This practice set contains high-yield board review questions covering key concepts in 9. Shoulder and Elbow. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 841
Topic: 9. Shoulder and Elbow
Initial management should consist of Review Topic
Correct Answer & Explanation
. cessation of throwing activities.
Explanation
The radiograph shows osteochondritis dissecans (OCD) of the capitellum, one manifestation of “pitcher’s elbow.” The lesion is nondisplaced, and healing is possible if the inciting throwing activities are curtailed. Long arm cast treatment may be reasonable for the noncompliant patient but should not exceed 6 weeks duration. Surgical treatment is indicated for loose bodies or cartilage flaps. Elbow OCD lesions are now being seen in younger children as more participate in organized sports, especially baseball and gymnastics.
Question 842
Topic: 9. Shoulder and Elbow
A 35-year-old man who is an avid weight lifter competing in local tournaments reports new onset pain and loss of motion in his dominant right shoulder. Examination reveals joint line tenderness, active elevation to 100 degrees, and external rotation to 10 degrees. His contralateral shoulder reveals 170 degrees forward elevation and 50 degrees external rotation. Radiographs are shown in Figures 46a and 46b. What is the next most appropriate step in management? Review Topic
Correct Answer & Explanation
. Anti-inflammatory drugs and a range-of-motion stretching program
Explanation
New onset pain and stiffness in the young arthritic shoulder is a difficult problem to treat. Initial management should be aimed at reducing pain and improving motion in all planes. This patient’s activities and age preclude a shoulder arthroplasty at this time. If nonsurgical management fails to provide relief, then arthroscopic debridement and capsular release may be beneficial.
Question 843
Topic: Elbow & Forearm
What is the most common site of nerve compression in radial tunnel syndrome?
Correct Answer & Explanation
. Proximal aponeurotic edge of the supinator (arcade of Frohse)Radial tunnel syndrome occurs as the result of radial nerve compression at 5 potential sites. These are the fibrous bands anterior to the radiocapitellar joint, the radial recurrent vessels (known as the leash of Henry), the medial edge of the ECRB, the proximal aponeurotic edge of the supinator (arcade of Frohse), and the distal edge of the supinator. The arcade of Frohse is the most common site of compression. The chief discomfort is deep, aching pain in the dorsoradial proximal forearm. Motor and sensory symptoms usually are absent. This condition often is seen when pain persists after surgery for lateral epicondylitis. Lateral epicondylitis and radial tunnel syndrome coexist 5% of the time.Examination findings are tenderness 4 cm distal to the lateral epicondyle, pain with resisted supination, and pain with resisted long finger extension. Electromyogram/nerve conduction study and MRI results usually are normal. A steroid injection can be diagnostic and also may provide temporary relief of symptoms. Surgery involves decompression of all potential areas of compression and allows good to excellent results in only 50% to 90% of cases. Symptoms may take 9 to 18 months to resolve after surgery.
Explanation
A 25-year-old man has an isolated flexor digitorum profundus laceration just proximal to the distal interphalangeal (DIP) flexion crease of his ring finger. The tendon ends are trimmed, removing 10 mm from each end (secondary to fraying) and the tendon repaired. Four months later, he reports limited finger motion of the long, ring, and small fingers. He cannot fully extend his wrist and all joints of the 3 fingers simultaneously. He has full passive flexion but cannot actively completely close his fingers into a fist. What is the most likely cause?A. QuadrigiaB. Intrinsic tightnessC. Lumbrical plus deformityD. Disruption of the tendon repai
Question 844
Topic: 9. Shoulder and Elbow
An 11-year-old boy has right shoulder pain and has been unwilling to use the arm after throwing a baseball in a Little League game 3 weeks ago. Examination reveals upper arm and shoulder tenderness with swelling. A radiograph and MRI scan are shown in Figures 27a and 27b. Management should consist of
Correct Answer & Explanation
. aspiration and injection with methylprednisolone.
Explanation
DISCUSSION: The radiograph is consistent with a unicameral (simple) bone cyst. The MRI scan reveals that the cyst is juxtaposed to the physis and therefore can be classified as active (latent cysts are more than 1 cm away from the physis). Active cysts are treated with aspiration and steroid injection, although repeated injections may be necessary. Curettage and bone grafting results in more reliable healing but may lead to growth arrest in active cysts. REFERENCES: Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 945-946. Malawer MM: Tumors of the shoulder girdle: Techniques of resection and description of surgical classification. Orthop Clin North Am 1991;22:7-35.
