AAOS Orthopedic MCQs (Set 1): Upper Extremity Trauma & Sports Injuries | Board Review

Deficiency of the rotator cuff interval may be acquired or congenital. In this patient, extensive debridement of the rotator cuff interval capsule at the time of arthroscopy most likely is the cause of the defect seen on the MRI scan. Surgical closure of the defect is the treatment of choice. During the repair, the shoulder should be placed in 30 degrees of external rotation to avoid overtightening. Care should be taken to include the leading edge of both the supraspinatus and subscapularis tendons in the repair because the rotator cuff interval capsular tissue is likely to be of poor quality. Cole BJ, Rodeo SA, O'Brien SJ, et al: The anatomy and histology of the rotator interval capsule of the shoulder. Clin Orthop 2001;390:129-137.

In a large series of mini-open rotator cuff repairs, an infection rate of at least 2% was found, with the majority of the infections caused by Propionibacterium acnes. To prevent this complication, the shoulder should be re-prepped before the mini-open incision is made to prevent bacterial contamination from the arthroscopic procedure. Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.

The coracoid process is an essential component of the superior shoulder suspensory complex and must be maintained. Open reduction and internal fixation is recommended if the fragment is large and displaced more than 1 cm. Froimson AI: Fracture of the coracoid process of the scapula. J Bone Joint Surg Am 1978;60:710-711.

Internal impingement of the shoulder is a leading cause of shoulder pain in the throwing athlete. The primary lesion in pathologic internal impingement is excessive tightening of the posterior band of the inferior glenohumeral ligament complex. To obtain an accurate assessment of true glenohumeral rotation, the scapula is stabilized during examination. A loss of 20 degrees or more of internal rotation, as measured with the shoulder positioned in 90 degrees of abduction, indicates excessive tightness of the posterior band of the inferior glenohumeral ligament complex. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420.

Instability following unconstrained elbow arthroplasty occurs in 10% of patients. Subluxation is twice as common as frank dislocation; however, only 20% of these patients undergo revision. Instability following unconstrained elbow arthroplasty can be caused by component malposition or ligament insufficiency. King GJ, Itoi E, Niebur GL, et al: Motion and laxity of the capitellocondylar total elbow prosthesis. J Bone Joint Surg Am 1994;76:1000-1008.

The glenoid labrum receives its blood supply from the suprascapular, posterior humeral circumflex, and circumflex scapular arteries. The labral vessels arise from the capsular and periosteal vessels that penetrate the periphery of the labrum. The bone does not appear to be a source of vascularity. The posterior/superior and inferior labrum have a fairly robust vascular supply, whereas the anterior/superior labrum has relatively poor vascularity, which may influence the success of superior lateral repairs.

The risk of synostosis is imminent with any technique for repairing a distal biceps tendon rupture. However, the risk is quite low for all approaches that avoid exposure of the ulna, including the muscle-splitting two-incision technique.

The MRI scan shows disruption of the subscapularis muscle. Subscapularis rupture is associated with weakness in internal rotation as shown with a positive lift-off test as described by Gerber and Krushell. The belly press test also has been shown to be a useful clinical test for this problem. Weakness in external rotation and abduction is more consistent with supraspinatus and infraspinatus tears. Deltoid atrophy is associated with an axillary nerve injury. Loss of biceps contour is associated with rupture of the long head of the biceps. Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.

A flexion contracture of the elbow is commonly seen in hemiplegic patients following cerebrovascular accidents. Spasticity and myostatic contracture of the joint are both causative factors. In patients with a flexion deformity of less than 90 degrees, musculocutaneous neurectomy is recommended, followed by serial casting to treat any residual deformity. At 9 months after injury, physical therapy will not significantly improve motion. Nerve blocks may be used in the early stages of recovery to facilitate therapy and serial casting.

