Orthopedic Board Review MCQs: Arthroplasty & Spine

About This Board Review Set

This is Part 36 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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

Topics Covered in Part 36

This module focuses heavily on: Arthroplasty, Elbow, Foot, Ligament.

Sample Questions from This Set

Sample Question 1: Arthrodesis of which of the following joints has the greatest cumulative effect on midfoot/hindfoot motion?...

Sample Question 2: Contraindications to cervical laminectomy as a treatment for cervical spondylotic myelopathy include which of the following findings?...

Sample Question 3: A 77-year-old woman underwent semiconstrained right total elbow arthroplasty 4 weeks ago through a Bryan-Morrey approach. Her recovery was uneventful until 2 days ago when she began her physical therapy session at an outpatient clinic. Duri...

Sample Question 4: Placing the starting point for an antegrade femoral nail too anterior to the axis of the medullary canal can lead to what intraoperative complication?...

Sample Question 5: Which of the following is more likely to occur with use of a bone patellar bone allograft instead of a bone patellar bone autograft for anterior cruciate ligament (ACL) reconstruction in an 18-year-old high school or collegiate athlete? Rev...

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

Arthrodesis of which of the following joints has the greatest cumulative effect on midfoot/hindfoot motion?

Explanation

DISCUSSION: Arthrodesis of the talonavicular joint eliminates almost all hindfoot motion. Arthrodesis of the subtalar joint eliminates 74% of talonavicular motion and 44% of calcaneocuboid motion. Arthrodesis of the calcaneocuboid joint eliminates 33% of talonavicular motion and 8% of subtalar motion. Arthrodesis of the naviculocuneiform or cuboid-fifth metatarsal joint has limited effect on hindfoot motion.
REFERENCES: Astion DJ, Deland JT, Otis JC, et al: Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am 1997;79:241-246.
Savory KM, Wülker N, Stukenborg C, et al: Biomechanics of the hindfoot joints in response to degenerative hindfoot arthrodeses. Clin Biomech 1998;13:62-70.

Question 2

Contraindications to cervical laminectomy as a treatment for cervical spondylotic myelopathy include which of the following findings?

Explanation

DISCUSSION: Cervical laminectomy is an accepted treatment for multilevel cervical spondylotic myelopathy. When the compression is posterior, laminectomy addresses it directly; when the compression is anterior, it is addressed indirectly (the spinal cord floats posteriorly away from the anterior compression). Preexisting kyphosis is a contraindication to laminectomy because the cord is unable to float posteriorly away from the anterior compression, and the risk for increasing kyphosis is significant. Kyphosis after laminectomy is more likely to develop in younger patients who have fewer degenerative changes to stabilize the spine.
REFERENCES: Malone DG, Benzyl EC: Laminotomy and laminectomy for spinal stenosis causing radiculopathy or myelopathy, in Clark CR (ed.): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 817-825.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 673-680.

Question 3

A 77-year-old woman underwent semiconstrained right total elbow arthroplasty 4 weeks ago through a Bryan-Morrey approach. Her recovery was uneventful until 2 days ago when she began her physical therapy session at an outpatient clinic. During resisted extension exercises, she felt a "pop" in her elbow, accompanied with pain and inability to extend her elbow against resistance. What is the most likely cause of her symptoms? Review Topic

Explanation

During a Bryan-Morrey approach for total elbow arthroplasty, the triceps is dissected free from its ulnar insertion and reflected laterally. At the conclusion of the procedure, the triceps tendon is reattached to the ulna through drill holes. Whereas motion can be initiated postoperatively, 6 to 8 weeks of protection are recommended before initiation of resistance exercises to protect the triceps repair. A periprosthetic fracture or component failure is rare in the absence of more significant trauma, and they are usually late complications.

Question 4

Placing the starting point for an antegrade femoral nail too anterior to the axis of the medullary canal can lead to what intraoperative complication?

Explanation

DISCUSSION: Usage of an anterior starting point that is too anterior leads to creation of significant hoop stresses in the proximal segment, potentially leading to iatrogenic fracture of the proximal segment. The referenced study by Johnson et al reviews the topic of femoral bursting and he notes that even shifting 6mm too far anteriorly can lead to proximal femoral fracture creation. He also reported that overreaming the canal by at least 0.5mm diameter is necessary to decrease hoop stresses throughout the femur, likely due to a mismatch in the radius of curvature of the femur and intramedullary nail.

