Orthopedic With Answer Sh Review | Dr Hutaif General Or -...

QUESTION 1

Figure 1 shows the radiograph of a 71-year-old man who has had increasing pain and weakness in his shoulder for the past 3 years. Nonsurgical management has failed to provide relief. Examination shows 130 degrees of active forward flexion and intact external rotation strength. During surgery, a 1- x 1-cm rotator cuff tear involving the supraspinatus is encountered. Treatment should include

1

humeral head replacement with rotator cuff repair.

2

humeral head replacement without rotator cuff repair.

3

arthrodesis of the shoulder.

4

total shoulder replacement with rotator cuff repair.

5

total shoulder replacement without rotator cuff repair.

QUESTION 2

Which of the following is considered the cause of Milwaukee shoulder, a joint disease similar to rotator cuff arthropathy?

1

Abundance of basic calcium phosphate crystals

2

Abundance of calcium pyrophosphate crystals

3

Gout

4

Rheumatoid arthritis

5

Osteonecrosis

QUESTION 3

The MRI scan of the shoulder shown in Figure 2 was performed with the arm in abduction and external rotation. The image reveals what condition?**

1

Contact between the rotator cuff and the posterior-superior labrum

2

Anterior instability

3

A ganglion cyst of the spinoglenoid notch

4

Osteonecrosis of the humeral head

5

Posterior subluxation

QUESTION 4

Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched arm and sustained a fracture-dislocation of the elbow. Initial management consisted of closed reduction of the dislocation. Surgical treatment should now include repair or reduction and fixation of the

1

medial and lateral collateral ligaments, radial head, and coronoid.

2

medial collateral ligament and coronoid.

3

lateral collateral ligament and radial head.

4

medial and lateral collateral ligaments.

5

radial head and coronoid.

QUESTION 5

It is important to avoid which of the following exercises in the immediate postoperative period after humeral head replacement for an acute four-part fracture?

1

Pendulum exercises

2

External rotation with a stick

3

Passive forward elevation

4

Active forward elevation

5

Active range of motion of the elbow, wrist, and hand

QUESTION 6

A 38-year-old man has winging of the ipsilateral scapula after undergoing a transaxillary resection of the first rib 3 weeks ago. What is the most likely cause of this finding?

1

Persistent thoracic outlet syndrome

2

Injury to the upper trunk of the brachial plexus

3

Injury to the long thoracic nerve

4

Injury to the lower trunk of the brachial plexus

5

Injury to the spinal accessory nerve

QUESTION 7

A 73-year-old man who underwent repair of the left rotator cuff 6 years ago reports good pain relief but notes residual weakness of the left shoulder, especially with overhead tasks. He denies having pain at night and has minimal discomfort with activities of daily living but is dissatisfied with his shoulder strength. Radiographs show an acromiohumeral interval of 2 mm. Appropriate management should consist of

1

an exercise program.

2

revision rotator cuff repair using local tissue transposition.

3

revision rotator cuff repair using allograft.

4

latissimus dorsi transfer.

5

combined latissimus dorsi and teres major transfer.

QUESTION 8

A 45-year-old woman has had progressive right shoulder pain for the past 6 months. She notes that the pain disrupts her sleep, she has pain at rest that requires the use of narcotic analgesics, and she has limited use of her left shoulder for most activities of daily living. History reveals the use of corticosteroids for systemic lupus erythematosus. Examination shows diminished range of motion. Radiographs of the right shoulder are shown in Figures 4a and 4b. Treatment should consist of

1

core decompression of the humeral head.

2

humeral arthroplasty.

3

total shoulder arthroplasty.

4

glenohumeral arthrodesis.

5

vascularized fibular allograft.

QUESTION 9

The relocation test is most reliable for diagnosing anterior subluxation of the glenohumeral joint when

1

posterior pressure placed on the humeral head results in increased pain.

2

external rotation with the arm in 90 degrees of abduction produces apprehension that is relieved by posterior pressure on the humeral head.

3

external rotation with the arm in 90 degrees of abduction produces pain that is relieved by posterior pressure on the humeral head.

4

external rotation with the arm in 90 degrees of abduction produces no symptoms, but posterior pressure on the humeral head produces pain and apprehension.

5

external rotation with the arm in 90 degrees of abduction produces no symptoms, but posterior pressure on the humeral head produces apprehension.

QUESTION 10

A 16-year-old high school pitcher notes acute pain on the medial side of his elbow during a pitch. Examination that day reveals medial elbow tenderness, pain with valgus stress, mild swelling, and loss of extension. Plain radiographs show closed physes and no fracture. Which of the following diagnostic studies will best reveal his injury?

1

Technetium Tc 99m bone scan

2

Contrast-enhanced MRI

3

CT

4

Electromyography

5

Arthroscopy

QUESTION 11

Figures 5a and 5b show the radiographs of a 45-year-old patient. What is the most
likely diagnosis?

1

Glenoid dysplasia

2

Rheumatoid arthritis with centralization

3

Osteoarthritis with posterior glenoid wear

4

Posterior scapular fracture deformity

5

Traumatic posterior subluxation of the shoulder

QUESTION 12

A 14-year-old boy sustains a twisting injury to his right shoulder and recalls feeling a snap during a wrestling match. Examination shows hesitancy to raise the arm away from the side, diffuse tenderness and swelling of the upper arm, and no evidence of neurovascular compromise. Figures 6a and 6b show an AP radiograph and MRI scan. What is the most likely diagnosis?

1

Anterior dislocation of the shoulder

2

Salter-Harris type I fracture of the proximal humeral physis

3

Rupture of the subscapularis tendon

4

Sprain of the acromioclavicular joint

5

Fracture of the glenoid neck

QUESTION 13

Figure 7 shows the radiograph of an otherwise healthy 65-year-old man who injured his right dominant shoulder while skiing 18 months ago. He did not seek treatment at the time of the injury. He now reports intermittent soreness when playing golf but has no other limitations. Examination reveals full range of motion and no tenderness, but he has slight pain with a crossed arm adduction stress test. He is neurologically intact. Initial management should consist of

1

excision of the distal clavicle.

2

open reduction and internal fixation with intramedullary partial threaded pins.

3

open reduction and internal fixation with a reconstruction plate, screws, and bone grafting.

