FREE Orthopedics MCQS 2022 1401-1450

1401. (1755) Q4-2152:

Prolonged nonsteroidal anti-inflammatory drugs (NSAIDs) cure which of the following lesions:

1) Osteosarcoma

3) Osteoblastoma

2) Osteoid osteoma

5) None of the above

4) Osteochondroma

An average 33-month course of treatment with NSAIDs cures osteoid osteoma. The prostaglandin E2 in osteoid osteoma is likely the reason for this response.

■Correct Answer:Osteoid osteoma

1402. (1756) Q4-2153:

The most common primary bone tumor in the hand is:

1) Enchondroma

3) Osteosarcoma

2) Osteochondroma

5) None of the above

4) Fibroma

Enchondroma preferentially occurs in the hand, most commonly in the phalanges and metacarpals, and is the most common primary tumor of bone found in the hand.

■Correct Answer:Enchondroma

1403. (1757) Q4-2154:

Which of the following statements regarding ganglions is false:

1) Surgery can lead to a decrease in range of motion.

3) Needle aspiration is diagnostic and therapeutic, although the rate of recurrence is high after this procedure.

2) Ganglions are filled with mucinous fluid that does not transilluminate.

5) Ganglions may be multilobulated.

4) Volar ganglion may arise in relation to the radial artery.

Transillumination is a hallmark of ganglions. Because of the location from which ganglia arise and the dissection performed during resection, a decrease in range of motion can be seen postoperatively. Needle aspiration is diagnostic and can be therapeutic, however, recurrence rates as high as 95% have been reported. Volar ganglia can often be intimately associated with the radial artery. Ganglia may often be multilobulated.

■Correct Answer:Ganglions are filled with mucinous fluid that does not transilluminate.

1404. (1758) Q4-2155:

Dorsal wrist ganglions originate from the:

1) Scapholunate ligament

3) Extensor digitorum communis (EDC ) tendon

2) Dorsal capsule

5) C apitolunate joint

4) Dorsal carpal ligament

Dorsal wrist ganglia do not arise from the dorsal capsule, EDC tendon, capitolunate joint, or dorsal intercarpal ligament. Dorsal wrist ganglia arise from the scapholunate ligament. Some surgeons advocate excising a small rim of the scapholunate ligament to avoid recurrence.

■Correct Answer:Scapholunate ligament

1405. (1759) Q4-2156:

Ganglions of the distal interphalangeal (DIP) joints of the fingers are called:

1) Mucous cysts

3) Heberden nodes

2) Bouchard nodes

5) Retinacular cysts

4) Inclusion cysts

Ganglions arising at the DIP joints are called mucous cysts and ganglions from the flexor tendon in the palm are called retinacular cysts.

Bouchard nodes are osteophytes that develop at the proximal interphalangeal joint.

Heberden nodes are bony spurs at the dorsal aspect of the DIP joint and are present in osteoarthritis. Inclusion cysts are mobile, nonadherent to skin, and can occur anywhere on a hand.

■Correct Answer:Mucous cysts

1406. (1760) Q4-2157:

Management of a mucous cyst entails:

1) Aspiration with injection of hyaluronidase

3) Excision and resection of osteophytes

2) Aspiration only

5) Arthrodesis of the distal interphalangeal joint

4) Aspiration with injection of steroids

Treatment of mucous cysts, which are ganglions of the distal interphalangeal joint associated with osteoarthritic changes, entails excision of the cyst and osteophyte resection of fusion.

Aspiration only or aspiration of the cyst with injection of hyaluronidase is not indicated or efficacious in the treatment of mucous cysts because the osteophyte must be addressed. Injection of steroids also fails to address the underlying cause of these cysts. Arthrodesis of the distal interphalangeal joint is not necessary in the treatment of typical mucous cysts.

■Correct Answer:Excision and resection of osteophytes

1407. (4047) Q4-2158:

A 30-year-old black woman presents with complaints of pain in the tip of her right index finger. The pain started approximately 6 months ago and becomes intense in cold weather. She also states that her nail on the index finger does not look as good as the others despite regular manicures. You notice a bluish discoloration and ridging of the nail. The nail is not split, but it appears clubbed. The patient does not have a history of respiratory or hemodynamic disease and appears healthy. The nail is exquisitely tender on pressure, but no mass is palpable. Two-point discrimination is intact and capillary refill is good. Radiographs do not reveal bony destruction, but you notice pressure indentation over the distal phalanx. The joint space is preserved, and the

patient has full range of motion. The most likely diagnosis is:

1) Glomus tumor

3) Paronychia

2) Acute perinychia

5) Turret exostosis

4) Giant cell tumor

This patient presents with the classic triad of glomus tumor: sharp lancinating pain, point tenderness, and cold sensitivity. Localized bluish discoloration is also strongly suggestive of a glomus tumor.

