, Allj rightsj reserved.j Nojpartj ofj Shoulderjandj Elbowj Self-
Assessmentj Examinationj mayj bej reproduced,jstoredjinj ajretrievalj system,j orjtransmittedj injanyj formj orj by
j anyj meansj (electronic,j mechanical,jphotocopying,j recording,j orj otherwise)j withoutj thej priorj writtenj per
missionj ofj thej publisher.
Publishedj Januaryj 2014
AmericanjAcademyjofjOrthopaedicjSurgeonsj
6300jNorthjRiverjRoad
Rosemont,j ILj 60018
Copyright©j 2014j byj thej Americanj Academyj ofj Orthopaedicj Surgeons
Requestsjforjpermissionjtojreproducejanyjpartjofjthejworkjshouldjbejmailedjto:j Attenti
on:jExaminationsjDepartment
AmericanjAcademyjofjOrthopaedicjSurgeonsj
6300jNorthjRiverjRoad
Rosemont,jILj60018jPrinte
djinjthejUSA
©j2014jAmericanjAcademyjofj OrthopaedicjSurgeon 2014jShoulderjandjElbowj Self-
s
AssessmentjExamination
, 2014j Shoulderj andj Elbowj Self-Assessmentj Examinationj Answerj Book•j 11
Questionj1
jAj45-year-oldj manjwhojhadjgoutjinjhisjfootj2jyearsjagojhasjaj3-
dayjhistoryjofjelbowjpainjwithoutjanjinjury.jThejpainjisjdiffuse,jconstant,jandjworsejwithjanyjmovement.
jExaminationjshowsjmotionjfromj20jdegreesjtoj90jdegrees.jTherejisjnojerythemajaroundjhisjelbow,jhejha
sjnojfever,jandjajsensoryjandjmotorjexaminationjofjhisjarmjisjunremarkable.jRadiographsj onlyjshowjanje
ffusion.jThejpatient'sjuricjacidjleveljisjwithinjdefinedjlimits.jWhatjisjthejnextjdiagnosticjstep?
1. Elbowjjointjaspiration
2. MRIjscan
3. Splintjforj2jweeksjandjrepeatjexamination
4. SedimentationjratejandjC-
reactivejproteinjleveljPREFERREDjRESPONSE:j1
DISCUSSION
Thejbestj wayj tojmakejthejdiagnosisj isj tojaspiratej thejfluidjfromj thejjointjandjsendjitj tojthejlaboratoryjfo
rjajcelljcountjandjcrystaljsearch.jThisjwilljallowjforjthejdiagnosisjofjanjinfection,jgout,jorjpseudogout.jAn
jMRIjscanjwilljconfirmjthejexaminationjfindingjofjanjeffusion,jbutjitjwilljnotjrevealjthejcausejofjanjinfla
mmatoryj effusion.jIfjthejpatientjhasjchronicjgout,janjMRIjscanjorjultrasoundjcanjaidjinjdiagnosisjif
goutjtophijarejseen.jAjsplintjwilljhelpjrelievejthejpainjfromjthejeffusionjandjthejeffusionjmayjresolvejonjitsjo
wn,jbutjitjwilljnotjcontributejtojajdiagnosis.jSedimentationjratejandjC-reactivejproteinjleveljwilljhelpjtoj
jrulejoutjanj infection,j butjtheyj arejnotjasjdiagnosticjasjanjaspiration.j
RECOMMENDEDjREADINGS
OrzechowskijNM,jMasonjTG.jSeronegativej inflammatoryj arthritis.jIn:jMorreyjBF,jSanchez-SotelojJ,jeds.
ThejElbowj andjItsj Disorders.j4thj ed.jPhiladelphia,j PA:jSaunders-Elsevier;j2009:1039-1041.
dejAvilajFernandesjE,jKubotajES,jSandimjGB,jMitraudjSA,jFerrarijAJ,jFernandesjAR.jUltrasoundjfeatu
resjoftophijinjchronicjtophaceousjgout.jSkeletaljRadiol.j2011jMar;40(3):309-
15.jEpubj2010jJulj31.jPubMedjPMID:j20676636.
