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Question 1High Yield

Macrodactyly that is present at birth is termed:

Explanation

Barsky described macrodactyly as either static or progressive. Static macrodactyly is present at birth, and the affected digit grows larger as the child develops. In the progressive type of macrodactyly, growth begins soon after birth. This form of the disorder is more common than static macrodactyly.

Question 2High Yield

The most accepted theory for the cause of macrodactyly is:

Explanation

Some surgeons believe that macrodactyly is a variant of neurofibromatosis. Although macrodactyly is not an inherited anomaly, there are syndromes that may be associated with enlarged digits such as Proteus syndrome. Although numerous causes have been suggested, the most accepted theory was described by Inglis in 1950. He theorized that the abnormal nerves exert influence on the local tissues to stimulate growth.

Question 3High Yield

Syndromes that may be associated with macrodactyly include:

Explanation

Some surgeons believe that macrodactyly is a variant of neurofibromatosis. Although macrodactyly is not an inherited anomaly, there are syndromes that may be associated with enlarged digits such as Proteus syndrome. Theoretical causes for macrodactyly include a neural cause, a vascular cause, as well as a humoral mechanism. The most accepted theory is that abnormal nerves exert some influence on the local tissues to stimulate growth.

Question 4High Yield

Macrodactyly affects:

Explanation

Although this is controversial, the majority of surgeons believe that macrodactyly affects bones, fat, and nerves.

Question 5High Yield

A 2-year-old child is brought to your office for evaluation of a "big hand." Upon examination, you notice that the child has mildly enlarged ring and small fingers. There is full range of motion without instability. After examination of the patient, you recommend:

Explanation

The child is not ready for surgery. Although surgery may coincide with the patient beginning school, this does not always occur. At this time, additional examination and testing are recommended.

Question 6High Yield

A 2-year-old child is brought to your office for evaluation of a "big hand." Upon examination, you notice that the child has mildly enlarged ring and small fingers. There is full range of motion without instability. The childâs parents inform you that they would like you to amputate the affected digits as soon as possible. You should:

Explanation

Although amputation may be necessary in some patients with macrodactyly, it is too early in the course of this case to begin entertaining such a drastic measure. A debulking procedure is not recommended for a 2-year-old child. Radiation therapy is not an option in uncomplicated cases of macrodactyly. The surgeon must educate the parents about the disease process and order additional testing.

Question 7High Yield

You discover that a patient who you have been treating for macrodactyly has been followed by the Proteus Syndrome
Foundation. Exhaustive work-up has been completed and radiographs of the hand reveal:

Explanation

In patients with macrodactyly, surgeons do not typically find enchondromas, especially not multiple enchondromas in the affected fingers. Enlargement of the bones is found in all dimensions â not only in the length and width. If the bones appear normal on radiograph, then they are not affected by macrodactyly.

Question 8High Yield

A 2-year-old child is brought to your office for evaluation of a "big hand." Upon examination, you notice that the child has mildly enlarged ring and small fingers. There is full range of motion without instability. After examination of the patient, you discuss the diagnosis of macrodactyly with the parents. The parents feel assured after your discussion of the disease process and your review of the radiographs. You should next see the patient:

Explanation

Patients with macrodactyly should be followed up yearly. Although the parents may be difficult, this is not a reason to stop seeing a patient. The other answers choices are incorrect because treatment would be too late.

Question 9High Yield

Which of the following is not a complication of macrodactyly surgery:

Explanation

C omplications of macrodactyly surgery include poor healing of flaps secondary to devascularization or undue tension, nerve injury or decreased sensation, infection, stiffness, bony nonunion or malunion, and failure of the epiphysiodesis.

Question 10High Yield

Epiphysiodesis for macrodactyly should be performed at the following location:

Explanation

Treatment by epiphysiodesis for macrodactyly is ineffective if only single phalanges are treated. Therefore, treatment of the proximal phalanx, distal phalanx, or the middle phalanx alone is incorrect. The author prefers to perform epiphysiodesis only on the proximal and distal phalanges. The middle phalanx is not treated to preserve motion at the proximal interphalangeal joint.

Question 11High Yield

When ruptured, which portion of the scapholunate ligament leads to scaphoid-lunate diastasis:

Explanation

The dorsal section of the scapholunate ligament is the strongest portion, requiring 300 N of load for failure. The volar (150 N) and intermediate portions (25 N to 50 N) contribute less to overall stability.

Question 12High Yield

Which of the following radiographic views is not routinely used to diagnose scapholunate injury:

Explanation

The semisupination oblique view is used to visualize the pisiform and pisotriquetral joint. The PA oblique and lateral views are the primary films used to diagnose scapholunate instability. The clenched fist view is used as a provocative view to bring out dynamic instability.

Question 13High Yield

Which of the following treatments is not used for acute scapholunate ligament ruptures:

Explanation

Proximal row carpectomy is a salvage procedure for chronic instability with focal radioscaphoid arthritis. Open repair with sutures through bone tunnels, open repair with suture anchors, and arthroscopically assisted reduction and pinning have been used successfully in acute cases.

