Orthopedics MCQ online 2022, Dec, 16 | 12:00 am

Orthopedic MCQS online Shoulder and Elbow 017

Orthopedic MCQS online Shoulder and Elbow 017

 

SHOULDER AND ELBOW SELF-

SCORED SELF-ASSESSMENT EXAMINATION

AAOS 2017

 

 

CLINICAL SITUATION FOR QUESTIONS 1 THROUGH 4

A 55-year-old man falls on his outstretched arm and sustains the injury shown in the 3-dimensional CT scans in Figures 1a and 1b.

 

 

 

Question 1 of 100

Which ligamentous structure attaches to the fracture fragment?

  1. Lateral ulnar collateral ligament

  2. Radial collateral ligament

  3. Posterior medial collateral ligament (MCL)

  4. Anterior MCL

 

PREFERRED RESPONSE: 4- Anterior MCL

 

Question 2 of 100

The bony landmark is known as the

  1. crista supinatoris.

  2. sublime tubercle.

  3. radial notch.

  4. coronoid.

 

PREFERRED RESPONSE: 2- sublime tubercle.

Question 3 of 100

The critical weight-bearing portion of the elbow joint that is damaged in this fracture is the

  1. anteromedial coronoid facet.

  2. posteromedial olecranon facet.

  3. coronoid.

  4. radial notch.

 

PREFERRED RESPONSE: 1- anteromedial coronoid facet.

 

Question 4 of 100

Treatment of this fracture should consist of

  1. closed reduction, limited immobilization (1-2 weeks), and early functional rehabilitation.

  2. limited immobilization in a long-arm cast (4 weeks) and early functional rehabilitation.

  3. open reduction and internal fixation.

  4. open reduction, capsular repair, and suture fixation of the bony fragment and ligament.

     

    PREFERRED RESPONSE: 3- open reduction and internal fixation.

    DISCUSSION

    Varus posteromedial rotatory instability is a complex injury pattern that starts with varus stress resulting in a fracture of the anteromedial coronoid. The anterior MCL attaches to the sublime tubercle, which is part of the anteromedial coronoid facet. The posterior MCL attaches to the posterior medial aspect of the ulna. The radial collateral and lateral ulnar collateral attach to the ulna at the crista supinatoris. The bony landmark is the sublime tubercle; as noted above, the crista supinatoris is lateral on the ulna. The radial notch is also lateral and is the articulation between the proximal ulna and proximal radius. The anteromedial coronoid facet is part of the coronoid, which extends more lateral and anterior than the anteromedial facet. The anteromedial facet represents the critical weight-bearing portion of the ulnohumeral joint. Damage to this structure causes posteromedial subluxation that often results in severe progressive arthritis. The coronoid is the larger structure of which the anteromedial coronoid facet is a portion. The posteromedial coronoid facet does not appear to be critical in weight bearing. The radial notch is not associated with increased stress with weight bearing. The treatment of displaced fractures of this structure is open reduction and internal fixation utilizing buttress plating. Closed treatment is acceptable only for nondisplaced fractures with appropriate radiographic follow-up. Suture fixation is not advocated because of inadequate strength.

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RESPONSES FOR QUESTIONS 13 THROUGH 17

  1. Isolated posterior instability with a posterior labral tear

  2. Multidirectional instability

  3. Anterior shoulder subluxation

  4. Thoracic outlet syndrome

  5. Superior labrum anterior to posterior (SLAP) tear

  6. Proximal humeral physeal injury

 

For each clinical scenario described below, please select the most likely diagnosis listed above.

Question 13 of 100

An 18-year-old female collegiate swimmer has a 1-year history of posterior shoulder pain and popping and a bilateral 2-cm sulcus sign.

  1. Isolated posterior instability with a posterior labral tear

  2. Multidirectional instability

  3. Anterior shoulder subluxation

  4. Thoracic outlet syndrome

  5. Superior labrum anterior to posterior (SLAP) tear

  6. Proximal humeral physeal injury

 

PREFERRED RESPONSE: 2- Multidirectional instability

 

Question 14 of 100

A 16-year-old high school football player has anterior shoulder pain after tackling an opponent with his arm in abduction and external rotation.