The MRI scans show a large paralabral ganglion cyst in the spinoglenoid notch that communicates with an extensive tear of the glenoid labrum. Snyder and associates have classified superior labral tears into several subtypes that reflect the location and extent of the injury. Arthroscopic repair of the labral tear and aspiration of the ganglion cyst is the treatment of choice. Open excision of the cyst does not address the underlying problem of the labral tear. Snyder SJ, Karzel RP, Delpizzo W: SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279. Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch cysts. J Shoulder Elbow Surg 2002;11:600-604. McFarland EG, Kim TK, Savino RM: Clinical assessment of three common tests for superior labral anterior-posterior lesions. Am J Sports Med 2002;30:810-815.

The findings are classic for a pectoralis major tendon avulsion. Deformity of the anterior axillary fold is a classic finding, and ecchymosis down the arm suggests that the injury is at the humeral attachment rather than at the musculotendinous junction. Good external rotation strength indicates that function in the supraspinatus and infraspinatus has been preserved. The treatment of choice for a tendon avulsion in a young individual is early surgical repair. Conversely, if the injury is within the muscle or at the musculotendinous junction, initial nonsurgical management is recommended. If the location of the injury cannot be determined by physical examination, then MRI of the pectoralis major can be helpful. Hanna CM, Glenny AB, Stanley SN, et al: Pectoralis major tears: Comparison of surgical and conservative treatment. Br J Sports Med 2001;35:202-206.

Pain relief is excellent after total elbow arthroplasty and is comparable to the results found with hip and knee arthroplasty. The failure of total elbow arthroplasty in the treatment of rheumatoid arthritis can be the result of infection, aseptic loosening, instability, and bearing surface wear. The radiographic findings shown here are consistent with bushing wear in a linked device. The bushings can be changed before continued wear results in osteolysis and implant loosening. If the implants become loose, then reimplantation is necessary. Resection arthroplasty is not indicated if the components are well fixed. Elbow arthrodesis is not indicated in patients with rheumatoid arthritis. Gill DR, Morrey BF: The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: A ten to fifteen-year follow-up study. J Bone Joint Surg Am 1998;80:1327-1335.

Displaced greater tuberosity fractures often will block abduction and/or external rotation by impinging on the underside of the acromion or posterior glenoid. The indications for open reduction and internal fixation are 1 cm of displacement or 45 degrees of rotation of the tuberosity fracture. Surgical treatment has recently been recommended for 0.5 cm of tuberosity displacement. Neer CS II: Displaced proximal humeral fractures: II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.

When external rotation at the side is limited, the most likely diagnosis is contracture of the rotator cuff interval, including the superior glenohumeral and coracohumeral ligaments. Therefore, the treatment of choice is arthroscopic release of the rotator cuff interval.

The MRI scan reveals a large chronic rotator cuff tear with retraction and fatty infiltration atrophy of the supraspinatus and infraspinatus tendons. This tear is responsible for the patient's severe weakness and inability to elevate the arm.

Loss of external rotation following stabilization procedures can result in progressive degenerative joint disease. A tight anterior capsule results in posterior humeral translation and progressive posterior glenoid wear. Patients with early degenerative joint disease and pain can be treated with anterior release to restore more normal glenohumeral biomechanics. This procedure not only improves function but also decreases pain in most patients. Closed manipulation at 15 years after surgery is unlikely to be successful and carries the risk of complications. Acromioplasty, posterior release, and removal of osteophytes do not address the pathology. Arthroscopic releases are favored for intra-articular procedures that have addressed the pathology of instability. Open releases are recommended for nonanatomic extra-articular repairs that include subscapularis tightening procedures. MacDonald PB, Hawkins RJ, Fowler PJ, et al: Release of the subscapularis for internal rotation contracture and pain after anterior repair for recurrent anterior dislocation of the shoulder. J Bone Joint Surg Am 1992;74:734-737.

The radiograph reveals primary osteoarthritis of the elbow; therefore, ulnohumeral arthroplasty is the preferred procedure. Patients with severely limited preoperative elbow extension of more than 60 degrees and flexion of less than 100 degrees are at risk for ulnar nerve dysfunction postoperatively and should undergo a concomitant ulnar nerve decompression. Nonsurgical methods are unlikely to improve his chronic condition. Elbow arthroplasty is contraindicated for patients in this age group and with this diagnosis. Antuna SA, Morrey BF, Adams RA, et al: Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: Long-term outcome and complications. J Bone Joint Surg Am 2002;84:2168-2173.

