ORTHOPEDIC MCQS BANK WITH ANSWER SHOULDER 02

 

 

            1-Which of the following statements best describes why the ulnar nerve is most prone to neuropathy at the elbow?

 

1-         It has the least longitudinal excursion required to accommodate elbow range of motion.

2-         It is subjected to both compression and traction during elbow motion.

3-         It passes between two muscle heads as it enters the forearm.

4-         The dimensions of the entrance of the cubital tunnel do not change with elbow motion.

5-         The vascular supply leaves a watershed area of diminished arterial supply.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The ulnar nerve is more prone to neuropathy than the radial or median nerves for many reasons.  It has the greatest longitudinal excursion required to accommodate elbow range of motion, subjecting it to potential traction forces.  The dimensions of the entrance of the cubital tunnel change with elbow motion, potentially causing compression in flexion.  For these two reasons, the ulnar nerve is subjected to both compression and traction during elbow motion.  Although it passes between two muscle heads as it enters the forearm, so do the median and radial nerves.  Finally, the vascular supply is adequate because of the anastamoses between the superior ulnar collateral artery, the posterior ulnar recurrent artery, and the inferior ulnar collateral artery.

 

REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 369-378.

Prevel CD, Matloub HS, Ye Z, Sanger JR, Yousif NJ: The extrinsic blood supply of the ulnar nerve at the elbow: An anatomic study.  J Hand Surg Am 1993;18:433-438.

Gelberman RH, Yamaguchi K, Hollstein SB, et al: Changes in interstitial pressure and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow. J Bone Joint Surg Am 1998;80:492-501.

 

 

 

2.      Figure 1 shows the radiograph of a 71-year-old man who has had increasing pain and weakness in his shoulder for the past 3 years.  Nonsurgical management has failed to provide relief.  Examination shows 130 degrees of active forward flexion and intact external rotation strength.  During surgery, a 1- x 1-cm rotator cuff tear involving the supraspinatus is encountered.  Treatment should include

 

1-         humeral head replacement with rotator cuff repair.

2-         humeral head replacement without rotator cuff repair.

3-         arthrodesis of the shoulder.

4-         total shoulder replacement with rotator cuff repair.

5-         total shoulder replacement without rotator cuff repair. 

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Given the size of the rotator cuff tear, it is likely to be repaired; therefore, the treatment of choice is a total shoulder replacement with rotator cuff repair.  Severe rotator cuff insufficiency can lead to early glenoid failure because of superior instability, and glenoid resurfacing should be avoided in those instances.

 

REFERENCES: Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing.  J Arthroplasty 1990;5:329-336.

Arntz CT, Jackins S, Matsen FA III: Prosthetic replacement of the shoulder for treatment of defects in the rotator cuff and surface of the glenohumeral joint.  J Bone Joint Surg Am 1993;75:485-491.

 

3.       Which of the following is considered the cause of Milwaukee shoulder, a joint disease similar to rotator cuff arthropathy?

 

1-         Abundance of basic calcium phosphate crystals

2-         Abundance of calcium pyrophosphate crystals

3-         Gout

4-         Rheumatoid arthritis

5-         Osteonecrosis

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Neer and associates focused on mechanical and nutritional factors as the etiology of rotator cuff arthropathy.  McCarty and associates, in describing a similar syndrome known as Milwaukee shoulder, focused on an inflammatory cause in proposing the pathogenic role of hydroxyapatite, a basic calcium phosphate.  

 

REFERENCES: Neer CS II, Craig EV, Fukuda H: Cuff-tear arthropathy.  J Bone Joint Surg Am 1983;65:1232-1244.

McCarty DJ, Halverson PB, Carrera GF, Brewer BJ, Kozin F: Milwaukee shoulder: Association of microspheroids containing hydroxyapatite crystals, active collagenase, and neutral protease with rotator cuff defects. I: Clinical aspects. Arthritis Rheum 1981;24:464-473.

 

 

4.       The MRI scan of the shoulder shown in Figure 2 was performed with the arm in abduction and external rotation.  The image reveals what condition?

 

1-         Contact between the rotator cuff and the posterior-superior labrum

2-         Anterior instability

3-         A ganglion cyst of the spinoglenoid notch

4-         Osteonecrosis of the humeral head

5-         Posterior subluxation

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Internal impingement of the shoulder is now a well-recognized cause of shoulder pain in the throwing athlete.  First described by Walch and associates, it involves contact of the rotator cuff and labrum in the maximally externally rotated and abducted shoulder, such as in the late cocking phase of the throwing motion.  Schickendantz and associates have shown this contact to be physiologic in most patients and becoming pathologic with repetitive overhead activity.

 

REFERENCES: Schickendantz MS, Ho CP, Keppler L, Shaw BD: MR imaging of the thrower’s shoulder: Internal impingement, latissimus dorsi/subscapularis strains, and related injuries.  Magn Reson Imaging Clin N Am 1999;7:39-49. 

Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study.  J Shoulder Elbow Surg 1992;1:238-245. 

McFarland EG, Hsu CY, Neira C, O’Neil O: Internal impingement of the shoulder: A clinical and arthroscopic analysis. J Shoulder Elbow Surg 1999;8:458-460.

 

 

5.       Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched arm and sustained a fracture-dislocation of the elbow.  Initial management consisted of closed reduction of the dislocation.  Surgical treatment should now include repair or reduction and fixation of the

 

1-         medial and lateral collateral ligaments, radial head, and coronoid.

2-         medial collateral ligament and coronoid.

3-         lateral collateral ligament and radial head.

4-         medial and lateral collateral ligaments.

5-         radial head and coronoid.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The radiographs show fractures of the coronoid and radial head.  The medial collateral ligament has been avulsed from the ulnar insertion, and there is a valgus opening on the medial side.  The lateral collateral ligament is always disrupted in elbow dislocations and fracture-dislocations that occur secondary to falls.  This is known as the terrible triad injury (dislocation and fractures of the coronoid and radial head); it has a very poor prognosis because of its propensity for recurrent or persistent instability and late arthritis.  The principle in treating this injury is to repair all of the injured parts or protect them with a hinged external fixator until they heal. 

 

REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354. 

Kasser JR (ed): Orthopaedic Knowledge Update 5.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294. 

O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102. 

 

 

6.       It is important to avoid which of the following exercises in the immediate postoperative period after humeral head replacement for an acute four-part fracture?

 

1-         Pendulum exercises

2-         External rotation with a stick

3-         Passive forward elevation

4-         Active forward elevation

5-         Active range of motion of the elbow, wrist, and hand

 

PREFERRED RESPONSE: 4

 

DISCUSSION: It is critical to withhold active range of motion of the shoulder within the first 6 weeks after arthroplasty for acute fracture to prevent tuberosity avulsion.  When radiographic and clinical findings show that the tuberosities are healed, active motion may be instituted, usually at 6 to 8 weeks.  Immediate passive range-of-motion exercises, including external rotation with a stick, pendulum, and passive elevation, should begin within the limits of the repair on the day of surgery to prevent stiffness.

 

REFERENCES: Hartstock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humerus fractures. Orthop Clin North Am 1998;29:467-475.

Hughes M, Neer CS: Glenohumeral joint replacment and postoperative rehabilitation.  Phys Ther 1975;55:850-858.

 

 

7.       A 38-year-old man has winging of the ipsilateral scapula after undergoing a transaxillary resection of the first rib 3 weeks ago.  What is the most likely cause of this finding?

 

1-         Persistent thoracic outlet syndrome

2-         Injury to the upper trunk of the brachial plexus

3-         Injury to the long thoracic nerve

4-         Injury to the lower trunk of the brachial plexus

5-         Injury to the spinal accessory nerve

 

PREFERRED RESPONSE: 3

 

DISCUSSION: During transaxillary resection of the first rib, the long thoracic nerve is at risk as it passes either through or posterior to the middle scalene muscle.  Injury to this nerve may occur as the result of overly aggressive retraction of the middle scalene during the procedure.

 

REFERENCES: Leffert RD: Thoracic outlet syndrome.  J Am Acad Orthop Surg 1994;2:317-325.

Todd TW: The descent of the shoulder after birth: Its significance in the production of pressure-symptoms on the lowest brachial trunk.  Anat Anz 1912;41:385-397.

 

8.       A 73-year-old man who underwent repair of the left rotator cuff 6 years ago reports good pain relief but notes residual weakness of the left shoulder, especially with overhead tasks.  He denies having pain at night and has minimal discomfort with activities of daily living but is dissatisfied with his shoulder strength.  Radiographs show an acromiohumeral interval of 2 mm.  Appropriate management should consist of

 

1-         an exercise program.

2-         revision rotator cuff repair using local tissue transposition.

3-         revision rotator cuff repair using allograft.

4-         latissimus dorsi transfer.

5-         combined latissimus dorsi and teres major transfer.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: An exercise program to strengthen the deltoid and remaining rotator cuff will most likely offer the best results.  Revision rotator cuff surgery yields better results in decreasing pain than improving strength and function, and this patient has only minimal pain.  Tendon transfers, involving the use of the latissimus dorsi or teres major, have been used when the rotator cuff is deemed irreparable but are not indicated in elderly patients with minimal symptoms.

 

REFERENCES: Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES: Operative treatment of failed repairs of the rotator cuff.  J Bone Joint Surg Am 1992;74:1505-1515.

DeOrio JK, Cofield RH: Results of a second attempt at surgical repair of a failed initial rotator-cuff repair.  J Bone Joint Surg Am 1984;66:563-567.

Gerber C, Vinh TS, Hertel R, Hess CW: Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff: A preliminary report.  Clin Orthop 1988;232:51-61.

 

 

9.       A 45-year-old woman has had progressive right shoulder pain for the past 6 months.  She notes that the pain disrupts her sleep, she has pain at rest that requires the use of narcotic analgesics, and she has limited use of her left shoulder for most activities of daily living.  History reveals the use of corticosteroids for systemic lupus erythematosus.  Examination shows diminished range of motion.  Radiographs of the right shoulder are shown in Figures 4a and 4b.  Treatment should consist of

 

1-         core decompression of the humeral head.

2-         humeral arthroplasty.

3-         total shoulder arthroplasty.

4-         glenohumeral arthrodesis.

5-         vascularized fibular allograft.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Humeral arthroplasty provides excellent pain relief and function for stage IV osteonecrosis with humeral collapse.  In late disease with glenoid involvement (stage V), total shoulder arthroplasty is preferred.  Some authors have reported satisfactory results with core decompression of the humeral head for early stages of osteonecrosis, but results for stage IV osteonecrosis are less satisfactory when compared with those for humeral arthroplasty.

 

REFERENCES: Cruess RL: Steroid-induced avascular necrosis of the head of the humerus: Natural history and management.  J Bone Joint Surg Br 1976;58:313-317.

LePorte DM, Mont MA, Mohan V, Pierre-Jacques H, Jones LC, Hungerford DS: Osteonecrosis of the humeral head treated by core decompression.  Clin Orthop 1998;355:254-260.

Neer CS II (ed): Shoulder Reconstruction.  Philadelphia, PA, WB Saunders, 1990, pp 194-202.

 

10.    The relocation test is most reliable for diagnosing anterior subluxation of the glenohumeral joint when

 

1-         posterior pressure placed on the humeral head results in increased pain.

2-         external rotation with the arm in 90 degrees of abduction produces apprehension that is relieved by posterior pressure on the humeral head.

3-         external rotation with the arm in 90 degrees of abduction produces pain that is relieved by posterior pressure on the humeral head.

4-         external rotation with the arm in 90 degrees of abduction produces no symptoms, but posterior pressure on the humeral head produces pain and apprehension.

5-         external rotation with the arm in 90 degrees of abduction produces no symptoms, but posterior pressure on the humeral head produces apprehension.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The relocation test is most accurate when true apprehension is produced with the arm in combined abduction and external rotation and then relieved when posterior pressure is placed on the humeral head.  Pain with this test is a less specific response and may occur with other shoulder disorders such as impingement.

 

REFERENCE: Speer KP, Hannafin JA, Altchek DW, Warren RF: An evaluation of the shoulder relocation test.  Am J Sports Med 1994;22:177-183.

 

11.     A 16-year-old high school pitcher notes acute pain on the medial side of his elbow during a pitch.  Examination that day reveals medial elbow tenderness, pain with valgus stress, mild swelling, and loss of extension.  Plain radiographs show closed physes and no fracture.  Which of the following diagnostic studies will best reveal his injury?

 

1-         Technetium Tc 99m bone scan

2-         Contrast-enhanced MRI

3-         CT

4-         Electromyography

5-         Arthroscopy

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The history and findings are consistent with a diagnosis of a sprain of the medial collateral ligament (MCL) of the elbow; therefore, contrast-enhanced MRI is considered the most sensitive and specific study for accurately showing this injury.  Arthroscopic visualization of the MCL is limited to the most anterior portion of the anterior bundle only; complete inspection of the MCL using the arthroscope is not possible.  CT without the addition of contrast is of no value in this situation.  Use of a technetium Tc 99m bone scan is limited to aiding in the diagnosis of occult fracture, a highly unlikely injury in this patient.  There are no clinical indications for electromyography.

 

REFERENCES: Timmerman LA, Andrews JR: Undersurface tear of the ulnar collateral ligament in baseball players: A newly recognized lesion. Am J Sports Med 1994;22:33-36.

Timmerman LA, Schwartz ML, Andrews JR: Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography: Evaluation of 25 baseball players with surgical confirmation. Am J Sports Med 1994;22:26-32.

Fritz RC, Stoller DW: The elbow, in Stoller DW (ed): Magnetic Resonance Imaging in Orthopedics and Sports Medicine, ed 2. Philadelphia, PA, Lippincott Raven, 1995, pp 743-849.

 

12.    Figures 5a and 5b show the radiographs of a 45-year-old patient.  What is the most
likely diagnosis?

 

1-         Glenoid dysplasia

2-         Rheumatoid arthritis with centralization

3-         Osteoarthritis with posterior glenoid wear

4-         Posterior scapular fracture deformity

5-         Traumatic posterior subluxation of the shoulder

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Glenoid dysplasia is an uncommon anomaly that usually has a benign course but may result in shoulder pain, arthritis, or multidirectional instability.  Shoulder pain and instability often improve with shoulder strengthening exercises.

 

REFERENCES: Wirth MA, Lyons FR, Rockwood CA Jr: Hypoplasia of the glenoid: A review of sixteen patients.  J Bone Joint Surg Am 1993;75:1175-1184.

Resnick D, Walter RD, Crudale AS: Bilateral dysplasia of the scapular neck. Am J Roentgenol 1982;139:387-390.

 

13.     A 14-year-old boy sustains a twisting injury to his right shoulder and recalls feeling a snap during a wrestling match.  Examination shows hesitancy to raise the arm away from the side, diffuse tenderness and swelling of the upper arm, and no evidence of neurovascular compromise.  Figures 6a and 6b show an AP radiograph and MRI scan.  What is the most likely diagnosis?

 

1-         Anterior dislocation of the shoulder

2-         Salter-Harris type I fracture of the proximal humeral physis

3-         Rupture of the subscapularis tendon

4-         Sprain of the acromioclavicular joint

5-         Fracture of the glenoid neck

 

PREFERRED RESPONSE: 2

 

DISCUSSION: While difficult to appreciate on the AP radiograph of the shoulder, the increased physeal signal demonstrated on the axial MRI scan is consistent with a nondisplaced growth plate fracture.  A comparison radiograph of the left shoulder also could be considered and the injured shoulder evaluated for physeal widening.

 

Proximal humeral fractures in children are somewhat unusual, representing less than 1% of all fractures seen in children and only 3% to 6% of all epiphyseal fractures.  Physeal injuries are classified according to the Salter-Harris classification scheme.  Salter-Harris type I fractures represent approximately 25% of physeal injuries to the proximal humerus in adolescents.

 

The proximal humeral physis is responsible for 80% of the longitudinal growth of the humerus; therefore, there is tremendous potential for remodeling of fractures in this region.  Management for nondisplaced Salter-Harris type I fractures is limited to a short period of immobilization followed by a gradual return to activities as clinical symptoms resolve.

