Upper Limb (2008-2019) Flashcards

Question

25.  What is a static restraint of the GH joint? a. CH ligament b. CA ligament c. biceps d. negative intra-articular pressure

Answer 1

ANSWER: D 2015 Miller's Orthopedics (p. 320) * Static Restraints: * Glenoid labrum, articular version, articular conformity, negative pressure, capsule, capsuloligamentous structures * Dynamic Restraints: * Joint concavity compression by cuff * Pagnani MJ (JSES 1994) Stabilizers of the glenohumeral joint * The coracohumeral ligament appeared to have no significant suspensory role

Answer 2

ANSWER: C 2015 JAAOS 2014 - Anterior Glenohumeral Instability Risk Factors for failure of arthroscopic capsulolabral repair: * Ligamentous laxity * Hill-Sachs \> 250mm3 * Immobilization \<4 weeks * \<28 years old * Glenoid bone loss \> 15% * Contact sports ISIS score components * Age at surgery * Competitive sports * Contact or forced overhead sports * Shoulder hyperlaxity * Hill-Sachs visible on ER A/P radiograph * Glenoid loss of contour on AP radiograph

Answer 3

ANSWER: A 2012, 2014 * The Hill-Sachs lesion: diagnosis, classification, and management. JAAOS. 2012 * “The Hill-Sachs lesion is a compression fracture of the posterosuperolateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint.” * Stryker notch view is most specific for evaluating a Hill-Sachs lesion - adduction and internal rotation view brings posterolateral aspect of humeral head into view * Lesions \<20% of humeral head are of no clinical significance; lesions \>40% are nearly always clinically significant and can result in recurrent anterior instability - basis of classification system (Flatow & Warner) * Consider all GH anatomy when planning treatment - small HS lesions can be clinically significant in the setting of large glenoid bone loss * Address primary problem prior to addressing HS lesion = Bankart or glenoid bone loss * Surgical options for HS lesions include auto/allograft, soft tissue filling (remplissage), disimpaction, hemiarthroplasty/resurfacing * Note: the ISIS score looks at whether the Hill-Sachs is visible on an AP view with the shoulder in maximal ER but this is NOT the best way to see it. IR is best, but they used ER for their score because they found that if the lesion was seen on a maximal ER view then it was located more superior on the head and therefore more likely to be engaging and associated with instability.

Answer 4

ANSWER: A 2013 * JAAOS – The Hill Sachs Lesions * Surgical management: * Capsular Shift * Glenoid bone augmentation * Humeral head bone augmentation * Autograft, fresh or frozen allograft or synthetic * Tissue Filling (Replissage) * Connolly procedure = open procedure involving transfer of the infraspinatus and portion of GT into defect * Remplissage: * Converted to extra-articular defect with soft-tissue coverage * Arthroscopic posterior capsulodesis and infraspinatus tenodesis with fixation to the surface of the Hill sachs defect * Disimpaction * Resurfacing/Prosthesis * Posterior Instability: * McLaughlin = open transfer of the subscap tendon and LT to fill humeral head defect

Answer 5

ANSWER: B 2016

Answer 6

ANSWER: D 2014 * OKU Shoulder and elbow 4 * Rotator interval is the area of the capsule between the supraspinatus and subscapularis, includes the… * SGHL * Coracohumeral ligament * Long head of biceps * Contracture common in adhesive capsulitis, should release if treating arthroscopically * Laxity in instability, tightening is controversial

Answer 7

ANSWER: A 2011 * Neviaser RJ (JBJS 1988) Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient * 31 patients unable to abduct arm after reduction of primary dislocation * All patients older than 35 * 29 presumed to have axillary nerve injury --\> only 1/24 positive on EMG * 7.8% axillary nerve injury, 100% rotator cuff tear

Answer 8

ANSWER: D 2008

Answer 9

ANSWER: A 2008  

Answer 10

ANSWER: B 2009 JAAOS 2017 – Posterior GH instability: Evidence based treatment * Operative open or arthroscopic posterior labral repair (Bankart) indications * recurrent posterior shoulder instability despite appropriate course of physical therapy * continued pain with loading of arm in forward flexed position (bench press, football blocking) * negative Beighton score * outcomes * 80% to 85% success at 5- to 7-year follow-up after open repair * similar outcomes with arthroscopic repair after shorter follow-ups * open or arthroscopic posterior capsular shift and rotator interval closureindications * positive Beighton score * posterior glenoid opening wedge osteotomyindications * excessive congenital glenoid retroversion * limited studies assessing outcomes with this approach * open reduction with subscapularis transfer (McLaughlin) or lesser tuberosity transfer to the defect (Modified McLaughlin) indications * chronic dislocation \< 6 months old * reverse Hill-Sachs defect \< 40% * hemiarthroplastyindications * chronic dislocation \> 6 months old * severe humeral head arthritis * collapse of humeral head during reduction * reverse Hill-Sachs defect \> 40% of articular surface * total shoulder arthroplastyindications * significant glenoid arthritis in addition to one of the hemiarthroplasty indications

Answer 11

Snyder Classification: 1. Labral fraying 2. Fraying with detached biceps tendon anchor 3. Bucket handle tear, intact biceps tendon anchor 4. Bucket hand with detached biceps anchor (bucket extends up biceps)

Answer 12

JAAOS 2009 - Superior Labral Tears of the Shoulder * Forceful traction injury to the arm * Direct compression load/blow * Repetitive overhead throwing activities (peel back)

Answer 13

JAAOS 2012- Hemiarthroplasty for three and four part proximal humerus fractures * Top of prosthesis should be 5.6cm from upper border of pec major * GT 10mm below articular surface * GT/LT fragments reduce without tension * GT superomedial corner 4.2cm above the pec major insertion * (GT should be between 10-16mm from superior margin of the humeral head, over or under reduction correlated with poor results) Side note: should be in 20-30deg retroversion as measured from the epicondylar axis. Can be done by placing lateral fin of prosthesis 30deg posterior to posterior edge of bicipital groove' CORR Course: Size/template other side Intra-operative fluoro

Answer 14

ANSWER: D 2010, 2012 JAAOS Adhesive Capsulitis * Associated Conditions: * Cardiovascular disease * Thyroid dysfunction/ACTH deficiency * Breast cancer treatment * Risk factors --\> CVA, MI, DM * DM has worse prognosis * Minor trauma to limb * Heart Disease, cardiac surgery * Parkinsonism * Malignancy * Hyperlipidemia * Drugs --\> MMP inhibitors (glaucoma), antiretroviral, pneumococcal/influenza vaccine, fluoroquinolones * Dupuytren's contracture * Transient pain relief with corticosteroid injections * Natural resolution of symptoms with mild treatment

Answer 15

ANSWER: C 2012 JAAOS - Management of Multidirectional Instability of the Shoulder Reconstructive techniques include glenoid osteotomy, labral augmentation, capsuloligamentous reconstruction Open Inferior Capsular Shift

Answer 16

ANSWER: A 2012 JAAOS 1996 - Neuropathic Arthropathy + Millers 8th edition p.40 * Neuropathy in the shoulder (upper extremity) is most commonly associated with syringomyelia * Second most common charcot upper extremity arthropathy is Hansen-Leprosy  

Answer 17

ANSWER: C (first to r/o syrinx then DM2) 2008 * Jackson et al. 2012. Charcot arthropathy of the wrist associated with cervical spondylotic myelopathy. * The most frequently cited cause of Charcot arthropathy of the upper extremity is syringomyelia, and magnetic resonance imaging of the cervical spine should be obtained at presentation.

