Orthopedic With Answer Upper L Review

In this comprehensive guide, we discuss everything you need to know about ORTHOPEDIC MCQS WITH ANSWER UPPER LIMB 05. Orthopedic management involves surgical closure for rotator cuff interval defects and debridement for post-operative infections, often by Propionibacterium acnes, with re-prepping as prevention. Coracoid process fractures require open reduction and internal fixation. These treatments are tailored to patient needs, acknowledging specific considerations for a `surg a yearold` and other demographics.

QUESTION 1

A 45-year-old recreational tennis player underwent arthroscopic decompression and mini-open repair of a small supraspinatus tendon tear 3 weeks ago after nonsurgical management failed to provide relief. He now has pain, swelling about the wound, erythema, and purulent drainage. The patient is returned to the operating room for irrigation, debridement, and cultures. What is the most common organism causing
this infection?

1

Staphylococcus epidermidis

2

Methicillin-resistant Staphylococcus aureus

3

Pseudomonas aeruginosa

4

Propionibacterium acnes

5

Clostridium tetani

QUESTION 2

A paraplegic 32-year-old man was pulling himself up in bed by grasping the headboard rails when he felt a pop and immediate pain. A radiograph and CT scan are shown in Figures 2a and 2b. Based on these findings, management should consist of

1

rest and a sling for 3 to 6 weeks.

2

physical therapy with modalities for pain relief.

3

pain medication and activity as tolerated.

4

open reduction and internal fixation.

5

coracoid excision.

QUESTION 3

A 23-year-old baseball pitcher reports pain in the posterior aspect of his dominant shoulder during the late cocking phase of throwing. With the dominant shoulder positioned in 90 degrees of abduction from the body and with the scapula stabilized, examination reveals 135 degrees of external rotation and 20 degrees of internal rotation. Examination of the opposite shoulder reveals 100 degrees of external rotation and 75 degrees of internal rotation. Both shoulders are stable on examination. Radiographs and MRI scans are unremarkable. What is the primary cause of his pain?

1

Posterior capsular tightness

2

Tightness of the rotator cuff interval

3

Anterior inferior glenohumeral ligament laxity

4

Excessive retroversion of the proximal humerus

5

Subacromial impingement

QUESTION 4

What is the most common indication for revision following unconstrained
elbow arthroplasty?

1

Polyethylene wear

2

Loosening of the humeral component

3

Loosening of the ulnar component

4

Instability

5

Component failure

QUESTION 5

What part of the glenoid labrum has the least vascularity?

1

Midanterior

2

Anterior/inferior

3

Anterior/superior

4

Posterior/superior

5

Posterior/inferior

QUESTION 6

One of the serious potential complications of repair of distal biceps tendon ruptures is limited pronation and supination as a result of synostosis. What surgical approach and technique presents the highest risk for development of this complication?

1

Single incision, anterior approach with fixation through drill holes in the radius

2

Single incision, anterior approach with suture anchor fixation to the radius

3

Single incision, anterior approach through a drill hole in the radius with sutures tied over bolster or button on the posterior forearm

4

Dual incision, limited anterior and posterior approach along the ulna with attachment through drill holes

5

Dual incision, limited anterior and posterior muscle-splitting approach (supinator and extensor muscles) with attachment through drill holes

QUESTION 7

A 25-year-old carpenter falls on his outstretched arm. What physical finding best correlates with the lesion seen on the MRI scan shown in Figure 3?

1

Weakness in external rotation

2

Weakness in abduction

3

Positive lift-off test

4

Loss of biceps contour

5

Deltoid atrophy

QUESTION 8

A 72-year-old woman who sustained a cerebrovascular accident 9 months ago now has a fixed elbow flexion contracture of 80 degrees. Management should consist of

1

passive physical therapy.

2

musculocutaneous neurectomy and serial casting.

3

musculocutaneous nerve block.

4

lengthening of the biceps tendon.

5

distraction arthroplasty.

QUESTION 9

A 44-year-old recreational weight lifter reports chronic deep pain in his left shoulder that is aggravated by any pressing exercises. He also notes a painful catch in the shoulder occurring with rotational movements. Physical therapy and nonsteroidal anti-inflammatory drugs for 3 months have failed to provide relief. Examination reveals pain with O’Brien’s test but no signs of instability. MRI scans are shown in Figures 4a
and 4b. Treatment should now consist of

1

arthroscopic repair of a superior labral tear with cyst decompression.

2

open excision of the ganglion cyst.

3

proximal biceps tenodesis.

4

rotator cuff repair.

5

anterior stabilization.

QUESTION 10

A 35-year-old carpenter sustained an injury to his dominant shoulder in a fall. He reports that he felt a sharp tearing sensation as he held on to a scaffold to keep from falling. Examination reveals swelling and ecchymosis down the upper arm, weakness to internal rotation, and deformity of the anterior axilla. He has good strength in external rotation and no apprehension with instability testing. Radiographs are normal. Management should consist of

1

physical therapy for range of motion and strengthening following a decrease in pain and swelling.

2

shoulder arthroscopy for diagnosis and treatment of a possible labral tear.

3

open exploration and repair of a pectoralis major tendon avulsion.

4

MRI of the rotator cuff.

5

immobilization in a sling and swathe for 3 to 6 weeks, followed by mobilization and strengthening.

QUESTION 11

A 48-year-old woman with rheumatoid arthritis reports increasing elbow pain for the past 6 months. History reveals that she underwent total elbow arthroplasty 7 years ago. A peripheral WBC count, erythrocyte sedimentation rate, and C-reactive protein studies are normal. An AP radiograph is shown in Figure 5. What is the next most appropriate step in management?

1

Continued observation

2

Synovectomy and bushing replacement

3

Reimplantation of both the humeral and ulnar components

4

Conversion to a resection arthroplasty

5

Conversion to elbow arthrodesis

QUESTION 12

Figure 6a shows the radiograph of a 50-year-old man who sustained an anterior dislocation of the shoulder. He undergoes closed reduction, and the postreduction radiograph is shown in Figure 6b. Management should now consist of

1

continued use of a sling for 3 to 4 weeks, followed by repeat radiographs.

2

open reduction and internal fixation of the greater tuberosity fracture.

3

repeat reduction and placement of an abduction orthosis.

4

hemiarthroplasty.

5

percutaneous pinning.

QUESTION 13

A 42-year-old man sustained a fracture of the distal radius with subsequent stiffness in the ipsilateral shoulder. Despite a 6-month program of range-of-motion exercises, external rotation at the side is limited to 10 degrees. Attempts at closed manipulation are unsuccessful. Treatment should now consist of

1

open release of the posterior capsule.

2

arthroscopic release of the rotator cuff interval.

3

arthroscopic release of the anteroinferior capsule.

4

open subscapularis lengthening.

5

open extra-articular release.

QUESTION 14

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

1

Axillary nerve injury

2

Anterior dislocation

3

Extension of a chronic large rotator cuff tear

4

Suprascapular nerve entrapment from a ganglion cyst

5

Greater tuberosity avulsion

QUESTION 15

A 45-year-old man who underwent an open capsulolabral stabilization procedure
15 years ago now reports pain and has no external rotation on the affected side. Nonsurgical management has failed to provide relief. Examination reveals external rotation to -5 degrees compared with 50 degrees of external rotation on the contralateral side. Radiographs show a small inferior osteophyte and minimal posterior glenoid wear. Which of the following procedures will offer the best chance of restoring motion, decreasing pain, and preserving the native joint?

