Ortho Free Review | Dr Hutaif General Orthopedics Revie -...

DISCUSSION: Overadvancement of the FDP tendon is one of the causes of the quadriga effect. Relative shortening of an FDP tendon decreases the excursion of the neighboring FDP tendons because they originate from a common muscle belly. The patient reports a weak grasp.
is not correct because there can be a fracture and the tendon can avulse off of the fracture fragment (Trumble JHS-A 1992). Whether the tendon has retracted into the palm or not does matter because retraction into the palm allows pulleys to collapse and contract and it also means that the vinculae have been stripped off of the tendon. Regarding answer 3, in chronic cases where the FDS is intact and strong, many patients may be better off with a sublimis finger and no FDP reconstruction that could, in the worst case scenario, worsen a functional proximal interphalangeal joint. Regarding the repair method, there is recent research showing method of repair (button vs anchor), suture type, and method do affect the biomechanical properties of the repair. The Preferred Response to Question # 78 is 4.

79. ##### What is the most common complication associated with the treatment of the distal biceps ruptures as shown in Figures 79a and 79b?
1. ##### Re-rupture
2. ##### Radioulnar synostosis
3. ##### Posterior interosseous nerve injury
4. ##### Lateral antebrachial cutaneous nerve irritation 5- Radial fracture

DISCUSSION: The patient shown underwent distal biceps repair with a button technique. Among the reports in the literature, the most commonly noted complication associated with this
technique is lateral antebrachial cutaneous nerve irritation. Re-rupture, radioulnar synostosis, and posterior interosseous nerve injury can occur, but are not as common as lateral antebrachial cutaneous nerve injury.The Preferred Response # 79 is 4.

80. ##### A 16-year-old right-hand dominant male pitcher has had increasing pain in his dominant shoulder for the past 6 months without treatment. A coronal T2-weighted MRI scan is shown in Figure 80. What is the most appropriate treatment plan?
1. ##### Decreased pitch count for 4 weeks
2. ##### Continued play with close observation 3- Cessation of all throwing for 6 weeks 4- Arthroscopic repair
5- Mini-open repair

DISCUSSION: The coronal MRI scan shows an undersurface partial-thickness rotator cuff tear. Initial treatment for this injury should include complete cessation of throwing (or other overhead activities dependent on the athlete). Despite the duration of symptoms, he has had no treatment to date; therefore, nonsurgical management should include activity cessation, a rotator cuff and periscapular strengthening program, and then a slow and supervised return to throwing with particular attention to proper pitching mechanics. Decreasing the pitch count or continued play with observation risks progression of the problem. Surgical intervention is not indicated for initial treatment. The Preferred Response to Question # 80 is 3.

81. ##### A 36-year-old woman reports vague right shoulder pain. She denies any previous shoulder problems or any recent trauma. MRI scans are shown in Figures 81a and 81b. Weakness of which of the following is the most likely finding in her physical examination?

1. ##### Shoulder abduction and internal rotation
2. ##### Shoulder external rotation and scapula protraction 3- Shoulder external rotation with the arm at the side 4- Shoulder internal rotation with the arm at the side 5- Scapula protraction

DISCUSSION: The MRI scans show a cyst formation within the suprascapular notch that can compress the suprascapular nerve. The suprascapular nerve innervates both the supraspinatus and the infraspinatus muscles. Therefore, patients with compression of

this nerve may demonstrate weakness of shoulder abduction and external rotation with the arm at the side. If the nerve is compressed after its innervation of the supraspinatus muscle, however, patients will demonstrate weakness of shoulder external rotation only. Suprascapular nerve does not innervate muscles that control scapula motion or shoulder internal rotation. The Preferred Response # 81 is 3.

82. ##### A 61-year-old man reports right shoulder pain and loss of external rotation since having a seizure 5 months ago. MRI scans are shown in Figures 82a and 82b. What is the most appropriate treatment?

1- Closed reduction and application of a shoulder immobilizer 2- Open reduction and lesser tuberosity transfer
3- Hemiarthroplasty placed in anatomic version 4- Hemiarthroplasty placed in anteversion
5- Total shoulder arthroplasty

DISCUSSION: The patient has a chronic posterior shoulder dislocation with loss of approximately half of the humeral head. Hemiarthroplasty or osteochondral allograft to fill the defect would be required. Given the time since injury, the remaining native head and articular surface may have lost structural integrity, making hemiarthroplasty the preferred choice. The implant should be placed close to the patient's natural version, which normally is in the range of 20 to 30 degrees of retroversion. Excessive anteversion is not recommended to avoid repeat posterior dislocation. Closed reduction is highly unlikely to achieve a reduction and may cause displacement of an unrecognized humeral surgical neck fracture. Open reduction and lesser tuberosity transfer is best suited for smaller head defects and a less chronic dislocation. Glenoid integrity is not affected, thus a glenoid implant is unnecessary.
The Preferred Response to Question # 82 is 3.

83. ##### A 17-year-old high school baseball player injured his dominant throwing arm sliding head first into third base. He has immediate pain and swelling along the medial aspect of the elbow and forearm, and demonstrates painful apprehension with any attempt at movement of the elbow. Radiographs of the elbow are shown in Figures 83a and 83b. What is the most appropriate management?
1. ##### Cast immobilization for 6 weeks followed by rehabilitation
2. ##### Hinged elbow brace for 6 weeks and initiation of early motion
3. ##### Open reduction and internal fixation 4- Fragment excision
5- Closed reduction and percutaneous pinning

DISCUSSION: The patient has sustained a significantly displaced fracture of the medial epicondyle. Nonsurgical management is unlikely to restore valgus stability to the elbow necessary for overhead throwing. The fragment is large enough that bony stability should be achieved with rigid internal fixation, thereby allowing early range of motion and rehabilitation. Closed reduction attempts are unlikely to result in anatomic reduction, and pinning of a displaced fracture may put the ulnar nerve at risk. Fracture excision may further destabilize the elbow. The Preferred Response # 83 is 3.