 

REFERENCES: Curtis RJ, Rockwood CA Jr:  Fractures and dislocations of the shoulder in children, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1990, pp 991-1007.

Salter RB, Harris WR:  Injuries involving the epiphyseal plate.  J Bone Joint Surg Am 1963;45:587-622.

 

14.     Figure 7 shows the radiograph of an otherwise healthy 65-year-old man who injured his right dominant shoulder while skiing 18 months ago.  He did not seek treatment at the time of the injury.  He now reports intermittent soreness when playing golf but has no other limitations.  Examination reveals full range of motion and no tenderness, but he has slight pain with a crossed arm adduction stress test.  He is neurologically intact.  Initial management should consist of

 

1-         excision of the distal clavicle.

2-         open reduction and internal fixation with intramedullary partial threaded pins.

3-         open reduction and internal fixation with a reconstruction plate, screws, and bone grafting.

4-         bone grafting and use of heavy sutures to secure the clavicle to the coracoid.

5-         observation and nonsteroidal anti-inflammatory drugs.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The radiograph shows a displaced type II distal clavicle fracture with nonunion.  Because the patient’s symptoms are minimal, the injury can be treated like a grade III acromioclavicular separation.  Present management should consist of ice, anti-inflammatory drugs, activity modification, and perhaps physical therapy.  If nonsurgical management fails to provide relief, the surgical options are varied with no uniformity in the literature regarding surgical treatment of this injury.

 

REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Craig EV: Fractures of the clavicle, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1998, vol 1, pp 428-482.

 

15.     Figure 8 shows the AP radiograph of a 33-year-old woman who sustained a midshaft clavicle fracture from a motorcycle accident 15 months ago.  She continues to have significant pain with activities of daily living.  Management should consist of

 

1-         use of an electrical bone stimulation unit.

2-         open reduction and internal fixation with a dynamic compression plate placed superiorly and autogenous bone grafting.

3-         open reduction and internal fixation with a dynamic compression plate placed inferiorly and autogenous bone grafting.

4-         intramedullary screw fixation.

5-         partial claviculectomy.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The patient has a symptomatic painful atrophic midclavicular nonunion, and the treatment of choice is rigid internal fixation with a dynamic compression plate and autogenous bone grafting.  A tension band effect is desired and achieved by placing the plate superiorly.  Excellent success rates of 90% to 100% have been reported using this technique.  Intramedullary screw fixation without bone grafting has a decreased success rate.  Partial claviculectomy is not a preferred option.

 

REFERENCES: Jupiter JB, Leffert RD: Non-union of the clavicle: Associated complications and surgical management.  J Bone Joint Surg Am 1987;69:753-760.

Simpson NS, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management.  J Am Acad Orthop Surg 1996;4:1-8.

 

 

16.     A 62-year-old patient with rheumatoid arthritis has had pain and instability of the elbow following total elbow replacement 2 years ago.  A complete work-up, including aspiration and cultures, is negative.  Figures 9a and 9b show the AP and lateral radiographs.  Treatment should consist of

 

1-         orthotic stabilization.

2-         removal of the components with resection arthroplasty.

3-         revision total elbow arthroplasty with an unconstrained prosthesis and ulnar allograft.

4-         revision total elbow arthroplasty with a semiconstrained long-stemmed ulnar prosthesis.

5-         elbow arthrodesis with bone grafting.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The patient has aseptic loosening of the original semiconstrained prosthesis and significant proximal ulnar bone destruction; therefore, the treatment of choice is revision arthroplasty using a semiconstrained design.  Although orthotic stabilization could be used, it will not provide long-term pain relief.  Resection arthroplasty after removal of the components may lead to painful instability.  Elbow arthrodesis would be difficult with the bone stock loss and is not considered the best option.  Two main contraindications to the use of an unconstrained prosthesis are significant bone loss and previous use of a hinged or semiconstrained prosthesis.  An ulnar allograft could be combined with the use of a semiconstrained long-stemmed ulnar prosthesis as a treatment modification.

 

REFERENCES: Ewald FC, Simmons ED Jr, Sullivan JA, et al:  Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. J Bone Joint Surg Am 1993;75:498-507.

Morrey BF, King GJ: Revision of failed total elbow arthroplasty, in Morrey BF (ed): The Elbow and Its Disorders, ed 3.  Philadelphia, PA, WB Saunders, 2000, pp 602-610.

 

 

17.     A 21-year-old football player reports increasing pain and a deformity involving his chest after colliding with another player during a scrimmage.  Imaging studies confirm an anterior sternoclavicular dislocation.  Management should consist of

 

1-         reconstruction of the sternoclavicular capsule.

2-         symptomatic nonsurgical treatment.

3-         medial clavicle excision.

4-         medial clavicle excision with capsular imbrication. 

5-         medial clavicle excision and rhomboid ligament reconstruction.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: For the patient with an anterior sternoclavicular dislocation, the most appropriate initial treatment should be symptomatic.  Surgical options are usually contraindicated because the incidence of intraoperative and postoperative complications is high.  A deformity from an anterior sternoclavicular dislocation is usually well tolerated.  Return to play is allowed when symptoms resolve.

 

REFERENCES: Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1998, vol 1, pp 477-525.

Rockwood CA Jr, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint.  J Bone Joint Surg Am 1989;71:1280-1288.

 

 

18.     During total shoulder replacement for rheumatoid arthritis, fracture of the humeral shaft occurs.  An intraoperative radiograph shows a displaced short oblique fracture at the tip of the prosthesis.  At this point, the surgeon should

 

1-         insert a standard humeral prosthesis with cerclage wires at the fracture site and autologous cancellous bone graft.

2-         insert a standard humeral component and apply a humeral orthosis postoperatively.

3-         cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.

4-         remove all instrumentation, perform an open reduction and internal fixation of the fracture, and delay completion of replacement surgery until the fracture has healed.

5-         discontinue the procedure and return for completion of total shoulder replacement when the fracture has healed.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The risk of intraoperative fracture in osteopenic rheumatoid bone is significant.  Fractures may occur with dislocation of the head and canal reaming, especially while extending and externally rotating the shoulder.  If the fracture occurs at the distal tip of the prosthesis, the use of a long-stemmed prosthesis to bypass the fracture site and supplementation with wire cables has been reported with good results. 

 

REFERENCES: Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty.  J Bone Joint Surg Am 1995;77:1340-1346. 

Boyd AD Jr, Thornhill TS, Barnes CL: Fractures adjacent to humeral protheses. J Bone Joint Surg Am 1992;74:1498-1504.

Petersen SA, Hawkins RJ: Revision of failed total shoulder arthroplasty. Orthop Clin North Am 1998;29:519-533. 

 

19.     What is the most common contracture deformity of the spastic shoulder secondary to a cerebrovascular accident?

 

1-         External rotation, abduction, and extension

2-         External rotation, adduction, and flexion

3-         Internal rotation, abduction, and flexion

4-         Internal rotation, adduction, and extension

5-         Internal rotation, adduction, and flexion

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The resultant spasticity and weakness (paresis) following a cerebrovascular accident leads to muscle imbalance that commonly results in contracture of the shoulder in adduction, internal rotation, and varying degrees of forward flexion.  In addition, the elbow is usually flexed and the forearm pronated.

 

REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity.  Clin Orthop 1999;368:54-65.

McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient.  Instr Course Lect 1975;24:45-55.

 

 

20.    A 21-year-old collegiate pitcher has had pain in his dominant shoulder for the past 3 months despite management consisting of rest, rehabilitation, and an analysis of throwing mechanics.  An arthroscopic photograph from the posterior portal is shown in Figure 10.  The biceps anchor to the bone was not detached to probing.  Treatment of the lesion to the left of the cannula should consist of arthroscopic

 

1-         biceps tenodesis.

2-         suture repair.

3-         capsulorraphy.

4-         debridement.

5-         release of the biceps tendon.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The lesion is a variation of a type I superior labrum anterior and posterior lesion; therefore, appropriate treatment is simple debridement.  Biceps tenodesis or release is not indicated because the biceps tendon and anchor are intact.  There is no indication for labral repair or capsulorraphy.

 

REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 261-270.

Snyder SJ, Banas MP, Karzel RP: An analysis of 140 injuries to the superior glenoid labrum.  J Shoulder Elbow Surg 1995;4:243-248.

 

 

21.    After humeral head replacement for four-part fractures, what is the most commonly reported difficulty?

 

1-         Pain

2-         Inability to carry 10 lb at the side

3-         Inability to wash the opposite axilla

4-         Reaching to the back pocket

5-         Working at shoulder level or above

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Results show that patients who underwent humeral head replacement for fracture almost routinely report pain relief, but functional reports vary.  The most commonly reported difficulty is the use of weight in the overhead position with wide variation in active elevation.  Factors found to affect active elevation include age, humeral offset, greater tuberosity positioning, and four-part (as compared with three-part) fractures.

 

REFERENCES: Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD: Functional outcome after humeral head replacement for acute three- and fourth-part proximal humeral fractures.  J Shoulder Elbow Surg 1995;4:81-86.

Hawkins RJ, Switlyk P: Acute prosthetic replacement for severe fractures of the proximal humerus.  Clin Orthop 1993;289:156-160.

 

 

22.    Figures 11a and 11b show the AP and lateral radiographs of a 32-year-old patient on hemodialysis who has increasing elbow pain and a visibly growing mass over the extensor surface.  Figure 11c shows the photomicrograph of the biopsy specimen.  What is the most likely diagnosis?

 

1-         Myositis ossificans

2-         Tumoral calcinosis

3-         Synovial cell sarcoma

4-         Fungal granuloma

5-         Hemochromatosis

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The radiographic findings are classic for tumoral calcinosis; they are not consistent with myositis ossificans, fungal granuloma, or hemochromatosis.  The condition typically appears as large aggregations of dense calcified lobules confined to the surrounding soft tissues.  Hyperphosphatemia is a fundamental factor in many patients with this condition.  Tumoral calcinosis also occurs in the setting of chronic renal failure when mineral homeostasis is not controlled.  The histologic appearance is essentially a foreign body granuloma reaction.  Multilocular cysts with purplish amorphous material are surrounded by thick connective tissue capsules.  The fibrous walls contain numerous foreign body giant cells.  Surgical excision is indicated if the tumor causes discomfort or interferes with function.

 

REFERENCES: Sisson HA, Murray RO, Kemp HBS (eds): Orthopaedic Diagnosis: Clinical, Radiological and Pathological Coordinates.  New York, NY, Springer-Verlag, 1984.

Boskey AL, Vigorita VJ, Sencer O, Stuchin SA, Lane JM: Chemical, microscopic, and ultrastructural characterization of the mineral deposits in tumoral calcinosis.  Clin Orthop 1983;178:258-269.

 

 

23.    A 52-year-old man who was a former high school pitcher now reports loss of elbow flexion and extension with pain at the extremes of motion.  Nonsurgical management has failed to provide relief.  Examination reveals movement from 50 degrees to 110 degrees and is painful only at the limits of motion.  A radiograph is shown in Figure 12.  Treatment should consist of

 

1-         excision of the osteophytes and loose bodies and anterior and posterior capsular releases.

2-         removal of the loose bodies.

3-         anterior capsular release.

4-         anterior and posterior capsular releases.

5-         interposition arthroplasty.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Based on the history, examination, and radiograph, the patient has typical degenerative arthritis of the elbow.  This condition is found almost exclusively in men, and there is almost universally a history of repetitive heavy use or overuse of the elbow.  Patients report pain at terminal extension and usually have a flexion contracture.  Radiographs reveal osteophytes on the coronoid and olecranon and in the coronoid and olecranon fossae.  The osteophytes are often associated with loose bodies that sometimes are attached to the soft tissues.  Treatment should consist of removal of all loose bodies and impinging osteophytes using open technique or by arthroscopy.  The capsular contractures should be released at the same time.

 

REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.

Morrey BF: Primary degenerative arthritis of the elbow: Treatment by ulnohumeral arthroplasty.  J Bone Joint Surg Br 1992;74:409-413.

Redden JF, Stanley D: Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow.  Arthroscopy 1993;9:14-16.

O’Driscoll SW: Elbow arthritis: Treatment options.  J Am Acad Orthop Surg 1993;1:106-116.

24.    A 79-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing right shoulder pain for the past year, and nonsurgical management has failed to provide relief.  Her neurologic examination is entirely normal, but she is unable to elevate her arm against gravity.  An AP radiograph is shown in Figure 13.  Treatment should consist of

 

1-         glenohumeral arthrodesis.

2-         total shoulder arthroplasty.

3-         humeral arthroplasty.

4-         open synovectomy and rotator cuff repair.

5-         anterior acromioplasty and rotator cuff repair.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Because the patient has end-stage rheumatoid arthritis with glenoid and rotator cuff deficiency, humeral arthroplasty is the treatment of choice.  When a patient has an intact rotator cuff and there is sufficient glenoid bone stock to implant a glenoid component, total shoulder arthroplasty is the preferred method because it appears to provide more predictable pain relief.  Glenohumeral arthrodesis is generally avoided when there is a functional deltoid or rotator cuff.  Open synovectomy is appropriate in early rheumatoid disease before articular changes are present.  Anterior acromioplasty with coracoacromial ligament resection is avoided in patients with rheumatoid arthritis because this procedure compromises the coracoacromial arch and may result in anterosuperior instability.

 

REFERENCES: Neer CS II, Watson KC, Stanton FJ: Recent experience in total shoulder replacement.  J Bone Joint Surg Am 1982;64:319-337.

Neer CS II: Glenohumeral arthroplasty, in Neer CS II (ed): Shoulder Reconstruction.  Philadelphia, PA, WB Saunders, 1990, pp 143-271.

Pollock RG, Deliz ED, McIlveen ST, et al: Prosthetic replacement in rotator cuff deficient shoulders.  J Shoulder Elbow Surg 1992;1:173-186.

Sneppen O, Fruensgaard S, Johannsen HV, Olsen BS, Sojbjerg JO, Anderson NH: Total shoulder replacement in rheumatoid arthritis: Proximal migration and loosening.  J Shoulder Elbow Surg 1996;5:47-52.

 

 

25.    A 22-year-old woman has had progressive upper extremity weakness for the past several years.  History reveals no pain in her neck or shoulders.  Examination reveals scapular winging of both shoulders and weakness in external rotation.  She can abduct to only 120 degrees bilaterally, and there is mild supraspinatus weakness.  She is otherwise neurologically intact with normal sensation and reflexes; however, she has difficulty whistling.  A clinical photograph is shown in Figure 14.  What is the most likely diagnosis?

 

1-         Bilateral long thoracic nerve palsies

2-         Central cervical disk herniation

3-         Duchenne muscular dystrophy, adult onset

4-         Fascioscapulohumeral dystrophy

5-         Disuse atrophy as the result of deconditioning

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Progressive weakness is a common sign with a large differential diagnosis.  Nerve, muscle, and joint problems should be excluded when a patient has diffuse weakness and atrophy.  Fascioscapulohumeral dystrophy is a rare disease characterized by facial muscle weakness and proximal shoulder muscle weakness.  The weakness is usually bilateral, and scapular winging is common.  If the scapular winging becomes pronounced, elevation of the shoulder can be affected.  In severe cases, scapulothoracic fusion or pectoralis muscle transfer to the scapula may be indicated.  Duchenne muscular dystrophy is typically severe and progressive.  The other diagnoses are not compatible with the history or the physical findings.

 

REFERENCES: Shapiro F, Specht L: The diagnosis and orthopaedic treatment of inherited muscular diseases of childhood.  J Bone Joint Surg Am 1993;75:439-454.

Bunch WH, Siegel IM: Scapulothoracic arthrodesis in fascioscapulohumeral muscular dystrophy: Review of seventeen procedures with three to twenty-one-year follow-up.  J Bone Joint Surg Am 1993;75:372-376.

 

26.    A 37-year-old electrician is diagnosed with a frozen shoulder after sustaining an electrical injury at work 2 weeks ago. Examination reveals that he cannot actively or passively externally rotate or abduct the arm.  The glenohumeral joint and scapula move in a 1:1 ratio.  Radiographs are shown in Figures 15a and 15b.  The best course of action
should be

 

1-         vigorous physical therapy for passive range of motion.