1

Arthroscopic removal of the osteophytes

2

Arthroscopic debridement and acromioplasty

3

Arthroscopic release of the posterior capsule

4

Release of the rotator interval and anterior capsule

5

Closed manipulation under anesthesia

QUESTION 16

A right-handed 44-year-old construction worker reports pain and limited range of motion in his right elbow that has limited his ability to work for the past year. Examination reveals range of motion from 60 to 90 degrees, and he has pain at the extremes of flexion and extension. Pronation and supination are minimally restricted. Anti-inflammatory drugs have failed to provide relief. A radiograph is shown in Figure 8. Management should now consist of

1

observation.

2

physical therapy.

3

ulnohumeral arthroplasty.

4

ulnohumeral arthroplasty and ulnar nerve decompression.

5

semiconstrained elbow arthroplasty.

QUESTION 17

Spontaneous recovery of upper extremtiy motor function after a cerebrovascular accident occurs in which of the following predictable patterns?

1

Shoulder flexion, elbow flexion, wrist flexion, finger flexion

2

Shoulder flexion, forearm supination, wrist flexion, finger flexion

3

Shoulder extension, elbow extension, wrist extension, finger extension

4

Finger flexion, wrist extension, elbow flexion, shoulder flexion

5

Finger flexion, wrist flexion, elbow flexion, shoulder flexion

QUESTION 18

A 65-year-old woman sustained an axial load on the arm followed by an abduction injury after falling on ice. Treatment in the emergency department consisted of reduction of an anterior dislocation. She now has a positive drop arm sign and a positive lift-off test. An MRI scan is shown in Figure 9. Based on these findings, management should consist of

1

tenolysis of the biceps.

2

repair of the subscapularis using suture anchors.

3

repair of the subscapularis tendon and biceps tenodesis.

4

repair of the subscapularis tendon and removal of the loose body.

5

observation.

QUESTION 19

What type of nerve palsy is most common following elbow arthroscopy?

1

Transient posterior interosseous

2

Transient ulnar

3

Transient radial

4

Transient median

5

Transient medial antebrachial cutaneous

QUESTION 20

A 72-year-old man injured his right shoulder after tripping over a chair leg. Radiographs obtained in the emergency department reveal an isolated anterior dislocation. After successful closed reduction, the patient has recurrent anterior instability and is unable to elevate the arm. What is the most likely cause of the recurrent instability?

1

Infection of the anterior glenoid labral detachment

2

Anterior glenoid fracture

3

Axilllary nerve palsy

4

Occult surgical neck fracture

5

Rotator cuff tear

QUESTION 21

A 54-year-old woman sustained an elbow injury 3 months ago that was treated with open reduction and internal fixation. She now reports pain and limited elbow motion. Radiographs are shown in Figures 10a and 10b. Treatment should now consist of

1

occupational therapy.

2

open reduction of the radial head and annular ligament reconstruction.

3

excision of the radial head.

4

ulnar osteotomy and closed reduction of the radial head.

5

ulnar osteotomy and open reduction of the radial head.

QUESTION 22

Ulnohumeral distraction interposition arthroplasty is considered the most appropriate treatment for which of the following patients?

1

A 41-year-old man with painful posttraumatic arthritis of the elbow

2

A 45-year-old laborer with painful primary osteoarthritis

3

A 51-year-old patient with polyarticular rheumatoid arthritis and multiple joint involvement

4

A 71-year-old woman with stage IV rheumatoid arthritis of the elbow

5

A 71-year-old patient with painful radiocapitellar arthritis from rheumatoid arthritis

QUESTION 23

A 57-year-old man with type I diabetes mellitus has had a tender, erythematous right sternoclavicular joint for the past 2 weeks. Radiographs reveal mild osteolysis without arthritic changes, within normal limits. Management should consist of

1

MRI.

2

sternoclavicular joint aspiration.

3

incision and drainage.

4

IV antibiotics.

5

nonsteroidal anti-inflammatory drugs.

QUESTION 24

A 58-year-old man has persistent pain and weakness of his right shoulder after undergoing primary rotator cuff repair 1 year ago. A clinical photograph is shown in Figure 11. Which of the following factors might make functional improvement problematic with revision rotator cuff surgery?

1

Patient’s age

2

Patient’s gender

3

Number of prior surgical procedures

4

Detachment of the deltoid

5

Duration of the rotator cuff tear

QUESTION 25

A 31-year-old man sustained a closed injury to his arm in a motor vehicle accident 16 months ago. Treatment of the fracture consisted of intramedullary nailing of the humerus. He now reports pain with minimal activities. Clinical examination and laboratory studies suggest no signs of infection. Radiographs are seen in Figures 12a through 12c. Treatment should now consist of

1

open reduction and exchange humeral nailing.

2

a custom orthosis and an external bone stimulator.

3

removal of the humeral nail and external fixation.

4

removal of the humeral nail and plate fixation with bone grafting.

5

open bone grafting and an internal bone stimulator.

QUESTION 26

A well-developed college football player reports swelling and a heaviness in the arm after lifting weights. Examination reveals that distal pulses are normal and equal in both arms. A venogram is shown in Figure 13. What is the most likely cause of this condition?

1

Intimal tearing of the subclavian artery

2

Compression of the subclavian vein by scalene muscle hypertrophy

3

Postural compression of the neurovascular bundle between the clavicle and the first rib

4

A congenital cervical rib

5

Arterial thrombosis induced by repeated overhead activities

QUESTION 27

Figure 14 shows the AP radiograph of a patient who underwent prosthetic arthroplasty 8 years ago and has now become symptomatic again over the past 18 months. A WBC count and erythrocyte sedimentation rate are within normal limits, and aspiration of the glenohumeral joint yields a negative Gram stain and cultures. Which of the following procedures will most likely provide the best pain relief and function?

1

Removal of the humeral and glenoid components

2

Removal of the glenoid component

3

Removal of the loose glenoid component and reimplantation of a new glenoid component

4

Removal of the glenoid component followed by biologic resurfacing of the glenoid

5

Arthrodesis after removal of both components

QUESTION 28

A 52-year-old woman reports the sudden onset of intense pain in the right shoulder. She denies any history of injury or previous shoulder problems. At a 2-week follow-up examination, she notes that the pain has decreased, but she now has severe weakness of the external rotators and abductors. Her cervical spine and remaining shoulder examination are otherwise unremarkable. Radiographs of the shoulder and neck are normal. What is the most likely diagnosis?

1

Calcific tendinitis

2

Rotator cuff tendinosis

3

Bursitis

4

Brachial neuritis

5

Glenohumeral arthritis

QUESTION 29

What is the most commonly reported complication following elbow arthroscopy?

1

Synovial cutaneous fistula

2

Nerve transection

3

Compartment syndrome

4

Infection

5

Transient neurapraxia

QUESTION 30

When an acute infection of a total elbow arthroplasty is managed with irrigation and debridement, which of the following organisms is associated with the highest risk of persistent infection?

1

Enterococcus cloacae

2

Klebsiella

3

Staphylococcus aureus

4

Staphylococcus epidermidis

5

Streptococcus

QUESTION 31

A professional baseball player has had intermittent, mild shoulder pain for the past 2 years. Nonsurgical management has consisted of anti-inflammatory drugs. Examination reveals atrophy of the infraspinatus muscle but not the supraspinatus. There is weakness in external rotation with the arm at his side but not at 90 degrees of abduction. He has no weakness or pain with resisted abduction. Electromyography confirms an isolated lesion of the suprascapular nerve branch to the infraspinatus. He is otherwise neurologically intact. An MRI scan of the shoulder shows no cysts but confirms atrophy of the infraspinatus muscle. What is the next most appropriate step in management?

