OITE & AAOS Board Prep MCQs: Foot, Fracture & Tumor

About This Board Review Set

This is Part 178 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

This set has been strictly audited and contains 100 100% verified, high-yield multiple-choice questions (MCQs) modelled on the exact format of the Orthopaedic In-Training Examination (OITE) and the American Academy of Orthopaedic Surgeons (AAOS) board examinations.

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 178

This module focuses heavily on: Foot, Fracture, Tumor.

Sample Questions from This Set

Sample Question 1: What is the most important muscle adaptation resulting from endurance training? Review Topic...

Sample Question 2: Flow cytometry of tumors measures the...

Sample Question 3: A 32-year-old construction worker reports a persistent burning, tingling sensation on the dorsum of his right foot and significant sensitivity on the plantar surface after a 500-lb steel beam dropped on it 8 weeks ago. Initial radiographs r...

Sample Question 4: Storage of musculoskeletal allografts by cryopreservation is achieved by...

Sample Question 5: -A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify...

Why Active MCQ Practice Works

Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

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Question 1

What is the most important muscle adaptation resulting from endurance training? Review Topic

Explanation

The most important muscle adaptation resulting from endurance training is an increase in capillary density. Increased capillary density improves blood and nutrient delivery and elimination of metabolic waste. Increased recruitment of motor units, hyperplasia, and hypertrophy are all adaptations that occur with resistance training or strength training. There is no significant change in glycolytic enzyme activity.

Question 2

Flow cytometry of tumors measures the

Explanation

Flow cytometry is a method of quantitating components or structural features of cells primarily by optical means. Ploidy and cell cycle analysis of cancers is the major diagnostic use. Cells are passed single file through a laser beam by continuous flow and several parameters are measured including Cell Diameter, proportional quantity of granular (DNA) within the cell, and using fluorescent probes the total DNA or a specific DNA/mRNA sequence can be counted. In examining tumors the amount of DNA in each cell is important for determining neoplasia.

Question 3

A 32-year-old construction worker reports a persistent burning, tingling sensation on the dorsum of his right foot and significant sensitivity on the plantar surface after a 500-lb steel beam dropped on it 8 weeks ago. Initial radiographs revealed no fractures, and the skin remained intact at the time of injury. Physical therapy, anti-inflammatory drugs, and a serotonin reuptake inhibitor have failed to provide relief. What is the next most appropriate step in management?

Explanation

DISCUSSION: Following failure of physical therapy and pharmacologic management in a patient with complex regional pain syndrome, the management of choice is sympathetic blocks. While continued physical therapy would be assistive, sympathetic blocks allow a more rapid relief of symptoms. Neurostimulation is not appropriate at this stage because of its invasive nature.
REFERENCES: Cepeda MS, Lau J, Carr DB: Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: A narrative and systematic review. Clin J Pain 2002;18:216-233.
Perez RS, Kwakkel G, Zuurmond WW, et al: Treatment of reflex sympathetic dystrophy (CRPS type 1): A research synthesis of 21 randomized clinical trials. J Pain Symptom Manage 2001;21:511-526.
Tran KM, Frank SM, Raja SN, et al: Lumbar sympathetic block for sympathetically maintained pain changes in cutaneous temperatures and pain perception. Anesth Analg 2000;90:1396-1401.
Stanton-Hicks M, Baron R, Boas R, et al: Complex regional pain syndromes: Guidelines for therapy. Clin J Pain 1998;14:155-166.

Question 4

Storage of musculoskeletal allografts by cryopreservation is achieved by

Explanation

DISCUSSION: Cryopreservation uses chemicals to remove cellular water and controlled rate freezing to prevent ice crystal formation. The tissue is procured, cooled to wet ice temperature for quarantine, and then stored in a container with cryoprotectant solution of dimethyl
sulfoxide or glycerol which displaces the cellular water. The controlled rate freezing is then done to prevent ice crystal formation. Fresh allografts are not frozen in order to maintain maximum cellular viability, and this process limits the shelf life of osteochondral allografts. Freeze-drying involves replacement of water in the tissue with alcohol to a moisture level of
5% and then uses a vacuum process to remove the alcohol from the tissue. Preparation of fresh frozen grafts involves freezing the graft twice and packaging the tissue without solution at
minus 80 degrees C.
REFERENCES: American Association of Tissue Banks: Standards for Tissue Banking. MacLean, VA, American Association of Tissue Banks, 1999.
Vangsness CT Jr, Triffon MJ, Joyce MJ, et al: Soft tissue allograft reconstruction of the human knee: A survey of the American Association of Tissue Banks. Am J Sports Med 1996;24:230-234.
Brautigan BE, Johnson DL, Caborn DM, et al: Allograft tissues, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, PA, WB Saunders, 2003, pp 205-213.

Question 5

A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Explanation

Neurogenic shock is defined as vascular hypotension with bradycardia as a result of spinal injury. The first few minutes after spinal cord injury are associated with hypertension and tachycardia, with a subsequent drop in pressure and pulse rate.

Question 6

5 mg/dL), vitamin D 50 ng/mL (reference range, 30-100 ng/mL), and urine phosphorus 2 g/24-hour collection (reference range, 0.4-1.3 g). What effect would treatment with only Calcitriol (1,25 dihydroxy vitamin D3) have?

Explanation

This patient has familial hypophosphatemic rickets, a vitamin D-resistant form of rickets that is an X-linked inherited disorder. Patients are short (< 10th percentile). Varus occurs both in the distal femur and proximal tibia. Patients have increased urinary excretion of phosphorus, leading to hypophosphatemia. Calcium levels are within defined limits and vitamin D levels can be normal as well. Treatment should include phosphate and 1,25 dihydroxy vitamin D3 (calcitriol). Phosphate administration increases the plasma concentration,
which lowers plasma ionized calcium concentration and further reduces plasma calcitriol concentration (removal of hypophosphatemic stimulus). Secondary hyperparathyroidism results because of both hypocalcemia and removal of the
normal inhibitory effect of calcitriol on parathyroid hormone (PTH) synthesis. Elevated PTH levels will increase urinary phosphate excretion, defeating the aim of oral therapy.
Addition of calcitriol is necessary to increase the intestinal absorption of calcium and phosphate to prevent secondary hyperparathyroidism. Massive doses of vitamin D alone can restore normal radiographic appearances to the epiphyses, but normal growth is not restored unless phosphate replacement is adequate.
A 35-year-old woman began to train for a half marathon. After 8 weeks of increasing her mileage, what changes can you expect in her Achilles tendon?
Net decrease of type I collagen
Net increase of type I collagen
Increased diameter of collagen fibrils
Increased cross-sectional area of the tendon
Training increases turnover of type I collagen, promoting both synthesis and degradation of collagen and a net increase synthesis of type I collagen in tendon-related tissue.
Strenuous endurance training has resulted in decreased collagen cross-links, suggesting increased collagen turnover, but decreased collagen maturation. In human studies, physical training results in increased turnover of collagen. Synthesis and degradation are elevated initially when beginning an exercise program, but degradation products decrease overall. It is not known if activity levels in humans affect the diameter of collagen fibrils or the cross-sectional area of tendons.
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Question 7

A 55-year-old man was injured when a large piece of sheet metal lacerated his medial elbow while working at a factory. He underwent primary repair of the lacerated structures shown in Figures 1 and 2 on the day of injury. In addition to this surgical treatment, what nerve transfer procedure should be considered during this primary operative intervention to improve his functional recovery?

Explanation

EXPLANATION:
In adults, the repair of high ulnar nerve injuries typically yields incomplete motor recovery and disappointing functional results despite early surgical intervention and careful surgical technique. Early transfer of the terminal branch of the AIN to the deep ulnar motor fascicle can rapidly reinnervate distal targets and potentially preserve motor end plate function in the intrinsic musculature of the hand because of the proximity of the nerve transfer to the target muscle. Sensory deficits due to an ulnar nerve injury
can be restored through a transfer of median sensory fascicles to the distal ulna sensory fascicles. This procedure typically would not be considered at the time of the original surgery, because sensory recovery is more likely than motor recovery in the setting of a high ulnar nerve injury. For radial nerve injuries, wrist extension can be restored through an FDS branch of the median nerve transfer to the ECRB branch of the radial nerve. The FCU fascicle of the ulnar nerve can be transferred to the biceps branch of the musculocutaneous nerve to restore elbow flexion and supination.

Question 8

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

Explanation

DISCUSSION: The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot.
REFERENCES: Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567.
Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.

Question 9

Surgical restoration of sagittal balance of an adult spinal deformity will have which effect on outcome?

Explanation

DISCUSSION
The influence of sagittal balance on outcomes following fusion-based procedures for degenerative conditions of the lumbar spine has only recently been appreciated. Restoration of sagittal spinal balance improves low-back-pain outcomes and quality of life. Sagittal spinal balance has not been shown to relieve neurogenic claudication attributable to spinal stenosis.
RECOMMENDED READINGS
Li Y, Hresko MT. Radiographic analysis of spondylolisthesis and sagittal spinopelvic deformity. J Am Acad Orthop Surg. 2012 Apr;20(4):194-205. doi: 10.5435/JAAOS-20-04-194. Review. PubMed PMID: 22474089. View Abstract at PubMed
Korovessis P, Repantis T, Papazisis Z, Iliopoulos P. Effect of sagittal spinal balance, levels of posterior instrumentation, and length of follow-up on low back pain in patients undergoing posterior decompression and instrumented fusion for degenerative lumbar spine disease: a multifactorial analysis. Spine (Phila Pa 1976). 2010 Apr 15;35(8):898-905. doi: 10.1097/BRS.0b013e3181d51e84. PubMed PMID: 20354466. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 99 AND 100
Figures 99a and 99b are MR images of a 59-year-old man with a history of intravenous (IV) drug abuse who arrives at the emergency department with malaise and fever. Upon admission, the patient's temperature is 38.9°C, his white blood cell count is 17000/µL (reference range [rr], 4500-11000/µL), his erythrocyte sedimentation rate is 98 mm/h (rr, 0-20 mm/h), and his C-reactive protein level is 45 mg/L (rr, 0.08-3.1 mg/L). He is admitted to the medical service to evaluate the source of his fevers. On hospital day 1, the patient reports weakness in his left arm and leg. Blood cultures are positive for methicillin-resistant Staphylococcus aureus.

A B

Question 10

Osteoclastic bone resorption is stimulated primarily by what molecular interaction?

Explanation

OPG is a receptor that competitively binds with RANKL, blocking the interaction with RANK and inhibiting osteoclastogenesis. PTH, secreted by the chief cells of the parathyroid gland, is active in calcium homeostasis independent of inflammatory arthropathies. PTH increases serum calcium indirectly by binding to osteoblasts, increasing expression of RANKL and decreasing expression of OPG. The interaction of RANKL to RANK in turn stimulates osteoclast precursors to fuse, forming
osteoclasts to enhance bone resorption. The pannus of rheumatoid arthritis and monosodium urate crystals of gouty tophi have been shown to trigger release of inflammatory cytokines such as IL-6, IL-8 and tumor necrosis factor alpha. The key to osteoclastic bone resorption of inflammatory arthropathy is regulated by the interaction of RANKL, expressed in osteoblasts and activated T cells, and RANK, expressed in osteoclast progenitors and mature osteoclasts. In inflammatory arthropathy, RANKL expression is increased and OPG is reduced, resulting in increased cortical and subchondral bone.

Question 11

It has been shown that bisphosphonate-based supportive therapy (pamidronate or zoledronate) reduces skeletal events (onset or progression of osteolytic lesions) both in patients with multiple myeloma and in cancer patients with bone metastasis. The use of biphosphonate therapy has been associated with Review Topic

Explanation

The use of bisphosphonates has been recently associated with the development of osteonecrosis of the jaw. Length of exposure seems to be the most important risk factor for this complication. The type of bisphosphonate may play a role and previous dental procedures may be a precipitating factor. Bisphosphonates are a class of therapeutic agents originally designed to treat loss of bone density (ie, alendronate). The primary mechanism of action of these drugs is inhibition of osteoclastic activity, and it has been shown that these drugs are useful in diseases with propensities toward osseous metastases. In particular, they are effective in diseases in which there is clear upregulation of osteoclastic or osteolytic activity, such as breast cancer and multiple myeloma, and have developed into a mainstay of treatment for individuals with these diseases. Although shown to reduce skeletal events, there has been no improvement in patient survival.

Question 12

Which of the following factors is most critical to the success of a meniscal allograft transplantation?

Explanation

Success of a meniscal allograft transplantation is strongly dependent on accurate graft sizing, typically within 5% of the native meniscus. Previous studies have established that donor cell viability is not mandatory for the survival of these grafts since they are replaced by the recipient’s cells (at least peripherally) within several weeks. Thus,
cryopreservation of the graft to ensure cell viability is not necessary. There is a limited immune response to musculoskeletal allografts; therefore, immunosuppression, as is required for visceral organ transplantation, is not indicated.

Question 13

A hip compression screw is placed in a test jig and a bending load is applied to the tip of the screw. After the load is released, the screw returns completely to its original shape. What is this type of deformation called?

Explanation

When an implant is loaded below the yield point, by definition, it undergoes elastic deformation, meaning that all of the deformation recovers when the load is removed. If it is loaded above the yield point, then plastic or permanent deformation occurs. Fatigue is the gradual accumulation and progression of cracks in the material, which, after many cycles of loading, can lead to gross failure. Creep is the gradual accumulation of permanent (plastic) deformation over time, which may occur with polymeric materials but is not typical of metals or ceramics. Torsion refers to a torque being applied about the long axis of a bone or an implant. In general, the materials and dimensions of an implant are chosen to avoid plastic deformation or fatigue failure during typical clinical use.

Question 14

An 76-year-old woman falls from standing and sustains the injury shown in Figure A. Her most recent T score was -1.9, 3 months prior to presentation. If labwork were performed, which values would be consistent with her bone density score?

Explanation

In osteopenia, elevated parathyroid hormone (PTH), high alkaline phosphatase as well as low calcium (Ca), phosphorus and vitamin D would be expected.
In the setting of osteopenia/osteoporosis, there is a positive feedback to increase PTH in response to low serum calcium levels. In response, there is a corresponding increase in alkaline phosphatase and decrease in phosphorous and circulating vitamin D levels.
Fraser writes a concise, yet thorough synopsis on primary and secondary hyperparathyroidism. In the article, the summary regarding osteopenia/osteoporosis (typically a state of hypovitamin D) begins by stating an initial state of decreased ionised calcium, which increases PTH, results in 3 primary effects: an attempt to increase gut absorption of Ca, mobilize Ca from the bone via osteoclasts and activate vitamin D at the kidney (1,25-vitamin D).
Figure A exhibits a left femoral neck fracture, which is a fragility fracture associated with poor bone density. Illustration A is a figure from Fraser's article exhibiting the feedback loop from the hypothalamus, pituitary, adrenal/glandular axis.
Incorrect answers:

Question 15

Which of the following clinical scenarios represents an appropriate indication for convex hemiepiphysiodesis/hemiarthrodesis in the treatment of a child with a congenital spinal deformity?

Explanation

DISCUSSION: Convex hemiarthrodesis and hemiepiphysiodesis are procedures designed to gradually reduce curve magnitude in congenital scoliosis because of hemivertebrae. They are used to surgically create an anterior and posterior bar to arrest growth on the convexity of the existing deformity. Success of the technique is predicated on continued growth on the concave side of the deformity. Prerequisites for this procedure include curves of limited length (less than or equal to five vertebrae), curves of reasonable magnitude (less than 70°), absence of kyphosis, concave growth potential, and appropriate age (younger than age 5 years).
REFERENCE: Winter RB, Lonstein JE, Denis F, Sta-Ana de la Rosa H: Convex growth arrest for progressive congenital scoliosis due to hemivertebrae. J Pediatr Orthop 1988;8:633-638.

Question 16

Figure 39 shows the radiograph of a 4-month old infant who has been undergoing weekly casting since birth for a congenital equinovarus deformity. Management should now consist of

Explanation

DISCUSSION: The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique.
REFERENCES: Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992,

pp 135-136.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,

pp 927-935.
Tachdjian MO: Pediatric Orthopedics, ed 2. Philadelphia, PA, WB Saunders, 1990,

pp 2461-2564.

Question 17

Based on the findings seen at C5-6 in Figure 30, the most likely deficit for this patient will be weakness of the

Explanation

DISCUSSION: A herniated cervical disk at C5-6 causes a C6 radiculopathy. There are eight cervical nerve roots and seven cervical vertebrae, and C8 exits between the C7 and T1 vertebrae. The C6 nerve root typically innervates the biceps and wrist extensor. The deltoid is predominantly innervated by C5. The wrist flexor and triceps are predominantly innervated by C7. Grip strength is predominantly a function of C8.
REFERENCE: Hoppenfeld S: Evaluation of nerve root lesions involving the upper extremity, in Orthopaedic Neurology. Philadelphia, PA, JB Lippincott, 1977, pp 7-23.

Question 18

Figure 43 shows an arthroscopic view of the posteromedial compartment of a patient’s left knee using a 70-degree arthroscope placed through the intercondylar notch. The arrow is pointing to what structure?

Explanation

DISCUSSION: Passing the 70-degree arthroscope through the intercondylar notch provides excellent visualization of the posteromedial corner of the knee. This view should be part of every knee arthroscopy because these structures are often not well visualized from the anterior portals. If this view is omitted, tears of the peripheral posterior horn of the medial meniscus can be overlooked. The arrow points to the peripheral aspect of the posterior horn of the medial meniscus. With an intact medial meniscus, the medial tibial plateau should not be seen from this view. The semimembranosus and gastrocnemius tendons are extra-articular and not visualized.
REFERENCES: Miller MD: Basic arthroscopic principles, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, Saunders, 2003, pp 224-237.
Gold DI, Schaner PJ, Sapega AA: The posteromedial portal in knee arthroscopy: An analysis of diagnostic and surgical utility. Arthoscopy 1995;11:139-145.

Question 19

An 18-year-old man recently underwent an uncomplicated arthroscopic partial medial meniscectomy that was complicated by reflex sympathetic dystrophy (RSD), also termed “sympathetically maintained pain” (SMP). What is the most common finding of this condition?

Explanation

DISCUSSION: The hallmark for RSD or SMP is the presence of pain that is out of proportion to that expected for the degree of the injury. SMP often extends well beyond the involved area and is present in a nonanatomic distribution. The pain is frequently described as a burning sensation, with extreme sensitivity to light touch. Joint stiffness can be present but is a nonspecific finding. There may be cold intolerance, but this is not a cardinal symptom. Sweating actually may be increased. Osteopenia, if present, is a late finding.
REFERENCES: Lindenfeld TN, Bach BR Jr, Wojtys EM: Reflex sympathetic dystrophy and pain dysfunction in the lower extremity. Instr Course Lect 1997;46:261-268.
O’Brien SJ, Ngeow J, Gibney MA, Warren RF, Fealy S: Reflex sympathetic dystrophy of the knee: Causes, diagnosis, and treatment. Am J Sports Med 1995;23:655-659.

Question 20

A B Figures 54a and 54b are the radiographs of a 21-year-old man who has a long history of thoracic back pain. His lumbar spine is asymptomatic. He has failed prolonged nonsurgical treatment. Surgical correction should consist of

Explanation

DISCUSSION
When planning surgical intervention for Scheuermann kyphosis, it is imperative that the instrumentation and fusion extend across the entirety of the deformity. Distally, this means extending across the first lordotic disk space. In this scenario, this disk is the L1-L2 disk, which means the fusion needs to extend to L2. Shorter and longer fusions are not necessary or appropriate.
RECOMMENDED READINGS
Denis F, Sun EC, Winter RB. Incidence and risk factors for proximal and distal junctional kyphosis following surgical treatment for Scheuermann kyphosis: minimum five-year followup. Spine (Phila Pa 1976). 2009 Sep 15;34(20):E729-34. PubMed PMID: 19752692. View
Abstract at PubMed
Macagno AE, O'Brien MF. Thoracic and thoracolumbar kyphosis in adults. Spine (Phila Pa 1976). 2006 Sep 1;31(19 Suppl):S161-70. Review. PubMed PMID: 16946634. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 55 THROUGH 59
A 60-year-old woman has severe neck and back pain. She is relatively healthy but has diabetes and neuropathy involving her lower extremities. Her body mass index is 38. She has a history of spinal fusion performed by your colleague 3 years ago. At that time, she was treated for degenerative scoliosis of the lumbar spine with concomitant spinal stenosis. A 360-degree fusion was performed from L4-S1 with a posterior decompression from L2-S1 and a posterior instrumented fusion from T3 to the pelvis. On examination, she has reproducible pain and a visible kyphosis in the periscapular region. Neurologic examination findings are within normal limits, with the exception of lower-extremity dysesthesias related to her neuropathy. The patient states that she has been having progressive difficulty dressing herself and taking care of her apartment for several months. Plain radiographs and a standing scoliosis series demonstrate a solid fusion from the sacrum to T3 without evidence of hardware failure. There is focal collapse of the T2-T3 disk space and a proximal kyphosis involving the T2 vertebrae that is indicative of disk and ligamentous failure.

Question 21

What is the primary benefit of using rhBMP-2 instead of autogenous bone graft inside an anterior spinal fusion cage?

Explanation

DISCUSSION: Radiographic fusion success rates are best described as slightly rather than substantially improved. Hospital stay and time to fusion also are not substantially decreased. Use of BMP does eliminate the need for autograft harvest for anterior lumbar interbody fusion/cage. The need for postoperative bracing is not altered based on graft choice. Early studies of posterolateral fusion applications appear to show a greater potential benefit of rhBMP-2 over autograft. Not all BMP formulations perform the same with regard to safety and effectiveness. Other osteoinductive proteins in clinical trials (BMP-7, GDF-5) will require individual analysis of these properties.
REFERENCE: Burkus JK, Gornet MF, Dickman CA, et al: Anterior lumbar interbody fusion using rhBMP-2 with tapered interbody cages. J Spinal Disord Tech 2002;15:337-349.

Question 22

A 65-year man has right hip pain after a fall. Radiographs reveal a reverse oblique intertrochanteric femoral fracture. Treatment consists of reduction and internal fixation. Which of the following implants is most commonly associated with nonunion and hardware failure?

Explanation

DISCUSSION: Reverse oblique intertrochanteric femoral fractures account for 5% of all intertrochanteric or subtrochanteric fractures. They are uncommon but not rare and will be encountered in practice. The sliding hip screw is associated with the most problems because of its design. When reverse oblique fractures are fixed with a sliding hip screw, the action of the construct causes medial displacement of the distal fragment rather than compression of the proximal and distal fragments. All of the other implants prevent medial displacement of the distal segment. It should not be assumed that simply using one of the other implants is reason for success. There is a significant failure rate for each of these implants with reverse oblique fractures. The implant must be ideally placed and the fracture must be reduced.
REFERENCES: Haidukewych GJ, Israel TA, Berry DB: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.
Baumgaertner MR, Chrostowski JH, Levy RN: Intertrochanteric hip fracture, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1833-1881.

Question 23

Radiographs of a 15-year-old girl with knee pain reveal a radiopaque lesion of the distal femoral metaphysis and epiphysis with a small associated soft-tissue mass. A biopsy specimen shows osteoid and pleomorphic cells with multiple mitotic figures. Staging studies show no other sites of disease. Treatment should consist of

Explanation

DISCUSSION: Based on the location and extent of the tumor, most patients are candidates for limb salvage surgery. The patient has an osteosarcoma; therefore, the treatment of choice is preoperative chemotherapy, wide resection, and reconstruction. There is no difference in survival rates between patients who undergo limb salvage surgery and those who undergo amputation. Curettage and placement of methylmethacrylate is used to treat benign lesions of bone and would not be appropriate in this patient.
REFERENCE: Simon MA, Springfield DS, et al: Common Malignant Bone Tumors: Osteosarcoma. Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 265-274.

Question 24

What structure (arrow) is shown in Figure 24?

Explanation

DISCUSSION: The structure illustrated is the sympathetic chain viewed from an anterolateral view of the lower lumbar spine. It descends along the anterolateral aspect of the spine into the pelvis closely adherent to the vertebral column. The spinal nerves, including L5, can be seen exiting from the foramen. The ureters descend from the kidneys and cross anterior to the iliac vessels to the bladder.
REFERENCES: Onibokun A, Khoo LT, Holly L: Anterior retroperitoneal approach to the lumbar spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 101-105.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 25

The palmar cutaneous branch of the median nerve (PCBMN) originates from the

Explanation

DISCUSSION: The PCBMN originates from the median nerve proper between 3 and 21 cm proximal to the wrist with moderate variation. It virtually always originates from the radial side of the nerve and travels distally with the median nerve, radial to the palmaris longus, and ulnar to the flexor carpi radialis.
REFERENCES: Hobbs RA, Magnussen PA, Tonkin MA: Palmar cutaneous branch of the median nerve. J Hand Surg Am 1990;15:38-43.
Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System: Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy, 1991, vol 8,

p 52.

Question 26

A 14-year-old boy sustained a 100% displaced distal radius Salter-Harris type II fracture. Neurologic examination demonstrates normal motor examination and two-point discrimination. He undergoes fracture reduction to the anatomic position with the application of a long arm cast. Postreduction he reports increasing hand and wrist pain with diminution of two-point discrimination to 10 mm over the index and middle fingers over the next several hours after surgery. The cast is bivalved and the padding released relieving all external pressure over the arm. Reevaluation reveals increasing sensory deficit over the affected area. What is the next most appropriate management intervention?

Explanation

The patient has an evolving acute carpal tunnel syndrome. Initial management for this injury is to relieve all external pressure that may elevate the neural compression. Surgical decompression of the median nerve at the carpal tunnel is the optimal intervention. Further nonsurgical interventions (cast removal or further bivalving) are insufficient to alleviate the neural compression.

Question 27

A 12-year-old girl who is Risser stage 3 has had intermittent mild midback pain for the past 4 weeks. The pain is worse after prolonged sitting and after carrying a heavy backpack at school. She occasionally takes acetaminophen, but the pain does not limit sport activities. Examination reveals a mild right rib prominence during forward bending. Neurologic examination is normal. Radiographs show a 20-degree right thoracic scoliosis with no congenital anomalies or lytic lesions. Management should consist of

Explanation

DISCUSSION: Mild scoliosis is not a painful condition, but it usually presents during adolescence. Intermittent back pain is reported by 25% to 30% of adolescents whether or not scoliosis is present. Such pain is often attributed to muscle strain from tight muscles, poor posture, or heavy school backpacks. The clinician must distinguish typical pain (mild, intermittent, nonlimiting) from atypical pain. The latter requires more careful examination and imaging studies (bone scan or MRI) to determine the source of pain. The patient’s age and right thoracic curve pattern are typical for idiopathic scoliosis; therefore, imaging of the neuroaxis is not necessary to look for cord syrinx, tethering, or tumor. Brace treatment is not required for this small curve unless future progression is demonstrated.
REFERENCES: Ramirez N, Johnston CE, Browne RH: The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am 1997;79:364-368.
Hollingworth P: Back pain in children. Br J Rheum 1996;35:1022-1028.
Siambanes D, Martinez JW, Butler EW, et al: Influence of school backpacks on adolescent back pain. J Pediatr Orthop 2004;24:211-217.

Question 28

A patient with a transverse femur fracture undergoes statically locked antegrade intramedullary nailing. Postoperatively, the patient appears to have a

Explanation

To establish negligence, certain criteria must be met. 1) A duty was owed by the surgeon (in this case, yes, a relationship was established). 2) The duty was breached, where the provider failed to meet the standard of care (there was a technical error, but it was corrected). 3) The breach caused an injury. In this case, the patient had an outcome that was very acceptable, as documented with outcome studies, for femur fractures. Also, the rotational error and locking distally would have had little impact on the hip, whereas antegrade nailing itself is expected to result in some objective impairment of the hip in some patients. 4) Damages were incurred as a result. In this case, the patient returned to work and could not rock climb which could be reasonably expected with a femur fracture in some patients, and cannot be causally linked to the corrective surgery. For all practical purposes, the patient had a very acceptable outcome. Thus, settling the case for an error would be rather permissive and the important issue is that the surgeon recognized the problem, addressed it, and fulfilled his or her postoperative responsibility. The case is very defendable, and thus it is unlikely to be lost. Defending the case and alleging no error is incorrect because there was an error. The surgeon should never function outside of his or her legal counsel once a suit is filed.

Question 29

A 45-year-old woman with stage II posterior tibial tendinitis has failed to respond to nonsurgical management. Recommended treatment now includes posterior tibial tendon debridement and medial calcaneal displacement osteotomy along with transfer of what tendon?

Explanation

DISCUSSION: The flexor digitorium longus is the commonly accepted tendon transfer for posterior tibial tendon insufficiency. The flexor hallucis longus has to be carefully rerouted to avoid crossing the neurovascular bundle and has not been shown clinically to provide superior results to flexor digitorum longus transfer. Use of the peroneus longus results in loss of plantar flexion strength of the first metatarsal, contributing to the flatfoot deformity. The anterior tibial tendon is in the anterior compartment and fires out of phase with the posterior tibial tendon.
REFERENCES: Sitler DF, Bell SJ: Soft tissue procedures. Foot Ankle Clin 2003;8:503-520.
Guyton GP, Jeng C, Krieger LE, et al: Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for posterior tibial tendon dysfunction: A middle-term clinical follow-up. Foot Ankle Int 2001;22:627-632.

Question 30

Figure 7 is the MR image of a 43-year-old man who has left shoulder pain with a traumatic rotator cuff tear after a fall. An examination reveals active forward elevation at 120 degrees and positive Yergason and lift-off test results. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?

Explanation

DISCUSSION

Video 7 for reference
The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove.
The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 31

A 44-year-old man sustains the injury shown in Figures 1 through 3. What is the most appropriate treatment?

Explanation

EXPLANATION:
Reduction, either open or closed, with internal fixation (pinning) is the recommended treatment for the majority of these injuries. Closed reduction with pinning is most often performed for acute injuries. Open reduction with pinning is performed for those injuries that cannot be reduced by closed means or those with a delayed presentation. Four cases of successful closed reduction and splinting, all performed upon presentation in the emergency department, have been described by Storken and associates, but the authors note that their review of three prior reports uncovered cases of secondary dislocation, which required surgical stabilization. One of the dislocations occurred 4 months after the reduction. They assert that an indication for primary ORIF is a CMC dislocation associated with major fractures. Primary arthrodesis can be considered in cases with severe intra-articular comminution, but this procedure substantially limits the ability of the hand to increase and decrease the transverse metacarpal arch, which is an important functional movement. It can also lead to osteoarthritis of the triquetrohamate joint. Suspension arthroplasty has been described for old fracture-dislocations of the fifth CMC joint, using a partial slip of the extensor carpi ulnaris.

Question 32

Based on the Young and Burgess classification of pelvic ring injuries, an anterior-posterior compression type II injury does not result in disruption of which of the following?

Explanation

DISCUSSION: An APC type 1 involves slight widening of pubic symphysis and/or anterior sacroiliac (SI) joint. An APC II is a continuation of this force, and additionally involves a disrupted anterior SI joint, as
well as sacrotuberous and sacrospinous ligaments. An APC III also involves disrupted posterior SI ligaments, causing complete SI joint disruption with potential translational and rotational displacement.
The reference by Young et al is a classic article that describes the Young and Burgess classification of pelvic ring injuries. They retrospectively analyzed pelvic ring radiographs and discussed four patterns of injury: anteroposterior compression, lateral compression, vertical shear, and a complex/combined pattern.
The reference by Burgess et al is a validation of the aforementioned classification and study, as they reviewed 210 consecutive patients who sustained a pelvic ring injury. They validated the classification scheme and found that overall blood replacement averaged: lateral compression, 3.6 units; anteroposterior compression, 14.8 units; vertical shear, 9.2 units; combined mechanical, 8.5 units. Overall mortality was: lateral compression, 7.0%; anteroposterior, 20.0%, vertical shear, 0%; combined mechanical, 18.0%.
Incorrect answers:
1,2,4,5: An APC - 2 pelvic ring injury involves injury to all of these structures.

Question 33

The risk of local recurrence after surgical resection of a soft-tissue sarcoma is most closely related to

Explanation

DISCUSSION: A positive margin is most closely related to subsequent local recurrence. The other factors cited, including the size and site of the tumor, may be related to local recurrence; however, they are more commonly prognostic because of the difficulty in obtaining wide surgical margins about large or proximal tumors. Radiation therapy has been noted to decrease the incidence of recurrence but is not felt to be as important as the surgical margin. The grade of the tumor has more influence on the prevalence of metastatic disease than the incidence of local recurrence.
REFERENCES: Lewis JJ, Leung D, Heslin M, Woodruff JM, Brennan MF: Association of local recurrence with subsequent survival in extremity soft tissue sarcoma. J Clin Oncol 1997;15:646-652.
Meterissian SH, Reilly JA Jr, Murphy A, Romsdahl MM, Pollock RE: Soft-tissue sarcomas of the shoulder girdle: Factors influencing local recurrence. Distant metastases and survival. Ann Surg Oncol 1995;2:530-536.

Question 34

What is the most common short-term complication following femoral impaction grafting for revision total hip arthroplasty?

Explanation

DISCUSSION: Impaction grafting is an alternative for severe femoral bone deficiency; however, stem subsidence is commonly observed during the first few months. Slight subsidence is felt to be integral to the success of the procedure. Predictable bone graft incorporation and stable stem fixation have been reported in the medium-term. The incidence of periprosthetic fractures has been reported as high as 24%.
REFERENCES: Mikhail MWE, Weidenhielm L, Jazrawi LM, et al: Collarless, polished, tapered stem failure. J Bone Joint Surg Am 2000;82:1513-1514.
Leopold SS, Rosenberg AG: Current status of impaction allografting for revision of a femoral component. Instr Course Lect 2000;49:111-118.

Question 35

Figures below show the radiographs, MRI, and MR arthrogram obtained from a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of 10. He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy.When counseling patients who have a cam deformity, the orthopaedic surgeon should note that

Explanation

Multiple studies have confirmed that cam or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, cam deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion is higher than 50% in the subgroup of athletes. Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in most nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between cam deformity and hip osteoarthritis, a corresponding link between the correction of the deformity and prevention of osteoarthritis has never been proven. The results of cam deformity correction, typically including repair of the degenerative labral tear, are much poorer when substantial joint space loss is present. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

Question 36

A 29-year-old woman is seen in the emergency department with a 24-hour history of severe back and leg pain precipitated by weight-lifting. The patient reports bilateral leg pain and is unable to urinate. She has dense anesthesia in the perineal region on examination. A MRI scan is shown in Figure 38. The patient is taken to surgery urgently. What is her prognosis for recovery? Review Topic

Explanation

The patient with cauda equina syndrome should be taken to surgery urgently to provide the best chance of symptom resolution. However, many studies indicate that patients with cauda equina syndrome do not return to a completely normal status even following urgent surgery. Whereas pain is typically relieved after surgery, other deficits, especially bladder and sexual dysfunction, may persist. Particularly in light of the patient's severe saddle anesthesia, she may have a poor prognosis for recovery of normal bladder function.

Question 37

Tumoral calcinosis Tumoral calcinosis is a heritable condition that is characterized by periarticular metastatic calcification. Most patients are black, and the inheritance is usually autosomal recessive. Metastatic calcifications occur around joints and in the skin, marrow, teeth, and blood vessels. The periarticular masses may grow quite large and are attached to the fascia, but they are extra-articular. The masses may occur at the shoulder, hip, and elbow. Radiographically: The masses are composed of heavy, amorphous calcification in nodules. Laboratory:

Explanation

Slide 1 Slide 2
A 20-year-old patient who is otherwise healthy has a soft mass over her hip. The mass has formed over the past 2 years. The radiographs are shown in Slides 1 and 2. Which of the following would be a common finding:

Question 38

A total shoulder arthroplasty (TSA) would be the most appropriate treatment in which of the following arthritic patients? Review Topic

Explanation

A total shoulder arthroplasty (TSA) is indicated in the 72 year old male with debilitating shoulder pain and an intact rotator cuff on MRI. The other patient scenarios are examples of contraindications for TSA.
A TSA involves replacement of the humeral head with a metal head and resurfacing of the glenoid to a cemented all-polyethylene surface. In order to achieve optimal results, patients must be selected carefully. Patients with an irreparable rotator cuff tear, non-functioning deltoid, inadequate glenoid bone stock and brachial plexopathy
are poor candidates for TSA.
Edwards et al. conducted a multicenter randomized controlled trial to compare TSA versus hemiarthroplasty in patients with primary osteoarthritis of the shoulder. They found that TSA provided better scores for pain, mobility, and activity than hemiarthroplasty at 2 year follow-up.
Boileau et al. followed 45 consecutive patients who underwent reverse TSA (rTSA) for cuff tear arthropathy (CTA), post-traumatic arthritis, and failure of revision arthroplasty. After a mean follow-up of 40 months, they found that the reverse prosthesis improved function and was able to restore active elevation in patients with incongruent cuff-deficient shoulders. They also found that the results were less predictable and complication and revision rates were higher in patients undergoing revision surgery as compared to those patients undergoing rTSA for CTA.
Illustrations A and B show the preoperative and postoperative x-rays of a patient with characteristic OA of the glenohumeral joint that was treated with TSA.
Incorrect Answers:

Question 39

Following insertion of a cementless femoral component into the total hip arthroplasty construct, the amount of femoral stress shielding is most associated with

Explanation

DISCUSSION
Although material modulus, characteristics of surface, and extent of coating all contribute to stress shielding, poor bone quality is the most important factor associated with stress shielding.

Question 40

A 58-year-old woman has a fracture through a metacarpal lesion after a motor vehicle accident. She denies any preinjury symptoms and the fracture heals uneventfully. Based on the radiograph and MRI scans shown in Figures 22a through 22c obtained following fracture healing, follow-up management should consist of

Explanation

DISCUSSION: Enchondromas are the most common benign skeletal lesions identified in the bones of the hand. Most are incidentally found or initially become clinically evident after a pathologic fracture. If the patient has a fracture, the hand is immobilized until union. If the lesion is large and further pathologic fractures are expected, then an intralesional curettage and grafting procedure may be warranted. In this patient, the lesion has not significantly altered the size, shape, or morphology of the involved metacarpal head and recurrent fracture is unlikely. Observation with follow-up radiographs is considered appropriate management.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 213-228.
Marco RA, Gitelis S, Brebach GT, et al: Cartilage tumors: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:292-304.

