Trauma, Spine, Upper Extremity Orthopedic MCQs - Part 41

About This Board Review Set

This is Part 41 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

This set has been strictly audited and contains 100 100% verified, high-yield multiple-choice questions (MCQs) modelled on the exact format of the Orthopaedic In-Training Examination (OITE) and the American Academy of Orthopaedic Surgeons (AAOS) board examinations.

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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 41

This module focuses heavily on: Elbow, Fracture, Scoliosis, Shoulder.

Sample Questions from This Set

Sample Question 1: Figure 1 shows a patient with an open tibia fracture who presents to the emergency department after a propeller injury in brackish water (river water and sea water). What is the most appropriate antibiotic coverage for this patient?...

Sample Question 2: A 32-year-old male electrical worker complains of isolated left shoulder pain after a fall from 6 feet. Radiographs of the shoulder are seen in Figures A and B. The radiology technician was unable to obtain a good axillary view due to signi...

Sample Question 3: ..Figures 83a and 83b are the radiographs of a 53-year-old otherwise healthy homemaker who had a syncopal episode and sustained a ground-level fall and injury to her right elbow. She presently admits to right elbow pain, swelling, and an in...

Sample Question 4: A 34-year- woman has pain at the base of the thumb that worsens é pinching activities. Nonsurgical treatment has failed to provide relief. Examination reveals that the basilar joint is hypermobile, tender and painful when stressed. A radiog...

Sample Question 5: A 13-year-old girl with adolescent idiopathic scoliosis is otherwise healthy with a normal neurologic examination and she began her menstrual cycle 3 months ago. Standing radiographs show a high left thoracic curve from T1-T6 that measures ...

Why Active MCQ Practice Works

Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

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Question 1

Figure 1 shows a patient with an open tibia fracture who presents to the emergency department after a propeller injury in brackish water (river water and sea water). What is the most appropriate antibiotic coverage for this patient?

Explanation

Discussion: The clinical photo shows significant soft tissue wounds with associated tibia fracture. With the amount of soft tissue damage and periosteal stripping this would be classified as a Gustilo Type IIIB injury. The brackish water environment where this particular injury occurred influences the antibiotic choice secondary to the particular organisms found in this setting. Brackish water is made up of both fresh and salt water with common organisms that include Vibrio species, Aeromonas hydrophila, Pseudomonas species, Erysipelothrix rhusiopathiae, and Mycobacterium marinum. The combination of both Doxycycline (tetracycline) and Ceftazidime (third-generation cephalosporin) cover these particular pathogens. Standard antibiotic coverage for Gustilo Type I and II injures is 1st generation cephalosporin (cefazolin), with Type III being 1st generation cephalosporin and aminoglycoside (cefazolin and gentamicin) or a fluoroquinolone. In Type III injuries, Penicillin is commonly added in barnyard injuries for extended coverage of
soil-borne pathogens (clostridial species). Vancomycin is not indicated for coverage in marine environments, rather it is more commonly used for populations with a high prevalence of nosocomial infections. Sulfamethoxazole-trimethoprim is not used for open fracture coverage.

Question 2

A 32-year-old male electrical worker complains of isolated left shoulder pain after a fall from 6 feet. Radiographs of the shoulder are seen in Figures A and B. The radiology technician was unable to obtain a good axillary view due to significant pain and muscle spasm. What would be the next most appropriate step in management? Review Topic

Explanation

This patient presents with risk factors of posterior shoulder dislocation. The next most appropriate step in the management of this patient would be to obtain orthogonal shoulder radiographs using a Velpeau view of the right shoulder as seen in Illustration A.
Risk factors for posterior shoulder dislocation include epilepsy, electrocution and high-energy trauma. To make a diagnosis, standard views of the shoulder are required. These include an anteroposterior (AP) view, lateral scapular view and an axillary view. The axillary view is essential for diagnosis, but this requires the arm to be positioned in 20 - 30 degrees of abduction. If pain and muscle spasm restrict arm movement, the next most appropriate view would include a modified axially view,
such as a Velpeau view.
Robinson et al. reviewed posterior shoulder dislocations and fracture-dislocations. They state that apical oblique, Velpeau, or modified axial radiographs are preferable to other alternative axillary views, as they can be obtained with the arm in a sling. When an osseous injury is suspected, a CT scan and three-dimensional reconstruction can be useful in planning operative management.
Millet et al. wrote a JAAOS article on recurrent posterior shoulder instability. They state that 5 radiographic views, or advanced imaging, is essential to evaluate the shoulder. Characteristics to consider include, joint location, humeral head position, glenoid morphology (e.g., retroversion, hypoplasia, posterior glenoid rim), and impaction fracture of the humeral head.
Figure A and B show a normal shoulder radiograph with the shoulder positioned in internal rotation and external rotation. Illustration A shows the correct positioning of a patient to obtain a Velpeau view of the shoulder. Illustration B shows the correct positioning of a patient to obtain a Stryker notch view of the shoulder. This is used to asses for humeral head defects.
Incorrect Answers:

Question 3

..Figures 83a and 83b are the radiographs of a 53-year-old otherwise healthy homemaker who had a syncopal episode and sustained a ground-level fall and injury to her right elbow. She presently admits to right elbow pain, swelling, and an inability to bend her elbow. What is the best initial treatment for this injury?

Explanation

He did not have an engaging Hill-Sachs lesion, the rotator cuff was unremarkable, and the capsule was not torn from the humerus. After surgery, he did well for 6 months until he jumped into a lake and again dislocated his shoulder anteriorly. He says his shoulder no longer felt stable after his reduction.

Question 4

A 34-year- woman has pain at the base of the thumb that worsens é pinching activities. Nonsurgical treatment has failed to provide relief. Examination reveals that the basilar joint is hypermobile, tender and painful when stressed. A radiograph of the trapeziometacarpal joint shows normal contour with widening when compared with the opposite side. Management should consist of

Explanation

Painful instability of the thumb carpometacarpal (CMC) joint as manifested by “idiopathic hypermobility of the basal joint is not uncommon, particularly in women, and would seem to be a significant factor in producing the arthrosis that so frequently afflicts this joint.” “Extra-articular ligament reconstruction to stabilize the thumb carpometacarpal (CMC) (basal) joint by routing a portion of the flexor carpi radialis (FCR) through the base of the thumb metacarpal … is recommended only for patients in stage I and stage II disease (i.e., patient’s having zero to only slight cartilage attrition). With 95 % of stage I and stage II patients having achieved and maintained good or excellent results, (restoration of stability, pain reduction and possibly retarding joint degeneration) … we feel the procedure has proved predictable and durable. Despite limited success in patients with significant articular deterioration (stage III and stage IV), we do not recommend ligament reconstruction alone in such cases. Instead we would recommend articular resurfacing or implant arthroplasty that would depend on the number of trapezium surfaces involved.”

Question 5

A 13-year-old girl with adolescent idiopathic scoliosis is otherwise healthy with a normal neurologic examination and she began her menstrual cycle 3 months ago. Standing radiographs show a high left thoracic curve from T1-T6 that measures 29 degrees, a right thoracic curve from T7-L1 that measures 65 degrees, and a left lumbar curve from L1-L5 that measures 31 degrees, correcting to 12, 37, and 10 degrees, respectively, on bending films. Her Risser sign is 1. What is the most appropriate management?

Explanation

DISCUSSION: The patient has typical adolescent idiopathic scoliosis with a right thoracic curve. This represents a Lenke-IB curve pattern; therefore, only treatment of the thoracic curve is required. The proximal thoracic and thoracolumbar curves are very flexible. The patient is Risser 1 and has just started her menstrual cycles; therefore, she is at significant risk for further curve progression. Bracing is not appropriate for a curve of this magnitude and will not halt the progression of this curve, nor will vertebral body stapling stop this curve. Vertebral body stapling is sometimes useful in small thoracic curves of less than 35 degrees and skeletally immature patients. Anterior and
14 • American Academy of Orthopaedic Surgeons
posterior spinal fusion is not required because the patient has no other risk factors, such as neurofibromatosis nor is she at risk for crankshaft. Anterior fusion is an option, but it is not listed.
REFERENCES: Lenke LG, Betz RR, Harmes J, et al: Adolescent idiopathic scoliosis: Anew classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83:1169-1181.
Lenke LG, Betz RR, Haher TR, et al: Multisurgeon assessment of surgical decision making in adolescent idiopathic scoliosis: Curve classification, operative approach, and fusion levels. Spine 2001;26:2347- 2353.

Question 6

What is the most likely complication after surgical treatment in this scenario?

Explanation

DISCUSSION
Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, and internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through as seen in this patient.
The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The 4 muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the 4 rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation.
This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Brighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion, a posterior opening-wedge osteotomy is appropriate.
The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instability and degenerative joint disease.

Question 7

The parents of a 14-year-old female soccer player are concerned about any future injury. They have been advised that she has the potential to play for the US Olympic team. They are especially concerned about the anterior cruciate ligament (ACL). What should you advise them? Review Topic

Explanation

ACL injuries are five to eight times more common in young women. The highest incidence is associated with basketball and soccer. These sports require rapid directional and rotational changes. Use of neuromuscular training programs has not been associated with a decrease in ACL injuries. It is recommended that there be more frequent rests. ACL injuries are commonly associated with meniscal injury.

Question 8

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow.The most substantial functional deficit that may develop if no surgical treatment is provided is

Explanation

This patient had an eccentric muscle contraction (muscle lengthening while contracting) of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps muscle belly). Eccentric contractors
have the highest potential for building strength but also are at highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force) do not describe the mechanism detailed. The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique. Although all of the listed complications have been reported with these techniques, LABC neuropraxia is by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared with the 2-incision technique. The most troubling complication for most surgeons is the development of a posterior interosseous nerve (PIN) palsy, which this patient clearly demonstrates in addition to the more common LABCN upon postsurgical examination. Because the LABCN injury is typically a neuropraxia from retraction, a period of observation is indicated. PIN injury can result from excessive traction during surgical exposure or from entrapment by the fixation button. Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the distance from the origin of the nerve to the muscle indicated. The extensor indicis proprius (EIP) muscle is the most distal muscle innervated and can be expected to recover last. First to return would be the EDC
followed by the ECU, EDQ, and, finally, the EIP.

Question 9

Figures below show the clinical photograph and radiograph obtained from a 62-year-old man who has deformity and pain 1 year after primary total hip arthroplasty. What is the reason for the observed deformity?

Explanation

DISCUSSION:
Figure 1 reveals an external rotation deformity of the right lower extremity. This deformity can have numerous causes, including extra-articular deformity. Figure 2 reveals a loose, subsided femoral component. Femoral stems typically subside into retroversion due to proximal femoral biomechanics, which cause a compensatory external rotation deformity. The combined findings from both images suggest an external rotation deformity most likely related to subsidence into retroversion.

Question 10

You are interested in learning a new technique for minimally invasive total knee arthroplasty. The Keyhole Genuflex system seems appealing to you because the instrumentation comes with wireless controls. What is an acceptable arrangement to learn more about this system?

Explanation

Both the American Academy of Orthopaedic Surgeons (AAOS) and AdvaMed, the medical device manufacturer's trade organization, have written guidelines that address potential conflicts of interest regarding interactions between physicians and manufacturer's representatives when it comes to patients' best interest. The AAOS feels that the orthopaedic profession exists for the primary purpose of caring for the patient and that the physician-patient relationship is the central focus of all ethical concerns. When an orthopaedic surgeon receives anything of significant value from industry, a potential conflict of interest exists. The AAOS believes that it is acceptable for industry to provide financial and other support to orthopaedic surgeons if such support has significant educational value and has the purpose of improving patient care. All dealings between orthopaedic surgeons and industry should benefit the patient and be able to withstand public scrutiny. A gift of any kind from industry should in no way influence the orthopaedic surgeon in determining the most appropriate treatment for his or her patient. Orthopaedic surgeons should not accept gifts or other financial support with conditions attached. Subsidies by industry to underwrite the costs of educational events where CME credits are provided can contribute to the improvement of patient care and are acceptable. A corporate subsidy received by the conference's sponsor is acceptable; however, direct industry reimbursement for an orthopaedic surgeon to attend a CME educational event is not appropriate. Special circumstances may arise in which orthopaedic surgeons may be required to learn new surgical techniques demonstrated by an expert or to review new implants or other devices on-site. In these circumstances, reimbursement for expenses may be appropriate.

Question 11

A 66-year-old woman who requires a cane for ambulation now notes increasing difficulty in using the cane after undergoing total elbow arthroplasty 3 months ago. AP and lateral radiographs are shown in Figures 15a and 15b. What is the most likely diagnosis?

Explanation

DISCUSSION: The lateral radiograph reveals a triceps avulsion with a small portion of bone. Triceps weakness and insufficiency can be a symptomatic problem after total elbow arthroplasty and is probably underreported. Ulnar nerve neuritis, aseptic loosening, instability, and infection are all complications of total elbow arthroplasty but would not account for the radiographic findings.
REFERENCES: Koval K (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orhthopaedic Surgeons, 2002, pp 323-327.
Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000,

pp 598-601.

Question 12

What molecules have been shown to promote fibrosis during muscle injury?

Explanation

A muscle's response to injury can be divided into 4 phases: necrosis, inflammation, repair, and fibrosis. Necrosis involves the degeneration of the muscle fibrils and death. The inflammatory cells then phagocytose the debris and secrete cytokines that promote vascularity. Muscle regeneration does not occur until phagocytic cells remove the debris. Consequently, anti-inflammatory drugs may have negative effects on muscle healing by inhibiting macrophage-induced phagocytosis. Muscle fibrosis occurs at the same time as muscle regeneration and has been shown to involve TGF-ß1. IGF-1 and bFGF are important trophic factors in muscle regeneration. Bone morphogenetic protein has several functions including bone and cartilage regeneration.

Question 13

Which of the following factors is responsible for causing the distal femur to pivot about a medial axis as the knee moves from full extension into early flexion?

Explanation

DISCUSSION: The radius of curvature of the distal femur is greater over the distal aspect of the lateral femoral condyle than the distal aspect of the medial femoral condyle. As the femur rolls posteriorly during early knee flexion, both condyles undergo similar angular changes equal to the amount of flexion. With a similar amount of angular rotation, the sphere with the larger radius experiences greater net rollback, producing a pivoting motion. Although the anterior cruciate ligament plays a role in producing tibial rotations, the posterior cruciate ligament does not play a significant role in producing such rotations. Similarly, the tibial tubercle does not play a significant role in producing normal rotations of the femur relative to the tibia. The popliteus may also play a role in producing rotational pivots, as might differential laxity of the medial and lateral collateral ligaments in early knee flexion.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:

Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 239-240.
Insall JN, Windsor RE, Scott WN, et al (eds): Surgery of the Knee, ed 2. New York, Churchill Livingstone, 1993, pp 1-13.

Question 14

A 54-year-old woman sustained an elbow injury 3 months ago that was treated with open reduction and internal fixation. She now reports pain and limited elbow motion. Radiographs are shown in Figures 10a and 10b. Treatment should now consist of

Explanation

DISCUSSION: Radiographs reveal malunion of a Monteggia fracture-dislocation. Dislocation of the posterior radial head is caused by the malunited ulnar fracture. The deformity includes shortening with an apex posterior angulation. In the acute setting, open reduction of the radial head rarely is necessary; however, in chronic dislocations, open reduction is required. Without ulnar osteotomy, recurrent radial head dislocation is likely.
REFERENCE: Horii E, Nakamura R, Koh S, et al: Surgical treatment for chronic radial head dislocation. J Bone Joint Surg Am 2002;84:1183-1188.

Question 15

A previously healthy 13-year-old girl has had thigh pain for the past 3 weeks. The radiograph shown in Figure 47a reveals a lesion in the right femur. A bone scan and CT scan of the chest show no evidence of other lesions. A biopsy specimen is shown in Figure 47b. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has Langerhans cell histiocytosis that may be solitary (eosinophilic granuloma) or associated with systemic illness (Hand-Schuller-Christian disease and Letterer-Siwe disease). The solitary form of the disease, eosinophilic granuloma, typically affects patients in the first three decades of life. Radiographically, it is characterized as a well-defined, lytic, “punched out” intramedullary lesion. Histologically, two cell types, eosinophils and Langerhans cells, are seen. The Langerhans cells are seen as mononuclear histiocyte-like cells with oval nuclei with well-defined round or oval cytoplasm. A prominent nuclear groove can be seen in most of the nuclei (coffee bean nuclei). A mixture of inflammatory cells and lipid-laden foam cells with nuclear debris may be present as well. The lack of nuclear atypia and atypical mitoses excludes malignant conditions such as Ewing’s sarcoma, lymphoma of bone, and metastatic neuroblastoma. The lack of acute inflammatory cells excludes the diagnosis of osteomyelitis. The eosinophils have bi-lobed nuclei and granular eosinophilic cytoplasm.
REFERENCES: Dorfman H, Czerniak B: Bone Tumors. St Louis, MO, Mosby, 1988.
Mirra, JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea & Febiger, 1989.

Question 16

An 11-year-old child has Ewing’s sarcoma of the femoral diaphysis with a small soft-tissue mass. Staging studies show no evidence of metastases. Treatment should consist of

Explanation

DISCUSSION: The use of chemotherapy has dramatically improved survival rates of patients with Ewing’s sarcoma. Local disease is best handled with wide resection to decrease local recurrence and to avoid the complications of radiation therapy (ie, secondary sarcomas). Radiation therapy alone is reserved for unresectable lesions or poor surgical margins. Amputation generally is not necessary.
REFERENCES: Toni A, Neff JR, Sudanese A, et al: The role of surgical therapy in patients with non-metastatic Ewing’s sarcoma of the limbs. Clin Orthop 1991;286:225.
Picci P, Rougraff BT, Bacci G, et al: Prognostic significance of histopathologic response to chemotherapy in non-metastatic Ewing’s sarcoma of the extremities. J Clin Oncol 1993;11:1763.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant Bone Tumors. Instr Course Lect 2002;51:413-428.
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Question 17

Figures 31a and 31b show the T1- and T2-weighted MRI scans of a patient’s knee joint. What is the most likely diagnosis?

Explanation

DISCUSSION: The scans show a lipohemarthrosis. There is the characteristic layering of a superior zone containing fat (high signal intensity), a central zone containing serum (low signal intensity), and an inferior zone that contains red blood cells (low signal intensity). The most common cause of a lipohemarthrosis is an intra-articular fracture with leakage of marrow fat into the joint.
REFERENCES: Resnick D, Kang HS: Synovial joints, in Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 49-53.
Kier R, McCarthy SM: Lipohemarthrosis of the knee: MR imaging. J Comput Assist Tomogr 1990;14:395-396.

Question 18

A 52-year-old woman who is right hand-dominant sustains an injury to her elbow in a fall. A radiograph is shown in Figure 60. The preferred treatment of this injury pattern should include

Explanation

DISCUSSION: The patient has a Bado type 2 variant Monteggia fracture with a radial head fracture. The type 2 variant is associated with a higher nonunion rate and poorer outcomes compared to other Bado-type Monteggia fractures. While it is potentially acceptable to repair the radial head, factors such as higher degrees of comminution and older age lead toward replacement as the treatment of choice. Plate and screw fixation is favored over Kirschner wire/tension band fixation because this is not a simple olecranon fracture. Plate placement in a type 2 fracture is dorsal to counteract very high tensile forces associated with fixation failure.
REFERENCES: Egol KA, Tejwani NC, Bazzi J, et al: Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res 2005;438:233-238.
Jupiter JB, Leibovic SJ, Ribbans W, et al: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.
Konrad GG, Kundel K, Kreuz PC, et al: Monteggia fractures in adults: Long-term results and prognostic factors. J Bone Joint Surg Br 2007;89:354-360.

Question 19

A 45-year-old man has persistent hindfoot pain that is aggravated by weight-bearing activities. History reveals that he sustained a calcaneus fracture 2 years ago, and he underwent a subtalar fusion 1 year ago. Examination reveals tenderness in the sinus tarsi and across the transverse tarsal joint. A plain radiograph and a CT scan are shown in Figures 24a and 24b. A technetium Tc 99m bone scan reveals uptake at the subtalar joint and at the transverse tarsal joints. Management should now consist of

Explanation

DISCUSSION: The patient has a nonunion at the subtalar joint because of poor preparation of the arthrodesis site with incomplete removal of the articular cartilage. Clinically, he has arthritis at the transverse tarsal joint. Casting with a bone stimulator is not expected to result in a union of the subtalar arthrodesis. To address both the subtalar nonunion and the transverse tarsal joint arthritis, revision of the subtalar arthrodesis and conversion to a triple arthrodesis is the preferred option.
REFERENCES: Graves SC, Mann RA, Graves KO: Triple arthrodesis in older adults: Results after long-term follow-up. J Bone Joint Surg Am 1993;75:355-362.
Haddad SL, Myerson MS, Pell RF IV, Schon LC: Clinical and radiographic outcome of revision surgery for failed triple arthrodesis. Foot Ankle Int 1997;18:489-499.
Sangeorzan BJ, Smith D, Veith R, Hansen ST Jr: Triple arthrodesis using internal fixation in treatment of adult foot disorders. Clin Orthop 1993;294:299-307.
Sangeorzan BJ: Salvage procedures for calcaneus fractures. Instr Course Lect 1997;46:339-346.
Wapner KL: Triple arthrodesis in adults. J Am Acad Orthop Surg 1998;6:188-196.

Question 20

A 58-year-old man reports a 2-month onset of groin pain with no history of trauma. Examination reveals that range of motion of the hip is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 20. Treatment should consist of

Explanation

DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip: A case report. J Bone Joint Surg Am 1991;73:451-455.

Question 21

A 40-year-old woman has had pain in the metatarsophal joint of the second toe for the past 6 months despite nonsurgical treatment. A dorsalplantar stress test reproduces the pain, and there is 10 mm of dorsal subluxation of the toe. Radiographs show a normal second metatarsophalangeal joint. Surgical treatment should consist of synovectomy and

Explanation

Number four is the correct answer because the flexor digitorum longus tendon will give excellent plantar support when transferred to the dorsum of the toe and this removes the main dynamic deforming force. Number one is incorrect because the planter plate will stretch in time and be insufficient. Number two is incorrect because the radiographs show a normal second metatarsophalangeal joint surface and it is not a fixed/dislocated joint and it is in a young patient. Number three is incorrect because it is not a frank dislocation. Number five is incorrect as this is reserved for mild deformity and would not be sufficient correction in this case.

Question 22

A patient with a history of chronic low back pain for several years reports decreased pain visual analog scores with the home use of a transcutaneous electrical neuromuscular stimulation (TENS) unit. This pain relief is most likely due to which of the following?

Explanation

TENS units deliver superficial electrical stimulation. This electrical stimulation induces analgesia via inhibitory effects at the spinal cord level. The stimulation of small myelinated afferent fibers produces a presynaptic inhibition of the nociceptive transmission via unmyelinated C fibers, thus decreasing the transmission of pain stimuli. Additional benefit may come from the endogenous release of endorphins in the stimulated tissues.

Question 23

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

Explanation

A provocative test for medial epicondylitis can be elicited by applying resistance to a patient with their fist clenched, wrist flexed and pronated.
Medial epicondylitis is an overuse syndrome of the flexor-pronator mass. The pronator teres (PT) and flexor carpi radialis (FCR) are thought to be most affected with this condition. It is most common in the dominant arm and occurs with activities that require repetitive wrist flexion/forearm pronation. Patients are most tender over the origin of PT and FCR at the medial epicondyle. Resisting a patient with their fist clenched, wrist flexed and pronated can cause worsening of their pain. This maneuver can be used as a provocative test for this condition.
Cain et al. reviewed elbow injuries in throwing athletes. They comment that the common flexor-pronator muscle origin provides dynamic support to valgus stress in the throwing elbow, especially during early arm acceleration and help produce wrist flexion during ball release.
Amin et al. reviewed the evaluation and management of medial epicondylitis. They report that medial epicondylitis typically occurs in the fourth through sixth decades of life, the peak working years, and equally affects men and women. Physical therapy and rehabilitation is the main aspect of recovery from medial epicondylitis, once acute symptoms have been alleviated.
Illustration A shows a video of this provocative test for medial epicondylitis. Incorrect Answers:

Question 24

Which of the following antibiotics is contraindicated in children?

Explanation

DISCUSSION: The tetracycline family of medications can stain teeth and bone in skeletally immature patients and as a result should be avoided in those patients. The remaining antibiotics have no known specific contraindication to use in children.
REFERENCE: Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 433-457.

Question 25

Five weeks after undergoing a successful L4-L5 diskectomy, with complete relief of his preoperative sciatica, a 36-year-old man has severe, relentless back and buttock pain. Examination and laboratory studies are unremarkable with the exception of an erythrocyte sedimentation rate (ESR) of 90 mm/h. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient’s history, including the timing and type of symptoms, is typical for postoperative diskitis. The elevated ESR, 5 weeks after surgery, is also consistent with infection; a normal WBC count is not unusual. Management should consist of MRI with gadolinium; if positive, this should be followed by percutaneous biopsy to confirm the organism. Open biopsy may be considered if the percutaneous biopsy is unsuccessful. Anterior debridement and interbody fusion is reserved for the occasional patient that fails to respond to intravenous antibiotics, bed rest, and immobilization.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.
Beatty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 713-721.

Question 26

A relative contraindication for anteromedial tibial tubercle transfer for patellar instability is arthrosis in what portion of the patella?

Explanation

DISCUSSION: Anteromedial displacement of the tibial tubercle unloads the distal and lateral facets of the patella and shifts the forces to the proximal and medial facets. Therefore, if findings indicate arthrosis predominately in the medial and proximal areas of the patella, this is considered a relative contraindication because it may accentuate arthritic symptoms.
REFERENCES: Fulkerson JP: Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop 1983;177:176-181.
Bellemans J, Cauwenberghs F, Witvrouw E, et al: Anteromedial tibial tubercle transfer in patients with chronic anterior knee pain and a subluxation-type patellar malalignment. Am J Sports Med 1997;25:375-381.
Kuroda R, Kambic H, Valdevit A, et al: Articular cartilage contact pressure after tibial tuberosity transfer: A cadaveric study. Am J Sports Med 2001;29:403-409.

Question 27

Figures 5a and 5b show the clinical photograph and radiograph of a patient who has difficulty wearing shoes and has persistent symptoms medially and laterally at the first and fifth metatarsophalangeal joints. Because shoe modifications have failed to provide relief, management should now consist of

Explanation

DISCUSSION: A significant bunionette deformity that fails to respond to conservative management is best addressed surgically, in this case with the bunion deformity. The radiograph reveals a prominent lateral condyle at the fifth metatarsal head without a significant increase in the intermetatarsal angle. Simple exostectomy is preferred with less risk of complications. Complete excision would risk transfer lesions to the medial metatarsals.
REFERENCES: Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 415-435.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 163-173.

Question 28

Which of the following areas of the vertebral segment has the highest ratio of cortical to cancellous bone? Review Topic

Explanation

The weight-bearing potential of bone is influenced by the ratio of cortical to cancellous bone. The area of the spinal anatomy that has the highest ratio is the pedicles of the thoracic spine. This is followed by the lumbar pedicles. The vertebral bodies have a lower ratio than the pedicles, with the sacrum having the very lowest ratio.

Question 29

Which of the following is indicative of a patient who has been successfully resuscitated following a trauma?

Explanation

DISCUSSION: Rapid fluid resuscitation is the cornerstone of therapy for hypovolemic shock. Fluid should be infused at a rate sufficient to rapidly correct the deficit. If the estimated blood loss is greater than 30% of the total volume(class III), blood replacement is also indicated. In general, a favorable response to fluid replacement therapy includes increased urinary output (at least 0.5ml/kg/hr), improved level of consciousness, increased peripheral perfusion, and changes in vital signs (such as increased BP, increased pulse pressure, and decreased heart rate). Lab values that are important include lactic acid, which is increased if the shock is severe enough to cause anaerobic metabolism, and decreased serum bicarbonate which leads to a negative base deficit. Successful resuscitation in a shock patient will therefore lead to a falling lactate and normalizing pH. Successful resuscitation in a shock patient will therefore lead to a falling lactate (i.e. <2.0mmol/L) and a normalizing pH.

Question 30

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with

Explanation

DISCUSSION: An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals.
REFERENCES: Bokor DJ, Conboy VB, Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96.
Wolf EM, Cheng JC, Dickson K: Humeral avulsion of the inferior glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.

Question 31

Which of the following is an important factor in performing a proper biopsy?

Explanation

DISCUSSION: There are a number of important technical details in performing a biopsy. Incisions should always be longitudinal in the extremity. Good hemostasis is important in avoiding contamination from hematoma. The approach should avoid neurovascular structures, and go through a single muscle belly when possible. Although a frozen section should be obtained to ensure adequate viable tissue has been obtained, definitive diagnosis is not necessary at the time of the frozen section.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 29-34.

Question 32

Figure 35 is the MR image of an 18-year-old man who has had knee pain with running for 5 months. What is the most appropriate treatment?

Explanation

DISCUSSION
The MR image shows an osteochondritis dissecans (OCD), which is an acquired lesion of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help to identify the lesion and establish the physes status. MRI is useful for assessing potential for the lesion to heal with nonsurgical treatment. This lesion is unstable, considering the fluid line between the OCD and the underlying normal bone. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary to address unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged and the normal articular surface restored whenever possible.

Question 33

A 26-year-old man falls off a motorcycle and injures his left wrist. There are no open wounds and the neurovascular examination is normal. Radiographs are shown in Figures 10a and 10b. Definitive management should consist of

Explanation

DISCUSSION: The patient has a high-energy injury with resultant comminution of the distal radius metaphysis. Cast immobilization is likely to lead to radial shortening and angulation due to the comminution. Similarly, while external fixation and pinning has been successful in the past, some loss of radial length and volar angulation is typically noted. Present plate fixation devices for the distal radius employing locking screw technology have a superior ability to resist radial shortening and dorsal angulation. Fixation of the ulnar styloid is warranted when there is distal radioulnar joint instability or significant displacement of the styloid. This is more likely to occur with a fracture at the base of the styloid. In this instance, the distal radioulnar joint does not appear to be disrupted.
REFERENCES: May MM, Lawton JN, Blazar PE: Ulnar styloid fractures associated with distal radius fractures: Incidence and implications for distal radioulnar joint instability. J Hand Surg Am 2002;27:965-971.
Nana AD, Joshi A, Lichtman DM: Plating of the distal radius. J Am Acad Orthop Surg 2005;13:159-171.

Question 34

During revision total knee arthroplasty (TKA), there is significant laxity in 90° of flexion and 10° short of full extension. Correcting the gap imbalance is best achieved by

Explanation

Figures 1 through 5 are the radiographs and MRI scans of an 80-year-old woman who had a total hip arthroplasty (THA) 10 years ago and recently experienced an episode of dislocation that was reduced. She currently has no pain, but has a limp and moderate apprehension. Her erythrocyte sedimentation rate is 32 and C-reactive protein is 34. Her cobalt level is 32.8 ug/L (normal <1ug/L) and chromium level 14 ug/L (normal < 5ug/L). The hip aspiration is negative. What is the most appropriate treatment? 35
A. Nonoperative treatment with close radiographic follow-up
B. Revision THA with ceramic- on-polyethylene with abductor reconstruction
C. Removal of components and placement of spacer as stage 1 of 2-stage revision
D. Revision THA with metal-on- polyethylene and trochanteric slide

Question 35

Figure 24 shows the radiograph of a 4-year-old girl with spina bifida. Examination reveals an L3 motor level, excellent sitting and standing balance, and satisfactory range of motion at the hips. Management should consist of

Explanation

DISCUSSION: Children with spina bifida and bilateral symmetrical dislocation of the hips usually do not require treatment. A level pelvis and good range of motion of the hips are more important for ambulation than reduction of bilateral hip dislocations. Because the patient has good sitting and standing balance and good range of motion, maintenance of that range of motion and symmetry is more important than reduction. Surgery is not recommended.
REFERENCE: Heeg M, Broughton NS, Menelaus MB: Bilateral dislocation of the hip in spina bifida: A long-term follow-up study. J Pediatr Orthop 1998;18:434-436.

Question 36

Figures 28a through 28c show the MRI scans of a 30-year-old woman who weighs 290 lb and has low back and left leg pain. She also reports frequent urinary dribbling, which her gynecologist has advised her may be related to obesity. Examination will most likely reveal

Explanation

DISCUSSION: The patient will most likely exhibit ipsilateral weakness of the tibialis anterior. Gaenslen’s test is designed to detect sacroiliac inflammation as a source of low back pain. Beevor’s sign tests the innervation of the rectus abdominus and paraspinal musculature (L1 innervation). The extensor hallucis longus is predominantly innervated by L5. The peroneals are predominantly innervated by S1.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Appleton, WI, Century-Crofts, 1976.
Hollinshead WH (ed): Anatomy for Surgeons: The Back and the Limbs, ed 3. Philadelphia, PA, Harper & Rowe, 1982.

Question 37

A 16-year-old girl has had pain in the left groin for the past 4 months. She notes that the pain is worse at night; however, she denies any history of trauma and has no constitutional symptoms. There is no history of steroid or alcohol use. Examination reveals pain in the left groin with rotation of the hip. There is no associated soft-tissue mass. A radiograph and MRI scan are shown in Figures 32a and 32b, and biopsy specimens are shown in Figures 32c and 32d. What is the most likely diagnosis?

Explanation

DISCUSSION: Based on the epiphyseal location and sharp, well-defined borders, the radiograph suggests chondroblastoma. Histologically, multinucleated giant cells are scattered among mononuclear cells. The nuclei are homogenous and contain a characteristic longitudinal groove. Although not seen here, “chicken-wire calcification” with a bland giant cell-rich matrix is also typical for chondroblastoma. Clear cell chondrosarcoma occurs in epiphyseal locations but has a more aggressive histologic pattern and occurs in an older age group. Giant cell tumors occur in the epiphysis but have a more uniform giant cell population histologically. Aneurysmal bone cyst often results in bone remodeling and has a different pathologic appearance. Osteonecrosis has a typical histologic pattern of empty lacunae and necrotic bone.
REFERENCES: Springfield DS, Capanna R, Gherlinzoni F, et al: Chondroblastoma: A review of seventy cases. J Bone Joint Surg Am 1985;67:748-755.
Simon M, Springfield D, et al: Chrondroblastoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 190.
Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990,
pp 62-67.

Question 38

During primary total knee arthroplasty with trial implants in place, the surgeon notes technically satisfactory patellar resurfacing and restoration of a physiologic mechanical axis but excessively lateral patellar tracking. Treatment should now include

Explanation

DISCUSSION: The most common causes of patellar instability after total knee arthroplasty are valgus malalignment, internal rotation of the femoral or tibial component, medialization of the femoral component, errors in patellar preparation and resurfacing, and failure to perform a lateral release. These factors should be addressed before considering capsular closure. Distal extensor mechanism realignment should be avoided because of the complication rate. The proximal extensor mechanism would not adequately compensate for implant malrotation.
REFERENCES: Barnes CL, Scott RD: Patellofemoral complications of total knee replacement, in Heckman JD (ed): Instructional Course Lectures 42. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1993, pp 309-314.
Hungerford DS: Alignment in total knee replacement, in Jackson DW (ed): Instructional Course Lectures 44. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 455-468.

Question 39

A 45-year-old right-hand dominant woman falls onto an outstretched left hand. Imaging shows a complex elbow dislocation. The postreduction CT scan demonstrates a reduced joint, comminuted radial head fracture, and type I coronoid fracture. Surgical intervention is recommended to address the involved structures. Which component of the intervention adds the most rotational stability?

Explanation

A 68-year-old right-hand dominant woman has experienced progressive right elbow pain and loss of motion for several years. She has failed nonsurgical treatment and elects to undergo a total elbow arthroplasty (TEA). In comparison to a linked prosthesis, an unlinked prosthesis has which reported distinction with extended follow-up?
A. Improved longevity in comparison to the linked prosthesis
B. A significantly larger flexion-extension arc
C. A higher incidence of postsurgical instability
D. Lower frequency of ulnar nerve dysfunction
TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.

Question 40

A 57-year-old man involved in a motor vehicle accident sustains an injury to his right shoulder. A spot AP radiograph is shown in Figure 34. What is the next most appropriate step in the orthopaedic management of this patient? Review Topic

Explanation

The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.

Question 41

During a transperitoneal approach to the L5-S1 interspace, care must be taken to protect the superior hypogastric plexus from injury. Which of the following techniques reduces the risk of neurologic injury?

Explanation

DISCUSSION: Retrograde ejaculation is the sequela of superior hypogastric plexus injury. This structure needs protection, especially during anterior exposure of the L5-S1 disk space. Only blunt dissection should be used, and use of monopolar electrocautery should be avoided. If possible, preserve and retract the middle sacral artery. Once the iliac veins are isolated, blunt dissection is begun along the course of the medial edge of the left iliac vein, reflecting the prevertebral tissues toward the patient’s right side. The dissection goes from left to right because the parasympathetic plexus is more adherent on the right side.
REFERENCE: Transperitoneal midline approach to L4-S1, in Watkins RG (ed): Surgical Approaches to the Spine, ed 1. New York, NY, Springer Verlag, 1983, pp 123-129.

Question 42

During right knee anterior cruciate ligament (ACL) reconstruction, after drilling an appropriately positioned and referenced tibial tunnel, the surgeon finds that the transtibial guide is placing the femoral tunnel at 11:30 within the intercondylar notch. Which of the following choices will best enable appropriate graft placement in this clinical scenario? Review Topic

Explanation

Anatomic placement of the femoral tunnel is best achieved in this clinical scenario by drilling the femoral tunnel through the anteromedial portal or via a two-incision technique. Several recent studies have demonstrated the difficulty that may be encountered in restoring true ACL anatomy on the femoral side when placing a femoral tunnel through a transtibial technique. While this is not always the case and this technique may be reasonable and sufficient, it is important for orthopaedic surgeons to critically assess tunnel placement intraoperatively and postoperatively to
minimize errant tunnel placement, demonstrated in the literature as the most common cause of ACL failure and need for revision. In this not uncommon clinical scenario, simply converting to a two-incision ACL technique or drilling through the anteromedial portal with the knee hyperflexed will permit accurate femoral tunnel placement and increase the likelihood of an optimal clinical outcome. Femoral tunnel accuracy with these techniques is enhanced by a lower starting point in the intercondylar notch. Familiarity with these techniques is valuable for surgeons performing ACL reconstruction. Revising the tibial tunnel in this scenario would likely lead to bone compromise of the proximal tibia and may interfere with graft fixation and incorporation. Converting to a double-bundle ACL with a transtibial technique would not correct the vertical femoral tunnel. Hyperflexion of the knee may improve femoral tunnel placement to some extent, but is unlikely to allow anatomic placement of a femoral tunnel when the transtibial guide lies in a clearly excessive vertical position.

Question 43

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Explanation

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.

The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 44

Figure 40 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. Closed reduction is readily accomplished, and the elbow seems stable. Management should now consist of application of a splint for

Explanation

DISCUSSION: Flexion contractures are the most common complication of elbow dislocations. About 15% of patients lose more than 30 degrees of flexion. The risk of contracture is proportional to the duration of immobilization. Elbows should be moved within the first few days after reduction. The splinting is for comfort and protection only while the pain subsides.
REFERENCES: Mehlhoff TL, Noble PC, Bennett JB, Tullos HS: Simple dislocation of the elbow in the adult: Results after closed treatment. J Bone Joint Surg Am 1988;70:244-249.
Linscheid RL, O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 441-452.
O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102.
Ross G, McDevitt ER, Chronister R, Ove PN: Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308-311.

Question 45

A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of Review Topic

Explanation

The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T1-weighted MRI scans and with high signal intensity on T2-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient.

Question 46

A year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Explanation

DISCUSSION:
This situation represents a definitively and chronically infected knee replacement. Antibiotic therapy alone might suppress the infection but would not eradicate it. Debridement and polyethylene exchange would be appropriate treatment for an early postoperative infection. The treatment of choice is to perform a two-stage debridement and reconstruction. Although not among the listed choices, an aspiration or culture could be done presurgically and might help clinicians identify the best antibiotics to treat the condition. Antibiotic selection would not affect the need for the two-stage reconstruction, however.

Question 47

A 52-year-old man has shoulder pain and stiffness after undergoing a “mini-lateral” rotator cuff repair 6 months ago. Examination reveals that he is afebrile with normal vital signs. There is slight erythema but no drainage from the incision. Range of motion is limited in all planes, and there is weakness with resisted external rotation and abduction. Radiographs show a well-positioned metal implant within the greater tuberosity. Laboratory studies reveal a WBC count of 8,400/ mm 3 (normal 3,500 to 10,500/ mm 3 ) and an erythrocyte sedimentation rate of 63 mm/h (normal up to 20 mm/h). What is the next most appropriate step in management?

Explanation

DISCUSSION: Deep sepsis of the shoulder following rotator cuff repair is an uncommon problem. Patients with infections of this type typically report persistent pain and are not systemically ill. They may have signs of local wound problems such as erythema, drainage, and dehiscence. Laboratory studies can be helpful in making an accurate diagnosis. Most patients will not show a significant elevation of the WBC count; however, an elevated erythrocyte sedimentation rate is nearly always present and should alert the clinician to the presence of infection. Aspiration of both subacromial and glenohumeral joint spaces is necessary to confirm the diagnosis. The most effective treatment for deep shoulder sepsis following rotator cuff repair involves extensive surgical debridement, removing all suspicious soft tissue as well as implants. Administration of appropriate antibiotic therapy is needed for complete control of the infection.
REFERENCES: Mirzayan R, Itamura JM, Vangsness CT, et al: Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am 2000;82:1115-1121.
Settecerri JJ, Pitnu MA, Rock MG, et al: Infection after rotator cuff repair. J Shoulder Elbow Surg 1994;8:105.
Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.

