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9. Shoulder and Elbow MCQs

Practice Set 59 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 1161

Topic: 9. Shoulder and Elbow
Figure 27 shows the radiograph of a 26-year-old man who sustained a closed head injury and a closed elbow dislocation 6 weeks ago. Examination reveals 65 degrees to 115 degrees of flexion, and intensive physical therapy has resulted in no improvement. A decision regarding the timing of surgical correction of the contracture should be based on
. bone scan results returning to normal.
. a decline in intensity on serial bone scans.
. the serum levels of alkaline phosphatase measured over time.
. the level of serum calcium-phosphorus product.
. the time since injury and evidence of bone maturation on plain radiographs.

Correct Answer & Explanation

. the time since injury and evidence of bone maturation on plain radiographs.

Explanation

DISCUSSION: The patient has heterotopic ossification, a more common finding in patients who have sustained head injuries. Treatment will require removal of the heterotopic bone and anterior and posterior capsulectomies. The main concern about timing is the possible recurrence of heterotopic bone. While an extended wait was once thought necessary, this is no longer true. The timing is based on the time since injury and evidence of bone maturation on plain radiographs. A sharp marginal demarcation of the new bone and a trabecular pattern within it are usually present 3 to 6 months after onset, indicating that it is safe to proceed with surgical excision. It is not necessary to wait more than 6 months. Bone scan results are not good indicators because they may remain โ€œhotโ€ for long periods of time. The levels of alkaline phosphatase and serum calcium-phosphorus product do not need to be measured. REFERENCE: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 325-335.

Question 1162

Topic: 9. Shoulder and Elbow
A 42-year-old patient has had painful inferior subluxation of the glenohumeral joint following a recent cerebrovascular accident (CVA). Figure 34 shows the AP radiograph of the shoulder. Management should consist of
. closed reduction.
. symptomatic sling support and range-of-motion exercises.
. arthroscopic thermal capsulorrhaphy.
. an open anterior-inferior capsular shift.
. a Laterjet procedure.

Correct Answer & Explanation

. symptomatic sling support and range-of-motion exercises.

Explanation

DISCUSSION: Following a CVA and with the resumption of upright posture, downward subluxation of the glenohumeral joint may occur. Although usually painless, some patients may report pain secondary to stretching of the brachial plexus. This is the result of flaccid paralysis of the deltoid muscle, and it will persist until some motor tone or spasticity returns to the shoulder girdle musculature. Early sling support and range-of-motion exercises to prevent contracture will provide the best relief. Surgical procedures are not indicated. REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65. McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient. Instr Course Lect 1975;24:45-55.

Question 1163

Topic: 9. Shoulder and Elbow

The standard Bankart lesion involves detachment of the labrum along with which of the following capsular ligaments? Review Topic

. Superior glenohumeral ligament and coracohumeral ligament
. Superior glenohumeral ligament and middle glenohumeral ligament
. Middle glenohumeral ligament and inferior glenohumeral ligament
. Inferior glenohumeral ligament
. Superior glenohumeral ligament, middle glenohumeral ligament, and inferior glenohumeral ligament

Correct Answer & Explanation

. Superior glenohumeral ligament and coracohumeral ligament

Explanation

The Bankart lesion involves detachment of the labrum corresponding to the attachment of the middle and inferior glenohumeral ligaments. The superior glenohumeral ligament and the coracohumeral ligament are too superior, inserting near the biceps tendon, and play no role in the Bankart lesion.

Question 1164

Topic: 9. Shoulder and Elbow
Thermal capsulorrhaphy of the inferior glenohumeral ligament can cause iatrogenic injury to which of the following nerves?
. Musculocutaneous
. Suprascapular
. Radial
. Axillary
. Median

Correct Answer & Explanation

. Axillary

Explanation

DISCUSSION: The axillary nerve courses from anterior to posterior just below the inferior shoulder capsule. Thermal energy applied to the inferior aspect of the shoulder capsule can result in injury to this nerve. REFERENCES: Wong KL, Williams GR: Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am 2001;83:151-155. Bryan WJ, Schauder K, Tullos HS: The axillary nerve and its relationship to common sports medicine shoulder procedures. Am J Sports Med 1986;15:113-116.

Question 1165

Topic: 9. Shoulder and Elbow

Item Deleted by AAOS Question 40 - Figure 8 shows the AP radiograph of a 38-yea-old woman who has constant pain in her shoulder as the results of a motor vehicle accident. Examination reveals marked restriction in external rotation. Which of the following studies should be ordered to aid in making a diagnosis?

