OITE & ABOS Board Review Part 240: Orthopedic MCQs

About This Board Review Set

This is Part 240 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.

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
Exam Mode — All feedback is hidden until you click Submit & See Results. A live timer tracks elapsed time. A percentage score and detailed breakdown are displayed upon submission.

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 240

This module focuses heavily on: Elbow, Fracture, Hip, Knee, Nerve, Trauma.

Sample Questions from This Set

Sample Question 1: A 220-lb 20-year-old man was involved in a motor vehicle accident. His work-up reveals that he has multiple long bone fractures as well as a splenic injury that is currently being managed nonsurgically. His initial blood pressure in the tra...

Sample Question 2: A patient undergoes an arthroscopic debridement for lateral epicondylitis. Postoperatively she reports pain and a sense of clicking of the elbow. Examination reveals apprehension to supination, load, and extension. What structure has been i...

Sample Question 3: Figures 155a and 155b are the plain radiographs of a 17-year-old boy who recently noted painless swelling in his distal thigh. Examination reveals a firm, fixed, deep distal thigh mass. There is no associated tenderness. What is the best ne...

Sample Question 4: Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal L...

Sample Question 5: A patient who was involved in a motor vehicle accident 2 weeks ago now reports neck pain. Work-up reveals no evidence of nerve root involvement or acute radiographic abnormality. The patient appears to have a hyperextension soft-tissue inju...

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

A 220-lb 20-year-old man was involved in a motor vehicle accident. His work-up reveals that he has multiple long bone fractures as well as a splenic injury that is currently being managed nonsurgically. His initial blood pressure in the trauma bay was 70/30 mm Hg. After receiving 4 liters of fluid and 3 units of packed red blood cells, his blood pressure is currently 110/70, his heart rate is 100, his urine output is 90 mL/h (normal 0.5 to 1 mL/kg/h), and his core temperature is 97.9 degrees F (36.5 degrees C). At this point, the patient’s resuscitation can be described as which of the following?

Explanation

DISCUSSION: Although the end points of resuscitation are still unclear, what is known is that normalization of the standard hemodynamic parameters (blood pressure, heart rate, and urine output) is not adequate. Up to 85% of patients with normal hemodynamic parameters can still have inadequate tissue oxygenation or uncompensated shock. The initial base deficit, lactate level, or gastric pHi can be used to stratify patients for resuscitation needs, risks of death, and multiple organ failure (level 1 evidence). The time it takes to normalize the base deficit, the lactate level, or gastric pHi, can predict survival (level 2 evidence). Patients who have been in uncompensated shock (abnormal vital signs) should have their resuscitation monitored using data other than vital signs.
REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: Endpoints of resuscitation. J Trauma 2004;57:898-912.
Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury,

a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.
Englehart MS, Schreiber MA: Measurement of acid-base resuscitation endpoints: Lactate, base deficit, bicarbonate or what? Curr Opin Crit Care 2006;12:569-574.

Question 2

A patient undergoes an arthroscopic debridement for lateral epicondylitis. Postoperatively she reports pain and a sense of clicking of the elbow. Examination reveals apprehension to supination, load, and extension. What structure has been injured resulting in the clinical presentation?

Explanation

DISCUSSION: The patient has an iatrogenic injury to the lateral ulnar collateral ligament following the arthroscopic procedure. Failure to adhere to known anatomic landmarks can lead to this devastating complication. The examination findings are classic for posterolateral elbow instability.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 318.
O’ Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

Question 3

Figures 155a and 155b are the plain radiographs of a 17-year-old boy who recently noted painless swelling in his distal thigh. Examination reveals a firm, fixed, deep distal thigh mass. There is no associated tenderness. What is the best next treatment step?

Explanation

Question 4

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. The injured structure is composed of an

Explanation

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used.
Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for vascular injury.

Question 5

A patient who was involved in a motor vehicle accident 2 weeks ago now reports neck pain. Work-up reveals no evidence of nerve root involvement or acute radiographic abnormality. The patient appears to have a hyperextension soft-tissue injury of the neck (whiplash). What is the best course of treatment at this time?

Explanation

DISCUSSION: Early mobilization and resumption of normal activities immediately after neck sprain has been shown to improve functional outcome and decrease subjective symptoms as measured 6 months after injury.
REFERENCES: Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I: Acute treatment of whiplash neck injuries: A randomized trial during the first 14 days after a car accident. Spine 1998;23:25-31.
Mealy K, Brennan H, Fenelon GC: Early mobilization of acute whiplash injuries. Br Med J 1986;292:656-657.

Question 6

The familial occurrence of Legg-Calve-Perthes disease may, in some cases, be attributed to

Explanation

One of the suggested causes of Perthes disease is a hypercoaguable state in a child. This would lead to thrombotic venous occlusion in the proximal femur resulting in venous hypertension and osteonecrosis of the femoral head. Therefore look for an answer that would result in a hypercoaguable state. There is no link between hypophosphatemia or high dietary cholesterol intake and a hypercoaguable state. Elevated levels of antithrombin III would result in bleeding, not coagulation. The referenced paper demonstrated a familial occurrence in protein S and protein C deficiency and elevated levels of lipoprotien A. Protein C and S are antithrombotic factors and lipoprotein A is a thrombogenic, atherogenic lipoprotein associated with osteonecrosis in adults.

Question 7

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 8

A total knee arthroplasty is recommended to a mentally competent 68-year-old woman who has disabling knee pain caused by degenerative arthritis. Her son has researched the procedure on the internet and prefers the Acme Female Knee for his mother. You have designed the Axis Woman's Knee, for which you receive royalties, and use it exclusively. Which of the following ethical principles takes precedence in guiding her treatment?

Explanation

Informed consent incorporates a number of ethical principles relevant to this case. The fundamentals of medical ethics include nonmaleficence, beneficence, autonomy, and justice. The patient is competent and capable of exercising her autonomy in choosing the Acme Female Knee. She also depends on her physician's paternalism and knowledge in looking out for her best interests, which in his opinion, may be use of the Axis Woman's Knee. The physician has a fiduciary responsibility to inform the patient that he has a financial interest in the implant system he recommends. A thorough informed consent will respect the patient's autonomy, explain the rationale for the physician's recommendation, and notify the patient that there may be a perceived conflict of interest. The ethical principle of justice has no relevance in this case.

Question 9

All of the following are factors associated with transfer of patients to Level 1 trauma centers EXCEPT:

Explanation

DISCUSSION: Caucasian race has not been found to be a predictor for transfer to a Level 1 trauma center. The retrospective case-control study by Koval et al found that African-American race, presence of medical comorbidity, medicaid insurance, and male gender are predictors for transfer of patients to a trauma center that have ISS scores less than 9. The article by Nathens et al found that lack of insurance was an independent predictor for transfer to a trauma center after adjusting for differences in injury severity. An injury severity score of 36 represents a patient that has sustained life-threatening polytrauma and should be transferred to a Level 1 trauma center.

Question 10

Surgical treatment for symptomatic disk herniations is associated with which of the following? Review Topic

Explanation

The recently published SPORT trial verifies that surgical treatment of symptomatic disk herniations is associated with early and sustained pain relief. The trial also verifies that nonsurgical management is associated with improved symptoms as well. Nerve root injury, recurrent herniation, and diskitis are known complications of surgery, but all are less common than described above.

Question 11

A 58-year-old woman underwent a left total knee arthroplasty 6 years ago. She initially did well after surgery but sustained a fall 2 months ago while at work. She now describes left knee pain and instability and an inability to straighten her knee since the fall. She has been using a hinged knee brace, which provides partial support. On examination, she has passive range of motion of 0° to 115° and active range of motion of 80° to -115°. Her radiographs are shown in Figures below. What is the best option for the restoration of her function?

Explanation

DISCUSSION:
The patient has an extensor mechanism disruption with patellar tendon rupture. This injury is treated with extensor mechanism reconstruction in the setting of previous total knee arthroplasty. There is a reported high failure rate with attempted repair. Revision to hinge knee arthroplasty would provide implant stability but would not restore the extensor mechanism. The patient is relatively young and is working, so reconstruction would offer better long-term function than a drop lock brace, which can be better used in low-functioning patients with this type of injury. Extensor mechanism reconstruction historically has been accomplished with allograft material, but a novel technique using synthetic mesh also has proved successful in treating this difficult problem.

Question 12

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 13

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared with a standard parapatellar approach, what is the expected outcome?

Explanation

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 14

In addition to the radiographic features seen in Figures 49a and 49b, this patient will most likely have which of the following findings?

Explanation

DISCUSSION: The radiographs show the characteristic features of osteopetrosis. The condition results from defective resorption of immature bone by osteoclasts. There are three distinct clinical forms: (1) infantile-malignant, which is autosomal recessive and fatal in the first few years of life if untreated; (2) intermediate autosomal recessive; and (3) autosomal dominant. These conditions do not follow a malignant course, and patients have normal life expectancy with orthopaedic problems and anemia. In the malignant form, the clinical features include frequent fractures, macrocephaly, progressive deafness and blindness, hepatosplenomegaly, and severe anemia beginning in early infancy or in utero. Deafness and blindness are generally thought to represent effects of pressure on nerves and usually occur later in life. The anemia is caused by encroachment of bone on marrow, resulting in obliteration, and the hepatosplenomegaly is caused by compensatory extramedullary hematopoiesis. Dental caries and abscesses, as well as osteomyelitis of the mandible, are also seen. Most patients have normal intelligence. Treatment of the malignant form includes high dose 1,25 dihydroxy vitamin D with a low-calcium diet to stimulate bone resorption, not because there are vitamin deficiencies. Bone marrow transplant has also been successful.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002, p 1550.
Zaleske DJ: Metabolic and endocrine abnormalities, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 212-214.
Kaplan FS, August CS, Fallon MD, et al: Successful treatment of infantile malignant osteopetrosis by bone-marrow transplantation: A case report. J Bone Joint Surg Am 1988;70:617-623.

Question 15

An otherwise healthy 35-year-old woman reports dorsal wrist pain and has trouble extending her thumb after sustaining a minimally displaced fracture of the distal radius 3 months ago. What is the next most appropriate step in management?

Explanation

DISCUSSION: Extensor pollicis longus tendon rupture can occur after a fracture of the distal radius, even a minimally displaced one. Poor vascularity of the tendon within the third dorsal compartment is the suspected etiology, not the displaced fracture fragments. Tendon transfer will suitably restore active extension of the thumb interphalangeal joint.
REFERENCES: Christophe K: Rupture of the extensor pollicis longus tendon following Colles fracture. J Bone Joint Surg Am 1953;35:1003-1005.
Hove LM: Delayed rupture of the thumb extensor tendon: A 5-year study of 18 consecutive cases. Acta Orthop Scand 1994;65:199-203.

Question 16

Figures 20a and 20b show the radiographs of a 14-year-old boy who sustained a twisting injury to his ankle. If attempted closed reduction is unsuccessful, what is the primary reason to proceed with surgical treatment?

Explanation

DISCUSSION: Triplane fractures generally occur in children who are near skeletal maturity. The injury is generally caused by a supination external rotation mechanism. The number of fracture fragments present (two or three) depends on what part of the physes is closed at the time of injury. Articular congruity is the major concern in the management of these injuries since the patient has almost reached skeletal maturity. The goal is to restore articular congruity to minimize the development of posttraumatic arthritis.
REFERENCES: Vaccaro A (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 757-765.
Kling TF Jr, Bright RW, Hensinger RN: Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am 1984;66:647-657.
Spiegel PG, Mast JW, Cooperman DR, et al: Triplane fractures of the distal tibial epiphysis.

Clin Orthop Relat Res 1984;188:74-89.

Question 17

What is the most likely reason open fractures tend to heal more slowly than closed fractures?

Explanation

DISCUSSION: In open fractures, the hematoma that forms beneath the periosteum and around the ends of the fracture site is lost from the open wound. In addition, the irrigation process washes out the hematoma that contains growth factors and cytokines from the platelets. While loss of blood supply at the fracture site and soft-tissue coverage are important factors, the most important is loss of the factors that initiate the inflammatory phase of fracture healing. Infection may also delay healing, but is less common in this population.
REFERENCES: Buckwalter JA, Einhom TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 377-381.
Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1-14.
2010 Pediatric Orthopaedic Examination Answer Book • 57

Question 18

82 • American Academy of Orthopaedic Surgeons A 12-year-old girl is seen for left ankle pain. Radiographs reveal osteochondritis dissecans (OCD) involving the talus. What should the parents be told regarding management?

Explanation

DISCUSSION: Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.
Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

Question 19

Figure 36a shows the current radiograph of a 65-year-old woman who slipped and fell. History reveals that prior to the fall she was actively functioning without pain. Figure 36b shows a radiograph obtained 1 year ago. Based on the fracture pattern, the failure is most likely related to

Explanation

DISCUSSION: The radiograph shows a fracture distal to the prosthesis in a stable, apparently well-fixed prosthetic stem. The well-fixed prosthesis-bone composite is stiff, creating a modulus mismatch between the proximal and distal femur. Therefore, the risk of fracture, particularly in osteoporotic bone, is increased at this level. Revision of the stem to a longer construct is unnecessary, and standard plate and screw fixation has been shown to yield union rates of greater than 90%. Nonsurgical treatment of fractures distal to the tip of the prosthesis results in high nonunion rates, reported to be from 25% to 42%.
REFERENCES: Johansson JE, McBroom R, Barrington TW, Hunter GA: Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surg Am 1981;63:1435-1442.
Bethea JS III, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB: Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;170:95-106.
Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.

Question 20

What gene is expressed the earliest during the differentiation of a chondrocyte during endochondral ossification?

Explanation

DISCUSSION: Transcription factors regulate the activation or repression of cartilage-specific genes. Sox-9, considered a major regulator of chondrogenesis, regulates several cartilage-specific genes during endochondral ossification, including collagen types II, IV, and XI and aggrecan.
REFERENCES: Li J, Sandell LJ: Transcriptional regulation of cartilage-specific genes, in Rosier RN, Evans C (eds): Molecular Biology in Orthoapedics, Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 21-24.
Sandell LJ: Genes and gene expression. Clin Orthop 2000;379:S9-S16.

Question 21

A 6-year-old boy has leg pain. A radiograph, MRI, CT, and bone scans, and a biopsy specimen are shown in Figures 14a through 14e. What is the most likely diagnosis?

Explanation

DISCUSSION: From an imaging point of view, all of the diagnoses are possible. Biopsy results and cultures are necessary to make the diagnosis. The biopsy specimen shows inflammatory cells and necrotic bone, consistent with osteomyelitis.
REFERENCES: Fletcher BD, Hanna SL: Pediatric musculoskeletal lesions simulating neoplasms. Magn Reson Imaging Clin N Am 1996;4:721-747.
Hanna SL, Fletcher BD, Kaste SC, Fairclough DL, Parham DM: Increased confidence of diagnosis of Ewing sarcoma using T2-weighted MR images. Magn Reson Imaging 1994;12:559-568.

Question 22

A 19-year-old football player who sustained three traumatic anterior shoulder dislocations underwent surgery to repair a Bankart lesion. Nine months after surgery, examination reveals stability, elevation to 150 degrees, external rotation to 0 degrees with the elbow at his side and to 50 degrees at 90 degrees of abduction, and internal rotation to T12. If his range of motion does not improve, he is at most risk for

Explanation

DISCUSSION: Loss of external rotation can lead to degenerative joint disease following an anterior stabilization procedure. A tight anterior capsule will prevent internal impingement. Risk of thoracic outlet syndrome should not be increased. Subscapularis detachment is a risk following open anterior repair; however, a gain in external rotation would be noted. In time, this patient’s shoulder may show increased posterior glenohumeral wear but should not have symptoms of recurrent subluxation unless multidirectional instability is present.
REFERENCES: Hawkins RJ, Angelo RL: Glenohumeral osteoarthrosis: A late complication of the Putti-Platt repair. J Bone Joint Surg Am 1990;72:1193-1197.
Norns TR: Complications following anterior instability repairs, in Bigliani LU (ed): Complication of Shoulder Surgery. Baltimore, MD, Williams and Wilkins, 1993, pp 98-116.

Question 23

A 21-year-old professional ballet dancer reports a painful popping sensation over her right hip joint. Examination reveals that symptoms are reproduced with hip flexion and external rotation. Which of the following studies will best confirm the diagnosis?