Question 48

Which of the following articulation couplings shows the lowest coefficient of friction as tested in the laboratory?

Explanation

DISCUSSION: Alumina ceramic is highly biocompatible when used as a biomaterial for joint arthroplasty implants. It has been shown to have good hardness, low roughness, and excellent wettability, therefore resulting in very low friction. However, it is expensive and limited reports have shown the problem of fracture on impact. The exact role for ceramic articulations is unknown at present.
REFERENCES: Cuckler JM, Bearcroft J, Asgian CM: Femoral head technologies to reduce polyethylene wear in total hip arthroplasty. Clin Orthop 1995;317:57-63.
Sharkey PF, Hozack WJ, Dorr LD, Maloney WJ, Berry D: The bearing surface in total hip arthroplasty: Evolution or revolution, in Price CT (ed): Instructional Course Lectures 49. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 41-56.

Question 49

After trial placement of components in a primary total knee arthroplasty, the knee is unable to come to full extension, but the flexion gap is appropriately balanced. After adequate soft-tissue releases have been performed, what is the next most appropriate action to balance the reconstruction?

Explanation

DISCUSSION: The reconstruction requires additional resection of the distal femur to allow increased extension while maintaining the current flexion gap tension. Resecting more proximal tibia or decreasing the tibial polyethylene thickness will decrease flexion tension as well as extension tension. Adding posterior femoral augments and using a larger femoral component will increase flexion tension.
REFERENCES: Ayers DC, Dennis DA, Johanson NA, et al: Common complications of total knee arthroplasty. J Bone Joint Surg Am 1997;79:278-311.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 281-286.

Question 50

A 7-year-old girl is hit by a motor vehicle and sustains the isolated ipsilateral injuries shown in Figures 16a and 16b. What is the optimal definitive method of treatment?

Explanation

DISCUSSION: The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur.
REFERENCES: Poolman RW, Kocher MS, Bhandari M: Pediatric femoral fractures:

A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-654.
Anglen JO, Choi L: Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733.
Beaty JH: Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 2005;434:114-122.

Question 51

A year-old woman experiences pain 1 year after total knee arthroplasty (TKA). She reports sharp anterior pain and a painful catching sensation that is aggravated by rising from a chair or climbing stairs. Physical examination reveals a mild effusion and a range of motion of 2° to 130°, with patellar crepitus. The symptoms are reproduced by resisted knee extension. Radiographs show a well-aligned posterior- stabilized TKA without evidence of component loosening. What is the recommended treatment for this patient?

Explanation

DISCUSSION:
Patellar clunk syndrome is caused by the development of a fibrous nodule on the posterior aspect of the quadriceps tendon at its insertion into the patella. It causes a painful catching sensation when the extensor
mechanism traverses over the trochlear notch as the knee extends from 45° of flexion to 30° from full extension. It characteristically occurs in posterior stabilized total knee arthroplasties and appears to be related to femoral component design. The syndrome can usually be prevented by excising the residual synovial fold just proximal to the patella. Flexion gap instability can also cause a painful total knee arthroplasty but is less common in posterior stabilized implants. Femoral component malrotation can cause pain attributable to a flexion gap imbalance or patellar tracking problems. Polyethylene wear would be unlikely after just 1 year. Patellar clunk syndrome can usually be addressed successfully with arthroscopic synovectomy. Recurrence is uncommon. Physical therapy may help to strengthen the quadriceps following synovectomy but would not resolve the clunk syndrome symptoms. Femoral or tibial insert revision is not indicated if patellar clunk syndrome is the only problem resulting in a painful
total knee arthroplasty.

Question 52

An axillary nerve lesion may cause weakness in the deltoid and the

Explanation

DISCUSSION: While the most prominent functional deficit from axillary nerve lesions occurs from denervation of the deltoid, denervation of the teres minor also occurs.
REFERENCE: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs. New York, NY, Harper & Row, 1969.

Question 53

Figures 32a and 32b show the radiographs of a 13-year-old boy who sustained a fracture while playing football 1 week ago. Management at the time of injury included application of a cast and the use of crutches. A follow-up office visit reveals a normal neurologic examination, and the patient reports no discomfort with the cast and crutches. Management should now include

Explanation

DISCUSSION: Stable fractures and minimally displaced fractures in children can and should be treated by closed methods. Because loss of reduction is common, alignment of tibia fractures must be monitored closely for the first 3 weeks after cast application. This is most easily handled in a cooperative patient by cast wedging. Some children require application of a second cast under general anesthesia 2 to 3 weeks after injury, particularly if the subsidence of swelling has caused the cast to loosen. Surgical indications include the presence of soft-tissue injuries, unstable fracture patterns, fractures associated with compartment syndrome, and the child with multiple injuries. Surgical options in children include percutaneous pins, external fixation, plates and screws, and intramedullary nails.
REFERENCES: Heinrich SD: Fractures of the shaft of the tibia and fibula, in Rockwood CA, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 1340-1346.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 583-595.

Question 54

A 25-year-old male involved in a motor vehicle accident sustains multiple injuries. He undergoes operative treatment for his humeral shaft fracture. Figures A and B show his preoperative and postoperative radiographs. The distal interlocks for this implant place which of the following nerves at risk?

Explanation

With intramedullary (IM) nailing of the humerus, the distal anterior-to-posterior interlocking screws place the musculocutaneous nerve at high risk for injury as it goes through the coracobrachialis muscle and courses anteriorly along the brachialis (of which it innervates the medial half).
Rupp et al performed a cadaveric study with IM nails utilizing either lateral-to-medial or anterior-to-posterior distal interlocking screws. They showed that anterior-to-posterior screws placed the musculocutaneous nerve at high risk, while lateral-to-medial screws placed the radial nerve at high risk as it courses laterally distally along the humerus.
OrthoCash 2020

Question 55

Which of the following materials best approximates the Young's modulus of elasticity of cortical bone?

Explanation

Of the materials listed titanium (100GPa) has an elastic modulus closest to cortical bone (approximately 18GPa) as well as cancellous bone (approximately 2GPa).
Titanium is a material that is light, highly ductile, strong and corrosion resistant. However, titanium has poor wear resistance and is notch sensitive. It is commonly used as an orthopaedic implant materials because it has torsional and axial stiffness (moduli) that most closely mimics bone. Young’s modulus is constant and different for each material and represents the material's ability to maintain shape under external loading.
Rho et al found that the average Young's modulus for trabecular bone measured ultrasonically and mechanically was 14.8 GPa (S.D. 1.4) and 10.4 (S.D. 3.5), respectively. The average Young's modulus of microspecimens of cortical bone measured ultrasonically and mechanically was 20.7 GPa (S.D. 1.9) and 18.6 GPa (S.D. 3.5), respectively.
Illustration A depicts a stress vs. strain curve. The slope of the line in the elastic zone represents the Young Modulus of Elasticity.
Incorrect Answers:

Question 56

A 21-year-old pregnant female arrives in the trauma bay with a closed head injury as well as an open ankle injury. During evaluation, what positioning is recommended to limit positional hypotension?

Explanation

DISCUSSION: An important hemodynamic consideration in the pregnant trauma patient is the potential hypotensive effect of supine positioning. This effect, which is caused by aortocaval compression by the enlarged uterus, may decrease cardiac output by 25%. Use of a right hip wedge, manual displacement of the uterus, or lateral tilt positioning of the patient may help avoid this situation. Patient positioning must be determined with a focus on the well-being of the fetus. To avoid compression of the inferior vena cava in the patient who is in her second or third trimester, the left lateral decubitus position (left side down) should be used. The referenced review article by Flik et al
reviews the appropriate physiological changes of pregnancy and covers the treatment of orthopedic trauma in the face of pregnancy.

Question 57

Acetabular reconstruction followed by external beam irradiation The plain radiographs show a purely lytic destructive lesion that is poorly marginated. The technetium bone scan does not show any major uptake. The computerized tomography scan shows purely lytic bone destruction with breakthrough of the cortical bone. Complete destruction of the cortical bone is suggestive of a malignancy. The magnetic resonance image shows a lesion that is homogenously low on T1-weighted images and high on T2-weighted images. Surgeons cannot make a definitive diagnosis based upon the radiographic features. The most common malignancies in this age group are:

Explanation

Slide 1 Slide 2 Slide 3 Slide 4
A 50-year-old woman has had severe hip pain for 4 months. Her plain radiographs (Slide 1), technetium bone scan (Slide 2), computerized tomography scan (Slide 3), and coronal T1- and T2-weighted magnetic resonance images (Slide 4) are presented. The most likely diagnosis based upon the radiographs would be:

Question 58

A patient has a vertically and rotationally unstable hemipelvis following a motor vehicle accident. An indication for application of an anterior resuscitative pelvic external fixator is made. Two options with regard to pin insertion location are considered as seen in Figure 20. When compared to pins in position A, the pins in position B may be more advantageous because

Explanation

Pelvic external fixation can be used for the acute resuscitation of patients with pelvic fractures and for definitive treatment of certain injury patterns. Typically frames are constructed with anterosuperior half-pin placement within the iliac crest. Intracortical placement of these pins may be difficult and erroneous placement may render purchase inadequate. Recently, external fixation of the pelvic ring with half-pin placement into the dense supra-acetabular bone in the region of the anterior inferior iliac spine has gained popularity. Kim and associates, in a biomechanical model, demonstrated that anterior-inferior pin placement was biomechanically superior to conventional anterior-superior pin placement in rotationally and vertically unstable fracture patterns. Haidukewych and associates performed a cadaveric study that demonstrated the lateral femoral cutaneous nerve is at risk within a mean distance of 10 mm from the inferior half-pin site but the femoral nerve and femoral artery are not at risk. The average superior extent of the hip capsule was 16 mm above the joint. They suggested that these pins be inserted at least 2 cm above the hip to avoid potential hip capsule penetration. Poelstra and Kahler described a case during which the lower pins were inserted without the benefit of imaging using only palpable landmarks. However, this technique is better reserved for nonresusitative purposes permitting the use of multiplanar fluoroscopic imaging. Image guidance better ensures proper pin placement within the pelvic cortices, minimizing penetration of the hip joint and sciatic notch. No anterior external fixator, regardless of design or region of application, offers sufficient posterior stability to serve as definitive treatment for vertically unstable pelvic fracture variants.

Question 59

01 (left). What is the most appropriate next step?

Explanation

This patient has a posterior knee dislocation with an ischemic limb that does not reverse following reduction. Emergent vascular exploration and reconstruction is indicated.
Knee dislocations are associated with popliteal artery injury in 18-45% of cases and range from intimal tears to complete transection. Amputation rates of 85% have been reported if revascularization is delayed greater than 6 to 8 hours. Neurologic injury occurs in 15-40% of cases and is most common after posterolateral dislocation. The peroneal nerve is more commonly injured.
Rihn et al. reviewed the acutely dislocated knee. They recommend a vascular consult if pulses are weak, or ABI is compromised. They warn that in arterial injury, pulses, temperature and capillary refill can be normal. If the limb remains ischemic, surgical exploration and revascularization is indicated.
Medina et al. systematically reviewed neurovascular injury after knee dislocation in 862 patients. Vascular injury rate was 18%, and nerve injury rate was 25%. Repair was performed in 80% of vascular injuries, and amputation in 12%. The most vascular injury was seen in KDIIIL injuries (32%) and posterior dislocation (25%).
Figure A is an AP radiograph of a posterior knee dislocation. Figure B is a lateral showing the same injury.
Incorrect Answers:

Question 60

A 53-year-old man has had a long history of multiple joint symptoms, and he notes that the worst pain is from his left shoulder. A radiograph and MRI scan are shown in Figures 13a and 13b. Prior to surgical treatment of the shoulder, what is the most appropriate work-up?

Explanation

DISCUSSION: Rheumatoid arthritis is sometimes associated with radiographic evidence of instability of the cervical spine. In a study by Grauer and associates, radiographs of the cervical spine of patients with rheumatoid arthritis who had undergone total joint arthroplasty over a

5-year period were retrospectively reviewed. Nearly one half of the patients had radiographic evidence of cervical instability on the basis of traditional measurements. While radiographic evidence of cervical instability was not infrequent in this population of patients who underwent total joint arthroplasty for rheumatoid arthritis, radiographic predictors of paralysis were much less common. MRI prior to surgery may also be a consideration if the radiographic appearance of the rotator cuff alters the consideration of surgical treatment. In a series of patients undergoing prosthetic arthroplasty for a variety of shoulder disorders, the presence of a rotator cuff tear has been shown to be associated with a less favorable outcome. Most often, the presence of a rotator cuff tear was associated with a diagnosis of rheumatoid or other inflammatory arthritis and the tears were large and generally irreparable. Some case series demonstrated a higher prevalence of loosening of the glenoid component in patients with a large rotator cuff tear associated with superior migration of the humeral head. However, obtaining an MRI scan of the shoulder is not considered the best response since failure to determine cervical instability may result in anesthetic death. Whereas MRI may be helpful in planning reconstruction, it would be a less important priority.
REFERENCES: Grauer JN, Tingstad EM, Rand N, et al: Predictors of paralysis in the rheumatoid cervical spine in patients undergoing total joint arthroplasty. J Bone Joint Surg Am 2004;86:1420-1424.
Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.

Question 61

Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles generated by metal-on-metal articulations are

Explanation

DISCUSSION: Retrieval studies have shown that the debris particles produced by

metal-on-metal articulations in total hip arthroplasty are several orders of magnitude smaller

and may be up to 100 times more numerous than those found with metal-on-polyethylene articulations.
REFERENCES: Davies AP, Willert HG, Campbell PA, et al: An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements.

J Bone Joint Surg Am 2005;87:18-27.
Firkins PJ, Tipper JL, Saadatzadeh MR, et al: Quantitative analysis of wear and wear debris from metal-on-metal hip prostheses tested in a physiological hip joint simulator. Biomed Mater Eng 2001;11:143-157.

Question 62

A year-old man with insulin-dependent diabetes mellitus underwent primary total knee arthroplasty (TKA). A full-thickness skin slough measuring 3 cm by 4 cm developed, with postsurgical exposure of the patellar tendon. No change is observed in the appearance of the wound after 2 weeks of wet-to-dry dressing changes. What is the best next treatment step for the soft-tissue defect?

Explanation

DISCUSSION:
If wound healing does not occur and deep soft tissues such as the patellar tendon are exposed following TKA, local rotational flap is the procedure of choice. The procedure should be performed relatively early after the recognition of a soft-tissue wound-healing problem. In the setting of TKA, the gastrocnemius muscle is an excellent source of flaps for wound coverage of the proximal tibia.

Question 63

A 65-year-old man has a painful and often audible crepitus after undergoing a total knee arthroplasty 8 months ago. His symptoms are reproduced with active extension of about 30°. Examination reveals no effusion or localized tenderness, a stable knee, and a range of motion of 5° to 120°. Radiographs are shown in Figures 37a and 37b. Management should consist of

Explanation

DISCUSSION: This is a typical presentation of the patellar clunk syndrome. The syndrome usually follows implantation of a posterior stabilized prosthesis. It is thought to be the result of femoral component design and altered extensor mechanics. The condition usually resolves with arthroscopic debridement of the suprapatellar fibrous nodule. Arthrotomy or revision is seldom warranted.
REFERENCES: Beight JL, Yao B, Hozack WJ, Hearn SL, Booth RE Jr: The patellar “clunk” syndrome after posterior stabilized total knee arthroplasty. Clin Orthop 1994;299:139-142.
Lintner DM, Bocell JR, Tullos HS: Arthroscopic treatment of intra-articular fibrous bands after total knee arthroplasty: A follow-up note. Clin Orthop 1994;309:230-233.

Question 64

An obese (BMI = 35) 72-year-old woman with diabetes mellitus, hyptertension and a 22-pack-year smoking history is scheduled to undergo posterior spinal fusion from T10 to S1 with a pedicle subtraction osteotomy at L3 for the spinal deformity seen in Figure 1. Which of the following risk factors is most predictive of major complication following surgery Review Topic

Explanation

The patients age (> 60 years) is the most significant risk factor for a major perioperative complication during posterior spinal fusion for adult spinal deformity correction.
The surgical treatment of adult spinal deformity often requires multilevel arthrodesis with complex osteotomies including three column osteotomies such as pedicle
subtraction (PSO) and vertebral column resection (VCR). They can involve both anterior and posterior surgical approaches. Surgical time, blood loss, length of hospital stay, and length of recovery can be greater than it is for the more common degenerative conditions.
Auerbach et al. characterized the risk factors for the development of major complications in patients undergoing 3-column osteotomies for adult spinal deformity correction. They also aimed to determine whether the presence of complications affected the ultimate clinical outcome. They found age > 60 years, > or = 3 comorbid conditions and preoperative sagittal imbalance of = 40mm was associated with a major complication. However, the presence of a major complication did not affect the ultimate clinical outcomes at 2 years or more.
Daubs et al. conducted a retrospective analysis of forty-six patients = 60 years of age who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure to determine the rate of complication and outcomes. The overall complication rate was 37% and the major complication rate was 20%. Increasing age was a significant factor (p<0.05) in predicting the presence of a complication, while presence of comorbidities was found to have no association.
Figure A is a standing preoperative lateral radiograph of the spine demonstrating a thoracic kyphosis of ~25° and thoracolumbar kyphosis of ~25°. Illustration A demonstrates proper sagittal balance after spinal fusion from T10 to S1 and L3 PSO.
Incorrect Answers:

Question 65

Bone morphogenetic proteins transduce intracellular signal through what class of cell surface receptor?

Explanation

Bone morphogenetic proteins (BMPs) are extracellular proteins belonging to the TGF-beta superfamily of molecules. Members of this family include BMPs, growth and differentiation factors (GDFs), anti-mnllerian hormone (AMH), activin, Nodal, and TGF-beta. These proteins exert their action by binding to cell surface receptors of the serine-threonine kinase class to activate intracellular signaling pathways. The other kinase participate in various cell signaling functions, but are not associated with BMP.

Question 66

A 70-year-old woman has a preoperative anterior interscalene block prior to undergoing a total shoulder arthroplasty. After seating her in the beach chair position, she becomes acutely hypotensive. What is the most likely cause for the hypotension?

Explanation

DISCUSSION: The beach chair position may cause sudden hypotension and bradycardia as a result of the Bezold-Jarisch reflex. This reflex occurs when venous pooling and increased sympathetic tone induce a low-volume, hypercontractile ventricle, resulting in activation of the parasympathetic nervous system and sympathetic withdrawal. The reported incidence of this phenomenon associated with the sitting position is between 13% to 24%. Left untreated, the result may be cardiac arrest. Pneumothorax or central nervous system toxicity after interscalene block is rare and has an incidence of less than 0.2%. Laryngeal nerve block associated with interscalene nerve block can occur but usually results in hoarseness secondary to ipsilateral vocal cord palsy.
REFERENCES: Long T, Wass C, Burkle C: Perioperative interscalene blockade: An overview of its history and current clinical use. J Clin Anesthesia 2002;14:546-556.
Norris T (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 433-442.

Question 67

Which of the following characteristics is seen in patients with osteochondritis dissecans of the elbow? Review Topic

Explanation

Osteochondritis dissecans occurs in the older child or adolescent (typically older than age 13 years). It involves the lateral compartment. The etiology is felt to be microtraumatic vascular insufficiency from repetitive rotatory and compressive forces. MRI typically shows separation of cartilage from the capitellum and chondral fissuring. Panner’s disease is usually seen in children younger than age 10 years, involves the entire capitellar ossific nucleus, and resolves typically with no residual deformity or late sequelae. There is no evidence of ligamentous injury.

Question 68

Where is the most common site for tuberculosis (TB) spondylitis in children?

Explanation

DISCUSSION: In children, the main route of infection in skeletal TB is through hematogenous spread from a primary source. The mycobacterium is deposited in the end arterials in the vertebral body adjacent to the anterior aspect of the vertebral end plate. Thus, the anterior portion of the vertebral body is most commonly involved. The lower thoracic region is the most common segment; next in decreasing order of frequency are the lumbar, upper thoracic, cervical, and sacral regions.
REFERENCES: Teo HE, Peh WC: Skeletal tuberculosis in children. Pediatric Radiol 2004;34:853-860.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 1831-1835.

Question 69

Which of the following factors is used to determine torsional rigidity of a long bone fracture under internal or external fixation?

Explanation

Torque is defined as: T=r x F, where r is the moment arm and F is the force applied. The moment arm is the perpendicular distance from the line of action or axis of rotation. Thus torque is a vector
quantity having a magnitude and direction. Torsion involves shear and tensile stresses that cause deformation. Thus torsional rigidity is related to bone rotation and the torque applied to it.

Question 70

A 6-month-old child is seen in the emergency department with a spiral fracture of the tibia. The parents are vague about the etiology of the injury. There is no family history of a bone disease. In addition to casting of the fracture, initial management should include Review Topic

Explanation

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
(SBQ13PE.60) If a child develops dynamic supination after treatment of idiopathic clubfoot with Ponseti casting, at what age would it be appropriate to consider transfer of the tibialis anterior tendon to the lateral dorsum of the foot? Review Topic
In the first six months of life, immediately following failed cast treatment
12 months
4 years
12 years
15 years
Tibialis tendon transfer to the dorsum of the foot should be performed to address dynamic supination when the lateral cuneiform has ossified. This is typically after at least 2 years of age and usually not before age 3.

Question 71

A 37-year-old man pulled his hamstring playing softball 3 weeks ago. The patient had not noted any mass prior to his injury. MRI scans of the posterior thigh are shown in Figures 4a and 4b. Figure 4c shows the biopsy specimen from a needle biopsy. What is the most likely diagnosis?

Explanation

DISCUSSION: Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma. MFH typically presents as a large mass, deep to the fascia with heterogeneous signal on MRI. The MRI scans show a heterogeneous lesion in the posterior thigh. There is significant high signal uptake on the T₂-weighted image. The histology shows malignant histiocytic cells with marked atypia and pleomorphism. Histology of a hematoma would show only old hemorrhage and some granulation tissue. Lipoma and liposarcoma are both seen as a fat-containing lesion on histology. No significant fat tissue is seen in this histologic specimen. Histology of myositis ossificans would show bone formation.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.
Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 965-981.

Question 72

What is the most common complication following total disk arthroplasty in the lumbar spine?

Explanation

DISCUSSION: In a midterm (7 to 11 years) follow-up study of lumbar total disk arthroplasty, 5 of 55 patients had transient radicular leg pain without evidence of nerve root compression. Implant migration is rare. Deep venous thrombosis, incisional hernia, and retrograde ejaculation are less common complications of disk arthroplasty.
REFERENCE: Tropiano P, Huang RC, Girardi FP, et al: Lumbar total disc replacement: Seven to eleven-year follow-up. J Bone Joint Surg Am 2005;87:490-496.

Question 73

Thoracic disk herniations most typically occur at what level of the thoracic spine? Review Topic

Explanation

Most thoracic disk herniations occur in the lower (caudal) third of the thoracic spine. This predilection may be related to the unique anatomic and biomechanical environment of that region. The 11th and 12th ribs do not join the rib cage anteriorly and do not form a true articulation with the transverse processes posteriorly. Furthermore, flexion and torsional forces tend to concentrate between T10 and L1.

Question 74

Which of the following clinical findings is commonly associated with symptomatic partial-thickness rotator cuff tears?

Explanation

DISCUSSION: In symptomatic partial-thickness rotator cuff tears, a painful arc with active range of motion is common, impingement signs are usually positive, and the lift-off test is normal. Active and passive range of motion measurements are often equal, although active range of motion can be painful. External rotation lag signs are often seen with larger full-thickness tears.
REFERENCES: Hertel R, Ballmer FT, Lambert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313.
McConville OR, Iannotti JP: Partial thickness tears of the rotator cuff: Evaluation and management. J Am Acad Orthop Surg 1999;7:32-43.
Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Fukuda H: Partial-thickness rotator cuff tears: A modern view on Codman’s classic. J Shoulder Elbow Surg 2000;9:163-168.

Question 75

An 11-year-old basketball player reports that he felt a painful pop in the left knee when he stumbled while running. He is unable to bear weight on the extremity and cannot actively extend the knee against gravity. Examination reveals a large knee effusion. A lateral radiograph is shown in Figure 7. Management should consist of

Explanation

DISCUSSION: The radiograph shows an avulsion fracture, or “sleeve fracture,” of the distal pole of the patella. The distal fragment is much larger than it appears on the radiograph because it largely consists of cartilage; therefore, excision of the fragment is contraindicated. The treatment of choice is open reduction and tension band fixation to correct patella alta and restore the extensor mechanism.
REFERENCES: Maguire JK, Canale ST: Fractures of the patella in children and adolescents.

J Pediatr Orthop 1993;13:567-571.
Grogan DP, Carey TP, Leffers D, et al: Avulsion fractures of the patella. J Pediatr Orthop 1990;10:721-730.

Question 76

A 58-year-old woman has had a slowly progressing mass over the distal interphalangeal (DIP) joint of her dominant hand with a worsening deformity of her nail. She has no significant medical history but underwent bilateral knee arthroplasties 1 year ago. Radiographs reveal a small osteophyte at the DIP joint dorsally. A clinical photograph and a biopsy specimen are shown in Figures 76a and 76b. What is the most likely diagnosis?

Explanation

DISCUSSION: A mucous cyst is thought to be a ganglion arising from the DIP joint in patients with osteoarthritis. They are frequently associated with nail deformities. Treatment involves removal of the cyst with debridement of DIP joint osteophytes.
REFERENCES: Fritz GR, Stern PJ, Dickey M: Complications following mucous cyst excision. J Hand Surg Br 1997;22:222-225.
Zook EG, Brown RE: The perionychium, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 1353-1380.

Question 77

Which of the following mechanisms is considered the most common cause of failure of osteoarticular allografts used for articular reconstruction?

Explanation

DISCUSSION: Mechanical loosening and infection can occur as complications after surgery, but the most common cause of osteoarticular allograft failure is graft collapse during revascularization. Clinical rejection because of an immune response is an unusual means of failure.
REFERENCES: Meyers MH, Akeson W, Convery FR: Resurfacing of the knee with fresh osteochondral allograft. J Bone Joint Surg Am 1989;71:704-713.
Beaver RJ, Mahomed M, Backstein D, Davis A, Zukor DJ, Gross AE: Fresh osteochondral allografts for posttraumatic defects in the knee: A survivorship analysis. J Bone Joint Surg Br 1992;74:105-110.

Question 78

A 27-year-old man now reports dorsiflexion and inversion weakness after an automobile collision 6 months ago in which compartment syndrome developed isolated to the anterior and deep posterior compartments. Examination reveals the development of a progressive cavovarus deformity, but the ankle and hindfoot remain flexible. In addition to Achilles tendon lengthening, which of the following procedures is most likely to improve the motor balance of his foot and ankle?

Explanation

DISCUSSION: Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus. Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque.
REFERENCES: Hansen ST: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott, Williams & Wilkins, 2000, pp 433-435.
Vienne P, Schoniger R, Helmy N, et al: Hindfoot instability in cavovarus deformity: Static and dynamic balancing. Foot Ankle Int 2007;28:96-102.

Question 79

Which of the following is considered the best cementless acetabular reconstruction method when planning for total hip arthroplasty in a patient with developmental dysplasia of the hip (DDH)?

Explanation

DISCUSSION: Anatomic positioning of the acetabular component has been shown to be the optimal position for reconstruction of the acetabulum in total hip arthroplasty for DDH. The use of medialized component positioning has been shown to be successful at maximizing the host bone coverage and minimizing the use of bone graft to structurally support the acetabular component. A small acetabular component can be used successfully as long as the femoral head is also reduced in size to maintain the thickness of the acetabular polyethylene. High and lateral positioning for the acetabular reconstruction will result in an increase in the joint reaction forces. In addition, a high and lateral placement will not provide adequate bone to stabilize the reconstruction.
REFERENCES: Numair J, Joshi AB, Murphy JC, Porter ML, Hardinge K: Total hip arthroplasty for congenital dysplasia or dislocation of the hip: Survivorship analysis and long-term results. J Bone Joint Surg Am 1997;79:1352-1360.
Dorr LD, Tawakkol S, Moorthy M, Long W, Wan Z: Medial protrusio technique for placement of a porous-coated, hemispherical acetabular component without cement in a total hip arthroplasty in patients who have acetabular dysplasia. J Bone Joint Surg Am 1999;81:83-92.
Jasty M, Anderson MJ, Harris WH: Total hip replacement for developmental dysplasia of the hip. Clin Orthop 1995;311:40-45.

Question 80

A 34-year-old man underwent a transtibial amputation as the result of a work-related injury. The amputation was performed at the inferior level of the tibial tubercle. The residual limb has a soft-tissue envelope composed of gastrocnemius muscle that is used as soft-tissue cushioning for the distal tibia. Despite undergoing several prosthetic fittings, he continues to report pain and instability. Examination reveals that the prosthesis appears to fit well with no apparent pressure points or areas of skin breakdown. He is not willing to have any further surgery. Which of the following modifications will most likely provide relief?

Explanation

DISCUSSION: While transtibial amputees can be fitted with a prosthesis with a residual limb as short as 5 cm, or with retention of the insertion of the patellar tendon, this patient has an unstable gait because of the limited ability of the prosthetic socket to maintain a snug and stable fit. While cumbersome and bulky, double metal uprights and a corset is the only predictable method of gaining stability. The other methods attempt to add an element of stability; however, they are unlikely to be successful.
REFERENCES: Bowker JH, Goldberg B, Poonekar PD: Transtibial amputation: Surgical procedures and postsurgical management, in Bowker JH, Michael JW (eds): Atlas of Limb Prosthetics. St Louis, MO, Mosby Year Book, 1992, pp 429-452.
Kapp S, Cummings D: Transtibial amputation: Prosthetic management, in Bowker JH, Michael JW (eds): Atlas of Limb Prosthetics. St Louis, MO, Mosby Year Book, 1992, pp 453-478.

Question 81

A 34-year-old man sustains an extra-articular fracture of the proximal phalanx of his right index finger in a fall. Examination reveals that the fracture is closed and oblique in orientation. Closed reduction and splinting fail to maintain the reduction. Management should now consist of

Explanation

DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.

Question 82

During total hip arthroplasty, what characteristic of irradiated (10 Mrad) and subsequently melted highly cross-linked polyethylene should provide a more wear-resistant construct than traditional gamma-irradiated (2.5-4 Mrad)-in-air polyethylene mated with the same head?

Explanation

DISCUSSION:
Highly cross-linked polyethylene makes material resistant to adhesive wear. Abrasive wear from third bodies does not decrease wear. The fatigue strength of such material is inferior to that of traditional polyethylene, and its resistance to creep is the same, if not lower, than that of traditional polyethylene.

Question 83

A 40-year-old man fell 10 feet from a tree and sustained the closed isolated injury shown in Figures 35a and 35b. Management consists of splinting. At his 2-week follow-up visit, he clinically passes the wrinkle test. He agrees to open reduction and internal fixation. What is the best surgical approach to obtain anatomic reduction and limit wound dehiscence?

Explanation

DISCUSSION: The approach to the calcaneus has evolved from several different patterns, driven by a high wound complication rate of 10%. The current extensile lateral approach was described by Zwipp and associates in 1988. The surgical exposure uses an L-shaped incision, with the vertical component positioned one half a finger’s breath anterior to the Achilles tendon and extending distally to the junction of the lateral skin and the plantar skin. Borrelli and Lashgari mapped the angiosome of the lateral calcaneal flap and found that the major arterial blood supply to this flap consisted of three arteries: the lateral calcaneal artery, the lateral malleolar artery, and the lateral tarsal artery. The lateral calcaneal artery appeared to be responsible for most of the blood supply to the corner of the flap. This was found 1.5 cm anterior to the Achilles tendon. Division of this artery with inaccurate placement of the vertical limb of the incision can cause ischemia of the lateral skin flap.
REFERENCES: Borrelli J Jr, Lashgari C: Vascularity of the lateral calcaneal flap: A cadaveric injection study. J Orthop Trauma 1999;13:73-77.
Freeman BJC, Duff S, Allen PE, et al: The extended lateral approach to the hindfoot: An anatomical basis and surgical implications. J Bone Joint Surg Br 1998;80:139-142.
Zwipp H, Tscherne H, Wulker N: Osteosynthesis of dislocated intra-articular calcaneus fractures. Unfallchirurg 1988;91:507-515.

Question 84

A 42-year-old man has increasing pain and, to a lesser extent, some occasional left knee instability. Several years earlier he sustained a noncontact twisting injury to his knee. He had some initial soreness and pain but was able to resume his normal activities while avoiding sports. On examination, the patient has medial joint line pain, a grade 2+ Lachman, and a slight varus thrust. His radiographs reveal mild-to-moderate medial compartment osteoarthritis with varus alignment. What surgical treatment strategy likely will alleviate his pain? Review Topic

Explanation

This patient had a previous anterior cruciate ligament (ACL) and posterolateral complex injury. With chronic instability and osteoarthritis, the best option is HTO with a decrease in the tibial slope to reduce anterior laxity. Distal femoral osteotomy is better suited to address valgus malalignment. The lateral closing-wedge osteotomy would not allow for adequate correction of the tibial slope. Unicompartmental knee replacement is not indicated when there is ligament instability. If the patient continues to experience instability following correction of the varus malalignment, reconstruction of the ACL and posterolateral corner would be appropriate at that time.

Question 85

positive skin-test response to CSD skin-test antigen; 3) characteristic lymph node lesions; and 4) negative laboratory investigation for unexplained lymphadenopathy. Treatment consists of azithromycin, ciprofloxacin, doxycycline, or multiple other antibiotics, all of which have been used successfully. Radiation therapy and chemotherapy would be reserved for malignant diseases and would not be appropriate in this setting. Treatment is necessary for this infectious entity; therefore, observation or physical therapy is not indicated.

Explanation

Trapeziometacarpal corticosteroid injection followed by aggressive occupational therapy
Trapeziectomy with interpositional palmaris longus arthroplasty
Trapeziectomy, interpositional arthroplasty, and palmar oblique ligament reconstruction using flexor carpi radialis autograft
Partial trapeziectomy with capsular interpositional arthroplasty
None of the above CORRECT ANSWER: 5
This patient has symptomatic basal joint arthritis with radiographic evidence of pantrapezial arthritis. Simple trapeziectomy has been shown to provide pain relief and improvement of key-pinch strength that is comparable to trapeziectomy plus interpositional arthroplasty.
Definitive surgical management of basal joint arthritis commonly involves excision of the diseased trapezium with concomitant interpositional arthroplasty at the carpometacarpal joint in an effort to mantain the height of the metacarpal. This is commonly done with flexor carpi radialis (FCR) or palmaris longus (PL) autograft. Recent studies have called into question the need for interpositional arthroplasty, suggesting that excision of the trapezium alone can provide non-inferior results.
Davis et. al. randomized 183 symptomatic trapeziometacarpal joints to one of three procedures: trapeziectomy alone, trapeziectomy with palmaris longus interpositional arthroplasty, or trapeziectomy with FCR interpositional arthroplasty and reconstruction of the palmar oblique ligament. For all patients, the thumb metacarpal was percutaneously pinned to the distal pole of the scaphoid to maintain the height of the digit. Patients were evaluated at three and 12 months post-operatively. At both time-points, they found no difference between groups with respect to subjective accounts of pain, function, stiffness, and weakness. Objective measures of thumb key-pinch strength were no different at either time point. The authors concluded that there may be no benefit to ligament reconstruction or tendon interposition in
the short term.
Li et. al. performed a systematic review of four randomized controlled trials and two systematic reviews to evaluate outcomes of trapeziectomy with and without LRTI for treatment of basal joint osteoarthritis. In their review, there were no statistically significant differences in post-op grip strength, pinch strength, visual analog pain scores, DASH scores, and complications. The authors concluded that both procedures produced similar clinical results.
Raven et. al. performed a retrospective analysis of 54 patients who underwent one of three procedures for basal joint osteoarthritis: resection arthroplasty, trapeziectomy with tendon interposition, or trapeziometacarpal arthrodesis.
The authors found resection arthroplasty to be a simple procedure with longterm results pain and functional outcomes comparable to trapeziectomy with tendon interposition.
Naram et. al. retrospectively reviewed 200 patients who underwent simple trapeziectomy with or without LRTI and with or without Kirschner wire stabilization, or a Weilby ligament reconstruction. They found that patients undergoing trapeziectomy with LRTI or a Weilby procedure had a greater incidence of complications compared to trapeziectomy alone, including infection and reoperation.
Figure A is a plain radiograph demonstrating pantrapezial arthritis with the thumb trapeziometacarpal joint being most significantly affected.
Incorrect Answers:
A 31-year-old patient has had a left medial elbow mass for 1 month. The mass has been increasing in size and has now become very painful and erythematous. MRI scans are shown in Figures 76a and 76b. Laboratory studies show an erythrocyte sedimentation rate of 49 mm/h (normal 0 to 20 mm/h) and C-reactive protein level of 23 mg/L (normal 0 to 0.3 mg/L). Histology showed lymphoid tissue and multiple necrotizing granulomas. What organism is responsible for this clinical picture?

Borrelia burgdorferi
Trichophyton tonsurans
Bartonella henselae
Mycobacterium avium
Corynebacterium minutissimum
Cat scratch disease (CSD) is an important diagnosis for the orthopaedic surgeon to consider in the differential diagnosis of soft-tissue masses adjacent to epitrochlear or cervical lymph nodes. It is a soft-tissue tumor simulator and a high index of suspicion is necessary in all patients with upper extremity or head and neck adenopathy and a history of cat exposure. Although generally not required for diagnosis, cross-sectional imaging will reveal a mass with surrounding edema in an area of lymphatic drainage. A peripheral blood sample can be tested for Bartonella henselae - the offending organism with this diagnosis. Classically the histology of these lesions when biopsied will show multiple necrotizing granulomas. Mycobacterium avium is the only other organism that would demonstrate a granulomatous reaction and the location is classic for CSD. Borrelia burgdorferi is associated with Lyme disease.
Mycobacterium avium may be a source of immunocompromised infections in HIV patients. Trichophyton tonsurans and corynebacterium minutissimum are not associated with orthopaedic diseases.
A 45-year-old woman has a painful mass in the dorsum of the right wrist. It is firm and nontender to palpation. She states it has slowly gotten bigger over the past 3 years. You suspect a dorsal wrist ganglion. What is the most definitive way to confirm this diagnosis?
Observe it for 1 year to see if it changes dramatically in size.
Obtain a gadolinium enhanced MRI scan.
Obtain radiographs, looking for scapholunate joint degenerative changes.
Perform a needle aspiration and send the aspirate for cytologic examination.
Apply direct firm manual pressure over the mass to see if it can be ruptured.
Dorsal wrist ganglions are synovial cysts that arise most frequently from the scapholunate joint. They often extend between the extensor digitorum communis and extensor pollicis longus tendons at the wrist. Aspiration of the cyst is both oncologically safe if done appropriately and also the easiest way to definitively confirm the diagnosis. Clear, yellow viscous fluid/gel is most often aspirated. Cytologic evaluation is mandatory to exclude myxoid neoplasms.
Because the lesion has been present for 3 years, further observation is not warranted. The classic presentation, physical examination findings, and location make MRI and radiographs unnecessary. Manual rupture of the mass is not recommended.
A 28-year-old man fell while ice skating 6 months ago and has had ulnar-sided wrist pain ever since. The patient's wrist radiograph is shown in Figure A and a CT scan is shown in Figure B. What is the most appropriate treatment?

Scapholunate ligament repair
Excision of the hook hamate
Excision of the pisiform
Open reduction internal fixation of the hamate
Open reduction internal fixation of the pisiform
Based on clinical history and imaging shown, this patient has developed a pisiform fracture nonunion. Treatment of symptomatic nonunions of the pisiform is by pisiformectomy
Fractures of the pisiform are rare. They often occur in conjunction with injuries to the distal radius or carpus. Non-operative management with cast immobilization in 30 degrees of wrist flexion is the first line of treatment.
Symptomatic nonunions are treated with pisiformectomy.
Palmieri et al. performed pisiformectomies on 21 patients who had pisiform area pain that was refractory to conservative management. Patients had a history of painful union or nonunion of pisiform fractures, arthritis or FCU tendonitis. In all cases, wrist strength and mobility was retained.
Lam et al. reviewed the effect of pisiform excision on wrist function in patients with piso-triquetral dysfunction. After an average follow up of 65 months, 75%
of patients had complete relief of pisiform area symptoms. No differences in grip, wrist motion, strength or power were found in comparison to the contralateral side.
Figure A shows an oblique radiograph of a pisiform fracture nonunion. Figure B shows an axial CT scan sequence of the wrist. A pisiform fracture nonunion is identified with subtle comminution. The pisotriquetral joint appears to be congruent.
Incorrect Answers
A 32-year-old woman jammed her ring finger. Figures 77a and 77b show radiographs of the finger after a closed reduction. Which of the following interventions, if done correctly, is likely to result in the best possible final clinical outcome?

