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Jonny Kent and Faizan Jabbar
D. Medialised
E. Remains the same
8. A student presents to clinic 3 months post injury.
Their main complaint is elbow clicking when
getting out of a chair.
Which structure is most commonly injured?
A. Annular ligament
B. Lateral ulna collateral ligament
C. Medial collateral ligament
D. Radial collateral ligament
E. Radial head
9. A right-handed 12-year-old gymnast presents
with insidious loss of elbow extension.
Where is the typical finding located?
A. Left capitellum
B. Left radial head
C. Left trochlea
D. Right capitellum
E. Right trochlea
10. Following arthroscopic release of a condition
characterised by angiofibroblast hyperplasia,
which structure is most at risk?
A. Annular ligament
B. LUCL
C. MCL
D. Posterior interosseous nerve
E. Ulna nerve
11. A runner falls with their arm in a supinate d
position and sustains a significant valgus
posterolateral force to their elbow.
What is the most common complete sequence
of events?
A. LCL–AP capsule–MCL
B. LCL–coronoid–radial head/neck
C. LUCL–AP capsule–MCL
D. LUCL–LCL–AP capsule
E. MCL–AP capsule–LUCL
12. A patient sustains a fall. They present with per-
sistent anteri or shoulder pain, and although all
movements are well maintained, resisted forearm
supination elicits pain and the patient occasionally experiences a clicking sensation.
Which structure is likely injured?
A. Anterior labrum
B. MGHL
C. Pectoralis major tendon
D. Subscapularis
E. Supraspinatus
13. A cricketer presents with decreased bowling
speeds and pain after throwi ng.
Which radiographic finding is least likely to be
observed?
A. Calcium deposits in MCL
B.
Hypertrophy of humerus
C. Loose bodies
D. Osteophyte formation on the posterolateral
olecranon
E. Traction spurs on medial aspect of ulnar
notch
14. Following a mastectomy with axillary node dissection, a patient presents with asymmetry of
their shoulders.
Which clinical presentation is most likely?
A. Lateral scapular winging
B. Medial scapular winging
C. Wasting of trapezius
D. Weak shoulder abduction
E. Weak shoulder external rotation
15. Following ‘awake’ rotator cuff repair under
regional block, a patient with pre-existing asthma
has mild difficulty breathing in the recovery ward.
Which finding is most likely?
A. Basal atelectasis
B. Horner syndrome
C. Local anaesthetic toxicity
D. Pulmonary embolism
E. Raised hemidiaphragm
16. On clinical examination of a patient with tingling
down the medial aspect of the arm as well as
gross wasting of all the intrinsic muscles of the
hand it is noticed that there is reducti on of the
radial pulse when the shoulder is externally
rotated and hyperabducted as opposed to when
it is by the side.
The structure most likely causing this reduction in pulse is:
A. Cervical rib
B. Costoclavicular ligament
C. Deltoid
D. Pectoralis minor
E. Scalenus anterior
294
Shoulder/Elbow II Structured SBA
Figure 14.1
Clinical picture
demonstrating
external rotation
shoulder and
hyperabduction.
Radial pulse
is monitored
17. With regards to damage of the ulnar nerve at the
elbow.
Which of the following statements is false?
A. Clawing of the little and ring finger
B. Inability to flex DIP joint of fourth and fifth
digits
C. Intrinsic muscle strength will always be lost
D. Paraesthesia ulnar 1½ digits
E. Positive Froment’s sign
18. A patient presents with weakness of APB, OP
and weakness of flexion of the PIPJ of the index
finger. FCR and FCU are intact.
The site of compression is most likely:
A. Between the heads of pronator teres
B. Deep to lacertus fibrosus (bicipital aponeurosis)
C. Deep to the fibrous arch of FDP
D. Deep to the ligament of Struthers
E. Deep to the transverse carpal ligament
19. A patient with AIN palsy due to entrapment
at the tendinous edge of the deep head of
pronator teres will have all the f ollowing
except:
A. Intact sensation at base of thenar eminence
B. Normal pronation strength with the elbows
fully flexed
C. Weakness of flexion to the index DIPJ
D. Weakness of flexion of the DIPJ of the
middle/long finger
E. Weakness of flexion of the IPJ of the thumb
20. A 48-year-old right hand-dominant builder
develops a 4-month history of weakness of
flexion of the right thumb IPJ and index DIPJ.
