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9. Shoulder and Elbow MCQs

Practice Set 48 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 941

Topic: 9. Shoulder and Elbow

A 72-year-old woman who is right hand-dominant has severe pain in the right shoulder that has failed to respond to nonsurgical management. She reports night pain and significant disability. Examination reveals 30 degrees of active forward elevation. An AP radiograph is shown in Figure 27. Which of the following treatment options will provide the best functional improvement? Review Topic

. Arthroscopic debridement
. Arthroscopic rotator cuff repair
. Hemiarthroplasty with rotator cuff repair
. Total shoulder arthroplasty
. Reverse shoulder arthroplasty

Correct Answer & Explanation

. Reverse shoulder arthroplasty

Explanation

The patient has end-stage rotator cuff tear arthropathy. The radiograph shows complete proximal humeral migration (acromiohumeral interval of 0 mm), severe glenohumeral arthritis, and acetabularization of the acromion. In addition, she has "pseudoparalysis" with active elevation of only 30 degrees. Reverse shoulder arthroplasty affords her the best opportunity for pain relief and functional improvement. The other procedures have mixed results but typically are better for pain relief than they are for functional gains.

Question 942

Topic: 9. Shoulder and Elbow

Figure A shows immediate post-operative radiographs of a 75-year-old patient with primary osteoarthritis. She presents 3 years later with increasing pain and weakness in the shoulder despite home physical therapy. Examination reveals limited active range of motion, with forward elevation of 80 degrees and external rotation of 50 degrees. Her deltoid function is intact. Repeat radiographs are seen in Figure B.

. Open tendon transfer
. Corticosteriod injection and supervised physical therapy
. Open rotator cuff repair, subacromial decompression and distal clavical excision
. Revision to reverse shoulder arthroplasty
. Revision to cuff arthropathy hemiarthroplasty

Correct Answer & Explanation

. Open tendon transfer

Explanation

This patient presents with failed total shoulder arthroplasty. The best treatment option for functional outcome would be revision to reverse shoulder arthroplasty (rTSA).RTSA is considered a viable treatment option for patients with failed shoulder arthroplasty. It allows for improved arm elevation and abduction in the setting of nonfunctional rotator cuff muscles, as seen in this example. Despite the expanding indications for rTSA, there are high complication rates in the revision setting. Complication rates for rTSA after failed shoulder arthroplasty have been reported to be between 11-36%. This procedure should, therefore, be performed by surgeons with extensive training in reconstructive shoulder arthroplasty.Patel et al. retrospectively reviewed 31 patients (mean age, 68.7 years) who underwent rTSA for treatment of a failed shoulder arthroplasty. They found the greatest improvement with active forward elevation from 44° preoperatively to 108° postoperatively (P < .001). Complications occurred in 3 patients with periprosthetic fracture.Hattrup et al. reviewed a series of 19 patients that underwent open rotator cuff repair after shoulder arthroplasty. Out of the 19 patients only 4 shoulders were successfully repaired. They concluded that successful rotator cuff repair after shoulder arthroplasty is possible but failure is more common.Figure A shows a left total shoulder arthroplasty that is well reduced in the glenoid. Figure B shows antero-superior escape of the prosthesis, indicative of a massive rotator cuff tear.Incorrect Answers:

Question 943

Topic: 9. Shoulder and Elbow

A 2-week-old infant has had diminished movement of the right upper extremity since birth. Examination reveals weakness of shoulder abduction and external rotation, elbow flexion, and forearm supination. Both pupils are equally round and responsive to light. The remainder of the examination is normal. Radiographs of the upper limb show a healing middle-third clavicle fracture. Management should consist of

. cervical spine radiographs.
. MRI of the shoulder.
. decompressive osteotomy of the clavicle.
. microsurgical repair of the brachial plexus.
. observation and range-of-motion exercises.

Correct Answer & Explanation

. cervical spine radiographs.

