9. Shoulder and Elbow MCQs

Varus posteromedial rotatory instability occurs following a fall onto an outstretched hand with axial loading and a varus stress to the elbow. This injury can result in a rupture of the posterior band of the medial collateral ligament (MCL), fracture of the anteromedial facet of the coronoid, and avulsion of the lateral ulnar collateral ligament (LUCL). Based on the examination findings, this patient has an acute MCL rupture. Furthermore, the LUCL appears intact, as evidence by the stability with varus stress. To protect the reduction in the acute setting, posterior splinting is recommended, but placing the forearm in full supination tightens the structures medially where the MCL is deficient. Splinting in neutral is indicated for valgus posterolateral rotatory instability, where both the LUCL and MCL are ruptured. Splinting in full pronation is indicated for isolated LUCL ruptures. Early active range of motion is not recommended for adults immediately after an acute elbow dislocation, as ligamentous injury or fracture nearly always accompanies the dislocation. In this case, theforearm should be splinted in full supination.

This is a rare injury, and it is important to recognize both the proximal and distal concurrent injuries. In the past, the radial head excision has been the primary form of treatment, but this has shown poor long-term results; silicone replacement has been fraught with reactive synovitis. Radial ulnar synostosis is a complication, not a planned course of treatment.

The hook test is the most reliable physical examination maneuver for diagnosing a distal biceps tendon rupture. The examiner hooks their finger under the biceps tendon from the lateral side to the medial side. If the tendon is intact, the examiner's finger will be blocked by the cord-like structure of the tendon.

This is a typical presentation for an osteochondral lesion of the capitellum. This patient is young and has, by definition, a stable lesion and has excellent potential to heal this lesion with nonsurgical management. However, the patient should stop her activities (gymnastics) to prevent further damage and the possible development of an unstable lesion that might then necessitate surgery. Surgical procedures are generally not necessary for the treatment of these lesions.

DISCUSSION: Rheumatoid arthritis is sometimes associated with radiographic evidence of instability of the cervical spine. In a study by Grauer and associates, radiographs of the cervical spine of patients with rheumatoid arthritis who had undergone total joint arthroplasty over a 5-year period were retrospectively reviewed. Nearly one half of the patients had radiographic evidence of cervical instability on the basis of traditional measurements. While radiographic evidence of cervical instability was not infrequent in this population of patients who underwent total joint arthroplasty for rheumatoid arthritis, radiographic predictors of paralysis were much less common. MRI prior to surgery may also be a consideration if the radiographic appearance of the rotator cuff alters the consideration of surgical treatment. In a series of patients undergoing prosthetic arthroplasty for a variety of shoulder disorders, the presence of a rotator cuff tear has been shown to be associated with a less favorable outcome. Most often, the presence of a rotator cuff tear was associated with a diagnosis of rheumatoid or other inflammatory arthritis and the tears were large and generally irreparable. Some case series demonstrated a higher prevalence of loosening of the glenoid component in patients with a large rotator cuff tear associated with superior migration of the humeral head. However, obtaining an MRI scan of the shoulder is not considered the best response since failure to determine cervical instability may result in anesthetic death.

DISCUSSION: The patient has a complex fracture-dislocation of the elbow. The radial head is fractured, and there is a displaced coronoid fracture. These associated fractures indicate that the elbow is at high risk for recurrent instability after initial treatment. To prevent this complication, surgical treatment will most likely be required and will consist of some or all of the following: radial head open reduction and internal fixation or replacement, coronoid open reduction and internal fixation, medial and lateral ligament repairs, and even articulated external fixation. This patient was treated with open reduction and internal fixation of the radial head, and the elbow redislocated postoperatively.

DISCUSSION: The image shows a view of the radiocapitellar joint from an anterior medial portal. The radial nerve lies on the elbow capsule at the midportion of the capitellum. It is at risk for injury when capsular excision is performed in this region.