Question 41

Figure 23 is the radiograph of a 22-year-old woman who was involved in a motor vehicle collision. She reports isolated pain in her left shoulder. She is hemodynamically stable, respiring comfortably, and neurovascularly intact. Based on these findings, which of the following statements regarding treatment is most appropriate?

Explanation

The patient has sustained an isolated, closed, transverse fracture of the middle third of the clavicle with greater than 100% displacement and greater than 2 cm of shortening. Whereas the traditional treatment of clavicle fractures has been overwhelmingly conservative, recent reports suggest that surgical fixation should be considered for certain injury patterns. The union rates of displaced clavicle fractures are more recently noted to be approximately 85%, which is lower than the traditional literature. In a prospective randomized trial of clavicle fractures with greater than 100% displacement, union rates were higher and functional outcomes were better at all time points up to 1 year after injury in the surgical group when compared with nonsurgical management.

Question 42

Figures 39a and 39b are the radiographs of a 45-year-old man with diabetes who fell 12 feet from a ladder and sustained an isolated closed injury to his left leg. Examination revealed that he was neurovascularly intact and compartments were soft. A damage control knee spanning external fixator was applied and after 2 weeks in the frame, his blisters have resolved and his skin now wrinkles. What is the most appropriate treatment?

Explanation

The patient has sustained a severely comminuted bicondylar fracture of the tibial plateau. The mechanism and radiographs highlight the high-energy mechanism of the injury and should warrant aggressive monitoring for compartment syndrome which is relatively common in this scenario. A staged surgical approach is warranted with application of a spanning damage control external fixator to maintain length and
alignment while the soft-tissue injury recovers and to allow for surveillance and examination of the limb. The radiographs reveal a comminuted bicondylar pattern with significant depression of the lateral articular surface and a split fracture with condylar widening. This element of the fracture will require direct elevation of the joint surface and reduction/buttress of the lateral condyle. This is best achieved with a lateral plate with subchondral rafting screws. The medial articular surface is coronally split and the posteromedial fragment is displaced. This fragment requires direct reduction and buttress via a separate posteromedial approach which is frequently performed prior to the lateral approach and fixation. A lateral buttress plate or a lateral locking plate alone does not reliably capture or adequately support the displaced posteromedial fragment. A medial and lateral plate construct is less soft-tissue friendly, particularly if inserted through a single incision. A medial plate would also fail to give direct buttress to the posteromedial fragment.

Question 43

In Dupuytren’s disease, the retrovascular cord typically displaces the radial proper digital nerve of the ring finger in what direction?

Explanation

DISCUSSION: Retrovascular cords are common in Dupuytren’s disease and commonly require surgical treatment. Nerve injury in Dupuytren’s surgery is an infrequent complication that occurs partly because the digital nerves can be displaced from their normal anatomic relationships by retrovascular cords. The nerves are displaced superficially, toward the center of the digit (palmarly and ulnarly). This displacement is typically seen at the level of the metacarpophalangeal joint.
REFERENCE: Rayan GM: Palmar fascial complex anatomy and pathology in Dupuytren’s disease. Hand Clin 1999;15:73-86.

Question 44

ofhat parameter is most commonly used to estimate the maximum tension a muscle can generating?

Explanation

The mass or volume of a muscle is proportional to its work capacity, and the fiber length of a muscle is proportional to its potential excursion. By dividing the fiber length into the volume of each muscle, the cross-sectional area of the muscle is determined.
The concept of physiologic cross section of a muscle from Weber and Fick, identifies the critical importance of the cross sectional area of all the fibers of a muscle as proportional to maximum tension. (Relationship between muscle size and muscle strength).

Question 45

A college athlete on a scholarship has a medical condition that you feel presents a life-threatening risk to him with participation in athletics. Because of the gravity of this decision and the potential effect it can have on the student/athlete's future, the college asks for your guidance. As the team physician for the college, what is your ethical obligation?

Explanation

There is legal precedent for banning a scholarship athlete from participation in college athletics if the physician feels that it presents a significant physical risk to the athlete. The courts have decided that the athlete has no constitutional right to participate in NCAA sports, and as a team physician you must advise your athlete and the school as to the best course of action. The athlete must be allowed to keep his or her college scholarship.

Question 46

Which group experiences the highest rate of anterior cruciate ligament (ACL) tears?

Explanation

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 67
Figure 64 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.

Question 47

The superior glenohumeral ligament primarily restrains

Explanation

DISCUSSION: Several cutting studies have evaluated the primary static restraints and the role of the glenohumeral ligaments in providing static stability. With the arm at the side in adduction, the superior glenohumeral ligament and coracohumeral ligament are the primary restraints to inferior translation. The middle glenohumeral ligament functions with the arm in 45 degrees of abduction and resists anterior translation. The inferior glenohumeral ligament is the primary restraint to anterior translation at 90 degrees of abduction.
REFERENCES: Warner JJ, Deng XH, Warren RF, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.
Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy Orthopaedic Surgeons, 1994, pp 165-177.

Question 48

A 22-year-old college football player reports shortness of breath and dyspnea after a tackle. Examination reveals tachypnea, tachycardia, the trachea is shifted to the right, and there are decreased breath sounds on the left lung fields. The first line of treatment on the field should be

Explanation

DISCUSSION: The patient has a tension pneumothorax. This is a life-threatening emergency where air is trapped between the pleura and the lung, which prevents expansion of the lung. This causes hypoxia and cardiopulmonary compromise. The first line of treatment is to place a needle into the second intercostal space in the midclavicular line. The athlete should then be transported to the emergency department for chest tube placement. The athlete cannot return to play, and resuscitation is not necessary because he has not gone into cardiopulmonary arrest.
REFERENCES: Amaral JF: Thoracoabdominal injuries in the athlete. Clin Sports Med 1997;16:739-753.
Perron AD: Chest pain in athletes. Clin Sports Med 2003;22:37-50.

Question 49

Figure 26 shows the radiograph of an otherwise healthy Caucasian 5-year-old boy who has a painless limp. What is the best treatment option?

Explanation

DISCUSSION: The prognosis of Legg-Perthes disease in children younger than age 6 years is good. There is no indication that surgical treatment will improve the outcome. Range-of-motion exercises to prevent contracture may be helpful.
REFERENCES: Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 691-704.

Question 50

A 16-year-old male fell from a roof onto his right shoulder and presents with decreased pulses in his right upper extremity. Imaging reveals a posterior sternoclavicular dislocation. What is the best treatment at this time?

Explanation

DISCUSSION: Symptomatic acute posterior sternoclavicular dislocations in adolescents should undergo open reduction and ligament (costoclavicular) reconstruction with thoracic surgery back-up. In patients younger than age 20-25, this is usually a physeal injury, as the medial clavicular physis does not close until this age range. Chronic anterior or posterior dislocations are recommended to be treated conservatively, especially if not symptomatic.
The review article by Wirth and Rockwood notes the following complications with posterior dislocation: respiratory distress, venous congestion or arterial insufficiency, brachial plexus compression, and myocardial conduction abnormalities. They recommend reconstruction of the costoclavicular ligaments with resection of the medial clavicular head as needed for unstable injuries.
The referenced article by Waters et al noted 100% excellent short-term outcomes in adolescents with open reduction and reconstruction of the costoclavicular ligament in pure dislocations or with suture fixation of the medial physis in physeal injuries.

Question 51

Figure 41 shows the MRI scan of a 38-year-old weightlifter. What does the arrow on the MRI scan indicate? Review Topic

Explanation

Pectoralis major ruptures typically occur in avid weightlifters (often on supplements) and typically while bench-pressing. Clinically there is significant discoloration/bruising over the pectoralis and into the axilla. MRI helps confirm the diagnosis and may help determine if the tear is in the muscle belly or at the bone-tendon junction.

Question 52

A metal-on-metal bearing used for total hip arthroplasty shows which of the following properties?

Explanation

DISCUSSION: Activity levels do not affect cobalt and chromium ion levels, which are the bulk of serum ion levels. The majority of ions are produced in the run-in period in the first several years. A gradual reduction in ion levels occurs thereafter. The kidneys are responsible for the bulk of clearance from the serum, and to date there is no relationship of cancer to ion levels in the serum.
REFERENCE: Heisel C, Silva M, Skipor AK, et al: The relationship between activity and ions in patients with metal-on-metal bearing hip prostheses. J Bone Joint Surg Am 2005;87:781-787.

Question 53

A 42-year-old woman with a long-standing history of rheumatoid arthritis undergoes total shoulder arthroplasty for persistent pain that has failed to respond to nonsurgical management. Intraoperative radiographs reveal an oblique, minimally displaced fracture of the greater tuberosity. Based on these findings, what is the best course of action?

Explanation

DISCUSSION: The risk of intraoperative fracture in osteoporotic bone in patients with rheumatoid arthritis is significant. Fractures most often occur during humeral head dislocation and positioning for canal reaming. If the fracture occurs at the greater tuberosity, cerclage suture fixation of the tuberosity fracture with autogenous cancellous bone graft from the resected humeral head is the treatment of choice.
REFERENCES: Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am 1995;77:1340-1346.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 215-225.
Frankle MA, Ondrovic LE, Markee BA, et al: Stability of tuberosity reattachment in proximal humeral hemiarthroplasty. J Shoulder Elbow Surg 2002;11:413-420.

Question 54

A 68-year-old woman underwent an uncemented medial/lateral tapered femoral placement during a total hip arthroplasty. The orthopaedic surgeon noticed a nondisplaced vertical fracture in the calcar region of the femoral neck during final implant insertion. What is the most appropriate treatment?

Explanation

DISCUSSION:
The recognized treatment for a proximal periprosthetic fracture is to first identify the extent and then optimize the correction of the fracture. Several studies indicate that proximal cerclage wiring is adequate to create "barrel hoop" stability of the proximal femur. Braided cables offer superior stability compared with twisted wires or Luque wires. Finally, the appropriate postoperative treatment is protected
weight bearing for 6 weeks, with periodic radiographs taken at 2-week intervals. Other options such as
cementing the femoral stem and using a revision arthroplasty device are indicated for unstable fractures.

Question 55

The load versus deformation curve of the functional spinal unit (FSU) is made up of the neutral zone, the elastic zone, and the plastic zone. What is the plastic zone of the curve believed to represent?

Explanation

DISCUSSION: Plastic deformation of viscoelastic tissues represents deformation of the soft tissues to the point of failure. The lining up of collagen fibers would be in the “toe region” of the curve, which, in the case of the FSU, would be mainly in the neutral zone. Elastin is a minor contributor to the composition of the ligaments and would be protected by the stiffer collagen fibers. The transition between flexion and extension occurs in the neutral zone, and reversible elongation occurs in the elastic zone.
REFERENCES: Fardon DF, Garfin SR, Abitbol J, et al (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 15-23.
Panjabi MM, White AA: Physical properties and functional biomechanics of the spine, in White AA, Panjabi MM: Clinical Biomechanics of the Spine, ed 2. Philadelphia, PA, JB Lippincott, 1990, pp 1-83.

Question 56

A 67-year-old woman has persistent anterior thigh and knee pain after undergoing total knee arthroplasty 1 year ago. Examination and radiographs reveal no problems in the knee, mild hip flexor weakness (grade 4+), and decreased sensation over the anterior thigh including and proximal to the incision. MRI of the lumbar spine will most likely reveal which of the following findings?

Explanation

DISCUSSION: Degenerative spondylolisthesis at L3-4 is the most likely diagnosis. This spondylolisthesis would result in foraminal stenosis affecting the third lumbar root and leading to anterior thigh and knee pain and hip flexor weakness. L4-5 spondylolisthesis would impinge on the L4 root in the foramen. Degenerative disk disease without hypertrophy is unlikely to have root impingement. Posterolateral herniations typically affect the inferior root and are less common in this age group.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Upper Saddle River, NJ, Prentice Hall, 1976, p 250.
Lauerman WC, Goldsmith ME: Spine, in Miller MD (ed): Review of Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 353-378.

Question 57

Which of the following types of intra-articular pathology is associated with lateral meniscal cysts? Review Topic

Explanation

Lateral meniscal cysts often arise from myxoid degeneration that progresses from the meniscal center and then outside the meniscus. Horizontal cleavage tears are commonly associated with the condition. Cysts of the lateral meniscus are most commonly the consequence of a tear located in the medial third. If the tear communicates with the joint, arthroscopic partial meniscectomy and cyst decompression are indicated. If the tear does not open into the joint, arthroscopy should be followed by an open cystectomy.

Question 58

An 82-year-old man has had episodic right thigh pain after undergoing a total hip arthroplasty 10 years ago. Initial postoperative radiographs are shown in Figures 26a and 26b, and current radiographs are shown in Figures 26c and 26d. What is the most likely cause of his pain?

Explanation

DISCUSSION: These radiographs are dominated by the subsidence of the femoral component. There is also evidence of polyethylene wear and femoral osteolysis in the region of the greater trochanter. There is no evidence of proximal (calcar) stress shielding, and there is a thick distal pedestal. Engh and associates defined two major signs of osseointegration - the absence of radiolucent lines around the porous-surfaced portion of the implant and new bone bridging the gap between the endosteal surface and the porous portion of the implant. Implant migration indicates failure of ingrowth. Osteolysis is a periprosthetic loss of bone secondary to particulate debris and it is often clinically silent unless it is accompanied by pathologic fracture. It is often globular. Acetabular loosening is based on radiolucent lines and implant migration. The current radiographs demonstrate subsidence of the stem with pedestal formation.
REFERENCES: Engh CA, Massin P, Suthers KE: Roentgenographic assessment of biologic fixation of porous-surface femoral components. Clin Orthop Relat Res 1990;257:107-128.
Engh CA, Hooten JP, Zettl-Schaffer KF, et al: Evaluation of bone ingrowth in proximally and extensively porous-coated anatomic medullary locking prostheses retrieved at autopsy. J Bone Joint Surg Am 1995;77:903-910.

Question 59

A 32-year-old man has posttraumatic arthritis after undergoing open reduction and internal fixation of a left acetabular fracture. A total hip arthroplasty is performed, and the radiograph is shown in Figure 18. What is the most common mode of failure leading to revision in this group of patients?

Explanation

DISCUSSION: Acetabular component loosening has been reported as the most common mode of failure following total hip arthroplasty in patients with a previous acetabular fracture. Following acetabular fracture and subsequent open reduction and internal fixation, the bone quality and vascularity are compromised, thus reducing the success rate of acetabular component cementless fixation.
REFERENCES: Jimenez ML, Tile M, Schenk RS: Total hip replacement after acetabular fracture. Orthop Clin 1997;28:435-446.
Romness DW, Lewallen DG: Total hip arthroplasty after fracture of the acetabulum: Long-term results. J Bone Joint Surg Br 1990;72:761-764.

Question 60

A biopsy of the involved physis in a patient with slipped capital femoral epiphysis (SCFE) would most likely reveal

Explanation

DISCUSSION: Vascular invasion, histologically similar to granulation tissue, has been noted between the columns in the zone of hypertrophy, leading to the theory of microtrauma as an etiology. SCFE is also associated with conditions that increase the height of the zone of hypertrophy, including the adolescent growth spurt and endocrinopathies. The perichondral ring has been shown to decrease in thickness with age. Normal undulations in the growth plate also decrease during this time, possibly further destabilizing the physis. Abnormal accumulations of proteoglycan have been reported.
REFERENCES: Chung SM, Batterman SC, Brighton CT: Shear strength of the human femoral capital epiphyseal plate. J Bone Joint Surg Am 1976;58:94-103.
Raney EM, Ogden JA: Slipped capital femoral epiphysis. Current Ortho 1995;9:111-116.

Question 61

Which of the following methods of treating a vertically oriented (eg, Pauwels III) femoral neck fracture is mechanically optimal?

Explanation

Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with nonoperative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than nonsmokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:

Question 62

A 25-year-old student sustains the injury shown in Figures 13a through 13c after falling off a curb. Initial management should consist of

Explanation

DISCUSSION: The radiographs reveal a fracture entering the 4-5 intermetatarsal articulation, consistent with a zone 2 injury. This classically is also referred to as a Jones fracture. The history and radiographic findings indicate this is an acute fracture, which guides management. A zone 1 fracture enters the fifth tarsometatarsal joint, and a zone 3 fracture is a proximal diaphyseal fracture distal to the 4-5 articulation. Initial management is usually nonsurgical and consists of non-weight-bearing in a short leg cast. This method has been shown to result in a better healing rate compared to weight bearing as tolerated.
REFERENCES: Rosenberg GA, Sterra JJ: Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg 2000;8:332-338.
Lawrence SJ, Botte MJ: Jones’ fracture and related fractures of the proximal fifth metatarsal. Foot Ankle 1993;14:358-365.

Question 63

An 82-year-old man is seen in consultation after being admitted for a fall from ground level. There was no loss of consciousness and the patient recalls striking his head and sustaining a hyperextension-type injury to the cervical spine. Examination reveals an 8-cm head laceration with only mild axial neck tenderness. He has generalized weakness throughout the upper extremities and maintained motor function of the lower extremities. There are no obvious sensory deficits, and the bulbocavernous reflex and deep tendon reflexes are maintained. What is the most appropriate diagnosis at this time? Review Topic

Explanation

Atlantoaxial rotatory instability
Syringomyelia
Spinal cord tumor
Dysraphism
Tethered cord
Early-onset scoliosis is associated with syringomyelia, spinal cord tumor, dysraphism, and tethered cord, and therefore they must be ruled out with a preoperative MRI. There is no association between early-onset scoliosis and atlantoaxial rotatory instability.
Early-onset scoliosis can be classified as idiopathic, neuromuscular, or congenital. For this patient without bony or neurologic abnormalities, it would likely be diagnosed as juvenile (bewteen ages 3 and 10 years) idiopathic scoliosis. Commonly associated spinal pathologies (even in patients with no radiographic or neurologic abnormalities) include syringomyelia, spinal cord tumor, dysraphism, tethered cord, and Arnold-Chiari malformation. Before considering any surgical intervention, such as a growing rod construct, these intra-spinal conditions must be ruled-out with an MRI of the spinal axis.
Gillingham et al. present a review of the etiology, diagnosis, and management of early-onset scoliosis. They cite other studies that demonstrated rates as high as 21% of patients with early-onset scoliosis and a normal neurologic exam having occult spinal pathology such as those mentioned above. They recommend MRI for patients with early-onset scoliosis measuring greater than 20° prior to any surgical intervention.
Figure A is a PA radiograph of a skeletally immature patient with a 90° right thoracic curve. Illustration A is an PA radiograph of the same patient after treatment with a growing-rod construct and correction of the scoliotic curve to 46°.
Incorrect Answers:

Question 64

If the structure marked by the tip of the probe in Figure 94 is repaired to the bony glenoid with suture anchors during an arthroscopic stabilization procedure, what is the most likely result? Review Topic

Explanation

The probe is on the middle glenohumeral ligament (MGHL), which, in this case, is a cord-like and robust structure, commonly known as a Buford complex. The space between the bony glenoid and the MGHL (in this case, a cord-like Buford complex) is a normal variant and should not be repaired or tightened to the bony glenoid with a soft-tissue anchor or other repair. If this structure is inadvertently repaired, the most common scenario is loss of external rotation with the arm at the side, as the MGHL/Buford complex becomes tight with the arm in this position. The loss of external rotation is more pronounced with the arm at the side than abducted at 90 degrees as the MGHL/Buford complex becomes tighter with the arm at the side than abducted.

Question 65

Figures 28a and 28b are the MR images of a 30-year-old man who has right shoulder pain and difficulty throwing a football. His history includes a shoulder injury from a skiing accident 2 years ago. He has not had a recent shoulder injury. Which shoulder motion is most likely to demonstrate weakness?

Explanation

DISCUSSION
The MR images reveal a large paralabral cyst extending into the spinoglenoid notch. This cyst can be expected to compress the branch of the suprascapular nerve to the infraspinatus. Compression of this branch could lead to weakness in the infraspinatus, which would manifest as external rotation weakness. Shoulder abduction would be unaffected because the axillary and main suprascapular nerves would be intact. Shoulder internal rotation and adduction would be unaffected because the subscapularis and pectoralis would be unaffected.

Question 66

A 70-year-old man underwent primary total knee arthroplasty 3 months ago. Figures 7a and 7b show the radiograph and clinical photograph following incision and drainage of the wound 1 week ago. Aspiration of the joint reveals methicillin-sensitive Staphylococcus aureus. What is the next most appropriate step in management?

Explanation

DISCUSSION: The overriding factor determining treatment in this case is the appearance of the surgical wound. Based on MacPhearson’s work, this “C” wound is best managed with two-stage exchange. The functional outcome is markedly diminished following a knee arthrodesis compared to revision knee arthroplasty.
REFERENCES: Harwin SF: The diagnosis and management of infected total knee replacement. Seminars Arthroplasty 2002;13:9-22.
Goldmann RT, Scuderi GR, Insall JN: 2-stage reimplantation for infected total knee replacement. Clin Orthop 1996;331:118-124.
Morrey BF, Westholm F, Schoifet S, Rand JA, Bryan RS: Long-term results of various treatment options for an infected total knee arthroplasty. Clin Orthop 1989;248:120-128.

Question 67

What mechanism is associated with the spontaneous resorption of herniated nucleus pulposus?

Explanation

DISCUSSION: Nonsurgical modalities remain the mainstay for treatment of herniated disks. Spontaneous resorption of herniated disks frequently is detected by MRI. Marked infiltration by macrophages and neovascularization are observed on histologic examination of herniated disks, and the resorption is believed to be related to this process. Many cytokines such as vascular endothelial growth factor, tumor necrosis factor-alpha, and metalloproteinases have been implicated in this process, but none has been found to be singularly responsible.
REFERENCES: Haro H, Kato T, Kamori H, et al: Vascular endothelial growth factor (VEGF)-induced angiogenesis in herniated disc resorption. J Orthop Res 2002;20:409-415.
Doita M, Kanatani T, Ozaki T, et al: Influence of macrophage infiltration of herniated disc tissue on the production of matrix metalloproteinases leading to disc resorption. Spine

2001;26:1522-1527.

Question 68

Which of the following findings best describes the effects of increasing conformity of a fixed tibial bearing component and femoral component in total knee arthroplasty?

Explanation

DISCUSSION: In the design of tibial and femoral components, a compromise must be made between contact stresses and constraint. Increased conformity increases constraint, limits motion, and potentially increases stress on the knee-cement interface. By increasing conformity, the surface area over which force is applied is increased, resulting in decreased peak contact stresses and decreased component wear rates.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 265-274.
Bartel DL, Rawlinson JJ, Burstein AH, Ranawat CS, Flynn WF Jr: Stresses in polyethylene components of contemporary total knee replacements. Clin Orthop 1995;317:76-82.

Question 69

A 54-year-old laborer has a 6-month history of lateral elbow pain. An elbow examination reveals full range of motion, tenderness over the lateral epicondyle, and pain with resisted wrist extension with the elbow in extension. Elbow radiograph findings are normal. You perform a steroid injection and the patient's symptoms are decreased 6 weeks later. One year after receiving the injection, this patient—when compared to a patient who did not have a steroid injection—is likely to

Explanation

EXPLANATION:
This patient has signs and symptoms of lateral epicondylitis. Treatments include various forms of physical therapy, iontophoresis, corticosteroid injection, nitroglycerin patch treatment, blood injections, prolotherapy, and surgical intervention. No single treatment is superior to other treatments for this common problem. Several studies have demonstrated a short-term decrease in symptoms following steroid injection (6 weeks) but an increased likelihood of persistent symptoms 1 year after treatment. Steroid injection at this site has not been associated with increased risk for tendon rupture or need for surgical intervention.

Question 70

A 14-year-old girl with polyarticular juvenile rheumatoid arthritis (JRA) has severe neck pain and reports the onset of urinary incontinence. A lateral radiograph and lateral tomogram of the cervical spine are shown in Figures 15a and 15b. An MRI scan of the upper cervical spine is shown in Figure 15c. Management should consist of

Explanation

DISCUSSION: The plain radiograph and tomogram show an abnormality of the upper cervical spine, with erosion of the dens. The MRI scan shows evidence of cord impingement. The cervical spine is frequently involved in polyarticular JRA. Stiffness and autofusion are commonly seen, but C1-2 instability can also occur secondary to synovitis and bony erosion. Basilar invagination is rare in JRA. There is no consensus regarding fusion in the asymptomatic patient. In patients with symptoms and neurologic signs, C1-2 posterior fusion is indicated.
REFERENCES: Fried JA, Athreya B, Gregg JR, Das M, Doughty R: The cervical spine in juvenile rheumatoid arthritis. Clin Orthop 1983;179:102-106.
Hensinger RN, DeVito PD, Ragsdale CG: Changes in the cervical spine in juvenile rheumatoid arthritis. J Bone Joint Surg Am 1986;68:189-198.

Question 71

Figures 1 and 2 show the intraoperative photographs obtained from a man who is undergoing open reduction and internal fixation of a fifth carpometacarpal joint fracture dislocation. If the structure marked with an arrow in Figure 2 is cut, the patient can expect to experience

Explanation

EXPLANATION:
The arrow in Figure 2 marks the dorsal sensory branch of the ulnar nerve. Injury to this nerve results in sensory loss of the dorsal ulnar palm and the dorsal small and ring finger digits. The dorsal sensory branch of the ulnar nerve exits the main ulnar nerve at an average distance of 8.3 cm from the proximal border of the pisiform. It becomes subcutaneous on the ulnar aspect of the forearm at an average distance of 5
cm from the proximal edge of the pisiform. It then travels dorsal to the extensor carpi ulnaris tendon to innervate the dorsal ulnar hand and the dorsal ring and small digits. Injuries to this nerve can occur from open and arthroscopic procedures (such as triangular fibrocartilage complex repair) as well as from procedures requiring percutaneous pinning. Care must be taken to identify and protect this nerve to avoid the complications of numbness and possible neuroma formation. The inability to extend the small finger would be caused by an injury to the extensor tendon(s) in this area, and the inability to abduct the small finger would require an injury to the abductor digiti minimi muscle/tendon unit or the ulnar nerve motor branch, which is located on the volar aspect of the proximal palm. Clawing of the small and ring fingers would be caused by absent intrinsic function due to an injury to the ulnar motor nerve branch located on the volar proximal palm.

Question 72

A 40-year-old man is thrown off his motorcycle and sustains an open Type IIIA fracture shown in Figure A. He is taken to the operating room for debridement and reamed intramedullary nailing with a 10mm diameter nail. He returns at 10 months with persistent pain at the fracture site with ambulation. Examination reveals healed wounds with no erythema, warmth or tenderness. Erythrocyte sedimentation rate and C-reactive protein levels are within normal limits. Radiographs taken at that time are shown in Figure B. What is the next best treatment step?

Explanation

This man had a mid-diaphyseal tibial fracture that has gone into nonunion. Reamed exchange nailing is indicated.
Tibial delayed union can be defined as lack of union from 20-26 weeks post-injury, while nonunion is defined as lack of healing at >9mths post-injury, or absence of progressive signs of healing on radiographs for 3 consecutive months. Persistent pain is a symptom of nonunion. ESR and CRP are performed to rule out infection.
Bhandari et al. performed a blinded, multicenter trial on 622 reamed tibial nails and 604 unreamed tibial nails. In closed fractures, patients in the unreamed nail group were at greater risk of primary events than the reamed nail group. There was no difference in groups for open fractures. Primary events were defined as bone-grafting, implant exchange/removal, dynamization, and debridement.
Hak reviewed aseptic tibial nonunion. They discuss exchanged reamed nailing for diaphyseal nonunion, adjunctive plate fixation for metaphyseal nonunion, and nail removal and plating for metadiaphyseal nonunion, external fixation for infected nonunion and distraction osteogenesis of defects.
Figure A shows a mid-diaphyseal tibial fracture Figure B shows nonunion following
IM nailing of the fracture. Illustration A shows union following exchange nailing with a larger 12mm diameter nail.
Incorrect Answers:

Question 73

An active 48-year-old woman has had progressive retrocalcaneal pain for the past 2 years. She reports that an injection into the retrocalcaneal bursa 3 weeks ago provided relief, but she now has swelling and weakness after tripping on the stairs 3 days ago. The Thompson test is positive. A radiograph is shown in Figure 36. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient’s long-standing symptoms and radiograph indicate a chronic insertional Achilles tendinopathy that has progressed to complete rupture. This situation is best treated with tendon debridement and repair, often requiring supplementation graft from the flexor hallucis longus. MRI could provide additional information on the quality of the Achilles tendon, but neither MRI nor ultrasound is necessary to make a diagnosis or determine the surgical indication. Conservative management will be unpredictable with a chronic degenerative tendon injury.
REFERENCES: Myerson MS, McGarvey W: Disorders of the Achilles tendon: Insertion and Achilles tendinitis. Instr Course Lect 1999;48:211-218.
Wilcox DK, Bohay DR, Anderson JG: Treatment of chronic Achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int 2000;21:1004-1010.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 253-277.

Question 74

Examination of a 30-year-old professional singer who has persistent neck and shoulder pain reveals a positive Hoffman’s sign and clonus because of anterior C2-3 cord compression. The MRI scan shown in Figure 11a and the cervical CT scan shown in Figure 11b reveal focal anterior cord compression at the C2-3 level. Which of the following surgical approaches would least affect her professional career?

Explanation

DISCUSSION: Protection of the superior laryngeal nerve is critical in a professional singer. The nerve is easily injured with retraction when using vertical extension of common anterior surgical approaches to gain exposure to the C2-3 level. McAfee and associates reported on 17 patients with C1-2 and C2-3 pathology. They used a modified submandibular approach as an anterior retropharyngeal exposure with modification of the superior extension of the Smith-Robinson technique that allows visualization of the superior laryngeal nerve and surrounding structures. No incidences of superior laryngeal nerve injury were recorded. The transoral approach should be avoided because of the high rate of infection and limited exposure.
REFERENCES: McAfee PC, Bohlman HH, Reilly LH Jr, Robinson RA, Southwick WO, Nachlas NE: The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surgery Am 1987;69:1371-1383.
Lu J, Ebraheim NA, Nadim Y, Huntoon M: Anterior approach to the cervical spine: Surgical anatomy. Orthopedics 2000;23:841-845.

Question 75

An 18-year-old collegiate football player injures his right shoulder during a tackle. He reports pain and numbness in the shoulder and numbness radiating to his fingers. His symptoms improve within 15 minutes and he has no residual symptoms. This condition is best known as Review Topic

Explanation

The condition described in this case is known as a stinger or burner. It is caused by stretching the upper trunk of the brachial plexus in the C5 and C6 nerve roots. The symptoms are temporary and last 15 to 20 minutes. There are no residual deficits, unless the patient has had multiple repetitive injuries. Once motor and sensory examination findings and reflexes have normalized, the athlete can return to play. Acute spinal cord injury may cause temporary complete paralysis in the upper and lower extremities with resolution of symptoms within 24 hours. Central cord syndrome affects the upper more than lower extermities and affects mostly elderly patients. Nerve root avulsions lead to permanent deficits and have a poor prognosis for return of function. Guillain-Barre syndrome is an autoimmune disease that presents as an ascending paralysis with weakness in the legs that spreads to the upper limbs and the face along with complete loss of deep tendon reflexes.

Question 76

Which of the following pieces of equipment currently offers the greatest opportunity for lowering the number of equestrian injuries? Review Topic

Explanation

Ball and associates reported that "horseback riding was more dangerous than motorcycle riding." In a 10-year study of major traumatic injuries, they reported that 151 (2%) of 7,941 trauma patients had major equestrian injuries (injury severity score
> or = 12). Injuries included the chest (54%), head (48%), abdomen (22%), and extremities (17%). Only 9% of riders wore helmets, and 64% believed the accident was preventable. The authors noted that "helmet and vest use will be targeted in future injury prevention strategies." In another study, Frankel and associates noted that helmet use was only documented in 34% of riders. Although orthopaedic injuries are common, knee pads, wrist guards, boots, and quick release stirrups would most likely have less impact on injury prevention.

Question 77

A 40 year-old-man was involved in a motor vehicle accident and sustained the pelvic injury seen in Figures 24a and 24b. Definitive management of the injury should consist of reduction by

Explanation

DISCUSSION: The radiograph reveals disruption of the symphysis pubis and a displaced left sacral fracture. A posterior injury with displacement of greater than 1 cm is unstable, and a sacral fracture is particularly unstable. Surgical stabilization is required for these unstable anterior and posterior injuries. External fixation provides little stability to an unstable posterior pelvic injury. Reduction and internal fixation of the symphysis pubis and sacral fracture will provide the most stable pelvis with the least resultant deformity and allow patient mobilization.
REFERENCES: Tile M: Management of pelvic ring injuries, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 168-202.
Kabak S, Halici M, Tuncel M, et al: Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): A report of 40 cases. J Orthop Trauma 2003;17:555-562.

Question 78

Figures 1 and 2 are the MRI scans of a 57-year-old man who dislocated his left shoulder after a fall while playing tennis. On examination, he had full passive shoulder range of motion, but he was unable to actively elevate his injured shoulder. Sensation was intact to light touch over the lateral shoulder. What is the most likely etiology of his shoulder weakness?

Explanation

This patient has a massive rotator cuff tear resulting in disruption of the transverse force couple between the subscapularis anteriorly and the infraspinatus and teres minor posteriorly. These muscles provide dynamic shoulder stability throughout active elevation, and loss of the force couple produces a pathologic increase in translation of the humeral head and decreased active abduction. Active shoulder elevation <90 degrees in the presence of full passive motion is termed pseudoparalysis. The most common neurologic deficit after shoulder dislocation is isolated injury to the axillary nerve. This patient's sensory examination suggests that the axillary nerve is intact. Cervical radiculopathy is less common after shoulder dislocation but has been reported. Conflicting evidence exists regarding the contribution of the long head of the biceps tendon to glenohumeral stability. One study reported minimal electromyographic activity in the biceps during ten basic shoulder motions.

Question 79

The most compelling clinical reason to convert a hip arthrodesis to a total hip arthroplasty is that the latter

Explanation

DISCUSSION: Studies show that degenerative arthritis of the spine associated with a hip arthrodesis can be decreased with conversion to a total hip arthroplasty. The pain associated with degenerative arthritis of the knee usually persists after arthrodesis take-down procedures and often requires total knee arthroplasty. Pain in the contralateral hip is not resolved by converting the arthrodesis. Improving range of motion of the hip and correcting a limb-length discrepancy are not good indications for take-down procedures.
REFERENCES: Strathy GM, Fitzgerald RH Jr: Total hip arthroplasty in the ankylosed hip: A ten-year follow-up. J Bone Joint Surg Am 1988;70:963-966.
Lubahn JD, Evarts CM, Feltner JB: Conversion of ankylosed hips to total hip arthroplasty. Clin Orthop 1980;153:146-152.

Question 80

Figures 1 and 2 are the radiographs of a 55-year-old woman homemaker with a 1-year history of insidious onset left wrist pain. She has failed conservative treatment and desires surgery. Her medical history is complicated by a smoking history of 1.5 packs of cigarettes per day. At the time of surgery her capitate articular surface is normal in appearance. The best procedure for her would be

Explanation

EXPLANATION:
This patient has Lichtman stage 3B Kienbock disease. She is 55 years old and is a "low-demand" patient; however, she is a heavy smoker. Based on her condition and her current smoking status, salvage treatment that does not require bone healing such as a proximal row carpectomy is likely the best treatment option. A radial shortening osteotomy and a capitate shortening osteotomy may be helpful in offloading the lunate, but both procedures require bone healing and are better options in earlier stages of Kienbock disease. A scaphoid excision and four-corner fusion is typically performed for scapholunate advanced collapse or scaphoid nonunion advanced collapse wrist arthritis and would not be recommended in this scenario, as the lunate is avascular.

Question 81

A 20-year-old woman sustained the closed injury shown in Figures 49a and 49b in a motor vehicle accident. Examination reveals that this is an isolated injury; however, she has a complete radial nerve palsy. Management should consist of

Explanation

DISCUSSION: Lacerated radial nerves are associated with open humeral fractures. All open humeral fractures with radial nerve palsy should be managed with radial nerve exploration and skeletal stabilization. Closed humeral fractures with associated radial nerve palsy usually have an intact nerve with neurapraxia. Most of these patients recover without surgical treatment. If the patient has multiple injuries, skeletal stabilization may be indicated to improve mobilization. For an isolated closed humeral fracture with a radial nerve palsy, the treatment of choice is splinting for 1 to 2 weeks, followed by a humeral fracture brace.
REFERENCES: Ring D, Chin K, Jupiter JB: Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am 2004;29:144-147.
Foster RJ, Swiontkowski MF, Bach AW, et al: Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am 1993;18:121-124.

Question 82

A 48-year-old man reports localized plantar forefoot pain. Examination reveals a discrete callus (intractable plantar keratosis) with well-localized tenderness beneath the second metatarsal head. The callus most likely lies beneath what structure?

Explanation

DISCUSSION: A discrete or focal callus is a response to excessive weight-bearing stress beneath the lateral (fibular) condyle of a lesser metatarsal head (most commonly second). The other structures generally have not been associated with a discrete callus.
REFERENCES: Coughlin MJ, Mann RA: Keratotic disorders of the plantar skin, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby-Year Book, 1993, pp 413-465.
Cracchiolo A: Surgical procedures of the lateral metatarsals, in Jahss MH (ed): Disorders of the Foot and Ankle, ed 2. Philadelphia, PA, WB Saunders, 1991, pp 1269-1283.

Question 83

What is the primary mechanism by which anabolic steroids increase muscle tissue? Review Topic

Explanation

Anabolic steroids have many effects on the body. Increased muscle mass occurs specifically through increased production of messenger RNA. HDL levels usually decrease but do not affect muscle. Also, steroids act to change the effects of cortisol to decrease catabolism.