4

bone grafting and use of heavy sutures to secure the clavicle to the coracoid.

5

observation and nonsteroidal anti-inflammatory drugs.

QUESTION 14

Figure 8 shows the AP radiograph of a 33-year-old woman who sustained a midshaft clavicle fracture from a motorcycle accident 15 months ago. She continues to have significant pain with activities of daily living. Management should consist of

1

use of an electrical bone stimulation unit.

2

open reduction and internal fixation with a dynamic compression plate placed superiorly and autogenous bone grafting.

3

open reduction and internal fixation with a dynamic compression plate placed inferiorly and autogenous bone grafting.

4

intramedullary screw fixation.

5

partial claviculectomy.

QUESTION 15

A 62-year-old patient with rheumatoid arthritis has had pain and instability of the elbow following total elbow replacement 2 years ago. A complete work-up, including aspiration and cultures, is negative. Figures 9a and 9b show the AP and lateral radiographs. Treatment should consist of**

1

orthotic stabilization.

2

removal of the components with resection arthroplasty.

3

revision total elbow arthroplasty with an unconstrained prosthesis and ulnar allograft.

4

revision total elbow arthroplasty with a semiconstrained long-stemmed ulnar prosthesis.

5

elbow arthrodesis with bone grafting.

QUESTION 16

A 21-year-old football player reports increasing pain and a deformity involving his chest after colliding with another player during a scrimmage. Imaging studies confirm an anterior sternoclavicular dislocation. Management should consist of

1

reconstruction of the sternoclavicular capsule.

2

symptomatic nonsurgical treatment.

3

medial clavicle excision.

4

medial clavicle excision with capsular imbrication.

5

medial clavicle excision and rhomboid ligament reconstruction.

QUESTION 17

During total shoulder replacement for rheumatoid arthritis, fracture of the humeral shaft occurs. An intraoperative radiograph shows a displaced short oblique fracture at the tip of the prosthesis. At this point, the surgeon should**

1

insert a standard humeral prosthesis with cerclage wires at the fracture site and autologous cancellous bone graft.

2

insert a standard humeral component and apply a humeral orthosis postoperatively.

3

cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.

4

remove all instrumentation, perform an open reduction and internal fixation of the fracture, and delay completion of replacement surgery until the fracture has healed.

5

discontinue the procedure and return for completion of total shoulder replacement when the fracture has healed.

QUESTION 18

What is the most common contracture deformity of the spastic shoulder secondary to a cerebrovascular accident?

1

External rotation, abduction, and extension

2

External rotation, adduction, and flexion

3

Internal rotation, abduction, and flexion

4

Internal rotation, adduction, and extension

5

Internal rotation, adduction, and flexion

QUESTION 19

A 21-year-old collegiate pitcher has had pain in his dominant shoulder for the past 3 months despite management consisting of rest, rehabilitation, and an analysis of throwing mechanics. An arthroscopic photograph from the posterior portal is shown in Figure 10. The biceps anchor to the bone was not detached to probing. Treatment of the lesion to the left of the cannula should consist of arthroscopic

1

biceps tenodesis.

2

suture repair.

3

capsulorraphy.

4

debridement.

5

release of the biceps tendon.

QUESTION 20

After humeral head replacement for four-part fractures, what is the most commonly reported difficulty?

1

Pain

2

Inability to carry 10 lb at the side

3

Inability to wash the opposite axilla

4

Reaching to the back pocket

5

Working at shoulder level or above

QUESTION 21

Figures 11a and 11b show the AP and lateral radiographs of a 32-year-old patient on hemodialysis who has increasing elbow pain and a visibly growing mass over the extensor surface. Figure 11c shows the photomicrograph of the biopsy specimen. What is the most likely diagnosis?

1

Myositis ossificans

2

Tumoral calcinosis

3

Synovial cell sarcoma

4

Fungal granuloma

5

Hemochromatosis

QUESTION 22

A 52-year-old man who was a former high school pitcher now reports loss of elbow flexion and extension with pain at the extremes of motion. Nonsurgical management has failed to provide relief. Examination reveals movement from 50 degrees to 110 degrees and is painful only at the limits of motion. A radiograph is shown in Figure 12. Treatment should consist of

1

excision of the osteophytes and loose bodies and anterior and posterior capsular releases.

2

removal of the loose bodies.

3

anterior capsular release.

4

anterior and posterior capsular releases.

5

interposition arthroplasty.

QUESTION 23

A 79-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing right shoulder pain for the past year, and nonsurgical management has failed to provide relief. Her neurologic examination is entirely normal, but she is unable to elevate her arm against gravity. An AP radiograph is shown in Figure 13. Treatment should consist of

1

glenohumeral arthrodesis.

2

total shoulder arthroplasty.

3

humeral arthroplasty.

4

open synovectomy and rotator cuff repair.

5

anterior acromioplasty and rotator cuff repair.

QUESTION 24

A 22-year-old woman has had progressive upper extremity weakness for the past several years. History reveals no pain in her neck or shoulders. Examination reveals scapular winging of both shoulders and weakness in external rotation. She can abduct to only 120 degrees bilaterally, and there is mild supraspinatus weakness. She is otherwise neurologically intact with normal sensation and reflexes; however, she has difficulty whistling. A clinical photograph is shown in Figure 14. What is the most likely diagnosis?

1

Bilateral long thoracic nerve palsies

2

Central cervical disk herniation

3

Duchenne muscular dystrophy, adult onset

4

Fascioscapulohumeral dystrophy

5

Disuse atrophy as the result of deconditioning

QUESTION 25

A 37-year-old electrician is diagnosed with a frozen shoulder after sustaining an electrical injury at work 2 weeks ago. Examination reveals that he cannot actively or passively externally rotate or abduct the arm. The glenohumeral joint and scapula move in a 1:1 ratio. Radiographs are shown in Figures 15a and 15b. The best course of action
should be**

1

vigorous physical therapy for passive range of motion.

2

manipulation of the shoulder under anesthesia.

3

an intra-articular steroid injection.

4

an axillary radiograph.

5

MRI.