Giant cell tumors can be found on the fingertip, however, a presentation of a giant cell tumor with these symptoms would be unusual. Mucous cysts would be part of the differential but does not cause a bluish discoloration or cold insensitivity. An acute paronychia would be painful and erythematous is infectious. A mucous cyst is not infectious. This classic triad does not describe a turret exotosis.

■Correct Answer:Glomus tumor

1408. (1761) Q4-2159:

A 30-year-old black woman presents with complaints of pain in the tip of her right index finger. The pain started approximately 6 months ago and becomes intense in cold weather. She also states that her nail on the index finger does not look as good as the others despite regular manicures. You notice a bluish discoloration and ridging of the nail. The nail is not split, but it appears clubbed. The patient does not have a history of respiratory or hemodynamic disease and appears healthy. The nail is exquisitely tender on pressure, but no mass is palpable. Two-point discrimination is intact and capillary refill is good. Radiographs do not reveal bony destruction, but you notice pressure indentation over the distal phalanx. The joint space is preserved, and the

patient has full range of motion. The next step in management includes:

1) Ordering a magnetic resonance image

3) Ordering a computed tomography scan

2) Ordering a bone scan

5) Injecting the distal phalanx medullary canal with corticosteroid

4) Performing an excisional biopsy

This is a classic case of a glomus tumor with cold intolerance and nail deformity. Imaging studies often are inconclusive, although computed tomography scans may show cortical reaction. This patient is symptomatic and should receive definitive treatment. It should be noted that magnetic resonance imaging is increasingly helpful for nonclassical presentations of finger pain.

■Correct Answer:Performing an excisional biopsy

1409. (1762) Q4-2160:

A 30-year-old black woman presents with complaints of pain in the tip of her right index finger. The pain started approximately 6 months ago and becomes intense in cold weather. She also states that her nail on the index finger does not look as good as the others despite regular manicures. You notice a bluish discoloration and ridging of the nail. The nail is not split, but it appears clubbed. The patient does not have a history of respiratory or hemodynamic disease and appears healthy. The nail is exquisitely tender on pressure, but no mass is palpable. Two-point discrimination is intact and capillary refill is good. Radiographs do not reveal bony destruction, but you notice pressure indentation over the distal phalanx. The joint space is preserved, and the

patient has full range of motion. Based on your clinical diagnoses, the histological findings will include which of the following:

1) Well-formed vascular channels with nonmyelinated nerve endings

3) Giant cells filled with inflammatory cells in the interstitium

2) Mucous islands with blood vessels

5) Amorphous calcium in pseudocapsule

4) Negatively birefringent cystals

Glomus tumors consist of well-formed vascular channels with nonmyelinated nerve endings. Glomus tumors are not associated with mucous islands or giant cells. Negatively birefringent crystals are found in patients with gout. The presentation of this patient does not suggest gout. Amorphous calcium in a pseudocapsule is diagnostic of calcinosis. C alcinosis occurs intracutaneoulsy or subcutaneously. These deposits can be tender but are not effected by changes in weather, as are glomus tumors.

■Correct Answer:Well-formed vascular channels with nonmyelinated nerve endings

1410. (1763) Q4-2161:

Glomus tumors are characterized by all of the following except:

1) Three-quarters of glomus tumors occur in the hand.

3) Glomera are neuromyoarterial apparatuses that regulate sympathetic outflow.

2) Pain, point tenderness, and cold sensitivity are clinically present.

5) None of the above

4) Persistence of symptoms for more than 3 months after excision is suggestive of recurrence.

Glomera are neuromyoarterial apparatuses that regulate temperature.

■Correct Answer:Glomera are neuromyoarterial apparatuses that regulate sympathetic outflow.

1411. (1764) Q4-2162:

All of the following are characteristic of hemangiomas except:

1) 70% of hemangiomas are visible by 4 weeks of age

3) Hemangiomas are three times more common in woman than men

2) 70% of hemangiomas regress by 7 years of age

5) None of the above

4) All cavernous hemangiomas regress by 12 years of age

C avernous hemangiomas are noninvoluting hemangiomas and require surgical excision.