Question 84

Osteochondritis dissecans of the capitellum is a source of elbow pain and most commonly occurs in what patient population?

Explanation

DISCUSSION: The etiology of osteochondritis dissecans of the capitellum is somewhat unclear. However, trauma has been implicated in this disease process. Gymnasts who load their upper extremities during tumbling and throwing athletes with repetitive trauma during the throwing motion are common patient subgroups in which osteochondritis dissecans of the elbow is seen. This often occurs in the adolescent age population.
REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520-523.
Takahara M, Ogino T, Fukushima S, et al: Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. Am J Sports Med 1999;27:728-732.

Question 85

Figure 25 shows the CT scan of an adult patient who has neck pain following a motor vehicle accident. What is the most likely diagnosis?

Explanation

DISCUSSION: If the atlanto-dens interval is greater than 3 mm in an adult, a transverse ligament rupture usually is suspected. The atlanto-dens interval can be seen with CT or in lateral radiographs of the upper cervical spine. Transverse ligament rupture can occur as an isolated entity or in association with an odontoid or a Jefferson’s fracture. Patients with this type of injury usually require fusion.
REFERENCES: Dickman CA, Greene KA, Sonntag VK: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;38:44-50.
Clark CR: The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 362-363.

Question 86

Which of the following complications is uniquely associated with an anterior approach to the lumbosacral junction?

Explanation

DISCUSSION: Retrograde ejaculation is a sequela of injury to the superior hypogastric plexus. The structure needs protection, especially during anterior exposure of the lumbosacral junction. The use of monopolar electrocautery should be avoided in this region. The ideal exposure starts with blunt dissection just to the medial aspect of the left common iliac vein, sweeping the prevertebral tissues toward the patient’s right side. Although erectile dysfunction can be seen after spinal surgery, it is not typically related to the surgical exposure because erectile function is regulated by parasympathetic fibers derived from the second, third, and fourth sacral segments that are deep in the pelvis and are not at risk with the anterior approach. The other choices are complications of spinal surgery but are not uniquely associated with an anterior L5-S1 exposure.
REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.
Watkins RG (ed): Surgical Approaches to the Spine, ed 1. New York, NY, Springer-Verlag, 1983, p 107.
An HS, Riley LH III: An Atlas of Surgery of the Spine. New York, NY, Lippincott Raven, 1998, p 263.

Question 87

006%-3.4 %. The typical skin flora includes staph and strep as well as P. acnes, which has a propensity for the shoulder. Because it is an anaerobic organism, cultures may only become positive after 7-21 days.

Explanation

Biological augmentation of rotator cuff with porcine small intestine xenograft Rotator cuff repair

Rotator cuff repair plus acromioplasty

Rotator cuff repair, remplissage procedure, bicep tenodesis and distal clavicle excision
This patient has an isolated supraspinatus rotator cuff tear with symptomatic weakness. The most appropriate treatment would be isolated rotator cuff repair.
The primary purpose of rotator cuff repair is to restore muscle function. Secondary outcomes include reduction of pain and prevention of irreversible cuff changes, specifically muscular atrophy. Non-operative treatment ( exercise, therapy and pain medications) are recommended for partial thickness tears. The indication of surgical repair includes, isolated supraspinatus weakness +/- pain
that correlates with MRI imaging of a respective full thickness tear. Routine acrominoplasty is not recommended in conjunction with rotator cuff repair, especially with no previous symptoms of impingement.
Pedowitz et al. developed clinical practice guidelines for the treatment of rotator cuff pathology. The strongest supporting evidence in current literature was given a grade of 'moderate' with four treatment recommendations. These were,
Exercise and non-steroidal anti-inflammatory drugs can be used to manage partial thickness tears,

Routine acromioplasty is not required the time of cuff repair,

Non-cross-linked, porcine small intestine submucosal xenograft patches should not be used to manage cuff tears, and

Surgeons can advise patients that workers' compensation status correlates with a less favorable outcome after rotator cuff surgery.
Illustration A shows the different shapes of rotator cuff tears. Incorrect Answers:

A 12-year-old baseball pitcher describes progressive worsening of medial elbow pain on
his throwing side. Examination reveals normal elbow range of motion. He is tender over the medial elbow to palpation. A dynamic ultrasound of his elbow shows no evidence of medial widening with valgus stress. His radiograph is shown in Figure A and an MRI is shown in Figure B. What is the most likely cause of his symptoms?

Displaced medial epicondyle avulsion fracture Medial apophysitis

Medial ulnar collateral ligament tear

Valgus extension overload with olecranon osteophytes Ulnar neuritis
The clinical presentation is consistent with Little League Elbow caused by medial apophysitis. Little League elbow is a general term explaining medial elbow pain in adolescent pitchers. The underlying pathology can include medial epicondyle stress fractures, avulsion fractures of the medial epicondyle, ulnar collateral ligament (UCL) injuries, or medial epicondyle apophysitis. In order to identify the underlying cause it is important to first rule out injury to the MCL by looking for medial widening on stress radiographs or dynamic ultrasound, or valgus instability on physical exam. Radiographs are useful to look for avulsion fractures or subtle physeal widening commonly seen with apophysitis.
Wei et al. obtained radiographs and magnetic resonance imaging on nine adolescent pitchers with a clinical diagnosis of Little League Elbow. They found radiographic findings in 4/9 and MRI findings in 6/9 patients. They emphasized that the MRI did not change management in any patients. Cain et al. review the different elbow conditions seen in throwing athletes. They emphasize the need to understand the underlying pathophysiology in order to treat and make appropriate changes to the biomechanics of the pitching technique.
Figure A shows an AP radiograph with slight widening of the apophysis, but no evidence of avulsion fracture. Figure B is an MRI which shows signal consistent with edema of the medial epicondyle apophysis.
Incorrect Answers:
The other responses are all typical throwing elbow conditions, but are much less common than apophysitis in the adolescent thrower.
What is the primary function of the structure labeled with an asterisk in Figure A?

Prevents inferior translation of the humerus with the arm by the side Provides internal rotation of the humerus

Prevents anterior translation of the humerus with the arm in 45 degrees of abduction Prevents anterior translation of the humerus with the arm in 90 degrees of abduction Provides supination of the forearm and elbow flexion
The labeled structure is the middle glenohumeral ligament (MGHL) of the shoulder. The primary function of the MGHL is to prevent anterior translation of the humeral head with the arm in 45-60 degrees of abduction.
This structure originates from the glenoid labrum and inserts medial to the lesser tuberosity running obliquely across the subscapularis. The size of the structure may be variable and there are recognized normal anatomic variants ( including a cord like MGHL in the Buford complex). It is important to be able to recognize the MGHL and differentiate this from the subscapularis, IGHL, SGHL, and other intraarticular structures in the shoulder to be able to perform effective and precise arthroscopic procedures.
Burkhart et al. describe the function of the glenohumeral ligaments in anterior shoulder instability, noting that the MGHL provides a restraint to anterior translation with the arm in 45-60 degrees of abduction.
Wang et al. discuss microdamage to the inferior glenohumeral ligament from a basic science perspective, indicating that over time it may stretch and compromise it's function in restraining humeral translation.
Figure A is an arthroscopic image of the intraarticular structures of the shoulder with an asterisk on the MGHL.
Incorrect Answers (these are labeled on Illustration A, with the exception of the subscapularis which is difficult to visualize):

In which of the following clinical circumstances would it be appropriate to eccentrically ream the anterior glenoid?

year-old male undergoing a shoulder arthroplasty due to rotator cuff arthropathy 65-year-old female with a glenoid retroversion of 13-degrees undergoing shoulder arthroplasty

year-old female with humeral anteversion of 13-degrees undergoing shoulder arthroplasty

year-old female with glenoid retroversion of 25-degrees undergoing shoulder arthroplasty

year-old male with significant glenoid bone stock deficiency and severe osteoarthritis
The surgeon should consider eccentrically reaming the anterior glenoid when performing a total shoulder arthroplasty on a patient with a retroverted glenoid due to posterior deficiency associated with osteoarthritic changes which is most consistent with answer choice #2.
Normal version of the glenoid is 0-3 degrees of retroversion, but when doing a total shoulder the goal should be to place the glenoid component in neutral to slight anteversion. Reaming the anterior glenoid to neutral is a technique to be considered by the operative surgeon when presented with a patient undergoing total shoulder arthroplasty with a retroverted glenoid, as failure to perform this step increases the chance for glenoid loosening. If reaming down the anterior glenoid will take away too much bone stock (down to the coracoid process), one may consider bone grafting the posterior glenoid. To perform a total shoulder arthroplasty patients will need a functioning rotator cuff and appropriate glenoid bone stock.
Clavert et al. performed cadaveric analysis to simulate glenoid retroversion of greater than 15 degrees and found that retroversion to this degree cannot be safely corrected with eccentric anterior reaming when using a glenoid component with peripheral pegs due to penetration into the glenoid vault.
Nowak et al. used 3D-CT models of patients with advanced shoulder osteoarthritis with varying degrees of glenoid retroversion and simulated glenoid resurfacing. They found that smaller size glenoid components may allow for greater version correction when using in-line pegged components, as they would be less likely to result in peg penetration.
Illustration A shows >25 degrees of glenoid retroversion seen by axial radiograph of the shoulder in a patient with advanced osteoarthritis. In this case, anterior glenoid reaming is not the correct answer and a posterior glenoid allograft reconstruction would be appropriate.
Incorrect Answers:

A 44-year-old left-hand dominant carpenter experienced immediate left elbow pain after trying to stop a heavy object from falling two days ago. Figure A shows a clinical image of the patient upon presentation. Physical exam shows full strength with wrist flexion, wrist extension, and pronation, but notable weakness with supination of the forearm. Sensory exam shows no deficits in the forearm or hand. There is a negative milking maneuver test and a positive hook test. Radiographs are shown in Figure B. What is the next most appropriate step in management?

Sling use as needed for comfort and progressive physical therapy Allograft reconstruction of the distal biceps tendon

Ulnar collateral ligament reconstruction Distal biceps tendon avulsion repair Brachioradialis and ECRB avulsion repair
Distal biceps tendon avulsion repair is the most appropriate next step in management.
Distal biceps tendon ruptures occur most commonly in middle-aged men and usually involve the dominant extremity. The mechanism of injury is usually a single traumatic event with eccentric force on the flexed elbow.
Sutton et al. authored a Level 5 review of distal biceps tendon ruptures. They discuss that nonsurgical management of distal biceps tears is appropriate in the low-demand or medically ill patient. Surgical repair improves elbow flexion strength by 30% and supination strength by 40% compared to nonoperative management.
O'Driscoll et al. conducted a Level 2 study examining the accuracy of the hook test for distal biceps rupture diagnosis. They found that the hook test was abnormal in 33 of 33 (100%) patients with complete biceps avulsions, and intact in 12 of 12 (100%) with partial detachments.
Figure A is a clinical image demonstrating ecchymosis in the distal arm and antecubital fossa. Figure B shows normal elbow radiographs. Illustration A shows a normal hook test with an intact distal biceps insertion.
Incorrect Answers:

Early reverse total shoulder designs (before the development of the Grammont-style prosthesis) had a high failure rate due to early loosening of the glenoid component. What biomechanical feature accounted for this problem?

Glenoid component did not have a neck Humeral component too horizontal Center of rotation too lateral

Center of rotation too anterior Center of rotation too inferior
Early reverse ball-and-socket designs failed because their center of rotation remained lateral to the scapula, which limited motion and produced excessive torque on the glenoid component, leading to early loosening. The first modern reverse prosthesis was designed by Paul Grammont. According to Boileau et al., Grammont's design "introduced 2 major innovations (1) a large glenoid hemisphere with no neck and (2) a small humeral cup almost horizontally oriented with a nonanatomic inclination of 155 degrees, covering less than half of the glenosphere. This design medializes the center of rotation compared to earlier versions which minimizes torque on the glenoid component. Furthermore, the humerus is lowered relative to the acromion, restoring and even increasing deltoid tension. The Grammont reverse prosthesis imposes a new biomechanical environment for the deltoid muscle to act, thus allowing it to compensate for the deficient rotator cuff muscles." According to Gerber, "moving the center of rotation more medial and distal as well as implanting a large glenoid hemisphere that articulates with a humeral cup in 155 degrees of valgus are the biomechanical keys to sometimes spectacular short- to midterm results".
Which of the following preoperative factors is a contraindication to total shoulder arthroplasty?

Passive external rotation less than 10 degrees Eccentric posterior glenoid erosion

A 2-cm full-thickness supraspinatus tendon tear Inflammatory arthritis

A preganglionic brachial plexus injury
A preganglionic brachial plexus palsy, otherwise known as a root avulsion injury, presents with a flail arm and has a poor prognosis for recovery of motor function. Patients with brachial plexus palsies are not candidates for total shoulder arthroplasty due to the substantial motor and sensory deficits associated with these injuries.
In contrast, patients with a preoperative loss of passive external rotation, posterior glenoid erosion, a reparable full-thickness rotator cuff tear isolated to the supraspinatus tendon, and inflammatory arthritis are not contraindicated for a total shoulder arthroplasty.
Iannotti et al. performed a Level I prospective study in 118 patients who underwent either a total shoulder arthroplasty or a shoulder hemiarthroplasty for primary osteoarthritis. The presence of a reparable full-thickness rotator cuff tear did not adversely affect outcomes in either group but rather provided better active external rotation in the cohort receiving total shoulder arthroplasties. The authors concluded that a reparable tear of supraspinatus is not a contraindication to the use of a glenoid component.
Norris et al. compared outcomes of total shoulder arthroplasty and hemiarthroplasty performed for primary osteoarthritis in 160 patients. There were no differences in postoperative pain, function, ASES scores, or range of motion between groups for patients with reparable rotator cuff tears. The authors concluded that minor thinning and small tears of the rotator cuff can be adequately addressed at the time of surgery without adversely affecting outcomes.
Illustration A is a cervical T2 axial MRI which shows a cervical root avulsion, a form of preganglionic brachial plexus injury. Notice the perineural hyperintensity.
Incorrect Answers:

A 42-year-old male sustains a flail chest injury and subsequently undergoes operative stabilization of his chest wall. At first follow-up, the inferior angle of his ipsilateral scapula translates medially with any attempt at overhead activity. Injury to which of the following structures would cause this abnormality?

Spinal accessory nerve C8 and T1 nerve roots

Upper and lower subscapular nerves Thoracodorsal nerve

Long thoracic nerve
The clinical vignette describes medial scapular winging, which is seen after injury to the long thoracic nerve.
Medial scapular winging due to a long thoracic nerve palsy can be seen after repetitive stretching in athletes, with direct compression injury, or even iatrogenically during surgical procedures to the lateral thorax. Injury to the long thoracic nerve will eliminate the function of the serratus anterior,
which acts to protract the scapula laterally and upward and stabilize the vertebral border of scapula. This results in upper extremity weakness in forward elevation or abduction as the scapula is not stabilized against the thorax.
Meininger et al. report that lesions of the long thoracic nerve and spinal accessory nerves are the most common cause of scapular winging, although numerous underlying etiologies have been described. They report patients describe diffuse neck pain, shoulder girdle discomfort, upper back pain, and weakness with abduction and overhead activities. They also report that most cases are treated nonsurgically.
Wiater et al. review injuries to the spinal accessory nerve which causes dysfunction of the trapezius and subsequent lateral scapular winging. They note that the superficial course of the spinal accessory nerve in the posterior cervical triangle makes it susceptible to injury, and iatrogenic injury to the nerve after a surgical procedure is one of the most common causes of trapezius palsy. Most injuries are treated nonoperatively, but the Eden-Lange procedure, in which the insertions of the levator scapulae, rhomboideus minor, and rhomboideus major muscles are transferred, relieves pain, corrects deformity, and improves function in patients with irreparable injury to the spinal accessory nerve.
Illustration A shows a clinical photo of medial scapular winging, while illustration B shows a clinical photo of lateral scapular winging. Illustration C shows the long thoracic nerve during a rib fixation procedure, with the nerve sitting directly on top of the serratus anterior. The trapezius is overlying the scapula at the bottom of the photo, and the patient's head is to the right of the photo. Incorrect Answers:

A patient sustains a distal biceps brachii tendon rupture. If treated non-operatively, the greatest loss of strength would be seen with which activity?

Forearm supination Forearm pronation

Elbow flexion

Shoulder forward flexion Shoulder internal rotation
While both elbow flexion and forearm supination strength are affected, there is a greater percentage loss of supination strength. Patients may complain of weakness and fatigue with rotational activities such as using a screwdriver. The primary elbow flexor is actually the brachialis, and therefore less weakness in flexion is reported.
Patterson reviewed distal biceps ruptures and found nonsurgical treatments had 21 55% loss of supination strength and 8 36% loss of flexion strength.
Klonz reviewed anatomic and non-anatomic repairs and found better results with anatomic repairs with 91% return of supination strength and 96% return of flexion strength. Supination strength after nonanatomic repair did not improve in 4 of 8 patients (42%-56% of the uninjured arm).
A 27-year-old right hand dominant construction worker falls off a scaffold onto his outstretched arm. Figure A exhibits the radiograph taken at a local emergency room.
Following treatment, he is placed in a sling and follows up at your office two weeks later. He complains of a feeling that his arm is going to 'pop out'. Which specific physical examination finding is likely to be present?

Hornblower's Test Jobe's Test

Apprehension Sign with shoulder abducted and externally rotated Speed's Test

Kim's Test
The patient suffered a posterior shoulder dislocation, likely injuring the posterior capsule and/or labrum. Out of all the answer choices, Kim's test assesses posterior structures. Thus, Kim's test is the physical examination finding most likely to be present.
Posterior dislocations occur less frequently than anterior dislocations, and are often missed. Following closed reduction, persistent instability can occur, usually associated with posterior capsular or labral pathology. Posteriorly directed provocative maneuvers, such as the Kim test can be positive.
Robinson et al. performed an epidemiologic analysis on 120 posterior dislocations. Recurrent instability occurred at a rate of 17.7%. Risk factors for recurrent instability included age less than 40-years-old, dislocation during seizure, and a large reverse Hill-sachs (>1.5 cm3). Kim et al. describe the Kim lesion, a separation between the posteroinferior labrum and the articular cartilage without complete detachment of the labrum, which cause persistent posterior instability.
Figure A depicts a posterior dislocation on xray. Illustration A depicts the Kim test, which is performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45° forward flexion while simultaneously applying axial load on the elbow and posterior-inferior force on the upper humerus. The test is positive when there is pain. Video 1 depicts the proper way to perform a Kim Test.
Incorrect answers:

A 27-year-old male bodybuilder presents to the office with vague, deep shoulder pain and weakness with his bench press. His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. Radiographs are normal, and an MRI arthrogram is shown in Figure A. Which of the following is the most likely etiology of his complaints?

Pectoralis major rupture Supraspinatus partial thickness tear SLAP lesion

Tendonitis of the long head of the biceps Posterior labral tear
The clinical presentation and MRI are consistent with a Posterior labral tear.
Posterior labral tears are commonly seen in individuals that have repeated posteriorly-directed stress across their glenohumeral joint (football linemen, bodybuilders). These patients will often present with ill-described pain deep in their shoulder joint, along with decreases in shoulder strength. Focused shoulder examinations, such as the Jahnke Jerk Test or Push-pull test, can elicit pain from posterior labral tears; however, the sensitivity and specificity of these tests remain under question.
Mair et al. reviewed the outcome of posterior labral injuries in nine athletes who underwent arthroscopic repair with a bioabsorbable tack after failure of conservative management; all were
able to return to contact sports. They note that posteriorly applied forces can result in a shear-type vector that can cause posterior labral tears without capsular injury.
Bradley et al. reviewed 91 athletes with unidirectional recurrent posterior shoulder instability that were treated with an arthroscopic posterior capsulolabral reconstruction. They found that significant improvements in stability, pain, and function at a mean of 27 months postoperatively. Eightynine percent of the patients were able to return to their sport.
Figure A shows an axial MRI arthrogram of the shoulder with a posterior labral tear and an associated paralabral cyst. Illustration A is another axial shoulder MRI arthrogram cut showing a posterior labral tear (red arrow) and an associated paralabral cyst (yellow arrows).
Incorrect Answers:

A patient sustains a full thickness tear of their teres minor. Which of the following test/signs would most likely be positive in this patient?

Jobe's test Belly press test

Internal rotation lag sign Hornblower's sign Hawkin's sign
Hornblower's test is completed by asking the patient to hold their shoulder in 90 degrees of abduction and 90 degrees of external rotation. The test is positive if the arm falls into internal rotation or they are unable to actively externally rotate against resistance. This suggests teres minor pathology.
There are various tests/signs used by clinicians to detect rotator cuff pathology. The teres minor is innervated by the axillary nerve and functions to externally rotate the humerus. The hornblower's test/sign has various descriptions, but all act to determine external rotation weakness. In addition to being sensitive and specific for teres minor pathology, it can also be positive with posterior supraspinatus tears.
Walch et al. review 54 patients that underwent repair of combined supraspinatus and infraspinatus rotator-cuff tears. They found that the hornblower's sign was highly sensitive and specific for irreparable degeneration of the teres minor, while the dropping-sign was highly sensitive and specific for irreparable degeneration of the infraspinatus.
Hertel et al. prospectively review 100 patients with painful shoulders and impingement syndrome. They compared various lag signs (ERLS-external rotation lag sign, IRLS-internal rotation lag sign, drop sign) to the Jobe and lift-off signs. The ERLS was less sensitive but more specific than the
Jobe sign for the supraspinatus/infraspinatus. The drop sign was the least sensitive but was as specific as the ERLS. The IRLS was as specific but more sensitive than the lift-off sign for subscapularis tears.
Illustration A shows another variation of the hornblower's sign as originally desbribed by Arthui et

positive if the patient is unable to do this without abducting the affected arm and demonstrates the difficulty in raising the hand to the mouth in the absence of external rotation of the shoulder. The video provided shows how to perform both variations of the hornblower's test.
Incorrect Answers:

Reverse total shoulder arthroplasty combined with latissimus dorsi transfer would be
most appropriate for which of the following patients?
year-old male with post-traumatic shoulder arthritis after a four-part proximal humerus fracture with no motor dysfunction

year-old male with grade 4 shoulder arthritis with severe deltoid muscle dysfunction secondary to a stroke

year-old female with significant rotator cuff arthropathy, a negative Hornblower sign and less than 5 degrees of external rotation lag

year-old female with pseudoparesis of anterior elevation and external rotation, narrowing of gleno-humeral joint and acetabularization of the acromion

year-old male with grade 4 shoulder arthritis and an isolated supraspinatus tear
Reverse total shoulder arthroplasty combined with latissimus dorsi transfer would be most appropriate in a patient with pseudoparesis of anterior elevation and external rotation, in the setting of shoulder arthritis (narrowing of glenohumeral joint and acetabularization of the acromion).
Combining a latissimus dorsi tendon transfers with reverse total shoulder arthroplasty (R-TSA) helps to restore control of active external rotation. Dysfunction with external rotation can be determined clinically with external rotation lag sign, a positive Hornblower's sign, and radiographically with fatty degeneration of the teres minor classified as stage 2 or greater according to the system of Goutallier et al. or Fuchs et al.
Gerber et al. found that R-TSA with combined lat dorsi transfer yielded minimal improvements in external rotation ROM (13 deg to 19 deg) compared to increases in shoulder ROM in flexion (94 deg to 137 deg) and abduction (87 deg to 145 deg), with this procedure.
Boileau et al. examined 17 consecutive patients treated with reverse shoulder arthroplasty and latissimus dorsi and teres major transfer (L'Episcopo). They found that external rotation increased from -21 degrees to 13 degrees (+34 degrees ). They recommend transferring both the LD and TM, rather than the LD alone as it results in better active external rotation.
Illustration A is a radiograph showing a right reverse total shoulder replacement. Illustration B shows a cadaveric image of the positioning of the latissimus dorsi tendon transfer prior to implantation of the reverse total shoulder components.
Incorrect Answers

Figure A and B are MRI images of a 42-year-old male with symptoms of right shoulder neuropathy. If this patient has an abnormality detected on EMG and nerve conduction testing, which of the following nerves is most likely to be involved?

Subscapular nerve Axillary nerve Musculocutaneous nerve Suprascapular nerve Long thoracic nerve
This patient is presenting with suprascapular nerve compression secondary to a spinoglenoid cyst. Injuries of the posterior shoulder joint capsule or posterior-superior labrum can result in spinoglenoid cysts. They may lead to suprascapular nerve palsy.
Patients will present with characteristic findings of external rotation
( infraspinatus) weakness when the cyst is isolated in the spinoglenoid notch. If the cyst is located in the suprascapular notch, both external rotation weakness and abduction (supraspinatus) weakness will be present. Electromyography and MRI are the investigations of choice in depicting the etiology of this mononeuropathy.
Piatt et al. found posterosuperior labral tears in 65/73 patients who had spinoglenoid notch cysts. All patients presented with should pain and weakness. Patients undergoing surgical intervention by drainage or excision +/- arthroscopic labral repair had a better outcome than non-operative care.
Westerheide et al. reported fourteen patients who underwent arthroscopic decompression of ganglion cysts associated with suprascapular neuropathy. All patients had a labral tear intraoperatively with arthroscopic drainage and labral repair. There was not recurrence at an average of 51 months of followup.
Piasecki et al. reviewed suprascapular neuropathy. Causes include:nerve entrapment along this path, particularly at the vulnerable suprascapular and spinoglenoid notch, as well as extrinsic compression by soft-tissue masses.
Figures A is a coronal MRI showing a large hyperintense mass medial to the glenoid articulation. Figure B shows an axial MRI of the lesion posterior to the glenoid. Illustration A shows a diagram of the posterior right shoulder. The suprascapular nerve can be seen traveling through the spinoglenoid notch. Incorrect Answers:

A 12-year-old right-hand-dominant pitcher presents with progressive right shoulder pain. He is now unable to pitch. He is tender to palpation over the lateral shoulder and has pain with rotation. An AP radiograph of the affected shoulder is shown in Figures A and a contralateral radiograph is shown in Figure B. What is the most likely diagnosis?

Septic arthritis of the shoulder SLAP tear

External impingement Internal impingement

proximal humerus. Patients may report a recent increase in pitching regimen. On examination, there is focal tenderness at the level of the physis. Treatment focuses on rest, physical therapy and a progressive throwing program. Pitching is often stopped for 2-3 months during rehabilitation.
Chen et al. review shoulder and elbow injuries in the young athlete. Little
Leaguer's shoulder results from epiphyseal lysis secondary to microtrauma. Pain over the anterolateral shoulder may be elicited on examination. The mainstay of treatment is 2-3 months of rest and return to pitching via a progressive throwing program.

Mcfarland et al. review techniques to prevent injuries in the throwing athletes. They note that overuse injures can be avoided when appropriate throwing mechanics are enforced and pitch counts are li
physeal widening noted especially when compared to the contralateral normal pediatric shoulder view seen in Figure B.
Incorrect Answers:
A 35-year-old carpenter has pain in the antecubital fossa that is worse with turning a screwdriver. He has undergone non-operative treatment for 6 months without relief. On physical examination his hook test is normal and there is pain and weakness with resisted supination. Radiographs are shown in Figures A-C. A MRI of the right elbow is shown in Figure D. The next most appropriate treatment is?

Exploration of the radial tunnel Superficial radial neurectomy

Detachment and repair of the biceps tendon Transfer of the biceps to the brachialis EMG with nerve conduction study
While complete trauamtic rupture of the distal biceps is more common, partial tears have been reported in the literature. The most common presentation is pain in the antecubital fossa worse with resisted supination.
Conservative management consists of NS

Transfer to the brachialis improves flexion strength but not supination.
Ramsey et al present a review article on distal biceps tendon injuries. They state that the most successful management of partial distal biceps tears that have failed conservative management is to surgically treat it like a complete rupture with release and surgical reattachment of the distal biceps to the radial tuberosity.
Figures A-C are normal radiographs of the elbow. Figure D is a crossreferenced axial and coronal T2 MRI that demonstrates increased signal and partial distal biceps tendon tearing. Illustration C shows the resected region of distal biceps tendon in the same patient and had an excellent functional outcome following distal biceps release and surgical reattachment with 2 double-loaded suture anchors.
Video V demonstrates The hook test for detecting complete distal biceps tendon avulsions.

A 49-year-old man sustains a dislocation of his left elbow that is successfully reduced and splinted. He misses his scheduled follow-up appointments and returns 6 weeks later. He is immediately enrolled in a course of vigorous physical therapy. At a repeat visit at 6 months, examination reveals that he lacks 40 degrees of elbow extension, and has flexion to 80 degrees. He is taken to the operating room for surgical release. Figures A and B are diagrams depicting the ligamentous attachments about the elbow. To restore elbow flexion, in addition to releasing the articular capsule, which ligament should be released?

Ligament A Ligament B Ligament C Ligament D Ligament E
In addition to capsular release, the posterior band of the medial collateral ligament (MCL) should be released.
The posterior band of the MCL is attached dorsal to the axis of rotation and has greater variation in length. It increases in length by 9 mm between 60° and 120° of flexion. Posterior band contracture leads to loss of elbow flexion. In contrast, the anterior band of the MCL (AMCL) maintains a constant length ( isometric) throughout the entire arc of movement. Anterior capsule contracture leads to loss of extension.
Wada et al. treated 14 elbows with post traumatic contracture. Through a medial incision, the ulnar nerve was freed and the posterior band and posteromedial joint capsule were excised. Mean flexion increased from 89° preop to 127° postop. Anterior capsulectomy was performed for limited extension.
Morrey et al. studied structures providing stability about the elbow. They found that the anterior capsule stabilizes the elbow to varus-valgus stress in extension, not in flexion. The anterior band of the MCL is a primary stabilizer, especially in flexion.
Figures A and B are medial and lateral illustrations of the elbow, respectively, depicting the ligamentous attachments. Illustrations A and B are radiographs are 3D CT reconstruction images of the left elbow, respectively, showing heterotopic ossification around the posterior band of the MCL.
Incorrect Answers:

A 23-year-old male sustains a dislocation of his elbow that was successfully closed reduced in the emergency room. 3 months later, the patient presents with pain and a catching sensation in his elbow. On physical exam, he is noted to have a positive lateral pivot-shift test. Incompetence of which of the following ligaments in Figure A is most commonly associated with his condition?

A B C D E
The patient is presenting with symptoms and physical exam consistent with posterolateral rotatory instability. Injury to the lateral ulnar collateral ligament
( LUCL), labeled C in Figure A, allows an abnormal external rotation
( supination) of the ulna on the humerus. This results in posterolateral rotatory instability. Posterolateral rotatory instability often presents as pain and recurrent clicking, snapping, clunking, or locking of the elbow. It should be noted that frank dislocations are not the most common presenting symptom. The physical exam is usually benign except for a positive lateral pivot-shift test or posterolateral rotatory drawer test. While injury to the LUCL is thought to be the primary pathology, other ligamentous stabilizers of the elbow may play a role.
Mehta et al. review posterolateral rotatory instability of the elbow. They state the instability usually results from an elbow dislocation with subsequent failure to heal of the ligamentous structures.
Patients with recurrent instability often require surgical intervention, as bracing is typically cumbersome and ineffective.
The video provided shows how to perform the lateral pivot-shift test. The patient is placed in the supine postion with forearm overhead and elbow extended. The elbow is then supinated with force and flexed to >40° while a valgus load applied. A positive result is palpable / visible clunk as the ulna and radius reduce suddenly. Illustration A shows the posterolateral rotatory drawer test.
External rotation and posterior forces are applied to the forearm attempting to sublux the radius posterior to the capitellum.
Incorrect Answers:

Figure A is the MR image of the left shoulder of an active 47year-old painter who has been experiencing shoulder pain for 9 months. In addition to the finding shown in Figure A, MRI examination of the intra-articular portion of the biceps tendon shows fraying greater than 50%. He has not obtained relief from an 8 month course of non-operative management including non-steroidal antiinflammatory medications, physical therapy and corticosteroid injection. What is the best next step in treatment?

New course of physical therapy

Activity shutdown with 6 weeks sling immobilization

Arthroscopic superior labrum anterior to posterior (SLAP) tear repair Arthroscopic debridement and possible biceps tenotomy versus tenodesis

Arthroscopic rotator cuff repair and acromioplasty
This patient has a Type II SLAP lesion. These should only rarely be repaired in patients older than 40 years of age. If a source of pain refractory to nonoperative management, biceps tenotomy or tenodesis should be considered.
SLAP repair for Type II SLAP lesions is a procedure that has enjoyed a high success rate in young patients. These are generally not indicated for repair in patients greater than 40 years of age due to high rate of stiffness postoperatively. A subset of patients continue to do poorly after SLAP repair. Poor range of motion and the development of post-surgical adhesive capsulitis is often an etiology for poor results. Arthrofibrosis recalcitrant to diligent therapy over many months can be treated with arthroscopic capsular release. This is predicated on failure of a dedicated course of physical therapy as part of a non-operative management course lasting greater than six months. As the propensity for stiffness increases with age, consideration should be treated with SLAP tear debridement and biceps tenotomy or tenodesis in patients greater than 40 years old. Tenotomy or tenodesis, however, can be effective at providing pain relief in the presence of proximal biceps tendon pathology.
Katz et al. reviewed 34 patients who presented to their group for management of failed SLAP repair. 50% were Worker's Compensation cases. The mean age at the time of initial SLAP repair was 43 years. They treated these patients conservatively initially followed by revision surgery in 21 cases. All completed a course of physical therapy initially. They concluded that once a patient has failed SLAP repair, there is a high chance of further conservative treatment failing. Although revision surgery improves outcomes, 32% will continue to have a "suboptimal" result. Holloway et al. reviewed 50 patients who underwent arthroscopic capsular release for adhesive capsulitis, comparing three groups: (1) post-surgical; (2) post-fracture; and (3) idiopathic adhesive capsulitis. All patients had completed supervised physical therapy and a home exercise program for at least one year. They concluded that arthroscopic capsular release improved range of motion equally for all three groups but patients in the post-surgical group had poorer subjective pain, function and satisfaction scores.
Figure A is an MRI showing a Type II SLAP tear. Illustration A shows the classification of SLAP lesions.
Incorrect Answers:

A 30-year-old man undergoes arthroscopic Bankart repair for recurrent anterior dislocation. He continues to experience instability postoperatively. Examination reveals a positive apprehension test. Radiographs of both shoulders are seen in Figure A. CT scan of his left shoulder is seen in Figure B. What is the best treatment option?

Bankart repair

Humeral head bone augmentation Remplissage

Coracoid autograft Connolly procedure
This patient has anterior glenoid bone deficiency (inverted pear glenoid) from a large bony Bankart lesion that was not adequately addressed in the index procedure. This is best treated with bony augmentation using the Latarjet vascularized coracoid transfer.
Patients with glenoid bone defects >20-30% have a high recurrence rate
(>60%) after Bankart repair alone. Bone grafting is necessary to offer containment. Autograft options include coracoid transfer (such as the Latarjet procedure which extends the articular arc and creates a conjoined tendon sling) and iliac crest bone grafting.
Burkhart et al. addressed glenohumeral bone defects. They advise that significant bone deficits cannot be adequately addressed via arthroscopic Bankart repair alone. The Latarjet transfer creates an extra-articular platform to extend the articular arc of the glenoid.
Hantes et al. assessed Latarjet repairs using CT. They found that there is almost complete repair of a 25% to 30% glenoid defect when using the Latarjet procedure.
Figure A comprises comparison Bernageau view glenoid profile radiographs of both shoulders.
Figure B is a 3D reconstruction CT with showing glenoid bone deficiency (inverted pear deformity) with a large bony Bankart lesion. Illustration A shows the method of obtaining a Bernageau glenoid profile view. Illustration B shows the "cliff sign" of anterior glenoid bone loss.
Illustration C depicts the Latarjet procedure. Illustration D depicts reduction in the articular arc with anterior glenoid loss.
Incorrect Answers:

Figure A shows an arthroscopic picture of a 62-year-old male undergoing repair of a torn subscapularis tendon. In the image shown, G represents the glenoid, H represents the humeral head, and the dotted line represents the superolateral border of the subscapularis tendon. Which two ligaments form the structure marked with the asterisk?

Inferior and middle glenohumeral ligaments Middle and superior glenohumeral ligaments Coracohumeral and coracoacromial ligaments

Coracohumeral and superior glenohumeral ligaments Superior and inferior glenohumeral ligaments
The coracohumeral and superior glenohumeral ligaments form a complex that marks the superolateral margin of the subscapularis tendon.
In chronic or degenerative tears, the subscapularis will often retract medially and become scarred to the deltoid fascia. This makes identification difficult during arthroscopic repair. The coracohumeral and superior glenohumeral ligaments form a complex that inserts on the superolateral margin of the subscapularis. This "comma sign" can usually be identified during arthroscopic repair making identification of the subscapularis tendon an easier task.
Burkhart and Brady present surgical pearls for arthroscopic repairs of the subscapularis. Amongst other things, they state the subscapularis is almost always repairable with proper mobilization, but an Achilles tendon allograft or a subcoracoid pectoralis major transfer may be used for a severely degenerated subscapularis.
Lo and Burkhart describe the comma sign for repair of chronic subscapularis tears. They describe how the superior glenohumeral ligament/coracohumeral ligament complex and subscapularis tendon are intimately associated, and often tear off the humerus while remaining attached to each other. This complex, when torn, forms a "comma sign," that marks the superior and lateral margins of the subscapularis tendon.
Illustration A shows why the convergence of the superior glenohumeral and coracohumeral ligaments on the superolateral border of the subscapularis is referred to as the "comma sign." Incorrect Answers:

A 52-year-old man sustained the left elbow injury shown in Figure A while playing basketball 2.5 months ago. He underwent the procedure shown in Figure B. Post-operatively he was mobilized in a hinged brace. On examination today, his arc of elbow flexion is 75 degrees with loss of 45 degrees of full extension. His Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure score is 45 points. What initial treatment option will likely provide the greatest improvement in this patients DASH score and functional range of motion?

