Ortho Shoulder And Elbow Review | Dr Hutaif Shoulder & - ...
Updated: Feb 2026
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Key Medical Takeaway
Your ultimate guide to ORTHO MCQS Shoulder and Elbow 019 starts here. For a radial head fracture with lateral collateral ligament (LCL) avulsion repaired surgically, initial postoperative rehabilitation should include elbow extension exercises with the forearm in pronation. This protects the compromised LCL, crucial for stability. Additional therapeutic insights, including the rationale, are elaborated upon in the response d discussion.
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ORTHO MCQS Shoulder and Elbow 019
QUESTION 1
of 100 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?
1
Open reduction internal fixation (ORIF) with parallel plates
2
ORIF with orthogonal plates and iliac crest bone grafting
3
Total elbow arthroplasty (TEA)
4
Closed reduction and percutaneous pinning
DISCUSSION:
TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower resurgical rate; one- quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again
superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed
reduction and percutaneous pinning studies have not been published on the adult population.
QUESTION 2
of 100 A complication associated with using the Morrey approach (triceps reflecting) to implant a semiconstrained total elbow arthroplasty is
1
loss of elbow extensor power.
2
implant dislocation.
3
implant malposition.
4
development of heterotopic ossification.
DISCUSSION:
Numerous approaches can be used to implant a total elbow arthroplasty. The Morrey approach identifies, transposes, and protects the ulnar nerve, and then subperiosteally reflects the triceps off the ulna. The sleeve of tissue is very thin distally, and the triceps need to be meticulously repaired at the time of closure. Implant dislocation and malposition are less likely with an extensile approach, and dislocation is unlikely with a semiconstrained implant. The development of heterotopic ossification is unrelated to the surgical approach
used for elbow arthroplasty.
QUESTION 3
of 100 A 45-year-old man falls from a skateboard and dislocates his elbow. After a closed reduction in the emergency department, his elbow is carefully examined. He has positive valgus stress, moving valgus stress, and milking maneuver tests. His elbow appears stable to varus stress and lateral pivot shift tests. What is the most appropriate manner of immobilizing the elbow for this patient?
1
Sling for 3 days, with early active range of motion
2
Posterior splint for 5 to 7 days, forearm in full pronation
3
Posterior splint for 5 to 7 days, forearm in neutral
4
Posterior splint for 5 to 7 days, forearm in full supination
DISCUSSION:
Varus posteromedial rotatory instability occurs following a fall onto an outstretched hand with axial loading and a varus stress to the elbow. This injury can result in a rupture of the posterior band of the medial collateral ligament (MCL), fracture of the anteromedial facet of the coronoid, and avulsion of the lateral ulnar collateral ligament (LUCL). Based on the examination findings, this patient has an acute MCL rupture. Furthermore, the LUCL appears intact, as evidence by the stability with varus stress. To protect the reduction in the acute setting, posterior splinting is recommended, but placing the forearm in full supination tightens the structures medially where the MCL is deficient. Splinting in neutral is indicated for valgus posterolateral rotatory instability, where both the LUCL and MCL are ruptured. Splinting in full pronation is indicated for isolated LUCL ruptures. Early active range of motion is not recommended for adults immediately after an acute elbow dislocation, as ligamentous injury or fracture nearly always accompanies the dislocation. In this case, the
forearm should be splinted in full supination.
QUESTION 4
of 100 A 38-year-old man sustains a terrible triad injury consisting of an elbow dislocation, comminuted and displaced radial head fracture, and a type I coronoid fracture. Intraoperative findings after radial head replacement and lateral collateral ligament complex repair reveal persistent instability consisting of medial opening on valgus stress and posteromedial subluxation of the ulnohumeral and radiocapitellar joints. What is the best next step?
