Orthopedic Upper Extrem Review | Dr Hutaif General Orth -...

..A 45-year-old man who had gout in his foot 2 years ago has a 3-day history of elbow pain without an injury. The pain is diffuse, constant, and worse with any movement. Examination shows motion from 20 degrees to 90 degrees. There is no erythema around his elbow, he has no fever, and a sensory and motor examination of his arm is unremarkable.
Radiographs only show an effusion. The patient’s uric acid level is within defined limits. What is the next diagnostic step?

..A 65-year-old man who underwent an uncomplicated reverse total shoulder arthroplasty (rTSA) to treat rotator cuff arthropathy 2 years ago has a routine follow-up visit in your clinic. A radiograph at 2-year followup is shown in Figure 2. He denies shoulder pain and dysfunction and constitutional symptoms, and his clinical examination findings are benign. Based upon the present radiologic evaluation, what is the next most appropriate step?

..A 61-year-old right-hand-dominant woman sustains a fall down 3 stairs, resulting in a left anteroinferior dislocation and noncomminuted greater tuberosity fracture. A closed glenohumeral reduction with intravenous sedation is performed in the emergency department. After reduction, the greater tuberosity fragment remains displaced by 2 mm.
What is the most appropriate treatment?

..A 30-year-old man with diabetes sustained an acute posterior dislocation of his right shoulder after a seizure event that required emergency department reduction. You initially treat him with a sling for 4 weeks and then refer him for outpatient therapy. During his therapy sessions, the patient admits to pain and instability symptoms during range of motion exercises. Repeat examination indicates a positive posterior load-shift test and apprehension with adduction and internal rotation of the shoulder. His CT and MRI scans are shown in Figures 4a and 4b. What is the most appropriate next step in treating his injury?

..He started physical therapy while continuing light duty at work. Eight weeks later, his pain remained unchanged. An MRI scan is shown in Figure 5. What histologic changes are likely to be found in the supraspinatus
tendon?

..What is the most likely predictor of postsurgical pain following a coracoid transfer procedure for recurrent shoulder instability?

..A 45-year-old woman with diabetes has a 3-month history of left shoulder pain and motion loss unrelated to trauma. She previously underwent treatment with nonsteroidal anti-inflammatory medication and a home stretching program, experiencing minimal relief of her symptoms. Examination reveals loss of passive external rotation, abduction, and forward elevation without reduction in strength. Radiograph findings are normal. What is the most appropriate next step?

..A 42-year-old woman has a posterior elbow dislocation. Closed reduction is performed, and the elbow appears stable under fluoroscopic examination. Further treatment should consist of

..The fracture seen in Figure 17 is most likely associated with injury to what ligamentous structure?

…A 36-year-old right-hand-dominant man fell from his motorcycle and sustained the acute right upper extremity injury seen in Figure 18. At surgery, an open reduction and internal fixation of the ulna is performed along with attempted open reduction of the radiocapitellar joint. However, the radial head is slightly subluxed in flexion and redislocates with elbow extension below 90 degrees. What is the most appropriate treatment at this time?

..Figure 19 is the radiograph of a 45-year-old right-hand-dominant man who has had a 2-day history of right shoulder pain, weakness, and a deformity involving the clavicle region after a fall from a scaffold during work activities. He was previously evaluated by his primary care physician and another orthopaedist. He has sought a second opinion regarding his treatment options. What is the most appropriate treatment for his injury?

..A 55-year-old woman develops posttraumatic arthritis in the elbow following a distal humerus fracture. What is the most likely mid-term (5-10 years after surgery) complication following semiconstrained total elbow arthroplasty (TEA)?

..Numbness after his first dislocation was related to

…The patient underwent an uneventful arthroscopic repair and did well until 1 year later when she crashed during a race. She tore her anterior cruciate ligament (ACL) and underwent reconstruction. Followup after her successful ACL reconstruction reveals complaints of new shoulder pain and posterior instability from using crutches after her ACL surgery. A new MRI scan is shown in Figure 24. What factors are most likely associated
with this patient’s recurrence?

..What is the best next step?