Answer 18

ANSWER: A 2014, 2016 JAAOS 2007 - Understanding Shoulder and Elbow Injuries in Baseball * Internal impingement has been through to have the following etiologies contributing: traction on biceps tendon, laxity of anterior band of IGHL caused by excessive external rotation stretch, posterior capsular tightness and scapular dyskinesia JAAOS - Posterior Capsular Contracture of the Shoulder: * Non-operative treatment includes sleeper stretches * Micro-instability is associated OKU Shoulder and Elbow: * Regardless of their etiology, injuries to the throwing shoulder share many final sequelae, including superior labrum anterior to posterior (SLAP) tears, proximal biceps pathology, partial thickness rotator cuff tears, and scapular dyskinesia * "Full thickness tears are uncommon, but partial thickness articular sided tears are almost ubiquitous in throwing athletes"

Answer 19

Answer: E. * C is false: depression * D is false: women more common * B is false: SL instability * A is false: anterior and middle scalene 2008, 2014 (confirmed McGill) 2008 question has female gender which I like best * JAAOS 2015 - Thoracic Outlet Syndrome * Thoracic outlet is interval from supraclavicular fossa to axilla (between clavicle and first rib) * Typical patient is young, thin, female with a long neck and drooping shoulders * Compression: * Inter-scalene -anterior scalene, middle scalene, first rib * Subclavian artery, trunks of brachial plexus * Costo-clavicular - clavicle, subclavius, costocorocoid ligament * Subclavian vessels, divisions of brachial plexus * Retro-pectoralis - inferior to coracoid process * Brachial plexus, axillary artery and vein * Provocative Tests: * Wright - decrease in pulse with hyper-abduction and ER with head on opposite side * Adson - extension with head towards side + deep breath * Roos - 90o abduction, elbows 90o + hand open/close "Nonsurgical management is reported to be less successful in obese patients, in patients who are on workers’ compensation, and in patients with double-crush neurologic pathology involving the carpal or cubital tunnels."

Answer 20

ANSWER: C 2010 * Wright test is symptoms with abduction an EXTERNAL rotation * Tests are neither sensitive nor specific (50-70% range) * " Gergoudis et al1challenged the clinical utility of this test by showing that 66 of 130 normal persons (51%) had a diminished pulse with the Adson maneuver." (JAAOS) * "In a series by Gillard et al. the specificity for the Adson test and for the Roos test was 76% and 30%, respectively; however, when both tests were positive, specificity increased to 82%." *  

Answer 21

ANSWER: A 2008 JAAOS 2015 - Thoracic Outlet Syndrome * Vascular causes rare (3-5% venous, \<1% arterial) * Females are more common * Neurogenic (90%) * Lower and combined plexus presentation is more common (85-90%) * Arterial cases --\> can develop and aneurysm, thrombosis and limb threatening ischemia

Answer 22

ANSWER: C 2015 * Brockmeier SF (JBJS 2009) Outcomes after arthroscopic repair of type II SLAP lesions * 47 patients at 2 years following arthroscopic SLAP repair with suture anchors * Return to sport (same level) = 74% * Neuman BJ (AJSM 2011) Results of arthroscopic repair of type II SLAP in overhead athletes * 30 patients at 3.5 years * 84% return to preinjury level of function * 2019 Systematic Review Return to Sport After Arthroscopic Superior Labral Anterior-Posterior Repair: A Systematic Review * 69% return to play at same level

Answer 23

ANSWER: A 2015 JAAOS 2007 - Rotator Cuff Tear Arthropathy * “Patients with cuff deficiency demonstrated significantly greater superior migration of the humeral prosthesis on the glenoid component compared with patients with no rotator cuff deficiency. The investigators suggested that this superior displacement of the humeral head on the glenoid led to loosening of the glenoid component and a “rocking horse” phenomenon of glenoid loosening” * Matsen, F (JBJS 2008) Glenoid component failure in total shoulder arthroplasty * As a special type of glenohumeral instability, the superior subluxation seen with massive rotator cuff deficiency is an important cause of eccentric loading, creating the risk of rocking-horse loosening of the glenoid component

Answer 24

ANSWER: C 2011 Bohsali KI (JBJS 2006) Complications of TSA * Anterior and superior instability accounted for 80% of instability cases * Anterior instability is associated with humeral component malrotation, anterior glenoid deficiency, anterior deltoid muscle dysfunction, failure of the subscapularis tendon and anterior aspect of the capsule Moeckel (JBJS 1993) * 100% of shoulders with anterior dislocation had subscap insufficiency (granted only 7 shoulders)

Answer 25

ANSWER: B 2008 * Levine WN (JSES 1997) Hemiarthroplasty for glenohumeral osteoarthritis: Results correlated to degree of glenoid wear * 31 shoulders * 86% satisfaction with concentric shoulders, 63% with non-concentric glenoids * Ianotti JP (JBJS 2003) Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis * 128 shoulders at 46 months * 10% had supraspinatus tear - no effect on ASES, decrease in pain or satisfaction * Patients with posterior subluxation of humeral head had worse outcomes * Levine WN (JBJS 2012) long term follow up of shoulder hemiarthroplastyfor glenohumeral osteoarthritis * 25% satisfaction at 17 years * Concentric glenoids and primary OA do better than non-concentric glenoids and secondary arthritis

Answer 26

ANSWER: A 2013, 2015 JAAOS 2001 - Medial Elbow Problems in the Over-head Throwing Athlete * Valgus instability * Valgus Extension Overload * Medial Epicondylitis (flexor-pronator mass) * Ulnar Neuropathy: * "athletes with ulnar neuropathy usually present with intermittent medial elbow pain that may occasionally radiate down the medial aspect of the forearm into the hand"

Answer 27

ANSWER: B 2008

Answer 28

ANSWER: D 2009

Answer 29

ANSWER: A 2016 Morrey (JBJS 1985) Rupture of the distal tendon of the biceps brachii. A biomechanical study 3 patients !! 40% supination strength, 30% flexion strength loss Freeman (JBJS 2009) Nonoperative treatment of distal biceps tendon rupture compared with a historical control group 18 patients 12% flexion loss, 26% supination strength All patients returned to their jobs at average of 12 weeks with no restrictions Nesterenko (JSES 2010) Elbow strength and endurance in patients with a ruptured distal biceps tendon No difference in 9 patients between injured arm and uninjured arm for either flexion or supination

Answer 30

ANSWER: B, C and D 2013 * Grewal R (JBJS 2012) Single versus double-incision technique for the repair of acute distal biceps tendon ruptures * RCT of male patients with 47 single incision repairs with suture anchors, 44 double incision with trans-osseous drill holes * No difference in supination/pronation strength * 10% increase in flexion strength in double incision (104% vs 94%) * More LACN injury with single incision (19 vs 3) * Majority of patients had HO prophylaxis with indomethacin

Answer 31

ANSWER: C 2012 Argument: most common nerve injuries are LACN, SRN and PIN Other options not common * Kelly EW (JBJS 2000) Complications of Repair of the Distal Biceps Tendon with the Modified Two-Incision Technique * Retrospective review of 78 two incision repairs * Neuropraxias: * 3 LACN * 2SRN * 1 PIN

Answer 32

ANSWER: B 2012 JAAOS 2010 - Distal Biceps Tendon Rupture "Lateral antebrachial cutaneous nerve paresthesia is the most common complication of distal biceps repair and is usually the consequence of aggressive retraction"

Answer 33

ANSWER: C 2014, 2016 * Eames (JBJS 2007) Distal biceps tendon anatomy: a cadaveric study * The distal biceps tendon: footprint and relevant anatomy. Journal of Hand Surgery. 2007 * Biceps musculotendinous unit rotates 90deg from origin to insertion * Long head inserts proximally and short head inserts distally - both insert on the very ulnar ridge of the radial tuberosity (however, the long head is slightly more radial… which makes the short head a stronger supinator) * Overall footprint is 23mm distal to the articular margin of the radial head

Answer 34

ANSWER: D 2009 Old Answer Summary: Loss of supination strength of 10-20% in old studies No difference of flexion strength in chronic tears, 10% supination strength loss

Answer 35

* Elbow stiffness * Radiocapitellar arthrosis * Loss of pronation/supination * Longitudinal forearm instability * Weaker: * Infection * PIN injury * HO/Synostosis * Elbow Instability

