A 72-year-old man with cuff tear arthropathy is scheduled for a reverse total shoulder - PowerPoint Presentation

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A 72-year-old man with cuff tear arthropathy is scheduled for a reverse total shoulder arthroplasty. Which examination finding most strongly indicates the need for a concomitant latissimus dorsi transfer?

PseudoparalysisAnterosuperior escapePositive drop arm signPositive Hornblower’s test resultPassive external rotation to 0 degrees

9/16/2015

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9/16/2015

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Answer

4. Positive Hornblower’s test result

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An 82-year-old right-hand-dominant man has progressive pain in his left shoulder and loss of overhead function. He underwent a reverse total shoulder arthroplasty for rotator cuff-deficient arthritis 30 months ago. Radiographs taken at the current visit are shown in Figures 26a through 26c, and select images from a CT scan are shown in Figures 26d through 26f. Infection workup findings are negative. Examination reveals 70 degrees of forward elevation with pain with 20 degrees of external rotation. Axillary nerve function is intact. Definitive treatment should consist of

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Figure 26a

Figure 26b

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Figure 26c

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Figure 26d

Figure 26e

Figure 26f

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Retention of the glenoid component with a reverse humeral stem revision.Removal of both glenoid and humeral components (“resection arthoplasty”)Removal of the glenoid component with humeral stem revision to hemiarthoplasty.In situ placement of the larger glenosphere component with revision reverse humeral stem.Revision glenoid base plate with superiorly placed bone graft with revision reverse humeral stem.

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Definitive treatment should consist of

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5. Revision glenoid baseplate with superiorly place bone graft with revision reverse humeral stem.

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Answer

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Figures 53a through 53e are the radiographs and CT scans of a 78--year-old man who is seen in the emergency department with persistent left shoulder pain 3 weeks after a fall. He had full function of his left shoulder prior to the fall. He lives alone, and his medical history includes diabetes and hypertension. Examination reveals pain with any attempted shoulder motion. He is neurovascularly intact in the left upper extremity. What is the next best step?

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Figure 53a

Figure 53b

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Figure 53c

Figure 53d

Figure 53e

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3. Reverse shoulder arthroplasty with tuberosity repair.

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Answer

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A 24-year-old man underwent closed reduction for an elbow dislocation 3 months ago. Now, he continues to experience elbow discomfort and feelings of instability. When his forearm is supinated and a valgus force is applied, his pain is recreated as the elbow is brought from flexion to extension. He also has difficulty getting out of a chair with his forearms supinated. He has completed a course of physical therapy without experiencing improvement. Which soft-tissue structure shown in figure 66 requires reconstruction?

A 2. B 3. C

4. D 5. E

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5. E

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Answer

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Figures 85a and 85b are the radiographs of a 32-year-old man who had an arthroscopic superior labral repair 5 months ago. Three-suture anchors were used to complete the repair, and all were placed through an anterior rotator interval portal. He has severe posterior shoulder pain with limited overhead elevation and “weakness.” Examination reveals active forward elevation limited to 120 degrees by pain, but he has full passive range of motion, and the belly press test finding is within normal limits. The patient has weakness of external rotation by the side. What is the most likely cause of his symptoms?

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Figure 85a

Figure 85b

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Rotator cuff tearAdhesive capsulitisAxillary nerve injurySuprascapular nerve injuryPosttraumatic arthritis

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What is the most likely cause of his symptoms?

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4. Suprascapular nerve injury

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Answer

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Figure 89 is the clinical photograph of a 42-year-old woman who has had gradual-onset atraumatic elbow pain for 2 months. She has pain with daily activities and especially when her elbow is extended. Her elbow is tender to palpation in the area shown in the photograph, but elbow radiograph findings are normal. What is the best next step?

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Elbow immobilizationCortisone injectionLigament reconstructionTendon repairTendon gliding exercises

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What is the next best step?

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5. Tendon gliding exercises

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Answer

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A 52-year-old otherwise healthy woman elects to undergo an arthroscopic right shoulder rotator cuff repair with decompression in the beach chair position. She receives an uncomplicated interscalene regional block using nerve stimulation localization that is supplemented with laryngeal mask airway. Twenty minutes into surgery, the anesthesiologist informs you that the patient has become hypotensive (mean arterial pressure 40-60 mmHg) and tachycardic despite repeated use of vasopressors. Decreased breath sounds are noted in the upper lung fields on the right.

