American Academy of Orthopaedic Surgeons
1. Which of the following statements best describes why the ulnar nerve is most prone to
neuropathy at the elbow?
1- It has the least longitudinal excursion required to accommodate elbow range of motion.
2- It is subjected to both compression and traction during elbow motion.
3- It passes between two muscle heads as it enters the forearm.
4- The dimensions of the entrance of the cubital tunnel do not change with elbow motion.
5- The vascular supply leaves a watershed area of diminished arterial supply.
DISCUSSION: The ulnar nerve is more prone to neuropathy than the radial or median nerves for
many reasons. It has the greatest longitudinal excursion required to accommodate elbow range of
motion, subjecting it to potential traction forces. The dimensions of the entrance of the cubital
tunnel change with elbow motion, potentially causing compression in flexion. For these two
reasons, the ulnar nerve is subjected to both compression and traction during elbow motion.
Although it passes between two muscle heads as it enters the forearm, so do the median and radial
nerves. Finally, the vascular supply is adequate because of the anastamoses between the superior
ulnar collateral artery, the posterior ulnar recurrent artery, and the inferior ulnar collateral artery.
PREFERRED RESPONSE: 2
2. Figure 1 shows the radiograph of a 71-year-old man who has had increasing pain and
weakness in his shoulder for the past 3 years. Nonsurgical management has failed to provide relief.
Examination shows 130 degrees of active forward flexion and intact external rotation strength.
During surgery, a 1- x 1-cm rotator cuff tear involving the supraspinatus is encountered. Treatment
should include
1- humeral head replacement with rotator cuff repair.
2- humeral head replacement without rotator cuff repair.
3- arthrodesis of the shoulder.
4- total shoulder replacement with rotator cuff repair.
5- total shoulder replacement without rotator cuff repair.
DISCUSSION: Given the size of the rotator cuff tear, it is
likely to be repaired; therefore, the treatment of choice is a
total shoulder replacement with rotator cuff repair. Severe
rotator cuff insufficiency can lead to early glenoid failure
because of superior instability, and glenoid resurfacing should
be avoided in those instances. PREFERRED RESPONSE: 4
3. Which of the following is considered the cause of Milwaukee shoulder, a joint disease
similar to rotator cuff arthropathy?
1- Abundance of basic calcium phosphate crystals
2- Abundance of calcium pyrophosphate crystals
3- Gout
2 1
,4- Rheumatoid arthritis
5- Osteonecrosis
2 1
,DISCUSSION: Neer and associates focused on mechanical and nutritional factors as the etiology of
rotator cuff arthropathy. McCarty and associates, in describing a similar syndrome known as
Milwaukee shoulder, focused on an inflammatory cause in proposing the pathogenic role of
hydroxyapatite, a basic calcium phosphate. PREFERRED RESPONSE: 1
4. The MRI scan of the shoulder shown in Figure 2 was performed with the arm in abduction
and external rotation. The image reveals what condition?
1- Contact between the rotator cuff and the posterior-superior labrum
2- Anterior instability
3- A ganglion cyst of the spinoglenoid notch
4- Osteonecrosis of the humeral head
5- Posterior subluxation
DISCUSSION: Internal impingement of the shoulder is now a well-
recognized cause of shoulder pain in the throwing athlete. First
described by Walch and associates, it involves contact of the rotator
cuff and labrum in the maximally externally rotated and abducted
shoulder, such as in the late cocking phase of the throwing motion.
Schickendantz and associates have shown this contact to be physiologic in most patients and
becoming pathologic with repetitive overhead activity.PREFERRED RESPONSE: 1
5. Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched
arm and sustained a fracture-dislocation of the elbow. Initial management consisted of closed
reduction of the dislocation. Surgical treatment should now include repair or reduction and fixation
of the
1- medial and lateral collateral ligaments, radial
head, and coronoid.
2- medial collateral ligament and coronoid.
3- lateral collateral ligament and radial head.
4- medial and lateral collateral ligaments.
5- radial head and coronoid.
DISCUSSION: The radiographs show fractures of
the coronoid and radial head. The medial collateral
ligament has been avulsed from the ulnar insertion,
and there is a valgus opening on the medial side.
The lateral collateral ligament is always disrupted in elbow dislocations and fracture-dislocations
that occur secondary to falls. This is known as the terrible triad injury (dislocation and fractures of
the coronoid and radial head); it has a very poor prognosis because of its propensity for recurrent or
persistent instability and late arthritis. The principle in treating this injury is to repair all of the
injured parts or protect them with a hinged external fixator until they heal. PREFER RESPO: 1
6. It is important to avoid which of the following exercises in the immediate postoperative
period after humeral head replacement for an acute four-part fracture?