..A 40-year-old right-hand-dominant construction worker has a 3-month history of right shoulder weakness secondary to a fall from a ladder at work. He underwent nonsurgical treatment with anti-inflammatory medication, cortisone injections, and therapy, with minimal relief of his symptoms. A subsequent MRI scan indicates a 1-cm full-thickness supraspinatus tendon tear. He has been referred to your clinic for discussion of surgical intervention. The patient's nurse case manager is concerned that he may not be able to return to his preinjury level of activity at work, even with surgical intervention. You tell the nurse case manager that, on average, the patient will

..A 75-year-old man sustains an anterior dislocation of his reverse total shoulder arthroplasty. What activity places the arm in the position most commonly associated with reverse total shoulder dislocation?

..When performing an ulnar nerve decompression at the elbow, the surgeon must be aware of the

..Figure 33 is the radiograph of a 27-year-old bicyclist who crashes. He has an isolated and closed injury. He is neurovascularly intact in the upper extremity. The lateral fragment is displaced inferiorly by

..Placement of the most distal interlocking screw seen in the Figures 34a and 34b radiographs most likely resulted in what motor weakness?

..One week after closed reduction of a primary anterior shoulder dislocation, a 25-year-old athlete should be counseled that

..At what point of glenoid retroversion is there risk for component perforation of the glenoid vault with traditional high side reaming and standard component implantation?

..A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a comminuted intra-articular distal humerus fracture. What is the best surgical option?

..A 67-year-old man with right shoulder osteoarthritis remains symptomatic despite a course of nonsurgical treatment. A CT scan of the shoulder before surgery shows eccentric posterior glenoid wear with 10 degrees of retroversion. What is the appropriate treatment of this glenoid bone loss?

..Figure 42 is the MRI scan of a 52-year-old active man who fell from a ladder 6 weeks ago and sustained an isolated glenohumeral dislocation that was reduced in the emergency department. He wore his sling for about 2 weeks and arrived at your clinic today after referral by his primary care doctor. Examination reveals sensation intact throughout his hand, forearm, and shoulder girdle. Belly press examination findings are normal, but painful. He has tenderness to palpation on the anterior shoulder and a painful speed test.
Rotator cuff repair associated with tenotomy of the indicated structure will result in what condition when compared to tenodesis of the same structure?

..A complication associated with using the Morrey approach (triceps reflecting) to implant a semiconstrained total elbow arthroplasty is

..The treating physician opted to perform a Latarjet coracoid transfer. What is the primary mechanism of stability?

..A 45-year-old woman has a 3-month history of left shoulder pain. She has tried 2 months of physical therapy focused on rotator cuff strengthening without experiencing relief. A subacromial corticosteroid injection fails to provide lasting relief. Examination reveals no atrophy or winging. She has anterior and posterior shoulder tenderness, full symmetric forward elevation and abduction, and pain with maximal passive forward elevation. She has pain with internal rotation in 90 degrees of forward elevation.
She has an increased distance between the antecubital fossa and coracoid process with cross chest adduction compared to the contralateral side. No weakness is appreciated. Radiographs reveal a type II acromion. What is the best next step?

..If the patient were a college pitcher with a similar presentation and examination, what structure would most likely be injured?

..A 21-year-old college swimmer presents with an inability to compete for longer than 1 year because of right shoulder pain and subjective symptoms of instability despite physical therapy. Recent radiographs and an MRI scan of her shoulder demonstrate an intact labral complex. Her symptoms are reproduced with sulcus testing and load and shift maneuvers in both anterior and posterior directions. What is the most appropriate next treatment step?

..What is the most appropriate treatment if instability is present at the time of evaluation?

..The best initial treatment would entail

..Figure 59 is the MRI scan of a 30-year-old fire fighter who dislocated his left shoulder during work activities. His shoulder was reduced in the emergency department. After 8 weeks of physical therapy, he continues to have apprehension when lifting and pushing the fire hose back into the truck. He has normal rotator cuff strength and a negative sulcus sign. What treatment option will allow this patient to return to work as soon as possible?

..What biomechanical forces and pathology most likely underlie this patient’s pain and injury?