. MRI scan
. Bone scan
. Arthrogram
. Axillary lateral radiograph
. CT arthrogram

Correct Answer & Explanation

. MRI scan

Explanation

Figure eight demonstrates a posterior dislocation. Therefore the simplest, and best test would be the Axillary lateral. Rockwood and Green (fourth edition) discusses several radiographic signs that indicate that a posterior dislocations exists. Absence of the normal elliptical overlap shadow; the vacant glenoid sign; presence of the Trough line; Loss of profile of the neck of the humerus; and void in the inferior or superior glenoid fossa. Furthermore the clinical picture of loss of external rotation should also make one suspect of a posterior dislocation.

Question 1166

Topic: 9. Shoulder and Elbow
The posterior circumflex artery provides blood supply to what portion of the proximal humerus?
. Almost the entire humeral head
. Lesser tuberosity
. Lesser tuberosity and posteroinferior humeral head
. Posterior portion of the greater tuberosity only
. Posterior portion of the greater tuberosity and a small portion of the posteroinferior humeral head

Correct Answer & Explanation

. Posterior portion of the greater tuberosity and a small portion of the posteroinferior humeral head

Explanation

The posterior circumflex artery provides blood supply only to the posterior portion of the greater tuberosity and a small posteroinferior portion of the humeral head. The humeral head is supplied primarily by the anterolateral ascending branch of the anterior circumflex artery; the terminal branch of this artery is termed the arcuate artery.

Question 1167

Topic: Elbow & Forearm
A 55-year-old man sustained an elbow dislocation in a fall. Postreduction radiographs are shown in Figures 40a and 40b. What is the best course of management?
. Closed reduction and casting for 4 weeks
. Closed reduction and bracing with immediate range of motion
. Open reduction, lateral collateral ligament repair, and open reduction and internal fixation or metallic replacement of the radial head
. Open reduction, radial head silastic arthroplasty, and lateral collateral ligament repair
. Open reduction, lateral collateral ligament repair, and radial head excision

Correct Answer & Explanation

. Open reduction, lateral collateral ligament repair, and open reduction and internal fixation or metallic replacement of the radial head

Explanation

The radiographs show an elbow dislocation associated with a comminuted radial head fracture. In the setting of comminution and instability, fractures of the radial head are best managed with an arthroplasty rather than open reduction and internal fixation. Resection of the radial head will worsen the instability and is not recommended. Silastic radial head replacements are contraindicated.

Question 1168

Topic: 9. Shoulder and Elbow
A 42-year-old man who is right-hand dominant injured his right shoulder when he fell from a ladder onto his outstretched arm 1 hour ago. Radiographs reveal a two-part greater tuberosity anterior fracture-dislocation. Initial management should consist of:
. closed reduction of the glenohumeral joint and open reduction of the displaced greater tuberosity with rotator cuff repair.
. closed reduction of the glenohumeral joint, followed by radiographic assessment of the tuberosity position to determine further treatment.
. open reduction of both the joint and greater tuberosity with rotator cuff repair.
. open reduction of the glenohumeral joint and closed treatment of the greater tuberosity.
. use of a sling until the patient reports no discomfort, then early passive range of motion.

Correct Answer & Explanation

. closed reduction of the glenohumeral joint, followed by radiographic assessment of the tuberosity position to determine further treatment.

Explanation

Greater tuberosity anterior fractures associated with anterior glenohumeral dislocations respond very well to closed methods in the majority of patients. Closed reduction of the glenohumeral joint often anatomically reduces the greater tuberosity into its cancellous bed, without the need for open fixation or cuff repair. Once closed reduction of the joint is performed, tuberosity displacement and joint articulation should be evaluated radiographically.

Question 1169

Topic: 9. Shoulder and Elbow
A 75-year-old woman sustained a 4-part fracture dislocation of the proximal humerus with a comminuted humeral head. You decide to perform a reverse total shoulder replacement because of her age and activity level. This will be your first reverse total shoulder replacement. It is common practice in your hospital for an industry representative to be present when new implants are brought into the operating room. What information are you required to disclose?
. This is an experimental procedure.
. You have no financial relationship with the implant company.
. There will be an implant company representative in the room.
. The hospital will lose money because of the cost of the implant.

Correct Answer & Explanation

. There will be an implant company representative in the room.

Explanation

Current recommendations from the American Orthopaedic Association and the Orthopaedic Institute of Medicine are that the patient be notified if an industry representative is going to be present in the operating room. This surgery is not experimental for this indication, and Medicare currently covers the surgery for patients with appropriate indications. Court cases have demonstrated that surgeon-related factors can be litigated (such as surgeon experience), but there are no current requirements to disclose this. Surgeons are not required to disclose cost and compensation information to their patients.