Osteochondritis of the capitellum is a common problem in young throwing athletes and gymnasts. The mechanism of injury involves lateral compression and axial loading of the capitellum. Repetitive trauma causes ischemia with resultant osteochondral necrosis and sometimes eventual separation. Initial management includes rest for a minimum of 6 weeks; occasionally bracing is used. At long-term follow-up, there is typically an observed radiographic abnormality indicating incomplete healing even in asymptomatic patients. Arthroscopy with in situ drilling is reserved for symptomatic lesions that have an intact articular surface. Lesions with partial separation often require fixation. Lateral column osteotomy is a new investigational procedure designed to relieve lateral compression forces and may be used in salvage cases.

DISCUSSION: Humeral arthroplasty is indicated for chronic posterior dislocations when the impression defect in the humeral head is greater than 45% to 50%. If the condition remains undiagnosed for more than 9 to 12 months, secondary degenerative changes on the glenoid may occur, necessitating total shoulder arthroplasty. Open reduction and transfer of the subscapularis and lesser tuberosity are used for impression defects that consist of 20% to 40% of the humeral articular surface. Closed reduction and immobilization with the arm in slight extension and external rotation is useful when the posterior dislocation is diagnosed within the first 6 weeks and the articular defect is less than 20%.

The patient presents with lateral epicondylitis and develops posterolateral rotatory instability (PLRI) of the elbow due to excessive arthroscopic debridement. The correct answer is reconstruction of the lateral ulnar collateral ligament using palmaris longus or gracilis allograft.PLRI is the result of an incompetent lateral ulnar collateral ligament (LUCL), a component of the elbow lateral collateral ligament complex. The LUCL originates on the lateral epicondyle of the humerus and inserts upon the supinator crest of the ulna. When deficient from acute trauma or from repetitive microtrauma, the elbow becomes rotationally unstable with elbow extension, supination, and an applied valgus force. In this case, the patient has had iatrogenic damage to the LUCL from an arthroscopic release of the extensor carpi radialis brevis (ECRB) for treatment of lateral epicondylitis. This patient exhibits an important manifestation of this: a positive chair pushup test. This test is positive when pushing off of a chair with a supinated forearm causes pain and instability. Due to the chronicity of the injury (3 months) and his persistent symptoms of instability (pain and clicking) the patient would benefit from surgical reconstruction of the damaged LUCL using either palmaris longus or gracilis allograft.Kelly et. al. reviewed the known major and minor complications of elbow arthroscopy among 473 consecutive cases at their institution from 1980-1998. The most common complications were transient nerve palsies in 10 patients. Among them, the majornerves involved included the anterior interosseous nerve, posterior interosseous nerve, ulnar nerve, superficial radial nerve, and medial antebrachial cutaneous nerve. The risk of iatrogenic nerve injury was increased among patients with rheumatoid arthritis. The most frequent complication was prolonged drainage from the portal sites.Calfee et. al. reviewed the management of lateral epicondylitis. The authors suggest open or arthroscopic surgical debridement of the common extensor origin after failure of rest, orthoses, nonsteroidal drugs, physical therapy, cortisone and platelet-rich plasma injections. They do acknowledge that excessive debridement may compromise lateral elbow stability and cause PLRI.O'Brien et. al. described the surgical techniques for managing PLRI, including an open technique for chronic injuries or revision treatment. In this setting, the authors suggest use of palmaris or gracilis allograft for reconstruction.Figures A and B are an axial and coronal T2 weighted MRI of an elbow demonstrating signal intensity in the origin of the ECRB, consistent with lateral epicondylitis.Incorrect Answers:

The radiographs show a posterior glenoid osteophyte, often termed a “thrower’s exostosis.” These exostoses are best visualized on the Stryker notch view and may be missed on other more standard radiographic views of the shoulder. CT and MRI scans may be used, but usually add little information to the radiographic findings. Arthroscopic examination of patients with this condition commonly reveals undersurface tearing of the rotator cuff and posterior labrum. Treatment of this condition remains somewhat controversial, with advocacy of both nonsurgical and surgical techniques.