2-         manipulation of the shoulder under anesthesia.

3-         an intra-articular steroid injection.

4-         an axillary radiograph.

5-         MRI.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The patient’s history, examination, and radiographs are classic for locked posterior dislocation of the glenohumeral joint.  Posterior dislocation of the shoulder remains the most commonly missed dislocation of a major joint.  Up to 80% are missed on initial presentation.  The primary cause for failure to accurately diagnose this injury is inadequate radiographic evaluation.  The typical presentation is a shoulder locked in internal rotation with loss of abduction.  An axillary view not only will make the definitive diagnosis but will help assess the size of the articular surface defect and help plan treatment.  This view can be done expediently as part of every trauma series.  The AP view is suspicious for a posteriorly dislocated humerus with loss of the humeral neck profile, a vacant glenoid sign, and an anterior humeral head compression fracture (reverse Hill-Sachs lesion).

 

REFERENCES: Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder.  J Bone Joint Surg Am 1987;69:9-18.

Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosement, IL, American Academy of Orthopaedic Surgeons, 1997, pp 181-189.

Rockwood CA Jr, Thomas SC, Matsen FA III: Subluxations and dislocations about the glenohumeral joint, in Rockwood CA Jr, Green DP, Bucholz RW (eds): Fractures in Adults, ed 3.  Philadelphia, PA, JB Lippincott, 1991, vol 1, pp 1058-1065.

 

 

27.    An 80-year-old man has had increasing shoulder pain for the past 4 months.  He reports that it began with soreness and stiffness after chopping some wood.  A coronal MRI scan is shown in Figure 16.  Initial management should consist of

 

1-         shoulder exercises, mild analgesics, and activity modification.

2-         transfer of the latissimus dorsi to the greater tuberosity.

3-         arthroscopy and debridement of the tendon edges.

4-         arthroscopy, arthroscopic acromioplasty, coracoacromial ligament release, and mini open repair.

5-         arthroscopy, arthrotomy, acromioplasty, and primary repair of the rotator cuff.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The MRI scan shows a massive tear of the supraspinatus tendon with medial retraction to the level of the glenoid.  This is most likely an attritional tear with a high risk of failure of the repair.  The preferred treatment is nonsurgical management for pain and stiffness.  Acromioplasty and coracoacromial ligament release in this setting are controversial, as they can result in the devastating complication of anterosuperior subluxation of the humerus. 

 

REFERENCES: Rockwood CA Jr, Williams GR Jr, Burkhead WZ Jr: Debridement of degenerative, irreparable lesions of the rotator cuff.  J Bone Joint Surg Am 1995;77:857-866.

Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 299-312.

 

 

 

28.    Figure 17 shows the radiograph of a 25-year-old professional football player who has superior shoulder pain that prevents him from sports participation.  History reveals that he sustained a shoulder injury that was treated with closed reduction and temporary pinning 3 years ago.  The best course of action should be

 

1-         no further participation in contact sports.

2-         open reduction of the acromioclavicular joint and coracoclavicular screw stabilization.

3-         open repair of the coracoclavicular ligaments.

4-         Weaver-Dunn reconstruction and coracoclavicular reconstruction.

5-         excision of the distal clavicle.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The radiograph shows a complete acromioclavicular separation.  Because the patient is a professional athlete who is unable to participate, surgery is indicated.  Chronic separations, especially those with previous trauma from joint pinning, should be treated with resection of the distal clavicle and stabilization to the coracoid.  Some type of biologic reconstruction of the coracoclavicular ligaments is generally recommended.  Open repair of the ligaments is generally not possible in such a delayed fashion.  Screw fixation alone will not provide a lasting solution as the screws usually need to be removed, leaving no fixation in place.  Reconstruction using the coracoacromial ligament is generally recommended with coracoclavicular fixation to protect the repair while it heals.

 

REFERENCES: Nuber GW, Bowen MK: Disorders of the acromioclavicular joint: Pathophysiology, diagnosis and management, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management.  Philadelphia, PA, Lippincott Williams and Wilkins, 1999.

Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU: Surgical treatment of complete acromioclavicular dislocations.  Am J Sports Med 1995;23:324-331.

 

 

29.    A 54-year-old man undergoes total shoulder arthroplasty for osteoarthritis.  Despite compliance with an early passive range-of-motion exercise program, he does not regain more than 90 degrees of elevation, 10 degrees of external rotation, and has internal rotation to the fifth lumbar vertebra.  At 6 months, his motion fails to improve.  Radiographs are shown in Figures 18a and 18b.  What is the best course of action?

 

1-         Continue with a more aggressive passive range-of-motion exercise program.

2-         Perform an open release.

3-         Revise the humeral component and increase retroversion.

4-         Revise the humeral component alone after osteotomizing more of the humeral neck and seating the component lower.

5-         Remove the glenoid component to decrease tension in the rotator cuff.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The patient has a global loss of motion that has failed to improve with 6 months of nonsurgical treatment; because he has reached a plateau, further nonsurgical management will likely be ineffective.  Revision in the form of an open release is indicated to lyse intra- and extra-articular adhesions; subscapularis lengthening may be done concurrently as needed.  Revising to a smaller head can be considered if adequate motion is not achieved.  The radiographs reveal an adequate neck cut with appropriate seating of the component.  Removing the glenoid component will decrease capsular tension but will probably increase pain because of the lack of glenoid resurfacing.  Increasing humeral retroversion will not improve motion.

 

REFERENCES: Cuomo F, Checroun A: Avoiding pitfalls and complication in total shoulder arthroplasty.  Orthop Clin North Am 1998;29:507-518.

Wirth MA, Rockwood CA Jr: Complications of shoulder arthroplasty.  Clin Orthop 1994;307:47-69.

 

 

 

30.    A 47-year-old patient has had persistent pain and weakness after undergoing a reamed intramedullary nailing for a midshaft humerus fracture 8 months ago.  There is no evidence of infection.  Radiographs are shown in Figures 19a and 19b.  Management should consist of

 

1-         electrical stimulation.

2-         retrograde nailing with multiple unreamed flexible nails to prevent further loss of shoulder function.

3-         leaving the same nail in place but adding cancellous bone graft.

4-         exchange nailing with over-reaming and dynamic locking.

5-         open reduction and plate fixation with autograft and rod removal.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Compression plating remains the treatment of choice for most established humeral nonunions.  Autograft is felt to be superior to allograft.  Electrical stimulation has not been found to improve healing rates in patients with nonunion after intramedullary nailing.  Retrograde nailing with flexible nails gives inadequate rotational control to promote healing in this patient.  Adding cancellous graft alone will not stabilize the nonunion site.  Dynamic locking has been successful only in the lower extremity because the bone can be loaded axially.

 

REFERENCES: McKee MD, Miranda MA, Riemer BL, et al: Management of humeral nonunion after the failure of locking intramedullary nails.  J Orthop Trauma 1996;10:492-499.

Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

 

31.     An 18-year-old man sustained closed humeral shaft and forearm fractures of his dominant arm in a motor vehicle accident.  Neurovascular examination is intact, and his condition is stable.  The best course of action for management of the injuries should be

 

1-         external fixation of the forearm fracture and functional bracing of the humeral shaft fracture.

2-         external fixation of both fractures.

3-         open reduction and internal fixation of both fractures.

4-         open reduction and the internal fixation of the forearm fracture and functional bracing of the humeral shaft fracture.

5-         application of a long arm cast.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Fractures above and below the elbow constitute floating elbow injuries and are best treated with internal fixation to allow early range of motion and to prevent elbow stiffness.  Use of a long arm cast would promote elbow stiffness.  External fixation is indicated primarily for open injuries.

 

REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Bell MJ, Beachamp CG, Kellam JK, McMurtry RY: The results of plating humeral shaft fractures in patients with multiple injuries: The Sunnybrook experience.  J Bone Joint Surg Br 1985;67:293-296.

 

32.    A 32-year-old woman has had pain and a visibly growing mass in the shoulder for 3 years but denies any history of trauma.  Examination reveals a swollen, boggy shoulder mass.  The AP radiograph and MRI scan are shown in Figures 20a and 20b.  Figures 20c through 20e show a portion of the excised mass and the photomicrographs of the biopsy specimen.  What is the most likely diagnosis?

 

1-         Synovial chondromatosis

2-         Pigmented villonodular synovitis

3-         Synovial cell sarcoma

4-         Tuberculosis

5-         Chondrosarcoma

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The radiographic findings are classic for synovial chondromatosis because of the small calcified opacities within the joint surrounding the synovium.  The histologic findings show cartilaginous foci of metaplasia, which may be markedly cellular.  However, unlike low-grade chondrosarcoma, it lacks cellular and nuclear pleomorphism.

 

REFERENCES: Murphy FP, Dahlin DC, Sullivan CR: Articular synovial chondromatosis.  J Bone Joint Surg Am 1982;44:77-86.

Milgram JW: Synovial osteochondromatosis: A histopathological study of thirty cases.  J Bone Joint Surg Am 1977;59:792-801.

 

 

33.    What is the most important factor regarding the risk of recurrent instability in a patient with an acute anterior dislocation of the shoulder?

 

1-         Age of the patient

2-         Time from injury to reduction

3-         Completion of 3 weeks of immobilization

4-         The degree of athletic participation

5-         Bilateral instability

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The recurrence rate of anterior dislocation of the shoulder after the first episode in athletes younger than age 20 years is thought to be as high as 90%, making surgery after the initial episode a consideration.  The rate drops from 50% to 75% in the 20- to 25-year age group and down to 15% in patients older than age 40 years.  An excellent prospective study of 257 patients in Sweden showed that there was no difference in those who did or did not complete 3 weeks of immobilization.  The study also showed variability among different age groups in the importance of athletic participation; athletes in the 12- to 22-year age group had a higher recurrence rate, whereas the more sedentary patients in the 23- to 29-year age group had a higher rate. 

 

REFERENCES: Hovelius L: The natural history of primary anterior dislocation of the shoulder in the young.  J Orthop Sci 1999;4:307-317. 

Simonet WT, Cofield RH: Prognosis in anterior shoulder dislocation.  Am J Sports Med 1984;12:19-24.

 

 

34.    A 25-year-old man injured his dominant shoulder after falling on his outstretched arm 4 months ago. Examination reveals that he cannot lift his arm above 90 degrees, and he has pronounced medial scapular winging.  Management should consist of

 

1-         spinal accessory nerve exploration with repair.

2-         long thoracic nerve exploration with repair.

3-         a sling for comfort, followed by shoulder strengthening exercises.

4-         scapulothoracic arthrodesis.

5-         split pectoralis major transfer.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Serratus anterior palsy or long thoracic nerve palsy is usually caused by traction injury to the nerve, blunt injury, or iatrogenic injury.  The palsy results in winging of the scapula and medial rotation of the inferior pole of the scapula.  A patient with this injury will usually recover in 12 to 18 months.  Initial treatment should include observation and shoulder strengthening exercises.  Nerve exploration with repair has not proven beneficial in changing the outcome.  Many orthopaedic surgeons favor using a split pectoralis major transfer for symptomatic patients.  Electrodiagnostic studies are helpful in confirming the diagnosis.

 

REFERENCES: Post M: Pectoralis major transfer for winging of the scapula.  J Shoulder Elbow Surg 1995;4:1-9.

Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging.  J Am Acad Orthop Surg 1995;3:319-325.  

 

 

35.    Treatment of adhesive capsulitis has a high failure rate when the underlying cause is

 

1-         idiopathic.

2-         traumatic.

3-         diabetes mellitus.

4-         hypothyroidism.

5-         hyperthyroidism.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Diabetes mellitus has been associated with resistant cases of adhesive capsulitis.  With other causes of onset, adhesive capsulitis frequently responds to nonsurgical management such as stretching exercises or, when this fails, manipulation under anesthesia and/or arthroscopic release.  Manipulation is rarely successful for the treatment of adhesive capsulitis associated with diabetes mellitus, and arthroscopic release may be preferred.

 

REFERENCES: Fisher L, Kurtz A, Shipley M: Association between cheiroarthropathy and frozen shoulder in patients with insulin-dependent diabetes mellitus.  Br J Rheumatol 1986;25:141-146.

Janda DH, Hawkins RJ: Shoulder manipulation in patients with adhesive capsulitis and diabetes mellitus: A clinical note.  J Shoulder Elbow Surg 1993;2:36-38.

Pollock RG, Duralde XA, Flatow EL, Bigliani LU: The use of arthroscopy in the treatment of resistant frozen shoulder.  Clin Orthop 1994;304:30-36.

 

 

36.    Figure 21 shows the AP radiograph of a 41-year-old patient who sustained a closed bicolumnar fracture of the distal humerus that resulted in a painful nonunion.  What is the best initial construct for rigid stabilization of this fracture pattern?

 

1-         Posterior “Y” plate fixation

2-         Dual one third tubular plate fixation with a hinged external fixator

3-         Dual one third tubular plate fixation

4-         Dual 3.5-mm reconstruction plate fixation

5-         Single lateral plate fixation with transcortical screw fixation

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The dual plate fixation construct is significantly stronger than single plate or “Y” plate fixation.  Two-plate constructs at right angles, the ulnar plate medially and the lateral plate posteriorly, would appear to be biomechanically optimal.  This approach usually is feasible at the time of surgery.  Clinically, dual 3.5-mm reconstruction or dynamic compression plates are superior to one third tubular plate fixation.  Supplementary external fixation is not considered a better treatment option.  Failure of fixation and nonunion are often the result of inadequate fixation and osteoporosis.

 

REFERENCES: Helfet DL, Hotchkiss RN: Internal fixation of the distal humerus: A biomechanical comparison of methods.  J Orthop Trauma 1990;4:260-264.

Sodergard J, Sandelin J, Bostman O: Mechanical failures of internal fixation in T and Y fractures of the distal humerus.  J Trauma 1992;33:687-690.

 

 

37.    Figure 22 shows the radiographs of a 16-year-old boy who injured his elbow in a fall 1 year ago.  Although he has no pain, he reports restricted forearm rotation and elbow flexion.  What is the most likely diagnosis?

 

1-         Posttraumatic soft-tissue contractures

2-         Congenital dislocation of the radial head

3-         Chronic posttraumatic dislocation of the radial head

4-         Combined annular and lateral collateral ligament injury

5-         An unrecognized Monteggia variant type of injury

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Congenital dislocation of the radial head is often confused with posttraumatic dislocation.  The distinguishing feature here is the dome-shaped radial head.  Some patients with congenital anomalies fail to recognize their limitations until an injury occurs.  Soft-tissue contractures do not cause radial head dislocation nor do they usually cause this pattern of motion restriction (mainly flexion and rotation without significant loss of extension).  There is no deformity of the ulna to suggest an old Monteggia lesion.

 

REFERENCES: Morrey BF (ed): The Elbow and Its Disorders, ed 2.  Philadelphia, PA, WB Saunders, 1993, p 196.

Bell SN, Morrey BF, Bianco AJ Jr: Chronic posterior subluxation and dislocation of the radial head.  J Bone Joint Surg Am 1991;73:392-396.

 

 

38.    A 55-year-old man has had progressive right shoulder pain for the past 2 years.  Examination reveals active elevation to 120 degrees, external rotation to 20 degrees, and internal rotation to the sacrum.  AP and axillary radiographs are shown in Figures 23a and 23b.  Which of the following procedures would result in the most predictable long-term pain relief?

 

1-         Arthroscopic debridement of the glenohumeral joint

2-         Open subscapularis lengthening and cheilectomy

3-         Humeral hemiarthroplasty

4-         Bipolar humeral hemiarthroplasty

5-         Total shoulder arthroplasty

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Total shoulder arthroplasty yields excellent pain relief and function in patients with osteoarthritis.  It is favored over humeral arthroplasty, especially when there is asymmetric posterior glenoid wear and posterior humeral subluxation as shown on the axillary radiograph.  Arthroscopic debridement of the glenohumeral joint may be helpful in delaying the need for arthroplasty when the arthritic changes are mild to moderate but is not indicated for advanced osteoarthritis.

 

REFERENCES: Cofield RH, Frankle MA, Zuckerman JD: Humeral head replacement for glenohumeral arthritis.  Semin Arthroplasty 1995;6:214-221.

