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Shoulder & Hip Sports MCQs

Practice Set 21 of 142

This practice set contains high-yield board review questions covering key concepts in Shoulder & Hip Sports. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 401

Topic: Shoulder & Hip Sports

Figures 25a and 25b show the clinical photographs of a 19-year-old baseball outfielder who has shoulder pain after sliding headfirst into second base. He reports pain while batting, sliding, and catching. Examination reveals a posterior prominence during midranges of forward elevation, which then disappears with a palpable clunk during terminal elevation and abduction. What is the most likely diagnosis?

. Superior labrum anterior and posterior (SLAP) lesion
. Bankart lesion
. Rotator cuff interval tear
. Rotator cuff tendinitis
. Posterior glenohumeral subluxation

Correct Answer & Explanation

. Superior labrum anterior and posterior (SLAP) lesion

Explanation

DISCUSSION: A headfirst slide with the arm extended can injure the posterior shoulder.  Winging of the scapula is dynamic and is considered a compensatory effort to prevent subluxation; it is not related to nerve injury.  Posterior glenohumeral subluxation can be present during the initiation of a bat swing.  Rotator cuff function, interval tears, and superior labrum tears can be painful but do not produce winging.REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging.  J Am Acad Orthop Surg 1995;3:319-325.Fiddian NJ, Kling RJ: The winged scapula.  Clin Orthop 1984;185:228-236.

Question 402

Topic: Shoulder & Hip Sports

Internal impingement is characterized by which of the following anatomic lesions? Review Topic

. Subscapularis tear
. Bursal-sided rotator cuff tear
. Articular-sided rotator cuff tear
. Tight anterior capsule
. Laxity of the posterior capsule

Correct Answer & Explanation

. Subscapularis tear

Explanation

Internal impingement is characterized by articular-sided partial-thickness rotator cuff tears and superior glenoid labral tears. The capsule is characterized by laxity anteriorly and tightness posteriorly.

Question 403

Topic: Shoulder & Hip Sports

Figures 71a and 71b/ are the MR images of a 65-year-old man who dislocated his shoulder. What is his most likely chief symptom?

. Numbness in the anterior aspect of his shoulder
. Recurrent instability
. Difficulty raising his arm
. Biceps muscle deformity

Correct Answer & Explanation

. Numbness in the anterior aspect of his shoulder

Explanation

DISCUSSIONThis patient has a massive rotator cuff tear resulting in disruption of the transverse force couple between the subscapularis anteriorly and the infraspinatus and teres minor posteriorly. These muscles provide dynamic shoulder stability throughout active elevation. Loss of the force couple produces a pathologic increase in translation of the humeral head and decreased active abduction and external rotation, which results in difficulty raising an arm. The most common neurologic deficit after shoulder dislocation is isolated injury to the axillary nerve that supplies sensation to the lateral aspect of the shoulder, not the anterior aspect. Recurrent instability is uncommon unless there is a labral tear or massive subscapularis tear. The biceps muscle is not viewed in the MR images, and a complete proximal biceps tendon rupture would be uncommon in the setting of an anterior shoulder dislocation.CLINICAL SITUATION FOR QUESTIONS 72 THROUGH 75Figures 72a through 72e are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0 degreesto 90 degrees and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

Question 404

Topic: Shoulder & Hip Sports

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

. Abundance of basic calcium phosphate crystals
. Abundance of calcium pyrophosphate crystals
. Gout
. Rheumatoid arthritis
. Osteonecrosis

Correct Answer & Explanation

. Abundance of basic calcium phosphate crystals

Explanation

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.

Question 405

Topic: Shoulder & Hip Sports

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

. Axillary nerve injury
. Anterior dislocation
. Extension of a chronic large rotator cuff tear
. Suprascapular nerve entrapment from a ganglion cyst
. Greater tuberosity avulsion

Correct Answer & Explanation

. Axillary nerve injury

Explanation

DISCUSSION: The MRI scan reveals a large chronic rotator cuff tear with retraction and fatty infiltration atrophy of the supraspinatus and infraspinatus tendons.  This tear is responsible for the patient’s severe weakness and inability to elevate the arm.REFERENCE: Gerber C, Myer DC, Schneeberger AG, et al: Effect of tendon release and delayed repair on the structure of the muscles of the rotator cuff: An experimental study in sheep.  J Bone Joint Surg Am 2004;86:1973-1982.

Question 406

Topic: Shoulder & Hip Sports

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with Review Topic

. an avulsion of the lesser tuberosity.
. a midsubstance tear of the capsule.
. a tear of the anterior inferior labrum.
. a tear of the subscapularis.
. a tear of the humeral insertion of the inferior glenohumeral ligament.

Correct Answer & Explanation

. an avulsion of the lesser tuberosity.

Explanation

An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals.