©j 2014jAmericanj Academyj ofj Orthopaedicj Surgeon 2014j Shoulderj andj Elbowj Self-
s Assessmentj Examination
, 12j•jAmericanjAcademyjofjOrthopaedicjSurgeon
s
Figurej 2
Questionj 2
Aj 65-year-
oldj manj whoj underwentj anjuncomplicatedj reversejtotaljshoulderj arthroplastyj (rTSA)j toj treatjrotatorj cuffj a
rthropathyj 2j yearsj agoj hasj aj routinejfollow-upj visitjinj yourj clinic.jAj radiographj atj 2-
yearjfollowupj isj shownj inj Figurej 2.j Hej deniesj shoulderj painj andj dysfunctionj andj constitutionalj symptom
s,jandjhisjclinicalj examinationj findingsj arejbenign.j Basedj uponjthejpresentj radiologicj evaluation,j whatj isjth
ejnextjmostjappropriatejstep?
1. Revisionj rTSA
2. Conversionj toj hemiarthroplasty
3. Continuedj observation
4. Infectionjwork-
upjwithjscreeningjlabsjandjjointjaspirationjPREFERREDjRESPONSE:j3
DISCUSSION
Basedj uponj thej patient'sj clinicalj examinationj andj symptoms,jjcontinuedj observationjjisj appropriate.jTh
ej remainingj optionsj arej notj indicated.j Thejradiographj revealsj scapularj notching,j onej ofjthej morejcom
monj complicationsj specificj toj rTSA.j Notchingj isj causedj byj repeatedj contactj betweenj thej humeraljcom
ponentj and/orj humerusj andj thej inferiorj pillarj ofj thej scapularj neck.jjGenerationj ofj particulatej debrisj
jfromj thisjinteractionj canj resultj injosteolysisj withjthejpotentialj forj screwj andj basej platej failure.j Thejoveralljinci
dencej ofj notchingj hasj beenj reportedj toj bej betweenjj51%j andj 96%.jjThisj nearlyj ubiquitousj findingj hasjbeenj at
tributedj toj implantjpositioning,j alteredj glenoidjandj humeralj anatomy,j andj durationj ofjimplantation.jRecentj stu
diesj thatj indicatejjincreasedj lateralj offset,jjincreasedj glenospherej size,j andjinferiorj positioningj ofj
jthej basej platejjmayjjreducej thej incidencejjofj scapularj notching.
©j2014jAmericanjAcademyjofjOrthopaedicjSurgeon 2014jShoulderjandjElbowjSelf-
s AssessmentjExamination
Assessmentj Examinationj mayj bej reproduced,jstoredjinj ajretrievalj system,j orjtransmittedj injanyj formj orj by
j anyj meansj (electronic,j mechanical,jphotocopying,j recording,j orj otherwise)j withoutj thej priorj writtenj per
missionj ofj thej publisher.
Publishedj Januaryj 2014
AmericanjAcademyjofjOrthopaedicjSurgeonsj
6300jNorthjRiverjRoad
Rosemont,j ILj 60018
Copyright©j 2014j byj thej Americanj Academyj ofj Orthopaedicj Surgeons
Requestsjforjpermissionjtojreproducejanyjpartjofjthejworkjshouldjbejmailedjto:j Attenti
on:jExaminationsjDepartment
AmericanjAcademyjofjOrthopaedicjSurgeonsj
6300jNorthjRiverjRoad
Rosemont,jILj60018jPrinte
djinjthejUSA
©j2014jAmericanjAcademyjofj OrthopaedicjSurgeon 2014jShoulderjandjElbowj Self-
s
AssessmentjExamination
, 2014j Shoulderj andj Elbowj Self-Assessmentj Examinationj Answerj Book•j 11
Questionj1
jAj45-year-oldj manjwhojhadjgoutjinjhisjfootj2jyearsjagojhasjaj3-
dayjhistoryjofjelbowjpainjwithoutjanjinjury.jThejpainjisjdiffuse,jconstant,jandjworsejwithjanyjmovement.
jExaminationjshowsjmotionjfromj20jdegreesjtoj90jdegrees.jTherejisjnojerythemajaroundjhisjelbow,jhejha
sjnojfever,jandjajsensoryjandjmotorjexaminationjofjhisjarmjisjunremarkable.jRadiographsj onlyjshowjanje
ffusion.jThejpatient'sjuricjacidjleveljisjwithinjdefinedjlimits.jWhatjisjthejnextjdiagnosticjstep?