Question 14High Yield

Which of the following is considered indicative of a scaphoid-lunate ligament tear on posteroanterior radiograph:

Explanation

The VISI, DISI, and spilled tea cup signs are seen on lateral radiographs, whereas the Watson-Jones scaphoid shift test is a clinical sign. The classic pattern after scaphoid-lunate ligament injury is a DISI pattern as the lunate extends and the scaphoid flexes. The spilled tea cup sign is present in perilunate dislocations.

Question 15High Yield

The Terry Thomas sign, which is considered indicative of scaphoid-lunate ligament rupture, is best described as:

Explanation

The Terry Thomas sign refers to scapholunate diastases that may be apparent on posteroanterior radiographs of the wrist and is indicative of rupture if the diastases are larger than 3 mm. It is named after the famous comedian who had a gap between his front teeth.

Question 16High Yield

The most important requirement for a diagnostic magnetic resonance image (MRI) study in cases of scaphoid-lunate ligament injury is:

Explanation

MRI is not considered the technique of choice for the evaluation of the scaphoid-lunate ligament. Standard MRI coils are not adequate for the evaluation of the ligaments of the wrist. To maximize the yield from a wrist MRI, high-field strength and high- resolution images must be obtained using dedicated wrist coils. Only with such dedicated coils can detailed information be derived regarding the continuity of the scapoid-lunate ligament. Physical examination and wrist arthroscopy remain the gold standards for the evaluation of a torn scaphoid-lunate ligament.

Question 17High Yield

In cases of subacute scaphoid-lunate ligament injury with no arthrosis, all of the following are acceptable options except:

Explanation

In cases of subacute scaphoid-lunate ligament injury without arthrosis, it is acceptable to attempt reconstruction with bone anchors, allograft ligament repair, capsulodesis, bone-ligament-bone autograft, and the RASL procedure with a Herbert screw. In the presence of localized arthritis, one might consider one of the limited wrist fusions such as scaphotrapeziotrapezoid fusion.

Question 18High Yield

Mallet finger injuries refer to:

Explanation

Mallet finger injuries may be associated with fractures of the bony tuft, fractures of the middle phalanx, flexor tendon injuries, and intrinsic tightness. However, mallet injuries refer to lack of continuity at the DIP joint.

Question 19High Yield

In mallet finger injuries, the distal phalanx posture is:

Explanation

The characteristic deformity is âdroopingâ at the distal interphalangeal (DIP) joint. The DIP is flexed. It is not hyperextended, neutral, or deviated.

Question 20High Yield

Mallet finger injuries are typically:

Explanation

Mallet finger usually results from a blow to the tip of the extended finger. This forces distal phalanx flexion and disruption of the extensor mechanism at the distal interphalangeal joint. Open injuries to the extensor mechanism can also cause mallet finger.

Question 21High Yield

Treatment of a type I mallet finger is typically closed. This involves:

Explanation

C ast immobilization is excessive and will cause undue stiffness in the affected finger. Dorsal blocking splints, splinting in flexion, and early active motion are contraindicated in these injuries. Only the affected joint should be splinted in extension.

Question 22High Yield

Type I mallet finger injuries must be immobilized constantly for a minimum of:

Explanation

Eight weeks of immobilization is preferred. If the finger is immobilized for a shorter period of time, the clock is reset and immobilization is started again.

Question 23High Yield

The most common mallet finger injuries are:

Explanation

Type I mallet injuries are by far the most common mallet injuries. There is no such classification as a type V injury.C orrect
Answer: Type I

Question 24High Yield

On physical examination, a mallet finger assumes a:

Explanation

The distal phalanx assumes a resting flexed posture. The patient is not able to actively extend the fingertip, but it can be passively extended.

Question 25High Yield

The following mallet finger injuries always require tendon repair:

Explanation

Type II and III injuries have absolute requirements for tendon repair as there is a laceration or loss of tendon substance.C orrect
Answer: Type II and type III

Question 26High Yield

After placing a type I mallet finger in a splint at the initial visit, next follow-up should be:

Explanation

After placement of the splint, the patient should follow-up in the next week to make sure the finger is still maintained in full extension. Loosening of the splint will occur as swelling decreases.

Question 27High Yield

The most common bone tumor of the upper extremity is:

Explanation

Osteochondromas are the most common primary benign bony tumors.

Question 28High Yield

The most common benign bone tumor of the hand is:

Explanation

Unlike the entire upper extremity, enchondromas are the most common tumors of the hand.

Question 29High Yield

Osteochondromas are benign but can have a malignant transformation in which of the following cases:

Explanation

Diaphyseal achalasia, also known as multiple hereditary exostoses, has a risk of malignant degeneration in up to 25% patients. Ollierâs disease and Mafucciâs syndrome are associated with enchondromas. There is no lesion called an osteochondromatosis malignant transformans.

Question 30High Yield

The risk of malignant transformation in patients with multiple hereditary exostoses is:

Explanation

The rate of malignant transformation in patients with multiple hereditary exostoses is variable and is generally reported between
0.5% to 25%.

