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9. Shoulder and Elbow MCQs

Practice Set 83 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 1641

Topic: 9. Shoulder and Elbow

A 70-year-old man seen in the emergency department has had left shoulder pain and a fever of 101.5 degrees F (38.6 degrees C) for the past 3 days. He denies any history of trauma. Examination reveals tenderness anterosuperiorly and at the posterior glenohumeral joint line. He has very limited range of motion (passive and active). Laboratory studies show a WBC count of 12,000/mm3 and an erythrocyte sedimentation rate of 48 mm/h. Initial management should consist of

. an oral cephalosporin antibiotic and discharge home.
. IV oxacillin and gentamicin.
. arthroscopic drainage of the glenohumeral joint.
. open irrigation and drainage of the glenohumeral joint.
. aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.

Correct Answer & Explanation

. aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.

Explanation

It appears that the patient has septic arthritis of the glenohumeral joint; therefore, initial management should consist of aspiration of the glenohumeral joint and subacromial space separately, followed by Gram stain and culture of the fluid. Based on the findings, broad-spectrum IV antibiotics should be started. If the diagnosis of septic arthritis is confirmed, then arthroscopic or open surgical drainage usually is indicated. Sawyer JR, Esterhai JL Jr: Shoulder infections, in Warner JJ, Iannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, PA, Lippincott-Raven, 1997.

Question 1642

Topic: 9. Shoulder and Elbow

A 15-year-old baseball pitcher who reports increasing pain in his right shoulder over the past 3 weeks states that the pain increases the more he pitches. Radiographs of both shoulders are shown in Figures 35a and 35b. What is the next most appropriate step in management?

. Increased pitching activity in conjunction with aggressive physical therapy
. Biopsy of the lesion in the proximal humerus
. Complete rest with no activity
. Immobilization in a shoulder spica cast in the salute position
. Cessation of pitching and a vigorous program of muscle strengthening

Correct Answer & Explanation

. Cessation of pitching and a vigorous program of muscle strengthening

Explanation

The patient has a rotational stress fracture of the proximal humeral physis (Little Leaguer's shoulder). The symptoms of increasing pain with activity and relief with rest are typical of a stress injury. Treatment should consist of cessation of throwing activity but rehabilitation of the shoulder girdle muscles. The pitching technique should be evaluated as well. Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in the adolescent baseball pitchers: A case report. J Bone Joint Surg Am 1985;67:495-496.

Question 1643

Topic: 9. Shoulder and Elbow

A right-handed 14-year-old pitcher has had a 3-month history of shoulder pain while pitching. Examination reveals full range of motion, a mildly positive impingement sign, pain with rotational movement, and no instability. Plain AP radiographs of both shoulders are shown in Figures 25a and 25b. Management should consist of

. referral to a pitching coach to improve throwing mechanics.
. a weight-training program that concentrates on rotator cuff strengthening.
. rest until symptoms have resolved, followed by a gradual return to pitching.
. a metabolic work-up.
. cessation of pitching until the physis is closed.

Correct Answer & Explanation

. rest until symptoms have resolved, followed by a gradual return to pitching.

Explanation

The patient has the classic signs of Little Leaguer's shoulder, with findings that include pain localized to the proximal humerus during the act of throwing and radiographic evidence of widening of the proximal humeral physis. Examination usually reveals tenderness to palpation over the proximal humerus, but the presence of any swelling, weakness, atrophy, or loss of motion is unlikely. The treatment of choice is rest from throwing for at least 3 months, followed by a gradual return to pitching once the shoulder is asymptomatic. Carson WG Jr, Gasser SI: Little Leaguer's shoulder: A report of 23 cases. Am J Sports Med 1998;26:575-580.

Question 1644

Topic: 9. Shoulder and Elbow

A 37-year-old electrician is diagnosed with a frozen shoulder after sustaining an electrical injury at work 2 weeks ago. Examination reveals that he cannot actively or passively externally rotate or abduct the arm. The glenohumeral joint and scapula move in a 1:1 ratio. Radiographs are shown in Figures 15a and 15b. The best course of action should be

. vigorous physical therapy for passive range of motion.
. manipulation of the shoulder under anesthesia.
. an intra-articular steroid injection.
. an axillary radiograph.
. MRI.

Correct Answer & Explanation

. an axillary radiograph.

