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Razvan Taranu and Shantanu Shahane
What would be your proposed treatment?
A. Arthroscopic debridement of rotator cuff
+/ posterior labrum
B. Arthroscopic rotator cuff repair
C. Mini-open rotator cuff repair
D. Physiotherapy, cessation from throwing and
posterior capsular stretching
E. Posterior capsular release
33. A 51-year-old warehouse worker presents to the
Upper Limb clinic with a 12-month history of
lateral elbow pain. Examinatio n reveals tenderness on direct palpation of lateral epicondyle and
pain in the elbow on active extension against
resistance of middle finger with the forearm
pronated.
The most likely histopathological finding of
this condition will be:
A. Angiofibroblastic hyperplasia
B. Fibroblasts/myofibroblasts with abundant
type III collagen
C. Mononuclear stromal cells that resemble
interstitial fibroblasts
D. Perineural fibrosis
E. Predominantly type III collagen with
myofibroblasts
34. A 75-year-old male is 6 weeks following right
total shoulder rep lacement. He was doing well
post-operatively until 1 week ago, when he felt
sudden anterior shoulder pain and weakness.
After detailed history, he admits not wearing
the sling at home and having a fall. The X-ray
does not show any evidence of dislocation.
What is the most likely clinical finding?
A. Excessive passive external rotation
B. Loss of internal rotation
C. ‘Popeye’ muscle
D. Reduced active external rotation
E. Weakness on empty can test
B. External jugular vein
C. Lung apex
D. Subclavian artery
E. Subclavian vein
36. A 78-year-old female patient suffers from severe
left shoulder pain with restricted mobility. Her
past medical history includes rheumatoid arthritis and she smokes 10 cigarettes per day. Nonoperative treatment, including two previous steroid injections (the last one given by GP 7 weeks
ago) has failed to alleviate her symptoms and she
is desperate for a shoulder replacement. She
undergoes this operation 3 weeks later and this
is complicated by a post-operative haematoma.
The following are considered to be risk facto rs
for post-operative joint infection, except:
A. Inflammatory arthritis
B. Old age
C. Post-operative haematoma
D. Smoking
E. Steroid injection within 3 months of surgery
37. A 59-year-old painter-decorator presents with
long-standing right dominant shoulder pain with
no history of trauma. Examination reveals tenderness on palpating the acromion and a positive
Hawkins test. The X-ray is presented in Figure 13.4.
Figure 13.4 X-ray
with os acromiale
35. A 35-year-old male underg oes surgery for a displaced, comminuted right clavicle fracture. The
surgeon decides to use a long plate with the
medial end seated close to the sternoclavicular
joint.
Which is the structure at most risk when
drilling the medial holes?
A. Brachial plexus
284
The following statement is true about this
condition:
A. Excision of the anterior acromion does not
carry any risks
B. It is associated with rotator cuff tears in
60–75% of the cases
C. It is best diagnosed on lateral Y-view
radiograph
Shoulder/Elbow I Structured SBA
D. Pain is given by impingement and motion at
the non-union site
E. The most common location is between pre-
and meso-acromion
38. A 34-year-old cricket player has been complaining of dominant shoulder pain for the past 6
months; his symptoms occur during late cocking
and early acceleration phases of throwing.
Which of the following features is not related
to the condition you are suspecting?
A. Bennett lesion
B. Bursal sided fraying of supraspinatus
C. Cartilage damage at posterior glenoid
D. Posterior labral lesion
E. Superior labral lesion
39. A 28-year-old overhead male athlete presents
with poorly localised pain in the postero-lateral
aspect of his dominant shoulder with a degree of
paraesthesia in the lateral shoulder. Examination
reveals weakness of external rotation with the
arm in abduction. Symptoms are worse at night,
without any red flag signs. MRI shows an inferior paralabral cyst and labral tear.
What is the most likely diagnosis?
A. Internal impingement
B. Long head of biceps tendinopathy
C. Parsonage–Turner syndrome
D. Quadrilateral space syndrome
E. Suprascapular neuropathy
40. A 36-year-old volleyball player presents with a 3-
month history of dominant shoulder pain and
weakness. Examination reveals weakness on
empty can test and external rotation at side.
