Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 PDF

SHOULDER AND ELBOW SELF- SCORED SELF-ASSESSMENT EXAMINATION AAOS 2017 Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei CLINICAL SITUATION FOR QUESTIONS 1 THROUGH 4 A 55-year-old man falls on his outstretched arm and sustains the injury sho...

SHOULDER AND ELBOW SELF- SCORED SELF-ASSESSMENT EXAMINATION AAOS 2017 Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei CLINICAL SITUATION FOR QUESTIONS 1 THROUGH 4 A 55-year-old man falls on his outstretched arm and sustains the injury shown in the 3-dimensional CT scans in Figures 1a and 1b. Question 1 of 100 Which ligamentous structure attaches to the fracture fragment? 1- Lateral ulnar collateral ligament 2- Radial collateral ligament 3- Posterior medial collateral ligament (MCL) 4- Anterior MCL PREFERRED RESPONSE: 4- Anterior MCL Question 2 of 100 The bony landmark is known as the 1- crista supinatoris. 2- sublime tubercle. 3- radial notch. 4- coronoid. PREFERRED RESPONSE: 2- sublime tubercle. Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Question 3 of 100 The critical weight-bearing portion of the elbow joint that is damaged in this fracture is the 1- anteromedial coronoid facet. 2- posteromedial olecranon facet. 3- coronoid. 4- radial notch. PREFERRED RESPONSE: 1- anteromedial coronoid facet. Question 4 of 100 Treatment of this fracture should consist of 1- closed reduction, limited immobilization (1-2 weeks), and early functional rehabilitation. 2- limited immobilization in a long-arm cast (4 weeks) and early functional rehabilitation. 3- open reduction and internal fixation. 4- open reduction, capsular repair, and suture fixation of the bony fragment and ligament. PREFERRED RESPONSE: 3- open reduction and internal fixation. DISCUSSION Varus posteromedial rotatory instability is a complex injury pattern that starts with varus stress resulting in a fracture of the anteromedial coronoid. The anterior MCL attaches to the sublime tubercle, which is part of the anteromedial coronoid facet. The posterior MCL attaches to the posterior medial aspect of the ulna. The radial collateral and lateral ulnar collateral attach to the ulna at the crista supinatoris. The bony landmark is the sublime tubercle; as noted above, the crista supinatoris is lateral on the ulna. The radial notch is also lateral and is the articulation between the proximal ulna and proximal radius. The anteromedial coronoid facet is part of the coronoid, which extends more lateral and anterior than the anteromedial facet. The anteromedial facet represents the critical weight-bearing portion of the ulnohumeral joint. Damage to this structure causes posteromedial subluxation that often results in severe progressive arthritis. The coronoid is the larger structure of which the anteromedial coronoid facet is a portion. The posteromedial coronoid facet does not appear to be critical in weight bearing. The radial notch is not associated with increased stress with weight bearing. The treatment of displaced fractures of this structure is open reduction and internal fixation utilizing buttress plating. Closed treatment is acceptable only for nondisplaced fractures with appropriate radiographic follow-up. Suture fixation is not advocated because of inadequate strength. RECOMMENDED READINGS Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei  Pollock JW, Brownhill J, Ferreira L, McDonald CP, Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. J Bone Joint Surg Am. 2009 Jun;91(6):1448-58. doi: 10.2106/JBJS.H.00222.  Sanchez-Sotelo J, O'Driscoll SW, Morrey BF. Anteromedial fracture of the coronoid process of the ulna. J Shoulder Elbow Surg. 2006 Sep-Oct;15(5):e5-8. Epub 2006 Jul 26. Erratum in: J Shoulder Elbow Surg. 2007 Jan-Feb;16(1):127. PubMed PMID: 16979044. Question 5 of 100 Figures 5a through 5d are the radiographs of a 55-year-old healthy woman who fell down a flight of steps while sleepwalking. When the surgeon replace the radial head, the elbow dislocates posteriorly at 60 degrees of flexion as it is brought out from full flexion. What is the best next step? 1- Only repair the lateral collateral ligament (LCL) 2- Do nothing further and place the elbow in 90 degrees of flexion 3- Repair the posterior band of the medial collateral ligament (MCL) 4- Repair the coronoid and reassess for stability PREFERRED RESPONSE: 4- Repair the coronoid and reassess for stability DISCUSSION Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei The coronoid is important for elbow stability because it moves into extension. Repairing the LCL alone after radial head replacement in “terrible triad” injuries may suffice if there is a type 1 coronoid fracture or an anterior capsular avulsion. For more extensive coronoid injuries, live dynamic examination of stability is needed to determine whether repair of the coronoid is needed. For this patient, doing nothing further will lead to immediate postsurgical instability, and repairing the LCL complex alone will not lead to stability. The posterior band of the MCL will not add to stability. The next step to attain stability is to repair the coronoid and reexamine the elbow for stability. RECOMMENDED READINGS  Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Clin Orthop Relat Res. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. PubMed PMID: 24474322View Abstract at PubMed  Reichel LM, Milam GS, Hillin CD, Reitman CA. Osteology of the coronoid process with clinical correlation to coronoid fractures in terrible triad injuries. J Shoulder Elbow Surg. 2013 Mar;22(3):323- 8. doi: 10.1016/j.jse.2012.10.038. Epub 2013 Jan 16. View Abstract at PubMed  Dodds SD, Fishler T. Terrible triad of the elbow. Orthop Clin North Am. 2013 Jan;44(1):47-58. doi: 10.1016/j.ocl.2012.08.006. PubMed PMID: 23174325.View Abstract at PubMed Question 6 of 100 A 70-year-old man has a 1-year history of progressive right shoulder pain, motion loss, and weakness associated with rotator cuff arthropathy. He has failed nonsurgical treatment. During the informed consent process, the patient is counseled regarding his treatment options, and the surgeon recommends that he undergo a right reverse total shoulder arthroplasty (rTSA). The patient must be informed about the complications associated with this type of procedure, the most common of which is 1- infection. 2- prosthetic joint instability. 3- neurologic injury. 4- scapular notching. PREFERRED RESPONSE: 4- scapular notching. DISCUSSION rTSA originally was used to address rotator cuff arthropathy. Current indications have expanded to include massive rotator cuff tears without arthritis, failed shoulder arthroplasty, 3- and 4-part proximal humerus fractures, and glenohumeral arthrosis associated with severe/uncorrectable glenoid retroversion. rTSA volume has increased, leading to identification of problems specific to the procedure. Some of the common complications include neurologic injury, periprosthetic fracture, hematoma, infection, scapular notching, prosthetic joint instability, baseplate failure, and acromial fracture. A meta-analysis performed by Bohsali and associates involving rTSA Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei demonstrated these complications in decreasing order of frequency: scapular notching, hematoma formation, glenoid dissociation such as baseplate failure or aseptic loosening, glenohumeral dislocation, acromial and/or scapular spine fracture, infection, loosening or dissociation of the humeral component, and nerve injury. RECOMMENDED READINGS  Cheung E, Willis M, Walker M, Clark R, Frankle MA. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011 Jul;19(7):439-49. Review. View Abstract at PubMed  Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006 Oct;88(10):2279-92. Review. PubMed PMID: 17015609. View Abstract at PubMed Question 7 of 100 A 24-year-old right-hand-dominant professional baseball pitcher has valgus extension overload (VEO) syndrome of the right elbow, as seen in Figure 7. Which letter in the figure corresponds to the typical area of osteophyte formation in this condition? 1- A 2- B 3- C 4- D PREFERRED RESPONSE: 2- B DISCUSSION VEO most commonly is seen in throwers for whom valgus stress across the elbow causes impingement of the posteromedial olecranon tip against the medial wall of the olecranon fossa. With repeated impingement, a bony osteophyte may grow on the olecranon at the site of impingement in this posteromedial region of the olecranon. Bony growth within the olecranon Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei fossa also has been seen. The distinction between this condition and ulnar collateral ligament injury is difficult to make, but VEO often can be distinguished from UCL injury by determining the exact location of pain a patient experiences. With VEO, the pain typically occurs with direct palpation of the posterior medial tip of the olecranon. The valgus extension overload provocative test also aids in diagnosis. A supervised physical therapy program and arthroscopic surgical decompression when nonsurgical treatment is unsuccessful are typical treatments for this condition. Locations C and D represent the origin and insertion, respectively, of the elbow medial collateral ligament (MCL) structure, and, although associated MCL pathology can exist in the setting of VEO syndrome, osteophyte formation is not typical in these areas. Location A is the radial head, and although the radiocapitellar joint is a known secondary stabilizer of elbow valgus stress, osteophyte formation in this area is less likely in this clinical scenario. RECOMMENDED READINGS  Reddy AS, Kvitne RS, Yocum LA, Elattrache NS, Glousman RE, Jobe FW. Arthroscopy of the elbow: a long-term clinical review. Arthroscopy. 2000 Sep;16(6):588-94. View Abstract at PubMed  Andrews JR, Craven WM. Lesions of the posterior compartment of the elbow. Clin Sports Med. 1991 Jul;10(3):637-52. Review. PubMed PMID: 1868565.View Abstract at PubMed  Wilson FD, Andrews JR, Blackburn TA, McCluskey G. Valgus extension overload in the pitching elbow. Am J Sports Med. 1983 Mar-Apr;11(2):83-8. View Abstract at PubMed Question 8 of 100 In rotator cuff tear arthropathy with pseudoparalysis, forward elevation of the humerus away from the body is prohibited because of 1- deltoid atony. 2- loss of the glenoid concavity. 3- loss of the humeral head depression of the biceps tendon. 