Self-directed exercise therapy Supervised exercise therapy

Supervised exercise therapy with static progressive elbow splinting Continuous passive motion device

Closed manipulation under anesthesia
The clinical presentation is consistent with post-traumatic elbow stiffness following an elbow fracture-dislocation. Supervised exercise therapy with static elbow splinting over a 6 month period
has shown to have a significant improvement on DASH scores and functional range of motion (ROM) in patients with post-traumatic elbow stiffness.
Post-traumatic elbow stiffness is often difficult to manage. The ultimate goal of treatment is to restore a functional range of elbow motion (30° to 130°). Nonoperative modalities are considered the first-line of treatment. Aggressive physical therapy has traditionally been advocated. However, the use of static progressive elbow splinting with a turnbuckle, alongside aggressive physical therapy, has shown to provide better functional outcomes. Treatment is usually maintained over a period of 6-12 months. Surgery is considered when nonoperative therapy fails.
Doornberg et al. looked at a retrospective case series of 29 patients with posttraumatic elbow stiffness. They showed that static progressive splinting can help gain additional motion when standard exercises fail to produce additional improvements.
Lindenhovius et al. randomized sixty-six patients with post-traumatic elbow stiffness into static progressive elbow splint therapy or dynamic elbow splinting over a 12 month period. There was no significant difference in outcomes between treatment modalities. ROM increased by 40° vs. 39° at six months, respectively. DASH scores improved from 50 vs 45 at enrollment to 32 vs. 25 at six months, respectively.
Figure A shows a posterior elbow dislocation with an associated medial epicondyle fracture. Figure B shows ORIF of the fracture seen in Figure A. Illustration A shows a static progressive turnbuckle elbow splint used for posttraumatic elbow stiffness.
Incorrect Answers:
tissues, causing hemarthrosis and additional fibrosis in the joint.

A 25-year-old right-hand baseball pitcher presents with persistent shoulder pain for the past several months in his dominant throwing arm. On physical examination, he is found to have full arc of motion with the exception of an internal rotation deficit of 30 degrees compared to his contralateral side. He is asked to complete the exercise shown in the video in Figure V. This form of rehabilitation is meant to address pathology in which anatomic structure?

Superior glenohumeral ligament Middle glenohumeral ligament

Anterior band of the inferior glenohumeral ligament Superior band of the inferior glenohumeral ligament

Posterior band of the inferior glenohumeral ligament

tissues in patients demonstrating symptoms of internal impingement. The sleeper stretch helps to address posterior tightness and the only posterior structure listed in the responses is the posterior band of the inferior glenohumeral ligament (posterior IGHL).
Internal impingement is a significant cause of pain in throwing athletes. It results from impingement of the articular undersurface of the posterior supraspinatus against the posteriorsuperior glenoid.
This is thought to be secondary to tightness in the posterior soft tissues including the capsule and posterior band of the IGHL. The mainstay of non-operative management is posterior capsular stretching with the sleeper stretches and cross-body adduction stretches. Heyworth et al. review the etiology, diagnosis and management of internal impingement of the shoulder. They note that repetitive contact between greater tuberosity and glenoid rim posterosuperiorly lead to impingement of the posterior rotator cuff and labrum. This occurs when the arm is externally rotated and abducted.
Tyler et al. reviewed the effects of posterior capsular stretching on alleviating symptoms in patients with internal impingement. Twenty-

Figure V is a video that demonstrates the sleeper stretch to address tightness of the posterior soft tissues. The arm is forward flexed 90 degrees and the patient lies on his side in order to stabilize the scapula while the arm is internally rotated. Illustration A depicts the sleeper stretch.
Incorrect Answers:
not the focus of the sleeper stretch.

A 28-year-old professional baseball pitcher sustains a complete rupture of his ulnar collateral ligament. He is neurovascularly intact on exam. Which of the following surgical reconstruction techniques has been shown to result in the lowest complication rate and best patient outcome?

Splitting of flexor-pronator mass, figure-of-8 graft fixation. Splitting of flexor-pronator mass, docking graft fixation.

Splitting of flexor-pronator mass, docking graft fixation, ulnar nerve transposition. Detachment of flexor-pronator mass, figure-of-8 graft fixation, ulnar nerve transposition.

Detachment of flexor-pronator mass, docking graft fixation, ulnar nerve transposition.
Ulnar collateral ligament (UCL) reconstruction using a flexor-pronator musclesplitting approach and a docking graft fixation technique are associated with the lowest complication rate and best patient outcomes.
Vitale et al. performed a systematic review of retrospective cohort studies evaluating UCL reconstruction techniques in overhead athletes. They demonstrated that the flexor-pronator musclesplitting approach was associated with better outcomes than detachment of the flexorpronator mass, had a lower rate of postoperative ulnar neuropathy, and a lower overal complication rate. They also found fixation of the graft utilizing the docking technique was associated with better outcomes than the figure-of-8 technique. Abandoning the obligatory ulnar nerve transposition was associated with improved patient outcomes (89% vs. 75%) and a lower rate of postoperative ulnar neuropathy (4% vs. 9%).
Rettig et al performed a case series review of 31 overhead throwing athletes with ulnar collateral ligament injuries managed nonoperatively with 3 months rest followed by rehabilitation exercises. They concluded that 42% of athletes were able to return to their previous level of competition at an average of 6 months from diagnosis (earlier than reconstruction). The authors were unable to identify any patient-specific factors (duration of symptoms, age, acuity of onset) that would predict the success of nonoperative treatment.
Illustration A shows the figure-of-8 (Jobe) graft fixation technique. It is performed by passing the tendon graft through two bone tunnels in the medial epicondyle of the humerus and through one tunnel in the ulnar sublime tubercle. The graft is then sutured to itself in a figure-of-8 configuration. Illustration B shows the docking graft fixation technique. The graft is placed in a triangular configuration through a single humeral tunnel. The suture limbs are then brought out through two separate bone holes and tied over a bony bridge on the superior aspect of the medial epicondyle.
Incorrect Answers:

The right shoulder exercise seen in Figure A will put the LEAST amount of stretch on which structure?

Inferior glenohumeral ligament Coracohumeral ligament Anterior-superior capsule Superior glenohumeral ligament Posterior capsule
Shoulder wand exercises, as shown in Figure A, are used to increase external range of motion of the shoulder. With the arm adducted and the elbow flexed, this exercise will put the LEAST amount of stretch on the posterior capsule.
External rotation shoulder wand exercises are commonly used for the treatment of adhesive capsulitis. Adhesive capsulitis is most commonly caused by contracture of the rotator interval. The rotator interval includes the anterior-superior capsule, superior glenohumeral ligament, coracohumeral ligament and long head biceps tendon. The structure most commonly contracted is the anterior-superior capsule, which limits external rotation when the arm is adducted. Kuhn et al. showed that in the neutral position, each ligament except the posterior capsule significantly affected the torque required for external rotation. The greatest effect on resisting external rotation at 0 degrees of abduction was the entire inferior glenohumeral ligament > coracohumeral ligament
> anterior band of the inferior glenohumeral ligament > superior and middle glenohumeral ligament.
Harryman et al. looked at the role of the rotator interval capsule in passive motion and stability of the shoulder. They found operative alteration of this capsular interval was found to affect flexion, extension, external rotation, and adduction of the humerus with respect to the scapula. Limitation of external motion was increased by operative imbrication of the rotator interval and decreased by sectioning of the rotator interval capsule.
Kim et al. reviewed shoulder MRIs to determine if abnormalities of the rotator interval were correlated with chronic shoulder instability. They found a significantly larger rotator interval height, rotator interval area, and rotator interval index in patients with chronic anterior shoulder instability compared to patients without instability.
Figure A shows a patient performing an exercise to increase right shoulder external rotation with a wand/stick. The right arm is fully adducted by her side, and her elbow flexed at 90 degrees.
Incorrect Answers:
) A 55-year-old male returns for followup 3 months after reverse shoulder arthroplasty. He reports limited function of his right shoulder but no antecedent trauma. A radiograph of his shoulder is shown in Figure A. All of the following variables are associated with this complication EXCEPT:

History of malunited proximal humerus fracture Proximal humeral bone loss

Failed primary arthroplasty Rheumatoid arthritis

Fixed preoperative glenohumeral dislocation
Rheumatoid arthritis is not associated with reverse shoulder arthroplasty (RSA) dislocation. RSA dislocation is a known complication of RSA. Risks include proximal humeral bone loss, chronic fracture sequelae with malunited/ununited tuberosities, failed previous arthroplasty, and fixed glenohumeral dislocation preoperatively. An irreparable subscapularis tears may be less of an issue with newer implant designs.
Trappey et al. studied instability and infection rates after RSA. They found that the rate of instability was similar in primary and revision surgery, but the rate of infection was higher in revision surgery. Instability was highest in the fracture sequelae group because of malunited tuberosities, contractures and proximal humeral bone loss.
Favre et al. examined the effect of component positioning on RSA stability.
They found that humeral version was more important than glenoid version. Stability is improved with the humerus in neutral or slight anterversion. They recommend avoiding retroversion >10deg. Edwards et al. examined subscapularis insufficiency and the risk of RSA dislocation. They found that of 138 RSA, all 7 dislocations occurred in patients with an irreparable subscapularis.
Dislocation was also more likely in patients with complex diagnoses, including proximal humeral nonunion, fixed dislocation, and failed prior arthroplasty.
Figure A shows reverse shoulder arthroplasty dislocation. Incorrect Answers:
) A 45-year-old man complains of chronic right shoulder pain. He has a history of chronic steroid use because of asthma. He recently completed a course of physical therapy

and has given up his job as a laborer in favor of a desk job. Examination reveals diminished shoulder abduction strength. A radiograph of his shoulder is shown in Figure A. Which of the following surgical treatment options (Figures B through F) is the most appropriate?

Figure B Figure C Figure D Figure E Figure F
This patient has early stage avascular necrosis (AVN) of the humeral head without subchondral collapse/flattening, likely related to chonic steroid use.
Core decompression is indicated.
Treatment of humeral head AVN is dependent on Cruess Stage. Precollapse stages (Stage I and II) may be treated by core decompression and joint preservation. Hemiarthroplasty is used for Stage III-IV disease. Total shoulder arthroplasty is used for Stage V disease. Resurfacing may be used for Stage III disease with focal chondral defects and sufficient remaining epiphyseal bone stock for fixation.
Harreld et al. reviewed humeral head AVN. They advocate attempting core decompression and arthroscopy for Stage III disease, and then tailoring resurfacing or replacement depending on defect size.
Smith et al. reviewed 31 hemiarthroplasties for steroid-related AVN (6 Stage III, 16 Stage IV, 5 Stage V). Unsatisfactory results were found in 45%. This was associated with glenoid cartilage wear over time. However, they still believed hemiarthroplasty was appropriate for younger active patients with stage III or stage IV disease.
LaPorte et al. performed core decompression for various stages of AVN.
Results were successful in 94%, 88%, 70% and 14% of Ficat-Arlet Stages I, II, III and IV humeral head AVN respectively, and more successful for nonsteroid related cases compared with steroidrelated cases. They recommend this treatment for Stages I-III.
Figure A comprises a radiograph showing Cruess Stage II disease ("snowcap" sign indicating sclerosis, preservation of the head contour and absence of subchondral collapse, left), a T1weighted
MRI (center) and T2-weighted fat saturated MRI (right) showing a variegated pattern of osteonecrosis, but with preservation of normal head contour. Figure B shows core decompression. Figure C shows hemiarthroplasty. Figure D shows reverse shoulder arthroplasty. Figure E shows resurfacing. Figure F shows total shoulder arthroplasty. Illustration A depicts the Cruess staging system. Illustration B shows a possible algorithm for management where they use the Ficat stages adapted from the hip.
Incorrect Answers:

A 56-year-old otherwise healthy woman undergoes uncomplicated arthroscopic repair of a full-thickness rotator cuff tear. Prior to the procedure, the patient had attempted a long,
protracted course of physical therapy in an attempt to regain function without surgery. At her 10 day post-operative visit, she tearfully informs you that she cannot see her physical therapist because she has used up her 24-visit allotment for the year. She has 4 more weeks
until her insurance year turns over, and she does not have the financial means to pay out of pocket. What is the best next course of action?
Request a peer-to-peer review for authorization of additional visits or else the patient is likely to have a poor result

Provide a brief explanation and sheet of exercises for periscapular and cuff strengthening exercises using a resistance band

Test her range of motion and strength, and if limited, have her return weekly to your clinic for a guided home rehabilitation program

Explain to her that seeing a physical therapist during the first 6 weeks following cuff repair will not affect her range of motion one year removed from surgery

Give her a prophylactic corticosteroid injection to avoid early post-operative adhesive capsulitis
Early motion following rotator cuff repair has not been shown to impact range of motion and stiffness at one year post-operative clinical examinations.
Stiffness is a complication of protecting rotator cuff repairs from early re-tear with sling immobilization. However, with sling immobilization of up to 6 weeks, there is evidence of no increase in long-term stiffness. Accordingly, supervised physical therapy is not required in the first 6 weeks following arthroscopic rotator cuff repairs in order to obtain a good result.
Parsons et al. retrospectively reviewed 43 patients with full-thickness cuff tears who underwent a conservative early-postoperative protocol involving sling immobilization for 6 weeks with no formal therapy during that time. 10 /43 patient were characterized as stiff at their 6-week postoperative visit. At one year, there was no difference in the range of motion of the early stiff group compared to the non-stiff group.
Trenerry et al. collected prospective data on 209 consecutive patients undergoing primary rotator cuff repair. They found that patients in the stiffest quartile of range of motion testing at 6 weeks progressively regained range of motion by a post-operative visit at 72 weeks. The predictor of slowest recovery of early post-operative stiffness was found to be an internal rotation deficit with the patient reaching behind his or her back.
Incorrect Answers:
1: Early supervised physical therapy has not been shown to be essential to obtaining good motion post-operatively.
2 and 3: Strength testing and home strengthening programs in the early postoperative period would put the repair at risk for early failure.
5: Prophylactic corticosteroids are not indicated for prevention of postoperative stiffness, and furthermore, could theoretically interfere with healing.
A 62-year-old woman presents with chronic shoulder pain. On physical exam, she has anterior shoulder pain and her symptoms are reproduced with provocative testing of the biceps including supination against resistance and forward flexion of the shoulder against resistance. Internal and external rotation are painful, but her range of motion is intact. Shoulder radiograph and MRI images are shown in Figures A-E. Which of the following statements is true regarding the patient's condition?

Her clinical examination is most consistent with a SLAP tear, which should be repaired. Her biceps pathology is due to her partial tearing of her subscapularis

She has isolated degenerative biceps tendonosis and an injection may cure her symptoms

She has end-stage rotator cuff arthropathy and should consider a reverse total shoulder arthroplasty

Her subacromial impingement is causing her biceps tendon sheath to be inflamed
The subscapularis tendon is the most important medial restraint to subluxation or dislocation of the long head of the biceps tendon (LHBT).
Anterior shoulder pain and positive provocative biceps clinical examination tests are common in patients with concomitant rotator cuff pathology. A consequence of subscapularis tendon tears -even partial tears - is that the LHBT can subluxate medially out of the intertubercular groove, as the subscapularis tendon is the most important restraint to medial instability of the LHBT. This instability can cause both pain and inflammation around the biceps tendon, leading to pain with resisted supination (Yergason's test) or resisted forward flexion (Speeds' test).
Walch et al. wrote a case series on 71 cases of biceps tendon instability. They found that dislocated LHBTs were associated with partial or complete subscapularis tears in 96% of cases.
Maier et al. published clinical results of treating acute traumatic medial LHBT instability with open repair of the subscapularis tendon and stabilization of the LHBT. They showed equivalent functional clinical outcomes to biceps tenotomy or tenodesis, with improved cosmesis and decreased muscle cramping.
Figures A and B show Grashey and axillary lateral views of the patient and demonstrate an os acromiale. Figures C, D, and E are axillary T2 MRI images. Figure C shows the tendon of the long head of the biceps in the distal aspect of the biceps grove. Moving proximally, Figure D shows the tendon subluxated onto the lesser tubercle and Figure E shows it fully dislocated medially.
Incorrect Answers:
A 78-year-old male presents to clinic 4 weeks after left total shoulder arthroplasty. He has not been wearing his sling and reports that he developed increased pain after slipping in the shower. He used the arm to catch himself from falling. On examination, he can flex the shoulder to 70 degrees, limited by pain. Active external rotation with arm at the side is 50 degrees and active internal rotation is 5 degrees. Passive external rotation is to 80 degrees. A radiograph of the left shoulder is shown below in Figure A. What other complaint is the patient most likely to have?

Pain with palpation of the bicipital groove Pain with palpation over the subdeltoid bursa Sensory loss over the lateral shoulder

Sensation of shoulder instability with external rotation Sensation of shoulder instability with internal rotation
The clinical presentation is consistent with a tear of the subscapularis, which is a well-described complication after total shoulder arthroplasty. The most likely additional complaint this patient will have is anterior shoulder instability, noticeable with external rotation of the shoulder.
Total shoulder arthroplasty is the preferred treatment for glenohumeral arthritis in patients with intact rotator cuff and good glenoid bone stock. The surgical approach involves detaching the subscapularis and capsule from the anterior humerus and dislocating the humeral head anteriorly. Post operatively, external rotation is limited to protect the subscapularis repair. If there is suspicion of a postoperative subscapularis tear, and ultrasound can be performed to confirm the diagnosis.
Miller et al. reported 7 cases of subscapularis tendon rupture after total shoulder arthroplasty, all of which were subsequently repaired. Decreased functional outcomes were observed in these patients, with lengthening techniques to address internal rotation contractures and prior surgery involving the subscapularis tendon as risk factors for rupture
Westoff et al. performed static and dynamic ultrasounds on 22 patients after total shoulder arthroplasty evaluating for numerous periarticular pathologies. The authors concluded that sonography is a useful tool for evaluation of periimplant tissues after TSA.
Figure A shows an intact left total shoulder arthroplasty without evidence of fracture, dislocation, or hardware loosening. Illustration A shows the incision for the subscapularis tendon during TSA. Incorrect Answers:

A 25-year-old lineman is referred to your office for a second opinion. 1 year ago, he underwent an arthroscopic procedure for shoulder instability. He complains of persistent sense of instability despite the surgery. Which of the following is a contraindication to revision arthroscopic labral repair for recurrent anterior glenohumeral instability?
Glenoid bone loss of 10%

Capsular attenuation from prior thermal capsulorraphy Anterior labral periosteal sleeve avulsion (ALSPA ) lesion Glenoid labral articular defect (GLAD) lesion

Combined Superior Labrum from Anterior to Posterior tear (SLAP) and recurrent Bankart lesion
Capsular attenuation or postthermal capsular necrosis from prior thermal capsulorraphy is a contraindicated to arthroscopic repair.
Thermal capsulorrhaphy utilizes heat generated by radiofrequency or laser ablation to cause capsular shrinkage in an effort to treat shoulder instability. However, high recurrence rates have been found, especially around two to three weeks after the index procedure, when the capsular tissue is the weakest. In the setting of recurrence following thermal capsulorrhaphy, open revision is recommended.
Creighton et al. reported on a series of 18 patients undergoing revision arthroscopic stabilization. Of the 18, 3 failed with recurrent instability, all with previous thermal capsulorrhaphy. Miniaci et al. reviewed the outcomes following thermal capsulorrhaphy noting high rates of recurrent instability, especially in the setting of initial treatment for multidirectional instability. Park et
al. reported on a series of 14 patients undergoing revision following thermal capsulorrhaphy. Ten out of 14 patients had signs of capsular thinning, insufficiency and attenuation.
Wong et al. surveyed 379 shoulder surgeons on the complications following thermal capsulorrhaphy. Capsular insufficiency and thinning were commonly associated with recurrent instability.
Hecht et al. performed thermal capsulorrhaphy and biomechanical analysis of the capsule in a sheep model. The authors found that the capsule was weakest at the 2-3 week post-operative timepoint, leading to the highest rate insufficiency, attenuation and mechanical failure at this time.
Incorrect answers:
A 47-year-old landscaper presents with worsening left shoulder pain and weakness. Three years ago, he injured the left shoulder in a fall and elected for nonoperative
management to minimize time off from work. Physical therapy was effective until 6 months ago when his shoulder function worsened to the point that he is now unable to work.

Examination of his active range of motion reveals forward elevation 120° with pain, abduction 100°, IR at neutral to T8 and ER at neutral 5°. He has a positive ER lag sign and Hornblower's sign. Belly press and lift-off tests are normal. A recent radiograph is shown in Figures A. MRI images are shown in Figures B and C. Which of the following is the best treatment option?

Continue physical therapy Latissimus dorsi transfer Arthroscopic rotator cuff repair Pectoralis major transfer

Reverse total shoulder arthroplasty
This patient has a chronic massive posterosuperior rotator cuff tear with marked atrophy, tendon retraction and loss of external rotation strength that is impacting his daily life. The best treatment option for this middle-aged laborer with an irreparable posterosuperior rotator cuff tear is a latissimus dorsi transfer to restore external rotation strength and motion.
Irreparable rotator cuff tears are marked by: (1) Superior displacement of the humeral head (AHI < 5-7mm), (2) Fatty infiltration of the rotator cuff muscles ( Goutallier stage 3-4), (3) Increased duration of the tendon tear and (4) Profound external rotation weakness. These findings are predictive of poorquality tissue and stiffness of the muscle-tendon unit, not amenable to primary repair. In this setting, a latissimus dorsi transfer can be utilized to restore shoulder strength, function and improve pain. Relative contraindications include subscapularis deficiency, deltoid deficiency, pseudoparalysis of the shoulder and advanced glenohumeral arthritis.
Gerber et al. performed a case series analysis of 67 patients with irreparable rotator cuff tears managed with latissimus dorsi transfer. Patients with an intact subscapularis demonstrated improvement in pain, range of motion and strength postoperatively, while no improvement was noted in patients with subscapularis deficiency. The authors conclude that latissimus dorsi transfer should not be performed in the setting of poor subscapularis function.
Iannotti et al. found that better clinical results following latissimus dorsi transfer were associated with: preserved active shoulder range of motion and strength (specifically forward elevation > 90° and external rotation > 20°), synchronous firing of the transferred latissimus dorsi muscle and male gender.
Figure A is an AP radiograph of the left shoulder with superior migration of the humeral head (AHI
< 5mm) and no evidence of glenohumeral arthritis. Figures B and C show a retracted posterosuperior rotator cuff tear and Goutallier stage 4 atrophy (more fat than muscle) of the supraspinatus, infraspinatus and teres minor, rendering this tear irreparable. Illustration A shows a latissimus dorsi transfer. The latissimus dorsi tendon is positioned over the top of the humeral head, covering most of the rotator cuff defect. The tendon is then secured to the subscapularis tendon edge and lesser tuberosity anteriorly, the remnant supraspinatus and infraspinatus tendons medially, and the greater tuberosity laterally.
Incorrect Answers:

A collegiate swimmer develops medial winging of the scapula. If the EMG and nerve conduction studies are abnormal, the most likely nerve roots to be involved are?

C7, C8, T 1 C6, C7, C 8 C5, C6, C 7 C4, C5, C 6 C3, C4, C 5
Classic medial winging of the scapula is due to paralysis of the serratus anterior muscle which is supplied by the long thoracic nerve which holds the scapula to the chest wall and prevents the inferior angle of the scapula from migrating medially. It is innervated by the long thoracic nerve (C5, 6, 7).
Surgical treatment may include partial pec major transfer. Lateral winging may be caused by spinal accessory nerve palsy (CN XI, also ventral ramus C2,3,4). The nerve may be injured during neck surgery. This causes trapezius weakness, allowing the inferior pole of the scapula to migrate laterally. The modified Eden-Lange procedure may be used for this type of winging.
Gregg et al. describes paralysis of the serratus muscle in young athletes which they felt was due to repetitive traction. Full recovery usually occurs in an average of 9 months, and they recommend that surgical methods of treatment should be reserved for patients in whom function fails to return after a twoyear period.
Foo et al. describes a larger cohort of 20 patients again treated expectantly with observation and physical therapy. They reported consistent recovery but that it can take up to 2 years.
Illustration A shows a clinical photo of medial scapular winging. Illustration V is an instructional video of scapular winging. It begins with a clinical video of the condition.

A 62-year-old man complains of shoulder pain for 2 years. He has had 1 course of intra articular sodium hyaluronate and 6 weeks of physical therapy with little relief. Examination reveals diminished arm flexion and abduction secondary to pain. Radiographs of his shoulder are shown in Figures A and B. According to the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, what is the next best step?

Humeral head replacement arthroplasty Hemiarthroplasty and ream-and-run glenoid procedure

Cuff tear arthropathy (CTA) prosthesis

Total shoulder arthroplasty with a metal-backed cemented glenoid component Total shoulder arthroplasty with an all-polyethylene cemented glenoid component
This patient has end-stage glenohumeral osteoarthritis (GH OA). According to the AAOS CPG, total shoulder arthroplasty (TSA) is recommended using an allpolyethylene cemented glenoid component.
TSA is indicated for cases of end-stage GH OA. It is preferred to hemiarthroplasty. It is contraindicated in cases with insufficient glenoid bone stock (glenoid wear to the level of the coracoid), rotator cuff arthropathy or irreparable cuff tears and deltoid dysfunction. It provides good pain relief and has good survival at 10 years (>90%).
Radnay et al. performed a systematic review involving 1952 patients comparing TSA with humeral head replacement (HHR). They found that TSR provided greater pain relief, range of motion, patient satisfaction, and had lower revision rates. They recommend TSA over HHR for GH OA. Izquierdo et al. described the AAOS Clinical Practice Guidelines (CPG) regarding treatment of GH OA. This is summarized in Illustration A.
Figures A and B show end-stage GH OA with large osteophytes and subchondral sclerosis. There is significant glenoid wear and posterior subluxation (Walch B glenoid deformity). Illustration A is a table summarizing the AAOS CPG on treatment of GH OA. Illustration B shows a CTA humeral component. It is not paired with a glenoid component.
Incorrect Answers:
Metal-backed glenoids have higher rates of revision than all-polyethylene glenoids.

Posterior glenohumeral dislocations are as common as anterior dislocations in which of the following patient groups?
Football players

Marfan's syndrome patients Renal failure patients Epilepsy patients

Women
Millett et al and Robinson et al provide review articles on posterior shoulder dislocations, which are rare clinical entities that occur during seizures and electrocution (due to tetanic muscle contraction) or as a result of high energy trauma. Robinson et al noted that poor prognostic factors associated with posterior shoulder dislocation include late diagnosis, large bony defect of humeral head, associated proximal humerus fracture, and need for arthroplasty. In Gerber's series, posterior dislocations occurred with equal frequency to anterior in a cohort of epilepsy patients.
What nerve is injured most commonly during the superficial dissection when repairing a distal biceps rupture through a single incision anterior approach?

Medial antebrachial cutaneous nerve Lateral antebrachial cutaneous nerve Superficial radial nerve

Ulnar nerve

Posterior interosseous nerve
The lateral antebrachial cutaneous nerve (LABCN) is at risk during the superficial dissection when repairing a distal biceps rupture through a single incision anterior approach.
The LABCN is the terminal cutaneous branch of the musculocutaneous nerve, which supplies sensation to the volar-lateral aspect of the forearm. The LABCN pierces the deep fascia of the arm lateral to the musculotendinous junction of the distal biceps tendon after lying on top or piercing through the brachialis muscle. It exits the arm and lies in the subcutaneous tissues of the antecubital fossa. It is important to retract this nerve laterally during the approach to the distal biceps tendon.
Cohen describes the importance of identifying the LABCN during the superficial dissection as injury to this nerve is not uncommon (5-7%). Injury to the PIN (5 %) is devastating and occurs with retractor placement during the deep dissection and the use of suspensory fixation on the posterior cortex of the radius.
The review article by Ramsey et al covers the surgical anatomy and complications of biceps surgery, including injury to the LABCN.
Illustration A shows the LABCN relative to the anterolateral approach to the elbow which is commonly used to repair distal biceps avulsions. Illustration B shows the close proximity of the LABCN to the distal biceps in a human specimen.
Incorrect Responses:

An MRI of the shoulder in a patient with chronic quadrilateral space syndrome is most likely to show which of the following?

Increased intra-capsular volume Loss of intra-capsular volume Fatty atrophy of the infraspinatus Fatty atrophy of the teres minor

Fatty atrophy of the latissimus dorsi
Quadrilateral space syndrome involves dysfunction of the axillary nerve, perhaps by entrapment or compression, resulting in the functional denervation of the teres minor.
The quadrilateral space is a potential space formed by the long head of the triceps medially, the humerus laterally, the teres minor above, and the teres major below. The axillary nerve and posterior circumflex humeral artery travel through this space.
The Sanders article describes the MRI appearance, which is that the muscle appears streaked with white on MRI and atrophied (See illustration A) consistent with fatty atrophy. Sanders group report this finding in 3% of shoulder MRIs. The posterior circumflex humeral artery also travels with the axillary nerve as it travels through this space. Loss of capsular volume on an arthrogram study is suggestive of adhesive capsulitis.
Illustration B is a diagram which shows the borders of the quadrilateral (or quadrangular) space.

A 21-year-old collegiate volleyball player is noted to have weakness in external rotation and isolated atrophy of the infraspinatus on physical examination as seen in Figure A. An axial MRI image is shown in Figure B. This clinical condition is most likely caused by compression of the:

Axillary nerve at the triangular space Suprascapular nerve in the suprascapular notch Axillary nerve in the quadrangular space Suprascapular nerve in the spinoglenoid notch

Long thoracic nerve anterior to the scalenus and the first rib and posterior to the clavicle
The clinical presentation is consistent for a suprascapular neuropathy caused by compression of the suprascapular nerve by a cyst in the spinoglenoid notch.
The suprascapular nerve arises from the upper trunk of the brachial plexus with contributions from C5-6. It travels through the suprascapular notch of the scapula where it gives motor branches to the supraspinatus then around the spinoglenoid notch where it innervates the infraspinatus.
Compression of the nerve at the suprascapular notch will cause denervation and atrophy of both the supraspinatus and infraspinatus while compression at the spinoglenoid notch affects the infraspinatus in isolation. This is commonly seen in overhead athletes who sustain a SLAP tear and resultant spinoglenoid notch cyst as seen in the MRI. This will cause weakness and atrophy of the infraspinatus and can be noted both clinically and radiographically. Appropriate operative management is still not clear in the literature with some authors reporting a need for labral repair + cyst decompression and others reporting good outcomes with labral repair alone. Other cases have been treated with needle aspiration.
The cited reference by Cummins et al reviews the various causes, diagnosis, and treatment of suprascapular neuropathy.

The reference by Martin et al is a retrospective study of the results of nonoperative treatment of suprascapular neuropathy in which 5 had excellent results and 7 had good results.
Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis?

Resisted forearm pronation and wrist flexion with a clenched fist Resisted forearm supination and wrist extension with a clenched fist Dynamic valgus stress test

Milking maneuver Pinch grip test
A provocative test for medial epicondylitis can be elicited by applying resistance to a patient with their fist clenched, wrist flexed and pronated.
Medial epicondylitis is an overuse syndrome of the flexor-pronator mass. The pronator teres (PT) and flexor carpi radialis (FCR) are thought to be most affected with this condition. It is most common in the dominant arm and occurs with activities that require repetitive wrist flexion/forearm pronation. Patients are most tender over the origin of PT and FCR at the medial epicondyle.
Resisting a patient with their fist clenched, wrist flexed and pronated can cause worsening of their pain. This maneuver can be used as a provocative test for this condition.
Cain et al. reviewed elbow injuries in throwing athletes. They comment that the common flexorpronator muscle origin provides dynamic support to valgus stress in the throwing elbow, especially during early arm acceleration and help produce wrist flexion during ball release.
Amin et al. reviewed the evaluation and management of medial epicondylitis. They report that medial epicondylitis typically occurs in the fourth through sixth decades of life, the peak working years, and equally affects men and women. Physical therapy and rehabilitation is the main aspect of recovery from medial epicondylitis, once acute symptoms have been alleviated.
Illustration A shows a video of this provocative test for medial epicondylitis. Incorrect Answers:

A 72-year-old woman presents for follow-up after elbow surgery. Her radiographs are shown in Figures A and B. Which of the following pre-operative diagnoses is a relative contraindication to the use of this prosthesis design?

Acute intra-articular distal humerus fracture Malunited intra-articular distal humerus fracture Late-stage rheumatoid arthritis

Post-traumatic bony ankylosis Osteoarthritis
This patient has had an unconstrained total elbow arthroplasty (TEA).
Unconstrained TEA is least preferred for late-stage rheumatoid arthritis where there is significant capsuloligamentous instability and bony erosion.
Unconstrained (unlinked or resurfacing prosthesis) TEA depend on intact bony and ligamentous constraints for stability. These are appropriate for humeroulnar conditions with intact collateral ligaments and radiocapitellar articulation e.g. osteoarthritis, post-traumatic arthritis, intra-articular distal humerus fracture, and malunion of the distal humerus. Conditions with increased risk of

instability (ligamentous injury, rheumatoid arthritis) will benefit from a linked or semiconstrained prosthesis.
Mansat et al. reviewed the Coonrad-Morrey linked (semi-constrained) TEA implant in 70 patients after 5 years. They found that patients with inflammatory arthritis had higher function than those with traumatic conditions
( fractures, nonunions and post-traumatic arthritis). Survival rate was 98% and 91 % at 5 and 10 years, respectively. They concluded that this implant provided satisfactory treatment for different indications although radiolucent lines and bushing wear were a concern.
Hildebrand et al. reviewed the functional outcome of the Coonrad-Moorey prosthesis in 51 elbows after 50 months. The inflammatory arthritis group had higher performance scores than the traumatic/post-traumatic conditions group. Isometric extensor torque was found to be less than the nonoperated side. Radiolucency was noted in 11 elbows.
Figures A and B show an unconstrained TEA with radial head replacement. Illustration A shows more examples of unconstrained TEA. Illustration B shows a semiconstrained TEA. The arrow points to the anterior flange. Illustration C shows radiolucent lines around the stems. Illustration D shows severe bushing wear leading to locking mechanism failure. Illustration E is a table comparing linked and unlinked implants.
Incorrect Answers:

A professional baseball team has several pitchers with complaints of velocity loss with their pitches and shoulder pain of their dominant shoulders during spring training. Pitch counts are properly monitored. The average glenohumeral internal rotation deficit on the pitching staff is 45 degrees. The best intervention would be:
Pitchers throwing less fastballs and more changeups

Evaluate the pitchers elbows for ulnar collateral ligament acute ruptures. Increasing the weight training for the deltoid and latissimus dorsi muscles Focused stretches and therapies that address posterior capsular tightness Firing the general manager for finding pitchers that "lose their stuff"
Glenohumeral Internal Rotation Deficit (GIRD) is a phenomenon that occurs in baseball pitchers and is due to posterior capsular tightness. Treatment should begin with a therapy program addressing the pathologic posterior capsule.
GIRD is a phenomenon that is frequently found in high-level overhead throwing athletes, predominantly baseball pitchers. It is defined as the measured difference in internal rotation between the non-dominant arm and dominant arm. Worsening range of motion deficits are seen with increased repetitions, both over a single season and a career. GIRD > 25º is associated with development of shoulder pathologies or pain requiring periods of inactivity. Cessation of overhead throwing activities and initiation of a stretching program to address posterior capsular contractures is largely effective (90% in some series).
Burkhart et al. reviewed the conditions associated with high-level overhead throwing athletes shoulders, culminating in a theory of pathologic progression to "dead arm syndrome" (loss of velocity and effective pitching). Their theory attributes adaptive hyperexternal rotation (occurs during late-cocking / early acceleration phases of pitching) to lead to posterior-inferior capsular contracture and GIRD. Subsequent injuries to anterior structures - including SLAP lesions - would then occur.
Illustration A is a cartoon depiction of how to perform the sleeper stretch. This is a common component of a pitcher's maintenance stretching program.
Incorrect Answers:

A 68-year-old man presents with severe right shoulder pain. He had a prolonged course of physical therapy and received several cortisone injections for his pain without improvement. Examination reveals pseudoparalysis of the right shoulder with a 20-degree external rotation lag with the shoulder adducted. With the shoulder placed in 90 degrees of abduction, he can actively externally rotate his shoulder. The patient was treated with a medialized reverse prosthesis shown in Figure A. Which of the following statement is true regarding this treatment option?

It is contraindicated in patients with shoulder pseudoparalysis

It can be used in patients with deltoid dysfunction when combined with latissimus dorsi transfer It shifts the center of rotation of the shoulder superior and lateral

The risk of scapular notching is increased with inferior placement of the glenoid component The risk of instability is increased with an irreparable subscapularis
The clinical presentation is consistent with a patient with pseudoparalysis that was treated with a reverse total shoulder arthroplasty (RTSA). The risk of postoperative instability is increased in patients with an irrepairable subscapularis when a medialized reverse prosthesis is used. Answers 1-4 are false statements.
RTSA is most commonly indicated for rotator cuff arthropathy. However, indications for use now include shoulder pseudoparalysis, anterosuperior escape of the humeral head, acute 3 or 4-part proximal humerus fractures, and greater tuberosity fracture nonunions. Contraindications to RTSA included deltoid dysfunction, insufficient glenoid bone stock, and bony deficiency of the acromion. Edwards et al. prospectively evaluated the risk of shoulder dislocation after reverse TSA. They found a significantly increased risk of dislocation (p=0.012) in patients with an irreparable subscapularis at time of surgery. There were no dislocations in the reparable group. Dislocations were more likely in patients with proximal humeral nonunions and failed prior arthroplasty. Mulieri et al. looked at the use of reverse TSA in patients with irreparable massive rotator cuff tears without evidence of glenohumeral arthritis. All outcomes were improved postoperatively, and they advocate
for reverse TSA in this subset of patients. Survivorship was over 90% at more than 4 years average follow up.
Boileau et al. evaluated the clinical outcomes of isolated biceps tenotomy/tenodesis in patients with massive rotator cuff tears and a biceps lesion. They found that the procedure can effectively treat pain and improve function in these patients. There was no difference in patients undergoing tenotomy versus tenodesis.
Figure A is a right shoulder radiograph status post RTSA with components in adequate position. Incorrect Answers:
Figure A shows immediate post-operative radiographs of a 75year-old patient with primary osteoarthritis. She presents 3 years later with increasing pain and weakness in the shoulder despite home physical therapy. Examination reveals limited active range of motion, with forward elevation of 80 degrees and external rotation of 50 degrees. Her deltoid function is intact. Repeat radiographs are seen in Figure B. Which treatment option would provide the best functional outcome for this patient?