1- Pendulum exercises
2- External rotation with a stick
3- Passive forward elevation
4- Active forward elevation
5- Active range of motion of the elbow, wrist, and hand
3 2
, DISCUSSION: It is critical to withhold active range of motion of the shoulder within the first 6
weeks after arthroplasty for acute fracture to prevent tuberosity avulsion. When radiographic and
clinical findings show that the tuberosities are healed, active motion may be instituted, usually at 6
to 8 weeks. Immediate passive range-of-motion exercises, including external rotation with a stick,
pendulum, and passive elevation, should begin within the limits of the repair on the day of surgery
to prevent stiffness. PREFERRED RESPONSE: 4
7. A 38-year-old man has winging of the ipsilateral scapula after undergoing a transaxillary
resection of the first rib 3 weeks ago. What is the most likely cause of this finding?
1- Persistent thoracic outlet syndrome
2- Injury to the upper trunk of the brachial plexus
3- Injury to the long thoracic nerve
4- Injury to the lower trunk of the brachial plexus
5- Injury to the spinal accessory nerve
DISCUSSION: During transaxillary resection of the first rib, the long thoracic nerve is at risk as it
passes either through or posterior to the middle scalene muscle. Injury to this nerve may occur as
the result of overly aggressive retraction of the middle scalene during the procedure. PREF RESP: 3
8. A 73-year-old man who underwent repair of the left rotator cuff 6 years ago reports good
pain relief but notes residual weakness of the left shoulder, especially with overhead tasks. He
denies having pain at night and has minimal discomfort with activities of daily living but is
dissatisfied with his shoulder strength. Radiographs show an acromiohumeral interval of 2 mm.
Appropriate management should consist of
1- an exercise program.
2- revision rotator cuff repair using local tissue transposition.
3- revision rotator cuff repair using allograft.
4- latissimus dorsi transfer.
5- combined latissimus dorsi and teres major transfer.
DISCUSSION: An exercise program to strengthen the deltoid and remaining rotator cuff will most
likely offer the best results. Revision rotator cuff surgery yields better results in decreasing pain
than improving strength and function, and this patient has only minimal pain. Tendon transfers,
involving the use of the latissimus dorsi or teres major, have been used when the rotator cuff is
deemed irreparable but are not indicated in elderly patients with minimal symptoms.
PREFERRED RESPONSE: 1
9. A 45-year-old woman has had progressive right shoulder pain for the past 6 months. She
notes that the pain disrupts her sleep, she has pain at rest that requires the use of narcotic analgesics,
and she has limited use of her left shoulder for most activities of daily living. History reveals the
use of corticosteroids for systemic lupus erythematosus. Examination shows diminished range of
motion. Radiographs of the right shoulder are shown in Figures 4a and 4b. Treatment should
consist of
4 3
1. Which of the following statements best describes why the ulnar nerve is most prone to
neuropathy at the elbow?
1- It has the least longitudinal excursion required to accommodate elbow range of motion.
2- It is subjected to both compression and traction during elbow motion.
3- It passes between two muscle heads as it enters the forearm.
4- The dimensions of the entrance of the cubital tunnel do not change with elbow motion.
5- The vascular supply leaves a watershed area of diminished arterial supply.
DISCUSSION: The ulnar nerve is more prone to neuropathy than the radial or median nerves for
many reasons. It has the greatest longitudinal excursion required to accommodate elbow range of
motion, subjecting it to potential traction forces. The dimensions of the entrance of the cubital
tunnel change with elbow motion, potentially causing compression in flexion. For these two
reasons, the ulnar nerve is subjected to both compression and traction during elbow motion.
Although it passes between two muscle heads as it enters the forearm, so do the median and radial
nerves. Finally, the vascular supply is adequate because of the anastamoses between the superior
ulnar collateral artery, the posterior ulnar recurrent artery, and the inferior ulnar collateral artery.
PREFERRED RESPONSE: 2
2. Figure 1 shows the radiograph of a 71-year-old man who has had increasing pain and
weakness in his shoulder for the past 3 years. Nonsurgical management has failed to provide relief.
Examination shows 130 degrees of active forward flexion and intact external rotation strength.
During surgery, a 1- x 1-cm rotator cuff tear involving the supraspinatus is encountered. Treatment
should include
1- humeral head replacement with rotator cuff repair.
2- humeral head replacement without rotator cuff repair.
3- arthrodesis of the shoulder.
4- total shoulder replacement with rotator cuff repair.
5- total shoulder replacement without rotator cuff repair.
DISCUSSION: Given the size of the rotator cuff tear, it is
likely to be repaired; therefore, the treatment of choice is a
total shoulder replacement with rotator cuff repair. Severe
rotator cuff insufficiency can lead to early glenoid failure
because of superior instability, and glenoid resurfacing should
be avoided in those instances. PREFERRED RESPONSE: 4
3. Which of the following is considered the cause of Milwaukee shoulder, a joint disease
similar to rotator cuff arthropathy?