Levine WN, Djurasovic M, Glasson JM, Pollock RG, Flatow EL, Bigliani LU: Hemiarthroplasty for glenohumeral osteoarthritis: Results correlated to degree of glenoid wear.  J Shoulder Elbow Surg 1997;6:449-454.

Matsen FA III: Early effectiveness of shoulder arthroplasty for patients who have primary glenohumeral degenerative joint disease.  J Bone Joint Surg Am 1996;78:260-264.

 

 

39.    A 20-year-old professional baseball pitcher has had a 3-year history of increased aching in his shoulder that is associated with pitching, and he is now seeking a second opinion.  Nonsurgical management consisting of rest, anti-inflammatory drugs, ice, heat, and cortisone injections has failed to provide relief.  A previous work-up that included radiographs and gadolinium-enhanced MRI arthrography was negative.  Results of an arteriogram suggest quadrilateral space syndrome.  Assuming that this is the correct diagnosis, what nerve needs to be decompressed?

 

1-         Suprascapular

2-         Infraspinatus branch of the suprascapular

3-         Long thoracic

4-         Axillary

5-         Lateral cord of the brachial plexus

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Quadrilateral space syndrome is a rare condition and is the result of compression of the contents of the quadrilateral space.  The contents of the quadrilateral space include the posterior circumflex vessels and the axillary nerve.

 

REFERENCES: Cahill BR, Palmer RE: Quadrilateral space syndrome.  J Hand Surg 1983;8:65-69.

Lester B, Jeong GK, Weiland AJ, Wickiewicz TL: Quadrilateral space syndrome: Diagnosis, pathology, and treatment.  Am J Orthop 1999;28:718-722.

 

 

40.    A right-handed 24-year-old woman underwent an arthroscopic Bankart repair for recurrent anterior dislocations 9 months ago.  Despite extensive physical therapy for 8 months, the patient has very limited range of motion (elevation to 130 degrees and external rotation to 10 degrees with the arm at the side).  Shoulder radiographs are normal.  The next step in management should consist of

 

1-         cessation of physical therapy and acceptance of the limited range of motion.

2-         additional physical therapy for 3 to 4 months.

3-         arthroscopic capsular release.

4-         open release with Z-plasty lengthening of the subscapularis tendon.

5-         closed manipulation under anesthesia.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Arthroscopic capsular release is an effective means of treating stiffness that is the result of capsular contractures, such as in the case of a tight Bankart repair.  Open release allows lengthening of a surgically shortened subscapularis, such as after a tight Putti-Platt repair.  Additional physical therapy is unlikely to be effective because 8 months of treatment has failed to result in improvement.  Accepting this degree of asymptomatic limited motion is not advisable because of the functional limitations for the patient and the increased risk of postoperative degenerative arthritis.

 

REFERENCES: Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder.  J Bone Joint Surg Am 1997;79:1151-1158.

Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness.  Arthroscopy 1997;13:133-147.

 

 

41.     A patient with deficient anteroinferior bone stock undergoes a Latarjet procedure that transfers a portion of the coracoid to the glenoid rim and secures it with two screws.  After surgery, the patient reports numbness on the anterolateral forearm.  To verify the diagnosis, what muscle should be tested for strength?

 

1-         Axillary

2-         Abductor pollicis brevis

3-         Supinator

4-         Triceps

5-         Biceps

 

PREFERRED RESPONSE: 5

 

DISCUSSION: A Latarjet procedure is similar to a Bristow procedure, but with the Latarjet procedure a larger portion of the coracoid is transferred to the scapular neck at the anteroinferior glenoid.  As in a Bristow procedure, if the fragment is pulled or twisted during the dissection or during fixation, the musculocutaneous nerve can be injured.  With loss of biceps function, elbow flexion and forearm supination will be weaker.

 

REFERENCES: Ho E, Cofield RH, Balm MR, Hattrup SJ, Rowland CM: Neurologic complications of surgery for anterior shoulder instability.  J Shoulder Elbow Surg 1999;8:266-270. 

Boardman ND 3rd, Cofield RH: Neurologic complications of shoulder surgery.  Clin Orthop 1999;368:44-53. 

Allain J, Goutallier D, Glorion C: Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;80:841-852.

 

42.    A 34-year-old woman has had painful snapping and popping in the elbow since falling while in-line skating 6 months ago.  The popping also occurs when she pushes off with her hands to rise from a seated position.  Initial radiographs were normal, and she was told that she had sprained her elbow.  Examination reveals few findings except that she is very apprehensive when the forearm is forcefully supinated with the elbow extended or partially flexed.  A radiograph taken in that position is shown in Figure 24.  Treatment should consist of

 

1-         arthroscopic loose body removal.

2-         arthroscopic debridement and loose body removal for osteochondritis dissecans of the capitellum.

3-         annular ligament reconstruction for posttraumatic posterior subluxation of the radial head.

4-         radial head resection for congenital type II dislocation of the radial head.

5-         lateral collateral ligament reconstruction for posterolateral rotatory instability.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The radiograph reveals posterolateral rotatory subluxation of the radiohumeral and ulnohumeral joints.  The space between the ulna and trochlea is enlarged, particularly posteriorly at the olecranon.  These findings are diagnostic of posterolateral rotatory instability, which causes recurrent subluxation and reduction as the elbow is flexed from an extended and supinated position with valgus load.  The posterolateral rotatory instability apprehension test was performed on this patient and the result was positive.  The lateral pivot-shift test causes a clunk as the elbow reduces but is more difficult to perform, even under general anesthesia.  The patient does not have isolated subluxation of the radial head, although these findings can be mistakenly diagnosed as such.  The radial head is normally shaped and does not represent a congenital dislocation.  There are no findings here to suggest osteochondritis dissecans or loose bodies.  

 

REFERENCES: O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow.  J Bone Joint Surg Am 1991;73:440-446. 

Burgess RC, Sprague HH: Post-traumatic posterior radial head subluxation: Two case reports. Clin Orthop 1984;186:192-194. 

Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354. 

 

 

43.    A 49-year-old woman noted pain in her right axilla 1 day after moving heavy furniture.  Two weeks later, she now reports persistent numbness and paresthesias along the inner aspect of her upper arm radiating into the ulnar digits.  Examination reveals full shoulder motion, tenderness over the first rib, and a decreased radial pulse with the shoulder placed overhead.  What is the most likely diagnosis?

 

1-         Brachial plexus stretch injury

2-         Cervical radiculopathy

3-         Rotator cuff tendinitis

4-         Anterior subluxation of the shoulder

5-         Thoracic outlet syndrome

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Thoracic outlet syndrome is thought to be caused by compression of the neurovascular supply to the upper limb in the supraclavicular and axillary regions of the shoulder.  While typically progressive in onset, thoracic outlet syndrome may develop after acute injury.  Injury or weakness of the scapular muscles, especially the trapezius, may result in descent of the scapula and cause compression of the thoracic outlet.  In general, most symptoms are the result of neural compression.  Typical symptoms include pain in the neck or shoulder and numbness or tingling that predominantly involves the ulnar side of the arm and hand.  Exacerbation of these symptoms is typical when the arm is abducted.  Initial management should consist of postural exercises aimed at restoring proper scapular stability.  Severe recalcitrant symptoms may warrant surgical decompression.

 

REFERENCES: Leffert RD: Thoracic outlet syndrome.  J Am Acad Orthop Surg 1994;2:317-325.

Todd TW: The descent of the shoulder after birth: Its significance in the production of pressure-symptoms on the lowest brachial trunk.  Anat Anz 1912;41:385-397.

 

 

44.    A patient has had a locked posterior dislocation of the shoulder for the past 6 months.  After undergoing total shoulder arthroplasty that includes adequate anterior releases and posterior capsulorrhaphy, the patient still exhibits posterior instability intraoperatively.  The postoperative rehabilitation regimen should include

 

1-         use of a sling with no range-of-motion exercises until the condition is stable.

2-         use of a sling and passive range-of-motion exercises within the limits of the repair.

3-         no sling and supine passive range-of-motion exercises.

4-         an internal rotation brace holding the arm at the side.

5-         an external rotation brace holding the arm at the side.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Achieving stability in chronic locked posterior dislocations of the shoulder remains a difficult challenge.  Intraoperative measures include decreased humeral retroversion, anterior releases, and posterior capsular tightening.  Postoperative rehabilitation is of equal importance.  Immobilization in an external rotation brace (10 degrees to 15 degrees) with the arm at the side for 4 to 6 weeks is recommended to decrease tension in the posterior capsule.  When passive range-of-motion exercises are instituted, they should be performed in the plane of the scapula to avoid stress posteriorly.  Internal rotation and supine elevation should be avoided for similar reasons.

 

REFERENCES: Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder.  J Bone Joint Surg Am 1987;69:9-18.

Loebenberg MI, Cuomo F: The treatment of chronic anterior and posterior dislocations of the glenohumeral joint and associated articular surface defects.  Orthop Clin North Am 2000;31:23-24.

 

 

45.    Which of the following factors is associated with failure of arthroscopic excision of the distal clavicle?

 

1-         Removal of less than 2 cm of bone

2-         Male gender

3-         Female gender

4-         Diagnosis of osteolysis

5-         Uneven resection of bone

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Uneven resection of bone, typically leaving a retained posterolateral corner of the distal clavicle, can lead to failure of arthroscopic distal clavicle excision.  The amount of bone resected, the gender of the patient, or the diagnosis (osteoarthritis versus osteolysis) does not appear to affect the results.

 

REFERENCE: Flatow EL, Duralde XA, Nicholson GP, Pollock RG, Bigliani LU: Arthroscopic resection of the distal clavicle with a superior approach.  J Shoulder Elbow Surg 1995;4:41-50.

 

46.    Anterior subluxation in a throwing athlete is most commonly the result of

 

1-         avulsion of the inferior glenohumeral ligament from the glenoid.

2-         avulsion of the inferior glenohumeral ligament from the humerus.

3-         fracture of the anterior glenoid rim.

4-         excessive capsular laxity from microtrauma.

5-         a large Hill-Sachs lesion.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Subtle anterior subluxation in the throwing athlete most frequently results from excessive capsular laxity because of repetitive microtrauma.  Avulsion of the inferior glenohumeral ligament from the glenoid, or more rarely from the humerus, occurs with macrotrauma.  A large Hill-Sachs lesion and a glenoid rim fracture also may result from a traumatic anterior dislocation.

 

REFERENCES: Kvitne RS, Jobe FW: The diagnosis and treatment of anterior instability in the throwing athlete.  Clin Orthop 1993;291:107-123. 

Jobe FW, Tibone JE, Jobe CM, Kvitne RS: The shoulder in sports, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder, ed 2.  Philadelphia, PA, WB Saunders, 1999, pp 961-990. 

 

47.    What is the most significant prognostic factor in nontraumatic osteonecrosis of the humeral head?

 

1-         Duration of symptoms

2-         Age of the patient

3-         Total amount of steroid use

4-         Stage of the disease

5-         Status of the rotator cuff

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Use of systemic steroids has been implicated in the development of nontraumatic osteonecrosis of the humeral head.  Staging of the disease is most relevant to prognosis and treatment.  Cruess has described a widely accepted staging system.  Several authors have shown that patients who have a lower stage of disease (ie, stage I or II) have a much less likely chance of progression compared with those who are in the later stages (IV and V).

 

REFERENCES: Cruess RL: Osteonecrosis of bone: Current concepts as to etiology and pathogenesis.  Clin Orthop 1986;208:30-39. 

Cruess RL: Steroid-induced avascular necrosis of the humeral head: Natural history and management.  J Bone Joint Surg Br 1976;58:313-317.

Rutherford CS, Cofield RH: Osteonecrosis of the shoulder.  Orthop Trans 1987;11:239. 

Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Relationship of disease stage, extent, and cause to natural history. J Shoulder Elbow Surg 1999;8:559-564.

 

 

48.    A 43-year-old former professional hockey player reports severe pain in his chest after being checked from the side in a pick-up hockey game.  An MRI scan and plain radiographs are shown in Figures 25a through 25c.  What is the most likely diagnosis?

 

1-         Anterior sternoclavicular joint dislocation

2-         Posteroinferior sternoclavicular joint dislocation

3-         Anterior acromioclavicular joint dislocation

4-         Posterior acromioclavicular joint dislocation

5-         Acromial fracture

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Anterior dislocation is the most common type of sternoclavicular dislocation.  The medial end of the clavicle is displaced anterior or anterosuperior to the anterior margin of the sternum.  In a study by Omer, 31% of athletic injuries have been known to cause a dislocation of the sternoclavicular joint.  The serendipity view can show this dislocation, as will CT of the chest.  This view requires the x-ray beam to be aimed at the manubrium with 40 degrees of cephalic tilt.  An anterior sternoclavicular joint dislocation will appear superiorly displaced, while a posterior sternoclavicular joint dislocation is inferiorly displaced on the serendipity view.

 

REFERENCES: Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1998, vol 1, pp 566-572.

Omer GE Jr: Osteotomy of the clavicle in surgical reduction of anterior sternoclavicular dislocation.  J Trauma 1967;7:584-590.

 

 

 

49.    Which of the following is considered a contraindication to functional bracing for the treatment of humeral shaft fractures?

 

1-         A closed midshaft fracture accompanied by a radial nerve palsy prior to an attempt at reduction

2-         A fracture with more than 30 degrees of varus angulation prior to reduction

3-         A distal one third spiral fracture

4-         A fracture caused by a low-velocity hand gun treated initially with wound debridement and antibiotics

5-         An inability to maintain less than 30 degrees of varus and 20 degrees of anterior or posterior angulation after reduction

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Most closed humeral shaft fractures and fractures caused by a low-velocity hand gun can be managed nonsurgically with closed reduction and application of a coaptation splint followed by a functional brace.  Contraindications to use of the functional brace include:
1) massive soft-tissue or bone loss; 2) an unreliable or noncompliant patient; and 3) an inability to maintain acceptable fracture alignment of up to 20 degrees of anterior or posterior angulation, 30 degrees of varus or valgus angulation, and greater than 3 cm of shortening.

 

REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus.  J Bone Joint Surg Am 1981;63:239-243.

Sarmiento A. Zagorski JB, Zych GA, et al: Functional bracing for the treatment of fractures of the humeral diaphysis.  J Bone Joint Surg Am 2000;82:478-486.

 

 

50.    A 20-year-old man with fascioscapulohumeral dystrophy has severe scapular winging of both shoulders.  He can no longer abduct above 80 degrees, and it affects his activities of daily living.  A clinical photograph is shown in Figure 26.  Definitive management should consist of

 

1-         a rehabilitation program to strengthen his remaining scapular muscles.

2-         a scapular brace to keep his scapula reduced.

3-         scapulothoracic fusion.

4-         pectoralis minor muscle transfer.

5-         latissimus dorsi muscle transfer.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient’s history is typical of patients with severe fascioscapulohumeral dystrophy.  The scapular winging can be so pronounced that there is significant loss of function of the upper extremity.  The surgical options include transfer of the pectoralis major muscle with a tendon graft or scapulothoracic fusion.  The latter is a technically demanding procedure but can provide a very stable platform for the upper extremity.  Most patients will see increased elevation of the extremity once the scapula is stabilized.  Pectoralis minor transfer has not been described and would not be effective.

 

REFERENCES: Shapiro F, Specht L: The diagnosis and orthopaedic treatment of inherited muscular diseases of childhood.  J Bone Joint Surg Am 1993;75:439-454.

Bunch WH, Siegel IM: Scapulothoracic arthrodesis in fascioscapulohumeral muscular dystrophy: Review of seventeen procedures with three to twenty-one-year follow-up.  J Bone Joint Surg Am 1993;75:372-376.

 

 

51.     Flexion and extension of the elbow occur about an axis of rotation that

 

1-         corresponds with a line drawn through the centers of the trochlea and the capitellum.

2-         corresponds with a line drawn through the center of the medial epicondyle and the lateral epicondyle.

3-         corresponds with a line drawn through the radial head and coronoid.

4-         moves with flexion and extension.