..A 35-year-old man fell off of a roof and sustained an extra-articular supracondylar elbow fracture. He had normal sensation in all fingers after the injury and before undergoing surgery to repair the fracture. The ulnar nerve was not transposed, but it was inspected prior to wound closure. Ten days after surgery, the patient has numbness in his small finger and is unable to cross his fingers. His elbow range of motion is between 40 degrees and 100 degrees. What is the next appropriate treatment step?

..A 54-year-old pipefitter falls from a ladder at work and dislocates his nondominant shoulder. His MRI scan shows supraspinatus and infraspinatus tears with retraction to the glenoid. He cannot actively raise his arm away from his side. He denies prior shoulder symptoms before his fall. Three weeks of physical therapy have failed to improve his function. You and the patient decide to proceed with surgical repair. Which is a risk factor for a poor outcome?

..If nonsurgical treatment has failed, what surgical procedure will best reduce the risk for recurrent instability?

..A 33-year old man sustains a posterior elbow dislocation after a fall. Attempts at closed reduction result in recurrent instability. What is the most common ligamentous injury found at the time of surgical stabilization?

..A 25-year-old man is planning to have an elbow contracture release. His elbow range of motion is 40 degrees to 90 degrees of flexion. He has no heterotopic ossification. His ring and small fingers become numb as his elbow approaches his flexion endpoint. There is no evidence of instability of the ulna-humeral or radioulnar joints. To achieve the best possible outcome, the surgeon should

..Figures 78a and 78b are the radiographs of a 47-year-old right-hand-dominant woman who has a 3-month history of gradually progressive right shoulder pain. She reports no previous trauma, but does report pain at night and with activity such as weight training. Examination demonstrates active and passive range of motion to be 110 degrees forward elevation, external rotation to 20 degrees, and internal rotation to the sacrum. The next treatment step should include

..Figures 83a and 83b are the radiographs of a 53-year-old otherwise healthy homemaker who had a syncopal episode and sustained a ground-level fall and injury to her right elbow. She presently admits to right elbow pain, swelling, and an inability to bend her elbow. What is the best initial treatment for this injury?

..What is the most common late complication of the revision procedure for this patient?

..Complete transection of the ulnar nerve at the elbow will result in

..Figures 91a through 91d are the radiographs of an 86-year-old man who lives independently who has fallen down the stairs. He has an isolated elbow injury. What treatment option is most likely to offer the most rapid return of function and pain relief?

…A 68-year-old right-hand-dominant man underwent a right total shoulder arthroplasty (TSA) 3 months ago. He was started on passive range of motion and started active motion 6 weeks after surgery. He notes that he fell onto his outstretched right arm 2 weeks ago but did not seek care. His primary symptom is poor active elevation of the right shoulder. His right shoulder motion has active elevation of 45 degrees, passive elevation of 140 degrees, 95-degree external rotation, and internal rotation to L3. His left shoulder has active and passive elevation of 160 degrees, external rotation of 70 degrees, and internal
rotation to T12. The right shoulder radiographs show a concentric total shoulder arthroplasty with no fractures or other abnormalities. What is the most appropriate treatment at this point?

..Figure 93 is the radiograph of a 72-year-old woman. Treatment includes fixation of the ulna. What options are recommended for the radius?

..A common postoperative radiographic observation associated with your surgery in an asymptomatic patient is

..What complication following total elbow arthroplasty poses more risk for a 60-year-old man with osteoarthritis than for a man of the same age with rheumatoid arthritis?

..Figure 99a is the radiograph of a 48-year-old woman 8 months after initial treatment of an injury. She initially was placed in a sling and progressive rehabilitation followed. She now has refractory pain but normal range of movement and strength. The current radiograph is shown in Figure 99b. The most appropriate next treatment step is

..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?

..Figures 105a and 105b are the radiograph and MRI scan of a 45-year-old woman with fibromyalgia that causes chronic neck and scapula pain. She has had new-onset lateral shoulder pain for 1 year. She has tenderness throughout her shoulder, back, and neck; a positive Hawkins impingement sign; and pain with resisted elevation. She tried physical therapy for 12 weeks and the pain is worse. What is the next appropriate treatment step for her shoulder pain?