Question 5

Which of the following is more likely to occur with use of a bone patellar bone allograft instead of a bone patellar bone autograft for anterior cruciate ligament (ACL) reconstruction in an 18-year-old high school or collegiate athlete? Review Topic

Explanation

The best reason to use an autograft (rather than an allograft) for anterior cruciate ligament (ACL) reconstruction in a young athlete is lower graft rupture rate.
Many factors can potentially contribute to the failure of ACL reconstructions, including the surgical technique, the selection of graft material, the integrity of the secondary restraints, the condition of the articular and meniscal cartilage, and postoperative rehabilitation. Early failure, usually within the first 6 months, most often is the result of technical errors, incorrect or overly aggressive rehabilitation,
premature return to sports, or failure of graft incorporation. Later failure, usually after one year, is more typically the result of recurrent injury.
Kaeding et al. report data from the MOON multicenter research consortium. They present Level 2 evidence that the odds of graft rupture with an allograft reconstruction are 4 times higher than those of autograft reconstruction in athletes aged 10-19 years old. For each age, the number of autograft ACL reconstructions (ACLRs) performed to prevent one failure is as follows: 14 years, 7 ACLRs; 18 years, 8 ACLRs; 22 years,
11 ACLRs; 30 years, 25 ACLRs; 40 years, 50 ACLRs.
Krych et al. present a systematic review of prospective trials using BTB autograft and BTB allograft tissue for ACL reconstruction with a minimum 2-year follow-up. They found that BTB allograft patients were more likely to rupture their graft than BTB autograft patients (OR, 5.03; P = .01), however once irradiated and chemically processed allografts were excluded there was no statistical difference in graft re-rupture between the groups.
Greenberg et al. conducted a study of nearly 1300 patients and found no increased clinical risk of infection with the use of allograft tissue compared with autologous tissue for primary anterior cruciate ligament reconstruction.
Incorrect Answers:
1: There is no proven increased clinical risk of postoperative superficial or deep bacterial infection with the use of allograft tissue compared with autologous tissue for primary anterior cruciate ligament reconstruction. 2: There is no definitive data suggesting different arthritis progression rates based on autograft versus allograft. 4: Cyclops lesion formation is not related to graft choice. 5: There is some literature that tunnel osteolysis and enlargement is more common and greater with hamstring soft tissue grafts, however it does not appear to affect the clinical outcome in the first 2 postoperative years. There is no definitive data comparing BTB auto vs allograft in regards to tunnel osteolysis.

Question 6

With respect to the structure identified by the arrow in Figure 22b, the meniscofemoral 25 ligaments are

Explanation

DISCUSSION
The stress radiographs demonstrate posterior instability of the right knee in flexion. The MR images demonstrate injury to both the anterior and posterior cruciate ligament (PCL), with the stump identified with the arrow on the MR image (Figure 22b). The PCL has 2 functional bands. The anterolateral bundle originates from the roof of the intercondylar notch. It runs in a posterolateral direction onto the tibial crest between the posterior attachment of the medial and lateral menisci. During a double-bundled posterior ligament reconstruction, the
anterolateral bundle is tensioned with the knee in a position of mid flexion. The posteromedial bundle has a variable pattern of tension both in extension and in high flexion. Tensioning of the posteromedial bundle in extension may contribute to resistance against knee hyperextension.
The meniscofemoral ligaments are variably present. Although 93% of knees have been reported to have at least 1 meniscofemoral ligament present, both ligaments are simultaneously present in approximately 50% of knees. The ligament of Humphrey (anterior meniscofemoral ligament) and ligament of Wrisberg (posterior meniscofemoral ligament) are delineated by their anatomic relationship to the posterior cruciate.
RECOMMENDED READINGS
Amis AA, Bull AM, Gupte CM, Hijazi I, Race A, Robinson JR. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):271-81. Epub 2003 Sep 5. Review. PubMed PMID: 12961064.View Abstract at PubMed
Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):257-63. Epub 2005 Oct 14. Review. PubMed PMID: 16228178.
View Abstract at PubMed . 26

Question 7

A 12-year-old boy has had progressive pain and flatfeet for the past year. Pain is increased with weight-bearing activities. Examination reveals that subtalar motion is absent. On standing, the patient has obvious hindfoot valgus and loss of the normal arch bilaterally. Plain radiographs are shown in Figures 43a through 43c, and a CT scan is shown in Figure 43d. What is the most likely diagnosis?