The medial ulnar collateral ligament is subjected to the greatest tensile stress during the late cocking/early acceleration phase of throwing.The medial ulnar collateral ligament, or medial collateral ligament of the elbow, is composed of three bundles: an anterior bundle, a posterior bundle, and a variabletransverse oblique bundle. During late cocking and early acceleration phases of the overhead throw, the medial UCL is subjected to the greatest amount of valgus stress to the elbow. During this phase, the forearm lags behind the upper arm and generates valgus stress while the elbow is primarily dependent on the anterior band of the UCL for stability. This puts the ligament at greatest risk of injury during this phase.Fleisig et al. examined the kinetics of baseball pitching and the implications on injury mechanisms. They showed that the UCL contributes to 54% of the varus torque that is generated during the early acceleration of throwing. The position of greatest load occurred when the arm was flexed to 95 +/14 degrees with an applied valgus load.Illustration A shows a diagram of the medial ulnar collateral ligament ligament bundles. Incorrect Answers:A 14-year-old elite basketball player develops acute medial elbow pain after a fall. Physical examination reveals medial elbow tenderness over the submlime tubercle, but full range of motion. The provocative tests seen in Figure A exacerbate his elbow pain. Radiographs of the elbow are normal. What would be the next best step in treatment?Supervised elbow stretching program Therapeutic elbow arthroscopyStatic elbow external fixation for 3 to 6 weeks, then MR arthrography if pain continues Activity avoidance for 6 weeksSerial inflammatory markers and rheumatology referralFigure A shows a moving valgus stress, which is a provocative test for ulnar collateral ligament (UCL) injury and elbow valgus instability. The initial treatment would be a short period of immobilization, rest and flexor pronator strengthening in this patient population.Adolescent UCL injuries can be effectively treated with a short period of rest and NSAIDs to control pain. As the acute inflammation resolves, the patient can be started on a supervised therapy program. This should target flexor pronator muscles, as they are important secondary dynamic stabilizers of valgus stress. Once symptoms have improved and the athlete has regained full range of motion and strength, a mediated throwing program may be initiated. Throwing athletes should be educated to avoid provocative activities during this period.Chen et al. wrote a JAAOS article on shoulder and elbow injuries in the skeletally immature athlete. They state that surgery is reserved for older athletes with persistent valgus instability despite > 6 months of non-surgical management.Murthi et al. reviewed recurrent elbow instability. They state the anterior bundle of the medial ulnar collateral ligament complex is the primary valgus stabilizer of the elbow. The anterior band is taut for the first 60° of elbow flexion, and the posterior band is taut from 60° to 120° of flexion. The secondary valgus stabilizers of the elbow joint include the radial head, the anterior and posterior aspects of the capsule, and the muscular forces around the joint.Figure A is showing a moving valgus stress. Illustration A shows provocative tests for valgus instability of the elbow. The image on the left shows a valgus stress test. This assesses the anterior bundle of the medial ulnar collateral ligament complex by flexing the elbow to 25-30 degrees and applying a valgus load across the elbow. The image on the right shows milking maneuver. This assesses the posterior bundle of the medial ulnar collateral ligament complex by pulling on thebeyond 90°. Incorrect Answers:A young, healthy male undergoes a distal biceps repair and sustains an iatrogenic nerve injury during the procedure. Which of the following clinical findings are most likely to be seen in this circumstance?Inability to extend the thumbLateral volar forearm numbness Inability to flex the middle finger Medial volar forearm numbness Dorsal thumb numbnessThe most commonly injured nerve during a distal biceps repair is the lateral antebrachial cutaneous nerve (LABCN). Injury to this nerve would result in lateral volar forearm numbness.Distal biceps avulsions can be partial or complete. Indications