QUESTION 26

An 80-year-old man has had increasing shoulder pain for the past 4 months. He reports that it began with soreness and stiffness after chopping some wood. A coronal MRI scan is shown in Figure 16. Initial management should consist of**

1

shoulder exercises, mild analgesics, and activity modification.

2

transfer of the latissimus dorsi to the greater tuberosity.

3

arthroscopy and debridement of the tendon edges.

4

arthroscopy, arthroscopic acromioplasty, coracoacromial ligament release, and mini open repair.

5

arthroscopy, arthrotomy, acromioplasty, and primary repair of the rotator cuff.

QUESTION 27

Figure 17 shows the radiograph of a 25-year-old professional football player who has superior shoulder pain that prevents him from sports participation. History reveals that he sustained a shoulder injury that was treated with closed reduction and temporary pinning 3 years ago. The best course of action should be

1

no further participation in contact sports.

2

open reduction of the acromioclavicular joint and coracoclavicular screw stabilization.

3

open repair of the coracoclavicular ligaments.

4

Weaver-Dunn reconstruction and coracoclavicular reconstruction.

5

excision of the distal clavicle.

QUESTION 28

A 54-year-old man undergoes total shoulder arthroplasty for osteoarthritis. Despite compliance with an early passive range-of-motion exercise program, he does not regain more than 90 degrees of elevation, 10 degrees of external rotation, and has internal rotation to the fifth lumbar vertebra. At 6 months, his motion fails to improve. Radiographs are shown in Figures 18a and 18b. What is the best course of action?**

1

Continue with a more aggressive passive range-of-motion exercise program.

2

Perform an open release.

3

Revise the humeral component and increase retroversion.

4

Revise the humeral component alone after osteotomizing more of the humeral neck and seating the component lower.

5

Remove the glenoid component to decrease tension in the rotator cuff.

QUESTION 29

A 47-year-old patient has had persistent pain and weakness after undergoing a reamed intramedullary nailing for a midshaft humerus fracture 8 months ago. There is no evidence of infection. Radiographs are shown in Figures 19a and 19b. Management should consist of

1

electrical stimulation.

2

retrograde nailing with multiple unreamed flexible nails to prevent further loss of shoulder function.

3

leaving the same nail in place but adding cancellous bone graft.

4

exchange nailing with over-reaming and dynamic locking.

5

open reduction and plate fixation with autograft and rod removal.

QUESTION 30

An 18-year-old man sustained closed humeral shaft and forearm fractures of his dominant arm in a motor vehicle accident. Neurovascular examination is intact, and his condition is stable. The best course of action for management of the injuries should be

1

external fixation of the forearm fracture and functional bracing of the humeral shaft fracture.

2

external fixation of both fractures.

3

open reduction and internal fixation of both fractures.

4

open reduction and the internal fixation of the forearm fracture and functional bracing of the humeral shaft fracture.

5

application of a long arm cast.

QUESTION 31

A 32-year-old woman has had pain and a visibly growing mass in the shoulder for 3 years but denies any history of trauma. Examination reveals a swollen, boggy shoulder mass. The AP radiograph and MRI scan are shown in Figures 20a and 20b. Figures 20c through 20e show a portion of the excised mass and the photomicrographs of the biopsy specimen. What is the most likely diagnosis?

1

Synovial chondromatosis

2

Pigmented villonodular synovitis

3

Synovial cell sarcoma

4

Tuberculosis

5

Chondrosarcoma

QUESTION 32

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

1

Age of the patient

2

Time from injury to reduction

3

Completion of 3 weeks of immobilization

4

The degree of athletic participation

5

Bilateral instability

QUESTION 33

A 25-year-old man injured his dominant shoulder after falling on his outstretched arm 4 months ago. Examination reveals that he cannot lift his arm above 90 degrees, and he has pronounced medial scapular winging. Management should consist of

1

spinal accessory nerve exploration with repair.

2

long thoracic nerve exploration with repair.

3

a sling for comfort, followed by shoulder strengthening exercises.

4

scapulothoracic arthrodesis.

5

split pectoralis major transfer.

QUESTION 34

Treatment of adhesive capsulitis has a high failure rate when the underlying cause is

1

idiopathic.

2

traumatic.

3

diabetes mellitus.

4

hypothyroidism.

5

hyperthyroidism.

QUESTION 35

Figure 21 shows the AP radiograph of a 41-year-old patient who sustained a closed bicolumnar fracture of the distal humerus that resulted in a painful nonunion. What is the best initial construct for rigid stabilization of this fracture pattern?

1

Posterior “Y” plate fixation

2

Dual one third tubular plate fixation with a hinged external fixator

3

Dual one third tubular plate fixation

4

Dual 3.5-mm reconstruction plate fixation

5

Single lateral plate fixation with transcortical screw fixation

QUESTION 36

Figure 22 shows the radiographs of a 16-year-old boy who injured his elbow in a fall 1 year ago. Although he has no pain, he reports restricted forearm rotation and elbow flexion. What is the most likely diagnosis?

1

Posttraumatic soft-tissue contractures

2

Congenital dislocation of the radial head

3

Chronic posttraumatic dislocation of the radial head

4

Combined annular and lateral collateral ligament injury

5

An unrecognized Monteggia variant type of injury

QUESTION 37

A 55-year-old man has had progressive right shoulder pain for the past 2 years. Examination reveals active elevation to 120 degrees, external rotation to 20 degrees, and internal rotation to the sacrum. AP and axillary radiographs are shown in Figures 23a and 23b. Which of the following procedures would result in the most predictable long-term pain relief?

1

Arthroscopic debridement of the glenohumeral joint

2

Open subscapularis lengthening and cheilectomy

3

Humeral hemiarthroplasty

4

Bipolar humeral hemiarthroplasty

5

Total shoulder arthroplasty

QUESTION 38

A 20-year-old professional baseball pitcher has had a 3-year history of increased aching in his shoulder that is associated with pitching, and he is now seeking a second opinion. Nonsurgical management consisting of rest, anti-inflammatory drugs, ice, heat, and cortisone injections has failed to provide relief. A previous work-up that included radiographs and gadolinium-enhanced MRI arthrography was negative. Results of an arteriogram suggest quadrilateral space syndrome. Assuming that this is the correct diagnosis, what nerve needs to be decompressed?