Explanation

DISCUSSION: The axial views show fusion of the talus and calcaneus at the medial facet (talocalcaneal coalition). Peroneal spastic flatfoot is a descriptive term applying to the symptoms of painful flatfoot associated with apparent peroneal spasm and is sometimes caused by tarsal coalition; however, this is not the most appropriate diagnosis for this patient. Flexible flatfoot with a short Achilles tendon often causes symptoms similar to the ones listed above, but subtalar motion should be normal. A diagnosis of calcaneonavicular coalition can be made based on plain oblique views of the foot but is not seen in these views. Posterior tibial tendon dysfunction in the absence of other pathology is uncommon in children.
REFERENCES: Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 583-595.

Question 8

A 77-year-old woman with osteoporosis who underwent cemented total hip arthroplasty 12 years ago fell down a flight of stairs. A radiograph is shown in Figure 15. What is the best option for treating this fracture?

Explanation

DISCUSSION: Type I fractures are trochanteric fractures usually secondary to osteolysis. Type II fractures are located around the stem. Type III fractures are distal to the stem. If the fracture and prosthesis are stable, the fracture can be treated nonsurgically. If the fracture is unstable, the stability of the prosthesis should be assessed. If the prosthesis is unstable (type IIB), treatment should consist of revision to a long stem prosthesis that bypasses the fracture by two cortical diameters. If, as in this patient, the prosthesis is not loose (type IIA), open reduction and internal fixation is the appropriate option. Proximal femoral allograft is appropriate for type IIIC fractures in which the proximal bone is significantly compromised and the femoral component is loose.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.
Paprosky WG (ed): Revision Total Hip Arthroplasty. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 64-69.

Question 9

..The best initial treatment would entail

Explanation

Question 10

Elbow distraction interposition arthroplasty may be most appropriate treatment for which of the following patient profiles? Review Topic

Explanation

Elbow interposition arthroplasty is reserved for younger, active patients who may otherwise be candidates for prosthetic replacement. Osteoarthritis, posttraumatic arthritis, and rheumatoid arthritis patients may all be candidates for interposition arthroplasty if bone stock is preserved and the elbow maintains inherent stability. Primary osteoarthritis may also be treated with ulnohumeral arthroplasty (ie, Outerbridge) or arthroscopic debridement with release. Patients with destructive juvenile rheumatoid arthritis and distal humerus osteonecrosis would better benefit from prosthetic replacement because of bone loss issues.

Question 11

A 69-year-old man has a painful slow-growing lesion of the distal phalanx of his thumb. History reveals that he has had chronic osteomyelitis of the thumb for the past 12 years. The radiograph and biopsy specimens are seen in Figures 9a through 9c. Treatment should consist of

Explanation

DISCUSSION: The diagnosis is squamous cell carcinoma. The radiograph shows a destructive lesion, and the histologic slides demonstrate squamous cells invading bone. The preferred treatment for squamous cell carcinoma is wide resection; however, in this location a wide margin can be achieved only with amputation. Overall survival in patients with squamous cell carcinoma secondary to chronic osteomyelitis is not significantly worse than that expected for age-matched controls.
REFERENCES: Dell PC: Hand, in Simon MA, Springfield D (eds): Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, pp 405-420.
McGrory JE, Pritchard DJ, Unni KK, Ilstrup D, Rowland CM: Malignant lesion arising in chronic osteomyelitis. Clin Orthop 1998;362:181-189.

Question 12

Figure 16 shows an axial MRI scan through the knee joint. What structure is identified by the arrow?

Explanation

DISCUSSION: The anterior cruciate ligament can be visualized on an axial MRI scan as a low-signal structure lying in the lateral aspect of the intercondylar notch. Visualization in multiple planes increases the accuracy of MRI to view the anterior cruciate ligament. The posterior cruciate ligament and ligament of Wrisberg are located on the medial wall of the notch. The ligamentum mucosum is anterior to the notch, and the popliteus tendon is posterior to the lateral femoral condyle.
REFERENCES: Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 675-699.
Fitzgerald SW, Remer EM, Friedman H, Rogers LF, Hendrix RW, Schafer MF: MR evaluation of the anterior cruciate ligament: Value of supplementing sagittal images with coronal and axial images. Am J Roentgenol 1993;160:1233-1237.

