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 1081
Topic: 9. Shoulder and Elbow
The anterior band of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow. Which of the following statements accurately describes the tension of its functional bundles during elbow range of motion?
Correct Answer & Explanation
. The anterior bundle is tight in extension, while the posterior bundle is tight in flexion.
Explanation
The anterior band of the UCL consists of distinct anterior and posterior bundles. The anterior bundle is tight in extension (primary restraint to valgus stress from 0-30 degrees), while the posterior bundle of the anterior band is tight in flexion (most active at 60-120 degrees).
Question 1082
Topic: 9. Shoulder and Elbow
A 25-year-old baseball pitcher undergoes an arthroscopic repair of a Type II SLAP tear. Postoperatively, he develops severe stiffness and loss of external rotation. Entrapment or over-tensioning of which structure is most likely responsible for this complication?
Correct Answer & Explanation
. Inferior glenohumeral ligament
Explanation
When repairing a SLAP lesion, placing an anchor anterior to the biceps root carries the risk of inadvertently capturing or over-tensioning the middle glenohumeral ligament (MGHL). This directly leads to a significant postoperative loss of external rotation.
Question 1083
Topic: 9. Shoulder and Elbow
No fractures were identified and the patient was treated nonsurgically in a range-of-motion brace. Two months later, he continued to experience elbow pain and was unable to return to sports. He regained motion and strength with physical therapy, there was no gross instability with varus or valgus testing, and he had a negative moving-valgus stress test. The orthopaedic surgeon performed an examination under anesthesia in the operating room (Video 54). Which anatomic structure is injured?
DISCUSSIONNinety percent of elbow dislocations occur in a posterolateral direction. O’Driscoll and associates described the mechanism of injury in posterolateral elbow dislocations in 1992, reporting that they occur most typically after a fall onto an outstretched arm. As the arm hits the ground it causes axial compression, forearm supination, and valgus load across the elbow. The triceps fires, pulling the olecranon posterior; the forearm supinates while simultaneous shoulder internal rotators fire; and the elbow falls into valgus. These 3 mechanisms cause the elbow to subluxate and dislocate posterolaterally. The elbow is most stable following posterolateral dislocation in a flexed and pronated position. The elbow is least stable in extension and supination. Simple dislocation often can be treated nonsurgically, while fracture dislocation will usually necessitate surgical intervention. The video shows the elbow pivot-shift test, which evaluates for posterolateral rotatory instability. A positive test finding elicits apprehension and, in this case, radial head subluxation and confirms an insufficient lateral UCL.
Question 1084
Topic: 9. Shoulder and Elbow
A 66-year-old man who underwent shoulder arthroplasty 7 years ago reports progressively worsening shoulder pain for the past 4 weeks after hospital discharge for community-acquired pneumonia. He is afebrile and reports no chills or night sweats. Laboratory studies show a white blood cell count of 11,200/mm3 and an erythrocyte sedimentation rate of 25/h. Shoulder radiographs are negative for fracture, dislocation, or signs of implant loosening. What is the most appropriate management? Review Topic
Correct Answer & Explanation
. Follow-up in 2 weeks with a repeat white blood cell count and erythrocyte sedimentation rate
Explanation
The patient may have hematologic spread of the pulmonary infection to the shoulder arthroplasty; however, further work-up is necessary at this point. The elevated laboratory studies may still be secondary to the pulmonary infection. Aspiration of the shoulder joint with stat Gram stain and culture of the fluid is indicated. If the aspirate shows signs of infection and irrigation and debridement is indicated, complete revision of the well-seated implants may not be necessary. Physical therapy and nonsteroidal anti-inflammatory drugs are not indicated until the possibility of a shoulder infection has been ruled out. A wait of 2 weeks to repeat the laboratory values, in the presence of new shoulder pain, is contraindicated.
Question 1085
Topic: 9. Shoulder and Elbow
Figures 186a and 186b are the radiographs of a 10-year-old girl who sustained an injury 2 days ago after jumping off another girl's shoulders while cheerleading. She is unable to walk and has no other injuries. Examination reveals swelling below the knee and a palpable defect at the tibial tubercle. The knee is ligamentously stable medial-lateral and anterior-posterior. What is the next most appropriate step in management? Review Topic
Correct Answer & Explanation
. MRI scan of the knee
Explanation
The radiographs show the patella elevated and the patellar ligament insertion retracted greater than 2 cm. The most appropriate treatment is repair of the patellar ligament. Excision of the fragment and application of a cast will not restore quadriceps function. A CT scan will only demonstrate what is evident on the radiographs and an MRI scan is not needed because the knee is ligamentously stable.