for surgical management include young, healthy patients who do not wish to sacrifice function, as well as partial biceps avulsions that do not respond to conservative management. Repair of a distal biceps avulsion can be approached through either an anterior one-incision technique or a two-incision technique (BoydAnderson). The one-incision technique uses the interval between the brachioradialis (radial nerve) and pronator teres (median nerve), while the two-incision technique uses this same interval in addition to a second posterolateral elbow incision. The lateral antebrachial cutaneous nerve is the most common nerve injured during either approach.Kelly et al. retrospectively reviewed 74 distal biceps tendon repairs, and found five sensory nerve paresthesias. The lateral antebrachial cutaneous nerve was most commonly injured, followed by the superficial radial nerve.Cain et al. retrospectively reviewed 198 distal biceps tendon repairs, and found a 36% complication rate. Lateral antebrachial cutaneous nerve paresthesias were found in 26%, while radial sensory nerve paresthesias were found in 6%, and posterior interosseous nerve (PIN) injury in 4%.Illustration A shows the close relationship between the lateral antebrachial cutaneous nerve (LABCN) and the distal biceps. Illustration B shows the sensory nerves of the upper extremity and their respective areas of innervation.Incorrect Answers:A 33-year-old female presents with left shoulder weakness. Two weeks prior to presentation, the patient experienced sudden-onset, left shoulder pain, which occurred a few days after receiving the influenza vaccine. The pain subsided over the next day, followed by gradual weakness of her shoulder and eventual general disuse of her left upper extremity. An initial visit to her primary care provider resulted in the recommendation of observation. On physical exam, there is weakness and gross atrophy of the shoulder girdle. Figures A & exhibit T2-weighted MRI images of her left shoulder. To further confirm her suspected diagnosis, she is sent for electromyography.What is the expected result?Normal resultsFibrillation potentials consistent with compression at the spinoglenoid notch 3 . Sharp waves and fibrillations potentials associated with the deltoid and bicepsAcute denervation of both peripheral nerve and nerve root distribution with sharp waves and fibrillation potentialsEarly reinnervation with polyphasic motor unit potentialsThis patient has Parsonage-Turner Syndrome, which, when tested on EMG during the first 3 weeks, exhibits acute denervation of both peripheral nerve and nerve root distributions with positive sharp waves and fibrillation potentials.Parsonage-Turner Syndrome is an idiopathic disorder with an etiology that is still unknown. Typical antecedent events can involve a viral illness, recent immunization, or elective surgery. Clinical presentation is usually initiated by acute onset shoulder pain, which quickly subsides and is followed by gradual weakness. Early MRI exhibits edema in the effected muscles, and fatty infiltration in later stages. Treatment is typically non-operative, and resolution can be seen as early as 6 weeks from onset.Tjoumakaris et al. provide a thorough review of the diagnosis and management of ParsonageTurner Syndrome. The authors report the usefulness of MRI, which exhibits early edema and later fatty infiltration in the affected muscles, and urge the use of EMG as a confirmatory diagnostic measure as well as a monitoring tool to track resolution. Early identification and diagnosis may be treated with a short course of steroids, which may help shorten symptoms.Stutz et al. concisely summarize Parsonage-Turner Syndrome and provide typical presentation, diagnosis and management principles. The authors note the common association with viral illness and/or recent immunization along with the importance of obtaining a baseline chest radiograph to rule out a compressive Pancoast tumor. Management is typically supportive with eventual resolution.Figures A, B, and C are T2-weighted coronal, sagittal, and axial cuts of the shoulder girdle with associated edema in the supraspinatus and infraspinatus typically seen in Parsonage-Turner Syndrome.Incorrect answers:A total shoulder arthroplasty (TSA) would be the most appropriate treatment in which of the following arthritic patients?

