. Arthroscopic debridement is not an option, considering the previous failure from this modality. Contraindications for soft-tissue interposition arthroplasty include elbow instability, active infection, and pain without motion loss. Common complications associated with this procedure include

 instability, infection, ulnar neuropathy, bone resorption, and heterotopic bone formation.

 

 Question 37 of 100 Figures 1 and 2 are the radiographs of a 47-year-old right-hand-dominant active man with a   10-year history of progressive right elbow pain associated with stiffness. He previously underwent collateral ligament reconstruction. He has pain throughout his range-of-motion arc, which currently measures 20° of extension to 80° of flexion. Initial treatment with nonsteroidal anti-inflammatory medication, physical therapy, cortisone injections, and arthroscopic debridement has failed to provide relief of his symptoms and improvement in function. What is the most appropriate next treatment step for this patient?

PREFERRED RESPONSE: D DISCUSSION

The radiographs reveal ulnohumeral arthrosis with relative sparing of the radiocapitellar articulation secondary to underlying osteoarthritis. Arthrosis of the elbow joint in this young and active patient presents a treatment dilemma for the surgeon. Interposition arthroplasty allows for improved function with pain relief and no weight-lifting restrictions, as required with TEA. This option is an intermediate procedure that preserves bone stock and allows for conversion to a TEA if necessary. Conventional TEA would provide pain relief with improved range of motion, but activity limitation and lifetime weight restrictions make this an

undesirable option. Arthroscopic debridement is not an option, considering the previous failure from this modality. Contraindications for soft-tissue interposition arthroplasty include elbow instability, active infection, and pain without motion loss. Common complications associated with this procedure include

 instability, infection, ulnar neuropathy, bone resorption, and heterotopic bone formation.

 

 Question 38 of 100 Figure 1 is the MRI arthrogram of a 21-year-old professional baseball pitcher who complains of  right elbow pain after pitching a game 3 months ago. He had initially been treated with rest and forearm strengthening. He now complains of persistent pain along his medial elbow during the long toss portion of his throwing program. What is the most appropriate treatment at this time?

 

PREFERRED RESPONSE: C DISCUSSION

MUCL reconstruction, using either ipsilateral palmaris longus, hamstring autograft, or allograft tendon is indicated for ulnar collateral ligament (UCL) injuries that fail nonsurgical management. The MRI arthrogram shows a rupture of the UCL from its ulnar insertion, with the classic T sign of contrast extravasation. The MRI study does not show any ulnohumeral or radiocapitellar osteoarthritis to suggest radial head resection or debridement/capsular release as indicated procedures; the patient’s symptoms are medial, precluding the need for a release of the extensor carpi radialis brevis. Finally, the common origin of the flexor pronator mass

 appears intact on the given arthrogram image.

 

 Question 39 of 100 A 35-year-old construction worker falls from a ladder, sustaining an injury to his elbow. An MRI demonstrates a rupture of his distal biceps tendon. He underwent a repair through a single transverse incision in the antecubital fossa using the fixation as seen in Figures 1 and 2. Postoperatively, the patient reports mildly decreased sensation over the anterolateral aspect of the forearm. Which other complication is this patient most at risk for in the early postoperative period?

 

PREFERRED RESPONSE: C DISCUSSION

Injury to the lateral antebrachial cutaneous (LABC) nerve is the most common complication following distal biceps tendon repair, primarily due to traction. The patient demonstrates some decreased sensation over the anterolateral forearm, consistent with an LABC neurapraxia. Additionally, the figures show fixation with the endobutton proximal to the radial tuberosity, in the region of the radial neck. This is associated with an increased risk of iatrogenic fracture of the radial neck, which occurs during the drilling of the bone tunnel. Heterotopic ossification and proximal radioulnar synostosis are more commonly associated with the dual- incision approach. The anterior interosseous nerve is not an at-risk structure during distal biceps repair. The posterior interosseous nerve (PIN) can be placed at risk during this procedure. The distance from the guide pin and the nerve is decreased with more distal drilling and more radially directed drilling. In this case, the PIN has not crossed posterior to the radius yet, making it less likely to be injured during placement of the

 tunnel.

 

 Question 40 of 100 A 20-year-old collegiate pitcher sustains a medial collateral ligament (MCL) rupture of his   throwing elbow for which surgical reconstruction is necessary. The goal of surgery is anatomic restoration of the MCL. Which statement best describes the kinematics of the native MCL?

1. The posterior bundle demonstrates the greatest change in tension from flexion to extension.

2. The posterior bundle is isometric.

3. The anterior bundle becomes tight in flexion and lax in extension.

4. The anterior and posterior bundles are isometric.

 

PREFERRED RESPONSE: A DISCUSSION

The anterior bundle is the most important portion of the complex when treating valgus instability of the elbow. The ligament originates from the anteroinferior surface of the medial epicondyle. The anterior bundle inserts on the medial border of the coronoid at the sublime tubercle. The anterior bundle of the medial collateral ligament (MCL) is the primary restraint to valgus stress, and the radial head is a secondary restraint. With anterior bundle sectioning, the resultant instability is most substantial between 60° and 70° and is   lowest at

full extension and full flexion. True lateral radiographs reveal that the flexion-extension axis, or center of rotation, of the elbow lies in the center of the trochlea and capitellum. The origin of the anterior bundle of the MCL lies slightly posterior to the rotational center of the elbow. The anterior bundle is further divided into an anterior band and a posterior band. The eccentric origin of these anterior bundle components in relation to the rotational center through the trochlea creates a CAM effect during flexion and extension. The anterior band tightens during extension, and the posterior band tightens during flexion. This reciprocal tightening of the two functional components of the anterior bundle allows the ligament to remain taut throughout the full range of flexion. Cadaver dissection studies have identified the origin and insertion of both the medial and lateral stabilizing elbow ligaments. The anterior bundle of the MCL is isometric throughout the flexion/extension arc of motion, making Response C incorrect. The posterior bundle of the MCL elongates with elbow flexion, so Responses B and D are incorrect. The posterior bundle of the MCL also demonstrates the most change in

 length from extension to flexion of all the elbow ligaments.

 

 Question 41 of 100 Figure 1 is the MRI of a 45-year-old woman with a medical history significant for rheumatoid   arthritis who returns to your office with persistent right elbow pain. Her rheumatologist has maximized her disease- modifying anti-rheumatoid drug regimen. She complains of diffuse joint pain and swelling. On examination, she has a pronounced joint effusion, elbow flexion arc of 45°, and crepitus with forearm rotation. Her elbow radiograph reveals preservation of her joint space. What is the most appropriate surgical treatment at this time?

 

PREFERRED RESPONSE: C DISCUSSION

Rheumatoid arthritis remains a common inflammatory arthropathy that can lead to progressive synovitis of the elbow joint. Patients often present with recalcitrant elbow pain and loss of motion. In the early stages, the joint space can be fairly well preserved. With progressive synovitis, cartilage destruction leads to symmetric joint space narrowing and joint destruction. For the younger patient with recalcitrant synovitis and a relatively well-preserved joint space, open or arthroscopic synovectomy provides successful improvement for 70% to 80% of patients. In most cases, radial head resection is not required. Synovitis that encircles the radial   head

and neck can lead to pain and crepitus with forearm rotation. Preserving the radial head prevents the rapid progression of wear at the lateral ulnohumeral joint. A total elbow replacement, while a successful treatment modality for the older, lower demand patient with rheumatoid arthritis, would not be appropriate for the

 younger patient given the significant postoperative restrictions imparted.

 

 Question 42 of 100 A  24-year-old  right-hand-dominant  professional  baseball  pitcher  has  valgus  extension overload (VEO) syndrome of the right elbow, as seen in Figure 1. Which letter in the Figure 1 corresponds to the typical area of osteophyte formation in this condition?

PREFERRED RESPONSE: B DISCUSSION

VEO is most commonly seen in throwers for whom valgus stress across the elbow causes impingement of the posteromedial olecranon tip against the medial wall of the olecranon fossa. With repeated impingement, a bony osteophyte may grow on the olecranon at the site of impingement in this posteromedial region of the olecranon. Bony growth within the olecranon fossa also has been seen. The distinction between this condition and ulnar collateral ligament (UCL) injury is difficult to make, but VEO often can be distinguished from UCL injury by determining the exact location of pain a patient experiences. With VEO, the pain typically occurs with direct palpation of the posterior medial tip of the olecranon. The valgus extension overload provocative test also aids in diagnosis. A supervised physical therapy program and arthroscopic surgical decompression when nonsurgical treatment is unsuccessful are typical treatments for this condition. Locations C and D represent the origin and insertion, respectively, of the elbow medial collateral ligament (MCL), and, although associated MCL pathology can exist in the setting of VEO syndrome, osteophyte formation is not typical in these areas. Location A is the radial head, and although the radiocapitellar joint is a known secondary stabilizer

 of elbow valgus stress, osteophyte formation in this area is less likely in this clinical scenario.

 

 Question 43 of 100

Figures 1 and 2 show the radiograph and axial CT scan of a 56-year-old right-hand-dominant man who sustains a right shoulder injury following a fall from a roof. He is seen in the emergency department and placed into a sling. He denies any previous injury to the shoulder. His medical history is significant only for hypertension. His arm is neurovascularly intact, and his deltoid is functioning. What is the most appropriate surgical option at this point?

PREFERRED RESPONSE: C DISCUSSION

The radiograph and axial CT image demonstrate a displaced right proximal humerus fracture, which has a head-splitting component. The fracture line extends through the greater and lesser tuberosities as well. The head-splitting nature of the fracture increases the risk for the developement of avascular necrosis and, potentially, failure of fixation. In the younger patient, <55 years, with a simple head-splitting fracture (tuberosities intact), one might consider ORIF. However, in this case of an older patient, >55 years, with a more complex head-splitting fracture pattern, a well-performed hemiarthroplasty provides a reliable clinical outcome. Clinical outcomes following hemiarthroplasty rely on successful healing of the greater tuberosity. In this case, the patient has no major medical comorbidities, has a non-comminuted greater tuberosity, and sought treatment shortly after injury. These factors have been associated with improved tuberosity healing. In an older patient with multiple medical comorbidities including osteopenia/osteoporosis, lower demand or with a lengthy delay from injury to surgery, a reverse shoulder arthroplasty might be a reasonable option. Reverse total shoulder arthroplasty has been shown to offer predictable functional results in the setting of fractures,

 although with a higher complication rate.

 

 Question 44 of 100 Figures 1 and 2 are the radiograph and MRI scan of a 40-year-old man who falls down a flight of  stairs. His upper arm is bruised and painful, and global weakness in the shoulder girdle function is noted. A radiograph is ordered to rule out a fracture or dislocation. You should recommend

PREFERRED RESPONSE: D DISCUSSION

The patient has an os acromiale. The type shown is of the meso-acromion. This is not an acute fracture; well corticated ends are seen on the axillary radiograph, and there is no bone edema on the T2 axial MRI image. A trial of nonsurgical care that includes rest, ice, and anti-inflammatory medications is recommended. If a patient continues to have symptoms, an arthroscopic evaluation is needed to determine if the os acromiale is mobile

 and if surgical fixation is appropriate.

 

 Question 45 of 100 Surgical management of the fracture shown in Figure 1 will have what outcome compared  with nonsurgical management in a sling?

 

PREFERRED RESPONSE: D DISCUSSION

Multiple prospective randomized clinical trials have compared operative treatment of displaced midshaft clavicle fractures with nonoperative management. While functional outcomes have not consistently been improved with surgery, rates of radiographic union have consistently been shown to improve. Fracture characteristics  associated  with  an  increased  risk  for  nonunion  of  a  midshaft  clavicle  fracture   include

comminution of the fracture and significant shortening/displacement of the fracture (>1.5-2.0 cm). Patient

 factors predicting nonunion include a smoking history.

 

 Question 46 of 100

The fracture seen in Figure 1 is most likely associated with injury to what ligamentous structure?