1
Medial collateral ligament repair or reconstruction
2
Reconstruction of the radial collateral ligament
3
Resection of the type I coronoid fracture and capsular repair to the remaining coronoid
4
Open reduction and buttress plating of the coronoid fracture
DISCUSSION:
Terrible triad injuries of the elbow are common, and the management of type I coronoid tip fractures remains controversial. Type I coronoid fractures result in only small changes in elbow kinematics that have been shown to be uncorrected with suture repair. A type I coronoid tip fracture is not amenable to buttress plate fixation. The radial collateral ligament is a component of the lateral collateral ligament complex and has already been repaired. The persistent medial laxity and posteromedial joint subluxation noted is indicative of ongoing instability. The next step would be repair or reconstruction of the medial collateral ligament, which will
normally correct the medial instability. Articulated versus static external fixation can be considered if
restoration of the ligamentous constraint of the medial side of the elbow cannot be accomplished surgically.
QUESTION 5
of 100 A 42-year-old woman sustains a closed posterior elbow dislocation. A closed reduction is performed, and the elbow appears stable under fluoroscopic examination. Initial treatment should consist of
1
early mobilization only.
2
surgical reconstruction of medial and lateral collateral ligaments.
3
active motion in a hinged brace from 30° to 120°.
4
application of hinged external fixator with early mobilization.
DISCUSSION:
This is a simple (no associated fracture) elbow dislocation. Such dislocations can be treated with closed reduction followed by mobilization after 5 to 7 days to avoid stiffness, provided the elbow is stable through a full arc of motion at the time of reduction. If the elbow is unstable but has a short arc of stability, then using a hinged brace in the stable arc may be considered. (Note: It may be necessary to splint the elbow in pronation if the medial collateral ligament [MCL] is intact and the lateral collateral ligament [LCL] is disrupted, or in supination if the LCL is intact but the MCL disrupted.) Surgical reconstruction of the LCL and MCL may be required only if the elbow does not have a stable arc at the time of reduction. If unstable after reconstruction,
application of a hinged external fixator may be considered.
QUESTION 6
of 100 A right-hand-dominant 45-year-old man sustains an injury to the anterior aspect of his right elbow while trying to lift a heavy load 3 days ago. He has ecchymosis in the anterior and medial elbow regions and has difficulty with resisted forearm supination with the elbow in a flexed position. A diagnosis of an acute distal biceps tendon rupture is made and surgical treatment is chosen. The anatomic relationship of the distal biceps tendon to the median nerve and recurrent radial artery within the antecubital fossa is such that the biceps tendon travels
1
lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery.
2
lateral (radial) to the median nerve and anterior (superficial) to the recurrent radial artery.
3
medial (ulnar) to the median nerve and posterior (deep) to the recurrent radial artery.
4
medial (ulnar) to the median nerve and anterior (superficial) to the recurrent radial artery.
DISCUSSION:
During surgical repair of a distal biceps tendon rupture, regardless of the surgical approach or technique, an understanding of the regional anatomy is important. The tendon passes distally into the antecubital fossa. The antecubital fossa is defined by the brachioradialis radially and the pronator teres ulnarly. A sheath surrounds the biceps tendon as it passes through the antecubital fossa toward its insertion on the radial tuberosity. The lateral antebrachial cutaneous nerve lies superficially in the subcutaneous tissue of the antecubital fossa. The nerve parallels the brachioradialis. While still superficial, the tendon is contiguous with the lacertus fibrosus that becomes confluent medially with the fascia overlying the flexor-pronator mass. The brachial artery lies just beneath the lacertus fibrosus at the level of the elbow flexion crease. The tendon travels just lateral (radial) to the median nerve within the antecubital fossa and passes posterior (deep) to the recurrent radial artery before it attaches to the radial tuberosity. Full forearm supination allows visualization of the tendinous insertion on
the radial tuberosity.
QUESTION 7
of 100 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?