1- Abundance of basic calcium phosphate crystals
2- Abundance of calcium pyrophosphate crystals
3- Gout
2 1
,4- Rheumatoid arthritis
5- Osteonecrosis
2 1
,DISCUSSION: Neer and associates focused on mechanical and nutritional factors as the etiology of
rotator cuff arthropathy. McCarty and associates, in describing a similar syndrome known as
Milwaukee shoulder, focused on an inflammatory cause in proposing the pathogenic role of
hydroxyapatite, a basic calcium phosphate. PREFERRED RESPONSE: 1
4. The MRI scan of the shoulder shown in Figure 2 was performed with the arm in abduction
and external rotation. The image reveals what condition?
1- Contact between the rotator cuff and the posterior-superior labrum
2- Anterior instability
3- A ganglion cyst of the spinoglenoid notch
4- Osteonecrosis of the humeral head
5- Posterior subluxation
DISCUSSION: Internal impingement of the shoulder is now a well-
recognized cause of shoulder pain in the throwing athlete. First
described by Walch and associates, it involves contact of the rotator
cuff and labrum in the maximally externally rotated and abducted
shoulder, such as in the late cocking phase of the throwing motion.
Schickendantz and associates have shown this contact to be physiologic in most patients and
becoming pathologic with repetitive overhead activity.PREFERRED RESPONSE: 1
5. Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched
arm and sustained a fracture-dislocation of the elbow. Initial management consisted of closed
reduction of the dislocation. Surgical treatment should now include repair or reduction and fixation
of the
1- medial and lateral collateral ligaments, radial
head, and coronoid.
2- medial collateral ligament and coronoid.
3- lateral collateral ligament and radial head.
4- medial and lateral collateral ligaments.
5- radial head and coronoid.
DISCUSSION: The radiographs show fractures of
the coronoid and radial head. The medial collateral
ligament has been avulsed from the ulnar insertion,
and there is a valgus opening on the medial side.
The lateral collateral ligament is always disrupted in elbow dislocations and fracture-dislocations
that occur secondary to falls. This is known as the terrible triad injury (dislocation and fractures of
the coronoid and radial head); it has a very poor prognosis because of its propensity for recurrent or
persistent instability and late arthritis. The principle in treating this injury is to repair all of the
injured parts or protect them with a hinged external fixator until they heal. PREFER RESPO: 1
6. It is important to avoid which of the following exercises in the immediate postoperative
period after humeral head replacement for an acute four-part fracture?
1- Pendulum exercises
2- External rotation with a stick
3- Passive forward elevation
4- Active forward elevation
5- Active range of motion of the elbow, wrist, and hand
3 2
, DISCUSSION: It is critical to withhold active range of motion of the shoulder within the first 6
weeks after arthroplasty for acute fracture to prevent tuberosity avulsion. When radiographic and
clinical findings show that the tuberosities are healed, active motion may be instituted, usually at 6
to 8 weeks. Immediate passive range-of-motion exercises, including external rotation with a stick,
pendulum, and passive elevation, should begin within the limits of the repair on the day of surgery
to prevent stiffness. PREFERRED RESPONSE: 4
7. A 38-year-old man has winging of the ipsilateral scapula after undergoing a transaxillary
resection of the first rib 3 weeks ago. What is the most likely cause of this finding?
1- Persistent thoracic outlet syndrome
2- Injury to the upper trunk of the brachial plexus
3- Injury to the long thoracic nerve
4- Injury to the lower trunk of the brachial plexus
5- Injury to the spinal accessory nerve
DISCUSSION: During transaxillary resection of the first rib, the long thoracic nerve is at risk as it
passes either through or posterior to the middle scalene muscle. Injury to this nerve may occur as
the result of overly aggressive retraction of the middle scalene during the procedure. PREF RESP: 3
8. A 73-year-old man who underwent repair of the left rotator cuff 6 years ago reports good
pain relief but notes residual weakness of the left shoulder, especially with overhead tasks. He
denies having pain at night and has minimal discomfort with activities of daily living but is
dissatisfied with his shoulder strength. Radiographs show an acromiohumeral interval of 2 mm.
Appropriate management should consist of
1- an exercise program.
2- revision rotator cuff repair using local tissue transposition.
3- revision rotator cuff repair using allograft.
4- latissimus dorsi transfer.
5- combined latissimus dorsi and teres major transfer.
DISCUSSION: An exercise program to strengthen the deltoid and remaining rotator cuff will most
likely offer the best results. Revision rotator cuff surgery yields better results in decreasing pain
than improving strength and function, and this patient has only minimal pain. Tendon transfers,
involving the use of the latissimus dorsi or teres major, have been used when the rotator cuff is
deemed irreparable but are not indicated in elderly patients with minimal symptoms.
PREFERRED RESPONSE: 1
9. A 45-year-old woman has had progressive right shoulder pain for the past 6 months. She
notes that the pain disrupts her sleep, she has pain at rest that requires the use of narcotic analgesics,
and she has limited use of her left shoulder for most activities of daily living. History reveals the
use of corticosteroids for systemic lupus erythematosus. Examination shows diminished range of
motion. Radiographs of the right shoulder are shown in Figures 4a and 4b. Treatment should
consist of
4 3