Explanation

DISCUSSION: The patient has a classic Erb’s palsy with weakness of the muscles innervated by the fifth and sixth cervical roots.  Horner syndrome, a poor prognostic indicator for recovery, is absent in this infant.  All infants with brachial plexus birth palsies initially should be monitored for spontaneous recovery during the first 3 to 6 months of life.  During this period of observation, glenohumeral motion, especially external rotation, should be maintained.  Many infants will begin to show recovery within the first 6 to 8 weeks after birth and continue on to normal function.  The timing of microsurgery is controversial.  A recent study found that the outcome of microsurgical repair in patients who had no recovery of biceps function within 3 months after birth was similar compared to those who had recovery of biceps function between 3 and 6 months and no microsurgical repair.  The author concluded that microsurgical repair was effective in improving function in those infants who had no evidence of recovery of biceps function within the first 6 months of life.REFERENCES: Waters PM: Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy.  J Bone Joint Surg Am 1999;81:649-659.Greenwald AG, Schute PC, Shiveley JL: Brachial plexus birth palsy: A 10-year report on the incidence and prognosis.  J Pediatr Orthop 1984;4:689-692.

Question 944

Topic: 9. Shoulder and Elbow

What structure is considered the single most important soft-tissue restraint to anterior-posterior stability of the sternoclavicular joint?

. Posterior capsular ligament
. Anterior capsular ligament
. Interclavicular ligament
. Intra-articular disk
. Subclavius tendon

Correct Answer & Explanation

. Posterior capsular ligament

Explanation

DISCUSSION: In a cadaver ligament sectioning study, the posterior capsular ligament was considered the most important structure for anterior-posterior stability of the sternoclavicular joint.  The anterior capsular ligament also helps prevent anterior displacement but not to the same degree as the posterior ligament.  The interclavicular ligament provides little support for anteroposterior translation.REFERENCES: Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint.  J Shoulder Elbow Surg 2002;11:43-47.Rockwood CA Jr, Matsen FA III, Jobe CM: Gross Anatomy of the Shoulder.  Philadelphia, PA, WB Saunders, 1998.

Question 945

Topic: 9. Shoulder and Elbow

A 20-year-old college baseball pitcher reports the insidious onset of medial elbow pain. Examination reveals medial elbow tenderness, a normal neurologic examination, and no obvious valgus laxity. Plain radiographs are normal. MRI scans are shown in Figures 39a and 39b. Management should consist of

. repair of the medial collateral ligament.
. excision of the posterior olecranon osteophyte.
. debridement of the degenerative portion of the common flexor origin.
. autograft reconstruction of the medial collateral ligament.
. ulnar nerve transposition.

Correct Answer & Explanation

. repair of the medial collateral ligament.

Explanation

DISCUSSION: Throwers and in particular, pitchers, are prone to high valgus loads to the elbow.  A constellation of medial elbow pathology can develop, including medial epicondylitis, ulnar nerve neuritis, medial ulnar collateral ligament injuries, and posteromedial osteophytes of the olecranon.  The MRI scans show significant increases in signal intensing as well as fiber disruption of the medial collateral ligament, indicating a complete tear.  The common flexor origin shows a homogeneous signal and normal morphology.  Therefore, excision of posterior osteophytes and debridement of the common flexor origin are not indicated.  Likewise, this patient’s symptoms do not indicate ulnar nerve pathology; therefore ulnar nerve transposition is not indicated.  Primary repair of medial collateral ligament tears of the elbow lead to unpredictable results with an unacceptable rate of reoperation.  The most predictable result in treating this high-demand athlete is reconstruction of the medial collateral ligament with autogenous tissue.REFERENCES: Norris TR (ed): Athletic Injuries of the Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 311-323.Hyman J, Breazeale NM, Altchek DW: Valgus instability of the elbow in athletes.  Clin Sports Med 2001;20:11-24.

Question 946

Topic: 9. Shoulder and Elbow

A 23-year-old baseball pitcher who has diffuse pain along the posterior deltoid reports pain during late acceleration and follow-through. Examination of his arc of motion from external rotation to internal rotation at 90 degrees of shoulder abduction reveals a significant deficit in internal rotation when compared to the nonthrowing shoulder. Initial management should consist of

. a cortisone injection to the subscapular bursa.
. posterior capsular stretching.
. strengthening of the external rotators and scapular stabilizers.
. continued pitching and working through the pain.
. a sling and rest.