1
Midsubstance tear of the lateral ulnar collateral ligament
2
Proximal avulsion of the ulnar collateral ligament
3
Proximal avulsion of the lateral ulnar collateral ligament
4
Distal bony avulsion of the ulnar collateral ligament from the sublime tubercle
DISCUSSION:
Classic posterior elbow dislocations result from a posterolateral rotatory mechanism, whereby the hand is fixed (typically on the ground) while the weight of the body creates a valgus and external rotation moment on the elbow. This results first in tearing of the lateral collateral ligament that proceeds medially through the anterior and posterior joint capsules, ending with potential involvement of the ulnar collateral ligament (but this is not universal). McKee and associates assessed the lateral soft-tissue injury pattern of elbow dislocations
with and without associated fractures at the time of surgery. Injury to the lateral collateral ligament complex was seen in every case, with avulsion from the distal humerus as the most common finding. Midsubstance
tears, proximal avulsions, and distal bony avulsions of the ulnar collateral ligament are less common.
QUESTION 8
of 100 A 35-year-old man falls off of a roof and sustains 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 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 40° to 100°. What is the next appropriate step in management?
1
Elbow splint at 40° for 6 weeks
2
Electromyography (EMG)
3
Exploration of ulnar nerve and transposition
4
Continued observation
DISCUSSION:
This patient has an early postsurgical ulnar nerve palsy. The causes of this injury are laceration of the nerve during surgery, entrapment of the nerve in the fracture or hardware, or traction injury during surgery. If the orthopaedic surgeon is sure that the nerve was not lacerated at the end of the case or entrapped in the hardware, then the nerve is probably intact and will recover. Observation is the best treatment in this case because the nerve was checked before wound closure. Elbow splinting has not been shown to help with postsurgical nerve recovery. EMG findings may not be accurate this early following the injury.
QUESTION 9
of 100 A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?
1
Inflammatory elbow arthritis
2
A presurgical flexion-extension elbow arc of approximately 50°
3
Retained distal humerus hardware on presurgical radiographs
4
Evidence of presurgical elbow instability
DISCUSSION:
End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight
restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion- extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability upon examination; retained hardware from prior
surgery was not deemed a contraindication.
QUESTION 10
of 100 A 23-year-old collegiate gymnast sustains a rupture of his medial collateral ligament of the elbow when he falls off the parallel bars. On physical examination, he has instability to valgus stress and tenderness along the medial elbow. Radiographs show no fracture. Which component of the medial collateral ligament of the elbow is the dominant restraint to valgus stress?
1
Transverse ligament
2
Anterior band of the medial collateral ligament
3
Posterior band of the medial collateral ligament
4
Posterior capsule
DISCUSSION:
The anterior bundle of the medial collateral ligament is the prime stabilizer against valgus stress. The posterior bundle, which originates on the medial epicondyle and inserts broadly along the medial edge of the trochlea from the sublime tubercle posteriorly, has stress only in elbow flexion. The transverse band, which originates on the posteromedial olecranon and inserts on the sublime tubercle, deepens the trochlea, but neither the band nor the posterior capsule provides significant restraint. The lateral collateral ligament, which originates from the lateral epicondyle and inserts on the crista supinatoris of the ulna, is the prime stabilizer of varus stress and posterolateral rotatory subluxation.
QUESTION 11
of 100 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?
1
Ulnar collateral ligament (UCL)
2
Pronator teres
3
Ligament of Struthers
4
Lateral collateral ligament
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 12
of 100 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)?
1
Bushing wear
2
Infection
3
Aseptic component loosening
4
Component fracture
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 13
of 100 A 26-year-old mixed martial arts fighter sustains a posterolateral elbow dislocation. The primary stabilizers of the elbow joint are the
1
radiocapitellar joint, the posterior band of the medial collateral ligament, and the annular ligament.
2
ulnohumeral joint, the anterior band of the medial collateral ligament, and the lateral ulnar collateral ligament.
3
radiocapitellar joint, the anterior band of the medial collateral ligament, and the radial collateral ligament.
4
ulnohumeral joint, the anterior band of the medial collateral ligament, and the posterior band of the medial collateral ligament.