PREFERRED RESPONSE: C DISCUSSION

The radiograph shows an extra-articular distal clavicle fracture lateral to the clavicular attachment point of the coracoclavicular ligaments (conoid and trapezoid). However, unlike a scenario featuring a typical Neer type I fracture, the interval between coracoid and clavicle is clearly widened, and there is marked fracture displacement. It is clear that the coracoclavicular ligaments must also be torn. The inferior glenohumeral ligament is important to glenohumeral joint stability but has no effect on the relationship between clavicle and scapula. The AC ligaments are thickenings of the AC joint capsule. They have been shown to be responsible for 90% of anteroposterior stability of the AC joint. The coracoclavicular ligaments are responsible for 77% of stability for superior translation (as in this case). The coracoacromial ligament connects two parts of the

 scapula (coracoid and acromion) and is part of the arch that supports the rotator cuff.

 

 Question 47 of 100 A  55-year-old  man  falls  from  a  ladder  and  dislocates  his  nondominant  shoulder.  He     undergoes  an uncomplicated closed reduction under sedation in the emergency department. Postreduction radiographs reveal a small Hill-Sachs lesion and no other bony abnormalities. Six weeks after the dislocation, the patient has persistent pain at rest and forward elevation and external rotation weakness, but the remaining motor function in the extremity and sensation are intact. What is the best next step?

1. Physical therapy with electrical stimulation and iontophoresis

2. Corticosteroid injection

3. MRI of the shoulder

4. Electromyography (EMG) of the arm

PREFERRED RESPONSE: C DISCUSSION

For a patient >40 years of age who has persistent pain and weakness isolated to the rotator cuff following an acute anterior shoulder dislocation, an MRI is indicated to evaluate rotator cuff integrity. EMG is not indicated in this case because this patient has no evidence of distal motor functional abnormality and their sensation is intact,  thereby making  a  brachial  plexus  injury unlikely.  Corticosteroid  injections  and  physical therapy

 modalities do not adequately address the concern over his potential for having sustained a rotator cuff tear.    

 

 Question 48 of 100 Figure 1 is the radiograph of a 27-year-old bicyclist who was involved in a crash. He has an isolated and closed injury. He is neurovascularly intact in the upper extremity. The lateral fragment is displaced inferiorly by

 

PREFERRED RESPONSE: A DISCUSSION

Open reduction and internal fixation with a plate and screw construct have been demonstrated to reduce nonunion rate and improve outcomes compared with sling immobilization for displaced clavicle fractures. Neurovascular injury and infection risk increase, however, with surgery. In the upright position, the weight of

 the extremity inferiorly displaces the lateral segment.

 

 Question 49 of 100 Figure 1 is the radiograph of a right-hand-dominant 70-year-old woman who arrives at the emergency department with acute left shoulder pain following a fall down a flight of stairs. She expresses acute diffuse left shoulder pain and swelling. Prior to her injury, she had fully active, painless shoulder range of motion.

 

Which radiographic parameter places this patient at the highest risk for osteonecrosis?

 

PREFERRED RESPONSE: D DISCUSSION

Fractures of the proximal humerus are now the third most common fracture in patients >60 years of age. This patient sustained a displaced, commonly described 3-part/4-part proximal humerus fracture. The number of fracture fragments and angulation, as initially described by Codman and then Neer, does not necessarily help to predict risk for subsequent AVN. Although the main blood supply to the humeral head historically was believed to be a branch from the anterior circumflex, adequate perfusion can remain through the posteromedial calcar following trauma. Hertel and associates reported that the most accurate predictor of ischemia was whether the length of the metaphyseal head extension for the calcar segment was <8 mm. Locking plates have provided surgical alternatives to many unstable fracture patterns previously considered ominous. Although much enthusiasm remains for this implant choice, a relatively high level of complications has been reported with their use. A multicenter study reported a 14% incidence of intra-articular screw perforation as the most common complication. When patients are deemed poor candidates for head preservation treatment, both hemiarthroplasty and rTSA can provide successful results when applied and performed appropriately. An increasing body of evidence appears to support consideration of a reverse prosthesis for older patients. A crucial aspect of hemiarthroplasty success is anatomic healing of the tuberosities around the implant. If the greater tuberosity displaces or reabsorbs, patients experience significant loss of active motion. The level of pain, however, is unpredictable. Although beneficial in a reverse prosthesis, anatomic tuberosity position does not appear to be as crucial. Depending on the definition of “complication,” some researchers have reported a higher complication rate for the reverse prosthesis. If posttraumatic osteonecrosis develops following head preservation treatment, conversion to an anatomic shoulder arthroplasty can provide good success in motion and function, particularly when the tuberosities heal in a relatively anatomic position. However, several researchers, most recently Moineau and associates, report suboptimal results when the greater tuberosity is positioned in a substantial amount of varus that necessitates osteotomy. In this scenario, rTSA should be considered.

 

 

 Question 50 of 100 Placing a plate too anteriorly against the lateral aspect of the bicipital groove while performing open reduction and internal fixation (ORIF) of a proximal humerus fracture has an increased risk of what complication?

1. Avascular necrosis

2. Loss of fixation of the fracture

3. Malunion leading to increased retroversion of the articular surface

4. Glenoid arthrosis

PREFERRED RESPONSE: A DISCUSSION

There are two major arteries that supply the humeral head. One is the ascending branch of the anterior humeral circumflex artery, which runs up the lateral aspect of the bicipital groove terminating in the arcuate artery. The other is the posterior humeral circumflex artery, which more recently has been demonstrated to supply a significant portion of the blood supply to the humeral head. Capsular arteries also play a role in humeral head perfusion. Care should be taken to preserve all intact arterial supply when performing ORIF, as injury to these arteries may result in avascular necrosis. In general, the most common complications of locked plating include loss of reduction with penetration of the joint by the screws, particularly with initial varus positioning of the humeral head. Placement of the plate in the position described, however, should not have an impact on any of

 the other complications noted.

 

 Question 51 of 100 When  performing  a  shoulder  hemiarthroplasty  for  an  unreconstructable  proximal      humerus  fracture, the relationship of the repaired greater tuberosity to the prosthetic humeral head should be

1. 6 mm to 8 mm superior to the top of the humeral head.

2. 6 mm to 8 mm inferior to the top of the humeral head.

3. 1.5 cm inferior to the top of the humeral head.

4. at the same height as the top of the humeral head.

PREFERRED RESPONSE: D DISCUSSION

The greater tuberosity lies anatomically 6 mm to 8 mm inferior to the top of the humeral head. Normal proximal humeral anatomy must be recreated when performing a hemiarthroplasty for fracture so as to minimize the complications associated with the greater tuberosity and maximize functional outcomes. Tuberosity malunion and nonunion are considered the most common reasons for poor clinical outcomes following this procedure. Placing the tuberosity too proximal can lead to issues with impingement during shoulder abduction, and placement too distal can increase the tension on the rotator cuff as it courses over the

 prosthetic humeral head.

 

 Question 52 of 100 Figure 1 is the radiograph of a right-hand-dominant 70-year-old woman who arrives at the emergency department with acute left shoulder pain following a fall down a flight of stairs. She expresses acute diffuse left shoulder pain and swelling. Prior to her injury, she had fully active, painless shoulder range of motion. When considering arthroplasty options, which statement regarding the use of hemiarthroplasty or reverse total shoulder arthroplasty (rTSA) is most accurate?

 

PREFERRED RESPONSE: B DISCUSSION

Fractures of the proximal humerus are now the third most common fracture in patients >60 years of age. This patient sustained a displaced, commonly described 3-part/4-part proximal humerus fracture. The number of fracture fragments and angulation, as initially described by Codman and then Neer, does not necessarily help to predict risk for subsequent AVN. Although the main blood supply to the humeral head historically was believed to be a branch from the anterior circumflex, adequate perfusion can remain through the posteromedial calcar following trauma. Hertel and associates reported that the most accurate predictor of ischemia was whether the length of the metaphyseal head extension for the calcar segment was <8 mm. Locking plates have provided surgical alternatives to many unstable fracture patterns previously considered ominous. Although much enthusiasm remains for this implant choice, a relatively high level of complications has been reported with their use. A multicenter study reported a 14% incidence of intra-articular screw perforation as the most common complication. When patients are deemed poor candidates for head preservation treatment, both hemiarthroplasty and rTSA can provide successful results when applied and performed appropriately. An increasing body of evidence appears to support consideration of a reverse prosthesis for older patients. A crucial aspect of hemiarthroplasty success is anatomic healing of the tuberosities around the implant. If the greater tuberosity displaces or reabsorbs, patients experience significant loss of active motion. The level of pain, however, is unpredictable. Although beneficial in a reverse prosthesis, anatomic tuberosity position does not appear to be as crucial. Depending on the definition of “complication,” some researchers have reported a higher complication rate for the reverse prosthesis. If posttraumatic osteonecrosis develops following head preservation treatment, conversion to an anatomic shoulder arthroplasty can provide good success in motion and function, particularly when the tuberosities heal in a relatively anatomic position. However, several researchers, most recently Moineau and associates, report suboptimal results when the greater tuberosity is positioned in a substantial amount of varus that necessitates osteotomy. In this scenario, rTSA should be

 considered.

 

 Question 53 of 100 A 61-year-old right-hand-dominant woman falls down the stairs, resulting in a left anteroinferior dislocation and noncomminuted greater tuberosity fracture. A closed glenohumeral reduction with intravenous  sedation

is performed in the emergency department. After reduction, the greater tuberosity fragment remains displaced by 2 mm. What is the most appropriate treatment?

1. Open reduction internal fixation with transosseous sutures

2. Arthroscopic fixation using a suture bridge technique

3. Nonsurgical treatment with early passive range of motion

4. Nonsurgical treatment with sling immobilization for 4 weeks

PREFERRED RESPONSE: C DISCUSSION

Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and

<3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range

 of motion is important to avoid stiffness.

 

 Question 54 of 100 Figure 1 is the radiograph of a 39-year-old man who has a syncopal episode and fall. After being  cleared by the emergency department, he is referred to your office for left shoulder pain and loss of external rotation.What is the most appropriate next step in management?

 

PREFERRED RESPONSE: B DISCUSSION

The patient has a posterior glenohumeral dislocation, as evidenced by the overlap on the initial radiograph. While posterior dislocations are rare, they can be overlooked. A CT scan will accurately show the lesion before proceeding to surgery. If a simple closed reduction is performed acutely and the arm is stable after the reduction, no further intervention may be needed, and treatment can be successful with a 2-week period of immobilization for defects involving <30% of the humeral head. However, in this scenario, open reduction is likely and stabilization may require a modified McLaughlin procedure or other intervention to fill in the humeral defect. Younger male patients, those with a large humeral head defect, and those with seizure disorder may be at highest risk for recurrence. For treatment of chronic posterior dislocations, it may be necessary to perform shoulder arthroplasty to restore stability. Stiffness is attributable to articular incongruity;   therefore,

 physical therapy and capsular release are inappropriate.

 

 Question 55 of 100

Figure 1 is the radiograph of a 27-year-old man who is involved in a motorcycle collision and sustains a right femoral and tibial shaft fracture, in addition to the injury shown in Figure 1. All fractures are closed. In addition to intramedullary nailing of the tibia and femur, appropriate treatment and weight-bearing status of the humeral shaft fracture should include

 

PREFERRED RESPONSE: D DISCUSSION

Bell and associates and Tingstad and associates both showed that immediate, full weight bearing through the upper extremity can be safely allowed for a humeral shaft fracture fixed using a plate and screw construct. Tingstad and associates showed no difference in malunion or nonunion rate following non-weight bearing or full weight bearing. Because he is a polytrauma patient, the patient would benefit from operative fixation of his humerus to expedite recovery and facilitate mobilization. A coaptation splint and a fracture brace would be appropriate treatment options for a non-polytrauma patient, but in neither case would full weight  bearing

 generally be allowed immediately following the injury.