Early removal of a splint and application of continuous passive motion
Application of dynamic extension bracing after the first week
Maintaining reduction of the middle phalanx on the condyles of the proximal phalanx with dynamic external fixation
Open reduction and anatomic restoration of the middle phalanx articular surface
Surgical advancement of the volar plate into the middle phalanx base
The most important determinant in the final clinical outcome in proximal interphalangeal (PIP) joint fracture locations is the maintenance of the PIP joint alignment on the lateral view. This can sometimes be done with just extension block splinting, sometimes the fracture requires dynamic external fixation, and sometimes the fracture requires open reduction or volar plate arthroplasty. Good function can be the result in the setting of an incongruent middle phalanx base as long as the PIP joint alignment is maintained.
Continuous passive motion has not been shown to be of benefit. Whereas dynamic external fixation in a flexed position is a very good treatment, dynamic extension bracing will just precipitate loss of PIP joint reduction and is therefore not indicated. Whereas open reduction of the articular surface is theoretically desirable, it is generally impossible in the setting of the comminution of the volar middle phalanx base. Furthermore, open reduction and internal fixation by itself does not guarantee that the PIP joint alignment will be maintained, and typically it causes finger stiffness given the extensive surgical approach. Likewise, volar plate arthroplasty is a surgery of last resort and requires careful attention to PIP joint alignment before joint pinning. In this case, with characteristics of comminution, dynamic external fixation is the preferred choice.
A 20-year-old woman sustained a laceration to her volar forearm 4 cm proximal to the wrist flexion crease. She has numbness in the thumb, index, and middle fingers. After microscopic repair of the median nerve, 2 weeks of splinting, and commencement of a hand therapy program, the patient is most likely to require what secondary operation 6 months after the injury?
Tenolysis of the profundus tendons at the wrist
Nerve transfer of the ulnar motor nerve to the median motor nerve
Opponensplasty with the extensor indicis
Open carpal tunnel release
Transfer of the extensor digiti minimi to the first dorsal interosseous tendon
The patient sustained a laceration of the median nerve in what would be considered a low median nerve injury. Standard treatment entails exploration and microscopic repair of the median nerve. With a good quality nerve repair in a young adult, return of some sensory function (albeit reduced compared with the normal nerve) is usual. Return of motor function to the thenar muscles is more unpredictable. If the patient begins a therapy program within a few weeks after nerve repair, it is unlikely that tenolysis of the profundus tendons would be required. An open carpal tunnel release would be unlikely to change functional return. The patient would not be expected to have lost first dorsal interosseous function after a median nerve laceration because this muscle is innervated by the ulnar nerve. A neurotization procedure for low median nerve palsy has been described, but it consists of transfer of the distal anterior interosseous nerve into the median nerve motor fascicles, not transfer of the ulnar nerve. Therefore, the most likely secondary procedure required in this scenario is an opponensplasty procedure to improve thumb opposition.
What is the most efficient pressure for use with negative pressure wound therapy?
25 mm Hg
75 mm Hg
125 mm Hg
300 mm Hg
500 mm Hg CORRECT ANSWER: 3
In animal and clinical studies, a range of pressures between 50 mm Hg to 500 mm Hg were tested; the most efficient pressure was 125 mm Hg, resulting in a fourfold increase in blood flow, 63% increase in granulation tissue with continuous pressure, and 103% increase in granulation tissue with intermittent pressure. When 125 mm Hg pressures were compared with either those less than 50, or those greater than 250, there was a decrease in granulation tissue in swine models.
Figures 125a and 125b are the current radiographs of a 52-year-old man who sustained an injury to his dominant wrist 8 weeks ago. He is an alcoholic and does not remember the details of how he injured it. Paperwork showing what treatment he received at an
urgent care facility indicates that he was given a splint for his "sprained wrist." Examination reveals the pain is getting better, but there is persistent swelling and range of motion is very limited.
Recommended treatment at this time should consist of

discontinuation of the splint and commencement of a regimen of hand therapy.
casting for an additional 2 weeks and reassessment of the fracture healing at that time.
open reduction and internal fixation of the injury.
proximal row carpectomy.
wrist arthrodesis.
The injury represents a very uncommon presentation of a perilunate injury pattern. Whereas these injuries are sometimes overlooked on initial radiographic studies, they are usually recognized much sooner. In this case of a late presenting perilunate injury in a patient that is not entirely responsible, a proximal row carpectomy represents the best treatment option. Open reduction and internal fixation is generally not successful because of cartilage degeneration and contracture that has developed in the interim. No further splinting or casting is indicated, and neglecting the injury would be indicated only if the patient refused any further treatment. Wrist arthrodesis is generally indicated only as a salvage procedure if a proximal row carpectomy is unsuccessful.
A 47-year-old woman sustained a nondisplaced distal radius fracture 6 months ago and is unable to extend her thumb. When performing reconstruction using the extensor indicis proprius to the extensor pollicis longus transfer, tension is ideally determined by securing the tendons in what manner?
In maximum tension with the wrist and thumb in extension
In maximum tension with the wrist and thumb in neutral
In maximum tension with the wrist and thumb in flexion
According to the tenodesis effect with wrist flexion and extension
According to functional testing with the patient awake under local anesthesia
Extensor pollicis longus rupture can result from distal radius fractures. Synergistic tendon transfer can be achieved using the extensor pollicis longus as the motor donor. Whereas different schemes for achieving optimal tension are available, the most reliable method is to tension the repair under local anesthesia while asking the patient to perform thumb flexion and extension. Tendon transfer tension can be adjusted accordingly to achieve maximum extension without compromising active flexion range. Other methods of tensioning are estimates at best, and maximum tensioning in patients without neuromuscular disease is rarely used in tendon transfers.
Which of the following substances is likely to cause the most soft-tissue damage in the long term if injected into a fingertip under
high pressure?
Grease
Latex paint
Water
Oil-based paint
Chlorofluorocarbon-based refrigerant
This type of injury represents a difficult problem in hand surgery. The factors that most determine outcome after high-pressure injection injuries into the fingertip include: involvement of the tendon sheath, extent of proximal spread of the injected substance, pressure setting, and delay to surgical treatment.
The other factor that likely is most important is the type of substance injected. Water and latex-based paints are least destructive. Grease and chlorofluorocarbon-based substances are intermediate, but aggressive surgical debridement can restore reasonable function. Oil-based paints are highly inflammatory and can cause such chronic inflammation such that amputation may be the only reasonable treatment option despite early aggressive surgical treatment.
A 37-year-old woman has right-hand numbness and tingling. Based on the history and examination, carpal tunnel syndrome is suspected, and electrodiagnostic tests also point to the same diagnosis. The patient has worn night splints for the last 8 weeks with continued persistent symptoms. What is the next most appropriate step in management?
Continue the night splinting for 1 additional month.
Continue the night splinting for 3 more months.
Switch to full-time splinting and reevaluate in 1 month.
Switch to full-time splinting for 3 more months.
Perform carpal tunnel release.
Various nonsurgical management options exist for carpal tunnel syndrome (local and oral steroids, splinting, and ultrasound). All effective or potentially effective nonsurgical forms of management have measureable effects on symptoms within 2 to 7 weeks of the initiation of treatment. If a treatment is not effective within that time frame, a different treatment option should be
chosen. In this case, continued splinting is unlikely to improve symptoms and steroid injection or surgery is indicated.
A 46-year-old man sustains an injury to his left index finger while cleaning his paint gun with paint thinner. Examination reveals a small puncture wound at the pulp. The finger is swollen. What is the next most appropriate step in management?
Elevation and observation
Surgical debridement and lavage
Infiltration with corticosteroids
Infiltration with a neutralizing agent
Administration of antibiotics
High-pressure injection injuries are associated with a high risk of amputation. The risk of amputation is highest with organic solvents. The presence of infection and the use of steroids do not impact the amputation rate.
Amputation risk is lower if surgical debridement is performed within 6 hours. Elevation and observation would delay necessary care. Neutralizing agents may be used in specific situations, such as hydrofluoric acid exposure or chemotherapeutic agent extravasation, but in high pressure paint thinner injection, the best outcome is achieved through early surgical lavage.
A 54-year-old woman who has a history of undergoing left trapezium excision with ligament reconstruction and tendon interposition using the entire flexor carpi radialis performed by another surgeon, now reports left basilar thumb pain. Examination reveals pain and subluxation of the carpometacarpal joint with axial loading. The metacarpophalangeal joint hyperextends to 60 degrees, but radiographs show intact joint space. What is the best option to improve function?
Bracing with a hand-based thumb spica splint
Pinning of the carpometacarpal joint
Pinning of the carpometacarpal and metacarpophalangeal joints
Carpometacarpal revision stabilization
Carpometacarpal revision stabilization and metacarpophalangeal joint fusion
The patient previously underwent ligament reconstruction and tendon interposition. However, the previous surgeon failed to address metacarpophalangeal joint hyperextension, which leads to adduction contracture and collapse of the basilar joint. With the basilar joint causing pain and instability, repeat ligament reconstruction should be performed. Splinting alone is unlikely to resolve instability problems. Because the flexor carpi radialis was used, the next option is to use the abductor pollicis longus.
Additionally, the severe metacarpophalangeal joint hyperextension should be corrected by fusion. Simple pinning is unlikely to provide long-term stability when this degree of hyperextension exists.
When evaluating a patient with suspected purulent flexor tenosynovitis in the thumb, the distal forearm and little finger are found to be swollen as well. The most likely anatomic explanation is the existence of a potential space in which of the following?
Through the carpal tunnel
Across the midpalmar space
Communicating with the subcutaneous tissue
Superficial to the distal antebrachial fascia
Between the fascia of the pronator quadratus and flexor digitorum profundus conjoined tendon sheaths
Pyogenic flexor tenosynovitis is an infection within the flexor tendon sheath that can involve the fingers or thumb. The tendon sheaths begin at the metacarpal neck level and extend to the distal interphalangeal joint. In the little finger and the thumb, the sheaths usually communicate with the ulnar and radial bursae, respectively. The potential space of communication, Parona's space, lies between the fascia of the pronator quadratus muscle and flexor digitorum profundus conjoined tendon sheaths. Infection tracking through this space presents as a horseshoe abscess.
Which of the following proximal phalanx fractures can most reliably be treated with a closed reduction and avoidance of surgical measures?
Midshaft transverse diaphyseal fracture with 30 degrees of angulation
Long spiral diaphyseal fracture with 15 degrees of malrotation
Open fracture with skin loss and exposed extensor tendon
Distal condylar intra-articular fracture with minimal displacement
Proximal metaphyseal fracture location with 30 degrees of dorsal tilting
Proximal phalanx fractures are very common, but care must be taken to understand which injuries are reliably treated with nonsurgical measures, and which ones are prone to clinically symptomatic malunion without surgical treatment. The proximal metaphyseal location is a problematic fracture to get reduced with closed measures, and due to the forces of the extensor apparatus, is prone to collapse into the original deformity. Imaging is also frequently difficult because of the overlap of the other fingers and frequently the true angulation is underappreciated. With 30 degrees of angulation, consideration should be given to surgical treatment. Long oblique/spiral fractures with malrotation are also most reliably treated with multiple lag screws, because maintaining the reduction with nonsurgical measures is unreliable, and can lead to significant functional problems in the form of crossover of the fingers with gripping. Open fractures with skin loss clearly are treated with surgical measures. Distal condylar fractures with minimal displacement are another fracture pattern that have a high rate of loss of reduction when treated nonsurgically. Like most articular fractures, they are best treated with anatomic reduction and rigid internal fixation. By comparison, closed midshaft transverse diaphyseal fractures can usually be anatomically reduced and held in this position with closed measures.
Figure 3 shows an arthroscopic view of the radiocarpal joint from the 3-4 portal, looking volarly and radially (Sc=scaphoid, R=Radius). What structure is marked by the asterisk?

Radioscaphocapitate ligament
Scapholunate ligament
Palmar oblique ligament
Dorsal intercarpal ligament
Triangular fibrocartilage complex (TFCC)
The radioscaphocapitate ligament is a volar capsular structure running obliquely from the radial styloid to the scaphoid waist, ultimately inserting on the proximal radial aspect of the capitate. The radioscaphocapitate ligament is important in preventing ulnar translocation of the carpus. The scapholunate ligament is located intra-articularly, between the scaphoid and lunate. The dorsal intercarpal ligament is a dorsal structure, and not visible during routine wrist arthroscopy. The palmar oblique ligament connects the first and second metacarpal bases. The TFCC is visible during wrist arthroscopy between the radius and ulna.
A 22-year-old man reports a 2-week history of a burning pain along the dorsoradial aspect of the distal forearm. The pain radiates to the dorsum of the thumb. Examination reveals tenderness and reproduction of symptoms with percussion 8 cm proximal to the radial styloid. Reproduction of symptoms also occurs with forearm pronation
and ulnar deviation of the wrist. No discrete sensory deficit is noted and electrodiagnostic studies are normal. Nonsurgical management consisting of rest, splinting, and anti-inflammatory medications for 6 weeks has failed to provide relief. Treatment should now consist of decompression of the
lateral antebrachial cutaneous nerve in the interval between the abductor pollicis longus and the extensor pollicis brevis in the forearm.
lateral antebrachial cutaneous nerve in the interval between the brachioradialis and the extensor carpi radialis longus in the distal forearm.
radial sensory nerve in the interval between the extensor carpi radialis longus and the extensor carpi radialis brevis in the distal forearm.
radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis longus in the distal forearm.
radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis brevis in the distal forearm.
Wartenberg's syndrome, or compression of the sensory branch of the radial nerve, occurs in the interval between the brachioradialis and the extensor carpi radialis longus approximately 8 cm proximal to the radial styloid. There may be history of repetitive wrist/forearm circumduction activity (ie, knitting) or of wearing a tight wristwatch or jewelry. It can occur in patients who have been handcuffed. Typical clinical findings are pain, paresthesia, and/or hypesthesia in the dorsoradial aspect of the wrist and hand in the distribution of the radial sensory nerve. There is often a positive Tinel's sign over the compression site. Hypesthesia may be present in the distribution of the radial sensory nerve which is typically on the dorsal aspect of the first dorsal web space and dorsum of the thumb; however, with overlap in the distribution of the superficial radial nerve and the lateral cutaneous nerve of the forearm this may not always be present. Surgical management consists of release of the nerve as it exits the interval between the brachioradialis and the extensor carpi radialis longus in the distal forearm.
A 55-year-old woman with rheumatoid arthritis reports that she awoke with an inability to flex the interphalangeal joint of her thumb. Figure 8 shows an intraoperative finding. What is the most appropriate surgical treatment?

Primary repair of the tendon
Tendon reconstruction with the palmaris longus tendon
Tendon reconstruction using a transfer of the flexor digitorum profundus (FDP) of the ring finger
Thumb metacarpophalangeal fusion
End-to-side repair of the flexor pollicis longus to the FDP of the index finger
The patient has sustained a chronic flexor pollicis longus rupture (Mannerfelt lesion). The injury is most likely a result of tendinopathy and attritional rupture of the tendon secondary to synovitis and bony osteophytosis at the scaphotrapeziotrapezoid joint. Because of the attritional injury and inherent tendinopathy, primary repair is unlikely to be successful. Among the options listed, tendon graft reconstruction with the palmaris longus tendon is the most appropriate treatment. Tendon reconstruction is possible with the flexor digitorum profundus of the index finger, not the flexor digitorum profundus of the ring finger. If osteophytes are encountered, these should be debrided.
Thumb interphalangeal fusion is an option, but metacarpophalangeal fusion is not beneficial. End-to-side repair of the flexor pollicis longus to the FDP of the index finger is not appropriate and would sacrifice needed function of the index finger.
Figures A and B show the initial radiographs of a 27-year-old snow boarder who fell backward onto his left outstretched hand. Which of the following most accurately describes the sequence of events that occurred during this injury?

Lunotriquetral ligament failure followed by distal row dissociation, scaphoid extension, scaphoid failure, and dorsal dislocation of the carpus
Volar dislocation of the lunate followed by scaphoid extension, scaphoid failure, lunotriquetral failure, and distal row dissociation
Dorsal intercarpal ligament failure followed by distal row dissociation, scaphoid failure, lunotriquetral ligament failure, and dorsal dislocation of the carpus
Short radiolunate ligament failure followed by volar dislocation of the lunate, lunotriquetral ligament failure, scaphoid failure, and distal row dissociation
Scaphoid extension followed by scaphoid failure, distal row dissociation, lunotriquetral ligament failure, and dorsal dislocation of the carpus
As described by Mayfield and associates, the typical sequence of events referred to as "progressive perilunar instability" that result in a volar
perilunate dislocation are as follows: scaphoid extension, followed by opening of the space of Poirer, scaphoid failure, and distal row dissociation, which in turn lead to hyperextension of the triquetrum, lunotriquetral ligament failure, and finally dorsal dislocation of the carpus. The lunate remains in the lunate fossa in a perilunate fracture-dislocation but is dislocated in a lunate dislocation. The short radiolunate and dorsal intercarpal ligaments typically remain intact.
Which of the following is the most consistently proposed tendon transfer for radial nerve palsy?
Pronator teres to extensor carpi radialis brevis
Brachioradialis to extensor carpi radialis brevis
Flexor carpi radialis to extensor digitorum communis
Palmaris longus to extensor pollicis longus
Flexor digitorum superficialis to abductor pollicis longus and extensor pollicis brevis
Whereas there are many variations of tendon transfers for radial nerve palsy, the most consistently proposed tendon transfer is the pronator teres to extensor carpi radialis brevis. The brachioradialis is innervated by the radial nerve so that is not an option. The flexor digitorum superficialis, flexor carpi radialis, and flexor carpi ulnaris are appropriate options to transfer to the extensor digitorum communis. The palmaris longus is not always present. A transfer to the abductor pollicis longus and extensor pollicis brevis may not be necessary if the extensor pollicis longus is rerouted to allow for abduction of the first ray.
A patient has severe cubital tunnel syndrome and marked wasting of the intrinsic muscles of the hand. Why is the little finger held in an abducted position?
Accessory slip of the extensor digiti minimi attaching to the abductor digiti minimi tendon
Tetanic contraction of the abductor digiti minimi
Radial collateral ligament insufficiency of the fifth metacarpophalangeal (MCP) joint
Unopposed pull of the flexor digitorum profundus
Muscle innervation from a Martin-Gruber anastomosis
A Wartenberg's sign, where the little finger is held in an abducted position, is associated with an ulnar nerve palsy. This happens when there is an accessory slip of the extensor digiti minimi, which is innervated by the radial nerve, crossing ulnar to the center of the MCP joint to attach to the tendon of the abductor digiti minimi and the proximal phalanx. The abductor digiti minimi and the volar interosseous muscles are both innervated by the ulnar nerve; therefore, there is no tetanic contraction of the abductor digiti minimi.
Unopposed pull of the flexor digitorum profundus results in excess flexion of the proximal interphalangeal and distal interphalangeal joints of the hand as seen with a clawing-type deformity. A Martin-Gruber anastomosis, which is a neural connection between the ulnar and median nerves in the forearm, cannot explain this finger position.
Figure 38 shows the radiograph of a 41-year-old man who reports ulnar palmar pain, decreased sensibility and tingling in the ring and little fingers, and a grating sensation in the ulnar fingers with motion. He reports that he sustained a fall on an outstretched hand 6 months ago. What is the most appropriate treatment option?

Ulnar gutter cast
Short arm cast
Carpal tunnel release
Decompression of Guyon's canal
Excision of a fractured hook of hamate
Excision of a fractured hook of hamate is the most appropriate management. The patient has a hook of hamate fracture with ulnar nerve compression and irritation of the flexor tendons by the fracture surfaces; this puts the tendons at risk for rupture. Cast treatment will most likely not gain union of the fracture and will not address the nerve or tendon problems. Decompression of Guyon's canal alone will not address the tendon issue.
A 25-year-old man was involved in an altercation. Examination reveals loss of active extension of the middle finger metacarpophalangeal (MCP) joint. A diagnosis of sagittal band rupture is made. Which of the following is considered the key diagnostic finding?
Extensor lag of 30 degrees
Extensor lag of 60 degrees
Positive Bunnell intrinsic tightness test
Ability to maintain active extension of the interphalangeal joints
Ability to maintain MCP extension after passive extension
In sagittal band rupture, the extensor tendon may subluxate into the valley between the metacarpal heads. The patient will not be able to actively extend the MCP joint from a flexed position with the subluxated tendon, but will be able to maintain MCP extension after it has been passively extended. Extensor lags can have other etiologies other than extensor digitorum communis subluxation such as tendon laceration or rupture, posterior interosseous nerve palsy, but in these conditions, patients cannot maintain MCP extension. Active interphalangeal extension can be achieved with the intrinsic muscles that are not affected by sagittal band rupture.
What is the effect of shortening of metacarpal fractures?
Causes the greatest degree of extensor lag in the index finger
Causes the greatest degree of extensor lag in the little finger
Results in an average extensor lag of 7 degrees for every 2 mm of shortening
Results in an average extensor lag of 14 degrees for every 2 mm of
shortening
Has no effect on grip strength
Cadaveric models have demonstrated a 7-degree extensor lag for every 2 mm of metacarpal shortening, with the amount of lag increasing in a linear fashion. There was no statistical difference in the amount of lag in regard to the digit involved. Based on muscle length-tension relationships, cadaveric models have also been used to demonstrate an 8% loss of power secondary to decreased interosseous force generation with 2 mm of shortening. Because the intrinsic muscles of the hand contribute anywhere from 40% to 90% of grip strength, decreased interosseous force generation secondary to metacarpal shortening will invariably cause a decrease in grip strength.
A 22-year-old motorcyclist sustains open fractures to the left radial shaft and second and third metacarpals with exposed extensor tendon and bone. The fractures are approached via the dorsal open wounds of the forearm and hand with no additional incisions made. The radiograph and clinical photograph of the remaining defect in the hand are shown in Figures 55a and 55b. The remaining wound can be most appropriately covered with which of the following?

Split-thickness skin grafting
Posterior interosseous rotational flap
Radial forearm rotational flap
Groin flap
Free lateral arm flap CORRECT ANSWER: 3
After adequate debridement, there is exposed bone, tendon, and hardware. Split-thickness skin grafting over exposed tendon will not have a viable bed to support the graft. The tendons would not have healthy surrounding tissue, resulting in poor tendon gliding. The dorsal wound has disrupted the posterior interosseous artery that runs in the septum between the extensor digiti minimi and the extensor carpi ulnaris. Following the reconstructive ladder, the radial forearm rotational flap accomplishes wound coverage with a local flap rather
than a groin flap (a distant flap) or a lateral arm flap (microvascular free tissue transfer).
What is the effect of performing a flexor tenosynovectomy with an open carpal tunnel release for idiopathic carpal tunnel syndrome?
Increased risk of nerve injury
Improved postoperative finger flexion
No added long-term clinical benefit versus open carpal tunnel release alone
Increased postoperative pain
Decreased recurrence of carpal tunnel syndrome
In patients with idiopathic carpal tunnel syndrome, flexor tenosynovectomy has not been shown to change the clinical outcome compared with open carpal tunnel release alone. This has been demonstrated in a randomized clinical trial of open carpal tunnel release with or without flexor tenosynovectomy. There has also been no evidence to suggest there is an added risk to performing the flexor tenosynovectomy. At time of surgery, the gross or histologic appearance of the flexor tenosynovium does not correlate with preoperative symptoms nor with clinical outcomes. The histology of the tenosynovium has been shown to be that of fibrosis in a setting of chronic inflammatory changes and no evidence of an acute inflammatory process exists. There may be an added role for flexor tenosynovectomy in non-idiopathic carpal tunnel syndrome such as in patients with renal disease or diabetes.
Figures 69a and 69b show the radiographs of a 62-year-old man with severe radially sided wrist pain. Management has consisted of wrist splinting, nonsteroidal anti-inflammatory drugs, and activity modification, but he continues to have pain and reports difficulty sleeping. What is the most appropriate treatment for this patient?

Arthroscopic debridement
Open reduction and internal fixation
Scaphoid nonvascularized bone graft and screw fixation
Scaphoid vascularized bone graft and screw fixation
Scaphoid excision and 4-corner fusion
Scaphoidectomy and 4-bone fusion is the most appropriate management based on the choices available. The patient has arthritic changes of SNAC (scaphoid nonunion advanced collapse) wrist, stage III. Stage I is at the radial styloid, stage II is at the radioscaphoid joint, and stage III is at the midcarpal joint. Arthroscopic debridement is not appropriate in patients with arthrosis.
Attempting to achieve scaphoid union is only appropriate if there is no arthrosis or the changes are classified as stage I where radial styloidectomy can be performed.
A 7-year-old boy is referred to your office 3 months after jamming his finger while playing basketball. Examination reveals 40 degrees of active and passive motion at the proximal interphalangeal (PIP) joint. The PIP joint is stable to radial and ulnar stressing. Radiographs are shown in Figures 76a and 76b. What is the most appropriate management?

Observation
Corrective osteotomy
Ostectomy
Hand therapy for aggressive stretching
Dynamic splinting CORRECT ANSWER: 3
The most appropriate management is an ostectomy, or resection of the bone in the subcondylar fossa region. This is a malunion where the subcondylar fossa is blocked by malaligned bone. Because it is a bony block to motion, stretching or dynamic splinting will be of no benefit. The physis of the proximal phalanx is proximal, making remodeling of a fracture at the distal end very
unlikely. A corrective osteotomy has a risk of osteonecrosis of the very small distal fragment.
Figure 78 shows the clinical photograph of a patient who injured his finger while playing football. He cannot actively flex the distal interphalangeal joint of the ring finger. Which of the following is the most accurate statement regarding the injury shown?

The tendon is attached to the avulsed fragment from the distal phalanx.
There is no difference in time sensitivity in an acute injury whether or not the tendon has retracted into the palm.
In a chronic (> 3 months) case of flexor digitorum profundus (FDP) avulsion, the FDP should be tenodesed to the flexor digitorum sublimis (FDS).
If the FDP is advanced more than 1.5 cm, there is a risk for quadriga effect.
The method of repair does not affect repair gapping or strength of the tendon repair.
Overadvancement of the FDP tendon is one of the causes of the quadriga effect. Relative shortening of an FDP tendon decreases the excursion of the neighboring FDP tendons because they originate from a common muscle belly. The patient reports a weak grasp. Answer 1 is not correct because there can be a fracture and the tendon can avulse off of the fracture fragment (Trumble JHS-A 1992). Whether the tendon has retracted into the palm or not does matter because retraction into the palm allows pulleys to collapse and contract and it also means that the vinculae have been stripped off of the tendon.
Regarding answer 3, in chronic cases where the FDS is intact and strong, many patients may be better off with a sublimis finger and no FDP reconstruction that could, in the worst case scenario, worsen a functional proximal interphalangeal joint. Regarding the repair method, there is recent
research showing method of repair (button vs anchor), suture type, and method do affect the biomechanical properties of the repair.
A 44-year-old woman with cubital tunnel syndrome and associated ulnar nerve subluxation with elbow flexion has failed to respond to nonsurgical management. Which of the following statements is most acccurate regarding in situ simple decompression of the nerve compared with subcutaneous anterior transposition?
Patients undergoing anterior transposition have improved motor outcomes.
Patients undergoing anterior transposition have improved sensory outcomes
Patients undergoing simple decompression have improved motor outcomes.
Patients undergoing simple decompression have improved sensory outcomes.
No differences in outcome are likely between treatment types.
Recent reports comparing outcomes of surgical treatment of ulnar nerve compression at the elbow have demonstrated no differences in outcome between simple decompression and anterior transposition. The presence of subluxation of the ulnar nerve was not a contraindication to in situ decompression in the study by Keiner and associates.
What anatomic structure must be excised when performing a volar plate arthroplasty of the proximal interphalangeal joint?
Central slip
Collateral ligament
Checkrein ligament
Triangular ligament
Flexor digitorum superficialis insertion
The collateral ligament must be excised or released from the proximal phalanx to allow gliding of the middle phalanx on the articular surface of the proximal phalanx. Failure to do so may prevent this gliding motion and make the middle phalanx just hinge on the proximal phalanx.
Figures 97a and 97b show a clinical photograph and radiograph of a patient who has a history of repeated drainage from the lesion. What is the preferred surgical treatment?

Excision of the lesion alone
Removal of the osteophyte alone
Distal interphalangeal joint fusion
Excision of the mass and osteophyte removal
Removal of the mass and skin with skin grafting
The patient has a mucoid cyst. Whereas many of these lesions are associated with osteoarthritis, the best surgical treatment of the lesions in patients who have little or no pain is typically excision of the mass with osteophyte removal. Studies have shown that osteophyte excision helps minimize the risk of recurrence. Distal interphalangeal joint fusion is reserved for patients with pain and more advanced radiographic arthritis. Excision of the lesion alone is a less favorable option than excision of the mass and osteophyte removal. The lesion is independent of the skin and thus, skin removal with the mass is unnecessary.
Which of the following structures cannot be seen during standard radiocarpal arthroscopy?
Scapholunate ligament
Lunotriquetral ligament
Radioscaphocapitate ligament
Extensor carpi ulnaris tendon
Superficial insertion of the triangular fibrocartilage complex (TFCC)
The extensor carpi ulnaris tendon is located in an extra-articular position, and as such, cannot be seen during arthroscopy. Wrist arthroscopy is a useful technique for evaluation and treatment of radiocarpal and midcarpal maladies. During standard radiocarpal arthroscopy, the scapholunate and lunotriquetral ligaments can be easily visualized. The superficial TFCC is seen overlying the ulnar head. Volarly, the radioscaphocapitate ligament can be seen as a discrete band of the capsule.
A 20-year-old skateboarder fell 6 months ago and has had radial-sided wrist pain since. His radiograph upon presentation to your office is shown in figure A. What is the most appropriate treatment at this time?

four corner fusion
long arm thumb spica cast
wrist arthroscopy to evaluate intercarpal ligaments
open reduction internal fixation with autologous bone graft
wrist arthrodesis CORRECT ANSWER: 4
This patient has a scaphoid waist fracture nonunion. Several studies indicate that scaphoid nonunions left untreated have a determined course of collapse and progressive arthritis (scaphoid nonunion advanced collapse - SNAC). Per Markiewitz et al, the standard treatment of scaphoid nonunions is open reduction internal fixation with bone graft; non-operative treatment is not appropriate. Proximal row carpectomy and wrist fusion are salvage procedures reserved for patient that has an advanced scaphoid nonunion, collapse and wrist arthritis.
Figures 112a and 112b show the radiographs of a 28-year-old motorcyclist who sustained a closed hand injury in a collision. What is
the most appropriate definitive treatment?

Closed reduction and a hand/forearm cast in the intrinsic plus position
Closed reduction and a hand splint
Primary fusion of the carpometacarpal joints
Closed versus open reduction and internal fixation
Closed reduction and external fixation
Closed versus open reduction and internal fixation is the most appropriate treatment. The radiographs show fracture-dislocations of all five carpometacarpal joints. These injuries are extremely unstable and not amenable to closed (splint or cast) treatment only. External fixation may be warranted in an open, contaminated injury. Fusion would be an option if this were a chronic, painful condition on presentation.
What additional procedure should be done when performing a radioscapholunate fusion for posttraumatic arthrosis following a distal radius fracture?
Excision of the triquetrum and distal pole of the scaphoid
Anterior interosseous neurectomy
Fascial interposition arthroplasty of the capitolunate joint
Sectioning of the dorsal intercarpal ligament
Ulnar shortening osteotomy
Excision of the triquetrum and distal pole of the scaphoid frees up the midcarpal joint, improving radial deviation and the flexion-extension arc of motion of the wrist. This offers an alternative to complete wrist arthrodesis for posttraumatic arthrosis of the radiocarpal joint. An anterior interosseous neurectomy is believed to decrease some pain transmission from the wrist but because the fusion is done dorsal, cutting this volar structure is not routinely done. Fascial interposition is not needed because the capitolunate should be preserved in posttraumatic radiocarpal arthrosis. Sectioning of the dorsal intercarpal ligament would provide no benefit. If the triquetrum is excised, then an ulnar shortening osteotomy is unnecessary.
Apert's syndrome is caused by a mutation in what gene?
Fibroblast growth factor receptor 2 (FGFR2)
Fibroblast growth factor receptor 3 (FGFR3)
Collagen type II alpha 1 chain (COL2A1)
SED late (SEDL)
Fibrillin
Apert's syndrome (acrocephalosyndactyly type 1) is characterized by anomalies of the cranium, hands, and feet. Mutations in the FGFR2 gene cause Apert syndrome.
Anderson et al report that in Apert's syndrome there is widespread anomalies of the feet, with defects including both predictable dysmorphic changes and progressive fusions of the skeletal components during skeletal maturity.
Incorrect Answers:
2: Achondroplasia is related to abnormalities in the FGFR3, not FGFR2.
3: SED congenita is caused by mutations in COL2A1 (type II collagen alpha 1 chain) on chromosome 12. These result in abnormal type II collagen.
4:The X-linked form of SED tarda is caused by mutation in SEDL (SED late)
gene.
5: Marfan syndrome is caused by defects in the fibrillin gene.
What is the most important measure to take to reduce the risk of frostbite of the toes while hiking in extreme temperatures?
Stop often for recovery breaks.
Drink enough warm liquids.
Reduce thermal heat loss from shoes.
Use triple socks.
Adequately "carbo load" before the start.
Several studies showed the most reliable method to reduce the risk of cold exposure injury is to reduce thermal heat loss. This can be done with a combination of protective socks and shoes, and reducing moisture in the shoes.
Figures 45a through 45e are the MRI scans, gross specimen, and histology of the specimen of a 19-year-old man who has an enlarging mass in the second interspace. He reports forefoot pain that is worse with athletic activity. Radiographs show erosive changes of the third metatarsal head. What is the most common complication associated with incomplete excision?

Metastatic disease
Malignant degeneration
Recurrence
Pathologic fracture
Infection
Giant cell tumor of the tendon sheath often arises from the synovial lining of tendon sheaths. This lesion is frequently found in the hand and foot. The lesion is slow growing and can invade adjacent structures. In the foot, wearing shoes or increased activity can cause pain. Incomplete or piecemeal excision can lead to recurrence.
A 42-year-old construction worker presents with pain in his right wrist. A current radiograph of the wrist is shown in Figure A. He reports that rotating activities, such as turning a screw driver, are bothersome and the pain is preventing him from working. A current MRI reveals a TFCC tear, and nonsurgical treatment has failed to provide relief. Treatment should now consist of:

Repair of the ulnar styloid nonunion
Darrach resection of the distal ulna
Complete ulnar head resection
Ulnar hemiresection arthroplasty and TFCC reconstruction/repair
Isolated arthroscopic TFCC reconstruction
The clinical presentation is consistent with DRUJ arthritis in a heavy laborer. Of the options listed, ulnar hemiresection arthroplasty with concurrent TFCC reconstruction or repair would be the most appropriate treatment.
While there are multiple treatment options, the ulnar hemiresection arthroplasty with concurrent TFCC reconstruction or repair is considered most appropriate in heavy laborers, as it would likely resolve the pain and enable them to return to work sooner. The TFCC should be intact when performing an ulnar hemiresection arthroplasty to prevent distal ulna instability with forearm rotation. One could also consider performing a Suave-Kapandji procedure. This procedure creates a distal radioulnar fusion and an ulnar pseudarthrosis proximal to the fusion site through which rotation can occur. The advantage is that the ulnocarpal joint is not sacrificed, and a stable wrist is created.
Scheker et al reported on the outcome of ulnar shortening performed on 32 wrists with early osteoarthritis of the DRUJ. The postoperative wrist ratings were 7/32 excellent, 11/32 good, 9/32 fair, 5/32 poor, with plate irritation being the most frequent postoperative complication.
Figure A is a radiograph showing significant DRUJ arthritis. Illustration A shows ulnar hemiresection arthroplasty. Illustration B shows a Darrach procedure.
Illustration C shows a Sauve-Kapandji procedure. Illustration D is a treatment schematic of TFCC reconstruction.
Incorrect Answers:

Figures 113a and 113b are the radiographs of a 7-year-old girl who was evaluated for a visible elbow deformity by a foster parent. She thought the child fell, but her history was vague. On physical examination, a large prominence was seen over the posterolateral elbow, and the girl lacks the terminal 20 degrees of elbow extension. She has 75 degrees of elbow pronation and supination. She was nontender on examination. What is the most appropriate next treatment step?

Child abuse workup
Closed reduction
Open reduction with possible osteotomy
Observation CORRECT ANSWER: 4
The most appropriate management of this condition is observation. The patient most likely has a congenital dislocation of the radial head, although this may also represent a posttraumatic deformity. The absence of findings on physical examination speaks against an acute injury. The appearance of the radial head reveals the typical findings of a congenital dislocation, namely the convex appearance of the proximal radial articular surface. These children typically have very functional range of motion and do not require treatment unless they are symptomatic. There is nothing in this child's history to suggest abuse.
The most common mechanism of injury to the triangular fibrocartilage complex (TFCC) involves
wrist extension and forearm pronation.
wrist extension and forearm supination.
wrist flexion and forearm pronation.
wrist flexion and forearm supination.
axial load in ulnar deviation.
TFCC tears are common in athletes. As the athlete braces for a fall, the wrist is most commonly in an extended position and the forearm is pronated.
A 28-year-old woman fell on her right wrist while rollerblading 6 days ago. She was seen in the emergency department at the time of injury and was told she had a sprain. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. Standard wrist radiographs are normal. What is the next most appropriate step in management?
Arthroscopy of the wrist
CT of the wrist
Bilateral PA clenched fist radiograph
Electromyography and nerve conduction velocity studies
AP and lateral radiographs of the forearm
When considering the diagnosis of scapholunate ligament injury, standard radiographic views of the hand will not always reveal widening of the scapholunate gap. Although MRI may reveal injury to the ligaments, the PA clenched fist view can be obtained in the office during the initial patient visit. Arthroscopy is not a first-line diagnostic tool.
Figures 12a through 12c show the radiographs of a 28-year-old professional baseball player who has ulnar-sided wrist pain and
numbness and tingling in the fourth and fifth digits for the past 6 weeks. Management should consist of

cast immobilization.
bone stimulation and splinting.
ulnar nerve exploration.
open reduction and internal fixation.
excision of the fragment.
Hook of the hamate fractures typically occur as a result of direct force from swinging a bat, golf club, or racket. Pain is localized to the hypothenar eminence. The injury is best seen on a carpal tunnel view. CT will confirm the diagnosis. Chronic cases can be associated with neuropathy of the ulnar nerve. Excision of the hook through the fracture site usually yields satisfactory results, allowing the athlete to return to competition.
A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. A radiograph is shown in Figure 21. Management should consist of

immobilization in a short arm thumb spica cast.
immobilization in a long arm thumb spica cast.
arthroscopic repair and percutaneous pinning.
open repair and percutaneous pinning.
dorsal capsulodesis.
The radiograph reveals an increased distance between the scaphoid and the lunate, which is indicative of scapholunate disassociation. A ring sign is also present, which represents the distal pole of the scaphoid viewed end on in a palmarly flexed position. In the acute setting, the scapholunate can be repaired. Open repair and percutaneous pinning is the treatment of choice. Dorsal capsulodesis is performed in the chronic setting if such an injury is initially missed.
An 18-year-old rugby player has had pain in his ring finger after missing a tackle 1 week ago. Examination reveals tenderness in the distal palm, and he is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs are normal. What is the most appropriate management?
Acute tendon repair
DIP joint extension splinting for 6 weeks
DIP and proximal interphalangeal joint extension splinting for 6 weeks
Buddy taping to the middle finger for 2 weeks
Early range-of-motion exercises and return to play as pain permits
Flexor digitorum profundus rupture or “rugger jersey finger” often occurs in the ring finger after the player misses a tackle and catches the digit on the shirt of the opposing player. Surgical repair is required for zone I-type injuries.
A 65-year-old right-hand-dominant man has a 5 year history of progressive right wrist pain. He relates spraining his wrist playing football in college, but otherwise has had no prior traumatic injury. He is a pack per day smoker. An AP radiograph of the wrist is shown in Figure A. Wrist immobilization, anti-inflammatory medications, and injections have failed to provide relief. Which appropriate surgical treatment option offers the lowest risk of postoperative complications?

Radial styloidectomy
Total wrist arthroplasty
Proximal row carpectomy
Scaphoid excision with four-corner fusion
Complete radiocarpal arthrodesis
Proximal row carpectomy (PRC) and scaphoid excision with four-corner fusion are both appropriate surgical treatment options for stage II scapholunate advanced collapse (SLAC) wrist; however PRC is associated with fewer postoperative complications, particularly in active smokers.
Scapholunate interosseous ligament disruption leads to abnormal wrist biomechanics and degenerative arthritis. This progression follows a predictable pattern termed scapholunate advanced collapse. In stage II disease where the entire radioscaphoid articulation is affected but the capitolunate articulation is spared, both proximal row carpectomy (PRC) and scaphoid excision with four-corner fusion offer long-term pain relief while preserving wrist motion and grip strength. Scaphoid excision with four-corner fusion has a higher rate of complications owing to nonunion, hardware issues, and dorsal impingement from malunion. PRC is not recommended in the setting of capitolunate arthritis (stage III).
Tomaino, et al. retrospectively compared PRC and limited intercarpal arthrodesis with scaphoid excision (LWF) at a mean of 5.5 years postoperatively in 24 symptomatic SLAC wrists. They noted good pain relief, grip strength, and function in all but 3 patients having undergone PRC - one of whom required revision to wrist arthrodesis (these patients had symptomatic capitate arthrosis). They concluded that in wrists without capitolunate arthritis, PRC had the benefit of being technically easier to perform, did not require prolonged postoperative immobilization, and avoided the risk of nonunion associated with LWF; however it was not an appropriate surgical option in stage III SLAC wrists with capitolunate involvement.
Strauch reviewed the evaluation and treatment of SLAC and SNAC (scaphoid nonunion advanced collapse) wrists. Treatment options for SLAC wrist include four-corner fusion, capitolunate arthrodesis, PRC, radial styloidectomy, wrist denervation, and complete radiocarpal fusion. Excision of the distal ununited scaphoid fragment is an additional option in the setting of SNAC wrist. He additionally highlights current controversies between PRC vs. four-corner fusion.
Figure A shows an AP radiograph with stage II SLAC wrist. The entire radioscaphoid articulation is arthritic with sparing of the capitolunate surface.
Illustration A shows the modified Watson classification of scapholunate advanced collapse.
Incorrect Answers:

A 25-year-old male presents to the clinic with a painful, enlarging mass at the volar radial wrist. He initially noticed the mass 6 months ago after he hurt his wrist golfing. Figure A shows a clinical photograph of the patient's wrist. Radiographs are unremarkable. An ultrasound of the mass is shown in Figure B. Surgical excision is planned. Which of the following is the most appropriate type of resection and histologic finding?

