Free Orthopedics Review | Dr Hutaif General Orthopedics -...
14 Apr 2026
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Key Takeaway
This article provides essential research regarding FREE Orthopedics MCQS 2022 1501-1550. Difficulty to directly flex his elbow, necessitating compensatory movements like wrist flexion and forearm pronation, often signals a brachial plexus injury. Specifically, weakness in muscles like the biceps and brachialis, typically innervated by C5-C6 nerve roots, causes this. A positive Tinel's sign near the clavicle can further indicate such a nerve lesion.
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Question 1High Yield
A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
Diagnosis of the condition is:
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
Diagnosis of the condition is:
Explanation
The involved muscles have C 5, C 6 root innervations. Positive Tinelâs sign, functioning rhomboids and serratus anterior, and the absence of Hornerâs syndrome rule out a preganglionic lesion. The EMG finding confirms the clinical finding. Subclinical involvement of any other muscle is not shown. Neuropraxia usually recovers in 6 weeks and EMG shows fibrillation, which is inconsistent with neuropraxia. Brachial plexus neuritis, Parsonage-Turner syndrome, has an acute presentation following a painful episode involving the whole arm. There is significant history of a fall in this case.
Question 2High Yield
A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The level of lesion is:
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The level of lesion is:
Explanation
The involved muscles have C 5, C 6 root innervations. Positive Tinelâs sign, functioning rhomboids and serratus anterior, and the absence of Hornerâs syndrome rule out a preganglionic lesion. The EMG finding confirms the clinical finding. Subclinical involvement of any other muscle is not shown. Neuropraxia usually recovers in 6 weeks and EMG shows fibrillation, which is inconsistent with neuropraxia. Brachial plexus neuritis, Parsonage-Turner syndrome, has an acute presentation following a painful episode involving the whole arm. There is significant history of a fall in this case.
Question 3High Yield
A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The least helpful test in further management of this patient is:
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The least helpful test in further management of this patient is:
Explanation
C omputed tomography scan of the cervical spine will not show the pseudomeningoceles nor provide any information on brachial plexus. C omputed tomography may be needed in case of a suspected neck injury but does not form part of a brachial plexus work up.
Question 4High Yield
A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The plan of management in this patient 5 months postinjury with no clinical improvement should be:
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The plan of management in this patient 5 months postinjury with no clinical improvement should be:
Explanation
Neurotization is appropriate in preganglionic lesions. If at 6 months a patient shows no evidence of recovery, it is time for plexus exploration. Further observation will not change the picture. Tendon transfers are reconstructive procedures, which are done at a later stage.
Question 5High Yield
A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The most important indication for early exploration in this patient is:
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The most important indication for early exploration in this patient is:
Explanation
An important indication for early exploration is the recovery of a distally supplied muscle, EC RLâC 6, in the absence of a proximally supplied muscle, bicepsâC 5. Trick movements are adaptive movements employed by the patient by recruiting other muscles, for example, the use of flexor-pronator as elbow flexors in this patient. Bony deformity is a late sequelae and biceps recovery at 3 months is important in obstetric brachial palsy.
Question 6High Yield
A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle eight weeks prior. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The most important function that needs to be restored in this patient is:
grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.
The most important function that needs to be restored in this patient is:
Explanation
Elbow flexion is central to management of brachial plexus management because it serves the most important function of feeding.
Question 7High Yield
An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of
5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.
Diagnosis of this condition is:
5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.
Diagnosis of this condition is:
Explanation
This is a case of obstetric brachial plexus injury involving the C 8, T1 roots (Klumpkeâs palsy). Erbâs palsy involves upper roots only. C ombined nerve injuries can present in a similar fashion, however low ulnar and median nerve lesions will not have weakness of the flexor digitorum profundus and flexor digitorum sublimis.
History of a large baby, shoulder dystocia, and clavicle fracture point to difficult labor. The most common type of brachial plexus injury related to birth is Erbâs palsy, which is usually associated with a breech presentation. Isolated Klumpkeâs palsy is quite rare and the involvement of C 8 and T1 usually occurs as part of global plexus injury.
History of a large baby, shoulder dystocia, and clavicle fracture point to difficult labor. The most common type of brachial plexus injury related to birth is Erbâs palsy, which is usually associated with a breech presentation. Isolated Klumpkeâs palsy is quite rare and the involvement of C 8 and T1 usually occurs as part of global plexus injury.
Question 8High Yield
An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of
5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.
The level of the lesion in this patient is:
5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.
The level of the lesion in this patient is:
Explanation
It is difficult to clinically differentiate between a pre- and postganglionic lesion of C 8, T1 in a child. Absence of Hornerâs syndrome and hemi-diaphragmatic palsy in this case indicates that this is not a preganglionic lesion. The ability of the patient to hold his
head suggests that the paravertebral muscles are functional, as is true in postganglionic lesions.
head suggests that the paravertebral muscles are functional, as is true in postganglionic lesions.