■Correct Answer:All cavernous hemangiomas regress by 12 years of age

1412. (1765) Q4-2163:

Pseudoaneurysms differ from true aneurysms in that:

1) Pseudoaneurysms are expansile.

3) Pseudoaneurysms have a fibrous wall.

2) Pseudoaneurysms occur secondary to trauma.

4) Pseudoaneurysms frequently occur in the ulnar artery.

Pseudoaneurysms occur secondary to penetrating trauma and have a fibrous wall, compared to true aneurysms that have all the elements of an arterial wall.

■Correct Answer:Pseudoaneurysms have a fibrous wall.

1413. (1766) Q4-2164:

Neurofibromas are characterized by all of the following except:

1) C afé-au-lait spots

3) Dumbbell tumors

2) Axillary freckles

5) C haracteristic oval avascular tumor in continuity with nerve trunk

4) Ease of surgical excision

Neurofibromas are benign tumors of neural origin that are transmitted as an autosomal dominant trait with variable penetrance. Neurofibromas are associated with cutaneous manifestations like cafe-au-lait spots and axillary freckles. They may be dumbbell shaped and can be identified with magnetic resonance imaging, which is especially helpful for deeper multiple lesions. They are infiltrative, making excision with preservation of peripheral nerve function difficult thus requiring bridge grafting for significant motor or sensory funtional requirements.

■Correct Answer:Ease of surgical excision

1414. (1767) Q4-2165:

Recklinghausenâs disease is associated with all of the following except:

1) Diffuse neurofibromatosis

3) High potential for malignant degeneration

2) Schwannoma

5) None of the above

4) Plexiform growth

Diffuse neurofibromatosis is a separate clinical presentation and is not associated with Recklinghausenâs disease.

■Correct Answer:Diffuse neurofibromatosis

1415. (1768) Q4-2166:

Schwannomas are differentiated from neurofibromas by all of the following except:

1) Ease of excision

3) Absence of fascicles

2) Eccentric location on the nerve

5) None of the above

4) Presence of schwann cells

Schwann cells contribute to schwannoma and neurofibroma.

■Correct Answer:Presence of schwann cells

1416. (1769) Q4-2167:

All of the following are true for infantile digital fibroma except:

1) 80% of infantile digital fibroma cases appear by 1 year of age

3) Intracytoplasmic inclusion bodies are present

2) Infantile digital fibroma is exclusive to fingers and toes

5) Recurrent disease never implies malignant transformation

4) Wide local excision is curative

Eighty percent of infantile digital fibromata appear before a child's first birthday. They are exclusive to the fingers and toes and are usually painless. Infantile digital fibromata are often small and the same color as the skin. On histological examination, intracytoplasmic inclusion bodies are present. Although benign, the fibromata are locally aggressive. They do not metastaaize, but recurrences after wide local excision are common. Surgery is indicated when deformity or contracture is imminent.

■Correct Answer:Wide local excision is curative

1417. (1770) Q4-2168:

Felon complications include all of the following except:

1) Phalangeal osteomyelitis

3) C ollar button abscess

2) Suppurative flexor tenosynovitis

5) Nailbed deformity

4) Distal interphalangeal joint septic arthritis

Felons that are chronic or neglected may penetrate adjacent structures such as the distal phalanx, nailbed, or distal interphalangeal joint. They can also contribute to the formation of a pyogenic flexor tenosynovitis. C ollar button abscesses are localized to web space. They typically arise from direct inoculation, not from distant felons.

■Correct Answer:C ollar button abscess

1418. (1771) Q4-2169:

Which of the following is not a classic Kanavel sign of flexor tenosynovitis:

1) Pain on passive extension

3) Tenderness of flexor sheath

2) Flexion attitude of the finger

5) Fusiform swelling of the entire finger

4) Anesthesia of the fingertip

The cardinal signs of flexor tenosynovitis described by Kanavel include pain on passive extension, flexion attitude of the finger, tenderness of flexor sheath, and swollen finger.