Intralesional excision; synovial cells with mucin accumulation
Incision & drainage; polymorphonuclear cells
Wide excision; histiocytes with frequent giant cells
Marginal excision; synovial cells with mucin accumulation
Intralesional excision; histiocytes with frequent giant cells
The patient presents with a volar wrist ganglion cyst. Surgical treatment consists of marginal excision. Histologic analysis demonstrates synovial cells with mucin accumulation.
Ganglion cysts are the most commonly presenting masses in the hand. These cysts consist of a synovial cell lining filled with mucin. Dorsal wrist ganglion cysts originate from the scapholunate interval and are more common than volar wrist ganglions, which typically originate from the scapho-trapezio-
trapezoidal joint articulation. Ganglion cysts can cause pain related to mass effect. Ultrasound can help differentiate these masses from vascular malformations or other tumors; ganglion cysts present as homogenous anechoic masses with well-defined borders.
Mayerson, et al. reviewed the diagnosis and management of soft-tissue masses. They highlight the typical presentation of ganglion cysts, which wax and wane in size and transilluminate with a pen light. The authors concluded that MRI is diagnostic if there remains any uncertainly after history and clinical exam.
Head et al compared surgical excision versus needle aspiration of 2,239 adult wrist ganglions in a meta-analysis of 35 studies. Surgical excision resulted in a 76% reduction in recurrence compared to aspiration. Mean recurrence for arthroscopic excision (6%), open surgical excision (21%) and aspiration (59%) and mean complication rate for arthroscopic excision (4%) open surgical excision (14%) and aspiration (3%) were also determined. Data from arthroscopic excision was limited but is a promising technique. Open surgical excision has a significantly lower recurrence rate as compared to aspiration.
Figure A shows a clinical photo of a volar wrist ganglion cyst. Figure B shows the ultrasound image of a volar wrist ganglion cyst.
Incorrect Answers:

A 27-year-old man falls on his hand at work. He notices an immediate deformity of his ring finger. Radiographs are provided in Figure A. Which of the following is the most appropriate initial treatment?

Closed reduction, buddy taping, and early motion to prevent stiffness
Closed reduction and full time extension splinting
Open reduction and repair of the central slip of the extensor tendon
Open reduction and repair of the volar plate
Amputation and immediate return to work
The radiograph demonstrates a volar PIP dislocation. The central slip of the extensor tendon is frequently ruptured and will lead to a boutonneire deformity if left untreated. The PIP must be immobilized in extension to allow the extensor mechanism to heal. Immobilization in extension should be maintained for 6 weeks to allow soft tissue healing. Open reduction and repair of the central slip would be the appropriate treatment for a developing boutonneire deformity that presents in a subacute or chronic time basis.
Illustrations A and B demonstrate a schematic and clinical photo of central slip disruption and secondary deformity with PIP flexion and DIP hyperextension (Boutonniere Deformity).
Posner et al reviewed 7 patients with chronic palmar dislocations of the PIP joint who were treated with open reduction and reconstruction of the extensor mechanism. All patients acheived satisfactory range of motion and the authors concluded that this technique is preferable to arthrodesis.
Peimer et al reviewed 15 patients with palmar dislocations of the PIP joint. Twelve of the fifteen were evaluated on a delayed basis (average 11 weeks following injury) and underwent open reduction and surgical repair of the extensor tendon. Three of the fifteen were seen earlier following injury and were treated with closed reduction and pinning. All fifteen patients acheived satisfactory clinical outcomes although finger range of motion was not fully recovered in any case.

Figure A is of a 22-year-old male college basketball player presents for evaluation of a right index finger deformity. He reports a fall during a game 8 weeks ago, with resultant deformity to the index finger. He "popped it back in" and returned to play. Physical exam is most likely to demonstrate:

Inability to passively extend the PIP joint to neutral, able to passively flex and extend the DIP joint
With the PIPJ flexed, resistance to PIPJ extension causes the DIPJ to become supple
Dorsal subluxation of the PIP joint, able to passively flex and extend DIP joint
With the PIPJ flexed, resistance to PIPJ extension causes the DIPJ to become rigid
Inability to actively flex the DIP joint, able to actively flex the PIP and the MCP joints
The patient presents with a Boutonniere deformity secondary to a traumatic central slip disruption in the setting of volar PIP joint dislocation. Physical exam will demonstrate a positive Elson's test, which is described in answer 4.
The digital extensor mechanism consists of the central slip and two lateral bands, all of which arise from the extensor digitorum communis (EDC) tendon. Flexion of the PIP joint puts the central slip on tension, and volarly subluxes the lateral bands causing them to become slack. Tension on the central slip causes extension of the PIP joint, with concomitant dorsal shift of the lateral bands which help to bring the DIP joint into extension.
In 1986, Elson described his physical examination maneuver for diagnosis closed rupture of the central slip. With the hand resting on the edge of a table, the PIP joint is flexed to 90 degrees over the table edge, and the patient is asked to extend the digit against resistance. Active extension of the middle phalanx can only be observed with an intact central slip, and the adjacent lateral bands will remain slack which allows the DIP joint to remain flail. In central slip ruptures, effort to extend the middle phalanx will be accompanied
by DIP rigidity/extension as the lateral bands are forced to contribute to extension.
Rubin et. al. performed a cadaveric study evaluating the efficacy of physical examination maneuvers to identify acute ruptures of the central slip. They
found that Elson’s test was the only maneuver that could discern central slip integrity in both tested scenarios: 1) pre-boutonniere deformity with division of the central slip and 2) passively correctible boutonniere deformity caused by division of the central slip, the triangular ligament, and the oblique fibers of the extensor expansion.
Figure A is a clinical image of an index finger with boutonniere deformity. Video A is a short demonstration of how to perform the Elson test.
Incorrect answers:
A 25-year-old woman presents to the clinic after knife injury to the volar aspect of her long finger 2 weeks ago. She is evaluated and diagnosed with tendon rupture of the flexor digitorum profundus (FDP). What finding on examination can be expected in this patient?
With passive wrist extension, extension remains at the distal interphalangeal joint
With passive wrist extension, extension remains at the proximal interphalangeal joint
With passive wrist flexion, extension is limited at the distal interphalangeal joint
With passive wrist flexion, flexion remains at the distal interphalangeal joint
With passive wrist flexion, flexion remains at the proximal interphalangeal joint
With an FDP rupture, physical exam would likely reveal loss of flexion at the DIP joint both actively and passively with wrist extension.
When the wrist is in extension, flexor tendons are stretched and should result in flexion at the DIP (FDP) and PIP (FDS) joints. The FDP tendon is responsible for flexion of the DIP joint, and this joint would remain extended during normal tenodesis on passive wrist exam. Inversely, with extensor tendon injuries, there may be a loss of digit extension with passive wrist flexion.
Strickland presents a review article (Part 1) on flexor tendon injuries discussing clinical presentation and repair techniques. A commonly tested concept is that tendon repair is proportional to the number of core sutures, and currently recommended repair includes at least 4 core sutures for strength with epitendinous suture to aid in gliding and provide some strength.
Kamal et al. present current evidence regarding flexor tendon injuries, reviewing examination, repair, and rehab. They note that to date there still remains heterogeneity in treatment patterns and no clear standard of care. Rehab options include no motion, early active range of motion, and controlled passive range of motion. The authors note that early loading may lead to improved strength.
Illustration A depicts the usual tenodesis effect of the digits where passive extension of the wrist produces flexion of the fingers.
Incorrect Answers:

A 20-year-old college football lineman sustains an injury to his index finger during a game. A radiograph of the hand is demonstrated in Figure A. What is the mechanism of injury and most common reason for unsuccessful closed reduction?

Hyperextension mechanism causes the metacarpal head to button hole between the flexor tendon and the lumbrical
Hyperextension mechanism causes volar plate avulsion and entrapment dorsal to the metacarpal head
Rotational mechanism causes the metacarpal head to button hole between the flexor tendon and the lumbrical
Hyperflexion mechanism causes volar plate avulsion and entrapment dorsal to the metacarpal head
Hyperflexion mechanism causes the metacarpal head to button hole between the flexor tendon and the lumbrical
Irreducible dorsal metacarpophalangeal (MP) joint dislocations occur from a hyperextension moment, which causes volar plate displacement and incarceration dorsal to the metacarpal head.
MP joint dislocations are most commonly dorsal and occur with hyperextension injuries. Simple dislocations are reducible with wrist flexion (to relax the intrinsic muscles) and direct palpation over the proximal phalanx base.
Complex dislocations occur with interposition of the volar plate. When irreducible, open reduction is required.
Afifi et al. performed a cadaver study defining the anatomy surrounding irreducible dorsal index MP joint dislocations. They found that of all local structures, only release of the volar plate allowed for reduction of the MP joint. They concluded that volar plate interposition dorsal to the metacarpal head was responsible for irreducible MP joint dislocations.
Bohart et al. describe 9 patients with irreducible dorsal MP joint dislocations (5 thumbs and 4 index fingers). A dorsal approach was performed in each case to allow for reduction of the volar plate. A stable MP joint was achieved in each case. They advocate for a dorsal approach, which minimizes the risk of iatrogenic injury to the neurovascular bundles, which are displaced volarly by the metacarpal head.
Figure A shows an oblique radiograph of the hand demonstrating a dorsal dislocation of the index MP joint. Illustration A provides a schematic of both a simple and a complex dorsal MP joint dislocation. In the case of a complex dislocation, the volar plate avulses from its origin and becomes entrapped dorsal to the metacarpal head.
Incorrect Responses:

A 3-year-old patient presents to clinic with her parents for the chest wall anomaly seen in Figure A. What other congenital disorder is associated with this syndrome?

Flexible pes planovalgus
Syndactyly
Polydactyly
Macrodactyly
Accessory navicular CORRECT ANSWER: 2
The figure shows an individual with Poland's Syndrome, as demonstrated by the absent sternoclavicular head of the pectorals major. Syndactyly and symbrachydactyly is often seen, in addition to hypoplasia and shortening of the fingers.
Poland's Syndrome, or Poland anomaly/sequence, is thought to be caused by disruption of the subclavian artery in utero, causing various hypoplastic anomalies of the upper extremity. These are typically ipsilateral ranging from aplasia of the sternocostal head of the pectorals major, radio-ulnar synostosis, symbrachydactyly and other limb hypoplasias, or syndactyly of the central digits. Syndactyly is often simple and either complete or incomplete. It is addressed surgically early on, with the chest wall deformities needing reconstruction and muscle transfers closer to sexual maturity. Thoracic, cardiovascular, and genitourinary anomalies may also be present.
Catena et al. proposed a new classification system for Poland Syndrome based on the degree of clinical severity of the entire upper extremity. The classification type increased with more proximal involvement up the upper extremity. This new system may help guide treatment as is takes into account the functional state of the rest of the upper extremity and not just the hand, as previous systems have.
Ireland et al. analyzed 43 consecutive cases of Poland's Syndrome. All cases involved congenital aplasia and syndactyly which was typically simple and incomplete. The thumb can be involved putting it the same plane as the fingers. Anomalies were more frequently seen on the right side. They noted favorable outcomes with surgical correction by syndactyly release initiated by 1 year, with some requiring periodic revision releases, while others required an amputation producing a three-fingered hand.
Figure A shows an absent stenocostal head of the pec major. Only the right side is involved. Illustrations A-C show pre-op and post-op digital release of an individual with syndactyly
Incorrect Answers:

A 32-year-old man sustains an injury to his left thumb. Examination in the ER demonstrates a 2x4 cm wound on the dorsal thumb overlying the proximal phalanx with exposed tendon and bone. What is the most appropriate option for soft tissue coverage?
Cross-finger flap
Moberg advancement flap
Full-thickness skin graft
First dorsal metacarpal artery flap
V-Y advancement CORRECT ANSWER: 4
The first dorsal metacarpal artery flap (Kite flap) is the most appropriate soft tissue coverage option for dorsal thumb wounds that disrupt vascularized tissue overlying the extensor tendon and bone (including the epidermis, dermis, subcutaneous tissue, and tenosynovium) when primary closure is not possible.
Kite flaps are based off of the first dorsal metacarpal artery, which overlies the index finger metacarpal. It offers a pedicle length up to 7 cm and can reliably cover soft tissue defects up to 3x5 cm in area. Given its location, it is appropriate for the treatment of thumb wounds including those to the web space, dorsum, and volar pulp, particularly when injury compromised the vascularity of the wound bed. It can be modified to include both dorsal branches of the proper digital nerve, thereby conferring sensibility to the covered wound. The donor site can subsequently be covered with a full-thickness skin graft.
Rehim et al. reviewed local flaps of the hand. They offer treatment options and appropriate indications based upon the anatomic location and size of the wound within the hand. They conclude that when there are no clinical limitations, local flaps provide ideal soft tissue coverage and function for hand wounds based upon the local anatomy without the need for more complex free tissue transfers.
Eberlin et al. review soft tissue coverage options in the hand. They present four clinical cases and offer one established and one non-traditional surgical treatment option for each. They recommend the first dorsal metacarpal artery flap as an established treatment option in a case of thumb volar pulp injury as it offers contour restoration as well as sensibility when the digital nerves are included with the vascular pedicle.
Illustration A demonstrates a large dorsal thumb soft-tissue injury that is treated with first dorsal metacarpal artery flap coverage and full-thickness skin grafting to cover the donor site.
Incorrect Answers:

A 65-year-old man complains of numbness and tingling in the thumb, index, and long fingers of his dominant right hand for 3 months. An EMG demonstrates prolonged median sensory latency and low amplitude compound muscle action potentials with fibrillations in the abductor pollicis brevis. What is the most appropriate treatment option and the rate of continued symptoms at 1 year after treatment?
Splinting and corticosteroids; 5%
Open carpal tunnel release; 20%
Splinting and corticosteroids; 30%
Endoscopic carpal tunnel release; 2%
Open carpal tunnel release; 5%
The most appropriate treatment of carpal tunnel syndrome (CTS) with EMG evidence of denervation is surgical release. The rate of residual symptoms at 1 year is approximately 20%.
The American Association of Electrodiagnostic Medicine (AAEM) criteria delineates CTS severity by EMG. Mild CTS is purely sensory. Moderate disease demonstrates prolonged sensory and motor latencies. Severe disease progresses to involve muscle denervation. Mild and moderate CTS may be treated with carpal tunnel release following failure of nonoperative treatment; however, early operative treatment is supported for severe disease to limit further denervation. Patients experience significant improvement in
symptoms; however, recovery is prolonged and persistent symptoms may be present in ~20% at 1 year.
Kronlage et al. compared changes in numbness and pain following carpal tunnel release in 47 patients with moderate and 48 patients with severe CTS diagnosed on EMG. At 1 year or longer, 1 (2%) patient with moderate disease had continued symptoms compared to 9 (19%) of patients with severe CTS. They concluded that patients with severe CTS experience significant reductions in symptoms following carpal tunnel release; however, recovery may be prolonged or incomplete at 1 year postop.
Ono et al. performed a systematic review of 25 studies reporting outcomes for the treatment of carpal tunnel syndrome. They noted an increasing trend towards recommending earlier surgery for CTS with or without median nerve denervation. They conclude that this differed from the 2007 AAOS guidelines, which recommended early surgery only in the setting of muscle denervation.
Incorrect Answers:
A 23-year-old man presents with chronic, progressive right wrist pain. He remembers falling onto an outstretched hand 2 years ago. Radiographs, CT scans and a T1-weighted coronal MRI are shown in Figures A through E. No bleeding was identified at surgery. In addition to surgical stabilization, what is the next best step?

Corticocancellous autograft inserted through a dorsal approach
Pedicled distal radius graft inserted through a dorsal approach
Pedicled distal radius graft inserted through a volar approach
Free vascularized femoral bone graft inserted through a dorsal approach
Free vascularized femoral bone graft inserted through a volar approach
This patient has an old scaphoid waist fracture with nonunion, proximal pole avascular necrosis (AVN), and carpal collapse. Optimal treatment is with a free vascularized medial femoral condyle (MFC) graft through a volar approach.
Where there is proximal pole AVN, union was achieved in 88% of patients with a vascularized graft versus 47% with screw and nonvascularized wedge bone graft fixation. The 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) pedicle graft leads to union rates of 71% for scaphoid nonunions and 50% for AVN. The risk for failure is higher when there is DISI or humpback deformity (underscoring the need to restore scaphoid geometry). The MFC graft uses a pedicle from the descending genicular artery or the superomedial genicular artery when the descending genicular artery is not present. The volar approach is preferred as it allows correction of the humpback deformity and anastomosis of the MFC pedicle to the radial artery.
Jones et al. retrospectively compared 2 vascularized bone grafts for treatment of scaphoid waist nonunions with proximal pole AVN and carpal collapse. 4 of
10 nonunions treated with distal radial pedicle graft healed at 19 weeks. 12 of 12 nonunions treated with free vascularized medial femoral condyle (MFC) graft healed at median of 13 weeks. Rate of union was higher, and time to healing was shorter for the MFC graft. They recommend the MFC vascularized bone graft for treatment of scaphoid waist nonunion with proximal pole AVN and carpal collapse.
Figures A, B, C and D are PA and lateral radiographs and coronal and sagittal CT images showing scaphoid waist nonunion with carpal collapse and osteonecrosis of the proximal pole, respectively. Figure E is a T1-weighted coronal image shows diffusely decreased signal within the proximal pole.
Illustrations A and B show harvest and inlay of the 1,2 ICSRA graft. Illustration C shows the MFC graft.
Incorrect Answers:

A 38-year-old female develops pain and pallor in all the digits of the right hand daily. Her symptoms have progressed over 2 years despite avoiding direct cold exposure and multiple medications including nifedipine. Recently she has developed the lesions seen Figure A. Workup for underlying disease by her rheumatologist was negative. She is a candidate for Botuninum toxin A injections. What is the physiologic effect of botulinum toxin in the hand for her condition?

Improving proprioception in the fingers and hand by binding to postsynaptic acetylcholine receptors
Improving digital perfusion by cleaving pre-synaptic SNAREs and preventing the release of acetylcholine
Decreasing glabrous skin sensation by reducing hyperexcitability of voltage dependent calcium channels
Strengthening the intrinsic muscles by increasing hyperexcitability of voltage dependent calcium channels
Increasing sympathetic innervation by cleaving pre-synaptic SNAREs and preventing the release of acetylcholine
The patient is displaying Raynaud's Disease with the development of ulcerations from chronic vasoconstriction. Botulinum toxin has been shown to increase the blood supply throughout the hand through the its well-known mechanism of pre-synaptic SNARE cleavage.
Botulinum toxin cleaves the pre-synaptic SNAREs (soluble NSF attachment potion receptor) and prevents the release of acetylcholine from the intracellular vesicles. This has been used for multiple medical purposes, including vasospastic disorders. Raynaud's Disease is characterized by idiopathic vasospasm of the digital arteries without known underlying cause. Usually afflicting pre-menopausal women, it begins with pain and pallor in the digits, typically affecting the bilateral hands. Avoiding cold environments and tobacco are the mainstays of treatment, with calcium-channel blockers being the most common medication used. When these and other medications fail, botulinum toxin injections have been shown to be of benefit by relieving vasoconstriction and decreasing ischemia and pain.
Neumeister et al. reviewed the application of botulinum toxin A and individuals with Raynaud's Disease and Syndrome. They showed marked increases (up to 300%) in digital perfusion in patients receiving these injections into the common digital vessel at the level of the palm. They concluded the mechanisms for this response are likely multifactorial, involving central and systemic effects on neurotransmitters involved in chronic pain pathways, local digital vessel tone, and sympathetic innervation.
Iodio et al. reviewed all clinical studies regarding the use of bootulinum toxin A in raynaud's. There was high variability among the studies in terms of dosage and application method, but all studies reported favorable patient outcomes and some showed improved healing of ulcerations. These studies are promising but are limited due to study design and lack of standardization of botulinum toxin application.
Figure A shows non-infected ulcerations in the digits, common in progressive raynaud's disease.
Illustration A shows ischemic digits due to Raynaud's Syndrome. Illustration B is the same hand after botulinum toxin A injection. Illustration C is a laser doppler of a hand both pre- and post-injection perfusion of botulinum toxin A in an individual with Raynaud's Disease. Illustration D depicts the recommended method of injection, placing 10 units of botulinum around the common digital vessel at the level of the palm.
Incorrect Answers: There is no shown effect on digital proprioception, skin sensation, muscle strengthening.

A 27-year-old male injures his thumb during a fall onto an outstretched hand. He has pain at the MCP joint and difficulty grasping objects between the thumb and index finger. He undergoes surgery with the planned incision shown in Figure A. What muscle and corresponding nerve innervates the structure that blocks reduction of the ligament shown in Figure B?

Opponens pollicis, median nerve
Flexor pollicis brevis, ulnar nerve
Adductor pollicis, ulnar nerve
Abductor pollicis brevis, median nerve
Adductor pollicis, median nerve
The patient has an ulnar collateral ligament injury. The structure that blocks reduction of the ligament is the adductor pollicis aponeurosis, which is innervated by the ulnar nerve.
Thumb ulnar collateral ligament injuries occur after a radially directed force on an extended thumb, stressing the ulnar collateral ligament, dorsal capsule and volar plate. The thumb should be radiographed before stress exam if the history warrants so as not to displace a possible bony avulsion. Exam includes valgus stress on the thumb at 0 and 30 degrees of flexion to test the accessory and proper collateral ligaments respectively. With complete rupture of both ligaments, a bump over the ulnar thumb MCP joint may be palpated, signifying a Stener lesion. The ligament usually tears at the distal insertion and displaces proximal and superficial to the adductor aponeurosis. The dorsal capsule and volar plate may also be injured.
Bean et al. evaluated the biomechanics of non-anatomic reconstruction of the ulnar collateral ligaments in cadaveric specimens. They showed that 2mm of volar displacement of the ligament origin will allow for 10 degrees more radial deviation than anatomic placement will. This highlights the need for anatomic reconstruction and that deviation from this will alter joint kinematics.
Figure A shows a planned incision over the ulnar aspect of the thumb MCP joint
Fibure B shows a Stener lesion that is migrated proximally compared to the aponeurosis which is marked by the forceps
Illustration A depicts the retraction of the collateral ligament proximal to the aponeurosis
Illustration B shows a T1 MR coronal image showing a distal avulsion of the UCL and the Stener lesion, denoted by the asterisk, and the arrow pointing to the aponeurosis
Incorrect Answers:

An otherwise healthy 5-year-old female is brought to your office for the deformity shown in Figures A and B. Only the small digit of the left hand is involved and it may be fully flexed, but there is limited passive extension. What is the next best step in treatment?

Observation and reassurance
Nighttime extension splinting and stretching regimen
Nighttime extension splinting and stretching regimen with full genetic workup
FDS transfer to radial lateral band
FDS split with transfer of limbs to A2 pulley and central tendon hood
The patient described has isolated camptodactyly with a mild flexion contracture. The best next step in treatment is to begin a stretching and splinting regimen.
Camptodactyly is a nontraumatic flexion deformity isolated to the proximal interphalangeal joint, typically involving the small finger. This is often seen
bilaterally and sporadically, although many congenital disorders are associated. Many underlying anatomical structures have been implicated in the pathogenesis of this condition, with various surgical techniques having been described to address these. If this condition remains untreated, adjacent joint involvement can develop, with MCP hyperextension seen most commonly.
Intrinsic-plus splinting of the hand with passive stretching exercises should be initiated first. Surgery is usually reserved in cases of failed splinting or significant contractures approaching 60 degrees.
Comer et al. reviewed the complications of campylodactly. Most common complications were progression or failed improvement of both PIP contracture and MP hyperextension, isolated PIP postoperative residual stiffness, and bony remodeling of proximal phalanx head preventing full extension. They note inconsistent results after surgical correction which supports early detection and conservative modalities as the mainstay of treatment, focusing heavily on a stretching program and night splinting.
Rhee et al. reviewed outcomes of passive stretching for isolated camptodactyly flexion contractures in a series of children under the age of three years. They showed marked improvement of contracture deformity in all children across all levels of severity, though to less extent with more severe deformities.
Figures A and B demonstrate early contracture of the left small finger. Illustration A is a radiograph showing maintenance of articular congruity.
Incorrect Answers:

A collegiate rower complains of dorsal wrist pain for 6 weeks refractory to NSAIDs and bracing. Maximal tenderness is palpated on the dorsoradial forearm approximately 5 cm proximal to the wrist. Pain is exacerbated with resisted wrist extension. Radiographs are unremarkable. A steroid injection should be directed into the compartment containing which of the following structures?
APL and EPB tendons
ECRL and ECRB tendons
EPL tendon
APL and ECRB tendons
Brachoradialis tendon CORRECT ANSWER: 2
The clinical scenario is consistent with intersection syndrome, a inflammatory response to overuse at the site of the second dorsal compartment crossing under the first dorsal compartment approximately 5 cm proximal to the wrist. An anatomical depiction is provided in illustration A. Injections of the second dorsal compartment, which includes ECRL and ECRB, may relieve symptoms
and quell inflammation. Intersection must be differentiated from DeQuervain's syndrome, which is tenosynovitis of the first dorsal compartment. Injections of the first dorsal compartment, which includes APL and EPB, are part of the treatment algorithm for Dequervain's. Wood et al summarizes the evaluation and treatment of sports-related wrist injuries. Grundberg et al demonstrates the pathologic abnormality of intersection syndrome is stenosing tenosynovitis of the second compartment explaining the rationale behind steroid injections into the sheath.

A 42-year-old chef has finally been transferred to the hand specialist 15 hours after injuring his non-dominant hand index finger with a butcher's knife as seen in figure A. He has kept the finger with him, which has been wrapped in saline-soaked gauze and placed on ice. What is the best reason the finger tip should not be replanted?

The replanted digit will likely have poor function due to the delay in care
Possible malingering
The replanted digit will likely have poor function due to the local anatomy
Patient age
Workers compensation patients will have worse outcomes
Single digit amputations proximal to the insertion of the flexor digitorum superficialis (FDS), in generally have poor function and severe stiffness following replantation.
Replantation between the FDS insertion and the distal palmar crease (zone 2 flexor tendon injuries) has historically led to poor results due to stiffness at the proximal interphalangeal joint, decreased sensation in the finger, and tendon adhesions between the FDP and slips of the FDS. Furthermore, outcome studies have demonstrated patients with index finger amputations through this region are more likely to bypass their stiff index finger and utilize their long finger for most tasks. However, amputation of multiple digits through zone 2 would be considered for replantation.
Urbaniak et al performed a retrospective case series of 59 patients who
underwent finger (thumb excluded) replantation for traumatic amputation. They found the functional results were most dependent on level of amputation and patients with amputation proximal to the insertion of the FDS had significantly decreased PIP motion. They concluded that replantation through zone 2 is seldom indicated due to severe stiffness.
Boulas et al reviewed digital replantation and recommend initial treatment should consist of wrapping amputated parts in moistened gauze and placing on ice. Sharp and clean amputations are considered more viable candidates for replantation due to limited damage to the replantation junction compared to crush injuries. Additionally, they state the patients with major psychiatric disorders or those that are unable to comply with postoperative protocols should also be considered poor candidates for replantation.
Figure A demonstrates an amputation through the left index finger proximal phalanx with no evidence of comminution or crush injury. Illustration A demonstrates the flexor tendon zones.
Incorrect Answers:

A patient sustains an acute, closed injury to his index finger. The clinical appearance of the finger is shown in Figure A. The patient is asked to extend the finger against resistance, with the PIP joint in 90 degrees of flexion. You note that PIP joint extension was weak, with hyperextension and restricted passive flexion of the DIP joint. When planning to treat this injury non-operatively which active joint motion is encouraged?

DIP flexion
MCP flexion
MCP extension
PIP extension
PIP flexion CORRECT ANSWER: 1
This patient has sustained a central slip injury. Treatment consists of full time extension splinting of the PIP joint for 5 weeks with active DIP motion (flexion) encouraged.
A central slip injury, or a zone 3 extensor tendon injury, is characterized by PIP flexion and DIP extension (boutonniere deformity). This is most often caused by a rupture of the central slip over the PIP joint caused by a laceration, a traumatic avulsion, or capsular distension in rheumatoid arthritis. A rupture of the central slip causes the extrinsic extension mechanism from the EDC to be lost and prevents extension at the PIP joint. This allows the lumbricals' pull to become unopposed, causing PIP flexion and DIP extension. The examination maneuver described in the question stem is the Elson Test. It is the most reliable way to diagnose a central slip injury before the deformity is present. Non-operative treatment may be undertaken if the injury is closed and presents acutely. The PIP is splinted in full extension for 5 weeks. Active DIP extension and flexion in the splint is encouraged to avoid contraction of the oblique retinacular ligament.
Posner et al. describe the diagnosis and treatment of finger deformities following injuries to the extensor tendon mechanism. They suggest that treatment of a boutonniere deformity depends on its stage. For the acute injury (within the first 2 weeks), immobilization of the proximal interphalangeal joint in full extension for 5 weeks using a static splint that permits active and passive flexion of the DIP joint is usually effective.
Figure A is a clinical photograph demonstrating an index finger with the classic boutonniere deformity of flexion at the PIP joint and hyperextension of the DIP joint. Figure B is a diagram showing the Elson test. When the central slip is intact, there is no hyperextension of the distal phalanx. When the central slip is disrupted, the distal phalanx can hyperextend due to the function of the tight lateral bands.
Incorrect Answers:
A 25-year-old male is stabbed in the proximal volar forearm while fighting in a bar. He presents to the ED with a 1 cm wound and moderate oozing of blood. On exam, he has normal sensation throughout all distributions in his hand, normal radial and ulnar pulses, and a normal tenodesis effect. He is unable to actively flex his index finger DIP joint. Which muscle will also likely not function as a result of his injury?
Flexor digitorum brevis
Flexor carpi radialis
Flexor carpi ulnaris
Flexor pollicis longus
Pronator teres CORRECT ANSWER: 4
The patient has sustained a laceration of the anterior interosseous nerve (AIN), which is a branch of the median nerve and innervates the flexor pollicis longus, pronator quadratus, and the flexor digitorum profundus to the index and long fingers. An intact tenodesis effect signifies that all of his tendons are structurally intact.
The AIN can be injured by a penetrating injury or chronic compression. It
arises from the dorsoradial aspect of the median nerve distal to the elbow. It then passes between the FPL and FDP to lie on the anterior interosseous membrane en route to the pronator quadratus and wrist capsule (Illustration A). Compression sites of the AIN include the deep head of the pronator teres, FDS arcade, edge of the lacertus fibrosus, an accessory head of the FPL, or other accessory muscles of the forearm (FDS, FDP, FCR). In this particular scenario of an acute, penetrating AIN injury, exploration and primary end-to-end suture repair is appropriate.
Rodner et al. review AIN syndrome and stress the importance of ruling out a tendon rupture, which can present similarly and can be differentiated by testing the patient's tenodesis effect. Non-traumatic AIN syndrome is usually the result of a neuritis, similar to Parsonage-Turner Syndrome (brachial plexus neuritis), and may have similar triggers such as viral infection or autoimmune disease. They recommend a prolonged period of observation (~12 months; in the absence of an obvious compressive or space-occupying lesion) due to high rates of spontaneous recovery at about one year.
Park et al. report on 11 patients that underwent surgical exploration for spontaneous AIN syndrome at an average of 7.8 months. The most common compressive structure was a fibrous band of the FDS, however, four patients had no obvious compressive structure, emphasizing the importance of at least six months of conservative treatment.
Incorrect answers:

A 38-year-old female presents with 8 months of gradual weakness of her right hand. She denies paresthesias, numbness, and pain in the right upper extremity. She has compensatory thumb interphalangeal flexion during key pinch and intact two point discrimination. She has a negative Tinel's sign at the wrist and elbow. Electromyography (EMG) shows normal sensory conduction velocities but delayed motor conduction to the first dorsal interosseous muscle. Figure A and B show MRI images of pre and post contrast, respectively. Ultrasound is shown in Figure C. What is the next best step?

Biopsy of the mass
Cyst excision
MRI of cervical spine
Excision of the hook of hamate
Cubital tunnel release CORRECT ANSWER: 2
The patient has pure motor symptoms from ulnar nerve compression by a ganglion cyst at Guyon's canal. The next best treatment is excision of the ganglion cyst.
Atraumatic compression of the ulnar nerve at Guyon's canal is caused by a ganglion cyst 80% of the time. Compression may present with mixed motor and sensory or pure motor symptoms. With purely motor compression the deep branch of the ulnar nerve is affected resulting in weakness of adductor pollicis. Subsequent loss of metacarpophalangeal flexion and adduction leads to a positive Froment's sign with compensatory thumb IP flexion. Pure motor compression will result in normal sensory examination and intact two point discrimination as sensory branches are unaffected. EMG will localize decreased velocities at the wrist. When neurologic symptoms are present, cyst excision is recommended. Ganglion cysts in this location often arise from the pisohamate joint and excision of the stalk is important to prevent recurrence.
Wang et al. retrospectively investigated the outcomes of 9 patients with
ganglion cysts with symptomatic compression of the deep branch of the ulnar nerve. At a mean follow-up of 23 months they found all patients had improved grip and tip pinch strength. They conclude that surgical intervention can lead to satisfactory outcomes.
Shen et al review the imaging findings possible in patients with ulnar neuropathy. They present a case of a patient with ulnar neuropathy secondary to a ganglion cyst in guyon's canal.
Maroukis et al. review the history of the clinical anatomy of Guyon's canal. They conclude that the three zone theory helped simplify the complex anatomy of ulnar nerve compression at Guyon's canal.
Figure A (Shen et al) shows a T2 fat saturation MRI of a well circumscribed lesion (black arrow) with homogeneous fluid signal intensity at Guyon's canal compressing the ulnar nerve (white arrow). Figure B (Shen et al) shows a post contrast T1 fat saturation MRI showing rim enhancement consistent with a cyst (black arrow) and compression of the ulnar nerve (white arrow). Figure C shows an longitudinal ultrasound view of a anechoic well defined structure consistent with a cyst. Illustration A shows the areas of potential ulnar nerve compression in Guyon's canal. Illustration B shows a table with potential causes for compression at each zone and expected symptoms.
Incorrect Answers:

A 20-year-old male presents to clinic for evaluation of right wrist pain. He fell playing flag football about 6 weeks ago. He initially had significant pain but since it slowly improved he did not seek immediate treatment. His improvement has now plateaued. Figures A and B are x-rays, and figures C and D select CT scan images of his right wrist. What is the best treatment option?

Percutaneous screw fixation
Open reduction internal fixation through a volar approach
Open reduction internal fixation through a dorsal approach
Open reduction internal fixation with bone grafting through a volar approach
Open reduction internal fixation with bone grafting through a dorsal approach
The patient presents with a displaced right scaphoid waist fracture with cyst formation. The best treatment would open reduction internal fixation (ORIF) with bone grafting through a volar approach.
The surgical management of scaphoid fracture depends on location and characteristics of the fracture as well as time from injury. Displaced distal pole and waist fractures are typically approached from the volar side, especially if there is a humpback deformity; the proximal pole is more easily accessed from the dorsal side. Injuries with significant comminution or cyst formation due to extended time to treatment are often augmented with bone graft. There is controversy as to the use of vascularized bone graft in nonunion cases.
Rettig et al. reported on fourteen patients undergoing acute surgical fixation for displaced scaphoid waist fractures. Thirteen patients united and regained functional wrist range of motion and grip strength. They advocate for early
operative intervention in these fractures.
Raskin et al. describe the utility of the dorsal approach for proximal pole scaphoid fractures. They report good fracture visualization and the ability to bone graft through the same incision with successful union in a majority of cases.
Pinder et al. reviewed the literature on management of scaphoid nonunions. They found no difference in use of nonvascularized or vascularized bone graft, choice of approach, or use of Kirschner wires versus screw fixation.
Figures A and B are postero-anterior lateral right wrist radiographs with a displaced scaphoid waist fracture and mild humpback deformity. Figures C and D are coronal and sagittal CT cuts, respectively, demonstrating cyst formation and better showing the humpback deformity.
Incorrect Answers:
A 53-year-old white male presents with contractures of his ring finger and lesions over the dorsum of his hand. On examination of the lesions, they are subcutaneous, solid, and firm lesions measuring about 5 mm in diameter. They are located over the dorsum of the PIP joints of his ring and long finger. They become more mobile while the joint is in neutral and less mobile when the joint is in flexion. He also has a 5 degree flexion contracture his ring finger MCP joint. Examination of his palm reveals a palpable cord over the volar ring finger. His neurovascular examination is normal. The appearance of the dorsum of his hand is seen in Figure A. What is the next most appropriate step in treatment?

Collagenase injection and resection of dorsal finger lesions
Collagenase injection without resection of dorsal finger lesions
Observation and follow up
Surgical resection/fasciectomy and resection of dorsal finger lesions
Surgical resection/fasciectomy without resection of dorsal finger lesions
This patient has mild Dupuytren's disease with associated dorsal Dupuytren nodules, which may be observed.
Dupuytren’s disease is a proliferative disorder characterized by fascial nodules and contractures of the hand. It is autosomal dominant with variable penetrance. It exhibits a 2:1 male to female ratio and is classically seen in Caucasian males of northern European descent. The main pathology of
Dupuytren’s disease is excessive myofibroblast proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia. Surgical intervention is often indicated in cases of ≥30° of MCP contracture or any PIP contracture (usually >15°).
Rayan et al report that dorsal Dupuytren's nodules are a subcutaneous, solid, firm, well-defined, tumor-like mass or a nodule 3 mm in diameter or larger, located over the dorsum of the PIP joint. It is seldom painful and becomes more mobile while the joint is in neutral position and less mobile during joint flexion.
Black et al report that diseased tissue is referred to as nodules or cords. The Dupuytren nodule is a palpable subcutaneous lump that may be fixed to the skin. Cords are highly organized collagen structures arranged in parallel with a relatively hypocellular matrix. Cords are predominantly composed of collagen III while normal palmar fascia is predominantly collagen I.
Figure A is a picture of a dorsal Dupuytren's nodule. Incorrect Answers:
at this time. The dorsal finger lesions should not be resected.
A 37-year-old man has a 2-year history of increasing right wrist pain that is worse at night and aggravated by activity. He denies systemic symptoms, history of trauma, or recent weight loss. On physical exam he has tenderness over the dorsal radiocarpal joint. Radiographs of the right wrist are shown in Figure A. Which of the following imaging studies would be most sensitive for determining the stage of this patient's underlying condition?

Ultrasound
Angiography
CT scan of the wrist
Clenched fist AP radiograph of wrist
Bone scan of the wrist CORRECT ANSWER: 3
The clinical presentation of dorsal radiocarpal wrist pain is suggestive of Kienbock’s disease. Figure A shows an AP radiograph of the right wrist with
evidence of lunate sclerosis with no obvious collapse. The imaging study most sensitive for identifying early lunate collapse in Kienbock's disease is CT scanning of the wrist.
Kienbock’s disease is defined by avascular necrosis of the lunate. It is classified into 4 stages under the Lichtman Classification. In stage 1, plain radiographs appear normal and magnetic resonance imaging is required for diagnosis. MRI is useful for detecting early disease when sclerosis is not evident on plain film radiographs. In stage 2, plain radiographs and/or CT scan images will show sclerosis of the lunate but no evidence of collapse. In stage 3, radiographs and/or CT scan images will show lunate collapse. For stage 4, radiographs show degenerative changes to the adjacent carpus and intercarpal joints.
Imaeda et al. examined the use of MRI for the diagnosis and staging of Kienbock's disease. They found that MRI was most sensitive in detecting early focal loss of signal intensity in the lunate on T1-weighted images. This was a key diagnostic feature in early stages of Kienböck's disease when plain radiographs appear normal.
Cross et al. reviewed the latest concepts for diagnosis, staging, and management of Keinbock's disease. They suggest that computed tomography (CT) or tomography will better characterize lunate necrosis and trabecular destruction once collapse or sclerosis has occurred in late stage disease.
Illustration A is a collection of CT scanning images that show osteonecrosis of the lunate. The blue arrow shows lunate flattening and sclerosis. The red double arrow shows a loss of lunate height and the yellow shows fragmentation of the bone.
Incorrect Answers:
widening of the scapholunate interval.