Question 9High Yield
An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of
5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.
Appropriate surgical management in this case is:
5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.
Appropriate surgical management in this case is:
Explanation
Neurotization is done for preganglionic lesions and has not been shown to produce successful results for lower root involvement. At 18 months, exploration and nerve grafting must be carried out. Neurolysis is reserved for cases in which recovery is partial or plateaus. Tendon transfers in children less than 3 years old do not work as well. Younger children do not cooperate well in rehabilitation. It is also difficult to decide upon the functioning motors for transfer.
Question 10High Yield
An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of
5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.
Reconstructive surgery includes all of the following except:
5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.
Reconstructive surgery includes all of the following except:
Explanation
This patient has developed contractures of first web space, which will not respond to passive stretching. Fusion of the MP joint is unneccesary, as tendon transfers will provide lateral and tip pinch as well as opposition.
Question 11High Yield
Which mechanism and long-term deformity is most often associated with a dorsal avulsion fracture at the base of the middle phalanx:
Explanation
Three types of PIP joint dislocations are identified: volar, dorsal, and central depression. Volar PIP joint dislocations result in avulsion of the dorsal fragment of the base of the middle phalanx, which represents the central tendonâs attachment. If displacement persists, than a boutonniere deformity may result. Volar avulsion fractures of the PIP joint are often due to a hyperextension injury at the attachment of the volar plate.
Question 12High Yield
At what degree of flexion is ulnar collateral ligament injury tested:
Explanation
At 30º of MC P joint flexion, the ulnar collateral ligament is isolated from the volar plate.
Question 13High Yield
Which of the following structures are found within the first dorsal compartment:
Explanation
The first dorsal compartment encompasses the abductor pollicis longus and extensor pollicis brevis. Multiple slips of abductor pollicus brevis may be present, which is important in de Quervainâs release.
Question 14High Yield
A 28-year-old man fell off his bike and sustained a fall onto his outstretched hand. He experiences thumb and index finger numbness. Attempts at reduction of his grade I open extra-articular distal radius fracture are unsuccessful. The next appropriate step of management is:
Explanation
A patient with this injury represents a high-energy fracture in a high demand individual. The patient will require incision and drainage of his open wound, open reduction with internal fixation, and carpal tunnel release. Bone grafting would not be appropriate in a patient with open fracture.
Question 15High Yield
Which of the following is not usually associated with radial deficiency:
Explanation
Patients with thrombocytopenia absent radii, Fanconi anemia, Holt-Oram syndrome, and cardiac anomolies all are associated with radial deficiency. Larsen syndrome is associated with multiple, larger joint dislocation.
Question 16High Yield
Which of the following is the most common carpal coalition in the hand:
Explanation
Lunotriquetral coalition has a 1.6% prevalence in the general population. The second most common coalition is the capitohamate. Incomplete coalition is treated by arthrodesis of the lunotriquetral joint.
Question 17High Yield
A 6-year-old boy presents with a Salter-Harris II distal radius fracture 3 weeks after injury. He is nontender and neurologically intact. On radiographs, he has a 35º dorsal angulation. The appropriate course of treatment is:
Explanation
For a patient with delayed presentation of a distal radius fracture, appropriate management includes casting and observation for at least 2 years to assess physeal damage and remodeling. The patient may require osteotomy if remodeling does not occur.
Question 18High Yield
The oblique retinacular ligament connects with what two structures:
Explanation
Landsmeer (oblique retinacular ligament) runs from the flexor tendon sheath of the proximal phalanx to the lateral extensor tendon as they insert onto the base of the proximal phalanx. A stay or retaining ligament maintains centralization of the extensor tendons.
Question 19High Yield
A patient presents with hand weakness. On examination, she has no sensory deficient, decreased strength with pronation, and her elbow is at 90º of flexion and pulp-to-pulp contact on key pinch. The most likely diagnosis is:
Explanation
Anterior interosseous nerve syndrome is due to compression of the anterior interosseous nerve (AIN) in the forearm by lacterus fibrosis, flexor digitorum superficialis, or pronator teres. The AIN innervates the pronator quadratus, flexor digitorum profundus (FDP) to the index finger and the flexor pollicis longus (FPL). Anatomy variation exists where the AIN may innervate part of the flexor digitorum superficialis. In this patient, she has decreased pronation at 90º flexion, which relaxes the humeral attachment of the pronator from the pronator quadrus weakness. She also has pulp-to-pulp contract due to weakness of the FPL and FDP to the index finger.
