Ortho Shoulder And Elbow Review | Dr Hutaif Shoulder & - ...
14 Apr 2026
37 min read
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Key Takeaway
This topic focuses on ORTHO MCQS Shoulder and Elbow 0192, Following surgical repair of a radial head fracture complicated by lateral collateral ligament (LCL) avulsion, initial postoperative rehabilitation should include elbow extension exercises performed with the forearm in pronation. This specific positioning helps protect the compromised LCL. A clear explanation of this approach forms a crucial response a discussion point for therapists to ensure optimal recovery and stability.
Ortho Shoulder And Elbow Review | Dr Hutaif S...
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Question 1High Yield
A 13-year-old pitcher reports the immediate onset of medial elbow pain after throwing a pitch. Upon examination, the patient is tender to palpation at the medial epicondyle and has pain and instability with valgus testing of the elbow. If the patient were a college pitcher with a similar clinical presentation and physical examination, what anatomic structure would most likely be injured?
Explanation
DISCUSSION:
The patient has an acute avulsion fracture of the medial epicondyle, which can occur in response to the valgus load placed on the elbow while throwing. Diagnosis is confirmed by radiograph, with comparison views of the uninjured elbow to evaluate for physeal closure versus injury. In older pitchers, the UCL fails rather than the bone of the medial epicondyle. Advanced imaging may be necessary to confirm the diagnosis of an UCL
injury and/or bony injury.
DISCUSSION:
The patient has an acute avulsion fracture of the medial epicondyle, which can occur in response to the valgus load placed on the elbow while throwing. Diagnosis is confirmed by radiograph, with comparison views of the uninjured elbow to evaluate for physeal closure versus injury. In older pitchers, the UCL fails rather than the bone of the medial epicondyle. Advanced imaging may be necessary to confirm the diagnosis of an UCL
injury and/or bony injury.
Question 2High Yield
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)?
Explanation
DISCUSSION:
TEA has been described for posttraumatic arthritis of the elbow and typically involves a young patient population with multiple previous operations on the affected elbow. Morrey and Schneeberger found aseptic component loosening to be uncommon (<10% of patients) and usually occurring >10 years after surgery. Prosthetic fracture, usually of the ulnar component, is also a late-term finding. Infection is the most common mode of early failure but usually occurs within the first 5 years and has an overall rate of approximately 5%. Bushing wear has been reported as the most common cause of mechanical TEA failure in this population at
intermediate-term follow-up.
DISCUSSION:
TEA has been described for posttraumatic arthritis of the elbow and typically involves a young patient population with multiple previous operations on the affected elbow. Morrey and Schneeberger found aseptic component loosening to be uncommon (<10% of patients) and usually occurring >10 years after surgery. Prosthetic fracture, usually of the ulnar component, is also a late-term finding. Infection is the most common mode of early failure but usually occurs within the first 5 years and has an overall rate of approximately 5%. Bushing wear has been reported as the most common cause of mechanical TEA failure in this population at
intermediate-term follow-up.
Question 3High Yield
A 45-year-old construction worker sees a surgeon 23 days after sustaining an eccentric injury to his dominant right elbow. An MRI demonstrates a distal biceps tendon rupture with 5 cm of proximal retraction. In the operating room, the surgeon encounters good tissue quality but finds that primary repair can only be performed with the elbow hyperflexed to 70°. What is the best next step?
Explanation
DISCUSSION:
Distal biceps ruptures, although relatively less common in comparison with other upper extremity tendon injuries, still garner considerable attention in the orthopaedic literature. The mechanism of injury typically results from an eccentric extension load to a flexed elbow. A biceps-deficient arm can result in up to 40% loss of supination strength and up to 80% loss of supination endurance. A delay in diagnosis can compromise the ability to reduce the tendon back to its anatomic insertion without having to hyperflex the elbow. Current literature confirms the ability to safely proceed with primary repair even with the elbow flexed up to 100° without fear of developing a flexion contracture. With time, patients can anticipate restoration of full elbow extension. An interposition graft should be used for a poor residual tendon quality stump <4 cm in length and in cases of delay to surgery of >6 weeks. Biceps to brachialis tendon transfer does not restore supination
strength. Isolated debridement of the distal tendon would not be an appropriate treatment.