Each of the following are indications for microvascular replantation EXCEPT?
Thumb amputation
Index finger amputation in a child
Through wrist amputation
Long finger amputation through the proximal phalanx
Mid-palm amputation of all four fingers
As reviewed by Soucacos, there are several major indications for single digit replantation: 1) Level of the amputation is distal to the insertion of FDS. 2) Amputations at the level of the distal phalanx. 3) Ring avulsion injuries involving both the dorsal and palmar skin and blood supply in an isolated finger, as long as FDS is intact. 4) Any amputation in a child. 5) Thumb amputation. Replantation of a single digit, which is amputated at the level of the proximal phalanx or at the PIP joint, particularly in avulsion or crush injury is contra-indicated. Soucacos also discusses appropriate surgical teams, transport, and other related issues surrounding a "transplant team."
All of the following are predictive findings for correctly diagnosing carpal tunnel syndrome EXCEPT:
Abnormal hand diagram
Abnormal Semmes-Weinstein testing in wrist-neutral position
Positive median nerve compression test (Durkan's sign)
Presence of night pain
Loss of small digit adduction (Wartenberg sign)
All of the listed physical exam findings, except for loss of small digit adduction (Wartenberg sign), has been found to be predictive for diagnosing carpal tunnel syndrome.
Szabo et al in a Level 3 study used a regression model to analyze the most predictive factors for correctly diagnosing carpal tunnel syndrome (CTS). Their analysis found that with an abnormal hand diagram, abnormal sensibility by Semmes-Weinstein testing in wrist-neutral position, a positive Durkan's test, and night pain, the probability that carpal tunnel syndrome will be correctly diagnosed is 0.86. They found the tests with the highest sensitivity were Durkan's compression test (89%), Semmes-Weinstein testing after Phalen's maneuver (83%), and hand diagram scores (76%). Night pain was a sensitive symptom predictor (96%). The most specific tests were the hand diagram (76%) and Tinel's sign (71%). The authors concluded that the addition of electrodiagnostic tests did not increase the diagnostic power of the combination of these 4 clinical tests, and proceeding with surgical release is appropriate even if the EMG is normal.
Wartenberg sign is persistent abduction and extension of the small digit when a patient is asked to adduct the digits and is seen in cubital tunnel syndrome, but not carpal tunnel syndrome.
Illustration V demonstrate the Durkan's Compression test for carpal tunnel syndrome.

Extrinsic imbalance from splinting a crushed hand with metacarpophalangeal joint extension causes what characteristic hand deformity?
Distal interphalangeal joint extension
Ulnar subluxation of the metacarpophalangeal joints
Proximal interphalangeal joint extension
Proximal interphalangeal joint flexion
Swan-neck deformity CORRECT ANSWER: 4
Failure to splint the hand in an intrinsic positive position leads to increased extrinsic finger flexor tension, leading the DIP and PIP joints to have an increasing flexion position. Illustration A and B show a clinical image and illustration of intrinsic minus hand.
von Schroeder et al present a Level 5 review of hand crush injuries. They conclude that early diagnosis and treatment is critical, but the functional outcome is often poor with associated Volkmann's contracture.

Axon regeneration almost always occurs following a Sunderland second-degree nerve injury because which anatomic structure is not injured?
Epineurium
Endoneurium
Perineurium
Myelin sheath
Schwann cell CORRECT ANSWER: 2
Following a Sunderland second-degree injury, axon regeneration is possible because the endoneurium is intact.
There are two classification schemes for peripheral nerve injuries, which include the Seddon and the Sunderland systems. Under the Sunderland
classification, a second-degree injury is considered a part of the axonotmesis spectrum. The endoneurium, perineurium and epineurium are still intact. This enables complete functional recovery.
Lee et al. review the pathophysiology and evaluation of peripheral nerve injuries. They note that in Sunderland type two injuries, there is physiologic disruption of the axons. Because the endoneurium is still intact, axons are able to regenerate. This process takes months.
Illustration A is a schematic of the various stages of peripheral nerve injury. Incorrect Answers
Sunderland type 2 injury, axon regeneration is possible because of an intact endoneurium.

A 29-year-old intravenous drug user undergoes irrigation and debridement of a ring finger abscess. After adequate eradication of the infection, he is left with the skin defect shown in Figure A. What is the most appropriate treatment at this time?

Local woundcare and healing by secondary intention
V-Y advancement flap
Thenar flap
Moberg flap
Cross-finger flap CORRECT ANSWER: 5
Based on the location of the lesion, a cross-finger flap would be most appropriate.
Cross finger flaps are indicated in patients > 30 years of age when the lesion is a volar oblique finger tip lacerations or a volar proximal finger lesions. The advantage is it leads to less stiffness.
Martin et al review the treatment options available for digit injuries. They report treatment of fingertip injuries is a continuous focus of controversy among hand and orthopaedic surgeons. Different treatment options have been described, depending on the affected segment and finger, type of lesion, gender and age of the patient, location, size, and depth of the defect.
Fassler et al reviews the proper management of fingertip injuries discussing variables such as the severity of soft tissue loss and whether bone is exposed.
Incorrect Answers:
A 4-year-old boy sustains a flexor tendon laceration in Zone 2 of his 4th digit when he attempts to grab a knife. Optimal surgical management and postoperative rehabilitation consists of:
2 strand core suture technique and gentle active flexion and extension exercises with wrist in extension
2 strand core suture technique and cast immobilization for 8 weeks
4 strand core suture technique and gentle active flexion and extension exercises with wrist in extension
4 strand core suture technique and cast immobilization for 4 weeks
4 strand core suture technique and cast immobilization for 8 weeks
4 strand core suture technique and cast immobilization for 4 weeks is the preferred postoperative rehabiltation in a 4 year old child.
Ordinarily, adult flexor tendon repair postoperative rehab protocols call for early light active digital flexion with wrist in gentle flexion as long as the tendon has been repaired with a 4 or 6 strand core suture technique and strong epitendinous suture. However, this method cannot succeed without the cooperation of a mature and motivated patient. Children or the mentally disabled are often lacking some of these prerequisites. Therefore, a flexor tendon repair in a child should be treated like a flexor tendon repair with interposed graft in an adult. Immobilization for a minimum of 3 – 4 weeks with a posterior molded plaster splint or cast from the tips of the fingers to just above the elbow. Wrist is flexed 35 degrees, MCPs flexed 60 – 70 degrees and IP joints relaxed in extension. Active motion can be started after the cast is removed at 4 weeks.
A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. A radiograph is shown in figure A. What joint is first affected if left untreated with subsequent development of a SLAC (scapholunate advanced collapse) wrist?

Capitolunate joint
Radioscaphoid
Radioulnar
Radiolunate
STT (scaphotrapezotrapezoidal)
The clinical presentation is consistent with a SLAC wrist. The radioscaphoid joint is the first to be affected in this process.
The radiographs of the right wrist demonstrate a scapholunate dissociation, as evidenced by an increased scapholunate joint space, referred to as scapholunate diastasis (abnormal when the gap is greater than 2 mm and increased from the opposite extremity and other intercarpal spaces).
If left untreated, the wrist may progress to a "SLAC" wrist, as originally described by Watson and Ballet in 1984, which is the most common form of wrist arthritis. The repetitive sequence of degenerative changes is based on and caused by articular alignment problems between the scaphoid, the lunate and the radius.
Kuo et al. review the stages of SLAC wrist. They report stage I SLAC wrist involves changes limited to an area of abnormal contact between the abnormally rotated scaphoid and the radial styloid. In stage II the remaining radioscaphoid joint is affected, as persistent abnormal load transfer and shear across the cartilaginous surfaces leads to degeneration of the proximal scaphoid facet. In stage III, the dorsally translated capitate migrates proximally into the widened scapholunate interval, and degenerative changes occur at the capitolunate joint. The relative congruency of the radiolunate joint in all positions of lunate rotation due to the spherical shape of the lunate facet preserves this articulation, and at all stages of SLAC wrist the radiolunate joint is not involved. The lunate is congruently loaded in every position and, thus, highly resistant to degenerative changes.
Illustration A below shows the stages of involvement in the SLAC wrist.

Question 86

Figure 10 is an anteroposterior pelvis radiograph of an 82-year-old man who had right hip pain that began 2 weeks ago but has since resolved with use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs). Currently he has no pain. Examination of his hip shows decreased internal rotation and minimal pain at the extremes of motion. What is the most appropriate treatment at this point?

Explanation

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams 14
& Wilkins; 2007:514-533.

Question 87

Figures 1 and 2 are the T2-weighted MR images of a 54-year-old woman with medial knee pain and catching of 6 months’ duration. Which treatment option is most likely to be associated with a favorable outcome?

Explanation

MR images reveal a posterior horn root tear of the medial meniscus. LaPrade and associates found that outcomes after posterior meniscal root repair significantly improved postoperatively and patient satisfaction was high, regardless of age or meniscal laterality. Patients aged <50 years had outcomes similar to those of patients ≥50 years, as did patients who underwent medial versus lateral root repair. In patients undergoing pullout fixation for posterior medial meniscus root tear, Chung and associates (in “Pullout Fixation of Posterior Medial Meniscus Root Tears”) found that patients with decreased meniscus extrusion at postoperative 1 year have more favorable clinical scores and radiographic findings at midterm follow-up than those with increased extrusion at 1 year. Krych and associates found that nonoperative treatment of medial meniscus posterior horn root tears is associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at 5-year follow-up. Reconstruction would have no role in the setting of a reparable meniscal root tear.

Question 88

Nutritional rickets in the US occurs more frequently in infants older than 6 months of age who do not receive vitamin D supplementation and are Review Topic

Explanation

Numerous reports suggest an increased frequency of nutritional rickets in the US in children with dark skin pigmentation who are breast fed past 6 months of age without vitamin D supplementation. Nutritional rickets is rare in light-skinned children or those who are formula fed.

Question 89

A 45-year-old man with a painful varus knee is being considered for an upper tibial osteotomy. Which of the following factors is considered the most compelling argument against this procedure?

Explanation

DISCUSSION: Proximal tibial osteotomy is appropriate for the younger and/or athletic patient who has mild to moderate medial compartment osteoarthritis. Relative contraindications include limited range of motion (eg, flexion contracture of 15°), anatomic varus of greater than 10°, advanced patellofemoral arthritis, and tibial subluxation. Inflammatory arthritides involve all the compartments and are a contraindication to osteotomies around the knee.
REFERENCE: Kelly MA: Nonprosthetic management of the arthritic knee, in Callaghan JJ, Dennis DA, Paprosky WG, Rosenberg AG (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 245-249.

Question 90

Figure 23 shows the radiograph of a 55-year-old man who underwent a total hip arthroplasty 5 years ago. Management should now consist of

Explanation

DISCUSSION: Because the radiograph shows that the femoral stem is loose within the femoral canal and there is a fracture in the distal cement mantle, the stem should be revised. The Ogden-type plate and the allograft bone plates will reconstruct the femur but will not restore stability to the stem. Similarly, traction may allow the femur to heal but will not restore stability to the femoral stem within the femur. Resection arthroplasty is considered a salvage option following failure of the other procedures.
REFERENCES: Lewallen DG, Berry DJ: Periprosthetic fracture of the femur after total hip arthroplasty: Treatment and results to date, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 243-249.
Bethea JS, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB: Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;170:95-106.

Question 91

-The patient asks if something about her anatomy has resulted in this injury. ACL anatomy differs between men and women in what manner?

Explanation

DISCUSSION FOR QUESTIONS 18 THROUGH 20
This patient has the clinical findings of an ACL rupture that is confirmed on MRI scan. She is a professional athlete and would like to return to her sport. Immediate ACL reconstruction in the setting of a knee with limited motion carries an increased risk for postsurgical stiffness. Delayed surgery after the patient regains range of motion is the preferred response. It has been shown that a woman’s ACL is smaller in the cross-sectional area.

Question 92

What pathology is most likely to result in failure of an arthroscopic Bankart repair?

Explanation

DISCUSSION: Recent studies have documented that an arthroscopic Bankart repair performed with good technique can produce success rates similar to an open repair. However, the results of an arthroscopic repair deteriorate significantly if there is a 25% or greater anterior-inferior glenoid rim defect (inverted pear configuration) or an engaging Hill-Sachs lesion in which the humeral head defect keys onto the glenoid rim in abduction and external rotation. If either of these entities exist or there is multidirectional instability with pathologic hyperextensible tissue laxity, an open repair is recommended. An associated SLAP lesion would not significantly affect the result of the Bankart procedure. Not infrequently, the anterior glenoid labrum is partially or completely disrupted and, in itself, is not a contraindication to arthroscopic Bankart repair. In almost all patients with predominantly unidirectional instability, some degree of capsular/anterior-inferior glenohumeral ligament attenuation is present and can be addressed during the arthroscopic repair.
REFERENCES: Burkhart SS, De Beer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694.
Cole BJ, Romeo AA: Arthroscopic shoulder stabilization with suture anchors: Technique, technology, and pitfalls. Clin Orthop 2001;390:17-30.

Question 93

A 52-year-old woman reports the sudden onset of intense pain in the right shoulder. She denies any history of injury or previous shoulder problems. At a 2-week follow-up examination, she notes that the pain has decreased, but she now has severe weakness of the external rotators and abductors. Her cervical spine and remaining shoulder examination are otherwise unremarkable. Radiographs of the shoulder and neck are normal. What is the most likely diagnosis?

Explanation

DISCUSSION: Patients with brachial neuritis or Parsonage-Turner syndrome usually report the sudden onset of intense pain that subsides in 1 to 2 weeks, followed by weakness for a period of up to 1 year in the muscle that is supplied by the involved nerve. Calcific tendinitis usually can be diagnosed radiographically, with calcium deposits seen in the rotator cuff. Bursitis and rotator cuff tendinosis usually are seen after an increase in activity, and both decrease with rest and medication. Glenohumeral arthritis is a slow, progressive problem that results in a loss of range of motion.
REFERENCES: Misamore GW, Lehman DE: Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am 1996;78:1405-1408.
Dillin L, Hoaglund FT, Scheck M: Brachial neuritis. J Bone Joint Surg Am 1985;67:878-880.

Question 94

A patient wakes up with a foot drop following open reduction internal fixation of a posterior wall/posterior column acetabular fracture. What position of the leg causes the highest intraneural pressure in the sciatic nerve?

Explanation

DISCUSSION: Borrelli et al examined the intraneural pressure of the sciatic nerve with the hip and knee in various different positions. They found that the "sciatic nerve appeared to exceed published critical thresholds for alterations of blood flow and neural function only when the hip was flexed to 90 degrees and the knee was fully extended." As a result, the leg is typically position with the hip in extension (or minimal flexion) and the knee in about 90 degrees of flexion when performing acetabular surgery via a posterior approach.

Question 95

A 20-year-old college pitcher reports medial elbow pain after 3 innings of hard throwing. He recalls no injury and reports no pain with light throwing. The examination shown in the clinical photograph in Figure 48 reproduces the elbow pain. What is the most likely diagnosis?

Explanation

DISCUSSION: The milking test, as seen in the photograph, elicits pain when a tear is present in the medial collateral ligament. Complete rupture is possible but unlikely when there is no history of trauma and the patient is able to throw pain-free for several innings. Subluxation of the ulnar nerve and triceps tendon subluxation present as a painful snapping over the medial aspect of the elbow.
REFERENCES: Williams RJ III, Urquhart ER, Altchek DW: Medial collateral ligament tears in the throwing athlete. Instr Course Lect 2004;53:579-586.
Cain EL Jr, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 2003;31:621-635.

Question 96

Figure 242 is the anteroposterior radiograph of a 28-year-old man who underwent resection and reconstruction for an Ewing sarcoma. What is the most common functional deficit encountered during rehabilitation?

Explanation

Question 97

A 35-year-old male suffers an anterior column acetabular fracture during a motor vehicle collision, and subsequently undergoes percutaneous acetabular fixation. Intraoperatively, fluoroscopy is positioned to obtain an obturator oblique-inlet view while placing a supraacetabular screw. Which of the following screw relationships is best evaluated with this view?

Explanation

DISCUSSION: The obturator oblique-inlet view, as seen in Illustration A, best demonstrates the position of a supraacetabular screw or pin relative to the tables of the ilium.
Starr et al review their initial results and technique of closed or limited open reduction and percutaneous fixation of acetabular fractures. They defined two groups of patients who may benefit from this technique; elderly patients with multiple comorbidities to facilitate early mobilization and restore hip morphology, and young patients with elementary fracture patterns and multiple associated injuries.
Starr et al describe their operative technique and outcomes for a case series of 3 patients using percutaneous acetabular fixation to augment open reduction of acetabular fractures. The authors state that, for placement of an
anterior colum ramus screw, an iliac oblique-inlet (not obturator oblique-inlet) will ensure that the screw is within the medullary canal of the ramus and does not exit anterior or posterior.
Gardner and Nork describe a technique for placement of a large femoral distractor in the supra-acetabular region to compress displaced posterior pelvic ring injuries. They note that the obturator oblique-inlet view is necessary to view the entire length of the pin as well as to ensure that pin remains in bone.
Incorrect answers:

Question 98

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints? Review Topic

Explanation

Anterior tibial pain can often be difficult to diagnose. A bone scan showing the tibial cortex in a diffuse, longitudinal orientation is consistent with shin splints compared to a more discreet, localized uptake more commonly seen with a stress fracture. Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but are also seem in otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient's history of increased physical activity and on imaging findings.
The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis. If the diagnosis is made early, most bone stress injuries heal well without complications.

Question 99

Which factor should most influence a patient's decision to have surgery for adult scoliosis if he or she is younger than age 50?

Explanation

DISCUSSION
In a retrospective review of 137 patients treated surgically and 153 patients treated nonsurgically for adult scoliosis, Bess and associates found that surgical treatment for patients younger than 50 years of age was driven by increased coronal plane deformity, and surgical treatment for older patients was mandated by pain and disability. They also concluded that age, comorbidities, and sagittal balance did not influence treatment decisions.
RECOMMENDED READINGS
Bess S, Boachie-Adjei O, Burton D, Cunningham M, Shaffrey C, Shelokov A, Hostin R, Schwab F, Wood K, Akbarnia B; International Spine Study Group. Pain and disability determine treatment modality for older patients with adult scoliosis, while deformity guides treatment for younger patients. Spine (Phila Pa 1976). 2009 Sep 15;34(20):2186-90. PubMed PMID: 19752704.View Abstract at PubMed
Anderson DG, Albert T, Tannoury C. Adult scoliosis. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:331-338.

Question 100

A 6-year-old child sustained a closed nondisplaced proximal tibial metaphyseal fracture 1 year ago. She was treated with a long leg cast with a varus mold, and the fracture healed uneventfully. She now has a 15-degree valgus deformity. What is the next step in management?

Explanation

DISCUSSION: The tibia has grown into valgus secondary to the proximal fracture. This occurs in about one half of these injuries, and maximal deformity occurs at 18 months postinjury. The deformity gradually improves over several years, with minimal residual deformity. Therefore, treatment at this age is unnecessary as there is a high rate of recurrence and complications regardless of technique. The valgus deformity is not a result of physeal injury or growth arrest. Medial proximal tibial hemiepiphysiodesis is an excellent method of correcting the residual deformity but is best reserved until close to the end of growth.
REFERENCES: Brougham DI, Nicol RO: Valgus deformity after proximal tibial fractures in children. J Bone Joint Surg Br 1987;69:482.
McCarthy JJ, Kim DH, Eilert RE: Posttraumatic genu valgum: Operative versus nonoperative treatment. J Pediatr Orthop 1998;18:518-521.
Robert M, Khouri N, Carlioz H, et al: Fractures of the proximal tibial metaphysis in children: Review of a series of 25 cases. J Pediatr Orthop 1987;7:444-449.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Gentamicin and penicillin
Cefazolin and penicillin
Doxycycline and ceftazidime
Vancomycin and sulfamethoxazole-trimethoprim

Correct Answer: Doxycycline and ceftazidime

Explanation:

Question 2:

Options:

Examination under anesthesia
MRI shoulder
Zanca view radiograph
Stryker notch view radiograph
Velpeau view radiograph

Correct Answer: Stryker notch view radiograph

Explanation:

Question 3:

Options:

Closed reduction with immobilization
Closed reduction with percutaneous pinning
Open reduction, bicolumnar fixation with plate and screws
Open reduction, bicolumnar fixation with Kirschner wires DISCUSSION.. The radiographs and CT scans indicate a comminuted and displaced intra-articular fracture of the distal humerus. Rigid internal fixation with bicolumnar orthogonal or parallel plating is the treatment of choice for most fractures of the distal humerus that involve the joint surface. Closed reduction and variations thereof will not yield a stable environment for healing. To achieve adequate exposure for fixation, a chevron olecranon osteotomy is the preferred approach. Disadvantages associated with this approach include complications such as nonunion of the osteotomy site and intra-articular adhesions. Prominent hardware may need to be removed during a secondary procedure, and intraoperative conversion to an elbow arthroplasty may be limited. The most common complications after open reduction and internal fixation include elbow stiffness, nonunion (2%-10%), and ulnar neuropathy (0%-12%).

Correct Answer: Open reduction, bicolumnar fixation with plate and screws

Explanation:

CLINICAL SITUATION FOR QUESTIONS 84 THROUGH 87
Figure 84 is the glenoid CT scan of a 20-year-old man who dislocated his shoulder anteriorly while playing football. He had persistent instability 2 months after the injury, but he did not have a sulcus sign or posterior instability. He underwent an arthroscopic Bankart repair with 4 bioabsorbable anchors with simple sutures through the labrum and capsule.
He did not have an engaging Hill-Sachs lesion, the rotator cuff was unremarkable, and the capsule was not torn from the humerus. After surgery, he did well for 6 months until he jumped into a lake and again dislocated his shoulder anteriorly. He says his shoulder no longer felt stable after his reduction.

Question 4:

Options:

Trapeziometacarpal arthrodesis
Osteotomy of the thumb metacarpal
Arthrotomy and joint debridement
Ligament reconstruction using one half of the flexor carpi radialis
Trapezium resection, tendon interposition, and reconstruction of the ligament

Correct Answer: Ligament reconstruction using one half of the flexor carpi radialis

Explanation:

Question 5:

Options:

Bracing
Posterior spinal fusion of only the right thoracic curve
Posterior spinal fusion from T2-L4
Vertebral body stapling to halt progression of the curve
Anterior and posterior spinal fusion

Correct Answer: Posterior spinal fusion of only the right thoracic curve

Explanation:

DISCUSSION: The patient has typical adolescent idiopathic scoliosis with a right thoracic curve. This represents a Lenke-IB curve pattern; therefore, only treatment of the thoracic curve is required. The proximal thoracic and thoracolumbar curves are very flexible. The patient is Risser 1 and has just started her menstrual cycles; therefore, she is at significant risk for further curve progression. Bracing is not appropriate for a curve of this magnitude and will not halt the progression of this curve, nor will vertebral body stapling stop this curve. Vertebral body stapling is sometimes useful in small thoracic curves of less than 35 degrees and skeletally immature patients. Anterior and
14 • American Academy of Orthopaedic Surgeons
posterior spinal fusion is not required because the patient has no other risk factors, such as neurofibromatosis nor is she at risk for crankshaft. Anterior fusion is an option, but it is not listed.
REFERENCES: Lenke LG, Betz RR, Harmes J, et al: Adolescent idiopathic scoliosis: Anew classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83:1169-1181.
Lenke LG, Betz RR, Haher TR, et al: Multisurgeon assessment of surgical decision making in adolescent idiopathic scoliosis: Curve classification, operative approach, and fusion levels. Spine 2001;26:2347- 2353.

Question 6:

What is the most likely complication after surgical treatment in this scenario?

Options:

Recurrent instability
Degenerative joint disease
Shoulder stiffness
Axillary nerve injury

Correct Answer: Shoulder stiffness

Explanation:

Question 7:

Options:

ACL injuries are more common in men younger than 30 years of age.
ACL injuries are more common in women younger than 30 years of age.
ACL injuries are usually the result of contact sports.
The incidence of ACL injuries can be decreased by a neuromuscular training program.
ACL injuries are rarely associated with meniscal injury.

Correct Answer: ACL injuries are more common in women younger than 30 years of age.

Explanation:

Question 8:

Options:

elbow flexion strength.
elbow supination strength.
lack of terminal extension at the elbow.
decrease of elbow pronation strength.

Correct Answer: elbow supination strength.

Explanation:

Question 9:

Options:

A Vancouver type B1 fracture
Residual leg-length discrepancy
Loosening and subsidence of the femoral stem into anteversion
Loosening and subsidence of the femoral stem into retroversion

Correct Answer: Loosening and subsidence of the femoral stem into retroversion

Explanation:

Question 10:

Options:

You and your spouse attend dinner at a local restaurant with the local representative to discuss the Keyhole Genuflex knee.
Keyhole pays your tuition to attend a CME course sponsored by the American Association of Hip & Knee Surgeons where both the Genuflex and the competing Styph total knee are discussed and demonstrated.
Keyhole will pay your expenses to attend a workshop at their company headquarters, to learn how to implant the Genuflex knee and to see how the implant is manufactured and tested.
Keyhole will pay you $500 for each knee that you implant if you switch from your current total knee system.
After you have implanted 25 Genuflex knees, Keyhole will list you on their website as a consultant, pay you a consulting fee of $5,000 per year, and invite you to a golf tournament for their consultants at a resort.

Correct Answer: Keyhole will pay your expenses to attend a workshop at their company headquarters, to learn how to implant the Genuflex knee and to see how the implant is manufactured and tested.

Explanation:

Question 11:

Options:

Ulnar nerve neuritis
Triceps insufficiency
Aseptic loosening
Instability
Infection

Correct Answer: Triceps insufficiency

Explanation:

Question 12:

What molecules have been shown to promote fibrosis during muscle injury?

Options:

Insulin growth factor 1 (IGF-1)
Basic fibroblast growth factor (bFGF)
Transforming growth factor beta 1 (TGF-ß1)
Bone morphogenetic protein

Correct Answer: Transforming growth factor beta 1 (TGF-ß1)

Explanation:

Question 13:

Which of the following factors is responsible for causing the distal femur to pivot about a medial axis as the knee moves from full extension into early flexion?

Options:

Differential forces generated from the vastus lateralis and vastus medialis
Differential tension within the bundles of the posterior cruciate ligament
Differential radius of curvature between the medial and lateral femoral condyles
Asymmetry of the tibial tubercle on the anterior surface of the tibia
Asymmetric forces generated from the uneven patellar facets

Correct Answer: Differential radius of curvature between the medial and lateral femoral condyles

Explanation:

DISCUSSION: The radius of curvature of the distal femur is greater over the distal aspect of the lateral femoral condyle than the distal aspect of the medial femoral condyle. As the femur rolls posteriorly during early knee flexion, both condyles undergo similar angular changes equal to the amount of flexion. With a similar amount of angular rotation, the sphere with the larger radius experiences greater net rollback, producing a pivoting motion. Although the anterior cruciate ligament plays a role in producing tibial rotations, the posterior cruciate ligament does not play a significant role in producing such rotations. Similarly, the tibial tubercle does not play a significant role in producing normal rotations of the femur relative to the tibia. The popliteus may also play a role in producing rotational pivots, as might differential laxity of the medial and lateral collateral ligaments in early knee flexion.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:
Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 239-240.
Insall JN, Windsor RE, Scott WN, et al (eds): Surgery of the Knee, ed 2. New York, Churchill Livingstone, 1993, pp 1-13.

Question 14:

Options:

occupational therapy.
open reduction of the radial head and annular ligament reconstruction.
excision of the radial head.
ulnar osteotomy and closed reduction of the radial head.
ulnar osteotomy and open reduction of the radial head.

Correct Answer: ulnar osteotomy and open reduction of the radial head.

Explanation:

Question 15:

Options:

Ewing’s sarcoma
Lymphoma of bone
Metastatic neuroblastoma
Langerhans cell histiocytosis
Osteomyelitis

Correct Answer: Langerhans cell histiocytosis

Explanation:

Question 16:

An 11-year-old child has Ewing’s sarcoma of the femoral diaphysis with a small soft-tissue mass. Staging studies show no evidence of metastases. Treatment should consist of

Options:

chemotherapy and radiation therapy to the femur.
chemotherapy and wide resection.
chemotherapy and above-knee amputation.
hip disarticulation.
wide resection.

Correct Answer: chemotherapy and wide resection.

Explanation:

Question 17:

Figures 31a and 31b show the T1- and T2-weighted MRI scans of a patient’s knee joint. What is the most likely diagnosis?

Options:

Torn anterior cruciate ligament
Torn medial meniscus
Staphylococcus infection
Rheumatoid arthritis
Tibial plateau fracture

Correct Answer: Tibial plateau fracture

Explanation:

Question 18:

A 52-year-old woman who is right hand-dominant sustains an injury to her elbow in a fall. A radiograph is shown in Figure 60. The preferred treatment of this injury pattern should include

Options:

lateral plating of the proximal ulna and fixation of the radial head.
Kirschner wire/tension band fixation of the proximal ulna alone.
closed reduction and casting.
dorsal plating of the proximal ulna and radial head replacement.
total elbow arthroplasty.

Correct Answer: dorsal plating of the proximal ulna and radial head replacement.

Explanation:

DISCUSSION: The patient has a Bado type 2 variant Monteggia fracture with a radial head fracture. The type 2 variant is associated with a higher nonunion rate and poorer outcomes compared to other Bado-type Monteggia fractures. While it is potentially acceptable to repair the radial head, factors such as higher degrees of comminution and older age lead toward replacement as the treatment of choice. Plate and screw fixation is favored over Kirschner wire/tension band fixation because this is not a simple olecranon fracture. Plate placement in a type 2 fracture is dorsal to counteract very high tensile forces associated with fixation failure.
REFERENCES: Egol KA, Tejwani NC, Bazzi J, et al: Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res 2005;438:233-238.
Jupiter JB, Leibovic SJ, Ribbans W, et al: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.
Konrad GG, Kundel K, Kreuz PC, et al: Monteggia fractures in adults: Long-term results and prognostic factors. J Bone Joint Surg Br 2007;89:354-360.

Question 19:

Options:

casting with an external bone stimulator.
ankle arthrodesis.
revision subtalar arthrodesis.
conversion to triple arthrodesis without revision of the subtalar arthrodesis.
conversion to triple arthrodesis with revision of the subtalar arthrodesis.

Correct Answer: conversion to triple arthrodesis with revision of the subtalar arthrodesis.

Explanation:

Question 20:

Options:

protected weight bearing and anti-inflammatory drugs.
core decompression of the femoral head.
vascularized free fibular grafting to the femoral head.
bipolar hemiarthroplasty of the hip.
total hip arthroplasty.

Correct Answer: protected weight bearing and anti-inflammatory drugs.

Explanation:

DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip: A case report. J Bone Joint Surg Am 1991;73:451-455.

Question 21:

- A 40-year-old woman has had pain in the metatarsophal joint of the second toe for the past 6 months despite nonsurgical treatment. A dorsalplantar stress test reproduces the pain, and there is 10 mm of dorsal subluxation of the toe. Radiographs show a normal second metatarsophalangeal joint. Surgical treatment should consist of synovectomy and

Options:

Advancement of the plantar plate
Resection of the second metatarsal head
Dorsiflexion osteotomy of the second metatarsal neck
Transfer of the flexor digitorum longus tendon to the dorsum of the toe
Transfer of the extensor digitorum comminus tendon to the metatarsal neck

Correct Answer: Transfer of the flexor digitorum longus tendon to the dorsum of the toe

Explanation:

Question 22:

Options:

Improved skeletal muscle strength and secondary spinal support
Neuromodulation via presynaptic inhibition in the dorsal horn of the spinal cord
Distraction sensory input
Enhancement of muscle metabolic activity with improved lactic acid excretion
Placebo effect

Correct Answer: Neuromodulation via presynaptic inhibition in the dorsal horn of the spinal cord

Explanation:

Question 23:

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

Options:

Resisted forearm pronation and wrist flexion with a clenched fist
Resisted forearm supination and wrist extension with a clenched fist
Dynamic valgus stress test
Milking maneuver
Pinch grip test

Correct Answer: Milking maneuver

Explanation:

Question 24:

Which of the following antibiotics is contraindicated in children?

Options:

Penicillin
Cephalexin
Tetracycline
Erythromycin
Ampicillin

Correct Answer: Tetracycline

Explanation:

DISCUSSION: The tetracycline family of medications can stain teeth and bone in skeletally immature patients and as a result should be avoided in those patients. The remaining antibiotics have no known specific contraindication to use in children.
REFERENCE: Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 433-457.

Question 25:

Options:

Broad-spectrum intravenous antibiotics
AP, lateral, and flexion-extension lateral radiographs
MRI with gadolinium
Open biopsy of the surgical disk space
Anterior debridement and interbody fusion

Correct Answer: MRI with gadolinium

Explanation:

Question 26:

A relative contraindication for anteromedial tibial tubercle transfer for patellar instability is arthrosis in what portion of the patella?

Options:

Lateral
Lateral and inferior
Central
Medial
Medial and proximal

Correct Answer: Medial and proximal

Explanation:

Question 27:

Options:

bunion repair only.
bunionette repair only with lateral condylectomy.
repair of both with lateral condylectomy.
repair of both with a proximal fifth metatarsal osteotomy.
repair of both with a fifth metatarsal head excision.

Correct Answer: repair of both with lateral condylectomy.

Explanation:

Question 28:

Which of the following areas of the vertebral segment has the highest ratio of cortical to cancellous bone? Review Topic

Options:

Thoracic vertebral bodies
Lumbar vertebral bodies
Sacrum
Pedicles of the lower lumbar spine
Pedicles of the thoracic spine

Correct Answer: Pedicles of the thoracic spine

Explanation:

Question 29:

Which of the following is indicative of a patient who has been successfully resuscitated following a trauma?

Options:

Urine output of 0.25 mL/kg/hour
Lactic acid of 1.9 mmol/L
Base deficit of -5.5
Gastric mucosal pH of 6.3
Pulse pressure of 15

Correct Answer: Urine output of 0.25 mL/kg/hour

Explanation:

Question 30:

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with

Options:

an avulsion of the lesser tuberosity.
a midsubstance tear of the capsule.
a tear of the anterior inferior labrum.
a tear of the subscapularis.
a tear of the humeral insertion of the inferior glenohumeral ligament.

Correct Answer: a tear of the humeral insertion of the inferior glenohumeral ligament.

Explanation:

Question 31:

Which of the following is an important factor in performing a proper biopsy?

Options:

Staying carefully in the proper intermuscular planes
Placing multiple drains
Dissecting and protecting critical neurovascular structures
Using longitudinal incisions in the extremity
Avoiding the use of a tourniquet

Correct Answer: Using longitudinal incisions in the extremity

Explanation:

DISCUSSION: There are a number of important technical details in performing a biopsy. Incisions should always be longitudinal in the extremity. Good hemostasis is important in avoiding contamination from hematoma. The approach should avoid neurovascular structures, and go through a single muscle belly when possible. Although a frozen section should be obtained to ensure adequate viable tissue has been obtained, definitive diagnosis is not necessary at the time of the frozen section.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 29-34.

Question 32:

Figure 35 is the MR image of an 18-year-old man who has had knee pain with running for 5 months. What is the most appropriate treatment?

Options:

Arthroscopic or open reduction and internal fixation with possible bone grafting
Arthroscopic chondroplasty
No weight-bearing activity for 6 weeks and then re-evaluate
Retrograde subchondral drilling without fixation

Correct Answer: Arthroscopic or open reduction and internal fixation with possible bone grafting

Explanation:

Question 33:

Options:

closed reduction and casting.
external fixation and percutaneous pinning of the distal radius.
open reduction and internal fixation of the distal radius.
open reduction and internal fixation of the distal radius and open repair of the ulnar styloid.
nonbridging external fixation of the distal radius.

Correct Answer: open reduction and internal fixation of the distal radius.

Explanation:

DISCUSSION: The patient has a high-energy injury with resultant comminution of the distal radius metaphysis. Cast immobilization is likely to lead to radial shortening and angulation due to the comminution. Similarly, while external fixation and pinning has been successful in the past, some loss of radial length and volar angulation is typically noted. Present plate fixation devices for the distal radius employing locking screw technology have a superior ability to resist radial shortening and dorsal angulation. Fixation of the ulnar styloid is warranted when there is distal radioulnar joint instability or significant displacement of the styloid. This is more likely to occur with a fracture at the base of the styloid. In this instance, the distal radioulnar joint does not appear to be disrupted.
REFERENCES: May MM, Lawton JN, Blazar PE: Ulnar styloid fractures associated with distal radius fractures: Incidence and implications for distal radioulnar joint instability. J Hand Surg Am 2002;27:965-971.
Nana AD, Joshi A, Lichtman DM: Plating of the distal radius. J Am Acad Orthop Surg 2005;13:159-171.

Question 34:

During revision total knee arthroplasty (TKA), there is significant laxity in 90° of flexion and 10° short of full extension. Correcting the gap imbalance is best achieved by

Options:

resecting more tibia.
resecting more distal femur to raise the joint line, along with resecting more tibia.
increasing femoral component size.
resecting distal femur and increasing femoral component size. When performing revision TKA, the management of gap imbalance and joint line is of critical importance. The flexion gap is generally driven by femoral component size; increasing femoral component size by tightening the flexion gap and downsizing the femoral component size increases the flexion gap. Resecting more distal femur will open up the extension gap; augmenting the femur distally will tighten up the extension gap. Resecting more tibia affects both flexion and extension gaps equally.

Correct Answer: resecting distal femur and increasing femoral component size. When performing revision TKA, the management of gap imbalance and joint line is of critical importance. The flexion gap is generally driven by femoral component size; increasing femoral component size by tightening the flexion gap and downsizing the femoral component size increases the flexion gap. Resecting more distal femur will open up the extension gap; augmenting the femur distally will tighten up the extension gap. Resecting more tibia affects both flexion and extension gaps equally.

Explanation:

Question 35:

Options:

observation.
closed reduction and cast immobilization.
bilateral medial open reduction of the hips.
anterior open reduction with femoral shortening.
valgus osteotomy.

Correct Answer: observation.

Explanation:

Question 36:

Options:

ipsilateral weakness of the tibialis anterior.
ipsilateral weakness of the peroneus longus and brevis.
ipsilateral weakness of the extensor hallucis longus.
a positive Beevor’s sign.
a positive ipsilateral Gaenslen’s sign.

Correct Answer: ipsilateral weakness of the tibialis anterior.

Explanation:

Question 37:

Options:

Clear cell chondrosarcoma
Chondroblastoma
Giant cell tumor
Aneurysmal bone cyst
Osteonecrosis of the femoral head

Correct Answer: Chondroblastoma

Explanation:

Question 38:

Options:

a lateral retinacular release.
a tubercle transfer to reduce the Q angle.
a repeat of the tibial and femoral cuts to introduce 5° of varus.
release of the popliteus.
medial vastus advancement.

Correct Answer: a lateral retinacular release.

Explanation:

Question 39:

Options:

ixation of the coronoid fragment
Radial head arthroplasty
Repair or reconstruction of the lateral collateral ligament (LCL) complex
Repair or reconstruction of the medial collateral ligament (MCL) This represents a terrible triad injury, with elbow dislocation, radial head fracture, and coronoid fracture. The LCL complex is typically disrupted in this injury pattern. Repair or reconstruction of this structure provides the greatest increase in rotational stability of the elbow.

Correct Answer: Repair or reconstruction of the lateral collateral ligament (LCL) complex

Explanation:

Question 40:

Options:

Axillary view
CT of the shoulder
Closed reduction
Sling and close follow-up
Functional brace

Correct Answer: Axillary view

Explanation:

Question 41:

Options:

Transverse incision across the posterior peritoneum and disk space, reflecting the tissues toward the sacral promontory
Transverse incision across the posterior peritoneum and disk space, reflecting the tissues toward the confluence of the iliac veins
Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the left iliac vein and extending toward the right iliac vein
Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the right iliac vein extending toward the left iliac vein
Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues bilaterally away from the midline

Correct Answer: Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the left iliac vein and extending toward the right iliac vein

Explanation:

Question 42:

Options:

Revise the tibial tunnel to be more oblique.
Revise the tibial tunnel to be more posterior.
Convert to a transtibial double-bundle ACL.
Prepare the femoral tunnel via an anteromedial portal or two-incision technique.
Hyperflex the knee and place the femoral tunnel with the transtibial guide.

Correct Answer: Prepare the femoral tunnel via an anteromedial portal or two-incision technique.

Explanation:

Question 43:

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Options:

within 1 standard deviation of aged-matched normals.
within 1 and 2.5 standard deviations below aged-matched normals.
within 1 standard deviation of young normals.
within 1 and 2.5 standard deviations below young normals.
more than 2.5 standard deviations below aged-matched normals.

Correct Answer: within 1 and 2.5 standard deviations below young normals.

Explanation:

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.
The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 44:

Options:

2 to 5 days, followed by initiation of assisted motion.
14 to 21 days, followed by initiation of assisted motion.
4 weeks, followed by active motion.
6 weeks, followed by physical therapy.
8 weeks, followed by active motion of the elbow.

Correct Answer: 2 to 5 days, followed by initiation of assisted motion.

Explanation:

Question 45:

Options:

aspiration and steroid injection.
rest.
acromioplasty.
arthroscopic repair and decompression.
rehabilitation.

Correct Answer: arthroscopic repair and decompression.

Explanation:

Question 46:

A year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Options:

Vacuum-assisted wound closure dressing
Intravenous antibiotics for 6 weeks, followed by long-term oral antibiotic administration
Irrigation and debridement, followed by polyethylene exchange
Two-stage debridement and reconstruction

Correct Answer: Two-stage debridement and reconstruction

Explanation:

Question 47:

Options:

Subacromial corticosteroid injection
Aspiration of the subacromial and glenohumeral joint spaces
Nonsteroidal anti-inflammatory drugs
Extensive surgical debridement
Diagnostic arthroscopy

Correct Answer: Aspiration of the subacromial and glenohumeral joint spaces

Explanation:

Question 48:

Which of the following articulation couplings shows the lowest coefficient of friction as tested in the laboratory?