Neurophysiological studies suggest suprascapular nerve neuropathy, the site of lesion being at
the suprascapular notch.
When you perform the decompression, you expect
to find the following structures (in this order):
A. Artery, ligament (arising from medial base of
coracoid), nerve
B. Artery, ligament (arising from medial base of
spine of scapula), nerve
C. Ligament (arising from medial base of corac-
oid), nerve, artery
D. Ligament (arising from medial base of corac-
oid), suprascapular artery, suprascapular nerve
E. Ligament (arising from medial base of spine
of scapula), artery, nerve
41. A 13-year-old boy falls off his bike and sustains an
injury to his right shoulder. Examination demonstrates a large swelling corresponding to the lateral
clavicle and an asymmetry between the 2 shoulders. No visible wounds can be seen. There is no
neurological or vascular deficit. The X-ray demonstrates a displaced lateral clavicle fracture.
Which of the following statements is correct
about this injury?
A. It is unstable
B. The conoid ligament is torn
C. The periosteal sleeve is intact
D. The trapezoid ligament is torn
E. Treatment is non-operative
42. A 78-year-old woman presents to your clinic
with increasing pain in her right shoulder which
was replaced 12 years ago. You decide that this
prosthesis needs revising.
Which is the most common cause of shoulder
replacement failure?
A. Glenoid component loosening
B. Humeral component loosening
C. Infection
D. Instability
E. Subscapularis repair failure
285
Razvan Taranu and Shantanu Shahane
SHOULDER/ELBOW I STRUCTURED SBA
ANSWERS
1. Answer C. MRI arthrogram
All these investigations are useful in diagnosing
shoulder pathology, but the most indicated
investigation in this scenario is an MRI arthrogram, which will clearly show a spinoglenoid
notch cyst +/– SLAP tear. Spinoglenoid cyst is a
recognised cause of suprascapular compressive
neuropathy, which results in wasting of infraspinatus muscle only as the branch to supraspinatus
is given proximal to the spinoglenoid notch. A
dye is necessary to ‘fill’ the cyst, and so a plain
MRI scan may not be as useful.
2. Answer E. X-ray
Loss of external rotation is most commonly
caused by osteoarthritis, adhesive capsulitis,
trauma or tumour. The first and most accessible
investigation is an X-ray, which, in the scenario,
is able to demonstrate any osteoarthritic changes
or lytic lesions in the proximal humerus/neck of
glenoid. The X-ray may in itself reveal the necessary diagnosis. If not, further investigations may
also be later needed.
3. Answer D. Inability to forward flex the arm
Superolateral approach carr ies the risk of injury
to the terminal branch of axillary nerve supplying the anterior deltoid (anterior deltoid palsy).
The associated motor deficit will be inability to
forward flex the arm, while arm abduction will
still be possible as the innervation to middle
deltoid is still preserved. The sensory branch to
the regimental badge area is given more posterior, thus sensation will still be intact.
4. Answer B. Altered sensation in lateral forearm
and weak supination
Though many structures can be injured during
this surgery, the structure most at risk when
placing the shoulder retractors under the conjoint tendon is the musculocutaneous nerve,
which innervates three muscles (biceps brachii,
coracobrachialis and medial part of the brachialis) and provides sensation to the lateral forearm.
An injury to this nerve results in altered sensation in lateral forearm and weakness of forearm supination and elbow flexion.
5. Answer D. Hornblower sign
Absent sensation in the deltoid area suggests an
injury to the axillary nerve, which also supplies
the deltoid and teres minor muscles. Out of all
the possible answers, Hornblower sign is positive
when ther e is weakness of the teres minor (test is
performed by assessing external rotation with
arm abducted to 90° and in 90° of external rotation). The other tests assess the following pathology: empty can – supraspinatus tear; Gerber’s
lift-off – subscapularis tear; external rotation lag
sign – infraspinatus tear; and O’Brien’s test –
SLAP tear.
6. Answer C. X-ray
X-ray is the first investigation when there is
functional deficit following a traumatic event.