Explanation

DISCUSSION: The patient has snapping hip syndrome of the internal type, which is more common in ballet dancers. It is caused by the iliopsoas tendon gliding over the iliopectineal line or the femoral head. The diagnosis usually can be made by the history and physical examination. Snapping is reproduced by hip flexion and extension or flexion with external rotation and abduction. Conventional and dynamic ultrasonography will confirm the snapping structure. Radiographs occasionally show calcifications near the lesser trochanter. MRI can be used to rule out other diagnoses that can simulate snapping hip.
REFERENCES: Gruen GS, Scioscia TN, Lowenstein JE: The surgical treatment of internal snapping hip. Am J Sports Med 2002;30:607-613.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 139-153.

Question 24

A 23 year old man has a minimally comminuted midshaft fracture of the femur with 2cm entrance and exit wounds as a result of a low-velocity gunshot. Definitive management should be

Explanation

There is no clear treatment of these fractures the reference literature reviewed shows that soft-tissue tracks of low-velocity gunshot wounds are not rendered sterile by the bullet force. Despite this information, the majority of studies that have followed the healing of fractures secondary to gunshot wounds reveal a surprising low infection rate.

Question 25

Figure 25 shows the radiograph of an 84-year-old woman who has pain and is unable to extend her knee. History reveals that she underwent total knee arthroplasty 8 years ago. Aspiration and studies for infection are negative. During revision surgery, management of the tibial bone loss should consist of

Explanation

DISCUSSION: Massive bone loss encountered in revision total knee arthroplasty remains a significant challenge. Recent reports have shown high success rates using structural allograft to reconstruct large structural bone defects. A hinged prosthesis is not required in this setting. In this patient, a large amount of posterior cortex has been lost, making the area too large to fill with cement or iliac crest bone graft. Because of her age, the treatment of choice is a revision tibial implant and metal augments. Structural allograft would be suitable in a younger patient.
REFERENCES: Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty. J Arthroplasty 1996;11:235-241.
Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.
Clatworthy MG, Ballance J, Brick GW, et al: The use of structural allograft for uncontained defects in revision total knee arthroplasty: A minimum five-year review. J Bone Joint Surg Am 2001;83:404-411.

Question 26

A 23-year-old man reports a 6-year history of recurrent instability in the right dominant shoulder. He has not undergone surgery and has essentially stopped all of his sporting activities. On examination, he has instability and apprehension in the midrange of motion (abduction of 45 to 60 degrees with external rotation) and a palpable clunk representing a transient dislocation over the anterior glenoid rim. A three-dimensional CT scan is shown in Figure 31. What is the most appropriate surgical intervention to provide him with reliable stability postoperatively?

Explanation

DISCUSSION: In the setting of significant anteroinferior glenoid bone deficiency (greater than 20% to 25%), both open and arthroscopic Bankart repairs have demonstrated higher rates of failure. Bony glenoid augmentation procedures such as the Bristow-Lataijet, which describe coracoid transfers to reconstruct the deficient glenoid, have led to decreased rates of recurrent shoulder instability. In this scenario, the patient has a significant loss of glenoid bone. There are also several clues in the history to suspect bone deficiency: multiple recurrences, a long history of recurrence, and instability in the midranges of motion.
A bony augmentation procedure such as the Lataijet has been well-described to provide a well functioning and stable shoulder joint. A hemiarthroplasty is not indicated in the absence of arthritis. Subscapularis
advancement will not address the bone loss.
REFERENCES: Hovelius L, Sandstrom B, Sundgren K, et al: One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study I— clinical results. J Shoulder Elbow Surg 2004;13:509-516.
Schroder DT, Provencher MT, Mologne TS, et al: The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. Am J Sports Med 2006;34:778-786.
Itoi E, Lee SB, Berglund LJ, et al: The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study. J Bone Joint Surg Am 2000;82:35-46.

Question 27

Metal-on-metal articulation has been reintroduced because of concern about polyethylene wear. This type of articulation is considered favorable because

Explanation

DISCUSSION: The improvements in metal-on-metal bearing surfaces come from the nonlinear wear rate and smaller particle size of the high carbon wrought material. Extremely low rates of wear have been demonstrated with high carbon metal-on-metal implants. There is no significant electrochemical effect of mating two like materials in vivo.
REFERENCE: 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 25-34.

Question 28

A 16-year-old girl has had hip pain for 1 year. Approximately 2 months ago she noted the development of a hard mass in the right buttock that has steadily increased in size. She now reports severe pain in the right buttock, with radiation down the leg and numbness involving the right foot and toes. A radiograph is shown in Figure 70a and an axial postcontrast T 1 -weighted MRI scan is shown in Figure 70b. A biopsy specimen is shown in Figure 70c. The chest CT shows multiple lung metastases. Treatment of this lesion should consist of

Explanation

DISCUSSION: Ewing’s sarcoma is the second most common primary tumor of bone in children. Depending on the site and extent of disease, chemotherapy, radiation therapy, and surgery are all treatment options. In this patient with extensive pelvic and metastatic disease, chemotherapy and radiation therapy offer the best oncologic control while preserving functional outcome.
REFERENCES: Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.
Thacker MM, Temple HT, Scully SP: Current treatment for Ewing’s sarcoma. Expert Rev Anticancer Ther 2005;5:319-331.
Weber KL: Current concepts in the treatment of Ewing’s sarcoma. Expert Rev Anticancer Ther 2002;2:687-694.

Question 29

Where is the underlying defect in a rhizomelic dwarf with the findings shown in Figure 5?

Explanation

DISCUSSION: The radiograph shows the typical findings of achondroplasia. The defect is in fibroblast growth factor receptor 3. The pedicles narrow distally in the lumbar spine. The pelvis is low and broad with narrow sciatic notches and ping-pong paddle-shaped iliac wings. This is often called a champagne glass pelvis. Type I collagen abnormalities are typically found in osteogenesis imperfecta, and type II collagen defects are found in spondyloepiphyseal dysplasia and Kneist syndrome. COMP is defective in multiple epiphyseal dysplasia. Sulfate transport defects are seen in diastrophic dysplasia.
REFERENCES: Johnson TR, Steinbach LS: Essentials of Musculoskeletal Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 809-812.
Caffey J: Achondroplasia of the pelvis and lumbosacral spine: Some roentgenographic features. Am J Roentgenol 1958;80:449.

Question 30

Examination of a 9-year-old girl who injured her left elbow in a fall reveals tenderness and swelling localized to the medial aspect of the elbow. Motor and sensory examinations of the hand are normal, and circulation is intact. A radiograph is seen in Figure 28. Management should consist of

Explanation

DISCUSSION: Avulsion fractures of the medial epicondyle are caused by a valgus stress applied to the immature elbow and usually occur in children between the ages of 9 and 14 years. Long-term studies have shown that isolated fractures of the medial epicondyle with between 5 to 15 mm of displacement heal well. Brief immobilization (1 to 2 weeks) in a long arm cast or splint yields results similar to open reduction and internal fixation. Fibrous union of the fragment is not associated with significant symptoms or diminished function. Surgical excision of the fragment yielded the worst results in one study and should be avoided. Open reduction is best reserved for those injuries in which the medial epicondylar fragment becomes entrapped in the elbow joint during reduction and cannot be extracted by closed manipulation.
REFERENCES: Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am

2001;83:1299-1305.
Josefsson PO, Danielsson LG: Epicondylar elbow fracture in children: 35-year follow-up of

56 unreduced cases. Acta Orthop Scand 1986;57:313-315.

Question 31

A 45-year-old distance runner has a hyaluronic acid injection to his knee because of degenerative arthritis. He immediately develops a severe rash and a systemic hypersensitivity reaction. This patient most likely is also allergic to which of the following?

Explanation

DISCUSSION: Preparations of hyaluronic acid can be divided into low and high molecular weight compounds. Contraindications to intra-articular hyaluronic acid include joint or skin infection, overlying skin disease, and allergies to chicken or egg products if using a preparation derived from rooster comb.
REFERENCES: Gloyscen DN, Gillespie MJ, Schenek RC: The effects of medication in sports injuries, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopedic Sports Medicine: Principles and Practice, ed 2.
Philadelphia, PA, WB Saunders, 2003, vol 1, pp 121-124.
Schenck RC Jr: New approaches to the treatment of osteoarthritis: Oral glucosamine and chondroitin sulfate. Instr Course Lect 2000;49:491-494.

Question 32

A 25 year-old amateur baseball player sustained a dorsal fracture-dislocation of the proximal interphalangeal joint of his long finger. He underwent closed reduction 3 hours ago. Examination reveals mild laxity of the radial collateral fragment involving 30% of the volar articular surface of the middle phalanx. Management should now include

Explanation

ORIF is most commonly used to treat displaced intrarticular, unstable, or unreducible injuries. Buddy taping is used for isolated volar plate injuries. Dynamic splints are used for volar dislocations in this presentation. Casting in the intrinsic plus position is falling out of favor for earlier range of motion options with PIP fracture dislocations.
“Intra-articular fractures that involve the base of the middle phalanx are usually one of three types 1. Dorsal chip fracture 2. Volar lip fracture, usually combined with a dorsal dislocation of subluxation of the middle phalanx 3. Lateral chip fracture, representing avulsion of bone by the collateral ligament.” Kuczynski has suggested that the volar plate is less mobile in the PIP joint than it is in the MP joint.
“What must always occur with dorsal dislocation, however, is rupture of the volar plate. According to Bowers, the plate is virtually always disrupted from its distal attachment into the base of the middle phalanx. This may with or without a small avulsion chip fracture.”
If the fracture involves more than a third of the joint or is unstable then the PIP joint must be stabilized in a reduced position with early range of motion while restricting PIP hyperextension.
The preferred method of treatment is dorsal extension block splinting for three weeks, then protected range of motion until united.

Question 33

Figures 52a and 52b show the radiographs of a left proximal femoral lesion noted serendipitously following minor trauma to the left hip. The patient has no thigh pain and is fully active without limitation. What is the most likely diagnosis of this bony lesion?

Explanation

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 34

A 20-year-old man sustained a closed tibial fracture and is treated with a reamed intramedullary nail. What is the most common complication associated with this treatment?

Explanation

DISCUSSION: The most common complication is anterior knee pain (57%). The knee pain is activity related (92%) and exacerbated by kneeling (83%). Although knee pain is the most common complication, most patients rate it as mild to moderate and only 10% are unable to return to previous employment. Some authors report less knee pain with a peritendinous approach when compared to a tendon-splitting approach. In one study, nail removal resolved pain in 27%, improved it in 70%, and made it worse in 3%. The incidence of the other complications was: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%. Compartment syndrome is rare after nailing.
REFERENCES: Court-Brown CM: Reamed intramedullary tibial nailing: An overview and analysis of 1106 cases. J Orthop Trauma 2004;18:96-101.
McQueen MM, Gaston P, Court-Brown CM: Acute compartment syndrome: Who is at risk?

J Bone Joint Surg Br 2000;82:200-203.
Keating JF, Orfaly R, O’Brien PJ: Knee pain after tibial nailing. J Orthop Trauma

1997;11:10-13.

Question 35

What is the preferred treatment of a symptomatic curly toe deformity in a 6-year-old child?

Explanation

DISCUSSION: While some curly toe deformities spontaneously improve in younger children, the deformity is likely to persist in a 6-year-old child. Taping techniques result in no change or only a temporary decrease in deformity. Studies have shown that simple flexor tenotomy is as effective as flexor tendon transfer. Arthrodesis is rarely indicated.
REFERENCES: Hamer A, Stanley D, Smith TW: Surgery for curly toe deformity: A

double-blind, randomized, prospective trial. J Bone Joint Surg Br 1993;75:662-663.
Ross ER, Menelaus MB: Open flexor tenotomy for hammer toes and curly toes in childhood.

J Bone Joint Surg Br 1984;66:770-771.

Question 36

All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT:

Explanation

DISCUSSION: Negative outcome factors have been shown to include: increasing patient age, time from injury to surgery (>3 weeks), intraoperative complications, femoral head bone or cartilage injury, and fracture reduction > 1-2mm from anatomic. Choice of surgical approach has not been shown to affect patient outcomes.
The referenced study by Matta evaluated outcomes of displaced acetabular fractures. The overall clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved.

Question 37

Figures 18a through 18c show the clinical photograph, radiograph, and CT scan of a 21-year-old man who reports persistent pain after injuring his right shoulder 4 months ago. What is the most likely factor associated with this patient’s diagnosis?

Explanation

The more severe the trauma, the higher the rate of subsequent clavicular nonunion. Neither duration nor type of immobilization has been clearly demonstrated to be a causative factor in the development of nonunion. Similarly, closed reduction has not been found to alter the healing course in midshaft clavicular fractures.

Question 38

If a percutaneous iliosacral screw is placed too anteriorly, and the screw exits anterior to the sacral ala before re-entering the sacral body, what will be the most likely finding postoperatively?

Explanation

DISCUSSION: This question is a simple review of anatomy and nerve innervation. The L5 root is at risk with an "in-out-in" screw, as described in the question, as the nerve root is just anterior to the sacral ala as it enters the true pelvis. L5 is primarily evaluated by extensor hallucis longus function. L4 is tested with tibialis anterior function and S1 by gastroc-soleus function (ankle plantarflexion).

Question 39

A 60-year-old man reports that he has had shoe pressure pain over his right great toe for several years but has minimal discomfort when barefoot or in sandals. A clinical photograph and radiographs are shown in Figures 1a through 1c. Management should consist of

Explanation

DISCUSSION: Some patients have minimal symptoms associated with hallux rigidus despite significant radiographic evidence of osteoarthritis. This patient’s symptoms are primarily related to shoe pressure from the exostosis and can be managed with extra-depth shoe wear.
REFERENCES: Smith RW, Katchis SD, Ayson LC: Outcomes in hallux rigidus patients treated nonoperatively: A long-term follow-up study. Foot Ankle Int 2000;21:906-913.
Shereff MJ, Baumhauer JF: Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. J Bone Joint Surg Am 1998;80:898-908.

Question 40

Figures 87a and 87b are the radiographs of an 18-year-old pedestrian who was struck by a car. During intramedullary nailing, it is difficult to maintain proper alignment. Poller blocking screws placed in the proximal fragment at which position(s) relative to the nail can help prevent the typical deformity?

Explanation

This is a proximal one third tibial shaft fracture. Typically nailing of this fracture creates a valgus and procurvatum malalignment that must be addressed. This can be difficult when using an intramedullary nail in the wide metaphyseal bone of the proximal tibia. To help direct and center the nail in the metaphysis, blocking screws can be used. Blocking screws should be placed where the nail should not travel. If the nail was passed with the proximal fragment in this position, it would occupy the lateral and posterior aspects of the metaphyseal fragment. To prevent this, blocking screws should be placed in the lateral and posterior aspects of the proximal fragment.

Question 41

A female cross-country runner has an insidious onset of right groin pain. Radiographs of the right hip reveal a tension-side stress fracture. History reveals that she was treated for a “foot” fracture 1 year ago. In addition to performing internal fixation of the femoral neck, which of the following should be obtained?

Explanation

DISCUSSION: Stress fractures in female long distance runners are frequently associated with the Female Athletic Triad. The triad consists of osteoporosis, amenorrhea, and altered eating habits. A thorough menstrual history, including age of menarche, history of amenorrhea, and use of oral contraceptives, is imperative. Amenorrhea leads to osteoporosis and predisposes the athlete to fractures. An MRI of the hip is not necessary because a fracture is evident on the radiograph. Serum calcium levels are normal in osteoporosis, a family history would be noncontributory, and it is highly unlikely that a contralateral hip radiograph will yield useful information.
REFERENCES: Bennell KL, Malcolm SA, Thomas SA, et al: Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-818.
Barrow GW, Saha H: Menstrual irregularity and stress fractures in collegiate female distance runners. Am J Sports Med 1988;16:209-216.

Question 42

Evaluation of an 8-year-old girl for scoliosis reveals a normal gestation, birth, and family history. Her parents state that she stopped gaining new motor skills at age 6 months. Examination shows the patient can sit independently, but she is nonverbal and she makes repetitive hand clapping movements. She has a 30-degree thoracolumbar kyphoscoliosis, and mildly increased tone in the hamstrings and gastrocnemius-soleus complex. What is the most likely diagnosis?