1. Elbowjjointjaspiration
2. MRIjscan
3. Splintjforj2jweeksjandjrepeatjexamination
4. SedimentationjratejandjC-
reactivejproteinjleveljPREFERREDjRESPONSE:j1
DISCUSSION
Thejbestj wayj tojmakejthejdiagnosisj isj tojaspiratej thejfluidjfromj thejjointjandjsendjitj tojthejlaboratoryjfo
rjajcelljcountjandjcrystaljsearch.jThisjwilljallowjforjthejdiagnosisjofjanjinfection,jgout,jorjpseudogout.jAn
jMRIjscanjwilljconfirmjthejexaminationjfindingjofjanjeffusion,jbutjitjwilljnotjrevealjthejcausejofjanjinfla
mmatoryj effusion.jIfjthejpatientjhasjchronicjgout,janjMRIjscanjorjultrasoundjcanjaidjinjdiagnosisjif
goutjtophijarejseen.jAjsplintjwilljhelpjrelievejthejpainjfromjthejeffusionjandjthejeffusionjmayjresolvejonjitsjo
wn,jbutjitjwilljnotjcontributejtojajdiagnosis.jSedimentationjratejandjC-reactivejproteinjleveljwilljhelpjtoj
jrulejoutjanj infection,j butjtheyj arejnotjasjdiagnosticjasjanjaspiration.j
RECOMMENDEDjREADINGS
OrzechowskijNM,jMasonjTG.jSeronegativej inflammatoryj arthritis.jIn:jMorreyjBF,jSanchez-SotelojJ,jeds.
ThejElbowj andjItsj Disorders.j4thj ed.jPhiladelphia,j PA:jSaunders-Elsevier;j2009:1039-1041.
dejAvilajFernandesjE,jKubotajES,jSandimjGB,jMitraudjSA,jFerrarijAJ,jFernandesjAR.jUltrasoundjfeatu
resjoftophijinjchronicjtophaceousjgout.jSkeletaljRadiol.j2011jMar;40(3):309-
15.jEpubj2010jJulj31.jPubMedjPMID:j20676636.
©j 2014jAmericanj Academyj ofj Orthopaedicj Surgeon 2014j Shoulderj andj Elbowj Self-
s Assessmentj Examination
, 12j•jAmericanjAcademyjofjOrthopaedicjSurgeon
s
Figurej 2
Questionj 2
Aj 65-year-
oldj manj whoj underwentj anjuncomplicatedj reversejtotaljshoulderj arthroplastyj (rTSA)j toj treatjrotatorj cuffj a
rthropathyj 2j yearsj agoj hasj aj routinejfollow-upj visitjinj yourj clinic.jAj radiographj atj 2-
yearjfollowupj isj shownj inj Figurej 2.j Hej deniesj shoulderj painj andj dysfunctionj andj constitutionalj symptom
s,jandjhisjclinicalj examinationj findingsj arejbenign.j Basedj uponjthejpresentj radiologicj evaluation,j whatj isjth
ejnextjmostjappropriatejstep?
1. Revisionj rTSA
2. Conversionj toj hemiarthroplasty
3. Continuedj observation
4. Infectionjwork-
upjwithjscreeningjlabsjandjjointjaspirationjPREFERREDjRESPONSE:j3
DISCUSSION
Basedj uponj thej patient'sj clinicalj examinationj andj symptoms,jjcontinuedj observationjjisj appropriate.jTh
ej remainingj optionsj arej notj indicated.j Thejradiographj revealsj scapularj notching,j onej ofjthej morejcom
monj complicationsj specificj toj rTSA.j Notchingj isj causedj byj repeatedj contactj betweenj thej humeraljcom
ponentj and/orj humerusj andj thej inferiorj pillarj ofj thej scapularj neck.jjGenerationj ofj particulatej debrisj
jfromj thisjinteractionj canj resultj injosteolysisj withjthejpotentialj forj screwj andj basej platej failure.j Thejoveralljinci
dencej ofj notchingj hasj beenj reportedj toj bej betweenjj51%j andj 96%.jjThisj nearlyj ubiquitousj findingj hasjbeenj at
tributedj toj implantjpositioning,j alteredj glenoidjandj humeralj anatomy,j andj durationj ofjimplantation.jRecentj stu
diesj thatj indicatejjincreasedj lateralj offset,jjincreasedj glenospherej size,j andjinferiorj positioningj ofj
jthej basej platejjmayjjreducej thej incidencejjofj scapularj notching.
©j2014jAmericanjAcademyjofjOrthopaedicjSurgeon 2014jShoulderjandjElbowjSelf-
s AssessmentjExamination