 

 Question 56 of 100 A 72-year-old man sustains a displaced four-part fracture of the proximal humerus with head split component following a fall. A primary shoulder arthroplasty has been recommended for acute management. In counseling the patient on pros and cons of hemiarthroplasty versus reverse arthroplasty, what statement can be made based on the available literature?

1. The risk of tuberosity nonunion/malunion appears higher with hemiarthroplasty.

2. Functional outcomes tend to be more consistent with hemiarthroplasty.

3. Forward elevation of reverse shoulder arthroplasty depends on tuberosity union.

4. Active elevation is likely to be better following hemiarthroplasty.

PREFERRED RESPONSE: D DISCUSSION

As the indications for reverse shoulder arthroplasty have expanded, the role for shoulder hemiarthroplasty appears to be narrowing. Several recent systematic reviews have evaluated outcomes of shoulder hemiarthroplasty and reverse shoulder arthroplasty for acute proximal humerus fractures. Their results suggest that reverse arthroplasty results in superior functional results and comparable elevation, at the expense of increased  complication  rates  and  decreased  shoulder  rotation.  One  of  the  benefits  of  reverse shoulder

arthroplasty in the setting of fracture is that forward elevation is independent of tuberosity healing and relies mainly on the deltoid muscle. Active external rotation following a reverse total shoulder for fracture, however, does appear to depend on successful union of the greater tuberosity. In a randomized controlled trial, the incidence of tuberosity healing was higher and the incidence of tuberosity resorption was lower in reverse arthroplasty compared with hemiarthroplasty. Forward elevation following a hemiarthroplasty for fracture generally follows a bimodal distribution, whereas outcomes following a reverse total shoulder have been more

 consistent.

 

 Question 57 of 100 Figure 1 is the radiograph of a 39-year-old man who has a syncopal episode and fall. After being  cleared by the emergency department, he is referred to your office for left shoulder pain and loss of external rotation.What is the most likely diagnosis?

 

PREFERRED RESPONSE: D DISCUSSION

The patient has a posterior glenohumeral dislocation, as evidenced by the overlap on the initial radiograph. While posterior dislocations are rare, they can be overlooked. A CT scan will accurately show the lesion before proceeding to surgery. If a simple closed reduction is performed acutely and the arm is stable after the reduction, no further intervention may be needed, and treatment can be successful with a 2-week period of immobilization for defects involving <30% of the humeral head. However, in this scenario, open reduction is likely and stabilization may require a modified McLaughlin procedure or other intervention to fill in the humeral defect. Younger male patients, those with a large humeral head defect, and those with seizure disorder may be at highest risk for recurrence. For treatment of chronic posterior dislocations, it may be necessary to perform shoulder arthroplasty to restore stability. Stiffness is attributable to articular incongruity;   therefore,

 physical therapy and capsular release are inappropriate.

 

 Question 58 of 100 A patient sustains a displaced diaphyseal humerus fracture following a motor vehicle accident. Open reduction internal fixation is indicated due to concomitant lower extremity trauma and is planned through an anterior approach. Which intramuscular interval is exploited during the deep dissection of the mid-humerus in this approach?

A.   Lateral head of triceps (radial nerve) and brachialis (musculocutaneous nerve)

 

PREFERRED RESPONSE: D DISCUSSION

The anterior approach to the mid-humerus courses along the lateral margin of the biceps brachii. This muscle is swept medially allowing exposure of the brachialis. The brachialis has a dual innervation, with the lateral fibers innervated by the radial nerve and the medial fibers innervated by the musculocutaneous nerve. The humerus is exposed by splitting this muscle in its midline. The lateral head of the triceps resides in the posterior compartment of the arm and is not involved in the anterior approach to the humerus. The interval between brachialis   and  coracobrachialis   is   not   an  internervous  plane,  as   both   muscles   are  supplied  by the

 musculocutaneous nerve.

 

 Question 59 of 100 Figure 1 is the radiograph of a right-hand-dominant 70-year-old woman who arrives at the emergency department with acute left shoulder pain following a fall down a flight of stairs. She expresses acute diffuse left shoulder pain and swelling. Prior to her injury, she had fully active, painless shoulder range of motion.What is the most common complication following open reduction and locking plate osteosynthesis of this injury?

 

PREFERRED RESPONSE: A DISCUSSION

Fractures of the proximal humerus are now the third most common fracture in patients >60 years of age. This patient sustained a displaced, commonly described 3-part/4-part proximal humerus fracture. The number of fracture fragments and angulation, as initially described by Codman and then Neer, does not necessarily help to predict risk for subsequent AVN. Although the main blood supply to the humeral head historically was believed to be a branch from the anterior circumflex, adequate perfusion can remain through the posteromedial calcar following trauma. Hertel and associates reported that the most accurate predictor of ischemia was whether the length of the metaphyseal head extension for the calcar segment was <8 mm. Locking plates have provided surgical alternatives to many unstable fracture patterns previously considered ominous. Although much enthusiasm remains for this implant choice, a relatively high level of complications has been  reported

with their use. A multicenter study reported a 14% incidence of intra-articular screw perforation as the most common complication. When patients are deemed poor candidates for head preservation treatment, both hemiarthroplasty and rTSA can provide successful results when applied and performed appropriately. An increasing body of evidence appears to support consideration of a reverse prosthesis for older patients. A crucial aspect of hemiarthroplasty success is anatomic healing of the tuberosities around the implant. If the greater tuberosity displaces or reabsorbs, patients experience significant loss of active motion. The level of pain, however, is unpredictable. Although beneficial in a reverse prosthesis, anatomic tuberosity position does not appear to be as crucial. Depending on the definition of “complication,” some researchers have reported a higher complication rate for the reverse prosthesis. If posttraumatic osteonecrosis develops following head preservation treatment, conversion to an anatomic shoulder arthroplasty can provide good success in motion and function, particularly when the tuberosities heal in a relatively anatomic position. However, several researchers, most recently Moineau and associates, report suboptimal results when the greater tuberosity is positioned in a substantial amount of varus that necessitates osteotomy. In this scenario, rTSA should be

 considered.

 

 Question 60 of 100 Figures 1 through 3 are the radiograph and select CT images of a 75-year-old smoker with hypertension who sustains a ground-level fall without loss of consciousness with impact to her left upper extremity 1 week ago. She reports living independently at home with her husband prior to her fall. What is the most appropriate next step?

 

PREFERRED RESPONSE: D DISCUSSION

The radiograph and CT scans indicate a 4-part left proximal humerus fracture with tuberosity comminution. Based upon her preinjury level of activity and current imaging studies, nonsurgical management is unlikely to restore her ability to perform activities of daily living, including hygiene care. There has been enthusiasm among surgeons regarding the use of the reverse shoulder prosthesis as the primary mode of surgical treatment for certain 3- and 4-part proximal humerus fractures. The main attribute of this implant is its ability to achieve functional shoulder forward flexion and abduction regardless of tuberosity healing, position, and degree of

comminution. Nevertheless, repair and union of the greater tuberosity fragment during rTSA demonstrate improved external rotation, clinical outcomes, and patient satisfaction than outcomes achieved after tuberosity resection, nonunion, or resorption. Based upon this patient’s age and imaging findings, an rTSA would provide pain relief and improved function with complication rates similar to those associated with hemiarthroplasty. ORIF would not be a viable option because of the high probability for a dysvascular head, increased risk for nonunion, and potential for revision surgery, including arthroplasty. Hemiarthroplasty for 4-part proximal humerus fractures remains a viable option for patients <70 years of age with minimal tuberosity comminution and an intact rotator cuff who can comply with a postsurgical rehabilitation program. Most studies indicate significant pain relief with this modality, with significant variation in functional outcomes. In this clinical scenario, the patient’s injury may not be best served with hemiarthroplasty because of uncertainty  regarding

 functional outcome.

 

 Question 61 of 100 A  67-year-old  man  with  right  shoulder  osteoarthritis  (OA)  remains  symptomatic  despite  a   course  of nonsurgical treatment. A CT scan of the shoulder shows eccentric posterior glenoid wear with 10° of retroversion. What is the appropriate management of this glenoid bone loss during surgery for an anatomic total shoulder arthroplasty?

1. In situ glenoid component implantation

2. Hemiarthroplasty

3. Eccentric reaming of glenoid

4. Posterior glenoid bone graft

PREFERRED RESPONSE: C DISCUSSION

Total shoulder arthroplasty (TSA) is superior to hemiarthroplasty for primary OA. The most common complication of TSA is glenoid loosening and malposition, which are common causes of glenoid failure. Glenoid malposition decreases the glenohumeral contact area and subsequently increases contact pressures. Altering the stem version to accommodate glenoid retroversion does not appropriately address soft-tissue balancing. A retroversion of <12° to 15° can be corrected with eccentric reaming without excessively compromising glenoid bone stock and risking glenoid vault penetration by the glenoid component. Posterior

 glenoid bone grafting may be considered for glenoid retroversion >15°.

 

 Question 62 of 100 A healthy 65-year-old woman undergoes anatomic total shoulder arthroplasty to address osteoarthritis (OA). The surgery is uncomplicated. What is the most common indication for future revision?

1. Deep infection

2. Periprosthetic fracture

3. Glenoid component loosening

4. Rotator cuff tear

 PREFERRED RESPONSE: C DISCUSSION

The most common reason for revision surgery following unconstrained shoulder arthroplasty for glenohumeral OA is loosening of an implant. In most studies that distinguish glenoid from humeral loosening, it appears the glenoid is the problem. Comprehensive systematic reviews have found that radiographic glenoid loosening can comprise  nearly 30% to 40% of  all complications following shoulder  arthroplasty for    non-

inflammatory arthritis. Infections, periprosthetic fractures, and rotator cuff tears are uncommon. In the population-based study by Matsen and associates, 10% of the revisions were performed for loosening versus

 7% for infection and 7% for rotator cuff tearing.

 

 Question 63 of 100 A 25-year-old minor league baseball pitcher has posteromedial elbow pain during the deceleration   phase of his motion. Examination reveals a mild flexion contracture of the elbow, moderate tenderness over the medial olecranon, mild tenderness over the radiocapitellar joint and medial collateral ligament, and a grossly stable valgus stress test. Figure 1 is a coronal MR arthrogram of his elbow. What is the most likely diagnosis?

 

 PREFERRED RESPONSE: C DISCUSSION

VEO is a condition most frequently seen in repetitive overhead throwing athletes. It represents a combination of pathologies resultant from tensile stress on the medial collateral ligament and common flexor pronator origin, lateral compressive force across the radiocapitellar joint, and shear stress between the medial tip of the olecranon and olecranon fossa. The deceleration and follow-through phases of the throwing motion are when contact between the olecranon tip and fossa are at their highest, often resulting in osteophyte formation that can both block terminal extension and cause local tenderness. While compromise of the medial collateral ligament (MCL) and osteochondral injury of the radiocapitellar joint can occur in VEO, these findings are part of the larger disease process. In this patient, the MR arthrogram reveals a grossly intact MCL and no evidence of radiocapitellar degeneration. Compromise of the lateral ulnar collateral ligament is not a component of

 VEO and is not suggested by the primary site of pain in the question.

 

 Question 64 of 100 A 19-year-old, right-hand-dominant collegiate baseball pitcher reports a 4-month history of right shoulder pain after a throwing activity. He localizes the pain primarily to the posterior aspect of his shoulder and describes the type of pain as an aching sensation. He has been involved with strength and conditioning with his team but denies any specific therapy other than the application of ice after throwing and use of occasional

over-the-counter anti-inflammatory drugs, neither of which has provided relief. He denies any specific traumatic event or previous history of shoulder problems. His pitching coach has noted a slight decrease in his throwing velocity during the last 2 months. The patient fails nonsurgical treatment and undergoes shoulder arthroscopy. At the time of surgery, the area marked by the asterisk in Figure 1 is visualized from the posterolateral portal. This anatomic structure impinges on which other structure during late cocking of the throwing phase?