Answer 36

JAAOS 2012 - Management of Post-traumatic Radioulnar Synostosis * Risk factors: * Injury: * Proximal Third * Fractures at the same level * Comminution of both bones * Severe local soft-tissue injury * Interosseous membrane injury * Head Injury * Surgical Technique: * Single Incision/Boyd Approach * Delayed Surgical Management * Violation of IO membrane * Retained bone fragment in IO space * Hardware into IO membrane * Primary onlay bone grafting

Answer 37

* Compare to fracture fragments (Alolabi JSES 2013) * Compare to contra-lateral side (Athwal JBJS 2011) * Ulnohumeral Symmetry (Doornberg JHS 2006) * PRUJ \<1mm proximal to lateral edge of coronoid (Dorrnberg JHS 2006)

Answer 38

JAAOS 2015 - Complex Elbow Dislocation, JAAOS - Proximal Ulna # * Skin incision * Median approach vs fixation through radial head or olecranon * Stable Fixation * Possible Ligament repair * ? Ulnar nerve transposition * Same article, another thought on points * Fix coronoid * Fix/replace radial head * Safe zone for hardware between Lister’s tubercule and radial styloid * Repair LCL * Suture anchors or through drill holes in lateral epicondyle * Tie with elbow at 90degrees and pronated * Potentially repair MCL * (this was listed as steps 1-4 in the article)

Answer 39

* Prone, elbows flexed to 90 deg, shoulders abducted, forearms supinated * Pt attempts elbow extension * Positive test is pt apprehension or frank subluxation/dislocation of radial head

Answer 40

list 3 stabilizers to posterolateral instability * Lateral Collateral Ligament * Radial Head * Coronoid (\>30-50% loss) What is the most important of these lateral structures * LCL

Answer 41

* Immobilize in 90o with arm in pronation * Follow on weekly basis /with radiographs to ensure congruent reduction * Hinged elbow brace at 2 weeks with extension blocks * Progressive ROM until full extension * Discontinue brace at 6-8 weeks

Answer 42

ANSWER: A 2013 * JAAOS 2007 - Fractures of the Radial Head and Neck * Overstuffing the radial capitellar joint has a pressure effect on the capitellum, leading to increased forces and early wear of capitellum * Overstuffing leads to decreased ROM and lateral elbow pain post-op * Too small of radial head will lead to instability

Answer 43

ANSWER: D 2015 * Pugh DMW (JBJS 2004) Standard surgical protocol to treat elbow dislocations with radial head and coronoid fracture * "protocol included fixation or replacement of the radial head, fixation of the coronoid fracture and repair of associated capsular and lateral ligamentous injuries, in selected cases repair of MCL"

Answer 44

ANSWER: B 2013 JAAOS 2004 - Posterolateral Rotatory Instability * Lateral side goes first * 3 stages of soft tissue disruption (Circle of Horii) * LUCL --\> PLRI * LUCL + posterior capsule --\> perched elbow * LUCL + capsule + MCL --\> anterior band and flexors intact * JAAOS - Coronoid Fracture * As the elbow dislocates, the lateral collateral ligament is torn from is humeral origin

Answer 45

ANSWER: A 2013 * JAAOS 1996 - Acute and Chronic Instability of the Elbow * Recurrence is uncommon (residual instability 2%) * 15% rate of stiffness (\>30o extension lost) * Myositis Ossificans is uncommon in uncomplicated dislocations (\<5%)

Answer 46

ANSWER: C 2015 Supination shortens extensor-supination mass --\> want to elongate this to provide stability that LCL is lacking 3 weeks too long for immobilization, generally only 1-2 weeks Stiffness more common than instability

Answer 47

ANSWER: C 2014, 2016 * Doornberg (JBJS 2006) Fractures of the anteromedial facet of the coronoid process * Several patterns of injuries involved: * Varus subluxation * Associated avulsion of LCL common, fracture of olecranon * Posterior dislocation: * Small anteromedial facet coronoid fractures in two * Three had associated radial head fractures (terrible triad) * Journal of Shoulder and Elbow Surgery 2014 - Strategic approach to O'Driscoll Type 2 anteromedial coronoid facet fracture * JAAOS 2008 Coronoid Process Fracture * An anteromedial coronoid fracture…mechanism is varus and posteromedial rotation force on the forearm…results in LCL rupture and then compression of medial coronoid on medial trochlea * "By varus force in forearm pronation, the LUCL injury and the AMCF fracture occur, but it may not be evident on a simple radiograph and can be mistakenly overlooked. If it is not detected and appropriate treatment is not carried out in the early stages, post-traumatic arthritis occurs relatively quickly, and its outcome is known to be poor."  Difficult elbow fractures: pearls and pitfall. Instructional course lectures. 2003 * Posteromedial varus instability of the elbow is associated with an O’Driscoll type II coronoid process fracture that involves the anteromedial facet * Occurs due to a posteromedial varus rotatory force to the elbow (vs more common posterolateral rotatory force), associated with injuries to the posterior band of the MCL and lateral collateral ligament; radial head fracture and injuries to the anterior band of the MCL are rare * Recommended treatment is direct medial exposure with fixation of the coronoid (buttress plate for larger fragments or sutures for smaller/rim fragments) + lateral collateral ligament repair * If untreated, can lead to elbow instability + early ulnohumeral OA (due to altered biomechanics and joint loading) 

Answer 48

ANSWER: B best answer (King)....but D is also very important. 2011, 2012, 2013 * McGill Variant of this question has Anterior capsule instead of radial head * Deutch (11) --\> LCL repair improved laxity without radial head replacement or coronoid fixation * LCL + RH improved stability even more * Scheeberger (8) * Removal of radial head and 30% of coronoid process dislocated elbow at 60o flexion * Stabilized just with fixation of RH * Defect of 50% of coronoid and RH could not be stabilized by RH alone * JAAOS 2009 - Posterolateral Rotatory Instability * Coronoid process is an important elbow stabilizer in response to axial, posteromedial and posterolateral forces * Morrey BF (CORR 1991) * Simulated VALGUS injury * With residual instability AFTER LCL and RH fixed, then repair of MCL more effective than fixation of small coronoid fractures * "The radial head is a secondary constraint to resist valgus and rotatory laxity and is significant only if the anterior bundle of the MCL is absent"

Answer 49

ANSWER: A 2016 * Ring D (JBJS 2002) ORIF of fractures of the radial head * Review of 56 patients at 2 years with type 4 radial head # * Most patients with Mason III fractures with \>3 fragments had poor results (13/14) * 12 patients with \< 3 --\> no non-union, early failure or severe loss of ROM * Greater than 3 fragments should be excised or replaced

Answer 50

ANSWER: D (posteromedial instability not usually associated with terrible triad, no radial head fracture so B also right) 2012, 2016 * JOT 2018 – canadian paper - https://pubmed.ncbi.nlm.nih.gov/30339648/ * Conclusion: Fixation of anteromedial coronoid fractures (type 2, subtype 3) is best achieved with a plating technique. Although LPs had greater stiffness, they did not offer any advantage over conventional non-LPs with respect to fracture fragment displacement in this study. * Newer research: Plate, but not locking plate * Manitoba/Toronto Answer Variation: (in this case locking plate more clearly correct) * Locking plate fixation preferred * Can be repaired with screws * MCL is attached to this fragment * Must be treated operatively * JAAOS 2008 – Coronoid Fractures: * “coronoid tip fracture is often seen in conjunction with an elbow dislocation and radial head fracture – an injury referred to as a terrible triad “ * Anteromedial Coronoid Fracture: * In an anteromedial coronoid fracture, the mechanism of injury is in the opposite direction of that of a tip fracture. A varus and posteromedial rotation force  rupture of LCL from humeral origin. As the LCL gives way the medial coronoid is forced against the medial trochlea. * Doornberg JN (JBJS 2006) Fracture of the Anteromedial Facet of the Coronoid Process * “Several patterns of injury were observed in associated with fracture of the anteromedial facet of the coronoid process. These were separated into fractures associated with either varus subluxation or complete posterior dislocation of the elbow” * 3 had an associated fracture of the radial head (a so called terrible triad injury) * JAAOS 2015 - Terrible Triad * "This results in an anteromedial facet fracture with associated disruption of the LCL due to a varus force. The radial head is usually not fractures * in a varus posteromedial instability pattern, and it is therefore by definition not a true terrible triad injury"