  1. Isolated posterior instability with a posterior labral tear

  2. Multidirectional instability

  3. Anterior shoulder subluxation

  4. Thoracic outlet syndrome

  5. Superior labrum anterior to posterior (SLAP) tear

  6. Proximal humeral physeal injury

 

PREFERRED RESPONSE: 3- Anterior shoulder subluxation

 

Question 15 of 100

A 21-year-old collegiate baseball player experiences posterior shoulder pain in the lead shoulder while batting.

  1. Isolated posterior instability with a posterior labral tear

  2. Multidirectional instability

  3. Anterior shoulder subluxation

  4. Thoracic outlet syndrome

  5. Superior labrum anterior to posterior (SLAP) tear

  6. Proximal humeral physeal injury

 

PREFERRED RESPONSE: 1- Isolated posterior instability with a posterior labral tear

 

Question 16 of 100

A 23-year-old professional baseball pitcher experiences worsening pain in the throwing shoulder. Examination reveals increased external rotation, decreased internal rotation, and loss of total arc of motion in the throwing arm compared to the opposite side.

  1. Isolated posterior instability with a posterior labral tear

  2. Multidirectional instability

  3. Anterior shoulder subluxation

  4. Thoracic outlet syndrome

  5. Superior labrum anterior to posterior (SLAP) tear

  6. Proximal humeral physeal injury

 

PREFERRED RESPONSE: 5- Superior labrum anterior to posterior (SLAP) tear

 

Question 17 of 100

A 14-year-old Little League pitcher who plays in 2 leagues concurrently has pain in his throwing shoulder while pitching but not at rest.

  1. Isolated posterior instability with a posterior labral tear

  2. Multidirectional instability

  3. Anterior shoulder subluxation

  4. Thoracic outlet syndrome

  5. Superior labrum anterior to posterior (SLAP) tear

  6. Proximal humeral physeal injury

     

    PREFERRED RESPONSE: 6- Proximal humeral physeal injury

    DISCUSSION

    Multidirectional shoulder instability can be diagnosed by demonstrating instability in at least 2 planes. The sulcus sign is often present with a prominent depression below the acromion when traction is applied to the arm. The mechanism of anterior shoulder dislocation or subluxation is most commonly a combination of abduction, external rotation, and a posteriorly directed force applied to the arm. Among baseball players, the lead shoulder is susceptible to posterior capsulolabral lesions termed “batter’s shoulder.” SLAP tears are common among overhead

    athletes and can cause symptoms similar to impingement as well as a glenohumeral internal rotation deficit, which may predispose players to labral tears. Little League shoulder is an overuse injury typically seen in baseball pitchers who are around 14 years of age. It is an osteochondrosis of the proximal humeral epiphysis attributable to overuse from throwing.

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CLINICAL SITUATION FOR QUESTIONS 54 THROUGH 57

Figures 54a through 54f are the radiographs, CT scans, and arthroscopic images of a right-hand-dominant 18-year-old man who reports a history of right shoulder recurrent anterior instability. He sustained his first traumatic anterior dislocation after a fall while playing basketball 9 months ago. After closed reduction in the emergency department, he was initially treated with sling immobilization for 2 weeks followed by physical therapy for progression to full range of motion with rotator cuff strengthening. He subsequently has sustained 2 anterior dislocations during overhead activities, each necessitating closed reduction in the emergency department. Upon examination, anterior apprehension and relocation test findings are positive with the shoulder in the abducted and externally rotated position; posterior jerk test and sulcus test findings are negative, and he has no evidence of generalized ligamentous laxity. Imaging studies reveal less than 10% bone loss of the anterior glenoid along with a Hill-Sachs lesion.

 

 

 

 

 

 

 

Question 54 of 100

The likely detached ligamentous lesion is tightest when the position of the shoulder is

  1. 45-degree abduction, internal rotation.

  2. 45-degree abduction, external rotation.

  3. 90-degree abduction, external rotation.

  4. 90-degree abduction, internal rotation.

 

PREFERRED RESPONSE: 3- 90-degree abduction, external rotation.

 

Question 55 of 100

For patients who sustain their first anterior glenohumeral dislocation during sports activity, which associated injury is most commonly expected at the time of the initial dislocation?

