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9. Shoulder and Elbow MCQs

Practice Set 81 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 1601

Topic: 9. Shoulder and Elbow

Figures 14a and 14b show the initial radiographs of an 18-year-old man who fell while snowboarding. Figures 14c and 14d show the radiographs obtained following closed reduction. Examination reveals that the elbow is stable with range of motion. Management should now consist of

. immediate return to unrestricted activity.
. a posterior long arm splint for 7 to 10 days, followed by elbow range-of-motion exercises.
. a long arm cast for 4 weeks.
. immediate surgical repair of the collateral ligaments.
. immediate surgical repair of the collateral ligaments and placement of a hinged external fixator.

Correct Answer & Explanation

. a posterior long arm splint for 7 to 10 days, followed by elbow range-of-motion exercises.

Explanation

The initial radiographs reveal a simple elbow dislocation without associated fractures. After successful closed reduction, the range of stability should be assessed. If the elbow is stable, nonsurgical management should consist of a short period of immobilization followed by range-of-motion exercises. Immobilization for more than 3 weeks results in significant elbow stiffness. Surgical repair is indicated for dislocations that are irreducible, have associated fractures, or where stability cannot be maintained with closed treatment. Cohen MS, Hastings H II: Acute elbow dislocations: Evaluation and management. J Am Acad Orthop Surg 1998;6:15-23.

Question 1602

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

Upper Extremity 2005 Practice Questions: Set 3 (Solved) - Figure 2

. 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

. open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.

Explanation

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. 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.

Question 1603

Topic: 9. Shoulder and Elbow

Figure 37 shows the radiograph of a 23-year-old football player who sustained a blow to the anterior aspect of his shoulder. Examination reveals pain and limited rotation. He is unable to flex the arm above the shoulder. Management should include which of the following studies?

Sports Medicine Board Review 2001: High-Yield MCQs (Set 4) - Figure 4

. Axillary radiograph
. Arthrogram
. Electromyogram
. Bone scan
. Arteriogram

Correct Answer & Explanation

. Axillary radiograph

Explanation

The patient has a posterior dislocation. The radiograph reveals marked internal rotation, but fails to show whether the humeral head is posteriorly displaced. Therefore, an axillary radiograph should be obtained to help confirm the diagnosis. Transverse view CT or MRI scans also may be useful. The other studies will not help confirm the diagnosis. In addition to a direct posterior blow, a shoulder dislocation may be caused by a seizure disorder or electrocution. Bloom MH, Obata WG: Diagnosis of posterior dislocation of the shoulder with the use of Velpeau axillary and angle-up roentgenographic views. J Bone Joint Surg Am 1967;49:943-949.

Question 1604

Topic: 9. Shoulder and Elbow

A 52-year-old man has shoulder pain and stiffness after undergoing a "mini-lateral" rotator cuff repair 6 months ago. Examination reveals that he is afebrile with normal vital signs. There is slight erythema but no drainage from the incision. Range of motion is limited in all planes, and there is weakness with resisted external rotation and abduction. Radiographs show a well-positioned metal implant within the greater tuberosity. Laboratory studies reveal a WBC count of 8,400/mm3 (normal 3,500 to 10,500/mm3) and an erythrocyte sedimentation rate of 63 mm/h (normal up to 20 mm/h). What is the next most appropriate step in management?

. Subacromial corticosteroid injection
. Aspiration of the subacromial and glenohumeral joint spaces
. Nonsteroidal anti-inflammatory drugs
. Extensive surgical debridement
. Diagnostic arthroscopy

Correct Answer & Explanation

. Extensive surgical debridement

Explanation

Deep sepsis of the shoulder following rotator cuff repair is an uncommon problem. Patients with infections of this type typically report persistent pain and are not systemically ill. They may have signs of local wound problems such as erythema, drainage, and dehiscence. Laboratory studies can be helpful in making an accurate diagnosis. Most patients will not show a significant elevation of the WBC count; however, an elevated erythrocyte sedimentation rate is nearly always present and should alert the clinician to the presence of infection. Aspiration of both subacromial and glenohumeral joint spaces is necessary to confirm the diagnosis. The most effective treatment for deep shoulder sepsis following rotator cuff repair involves extensive surgical debridement, removing all suspicious soft tissue as well as implants. Administration of appropriate antibiotic therapy is needed for complete control of the infection. Mirzayan R, Itamura JM, Vangsness CT, et al: Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am 2000;82:1115-1121. Settecerri JJ, Pitnu MA, Rock MG, et al: Infection after rotator cuff repair. J Shoulder Elbow Surg 1994;8:105.