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CT angiogram.Venous duplex ultrasound.Portable chest radiograph.Critical care consultation.Transesophageal echocardiogram.

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In addition to halting the surgery, the most appropriate next step is a

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3. Portable chest radiograph

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Answer

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During arthroscopic evaluation of a 44-year-old mechanic’s shoulder, the pathology noted in Figure 116 is seen. What is the best treatment option?

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Labral repairBiceps tenodesisRotator cuff repairRotator cuff debridementSubacromial decompression

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What is the best treatment option?

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3. Rotator cuff repair

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Answer

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Figures 149a through 149e are the radiographs and MR images of a 78-year-old woman who has pain in the left shoulder. The pain is worse at night and seems to “come and go”. She has functional restrictions for simple activities of daily living. Her treatment to date has consisted of occasional acetaminophen, which temporarily eases the pain. Examination reveals 140 degrees of overhead elevation and 30 degrees of external rotation with a 10-degree external rotation lag. There is moderate pain at the extremes of motion and weakness to resistance. What is the best next step?

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Figure 149a

Figure 149b

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Figure 149c

Figure 149d

Figure 149e

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Injection of corticosteroids followed by physical therapy.Trial of immobilization with referral to pain management.Reverse total shoulder arthroplasty with latissimus dorsi transfer.Arthroscopic capsular release with manipulation under anesthesia.Arthroscopic partial rotator cuff repair with concomitant interpositional allograft.

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What is the best next step?

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Injection of corticosteroids followed by physical therapy.

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Answer

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An active 65-year-old woman slipped on ice, fell down 2 steps, and injured her right shoulder. Prior to the injury her shoulder “was normal,” and she denies any history of shoulder pain or injury. She sustained a distal radius fracture 1 year ago after sustaining a simple mechanical fall, which was treated with cast immobilization. Examination reveals that her skin is intact and the deltoid contracts well. Radiographs demonstrate a displaced 4-part proximal humeral fracture with a fracture through the anatomic neck that has a 2-mm posteromedial metaphyseal extension. The head fragment is in 90 degrees of varus. What is the best treatment option?

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HemiarthroplastyPercutaneous pinning.Unconstrained total shoulder arthroplastyOpen reduction and internal fixation (ORIF)Sling immobilization and physical therapy

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What is the best treatment option?

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Hemiarthroplasty

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Answer

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Rheumatoid arthritisPosttraumatic arthritisPrimary osteoarthritisDistal humeral nonunionAcute distal humeral fracture

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Which diagnosis most favorably influences implant survivorship among patients who undergo total elbow arthroplasty?

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Rheumatoid arthritis

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Answer

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$10$25$50$100 $200

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Under the Physician Payments Sunshine Act, What is the annual monetary value limit for items given to physicians by orthopaedic implants companies? (These companies must report this type of activity to the Centers for Medicare and Medicaid Services.)

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$10

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Answer

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A 55-year-old woman has had pain in her left shoulder for 3 months with no preceding trauma. Examination reveals substantial reduction in her left shoulder motion, both actively and passively. MR imaging reveals space reduction in the axillary recess. Which comorbidity is associated with a much worse Prognosis and poorer outcomes of both nonsurgical and surgical treatment?

Diabetes mellitus

Crohn’s disease

Renal disease

Congestive obstructive pulmonary disease

Breast cancer

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Diabetes mellitus

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Answer

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Scapular protraction and inferior rotation.Scapular elevation and superior rotationFlexion and supination of the forearmExtension of the humerusCompression of the humeral head against the glenoid

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A 55-year-old woman had successful reduction of an anterior shoulder dislocation 2 weeks ago. Examination reveals she is unable to actively elevate her arm. Her passive range of motion is equal to uninjured shoulder motion. What is the function of the structure that is most likely injured?

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5. Compression of the humeral head against the glenoid.

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Answer

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Neer testLift-off testApprehension testHornblower’s testIncreased passive internal rotation

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A 45-year-old man has a painful shoulder after a fall and difficulty elevating his arm above waist level. Shoulder radiograph findings are normal. His bellypress sign is positive, but there is no external rotation lag. His deltoid contracts strongly. Which other examination finding would most likely be positive?

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2. lift-off test

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Answer

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Female genderAthletic throwing activityAge older than 20 yearsUnidirectional instabilityAttritional glenoid bone loss

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What is the most likely risk factor for recurrent shoulder instability after arthroscopic anterior shoulder stabilization?

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5. Attritional glenoid bone loss

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Answer