1

Immediate MRI of the brain

2

Physical therapy and observation

3

Subacromial injection

4

Decompression of the suprascapular nerve at the suprascapular notch

5

Decompression of the infraspinatus branch of the suprascapular nerve at the spinoglenoid notch

QUESTION 32

A 66-year-old woman who requires a cane for ambulation now notes increasing difficulty in using the cane after undergoing total elbow arthroplasty 3 months ago. AP and lateral radiographs are shown in Figures 15a and 15b. What is the most likely diagnosis?

1

Ulnar nerve neuritis

2

Triceps insufficiency

3

Aseptic loosening

4

Instability

5

Infection

QUESTION 33

The mother of a healthy 8-month-old boy reports that her son refuses to use his left arm. Examination reveals that the arm hangs limp at his side in an adducted and internally rotated position, and the affected shoulder subluxates posteriorly. Passive external rotation measures 15 degrees. Management should consist of

1

release of the latissimus dorsi and teres major.

2

release of the subscapularis and pectoralis major.

3

passive range-of-motion exercises.

4

exploration of the brachial plexus.

5

functional bracing.

QUESTION 34

During shoulder motion with the elbow controlled in a brace, electromyographic studies of the supraspinatus show significant activity with all range-of-motion testing. Concurrent electromyographic studies of the long head of the biceps will most
likely show

1

minimal activity.

2

moderate activity compared to the supraspinatus.

3

significant activity with a supraspinatus tear.

4

significant activity with an intact supraspinatus.

5

significant activity with both intact and torn rotator cuffs.

QUESTION 35

A right-handed 24-year-old professional baseball player injured his left shoulder 6 weeks ago when he dove forward and landed hard with the arm extended. He reports that the shoulder “slipped out” and “went back in.” The shoulder did not need to be reduced. He now reports deep pain in the front of the shoulder when batting on either side and is hesitant to raise his left arm up over his head to catch a ball. Examination reveals no obvious deformities of the shoulder and a somewhat guarded, limited range of motion in all planes. Provocative tests for the rotator cuff and labrum are equivocal. MRI scans are shown in Figures 16a and 16b. What is the best course of action?

1

Physical therapy

2

Arthroscopic labral repair

3

Arthroscopic subscapularis repair

4

Arthroscopic thermal capsular shift

5

Open Bankart repair

QUESTION 36

A 35-year-old woman dislocated her right shoulder in a fall from a step stool several months ago. She now reports several painful recurrences. Examination reveals anterior and inferior apprehension that reproduces her symptoms. An MRI scan is shown in Figure 17. Management should consist of

1

open repair of the lateral joint capsule disruption.

2

open Bankart-type repair of the labral-glenoid tear.

3

arthroscopic repair of the Bankart lesion.

4

physical therapy for rotator cuff strengthening.

5

immobilization for 6 weeks, followed by rehabilitation.

QUESTION 37

A 20-year-old man sustained an injury to his arm during a tug-of-war contest. An MRI scan is shown in Figure 18. What is the most likely diagnosis?

1

Lipoma

2

Proximal biceps rupture

3

Distal biceps rupture

4

Biceps and brachialis rupture

5

Biceps brachii transection

QUESTION 38

When the elbow is extended and an axial load is applied, what percent of stress distribution occurs across the ulnohumeral and radiohumeral articular surface, respectively?

1

20% and 80%

2

40% and 60%

3

50% and 50%

4

60% and 40%

5

80% and 20%

QUESTION 39

Which of the following is most frequently associated with heterotopic ossification about the shoulder?

1

Acute anterior dislocation

2

Acute posterior dislocation

3

Multiple attempts at closed reduction of chronic unreduced fracture-dislocations

4

Immediate open reduction and internal fixation of greater tuberosity fractures

5

Open reduction of midshaft clavicular fractures

QUESTION 40

A 55-year-old woman with a 15-year history of systemic lupus erythematosus has had left shoulder pain for the past 3 months. She reports that the pain has grown progressively worse over the past few months, and her shoulder function is severely limited. She is presently being treated with azathioprine and has used corticosteroids in the past. AP and axillary radiographs are shown in Figures 19a and 19b, and MRI scans are shown in Figures 19c and 19d. Which of the following forms of management will yield the most predictable pain relief and return of shoulder function?

1

Stretching exercises with a physical therapist

2

Arthroscopic debridement

3

Core decompression of the humeral head

4

Humeral hemiarthroplasty

5

Resection of the proximal humerus

QUESTION 41

A 45-year-old man sustains an acute closed posterolateral elbow dislocation. The elbow is reduced, and examination reveals that the elbow dislocates posteriorly at 35 degrees with the forearm placed in supination. What is the best course of action?

1

Cast immobilization for 6 weeks

2

Hinged brace with early range of motion in supination

3

Hinged brace with early range of motion in pronation

4

Primary ligament repair

5

Lateral collateral ligament reconstruction with tendon graft

QUESTION 42

Figure 20 shows the MRI scan of a 20-year-old athlete who has a painful shoulder. This pathology is most commonly seen in

1

baseball pitchers.

2

downhill skiers.

3

football linemen.

4

volleyball players.

5

tennis players.

QUESTION 43

Figure 21 shows the radiograph of an 18-year-old man who was brought to the emergency department with shoulder pain following a rollover accident on an all-terrain vehicle. Examination reveals a fracture with massive swelling; however, the skin is intact and not tented over the fracture. Based on these findings, initial management should consist of

1

closed reduction of the displaced clavicular fracture.

2

a figure-of-8 clavicular brace to stabilize the clavicular fracture.

3

arteriography to evaluate for vascular injury.

4

electromyography to evaluate for a brachial plexus injury.

5

CT to evaluate for a scapular fracture.

QUESTION 44

A 55-year-old man reports increasing weakness in his arms that has progressed to his lower limbs, resulting in frequent tripping and falling. Examination reveals weakness in shoulder abduction and external and internal rotation bilaterally. Fasciculation is noted. He also has weakness in elbow flexion and extension bilaterally, and his grip strength is diminished. An electromyogram and nerve conduction velocity studies show decreased amplitude of compound motor action potential, slightly slowed motor conduction velocity, and denervation signs with decreased recruitment in all extremities. The sensory study is normal. Based on these findings, what is the most likely diagnosis?

1

Syrinx of the cervical spine

2

Intracranial mass

3

Myasthenia gravis

4

Amyotrophic lateral sclerosis (ALS)

5

Fascioscapulohumeral dystrophy

QUESTION 45

Which of the following positions of immobilization has been shown to best approximate the anterior labrum against the glenoid rim following anterior dislocation of the shoulder?

1

Abduction and external rotation

2

Abduction and internal rotation

3

Adduction and external rotation

4

Adduction and internal rotation

5

Extension

QUESTION 46

What is the most common complication following arthroscopic capsular release in a patient with adhesive capsulitis of the shoulder?

1

Wound infection

2

Failure to maintain range of motion

3

Instability

4

Axillary nerve injury

5

Impingement syndrome

QUESTION 47

What is the most common complication following surgical fixation of a distal
humeral fracture?

