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9. Shoulder and Elbow MCQs

Practice Set 46 of 197

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 901

Topic: 9. Shoulder and Elbow
A 13-year-old girl who competes in gymnastics reports the insidious onset of lateral left elbow pain over the past 6 months. She also notes occasional catching episodes in the elbow; however, she denies any history of trauma. Examination reveals tenderness over the lateral epicondyle and extensor muscle origin. The elbow is stable and has full flexion, but lacks 10° of full extension. An AP plain radiograph and an MRI scan are shown in Figures 17a and 17b. Management of the elbow should consist of
. open excision of the radial head.
. a cortisone injection into the extensor muscle origin.
. a tennis elbow release.
. arthroscopic removal of loose bodies and microfracture of the crater.
. rest, physical therapy, pulsed electromagnetic therapy, and no further gymnastic activities.

Correct Answer & Explanation

. arthroscopic removal of loose bodies and microfracture of the crater.

Explanation

DISCUSSION: The radiograph and MRI scan show osteochondritis dissecans of the capitellum, and the patient’s history suggests a loose body. The treatment of choice is arthroscopic removal of the loose body and microfracture of the crater. Excision of the radial head, a cortisone injection, or tennis elbow release does not treat the pathology in the capitellum. Nonsurgical treatment would not relieve the mechanical symptoms of the loose body or promote healing in the crater. REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520-530. Jackson DW, Silvino N, Reiman P: Osteochondritis in the female gymnast’s elbow. Arthroscopy 1989;5:129-136. Ruch DS, Cory JW, Poehling GG: The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797-803.

Question 902

Topic: 9. Shoulder and Elbow

A 68-year-old man presents with severe right shoulder pain. He had a prolonged course of physical therapy and received several cortisone injections for his pain without improvement. Examination reveals pseudoparalysis of the right shoulder with a 20-degree external rotation lag with the shoulder adducted. With the shoulder placed in 90 degrees of abduction, he can actively externally rotate his shoulder. The patient was treated with a medialized reverse prosthesis shown in Figure A. Which of the following statement is true regarding this treatment option? Review Topic

. It is contraindicated in patients with shoulder pseudoparalysis
. It can be used in patients with deltoid dysfunction when combined with latissimus dorsi transfer
. It shifts the center of rotation of the shoulder superior and lateral
. The risk of scapular notching is increased with inferior placement of the glenoid component
. The risk of instability is increased with an irreparable subscapularis

Correct Answer & Explanation

. It is contraindicated in patients with shoulder pseudoparalysis

Explanation

The clinical presentation is consistent with a patient with pseudoparalysis that was treated with a reverse total shoulder arthroplasty (RTSA). The risk of postoperative instability is increased in patients with an irrepairable subscapularis when a medialized reverse prosthesis is used. Answers 1-4 are false statements.RTSA is most commonly indicated for rotator cuff arthropathy. However, indications for use now include shoulder pseudoparalysis, anterosuperior escape of the humeral head, acute 3 or 4-part proximal humerus fractures, and greater tuberosity fracture nonunions. Contraindications to RTSA included deltoid dysfunction, insufficient glenoid bone stock, and bony deficiency of the acromion.Edwards et al. prospectively evaluated the risk of shoulder dislocation after reverse TSA. They found a significantly increased risk of dislocation (p=0.012) in patients with an irreparable subscapularis at time of surgery. There were no dislocations in the reparable group. Dislocations were more likely in patients with proximal humeral nonunions and failed prior arthroplasty.Mulieri et al. looked at the use of reverse TSA in patients with irreparable massive rotator cuff tears without evidence of glenohumeral arthritis. All outcomes were improved postoperatively, and they advocate for reverse TSA in this subset of patients. Survivorship was over 90% at more than 4 years average follow up.Boileau et al. evaluated the clinical outcomes of isolated biceps tenotomy/tenodesis in patients with massive rotator cuff tears and a biceps lesion. They found that the procedure can effectively treat pain and improve function in these patients. There was no difference in patients undergoing tenotomy versus tenodesis.Figure A is a right shoulder radiograph status post RTSA with components in adequate position.Incorrect Answers:

Question 903

Topic: 9. Shoulder and Elbow

A 13-year-old baseball pitcher presents with worsening medial-sided elbow pain. He pitches 7 months out of the year, throws 85 pitches per game and plays in two games per week. His fastball speed is approximately 75mph. He regularly plays outfield once he has been relieved of pitching. Which of the following is most likely contributing to his elbow pain? Review Topic