Answer 51

ANSWER: A 2015 * JAAOS - Acute and Chronic Instability of the Elbow * "acute tear of the MCL is the most frequent isolated ligamentous injury of the elbow" * Confirmed at CORR Recon * JBJS BR 2008 Posterolateral rotator instability of the elbow * "Posterolateral rotatory instability is the most common type of symptomatic chronic instability of the elbow"

Answer 52

ANSWER: C 2009 I think this is dumb because the muscle masses are probably torn off anyhow. Regardless. AAOS - Simple Elbow Dislocation Point thumb away from injured ligaments

Answer 53

ANSWER: B 2011 Sheps/Hildebrand/Boorman (Hand Clin 2004) In the setting of a simple dislocation with incompetent unstable valgus stress, medial side (MCL) disruption then treat with splint in 90o in supination for 1-2 weeks, then ROM

Answer 54

ANSWER: A 2008 Posterolateral Rotatory Instability of the Elbow: Part II. Supplementary Examination and Dynamic Imaging Techniques To perform the lateral pivot-shift test, as shown on the left elbow of the patient in the supine position, the arm is held securely by the examiner over the patient's head. The arm is moved from an extended to a flexed position, while the forearm is supinated and axial compression and a valgus load are applied to the elbow. As the subluxation increases, the supination torque is reduced while increasing the valgus torque. The pivot shift tends to occur between 20° and 40° of flexion, but it should be assessed at multiple angles.

Answer 55

ANSWER: A 2008 Longitudinal instability of IO membrane

Answer 56

ANSWER: B 2011, 2014 JAAOS. The elbow and its disorders, Morrey * “If bilateral arthrodesis is performed, one elbow should be fused in 90deg of flexion for personal care and hygiene functions and the other in 45 to 65deg of flexion for other uses. Functionally, a limited range of 100deg in mid-position is enough for most daily activities.” * Orthopedics 2014 - Elbow arthrodesis, a novel technique and review of the literature * For both sexes, 90° to 110° seems to be better for personal hygiene, whereas 40° to 70° is better for extrapersonal needs and activities. In the case of bilateral elbow arthrodesis, it is generally recommended that the dominant arm be fused at 110° and the nondominant arm at 65°

Answer 57

ANSWER: B 2010 JAAOS 2008 Characterized by the relative preservation of the articular cartilage and maintenance of joint space, but with hypertrophic osteophyte formation and capsular contracture OA at the elbow is characterized by pain, stiffness, mechanical symptoms and weakness

Answer 58

ANSWER: C 2008 * Memory obviously an issue, perhaps an except question where B is the answer * JAAOS 2003 - Surgical management of rheumatoid elbow * Synovectomy with or without radial head excision is well-recognized and accepted form of treatment * When done early, may be an effective treatment, lasting \>10 years in up to 80% of patients * Pain relief is common, but the rate of recurrence increases after 5 years * Even in patients with advanced disease, synovectomy and capsular release with or without radial head excision may result in acceptable pain relief and increased elbow ROM * Radial head excision may improve forearm rotation and reduce impingement…however can lead to instability

Answer 59

ANSWER: B 2015 JAAOS 2010 - Distal Triceps Rupture * Most common in young men * May have elbow extension despite complete tear * Weakness of extension, not flexion * "regardless of the mechanism of injury, triceps tendon ruptures are usually seen at the osseous insertion"

Answer 60

ANSWER: C 2013 * JAAOS - Elbow Arthroscopy * Many of the attenuated portals described in the literature place surrounding NV structures at a higher risk than do the portals described above (ie, midlateral, proximal lateral, posterolateral, transtriceps) * The most common nerve injury is the ulnar\>SRN\>PIN\>AIN * Kelly EW (JBJS 2001) Complications of Elbow Arthroscopy: * 5 ulnar nerve palsy, 1 PIN, 1 SRN, 1MABC * * * JAAOS 2014 - Elbow Arthroscopy: Indications, Techniques, Outcomes, and Complications * * Published reports document injury to all major peripheral nerves about the elbow. In one series of 473 elbow arthroscopies, the ulnar nerve was most commonly involved, followed by the superficial radial nerve, posterior interosseous nerve, anterior interosseous nerve, and medial antebrachial cutaneous nerve, respectively.13,21,23-25 Nerve injury is more common in patients with rheumatoid arthritis because the capsule is thinned or absent, in profound preoperative contractures, and in distorted anatomy

Answer 61

ANSWER: D 2016 JAAOS 2008 – Elbow Arthroscopy Complications Sections “In every clinical case, the bony anatomy should be drawn on the patient’s elbow, an 18-guage spinal needle should be used to confirm the correct portal location before introducing the trocar and the elbow should be maximally distended at all times to displace the neurovascular structures away from the entering instruments”

Answer 62

ANSWER: A 2008 * It's a trick! Radial tunnel syndrome * Dang (JHS 2008) Unusual compression neuropathies of the forearm * Provocative maneuvers for radial tunnel: * Resisted supination * Pain with resisted middle finger extension * Therefore decompress at supinator * Brachioradialis would be for Wartenberg (Cheiralgia)syndrome – compression at ECRL and brachioradialis, and would have pain with resisted pronation.

Answer 63

ANSWER: A 2008 * JAAOS 2008 - Radial Head Arthroplasty * Anterior bundle of the MCL is the primary stabilizer to valgus force across the elbow * Radial head fractures represent 5.4% of all fractures * JAAOS 2007 - Radial Head Fractures * Radius bears 80% of load at wrist, but load sharing ratio equalizes at the elbow * Radiocapitellar articular accounts for as much as 60% of load transfer across the elbow *  

Answer 64

ANSWER: A 2019 * a) Flexor pronator (2019) * No obvious radial head # - don’t need to go lateral (eliminates d and b) * No reason to go anterior * Leaves FP approach * Muscle-splitting approach is less traumatic to the flexor-pronator muscle mass, and it could decrease operative time and lessen immediate morbidity after surgery (compared to lifting off tendon from medial epicondyle) * Muscle-split through the common flexor bundle extends from the medial humeral epicondyle to a point distal to the tubercle of the ulna such that repair or reconstruction can be performed on the ulnar collateral ligament. * Technique * Standard posterior incision raising large fasciocutaneous flap * Site of muscle-split is through the posterior 1/3 of the common flexor bundle within the most anterior fibers of FCU * Principle – split muscle in safe zone between median and ulnar nerve innervated muscles * This is the raphe between the FCU and palmaris longus muscles superficially and the FCU and FDS muscles slightly deeper. * This raphe is more easily identified in the distal portion of the incision because proximally the muscles have a coalesced tendinous origin. * After making the fascial incision extending from the medial humeral epicondyle to a point overlying the suspected sublime tubercle (approximately 3 to 4 cm distally), the muscle is bluntly split down to the level of the UCL. * The muscle-split can safely be extended 1 cm distal to the UCL’s insertion on the sublime tubercle of ulna * This takes you right down onto UCL and also can repair coronoid fractures (King) * Don’t need to transpose ulnar nerve – but on exam always do this