1

Suprascapular

2

Infraspinatus branch of the suprascapular

3

Long thoracic

4

Axillary

5

Lateral cord of the brachial plexus

QUESTION 39

A right-handed 24-year-old woman underwent an arthroscopic Bankart repair for recurrent anterior dislocations 9 months ago. Despite extensive physical therapy for 8 months, the patient has very limited range of motion (elevation to 130 degrees and external rotation to 10 degrees with the arm at the side). Shoulder radiographs are normal. The next step in management should consist of

1

cessation of physical therapy and acceptance of the limited range of motion.

2

additional physical therapy for 3 to 4 months.

3

arthroscopic capsular release.

4

open release with Z-plasty lengthening of the subscapularis tendon.

5

closed manipulation under anesthesia.

QUESTION 40

A patient with deficient anteroinferior bone stock undergoes a Latarjet procedure that transfers a portion of the coracoid to the glenoid rim and secures it with two screws. After surgery, the patient reports numbness on the anterolateral forearm. To verify the diagnosis, what muscle should be tested for strength?

1

Axillary

2

Abductor pollicis brevis

3

Supinator

4

Triceps

5

Biceps

QUESTION 41

A 34-year-old woman has had painful snapping and popping in the elbow since falling while in-line skating 6 months ago. The popping also occurs when she pushes off with her hands to rise from a seated position. Initial radiographs were normal, and she was told that she had sprained her elbow. Examination reveals few findings except that she is very apprehensive when the forearm is forcefully supinated with the elbow extended or partially flexed. A radiograph taken in that position is shown in Figure 24. Treatment should consist of

1

arthroscopic loose body removal.

2

arthroscopic debridement and loose body removal for osteochondritis dissecans of the capitellum.

3

annular ligament reconstruction for posttraumatic posterior subluxation of the radial head.

4

radial head resection for congenital type II dislocation of the radial head.

5

lateral collateral ligament reconstruction for posterolateral rotatory instability.

QUESTION 42

A 49-year-old woman noted pain in her right axilla 1 day after moving heavy furniture. Two weeks later, she now reports persistent numbness and paresthesias along the inner aspect of her upper arm radiating into the ulnar digits. Examination reveals full shoulder motion, tenderness over the first rib, and a decreased radial pulse with the shoulder placed overhead. What is the most likely diagnosis?

1

Brachial plexus stretch injury

2

Cervical radiculopathy

3

Rotator cuff tendinitis

4

Anterior subluxation of the shoulder

5

Thoracic outlet syndrome

QUESTION 43

A patient has had a locked posterior dislocation of the shoulder for the past 6 months. After undergoing total shoulder arthroplasty that includes adequate anterior releases and posterior capsulorrhaphy, the patient still exhibits posterior instability intraoperatively. The postoperative rehabilitation regimen should include

1

use of a sling with no range-of-motion exercises until the condition is stable.

2

use of a sling and passive range-of-motion exercises within the limits of the repair.

3

no sling and supine passive range-of-motion exercises.

4

an internal rotation brace holding the arm at the side.

5

an external rotation brace holding the arm at the side.

QUESTION 44

Which of the following factors is associated with failure of arthroscopic excision of the distal clavicle?

1

Removal of less than 2 cm of bone

2

Male gender

3

Female gender

4

Diagnosis of osteolysis

5

Uneven resection of bone

QUESTION 45

Anterior subluxation in a throwing athlete is most commonly the result of

1

avulsion of the inferior glenohumeral ligament from the glenoid.

2

avulsion of the inferior glenohumeral ligament from the humerus.

3

fracture of the anterior glenoid rim.

4

excessive capsular laxity from microtrauma.

5

a large Hill-Sachs lesion.

QUESTION 46

What is the most significant prognostic factor in nontraumatic osteonecrosis of the humeral head?

1

Duration of symptoms

2

Age of the patient

3

Total amount of steroid use

4

Stage of the disease

5

Status of the rotator cuff

QUESTION 47

A 43-year-old former professional hockey player reports severe pain in his chest after being checked from the side in a pick-up hockey game. An MRI scan and plain radiographs are shown in Figures 25a through 25c. What is the most likely diagnosis?

1

Anterior sternoclavicular joint dislocation

2

Posteroinferior sternoclavicular joint dislocation

3

Anterior acromioclavicular joint dislocation

4

Posterior acromioclavicular joint dislocation

5

Acromial fracture

QUESTION 48

Which of the following is considered a contraindication to functional bracing for the treatment of humeral shaft fractures?

1

A closed midshaft fracture accompanied by a radial nerve palsy prior to an attempt at reduction

2

A fracture with more than 30 degrees of varus angulation prior to reduction

3

A distal one third spiral fracture

4

A fracture caused by a low-velocity hand gun treated initially with wound debridement and antibiotics

5

An inability to maintain less than 30 degrees of varus and 20 degrees of anterior or posterior angulation after reduction

QUESTION 49

A 20-year-old man with fascioscapulohumeral dystrophy has severe scapular winging of both shoulders. He can no longer abduct above 80 degrees, and it affects his activities of daily living. A clinical photograph is shown in Figure 26. Definitive management should consist of

1

a rehabilitation program to strengthen his remaining scapular muscles.

2

a scapular brace to keep his scapula reduced.

3

scapulothoracic fusion.

4

pectoralis minor muscle transfer.

5

latissimus dorsi muscle transfer.

QUESTION 50

Flexion and extension of the elbow occur about an axis of rotation that

1

corresponds with a line drawn through the centers of the trochlea and the capitellum.

2

corresponds with a line drawn through the center of the medial epicondyle and the lateral epicondyle.

3

corresponds with a line drawn through the radial head and coronoid.

4

moves with flexion and extension.

5

is polycentric.

QUESTION 51

Figure 27 shows the radiograph of a 26-year-old man who sustained a closed head injury and a closed elbow dislocation 6 weeks ago. Examination reveals 65 degrees to 115 degrees of flexion, and intensive physical therapy has resulted in no improvement. A decision regarding the timing of surgical correction of the contracture should be based on**

1

bone scan results returning to normal.

2

a decline in intensity on serial bone scans.

3

the serum levels of alkaline phosphatase measured over time.

4

the level of serum calcium-phosphorus product.

5

the time since injury and evidence of bone maturation on plain radiographs.

