, All rights reserved. No part of Shoulder and Elbow Self-Assessment Examination may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical,
photocopying, recording, or otherwise) without the prior written permission of the publisher.
Published January 2014
American Academy of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
Copyright© 2014 by the American Academy of Orthopaedic Surgeons
Requests for permission to reproduce any part of the work should be mailed to:
Attention: Examinations Department
American Academy of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
Printed in the USA
© 2014 American Academy of Orthopaedic Surgeons 2014 Shoulder and Elbow Self-Assessment Examination
, 2014 Shoulder and Elbow Self-Assessment Examination Answer Book• 11
Question 1
A 45-year-old man who had gout in his foot 2 years ago has a 3-day history of elbow pain without an
injury. The pain is diffuse, constant, and worse with any movement. Examination shows motion from 20
degrees to 90 degrees. There is no erythema around his elbow, he has no fever, and a sensory and motor
examination of his arm is unremarkable. Radiographs only show an effusion. The patient's uric acid level
is within defined limits. What is the next diagnostic step?
1. Elbow joint aspiration
2. MRI scan
3. Splint for 2 weeks and repeat examination
4. Sedimentation rate and C-reactive protein level
PREFERRED RESPONSE: 1
DISCUSSION
The best way to make the diagnosis is to aspirate the fluid from the joint and send it to the laboratory
for a cell count and crystal search. This will allow for the diagnosis of an infection, gout, or pseudogout.
An MRI scan will confirm the examination finding of an effusion, but it will not reveal the cause of an
inflammatory effusion. If the patient has chronic gout, an MRI scan or ultrasound can aid in diagnosis if
gout tophi are seen. A splint will help relieve the pain from the effusion and the effusion may resolve on its
own, but it will not contribute to a diagnosis. Sedimentation rate and C-reactive protein level will help to
rule out an infection, but they are not as diagnostic as an aspiration.
RECOMMENDED READINGS
Orzechowski NM, Mason TG. Seronegative inflammatory arthritis. In: Morrey BF, Sanchez-Sotelo J, eds.
The Elbow and Its Disorders. 4th ed. Philadelphia, PA: Saunders-Elsevier; 2009:1039-1041.
de Avila Fernandes E, Kubota ES, Sandim GB, Mitraud SA, Ferrari AJ, Fernandes AR. Ultrasound
features oftophi in chronic tophaceous gout. Skeletal Radiol. 2011 Mar;40(3):309-15. Epub 2010 Jul 31.
PubMed PMID: 20676636.
© 2014 American Academy of Orthopaedic Surgeons 2014 Shoulder and Elbow Self-Assessment Examination
, 12 • American Academy of Orthopaedic Surgeons
Figure 2
Question 2
A 65-year-old man who underwent an uncomplicated reverse total shoulder arthroplasty (rTSA) to treat
rotator cuff arthropathy 2 years ago has a routine follow-up visit in your clinic. A radiograph at 2-year
followup is shown in Figure 2. He denies shoulder pain and dysfunction and constitutional symptoms,
and his clinical examination findings are benign. Based upon the present radiologic evaluation, what is the
next most appropriate step?
1. Revision rTSA
2. Conversion to hemiarthroplasty
3. Continued observation
4. Infection work-up with screening labs and joint aspiration
PREFERRED RESPONSE: 3
DISCUSSION
Based upon the patient's clinical examination and symptoms, continued observation is appropriate.
The remaining options are not indicated. The radiograph reveals scapular notching, one of the more
common complications specific to rTSA. Notching is caused by repeated contact between the humeral
component and/or humerus and the inferior pillar of the scapular neck. Generation of particulate debris
from this interaction can result in osteolysis with the potential for screw and base plate failure. The overall
incidence of notching has been reported to be between 51% and 96%. This nearly ubiquitous finding has
been attributed to implant positioning, altered glenoid and humeral anatomy, and duration of implantation.
Recent studies that indicate increased lateral offset, increased glenosphere size, and inferior positioning of
the base plate may reduce the incidence of scapular notching.