Question 407

Topic: Shoulder & Hip Sports

A 20-year-old man reports painless snapping about the lateral aspect of the right hip. He denies any history of trauma. Examination reveals no limp or tenderness. Hip range of motion is full, and there is good strength. Radiographs are normal. What anatomic structure is most likely causing these symptoms?

. Acetabular labrum
. Iliopsoas
. Loose body
. Piriformis
. Iliotibial band

Correct Answer & Explanation

. Acetabular labrum

Explanation

DISCUSSION: Coxa saltans (snapping hip syndrome) can occur in two forms: external/lateral or interior/medial/anterior.  This patient has the external/lateral form.  The external/lateral form involves the iliotibial band, tensor fascia, or gluteus medius, which snaps over the greater trochanter.  The external form usually can be treated with physical therapy alone; however, several recent studies report satisfactory results with surgical treatment.  Faraj and associates reported good results from surgical Z-plasty in a series of 10 patients.  White and associates reported good results in a series of 16 patients with 17 hips who underwent surgical release of an external snapping hip.  The interior/medial/anterior form can involve the iliopsoas tendon, acetabular labrum, subluxation of the hip, and loose bodies.REFERENCES: White RA, Hughes MS, Burd T, et al: A new operative approach in the correction of external coxa saltans: The snapping hip.  Am J Sports Med 2004;32:1504-1508.Faraj AA, Moulton A, Sirivastava VM: Snapping iliotibial band: Report of ten cases and review of the literature.  Acta Orthop Belg 2001;67:19-23.Choi YS, Lee SM, Song BY, et al: Dynamic sonography of external snapping hip syndrome.J Ultrasound Med 2002;21:753-758.

Question 408

Topic: Shoulder & Hip Sports

A 24-year-old avid volleyball player has noted gradual onset of shoulder fatigue and weakness limiting his game. Radiographs done by his primary care physician were normal and he has failed to improve with 6 weeks of physical therapy. Given the MRI image shown in Figure A, this patients physical exam may reveal weakness with which of the following actions? Review Topic

. Adduction
. Internal rotation
. Abduction and external rotation
. Abduction
. External rotation

Correct Answer & Explanation

. Adduction

Explanation

The MRI demonstrates of a ganglion cyst within the suprascapular notch, leading to atrophy of both the supraspinatus and infraspinatus. Thus, the patient would have weakness with both abduction and external rotation.Extrinsic compression or traction on the suprascapular nerve can result in suprascapular neuropathy. Compression of the nerve may occur at two distinct locations: the suprascapular notch and the spinoglenoid notch. Extrinsic compression of the suprascapular nerve by ganglion cysts can occur at the spinoglenoid notch or, less commonly, at the suprascapular notch. These cysts may originate from the transverse scapular ligament, the fibrous tissue of the scapula, or the glenohumeral joint.Mittal et al. reviewed the literature and found that the formation of ganglionic cysts in the spinoglenoid fossa occurs with cumulative trauma and leads to entrapment neuropathy of the suprascapular nerve and denervation of the infraspinatus muscle.Romeo et al. reported on various etiologies of suprascapular neuropathy including traction injury at the level of the transverse scapular ligament or the spinoglenoid ligament and direct trauma to the nerve. They noted that sports involving overhead motion, such as tennis, swimming, and weight lifting, may result in traction injury to the suprascapular nerve, leading to dysfunction. They also reported that the onset of weakness can be subtle and must be differentiated from cervical radiculopathy and degenerative disease of the shoulder.Figure A depicts a T2 coronal MRI of the shoulder with a cyst easily visualized occupying the suprascapular notch. Illustration A is an algorithm for the management of suprascapular neuropathy. Illustration B is a sagittal MRI from the same patient depicting the ganglion cyst within the suprascapular notch once again leading to atrophy of both the supraspinatus and infraspinatus (asterisks).Incorrect Answers:

Question 409

Topic: Shoulder & Hip Sports

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

. Restore normal humeral head glenoid contact location
. Restore full active overhead motion
. Restore proper glenoid version with bone preparation and use of a cemented glenoid component
. Achieve formal decompression and acromioplasty with resection of the coracoacromial ligament and distal clavicle
. Achieve a secure closure of the subscapularis with an appropriate head size

Correct Answer & Explanation

. Restore normal humeral head glenoid contact location

Explanation

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.

Question 410

Topic: Shoulder & Hip Sports

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable. If present, what is the most likely complication after surgical treatment in this scenario?

. Recurrent instability
. Degenerative joint disease
. Shoulder stiffness
. Axillary nerve injury

Correct Answer & Explanation

. Recurrent instability

Explanation

Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through, as seen in this patient. The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation. This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate. The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instabilityand         degenerative         joint         disease.