In this case, the first diagnosis to rule out would
be posterior dislocation. MRI , MRI arthrogram
and US are useful in diagnosing shoulder pathology but should only be requested when fracture
or dislocation has been excluded or as additional
investigation for correct assessment of soft tissue
status (after X-ray).
7. Answer C. Altered sensation in the lateral
forearm
The most common neurological deficit encountered with distal biceps tendon repair is injury to
lateral antebrachial cutaneous nerve (up to
9.9%), leading to altered sensation in the lateral
forearm. The other possible answers suggest
injuries to other nerves, but with a lower incidence. These will result in the following deficits:
altered sensation in the first web space (superficial radial nerve), inability to extend the thumb
with preserved wrist extension and radial deviation (posterior interosseous nerve), inability to
flex the thumb IPJ and index/middle fingers
DIPJ (anterior interosseous nerve).
Amin NH et al. Complications of distal
biceps tendon repair: a meta-analysis of singleincision versus double-incision surgical technique. Orthop J Sports Med. 2016;4(10).
8. Answer B. Inability to adduct the thumb
Lateral mass fracture can result in lateral physeal
arrest and cubitus valgus with tardy ulnar nerve
palsy. Weakness of adductor pollicis (innervated
by ulnar nerve) leads to inability to properly
286
Shoulder/Elbow I Structured SBA
adduct the thumb. Inability to abduct the thumb
is due to injury to PIN, weakness of wrist extension – PIN/radial nerve; weakness of forearm
supination – musculocutaneous nerve; loss of
IPJ thumb flexion – anteri or interosseous nerve.
9. Answer B. Inability to flex DIPJ of index finger
The anterior interosseous nerve is the most commonly injured nerve in extension-type paediatric
supracondylar elbow fractures. This results in
the inability to flex the index finger DIPJ
and IPJ of thumb (inability to make an ‘O’ sign
with thumb and index finger). The other
answers suggest an injury to the following
nerves: altered sensation over the lateral aspect
of forearm – lateral antebrachial cutaneous nerve
(terminal branch of musculocutaneous nerve);
inability to extend the wrist – radial nerve; inability to flex DIPJ of little finger – ulnar nerve;
inability to oppose thumb to little finger –
median nerve.
10. Answer B. 40% of supination strength
Patients who are counselled for non-operative
management of distal biceps tendon rupture
should be told that their supination strength will
reduce by 40%, flexion strength by 30% and grip
strength by 15%.
Morrey BF, Askew LJ, An KN, Dobyns JH.
Rupture of the distal tendon of the biceps brachii: a biomechanical study. J Bone Joint Surg
Am. 1985;67:418–421.
11. Answer E. Synostosis
The more common complication using a twoincisiontechnique as compared with the 1-incision
techniqueis synostosis. All theother complications
are more common with a 1-incision technique.
Amin NH et al. Complications of distal
biceps tendon repair: a meta-analysis of singleincision versus double-incision surgical technique. Orthop J Sports Med. 2016;4(10).
12. Answer B. HAGL
HAGL lesions (humeral avulsion of glenohumeral ligaments) are a rare and therefore often
missed cause of recurrent instability. This can
be diagnosed by MR arthrogram as an investigative modality (when the dye is seen to leak
extra articular, close to the neck of the humerus).
At arthroscopy, if a patient is experiencing recurrent instability and an obvious cause such as a
Bankart lesion is not found, a 70° scope should
be used to examine for a HAGL lesion, or the
scope moved to the anterior portal to diagnose
this pathology.
Rhee YG, Cho NS. Anterior shoulder
instability with humeral avulsion of the glenohumeral ligament lesion. J Shoulder Elbow Surg.
2007;16:188–192.
13. Answer C. Sensory action potentials intact and
motor action potentials deficit
A preganglionic in jury is an avulsion to the
dorsal root ganglion with a poor prognosis (little
potential for motor function recovery; see Figure
13.5 (a) and (b)). Clinical signs of preganglionic
injury are sensory intact, Horner syndrome,
medial scapula winging, paralysis of hemidiaphragm (phrenic nerve), inability to retract shoulder (rhom boid-dorsal scapular nerve), weak
abduction/external rotation (supraspinatus/
infraspinatus – suprascapular nerve), paralysis
of latissimus dorsi (thoraco-dorsal nerve).