Question 1086
Topic: Shoulder Pathology
In the most common condition causing a winged scapula, which of the following nerves is affected? Review Topic
Correct Answer & Explanation
. Long thoracic nerve
Explanation
A winged scapula is most often associated with Parsonage-Turner syndrome, a condition thought to be due to an inflammatory or immune-mediated mechanism. Certain muscles are predisposed, particularly the serratus anterior muscle innervated by the long thoracic nerve. Other less common nerve lesions (eg, the spinal accessory and dorsal scapular nerves) may also cause winged scapulae.
Question 1087
Topic: 9. Shoulder and Elbow
A 32-year-old male electrical worker complains of isolated left shoulder pain after a fall from 6 feet. Radiographs of the shoulder are seen in Figures A and B. The radiology technician was unable to obtain a good axillary view due to significant pain and muscle spasm. What would be the next most appropriate step in management? Review Topic
Correct Answer & Explanation
. Examination under anesthesia
Explanation
This patient presents with risk factors of posterior shoulder dislocation. The next most appropriate step in the management of this patient would be to obtain orthogonal shoulder radiographs using a Velpeau view of the right shoulder as seen in Illustration A.Risk factors for posterior shoulder dislocation include epilepsy, electrocution and high-energy trauma. To make a diagnosis, standard views of the shoulder are required. These include an anteroposterior (AP) view, lateral scapular view and an axillary view. The axillary view is essential for diagnosis, but this requires the arm to be positioned in 20 - 30 degrees of abduction. If pain and muscle spasm restrict arm movement, the next most appropriate view would include a modified axially view,such as a Velpeau view.Robinson et al. reviewed posterior shoulder dislocations and fracture-dislocations. They state that apical oblique, Velpeau, or modified axial radiographs are preferable to other alternative axillary views, as they can be obtained with the arm in a sling. When an osseous injury is suspected, a CT scan and three-dimensional reconstruction can be useful in planning operative management.Millet et al. wrote a JAAOS article on recurrent posterior shoulder instability. They state that 5 radiographic views, or advanced imaging, is essential to evaluate the shoulder. Characteristics to consider include, joint location, humeral head position, glenoid morphology (e.g., retroversion, hypoplasia, posterior glenoid rim), and impaction fracture of the humeral head.Figure A and B show a normal shoulder radiograph with the shoulder positioned in internal rotation and external rotation. Illustration A shows the correct positioning of a patient to obtain a Velpeau view of the shoulder. Illustration B shows the correct positioning of a patient to obtain a Stryker notch view of the shoulder. This is used to asses for humeral head defects.Incorrect Answers:
Question 1088
Topic: Elbow & Forearm
Histologic studies of surgically resected tissue in lateral epicondylitis demonstrate which of the following findings? Review Topic
Correct Answer & Explanation
. Chondroblastic proliferation
Explanation
The extensor carpi radialis brevis is most often cited as the anatomic location of pathology in lateral epicondylitis. Histologic examination demonstrates noninflammatory tissue, primarily angiofibroblastic tendinosis though normal tendon histology is also present. There is usually no evidence of acute inflammation or chondroblastic tissue, or significant calcium deposition.
Question 1089
Topic: 9. Shoulder and Elbow
Osteonecrosis of the humeral head is a rare complication seen after dislocation of the glenohumeral joint in skeletally immature patients. When this complication is encountered, treatment should consist of Review Topic
Correct Answer & Explanation
. humeral head arthroplasty.
Explanation
This rare complication occurs after fracture-dislocation and has been seen after surgical stabilization in the adolescent. In most reported cases, prolonged observation has been shown to result in revascularization.
Question 1090
Topic: 9. Shoulder and Elbow
A 52-year-old man who dislocated his dominant shoulder has it reduced in the emergency department and he is placed in a sling. At his 5-day followup evaluation, he reports that this is his first shoulder dislocation and that the pain is mostly gone but he notes difficulty using his arm overhead and away from his body. Examination reveals minimal pain with passive range of motion, a positive apprehension and relocation test, and 3/5 strength with the empty can test and external rotation at the side compared with 5/5 with those tests on the contralateral side. Cutaneous sensation over the lateral aspect of the shoulder is intact. Radiographs show the glenohumeral joint is reduced with no fractures or degenerative changes. What is the next step in management? Review Topic
Correct Answer & Explanation
. CT of the shoulder
Explanation
Obtaining an MRI scan to evaluate for a rotator cuff tear is a reasonable next step. The patient sustained a first-time shoulder dislocation, and given his age and clinical presentation, it is likely that he injured the rotator cuff. Large, full-thickness rotatorcuff tears following dislocation in young individuals warrants early surgical intervention. Delay of surgical repair for large, full-thickness tears may lead to irreversible changes, including atrophy and retraction of the tendon. As a result, clinical outcomes may be compromised. CT will demonstrate bony changes, but it is not as effective as MRI for soft-tissue pathology. While in the short term a sling for comfort might be helpful, 6 weeks of immobilization is unnecessary because recurrent instability is rarely an issue. Physical therapy can be beneficial but could potentially delay identification of an acute rotator cuff tear. In the event the MRI does not reveal a large, full-thickness rotator cuff tear, physical therapy would be an appropriate next step. There is no indication for urgent shoulder arthroscopy.