QUESTION 52

A 70-year-old man who underwent an uncomplicated large rotator cuff repair 6 months ago is now seeking a second opinion regarding persistent pain and weakness in his shoulder. Examination reveals that his incision is well healed and unreactive. The surgical report suggests that the tendons were secured back to bone with sutures through the greater tuberosity. Figure 28 shows a radiograph that was obtained 1 week ago. What is the most likely diagnosis?

1

Infection

2

Complex regional pain syndrome with associated osteopenia

3

Frozen shoulder

4

Failed rotator cuff repair

5

Acromioclavicular joint arthritis

QUESTION 53

A 29-year-old man who lifts weights states that he injured his left shoulder while performing a bench press 2 days ago. The following morning he noted ecchymosis and swelling in the left chest wall. Examination reveals ecchymosis and tenderness and deformity in the left anterior chest wall and axillary fold that is accentuated with resisted adduction of the arm. Passive range of motion beyond 90 degrees of forward flexion and 45 degrees of external rotation is extremely painful. Glenohumeral stability is difficult to assess because of severe guarding. Figure 29 shows an MRI scan. Management should
consist of

1

proximal biceps tenodesis.

2

application of a sling for 3 weeks, followed by physical therapy.

3

anterior capsulolabral reconstruction.

4

repair of the subscapularis tendon.

5

repair of the pectoralis major tendon.

QUESTION 54

What range of motion parameters are required for a patient with posttraumatic elbow stiffness to accomplish all the normal activities of daily living?

1

Flexion and extension of 10 degrees to 110 degrees, pronation of 50 degrees, and supination of 50 degrees

2

Flexion and extension of 10 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees

3

Flexion and extension of 30 degrees to 110 degrees, pronation of 60 degrees, and supination of 30 degrees

4

Flexion and extension of 30 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees

5

Flexion and extension of 30 degrees to 130 degrees, pronation of 60 degrees, and supination of 30 degrees

QUESTION 55

A 24-year-old athlete has a painful right shoulder. Figure 30 shows an intra-articular photograph that was obtained through a posterior portal during arthroscopy; the labrum is indicated by the arrow. Based on these findings, management should consist of

1

stabilization with suture anchors.

2

debridement only.

3

no treatment.

4

stabilization using absorbable tacks with the arm in external rotation.

5

release of the attachment to the middle glenohumeral ligament, followed by stabilization with any device.

QUESTION 56

The use of a screw between the clavicle and the coracoid process to maintain the clavicle and acromioclavicular (AC) joint in a reduced position is a treatment option for AC joint separations. Screw removal is generally recommended after soft-tissue healing. What effect does this rigid coracoclavicular fixation have on shoulder kinematics?**

1

Significant limitation of humeral elevation

2

Significant limitation of shoulder abduction

3

Significant loss of motion in all directions

4

Little to no limitation of shoulder range of motion

5

Limitation of humeral rotation

QUESTION 57

Figure 31 shows the AP and lateral radiographs of the elbow of a 56-year-old man with chronic polyarticular rheumatoid arthritis. His function continues to be limited by pain with activities of daily living. Examination shows that his total arc of motion is 110 degrees. Nonsurgical management has failed to provide relief. Treatment should now consist of

1

elbow fusion with a contoured dynamic compression plate.

2

radial head excision and synovectomy.

3

distraction arthroplasty with interpositional tissue.

4

total elbow replacement with an unconstrained prosthesis.

5

total elbow replacement with a semiconstrained prosthesis.

QUESTION 58

A 12-year-old pitcher has had a 2-month history of pain in his right dominant shoulder after throwing. He reports that the pain has gradually progressed to the point where he cannot throw without pain. He also notes that the pain now awakens him at night if he has been active. Anti-inflammatory drugs have failed to provide relief. Examination reveals no abnormalities except for some localized tenderness over the proximal humerus. Figures 32a and 32b show radiographs of both shoulders. What is the most likely diagnosis?

1

Chondroblastoma

2

Osteoid osteoma

3

Occult instability

4

Rotator cuff tear

5

Injury to the proximal humeral physis

QUESTION 59

Which of the following ligaments is the primary static restraint against inferior translation of the arm when the shoulder is in 0 degrees of abduction?

1

Middle glenohumeral

2

Inferior glenohumeral

3

Coracoacromial

4

Coracoclavicular

5

Coracohumeral

QUESTION 60

A 16-year-old high school student undergoes a routine preparticipation physical examination at the beginning of the school year. Examination reveals marked laxity of both shoulders but only mild generalized laxity in other joints. The load and shift test allows for anterior humeral translation to the glenoid rim and posterior humeral translation beyond the glenoid rim. The sulcus sign is present. What is the next most appropriate step in management?

1

Inform the student that participation in sports is prohibited.

2

Order MRI of the shoulders to evaluate for labral tears.

3

Consider arthroscopic thermal capsulorraphy to tighten the shoulders.

4

Consider open capsular shift procedures to stabilize the shoulders.

5

Recommend a program of shoulder strengthening exercises and allow participation in sports.

QUESTION 61

A 21-year-old professional baseball player has had painful catching and stiffness in his dominant right elbow for the past year. Examination reveals a flexion contracture of 2 degrees and mild pain with full elbow flexion. Radiographs are shown in Figures 33a and 33b. The most effective management should consist of**

1

reconstruction of the medial collateral ligament.

2

a short period of rest followed by a gradual return to activity.

3

physical therapy and dynamic extension splinting.

4

arthroscopic removal of the loose body.

5

a corticosteroid injection.

QUESTION 62

A 42-year-old patient has had painful inferior subluxation of the glenohumeral joint following a recent cerebrovascular accident (CVA). Figure 34 shows the AP radiograph of the shoulder. Management should consist of**

1

closed reduction.

2

symptomatic sling support and range-of-motion exercises.

3

arthroscopic thermal capsulorrhaphy.

4

an open anterior-inferior capsular shift.

5

a Laterjet procedure.

QUESTION 63

A 50-year-old man who underwent an arthroscopic rotator cuff repair 5 days ago now returns for an early postoperative follow-up because of increasing pain in his shoulder. He reports increasing malaise and has a low-grade fever. Examination reveals no redness or swelling, but he has scant serous drainage from the posterior portal. An emergent Gram stain is positive for gram-positive cocci. The next most appropriate step in management should consist of

1

oral antibiotics and observation.