. The number of months he plays per year
. The number of pitches he throws per game
. The number of games he plays per week
. His fastball speed
. Playing in another position once being relieved of pitching

Correct Answer & Explanation

. The number of months he plays per year

Explanation

Young athletes who throw greater than 80 pitches per game have an increased risk of shoulder and elbow injury. For a 13-year-old, the recommended maximum number of pitches per game is 75.Little League elbow is a medial-sided overuse injury that occurs in the skeletally immature athlete. During execution of the baseball pitch, tremendous valgus and extension stresses occur at the elbow. Repetitive microtrauma can ultimately injure the medial epicondyle apophysis, ulnar collateral ligament or the flexor-pronator muscle mass. Limiting the number of pitches and innings played per game, as well as the number of months of competitive pitching per year, has been recommended to prevent these overuse injuries in the young athlete.Olsen et al performed a case control study to determine risk factors associated with the development of shoulder and elbow injuries in adolescent baseball pitchers. Greater than 8 months of competitive pitching per year, more than 80 pitches per game and a fastball speed of greater than 85mph were all associated with increased risk of injury. Continued pitching despite arm fatigue and pain, being a starting pitcher, greater number of warm-up pitches, participating in showcases and regular use of NSAIDs were also associated with injury. The type of pitch (fastball, changeups and breaking balls) and continued play in a different position once being relieved was not associated with increased risk of injury.Andrews et al authored a review article on ulnar collateral ligament injuries in throwing athletes. According to the USA Baseball Medical/Safety Advisory Committee, young baseball pitchers should avoid breaking pitches, such as curveballs and sliders, and avoid year-round baseball. A minimum of 3 months of complete rest from pitching per year is vital. Youth pitching coaches should be educated to ensure proper pitching mechanics are being reinforced.Illustration A is a table depicting the recommended maximum number of pitches by age group.Incorrect Answers:

Question 904

Topic: 9. Shoulder and Elbow

A 16-year-old competitive female swimmer has a 1-year history of left shoulder pain. She denies any specific injury to her shoulder. She reports that the pain is worse with swimming but also has pain with daily activities. She also notes similar occasional symptoms in her right shoulder. Examination reveals symmetric range of motion and rotator cuff strength. Examination of the left shoulder reveals 2+ anterior and posterior translation with pain in both directions and a 2-cm sulcus sign. The right shoulder also has 2+ anterior and posterior translation and a 2-cm sulcus sign with no pain. She also has hyperextension of the elbows and the ability to touch the radial border of her thumb to her forearm. What is the next step in management? Review Topic

. Open inferior capsular shift
. Arthroscopic thermal capsulorrhaphy
. Sling at all times until the pain resolves
. Arthroscopic anterior and posterior capsular plication
. Physical therapy for rotator cuff and scapulothoracic strengthening

Correct Answer & Explanation

. Open inferior capsular shift

Explanation

The patient has symptomatic multidirectional instability. A comprehensive program involving physical therapy to restore dynamic stability to her shoulder is indicated as a first-line treatment. Periscapular strengthening focusing on the serratus anterior and rhomboids and rotator cuff strengthening should be emphasized. A sling might be used occasionally for comfort but will not provide long-term relief of her symptoms. Thermal capsulorrhaphy, although widely used in the past for shoulder instability, has been abandoned because of a high complication rate. Surgical interventions, such as capsular plications or open capsular shift procedures, might be indicated if rehabilitation fails to relieve her symptoms.

Question 905

Topic: 9. Shoulder and Elbow
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
. biceps tenodesis.
. suture repair.
. capsulorraphy.
. debridement.
. release of the biceps tendon.

Correct Answer & Explanation

. debridement.

Explanation

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.

Question 906

Topic: 9. Shoulder and Elbow

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

. excision of the osteophytes and loose bodies and anterior and posterior capsular releases.
. removal of the loose bodies.
. anterior capsular release.
. anterior and posterior capsular releases.
. interposition arthroplasty.

Correct Answer & Explanation

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

Explanation

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.

Question 907

Topic: 9. Shoulder and Elbow

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 35-year-old man who has elbow pain after falling from a ladder onto an outstretched hand. Examination reveals elbow pain, swelling, limited motion, and normal neurologic function. A pathognomonic radiographic feature of this injury is a

. radiocapitellar joint dislocation.
. fat pad sign.
. proximal radioulnar joint dislocation.
. double arc sign.

Correct Answer & Explanation

. radiocapitellar joint dislocation.