 PREFERRED RESPONSE: D DISCUSSION

This patient’s clinical presentation is consistent with internal impingement accompanied by glenohumeral internal rotation deficit (GIRD). Although throwers may have increased external rotation, their overall arc of motion should be the same as on the nonthrowing side. In comparison, patients with GIRD experience a marked decrease in arc of motion, particularly in internal rotation. Internal impingement represents a spectrum of findings that can include superior and posterior labral tears, undersurface (articular-sided) tearing of the posterior supraspinatus, posterior glenoid wear, and scar formation of the posterior capsule. Myers and associates demonstrated internal impingement is associated with GIRD, although the latter by itself may be asymptomatic and perhaps a sports-specific adaptation. However, posterior capsular tightness can lead to posterosuperior translation of the humerus during throwing, leading to these injuries. Internal impingement is common among overhead throwing athletes and occurs during the late cocking and early acceleration phases of throwing. Humeral migration during the abducted/externally rotated throwing position results in abutment of the greater tuberosity against the posterosuperior glenoid labrum, which impinges the rotator cuff (Paley and associates). Pain is often posterior, but symptoms can be vague. Patients may have examination findings consistent with rotator cuff weakness and superior labrum anterior to posterior (SLAP)/biceps involvement. Radiographic findings can be negative, although a Bennett lesion involving hypertrophy and mineralization of the posterior capsular injury may be seen (Wright and Paletta). A CT scan may show glenoid retroversion (Crockett and associates), whereas MR imaging should be reviewed for a possible partial articular-sided rotator cuff tear, SLAP tear, or increased signal in the posterosuperior labrum, or greater tuberosity. Treatment of this condition should be the focus on therapy, and most cases can be treated nonsurgically. Stretching aimed at the posterior capsule (ie, sleeper stretch) has been reported as effective (Tyler and associates, Lintner  and

associates). Burkhart and associates also demonstrated that posterior capsular stretching can help to prevent throwing injuries. Because cuff pathology may be present, physical therapy also should include rotator strengthening, scapular stabilization, and addressing of issues related to throwing mechanics (Drakos and associates). Kibler and associates published a comprehensive rehabilitation guideline. Surgical intervention is reserved for those who fail 6 months of nonsurgical treatment and is directed by intra-articular pathology

 (debridement vs repair of the rotator cuff and labrum) (Braun and associates).

 

 Question 65 of 100 Figures 1 through 4 are the radiograph and MRI scans of a 70-year-old woman who has a 10-year  history of worsening shoulder pain. She has had multiple corticosteroids, several rounds of physical therapy, and continues to take nonsteroidal anti-inflammatory medications. She has pain with all activities and has to use the contralateral hand to aid in elevation of the arm. The pain prevents her from sleeping. Her active forward elevation is 40°; her passive forward elevation is 160° with a positive lag sign. Her active external rotation with the arm at the side is 10°; her passive external rotation is 40° with a positive lag sign. Her hornblower’s sign is negative. What would be the most effective treatment option for this patient?

 

 PREFERRED RESPONSE: D DISCUSSION

This patient has failed nonsurgical measures and continues to demonstrate pseudoparalysis. The images show proximal humeral migration with acetabularization of the acromion. The teres minor is intact and the hornblower’s sign is negative. This patient would benefit most from a reverse total shoulder arthroplasty. If there was severe atrophy or absence of teres minor and/or if the hornblower’s sign was positive, then the best choice for treatment to restore external rotation would be reverse total shoulder arthroplasty with a latissimus transfer. Ten-year follow-up following reverse total shoulder arthroplasty for the treatment of a massive rotator cuff tear in the setting of arthritis demonstrated >90% survivorship. All patients demonstrated improved range of motion and pain relief, as well as improved patient-reported outcomes scores. The key to restoration of function, especially external rotation, is the teres minor. Indications for the addition of a latissimus transfer to reverse total shoulder arthroplasty include rotator cuff tears in which the teres minor is absent or atrophic (as all remaining external rotators are absent). Patients who do not regain external rotation control will have a difficult time performing activities of daily living such as bringing their hand to their mouth. The rotator cuff in the MRI scan demonstrates significant retraction and fatty atrophy/infiltration, making repair of the tendon

a non-viable option. An unconstrained total shoulder arthroplasty requires an intact rotator cuff, or a repairable

 tendon, to minimize edge-loading of the glenoid component and potential loosening.

 

 Question 66 of 100 A 37-year-old recreational athlete has osteoarthritis of the glenohumeral joint. He has failed nonsurgical measures and is interested in surgical intervention but would like to avoid arthroplasty. When performing shoulder arthroscopy for glenohumeral arthritis, which radiographic parameter is most predictive of clinical failure?

1. Unipolar arthritis

2. >3 mm of glenohumeral joint space

3. Walch B2 glenoid morphology

4. Small inferior humeral osteophyte

 PREFERRED RESPONSE: C DISCUSSION

Multiple studies have evaluated the utility of arthroscopy in the treatment of shoulder arthritis. Despite differing levels of success, a few common characteristics have been shown to lead to a higher probability of clinical failure. Mitchell and associates showed that shoulders with less joint space (1.3 mm vs 2.6 mm) and Walch type B2 and C glenoids were significantly more likely to fail than were Walch types A1, A2, and B1. Additionally, older patients (age >50 years) tended to have worse outcomes. Skelley and associates found that isolated capsular release and debridement had a high failure rate (conversion to total shoulder arthroplasty in 42% within 9 months) and postulated that patients undergoing concomitant procedures, such as biceps tenodesis, may fare better. Van Theil and associates found significant risk factors for failure included the presence of grade 4 bipolar disease, joint space <2 mm, and the presence of large osteophytes. They had a

 22% conversion to total shoulder arthroplasty at 10.1 months.

 

 Question 67 of 100 A 19-year-old, right-hand-dominant collegiate baseball pitcher reports a 4-month history of right shoulder pain after a throwing activity. He localizes the pain primarily to the posterior aspect of his shoulder and describes the type of pain as an aching sensation. He has been involved with strength and conditioning with his team but denies any specific therapy other than the application of ice after throwing and use of occasional over-the-counter anti-inflammatory drugs, neither of which has provided relief. He denies any specific traumatic event or previous history of shoulder problems. His pitching coach has noted a slight decrease in his throwing velocity during the last 2 months.Which image seen during arthroscopic treatment is most likely associated with this patient's condition?

 PREFERRED RESPONSE: A DISCUSSION

This patient’s clinical presentation is consistent with internal impingement accompanied by glenohumeral internal rotation deficit (GIRD). Although throwers may have increased external rotation, their overall arc of motion should be the same as on the nonthrowing side. In comparison, patients with GIRD experience a marked decrease in arc of motion, particularly in internal rotation. Internal impingement represents a spectrum of findings that can include superior and posterior labral tears, undersurface (articular-sided) tearing of the posterior supraspinatus, posterior glenoid wear, and scar formation of the posterior capsule. Myers and associates demonstrated internal impingement is associated with GIRD, although the latter by itself may be asymptomatic and perhaps a sports-specific adaptation. However, posterior capsular tightness can lead to posterosuperior translation of the humerus during throwing, leading to these injuries. Internal impingement is common among overhead throwing athletes and occurs during the late cocking and early acceleration phases of throwing. Humeral migration during the abducted/externally rotated throwing position results in abutment of the greater tuberosity against the posterosuperior glenoid labrum, which impinges the rotator cuff (Paley and associates). Pain is often posterior, but symptoms can be vague. Patients may have examination findings consistent with rotator cuff weakness and superior labrum anterior to posterior (SLAP)/biceps involvement. Radiographic findings can be negative, although a Bennett lesion involving hypertrophy and mineralization of the posterior capsular injury may be seen (Wright and Paletta). A CT scan may show glenoid retroversion (Crockett and associates), whereas MR imaging should be reviewed for a possible partial articular-sided rotator cuff tear, SLAP tear, or increased signal in the posterosuperior labrum, or greater tuberosity. Treatment of this condition should be the focus on therapy, and most cases can be treated nonsurgically. Stretching aimed at the posterior capsule (ie, sleeper stretch) has been reported as effective (Tyler and associates, Lintner and associates). Burkhart and associates also demonstrated that posterior capsular stretching can help to prevent throwing injuries. Because cuff pathology may be present, physical therapy also should include rotator strengthening, scapular stabilization, and addressing of issues related to throwing mechanics (Drakos and associates). Kibler and associates published a comprehensive rehabilitation guideline. Surgical intervention is reserved for those who fail 6 months of nonsurgical treatment and is directed by intra-articular pathology (debridement vs repair of the rotator cuff and labrum) (Braun and associates).

 

 

 Question 68 of 100 Figures 1 through 4 are the radiographs and CT scans of a 78-year-old right-hand dominant man with a recent- onset painful left shoulder and limited range of motion. He was reaching overhead and felt a pop, which resulted in severe pain and dysfunction. The patient underwent an anatomic total shoulder arthroplasty 5 years prior for glenohumeral osteoarthritis. A select axial CT image from before the index surgery is seen in Figure

4. The patient has not had any fevers or systemic symptoms of infection. ESR, CRP, and CBC levels remain normal. What preoperative factors are most predictive of the complication experienced by this patient?

 PREFERRED RESPONSE: D DISCUSSION

This patient has an anatomic total shoulder arthroplasty with a completely dislocated glenoid component. The glenoid component can be seen in the posterior axillary pouch, as evidenced by the radiographic marker seen best on the axial cut CT. Preoperative factors that influence the outcome of an anatomic total shoulder arthroplasty resulting in the need for revision surgery for failed glenoid component include preoperative fixed posterior humeral head subluxation and moderate to severe eccentric glenoid erosion. Walch and   associates

describe three patterns of glenoid component migration including superior tilting, subsidence, and posterior tilting. Superior tilting was associated with implant position and rotator cuff integrity. Subsidence was associated with aggressive reaming for correction of glenoid version, which does not maintain the subchondral bone  support.  Posterior  subluxation  was  associated  with  glenoid  erosion  and  posterior  humeral    head

 subluxation.

 

 Question 69 of 100 Placement of the most distal interlocking screw seen in the radiographs provided in Figures 1 and 2 would most likely result in what clinical examination finding?

 PREFERRED RESPONSE: C DISCUSSION

Blunt dissection and soft-tissue protection is warranted with distal interlocking screw placement following humeral intramedullary nailing. The most distal locking screw in this intramedullary nail construct was placed from anterior to posterior, passing through the distal portion of the biceps and brachialis muscle bellies. The musculocutaneous nerve which continues as the sensory lateral antebrachial cutaneous (LABC) nerve is at risk, as it lies between these two muscles. Injury to the LABC nerve results in decreased sensation over the radial volar aspect of the forearm. Malrotation of the nail, producing a more anteromedial starting point for the anterior-to-posterior screw, can lead to a path that intersects with the median nerve and brachial artery. More commonly, the median nerve can be injured with overpenetration of the medial cortex with a lateral-to- medial directed screw. Median nerve injury would affect innervations of the flexor digitorum superficialis and profundus to the index finger (among other motors). Although the dissection violates the muscle belly of these

two elbow flexors, measurable weakness in elbow flexion is not typically seen. The radial nerve has already provided function to triceps (elbow extension) proximal to this level and lies sufficiently lateral to be more of a concern with a lateral-to-medial screw placement (thumb IP extension). The ulnar nerve (decreased sensation of small and ring fingers) is further medial at this level and would similarly be at risk with a lateral-to-medial

interlocking screw.

 Question 70 of 100 A 72-year-old active man has shoulder pain after undergoing an explantation of an anatomic shoulder arthroplasty 6 months prior with an antibiotic cement spacer placed. The patient has 60° of forward flexion, 40° of external rotation, and a positive belly press with limited internal rotation. A recent work-up for continued infection is negative, and a follow-up MRI reveals grade 2 atrophy of the supraspinatus and grade 3 atrophy of the subscapularis with tendon retraction to the glenoid rim. What is the best next step in definitive management?