Correct Answer & Explanation

. a cortisone injection to the subscapular bursa.

Explanation

DISCUSSION: Loss of internal rotation is common among overhead throwers and tennis players.  Posterior capsular stretching can improve symptoms when accompanied by rest and gradual resumption of throwing.  To avoid a false impression of improvement, cortisone injection is not recommended.  Pitching through pain can cause further damage to the labrum and capsule.  A sling and external rotator strengthening will not improve internal rotation.REFERENCES: Kibler WB: Biomechanical analysis of the shoulder during tennis activities.  Clin Sports Med 1995;14:79-85.Jobe FW, Tibone JE, Jobe CM, Kvitne RS: The shoulder in sports, in Rockwood CA, Matsen FA (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1990, pp 961-990.

Question 947

Topic: 9. Shoulder and Elbow

What portion of the pitching phase creates forces approaching the tensile limit of the medial ulnar collateral ligament of the elbow? Review Topic

. Early cocking
. Late cocking / Early acceleration
. Ball release
. Follow-through
. Deceleration

Correct Answer & Explanation

. Early cocking

Explanation

The late cocking and early acceleration phases are often combined when discussing medial stress on the elbow of the overhand thrower. This is when the greatest valgus moment across the medial elbow occurs and the forces reach the tensile limits of the medial ulnar collateral ligament.Fleisig et al. were among the first to elucidate the elbow and shoulder kinetics in healthy adult pitchers using high-speed motion capture analysis. Inability to generate sufficient elbow varus torque may result in medial tension, lateral compression, or posteromedial impingement injury.According to Lynch et al. the late cocking phase of the overhand throw places a marked valgus moment across the medial elbow. This repetitive force reaches the tensile limits of the medial collateral ligament, subjecting it to microtraumatic injury and attenuation. The anterior bundle of the medial collateral ligament has been identified as the primary restraint to valgus load and is the focus of reconstruction.Incorrect Responses:1,4,5: The medial elbow forces are less during these phases. 4: Ball release is not one of the 5 phases of throwing and marks the end of the acceleration and beginning of deceleration phase.

Question 948

Topic: Shoulder Pathology

A 19-year-old male collegiate rower has a 3-month history of right shoulder pain. There was no inciting trauma prior to the onset of his pain. He also complains of weakness, particularly in abduction and overhead activity. Examination reveals no range-of-motion deficits. Strength testing of the right shoulder demonstrates 4/5 motor strength in forward elevation and abduction. His Beighton hypermobility score is 3/9. Figure 1 shows his scapular position during a wall pushup maneuver. An EMG would likely reveal damage to what nerve?

. Long thoracic nerve
. Cranial nerve XI (spinal accessory nerve)
. Suprascapular nerve
. Axillary nerve

Correct Answer & Explanation

. Long thoracic nerve

Explanation

Figure 1 reveals medial scapular winging secondary to weakness of the serratus anterior, which is innervated by the long thoracic nerve. Damage to the long thoracic nerve can occur via repetitive stretching, compression, or iatrogenic injury during a surgical procedure. Lateral thoracic winging is caused by weakness of the trapezius, which is innervated by cranial nerve XI (spinal accessory nerve). The direction of scapular winging is judged by the upper medial border of the scapula. Observation of a period of at least 6 months with serratus anterior strengthening while the nerve recovers is the mainstayof treatment for medial scapular winging.