Question 1091
Topic: 9. Shoulder and Elbow
Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched arm and sustained a fracture-dislocation of the elbow. Initial management consisted of closed reduction of the dislocation. Surgical treatment should now include repair or reduction and fixation of the
Correct Answer & Explanation
. medial and lateral collateral ligaments, radial head, and coronoid.
Explanation
DISCUSSION: The radiographs show fractures of the coronoid and radial head. The medial collateral ligament has been avulsed from the ulnar insertion, and there is a valgus opening on the medial side. The lateral collateral ligament is always disrupted in elbow dislocations and fracture-dislocations that occur secondary to falls. This is known as the terrible triad injury (dislocation and fractures of the coronoid and radial head); it has a very poor prognosis because of its propensity for recurrent or persistent instability and late arthritis. The principle in treating this injury is to repair all of the injured parts or protect them with a hinged external fixator until they heal. REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354. Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294. O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102.
Question 1092
Topic: 9. Shoulder and Elbow
Figure 37 shows a coronal T2-weighted MRI scan. What is the name of the labeled torn structure?
Correct Answer & Explanation
. Lateral collateral ligament (LCL)
Explanation
DISCUSSION: The labeled structure is the LCL, and it is avulsed from the lateral humeral epicondyle. This is the most common site of injury for the LCL. The biceps and brachialis tendon insertions are not well visualized in this section. The MCL and flexor/pronator origin are intact.
Question 1093
Topic: 9. Shoulder and Elbow
A 25-year-old man underwent a Putti-Platt repair for recurrent anterior dislocation of his right shoulder 9 months ago. He reports no further episodes of instability but continues to have severely restricted motion, with external rotation limited to less than 0 degrees with the arm at the side. He has pain at the ends of range of motion and restricted activities of daily living despite undergoing nearly 9 months of physical therapy. Radiographs of the shoulder show no arthritic changes. Management should now consist of
Correct Answer & Explanation
. open release with Z-plasty lengthening of the subscapularis and capsule.
Explanation
Open release allows lengthening of the shortened subscapularis and is preferred when there are extra-articular contractures. Arthroscopic release, combined with the use of an interscalene catheter postoperatively, is an excellent treatment for capsular contractures but is contraindicated after procedures that result in extracapsular shortening (i.e., Magnuson-Stack, Putti-Platt). Additional physical therapy or manipulation under anesthesia is not likely to be helpful. Shoulder hemiarthroplasty is contraindicated with normal articular surfaces, but prosthetic arthroplasty is sometimes necessary for arthritis associated with instability or overly tight instability repairs.
Question 1094
Topic: 9. Shoulder and Elbow
Which of the following anatomic structures is often difficult to visualize during elbow arthroscopy?
Correct Answer & Explanation
. Ulnar collateral ligament
Explanation
The ulnar collateral ligament is often difficult to visualize during elbow arthroscopy. It can be seen clearly in only 10% to 30% of elbow arthroscopies. All of the other structures should be easily and thoroughly seen and palpated during elbow arthroscopy.
Question 1095
Topic: 9. Shoulder and Elbow
Which of the following shoulder girdle muscles is most active during forward flexion?
Correct Answer & Explanation
. Biceps
Explanation
The percentage of recorded EMG activity indicates the level of activity of a given muscle but does not indicate the force generated. During forward elevation, the upper portion of the trapezius, levator scapulae, and serratus anterior contract to produce a scapular rotating force upward, increasing the stability of the glenohumeral joint. The essential muscles for forward elevation are the deltoid, the supraspinatus, the trapezius and the serratus anterior. EMG reveals the serratus to be most active.
Question 1096
Topic: 9. Shoulder and Elbow
A 45-year-old right-hand dominant woman falls onto an outstretched left hand. Imaging shows a complex elbow dislocation. The postreduction CT scan demonstrates a reduced joint, comminuted radial head fracture, and type I coronoid fracture. Surgical intervention is recommended to address the involved structures. Which component of the intervention adds the most rotational stability?
Correct Answer & Explanation
. Repair or reconstruction of the lateral collateral ligament (LCL) complex
Explanation
This represents a terrible triad injury, with elbow dislocation, radial head fracture, and coronoid fracture. The LCL complex is typically disrupted in this injury pattern. Repair or reconstruction of this structure provides the greatest increase in rotational stability of the elbow.