DISCUSSION:
The primary stabilizers of the elbow are the ulnohumeral joint, the lateral collateral ligament (lateral epicondyle to the crista supinatoris), and the anterior band of the medial collateral ligament (anterior inferior medial epicondyle to the sublime tubercle). Secondary stabilizers are the radial head, the common flexor and
extensor origins, and the joint capsule. The muscles that cross the elbow joint act as dynamic stabilizers.
QUESTION 14
of 100 A 51-year-old butcher has an 18-month history of recalcitrant medial elbow pain, which is affecting his occupational demands. He describes the pain as mainly anterior and distal to the medial epicondyle. His symptoms are exacerbated with resisted wrist flexion and forearm pronation. On examination, he is also found to have a positive Tinel’s sign at the elbow with weakness of intrinsic strength. He has attempted physical therapy, activity modification, bracing, and anti-inflammatory medication without any significant improvement. Presurgical counseling should include the understanding that
1
concomitant ulnar neuropathy is a potential poor prognostic factor.
2
a change in occupation will likely be required after surgery.
3
weakness in wrist flexion strength will result postoperatively.
4
prior corticosteriod injections are a potential poor prognostic factor.
DISCUSSION:
Although less common in comparison with lateral elbow tendinopathy, medial elbow tendinopathy remains a significant cause of elbow disability. Fortunately, most patients can anticipate resolution of symptoms with nonsurgical management. For patients with recalcitrant symptoms, surgical intervention should be discussed as a treatment alternative. The literature reports successful results with surgical intervention via debridement
of pathologic tissue, release of the flexor carpi radialis - pronator teres origin, and/or repair of the flexor carpi radialis - pronator teres origin. Several authors have raised concern of the impact of concomitant ulnar neuropathy on results following surgical treatment for medial epicondylitis. Kurvers and Verhaar and Gabel and Morrey, among others, have reported a statistically significant association between concomitant ulnar neuropathy and worse outcomes following surgery. Most patients can anticipate a return to prior activity levels after surgery without any consistently reported loss of flexor/pronator strength. Prior corticosteroid injections
have not been found to impact results.
QUESTION 15
of 100 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. What would be the most appropriate initial diagnostic test for this patient?
1
MRI arthrogram
2
CT scan with 3-dimensional reconstructions
3
Plain radiographs of both elbows
4
Ultrasonography
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 16
of 100 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?
1
Proceed with primary repair with the elbow hyperflexed
2
Use interposition allograft to reconstruct with elbow in extension
3
Tenodese distal biceps tendon to underlying brachialis muscle
4
Forego primary repair, but perform stump debridement
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 17
of 100 A 53-year-old man complains of recurrent lateral elbow pain. He was surgically treated approximately one year ago with some improvement in his direct lateral elbow pain. He now reports new-onset discomfort at the posterolateral elbow, as well as difficulty when pushing himself up from a chair. On examination, he has a well-healed 6-cm incision over the lateral epicondyle with full active and passive range of motion. He has
pain with palpation along the posterior lateral elbow and a positive posterior drawer test. Radiographs are unremarkable. What is the best next step?
1
Platelet-rich plasma
2
Physical therapy
3
Lateral epicondyle debridement
4
Lateral collateral ligament reconstruction
DISCUSSION
Lateral elbow tendinopathy remains a frequently encountered pathology of the elbow. Open or arthroscopic lateral epicondyle debridement can be considered for patients with refractory symptoms. With either technique, the lateral collateral ligament complex of the elbow is at risk for compromise, with excessive debridement distal and posterior to the center of rotation of the capitellum. When injured, patients often complain of pain around the posterior lateral elbow, which is commonly misdiagnosed as recurrent lateral epicondylitis. The push-up test (apprehension using the supinated forearm to push up from a chair) is a typical examination finding, along with a positive posterior drawer test. Patients may also develop posterior lateral
instability of the elbow, for which the recommended treatment is lateral collateral ligament reconstruction.