Question 949

Topic: 9. Shoulder and Elbow

A 47-year-old man comes for evaluation of his dominant right elbow, which has been bothering him with activity for the past 3 months, especially with activities requiring wrist extension. He is an active squash player and has been unable to continue this sport. Examination shows tenderness at the common extensor origin. What is the next best step? Review Topic

. Platelet rich plasma injection
. Eccentric exercises
. Corticosteroid injection
. Ultrasonic emulsification/aspiration
. Surgical debridement and repair of the extensor carpi radialis brevis

Correct Answer & Explanation

. Eccentric exercises

Explanation

This patient has tennis elbow or lateral epicondylitis. First line treatment is conservative.Lateral epicondylitis is a common problem with numerous non-operative treatments available. There is little scientific evidence to support any of these treatments however and the quality of most reports is low and their conclusions limited by bias and/or study design. Tennis elbow often resolves with time regardless of which conservative treatment is chosen.Coombes et al. randomized patients with unilateral tennis elbow to receive either (1) corticosteroid injection, (2) placebo injection, (3) corticosteroid injection plus physical therapy or (4) placebo injection plus physical therapy. They found thatcorticosteroid resulted in worse clinical outcome and recurrence rate compared to placebo injection. Use of physical therapy did not produce any significant differences.Dines et al. review the diagnosis and of tennis injuries, including lateral epicondylitis. Although they acknowledge that there is "no long term benefit with regard to tendon healing," they note that steroid injection may be useful to control acute symptoms.Boyer et al. review the myths surrounding lateral epicondylitis. They note that despite widespread use, corticosteroid injection has repeatedly been shown to have no long term benefit. They conclude based on their review of the literature that if there is any benefit to steroid injection, it is of short duration, and in patients whose symptoms have been of short duration, without any previous treatment.Incorrect answers:

Question 950

Topic: 9. Shoulder and Elbow

A 54-year-old laborer has a 6-month history of lateral elbow pain. An elbow examination reveals full range of motion, tenderness over the lateral epicondyle, and pain with resisted wrist extension with the elbow in extension. Elbow radiograph findings are normal. You perform a steroid injection and the patient's symptoms are decreased 6 weeks later. One year after receiving the injection, this patient—when compared to a patient who did not have a steroid injection—is likely to

. have no difference in elbow pain.
. no longer have elbow pain.
. need surgery.
. experience tendon rupture.

Correct Answer & Explanation

. have no difference in elbow pain.

Explanation

EXPLANATION:This patient has signs and symptoms of lateral epicondylitis. Treatments include various forms of physical therapy, iontophoresis, corticosteroid injection, nitroglycerin patch treatment, blood injections, prolotherapy, and surgical intervention. No single treatment is superior to other treatments for this common problem. Several studies have demonstrated a short-term decrease in symptoms following steroid injection (6 weeks) but an increased likelihood of persistent symptoms 1 year after treatment. Steroid injection at this site has not been associated with increased risk for tendon rupture or need forsurgical intervention.

Question 951

Topic: 9. Shoulder and Elbow

A 28-year-old man sustained numerous injuries in an accident including a dislocation of the elbow and a severe closed head injury that resulted in unconsciousness. The elbow was reduced in the emergency department. After 1 month of rehabilitation, the patient reports pain and stiffness. A radiograph is shown in Figure 23. Management should now consist of

. semiconstrained total elbow arthroplasty.
. ulnohumeral arthroplasty and anterior and posterior capsular releases.
. closed reduction and external fixation.
. open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.
. open reduction, heterotopic excision, anterior and posterior capsular releases, and pin fixation across the joint for 3 weeks.

Correct Answer & Explanation

. semiconstrained total elbow arthroplasty.

Explanation

DISCUSSION: In a young individual with a chronic dislocation of the elbow and heterotopic bone formation, the treatment of choice is open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a dynamic hinged fixator to begin protected early postoperative range of motion.  It is important to understand that the fixator protects the reconstruction and allows early range of motion, but it does not maintain the reduction and should not be expected to do so.  Pin fixation across the elbow delays early motion and is not recommended.  Total elbow arthroplasty is not indicated, and ulnohumeral arthroplasty is for a primary arthritic condition.REFERENCES: Garland DE, Hanscom DA, Keenan MA, et al: Resection of heterotopic ossification in the adult with head trauma.  J Bone Joint Surg Am 1985;67:1261-1269.Moor TJ: Functional outcome following surgical excision of heterotopic ossification in patients with traumatic brain injury.  J Orthop Trauma 1993;7:11-14.