  1. Rotator cuff tear

  2. Axillary nerve palsy

  3. Greater tuberosity fracture

  4. Biceps tendon rupture

 

PREFERRED RESPONSE: 2- Axillary nerve palsy

 

Question 56 of 100

At the time of arthroscopy, the posterior humeral head Hill-Sachs lesion substantially engages with the glenoid; CT and arthroscopic findings reveal minimal glenoid bone loss. In addition to arthroscopic Bankart repair, arthroscopic Hill-Sachs remplissage with suture anchors is performed. In combined Bankart repair with Hill-Sachs remplissage vs Bankart repair alone, which complication is of highest potential concern?

  1. Increase in shoulder external rotation of approximately 10 degrees vs the uninjured shoulder

  2. Increased rate of recurrent dislocation

  3. Loss of shoulder external rotation of approximately 10 degrees vs the uninjured shoulder

  4. Lower rate of return to previous level of sports participation

 

PREFERRED RESPONSE: 3- Loss of shoulder external rotation of approximately 10 degrees vs the uninjured shoulder

 

Question 57 of 100

If the site of the pathologic lesion is revealed in Figure 54f and not in Figure 54e after traumatic anterior shoulder dislocation, the mechanism of shoulder injury is likely

 

 

 

  1. axial loading of the glenohumeral joint.

  2. isolated hyperabduction.

  3. combined 45-degree abduction and external rotation.

  4. combined hyperabduction and external rotation.

     

    PREFERRED RESPONSE: 4- combined hyperabduction and external rotation.

    DISCUSSION

    For patients with anterior shoulder instability, most commonly, a Bankart lesion, or detachment of the anteroinferior labrum with the attached inferior glenohumeral ligament from the glenoid rim is found. A medialized anteroinferior capsulolabral attachment (ALPSA lesion) is a common finding in shoulders with chronic anterior instability. The anterior band of the inferior glenohumeral ligament is tightest with the arm in 90 degrees of abduction with the shoulder externally rotated, creating a “hammock” that supports the humeral head. At 45 degrees of shoulder

    abduction, the capsuloligamentous components of the shoulder are at their loosest, resulting in the most total superior-inferior translation.

    During traumatic anterior glenohumeral dislocation, associated injuries commonly occur. In a prospective database of 3633 patients who sustained a traumatic anterior glenohumeral dislocation, 13.5% had a neurologic deficit following reduction, the majority of which were injuries to the axillary nerve. The injuries typically were sensory but not motor deficits and resolved spontaneously over time. These isolated axillary nerve injuries were more common in young, athletic patients. Associated rotator cuff tears and greater tuberosity fractures are commonly associated with shoulder dislocation as well and are more common in patients 60 years of age and older.

    Large, engaging posterior humeral head Hill-Sachs lesions are associated with increased rates of recurrent shoulder instability. At the time of surgical arthroscopy, the Hill-Sachs lesion should be assessed for engagement with the glenoid. In the absence of significant glenoid bone loss, some patients with engaging Hill-Sachs defects may be suitable for combined Bankart repair and Hill-Sachs remplissage at the time of surgery. When these procedures are combined, patients have an approximate 10-degree decreased shoulder external rotation with the arm at the side and in abduction when compared to the contralateral, uninjured shoulder. Rates of recurrent dislocation and return to sport are comparable to those for patients undergoing Bankart repair alone.

    Humeral avulsion of the glenohumeral ligaments (HAGL) has become a well-recognized cause of recurrent shoulder instability and is reported in 1% to 9% of patients. HAGL lesions can occur in isolation or, more commonly, may be associated with other abnormalities such as a tear of the rotator cuff, Bankart lesion, Hill-Sachs deformity, or labral tear. Recurrence of shoulder instability is more likely to occur if there is failure to identify a HAGL lesion. HAGL lesions can result from trauma in the setting of combined hyperabduction and external rotation. This is in contrast to a Bankart lesion, which is a result of trauma when the shoulder is hyperabducted without substantial associated rotation.

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PREFERRED RESPONSE: 4- A TEA, which likely will provide better longevity than if performed for posttraumatic arthritis

DISCUSSION

This patient has symptoms and radiograph findings consistent with advanced inflammatory arthritis of the elbow. Although synovectomy has utility during earlier stages of disease, once bony changes occur, arthroscopic synovectomy is unlikely to provide long-term pain relief. Interposition arthroplasty is advocated in younger patients who may not be able to comply with the permanent 5- to 10-pound lifting restriction that accompanies a TEA, but it is less reliable for long-term pain relief. Infection after TEA remains a concern and is more common when this procedure is performed to address inflammatory arthritis and not posttraumatic sequelae. Persistent wound drainage after TEA is highly suggestive of a deep infection and is predictive of eventual component resection. However, TEA longevity is superior when performed to address inflammatory arthritis.

