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Prasad Karpe
Koivikko et al. (2004) looked at the risk factors
for non-union in type II odontoid fractures
treated with halo immobilisation. They found
non-union correlated with a fracture gap
(>1mm), posterior displacement (>5mm),
delayed start of treatment (>4 days) and posterior redisplacement (>2mm). Anterior dislocation, gender and age were unrelated to nonunion.
Type II odontoid fractures are at increased
risk of non-union due to poor blood supply at
the junction between the dens and odontoid
body.
Posterior C1/C2 fusion is indicated for pseudoarthrosis of the odontoid. Anterior screw osteosynthesis is not indicated for pseudoarthrosis.
Koivikko MP et al. Factors associated with
nonunion in conservatively treated type-II fractures of the odontoid process. J Bone Joint Surg.
Br. 2004;86:1146–1151.
40. Answer D. Scheuermann’s kyphosis
Since there is no history of trauma, fever or back
pain, traumatic fractures or infection are
unlikely.
Postural kyphosis will correct on hyperextension.
Congenital kyphosis deformity will be
noticed much earlier, as it has been present since
birth and rapidly progresses during growth.
Normal thoracic kyphosis range is between
20–40°.
Scheuermann’s kyphosis is most commonly
diagnosed from ages 12–14 years of age. It is
rigid thoracic kyphosis more than 45° and caused
by anterior wedging of >5° at three consecutive
vertebrae. Patients rarely complain of pain, but
there are cosmetic concerns.
41. Answer C. Loss of pain, temperature and crude
touch on the left side, T12 downwards
The spinothalamic tract is an ascending sensory
pathway:
- Anterior tract carries information about
crude touch (can’t localise).
- Lateral tract carries information about pain
and temperature.
The second order axon in this tract ascends
upwardsone or two levelsand crossesto the opposite side, eventually synapsing in the thalamus.
In the scenario, with damage to the spinothalamic tract on the right at T10, the likely finding
is loss of pain, temperature and crude touch on
the opposite side, two levels below which is left
T12. It should also be noted that this patient will
also have complete loss of pain, temperature and
crude touch at the right T10, as the tracts are
entering at this level too, to cross two levels
higher. But this loss will be only at right T10
and not below it.
Loss of fine touch, pressure and vibration is
seen in damage to the posterior column (fasciculus gracilis and fasciculus cuneatus).
Summary of structures on right T10 of the
cord
1. Corticospinal tract – Spastic paralysis below
right T10 (upper motor neuron), these are
tracts travelling from below.
2. Corticospinal tract – Flaccid paralysis only
at the right T10 level (lower motor lesion)
and not above or below that myotome
level. Tracts entering or starting at right
T10.
3. Spinothalamic from left decussation (Left
T12) – Loss of pain and temperature two
levels below (T12 on the left side). As
spinothalamic tracts enter and decussate one/
two levels above.
4. Spinothalamic tract entering/starting at right
T10 to decussate above level that will get
damaged – Loss of pain and temp only at
right T10 segment level and not above or
below.
5. Post column – Loss of position and vibration
on right below T10.
Corticospinal and post columns decussate in
medulla (brain) unlike the spinothalamic tract
that decussates at the spinal cord level (fasciculus
gracilis and fasciculus cuneatus).
42. Answer C. Fasciculus cuneatus
Lateral spinothalamic – pain and
temperature.
Anterior spinothalamic – crude touch (can’t
localise).
Fasciculus gracilis – fine touch,
proprioception, pressure and vibration from
levels inferior to T6.
274
Spine II Structured SBA
Fasciculus cuneatus – fine touch,
proprioception, pressure and vibration from
levels superior to T6.
Corticospinal tract – motor tracts.
43. Answer B. Chordoma
Although chordoma is the most common primary bone tumour of the spine, unlike the rest
of the options, chordoma usually presents in
patients older than 50 years of age and involves
vertebral body more than the posterior elements.
Also, 50% of chordomas occur in sacrum and
coccyx.
The most common tumour of the spine is
metastases and the most common primary
tumour is chordoma.