Question 1605

Topic: 9. Shoulder and Elbow

A cord-like middle glenohumeral ligament and absent anterosuperior labrum complex can be a normal anatomic capsulolabral variant. If this normal variation is repaired during arthroscopy, it will cause

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 14

. anterior translation of the humeral head.
. loss of external rotation.
. excessive tightening of the biceps tendon.
. superior migration of the humeral head.
. no excessive changes.

Correct Answer & Explanation

. loss of external rotation.

Explanation

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur. Williams MM, Snyder SJ, Buford D Jr: The Buford complex - the "cord-like" middle glenohumeral ligament and absent anterosuperior labrum complex: A normal anatomic capsulolabral variant. Arthroscopy 1994;10:241-247.

Question 1606

Topic: Shoulder Pathology

A 20-year-old-man sustained a scapular fracture after attempting to grab a beam as he fell through a ceiling at a job site 3 months ago. A clinical photograph is shown in Figure 36. He now reports pain in the anterior shoulder and difficulty with overhead activities. What nerve roots make up the involved peripheral nerve?

Upper Extremity Board Review 2005: High-Yield MCQs (Set 4) - Figure 5

. C3-T1
. C4-C5
. C5-C7
. C6-C8
. C8-T1

Correct Answer & Explanation

. C3-T1

Explanation

The patient sustained an injury to the long thoracic nerve, which supplies the serratus anterior. Branches of C5 and C6 enter the scalenus medius, unite in the muscle, and emerge as a single trunk and pass down the axilla. On the surface of the serratus anterior, the long thoracic nerve is joined by the branch from C7 and descends in front of the serratus anterior, providing segmental innervation to the serratus anterior.

Question 1607

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?

Upper Extremity 2008 Practice Questions: Set 3 (Solved) - Figure 9

. 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. Frankle M, Siegal S, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am 2005;87:1697-1705.

Question 1608

Topic: 9. Shoulder and Elbow

A 32-year-old powerlifter who was performing a dead lift 3 days ago noted a sharp pain in the front of his dominant right arm just after beginning to lower the weight. He now reports pain in the anterior aspect of the arm that worsens when he opens a door. Examination reveals moderate ecchymosis and swelling of the forearm and tenderness in the antecubital fossa. The MRI scans are shown in Figures 15a and 15b. If the injury is left unrepaired, the greatest functional deficit will most likely be the loss of

. elbow extension motion.
. elbow flexion strength.
. forearm supination motion.
. forearm pronation strength.
. forearm supination strength.

Correct Answer & Explanation

. forearm supination strength.

Explanation

A complete tear of the distal biceps brachii most often occurs from a large, rapid eccentric elbow extension load. A pop or tearing sensation usually occurs, and a palpable defect in the antecubital fossa is often present on examination. The treatment of choice is a direct primary repair by a two-incision technique. If left unrepaired, the most disabling consequence is the loss of forearm supination strength. It is unlikely that significant elbow or forearm motion will be lost if the rupture is left unrepaired and early motion exercises are initiated. Elbow flexion strength tends to return with time, but the loss of forearm supination strength remains problematic. D'Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.

Question 1609

Topic: 9. Shoulder and Elbow

A 52-year-old woman reports the sudden onset of intense pain in the right shoulder. She denies any history of injury or previous shoulder problems. At a 2-week follow-up examination, she notes that the pain has decreased, but she now has severe weakness of the external rotators and abductors. Her cervical spine and remaining shoulder examination are otherwise unremarkable. Radiographs of the shoulder and neck are normal. What is the most likely diagnosis?

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 6

. Calcific tendinitis
. Rotator cuff tendinosis
. Bursitis
. Brachial neuritis
. Glenohumeral arthritis

Correct Answer & Explanation

. Brachial neuritis

Explanation

Patients with brachial neuritis or Parsonage-Turner syndrome usually report the sudden onset of intense pain that subsides in 1 to 2 weeks, followed by weakness for a period of up to 1 year in the muscle that is supplied by the involved nerve. Calcific tendinitis usually can be diagnosed radiographically, with calcium deposits seen in the rotator cuff. Bursitis and rotator cuff tendinosis usually are seen after an increase in activity, and both decrease with rest and medication. Glenohumeral arthritis is a slow, progressive problem that results in a loss of range of motion. Misamore GW, Lehman DE: Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am 1996;78:1405-1408.

Question 1610

Topic: 9. Shoulder and Elbow

A patient undergoes an arthroscopic debridement for lateral epicondylitis. Postoperatively she reports pain and a sense of clicking of the elbow. Examination reveals apprehension to supination, load, and extension. What structure has been injured resulting in the clinical presentation?