QUESTION 18
of 100 A 54-year-old woman undergoes an interposition arthroplasty that fails and requires conversion to a total elbow arthroplasty. She has progressive elbow pain and radiographic loosening. Erythrocyte sedimentation rate and C-reactive protein are normal. Joint aspiration is positive for Staphylococcus epidermidis. What surgical treatment would best optimize function and decrease risk of recurrence?
1
Resection arthroplasty
2
Single-stage revision total elbow arthroplasty
3
Two-stage revision elbow arthroplasty
4
Aggressive arthroscopic debridement and retention of components
DISCUSSION
The most reliable surgical option in this case for eradicating a deep infection following a total elbow arthroplasty is a two-stage revision. One study, however, reported that staged reimplantation of an infected total elbow replacement could be successful in the setting of organisms other than S epidermidis. Arthroscopic debridement is not a viable option with poorly fixed or loose components. A single-stage revision, while considered an option in hip and knee arthroplasty, has not been definitively proven to be an option for revision total elbow arthroplasty. Single-stage revision has shown moderate success in the setting of Staphylococcus aureus infections, although with only short-term follow-up. A resection arthroplasty would likely be successful in managing the deep infection but would not optimize the functional result. Resection arthroplasty
is best reserved for low-demand or infirm patients.
QUESTION 19
of 100 A 20-year-old collegiate pitcher sustains a medial collateral ligament (MCL) rupture of his throwing elbow for which surgical reconstruction is necessary. The goal of surgery is anatomic restoration of the MCL. Which statement best describes the kinematics of the native MCL?
1
The posterior bundle demonstrates the greatest change in tension from flexion to extension.
2
The posterior bundle is isometric.
3
The anterior bundle becomes tight in flexion and lax in extension.
4
The anterior and posterior bundles are isometric.
DISCUSSION
The anterior bundle is the most important portion of the complex when treating valgus instability of the elbow. The ligament originates from the anteroinferior surface of the medial epicondyle. The anterior bundle inserts on the medial border of the coronoid at the sublime tubercle. The anterior bundle of the medial collateral ligament (MCL) is the primary restraint to valgus stress, and the radial head is a secondary restraint. With anterior bundle sectioning, the resultant instability is most substantial between 60° and 70° and is lowest at
full extension and full flexion. True lateral radiographs reveal that the flexion-extension axis, or center of rotation, of the elbow lies in the center of the trochlea and capitellum. The origin of the anterior bundle of the MCL lies slightly posterior to the rotational center of the elbow. The anterior bundle is further divided into an anterior band and a posterior band. The eccentric origin of these anterior bundle components in relation to the rotational center through the trochlea creates a CAM effect during flexion and extension. The anterior band tightens during extension, and the posterior band tightens during flexion. This reciprocal tightening of the two functional components of the anterior bundle allows the ligament to remain taut throughout the full range of flexion. Cadaver dissection studies have identified the origin and insertion of both the medial and lateral stabilizing elbow ligaments. The anterior bundle of the MCL is isometric throughout the flexion/extension arc of motion, making Response C incorrect. The posterior bundle of the MCL elongates with elbow flexion, so Responses B and D are incorrect. The posterior bundle of the MCL also demonstrates the most change in
length from extension to flexion of all the elbow ligaments.
QUESTION 20
of 100 A 55-year-old man falls from a ladder and dislocates his nondominant shoulder. He undergoes an uncomplicated closed reduction under sedation in the emergency department. Postreduction radiographs reveal a small Hill-Sachs lesion and no other bony abnormalities. Six weeks after the dislocation, the patient has persistent pain at rest and forward elevation and external rotation weakness, but the remaining motor function in the extremity and sensation are intact. What is the best next step?