Question 13

A 33-year-old woman reports a mass on the right hand that has been enlarging for 1 year. An intraoperative photograph is shown in Figure 28a, and a biopsy specimen is shown in Figure 28b. What is the most likely diagnosis?

Explanation

DISCUSSION: Giant cell tumor of the tendon sheath is the most common solid soft-tissue mass in the hand. These tumors are slow-growing and may be present for months or years before coming to medical attention. Patients usually report mechanical difficulties because of the size or position of the tumor. The gross appearance is that of a lobulated mass that may be multicolored; typically yellow, brown, red, and gray. Histologically the lesion consists of multinucleated giant cells, polygonal mononuclear cells, and histiocytes that may contain abundant hemosiderin or lipid.
REFERENCES: Walsh EF, Mechrefe A, Akelman E, et al: Giant cell tumor of tendon sheath. Am J Orthop 2005;34;116-121.
Weiss SW, Goldblum JR (eds): Enzinger and Weiss’s Soft Tissue Tumors, ed 4. St Louis, MO, Mosby, 2001, pp 1038-1047.

Question 14

Which component position is associated with poor patellar tracking during total knee arthroplasty (TKA)?

Explanation

RESPONSES FOR QUESTIONS 106 THROUGH 109
Immobilization/nonsurgical management
Irrigation and debridement
stage reimplantation total knee arthroplasty (TKA)
Increased constraint/polyethylene exchange
Revision of the femoral component only
Revision of the tibial component only
Revision of both components
Revision of the patellar component
Select the treatment listed above that most appropriately addresses each scenario described below.

Question 15

A 36-year-old woman dislocated her elbow 6 months ago. The elbow was congruently reduced and rehabilitated. She continues to have a sense of painful clunking in her elbow when she pushes up from a chair with forearm supination, but not pronation. What structure did not heal properly?

Explanation

A 36-year-old right-hand dominant butcher presents with a 6-week history of medial elbow pain. On physical examination, she is tender to palpation over the anteroinferior aspect of the medial epicondyle. Pain is reproduced with combined elbow extension/resisted wrist flexion. Nonsurgical treatment of this pathology results in pain relief within one year in what percentage of individuals?
A. 25% to 35%
B. 45% to 55%
C. 65% to 75%
D. 85% to 95%
The patient has medial epicondylitis. Nonsurgical treatment is the hallmark of treatment and has been shown to relieve pain in approximately 90% of cases within one year. Nonsurgical modalities include bracing, physical therapy, nonsteroidal anti-inflammatory medications, activity modification, and injections.

Question 16

A surgeon is preparing a medial gastrocnemius rotational flap to cover a medial proximal tibia defect at the time of revision knee replacement surgery. To optimize coverage, the surgeon must optimally mobilize which artery?

Explanation

DISCUSSION
The medial sural arteries vascularize the gastrocnemius, plantaris, and soleus muscles proximally. They arise from the popliteal artery. If not adequately mobilized, a gastroc soleus flap can be devascularized.
RESPONSES FOR QUESTIONS 15 THROUGH 17
Semimembranosis release
Medial gastrocnemius release
Medial tibial plateau downsizing osteotomy
Iliotibial band pie crusting
Popliteus tendon release
Cruciate release of the capsule posterior lateral corner
Select the most appropriate release listed above to address each scenario described below.

Question 17

A 58-year-old man with type 1 diabetes mellitus is seen in the emergency department and he reports a 3-day history of a red swollen foot but no history of trauma. Examination reveals that the skin is intact, and the patient has discomfort with passive range of motion at the ankle, hindfoot, and midfoot joints. He denies any fever. Laboratory studies show a WBC count of 7,800/mm 3 , an erythrocyte sedimentation rate of 40 mm/h, a C-reactive protein level of 23, and a serum glucose of 100. A radiograph and MRI scans are shown in Figures 16a through 16c. What is the next most appropriate step in management?