Open tendon transfer
Corticosteriod injection and supervised physical therapy

Open rotator cuff repair, subacromial decompression and distal clavical excision Revision to reverse shoulder arthroplasty

Revision to cuff arthropathy hemiarthroplasty
This patient presents with failed total shoulder arthroplasty. The best treatment option for functional outcome would be revision to reverse shoulder arthroplasty (rTSA).
RTSA is considered a viable treatment option for patients with failed shoulder arthroplasty. It allows for improved arm elevation and abduction in the setting of nonfunctional rotator cuff muscles, as seen in this example. Despite the expanding indications for rTSA, there are high complication rates in the revision setting. Complication rates for rTSA after failed shoulder arthroplasty have been reported to be between 11-36%. This procedure should, therefore, be performed by surgeons with extensive training in reconstructive shoulder arthroplasty.
Patel et al. retrospectively reviewed 31 patients (mean age, 68.7 years) who underwent rTSA for treatment of a failed shoulder arthroplasty. They found the greatest improvement with active forward elevation from 44° preoperatively to 108 ° postoperatively (P < .001). Complications occurred in 3 patients with periprosthetic fracture.
Hattrup et al. reviewed a series of 19 patients that underwent open rotator cuff repair after shoulder arthroplasty. Out of the 19 patients only 4 shoulders were successfully repaired. They concluded that successful rotator cuff repair after shoulder arthroplasty is possible but failure is more common. Figure A shows a left total shoulder arthroplasty that is well reduced in the glenoid. Figure B shows antero-superior escape of the prosthesis, indicative of a massive rotator cuff tear.
Incorrect Answers:
A 35-year-old man awoke following a night of heavy drinking with severe right shoulder pain and inability to raise his arm above his head. A radiograph from the emergency room is provided in Figure A. He was treated with a sling for a diagnosis of rotator cuff tear. Six weeks later, he complains of continued pain and difficulty using the arm. Which of the following is the next best step in management?

Physical therapy for range of motion followed by rotator cuff and deltoid strengthening exercises

Axillary radiograph of the shoulder

EMG to evaluate the suprascapular and axillary nerves Arthroscopic rotator cuff repair

Open subacromial decompression and latissimus dorsi transfer for massive cuff tear
The radiograph demonstrates overlap of the humeral head and glenoid suggesting shoulder dislocation. An Axillary radiograph is necessary to evaluate concentric reduction vs. dislocation of the shoulder. An example is provided in illustration A. Posterior shoulder dislocations can be easily be missed without the proper orthogonal views of the shoulder. Perron reviews the proper identification and emergency room care of posterior shoulder dislocation. Richardson found axillary radiographs to be more sensitive than trans-scapular radiographs for identifying posterior shoulder dislocations.

Recent randomized controlled trials comparing early passive range of motion to 6 weeks of immobilization after successful arthroscopic rotator cuff repair concluded that, compared to immobilization, early passive range of motion resulted in:
Higher Constant scores at 12 months

Increased rates of re-rupture as determined by ultrasound Equivalent functional outcomes

Less pain at 6 months

Inceased range of motion at 12 months
A series of high-quality RCTs have demonstrated that early passive range of motion has equivalent functional outcomes when compared to 6 weeks of immobilization after arthroscopic rotator cuff surgery.
Traditionally, most surgeons recommended early post-operative range of motion exercises for their patients in order to prevent adhesions and ultimately stiffness. However, recent evidence has found that there is no difference in the healing rate, range of motion or functional outcome between patients who undergo early versus delayed (i.e. initial 6 weeks of immobilization) passive range of motion exercises after arthroscopic rotator cuff repair.
Kim et al. conducted a randomized controlled trial comparing early passive range of motion vs. immobilization in 106 patients who underwent arthroscopic repair for full-thickness rotator cuff tears. They found that there was no clinically or statistically significant difference between the two groups in pain, healing or function.
Keener et al. also conducted a randomized controlled trial of 124 patients who were undergoing arthroscopic repair of a full-thickness rotator cuff tear and found no difference between early and delayed range of motion in healing and functional outcome.
Cuff & Pupello also compared early vs. delayed range of motion during the post-operative rehabilitation phase in a randomized controlled trial of 68 individuals undergoing arthroscopic rotator cuff repair and found no significant difference in range of motion or healing.
Incorrect Answers:
A 49-year-old male presents with right shoulder pain and weakness after undergoing open cervical lymph node biopsy approximately one year ago. A pertinent finding from the physical exam is seen in Figure A, with the patients arms by his side. Physical exam finding with the arms in a position of 90 degrees of forward elevation and 10 degrees of external rotation are shown in Figure B.
What nerve is most likely injured?

Long thoracic Suprascapular Spinal accessory Axillary Thoracodorsal
The patient is presenting with LATERAL scapular winging which is a result of injury to the spinal accessory nerve and resultant trapezius muscle palsy.
The spinal accessory nerve is fundamental to scapulothoracic function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. The majority of injuries to the spinal accessory nerve are iatrogenic and occur secondary to head and neck surgery. There is often a marked delay in recognition and initiating treatment. Surgical treatment with the Eden-Lange transfer lateralizes the levator scapulae and rhomboids (transfer from medial border to lateral border)
Camp et al. reviewed the results of 111 patients who underwent operative management of a lesion to the spinal accessory nerve. They found that the majority (~80%) of injuries were sustained iatrogenically and that diagnosis was delayed for approximately 12 months.
Pikkarainen et al. reviewed the natural history of isolated serratus palsy. They found that symptoms mostly recover in 2 years, but at least one-fourth of the patients will have long-lasting symptoms, especially pain.
Figure A depicts a patient with lateral scapular winging. Figure B demonstrates physical exam of this patient with their arms in a position of 90 degrees of forward elevation and 10 degrees of external rotation. Illustration A highlights the difference between medial and lateral scapular winging. Illustration B depicts another example of a patient with lateral scapular winging.
Incorrect Answers:
An injury to the long thoracic nerve would result in serratus anterior palsy which would lead to MEDIAL scapular winging.

An injury to the suprascapular nerve would result in weakness and wasting of the supraspinatus and/or infraspinatus.

Question 88

Figures 80a and 80b are the radiographs of a 21-year-old football player who underwent anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft 1 year ago. He reports mild stiffness in his knee. Upon examination, he has a negative Lachman test result, trace effusion, and range of motion from 0 to 85 degrees of knee flexion. Which factor is most contributory to his examination findings?

Explanation

DISCUSSION
Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause of technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. This patient has anterior and vertical placement of his femoral tunnel, which has been shown to cause stiffness in knee flexion. Although graft choice is an important factor when planning ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position. Fixing the graft in flexion can cause extension loss when isometry is not achieved, but this condition is not touched upon in this scenario.

CLINICAL SITUATION FOR QUESTIONS 81 THROUGH 84
Figures 81a through 81d are the MR images of a 25-year-old man with left knee pain after a motorcycle collision. He has palpable pedal pulses with an ankle-brachial index of 0.95. Neurologic examination findings of the injured extremity are normal.

Question 89

A 47-year-old woman underwent a distal chevron bunionectomy 2 months ago. Her postoperative recovery had been uneventful until 1 week ago. She now has new onset pain and dorsal swelling in the area of the third metatarsal. A radiograph is shown in Figure 27. What is the most likely diagnosis?

Explanation

DISCUSSION: Based on findings of a sudden increase in pain with associated swelling, the most likely diagnosis is a stress fracture. The initial radiographic findings usually will be negative. Morton’s neuroma and transfer metatarsalgia are not associated with swelling. Metatarsophalangeal synovitis usually involves the second metatarsophalangeal joint. Freiberg’s infraction is seen clearly on a radiograph.
REFERENCE: Boden BP, Osbahr DC: High risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.

Question 90

Which of the following is considered an advantage of the tibial inlay fixation compared to transtibial tunnel technique when used in posterior cruciate ligament reconstruction? Review Topic

Explanation

One of the most difficult aspects of posterior cruciate ligament reconstruction is placement of the tibial tunnel and passing of the graft through this tunnel. The tibial inlay technique requires a posteromedial approach to the tibia whereby the graft is directly fixed to the posterior aspect of the tibia. This obviates the need for a tibial tunnel. This technique has never been shown to be less invasive, more cosmetic, or require decreased surgical time. It has also never been shown in a published level I study to have superior clinical results. However, it does eliminate the need for the 90-degree critical "killer" turn and passing of the tibial graft through the tibial tunnel which may lead to graft failure.

Question 91

Figure 40 shows the radiograph of a 30-year-old woman who has a painful elbow. Examination reveals a deformed skull, multiple cafe-au-lait spots, and bone deformities. What is the most likely diagnosis?

Explanation

DISCUSSION: Findings in patients with McCune-Albright syndrome include polyostotic fibrous dysplasia, multiple cafe-au-lait spots, and precocious puberty. The bone changes in NF-1 resemble nonossifying fibromas, not fibrous dysplasia. NF-2 has little bony change with typical ocular abnormalities. Paget’s disease occurs in older individuals and does not present with cafe-au-lait spots. Ollier’s disease (multiple enchondromatosis) may show bone changes but not the other findings.
REFERENCES: Albright F, Butler AM, Hampton AO, et al: Syndrome characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction with precocious puberty in females. N Engl J Med 1937;216:727-746.
Danon M, Robboy SJ, Kim S, Scully R, Crawford JD: Cushing syndrome, sexual precocity, and polyostotic fibrous dysplasia (Albright syndrome) in infancy. J Pediatr 1975;87:917-921.
Grabias SL, Campbell CJ: Fibrous dysplasia. Orthop Clin North Am 1977;8:771-783.

Question 92

What is the most important factor regarding the risk of recurrent instability in a patient with an acute anterior dislocation of the shoulder?

Explanation

DISCUSSION: The recurrence rate of anterior dislocation of the shoulder after the first episode in athletes younger than age 20 years is thought to be as high as 90%, making surgery after the initial episode a consideration. The rate drops from 50% to 75% in the 20- to 25-year age group and down to 15% in patients older than age 40 years. An excellent prospective study of 257 patients in Sweden showed that there was no difference in those who did or did not complete 3 weeks of immobilization. The study also showed variability among different age groups in the importance of athletic participation; athletes in the 12- to 22-year age group had a higher recurrence rate, whereas the more sedentary patients in the 23- to 29-year age group had a higher rate.
REFERENCES: Hovelius L: The natural history of primary anterior dislocation of the shoulder in the young. J Orthop Sci 1999;4:307-317.
Simonet WT, Cofield RH: Prognosis in anterior shoulder dislocation. Am J Sports Med 1984;12:19-24.

Question 93

A 56-year-old woman undergoes an arthroscopic rotator cuff repair for a two-tendon retracted tear (supraspinatus and infraspinatus), requiring the use of four suture anchors placed in a double row technique. At her 1 month follow-up visit, what is the appropriate recommendation for her continued rehabilitation program? Review Topic

Explanation

Regardless of the technique of rotator cuff repair, the biology of tendon healing remains the same. Therefore, the repaired muscle tendon(s) must be protected from stress for a minimum of 6 weeks and more likely 8 weeks in a large two-tendon tear such as this patient had repaired. Therefore, at the 1 month follow-up visit, the patient should continue strict passive motion exercises and should perform no strengthening activities. Deltoid strengthening cannot be isolated from rotator cuff strengthening; therefore, deltoid strengthening is inappropriate as well. Because the infraspinatus is the primary shoulder external rotator, it should not be strengthened for 6 to 8 weeks. Supraspinatus strengthening at this time frame would likely ensure its disruption and result in failure of the surgery. Any resistance training at 1 month from surgery would likely result in tendon failure at the tendon-bone interface. The obligatory need to protect the muscles during healing will predictably result in atrophy but it is easier to strengthen healed muscles than it is to strengthen muscle/tendon units that have failed to heal.

Question 94

Which sterilization method is expected to produce the most degradation of an allograft used for anterior cruciate ligament reconstruction?

Explanation

CLINICAL SITUATION FOR QUESTIONS 43 THROUGH 46
Figures 43a and 43b are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable.

Question 95

Sterilization of ultra-high molecular weight polyethylene by gamma irradiation in air will degrade its wear performance because of

Explanation

DISCUSSION: Gamma irradiation has long been used as a sterilization method for polyethylene. Exposure to gamma irradiation causes breakage of the chemical bonds in the polyethylene, and oxidation will occur if the material is subsequently exposed to air. The amount of oxidation and decrease in wear performance is also related to the length of time that the gamma-irradiated polyethylene is exposed to oxygen.
REFERENCES: Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
McKellop H, Shen FW, Lu B, et al: Effect of sterilization method and other modifications on the wear resistance of acetabular cups made of ultra-high molecular weight polyethylene: A hip-simulator study. J Bone Joint Surg Am 2000;82:1708-1725.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.

Question 96

A 3-year-old patient with L3 myelomeningocele has bilateral dislocated hips. Management should consist of

Explanation

DISCUSSION: In patients with myelomeningocele, the presence of bilateral hip dislocation does not affect ambulation, bracing requirements, sitting ability, degree of scoliosis, or level of comfort. There is little evidence to support active treatment of bilateral hip dislocations in patients with myelomeningocele proximal to L4.
REFERENCES: Fraser RK, Hoffman EB, Sparks LT, et al: The unstable hip and mid-lumbar myelomeningocele. J Bone Joint Surg Br 1992;74:143-146.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 65-76.

Question 97

What structure is the primary restraint to inferior translation of the shoulder?

Explanation

DISCUSSION: The coracohumeral ligament has been shown to be the primary restraint to inferior translation of the shoulder. Although Bigliani and associates have demonstrated that the inferior capsule and inferior glenohumeral ligaments also play a role, none of the other choices provide primary inferior stability of the shoulder. The coracohumeral ligament is an important structure of the rotator interval of the shoulder (the rotator interval contains the long head of the biceps, the superior glenohumeral ligament, the coracohumeral ligament, and a thin layer of capsule). Harryman and associates demonstrated that an open rotator interval closure via imbrication of the coracohumeral ligament improves inferior stability of the glenohumeral joint.
REFERENCES: Harryman DTII, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53 -66.
Bigliani LU, Pollock RG, Soslowsky LJ, et al: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.
Boardman ND, Debski RE, Warner JJ, et al: Tensile properties of the superior glenohumeral and coracohumeral ligaments. J Shoulder Elbow Surg 1996;5:249-254.

Question 98

In regards to a genetic disorder, which of the following is an example of "anticipation?"

Explanation

Genetic anticipation is a phenomenon in which a genetic disorder becomes progressively more severe and earlier in onset with each generation. Examples of disorders exhibiting anticipation include Huntington's disease and myotonic dystrophy.
Genetic anticipation is an important concept in understanding the development and genetic implications of many heritable disorders. It is a common phenomenon in trinucleotide repeat expansion disorders. These disorders are due to unstable microsatellite trinucleotide repeats that expand beyond the normal threshold. In subsequent generations these expansions become longer and thus express disease characteristics at a younger age of onset, and often with greater severity.
Martorell et al. investigated the development of CTG trinucleotide repeats in patients with myotonic dystrophy type 1 (DM1) and their relatives. They discovered unaffected individuals carry a pre-mutation sequence which can lead to trinucleotide repeat expansion in subsequent generations and thus produce offspring with the disorder.
Kamsteeg et al. compare the characteristics of DM1 and DM2. Both are due to trinucleotide repeat expansions. However, while DM1 can present with earlier onset and increasing severity in each generation, DM2 does not exhibit this genetic anticipation.
Incorrect Answers

Question 99

A 12-year-old child with spina bifida paraplegia requires brace management for ankle stability. Which of the following principles applies to brace management in this individual?

Explanation

DISCUSSION: Bracing for spina bifida paraplegia provides both support and improved function of the movable limb. An orthosis has value in controlling unstable joints. The three-point pressure effect applies a force above and below the joint to prevent it from buckling. A four-point pressure effect is only required for a two-joint system (this patient has problems only at the ankle). A longer lever arm brace and a brace with a greater area of support provide better stability. Finally, a straighter limb, without contracture, applies less pressure to the brace and lessens overload to the skin.
REFERENCES: Gage JR: An overview of normal walking. Instr Course Lect 1990;39:291-303.
Bleck EE: Current concepts review: Management of the lower extremities in children who have cerebral palsy. J Bone Joint Surg Am 1990;72:140-144.
Harris MB, Banta JV: Cost of skin care in the myelomeningocele population. J Pediatr Orthop 1990;10:355:361.

Question 100

A 10-year-old boy with severe hemophilia A (factor VIII) sustained an injury to his right forearm 2 hours ago when a classmate fell on his arm during a scuffle. Examination reveals moderate swelling in the forearm, decreased sensation in the distribution of the median and ulnar nerves, and pain on passive extension of the fingers. What is the most appropriate sequence of treatment?

Explanation

DISCUSSION: The patient has severe hemophilia with a volar forearm hemorrhage and an emerging compartment syndrome. Therefore, it is critical to normalize the clotting deficiency as the first step in treatment. In a patient who has a factor VIII level of less than 1% and no inhibitors to factor VIII, transfusion with 4 unit/kg will typically raise the factor VIII level to 100%. Continuous transfusion can then be used to maintain this level. Compartment pressures can be safely measured after infusion of factor VIII. Because the hemorrhage is of limited duration and any surgery is considered serious in a patient with hemophilia, the compartment pressure should be measured before making a decision regarding a fasciotomy. However, it is important to note that the use of factor VIII concentrates allows both emergency and elective surgery provided that adequate hematology backup is available. Splinting the elbow and wrist in flexion reduces the pressure in the volar compartments, protects the forearm from further trauma, and makes the patient more comfortable.
REFERENCES: Greene WB: Diseases related to the hematopoietic system, in Morrissy RT, Weinstein SL (eds): Lovell & Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 345-391.
Greene WB, McMillan CW: Nonsurgical management of hemophilic arthropathy, in Barr JS (ed): Instructional Course Lectures 38. Park Ridge, Ill, American Academy of Orthopaedic Surgeons, 1989, pp 367-381.
Naranja RJ Jr, Chan PS, High K, Esterhai JL Jr, Heppenstall RB: Treatment considerations in patients with compartment syndrome and an inherited bleeding disorder. Orthopedics 1997;20:706-711.

Full Question & Answer Text (for Search Engines)

Question 1:

What is the most important muscle adaptation resulting from endurance training? Review Topic

Options:

Increased recruitment of motor units
Formation of additional myofibers (hyperplasia)
Hypertrophy of individual myofibrils
Increase in capillary density
Increased activity of glycolytic enzyme

Correct Answer: Increase in capillary density

Explanation:

Question 2:

Flow cytometry of tumors measures the

Options:

Size of cells
Amount of DNA in cells
Nucleus-cytoplasm ratio
Specific DNA sequences
Specific messenger RNA sequences

Correct Answer: Amount of DNA in cells

Explanation:

Question 3:

Options:

Continued physical therapy
Alteration of medication to include an anti-epileptic
Tarsal tunnel release
Sympathetic blocks
Neurostimulation

Correct Answer: Sympathetic blocks

Explanation:

Question 4:

Storage of musculoskeletal allografts by cryopreservation is achieved by

Options:

replacing water in the tissue with alcohol to a moisture level of 5% and then using a vacuum process to remove the alcohol from the tissue.
maintaining maximum cellular viability of fresh tissue without long-term storage.
using chemicals to remove cellular water and controlled rate freezing to prevent ice crystal formation.
freezing the graft twice and packaging the tissue without solution at minus 80 degrees C.
freezing the graft in water without an antibiotic solution soak during quarantine, with final storage in liquid nitrogen.

Correct Answer: using chemicals to remove cellular water and controlled rate freezing to prevent ice crystal formation.

Explanation:

Question 5:

- A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Options:

Spinal shock
Neurogenic shock
Hypovolemic shock
Pulmonary embolism
Fat embolus syndrome

Correct Answer: Neurogenic shock

Explanation:

Question 6:

Options:

Restore normal limb alignment
Restore normal limb alignment and height
Have no effect on limb alignment and height
Stabilize degree of genu varum, but not improve limb alignment

Correct Answer: Restore normal limb alignment and height

Explanation:

This patient has familial hypophosphatemic rickets, a vitamin D-resistant form of rickets that is an X-linked inherited disorder. Patients are short (< 10th percentile). Varus occurs both in the distal femur and proximal tibia. Patients have increased urinary excretion of phosphorus, leading to hypophosphatemia. Calcium levels are within defined limits and vitamin D levels can be normal as well. Treatment should include phosphate and 1,25 dihydroxy vitamin D3 (calcitriol). Phosphate administration increases the plasma concentration,
which lowers plasma ionized calcium concentration and further reduces plasma calcitriol concentration (removal of hypophosphatemic stimulus). Secondary hyperparathyroidism results because of both hypocalcemia and removal of the
normal inhibitory effect of calcitriol on parathyroid hormone (PTH) synthesis. Elevated PTH levels will increase urinary phosphate excretion, defeating the aim of oral therapy.
Addition of calcitriol is necessary to increase the intestinal absorption of calcium and phosphate to prevent secondary hyperparathyroidism. Massive doses of vitamin D alone can restore normal radiographic appearances to the epiphyses, but normal growth is not restored unless phosphate replacement is adequate.
A 35-year-old woman began to train for a half marathon. After 8 weeks of increasing her mileage, what changes can you expect in her Achilles tendon?
Net decrease of type I collagen
Net increase of type I collagen
Increased diameter of collagen fibrils
Increased cross-sectional area of the tendon
Training increases turnover of type I collagen, promoting both synthesis and degradation of collagen and a net increase synthesis of type I collagen in tendon-related tissue.
Strenuous endurance training has resulted in decreased collagen cross-links, suggesting increased collagen turnover, but decreased collagen maturation. In human studies, physical training results in increased turnover of collagen. Synthesis and degradation are elevated initially when beginning an exercise program, but degradation products decrease overall. It is not known if activity levels in humans affect the diameter of collagen fibrils or the cross-sectional area of tendons.
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Question 7:

Options:

Flexor digitorum superficialis (FDS) branch transfer to the extensor carpi radialis brevis (ECRB) branch
Third web space median fascicle transfer to the ulnar sensory fascicle
Flexor carpi ulnaris fascicle (FCU) transfer to the biceps branch
Terminal anterior interosseous nerve (AIN) transfer to the deep ulnar motor fascicle

Correct Answer: Terminal anterior interosseous nerve (AIN) transfer to the deep ulnar motor fascicle

Explanation:

EXPLANATION:
In adults, the repair of high ulnar nerve injuries typically yields incomplete motor recovery and disappointing functional results despite early surgical intervention and careful surgical technique. Early transfer of the terminal branch of the AIN to the deep ulnar motor fascicle can rapidly reinnervate distal targets and potentially preserve motor end plate function in the intrinsic musculature of the hand because of the proximity of the nerve transfer to the target muscle. Sensory deficits due to an ulnar nerve injury
can be restored through a transfer of median sensory fascicles to the distal ulna sensory fascicles. This procedure typically would not be considered at the time of the original surgery, because sensory recovery is more likely than motor recovery in the setting of a high ulnar nerve injury. For radial nerve injuries, wrist extension can be restored through an FDS branch of the median nerve transfer to the ECRB branch of the radial nerve. The FCU fascicle of the ulnar nerve can be transferred to the biceps branch of the
musculocutaneous nerve to restore elbow flexion and supination.

Question 8:

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

Options:

Posterior heel
Plantar-lateral foot
Plantar-medial foot
Dorso-lateral foot
Dorso-medial foot

Correct Answer: Dorso-lateral foot

Explanation:

DISCUSSION: The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot.
REFERENCES: Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567.
Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.

Question 9:

Surgical restoration of sagittal balance of an adult spinal deformity will have which effect on outcome?

Options:

No effect
Improve leg-related symptoms but not back pain
Improve quality of life and back pain
Improve quality of life and leg-related symptoms

Correct Answer: Improve quality of life and back pain

Explanation:

DISCUSSION
The influence of sagittal balance on outcomes following fusion-based procedures for degenerative conditions of the lumbar spine has only recently been appreciated. Restoration of sagittal spinal balance improves low-back-pain outcomes and quality of life. Sagittal spinal balance has not been shown to relieve neurogenic claudication attributable to spinal stenosis.
RECOMMENDED READINGS
Li Y, Hresko MT. Radiographic analysis of spondylolisthesis and sagittal spinopelvic deformity. J Am Acad Orthop Surg. 2012 Apr;20(4):194-205. doi: 10.5435/JAAOS-20-04-194. Review. PubMed PMID: 22474089.
View Abstract at PubMed
Korovessis P, Repantis T, Papazisis Z, Iliopoulos P. Effect of sagittal spinal balance, levels of posterior instrumentation, and length of follow-up on low back pain in patients undergoing posterior decompression and instrumented fusion for degenerative lumbar spine disease: a multifactorial analysis. Spine (Phila Pa 1976). 2010 Apr 15;35(8):898-905. doi: 10.1097/BRS.0b013e3181d51e84. PubMed PMID: 20354466.
View
Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 99 AND 100
Figures 99a and 99b are MR images of a 59-year-old man with a history of intravenous (IV) drug abuse who arrives at the emergency department with malaise and fever. Upon admission, the patient's temperature is 38.9°C, his white blood cell count is 17000/µL (reference range [rr], 4500-11000/µL), his erythrocyte sedimentation rate is 98 mm/h (rr, 0-20 mm/h), and his C-reactive protein level is 45 mg/L (rr, 0.08-3.1 mg/L). He is admitted to the medical service to evaluate the source of his fevers. On hospital day 1, the patient reports weakness in his left arm and leg. Blood cultures are positive for methicillin-resistant Staphylococcus aureus.
A B

Question 10:

Osteoclastic bone resorption is stimulated primarily by what molecular interaction?

Options:

Parathyroid hormone (PTH)-osteoclasts
Interleukin-6 (IL-6) and IL-8
Receptor activator of nuclear factor kappa beta (RANK)-RANK ligand (RANKL)
Osteoprotegrin (OPG)-RANKL

Correct Answer: Receptor activator of nuclear factor kappa beta (RANK)-RANK ligand (RANKL)

Explanation:

Question 11:

Options:

increased medical complications of treatment.
osteonecrosis of the jaw.
improved long-term survival rates.
anorexia.
decreased quality of life measures.

Correct Answer: osteonecrosis of the jaw.

Explanation:

Question 12:

Which of the following factors is most critical to the success of a meniscal allograft transplantation?

Options:

Accurate graft size
Donor cell viability
Reestablishment of the central meniscal blood supply
Suppression of the immune response
Cryopreservation of the donor graft

Correct Answer: Accurate graft size

Explanation:

Question 13:

Options:

Plastic
Elastic
Fatigue
Creep
Torsion

Correct Answer: Elastic

Explanation:

Question 14:

Options:

High parathyroid hormone, normal calcium, normal alkaline phosphatase, low phosphorus, low vitamin D
High parathyroid hormone, low calcium, high alkaline phosphatase, low phosphorus, low vitamin D
Normal parathyroid hormone, high calcium, low alkaline phosphatase, low phosphorus, low vitamin D
Low parathyroid hormone, normal calcium, normal alkaline phosphatase, low phosphorus, low vitamin D
Low parathyroid hormone, low calcium, high alkaline phosphatase, low phosphorus, low vitamin D

Correct Answer: High parathyroid hormone, normal calcium, normal alkaline phosphatase, low phosphorus, low vitamin D

Explanation:

Question 15:

Which of the following clinical scenarios represents an appropriate indication for convex hemiepiphysiodesis/hemiarthrodesis in the treatment of a child with a congenital spinal deformity?

Options:

A 3-year-old child with a hemivertebra opposite a contralateral bar and thoracic scoliosis that measures 53°
A 4-year-old child with a fully segmented L1 hemivertebra and scoliosis that measures 80°
A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50°
A 4-year-old child with a posterolateral hemivertebra at the thoracolumbar junction and a kyphoscoliotic deformity that measures 45°
A 10-year-old child with a hemivertebra and scoliosis that measures 50°

Correct Answer: A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50°

Explanation:

Question 16:

Figure 39 shows the radiograph of a 4-month old infant who has been undergoing weekly casting since birth for a congenital equinovarus deformity. Management should now consist of

Options:

surgical correction.
continued casting.
botulinum toxin injection into the gastrocnemius-soleus complex.
an ankle-foot orthosis.
observation with no further treatment.

Correct Answer: surgical correction.

Explanation:

DISCUSSION: The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique.
REFERENCES: Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992,
pp 135-136.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,
pp 927-935.
Tachdjian MO: Pediatric Orthopedics, ed 2. Philadelphia, PA, WB Saunders, 1990,
pp 2461-2564.

Question 17:

Based on the findings seen at C5-6 in Figure 30, the most likely deficit for this patient will be weakness of the

Options:

deltoid.
wrist flexor.
wrist extensor.
triceps.
grip.

Correct Answer: wrist extensor.

Explanation:

Question 18:

Options:

Posterior horn of the medial meniscus
Semimembranosus tendon
Medial tibial plateau
Medial head of the gastrocnemius tendon
Medial plica

Correct Answer: Posterior horn of the medial meniscus

Explanation:

Question 19:

Options:

Joint stiffness
Cold intolerance
Decreased sweating
Osteopenia
Disproportionate pain

Correct Answer: Disproportionate pain

Explanation:

Question 20:

Options:

anterior release and fusion at T4-10.
posterior instrumentation and fusion at T9-L5.
posterior instrumentation and fusion at T2-L2.
posterior instrumentation and fusion at T6-pelvis.

Correct Answer: posterior instrumentation and fusion at T2-L2.

Explanation:

DISCUSSION
When planning surgical intervention for Scheuermann kyphosis, it is imperative that the instrumentation and fusion extend across the entirety of the deformity. Distally, this means extending across the first lordotic disk space. In this scenario, this disk is the L1-L2 disk, which means the fusion needs to extend to L2. Shorter and longer fusions are not necessary or appropriate.
RECOMMENDED READINGS
Denis F, Sun EC, Winter RB. Incidence and risk factors for proximal and distal junctional kyphosis following surgical treatment for Scheuermann kyphosis: minimum five-year followup. Spine (Phila Pa 1976). 2009 Sep 15;34(20):E729-34. PubMed PMID: 19752692.
View
Abstract at PubMed
Macagno AE, O'Brien MF. Thoracic and thoracolumbar kyphosis in adults. Spine (Phila Pa 1976). 2006 Sep 1;31(19 Suppl):S161-70. Review. PubMed PMID: 16946634.
View Abstract
at PubMed
CLINICAL SITUATION FOR QUESTIONS 55 THROUGH 59
A 60-year-old woman has severe neck and back pain. She is relatively healthy but has diabetes and neuropathy involving her lower extremities. Her body mass index is 38. She has a history of spinal fusion performed by your colleague 3 years ago. At that time, she was treated for degenerative scoliosis of the lumbar spine with concomitant spinal stenosis. A 360-degree fusion was performed from L4-S1 with a posterior decompression from L2-S1 and a posterior instrumented fusion from T3 to the pelvis. On examination, she has reproducible pain and a visible kyphosis in the periscapular region. Neurologic examination findings are within normal limits, with the exception of lower-extremity dysesthesias related to her neuropathy. The patient states that she has been having progressive difficulty dressing herself and taking care of her apartment for several months. Plain radiographs and a standing scoliosis series demonstrate a solid fusion from the sacrum to T3 without evidence of hardware failure. There is focal collapse of the T2-T3 disk space and a proximal kyphosis involving the T2 vertebrae that is indicative of disk and ligamentous failure.

Question 21:

What is the primary benefit of using rhBMP-2 instead of autogenous bone graft inside an anterior spinal fusion cage?

Options:

Substantially improved radiographic fusion success rate
Substantially decreased time to fusion healing
Substantially decreased hospital stay
Elimination of autograft harvest
Elimination of need for postoperative bracing

Correct Answer: Elimination of autograft harvest

Explanation:

Question 22:

Options:

Sliding hip screw
Dynamic condylar screw
95 blade plate
Cephalomedullary nail
Intramedullary hip screw

Correct Answer: Sliding hip screw

Explanation:

Question 23:

Options:

above-knee amputation.
preoperative chemotherapy, wide resection of the distal femur, and reconstruction.
preoperative chemotherapy and above-knee amputation.
wide resection of the distal femur and subsequent reconstruction, followed by chemotherapy.
curettage and placement of methylmethacrylate.

Correct Answer: preoperative chemotherapy, wide resection of the distal femur, and reconstruction.

Explanation:

Question 24:

What structure (arrow) is shown in Figure 24?

Options:

Ilioinguinal nerve
Sympathetic chain
Ureter
Iliac vein
L5 nerve

Correct Answer: Sympathetic chain

Explanation:

DISCUSSION: The structure illustrated is the sympathetic chain viewed from an anterolateral view of the lower lumbar spine. It descends along the anterolateral aspect of the spine into the pelvis closely adherent to the vertebral column. The spinal nerves, including L5, can be seen exiting from the foramen. The ureters descend from the kidneys and cross anterior to the iliac vessels to the bladder.
REFERENCES: Onibokun A, Khoo LT, Holly L: Anterior retroperitoneal approach to the lumbar spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 101-105.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 25:

The palmar cutaneous branch of the median nerve (PCBMN) originates from the

Options:

radial side of the median nerve and travels radial to the palmaris longus and ulnar to the flexor carpi radialis.
radial side of the median nerve and travels distally radial to the palmaris longus and flexor carpi radialis.
ulnar side of the median nerve and travels radial to the palmaris longus and ulnar to the flexor carpi radialis.
ulnar side of the median nerve and travels radial to the flexor carpi radialis.
ulnar side of the median nerve and travels radial to the palmaris longus volar.

Correct Answer: radial side of the median nerve and travels radial to the palmaris longus and ulnar to the flexor carpi radialis.

Explanation:

Question 26:

Options:

Cast removal and measurement of carpal canal pressure
Immediate carpal tunnel release and pinning of the fracture
Continued observation
Surgical reduction and pinning of the fracture
Electromyography/nerve conduction velocity studies

Correct Answer: Immediate carpal tunnel release and pinning of the fracture

Explanation:

Question 27:

Options:

back muscle stretching and reduced weight in the backpack.
consultation with a pain management specialist.
MRI of the thoracic spine.
a technetium Tc 99m bone scan.
a thoracolumbosacral orthosis.

Correct Answer: back muscle stretching and reduced weight in the backpack.

Explanation:

DISCUSSION: Mild scoliosis is not a painful condition, but it usually presents during adolescence. Intermittent back pain is reported by 25% to 30% of adolescents whether or not scoliosis is present. Such pain is often attributed to muscle strain from tight muscles, poor posture, or heavy school backpacks. The clinician must distinguish typical pain (mild, intermittent, nonlimiting) from atypical pain. The latter requires more careful examination and imaging studies (bone scan or MRI) to determine the source of pain. The patient’s age and right thoracic curve pattern are typical for idiopathic scoliosis; therefore, imaging of the neuroaxis is not necessary to look for cord syrinx, tethering, or tumor. Brace treatment is not required for this small curve unless future progression is demonstrated.
REFERENCES: Ramirez N, Johnston CE, Browne RH: The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am 1997;79:364-368.
Hollingworth P: Back pain in children. Br J Rheum 1996;35:1022-1028.
Siambanes D, Martinez JW, Butler EW, et al: Influence of school backpacks on adolescent back pain. J Pediatr Orthop 2004;24:211-217.

Question 28:

A patient with a transverse femur fracture undergoes statically locked antegrade intramedullary nailing. Postoperatively, the patient appears to have a

Options:

Settle the case because the surgeon made an error that resulted in unnecessary surgery, and thus the case is indefensible.
Settle the case because they are likely to lose the case, and it would be cheaper to settle than to defend.
Defend the case alleging that there was no error, and no damages, and that the patient is malingering.
Defend the case because despite there being an error, the error was corrected and there were little or no damages compared with expected outcomes.
Contact the patient directly to discuss why he is suing and attempt an amicable resolution.

Correct Answer: Defend the case because despite there being an error, the error was corrected and there were little or no damages compared with expected outcomes.

Explanation:

Question 29:

Options:

Flexor hallucis longus
Flexor digitorum longus
Flexor digitorum brevis
Peroneus longus
Split anterior tibial tendon

Correct Answer: Flexor digitorum longus

Explanation:

Question 30:

Options:

Rotator cuff repair and biceps tenodesis
Rotator cuff repair and loose body removal
Latissimus dorsi transfer
Bankart repair

Correct Answer: Rotator cuff repair and biceps tenodesis

Explanation:

DISCUSSION
Video 7 for reference
The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove.
The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 31:

A 44-year-old man sustains the injury shown in Figures 1 through 3. What is the most appropriate treatment?

Options:

Reduction and internal fixation
Closed reduction and splinting alone
Carpometacarpal arthrodesis
Carpometacarpal (CMC) joint suspension arthroplasty

Correct Answer: Reduction and internal fixation

Explanation:

Question 32:

Based on the Young and Burgess classification of pelvic ring injuries, an anterior-posterior compression type II injury does not result in disruption of which of the following?

Options:

pubic symphysis
anterior sacroiliac ligaments
posterior sacroiliac ligaments
sacrospinous ligament
sacrotuberous ligament

Correct Answer: pubic symphysis

Explanation:

Question 33:

The risk of local recurrence after surgical resection of a soft-tissue sarcoma is most closely related to

Options:

the size of the tumor.
the grade of the tumor.
the site of the tumor.
the surgical margin.
radiation therapy.

Correct Answer: the surgical margin.

Explanation:

Question 34:

What is the most common short-term complication following femoral impaction grafting for revision total hip arthroplasty?