Answer 65

ANSWER: A 2019 * Spring Theory * Column theory * lateral (mobile) column  * comprises scaphoid, trapezoid and trapezium * scaphoid is center of motion and function is mobile * central (flexion-extension) column * comprises lunate, capitate and hamate * luno-capitate articulation is center of motion  * motion is flexion/extension * medial (rotation) column * comprises triquetrum and distal carpal row  * motion is rotation * Oval ring theory * The oval-ring theory functionally depicts the carpus as a transverse ring formed by proximal and distal rows and joined by two physiologic links, one radial and the other ulnar. * The radial link is the mobile scaphotrapezial joint, and the ulnar link is the rotatory triquetrohamate joint. * (Rows concept) * comprises proximal and distal rows  * scaphoid is a bridge between rows * motion occurs within and between rows * Linked theory * three links in a chain composed of radius, lunate and capitate  * head of capitate acts as center of rotation * proximal row (lunate) acts as a unit and is an intercalated segment with no direct tendon attachments * distal row functions as unit * advantage * efficient motion (less motion at each link)  * strong volar ligaments enhance stability * disadvantage * more links increases instability of the chain * scaphoid bridges both carpal rows * resting forces/radial deviation push the scaphoid into flexion and push the triquetrum into extension * ulnar deviation pushes the scaphoid into extension

Answer 66

ANSWER: B and C - not common (tpe 2 PIPJ most common) and needs sx within 7-10 days (lacuna vasorum disrupted)) 2019 * ANSWER: Good outcomes if repair within 6 weeks * Jersey finger = avulsion of FDP from insertion at base of distal phalanx * Ring finger most common – 75% * Type II most common type – retraction to PIPJ * Often delayed dx – sprain * Type I * FDP tendon retracted to the palm * Vascular supply disrupted * Prompt repair recommended – 7-10 days\*\*\* * These injuries have a worse prognosis if not diagnosed and treated within 7–10 days as the tendon contracts and becomes less viable.

Answer 67

ANSWER: B 2019 * Dorsal blocking splint * Type 1 - \<30% articular surface * Closed reduction + splinting * Dorsal blocking splint

Answer 68

ANSWER: B 2019 * Blatts capsulodesis (scapholunate instability) * Adams procedure * Anatomic reconstruction of distal radioulnar ligaments * Ulnar shortening osteotomy * Resection arthroplasty * Matched resection * Darrach procedure (ulnar head resection) * reserved for low-demand, elderly patients * an unstable, painful proximal ulna stump may result * TFCC repair * Stabilizes DRUJ * Blatts capsulodesis --\> for scapholunate instability

Answer 69

ANSWER: C) FCU TFCC made up of: * dorsal and volar radioulnar ligaments  * deep ligaments known as ligamentum subcruentum * central articular disc * meniscus homolog * ulnar collateral ligament * ECU subsheath  * origin of ulnolunate and ulnotriquetral ligaments

Answer 70

ANSWER: C 2019 * Increased contact pressures * The pressure on the radiocapitellar joint was significantly increased after 2.5 mm of lengthening. * Overstuffing can lead to loss of extension – not pro/sup * Inc radial head height = dec ulnar variance

Answer 71

ANSWER: B 2019 * Superior glenosphere tilt 15-20 degrees * Humeral lengthening – soft tissue tension * A 10° inferior tilt of the glenoid component in reverse shoulder arthroplasty is associated with a reduced risk of dislocation when compared to neutral tilt. * Factors that contribute to postoperative instability include soft-tissue tension, glenosphere diameter, constraint on the humeral socket, mechanical impingement (GT, scapular spine, coracoid process), bony deficiency, erroneous version of the prosthesis (ie, rotational position on the glenoid, NSA on humerus, version), and axillary nerve/deltoid dysfunction. * Treatment – increase lateral glenosphere offset, adjust NSA on humerus, adjust version, increase thickness of humeral PE, inferiorize glenoid, offset humeral component, remove impinging soft tissue (usually inferior glenoid)

Answer 72

ANSWER: C 2019 * Prob don’t expect osteophytes 3 months after * Loss of joint volume = impingement of ulno-humeral on capsule (usually only affects one plane, so pro-sup can be good) * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5296847/?report=printable * JAAOS – Open surgical release for contractures of the elbow 2015 * Extension loss is better tolerated than flexion loss. * Loss of elbow flexion past 110 exceeds the ability of positional adaptation of the neck/wrist/shoulder = inability to button collar, shave, place earings * If flexion of elbow is \<100°, it requires the release of posterior band of medial collateral ligament (MCL) of elbow * A stiff elbow is usually defined as having less than 30 in extension or flexion of less than 130. Most activities of daily living are possible if the elbow has a range of motion of 100 (30–130 of flexion, Morreys “arc of motion”)….functional is 50-50 pro-sup * Aside from an elevation of the number and activation of myofibroblasts in the contracted capsule they showed that TGF-ß1 and PDGF induced a cell proliferation of MFs and increased the contraction of extracellular matrices (ECM). (Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction) * JAAOS 2002 – Posttraumatic elbow stiffness: Evaluation and management * Deficits in flexion extension are most often caused by ulnohumeral joint pathology. Unless there is HO or complete ankylosing, WILL USUALLY ONLY EXPERIENCE LOSS IN ONE FUNCTIONAL ARC , flex-ext or pro-sup * Soft tissue constraint has soft end point vs hard end point (bony impingement). * DISPLACED CORONOID FRAGMENTS OFTEN MAY BLOCK FLEXION.

Answer 73

ANSWER: D (poor question...it does have DIP pathology since tenotomize terminal extensor at dorsal DIP) 2019 * https://www.orthobullets.com/hand/6012/boutonniere-deformity * pathoanatomic sequence includes * rupture of central slip * causes the extrinsic extension mechanism from the EDC to be lost * prevents extension at the PIP joint * attenuation of triangular ligament * causes intrinsic muscles of the hand (lumbricals) to act as flexors at the PIP joint * lumbricals also extend the DIP joint without an opposing or balancing force * palmar migration of collateral bands and lateral bands * the lumbricals' pull becomes unopposed, pulling through the base of the distal phalanx and volar to the PIP * causes PIP flexion and DIP extension

Answer 74

ANSWER: B 2019 * 2016 A Meta-analysis of Single-Incision Versus Double-Incision Surgical Technique * Outdated since recent Grewal UWO paper says no difference in HO, just showed that single incision = more LABCN palsy * 10% better flexion strength in double incision * Single versus double incision technique for the repair of acute distal biceps tendon ruptures – 2012 Grewal et al.

Answer 75

ANSWER: B 2019 * https://www.orthobullets.com/hand/6050/kienbocks-disease * Pathophysiology * thought to be caused by multiple factors * biomechanical factors * ulnar negative variance * leads to increased radial-lunate contact stress * decreased radial inclination * repetitive trauma * anatomic factors * geometry of lunate * vascular supply to lunate * patterns of arterial blood supply have differential incidences of AVN * disruption of venous outflow leading to increased intraosseous pressure * Blood supply to capitate is also poor and may lead to AVN.

Answer 76

ANSWER: C 2019 * Maudsley test – resisted middle finger extension selectively recruits ECRB – tests lateral epicondylitis * Regan and Lapner31 performed a prospective evaluation of the prone push-up test, the chair push-up test, and the lateral pivot shift test; the prone and chair push-up tests demonstrated a higher diagnostic sensitivity compared with the lateral pivot shift test. For the prone and chair push-up tests, they reported 87.5% sensitivity for each test, with a combined sensitivity of 100%, compared with 37.5% for the lateral pivot shift test. * Milking test - The test is positive if the patient experiences a subjective feeling of apprehension and instability along with medial elbow pain. The maneuver’s sensitivity has been reported as 87.5%, with a negative predictive value of 100%.