5-         is polycentric.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The elbow mimics a true hinge and flexes and extends around an axis that is centered in the centers of the trochlea and capitellum.  The medial epicondyle is not perfectly isometrically placed; rather the axis of rotation passes through a point on the anteroinferior aspect of the medial epicondyle.  Application of a hinged external fixator is possible because of the fact that there is a single axis of rotation. 

 

REFERENCES: Morrey BF (ed): The Elbow and Its Disorders, ed 2.  Philadelphia, PA, WB Saunders, 1993, pp 53-54. 

London JT: Kinematics of the elbow. J Bone Joint Surg Am 1981;63:529-535.

Morrey BF, Chao EY: Passive motion of the elbow joint. J Bone Joint Surg Am 1976;58:501-508.

 

 

52.    Figure 27 shows the radiograph of a 26-year-old man who sustained a closed head injury and a closed elbow dislocation 6 weeks ago.  Examination reveals 65 degrees to 115 degrees of flexion, and intensive physical therapy has resulted in no improvement.  A decision regarding the timing of surgical correction of the contracture should be based on

 

1-         bone scan results returning to normal.

2-         a decline in intensity on serial bone scans.

3-         the serum levels of alkaline phosphatase measured over time.

4-         the level of serum calcium-phosphorus product.

5-         the time since injury and evidence of bone maturation on plain radiographs.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The patient has heterotopic ossification, a more common finding in patients who have sustained head injuries.  Treatment will require removal of the heterotopic bone and anterior and posterior capsulectomies.  The main concern about timing is the possible recurrence of heterotopic bone.  While an extended wait was once thought necessary, this is no longer true.  The timing is based on the time since injury and evidence of bone maturation on plain radiographs.  A sharp marginal demarcation of the new bone and a trabecular pattern within it are usually present 3 to 6 months after onset, indicating that it is safe to proceed with surgical excision.  It is not necessary to wait more than 6 months.  Bone scan results are not good indicators because they may remain “hot” for long periods of time.  The levels of alkaline phosphatase and serum calcium-phosphorus product do not need to be measured. 

 

REFERENCE: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 325-335.

 

 

53.    A 70-year-old man who underwent an uncomplicated large rotator cuff repair 6 months ago is now seeking a second opinion regarding persistent pain and weakness in his shoulder.  Examination reveals that his incision is well healed and unreactive.  The surgical report suggests that the tendons were secured back to bone with sutures through the greater tuberosity.  Figure 28 shows a radiograph that was obtained 1 week ago.  What is the most likely diagnosis?

 

1-         Infection

2-         Complex regional pain syndrome with associated osteopenia

3-         Frozen shoulder

4-         Failed rotator cuff repair

5-         Acromioclavicular joint arthritis

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Symptoms can persist following a rotator cuff repair for a variety of reasons.  In the early postoperative period, infection is the primary concern.  Stiffness and loss of motion can occur because of postoperative scarring.  Complex regional pain syndrome can occur but is rare, and the diagnosis is not made with a plain radiograph.  This radiograph shows a superiorly migrated humeral head that articulates with the acromion, indicating that the repair has failed.  While large to massive tears may fail more commonly than once thought, the clinical outcome may be satisfactory in many patients.

 

REFERENCES: Mansat P, Cofield RH, Kersten TE, Rowland CM: Complications of rotator cuff repair.  Orthop Clin North Am 1997;28:205-213.

Jost B, Pfirrmann CW, Gerber C, Switzerland Z: Clinical outcome after structural failure of rotator cuff repairs.  J Bone Joint Surg Am 2000;82:304-314.

 

54.    A 29-year-old man who lifts weights states that he injured his left shoulder while performing a bench press 2 days ago.  The following morning he noted ecchymosis and swelling in the left chest wall.  Examination reveals ecchymosis and tenderness and deformity in the left anterior chest wall and axillary fold that is accentuated with resisted adduction of the arm.  Passive range of motion beyond 90 degrees of forward flexion and 45 degrees of external rotation is extremely painful.  Glenohumeral stability is difficult to assess because of severe guarding.  Figure 29 shows an MRI scan.  Management should
consist of

 

1-         proximal biceps tenodesis.

2-         application of a sling for 3 weeks, followed by physical therapy.

3-         anterior capsulolabral reconstruction.

4-         repair of the subscapularis tendon.

5-         repair of the pectoralis major tendon.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Rupture of the pectoralis major tendon most commonly occurs during bench pressing.  Wolfe and associates have shown that the most inferiorly located fibers of the sternal head lengthen disproportionately during the final 30 degrees of humeral extension during the bench press.  This creates a mechanical disadvantage in the final portion of the eccentric phase of the lift; with forceful flexion of the shoulder these maximally stretched fibers may rupture.  In most patients, particularly in young athletes, the treatment of choice is anatomic repair of the ruptured tendon to its insertion in the proximal humerus either with suture anchors or transosseous sutures.  Following surgery, most patients experience a near normal return of strength and significant improvement in the cosmetic appearance of the deformity.  While more technically challenging, repair of chronic rupture is possible and is indicated in some patients.

 

REFERENCES: Wolfe SW, Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: An anatomic and clinical analysis.  Am J Sports Med 1992;20:587-593.

Schepsis AA, Grafe MW, Jones HP, Lemos MJ: Rupture of the pectoralis major muscle: Outcome after repair of acute and chronic injuries.  Am J Sports Med 2000;28:9-15.

 

55.    What range of motion parameters are required for a patient with posttraumatic elbow stiffness to accomplish all the normal activities of daily living?

 

1-         Flexion and extension of 10 degrees to 110 degrees, pronation of 50 degrees, and supination of 50 degrees

2-         Flexion and extension of 10 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees

3-         Flexion and extension of 30 degrees to 110 degrees, pronation of 60 degrees, and supination of 30 degrees

4-         Flexion and extension of 30 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees

5-         Flexion and extension of 30 degrees to 130 degrees, pronation of 60 degrees, and supination of 30 degrees

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Activities of daily living such as dressing, eating, and bathing can all be performed with elbow motion through a 100 degrees arc of flexion and extension (30 degrees to 130 degrees) and a 100 degrees arc of forearm rotation (50 degrees pronation, 50 degrees supination).  Some patients can accomplish these activities of daily living with 10 degrees less motion at each end point.  This is referred to as the functional arc of motion.

 

REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.

Morrey BF, Askew LJ, Chao EY: A biomechanical study of normal functional elbow motion.  J Bone Joint Surg Am 1981;63:872-877.

 

 

56.    A 24-year-old athlete has a painful right shoulder.  Figure 30 shows an intra-articular photograph that was obtained through a posterior portal during arthroscopy; the labrum is indicated by the arrow.  Based on these findings, management should consist of

 

1-         stabilization with suture anchors.

2-         debridement only.

3-         no treatment.

4-         stabilization using absorbable tacks with the arm in external rotation.

5-         release of the attachment to the middle glenohumeral ligament, followed by stabilization with any device.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The photograph shows a normal variant that is a sublabral hole beneath the anterosuperior labrum.  In some instances, the labrum will become confluent with the middle glenohumeral ligament as a stout band.  Because this variant is not abnormal, no treatment is necessary.  Securing this portion of the labrum to the capsule may tighten the middle glenohumeral ligament complex and restrict external rotation of the arm.

 

REFERENCES: Andrews JR, Guerra JJ, Fox GM: Normal and pathologic arthroscopic anatomy of the shoulder, in Andrews JR, Timmerman LA (eds): Diagnostic and Operative Arthroscopy, ed 1.  Philadelphia, PA, WB Saunders, 1997, pp 60-76.

Williams MM, Snyder SJ, Buford D Jr: The Buford complex: The “cord-like” middle glenohumeral ligament and absent anterosuperior labrum complex. A normal anatomic capsulolabral variant.  Arthroscopy 1994;10:241-247.

 

 

57.    The use of a screw between the clavicle and the coracoid process to maintain the clavicle and acromioclavicular (AC) joint in a reduced position is a treatment option for AC joint separations.  Screw removal is generally recommended after soft-tissue healing.  What effect does this rigid coracoclavicular fixation have on shoulder kinematics?

 

1-         Significant limitation of humeral elevation

2-         Significant limitation of shoulder abduction

3-         Significant loss of motion in all directions

4-         Little to no limitation of shoulder range of motion

5-         Limitation of humeral rotation

 

PREFERRED RESPONSE: 4

 

DISCUSSION: This issue has been debated since Inman published his classic study on clavicular rotation in 1944.  Subsequently, it has been shown by several authors that the clinical evaluation of patients with either coracoclavicular screws in place or with arthrodesis of the coracoclavicular reveals little to no loss of shoulder motion.  This is most likely the result of synchronous motion of the scapula and clavicle in shoulder movements.

 

REFERENCES: Flatow EL: The biomechanics of the acromioclavicular, sternoclavicular, and scapulothoracic joints. Instr Course Lect 1993;42:237-245.

Kenedy JC, Cameron H: Complete dislocation of the acromioclavicular joint.  J Bone Joint Surg Br 1954;36:202-208. 

Rockwood CA Jr, Williams GR, Young CD: Disorders of the acromioclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1998, vol 1, pp 483-553. 

Inman VT, Saunders JB, Abbott LC: Observations of the function of the shoulder joint.  Clin Orthop 1996;330:3-12. 

 

 

58.    Figure 31 shows the AP and lateral radiographs of the elbow of a 56-year-old man with chronic polyarticular rheumatoid arthritis.  His function continues to be limited by pain with activities of daily living.  Examination shows that his total arc of motion is 110 degrees.  Nonsurgical management has failed to provide relief.  Treatment should now consist of

 

1-         elbow fusion with a contoured dynamic compression plate.

2-         radial head excision and synovectomy.

3-         distraction arthroplasty with interpositional tissue.

4-         total elbow replacement with an unconstrained prosthesis.

5-         total elbow replacement with a semiconstrained prosthesis.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: A semiconstrained prosthesis can provide excellent results in carefully selected patients.  Because the radiographs show extensive joint destruction with loss of the capitellum and trochlea, a capitellocondylar total elbow (unconstrained) prosthesis is contraindicated.  Elbow fusion is poorly accepted, and the radiographs show too much articular destruction for a radial head excision, synovectomy, or interposition arthroplasty to be effective. 

 

REFERENCES: Ewald FC, Simmons ED Jr, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results.  J Bone Joint Surg Am 1993;75:498-507. 

Morrey BF, Adams RA: Capitellocondylar total elbow replacement in rheumatoid arthritis.  J Bone Joint Surg Am 1992;74:479-490.

 

 

59.    A 12-year-old pitcher has had a 2-month history of pain in his right dominant shoulder after throwing.  He reports that the pain has gradually progressed to the point where he cannot throw without pain.  He also notes that the pain now awakens him at night if he has been active.  Anti-inflammatory drugs have failed to provide relief.  Examination reveals no abnormalities except for some localized tenderness over the proximal humerus.  Figures 32a and 32b show radiographs of both shoulders.  What is the most likely diagnosis?

 

1-         Chondroblastoma

2-         Osteoid osteoma

3-         Occult instability

4-         Rotator cuff tear

5-         Injury to the proximal humeral physis

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The history, examination, and radiographs are pathognomonic for Little League shoulder, a stress syndrome of the proximal humeral physis caused by overuse.  Complete fracture rarely occurs, and recovery usually occurs with rest.  Night pain is always a serious concern and further work-up is needed if the patient does not respond to activity modification.  Occult instability is not a real concern in this patient, although it should be included in the differential diagnosis.

 

REFERENCES: Albert MJ, Drvaric DM: Little League shoulder: Case report.  Orthopedics 1990;13:779-781.

Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in adolescent baseball pitchers. A case report.  J Bone Joint Surg Am 1985;67:495-496.

 

 

60.    Which of the following ligaments is the primary static restraint against inferior translation of the arm when the shoulder is in 0 degrees of abduction?

 

1-         Middle glenohumeral

2-         Inferior glenohumeral

3-         Coracoacromial

4-         Coracoclavicular

5-         Coracohumeral

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The superior glenohumeral ligament (SGHL) and coracohumeral ligament serve as primary static restraints against inferior translation of the arm when the shoulder is in 0 degrees of abduction.  Of these, the coracohumeral ligament has been shown to have a greater cross-sectional area, greater stiffness, and greater ultimate load than the SGHL.  The inferior glenohumeral ligament plays a greater stabilizing role with increasing abduction of the arm.  The coracoacromial ligament may help provide superior stability, especially when the rotator cuff is deficient.  The coracoclavicular ligaments stabilize the acromioclavicular joint.

 

REFERENCES: Boardman ND, Debski RE, Warner JJ, et al: Tensile properties of the superior glenohumeral and coracohumeral ligaments.  J Shoulder Elbow Surg 1996;5:249-254.

Warner JJ, Deng XH, Warren RF, Torzilli PA: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint.  Am J Sports Med 1992;20:675-685.

 

 

 

61.     A 16-year-old high school student undergoes a routine preparticipation physical examination at the beginning of the school year.  Examination reveals marked laxity of both shoulders but only mild generalized laxity in other joints.  The load and shift test allows for anterior humeral translation to the glenoid rim and posterior humeral translation beyond the glenoid rim.  The sulcus sign is present.  What is the next most appropriate step in management?

 

1-         Inform the student that participation in sports is prohibited.

2-         Order MRI of the shoulders to evaluate for labral tears.

3-         Consider arthroscopic thermal capsulorraphy to tighten the shoulders.

4-         Consider open capsular shift procedures to stabilize the shoulders.

5-         Recommend a program of shoulder strengthening exercises and allow participation in sports.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: This patient has shoulder laxity without apprehension.  Because there is a wide range of normal laxity in asymptomatic shoulders, the physician should inform the student of these findings, recommend shoulder strengthening exercises, and allow unrestricted sports participation unless symptoms develop.

 

REFERENCES: Harryman DT, Sidles JA, Harris SL, Matsen FA III: Laxity of the normal glenohumeral joint: A quantitative in vivo assessment.  J Shoulder Elbow Surg 1992;1:66-76. 

Hawkins RJ, Bokor RJ: Clinical evaluation of shoulder problems, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1998, vol 1, p 186. 

McFarland EG, Campbell G, McDowell J: Posterior shoulder laxity in asymptomatic athletes. Am J Sports Med 1996;24:468-471. 

Linter SA, Levy A, Kenter K, Speer KP: Glenohumeral translation in the asymptomatic athlete’s shoulder and its relationship to clinically measurable anthropometric variables.  Am J Sports Med 1996;24:716-720. 

 

 

62.    A 21-year-old professional baseball player has had painful catching and stiffness in his dominant right elbow for the past year.  Examination reveals a flexion contracture of 2 degrees and mild pain with full elbow flexion.  Radiographs are shown in Figures 33a and 33b.  The most effective management should consist of

 

1-         reconstruction of the medial collateral ligament.

2-         a short period of rest followed by a gradual return to activity.

3-         physical therapy and dynamic extension splinting.

4-         arthroscopic removal of the loose body.

5-         a corticosteroid injection.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The radiographs show osteochondritis dissecans of the capitellum and a loose body in the anterior compartment.  Arthroscopic removal is indicated because symptoms referable to the loose body are present.

 

REFERENCES: Baumgarten TE: Osteochondritis dissecans of the capitellum.  Sports Med Arthroscopy Rev 1995;3:219-223.

Shaughnessy WJ, Bianco AJ: Osteochondritis dissecans, in Morrey BF (ed): The Elbow and Its Disorders, ed 2.  Philadelphia, PA, WB Saunders, 1993, pp 282-287.

 

 

63.    A 42-year-old patient has had painful inferior subluxation of the glenohumeral joint following a recent cerebrovascular accident (CVA).  Figure 34 shows the AP radiograph of the shoulder.  Management should consist of

 

1-         closed reduction.

2-         symptomatic sling support and range-of-motion exercises.

3-         arthroscopic thermal capsulorrhaphy.

4-         an open anterior-inferior capsular shift.

5-         a Laterjet procedure.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Following a CVA and with the resumption of upright posture, downward subluxation of the glenohumeral joint may occur.  Although usually painless, some patients may report pain secondary to stretching of the brachial plexus.  This is the result of flaccid paralysis of the deltoid muscle, and it will persist until some motor tone or spasticity returns to the shoulder girdle musculature.  Early sling support and range-of-motion exercises to prevent contracture will provide the best relief.  Surgical procedures are not indicated.