Explanation

DISCUSSION: Whereas it is difficult to distinguish between cellulitis, septic joint, osteomyelitis, and early Eichenholtz stage 1 Charcot, the presence of a fracture in the absence of ulcerations with a normal WBC count and serum glucose strongly indicates that the described symptoms are due to an early Charcot process alone. A technetium Tc 99m scan alone would not be helpful; however, the addition of a sulfur colloid marrow scan or indium In 111 scan may be more specific to rule out infection, though it is not warranted here. Total contact casting with non-weight-bearing or limited weight bearing during Eichenholtz stage 1 when the foot is warm, erythematous, and swollen is advised to help prevent deformity. Alternatively, stabilization with pneumatic bracing may also be considered. While some authors have proposed early fixation or arthrodesis for Eichenholtz stage 1, the gold standard is still total contact casting with no to limited weight bearing until the swelling resolves and evidence of consolidation is seen on radiographs.
REFERENCES: Trepman E, Nihal A, Pinzur MS: Current topics review: Charcot neuropathy of the foot and ankle. Foot Ankle Int 2005;26:46-63.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 123-134.
Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950.

Question 18

Figure 1 is the radiograph of an otherwise healthy 68-year-old man with a 4-year history of increasing global left knee pain. He has noticed stiffness, and despite physical therapy, bracing and nonsteroidal anti-inflammatory drugs, he has continued to develop worsening symptoms and progression in his deformity. Physical examination demonstrates 80°of flexion and a 10° flexion contracture. What is the best next step?

Explanation

Figures 1 and 2 are the radiographs of a 70-year-old man who underwent knee explantation with antibiotic spacer placement. At the time of second- stage surgery for reimplantation of a total knee arthroplasty, a medial parapatellar arthrotomy is used to access the knee. An extensive synovectomy is performed and the gutters are recreated. Medial and lateral joint line releases are done, and scar tissue is removed from around the patella. The cement spacer is removed and the nail is cut and extracted. However, despite this, the knee only flexes 45° and lateral exposure is compromised. What is the best next step?

Question 19

Intradiskal electrothermal therapy (IDET) uses an intradiskal catheter to deliver controlled thermal energy to the inner periphery of the annulus fibrosis of a chronically painful intervertebral disk. Lumbar diskography is used diagnostically to identify the presumed pain generator to be targeted with IDET. Based on the medical literature, what can be said about the current status of IDET?

Explanation

DISCUSSION: Intradiskal electrothermal therapy (IDET) initial clinical results were reported in 2000. The early case series were quite encouraging with reported therapeutic success rates of 60% to 80%. Early enthusiasm was high as IDET provided a nonsurgical treatment option for an otherwise complex and difficult clinical entity, chronic diskogenic low back pain. The actual mechanism of action was not well understood, and while the theoretic explanation made good sense, it did not hold up under laboratory testing. Soon clinical results from the field did not meet the high expectations set by the developers of the technique. Since those early case studies, a few level I evidence studies have been conducted, one by Freeman and associates and one by Pauza and associates. These randomized, placebo-controlled trials demonstrated no significant benefit of IDET over the placebo.
REFERENCES: Freeman BJ, Fraser RD, Cain CM, et al: A randomized, double-blind, controlled trial: Intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine 2005;30:2369-2377.
Pauza KJ, Howell S, Dreyfuss P, et al: A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 2004;4:27-35.
Wetzel FT, McNally TA: Treatment of chronic discogenic low back pain with intradiskal electrothermal therapy. J Am Acad Orthop Surg 2003;11:6-11.

Question 20

A 70-year-old woman has a 3-year history of gradually increasing diffuse and global right knee pain. Her main issues are difficulty with stairs, stiffness with prolonged sitting, and swelling. She has taken NSAIDs and has received intra-articular steroid injections, all with decreasing efficacy. Her right knee examination reveals a range of motion of 15° to 80° with a fixed deformity to varus and valgus stress. Her symptoms are no longer manageable nonsurgically. Radiographs reveal a 30-degree mechanical axis deformity. When using the measured resection technique during total knee arthroplasty (TKA), the best way to avoid femoral malrotation is to reference the

Explanation

DISCUSSION:
In the setting of valgus deformities, TKA poses different challenges than those encountered when varus deformities are present. Most valgus alignment is attributable to a deformity of the distal femur rather than of the proximal tibia, as seen in varus knees. One of the major anatomical differences is a hypoplastic lateral femoral condyle which, when not recognized and used as a rotational reference point, can lead to internal rotation of the femoral component. This malrotation in turn leads to patellofemoral maltracking or instability, which is a common complication associated with primary TKA.

Question 21

A 27-year-old male competitive soccer player reports a 1-year history of pain in the adductor region that has prevented him from playing. Examination reveals tenderness about the adductor attachment to the pelvis, and pain at the same site with resisted contraction of the adductors. There is no tenderness over the hip joint and no signs of a sports hernia. Radiographs are normal. MRI does not show any evidence of enthesopathy. What is the next best step in management?