4- loss of compressive force on the humeral head. PREFERRED RESPONSE: 4- loss of compressive force on the humeral head. DISCUSSION The rotator cuff serves as a humeral head compressor that stabilizes the humeral head in the glenoid concavity so that the deltoid can convert a vertical force into abduction and forward elevation. The deltoid functions normally in patients with this condition, so no atony is present. Glenoid concavity can be lost over time, but this is not the primary mechanism for failure of elevation. The biceps tendon does not serve as a humeral head compressor and does not prevent proximal migration of the shoulder when it is present. RECOMMENDED READINGS Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei  Drake GN, O'Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res. 2010 Jun;468(6):1526-33. doi: 10.1007/s11999-009-1188-9. Review. PubMed PMID: 20049573.View Abstract at PubMed  Walker M, Brooks J, Willis M, Frankle M. How reverse shoulder arthroplasty works. Clin Orthop Relat Res. 2011 Sep;469(9):2440-51. doi: 10.1007/s11999-011-1892-0. Review.View Abstract at PubMed CLINICAL SITUATION FOR QUESTIONS 9 AND 10 A 19-year-old, right-hand-dominant collegiate baseball pitcher reports a 4-month history of right shoulder pain after a throwing activity. He localizes the pain primarily to the posterior aspect of his shoulder and describes the type of pain as an aching sensation. He has been involved with strength and conditioning with his team, but denies any specific therapy other than the application of ice after throwing and use of occasional over-the-counter anti-inflammatory drugs, neither of which has provided relief. He denies any specific traumatic event or previous history of shoulder problems. His pitching coach has noted a slight decrease in his throwing velocity during the last 2 months. Question 9 of 100 The patient fails nonsurgical treatment and undergoes shoulder arthroscopy. At the time of surgery, the area marked by the asterisk in Figure 9 is visualized from the posterolateral portal. This anatomic structure impinges on which other structure during late cocking of the throwing phase? 1- Biceps tendon 2- Posterior band of the inferior glenohumeral ligament 3- Hill-Sachs lesion 4- Undersurface of the supraspinatus and infraspinatus tendons PREFERRED RESPONSE: 4- Undersurface of the supraspinatus and infraspinatus tendons Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Question 10 of 100 Which image seen during arthroscopic treatment is most likely associated with this patient’s condition? A b c d 1- Figure 10a 2- Figure 10b 3- Figure 10c 4- Figure 10d PREFERRED RESPONSE: 1- Figure 10a DISCUSSION This patient’s clinical presentation is consistent with internal impingement accompanied by glenohumeral internal rotation deficit (GIRD). Although throwers may have increased external rotation, their overall arc of motion should be the same as on the nonthrowing side. In comparison, patients with GIRD experience a marked decrease in arc of motion, particularly in internal rotation. Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Internal impingement represents a spectrum of findings that can include superior and posterior labral tears, undersurface (articular-sided) tearing of the posterior supraspinatus, posterior glenoid wear, and scar formation of the posterior capsule. Myers and associates demonstrated internal impingement is associated with GIRD, although the latter by itself may be asymptomatic and perhaps a sports-specific adaptation. However, posterior capsular tightness can lead to posterosuperior translation of the humerus during throwing, leading to these injuries. Internal impingement is common among overhead throwing athletes and occurs during the late cocking and early acceleration phases of throwing. Humeral migration during the abducted/externally rotated throwing position results in abutment of the greater tuberosity against the posterosuperior glenoid labrum, which impinges the rotator cuff (Paley and associates). Pain is often posterior, but symptoms can be vague. Patients may have examination findings consistent with rotator cuff weakness and superior labrum anterior to posterior (SLAP)/biceps involvement. Radiograph findings can be negative, although a Bennett lesion involving hypertrophy and mineralization of the posterior capsular injury may be seen (Wright and Paletta). A CT scan may show glenoid retroversion (Crockett and associates), while MR imaging should be reviewed for a possible partial articular-sided rotator cuff tear, SLAP tear, or increased signal in the posterosuperior labrum or greater tuberosity. Treatment of this condition should be the focus on therapy, and most cases can be treated nonsurgically. Stretching aimed at the posterior capsule (ie, sleeper stretch) has been reported as effective (Tyler and associates, Litner and associates). Burkhart and associates also demonstrated posterior capsular stretching can help prevent throwing injuries. Because cuff pathology may be present, physical therapy also should include rotator strengthening, scapular stabilization, and addressing of issues related to throwing mechanics (Drakos and associates). Kibler and associates published a comprehensive rehabilitation guideline. Surgical intervention is reserved for those who fail 6 months of nonsurgical treatment and is directed by intra-articular pathology (debridement vs repair of the rotator cuff and labrum) (Braun and associates). RECOMMENDED READINGS  Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 2003 Apr;19(4):404-20. Review. PubMed PMID: 12671624. View Abstract at PubMed  Braun S, Kokmeyer D, Millett PJ. Shoulder injuries in the throwing athlete. J Bone Joint Surg Am. 2009 Apr;91(4):966-78. doi: 10.2106/JBJS.H.01341. Review. View Abstract at PubMed  Crockett HC, Gross LB, Wilk KE, Schwartz ML, Reed J, O'Mara J, Reilly MT, Dugas JR, Meister K, Lyman S, Andrews JR. Osseous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med. 2002 Jan-Feb;30(1):20-6. View Abstract at PubMed  Drakos MC, Rudzki JR, Allen AA, Potter HG, Altchek DW. Internal impingement of the shoulder in the overhead athlete. J Bone Joint Surg Am. 2009 Nov;91(11):2719-28. doi: 10.2106/JBJS.I.00409. Review. PubMed PMID: 19884449.View Abstract at PubMed  Kibler WB, McMullen J, Uhl T. Shoulder rehabilitation strategies, guidelines, and practice. Orthop Clin North Am. 2001 Jul;32(3):527-38. Review. View Abstract at PubMed  Lintner D, Mayol M, Uzodinma O, Jones R, Labossiere D. Glenohumeral internal rotation deficits in professional pitchers enrolled in an internal rotation stretching program. Am J Sports Med. 2007 Apr;35(4):617-21. Epub 2007 Feb 9. PubMed PMID: 17293473. View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei  Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med. 2006 Mar;34(3):385-91. Epub 2005 Nov 22. PubMed PMID: 16303877. View Abstract at PubMed  Paley KJ, Jobe FW, Pink MM, Kvitne RS, ElAttrache NS. Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff. Arthroscopy. 2000 Jan-Feb;16(1):35-40. PubMed PMID: 10627343. View Abstract at PubMed  Tyler TF, Nicholas SJ, Lee SJ, Mullaney M, McHugh MP. Correction of posterior shoulder tightness is associated with symptom resolution in patients with internal impingement. Am J Sports Med. 2010 Jan;38(1):114-9. doi: 10.1177/0363546509346050. Epub 2009 Dec 4. View Abstract at PubMed  Wright RW, Paletta GA Jr. Prevalence of the Bennett lesion of the shoulder in major league pitchers. Am J Sports Med. 2004 Jan-Feb;32(1):121-4. PubMed PMID: 14754734. View Abstract at PubMed Question 11 of 100 Which organism is most likely responsible for a periprosthetic shoulder infection? 1- A gram-positive aerotolerant anaerobic Bacillus 2- A gram-negative anaerobic Bacillus 3- Aerobic gram-positive cocci in clusters 4- Aerobic gram-positive cocci in pairs PREFERRED RESPONSE: 1- A gram-positive aerotolerant anaerobic Bacillus DISCUSSION Propionibacterium acnes (P. acnes) has emerged as the most likely cause of infection associated with shoulder arthroplasty. A gram-positive, aerotolerant anaerobic rod that lives in the skin, not on the skin, it is more difficult to diagnose and treat than more conventional organisms. As an anaerobe, it does not create pus, but rather a turbid fluid, and is associated with humeral stem loosening when a clinically significant infection is present. P. acnes remains sensitive to most antibiotics, and, although some resistance to clindamycin has been reported, highly resistant strains have not yet evolved. P. acnes often remains a diagnostic challenge. Conventional tests measuring C-reactive protein, sedimentation rate, Interleukin-6, and white cell counts are not highly accurate. Even aspiration and culture of the affected joint is not reliable. Cultures should be kept at least 2 weeks to avoid false-negative results with slow-growing organisms. Some investigators have advocated diagnostic arthroscopy with biopsy as another diagnostic alternative. Treatment of shoulder replacements infected with P. acnes is evolving. For shoulders associated with low clinical suspicion for infection but an unexpected positive culture result, treatment can be 1-stage reconstruction without an extended course of intravenous antibiotics. Most commonly, an infected shoulder arthroplasty is treated with a 2-stage reconstruction similar to that seen in the setting of hip and knee arthroplasty. Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei RECOMMENDED READINGS  Kelly JD 2nd, Hobgood ER. Positive culture rate in revision shoulder arthroplasty. Clin Orthop Relat Res. 2009 Sep;467(9):2343-8. doi: 10.1007/s11999-009-0875-x. Epub 2009 May 12. PubMed PMID: 19434469. View Abstract at PubMed  Dodson CC, Craig EV, Cordasco FA, Dines DM, Dines JS, Dicarlo E, Brause BD, Warren RF. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg. 2010 Mar;19(2):303-7. doi: 10.1016/j.jse.2009.07.065. Epub 2009 Nov 1. PubMed PMID: 19884021. View Abstract at PubMed  Grosso MJ, Sabesan VJ, Ho JC, Ricchetti ET, Iannotti JP. Reinfection rates after 1-stage revision shoulder arthroplasty for patients with unexpected positive intraoperative cultures. J Shoulder Elbow Surg. 2012 Jun;21(6):754-8. doi: 10.1016/j.jse.2011.08.052. Epub 2012 Feb 3. PubMed PMID: 22305921. View Abstract at PubMed  Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, Jette JL, Warme WJ, Matsen FA 3rd. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am. 2012 Nov 21;94(22):2075-83. doi: 10.2106/JBJS.K.00861.View Abstract at PubMed Question 12 of 100 For humeral shaft fractures, the characteristic most associated with radial nerve palsy is 1- open fracture. 2- distal one-third humeral shaft fracture. 3- proximal one-third humeral shaft fracture. 4- closed, comminuted humeral shaft fracture. PREFERRED RESPONSE: 2- distal one-third humeral shaft fracture. DISCUSSION Open fractures are not associated with a higher incidence of radial nerve palsy than closed fractures. Comminution has not been associated with an increase in radial nerve palsy. Transverse and spiral fractures are associated with a higher incidence of radial nerve palsy than comminuted fractures. Proximal humerus fractures have an incidence of only 1.8%. Distal one-third humeral shaft fractures are associated with the highest incidence of radial nerve palsy at 23.6%. RECOMMENDED READINGS  Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005 Dec;87(12):1647-52. Review. PubMed PMID: 16326879. View Abstract at PubMed  Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am. 2004 Jan;29(1):144-7. PubMed PMID: 14751118. View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei RESPONSES FOR QUESTIONS 13 THROUGH 17 1- Isolated posterior instability with a posterior labral tear 2- Multidirectional instability 3- Anterior shoulder subluxation 4- Thoracic outlet syndrome 5- Superior labrum anterior to posterior (SLAP) tear 6- Proximal humeral physeal injury For each clinical scenario described below, please select the most likely diagnosis listed above. Question 13 of 100 An 18-year-old female collegiate swimmer has a 1-year history of posterior shoulder pain and popping and a bilateral 2-cm sulcus sign. 1- Isolated posterior instability with a posterior labral tear 2- Multidirectional instability 3- Anterior shoulder subluxation 4- Thoracic outlet syndrome 5- Superior labrum anterior to posterior (SLAP) tear 6- Proximal humeral physeal injury PREFERRED RESPONSE: 2- Multidirectional instability Question 14 of 100 A 16-year-old high school football player has anterior shoulder pain after tackling an opponent with his arm in abduction and external rotation. 