 

REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity.  Clin Orthop 1999;368:54-65.

McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient.  Instr Course Lect 1975;24:45-55.

 

64.    A 50-year-old man who underwent an arthroscopic rotator cuff repair 5 days ago now returns for an early postoperative follow-up because of increasing pain in his shoulder.  He reports increasing malaise and has a low-grade fever.  Examination reveals no redness or swelling, but he has scant serous drainage from the posterior portal.  An emergent Gram stain is positive for gram-positive cocci.  The next most appropriate step in management should consist of

 

1-         oral antibiotics and observation.

2-         IV antibiotics and observation.

3-         immediate arthroscopic debridement and lavage.

4-         blood cultures, oral antibiotics, and a reculture in 2 days.

5-         aspiration of the joint at his regular follow-up in 7 days if the symptoms increase.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: An infection of the shoulder is considered a surgical emergency unless there are medical reasons that a patient cannot be taken to the operating room.  If cultures of wound drainage are in question, then an aspiration should be done emergently, not several days later.  The hallmark of infection in any major joint is increasing pain out of proportion to what is expected.  Drainage occurring 1 to 2 days after an arthroscopic procedure is not normal, and it should be aggressively treated.  Delay in diagnosis can result in sepsis and on a delayed basis, postinfectious arthritis.  Both the glenohumeral joint and the subacromial space require debridement and irrigation, followed by antibiotics after both areas are cultured.

 

REFERENCES: Mansat P, Cofield RH, Kersten TE, Rowland CM: Complications of rotator cuff repair.  Orthop Clin North Am 1997;28:205-213.

Settecerri JJ, Pitner MA, Rock MG, Hanssen AD, Cofield RH: Infection after rotator cuff repair.  J Shoulder Elbow Surg 1999;8:1-5.

Ward WG, Eckardt JJ: Subacromial/subdeltoid bursa abscesses: An overlooked diagnosis.  Clin Orthop 1993;288:189-194.

Ward WG, Goldner RD: Shoulder pyarthrosis: A concomittant process.  Orthopedics 1994;17:591-595.

 

65.    A 42-year-old man who is right-hand dominant injured his right shoulder when he fell from a ladder onto his outstretched arm 1 hour ago.  Radiographs reveal a two-part greater tuberosity anterior fracture-dislocation.  Initial management should consist of

 

1-         closed reduction of the glenohumeral joint and open reduction of the displaced greater tuberosity with rotator cuff repair.

2-         closed reduction of the glenohumeral joint, followed by radiographic assessment of the tuberosity position to determine further treatment.

3-         open reduction of both the joint and greater tuberosity with rotator cuff repair.

4-         open reduction of the glenohumeral joint and closed treatment of the greater tuberosity.

5-         use of a sling until the patient reports no discomfort, then early passive range of motion.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Greater tuberosity anterior fractures associated with anterior glenohumeral dislocations respond very well to closed methods in the majority of patients.  Closed reduction of the glenohumeral joint often anatomically reduces the greater tuberosity into its cancellous bed, without the need for open fixation or cuff repair.  Once closed reduction of the joint is performed, tuberosity displacement and joint articulation should be evaluated radiographically with AP and scapular lateral views as well as an axillary view.  The axillary view will not only definitively show the joint articulation but also demonstrate posterior displacement of the greater tuberosity missed on the AP and lateral views.  If no or minimal (5 mm) displacement is found, then nonsurgical management consisting of a sling and gentle passive range-of-motion exercises can be instituted.

 

REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU: Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus.  J Bone Joint Surg Am 1991;73:1213-1218.

 

 

66.    A 19-year-old man who plays college volleyball undergoes a routine preparticipation physical examination.  Figure 35 shows a posterior view of his dominant shoulder.  An electromyogram shows that this is a chronic injury, and an MRI scan shows no abnormalities.  The best course of action should be

 

1-         a program of shoulder strengthening exercises.

2-         decompression of the nerve at the spinoglenoid notch.

3-         decompression of the nerve at the transverse suprascapular ligament.

4-         release of the fascial elements of the muscle tethering the nerve.

5-         arthroscopy, repair of the posterior labrum lesion, and an anterior capsular shift.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Isolated palsy of the infraspinatus portion of the suprascapular nerve is common in volleyball players and is seen frequently in the throwing arm of baseball players.  The exact cause is not known, but it may be the result of either tethering or traction on the nerve at the spinoglenoid notch.  Synovial cysts in the spinoglenoid notch also can be a cause, but the patient’s negative MRI findings rule out that entity.  Because many isolated nerve palsies of the infraspinatus branch are asymptomatic, initial management should always be nonsurgical.  Surprisingly, many athletes with this injury can participate fully in sports.  Surgical treatment with decompression at the notch is unpredictable and generally is indicated only if nonsurgical management fails.

 

REFERENCES: Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players.  J Bone Joint Surg Am 1987;69:260-263. 

Martin SD, Warren RF, Martin TL, Kennedy K, O’Brien SJ, Wickiewicz TL: Suprascapular neuropathy: Results of non-operative treatment.  J Bone Joint Surg Am 1997;79:1159-1165. 

 

67.    A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury.  Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nonsteroidal anti-inflammatory drugs has failed to provide lasting relief.  Examination reveals tenderness over the acromioclavicular (AC) joint and over the subacromial bursa.  He has positive Neer and Hawkins impingement signs and AC joint pain with adduction of the shoulder.  Radiographs are shown in Figures 36a and 36b.  An MRI scan reveals an intact rotator cuff. Management should now consist of

 

1-         open anterior acromioplasty and rotator cuff repair.

2-         arthroscopic acromioplasty.

3-         anterior acromioplasty and distal clavicle excision.

4-         an open Mumford procedure.

5-         immobilization in a sling for 4 weeks followed by additional physical therapy.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Because the patient has clinical and radiographic signs of AC arthritis and subacromial impingement, the treatment of choice is anterior acromioplasty and distal clavicle excision.  Arthroscopic acromioplasty alone would not address the AC arthritis.  The rotator cuff is intact; therefore, rotator cuff repair is not indicated.  An open Mumford procedure would address the AC arthritis only and not the impingement symptoms.  Immobilization might lead to stiffness of the shoulder and is not recommended for treating impingement.

 

REFERENCE: Peterson CA, Altchek DW, Warren RF: Shoulder arthroscopy, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1990, pp 290-335.

 

 

68.    What three structures are considered the primary constraints necessary for
elbow stability?

 

1-         Coronoid, ulnar part of the lateral collateral ligament, capsule

2-         Capsule, anterior band of the medial collateral ligament, radial head

3-         Radial head, ulnar part of the lateral collateral ligament, capsule

4-         Anterior band of the medial collateral ligament, coronoid, radial head

5-         Ulnar part of the lateral collateral ligament, anterior band of the medial collateral ligament, coronoid

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The three primary constraints necessary for elbow stability in all directions are the ulnar part of the lateral collateral ligament (also called the lateral ulnar collateral ligament), the anterior band of the medial collateral ligament, and the coronoid.  The radial head and capsule are secondary constraints to elbow instability.

 

REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.

Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.

 

 

69.    A 68-year-old woman has been progressing slowly after undergoing humeral head replacement for a four-part fracture 3 months ago.  She has not regained active elevation, she feels an audible clunk on attempting elevation, and she reports pain and weakness.  She used a sling for 2 weeks in the immediate postoperative period.  Radiographs are shown in Figure 37a through 37c.  Management should consist of

 

1-         tuberosity and rotator cuff repair with bone graft.

2-         revision arthroplasty leaving the prosthesis proud to increase humeral length and muscle tension.

3-         revision total shoulder arthroplasty to neutralize eccentric glenoid wear.

4-         revision of the humeral head replacement alone with increased retroversion.

5-         additional therapy to include internal and external rotation strengthening of the rotator cuff.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Immediate repair of the tuberosity and rotator cuff is recommended on identifying the avulsion or nonunion.  Revising the humeral component to increase tension and length will overtighten the cuff and increase the chance of tuberosity pull-off.  The glenoid is uninvolved and should not be replaced.  Attempts to strengthen the rotator cuff will be unsuccessful because the insertions are no longer attached to the humerus when the tuberosities avulse.

 

REFERENCES: Brown TD, Bigliani LU: Complications with humeral head replacement.  Orthop Clin North Am 2000;31:77-90.

Muldoon MP, Cofield RH: Complications of humeral head replacement for proximal humeral fractures. Instr Course Lect 1997;46:15-24.

 

70.    What is the most important feature in choosing an outcome instrument to assess
shoulder disorders?

 

1-         Ease of use

2-         Validity

3-         Ability to use it by mail or phone so the subject is not required to return in person to measure the outcome

4-         Inclusion of radiographic assessment at follow-up

5-         Scoring that is on a 100-point scale so that it can be compared with other instruments

 

PREFERRED RESPONSE: 2

 

DISCUSSION: There has been a recent increase in the use of outcome instruments to document and measure effects of treatment of medical conditions, including shoulder disorders.  The most important feature of an instrument is whether it actually measures what it purports to measure; this is defined as its validity.

 

REFERENCES: Leggin BG, Iannotti JP: Shoulder outcome measurement, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management.  Philadelphia, PA, Lippincott Williams and Wilkins, 1999, p 1027.

Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 47-55.

 

71.     Figure 38 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent.  To minimize additional trauma to the medial soft tissues, the elbow should be reduced in

 

1-         neutral rotation.

2-         full pronation.

3-         full supination.

4-         full extension.

5-         full flexion.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The elbow dislocates by a three-dimensional movement of supination and valgus during flexion.  Additional trauma during reduction is minimized by recreating the deformity and reducing the elbow in supination.  The actual maneuver includes full supination (actually hypersupination) of the elbow in a valgus position.  This is followed by pushing the olecranon distally in line with the long axis of the ulna while swinging the elbow into varus, and then relaxing the supination torque.  Postreduction stability is enhanced in pronation, except when the soft-tissue disruption is extensive. 

 

REFERENCES: O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2.  Philadelphia, PA, WB Saunders, 1993, p 414.

Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.

 

72.    In patients older than age 40 years who sustain a first-time anterior dislocation of the shoulder, prolonged morbidity is most commonly associated with

 

1-         recurrent dislocation.

2-         posttraumatic arthritis.

3-         a rotator cuff tear.

4-         stiffness secondary to immobilization.

5-         nerve injury.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: In the study done by Pevny and associates, 35% of patients older than age 40 years sustained rotator cuff tears and 8% had axillary nerve palsies.  All of the patients with axillary nerve palsy also had rotator cuff tears.  Imaging of the rotator cuff is indicated in this age group.  The incidence of recurrent instability in patients older than age 40 years is 10% to 15%.

 

REFERENCES: Pevny T, Hunter RE, Freeman JR: Primary traumatic anterior shoulder dislocation in patients 40 years of age and older.  Arthroscopy 1998;14:289-294.  

Sonnabend DH: Treatment of primary anterior shoulder dislocation in patients older than 40 years of age: Conservative versus operative.  Clin Orthop 1994;304:74-77.

Hawkins RJ, Mohtadi NG: Controversy in anterior shoulder instability.  Clin Orthop 1991;272:152-161.

 

 

73.    Figure 39 shows the AP radiograph of a 62-year-old man with degenerative osteoarthritis secondary to trauma.  History reveals that he underwent total elbow arthroplasty 3 years ago.  He continues to report instability and constant pain.  A complete work-up, including aspiration and cultures, is negative.  Treatment should consist of removal of the components and

 

1-         distraction interpositional arthroplasty.

2-         elbow arthrodesis.

3-         conversion to a resection arthroplasty.

4-         conversion to semiconstrained elbow arthroplasty.

5-         revision to unconstrained total elbow arthroplasty.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: An unconstrained prosthesis dislocation is a disconcerting problem that is not easily resolved; however, revision to a semiconstrained prosthesis would best achieve both pain relief and stability.  Removal of the components and distraction arthroplasty or conversion to a resection arthroplasty are options, but the results would be unpredictable with regards to pain relief, postoperative motion, or elbow stability.  Arthrodesis is poorly tolerated.  With revision to another unconstrained prosthesis, there is the risk of continued redislocation because of chronic ligamentous insufficiency.

 

REFERENCES: Linscheid RL: Resurfacing elbow replacement arthroplasty:  Rationale, technique and results, in Morrey BF (ed): The Elbow and Its Disorders, ed 3.  Philadelphia, PA, WB Saunders, 2000, pp 602-610.

Morrey BF, King GJ: Revision of failed total elbow arthroplasty, in Morrey BF (ed): The Elbow and Its Disorders, ed 3.  Philadelphia, PA, WB Saunders, 2000, pp 685-700.

 

 

74.    A 67-year-old woman undergoes a revision total shoulder arthroplasty for replacement of a loose glenoid component.  Examination in the recovery room reveals absent voluntary deltoid and triceps contraction, weakness of wrist and thumb extension, and absent sensation in the palmar aspect of all fingertips and the radial forearm.  The next most appropriate step in management should consist of

 

1-         an immediate return to the operating room to explore the brachial plexus.

2-         immediate electromyography and nerve conduction velocity studies.

3-         MRI of the brachial plexus.

4-         MRI of the cervical spine.

5-         immobilization in a sling, followed by early passive range of motion.  

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Neurologic injury after shoulder replacement is relatively uncommon, occurring in 4% of shoulders in one large series.  The importance of identifying and protecting the musculocutaneous and axillary nerves cannot be overemphasized; it is especially critical during revision arthroplasty when the normal anatomic relationships have been distorted.  The long deltopectoral approach leaving the deltoid attached to the clavicle was found to be significant in the development of postoperative neurologic complications.  A correlation was found between surgical time and postoperative neurologic complications, with long surgical times being associated with more neurologic complications.  The presumed mechanism of injury is traction on the plexus that occurs during the surgery.  A neurologic injury after total shoulder arthroplasty usually does not interfere with the long-term outcome of the arthroplasty itself; it is best managed by protective measures with passive range of motion of the involved extremity.  

 

REFERENCES: Wirth MA, Rockwood CA Jr: Complications of shoulder arthroplasty.  Clin Orthop 1994;307:47-69.

Lynch NM, Cofield RH, Silbert PL, Hermann RC: Neurologic complications after total shoulder arthroplasty.  J Shoulder Elbow Surg 1996;5:53-61.

 

 

75.    Figure 40 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent.  Closed reduction is readily accomplished, and the elbow seems stable.  Management should now consist of application of a splint for

 

1-         2 to 5 days, followed by initiation of assisted motion.

2-         14 to 21 days, followed by initiation of assisted motion.

3-         4 weeks, followed by active motion.

4-         6 weeks, followed by physical therapy.

5-         8 weeks, followed by active motion of the elbow.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Flexion contractures are the most common complication of elbow dislocations.  About 15% of patients lose more than 30 degrees of flexion.  The risk of contracture is proportional to the duration of immobilization.  Elbows should be moved within the first few days after reduction.  The splinting is for comfort and protection only while the pain subsides.

REFERENCES: Mehlhoff TL, Noble PC, Bennett JB, Tullos HS: Simple dislocation of the elbow in the adult: Results after closed treatment.  J Bone Joint Surg Am 1988;70:244-249. 

Linscheid RL, O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2.  Philadelphia, PA, WB Saunders, 1993, pp 441-452. 

O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow.  Instr Course Lect 2001;50:89-102. 

Ross G, McDevitt ER, Chronister R, Ove PN: Treatment of simple elbow dislocation using an immediate motion protocol.  Am J Sports Med 1999;27:308-311.  

 

 

76.    A 50-year-old electrician who is right-hand dominant has had right shoulder pain and stiffness after sustaining an electric shock 2 months ago.  An AP radiograph obtained at the time of injury was considered negative, and the patient was diagnosed with a shoulder sprain.  The patient now reports continued shoulder pain and restricted motion.  AP and axillary radiographs and a CT scan are shown in Figures 41a through 41c.  Management should consist of

 

1-         continued observation and physical therapy.

2-         closed reduction in the office.