1
Physical therapy with electrical stimulation and iontophoresis
2
Corticosteroid injection
3
MRI of the shoulder
4
Electromyography (EMG) of the arm
DISCUSSION
For a patient >40 years of age who has persistent pain and weakness isolated to the rotator cuff following an acute anterior shoulder dislocation, an MRI is indicated to evaluate rotator cuff integrity. EMG is not indicated in this case because this patient has no evidence of distal motor functional abnormality and their sensation is intact, thereby making a brachial plexus injury unlikely. Corticosteroid injections and physical therapy
modalities do not adequately address the concern over his potential for having sustained a rotator cuff tear.
QUESTION 21
of 100 Placing a plate too anteriorly against the lateral aspect of the bicipital groove while performing open reduction and internal fixation (ORIF) of a proximal humerus fracture has an increased risk of what complication?
1
Avascular necrosis
2
Loss of fixation of the fracture
3
Malunion leading to increased retroversion of the articular surface
4
Glenoid arthrosis
DISCUSSION
There are two major arteries that supply the humeral head. One is the ascending branch of the anterior humeral circumflex artery, which runs up the lateral aspect of the bicipital groove terminating in the arcuate artery. The other is the posterior humeral circumflex artery, which more recently has been demonstrated to supply a significant portion of the blood supply to the humeral head. Capsular arteries also play a role in humeral head perfusion. Care should be taken to preserve all intact arterial supply when performing ORIF, as injury to these arteries may result in avascular necrosis. In general, the most common complications of locked plating include loss of reduction with penetration of the joint by the screws, particularly with initial varus positioning of the humeral head. Placement of the plate in the position described, however, should not have an impact on any of
the other complications noted.
QUESTION 22
of 100 When performing a shoulder hemiarthroplasty for an unreconstructable proximal humerus fracture, the relationship of the repaired greater tuberosity to the prosthetic humeral head should be
1
6 mm to 8 mm superior to the top of the humeral head.
2
6 mm to 8 mm inferior to the top of the humeral head.
3
1.5 cm inferior to the top of the humeral head.
4
at the same height as the top of the humeral head.
DISCUSSION
The greater tuberosity lies anatomically 6 mm to 8 mm inferior to the top of the humeral head. Normal proximal humeral anatomy must be recreated when performing a hemiarthroplasty for fracture so as to minimize the complications associated with the greater tuberosity and maximize functional outcomes. Tuberosity malunion and nonunion are considered the most common reasons for poor clinical outcomes following this procedure. Placing the tuberosity too proximal can lead to issues with impingement during shoulder abduction, and placement too distal can increase the tension on the rotator cuff as it courses over the
prosthetic humeral head.
QUESTION 23
of 100 A 61-year-old right-hand-dominant woman falls down the 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?
1
Open reduction internal fixation with transosseous sutures
2
Arthroscopic fixation using a suture bridge technique
3
Nonsurgical treatment with early passive range of motion
4
Nonsurgical treatment with sling immobilization for 4 weeks
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 24
of 100 A 72-year-old man sustains a displaced four-part fracture of the proximal humerus with head split component following a fall. A primary shoulder arthroplasty has been recommended for acute management. In counseling the patient on pros and cons of hemiarthroplasty versus reverse arthroplasty, what statement can be made based on the available literature?
1
The risk of tuberosity nonunion/malunion appears higher with hemiarthroplasty.
2
Functional outcomes tend to be more consistent with hemiarthroplasty.
3
Forward elevation of reverse shoulder arthroplasty depends on tuberosity union.
4
Active elevation is likely to be better following hemiarthroplasty.
DISCUSSION
As the indications for reverse shoulder arthroplasty have expanded, the role for shoulder hemiarthroplasty appears to be narrowing. Several recent systematic reviews have evaluated outcomes of shoulder hemiarthroplasty and reverse shoulder arthroplasty for acute proximal humerus fractures. Their results suggest that reverse arthroplasty results in superior functional results and comparable elevation, at the expense of increased complication rates and decreased shoulder rotation. One of the benefits of reverse shoulder
arthroplasty in the setting of fracture is that forward elevation is independent of tuberosity healing and relies mainly on the deltoid muscle. Active external rotation following a reverse total shoulder for fracture, however, does appear to depend on successful union of the greater tuberosity. In a randomized controlled trial, the incidence of tuberosity healing was higher and the incidence of tuberosity resorption was lower in reverse arthroplasty compared with hemiarthroplasty. Forward elevation following a hemiarthroplasty for fracture generally follows a bimodal distribution, whereas outcomes following a reverse total shoulder have been more
consistent.