44. Answer B. Arterial
Bacteraemia (haematogenous – arterial) from an
extra spinal primary source is the most common
route of infection to the spinal column. This could
be pulmonary, cardiac, urogenital, gut, cutaneous
or mucous. Vascularised subchondral bone seeding
occurs primarily with secondary involvement of the
disc space and adjacent vertebrae. In children, however, the disc space infection is primarily owing to
vascular channels across the growth plate.
Batson plexus (venous) is less common than
arterial.
Lymphatic is the common mode of spre ad in
tuberculosis infection. The most common mode
of spread within the spinal column would be
directly after tuberculosis infection.
45. Answer B. Inform the entire team about loss of
signals
Loss of signals is a known entity in deformity
surgery. The aetiology could be one of many
factors. It could be surgery (screw misplacement,
correction), low blood pressure or oxygenation
(poor perfusion of the cord) or simple factors
such as disconnected leads. While the most
recent action is to be reversed, it is pertinent to
inform all team members so that simultaneously
corrective actions are undertaken.
46. Answer D. Weakness of great toe extension
Degenerative listhesis is more common at L4–L5,
as the more sagittally oriented facets predispose
to this pathology. Isthmic listhesis, on the other
hand, occurs due to repetitive hyperextension
forces that are prevalent at L5–S1.
The exiting nerve root is involved in isthmic
listhesis, while the traversing nerve root is
involved in degenerative listhesis. Therefore,
L5–S1 lytic listhesis will involve the L5 root,
while the S1 root will be involved in degenerative
listhesis at L5–S1. In a case of L4–L5 degenerative
listhesis, the L5 nerve root will be involved
(weakness of great toe extension). Weakness of
ankle dorsiflexion (L4), weakness of ankle plantar flexion (S1), loss of sensation along the lateral
border of the foot (S1) and weakness of hip
flexion (L2) are unlikely in this clinical scenario.
47. Answer B. Pain on spinal extension
Patients with lumbar canal stenosis have relief of
symptoms on spine flexion such as leaning over a
shopping cart, walking downhill or sleeping in a
foetal position. Pulses are normal, and they usually have no neurological deficit on examination.
Patients with vascular claudication have weak
pulses and their symptoms worsen on walking
uphill.
Positive straight leg raise is pathognomonic
of nerve irritation in prolapsed disc and not
lumbar canal stenosis.
48. Answer A. Admit, neurological observations,
consider surgery following day within 24 hours
of MRI
Todd and Dickson (2016) provided standards of
care for cauda equina. They divided CES into the
following:
1. CES-S (cauda equina syndrome suspected) –
Bilateral radiculopathy. Management –
Admission, operate or wait and watch.
2. CES-I (cauda equina syndrome incomplete) –
Patient with urinary difficulties. Management
– Emergency surgery.
3. CES-R (cauda equina syndrome retention) –
Painless retention of urine w ith overflow
incontinence. Management – Emergency
surgery. – Early CES-R (<12 hours),
uncertain CES-I/CES-R, residual sacral nerve
function present. Management – Next acute
list – Prolonged CES-R.
4. CES-C (cauda equina syndrome complete) –
Loss of all cauda equina function (absent
275
Prasad Karpe
perianal sensations, patulous anus and
paralysed insensate bladder and bowel).
Management – Next acute list – Prolonged
CES-R.
Bilateral radiculopathy with large central disc is
cauda equina suspected, even with no bowel or
bladder symptoms. This patient needs admission
and neurological observations. If they deteriorate, then emergency surgery needs to be performed. Otherwise, surgery should occur on the
following day, acute list.
Injections carry no role in this scenario.
Even though the pain is under control, this
patient needs admission for neurological deterioration as she is at high risk of progression to
cauda equina syndrome. Emergency surgery is
indicated for patients with incomplete cauda
equina (bladder or bowel disturbances) or cauda
equina patients with retention.
Todd NV, Dickson RA. Standards of care in
cauda equina syndrome. Br J Neurosurg.
2016;30:518–522.
49. Answer E. Thoracic disc disease T1–T2
Normal reflexes in upper limbs and brisk reflexes
in lower limbs means the lesion should be in the
thoracic spine (upper motor neuron). Peripheral
neuropathy, lumbar canal stenosis and lumbar
disc prolapse are all lower motor neuron lesions.
Cervical spondylotic myelopathy would have
brisk reflexes in the upper limbs.
