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Choose the ONE BEST response from the five suggested answers to each question. Click the grey Submit button (in the pink box) when you have made your selection. This arthrogram of the shoulder shows: Osteoarthritis of the glenohumeral joint Para-articular ossification Tuberculosis of the shoulder Supraspinatus tendonitis A tear of the rotator cuff Correct, This arthrogram shows extravasation of dye into the subacromial space which must imply that there is a tear in the capsule and therefore of the rotator cuff This young man was knocked off his motorcycle by a car travelling at high speed. He landed on the point of his left shoulder and the left side of his face. Which of the following injuries is the LEAST likely? Dislocation of the shoulder Correct, The injuries that are common are caused by the direct effect of the impact and by the stretching effect of depressing the shoulder and pushing the neck in the opposite direction. Therefore fractures of the clavicle, acromion and the first rib occur. The brachial plexus may be stretched or avulsed. If there is complete avulsion of the plexus than the cervical sympathetic chain may be damaged and a Horners syndrome results. Dislocation of the shoulder is unlikely between the mechanism for a dislocation is an indirect injury, usually a fall on the outstretched arm. Fracture of the first rib Fracture of the clavicle Injury to the brachial plexus Horners syndrome This x-ray of the shoulder shows: Osteoarthritis of the glenohumeral joint Para-articular ossification Tuberculosis of the shoulder Supraspinatus tendonitis Correct, The x-ray shows calcification in the line of the supraspinatus tendon. This is therefore calcific supraspinatus tendonitis. Tuberculosis of the shoulder destroys the joint. A rotator cuff tear cannot be shown on plain x-rays with any degree of certainty. A tear of the rotator cuff This man has: A dislocation of the shoulder Correct, This man has a chronic unreduced dislocation of the shoulder. The alignment of the humerus if projected proximally is quite different from that of the other side. There is secondary wasting of the deltoid. A dislocation of the acromioclavicular joint Paralysis of the suprascapular nerve Paralysis of the nerve to serratus anterior Sprengels shoulder On clinical examination, this patient demonstrates a painful arc of movement. This painful arc is most likely to be: From 0 - 90 degrees abduction From 140 - 180 degress abduction From 0 - 30 degrees extension From 60 - 120 degrees abduction Correct, This man has calcification in the supraspinatus tendon. This will give him a subacromial painful arc. The pain is produced by the rubbing of the inflamed tendon under the acromion and under the coraco-acromial ligament. Once the arm is abducted beyond 90 degrees, then the tendon is no longer under the leading edge of the coracoacromial complex and therefore further movement becomes painless. Therefore, the range of movement which will be painful will be from 60 - 120 degrees. Painful arcs which show pain from 90 degrees onwards are the acromioclavicular painful arcs which are caused by pathology in the acromioclavicular joint. From 0 - 90 degrees forward flexion This patient: Has a lesion of the nerve to latissimus dorsi Has a posterior dislocation of the shoulder Has lesions involving both the suprascapular and circumflex humeral (axillary) nerves Correct, This man shows wasting of the supraspinatus, infraspinatus and the deltoid. Therefore his suprascapular nerve and the axillary nerves are damaged or else he has damage to the superior roots of the brachial plexus. Although there is muscle wasting, the overall contour of the shoulder is not disturbed. Sprengels shoulder is an elevation of the scapular caused by a persistence of a band between the angle of the scapula and the cervical spine. This scapula is not normally elevated. Has a Sprengels shoulder Has a partial brachial plexus lesion involving the lower nerve roots The appearance of this shoulder is most likely to be caused by: A C5 nerve root lesion from a cervical disc A fractured clavicle An acromio-clavicular dislocation A fracture of the surgical neck of the humerus Anterior dislocation of the shoulder Correct, This is an anterior dislocation of the shoulder and it is a typical appearance with a 'squaring off' of the shoulder. The head of the humerus is now anterior and below the level of the glenoid. This radiograph of an injured shoulder shows: A fracture dislocation of the humerusCorrect, This radiograph shows a fracture dislocation of the shoulder with the dislocation being posterior. The fractures are obvious with a fragment off the metaphysis. There is a fracture through the surgical neck and another one through the head of the humerus. The injury that is difficult to spot is posterior subluxation and this is a classic catch in injuries of the shoulder. Nevertheless, one can see that the overlap between the glenoid and the humeral head is only partial. A fracture of the humerus A fracture of the acromion A fracture of the coracoid The asymmetry in this man's shoulders: Indicates a dislocation of the left shoulder Is caused by a scoliosis Is a normal variant Correct, This man is asymptomic and therefore the asymmetry in the two sides of his body must be looked upon as normal variants. There are quite significant differences in the two sides of the body. The right shoulder is very commonly lower than the left in righthanded people. Leg length can vary up to an inch without producing any symptoms. Foot size varies by half a shoe size. This man shows quite a significant hemihypertrophy on the right side. However, because both limbs function normally it can not be regarded as pathological in any way. Needs further investigation This patient has an obvious deformity of his right shoulder. You would expect to find: Paralysis of serratus anterior Dislocation of the glenohumeral joint Correct, The appearance of this patient is consistent with a dislocation of the glenohumeral joint. The acromion on the affected side is much more easily seen than on the normal side due to the loss of normal shoulder contour. The long thoracic nerve supplies the serratus anterior muscle and paralysis of this results in winging of the scapula. This patient does not have this sign. Limb-girdle muscular dystrophy is a primary muscle disorder and is bilateral. Dislocation of the acromioclavicular joint Neuropraxia of long thoracic nerve Limb-girdle muscular dystrophy This injury was sustained by a rugby player. You would: Send the patient home Correct, This x-ray shows a dislocation of the acromioclavicular joint. The distal end of the clavicle is sitting above the medial edge of the acromium and the distance between the calvicle and coracoid is increased. This signifies disruption of the coracoclavicular ligaments. This injury is adequately managed with resting the elbow in a broad arm sling until the pain settles down. Patients with this injury usually become asymptomatic and have return to football within six weeks. Remanipulate the elbow Admit for observation Arrange for surgery Start physiotherapy within the next few days This x-ray shows: A subluxation of the shoulder A posterior dislocation of the shoulder An anterior dislocation of the shoulder Correct, This is an anterior dislocation of the shoulder. In this axial view it is possible to identify the spine of the scapula, the coracoid and the glenoid. The head of the humerus is lying anteriorly, beneath the coracoid. The coracoid is normal. Destruction of the coracoid A normal shoulder in an axial projection This patient sustained this injury playing football. Which of the following must have occurred: Rupture of the rotator cuff Rupture of the coraco-acromial ligament Rupture of the rhomboid ligament Rupture of the coraco-clavicular ligament Correct, The radiograph demonstrates a dislocation of the acromio-clavicular joint. One of the primary group of stabilising ligaments are the conoid and trapezoid ligaments which run from the superior surface of the coracoid process to the undersurface of the lateral third of the clavicle. These are also known therefore as the coracoclavicular ligaments. To enable the joint to dislocate, these ligaments must rupture. Rupture of the coraco-humeral ligament