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RESPONSES FOR QUESTIONS 60 THROUGH 66

  1. Initial period of sling immobilization followed by physical therapy

  2. Open reduction and internal fixation with or without bone grafting

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Hemiarthroplasty

  5. Unconstrained (TSA)

  6. Closed reduction and Kirschner wire (K-wire) stabilization

 

Match the treatment listed above with the clinical scenario described below.

Question 60 of 100

A 70-year-old woman with a 4-part proximal humerus fracture dislocation and history of failed rotator cuff repair

  1. Initial period of sling immobilization followed by physical therapy

  2. Open reduction and internal fixation with or without bone grafting

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Hemiarthroplasty

  5. Unconstrained (TSA)

  6. Closed reduction and Kirschner wire (K-wire) stabilization

 

PREFERRED RESPONSE: 3- Reverse total shoulder arthroplasty (rTSA)

 

Question 61 of 100

A 35-year-old man with a 2-part anterior proximal humerus fracture-dislocation

  1. Initial period of sling immobilization followed by physical therapy

  2. Open reduction and internal fixation with or without bone grafting

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Hemiarthroplasty

  5. Unconstrained (TSA)

  6. Closed reduction and Kirschner wire (K-wire) stabilization

 

PREFERRED RESPONSE: 2- Open reduction and internal fixation with or without bone grafting

 

Question 62 of 100

A 55-year-old man with a 4-part proximal humerus fracture with intra-articular comminution and a large greater tuberosity fragment

  1. Initial period of sling immobilization followed by physical therapy

  2. Open reduction and internal fixation with or without bone grafting

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Hemiarthroplasty

  5. Unconstrained (TSA)

  6. Closed reduction and Kirschner wire (K-wire) stabilization

 

PREFERRED RESPONSE: 4- Hemiarthroplasty

 

Question 63 of 100

A 37-year-old man with an irreducible posterior 2-part proximal humerus fracture dislocation

  1. Initial period of sling immobilization followed by physical therapy

  2. Open reduction and internal fixation with or without bone grafting

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Hemiarthroplasty

  5. Unconstrained (TSA)

  6. Closed reduction and Kirschner wire (K-wire) stabilization

 

PREFERRED RESPONSE: 2- Open reduction and internal fixation with or without bone grafting

 

Question 64 of 100

A 65-year-old woman with a nondisplaced surgical neck proximal humerus fracture

  1. Initial period of sling immobilization followed by physical therapy

  2. Open reduction and internal fixation with or without bone grafting

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Hemiarthroplasty

  5. Unconstrained (TSA)

  6. Closed reduction and Kirschner wire (K-wire) stabilization

 

PREFERRED RESPONSE: 1- Initial period of sling immobilization followed by physical therapy

 

Question 65 of 100

A 75-year-old man with a 4-part proximal humerus fracture and comminuted tuberosities

  1. Initial period of sling immobilization followed by physical therapy

  2. Open reduction and internal fixation with or without bone grafting

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Hemiarthroplasty

  5. Unconstrained (TSA)

  6. Closed reduction and Kirschner wire (K-wire) stabilization

 

PREFERRED RESPONSE: 3- Reverse total shoulder arthroplasty (rTSA)

 

Question 66 of 100

A 50-year-old woman with a 2-part surgical neck proximal humerus fracture and metaphyseal comminution

  1. Initial period of sling immobilization followed by physical therapy

  2. Open reduction and internal fixation with or without bone grafting

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Hemiarthroplasty

  5. Unconstrained (TSA)

  6. Closed reduction and Kirschner wire (K-wire) stabilization

 

PREFERRED RESPONSE: 2- Open reduction and internal fixation with or without bone grafting