84. ##### A 51-year-old woman with shoulder pain responds transiently to a subacromial injection and physical therapy exercise program. When her symptoms recur, an arthroscopic subacromial decompression is recommended. During the surgery, a partial-thickness articular-sided supraspinatus tear is noted. The supraspinatus footprint is exposed for 3 mm from the articular margin. The remaining intra- articular structures are normal. Inspection from the bursal surface reveals the tendon to be intact. What is the most appropriate course of management?
1- Completion of the tear from the bursal surface and rotator cuff repair 2- Arthroscopic long head biceps tenotomy
3. ##### Arthroscopic glenohumeral synovectomy
4. ##### Arthroscopic tendon debridement and subacromial decompression 5- Transtendinous rotator cuff repair

DISCUSSION: The patient has a partial articular supraspinatus tendon avulsion (PASTA) lesion. Outcome studies suggest that articular-sided tears of this magnitude do well with arthroscopic decompression and debridement alone. Determination of lesion thickness is important in recommending treatment, and may be done with a variety of methods. Tears that involve exposure of less than 5 mm of the rotator cuff footprint likely measure less than half of the tendon thickness. In the absence of other associated pathology, bicipital tenotomy or synovectomy would be unnecessary.
Completion of the tear or transtendinous tear would be considered for lesions of greater than 50% thickness. The Preferred Response to Question # 84 is 4.

85. ##### A 40-year-old man sustains a scapular body fracture after an all-terrain vehicle accident. Which of the following is the most commonly associated injury?
1. ##### Chest injury
2. ##### Clavicle fracture
3. ##### Glenohumeral dislocation
4. ##### Humeral fracture
5. ##### Axillary nerve injury

DISCUSSION: Chest injury (rib fracture, pneumothorax, hemothorax, contusion) is the most commonly associated injury in patients who have sustained a significant scapular injury. Chest injury becomes even more commonly found when the scapula has more than one zone of injury (ie, multiple fractures). Humeral fracture, clavicle fracture, and axillary nerve injury are not as common as chest injury. The Preferred Respo# 85 is 1.

86. ##### A 44-year-old woman with cubital tunnel syndrome and associated ulnar nerve subluxation with elbow flexion has failed to respond to nonsurgical management. Which of the following statements is most acccurate regarding in situ simple decompression of the nerve compared with subcutaneous anterior transposition? 1- Patients undergoing anterior transposition have improved motor outcomes.
2- Patients undergoing anterior transposition have improved sensory outcomes 3- Patients undergoing simple decompression have improved motor outcomes. 4- Patients undergoing simple decompression have improved sensory outcomes. 5- No differences in outcome are likely between treatment types.

DISCUSSION: Recent reports comparing outcomes of surgical treatment of ulnar nerve compression at the elbow have demonstrated no differences in outcome between simple decompression and anterior transposition. The presence of subluxation of the ulnar nerve was not a contraindication to in situ decompression in the study by Keiner and associates. The Preferred Response to Question # 86 is 5.

87. ##### A 25-year-old electrician sustained an injury to his dominant arm while bench pressing at the gym. He reports that he felt a tearing sensation while extending his arms. Examination reveals that he has lost the normal contour of the axillary fold which worsens with resisted adduction. Additionally, there is extensive ecchymosis down the arm and weakness to adduction and internal rotation. Radiographs are normal. What is the most appropriate management?
1. ##### Arthroscopic subscapularis repair
2. ##### Repair of the long head of the biceps with tenodesis 3- Open repair of the pectoralis major tendon avulsion
4- Ultrasound and physical therapy to reduce swelling and improve strength 5- Brace immobilization for 6 weeks

DISCUSSION: This description is classic for an acute pectoralis major humeral avulsion. The loss of contour in the axillary fold confirms this diagnosis. Treatment for a pectoralis tendon avulsion should be open surgical repair in this young patient.
Therapy may be considered for injuries within the muscle or at the musculotendinous junction. Examination for subscapularis rupture and biceps injuries would not cause a change in the axillary fold. Bracing will not improve long-term strength.P R# 87 is 3.

88An otherwise healthy 30-year-old man undergoes right shoulder arthroscopic Bankart repair under regional anesthesia using an interscalene brachial plexus block. In the recovery room, he reports mild difficulty breathing and his chest radiograph shows a high riding diaphragm on the right side. His peripheral oxygenation is 97% on 2 liters of oxygen by nasal cannula. What is the most appropriate management? 1- Continued observation and monitoring
2. ##### Obtain arterial blood gas measurements
3. ##### Obtain emergent spiral CT scan to assess for pulmonary embolism

4. ##### Insertion of a chest tube
5. ##### Airway control and, if necessary, endotracheal intubation

DISCUSSION: Because the phrenic nerve lies in close proximity to the site of anesthetic injection, temporary hemidiaphragmatic paresis is a very common side effect of interscalene brachial plexus block. Pulmonary function and chest wall mechanics may be slightly compromised, but can easily be compensated in a healthy patient.
Therefore, with sufficient oxygenation, aggressive assessments or treatments such as arterial blood gas measurements, emergent spiral CT scans, chest tube insertions, or endotracheal intubation are not warranted. For this stable patient, continued monitoring with gradual withdrawal of oxygen is the most appropriate treatment.
The Preferred Response to Question # 88 is 1.

89. ##### What is the interval used during an anterior approach (Henry) for a distal radius shaft fracture?
1- Flexor digitorum superficialis-flexor carpis ulnaris 2- Flexor carpi radialis-flexor digitorum superficialis 3- Brachioradialis-flexor carpi radialis
4- Flexor pollicis longus-flexor digitorum profundus 5- Flexor pollicis longus-flexor carpi radialis

DISCUSSION: The anterior approach to the radial shaft uses the internervous plane between the brachioradialis (radial n) and flexor carpi radialis (median n) distally, and the brachioradialis and pronator teres (median n) proximally. The Preferred Response to Question # 89 is 3.

90. ##### A 37-year-old man with a nondisplaced radial neck fracture has failed to respond to 8 months of nonsurgical management. He has undergone extensive physical therapy and bracing without improvement. Examination reveals that active and passive range of motion is limited to 50 degrees to 85 degrees, with full pronosupination. He has mildly diminished sensation in the little and ring fingers.
Radiographs reveal healing of the fracture, no deformity, and no arthrosis or heterotopic bone formation. What is the most appropriate management?