The compression of the anterior root of T1
containing the myelinated axons of the sympathetic cells of origin can explain the Horner
syndrome.
50. Answer A. Anterior spinal artery
Anterior spinal artery supplies anterior twothirds of the spinal cord and is the predominant
blood supply. Paired posterior spinal arteries
supply the posterior one-third of the spinal cord.
Artery of Adamkiewicz typically originates
on the left side between T9 and L2. Damage to
it can result in infarction of the lumbosacral
segments only.
51. Answer C. Epidural space–dura mater–arach-
noid membrane–subarachnoid space–pia mater
In this scenario, one can rule out some options.
For example, the epidural (above dura) has to be
superficial to the dura. So too the subarachnoid
(below arachnoid) has to be below the arachnoid
membrane. Therefore, even if one does not recollect the exact layers in order, the first four
options are clearly wrong.
52. Answer A. Cervical spondylotic myelopathy
Cervical spondylotic myelopathy in the absence
of significant facet disease is not a contraindication for disc arthroplasty. A cross-sectional
study of 199 patients who underwent either
arthrodesis or arthroplasty found no worsening
of myelopathy in the arthroplast y group.
Buchowski JM, Anderson PA, Sekhon L,
Riew KD. Cervical disc arthroplasty compared
with arthrodesis for the treatment of myelopathy:
surgical technique. J Bo ne Joint Surg Am.
2009;91:223–232.
53. Answer E. Surgery
Patients with cervical spondylotic myelopathy
are generally thought to have a poor prognosis
without surgical treatment, with a gradual stepwise progression of symptoms.
So, too, patients with cervical canal stenosis
and cord compression secondary to spondylosis,
without clinical evidence of myelopathy, and
who present with clinical or electrophysiological
evidence of cervical radicular dysfunction or central conduction def icits, seem to be at higher risk
for developing myelopathy and should be counselled to consider surgical treatment.
Clarke E, Robinson PK. Cervical myelopathy: a complication of cervical spondylosis. Brain
1956;79:483–510.
Wilson JR et al. Frequency, timing, and predictors of neurological dysfunction in the nonmyelopathic patient with cervical spinal cord
compression, canal stenosis, and/or ossification
of the posterior longitudinal ligament. Spine
2013;38:S37–S54.
54. Answer C. Psychological concerns
Depression and other psychological concerns are
common in untreated scoliosis.
68% of curves progress after maturity (1° per
year for curve more than 50°).
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Spine II Structured SBA
Back pain is not uncommon and could be
due to age-related degenerative changes, sagittal
imbalance.
Sagittal imbalance starts due to thoracic
hypokyphosis followed by flattening of lumbar
lordosis, pelvic retroversion and finally positive
sagittal imbalance.
Lumbar lordosis reduces with age and more
so in AIS due to sagittal imbalance.
55. Answer B. C5 nerve palsy
C5 nerve palsy is a known complication after
surgery for cervical myelopathy (4%).
Loosening is the most common complication
of haloapplication and is treated with retightening.
Abducens nerve palsy happens because of
traction injury after halo application.
Supratrochlear nerve palsy and supraorbital
nerve palsy can happen due to incorrectly placed
anterior pins.
56. Answer C. Laryngoscopy
Laryngoscopy is needed to check vocal cord
function. An asymptomatic damage may be present to the unilateral recurrent laryngea l nerve on
the side of the previous approach. If that nerv e is
damaged, anterior approach on the non-operated
side could lead to damage of the recurrent laryngeal nerve on that side, resulting in bilateral
recurrent nerve palsy. This can be catastrophic,
leading to difficulty in breathing and inability to
speak. Checking the vocal cords by laryngoscopy
is vital for medico-legal purposes too.
Since fusion is well seen on X-rays and it is a
soft disc (not an osteophyte), CT scan is not
needed. Gadolinium scans are usually useful to
distinguish recurrent disc from epidural scar
tissue. However, since the pathologies are at different levels and it has been a long time since
primary surgery, this scan is not indicated.
Open mouth views are for C1–C2 pathologies.
Nerve conduction studies have a high false
negative rate and may be useful to distinguish
radiculopathy from peripheral neuropathy or
central causes.