Question 31High Yield

Recurrence of osteochondroma is likely if:

Explanation

The cartilaginous portion of an osteochondroma is the neoplastic part; its complete excision is essential to avoid recurrences.

Question 32High Yield

Malignant transformation of osteochondroma commonly occurs to:

Explanation

Osteochondroma is a cartilaginous tumor and malignant transformation is to a low-grade chondrosarcoma.

Question 33High Yield

All of the following suggest a possibility of malignant transformation in multiple hereditary exostoses except:

Explanation

Stippling on radiographs in the cap is due to calcification and is a common characteristic of cartilaginous tumors.

Question 34High Yield

Enchondromas are commonly involved in which of the following sites:

Explanation

Metacarpals and phalanges are the most common areas of hand involvement, and the hand is involved in 40% to 65% of cases. Enchondromas are also the most common primary benign bone tumor of the hand (90% cases).

Question 35High Yield

The most common forearm deformity in patients with hereditary multiple osteochondromatosis is:

Explanation

Ulnar involvement and shortening frequently occurs in patients with hereditary multiples osteochondromatosis because the distal ulnar growth plate is smaller than that of the radius, consequently its length is affected more. The ulnar shortening causes radial bowing or radial head dislocation.

Question 36High Yield

Slide 1
A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.
The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.
You order a radiograph of the patientâs forearm. The anteroposterior radiograph is shown (Slide). The next step is to order a:

Explanation

The next step is to order a skeletal survey to rule out involvement of other areas.

Question 37High Yield

Slide 1 Slide 2 Slide 3
A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.
The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.
An immediate appointment for magnetic resonance imagine (MRI) and computed tomography (C T) scan are not available, and a genetic evaluation has been carried out previously. As you await the report from the geneticist office, you decide to get a skeletal radiograph series on the patient. The radiograph of the opposite forearm (Slide 1) and right leg are shown (Slide 2).
You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 3). Your suspected diagnosis is:

Explanation

Diaphyseal achalasia, also called multiple hereditary exostoses, classically presents in a young individual with multiple sites of involvement. The more involved the disease, the more likely hand involvement becomes. Forearm involvement is also common. The radius is bowed due to the shortened ulna. The risk of radial head dislocation is higher if the radius does not bow. While infection or traumatic injury could have produced early physeal arrest as seen in the first radiograph, presence of lesions elsewhere indicates multiple hereditary exostoses and should be investigated with skeletal surveys. Multiple epiphyseal dysplasia is not a possible diagnosis as only the ulna is involved in the first radiograph and radius alone in the left forearm. No enchondromas are present.

Question 38High Yield

Slide 1 Slide 2 Slide 3
A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.
The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.
You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).
The genetic pattern seen in patients with this type of presentation is:

Explanation

Multiple hereditary exostoses is inherited in an autosomal-dominant manner with 90% penetrance.

Question 39High Yield

Slide 1 Slide 2 Slide 3
A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.
The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.
You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).
Which of the following areas is unlikely to be involved:

Explanation

The clavicle is a membranous bone, and osteochondromas do not arise in membranous bones.

Question 40High Yield

Slide 1 Slide 2 Slide 3
A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.
The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.
You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).
The chance of hand involvement in this child is:

Explanation

The hand is involved in 30% to 80% of cases.

Question 41High Yield

Slide 1 Slide 2 Slide 3
A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.
The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.
You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).
The most likely complication in this child is:

Explanation

Ulnar carpal translocation occurs due to the steep radial articular angulation that occurs due to the tethering effect of a shortened ulna and is already apparent in early stages in the first radiograph. While peroneal palsy is possible due to a proximal fibula lesion, it is less common. Malignant transformation occurs, risk varies with families.

Question 42High Yield

Slide 1 Slide 2 Slide 3
A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.
The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.
You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).
The difference between Madelungâs deformity and this boyâs condition is:

Explanation

The ulna is elongated or dorsally subluxed in Madelung's deformity.

Question 43High Yield

Slide 1 Slide 2 Slide 3
A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.
The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.
You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).
All of the following are acceptable options, either alone or in combination, for management of this childâs condition, except:

Explanation

Although hemiphyseal stapling is an acceptable option to correct radial articular angulation, in this boy the distal radial physis is already fused as is seen in the first radiograph.

Question 44High Yield

Slide 1 Slide 2 Slide 3
A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.
The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.
You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).
Which of the following is not true regarding the possibility of malignant degeneration in this child:

Explanation

Bone scan cannot differentiate between an active lesion and a malignant transformation.

Question 45High Yield

Hornerâs syndrome includes all of the following except:

Explanation

Hornerâs syndrome is caused by disruption of sympathetic innervation and is characterized by enophthalmosis, not exophthalmosis. Other symptoms include anhidrosis, miosis, and ptosis.

Question 46High Yield

Axonotmesis involves injury to the:

Explanation

Axontmesis, as described in Seddonâs classification, implies injury to the axon and myelin sheath. Neurontmesis involves injury to all three layers.
■Correct Answer:Axon

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