Explanation

Discussion: Coronal shear fractures of the distal end of the humerus are rare. Failure to recognize the fracture pattern can lead to poor patient outcomes secondary to poor surgical decision making. The double arc sign is considered a pathognomonic finding on the lateral elbow radiograph seen in Figure 2. This is created by the subchondral bone of the capitellum and lateral trochlear ridge. Excessive internal rotation of the fracture fragment or a subpar lateral radiograph can make recognition of this sign difficultyIdeal visualization of the fragment during surgery is provided through a laterally based elbow approach (Kaplan or Kocher) with the patient in the supine position. Extension of the approach can be accomplished by releasing the lateral collateral ligament origin, which must be repaired to prevent post-operative instability. Posterior comminution and lateral column impaction are occasionally seen. When present, a posterior approach with an olecranon osteotomy is considered an alternative, but still does not allow ideal visualization of the anterior articular cartilage or safe angles for anterior to posterior screw placement. Therefore, the posterior approach not the preferred approach.Headless screws are useful because this is typically a partial articular injury and screw orientation is ideally from anterior to posterior. The anterior entry of the screw should be buried beneath the articular cartilage margin.

Question 908

Topic: Shoulder Pathology

A 50-year-old man reports left shoulder pain and weakness after undergoing a lymph node biopsy in his neck 2 years ago. Examination reveals winging of the left scapula. Electromyography shows denervation of the trapezius. Surgical treatment for this condition involves Review Topic

. pectoralis transfer to the medial border of the scapula.
. pectoralis transfer to the inferior border of the scapula.
. lateral transfer of the levator scapulae only.
. lateral transfer of the levator scapulae and rhomboid minor and major.
. latissimus dorsi transfer.

Correct Answer & Explanation

. pectoralis transfer to the medial border of the scapula.

Explanation

The muscle transfer procedure most commonly performed for trapezius paralysis is the Eden-Lange procedure. Trapezius paralysis in this patient is secondary to iatrogenic injury to the spinal accessory nerve during lymph node biopsy. In this procedure, the levator scapulae and rhomboid minor and major muscles are transferred laterally. Pectoralis transfer to the inferior border of the scapula is used as a dynamic transfer for serratus anterior winging.

Question 909

Topic: 9. Shoulder and Elbow

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?

. Bilateral long thoracic nerve palsies
. Central cervical disk herniation
. Duchenne muscular dystrophy, adult onset
. Fascioscapulohumeral dystrophy
. Disuse atrophy as the result of deconditioning

Correct Answer & Explanation

. Bilateral long thoracic nerve palsies

Explanation

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.

Question 910

Topic: 9. Shoulder and Elbow

One of the serious potential complications of repair of distal biceps tendon ruptures is limited pronation and supination as a result of synostosis. What surgical approach and technique presents the highest risk for development of this complication?

. Single incision, anterior approach with fixation through drill holes in the radius
. Single incision, anterior approach with suture anchor fixation to the radius
. Single incision, anterior approach through a drill hole in the radius with sutures tied over bolster or button on the posterior forearm
. Dual incision, limited anterior and posterior approach along the ulna with attachment through drill holes
. Dual incision, limited anterior and posterior muscle-splitting approach (supinator and extensor muscles) with attachment through drill holes

Correct Answer & Explanation

. Single incision, anterior approach with fixation through drill holes in the radius

Explanation

DISCUSSION: The risk of synostosis is imminent with any technique for repairing a distal biceps tendon rupture.  However, the risk is quite low for all approaches that avoid exposure of the ulna, including the muscle-splitting two-incision technique.REFERENCE: Norris TR: Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, p 342.

Question 911

Topic: 9. Shoulder and Elbow

A 45-year-old man sustains an acute closed posterolateral elbow dislocation. The elbow is reduced, and examination reveals that the elbow dislocates posteriorly at 35 degrees with the forearm placed in supination. What is the best course of action?

. Cast immobilization for 6 weeks
. Hinged brace with early range of motion in supination
. Hinged brace with early range of motion in pronation
. Primary ligament repair
. Lateral collateral ligament reconstruction with tendon graft

Correct Answer & Explanation

. Cast immobilization for 6 weeks

Explanation

DISCUSSION: Most closed simple dislocations are best managed with early range of motion.  Posterior dislocation typically occurs through a posterolateral rotatory mechanism.  When placed in pronation, the elbow has greater stability when the medial ligamentous structures are intact.  In traumatic dislocations, MRI rarely provides additional information that will affect treatment.  In elbows that remain unstable, primary repair is preferred over ligament reconstruction.  Cast immobilization increases the risk of arthrofibrosis.REFERENCE: O’Driscoll SW, Morrey BF, Korinek S, et al: Elbow subluxation and dislocation: A spectrum of instability.  Clin Orthop 1992;280:186-197.