Postganglionic injuries have a better prognosis
for recovery (Figure 13.5 (c) and (d)).
(b)(a)
Avulsion
Dorsal root
ganglion
Figure 13.5 (a) Normal anatomy of rootlets and roots. (b) Avulsive preganglionic injury. (c, d) Postganglionic injury
Stretch
(d)(c)
Rupture
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Razvan Taranu and Shantanu Shahane
14. Answer C. COR is fixed and moves inferiorly
and medially
Reverse polarity shoulder prosthesis provides a
fixed fulcrum, which prevents superior migration
of the humeral head and facilitates deltoid function. COR is also displaced medially and inferiorly
to increase deltoid lever arm and length, thus
improving its efficiency. This is essential knowledge even if the SBA is rather easy. If you have
got this question incorrect, re-evaluate your core
knowledge and revision methods.
Although the question is relatively easy it is
testing essential knowledge. The question was kept
and not discarded as it is those candidates getting
this question wrong who are on a sticky wicket.
15. Answer E. Weakness on belly press test
The posterior cord gives rise to five nerves: upper
subscapular (subscapularis muscle) , lower subscapular (subscapularis and teres major), thoracodorsal (latissimus dorsi), axillary (deltoid, teres
minor, lateral aspect of proximal arm, glenohumeral joint) and radial (elbow and forearm
extensors, supinators, posterior brachial cutaneous, inferolateral brachial cutaneous, superficial
radial nerve, posterior antebrachial cutaneous).
Belly press test is performed to assess for
weakness of the subscapularis muscle. Weakness
is a result of injury to the upper and lower subscapular nerves. All the other answers present a
combination of injury to different nerves not
limited to the posterior cord:
D. upper/lower subscapular (posterior cord) and
musculocutaneous (lateral cord)
C. superficial radial/axillary (posterior cord) and
musculocutaneous (lateral cord)
B. ulnar/medial antebrachial cutaneous (medial
cord) and radial (posterior cord)
A. musculocutaneous (lateral) and radial
(posterior cord)
16. Answer B. Miosis, anhidrosis, low oxygen
saturation
This patient developed hemidiaphragmatic paresis and Horner syndrome characterised by
miosis (small pupil), partial ptosis and anhidrosis
(absent sweating). This was due to involvement
of sympathetic trunk and phrenic nerve.
Side effects of interscalene block are phrenic
nerve block with diaphragmatic hemiparesis
288
(100% incidence, 25% reduction in pulmonary
function), Horner syndrome, block of vagus nerve
and recurrent laryngeal nerve (voice hoarseness),
pneumothorax, permanent neurological injury,
vertebral artery injection, severe hypotension and
bradycardia (Bezold–Jarisch reflex).
17. Answer A. Inability to retract left shoulder
This SBA is testing anatomy of the brachial plexus.
The level of injury is at the roots of brachial plexus.
The two nerves arising at this level are the dorsal
scapular nerve (C5) (rhomboids – shoulder retraction) and long thoracic nerve (serratus anterior
(C5, C6, C7) – protracts, upwardly rotates and
stabilises the scapula). The sympathetic chain can
also be injured, resulting in Horner syndrome
(miosis, anhidrosis, ptosis) (answer D), but this is
lower (C7, C8, T1). Shoulder shrug is performed
by the trapezius (innervated by spinal accessory
nerve, which is the XI cranial nerve). Froment’s
sign is positive in ulnar nerve injury.
18. Answer E. Weakness of forearm supination
The nerve at most risk when harvesting and
preparing the coracoid graft is the musculocutaneous, which pierces the coracobrachialis
approximately 3–8cm distal to the coracoid.
The patient will complain of weak forearm
supination due to biceps paralysis.
Elbow flexion will be weak but not absent, as
other muscles contribute to elbow flexion and are
not innervated by musculocutaneous nerve (brachioradialis and lateral part of brachialis – radial
nerve). Reduced sensation in regimental badge
area and weak shoulder abduction suggest an
injury to the axillary nerve. Weak elbow extension and reduced sensation in the first web space
are due to radial nerve injury.