■Correct Answer:Anesthesia of the fingertip

1419. (1772) Q4-2170:

Septic flexor tenosynovitis may involve all of the following areas except the:

1) Radial bursa

3) Paronaâs space

2) Thenar space

5) Ulnar bursa

4) Snuffbox

The radial and ulnar bursae are extensions of the tendon sheaths of the flexor pollicis longus and the flexor digitorum profundus of the small fingers. They can easily be involved in a case of pyogenic flexor tenosynovitis. Although not direct extensions of the flexor sheaths, the thenar space and Parona's space are adjacent to the flexor sheaths and can be involved in suppurative conditions. The snuffbox, however, does not have any contributions from the flexor system and is not usually involved in cases of pyogenic flexor tenosynovitis.

■Correct Answer:Snuffbox

1420. (1773) Q4-2171:

Regarding the management of web space abscess, which of the following statements is not true:

1) Transverse incisions should be used.

3) Drains are often used following evacuation.

2) Wounds may be left open.

5) Thorough debridement of the dead muscle is required.

4) Early motion must be encouraged.

Transverse incisions can lead to contractures that limit finger abduction. Leaving wounds open allow for continued drainage. If preferred, closed suction drains can be used after closure of the wound. All devitalized tissue must be debrided and all signs of infection removed and irrigated copiously. Early motion is encouraged to prevent stiffness.

■Correct Answer:Transverse incisions should be used.

1421. (1774) Q4-2172: Meleneyâs infection is a:

1) Spreading ulcer rimmed with gangrenous skin

3) Dry gangrene with superimposed infection

2) Patchy gangrenous involvement of the hand

5) C reates a sinus fistula to the midcarpal space

4) Multiple infective ulcer of the forearm

Found in necrotizing fasciitis, Meleneyâs infection is a spreading ulcer rimmed with gangrenous skin. The affected area must be debrided immediately. C ultures are taken at the time of surgery to tailor antibiotic coverage. Amputation is not unusual to control the spread of the gangrenous infection.

■Correct Answer:Spreading ulcer rimmed with gangrenous skin

1422. (1775) Q4-2173:

Meleneyâs infection is caused by:

1) Streptococcus viridans

3) Microaerophyllic non-hemolytic streptococci

2) Aerobic hemolytic staphylococci

5) Staphylococcus aureus

4) B & C

Aerobic hemolytic staphylococci and microaerophyllic non-hemolytic streptococci synergistically act to produce Meleneyâs infection. Meleney's infection is a gangrenous infection that often results after a small injury. The infection is characterized by significant, rapid swelling with gangrenous changes.

■Correct Answer:B & C

1423. (1776) Q4-2174:

The most common pathogen for osteomyelitis of phalanges is:

1) Staphylococcus aureus

3) Haemophilus influenzae

2) Streptococci

5) Pasturella multocida

4) Mix of gram-negative and gram-positive organisms

Staphylococcus aureus is the most common pathogen that causes osteomyelitis in the hand. Most cases of osteomyelitis in the hand are due to direct extension. Other pathogens can be found if there is a contaminated injury that penetrates directly into the bone. H. infuenza , mixed pathogens, and Pasturella multocida are less likely causes of osteomyelitis and are often caused by direct inoculation injuries or bites.

■Correct Answer:Staphylococcus aureus

1424. (1777) Q4-2175:

The most common pathogen causing septic arthritis in the hand is:

1) Staphylococcus aureus

3) Haemophilus influenzae

2) Streptococci

5) Atypical mycobacterium

4) Mix of gram-negative and gram-positive organisms

Staphylococcus aureus is the most common pathogen that causes septic arthritis in the hand. The second most common pathogen is streptococcus species infections, which are often the result of trauma. Treatment includes incision and drainage with copius irrigation.

■Correct Answer:Staphylococcus aureus

1425. (1778) Q4-2176:

"C ollar button" abscess refers to:

1) Web space infection

3) Extension of infection from mid-palmar space to Paronaâs space in the forearm

2) Finger pulp infection

5) Septic joint with dorsal and palmar extension

4) Eponychial infection

C ollar button abscess is an infection of web space and is usually a result of penetrating trauma. Treatment of such abscesses requires incision and drainage through dorsal and palmar incisions. C are must be taken to avoid the neurovascular bundles. Finger pulp infections are known as felon. Infections involving Parona's space is typically involved in a horseshoe abscess. Eponychial infections are limited to the nail fold. C ollar button abscesses do not include joint involvement.