1. ##### Radial head resection and release of the anterior capsule
2. ##### Anterior and posterior capsule release, with ulnar nerve transposition 3- Ulnar nerve transposition and release of the posterior capsule
4. ##### Ulnar nerve transposition
5. ##### Intra-articular corticosteroid injection

DISCUSSION: The patient has refractory extra-articular elbow stiffness and ulnar neuritis following trauma. Important considerations are ruling out failure of fracture healing, persistent deformity, and heterotopic bone formation. In this patient, further nonsurgical management is unlikely to provide any benefit; therefore, the treatment of choice is anterior and posterior capsule release, with ulnar nerve transposition. Radial head resection is not indicated because of the absence of deformity or arthrosis. There is restriction of both flexion and extension, so limited capsular release techniques will not maximize functional restoration. Ulnar nerve transposition alone will not restore motion. An intra-articular injection is not likely to improve motion 8 months after the injury. The Preferred Response to Question # 90 is 2.

91. ##### Figure 91 shows the radiograph of a 57-year-old man who fell 6 feet off a ladder. He is neurovascularly intact but reports shoulder pain. What is the most appropriate acute treatment for this patient?

1- Physical therapy for range of motion, advancing to strengthening as tolerated 2- Sling immobilization and a recheck in 1 week with radiographs
3. ##### CT scan of the shoulder
4. ##### Open reduction and surgical stabilization with plates and screws
5. ##### Ice, nonsteroidal anti-inflammatory drugs, and activity as tolerated

DISCUSSION: The patient has sustained a traumatic surgical neck fracture of the humerus. Sling immobilization and a recheck in 1 week with radiographs is appropriate

to check for maintenance of alignment. The fracture is minimally displaced and therefore does not require surgical stabilization or further diagnostic imaging. Surgical reduction and plating is not indicated in this nondisplaced fracture. Physical therapy and activity as tolerated at this point are contraindicated because of the acuity of the fracture. The Preferred Response to Question # 91 is 2.

92. ##### What anatomic structure must be excised when performing a volar plate arthroplasty of the proximal interphalangeal joint?
1. ##### Central slip
2. ##### Collateral ligament
3. ##### Checkrein ligament
4. ##### Triangular ligament
5. ##### Flexor digitorum superficialis insertion

DISCUSSION: The collateral ligament must be excised or released from the proximal phalanx to allow gliding of the middle phalanx on the articular surface of the proximal phalanx. Failure to do so may prevent this gliding motion and make the middle phalanx just hinge on the proximal phalanx. The Preferred Response to Question # 92 is 2.

93A 67-year-old woman with rheumatoid arthritis has had a 3-year history of gradually progressive right elbow pain and limited function despite intra-articular injections and medical management. She previously underwent a rheumatoid hand reconstruction, and has no pain or dysfunction of the ipsilateral shoulder.
Radiographs are shown in Figures 93a and 93b. What is the most appropriate treatment?
1. ##### Soft-tissue interposition arthroplasty with radial head resection
2. ##### Arthroscopic synovectomy with radial head resection 3- Elbow arthrodesis
4- Total elbow arthroplasty 5- Resection arthroplasty

DISCUSSION: Total elbow arthroplasty is the treatment of choice. The patient has end- stage rheumatoid involvement of the ulnohumeral and radiocapitellar joints. Given the advanced nature of the disease and evidence of bony erosion, arthroscopic synovectomy and interposition arthroplasty are unlikely to provide lasting benefit or functional improvement. Elbow arthrodesis and resection arthroplasty are considered salvage techniques and are generally not considered as a primary treatment method.
The Preferred Response to Question # 93 is 4.

94A 78-year-old woman undergoes an uneventful semiconstrained total elbow arthroplasty through a Bryan-Morrey approach. Her immediate postoperative management should include which of the following?
1. ##### Five days of intravenous antibiotics for perioperative prophylaxis
2. ##### Use of continuous passive motion beginning on postoperative day one
3. ##### Immediate initiation of active flexion and gravity-assisted passive extension
4. ##### Splinting at 60 to 90 degrees of flexion for 5 to 10 days, followed by initiation of active flexion and gravity-assisted passive extension
5. ##### Splinting at 60 to 90 degrees of flexion until the triceps has healed, followed by initiation of active flexion and extension

DISCUSSION: Postoperative management of total elbow arthroplasty patients is directed to avoidance of complications commonly associated with this procedure. Following total elbow arthroplasty, 24 hours of perioperative antibiotics should be given, consistent with other arthroplasty procedures. Because of the relatively thin soft-tissue envelope surrounding the elbow, particularly in patients with rheumatoid arthritis, consideration must be given to the surrounding soft tissues postoperatively. The surgical wound should be given several days of quiescence prior to initiation of motion to minimize wound healing complications. Splinting at 60 to 90 degrees allows tension to be removed from the soft tissues. Immediate motion places these tissues under immediate stress; immobilization of the elbow for 6 to 8 weeks until the triceps has healed would result in significant stiffness. Splinting should not be used more than 10 days to avoid stiffness of the elbow.
The Preferred Response to Question # 94 is 4.

95. ##### A 55-year-old man who underwent total shoulder arthroplasty 10 years ago recently reports an increase in shoulder pain. Laboratory studies consisting of a white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are all negative, as is joint aspiration. Radiographs are shown in Figures 95a and 95b. If all intraoperative frozen sections are negative, what is the appropriate treatment during revision surgery to provide pain relief and improved function?
1. ##### Placement of antibiotic spacer
2. ##### Removal of the glenoid, and possible bone grafting 3- Conversion to reverse shoulder arthroplasty
4- Referral to pain management 5- Shoulder arthrodesis

DISCUSSION: The radiographs reveal a loose glenoid in the setting of no infection. Glenoid removal may give this
patient the best chance of improved function and pain relief if sufficient bone stock remains. Bone grafting of defects may allow future glenoid implantation. Conversion to reverse shoulder arthroplasty would be a salvage procedure in this younger patient.
Shoulder arthrodesis would be difficult and unpredictable after shoulder arthroplasty. The Preferred Response # 95 is 2.

96. ##### Which of the following clinical tests is used to diagnose medial instability of the elbow?
1- Posterolateral rotatory drawer test 2- Lateral pivot-shift test
3. ##### Moving valgus stress test
4. ##### Chair test (apprehension or dislocation on terminal extension of the supinated forearmwhen rising from a seated position)
5. ##### Pushup sign

DISCUSSION: The moving valgus stress test is used in the diagnosis of medial collateral ligament instability of the elbow. The other tests apply a varus force to the elbow and are used to diagnose lateral ulnar collateral insufficiency. Preferred Respo# 96 is 3.