Which of the following would be your likely
treatment?
A. Decompression of the nerve between the two
heads of pronator teres
B. Reassurance
C. Release of the Gantzer muscle
D. Release of the lacertus fibrosus edge
E. Splinting of the joints in slight flexion
21. When counselling a patient with a brachial
plexus injury following an RTA, which of the
following would be a clinical finding that does
not necessarily indicate a poor prognosis with
regards to the brachial plexus injury?
A. Jobe’s test positive
B. Medial winging of the scapula
C. Ptosis
D. Raised ipsilateral hemidiaphragm
E. Unsteadiness in standing
22. A 59-year-old man underwent an uneventful
anterior cervical discectomy and fusion (ACDF)
C5/C7 for cervical disc prolapses with an excellent result. Four weeks post-operatively, he
experienced severe pain in the right shoulder
and arm, after gardening. The pain increased in
the next 2 days and was followed by weakness of
the right arm. There was also hypaesthesia in the
right thumb. Three months after surgery he was
seen with marked atrophy of the right shoulder
girdle, mainly the deltoid and biceps muscles.
There was severe tenderness over the right shoulder, biceps and elbow. Active and passive range
of motion of the right shoulder were limited. The
right biceps and brachioradialis reflexes were
absent. The right deltoid strength was graded
MRC 2/5, right biceps strength 3/5; all other
muscles were normal. Plain radiographs and US
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Jonny Kent and Faizan Jabbar
scan showed glenohumeral subluxation but an
intact rotator cuff. A CT-scan cervical spine
showed correct instrumentation. RI cervical
spine did not show any significant residual foraminal stenosis.
The most likely diagnosis is
A. HIV infection
B. Lyme disease (neuroborreliosis)
C. Parsonage–Turner syndrome
D. Post-operative C5 palsy
E. Thoracic outlet syndrome
23. A 23-year-old male sustained a dislocation of his
left elbow following a football injury. A closed
reduction was performed in the ED. At fracture
clinic appointment one week later, he was noted
to have weakness in his left forearm and hand.
Which of the following muscle actions is most
likely to be the last to recover?
A. Palmer abduction
B. Flexion and abduction of the wrist
C. Flexion at the PIP joint index finger
D. Opposition of the thumb
E. Ring and little finger MCP joint flexion and
IP joint extension
24. A 21-year-old male sustains a knife laceration to
the dorsal surface of his left arm. This was
explored in theatre, and a nerve repair was performed. At follow-up review 3 months later, he
still complains of weakness and functional deficit
of his left wrist and hand. He is concerned about
the lack of progress.
Which of the following muscle def icit(s) is most
likely to be the last to recover?
A. Weakness of extension and abduction of the
thumb at the MCPJ and CMCJ
B. Weakness of index finger extension at the
MCPJ and IPJs
C. Weakness of IPJ thumb extension
D. Weakness of thumb abduction at the CMCJ
E. Weakness unscrewing a jar
25. A 22-year-old right-handed professional javelin
thrower attends the outpatient clinic with a 1month history of right elbow pain. Pain is localised to the medial side of the elbow, and his pain
is exacerbated by overhead throwing activities.
He denies any locking or catching within the
elbow. Clinical examination demonstrates focal
tenderness over the medial epicondyle. There is
significant pain when a valgus stress is applied to
the elbow.
The most likely diagnosis is which of the
following?
A. Flexor pronator muscle strain
B. Medial epicondylitis
C. Osteochondral lesion at the humeral ulnar
joint
D. Ulnar collateral ligament (UCL) tear
E. Ulnar nerve subluxation
26. A 23-year-old bodybuilder and regular gym user
attends clinic complaining of several months’
history of tingling and numbness of his right
little finger. Examination reveals weakness of
pinch.
The most likely site of nerve compression
would be which of the following?
A. Anconeus epitrochlearis
B. Arcuate ligament
C. Guyon’s canal between the pisiform and hook
of hamate
D. Medial head of triceps
E. Osbourne fascia
27. A 53-year-old male patient attends follow-up OP
clinic after an MRI scan has been ordered for
right shoulder pain. The scan reports a fullthickness tear.