■Correct Answer:Web space infection

1426. (1779) Q4-2177:

A 35-year-old woman is bitten on her left index finger by a snake in her backyard. Management of snake bites includes all of the following except:

1) Keeping the patient emotionally and physically still

3) Identifying the snake

2) Applying a tourniquet

5) C all immediately for help

4) Injecting antivenin locally based on recommended guidelines

There are different snake bite protocols depending on the species of snake. However, common steps in all snake bite protocols include keeping the patient emotionally and physically still, calling for help immediately, applying a moderately tight tourniquet proximally to prevent further spread of venom, and capture or identification of the snake. Local injection of the antivenin in the fingers or toes is contraindicated.

■Correct Answer:Injecting antivenin locally based on recommended guidelines

1427. (1780) Q4-2178:

C ardinal signs of evenomation include all of the following except:

1) Fang marks

3) Pain

2) C yanosis

5) Ascending lymphangitis

4) Swelling

The cardinal signs of evenomation appear between 10 minutes and 4 hours after a person is bitten. The signs include fang marks, pain, swelling, and local necrosis. C yanosis is not considered a cardinal sign of evenomation.

■Correct Answer:C yanosis

1428. (1781) Q4-2179:

All of the following nerves are involved in infection with Mycobacterium leprae except the:

1) Ulnar nerve at the elbow

3) Supraorbital nerve

2) Median nerve in the carpal tunnel

5) Spinal accessory nerve

4) Vagus nerve

Mycobacterium leprae causes skin, nerve, and tendon sheath infections. M leprae commonly affects the hands because it has a predilection for cool parts of the body. M leprae causes neuropathy, which frequently involves the ulnar nerve at the elbow and the median nerve at the wrist. The resulting limb deformities require various surgical procedures. C ranial nerves and autonomic nerves are not affected.

■Correct Answer:Vagus nerve

1429. (1782) Q4-2180:

A 24-year-old white man presents to the emergency department. He was bitten on his fist while fighting with another man. You notice teeth marks on the dorsum of the metacarpophalangeal (MC P) joint of the right middle finger. The bite does not appear to be deep because the joint is not exposed, and you can see the extensor tendon, which seems intact. The patient has active extension at the MC P joint. The wound is red and swollen, but there is no tenderness or redness on the volar aspect of the MC P joint. The patient has some limitation in range of motion. He is afebrile. Radiographs reveal air in the joint but no joint

dislocation or fracture, and there is no neurovascular deficit. All of the following are appropriate steps in the management of this patient except:

1) Injection of tetanus toxoid

3) Exploration for air in the joint

2) C losure of the wound

5) Splinting

4) Admitting the patient for observation and intravenous antibiotics

Human bite wounds on the hand are typically found over the MP joint. The mechanism of injury is a clenched-fist blow to the mouth. Oral flora enters the wound, which often communicates with the joint. Eikenella corrodens is frequently cultured from human bite wounds, but the most common pathogen is staphylococcus aureus. Appropriate treatment includes the administration of tetanus toxoid, exploration if there is air in the joint or frank infection, observation, intravenous antibiotics, arm elevation, and splinting. All bites over joints should be assumed to penetrate and require formal incision and drainage.

■Correct Answer:C losure of the wound

1430. (1783) Q4-2181:

A 24-year-old man presents to the emergency department. He was bitten on his fist while fighting with another man. You notice teeth marks on the dorsum of the metacarpophalangeal (MC P) joint of the right middle finger. The bite does not appear to be deep because the joint is not exposed, and you can see the extensor tendon, which seems intact. The patient has active extension at the MC P joint. The wound is red and swollen, but there is no tenderness or redness on the volar aspect of the MC P joint. The patient has some limitation in range of motion. He is afebrile. Radiographs reveal soft tissue involvement but no joint dislocation or fracture, and there is no neurovascular deficit. An important step in assessment of human bites is:

1) Evaluation for tendon injury in clenched-fist position

3) Ultrasound to rule out septic arthritis

2) Bone scan to rule out osteomyelitis

5) None of the above

4) Monitoring finger girth to document progress

Evaluation for tendon injury in a clenched-fist position is essential because tendons slide proximally in the open-hand position. Involvement of tendon or joint usually necessitates surgical debridement.