3-         closed reduction under anesthesia in the hospital.

4-         humeral arthroplasty.

5-         open reduction and transfer of the subscapularis and lesser tuberosity into the anteromedial humeral head defect.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Open reduction and transfer of the subscapularis and lesser tuberosity into the humeral head defect is the treatment of choice for chronic posterior dislocations in which the articular defect consists of 20% to 40% of the articular surfaces.  Closed reduction can be used if the dislocation is recognized early and the articular defect is less than 20% of the articular surface.  Humeral arthroplasty is reserved for patients with an articular defect that is greater than 45% to 50% of the head.

 

REFERENCES: Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder.  J Bone Joint Surg Am 1987;69:9-18.

Checchia SL, Santos PD, Miyazaki AN: Surgical treatment of acute and chronic posterior fracture-dislocation of the shoulder.  J Shoulder Elbow Surg 1998;7:53-65.

 

77.    Figure 42 shows the radiograph of a 70-year-old woman who has had a painful near ankylosis of her dominant elbow for 1 year.  Treatment should consist of

 

1-         total elbow replacement.

2-         hardware removal and joint release.

3-         medial and lateral column humerus plating and a bone graft.

4-         distal humerus replacement.

5-         resection arthroplasty.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The patient has arthritis and supracondylar nonunion of the elbow.  Total elbow replacement has been shown to give almost immediate return of function as it can be performed while leaving the triceps intact and resecting the distal humerus fragment.  Attempts at osteosynthesis are indicated in younger individuals with good joint surface.  Resection arthroplasty yields poor function and is reserved as a salvage procedure. 

 

REFERENCES: Ramsey ML, Morrey BF: Total elbow arthroplasty for nonunion and dysfunctional instability, in Morrey BF (ed): The Elbow and Its Disorders, ed 3.  Philadelphia, PA, WB Saunders, 2000, pp 655-661.

Sim FH, Morrey BF: Nonunion and delayed union of distal humeral fractures, in Morrey BF (ed): The Elbow and Its Disorders, ed 3.  Philadelphia, PA, WB Saunders, 2000, pp 655-661.

 

 

78.    A 72-year-old woman who was doing well after undergoing total shoulder arthroplasty for arthritis 4 months ago is suddenly unable to elevate her arm.  Examination reveals 70 degrees of external rotation compared with 45 degrees on the uninvolved side, and she is unable to lift her hand off her lower back.  Radiographs are shown in Figures 43a through 43c.  Treatment should consist of

 

1-         fascia lata graft to restore the coracoacromial arch.

2-         immediate subscapularis repair.

3-         revision arthroplasty with glenoid reaming to centralize the component.

4-         revision arthroplasty with increased retroversion in the humeral component.

5-         arthroscopic subacromial decompression.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Results of treatment of subscapularis rupture are best when immediate repair is performed.  When the cause of the anterior instability is the result of rupture of the subscapularis tendon and the component position is acceptable, revising the position of the component is unnecessary.  Restoring the coracoacromial arch and subacromial decompression are related to superior instability and rotator cuff pathology, respectively, and would not correct the instability caused by subscapularis rupture.

 

REFERENCES: Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM: Instability of the shoulder after arthroplasty.  J Bone Joint Surg Am 1993;75:492-497.

Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon.  J Bone Joint Surg Am 1996;78:1015-1023.

 

 

79.    A 25-year-old man underwent a Putti-Platt repair for recurrent anterior dislocation of his right shoulder 9 months ago.  He reports no further episodes of instability but continues to have severely restricted motion, with external rotation limited to less than 0 degrees with the arm at the side.  He has pain at the ends of range of motion and restricted activities of daily living despite undergoing nearly 9 months of physical therapy.  Radiographs of the shoulder show no arthritic changes.  Management should now consist of

 

1-         additional physical therapy for 6 months followed by reassessment.

2-         manipulation under anesthesia.

3-         arthroscopic release combined with the use of an interscalene catheter postoperatively.

4-         open release with Z-plasty lengthening of the subscapularis and capsule.

5-         shoulder hemiarthroplasty.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Open release allows lengthening of the shortened subscapularis and is preferred when there are extra-articular contractures.  Arthroscopic release, combined with the use of an interscalene catheter postoperatively, is an excellent treatment for capsular contractures but is contraindicated after procedures that result in extracapsular shortening (ie, Magnuson-Stack, Putti-Platt).  Additional physical therapy or manipulation under anesthesia is not likely to be helpful.  Shoulder hemiarthroplasty is contraindicated with normal articular surfaces, but prosthetic arthroplasty is sometimes necessary for arthritis associated with instability or overly tight instability repairs.

 

REFERENCES: Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness.  Arthroscopy 1997;13:133-147. 

Warner JJ: Frozen shoulder: Diagnosis and management.  J Am Acad Orthop Surg 1997;5:130-140.  

Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder.  J Bone Joint Surg Am 1997;79:1151-1158. 

MacDonald PB, Hawkins RJ, Fowler PJ, Miniaci A: Release of the subscapularis for internal rotation contracture and pain after anterior repair for recurrent anterior dislocation of the shoulder. J Bone Joint Surg Am 1992;74:734-737.

 

 

80.    A 43-year-old bus driver sustains a hyperextension injury to her arm and shoulder 4 months after undergoing an open Bankart repair.  Examination reveals increased external rotation, anterior shoulder pain, and internal rotation weakness.  Her examination also reveals the findings shown in Figure 44.  What is the most likely diagnosis?

 

1-         Superior labrum anterior and posterior lesion, type III

2-         Isolated traumatic dislocation

3-         Axillary nerve disruption

4-         Subscapularis rupture

5-         Internal impingement

 

PREFERRED RESPONSE: 4

 

DISCUSSION: An isolated tear of the subscapularis tendon has been noted as early as 1835 by Smith.  In Gerber and associates’ 1991 report of 16 men with an average age of 51 years, isolated subscapularis tendon rupture was often caused by a violent hyperextension injury.  All patients reported pain anteriorly along with night pain.  They also noted pain and weakness of the arm.  The lift-off test is performed by having the patient lift the palm of the hand away from the small of the back.  The patient must have sufficient internal rotation to allow this test to be performed.  A subscapularis rupture is likely if the patient cannot perform the lift-off test.

 

REFERENCES: Hertel R, Ballmer FT, Lombert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313. 

Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases.  J Bone Joint Surg Br 1991;73:389-394. 

Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593. 

Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023. 

 

 

81.     Radial nerve palsy is most commonly associated with which of the following types of humeral fractures?

 

1-         Proximal one third spiral

2-         Proximal one third transverse

3-         Distal one third spiral

4-         Distal one third transverse

5-         Middle one third

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Although the Holstein-Lewis fracture, described as an oblique distal one third fracture, is best known for its association with neurologic injury, radial nerve palsy is most commonly associated with middle one third humeral fractures.  Most nerve injuries are neurapraxias or axonotmeses, with up to 90% resolving in 3 to 4 months.

 

REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus.  J Bone Joint Surg Am 1981;63:239-243.

 

 

82.    A 30-year-old firefighter sustained a longitudinal pulling injury to the arm while attempting to move a heavy object during a fire.  Figure 45 shows an MRI scan of the elbow.  Initial management should consist of

 

1-         rest and a sling followed by a gradual return to activities.

2-         physical therapy and extension-block bracing.

3-         repair of the biceps tendon to the brachialis muscle.

4-         repair of the common flexor origin.

5-         anatomic repair of the distal biceps tendon.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Because the MRI scan shows a complete rupture of the distal biceps tendon, the preferred treatment is anatomic repair of the tendon to the radial tuberosity either with the use of suture anchors or transosseous sutures through a two-incision technique.  Several studies have documented superior results with anatomic repair of the distal biceps tendon when compared with results of nonsurgical management or repair of the tendon by attachment to the brachialis muscle.  Patients undergoing anatomic repair of the distal biceps tendon through a two-incision technique typically regain a functional range of motion and nearly normal strength.

 

REFERENCES: D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes.  Am J Sports Med 1993;21:114-119. 

Boyd JB, Anderson LD: A method for reinsertion of the distal biceps brachii tendon.  J Bone Joint Surg Am 1961;43:1041-1043. 

Morrey BF, Askew LJ, An KN, Dobyns JH: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 1985;67:418-421.

Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases. Clin Orthop 1990;253:133-136.

 

 

83.    Which of the following is considered a reasonable goal for arthroplasty surgery in rotator cuff arthropathy?

 

1-         Restore normal humeral head glenoid contact location

2-         Restore full active overhead motion

3-         Restore proper glenoid version with bone preparation and use of a cemented glenoid component

4-         Achieve formal decompression and acromioplasty with resection of the coracoacromial ligament and distal clavicle

5-         Achieve a secure closure of the subscapularis with an appropriate head size

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Absence of the rotator cuff results in superior migration of the humeral head because of unopposed deltoid function.  This proximal migration results in eccentric loading of glenoid components with early loosening.  Hemiarthroplasty yields good pain relief with limited goals of active elevation of 90 degrees.  The coracoacromial arch should be preserved.  Achieving satisfactory subscapularis tension is preferred to the use of an oversized humeral component.

 

REFERENCES: Zeman CA, Arcand MA, Cantrell JS, Skedros JG, Burkhead WZ Jr: The rotator cuff-deficient arthritic shoulder: Diagnosis and surgical management.  J Am Acad Orthop Surg 1998;6:337-348.  

Arntz CT, Jackins S, Matsen FA III: Prosthetic replacement of the shoulder for the treatment of defects in the rotator cuff and the surface of the glenohumeral joint.  J Bone Joint Surg Am 1993;75:485-491.

Williams GR Jr, Rockwood CA Jr: Hemiarthroplasty in rotator cuff-deficient shoulders.  J Shoulder Elbow Surg 1996;5:362-367.

Zuckerman JD, Scott AJ, Gallagher MA: Hemiarthroplasty for cuff tear arthropathy.  J Shoulder Elbow Surg 2000;9:169-172.

 

 

84.    What is the best surgical approach for the scapular fracture shown in Figure 46?

 

1-         Anterior

2-         Anterior and superior

3-         Posterior

4-         Percutaneous pinning

5-         Closed reduction

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Indications for open reduction of glenoid intra-articular fractures include those fractures with a 5-mm articular surface displacement or when the humeral head is subluxated with the fracture fragment.  Kavanaugh and associates and Leung and Lam have shown that the posterior approach with plate fixation is best for most glenoid fractures, including the Ideberg type II fracture shown here.  The anterior approach is best used for anterior rim and transverse fractures. 

 

REFERENCES: Kavanagh BF, Bradway JK, Cofield RH: Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa.  J Bone Joint Surg Am 1993;75:479-484.

Leung KS, Lam TP: Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle.  J Bone Joint Surg Am 1993;75:1015-1018.

Ideberg R: Unusual glenoid fractures: A report on 92 cases.  Acta Orthop Scand 1995;66:395-397.

 

 

85.    Management of a grade IV osteochondritis dissecans lesion of the capitellum should consist of

 

1-         use of a sling for 3 weeks followed by a gradual return to activities.

2-         physical therapy.

3-         arthroscopy with removal of the loose fragment.

4-         arthroscopy with in situ drilling of the fragment.

5-         internal fixation of the fragment.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Osteochondritis dissecans of the capitellum is seen most commonly in adolescent athletes.  It should be distinguished from osteochondrosis of the capitellum (Panner’s disease), a self-limiting condition seen in younger patients.

 

Lesions are graded I through V based on radiographic and arthroscopic appearance.  Grade I lesions show intact but soft cartilage.  Grade II lesions show fissuring of the overlying cartilage.  Grade III lesions show exposed bone or an attached osteoarticular flap that is not loose.  Grade IV lesions show a loose but nondisplaced osteoarticular flap.  Grade V lesions show a displaced fragment.

 

Simple excision of the loose osteoarticular flap is the treatment of choice for grade IV and V lesions.  More complex procedures such as drilling of the in situ lesion, bone grafting, or internal fixation are associated with significantly worse results.  While some authors advocate abrasion chondroplasty, the long-term benefits of the procedure are yet to be proven.

 

REFERENCES: Baumgarten TE: Osteochondritis dissecans of the capitellum.  Sports Med Arthroscopy Rev 1995;3:219-223.

Shaughnessy WJ, Bianco AJ: Osteochondritis dissecans, in Morrey BF (ed): The Elbow and Its Disorders, ed 2.  Philadelphia, PA, WB Saunders, 1993, pp 282-287.

 

 

86.    What preoperative factor correlates best with the outcome of rotator cuff repair?

 

1-         Size of the tear

2-         Age of the patient

3-         Arm dominance

4-         Rupture of the long head of the biceps

5-         Preoperative pain score

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The size of the rotator cuff tear in both anteroposterior and mediolateral dimensions has been found to correlate best with outcome.  Older patient age and rupture of the long head of the biceps tend to be associated with larger tears and, therefore, may be associated indirectly with a poorer outcome.

 

REFERENCES: Iannotti JP: Full-thickness rotator cuff tears: Factors affecting surgical outcome.  J Am Acad Orthop Surg 1994;2:87-95.

Iannotti JP, Bernot MP, Kuhlman JR, Kelley MJ, Williams GR: Postoperative assessment of shoulder function: A prospective study of full-thickness rotator cuff tears.  J Shoulder Elbow Surg 1996;5:449-457.

 

 

87.    A 55-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing left shoulder pain for the past 2 years despite nonsurgical management.  No focal weakness is noted during examination of the shoulder.  AP and axillary radiographs are shown in Figures 47a and 47b.  Treatment should consist of

 

1-         arthroscopic synovectomy.

2-         humeral arthroplasty.

3-         unconstrained total shoulder arthroplasty.

4-         constrained total shoulder arthroplasty with a fixed-fulcrum prosthesis.

5-         glenohumeral arthrodesis.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Unconstrained total shoulder arthroplasty has been found to yield satisfactory results in a high percentage of patients with rheumatoid involvement of the glenohumeral joint.  Pain relief has been more predictable with total shoulder arthroplasty than humeral arthroplasty, and a glenoid component is favored when there is sufficient glenoid bone stock and an intact rotator cuff.  Constrained or fixed-fulcrum devices have an unacceptably high failure rate because of loosening.  Glenohumeral arthrodesis is avoided when the deltoid or rotator cuff is functioning because the functional results after arthroplasty are superior when compared with results of arthrodesis.  Arthroscopic synovectomy may be helpful in early stages of the disease before extensive cartilage damage has occurred.

 

REFERENCES: Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing.  J Arthroplasty 1990;5:329-336.

Kelly IG, Foster RS, Fisher WD: Neer total shoulder replacement in rheumatoid arthritis.  J Bone Joint Surg Br 1987;69:723-726.

 

88.    When elevating the arm, the ratio of scapulothoracic to glenohumeral motion over the total range of motion is best described as

 

1-         1:2, and in the first 30 degrees the ratio is 1:5.

2-         1:2, and in the first 30 degrees the ratio is variable.

3-         2:1, and in the first 30 degrees the ratio is variable.

4-         2:1, and in the first 30 degrees the ratio is 3:1.

5-         highly variable and no definitive statement can be made about the ratios.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The ratio of scapulothoracic to glenohumeral motion with elevation has been shown to vary depending on what portion of elevation is examined, how much load is on the arm, and the technique used to measure increments of elevation.  However, almost every study shows that the ratio of scapulothoracic to glenohumeral motion is 1:2 for the contributions over a full range of elevation to 170 degrees.  In the first 30 degrees of elevation, there is significant variability in the ratio, and there may be significant variability up to around 60 degrees.

 

REFERENCES: Inman VT, Saunders JR, Abbott LC: Observations of the function of the shoulder joint.  Clin Orthop 1996;330:3-12.

Freedman L, Munro RH: Abduction of the arm in the scapular plane: Scapular and glenohumeral movements.  J Bone Joint Surg Am 1966;18:1503.

 

 

89.    Figure 48 shows the initial AP chest radiograph of a 21-year-old motorcycle rider who sustained multiple injuries after striking a telephone pole at high speed.  What is the most significant radiographic finding leading to a diagnosis?