Options:

Cobalt-on-polyethylene
Cobalt-on-cobalt
Titanium-on-polyethylene
Stainless steel-on-polyethylene
Ceramic-on-ceramic

Correct Answer: Ceramic-on-ceramic

Explanation:

Question 49:

Options:

Use a larger femoral component
Use a thinner polyethylene insert
Add posterior femoral augments
Resect more proximal tibia
Resect additional distal femur

Correct Answer: Resect additional distal femur

Explanation:

DISCUSSION: The reconstruction requires additional resection of the distal femur to allow increased extension while maintaining the current flexion gap tension. Resecting more proximal tibia or decreasing the tibial polyethylene thickness will decrease flexion tension as well as extension tension. Adding posterior femoral augments and using a larger femoral component will increase flexion tension.
REFERENCES: Ayers DC, Dennis DA, Johanson NA, et al: Common complications of total knee arthroplasty. J Bone Joint Surg Am 1997;79:278-311.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 281-286.

Question 50:

A 7-year-old girl is hit by a motor vehicle and sustains the isolated ipsilateral injuries shown in Figures 16a and 16b. What is the optimal definitive method of treatment?

Options:

Spica cast immobilization
Rigid reamed nailing of the femur and a short leg cast
Flexible nailing of the femur and tibia
Reamed nails of the femur and tibia
Spanning external fixator

Correct Answer: Flexible nailing of the femur and tibia

Explanation:

DISCUSSION: The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur.
REFERENCES: Poolman RW, Kocher MS, Bhandari M: Pediatric femoral fractures:
A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-654.
Anglen JO, Choi L: Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733.
Beaty JH: Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 2005;434:114-122.

Question 51:

Options:

Physical therapy
Arthroscopic synovectomy
Tibial insert revision
Femoral component revision

Correct Answer: Arthroscopic synovectomy

Explanation:

Question 52:

An axillary nerve lesion may cause weakness in the deltoid and the

Options:

teres major.
teres minor.
teres major and teres minor.
latissimus dorsi.
latissimus dorsi and teres major.

Correct Answer: teres minor.

Explanation:

DISCUSSION: While the most prominent functional deficit from axillary nerve lesions occurs from denervation of the deltoid, denervation of the teres minor also occurs.
REFERENCE: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs. New York, NY, Harper & Row, 1969.

Question 53:

Options:

cast wedging in the outpatient clinic.
closed reduction under anesthesia and application of a new long leg cast.
reduction and placement of an intramedullary rod.
anatomic open reduction and compression plating with interfragmentary screws.
pins and plaster to maintain the reduction.

Correct Answer: cast wedging in the outpatient clinic.

Explanation:

Question 54:

Options:

Radial
Ulnar
Anterior interosseous
Axillary
Musculocutaneous

Correct Answer: Musculocutaneous

Explanation:

Question 55:

Which of the following materials best approximates the Young's modulus of elasticity of cortical bone?

Options:

Titanium
Cobalt-chrome alloy
Alumina
Zirconia
Stainless steel

Correct Answer: Cobalt-chrome alloy

Explanation:

Question 56:

A 21-year-old pregnant female arrives in the trauma bay with a closed head injury as well as an open ankle injury. During evaluation, what positioning is recommended to limit positional hypotension?

Options:

Reverse trendelenburg
Trendelenburg
Left lateral decubitus
Right lateral decubitus
Supine

Correct Answer: Reverse trendelenburg

Explanation:

Question 57:

Options:

Metastatic bone disease
Multiple myeloma
Lymphoma
Chondrosarcoma
Malignant fibrous histiocytoma The biopsy specimen shows round, epithelial-like cells that are grouped in clusters. The cells are arranged in a fibrous background. The diagnosis is metastatic bone disease. The treatment of metatastic bone disease is either internal fixation with postoperative external beam irradiation or external beam irradiation alone. In this case, there is extensive destruction and fracture is imminent. The treatment of choice is acetabular reconstruction followed by external beam irradiation.

Correct Answer: Malignant fibrous histiocytoma The biopsy specimen shows round, epithelial-like cells that are grouped in clusters. The cells are arranged in a fibrous background. The diagnosis is metastatic bone disease. The treatment of metatastic bone disease is either internal fixation with postoperative external beam irradiation or external beam irradiation alone. In this case, there is extensive destruction and fracture is imminent. The treatment of choice is acetabular reconstruction followed by external beam irradiation.

Explanation:

Slide 1 Slide 2 Slide 3 Slide 4
A 50-year-old woman has had severe hip pain for 4 months. Her plain radiographs (Slide 1), technetium bone scan (Slide 2), computerized tomography scan (Slide 3), and coronal T1- and T2-weighted magnetic resonance images (Slide 4) are presented. The most likely diagnosis based upon the radiographs would be:

Question 58:

Options:

there is less risk to regional neurologic structures.
of superior bone purchase.
they more definitively stabilize the posterior fracture.
they may be more easily applied in the emergency department setting.
there is less risk of intra-articular hip joint penetration.

Correct Answer: of superior bone purchase.

Explanation:

Question 59:

01 (left). What is the most appropriate next step?

Options:

Splint the knee and admit the patient for hourly ankle brachial index monitoring
Emergent vascular surgical exploration
Emergent external fixation and reassessment of perfusion
CT angiography and admit the patient for hourly neurovascular checks
Interventional radiology consult for formal angiography and stenting

Correct Answer: Emergent external fixation and reassessment of perfusion

Explanation:

Question 60:

Options:

Hip radiograph
Knee radiograph
MRI of both shoulders
Cervical spine radiographs, including flexion and extension views
Arthrography of both shoulders

Correct Answer: Cervical spine radiographs, including flexion and extension views

Explanation:

DISCUSSION: Rheumatoid arthritis is sometimes associated with radiographic evidence of instability of the cervical spine. In a study by Grauer and associates, radiographs of the cervical spine of patients with rheumatoid arthritis who had undergone total joint arthroplasty over a
5-year period were retrospectively reviewed. Nearly one half of the patients had radiographic evidence of cervical instability on the basis of traditional measurements. While radiographic evidence of cervical instability was not infrequent in this population of patients who underwent total joint arthroplasty for rheumatoid arthritis, radiographic predictors of paralysis were much less common. MRI prior to surgery may also be a consideration if the radiographic appearance of the rotator cuff alters the consideration of surgical treatment. In a series of patients undergoing prosthetic arthroplasty for a variety of shoulder disorders, the presence of a rotator cuff tear has been shown to be associated with a less favorable outcome. Most often, the presence of a rotator cuff tear was associated with a diagnosis of rheumatoid or other inflammatory arthritis and the tears were large and generally irreparable. Some case series demonstrated a higher prevalence of loosening of the glenoid component in patients with a large rotator cuff tear associated with superior migration of the humeral head. However, obtaining an MRI scan of the shoulder is not considered the best response since failure to determine cervical instability may result in anesthetic death. Whereas MRI may be helpful in planning reconstruction, it would be a less important priority.
REFERENCES: Grauer JN, Tingstad EM, Rand N, et al: Predictors of paralysis in the rheumatoid cervical spine in patients undergoing total joint arthroplasty. J Bone Joint Surg Am 2004;86:1420-1424.
Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.

Question 61:

Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles generated by metal-on-metal articulations are

Options:

larger and less numerous.
larger and more numerous.
smaller and less numerous.
smaller and more numerous.
not detectable.

Correct Answer: smaller and more numerous.

Explanation:

DISCUSSION: Retrieval studies have shown that the debris particles produced by
metal-on-metal articulations in total hip arthroplasty are several orders of magnitude smaller
and may be up to 100 times more numerous than those found with metal-on-polyethylene articulations.
REFERENCES: Davies AP, Willert HG, Campbell PA, et al: An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements.
J Bone Joint Surg Am 2005;87:18-27.
Firkins PJ, Tipper JL, Saadatzadeh MR, et al: Quantitative analysis of wear and wear debris from metal-on-metal hip prostheses tested in a physiological hip joint simulator. Biomed Mater Eng 2001;11:143-157.

Question 62:

Options:

Continued dressing changes
Split-thickness skin graft C. Full-thickness skin graft D. Local rotational flap

Correct Answer: Continued dressing changes

Explanation:

Question 63:

Options:

revision of all components to ensure patellar tracking.
athroscopic debridement.
arthrotomy and keloid excision.
intra-articular corticosteroid injections.
patellar component revision.

Correct Answer: athroscopic debridement.

Explanation:

Question 64:

Options:

Age > 60 years
> or = 2 comorbid conditions
History of tobacco use
BMI > 30 kg/m²
Using a pedicle subtraction osteotomy

Correct Answer: > or = 2 comorbid conditions

Explanation:

Question 65:

Bone morphogenetic proteins transduce intracellular signal through what class of cell surface receptor?

Options:

Mitogen-activated protein kinase
Tyrosine kinase
Serine-threonine kinase
Aurora kinase
Glycogen synthase kinase 3

Correct Answer: Serine-threonine kinase

Explanation:

Question 66:

Options:

Tension pneumothorax
Inadvertent epidural injection
Inadvertent intravascular injection
Laryngeal nerve block
Bezold-Jarisch reflex

Correct Answer: Bezold-Jarisch reflex

Explanation:

Question 67:

Which of the following characteristics is seen in patients with osteochondritis dissecans of the elbow? Review Topic

Options:

MRI reveals separation of cartilage from the capitellum and chondral fissuring
Fragmentation of the entire capitellar ossific nucleus
Normal capitellar regrowth with no late sequelae
Age younger than 10 years
Medial ulnar collateral ligament laxity

Correct Answer: MRI reveals separation of cartilage from the capitellum and chondral fissuring

Explanation:

Question 68:

Where is the most common site for tuberculosis (TB) spondylitis in children?

Options:

Anterior aspect of the lower thoracic region
Anterior aspect of the cervical spine
Posterior elements of the lower thoracic region
Posterior elements of the cervical spine
Transverse process of the lower lumbar spine

Correct Answer: Anterior aspect of the lower thoracic region

Explanation:

DISCUSSION: In children, the main route of infection in skeletal TB is through hematogenous spread from a primary source. The mycobacterium is deposited in the end arterials in the vertebral body adjacent to the anterior aspect of the vertebral end plate. Thus, the anterior portion of the vertebral body is most commonly involved. The lower thoracic region is the most common segment; next in decreasing order of frequency are the lumbar, upper thoracic, cervical, and sacral regions.
REFERENCES: Teo HE, Peh WC: Skeletal tuberculosis in children. Pediatric Radiol 2004;34:853-860.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 1831-1835.

Question 69:

- Which of the following factors is used to determine torsional rigidity of a long bone fracture under internal or external fixation?

Options:

Bone rotation versus torque applied
Bone deflection versus bending moment applied
Axial displacement versus tension applied
Lateral translation versus shear force applied
Fracture gap closing versus compressive force applied

Correct Answer: Bone rotation versus torque applied

Explanation:

Question 70:

Options:

a skeletal survey to rule out other fractures.
a punch biopsy of the skin for collagen analysis to rule out osteogenesis imperfecta.
DNA testing for osteogenesis imperfecta.
blood studies for calcium, phosphorus, and alkaline phosphate levels.
blood studies for parathyroid hormone levels.

Correct Answer: DNA testing for osteogenesis imperfecta.

Explanation:

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
(SBQ13PE.60) If a child develops dynamic supination after treatment of idiopathic clubfoot with Ponseti casting, at what age would it be appropriate to consider transfer of the tibialis anterior tendon to the lateral dorsum of the foot?
Review Topic
In the first six months of life, immediately following failed cast treatment
12 months
4 years
12 years
15 years
Tibialis tendon transfer to the dorsum of the foot should be performed to address dynamic supination when the lateral cuneiform has ossified. This is typically after at least 2 years of age and usually not before age 3.

Question 71:

Options:

Intramuscular hematoma
Lipoma
Myositis ossificans
Malignant fibrous histiocytoma
Liposarcoma

Correct Answer: Malignant fibrous histiocytoma

Explanation:

DISCUSSION: Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma. MFH typically presents as a large mass, deep to the fascia with heterogeneous signal on MRI. The MRI scans show a heterogeneous lesion in the posterior thigh. There is significant high signal uptake on the T
2
-weighted image. The histology shows malignant histiocytic cells with marked atypia and pleomorphism. Histology of a hematoma would show only old hemorrhage and some granulation tissue. Lipoma and liposarcoma are both seen as a fat-containing lesion on histology. No significant fat tissue is seen in this histologic specimen. Histology of myositis ossificans would show bone formation.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.
Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 965-981.

Question 72:

What is the most common complication following total disk arthroplasty in the lumbar spine?

Options:

Implant migration
Deep venous thrombosis
Transient retrograde ejaculation
Transient radicular leg pain
Incisional hernia

Correct Answer: Transient radicular leg pain

Explanation:

Question 73:

Thoracic disk herniations most typically occur at what level of the thoracic spine? Review Topic

Options:

Upper third
Junction of upper third and middle third
Middle third
Junction of middle third and lower third
Lower third

Correct Answer: Lower third

Explanation:

Question 74:

Which of the following clinical findings is commonly associated with symptomatic partial-thickness rotator cuff tears?

Options:

Negative impingement signs
Abnormal lift-off test
External rotation lag sign
Painful arc with active range of motion
Mismatch in active and passive motion

Correct Answer: Painful arc with active range of motion

Explanation:

Question 75:

Options:

physical therapy for quadriceps strengthening exercises.
a long leg cast with the knee fully extended.
excision of the fragment.
suture reattachment of the patellar tendon to the tibial tuberosity.
open reduction and tension band fixation.

Correct Answer: open reduction and tension band fixation.

Explanation:

DISCUSSION: The radiograph shows an avulsion fracture, or “sleeve fracture,” of the distal pole of the patella. The distal fragment is much larger than it appears on the radiograph because it largely consists of cartilage; therefore, excision of the fragment is contraindicated. The treatment of choice is open reduction and tension band fixation to correct patella alta and restore the extensor mechanism.
REFERENCES: Maguire JK, Canale ST: Fractures of the patella in children and adolescents.
J Pediatr Orthop 1993;13:567-571.
Grogan DP, Carey TP, Leffers D, et al: Avulsion fractures of the patella. J Pediatr Orthop 1990;10:721-730.

Question 76:

Options:

Metastatic lung carcinoma
Mucous cyst
Synovial sarcoma
Inclusion cyst
Felon abscess

Correct Answer: Mucous cyst

Explanation:

DISCUSSION: A mucous cyst is thought to be a ganglion arising from the DIP joint in patients with osteoarthritis. They are frequently associated with nail deformities. Treatment involves removal of the cyst with debridement of DIP joint osteophytes.
REFERENCES: Fritz GR, Stern PJ, Dickey M: Complications following mucous cyst excision. J Hand Surg Br 1997;22:222-225.
Zook EG, Brown RE: The perionychium, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 1353-1380.

Question 77:

Which of the following mechanisms is considered the most common cause of failure of osteoarticular allografts used for articular reconstruction?

Options:

Osteocyte surface antigens that trigger an immune rejection
Chondrocyte surface antigens that trigger an immune rejection
Graft collapse during revascularization
Mechanical loosening at the bone-bone junction
Infection via graft contamination

Correct Answer: Graft collapse during revascularization

Explanation:

Question 78:

Options:

Anterior tibialis tendon transfer to the dorsolateral midfoot
Posterior tibialis tendon transfer to the dorsolateral midfoot
Peroneus longus tendon transfer to the dorsolateral midfoot
Peroneus brevis tendon transfer to the dorsolateral midfoot
Flexor hallucis longus tendon transfer to the peroneus brevis

Correct Answer: Peroneus longus tendon transfer to the dorsolateral midfoot

Explanation:

DISCUSSION: Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus. Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque.
REFERENCES: Hansen ST: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott, Williams & Wilkins, 2000, pp 433-435.
Vienne P, Schoniger R, Helmy N, et al: Hindfoot instability in cavovarus deformity: Static and dynamic balancing. Foot Ankle Int 2007;28:96-102.

Question 79:

Which of the following is considered the best cementless acetabular reconstruction method when planning for total hip arthroplasty in a patient with developmental dysplasia of the hip (DDH)?

Options:

Cemented reconstruction with the cup in an anatomic position and cement filling the defect
Medialized component positioning with no femoral head graft, leaving up to 20% of the shell uncovered
High and lateral positioning of the acetabular component with a femoral head graft
Anatomic positioning of a small shell with a 28-mm liner and 4 mm of polyethylene
Anatomic positioning of the cup and a femoral head graft covering 70% of the cup

Correct Answer: Medialized component positioning with no femoral head graft, leaving up to 20% of the shell uncovered

Explanation:

Question 80:

Options:

Add double metal uprights and a leather corset.
Add a supracondylar suspension to the soft suspension.
Add supracondylar and suprapatellar suspensions to the socket design.
Replace the socket insert with a silicone suction socket with locking bolt suspension.
Replace the prosthetic socket with a negative pressure vacuum system.

Correct Answer: Add double metal uprights and a leather corset.

Explanation:

Question 81:

Options:

repeat closed reduction and buddy taping.
closed reduction and percutaneous pin fixation, followed by casting.
open reduction and plate fixation, followed by casting.
open reduction and screw fixation, followed by splinting and early motion.
open reduction and intramedullary fixation with absorbable implants.

Correct Answer: closed reduction and percutaneous pin fixation, followed by casting.

Explanation:

DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.

Question 82:

Options:

Resistance to adhesive wear
Resistance to abrasive wear
Resistance to fatigue wear
Resistance to creep

Correct Answer: Resistance to abrasive wear

Explanation:

Question 83:

Options:

Closed reduction and percutaneous pinning
Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 0.5 cm anterior to the Achilles tendon, and horizontal limb at the junction of the lateral skin and the plantar glabrous skin
Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 2.0 cm anterior to the Achilles tendon, and horizontal limb 2.0 cm proximal to the line marking the plantar glabrous skin
Sinus tarsi approach
Ollier approach

Correct Answer: Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 0.5 cm anterior to the Achilles tendon, and horizontal limb at the junction of the lateral skin and the plantar glabrous skin

Explanation:

Question 84:

Options:

Distal femoral osteotomy
Unicompartmental knee replacement
High tibial osteotomy (HTO), lateral closing wedge
HTO, medial opening wedge with decreased tibial slope

Correct Answer: HTO, medial opening wedge with decreased tibial slope

Explanation:

Question 85:

Options:

A 45-year-old woman has a slowly enlarging mass over the radial aspect of her middle finger at the level of the proximal interphalangeal joint. It is associated with decreased flexion of the joint and clinically is fixed to the underlying bone. Radiographs reveal erosion of the lateral cortex of the proximal phalanx. Gross observation at the time of surgery reveals that the mass has a yellowish-brown tint and lobulated areas. Histology demonstrates bland fibrous stroma with scattered histiocytes, giant cells, and hemosiderin. What is the most likely diagnosis?
Epithelioid sarcoma
Giant cell tumor of tendon sheath
Gouty tophus
Hemangioma
Epithelial inclusion cyst

Correct Answer: Epithelioid sarcoma

Explanation:

The clinical and pathologic description is typical of a giant cell tumor of tendon sheath. Epithelioid sarcoma is the most common soft-tissue sarcoma in the hand and is composed of a nodular arrangement of tumor cells with epithelioid appearance and eosinophilia with a tendency to undergo central degeneration and ulceration. Gouty tophi have a characteristic white, chalky gross appearance and will demonstrate negatively birefringent crystals on polarized light microscopy. Hemangiomas are composed of a variable amount of fat and vessels. Epithelial inclusion cysts are filled with keratin from desquamation of the hyperkeratotic, stratified squamous epithelial cells that line the cysts.
A 56-year-old right hand dominant male presents to your office complaining of right thumb pain worsened with pincer grip and using his mobile phone. He is a writer, and is having difficulty holding his pen. Radiographs from this visit are shown in Figure A. Compared with trapeziectomy alone, which of the following treatment options is likely to result in superior pain relief and improvement of key-pinch strength?
Trapeziometacarpal corticosteroid injection followed by aggressive occupational therapy
Trapeziectomy with interpositional palmaris longus arthroplasty
Trapeziectomy, interpositional arthroplasty, and palmar oblique ligament reconstruction using flexor carpi radialis autograft
Partial trapeziectomy with capsular interpositional arthroplasty
None of the above
CORRECT ANSWER: 5
This patient has symptomatic basal joint arthritis with radiographic evidence of pantrapezial arthritis. Simple trapeziectomy has been shown to provide pain relief and improvement of key-pinch strength that is comparable to trapeziectomy plus interpositional arthroplasty.
Definitive surgical management of basal joint arthritis commonly involves excision of the diseased trapezium with concomitant interpositional arthroplasty at the carpometacarpal joint in an effort to mantain the height of the metacarpal. This is commonly done with flexor carpi radialis (FCR) or palmaris longus (PL) autograft. Recent studies have called into question the need for interpositional arthroplasty, suggesting that excision of the trapezium alone can provide non-inferior results.
Davis et. al. randomized 183 symptomatic trapeziometacarpal joints to one of three procedures: trapeziectomy alone, trapeziectomy with palmaris longus interpositional arthroplasty, or trapeziectomy with FCR interpositional arthroplasty and reconstruction of the palmar oblique ligament. For all patients, the thumb metacarpal was percutaneously pinned to the distal pole of the scaphoid to maintain the height of the digit. Patients were evaluated at three and 12 months post-operatively. At both time-points, they found no difference between groups with respect to subjective accounts of pain, function, stiffness, and weakness. Objective measures of thumb key-pinch strength were no different at either time point. The authors concluded that there may be no benefit to ligament reconstruction or tendon interposition in
the short term.
Li et. al. performed a systematic review of four randomized controlled trials and two systematic reviews to evaluate outcomes of trapeziectomy with and without LRTI for treatment of basal joint osteoarthritis. In their review, there were no statistically significant differences in post-op grip strength, pinch strength, visual analog pain scores, DASH scores, and complications. The authors concluded that both procedures produced similar clinical results.
Raven et. al. performed a retrospective analysis of 54 patients who underwent one of three procedures for basal joint osteoarthritis: resection arthroplasty, trapeziectomy with tendon interposition, or trapeziometacarpal arthrodesis.
The authors found resection arthroplasty to be a simple procedure with longterm results pain and functional outcomes comparable to trapeziectomy with tendon interposition.
Naram et. al. retrospectively reviewed 200 patients who underwent simple trapeziectomy with or without LRTI and with or without Kirschner wire stabilization, or a Weilby ligament reconstruction. They found that patients undergoing trapeziectomy with LRTI or a Weilby procedure had a greater incidence of complications compared to trapeziectomy alone, including infection and reoperation.
Figure A is a plain radiograph demonstrating pantrapezial arthritis with the thumb trapeziometacarpal joint being most significantly affected.
Incorrect Answers:
A 31-year-old patient has had a left medial elbow mass for 1 month. The mass has been increasing in size and has now become very painful and erythematous. MRI scans are shown in Figures 76a and 76b. Laboratory studies show an erythrocyte sedimentation rate of 49 mm/h (normal 0 to 20 mm/h) and C-reactive protein level of 23 mg/L (normal 0 to 0.3 mg/L). Histology showed lymphoid tissue and multiple necrotizing granulomas. What organism is responsible for this clinical picture?
Borrelia burgdorferi
Trichophyton tonsurans
Bartonella henselae
Mycobacterium avium
Corynebacterium minutissimum
Cat scratch disease (CSD) is an important diagnosis for the orthopaedic surgeon to consider in the differential diagnosis of soft-tissue masses adjacent to epitrochlear or cervical lymph nodes. It is a soft-tissue tumor simulator and a high index of suspicion is necessary in all patients with upper extremity or head and neck adenopathy and a history of cat exposure. Although generally not required for diagnosis, cross-sectional imaging will reveal a mass with surrounding edema in an area of lymphatic drainage. A peripheral blood sample can be tested for Bartonella henselae - the offending organism with this diagnosis. Classically the histology of these lesions when biopsied will show multiple necrotizing granulomas. Mycobacterium avium is the only other organism that would demonstrate a granulomatous reaction and the location is classic for CSD. Borrelia burgdorferi is associated with Lyme disease.
Mycobacterium avium may be a source of immunocompromised infections in HIV patients. Trichophyton tonsurans and corynebacterium minutissimum are not associated with orthopaedic diseases.
A 45-year-old woman has a painful mass in the dorsum of the right wrist. It is firm and nontender to palpation. She states it has slowly gotten bigger over the past 3 years. You suspect a dorsal wrist ganglion. What is the most definitive way to confirm this diagnosis?
Observe it for 1 year to see if it changes dramatically in size.
Obtain a gadolinium enhanced MRI scan.
Obtain radiographs, looking for scapholunate joint degenerative changes.
Perform a needle aspiration and send the aspirate for cytologic examination.
Apply direct firm manual pressure over the mass to see if it can be ruptured.
Dorsal wrist ganglions are synovial cysts that arise most frequently from the scapholunate joint. They often extend between the extensor digitorum communis and extensor pollicis longus tendons at the wrist. Aspiration of the cyst is both oncologically safe if done appropriately and also the easiest way to definitively confirm the diagnosis. Clear, yellow viscous fluid/gel is most often aspirated. Cytologic evaluation is mandatory to exclude myxoid neoplasms.
Because the lesion has been present for 3 years, further observation is not warranted. The classic presentation, physical examination findings, and location make MRI and radiographs unnecessary. Manual rupture of the mass is not recommended.
A 28-year-old man fell while ice skating 6 months ago and has had ulnar-sided wrist pain ever since. The patient's wrist radiograph is shown in Figure A and a CT scan is shown in Figure B. What is the most appropriate treatment?
Scapholunate ligament repair
Excision of the hook hamate
Excision of the pisiform
Open reduction internal fixation of the hamate
Open reduction internal fixation of the pisiform
Based on clinical history and imaging shown, this patient has developed a pisiform fracture nonunion. Treatment of symptomatic nonunions of the pisiform is by pisiformectomy
Fractures of the pisiform are rare. They often occur in conjunction with injuries to the distal radius or carpus. Non-operative management with cast immobilization in 30 degrees of wrist flexion is the first line of treatment.
Symptomatic nonunions are treated with pisiformectomy.
Palmieri et al. performed pisiformectomies on 21 patients who had pisiform area pain that was refractory to conservative management. Patients had a history of painful union or nonunion of pisiform fractures, arthritis or FCU tendonitis. In all cases, wrist strength and mobility was retained.
Lam et al. reviewed the effect of pisiform excision on wrist function in patients with piso-triquetral dysfunction. After an average follow up of 65 months, 75%
of patients had complete relief of pisiform area symptoms. No differences in grip, wrist motion, strength or power were found in comparison to the contralateral side.
Figure A shows an oblique radiograph of a pisiform fracture nonunion. Figure B shows an axial CT scan sequence of the wrist. A pisiform fracture nonunion is identified with subtle comminution. The pisotriquetral joint appears to be congruent.
Incorrect Answers
A 32-year-old woman jammed her ring finger. Figures 77a and 77b show radiographs of the finger after a closed reduction. Which of the following interventions, if done correctly, is likely to result in the best possible final clinical outcome?
Early removal of a splint and application of continuous passive motion
Application of dynamic extension bracing after the first week
Maintaining reduction of the middle phalanx on the condyles of the proximal phalanx with dynamic external fixation
Open reduction and anatomic restoration of the middle phalanx articular surface
Surgical advancement of the volar plate into the middle phalanx base
The most important determinant in the final clinical outcome in proximal interphalangeal (PIP) joint fracture locations is the maintenance of the PIP joint alignment on the lateral view. This can sometimes be done with just extension block splinting, sometimes the fracture requires dynamic external fixation, and sometimes the fracture requires open reduction or volar plate arthroplasty. Good function can be the result in the setting of an incongruent middle phalanx base as long as the PIP joint alignment is maintained.
Continuous passive motion has not been shown to be of benefit. Whereas dynamic external fixation in a flexed position is a very good treatment, dynamic extension bracing will just precipitate loss of PIP joint reduction and is therefore not indicated. Whereas open reduction of the articular surface is theoretically desirable, it is generally impossible in the setting of the comminution of the volar middle phalanx base. Furthermore, open reduction and internal fixation by itself does not guarantee that the PIP joint alignment will be maintained, and typically it causes finger stiffness given the extensive surgical approach. Likewise, volar plate arthroplasty is a surgery of last resort and requires careful attention to PIP joint alignment before joint pinning. In this case, with characteristics of comminution, dynamic external fixation is the preferred choice.
A 20-year-old woman sustained a laceration to her volar forearm 4 cm proximal to the wrist flexion crease. She has numbness in the thumb, index, and middle fingers. After microscopic repair of the median nerve, 2 weeks of splinting, and commencement of a hand therapy program, the patient is most likely to require what secondary operation 6 months after the injury?
Tenolysis of the profundus tendons at the wrist
Nerve transfer of the ulnar motor nerve to the median motor nerve
Opponensplasty with the extensor indicis
Open carpal tunnel release
Transfer of the extensor digiti minimi to the first dorsal interosseous tendon
The patient sustained a laceration of the median nerve in what would be considered a low median nerve injury. Standard treatment entails exploration and microscopic repair of the median nerve. With a good quality nerve repair in a young adult, return of some sensory function (albeit reduced compared with the normal nerve) is usual. Return of motor function to the thenar muscles is more unpredictable. If the patient begins a therapy program within a few weeks after nerve repair, it is unlikely that tenolysis of the profundus tendons would be required. An open carpal tunnel release would be unlikely to change functional return. The patient would not be expected to have lost first dorsal interosseous function after a median nerve laceration because this muscle is innervated by the ulnar nerve. A neurotization procedure for low median nerve palsy has been described, but it consists of transfer of the distal anterior interosseous nerve into the median nerve motor fascicles, not transfer of the ulnar nerve. Therefore, the most likely secondary procedure required in this scenario is an opponensplasty procedure to improve thumb opposition.
What is the most efficient pressure for use with negative pressure wound therapy?
25 mm Hg
75 mm Hg
125 mm Hg
300 mm Hg
500 mm Hg
CORRECT ANSWER: 3
In animal and clinical studies, a range of pressures between 50 mm Hg to 500 mm Hg were tested; the most efficient pressure was 125 mm Hg, resulting in a fourfold increase in blood flow, 63% increase in granulation tissue with continuous pressure, and 103% increase in granulation tissue with intermittent pressure. When 125 mm Hg pressures were compared with either those less than 50, or those greater than 250, there was a decrease in granulation tissue in swine models.
Figures 125a and 125b are the current radiographs of a 52-year-old man who sustained an injury to his dominant wrist 8 weeks ago. He is an alcoholic and does not remember the details of how he injured it. Paperwork showing what treatment he received at an
urgent care facility indicates that he was given a splint for his "sprained wrist." Examination reveals the pain is getting better, but there is persistent swelling and range of motion is very limited.
Recommended treatment at this time should consist of
discontinuation of the splint and commencement of a regimen of hand therapy.
casting for an additional 2 weeks and reassessment of the fracture healing at that time.
open reduction and internal fixation of the injury.
proximal row carpectomy.
wrist arthrodesis.
The injury represents a very uncommon presentation of a perilunate injury pattern. Whereas these injuries are sometimes overlooked on initial radiographic studies, they are usually recognized much sooner. In this case of a late presenting perilunate injury in a patient that is not entirely responsible, a proximal row carpectomy represents the best treatment option. Open reduction and internal fixation is generally not successful because of cartilage degeneration and contracture that has developed in the interim. No further splinting or casting is indicated, and neglecting the injury would be indicated only if the patient refused any further treatment. Wrist arthrodesis is generally indicated only as a salvage procedure if a proximal row carpectomy is unsuccessful.
A 47-year-old woman sustained a nondisplaced distal radius fracture 6 months ago and is unable to extend her thumb. When performing reconstruction using the extensor indicis proprius to the extensor pollicis longus transfer, tension is ideally determined by securing the tendons in what manner?
In maximum tension with the wrist and thumb in extension
In maximum tension with the wrist and thumb in neutral
In maximum tension with the wrist and thumb in flexion
According to the tenodesis effect with wrist flexion and extension
According to functional testing with the patient awake under local anesthesia
Extensor pollicis longus rupture can result from distal radius fractures. Synergistic tendon transfer can be achieved using the extensor pollicis longus as the motor donor. Whereas different schemes for achieving optimal tension are available, the most reliable method is to tension the repair under local anesthesia while asking the patient to perform thumb flexion and extension. Tendon transfer tension can be adjusted accordingly to achieve maximum extension without compromising active flexion range. Other methods of tensioning are estimates at best, and maximum tensioning in patients without neuromuscular disease is rarely used in tendon transfers.
Which of the following substances is likely to cause the most soft-tissue damage in the long term if injected into a fingertip under
high pressure?
Grease
Latex paint
Water
Oil-based paint
Chlorofluorocarbon-based refrigerant
This type of injury represents a difficult problem in hand surgery. The factors that most determine outcome after high-pressure injection injuries into the fingertip include: involvement of the tendon sheath, extent of proximal spread of the injected substance, pressure setting, and delay to surgical treatment.
The other factor that likely is most important is the type of substance injected. Water and latex-based paints are least destructive. Grease and chlorofluorocarbon-based substances are intermediate, but aggressive surgical debridement can restore reasonable function. Oil-based paints are highly inflammatory and can cause such chronic inflammation such that amputation may be the only reasonable treatment option despite early aggressive surgical treatment.
A 37-year-old woman has right-hand numbness and tingling. Based on the history and examination, carpal tunnel syndrome is suspected, and electrodiagnostic tests also point to the same diagnosis. The patient has worn night splints for the last 8 weeks with continued persistent symptoms. What is the next most appropriate step in management?
Continue the night splinting for 1 additional month.
Continue the night splinting for 3 more months.
Switch to full-time splinting and reevaluate in 1 month.
Switch to full-time splinting for 3 more months.
Perform carpal tunnel release.
Various nonsurgical management options exist for carpal tunnel syndrome (local and oral steroids, splinting, and ultrasound). All effective or potentially effective nonsurgical forms of management have measureable effects on symptoms within 2 to 7 weeks of the initiation of treatment. If a treatment is not effective within that time frame, a different treatment option should be
chosen. In this case, continued splinting is unlikely to improve symptoms and steroid injection or surgery is indicated.
A 46-year-old man sustains an injury to his left index finger while cleaning his paint gun with paint thinner. Examination reveals a small puncture wound at the pulp. The finger is swollen. What is the next most appropriate step in management?
Elevation and observation
Surgical debridement and lavage
Infiltration with corticosteroids
Infiltration with a neutralizing agent
Administration of antibiotics
High-pressure injection injuries are associated with a high risk of amputation. The risk of amputation is highest with organic solvents. The presence of infection and the use of steroids do not impact the amputation rate.
Amputation risk is lower if surgical debridement is performed within 6 hours. Elevation and observation would delay necessary care. Neutralizing agents may be used in specific situations, such as hydrofluoric acid exposure or chemotherapeutic agent extravasation, but in high pressure paint thinner injection, the best outcome is achieved through early surgical lavage.
A 54-year-old woman who has a history of undergoing left trapezium excision with ligament reconstruction and tendon interposition using the entire flexor carpi radialis performed by another surgeon, now reports left basilar thumb pain. Examination reveals pain and subluxation of the carpometacarpal joint with axial loading. The metacarpophalangeal joint hyperextends to 60 degrees, but radiographs show intact joint space. What is the best option to improve function?
Bracing with a hand-based thumb spica splint
Pinning of the carpometacarpal joint
Pinning of the carpometacarpal and metacarpophalangeal joints
Carpometacarpal revision stabilization
Carpometacarpal revision stabilization and metacarpophalangeal joint fusion
The patient previously underwent ligament reconstruction and tendon interposition. However, the previous surgeon failed to address metacarpophalangeal joint hyperextension, which leads to adduction contracture and collapse of the basilar joint. With the basilar joint causing pain and instability, repeat ligament reconstruction should be performed. Splinting alone is unlikely to resolve instability problems. Because the flexor carpi radialis was used, the next option is to use the abductor pollicis longus.
Additionally, the severe metacarpophalangeal joint hyperextension should be corrected by fusion. Simple pinning is unlikely to provide long-term stability when this degree of hyperextension exists.
When evaluating a patient with suspected purulent flexor tenosynovitis in the thumb, the distal forearm and little finger are found to be swollen as well. The most likely anatomic explanation is the existence of a potential space in which of the following?
Through the carpal tunnel
Across the midpalmar space
Communicating with the subcutaneous tissue
Superficial to the distal antebrachial fascia
Between the fascia of the pronator quadratus and flexor digitorum profundus conjoined tendon sheaths
Pyogenic flexor tenosynovitis is an infection within the flexor tendon sheath that can involve the fingers or thumb. The tendon sheaths begin at the metacarpal neck level and extend to the distal interphalangeal joint. In the little finger and the thumb, the sheaths usually communicate with the ulnar and radial bursae, respectively. The potential space of communication, Parona's space, lies between the fascia of the pronator quadratus muscle and flexor digitorum profundus conjoined tendon sheaths. Infection tracking through this space presents as a horseshoe abscess.
Which of the following proximal phalanx fractures can most reliably be treated with a closed reduction and avoidance of surgical measures?
Midshaft transverse diaphyseal fracture with 30 degrees of angulation
Long spiral diaphyseal fracture with 15 degrees of malrotation
Open fracture with skin loss and exposed extensor tendon
Distal condylar intra-articular fracture with minimal displacement
Proximal metaphyseal fracture location with 30 degrees of dorsal tilting
Proximal phalanx fractures are very common, but care must be taken to understand which injuries are reliably treated with nonsurgical measures, and which ones are prone to clinically symptomatic malunion without surgical treatment. The proximal metaphyseal location is a problematic fracture to get reduced with closed measures, and due to the forces of the extensor apparatus, is prone to collapse into the original deformity. Imaging is also frequently difficult because of the overlap of the other fingers and frequently the true angulation is underappreciated. With 30 degrees of angulation, consideration should be given to surgical treatment. Long oblique/spiral fractures with malrotation are also most reliably treated with multiple lag screws, because maintaining the reduction with nonsurgical measures is unreliable, and can lead to significant functional problems in the form of crossover of the fingers with gripping. Open fractures with skin loss clearly are treated with surgical measures. Distal condylar fractures with minimal displacement are another fracture pattern that have a high rate of loss of reduction when treated nonsurgically. Like most articular fractures, they are best treated with anatomic reduction and rigid internal fixation. By comparison, closed midshaft transverse diaphyseal fractures can usually be anatomically reduced and held in this position with closed measures.
Figure 3 shows an arthroscopic view of the radiocarpal joint from the 3-4 portal, looking volarly and radially (Sc=scaphoid, R=Radius). What structure is marked by the asterisk?
Radioscaphocapitate ligament
Scapholunate ligament
Palmar oblique ligament
Dorsal intercarpal ligament
Triangular fibrocartilage complex (TFCC)
The radioscaphocapitate ligament is a volar capsular structure running obliquely from the radial styloid to the scaphoid waist, ultimately inserting on the proximal radial aspect of the capitate. The radioscaphocapitate ligament is important in preventing ulnar translocation of the carpus. The scapholunate ligament is located intra-articularly, between the scaphoid and lunate. The dorsal intercarpal ligament is a dorsal structure, and not visible during routine wrist arthroscopy. The palmar oblique ligament connects the first and second metacarpal bases. The TFCC is visible during wrist arthroscopy between the radius and ulna.
A 22-year-old man reports a 2-week history of a burning pain along the dorsoradial aspect of the distal forearm. The pain radiates to the dorsum of the thumb. Examination reveals tenderness and reproduction of symptoms with percussion 8 cm proximal to the radial styloid. Reproduction of symptoms also occurs with forearm pronation
and ulnar deviation of the wrist. No discrete sensory deficit is noted and electrodiagnostic studies are normal. Nonsurgical management consisting of rest, splinting, and anti-inflammatory medications for 6 weeks has failed to provide relief. Treatment should now consist of decompression of the
lateral antebrachial cutaneous nerve in the interval between the abductor pollicis longus and the extensor pollicis brevis in the forearm.
lateral antebrachial cutaneous nerve in the interval between the brachioradialis and the extensor carpi radialis longus in the distal forearm.
radial sensory nerve in the interval between the extensor carpi radialis longus and the extensor carpi radialis brevis in the distal forearm.
radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis longus in the distal forearm.
radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis brevis in the distal forearm.
Wartenberg's syndrome, or compression of the sensory branch of the radial nerve, occurs in the interval between the brachioradialis and the extensor carpi radialis longus approximately 8 cm proximal to the radial styloid. There may be history of repetitive wrist/forearm circumduction activity (ie, knitting) or of wearing a tight wristwatch or jewelry. It can occur in patients who have been handcuffed. Typical clinical findings are pain, paresthesia, and/or hypesthesia in the dorsoradial aspect of the wrist and hand in the distribution of the radial sensory nerve. There is often a positive Tinel's sign over the compression site. Hypesthesia may be present in the distribution of the radial sensory nerve which is typically on the dorsal aspect of the first dorsal web space and dorsum of the thumb; however, with overlap in the distribution of the superficial radial nerve and the lateral cutaneous nerve of the forearm this may not always be present. Surgical management consists of release of the nerve as it exits the interval between the brachioradialis and the extensor carpi radialis longus in the distal forearm.
A 55-year-old woman with rheumatoid arthritis reports that she awoke with an inability to flex the interphalangeal joint of her thumb. Figure 8 shows an intraoperative finding. What is the most appropriate surgical treatment?
Primary repair of the tendon
Tendon reconstruction with the palmaris longus tendon
Tendon reconstruction using a transfer of the flexor digitorum profundus (FDP) of the ring finger
Thumb metacarpophalangeal fusion
End-to-side repair of the flexor pollicis longus to the FDP of the index finger
The patient has sustained a chronic flexor pollicis longus rupture (Mannerfelt lesion). The injury is most likely a result of tendinopathy and attritional rupture of the tendon secondary to synovitis and bony osteophytosis at the scaphotrapeziotrapezoid joint. Because of the attritional injury and inherent tendinopathy, primary repair is unlikely to be successful. Among the options listed, tendon graft reconstruction with the palmaris longus tendon is the most appropriate treatment. Tendon reconstruction is possible with the flexor digitorum profundus of the index finger, not the flexor digitorum profundus of the ring finger. If osteophytes are encountered, these should be debrided.
Thumb interphalangeal fusion is an option, but metacarpophalangeal fusion is not beneficial. End-to-side repair of the flexor pollicis longus to the FDP of the index finger is not appropriate and would sacrifice needed function of the index finger.
Figures A and B show the initial radiographs of a 27-year-old snow boarder who fell backward onto his left outstretched hand. Which of the following most accurately describes the sequence of events that occurred during this injury?
Lunotriquetral ligament failure followed by distal row dissociation, scaphoid extension, scaphoid failure, and dorsal dislocation of the carpus
Volar dislocation of the lunate followed by scaphoid extension, scaphoid failure, lunotriquetral failure, and distal row dissociation
Dorsal intercarpal ligament failure followed by distal row dissociation, scaphoid failure, lunotriquetral ligament failure, and dorsal dislocation of the carpus
Short radiolunate ligament failure followed by volar dislocation of the lunate, lunotriquetral ligament failure, scaphoid failure, and distal row dissociation
Scaphoid extension followed by scaphoid failure, distal row dissociation, lunotriquetral ligament failure, and dorsal dislocation of the carpus
As described by Mayfield and associates, the typical sequence of events referred to as "progressive perilunar instability" that result in a volar
perilunate dislocation are as follows: scaphoid extension, followed by opening of the space of Poirer, scaphoid failure, and distal row dissociation, which in turn lead to hyperextension of the triquetrum, lunotriquetral ligament failure, and finally dorsal dislocation of the carpus. The lunate remains in the lunate fossa in a perilunate fracture-dislocation but is dislocated in a lunate dislocation. The short radiolunate and dorsal intercarpal ligaments typically remain intact.
Which of the following is the most consistently proposed tendon transfer for radial nerve palsy?
Pronator teres to extensor carpi radialis brevis
Brachioradialis to extensor carpi radialis brevis
Flexor carpi radialis to extensor digitorum communis
Palmaris longus to extensor pollicis longus
Flexor digitorum superficialis to abductor pollicis longus and extensor pollicis brevis
Whereas there are many variations of tendon transfers for radial nerve palsy, the most consistently proposed tendon transfer is the pronator teres to extensor carpi radialis brevis. The brachioradialis is innervated by the radial nerve so that is not an option. The flexor digitorum superficialis, flexor carpi radialis, and flexor carpi ulnaris are appropriate options to transfer to the extensor digitorum communis. The palmaris longus is not always present. A transfer to the abductor pollicis longus and extensor pollicis brevis may not be necessary if the extensor pollicis longus is rerouted to allow for abduction of the first ray.
A patient has severe cubital tunnel syndrome and marked wasting of the intrinsic muscles of the hand. Why is the little finger held in an abducted position?
Accessory slip of the extensor digiti minimi attaching to the abductor digiti minimi tendon
Tetanic contraction of the abductor digiti minimi
Radial collateral ligament insufficiency of the fifth metacarpophalangeal (MCP) joint
Unopposed pull of the flexor digitorum profundus
Muscle innervation from a Martin-Gruber anastomosis
A Wartenberg's sign, where the little finger is held in an abducted position, is associated with an ulnar nerve palsy. This happens when there is an accessory slip of the extensor digiti minimi, which is innervated by the radial nerve, crossing ulnar to the center of the MCP joint to attach to the tendon of the abductor digiti minimi and the proximal phalanx. The abductor digiti minimi and the volar interosseous muscles are both innervated by the ulnar nerve; therefore, there is no tetanic contraction of the abductor digiti minimi.
Unopposed pull of the flexor digitorum profundus results in excess flexion of the proximal interphalangeal and distal interphalangeal joints of the hand as seen with a clawing-type deformity. A Martin-Gruber anastomosis, which is a neural connection between the ulnar and median nerves in the forearm, cannot explain this finger position.
Figure 38 shows the radiograph of a 41-year-old man who reports ulnar palmar pain, decreased sensibility and tingling in the ring and little fingers, and a grating sensation in the ulnar fingers with motion. He reports that he sustained a fall on an outstretched hand 6 months ago. What is the most appropriate treatment option?
Ulnar gutter cast
Short arm cast
Carpal tunnel release
Decompression of Guyon's canal
Excision of a fractured hook of hamate
Excision of a fractured hook of hamate is the most appropriate management. The patient has a hook of hamate fracture with ulnar nerve compression and irritation of the flexor tendons by the fracture surfaces; this puts the tendons at risk for rupture. Cast treatment will most likely not gain union of the fracture and will not address the nerve or tendon problems. Decompression of Guyon's canal alone will not address the tendon issue.
A 25-year-old man was involved in an altercation. Examination reveals loss of active extension of the middle finger metacarpophalangeal (MCP) joint. A diagnosis of sagittal band rupture is made. Which of the following is considered the key diagnostic finding?
Extensor lag of 30 degrees
Extensor lag of 60 degrees
Positive Bunnell intrinsic tightness test
Ability to maintain active extension of the interphalangeal joints
Ability to maintain MCP extension after passive extension
In sagittal band rupture, the extensor tendon may subluxate into the valley between the metacarpal heads. The patient will not be able to actively extend the MCP joint from a flexed position with the subluxated tendon, but will be able to maintain MCP extension after it has been passively extended. Extensor lags can have other etiologies other than extensor digitorum communis subluxation such as tendon laceration or rupture, posterior interosseous nerve palsy, but in these conditions, patients cannot maintain MCP extension. Active interphalangeal extension can be achieved with the intrinsic muscles that are not affected by sagittal band rupture.
What is the effect of shortening of metacarpal fractures?
Causes the greatest degree of extensor lag in the index finger
Causes the greatest degree of extensor lag in the little finger
Results in an average extensor lag of 7 degrees for every 2 mm of shortening
Results in an average extensor lag of 14 degrees for every 2 mm of
shortening
Has no effect on grip strength
Cadaveric models have demonstrated a 7-degree extensor lag for every 2 mm of metacarpal shortening, with the amount of lag increasing in a linear fashion. There was no statistical difference in the amount of lag in regard to the digit involved. Based on muscle length-tension relationships, cadaveric models have also been used to demonstrate an 8% loss of power secondary to decreased interosseous force generation with 2 mm of shortening. Because the intrinsic muscles of the hand contribute anywhere from 40% to 90% of grip strength, decreased interosseous force generation secondary to metacarpal shortening will invariably cause a decrease in grip strength.
A 22-year-old motorcyclist sustains open fractures to the left radial shaft and second and third metacarpals with exposed extensor tendon and bone. The fractures are approached via the dorsal open wounds of the forearm and hand with no additional incisions made. The radiograph and clinical photograph of the remaining defect in the hand are shown in Figures 55a and 55b. The remaining wound can be most appropriately covered with which of the following?
Split-thickness skin grafting
Posterior interosseous rotational flap
Radial forearm rotational flap
Groin flap
Free lateral arm flap
CORRECT ANSWER: 3
After adequate debridement, there is exposed bone, tendon, and hardware. Split-thickness skin grafting over exposed tendon will not have a viable bed to support the graft. The tendons would not have healthy surrounding tissue, resulting in poor tendon gliding. The dorsal wound has disrupted the posterior interosseous artery that runs in the septum between the extensor digiti minimi and the extensor carpi ulnaris. Following the reconstructive ladder, the radial forearm rotational flap accomplishes wound coverage with a local flap rather
than a groin flap (a distant flap) or a lateral arm flap (microvascular free tissue transfer).
What is the effect of performing a flexor tenosynovectomy with an open carpal tunnel release for idiopathic carpal tunnel syndrome?
Increased risk of nerve injury
Improved postoperative finger flexion
No added long-term clinical benefit versus open carpal tunnel release alone
Increased postoperative pain
Decreased recurrence of carpal tunnel syndrome
In patients with idiopathic carpal tunnel syndrome, flexor tenosynovectomy has not been shown to change the clinical outcome compared with open carpal tunnel release alone. This has been demonstrated in a randomized clinical trial of open carpal tunnel release with or without flexor tenosynovectomy. There has also been no evidence to suggest there is an added risk to performing the flexor tenosynovectomy. At time of surgery, the gross or histologic appearance of the flexor tenosynovium does not correlate with preoperative symptoms nor with clinical outcomes. The histology of the tenosynovium has been shown to be that of fibrosis in a setting of chronic inflammatory changes and no evidence of an acute inflammatory process exists. There may be an added role for flexor tenosynovectomy in non-idiopathic carpal tunnel syndrome such as in patients with renal disease or diabetes.
Figures 69a and 69b show the radiographs of a 62-year-old man with severe radially sided wrist pain. Management has consisted of wrist splinting, nonsteroidal anti-inflammatory drugs, and activity modification, but he continues to have pain and reports difficulty sleeping. What is the most appropriate treatment for this patient?
Arthroscopic debridement
Open reduction and internal fixation
Scaphoid nonvascularized bone graft and screw fixation
Scaphoid vascularized bone graft and screw fixation
Scaphoid excision and 4-corner fusion
Scaphoidectomy and 4-bone fusion is the most appropriate management based on the choices available. The patient has arthritic changes of SNAC (scaphoid nonunion advanced collapse) wrist, stage III. Stage I is at the radial styloid, stage II is at the radioscaphoid joint, and stage III is at the midcarpal joint. Arthroscopic debridement is not appropriate in patients with arthrosis.
Attempting to achieve scaphoid union is only appropriate if there is no arthrosis or the changes are classified as stage I where radial styloidectomy can be performed.
A 7-year-old boy is referred to your office 3 months after jamming his finger while playing basketball. Examination reveals 40 degrees of active and passive motion at the proximal interphalangeal (PIP) joint. The PIP joint is stable to radial and ulnar stressing. Radiographs are shown in Figures 76a and 76b. What is the most appropriate management?
Observation
Corrective osteotomy
Ostectomy
Hand therapy for aggressive stretching
Dynamic splinting
CORRECT ANSWER: 3
The most appropriate management is an ostectomy, or resection of the bone in the subcondylar fossa region. This is a malunion where the subcondylar fossa is blocked by malaligned bone. Because it is a bony block to motion, stretching or dynamic splinting will be of no benefit. The physis of the proximal phalanx is proximal, making remodeling of a fracture at the distal end very
unlikely. A corrective osteotomy has a risk of osteonecrosis of the very small distal fragment.
Figure 78 shows the clinical photograph of a patient who injured his finger while playing football. He cannot actively flex the distal interphalangeal joint of the ring finger. Which of the following is the most accurate statement regarding the injury shown?
The tendon is attached to the avulsed fragment from the distal phalanx.
There is no difference in time sensitivity in an acute injury whether or not the tendon has retracted into the palm.
In a chronic (> 3 months) case of flexor digitorum profundus (FDP) avulsion, the FDP should be tenodesed to the flexor digitorum sublimis (FDS).
If the FDP is advanced more than 1.5 cm, there is a risk for quadriga effect.
The method of repair does not affect repair gapping or strength of the tendon repair.
Overadvancement of the FDP tendon is one of the causes of the quadriga effect. Relative shortening of an FDP tendon decreases the excursion of the neighboring FDP tendons because they originate from a common muscle belly. The patient reports a weak grasp. Answer 1 is not correct because there can be a fracture and the tendon can avulse off of the fracture fragment (Trumble JHS-A 1992). Whether the tendon has retracted into the palm or not does matter because retraction into the palm allows pulleys to collapse and contract and it also means that the vinculae have been stripped off of the tendon.
Regarding answer 3, in chronic cases where the FDS is intact and strong, many patients may be better off with a sublimis finger and no FDP reconstruction that could, in the worst case scenario, worsen a functional proximal interphalangeal joint. Regarding the repair method, there is recent
research showing method of repair (button vs anchor), suture type, and method do affect the biomechanical properties of the repair.
A 44-year-old woman with cubital tunnel syndrome and associated ulnar nerve subluxation with elbow flexion has failed to respond to nonsurgical management. Which of the following statements is most acccurate regarding in situ simple decompression of the nerve compared with subcutaneous anterior transposition?
Patients undergoing anterior transposition have improved motor outcomes.
Patients undergoing anterior transposition have improved sensory outcomes
Patients undergoing simple decompression have improved motor outcomes.
Patients undergoing simple decompression have improved sensory outcomes.
No differences in outcome are likely between treatment types.
Recent reports comparing outcomes of surgical treatment of ulnar nerve compression at the elbow have demonstrated no differences in outcome between simple decompression and anterior transposition. The presence of subluxation of the ulnar nerve was not a contraindication to in situ decompression in the study by Keiner and associates.
What anatomic structure must be excised when performing a volar plate arthroplasty of the proximal interphalangeal joint?
Central slip
Collateral ligament
Checkrein ligament
Triangular ligament
Flexor digitorum superficialis insertion
The collateral ligament must be excised or released from the proximal phalanx to allow gliding of the middle phalanx on the articular surface of the proximal phalanx. Failure to do so may prevent this gliding motion and make the middle phalanx just hinge on the proximal phalanx.
Figures 97a and 97b show a clinical photograph and radiograph of a patient who has a history of repeated drainage from the lesion. What is the preferred surgical treatment?
Excision of the lesion alone
Removal of the osteophyte alone
Distal interphalangeal joint fusion
Excision of the mass and osteophyte removal
Removal of the mass and skin with skin grafting
The patient has a mucoid cyst. Whereas many of these lesions are associated with osteoarthritis, the best surgical treatment of the lesions in patients who have little or no pain is typically excision of the mass with osteophyte removal. Studies have shown that osteophyte excision helps minimize the risk of recurrence. Distal interphalangeal joint fusion is reserved for patients with pain and more advanced radiographic arthritis. Excision of the lesion alone is a less favorable option than excision of the mass and osteophyte removal. The lesion is independent of the skin and thus, skin removal with the mass is unnecessary.
Which of the following structures cannot be seen during standard radiocarpal arthroscopy?
Scapholunate ligament
Lunotriquetral ligament
Radioscaphocapitate ligament
Extensor carpi ulnaris tendon
Superficial insertion of the triangular fibrocartilage complex (TFCC)
The extensor carpi ulnaris tendon is located in an extra-articular position, and as such, cannot be seen during arthroscopy. Wrist arthroscopy is a useful technique for evaluation and treatment of radiocarpal and midcarpal maladies. During standard radiocarpal arthroscopy, the scapholunate and lunotriquetral ligaments can be easily visualized. The superficial TFCC is seen overlying the ulnar head. Volarly, the radioscaphocapitate ligament can be seen as a discrete band of the capsule.
A 20-year-old skateboarder fell 6 months ago and has had radial-sided wrist pain since. His radiograph upon presentation to your office is shown in figure A. What is the most appropriate treatment at this time?
four corner fusion
long arm thumb spica cast
wrist arthroscopy to evaluate intercarpal ligaments
open reduction internal fixation with autologous bone graft
wrist arthrodesis
CORRECT ANSWER: 4
This patient has a scaphoid waist fracture nonunion. Several studies indicate that scaphoid nonunions left untreated have a determined course of collapse and progressive arthritis (scaphoid nonunion advanced collapse - SNAC). Per Markiewitz et al, the standard treatment of scaphoid nonunions is open reduction internal fixation with bone graft; non-operative treatment is not appropriate. Proximal row carpectomy and wrist fusion are salvage procedures reserved for patient that has an advanced scaphoid nonunion, collapse and wrist arthritis.
Figures 112a and 112b show the radiographs of a 28-year-old motorcyclist who sustained a closed hand injury in a collision. What is
the most appropriate definitive treatment?
Closed reduction and a hand/forearm cast in the intrinsic plus position
Closed reduction and a hand splint
Primary fusion of the carpometacarpal joints
Closed versus open reduction and internal fixation
Closed reduction and external fixation
Closed versus open reduction and internal fixation is the most appropriate treatment. The radiographs show fracture-dislocations of all five carpometacarpal joints. These injuries are extremely unstable and not amenable to closed (splint or cast) treatment only. External fixation may be warranted in an open, contaminated injury. Fusion would be an option if this were a chronic, painful condition on presentation.
What additional procedure should be done when performing a radioscapholunate fusion for posttraumatic arthrosis following a distal radius fracture?
Excision of the triquetrum and distal pole of the scaphoid
Anterior interosseous neurectomy
Fascial interposition arthroplasty of the capitolunate joint
Sectioning of the dorsal intercarpal ligament
Ulnar shortening osteotomy
Excision of the triquetrum and distal pole of the scaphoid frees up the midcarpal joint, improving radial deviation and the flexion-extension arc of motion of the wrist. This offers an alternative to complete wrist arthrodesis for posttraumatic arthrosis of the radiocarpal joint. An anterior interosseous neurectomy is believed to decrease some pain transmission from the wrist but because the fusion is done dorsal, cutting this volar structure is not routinely done. Fascial interposition is not needed because the capitolunate should be preserved in posttraumatic radiocarpal arthrosis. Sectioning of the dorsal intercarpal ligament would provide no benefit. If the triquetrum is excised, then an ulnar shortening osteotomy is unnecessary.
Apert's syndrome is caused by a mutation in what gene?
Fibroblast growth factor receptor 2 (FGFR2)
Fibroblast growth factor receptor 3 (FGFR3)
Collagen type II alpha 1 chain (COL2A1)
SED late (SEDL)
Fibrillin
Apert's syndrome (acrocephalosyndactyly type 1) is characterized by anomalies of the cranium, hands, and feet. Mutations in the FGFR2 gene cause Apert syndrome.
Anderson et al report that in Apert's syndrome there is widespread anomalies of the feet, with defects including both predictable dysmorphic changes and progressive fusions of the skeletal components during skeletal maturity.
Incorrect Answers:
2: Achondroplasia is related to abnormalities in the FGFR3, not FGFR2.
3: SED congenita is caused by mutations in COL2A1 (type II collagen alpha 1 chain) on chromosome 12. These result in abnormal type II collagen.
4:The X-linked form of SED tarda is caused by mutation in SEDL (SED late)
gene.
5: Marfan syndrome is caused by defects in the fibrillin gene.
What is the most important measure to take to reduce the risk of frostbite of the toes while hiking in extreme temperatures?
Stop often for recovery breaks.
Drink enough warm liquids.
Reduce thermal heat loss from shoes.
Use triple socks.
Adequately "carbo load" before the start.
Several studies showed the most reliable method to reduce the risk of cold exposure injury is to reduce thermal heat loss. This can be done with a combination of protective socks and shoes, and reducing moisture in the shoes.
Figures 45a through 45e are the MRI scans, gross specimen, and histology of the specimen of a 19-year-old man who has an enlarging mass in the second interspace. He reports forefoot pain that is worse with athletic activity. Radiographs show erosive changes of the third metatarsal head. What is the most common complication associated with incomplete excision?
Metastatic disease
Malignant degeneration
Recurrence
Pathologic fracture
Infection
Giant cell tumor of the tendon sheath often arises from the synovial lining of tendon sheaths. This lesion is frequently found in the hand and foot. The lesion is slow growing and can invade adjacent structures. In the foot, wearing shoes or increased activity can cause pain. Incomplete or piecemeal excision can lead to recurrence.
A 42-year-old construction worker presents with pain in his right wrist. A current radiograph of the wrist is shown in Figure A. He reports that rotating activities, such as turning a screw driver, are bothersome and the pain is preventing him from working. A current MRI reveals a TFCC tear, and nonsurgical treatment has failed to provide relief. Treatment should now consist of:
Repair of the ulnar styloid nonunion
Darrach resection of the distal ulna
Complete ulnar head resection
Ulnar hemiresection arthroplasty and TFCC reconstruction/repair
Isolated arthroscopic TFCC reconstruction
The clinical presentation is consistent with DRUJ arthritis in a heavy laborer. Of the options listed, ulnar hemiresection arthroplasty with concurrent TFCC reconstruction or repair would be the most appropriate treatment.
While there are multiple treatment options, the ulnar hemiresection arthroplasty with concurrent TFCC reconstruction or repair is considered most appropriate in heavy laborers, as it would likely resolve the pain and enable them to return to work sooner. The TFCC should be intact when performing an ulnar hemiresection arthroplasty to prevent distal ulna instability with forearm rotation. One could also consider performing a Suave-Kapandji procedure. This procedure creates a distal radioulnar fusion and an ulnar pseudarthrosis proximal to the fusion site through which rotation can occur. The advantage is that the ulnocarpal joint is not sacrificed, and a stable wrist is created.
Scheker et al reported on the outcome of ulnar shortening performed on 32 wrists with early osteoarthritis of the DRUJ. The postoperative wrist ratings were 7/32 excellent, 11/32 good, 9/32 fair, 5/32 poor, with plate irritation being the most frequent postoperative complication.
Figure A is a radiograph showing significant DRUJ arthritis. Illustration A shows ulnar hemiresection arthroplasty. Illustration B shows a Darrach procedure.
Illustration C shows a Sauve-Kapandji procedure. Illustration D is a treatment schematic of TFCC reconstruction.
Incorrect Answers:
Figures 113a and 113b are the radiographs of a 7-year-old girl who was evaluated for a visible elbow deformity by a foster parent. She thought the child fell, but her history was vague. On physical examination, a large prominence was seen over the posterolateral elbow, and the girl lacks the terminal 20 degrees of elbow extension. She has 75 degrees of elbow pronation and supination. She was nontender on examination. What is the most appropriate next treatment step?
Child abuse workup
Closed reduction
Open reduction with possible osteotomy
Observation
CORRECT ANSWER: 4
The most appropriate management of this condition is observation. The patient most likely has a congenital dislocation of the radial head, although this may also represent a posttraumatic deformity. The absence of findings on physical examination speaks against an acute injury. The appearance of the radial head reveals the typical findings of a congenital dislocation, namely the convex appearance of the proximal radial articular surface. These children typically have very functional range of motion and do not require treatment unless they are symptomatic. There is nothing in this child's history to suggest abuse.
The most common mechanism of injury to the triangular fibrocartilage complex (TFCC) involves
wrist extension and forearm pronation.
wrist extension and forearm supination.
wrist flexion and forearm pronation.
wrist flexion and forearm supination.
axial load in ulnar deviation.
TFCC tears are common in athletes. As the athlete braces for a fall, the wrist is most commonly in an extended position and the forearm is pronated.
A 28-year-old woman fell on her right wrist while rollerblading 6 days ago. She was seen in the emergency department at the time of injury and was told she had a sprain. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. Standard wrist radiographs are normal. What is the next most appropriate step in management?
Arthroscopy of the wrist
CT of the wrist
Bilateral PA clenched fist radiograph
Electromyography and nerve conduction velocity studies
AP and lateral radiographs of the forearm
When considering the diagnosis of scapholunate ligament injury, standard radiographic views of the hand will not always reveal widening of the scapholunate gap. Although MRI may reveal injury to the ligaments, the PA clenched fist view can be obtained in the office during the initial patient visit. Arthroscopy is not a first-line diagnostic tool.
Figures 12a through 12c show the radiographs of a 28-year-old professional baseball player who has ulnar-sided wrist pain and
numbness and tingling in the fourth and fifth digits for the past 6 weeks. Management should consist of
cast immobilization.
bone stimulation and splinting.
ulnar nerve exploration.
open reduction and internal fixation.
excision of the fragment.
Hook of the hamate fractures typically occur as a result of direct force from swinging a bat, golf club, or racket. Pain is localized to the hypothenar eminence. The injury is best seen on a carpal tunnel view. CT will confirm the diagnosis. Chronic cases can be associated with neuropathy of the ulnar nerve. Excision of the hook through the fracture site usually yields satisfactory results, allowing the athlete to return to competition.
A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. A radiograph is shown in Figure 21. Management should consist of
immobilization in a short arm thumb spica cast.
immobilization in a long arm thumb spica cast.
arthroscopic repair and percutaneous pinning.
open repair and percutaneous pinning.
dorsal capsulodesis.
The radiograph reveals an increased distance between the scaphoid and the lunate, which is indicative of scapholunate disassociation. A ring sign is also present, which represents the distal pole of the scaphoid viewed end on in a palmarly flexed position. In the acute setting, the scapholunate can be repaired. Open repair and percutaneous pinning is the treatment of choice. Dorsal capsulodesis is performed in the chronic setting if such an injury is initially missed.
An 18-year-old rugby player has had pain in his ring finger after missing a tackle 1 week ago. Examination reveals tenderness in the distal palm, and he is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs are normal. What is the most appropriate management?
Acute tendon repair
DIP joint extension splinting for 6 weeks
DIP and proximal interphalangeal joint extension splinting for 6 weeks
Buddy taping to the middle finger for 2 weeks
Early range-of-motion exercises and return to play as pain permits
Flexor digitorum profundus rupture or “rugger jersey finger” often occurs in the ring finger after the player misses a tackle and catches the digit on the shirt of the opposing player. Surgical repair is required for zone I-type injuries.
A 65-year-old right-hand-dominant man has a 5 year history of progressive right wrist pain. He relates spraining his wrist playing football in college, but otherwise has had no prior traumatic injury. He is a pack per day smoker. An AP radiograph of the wrist is shown in Figure A. Wrist immobilization, anti-inflammatory medications, and injections have failed to provide relief. Which appropriate surgical treatment option offers the lowest risk of postoperative complications?
Radial styloidectomy
Total wrist arthroplasty
Proximal row carpectomy
Scaphoid excision with four-corner fusion
Complete radiocarpal arthrodesis
Proximal row carpectomy (PRC) and scaphoid excision with four-corner fusion are both appropriate surgical treatment options for stage II scapholunate advanced collapse (SLAC) wrist; however PRC is associated with fewer postoperative complications, particularly in active smokers.
Scapholunate interosseous ligament disruption leads to abnormal wrist biomechanics and degenerative arthritis. This progression follows a predictable pattern termed scapholunate advanced collapse. In stage II disease where the entire radioscaphoid articulation is affected but the capitolunate articulation is spared, both proximal row carpectomy (PRC) and scaphoid excision with four-corner fusion offer long-term pain relief while preserving wrist motion and grip strength. Scaphoid excision with four-corner fusion has a higher rate of complications owing to nonunion, hardware issues, and dorsal impingement from malunion. PRC is not recommended in the setting of capitolunate arthritis (stage III).
Tomaino, et al. retrospectively compared PRC and limited intercarpal arthrodesis with scaphoid excision (LWF) at a mean of 5.5 years postoperatively in 24 symptomatic SLAC wrists. They noted good pain relief, grip strength, and function in all but 3 patients having undergone PRC - one of whom required revision to wrist arthrodesis (these patients had symptomatic capitate arthrosis). They concluded that in wrists without capitolunate arthritis, PRC had the benefit of being technically easier to perform, did not require prolonged postoperative immobilization, and avoided the risk of nonunion associated with LWF; however it was not an appropriate surgical option in stage III SLAC wrists with capitolunate involvement.
Strauch reviewed the evaluation and treatment of SLAC and SNAC (scaphoid nonunion advanced collapse) wrists. Treatment options for SLAC wrist include four-corner fusion, capitolunate arthrodesis, PRC, radial styloidectomy, wrist denervation, and complete radiocarpal fusion. Excision of the distal ununited scaphoid fragment is an additional option in the setting of SNAC wrist. He additionally highlights current controversies between PRC vs. four-corner fusion.
Figure A shows an AP radiograph with stage II SLAC wrist. The entire radioscaphoid articulation is arthritic with sparing of the capitolunate surface.
Illustration A shows the modified Watson classification of scapholunate advanced collapse.
Incorrect Answers:
A 25-year-old male presents to the clinic with a painful, enlarging mass at the volar radial wrist. He initially noticed the mass 6 months ago after he hurt his wrist golfing. Figure A shows a clinical photograph of the patient's wrist. Radiographs are unremarkable. An ultrasound of the mass is shown in Figure B. Surgical excision is planned. Which of the following is the most appropriate type of resection and histologic finding?
Intralesional excision; synovial cells with mucin accumulation
Incision & drainage; polymorphonuclear cells
Wide excision; histiocytes with frequent giant cells
Marginal excision; synovial cells with mucin accumulation
Intralesional excision; histiocytes with frequent giant cells
The patient presents with a volar wrist ganglion cyst. Surgical treatment consists of marginal excision. Histologic analysis demonstrates synovial cells with mucin accumulation.
Ganglion cysts are the most commonly presenting masses in the hand. These cysts consist of a synovial cell lining filled with mucin. Dorsal wrist ganglion cysts originate from the scapholunate interval and are more common than volar wrist ganglions, which typically originate from the scapho-trapezio-
trapezoidal joint articulation. Ganglion cysts can cause pain related to mass effect. Ultrasound can help differentiate these masses from vascular malformations or other tumors; ganglion cysts present as homogenous anechoic masses with well-defined borders.
Mayerson, et al. reviewed the diagnosis and management of soft-tissue masses. They highlight the typical presentation of ganglion cysts, which wax and wane in size and transilluminate with a pen light. The authors concluded that MRI is diagnostic if there remains any uncertainly after history and clinical exam.
Head et al compared surgical excision versus needle aspiration of 2,239 adult wrist ganglions in a meta-analysis of 35 studies. Surgical excision resulted in a 76% reduction in recurrence compared to aspiration. Mean recurrence for arthroscopic excision (6%), open surgical excision (21%) and aspiration (59%) and mean complication rate for arthroscopic excision (4%) open surgical excision (14%) and aspiration (3%) were also determined. Data from arthroscopic excision was limited but is a promising technique. Open surgical excision has a significantly lower recurrence rate as compared to aspiration.
Figure A shows a clinical photo of a volar wrist ganglion cyst. Figure B shows the ultrasound image of a volar wrist ganglion cyst.
Incorrect Answers:
A 27-year-old man falls on his hand at work. He notices an immediate deformity of his ring finger. Radiographs are provided in Figure A. Which of the following is the most appropriate initial treatment?
Closed reduction, buddy taping, and early motion to prevent stiffness
Closed reduction and full time extension splinting
Open reduction and repair of the central slip of the extensor tendon
Open reduction and repair of the volar plate
Amputation and immediate return to work
The radiograph demonstrates a volar PIP dislocation. The central slip of the extensor tendon is frequently ruptured and will lead to a boutonneire deformity if left untreated. The PIP must be immobilized in extension to allow the extensor mechanism to heal. Immobilization in extension should be maintained for 6 weeks to allow soft tissue healing. Open reduction and repair of the central slip would be the appropriate treatment for a developing boutonneire deformity that presents in a subacute or chronic time basis.
Illustrations A and B demonstrate a schematic and clinical photo of central slip disruption and secondary deformity with PIP flexion and DIP hyperextension (Boutonniere Deformity).
Posner et al reviewed 7 patients with chronic palmar dislocations of the PIP joint who were treated with open reduction and reconstruction of the extensor mechanism. All patients acheived satisfactory range of motion and the authors concluded that this technique is preferable to arthrodesis.
Peimer et al reviewed 15 patients with palmar dislocations of the PIP joint. Twelve of the fifteen were evaluated on a delayed basis (average 11 weeks following injury) and underwent open reduction and surgical repair of the extensor tendon. Three of the fifteen were seen earlier following injury and were treated with closed reduction and pinning. All fifteen patients acheived satisfactory clinical outcomes although finger range of motion was not fully recovered in any case.
Figure A is of a 22-year-old male college basketball player presents for evaluation of a right index finger deformity. He reports a fall during a game 8 weeks ago, with resultant deformity to the index finger. He "popped it back in" and returned to play. Physical exam is most likely to demonstrate:
Inability to passively extend the PIP joint to neutral, able to passively flex and extend the DIP joint
With the PIPJ flexed, resistance to PIPJ extension causes the DIPJ to become supple
Dorsal subluxation of the PIP joint, able to passively flex and extend DIP joint
With the PIPJ flexed, resistance to PIPJ extension causes the DIPJ to become rigid
Inability to actively flex the DIP joint, able to actively flex the PIP and the MCP joints
The patient presents with a Boutonniere deformity secondary to a traumatic central slip disruption in the setting of volar PIP joint dislocation. Physical exam will demonstrate a positive Elson's test, which is described in answer 4.
The digital extensor mechanism consists of the central slip and two lateral bands, all of which arise from the extensor digitorum communis (EDC) tendon. Flexion of the PIP joint puts the central slip on tension, and volarly subluxes the lateral bands causing them to become slack. Tension on the central slip causes extension of the PIP joint, with concomitant dorsal shift of the lateral bands which help to bring the DIP joint into extension.
In 1986, Elson described his physical examination maneuver for diagnosis closed rupture of the central slip. With the hand resting on the edge of a table, the PIP joint is flexed to 90 degrees over the table edge, and the patient is asked to extend the digit against resistance. Active extension of the middle phalanx can only be observed with an intact central slip, and the adjacent lateral bands will remain slack which allows the DIP joint to remain flail. In central slip ruptures, effort to extend the middle phalanx will be accompanied
by DIP rigidity/extension as the lateral bands are forced to contribute to extension.
Rubin et. al. performed a cadaveric study evaluating the efficacy of physical examination maneuvers to identify acute ruptures of the central slip. They
found that Elson’s test was the only maneuver that could discern central slip integrity in both tested scenarios: 1) pre-boutonniere deformity with division of the central slip and 2) passively correctible boutonniere deformity caused by division of the central slip, the triangular ligament, and the oblique fibers of the extensor expansion.
Figure A is a clinical image of an index finger with boutonniere deformity. Video A is a short demonstration of how to perform the Elson test.
Incorrect answers:
A 25-year-old woman presents to the clinic after knife injury to the volar aspect of her long finger 2 weeks ago. She is evaluated and diagnosed with tendon rupture of the flexor digitorum profundus (FDP). What finding on examination can be expected in this patient?
With passive wrist extension, extension remains at the distal interphalangeal joint
With passive wrist extension, extension remains at the proximal interphalangeal joint
With passive wrist flexion, extension is limited at the distal interphalangeal joint
With passive wrist flexion, flexion remains at the distal interphalangeal joint
With passive wrist flexion, flexion remains at the proximal interphalangeal joint
With an FDP rupture, physical exam would likely reveal loss of flexion at the DIP joint both actively and passively with wrist extension.
When the wrist is in extension, flexor tendons are stretched and should result in flexion at the DIP (FDP) and PIP (FDS) joints. The FDP tendon is responsible for flexion of the DIP joint, and this joint would remain extended during normal tenodesis on passive wrist exam. Inversely, with extensor tendon injuries, there may be a loss of digit extension with passive wrist flexion.
Strickland presents a review article (Part 1) on flexor tendon injuries discussing clinical presentation and repair techniques. A commonly tested concept is that tendon repair is proportional to the number of core sutures, and currently recommended repair includes at least 4 core sutures for strength with epitendinous suture to aid in gliding and provide some strength.
Kamal et al. present current evidence regarding flexor tendon injuries, reviewing examination, repair, and rehab. They note that to date there still remains heterogeneity in treatment patterns and no clear standard of care. Rehab options include no motion, early active range of motion, and controlled passive range of motion. The authors note that early loading may lead to improved strength.
Illustration A depicts the usual tenodesis effect of the digits where passive extension of the wrist produces flexion of the fingers.
Incorrect Answers:
A 20-year-old college football lineman sustains an injury to his index finger during a game. A radiograph of the hand is demonstrated in Figure A. What is the mechanism of injury and most common reason for unsuccessful closed reduction?
Hyperextension mechanism causes the metacarpal head to button hole between the flexor tendon and the lumbrical
Hyperextension mechanism causes volar plate avulsion and entrapment dorsal to the metacarpal head
Rotational mechanism causes the metacarpal head to button hole between the flexor tendon and the lumbrical
Hyperflexion mechanism causes volar plate avulsion and entrapment dorsal to the metacarpal head
Hyperflexion mechanism causes the metacarpal head to button hole between the flexor tendon and the lumbrical
Irreducible dorsal metacarpophalangeal (MP) joint dislocations occur from a hyperextension moment, which causes volar plate displacement and incarceration dorsal to the metacarpal head.
MP joint dislocations are most commonly dorsal and occur with hyperextension injuries. Simple dislocations are reducible with wrist flexion (to relax the intrinsic muscles) and direct palpation over the proximal phalanx base.
Complex dislocations occur with interposition of the volar plate. When irreducible, open reduction is required.
Afifi et al. performed a cadaver study defining the anatomy surrounding irreducible dorsal index MP joint dislocations. They found that of all local structures, only release of the volar plate allowed for reduction of the MP joint. They concluded that volar plate interposition dorsal to the metacarpal head was responsible for irreducible MP joint dislocations.
Bohart et al. describe 9 patients with irreducible dorsal MP joint dislocations (5 thumbs and 4 index fingers). A dorsal approach was performed in each case to allow for reduction of the volar plate. A stable MP joint was achieved in each case. They advocate for a dorsal approach, which minimizes the risk of iatrogenic injury to the neurovascular bundles, which are displaced volarly by the metacarpal head.
Figure A shows an oblique radiograph of the hand demonstrating a dorsal dislocation of the index MP joint. Illustration A provides a schematic of both a simple and a complex dorsal MP joint dislocation. In the case of a complex dislocation, the volar plate avulses from its origin and becomes entrapped dorsal to the metacarpal head.
Incorrect Responses:
A 3-year-old patient presents to clinic with her parents for the chest wall anomaly seen in Figure A. What other congenital disorder is associated with this syndrome?
Flexible pes planovalgus
Syndactyly
Polydactyly
Macrodactyly
Accessory navicular
CORRECT ANSWER: 2
The figure shows an individual with Poland's Syndrome, as demonstrated by the absent sternoclavicular head of the pectorals major. Syndactyly and symbrachydactyly is often seen, in addition to hypoplasia and shortening of the fingers.
Poland's Syndrome, or Poland anomaly/sequence, is thought to be caused by disruption of the subclavian artery in utero, causing various hypoplastic anomalies of the upper extremity. These are typically ipsilateral ranging from aplasia of the sternocostal head of the pectorals major, radio-ulnar synostosis, symbrachydactyly and other limb hypoplasias, or syndactyly of the central digits. Syndactyly is often simple and either complete or incomplete. It is addressed surgically early on, with the chest wall deformities needing reconstruction and muscle transfers closer to sexual maturity. Thoracic, cardiovascular, and genitourinary anomalies may also be present.
Catena et al. proposed a new classification system for Poland Syndrome based on the degree of clinical severity of the entire upper extremity. The classification type increased with more proximal involvement up the upper extremity. This new system may help guide treatment as is takes into account the functional state of the rest of the upper extremity and not just the hand, as previous systems have.
Ireland et al. analyzed 43 consecutive cases of Poland's Syndrome. All cases involved congenital aplasia and syndactyly which was typically simple and incomplete. The thumb can be involved putting it the same plane as the fingers. Anomalies were more frequently seen on the right side. They noted favorable outcomes with surgical correction by syndactyly release initiated by 1 year, with some requiring periodic revision releases, while others required an amputation producing a three-fingered hand.
Figure A shows an absent stenocostal head of the pec major. Only the right side is involved. Illustrations A-C show pre-op and post-op digital release of an individual with syndactyly
Incorrect Answers:
A 32-year-old man sustains an injury to his left thumb. Examination in the ER demonstrates a 2x4 cm wound on the dorsal thumb overlying the proximal phalanx with exposed tendon and bone. What is the most appropriate option for soft tissue coverage?
Cross-finger flap
Moberg advancement flap
Full-thickness skin graft
First dorsal metacarpal artery flap
V-Y advancement
CORRECT ANSWER: 4
The first dorsal metacarpal artery flap (Kite flap) is the most appropriate soft tissue coverage option for dorsal thumb wounds that disrupt vascularized tissue overlying the extensor tendon and bone (including the epidermis, dermis, subcutaneous tissue, and tenosynovium) when primary closure is not possible.
Kite flaps are based off of the first dorsal metacarpal artery, which overlies the index finger metacarpal. It offers a pedicle length up to 7 cm and can reliably cover soft tissue defects up to 3x5 cm in area. Given its location, it is appropriate for the treatment of thumb wounds including those to the web space, dorsum, and volar pulp, particularly when injury compromised the vascularity of the wound bed. It can be modified to include both dorsal branches of the proper digital nerve, thereby conferring sensibility to the covered wound. The donor site can subsequently be covered with a full-thickness skin graft.
Rehim et al. reviewed local flaps of the hand. They offer treatment options and appropriate indications based upon the anatomic location and size of the wound within the hand. They conclude that when there are no clinical limitations, local flaps provide ideal soft tissue coverage and function for hand wounds based upon the local anatomy without the need for more complex free tissue transfers.
Eberlin et al. review soft tissue coverage options in the hand. They present four clinical cases and offer one established and one non-traditional surgical treatment option for each. They recommend the first dorsal metacarpal artery flap as an established treatment option in a case of thumb volar pulp injury as it offers contour restoration as well as sensibility when the digital nerves are included with the vascular pedicle.
Illustration A demonstrates a large dorsal thumb soft-tissue injury that is treated with first dorsal metacarpal artery flap coverage and full-thickness skin grafting to cover the donor site.
Incorrect Answers:
A 65-year-old man complains of numbness and tingling in the thumb, index, and long fingers of his dominant right hand for 3 months. An EMG demonstrates prolonged median sensory latency and low amplitude compound muscle action potentials with fibrillations in the abductor pollicis brevis. What is the most appropriate treatment option and the rate of continued symptoms at 1 year after treatment?
Splinting and corticosteroids; 5%
Open carpal tunnel release; 20%
Splinting and corticosteroids; 30%
Endoscopic carpal tunnel release; 2%
Open carpal tunnel release; 5%
The most appropriate treatment of carpal tunnel syndrome (CTS) with EMG evidence of denervation is surgical release. The rate of residual symptoms at 1 year is approximately 20%.
The American Association of Electrodiagnostic Medicine (AAEM) criteria delineates CTS severity by EMG. Mild CTS is purely sensory. Moderate disease demonstrates prolonged sensory and motor latencies. Severe disease progresses to involve muscle denervation. Mild and moderate CTS may be treated with carpal tunnel release following failure of nonoperative treatment; however, early operative treatment is supported for severe disease to limit further denervation. Patients experience significant improvement in
symptoms; however, recovery is prolonged and persistent symptoms may be present in ~20% at 1 year.
Kronlage et al. compared changes in numbness and pain following carpal tunnel release in 47 patients with moderate and 48 patients with severe CTS diagnosed on EMG. At 1 year or longer, 1 (2%) patient with moderate disease had continued symptoms compared to 9 (19%) of patients with severe CTS. They concluded that patients with severe CTS experience significant reductions in symptoms following carpal tunnel release; however, recovery may be prolonged or incomplete at 1 year postop.
Ono et al. performed a systematic review of 25 studies reporting outcomes for the treatment of carpal tunnel syndrome. They noted an increasing trend towards recommending earlier surgery for CTS with or without median nerve denervation. They conclude that this differed from the 2007 AAOS guidelines, which recommended early surgery only in the setting of muscle denervation.
Incorrect Answers:
A 23-year-old man presents with chronic, progressive right wrist pain. He remembers falling onto an outstretched hand 2 years ago. Radiographs, CT scans and a T1-weighted coronal MRI are shown in Figures A through E. No bleeding was identified at surgery. In addition to surgical stabilization, what is the next best step?
Corticocancellous autograft inserted through a dorsal approach
Pedicled distal radius graft inserted through a dorsal approach
Pedicled distal radius graft inserted through a volar approach
Free vascularized femoral bone graft inserted through a dorsal approach
Free vascularized femoral bone graft inserted through a volar approach
This patient has an old scaphoid waist fracture with nonunion, proximal pole avascular necrosis (AVN), and carpal collapse. Optimal treatment is with a free vascularized medial femoral condyle (MFC) graft through a volar approach.
Where there is proximal pole AVN, union was achieved in 88% of patients with a vascularized graft versus 47% with screw and nonvascularized wedge bone graft fixation. The 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) pedicle graft leads to union rates of 71% for scaphoid nonunions and 50% for AVN. The risk for failure is higher when there is DISI or humpback deformity (underscoring the need to restore scaphoid geometry). The MFC graft uses a pedicle from the descending genicular artery or the superomedial genicular artery when the descending genicular artery is not present. The volar approach is preferred as it allows correction of the humpback deformity and anastomosis of the MFC pedicle to the radial artery.
Jones et al. retrospectively compared 2 vascularized bone grafts for treatment of scaphoid waist nonunions with proximal pole AVN and carpal collapse. 4 of
10 nonunions treated with distal radial pedicle graft healed at 19 weeks. 12 of 12 nonunions treated with free vascularized medial femoral condyle (MFC) graft healed at median of 13 weeks. Rate of union was higher, and time to healing was shorter for the MFC graft. They recommend the MFC vascularized bone graft for treatment of scaphoid waist nonunion with proximal pole AVN and carpal collapse.
Figures A, B, C and D are PA and lateral radiographs and coronal and sagittal CT images showing scaphoid waist nonunion with carpal collapse and osteonecrosis of the proximal pole, respectively. Figure E is a T1-weighted coronal image shows diffusely decreased signal within the proximal pole.
Illustrations A and B show harvest and inlay of the 1,2 ICSRA graft. Illustration C shows the MFC graft.
Incorrect Answers:
A 38-year-old female develops pain and pallor in all the digits of the right hand daily. Her symptoms have progressed over 2 years despite avoiding direct cold exposure and multiple medications including nifedipine. Recently she has developed the lesions seen Figure A. Workup for underlying disease by her rheumatologist was negative. She is a candidate for Botuninum toxin A injections. What is the physiologic effect of botulinum toxin in the hand for her condition?
Improving proprioception in the fingers and hand by binding to postsynaptic acetylcholine receptors
Improving digital perfusion by cleaving pre-synaptic SNAREs and preventing the release of acetylcholine
Decreasing glabrous skin sensation by reducing hyperexcitability of voltage dependent calcium channels
Strengthening the intrinsic muscles by increasing hyperexcitability of voltage dependent calcium channels
Increasing sympathetic innervation by cleaving pre-synaptic SNAREs and preventing the release of acetylcholine
The patient is displaying Raynaud's Disease with the development of ulcerations from chronic vasoconstriction. Botulinum toxin has been shown to increase the blood supply throughout the hand through the its well-known mechanism of pre-synaptic SNARE cleavage.
Botulinum toxin cleaves the pre-synaptic SNAREs (soluble NSF attachment potion receptor) and prevents the release of acetylcholine from the intracellular vesicles. This has been used for multiple medical purposes, including vasospastic disorders. Raynaud's Disease is characterized by idiopathic vasospasm of the digital arteries without known underlying cause. Usually afflicting pre-menopausal women, it begins with pain and pallor in the digits, typically affecting the bilateral hands. Avoiding cold environments and tobacco are the mainstays of treatment, with calcium-channel blockers being the most common medication used. When these and other medications fail, botulinum toxin injections have been shown to be of benefit by relieving vasoconstriction and decreasing ischemia and pain.
Neumeister et al. reviewed the application of botulinum toxin A and individuals with Raynaud's Disease and Syndrome. They showed marked increases (up to 300%) in digital perfusion in patients receiving these injections into the common digital vessel at the level of the palm. They concluded the mechanisms for this response are likely multifactorial, involving central and systemic effects on neurotransmitters involved in chronic pain pathways, local digital vessel tone, and sympathetic innervation.
Iodio et al. reviewed all clinical studies regarding the use of bootulinum toxin A in raynaud's. There was high variability among the studies in terms of dosage and application method, but all studies reported favorable patient outcomes and some showed improved healing of ulcerations. These studies are promising but are limited due to study design and lack of standardization of botulinum toxin application.
Figure A shows non-infected ulcerations in the digits, common in progressive raynaud's disease.
Illustration A shows ischemic digits due to Raynaud's Syndrome. Illustration B is the same hand after botulinum toxin A injection. Illustration C is a laser doppler of a hand both pre- and post-injection perfusion of botulinum toxin A in an individual with Raynaud's Disease. Illustration D depicts the recommended method of injection, placing 10 units of botulinum around the common digital vessel at the level of the palm.
Incorrect Answers: There is no shown effect on digital proprioception, skin sensation, muscle strengthening.
A 27-year-old male injures his thumb during a fall onto an outstretched hand. He has pain at the MCP joint and difficulty grasping objects between the thumb and index finger. He undergoes surgery with the planned incision shown in Figure A. What muscle and corresponding nerve innervates the structure that blocks reduction of the ligament shown in Figure B?
Opponens pollicis, median nerve
Flexor pollicis brevis, ulnar nerve
Adductor pollicis, ulnar nerve
Abductor pollicis brevis, median nerve
Adductor pollicis, median nerve
The patient has an ulnar collateral ligament injury. The structure that blocks reduction of the ligament is the adductor pollicis aponeurosis, which is innervated by the ulnar nerve.
Thumb ulnar collateral ligament injuries occur after a radially directed force on an extended thumb, stressing the ulnar collateral ligament, dorsal capsule and volar plate. The thumb should be radiographed before stress exam if the history warrants so as not to displace a possible bony avulsion. Exam includes valgus stress on the thumb at 0 and 30 degrees of flexion to test the accessory and proper collateral ligaments respectively. With complete rupture of both ligaments, a bump over the ulnar thumb MCP joint may be palpated, signifying a Stener lesion. The ligament usually tears at the distal insertion and displaces proximal and superficial to the adductor aponeurosis. The dorsal capsule and volar plate may also be injured.
Bean et al. evaluated the biomechanics of non-anatomic reconstruction of the ulnar collateral ligaments in cadaveric specimens. They showed that 2mm of volar displacement of the ligament origin will allow for 10 degrees more radial deviation than anatomic placement will. This highlights the need for anatomic reconstruction and that deviation from this will alter joint kinematics.
Figure A shows a planned incision over the ulnar aspect of the thumb MCP joint
Fibure B shows a Stener lesion that is migrated proximally compared to the aponeurosis which is marked by the forceps
Illustration A depicts the retraction of the collateral ligament proximal to the aponeurosis
Illustration B shows a T1 MR coronal image showing a distal avulsion of the UCL and the Stener lesion, denoted by the asterisk, and the arrow pointing to the aponeurosis
Incorrect Answers:
An otherwise healthy 5-year-old female is brought to your office for the deformity shown in Figures A and B. Only the small digit of the left hand is involved and it may be fully flexed, but there is limited passive extension. What is the next best step in treatment?
Observation and reassurance
Nighttime extension splinting and stretching regimen
Nighttime extension splinting and stretching regimen with full genetic workup
FDS transfer to radial lateral band
FDS split with transfer of limbs to A2 pulley and central tendon hood
The patient described has isolated camptodactyly with a mild flexion contracture. The best next step in treatment is to begin a stretching and splinting regimen.
Camptodactyly is a nontraumatic flexion deformity isolated to the proximal interphalangeal joint, typically involving the small finger. This is often seen
bilaterally and sporadically, although many congenital disorders are associated. Many underlying anatomical structures have been implicated in the pathogenesis of this condition, with various surgical techniques having been described to address these. If this condition remains untreated, adjacent joint involvement can develop, with MCP hyperextension seen most commonly.
Intrinsic-plus splinting of the hand with passive stretching exercises should be initiated first. Surgery is usually reserved in cases of failed splinting or significant contractures approaching 60 degrees.
Comer et al. reviewed the complications of campylodactly. Most common complications were progression or failed improvement of both PIP contracture and MP hyperextension, isolated PIP postoperative residual stiffness, and bony remodeling of proximal phalanx head preventing full extension. They note inconsistent results after surgical correction which supports early detection and conservative modalities as the mainstay of treatment, focusing heavily on a stretching program and night splinting.
Rhee et al. reviewed outcomes of passive stretching for isolated camptodactyly flexion contractures in a series of children under the age of three years. They showed marked improvement of contracture deformity in all children across all levels of severity, though to less extent with more severe deformities.
Figures A and B demonstrate early contracture of the left small finger. Illustration A is a radiograph showing maintenance of articular congruity.
Incorrect Answers:
A collegiate rower complains of dorsal wrist pain for 6 weeks refractory to NSAIDs and bracing. Maximal tenderness is palpated on the dorsoradial forearm approximately 5 cm proximal to the wrist. Pain is exacerbated with resisted wrist extension. Radiographs are unremarkable. A steroid injection should be directed into the compartment containing which of the following structures?
APL and EPB tendons
ECRL and ECRB tendons
EPL tendon
APL and ECRB tendons
Brachoradialis tendon
CORRECT ANSWER: 2
The clinical scenario is consistent with intersection syndrome, a inflammatory response to overuse at the site of the second dorsal compartment crossing under the first dorsal compartment approximately 5 cm proximal to the wrist. An anatomical depiction is provided in illustration A. Injections of the second dorsal compartment, which includes ECRL and ECRB, may relieve symptoms
and quell inflammation. Intersection must be differentiated from DeQuervain's syndrome, which is tenosynovitis of the first dorsal compartment. Injections of the first dorsal compartment, which includes APL and EPB, are part of the treatment algorithm for Dequervain's. Wood et al summarizes the evaluation and treatment of sports-related wrist injuries. Grundberg et al demonstrates the pathologic abnormality of intersection syndrome is stenosing tenosynovitis of the second compartment explaining the rationale behind steroid injections into the sheath.
A 42-year-old chef has finally been transferred to the hand specialist 15 hours after injuring his non-dominant hand index finger with a butcher's knife as seen in figure A. He has kept the finger with him, which has been wrapped in saline-soaked gauze and placed on ice. What is the best reason the finger tip should not be replanted?
The replanted digit will likely have poor function due to the delay in care
Possible malingering
The replanted digit will likely have poor function due to the local anatomy
Patient age
Workers compensation patients will have worse outcomes
Single digit amputations proximal to the insertion of the flexor digitorum superficialis (FDS), in generally have poor function and severe stiffness following replantation.
Replantation between the FDS insertion and the distal palmar crease (zone 2 flexor tendon injuries) has historically led to poor results due to stiffness at the proximal interphalangeal joint, decreased sensation in the finger, and tendon adhesions between the FDP and slips of the FDS. Furthermore, outcome studies have demonstrated patients with index finger amputations through this region are more likely to bypass their stiff index finger and utilize their long finger for most tasks. However, amputation of multiple digits through zone 2 would be considered for replantation.
Urbaniak et al performed a retrospective case series of 59 patients who
underwent finger (thumb excluded) replantation for traumatic amputation. They found the functional results were most dependent on level of amputation and patients with amputation proximal to the insertion of the FDS had significantly decreased PIP motion. They concluded that replantation through zone 2 is seldom indicated due to severe stiffness.
Boulas et al reviewed digital replantation and recommend initial treatment should consist of wrapping amputated parts in moistened gauze and placing on ice. Sharp and clean amputations are considered more viable candidates for replantation due to limited damage to the replantation junction compared to crush injuries. Additionally, they state the patients with major psychiatric disorders or those that are unable to comply with postoperative protocols should also be considered poor candidates for replantation.
Figure A demonstrates an amputation through the left index finger proximal phalanx with no evidence of comminution or crush injury. Illustration A demonstrates the flexor tendon zones.
Incorrect Answers:
A patient sustains an acute, closed injury to his index finger. The clinical appearance of the finger is shown in Figure A. The patient is asked to extend the finger against resistance, with the PIP joint in 90 degrees of flexion. You note that PIP joint extension was weak, with hyperextension and restricted passive flexion of the DIP joint. When planning to treat this injury non-operatively which active joint motion is encouraged?
DIP flexion
MCP flexion
MCP extension
PIP extension
PIP flexion
CORRECT ANSWER: 1
This patient has sustained a central slip injury. Treatment consists of full time extension splinting of the PIP joint for 5 weeks with active DIP motion (flexion) encouraged.
A central slip injury, or a zone 3 extensor tendon injury, is characterized by PIP flexion and DIP extension (boutonniere deformity). This is most often caused by a rupture of the central slip over the PIP joint caused by a laceration, a traumatic avulsion, or capsular distension in rheumatoid arthritis. A rupture of the central slip causes the extrinsic extension mechanism from the EDC to be lost and prevents extension at the PIP joint. This allows the lumbricals' pull to become unopposed, causing PIP flexion and DIP extension. The examination maneuver described in the question stem is the Elson Test. It is the most reliable way to diagnose a central slip injury before the deformity is present. Non-operative treatment may be undertaken if the injury is closed and presents acutely. The PIP is splinted in full extension for 5 weeks. Active DIP extension and flexion in the splint is encouraged to avoid contraction of the oblique retinacular ligament.
Posner et al. describe the diagnosis and treatment of finger deformities following injuries to the extensor tendon mechanism. They suggest that treatment of a boutonniere deformity depends on its stage. For the acute injury (within the first 2 weeks), immobilization of the proximal interphalangeal joint in full extension for 5 weeks using a static splint that permits active and passive flexion of the DIP joint is usually effective.
Figure A is a clinical photograph demonstrating an index finger with the classic boutonniere deformity of flexion at the PIP joint and hyperextension of the DIP joint. Figure B is a diagram showing the Elson test. When the central slip is intact, there is no hyperextension of the distal phalanx. When the central slip is disrupted, the distal phalanx can hyperextend due to the function of the tight lateral bands.
Incorrect Answers:
A 25-year-old male is stabbed in the proximal volar forearm while fighting in a bar. He presents to the ED with a 1 cm wound and moderate oozing of blood. On exam, he has normal sensation throughout all distributions in his hand, normal radial and ulnar pulses, and a normal tenodesis effect. He is unable to actively flex his index finger DIP joint. Which muscle will also likely not function as a result of his injury?
Flexor digitorum brevis
Flexor carpi radialis
Flexor carpi ulnaris
Flexor pollicis longus
Pronator teres
CORRECT ANSWER: 4
The patient has sustained a laceration of the anterior interosseous nerve (AIN), which is a branch of the median nerve and innervates the flexor pollicis longus, pronator quadratus, and the flexor digitorum profundus to the index and long fingers. An intact tenodesis effect signifies that all of his tendons are structurally intact.
The AIN can be injured by a penetrating injury or chronic compression. It
arises from the dorsoradial aspect of the median nerve distal to the elbow. It then passes between the FPL and FDP to lie on the anterior interosseous membrane en route to the pronator quadratus and wrist capsule (Illustration A). Compression sites of the AIN include the deep head of the pronator teres, FDS arcade, edge of the lacertus fibrosus, an accessory head of the FPL, or other accessory muscles of the forearm (FDS, FDP, FCR). In this particular scenario of an acute, penetrating AIN injury, exploration and primary end-to-end suture repair is appropriate.
Rodner et al. review AIN syndrome and stress the importance of ruling out a tendon rupture, which can present similarly and can be differentiated by testing the patient's tenodesis effect. Non-traumatic AIN syndrome is usually the result of a neuritis, similar to Parsonage-Turner Syndrome (brachial plexus neuritis), and may have similar triggers such as viral infection or autoimmune disease. They recommend a prolonged period of observation (~12 months; in the absence of an obvious compressive or space-occupying lesion) due to high rates of spontaneous recovery at about one year.
Park et al. report on 11 patients that underwent surgical exploration for spontaneous AIN syndrome at an average of 7.8 months. The most common compressive structure was a fibrous band of the FDS, however, four patients had no obvious compressive structure, emphasizing the importance of at least six months of conservative treatment.
Incorrect answers:
A 38-year-old female presents with 8 months of gradual weakness of her right hand. She denies paresthesias, numbness, and pain in the right upper extremity. She has compensatory thumb interphalangeal flexion during key pinch and intact two point discrimination. She has a negative Tinel's sign at the wrist and elbow. Electromyography (EMG) shows normal sensory conduction velocities but delayed motor conduction to the first dorsal interosseous muscle. Figure A and B show MRI images of pre and post contrast, respectively. Ultrasound is shown in Figure C. What is the next best step?
Biopsy of the mass
Cyst excision
MRI of cervical spine
Excision of the hook of hamate
Cubital tunnel release
CORRECT ANSWER: 2
The patient has pure motor symptoms from ulnar nerve compression by a ganglion cyst at Guyon's canal. The next best treatment is excision of the ganglion cyst.
Atraumatic compression of the ulnar nerve at Guyon's canal is caused by a ganglion cyst 80% of the time. Compression may present with mixed motor and sensory or pure motor symptoms. With purely motor compression the deep branch of the ulnar nerve is affected resulting in weakness of adductor pollicis. Subsequent loss of metacarpophalangeal flexion and adduction leads to a positive Froment's sign with compensatory thumb IP flexion. Pure motor compression will result in normal sensory examination and intact two point discrimination as sensory branches are unaffected. EMG will localize decreased velocities at the wrist. When neurologic symptoms are present, cyst excision is recommended. Ganglion cysts in this location often arise from the pisohamate joint and excision of the stalk is important to prevent recurrence.
Wang et al. retrospectively investigated the outcomes of 9 patients with
ganglion cysts with symptomatic compression of the deep branch of the ulnar nerve. At a mean follow-up of 23 months they found all patients had improved grip and tip pinch strength. They conclude that surgical intervention can lead to satisfactory outcomes.
Shen et al review the imaging findings possible in patients with ulnar neuropathy. They present a case of a patient with ulnar neuropathy secondary to a ganglion cyst in guyon's canal.
Maroukis et al. review the history of the clinical anatomy of Guyon's canal. They conclude that the three zone theory helped simplify the complex anatomy of ulnar nerve compression at Guyon's canal.
Figure A (Shen et al) shows a T2 fat saturation MRI of a well circumscribed lesion (black arrow) with homogeneous fluid signal intensity at Guyon's canal compressing the ulnar nerve (white arrow). Figure B (Shen et al) shows a post contrast T1 fat saturation MRI showing rim enhancement consistent with a cyst (black arrow) and compression of the ulnar nerve (white arrow). Figure C shows an longitudinal ultrasound view of a anechoic well defined structure consistent with a cyst. Illustration A shows the areas of potential ulnar nerve compression in Guyon's canal. Illustration B shows a table with potential causes for compression at each zone and expected symptoms.
Incorrect Answers:
A 20-year-old male presents to clinic for evaluation of right wrist pain. He fell playing flag football about 6 weeks ago. He initially had significant pain but since it slowly improved he did not seek immediate treatment. His improvement has now plateaued. Figures A and B are x-rays, and figures C and D select CT scan images of his right wrist. What is the best treatment option?
Percutaneous screw fixation
Open reduction internal fixation through a volar approach
Open reduction internal fixation through a dorsal approach
Open reduction internal fixation with bone grafting through a volar approach
Open reduction internal fixation with bone grafting through a dorsal approach
The patient presents with a displaced right scaphoid waist fracture with cyst formation. The best treatment would open reduction internal fixation (ORIF) with bone grafting through a volar approach.
The surgical management of scaphoid fracture depends on location and characteristics of the fracture as well as time from injury. Displaced distal pole and waist fractures are typically approached from the volar side, especially if there is a humpback deformity; the proximal pole is more easily accessed from the dorsal side. Injuries with significant comminution or cyst formation due to extended time to treatment are often augmented with bone graft. There is controversy as to the use of vascularized bone graft in nonunion cases.
Rettig et al. reported on fourteen patients undergoing acute surgical fixation for displaced scaphoid waist fractures. Thirteen patients united and regained functional wrist range of motion and grip strength. They advocate for early
operative intervention in these fractures.
Raskin et al. describe the utility of the dorsal approach for proximal pole scaphoid fractures. They report good fracture visualization and the ability to bone graft through the same incision with successful union in a majority of cases.
Pinder et al. reviewed the literature on management of scaphoid nonunions. They found no difference in use of nonvascularized or vascularized bone graft, choice of approach, or use of Kirschner wires versus screw fixation.
Figures A and B are postero-anterior lateral right wrist radiographs with a displaced scaphoid waist fracture and mild humpback deformity. Figures C and D are coronal and sagittal CT cuts, respectively, demonstrating cyst formation and better showing the humpback deformity.
Incorrect Answers:
A 53-year-old white male presents with contractures of his ring finger and lesions over the dorsum of his hand. On examination of the lesions, they are subcutaneous, solid, and firm lesions measuring about 5 mm in diameter. They are located over the dorsum of the PIP joints of his ring and long finger. They become more mobile while the joint is in neutral and less mobile when the joint is in flexion. He also has a 5 degree flexion contracture his ring finger MCP joint. Examination of his palm reveals a palpable cord over the volar ring finger. His neurovascular examination is normal. The appearance of the dorsum of his hand is seen in Figure A. What is the next most appropriate step in treatment?
Collagenase injection and resection of dorsal finger lesions
Collagenase injection without resection of dorsal finger lesions
Observation and follow up
Surgical resection/fasciectomy and resection of dorsal finger lesions
Surgical resection/fasciectomy without resection of dorsal finger lesions
This patient has mild Dupuytren's disease with associated dorsal Dupuytren nodules, which may be observed.
Dupuytren’s disease is a proliferative disorder characterized by fascial nodules and contractures of the hand. It is autosomal dominant with variable penetrance. It exhibits a 2:1 male to female ratio and is classically seen in Caucasian males of northern European descent. The main pathology of
Dupuytren’s disease is excessive myofibroblast proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia. Surgical intervention is often indicated in cases of ≥30° of MCP contracture or any PIP contracture (usually >15°).
Rayan et al report that dorsal Dupuytren's nodules are a subcutaneous, solid, firm, well-defined, tumor-like mass or a nodule 3 mm in diameter or larger, located over the dorsum of the PIP joint. It is seldom painful and becomes more mobile while the joint is in neutral position and less mobile during joint flexion.
Black et al report that diseased tissue is referred to as nodules or cords. The Dupuytren nodule is a palpable subcutaneous lump that may be fixed to the skin. Cords are highly organized collagen structures arranged in parallel with a relatively hypocellular matrix. Cords are predominantly composed of collagen III while normal palmar fascia is predominantly collagen I.
Figure A is a picture of a dorsal Dupuytren's nodule. Incorrect Answers:
at this time. The dorsal finger lesions should not be resected.
A 37-year-old man has a 2-year history of increasing right wrist pain that is worse at night and aggravated by activity. He denies systemic symptoms, history of trauma, or recent weight loss. On physical exam he has tenderness over the dorsal radiocarpal joint. Radiographs of the right wrist are shown in Figure A. Which of the following imaging studies would be most sensitive for determining the stage of this patient's underlying condition?
Ultrasound
Angiography
CT scan of the wrist
Clenched fist AP radiograph of wrist
Bone scan of the wrist
CORRECT ANSWER: 3
The clinical presentation of dorsal radiocarpal wrist pain is suggestive of Kienbock’s disease. Figure A shows an AP radiograph of the right wrist with
evidence of lunate sclerosis with no obvious collapse. The imaging study most sensitive for identifying early lunate collapse in Kienbock's disease is CT scanning of the wrist.
Kienbock’s disease is defined by avascular necrosis of the lunate. It is classified into 4 stages under the Lichtman Classification. In stage 1, plain radiographs appear normal and magnetic resonance imaging is required for diagnosis. MRI is useful for detecting early disease when sclerosis is not evident on plain film radiographs. In stage 2, plain radiographs and/or CT scan images will show sclerosis of the lunate but no evidence of collapse. In stage 3, radiographs and/or CT scan images will show lunate collapse. For stage 4, radiographs show degenerative changes to the adjacent carpus and intercarpal joints.
Imaeda et al. examined the use of MRI for the diagnosis and staging of Kienbock's disease. They found that MRI was most sensitive in detecting early focal loss of signal intensity in the lunate on T1-weighted images. This was a key diagnostic feature in early stages of Kienböck's disease when plain radiographs appear normal.
Cross et al. reviewed the latest concepts for diagnosis, staging, and management of Keinbock's disease. They suggest that computed tomography (CT) or tomography will better characterize lunate necrosis and trabecular destruction once collapse or sclerosis has occurred in late stage disease.
Illustration A is a collection of CT scanning images that show osteonecrosis of the lunate. The blue arrow shows lunate flattening and sclerosis. The red double arrow shows a loss of lunate height and the yellow shows fragmentation of the bone.
Incorrect Answers:
widening of the scapholunate interval.
Each of the following are indications for microvascular replantation EXCEPT?
Thumb amputation
Index finger amputation in a child
Through wrist amputation
Long finger amputation through the proximal phalanx
Mid-palm amputation of all four fingers
As reviewed by Soucacos, there are several major indications for single digit replantation: 1) Level of the amputation is distal to the insertion of FDS. 2) Amputations at the level of the distal phalanx. 3) Ring avulsion injuries involving both the dorsal and palmar skin and blood supply in an isolated finger, as long as FDS is intact. 4) Any amputation in a child. 5) Thumb amputation. Replantation of a single digit, which is amputated at the level of the proximal phalanx or at the PIP joint, particularly in avulsion or crush injury is contra-indicated. Soucacos also discusses appropriate surgical teams, transport, and other related issues surrounding a "transplant team."
All of the following are predictive findings for correctly diagnosing carpal tunnel syndrome EXCEPT:
Abnormal hand diagram
Abnormal Semmes-Weinstein testing in wrist-neutral position
Positive median nerve compression test (Durkan's sign)
Presence of night pain
Loss of small digit adduction (Wartenberg sign)
All of the listed physical exam findings, except for loss of small digit adduction (Wartenberg sign), has been found to be predictive for diagnosing carpal tunnel syndrome.
Szabo et al in a Level 3 study used a regression model to analyze the most predictive factors for correctly diagnosing carpal tunnel syndrome (CTS). Their analysis found that with an abnormal hand diagram, abnormal sensibility by Semmes-Weinstein testing in wrist-neutral position, a positive Durkan's test, and night pain, the probability that carpal tunnel syndrome will be correctly diagnosed is 0.86. They found the tests with the highest sensitivity were Durkan's compression test (89%), Semmes-Weinstein testing after Phalen's maneuver (83%), and hand diagram scores (76%). Night pain was a sensitive symptom predictor (96%). The most specific tests were the hand diagram (76%) and Tinel's sign (71%). The authors concluded that the addition of electrodiagnostic tests did not increase the diagnostic power of the combination of these 4 clinical tests, and proceeding with surgical release is appropriate even if the EMG is normal.
Wartenberg sign is persistent abduction and extension of the small digit when a patient is asked to adduct the digits and is seen in cubital tunnel syndrome, but not carpal tunnel syndrome.
Illustration V demonstrate the Durkan's Compression test for carpal tunnel syndrome.
Extrinsic imbalance from splinting a crushed hand with metacarpophalangeal joint extension causes what characteristic hand deformity?
Distal interphalangeal joint extension
Ulnar subluxation of the metacarpophalangeal joints
Proximal interphalangeal joint extension
Proximal interphalangeal joint flexion
Swan-neck deformity
CORRECT ANSWER: 4
Failure to splint the hand in an intrinsic positive position leads to increased extrinsic finger flexor tension, leading the DIP and PIP joints to have an increasing flexion position. Illustration A and B show a clinical image and illustration of intrinsic minus hand.
von Schroeder et al present a Level 5 review of hand crush injuries. They conclude that early diagnosis and treatment is critical, but the functional outcome is often poor with associated Volkmann's contracture.
Axon regeneration almost always occurs following a Sunderland second-degree nerve injury because which anatomic structure is not injured?
Epineurium
Endoneurium
Perineurium
Myelin sheath
Schwann cell
CORRECT ANSWER: 2
Following a Sunderland second-degree injury, axon regeneration is possible because the endoneurium is intact.
There are two classification schemes for peripheral nerve injuries, which include the Seddon and the Sunderland systems. Under the Sunderland
classification, a second-degree injury is considered a part of the axonotmesis spectrum. The endoneurium, perineurium and epineurium are still intact. This enables complete functional recovery.
Lee et al. review the pathophysiology and evaluation of peripheral nerve injuries. They note that in Sunderland type two injuries, there is physiologic disruption of the axons. Because the endoneurium is still intact, axons are able to regenerate. This process takes months.
Illustration A is a schematic of the various stages of peripheral nerve injury. Incorrect Answers
Sunderland type 2 injury, axon regeneration is possible because of an intact endoneurium.
A 29-year-old intravenous drug user undergoes irrigation and debridement of a ring finger abscess. After adequate eradication of the infection, he is left with the skin defect shown in Figure A. What is the most appropriate treatment at this time?
Local woundcare and healing by secondary intention
V-Y advancement flap
Thenar flap
Moberg flap
Cross-finger flap
CORRECT ANSWER: 5
Based on the location of the lesion, a cross-finger flap would be most appropriate.
Cross finger flaps are indicated in patients > 30 years of age when the lesion is a volar oblique finger tip lacerations or a volar proximal finger lesions. The advantage is it leads to less stiffness.
Martin et al review the treatment options available for digit injuries. They report treatment of fingertip injuries is a continuous focus of controversy among hand and orthopaedic surgeons. Different treatment options have been described, depending on the affected segment and finger, type of lesion, gender and age of the patient, location, size, and depth of the defect.
Fassler et al reviews the proper management of fingertip injuries discussing variables such as the severity of soft tissue loss and whether bone is exposed.
Incorrect Answers:
A 4-year-old boy sustains a flexor tendon laceration in Zone 2 of his 4th digit when he attempts to grab a knife. Optimal surgical management and postoperative rehabilitation consists of:
2 strand core suture technique and gentle active flexion and extension exercises with wrist in extension
2 strand core suture technique and cast immobilization for 8 weeks
4 strand core suture technique and gentle active flexion and extension exercises with wrist in extension
4 strand core suture technique and cast immobilization for 4 weeks
4 strand core suture technique and cast immobilization for 8 weeks
4 strand core suture technique and cast immobilization for 4 weeks is the preferred postoperative rehabiltation in a 4 year old child.
Ordinarily, adult flexor tendon repair postoperative rehab protocols call for early light active digital flexion with wrist in gentle flexion as long as the tendon has been repaired with a 4 or 6 strand core suture technique and strong epitendinous suture. However, this method cannot succeed without the cooperation of a mature and motivated patient. Children or the mentally disabled are often lacking some of these prerequisites. Therefore, a flexor tendon repair in a child should be treated like a flexor tendon repair with interposed graft in an adult. Immobilization for a minimum of 3 – 4 weeks with a posterior molded plaster splint or cast from the tips of the fingers to just above the elbow. Wrist is flexed 35 degrees, MCPs flexed 60 – 70 degrees and IP joints relaxed in extension. Active motion can be started after the cast is removed at 4 weeks.
A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. A radiograph is shown in figure A. What joint is first affected if left untreated with subsequent development of a SLAC (scapholunate advanced collapse) wrist?
Capitolunate joint
Radioscaphoid
Radioulnar
Radiolunate
STT (scaphotrapezotrapezoidal)
The clinical presentation is consistent with a SLAC wrist. The radioscaphoid joint is the first to be affected in this process.
The radiographs of the right wrist demonstrate a scapholunate dissociation, as evidenced by an increased scapholunate joint space, referred to as scapholunate diastasis (abnormal when the gap is greater than 2 mm and increased from the opposite extremity and other intercarpal spaces).
If left untreated, the wrist may progress to a "SLAC" wrist, as originally described by Watson and Ballet in 1984, which is the most common form of wrist arthritis. The repetitive sequence of degenerative changes is based on and caused by articular alignment problems between the scaphoid, the lunate and the radius.
Kuo et al. review the stages of SLAC wrist. They report stage I SLAC wrist involves changes limited to an area of abnormal contact between the abnormally rotated scaphoid and the radial styloid. In stage II the remaining radioscaphoid joint is affected, as persistent abnormal load transfer and shear across the cartilaginous surfaces leads to degeneration of the proximal scaphoid facet. In stage III, the dorsally translated capitate migrates proximally into the widened scapholunate interval, and degenerative changes occur at the capitolunate joint. The relative congruency of the radiolunate joint in all positions of lunate rotation due to the spherical shape of the lunate facet preserves this articulation, and at all stages of SLAC wrist the radiolunate joint is not involved. The lunate is congruently loaded in every position and, thus, highly resistant to degenerative changes.
Illustration A below shows the stages of involvement in the SLAC wrist.