2

IV antibiotics and observation.

3

immediate arthroscopic debridement and lavage.

4

blood cultures, oral antibiotics, and a reculture in 2 days.

5

aspiration of the joint at his regular follow-up in 7 days if the symptoms increase.

QUESTION 64

A 42-year-old man who is right-hand dominant injured his right shoulder when he fell from a ladder onto his outstretched arm 1 hour ago. Radiographs reveal a two-part greater tuberosity anterior fracture-dislocation. Initial management should consist of

1

closed reduction of the glenohumeral joint and open reduction of the displaced greater tuberosity with rotator cuff repair.

2

closed reduction of the glenohumeral joint, followed by radiographic assessment of the tuberosity position to determine further treatment.

3

open reduction of both the joint and greater tuberosity with rotator cuff repair.

4

open reduction of the glenohumeral joint and closed treatment of the greater tuberosity.

5

use of a sling until the patient reports no discomfort, then early passive range of motion.

QUESTION 65

A 19-year-old man who plays college volleyball undergoes a routine preparticipation physical examination. Figure 35 shows a posterior view of his dominant shoulder. An electromyogram shows that this is a chronic injury, and an MRI scan shows no abnormalities. The best course of action should be**

1

a program of shoulder strengthening exercises.

2

decompression of the nerve at the spinoglenoid notch.

3

decompression of the nerve at the transverse suprascapular ligament.

4

release of the fascial elements of the muscle tethering the nerve.

5

arthroscopy, repair of the posterior labrum lesion, and an anterior capsular shift.

QUESTION 66

A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury. Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nonsteroidal anti-inflammatory drugs has failed to provide lasting relief. Examination reveals tenderness over the acromioclavicular (AC) joint and over the subacromial bursa. He has positive Neer and Hawkins impingement signs and AC joint pain with adduction of the shoulder. Radiographs are shown in Figures 36a and 36b. An MRI scan reveals an intact rotator cuff. Management should now consist of

1

open anterior acromioplasty and rotator cuff repair.

2

arthroscopic acromioplasty.

3

anterior acromioplasty and distal clavicle excision.

4

an open Mumford procedure.

5

immobilization in a sling for 4 weeks followed by additional physical therapy.

QUESTION 67

What three structures are considered the primary constraints necessary for
elbow stability?

1

Coronoid, ulnar part of the lateral collateral ligament, capsule

2

Capsule, anterior band of the medial collateral ligament, radial head

3

Radial head, ulnar part of the lateral collateral ligament, capsule

4

Anterior band of the medial collateral ligament, coronoid, radial head

5

Ulnar part of the lateral collateral ligament, anterior band of the medial collateral ligament, coronoid

QUESTION 68

A 68-year-old woman has been progressing slowly after undergoing humeral head replacement for a four-part fracture 3 months ago. She has not regained active elevation, she feels an audible clunk on attempting elevation, and she reports pain and weakness. She used a sling for 2 weeks in the immediate postoperative period. Radiographs are shown in Figure 37a through 37c. Management should consist of**

1

tuberosity and rotator cuff repair with bone graft.

2

revision arthroplasty leaving the prosthesis proud to increase humeral length and muscle tension.

3

revision total shoulder arthroplasty to neutralize eccentric glenoid wear.

4

revision of the humeral head replacement alone with increased retroversion.

5

additional therapy to include internal and external rotation strengthening of the rotator cuff.

QUESTION 69

What is the most important feature in choosing an outcome instrument to assess
shoulder disorders? **

1

Ease of use

2

Validity

3

Ability to use it by mail or phone so the subject is not required to return in person to measure the outcome

4

Inclusion of radiographic assessment at follow-up

5

Scoring that is on a 100-point scale so that it can be compared with other instruments

QUESTION 70

Figure 38 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. To minimize additional trauma to the medial soft tissues, the elbow should be reduced in

1

neutral rotation.

2

full pronation.

3

full supination.

4

full extension.

5

full flexion.

QUESTION 71

In patients older than age 40 years who sustain a first-time anterior dislocation of the shoulder, prolonged morbidity is most commonly associated with

1

recurrent dislocation.

2

posttraumatic arthritis.

3

a rotator cuff tear.

4

stiffness secondary to immobilization.

5

nerve injury.

QUESTION 72

Figure 39 shows the AP radiograph of a 62-year-old man with degenerative osteoarthritis secondary to trauma. History reveals that he underwent total elbow arthroplasty 3 years ago. He continues to report instability and constant pain. A complete work-up, including aspiration and cultures, is negative. Treatment should consist of removal of the components and**

1

distraction interpositional arthroplasty.

2

elbow arthrodesis.

3

conversion to a resection arthroplasty.

4

conversion to semiconstrained elbow arthroplasty.

5

revision to unconstrained total elbow arthroplasty.

QUESTION 73

A 67-year-old woman undergoes a revision total shoulder arthroplasty for replacement of a loose glenoid component. Examination in the recovery room reveals absent voluntary deltoid and triceps contraction, weakness of wrist and thumb extension, and absent sensation in the palmar aspect of all fingertips and the radial forearm. The next most appropriate step in management should consist of**

1

an immediate return to the operating room to explore the brachial plexus.

2

immediate electromyography and nerve conduction velocity studies.

3

MRI of the brachial plexus.

4

MRI of the cervical spine.

5

immobilization in a sling, followed by early passive range of motion.

QUESTION 74

Figure 40 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. Closed reduction is readily accomplished, and the elbow seems stable. Management should now consist of application of a splint for

1

2 to 5 days, followed by initiation of assisted motion.

2

14 to 21 days, followed by initiation of assisted motion.

3

4 weeks, followed by active motion.

4

6 weeks, followed by physical therapy.

5

8 weeks, followed by active motion of the elbow.

QUESTION 75

A 50-year-old electrician who is right-hand dominant has had right shoulder pain and stiffness after sustaining an electric shock 2 months ago. An AP radiograph obtained at the time of injury was considered negative, and the patient was diagnosed with a shoulder sprain. The patient now reports continued shoulder pain and restricted motion. AP and axillary radiographs and a CT scan are shown in Figures 41a through 41c. Management should consist of

1

continued observation and physical therapy.

