Shoulder Arthroplasty — MCQs

10 questions

Complications of sling procedures (TVT) for USI are all except:

Most common complication of extra capsular fracture of neck of femur is:

A patient who has taken the first COVID vaccine comes for the second dose. An astute nurse noticed that the shoulder was flabby, flat, and was asymmetrical. There was an associated loss of contour of the shoulder joint. Injury to which of the structures might have resulted and was avoidable?

Which of the following techniques is appropriate for the reduction of the shoulder?

Severe disability in primary osteoarthritis of hip is best managed by -

The Henderson-Jones classification is used for:

Fracture shaft of humerus can cause damage to which of the following nerves?

Which of the following statements is true regarding supracondylar fractures of the humerus?

What is the best treatment for a 60-year-old man with intracapsular femoral neck fracture?

Q10

79 yrs old lady had fall, the following X-ray was taken. Which of the following is treatment?

Shoulder Arthroplasty Indian Medical PG Practice Questions and MCQs

Question 1: Complications of sling procedures (TVT) for USI are all except:

A. Obturator nerve injury is about 10% (Correct Answer)
B. Overactive bladder in about 7% cases
C. Injury to bladder and wound haematoma
D. Sling erosion particularly with polytetrafluoroethylene (Goretex)

Explanation: ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.

Question 2: Most common complication of extra capsular fracture of neck of femur is:

A. Malunion
B. Ischemic necrosis
C. Pulmonary complications
D. Non union (Correct Answer)

Explanation: ***Non union*** - **Non-union** is a common complication in extracapsular femoral neck fractures due to the **disrupted blood supply** and mechanical forces across the fracture site. - The **fracture fragments** may fail to heal properly, leading to persistent pain, instability, and functional impairment. *Malunion* - **Malunion** occurs when the fracture heals in an **unacceptable anatomical position**, causing deformity or altered biomechanics. - While it can be a complication, **non-union** is generally more prevalent and problematic in extracapsular femoral neck fractures. *Ischemic necrosis* - **Ischemic necrosis** (or avascular necrosis) is less common in extracapsular femoral neck fractures compared to intracapsular fractures. - This is because the **extracapsular location** often spares the crucial blood supply to the femoral head, which is frequently compromised in intracapsular injuries. *Pulmonary complications* - **Pulmonary complications** (e.g., pneumonia, pulmonary embolism) are significant risks in elderly patients with hip fractures due to prolonged immobility and surgery. - However, direct fracture-related complications like **non-union** are distinct and represent issues specifically with bone healing.

Question 3: A patient who has taken the first COVID vaccine comes for the second dose. An astute nurse noticed that the shoulder was flabby, flat, and was asymmetrical. There was an associated loss of contour of the shoulder joint. Injury to which of the structures might have resulted and was avoidable?

A. Supraspinatus muscle
B. Infraspinatus muscle
C. Teres minor muscle
D. Deltoid muscle (Correct Answer)

Explanation: ***Deltoid muscle*** - The **deltoid muscle** is the principal muscle that gives the shoulder its rounded contour. Damage to or atrophy of the deltoid can lead to a **flat, flabby, and asymmetrical shoulder**. - Improper vaccine administration, such as injecting too high or too deep, can directly injure the deltoid muscle, leading to inflammation (**SIRVA - Shoulder Injury Related to Vaccine Administration**) or even deltoid atrophy, which would cause the observed lack of contour. *Supraspinatus muscle* - The **supraspinatus** is primarily involved in the initial **abduction** of the arm and stabilization of the shoulder joint, but it does not significantly contribute to the visible external contour of the shoulder. - Injury to the supraspinatus mainly causes **pain and weakness** with abduction, rather than a visible change in shoulder shape. *Infraspinatus muscle* - The **infraspinatus** is a rotator cuff muscle primarily responsible for **external rotation** of the arm. - Injury to this muscle would cause weakness in external rotation and potentially posterior shoulder pain, but not the noticeable loss of shoulder contour described. *Teres minor muscle* - The **teres minor** is also a rotator cuff muscle assisting in **external rotation** and stabilization of the humeral head. - Similar to the infraspinatus, its injury would impair external rotation and cause posterior shoulder pain, but it doesn't define the overall shape of the shoulder.

Question 4: Which of the following techniques is appropriate for the reduction of the shoulder?