Explanation

DISCUSSION: Schilders and associates reported their results of treating adductor-related groin pain in competitive athletes. They reported that a single corticosteroid injection into the pubic cleft can be expected to provide at least 1 year of relief of adductor-related groin pain in a competitive athlete with normal findings on MRI. In contrast, when there is evidence of enthesopathy on MRI in this competitive- athlete population, these injections are not therapeutic and are associated with a high likelihood of recurrence of symptoms. Hip arthroscopy is generally reserved for intra-articular problems. Percutaneous adductor tenotomy is not indicated for this condition. A bone scan is unlikely to provide any useful information for clinical decision-making. Rheumatology consultation is also not indicated in the absence of any evidence of inflammatory arthropathy.
REFERENCES: Schilders E, Bismil Q, Robinson P, et al: Adductor-related groin pain in competitive athletes: Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007;89:2173-2178.
Robinson P, Barron DA, Parsons W, et al: Adductor-related groin pain in athletes: Correlation of MR imaging with clinical findings. Skelet Radiol 2004;33:451-457.

Question 22

Figures below 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?

Explanation

DISCUSSION:
This 86-year-old woman has poor bone quality and osteoarthritis of the left hip. Her lateral radiograph confirms Dorr type C bone quality. A hybrid left THA with a cemented femoral stem would be the treatment of choice.

Question 23

Figure below depicts the radiograph obtained from a 52-year-old woman who has leg-length inequality and chronic, activity-related buttock discomfort. This problem has been lifelong, but it is getting worse and increasingly causing back pain. What is the best current technique for total hip arthroplasty?

Explanation

DISCUSSION:
A high hip center is not recommended for Crowe type IV hips because of the lack of acetabular bone and altered hip biomechanics. An anatomic center is a better option but necessitates a technique to address the tight soft-tissue envelope. A trochanteric osteotomy with progressive femoral shortening has been described but can be prone to trochanter nonunion. Iliofemoral lengthening prior to surgery has been described but may not be tolerated by all patients. A shortening subtrochanteric osteotomy avoids trochanter nonunion and allows adjustment of femoral anteversion. Fixation of the osteotomy can include a stem with distal rotational control, plate fixation, a step versus oblique cut, or strut grafts.

Question 24

A patient with rheumatoid arthritis with both ankle and subtalar involvement was treated as shown in Figures 11a and 11b. What complication is unique to this type of fixation?

Explanation

DISCUSSION: The interlocking screws at the proximal end of the rod can act as a stress riser and lead to fracture. Postoperative pain at this level should prompt inclusion of this diagnosis in the differential. Removing the screws following bone union can decrease the chances of this occurring. A short rod that avoids the diaphyseal area may also be beneficial. Rotatory deformity is controlled by the perpendicularly oriented distal transfixion screws. Talar osteonecrosis would be unusual since the dissection can be minimized with an intramedullary rod. Any type of hardware can fail if the construct does not lead to a solid arthrodesis.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 236-237.
Thordarson DB, Chang D: Stress fractures and tibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail. Foot Ankle Int 1999;20:497-500.
Hammett R, Hepple S, Forster B, et al: Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail: The results of 52 procedures. Foot Ankle Int 2005;26:810-815.

Question 25

03 Which of the following findings is the best indication for the use of temporary external fixation of a femoral shaft fracture?

Explanation

Tulane defines “Orthopaedic Tunnel Vision” as a condition commonly associated with a young MD at the Bulldog without a proper wing-man, trying to make advances on the wrong patron due to his relatively easy 80-hour work week schedule and a few too many refined hops.

Skeletal Trauma (p. 1967) describes “Orthopaedic Tunnel Vision” as looking at the orthopaedic injury without considering the patient’s injury in general. Femoral shaft fractures are typically high energy injuries which often do not occur in isolation. In these fractures, it is particularly important to not have tunnel vision.

Indications for temporary bridging external fixation includes hemodynamic instability
(ans. 2), acidosis, hypothermjia, hypoxemia, coagulopathy, sepsis or severely contaminated soft tissues that cannot be adequately debrided. Definitive fixation is performed after the general surgical and medical issues have resolved.