19. Answer A. Apply back slab and immediate
closed/open reduction in theatre.
According to BOAST 11 guidelines revised in
October 2020, in the case of a child presenting
with an ischaemic limb and elbow supracondylar
fracture, the child should be taken to theatre
urgently and fracture should be reduced and
stabilised. In the majority of cases, vascular
impairment resolves with fracture reduction. If
there are no clinical signs of ischaemia, brachial
artery exploration is not required whether or not
the radial pulse is present.
Shoulder/Elbow I Structured SBA
20. Answer D. Return to theatre urgently and
explore the ulnar nerve
There is a concern of iatrogenic ulnar nerve
injury, which can occur with a crossed pinning
technique. There is no information regarding
intraoperative visualisation of the ulnar nerve,
which should be documented when medial wire
is used. In this particular situation, the patient
should return to theatre and ulnar nerve exploration should be performed.
21. Answer C. Dislocation
Fracture of the acromion, loosening of the glenosphere and infection are usually painful. A
patient elevating the arm adequately after surgery is unlikely to develop delayed onset axillary
nerve palsy. The most common cause of painlesslossofrangeofmotionat8weeksis
dislocation.
22. Answer D. Fracture of the acromion
This is due to incr eased stresses on the acromion,
resulting from an increase in deltoid tension,
especially in poor rheumatoid bone. Dislocation
is usually painless. Infection does not often
manifest with sudden loss of range of motion.
Delayed axillary nerve injury is uncommon.
Loosening of the glenosphere is a possible
explanation (though often does not happen so
soon after surgery), but fracture of the acromion
is more common.
23. Answer A. Anatomical total shoulder
replacement
Intact cuff and less than 10° of retroversion are
good indicators for success of anatomical TSR.
Injection is likely to give only short-term relief,
and surface replacement or stemmed hemiarthroplasty, thou gh possible, are known to create
increased glenoid erosive pain. In this age group,
in the presence of intact cuff, reverse TSR is not
indicated.
24. Answer A. Avulsion injury of triceps tendon
(‘flake sign’)
The image presents the ‘flake sign’, suggesting an
avulsion of the triceps tendon. Loose bodies in
elbow are rounded, intra-articular and usually
anterior. Fractures of the olecranon have a different configuration.
25. Answer C. Fragment overlap of more than 2cm
All are absolute ind ications for operative fixation except option C, which represents a relative indication. Other relative indications are
polytrauma patient, closed head injury, bilateral and displaced fractures, brachial plexus
injury.
26. Answer E. Surgery for non-union of the
humeral fracture
Though any of the complications are possible,
distraction non-union is the most common complication after humeral fracture nailing with a
reported incidence of 33%.
Hems TE, Bhullar TP. Interlocking nailing
of humeral shaft fractures: the Oxford experience
1991 to 1994 . Injury 1996;27:485–489.
27. Answer D. The coracoclavicular ligaments are
attached to the medial fracture fragment and
there is minimal fracture displacement
Neer’s classification of lateral third clavicle fractures consists of the following:
Type I – fracture occurs laterally to
coracoclavicular ligaments, which are intact.
Type II – A. between CC ligaments (intact
trapezoid and torn conoid), B. lateral to CC
ligaments (which are torn). Unstable injuries,
high non-union rate.
Type III – intra-articular extension into the ACJ
(CC ligaments intact). Risk of early
osteoarthritis, stable injury.
28. Answer E. Beighton’s score of more than 6,
multi-directional instability and no Bankart
lesion
This patient has a hypermobile shoulder and a
Polar type II/III instability on the Stanmore triangle (multidirectional, atraumatic, nonstructural). They very rarely if ever have a structural pathology such as a Bankart lesion. A
Beighton’s score of 5 or more is an indication
of generalised hypermobility.
The Polar classification of instability are: type
I – traumatic, structural, usually unilateral; type
II – atraumatic, occasionally secondary structural, not uncommonly bilateral, no muscle patterning; type III – muscle patterning, nonstructural.