1

Wound infection

2

Ulnar nerve injury

3

Failure of fixation

4

Nonunion

5

Elbow stiffness

QUESTION 48

A 16-year-old female swimmer reports several episodes of atraumatic glenohumeral instability that occur with different arm positions. Examination reveals generalized ligamentous laxity and a positive sulcus sign, and her shoulder can be subluxated both anteriorly and posteriorly. Initial management should consist of

1

a strengthening program for the rotator cuff and scapular muscles.

2

arthroscopic thermal capsulorrhaphy.

3

an inferior capsular shift.

4

a glenoid osteotomy.

5

a Putti-Platt repair.

QUESTION 49

A 13-year-old boy has a mild deformity of the left sternoclavicular joint after being involved in a rollover accident while riding an all-terrain vehicle. Examination in the emergency department reveals that he is hemodynamically stable, and his neurovascular examination is normal. The CT scan shown in Figure 22 was obtained because radiographs were inconclusive. Management should consist of

1

ice, analgesics, and symptomatic treatment, with delayed reconstruction if necessary.

2

closed reduction in the emergency department.

3

closed reduction in the operating room under anesthesia.

4

open reduction and temporary stabilization with a threaded pin.

5

open reduction and reconstruction of the sternoclavicular joint ligaments.

QUESTION 50

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?

1

Discontinue the procedure and delay completion of the total arthroplasty until the fracture has healed.

2

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

3

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.

4

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

5

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

QUESTION 51

A 13-year-old gymnast has had recurrent right elbow pain for the past year. She denies any history of trauma. Rest and anti-inflammatory drugs have failed to provide relief. Examination reveals no localized tenderness and only slight loss of both flexion and extension (10 degrees). What is the most likely diagnosis?

1

Recurrent valgus overload (medial collateral ligament sprain)

2

Posterior lateral rotatory instability

3

Biceps tendinitis

4

Medial epicondylitis

5

Osteochondritis of the capitellum

QUESTION 52

The incidence of ipsilateral phrenic nerve blockade after an interscalene
block approaches

1

15%.

2

25%.

3

50%.

4

75%.

5

100%.

QUESTION 53

What is the most consistent finding regarding glenohumeral kinematics in patients with symptomatic tears of the rotator cuff?

1

No superior translation during abduction

2

Retention of ball-and-socket kinematics with more than 30 degrees of abduction

3

Loss of ball-and-socket kinematics with less than 30 degrees of abduction

4

Superior translation of the humeral head with more than 30 degrees of abduction

5

Superior translation of the humeral head with external rotation

QUESTION 54

A 28-year-old man sustained numerous injuries in an accident including a dislocation of the elbow and a severe closed head injury that resulted in unconsciousness. The elbow was reduced in the emergency department. After 1 month of rehabilitation, the patient reports pain and stiffness. A radiograph is shown in Figure 23. Management should now consist of

1

semiconstrained total elbow arthroplasty.

2

ulnohumeral arthroplasty and anterior and posterior capsular releases.

3

closed reduction and external fixation.

4

open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.

5

open reduction, heterotopic excision, anterior and posterior capsular releases, and pin fixation across the joint for 3 weeks.

QUESTION 55

A 52-year-old man has had right shoulder pain in the deltoid region that increases at night for the past 2 months. He denies any history of trauma. Examination reveals mild tenderness over the greater tuberosity, and the Neer and Hawkins impingement signs are positive. AP and outlet lateral radiographs are shown in Figures 24a and 24b. Initial management should consist of

1

a program of stretching exercises and rotator cuff strengthening exercises.

2

a series of six cortisone injections.

3

arthroscopic acromioplasty.

4

arthroscopic acromioplasty and laser capsulorrhaphy.

5

open acromioplasty.

QUESTION 56

A 70-year-old woman is brought to the emergency department with a two-part greater tuberosity fracture with an anterior subcoracoid dislocation. One day after successful closed reduction, examination reveals marked swelling of the involved arm, forearm, and hand, as well as large amounts of “weeping” serous fluid but no obvious lacerations. The fingers are warm and pink, and the pulses are normal distally with good refill. Edema is present. There is no pain with passive and active motion of the elbow, wrist, and fingers. What is the next most appropriate step in management?

1

Sympathetic stellate block

2

Emergent fasciotomy

3

Emergent arterial thrombectomy

4

Venous duplex ultrasound studies

5

Arteriography

QUESTION 57

A baseball pitcher has intractable posterior and superior shoulder pain. The arthroscopic view seen in Figure 25 shows no Bankart or Hill-Sachs lesion and a negative drive-through sign. There are no signs of ligamentous laxity, but active compression and anterior slide tests are positive. Treatment should consist of

1

open fixation of the SLAP lesion with a screw that can be removed later.

2

arthroscopic repair of the SLAP lesion with suture anchors.

3

arthroscopic repair of the SLAP lesion with suture anchors with a thermal capsular shift.

4

arthroscopic repair of the SLAP lesion with suture anchors and a rotator cuff interval closure.

5

arthroscopic repair of the SLAP lesion with suture anchors and an arthroscopic capsular placation.

QUESTION 58

With increasing abduction in the scapular plane, maintaining neutral rotation, contact area, and contact pressure per unit area between the humeral head and glenoid follows what pattern if the total load across the joint is held constant?

1

Contact area and contact pressure both decrease.

2

Contact area and contact pressure both increase.

3

Contact area and contact pressure both remain the same.

4

Contact area increases and contact pressure decreases.

5

Contact area decreases and contact pressure increases.

QUESTION 59

A 21-year-old patient has had pain and a marked decrease in active and passive shoulder motion after having had a seizure 2 months ago as the result of alcohol abuse. Current AP and axillary radiographs and a CT scan are shown in Figures 26a through 26c. Management should consist of

1

closed reduction under sedation.

2

total shoulder arthroplasty.

3

open reduction and subscapularis and lesser tuberosity transfer.

4

open reduction and disimpaction with bone grafting.

5

hemiarthroplasty with the humeral component placed in less than 20 degrees of retroversion.

QUESTION 60

Which of the following ligaments are the primary static restraints to inferior translation of the arm when the shoulder is in 0 degrees of abduction and neutral rotation?

1

Inferior and middle glenohumeral

2

Middle and superior glenohumeral

3

Superior glenohumeral and coracohumeral

4

Coracohumeral and coracoclavicular

5

Coracoacromial and coracoclavicular

QUESTION 61

A 44-year-old man who sustained an elbow dislocation 3 months ago now reports pain and restricted elbow motion. Radiographs are shown in Figures 27a and 27b. Management should consist of

1

closed reduction and casting.

2

static splinting.

3

open reduction and lateral collateral ligament reconstruction.

4

open reduction and lateral collateral ligament repair.

5

open reduction, application of a hinged external fixator, and radial head arthroplasty.

QUESTION 62

A 67-year-old man who underwent humeral head arthroplasty for a four-part fracture 6 months ago reports that he is still unable to actively elevate his arm. Rehabilitation after surgery consisted of a sling with passive range-of-motion exercises for 2 weeks and then progressed to active-assisted and strengthening exercises at 3 weeks. Radiographs are shown in Figures 28a and 28b. What is the primary cause of his inability to elevate
the arm?

1

Rotator cuff tear

2

inadequate strengthening exercises

3

Instability

4

Tuberosity nonunion

5

Prosthetic loosening

QUESTION 63

Initial postoperative management after repair of an acute rotator cuff tear includes

1

active range of motion.

2

active abduction to prevent scarring.

3

passive forward elevation and external rotation within a safe zone determined at surgery.

4

eccentric strengthening exercises.