A. Spinal anesthesia
B. Interscalene block (Correct Answer)
C. Axillary brachial block
D. Bier block

Explanation: ***Interscalene block*** - An **interscalene block** targets the brachial plexus at the level of the neck, providing excellent anesthesia for shoulder procedures. - This technique effectively blocks the nerves innervating the shoulder joint, allowing for **muscle relaxation** and pain control necessary for reduction. *Spinal anesthesia* - **Spinal anesthesia** provides anesthesia to the lower body and is primarily used for procedures below the waist. - It does not provide adequate **analgesia or muscle relaxation** for a shoulder reduction. *Axillary brachial block* - An **axillary brachial block** anesthetizes the distal arm and hand, but it often spares the more proximal shoulder innervation. - While useful for forearm and hand surgery, it typically does not provide sufficient **anesthesia for the shoulder** joint itself. *Bier block* - A **Bier block**, or intravenous regional anesthesia, is suitable for procedures on the distal extremities, such as the hand or foot. - It involves tourniquet inflation and intravenous injection of local anesthetic, making it **unsuitable for shoulder reduction** due to the large muscle mass and proximal location.

Question 5: Severe disability in primary osteoarthritis of hip is best managed by -

A. Arthroplasty (Correct Answer)
B. Arthrodesis
C. Mc Murray's osteotomy
D. Intra-articular hydrocortisone and physiotherapy

Explanation: ***Arthroplasty*** - **Total hip arthroplasty (THA)** is the most effective treatment for severe osteoarthritis of the hip, providing significant pain relief and functional improvement. - It involves replacing the damaged joint surfaces with **prosthetic components**, addressing advanced cartilage loss and structural damage. *Arthrodesis* - **Arthrodesis (joint fusion)** is an older technique that fixes the joint in a permanent position, eliminating pain but sacrificing all motion in that joint. - While it relieves pain, the severe loss of motion makes it generally less desirable than arthroplasty for the hip, especially in active patients. *Mc Murray's osteotomy* - **McMurray's osteotomy** is a surgical procedure primarily used for some types of **femoral neck fractures** or a specific type of **avascular necrosis** of the femoral head, not for severe osteoarthritis affecting the entire joint. - It involves cutting and realigning the bone, but it does not address advanced, widespread articular cartilage degeneration seen in severe osteoarthritis. *Intra-articular hydrocortisone and physiotherapy* - **Intra-articular hydrocortisone injections** and **physiotherapy** are conservative treatments used for mild to moderate hip osteoarthritis to manage pain and improve function. - These methods do not resolve severe structural damage and are typically insufficient for managing severe disability due to advanced osteoarthritis.

Question 6: The Henderson-Jones classification is used for:

A. Diabetic foot
B. Prosthetic joint infection (Correct Answer)
C. Pressure ulcers
D. Burns

Explanation: ***Prosthetic joint infection*** - The **Henderson-Jones classification** is a system used to categorize **prosthetic joint infections (PJI)** based on their **timing** of onset, distinguishing between early, delayed, and late infections. - This classification aids in guiding **treatment strategies**, as the approach for PJI varies depending on when the infection develops after surgery. *Diabetic foot* - **Diabetic foot ulcers** are typically classified using systems like the **Wagner classification** or the **University of Texas Wound Classification System**, which focus on wound depth, presence of infection, and ischemia. - These classifications specifically address the unique pathology and progression of **foot complications** in diabetic patients. *Pressure ulcers* - **Pressure ulcers (bedsores)** are commonly classified using the **National Pressure Ulcer Advisory Panel (NPUAP)** staging system or the **International Pressure Ulcer Classification System**, which categorize ulcers by depth of tissue damage. - These systems are crucial for assessing severity, guiding treatment, and predicting outcomes for **skin and underlying tissue injury** caused by sustained pressure. *Burns* - **Burns** are traditionally classified by **depth** (e.g., first, second, third, and fourth-degree burns) and **total body surface area (TBSA)** affected, using tools like the Rule of Nines. - This classification helps determine the **severity** of the burn and guides initial management, fluid resuscitation, and surgical intervention.

Question 7: Fracture shaft of humerus can cause damage to which of the following nerves?

A. Ulnar nerve
B. Radial nerve (Correct Answer)
C. Axillary nerve
D. Median nerve

Explanation: ***Radial nerve*** - The **radial nerve** runs in the **spiral groove** along the posterior aspect of the humerus shaft, making it highly susceptible to injury during a fracture in this region. - Damage can lead to **wrist drop** and impaired sensation over the posterior forearm and hand. *Ulnar nerve* - The **ulnar nerve** primarily runs along the medial epicondyle of the humerus, making it more vulnerable to injuries around the **elbow joint**, not typically the humeral shaft. - Injury to the ulnar nerve results in a characteristic **"claw hand"** deformity and sensory loss over the medial aspect of the hand. *Axillary nerve* - The **axillary nerve** wraps around the surgical neck of the humerus and is most commonly injured with **shoulder dislocations** or fractures involving the surgical neck, not the shaft. - Damage to the axillary nerve causes weakness in **deltoid abduction** and sensory loss over the lateral shoulder (regimental badge area). *Median nerve* - The **median nerve** travels more anteriorly and medially in the arm and is generally protected from direct injury in a mid-shaft humeral fracture. - Injury to the median nerve can cause a **"ape hand" deformity** and sensory loss over the radial aspect of the palm.