Answer 77

ANSWER: A 2019 * https://www.orthobullets.com/hand/6058/dupuytrens-disease * NOT involved in Dupuytren's disease * Cleland's ligament  * transverse ligament of the palmar aponeurosis * disease only involves longitudinally oriented structures * needle aponeurotomy * indications * mild contractures (at the MCP \> PIP) * medical co-morbidities that preclude surgery * technique * perform in office using 22G or 25G needle * followed by manipulation and night orthosis wear * outcomes * more successful for MCP contracture than PIP * less improvement and higher recurrence rate than surgery (open partial fasciectomy)

Answer 78

ANSWER: B 2019 2015 * JAAOS 2014 - single-row versus double-row rotator cuff repairs * "double-row repair configurations for rotator cuff tears provide a superior biomechanical construct and improved footprint coverage. However, clinical studies are needed to determine whether double-row repairs provides substantially better structural healing or functional outcomes than does single-row repair" * "…justify the increased surgical time and expense of double row repair" * (JBJS 2010) Outcomes of Single Row and Double Row Arthroscopic Rotator Cuff Repair * No difference in clinical outcomes * One study shows double row better for massive tears (\>3cm) compared to small-medium tears * One of my CSES preceptors argued that although double row repairs have not been shown to improve clinical outcomes, they HAVE been shown to be associated with better healing rates (however we know that retears are not necessarily correlated with worse outcomes, so this still might not matter) * Arthroscopy 2011 - Single row repair versus double-row repair of full-thickness rotator cuff tears * Meta-analysis * "Despite the fact that double-row repair shows a significantly higher rate of tendon healing and greater external rotation than does single-row repair, there is no significant improvement in shoulder function, muscle strength, forward flexion, internal rotation, patient satisfaction, or return to work."

Answer 79

ANSWER: B 2019 Dorsal approach for proximal pole #s, Volar approach for waist #s. Question depends on if it was a waste or proximal pole fracture and whether there is osteonecrosis.

Answer 80

ANSWER: C 2019

Answer 81

ANSWER: B One maneuver is the Expanded Baker Modified Exam, where all fingers are held in extension by the examiner except the digit of interest, and then the examinee is asked to flex the PIP and DIP joints independently to test the FDS and the FDP, respectively

Answer 82

ANSWER: B 2019

Answer 83

ANSWER: C 2019 * Dorsal grafts may be better suited for management of scaphoid nonunions that involve the proximal pole and those without significant humpback deformity because adequate correction of the deformity often * requires a separate volar approach and increased soft-tissue dissection. * The use of VBG harvested from the radius and based on the volar carpal artery has also been described. Gras and Mathoulin17 reported on 38 persistent scaphoid nonunions (with no evidence of ON) following previous surgical management with a volar vascularized radius bone graft. * Also Ulnar Bone Grafts - corticocancellous graft is harvested with its periosteum from the medial distal third of the ulna, with the ulnar artery serving as the pedicle. * Thumb metacarpal vascularized bone graft in long-standing scaphoid nonunion--a useful graft via dorsal or palmar approach: a cohort study of 24 patients. * J Hand Surg Am. 2004 Nov;29(6):1089-97.

Answer 84

ANSWER: B 2019 A, C, D described Confirmed with Suh

Answer 85

ANSWER: B 2019 * The quadriga effect is characterized by an active flexion lag in fingers adjacent to a digit with a previously injured or repaired flexor digitorum profundus tendon. * Mechanism * most commonly caused by a functional shortening of the FDP tendon due to * over-advancement of the FDP during tendon repair * \>1 cm advancement associated with quadriga * adhesions * retraction of the tendon * "over-the-top" FDP repair of the distal phalanx after amputation * Pathoanatomy * FDP tendons of long, ring, and little fingers share a common muscle belly * therefore excursion of the combined tendons is equal to the shortest tendon * improper shortening of a tendon during repair results in inability to fully flex adjacent fingers * Symptoms * inability to fully flex the fingers of the hand adjacent to the injured finger * patient may complain of "weak grip" * Physical exam * upon making a fist the fingers adjacent to the injured digit will not reach full flexion * grip strength decreased * Treatment * Release FDP of injured digit

Answer 86

ANSWER: B or C (better is C...newer data, suggest RL stays congruent) * SCAPHOID PRONATES\*\*\* later stages supinates?? * mentioned a couple times in Green’s that the scaphoid definitely Pronates in SL injury * Current status of scapholunate ligament injuries. JAAOS. 2002. * DISI = dorsal intercalated segment instability; radiographic finding defined by increased radiolunate angle (\>15deg dorsal); typically associated with scapholunate ligament disruption, scaphoid fracture/malunion, or distal radius malunion; associated with characteristic pattern of wrist arthrosis (SLAC/SNAC) * Scaphoid flexes due to its attachments to trapezium, trapezoid, and capitate * Triquetrum extends and pulls lunate into extension * Radiolunate joint remains congruent until… end-stage SLAC (type IV) 

Answer 87

ANSWER: B 2019 * Pathophysiology * mechanisms of tear includes * chronic degenerative tear ( intrinsic degeneration is the primary etiology) * usually seen in older patients * usually involves the SIT (supraspinatus, infraspinatus, teres minor) muscles but may extend anteriorly to involve the superior margin of subscapularis tendon in larger tears * chronic impingement * typically starts on the bursal surface or within the tendon * acute avulsion injuries * acute subscapularis tears seen in younger patients following a fall * acute SIT tears seen in patients \> 40 yrs with a shoulder dislocation * full thickness rotator cuff tears need to be repaired in throwing athletes * iatrogenic injuries * due to failure of surgical repair * often seen in repair failure of the subscapularis tendon following open anterior shoulder surgery.

Answer 88

ANSWER: B 2019 A concomitant fracture of the greater tuberosity (GT) is seen in approximately 20% (range: 15.5–25%) of patients presenting with anterior shoulder dislocation 

Answer 89

* ANSWER: A 2019 Supercharged End to Side Transfer (SETS). Originally described for ulnar nerve injuries.  For nerve injuries in which incomplete regeneration is anticipated, a SETS nerve transfer may be useful to augment the regenerating nerve with additional axons and to more quickly reinnervate target muscle. We describe our technique for a SETS nerve transfer of the terminal anterior interosseous nerve (AIN) to the pronator quadratus muscle (PQ) end-to-side to the deep motor fascicle of the ulnar nerve in the distal forearm. In addition, we describe our postoperative therapy regimen for these transfers and an evaluation tool for monitoring progressive muscle reinnervation. Although the AIN-to-ulnar motor group SETS nerve transfer was specifically designed for ulnar nerve injuries * Ulnar nerve to musculocutaneous nerve (Oberlin transfer) – Used commonly in obstetrical brachial palsy injuries a fascicle of the ulnar nerve (supplying the flexor carpi ulnaris muscle) is cut and sutured end-to-end to the biceps nerve in the upper arm

Answer 90

ANSWER: D 2019 * Calcific tendinitis should be differentiated from insertional calcific tendinitis, which is believed to be a degenerative process. Similarly, calcific tendinitis of the rotator cuff tendons is thought to have a different pathophysiologic mechanism than calcific tendinitis at other sites, such as the Achilles or patellar tendons. Although theories of a primarily degenerative etiology have been supported in the past, Uhthoff and Loehr described an active, cell-mediated process that is now widely accepted. Unlike previous theories in which a necrotic degenerative tendon eventually calcified, Uhthoff and Loehr described cartilage metaplasia as a reactionary process in an active biologic environment. They described three main stages of calcification: precalcific, calcific, and postcalcific. The calcific stage was subdivided into three separate phases: formative, resting, and resorptive * * The typical calcific deposit will be approximately 1.5 to 2 cm from the insertion near the tendon’s critical zone, an area of decreased vascularity near the insertion of the superior rotator cuff15. The * calcification may be differentiated from dystrophic calcification, which occurs at the tendon’s insertion.

Answer 91

ANSWER: C 2019 The proximity of the radial sensory nerve to the A1 pulleys of the thumb and the index finger has prompted some authors to recommend that these digits not be treated with percutaneous re- lease. JAAOS.  

Answer 92

ANSWER: C 2019 https://oce-ovid-com.proxy1.lib.uwo.ca/article/00004623-201401010-00012/HTML Acromioclavicular joint injuries often present with associated injuries to the glenohumeral joint, including an increased incidence of superior labrum anterior posterior (SLAP) tears that may warrant further evaluation and treatment.

Answer 93

ANSWER: C 2019 Yes – loss of pronation more with distal # But better answer is mid-shaft or prox loss of supination (more affected, sup barely affected by distal #)

Answer 94

ANSWER: C 2019 Hook plate fixation does not lead to improved general health status compared with Non-op treatment. Presently, there is no definitive evidence that hook plate fixation is superior to Non-op treatment for acute complete AC joint dislocations.