Question 952

Topic: 9. Shoulder and Elbow

A 50-year-old competitive tennis player sustained a shoulder dislocation after falling on his outstretched arm 3 weeks ago. He now reports that he has regained motion but continues to have painful elevation and weakness in external rotation. A subacromial cortisone injection provided 3 weeks of relief, but the pain has returned. Which of the following studies will best aid in diagnosis?

. CT
. Limited bone scan
. MRI
. Joint aspiration
. Functional capacity examination

Correct Answer & Explanation

. CT

Explanation

DISCUSSION: Based on these findings, the most likely diagnosis is a rotator cuff injury and probable tear; therefore, MRI is the study of choice.  CT is preferred for articular fractures.  A bone scan is nonspecific and can identify inflammation or occult fracture.  Joint aspiration is not likely to identify an effusion.  Physical therapy and a functional capacity examination are used to identify weakness during recovery prior to a return to work or sports.REFERENCES: Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient.  Clin Orthop 1986;206:192-195.Matsen FA III, Thomas SC, Rockwood CA: Anterior glenohumeral instability, in Rockwood CA, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1990, pp 526-622.

Question 953

Topic: 9. Shoulder and Elbow

Figure 56 is the MR image of a 20-year-old Division I baseball pitcher who has a 1-month history of medial elbow pain in his throwing arm. He also notes a decrease in both control and pitching velocity. An examination reveals tenderness at the medial epicondyle that is exacerbated with valgus elbow stress. The strongest indication for ulnar collateral ligament (UCL) reconstruction is

. progressive ulnar neuropathy.
. a decision to enter the Major League Baseball (MLB) draft.
. pain with resisted wrist flexion.
. failure to improve after prolonged nonsurgical treatment.

Correct Answer & Explanation

. progressive ulnar neuropathy.

Explanation

DISCUSSIONAll responses represent findings that may be associated with chronic UCL insufficiency. Responses 1 and 3 reflect injury to the UCL itself. In most patients, particularly young patients, UCL reconstruction should not be considered until an appropriate trial of nonsurgical measures has failed. This trial should include, at a minimum, 6 weeks of throwing abstinence followed by rehabilitation to address pitching mechanics and shoulder motion deficits and core strengthening. Although the decision to enter the MLB draft may influence surgical decision making, a pitcher with a 1-month history of elbow symptoms should attempt nonsurgical therapy before making a surgical decision that is not based on clinical data.

Question 954

Topic: 9. Shoulder and Elbow

A 23-year-old male college quarterback presents with acute left shoulder pain after being tackled. A radiograph of the injury is shown in figure A. After successful closed reduction, what shoulder position should be avoided in order to minimize the risk of a repeat injury? Review Topic

. Abduction to 90 degrees with maximal external rotation
. Forward elevation to 170 degrees with neutral rotation
. Cross-body adduction at 90 degrees flexion, with internal rotation
. Extension with maximal internal rotation
. Flexion to 90 degrees with maximal external rotation

Correct Answer & Explanation

. Abduction to 90 degrees with maximal external rotation

Explanation

The patient presents with a traumatic posterior shoulder dislocation and radiographic evidence of a reverse Hill-Sachs type injury. The patient should avoid adduction, 90 degrees flexion, and internal rotation in order to decrease the risk of re-dislocation.Shoulder stability is achieved through the both dynamic and static stabilizers. The static stabilizers include the bony morphology of the joint, glenoid labrum, capsule, and glenohumeral ligaments. The contributions of the glenohumeral ligaments to shoulder stability are dependent upon the position of the humerus relative to the glenoid. Posterior stability is afforded to the joint by the superior glenohumeral ligament (SGHL) and the posterior band of the inferior glenohumeral ligament (IGHL). The SGHL specifically is taught and provides posterior stability with the shoulder in flexion, adduction, and internal rotation.Kim et. al. reviewed their experience treating 27 athletes diagnosed with traumatic posterior shoulder instability and treated with arthroscopic posterior labral repair and capsular shift. Most patients were found to have an incompletely stripped posterior capsulolabral complex. After arthroscopic repair and shift, all 26 of the 27 patients treated had improved shoulder function and objective scores, a stable shoulder, and were able to return to sport.Millett et. al. reviewed posterior shoulder instability. They describe the static restraints of the posterior shoulder as the SGHL, posterior band of IGHL, and the coraohumeral ligament (CHL). The SGHL and CHL are both taught in the position of flexion, adduction, and internal rotation, whereas the posterior band of the IGHL is taught in abduction. They describe posterior instability occuring secondary to overhead sports due to repetitive microtrauma causing gradual capsular failure.Figure A is an axillary radiograph of the left shoulder demonstrating a posterior dislocation and an engaging reverse Hill-Sachs lesion.Incorrect Answers:

Question 955

Topic: 9. Shoulder and Elbow

A 4-year-old boy with arthrogryposis has little active motion of his knees or elbows. Both elbows are in full extension with good triceps strength, but he is unable to bring his hand to his face or feed himself. Management should consist of

. observation.
. serial casting.
. flexion osteotomy of the distal humerus.
. posterior soft-tissue elbow release and anterior triceps transfer.
. adaptive equipment.

Correct Answer & Explanation

. observation.

Explanation

DISCUSSION: Elbow release and triceps transfer to restore motion can be performed in children who are age 4 years and older.  The ability to flex the elbow either actively or passively is of great assistance in activities of daily living.REFERENCES: Van Heest A, Waters PM, Simmons BP: Surgical treatment of arthrogrypsosis of the elbow.  J Hand Surg Am 1998;23:1063-1070.Caroll RE, Hill NA: Triceps transfer to restore elbow flexion: A study of fifteen patients with paralytic lesions and arthrogryposis.  J Bone Joint Surg Am 1970;52:239-244.

Question 956

Topic: 9. Shoulder and Elbow

-A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test. What phase of the throwing cycle most likely will reproduce his symptoms?

. Early cocking
. Late cocking
. Acceleration
. DecelerationDISCUSSION --This patient is experiencing soreness over his medial (ulnar) collateral ligament. Valgus overload is likely to reproduce his symptoms and is most pronounced during the late cocking phase of the throwing cycle.In wind up, very little elbow torque is required. In early cocking, the arm is getting loaded and maximum valgus is not yet achieved at the elbow. In acceleration and deceleration, more force is generated at the level of the shoulder joint.

Correct Answer & Explanation

. Early cocking

Explanation

Question 957

Topic: 9. Shoulder and Elbow

A 19-year-old football player who sustained three traumatic anterior shoulder dislocations underwent surgery to repair a Bankart lesion. Nine months after surgery, examination reveals stability, elevation to 150 degrees, external rotation to 0 degrees with the elbow at his side and to 50 degrees at 90 degrees of abduction, and internal rotation to T12. If his range of motion does not improve, he is at most risk for

. glenohumeral osteoarthritis.
. recurrent posterior subluxation.
. internal impingement syndrome.
. thoracic outlet syndrome.
. subscapularis tendon detachment.

Correct Answer & Explanation

. glenohumeral osteoarthritis.

Explanation

DISCUSSION: Loss of external rotation can lead to degenerative joint disease following an anterior stabilization procedure.  A tight anterior capsule will prevent internal impingement.  Risk of thoracic outlet syndrome should not be increased.  Subscapularis detachment is a risk following open anterior repair; however, a gain in external rotation would be noted.  In time, this patient’s shoulder may show increased posterior glenohumeral wear but should not have symptoms of recurrent subluxation unless multidirectional instability is present.REFERENCES: Hawkins RJ, Angelo RL: Glenohumeral osteoarthrosis: A late complication of the Putti-Platt repair.  J Bone Joint Surg Am 1990;72:1193-1197.Norns TR: Complications following anterior instability repairs, in Bigliani LU (ed): Complication of Shoulder Surgery.  Baltimore, MD, Williams and Wilkins, 1993, pp 98-116.

