AAOS | ABOS Upper Extremity MCQs (Set 2): Shoulder, Elbow & Wrist Trauma Review

In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate step in management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography. Stayner LR, Cumming J, Andersen J, et al: Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231-239.

Comminuted, displaced radial head fractures (Hotchkiss type 3) require anatomic metallic radial head arthroplasty to regain function. Radial head excision has led to catastrophic sequelae including chronic wrist pain, elbow instability, and proximal radius migration. Immobilization, internal fixation, or anconeus arthroplasty are not recommended at this time because of the potentially poorer outcomes. Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

The radiographs reveal severe arthritic changes with no joint space, and the AP view shows a progressive malalignment secondary to the radial head resection. A prosthetic arthroplasty is indicated given the severe arthritis (Larsen grade III). Unconstrained arthroplasties have not performed as well as semiconstrained arthroplasties after previous radial head resections. However, both types of arthroplasties performed better in native elbows. Synovectomies should be reserved for less advanced disease states. Whaley A, Morrey BF, Adams R: Total elbow arthroplasty after previous resection of the radial head and synovectomy. J Bone Joint Surg Br 2005;87:47-53. Maenpaa HM, Kuusela PP, Kaarela KK, et al: Reoperation rate after elbow synovectomy in rheumatoid arthritis. J Shoulder Elbow Surg 2003;12:480-483.

Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis. Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 608-609.

The MRI scans show a rupture of the sternocostal portion of the pectoralis major tendon. This is the most common site of rupture and bench pressing is the most common etiology. Surgical repair yields better functional outcomes and patient satisfaction for tears not only at the tendon/bone interface but also at the myotendinous junction. Bak K, Cameron EA, Henderson IJ: Rupture of the pectoralis major: A meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8:113-119.

The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation. Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.

The patient's symptoms and examination findings are consistent with ulnar neuritis/cubital tunnel syndrome, most probably exacerbated by javelin throwing. The first step includes rest and extension splinting. Surgical intervention should only be considered after failure of nonsurgical management. Posner MA: Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-317.

The lesion lies in zone II of the ulnar tunnel. In that zone the deep motor branch of the ulnar nerve is susceptible to compression. Distal to the hook of the hamate, the motor branch of the ulnar nerve dives deep to innervate the interossei as it begins to move from an ulnar to radial direction. Because of its course, it has little or no give in response to a mass effect from the floor of Guyon's canal. Ganglions are the most common cause of ulnar nerve entrapment in the wrist. Lesions in zone I can affect both sensory and motor aspects of the ulnar nerve as well as the motor innervation of the hypothenar muscles. Lesions at the elbow or mid-to-proximal forearm are associated with dorsal hand numbness and tingling. Kuschner SH, Gelberman RH, Jennings C: Ulnar nerve compression at the wrist. J Hand Surg Am 1988;13:577-580.

In an acute first-time dislocation, arthroscopy has been shown to reveal a Bankart lesion in most shoulders. The classic finding of labral detachment from the anterior inferior glenoid along with occasional hemorrhage within the inferior glenohumeral ligament is the most common sequelae of a traumatic anterior inferior dislocation. Acute treatment, if chosen, is repair of the labral tissue back to the glenoid plus or minus any capsular plication to address potential plastic deformation of the glenohumeral ligament. Acute treatment of a patient sustaining a first-time dislocation remains controversial. The potential indications may be patients whose dislocation occurs at the end of a season and when the desire to minimize risk of future instability outweighs the risks of surgical intervention. Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311. DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.

In a study of 19 patients with compartment syndrome of the hand, all had tense swollen hands with elevated compartment pressures. Most patients were neurologically compromised so pain with passive stretch may be difficult to illicit. Arterial inflow is present in the arch and thus pallor is not present. The typical posture of the hand is not clenched, rather it is an intrinsic minus posture of metacarpophalangeal joint extension and flexion of the proximal and distal interphalangeal joints. Oullette EA, Kelly R: Compartment syndromes of the hand. J Bone Joint Surg Am 1996;78:1515-1522.

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur. Williams MM, Snyder SJ, Buford D Jr: The Buford complex - the "cord-like" middle glenohumeral ligament and absent anterosuperior labrum complex: A normal anatomic capsulolabral variant. Arthroscopy 1994;10:241-247.

The more severe the trauma, the higher the rate of subsequent clavicular nonunion. Neither duration nor type of immobilization has been clearly demonstrated to be a causative factor in the development of nonunion. Similarly, closed reduction has not been found to alter the healing course in midshaft clavicular fractures. Lazarus MD, Seon C: Fractures of the clavicle, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, vol 2, pp 1241-1242.

The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism's susceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time. Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 953-954.