Recovery of upper extremity motor function after a cerebrovascular accident follows a predictable pattern. The greatest amount of recovery is seen within the first 6 weeks. Return of function proceeds from proximal to distal. Shoulder flexion occurs first, followed by return of flexion to the elbow, wrist, and fingers. Return of forearm supination follows the return of finger flexion.

Dislocation of the long head of the biceps tendon is the result of a defect in the region of the rotator cuff interval, coracohumeral ligament-superior glenohumeral ligament pulley, or an associated tear of the medial insertion of the subscapularis tendon. In the case of an intra-articular dislocation of the long head of the biceps tendon associated with a tear of the subscapularis tendon, stabilization of the biceps tendon is difficult in this situation; therefore, biceps release or tenodesis and repair of the subscapularis tendon is the treatment of choice. Eakin CL, Faber KJ, Hawkins RJ, et al: Biceps tendon disorders in athletes. J Am Acad Orthop Surg 1999;7:300-310. Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654.

Transient ulnar nerve palsy is the most common palsy following elbow arthroscopy. The ulnar nerve is most frequently affected, followed by the radial nerve. Injury to the other nerves has been reported but less frequently. Kelly EW, Morrey BF, O'Driscoll SW: Complications of elbow arthroscopy. J Bone Joint Surg Am 2001;83:25-34.

A rotator cuff tear is the most common cause of recurrent instability following a first-time dislocation in patients older than age 40 years. Dislocations occur through a posterior mechanism rather than by an isolated labral avulsion or a Bankart lesion as seen in younger patients. Nevaiser RJ, Nevaiser TJ: Recurrent instability of the shoulder after age 40. J Shoulder Elbow Surg 1995;4:416-418.

Radiographs reveal malunion of a Monteggia fracture-dislocation. Dislocation of the posterior radial head is caused by the malunited ulnar fracture. The deformity includes shortening with an apex posterior angulation. In the acute setting, open reduction of the radial head rarely is necessary; however, in chronic dislocations, open reduction is required. Without ulnar osteotomy, recurrent radial head dislocation is likely.

Distraction interposition arthroplasty is indicated for the treatment of both rheumatoid and posttraumatic arthritis and is reserved for younger patients who are not suitable candidates for total elbow arthroplasty. Although less reliable than prosthetic replacement, distraction interposition arthroplasty is a useful option in the treatment of young, high-demand patients with elbow arthritis. It is rarely indicated in the presence of polyarticular inflammatory arthritis but may be of value in those patients in whom the disease is limited primarily to the elbow. Isolated radiocapitellar arthritis can be successfully treated with radial head resection, although caution should be exercised if there is evidence of instability. Osteoarthritis is best treated with ulnohumeral arthroplasty. Cheng SL, Morrey BF: Treatment of the mobile, painful arthritic elbow by distraction interposition arthroplasty. J Bone Joint Surg Br 2000;82:233-238.

Sternoclavicular joint sepsis is a rare condition that is most often restricted to patients who are immunocompromised, diabetic, or IV drug abusers. Examination commonly reveals a tender, painful, and possibly swollen sternoclavicular joint. If suspicion remains high following a thorough history, physical examination, radiographs, and routine blood tests, joint aspiration should be performed prior to incision and drainage or administration of antibiotics. Bremner RA: Monarticular noninfected subacute arthritis of the sternoclavicular joint. J Bone Joint Surg Br 1959;41:749-753.

Functional improvement after revision rotator cuff surgery is most likely to occur in patients with an intact deltoid, good-quality rotator cuff tissue, preoperative active elevation alone to 90 degrees, and only one prior rotator cuff repair. In this patient, the compromised deltoid origin might make functional improvement less likely. Djurasovic M, Marra G, Arroyo JS, et al: Revision rotator cuff repair: Factors influencing results. J Bone Joint Surg Am 2001;83:1849-1855. Bigliani LU, Cordasco FA, McIlveen SJ, et al: Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am 1992;74:1505-1515.