1- Isolated posterior instability with a posterior labral tear 2- Multidirectional instability 3- Anterior shoulder subluxation 4- Thoracic outlet syndrome 5- Superior labrum anterior to posterior (SLAP) tear 6- Proximal humeral physeal injury PREFERRED RESPONSE: 3- Anterior shoulder subluxation Question 15 of 100 A 21-year-old collegiate baseball player experiences posterior shoulder pain in the lead shoulder while batting. 1- Isolated posterior instability with a posterior labral tear Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei 2- Multidirectional instability 3- Anterior shoulder subluxation 4- Thoracic outlet syndrome 5- Superior labrum anterior to posterior (SLAP) tear 6- Proximal humeral physeal injury PREFERRED RESPONSE: 1- Isolated posterior instability with a posterior labral tear Question 16 of 100 A 23-year-old professional baseball pitcher experiences worsening pain in the throwing shoulder. Examination reveals increased external rotation, decreased internal rotation, and loss of total arc of motion in the throwing arm compared to the opposite side. 1- Isolated posterior instability with a posterior labral tear 2- Multidirectional instability 3- Anterior shoulder subluxation 4- Thoracic outlet syndrome 5- Superior labrum anterior to posterior (SLAP) tear 6- Proximal humeral physeal injury PREFERRED RESPONSE: 5- Superior labrum anterior to posterior (SLAP) tear Question 17 of 100 A 14-year-old Little League pitcher who plays in 2 leagues concurrently has pain in his throwing shoulder while pitching but not at rest. 1- Isolated posterior instability with a posterior labral tear 2- Multidirectional instability 3- Anterior shoulder subluxation 4- Thoracic outlet syndrome 5- Superior labrum anterior to posterior (SLAP) tear 6- Proximal humeral physeal injury PREFERRED RESPONSE: 6- Proximal humeral physeal injury DISCUSSION Multidirectional shoulder instability can be diagnosed by demonstrating instability in at least 2 planes. The sulcus sign is often present with a prominent depression below the acromion when traction is applied to the arm. The mechanism of anterior shoulder dislocation or subluxation is most commonly a combination of abduction, external rotation, and a posteriorly directed force applied to the arm. Among baseball players, the lead shoulder is susceptible to posterior capsulolabral lesions termed “batter’s shoulder.” SLAP tears are common among overhead Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei athletes and can cause symptoms similar to impingement as well as a glenohumeral internal rotation deficit, which may predispose players to labral tears. Little League shoulder is an overuse injury typically seen in baseball pitchers who are around 14 years of age. It is an osteochondrosis of the proximal humeral epiphysis attributable to overuse from throwing. RECOMMENDED READINGS  Kang RW, Mahony GT, Harris TC, Dines JS. Posterior instability caused by batter's shoulder. Clin Sports Med. 2013 Oct;32(4):797-802. doi: 10.1016/j.csm.2013.07.012. Epub 2013 Aug 22. Review. PubMed PMID: 24079435. View Abstract at PubMed  Carson WG Jr, Gasser SI. Little Leaguer's shoulder. A report of 23 cases. Am J Sports Med. 1998 Jul- Aug;26(4):575-80. PubMed PMID: 9689382. View Abstract at PubMed  Ren H, Bicknell RT. From the unstable painful shoulder to multidirectional instability in the young athlete. Clin Sports Med. 2013 Oct;32(4):815-23. doi: 10.1016/j.csm.2013.07.014. Review. PubMed PMID: 24079437. View Abstract at PubMed  Werner BC, Brockmeier SF, Miller MD. Etiology, Diagnosis, and Management of Failed SLAP Repair. J Am Acad Orthop Surg. 2014 Sep;22(9):554-565. Review. View Abstract at PubMed Question 18 of 100 A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications? 1- Inflammatory elbow arthritis 2- A presurgical flexion-extension elbow arc of approximately 50 degrees 3- Retained distal humerus hardware on presurgical radiographs 4- Evidence of presurgical elbow instability PREFERRED RESPONSE: 4- Evidence of presurgical elbow instability DISCUSSION End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to the concerns about implant longevity. The soft-tissue interposition arthroplasty does not necessitate the same activity and weight restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Mayo Elbow Performance Score in addition to improvement in the flexion-extension arc from 51 degrees to 97 degrees after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability upon examination; retained hardware from prior surgery was not deemed a contraindication. RECOMMENDED READINGS  Larson AN, Morrey BF. Interposition arthroplasty with an Achilles tendon allograft as a salvage procedure for the elbow. J Bone Joint Surg Am. 2008 Dec;90(12):2714-23. doi: 10.2106/JBJS.G.00768. PubMed PMID: 19047718.View Abstract at PubMed  Nolla J, Ring D, Lozano-Calderon S, Jupiter JB. Interposition arthroplasty of the elbow with hinged external fixation for post-traumatic arthritis. J Shoulder Elbow Surg. 2008 May-Jun;17(3):459-64. doi: 10.1016/j.jse.2007.11.008. Epub 2008 Mar 14. PubMed PMID: 18342545. View Abstract at PubMed Question 19 of 100 Left shoulder MR imaging results are shown in Figure 19 for a 22-year-old, right-hand-dominant collegiate athlete who reports a 6-month history of weakness in his right arm that first was noticed during weight training. He reports the weakness seems worse now than several months ago. He denies any specific traumatic event, has altered his weight-lifting activities, and has tried over-the- counter ibuprofen without experiencing any benefit. Upon examination of the bilateral upper extremities, there is no appreciable deformity or atrophy. He demonstrates full active shoulder range of motion, and there is no weakness with abduction in the plane of the scapula. Belly press test findings are normal, but there is weakness in external rotation with the arm in adduction. He does not demonstrate anterior apprehension, and there is no instability with load and shift testing. He has normal sensation and pulses to the upper extremity. A standard radiographic shoulder series yields unremarkable results. What is the best surgical option? 1- Arthroscopic labral debridement and biceps tenodesis 2- Shoulder arthroscopy with undersurface cuff debridement and acromioplasty 3- Cyst decompression at the spinoglenoid notch with possible labral repair 4- Cyst decompression at the suprascapular notch with possible labral repair Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei PREFERRED RESPONSE: 3- Cyst decompression at the spinoglenoid notch with possible labral repair DISCUSSION This patient’s clinical and MR imaging findings are consistent with a posterior paralabral cyst with compression of the suprascapular nerve, specifically at the spinoglenoid notch. Compression of the suprascapular nerve can occur at either the suprascapular or spinoglenoid notch. Compression of the nerve at the suprascapular notch affects innervation to both the supraspinatus and infraspinatus muscles, resulting in weakness in both shoulder abduction and external rotation. However, compression at the spinoglenoid notch only affects innervation to the infraspinatus muscle, resulting in isolated weakness in external rotation. Compression at the spinoglenoid notch often is seen in overhead athletes, and studies have shown associated posterior labral tears (Piatt and associates). Several studies have addressed nonsurgical and surgical treatment options. The treatment decision should focus on the underlying cause (Martin and associates)—in this patient, the cyst. Nonsurgical treatment in the presence of a known lesion has been associated with a higher failure rate than addressing the lesion, which can result in functional improvement (Chen and associates, Cummins and associates). The best response in this scenario is decompression of the cyst at the spinoglenoid notch with possible labral repair. RECOMMENDED READINGS  Piasecki DP, Romeo AA, Bach BR Jr, Nicholson GP. Suprascapular neuropathy. J Am Acad Orthop Surg. 2009 Nov;17(11):665-76. Review. PubMed PMID: 19880677.View Abstract at PubMed  Piatt BE, Hawkins RJ, Fritz RC, Ho CP, Wolf E, Schickendantz M. Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg. 2002 Nov-Dec;11(6):600-4. PubMed PMID: 12469086.View Abstract at PubMed  Martin SD, Warren RF, Martin TL, Kennedy K, O'Brien SJ, Wickiewicz TL. Suprascapular neuropathy. Results of non-operative treatment. J Bone Joint Surg Am. 1997 Aug;79(8):1159-65. PubMed PMID: 9278075.View Abstract at PubMed  Chen AL, Ong BC, Rose DJ. Arthroscopic management of spinoglenoid cysts associated with SLAP lesions and suprascapular neuropathy. Arthroscopy. 2003 Jul-Aug;19(6):E15-21. PubMed PMID: 12861219. View Abstract at PubMed  Cummins CA, Messer TM, Nuber GW. Suprascapular nerve entrapment. J Bone Joint Surg Am. 2000 Mar;82(3):415-24. Review. PubMed PMID: 10724234.View Abstract at PubMed Question 20 of 100 A 65-year-old patient undergoes revision total shoulder arthroplasty. Intraoperative culture results held for 5 days are negative. Five days after surgery, this afebrile patient experiences increasing pain, modest redness, and decreased motion. His postsurgical erythrocyte sedimentation rate is 25 mm/h (reference range, 0-20 mm/h), and his white blood cell level is normal. What is the best next step? Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei 1- Additional imaging 2- Anti-inflammatory medications 3- Physical therapy 4- Ask microbiology to hold the intraoperative cultures for 2 weeks PREFERRED RESPONSE: 4- Ask microbiology to hold the intraoperative cultures for 2 weeks DISCUSSION Propionibacterium acnes is increasingly recognized as a pathogen in shoulder surgery of all types and a cause of postsurgical shoulder pain. Its presentation often is characterized by pain and only minimally elevated laboratory study results and low-grade clinical findings. Cultures should be held for 2 weeks to identify this organism. RECOMMENDED READINGS  Hudek R, Sommer F, Kerwat M, Abdelkawi AF, Loos F, Gohlke F. Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue? J Shoulder Elbow Surg. 2014 Dec;23(12):1763-71. doi: 10.1016/j.jse.2014.05.024. Epub 2014 Aug 29. PubMed PMID: 25179369. View Abstract at PubMed  Matsen FA 3rd, Butler-Wu S, Carofino BC, Jette JL, Bertelsen A, Bumgarner R. Origin of propionibacterium in surgical wounds and evidence-based approach for culturing propionibacterium from surgical sites. J Bone Joint Surg Am. 2013 Dec 4;95(23):e1811-7. doi: 10.2106/JBJS.L.01733. PubMed PMID: 24306704. View Abstract at PubMed  Sethi PM, Sabetta JR, Stuek SJ, Horine SV, Vadasdi KB, Greene RT, Cunningham JG, Miller SR. Presence of Propionibacterium acnes in primary shoulder arthroscopy: results of aspiration and tissue cultures. J Shoulder Elbow Surg. 2015 May;24(5):796-803. doi: 10.1016/j.jse.2014.09.042. Epub 2014 Dec 4. PubMed PMID: 25483906. View Abstract at PubMed CLINICAL SITUATION FOR QUESTIONS 21 AND 22 Figures 21a through 21c are the radiographs of a 45-year-old man following acute trauma. Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Question 21 of 100 Which radiographic finding indicates likely radial head replacement? 1- 2 or fewer fragments of the radial head 2- Age younger than 21 years 3- Wrist pain and asymmetry of the ipsilateral distal radioulnar joint 4- Anteromedial coronoid comminution PREFERRED RESPONSE: 3- Wrist pain and asymmetry of the ipsilateral distal radioulnar joint Question 22 of 100 Following radial head replacement, the elbow exhibits persistent laxity to valgus stress in extension. What is the best next step to regain stability? 1- Posterior capsular repair 2- Anterior capsular repair 3- Fixation of the type I coronoid fracture 4- Repair of the medial collateral ligament (MCL) PREFERRED RESPONSE: 4- Repair of the medial collateral ligament (MCL) DISCUSSION Longitudinal forearm instability is an indication for radial head replacement to prevent proximal migration of the radial shaft. Radial head replacement is indicated in radial head fractures involving 3 or more fragments. Younger age is not a contraindication or indication for radial head replacement. Anteromedial coronoid facet fractures usually are associated with a posteromedial rotatory mechanism that does not increase or decrease risk for radial head fractures necessitating replacement. Following restoration of the radial head, a lateral collateral ligament repair would be the next step to restore stability if necessary. MCL repair would restore medial stability if stability persisted following restoration of posterolateral laxity. Repair of type I coronoid fractures does not substantially affect stability. Application of a hinged external fixator can restore stability in severe cases but is usually reserved for refractory instability after ligament repair has been performed and instability persists. Anterior and posterior capsular repair do not significantly affect instability. MCL repair is generally the next step to obtain stability, with application of a hinged external fixator as a last step to maintain joint congruity. RECOMMENDED READINGS  Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop Relat Res. 1991 Apr;(265):187-95. View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei  Pollock JW, Brownhill J, Ferreira L, McDonald CP, Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. J Bone Joint Surg Am. 2009 Jun;91(6):1448-58. doi: 10.2106/JBJS.H.00222. PubMed PMID: 19487524. View Abstract at PubMed  Beingessner DM, Stacpoole RA, Dunning CE, Johnson JA, King GJ. The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair. J Shoulder Elbow Surg. 2007 Mar-Apr;16(2):213-7.View Abstract at PubMed  Bryce CD, Armstrong AD. Anatomy and biomechanics of the elbow. Orthop Clin North Am. 2008 Apr;39(2):141-54, v. doi: 10.1016/j.ocl.2007.12.001. Review. View Abstract at PubMed Question 23 of 100 A 45-year-old woman has a 3-month history of left shoulder pain. Her symptoms have failed to improve despite receiving an injection and participating in 2 months of physical therapy focusing on rotator cuff strengthening. An examination reveals no weakness, atrophy, or scapular winging. She has anterior and posterior shoulder tenderness and full symmetric forward elevation and abduction, but internal rotation on the left is decreased. She has pain with internal rotation in 90 degrees of forward elevation and an increased distance between the antecubital fossa and coracoid process with cross-chest adduction when compared to the contralateral side. Radiographs reveal a type II acromion. What is the most appropriate next step? 1- MR imaging 2- MRI arthrogram 3- Posterior capsular stretching exercises 4- Arthroscopic subacromial decompression and acromioplasty PREFERRED RESPONSE: 3- Posterior capsular stretching exercises DISCUSSION This patient demonstrates symptoms consistent with posterior capsular tightness with loss of internal rotation. This can be evaluated by comparing internal rotation to the contralateral side with the arm in 90 degrees of abduction or by reaching behind the back. Treatment consists of posterior capsular stretching such as the sleeper stretch. MR imaging or MRI arthrogram findings would most likely be unremarkable and not change the initial treatment plan. Arthroscopic surgery would be indicated for failure of nonsurgical treatment, including a dedicated stretching program. Surgery would consist of arthroscopic release of the tight posterior capsule. RECOMMENDED READINGS  Kinsella SD, Thomas SJ, Huffman GR, Kelly JD 4th. The thrower's shoulder. Orthop Clin North Am. 2014 Jul;45(3):387-401. doi: 10.1016/j.ocl.2014.04.003. Review. View Abstract at PubMed  Bach HG, Goldberg BA. Posterior capsular contracture of the shoulder. J Am Acad Orthop Surg. 2006 May;14(5):265-77. Review. PubMed PMID: 16675620.View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Question 24 of 100 A 55-year-old man falls from a ladder and dislocates his nondominant shoulder. He undergoes a sedated reduction in the emergency department without complications. Postreduction radiographs reveal a small Hill-Sachs lesion and no other bony abnormalities. Six weeks after the dislocation, he has persistent pain at rest and forward elevation and external rotation weakness. He has no abnormal sensation. What is the best next step? 1- Physical therapy with electrical stimulation and iontophoresis 2- Corticosteroid injection 3- MR imaging of the shoulder 4- Electromyography (EMG) of the arm PREFERRED RESPONSE: 3- MR imaging of the shoulder DISCUSSION For a patient in his mid 50s who has shoulder instability and persistent weakness, MR imaging is indicated to evaluate rotator cuff integrity. EMG is not indicated because this patient has no evidence of deltoid functional abnormality. Corticosteroid injections and physical therapy modalities do not address the concern about his potential for a rotator cuff tear. RECOMMENDED READINGS  Gombera MM, Sekiya JK. Rotator cuff tear and glenohumeral instability: a systematic review. Clin Orthop Relat Res. 2014 Aug;472(8):2448-56. doi: 10.1007/s11999-013-3290-2. Review. Erratum in: Clin Orthop Relat Res. 2015 Feb;473(2):751. Gomberawalla, M Mustafa View Abstract at PubMed  Paxton ES, Dodson CC, Lazarus MD. Shoulder instability in older patients. Orthop Clin North Am. 2014 Jul;45(3):377-85. doi: 10.1016/j.ocl.2014.04.002. Review. View Abstract at PubMed Question 25 of 100 A right-hand-dominant 45-year-old man sustained an injury to the anterior aspect of his right elbow during sudden elbow flexion while trying to lift a heavy load 3 days ago. He reports the sensation of a sudden, sharp pain at the time of injury, which has since subsided. He has ecchymosis in the anterior and medial elbow regions and has difficulty with resisted forearm supination with the elbow in a flexed position. A diagnosis of an acute distal biceps tendon rupture is made, and, after having a discussion with the patient, surgical treatment is chosen. During surgical reattachment, what is the relationship of the distal biceps tendon within the antecubital fossa to the median nerve and recurrent radial artery before the tendon attaches to the bicipital tuberosity? 1- The tendon travels lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery 2- The tendon travels lateral (radial) to the median nerve and anterior (superficial) to the recurrent radial artery Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei 3- The tendon travels medial (ulnar) to the median nerve and posterior (deep) to the recurrent radial artery 4- The tendon travels medial (ulnar) to the median nerve and anterior (superficial) to the recurrent radial artery PREFERRED RESPONSE: 1- The tendon travels lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery DISCUSSION During surgical repair of a distal biceps tendon rupture, regardless of the surgical approach or technique, an understanding of the regional anatomy is important. The tendon passes distally into the antecubital fossa. The antecubital fossa is defined by the brachioradialis radially and the pronator teres ulnarly. A sheath surrounds the biceps tendon as it passes through the antecubital fossa toward its insertion on the radial tuberosity. The lateral antebrachial cutaneous nerve lies superficially in the subcutaneous tissue of the antecubital fossa. The nerve parallels the brachioradialis. While still superficial, the tendon is contiguous with the lacertus fibrosus that becomes confluent medially with the fascia overlying the flexor-pronator mass. The brachial artery lies just beneath the lacertus fibrosus at the level of the elbow flexion crease. The tendon travels just lateral (radial) to the median nerve within the antecubital fossa and passes posterior (deep) to the recurrent radial artery before it attaches to the radial tuberosity. Full forearm supination allows visualization of the tendinous insertion on the radial tuberosity. RECOMMENDED READINGS  Leslie BM, Ranger H. Biceps tendon and triceps tendon ruptures. In: Baker CL, Plancher KD, eds. Operative treatment of elbow injuries. New York: Springer-Verlag; 2002:110-122.  Eames MH, Bain GI, Fogg QA, van Riet RP. Distal biceps tendon anatomy: a cadaveric study. J Bone Joint Surg Am. 2007 May;89(5):1044-9. PubMed PMID: 17473142. View Abstract at PubMed Question 26 of 100 Figure 26 is the MR image of a 55-year-old man who sustained an acute traumatic injury to his right shoulder and loss of active range of motion. He was initially evaluated by his primary care physician and treated with physical therapy without success. He was referred to an orthopaedist for surgical consultation 8 weeks after sustaining the injury. The orthopaedic surgeon performs a successful arthroscopic repair but notes poor tendon quality at the repair site. The treating surgeon keeps the patient in a sling full time for 6 weeks without formal therapy. One year after surgery, in comparison to early therapy, this rehabilitation program will likely result in 1- no difference in terminal range of motion. 2- a lower functional outcome score. 3- a clinically significant reduction in passive forward flexion and external rotation. 4- a higher retear rate of the rotator cuff repair. Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei PREFERRED RESPONSE: 1- no difference in terminal range of motion. DISCUSSION Historically, orthopaedic surgeons considered early range-of-motion programs following rotator cuff surgery secondary to concerns about potential postsurgical stiffness. Although this may have been a primary open repair concern, arthroscopic surgery appears to substantially decrease this risk. More recently, investigators are reporting similar results in terms of range of motion, retear rate, and functional outcome scores among patients who undergo early and delayed rehabilitation programs. RECOMMENDED READINGS  Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg. 2010 Oct;19(7):1034-9. doi: 10.1016/j.jse.2010.04.006. Epub 2010 Jul 24. View Abstract at PubMed  Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg. 2012 Nov;21(11):1450-5. doi: 10.1016/j.jse.2012.01.025. Epub 2012 May 2. View Abstract at PubMed  Jarrett CD, Schmidt CC. Arthroscopic treatment of rotator cuff disease. J Hand Surg Am. 2011 Sep;36(9):1541-52; quiz 1552. doi: 10.1016/j.jhsa.2011.06.026. Epub 2011 Aug 6. Review. PubMed PMID: 21821368. View Abstract at PubMed  Chan K, MacDermid JC, Hoppe DJ, Ayeni OR, Bhandari M, Foote CJ, Athwal GS. Delayed versus early motion after arthroscopic rotator cuff repair: a meta-analysis. J Shoulder Elbow Surg. 2014 Nov;23(11):1631-9. doi: 10.1016/j.jse.2014.05.021. Epub 2014 Aug 13. View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Question 27 of 100 A 44-year-old right-hand-dominant mechanic has left lateral elbow pain. He was injured at work 6 months ago when he sustained a hyperextension injury to his left arm when a tire fell off of a truck. He experienced immediate left lateral elbow pain and swelling. Initial radiograph findings in the emergency department were normal. He was given a sling, which he continues to use. He tried to do physical therapy, but he stopped after 1 visit because he said it made his pain worse. He denies any numbness or tingling but has not been able to return to work. He was given an injection in the region of the lateral epicondyle 1 month ago, which did not improve his symptoms. Upon examination, he is maximally tender to palpation about 5 cm distal to the lateral epicondyle. Active range of motion is limited by pain. He has lateral elbow pain with resisted wrist extension and resisted middle finger extension. Which test would most likely confirm a diagnosis? 1- MR imaging 2- Electromyography (EMG) 3- Bone scan 4- Lidocaine injection test PREFERRED RESPONSE: 4- Lidocaine injection test DISCUSSION This patient’s symptoms are most consistent with radial tunnel syndrome. This diagnosis should be considered in the differential of lateral elbow pain and can often be confused with lateral epicondylitis. The patient’s symptoms did not improve with a lateral elbow injection, and his pain is located in the region of the radial tunnel. A diagnostic injection can help confirm the diagnosis. MR imaging would be helpful to rule out a ligamentous or tendon injury, which is less likely based upon the history and examination. EMG findings will most likely be normal for patients with radial tunnel syndrome. A bone scan would help to confirm complex regional pain syndrome, which is less likely in this scenario because the patient does not have hyperesthesia, loss of motion, or skin changes. RECOMMENDED READINGS  Naam NH, Nemani S. Radial tunnel syndrome. Orthop Clin North Am. 2012 Oct;43(4):529-36. doi: 10.1016/j.ocl.2012.07.022. Review. PubMed PMID: 23026469.View Abstract at PubMed  Knutsen EJ, Calfee RP, Chen RE, Goldfarb CA, Park KW, Osei DA. Factors associated with failure of nonoperative treatment in lateral epicondylitis. Am J Sports Med. 2015 Sep;43(9):2133-7. doi: 10.1177/0363546515590220. Epub 2015 Jun 29. PubMed PMID: 26122386. View Abstract at PubMed CLINICAL SITUATION FOR QUESTIONS 28 THROUGH 31 Figure 28 is the radiograph of a 78-year-old patient with a painful uncemented hemiarthroplasty of 6 months duration. Complete blood count and erythrocyte sedimentation rate findings are negative, and trauma is not a factor. Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Question 28 of 100 The radiograph shows components that are 1- subluxed. 2- fractured. 3- loose and potentially infected. 4- normal. PREFERRED RESPONSE: 3- loose and potentially infected.. Question 29 of 100 The next step in this patient’s workup should be 1- aspiration. 2- observation. 3- physical therapy. 4- revision to total shoulder arthroplasty. PREFERRED RESPONSE: 1- aspiration. Question 30 of 100 If aspiration findings are negative or equivocal, the diagnosis can be established with 1- arthroscopy. 2- a bone scan. Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei 3- a serum white blood cell level. 4- a C-reactive protein level. PREFERRED RESPONSE: 1- arthroscopy. Question 31 of 100 If the culture results are positive, which treatment will most likely resolve the infection? 1- Arthroscopic debridement 2- Intravenous antibiotics 3- Single-stage revision 4- Double-stage revision PREFERRED RESPONSE: 4- Double-stage revision DISCUSSION Osteolysis of this magnitude is uncommon in the setting of an uncemented hemiarthroplasty. Further workup for infection is indicated, such as aspiration under fluoroscopy or ultrasound. Infection needs to be ruled out before proceeding. Observation and physical therapy are not indicated. Arthroscopy has been shown in several studies to have greater sensitivity and specificity than aspiration and can be especially effective to obtain cultures of slow-growing organisms such as Propionibacterium acnes. Blood tests are unreliable, and a bone scan would not reliably differentiate between loosening and infection. Arthroscopic debridement would not be reliable for treatment. Intravenous antibiotics can be used for suppression, but the best results in terms of resolving the infection would be achieved with 2-stage revision. RECOMMENDED READINGS  Dilisio MF, Miller LR, Warner JJ, Higgins LD. Arthroscopic tissue culture for the evaluation of periprosthetic shoulder infection. J Bone Joint Surg Am. 2014 Dec 3;96(23):1952-8. doi: 10.2106/JBJS.M.01512. PubMed PMID: 25471909. View Abstract at PubMed  Hersch JC, Dines DM. Arthroscopy for failed shoulder arthroplasty. Arthroscopy. 2000 Sep;16(6):606- 12. PubMed PMID: 10976121. View Abstract at PubMed  Foruria AM, Fox TJ, Sperling JW, Cofield RH. Clinical meaning of unexpected positive cultures (UPC) in revision shoulder arthroplasty. J Shoulder Elbow Surg. 2013 May;22(5):620-7. doi: 10.1016/j.jse.2012.07.017. Epub 2012 Sep 13. PubMed PMID: 22981448. View Abstract at PubMed Question 32 of 100 Figures 32a through 32c are the radiograph and CT scans of a 75-year-old smoker with hypertension who sustained a ground-level fall without loss of consciousness with impact to her Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei left upper extremity 1 week ago. She states that she lived independently at home with her husband prior to her fall. What is the most appropriate next step? 1- Hemiarthroplasty 2- Initial sling immobilization with subsequent physical therapy 3- Open reduction and internal fixation 4- Reverse total shoulder arthroplasty (rTSA) PREFERRED RESPONSE: 4- Reverse total shoulder arthroplasty (rTSA) DISCUSSION The radiographs and CT scans indicate a 4-part left proximal humerus fracture with tuberosity comminution. Based upon her preinjury level of activity and current imaging studies, nonsurgical management is not the correct option to restore her ability to perform activities of daily living, including hygiene care. There has been enthusiasm among surgeons regarding the use of the reverse shoulder prosthesis as the primary mode of surgical treatment of certain 3- and 4-part proximal humerus fractures. The main attribute of this implant is its ability to achieve functional shoulder forward flexion and abduction regardless of tuberosity healing, position, and degree of comminution. Nevertheless, repair and union of the greater tuberosity fragment during rTSA demonstrate improved external rotation, clinical outcomes, and patient satisfaction than outcomes achieved after tuberosity resection, nonunion, or resorption. Based upon this patient’s age and imaging findings, an rTSA would provide pain relief and improved function with complication rates similar to those associated with hemiarthroplasty. Open reduction with internal fixation would not be a viable option because of the high probability for a dysvascular head, increased risk for nonunion, and potential for revision surgery, including arthroplasty. Hemiarthroplasty for 4- part proximal humerus fractures remains a viable option for patients younger than 70 years of age with minimal tuberosity comminution and an intact rotator cuff who can comply with a postsurgical rehabilitation program. Most studies indicate significant pain relief with this modality with significant variation in functional outcomes. In this clinical scenario, the patient’s injury may not be best served with hemiarthroplasty because of uncertainty regarding functional outcome. RECOMMENDED READINGS Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei  Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg. 2015 Mar;23(3):190-201. doi: 10.5435/JAAOS-D-13-00190. Epub 2015 Jan 28. Review. View Abstract at PubMed  Bufquin T, Hersan A, Hubert L, Massin P. Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short- term follow-up. J Bone Joint Surg Br. 2007 Apr;89(4):516-20. View Abstract at PubMed  Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am. 2013 Nov 20;95(22):2050-5. doi: 10.2106/JBJS.L.01637. PubMed PMID: 24257664.View Abstract at PubMed  Boyle MJ, Youn SM, Frampton CM, Ball CM. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elbow Surg. 2013 Jan;22(1):32-7. doi: 10.1016/j.jse.2012.03.006. Epub 2012 May 29. View Abstract at PubMed Question 33 of 100 What is the role of the long head of the biceps brachii tendon in providing stability to the humeral head? 1- It provides no stability to the humeral head 2- Its stabilizing function is greatest with the shoulder forward elevated 120 degrees 3- It decreases superior translation of the humeral head only 4- It decreases anterior, inferior, and superior translation of the humeral head PREFERRED RESPONSE: 4- It decreases anterior, inferior, and superior translation of the humeral head DISCUSSION Cadaveric studies have been performed to evaluate the biomechanical role of the long head of the biceps brachii tendon in providing shoulder stability. A study performed by Pagnani and associates assessed the impact of contraction of the long head of the biceps brachii on glenohumeral translation. Sequential 50-N anterior, posterior, superior, and inferior forces and a 22-N joint compressive load were applied to the shoulders. A constant force to the tendon of the long head of the biceps brachii was applied. The shoulders were tested in 7 positions of glenohumeral elevation and rotation. Application of a force to the long head of the biceps brachii resulted in statistically significant decreases in humeral head translation. The influence of the long head of the biceps was more pronounced at middle and lower elevation angles. When the shoulder was placed in 45 degrees of elevation and neutral rotation, application of a 55-N force to the biceps tendon reduced anterior translation by 10.4 mm, inferior translation by 5.3 mm, and superior translation by 1.2 mm. A cadaveric study by Kumar and associates assessed the role of the tendon of the long head of the biceps in the stabilization of the head of the humerus. Upward migration of the humeral head was measured by noting any reduction in the acromiohumeral distance in radiographs of the shoulder. Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei There was a statistically significant decrease in the acromiohumeral interval on tensing the short head of biceps, but there was no significant change in the interval on tensing either the long head or both heads of the biceps brachii. Complete transection of the tendon of the long head while both heads were tensed caused a significant upward migration of the head of the humerus. This study concluded that 1 of the important functions of the long head of the biceps is to stabilize the humeral head in the glenoid during powerful elbow flexion and forearm supination. Additionally, transection of the intra-articular segment of this tendon in surgical procedures of the shoulder may produce instability and dysfunction. RECOMMENDED READINGS  Pagnani MJ, Deng XH, Warren RF, Torzilli PA, O'Brien SJ. Role of the long head of the biceps brachii in glenohumeral stability: a biomechanical study in cadavera. J Shoulder Elbow Surg. 1996 Jul- Aug;5(4):255-62. PubMed PMID: 8872922. View Abstract at PubMed  Kumar VP, Satku K, Balasubramaniam P. The role of the long head of biceps brachii in the stabilization of the head of the humerus. Clin Orthop Relat Res. 1989 Jul;(244):172-5. View Abstract at PubMed Question 34 of 100 An arthroscopic image taken from the posterior portal with the patient in the lateral decubitus position is shown in Figure 34. The most appropriate treatment of this abnormality is 1- anterior labral repair with suture anchors. 2- superior labral repair with suture anchors. 3- biceps tenotomy. 4- no treatment. PREFERRED RESPONSE: 4- no treatment. DISCUSSION Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei The image reveals a cordlike middle glenohumeral ligament known as a Buford complex. This is a normal variant and does not necessitate treatment. The superior labrum and anterior inferior labrum are intact, and repair is not required. The biceps tendon also appears normal, making a biceps tenotomy unnecessary. RECOMMENDED READINGS  Farmer KW, Wright TW. Shoulder arthroscopy: the basics. J Hand Surg Am. 2015 Apr;40(4):817-21. doi: 10.1016/j.jhsa.2015.01.002. Epub 2015 Feb 26. Review. View Abstract at PubMed  Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009 Oct;17(10):627-37. Review. View Abstract at PubMed CLINICAL SITUATION FOR QUESTIONS 35 THROUGH 38 A 43-year-old right-hand-dominant man has acute right distal anterior arm pain and swelling after attempting to move his sofa. Upon examination, you find ecchymosis in the antecubital fossa with moderate swelling. He expresses pain and weakness with resisted supination of the forearm and flexion of the elbow. He is distally neurovascularly intact. Question 35 of 100 The surgeon orders MR imaging to confirm the diagnosis. How should the patient position his arm to increase study sensitivity? 1- Extended elbow, abducted shoulder, and supinated forearm 2- Extended elbow, adducted shoulder, and pronated forearm 3- Flexed elbow, abducted shoulder, and pronated forearm 4- Flexed elbow, abducted shoulder, and supinated forearm PREFERRED RESPONSE: 4- Flexed elbow, abducted shoulder, and supinated forearm Question 36 of 100 If the patient chooses nonsurgical treatment, which functional loss should he anticipate? 1- 10% loss of flexion strength 2- 40% loss of supination strength 3- 60% loss of flexion strength 4- 80% loss of supination strength PREFERRED RESPONSE: 2- 40% loss of supination strength Question 37 of 100 Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei The patient elects surgical intervention. You proceed with an anterior single-incision primary repair. When comparing single- and double-incision approach complication rates, the single- incision approach is associated with 1- a lower risk for forearm synostosis. 2- a higher incidence of lateral antebrachial cutaneous nerve palsy. 3- improved objective outcome scores. 4- stronger isometric forearm supination strength. PREFERRED RESPONSE: 2- a higher incidence of lateral antebrachial cutaneous nerve palsy. Question 38 of 100 If surgical intervention is delayed for 3 months and intraoperatively the surgeon finds that primary repair can be performed but hyperflexion of the elbow to 90 degrees is necessary, what is the likely long-term consequence? 1- 30% loss of elbow flexion strength 2- 60-degree elbow flexion contracture 3- Inability to pronate the forearm past neutral 4- No significant loss of elbow range of motion PREFERRED RESPONSE: 4- No significant loss of elbow range of motion DISCUSSION This patient classically depicts an acute complete distal biceps rupture. This injury typically results from an eccentric load applied to a flexed elbow. This occurs most often among middle-aged men. Often, a clinical examination is adequate to confirm the diagnosis. When needed, standardized MR imaging at the point at which the injured arm is flexed at the elbow and abducted at the shoulder with the forearm in supination can increase sensitivity for diagnosis of a complete tear. Patients who do not undergo surgical repair have an approximate 40% loss of supination strength and 30% loss of elbow flexion strength. Some patients describe persistent painful cramping and difficulty with repetitive activities such as using a screwdriver. Others may be able to modify their activities and tolerate the functional loss. Studies comparing single anterior repair to double-incision posterior repair have reported similar success rates for pain and function. Grewal and associates performed a prospective randomized clinical trial comparing single- vs double-incision distal biceps tendon repairs and reported that both techniques can provide equally successful results. However, the anterior single-incision approach resulted in a statistically significant higher incidence of transient lateral antebrachial nerve palsy (19/47 vs 3/43). Studies have shown that primary repair may be possible for patients with subacute or chronic distal biceps tears. This may obviate the need for an additional interposition allograft reconstruction. Morrey and associates performed primary repair on 19 chronic distal biceps ruptures by hyperflexing the elbow to anatomically reattach the tendon to the biceps tuberosity. Surprisingly, Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei this did not lead to any significant loss of elbow range of motion or flexion contracture. Elbow flexion strength was improved. RECOMMENDED READINGS  Schmidt CC, Jarrett CD, Brown BT. The distal biceps tendon. J Hand Surg Am. 2013 Apr;38(4):811- 21; quiz 821. doi: 10.1016/j.jhsa.2013.01.042. Epub 2013 Mar 7. Review. View Abstract at PubMed  Giuffrè BM, Moss MJ. Optimal positioning for MRI of the distal biceps brachii tendon: flexed abducted supinated view. AJR Am J Roentgenol. 2004 Apr;182(4):944-6. View Abstract at PubMed  Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non- operative treatment. J Bone Joint Surg Am. 1985 Mar;67(3):414-7. View Abstract at PubMed  Nesterenko S, Domire ZJ, Morrey BF, Sanchez-Sotelo J. Elbow strength and endurance in patients with a ruptured distal biceps tendon. J Shoulder Elbow Surg. 2010 Mar;19(2):184-9. doi: 10.1016/j.jse.2009.06.001. Epub 2009 Aug 6. PubMed PMID: 19664936. View Abstract at PubMed  Grewal R, Athwal GS, MacDermid JC, Faber KJ, Drosdowech DS, El-Hawary R, King GJ. Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am. 2012 Jul 3;94(13):1166-74. doi: 10.2106/JBJS.K.00436. PubMed PMID: 22760383. View Abstract at PubMed  Morrey ME, Abdel MP, Sanchez-Sotelo J, Morrey BF. Primary repair of retracted distal biceps tendon ruptures in extreme flexion. J Shoulder Elbow Surg. 2014 May;23(5):679-85. doi: 10.1016/j.jse.2013.12.030. PubMed PMID: 24745316. View Abstract at PubMed Question 39 of 100 Figures 39a and 39b are the radiographs of a 60-year-old woman with elbow pain at the extremes of motion; occasional locking; flexion/extension, 30-130; pronation/supination, 60/70; and no pain on forearm rotation. She injured her elbow as a teenager and had surgery at that time. What is the best next step? Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei 1- Debridement, capsular excision, and loose body removal 2- Unconstrained total elbow arthroplasty (TEA) 3- Radial head excision 4- Elbow arthrodesis PREFERRED RESPONSE: 1- Debridement, capsular excision, and loose body removal DISCUSSION This patient appears to have sustained a lateral condyle fracture as a young adult. She was treated with surgical repair and now has posttraumatic arthritis. The best treatment, especially in the setting of mechanical symptoms, is debridement with capsular excision to regain motion and loose body removal. Radial head excision is not indicated because she has no pronation/supination loss or pain with forearm rotation. Elbow arthrodesis is severely limiting because of an associated inability to perform activities of daily living. Unconstrained TEA is more effectively used as a salvage for an older person who has failed debridement and has mid arc motion pain. Unconstrained elbow arthroplasty mandates near-normal elbow bony architecture and intact and normal collateral ligaments, both of which may be compromised in this case. RECOMMENDED READINGS  Papatheodorou LK, Baratz ME, Sotereanos DG. Elbow arthritis: current concepts. J Hand Surg Am. 2013 Mar;38(3):605-13. doi: 10.1016/j.jhsa.2012.12.037. Epub 2013 Feb 5. Review. PubMed PMID: 23391361. View Abstract at PubMed  Ring D. Instability after total elbow arthroplasty. Hand Clin. 2008 Feb;24(1):105-12. doi: 10.1016/j.hcl.2007.11.002. Review. PubMed PMID: 18299024. View Abstract at PubMed Question 40 of 100 A 26-year-old recreational athlete sustained an initial dislocation 1 year ago and was treated nonsurgically. He recently sustained a second dislocation and is scheduled for surgical repair. Plain radiographs and MR images reveal no bony defect. What is the difference in recurrence rate after open and arthroscopic repair? 1- Recurrence after open surgery is twice that of arthroscopic repair 2- Recurrence after arthroscopic surgery is twice that of open repair 3- Recurrence after arthroscopic repair generally occurs at an earlier time than after open repair 4- There is no difference in recurrence after open and arthroscopic repair PREFERRED RESPONSE: 4- There is no difference in recurrence after open and arthroscopic repair DISCUSSION Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Traditionally, recurrence rates associated with open stabilization procedures have been lower than rates associated with arthroscopic repair. Recent studies show that for patients without significant bone loss, however, the recurrence rate is the same for open and arthroscopic surgeries. RECOMMENDED READINGS  Chalmers PN, Mascarenhas R, Leroux T, Sayegh ET, Verma NN, Cole BJ, Romeo AA. Do arthroscopic and open stabilization techniques restore equivalent stability to the shoulder in the setting of anterior glenohumeral instability? a systematic review of overlapping meta-analyses. Arthroscopy. 2015 Feb;31(2):355-63. doi: 10.1016/j.arthro.2014.07.008. Epub 2014 Sep 10. Review. PubMed PMID: 25217207. View Abstract at PubMed  Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM, Cole BJ, Bach BR Jr, Romeo AA, Verma NN. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy. 2013 May;29(5):920-33. doi: 10.1016/j.arthro.2012.11.010. Epub 2013 Feb 5. Review. PubMed PMID: 23395467. View Abstract at PubMed CLINICAL SITUATION FOR QUESTIONS 41 THROUGH 43 Figures 41a and 41b are the radiographs of a 69-year-old, left-hand-dominant retired man with left shoulder pain. The pain has been present for several years, although he cannot pinpoint the exact time at which it started. He worked in construction but retired 3 years ago. He now reports pain interfering with activities around the house but declines recent trauma or prior shoulder surgery. He has tried different nonsteroidal anti-inflammatory drugs prescribed by his primary care physician, but these do not provide complete relief. Upon examination, he demonstrates pain and crepitus with active and passive shoulder motion. Motion is restricted, but he can actively forward flex to 100 degrees and external rotate to 30 degrees. Rotator cuff testing reveals 5/5 strength bilaterally. He has normal neurovascular examination findings. Question 41 of 100 After discussing his diagnosis along with surgical and nonsurgical treatment options, the patient wishes to proceed with surgical intervention. He has done some online research and has questions about which procedure will produce the best outcome. Based on the current literature, what is the optimal next procedure? Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei 1- Arthroscopic glenohumeral debridement with biceps tenotomy 2- Hemiarthroplasty 3- Total shoulder arthroplasty (TSA) 4- Reverse TSA (rTSA) PREFERRED RESPONSE: 3- Total shoulder arthroplasty (TSA) Question 42 of 100 During the patient’s presurgical history and physical visit, he tells the nurse that he has a history of rheumatoid arthritis for which management by his primary care physician is required. With this new information in hand, which finding is most commonly seen on imaging during presurgical planning? 1- Glenoid medicalization 2- Posterior glenoid wear 3- Posterior subluxation of the humeral head 4- Inferior osteophytes at the humeral head PREFERRED RESPONSE: 1- Glenoid medialization Question 43 of 100 Following a successful shoulder arthroplasty and hospital discharge, the patient returns for his 1- month follow-up. His staples were removed at his 2-week visit. At today’s visit his wound appears benign, and he denies drainage or fevers. He reports he was doing well until last week, at which time he reached out to close the car door, which resulted in new anterior shoulder pain. His postsurgical radiograph is shown in Figure 43. What is the most likely cause of this new finding? 1- Supraspinatus tear 2- Subscapularis tear 3- Glenoid component loosening 4- Infection Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei PREFERRED RESPONSE: 2- Subscapularis tear DISCUSSION The examination and radiograph findings are consistent with glenohumeral osteoarthritis, which is now interfering with this patient’s daily activities. Regarding surgical treatment for glenohumeral arthritis, several studies have shown that TSA is associated with better functional outcomes than hemiarthroplasty. A recent meta-analysis comparing outcomes between TSA and hemiarthroplasty revealed better function after TSA regarding pain, University of California-Los Angeles Shoulder Scores, and postsurgical forward elevation at a minimum of 2 years (Bryant and associates). In addition, Gartsman and associates showed that TSA resulted in better pain relief, function, strength, and patient satisfaction than hemiarthroplasty at 3-year follow-up. The patient in this scenario exhibits good rotator cuff strength on examination; therefore, arthroscopy with debridement or rTSA used in the setting of a massive cuff tear would not be the best answer. Several studies have similarly shown good results with TSA in the setting of inflammatory and rheumatoid arthritis (Thomas and associates, Jolles and associates). Posterior glenoid wear is a common pattern in osteoarthritis (OA) and not a contraindication (Walch and associates). However, patients with a brachial plexus root avulsion or preganglionic injury resulting in a flail arm are not candidates for TSA because of the poor prognosis for recovery of motor and sensory deficits. Inflammatory arthritis seen in patients with rheumatoid disease characteristically results in concentric glenoid wear and not the eccentric posterior erosion seen in OA. This concentric wear results in medialization of the glenohumeral joint line. This wear pattern can lead to severe erosion, making it difficult to achieve glenoid resurfacing. Eccentric posterior glenoid wear would lead to posterior humeral head subluxation, which is not as common in inflammatory arthritis. In addition, inferior humeral head osteophytes are seen in OA. Walch and associates have developed and published a classification system describing glenoid wear. During TSA, exposure to the glenohumeral joint involves subscapularis management, tendon peel, or lesser tuberosity osteotomy. As a result, early postsurgical rehabilitation limits passive external rotation and active internal rotation, typically for 6 weeks, to protect the subscapularis repair. The patient in this scenario likely contracted his subscapularis, resulting in rupture of his repair. Upon clinical examination, internal rotation weakness, increased passive external rotation, and abnormal belly press or lift-off test results can be expected. One study revealed that rupture of the subscapularis was seen in all anterior dislocations following TSA (Wirth and associates). RECOMMENDED READINGS  Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone Joint Surg Am. 2005 Sep;87(9):1947-56. Review. View Abstract at PubMed  Gartsman GM, Roddey TS, Hammerman SM. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am. 2000 Jan;82(1):26-34. PubMed PMID: 10653081.View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei  Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg. 2002 Mar-Apr;11(2):130-5. View Abstract at PubMed  Thomas S, Price AJ, Sankey RA, Thomas M. Shoulder hemiarthroplasty in patients with juvenile idiopathic arthritis. J Bone Joint Surg Br. 2005 May;87(5):672-6. View Abstract at PubMed  Jolles BM, Grosso P, Bogoch ER. Shoulder arthroplasty for patients with juvenile idiopathic arthritis. J Arthroplasty. 2007 Sep;22(6):876-83. PubMed PMID: 17826280.View Abstract at PubMed  Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty. 1999 Sep;14(6):756-60. View Abstract at PubMed  Iannotti JP, Norris TR. Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am. 2003 Feb;85-A(2):251-8 View Abstract at PubMed  Miller BS, Joseph TA, Noonan TJ, Horan MP, Hawkins RJ. Rupture of the subscapularis tendon after shoulder arthroplasty: diagnosis, treatment, and outcome. J Shoulder Elbow Surg. 2005 Sep- Oct;14(5):492-6. PubMed PMID: 16194740.View Abstract at PubMed  Wirth MA, Rockwood CA Jr. Complications of total shoulder-replacement arthroplasty. J Bone Joint Surg Am. 1996 Apr;78(4):603-16. Review. PubMed PMID: 8609143. View Abstract at PubMed Question 44 of 100 A healthy 65-year-old woman undergoes anatomic total shoulder arthroplasty to address osteoarthritis. The surgery is uncomplicated. What is the most common indication for future revision? 1- Infection 2- Periprosthetic fracture 3- Glenoid component loosening 4- Rotator cuff tearing PREFERRED RESPONSE: 3- Glenoid component loosening DISCUSSION The most common reason for revision surgery is loosening of an implant. In most studies that distinguish glenoid from humeral loosening, it appears the glenoid is the problem. Infections, periprosthetic fractures, and rotator cuff tears are uncommon. In the population-based study by Matsen and associates, 10% of the revisions were performed for loosening vs 7% for infection and 7% for rotator cuff tearing. RECOMMENDED READINGS  Matsen FA 3rd, Li N, Gao H, Yuan S, Russ SM, Sampson PD. Factors Affecting Length of Stay, Readmission, and Revision After Shoulder Arthroplasty: A Population-Based Study. J Bone Joint Surg Am. 2015 Aug 5;97(15):1255-63. doi: 10.2106/JBJS.N.01107. Erratum in: J Bone Joint Surg Am. 2015 Sep 2;97(17):e60. PubMed PMID: 26246260.View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei  Dillon MT, Ake CF, Burke MF, Singh A, Yian EH, Paxton EW, Navarro RA. The Kaiser Permanente shoulder arthroplasty registry: results from 6,336 primary shoulder arthroplasties. Acta Orthop. 2015 Jun;86(3):286-92. Epub 2015 Mar 2. PubMed PMID: 25727949. View Abstract at PubMed Question 45 of 100 A 68-year-old right-hand-dominant woman has experienced progressive right elbow pain and loss of motion for several years. She has failed nonsurgical treatment and elects to undergo a total elbow arthroplasty (TEA). In comparison to a linked prosthesis, an unlinked prosthesis has which reported distinction with extended follow-up? 1- Improved longevity in comparison to the linked prosthesis 2- A significantly larger flexion-extension arc 3- A higher incidence of postsurgical instability 4- Lower frequency of ulnar nerve dysfunction PREFERRED RESPONSE: 3- A higher incidence of postsurgical instability DISCUSSION TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants. RECOMMENDED READINGS  Kudo H, Iwano K. Total elbow arthroplasty with a non-constrained surface-replacement prosthesis in patients who have rheumatoid arthritis. A long-term follow-up study. J Bone Joint Surg Am. 1990 Mar;72(3):355-62. PubMed PMID: 2312530.View Abstract at PubMed  Plaschke HC, Thillemann TM, Brorson S, Olsen BS. Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008. J Shoulder Elbow Surg. 2014 Jun;23(6):829-36. doi: 10.1016/j.jse.2014.02.001. Epub 2014 Apr 22. View Abstract at PubMed  Dos Remedios C, Chantelot C, Giraud F, Migaud H, Fontaine C. Results with Kudo elbow prostheses in non-traumatic indications : a study of 36 cases. Acta Orthop Belg. 2005 Jun;71(3):273-88. PubMed PMID: 16035700. View Abstract at PubMed Question 46 of 100 Figures 46a and 46b are the radiographs of a 60-year-old man with gradual onset of right shoulder pain and motion loss 1 year after undergoing an uncomplicated right total shoulder arthroplasty Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei (TSA) for end-stage osteoarthritis. He denies trauma to his right shoulder and constitutional symptoms, but admits to difficulty performing activities of daily living. His surgical wound site is benign. He demonstrates active and passive forward flexion to 90 degrees, abduction to 60 degrees, external rotation to 30 degrees, and internal rotation to the lumbosacral junction. His rotator cuff strength is graded as normal and symmetrical to his unaffected left shoulder. Based upon the current evaluation, what is the most appropriate next step? 1- Revision TSA 2- Infection workup 3- CT scan of the shoulder 4- Observation and physical therapy PREFERRED RESPONSE: 2- Infection workup DISCUSSION This patient’s radiographs do not reveal prosthetic loosening, osteolysis, instability, or rotator cuff deficiency. History and examination findings suggest a possible indolent infectious process, and it is incumbent upon the treating surgeon to obtain screening laboratory studies (complete blood count with differential, erythrocyte sedimentation rate, and C-reactive protein) and proceed with obtaining cultures (via joint aspiration or arthroscopic soft-tissue biopsy) to rule out an infectious process. Cultures should be held for 2 weeks to evaluate for the possibility of a Propionibacterium acnes infection, which is the predominant organism elicited from painful and stiff TSAs for which revision is required. Immediate revision TSA is not indicated in this scenario because the components appear well fixed and positioned. Observation and therapy in the setting of deterioration of a previously well-functioning TSA also are not appropriate. RECOMMENDED READINGS  Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, Jette JL, Warme WJ, Matsen FA 3rd. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am. 2012 Nov 21;94(22):2075-83. doi: 10.2106/JBJS.K.00861. View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei  Dodson CC, Craig EV, Cordasco FA, Dines DM, Dines JS, Dicarlo E, Brause BD, Warren RF. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg. 2010 Mar;19(2):303-7. doi: 10.1016/j.jse.2009.07.065. Epub 2009 Nov 1. PubMed PMID: 19884021. View Abstract at PubMed  Dilisio MF, Miller LR, Warner JJ, Higgins LD. Arthroscopic tissue culture for the evaluation of periprosthetic shoulder infection. J Bone Joint Surg Am. 2014 Dec 3;96(23):1952-8. doi: 10.2106/JBJS.M.01512. PubMed PMID: 25471909. View Abstract at PubMed CLINICAL SITUATION FOR QUESTIONS 47 AND 48 A 42-year-old mechanic has right medial elbow pain that is worse with use at work. He denies any injury to the arm. He has no significant medical history, but he smokes a pack of cigarettes each day. He has filed a Workers’ Compensation claim and has hired an attorney. He is still working his full job duty, but he expresses dissatisfaction with his employer. An examination reveals tenderness to palpation maximally anterior to the medial epicondyle. Pain is worse with resisted wrist flexion and resisted forearm pronation. Question 47 of 100 What is the most common coexisting pathology in this scenario? 1- Ulnar neuropathy at the cubital tunnel 2- Lateral epicondylitis 3- Triceps tendinosis 4- Posterolateral rotatory instability PREFERRED RESPONSE: 1- Ulnar neuropathy at the cubital tunnel Question 48 of 100 The patient’s symptoms fail to improve after a 6-month course of nonsurgical treatment. His inability to return to his full job duties after surgery is most likely related to 1- poor job satisfaction. 2- his smoking habit. 3- representation by an attorney. 4- ligament instability. PREFERRED RESPONSE: 1- poor job satisfaction. DISCUSSION This patient has typical signs and symptoms of medial epicondylitis. The most common coexisting pathology is ulnar nerve compression. Less commonly, patients may have other tendon issues Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei including lateral epicondylitis and triceps tendinosis. Posterolateral instability is most commonly a tennis elbow surgery complication or results from trauma with injury to the lateral ulnar collateral ligament. A patient’s ability to return to work is most commonly predicated upon his or her job satisfaction prior to sustaining a work-related injury. RECOMMENDED READINGS  Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015 Jun;23(6):348-55. doi: 10.5435/JAAOS-D-14-00145. Review. PubMed PMID: 26001427. View Abstract at PubMed  Gruson KI, Huang K, Wanich T, Depalma AA. Workers' compensation and outcomes of upper extremity surgery. J Am Acad Orthop Surg. 2013 Feb;21(2):67-77. doi: 10.5435/JAAOS-21-02-67. Review. PubMed PMID: 23378370. View Abstract at PubMed Question 49 of 100 Figure 49 is the radiograph of a 54-year-old man who has increasing weakness and numbness in his lateral arm. No prior surgery or injury is reported. What is the most appropriate next diagnostic test? 1- MR imaging of the shoulder 2- MR imaging of the cervical spine 3- Chest CT scan 4- Chest radiograph PREFERRED RESPONSE: 2- MR imaging of the cervical spine DISCUSSION Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei The radiograph reveals a Charcot shoulder. The atraumatic dissolving of the humeral head is concerning for a neuropathic etiology and necessitates MR imaging of the cervical spine to evaluate for the presence of a syrinx. RECOMMENDED READINGS  Drvaric DM, Rooks MD, Bishop A, Jacobs LH. Neuropathic arthropathy of the shoulder. A case report. Orthopedics. 1988 Feb;11(2):301-4. PubMed PMID: 3357846. View Abstract at PubMed  Patel AY, Eagle KA, Vaishnava P. Cardiac Risk of Noncardiac Surgery. J Am Coll Cardiol. 2015 Nov 10;66(19):2140-8. doi: 10.1016/j.jacc.2015.09.026. Review. View Abstract at PubMed Question 50 of 100 When a patient has acute or chronic anterior shoulder instability, a bony or glenoid reconstructive procedure should be considered in which clinical setting? 1- Associated humeral avulsion of the glenohumeral ligament (HAGL) lesion 2- Nonengaging Hill-Sachs lesion 3- Glenoid bone loss of at least 25% 4- Anterior labral periosteal sleeve avulsion (ALPSA) PREFERRED RESPONSE: 3- Glenoid bone loss of at least 25% DISCUSSION HAGL lesions may be initially treated without surgery. Recurrent instability in the setting of a HAGL lesion may be treated with a soft-tissue repair. A nonengaging or nontracking Hill-Sachs lesion may be treated with an anterior soft-tissue (Bankart) repair. A tracking or engaging lesion may be treated with a bony glenoid procedure or a soft-tissue procedure plus remplissage. An ALPSA lesion may be treated with a soft-tissue procedure unless it is associated with a glenoid bony defect exceeding 25%. A glenoid bony defect exceeding 25% is associated with substantially higher recurrence than defects smaller than 20%, and consideration for bony glenoid reconstruction is advised. RECOMMENDED READINGS  Beran MC, Donaldson CT, Bishop JY. Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review. J Shoulder Elbow Surg. 2010 Jul;19(5):769-80. doi: 10.1016/j.jse.2010.01.011. Epub 2010 Apr 14. Review. PubMed PMID: 20392650. View Abstract at PubMed  Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006 Aug;88(8):1755-63. PubMed PMID: 16882898. View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Question 51 of 100 Figure 51 is the MR image of a 23-year-old Minor League pitcher who has dominant elbow pain. He reports a pop while throwing and loss of velocity and control. He has failed nonsurgical treatment that included rest and physical therapy. What is the most common complication following surgical treatment of this injury? 1- Infection 2- Medial epicondyle fracture 3- Arthrofibrosis 4- Ulnar nerve irritation PREFERRED RESPONSE: 4- Ulnar nerve irritation DISCUSSION This competitive thrower’s clinical picture and imaging findings are consistent with an ulnar collateral ligament (UCL) injury. For patients who fail nonsurgical treatment, UCL reconstruction is an accepted surgical solution. About 80% of overhead athletes return to at least the same level of competition. All of the responses are potential complications following UCL reconstruction, but ulnar neuritis is the most common, occurring in approximately 6% to 13% of patients. RECOMMENDED READINGS  Vitale MA, Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. Am J Sports Med. 2008 Jun;36(6):1193-205. doi: 10.1177/0363546508319053. Review. PubMed PMID: 18490476. View Abstract at PubMed  Cain EL Jr, Andrews JR, Dugas JR, Wilk KE, McMichael CS, Walter JC 2nd, Riley RS, Arthur ST. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010 Dec;38(12):2426-34. doi: 10.1177/0363546510378100. Epub 2010 Oct 7. PubMed PMID: 20929932. View Abstract at PubMed  Watson JN, McQueen P, Hutchinson MR. A systematic review of ulnar collateral ligament reconstruction techniques. Am J Sports Med. 2014 Oct;42(10):2510-6. doi: 10.1177/0363546513509051. Epub 2013 Nov 12. Review. PubMed PMID: 24220014. View Abstract at PubMed Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Question 52 of 100 What most accurately describes treatment of displaced proximal humerus fractures involving the humeral neck for elderly patients? 1- Hemiarthroplasty provides better clinical outcome measures at 2 years 2- Early physiotherapy improves outcomes at 2 years 3- Complication rates are higher after surgical treatment than with a sling 4- Surgical treatment increases risk for future surgery PREFERRED RESPONSE: 4- Surgical treatment increases risk for future surgery DISCUSSION A Cochrane Review of the literature demonstrated no differences regarding inclusion of physical therapy and complication rates between surgical and nonsurgical treatment and outcomes. Surgery as initial treatment is associated with an increased risk for later surgery than nonsurgical initial treatment. RECOMMENDED READINGS  Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015 Nov 11;11:CD000434. doi: 10.1002/14651858.CD000434.pub4. Review. PubMed PMID: 26560014.View Abstract at PubMed  Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am. 2013 Nov 20;95(22):2050-5. doi: 10.2106/JBJS.L.01637. PubMed PMID: 24257664. View Abstract at PubMed Question 53 of 100 A 35-year-old high school volleyball coach has an acute 1-day history of right elbow pain and swelling in the antecubital fossa. He was moving equipment when his symptoms began. He describes considerable weakness with forearm supination and elbow flexion. Upon examination, he has a proximal “Popeye” deformity. In surgery, attention is first focused on identifying the ruptured tendon stump. During the anterior exposure, a nerve is appreciated just lateral of midline as it appears in between the brachialis and biceps stump. It continues distally under the cephalic vein and disappears distally down the forearm. This anatomic structure is the 1- radial nerve. 2- lateral antebrachial cutaneous nerve. 3- superficial branch of the radial nerve. 4- median nerve. PREFERRED RESPONSE: 2- lateral antebrachial cutaneous nerve. DISCUSSION Shoulder and Elbow Self-Scored Self-Assessment Examination 2017 Ahmed Altaei Injury to the lateral antebrachial cutaneous nerve is among the most common complications following repair of distal biceps ruptures. This nerve enters the antecubital fossa between the biceps and brachialis muscles. It usually emerges from beneath the lateral aspect of the biceps tendon at the level of the interepicondylar line. It then travels down the forearm more superficially beneath the cephalic vein. The ruptured biceps tendon may displace it further midline, distorting its normal course. The orthopaedic surgeon must maintain a heightened awareness to this nerve’s location during exposure to minimize risk for iatrogenic injury. RECOMMENDED READINGS  Doyle JR. Forearm. In: Doye JR, Botte MJ, eds. Surgical Anatomy of the Hand and Upper Extremity. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:365-406.  Jarrett CD, Brown BT, Schmidt CC. Anatomic distal biceps and triceps tendon repairs. Oper Tech Orthop. 2013; 23: 215-223. https://www.researchgate.net/publication/259141943_ Anatomic_Distal_Biceps_and_Triceps_Tendon_Repairs (Accessed June 9, 2016).  Bourne MH, Wood MB, Carmichael SW. Locating the lateral antebrachial cutaneous nerve. J Hand Surg Am. 1987 Sep;12(5 Pt 1):697-9