Question 1170

Topic: 9. Shoulder and Elbow

With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus? Review Topic

. Coracohumeral ligament
. Superior glenohumeral ligament
. Middle glenohumeral ligament
. Anterior band of the inferior glenohumeral ligament complex
. Posterior band of the inferior glenohumeral ligament complex

Correct Answer & Explanation

. Coracohumeral ligament

Explanation

With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45 degrees. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated.

Question 1171

Topic: 9. Shoulder and Elbow

A 43-year-old man who works as a plumber has a painful stiff elbow in his dominant arm. He notes that while he recalls no single event of injury, he thinks the many years of pulling wrenches and soldering pipes have resulted in his problem. He reports that he has pain with any motion in bending his arm and can no longer straighten his elbow. Examination reveals generalized swelling of the elbow, both medial and lateral with a range of motion that lacks 45 degrees of extension and flexes only to 110 degrees. Pronation and supination are also limited to 45 degrees. Audible crepitus is perceived but there is no instability. Radiographs reveal advanced osteoarthritis at the radiocapitellar and ulnohumeral joints with complete loss of articular cartilage. What is the most appropriate initial treatment option? Review Topic

. Elbow fusion
. Radial head resection
. Total elbow arthroplasty
. Osteophyte resection and capsular release
. Physical therapy with dynamic extension and flexion splints

Correct Answer & Explanation

. Elbow fusion

Explanation

Osteoarthritis of the elbow is more common in the middle-age laborer such as this plumber, whereas rheumatoid arthritis is more common in older females. Treatmentmust respect the physical demands of the patient while trying to preserve joint motion and function with tolerable symptoms. Osteophyte resection and capsular release have offered many patients significant improvement in their symptoms while allowing them to return to most activities. The osteophyte resection and releases can be done effectively by an open or arthroscopic approach. Whereas total elbow arthroplasty would likely result in better and more thorough pain relief, it would not tolerate the occupational demands of this individual. There is no role for physical therapy initially in the face of advanced, painful arthritis associated with long-standing fixed joint contractures. Elbow fusion results in severe loss of function and its indication is rare and usually considered in the face of unmanageable sepsis. Radial head resection may improve symptoms related to the radial capitellar arthritis but would not improve range of motion or end range impingement pain. Also, radial head resection should be avoided in heavy laborers with elbow arthritis because it would lead to increased loads across the arthritic ulnohumeral joint.

Question 1172

Topic: 9. Shoulder and Elbow

-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?

. Child abuse workup
. Closed reduction
. Open reduction with possible osteotomy
. ObservationDISCUSSION-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 childโ€™s history to suggest abuse.

Correct Answer & Explanation

. Child abuse workup

Explanation

Question 1173

Topic: 9. Shoulder and Elbow
A 72-year-old man sustains a displaced four-part fracture of the proximal humerus with a head split component following a fall. A primary shoulder arthroplasty has been recommended for acute management. In counseling the patient on the pros and cons of hemiarthroplasty versus reverse arthroplasty, what statement can be made based on the available literature?
. The risk of tuberosity nonunion/malunion appears higher with hemiarthroplasty.
. Functional outcomes tend to be more consistent with hemiarthroplasty.
. Forward elevation of reverse shoulder arthroplasty depends on tuberosity union.
. Active elevation is likely to be better following hemiarthroplasty.

Correct Answer & Explanation

. The risk of tuberosity nonunion/malunion appears higher with hemiarthroplasty.

Explanation

As the indications for reverse shoulder arthroplasty have expanded, the role for shoulder hemiarthroplasty appears to be narrowing. Several recent systematic reviews have evaluated outcomes of shoulder hemiarthroplasty and reverse shoulder arthroplasty for acute proximal humerus fractures. Their results suggest that reverse arthroplasty results in superior functional results and comparable elevation, at the expense of increased complication rates and decreased shoulder rotation. One of the benefits of reverse shoulder arthroplasty in the setting of fracture is that forward elevation is independent of tuberosity healing and relies mainly on the deltoid muscle. Active external rotation following a reverse total shoulder for fracture, however, does appear to depend on successful union of the greater tuberosity. In a randomized controlled trial, the incidence of tuberosity healing was higher and the incidence of tuberosity resorption was lower in reverse arthroplasty compared with hemiarthroplasty. Forward elevation following a hemiarthroplasty for fracture generally follows a bimodal distribution, whereas outcomes following a reverse total shoulder have been more consistent.