Question 845
Topic: 9. Shoulder and Elbow
In the shoulder position of 90-degree forward flexion and internal rotation, what is the most important static stabilizer of the glenohumeral joint?
Correct Answer & Explanation
. Posterior band of the inferior glenohumeral ligament
Explanation
DISCUSSION: In the position of 90 degrees forward flexion and internal rotation, the most important static stabilizer of the glenohumeral joint is the posterior band of the inferior glenohumeral ligament. This position places the posterior-inferior glenohumeral ligament in an anterior-posterior direction and under tension. The superior glenohumeral ligament and the middle glenohumeral ligament provide static stability in the fully adducted and midrange-adducted positions, respectively. The subscapularis and infraspinatus provide primarily dynamic stability to the glenohumeral joint. Though not fully clear, the rotator interval appears to provide more static stability with the arm adducted, limiting inferior and posterior translation, and less so in the forward flexion and internal rotation position.
Question 846
Topic: 9. Shoulder and Elbow
A patient undergoes an arthroscopic debridement for lateral epicondylitis. Postoperatively she reports pain and a sense of clicking of the elbow. Examination reveals apprehension to supination, load, and extension. What structure has been injured resulting in the clinical presentation?
Correct Answer & Explanation
. Lateral ulnar collateral ligament
Explanation
DISCUSSION: The patient has an iatrogenic injury to the lateral ulnar collateral ligament following the arthroscopic procedure. Failure to adhere to known anatomic landmarks can lead to this devastating complication. The examination findings are classic for posterolateral elbow instability. REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 318. O’ Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.
Question 847
Topic: 9. Shoulder and Elbow
What mechanism of injury is most likely to cause a fracture of the anteromedial facet of the coronoid?
Correct Answer & Explanation
. Varus and posteromedial rotation
Explanation
The mechanism of injury in a fracture of the anteromedial facet of the coronoid is typically a varus and posteromedial rotation force on the forearm which is the opposite of a terrible triad injury. First, the lateral collateral ligament is injured and then the medial coronoid is compressed against and then under the medial trochlea.(SBQ12TR.86) Figure A shows intraoperative radiographs of a 45-year-old patient with a left elbow injury. What would be the next most appropriate step in this patients care?Early range of motionHinged elbow brace for 4 weeksRepair lateral collateral ligamentRemove and upsize implantRemove and downsize implantThe intraoperative images are consistent with overstuffing of the ulnohumeral joint during a radial head replacement. The most appropriate next step would be removing and downsizing the implant.Overstuffing the radiohumeral joint by >2.5 mm can significantly alter elbow kinematics. It has also shown to lead to pain and early joint disease. The most sensitive method to assess for overstuffing of the joint is by direct visualisation intraoperatively. This can be performed by visualising the lateral aspect of the ulnohumeral joint when the radial head is resected and comparing this to when the trial radial head is reduced in place. In comparison, radiographic asymmetry of the medial ulnohumeral joint has been shown to be less sensitive. Radiographic findings of incongruity of ulnohumeral joint only occurs when significant overlengthening of the radius occurs.Frank et al. examined the effect of radial head thickness in seven cadaver specimens. They found that incongruity of the medial ulnohumeral joint would only become apparent radiographically after overlengthening of the radius by >or=6 mm.Doornberg et al. examined seventeen computed tomography scans of the elbow to investigate the height of the radial head relative to the lateral edge and central ridge of the coronoid process. They found that the radial head was on average only 0.9 mm more proximal than the lateral edge of the coronoid process.Figure A shows intraoperative radiographs of a patient that has undergone a radial head arthroplasty. There is significant widening of the medial ulnohumeral joint on an AP radiograph as well as widening of the ulnohumeral joint on the lateral radiograph,Incorrect Answers:
Question 848
Topic: 9. Shoulder and Elbow
.Figures 89a and 89b are the radiographs of an 18-year-old woman who has had elbow pain after falling on an outstretched hand. She is evaluated 5 days after the injury. Examination reveals the wrist is normal and her elbow has a limited arc of motion of 30 to 90 degrees of flexion/extension and 20 to 20 degrees of pronation and supination, with tenderness isolated to the lateral side of the elbow. What is the most appropriate treatment option?