. Medial collateral ligament
. Annular ligament
. Lateral ulnar collateral ligament
. Extensor carpi radialis brevis
. Extensor carpi radialis longus

Correct Answer & Explanation

. Lateral ulnar collateral ligament

Explanation

The patient has an iatrogenic injury to the lateral ulnar collateral ligament following the arthroscopic procedure. Failure to adhere to known anatomic landmarks can lead to this devastating complication. The examination findings are classic for posterolateral elbow instability. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 318.

Question 1611

Topic: 9. Shoulder and Elbow
Figure 38 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment?
. Reverse shoulder arthroplasty
. Hemiarthroplasty
. Resurfacing of the humeral head
. Arthroscopic debridement
. Shoulder fusion

Correct Answer & Explanation

. Reverse shoulder arthroplasty

Explanation

The authors of several studies conducted in Europe have reported promising results in the short- and medium-term with use of a reversed or inverted shoulder implant. The most recent investigation, a multicenter study in Europe in which 77 patients (80 shoulders) with glenohumeral osteoarthritis and a massive rupture of the rotator cuff were treated with the Delta III prosthesis, described an improvement in the mean constant score of 42 points, an increase of 65 degrees in forward elevation, and minimal or no pain in 96% of the patients. Hemiarthroplasty, the "nonconstrained" option, has long been the standard of care for rotator cuff tear arthropathy. However, careful examination of the literature reveals that the results have not been uniform.

Question 1612

Topic: 9. Shoulder and Elbow

A 58-year-old reports pain and stiffness in his left shoulder following a seizure episode. Diagnosis at the time of the seizure is a frozen shoulder, and management consists of an aggressive physical therapy program of stretching exercises. Four months later he continues to have shoulder pain and has not gained any additional range of motion. A CT scan is shown in Figure 50. Management should now consist of

Shoulder Board Review 2002: High-Yield MCQs (Set 4) - Figure 16

. additional physical therapy and home stretching exercises.
. closed reduction and immobilization in a spica cast.
. open reduction and transfer of the subscapularis and lesser tuberosity.
. humeral arthroplasty.
. total shoulder arthroplasty.

Correct Answer & Explanation

. humeral arthroplasty.

Explanation

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%. Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.

Question 1613

Topic: Elbow & Forearm

A man sustained the injury shown in Figures 51a and 51b. He underwent closed reduction of the radial head dislocation and open reduction and internal fixation of the ulnar fracture. What is the most common cause of persistent radial head subluxation?

. Interosseous ligament disruption
. Annular ligament disruption
. Avulsion of the common extensor origin
. Malreduction of the ulnar fracture
. Intra-articular osteochondral debris

Correct Answer & Explanation

. Malreduction of the ulnar fracture

Explanation

The radiographs reveal a Monteggia injury, with a proximal ulnar shaft fracture and a radial head dislocation. Treatment involves open reduction and internal fixation of the ulnar fracture. With correct reduction of the ulna, the radial head is reducible and remains stable, despite an obvious soft-tissue injury around the elbow. Problems with persistent radial head subluxation are almost always attributed to malreduction of the ulnar fracture. Rare causes of persistent radial head subluxation are interposition of soft tissues in the joint and lateral ligamentous injuries. Jupiter JB, Kellam JF: Diaphyseal fractures of the forearm, in Browner B, Jupiter J, Levine A, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1992, pp 1421-1454.

Question 1614

Topic: 9. Shoulder and Elbow

An 18-month-old child with obstetrical palsy has a maximum external rotation as shown in Figure 34. The parents should be advised that without surgical treatment the likelihood that glenoid dysplasia will develop is approximately what percent?

Pediatrics 2004 Practice Questions: Set 3 (Solved) - Figure 18

. 5%
. 10%
. 20%
. 30%
. 70%

Correct Answer & Explanation

. 70%

Explanation

Based on the available literature, the probability of development of glenoid dysplasia in the setting of a significant limitation of external rotation is close to 70%. Humeral dysplasia is also likely and can be managed surgically. Efforts are being made to identify procedures that will prevent glenoid dysplasia and help maintain function. Pearl ML, Edgerton BW: Glenoid deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:659-667. Waters PM, Smith GR, Jaramillo D: Glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:668-677.

Question 1615

Topic: 9. Shoulder and Elbow

A 12-year-old Little League pitcher reports lateral elbow pain and "catching." Examination reveals painful pronation and supination and tenderness over the lateral elbow. Radiographs are shown in Figures 22a and 22b. Initial management should consist of

. rest and repeat examination and radiographs until complete healing occurs.
. rest and resumption of play when he is asymptomatic and examination shows restoration of painless range of motion.
. arthroscopic in situ drilling.
. arthroscopic drilling and internal fixation.
. arthroscopy with removal of the loose body, followed by lateral column osteotomy.