Explanation

The patient's history, examination, and radiographs are classic for locked posterior dislocation of the glenohumeral joint. Posterior dislocation of the shoulder remains the most commonly missed dislocation of a major joint. Up to 80% are missed on initial presentation. The primary cause for failure to accurately diagnose this injury is inadequate radiographic evaluation. The typical presentation is a shoulder locked in internal rotation with loss of abduction. An axillary view not only will make the definitive diagnosis but will help assess the size of the articular surface defect and help plan treatment. This view can be done expediently as part of every trauma series. The AP view is suspicious for a posteriorly dislocated humerus with loss of the humeral neck profile, a vacant glenoid sign, and an anterior humeral head compression fracture (reverse Hill-Sachs lesion). Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosement, IL, American Academy of Orthopaedic Surgeons, 1997, pp 181-189.

Question 1645

Topic: 9. Shoulder and Elbow

Which of the following characteristics is seen in patients with osteochondritis dissecans of the elbow?

. MRI reveals separation of cartilage from the capitellum and chondral fissuring
. Fragmentation of the entire capitellar ossific nucleus
. Normal capitellar regrowth with no late sequelae
. Age younger than 10 years
. Medial ulnar collateral ligament laxity

Correct Answer & Explanation

. MRI reveals separation of cartilage from the capitellum and chondral fissuring

Explanation

Osteochondritis dissecans occurs in the older child or adolescent (typically older than age 13 years). It involves the lateral compartment. The etiology is felt to be microtraumatic vascular insufficiency from repetitive rotatory and compressive forces. MRI typically shows separation of cartilage from the capitellum and chondral fissuring. Panner's disease is usually seen in children younger than age 10 years, involves the entire capitellar ossific nucleus, and resolves typically with no residual deformity or late sequelae. There is no evidence of ligamentous injury. Defelice GS, Meunier MJ, Paletta GA: Elbow injury in the adolescent athlete, in Altchek DW, Andrews JR (eds): The Athlete's Elbow. New York, NY, Lippincott Williams & Wilkins, 2001, pp 231-248.

Question 1646

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, radial head silastic arthroplasty, and lateral collateral ligament repair

Explanation

The radiographs show an elbow dislocation associated with a comminuted radial head fracture. In the setting of comminution and instability, factures 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. Hildebrand KA, Patterson SD, King GJ: Acute elbow dislocations: Simple and complex. Orthop Clin North Am 1999;30:63-79.

Question 1647

Topic: 9. Shoulder and Elbow

A 42-year-old patient undergoes resection of the medial clavicle for painful sternoclavicular degenerative joint disease. The postoperative course is complicated by an increase in symptoms, a medial bump, and subjective tingling in the digits. A clinical photograph and radiograph are shown in Figures 20a and 20b. What is the most appropriate procedure at this time?

. Semitendinosis figure-of-eight graft
. Subclavius tendon transfer
. Medial clavicular osteotomy
. Medial clavicular resection
. Sternoclavicular arthrodesis

Correct Answer & Explanation

. Semitendinosis figure-of-eight graft

Explanation

Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-eight pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability. Rockwood CA, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 608-609.

Question 1648

Topic: 9. Shoulder and Elbow

Figure 12a shows the clinical photograph of a 36-year-old man who has left shoulder pain and dysfunction after undergoing a lymph node biopsy 2 years ago. The appearance of the shoulder during abduction and a wall push-up maneuver is shown in Figures 12b and 12c, respectively. Which of the following procedures provides the best pain relief and function?

. Direct nerve repair
. Sural nerve graft
. Pectoralis major transfer
. Levator scapula and rhomboid transfer
. Scapulothoracic fusion

Correct Answer & Explanation

. Levator scapula and rhomboid transfer

Explanation

Injury to the spinal accessory nerve can occur after penetrating trauma to the shoulder. Blunt trauma may also cause loss of trapezius function. Most commonly, surgical dissection in the posterior triangle of the neck, such as lymph node biopsy, may expose the nerve to possible damage. Surgical repair of the nerve may be considered up to 1 year after injury; after this time muscle transfer is usually associated with a better functional outcome. Steinman SP, Spinner RJ: Nerve problems in the shoulder, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 1013-1015.

Question 1649

Topic: 9. Shoulder and Elbow

A 2-year-old girl has had a 2-day history of fever and refuses to move her left shoulder following varicella. Laboratory studies show an erythrocyte sedimentation rate of 75 mm/h and a peripheral WBC count of 18,000/mm3. What is the most common organism in this scenario?