Concerning rotator cuff tears, which of the
following is true?
A. A large proportion of patients with full-
thickness tears eventually require surgery
B. Cut-off size for tears to be symptomatic is
2.5cm
C. Failure of arthrosco pic rotator cuff repair is
unusual
D. Most full-thickness rotator cuff tears are
symptomatic
E. Pain and functional status are associated with
tear size, fatty infiltration and muscle atrophy
28. A 71-year-old woman attends the ED with a
periprosthetic fracture of her left shoulder. Her
shoulder radiograph is shown in Figure 14.2.
The most common cause for this fracture
would be which of the following?
296
Shoulder/Elbow II Structured SBA
Figure 14.2
Anteroposterior
(AP) radiograph
periprosthetic
shoulder fracture
A. A fall onto the outstretched hand
B. Cortical weakening due to a stress riser
C. Low virulence infection
D. Prosthetic loosening
E. Steroid therapy
29. A 53-year-old male right-handed painter and
decorator presents to clinic with a 2-year history
of right shoulder pain associated with shoulder
movement. He is taking regular paracetamol and
NSAIDs. On examination, he had bilateral shoulder symmetry with tenderness limi ted to the
anterior border of the acromion. Active abduction and forward flexion were both limited to
50°. External rotation of the shoulder was full
but weak compared with the opposite shoulder.
The next most appropriate step in management
would be which of the following?
A. Injection of local anaesthetic into the suba-
cromial space
B. MRI scan of the shoulder
C. Outpatient ultrasound scan of the shoulder
D. Shoulder arthrogram
E. X-ray of the shoulder
30. A 60-year-old male patient without any history
of recent trauma had been experiencing disabling
pain in the right shoulder for 5 months. The pain
progressed at night, especially when he rested on
his right shoulder. The weakness of the right
shoulder was noted when he lifted objects that
weighed more than 5kg. There were neither limitations in range of motion nor atrophy of the
musculature of his right shoulder. The empty can
test yielded positive results, but there was no
dropping sign or external rotation lag in his right
shoulder.
Given the history and exami nation findings,
the most appropriate operative intervention
would be?
A. Arthroscopic cuff repair
B. Mini open rotator cuff repair
C. Reverse total shoulder arthroplasty
D. Superior capsule repair
E. Tendon transfer
31. A 69-year-old, right hand-dominant female pre-
sents to the clinic with an 8-month history of
worsening right shoulder pain. She continues to
work part-time in a post office. She is generally
fit and healthy. On examination, she has terminal loss of full shoulder movement with pain.
There is good rotator cuff strength. Her radiographs are shown in Figure 14.3.
Figure 14.3
Anteroposterior (AP)
radiograph shoulder
What is the most suitable treatment option?
A. Resurfacing hemiarthroplasty shoulder
B. Reverse shoulder replacement (RSA)
C. Shoulder hemiarthroplasty
D. Stemless shoulder prosthesis
E. Total shoulder arthroplasty (TSA)
32. Which of the following is true concerning the
carrying angle of the elbow?
A. The carrying angle decreases with age
B. The carrying angle increases with elbow
flexion
C. The carrying angle is defined as the angle
between the long axis of the extended and
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Jonny Kent and Faizan Jabbar
supinated forearm as it lies lateral to the long
axis of the arm
D. The carrying angle is greater in males than
females
E. The normalrange for the carrying angle is 5–15°
33. Concerning the biomechanics of reverse total
shoulder arthroplasty, all the following are true
except which?
A. Effective lever arm of deltoid to initiate
movement
B. Fixed centre of rotation, distalised and med-
ialised in relation to the glenoid surface
C. Intrinsic stability
D. Medialising the joint centre of rotation
increases the torque on the glenoid bone–
implant interface and decreases the lengths
of the deltoid abductor moment arm
E. Semi-constrained design by large glenosphere
and small humeral cup
34. A 78-year-old patient attends for an outpatient
follow-up appointment 2 years following reverse
total shoulder arthroplasty (RTSA). She complains of loss of active abduction and significantly less shoulder strength than expected. Her
radiographs are shown in Figure 14.4.