57. Answer C. Flexionextension cervicalspine X-rays
Atlantoaxial subluxation is the most common
instability of the cervical spine in rheumatoid
patients. This can be picked up by flexion
extension X-rays and will need further imaging/
precautions such as fibreoptic intubation within
line immobilisation.
Methotrexate should not be stopped before
elective surgery.
Grennan DM, Gray J, Loudon J, Fear S.
Methotrexate and early postoperative complications in patients with rheumatoid arthritis
undergoing elective orthopaedic surgery, Ann
Rheum Dis. 2001;60:214–217.
58. Answer D. Multiple systemic anomalies are
common
Klippel–Feil syndrome has a classic triad of short
neck, low hairline and reduced neck range of
motion. It is associated with Sprengel’ s shoulder
and multiple systemic anomalies such as renal
aplasia and congenital heart disease.
Patient with long fusions should refrain from
contact sports due to increased risk of neurological injury following minor trauma. As the
spine is fused at some levels, it predisposes to
degeneration at other levels.
This condition happens due to failure of
normal segmentation at 3–8 weeks of gestation
and not during first 6 months of life.
59. Answer C. Laminectomy with instrumented
fusion
The patient in the scenario is getting rest pain or
critical stenosis and had failed conservative
management.
Epidural injection in a tight canal is not indicated and it carries a risk of further canal compromise. Besides, it will not relieve the back pain.
In addition,acupuncture has no rolein thispatient.
Surgery is indicated in this case and is supported by the SPORT study. Compared with
patients who are treated non-operatively,
patients whose degen erative spondylolisthesis
and associated spinal stenosis are treated surgically maintain substantially greater pain relief
and improvement in function for 4 years.
Laminectomy alone or with noninstrumented fusion will no t address the instability. Resection of the hypertrophic facets during
laminectomy can lead to furth er instability.
Weinstein JN et al. Surgical compared with
nonoperative treatment for lumbar degenerative
spondylolisthesis: four-year results in the Spine
277
Prasad Karpe
Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint
Surg Am. 2009;91:1295–1304.
60. Answer C. Thoracic spine is the most common
site followed by lumbar and cervical
Vertebral body accounts for 80% of spinal metastases with 20% posterior elements
Breast (30%) followed by lung (14%), prostate
(7.5%), renal (5%), GI (5%), thyroid (4%) and
lastly haemopoietic.
Spinal cord compression is not a component
if SINS.
Vertebroplasty is performed with neurologically intact patients and mechanical instability
with NO posterior wall defect.
278
Section 2
Chapter
13
Adult Elective Orthopaedics and Spine
Shoulder/Elbow I Structured SBA
Razvan Taranu and Shantanu Shahane
SHOULDER/ELBOW I STRUCTURED SBA
QUESTIONS
1. A 36-year-old sportsman attends the clinic complaining of left shoulder weakness and deep-seated
pain. Examination reveals wasting below the spine
of scapula affecting the infraspinous fossa only.
Which of the following would be the most
useful investigation?
A. CT
B. MRI
C. MRI arthrogram
D. US
E. X-ray
2. A 71-year-old woman attends complaining of a
3-month history of right shoulder pain and stiffness. There is no history of trauma. Examination
reveals active movements of 30° of flexion, 30°
abduction and no active external rotation.
What is the next most useful step in this
patient’s management?
A. Arthroscopic capsular release +/– MUA
B. Bone scan
C. MRI scan
D. US
E. X-ray
3. An 83-year-old man undergoes a reverse polarity
shoulder replacement for rotator cuff arthropathy
using a McKenzie approach.
An injury to the axillary nerve directly related
to this app roach leads to which deficit?
A. Absent sensation in regimental badge area
B. Absent sensation in regimental badge area
and inability to forward flex the arm
C. Inability to abduct the arm
D. Inability to forward flex the arm
E. Loss of deltoid function
4. An obese patient undergoes a total shoulder
replacement through a deltopectoral approach.
The surgeon states that large soft tissue retractors
had to be used.
Given the history, the most likely neurological
deficit would be which of the following?
A. Altered sensation in lateral forearm and weak
pronation
B. Altered sensation in lateral forearm and weak
supination
C. Altered sensation in regimental badge area
D. Altered sensation in regimental badge area
and deltoid palsy
E. Middle and anterior deltoid palsy
5. A 24-year-old athlete sustains a traumatic disloca-
tion of the left shoulder. Following reduction, he is
noted to have absent sensation in the deltoid area.