1. Revision anatomic total shoulder arthroplasty

2. Reverse total shoulder arthroplasty

3. Hemiarthroplasty with latissimus dorsi transfer

4. Resection arthoplasty

 PREFERRED RESPONSE: B DISCUSSION

This patient has a previously failed total shoulder arthroplasty for which he underwent placement of an antibiotic spacer, and now has continued shoulder  pain.  The  recent MRI  demonstrates  a  likely  irreparable subscapularis tendon, making revision with an anatomic shoulder arthroplasty contraindicated. Use of a hemiarthroplasty is unlikely to restore function in this older patient with underlying rotator cuff disease, though it may be helpful for pain relief. Furthermore, a latissimus dorsi transfer is also contraindicated in the setting of a chronic subscapularis tear. A reverse shoulder arthroplasty offers the most reliable clinical outcome. Given that the preoperative infection work-up was negative, resection arthroplasty

 is not indicated for this otherwise active patient.

 

 Question 71 of 100 Figures 1 and 2 are the radiograph and axial CT scan of a 75-year-old woman with diffuse superior shoulder pain 5 months after an uneventful reverse shoulder arthroplasty. She denies trauma, but felt a "pop" when reaching overhead. She had initially done well postoperatively. On physical examination, she has decreased active forward flexion with pain and diffuse superior tenderness along the scapular spine and acromion. There are no signs or symptoms of infection. What is the best next step in management?

 

 PREFERRED RESPONSE: D DISCUSSION

The radiograph shows a well-positioned reverse total shoulder and the axial CT image demonstrates a minimally displaced fracture through the midacromion. Acromial fracture is a concerning and not uncommon complication that can have devastating effects after reverse shoulder arthroplasty, as function is highly dependent on the deltoid muscle. Fracture can occur at the scapular spine, which may be related to placement of peripheral baseplate screws. Acromial fracture has been reported to occur as early as 1 month postoperatively and as late as 8 years postoperatively. The reported incidence is <8%, and multiple authors note decreases in shoulder elevation and shoulder outcome scores compared with that in patients with reverse shoulder arthroplasty without a fracture. Patients with a fracture can complain of superior shoulder pain that may radiate to the deltoid area and usually relate an acute onset of pain or loss of function after initially good clinical progress. The diagnosis can be difficult to determine and is missed on plain radiographs in up to 20% of cases. CT scans are helpful. Treatment is typically nonoperative with sling immobilization for 6 weeks and then advancing activities as tolerated. A bone stimulator and ORIF would not be indicated for a minimally displaced   acute  acromion   fracture.   Continued   physical   therapy  with   strengthening   would   also  be

 contraindicated.

 

 Question 72 of 100 Figures 1 and 2 are the radiographs of a 30-year old recreational polo player who sustained an injury to his right shoulder following a fall from a horse. He denies any prior injuries to the shoulder. He reports pain in the superior aspect of the shoulder and has an abrasion over the lateral acromion. Which anatomic structure is most important for maintaining the anterior-posterior stability of the injured joint?

 

PREFERRED RESPONSE: D DISCUSSION

The patient has radiographic evidence of a grade III AC joint separation. Treatment of grade III AC separations remains controversial. In a grade III AC separation, both the AC joint capsule, as well as the coracoclavicular ligaments (conoid and trapezoid) are disrupted. The coracoclavicular ligaments primarily provide superior/inferior stability to the clavicle, and the AC joint capsule/ligament complex provides anterior- posterior stability. Within this capsule complex, biomechanical studies have shown that the posterosuperior portion is most crucial for maintaining anterior-posterior stability of the AC joint and should be preserved during AC joint resection procedures. The inferior AC capsule/ligament does not play a significant role in AC joint horizontal stability.

 

 Question 73 of 100 Figure 1 is the radiograph of a 54-year-old man who has increasing weakness and numbness in his lateral arm. No prior surgery or injury is reported. What is the most appropriate next diagnostic test?

PREFERRED RESPONSE: B DISCUSSION

The radiograph reveals a Charcot neuropathic shoulder. The atraumatic destruction of the humeral head is concerning for a neuropathic etiology and warrants MR imaging of the cervical spine to evaluate for the presence of a syrinx. Shoulder arthroplasty in the setting of a neuropathic joint is challenging given the local bone and soft-tissue loss, in addition to the loss of protective sensation. The scant literature on the use of shoulder  arthroplasty  in  these  challenging  patients  reports  an  improvement  in  pain  but  only    modest

 improvements in shoulder function.

Question 74 of 100 A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of the bone fragment and returns to play football the following year. He has a recurrent dislocation at football practice but decides to finish the football season before considering additional treatment. He sustains nine additional dislocations, with the last dislocation occurring while sleeping. The patient has eroded one-third of the inferior glenoid surface area. What is the most appropriate surgical treatment?

1. Revision arthroscopic Bankart repair with capsular shift

2. Open Bankart repair with capsular shift

3. Repair of infraspinatus tendon into the Hill-Sachs defect (remplissage procedure)

4. Coracoid transfer to the glenoid (Latarjet procedure)

PREFERRED RESPONSE: D DISCUSSION

A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an “inverted pear.” Quantitative bone loss is best evaluated by CT scan with 3-D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting. A revision arthroscopic or open Bankart repair with capsular shift or remplissage do not address bone loss. The Latarjet procedure can effectively restore stability with glenoid bone loss and after failed stabilizing procedures. Patients with pain before surgery  are

 more likely to have pain after surgery. Age and activity level are lesser influences on satisfaction.

 

 Question 75 of 100

What phase of overhead throwing puts the rotator cuff at most risk of injury from internal impingement?

1. Wind up

2. Late cocking

3. Deceleration

4. Follow through

PREFERRED RESPONSE: D DISCUSSION

Internal impingement occurs when there is repetitive contact of the posterior superior aspect of the glenoid with the humeral head causing damage to the undersurface of the supraspinatus and anterior aspect of the infraspinatus tendons, as well as posterior superior glenoid labrum. This occurs when the arm is in maximum abduction and external rotation such as during the late cocking phase of the normal throwing motion. The 6 phases of throwing are wind up, early cocking, late cocking, deceleration, and follow through. When the arm is repeatedly placed in the abducted externally rotated position, the anterior capsule can become lax and posterior capsular contractures can develop. When there are kinetic chain abnormalities such as scapular internal rotation or muscle fatigue, there is exacerbation of abnormal anterior humeral head translation and increased contact of the rotator cuff on the posterior glenoid rim, with concomitant increased risk of injury

 and symptoms.

 

 Question 76 of 100 A 65-year-old man undergoes an uneventful left total shoulder arthroplasty for primary osteoarthritis using a lesser tuberosity osteotomy. At his 6-week postoperative visit, he is progressing well with physical therapy. Two months after surgery, he slips and falls in his driveway. His subsequent visits over the next 8 weeks with

therapy are fraught with marked deterioration of his active motion and the inability to reach his lower back. A subsequent radiograph and axial CT view of his shoulder are shown in Figures 1 and 2. What is the best next step in management?

PREFERRED RESPONSE: D DISCUSSION

Anatomic total shoulder arthroplasty remains the most utilized surgical modality for patients with primary osteoarthritis of the shoulder. Recently, the lesser tuberosity osteotomy has generated enthusiasm as a theoretical avenue to improve subscapularis function postoperatively. With modern repair techniques, this approach has a reported high union rate, making it a comparable alternative with the traditional subscapularis peel or tenotomy. However, loss of fixation and subscapularis failure may still occur. The patient’s radiograph reveals a medially displaced lesser tuberosity with extension of a fracture line to the lateral cortex of the proximal humerus. As a result, the patient now has subscapularis insufficiency that has affected his active range of motion, as evidence by his inability to reach his lower back. Owing to the timing following the injury to presentation, conversion to a reverse shoulder arthroplasty would most reliably maximize the patient’s outcome. In the acute setting, an attempt at operative repair of the failed lesser tuberosity may be considered. Sling immobilization would not be recommended. One of the benefits of an osteotomy is that plain radiographs are often more than adequate to confirm the diagnosis of subscapularis failure secondary to loss of tuberosity

 fixation.

 

 Question 77 of 100 A 23-year-old left-hand dominant professional football player sustains a left shoulder injury after being tackled and lands directly on his shoulder 1 month ago. The patient was diagnosed with a Rockwood type 2 acromioclavicular separation. Following physical therapy, his symptoms have improved. He has good scapular control and shoulder strength. What physical examination test would help determine the contribution of the acromioclavicular joint injury to his residual symptoms?

 

PREFERRED RESPONSE: A DISCUSSION

The clinical scenario describes an athlete who is recovering from a type 2 acromioclavicular joint separation. The goal of this question is to stress the importance of the physical examination to guide treatment decisions, as well as recovery. It is important to recognize which factors can aid in decision making especially with type type 2 acromioclavicular joint separation injuries as the data are still not clear as to who would best be served with surgical versus nonsurgical management. The active compression test as described by O’Brien and associates in 1998 was equally as effective at assessing the acromioclavicular joint as it was for assessment of the integrity of the superior labrum. The Hawkins-Kennedy test has demonstrated utility in the diagnosis of rotator cuff impingement, wherein the greater tuberosity comes into contact with the coracoacromial ligament. The DLST has been described for the diagnosis of superior labral anterior-posterior (SLAP) tears, wherein the patient reports pain and a click felt with movement of the shoulder through an arc of abduction with the shoulder externally rotated. The upper cut test has been described in the setting of biceps tendinopathy and

 SLAP tears.

 

 Question 78 of 100 Stemless  shoulder  arthroplasty  prostheses  have  recently  been  suggested  as  an  alternative to traditional stemmed replacement. Advantages of the stemless surgical technique would include

1. better glenoid exposure than with stemmed prosthesis.

2. reliable use in four-part proximal humerus fracture surgery.

3. use in proximal humeral malunion without need for osteotomy.

4. improved long-term survivorship profile.

PREFERRED RESPONSE: C DISCUSSION

Glenoid exposure, while better than with surface replacements, is not improved over traditional stemmed replacements. Metaphyseal comminution would make it unlikely that a stemless implant could be used in most four-part fractures. Stemless replacement does have the unique advantage of allowing placement of a prosthesis with a malunion without an osteotomy, as the prosthesis is not constrained by the position of the stem. While early results are encouraging, there is no long-term data to suggest that survivorship is increased

 with stemless arthroplasty.

 

 Question 79 of 100 A 73-year old woman reports activity-related pain in the right shoulder. She had undergone surgery on her shoulder following a fall at home. A select radiograph is given in Figure 1. The radiographic changes seen along the glenoid neck would most likely have been minimized through the use of what implant-related technique?

 

PREFERRED RESPONSE: B DISCUSSION

In a reverse shoulder arthroplasty, multiple designs with varying amounts of valgus neck-shaft angles have been developed since the original 155° of the neck-shaft angle Grammont prosthesis design. Regardless of neck-shaft angle utilized, average forward elevation flexion improvement ranges from 78° to 131°, with no difference in dislocation rates and range of motion. A 135° neck-shaft angle has been shown to have less scapular notching. The radiograph demonstrates a commonly utilized reverse total shoulder replacement with a 135°-angled humeral stem. The baseplate has not been placed at the inferior-most aspect of the glenoid with the result being that the inferior aspect of the glenosphere lies superior to the glenoid neck. While the clinical implications of scapular notching were previously controversial, it has more recently been shown that advanced scapular notching is associated with a decrease in functional outcomes and possibly baseplate loosening. Strategies for reducing the prevalence of notching have been shown through clinical, computer simulation, and biomechanical studies. A more valgus stem, increased superior tilt, and a more medialized offset have been shown to increase the risk for scapular notching. The number of screws can affect initial baseplate stability but has not been shown to have an effect on scapular notching. In this case, more distal placement of the baseplate (or use of a larger or more laterally offset glenosphere) would have decreased the

 adduction deficit and reduced impingement of the polyethylene onto the lateral scapula.