Explanation

Rett syndrome is a progressive encephalopathy of unknown etiology observed only in girls, who are apparently normal physically and mentally until the age of 6-18 months. It is characterized by autism, gait apraxia, dementia, stereotypical hand movements, loss of hand motor skills, hyperreflexia, spasticity, jerky trunk ataxia, seizures, and acquired microcephaly. Neurologically, abnormal development starts with hypotonia and is followed by ataxia and finally spasticity. The orthopaedic aspects of Rett syndrome have been mentioned only briefly in the literature. They include scoliosis, kyphosis, flexion contractures of the joints, and bilateral tight heel cords. Scoliosis is the major orthopaedic deformity in Rett syndrome. Eight of Ten girls in one series had developed scoliosis at the average age of 11 years. All eight girls had C-shaped thoracolumbar neuromuscular curves with pelvic obliquity. The right thoracolumbar curve was by far the most common pattern, occurring in seven patients (88%), whereas only one patient (12%) had a left thoracolumbar curve.

Question 43

A 43-year-old woman has a 2-week history of right shoulder pain. She denies any injury to initiate her symptoms but states that she has shoulder pain with range of motion and lifting objects. Examination reveals mild pain with abduction, empty can testing, and with the Neer and Hawkins impingement tests. Her range of motion with the right shoulder reveals passive forward flexion to 90 degrees, abduction to 90 degrees, external rotation at the side to 15 degrees, and internal rotation to her buttock. The uninvolved left shoulder has forward flexion to 160 degrees, abduction to 150 degrees, external rotation at the side to 60 degrees, and internal rotation to T6. Radiographs of the shoulder are normal. What is the next most appropriate step in management? Review Topic

Explanation

The patient has the recent onset of adhesive capsulitis, which is characterized by loss of both active and passive range of motion. A home exercise program is as helpful as organized therapy to improve her range of motion. While a sling might be appropriate for comfort, continuous use might increase her shoulder stiffness. Surgical treatments, such as a manipulation under anesthesia or arthroscopic capsular release, might be necessary if her motion cannot be restored with physical therapy and home exercises. However, the natural history of idiopathic adhesive capsulitis is self limited and does not usually require surgery. An arthroscopic rotator cuff repair is not indicated because she does not have a rotator cuff tear.

Question 44

Figures 2a and 2b are the MR arthrograms of a 19-year-old college baseball pitcher who injured his throwing elbow during a game 5 days ago when he felt a pop. Immediately after the throw he reported significant discomfort with pitching and noted that he could not achieve his normal velocity or accuracy in location with his subsequent pitches. On further questioning, he admits to increasing medial elbow pain over the last few seasons with pitching. Examination reveals medial elbow swelling and somewhat diffuse tenderness to palpation medially. Valgus stress at 30 degrees of flexion and resisted wrist flexion produced discomfort. He notes some tingling in his fourth and fifth fingers but Tinel's test posterior to the medial epicondyle is unremarkable. Radiographs of the elbow show no fracture. Because the patient wishes to return to competitive throwing, what is the next step in management? Review Topic

Explanation

This high level throwing athlete has a full-thickness injury to the ulnar collateral ligament and is most likely to be able to return to competitive throwing with an ulnar collateral ligament reconstruction. There is no radiographic evidence of a medial epicondyle fracture. The clinical presentation and lack of a posteromedial olecranon osteophyte makes valgus extension overload unlikely, and therefore, makes arthroscopic osteophyte excision a suboptimal choice. Whereas ulnar nerve pathology can coexist with an ulnar collateral ligament injury, isolated ulnar nerve transposition without addressing the ligament injury is not warranted in this patient. Initial nonsurgical management with activity modification and physical therapy is appropriate for partial-thickness injury to the ulnar collateral ligament in a nonthrowing athlete, and in athletes whose sporting activity places them at low risk.

Question 45

In regards to a genetic disorder, which of the following is an example of "anticipation?"

Explanation

Genetic anticipation is a phenomenon in which a genetic disorder becomes progressively more severe and earlier in onset with each generation. Examples of disorders exhibiting anticipation include Huntington's disease and myotonic dystrophy.
Genetic anticipation is an important concept in understanding the development and genetic implications of many heritable disorders. It is a common phenomenon in trinucleotide repeat expansion disorders. These disorders are due to unstable microsatellite trinucleotide repeats that expand beyond the normal threshold. In subsequent generations these expansions become longer and thus express disease characteristics at a younger age of onset, and often with greater severity.
Martorell et al. investigated the development of CTG trinucleotide repeats in patients with myotonic dystrophy type 1 (DM1) and their relatives. They discovered unaffected individuals carry a pre-mutation sequence which can lead to trinucleotide repeat expansion in subsequent generations and thus produce offspring with the disorder.
Kamsteeg et al. compare the characteristics of DM1 and DM2. Both are due to trinucleotide repeat expansions. However, while DM1 can present with earlier onset and increasing severity in each generation, DM2 does not exhibit this genetic anticipation.
Incorrect Answers

Question 46

What is the most common complication following surgical fixation of a distal humeral fracture?

Explanation

DISCUSSION: In most series, elbow stiffness is the most common complication and can be overcome by achieving stable fixation and initiating early motion after surgery. All of the other complications are seen but to a lesser degree than elbow stiffness.
REFERENCES: Sanders RA, Raney EM, Pipkin S: Operative treatment of bicondylar intra-articular fractures of the distal humerus. Orthopedics 1992;15:159-163.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 397-404.

Question 47

A 42-year-old female undergoes a subtalar bone block distraction arthrodesis as sequelae of a nonoperatively treated calcaneus fracture ten years prior. This procedure addresses which of the following issues?

Explanation

DISCUSSION: The subtalar fusion technique involves distraction of the subtalar joint, insertion of a bone block, fusion, and rigid screw fixation. The distraction allows correction of the talocalcaneal relationship. In Carr’s series, pre- and postoperative radiographic analysis for tibiotalar impingement, lateral talocalcaneal angle, and talonavicular subluxation was performed, with improvement to a normal range seen in the cases analyzed. Bednarz did a radiographic analysis and showed an average increase of 8 mm in hindfoot height, 9 degrees in lateral talocalcaneal angle, and 11 degrees in lateral talar declination angle. Rammelt found that compared with the unaffected side, the talocalcaneal height was corrected by 61.8%, the talus-first metatarsal axis by 46.5%, the talar declination angle by 38.5% and the talocalcaneal angle by 35.4%. Based on these three references, this procedure ultimately addresses the lost hindfoot height, subtalar arthritis (joint is fused), ankle impingement (improvement of the talus 1st MT axis), and peroneal impingement. It does not address hindfoot valgus. However, the deformity after a calcaneus fracture is usually from lateral wall blowout and hidfoot varus

Question 48

A 62-year-old man with a long history of right shoulder pain and weakness is scheduled to undergo hemiarthroplasty. Based on the radiographs shown in Figures 6a through 6c, what preoperative factor will most affect postoperative functional outcome?

Explanation

DISCUSSION: The radiographs reveal osteoarthritis and proximal humeral head migration. Integrity of the rotator cuff must be questioned based on these radiographic changes. The status of the rotator cuff is the most influential factor affecting postoperative function in shoulder hemiarthroplasty. The coracoacromial ligament provides a barrier to humeral head proximal migration in the face of a rotator cuff tear. The radiographs do not indicate significant humeral head or glenoid erosion. Acromioclavicular arthritis is often asymptomatic.
REFERENCES: 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.
Hettrich CM, Weldon E III, Boorman RS, et al: Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty. J Bone Joint Surg Am 2004;86:1446-1451.

Question 49

The spinal cord terminates as the conus medullaris at what vertebral level in adults? Review Topic 1 T12

Explanation

The spinal cord anatomy changes at the thoracolumbar junction. The spinal cord terminates as the conus medullaris at the lower portion of L1 in women and the pedicle of L1 in men.

Question 50

Figures 57a and 57b are the MRI scans of a 61-year-old man who is unable to elevate his dominant arm following a golf injury 24 hours ago. He has moderate pain during attempted arm elevation. Examination reveals significant spinati atrophy and he is only able to elevate his arm fully overhead while supine. The neurologic examination is normal. What is the next most appropriate step in management? Review Topic

Explanation

The patient unknowingly has a chronic massive rotator cuff tear. Because of excellent compensation, he remained functional and was without symptoms. This is evidenced by the significant muscle atrophy. Following even trivial injury, the compensation process of arm elevation fails and the patient suddenly loses the ability to elevate the arm. At this time in management, it is critical to recognize that the rotator cuff had already been torn and that pain now prevents the patient from actively using the arm. To better ascertain a prognosis of return of function, injecting a local anesthetic (lidocaine) into the joint is important. If, with an anesthetized joint, the patient can now elevate the arm, a supine strengthening program will likely return the patient to his pre-injury state. If there is no improvement in the ability to elevate the arm after the injection, surgical considerations may become relevant. There is no role for arthroscopic repair in this chronic, massive rotator cuff tear and decompression would likely lead to superior escape. A reverse shoulder arthroplasty would be contraindicated in a very active 61-year-old patient who 2 days ago was functioning normally. Based on the MRI scan, there is no supraspinatus muscle remaining to strengthen. Total shoulder arthroplasty is contraindicated in patients with a deficient rotator cuff mechanism.

Question 51

Venous thromboembolism may occur after total joint arthroplasty. The risk of this complication is elevated in patients with

Explanation

DISCUSSION:
Obesity, a prior history of venous thromboembolism, and metabolic syndrome have all been associated with an increased risk of thromboembolism. A recent meta-analysis showed that diabetes had no significant relationship with venous thromboembolism following hip or knee arthroplasty. Tranexamic acid is an antifibrinolytic agent that has been shown to reduce blood loss substantially following hip and knee arthroplasty. It has also been shown to be safe in patients with severe medial comorbidities and a prior history of venous thromboembolism.

Question 52

Figure 13 shows the radiographs of a 56-year-old woman who has pain and varus knee deformity after undergoing total knee arthroplasty 8 years ago. Aspiration and studies for infection are negative. During revision surgery, management of the tibial bone loss is best achieved by

Explanation

DISCUSSION: Massive bone loss encountered in revision total knee arthroplasty remains a significant challenge. Recent reports have shown high success rates using structural allograft to reconstruct massive bone defects. Custom and hinged prostheses in this setting are no longer favored. The defect shown is segmental and is too large to be filled with cement or iliac crest bone graft.
REFERENCES: Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty. J Arthroplasty 1996;11:235-241.
Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.
Clatworthy MG, Ballance J, Brick GW, Chandler HP, Gross AE: The use of structural allograft for uncontained defects in revision total knee arthroplasty: A minimum five-year review. J Bone Joint Surg Am 2001;83:404-411.

Question 53

During placement of an external fixator for a distal radius fracture, the most commonly injured nerve is a branch of which of the following nerves? Review Topic

Explanation

Post-surgical mortality rates are significantly lower after total hip arthroplasty compared to hemiarthroplasty
Internal fixation shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to arthroplasty
Bipolar hemiarthroplasty shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to unipolar hemiarthroplasty
A delay in surgery greater than 48 hours is recommended if the patient has multiple medical comorbiditiesm which are not fully optimized
Dislocation rates are equivalent between total hip arthroplasty and hemiarthroplasty
Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. However, patients with significant medical comorbidity should be fully optimized before surgery.
Although several studies have shown a benefit to surgery within 48 hours, no definitive time frame has been elucidated. The majority of literature has shown improved outcomes in regards to pain, complications, and length of stay with early surgery. Patients with significant medical comorbidities have been shown to have the highest mortality rates.
Moran et al. aimed to determine whether a delay in surgery for hip fractures had an affect on postoperative mortality among elderly patients. In an observational study of 2660 patients, they showed that mortality following hip fracture surgery was 9% at 30-days, 19% at 90-days, and 30% at 12-months. Patients with medical comorbidities had 2.5 times the risk of death within 30-days of surgery. In addition, individuals who had surgery delayed beyond 4 days had increased mortality at 90-days and 12-months.
Papakostidis et al. examined the timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. They showed no benefit of
early surgery on incidence of AVN. However, delay of internal fixation of more than
24 hours showed increased rates of non-union.
Figure A shows a displaced right femoral neck fracture. Incorrect Answers:

Question 54

Which of the following is considered the most important factor in eliminating infection in chronic osteomyelitis?

Explanation

DISCUSSION: The most important factor in eliminating infection in chronic osteomyelitis is a complete debridement of the compromised bone and soft tissue. Antibiotics should be used in conjunction with surgical debridement. However, the foundation of treating infected bone is removal of the diseased tissue.
REFERENCES: Cierny G III, Cook WG, Mader JT: Ankle arthrodesis in the presence of ongoing sepsis: Indications, methods, and results. Orthop Clin North Am 1989;20:709-721.
Cierny G, Zorn EZ: Arthrodesis of the tibiotalar joint for sepsis. Foot Ankle Clin 1996;1:177-197.
Richter D, Hahn MP, Laun RA, Ekkernkamp A, Muhr G, Osterman PA: Arthrodesis of the infected ankle and subtalar joint: Technique, indications and results of 45 consecutive cases. J Trauma 1999;47:1072-1078.

Question 55

Which of the following best describes the function of the notochord?

Explanation

DISCUSSION: The notochord is the anatomic structure that defines the phylum Chordata. The notochord plays a fundamental role in the development of the skeleton, and it exists only for a short period of time. During its temporary existence, the notochord serves as a transient axis of support, provides for the initial axis of orientation of the developing embryo, and most importantly, plays a vital role in the induction of the tissues that eventually form the vertebral column.
REFERENCE: Rosenberg A: Embryology of the skull base and vertebral column, in Harsh G (ed): Chordomas and Chondrosarcomas of the Skull Base and Spine. New York, NY, Thieme, 2003, pp 3-8.

Question 56

Stiffness relates the amount of load applied to a structure like a long bone or an intramedullary nail to the amount of resulting deformation that occurs in the structure. What is the most important material property affecting the axial and bending stiffness of a structure?

Explanation

DISCUSSION: The amount of deformation resulting in response to an applied load depends on the stress distribution that the load creates in the structure and the stress versus strain behavior of the material that makes up the structure. Axial and bending loads create stress distributions that involve normal stresses and normal strains. Although all five responses are indeed material properties, only one, elastic modulus, relates normal stresses to normal strains. In fact, axial and bending stiffness are directly proportional to modulus, so that a nail made from stainless steel will have nearly twice the stiffness of a nail made from titanium alloy (because their respective elastic moduli differ by about a factor of two).
REFERENCES: Hayes WC, Bouxsein ML: Analysis of muscle and joint loads, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. New York, NY, Lippincott-Raven, 1997, pp 74-82.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 159-165.
Wright TM, Maher SA: Biomaterials, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 57

An obese patient undergoing total knee arthroplasty is at increased risk for which of the following complications?

Explanation

DISCUSSION: The rate of wound complications is significantly increased after total knee arthroplasty in obese patients. Knee scores and the rate of aseptic loosening or patellar subluxation do not appear to be significantly altered.
REFERENCES: Winiarsky R, Barth P, Lotke P: Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg Am 1998;80:1770-1774.
Stern SH, Insall JN: Total knee arthroplasty in obese patients. J Bone Joint Surg Am 1990;72:1400-1404.
Griffin FM, Scuderi GR, Insall JN, Colizza W: Total knee arthroplasty in patients who were obese with 10 years follow-up. Clin Orthop 1998;356:28-33.

Question 58

A 20-year-old football player sustains a dorsiflexion external rotation injury to his right ankle. During sideline evaluation, which of the following findings best indicates a syndesmosis ankle sprain without diastasis?

Explanation

DISCUSSION: The inability to single leg hop is considered the best indicator of a syndesmosis ankle sprain without diastasis. Tenderness along the syndesmosis, the deltoid, or over the anterior talofibular ligament or anterior distal tibia/fibula may present later, following the initial injury. The squeeze test and tenderness with dorsiflexion and external rotation may be positive but often are not present initially. The best determinant for prediction of return to play is the amount of tenderness along the syndesmosis, measured from the distal fibula up the syndesmosis.
REFERENCES: Nussbaum ED, Hosea TM, et al: Prospective evaluation of syndesmosis ankle sprains without diastasis. Am J Sports Med 2001;29:31-35.
Miller CD, Shelton WR, Barrett GR, et al: Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med 1985;23:746-750.
Amendola A: Controversies in diagnosis and management of syndesmosis injuries of the ankle. Foot Ankle 1992;13:44-50.

Question 59

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads?

Explanation

DISCUSSION: The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.
REFERENCE: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.

Question 60

A 58-year-old woman with rheumatoid arthritis has progressive neck pain, upper extremity and lower extremity weakness, and difficulty with fine motor movements. Examination reveals hyperreflexia with mild to moderate objective weakness but the patient has no difficulty with ambulation for short distances. What is the most important preoperative imaging finding that predicts full neurologic recovery with surgical stabilization?