289
Razvan Taranu and Shantanu Shahane
29. Answer E. Posterolateral rotatory instability
Most common traumatic elbow dislocation is
posterolateral which can result in injury to
LUCL (lateral ulnar collateral ligament). LUCL
is the main structure to prevent posterolateral
instability (PLI). Chronic PLRI presents with
intermittent clicking, often with elbow in extension and when pushing off a chair.
30. Answer B. Right brachiocephalic vein
The closest posterior structure to the right sternoclavicular joint is the right brachiocephalic
vein.
31. Answer A. Elbow extension
Adequate patient positioning and insufflation of
joint prior to instrumentation is crucial to avoid
intraoperative nerve injury. It has been demonstrated that joint insufflation with normal saline
and flexion to 90° leads to a maximum nerve-tobone distance (12mm for median nerv e and
6mm for radial nerve). However, insufflation
does not increase the capsule-to-nerve distance.
Extension of the elbow negates any advantage
obtained through insufflation of the joint.
Miller CD, Jobe CM, Wright MH.
Neuroanatomy in elbow arthroscopy. J Shoulder
Elbow Surg. 1995;4:168–174.
32. Answer D. Physiotherapy, cessation from
throwing and posterior capsular stretching
The patient suffers from internal shoulder
impingement which includes a spectrum of
injuries: superior and posterior labral lesions,
fraying of posterior rotator cuff, hypertrophy
and scarring of posterior capsule, cartilage
damage at posterior glenoid. All answers are
acceptable treatment options, but the first-line
management is physiotherapy, cessation from
throwing and posterior capsular stretching.
33. Answer: A. Angiofibroblastic hyperplasia
Angiofibroblastic hyperplasia occurs in lateral
elbow epicondylitis. The other histopathological
findings occur in: B – Adhesive capsulitis,
C – Dupuytren’s disease, D – Giant Cell
Tumour, E – Neuroma.
Tendinosis is incompletely understood.
Although the term tendinitis is used frequently
and often indiscriminately, histopathological
studies have shown that specimens of tendon
obtained from areas of chronic overuse do
not contain large numbers of macrophages,
lymphocytes or neutrophils. Rather, tendinosis
appears to be a degenerative process that is
characterised by the presence of dense populations of fibroblasts, vascular hyperplasia and
disorganised collagen. This constellation of
findings has been termed angiofibroblastic
hyperplasia.
Angiofibroblastic tendinosis refers to the
degenerative changes that occur when a tendon
has failed to heal properly after an injury or after
repetitive microtrauma resulting from overuse.
Tendinitis is characterised by the presence of an
increased number of lymphocytes or neutrophils.
Tendinosis is characterised by the presence of
active fibroblasts and vascular hyperplasia.
Bhabra G et al. Lateral elbow tendinopathy:
development of a pathophysiology-based treatment algorithm. Orthop J Sports Med.
2016;4:2325967116670635.
Kraushaar BS, Nirschl RP. Tendinosis of the
elbow (tennis elbow): clinical features and findings of histological, immunohistochemical, and
electron microscopy studies. J Bone Joint Surg
Am. 1999;81:259–278.
34. Answer: A. Excessive passive external rotation
Failure of subscapularis repair is a recognised
complication following total shoulder arthroplasty (TSA), especially if the patient is not compliant with the post-operative protocol. Patient
will have excessive passive external rotatio n.
Internal rotation of shoulder is reduced, but still
possible due to teres major, latissimus dorsi and
pectoralis major. Supraspinatus and infraspinatus are expected to be intact 6 weeks following
TSA. ‘Popeye’ muscle may occur prior to surgery
(spontaneous rupture in degenerative shoulder
or previous surgical intervention) or postoperatively (failed tenodesis). In the latter case,
the patient experiences a ‘pop’ in the anterior
aspect of the shoulder.
35. Answer E. Subclavian vein
All the above structures are at risk when performing fixation of clavicle fractures. The structure in most danger of being injured when
drilling into the medial clavicle is the subclavian
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Shoulder/Elbow I Structured SBA
vein, which in some cases is localised immediately behind the posterior cortex.