Question 86:

Options:

Observation and NSAID use as needed
MRI scan
Bone biopsy
Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP).

Correct Answer: Observation and NSAID use as needed

Explanation:

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.
View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams
14
& Wilkins; 2007:514-533.

Question 87:

Options:

Physical therapy
Meniscal repair
Menisectomy
Reconstruction

Correct Answer: Menisectomy

Explanation:

Question 88:

Nutritional rickets in the US occurs more frequently in infants older than 6 months of age who do not receive vitamin D supplementation and are Review Topic

Options:

Caucasian and formula fed.
Caucasian and breast fed.
African American and formula fed.
African American and breast fed.
Asian and formula fed.

Correct Answer: African American and breast fed.

Explanation:

Question 89:

A 45-year-old man with a painful varus knee is being considered for an upper tibial osteotomy. Which of the following factors is considered the most compelling argument against this procedure?

Options:

Flexion contracture of 5°
Subchondral cyst in the medial tibial condyle
Lateral meniscal degeneration seen in an MRI scan
Rheumatoid arthropathy
Previous medial meniscectomy

Correct Answer: Rheumatoid arthropathy

Explanation:

Question 90:

Figure 23 shows the radiograph of a 55-year-old man who underwent a total hip arthroplasty 5 years ago. Management should now consist of

Options:

an Ogden-type plate with screws and cerclage bands or cables.
allograft bone plates fixed with cerclage cables and wires.
skeletal traction for 8 weeks.
revision of the femoral stem.
resection arthroplasty.

Correct Answer: revision of the femoral stem.

Explanation:

Question 91:

-The patient asks if something about her anatomy has resulted in this injury. ACL anatomy differs between men and women in what manner?

Options:

There is no significant difference in ACL anatomy between men and women.
A woman’s ACL has a smaller cross-sectional area.
The cross-sectional area of a woman’s ACL is larger.
The intercondylar notch is wider in women than in men.

Correct Answer: A woman’s ACL has a smaller cross-sectional area.

Explanation:

DISCUSSION FOR QUESTIONS 18 THROUGH 20
This patient has the clinical findings of an ACL rupture that is confirmed on MRI scan. She is a professional athlete and would like to return to her sport. Immediate ACL reconstruction in the setting of a knee with limited motion carries an increased risk for postsurgical stiffness. Delayed surgery after the patient regains range of motion is the preferred response. It has been shown that a woman’s ACL is smaller in the cross-sectional area.

Question 92:

What pathology is most likely to result in failure of an arthroscopic Bankart repair?

Options:

A 25% or greater anterior-inferior glenoid rim defect
Nonengaging moderate Hill-Sachs defect
Associated type IV superior labrum anterior and posterior (SLAP) lesion
Absence of an intact cartilaginous labrum
Atttenuated anterior-inferior capsule and glenohumeral ligament complex

Correct Answer: A 25% or greater anterior-inferior glenoid rim defect

Explanation:

Question 93:

Options:

Calcific tendinitis
Rotator cuff tendinosis
Bursitis
Brachial neuritis
Glenohumeral arthritis

Correct Answer: Brachial neuritis

Explanation:

Question 94:

Options:

hip and knee extension
hip flexion to 90, knee extension
hip internal rotation, knee flexion to 90
hip and knee flexion to 90
hip extension, knee flexion to 90

Correct Answer: hip and knee extension

Explanation:

Question 95:

Options:

Flexor-pronator avulsion
Ulnar nerve subluxation
Medial collateral ligament injury
Lateral ulnar collateral ligament rupture
Triceps tendon subluxation

Correct Answer: Medial collateral ligament injury

Explanation:

DISCUSSION: The milking test, as seen in the photograph, elicits pain when a tear is present in the medial collateral ligament. Complete rupture is possible but unlikely when there is no history of trauma and the patient is able to throw pain-free for several innings. Subluxation of the ulnar nerve and triceps tendon subluxation present as a painful snapping over the medial aspect of the elbow.
REFERENCES: Williams RJ III, Urquhart ER, Altchek DW: Medial collateral ligament tears in the throwing athlete. Instr Course Lect 2004;53:579-586.
Cain EL Jr, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 2003;31:621-635.

Question 96:

Options:

Hip instability
Abductor weakness
Adductor weakness
Quadriceps weakness
Leg-length discrepancy

Correct Answer: Abductor weakness

Question 97:

Options:

Intraarticular penetration of the screw
Position of the screw cephalad to the sciatic notch
Screw starting point at the anterior inferior iliac spine
Screw starting point at the gluteal pillar
Screw position between the inner and outer tables of the ilium

Correct Answer: Intraarticular penetration of the screw

Explanation:

Question 98:

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints? Review Topic

Options:

With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.
With tibial shin splints, the bone scan is more intense.
A more diffuse area of tenderness is seen in tibial stress fractures.
A three-phase bone scan is positive in all phases with shin splints, but only positive in delayed images with tibial stress fractures.
After activity, pain persists longer with tibial stress fractures.

Correct Answer: With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.

Explanation:

Question 99:

Which factor should most influence a patient's decision to have surgery for adult scoliosis if he or she is younger than age 50?

Options:

Increasing coronal plane deformity
Increasing pain
Increasing sagittal balance
Invasiveness of the surgical procedure

Correct Answer: Increasing coronal plane deformity

Explanation:

DISCUSSION
In a retrospective review of 137 patients treated surgically and 153 patients treated nonsurgically for adult scoliosis, Bess and associates found that surgical treatment for patients younger than 50 years of age was driven by increased coronal plane deformity, and surgical treatment for older patients was mandated by pain and disability. They also concluded that age, comorbidities, and sagittal balance did not influence treatment decisions.
RECOMMENDED READINGS
Bess S, Boachie-Adjei O, Burton D, Cunningham M, Shaffrey C, Shelokov A, Hostin R, Schwab F, Wood K, Akbarnia B; International Spine Study Group. Pain and disability determine treatment modality for older patients with adult scoliosis, while deformity guides treatment for younger patients. Spine (Phila Pa 1976). 2009 Sep 15;34(20):2186-90. PubMed PMID: 19752704.
View
Abstract at PubMed
Anderson DG, Albert T, Tannoury C. Adult scoliosis. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:331-338.

Question 100:

Options:

Proximal tibial/fibular osteotomy with acute correction and pin fixation
Proximal tibial/fibular osteotomy with gradual correction and external fixation
MRI of the proximal tibial physis
Medial proximal tibial hemiepiphysiodesis
Continued observation

Correct Answer: Continued observation

Explanation:

DISCUSSION: The tibia has grown into valgus secondary to the proximal fracture. This occurs in about one half of these injuries, and maximal deformity occurs at 18 months postinjury. The deformity gradually improves over several years, with minimal residual deformity. Therefore, treatment at this age is unnecessary as there is a high rate of recurrence and complications regardless of technique. The valgus deformity is not a result of physeal injury or growth arrest. Medial proximal tibial hemiepiphysiodesis is an excellent method of correcting the residual deformity but is best reserved until close to the end of growth.
REFERENCES: Brougham DI, Nicol RO: Valgus deformity after proximal tibial fractures in children. J Bone Joint Surg Br 1987;69:482.
McCarthy JJ, Kim DH, Eilert RE: Posttraumatic genu valgum: Operative versus nonoperative treatment. J Pediatr Orthop 1998;18:518-521.
Robert M, Khouri N, Carlioz H, et al: Fractures of the proximal tibial metaphysis in children: Review of a series of 25 cases. J Pediatr Orthop 1987;7:444-449.

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

Orthopedic Surgery Board Review MCQs: Trauma, Spine & Upper Extremity | Part 41

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 41

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index