Pediatrics 2007 Practice Questions: Set 1 (Solved) - Figure 16

. Kingella kingae
. Group A beta-hemolytic streptococcus
. Group B streptococcus
. Staphylococcus epidermidis
. Staphylococcus aureus

Correct Answer & Explanation

. Group A beta-hemolytic streptococcus

Explanation

The most common bacterial etiologic agent following varicella is group A beta-hemolytic streptococcus. The other organisms are much less common. Staphylococcus aureus is the most common bone infection organism. Staphylococcus epidermidis is increasingly a bone infection organism. Group B streptococcus occurs more commonly in newborns. Kingella kingae is a common joint pathogen but is not as common following varicella. Schreck P, Schreck P, Bradley J, et al: Musculoskeletal complications of varicella. J Bone Joint Surg Am 1996;78:1713-1719.

Question 1650

Topic: 9. Shoulder and Elbow

A 30-year-old farmer undergoes replantation of an above-the-elbow amputation. What form of management is most important following this surgery?

. High volume diuresis with alkalinization of the urine
. Systemic heparinization of the patient for 72 hours
. Elevation of the extremity, with maintanence of the patient's room temperature at 80 degrees F (26.6 degrees C)
. Satellite ganglion continuous sympathetic block
. Daily IV administration of low-molecular-weight dextran

Correct Answer & Explanation

. High volume diuresis with alkalinization of the urine

Explanation

After major limb replantation, the occurrence of ischemic rhabdomyonecrosis can result in lactic acidosis and myoglobulinemia. These complications can be limited by rapid repair of the arterial supply, potentially using a shunt before skeletal stability. Repair of the venous system should be performed after repair of the artery. High volume fluid replacement will maintain a diuresis, thus limiting the complications from myoglobulinemia. Wood MB: Replantations about the elbow, in Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, WB Saunders, 1985, pp 472-480.

Question 1651

Topic: 9. Shoulder and Elbow

Figure 37 shows the clinical photograph of a 1-day-old infant who weighed 10.25 lb at birth. Examination reveals an absent right Moro reflex and limited active motion of the right shoulder, elbow, and wrist, but flexion of the fingers. Passive range of motion of the shoulder and elbow is normal. What is the most likely diagnosis?

Pediatrics 2001 Practice Questions: Set 3 (Solved) - Figure 15

. Pseudoparalysis secondary to fracture of the proximal humerus
. Cervical myelomeningocele
. Erb palsy
. Arthrogryposis
. Cerebral palsy and spastic hemiplegia

Correct Answer & Explanation

. Erb palsy

Explanation

The patient's right upper extremity is held in the "head waiter's" posture with the shoulder internally rotated, the elbow extended, and the wrist in flexion. The Erb type of obstetrical brachial plexus palsy involves the C5 and C6 nerve root, and occasionally, as in this child, the C7 nerve root. Obstetrical palsy is a traction injury, and is associated with a high birth weight, shoulder dystocia, cephalopelvic disproportion, or the use of forceps. Erb palsy is four times more common than injury to the entire plexus or injury to the C8 and T1 nerve roots. It results from the shoulder being depressed while the head and neck are laterally rotated, extended, and tilted in the opposite direction. Most patients recover wrist extension and elbow flexion. Patients with residual weakness of shoulder external rotation and abduction will benefit from release of the pectoralis major, latissimus dorsi, and teres major, with transfer of the latissimus dorsi and the teres major to the posterosuperior aspect of the rotator cuff. Recent studies using arthrograms and CT scans have shown a higher incidence of posterior glenoid deficiency and posterior subluxation than that observed with plain radiographs. The posterior subluxation or dislocation can be effectively reduced by tendon release and transfer procedures. Hoffer MM, Phipps GJ: Closed reduction and tendon transfer for treatment of dislocation of the glenohumeral joint secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:997-1001. Pearl ML, Edgerton BW: Glenoid deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:659-667.

Question 1652

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?

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 5

. Removal of the humeral and glenoid components
. Removal of the glenoid component
. Removal of the loose glenoid component and reimplantation of a new glenoid component
. Removal of the glenoid component followed by biologic resurfacing of the glenoid
. Arthrodesis after removal of both components

Correct Answer & Explanation

. Removal of the loose glenoid component and reimplantation of a new glenoid component

Explanation

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. Antuna SA, Sperling JW, Cofield RH, et al: Glenoid revision surgery after total shoulder arthroplasty. J Shoulder Elbow Surg 2001;10:217-224.