DISCUSSION

Proximal humerus fractures account for approximately 5% of all fractures, with incidence increasing to reflect an aging population and related osteoporosis. Treatment is dependent upon the mechanism of injury, the patient’s physiologic age and activity level, the fracture pattern, and rotator cuff integrity. Most of these injuries are nondisplaced or minimally displaced and are associated with a good overall prognosis with nonsurgical treatment and temporary impairment. A patient with a nondisplaced surgical neck fracture should be treated without surgery. K-wire stabilization, although technically difficult to achieve, is an option for compliant patients with 2-part, 3-part, and valgus-impacted 4-part fractures who have adequate bone stock. Valgus-impacted 4-part fractures pose reduced risk for osteonecrosis because of the preserved blood supply through the medial hinge, which allows for this technique. For displaced 2-part fractures accompanied by

metaphyseal comminution, K-wire fixation cannot provide adequate stability to initiate a graduated home exercise or outpatient physical therapy program. Formal open reduction with intramedullary or plate fixation in addition to bone grafting (fibular strut allograft) is the best surgical option for the clinical scenario involving a displaced surgical neck fracture with comminution. Osteosynthesis of 3-part fractures may be feasible for physiologically young and active patients without humeral head involvement and osteoporosis.

Current indications for primary hemiarthroplasty include most 4-part fractures, 3-part fractures and dislocations in elderly patients with osteoporotic bone, head-splitting articular segment fractures, and chronic anterior or posterior humeral head dislocations with more than 40% of articular surface involvement. Because of the intra-articular nature of this patient’s 4-part injury in this scenario, hemiarthroplasty with anatomic reconstruction of the greater and lesser tuberosities is most appropriate. Relative indications for hemiarthroplasty also include fractures with more than 20 degrees of varus, associated moderate to severe osteopenia, and revision surgery for failed osteosynthesis. Currently accepted indications for rTSA include scenarios in which the fracture pattern, level of comminution, bone quality, and rotator cuff deficiency preclude plate fixation or hemiarthroplasty. Scenarios involving 4-part fractures and associated rotator cuff tears and tuberosity comminution are best served with a reverse shoulder prosthesis. One of the positive attributes of this implant is the ability to achieve functional forward flexion and abduction regardless of tuberosity healing, position, and degree of comminution. Caution is warranted with this surgical technique because complication rates are higher than for hemiarthroplasty reconstruction. Acute, irreducible 2-part fracture-dislocations of the proximal humerus necessitate open reduction and internal fixation of the affected tuberosities (posterior, lesser tuberosity; anterior, greater tuberosity) through screw, anchor, and/or suture fixation. These fracture-dislocations can be managed with this technique because of the integrity of the vascular supply, which is maintained by the soft-tissue attachments to the intact tuberosities. Repeated attempts at a closed reduction in the 37-year-old with the posterior fracture-dislocation could result in neurovascular injury and myositis ossificans and should be avoided. Arthroplasty reconstruction in this scenario should not be the index procedure in light of concerns regarding implant survivorship in patients of this age and their assumed elevated activity levels.

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CLINICAL SITUATION FOR QUESTIONS 79 THROUGH 81

Figure 79 is the radiograph of a 65-year-old active, right-hand-dominant woman with a 6-month history of right shoulder pain, motion loss, and progressive weakness after undergoing a hemiarthroplasty to address osteoarthritis 1 year ago. She denies recent trauma to her right shoulder and denies constitutional symptoms. Her surgical wound site is benign. She can actively forward flex to 90 degrees and abduct to 60 degrees. Passive forward flexion and abduction are 150 degrees and 90 degrees, respectively.

 

 

 

Question 79 of 100

What is the most likely cause of her symptoms?

  1. Infection

  2. Rotator cuff tear

  3. Implant loosening

  4. Implant instability

     

    PREFERRED RESPONSE: 2- Rotator cuff tear

     

    Question 80 of 100

    She completes the necessary testing and wishes to proceed with revision surgery. The most appropriate surgical option in this scenario involves implant removal and

    1. unconstrained total shoulder arthroplasty (TSA).

    2. resection arthroplasty.

    3. reverse total shoulder arthroplasty (rTSA).

    4. hemiarthroplasty.

PREFERRED RESPONSE: 3- reverse total shoulder arthroplasty (rTSA).

 

Question 81 of 100

Intraoperative frozen section analysis reveals 10 neutrophils per high-power field and a positive gram stain result. What is the best next step?

  1. Implant removal, irrigation and debridement, and resection arthroplasty

  2. Implant removal, irrigation and debridement, and rTSA

  3. Implant removal, irrigation and debridement, and revision hemiarthroplasty

  4. Implant removal, irrigation and debridement, and antibiotic cement spacer placement

 

PREFERRED RESPONSE: 4- Implant removal, irrigation and debridement, and antibiotic cement spacer placement

DISCUSSION

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

In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion to rTSA Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be reserved for recalcitrant cases of infection because this procedure does not provide functional improvement.