35. A 48-year-old male presents to clinic with a
positive Hornblower sign.
The most likely rotator cuff muscles involved in
a tear include:
A. Infraspinatus and subscapularis
B. Supraspinatus
C. Supraspinatus and infraspinatus
D. Supraspinatus and subscapularis
E. Supraspinatus, infraspinatus and teres minor
36. A 40-year-old male diabetic patient who 6 weeks
ago had shoulder arthroscopy for a labral tear,
presents with a 2-week history of severe pain in
the same shoulder. Examination found significant wasting of the supra and infraspinatus
fossae and an almost full range of passive shoulder movement. His inflammatory markers were
within normal limits.
Of the following options, which is the most
likely diagnosis?
A. Adhesive capsulitis
B. Cervical discs prolapse
C. Entrapment neuropathy in the supra-glenoid
notch
D. Parsonage–Turner syndrome
E. Septic arthritis
298
Figure 14.4
Anteroposterior
(AP) radiograph
right shoulder
Numerous technical strategies have been proposed to reduce the occurrence of this condition including which of the following?
A. Allowing inferior overhang of the
glenosphere
B. Concentric glenosphere position
C. Decreased inclination (neck–shaft angle) of
the humeral component
D. Implanting of the glenoid component in a
position with inferior inclination
E. Increased medial offset
37. A 12-year-old boy suffers a Salter-Harris type 3
anterior fracture dislocation of the proximal
humerus subsequent to a high energy trauma.
He undergoes open reduction and internal stabilisation. After regaining function and achieving
union you have concerns, he has focused osteonecrosis of the epiphyseal fragment.
How would you best manage this patient’s subsequent care?
A. Capsular release
B. Close outpatient follow up
C. Humeral head surgical debridement and
bone grafting
D. Pulsed electrical stimulation
E.
Removal of metal work
38. A 68-year-old woman presents with progressive
elbow pain over the last 2 years, with a background of previous traumatic elbow injury. Her
symptoms now impact her activities of daily
living and are severely debilitating. X-rays demonstrate severe end-stage arthritis with multiple
Shoulder/Elbow II Structured SBA
loose bodies, osteophyte formation and complete
loss of joint space. You perform a semiconstrained total elbow arthroplasty.
With regard to early presentation, what would
be the likely mode of failure?
A. Aseptic loosening
B. Bushing failure
C. Component loosening
D. Infection
E. Instability secondary to component
malposition
39. You perform a diagnostic shoulder arthroscopy
to assess a patient’s rotator cuff with an aim to
perform a repair in a high BMI patient. Due to
body habitus your posterior portal placement is
challenging and you are required to adjust your
portal further lateral to establish access.
Which nerve could potentially be at risk in this
case?
A. Axillary nerve
B. Musculocutaneous nerve
C. Phrenic nerve
D. Subscapular nerve
E. Suprascapular nerve
40. A 30-year-old male athlete presents with a 1-year
history of intermittent posterior shoulder pain
and weakness. Clinically he was found to have a
degree of unidirectional shoulder instability,
weakness in external rotation and inferior scapular muscle hypotrophy. You arrange an outpatient MRI.
Where would you likely find the anatomical
location of the underlying pathology?
A. Brachial plexus upper trunk
B. Cervical disc
C. Rotator cuff
D. Spinoglenoid notch and ligament
E. Suprascapular notch and transverse ligament
41. As the upper limb specialist, you see a 35-year-
old manual worker who presents with a posttraumatic flail shoulder, however intact distal
function. He has found to have complete paralysis and massive rotator cuff pathology. You plan
to perform a shoulder arthrodesis.
What position will you fuse his joint to maximise his functional outcome?
A. 10° forward flexion, 10° abduction, 20°
internal rotation
B. 10° forward flexion, 20° abduction, 10° exter-
nal rotation
C. 30° forward flexion, 30° abduction, 20° exter-
nal rotation
D. 30° forward flexion, 30° abduction, 30°
internal rotation
E. 40° forward flexion, 30° abduction, 20°
internal rotation
42. An 18-year-old male suffers a traumatic elbow dislocation. Subsequent to this he struggles to perform
push-ups at the gym 6 months following his injury.