Answer 95

ANSWER: B Looks like newer evidence suggests smaller percentage (16-17%) - ALPSA lesion a risk factor (however, only found in Boileau study) Let's all agree this question sucks 2019 * AK – ALPSA not a risk factor???...Charles: agreed * Historically, 20% to 25% has been accepted as the "critical" cutoff where glenoid bone loss should be addressed in a primary procedure. Few data are available, however, on lesser, "subcritical" amounts of bone loss (below the 20%-25% range) on functional outcomes and failure rates after primary arthroscopic stabilization for shoulder instability......some studies says it is less then this * * The critical size of a defect in the glenoid causing anterior instability of the shoulder after a Bankart repair, under physiological joint loading - 2019 * * This computational study suggests that bone grafting should be undertaken for an anterior osseous defect in the glenoid of more than 16% of its length rather than a solely soft-tissue procedure, in order to optimize stability by restoring the concavity of the glenoid. * ALPSA lesion The overall risk of recurrence in the pres- ence of ALPSA-type lesions (Fig. 4) was 12.6 % compared to a risk of 6.5 % for Bankart’s lesions (p = 0.03) [25, 28] Critical Value of Anterior Glenoid Bone Loss That Leads to Recurrent Glenohumeral Instability After Arthroscopic Bankart Repair Show all authors Sang-Jin Shin, MD, PhD\*, Rag Gyu Kim, MD, Yoon Sang Jeon, MD, ... First Published March 23, 2017 Research Article Find in PubMed https://doi.org/10.1177/0363546517697963 Article information Abstract Background: Generally, a glenoid bone loss greater than 20% to 25% is considered critical for poor surgical outcomes after a soft tissue repair. However, recent studies have suggested that the critical value should be lower. Purpose: To determine the critical value of anterior glenoid bone loss that led to surgical failure in patients with anterior shoulder instability. Study Design: Case-control study; Level of evidence, 3. Methods: The study included 169 patients with anterior glenoid erosion. The percentage of glenoid erosion was calculated as the ratio of the glenoid loss width and the glenoid width to the diameter of the outer-fitting circle based on the inferior portion of the glenoid contour. The critical value of the glenoid bone loss was analyzed by means of receiver operating characteristic (ROC) curve analysis. Patients were divided into 2 groups based on the amount of glenoid bone loss: group A (less than the critical value) and group B (more than the critical value). Patients evaluated their shoulder function as a percentage of their preinjury level using the Single Assessment Numeric Evaluation (SANE) score, and postoperative clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score and Rowe score. Surgical failure was defined as the need for revision surgery or the presence of subjective symptoms of instability. Results: The optimal critical value of glenoid bone loss was 17.3% (area under the curve = 0.82; 95% confidence interval, 0.73-0.91; P \< .001; sensitivity 75%; specificity 86.6%). Group A and B contained 134 and 35 patients, respectively. Shoulder functional scores were significantly lower in group B than in group A (P \< .001). Five patients (3.7%) in group A and 15 (42.9%) in group B had surgical failure (P \< .001). The SANE score was significantly lower in group B (83.8 ± 12.1) than in group A (92.9 ± 4.7, P = .001). Conclusion: An anterior glenoid bone loss of 17.3% or more with respect to the longest anteroposterior glenoid width should be considered as the critical amount of bone loss that may result in recurrent glenohumeral instability after arthroscopic Bankart repair.

Answer 96

ANSWER: C 2019

Answer 97

Answer: A (2017) - Repeat A – True – lateral column or posterior approach B – false - both C – False - both D - False

Answer 98

Answer: A (2017) - Repeat A – yes, \>2.5mm it does B – No - be careful not to "over stuff" the component into the joint as this can lead to loss of extension C - No D – No – it would be ulnar negative * Radiographic incongruity of the medial facet of the ulnohumeral joint was an unreliable indicator of radial head overstuffing. Radiographic gapping of the lateral ulnohumeral facet demonstrated sufficient sensitivity to diagnose radial head overstuffing when compare to the standard length implant radiographs. Visual gapping of the lateral ulnohumeral facet on the cadaver specimens reliably indicated radial head overstuffing and should be a useful anatomic feature to assess intraoperatively.

Answer 99

Answer: A (2017) A – Yes for dislcoations B – put in supination – thumb point away from injury C – no it’s stable D – Never the answer, MCL repair not relevant in this case.

Answer 100

Answer: B 2017 peg design is biomechanically superior to keel design polyethylene-backed components superior to metal-backed components glenoid not large enough to accommodate both metal and PE

Answer 101

Answer: C (2017) A – not enough anterior B – not enough anterior C - yes D – no external The medial plate incorporates 6–8° valgus alignment for the carrying angle. As the articular surface of the two condyles are not in the same coronal plane, the distal end of the medial plate was rotated about 5° internally and bent 30° anteriorly in relation with the humeral shaft. 

Answer 102

Answer: C (2017) – indication for Reverse TSA is that description

Answer 103

Answer: C (2017) Displaced scapula neck fx: * With \> 40 degrees angulation or 1 cm translation need ORIF Except for anterior fractures, there is little evidence supporting operative treatment for glenoid fractures and late instability of the shoulder does not appear to be a significant complication of non-operative treatment of fossa fractures Whereas neck fractures are often managed through a posterior approach. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467683/#:~:text=A%20fracture%20of%20the%20scapular,fall%20on%20the%20outstretched%20arm.&text=Depending%20on%20the%20severity%20of,glenoid%20body%20may%20be%20seen.

Answer 104

Answer: B (2017) Wires pull out. Old question, previous exam. Need to place K wires under triceps or they have high likelihood of pullout.

Answer 105

Answer: D (2017) A – False. Mimimal biceps means it’s still intact B - irreparable C – No. Low palsy D – true.

Answer 106

Answer: D (2017) - althought in a 3-part A probably isnt a good choice either... Function would be good with the hemi but longevity would be a concern...

Answer 107

Answer: A 2017

Answer 108

Answer: B (2017) * Early dislocation after reverse total shoulder arthroplasty. * Chalmers PN1, Rahman Z2, Romeo AA2, Nicholson GP2. * Early dislocations of the RTSA prosthesis were uncommon. The most common associated factors were a BMI \>30 kg/m(2), male gender, subscapularis deficiency, and previous surgery

Answer 109

Answer: B (2017) \>5 mm of displacement in the general population or \>3 mm of dis- placement in active patients who are involved in frequent overhead activity.

Answer 110

Answer C (2017) Still important – but secondary stabilizer vs others are primary

Answer 111

Answer: C (2017) A - false B – false – endobutton \> suture anchor \> transosseus \> interference screw ...this is failure strengths and not necessarily “complication rates” however.... Clay C - true D – false * The greater rates of complications occurred in the single-incision group at 28.3% (222/785) versus 20.9% (104/498) in the double-incision group. * * Both over 20% minor and major from newer papers, but JAAOS 2010 - showed complication \<10% * * Comparing repairs: BEST Endobutton\> suture anchors=\>Trans osseus \>interference

Answer 112

Answer: A (2017) - think this probably still the best answer MRI - “Test of choice” - tough call though, less sens, more specific than MVST (MRI arthrogram is the clear best) * “The moving valgus stress test, described by O’Driscoll et al,11 was found to be 100% sensitive and 75% specific for MCL injuries. The test is performed with the patient upright; the shoulder is placed in 90° of abduction and maximal external rotation with the elbow in maximal flexion. A constant valgus force is applied as the elbow is extended to 30° of flexion. A positive test must reproduce pain over the MCL between 70° and 120° of flexion, which is reminiscent of throwing between the late cocking and the early acceleration phases.” * * Aside: Regan and Lapner reviewed the prone push-up and chair push-up test and demonstrated 87.5% sensitivity in individual test use and 100% sensitivity when both tests are used together * * Magnetic resonance imaging is the test of choice for valgus instability. Nonenhanced MRI is 57% to 79% sensitive and 100% specific for MCL tears, whereas magnetic resonance arthrogram with saline or gadolinium is 97% sensitive and 100% specific.9,23 The AMCL is visualized on coronal T1 images as a thin band of low signal intensity along the medial joint line. Sprains appear as increased signal on T1 and T2 images, whereas complete ruptures demonstrate poor definition, redundancy, or an irregular pattern.