Explanation

DISCUSSION: Boden and associates’ article presents compelling evidence that patients with rheumatoid arthritis and neurologic deterioration in C1-2 instability are more likely to achieve some improvement if the posterior atlanto-dens interval is greater than 10 mm on preoperative studies. All the patients in their series who had neurologic deterioration and a preoperative posterior atlanto-dens interval of greater than 14 mm achieved complete motor recovery.
REFERENCES: Boden SD, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.
Boden SD, Clark CR: Rheumatoid arthritis of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 755-764.
Monsey RD: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg 1997;5:240-248.

Question 61

Figure 41 shows the MRI scan of a 38-year-old weightlifter. What does the arrow on the MRI scan indicate? Review Topic

Explanation

Pectoralis major ruptures typically occur in avid weightlifters (often on supplements) and typically while bench-pressing. Clinically there is significant discoloration/bruising over the pectoralis and into the axilla. MRI helps confirm the diagnosis and may help determine if the tear is in the muscle belly or at the bone-tendon junction.

Question 62

An 18-month-old infant with myelomeningocele and rigid clubfeet has grade 5 quadriceps and hamstring strength, but no muscles are functioning below the knee. What is the best treatment option for the rigid clubfeet?

Explanation

DISCUSSION: This child has the potential to walk and therefore should have all the contracted structures in the feet released as necessary to place the feet in a plantigrade position for fitting of ankle-foot orthoses. Physical therapy, manipulation, and casting may provide some benefit in a newborn with flexible feet but are not effective in an older infant with rigid clubfeet. Botulinum injections and tendon transfers are of no use because there are no muscles functioning below the knee. Tendon releases are more effective than tendon transfers in children with myelomeningocele.
REFERENCES: Mazur JM: Management of foot and ankle deformities in the ambulatory child with myelomeningocele, in Sarwark JR, Lubicky JP (eds): Caring for the Child with Spina Bifida. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 155-160.
Dias LS: Surgical management of acquired foot and ankle deformities, in Sarwark JR, Lubicky JP (eds): Caring for the Child with Spina Bifida. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 161-170.

Question 63

The inheritance of the deformity shown in Figure 1 is most commonly

Explanation

DISCUSSION: Cleft hand and cleft foot malformations are commonly inherited as autosomal-dominant traits and are associated with a number of syndromes. An autosomal-recessive and an x-linked inheritance pattern have also been described, but these are much less common and are usually atypical. In the common autosomal-dominant condition, nearly one third of the known carriers of the gene show no hand or foot abnormalities. This is known as reduced penetrance. The disorder may be variably expressed; affected family members often exhibit a range from mild abnormalities in one limb only to severe anomalies in four limbs. Variable expressivity and reduced penetrance can cause difficulty in counseling families regarding future offspring in an affected family. Many patients have a cleft hand that may be caused by the split-hand, split-foot gene (SHFM1) localized on chromosome 7q21.
REFERENCE: Kay SPJ: Cleft hand, in Green DP (ed): Green’s Operative Hand Surgery. Philadelphia, Pa, Churchill Livingston, 1999, pp 402-414.

Question 64

Almost 50% of all long-term complications following total knee arthroplasty are due to

Explanation

50% of failures are due to the patellofemoral component and extensor mechanisms. These include failure of the metal backed components, patellofemoral instability, component loosening, patellar fracture, osteonecrosis,
and failure of the extensor mechanism. The incidence of the other choices are far less.

Question 65

Figure 50 shows the MRI scan of a 20-year-old female college soccer player with knee pain. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan shows an acute complete tear of the posterior cruciate ligament. No evidence is seen of a quadriceps tendon rupture, a tibia fracture, or a bone contusion.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 533-557.
Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

Question 66

Which structure is shown in Video 27? 27

Explanation

DISCUSSION
Video 27 shows the medial patellofemoral ligament running from the medial epicondyle of the femur to the medial portion of the patella. The posterior oblique ligament and the superficial medial collateral ligament run from medial epicondyle to the tibia.
RECOMMENDED READINGS
Babb JR, Detterline AJ, Noyes FR. AAOS Orthopaedic Video Theater. The Key to the Knee: A Layer-by-Layer Video Demonstration of Medial and Anterior Aatomy. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009.
Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:493-568.

Question 67

An ulnar nerve palsy at the level of the wrist is typically associated with deficits in the palmaris brevis, the hypothenar muscles, and what other groups of muscles?

Explanation

DISCUSSION: The intrinsic muscles innervated by the ulnar nerve include the palmaris brevis, hypothenar muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. The superficial head of the flexor pollicis brevis is innervated by the

median nerve.
REFERENCES: Goldfarb CA, Stern PJ: Low ulnar nerve palsy. JASSH 2003;3:14-26.
Omer G: Ulnar nerve palsy, in Green DP, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 1526-1541.

Question 68

Figure 51 shows the radiograph of a 42-year-old construction worker who has pain and limited motion in his dominant elbow. Management consisting of nonsteroidal anti-inflammatory drugs and cortisone has failed to provide relief. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The patient has symptomatic primary osteoarthritis of the elbow with multiple loose bodies. Given his age and occupation, an elbow arthroplasty is not an option. Arthroscopic debridement and removal of loose bodies has been shown to be effective for osteoarthritis of the elbow.
REFERENCES: Gramstad GD, Galatz LM: Management of elbow osteoarthritis. J Bone Joint Surg Am 2006;88:421-430.
Steinmann SP, King GJ, Savoie FH III, et al: Arthroscopic treatment of the arthritic elbow.

J Bone Joint Surg Am 2005;87:2114-2121.

Question 69

A 12-year-old boy reports limping and chronic knee pain that is now inhibiting his ability to participate in sports. Clinical examination and radiographs of the knee are normal. Additional evaluation should include

Explanation

DISCUSSION: While all of the answers may be appropriate, radiating pain from hip pathology must be excluded. At this age, a slipped capital femoral epiphysis is likely. Therefore, the hip must be examined.
REFERENCES: Kocher MS, Bishop JA, Weed B, et al: Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics 2004;113:322-325.
Matava MJ, Patton CM, Luhmann S, et al: Knee pain as the initial symptom of slipped capital femoral epiphysis: An analysis of initial presentation and treatment. J Pediatr Orthop 1999;19:455-460.

Question 70

04 Which of the following laboratory studies is predictive of wound healing prior to performing a lower extremity amputation?

Explanation

A serum albumin level of below 3.5 g/dl indicates malnourished patient. An absolute lymphocyte count below 1500/mm3 is a sign of immune deficiency. If possible, amputation surgery should be delayed in such patients. An absolute Doppler pressure of 70 mm Hg is the minimum inflow level. The ischemic index is the ratio of the Doppler pressure at the level being tested to the brachial systolic pressure. Genreally accepted to require an ischemic index of 0.5 or greater. Transcutaneous partial pressure of oxygen (TcpO2) is the present gold standard of vascular inflow. TcpO2 values of 40 mm Hg correlate with acceptable wound healing
(eliminates false positive predictions with using area under the Doppler waveform). Pressures less than 20 mm Hg are predictive of poor healing. Miller 505-6
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Question 71

A 42-year-old man undergoes right total hip arthroplasty for hip dysplasia. Postoperatively, he has a significant limb-length increase with a foot drop. A preoperative radiograph is shown in Figure 19. Which of the following should have been considered preoperatively to avoid this complication?

Explanation

DISCUSSION: In a patient with bilateral hip dysplasia, there are significant technical challenges that need to be addressed to ensure a successful total hip arthroplasty. Restoring the center of the hip may cause significant lengthening and require femoral shortening. Lengthening of greater than 4 cm can lead to sciatic nerve palsy that will present clinically as a foot drop. A high hip center can be used when there is inadequate bone stock in the acetabulum to achieve adequate host bone coverage. A modular femoral implant may be used for a dysplastic hip with significant rotational deformity. Although an anterolateral approach to the hip may decrease the incidence of sciatic nerve palsy during the exposure, it will not be helpful when there is more than 4 cm of limb lengthening.
REFERENCES: Schmalzried TP, Amstutz HC, Dorey FJ: Nerve palsy associated with total hip replacement: Risk factors and prognosis. J Bone Joint Surg Am 1991;73:1074-1080.
Papagelopoulos PJ, Trousdale RT, Lewallen DG: Total hip arthroplasty with femoral osteotomy for proximal femoral deformity. Clin Orthop 1996;332:151-162.
Huo MH, Zatorski LE, Keggi KJ: Oblique femoral osteotomy in cementless total hip arthroplasty: Prospective consecutive series with a 3-year minimum follow-up period.
J Arthroplasty 1995;10:319-327.

Question 72

A 50-year-old woman has a painful hallux valgus and a painful callus beneath the second metatarsal head. A radiograph is shown in Figure 46. To correct these problems, treatment of the great toe deformity should consist of

Explanation

DISCUSSION: The patient has a significant hallux valgus and instability of the first ray, causing transfer metatarsalgia to the second metatarsal head. Therefore, the best procedure is fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint. This procedure provides the best chance of relieving symptoms under the second metatarsal head, as well as correcting the hallux valgus.
REFERENCE: Sangeorzan BJ, Hansen ST Jr: Modified Lapidus procedure for hallux valgus. Foot Ankle 1989;9:262-266.

Question 73

A 58-year-old man has anterior knee pain after undergoing total knee arthroplasty for osteoarthritis 2 years ago. He denies any history of trauma. A Merchant view is shown in Figure 20. What is the most likely cause of his pain?

Explanation

DISCUSSION: The patient has a patellar stress fracture after resurfacing in a total knee arthroplasty. Several studies have shown that over-resection of the patella to less than 12 to 15 mm increases anterior patellar surface strains to a point where the risk of fracture is increased. Increasing the patellar thickness, positioning of the femoral component, lateral releases, and component types have not been clearly associated with increased fracture risk.
REFERENCES: Reuben JD, McDonald CL, Woodard PL, Hennington LJ: Effect of patella thickness on patella strain following total knee arthroplasty. J Arthroplasty 1991;6:251-258.
Hsu HC, Luo ZP, Rand JA, An KN: Influence of patellar thickness on patellar tracking and patellofemoral contact characteristics after total knee arthroplasty. J Arthroplasty 1996;11:69-80.
Greenfield MA, Insall JN, Case GC, Kelly MA: Instrumentation of the patellar osteotomy in total knee arthroplasty: The relationship of patellar thickness and lateral retinacular release. Am J Knee Surg 1996;9:129-131.

Question 74

A 56-year-old woman presents with left hip pain and diminishing range of motion. Examination reveals pain with range of motion of the hip. Radiographs reveal multiple calcific lesions within the hip and well-preserved joint space. MRI scan shows thickened synovium nodular loose bodies with decreased signal on T1 and T2. What is the best next step?

Explanation

Figures 1 through 3 show the radiographs obtained from an 86-year-old- woman who has had chronic left hip pain for several years. She now uses a walker and a wheelchair for ambulation. She is medically healthy. What is the most appropriate surgical intervention?

Question 75

The parents of a previously healthy 3-year-old child report that she refused to walk on awakening. Examination later in the day reveals that the patient can walk but with a noticeable limp. She has a temperature of 99.5 degrees F (37.5 degrees C). Range of motion measurements are shown in Figure 50. An AP pelvis radiograph is normal. Laboratory studies show a WBC count of 9,000/mm 3 and an erythrocyte sedimentation rate of 10 mm/h. Management should consist of

Explanation

DISCUSSION: The patient has the typical history and presentation of transient synovitis of the hip, a condition that is more common in children age 2 to 5 years but which may affect children up to 12 years. The discomfort typically is noted on awakening, and the child will refuse to walk. Later in the day, the pain commonly improves and the child can walk but will have a limp. Mild to moderate restriction of hip abduction is the most sensitive range-of-motion restriction. The extent of the evaluation for transient synovitis depends on the intensity and duration of symptoms. Because she has been afebrile for the past 24 hours, observation is the management of choice. In the differential diagnosis of suspected transient synovitis, septic arthritis of the hip is the primary disorder to exclude. Osteomyelitis of the proximal femur also should be considered. In most patients, clinical examination will differentiate of these disorders to a reasonable certainty. Plain radiographs are normal in the early stage of an infectious process. Ultrasonography shows increased fluid in the hip joint in both transient synovitis and septic arthritis. MRI can differentiate the two conditions; however, this test would require general anesthesia and is not required in most patients in this age group. If a child with transient synovitis has a concurrent infectious process such as an upper respiratory tract infection or otitis media, the temperature will most likely be elevated. In this situation, a full evaluation for an infectious process and initiation of IV antibiotics should be considered. This would include radiographs, CBC count, erythrocyte sedimentation rate, blood cultures, aspiration of the hip joint, and IV antibiotics.
REFERENCES: Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM: Septic arthritis versus transient synovitis of the hip: The value of screening laboratory tests. Annals Emerg Med 1992;21:1418-1422.
Kehl DK: Developmental coxa vara, transient synovitis, and idiopathic chondrolysis of the hip, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1035-1058.

Question 76

A 20-year-old man involved in a motor vehicle accident is brought to the emergency department with a C6-7 unilateral facet dislocation. His neurologic examination reveals a focal left-sided C7 nerve root palsy. He is awake and cooperative with questioning and has no other obvious traumatic injuries. What is the most appropriate treatment at this time?

Explanation

DISCUSSION: In the patient who is neurologically intact or has an incomplete injury from a cervical facet dislocation, a closed reduction with weighted tong traction is appropriate when the patient is awake, alert, and cooperative. Although there is a risk that a cervical facet dislocation could occur with an underlying cervical disk herniation, Vaccaro and associates have shown that closed reduction can be safely carried out in the awake, responsive patient. Closed reduction can be performed in the emergency department with traction with skull tongs or a halo ring. A slow stepwise application of weight is added until a reduction is achieved. Any worsening of the neurologic status of the patient requires immediate termination of the closed reduction and further diagnostic imaging before proceeding with further treatment.
REFERENCES: Vaccaro AR, Falatyn SP, Flanders AE, et al: Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine 1999;24:1210-1217.
Hart RA: Cervical facet dislocation: When is magnetic resonance imaging indicated? Spine 2002;27:116-117.
Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.

Question 77

A complication unique to computer navigation of total knee arthroplasty (TKA) is

Explanation

CLINICAL SITUATION FOR QUESTIONS 111 THROUGH 113
Figure 111 is the anteroposterior radiograph of a 79-year-old woman with a presurgical diagnosis of osteonecrosis who sustained a periprosthetic tibia fracture following her total knee arthroplasty (TKA).

Question 78

Figures 27a through 27c show the radiographs of the femur of a 46-year-old man who has a fracture of the right humerus, multiple rib fractures, and fractures of the right femur as a result of a motor vehicle accident. There is a 10-cm clean wound over the anteromedial thigh that communicates with the femoral shaft fracture. The neurovascular examination of the right leg is normal. After meticulous irrigation and debridement, management of the femoral fractures should consist of

Explanation

Debridement of wound and immediate reamed nailing performed on 67 patients with open fractures of femoral diaphysis including 36% grade 1, 45% grade II. All fractures healed within four months after injury.

Question 79

A 21-year-old woman has a nontraumatic rupture of the Achilles tendon. Which of the following commonly prescribed medications has been associated with this condition?

Explanation

DISCUSSION: Fluoroquinolones have been associated with increased rates of tendinitis, with special predilection for the Achilles tendon. Tenocytes in the Achilles tendon have exhibited degenerative changes when viewed microscopically after fluoroquinolone administration. Recent clinical studies have shown an increased relative risk of Achilles tendon rupture of 3.7. The other listed drugs have no known increase in tendon rupture rates nor tendinitis.
REFERENCES: van der Linden PD, van de Lei J, Nab HW, et al: Achilles tendinitis associated with fluoroquinolones. Br J Clin Pharmacol 1999;48:433-437.
Bernard-Beaubois K, Hecquet C, Hayem G, et al: In vitro study of cytotoxicity of quinolones on rabbit tenocytes. Cell Biol Toxicol 1998;14:283-292.
Maffulli N: Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036.