Question 1174

Topic: 9. Shoulder and Elbow

A 21-year-old minor league pitcher reports decreasing velocity and ability to target his pitches over the last 2 months. He notes that his arm will start to feel heavy in the later innings and notes pain in the posterior aspect of his shoulder in the late cocking phase of his motion. He denies any specific event that initiated his symptoms. Examination reveals symmetric rotator cuff strength and no increased anterior or posterior translation of either shoulder. Supine range of motion of the right shoulder in 90 degrees of abduction reveals external rotation to 100 degrees and internal rotation to 25 degrees. The left shoulder has 95 degrees of external rotation and 60 degrees of internal rotation. He has pain with an O'Brien's maneuver and a negative apprehension sign. What is the next most appropriate step in management? Review Topic

. Subacromial corticosteroid injection
. Use of a sling until the pain resolves
. Posterior capsular stretching
. Arthroscopic SLAP repair
. Arthroscopic anterior-inferior capsulolabral plication with posterior capsular release

Correct Answer & Explanation

. Subacromial corticosteroid injection

Explanation

The patient has glenohumeral internal rotation deficit with posterior capsular tightness; therefore, initial management should be directed at physical therapy and posterior capsular stretching. The total arc of motion (external rotation + internal rotation) should be equal between the shoulders. He has a deficit of 30 degrees in his throwing shoulder. A "sleeper stretch" is a common way for patients to stretch the posterior capsule and involves lying on the involved side with the shoulder abducted 90 degrees, the elbow flexed 90 degrees, and pushing the forearm toward the table. Subacromial injection is not indicated because the pathology of an internal rotation contracture is located within the glenohumeral joint space and not the subacromial space. A sling might be useful for comfort but will not resolve his symptoms. There is no indication for arthroscopy, SLAP repair, or anterior-inferior capsulolabral plication at this time.

Question 1175

Topic: Elbow & Forearm
Figure 2 shows the radiograph of a 26-year-old auto mechanic who injured his right dominant elbow in a fall during a motocross race. Examination reveals pain and catching that limits his range of motion to 45 degrees of supination and 20 degrees of pronation. The interosseous space and distal radioulnar joint are stable. Management should consist of
. splinting for 3 weeks, followed by range-of-motion exercises.
. aspiration of the hemarthrosis, followed by range-of-motion exercises the following day.
. fragment excision.
. open reduction and internal fixation.
. radial head excision.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The radial head is an important secondary stabilizer of the elbow, helping to resist valgus forces. There has been a movement toward open reduction and internal fixation of the radial head when technically feasible, especially in a relatively high-demand athlete or laborer. The examination and radiograph suggest that displacement of the fragment is great enough to create a mechanical block. Extended splinting would only serve to encourage arthrofibrosis. Early range of motion is appropriate if there is minimal displacement of the radial head fragment, it is stable, and there is no mechanical block to motion. Fragments larger than one third of the joint surface should be excised only if it is not possible to reduce and repair the fragment. Primary excision of the radial head should be avoided if possible. Complications after excision of the radial head include muscle weakness, wrist pain, valgus elbow instability, heterotopic ossification, and arthritis.

Question 1176

Topic: 9. Shoulder and Elbow

An 18-year-old male football player dislocated his elbow during a game. A post-reduction MRI scan is shown in Figure 1. The injury is initially treated non-operatively, but the patient continues to note subjective instability and pain when attempting to push up from a chair. Surgical intervention is planned for repair/reconstruction. What guidance should be provided to the patient and therapist in the early postoperative period?

. No range-of-motion exercises until 6 weeks postoperative
. Begin immediate strengthening
. Avoid valgus stress to elbow
. Avoid shoulder abductionThe MRI scan shows injuries to both the medial and lateral ligamentous structures of the elbow, with significant widening of the radiocapitellar joint space. The patientโ€™s ongoing symptoms are consistent with posterolateral rotatory instability related to lateral collateral ligament insufficiency. After surgical repair versus reconstruction of thelateral collateral ligament, it is important to avoid varus stress to the elbow, which can result in failure or loosening of the lateral structures. During shoulder abduction, gravity applies a varus stress to the elbow, and it should be avoided.Limiting range of motion for the first 6 weeks would result in significant elbow stiffness. Valgus stress should be avoided in the setting of a medial collateral ligament repair or reconstruction. Strengthening is usually delayed until appropriate soft-tissue healing has been achieved.