■Correct Answer:Evaluation for tendon injury in clenched-fist position

1431. (1784) Q4-2182:

A 24-year-old white man presents to the emergency department. He was bitten on his fist while fighting with another man. You notice teeth marks on the dorsum of the metacarpophalangeal (MC P) joint of the right middle finger. The bite does not appear to be deep because the joint is not exposed, and you can see the extensor tendon, which seems intact. The patient has active extension at the MC P joint. The wound is red and swollen, but there is no tenderness or redness on the volar aspect of the MC P joint. The patient has some limitation in range of motion. He is afebrile. Radiographs reveal soft tissue involvement but no joint dislocation or fracture, and there is no neurovascular deficit. After cultures are taken, the next important step in treatment is:

1) Debridement in the emergency department and suture

3) Admit and administer IV antibiotics

2) Single dose intravenous (IV) antibiotics and discharge on oral antibiotics with follow-up instructions

5) None of the above

4) Patient work up for human immunodeficiency virus

A patient with a human bite must be admitted for IV antibiotics and observation. If left untreated, human bites are commonly infected by a mixed flora of organisms. Therefore, they must be treated diligently.

■Correct Answer:Admit and administer IV antibiotics

1432. (1785) Q4-2183:

A 24-year-old white man presents to the emergency department. He was bitten on his fist while fighting with another man. You notice teeth marks on the dorsum of the metacarpophalangeal (MC P) joint of the right middle finger. The bite does not appear to be deep because the joint is not exposed, and you can see the extensor tendon, which seems intact. The patient has active extension at the MC P joint. The wound is red and swollen, but there is no tenderness or redness on the volar aspect of the MC P joint. The patient has some limitation in range of motion. He is afebrile. Radiographs reveal soft tissue involvement but no joint dislocation or fracture, and there is no neurovascular deficit. The most appropriate antibiotic treatment includes:

1) Imipenam and ciprofloxacin

3) Amoxicillin and ciprofloxacin

2) C efotaxime and ciprofloxacin

5) Bactrim and rifampin

4) Amoxicillin and flocloxacillin

Imipenam and ciprofloxacin provide treatment for gram-negative and gram-positive organisms.

■Correct Answer:Imipenam and ciprofloxacin

1433. (1786) Q4-2184:

Which of the following organisms is most likely found in a cat bite:

1) Eikenella corrodens

3) Micrococcus

2) Pasteurella multocida

5) None of the above

4) Borrelia recurrentis

Pasteurella multocida is the most common organism found in animal bites.

■Correct Answer:Pasteurella multocida

1434. (1787) Q4-2185:

Which of the following is the atypical mycobacterium that infects a penetrating wound sustained in an aquatic environment:

1) Mycobacterium avium

3) Mycobacterium aquaticum

2) Mycobacterium marinum

5) Mycobacterium chelorei

4) Mycobacterium tuberculosis hominis

Tuberculosis is the most common chronic infection found in the hand. Mycobacterium marinum is the atypical mycobacterium that can infect a wound sustained in a marine environment, freshwater lake, or tropical fish tanks. It is also called swimming pool granuloma or fish tank granuloma.

■Correct Answer:Mycobacterium marinum

1435. (1788) Q4-2186:

Which of the following is not true for infections caused by Mycobacterium marinum:

1) Noncaseating granuloma is present.

3) Lowenstein-Jensen media can be used for cultures.

2) Minocycline is the preferred treatment.

5) It is also referred to as fish tank granuloma.

4) Painful swelling of digit, palm, or wrist is present with redness, warmth, and tenderness.

Tuberculous infections are chronic infections and do not produce acute signs of inflammation. Therefore, pain and tenderness are present in these infections but warmth and redness are absent. Abscesses produced in tuberculous infections are termed "cold abcesses."

■Correct Answer:Painful swelling of digit, palm, or wrist is present with redness, warmth, and tenderness.

1436. (1967) Q4-2379:

Which of the following fascial structures does not contribute to the formation of the spiral cord:

1) Pretendinous band

3) Graysonâs ligament

2) Lateral digital sheet

5) Spiral band

4) C lelandâs ligament

The pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament are all parts of the normal fascia that contribute to the formation of the spiral cord. C leland's ligament is not involved at all in the disease process.

■Correct Answer:C lelandâs ligament

1437. (1968) Q4-2380:

Which of the following structures contribute to the formation of the spiral cord:

1) Pretendinous band, Graysonâs ligament, and C lelandâs ligament

3) Pretendinous band, Landsmeer ligament, and Graysonâs ligament

2) Pretendinous band, lateral digital sheet, and Graysonâs ligam

5) C leland's ligament and Grayson's ligament

4) Pretendinous band, Landsmeer ligament, and natatory ligament

The spiral cord is formed from the pretendinous band, spiral band, Grayson's ligament, and lateral digital sheet. C leland's ligament is not affected in Dupuytren's contracture. Remember that bands and ligaments give rise to cords, which are the diseased state.