Question 1653

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
. additional physical therapy for 6 months followed by reassessment.
. manipulation under anesthesia.
. arthroscopic release combined with the use of an interscalene catheter postoperatively.
. open release with Z-plasty lengthening of the subscapularis and capsule.
. shoulder hemiarthroplasty.

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 (ie, 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 1654

Topic: 9. Shoulder and Elbow

Figure 43 shows an arthroscopic view of a right shoulder through a lateral portal in the beach chair position. The arrow is pointing to what structure?

Anatomy 2008 Practice Questions: Set 3 (Solved) - Figure 26

. Biceps tendon
. Coracohumeral ligament
. Superior glenohumeral ligament
. Middle glenohumeral ligament
. Inferior glenohumeral ligament

Correct Answer & Explanation

. Biceps tendon

Explanation

This view from the lateral portal shows a full-thickness rotator cuff tear. The glenohumeral joint can be visualized through this tear. The glenoid, labrum, and biceps tendon attaching to the superior aspect of the glenoid are easily viewed from this portal, and the arrow is pointing to the biceps tendon. Arthroscopic rotator cuff repair can be performed while visualizing from this portal and using anterior and posterior working portals. Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principles of techniques, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427.

Question 1655

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 with AP and scapular lateral views as well as an axillary view. The axillary view will not only definitively show the joint articulation but also demonstrate posterior displacement of the greater tuberosity missed on the AP and lateral views. If no or minimal (5 mm) displacement is found, then nonsurgical management consisting of a sling and gentle passive range-of-motion exercises can be instituted. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Question 1656

Topic: 9. Shoulder and Elbow

A 68-year-old man had a 3-year history of shoulder pain that failed to respond to nonsurgical management. Examination reveals forward elevation to 120 degrees and external rotation to 30 degrees. True AP and axillary radiographs and an axial CT scan are shown in Figures 1a through 1c. What management option would lead to the best long-term results?

. Hemiarthroplasty
. Total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic debridement
. Glenoid osteotomy and interposition arthroplasty

Correct Answer & Explanation

. Total shoulder arthroplasty

Explanation

The radiographs and CT scan reveal osteoarthritis with posterior subluxation and posterior bone loss. Total shoulder arthroplasty with reaming of the high side to neutralize the glenoid surface has been shown to yield better results than hemiarthroplasty. The amount of bone loss in this patient does not require posterior glenoid augmentation. Reverse total shoulder arthroplasty is indicated for rotator cuff tear arthropathy; therefore, it is not applicable. Arthroscopic debridement has yielded poor results with advanced osteoarthritis and posterior subluxation. Results from glenoid osteotomy have been variable and glenoid osteotomy is not indicated with associated osteoarthritis. Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.

Question 1657

Topic: Elbow & Forearm

A 10-year-old girl has a right elbow deformity that is the result of trauma 5 years ago. She has no pain despite the arm deformity. The radiographs in Figures 42a and 42b show complete healing. This radiographic appearance demonstrates what complication?

. Growth arrest of the medial trochlear physis
. Varus malunion of a supracondylar humeral fracture
. Valgus malunion of a lateral condylar fracture
. Posterior and lateral dislocation of the radial head
. Osteonecrosis of the capitellum

Correct Answer & Explanation

. Varus malunion of a supracondylar humeral fracture

Explanation

Cubitus varus is a common complication of displaced supracondylar humeral fractures that are treated with closed reduction and cast immobilization. Treatment with closed reduction and percutaneous pinning decreases the incidence of this complication. Cubitus varus also can occur in minimally displaced fractures when unrecognized collapse of the medial column of the distal humerus is not corrected with manipulation. This can be detected on physical examination of the carrying angle or on radiographs measuring Baumann's angle, both in comparison to the opposite side. Cubitus varus may result in unacceptable cosmesis and may predispose the patient to fractures of the lateral condyle. The lateral radiograph demonstrates the crescent sign from overlap of the distal humerus with the olecranon seen in patients with cubitus varus. Patients with growth arrest to the medial trochlear physis would have atrophy of the trochlea on radiographs. Flynn JM, Sarwark JF, Waters PM, et al: The surgical management of pediatric fractures of the upper extremity. Instr Course Lect 2003;52:635-45. Papandrea R, Waters PM: Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop 2000;370:115-126.