© 2014 American Academy of Orthopaedic Surgeons 2014 Shoulder and Elbow Self-Assessment Examination
stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical,
photocopying, recording, or otherwise) without the prior written permission of the publisher.
Published January 2014
American Academy of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
Copyright© 2014 by the American Academy of Orthopaedic Surgeons
Requests for permission to reproduce any part of the work should be mailed to:
Attention: Examinations Department
American Academy of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
Printed in the USA
© 2014 American Academy of Orthopaedic Surgeons 2014 Shoulder and Elbow Self-Assessment Examination
, 2014 Shoulder and Elbow Self-Assessment Examination Answer Book• 11
Question 1
A 45-year-old man who had gout in his foot 2 years ago has a 3-day history of elbow pain without an
injury. The pain is diffuse, constant, and worse with any movement. Examination shows motion from 20
degrees to 90 degrees. There is no erythema around his elbow, he has no fever, and a sensory and motor
examination of his arm is unremarkable. Radiographs only show an effusion. The patient's uric acid level
is within defined limits. What is the next diagnostic step?
1. Elbow joint aspiration
2. MRI scan
3. Splint for 2 weeks and repeat examination
4. Sedimentation rate and C-reactive protein level
PREFERRED RESPONSE: 1
DISCUSSION
The best way to make the diagnosis is to aspirate the fluid from the joint and send it to the laboratory
for a cell count and crystal search. This will allow for the diagnosis of an infection, gout, or pseudogout.
An MRI scan will confirm the examination finding of an effusion, but it will not reveal the cause of an
inflammatory effusion. If the patient has chronic gout, an MRI scan or ultrasound can aid in diagnosis if
gout tophi are seen. A splint will help relieve the pain from the effusion and the effusion may resolve on its
own, but it will not contribute to a diagnosis. Sedimentation rate and C-reactive protein level will help to
rule out an infection, but they are not as diagnostic as an aspiration.
RECOMMENDED READINGS
Orzechowski NM, Mason TG. Seronegative inflammatory arthritis. In: Morrey BF, Sanchez-Sotelo J, eds.
The Elbow and Its Disorders. 4th ed. Philadelphia, PA: Saunders-Elsevier; 2009:1039-1041.
de Avila Fernandes E, Kubota ES, Sandim GB, Mitraud SA, Ferrari AJ, Fernandes AR. Ultrasound
features oftophi in chronic tophaceous gout. Skeletal Radiol. 2011 Mar;40(3):309-15. Epub 2010 Jul 31.
PubMed PMID: 20676636.
© 2014 American Academy of Orthopaedic Surgeons 2014 Shoulder and Elbow Self-Assessment Examination
, 12 • American Academy of Orthopaedic Surgeons
Figure 2
Question 2
A 65-year-old man who underwent an uncomplicated reverse total shoulder arthroplasty (rTSA) to treat
rotator cuff arthropathy 2 years ago has a routine follow-up visit in your clinic. A radiograph at 2-year
followup is shown in Figure 2. He denies shoulder pain and dysfunction and constitutional symptoms,
and his clinical examination findings are benign. Based upon the present radiologic evaluation, what is the
next most appropriate step?
1. Revision rTSA
2. Conversion to hemiarthroplasty
3. Continued observation
4. Infection work-up with screening labs and joint aspiration
PREFERRED RESPONSE: 3
DISCUSSION
Based upon the patient's clinical examination and symptoms, continued observation is appropriate.
The remaining options are not indicated. The radiograph reveals scapular notching, one of the more
common complications specific to rTSA. Notching is caused by repeated contact between the humeral
component and/or humerus and the inferior pillar of the scapular neck. Generation of particulate debris
from this interaction can result in osteolysis with the potential for screw and base plate failure. The overall
incidence of notching has been reported to be between 51% and 96%. This nearly ubiquitous finding has
been attributed to implant positioning, altered glenoid and humeral anatomy, and duration of implantation.
Recent studies that indicate increased lateral offset, increased glenosphere size, and inferior positioning of
the base plate may reduce the incidence of scapular notching.
© 2014 American Academy of Orthopaedic Surgeons 2014 Shoulder and Elbow Self-Assessment Examination