 

 Question 80 of 100 Figures 1 and 2 are the radiographs of a 69-year-old, left-hand-dominant retired man with left shoulder pain. The pain has been present for several years. He worked in construction but retired 3 years ago. He now reports

pain interfering with activities around the house but denies recent trauma or prior shoulder surgery. He has tried nonsteroidal anti-inflammatory drugs, but these do not provide complete relief. He demonstrates pain and crepitus with active and passive shoulder motion. He can actively forward flex to 100° and external rotate to 30°. Rotator cuff testing reveals 5/5 strength and he is neurovascularly intact. After discussion regarding surgical and nonsurgical treatment options, the patient wishes to proceed with surgical intervention. He has done online research and has questions about which procedure will produce the best outcome. Based on the current literature, what is the most appropriate surgical procedure?

PREFERRED RESPONSE: C DISCUSSION

The examination and radiograph findings are consistent with glenohumeral osteoarthritis (OA), which is now interfering with this patient’s daily activities. Regarding surgical treatment for glenohumeral arthritis, several studies have shown that TSA is associated with better functional outcomes than hemiarthroplasty. A recent meta-analysis comparing outcomes between TSA and hemiarthroplasty revealed better function after TSA regarding pain, University of California-Los Angeles Shoulder Scores, and postsurgical forward elevation at a minimum of 2 years (Bryant and associates). In addition, Gartsman and associates showed that TSA resulted in better pain relief, function, strength, and patient satisfaction than hemiarthroplasty at 3-year follow-up. The patient in this scenario exhibits good rotator cuff strength on examination; therefore, arthroscopy with debridement or rTSA used in the setting of a massive cuff tear would not be the best answer. Several studies have similarly shown good results with TSA in the setting of inflammatory and rheumatoid arthritis (Thomas and associates, Jolles and associates). Posterior glenoid wear is a common pattern in OA and not a contraindication (Walch and associates). However, patients with a brachial plexus root avulsion or preganglionic injury resulting in a flail arm are not candidates for TSA because of the poor prognosis for recovery of motor and sensory deficits. Inflammatory arthritis characteristically results in concentric glenoid wear and not the eccentric posterior erosion seen in OA. This concentric wear results in medialization of the glenohumeral joint line. This wear pattern can lead to severe erosion, making it difficult to achieve glenoid resurfacing. Eccentric posterior glenoid wear would lead to posterior humeral head subluxation, which is not

as common in inflammatory arthritis. In addition, inferior humeral head osteophytes are seen in OA. Walch and associates have developed a classification system describing glenoid wear patterns. During TSA, exposure to the glenohumeral joint involves subscapularis management, tendon peel, or lesser tuberosity osteotomy. As a result, early postsurgical rehabilitation limits passive external rotation and active internal rotation, typically for 6 weeks, to protect the subscapularis repair. The patient in this scenario likely eccentrically contracted his subscapularis, resulting in repair failure. Upon clinical examination, internal rotation weakness, increased passive external rotation, and abnormal belly press or lift-off test results can be expected. One study revealed

 that rupture of the subscapularis was seen in all anterior dislocations following TSA (Wirth and Rockwood). 

 

 Question 81 of 100 A 75-year-old man sustains an anterior dislocation of his reverse total shoulder arthroplasty. What activity places the arm in the position most commonly associated with reverse total shoulder dislocation?

1. Scratching the opposite shoulder

2. Pushing off ipsilateral chair armrest while standing up

3. Tying shoelaces on the contralateral foot

4. Reaching up to comb hair

PREFERRED RESPONSE: B DISCUSSION

Proper soft-tissue tension is critical to prevent instability of a reverse total shoulder implanted with the deltopectoral approach; dislocation of the prosthesis is exceedingly rare if the superior approach is employed. The arm position implicated in reverse total shoulder instability is extension, adduction, and internal rotation,

 such as pushing out of a chair. The other positions described do not involve extension of the shoulder.

 

 Question 82 of 100 Figures 1 and 2 are the radiographs of a 69-year-old, left-hand-dominant retired man with left shoulder pain. The pain has been present for several years. He worked in construction but retired 3 years ago. He now reports pain interfering with activities around the house but denies recent trauma or prior shoulder surgery. He has tried nonsteroidal anti-inflammatory drugs, but these do not provide complete relief. He demonstrates pain and crepitus with active and passive shoulder motion. He can actively forward flex to 100° and external rotate to 30°. Rotator cuff testing reveals 5/5 strength and he is neurovascularly intact. During the patient's presurgical history and physical visit, he reports to the nurse that he has a history of rheumatoid arthritis which is being managed by his primary care physician. With this new information in hand, which finding is most commonly seen on imaging during presurgical planning?

 

PREFERRED RESPONSE: A DISCUSSION

The examination and radiograph findings are consistent with glenohumeral osteoarthritis (OA), which is now interfering with this patient’s daily activities. Regarding surgical treatment for glenohumeral arthritis, several studies have shown that TSA is associated with better functional outcomes than hemiarthroplasty. A recent meta-analysis comparing outcomes between TSA and hemiarthroplasty revealed better function after TSA regarding pain, University of California-Los Angeles Shoulder Scores, and postsurgical forward elevation at a minimum of 2 years (Bryant and associates). In addition, Gartsman and associates showed that TSA resulted in better pain relief, function, strength, and patient satisfaction than hemiarthroplasty at 3-year follow-up. The patient in this scenario exhibits good rotator cuff strength on examination; therefore, arthroscopy with debridement or rTSA used in the setting of a massive cuff tear would not be the best answer. Several studies have similarly shown good results with TSA in the setting of inflammatory and rheumatoid arthritis (Thomas and associates, Jolles and associates). Posterior glenoid wear is a common pattern in OA and not a contraindication (Walch and associates). However, patients with a brachial plexus root avulsion or preganglionic injury resulting in a flail arm are not candidates for TSA because of the poor prognosis for recovery of motor and sensory deficits. Inflammatory arthritis characteristically results in concentric glenoid wear and not the eccentric posterior erosion seen in OA. This concentric wear results in medialization of the glenohumeral joint line. This wear pattern can lead to severe erosion, making it difficult to achieve glenoid resurfacing. Eccentric posterior glenoid wear would lead to posterior humeral head subluxation, which is not as common in inflammatory arthritis. In addition, inferior humeral head osteophytes are seen in OA. Walch and associates have developed a classification system describing glenoid wear patterns. During TSA, exposure to the glenohumeral joint involves subscapularis management, tendon peel, or lesser tuberosity osteotomy. As a result, early postsurgical rehabilitation limits passive external rotation and active internal rotation, typically for 6 weeks, to protect the subscapularis repair. The patient in this scenario likely eccentrically contracted his subscapularis, resulting in repair failure. Upon clinical examination, internal rotation weakness, increased passive external rotation, and abnormal belly press or lift-off test results can be expected. One study revealed

 that rupture of the subscapularis was seen in all anterior dislocations following TSA (Wirth and Rockwood). 

 

 Question 83 of 100 A 65-year-old man who underwent an uncomplicated reverse total shoulder arthroplasty (rTSA) to treat rotator cuff arthropathy 2 years ago has a routine follow-up visit in your clinic. A radiograph at 2-year follow-up is shown in Figure 1. He denies shoulder pain and dysfunction and constitutional symptoms, and his clinical examination findings are benign. Based upon the present radiologic evaluation, what is the next most appropriate step?

 

PREFERRED RESPONSE: C DISCUSSION

Based upon the patient’s clinical examination and symptoms, continued observation is most appropriate. The remaining options are not indicated. The radiograph reveals scapular notching, one of the more common complications specific to rTSA. Notching is caused by repeated contact between the humeral component and/or humerus and the inferior pillar of the scapular neck. Generation of particulate debris from this interaction can result in osteolysis with the potential for screw and base plate failure. The overall incidence of notching has been reported to be between 51% and 96%. This nearly ubiquitous finding has been attributed to implant positioning, altered glenoid and humeral anatomy, and duration of implantation. Recent studies that indicate increased lateral offset, increased glenosphere size, and inferior positioning of the base plate may reduce the incidence of scapular notching.

 

 Question 84 of 100 Figures 1 and 2 are the radiographs of a 69-year-old, left-hand-dominant retired man with left shoulder pain. The pain has been present for several years. He worked in construction but retired 3 years ago. He now reports pain interfering with activities around the house but denies recent trauma or prior shoulder surgery. He has tried nonsteroidal anti-inflammatory drugs, but these do not provide complete relief. He demonstrates pain and crepitus with active and passive shoulder motion. He can actively forward flex to 100° and external rotate to 30°. Rotator cuff testing reveals 5/5 strength and he is neurovascularly intact. Following a successful shoulder arthroplasty, the patient returns for his 1-month follow-up. At today's visit, his wound appears benign, and he denies drainage or fevers. He reports he was doing well until last week, when he reached out to close the car door, which resulted in new-onset anterior shoulder pain. His radiograph from the current visit is shown in Figure 3. What is the most likely cause of this new finding?

 

PREFERRED RESPONSE: B DISCUSSION

The examination and radiograph findings are consistent with glenohumeral osteoarthritis (OA), which is now interfering with this patient’s daily activities. Regarding surgical treatment for glenohumeral arthritis, several studies have shown that TSA is associated with better functional outcomes than hemiarthroplasty. A recent meta-analysis comparing outcomes between TSA and hemiarthroplasty revealed better function after TSA regarding pain, University of California-Los Angeles Shoulder Scores, and postsurgical forward elevation at a minimum of 2 years (Bryant and associates). In addition, Gartsman and associates showed that TSA resulted in better pain relief, function, strength, and patient satisfaction than hemiarthroplasty at 3-year follow-up. The patient in this scenario exhibits good rotator cuff strength on examination; therefore, arthroscopy with debridement or rTSA used in the setting of a massive cuff tear would not be the best answer. Several studies have similarly shown good results with TSA in the setting of inflammatory and rheumatoid arthritis (Thomas and associates, Jolles and associates). Posterior glenoid wear is a common pattern in OA and not a contraindication (Walch and associates). However, patients with a brachial plexus root avulsion or preganglionic injury resulting in a flail arm are not candidates for TSA because of the poor prognosis for recovery of motor and sensory deficits. Inflammatory arthritis characteristically results in concentric glenoid wear and not the eccentric posterior erosion seen in OA. This concentric wear results in medialization of the glenohumeral joint line. This wear pattern can lead to severe erosion, making it difficult to achieve glenoid resurfacing. Eccentric posterior glenoid wear would lead to posterior humeral head subluxation, which is not as common in inflammatory arthritis. In addition, inferior humeral head osteophytes are seen in OA. Walch and associates have developed a classification system describing glenoid wear patterns. During TSA, exposure to the glenohumeral joint involves subscapularis management, tendon peel, or lesser tuberosity osteotomy. As a result, early postsurgical rehabilitation limits passive external rotation and active internal rotation, typically for 6 weeks, to protect the subscapularis repair. The patient in this scenario likely eccentrically contracted his subscapularis, resulting in repair failure. Upon clinical examination, internal rotation weakness, increased passive external rotation, and abnormal belly press or lift-off test results can be expected. One study revealed

 that rupture of the subscapularis was seen in all anterior dislocations following TSA (Wirth and Rockwood). 

Question 85 of 100 A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of the bone fragment and returns to play football the following year. He has a recurrent dislocation at football practice but decides to finish the football season before considering additional treatment. He sustains nine additional dislocations, with the last dislocation occurring while sleeping.What diagnostic test is most appropriate when planning revision surgery?

1. CT scan with 3D reconstructions

2. Ultrasonography

3. MRI scan

4. Fluoroscopically-guided arthrogram

PREFERRED RESPONSE: A DISCUSSION

A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an “inverted pear.” Quantitative bone loss is best evaluated by CT scan with 3-D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting. A revision arthroscopic or open Bankart repair with capsular shift or remplissage do not address bone loss. The Latarjet procedure can effectively restore stability with glenoid bone loss and after failed stabilizing procedures. Patients with pain before surgery  are

 more likely to have pain after surgery. Age and activity level are lesser influences on satisfaction.

 

 Question 86 of 100 When a patient has recurrent anterior shoulder instability, a bony glenoid reconstructive procedure should be considered in which clinical setting?