Question 80

A unilateral "piano key" sign, indicates

Explanation

EXPLANATION:
The piano key sign is a demonstration of instability at the DRUJ, typically seen after healing from a distal radius fracture with an associated ulnar styloid fracture (as in this case) or other wrist injury. The hand is pushed down against a table top, and the distal radius translates dorsally (with the distal ulna apparently moving volarly). In fact, the distal radius is the mobile segment, while the distal ulna is fixed in space. Treatment involves repair or reconstruction of the foveal insertion of the triangular fibrocartilage complex (TFCC) and distal radioulnar ligaments. This type of instability is also common in malunions of the distal radius or distal one-third of the radial shaft (Galeazzi-type fractures). In malunions, DRUJ instability can be treated with a corrective osteotomy of the distal radius to restore the anatomic relationship between the distal ulna and the distal radius at the DRUJ. Radiocarpal and midcarpal instability do not involve the DRUJ. Disruption of the interosseous membrane (in isolation, with intact distal radioulnar ligaments and an intact TFCC) does not lead to translational instability of the DRUJ. Although hypermobility syndrome may lead to ligamentous laxity, it does not lead to unilateral DRUJ instability.

Question 81

A 10-year-old girl who is Risser stage 0 has back deformity associated with neurofibromatosis type 1 (NF1). She has no back pain. Examination shows multiple cafe-au-lait nevi with normal lower extremity neurologic function and reflexes. Standing radiographs of the spine show a short 50-degree right thoracic scoliosis with a kyphotic deformity of 55 degrees (apex T8). A 10-degree progression in scoliosis has occurred during the past 1 year. There is no cervical deformity. MRI shows mild dural ectasia, primarily in the upper lumbar region. Management should consist of Review Topic

Explanation

Scoliotic deformities in patients with NF1 are often dysplastic with short, angular curves. Posterior arthrodesis is made more difficult by the presence of kyphosis and of weak posterior elements caused by dural ectasia. Combined anterior and posterior spinal arthrodesis is generally preferred for progressive dysplastic curves to maximize deformity correction and to decrease the risk of pseudarthrosis. Anterior fusion may also prevent crankshaft phenomenon in young children. Brace treatment is not effective for large, rigid, or dysplastic curves.

Question 82

-Use of the shorter, anterior screw may result in

Explanation

Question 83

Which of the following neurovascular structures is at greatest risk during the introduction of acetabular component fixation screws during total hip replacement?

Explanation

Wasielewski et al found on reviewing the literature that vascular injuries during acetabuIar screw placement are an uncommon yet devastating complication of total hip arthroplasty. Damage to the external iliac artery was the most frequent injury yet injury to the external iliac vein and the superior gluteal artery has also been reported Based upon their anatomic study and development of a quadrant
system they found that the posterior superior and posterior inferior quadrants of the acetabulum are the safest locations for screw placement because of better bone stock as well as less neurovascular structures as compared to the anterior quadrants.

Question 84

The knee arthroplasty type associated with the highest 5-year revision rate is

Explanation

CLINICAL SITUATION QUESTIONS 167 THROUGH 169
Figures 167a and 167b are the radiographs of a middle-age man. He is a noncompliant patient who has severe insulin-dependent diabetes and a below-knee amputation on the right side. He is usually in a wheelchair, does not use a prosthesis, transfers using a walker, and resides in an institution. He had an infection in the left leg years ago, which was treated successfully with intravenous antibiotics (the details are unknown). His left knee is mildly painful, swollen but not warm, has limited range of motion (40-140 degrees), and is grossly unstable.

Question 85

Thyroid hormone regulates skeletal growth at the physis by stimulation of

Explanation

DISCUSSION: Children with hypothyroidism have delayed bone age, reduced thickness of the physis, disorganization of the cartilage columns of the physis, and impaired differentiation of proliferating chondrocytes into hypertrophic cells. As a result, these children have severe growth retardation, and slipped capital femoral epiphysis may develop because of mechanical weakening of the physis. Thyroid hormone regulates terminal differentiation of the growth plate chondrocytes, with a resultant increase in type X collagen and alkaline phosphatase. These substances are important factors in matrix mineralization. Insulin-like growth factors and FGF-2 appear to act synergistically to stimulate mitotic activity of the growth plate chondrocytes. TGF-b= and PTHrP stimulate proteoglycan synthesis and mitotic activity of the chondrocytes and inhibit type X collagen and alkaline phosphatase activity.
REFERENCES: Ballock RT: Regulation of skeletal growth and maturation by thyroid hormone, in Buckwalter JA, Ehrlich MG, Sandell LJ, Trippel SB (eds): Skeletal Growth and Development: Clinical Issues and Basic Science Advances. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1998, pp 301-317.
Rosier RN, O’Keefe RJ, Reynolds PR, Hicks DG, Puzas JE: Expression and function of TGF-b= and PTHrP in the growth plate, in Buckwalter JA, Ehrlich MG, Sandell LJ, Trippel SB (eds): Skeletal Growth and Development: Clinical Issues and Basic Science Advances. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1998, pp 285-299.
Trippel SB: IGF-I and FGF-2 in growth plate regulation, in Buckwalter JA, Ehrlich MG, Sandell LJ, Trippel SB (eds): Skeletal Growth and Development: Clinical Issues and Basic Science Advances. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1998, pp 263-283.

Question 86

What is the most common malignant bone tumor seen in patients with multiple hereditary exostosis?

Explanation

DISCUSSION: Secondary chondrosarcomas are most common in patients with multiple hereditary exostosis. Dedifferentiated chondrosarcoma is less common and refers to bone lesions in which a high-grade spindle cell sarcoma component is located immediately adjacent to a low-grade cartilage neoplasm. Mesenchymal chondrosarcoma, clear cell chondrosarcoma, and periosteal osteosarcoma are no more common in patients with multiple hereditary exostosis than in the general population.
REFERENCES: Mirra JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea and Febiger, 1989, pp 1660-1669.
Simon MA, Springfield DS, et al: Common Malignant Bone Tumors: Chondrosarcoma. Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 275-286.

Question 87

-An athletic 30-year-old sustained multiple injuries in a high-speed motor vehicle collision that resulted in a loss of approximately 30% of blood volume. On arrival to the emergency department, the heart rate is100 and blood pressure is 104/62. The best means with which to evaluate true hemodynamic status is

Explanation

Question 88

Which of the following can be seen in the heart of a well-conditioned athlete? Review Topic

Explanation

The well-conditioned heart of an athlete leads to increased ventricular wall thickness which in turn increases the amount of blood ejected from the heart per given stroke (stroke volume). The increased parasympathetic (vagal) tone also leads to a lower (decreased) resting heart rate. Cardiac output is equal to stroke volume X heart rate and is increased during exercise in a well-conditioned athlete.

Question 89

What is the most common long-term complication of the fracture shown in Figure 32?

Explanation

DISCUSSION: The fracture pattern shown in the radiograph involves both a talar neck fracture and a talar body fracture. The body fracture propagates into the subtalar joint, with significant risk for the development of arthritis in that surface even with an anatomic reduction. In addition, Canale and Kelly reported a 25% incidence of malunion of talar neck fractures, with varus angulation occurring most frequently. Of these patients, 50% required a secondary surgical procedure because of the development of degenerative joint disease of the subtalar joint.
REFERENCES: Canale ST, Kelly FB Jr: Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978;60:143-156.
Higgins TF, Baumgaertner MR: Diagnosis and treatment of fractures of the talus: A comprehensive review of the literature. Foot Ankle Int 1999;20:595-605.

Question 90

Which of the following best characterizes the antigenicity of allograft bone?

Explanation

DISCUSSION: Cell surface glycoproteins present in the heterogeneous population of the cells within the graft are primarily responsible for the antigenicity. Macromolocules of the matrix have also been implicated. Cryopreserved grafts have less antigenicity than fresh. Freezing, freeze-drying, or chemical sterilization and antigen extraction of the bone allograft have all been shown to reduce the antigenicity of the graft. Freeze-drying of retroviral-infected cortical bone and tendon does not inactivate retrovirus. Immunosuppression has been shown to decrease response. Hematopoietic elements along with osteogenic, chondrogenic, fibrous, and vascular cells have been shown to be antigenic.
REFERENCES: Crawford MJ, Swenson CL, Arnoczky SP, et al: Lyophilization does not inactivate infectious retrovirus in systemically infected bone and tendon allografts. Am J Sports Med 2004;32:580-586.
Stevenson S, Li XQ, Davy DT, et al: Critical biological determinants of incorporation of non-vascularized cortical bone grafts: Quantification of a complex process and structure. J Bone Joint Surg Am 1997;79:1-16.
Simon SR (eds): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 277-320.

Question 91

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 92

A 70-year-old woman with a body mass index (BMI) of 34 and a history of hypercholesterolemia has elected to undergo total hip arthroplasty. Her son recently learned he has factor V Leiden following an episode of pulmonary embolism. What are this patient's risk factors for thromboembolic disease?

Explanation

DISCUSSION:
Risk stratification is one of the most critical clinical evaluations to undertake before performing total joint arthroplasty. Many factors have been identified that increase the risk for venous thromboembolism (VTE) The major factors include previous VTE, obesity, type of surgery (such as total joint arthroplasty), hypercoagulable states, myocardial infarction, congestive heart failure, family history of VTE, and hormone replacement therapy. Hypercholesterolemia is not a risk factor for thromboembolic disease.

Question 93

A 10-year-old girl has been unable to walk for the past 5 days because of bilateral hip pain. Administration of IV morphine has provided some pain relief. She is afebrile. History reveals that she had an upper respiratory tract infection 3 weeks ago that resolved uneventfully. Examination reveals moderate pain with internal rotation and abduction, while log rolling maneuvers do not cause significant pain. An MRI scan shows a small effusion of one hip; however, a bone scan and plain radiographs are normal. Initial laboratory studies showed a markedly elevated WBC count, which subsequently declined to normal levels with IV antibiotics. Current studies show an erythrocyte sedimentation rate (ESR) of 100 mm/h. Aspiration of the hip obtains 3 mL of fluid; Gram stain is negative for bacteria, but a cell count shows a WBC count of 16,500/mm 3 . Streptozyme titer of the peripheral blood is 200 units (normal is less than 100 units). Management should now consist of

Explanation

DISCUSSION: This clinical situation requires careful analysis because some data suggest infection and some a noninfectious inflammatory process. Bilateral hip involvement, the absence of significant fluid collection or fever, the streptozyme level, and the history of upper respiratory infection all suggest poststreptococcal toxic synovitis as the most likely cause for the clinical presentation. In the first 24 hours, this type of presentation might warrant incision and drainage given uncertainty of the diagnosis and the risks associated with missing an infection. However, 5 days after onset, surgery is not warranted, especially given that the patient remains afebrile and her symptoms are improving. Cardiology consultation would be appropriate. There is no evidence to suggest slipped capital femoral epiphysis. Treatment with antibiotics is not advised because there is no bacteriologic data on which to base treatment.
REFERENCES: De Cunto CL, Giannini EH, Fink CW, et al: Prognosis of children with poststreptococcal reactive arthritis. J Pediatr Infect Dis 1988;7:683-686.
Haueisen DC, Weiner DS, Weiner SD: The characterization of “transient synovitis of the hip” in children. J Pediatr Orthop 1986;6:11-17.

Question 94

A 12-year-old girl has had lower back pain for the past 6 months that interferes with her ability to participate in sports. She denies any history of radicular symptoms, sensory changes, or bowel or bladder dysfunction. Examination reveals a shuffling gait, restriction of forward bending, and tight hamstrings. Radiographs show a grade III spondylolisthesis of L5 on S1, with a slip angle of 20°. Management should consist of

Explanation

DISCUSSION: Indications for surgical treatment of spondylolisthesis include pain and/or progression of deformity. Specifically, surgery is necessary when there is persistent pain or a neurologic deficit that fails to respond to nonsurgical therapy, there is significant slip progression, or the slip is greater than 50%. For patients with mild spondylolisthesis, in situ posterolateral L5-S1 fusion is adequate. In patients with more severe slips (greater than 50%), extension of the fusion to L4 offers better mechanical advantage. Postoperative immobilization may be achieved with instrumentation, casting, or both. In patients with a slip angle of greater than 45°, reduction of the lumbosacral kyphosis with instrumentation or casting is desirable to prevent slip progression. Laminectomy alone is contraindicated in a child. Nerve root decompression is indicated if radiculopathy is present clinically.
REFERENCES: Seitsalo S, Osterman K, Hyvarinen H, Tallroth K, Schlenzka D, Poussa M: Progression of spondylolisthesis in children and adolescents: A long-term follow-up of 272 patients. Spine 1991;16:417-421.
Newton PO, Johnston CE II: Analysis and treatment of poor outcomes following in situ arthrodesis in adolescent spondylolisthesis. J Pediatr Orthop 1997;17:754-761.

Question 95

After completion of bone cuts and ligament balancing of a severe valgus knee during primary total knee arthroplasty, there is a 5-mm increased medial gap that cannot be corrected. In this scenario, what is the most appropriate level of constraint?

Explanation

DISCUSSION
Cruciate-retaining implants are typically used in the presence of a functioning posterior cruciate ligament (PCL). A posterior stabilized insert improves anteroposterior stability in the absence of a PCL but does not account for imbalance of the collateral ligaments. An
uncorrectable laxity medially indicates insufficiency of the medial collateral ligament (MCL), which is best treated with a varus-valgus constrained component. A rotating hinge is generally reserved for complete absence of the MCL or both collateral ligaments.
Change of IV antibiotics and splinting
Arthroscopic irrigation and debridement
CT-guided needle aspiration
Open debridement
DISCUSSION
In an acutely febrile child with bone pain and elevated acute-phase reactants, osteomyelitis is suspected. Blood cultures will yield the offending organism in 30% to 60% of patients and are the most appropriate next step. Knee aspiration in the absence of an effusion likely will not be helpful. Although a bone scan may show an osteomyelitic focus, an indium-labeled WBC scan is unnecessarily complex and costly in this case. Pelvic radiographs would add little to the unremarkable femur films.
Initiating IV antibiotics after obtaining blood cultures is appropriate, even in the presence of an MRI with normal findings. Observation or discharge may be considered, but suspicion for infection should be strong in this clinical situation and delay is not warranted. A CT scan of the knee in the setting of normal MRI findings will not be helpful.
Most hematogenous osteomyelitis cases among children are attributable to S. aureus. In many areas of the country, MRSA is endemic, and initial coverage for resistance is appropriate. The other listed organisms would rarely be seen in this scenario.
The MR images show early abscess formation in the distal medial femoral metaphysis. Because the formation developed during antibiotic treatment, surgical drainage (rather than a change of antibiotic) is appropriate. Arthroscopy is not helpful because this is not an intra-articular process. Although aspiration prior to surgical debridement could be considered, the organism has already been identified from the blood culture, and CT guidance is not needed to locate this large abscess in such an accessible area.

Question 96

Figure 54 is the lateral radiograph of a 55-year-old man who is evaluated for a 2-year history of pain and stiffness of his right metatarsophalangeal (MTP) joint. Upon examination he has dorsal bossing, severe crepitation, and pain with passive range of motion. There is pain with the "grind" test. Dorsiflexion is limited to 0 degrees. No sesamoid tenderness is present. What is the most appropriate surgical treatment?

Explanation

DISCUSSION
The radiograph reveals end-stage degenerative changes of the first MTP joint with a dorsal loose body. MTP arthritis and decreased joint dorsiflexion is referred to as hallux rigidus. A chevron bunionectomy is used to correct hallux valgus deformity without arthritis. The cheilectomy is used in lesser degrees of joint destruction. Resection of the proximal phalanx results in a floppy toe and is generally not recommended.
RECOMMENDED READINGS
McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int. 2013 Jan;34(1):15-32. doi: 10.1177/1071100712460220. Review. PubMed PMID: 23386758.
View Abstract at PubMed
Deland JT, Williams BR. Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012 Jun;20(6):347-58. doi: 10.5435/JAAOS-20-06-347. Review. PubMed PMID: 22661564.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 55 THROUGH 58
Figures 55a and 55b are the anteroposterior and lateral radiographs of a 57-year-old man who fell off of a ladder 10 days ago and landed on his left foot. He is now unable to weight bear on the left. He has no history of trauma to this foot, and his medical history is unremarkable. Upon examination his left foot is swollen and tender. Pulses and sensation are intact.

A B

Question 97

The Coleman block test is used to test for Review Topic

Explanation

The Coleman block test is used to determine the flexibility of the hindfoot. When a block is placed under the lateral border of the foot, the medial column is unsupported. As a result, the first metatarsal drops off the side of the block. If the subtalar joint is flexible, there is no fixed varus deformity of the hindfoot. The hindfoot will no longer be in varus from behind. The varus deformity of the hindfoot will be corrected. If there is no subtalar motion, the varus deformity remains fixed.