DISCUSSION:
Distal biceps ruptures, although relatively less common in comparison with other upper extremity tendon injuries, still garner considerable attention in the orthopaedic literature. The mechanism of injury typically results from an eccentric extension load to a flexed elbow. A biceps-deficient arm can result in up to 40% loss of supination strength and up to 80% loss of supination endurance. A delay in diagnosis can compromise the ability to reduce the tendon back to its anatomic insertion without having to hyperflex the elbow. Current literature confirms the ability to safely proceed with primary repair even with the elbow flexed up to 100° without fear of developing a flexion contracture. With time, patients can anticipate restoration of full elbow extension. An interposition graft should be used for a poor residual tendon quality stump <4 cm in length and in cases of delay to surgery of >6 weeks. Biceps to brachialis tendon transfer does not restore supination
strength. Isolated debridement of the distal tendon would not be an appropriate treatment.
Question 4High Yield
is performed in the emergency department. After reduction, the greater tuberosity fragment remains displaced by 2 mm. What is the most appropriate treatment?
Explanation
DISCUSSION
Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and
<3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range
of motion is important to avoid stiffness.
DISCUSSION
Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and
<3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range
of motion is important to avoid stiffness.
Question 5High Yield
A 72-year-old active man has shoulder pain after undergoing an explantation of an anatomic shoulder arthroplasty 6 months prior with an antibiotic cement spacer placed. The patient has 60° of forward flexion, 40° of external rotation, and a positive belly press with limited internal rotation. A recent work-up for continued infection is negative, and a follow-up MRI reveals grade 2 atrophy of the supraspinatus and grade 3 atrophy of the subscapularis with tendon retraction to the glenoid rim. What is the best next step in definitive management?
Explanation
DISCUSSION
This patient has a previously failed total shoulder arthroplasty for which he underwent placement of an antibiotic spacer, and now has continued shoulder pain. The recent MRI demonstrates a likely irreparable subscapularis tendon, making revision with an anatomic shoulder arthroplasty contraindicated. Use of a hemiarthroplasty is unlikely to restore function in this older patient with underlying rotator cuff disease, though it may be helpful for pain relief. Furthermore, a latissimus dorsi transfer is also contraindicated in the setting of a chronic subscapularis tear. A reverse shoulder arthroplasty offers the most reliable clinical outcome. Given that the preoperative infection work-up was negative, resection arthroplasty
is not indicated for this otherwise active patient.
DISCUSSION
This patient has a previously failed total shoulder arthroplasty for which he underwent placement of an antibiotic spacer, and now has continued shoulder pain. The recent MRI demonstrates a likely irreparable subscapularis tendon, making revision with an anatomic shoulder arthroplasty contraindicated. Use of a hemiarthroplasty is unlikely to restore function in this older patient with underlying rotator cuff disease, though it may be helpful for pain relief. Furthermore, a latissimus dorsi transfer is also contraindicated in the setting of a chronic subscapularis tear. A reverse shoulder arthroplasty offers the most reliable clinical outcome. Given that the preoperative infection work-up was negative, resection arthroplasty
is not indicated for this otherwise active patient.
Question 6High Yield
A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of the bone fragment and returns to play football the following year. He has a recurrent dislocation at football practice but decides to finish the football season before considering additional treatment. He sustains nine additional dislocations, with the last dislocation occurring while sleeping. The patient has eroded one-third of the inferior glenoid surface area. What is the most appropriate surgical treatment?
Explanation
DISCUSSION
A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an "inverted pear." Quantitative bone loss is best evaluated by CT scan with 3-D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting. A revision arthroscopic or open Bankart repair with capsular shift or remplissage do not address bone loss. The Latarjet procedure can effectively restore stability with glenoid bone loss and after failed stabilizing procedures. Patients with pain before surgery are
more likely to have pain after surgery. Age and activity level are lesser influences on satisfaction.
DISCUSSION
A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an "inverted pear." Quantitative bone loss is best evaluated by CT scan with 3-D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting. A revision arthroscopic or open Bankart repair with capsular shift or remplissage do not address bone loss. The Latarjet procedure can effectively restore stability with glenoid bone loss and after failed stabilizing procedures. Patients with pain before surgery are
more likely to have pain after surgery. Age and activity level are lesser influences on satisfaction.