He is referred into your clinic for further assessment.
Which of the following tests will likely demonstrate positive findings?
A. Cozen’s test
B. Hyperpronation test
C. Lateral pivot shift-test
D. Provocation testing with passive extension of
wrist and elbow
E. Varus stress test with elbow in 30° flexion
43. A young patient undergoes a shoulder arthro-
scopic Bankart repair subsequent to acute shoulder dislocation.
Which of the following predisposing factors does
not increase the risk of recurrent instability?
A. Age under 20
B. Associated greater tuberosity fracture
C. Bilateral shoulder laxity
D. Hill–
E. Involvement in competitive sport
44. A 60-year-old female presents with a progressive
history of a painless, swollen elbow, with progressive loss of function and no constitutional
symptoms. Radiographs performed demonstrate
severe fragmentation, dislocation and severe
sclerotic changes throughout the elbow.
From the below options, what is the most
common aetiology of the underlying condition?
A. Syringomyelia
B. Hansen’s disease
C. Neurosyphilis
D. Diabetes
E. Septic arthritis
Sachs lesion on external rotation AP
radiograph
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Jonny Kent and Faizan Jabbar
SHOULDER AND ELBOW II STRUCTURED
SBA ANSWERS
1. Answer C. Open bone block procedure i.e.
Laterjet
Rationale: The patient ’s instability severity index
score is 6, even without X-rays, which could
highlight a Hill–Sachs lesion or glenoid bone
loss, increasing it further. Risk factors for recurrent shoulder instability identified by Balg and
Boileau (2007) as age (20 years), competitive
sportsman, overhead/contact sport, hyperlaxity,
Hill–Sachs on A/P X-ray, loss of inferior glenoid
contour. A score of 6 points = an acceptable
recurrence risk of 10% with arthroscopic stabilisation. A score of >6 points = an unacceptable
recurrence risk of 70% and should be advised to
undergo open surgery (i.e. Laterjet procedure).
This patient has recurrent instability (fourth
dislocation) and is highly likely to have critical
bone loss of the glenoid (Hasegawa et al. 2019).
Although possible, an arthroscopic stabilisation would likely have a higher failure rate.
Physiotherapy would not address the pathoanatomical reasons for dislocation although would
be useful as pre-hab and necessary as rehab.
Remplissage can be used to fill a Hill–Sachs
lesion and can therefore help with off-tack
lesions although this is often combined with a
Laterjet type procedure if necessary.
Key points:
Description of patient points towards high ISIS
(age = 2, competitive = 2, overhead/contact = 1).
Fourth time dislocation – recurrence and
therefore glenoid bone loss or the development of
Hill–Sachs lesion likely to be present. This would
increase ISIS and degree of glenoid bone loss could
push towards an open bone block procedure.
High Beighton score suggests hyperlaxity
(scores 1 on ISIS).
Balg F, Boileau P. The instability severity
index score: a simple pre-operative score to select
patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89:1470–1477.
Hasegawa Y et al. The number of injury
events associated with the critical size of bipolar
bone def ects in rugby players with traumatic
anterior shoulder instability. Am J Sports Med.
2019;47:2803–2808.
2. Answer B. Altered/absent sensation volar lat-
eral forearm
Rationale: Distal biceps tendon attaches to the
radial tuberosity. A single incision approach utilises a single transverse or ‘lazy-s’ incision on the
proximal volar forearm. The most commonly
injured nerve is the lateral cutaneous nerve of
the forearm (9.8%) which supplies sensation to
the volar surface of the lateral forearm. This can
be damaged by excessive retraction or during the
skin and subcutaneous fat dissection itself. Other
nerves cited as being injured include PIN (2.7%)
and median nerve (0.1%).
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).
3. Answer B. Normal anatomical variant
Rationale: This description is of a Buford complex or sub-labral foramen. The cord-like MGHL
originates from near to the bicep anchor and
crosses the sub-scapularis tendon to attach onto
the humerus. Unlike labral pathology for
instability which classically affects the 3–6
o’clock position, the antero-superior labrum is
also deficient. While a normal variant, patients
with Buford complexes have been shown to have
increased ROM and a high incidence of concurrent SLAP lesions. Frozen shoulders are characterised by capsular tightening.