Question 98

Figures 29a and 29b show the AP radiograph and CT scan of a 70-year-old man who has left thigh pain. Serum protein electrophoresis shows a monoclonal gammopathy. Additional radiographs of the femur show other lesions. Management should consist of

Explanation

DISCUSSION: The underlying diagnosis is multiple myeloma. Because the patient has a large lucent lesion in the peritrochanteric region of the left proximal femur, the risk of pathologic fracture is high. Consideration should be given to prophylactic internal fixation with a locked intramedullary rod. The lesion does not appear to be a sarcoma requiring wide resection and endoprosthetic reconstruction. Neither chemotherapy nor radiation therapy alone is likely to result in long-term stabilization of the proximal femur. Postoperative treatment with bisphosphonates and radiation therapy is indicated to decrease the risk of future pathologic fractures. The patient should also be referred to a medical oncologist for medical management.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 364.
Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989;249:256-264.

Question 99

Back pain and ipsilateral knee pain are common long-term sequelae of hip arthrodesis. To limit these problems, what position should be avoided during fusion of the hip?

Explanation

DISCUSSION: The recommended position for a hip fusion is flexion of 20° to 30°, slight adduction (5°) or neutral, and 10° of external rotation. In long-term follow-up, patients who underwent fusion in abduction had more ipsilateral knee and low back pain than patients who were positioned in adduction. Internal rotation should be avoided to prevent interference with the opposite foot during gait. External rotation facilitates the application of shoe wear.
REFERENCES: Callaghan JJ, Brand RA, Pederson DR: Hip arthrodesis: A long-term follow-up. J Bone Joint Surg Am 1985;67:1328-1335.
Callaghan JJ, McBeath AA: Arthrodesis, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 749-759.

Question 100

A 62-year-old man has cervical myelopathy with no evidence of cervical radiculopathy. MRI reveals stenosis at C4-5 and C5-6 with severe cord compression. Examination will most likely reveal which of the following findings?

Explanation

DISCUSSION: Cervical myelopathy involves compression of the spinal cord and presents as an upper motor neuron disorder. Patients commonly have extremity spasticity and problems with ambulation and balance. Hoffman’s sign is often present and is elicited by suddenly extending the distal interphalangeal joint of the middle finger; reflexive finger flexion represents a positive finding. The extremities are usually hyperreflexic with myelopathy. With cervical radiculopathy (lower motor neuron disorder), reflexes are hyporeflexic, and patients report pain along a dermatomal distribution. A hyperactive jaw jerk reflex indicates pathology above the foramen magnum or in some cases, systemic disease. Flaccid paraparesis suggests a lower motor neuron problem.
REFERENCES: Sachs BL: Differential diagnosis of neck pain, arm pain and myelopathy, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 741-742.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 673-680.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Complete based on the normalization of his blood pressure, urine output, and heart rate
Cannot be determined based on the data presented
Incomplete based on his fluid requirements calculated using his initial blood pressure as a measure of blood volume loss
Incomplete since he will need surgery on the long bone fractures and should be “tanked up” prior to losing blood in the operating room
Incomplete based on his heart rate

Correct Answer: Cannot be determined based on the data presented

Explanation:

DISCUSSION: Although the end points of resuscitation are still unclear, what is known is that normalization of the standard hemodynamic parameters (blood pressure, heart rate, and urine output) is not adequate. Up to 85% of patients with normal hemodynamic parameters can still have inadequate tissue oxygenation or uncompensated shock. The initial base deficit, lactate level, or gastric pHi can be used to stratify patients for resuscitation needs, risks of death, and multiple organ failure (level 1 evidence). The time it takes to normalize the base deficit, the lactate level, or gastric pHi, can predict survival (level 2 evidence). Patients who have been in uncompensated shock (abnormal vital signs) should have their resuscitation monitored using data other than vital signs.
REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: Endpoints of resuscitation. J Trauma 2004;57:898-912.
Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury,
a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.
Englehart MS, Schreiber MA: Measurement of acid-base resuscitation endpoints: Lactate, base deficit, bicarbonate or what? Curr Opin Crit Care 2006;12:569-574.

Question 2:

Options:

Medial collateral ligament
Annular ligament
Lateral ulnar collateral ligament
Extensor carpi radialis brevis
Extensor carpi radialis longus

Correct Answer: Lateral ulnar collateral ligament

Explanation:

DISCUSSION: The patient has an iatrogenic injury to the lateral ulnar collateral ligament following the arthroscopic procedure. Failure to adhere to known anatomic landmarks can lead to this devastating complication. The examination findings are classic for posterolateral elbow instability.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 318.
O’ Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

Question 3:

Options:

Biopsy
Resection
A CT scan
An MRI scan
Observation

Correct Answer: Observation

Question 4:

Options:

anterolateral bundle that is tight in flexion and a posteromedial bundle that is tight in extension.
anterolateral bundle that is tight in extension and a posteromedial bundle that is tight in flexion.
anteromedial bundle that is tight in flexion and a posterolateral bundle that is tight in extension.
anteromedial bundle that is tight in extension and a posterolateral bundle that is tight in flexion.

Correct Answer: anterolateral bundle that is tight in flexion and a posteromedial bundle that is tight in extension.

Explanation:

Question 5:

Options:

No immobilization, no time off from work, and instructions to go about normal activities
Part-time soft collar immobilization and modified duty at work for 1 to 2 weeks
Full-time soft collar immobilization and modified duty at work for 1 to 2 weeks
Full-time rigid collar immobilization and time off from work for 1 to 2 weeks
Repeat MRI to assess for occult disk or ligamentous injury

Correct Answer: No immobilization, no time off from work, and instructions to go about normal activities

Explanation:

Question 6:

- The familial occurrence of Legg-Calve-Perthes disease may, in some cases, be attributed to

Options:

hypophosphatemia
high dietary cholesterol intake
deficiency of lipoprotein A
deficiency of protein S and protein C
elevated levels of antithrombin III

Correct Answer: deficiency of protein S and protein C

Explanation:

Question 7:

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 8:

Options:

Informed consent
Patient autonomy
Fiduciary responsibility
Physician paternalism
Justice

Correct Answer: Informed consent

Explanation:

Question 9:

All of the following are factors associated with transfer of patients to Level 1 trauma centers EXCEPT:

Options:

Male
Medicaid insurance
Injury severity score of 36
Caucasian race
One or more comorbidity

Correct Answer: Male

Explanation:

Question 10:

Surgical treatment for symptomatic disk herniations is associated with which of the following? Review Topic

Options:

Substantial rate of nerve root injury
Early relief of pain sustained out to 2 years
Recurrent herniation rate of 35%
Outcomes that are substantially worse than nonsurgical management
10% rate of infectious diskitis

Correct Answer: Early relief of pain sustained out to 2 years

Explanation:

Question 11:

Options:

Revision total knee arthroplasty with placement of a hinge constrained device
Patellar tendon repair with nonabsorbable suture and patellar resurfacing
Hinged knee brace with drop lock design to restore stability during ambulation
Extensor mechanism reconstruction using synthetic mesh or allograft

Correct Answer: Extensor mechanism reconstruction using synthetic mesh or allograft

Explanation:

Question 12:

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 13:

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared with a standard parapatellar approach, what is the expected outcome?

Options:

Improvement in range of motion
Reduction in range of motion
Increase in extensor mechanism lag
No differences in motion and strength

Correct Answer: No differences in motion and strength

Explanation:

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 14:

In addition to the radiographic features seen in Figures 49a and 49b, this patient will most likely have which of the following findings?

Options:

Microcephaly
1,25 dihydroxy vitamin D deficiency
Normal dentition
Anemia
Developmental delays

Correct Answer: Anemia

Explanation:

Question 15:

Options:

Neurophysiologic test to evaluate the posterior interosseous nerve
Transfer of the extensor indicis proprius to the extensor pollicis longus tendon
Interphalangeal joint arthrodesis of the thumb
Extension splinting of the thumb
Fine cut CT of the distal radius to evaluate Lister’s tubercle

Correct Answer: Transfer of the extensor indicis proprius to the extensor pollicis longus tendon

Explanation:

Question 16:

Options:

Decreased risk of posttraumatic arthritis
Avoid growth arrest
Minimize risk of osteonecrosis
Prevent clinical internal rotation deformity
Prevent development of a late tarsal tunnel syndrome

Correct Answer: Decreased risk of posttraumatic arthritis

Explanation:

DISCUSSION: Triplane fractures generally occur in children who are near skeletal maturity. The injury is generally caused by a supination external rotation mechanism. The number of fracture fragments present (two or three) depends on what part of the physes is closed at the time of injury. Articular congruity is the major concern in the management of these injuries since the patient has almost reached skeletal maturity. The goal is to restore articular congruity to minimize the development of posttraumatic arthritis.
REFERENCES: Vaccaro A (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 757-765.
Kling TF Jr, Bright RW, Hensinger RN: Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am 1984;66:647-657.
Spiegel PG, Mast JW, Cooperman DR, et al: Triplane fractures of the distal tibial epiphysis.
Clin Orthop Relat Res 1984;188:74-89.

Question 17:

What is the most likely reason open fractures tend to heal more slowly than closed fractures?

Options:

Loss of osteoinductive potential from the hematoma that is lost around the fracture
Introduction of foreign material
Subclinical infection
Loss of blood supply at the fracture site
Loss of soft-tissue coverage at the fracture site

Correct Answer: Loss of osteoinductive potential from the hematoma that is lost around the fracture

Explanation:

Question 18:

Options:

No treatment is required because spontaneous healing is common.
Nonsurgical management typically relieves pain and results in radiographic healing in less than 12 weeks.
Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.
Hyperbaric oxygen treatment is helpful.
Ankle fusion is frequently necessary.

Correct Answer: Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.

Explanation:

Question 19:

Options:

repetitive loading and fatigue failure.
incomplete bone ingrowth with focal osteolysis.
rotational bone axial loading.
a fixed component with a modulus mismatch.
use of titanium instead of cobalt-chromium.

Correct Answer: a fixed component with a modulus mismatch.

Explanation:

Question 20:

What gene is expressed the earliest during the differentiation of a chondrocyte during endochondral ossification?

Options:

Aggrecan
Sox-9
Collagen type II
Collagen type IV
Collagen type XI

Correct Answer: Sox-9

Explanation:

Question 21:

A 6-year-old boy has leg pain. A radiograph, MRI, CT, and bone scans, and a biopsy specimen are shown in Figures 14a through 14e. What is the most likely diagnosis?

Options:

Ewing’s sarcoma
Osteomyelitis
Osteosarcoma
Eosinophilic granuloma
Fibrous dysplasia

Correct Answer: Osteomyelitis

Explanation:

Question 22:

Options:

glenohumeral osteoarthritis.
recurrent posterior subluxation.
internal impingement syndrome.
thoracic outlet syndrome.
subscapularis tendon detachment.

Correct Answer: glenohumeral osteoarthritis.

Explanation:

Question 23:

Options:

Radiographs
Bone scan
CT
Ultrasonography
MRI

Correct Answer: Ultrasonography

Explanation:

Question 24:

- A 23 year old man has a minimally comminuted midshaft fracture of the femur with 2cm entrance and exit wounds as a result of a low-velocity gunshot. Definitive management should be

Options:

Debriding the skin edges and performing plate fixation of the fracture
Debriding the skin edges and intramedullary rodding of the fracture
Extending the wounds, debriding the bone ends, and applying distal femoral traction
Extending the wounds, debriding the bone ends, and performing plate fixation of the fracture
Extending the wounds, debriding the bone ends, and intramedullary rodding of the fracture

Correct Answer: Debriding the skin edges and intramedullary rodding of the fracture

Explanation:

Question 25:

Options:

reconstruction with a metal augmented revision tibial implant.
reconstruction with a hinged prosthesis.
reconstruction with a structural allograft.
reconstruction with iliac crest bone graft.
filling the defect with cement.

Correct Answer: reconstruction with a metal augmented revision tibial implant.

Explanation:

DISCUSSION: Massive bone loss encountered in revision total knee arthroplasty remains a significant challenge. Recent reports have shown high success rates using structural allograft to reconstruct large structural bone defects. A hinged prosthesis is not required in this setting. In this patient, a large amount of posterior cortex has been lost, making the area too large to fill with cement or iliac crest bone graft. Because of her age, the treatment of choice is a revision tibial implant and metal augments. Structural allograft would be suitable in a younger patient.
REFERENCES: Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty. J Arthroplasty 1996;11:235-241.
Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.
Clatworthy MG, Ballance J, Brick GW, et al: The use of structural allograft for uncontained defects in revision total knee arthroplasty: A minimum five-year review. J Bone Joint Surg Am 2001;83:404-411.

Question 26:

Options:

Arthroscopic Bankart surgery
Bony glenoid augmentation procedure
Subscapularis advancement
Open capsular shift
Hemiarthroplasty

Correct Answer: Bony glenoid augmentation procedure

Explanation:

Question 27:

Metal-on-metal articulation has been reintroduced because of concern about polyethylene wear. This type of articulation is considered favorable because

Options:

metal particles are inert.
metal particles are larger than polyethylene particles.
the surfaces can now be fabricated with low carbon, machined cobalt-chromium.
less than 0.6 mm 3 of metallic debris are generated per year.
electrochemical problems of the articulation have now been solved through passivation.

Correct Answer: less than 0.6 mm 3 of metallic debris are generated per year.

Explanation:

Question 28:

Options:

surgery alone.
neoadjuvant chemotherapy and surgical resection.
radiation therapy.
chemotherapy and radiation therapy.
chemotherapy only.

Correct Answer: chemotherapy and radiation therapy.

Explanation:

DISCUSSION: Ewing’s sarcoma is the second most common primary tumor of bone in children. Depending on the site and extent of disease, chemotherapy, radiation therapy, and surgery are all treatment options. In this patient with extensive pelvic and metastatic disease, chemotherapy and radiation therapy offer the best oncologic control while preserving functional outcome.
REFERENCES: Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.
Thacker MM, Temple HT, Scully SP: Current treatment for Ewing’s sarcoma. Expert Rev Anticancer Ther 2005;5:319-331.
Weber KL: Current concepts in the treatment of Ewing’s sarcoma. Expert Rev Anticancer Ther 2002;2:687-694.

Question 29:

Where is the underlying defect in a rhizomelic dwarf with the findings shown in Figure 5?

Options:

Type I collagen
Type II collagen
Collagen oligomeric protein (COMP)
Sulfate transport
Fibroblast growth factor receptor 3

Correct Answer: Fibroblast growth factor receptor 3

Explanation:

DISCUSSION: The radiograph shows the typical findings of achondroplasia. The defect is in fibroblast growth factor receptor 3. The pedicles narrow distally in the lumbar spine. The pelvis is low and broad with narrow sciatic notches and ping-pong paddle-shaped iliac wings. This is often called a champagne glass pelvis. Type I collagen abnormalities are typically found in osteogenesis imperfecta, and type II collagen defects are found in spondyloepiphyseal dysplasia and Kneist syndrome. COMP is defective in multiple epiphyseal dysplasia. Sulfate transport defects are seen in diastrophic dysplasia.
REFERENCES: Johnson TR, Steinbach LS: Essentials of Musculoskeletal Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 809-812.
Caffey J: Achondroplasia of the pelvis and lumbosacral spine: Some roentgenographic features. Am J Roentgenol 1958;80:449.

Question 30:

Options:

long arm cast immobilization.
open reduction and internal fixation, followed by cast immobilization.
closed reduction and percutaneous pin fixation.
anterior transposition of the ulnar nerve.
excision of the loose fragment and repair of the common flexor origin.

Correct Answer: long arm cast immobilization.

Explanation:

DISCUSSION: Avulsion fractures of the medial epicondyle are caused by a valgus stress applied to the immature elbow and usually occur in children between the ages of 9 and 14 years. Long-term studies have shown that isolated fractures of the medial epicondyle with between 5 to 15 mm of displacement heal well. Brief immobilization (1 to 2 weeks) in a long arm cast or splint yields results similar to open reduction and internal fixation. Fibrous union of the fragment is not associated with significant symptoms or diminished function. Surgical excision of the fragment yielded the worst results in one study and should be avoided. Open reduction is best reserved for those injuries in which the medial epicondylar fragment becomes entrapped in the elbow joint during reduction and cannot be extracted by closed manipulation.
REFERENCES: Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am
2001;83:1299-1305.
Josefsson PO, Danielsson LG: Epicondylar elbow fracture in children: 35-year follow-up of
56 unreduced cases. Acta Orthop Scand 1986;57:313-315.