Answer 113

Answer: A (2017) * subjective shoulder instability * failure of the scapula to provide a stable platform for rotation of the glenohumeral joint  * Since the supraspinatus and infraspinatus are dynamic shoulder stabilizers, their weakness and fatigue may result in occult shoulder instability with associated tendinitis and/or bursitis

Answer 114

ANSWER: B 2018 - articles for both entrapment at spinoglenoid notch and suprascapular, but suprascapular more common - b/c tear of supra and infraspinatus causes retraction of and medialization of muscle fibers leading to teathering/sling which creates tension on the SSN

Answer 115

ANSWER: A 2018 -the goal of maintaining the GT is to help with ER and the goal of keeping the LT is to prevent excessive ER which leads to dysfunction

Answer 116

ANSWER: B 2018

Answer 117

ANSWER: D 2018

Answer 118

ANSWER: A 2018 Ulnar most common overall, SRN 2nd Distal AL portal = Radial (SRN) most common purely sensory Proximal AM = Ulnar most common motor/sens http://www.wheelessonline.com/ortho/elbow\_arthroscopy AM portal for MABCN if no other option listed.

Answer 119

ANSWER: B 2018 * Neurotization (nerve transfer) * transfer working but less important motor nerve to a nonfunctioning more important denervated muscle * use extraplexal source of axons * spinal accessory nerve (CN XI) * intercostal nerves * contralateral C7 * hypoglossal nerve (CN XII) * intraplexal nerves * phrenic nerve * portion of median or ulnar nerves * pectoral nerve * Oberlin transfer * ulnar nerve used for upper trunk injury for biceps function * Muscle or tendon transfer * indications * isolated C8-T1 injury in adult (reinervation unlikely due to distance between injury site and hand intrinsic muscles) * priorities of repair/reconstruction * elbow flexion (musculocutaneous nerve) * shoulder stability (suprascapular nerve) * brachial-thoracic pinch (pectoral nerve) * C6-C7 sensory (lateral cord) * wrist extension / finger flexion (lateral and posterior cords) * wrist flexion / finger extension * intrinsic function * technique * gracilis most common free muscle transfer

Answer 120

ANSWER: D 2018

Answer 121

ANSWER: B (Shitty Q) 2018 * \*poorly remembered * JAAOS 2014 – malunion * Subacromial decompression has good results if tuberosity malunion is less than 1.5cm – no reason to do anymore * You should do a hemiarthroplasty and tuberosity osteotomy – possibly best of these three * * JBJS 2003 - Nonprosthetic Management of Proximal Humeral Fractures * Persistent pain due to malunion of the greater tuberosity can occur with as little as 0.5 cm of superior displacement. The symptoms result from subacromial impingement. Such subacromial pain can be treated with subacromial decompression if the displacement is \<1 cm. If the displacement is minimal and the fragment is ≤1 cm in size, excision of the osseous prominence that is causing impingement followed by rotator * ORIF +/- osteotomy, subacromial decompression, and soft tissue technique * Indications * symptomatic malunion following * nonoperative treatment * failed internal fixation * anatomical requirements * adequate bone stock for fixation * preserved articular surface * intact blood supply to humeral head * techniques * humeral head deformities * minor deformity techniques * open/arthroscopic tuberoplasty * +/- acromioplasty * +/- capsular release * +/- bursectomy * severe deformity techniques * varus/valgus osteotomy * +/- rotational osteotomy and lateral plate fixation * treated with corrective osteotomy/fixation if patient is young or active * may be augmented with strut allograft for poor bone stock * greater tuberosity deformities * \<1.5 cm displacement * arthroscopic subacromial decompression +/- rotator cuff repair * \>1.5 cm displacement * open/arthroscopic tuberosity osteotomy +/- subacromial decompression * outcomes * complication rates associated with surgical management of malunions are higher than those associated with acute fractures * shoulder arthroplasty * indications * symptomatic malunion following * nonoperative treatment * failed internal fixation * anatomical requirements * inadequate bone stock for fixation techniques * articular incongruity, destruction or collapse (e.g. osteonecrosis or head-split) * compromised blood supply * chronic dislocation * techniques * hemiarthroplasty * total shoulder arthroplasty * reverse total shoulder arthroplasty

Answer 122

ANSWER: A 2018 * Head should be 0.5-1.5cm above GT - 0.5-0.8 * uncemented prosthesis should be used * prosthesis should be 3.5cm above pec insertion - should be 5-8cm * prosthesis should be in 50deg retroversion – 30 retro

Answer 123

ANSWER: B 2018 * If proximal ulna dorsal angulation is decreased, the patient will lose elbow extension * It is sometimes acceptable to leave an articular gap or bone loss in comminuted olecranon fractures * Some bone loss can be accepted in the bare area. Bone graft should be used to bring the proximal ulna out to length at the posterior cortex. A gap in the nonarticulating bare area will fill with fibrous tissue as long as the posterior cortex is rigidly fixed. To secure the repair, tendon-grasping sutures are placed in the triceps tendon and passed through bone tunnels in the distal fragment. Management of bone insufficiency of the olecranon is based in large part on biomechanical studies on the amount of bone required to maintain stability. An et al17 suggested that up to 50% of the olecranon can be removed without rendering the elbow completely unstable. * A tension band wire construct creates more compression across the joint surface compared to a pre-contoured anatomic plate * The mean compression for plating was 819 N (sd 602, 95% confidence interval (CI)) and for tension band wiring was 77 N (sd 19, 95% CI) (p = 0.039). The mean compression on the articular side of the fracture for plating was 343 N (sd 276, 95% CI) and for tension band wiring was 1 N (sd 2, 95% CI) (p = 0.038). * During simulated movements, the mean compression was reduced in both groups, with tension band wiring at −14 N (sd 7) and for plating −173 N (sd 32). No increase in compression on the articular side was detected in the tension band wiring group. * Pre-contoured plates provide significantly greater compression than tension bands in the treatment of transverse fractures of the olecranon, both over the whole fracture and specifically at the articular side of the fracture. In tension band wiring the overall compression was reduced and articular compression remained negligible during simulated contraction of the triceps, challenging the tension band principle. * After excision of the olecranon fragment, advancement of the triceps to the anterior bony surface will result in better extension strength * JAAOS - Triceps reattachment in this manner creates a smooth, congruent transition from the triceps tendon to the articular cartilage of the olecranon but decreases the moment arm and may result in greater extensor weakness.

Answer 124

ANSWER: B 2018

Answer 125

ANSWER: C 2018 * Most true, can argue A too for standard Grammont style (old) prosthesis that previously had non-lateralized glenospheres and neck shaft angle 155. * JAAOS 2019 – Scapular Notching in rTSA * Systematic review 2000 rTSA = Neck shaft 155 sig more scapular notching then 135 * -scapular notching is decreased by inferior translation and lateralization and decreased neck shaft angel (120-135 degrees) and glenosphere \>42 * -Articles: Athwal et al 2014. Does bony increased-offset reverse shoulder arthroplasty decrease scapular notching? * -Athwal et al 2015 JSES

Answer 126

ANSWER: C 2019 * Heterotopic bone was identified on the radiographs of forty-eight elbows (37%). * More severe heterotopic ossification was encountered in patients presenting with an associated distal humeral fracture, terrible triad injury, transolecranon fracture-dislocation, or Monteggia fracture-dislocation. Patients with an open injury, instability, severe chest trauma, or delay in definitive surgical treatment had a higher prevalence of heterotopic ossification. PIN palsy – 10%

Upper Limb (2008-2019) Flashcards

(150 cards)