The brachial plexus, although at risk of
injury, is further away from clavicle than the
vessels in relation to the medial two-thirds of
the bone.
The vein is intimately related to the clavicle,
whereas the artery is somewhat protected by the
intervening scalenus anterior. An anteroposterior screw trajectory poses the greatest risk of
injury to the subclavian vein in this zone,
whereas a craniocaudal screw trajectory, as performed in superior plating, appears to be a safe
option.
Sinha A, Edwin J, Sreeharsha B, Bhalaik V,
Brownson P. A radiological study to define safe
zones for drilling during plating of clavicle fractures. J Bone Joint Surg Br. 2011;93:1247–1252.
36. Answer B. Old age
Inflammatory arthritis, young age, smoking,
post-operative haematoma and steroid injection
within 3 months of surgery are risk factors for
prosthetic shoulder joint infection.
Aibinder W et al. Risk factors for complications and revision surgery after anatomic and
reverse total shoulder arthroplasty. J Shoulder
Elbow Surg. 2021;30:e689–e701.
Werner BC et al. The timing of elective
shoulder surgery after shoulder injection affects
postoperative infection risk in Medicare patients.
J Shoulder Elbow Surg. 2016;25:390–397.
37. Answer D. Pain is given by impingement and
motion at the non-union site
Os acromiale is a failure of fusion at one of the
three ossification centres of the acromion: preacromion, meso-acromion and meta-acromion.
The most common location is between the mesoand meta-acromion. It is associated with rotator
cuff tears in up to 50% of the cases, although some
studies suggest that this figure is exaggerated. It is
best diagnosed on axillary view radiograph with
some additional benefit of CT to detect degenerative changes. Pain is given by impingement as the
anterior fragment flexes with contraction of deltoid and arm elevation and by motion at the nonunion site. Excision of the anterior acromion can
lead to weakness of anterior deltoid, depending on
the size of the fragment.
You T, Frostick S, Zhang WT, Yin Q. Os
acromiale: reviews and current perspectives.
Orthopaedic Surg. 2019;11:738–744.
38. Answer B. Bursal sided fraying of
supraspinatus
This patient suffers from internal impingement
which is a recognised cause of shoulder pain in
overhead athletes. This occurs due to repetitive
impingement between the undersurface of the
rotator cuff and the posterosuperior glenoid,
during late cocking and early acceleration phases
of throwing. Bennett lesion (also known as
thrower’s exostosis, ossification near the glenoid
attachment of posterior band of inferior glenohumeral ligament), superior and posterior labral
lesions, cartilage damage at posterior glenoid are
features of internal impingement. Bursal sided
fraying of supraspinatus is found in external
impingement.
39. Answer D. Quadrilateral space syndrome
Quadrilateral space syndrome is a rare cause of
postero-lateral shoulder pain in overhead athletes. Symptoms are usually worse at night and
are exacerbated by overhead activity or late
cocking phase/acceleration phase of throwing.
An inferior paralabral cyst can cause compression of the axillary nerve in the quadrangular
space. Suprascapular neuropathy is caused by a
superior labral cyst with SLAP tear. Long head of
biceps tendinopathy and internal impingement
are also causes of shoulder pain in athletes, but
they are not associated with paraesthesia or
weakness of external rotation with arm abducted.
Parsonage–Turner syndrome (brachial neuritis)
results in patchy muscle paralys is and sensory
loss involving the shoulder girdle and upper
extremity.
40. Answer A. Artery, ligament (arising from
medial base of coracoid), nerve
The following structures are present at the level
of the suprascapular notch: suprascapular artery,
suprascapular transverse ligament (arising from
the medial base of coracoid), suprascapular
nerve. The surgeon should be aware that the
artery is overlying the ligament and can be
injured during decompression of the nerve. The
nerve is the deepest structure of the three.
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Razvan Taranu and Shantanu Shahane
41. Answer E. Treatment is non-operative
Type IV distal clavicle fractures (paediatric) is a
physeal fracture which occurs in skeletally immature patients. Conoid and trapezoid ligaments
remain intact, but the clavicle pulls out of the
periosteal sleeve. It is a stable injury, with great
potential for remodelling and treatment is nonoperative.