2

closed reduction in the office.

3

closed reduction under anesthesia in the hospital.

4

humeral arthroplasty.

5

open reduction and transfer of the subscapularis and lesser tuberosity into the anteromedial humeral head defect.

QUESTION 76

Figure 42 shows the radiograph of a 70-year-old woman who has had a painful near ankylosis of her dominant elbow for 1 year. Treatment should consist of

1

total elbow replacement.

2

hardware removal and joint release.

3

medial and lateral column humerus plating and a bone graft.

4

distal humerus replacement.

5

resection arthroplasty.

QUESTION 77

A 72-year-old woman who was doing well after undergoing total shoulder arthroplasty for arthritis 4 months ago is suddenly unable to elevate her arm. Examination reveals 70 degrees of external rotation compared with 45 degrees on the uninvolved side, and she is unable to lift her hand off her lower back. Radiographs are shown in Figures 43a through 43c. Treatment should consist of

1

fascia lata graft to restore the coracoacromial arch.

2

immediate subscapularis repair.

3

revision arthroplasty with glenoid reaming to centralize the component.

4

revision arthroplasty with increased retroversion in the humeral component.

5

arthroscopic subacromial decompression.

QUESTION 78

A 25-year-old man underwent a Putti-Platt repair for recurrent anterior dislocation of his right shoulder 9 months ago. He reports no further episodes of instability but continues to have severely restricted motion, with external rotation limited to less than 0 degrees with the arm at the side. He has pain at the ends of range of motion and restricted activities of daily living despite undergoing nearly 9 months of physical therapy. Radiographs of the shoulder show no arthritic changes. Management should now consist of

1

additional physical therapy for 6 months followed by reassessment.

2

manipulation under anesthesia.

3

arthroscopic release combined with the use of an interscalene catheter postoperatively.

4

open release with Z-plasty lengthening of the subscapularis and capsule.

5

shoulder hemiarthroplasty.

QUESTION 79

A 43-year-old bus driver sustains a hyperextension injury to her arm and shoulder 4 months after undergoing an open Bankart repair. Examination reveals increased external rotation, anterior shoulder pain, and internal rotation weakness. Her examination also reveals the findings shown in Figure 44. What is the most likely diagnosis?

1

Superior labrum anterior and posterior lesion, type III

2

Isolated traumatic dislocation

3

Axillary nerve disruption

4

Subscapularis rupture

5

Internal impingement

QUESTION 80

Radial nerve palsy is most commonly associated with which of the following types of humeral fractures?

1

Proximal one third spiral

2

Proximal one third transverse

3

Distal one third spiral

4

Distal one third transverse

5

Middle one third

QUESTION 81

A 30-year-old firefighter sustained a longitudinal pulling injury to the arm while attempting to move a heavy object during a fire. Figure 45 shows an MRI scan of the elbow. Initial management should consist of**

1

rest and a sling followed by a gradual return to activities.

2

physical therapy and extension-block bracing.

3

repair of the biceps tendon to the brachialis muscle.

4

repair of the common flexor origin.

5

anatomic repair of the distal biceps tendon.

QUESTION 82

Which of the following is considered a reasonable goal for arthroplasty surgery in rotator cuff arthropathy?

1

Restore normal humeral head glenoid contact location

2

Restore full active overhead motion

3

Restore proper glenoid version with bone preparation and use of a cemented glenoid component

4

Achieve formal decompression and acromioplasty with resection of the coracoacromial ligament and distal clavicle

5

Achieve a secure closure of the subscapularis with an appropriate head size

QUESTION 83

What is the best surgical approach for the scapular fracture shown in Figure 46?

1

Anterior and superior

3

Posterior

4

Percutaneous pinning

5

Closed reduction

QUESTION 84

Management of a grade IV osteochondritis dissecans lesion of the capitellum should consist of

1

use of a sling for 3 weeks followed by a gradual return to activities.

2

physical therapy.

3

arthroscopy with removal of the loose fragment.

4

arthroscopy with in situ drilling of the fragment.

5

internal fixation of the fragment.

QUESTION 85

What preoperative factor correlates best with the outcome of rotator cuff repair?

1

Size of the tear

2

Age of the patient

3

Arm dominance

4

Rupture of the long head of the biceps

5

Preoperative pain score

QUESTION 86

A 55-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing left shoulder pain for the past 2 years despite nonsurgical management. No focal weakness is noted during examination of the shoulder. AP and axillary radiographs are shown in Figures 47a and 47b. Treatment should consist of

1

arthroscopic synovectomy.

2

humeral arthroplasty.

3

unconstrained total shoulder arthroplasty.

4

constrained total shoulder arthroplasty with a fixed-fulcrum prosthesis.

5

glenohumeral arthrodesis.

QUESTION 87

When elevating the arm, the ratio of scapulothoracic to glenohumeral motion over the total range of motion is best described as

1

1:2, and in the first 30 degrees the ratio is 1:5.

2

1:2, and in the first 30 degrees the ratio is variable.

3

2:1, and in the first 30 degrees the ratio is variable.

4

2:1, and in the first 30 degrees the ratio is 3:1.

5

highly variable and no definitive statement can be made about the ratios.

QUESTION 88

Figure 48 shows the initial AP chest radiograph of a 21-year-old motorcycle rider who sustained multiple injuries after striking a telephone pole at high speed. What is the most significant radiographic finding leading to a diagnosis?**

1

Subdiaphragmatic free air

2

Right midshaft clavicular fracture

3

Right scapulothoracic dissociation

4

Left diaphragmatic rupture

5

Left sternoclavicular dislocation

QUESTION 89

A 21-year-old man who underwent repair of a distal biceps tendon rupture using a two-incision approach 4 months ago now reports difficulty gaining rotation of his forearm. Figures 49a and 49b show the AP and lateral radiographs. What is the most likely cause of his problem?