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

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RESPONSES FOR QUESTIONS 89 THROUGH 96

  1. Humeral head resurfacing/shoulder hemiarthroplasty

  2. Anatomic total shoulder arthroplasty (TSA)

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Rotator cuff repair

  5. Open reduction and internal fixation (ORIF)

Which intervention listed above is most appropriate to address each scenario described below? When chronic conditions are described, nonsurgical interventions such as physical therapy, anti-inflammatory medications, and corticosteroid injections have been exhausted.

 

Question 89 of 100

A 62-year-old man experiences pain in his right shoulder (Figures 89a through 89c).

  1. Humeral head resurfacing/shoulder hemiarthroplasty

  2. Anatomic total shoulder arthroplasty (TSA)

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Rotator cuff repair

  5. Open reduction and internal fixation (ORIF)

 

 

 

 

PREFERRED RESPONSE: 2- Anatomic total shoulder arthroplasty (TSA)

 

Question 90 of 100

A 58-year-old man has right shoulder pain. An examination reveals full range of motion in all planes but 4/5 forward elevation strength (Figures 90a and 90b).

 

 

 

  1. Humeral head resurfacing/shoulder hemiarthroplasty

  2. Anatomic total shoulder arthroplasty (TSA)

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Rotator cuff repair

  5. Open reduction and internal fixation (ORIF)

PREFERRED RESPONSE: 4- Rotator cuff repair

 

Question 91 of 100

A 78-year-old woman with an acute shoulder injury (Figures 91a and 91b).

 

 

 

  1. Humeral head resurfacing/shoulder hemiarthroplasty

  2. Anatomic total shoulder arthroplasty (TSA)

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Rotator cuff repair

  5. Open reduction and internal fixation (ORIF)

 

PREFERRED RESPONSE: 3- Reverse total shoulder arthroplasty (rTSA)

 

Question 92 of 100

A 55-year-old man experiences right shoulder pain 2 years after undergoing hemiarthroplasty for osteoarthritis. His laboratory values indicate normal C-reactive protein, erythrocyte sedimentation rate, and white blood cell count levels. He undergoes a shoulder aspiration and culture and an arthroscopic biopsy; all findings are negative. Belly-press and bear-hug test results are normal (Figures 92a and 92b).

  1. Humeral head resurfacing/shoulder hemiarthroplasty

  2. Anatomic total shoulder arthroplasty (TSA)

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Rotator cuff repair

  5. Open reduction and internal fixation (ORIF)

 

 

 

PREFERRED RESPONSE: 2- Anatomic total shoulder arthroplasty (TSA)

 

Question 93 of 100

A 72-year-old woman experiences left shoulder pain and dysfunction. An examination demonstrates 45 degrees of active forward elevation with 2/5 strength. The deltoid fires in the anterior, middle, and posterior heads (Figure 93).

 

 

 

  1. Humeral head resurfacing/shoulder hemiarthroplasty

  2. Anatomic total shoulder arthroplasty (TSA)

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Rotator cuff repair

  5. Open reduction and internal fixation (ORIF)

 

PREFERRED RESPONSE: 3- Reverse total shoulder arthroplasty (rTSA)

 

Question 94 of 100

A 40-year-old male laborer with an acute left shoulder injury (Figures 94a and 94b).

 

 

 

  1. Humeral head resurfacing/shoulder hemiarthroplasty

  2. Anatomic total shoulder arthroplasty (TSA)

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Rotator cuff repair

  5. Open reduction and internal fixation (ORIF)

 

PREFERRED RESPONSE: 5- Open reduction and internal fixation (ORIF)

 

Question 95 of 100

A 71-year-old woman has had 2 previous rotator cuff repairs to her right shoulder. An examination reveals 70 degrees of active forward elevation and 3/5 strength. An infection workup is negative (Figures 95a through 95c).