Question 912

Topic: 9. Shoulder and Elbow

Figures 1 and 2 are of a 51-year-old man who underwent open reduction and internal fixation of a right proximal humerus fracture with concomitant rotator cuff repair. Within 1 year, he develops heterotopic ossification, for which he undergoes excision and hardware removal. Postoperatively, he was noted to have progressive atrophy in the shoulder and anterior humeral head subluxation with attempted shoulder abduction. What nerve was damaged during the most recent procedure?

. Suprascapular
. Radial
. Anterior branch of axillary
. Spinal accessory (cranial nerve XI)

Correct Answer & Explanation

. Suprascapular

Explanation

EXPLANATION:This patient has a deficiency of the anterior deltoid muscle, resulting in inferior subluxation of the humerus with associated glenohumeral instability. Axillary nerve injury during shoulder surgery accounts for 6% to 10% of brachial plexus injuries. In the posterior scapular region, the axillary nerve terminates by dividing into two main branches: the posterior terminal branch, which provides motor innervation to the teres minor and posterior deltoid muscles, and the anterior terminal branch, which provides motor innervation to the anterior and middle portions of the deltoid muscle. The deltoid determines the silhouetteof the shoulder and is a stabilizer of the humeral head.

Question 913

Topic: 9. Shoulder and Elbow

Figures 113a and 113b are the radiographs of a 7-year-old girl who was evaluated for a visible elbow deformity by a foster parent. She thought the child fell, but her history was vague. On physical examination, a large prominence was seen over the posterolateral elbow, and the girl lacks the terminal 20 degrees of elbow extension. She has 75 degrees of elbow pronation and supination. She was nontender on examination. What is the most appropriate next treatment step? Review Topic

. Child abuse workup
. Closed reduction
. Open reduction with possible osteotomy
. Observation

Correct Answer & Explanation

. Child abuse workup

Explanation

The most appropriate management of this condition is observation. The patient most likely has a congenital dislocation of the radial head, although this may also represent a posttraumatic deformity. The absence of findings on physical examination speaks against an acute injury. The appearance of the radial head reveals the typical findings of a congenital dislocation, namely the convex appearance of the proximal radial articular surface. These children typically have very functional range of motion and do not require treatment unless they are symptomatic. There is nothing in this child's history to suggest abuse.

Question 914

Topic: 9. Shoulder and Elbow

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

. stabilization with suture anchors.
. debridement only.
. no treatment.
. stabilization using absorbable tacks with the arm in external rotation.
. release of the attachment to the middle glenohumeral ligament, followed by stabilization with any device.

Correct Answer & Explanation

. stabilization with suture anchors.

Explanation

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.

Question 915

Topic: 9. Shoulder and Elbow

Which of the following statements best describes the typical early presentation of osteochondritis dissecans of the elbow? Review Topic

. Often associated with loss of elbow extension
. Often associated with catching or locking
. Involves the capitellum or lateral trochlea
. Presents in boys younger than age 10 years
. Outlining of the margins of the lesion on MR arthrogram is a good prognostic sign

Correct Answer & Explanation

. Often associated with loss of elbow extension

Explanation

This condition is the result of repetitive valgus overload of the radiocapitellar joint in the immature elbow. The clinical presentation is of lateral elbow pain and loss of extension in a juvenile older than age 10 years. Panner's disease typically affects the capitellum in boys younger than age 10 years. Osteochondritis dissecans (OCD) of the elbow affects the capitellum and occasionally the radial head. Fracturing of the OCD region can lead to an unstable fragment with margins outlined on an MR arthrogram and can progress to loose bodies that cause clinical catching or locking. These are typically late signs with a poorer prognosis.

Question 916

Topic: 9. Shoulder and Elbow

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?

. Chondroblastoma
. Osteoid osteoma
. Occult instability
. Rotator cuff tear
. Injury to the proximal humeral physis

Correct Answer & Explanation

. Chondroblastoma

Explanation

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.