 

1-         Subdiaphragmatic free air

2-         Right midshaft clavicular fracture

3-         Right scapulothoracic dissociation

4-         Left diaphragmatic rupture

5-         Left sternoclavicular dislocation

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Scapulothoracic dissociation is a rare, violent traumatic injury in which the scapula is torn away from the chest wall but the skin remains intact.  Massive swelling and ecchymosis are common.  Neurovascular injury is the rule with possible subclavian or axillary artery disruption and severe partial or complete brachial plexus paralysis.  The diagnosis is made on a nonrotated chest radiograph that shows significant lateral displacement of the medial scapular border from the sternal notch.  A right midshaft clavicular fracture is present but is not considered the most significant finding.

 

REFERENCES: Ebraheim NA, An HS, Jackson WT, et al: Scapulothoracic dissociation.  J Bone Joint Surg Am 1988;70:428-432. 

Ebraheim NA, Pearlstein SR, Savolaine ER, et al: Scapulothoracic dissociation.  J Orthop Trauma 1987;1:18-23. 

Sampson LN, Britton JC, Eldrup-Jorgensen J, et al: The neurovascular outcome of scapulothoracic dissociation. J Vasc Surg 1993;17:1083-1088.

Oreck SL, Burgess A, Levine AM: Traumatic lateral displacement of the scapula: A radiographic sign of neurovascular disruption. J Bone Joint Surg Am 1984;66:758-763. 

 

 

90.    A 21-year-old man who underwent repair of a distal biceps tendon rupture using a two-incision approach 4 months ago now reports difficulty gaining rotation of his forearm.  Figures 49a and 49b show the AP and lateral radiographs.  What is the most likely cause of his problem?

 

1-         Inadequate physical therapy

2-         Exposure of the periosteum of the lateral ulna during surgery

3-         Inappropriate location of the suture anchor

4-         Fixation of the tendon with the forearm fully pronated

5-         Subluxation of the radial head

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The radiographs show early ectopic bone formation originating between the ulna and the radius.  The development of ectopic bone in this area following a two-incision approach for anatomic repair of the distal biceps tendon is thought to be related to exposure of the periosteum of the lateral ulna during surgery.  This can be avoided by the use of a muscle-splitting incision between the extensor carpi ulnaris and common extensor muscles.  Full pronation of the forearm allows for the necessary exposure of the radial tuberosity during the procedure and for fixation of the tendon at its maximal length.

 

REFERENCES: Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed. 2.  Philadelphia, PA, WB Saunders, 1993, pp 492-503.

Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases.  Clin Orthop 1990;253:133-136.

 

 

91.     A 53-year-old man reports acute, severe left shoulder pain after undergoing abdominal surgery 10 days ago.  Initial management, consisting of anti-inflammatory drugs, physical therapy, and a subacromial injection of corticosteroid, fails to provide relief.  Reexamination of the shoulder 2 months after the onset of symptoms reveals atrophy of the infraspinous and supraspinous fossa and profound weakness of active abduction and external rotation.  His neck is supple with a full range of motion.  Plain radiographs and an MRI scan of the shoulder are normal.  What diagnostic study should be performed next in the evaluation of this patient?

 

1-         Shoulder arthrography 

2-         MRI of the cervical spine

3-         CT of the head

4-         Technetium Tc 99m bone scan

5-         Electromyography and nerve conduction velocity studies

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Suprascapular nerve palsy is a fairly uncommon yet well-known cause of shoulder pain and weakness.  A variety of causes have been described, including compression by a ganglion cyst, an anomalous or thickened superior transverse scapular ligament, a humeral and scapular fracture, and traction or kinking of the nerve in the suprascapular notch.

 

In this patient, the injury is most likely caused by traction or compression of the nerve in the suprascapular notch as the result of positioning during abdominal surgery; therefore, the studies of choice are electromyography and nerve conduction velocity studies.  While MRI of the cervical spine may be of some value in ruling out a radiculopathy, the clinical history does not support such a cause for this condition.

 

REFERENCES: Rengachary SS, Neff JP, Singer PA, Brackett CE: Suprascapular entrapment neuropathy: A clinical, anatomical, and comparative study. Part 1: Clinical study.  Neurosurgery 1979;5:441-446.

Rengachary SS, Burr D, Lucas S, Hassanein KM, Mohn MP, Matzke H: Suprascapular entrapment neuropathy: A clinical, anatomical and comparative study. Part 2: Anatomical study.  Neurosurgery 1979;5:447-451.

Bigliani LU, Dalsey RM, McCann PD, April EW: An anatomical study of the suprascapular nerve. Arthoscopy 1990;6:301-305.

 

92.    A 58-year-old reports pain and stiffness in his left shoulder following a seizure episode.  Diagnosis at the time of the seizure is a frozen shoulder, and management consists of an aggressive physical therapy program of stretching exercises.  Four months later he continues to have shoulder pain and has not gained any additional range of motion.  A CT scan is shown in Figure 50.  Management should now consist of

 

1-         additional physical therapy and home stretching exercises.

2-         closed reduction and immobilization in a spica cast.

3-         open reduction and transfer of the subscapularis and lesser tuberosity.

4-         humeral arthroplasty.

5-         total shoulder arthroplasty.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Humeral arthroplasty is indicated for chronic posterior dislocations when the impression defect in the humeral head is greater than 45% to 50%.  If the condition remains undiagnosed for more than 9 to 12 months, secondary degenerative changes on the glenoid may occur, necessitating total shoulder arthroplasty.  Open reduction and transfer of the subscapularis and lesser tuberosity are used for impression defects that consist of 20% to 40% of the humeral articular surface.  Closed reduction and immobilization with the arm in slight extension and external rotation is useful when the posterior dislocation is diagnosed within the first 6 weeks and the articular defect is less than 20%.

 

REFERENCES: Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder.  J Bone Joint Surg Am 1987;69:9-18.

Checchia SL, Santos PD, Miyazaki AN: Surgical treatment of acute and chronic posterior fracture-dislocation of the shoulder.  J Shoulder Elbow Surg 1998;7:53-65.

93.    When conducted at near physiologic strain rates, tensile studies of the inferior glenohumeral ligament (IGHL) have shown that the

 

1-         anterior band of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

2-         anterior band of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.

3-         axillary pouch of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

4-         axillary pouch of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.

5-         posterior portion of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Tensile testing of the inferior glenohumeral ligament at near physiologic strain rates has shown that the anterior band of the IGHL has the greatest stiffness of the three ligament regions and the glenoid insertion site shows greater strain than the ligament midsubstance.

 

REFERENCES: Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament.  J Orthop Res 1992;10:187-197.

Ticker JB, Bigliani LU, Soslowsky LJ, Pawluk RJ, Flatow EL, Mow VC: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties.  J Shoulder Elbow Surg 1996;5:269-279.

 

 

94.    Manipulation under anesthesia for resistant frozen shoulder should be avoided in
patients with

 

1-         idiopathic onset.

2-         gout.

3-         hyperthyroidism.

4-         hypothyroidism.

5-         severe osteoporosis.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Severe osteoporosis is a contraindication to manipulation under anesthesia in patients with a resistant frozen shoulder because of the higher risk of humeral fracture.  Manipulation is considered for frozen shoulder in patients who are symptomatic despite undergoing a reasonable course of appropriate physical therapy.

 

REFERENCES: Harryman DT II: Shoulder: Frozen and stiff.  Instr Course Lect 1997;42:247-257.

Warner JJ: Frozen shoulder: Diagnosis and management.  J Am Acad Orthop Surg 1997;5:130-140.

 

95.    A patient who sustained a cerebrovascular accident (CVA) 18 months ago has a long-standing spastic adduction contracture of the shoulder with a rigid block to passive external rotation.  Significant hygiene problems exist with maceration and continued skin breakdown.  Management should consist of

 

1-         a percutaneous pectoralis tenotomy.

2-         a modified L’Episcopo procedure.

3-         serial lidocaine nerve blocks.

4-         pectoralis tenotomy and subscapularis tendon lengthening.

5-         phenol nerve blocks.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Following a CVA, the muscular imbalance often leads to a fixed contracture of the shoulder in adduction, internal rotation, and flexion.  The responsible muscles include the pectoralis major, subscapularis, teres major, and latissimus dorsi.  If stretching cannot produce enough improvement for axillary hygiene, then surgery is an option.  If the shoulder resists external rotation during examination with the arm at the side, as in this patient, then the subscapularis is spastic and contributing to the deformity as well and needs to be released along with the pectoralis.  Phenol nerve blocks are most effective and best given within 6 months of the initial CVA to be effective.  Lidocaine blocks may be helpful in determining whether a deformity is caused by a fixed soft-tissue contracture or by spasticity but play no role once the contracture is present.  The modified L’Episcopo procedure is indicated in patients with contracture secondary to brachial plexus birth palsies.

 

REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity.  Clin Orthop 1999;368:54-65.

McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient.  Instr Course Lect 1975;24:45-55.

 

 

96.    A patient with degenerative osteoarthritis of the sternoclavicular (SC) joint reports constant pain, discomfort, and marked prominence and instability of the SC joint following medial clavicle resection.  Which of the following procedures is most likely to produce these signs and symptoms?

 

1-         Excision medial to the costoclavicular ligament

2-         Excision lateral to the costoclavicular ligament

3-         Excision of the coracoclavicular ligaments and lateral clavicle

4-         Excision of the coracohumeral ligaments

5-         Leaving the costoclavicular ligament intact

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Medial clavicle excision alone can be associated with postoperative instability of the clavicle.  The clavicle should be stabilized to the first rib by reconstructing the costoclavicular ligament if it is torn or if the resection is lateral to its clavicular insertion.  Therefore, care must be taken to resect only that part of the clavicle that is medial to the costoclavicular ligament.  Adequate protection for vital structures that lie posterior to the medial end of the clavicle must be provided.  

 

REFERENCES: Bremner RA: Nonarticular noninfected subacute arthritis of the sternoclavicular joint.  J Bone Joint Surg Br 1959;41:749-753.

Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1998, vol 1, pp 583-586.

 

 

97.    A 26-year-old man has had a 2-year history of pain and stiffness after sustaining a comminuted olecranon fracture.  Treatment at the time of injury consisted of open reduction and internal fixation with tension band wiring.  Examination reveals motion of 45 degrees to 110 degrees and pain throughout the arc of motion.  Resisted flexion and extension are painful.  Forearm rotation is normal.  Radiographs are shown in Figure 51.  Treatment should consist of

 

1-         excision of heterotopic bone.

2-         hardware removal and elbow joint release with splinting.

3-         semiconstrained total elbow arthroplasty.

4-         distraction arthroplasty.

5-         synovectomy and radial head excision.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The patient has posttraumatic arthritis of the elbow; therefore, the treatment of choice is hardware removal and soft-tissue releases with splinting to avoid recurrence of contractures.  The combination of pain and stiffness in an elbow that has sustained significant joint surface damage renders it unresponsive to simple soft-tissue releases and heterotopic bone excision.  Joint distraction and interposition arthroplasty offer the possibility of maintaining motion and relieving pain as a later salvage procedure.  Joint replacement should not be performed in young, active, strong individuals because the prosthesis will fail quickly and complications will develop.  Synovectomy and radial head excision are not indicated.

 

REFERENCES: Morrey BF: Distraction arthroplasty: Clinical applications.  Clin Orthop 1993;293:46-54.

O’Driscoll SW: Elbow arthritis: Treatment options.  J Am Acad Orthop Surg 1993;1:106-116.

 

98.    What is the most common cause of rotator cuff injury in high school athletes?

 

1-         A curved or type III acromion

2-         A tight coracoacromial ligament

3-         Overuse

4-         Limited internal rotation

5-         Scapulothoracic dyskinesia

 

PREFERRED RESPONSE: 3

 

DISCUSSION: A large number of etiologies of rotator cuff injury have been proposed.  Both intrinsic and extrinsic mechanisms have been suggested.  In the young athlete the common underlying mechanism is overuse.  Contributing factors include increased laxity, anatomic variation in the coracoacromial arch, and altered kinematics. 

 

REFERENCES: Wilkins KE: Shoulder injuries: Epidemiology, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine.  Philadelphia, PA, WB Saunders, 1994, pp 175-182.

Sher JS: Anatomy, biomechanics, and pathophysiology of rotator cuff disease, in Iannnotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, pp 3-30.

 

 

99.    A 16-year-old boy with osteochondritis dissecans of the capitellum has intermittent symptoms of catching and locking.  Examination is unremarkable.  Radiographs reveal a loose body anteriorly with a diameter of 10 mm.  To remove the loose body, elbow arthroscopy is being considered.  Which of the following procedures would minimize the risk of neurovascular complication during the procedure?

 

1-         Keeping a smooth plastic cannula in each portal after it is established

2-         Using an image intensifier to localize the loose body

3-         Distending the elbow joint capsule prior to establishing the anterolateral portal

4-         Placing the scope in the proximal anteromedial portal and then enlarging the anterolateral portal so that it is bigger than the maximum diameter of the loose body

5-         Breaking up the loose body into several pieces prior to extracting it

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Complications of elbow arthroscopy are usually minor or temporary.  However, serious complications include nerve injuries.  The deep radial nerve is the closest to any of the portals, resting as close as 1 mm away from the scope inserted in the anterolateral portal.  The capsule can be displaced anteriorly by distending the joint with about 25 mL of saline solution, thus moving the deep radial nerve approximately 1 cm anteriorly and decreasing the risk of injuring it while establishing the anterolateral portal.  Keeping plastic cannulae in the portals may help to diminish fluid extravasation and swelling, which is more of an impediment than a serious complication.  The image intensifier has no documented role in guiding loose body removal.  While the proximal anteromedial portal is probably the safest anterior portal to establish, it is actually easier to remove a large loose body from this portal while viewing it from an anterolateral position.  There is less tendon and muscle bulk to pass through at the site of the proximal anteromedial portal than at the anterolateral portal, making it less likely for the loose body to get stuck in the soft tissues.  Techniques have been developed to permit removal of loose bodies as large as 2 cm in diameter without breaking them up into pieces.  If it is possible to remove a large loose body intact, doing so greatly simplifies and shortens the procedure. 

 

REFERENCES: Lynch GJ, Meyers JF, Whipple TL, Caspari RB: Neurovascular anatomy and elbow arthroscopy: Inherent risks.  Arthroscopy 1986;2:190-197.

O’Driscoll S: Loose bodies and synovial conditions, in Green D, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery.  New York, NY, Churchill Livingstone, 1999, pp 235-249.

 

 

100.  Examination of the shoulder seen in Figure 52 shows atrophy and tenderness of the infraspinous fossa and profound weakness in external rotation.  The supraspinous fossa shows normal muscle bulk.  What is the most likely cause of this condition?

 

1-         Neurofibroma of the suprascapular nerve

2-         Ganglion cyst of the suprascapular notch

3-         Ganglion cyst of the spinoglenoid notch

4-         Lipoma of the suprascapular notch

5-         Lipoma of the spinoglenoid notch

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Compression of the suprascapular nerve by a ganglion cyst is a well-documented cause of pain and weakness in the shoulder.  Isolated involvement of the infraspinatus indicates that the area of entrapment is at the spinoglenoid notch and not the suprascapular notch.  The majority of ganglion cysts found in the shoulder are related to tears of the labrum.  When such a compressive lesion is found, decompression can be accomplished through either an open or arthroscopic approach.  Several authors have shown the value of arthroscopy in the treatment of this condition.  It has been shown that it is technically possible to decompress a paralabral ganglion cyst using arthroscopy; this method is usually followed by repair of the torn labrum.  Alternatively, arthroscopic repair of the labrum can be performed and the cyst may be aspirated at the time of surgery.  Open cyst excision through a posterior approach is also an acceptable method of treatment.

 

REFERENCES: Schickendantz MS, Ho CP: Suprascapular nerve compression by a ganglion cyst: Diagnosis by magnetic resonance imaging.  J Shoulder Elbow Surg 1993;2:110-114.

Thompson RC, Schneider W, Kennedy T: Entrapment neuropathy of the inferior branch of the suprascapular nerve by ganglia.  Clin Orthop 1982;166:185-187.

Iannotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression.  Arthroscopy 1996;12:739-745.

 

 

 

 

1.

 

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