■Correct Answer:Pretendinous band, lateral digital sheet, and Graysonâs ligam

1438. (1969) Q4-2381:

Surgical release in Dupuytrenâs disease is indicated in which of the following:

1) A 15° metacarpophalangeal (MP) joint contracture and a 15° proximal interphalangeal (PIP) joint contracture

3) Palpable spiral cord involving ring and small fingers

2) A 15° MP joint contracture and a 0° PIP joint contracture

5) Palpable spiral cord involving ring and small fingers in both of the hands

4) Palpable spiral cord involving ring and small fingers with multiple skin pits

The indication for surgery in Dupuytrenâs disease is MP joint contracture larger than 30° and any degree of PIP joint deformity. The other answers are incorrect because they are subjective descriptions and do not necessarily indicate joint involvement.

■Correct Answer:A 15° metacarpophalangeal (MP) joint contracture and a 15° proximal interphalangeal (PIP) joint contracture

1439. (1970) Q4-2382:

Skin pits in Dupuytrenâs disease are caused by:

1) Vertical septae of Legueu and Juvara

3) Longitudinal fibers of palmar aponeurosis inserting into the skin

2) Vertical fibers of palmar aponeurosis anchoring to the skin

5) C ontractures of the natatory ligaments

4) Longitudinal pretendinous bands

The longitudinal fibers forming layer 1 of the palmar aponeurosis insert into the dermis and, when contracted, give rise to skin pits. The pretendinous bands give rise to the central cord. C ontractures of the natatory ligament give rise to the natatory cord. Vertical fibers and septae do not give rise to pits.

■Correct Answer:Longitudinal fibers of palmar aponeurosis inserting into the skin

1440. (1971) Q4-2383:

An otherwise healthy man has Dupuytrenâs disease, which involves his small finger with 40° proximal interphalangeal joint involvement. The preferred surgery in this patient is:

1) Partial fasciectomy

3) Arthroplasty

2) Arthrodesis

5) Fasciotomy with skin grafting

4) Osteotomy

A partial fasciectomy is the preferred surgery in this situation. It is recommended that involved fascial cords be resected rather than performing prophylactic fasciectomies. C are must be taken to preserve the neurovascular bundles. Arthrodesis, arthroplasty, and osteotomies are salvage procedures meant for recurrent disease. Fasciotomy has been recommended for elderly patients

who cannot tolerate a long operation.

■Correct Answer:Partial fasciectomy

1441. (1972) Q4-2384:

Marjolinâs ulcers are risk factors for which of the following tumors:

1) Squamous cell carcinoma

3) Melanoma

2) Basal cell carcinoma

5) Osteosarcoma

4) Synovial sarcoma

Marjolinâs ulcers are malignant degenerations in chronic skin ulcers, sinuses, and burn scars and are risk factors for squamous cell carcinoma. Any patient with chronic, nonhealing ulcers should undergo biopsy for malignant degeneration. Basal cell carcinoma, malignant melanoma, synovial sarcoma, and osteosarcoma are not commonly associated with Marjolin's ulcer.

■Correct Answer:Squamous cell carcinoma

1442. (1973) Q4-2385:

Which of the following tumors rarely metastasizes:

1) Malignant melanoma

3) C lear cell carcinoma

2) Synovial sarcoma

5) Squamous cell carcinoma

4) Dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans presents as a variably colored, slow-growing nodule involving the subcutaneous tissue. This tumor has a low incidence of metastasis; however, the recurrence rate is high even with wide local excision.

■Correct Answer:Dermatofibrosarcoma protuberans

1443. (1974) Q4-2386:

Lymph node involvement is common in all of the following tumors except:

1) Sweat gland tumors

3) Melanoma

2) Squamous cell carcinoma

5) Merkel's cell carcinoma

4) Basal cell carcinoma

Basal cell carcinomas rarely metastasize. Malignant sweat gland tumors, malignant melanoma, and Merkel's cell carcinoma are aggressive. Treatment usually includes regional lymphadenectomy. Squamous cell carcinoma is one of the most common hand malignancies and has the capacity to metastasize via the lymphatics.