QUESTION 25
of 100 A 67-year-old man with right shoulder osteoarthritis (OA) remains symptomatic despite a course of nonsurgical treatment. A CT scan of the shoulder shows eccentric posterior glenoid wear with 10° of retroversion. What is the appropriate management of this glenoid bone loss during surgery for an anatomic total shoulder arthroplasty?
1
In situ glenoid component implantation
2
Hemiarthroplasty
3
Eccentric reaming of glenoid
4
Posterior glenoid bone graft
DISCUSSION
Total shoulder arthroplasty (TSA) is superior to hemiarthroplasty for primary OA. The most common complication of TSA is glenoid loosening and malposition, which are common causes of glenoid failure. Glenoid malposition decreases the glenohumeral contact area and subsequently increases contact pressures. Altering the stem version to accommodate glenoid retroversion does not appropriately address soft-tissue balancing. A retroversion of <12° to 15° can be corrected with eccentric reaming without excessively compromising glenoid bone stock and risking glenoid vault penetration by the glenoid component. Posterior
glenoid bone grafting may be considered for glenoid retroversion >15°.
QUESTION 26
of 100 A healthy 65-year-old woman undergoes anatomic total shoulder arthroplasty to address osteoarthritis (OA). The surgery is uncomplicated. What is the most common indication for future revision?
1
Deep infection
2
Periprosthetic fracture
3
Glenoid component loosening
4
Rotator cuff tear
DISCUSSION
The most common reason for revision surgery following unconstrained shoulder arthroplasty for glenohumeral OA is loosening of an implant. In most studies that distinguish glenoid from humeral loosening, it appears the glenoid is the problem. Comprehensive systematic reviews have found that radiographic glenoid loosening can comprise nearly 30% to 40% of all complications following shoulder arthroplasty for non-
inflammatory arthritis. Infections, periprosthetic fractures, and rotator cuff tears are uncommon. In the population-based study by Matsen and associates, 10% of the revisions were performed for loosening versus
7% for infection and 7% for rotator cuff tearing.
QUESTION 27
of 100 A 37-year-old recreational athlete has osteoarthritis of the glenohumeral joint. He has failed nonsurgical measures and is interested in surgical intervention but would like to avoid arthroplasty. When performing shoulder arthroscopy for glenohumeral arthritis, which radiographic parameter is most predictive of clinical failure?
1
Unipolar arthritis
2
>3 mm of glenohumeral joint space
3
Walch B2 glenoid morphology
4
Small inferior humeral osteophyte
DISCUSSION
Multiple studies have evaluated the utility of arthroscopy in the treatment of shoulder arthritis. Despite differing levels of success, a few common characteristics have been shown to lead to a higher probability of clinical failure. Mitchell and associates showed that shoulders with less joint space (1.3 mm vs 2.6 mm) and Walch type B2 and C glenoids were significantly more likely to fail than were Walch types A1, A2, and B1. Additionally, older patients (age >50 years) tended to have worse outcomes. Skelley and associates found that isolated capsular release and debridement had a high failure rate (conversion to total shoulder arthroplasty in 42% within 9 months) and postulated that patients undergoing concomitant procedures, such as biceps tenodesis, may fare better. Van Theil and associates found significant risk factors for failure included the presence of grade 4 bipolar disease, joint space <2 mm, and the presence of large osteophytes. They had a
22% conversion to total shoulder arthroplasty at 10.1 months.
QUESTION 28
of 100 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?
1
Revision anatomic total shoulder arthroplasty
2
Reverse total shoulder arthroplasty
3
Hemiarthroplasty with latissimus dorsi transfer
4
Resection arthoplasty
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 29
of 100 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?