Reliability is a measure of how reproducible a test is. This can be interobserver reliability (i.e., reliability between people), or intraobserver reliability (i.e., reliability for the same person doing the outcome measure at different occasions).

Closed central slip injuries treated nonsurgically require extension splinting of the PIP joint. DIP joint active range of motion is allowed during this time period. This allows the connections between the lateral bands and the central slip to pull the central slip distally with DIP joint active motion, minimizing the gap across the central tendon injury and keeping the DIP joint from getting stiff as well.

Results have been satisfactory in many patients; however, at long-term follow-up, examination of the affected shoulder often shows some decrease in range of motion compared with the contralateral side. Although range of motion often improves over time, it does not return to normal in 60% of patients. Pain improves but is often increased compared with the contralateral side.

The metaglen (glenoid baseplate) failed because the central peg of the baseplate was not implanted in the glenoid, and the metaglen did not have a long enough central peg. This was the technical error during baseplate implantation.Glenoid complications are the primary concern of rTSA. Historically, rTSA fail at the glenoid interface because of inadequate fixation. The Grammont-style prosthesis has a medialized center of rotation to circumvent this, but this lead to inferior scapular notching. Newer prosthesis include locking peripheral screws and 15° inferior tilt of the base plate. Further, changing the neck-shaft angle from 155 deg to 143 deg or 135 deg has reduced notching and instability, and reduced the need to for subscapularis repair.Boileau et al. examined revision surgery for rTSA. They found that the most common cause for revision was prosthetic instability (48%). Humeral complications (loosening/derotation/fracture) were 2nd most common and infection was 3rd most common. Underestimation of humeral shortening and excessive medialization were common causes of recurrent prosthetic instability. Proximal humeral bone loss was found to be a cause for humeral loosening or derotation.Holcomb et al. reviewed failure of the rTSA glenoid baseplate in 14 patients, which was defined as shift of the baseplate with or without screw breakage. Strategies for success include: (1) Incorporating increased inferior baseplate tilt in post-revision prosthesis-scapular neck angle (PSNA) compared to pre-failure PSNA because inferior tilt maximizes compressive force across the baseplate-glenoid interface. (2) Locking peripheral 5.0mm screws (rather than non-locking 3.5mm screws). (3) Using larger glenospheres to tighten the patulous soft tissue envelope and secure the glenoid allograft. Four patients required structural allograft (2 iliac crest, 2 femoral head).Figures A shows Hamada 4A cuff tear arthropathy. Figure B shows severe static posterior instability of the humeral head and posterior Walch B2 erosion of the glenoid. Figure C shows the same patient treated with rTSA and iliac crest bone graft. Because of technical error, the central peg was not implanted in the native glenoid. Illustration A shows catastrophic failure of the glenoid baseplate. Illustration B shows the PSNA, with increase in the PSNA from initial rTSA to revision rTSA. Illustration C shows baseplate-glenosphere dissociation. Illustration D shows correction of technical error/too short peg with exchange to a baseplate with a longer peg. Illustration E shows and algorithm for treating unstable rTSA.Incorrect Answers:

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.

A  51-year-old  man  presents  with  persistent  right  shoulder  pain several weeks after falling off a roof. On examination, he has pain with palpation over the greater tuberosity, active forward shoulder flexion of60°, and passive forward shoulder flexion of 160°. He has 2/5 forward flexion and external rotation strength. Initial plain radiographs are unremarkable. A coronal MRI scan of his shoulder is shown in Figure 1. After a thorough discussion, the patient elects to proceed with surgical intervention. During intraoperative assessment, the surgeon contemplates performing a single versus a dual row repair. Currently, what is the consistent difference between the two repair techniques?A.   Dual row repairs result in superior objective clinical outcomesB.   Dual row repairs provide a larger footprint coverage.C.   Single row repairs have a reported higher complete retear rate.D.   Single row repairs have fewer points of tendon fixation.

SICK scapula syndrome typically involves a tight pectoralis minor and weak scapular stabilizers, namely the serratus anterior and lower trapezius. Rehabilitation focuses on stretching the pectoralis minor (to reduce anterior tilt) and strengthening the serratus anterior and lower trapezius to restore proper scapular kinematics.