97Figures 97a and 97b show a clinical photograph and radiograph of a patient who has a history of repeated drainage from the lesion. What is the preferred surgical treatment?

1. ##### Excision of the lesion alone
2. ##### Removal of the osteophyte alone 3- Distal interphalangeal joint fusion
4. ##### Excision of the mass and osteophyte removal
5. ##### Removal of the mass and skin with skin grafting

DISCUSSION: The patient has a mucoid cyst. Whereas many of these lesions are associated with osteoarthritis, the best surgical treatment of the lesions in patients who have little or no pain is typically excision of the mass with osteophyte removal. Studies have shown that osteophyte excision helps minimize the risk of recurrence. Distal interphalangeal joint fusion is reserved for patients with pain and more advanced radiographic arthritis. Excision of the lesion alone is a less favorable option than excision of the mass and osteophyte removal. The lesion is independent of the skin and thus, skin removal with the mass is unnecessary.Preferred Respo# 97 is 4.

98. ##### Isolated coronoid fractures are most likely related to what instability pattern? 1- Posterolateral rotary instability
2- Valgus anterolateral instability 3- Posterior instability
4- Varus posteromedial instability 5- Anterior instability

DISCUSSION: Coronoid fractures in the absence of radial head or associated fractures are often a sign of a varus posteromedial instability. Depending on the size of the coronoid fragment, fixation and stabilization of the coronoid may be necessary to restore medial stability of the elbow. Posterolateral instability is related to lateral ulnar collateral ligament incompetance. Anterior, valgus anterolateral, and posterior instability are not generally specific to isolated coronoid fractures. Pre Respo # 98 is 4.

99. ##### A 35-year-old man has pain and swelling of his right, dominant wrist. Radiographs and MRI scans are shown in Figures 99a through 99d. What is the most appropriate management?

1. ##### Incisional biopsy
2. ##### Allograft reconstruction
3. ##### Vascularized fibula reconstruction 4- Nonvascularized fibular autograft
5- Intralesional curettage and polymethylmethacrylate (PMMA) packing

DISCUSSION: Whereas the imaging studies show a benign giant cell tumor of bone, an incisional biopsy is still the first surgery that should be performed. After a tissue diagnosis is confirmed, then the reconstructive options can be discussed. A malignancy may present like a benign, aggressive giant cell tumor. Preferred Resp# 99 is 1.

100. ##### A 27-year-old woman underwent shoulder arthroscopy for multidirectional instability 3 years ago. She was unable to regain shoulder range of motion despite therapy and has had progressively worsening pain. A current axillary radiograph is shown in Figure 100. In reviewing the medical records from the index procedure, what factor may be significant in contributing to her current condition?

1- Subsequent development of a supraspinatus tear 2- Subscapularis tendon dehiscence
3. ##### Coagulation of the anterior humeral circumflex artery
4. ##### Use of monopolar radiofrequency thermal capsulorrhaphy 5- Lack of compliance with postoperative therapy program

DISCUSSION: Reports from several centers suggest the potential to develop glenohumeral chondrolysis because of the heat production associated with use of radiofrequency or laser thermal capsulorrhaphy. A tear of the supraspinatus may lead to poor function and progression to rotator cuff tear arthropathy with superior humeral head migration. Subscapularis dehiscence is a risk in open surgery through a deltopectoral approach and can lead to anterior instability. The anterior humeral circumflex artery is the main supply to the humeral head and its coagulation can lead to osteonecrosis. Whereas a lack of postoperative therapy can lead to unresolved pain and stiffness, chondrolysis is not reported. The Preferred Response # 100 is 4.

101Which of the following structures cannot be seen during standard radiocarpal arthroscopy?
1. ##### Scapholunate ligament
2. ##### Lunotriquetral ligament
3. ##### Radioscaphocapitate ligament 4- Extensor carpi ulnaris tendon
5- Superficial insertion of the triangular fibrocartilage complex (TFCC)

DISCUSSION: The extensor carpi ulnaris tendon is located in an extra-articular position, and as such, cannot be seen during arthroscopy. Wrist arthroscopy is a useful technique for evaluation and treatment of radiocarpal and midcarpal maladies. During standard radiocarpal arthroscopy, the scapholunate and lunotriquetral ligaments can be easily visualized. The superficial TFCC is seen overlying the ulnar head. Volarly, the radioscaphocapitate ligament can be seen as a discrete band of the capsule. The Preferred Response to Question # 101 is 4.

102An active 66-year-old man who underwent total shoulder arthroplasty 3 years ago now reports pain. Laboratory studies reveal an elevated erythrocyte sedimentation rate and C-reactive protein. Intraoperative frozen section reveals greater than 10 white blood cells per high power field on two slides and the Gram stain reveals gram-positive cocci in clusters. What is the most appropriate surgical treatment to eradicate the infection and maintain function?

1. ##### Removal of the components and placement of an antibiotic spacer
2. ##### Removal of the components, placement of an antibiotic spacer, and bone grafting of the glenoid defect
3. ##### Resection arthroplasty
4. ##### Exchange of the humeral head and debridement 5- Arthroscopic debridement

DISCUSSION: The prosthesis is grossly infected. Removal of the components and placement of an antibiotic spacer is necessary to eradicate the infection and allow for a second stage reimplantation. Resection arthroplasty is an option to treat the infection but the functional outcome would be limited. Bone grafting with concurrent infection is not likely to heal and should be delayed until the second stage. Humeral head exchange and debridement or arthroscopic debridement alone is unlikely to eradicate the infection. The Preferred Response to Question # 102 is 1.