Options:

Periprosthetic fracture
Infection
Loosening
Osteolysis
Dislocation

Correct Answer: Periprosthetic fracture

Explanation:

Question 35:

Options:

osteoarthritis of the hip is likely to occur later in life.
correction prevents later development of osteoarthritis.
most acetabular tears are symptomatic, and surgical treatment will be necessary.
this is an inherited deformity.

Correct Answer: osteoarthritis of the hip is likely to occur later in life.

Explanation:

Question 36:

Options:

Improvement in her pain and sensory symptoms following surgery but may have residual bladder dysfunction
Decreased pain following surgery; sensory deficits and bladder function are not likely to improve
No change in her symptoms following surgery
Complete resolution of pain and will have normal sensation and bladder function following surgery
Improvement in her pain and complete return of bladder function following surgery; sensation may not return

Correct Answer: Improvement in her pain and sensory symptoms following surgery but may have residual bladder dysfunction

Explanation:

Question 37:

Options:

Serum calcium normal
Serum alkaline phosphatase normal
Urine calcium is low
Serum phosphate is often high When symptomatic, the masses are excised. This lesion is benign and removal of normal tissue and radiation therapy are not necessary. Notice the lobules of amorphous calcification that are centered about the hip joint. This is the characteristic appearance of tumoral calcinosis.

Correct Answer: Serum phosphate is often high When symptomatic, the masses are excised. This lesion is benign and removal of normal tissue and radiation therapy are not necessary. Notice the lobules of amorphous calcification that are centered about the hip joint. This is the characteristic appearance of tumoral calcinosis.

Explanation:

Slide 1 Slide 2
A 20-year-old patient who is otherwise healthy has a soft mass over her hip. The mass has formed over the past 2 years. The radiographs are shown in Slides 1 and 2. Which of the following would be a common finding:

Question 38:

A total shoulder arthroplasty (TSA) would be the most appropriate treatment in which of the following arthritic patients? Review Topic

Options:

A 75-year-old female with a longstanding history of brachial plexus palsy
A 63-year-old male with a 6 month history of shoulder pain and inability to abduct past 30 degrees
A 67-year-old female with chronic shoulder pain and evidence of significant proximal migration of the humerus on x-ray
A 70-year-old female with severe shoulder pain and radiographic evidence of glenoid erosion to the coracoid process
A 72-year-old male who is 9 months status post right TKA for OA with debilitating shoulder pain and an MRI demonstrating an intact rotator cuff

Correct Answer: A 75-year-old female with a longstanding history of brachial plexus palsy

Explanation:

Question 39:

Following insertion of a cementless femoral component into the total hip arthroplasty construct, the amount of femoral stress shielding is most associated with

Options:

presurgical bone mineral density.
material modulus.
characteristics of the ingrowth/ongrowth surface.
extent of the ingrowth/ongrowth surface.

Correct Answer: presurgical bone mineral density.

Explanation:

Question 40:

Options:

curettage.
radiation therapy.
observation.
bisphosphonates.
ray resection.

Correct Answer: observation.

Explanation:

DISCUSSION: Enchondromas are the most common benign skeletal lesions identified in the bones of the hand. Most are incidentally found or initially become clinically evident after a pathologic fracture. If the patient has a fracture, the hand is immobilized until union. If the lesion is large and further pathologic fractures are expected, then an intralesional curettage and grafting procedure may be warranted. In this patient, the lesion has not significantly altered the size, shape, or morphology of the involved metacarpal head and recurrent fracture is unlikely. Observation with follow-up radiographs is considered appropriate management.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 213-228.
Marco RA, Gitelis S, Brebach GT, et al: Cartilage tumors: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:292-304.

Question 41:

Options:

Union rates are in excess of 95% if treated nonsurgically.
A figure-of-8 brace is superior to a sling for nonsurgical management.
Open reduction and internal fixation increases the likelihood of a nonunion.
Open reduction and internal fixation results in improved functional outcomes.
Open reduction and internal fixation and nonsurgical management have equivalent outcomes at 1 year.

Correct Answer: Open reduction and internal fixation results in improved functional outcomes.

Explanation:

Question 42:

Options:

Conversion to a periarticular 'hybrid' frame
Open reduction and internal fixation with a lateral nonlocking plate
Open reduction and internal fixation with a lateral locking plate
Open reduction and internal fixation with medial and lateral plates
Open reduction and internal fixation with posteromedial and lateral plates

Correct Answer: Open reduction and internal fixation with posteromedial and lateral plates

Explanation:

Question 43:

In Dupuytren’s disease, the retrovascular cord typically displaces the radial proper digital nerve of the ring finger in what direction?

Options:

Palmarly and radially
Dorsally and ulnarly
Palmarly and ulnarly
Dorsally and radially
Directly dorsal

Correct Answer: Palmarly and ulnarly

Explanation:

DISCUSSION: Retrovascular cords are common in Dupuytren’s disease and commonly require surgical treatment. Nerve injury in Dupuytren’s surgery is an infrequent complication that occurs partly because the digital nerves can be displaced from their normal anatomic relationships by retrovascular cords. The nerves are displaced superficially, toward the center of the digit (palmarly and ulnarly). This displacement is typically seen at the level of the metacarpophalangeal joint.
REFERENCE: Rayan GM: Palmar fascial complex anatomy and pathology in Dupuytren’s disease. Hand Clin 1999;15:73-86.

Question 44:

ofhat parameter is most commonly used to estimate the maximum tension a muscle can generating?

Options:

Length
Moment arm
Total volume
Physiologic cross-sectional area
Distribution of slow and fast twitch fibers

Correct Answer: Physiologic cross-sectional area

Explanation:

Question 45:

Options:

Ban the athlete from sports participation.
Allow the athlete to participate as it is his constitutional right to do so.
Advise the college to revoke the athlete's college scholarship.
Offer no opinion as it is a matter strictly between the college and the athlete.
Recuse yourself from all decision making and advise the athlete to get an opinion from a third-party physician who is not employed by the college or university.

Correct Answer: Ban the athlete from sports participation.

Explanation:

Question 46:

Which group experiences the highest rate of anterior cruciate ligament (ACL) tears?

Options:

Female athletes with valgus knee alignment and small femoral notch width
Female athletes with valgus knee alignment and large ACL width
Male athletes with valgus knee alignment and small ACL width
Male athletes with varus knee alignment and small femoral notch width

Correct Answer: Female athletes with valgus knee alignment and small femoral notch width

Explanation:

DISCUSSION
ACL tears are several times more common among women than men. Women who land from jumps in increased valgus and external rotation are at particularly increased risk for ACL tears. Women have smaller notch widths and a smaller ACL cross-sectional area than men, but these factors have not been proven to increase risk for ACL tears.
CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 67
Figure 64 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.

Question 47:

The superior glenohumeral ligament primarily restrains

Options:

posterior translation of the humeral head with the arm in 90 degrees of abduction.
inferior translation of the humeral head with the arm in adduction.
anterior translation of the humeral head in 90 degrees of abduction.
anterior translation of the humeral head with the arm in 45 degrees of abduction.
anterior translation of the humeral head with the arm in 90 degrees of abduction and external rotation.

Correct Answer: inferior translation of the humeral head with the arm in adduction.

Explanation:

Question 48:

Options:

placement of a chest tube.
insertion of a large gauge needle into the second intercostal space.
cardiopulmonary resuscitation.
administration of adrenaline.
immediate transfer to the emergency department.

Correct Answer: insertion of a large gauge needle into the second intercostal space.

Explanation:

Question 49:

Figure 26 shows the radiograph of an otherwise healthy Caucasian 5-year-old boy who has a painless limp. What is the best treatment option?

Options:

Shelf procedure
Salter osteotomy
Chiari osteotomy
Varus derotation osteotomy
Physical therapy and range-of-motion exercises

Correct Answer: Physical therapy and range-of-motion exercises

Explanation:

DISCUSSION: The prognosis of Legg-Perthes disease in children younger than age 6 years is good. There is no indication that surgical treatment will improve the outcome. Range-of-motion exercises to prevent contracture may be helpful.
REFERENCES: Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 691-704.

Question 50:

Options:

Nonoperative treatment with a sling and swathe for six weeks
Nonoperative treatment with immediate active range of motion of the shoulder
Closed reduction in the emergency room
Open reduction and percutaneous pinning with thoracic surgery back-up
Open reduction and ligament reconstruction with thoracic surgery back-up

Correct Answer: Nonoperative treatment with a sling and swathe for six weeks

Explanation:

Question 51:

Figure 41 shows the MRI scan of a 38-year-old weightlifter. What does the arrow on the MRI scan indicate? Review Topic

Options:

Biceps tear
Pectoralis minor tear
Pectoralis major tear
Subscapularis tear
Abscess formation

Correct Answer: Pectoralis major tear

Explanation:

Question 52:

A metal-on-metal bearing used for total hip arthroplasty shows which of the following properties?

Options:

Baseline serum ion levels increase with increasing activity levels.
The risk of cancer is substantially increased.
Linear ion production increases over time.
Ions produced are excreted primarily through the kidney.
Nickel is the most prevalent ion released into circulation.

Correct Answer: Ions produced are excreted primarily through the kidney.

Explanation:

DISCUSSION: Activity levels do not affect cobalt and chromium ion levels, which are the bulk of serum ion levels. The majority of ions are produced in the run-in period in the first several years. A gradual reduction in ion levels occurs thereafter. The kidneys are responsible for the bulk of clearance from the serum, and to date there is no relationship of cancer to ion levels in the serum.
REFERENCE: Heisel C, Silva M, Skipor AK, et al: The relationship between activity and ions in patients with metal-on-metal bearing hip prostheses. J Bone Joint Surg Am 2005;87:781-787.

Question 53:

Options:

Discontinue the procedure and delay completion of the total arthroplasty until the fracture has healed.
Cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.
Remove all instrumentation, perform an open reduction and internal fixation of the fracture, and delay completion of the total arthroplasty until the fracture has healed.
Insert a standard humeral component and apply a humeral orthosis postoperatively.
Insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture.

Correct Answer: Insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture.

Explanation:

Question 54:

Options:

Removal of the press-fit implant and cementing of the same femoral stem
Removal of the uncemented femoral component and placement of a revision modular taper- fluted femoral stem
Removal of the implant, placement of a cerclage wire around the femoral neck above the lesser trochanter, and reinsertion of the implant
Final seating of the uncemented femoral component without additional measures

Correct Answer: Removal of the implant, placement of a cerclage wire around the femoral neck above the lesser trochanter, and reinsertion of the implant

Explanation:

Question 55:

Options:

Lining up of collagen fibers within the ligaments
Stretching of elastin within the disk and ligaments
Transition between flexion and extension
Reversible elongation of the soft tissues
Traumatic range of motion, resulting in damage to the soft tissues

Correct Answer: Traumatic range of motion, resulting in damage to the soft tissues

Explanation:

Question 56:

Options:

Posterolateral herniated nucleus pulposus at L3-4
Posterolateral herniated nucleus pulposus at L4-5
Degenerative disk disease at L3-4 and L4-5 with no significant facet hypertrophy
Degenerative spondylolisthesis at L3-4 with central and foramenal stenosis
Degenerative spondylolisthesis at L4-5 with central stenosis

Correct Answer: Degenerative spondylolisthesis at L3-4 with central and foramenal stenosis

Explanation:

Question 57:

Which of the following types of intra-articular pathology is associated with lateral meniscal cysts? Review Topic

Options:

Discoid meniscus
Posterolateral corner injury
Vertical meniscal tears
Middle third lateral meniscal tears
Popliteus tendon tears

Correct Answer: Middle third lateral meniscal tears

Explanation:

Question 58:

Options:

Acetabular osteolysis
Femoral osteolysis
Acetabular loosening
Femoral loosening
Femoral and acetabular loosening

Correct Answer: Femoral loosening

Explanation:

DISCUSSION: These radiographs are dominated by the subsidence of the femoral component. There is also evidence of polyethylene wear and femoral osteolysis in the region of the greater trochanter. There is no evidence of proximal (calcar) stress shielding, and there is a thick distal pedestal. Engh and associates defined two major signs of osseointegration - the absence of radiolucent lines around the porous-surfaced portion of the implant and new bone bridging the gap between the endosteal surface and the porous portion of the implant. Implant migration indicates failure of ingrowth. Osteolysis is a periprosthetic loss of bone secondary to particulate debris and it is often clinically silent unless it is accompanied by pathologic fracture. It is often globular. Acetabular loosening is based on radiolucent lines and implant migration. The current radiographs demonstrate subsidence of the stem with pedestal formation.
REFERENCES: Engh CA, Massin P, Suthers KE: Roentgenographic assessment of biologic fixation of porous-surface femoral components. Clin Orthop Relat Res 1990;257:107-128.
Engh CA, Hooten JP, Zettl-Schaffer KF, et al: Evaluation of bone ingrowth in proximally and extensively porous-coated anatomic medullary locking prostheses retrieved at autopsy. J Bone Joint Surg Am 1995;77:903-910.

Question 59:

Options:

Infection
Heterotopic ossification
Dislocation
Periprosthetic fracture
Acetabular component loosening

Correct Answer: Acetabular component loosening

Explanation:

Question 60:

A biopsy of the involved physis in a patient with slipped capital femoral epiphysis (SCFE) would most likely reveal

Options:

a dense perichondral ring.
an abnormally thick zone of proliferation.
increased undulations or irregularity of the growth plate.
granulation tissue between the columns in the zone of hypertrophy.
normal proteoglycan content.

Correct Answer: granulation tissue between the columns in the zone of hypertrophy.

Explanation:

Question 61:

Which of the following methods of treating a vertically oriented (eg, Pauwels III) femoral neck fracture is mechanically optimal?

Options:

Two parallel fully threaded screws
Three parallel partially threaded screws
Three parallel fully threaded screws
Four parallel partially threaded screws
Sliding hip screw and side plate

Correct Answer: Two parallel fully threaded screws

Explanation:

Vertical fractures have a higher rate of displacement and nonunion because of shearing forces across the fracture. Biomechanical and clinical studies indicate that for the vertically oriented fracture of the femoral neck, the most stable fixation construct is a sliding hip screw and side plate. Antirotation screws may be used as well. Nonsurgical management carries a high risk of early displacement because of shear forces. Three screws are loaded as a cantilever and have less resistance to displacement compared with a fixed-angle device with a side plate. Fully threaded screws will not allow any compression and have the same drawbacks as partially threaded screws. The addition of a fourth screw has not been shown to be of benefit.
(SBQ12TR.68) Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated non-operatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?
Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with nonoperative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than nonsmokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:

Question 62:

A 25-year-old student sustains the injury shown in Figures 13a through 13c after falling off a curb. Initial management should consist of

Options:

weight bearing as tolerated in a hard-soled shoe.
weight bearing as tolerated in an ankle lacer.
weight bearing as tolerated in a short leg cast.
non-weight-bearing in a hard-soled shoe.
non-weight-bearing in a short leg cast.

Correct Answer: non-weight-bearing in a short leg cast.

Explanation:

Question 63:

Options:

Anterior cord syndrome
Central cord syndrome
Posterior cord syndrome
Brown-Séquard syndrome
Spinal shock

Correct Answer: Anterior cord syndrome

Explanation:

Incomplete cord syndromes have variable neurologic findings with partial loss of sensory and/or motor function below the level of injury. Incomplete cord syndromes include the anterior cord syndrome, the Brown-Séquard syndrome, central cord syndrome, and posterior cord syndrome. Central cord syndrome is characterized with greater motor weakness in the upper extremities than in the lower extremities. The pattern of motor weakness shows greater distal involvement in the affected extremity than proximal muscle weakness. Anterior cord syndrome involves a variable loss of motor function and pain and/or temperature sensation, with preservation of proprioception. The Brown-Séquard syndrome involves a relatively greater ipsilateral loss of proprioception and motor function, with contralateral loss of pain and temperature sensation. Posterior cord syndrome is a rare injury and is characterized by preservation of motor function, sense of pain, and light touch, with loss of proprioception and temperature sensation below the level of the lesion. Spinal shock is the period of time, usually 24 hours, after a spinal injury that is characterized by absent reflexes, flaccidity, and loss of sensation below the level of the injury.
(SBQ13PE.25) A 7-year-old girl presents with a early onset scoliosis as seen in the PA radiograph in Figure A. Images do not demonstrate any vertebral anomalies. Physical exam shows normal neurologic function in her lower extremities. An MRI of the spinal axis should be obtained to rule out all of the following pathologies EXCEPT:
Review Topic
Atlantoaxial rotatory instability
Syringomyelia
Spinal cord tumor
Dysraphism
Tethered cord
Early-onset scoliosis is associated with syringomyelia, spinal cord tumor, dysraphism, and tethered cord, and therefore they must be ruled out with a preoperative MRI. There is no association between early-onset scoliosis and atlantoaxial rotatory instability.
Early-onset scoliosis can be classified as idiopathic, neuromuscular, or congenital. For this patient without bony or neurologic abnormalities, it would likely be diagnosed as juvenile (bewteen ages 3 and 10 years) idiopathic scoliosis. Commonly associated spinal pathologies (even in patients with no radiographic or neurologic abnormalities) include syringomyelia, spinal cord tumor, dysraphism, tethered cord, and Arnold-Chiari malformation. Before considering any surgical intervention, such as a growing rod construct, these intra-spinal conditions must be ruled-out with an MRI of the spinal axis.
Gillingham et al. present a review of the etiology, diagnosis, and management of early-onset scoliosis. They cite other studies that demonstrated rates as high as 21% of patients with early-onset scoliosis and a normal neurologic exam having occult spinal pathology such as those mentioned above. They recommend MRI for patients with early-onset scoliosis measuring greater than 20° prior to any surgical intervention.
Figure A is a PA radiograph of a skeletally immature patient with a 90° right thoracic curve. Illustration A is an PA radiograph of the same patient after treatment with a growing-rod construct and correction of the scoliotic curve to 46°.
Incorrect Answers:

Question 64:

Options:

Loss of external rotation with the glenohumeral joint abducted 90 degrees
Loss of external rotation with the arm at the side of the body
Loss of internal rotation with the glenohumeral joint abducted 90 degrees
Loss of internal rotation up the back
Loss of flexion

Correct Answer: Loss of external rotation with the arm at the side of the body

Explanation:

Question 65:

Options:

Shoulder abduction
Shoulder internal rotation
Shoulder external rotation
Shoulder adduction

Correct Answer: Shoulder external rotation

Explanation:

Question 66:

Options:

Repeat debridement, followed by 6 weeks of IV antibiotics
Repeat debridement, followed by direct exchange arthroplasty
Delayed exchange reimplantation
Immediate knee arthrodesis
Amputation

Correct Answer: Delayed exchange reimplantation

Explanation:

Question 67:

What mechanism is associated with the spontaneous resorption of herniated nucleus pulposus?

Options:

Macrophage infiltration and phagocytosis
Granuloma formation
Antibody mediated destruction
Complement cascade activation
Major histocompatibility complex mediated pathways

Correct Answer: Macrophage infiltration and phagocytosis

Explanation:

Question 68:

Which of the following findings best describes the effects of increasing conformity of a fixed tibial bearing component and femoral component in total knee arthroplasty?

Options:

Increased peak contact stress, decreased component edge loading
Increased peak contact stress, increased component wear rates
Decreased peak contact stress, increased component wear rates
Decreased peak contact stress, decreased component wear rates
Decreased peak contact stress, decreased component edge loading

Correct Answer: Decreased peak contact stress, decreased component wear rates

Explanation:

Question 69:

Options:

have no difference in elbow pain.
no longer have elbow pain.
need surgery.
experience tendon rupture.

Correct Answer: have no difference in elbow pain.

Explanation:

Question 70:

Options:

a rigid cervical orthosis.
a soft cervical collar.
posterior C1-2 fusion with halo immobilization.
administration of methotrexate.
activity restrictions.

Correct Answer: posterior C1-2 fusion with halo immobilization.

Explanation:

Question 71:

Options:

the inability to extend the small finger.
weakness of small finger abduction.
sensory loss of the dorsal ulnar hand.
clawing of the small and ring fingers.

Correct Answer: sensory loss of the dorsal ulnar hand.

Explanation:

Question 72:

Options:

Adjunctive plate fixation without nail removal
Nail removal and plating
Partial fibulectomy at the same level as the tibia fracture and weightbearing cast application
Exchange nailing
Local administration of rhBMP-2

Correct Answer: Adjunctive plate fixation without nail removal

Explanation:

Question 73:

Options:

MRI to rule out a complete rupture
Ultrasound of the tendon apposition
Open reduction and internal fixation of the calcaneal fracture
Symptomatic care and physical therapy
Surgical repair with tendon debridement and flexor hallucis longus transfer

Correct Answer: Surgical repair with tendon debridement and flexor hallucis longus transfer

Explanation:

Question 74:

Options:

Transoral, transmucosal direct anterior approach to C2-3
Left-sided anterior approach to C2-3 (Smith-Robinson)
Right-sided posterior retropharyngeal approach to C2-3 (Whitesides)
Right-sided anterior approach to C2-3 (Smith-Robinson)
Right-sided anterior retropharyngeal approach with extended vertical incision (superior extension Smith-Robinson)

Correct Answer: Right-sided anterior retropharyngeal approach with extended vertical incision (superior extension Smith-Robinson)

Explanation:

Question 75:

Options:

acute and transient spinal cord injury.
central cord syndrome.
nerve root avulsion.
Guillain-Barre syndrome.
stinger/burner.

Correct Answer: stinger/burner.

Explanation:

Question 76:

Which of the following pieces of equipment currently offers the greatest opportunity for lowering the number of equestrian injuries? Review Topic

Options:

Knee pads
Wrist guards
Boots
Helmets
Quick release stirrups

Correct Answer: Helmets

Explanation:

Question 77:

A 40 year-old-man was involved in a motor vehicle accident and sustained the pelvic injury seen in Figures 24a and 24b. Definitive management of the injury should consist of reduction by

Options:

skeletal traction and bed rest.
anterior external fixation.
internal fixation of the symphysis pubis.
internal fixation of the symphysis pubis with supplemental external fixation.
internal fixation of the symphysis pubis and sacral fracture.

Correct Answer: internal fixation of the symphysis pubis and sacral fracture.

Explanation:

Question 78:

Options:

Axillary nerve injury
Cervical radiculopathy involving the C6 nerve root
Massive rotator cuff tear with loss of the transverse force couple
Long head of the biceps tendon rupture with loss of superior stabilizing effect

Correct Answer: Massive rotator cuff tear with loss of the transverse force couple

Explanation:

Question 79:

The most compelling clinical reason to convert a hip arthrodesis to a total hip arthroplasty is that the latter

Options:

improves hip range of motion.
relieves pain associated with arthritis of the lumbar spine.
relieves pain associated with arthritis of the knee.
relieves pain in the contralateral hip.
corrects a limb-length discrepancy.

Correct Answer: relieves pain associated with arthritis of the lumbar spine.

Explanation:

Question 80:

Options:

radial shortening osteotomy.
capitate shortening osteotomy.
scaphoid excision and four-corner fusion.
proximal row carpectomy.

Correct Answer: proximal row carpectomy.

Explanation:

Question 81:

Options:

splinting for 1 to 2 weeks, followed by a humeral fracture brace.
intramedullary nailing.
exploration of the radial nerve and intramedullary nailing.
exploration of the radial nerve and a humeral fracture brace.
exploration of the radial nerve and open reduction and internal fixation with plates and screws.

Correct Answer: splinting for 1 to 2 weeks, followed by a humeral fracture brace.

Explanation:

Question 82:

Options:

Lateral (fibular) condyle of the second metatarsal head
Second metatarsophalangeal sesamoid
Plantar condyle of the base of the proximal phalanx
Exostosis of the plantar second metatarsal head
Osteochondroma of the second metatarsal distal metaphysis

Correct Answer: Lateral (fibular) condyle of the second metatarsal head

Explanation:

Question 83:

What is the primary mechanism by which anabolic steroids increase muscle tissue? Review Topic

Options:

Increased production of cortisol
Increased production of messenger RNA
Increased secretion of vascular endothelial factor
Decreased production of HDL
Attenuation of the effects of cortisol

Correct Answer: Increased production of messenger RNA

Explanation:

Question 84:

Osteochondritis dissecans of the capitellum is a source of elbow pain and most commonly occurs in what patient population?

Options:

Swimmers and divers
Football lineman
Rugby players
Gymnasts and throwing athletes
Cyclists

Correct Answer: Gymnasts and throwing athletes

Explanation:

DISCUSSION: The etiology of osteochondritis dissecans of the capitellum is somewhat unclear. However, trauma has been implicated in this disease process. Gymnasts who load their upper extremities during tumbling and throwing athletes with repetitive trauma during the throwing motion are common patient subgroups in which osteochondritis dissecans of the elbow is seen. This often occurs in the adolescent age population.
REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520-523.
Takahara M, Ogino T, Fukushima S, et al: Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. Am J Sports Med 1999;27:728-732.

Question 85:

Figure 25 shows the CT scan of an adult patient who has neck pain following a motor vehicle accident. What is the most likely diagnosis?

Options:

Jefferson’s fracture
C1-C2 rotational instability
Transverse ligament rupture
Normal finding
Basilar invagination

Correct Answer: Transverse ligament rupture

Explanation:

Question 86:

Which of the following complications is uniquely associated with an anterior approach to the lumbosacral junction?

Options:

Nerve root injury
Erectile dysfunction
Dural tear
Pulmonary embolism
Retrograde ejaculation

Correct Answer: Retrograde ejaculation

Explanation:

Question 87:

Options:

Millett et al. reviewed 10 patients with post-operative shoulder infections and confirmed P. acnes infection. Cultures became positive at an average of 7 days after the start of incubation. They indicate that P. acnes shoulder infections may be insidious in onset and may lead to persistent shoulder pain.
Dodson et al. reviewed 11 patients who sustained P. acnes shoulder infections after undergoing shoulder arthroplasty. They found that cultures became positive at an average of 9 days from the start of incubation. They note that P. acnes shoulder infections are an important cause of implant failure, especially because patents may lack traditional signs of infection (clinical/laboratory).
Saltzman et al. review the microbiology, risk factors and management of infections after shoulder surgery. They indicate that deeper infections are more difficult to identify and can present in an insidious fashion. Cultures should be held for up to 21 days in order to account for fastidious organisms such as P. acnes., for 4 weeks to account for fungal organisms, and for 8 weeks to account for mycobacterium.
Matsen et al. studied the presence of P. acnes on skin and in surgical wounds of patients undergoing revision shoulder arthroplasty. Males were found to have more positive cultures for P.acnes than females; this included superficial and deep cultures. They recommend observing cultures for at least 17 days and being vigilant to minimize potential surgical wound contamination. Illustration A shows a gram stain of P. acnes, a gram-positive rod. Illustration B shows a scanning electron microscopic view of P. acnes.
Incorrect Answers:

Correct Answer: Saltzman et al. review the microbiology, risk factors and management of infections after shoulder surgery. They indicate that deeper infections are more difficult to identify and can present in an insidious fashion. Cultures should be held for up to 21 days in order to account for fastidious organisms such as P. acnes., for 4 weeks to account for fungal organisms, and for 8 weeks to account for mycobacterium.

Explanation:

A 47-year-old, healthy, active patient presents with a sub-acute, full-thickness supraspinatus tear. His physical examination reveals significant weakness and pain with abduction. There was no glenohumeral instability. Radiographs demonstrate a type 1 acromion. An MRI scan shows a crescent shaped tear with 2-cm of tendinous retraction and no tendinous fatty changes. A subacromial corticosteroid injection 6 weeks ago provided him with 24 hours of pain relief but no improvement in strength. What would be the most appropriate treatment option?
Repeat subacromial corticosteriod injection
Biological augmentation of rotator cuff with porcine small intestine xenograft Rotator cuff repair
Rotator cuff repair plus acromioplasty
Rotator cuff repair, remplissage procedure, bicep tenodesis and distal clavicle excision
This patient has an isolated supraspinatus rotator cuff tear with symptomatic weakness. The most appropriate treatment would be isolated rotator cuff repair.
The primary purpose of rotator cuff repair is to restore muscle function. Secondary outcomes include reduction of pain and prevention of irreversible cuff changes, specifically muscular atrophy. Non-operative treatment ( exercise, therapy and pain medications) are recommended for partial thickness tears. The indication of surgical repair includes, isolated supraspinatus weakness +/- pain
that correlates with MRI imaging of a respective full thickness tear. Routine acrominoplasty is not recommended in conjunction with rotator cuff repair, especially with no previous symptoms of impingement.
Pedowitz et al. developed clinical practice guidelines for the treatment of rotator cuff pathology. The strongest supporting evidence in current literature was given a grade of 'moderate' with four treatment recommendations. These were,
Exercise and non-steroidal anti-inflammatory drugs can be used to manage partial thickness tears,
Routine acromioplasty is not required the time of cuff repair,
Non-cross-linked, porcine small intestine submucosal xenograft patches should not be used to manage cuff tears, and
Surgeons can advise patients that workers' compensation status correlates with a less favorable outcome after rotator cuff surgery.
Illustration A shows the different shapes of rotator cuff tears. Incorrect Answers:
A 12-year-old baseball pitcher describes progressive worsening of medial elbow pain on
his throwing side. Examination reveals normal elbow range of motion. He is tender over the medial elbow to palpation. A dynamic ultrasound of his elbow shows no evidence of medial widening with valgus stress. His radiograph is shown in Figure A and an MRI is shown in Figure B. What is the most likely cause of his symptoms?
Displaced medial epicondyle avulsion fracture Medial apophysitis
Medial ulnar collateral ligament tear
Valgus extension overload with olecranon osteophytes Ulnar neuritis
The clinical presentation is consistent with Little League Elbow caused by medial apophysitis. Little League elbow is a general term explaining medial elbow pain in adolescent pitchers. The underlying pathology can include medial epicondyle stress fractures, avulsion fractures of the medial epicondyle, ulnar collateral ligament (UCL) injuries, or medial epicondyle apophysitis. In order to identify the underlying cause it is important to first rule out injury to the MCL by looking for medial widening on stress radiographs or dynamic ultrasound, or valgus instability on physical exam. Radiographs are useful to look for avulsion fractures or subtle physeal widening commonly seen with apophysitis.
Wei et al. obtained radiographs and magnetic resonance imaging on nine adolescent pitchers with a clinical diagnosis of Little League Elbow. They found radiographic findings in 4/9 and MRI findings in 6/9 patients. They emphasized that the MRI did not change management in any patients. Cain et al. review the different elbow conditions seen in throwing athletes. They emphasize the need to understand the underlying pathophysiology in order to treat and make appropriate changes to the biomechanics of the pitching technique.
Figure A shows an AP radiograph with slight widening of the apophysis, but no evidence of avulsion fracture. Figure B is an MRI which shows signal consistent with edema of the medial epicondyle apophysis.
Incorrect Answers:
The other responses are all typical throwing elbow conditions, but are much less common than apophysitis in the adolescent thrower.
What is the primary function of the structure labeled with an asterisk in Figure A?
Prevents inferior translation of the humerus with the arm by the side Provides internal rotation of the humerus
Prevents anterior translation of the humerus with the arm in 45 degrees of abduction Prevents anterior translation of the humerus with the arm in 90 degrees of abduction Provides supination of the forearm and elbow flexion
The labeled structure is the middle glenohumeral ligament (MGHL) of the shoulder. The primary function of the MGHL is to prevent anterior translation of the humeral head with the arm in 45-60 degrees of abduction.
This structure originates from the glenoid labrum and inserts medial to the lesser tuberosity running obliquely across the subscapularis. The size of the structure may be variable and there are recognized normal anatomic variants ( including a cord like MGHL in the Buford complex). It is important to be able to recognize the MGHL and differentiate this from the subscapularis, IGHL, SGHL, and other intraarticular structures in the shoulder to be able to perform effective and precise arthroscopic procedures.
Burkhart et al. describe the function of the glenohumeral ligaments in anterior shoulder instability, noting that the MGHL provides a restraint to anterior translation with the arm in 45-60 degrees of abduction.
Wang et al. discuss microdamage to the inferior glenohumeral ligament from a basic science perspective, indicating that over time it may stretch and compromise it's function in restraining humeral translation.
Figure A is an arthroscopic image of the intraarticular structures of the shoulder with an asterisk on the MGHL.
Incorrect Answers (these are labeled on Illustration A, with the exception of the subscapularis which is difficult to visualize):
In which of the following clinical circumstances would it be appropriate to eccentrically ream the anterior glenoid?
year-old male undergoing a shoulder arthroplasty due to rotator cuff arthropathy 65-year-old female with a glenoid retroversion of 13-degrees undergoing shoulder arthroplasty
year-old female with humeral anteversion of 13-degrees undergoing shoulder arthroplasty
year-old female with glenoid retroversion of 25-degrees undergoing shoulder arthroplasty
year-old male with significant glenoid bone stock deficiency and severe osteoarthritis
The surgeon should consider eccentrically reaming the anterior glenoid when performing a total shoulder arthroplasty on a patient with a retroverted glenoid due to posterior deficiency associated with osteoarthritic changes which is most consistent with answer choice #2.
Normal version of the glenoid is 0-3 degrees of retroversion, but when doing a total shoulder the goal should be to place the glenoid component in neutral to slight anteversion. Reaming the anterior glenoid to neutral is a technique to be considered by the operative surgeon when presented with a patient undergoing total shoulder arthroplasty with a retroverted glenoid, as failure to perform this step increases the chance for glenoid loosening. If reaming down the anterior glenoid will take away too much bone stock (down to the coracoid process), one may consider bone grafting the posterior glenoid. To perform a total shoulder arthroplasty patients will need a functioning rotator cuff and appropriate glenoid bone stock.
Clavert et al. performed cadaveric analysis to simulate glenoid retroversion of greater than 15 degrees and found that retroversion to this degree cannot be safely corrected with eccentric anterior reaming when using a glenoid component with peripheral pegs due to penetration into the glenoid vault.
Nowak et al. used 3D-CT models of patients with advanced shoulder osteoarthritis with varying degrees of glenoid retroversion and simulated glenoid resurfacing. They found that smaller size glenoid components may allow for greater version correction when using in-line pegged components, as they would be less likely to result in peg penetration.
Illustration A shows >25 degrees of glenoid retroversion seen by axial radiograph of the shoulder in a patient with advanced osteoarthritis. In this case, anterior glenoid reaming is not the correct answer and a posterior glenoid allograft reconstruction would be appropriate.
Incorrect Answers:
A 44-year-old left-hand dominant carpenter experienced immediate left elbow pain after trying to stop a heavy object from falling two days ago. Figure A shows a clinical image of the patient upon presentation. Physical exam shows full strength with wrist flexion, wrist extension, and pronation, but notable weakness with supination of the forearm. Sensory exam shows no deficits in the forearm or hand. There is a negative milking maneuver test and a positive hook test. Radiographs are shown in Figure B. What is the next most appropriate step in management?
Sling use as needed for comfort and progressive physical therapy Allograft reconstruction of the distal biceps tendon
Ulnar collateral ligament reconstruction Distal biceps tendon avulsion repair Brachioradialis and ECRB avulsion repair
Distal biceps tendon avulsion repair is the most appropriate next step in management.
Distal biceps tendon ruptures occur most commonly in middle-aged men and usually involve the dominant extremity. The mechanism of injury is usually a single traumatic event with eccentric force on the flexed elbow.
Sutton et al. authored a Level 5 review of distal biceps tendon ruptures. They discuss that nonsurgical management of distal biceps tears is appropriate in the low-demand or medically ill patient. Surgical repair improves elbow flexion strength by 30% and supination strength by 40% compared to nonoperative management.
O'Driscoll et al. conducted a Level 2 study examining the accuracy of the hook test for distal biceps rupture diagnosis. They found that the hook test was abnormal in 33 of 33 (100%) patients with complete biceps avulsions, and intact in 12 of 12 (100%) with partial detachments.
Figure A is a clinical image demonstrating ecchymosis in the distal arm and antecubital fossa. Figure B shows normal elbow radiographs. Illustration A shows a normal hook test with an intact distal biceps insertion.
Incorrect Answers:
Early reverse total shoulder designs (before the development of the Grammont-style prosthesis) had a high failure rate due to early loosening of the glenoid component. What biomechanical feature accounted for this problem?
Glenoid component did not have a neck Humeral component too horizontal Center of rotation too lateral
Center of rotation too anterior Center of rotation too inferior
Early reverse ball-and-socket designs failed because their center of rotation remained lateral to the scapula, which limited motion and produced excessive torque on the glenoid component, leading to early loosening. The first modern reverse prosthesis was designed by Paul Grammont. According to Boileau et al., Grammont's design "introduced 2 major innovations (1) a large glenoid hemisphere with no neck and (2) a small humeral cup almost horizontally oriented with a nonanatomic inclination of 155 degrees, covering less than half of the glenosphere. This design medializes the center of rotation compared to earlier versions which minimizes torque on the glenoid component. Furthermore, the humerus is lowered relative to the acromion, restoring and even increasing deltoid tension. The Grammont reverse prosthesis imposes a new biomechanical environment for the deltoid muscle to act, thus allowing it to compensate for the deficient rotator cuff muscles." According to Gerber, "moving the center of rotation more medial and distal as well as implanting a large glenoid hemisphere that articulates with a humeral cup in 155 degrees of valgus are the biomechanical keys to sometimes spectacular short- to midterm results".
Which of the following preoperative factors is a contraindication to total shoulder arthroplasty?
Passive external rotation less than 10 degrees Eccentric posterior glenoid erosion
A 2-cm full-thickness supraspinatus tendon tear Inflammatory arthritis
A preganglionic brachial plexus injury
A preganglionic brachial plexus palsy, otherwise known as a root avulsion injury, presents with a flail arm and has a poor prognosis for recovery of motor function. Patients with brachial plexus palsies are not candidates for total shoulder arthroplasty due to the substantial motor and sensory deficits associated with these injuries.
In contrast, patients with a preoperative loss of passive external rotation, posterior glenoid erosion, a reparable full-thickness rotator cuff tear isolated to the supraspinatus tendon, and inflammatory arthritis are not contraindicated for a total shoulder arthroplasty.
Iannotti et al. performed a Level I prospective study in 118 patients who underwent either a total shoulder arthroplasty or a shoulder hemiarthroplasty for primary osteoarthritis. The presence of a reparable full-thickness rotator cuff tear did not adversely affect outcomes in either group but rather provided better active external rotation in the cohort receiving total shoulder arthroplasties. The authors concluded that a reparable tear of supraspinatus is not a contraindication to the use of a glenoid component.
Norris et al. compared outcomes of total shoulder arthroplasty and hemiarthroplasty performed for primary osteoarthritis in 160 patients. There were no differences in postoperative pain, function, ASES scores, or range of motion between groups for patients with reparable rotator cuff tears. The authors concluded that minor thinning and small tears of the rotator cuff can be adequately addressed at the time of surgery without adversely affecting outcomes.
Illustration A is a cervical T2 axial MRI which shows a cervical root avulsion, a form of preganglionic brachial plexus injury. Notice the perineural hyperintensity.
Incorrect Answers:
A 42-year-old male sustains a flail chest injury and subsequently undergoes operative stabilization of his chest wall. At first follow-up, the inferior angle of his ipsilateral scapula translates medially with any attempt at overhead activity. Injury to which of the following structures would cause this abnormality?
Spinal accessory nerve C8 and T1 nerve roots
Upper and lower subscapular nerves Thoracodorsal nerve
Long thoracic nerve
The clinical vignette describes medial scapular winging, which is seen after injury to the long thoracic nerve.
Medial scapular winging due to a long thoracic nerve palsy can be seen after repetitive stretching in athletes, with direct compression injury, or even iatrogenically during surgical procedures to the lateral thorax. Injury to the long thoracic nerve will eliminate the function of the serratus anterior,
which acts to protract the scapula laterally and upward and stabilize the vertebral border of scapula. This results in upper extremity weakness in forward elevation or abduction as the scapula is not stabilized against the thorax.
Meininger et al. report that lesions of the long thoracic nerve and spinal accessory nerves are the most common cause of scapular winging, although numerous underlying etiologies have been described. They report patients describe diffuse neck pain, shoulder girdle discomfort, upper back pain, and weakness with abduction and overhead activities. They also report that most cases are treated nonsurgically.
Wiater et al. review injuries to the spinal accessory nerve which causes dysfunction of the trapezius and subsequent lateral scapular winging. They note that the superficial course of the spinal accessory nerve in the posterior cervical triangle makes it susceptible to injury, and iatrogenic injury to the nerve after a surgical procedure is one of the most common causes of trapezius palsy. Most injuries are treated nonoperatively, but the Eden-Lange procedure, in which the insertions of the levator scapulae, rhomboideus minor, and rhomboideus major muscles are transferred, relieves pain, corrects deformity, and improves function in patients with irreparable injury to the spinal accessory nerve.
Illustration A shows a clinical photo of medial scapular winging, while illustration B shows a clinical photo of lateral scapular winging. Illustration C shows the long thoracic nerve during a rib fixation procedure, with the nerve sitting directly on top of the serratus anterior. The trapezius is overlying the scapula at the bottom of the photo, and the patient's head is to the right of the photo. Incorrect Answers:
A patient sustains a distal biceps brachii tendon rupture. If treated non-operatively, the greatest loss of strength would be seen with which activity?
Forearm supination Forearm pronation
Elbow flexion
Shoulder forward flexion Shoulder internal rotation
While both elbow flexion and forearm supination strength are affected, there is a greater percentage loss of supination strength. Patients may complain of weakness and fatigue with rotational activities such as using a screwdriver. The primary elbow flexor is actually the brachialis, and therefore less weakness in flexion is reported.
Patterson reviewed distal biceps ruptures and found nonsurgical treatments had 21 55% loss of supination strength and 8 36% loss of flexion strength.
Klonz reviewed anatomic and non-anatomic repairs and found better results with anatomic repairs with 91% return of supination strength and 96% return of flexion strength. Supination strength after nonanatomic repair did not improve in 4 of 8 patients (42%-56% of the uninjured arm).
A 27-year-old right hand dominant construction worker falls off a scaffold onto his outstretched arm. Figure A exhibits the radiograph taken at a local emergency room.
Following treatment, he is placed in a sling and follows up at your office two weeks later. He complains of a feeling that his arm is going to 'pop out'. Which specific physical examination finding is likely to be present?
Hornblower's Test Jobe's Test
Apprehension Sign with shoulder abducted and externally rotated Speed's Test
Kim's Test
The patient suffered a posterior shoulder dislocation, likely injuring the posterior capsule and/or labrum. Out of all the answer choices, Kim's test assesses posterior structures. Thus, Kim's test is the physical examination finding most likely to be present.
Posterior dislocations occur less frequently than anterior dislocations, and are often missed. Following closed reduction, persistent instability can occur, usually associated with posterior capsular or labral pathology. Posteriorly directed provocative maneuvers, such as the Kim test can be positive.
Robinson et al. performed an epidemiologic analysis on 120 posterior dislocations. Recurrent instability occurred at a rate of 17.7%. Risk factors for recurrent instability included age less than 40-years-old, dislocation during seizure, and a large reverse Hill-sachs (>1.5 cm3). Kim et al. describe the Kim lesion, a separation between the posteroinferior labrum and the articular cartilage without complete detachment of the labrum, which cause persistent posterior instability.
Figure A depicts a posterior dislocation on xray. Illustration A depicts the Kim test, which is performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45° forward flexion while simultaneously applying axial load on the elbow and posterior-inferior force on the upper humerus. The test is positive when there is pain. Video 1 depicts the proper way to perform a Kim Test.
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A 27-year-old male bodybuilder presents to the office with vague, deep shoulder pain and weakness with his bench press. His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. Radiographs are normal, and an MRI arthrogram is shown in Figure A. Which of the following is the most likely etiology of his complaints?
Pectoralis major rupture Supraspinatus partial thickness tear SLAP lesion
Tendonitis of the long head of the biceps Posterior labral tear
The clinical presentation and MRI are consistent with a Posterior labral tear.
Posterior labral tears are commonly seen in individuals that have repeated posteriorly-directed stress across their glenohumeral joint (football linemen, bodybuilders). These patients will often present with ill-described pain deep in their shoulder joint, along with decreases in shoulder strength. Focused shoulder examinations, such as the Jahnke Jerk Test or Push-pull test, can elicit pain from posterior labral tears; however, the sensitivity and specificity of these tests remain under question.
Mair et al. reviewed the outcome of posterior labral injuries in nine athletes who underwent arthroscopic repair with a bioabsorbable tack after failure of conservative management; all were
able to return to contact sports. They note that posteriorly applied forces can result in a shear-type vector that can cause posterior labral tears without capsular injury.
Bradley et al. reviewed 91 athletes with unidirectional recurrent posterior shoulder instability that were treated with an arthroscopic posterior capsulolabral reconstruction. They found that significant improvements in stability, pain, and function at a mean of 27 months postoperatively. Eightynine percent of the patients were able to return to their sport.
Figure A shows an axial MRI arthrogram of the shoulder with a posterior labral tear and an associated paralabral cyst. Illustration A is another axial shoulder MRI arthrogram cut showing a posterior labral tear (red arrow) and an associated paralabral cyst (yellow arrows).
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A patient sustains a full thickness tear of their teres minor. Which of the following test/signs would most likely be positive in this patient?
Jobe's test Belly press test
Internal rotation lag sign Hornblower's sign Hawkin's sign
Hornblower's test is completed by asking the patient to hold their shoulder in 90 degrees of abduction and 90 degrees of external rotation. The test is positive if the arm falls into internal rotation or they are unable to actively externally rotate against resistance. This suggests teres minor pathology.
There are various tests/signs used by clinicians to detect rotator cuff pathology. The teres minor is innervated by the axillary nerve and functions to externally rotate the humerus. The hornblower's test/sign has various descriptions, but all act to determine external rotation weakness. In addition to being sensitive and specific for teres minor pathology, it can also be positive with posterior supraspinatus tears.
Walch et al. review 54 patients that underwent repair of combined supraspinatus and infraspinatus rotator-cuff tears. They found that the hornblower's sign was highly sensitive and specific for irreparable degeneration of the teres minor, while the dropping-sign was highly sensitive and specific for irreparable degeneration of the infraspinatus.
Hertel et al. prospectively review 100 patients with painful shoulders and impingement syndrome. They compared various lag signs (ERLS-external rotation lag sign, IRLS-internal rotation lag sign, drop sign) to the Jobe and lift-off signs. The ERLS was less sensitive but more specific than the
Jobe sign for the supraspinatus/infraspinatus. The drop sign was the least sensitive but was as specific as the ERLS. The IRLS was as specific but more sensitive than the lift-off sign for subscapularis tears.
Illustration A shows another variation of the hornblower's sign as originally desbribed by Arthui et
positive if the patient is unable to do this without abducting the affected arm and demonstrates the difficulty in raising the hand to the mouth in the absence of external rotation of the shoulder. The video provided shows how to perform both variations of the hornblower's test.
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Reverse total shoulder arthroplasty combined with latissimus dorsi transfer would be
most appropriate for which of the following patients?
year-old male with post-traumatic shoulder arthritis after a four-part proximal humerus fracture with no motor dysfunction
year-old male with grade 4 shoulder arthritis with severe deltoid muscle dysfunction secondary to a stroke
year-old female with significant rotator cuff arthropathy, a negative Hornblower sign and less than 5 degrees of external rotation lag
year-old female with pseudoparesis of anterior elevation and external rotation, narrowing of gleno-humeral joint and acetabularization of the acromion
year-old male with grade 4 shoulder arthritis and an isolated supraspinatus tear
Reverse total shoulder arthroplasty combined with latissimus dorsi transfer would be most appropriate in a patient with pseudoparesis of anterior elevation and external rotation, in the setting of shoulder arthritis (narrowing of glenohumeral joint and acetabularization of the acromion).
Combining a latissimus dorsi tendon transfers with reverse total shoulder arthroplasty (R-TSA) helps to restore control of active external rotation. Dysfunction with external rotation can be determined clinically with external rotation lag sign, a positive Hornblower's sign, and radiographically with fatty degeneration of the teres minor classified as stage 2 or greater according to the system of Goutallier et al. or Fuchs et al.
Gerber et al. found that R-TSA with combined lat dorsi transfer yielded minimal improvements in external rotation ROM (13 deg to 19 deg) compared to increases in shoulder ROM in flexion (94 deg to 137 deg) and abduction (87 deg to 145 deg), with this procedure.
Boileau et al. examined 17 consecutive patients treated with reverse shoulder arthroplasty and latissimus dorsi and teres major transfer (L'Episcopo). They found that external rotation increased from -21 degrees to 13 degrees (+34 degrees ). They recommend transferring both the LD and TM, rather than the LD alone as it results in better active external rotation.
Illustration A is a radiograph showing a right reverse total shoulder replacement. Illustration B shows a cadaveric image of the positioning of the latissimus dorsi tendon transfer prior to implantation of the reverse total shoulder components.
Incorrect Answers
Figure A and B are MRI images of a 42-year-old male with symptoms of right shoulder neuropathy. If this patient has an abnormality detected on EMG and nerve conduction testing, which of the following nerves is most likely to be involved?
Subscapular nerve Axillary nerve Musculocutaneous nerve Suprascapular nerve Long thoracic nerve
This patient is presenting with suprascapular nerve compression secondary to a spinoglenoid cyst. Injuries of the posterior shoulder joint capsule or posterior-superior labrum can result in spinoglenoid cysts. They may lead to suprascapular nerve palsy.
Patients will present with characteristic findings of external rotation
( infraspinatus) weakness when the cyst is isolated in the spinoglenoid notch. If the cyst is located in the suprascapular notch, both external rotation weakness and abduction (supraspinatus) weakness will be present. Electromyography and MRI are the investigations of choice in depicting the etiology of this mononeuropathy.
Piatt et al. found posterosuperior labral tears in 65/73 patients who had spinoglenoid notch cysts. All patients presented with should pain and weakness. Patients undergoing surgical intervention by drainage or excision +/- arthroscopic labral repair had a better outcome than non-operative care.
Westerheide et al. reported fourteen patients who underwent arthroscopic decompression of ganglion cysts associated with suprascapular neuropathy. All patients had a labral tear intraoperatively with arthroscopic drainage and labral repair. There was not recurrence at an average of 51 months of followup.
Piasecki et al. reviewed suprascapular neuropathy. Causes include:nerve entrapment along this path, particularly at the vulnerable suprascapular and spinoglenoid notch, as well as extrinsic compression by soft-tissue masses.
Figures A is a coronal MRI showing a large hyperintense mass medial to the glenoid articulation. Figure B shows an axial MRI of the lesion posterior to the glenoid. Illustration A shows a diagram of the posterior right shoulder. The suprascapular nerve can be seen traveling through the spinoglenoid notch. Incorrect Answers:
A 12-year-old right-hand-dominant pitcher presents with progressive right shoulder pain. He is now unable to pitch. He is tender to palpation over the lateral shoulder and has pain with rotation. An AP radiograph of the affected shoulder is shown in Figures A and a contralateral radiograph is shown in Figure B. What is the most likely diagnosis?
Septic arthritis of the shoulder SLAP tear
External impingement Internal impingement
proximal humerus. Patients may report a recent increase in pitching regimen. On examination, there is focal tenderness at the level of the physis. Treatment focuses on rest, physical therapy and a progressive throwing program. Pitching is often stopped for 2-3 months during rehabilitation.
Chen et al. review shoulder and elbow injuries in the young athlete. Little
Leaguer's shoulder results from epiphyseal lysis secondary to microtrauma. Pain over the anterolateral shoulder may be elicited on examination. The mainstay of treatment is 2-3 months of rest and return to pitching via a progressive throwing program.
Mcfarland et al. review techniques to prevent injuries in the throwing athletes. They note that overuse injures can be avoided when appropriate throwing mechanics are enforced and pitch counts are li
physeal widening noted especially when compared to the contralateral normal pediatric shoulder view seen in Figure B.
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A 35-year-old carpenter has pain in the antecubital fossa that is worse with turning a screwdriver. He has undergone non-operative treatment for 6 months without relief. On physical examination his hook test is normal and there is pain and weakness with resisted supination. Radiographs are shown in Figures A-C. A MRI of the right elbow is shown in Figure D. The next most appropriate treatment is?
Exploration of the radial tunnel Superficial radial neurectomy
Detachment and repair of the biceps tendon Transfer of the biceps to the brachialis EMG with nerve conduction study
While complete trauamtic rupture of the distal biceps is more common, partial tears have been reported in the literature. The most common presentation is pain in the antecubital fossa worse with resisted supination.
Conservative management consists of NS
Transfer to the brachialis improves flexion strength but not supination.
Ramsey et al present a review article on distal biceps tendon injuries. They state that the most successful management of partial distal biceps tears that have failed conservative management is to surgically treat it like a complete rupture with release and surgical reattachment of the distal biceps to the radial tuberosity.
Figures A-C are normal radiographs of the elbow. Figure D is a crossreferenced axial and coronal T2 MRI that demonstrates increased signal and partial distal biceps tendon tearing. Illustration C shows the resected region of distal biceps tendon in the same patient and had an excellent functional outcome following distal biceps release and surgical reattachment with 2 double-loaded suture anchors.
Video V demonstrates The hook test for detecting complete distal biceps tendon avulsions.
A 49-year-old man sustains a dislocation of his left elbow that is successfully reduced and splinted. He misses his scheduled follow-up appointments and returns 6 weeks later. He is immediately enrolled in a course of vigorous physical therapy. At a repeat visit at 6 months, examination reveals that he lacks 40 degrees of elbow extension, and has flexion to 80 degrees. He is taken to the operating room for surgical release. Figures A and B are diagrams depicting the ligamentous attachments about the elbow. To restore elbow flexion, in addition to releasing the articular capsule, which ligament should be released?
Ligament A Ligament B Ligament C Ligament D Ligament E
In addition to capsular release, the posterior band of the medial collateral ligament (MCL) should be released.
The posterior band of the MCL is attached dorsal to the axis of rotation and has greater variation in length. It increases in length by 9 mm between 60° and 120° of flexion. Posterior band contracture leads to loss of elbow flexion. In contrast, the anterior band of the MCL (AMCL) maintains a constant length ( isometric) throughout the entire arc of movement. Anterior capsule contracture leads to loss of extension.
Wada et al. treated 14 elbows with post traumatic contracture. Through a medial incision, the ulnar nerve was freed and the posterior band and posteromedial joint capsule were excised. Mean flexion increased from 89° preop to 127° postop. Anterior capsulectomy was performed for limited extension.
Morrey et al. studied structures providing stability about the elbow. They found that the anterior capsule stabilizes the elbow to varus-valgus stress in extension, not in flexion. The anterior band of the MCL is a primary stabilizer, especially in flexion.
Figures A and B are medial and lateral illustrations of the elbow, respectively, depicting the ligamentous attachments. Illustrations A and B are radiographs are 3D CT reconstruction images of the left elbow, respectively, showing heterotopic ossification around the posterior band of the MCL.
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A 23-year-old male sustains a dislocation of his elbow that was successfully closed reduced in the emergency room. 3 months later, the patient presents with pain and a catching sensation in his elbow. On physical exam, he is noted to have a positive lateral pivot-shift test. Incompetence of which of the following ligaments in Figure A is most commonly associated with his condition?
A B C D E
The patient is presenting with symptoms and physical exam consistent with posterolateral rotatory instability. Injury to the lateral ulnar collateral ligament
( LUCL), labeled C in Figure A, allows an abnormal external rotation
( supination) of the ulna on the humerus. This results in posterolateral rotatory instability. Posterolateral rotatory instability often presents as pain and recurrent clicking, snapping, clunking, or locking of the elbow. It should be noted that frank dislocations are not the most common presenting symptom. The physical exam is usually benign except for a positive lateral pivot-shift test or posterolateral rotatory drawer test. While injury to the LUCL is thought to be the primary pathology, other ligamentous stabilizers of the elbow may play a role.
Mehta et al. review posterolateral rotatory instability of the elbow. They state the instability usually results from an elbow dislocation with subsequent failure to heal of the ligamentous structures.
Patients with recurrent instability often require surgical intervention, as bracing is typically cumbersome and ineffective.
The video provided shows how to perform the lateral pivot-shift test. The patient is placed in the supine postion with forearm overhead and elbow extended. The elbow is then supinated with force and flexed to >40° while a valgus load applied. A positive result is palpable / visible clunk as the ulna and radius reduce suddenly. Illustration A shows the posterolateral rotatory drawer test.
External rotation and posterior forces are applied to the forearm attempting to sublux the radius posterior to the capitellum.
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Figure A is the MR image of the left shoulder of an active 47year-old painter who has been experiencing shoulder pain for 9 months. In addition to the finding shown in Figure A, MRI examination of the intra-articular portion of the biceps tendon shows fraying greater than 50%. He has not obtained relief from an 8 month course of non-operative management including non-steroidal antiinflammatory medications, physical therapy and corticosteroid injection. What is the best next step in treatment?
New course of physical therapy
Activity shutdown with 6 weeks sling immobilization
Arthroscopic superior labrum anterior to posterior (SLAP) tear repair Arthroscopic debridement and possible biceps tenotomy versus tenodesis
Arthroscopic rotator cuff repair and acromioplasty
This patient has a Type II SLAP lesion. These should only rarely be repaired in patients older than 40 years of age. If a source of pain refractory to nonoperative management, biceps tenotomy or tenodesis should be considered.
SLAP repair for Type II SLAP lesions is a procedure that has enjoyed a high success rate in young patients. These are generally not indicated for repair in patients greater than 40 years of age due to high rate of stiffness postoperatively. A subset of patients continue to do poorly after SLAP repair. Poor range of motion and the development of post-surgical adhesive capsulitis is often an etiology for poor results. Arthrofibrosis recalcitrant to diligent therapy over many months can be treated with arthroscopic capsular release. This is predicated on failure of a dedicated course of physical therapy as part of a non-operative management course lasting greater than six months. As the propensity for stiffness increases with age, consideration should be treated with SLAP tear debridement and biceps tenotomy or tenodesis in patients greater than 40 years old. Tenotomy or tenodesis, however, can be effective at providing pain relief in the presence of proximal biceps tendon pathology.
Katz et al. reviewed 34 patients who presented to their group for management of failed SLAP repair. 50% were Worker's Compensation cases. The mean age at the time of initial SLAP repair was 43 years. They treated these patients conservatively initially followed by revision surgery in 21 cases. All completed a course of physical therapy initially. They concluded that once a patient has failed SLAP repair, there is a high chance of further conservative treatment failing. Although revision surgery improves outcomes, 32% will continue to have a "suboptimal" result. Holloway et al. reviewed 50 patients who underwent arthroscopic capsular release for adhesive capsulitis, comparing three groups: (1) post-surgical; (2) post-fracture; and (3) idiopathic adhesive capsulitis. All patients had completed supervised physical therapy and a home exercise program for at least one year. They concluded that arthroscopic capsular release improved range of motion equally for all three groups but patients in the post-surgical group had poorer subjective pain, function and satisfaction scores.
Figure A is an MRI showing a Type II SLAP tear. Illustration A shows the classification of SLAP lesions.
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A 30-year-old man undergoes arthroscopic Bankart repair for recurrent anterior dislocation. He continues to experience instability postoperatively. Examination reveals a positive apprehension test. Radiographs of both shoulders are seen in Figure A. CT scan of his left shoulder is seen in Figure B. What is the best treatment option?
Bankart repair
Humeral head bone augmentation Remplissage
Coracoid autograft Connolly procedure
This patient has anterior glenoid bone deficiency (inverted pear glenoid) from a large bony Bankart lesion that was not adequately addressed in the index procedure. This is best treated with bony augmentation using the Latarjet vascularized coracoid transfer.
Patients with glenoid bone defects >20-30% have a high recurrence rate
(>60%) after Bankart repair alone. Bone grafting is necessary to offer containment. Autograft options include coracoid transfer (such as the Latarjet procedure which extends the articular arc and creates a conjoined tendon sling) and iliac crest bone grafting.
Burkhart et al. addressed glenohumeral bone defects. They advise that significant bone deficits cannot be adequately addressed via arthroscopic Bankart repair alone. The Latarjet transfer creates an extra-articular platform to extend the articular arc of the glenoid.
Hantes et al. assessed Latarjet repairs using CT. They found that there is almost complete repair of a 25% to 30% glenoid defect when using the Latarjet procedure.
Figure A comprises comparison Bernageau view glenoid profile radiographs of both shoulders.
Figure B is a 3D reconstruction CT with showing glenoid bone deficiency (inverted pear deformity) with a large bony Bankart lesion. Illustration A shows the method of obtaining a Bernageau glenoid profile view. Illustration B shows the "cliff sign" of anterior glenoid bone loss.
Illustration C depicts the Latarjet procedure. Illustration D depicts reduction in the articular arc with anterior glenoid loss.
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Figure A shows an arthroscopic picture of a 62-year-old male undergoing repair of a torn subscapularis tendon. In the image shown, G represents the glenoid, H represents the humeral head, and the dotted line represents the superolateral border of the subscapularis tendon. Which two ligaments form the structure marked with the asterisk?
Inferior and middle glenohumeral ligaments Middle and superior glenohumeral ligaments Coracohumeral and coracoacromial ligaments
Coracohumeral and superior glenohumeral ligaments Superior and inferior glenohumeral ligaments
The coracohumeral and superior glenohumeral ligaments form a complex that marks the superolateral margin of the subscapularis tendon.
In chronic or degenerative tears, the subscapularis will often retract medially and become scarred to the deltoid fascia. This makes identification difficult during arthroscopic repair. The coracohumeral and superior glenohumeral ligaments form a complex that inserts on the superolateral margin of the subscapularis. This "comma sign" can usually be identified during arthroscopic repair making identification of the subscapularis tendon an easier task.
Burkhart and Brady present surgical pearls for arthroscopic repairs of the subscapularis. Amongst other things, they state the subscapularis is almost always repairable with proper mobilization, but an Achilles tendon allograft or a subcoracoid pectoralis major transfer may be used for a severely degenerated subscapularis.
Lo and Burkhart describe the comma sign for repair of chronic subscapularis tears. They describe how the superior glenohumeral ligament/coracohumeral ligament complex and subscapularis tendon are intimately associated, and often tear off the humerus while remaining attached to each other. This complex, when torn, forms a "comma sign," that marks the superior and lateral margins of the subscapularis tendon.
Illustration A shows why the convergence of the superior glenohumeral and coracohumeral ligaments on the superolateral border of the subscapularis is referred to as the "comma sign." Incorrect Answers:
A 52-year-old man sustained the left elbow injury shown in Figure A while playing basketball 2.5 months ago. He underwent the procedure shown in Figure B. Post-operatively he was mobilized in a hinged brace. On examination today, his arc of elbow flexion is 75 degrees with loss of 45 degrees of full extension. His Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure score is 45 points. What initial treatment option will likely provide the greatest improvement in this patients DASH score and functional range of motion?
Self-directed exercise therapy Supervised exercise therapy
Supervised exercise therapy with static progressive elbow splinting Continuous passive motion device
Closed manipulation under anesthesia
The clinical presentation is consistent with post-traumatic elbow stiffness following an elbow fracture-dislocation. Supervised exercise therapy with static elbow splinting over a 6 month period
has shown to have a significant improvement on DASH scores and functional range of motion (ROM) in patients with post-traumatic elbow stiffness.
Post-traumatic elbow stiffness is often difficult to manage. The ultimate goal of treatment is to restore a functional range of elbow motion (30° to 130°). Nonoperative modalities are considered the first-line of treatment. Aggressive physical therapy has traditionally been advocated. However, the use of static progressive elbow splinting with a turnbuckle, alongside aggressive physical therapy, has shown to provide better functional outcomes. Treatment is usually maintained over a period of 6-12 months. Surgery is considered when nonoperative therapy fails.
Doornberg et al. looked at a retrospective case series of 29 patients with posttraumatic elbow stiffness. They showed that static progressive splinting can help gain additional motion when standard exercises fail to produce additional improvements.
Lindenhovius et al. randomized sixty-six patients with post-traumatic elbow stiffness into static progressive elbow splint therapy or dynamic elbow splinting over a 12 month period. There was no significant difference in outcomes between treatment modalities. ROM increased by 40° vs. 39° at six months, respectively. DASH scores improved from 50 vs 45 at enrollment to 32 vs. 25 at six months, respectively.
Figure A shows a posterior elbow dislocation with an associated medial epicondyle fracture. Figure B shows ORIF of the fracture seen in Figure A. Illustration A shows a static progressive turnbuckle elbow splint used for posttraumatic elbow stiffness.
Incorrect Answers:
tissues, causing hemarthrosis and additional fibrosis in the joint.
A 25-year-old right-hand baseball pitcher presents with persistent shoulder pain for the past several months in his dominant throwing arm. On physical examination, he is found to have full arc of motion with the exception of an internal rotation deficit of 30 degrees compared to his contralateral side. He is asked to complete the exercise shown in the video in Figure V. This form of rehabilitation is meant to address pathology in which anatomic structure?
Superior glenohumeral ligament Middle glenohumeral ligament
Anterior band of the inferior glenohumeral ligament Superior band of the inferior glenohumeral ligament
Posterior band of the inferior glenohumeral ligament
tissues in patients demonstrating symptoms of internal impingement. The sleeper stretch helps to address posterior tightness and the only posterior structure listed in the responses is the posterior band of the inferior glenohumeral ligament (posterior IGHL).
Internal impingement is a significant cause of pain in throwing athletes. It results from impingement of the articular undersurface of the posterior supraspinatus against the posteriorsuperior glenoid.
This is thought to be secondary to tightness in the posterior soft tissues including the capsule and posterior band of the IGHL. The mainstay of non-operative management is posterior capsular stretching with the sleeper stretches and cross-body adduction stretches. Heyworth et al. review the etiology, diagnosis and management of internal impingement of the shoulder. They note that repetitive contact between greater tuberosity and glenoid rim posterosuperiorly lead to impingement of the posterior rotator cuff and labrum. This occurs when the arm is externally rotated and abducted.
Tyler et al. reviewed the effects of posterior capsular stretching on alleviating symptoms in patients with internal impingement. Twenty-
Figure V is a video that demonstrates the sleeper stretch to address tightness of the posterior soft tissues. The arm is forward flexed 90 degrees and the patient lies on his side in order to stabilize the scapula while the arm is internally rotated. Illustration A depicts the sleeper stretch.
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not the focus of the sleeper stretch.
A 28-year-old professional baseball pitcher sustains a complete rupture of his ulnar collateral ligament. He is neurovascularly intact on exam. Which of the following surgical reconstruction techniques has been shown to result in the lowest complication rate and best patient outcome?
Splitting of flexor-pronator mass, figure-of-8 graft fixation. Splitting of flexor-pronator mass, docking graft fixation.
Splitting of flexor-pronator mass, docking graft fixation, ulnar nerve transposition. Detachment of flexor-pronator mass, figure-of-8 graft fixation, ulnar nerve transposition.
Detachment of flexor-pronator mass, docking graft fixation, ulnar nerve transposition.
Ulnar collateral ligament (UCL) reconstruction using a flexor-pronator musclesplitting approach and a docking graft fixation technique are associated with the lowest complication rate and best patient outcomes.
Vitale et al. performed a systematic review of retrospective cohort studies evaluating UCL reconstruction techniques in overhead athletes. They demonstrated that the flexor-pronator musclesplitting approach was associated with better outcomes than detachment of the flexorpronator mass, had a lower rate of postoperative ulnar neuropathy, and a lower overal complication rate. They also found fixation of the graft utilizing the docking technique was associated with better outcomes than the figure-of-8 technique. Abandoning the obligatory ulnar nerve transposition was associated with improved patient outcomes (89% vs. 75%) and a lower rate of postoperative ulnar neuropathy (4% vs. 9%).
Rettig et al performed a case series review of 31 overhead throwing athletes with ulnar collateral ligament injuries managed nonoperatively with 3 months rest followed by rehabilitation exercises. They concluded that 42% of athletes were able to return to their previous level of competition at an average of 6 months from diagnosis (earlier than reconstruction). The authors were unable to identify any patient-specific factors (duration of symptoms, age, acuity of onset) that would predict the success of nonoperative treatment.
Illustration A shows the figure-of-8 (Jobe) graft fixation technique. It is performed by passing the tendon graft through two bone tunnels in the medial epicondyle of the humerus and through one tunnel in the ulnar sublime tubercle. The graft is then sutured to itself in a figure-of-8 configuration. Illustration B shows the docking graft fixation technique. The graft is placed in a triangular configuration through a single humeral tunnel. The suture limbs are then brought out through two separate bone holes and tied over a bony bridge on the superior aspect of the medial epicondyle.
Incorrect Answers:
The right shoulder exercise seen in Figure A will put the LEAST amount of stretch on which structure?
Inferior glenohumeral ligament Coracohumeral ligament Anterior-superior capsule Superior glenohumeral ligament Posterior capsule
Shoulder wand exercises, as shown in Figure A, are used to increase external range of motion of the shoulder. With the arm adducted and the elbow flexed, this exercise will put the LEAST amount of stretch on the posterior capsule.
External rotation shoulder wand exercises are commonly used for the treatment of adhesive capsulitis. Adhesive capsulitis is most commonly caused by contracture of the rotator interval. The rotator interval includes the anterior-superior capsule, superior glenohumeral ligament, coracohumeral ligament and long head biceps tendon. The structure most commonly contracted is the anterior-superior capsule, which limits external rotation when the arm is adducted. Kuhn et al. showed that in the neutral position, each ligament except the posterior capsule significantly affected the torque required for external rotation. The greatest effect on resisting external rotation at 0 degrees of abduction was the entire inferior glenohumeral ligament > coracohumeral ligament
> anterior band of the inferior glenohumeral ligament > superior and middle glenohumeral ligament.
Harryman et al. looked at the role of the rotator interval capsule in passive motion and stability of the shoulder. They found operative alteration of this capsular interval was found to affect flexion, extension, external rotation, and adduction of the humerus with respect to the scapula. Limitation of external motion was increased by operative imbrication of the rotator interval and decreased by sectioning of the rotator interval capsule.
Kim et al. reviewed shoulder MRIs to determine if abnormalities of the rotator interval were correlated with chronic shoulder instability. They found a significantly larger rotator interval height, rotator interval area, and rotator interval index in patients with chronic anterior shoulder instability compared to patients without instability.
Figure A shows a patient performing an exercise to increase right shoulder external rotation with a wand/stick. The right arm is fully adducted by her side, and her elbow flexed at 90 degrees.
Incorrect Answers:
) A 55-year-old male returns for followup 3 months after reverse shoulder arthroplasty. He reports limited function of his right shoulder but no antecedent trauma. A radiograph of his shoulder is shown in Figure A. All of the following variables are associated with this complication EXCEPT:
History of malunited proximal humerus fracture Proximal humeral bone loss
Failed primary arthroplasty Rheumatoid arthritis
Fixed preoperative glenohumeral dislocation
Rheumatoid arthritis is not associated with reverse shoulder arthroplasty (RSA) dislocation. RSA dislocation is a known complication of RSA. Risks include proximal humeral bone loss, chronic fracture sequelae with malunited/ununited tuberosities, failed previous arthroplasty, and fixed glenohumeral dislocation preoperatively. An irreparable subscapularis tears may be less of an issue with newer implant designs.
Trappey et al. studied instability and infection rates after RSA. They found that the rate of instability was similar in primary and revision surgery, but the rate of infection was higher in revision surgery. Instability was highest in the fracture sequelae group because of malunited tuberosities, contractures and proximal humeral bone loss.
Favre et al. examined the effect of component positioning on RSA stability.
They found that humeral version was more important than glenoid version. Stability is improved with the humerus in neutral or slight anterversion. They recommend avoiding retroversion >10deg. Edwards et al. examined subscapularis insufficiency and the risk of RSA dislocation. They found that of 138 RSA, all 7 dislocations occurred in patients with an irreparable subscapularis.
Dislocation was also more likely in patients with complex diagnoses, including proximal humeral nonunion, fixed dislocation, and failed prior arthroplasty.
Figure A shows reverse shoulder arthroplasty dislocation. Incorrect Answers:
) A 45-year-old man complains of chronic right shoulder pain. He has a history of chronic steroid use because of asthma. He recently completed a course of physical therapy
and has given up his job as a laborer in favor of a desk job. Examination reveals diminished shoulder abduction strength. A radiograph of his shoulder is shown in Figure A. Which of the following surgical treatment options (Figures B through F) is the most appropriate?
Figure B Figure C Figure D Figure E Figure F
This patient has early stage avascular necrosis (AVN) of the humeral head without subchondral collapse/flattening, likely related to chonic steroid use.
Core decompression is indicated.
Treatment of humeral head AVN is dependent on Cruess Stage. Precollapse stages (Stage I and II) may be treated by core decompression and joint preservation. Hemiarthroplasty is used for Stage III-IV disease. Total shoulder arthroplasty is used for Stage V disease. Resurfacing may be used for Stage III disease with focal chondral defects and sufficient remaining epiphyseal bone stock for fixation.
Harreld et al. reviewed humeral head AVN. They advocate attempting core decompression and arthroscopy for Stage III disease, and then tailoring resurfacing or replacement depending on defect size.
Smith et al. reviewed 31 hemiarthroplasties for steroid-related AVN (6 Stage III, 16 Stage IV, 5 Stage V). Unsatisfactory results were found in 45%. This was associated with glenoid cartilage wear over time. However, they still believed hemiarthroplasty was appropriate for younger active patients with stage III or stage IV disease.
LaPorte et al. performed core decompression for various stages of AVN.
Results were successful in 94%, 88%, 70% and 14% of Ficat-Arlet Stages I, II, III and IV humeral head AVN respectively, and more successful for nonsteroid related cases compared with steroidrelated cases. They recommend this treatment for Stages I-III.
Figure A comprises a radiograph showing Cruess Stage II disease ("snowcap" sign indicating sclerosis, preservation of the head contour and absence of subchondral collapse, left), a T1weighted
MRI (center) and T2-weighted fat saturated MRI (right) showing a variegated pattern of osteonecrosis, but with preservation of normal head contour. Figure B shows core decompression. Figure C shows hemiarthroplasty. Figure D shows reverse shoulder arthroplasty. Figure E shows resurfacing. Figure F shows total shoulder arthroplasty. Illustration A depicts the Cruess staging system. Illustration B shows a possible algorithm for management where they use the Ficat stages adapted from the hip.
Incorrect Answers:
A 56-year-old otherwise healthy woman undergoes uncomplicated arthroscopic repair of a full-thickness rotator cuff tear. Prior to the procedure, the patient had attempted a long,
protracted course of physical therapy in an attempt to regain function without surgery. At her 10 day post-operative visit, she tearfully informs you that she cannot see her physical therapist because she has used up her 24-visit allotment for the year. She has 4 more weeks
until her insurance year turns over, and she does not have the financial means to pay out of pocket. What is the best next course of action?
Request a peer-to-peer review for authorization of additional visits or else the patient is likely to have a poor result
Provide a brief explanation and sheet of exercises for periscapular and cuff strengthening exercises using a resistance band
Test her range of motion and strength, and if limited, have her return weekly to your clinic for a guided home rehabilitation program
Explain to her that seeing a physical therapist during the first 6 weeks following cuff repair will not affect her range of motion one year removed from surgery
Give her a prophylactic corticosteroid injection to avoid early post-operative adhesive capsulitis
Early motion following rotator cuff repair has not been shown to impact range of motion and stiffness at one year post-operative clinical examinations.
Stiffness is a complication of protecting rotator cuff repairs from early re-tear with sling immobilization. However, with sling immobilization of up to 6 weeks, there is evidence of no increase in long-term stiffness. Accordingly, supervised physical therapy is not required in the first 6 weeks following arthroscopic rotator cuff repairs in order to obtain a good result.
Parsons et al. retrospectively reviewed 43 patients with full-thickness cuff tears who underwent a conservative early-postoperative protocol involving sling immobilization for 6 weeks with no formal therapy during that time. 10 /43 patient were characterized as stiff at their 6-week postoperative visit. At one year, there was no difference in the range of motion of the early stiff group compared to the non-stiff group.
Trenerry et al. collected prospective data on 209 consecutive patients undergoing primary rotator cuff repair. They found that patients in the stiffest quartile of range of motion testing at 6 weeks progressively regained range of motion by a post-operative visit at 72 weeks. The predictor of slowest recovery of early post-operative stiffness was found to be an internal rotation deficit with the patient reaching behind his or her back.
Incorrect Answers:
1: Early supervised physical therapy has not been shown to be essential to obtaining good motion post-operatively.
2 and 3: Strength testing and home strengthening programs in the early postoperative period would put the repair at risk for early failure.
5: Prophylactic corticosteroids are not indicated for prevention of postoperative stiffness, and furthermore, could theoretically interfere with healing.
A 62-year-old woman presents with chronic shoulder pain. On physical exam, she has anterior shoulder pain and her symptoms are reproduced with provocative testing of the biceps including supination against resistance and forward flexion of the shoulder against resistance. Internal and external rotation are painful, but her range of motion is intact. Shoulder radiograph and MRI images are shown in Figures A-E. Which of the following statements is true regarding the patient's condition?
Her clinical examination is most consistent with a SLAP tear, which should be repaired. Her biceps pathology is due to her partial tearing of her subscapularis
She has isolated degenerative biceps tendonosis and an injection may cure her symptoms
She has end-stage rotator cuff arthropathy and should consider a reverse total shoulder arthroplasty
Her subacromial impingement is causing her biceps tendon sheath to be inflamed
The subscapularis tendon is the most important medial restraint to subluxation or dislocation of the long head of the biceps tendon (LHBT).
Anterior shoulder pain and positive provocative biceps clinical examination tests are common in patients with concomitant rotator cuff pathology. A consequence of subscapularis tendon tears -even partial tears - is that the LHBT can subluxate medially out of the intertubercular groove, as the subscapularis tendon is the most important restraint to medial instability of the LHBT. This instability can cause both pain and inflammation around the biceps tendon, leading to pain with resisted supination (Yergason's test) or resisted forward flexion (Speeds' test).
Walch et al. wrote a case series on 71 cases of biceps tendon instability. They found that dislocated LHBTs were associated with partial or complete subscapularis tears in 96% of cases.
Maier et al. published clinical results of treating acute traumatic medial LHBT instability with open repair of the subscapularis tendon and stabilization of the LHBT. They showed equivalent functional clinical outcomes to biceps tenotomy or tenodesis, with improved cosmesis and decreased muscle cramping.
Figures A and B show Grashey and axillary lateral views of the patient and demonstrate an os acromiale. Figures C, D, and E are axillary T2 MRI images. Figure C shows the tendon of the long head of the biceps in the distal aspect of the biceps grove. Moving proximally, Figure D shows the tendon subluxated onto the lesser tubercle and Figure E shows it fully dislocated medially.
Incorrect Answers:
A 78-year-old male presents to clinic 4 weeks after left total shoulder arthroplasty. He has not been wearing his sling and reports that he developed increased pain after slipping in the shower. He used the arm to catch himself from falling. On examination, he can flex the shoulder to 70 degrees, limited by pain. Active external rotation with arm at the side is 50 degrees and active internal rotation is 5 degrees. Passive external rotation is to 80 degrees. A radiograph of the left shoulder is shown below in Figure A. What other complaint is the patient most likely to have?
Pain with palpation of the bicipital groove Pain with palpation over the subdeltoid bursa Sensory loss over the lateral shoulder
Sensation of shoulder instability with external rotation Sensation of shoulder instability with internal rotation
The clinical presentation is consistent with a tear of the subscapularis, which is a well-described complication after total shoulder arthroplasty. The most likely additional complaint this patient will have is anterior shoulder instability, noticeable with external rotation of the shoulder.
Total shoulder arthroplasty is the preferred treatment for glenohumeral arthritis in patients with intact rotator cuff and good glenoid bone stock. The surgical approach involves detaching the subscapularis and capsule from the anterior humerus and dislocating the humeral head anteriorly. Post operatively, external rotation is limited to protect the subscapularis repair. If there is suspicion of a postoperative subscapularis tear, and ultrasound can be performed to confirm the diagnosis.
Miller et al. reported 7 cases of subscapularis tendon rupture after total shoulder arthroplasty, all of which were subsequently repaired. Decreased functional outcomes were observed in these patients, with lengthening techniques to address internal rotation contractures and prior surgery involving the subscapularis tendon as risk factors for rupture
Westoff et al. performed static and dynamic ultrasounds on 22 patients after total shoulder arthroplasty evaluating for numerous periarticular pathologies. The authors concluded that sonography is a useful tool for evaluation of periimplant tissues after TSA.
Figure A shows an intact left total shoulder arthroplasty without evidence of fracture, dislocation, or hardware loosening. Illustration A shows the incision for the subscapularis tendon during TSA. Incorrect Answers:
A 25-year-old lineman is referred to your office for a second opinion. 1 year ago, he underwent an arthroscopic procedure for shoulder instability. He complains of persistent sense of instability despite the surgery. Which of the following is a contraindication to revision arthroscopic labral repair for recurrent anterior glenohumeral instability?
Glenoid bone loss of 10%
Capsular attenuation from prior thermal capsulorraphy Anterior labral periosteal sleeve avulsion (ALSPA ) lesion Glenoid labral articular defect (GLAD) lesion
Combined Superior Labrum from Anterior to Posterior tear (SLAP) and recurrent Bankart lesion
Capsular attenuation or postthermal capsular necrosis from prior thermal capsulorraphy is a contraindicated to arthroscopic repair.
Thermal capsulorrhaphy utilizes heat generated by radiofrequency or laser ablation to cause capsular shrinkage in an effort to treat shoulder instability. However, high recurrence rates have been found, especially around two to three weeks after the index procedure, when the capsular tissue is the weakest. In the setting of recurrence following thermal capsulorrhaphy, open revision is recommended.
Creighton et al. reported on a series of 18 patients undergoing revision arthroscopic stabilization. Of the 18, 3 failed with recurrent instability, all with previous thermal capsulorrhaphy. Miniaci et al. reviewed the outcomes following thermal capsulorrhaphy noting high rates of recurrent instability, especially in the setting of initial treatment for multidirectional instability. Park et
al. reported on a series of 14 patients undergoing revision following thermal capsulorrhaphy. Ten out of 14 patients had signs of capsular thinning, insufficiency and attenuation.
Wong et al. surveyed 379 shoulder surgeons on the complications following thermal capsulorrhaphy. Capsular insufficiency and thinning were commonly associated with recurrent instability.
Hecht et al. performed thermal capsulorrhaphy and biomechanical analysis of the capsule in a sheep model. The authors found that the capsule was weakest at the 2-3 week post-operative timepoint, leading to the highest rate insufficiency, attenuation and mechanical failure at this time.
Incorrect answers:
A 47-year-old landscaper presents with worsening left shoulder pain and weakness. Three years ago, he injured the left shoulder in a fall and elected for nonoperative
management to minimize time off from work. Physical therapy was effective until 6 months ago when his shoulder function worsened to the point that he is now unable to work.
Examination of his active range of motion reveals forward elevation 120° with pain, abduction 100°, IR at neutral to T8 and ER at neutral 5°. He has a positive ER lag sign and Hornblower's sign. Belly press and lift-off tests are normal. A recent radiograph is shown in Figures A. MRI images are shown in Figures B and C. Which of the following is the best treatment option?
Continue physical therapy Latissimus dorsi transfer Arthroscopic rotator cuff repair Pectoralis major transfer
Reverse total shoulder arthroplasty
This patient has a chronic massive posterosuperior rotator cuff tear with marked atrophy, tendon retraction and loss of external rotation strength that is impacting his daily life. The best treatment option for this middle-aged laborer with an irreparable posterosuperior rotator cuff tear is a latissimus dorsi transfer to restore external rotation strength and motion.
Irreparable rotator cuff tears are marked by: (1) Superior displacement of the humeral head (AHI < 5-7mm), (2) Fatty infiltration of the rotator cuff muscles ( Goutallier stage 3-4), (3) Increased duration of the tendon tear and (4) Profound external rotation weakness. These findings are predictive of poorquality tissue and stiffness of the muscle-tendon unit, not amenable to primary repair. In this setting, a latissimus dorsi transfer can be utilized to restore shoulder strength, function and improve pain. Relative contraindications include subscapularis deficiency, deltoid deficiency, pseudoparalysis of the shoulder and advanced glenohumeral arthritis.
Gerber et al. performed a case series analysis of 67 patients with irreparable rotator cuff tears managed with latissimus dorsi transfer. Patients with an intact subscapularis demonstrated improvement in pain, range of motion and strength postoperatively, while no improvement was noted in patients with subscapularis deficiency. The authors conclude that latissimus dorsi transfer should not be performed in the setting of poor subscapularis function.
Iannotti et al. found that better clinical results following latissimus dorsi transfer were associated with: preserved active shoulder range of motion and strength (specifically forward elevation > 90° and external rotation > 20°), synchronous firing of the transferred latissimus dorsi muscle and male gender.
Figure A is an AP radiograph of the left shoulder with superior migration of the humeral head (AHI
< 5mm) and no evidence of glenohumeral arthritis. Figures B and C show a retracted posterosuperior rotator cuff tear and Goutallier stage 4 atrophy (more fat than muscle) of the supraspinatus, infraspinatus and teres minor, rendering this tear irreparable. Illustration A shows a latissimus dorsi transfer. The latissimus dorsi tendon is positioned over the top of the humeral head, covering most of the rotator cuff defect. The tendon is then secured to the subscapularis tendon edge and lesser tuberosity anteriorly, the remnant supraspinatus and infraspinatus tendons medially, and the greater tuberosity laterally.
Incorrect Answers:
A collegiate swimmer develops medial winging of the scapula. If the EMG and nerve conduction studies are abnormal, the most likely nerve roots to be involved are?
C7, C8, T 1 C6, C7, C 8 C5, C6, C 7 C4, C5, C 6 C3, C4, C 5
Classic medial winging of the scapula is due to paralysis of the serratus anterior muscle which is supplied by the long thoracic nerve which holds the scapula to the chest wall and prevents the inferior angle of the scapula from migrating medially. It is innervated by the long thoracic nerve (C5, 6, 7).
Surgical treatment may include partial pec major transfer. Lateral winging may be caused by spinal accessory nerve palsy (CN XI, also ventral ramus C2,3,4). The nerve may be injured during neck surgery. This causes trapezius weakness, allowing the inferior pole of the scapula to migrate laterally. The modified Eden-Lange procedure may be used for this type of winging.
Gregg et al. describes paralysis of the serratus muscle in young athletes which they felt was due to repetitive traction. Full recovery usually occurs in an average of 9 months, and they recommend that surgical methods of treatment should be reserved for patients in whom function fails to return after a twoyear period.
Foo et al. describes a larger cohort of 20 patients again treated expectantly with observation and physical therapy. They reported consistent recovery but that it can take up to 2 years.
Illustration A shows a clinical photo of medial scapular winging. Illustration V is an instructional video of scapular winging. It begins with a clinical video of the condition.
A 62-year-old man complains of shoulder pain for 2 years. He has had 1 course of intra articular sodium hyaluronate and 6 weeks of physical therapy with little relief. Examination reveals diminished arm flexion and abduction secondary to pain. Radiographs of his shoulder are shown in Figures A and B. According to the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, what is the next best step?
Humeral head replacement arthroplasty Hemiarthroplasty and ream-and-run glenoid procedure
Cuff tear arthropathy (CTA) prosthesis
Total shoulder arthroplasty with a metal-backed cemented glenoid component Total shoulder arthroplasty with an all-polyethylene cemented glenoid component
This patient has end-stage glenohumeral osteoarthritis (GH OA). According to the AAOS CPG, total shoulder arthroplasty (TSA) is recommended using an allpolyethylene cemented glenoid component.
TSA is indicated for cases of end-stage GH OA. It is preferred to hemiarthroplasty. It is contraindicated in cases with insufficient glenoid bone stock (glenoid wear to the level of the coracoid), rotator cuff arthropathy or irreparable cuff tears and deltoid dysfunction. It provides good pain relief and has good survival at 10 years (>90%).
Radnay et al. performed a systematic review involving 1952 patients comparing TSA with humeral head replacement (HHR). They found that TSR provided greater pain relief, range of motion, patient satisfaction, and had lower revision rates. They recommend TSA over HHR for GH OA. Izquierdo et al. described the AAOS Clinical Practice Guidelines (CPG) regarding treatment of GH OA. This is summarized in Illustration A.
Figures A and B show end-stage GH OA with large osteophytes and subchondral sclerosis. There is significant glenoid wear and posterior subluxation (Walch B glenoid deformity). Illustration A is a table summarizing the AAOS CPG on treatment of GH OA. Illustration B shows a CTA humeral component. It is not paired with a glenoid component.
Incorrect Answers:
Metal-backed glenoids have higher rates of revision than all-polyethylene glenoids.
Posterior glenohumeral dislocations are as common as anterior dislocations in which of the following patient groups?
Football players
Marfan's syndrome patients Renal failure patients Epilepsy patients
Women
Millett et al and Robinson et al provide review articles on posterior shoulder dislocations, which are rare clinical entities that occur during seizures and electrocution (due to tetanic muscle contraction) or as a result of high energy trauma. Robinson et al noted that poor prognostic factors associated with posterior shoulder dislocation include late diagnosis, large bony defect of humeral head, associated proximal humerus fracture, and need for arthroplasty. In Gerber's series, posterior dislocations occurred with equal frequency to anterior in a cohort of epilepsy patients.
What nerve is injured most commonly during the superficial dissection when repairing a distal biceps rupture through a single incision anterior approach?
Medial antebrachial cutaneous nerve Lateral antebrachial cutaneous nerve Superficial radial nerve
Ulnar nerve
Posterior interosseous nerve
The lateral antebrachial cutaneous nerve (LABCN) is at risk during the superficial dissection when repairing a distal biceps rupture through a single incision anterior approach.
The LABCN is the terminal cutaneous branch of the musculocutaneous nerve, which supplies sensation to the volar-lateral aspect of the forearm. The LABCN pierces the deep fascia of the arm lateral to the musculotendinous junction of the distal biceps tendon after lying on top or piercing through the brachialis muscle. It exits the arm and lies in the subcutaneous tissues of the antecubital fossa. It is important to retract this nerve laterally during the approach to the distal biceps tendon.
Cohen describes the importance of identifying the LABCN during the superficial dissection as injury to this nerve is not uncommon (5-7%). Injury to the PIN (5 %) is devastating and occurs with retractor placement during the deep dissection and the use of suspensory fixation on the posterior cortex of the radius.
The review article by Ramsey et al covers the surgical anatomy and complications of biceps surgery, including injury to the LABCN.
Illustration A shows the LABCN relative to the anterolateral approach to the elbow which is commonly used to repair distal biceps avulsions. Illustration B shows the close proximity of the LABCN to the distal biceps in a human specimen.
Incorrect Responses:
An MRI of the shoulder in a patient with chronic quadrilateral space syndrome is most likely to show which of the following?
Increased intra-capsular volume Loss of intra-capsular volume Fatty atrophy of the infraspinatus Fatty atrophy of the teres minor
Fatty atrophy of the latissimus dorsi
Quadrilateral space syndrome involves dysfunction of the axillary nerve, perhaps by entrapment or compression, resulting in the functional denervation of the teres minor.
The quadrilateral space is a potential space formed by the long head of the triceps medially, the humerus laterally, the teres minor above, and the teres major below. The axillary nerve and posterior circumflex humeral artery travel through this space.
The Sanders article describes the MRI appearance, which is that the muscle appears streaked with white on MRI and atrophied (See illustration A) consistent with fatty atrophy. Sanders group report this finding in 3% of shoulder MRIs. The posterior circumflex humeral artery also travels with the axillary nerve as it travels through this space. Loss of capsular volume on an arthrogram study is suggestive of adhesive capsulitis.
Illustration B is a diagram which shows the borders of the quadrilateral (or quadrangular) space.
A 21-year-old collegiate volleyball player is noted to have weakness in external rotation and isolated atrophy of the infraspinatus on physical examination as seen in Figure A. An axial MRI image is shown in Figure B. This clinical condition is most likely caused by compression of the:
Axillary nerve at the triangular space Suprascapular nerve in the suprascapular notch Axillary nerve in the quadrangular space Suprascapular nerve in the spinoglenoid notch
Long thoracic nerve anterior to the scalenus and the first rib and posterior to the clavicle
The clinical presentation is consistent for a suprascapular neuropathy caused by compression of the suprascapular nerve by a cyst in the spinoglenoid notch.
The suprascapular nerve arises from the upper trunk of the brachial plexus with contributions from C5-6. It travels through the suprascapular notch of the scapula where it gives motor branches to the supraspinatus then around the spinoglenoid notch where it innervates the infraspinatus.
Compression of the nerve at the suprascapular notch will cause denervation and atrophy of both the supraspinatus and infraspinatus while compression at the spinoglenoid notch affects the infraspinatus in isolation. This is commonly seen in overhead athletes who sustain a SLAP tear and resultant spinoglenoid notch cyst as seen in the MRI. This will cause weakness and atrophy of the infraspinatus and can be noted both clinically and radiographically. Appropriate operative management is still not clear in the literature with some authors reporting a need for labral repair + cyst decompression and others reporting good outcomes with labral repair alone. Other cases have been treated with needle aspiration.
The cited reference by Cummins et al reviews the various causes, diagnosis, and treatment of suprascapular neuropathy.
The reference by Martin et al is a retrospective study of the results of nonoperative treatment of suprascapular neuropathy in which 5 had excellent results and 7 had good results.
Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis?
Resisted forearm pronation and wrist flexion with a clenched fist Resisted forearm supination and wrist extension with a clenched fist Dynamic valgus stress test
Milking maneuver Pinch grip test
A provocative test for medial epicondylitis can be elicited by applying resistance to a patient with their fist clenched, wrist flexed and pronated.
Medial epicondylitis is an overuse syndrome of the flexor-pronator mass. The pronator teres (PT) and flexor carpi radialis (FCR) are thought to be most affected with this condition. It is most common in the dominant arm and occurs with activities that require repetitive wrist flexion/forearm pronation. Patients are most tender over the origin of PT and FCR at the medial epicondyle.
Resisting a patient with their fist clenched, wrist flexed and pronated can cause worsening of their pain. This maneuver can be used as a provocative test for this condition.
Cain et al. reviewed elbow injuries in throwing athletes. They comment that the common flexorpronator muscle origin provides dynamic support to valgus stress in the throwing elbow, especially during early arm acceleration and help produce wrist flexion during ball release.
Amin et al. reviewed the evaluation and management of medial epicondylitis. They report that medial epicondylitis typically occurs in the fourth through sixth decades of life, the peak working years, and equally affects men and women. Physical therapy and rehabilitation is the main aspect of recovery from medial epicondylitis, once acute symptoms have been alleviated.
Illustration A shows a video of this provocative test for medial epicondylitis. Incorrect Answers:
A 72-year-old woman presents for follow-up after elbow surgery. Her radiographs are shown in Figures A and B. Which of the following pre-operative diagnoses is a relative contraindication to the use of this prosthesis design?
Acute intra-articular distal humerus fracture Malunited intra-articular distal humerus fracture Late-stage rheumatoid arthritis
Post-traumatic bony ankylosis Osteoarthritis
This patient has had an unconstrained total elbow arthroplasty (TEA).
Unconstrained TEA is least preferred for late-stage rheumatoid arthritis where there is significant capsuloligamentous instability and bony erosion.
Unconstrained (unlinked or resurfacing prosthesis) TEA depend on intact bony and ligamentous constraints for stability. These are appropriate for humeroulnar conditions with intact collateral ligaments and radiocapitellar articulation e.g. osteoarthritis, post-traumatic arthritis, intra-articular distal humerus fracture, and malunion of the distal humerus. Conditions with increased risk of
instability (ligamentous injury, rheumatoid arthritis) will benefit from a linked or semiconstrained prosthesis.
Mansat et al. reviewed the Coonrad-Morrey linked (semi-constrained) TEA implant in 70 patients after 5 years. They found that patients with inflammatory arthritis had higher function than those with traumatic conditions
( fractures, nonunions and post-traumatic arthritis). Survival rate was 98% and 91 % at 5 and 10 years, respectively. They concluded that this implant provided satisfactory treatment for different indications although radiolucent lines and bushing wear were a concern.
Hildebrand et al. reviewed the functional outcome of the Coonrad-Moorey prosthesis in 51 elbows after 50 months. The inflammatory arthritis group had higher performance scores than the traumatic/post-traumatic conditions group. Isometric extensor torque was found to be less than the nonoperated side. Radiolucency was noted in 11 elbows.
Figures A and B show an unconstrained TEA with radial head replacement. Illustration A shows more examples of unconstrained TEA. Illustration B shows a semiconstrained TEA. The arrow points to the anterior flange. Illustration C shows radiolucent lines around the stems. Illustration D shows severe bushing wear leading to locking mechanism failure. Illustration E is a table comparing linked and unlinked implants.
Incorrect Answers:
A professional baseball team has several pitchers with complaints of velocity loss with their pitches and shoulder pain of their dominant shoulders during spring training. Pitch counts are properly monitored. The average glenohumeral internal rotation deficit on the pitching staff is 45 degrees. The best intervention would be:
Pitchers throwing less fastballs and more changeups
Evaluate the pitchers elbows for ulnar collateral ligament acute ruptures. Increasing the weight training for the deltoid and latissimus dorsi muscles Focused stretches and therapies that address posterior capsular tightness Firing the general manager for finding pitchers that "lose their stuff"
Glenohumeral Internal Rotation Deficit (GIRD) is a phenomenon that occurs in baseball pitchers and is due to posterior capsular tightness. Treatment should begin with a therapy program addressing the pathologic posterior capsule.
GIRD is a phenomenon that is frequently found in high-level overhead throwing athletes, predominantly baseball pitchers. It is defined as the measured difference in internal rotation between the non-dominant arm and dominant arm. Worsening range of motion deficits are seen with increased repetitions, both over a single season and a career. GIRD > 25º is associated with development of shoulder pathologies or pain requiring periods of inactivity. Cessation of overhead throwing activities and initiation of a stretching program to address posterior capsular contractures is largely effective (90% in some series).
Burkhart et al. reviewed the conditions associated with high-level overhead throwing athletes shoulders, culminating in a theory of pathologic progression to "dead arm syndrome" (loss of velocity and effective pitching). Their theory attributes adaptive hyperexternal rotation (occurs during late-cocking / early acceleration phases of pitching) to lead to posterior-inferior capsular contracture and GIRD. Subsequent injuries to anterior structures - including SLAP lesions - would then occur.
Illustration A is a cartoon depiction of how to perform the sleeper stretch. This is a common component of a pitcher's maintenance stretching program.
Incorrect Answers:
A 68-year-old man presents with severe right shoulder pain. He had a prolonged course of physical therapy and received several cortisone injections for his pain without improvement. Examination reveals pseudoparalysis of the right shoulder with a 20-degree external rotation lag with the shoulder adducted. With the shoulder placed in 90 degrees of abduction, he can actively externally rotate his shoulder. The patient was treated with a medialized reverse prosthesis shown in Figure A. Which of the following statement is true regarding this treatment option?
It is contraindicated in patients with shoulder pseudoparalysis
It can be used in patients with deltoid dysfunction when combined with latissimus dorsi transfer It shifts the center of rotation of the shoulder superior and lateral
The risk of scapular notching is increased with inferior placement of the glenoid component The risk of instability is increased with an irreparable subscapularis
The clinical presentation is consistent with a patient with pseudoparalysis that was treated with a reverse total shoulder arthroplasty (RTSA). The risk of postoperative instability is increased in patients with an irrepairable subscapularis when a medialized reverse prosthesis is used. Answers 1-4 are false statements.
RTSA is most commonly indicated for rotator cuff arthropathy. However, indications for use now include shoulder pseudoparalysis, anterosuperior escape of the humeral head, acute 3 or 4-part proximal humerus fractures, and greater tuberosity fracture nonunions. Contraindications to RTSA included deltoid dysfunction, insufficient glenoid bone stock, and bony deficiency of the acromion. Edwards et al. prospectively evaluated the risk of shoulder dislocation after reverse TSA. They found a significantly increased risk of dislocation (p=0.012) in patients with an irreparable subscapularis at time of surgery. There were no dislocations in the reparable group. Dislocations were more likely in patients with proximal humeral nonunions and failed prior arthroplasty. Mulieri et al. looked at the use of reverse TSA in patients with irreparable massive rotator cuff tears without evidence of glenohumeral arthritis. All outcomes were improved postoperatively, and they advocate
for reverse TSA in this subset of patients. Survivorship was over 90% at more than 4 years average follow up.
Boileau et al. evaluated the clinical outcomes of isolated biceps tenotomy/tenodesis in patients with massive rotator cuff tears and a biceps lesion. They found that the procedure can effectively treat pain and improve function in these patients. There was no difference in patients undergoing tenotomy versus tenodesis.
Figure A is a right shoulder radiograph status post RTSA with components in adequate position. Incorrect Answers:
Figure A shows immediate post-operative radiographs of a 75year-old patient with primary osteoarthritis. She presents 3 years later with increasing pain and weakness in the shoulder despite home physical therapy. Examination reveals limited active range of motion, with forward elevation of 80 degrees and external rotation of 50 degrees. Her deltoid function is intact. Repeat radiographs are seen in Figure B. Which treatment option would provide the best functional outcome for this patient?
Open tendon transfer
Corticosteriod injection and supervised physical therapy
Open rotator cuff repair, subacromial decompression and distal clavical excision Revision to reverse shoulder arthroplasty
Revision to cuff arthropathy hemiarthroplasty
This patient presents with failed total shoulder arthroplasty. The best treatment option for functional outcome would be revision to reverse shoulder arthroplasty (rTSA).
RTSA is considered a viable treatment option for patients with failed shoulder arthroplasty. It allows for improved arm elevation and abduction in the setting of nonfunctional rotator cuff muscles, as seen in this example. Despite the expanding indications for rTSA, there are high complication rates in the revision setting. Complication rates for rTSA after failed shoulder arthroplasty have been reported to be between 11-36%. This procedure should, therefore, be performed by surgeons with extensive training in reconstructive shoulder arthroplasty.
Patel et al. retrospectively reviewed 31 patients (mean age, 68.7 years) who underwent rTSA for treatment of a failed shoulder arthroplasty. They found the greatest improvement with active forward elevation from 44° preoperatively to 108 ° postoperatively (P < .001). Complications occurred in 3 patients with periprosthetic fracture.
Hattrup et al. reviewed a series of 19 patients that underwent open rotator cuff repair after shoulder arthroplasty. Out of the 19 patients only 4 shoulders were successfully repaired. They concluded that successful rotator cuff repair after shoulder arthroplasty is possible but failure is more common. Figure A shows a left total shoulder arthroplasty that is well reduced in the glenoid. Figure B shows antero-superior escape of the prosthesis, indicative of a massive rotator cuff tear.
Incorrect Answers:
A 35-year-old man awoke following a night of heavy drinking with severe right shoulder pain and inability to raise his arm above his head. A radiograph from the emergency room is provided in Figure A. He was treated with a sling for a diagnosis of rotator cuff tear. Six weeks later, he complains of continued pain and difficulty using the arm. Which of the following is the next best step in management?
Physical therapy for range of motion followed by rotator cuff and deltoid strengthening exercises
Axillary radiograph of the shoulder
EMG to evaluate the suprascapular and axillary nerves Arthroscopic rotator cuff repair
Open subacromial decompression and latissimus dorsi transfer for massive cuff tear
The radiograph demonstrates overlap of the humeral head and glenoid suggesting shoulder dislocation. An Axillary radiograph is necessary to evaluate concentric reduction vs. dislocation of the shoulder. An example is provided in illustration A. Posterior shoulder dislocations can be easily be missed without the proper orthogonal views of the shoulder. Perron reviews the proper identification and emergency room care of posterior shoulder dislocation. Richardson found axillary radiographs to be more sensitive than trans-scapular radiographs for identifying posterior shoulder dislocations.
Recent randomized controlled trials comparing early passive range of motion to 6 weeks of immobilization after successful arthroscopic rotator cuff repair concluded that, compared to immobilization, early passive range of motion resulted in:
Higher Constant scores at 12 months
Increased rates of re-rupture as determined by ultrasound Equivalent functional outcomes
Less pain at 6 months
Inceased range of motion at 12 months
A series of high-quality RCTs have demonstrated that early passive range of motion has equivalent functional outcomes when compared to 6 weeks of immobilization after arthroscopic rotator cuff surgery.
Traditionally, most surgeons recommended early post-operative range of motion exercises for their patients in order to prevent adhesions and ultimately stiffness. However, recent evidence has found that there is no difference in the healing rate, range of motion or functional outcome between patients who undergo early versus delayed (i.e. initial 6 weeks of immobilization) passive range of motion exercises after arthroscopic rotator cuff repair.
Kim et al. conducted a randomized controlled trial comparing early passive range of motion vs. immobilization in 106 patients who underwent arthroscopic repair for full-thickness rotator cuff tears. They found that there was no clinically or statistically significant difference between the two groups in pain, healing or function.
Keener et al. also conducted a randomized controlled trial of 124 patients who were undergoing arthroscopic repair of a full-thickness rotator cuff tear and found no difference between early and delayed range of motion in healing and functional outcome.
Cuff & Pupello also compared early vs. delayed range of motion during the post-operative rehabilitation phase in a randomized controlled trial of 68 individuals undergoing arthroscopic rotator cuff repair and found no significant difference in range of motion or healing.
Incorrect Answers:
A 49-year-old male presents with right shoulder pain and weakness after undergoing open cervical lymph node biopsy approximately one year ago. A pertinent finding from the physical exam is seen in Figure A, with the patients arms by his side. Physical exam finding with the arms in a position of 90 degrees of forward elevation and 10 degrees of external rotation are shown in Figure B.
What nerve is most likely injured?
Long thoracic Suprascapular Spinal accessory Axillary Thoracodorsal
The patient is presenting with LATERAL scapular winging which is a result of injury to the spinal accessory nerve and resultant trapezius muscle palsy.
The spinal accessory nerve is fundamental to scapulothoracic function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. The majority of injuries to the spinal accessory nerve are iatrogenic and occur secondary to head and neck surgery. There is often a marked delay in recognition and initiating treatment. Surgical treatment with the Eden-Lange transfer lateralizes the levator scapulae and rhomboids (transfer from medial border to lateral border)
Camp et al. reviewed the results of 111 patients who underwent operative management of a lesion to the spinal accessory nerve. They found that the majority (~80%) of injuries were sustained iatrogenically and that diagnosis was delayed for approximately 12 months.
Pikkarainen et al. reviewed the natural history of isolated serratus palsy. They found that symptoms mostly recover in 2 years, but at least one-fourth of the patients will have long-lasting symptoms, especially pain.
Figure A depicts a patient with lateral scapular winging. Figure B demonstrates physical exam of this patient with their arms in a position of 90 degrees of forward elevation and 10 degrees of external rotation. Illustration A highlights the difference between medial and lateral scapular winging. Illustration B depicts another example of a patient with lateral scapular winging.
Incorrect Answers:
An injury to the long thoracic nerve would result in serratus anterior palsy which would lead to MEDIAL scapular winging.
An injury to the suprascapular nerve would result in weakness and wasting of the supraspinatus and/or infraspinatus.