Question 7High Yield
What phase of overhead throwing puts the rotator cuff at most risk of injury from internal impingement?
Explanation
DISCUSSION
Internal impingement occurs when there is repetitive contact of the posterior superior aspect of the glenoid with the humeral head causing damage to the undersurface of the supraspinatus and anterior aspect of the infraspinatus tendons, as well as posterior superior glenoid labrum. This occurs when the arm is in maximum abduction and external rotation such as during the late cocking phase of the normal throwing motion. The 6 phases of throwing are wind up, early cocking, late cocking, deceleration, and follow through. When the arm is repeatedly placed in the abducted externally rotated position, the anterior capsule can become lax and posterior capsular contractures can develop. When there are kinetic chain abnormalities such as scapular internal rotation or muscle fatigue, there is exacerbation of abnormal anterior humeral head translation and increased contact of the rotator cuff on the posterior glenoid rim, with concomitant increased risk of injury
and symptoms.
DISCUSSION
Internal impingement occurs when there is repetitive contact of the posterior superior aspect of the glenoid with the humeral head causing damage to the undersurface of the supraspinatus and anterior aspect of the infraspinatus tendons, as well as posterior superior glenoid labrum. This occurs when the arm is in maximum abduction and external rotation such as during the late cocking phase of the normal throwing motion. The 6 phases of throwing are wind up, early cocking, late cocking, deceleration, and follow through. When the arm is repeatedly placed in the abducted externally rotated position, the anterior capsule can become lax and posterior capsular contractures can develop. When there are kinetic chain abnormalities such as scapular internal rotation or muscle fatigue, there is exacerbation of abnormal anterior humeral head translation and increased contact of the rotator cuff on the posterior glenoid rim, with concomitant increased risk of injury
and symptoms.
Question 8High Yield
A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of the bone fragment and returns to play football the following year. He has a recurrent dislocation at football practice but decides to finish the football season before considering additional treatment. He sustains nine additional dislocations, with the last dislocation occurring while sleeping.What diagnostic test is most appropriate when planning revision surgery?
Explanation
DISCUSSION
A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an "inverted pear." Quantitative bone loss is best evaluated by CT scan with 3-D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting. A revision arthroscopic or open Bankart repair with capsular shift or remplissage do not address bone loss. The Latarjet procedure can effectively restore stability with glenoid bone loss and after failed stabilizing procedures. Patients with pain before surgery are
more likely to have pain after surgery. Age and activity level are lesser influences on satisfaction.
DISCUSSION
A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an "inverted pear." Quantitative bone loss is best evaluated by CT scan with 3-D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting. A revision arthroscopic or open Bankart repair with capsular shift or remplissage do not address bone loss. The Latarjet procedure can effectively restore stability with glenoid bone loss and after failed stabilizing procedures. Patients with pain before surgery are
more likely to have pain after surgery. Age and activity level are lesser influences on satisfaction.
Question 9High Yield
In rotator cuff tear arthropathy with pseudoparalysis, forward elevation of the humerus away from the body is prohibited because of
Explanation
DISCUSSION
The rotator cuff serves as a humeral head compressor that stabilizes the humeral head in the glenoid concavity so that the deltoid can convert a vertical force into abduction and forward elevation. The deltoid functions normally in patients with chronic rotator cuff arthropathy, so no atony is present. Glenoid concavity can be lost over time, but this is not the primary mechanism for failure of elevation. The biceps tendon does not serve as a humeral head compressor and does not prevent proximal migration of the shoulder when it is present.
DISCUSSION
The rotator cuff serves as a humeral head compressor that stabilizes the humeral head in the glenoid concavity so that the deltoid can convert a vertical force into abduction and forward elevation. The deltoid functions normally in patients with chronic rotator cuff arthropathy, so no atony is present. Glenoid concavity can be lost over time, but this is not the primary mechanism for failure of elevation. The biceps tendon does not serve as a humeral head compressor and does not prevent proximal migration of the shoulder when it is present.
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Prof. Dr. Mohammed Hutaif
Consultant Orthopedic & Spine Surgeon