Correct Answer & Explanation

. rest and resumption of play when he is asymptomatic and examination shows restoration of painless range of motion.

Explanation

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. Kobayashi K, Burton KJ, Rodner C, et al: Lateral compression injuries in the pediatric elbow: Panner's disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg 2004;12:246-254.

Question 1616

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

Shoulder 2002 Practice Questions: Set 3 (Solved) - Figure 2

. 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

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 "hot" for long periods of time. The levels of alkaline phosphatase and serum calcium-phosphorus product do not need to be measured.

Question 1617

Topic: 9. Shoulder and Elbow

A 12-year-old boy has severe left shoulder pain after being struck by an automobile. A chest radiograph, AP and lateral radiographs, and a CT scan with three-dimensional reconstruction of the scapula are shown in Figures 38a through 38d. Management should consist of

. closed reduction and a shoulder spica cast.
. open reduction and internal fixation.
. an abduction orthosis.
. sling immobilization.
. a figure-of-8 splint.

Correct Answer & Explanation

. sling immobilization.

Explanation

Scapular body fractures in children are rare and are often associated with other injuries of the chest and thorax. Management is generally nonsurgical, unless the injury is open, and usually consists of support with a sling and gentle range-of-motion exercises to minimize shoulder stiffness. Green N, Swiontkowski M: Skeletal Trauma in Children, ed 2. Philadelphia, PA, WB Saunders, 1998, vol 3, pp 319-341.

Question 1618

Topic: 9. Shoulder and Elbow

A 15-year-old boy falls from his bicycle and sustains an injury to his elbow. Prereduction radiographs are shown in Figure 12a. Closed reduction is performed without difficulty and postreduction radiographs are shown in Figure 12b. What is the next most appropriate step in treatment?

. Conversion to cast immobilization for 6 weeks
. Application of an articulated external fixator
. Begin early motion as soon as pain resolves
. Open reduction
. MRI to assess ligament integrity

Correct Answer & Explanation

. Open reduction

Explanation

Elbow dislocations in children are rare injuries and usually result from a fall on an outstretched arm. The incidence of these injuries increases as patients age and concurrently the incidence of supracondylar humerus fractures decreases. In adolescent patients, simple elbow dislocations are treated with splint immobilization and the initiation of physical therapy once comfortable. The practitioner must be aware of structures that may get caught in the joint on reduction. These include the median nerve as well as the medial epicondyle. In this patient, the radiographs reveal a medial epicondyle fracture. Postreduction radiographs show the joint to be incongruous secondary to intra-articular displacement. At this point, the most appropriate treatment is to perform an open reduction and repair of the medial epicondyle fragment. Rasool MN: Dislocations of the elbow in children. J Bone Joint Surg Br 2004;86:1050-1058.

Question 1619

Topic: 9. Shoulder and Elbow

A 35-year-old man who is an avid weight lifter competing in local tournaments reports new onset pain and loss of motion in his dominant right shoulder. Examination reveals joint line tenderness, active elevation to 100 degrees, and external rotation to 10 degrees. His contralateral shoulder reveals 170 degrees forward elevation and 50 degrees external rotation. Radiographs are shown in Figures 46a and 46b. What is the next most appropriate step in management?

. Total shoulder arthroplasty
. Hemiarthroplasty with glenoid interposition
. Surface replacement hemiarthroplasty
. Arthroscopic debridement
. Anti-inflammatory drugs and a range-of-motion stretching program

Correct Answer & Explanation

. Arthroscopic debridement

Explanation

New onset pain and stiffness in the young arthritic shoulder is a difficult problem to treat. Initial management should be aimed at reducing pain and improving motion in all planes. This patient's activities and age preclude a shoulder arthroplasty at this time. If nonsurgical management fails to provide relief, then arthroscopic debridement and capsular release may be beneficial. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 257-266.

Question 1620

Topic: 9. Shoulder and Elbow

An 18-month-old boy with obstetric brachial plexus palsy is being evaluated for limited right shoulder motion. Physical therapy for the past 6 months has failed to result in improvement of the contracture. Which of the following studies is necessary prior to any shoulder reconstruction?

Pediatrics 2007 Practice Questions: Set 1 (Solved) - Figure 12

. Electromyography
. MRI of the shoulder joint
. MRI of the brain
. Radiograph of the elbow
. Aspiration of the right shoulder

Correct Answer & Explanation

. MRI of the shoulder joint

Explanation

The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful. Waters PM: Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B 2005;14:233-244. Waters PM, Bae DS: Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am 2005;87:320-325.

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