Bents RT et al. The correlation of the Buford
complex and SLAP lesions. J Shoulder Elbow
Surg. 2005;14:565–
Williams MM. et al. The Buford complex –
the ‘cord-like’ middle glenohumeral ligament
and absent anterosuperior labrum complex: a
normal anatomic capsulolabral variant.
Arthroscopy 1994;10:241–247.
4. Answer D. Sebaceous glands
Rationale: Cutibacterium acnes is the most frequently isolated bacteria following shoulder PJI.
C. acnes resides in sebaceous glands. Males have
increased numbers of sebaceous glands thus
increasing the chance of seeding during surgery.
Diagnosis is difficult as it has low virulence and
patients are often systemically well with no local
signs and normal or only mildly elevated biochemical markers.
569.
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Shoulder/Elbow II Structured SBA
Key points: Male patient, normal inflamma-
tory markers point towards C. acnes infection.
Foster AL et al. Cutibacteriu m acnes in
shoulder surgery: a scoping review of strategies
for prevention, diagnosis, and treatment. J
Shoulder Elbow Surg. 2021;30:1410–1422.
5. Answer B. Disrupted medial hinge
Rationale: AVN of the humeral head is a risk
associated with proximal humerus fractures.
Hertl et al. (2004) assessed fracture morphology
to ascertain the relative risks linked to AVN.
Strong predictors of ischaemia include a medial
metaphyseal calcar length <8mm, a disrupted
medial hinge and more complex fracture patterns. Campochiaro (2015) found no correlation
with age, sex and fracture type with AVN, citing
accuracy of reduction as the most important
predictor following fixation.
Campochiaro G. Complex proximal
humerus fractures: Hertel’s criteria reliability to
predict head necrosis. Musculoskelet Surg.
2015;99:S9–15.
Hertel R et al. Predictors of humeral head
ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg.
2004;13:427–433.
6. Answer C. Decreased external rotation
Rationale: A Buford complex is a normal anatomical variant seen in shoulders. It is characterised by a cord like MGHL and an absent anterosuperior labrum. It is important to distinguish
this from pathological findings. If mistaken for a
labral tear and repaired, the anterior capsule and
MGHL can restrict external rotation. The key
here is being aware of what a Buford complex
is, and that tightening of the MGHL will restrict
external rotation.
Modarresi S et al. Superior labral anteropos-
terior lesions of the shoulder. Part 1, anatomy
and anatomic variants. Am J Roentgenol.
2011;197:596–603.
and humeral cup, the COR is medialised. This
medialisation of the COR decreases shea r forces
across the glenoid component and creates compressive forces at the bone-impla nt interface and
minimises the ratio of shear to compressive
forces at the joint leading to an inherently stable
prosthesis.
The humerus is distali sed which recruits
more parts of deltoid and aligns muscle fibres
more vertically whilst increasing the muscles
lever arm, gaining a bio mechanical advantage.
Rugg CM et al. Reverse total shoulder arthro-
plasty: biomechanics and indications. Curr Rev
Musculoskelet Med. 2019;12:542–553.
8. Answer B. Lateral ulna collateral ligament
Rationale: The symptom described is classically
associated with posterolateral rotatory instability.
When an axial force is applied with the elbow
moving into extension and supinated, the radial
head subluxes and can cause mechanical symptoms such as clicking and popping.
The most commonly implicated structure for
PLRI is a torn or attenuated LUCL. This can be
seen as direct trauma following elbow dislocations/subluxations or due to chronic attrition.
O’Driscoll SW, Morrey BF, Korinek S, An
KN. Elbow subluxation and dislocation: a spec-
trum of instability. Clin Orthop Relat Res.
1992;280:186–197.
9.
Answer D. Right capitellum
Rationale: Age (>10 years old) and sport (gymnast) point towards osteochondritis dissecans
(OCD). This is strengthened by the insidious loss
of extension – an early sign and there not being
any specific trauma or mention of systemic signs.
With this diagnosis the knowledge aspect is
where the OCD is most commonly located. It is
most frequently in the dominant capitellum.