5

internal rotation behind the back.

QUESTION 64

A 34-year-old woman reports constant midlateral arm pain after sustaining minimal trauma to the shoulder. Radiographs and a biopsy specimen are shown in Figures 29a and 29b. What is the most likely diagnosis?

1

Chondroblastoma

2

Lymphoma

3

Giant cell tumor

4

Chondromyxoid fibroma

5

Desmoplastic fibroma

QUESTION 65

A 25-year-old professional baseball pitcher reports a 4-month history of gradually increasing medial elbow pain that occurs during the late cocking and acceleration phases of throwing. The pain occasionally refers distally along the ulnar aspect of the forearm. He denies any weakness; however, he notes occasional paresthesias. A nerve conduction velocity study demonstrates increased latency across the cubital tunnel. Management consisting of 6 weeks of rest and rehabilitation fails to provide relief as the symptoms returned when he resumed throwing. What is the best course of action?

1

Further rehabilitation

2

Corticosteroid injection

3

Reconstruction of the medial collateral ligament

4

Subcutaneous transposition of the ulnar nerve

5

Arthroscopic debridement of medial osteophytes

QUESTION 66

What artery provides the only direct vascularizaton to both the intraneural and extraneural blood supply of the ulnar nerve just proximal to the cubital tunnel?

1

Superior ulnar collateral

2

Inferior ulnar collateral

3

Posterior ulnar recurrent

4

Brachial

5

Ulnar

QUESTION 67

A 56-year-old man underwent right total shoulder arthroplasty 2 months ago. Recently while reaching with his shoulder in a flexed and adducted position, he noted shoulder pain and afterwards he could not externally rotate his arm. An axillary radiograph is shown in Figure 30. What is the most likely cause of this problem?

1

Excessive anteversion of the humeral component

2

Excessive anteversion of the glenoid component

3

Excessive posterior capsular laxity

4

Anterior capsular laxity

5

Use of an oversized humeral head

Anteversion of the humeral component may result in anterior instability of the component. Posterior instability after total shoulder arthroplasty is usually the result of some combination of the following factors: untreated anterior soft-tissue contractures, excessive posterior capsular laxity, and excessive retroversion of the humeral and/or glenoid components.
REFERENCES: Cofield RH, Edgerton BC: Total shoulder arthroplasty: Complications and revision surgery. Instr Course Lect 1990;39:449-462.
Wirth MA, Rockwood CA Jr: Complications of total shoulder replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-616.
69. A 70-year-old man seen in the emergency department has had left shoulder pain and a fever of 101.5 degrees F (38.6 degrees C) for the past 3 days. He denies any history of trauma. Examination reveals tenderness anterosuperiorly and at the posterior glenohumeral joint line. He has very limited range of motion (passive and active). Laboratory studies show a WBC count of 12,000/mm3 and an erythrocyte sedimentation rate of 48 mm/h. Initial management should consist of
1- an oral cephalosporin antibiotic and discharge home.
2- IV oxacillin and gentamicin.
3- arthroscopic drainage of the glenohumeral joint.
4- open irrigation and drainage of the glenohumeral joint.
5- aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.
PREFERRED RESPONSE: 5
DISCUSSION: It appears that the patient has septic arthritis of the glenohumeral joint; therefore, initial management should consist of aspiration of the glenohumeral joint and subacromial space separately, followed by Gram stain and culture of the fluid. Based on the findings, broad-spectrum IV antibiotics should be started. If the diagnosis of septic arthritis is confirmed, then arthroscopic or open surgical drainage usually is indicated.
REFERENCES: Sawyer JR, Esterhai JL Jr: Shoulder infections, in Warner JJ, Iannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, PA, Lippincott-Raven, 1997.
Leslie BM, Harris JM, Driscoll D: Septic arthritis of the shoulder in adults. J Bone Joint Surg Am 1989;71:1516-1522.

QUESTION 68

A 40-year-old man who is an avid weight lifter has had chronic pain in the proximal anterior shoulder for the past year. He denies any history of trauma. Examination reveals tenderness at the intertubercular groove, a positive speed test, and a positive Neer impingement sign. Nonsurgical management has failed to provide relief, and he is now considering surgery. Arthroscopic findings in the glenohumeral joint are shown in Figure 31. Based on these findings, treatment should consist of

1

debridement of the biceps tendon.

2

debridement of the rotator cuff tear.

3

repair of the biceps pulley system.

4

repair of the rotator cuff tear.

5

tenodesis of the biceps tendon.

QUESTION 69

A 59-year-old man reports moderate shoulder pain and very restricted range of motion after undergoing humeral arthroplasty for osteoarthritis 1 year ago. An AP radiograph is shown in Figure 32. Management should now consist of

1

an aggressive program of stretching exercises.

2

soft-tissue release and subscapularis lengthening.

3

exchange of the modular humeral head to a smaller size, with glenoid arthroplasty.

4

revision of the humeral component, re-cutting of the humeral neck, soft-tissue releases, and glenoid arthroplasty.

5

glenohumeral arthrodesis.

QUESTION 70

A 70-year-old woman has a preoperative anterior interscalene block prior to undergoing a total shoulder arthroplasty. After seating her in the beach chair position, she becomes acutely hypotensive. What is the most likely cause for the hypotension?

1

Tension pneumothorax

2

Inadvertent epidural injection

3

Inadvertent intravascular injection

4

Laryngeal nerve block

5

Bezold-Jarisch reflex

QUESTION 71

What structure is considered the single most important soft-tissue restraint to anterior-posterior stability of the sternoclavicular joint?

1

Posterior capsular ligament

2

Anterior capsular ligament

3

Interclavicular ligament

4

Intra-articular disk

5

Subclavius tendon

QUESTION 72

A 35-year-old man has atraumatic painless limited elbow motion. Radiographs are shown in Figures 33a and 33b. What is the most likely diagnosis?

1

Melorheostosis

2

Ectopic bone formation

3

Bone infarct

4

Infection

5

Juxacortical chondroma

QUESTION 73

A 64-year-old man who underwent total shoulder arthroplasty 4 weeks ago is making satisfactory progress in physical therapy, but his therapist notes limitations in external rotation to neutral. A stretching program is started, and the patient suddenly gains 90 degrees of external rotation but now reports increased pain and weakness. What is the best course of action?