Question 31:

Options:

Penicillin
Sulfur
Shellfish
Chicken or eggs
Lidocaine

Correct Answer: Chicken or eggs

Explanation:

Question 32:

- A 25 year-old amateur baseball player sustained a dorsal fracture-dislocation of the proximal interphalangeal joint of his long finger. He underwent closed reduction 3 hours ago. Examination reveals mild laxity of the radial collateral fragment involving 30% of the volar articular surface of the middle phalanx. Management should now include

Options:

open reduction and internal fixation
buddy taping to the adjacent index finger
early motion with application of a dynamic banjo splint
application of a cast with the hand in a “safe position” for 3 weeks.
dorsal extension block splinting

Correct Answer: dorsal extension block splinting

Explanation:

Question 33:

Options:

Chondroblastoma
Enchondroma
Giant cell tumor
Fibrous dysplasia
Osteoblastoma

Correct Answer: Fibrous dysplasia

Explanation:

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 34:

A 20-year-old man sustained a closed tibial fracture and is treated with a reamed intramedullary nail. What is the most common complication associated with this treatment?

Options:

Nonunion
Malunion
Infection
Knee pain
Compartment syndrome

Correct Answer: Knee pain

Explanation:

DISCUSSION: The most common complication is anterior knee pain (57%). The knee pain is activity related (92%) and exacerbated by kneeling (83%). Although knee pain is the most common complication, most patients rate it as mild to moderate and only 10% are unable to return to previous employment. Some authors report less knee pain with a peritendinous approach when compared to a tendon-splitting approach. In one study, nail removal resolved pain in 27%, improved it in 70%, and made it worse in 3%. The incidence of the other complications was: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%. Compartment syndrome is rare after nailing.
REFERENCES: Court-Brown CM: Reamed intramedullary tibial nailing: An overview and analysis of 1106 cases. J Orthop Trauma 2004;18:96-101.
McQueen MM, Gaston P, Court-Brown CM: Acute compartment syndrome: Who is at risk?
J Bone Joint Surg Br 2000;82:200-203.
Keating JF, Orfaly R, O’Brien PJ: Knee pain after tibial nailing. J Orthop Trauma
1997;11:10-13.

Question 35:

What is the preferred treatment of a symptomatic curly toe deformity in a 6-year-old child?

Options:

Observation
Tape the toe to the adjacent toes for 8 weeks
Tenotomy of the flexor tendons
Transfer of the flexor tendons to the extensor mechanism
Arthrodesis of the proximal interphalangeal joint

Correct Answer: Tenotomy of the flexor tendons

Explanation:

DISCUSSION: While some curly toe deformities spontaneously improve in younger children, the deformity is likely to persist in a 6-year-old child. Taping techniques result in no change or only a temporary decrease in deformity. Studies have shown that simple flexor tenotomy is as effective as flexor tendon transfer. Arthrodesis is rarely indicated.
REFERENCES: Hamer A, Stanley D, Smith TW: Surgery for curly toe deformity: A
double-blind, randomized, prospective trial. J Bone Joint Surg Br 1993;75:662-663.
Ross ER, Menelaus MB: Open flexor tenotomy for hammer toes and curly toes in childhood.
J Bone Joint Surg Br 1984;66:770-771.

Question 36:

All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT:

Options:

Increased age
Intraoperative complications
Ipsilateral femoral head injury
Involvement of both columns
Non-anatomic fracture reduction

Correct Answer: Increased age

Explanation:

Question 37:

Options:

Shortening of 3 cm
Severity of trauma
Duration of immobilization
Type of immobilization
Closed reduction

Correct Answer: Severity of trauma

Explanation:

Question 38:

If a percutaneous iliosacral screw is placed too anteriorly, and the screw exits anterior to the sacral ala before re-entering the sacral body, what will be the most likely finding postoperatively?

Options:

Lack of ankle dorsiflexion
Lack of ankle plantarflexion
Lack of knee extension
Loss of bowel and/or bladder control
Lack of great toe extension

Correct Answer: Lack of ankle dorsiflexion

Explanation:

Question 39:

Options:

cheilectomy.
extra-depth shoes.
steroid injection.
arthrodesis.
joint replacement arthroplasty.

Correct Answer: extra-depth shoes.

Explanation:

Question 40:

Options:

Anterior only
Anterior and medial
Anterior and lateral
Posterior and medial
Posterior and lateral

Correct Answer: Posterior and lateral

Explanation:

Question 41:

Options:

Menstrual history
Family history
Serum calcium level
MRI of the hip
Contralateral hip radiograph

Correct Answer: Menstrual history

Explanation:

Question 42:

Options:

Rett syndrome
Cerebral palsy
Myotonic dystrophy
Fragile-X syndrome
Adrenoleukodystrophy

Correct Answer: Rett syndrome

Explanation:

Question 43:

Options:

Home exercise program
Sling at all times until her pain decreases
Closed manipulation under anesthesia
Arthroscopic rotator cuff repair
Arthroscopic anterior and posterior capsular release

Correct Answer: Home exercise program

Explanation:

Question 44:

Options:

Ulnar nerve transposition
Ulnar collateral ligament reconstruction
Long arm cast for a medial epicondyle fracture
Open reduction and internal fixation of the medial epicondyle
Elbow arthroscopy and excision of a posteromedial olecranon osteophyte

Correct Answer: Ulnar collateral ligament reconstruction

Explanation:

Question 45:

In regards to a genetic disorder, which of the following is an example of "anticipation?"

Options:

Gene characteristics more severe and earlier in onset in subsequent generations
A disorder inherited from a genetic mutation specific to maternal DNA
Gene characteristics expressed to varying degrees in different individuals
Variation in the relative frequency of a genotype due to chance
The presence of an extra copy of a chromosome

Correct Answer: Variation in the relative frequency of a genotype due to chance

Explanation:

Question 46:

What is the most common complication following surgical fixation of a distal humeral fracture?

Options:

Wound infection
Ulnar nerve injury
Failure of fixation
Nonunion
Elbow stiffness

Correct Answer: Elbow stiffness

Explanation:

Question 47:

Options:

Hindfoot valgus
Midfoot supination
Sinus tarsi impingement
Anterior ankle impingement
Hammertoe deformity

Correct Answer: Hindfoot valgus

Explanation:

Question 48:

Options:

Humeral head erosion
Glenoid erosion
Rotator cuff integrity
Status of the coracoacromial ligament
Acromioclavicular arthritis

Correct Answer: Rotator cuff integrity

Explanation:

Question 49:

The spinal cord terminates as the conus medullaris at what vertebral level in adults? Review Topic 1 T12

Options:

Correct Answer: L2

Explanation:

The spinal cord anatomy changes at the thoracolumbar junction. The spinal cord terminates as the conus medullaris at the lower portion of L1 in women and the pedicle of L1 in men.

Question 50:

Options:

Lidocaine injection test
Supraspinatus strengthening
Reverse shoulder arthroplasty
Conventional total shoulder arthroplasty
Arthroscopic rotator cuff repair/subacromial decompression

Correct Answer: Lidocaine injection test

Explanation:

Question 51:

Venous thromboembolism may occur after total joint arthroplasty. The risk of this complication is elevated in patients with

Options:

a BMI lower than 30.
diabetes mellitus, with a hemoglobin A1c test result less than 7.
tranexamic acid use.
metabolic syndrome.

Correct Answer: metabolic syndrome.

Explanation:

Question 52:

Options:

a custom tibial implant.
a hinged prosthesis.
reconstruction with structural allograft.
reconstruction with iliac crest bone graft.
filling the defect with cement.

Correct Answer: reconstruction with structural allograft.

Explanation:

DISCUSSION: Massive bone loss encountered in revision total knee arthroplasty remains a significant challenge. Recent reports have shown high success rates using structural allograft to reconstruct massive bone defects. Custom and hinged prostheses in this setting are no longer favored. The defect shown is segmental and is too large to be filled with cement or iliac crest bone graft.
REFERENCES: Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty. J Arthroplasty 1996;11:235-241.
Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.
Clatworthy MG, Ballance J, Brick GW, Chandler HP, Gross AE: The use of structural allograft for uncontained defects in revision total knee arthroplasty: A minimum five-year review. J Bone Joint Surg Am 2001;83:404-411.

Question 53:

During placement of an external fixator for a distal radius fracture, the most commonly injured nerve is a branch of which of the following nerves? Review Topic

Options:

Ulnar
Median
Superficial radial
Lateral antebrachial cutaneous
Medial antebrachial cutaneous

Correct Answer: Superficial radial

Explanation:

Pin track infections and sensory injuries are among the most common complications of external fixation for distal radius fractures. The proximal pins of most distal radius external fixators are placed in the “bare area” of the distal radius, about four finger-breadths above the radial styloid. This corresponds to the area where the dorsal sensory branch of the radial nerve penetrates the fascia dorsal to the brachioradialis tendon to become a subcutaneous structure. Injury to the superficial radial nerve may produce painful dysesthesias and neuromas.
(SBQ12TR.106) A 67-year-old female sustains the injury shown in Figure A after a trip and fall. When discussing the outcomes of surgery with the patient, which of the following statements is true?
Post-surgical mortality rates are significantly lower after total hip arthroplasty compared to hemiarthroplasty
Internal fixation shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to arthroplasty
Bipolar hemiarthroplasty shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to unipolar hemiarthroplasty
A delay in surgery greater than 48 hours is recommended if the patient has multiple medical comorbiditiesm which are not fully optimized
Dislocation rates are equivalent between total hip arthroplasty and hemiarthroplasty
Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. However, patients with significant medical comorbidity should be fully optimized before surgery.
Although several studies have shown a benefit to surgery within 48 hours, no definitive time frame has been elucidated. The majority of literature has shown improved outcomes in regards to pain, complications, and length of stay with early surgery. Patients with significant medical comorbidities have been shown to have the highest mortality rates.
Moran et al. aimed to determine whether a delay in surgery for hip fractures had an affect on postoperative mortality among elderly patients. In an observational study of 2660 patients, they showed that mortality following hip fracture surgery was 9% at 30-days, 19% at 90-days, and 30% at 12-months. Patients with medical comorbidities had 2.5 times the risk of death within 30-days of surgery. In addition, individuals who had surgery delayed beyond 4 days had increased mortality at 90-days and 12-months.
Papakostidis et al. examined the timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. They showed no benefit of
early surgery on incidence of AVN. However, delay of internal fixation of more than
24 hours showed increased rates of non-union.
Figure A shows a displaced right femoral neck fracture. Incorrect Answers:

Question 54:

Which of the following is considered the most important factor in eliminating infection in chronic osteomyelitis?

Options:

Antibiotic use
Complete debridement of the compromised bone and soft tissue
Immobilization of the infected joint
Irrigation of the tissues
Arthrodesis of the adjacent joint

Correct Answer: Complete debridement of the compromised bone and soft tissue

Explanation:

Question 55:

Which of the following best describes the function of the notochord?

Options:

The notochord becomes the medulla oblongata in adults.
The notochord induces tissues that eventually become the vertebral column.
The notochord disappears with ossification of vertebral bodies.
The notochord develops into the ring apophysis.
Remnants of the notochord are often found in the coccyx.

Correct Answer: The notochord induces tissues that eventually become the vertebral column.

Explanation:

Question 56:

Options:

Elastic modulus
Ductility
Ultimate stress
Yield stress
Toughness

Correct Answer: Elastic modulus

Explanation:

Question 57:

An obese patient undergoing total knee arthroplasty is at increased risk for which of the following complications?

Options:

Wound complication
Infection
Lower knee score
Aseptic loosening
Patellar subluxation

Correct Answer: Wound complication

Explanation:

Question 58:

Options:

Tenderness over the anterior talofibular and calcaneofibular ligaments
A positive dorsiflexion external rotation test
Loss of passive range of motion
Positive squeeze test
Inability to single leg hop

Correct Answer: Inability to single leg hop

Explanation:

Question 59:

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads?

Options:

Nucleus pulposus
Cartilaginous end plate
Anterior longitudinal ligament
Annulus fibrosis
Cellular matrix

Correct Answer: Annulus fibrosis

Explanation:

DISCUSSION: The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.
REFERENCE: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.

Question 60:

Options:

Basilar invagination of less than 1 cm
Anterior atlanto-dens interval of 4 mm
Posterior atlanto-dens interval of greater than 14 mm
Rotatory subluxation of less than 10 degrees
Subaxial subluxation of less than 3.5 mm

Correct Answer: Posterior atlanto-dens interval of greater than 14 mm

Explanation:

DISCUSSION: Boden and associates’ article presents compelling evidence that patients with rheumatoid arthritis and neurologic deterioration in C1-2 instability are more likely to achieve some improvement if the posterior atlanto-dens interval is greater than 10 mm on preoperative studies. All the patients in their series who had neurologic deterioration and a preoperative posterior atlanto-dens interval of greater than 14 mm achieved complete motor recovery.
REFERENCES: Boden SD, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.
Boden SD, Clark CR: Rheumatoid arthritis of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 755-764.
Monsey RD: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg 1997;5:240-248.

Question 61:

Figure 41 shows the MRI scan of a 38-year-old weightlifter. What does the arrow on the MRI scan indicate? Review Topic

Options:

Biceps tear
Pectoralis minor tear
Pectoralis major tear
Subscapularis tear
Abscess formation

Correct Answer: Pectoralis major tear

Explanation:

Question 62:

Options:

Triple arthrodesis
Soft-tissue releases as necessary
Tendon transfers to balance the feet in a neutral plantigrade position
Physical therapy for range of motion and stretching
Botulinum injections followed by serial casting

Correct Answer: Soft-tissue releases as necessary

Explanation:

Question 63:

The inheritance of the deformity shown in Figure 1 is most commonly

Options:

autosomal-recessive.
autosomal-dominant.
x-linked dominant.
mitochondrial.
sporadic.

Correct Answer: autosomal-dominant.

Explanation:

Question 64:

- Almost 50% of all long-term complications following total knee arthroplasty are due to

Options:

Early and late infection
Periprosthetic fracture of the femur
Failure of the patellofemoral and extensor mechanisms
Aseptic loosening of cementing tibial components
Asceptic loosening of cemented femoral components

Correct Answer: Failure of the patellofemoral and extensor mechanisms

Explanation:

Question 65:

Figure 50 shows the MRI scan of a 20-year-old female college soccer player with knee pain. What is the most likely diagnosis?

Options:

Normal knee
Posterior cruciate ligament tear
Quadriceps tendon rupture
Proximal tibia fracture
Femoral subchondral contusion

Correct Answer: Posterior cruciate ligament tear

Explanation:

Question 66:

Which structure is shown in Video 27? 27

Options:

Superficial medial collateral ligament
Semimembranosus tendon
Posterior oblique ligament
Medial patellofemoral ligament

Correct Answer: Medial patellofemoral ligament

Explanation:

Question 67:

An ulnar nerve palsy at the level of the wrist is typically associated with deficits in the palmaris brevis, the hypothenar muscles, and what other groups of muscles?

Options:

Volar interossei, adductor pollicis, and the deep head of the flexor pollicis brevis
Dorsal interossei, adductor pollicis, and the deep head of the flexor pollicis brevis
Dorsal interossei, adductor pollicis, and both heads of the flexor pollicis brevis
All of the interossei and the abductor pollicis brevis
All of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis

Correct Answer: All of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis

Explanation:

DISCUSSION: The intrinsic muscles innervated by the ulnar nerve include the palmaris brevis, hypothenar muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. The superficial head of the flexor pollicis brevis is innervated by the
median nerve.
REFERENCES: Goldfarb CA, Stern PJ: Low ulnar nerve palsy. JASSH 2003;3:14-26.
Omer G: Ulnar nerve palsy, in Green DP, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 1526-1541.

Question 68:

Options:

Unlinked elbow arthroplasty
Linked elbow arthroplasty
Interposition arthroplasty
Arthroscopic or open debridement
Radial head excision

Correct Answer: Arthroscopic or open debridement

Explanation:

DISCUSSION: The patient has symptomatic primary osteoarthritis of the elbow with multiple loose bodies. Given his age and occupation, an elbow arthroplasty is not an option. Arthroscopic debridement and removal of loose bodies has been shown to be effective for osteoarthritis of the elbow.
REFERENCES: Gramstad GD, Galatz LM: Management of elbow osteoarthritis. J Bone Joint Surg Am 2006;88:421-430.
Steinmann SP, King GJ, Savoie FH III, et al: Arthroscopic treatment of the arthritic elbow.
J Bone Joint Surg Am 2005;87:2114-2121.