Question 411

Topic: Shoulder & Hip Sports

Figure 53 shows the MRI scan of a 53-year-old carnival worker who has pain and swelling in the left shoulder as a result of attempting to stop a roller coaster car with his arm. Examination reveals decreased ROM, apprehension, and inability to move the dorsum of his hand away from his back. Treatment should consist of

. open acromioplasty
. open Bankart repair
. open subscapularis tendon repair
. inferior capsular shift
. a supervised physical therapy program

Correct Answer & Explanation

. open acromioplasty

Explanation

This patient has an acute tear of the subscapularis tendon both by MRI and physical exam. Treatment of choice is open repair. Nonoperative treatment is not indicated.

Question 412

Topic: Shoulder & Hip Sports

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

. Size of the tear
. Age of the patient
. Arm dominance
. Rupture of the long head of the biceps
. Preoperative pain score

Correct Answer & Explanation

. Size of the tear

Explanation

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.

Question 413

Topic: Shoulder & Hip Sports

A 40-year-old female recreational basketball player notes pain deep within her shoulder that occurs with activity. Pain began insidiously 6 months previously. She has completed a physical therapy program, and an intra-articular corticosteroid injection provided excellent temporary relief. Physical examination shows symmetric range of motion of her shoulder. She has a positive O'Brien’s active compression test. There is no pain with cross-arm adduction or tenderness to palpation over the acromioclavicular joint.  Resisted abduction is  nonpainful and strong. MRI shows increased signal in the substance of the superior labrum, low-grade bursal surface fraying of the supraspinatus, and mild degenerative changes within the acromioclavicular joint. What is the best treatment option?

. Biceps tenodesis
. Superior labrum anterior to posterior (SLAP) repair
. Rotator cuff repair
. Distal clavicle excisionThe patient has a clinical history and physical examination consistent with degenerative superior labral pathology, which is supported by the MRI scan. She has failed appropriate nonoperative treatment, and surgical intervention would be indicated. In a middle-aged patient with a degenerative superior labral tear, biceps tenodesis has been shown to have better outcomes and return to sport than SLAP repair. In a young patient with a traumatic superior labral tear, repair would be indicated. The other MRI findings noted are incidental and asymptomatic in this patient. As a result, rotator cuff repair or distal clavicle excision is not indicated.

Correct Answer & Explanation

. Biceps tenodesis

Explanation

A 50-year-old man sustained an external rotation traction injury to his right arm. He felt a pop in the anterior aspect of his shoulder associated with immediate pain and swelling. The MRI scan shows a tear of the subscapularis tendon, as shown in Figures 1 and 2. The arrow points to what anatomic structure?

Question 414

Topic: Shoulder & Hip Sports

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

. Physical therapy with electrical stimulation and iontophoresis
. Corticosteroid injection
. MRI of the shoulder
. Electromyography (EMG) of the arm

Correct Answer & Explanation

. Physical therapy with electrical stimulation and iontophoresis

Explanation

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

Question 415

Topic: Shoulder & Hip Sports

A 22-year-old volleyball player reports the insidious onset of superior and posterior shoulder pain. Radiographs are normal. An MRI scan is shown in Figure 25. What is the most specific physical examination finding?

. Positive impingement sign
. Positive apprehension
. Positive active compression
. Weakness of external rotation
. Weakness of abduction

Correct Answer & Explanation

. Positive impingement sign

Explanation

DISCUSSION: Overhead athletes are prone to a number of problems involving the shoulder.  Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement.  These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test.  Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan.  These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation.REFERENCES: Romeo AA, Rotenberg DD, Bach BR Jr: Suprascapular neuropathy.  J Am Acad Orthop Surg 1999;7:358-367.Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment.  J Bone Joint Surg Am 2000;82:415-424.

Question 416

Topic: Shoulder & Hip Sports

What structure provides the major blood supply to the humeral head?

. Posterior circumflex humeral artery
. Anterior circumflex humeral artery, ascending branch
. Nutrient humeral artery
. Thoracoacromial artery, deltoid branch
. Small arteries of the rotator cuff insertions

Correct Answer & Explanation

. Posterior circumflex humeral artery

Explanation

DISCUSSION: The ascending branch of the anterior circumflex humeral artery providesthe major blood supply to the humeral head.  The posterior circumflex humeral arterysupplies a much smaller portion of the proximal humerus.  The nutrient humeral artery is the main blood supply for the humeral shaft.  The thoracoacromial artery is primarily a muscular branch.  The rotator cuff insertions contribute some blood supply to the tuberosities but not a major contribution.REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.Cushner MA, Friedman RJ: Osteonecrosis of the humeral head.  J Am Acad Orthop Surg 1997;5:339-346.