1

Early surgical exploration and repair of the torn subscapularis tendon

2

Observation and reassurance that the pain will resolve

3

A slow progressive resistance program to restore strength

4

CT to assess for component malrotation

5

Electromyography to evaluate for possible nerve injury

Nearly all approaches to shoulder arthroplasty require detachment of the subscapularis tendon from the humerus and subsequent repair. Healing of this tenotomy is one of the limiting factors in postoperative recovery. Failure of the tenotomy repair must be recognized and treated early with repeat repair or pectoralis muscle transfer for optimal results. Failure of the subscapularis is diagnosed clinically as excessive external rotation and weakness, especially in the lift-off or belly press position. Muscle testing can be difficult in the postoperative period and may not be possible to assess in those positions. Although MRI might be useful to confirm the diagnosis, studies may be limited by artifact. CT or electromyography would not be diagnostic.
REFERENCES: Wirth MA, Rockwood CA Jr: Complications of total shoulder-replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-616.
Miuer SL, Hazrati Y, Klepps S, et al: Loss of subscapularis function after shoulder replacement: A seldom recognized problem. J Shoulder Elbow Surg 2003;12:29-34.
76. A 52-year-old man has shoulder pain and stiffness after undergoing a “mini-lateral” rotator cuff repair 6 months ago. Examination reveals that he is afebrile with normal vital signs. There is slight erythema but no drainage from the incision. Range of motion is limited in all planes, and there is weakness with resisted external rotation and abduction. Radiographs show a well-positioned metal implant within the greater tuberosity. Laboratory studies reveal a WBC count of 8,400/ mm3 (normal 3,500 to 10,500/ mm3) and an erythrocyte sedimentation rate of 63 mm/h (normal up to 20 mm/h). What is the next most appropriate step in management?
1- Subacromial corticosteroid injection
2- Aspiration of the subacromial and glenohumeral joint spaces
3- Nonsteroidal anti-inflammatory drugs
4- Extensive surgical debridement
5- Diagnostic arthroscopy
PREFERRED RESPONSE: 2
DISCUSSION: Deep sepsis of the shoulder following rotator cuff repair is an uncommon problem. Patients with infections of this type typically report persistent pain and are not systemically ill. They may have signs of local wound problems such as erythema, drainage, and dehiscence. Laboratory studies can be helpful in making an accurate diagnosis. Most patients will not show a significant elevation of the WBC count; however, an elevated erythrocyte sedimentation rate is nearly always present and should alert the clinician to the presence of infection. Aspiration of both subacromial and glenohumeral joint spaces is necessary to confirm the diagnosis. The most effective treatment for deep shoulder sepsis following rotator cuff repair involves extensive surgical debridement, removing all suspicious soft tissue as well as implants. Administration of appropriate antibiotic therapy is needed for complete control of the infection.
REFERENCES: Mirzayan R, Itamura JM, Vangsness CT, et al: Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am 2000;82:1115-1121.
Settecerri JJ, Pitnu MA, Rock MG, et al: Infection after rotator cuff repair. J Shoulder Elbow Surg 1994;8:105.
Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.

QUESTION 74

A 21-year-old pitcher reports shoulder pain with hard throwing. He notes that the pain occurs in the early acceleration phase of his throw. Given his history, what structures are at greatest risk for injury?

1

Posterosuperior labrum, greater tuberosity, articular side of the rotator cuff

2

Posterior glenoid, humeral head, bursal side of the rotator cuff

3

Biceps anchor, articular side of the rotator cuff, supraspinatus tendon

4

Biceps tendon, bursal side of the rotator cuff, superior labrum

5

Subscapularis, anterior labrum, humeral head

QUESTION 75

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should
consist of

1

immobilization in a sling and swathe.

2

open reduction and internal fixation.

3

humeral arthroplasty.

4

subscapularis transfer into the humeral head articular defect.

5

a hanging cast.

QUESTION 76

A 22-year-old professional baseball pitcher has had pain in the axillary region of his dominant shoulder for the past several weeks. While throwing a pitch during a game, he notes a sharp pulling sensation with a “pop” in his shoulder. Examination the following day reveals tenderness along the posterior axillary fold and pain and weakness with resisted extension of the shoulder. What is the most likely cause of his symptoms?

1

Type 2 tear of the superior labrum anterior and posterior

2

Tear of the anterior labrum

3

Tear of the subscapularis tendon

4

Tear of the latissimus dorsi tendon

5

Tear of the supraspinatus tendon

QUESTION 77

When comparing the addition of a trough at the greater tuberosity to direct repair of cortical bone, simulated rotator cuff repair in animal models has shown what type of change in the strength of the repair?

1

0% increase

2

25% increase

3

50% increase

4

25% decrease

5

50% decrease

QUESTION 78

Figures 35a and 35b show the radiographs of a 20-year-old man who is unable to rotate his dominant forearm. Examination reveals that the arm is fixed in supination. To regain motion, management should consist of

1

observation.

2

dynamic splinting.

3

resection of the synostosis.

4

proximal radial excision.

5

forearm osteotomy.

QUESTION 79

A 20-year-old-man sustained a scapular fracture after attempting to grab a beam as he fell through a ceiling at a job site 3 months ago. A clinical photograph is shown in Figure 36. He now reports pain in the anterior shoulder and difficulty with overhead activities. What nerve roots make up the involved peripheral nerve?

1

C3-T1

2

C4-C5

3

C5-C7

4

C6-C8

5

C8-T1

QUESTION 80

A 20-year-old collegiate baseball pitcher has persistent deep shoulder pain. Examination reveals normal strength, 130 degrees of external rotation in abduction, 10 degrees of internal rotation in abduction, mild dynamic scapular winging, and equivocal findings on provocative tests for labral tears. Management should consist of

1

shoulder arthroscopy and repair of a possible labral tear.

2

anterior capsulorrhaphy for subtle anterior instability.

3

diagnostic arthroscopy of the glenohumeral joint and arthroscopic subacromial decompression.

4

rest from pitching, initiation of a rehabilitation program to restore internal rotation, and scapular stabilization.

5

rest from pitching and a corticosteroid injection into the subacromial space.

QUESTION 81

Which of the following best describes the most common anatomic variation seen in the glenoid labrum and the middle glenohumeral ligament in the anterosuperior quadrant of the shoulder?

1

Labrum attached to the glenoid rim and a flat/broad middle glenohumeral ligament

2

Sublabral hole with the labrum absent and a flat/broad middle glenohumeral ligament

3

Sublabral hole with a cord-like labrum and a flat/broad middle glenohumeral ligament

4

Anterosuperior labrum confluent with a cord-like middle glenohumeral ligament and no labral attachment to bone

5

Anterosuperior labrum confluent with a cord-like middle glenohumeral ligament and glenoid deficiency

QUESTION 82

A 21-year-old hockey player who has recurrent shoulder subluxations undergoes an anterior capsulorrhaphy under general anesthesia, and an interscalene block is used to relieve postoperative pain. At the 1-week follow-up examination, he reports loss of sensation over the lateral region of the shoulder and is unable to actively contract the deltoid muscle. The remainder of the examination is normal. What is the best course of action at this time?

1

Early exploration and possible repair of the axillary nerve

2

Urgent electromyography to assess for level of nerve injury

3

Continued normal postoperative care and observation of the nerve injury

4

Consultation with the anesthesiologist regarding a complication of the interscalene block

5

MRI to evaluate for a possible hematoma compressing the neurovascular bundle

QUESTION 83

A 10-year-old boy has had a prominent scapula for the past year. He reports crepitus and aching over the area, but only when he is active. A radiograph and CT scans are shown in Figures 37a through 37c. What is the most likely diagnosis?

1

Enchondroma

2

Osteochondroma

3

Chondroblastoma

4

Ewing’s sarcoma

5

Chondrosarcoma

QUESTION 84

In patients who have undergone nonsurgical management for idiopathic adhesive capsulitis, long-term follow-up studies have shown which of the following results?

1

Continued night pain

2

Continuous decrease in forward elevation over time

3

Resolution of most symptoms, with range of motion equal to the contralateral shoulder

4

Decreased range of motion compared with the contralateral shoulder

5

Decreased pain compared with the contralateral shoulder

QUESTION 85

Which of the following statements best describes the relationship between tissue response to thermal capsulorrhaphy and the type of device used?

1

Laser devices produce photon excitation, which produces less effect than electromagnetic devices.

2

Bipolar devices cause less tissue damage than monopolar devices.

3

Monopolar devices cause less tissue damage than bipolar devices.

4

The tissue response is the same regardless of the device.

5

Tissue response is greatest with bipolar devices when not in ablate mode.