Which of the following is most likely to be positive?
A. Empty can test
B. External rotation lag sign
C. Gerber’s lift-off test
D. Hornblower sign
E. O’Brien’s test
6. A 36-year-old woman sustained a fall 3 months
ago and was referred by her GP to physiotherapy.
She was noted to have her arm in fixed internal
rotation with reduced flexion.
What would be the most useful investigation at
this stage?
A. MRI
B. MRI arthrogram
C. X-ray
D. Diagnostic arthroscopy
E. US
7. A 32-year-old male undergoes a distal biceps
tendon repair.
279
Razvan Taranu and Shantanu Shahane
The most likely neurological deficit with this
procedure is which of the following?
A. Altered sensation in the first web space
B. Inability to extend the thumb but wrist exten-
sion with radial deviation present
C. Altered sensation in the latera l forearm
D. Altered sensation in the lateral forearm and
weak supination
E. Inability to flex the thumb IPJ and index/
middle fingers DIPJ
8. A 7-year-old child sustains a lateral mass fracture
of the right elbow.
What is the most likely late onset functional
deficit?
A. Inability to abduct the thumb
B. Inability to adduct the thumb
C. Loss of forearm supination
D. Loss of thumb IPJ flexion
E. Weakness of wrist extension
9. A 9-year-old girl falls off a trampoline and sus-
tains an injury to her elbow (Figure 13.1).
elbow. He says that 3 days ago he was in the gym
and felt a pop in his distal arm.
If he wishes to proceed with non-operative
management, he will likely lose approximately
which of the following?
A. 50% of grip strength
B. 40% of supination strength
C. 80% of supination strength
D. 60% of flexion strength
E. 10% of flexion strength
11. A 36-year-old body builder sustains a distal
biceps tendon rupture and is offered surgical
repair.
The more common complication encountered
with a two-incision technique as compared
with a 1-incision is which of the following?
A. Lateral antebrachial nerve injury
B. Musculocu taneous nerve injury
C. PIN injury
D. Radial nerve injury
E. Synostosis
12. A 25-year-old rugby player sustains recurrent
anteroinferior traumatic dislocations of the
shoulder. Plain MRI scan was normal and at
arthroscopy, no soft tissue or bony Bankart
lesion was found. The patient continued to
experience recurrent instability.
Which of the following was the most likely
lesion that was missed?
A. GLAD
B. HAGL
C. Kim lesion
D. Long head of biceps tendon rupture
E. SLAP lesion
Figure 13.1 AP radiograph elbow
The most likely structure to be injured will
result in which of the following deficits?
A. Altered sensations over the lateral aspect of
forearm
B. Inability to flex DIPJ of index finger
C. Inability to extend the wrist
D. Inability to flex DIPJ of ring finger
E. Inability to oppose the thumb to little finger
10. A 30-year-old male presents to clinic with pain
and bruising in the anterior aspect of his right
280
13. A 49-year-old male sustains a traction injury to
his left arm while operating a machin e in a
chocolate factory. Neurophysiological studies
suggest a preganglionic lesion.
This is characterised by which of the following?
A. Sensory action potentials deficit and F waves
B. Sensory action potentials deficits only
C. Sensory action potentials intact and motor
action potentials deficit
D. Sensory and motor action potential deficits
E. Sensory action potentials deficit and motor
action potentials intact
Shoulder/Elbow I Structured SBA
14. A 72-year-old patient is diagnosed with rotator
cuff arthropathy. She is offered a reverse polarity
shoulder replacement.
What are the main biomechanical advantages
of this prosthesis?
A. COR (centre of rotation) moves superiorly
and medially
B. COR is fixed and moves inferiorly and
laterally
C. COR is fixed and moves inferiorly and
medially
D. COR is mobile and moves inferiorly and
medially
E. COR is mobile and moves superiorly and
medially
15. A 36-year-old male sustains a penetrating injury
in the right infraclavicular area. He is noticed to
be unable to extend right wrist and fingers. EMG
confirms injury to the posterior trunk.
What other positive neurological findings is he
expected to have?