103. ##### A 77-year-old woman underwent semiconstrained right total elbow arthroplasty 4 weeks ago through a Bryan-Morrey approach. Her recovery was uneventful until 2 days ago when she began her physical therapy session at an outpatient clinic. During resisted extension exercises, she felt a "pop" in her elbow, accompanied with pain and inability to extend her elbow against resistance. What is the most likely cause of her symptoms?
1. ##### Fracture of the ulnar component
2. ##### Disengagement of the axle of the prosthesis 3- Failure of the triceps mechanism repair
4- Periprosthetic fracture of the humerus 5- Periprosthetic fracture of the ulna

DISCUSSION: During a Bryan-Morrey approach for total elbow arthroplasty, the triceps is dissected free from its ulnar insertion and reflected laterally. At the conclusion of the procedure, the triceps tendon is reattached to the ulna through drill holes. Whereas motion can be initiated postoperatively, 6 to 8 weeks of protection are recommended before initiation of resistance exercises to protect the triceps repair. A periprosthetic

fracture or component failure is rare in the absence of more significant trauma, and they are usually late complications. The Preferred Response to Question # 103 is 3.

104. ##### A 47-year-old man who is right-hand dominant reports lateral-sided elbow pain after playing golf. His symptoms developed gradually and without trauma, and he has pain with gripping and repetitive movements with the hand and wrist.
Examination reveals his shoulder and wrist to be normal, and the elbow has no effusion and normal range of movement. He is tender near the lateral epicondyle, and symptoms are exacerbated with resisted wrist extension. Radiographs are shown in Figures 104a and 104b. What is the next most appropriate step in management?

1- Subtendinous epicondylar corticosteroid injection 2- Corticosteroid injection into the radial tunnel
3. ##### MRI of the elbow
4. ##### Percutaneous extensor carpi radialis brevis tenotomy
5. ##### Physical therapy for an eccentric conditioning and strengthening program

DISCUSSION: The patient has lateral epicondylitis of relatively short duration. At this early stage of disease, nonsurgical management is indicated. An eccentric physical therapeutic exercise program has been shown to have a beneficial effect on tendon biology; therefore, it would be the most appropriate initial management. While the diagnosis of lateral epicondylitis may be confused with radial tunnel syndrome, the clinical examination and history are most suggestive of the former. Corticosteroid injection has been shown to help with symptoms in short-term follow-up, but does little to affect the natural progression of the condition; it is more appropriate as a

second line of treatment. MRI may be beneficial in patients with refractory disease and/or when the diagnosis is in question. Percutaneous surgical treatment is indicated only when nonsurgical measures fail to provide relief. The Preferred Respo# 104 is 5.

105. ##### A 45-year-old woman has had a 4-month history of mild to moderate lateral shoulder pain that is aggravated with active elevation. Radiographs and MRI scans are shown in Figures 105a through 105d. Initial treatment should include which of the following?

1- Moist heat and a stretching program 2- Attempted calcium aspiration
3- Extracorporeal shock wave therapy 4- Low-dose radiation therapy
5- Arthroscopic rotator cuff debridement

DISCUSSION: The images show a well-circumscribed mass consistent with calcific tendinitis in the formation phase. Pain is not typically as severe as in the resorptive phase and amenable to nonsurgical management. The calcific deposit in this phase is granular, making aspiration difficult to achieve. Extracorporeal shock wave therapy has been studied with numerous protocols of amount of energy and number of treatments. Its role in the treatment of calcific tendinitis is still poorly defined. Low- dose radiation therapy has been successfully applied to calcific tendinitis in the past but is not currently used because of concerns of malignant tissue transformation and success with lower risk modalities. Arthroscopic debridement of the calcific deposit can be considered in patients who have not responded to nonsurgical management.
The Preferred Response to Question # 105 is 1.

106. ##### A 62-year-old man has had worsening pain in the left shoulder for the past 6 weeks without trauma. He participated in physical therapy to "strengthen" his shoulder; however, it failed to provide relief. On examination, his right shoulder motion is 180, 60, and T8 (forward flexion, external rotation, and internal rotation). His left shoulder motion, both active and passive, is 150, 40, and L1. T1- and T2- weighted MRI scans are shown in Figures 106a and 106b with an official diagnosis of partial supraspinatus tendon tear. What is the appropriate treatment?

1- Physical therapy for rotator cuff strengthening and scapula stabilization 2- Regimen of stretching exercises for motion
3. ##### Arthroscopic acromioplasty
4. ##### Arthroscopic acromioplasty and rotator cuff repair 5- Open rotator cuff repair

DISCUSSION: The patient lacks both active and passive motion in all planes of shoulder motion; his primary pathology is adhesive capsulitis. Although the MRI scans reveal a partial-thickness rotator cuff tear, this is not uncommon in asymptomatic patients older than age 60 years. Physical therapy for patients with adhesive capulitis should stress shoulder motion rather than rotator cuff strengthening. Because most cases of adhesive capsulitis improve without surgical management, surgical treatment options are not appropriate at this time. The Preferred Response to Question # 106 is 2.

107. ##### A 66-year-old woman with known poorly controlled rheumatoid arthritis reports that for the past 4 weeks she has been unable to extend the metacarpophalangeal (MCP) joints of her right hand index, middle, ring and little fingers. She cannot hyperextend the thumb interphalangeal joint. Active wrist extension is possible, but shows radial deviation. Examination reveals mild synovitis at the wrist and MCP joints of the affected hand. There is no ulnar deviation at the MCP joints with normal

alignment. When the MCP joints are passively extended, the patient is unable to maintain them in this position. There is no piano key sign at the distal ulna. Passive wrist motion shows a normal tenodesis effect. Which of the following would most likely confirm your diagnosis?
1. ##### Radiographs of the hand
2. ##### Radiographs of the cervical spine
3. ##### Electrodiagnostic studies of the affected upper extremity 4- Surgical exploration of the extensor tendon ruptures
5- MRI of the elbow
DISCUSSION: There are many causes of inability to extend the MCP joints in a patient with rheumatoid arthritis. The most common cause is rupture of the extensor tendons. An intact tenodesis test suggests that the extensor tendons are intact, thus surgical exploration is not indicated and would not confirm the diagnosis. The patient has normal alignment of the fingers without ulnar deviation, suggesting that there are no MCP dislocations to account for the inability to extend the MCP joints; therefore, radiographs would not confirm the diagnosis. The most likely cause of inability to extend the fingers in this patient is posterior interosseous nerve (PIN) palsy.
Electrodiagnostic studies would confirm the presence of PIN palsy. An MRI of the elbow may show synovitis at the radiocapitellar joint, which can cause the PIN palsy. This finding however, is nonspecific and many patients without PIN palsy would also demonstrate synovitis at the radiocapitellar joint. Therefore, although an MRI would be helpful in localizing a potential cause of PIN compression, it would not in itself confirm the diagnosis. The Preferred Response to Question # 107 is 3.