Correct Answer & Explanation
. Cast for 2 weeks
Explanation
Question 849
Topic: 9. Shoulder and Elbow
A 52-year-old man has pain in the sternal area after landing on his right shoulder in a fall from his bicycle. In addition, he reports that he had difficulty swallowing and breathing immediately after the fall, but the symptoms resolved. A CT scan reveals a posterior sternoclavicular dislocation. Initial management should include:
Correct Answer & Explanation
. closed reduction under general anesthesia.
Explanation
DISCUSSION: Posterior sternoclavicular dislocations require rapid treatment because of the proximity of major neurovascular structures and the airway. Initial management should consist of closed reduction under general anesthesia in the operating room with a chest surgeon available. A successful closed reduction is usually stable. Internal fixation of sternoclavicular injuries should be avoided because of the likelihood of hardware migration and possible injury to the mediastinal structures. If closed reduction is unsuccessful, open reduction is indicated. Treatment following reduction of the sternoclavicular joint includes the application of a figure-of-8 splint and a sling for 6 weeks, followed by stretching and strengthening exercises. REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont IL, American Academy of Orthopaedic Surgeons, 1999, pp 287-297. Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, vol 2, pp 1010-1017.
Question 850
Topic: 9. Shoulder and Elbow
An extended head hemiarthroplasty (rotator cuff tear arthropathy head) has what theoretic advantage when compared to a standard hemiarthroplasty?
Correct Answer & Explanation
. Creates a metal-to-bone articulation with the acromion
Explanation
The theoretic advantage of a metal-to-bone articulation with the acromion is that there is a greater arc in which a smooth metal surface contacts the glenoid and acromion. This may improve pain and function, but no studies have evaluated this to date. One study showed results comparable to that of a standard hemiarthroplasty. There are no other biomechanic advantages.
Question 851
Topic: 9. Shoulder and Elbow
A 70-year-old woman has a preoperative anterior interscalene block prior to undergoing a total shoulder arthroplasty. After seating her in the beach chair position, she becomes acutely hypotensive. What is the most likely cause for the hypotension?
Correct Answer & Explanation
. Bezold-Jarisch reflex
Explanation
DISCUSSION: The beach chair position may cause sudden hypotension and bradycardia as a result of the Bezold-Jarisch reflex. This reflex occurs when venous pooling and increased sympathetic tone induce a low-volume, hypercontractile ventricle, resulting in activation of the parasympathetic nervous system and sympathetic withdrawal. The reported incidence of this phenomenon associated with the sitting position is between 13% to 24%. Left untreated, the result may be cardiac arrest. Pneumothorax or central nervous system toxicity after interscalene block is rare and has an incidence of less than 0.2%. Laryngeal nerve block associated with interscalene nerve block can occur but usually results in hoarseness secondary to ipsilateral vocal cord palsy.
Question 852
Topic: 9. Shoulder and Elbow
When addressing a proximal intertrochanteric or subtrochanteric fracture in a juvenile with open growth plates, the arterial supply from what artery at the neck must be preserved?
Correct Answer & Explanation
. Medial femoral circumflex
Explanation
DISCUSSION: The medial femoral circumflex artery supplies blood to the femoral head. Its position along the posterior-superior femoral neck places this structure at risk with intramedullary nailing of the femur. Therefore, lateral entry through the greater trochanter is preferred when intramedullary fixation is performed.
Question 853
Topic: 9. Shoulder and Elbow
.Figures 41a through 41c are the radiograph and MRI scans of a 76-year-old woman who has intractable left shoulder pain. She was given 2 cortisone injections and oral pain medication without experiencing lasting relief. Examination reveals 60 degrees of active forward elevation (120 degrees passively), 30 degrees of external rotation lag, and a positive Hornblower sign. Pain relief and improved functionality will most likely be achieved with
Correct Answer & Explanation
. continued nonsurgical treatment.
Explanation
Question 854
Topic: 9. Shoulder and Elbow
A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management? Review Topic
Correct Answer & Explanation
. Physical therapy and home exercises
Explanation
Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury.
Question 855
Topic: 9. Shoulder and Elbow
A 22-year-old right hand-dominant man who fell off his motorcycle onto the tip of his right shoulder 2 weeks ago now reports pain and difficulty raising his right arm. Examination reveals tenderness and gross movement over the lateral scapular spine and severe weakness during resisted abduction. A radiograph and 3D-CT scan are shown in Figures 24a and 24b. What is the next most appropriate step in management?