QUESTION 86

A 35-year-old man has profound deltoid weakness after sustaining a traumatic anterior shoulder dislocation 6 weeks ago. Electromyographic (EMG) studies confirm an axillary nerve injury. Follow-up examination at 3 months reveals no recovery of function. What is the best course of action?

1

Surgical repair of the Bankart lesion

2

Exploration of the axillary nerve

3

MRI neurography

4

Repeat EMG studies

5

Continued observation and physical therapy

QUESTION 87

A 65-year-old woman has had chronic aching discomfort involving her elbow for the past 6 months. Radiographs and a biopsy specimen are shown in Figures 38a through 38c. What is the most likely diagnosis?

1

Metastatic carcinoma (thyroid)

2

Multiple myeloma

3

Lymphoma

4

Synovial cell sarcoma

5

Osteomyelitis

QUESTION 88

Which of the following clinical findings is commonly associated with symptomatic partial-thickness rotator cuff tears?

1

Negative impingement signs

2

Abnormal lift-off test

3

External rotation lag sign

4

Painful arc with active range of motion

5

Mismatch in active and passive motion

QUESTION 89

A 65-year-old woman landed on her nondominant left shoulder in a fall. An AP radiograph is shown in Figure 39. Management should consist of

1

closed reduction and immobilization.

2

closed reduction and percutaneous pinning.

3

open reduction and internal fixation.

4

humeral hemiarthroplasty with tuberosity repair.

5

total shoulder arthroplasty.

QUESTION 90

To avoid damage to the ascending branch of the anterior humeral circumflex artery during open reduction and internal fixation of a proximal humeral fracture, the blade plate should be placed in what position?

1

Medial to the bicipital groove and pectoralis major tendon

2

Medial to the bicipital groove and lateral to the pectoralis major tendon

3

Lateral to the bicipital groove and pectoralis major tendon

4

Lateral to the bicipital groove and medial to the pectoralis major tendon

5

In the bicipital groove

QUESTION 91

An otherwise healthy 13-year-old boy sustains the fracture shown in Figure 40 while throwing a fastball. Management should consist of

1

an arm sling.

2

functional bracing supporting the humerus and arm.

3

closed reduction and a shoulder spica cast.

4

open reduction and internal fixation with retrograde rods.

5

open reduction and internal fixation with a rigid plate and screws.

QUESTION 92

A 24-year-old man sustains an injury to his right elbow after falling 10 feet. Radiographs are shown in Figures 41a and 41b. Treatment should consist of

1

open reduction and internal fixation, followed by casting.

2

open reduction and internal fixation, followed by early range of motion.

3

open reduction and internal fixation, medial collateral ligament repair, and early range of motion.

4

open reduction and internal fixation of the ulna, application of a hinged external fixator, and early range of motion.

5

closed reduction and splinting, followed by early range of motion.

QUESTION 93

After closed reduction of the dislocation shown in Figure 42, it is essential to avoid placing the upper extremity in what position for the first 4 to 6 weeks?

1

Abduction

2

External rotation

3

Internal rotation

4

Extension

5

Elevation

QUESTION 94

A baseball player has had diffuse scapular soreness for the past 8 weeks. He reports that it began insidiously over several days and gradually has become worse. He denies any history of trauma. Examination reveals drooping of the shoulder, with lateral winging of the scapula at rest. He is otherwise neurologically intact. What is the best course
of action?

1

Immediate MRI of the brain

2

Electromyography and nerve conduction velocity studies

3

Physical therapy and observation

4

Lyme titer

5

Psychiatric consultation

QUESTION 95

Which of the following best describes the mechanical response of the inferior glenohumeral ligament to repetitive subfailure strains?

1

Decreased peak load response and length decreases

2

Decreased peak load response and recoverable length increases

3

Decreased peak load response and unrecoverable length increases

4

Increased peak load response and recoverable length increases

5

Increased peak load response and unrecoverable length increases

QUESTION 96

A 38-year-old woman who tripped and fell on her outstretched arm reports pain with movement. Examination reveals swelling. AP and lateral radiographs are shown in Figures 43a and 43b. Management should consist of

1

excision of the fracture fragment.

2

radial head replacement.

3

closed reduction and cast immobilization.

4

open reduction and internal fixation of the radial head.

5

open reduction and internal fixation of the capitellum.

QUESTION 97

A 15-year-old girl reports popping and clicking at the sternoclavicular joint and an intermittent asymmetrical prominence of the medial head of the clavicle. She denies any history of trauma or other symptoms. Management should consist of

1

figure-of-8 splinting to maintain the clavicle in a reduced position.

2

an exercise program to stabilize the joint in a reduced position.

3

elective reconstruction of the sternoclavicular joint ligaments.

4

reassurance and local symptomatic treatment.

5

closed reduction and temporary pin fixation to stabilize the joint.

QUESTION 98

A 45-year-old woman who recently underwent biopsy of a lymph node in the right posterior cervical triangle now finds it difficult to hold objects overhead and has diffuse aching in the right shoulder region. What is the most likely diagnosis?

1

Rotator cuff tear

2

Rhomboid paralysis

3

Deltoid paralysis

4

Triceps paralysis

5

Trapezius paralysis

QUESTION 99

The posterior cord of the brachial plexus terminates into what two main branches?

1

Lateral and medial pectorals

2

Lateral pectoral and suprascapular

3

Radial and axillary nerves

4

Musculocutaneous and the lateral root of the median nerve

5

Ulnar and medial roots of the median nerve

QUESTION 100

Atraumatic neuropathy of the suprascapular nerve usually occurs at what
anatomic location?

1

Suprascapular and spinoglenoid notches

2

Omohyoid muscle

3

Anterior trapezius muscle

4

Infraspinatus fascia

5

Teres minor superior border

QUESTION 101

A 22-year-old patient underwent successful reduction of a posterolateral elbow dislocation. Management should now consist of

1

splinting for 5 weeks.

2

active range-of-motion exercises after 1 to 3 days.

3

delayed passive stretching at 2 weeks.

4

open medial collateral ligament reconstruction.

5

open lateral collateral ligament reconstruction.

QUESTION 102

A 56-year-old woman who underwent axillary node dissection 4 months ago now reports shoulder pain, weakness of forward elevation, and obvious winging of the scapula. What structure has been injured?

1

Long thoracic nerve

2

Spinal accessory nerve

3

Thoracodorsal nerve

4

Lower trunk of the brachial plexus

5

Posterior cord of the brachial plexus

QUESTION 103

The lateral arm flap is based on what arterial supply?

1

Posterior radial collateral

2

Anterior radial collateral

3

Brachial

4

Subscapular

5

Circumflex scapular

QUESTION 104

A 32-year-old man has a closed oblique displaced fracture at the junction of the lower and middle third of the humeral shaft and a complete radial nerve palsy. Closed reduction is performed and is felt to be acceptable. Management of the radial nerve palsy should consist of

1

exploration and repair of the radial nerve if clinical findings or electromyographic studies show no improvement at 2 to 3 weeks.

2

exploration and repair of the radial nerve if clinical findings or electromyographic studies show no improvement at 14 weeks.

3

transfer of the pronator teres to the extensor carpi radialis brevis if clinical findings or electromyographic studies show no improvement at 14 weeks.

4

immediate exploration and repair of the radial nerve, along with internal fixation with a plate and screws.

5

immediate exploration and repair of the radial nerve, along with internal fixation with an intramedullary nail.