Question 20High Yield
Indications for operative treatment in an acute elbow dislocation include:
Explanation
Recurrent dislocations with extension past 50° represent a significant injury to the elbow and require a stabilization period. Instability to valgus stress represents injury to the anterior band of the medial collateral ligament of the elbow and will heal with protected motion. The majority of radial head fractures (Mason type I and II) that are less than 30º of the radial head and less than 30º angulation heal with good functional results. Most dislocations will have osteochondral lesions. Ulnar nerve parathesias can be associated with dislocations but is not an indication for operative fixation.
Question 21High Yield
When performing open reduction and internal fixation of radial neck fractures, the plate should be placed:
Explanation
The "nonarticular safe-zone" comprising only 90º of the radial head circumference is achieved by placing the plate posterior with the arm in supination.
Question 22High Yield
Heterotopic ossification after elbow dislocations is not associated with which of the following:
Explanation
Heterotopic ossification is commonly associated with delay of surgical intervention, closed head injury, aggressive passive range of motion after dislocation, and extensive surgical dissection. Radiographic evidence of heterotopic ossification is present in 75% of patients with elbow dislocations but only 5% of these are clinically significant.
Question 23High Yield
What is the order of joint destruction in a patient with scapholunate disassociation:
Explanation
Patients with scapholunate disassociation can develop a scapholunate advanced collapsed wrist. The progression is from the radial styloid to proximal radioscaphoid, to midcarpal (capitolunate). The lunate is extended and unloaded due to its concentric design, which results in preservation of the radiolunate.
Question 24High Yield
Which of the following is not characteristic of Dupuytrenâs disease:
Explanation
Dupuytrenâs disease is characteristically unpredictable in its clinical progression. It may spontaneously resolve or quickly progress to advanced disease.
Question 25High Yield
Operative indications for Dupuytrenâs contracture include:
Explanation
As a general guideline the "table test" is used as an indication for operative intervention. If the patient cannot lay his/her hand flat onto a table, the disease has usually progressed to the point where surgery is required. A metacarpophalangeal joint contracture of 30º to 40º or a proximal interphalangeal joint contracture of 30º or more is an indication for surgery.
Question 26High Yield
Favorable indications for attempted replantation include:
Explanation
Favorable indications for replantation include thumb amputations because of the functional importance of the thumb. Warm ischemias less than 8 hours or cold ischemia time less than 16 hours are more favorable for replantation.
Question 27High Yield
Injuries to the central articular disk portion of the triangular fibrocartilage complex are related to all of the following except:
Explanation
Scaphoid nonunion is not related to central triangular fibrocartilage complex injuries. A positive ulnar variance is most strongly associated with triangular fibrocartilage complex central disk injuries.
Question 28High Yield
A patient reports that he felt a pop and immediate pain over the MP joint of his finger. Examination reveals tenderness on the dorsum of the joint and subluxation of the extensor tendon. Which of the following is the most common defect:
Explanation
Tears of the sagittal fibers of the dorsal aponeurosis result in subluxation of the extensor tendon. This usually occurs on the long finger with subluxation to the ulnar side. Treatment for acute injuries requires immobilization of the metacarpophalangeal joint in extension for 6 weeks. Treatment for chronic injuries includes repair of the torn radial sagittal fibers.
Question 29High Yield
All of the following transfers may be used to improve function in a patient who has had radial nerve paralysis longer than 6 months, except:
Explanation
Radial nerve paralysis is a common injury, and many patients recover after repair. Tendon transfers should be delayed until sufficient time for reinnervation has passed. Pronator to extensor carpi radialis brevis can be performed at time of nerve repair to provide wrist extension and grasp during period of nerve recovery. Transfers for radial nerve palsy need to address wrist extension, thumb extension, and finger extenstion. All of the above transfer would provide these functions except a transfer to the brachioradialis.
Question 30High Yield
Slide 1
A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). Your diagnosis is:
A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). Your diagnosis is:
Explanation
This is a classic appearance of a radial club hand, which is often referred to as preaxial longitudinal deficiency. Ulnar club hand and postaxial longitudinal deficiency are synonymous.
Question 31High Yield
Slide 1
A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other
congenital defects. The clinical appearance of his forearm is shown (Slide). The patient has an elbow flexion contracture of 70°
and desires lengthening. Which of the following statements is not true regarding lengthening:
A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other
congenital defects. The clinical appearance of his forearm is shown (Slide). The patient has an elbow flexion contracture of 70°
and desires lengthening. Which of the following statements is not true regarding lengthening:
Explanation
In most cases of radial club hand, excluding a hypoplastic radius, full correction cannot be achieved.