108. ##### A 23-year-old woman with recurrent anterior instability undergoes an open Bankart procedure. Six months after surgery the patient reports shoulder weakness and is concerned about instability of the shoulder joint. An MRI scan is shown in Figure 108. What is the most appropriate management?
1. ##### Physical therapy
2. ##### Biceps tenolysis
3. ##### Subscapularis repair
4. ##### Supraspinatus repair
5. ##### Pectoralis major repair

DISCUSSION: The axial MRI scan shows rupture of the subscapularis tendon with dislocation of the biceps tendon. Treatment should include a biceps tenotomy or tenodesis in conjunction with a subscapularis repair. A pectoralis major transfer may be necessary in chronic cases where the subscapularis is irreparable, but in this patient the tendon is repairable. As a single operation, biceps tenolysis will not correct the instability, and would likely result in a cosmetic deformity. Physical therapy will not restore subscapularis function. The Preferred Response to Question # 108 is 3.

109. ##### A patient has a mass at the base of the middle finger just distal to the distal palmar flexion crease. The mass is 2 mm in size, firm, round, and does not move with finger motion. It is painful with gripping activites such as a steering wheel. What is the most appropriate management?

1. ##### Diagnostic ultrasound
2. ##### MRI
3. ##### Needle aspiration
4. ##### Observation
5. ##### Surgical excision

DISCUSSION: The clinical scenario is of an A2 retinacular cyst. These are firm round cysts arising from the pulley system so they do not move with tendon motion. Needle aspiration in the office is highly effective, thus surgery can be avoided. Based on the clinical diagnosis, ultrasound and MRI are unnecessary. Because the patient has pain and functional limitations, observation is not recommended. The Prefer Resp# 109 is 3.

110A 72-year-old woman was evaluated with an MRI scan for a shoulder mass that was confirmed to be a lipoma. Additional MRI findings included a 7-mm full- thickness tear of the supraspinatus tendon. Therefore, the patient was referred by her internist for evaluation and management of the rotator cuff tear. The patient reports mild "stiffness" with certain motion but denies any limitations in her functional capacity. Examination reveals a slight decrease in internal rotation and mild weakness with resisted abduction of the shoulder. What is the most appropriate management?

1. ##### Observation
2. ##### Arthroscopic rotator cuff debridement
3. ##### Arthroscopic rotator cuff repair with acromioplasty 4- Arthroscopic biceps tendon tenotomy
5- Open rotator cuff repair with bone tunnels

DISCUSSION: In patients older than age 60 years, over 30% of asymptomatic shoulders show MRI findings of full-thickness rotator cuff tears. Therefore, without significant symptoms, surgical treatment is not warranted. The Preferred Response# 110 is 1.

111A baseball player reports a dull pain in the posterior aspect of his throwing arm. Examination reveals decreased internal rotation and prominence of the inferomedial corner of the scapula. An MRI scan suggests a partial-thickness tear of the posterior supraspinatus tendon. Successful treatment would most likely include which of the following?

1. ##### Anti-inflammatory medication, posterior capsular stretching, and rotator cuff strengthening
2. ##### SLAP repair
3. ##### Debridement of the partial-thickness rotator cuff tear 4- Rotator cuff repair
5- Imbrication of the labrum and anterior capsule

DISCUSSION: Internal impingement is related to an internal rotation contracture (GIRD- glenohumeral internal rotation deficit) and an increase in external rotation caused by repetitive overhead throwing. Most patients can be successfully treated with rehabilitation that focuses on internal rotation stretches along with anti-inflammatory medication and strengthening as symptoms improve. SLAP repair and rotator cuff debridement may be considered in refractory cases. Rotator cuff repair is not typically required, and capsulolabral imbrication is more consistent with the surgical treatment for multidirectional instability.
The Preferred Response to Question # 111 is 1.

112Figures 112a and 112b show the radiographs of a 28-year-old motorcyclist who sustained a closed hand injury in a collision. What is the most appropriate definitive treatment?

1- Closed reduction and a hand/forearm cast in the intrinsic plus position 2- Closed reduction and a hand splint
3. ##### Primary fusion of the carpometacarpal joints
4. ##### Closed versus open reduction and internal fixation 5- Closed reduction and external fixation

DISCUSSION: Closed versus open reduction and internal fixation is the most appropriate treatment. The radiographs show fracture-dislocations of all five carpometacarpal joints. These injuries are extremely unstable and not amenable to closed (splint or cast) treatment only. External fixation may be warranted in an open, contaminated injury. Fusion would be an option if this were a chronic, painful condition on presentation. The Preferred Response to Question # 112 is 4.

113A 32-year-old male hockey player who is right-hand dominant was checked from behind and landed with full force into the boards. In the emergency department he reports shortness of breath. Figure 113 shows a 2-D CT scan. What is the best initial treatment for this injury?
1. ##### Observation
2. ##### Closed reduction with a towel clip 3- Open reduction
4. ##### Open reduction and internal fixation
5. ##### Open reduction and sternoclavicular ligament allograft reconstruction

DISCUSSION: The CT scan shows a posterior sternoclavicular joint dislocation. Initial management involves attempted closed reduction in the operating room. This can be performed with a towel clip and anterior translation of the displaced clavicle. However,

the orthopaedic surgeon should be prepared to open this injury and reconstruct the joint if necessary. Furthermore, it is recommended that a thoracic surgeon be available prior to beginning these procedures. Open reduction should be done only if closed reduction is unsuccessful. The Preferred Response to Question # 113 is 2.