1

Inadequate physical therapy

2

Exposure of the periosteum of the lateral ulna during surgery

3

Inappropriate location of the suture anchor

4

Fixation of the tendon with the forearm fully pronated

5

Subluxation of the radial head

QUESTION 90

A 53-year-old man reports acute, severe left shoulder pain after undergoing abdominal surgery 10 days ago. Initial management, consisting of anti-inflammatory drugs, physical therapy, and a subacromial injection of corticosteroid, fails to provide relief. Reexamination of the shoulder 2 months after the onset of symptoms reveals atrophy of the infraspinous and supraspinous fossa and profound weakness of active abduction and external rotation. His neck is supple with a full range of motion. Plain radiographs and an MRI scan of the shoulder are normal. What diagnostic study should be performed next in the evaluation of this patient?**

1

Shoulder arthrography

2

MRI of the cervical spine

3

CT of the head

4

Technetium Tc 99m bone scan

5

Electromyography and nerve conduction velocity studies

QUESTION 91

A 58-year-old reports pain and stiffness in his left shoulder following a seizure episode. Diagnosis at the time of the seizure is a frozen shoulder, and management consists of an aggressive physical therapy program of stretching exercises. Four months later he continues to have shoulder pain and has not gained any additional range of motion. A CT scan is shown in Figure 50. Management should now consist of

1

additional physical therapy and home stretching exercises.

2

closed reduction and immobilization in a spica cast.

3

open reduction and transfer of the subscapularis and lesser tuberosity.

4

humeral arthroplasty.

5

total shoulder arthroplasty.

QUESTION 92

When conducted at near physiologic strain rates, tensile studies of the inferior glenohumeral ligament (IGHL) have shown that the

1

anterior band of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

2

anterior band of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.

3

axillary pouch of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

4

axillary pouch of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.

5

posterior portion of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

QUESTION 93

Manipulation under anesthesia for resistant frozen shoulder should be avoided in
patients with

1

idiopathic onset.

2

gout.

3

hyperthyroidism.

4

hypothyroidism.

5

severe osteoporosis.

QUESTION 94

A patient who sustained a cerebrovascular accident (CVA) 18 months ago has a long-standing spastic adduction contracture of the shoulder with a rigid block to passive external rotation. Significant hygiene problems exist with maceration and continued skin breakdown. Management should consist of**

1

a percutaneous pectoralis tenotomy.

2

a modified L’Episcopo procedure.

3

serial lidocaine nerve blocks.

4

pectoralis tenotomy and subscapularis tendon lengthening.

5

phenol nerve blocks.

QUESTION 95

A patient with degenerative osteoarthritis of the sternoclavicular (SC) joint reports constant pain, discomfort, and marked prominence and instability of the SC joint following medial clavicle resection. Which of the following procedures is most likely to produce these signs and symptoms?**

1

Excision medial to the costoclavicular ligament

2

Excision lateral to the costoclavicular ligament

3

Excision of the coracoclavicular ligaments and lateral clavicle

4

Excision of the coracohumeral ligaments

5

Leaving the costoclavicular ligament intact

QUESTION 96

A 26-year-old man has had a 2-year history of pain and stiffness after sustaining a comminuted olecranon fracture. Treatment at the time of injury consisted of open reduction and internal fixation with tension band wiring. Examination reveals motion of 45 degrees to 110 degrees and pain throughout the arc of motion. Resisted flexion and extension are painful. Forearm rotation is normal. Radiographs are shown in Figure 51. Treatment should consist of

1

excision of heterotopic bone.

2

hardware removal and elbow joint release with splinting.

3

semiconstrained total elbow arthroplasty.

4

distraction arthroplasty.

5

synovectomy and radial head excision.

QUESTION 97

What is the most common cause of rotator cuff injury in high school athletes?

1

A curved or type III acromion

2

A tight coracoacromial ligament

3

Overuse

4

Limited internal rotation

5

Scapulothoracic dyskinesia

QUESTION 98

A 16-year-old boy with osteochondritis dissecans of the capitellum has intermittent symptoms of catching and locking. Examination is unremarkable. Radiographs reveal a loose body anteriorly with a diameter of 10 mm. To remove the loose body, elbow arthroscopy is being considered. Which of the following procedures would minimize the risk of neurovascular complication during the procedure?

1

Keeping a smooth plastic cannula in each portal after it is established

2

Using an image intensifier to localize the loose body

3

Distending the elbow joint capsule prior to establishing the anterolateral portal

4

Placing the scope in the proximal anteromedial portal and then enlarging the anterolateral portal so that it is bigger than the maximum diameter of the loose body

5

Breaking up the loose body into several pieces prior to extracting it

QUESTION 99

Examination of the shoulder seen in Figure 52 shows atrophy and tenderness of the infraspinous fossa and profound weakness in external rotation. The supraspinous fossa shows normal muscle bulk. What is the most likely cause of this condition?

1

Neurofibroma of the suprascapular nerve

2

Ganglion cyst of the suprascapular notch

3

Ganglion cyst of the spinoglenoid notch

4

Lipoma of the suprascapular notch

5

Lipoma of the spinoglenoid notch

Compression of the suprascapular nerve by a ganglion cyst is a well-documented cause of pain and weakness in the shoulder. Isolated involvement of the infraspinatus indicates that the area of entrapment is at the spinoglenoid notch and not the suprascapular notch. The majority of ganglion cysts found in the shoulder are related to tears of the labrum. When such a compressive lesion is found, decompression can be accomplished through either an open or arthroscopic approach. Several authors have shown the value of arthroscopy in the treatment of this condition. It has been shown that it is technically possible to decompress a paralabral ganglion cyst using arthroscopy; this method is usually followed by repair of the torn labrum. Alternatively, arthroscopic repair of the labrum can be performed and the cyst may be aspirated at the time of surgery. Open cyst excision through a posterior approach is also an acceptable method of treatment.
REFERENCES: Schickendantz MS, Ho CP: Suprascapular nerve compression by a ganglion cyst: Diagnosis by magnetic resonance imaging. J Shoulder Elbow Surg 1993;2:110-114.
Thompson RC, Schneider W, Kennedy T: Entrapment neuropathy of the inferior branch of the suprascapular nerve by ganglia. Clin Orthop 1982;166:185-187.
Iannotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.
**1****.**

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Orthopedic With Answer Sh Review | Dr Hutaif General Or -...

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ORTHOPEDIC MCQS BANK WITH ANSWER SHOULDER 02

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