Question 88:

Options:

Incorrect graft choice
Improper tunnel position
Tibial graft-tunnel mismatch
Poor femoral fixation

Correct Answer: Improper tunnel position

Explanation:

Question 89:

Options:

Transfer metatarsalgia
Morton’s neuroma
Metatarsal stress fracture
Freiberg’s infraction
Metatarsophalangeal synovitis

Correct Answer: Metatarsal stress fracture

Explanation:

Question 90:

Which of the following is considered an advantage of the tibial inlay fixation compared to transtibial tunnel technique when used in posterior cruciate ligament reconstruction? Review Topic

Options:

Less invasive
Superior published clinical results
Decreased surgical time
Elimination of the critical 90-degree turn at the tibial aperture of the tunnel
Improved cosmesis

Correct Answer: Elimination of the critical 90-degree turn at the tibial aperture of the tunnel

Explanation:

Question 91:

Options:

McCune-Albright syndrome
Neurofibromatosis, type I (NF-1)
Neurofibromatosis, type II (NF-2)
Paget’s disease
Ollier’s disease

Correct Answer: McCune-Albright syndrome

Explanation:

Question 92:

What is the most important factor regarding the risk of recurrent instability in a patient with an acute anterior dislocation of the shoulder?

Options:

Age of the patient
Time from injury to reduction
Completion of 3 weeks of immobilization
The degree of athletic participation
Bilateral instability

Correct Answer: Age of the patient

Explanation:

Question 93:

Options:

Initiate isometric external rotation strengthening and continue passive range of motion.
Initiate eccentric supraspinatus strengthening and continue passive range of motion.
Initiate light resistance training to minimize atrophy and continue passive range of motion.
Continue passive range of motion and initiate concentric deltoid strengthening.
Continue passive range of motion with no active strengthening of the shoulder muscles.

Correct Answer: Continue passive range of motion with no active strengthening of the shoulder muscles.

Explanation:

Question 94:

Which sterilization method is expected to produce the most degradation of an allograft used for anterior cruciate ligament reconstruction?

Options:

Deep freezing
Supercritical CO2 treatment
Gamma irradiation with 1.2 Mrad
Chlorhexidine gluconate 4% cleansing

Correct Answer: Supercritical CO2 treatment

Explanation:

DISCUSSION
A biomechanical study compared unprocessed, irradiated (2.0 Mrad-2.8 Mrad), and supercritical CO2-treated soft-tissue allografts and demonstrated a 27% to 36% decrease in stiffness of the supercritical CO2-treated grafts. No significant difference was found between the irradiated and untreated soft-tissue allografts. Low-dose (1.0 Mrad-1.2 Mrad) gamma irradiation of bone-patellar-tendon-allograft has been shown to produce a 20% decrease in graft stiffness. Deep freezing or cleansing with 4% chlorhexidine gluconate does not appear to adversely affect the biomechanical properties of the allograft tissue.
CLINICAL SITUATION FOR QUESTIONS 43 THROUGH 46
Figures 43a and 43b are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable.

Question 95:

Sterilization of ultra-high molecular weight polyethylene by gamma irradiation in air will degrade its wear performance because of

Options:

oxidation.
melting.
cross-linking.
corrosion.
creep.

Correct Answer: oxidation.

Explanation:

DISCUSSION: Gamma irradiation has long been used as a sterilization method for polyethylene. Exposure to gamma irradiation causes breakage of the chemical bonds in the polyethylene, and oxidation will occur if the material is subsequently exposed to air. The amount of oxidation and decrease in wear performance is also related to the length of time that the gamma-irradiated polyethylene is exposed to oxygen.
REFERENCES: Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
McKellop H, Shen FW, Lu B, et al: Effect of sterilization method and other modifications on the wear resistance of acetabular cups made of ultra-high molecular weight polyethylene: A hip-simulator study. J Bone Joint Surg Am 2000;82:1708-1725.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.

Question 96:

A 3-year-old patient with L3 myelomeningocele has bilateral dislocated hips. Management should consist of

Options:

observation.
bilateral open reduction.
bilateral open reduction and psoas transfers.
bilateral open reduction and external oblique transfers.
bilateral valgus osteotomies.

Correct Answer: observation.

Explanation:

Question 97:

What structure is the primary restraint to inferior translation of the shoulder?

Options:

Middle glenohumeral ligament
22 • American Academy of Orthopaedic Surgeons
Subscapularis
Long head of the biceps
Coracohumeral ligament
Coracoacromial ligament

Correct Answer: Long head of the biceps

Explanation:

Question 98:

In regards to a genetic disorder, which of the following is an example of "anticipation?"

Options:

Gene characteristics more severe and earlier in onset in subsequent generations
A disorder inherited from a genetic mutation specific to maternal DNA
Gene characteristics expressed to varying degrees in different individuals
Variation in the relative frequency of a genotype due to chance
The presence of an extra copy of a chromosome

Correct Answer: Variation in the relative frequency of a genotype due to chance

Explanation:

Question 99:

A 12-year-old child with spina bifida paraplegia requires brace management for ankle stability. Which of the following principles applies to brace management in this individual?

Options:

A shorter lever arm is more effective in limiting pressure.
Limbs with mild contractures do better with bracing than flaccid limbs through increased force concentration.
Three-point pressure effect works best to prevent the joint from buckling.
Four-point pressure effect works best to prevent the joint from buckling.
Smaller base support provides increased stability.

Correct Answer: Three-point pressure effect works best to prevent the joint from buckling.

Explanation:

Question 100:

Options:

Measurement of volar compartment pressures and, if elevated, a bolus transfusion of 4 unit/kg of factor VIII concentrate, followed by continuous transfusion of factor VIII
Splinting of the extremity with the elbow flexed and the wrist in extension, elevation of the extremity, observation, and if no improvement, continuous transfusion of factor VIII (4 unit/kg)
A bolus transfusion of 4 unit/kg of factor VIII concentrate, followed by continuous transfusion of factor VIII, measurement of forearm compartment pressures, splinting of the extremity with the elbow and wrist flexed, and surgical release of the volar forearm compartments if pressures are elevated
A bolus transfusion of 4 unit/kg of factor VIII concentrate, followed by continuous transfusion of factor VIII and an emergency fasciotomy
A bolus transfusion of 4 unit/kg of factor VIII concentrate, laboratory studies consisting of serum electrolytes and creatine phosphokinase levels, IV injections of bicarbonate to alkalize the urine, and renal dialysis

Correct Answer: A bolus transfusion of 4 unit/kg of factor VIII concentrate, followed by continuous transfusion of factor VIII, measurement of forearm compartment pressures, splinting of the extremity with the elbow and wrist flexed, and surgical release of the volar forearm compartments if pressures are elevated

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

Orthopedic Board Prep MCQs: Foot, Fracture & Tumor | Part 178

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 178

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index