Correct Answer & Explanation
. Open reduction and internal fixation
Explanation
DISCUSSION: The patient has a displaced scapular spine fracture that has resulted in shoulder weakness from a poor deltoid lever arm. The downward tilt may lead to subacromial impingement and rotator cuff dysfunction. Open reduction and internal fixation would best allow normal deltoid and shoulder function. Bone stimulators and abduction bracing may lead to healing but in a malunited position. Arthroscopic acromioplasty and fragment excision should be avoided. REFERENCES: Ogawa K, Naniwa T: Fractures of the acromion and the lateral scapular spine. J Shoulder Elbow Surg 1997;6:544-548. Ada Jr, Miller ME: Scapular fractures: Analysis of 113 cases. Clin Orthop Relat Res 1991;269:174-180.
Question 856
Topic: 9. Shoulder and Elbow
A 22-year-old man sustained a shoulder dislocation while playing collegiate football at age 18. Since that time, he has dislocated the shoulder three more times despite physical therapy. His last dislocation occurred 4 weeks ago while sleeping. What is the most appropriate management for this patient? Review Topic
Correct Answer & Explanation
. A discussion regarding surgical stabilization procedures
Explanation
The patient sustained a traumatic shoulder dislocation at age 18 that has subsequently failed to respond to nonsurgical management. Discussion of surgical stabilization procedures is warranted at this time. A corticosteroid injection or a trial of NSAIDs will not provide any stabilizing effect. Further immobilization in this patient population has not been shown to improve stability.
Question 857
Topic: 9. Shoulder and Elbow
Which component is most common to both simple and complex elbow dislocations?
Correct Answer & Explanation
. loss of terminal extension
Explanation
DISCUSSION: Elbow dislocations are classified as either simple (no associated fracture) or complex (associated fracture). The goal of treatment is a stable joint that tolerates early motion. The initial range of motion is the stable arc found on postreduction examination. Studies have demonstrated a better outcome when simple elbow dislocations are treated non-surgically rather than with surgical repair. Simple elbow dislocations usually have an excellent outcome (return of functional range of motion with normal strength). A loss of terminal extension is the most common sequelae.
Question 858
Topic: 9. Shoulder and Elbow
Figures 5a and 5b show the radiographs of a 45-year-old patient. What is the most likely diagnosis?
Correct Answer & Explanation
. Glenoid dysplasia
Explanation
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.
Question 859
Topic: 9. Shoulder and Elbow
A 13-year-old pitcher reports the immediate onset of medial elbow pain after throwing a pitch. Upon examination, the patient is tender to palpation at the medial epicondyle and has pain and instability with valgus testing of the elbow. If the patient were a college pitcher with a similar clinical presentation and physical examination, what anatomic structure would most likely be injured?
Correct Answer & Explanation
. Ulnar collateral ligament (UCL)
Explanation
The patient has an acute avulsion fracture of the medial epicondyle, which can occur in response to the valgus load placed on the elbow while throwing. Diagnosis is confirmed by radiograph, with comparison views of the uninjured elbow to evaluate for physeal closure versus injury. In older pitchers, the UCL fails rather than the bone of the medial epicondyle. Advanced imaging may be necessary to confirm the diagnosis of an UCLinjury and/or bony injury.
Question 860
Topic: 9. Shoulder and Elbow
Excision of heterotopic bone about the forearm or elbow can be done with limited recurrence rates as early as which of the following after initial injury?
Correct Answer & Explanation
. 6 months
Explanation
DISCUSSION: Excision of heterotopic bone about the elbow and forearm was classically treated once the bone was mature and no further bone development was occurring (bone scan became negative). However, several studies have shown that earlier removal before this point in time is safe, when done in conjunction with radiation therapy (XRT). The referenced study by McAuliffe et al is a retrospective review of heterotopic ossification (HO) about the elbow followed by 100 cGy (5 fractions over 1 week) of XRT as early as 3 months post-injury. They were able to achieve an average arc of motion > 100 degrees. The other referenced study by Beingessner et al is a review of HO excision of the forearm. They found that excision and XRT, followed by 6 weeks of indomethacin, led to an increase of forearm motion from an average of 17 degrees to 136 degrees when the excision was done at 4 months post-injury.
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