Question 417

Topic: Shoulder & Hip Sports

A 27-year-old man has recurrent anterior shoulder instability following an arthroscopic Bankart repair 4 years ago. Current CT scans are shown in Figures 19a and 19b. Deficiency of what mechanism is most likely to contribute to the current joint instability? Review Topic

. Synovial fluid adhesion-cohesion
. Negative intra-articular pressure
. Concavity-compression of the humeral head in the glenoid
. Decreased functional arc of motion as a result of a Hill-Sachs lesion
. Poor rehabilitation of scapulothoracic rhythm

Correct Answer & Explanation

. Synovial fluid adhesion-cohesion

Explanation

Loss of the anterior glenoid rim can commonly occur as a result of acute fracture or progressive wear following multiple dislocations. This decreases the effective depth of the glenoid. The ability of the rotator cuff to stabilize the joint through production of a joint reactive force is markedly decreased. Synovial fluid adhesion-cohesion and negative intra-articular pressure are maintained in the closed capsular space. The Hill-Sachs lesion in this case is not large enough to be a significant factor in failed Bankart repair. Poor scapulothoracic rhythm can increase the risk of instability but is not typically the primary factor.

Question 418

Topic: Shoulder & Hip Sports
  • Figures 38a & 38b show radiographs of a 40 year old man who underwent a Putti-Platt repair for recurrent dislocations at age 22. He reports increasing pain in the shoulder and limited motion for five years. Examination reveals 130 degrees of elevation and 15 degrees of external rotation. Non-surgical treatment has failed. Treatment should now consist of what?

. Manipulation Under Anesthesia
. Arthroscopic acromioplasty
. Arthroscopic debridement of G-H joint
. Replacement of the humeral head
. Lengthening of the subscapularis and release of the anterior capsule

Correct Answer & Explanation

. Manipulation Under Anesthesia

Explanation

[Radiograph: Well positioned G-H joint. Mild degenerative changes.]Late onset of pain (average 13 years) was noted following this procedure in a small number of patients. The pain is attributed to excessive G-H compressive forces due to limited external rotation. NSAIDS and PT are first line treatments. If these fail, the authors demonstrated good results with release of the anterior structures. Choices 3 & 4 would probably be reserved for patients older than 50 with more advanced signs of degenerative disease.

Question 419

Topic: Shoulder & Hip Sports

A 23-year-old man reports a 6-year history of recurrent instability in the right dominant shoulder. He has not undergone surgery and has essentially stopped all of his sporting activities. On examination, he has instability and apprehension in the midrange of motion (abduction of 45 to 60 degrees with external rotation) and a palpable clunk representing a transient dislocation over the anterior glenoid rim. A three-dimensional CT scan is shown in Figure 31. What is the most appropriate surgical intervention to provide him with reliable stability postoperatively? Review Topic

. Arthroscopic Bankart surgery
. Bony glenoid augmentation procedure
. Subscapularis advancement
. Open capsular shift
. Hemiarthroplasty

Correct Answer & Explanation

. Arthroscopic Bankart surgery

Explanation

In the setting of significant anteroinferior glenoid bone deficiency (greater than 20% to 25%), both open and arthroscopic Bankart repairs have demonstrated higher rates of failure. Bony glenoid augmentation procedures such as the Bristow-Latarjet, which describe coracoid transfers to reconstruct the deficient glenoid, have led to decreased rates of recurrent shoulder instability. In this scenario, the patient has a significant loss of glenoid bone. There are also several clues in the history to suspect bone deficiency: multiple recurrences, a long history of recurrence, and instability in the midranges of motion. A bony augmentation procedure such as the Latarjet has been well-described to provide a well functioning and stable shoulder joint. A hemiarthroplasty is not indicated in the absence of arthritis. Subscapularis advancement will not address the bone loss.

Question 420

Topic: Shoulder & Hip Sports

An otherwise healthy 30-year-old man undergoes right shoulder arthroscopic Bankart repair under regional anesthesia using an interscalene brachial plexus block. In the recovery room, he reports mild difficulty breathing and his chest radiograph shows a high riding diaphragm on the right side. His peripheral oxygenation is 97% on 2 liters of oxygen by nasal cannula. What is the most appropriate management?

. Continued observation and monitoring
. Obtain arterial blood gas measurements
. Obtain emergent spiral CT scan to assess for pulmonary embolism
. Insertion of a chest tube
. Airway control and, if necessary, endotracheal intubation

Correct Answer & Explanation

. Continued observation and monitoring

Explanation

Because the phrenic nerve lies in close proximity to the site of anesthetic injection, temporary hemidiaphragmatic paresis is a very common side effect of interscalene brachial plexus block. Pulmonary function and chest wall mechanics may be slightly compromised, but can easily be compensated in a healthy patient. Therefore, with sufficient oxygenation, aggressive assessments or treatments such as arterial blood gas measurements, emergent spiral CT scans, chest tube insertions, or endotracheal intubation are not warranted. For this stable patient, continued monitoring with gradual withdrawal of oxygen is the most appropriate treatment.

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