Question 958

Topic: 9. Shoulder and Elbow

Examination of a 9-year-old girl who injured her left elbow in a fall reveals tenderness and swelling localized to the medial aspect of the elbow. Motor and sensory examinations of the hand are normal, and circulation is intact. A radiograph is seen in Figure 28. Management should consist of

. long arm cast immobilization.
. open reduction and internal fixation, followed by cast immobilization.
. closed reduction and percutaneous pin fixation.
. anterior transposition of the ulnar nerve.
. excision of the loose fragment and repair of the common flexor origin.

Correct Answer & Explanation

. long arm cast immobilization.

Explanation

DISCUSSION: Avulsion fractures of the medial epicondyle are caused by a valgus stress applied to the immature elbow and usually occur in children between the ages of 9 and 14 years.  Long-term studies have shown that isolated fractures of the medial epicondyle with between 5 to 15 mm of displacement heal well.  Brief immobilization (1 to 2 weeks) in a long arm cast or splint yields results similar to open reduction and internal fixation.  Fibrous union of the fragment is not associated with significant symptoms or diminished function.  Surgical excision of the fragment yielded the worst results in one study and should be avoided.  Open reduction is best reserved for those injuries in which the medial epicondylar fragment becomes entrapped in the elbow joint during reduction and cannot be extracted by closed manipulation.REFERENCES: Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term results of treatment of fractures of the medial humeral epicondyle in children.  J Bone Joint Surg Am2001;83:1299-1305.Josefsson PO, Danielsson LG: Epicondylar elbow fracture in children: 35-year follow-up of56 unreduced cases.  Acta Orthop Scand 1986;57:313-315.

Question 959

Topic: 9. Shoulder and Elbow

Figure 51 shows the radiograph of a 42-year-old construction worker who has pain and limited motion in his dominant elbow. Management consisting of nonsteroidal anti-inflammatory drugs and cortisone has failed to provide relief. What is the next most appropriate step in treatment?

. Unlinked elbow arthroplasty
. Linked elbow arthroplasty
. Interposition arthroplasty
. Arthroscopic or open debridement
. Radial head excision

Correct Answer & Explanation

. Unlinked elbow arthroplasty

Explanation

DISCUSSION: The patient has symptomatic primary osteoarthritis of the elbow with multiple loose bodies.  Given his age and occupation, an elbow arthroplasty is not an option.  Arthroscopic debridement and removal of loose bodies has been shown to be effective for osteoarthritis of the elbow.REFERENCES: Gramstad GD, Galatz LM: Management of elbow osteoarthritis.  J Bone Joint Surg Am 2006;88:421-430.Steinmann SP, King GJ, Savoie FH III, et al: Arthroscopic treatment of the arthritic elbow.J Bone Joint Surg Am 2005;87:2114-2121.

Question 960

Topic: 9. Shoulder and Elbow
Which of the following has been associated with a decreased rate of glenoid component radiolucent lines?
. A curve-backed pegged cemented polyethylene glenoid component
. A curve-backed keeled cemented polyethylene glenoid component design
. A flat-backed keeled cemented polyethylene glenoid component
. An oversized pegged cemented glenoid component
. A superiorly placed pegged glenoid component

Correct Answer & Explanation

. A curve-backed pegged cemented polyethylene glenoid component

Explanation

DISCUSSION: According to a recent study, cemented pegged glenoid components had fewer radiolucent lines initially and at 2-year follow-up when compared to a cemented keeled design. Curve-backed designs have also shown fewer radiolucent lines when compared to flat-backed designs. Oversizing the glenoid can lead to impaired rotator cuff function and decreased range of motion. An off-centered glenoid can lead to early loosening. REFERENCES: Gartsman GM, Elkousy HA, Warnock KM, et al: Radiographic comparison of pegged and keeled glenoid components. J Shoulder Elbow Surg 2005;14:252-257. Szabo I, Buscayret F, Edwards TB, et al: Radiographic comparison of flat-back and convex-back glenoid components in total shoulder arthroplasty. J Shoulder Elbow Surg 2005;14:636-642. Mileti J, Boardman ND III, Sperling JW, et al: Radiographic analysis of polyethylene glenoid components using modern cementing techniques. J Shoulder Elbow Surg 2004;13:492-498.

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