Correct Answer & Explanation

. Avoid shoulder abductionThe MRI scan shows injuries to both the medial and lateral ligamentous structures of the elbow, with significant widening of the radiocapitellar joint space. The patientโ€™s ongoing symptoms are consistent with posterolateral rotatory instability related to lateral collateral ligament insufficiency. After surgical repair versus reconstruction of thelateral collateral ligament, it is important to avoid varus stress to the elbow, which can result in failure or loosening of the lateral structures. During shoulder abduction, gravity applies a varus stress to the elbow, and it should be avoided.Limiting range of motion for the first 6 weeks would result in significant elbow stiffness. Valgus stress should be avoided in the setting of a medial collateral ligament repair or reconstruction. Strengthening is usually delayed until appropriate soft-tissue healing has been achieved.

Explanation

When performing reverse shoulder arthroplasty, what factor leads to an increase in the complication indicated by the black arrow in Figure 1?

Question 1177

Topic: 9. Shoulder and Elbow
What is the most common cause for poor outcomes in patients who undergo total shoulder arthroplasty?
. Loosening of the humeral component
. Loosening of the glenoid component
. Infection
. Brachial plexus injury
. Rotator cuff tear

Correct Answer & Explanation

. Rotator cuff tear

Explanation

Discussion: In an article in the Journal of Shoulder and Elbow, 431 total shoulder arthroplasties were performed with a cemented all-polyethylene glenoid component between 1990 and 2000. Follow-up averaged 4.2 years. In total, 53 surgical complications occurred in 53 patients (12%). Of these, 32 were major complications (7.4%), with 17 of these requiring reoperation. Index complications in order of frequency included rotator cuff tearing, postoperative glenohumeral instability, and periprosthetic humeral fracture. Notably, glenoid and humeral component loosening requiring reoperation occurred in only one shoulder. Data from the contemporary patient group suggest that there are fewer complications of shoulder arthroplasty and less need for reoperation. Especially striking is the near absence of component revision because of loosening or other mechanical factors. Complications involving the brachial plexus have been reported following total shoulder arthroplasty but are not as common of a cause for failure.

Question 1178

Topic: 9. Shoulder and Elbow
A 65-year-old woman who works as a florist has had pain in her right elbow for the past 6 months after lifting a flowerpot. MRI scans are shown in Figures 55a and 55b. The area of increased signal intensity seen in Figure 55b most likely represents which of the following findings?
. Hematoma
. Edema
. Soft-tissue sarcoma
. Antecubital lipoma
. Brachial artery aneurysm

Correct Answer & Explanation

. Edema

Explanation

The MRI scans reveal a chronic distal biceps tendinitis. The T1-weighted scan shows the anatomic detail of the biceps tendon, and the T2-weighted scan shows increased signal caused by edema surrounding the tendon. The T1-weighted scan is not consistent with an antecubital lipoma. The chronicity of the lesion makes hematoma unlikely. An aneurysm usually appears with blood flow through the region and is dark on T1- and T2-weighted scans.

Question 1179

Topic: 9. Shoulder and Elbow
Figures 1 through 3 demonstrate the MRIs obtained from a 36-year-old man with an injury to the elbow. The expected result of nonsurgical treatment would be weakness of
. finger flexion.
. elbow extension.
. finger extension.
. forearm supination.

Correct Answer & Explanation

. forearm supination.

Explanation

EXPLANATION: The axial T2-weighted MRIs demonstrate a distal biceps rupture. The increased signal is noted superficial to the brachialis muscle and adjacent to the biceps tuberosity. The distal biceps tendon is not seen in the distal cuts and has retracted proximally. The physical examination of patients with these injuries shows an abnormal contour of the arm and tenderness in the antecubital fossa. The hook test is a provocative maneuver that documents biceps integrity. When performing the maneuver, the examiner attempts to hook a finger around the distal biceps tendon while the patient actively supinates with the elbow held in flexion. Nonsurgical treatment has been documented to result in an average loss of 40% of supination strength and 30% of elbow flexion strength. Repair is optimal within several weeks of injury. The alternative options would not occur with a distal biceps rupture.

Question 1180

Topic: 9. Shoulder and Elbow
What is the most important feature in choosing an outcome instrument to assess shoulder disorders?
. Ease of use
. Validity
. Ability to use it by mail or phone so the subject is not required to return in person to measure the outcome
. Inclusion of radiographic assessment at follow-up
. Scoring that is on a 100-point scale so that it can be compared with other instruments

Correct Answer & Explanation

. Validity

Explanation

DISCUSSION: There has been a recent increase in the use of outcome instruments to document and measure effects of treatment of medical conditions, including shoulder disorders. The most important feature of an instrument is whether it actually measures what it purports to measure; this is defined as its validity.

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