1. Associated humeral avulsion of the glenohumeral ligament (HAGL) lesion

2. Non-engaging Hill-Sachs lesion

3. Glenoid bone loss of at least 25%

4. Anterior labral periosteal sleeve avulsion (ALPSA)

PREFERRED RESPONSE: C DISCUSSION

HAGL lesions may initially be treated without surgery. Recurrent instability in the setting of a HAGL lesion may be treated with a soft-tissue repair. A non-engaging or non-tracking Hill-Sachs lesion may be treated with an anterior soft-tissue (Bankart) repair. A tracking or engaging lesion may be treated with a bony glenoid procedure or a soft-tissue procedure plus remplissage. An ALPSA lesion may be treated with a soft-tissue procedure unless it is associated with a glenoid bony defect >25%. A glenoid bony defect >25% is associated with substantially higher recurrence than defects <20%, and consideration for bony glenoid reconstruction is advised. Consideration of bone augmentation procedures with less severe glenoid bone loss may be considered

 in collision athletes.

 

 Question 87 of 100 A 45-year-old woman with diabetes has a 3-month history of atraumatic left shoulder pain and   motion loss. She previously underwent treatment with nonsteroidal anti-inflammatory medication and a home stretching program, experiencing minimal relief of her symptoms. Examination reveals loss of passive external rotation, abduction, and forward elevation without reduction in strength. Radiographs are normal. What is the most appropriate next step?

 

PREFERRED RESPONSE: B DISCUSSION

Based upon the duration of symptoms and clinical presentation, this patient would benefit from cortisone injection therapy and continued PT. Adhesive capsulitis, most commonly an idiopathic process that results in joint pain and loss of motion from capsular contracture, affects approximately 2% to 5% of the general population. The process typically affects middle-age women. There are secondary causes such as previous trauma and fractures, as well as associated medical conditions such as diabetes, stroke, and cardiac and thyroid disease. Debate remains as to whether a genetic predisposition for the development of adhesive capsulitis exists, despite the increased frequency noted in twin studies. Although the underlying etiology and pathophysiology are not well understood, the consensus is that synovial inflammation and capsular fibrosis result in pain and joint volume loss. It is hypothesized that in patients with diabetes, an increased rate of glycosylation and cross-linking of the shoulder capsule raises the incidence of frozen shoulder. For this patient, history reveals a short duration of symptoms that did not improve with nonsurgical modalities. Clinically, the patient has reduced passive range of motion, particularly with external and internal rotation and forward elevation. Radiographs are usually obtained to exclude other causes of shoulder pain such as glenohumeral arthrosis, malignancy, calcific tendonitis, impingement, and acromioclavicular degeneration. If pain and stiffness persist beyond 6 months, closed manipulation may be an option. Complications associated with this modality may include humerus fracture, dislocation, hematoma, rotator cuff and labral tears, and brachial plexus injury. Some surgeons advocate arthroscopic capsular release to allow for examination of concomitant pathology and controlled release of capsular tissue, with the potential for reduced required force when performing the manipulation portion of the procedure. This modality may be appropriate after an initial treatment with PT. Controversy remains as to whether posterior capsular release should be routinely performed because studies have shown outcomes to be similar with anterior and combined approaches. Therapy should be initiated early after intervention, with some surgeons advocating admission to the hospital with   inpatient

 therapy for pain management and compliance.

 

 Question 88 of 100 Figures 1 through 4 are the radiographs and CT scans of a 78-year-old right-hand dominant man with a recent-onset painful left shoulder and limited range of motion. He was reaching overhead and felt a pop, which resulted in severe pain and dysfunction. The patient underwent an anatomic total shoulder arthroplasty 5 years prior for glenohumeral osteoarthritis. A select axial CT image from before the index surgery is seen in Figure 4. The patient has not had any fevers or systemic symptoms of infection. ESR, CRP, and CBC levels remain normal. What preoperative factors are most predictive of the complication experienced by this patient?

PREFERRED RESPONSE: D DISCUSSION

This patient has an anatomic total shoulder arthroplasty with a completely dislocated glenoid component. The glenoid component can be seen in the posterior axillary pouch, as evidenced by the radiographic marker seen best on the axial cut CT. Preoperative factors that influence the outcome of an anatomic total shoulder arthroplasty resulting in the need for revision surgery for failed glenoid component include preoperative fixed posterior humeral head subluxation and moderate to severe eccentric glenoid erosion. Walch and associates describe three patterns of glenoid component migration including superior tilting, subsidence, and posterior tilting. Superior tilting was associated with implant position and rotator cuff integrity. Subsidence was associated with aggressive reaming for correction of glenoid version, which does not maintain the subchondral bone  support.  Posterior  subluxation  was  associated  with  glenoid  erosion  and  posterior  humeral    head

 subluxation.

 Question 89 of 100 In rotator cuff tear arthropathy with pseudoparalysis, forward elevation of the humerus away from the body is prohibited because of

1. deltoid atony.

2. loss of the glenoid concavity.

3. loss of the humeral head depression of the biceps tendon.

4. loss of compressive force on the humeral head.

PREFERRED RESPONSE: D DISCUSSION

The rotator cuff serves as a humeral head compressor that stabilizes the humeral head in the glenoid concavity so that the deltoid can convert a vertical force into abduction and forward elevation. The deltoid functions normally in patients with chronic rotator cuff arthropathy, so no atony is present. Glenoid concavity can be lost over time, but this is not the primary mechanism for failure of elevation. The biceps tendon does not serve as a humeral head compressor and does not prevent proximal migration of the shoulder when it is present.

 Question 90 of 100 Figure 1 is the radiograph of a 65-year-old active, right-hand-dominant woman with a 6-month history of right shoulder pain, motion loss, and progressive weakness after undergoing a hemiarthroplasty to address

osteoarthritis 1 year ago. She denies recent trauma to her right shoulder and denies constitutional symptoms. Her surgical wound site is benign. She can actively forward flex to 90° degrees and abduct to 60°.    Passive    forward     flexion     and     abduction     are     150°     and     90°,     respectively.     She completes the necessary testing and wishes to proceed with revision surgery. The most appropriate surgical option in this scenario involves implant removal and

PREFERRED RESPONSE: C DISCUSSION

The radiograph reveals a rotator cuff dysfunction secondary to malpositioning of the humeral stem and a nonanatomic humeral head. Glenohumeral kinematics have been altered, resulting in damage to the rotator cuff, which in turn has led to impingement with the coracoacromial arch. This single radiograph reveals excessive humeral head height, “overstuffing” of the joint, and severe narrowing of the acromiohumeral interval. Osteolysis and implant loosening are not radiographically apparent. An orthogonal view (axillary lateral) would be necessary to evaluate for shoulder instability. A CT arthrogram is the most appropriate advanced imaging test in the setting of a retained shoulder arthroplasty to evaluate the integrity of the rotator cuff. An MRI evaluation would be obfuscated by artifact. Three-phase and indium-tagged WBC scans may be appropriate in the setting of an occult infection evaluation but not as a test to evaluate rotator cuff injury. In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion to rTSA. Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be  reserved  for  recalcitrant  cases  of  infection,  because  this  procedure  does  not  provide functional

improvement. In the event that frozen section analysis and positive Gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate (in light of laboratory studies, repeat shoulder aspiration, frozen section analysis, and arthroscopic soft-tissue biopsy findings). Irrigation and debridement with primary exchange/conversion of components remains inferior to 2-stage reconstruction for infection eradication. Resection arthroplasty remains a salvage procedure for resistant cases that preclude reimplantation and generally is performed for symptom control and sepsis prevention.

 

 Question 91 of 100 A 23-year-old minor league pitcher describes the insidious onset of posterior shoulder pain during the late cocking phase of his throwing motion. He has gone 6 weeks without throwing, but symptoms have returned on return to play. An MR arthrogram of the shoulder reveals fraying of the superior labrum and proximal biceps, and a partial-thickness articular-sided supraspinatus tear (30% tendon thickness). Figure

1 is a representative coronal MRI slice. Clinical examination demonstrates mild weakness of the periscapular muscles, mild superior rotator cuff weakness, and negative instability testing. Internal rotation with the arm in 90° of abduction is 40° in the affected shoulder versus 70° in the contralateral shoulder. What is the best next step?

PREFERRED RESPONSE: B DISCUSSION

Internal impingement is a condition that affects overhead throwing athletes, as the greater tuberosity and articular surface of the rotator cuff contact the posterosuperior glenoid during maximal shoulder abduction and external rotation. The etiology is typically multifactorial, but common contributors include posterior capsular contracture, scapular dyskinesia, and subtle anterior shoulder laxity. Nonoperative management, the mainstay of treatment, includes rest, stretching, scapular strengthening, and proprioception. Results of surgical intervention are variable; therefore, nonoperative measures should be exhausted first.   While

PRP is currently being investigated as a biologic augmentation in a number of shoulder pathologies, it is not considered first-line treatment.

 Question 92 of 100 Figure 1 is the radiograph of a 65-year-old active, right-hand-dominant woman with a 6-month history of right shoulder pain, motion loss, and progressive weakness after undergoing a hemiarthroplasty to address osteoarthritis 1 year ago. She denies recent trauma to her right shoulder and denies constitutional symptoms. Her surgical wound site is benign. She can actively forward flex to 90° degrees and abduct to 60°.    Passive    forward    flexion    and     abduction     are     150°     and     90°,     respectively.     What is the most likely cause of her symptoms?

 

PREFERRED RESPONSE: B DISCUSSION

The radiograph reveals a rotator cuff dysfunction secondary to malpositioning of the humeral stem and a nonanatomic humeral head. Glenohumeral kinematics have been altered, resulting in damage to the rotator cuff, which in turn has led to impingement with the coracoacromial arch. This single radiograph reveals excessive humeral head height, “overstuffing” of the joint, and severe narrowing of the acromiohumeral interval. Osteolysis and implant loosening are not radiographically apparent. An orthogonal view (axillary lateral) would be necessary to evaluate for shoulder instability. A CT arthrogram is the most appropriate advanced imaging test in the setting of a retained shoulder arthroplasty to evaluate the integrity of the rotator cuff. An MRI evaluation would be obfuscated by artifact. Three-phase and indium-tagged WBC scans may be appropriate in the setting of an occult infection evaluation but not as a test to evaluate rotator cuff injury. In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion

to rTSA. Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be reserved for recalcitrant cases of infection, because this procedure does not provide functional improvement. In the event that frozen section analysis and positive Gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate (in light of laboratory studies, repeat shoulder aspiration, frozen section analysis, and arthroscopic soft-tissue biopsy findings). Irrigation and debridement with primary exchange/conversion of components remains inferior to 2-stage reconstruction for infection eradication. Resection arthroplasty remains a salvage procedure for resistant cases that preclude reimplantation and generally is performed for symptom control and sepsis prevention.

 

 Question 93 of 100 A 50-year-old pipefitter falls from a ladder at work and dislocates his non-dominant shoulder.  His MRI scan shows supraspinatus and infraspinatus tears with retraction to the glenoid. He cannot actively raise his arm away from his side. He denies prior shoulder symptoms before his fall. Three weeks of physical therapy have failed to improve his function. Which factor has been demonstrated to result in a poor clinical outcome following surgical intervention?

1. The patient's age

2. he patient's gender

3. Work-related injury

4. Acute nature of the tear

PREFERRED RESPONSE: C DISCUSSION

Several studies have demonstrated that patients with work-related injuries do not do as well as those whose injuries are not work-related after repair of the rotator cuff. This patient’s age and gender are not negative prognostic indicators. The acute nature of the tear does not lead to an inferior outcome.

 Question 94 of 100 MRI results are shown in Figure 1 for a 22-year-old, right-hand-dominant collegiate athlete who reports a 6-month history of progressive weakness in his right arm. He denies any specific traumatic event, has altered his weight-lifting activities, and has tried over-the-counter ibuprofen without having a benefit. No appreciable deformity or atrophy is found on examination of the upper extremities. He demonstrates full active shoulder range of motion, and there is no weakness with abduction in the plane of the scapula. Belly press test findings are normal, but weakness is seen in external rotation with the arm in adduction. He does not demonstrate anterior apprehension, and there is no instability with load and shift testing. Radiographs are unremarkable. What is the best surgical option?