114What additional procedure should be done when performing a radioscapholunate fusion for posttraumatic arthrosis following a distal radius fracture?
1- Excision of the triquetrum and distal pole of the scaphoid 2- Anterior interosseous neurectomy
3- Fascial interposition arthroplasty of the capitolunate joint 4- Sectioning of the dorsal intercarpal ligament
5- Ulnar shortening osteotomy

DISCUSSION: Excision of the triquetrum and distal pole of the scaphoid frees up the mid-carpal joint, improving radial deviation and the flexion-extension arc of motion of the wrist. This offers an alternative to complete wrist arthrodesis for posttraumatic arthrosis of the radiocarpal joint. An anterior interosseous neurectomy is believed to decrease some pain transmission from the wrist but because the fusion is done dorsal, cutting this volar structure is not routinely done. Fascial interposition is not needed because the capitolunate should be preserved in posttraumatic radiocarpal arthrosis. Sectioning of the dorsal intercarpal ligament would provide no benefit. If the triquetrum is excised, then an ulnar shortening osteotomy is unnecessary. The Preferred Response to Question # 114 is 1.

115A 72-year-old man who underwent an uncomplicated total shoulder arthroplasty 4 weeks ago now reports injuring his shoulder in a fall on the ice. He attempted to catch himself on a railing with his operative arm. He continues to feel pain anteriorly in the shoulder. His range of motion is 140 degrees forward elevation, 90 degrees external rotation with the arm at the side, and internal rotation up the back to L1.
Radiographs are normal. What is the most likely diagnosis? 1- Deltoid contusion
2. ##### Rupture of the subscapularis repair

3. ##### Traumatic loosening of the glenoid
4. ##### Locked posterior shoulder dislocation 5- Biceps tendon rupture

DISCUSSION: The patient sustained a rupture of the subscapularis tendon repair. This can occur in the postoperative period with forced internal rotation or excessive external rotation beyond the normal 40 to 60 degrees. On examination, the patient has 90 degrees of external rotation at the side; this is not a normal finding for a 72-year-old man. There is no indication at this time that the glenoid component has loosened or that the patient has a locked posterior dislocation. Both of these would be evident on radiographs. A biceps tendon rupture or a deltoid contusion would not explain the excessive external rotation to 90 degrees as seen on examination. The Preferred Response to Question # 115 is 2.

116. ##### A 68-year-old man with a history of diabetes and total shoulder arthroplasty 4 years ago, now reports increasing shoulder pain and stiffness. Radiographs show lucent lines around both the humeral and glenoid components. Laboratory studies show a white blood cell count of 12,600/mm3, an erythrocyte sedimentation rate of 72 mm/h, and a c-reactive protein of 3.5. The shoulder is aspirated and cultures are negative at 3 days. What is the most appropriate treatment for this patient?
1- 4-week trial of nonsteroidal anti-inflammatory drugs (NSAIDs) 2- Physical therapy for range-of-motion work
3. ##### Repeat aspiration and culture
4. ##### Open irrigation and debridement with implant removal and possible exchange arthroplasty
5. ##### Arthroscopic irrigation and debridement

DISCUSSION: The patient has clinical and radiographic signs of infection. Open debridement, component removal, an antibiotic spacer, and possible exchange arthroplasty are necessary to resolve the infection. Aspiration and culture can often be negative at 3 days. NSAIDs, sling immobilization, or physical therapy are not indicated. With radiographs indicating lucent lines surrounding the prosthetic implants,

arthroscopic irrigation and debridement will not eradicate the infection. The Preferred Response to Question # 116 is 4.

117. ##### A 35-year-old construction worker sustained a midshaft clavicle fracture that developed a hypertrophic nonunion. One year after the injury, it was internally fixed without bone graft. Four months after the surgery he was asymptomatic and he was released to full activity. Five months following surgery, the patient was digging a ditch and he felt pain in the clavicle. The 4-month and 5-month postoperative radiographs are shown in Figures 117a and 117b. What is the most likely cause of this failure?

1- Iliac crest bone graft was not used to augment the fixation 2- Infection
3. ##### Inadequate strength of the plate
4. ##### Use of superior plating rather than anterior plating 5- Inadequate medial screw fixation

DISCUSSION: In this patient, the hardware was intact for 5 months without any evidence of loosening prior to the catastrophic failure. This suggests that the primary cause of nonunion was poor biology rather than insufficient fixation. Biologic compromise can be caused by either infection, poor blood supply, or lack of osteogenic induction cells. Iliac crest bone graft has been used by some for any nonunion of the clavicle, but two studies have shown that bone graft is not necessary to achieve union. Rigid fixation is all that is required. Infection will still complicate any fixation technique. The radiographs show unicortical screw fixation medially, but the construct did not loosen; therefore, it is not the cause of failure.
The Preferred Response # 117 is 2.

118. ##### A 60-year-old woman with a history of osteoporosis fell from a standing height and sustained a supracondylar distal humerus fracture with an intercondylar extension. Which of the following plate constructs yields the highest stiffness for fixation of the fracture?
1. ##### Single posterior Y plate
2. ##### Single medial plate with bicortical locking screws
3. ##### Dual plating with medial and posterolateral LC-DCP
4. ##### Dual plating with medial and posterolateral one third tubular plates 5- Dual plating with medial and lateral LC-DCP

DISCUSSION: Optimal treatment of distal humeral fractures relies on reestablishment of a congruent articular surface with a fixation construct that is stable enough to allow for early range of motion. Several biomechanical studies have been performed to evaluate the biomechanical strength of various plating configurations. These studies have shown that dual plate configurations are more stable than single plates, regardless of the type of plate used. One third tubular plates have been shown to be significantly weaker than LC-DCP or reconstruction plates, resulting in weaker constructs, and clinically higher rates of hardware failure and nonunion. Whereas traditional teaching has suggested plating in perpendicular planes, recent biomechanical studies have demonstrated that parallel medial and lateral plates confer a greater rigidity to the construct than perpendicular plating schemes. The Preferred Response to Question # 118 is 5.

119. ##### A 35-year-old construction worker continues to have weakness with lifting overhead 2 years after he was treated with physical therapy for a "chest muscle" tear. An obvious deformity noted in his axilla worsens with resisted extension and adduction. A clinical photograph and MRI scan are shown in Figures 119a and 119b. What is the most appropriate treatment?

1- Allograft reconstruction with semitendinosis weave to the humerus 2- Latissimus dorsi tendon transfer
3. ##### Electrical stimulation
4. ##### Shoulder arthrodesis
5. ##### Arthroscopic pectoralis major tendon repair

DISCUSSION: This scenario describes a chronic, symptomatic pectoralis major tendon rupture in a young laborer. Direct repair is difficult at this time; therefore, allograft reconstruction is a good alternative to recover strength. Tendon transfers, electrical stimulation, shoulder arthrodesis, and arthroscopy are not indicated in this patient. They will not offer proper reconstruction of the lost muscle tendon unit and/or cosmetic repair. The Preferred Response to Question # 119 is 1.