The typical mechanism of injury is a fall and the patient grasps something to prevent the fall. This maneuver forces the arm into external rotation against resistance. Kreuz PC, Remiger A, Erggelet C, et al: Isolated and combined tears of the subscapularis tendon. Am J Sports Med 2005;33:1831-1837.

In this young patient, every attempt must be made to retain the native proximal humerus; therefore, open reduction and internal fixation should be attempted of both the articular segment and tuberosities to the humeral shaft. This is best accomplished through an open approach. Shoulder arthroplasty should be reserved for the elderly and for failed internal fixation. Ko JY, Yamamoto R: Surgical treatment of complex fractures of the proximal humerus. Clin Orthop Relat Res 1996;327:225-237.

Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-eight pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability. Rockwood CA, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 608-609.

The natural history of nontraumatic osteonecrosis varies greatly, so it is difficult to predict which patients will have severe arthrosis develop. Patients with sickle cell disease tend to have the most benign course. The most commonly reported cause of nontraumatic osteonecrosis is corticosteroid therapy. Fortunately, the incidence of osteonecrosis among patients treated with long-term systemic corticosteroids has fallen from more than 25% to less than 5% in recent years, owning to judicious steroid use and dosing. The interval between corticosteroid administration and the onset of shoulder symptoms is also variable, ranging from 6 to 18 months in one large series. This is comparable to the interval leading up to the onset of hip symptoms, which ranges from 6 months to 3 years or longer. The incidence of humeral head involvement has not been shown to vary with the underlying indication for steroid use. Hasan SS, Romeo AA: Nontraumatic osteonecrosis of the humeral head. J Shoulder Elbow Surg 2002;11:281-298.

MRI-arthrography has been shown to be an accurate technique for assessing the glenoid labrum in patients with suspected labral tears. Often standard MRI technique will not identify labral lesions. The use of MRI-arthrography with an intra-articular injection of gadolinium provides improved visualization of labral lesions. Bencardino and associates demonstrated a sensitivity of 89%, a specificity of 91%, and an accuracy of 90% in detecting labral lesions. SLAP lesions can be visualized on coronal oblique sequences as a deep cleft between the superior labrum and the glenoid that extends well around and below the biceps anchor. Often, contrast will diffuse into the labral fragment, causing it to appear ragged or indistinct. Applegate GR, Hewitt M, Snyder SJ, et al: Chronic labral tears: Value of magnetic resonance arthrography in evaluating the glenoid labrum and labral-bicipital complex. Arthroscopy 2004;20:959-963. Bencardino JT, Beltran J, Rosenberg ZS, et al: Superior labrum anterior-posterior lesions: Diagnosis with MR arthrography of the shoulder. Radiology 2000;214:267-271.

The photograph shows the characteristic attitude of the hand when an anterior interosseous nerve palsy is present. The patient is unable to flex the interphalangeal joint to the joint of the thumb. Anterior interosseous nerve palsies are often misdiagnosed as tendon ruptures. Schantz K, Reigels-Nielsen P: The anterior interosseous nerve syndrome. J Hand Surg Br 1992;17:510-512.

In a series reported by Blaine and associates, 12 patients were converted from interposition to total elbow arthroplasty. This procedure was successful in 10 out of 12 patients. Blaine TA, Adams R, Morrey BF: Total elbow arthroplasty after interposition arthroplasty for elbow arthritis. J Bone Joint Surg Am 2005;87;286-292.

The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid. Werner CM, Steinmann PA, Gilbert M: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.

The patient has an acute fracture of the proximal pole. A 100% healing rate has been reported for open reduction and internal fixation of proximal pole fractures via a dorsal approach. This allows for direct viewing of the fracture line, facilitates reduction, and bone grafting can be done through the same incision if necessary. A vascularized or corticocancellous graft is reserved for nonunions. Proximal fractures are very slow to heal with a cast, if they heal at all. As a small fragment, percutaneous fixation is very difficult and has been reported for waist fractures. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.

Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared to hemiarthroplasty in patients with rheumatoid arthritis. Although rotator cuff tears are more common in this patient population, this patient has good forward elevation and no significant superior migration of the humeral head; therefore, a reverse arthroplasty is not indicated. The arthritis is too advanced in this patient to consider arthroscopy, but in less advanced cases it can improve range of motion and decrease pain. Metal-backed glenoid components have shown higher rates of loosening. Collin DN, Harryman DT II, Wirth MA: Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am 2004;86:2489-2496. Baumgarten KM, Lashgari CM, Yamaguchi K: Glenoid resurfacing in shoulder arthroplasty: Indications and contraindications. Instr Course Lect 2004;53:3-11.

The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal. Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.

The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely. Turner JW, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis). Lancet 1957;2:209-212.