Takahara M et al. Long term outcome of
osteochondritis dissecans of the humeral capitellum. Clin Orthop Relat Res. 1999;363:108–115.
7. Answer D. Medialised
Rationale: The presence of antero-superior
humeral escape and evidence of arthritis points
to cuff arthropathy. In this age group the most
appropriate operation would be a reverse polarity shoulder arthroplasty. By using a glenosphere
10. Answer B. LUCL
Rationale: Lateral epicondylitis (tennis elbow) is
characterised by angiofibroblastic hyperplasia. It
occurs within the ECRB origin. Following failure
of non-operative management debridement can
be perf ormed. The ECRB arises from the lat eral
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epicondyle with the LUCL origin being deep and
distal to this. As such, during debridement, a
clear view of the LUCL is necessary to prevent
iatrogenic injury. Unrecognised, this could lead
to PLRI.
Kalainov DM, Cohen MS. Posterolateral
rotatory instability of the elbow in assoc iation
with lateral epicondylitis: a report of three cases.
J Bone Joint Surg Am. 2005;87:1120–1125.
11. Answer C. LUCL–AP capsule–MCL
Rationale: The patient has sustained an elbow
dislocation. This can be ascertained from the
position of the arm and the direction of the force
applied, in conjunction with the possible
answers. With this information it is then applying the knowledge of elbow dislocations and the
Horii circle. This describes the patho-anatomy as
three stages from PLRI to perched up to a dislocation with increasing instability.
Robinson PM, Griffiths E, Watts AC.
Simple elbow dislocation. Shoulder Elbow
2017;9:195–204.
12. Answer D. Subscapularis
Rationale: The patient is most likely to have a
partial subscapularis tear and presents with signs
and symptoms of an unstable and inflamed long
head of biceps (LHB) tendon. The subscapularis is
the main medial constraint to the LHB and when
torn, allows subluxation. The key points include
the anterior pain and positive Yergason’s test
(resisted forearm supination) pointing towards
bicep pathology coupled with the clicking which
highlights LHB instability. Clicking can occur for
a variety of reasons including labral pathology.
Shi LL et al. Accuracy of long head of the
bicep’s subluxation as a predictor for subscapularis tears. Arthroscopy 2015;31:615–619.
13. Answer D. Osteophyte formation on the poster-
olateral olecranon
Rationale: This cricketer has symptoms suggestive of elbow valgus overload. Pain after throwing
and a reduction in throwing, bowling or pitching
speed and frequency are commonly described. Xrays and CTs often highlight loose bodies (from
capitellum), traction spurs on the ulnar, as well
as hypertrophy of the humerus (causing further
deceased joint space). Osteophyte formation on
the posteromedial olecranon is commonly seen
due to excessive shear forces on medial aspect of
olecranon tip and olecranon fossa.
Wilson FD et al. Valgus extension overload
in the pitching elbow. Am J Sports Med.
1983;11:83–88.
14. Answer B. Medial scapular winging
Rationale: Axillary dissection puts peripheral
nerves at risk, specifically, long thoracic and
thoracodorsal nerves. The long thoracic nerve
supplies serratus anterior and results in medial
scapular winging (describes the direction in
which the scapular migrates), the thoracodorsal
nerve supplies the latissimus dorsi and injury
would result in weakness and atrophy. Lateral
scapular winging occurs with weak levator scapulae, trapezius and rhomboids. Trapezius is supplied by the spinal accessory nerve (CN XI).
Martin RM, Fish DE. Scapular winging: ana-
tomical review, diagnosis, and treatments. Curr
Rev Musculoskelet Med. 2008;1:1–11.
15. Answer E. Raised hemidiaphragm
Rationale: A variety of regional blocks can be
performed for shoulder surgery, either in conjunction with or instead of a GA. One commonly
performed technique is the interscalene block. A
phrenic nerve palsy would cause a raised hemidiaphragm on the ipsilateral side and is most
likely. This can cause a reduction of 25% of
FVC and in patients with pre-existing lung disease can cause symptoms, albeit in this case mild.
Although Horner syndrome is recognised
following interscalene block, it would not lead
to any respiratory symptoms.
Bergmann L et al. Phrenic nerve block
caused by interscalene brachial plexus block:
breathing effects of different sites of injection.