120. ##### A 74-year-old patient is seen for follow-up 6 weeks after undergoing a total shoulder arthroplasty for glenohumeral osteoarthritis. The patient missed the 2- week follow-up appointment and is currently wearing a sling. The incision is well healed with no signs of breakdown. Examination reveals that passive range of motion is forward elevation of 90 degrees, external rotation at the side 0 degrees, and internal rotation up the back is to the level of the greater trochanter. A radiograph shows no signs of fracture or dislocation. What is the next most appropriate management for this patient?
1- Physical therapy for range-of-motion exercises 2- Aspiration for possible infection
3. ##### MRI to evaluate for possible rotator cuff tear
4. ##### Sling immobilization and reevaluation in 4 weeks
5. ##### Duplex ultrasound for possible upper extremity deep venous thrombosis

DISCUSSION: The patient has a postoperative stiff shoulder. The patient missed follow- up appointments and has not been participating in physical therapy for stretching.
Based on normal radiographic findings, the shoulder is not dislocated; therefore, physical therapy should begin immediately. Continued sling immobilization will further worsen the stiffness. There is no indication of an infection or rotator cuff tear. Deep

venous thrombosis would present with abnormal swelling and pain. The Preferred Response to Question # 120 is 1.

121. ##### A 22-year-old man sustained a shoulder dislocation while playing collegiate football at age 18. Since that time, he has dislocated the shoulder three more times despite physical therapy. His last dislocation occurred 4 weeks ago while sleeping. What is the most appropriate management for this patient?
1. ##### Corticosteroid injection
2. ##### Changing the physical therapist to an athletic trainer
3. ##### A 1-month trial of nonsteroidal anti-inflammatory drugs (NSAIDs) 4- Shoulder immobilization for 6 weeks
5- A discussion regarding surgical stabilization procedures

DISCUSSION: The patient sustained a traumatic shoulder dislocation at age 18 that has subsequently failed to respond to nonsurgical management. Discussion of surgical stabilization procedures is warranted at this time. A corticosteroid injection or a trial of NSAIDs will not provide any stabilizing effect. Further immobilization in this patient population has not been shown to improve stability.Prefer Respons# 121 is 5.

122. ##### While performing a total shoulder arthroplasty, excessive retraction is placed on the "strap muscles" (short head of biceps and coracobrachialis). Neurovascular examination would reveal weakness of which of the following?
1. ##### Shoulder abduction
2. ##### Shoulder external rotation 3- Shoulder internal rotation 4- Elbow extension
5- Forearm supination

DISCUSSION: The musculocutaneous nerve can be as close as 3 cm to the coracoid process; therefore, this relationship is important to keep in mind when performing surgery in this area. Excessive traction on the musculocutaneous nerve could lead to a neurapraxia with resultant weakness of elbow flexion and forearm supinaton because of the loss of biceps function. The Preferred Response to Question # 122 is 5.

123With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus? 1- Coracohumeral ligament
2- Superior glenohumeral ligament 3- Middle glenohumeral ligament
4- Anterior band of the inferior glenohumeral ligament complex 5- Posterior band of the inferior glenohumeral ligament complex

DISCUSSION: With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45 degrees. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated. The Preferred Response to Question # 123 is 4.

124. ##### Which of the following statements regarding the use of thermal shrinkage during arthroscopic shoulder surgery is most accurate?
1. ##### The amount of shrinkage is fixed for a given peak temperature, irrespective of the time of application.
2. ##### Denatured capsular tissue does not undergo a healing response.
3. ##### The capsule is typically found to be thick and fibrotic in revision cases following thermal shrinkage.
4. ##### Patients with good results at 1 year are unlikely to develop recurrent instability in the future.
5. ##### High failure rates have been reported in its use for anterior, posterior, and multidirectional instability.

DISCUSSION: Reports of clinical results at 2- and 5-year follow-up indicate much higher failure rates than traditional stabilization techniques for all common instability patterns. The degree of capsular shrinkage is dependent on the total amount of

thermal energy delivered, as well as the rate of delivery. Denatured tissue undergoes a healing response. The capsule typically encountered in revision cases is thin and patulous, rather than thick and fibrotic. The Preferred Response to Question # 124 is 5.

125. ##### A 54-year-old man with a history of diabetes mellitus underwent internal fixation for a humeral shaft nonunion 8 months ago. His postoperative course had been unremarkable. However, over the past few weeks, he reports mild pain with activity. At rest, he has no pain. He denies any recent fevers or chills. Radiographs are shown in Figures 125a and 125b. What is the next most appropriate step in management?

1- CT scan of the humerus to confirm the nonunion 2- Application of a functional fracture brace
3. ##### Laboratory evaluation
4. ##### Removal of hardware and intramedullary fixation 5- Revision internal fixation with a plate
DISCUSSION: Radiographs showing broken hardware (screw head) and the clinical history are consistent with fracture nonunion; therefore, a CT scan is not required. Treatment for this nonunion may include various options including functional fracture bracing, intramedullary fixation, or revision internal fixation. However, prior to any treatment, infection must be eliminated as a cause for the nonunion. Evaluation for infection can include laboratory studies such as erythrocyte sedimentation rate and C- reactive protein level. The Preferred Response to Question # 125 is 3.

The next most appropriate step in management is to proceed with a biopsy of the most accessible site. This can be done
by the surgeon or by an interventional radiologist trained in core biopsy techniques. It is imperative to make a pathologic diagnosis prior to proceeding with any further medical, surgical, or radiation treatments. A histologic diagnosis at this point is the only way a medical oncologist can have a meaningful discussion with the patient about their disease, its natural history, and ultimately discuss treatment options and prognosis. Further imaging at this point only delays the time to histologic evaluation. Consideration of surgical stabilization can be delayed until a diagnosis is established and a multidisciplinary approach is initiated. This fracture can be treated at least temporarily with nonsurgical protected weight bearing with a walker or crutches.
Hospice may soon serve a useful role but a diagnosis must first be rendered and a limited life expectancy anticipated. Pre Res # 100 is 2
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