Question 8: Which of the following statements is true regarding supracondylar fractures of the humerus?

A. Extension type most common (Correct Answer)
B. Flexion type is less common than extension type
C. Both types are equally common
D. More common in adults

Explanation: **Extension type most common** - **Extension-type supracondylar fractures** account for the vast majority (about 95%) of all supracondylar humerus fractures. - This type typically results from a fall on an **outstretched hand** with the elbow in extension, forcing the distal fragment posteriorly. *More common in adults* - **Supracondylar fractures of the humerus** are predominantly observed in children, especially between 5 and 10 years of age. - They are the **most common elbow fracture in children**, making this statement incorrect. *Flexion type is less common than extension type* - While flexion-type fractures do occur, they are significantly less common, representing only about 5% of all supracondylar fractures. - This type typically results from a direct blow to the posterior aspect of the elbow, with the distal fragment displaced anteriorly. *Both types are equally common* - As established, extension-type fractures are far more prevalent than flexion-type fractures, making them not equally common. - The significant disparity in incidence confirms that this statement is incorrect.

Question 9: What is the best treatment for a 60-year-old man with intracapsular femoral neck fracture?

A. Hemiarthroplasty (Correct Answer)
B. Total hip replacement
C. Internal fixation
D. Casting

Explanation: **Hemiarthroplasty** * **Hemiarthroplasty** is generally preferred in older patients with **displaced intracapsular femoral neck fractures** due to the high risk of **avascular necrosis** and non-union with internal fixation. * In a 60-year-old, a hemiarthroplasty provides a good balance between **mobility** and avoiding the complexities of a total hip replacement, especially if the patient has lower functional demands or comorbidities. *Total hip replacement* * **Total hip replacement** might be considered for younger, more active patients with minimal comorbidities, or older patients with pre-existing **hip arthritis**, as it offers better long-term function and pain relief. * However, it's a more extensive procedure with a higher risk of complications like **dislocation** and necessitates careful selection based on the patient's physiological age and functional expectations. *Internal fixation* * **Internal fixation** is primarily used for **non-displaced** or minimally displaced intracapsular femoral neck fractures in active patients, or displaced fractures in younger patients (usually <60 years old) to preserve their native femoral head. * In a 60-year-old with a displaced fracture, the risk of **avascular necrosis** of the femoral head and **non-union** is significantly higher with internal fixation, making it a less preferred option. *Casting* * **Casting** is not an appropriate treatment for a femoral neck fracture. * Femoral neck fractures are **intra-articular** and require surgical stabilization to achieve stability and allow for early mobilization.

Question 10: 79 yrs old lady had fall, the following X-ray was taken. Which of the following is treatment?

A. Hip spica
B. Nailing
C. Hemiahroplasty (Correct Answer)
D. Total Hip Replacement

Explanation: ***Hemiarthroplasty*** - The X-ray shows a **displaced femoral neck fracture** in an elderly patient, which typically has a high risk of **avascular necrosis** of the femoral head due to disruption of blood supply. - Hemiarthroplasty involves replacing only the **femoral head and neck** with a prosthetic component, leaving the acetabulum intact, which is suitable for elderly patients with good acetabular cartilage and less active lifestyles. *Hip spica* - A hip spica cast is primarily used for **pediatric femur fractures** or certain types of hip dislocations in children, not for displaced femoral neck fractures in elderly adults. - This method would not provide stable fixation or address the high risk of **avascular necrosis** associated with these fractures in older patients. *Nailing* - Nailing (intramedullary nailing) is typically used for **intertrochanteric fractures** or subtrochanteric fractures, where the fracture line is distal to the femoral neck. - For displaced femoral neck fractures, nailing alone may not provide adequate stability and carries a higher risk of **non-union** or **avascular necrosis** compared to arthroplasty in elderly patients. *Total Hip Replacement* - Total hip replacement involves replacing both the **femoral head and the acetabulum** with prosthetic components. - While an option for femoral neck fractures, it is generally reserved for younger, more active patients or those with pre-existing **acetabular pathology** like arthritis, as it is a more extensive and complex procedure than hemiarthroplasty.

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