Question 32High Yield
Slide 1
A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). The potential complications of lengthening are discussed, and the patient is advised against it. However, the elbow flexion contracture is corrected by gradual distraction. One year postoperatively, the patient has attained a 30° correction of the flexion deformity, which remains mobile. Now, he desires that his wrist deformity be corrected. The procedure of choice is:
A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). The potential complications of lengthening are discussed, and the patient is advised against it. However, the elbow flexion contracture is corrected by gradual distraction. One year postoperatively, the patient has attained a 30° correction of the flexion deformity, which remains mobile. Now, he desires that his wrist deformity be corrected. The procedure of choice is:
Explanation
Wrist arthrodesis is the best solution for this patient and his recurrent deformity because it provides a stable platform for grasp.
Question 33High Yield
Slide 1
A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). Although the patient has a thumb, it is in an abnormal position. Any attempt to make his thumb more functional will be influenced by:
A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). Although the patient has a thumb, it is in an abnormal position. Any attempt to make his thumb more functional will be influenced by:
Explanation
The pattern of usage of the hand is established in the brain by 2 to 3 years of age. Although pollicization has been performed in adolescents, patients continue to prefer a scissor pinch. At 24 years of age, this pattern will be well established. The patient can be coaxed to use his thumb, but it will not be involuntary and automatic.
Question 34High Yield
Slide 1
A radial club hand is the result of an insult during which phase of the gestation period:
A radial club hand is the result of an insult during which phase of the gestation period:
Explanation
A radial club hand is the result of an insult during weeks 4 to 7 of gestation.
Question 35High Yield
A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; platelet 254 254×103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes
40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.
Diagnosis is:
40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.
Diagnosis is:
Explanation
The patient has a radial club hand with a cardiac defect. Because the spine radiograph is normal, the diagnosis cannot be VATER or VAC TERL anomaly as both involve vertebrae. Blood work up is normal, making this diagnosis Holt-Oram syndrome.
Question 36High Yield
The principal abnormality associated with Holt-Oram syndrome is:
Explanation
Holt-Oram syndrome is associated with cardiac defects. The most common defect is aldosterone secretion.
Question 37High Yield
The hereditary pattern for Holt-Oram syndrome is:
Explanation
Holt-Oram syndrome is inherited in an autosomal dominant manner.
Question 38High Yield
A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; 254×103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes 40%; Hct
45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.
The next step in the management of the radial club hand is:
45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.
The next step in the management of the radial club hand is:
Explanation
For the first 6 to 9 months, parents and therapists perform passive stretching. Serial casting and splinting may also be used. Sometimes, preoperative soft-tissue distraction is performed, usually before a wrist stabilization procedure.
Question 39High Yield
A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; platelet 254×103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes
40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.
C entralization will be performed on the patient. All of the following statements are true about centralization except:
40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.
C entralization will be performed on the patient. All of the following statements are true about centralization except:
Explanation
In a centralization procedure, the forearm is aligned with the third metacarpal, not the second.
Question 40High Yield
A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; 254Ã103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes 40%; Hct
45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.
When the patient is 10 years old, he is not satisfied with the length of his forearm and wishes to lengthen it. Which of the following is not a satisfactory recommendation:
45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.
When the patient is 10 years old, he is not satisfied with the length of his forearm and wishes to lengthen it. Which of the following is not a satisfactory recommendation:
Explanation
Acute lengthening is done for small defects and, if performed in this patient, may result in severe neurovascular compromise.
Question 41High Yield
Which of the following conditions is present in patients with radial club hand but not in patients with ulnar club hand:
Explanation
Ulnar club hand differs from radial club hand in that cardiopulmonary, hematopoeitic, gastrointestinal, and genitourinary anomalies are uncommon.
Question 42High Yield
All of the following developmental anomalies are associated with ulnar club hand except:
Explanation
Atrial septal defects are developmental abnormalities present in patients with radial club hand or Holt-Oram syndrome.
Question 43High Yield
Which of the following syndromes is associated with ulnar club hand:
Explanation
VATER, VAC TERL, Holt-Oram syndrome, and TAR syndrome are associated with radial club hand. Femur-fibular-ulnar syndrome is characterized by proximal femoral focal deficiency, fibular agenesis, and ulnar ray defects.
Question 44High Yield
Which of the following areas is not involved in ulnar club hand:
Explanation
Vertebrae are usually not involved in ulnar club hand.
Question 45High Yield
All of the following are true statements regarding elbow involvement in ulnar club hand except:
Explanation
Elbow instability does not correspond with severity of involvement. Fifty percent of patients with total aplasia have radiohumeral synostosis, which provides adequate stability.
Question 46High Yield
All of the following statements are true regarding the carpal bones in patients with ulnar club hand except:
Explanation
A notch is often created in centralization procedures for radial club hand. Wrist stabilization procedures are not performed for ulnar club hand.
Question 47High Yield
All of the following anomalies are present in patients with ulnar club hand except:
Explanation
Vertebral anomalies are not common in patients with ulnar club hand.
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Prof. Dr. Mohammed Hutaif
Consultant Orthopedic & Spine Surgeon