They are commonly misinterpreted as dis-
locations of the acromioclavicular joint (ACJ),
although they are in fact Salter–Harris type 2
fractures of the lateral clavicular physis. The coracoclavicular ligaments remain intact, unlike
following a dislocation of the ACJ, allowing the
periosteal sleeve to maintain its relationship with
the ACJ. Instead, the metaphysis displaces
through the periosteal sleeve, akin to a banana
slipping out of its skin; this has been described as
a ‘pseudo dislocation’.
Dameron and Rockwood (1984) classified
these injuries in a similar manner to dislocations
of the ACJ, based on the disruption of the
periosteal tube and the consequent metaphyseal
displacement.
Dameron TB, Rockwood CA. Fractures and
dislocations of the shoulder. In Rockwood CA,
Wilkins KE, King RE, eds. Fractures in Children,
624–653. Philadelphia: JB Lippincott; 1984.
Rashid A, Christofi T, Thomas M. Surgical
treatment of physeal injuries of the lateral aspect
of the clavicle: a case series. Bone Joint J. 2013;95-
B:664–667.
42. Answer A. Glenoid component loosening
All answers listed above can cause failure of
shoulder prosthesis, glenoid component
loosening being the most common one (around
20%). Humeral stem loosening occurs more
often in rheu matoid patients.
Somerson JS, Hsu JE, Neradilek MB,
Matsen FA 3rd. Analysis of 4063 complications
of shoulder arthroplasty reported to the US Food
and Drug Administration from 2012 to 2016. J
Shoulder Elbow Surg. 2018;27:1978–1986.
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Section 2
Chapter
14
Adult Elective Orthopaedics and Spine
Shoulder/Elbow II Structured SBA
Jonny Kent and Faizan Jabbar
SHOULDER AND ELBOW II STRUCTURED
SBA QUESTIONS
1. A 19-year-old competitive rugby player sustains a
fourth time shoulder dislocation. Their Beighton
score is 6.
Which management option is most appropriate?
A. Arthroscopic capsular plication
B. Arthroscopic shoulder stabili sation
C. Open bone block procedure i.e. Laterjet
D. Physiotherapy alone
E. Remplissage procedure
2. Whilst working out in the gym, a patient feels a
pop in their elbow and notices bruising on the
medial forearm.
A structure is repaired through a single incision approach, which deficit will be seen if the
most involved nerve is injured?
A. Altered/absent sensation in first dorsal web space
B. Altered/absent sensation volar lateral forearm
C. Altered/absent sensation volar medial forearm
D. Weakness/inability to extend fingers
E. Weakness/inability to flex thumb IPJ
3. During a shoulder arthroscopy the antero-
superior labrum was noted to be absent and the
MGHL to be cord-like.
Which answer is most appropriate to account
for this finding?
A. Frozen shoulder
B. Normal anatomical variant
C. Recurrent instability
D. Rotator cuff tear
E. SLAP lesion
4. A male patient presents with increasing pain
several months following shoulder arthroplasty.
His CRP and ESR are normal.
If infected, where is the most frequently causal
bacteria commonly found?
A. GI tract
B. GU tract
C. Oral cavity
D. Sebaceous glands
E. Skin surface
5. Following a fall, an 82-year-old female patient
sustains a three-part proximal humerus fracture.
Which factor predispo ses her to humeral head
AVN the mo st?
A. Age
B. Disrupted medial hinge
C. Fracture configuration
D. Medial calcar segment >8mm
E. Sex
6. During shoulder arthroscopy a Buford complex
was inadvertently ‘repaired’ and ‘re-attached’ to
the glenoid.
As a result of this, what sign is the patient likely
to exhibit?
A. Decreased abduction
B. Decrease d forwards flexion
C. Decreased external rotation
D. Decreased internal rotation
E.
Instability
7. A 75-year-old patient with antero-superior
escape of the humeral head and arthritis undergoes shoulder surgery.
Following the most appropriate operation,
what predominantly happens to the patient’s
centre of rotation (COR) compared with their
anatomic one (glenohumeral joint)?
A. Distalised
B. Distalised and lateralised
C. Lateralised
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