QUESTION 105

A 19-year-old man sustains a low-velocity gunshot wound to the forearm. What
factor most strongly correlates with the development of compartment syndrome
after this injury?

1

Fracture comminution

2

Fracture of both the radius and ulna

3

Fracture of the proximal third of the forearm

4

Fracture displacement of more than 10 mm

5

Retained bullet fragments

QUESTION 106

A 30-year-old farmer undergoes replantation of an above-the-elbow amputation. What form of management is most important following this surgery?

1

High volume diuresis with alkalinization of the urine

2

Systemic heparinization of the patient for 72 hours

3

Elevation of the extremity, with maintanence of the patient’s room temperature at 80 degrees F (26.6 degrees C)

4

Satellite ganglion continuous sympathetic block

5

Daily IV administration of low-molecular-weight dextran

QUESTION 107

Figures 44a through 44c show the radiographs of an 18-year-old female soccer player who fell on her outstretched hand 1 day ago. She denies any history of wrist pain. Examination reveals tenderness at the anatomic snuffbox. Management should consist of

1

a long arm cast for 6 weeks, followed by a short arm cast for 6 weeks.

2

vascularized bone graft from the 1,2 intercompartmental supraretinacular artery.

3

open reduction and internal fixation with a differential pitch screw via a dorsal approach.

4

open reduction and internal fixation with a differential pitch screw via a volar approach

5

a removable thumb spica splint.

QUESTION 108

An excessively large radial styloidectomy poses a risk for wrist instability. What ligament is at greatest risk for injury?

1

Long radiolunate

2

Short radiolunate

3

Radioscaphocapitate

4

Scapholunate

5

Dorsal radiocarpal

QUESTION 109

What joint always remains uninvolved in all stages of scapholunate advanced collapse (SLAC) deformity of the wrist?

1

Distal radioscaphoid

2

Proximal radioscaphoid

3

Radiolunate

4

Scaphocapitate

5

Capitolunate

QUESTION 110

Free flap coverage for severe trauma to the upper extremity has the fewest complications when performed within what time period after injury?

1

72 hours

2

7 to 10 days

3

2 weeks

4

4 weeks

5

4 months

QUESTION 111

A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show

1

fibrosis and edema.

2

polymorphonuclear cells.

3

negatively birefringent crystals.

4

macrophages and lymphocytes.

5

fibrinous degeneration of collagen fibers.

QUESTION 112

Examination of a 10-year-old girl with a hypoplastic breast and atrophic pectoralis major may also reveal which of the following findings?

1

Absent middle phalanx

2

Absent deltoid muscle

3

Absent radius

4

Contralateral hypoplastic thumb

5

Clubfoot deformity

QUESTION 113

Figures 45a and 45b show the radiographs of a 40-year-old woman with rheumatoid arthritis who is unable to straighten her ring and little fingers. Examination reveals that the fingers can be passively corrected, but she is unable to actively maintain the fingers in extension. Management should consist of

1

radial head resection.

2

dynamic splinting.

3

metacarpophalangeal arthroplasties.

4

total wrist arthrodesis with a flexor digitorum sublimis to extensor digitorum communis transfer.

5

distal ulnar resection with an extensor indius proprius to extensor digitorum communis transfer.

QUESTION 114

Figures 46a through 46e show the radiographs of a 22-year-old man who injured his wrist in a motorcycle accident. He has no other injuries. What is the best course of action?

1

Radiolunate fusion

2

Open repair of the volar extrinsic wrist ligaments

3

Open reduction and internal fixation

4

Thumb spica cast immobilization for 6 weeks

5

External fixator

QUESTION 115

A 36-year-old nurse has had redness, pain, and small vesicles on the pulp of her middle finger for the past 3 days. Management should consist of

1

observation.

2

marsupialization of the nail fold.

3

application of copper sulfate.

4

application of calcium gluconate.

5

incision and drainage of the pulp.

QUESTION 116

A 35-year-old man has numbness and tingling in the index, middle, and ring fingers. History reveals that he also has had vague wrist pain and stiffness since being injured in a motorcycle accident 1 year ago. Radiographs are shown in Figures 47a through 47c. Management should consist of

1

splinting and injections for carpal tunnel syndrome.

2

scaphoid excision and four-bone fusion.

3

proximal row carpectomy via dorsal and volar incisions.

4

MRI of the wrist.

5

carpal tunnel release.

QUESTION 117

A 42-year-old woman has persistent thumb pain that she notes is worse with opening jars and turning her car key. Opponens splinting provides some relief, but she is poorly tolerant of the splint. Finkelstein’s test is negative, and a carpometacarpal grind test is positive. The radiographs shown in Figures 48a and 48b reveal minimal degenerative changes at the first carpometacarpal joint. What is the best course of action?

1

Arthroscopic debridement of the first carpometacarpal joint with thermal shrinkage of the volar capsule

2

Extension osteotomy of the first metacarpal

3

Arthrodesis of the first carpometacarpal joint

4

Denervation of the first carpometacarpal joint

5

Nerve conduction velocity studies

QUESTION 118

A 45-year-old man sustains a low-velocity gunshot wound to the base of the right thumb. The open wound is allowed to heal by secondary intention, resulting in a contracture of the first web space. Clinical photographs are shown in Figures 49a through 49c. Treatment should now consist of

1

Z-plasty.

2

a posterior interosseous fasciocutaneous flap.

3

a reverse cross-finger flap from the index finger.

4

excision of the contracture with placement of a full-thickness skin graft.

5

excision of the contracture with placement of a split-thickness skin graft.

QUESTION 119

The vessel seen in the clinical photographs shown in Figures 50a and 50b (1,2 intercompartmental supraretinacular artery) is being dissected to be used as a source of vascularized bone graft for a patient who is scheduled to undergo internal fixation of a scaphoid nonunion. This vessel is a branch of what artery?

1

Radial

2

Ulnar

3

Median

4

Posterior interosseous

5

Anterior interosseous

QUESTION 120

The flap shown in the clinical photograph seen in Figure 51 is based on what
arterial supply?

1

Superficial circumflex iliac

2

Femoral lateral accessory

3

Inferior epigastric

4

Inferior inguinal

5

Lateral obturator

QUESTION 121

A 63-year-old woman who sustained a distal radial fracture 2 months ago now reports that she is unable to achieve active extension of the thumb at the interphalangeal joint. What type of trauma may lead to this clinical finding?

1

Nondisplaced fracture

2

Open fracture

3

Severely comminuted fracture

4

Dorsal perilunate dislocation

5

Repeated attempts at reduction

QUESTION 122

What radiographic view will best reveal degeneration of the pisotriquetral joint in a patient who is being evaluated for pisotriquetral arthrosis?

1

True lateral

2

Lateral in 30 degrees of pronation

3

Lateral in 30 degrees of supination

4

Posteroanterior in 30 degrees of pronation

5

Carpal tunnel

The pisotriquetral joint is best seen on a lateral view in 30 degrees of supination. The carpal tunnel view provides visualization of the joint but to a lesser extent. The other views do not provide clear and accurate visualization.
REFERENCES: Paley D, McMurty RY, Cruickshank B: Pathologic conditions of the pisiform and pisotriquetral joint. J Hand Surg Am 1987;12:110-119.
Steinmann SP, Linsheid RL: Pisotriquetral loose bodies. J Hand Surg 1997;22:918-921.
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Orthopedic With Answer Upper L Review | Dr Hutaif Gener -...

Key Medical Takeaway

ORTHOPEDIC MCQS WITH ANSWER UPPER LIMB 05

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