 

 

 

 

  1. Humeral head resurfacing/shoulder hemiarthroplasty

  2. Anatomic total shoulder arthroplasty (TSA)

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Rotator cuff repair

  5. Open reduction and internal fixation (ORIF)

 

PREFERRED RESPONSE: 3- Reverse total shoulder arthroplasty (rTSA)

 

Question 96 of 100

A 35-year-old active woman with rheumatoid arthritis experiences right shoulder pain following an extended course of corticosteroids (Figures 96a and 96b).

 

 

 

  1. Humeral head resurfacing/shoulder hemiarthroplasty

  2. Anatomic total shoulder arthroplasty (TSA)

  3. Reverse total shoulder arthroplasty (rTSA)

  4. Rotator cuff repair

  5. Open reduction and internal fixation (ORIF)

 

PREFERRED RESPONSE: 1- Humeral head resurfacing/shoulder hemiarthroplasty

DISCUSSION

The indication for anatomic TSA is end-stage glenohumeral arthritis with an intact rotator cuff. For the 62-year-old man, his radiographs reveal osteoarthritis, and his MR image shows an intact rotator cuff. Although humeral head replacement has historically been employed for this disorder, pain relief is not as reliable as with TSA, and the revision rate is higher. rTSA is generally reserved for patients with a nonfunctional rotator cuff.

For this 58-year-old patient with a full-thickness rotator cuff tear, preserved motion, and weakness in forward elevation, a rotator cuff repair is the most appropriate treatment. In the absence of degenerative changes, shoulder hemiarthroplasty or anatomic TSA is not indicated. Although indications for rTSA continue to evolve, well-compensated range of motion and a medium-sized rotator cuff tear in a younger patient are not among them.

rTSA is an emerging treatment for comminuted proximal humerus fractures in elderly patients. Although hemiarthroplasty has been a traditional treatment, current evidence suggests rTSA more reliably restores range of motion, and this 78-year-old patient's CT scan shows a small and comminuted greater tuberosity fragment that is unlikely to heal. ORIF is another option, but the CT scan also shows a small humeral head fragment that suggests osteopenia, making fixation more tenuous and likely less reliable.

A common problem associated with hemiarthroplasty for glenohumeral osteoarthritis is symptomatic glenoid degeneration that necessitates revision. This 55-year-old patient’s images reveal this is the case, although his infection workup is negative. His examination findings suggest an intact subscapularis repair. With a functioning rotator cuff and symptomatic glenoid arthritis, a conversion to anatomic TSA is indicated. In the absence of a functioning rotator cuff in an older patient, an rTSA is a better option.

This 72-year-old patient has classic symptoms and radiographs of cuff tear arthropathy. For patients with massive rotator cuff tear and glenohumeral arthritis, neither anatomic TSA nor rotator cuff repair is indicated. Hemiarthroplasty has historically been indicated for cuff tear arthropathy, but rTSA outcomes for this disorder have been superior and are now the preferred option.

Comminuted proximal humerus fractures in young, active patients are treated primarily with ORIF. The absence of glenohumeral arthritis removes anatomic TSA as a possibility, and concerns about implant longevity in younger, active patients such as this 40-year-old laborer contraindicate rTSA. Hemiarthroplasty is still employed in 3- and 4-part fractures but is generally reserved for subacute presentations or dislocations in which the humeral head is dysvascular and unlikely to survive. In this acute setting, a fixation procedure is preferred.

The 71-year-old patient who has had 2 failed rotator cuff repairs has an MR image that reveals another recurrent tear that is retracted to the glenoid. Her examination findings reveal classic signs

of a decompensated rotator cuff tear with pseudoparalysis and weakness in forward elevation. Although infection is a concern in the setting of multiply failed rotator cuff repair, the workup is negative in this scenario. Because this patient has a dysfunctional rotator cuff and has failed previous attempts at repair, a conversion to rTSA is the better option. In the absence of degenerative changes, hemiarthroplasty and anatomic TSA are not indicated.

The indications for hemiarthroplasty continue to narrow, but it is still a consideration for young patients with unipolar shoulder degeneration. In this 35-year-old patient, her MR image shows avascular necrosis in the humeral head, and her arthroscopy suggests arthritic change only on the humeral side with an uncompromised glenoid. To best treat young and active patients, a hemiarthroplasty that articulates with healthy glenoid cartilage can provide good pain relief and functional outcomes. Anatomic TSA is also reasonable but not an optimal option considering the normal glenoid condition. rTSA is not a consideration when a young patient’s MR images reveal an intact rotator cuff.

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