■Correct Answer:Basal cell carcinoma

1444. (1975) Q4-2387:

Which of the following is not a characteristic of an acrolentiginous melanoma:

1) Involves palm and nail bed

3) Presents in older patients

2) Delays in diagnosis are common

5) Develops rapidly

4) Does not commonly metastasize

Acrolentiginous melanomas are usually flat, pigmented lesions. These melanomas often occur in older patients, affecting the palm and nail bed. At the time of presentation, acrolentiginous melanomas are frequently metastasized.

■Correct Answer:Does not commonly metastasize

1445. (1976) Q4-2388:

Nevi at greatest risk for malignant degeneration are:

1) Giant congenital hair variety

3) Junctional nevi

2) Blue nevi

5) Nevus sebaceous

4) C ompound nevi

Giant congenital hairy nevi, dysplastic nevi, senile lentigo, and congenital melanocytic nevi have significant risk for malignant degeneration.

Nevus sebaceous is present at birth in the head and neck region and has a 10% incidence of malignant transformation. Blue nevi, junctional nevi, and compound nevi have lower risks for transformation.

■Correct Answer:Giant congenital hair variety

1446. (1977) Q4-2389:

All of the following are risk factors for malignant melanoma except:

1) Sunlight

3) C opper-based tanning lotions

2) Genetic predisposition

5) Immunosuppressive state

4) Atypical nevi

Sun exposure is the most important risk factor for melanoma. Family history, atypical nevi, and an immunosuppressive state increases an individual's risk for developing melanoma. It is unknown if tanning lotions cause malignant melanomas.

■Correct Answer:C opper-based tanning lotions

1447. (1978) Q4-2390:

Which of the following statements is true regarding soft tissue sarcomas:

1) Soft tissue sarcomas frequently metastasize to bone.

3) Soft tissue sarcomas present as a painful mass in the hand.

2) Patients with soft tissue sarcomas of the hand have worse prognosis than patients with similar tumors in other extremities.

5) Soft tissue sarcomas can be "shelled out".

4) Overall prognosis is better with radical resection than wide excision.

Soft tissue sarcomas in the hand present as painless lesions, do not metastasize to bone, and although local control is better with radical resection, there is no improvement in overall survival when compared to wide excision. Soft tissue sarcomas should not be "shelled out."

■Correct Answer:Patients with soft tissue sarcomas of the hand have worse prognosis than patients with similar tumors in other extremities.

1448. (1979) Q4-2391:

Which of the following tumor metastasizes to lungs:

1) Squamous cell carcinoma

3) Soft tissue sarcoma

2) Basal cell carcinoma

5) Actinic keratosis

4) Schwannoma

Squamous cell carcinoma and basal cell carcinoma do not commonly metastasize to the lungs. Actinic keratoses are premalignant lesions that progress into squamous cell carcinomas. Schwannomas are common benign nerve tumors.

■Correct Answer:Soft tissue sarcoma

1449. (1980) Q4-2393:

Which of the following is not a characteristic of synovial sarcomas:

1) Synovial sarcomas are poorly differentiated masses located close to joints, tendon, or bursa.

3) Lymphatic spread is common.

2) Spindle and epithelial-type cells with monophasic or biphasic cells are present on histology.

5) High grade malignant soft tissue sarcoma

4) Wide or radical excision with radiation or chemotherapy prevents metastases.

Synovial sarcomas are high grade malignant soft tissue sarcomas, in which metastases can occur years after surgery. Long term followup is necessary. They arise close to joints, tendons or bursa and lymphatic spred is common. Histology reveals spindle and epithelial type cells with menophasic or biphasic pattern. Treatment includes wide resection and radiation, chemotherapy is not usually used.

■Correct Answer:Wide or radical excision with radiation or chemotherapy prevents metastases.

1450. (1981) Q4-2394:

C haracteristic histological features of malignant schwannoma are best described as:

1) Fusiform cells with neoplastic schwann cells and nerve fascicles

3) Round or fusiform cells with clear cytoplasm and nerve fascicles

2) Spindle and epithelial-type cell mix with monphasic or biphasic cells

5) None of the above

4) Pleomorphic spindle histiocytes and giant cells in a storiform pattern

The histological features of malignant schwannoma have characteristic fusiform cells with neoplastic schwann cells and nerve fascicles.

■Correct Answer:Fusiform cells with neoplastic schwann cells and nerve fascicles