Question 1097
Topic: 9. Shoulder and Elbow
Figure A is an AP radiograph of a 68-year-old man who presents to clinic with shoulder pain and dysfunction. On examination of his shoulder, he has pseudoparalysis with attempt at forward elevation and a positive hornblower's sign while demonstrating normal belly press test. Treatment should consist of: Review Topic
Correct Answer & Explanation
. Arthroscopic rotator cuff repair
Explanation
The clinical presentation and radiograph is consistent with a diagnosis of a massive posterosuperior rotator cuff tear and arthropathy. Of the options listed, a reverse total shoulder arthroplasty (RTSA) with latissmus dorsi transfer (LDT) is most appropriate.RTSA can improve pain and function in shoulders with forward elevation pseudoparalysis secondary to rotator cuff tear arthropathy. Following arthroplasty, the deltoid alone can restore overhead elevation but it does not address active external rotation deficit. LDT is a well described procedure for treatment of irreparable posterosuperior rotator cuff tear. Combining RTSA and LDT can address both deficits and in select patients yields significant pain relief and restoration of function.Walch et al found that hornblower's sign had 100% sensitivity and 93% specificity for irreparable degeneration of teres minor.Puskas et al present clinical outcomes of RTSA combined with LDT for treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder in 40 patients. At a mean follow-up of 53 months, the author report excellent clinical outcomes.Figure A demonstrates a proximal migration of the humerus resulting in femoralization of the humeral head and acetabularization of the acromion from a massive rotator cuff tear.Incorrect answers:
Question 1098
Topic: 9. Shoulder and Elbow
Figure 14 shows the AP radiograph of a patient who underwent prosthetic arthroplasty 8 years ago and has now become symptomatic again over the past 18 months. A WBC count and erythrocyte sedimentation rate are within normal limits, and aspiration of the glenohumeral joint yields a negative Gram stain and cultures. Which of the following procedures will most likely provide the best pain relief and function?
Correct Answer & Explanation
. Removal of the loose glenoid component and reimplantation of a new glenoid component
Explanation
DISCUSSION: Simple removal of the loose glenoid component or removal of the loose component followed by implantation of a new glenoid component are both appropriate treatment choices, depending on the remaining glenoid bone stock. However, removal and reimplantation appears to provide the most predictable pain relief and better function than removal alone. REFERENCES: Antuna SA, Sperling JW, Cofield RH, et al: Glenoid revision surgery after total shoulder arthroplasty. J Shoulder Elbow Surg 2001;10:217-224. Rodosky MW, Bigliani LU: Surgical treatment of non-constrained glenoid component failure. Oper Tech Orth 1994;4:226-236.
Question 1099
Topic: 9. Shoulder and Elbow
Figure 16 shows the radiograph of a 23-year-old man who has severe right shoulder pain after his motorcycle hit a bridge guardrail. He is neurologically intact. Nonsurgical management will most likely result in
Correct Answer & Explanation
. high patient satisfaction and good shoulder function.
Explanation
DISCUSSION: Internal fixation of the clavicle, glenoid, or both has been recommended for fractures of the clavicle and glenoid neck (floating shoulders). Recently, the inherent instability of these dual fractures has been questioned in a biomechanical model without further disruption of the coracoclavicular or acromioclavicular ligamentous structures. Nonsurgical management of the majority of combined scapular/glenoid fractures in patients with less than 10 mm of displacement has resulted in excellent shoulder function and will most likely achieve an excellent result in this patient. REFERENCES: Egol KA, Connor PM, Karunakar MA, Sims SH, Bosse MJ, Kellam JF: The floating shoulder: Clinical and functional results. J Bone Joint Surg Am 2001;83:1188-1194. Williams GR Jr, Naranja J, Klimkiewicz J, et al: The floating shoulder: A biomechanical basis for classification and management. J Bone Joint Surg Am 2001;83:1182-1187. Edwards SG, Whittle AP, Wood GW: Nonoperative treatment of ipsilateral fractures of the scapular and clavicle. J Bone Joint Surg Am 2000;82:774-779.
Question 1100
Topic: 9. Shoulder and Elbow
A 78-year-old woman falls onto her nondominant left elbow and sustains the injury shown in Figure 5. What treatment option allows her the shortest recovery time and highest likelihood of good function and range of motion?
Correct Answer & Explanation
. Total elbow arthroplasty
Explanation
DISCUSSION: Total elbow arthroplasty has become the treatment of choice for complex, comminuted distal humeral fractures in patients older than age 70 years. It yields a faster recovery with more predictable functional outcomes, although limitations of lifting weight of more than 5 pounds must be followed to avoid loosening.
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