Question 1658

Topic: 9. Shoulder and Elbow

A 24-year-old athlete has a painful right shoulder. Figure 30 shows an intra-articular photograph that was obtained through a posterior portal during arthroscopy; the labrum is indicated by the arrow. Based on these findings, management should consist of

Shoulder 2002 Practice Questions: Set 3 (Solved) - Figure 5

. stabilization with suture anchors.
. debridement only.
. no treatment.
. stabilization using absorbable tacks with the arm in external rotation.
. release of the attachment to the middle glenohumeral ligament, followed by stabilization with any device.

Correct Answer & Explanation

. no treatment.

Explanation

The photograph shows a normal variant that is a sublabral hole beneath the anterosuperior labrum. In some instances, the labrum will become confluent with the middle glenohumeral ligament as a stout band. Because this variant is not abnormal, no treatment is necessary. Securing this portion of the labrum to the capsule may tighten the middle glenohumeral ligament complex and restrict external rotation of the arm. Andrews JR, Guerra JJ, Fox GM: Normal and pathologic arthroscopic anatomy of the shoulder, in Andrews JR, Timmerman LA (eds): Diagnostic and Operative Arthroscopy, ed 1. Philadelphia, PA, WB Saunders, 1997, pp 60-76.

Question 1659

Topic: 9. Shoulder and Elbow

A 74-year-old woman with rheumatoid arthritis reports shoulder pain that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 23a and 23b. Examination reveals active forward elevation to 120 degrees and external rotation to 30 degrees. What treatment option results in the most predictable pain relief and function?

. Hemiarthroplasty
. Arthroscopic debridement
. Total shoulder arthroplasty with a cemented all-polyethelene glenoid component
. Reverse total shoulder arthroplasty
. Total shoulder arthroplasty with a metal-backed glenoid component

Correct Answer & Explanation

. Total shoulder arthroplasty with a cemented all-polyethelene glenoid component

Explanation

Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared to hemiarthroplasty in patients with rheumatoid arthritis. Although rotator cuff tears are more common in this patient population, this patient has good forward elevation and no significant superior migration of the humeral head; therefore, a reverse arthroplasty is not indicated. The arthritis is too advanced in this patient to consider arthroscopy, but in less advanced cases it can improve range of motion and decrease pain. Metal-backed glenoid components have shown higher rates of loosening. Collin DN, Harryman DT II, Wirth MA: Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am 2004;86:2489-2496. Baumgarten KM, Lashgari CM, Yamaguchi K: Glenoid resurfacing in shoulder arthroplasty: Indications and contraindications. Instr Course Lect 2004;53:3-11.

Question 1660

Topic: Elbow & Forearm

A 34-year-old woman has had painful snapping and popping in the elbow since falling while in-line skating 6 months ago. The popping also occurs when she pushes off with her hands to rise from a seated position. Initial radiographs were normal, and she was told that she had sprained her elbow. Examination reveals few findings except that she is very apprehensive when the forearm is forcefully supinated with the elbow extended or partially flexed. A radiograph taken in that position is shown in Figure 24. Treatment should consist of

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 25

. arthroscopic loose body removal.
. arthroscopic debridement and loose body removal for osteochondritis dissecans of the capitellum.
. annular ligament reconstruction for posttraumatic posterior subluxation of the radial head.
. radial head resection for congenital type II dislocation of the radial head.
. lateral collateral ligament reconstruction for posterolateral rotatory instability.

Correct Answer & Explanation

. lateral collateral ligament reconstruction for posterolateral rotatory instability.

Explanation

The radiograph reveals posterolateral rotatory subluxation of the radiohumeral and ulnohumeral joints. The space between the ulna and trochlea is enlarged, particularly posteriorly at the olecranon. These findings are diagnostic of posterolateral rotatory instability, which causes recurrent subluxation and reduction as the elbow is flexed from an extended and supinated position with valgus load. The posterolateral rotatory instability apprehension test was performed on this patient and the result was positive. The lateral pivot-shift test causes a clunk as the elbow reduces but is more difficult to perform, even under general anesthesia. The patient does not have isolated subluxation of the radial head, although these findings can be mistakenly diagnosed as such. The radial head is normally shaped and does not represent a congenital dislocation. There are no findings here to suggest osteochondritis dissecans or loose bodies. O'Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446. Burgess RC, Sprague HH: Post-traumatic posterior radial head subluxation: Two case reports. Clin Orthop 1984;186:192-194.

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