BMC Anesthesiol 2015;16:45.
Urmey F et al. Hemidiaphragmatic paresis
during interscalene brachial plexus block: effects
on pulmonary function and chest wall mechanics. Anesth. Analg. 1992;74;352–357.
16. Answer D. Pectoralis minor
Reduction of subcoracoid space by pectoralis
minor.
There are four forms of thoracic outlet
syndrome.
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Shoulder/Elbow II Structured SBA
1. Anterior scalene syndrome.
Anterior scalene syndrome is a
neurovascular entrapment syndrome
caused by tight anterior and middle scalenes.
Adson’s test is used to diagnose this
condition.
2. Costoclavicular syndrome.
Costoclavicular syndrome is a neurovascular
entrapment syndrome caused by a decrease of
the costoclavicular space between the first rib.
Diagnosed by Eden’stest.
3. Pectoralis minor syndrome.
This is a neurovascular entrapment
syndrome caused by a tight pectoralis minor.
Wright’s hyperabduction test stretches and
pull this muscle taut, causing it to further
compress the brachial plexus and the
subclavian/axillary artery and vein.
4. Cervical rib syndrome.
Usually has a positive Adson’ s test. The
condition is diagnosed with radiographies.
Pectoralis minor syndrome is a
neurovascular entrapment syndrome caused by
a tight pectoralis minor; the idea is to stretch and
pull this muscle taut, causing it to further
compress the brachial plexus and the
subclavian/axillary artery and vein that run
between it and the ribcage. Wright’stestinvolves
bringing the patient’s upper extremity back into
abduction and extension while the examiner
palpates the strength of the radial pulse. A
positive finding is weakness of the radial pulse.
Costoclavicular syndrome is a
neurovascular entrapment syndrome caused
by a decrease of the costoclavicular space
between the first rib clavicle. Eden’s test
further decreases this space by bringing the
clavicle and first rib closer together, causing
further compression of the brachial plexus
and the subclavian artery and vein, which run
through this space. Eden’s test involves
asking the client to push out the chest and
pull the shoulder girdles back, as if assuming
a military position of attention, while the
examiner palpates the strength of the radial
pulse. Pushing the chest out brings the first
rib forward, while pulling the shoulder
girdles back brings the clavicle back, thereby
decreasing the space between them.
17. Answer C. Intrinsic muscle strength will always
be lost
Loss of grip strength from denervation of FDP
(flexion at ring and little DIPJ) and loss of the
FCU (stabilisation of the hand during power
grip). The inability to close the ulnar side of the
palm in forceful grip results in difficulty grasping
objects.
There will still be clawing of the hand, but
this may be mild (ulnar paradox).
Remember the Martin–Gruber anastomosis
is present in 15–20% patients – i.e. median nerve
supplies these muscles normally supplied by the
ulnar due to crossover of the nerve. Only motor
not sensory. The Martin–Gruber anastomosis is
a median to ulnar anastomosis in the forearm. It
occurs through a communicating nerve branch
between the median nerve and the ulnar nerve in
the forearm. An isolated ulnar nerve lesion at the
elbow will produce an unusual pattern for intrinsic muscle paralysis. In cases of nerve lesions of
the median or ulnar nerve, this anastomosis
serves as a conduit or an alternative innervation
of parts of the hand and the forearm (it is really a
detour). This can be a good explanation for difficult challenges, especially in the differential
diagnosis.
Froment’s sign is due to a loss of adductor
pollicis. A patient grasps a piece of paper
between thumb and index finger.
18. Answer E. Deep to the transverse carpal
ligament
The clinical scenario describes a low median
nerve lesion.
The TCL is the middle portion of the flexor
retinaculum that runs between the hamate and
pisiform medially to scaphoid and trapezium
laterally and forms a fibrous sheath which contains carpal tunnel anteriorly within fibroosseous tunnel.
Posteriorly the tunnel is bordered by carpal
bones and transports the median nerve and
finger flexor tendons from the forearm to the
hand.
Median nerve palsy can be separated into 2
subsections – high and low median nerve palsy.
High MNP involves lesions at the elbow and
forearm areas. Low median nerve palsy results
from lesions at the wrist.
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