A. Absent sensation in lateral aspect of forearm,
weak finger flexion and elbow flexion
B. Absent sensation in ring and little fingers, medial
aspect of forearm and weak elbow extension
C. Absent sensation in the first dorsal web space,
regimental badge area and weak shoulder
flexion
D. Weakness of shoulder internal rotation and
elbow flexion
E. Weakness on belly press test
A. Inability to retract left shoulder
B. Inability to shrug left shoulder
C. Positive Froment’s sign
D. Ptosis, miosis, anhidrosis
E. Ptosis, mydriasis, anhidrosis
18. A patient undergoes an open Latarjet procedure
for recurrent shoulder dislocations.
A nerve injury most likely to occur during
harvesting and preparation of the coracoid
graft is most likely to lead to which of the
following?
A. Absent elbow flexion
B. Absent elbow flexion and reduced sensation
in lateral forearm
C. Reduced sensation in the regimental badge
area and weak shoulder abduction
D. Weak elbow extension and reduced sensation
in the first web space
E. Weakness of forearm supination
19. A 6-year-old child presents to ED w ith an elbow
injury (Figure 13.2). On vascular assessment, the
radial pulse is absent and CRT >5s.
Figure 13.2 Lateral
radiograph elbow
16. An elderly patient undergoes shoulder surgery
under regional anaesthesia. Post-operatively, he
is noticed to keep his right eye half closed.
What other clinical signs is he most likely to
present with?
A. Miosis, anhidrosis, high systolic BP
B. Miosis, anhidrosis, low oxygen saturation
C. Miosis, hyperhidrosis, low oxygen saturation
D. Mydriasis, anhidrosis, low oxygen saturation
E. Mydriasis, hyperhidrosis, low systolic BP
17. A 55-year-old female undergoes cervical spine
surgery. A few weeks after surgery, she presents
with left scap ula winging.
What other po sitive findings is she likely to
have?
What is the next step in this patient’s
management?
A. Apply back slab and immediate closed/open
reduction in theatre
B. Apply back slab, immediate closed/open reduc-
tion in theatre and brachial artery exploration
C. Immediate closed/open reduction, re-check
pulse and if hand is still ischaemic discuss
with the senior orthopaedic surgeon on call
D. Immediate closed/open reduction, re-check
pulse and, if absent, discuss with the vascular
surgeon on call even if the hand is well
perfused
281
Razvan Taranu and Shantanu Shahane
E. Monitor for compartment syndrome and
operate on the next available trauma list with
the vascular surgery cover
20. A 5-year-old child sustains a Gartland type III
supracondylar fracture and undergoes closed
reduction and crossed pinning technique. A few
hours post-operatively he is noticed to complain
of increasing pain, has absent sensations in the
little finger and weak interossei.
What is the next step in this patient’s
management?
A. Analgesia and continue to monitor neurovas-
cular status, as this is most likely due to
neurapraxia and is likely to recover
B. Perform urgent nerve conduction studies to
assess the level and severity of injury
C. Return to theatre after you discuss with a
surgeon experienced in nerve repair
D. Return to theatre urgently and explore the
ulnar nerve
E. Split the bandages, gently reposition the limb
and reassess
21. An 80-year-old woman undergoes reverse polarity total shoulder replacement. She is doing very
well post-operatively, but 8 weeks after surgery
she develops sudden, non-traumatic and painless
loss of range of motion.
The most likely compl ication is which of the
following?
A. Axillary nerve injury
B. Deep-seated infection
C. Dislocation
D. Fracture of the acromion
E. Loosening of the glenosphere
22. An 84-year-old man with rheumatoid arthritis
undergoes reverse polarity total shoulder
replacement with excellent post-operati ve recovery. At 6-month follow up, he complains of
sudden pain in the operated shoulder with loss
of range of motion. There is no history of
trauma.
What is the most likely diagnosis?
A. Axillary nerve injury
B. Deep-seated infection
C. Dislocation
D. Fracture of the acromion
E. Loosening of the glenosphere
23. A 60-year-old fit a nd healthy woman prese nts
with severe shoulder pain. X-ray reveals severe
bipolar glenohumeral joint osteoarthritis. There
is less than 10° of glenoid retroversion, and the
rotator cuff, though degenerate, is structurally
intact.
What is the most appropriate intervention?