Question 917

Topic: 9. Shoulder and Elbow

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

. Midsubstance tear of the lateral ulnar collateral ligament
. Proximal avulsion of the ulnar collateral ligament
. Proximal avulsion of the lateral ulnar collateral ligament
. Distal bony avulsion of the ulnar collateral ligament from the sublime tubercle

Correct Answer & Explanation

. Midsubstance tear of the lateral ulnar collateral ligament

Explanation

Classic posterior elbow dislocations result from a posterolateral rotatory mechanism, whereby the hand is fixed (typically on the ground) while the weight of the body creates a valgus and external rotation moment on the elbow. This results first in tearing of the lateral collateral ligament that proceeds medially through the anterior and posterior joint capsules, ending with potential involvement of the ulnar collateral ligament (but this is not universal). McKee and associates assessed the lateral soft-tissue injury pattern of elbow dislocationswith and without associated fractures at the time of surgery. Injury to the lateral collateral ligament complex was seen in every case, with avulsion from the distal humerus as the most common finding. Midsubstancetears, proximal avulsions, and distal bony avulsions of the ulnar collateral ligament are less common.

Question 918

Topic: 9. Shoulder and Elbow

Figure 12a shows the clinical photograph of a 36-year-old man who has left shoulder pain and dysfunction after undergoing a lymph node biopsy 2 years ago. The appearance of the shoulder during abduction and a wall push-up maneuver is shown in Figures 12b and 12c, respectively. Which of the following procedures provides the best pain relief and function?

. Direct nerve repair
. Sural nerve graft
. Pectoralis major transfer
. Levator scapula and rhomboid transfer
. Scapulothoracic fusion

Correct Answer & Explanation

. Direct nerve repair

Explanation

DISCUSSION: Injury to the spinal accessory nerve can occur after penetrating trauma to the shoulder.  Blunt trauma may also cause loss of trapezius function.  Most commonly, surgical dissection in the posterior triangle of the neck, such as lymph node biopsy, may expose the nerve to possible damage.  Surgical repair of the nerve may be considered up to 1 year after injury; after this time muscle transfer is usually associated with a better functional outcome.REFERENCES: Steinman SP, Spinner RJ: Nerve problems in the shoulder, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 2004, vol 2, pp 1013-1015.Wiater JM, Bigliani LU: Spinal accessory nerve injury.  Clin Orthop Relat Res 1999;368:5-16.

Question 919

Topic: 9. Shoulder and Elbow

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?

. Excision medial to the costoclavicular ligament
. Excision lateral to the costoclavicular ligament
. Excision of the coracoclavicular ligaments and lateral clavicle
. Excision of the coracohumeral ligaments
. Leaving the costoclavicular ligament intact

Correct Answer & Explanation

. Excision medial to the costoclavicular ligament

Explanation

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.

Question 920

Topic: 9. Shoulder and Elbow

-T1-weighted, fat-saturated MRI scans are shown in Figures 37a and 37b. What is the next step intreatment?

. Open reduction internal fixation (ORIF)
. Rotator cuff repair
. Labrum repair
. Chondroplasty

Correct Answer & Explanation

. Open reduction internal fixation (ORIF)

Explanation

DISCUSSION FOR QUESTIONS 37 AND 38Examination findings of posterior glenohumeral tenderness, decreased internal rotation, and reproduction of symptoms with a posterior stress test indicate a posterior shoulder injury or instability. The jerk test,with the patient seated, positions the arm in forward flexion and internal rotation with elbow flexion. One hand of the examiner is placed on the patient’s distal clavicle and scapular spine and the other hand grasps the elbow. The arm is jerked posteriorly while the shoulder girdle is jerked anteriorly, which creates pain as the posteriorly subluxated humeral head relocates into the glenoid fossa. During the Kim test, the patient is seated with the arm in 90 degrees of abduction. While the arm is elevated 45 degrees diagonally (forward flexion and adduction), the examiner applies an axial load to the elbow and a downward and posterior force to the upper arm. A positive result causes a sudden onset of posterior shoulder pain. A positive jerk test combined with a positive Kim test has a 97% sensitivity for posterior instability. After extensive PT, the patient continues to have examination findings consistent with posterior shoulder injury or instability, so an MRI scan or MRI arthrography would be helpful to assess for any pathology.A subacromial injection is not indicated by this examination, which shows a strong rotator cuff and no demonstrated bursal-sided symptoms. A CT scan can be helpful in scenarios involving bony pathology,but an MRI is indicated at this stage in the evaluation of soft tissue. Although continuing PT may help to abate symptoms, the patient was continuing to have symptoms with PT. The MRI arthrogram shows a complex posterior labrum tear at the inferior to mid glenoid with separation of labrum from the glenoid. Because the examination findings are consistent with the MRI findings and nonsurgical treatment has failed to resolve symptoms, the next step is to recommend surgical treatment with labrum debridement and/or repair. No examination or MRI findings indicate a need for injection, rotator cuff repair, ORIF, or chondroplasty unless incidental intrasurgical findings are found.

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