1
Revision arthroscopic Bankart repair with capsular shift
2
Open Bankart repair with capsular shift
3
Repair of infraspinatus tendon into the Hill-Sachs defect (remplissage procedure)
4
Coracoid transfer to the glenoid (Latarjet procedure)
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 30
of 100
What phase of overhead throwing puts the rotator cuff at most risk of injury from internal impingement?
1
Wind up
2
Late cocking
3
Deceleration
4
Follow through
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 31
of 100 Stemless shoulder arthroplasty prostheses have recently been suggested as an alternative to traditional stemmed replacement. Advantages of the stemless surgical technique would include
1
better glenoid exposure than with stemmed prosthesis.
2
reliable use in four-part proximal humerus fracture surgery.
3
use in proximal humeral malunion without need for osteotomy.
4
improved long-term survivorship profile.
DISCUSSION
Glenoid exposure, while better than with surface replacements, is not improved over traditional stemmed replacements. Metaphyseal comminution would make it unlikely that a stemless implant could be used in most four-part fractures. Stemless replacement does have the unique advantage of allowing placement of a prosthesis with a malunion without an osteotomy, as the prosthesis is not constrained by the position of the stem. While early results are encouraging, there is no long-term data to suggest that survivorship is increased
with stemless arthroplasty.
QUESTION 32
of 100 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?
1
Scratching the opposite shoulder
2
Pushing off ipsilateral chair armrest while standing up
3
Tying shoelaces on the contralateral foot
4
Reaching up to comb hair
DISCUSSION
Proper soft-tissue tension is critical to prevent instability of a reverse total shoulder implanted with the deltopectoral approach; dislocation of the prosthesis is exceedingly rare if the superior approach is employed. The arm position implicated in reverse total shoulder instability is extension, adduction, and internal rotation,
such as pushing out of a chair. The other positions described do not involve extension of the shoulder.
QUESTION 33
of 100 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?
1
CT scan with 3D reconstructions
2
Ultrasonography
3
MRI scan
4
Fluoroscopically-guided arthrogram
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 34
of 100 When a patient has recurrent anterior shoulder instability, a bony glenoid reconstructive procedure should be considered in which clinical setting?
1
Associated humeral avulsion of the glenohumeral ligament (HAGL) lesion
DISCUSSION
HAGL lesions may initially be treated without surgery. Recurrent instability in the setting of a HAGL lesion may be treated with a soft-tissue repair. A non-engaging or non-tracking Hill-Sachs lesion may be treated with an anterior soft-tissue (Bankart) repair. A tracking or engaging lesion may be treated with a bony glenoid procedure or a soft-tissue procedure plus remplissage. An ALPSA lesion may be treated with a soft-tissue procedure unless it is associated with a glenoid bony defect >25%. A glenoid bony defect >25% is associated with substantially higher recurrence than defects <20%, and consideration for bony glenoid reconstruction is advised. Consideration of bone augmentation procedures with less severe glenoid bone loss may be considered
in collision athletes.
QUESTION 35
of 100 In rotator cuff tear arthropathy with pseudoparalysis, forward elevation of the humerus away from the body is prohibited because of
1
deltoid atony.
2
loss of the glenoid concavity.
3
loss of the humeral head depression of the biceps tendon.
4
loss of compressive force on the humeral head.
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.
QUESTION 36
of 100 A 50-year-old pipefitter falls from a ladder at work and dislocates his non-dominant 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. Which factor has been demonstrated to result in a poor clinical outcome following surgical intervention?
1
The patient's age
2
he patient's gender
3
Work-related injury
4
Acute nature of the tear
DISCUSSION
Several studies have demonstrated that patients with work-related injuries do not do as well as those whose injuries are not work-related after repair of the rotator cuff. This patient’s age and gender are not negative prognostic indicators. The acute nature of the tear does not lead to an inferior outcome.