 

PREFERRED RESPONSE: C DISCUSSION

This patient’s clinical and MRI findings are consistent with a posterior paralabral cyst with compression of the suprascapular nerve, specifically at the spinoglenoid notch. Compression of the suprascapular nerve can occur at either the suprascapular or spinoglenoid notch. Compression of the nerve at the suprascapular notch affects innervation to both the supraspinatus and infraspinatus muscles, resulting in weakness in both shoulder abduction and external rotation. However, compression at the spinoglenoid notch only affects  innervation  to  the  infraspinatus  muscle,  resulting  in  isolated  weakness  in  external   rotation. Compression at the spinoglenoid notch often is seen in overhead athletes, and studies have shown associated posterior labral tears (Piatt and associates). Several studies have addressed nonsurgical and surgical treatment options. The treatment decision should focus on the underlying cause (Martin and associates)—in this patient, the cyst. Nonsurgical treatment in the presence of a known lesion has been associated with a higher failure rate than addressing the lesion, which can result in functional improvement (Chen and associates, Cummins and associates). The best response in this scenario is decompression of the cyst at the spinoglenoid notch with possible labral repair.

 Question 95 of 100 Figure 1 is the radiograph of a 47-year-old woman who has pain and difficulty raising her arm after playing 36 holes of golf in a weekend and now has difficulty sleeping. She denies prior episodes of shoulder pain. Examination demonstrates guarding with any shoulder motion, tenderness around the superolateral shoulder, and normal sensory findings.The best initial treatment would entail

 

PREFERRED RESPONSE: A DISCUSSION

Calcific tendinitis of the shoulder is a deposition of calcium carbonate apatite crystals into the structure of the rotator cuff tendon. The crystalline form appears to progress throughout the clinical disease process, demonstrating increasing matured stoichiometric apatite deposition during the resorptive phase. MRI can be difficult to interpret because the signal of the calcific lesion is frequently similar to that seen in normal supraspinatus tendon. Plain radiographs remain the gold standard for diagnosis. Ultrasound can be a useful ancillary study to determine the location and size of the lesion. Primary management of calcific tendinitis starts with nonsurgical treatment including physiotherapy and injections, if indicated. Mixed results have been reported with extracorporeal shock wave therapy. Surgical removal with repair of the tendon in larger lesions remains the definitive treatment when nonsurgical modalities fail. Subacromial decompression may improve pain relief in patients who require surgery; however, patients with decompression may take longer to fully recover.

 Question 96 of 100 Figures 1 and 2 are the radiographs of a 60-year-old man with gradual onset of right shoulder pain and motion loss 1 year after undergoing an uncomplicated right total shoulder arthroplasty (TSA) for end-stage osteoarthritis. He denies trauma to his right shoulder and constitutional symptoms but admits to difficulty performing activities of daily living. His surgical wound site is benign. He demonstrates active and passive forward flexion to 90°, abduction to 60°, external rotation to 30°, and internal rotation to the lumbosacral junction. His rotator cuff strength is graded as normal and symmetrical to his unaffected left shoulder. Based upon the current evaluation, what is the most appropriate next step?

 

PREFERRED RESPONSE: B DISCUSSION

This patient’s radiographs do not reveal prosthetic loosening, osteolysis, instability, or rotator cuff deficiency. History and examination findings suggest a possible indolent infectious process, and it is incumbent upon the treating surgeon to obtain screening laboratory studies (CBC with differential, ESR, C-reactive protein) and proceed with obtaining cultures (via joint aspiration or arthroscopic soft-tissue biopsy) to rule out an infectious process. Cultures should be held for 2 weeks to evaluate for the possibility of a Propionibacterium acnes infection, which is the predominant organism elicited from painful and stiff TSAs for which revision is required. Immediate revision TSA is not indicated in this scenario because the components appear well fixed and positioned. Observation and therapy in the setting of deterioration of a previously well-functioning TSA also are not appropriate.

 

 Question 97 of 100 A 30-year-old man with diabetes sustains an acute posterior dislocation of his right shoulder after a seizure that required emergency department reduction. You initially treat him with a sling for 4 weeks and then refer him for outpatient therapy. During his therapy sessions, the patient admits to pain and instability symptoms during range-of-motion exercises. Repeat examination indicates a positive posterior load-shift test and apprehension with adduction and internal rotation of the shoulder. His CT and MRI scans are shown in Figures 1 and 2. What is the most appropriate next step in treatment?

 

PREFERRED RESPONSE: C DISCUSSION

Posterior glenohumeral dislocations are much less common than anterior glenohumeral dislocations, with a prevalence of 1.1 per 100,000 per year. There is a bimodal distribution with a peak in young men (2.4 men to 1 woman) and a second peak in elderly people with a more equivalent gender ratio. Posterior dislocations most commonly result from trauma, with the remainder of events secondary to seizure activity. According to Robinson and associates, age <40 years, dislocation during a seizure, and a large reverse Hill-Sachs lesion were all predictive of recurrent instability. Concomitant injuries associated with posterior shoulder dislocations include capsulolabral tears, fractures, and rotator cuff tears. Imaging studies in this patient indicate a reverse Hill-Sachs lesion with a corresponding posterior labral tear. Because of his persistent mechanical symptoms, continued immobilization and therapy is not appropriate. An open capsular shift with labral repair alone would not address symptoms related to an engaging reverse Hill-Sachs lesion and has the added morbidity from the surgical approach. Based upon the patient’s age, activity level, and percentage of humeral head involvement, a resurfacing arthroplasty is not recommended. A subscapularis or lesser tuberosity transfer has been used to address symptomatic reverse Hill-Sachs lesions (20%-40% humeral head involvement) associated with posterior shoulder dislocations. Modifications of this technique such as arthroscopic transfer of the subscapularis tendon with posterior capsulorrhaphy have proven beneficial. The indications for the concomitant subscapularis transfer into the defect (arthroscopic McLaughlin) have not been as well-defined as for patients with a Hill-Sachs lesion in the setting of recurrent anterior instability.

 Question 98 of 100 Figure 1 is the radiograph of a 47-year-old woman who has pain and difficulty raising her arm after playing 36 holes of golf in a weekend and now has difficulty sleeping. She denies prior episodes of shoulder pain. Examination demonstrates guarding with any shoulder motion, tenderness around the superolateral shoulder, and normal sensory findings. An MRI arthrogram scan of her shoulder would most likely reveal

 

PREFERRED RESPONSE: D DISCUSSION

Calcific tendinitis of the shoulder is a deposition of calcium carbonate apatite crystals into the structure of the rotator cuff tendon. The crystalline form appears to progress throughout the clinical disease process, demonstrating increasing matured stoichiometric apatite deposition during the resorptive phase. MRI can be difficult to interpret because the signal of the calcific lesion is frequently similar to that seen in normal supraspinatus tendon. Plain radiographs remain the gold standard for diagnosis. Ultrasonography can be a useful ancillary study to determine the location and size of the lesion. MRI demonstrates a hypointense homogenous signal on the T1- and T2 fat suppressed sequences in the region of the calcific deposit. There may be some increased T2-signal surrounding the lesion indicated localized inflammation. Primary management of calcific tendinitis starts with nonsurgical treatment including physiotherapy and injections, if indicated. Mixed results have been reported with extracorporeal shock wave therapy. Surgical removal with repair of the tendon in larger lesions remains the definitive treatment when nonsurgical modalities fail. Subacromial decompression may improve pain relief in patients who require surgery; however, patients with decompression may take longer to fully recover.

 Question 99 of 100 In the work-up of a painful shoulder arthroplasty, arthroscopic biopsy specimens that are sent for culture and discarded after 5 days will most likely yield a false-negative result in the setting of infection by which organism?

 

PREFERRED RESPONSE: B DISCUSSION

It has been increasingly recognized that P acnes is a common pathogen implicated in infections of the shoulder. Multiple studies have shown that discarding the cultures prior to 2 weeks will result in a high rate of false-negative cultures. This is likely because P acnes is a semiobligate anaerobe and grows slowly

in the lab. As such, the clinical presentations are often nonspecific, without overt fever or wound breakdown, and traditional infection lab values are commonly within normal limits. In addition to S aureus, P acnes has been cited as the most common etiology for infection following shoulder arthroplasty.

 Question 100 of 100 Figure 1 is the radiograph of a 65-year-old active, right-hand-dominant woman with a 6-month history of right shoulder pain, motion loss, and progressive weakness after undergoing a hemiarthroplasty to address osteoarthritis 1 year ago. She denies recent trauma to her right shoulder and denies constitutional symptoms. Her surgical wound site is benign. She can actively forward flex to 90° degrees and abduct to 60°. Passive forward flexion and abduction are 150° and 90°, respectively. Intraoperative frozen section analysis reveals 10 neutrophils per high-power field and a positive Gram stain result. The most appropriate next step would consist of implant removal, irrigation and debridement, and

PREFERRED RESPONSE: D DISCUSSION

The radiograph reveals a rotator cuff dysfunction secondary to malpositioning of the humeral stem and a nonanatomic humeral head. Glenohumeral kinematics have been altered, resulting in damage to the rotator cuff, which in turn has led to impingement with the coracoacromial arch. This single radiograph reveals excessive humeral head height, “overstuffing” of the joint, and severe narrowing of the acromiohumeral interval. Osteolysis and implant loosening are not radiographically apparent. An orthogonal view (axillary lateral) would be necessary to evaluate for shoulder instability. A CT arthrogram is the most appropriate advanced imaging test in the setting of a retained shoulder arthroplasty to evaluate the integrity of the rotator cuff. An MRI evaluation would be obfuscated by artifact. Three-phase and indium-tagged WBC scans may be appropriate in the setting of an occult infection evaluation but not as a test to evaluate rotator cuff injury. In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion

to rTSA. Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be reserved for recalcitrant cases of infection, because this procedure does not provide functional improvement. In the event that frozen section analysis and positive Gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate (in light of laboratory studies, repeat shoulder aspiration, frozen section analysis, and arthroscopic soft-tissue biopsy findings). Irrigation and debridement with primary exchange/conversion of components remains inferior to 2-stage reconstruction for infection eradication. Resection arthroplasty remains a salvage procedure for resistant cases that preclude reimplantation and generally is performed for symptom control and sepsis prevention.

 

 Question 101 Figure 1 is the radiograph of a 47-year-old woman who has pain and difficulty raising her arm after playing 36 holes of golf in a weekend and now has difficulty sleeping. She denies prior episodes of shoulder pain. Examination demonstrates guarding with any shoulder motion, tenderness around the superolateral shoulder, and normal sensory findings. The lesion indicated in the image is comprised of

PREFERRED RESPONSE: A DISCUSSION

Calcific tendinitis of the shoulder is a deposition of calcium carbonate apatite crystals into the structure of the rotator cuff tendon. The crystalline form appears to progress throughout the clinical disease process, demonstrating increasing matured stoichiometric apatite deposition during the resorptive phase. MRI can be difficult to interpret because the signal of the calcific lesion is frequently similar to that seen in normal supraspinatus tendon. Plain radiographs remain the gold standard for diagnosis. Ultrasonography can be a useful ancillary study to determine the location and size of the lesion. MRI demonstrates a hypointense homogenous signal on the T1- and T2 fat suppressed sequences in the region of the calcific deposit. There may be some increased T2-signal surrounding the lesion indicated localized inflammation. Primary

management of calcific tendinitis starts with nonsurgical treatment including physiotherapy and injections, if indicated. Mixed results have been reported with extracorporeal shock wave therapy. Surgical removal with repair of the tendon in larger lesions remains the definitive treatment when nonsurgical modalities fail. Subacromial decompression may improve pain relief in patients who require surgery; however, patients with decompression may take longer to fully recover.