A. Anatomical total shoulder replacement
B. Glenohumeral joint steroid injection
C. Reverse polarity total shoulder replacement
D. Stemmed hemiarthroplasty
E. Surface replacement hemiarthroplasty
24. A 26-year-old sustains pain on the back of the
elbow while lifting overhead weights. An X-ray
reveals the finding shown in Figure 13.3.
Figure 13.3
Lateral radiograph
elbow
What is the most likely diagnosis?
A. Avulsion injury of triceps tendon (‘flake
sign’)
B. Ectopic bone formation
C. Fracture of the distal humerus
D. Fracture olecranon
E. Loose body in the elbow joint
25. Controversy exists regarding fixation surgery for
clavicle fracture.
All of the following are absolute indications for
internal fixation of midshaft clavicle fracture
with displacement except which?
A. Associated fracture neck of scapula
B. Compound fracture
C. Fragment overlap of more than 2cm
D. Neurovascular compromise
E. Threatened skin condition with tenting
282
Shoulder/Elbow I Structured SBA
26. A 43-year-old lady undergoes a humeral nailing
procedure for a transverse midshaft humeral
fracture. She undergoes a further surgical procedure 6 months later.
What is this surgical procedure most likely to be?
A. Removal of distal locking screws due to
backout
B. Removal of nail due to prominence at the
greater tuberosity
C. Removal of proximal locking screws due to
backout
D. Rotator cuff repair
E. Surgery for non-union of the humeral
fracture
27. Neer classified lateral third clavicle fracture s into
three types.
What characteristic best represents a Neer type
I lateral third clavicle fracture?
A. The coracoclavicular ligaments are disrupted
completely
B. The coracoclavicular ligaments are attached
to the lateral fracture fragment and there is
gross fracture displacement
C. The coracoclavicular ligaments are attached
to the lateral fracture fragment and there is
minimal fracture displacement
D. The coracoclavicular ligaments are attached
to the medial fracture fragment and there is
minimal fracture displacement
E. The coracoclavicular ligaments are attached
to the medial fracture fragment and there is
gross fracture displacement
28. A 12-year-old girl is a keen swimmer. She swims
for up to 16 hours a week and is planning a
professional career in swimming. She presents
to the clinic complaining of non-traumatic
shoulder instability.
The most likely clinical and radiological findings are which of the following?
A. Beighton’s score of less than 3 and a positive
sulcus sign
B. Beighton’s sco re of less than 3 and multi-
directional instability
C. Beighton’s score of less than 4 and a Bankart
lesion
D. Beighton’s score of more than 5 and a
Bankart lesion
E. Beighton’s score of more than 6, multi-
directional instability and no Bankart lesion
29. A 20-year-old female presents to A&E having
dislocated her elbow due to a fall on her outstretched hand. This is reduced under sedation.
There are no associated bony injuries. She is
discharged from the fracture clinic 6 weeks later
after an uneventful recovery with full range of
motion and no pain. She presents to the elbow
clinic 6 months later complaining of clicking in
the elbow joint.
What is the most likely diagnosis?
A. A missed coronoid fracture
B. Ectopic bone formation
C. Loose body in the elbow
D. Medial collateral ligament insufficiency
E. Posterolateral rotatory instability
30. A 45-year-old patient undergoes excision of right
medial clavicle for severe osteoarthritis.
Which structure is at most surgical risk?
A. Right brachiocephalic trunk
B. Right brachiocephalic vein
C. Right internal jugular vein
D. Right subclavian vein
E. Right suprascapular artery
31.
A 45-year-old male presents to your clinic with
intermittent clicking sensation of his right elbow
which he has experienced for approximately 6
months. He states that the elbow locks on a
weekly basis and this affects his job. You decide
to perform an arthroscopy but following the
procedure the patient experiences paraesthesia
in the radial digits and weakness on flexing his
fingers.
Which is the most probable intraoperative
technical error when instrumenting the joint?
A. Elbow extension
B. Elbow flexion to 90°
C. Insufficient joint insufflation with saline
D. Joint insufflation and flexion to 90°
E. Lateral position of patient
32. A 29-year-old cricket player has been complain-
ing of pain during throwing for approximately 5
months. His pain occurs with maximum arm
abduction and external rotation.
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