Question 69:

Options:

mechanical alignment radiographs.
stress radiographs of the knee.
comparison radiographs of both knees.
an erythrocyte sedimentation rate and a C-reactive protein.
examination of the hip.

Correct Answer: examination of the hip.

Explanation:

DISCUSSION: While all of the answers may be appropriate, radiating pain from hip pathology must be excluded. At this age, a slipped capital femoral epiphysis is likely. Therefore, the hip must be examined.
REFERENCES: Kocher MS, Bishop JA, Weed B, et al: Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics 2004;113:322-325.
Matava MJ, Patton CM, Luhmann S, et al: Knee pain as the initial symptom of slipped capital femoral epiphysis: An analysis of initial presentation and treatment. J Pediatr Orthop 1999;19:455-460.

Question 70:

04 Which of the following laboratory studies is predictive of wound healing prior to performing a lower extremity amputation?

Options:

Total protein level
Calcium level
Serum albumin level
Platelet count
ESR back answer Question 11.04

Correct Answer: Serum albumin level

Explanation:

Question 71:

Options:

Medialization of the acetabular component
Use of a modular femoral implant
Anterolateral approach to the hip
Femoral shortening
Electromyography

Correct Answer: Femoral shortening

Explanation:

DISCUSSION: In a patient with bilateral hip dysplasia, there are significant technical challenges that need to be addressed to ensure a successful total hip arthroplasty. Restoring the center of the hip may cause significant lengthening and require femoral shortening. Lengthening of greater than 4 cm can lead to sciatic nerve palsy that will present clinically as a foot drop. A high hip center can be used when there is inadequate bone stock in the acetabulum to achieve adequate host bone coverage. A modular femoral implant may be used for a dysplastic hip with significant rotational deformity. Although an anterolateral approach to the hip may decrease the incidence of sciatic nerve palsy during the exposure, it will not be helpful when there is more than 4 cm of limb lengthening.
REFERENCES: Schmalzried TP, Amstutz HC, Dorey FJ: Nerve palsy associated with total hip replacement: Risk factors and prognosis. J Bone Joint Surg Am 1991;73:1074-1080.
Papagelopoulos PJ, Trousdale RT, Lewallen DG: Total hip arthroplasty with femoral osteotomy for proximal femoral deformity. Clin Orthop 1996;332:151-162.
Huo MH, Zatorski LE, Keggi KJ: Oblique femoral osteotomy in cementless total hip arthroplasty: Prospective consecutive series with a 3-year minimum follow-up period.
J Arthroplasty 1995;10:319-327.

Question 72:

Options:

excision of the base of the phalanx of the great toe with dorsiflexion osteotomy of the second metatarsal.
osteotomy of the proximal phalanx of the great toe.
distal first metatarsal osteotomy with soft-tissue realignment of the great toe.
fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint.
joint replacement arthroplasty of the first metatarsophalangeal joint.

Correct Answer: fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint.

Explanation:

Question 73:

Options:

External rotation of the femoral component
Overstuffing of the patellofemoral joint
Less than 12 mm of bony patella remaining after resection
Lateral retinacular release
Use of a cemented patellar component

Correct Answer: Less than 12 mm of bony patella remaining after resection

Explanation:

Question 74:

Options:

Hip arthroscopy versus open debridement with synovectomy
CT of the chest, abdomen and pelvis as part of a staging protocol
Total hip arthroplasty (THA)
Nonoperative treatment with routine follow-up The patient has synovial chondromatosis, a benign metaplastic disorder of cartilagenous synovial nodules, often intra-articular. This condition is usually monoarticular, most commonly affecting the knee, followed by hip, elbow and shoulder. It occurs preferentially in men between the ages of 20 to 40. It may cause pain, mechanical or impingement symptoms and loss of motion, and may cause degenerative changes due to impingement. Synovectomy with excision of the cartilaginous nodules is the treatment of choice, and equally good results may be achieved with arthroscopic debridement and open debridement. Recurrence rates vary, reported from 0% to 22%. THA would not be indicated without the presence of arthritis.

Correct Answer: Hip arthroscopy versus open debridement with synovectomy

Explanation:

Question 75:

Options:

observation.
technetium Tc 99m bone scan.
MRI of the pelvis.
aspiration of the hip joint.
IV antibiotics.

Correct Answer: observation.

Explanation:

Question 76:

Options:

Further imaging studies, including MRI
An awake closed reduction with Gardner-Wells traction with neurologic examination
Immobilization in a halo skeletal fixation for definitive treatment
Closed reduction under general anesthesia
Immediate open reduction and internal fixation in the surgical suite

Correct Answer: An awake closed reduction with Gardner-Wells traction with neurologic examination

Explanation:

DISCUSSION: In the patient who is neurologically intact or has an incomplete injury from a cervical facet dislocation, a closed reduction with weighted tong traction is appropriate when the patient is awake, alert, and cooperative. Although there is a risk that a cervical facet dislocation could occur with an underlying cervical disk herniation, Vaccaro and associates have shown that closed reduction can be safely carried out in the awake, responsive patient. Closed reduction can be performed in the emergency department with traction with skull tongs or a halo ring. A slow stepwise application of weight is added until a reduction is achieved. Any worsening of the neurologic status of the patient requires immediate termination of the closed reduction and further diagnostic imaging before proceeding with further treatment.
REFERENCES: Vaccaro AR, Falatyn SP, Flanders AE, et al: Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine 1999;24:1210-1217.
Hart RA: Cervical facet dislocation: When is magnetic resonance imaging indicated? Spine 2002;27:116-117.
Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.

Question 77:

A complication unique to computer navigation of total knee arthroplasty (TKA) is

Options:

femoral shaft fracture.
intercondylar femur fracture.
ligament disruption.
nerve palsy.

Correct Answer: femoral shaft fracture.

Explanation:

DISCUSSION
Threaded pins are frequently inserted into the femoral shaft and tibial shafts or proximal tibia to attach arrays for tracking devices. There have been case reports of fractures propagating through the pin tracks, which is a complication unique to computer navigation. Intercondylar fractures can occur following posterior stabilized TKA. Vascular injury, ligament disruption, and nerve palsy are rare complications following TKA performed with or without computer navigation.
CLINICAL SITUATION FOR QUESTIONS 111 THROUGH 113
Figure 111 is the anteroposterior radiograph of a 79-year-old woman with a presurgical diagnosis of osteonecrosis who sustained a periprosthetic tibia fracture following her total knee arthroplasty (TKA).

Question 78:

- Figures 27a through 27c show the radiographs of the femur of a 46-year-old man who has a fracture of the right humerus, multiple rib fractures, and fractures of the right femur as a result of a motor vehicle accident. There is a 10-cm clean wound over the anteromedial thigh that communicates with the femoral shaft fracture. The neurovascular examination of the right leg is normal. After meticulous irrigation and debridement, management of the femoral fractures should consist of

Options:

Primary internal fixation at both fracture levels
External fixation as definitive ttt for both #
Skeletal traction and delayed internal fixation of both fractures
Primary internal fixation of the proximal fracture and delayed fixation of the femoral fracture
Primary internal fixation of the femoral shaft fracture and delayed fixation of the proximal #

Correct Answer: Primary internal fixation at both fracture levels

Explanation:

Question 79:

A 21-year-old woman has a nontraumatic rupture of the Achilles tendon. Which of the following commonly prescribed medications has been associated with this condition?

Options:

Ibuprofen
Fluoroquinolones
Bisphosphonates
Metoprolol
Simvistatin

Correct Answer: Fluoroquinolones

Explanation:

Question 80:

A unilateral "piano key" sign, indicates

Options:

distal radioulnar joint (DRUJ) instability.
interosseous membrane disruption.
midcarpal instability.
physiologic motion of hypermobility syndrome.

Correct Answer: distal radioulnar joint (DRUJ) instability.

Explanation:

Question 81:

Options:

observation with repeat radiographs in 6 months.
a thoracolumbosacral orthosis (TLSO).
in situ posterior spinal fusion without instrumentation, followed by full-time TLSO bracing.
anterior spinal convex hemiepiphysiodesis.
combined anterior and posterior spinal arthrodesis with instrumentation.

Correct Answer: combined anterior and posterior spinal arthrodesis with instrumentation.

Explanation:

Question 82:

-Use of the shorter, anterior screw may result in

Options:

deformity of the acetabular labrum when the hip is flexed.
injury to the femoral artery.
chondrolysis.
lack of stabilization of the epiphysis.

Correct Answer: deformity of the acetabular labrum when the hip is flexed.

Question 83:

- Which of the following neurovascular structures is at greatest risk during the introduction of acetabular component fixation screws during total hip replacement?

Options:

Sciatic nerve
Superior gluteal artery
Profunda femoris artery
Femoral artery and nerve
External iliac artery and vein

Correct Answer: External iliac artery and vein

Explanation:

Question 84:

The knee arthroplasty type associated with the highest 5-year revision rate is

Options:

medial unicondylar arthroplasty.
mobile-bearing total knee arthroplasty (TKA).
patellofemoral arthroplasty.
lateral unicondylar knee arthroplasty (UKA).

Correct Answer: patellofemoral arthroplasty.

Explanation:

DISCUSSION
Revision rates for UKA at 10 years are lower than 5% at specialty centers. However, the 10-year revision rate associated with UKA in registries such as the National Joint Registry for England and Wales is 2 to 3 times that of TKA. Among partial knee replacements, patellofemoral arthroplasty is associated with the highest revision rate at every time interval.
CLINICAL SITUATION QUESTIONS 167 THROUGH 169
Figures 167a and 167b are the radiographs of a middle-age man. He is a noncompliant patient who has severe insulin-dependent diabetes and a below-knee amputation on the right side. He is usually in a wheelchair, does not use a prosthesis, transfers using a walker, and resides in an institution. He had an infection in the left leg years ago, which was treated successfully with intravenous antibiotics (the details are unknown). His left knee is mildly painful, swollen but not warm, has limited range of motion (40-140 degrees), and is grossly unstable.

Question 85:

Thyroid hormone regulates skeletal growth at the physis by stimulation of

Options:

proteoglycan and aggrecan synthesis in the zone of proliferation.
fibroblast growth factor (FGF) activity.
transforming growth factor type beta (TGF- b =) and parathyroid hormone-related protein (PTHrP) activity.
chondrocyte proliferation.
chondrocyte hypertrophy, type X collagen synthesis, and alkaline phosphatase activity.

Correct Answer: chondrocyte hypertrophy, type X collagen synthesis, and alkaline phosphatase activity.

Explanation:

DISCUSSION: Children with hypothyroidism have delayed bone age, reduced thickness of the physis, disorganization of the cartilage columns of the physis, and impaired differentiation of proliferating chondrocytes into hypertrophic cells. As a result, these children have severe growth retardation, and slipped capital femoral epiphysis may develop because of mechanical weakening of the physis. Thyroid hormone regulates terminal differentiation of the growth plate chondrocytes, with a resultant increase in type X collagen and alkaline phosphatase. These substances are important factors in matrix mineralization. Insulin-like growth factors and FGF-2 appear to act synergistically to stimulate mitotic activity of the growth plate chondrocytes. TGF-
b
= and PTHrP stimulate proteoglycan synthesis and mitotic activity of the chondrocytes and inhibit type X collagen and alkaline phosphatase activity.
REFERENCES: Ballock RT: Regulation of skeletal growth and maturation by thyroid hormone, in Buckwalter JA, Ehrlich MG, Sandell LJ, Trippel SB (eds): Skeletal Growth and Development: Clinical Issues and Basic Science Advances. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1998, pp 301-317.
Rosier RN, O’Keefe RJ, Reynolds PR, Hicks DG, Puzas JE: Expression and function of TGF-
b
= and PTHrP in the growth plate, in Buckwalter JA, Ehrlich MG, Sandell LJ, Trippel SB (eds): Skeletal Growth and Development: Clinical Issues and Basic Science Advances. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1998, pp 285-299.
Trippel SB: IGF-I and FGF-2 in growth plate regulation, in Buckwalter JA, Ehrlich MG, Sandell LJ, Trippel SB (eds): Skeletal Growth and Development: Clinical Issues and Basic Science Advances. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1998, pp 263-283.

Question 86:

What is the most common malignant bone tumor seen in patients with multiple hereditary exostosis?

Options:

Dedifferentiated chondrosarcoma
Mesenchymal chondrosarcoma
Secondary chondrosarcoma
Clear cell chondrosarcoma
Periosteal osteosarcoma

Correct Answer: Secondary chondrosarcoma

Explanation:

Question 87:

Options:

hematocrit.
serial heart rate.
serial blood pressure with a manual cuff.
serial blood pressure with an arterial line.
lactate and base deficit levels.

Correct Answer: lactate and base deficit levels.

Question 88:

Which of the following can be seen in the heart of a well-conditioned athlete? Review Topic

Options:

Decreased stroke volume
Decreased cardiac output
Decreased resting heart rate
Decreased ventricular wall thickness
Decreased vagal tone

Correct Answer: Decreased resting heart rate

Explanation:

Question 89:

What is the most common long-term complication of the fracture shown in Figure 32?

Options:

Nonunion
Ankle arthritis
Subtalar arthritis
Talonavicular arthritis
Posterior tibial tendinitis

Correct Answer: Subtalar arthritis

Explanation:

Question 90:

Which of the following best characterizes the antigenicity of allograft bone?

Options:

Cell surface glycoproteins are primarily responsible for the antigenicity of the graft.
Fresh grafts have less antigenicity than cryopreserved grafts.
Immunosupression provides little difference in response to allogenic bone.
Hematopoietic elements are the primary cells causing antigenic response.
Lyophilization (freeze-drying) or chemical sterilization does not change the antigenicity of the graft.

Correct Answer: Cell surface glycoproteins are primarily responsible for the antigenicity of the graft.

Explanation:

Question 91:

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 92:

Options:

Type of surgery, age, and BMI
Type of surgery, hypercholesterolemia, and age
Age, BMI, and hypercholesterolemia
BMI, type of surgery, and hypercholesterolemia

Correct Answer: Type of surgery, age, and BMI

Explanation:

Question 93:

Options:

discontinuation of antibiotics and administration of nonsteroidal anti-inflammatory drugs, followed by physical therapy.
incision and drainage of both hips.
in situ pinning of both hips.
broad-spectrum antibiotics in accordance with the recommendations of a pediatric infectious diseases consultant.
continued use of IV antibiotics for 2 weeks, followed by oral antibiotics until the ESR returns to normal.

Correct Answer: discontinuation of antibiotics and administration of nonsteroidal anti-inflammatory drugs, followed by physical therapy.

Explanation:

Question 94:

Options:

brace treatment.
laminectomy, nerve root decompression, and in situ fusion of L4 to the sacrum.
in situ fusion of L4 to the sacrum.
excision of the L5 lamina.
physical therapy.

Correct Answer: in situ fusion of L4 to the sacrum.

Explanation:

Question 95:

Options:

Cruciate-retaining
Posterior stabilized
Varus-valgus constrained
Rotating hinge

Correct Answer: Rotating hinge

Explanation:

Question 96:

Options:

Chevron bunionectomy
Cheilectomy and removal of loose body
MTP arthrodesis
Resection of proximal phalanx

Correct Answer: MTP arthrodesis

Explanation:

Question 97:

The Coleman block test is used to test for Review Topic

Options:

flexibility of the forefoot.
flexibility of the hindfoot.
valgus deformity of the hindfoot.
tightness of tendo Achilles.

Correct Answer: flexibility of the hindfoot.

Explanation:

Question 98:

Options:

chemotherapy, wide resection, and endoprosthetic reconstruction.
radiation therapy only.
chemotherapy only.
prophylactic internal fixation with a locked intramedullary rod.
open curettage, bone grafting, dynamic hip screw fixation, and radiation therapy.

Correct Answer: prophylactic internal fixation with a locked intramedullary rod.

Explanation:

Question 99:

Back pain and ipsilateral knee pain are common long-term sequelae of hip arthrodesis. To limit these problems, what position should be avoided during fusion of the hip?

Options:

Flexion
Abduction
Adduction
External rotation
Internal rotation

Correct Answer: Abduction

Explanation:

Question 100:

Options:

Spastic gait and a positive Hoffman’s sign
Severe arm pain with upper extremity hyporeflexia
Normal neurologic findings
Hyperactive jaw jerk reflex with extremity numbness
Flaccid paraparesis

Correct Answer: Spastic gait and a positive Hoffman’s sign

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

Orthopedic Trauma, Joint & Nerve MCQs: OITE & ABOS Board Review Part 240

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 240

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index