The other answer choices, including the type IIIA open fracture are not contraindications to definitive fixation in themselves (typically IM nailing—antegrade or retrograde).

Question 26

While performing long fusion with osteotomies for a patient with adult scoliosis and sagittal plane deformity, the neurophysiologist reports a change in motor-evoked potentials in the lower extremities. What is the most appropriate next step?

Explanation

DISCUSSION
The use of intraoperative neuromonitoring is expanding, especially in the setting of deformity surgery. Changes in monitoring are concerning for the possibility of a neurologic injury; however, several other factors can alter signals. These include hypotension, changes in anesthesia depth and medications, the use of paralytic agents, and technical issues such as leads falling out or becoming disconnected. If a change in neuromonitoring signals is noted, these factors should be checked first to rule out false-positive findings. If this does not correct the problem, the wound should be explored to ensure there is no compression on the neural elements. Finally, if the deformity has been corrected, some of the correction can be released in an attempt to improve the signals. A wake-up test is difficult to perform and does not provide specific information regarding the location of the problem or how to correct it. Steroids may be used depending on surgeon preference, but should not be used until neurologic injury is ruled out. Any neuromonitoring changes always necessitate immediate investigation.
RECOMMENDED READINGS
Ziewacz JE, Berven SH, Mummaneni VP, Tu TH, Akinbo OC, Lyon R, Mummaneni PV. The design, development, and implementation of a checklist for intraoperative neuromonitoring changes. Neurosurg Focus. 2012 Nov;33(5):E11. doi: 10.3171/2012.9.FOCUS12263. PubMed PMID: 23116091. View Abstract at PubMed
Malhotra NR, Shaffrey CI. Intraoperative electrophysiological monitoring in spine surgery. Spine (Phila Pa 1976). 2010 Dec 1;35(25):2167-79. doi: 10.1097/BRS.0b013e3181f6f0d0.
Review. PubMed PMID: 21102290. View Abstract at PubMed

Question 27

A 21-year-old professional baseball player has had painful catching and stiffness in his dominant right elbow for the past year. Examination reveals a flexion contracture of 2 degrees and mild pain with full elbow flexion. Radiographs are shown in Figures 33a and 33b. The most effective management should consist of

Explanation

DISCUSSION: The radiographs show osteochondritis dissecans of the capitellum and a loose body in the anterior compartment. Arthroscopic removal is indicated because symptoms referable to the loose body are present.
REFERENCES: Baumgarten TE: Osteochondritis dissecans of the capitellum. Sports Med Arthroscopy Rev 1995;3:219-223.
Shaughnessy WJ, Bianco AJ: Osteochondritis dissecans, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 282-287.

Question 28

A 7-year-old boy presents to the ED with visible right elbow deformity after a fall on the playground. His injury films are shown in figures A and B. The injury is closed, and there is a palpable radial pulse with a well-perfused hand. He undergoes multiple attempts at closed reduction and percutaneous pinning with 3 lateral pins in the operating room. Final radiographs show some gapping at the fracture site. At the end of the case, the radial pulse is no longer palpable and the hand appears pale. What is the next best step in management? Review Topic

Explanation

The patient has a type III supracondylar humerus fracture that lost a palpable radial pulse after closed reduction. Due to continued gapping at the fracture site, the next best step is to remove the pins, displace the fracture, and reassess perfusion as the brachial artery was likely interposed in the fracture site during the reduction maneuver.
The management of supracondylar humerus fractures is dictated significantly by the neurovascular examination. Loss of pulse and a pale, cool hand warrants emergent closed reduction and percutaneous pinning. If the vascular status does not change, open exploration is warranted. When a hand becomes pulseless and cool after reduction, it is typically due to the brachial artery being interposed in the fracture site. Undoing the reduction can often help. If there is still evidence of vascular compromise, open exploration is warranted. A pale (poorly perfused) hand or any change in neurovascular status requires urgent intervention. A pink, pulseless but well perfused hand can be observed.
Carter et al. surveyed over 300 pediatric orthopaedic surgeons on the management of type III supracondylar humerus fractures. They found an increasing trend toward lateral pin configuration and non-emergent delayed treatment.
Abzug et al. reviewed current concepts regarding management of supracondylar humerus fractures. They report an increased trend in surgical management of type II supracondylar humerus fractures. For the pink pulseless hand, they recommend admission for observation and splinting in 45 degrees of flexion.
Babal et al. reviewed nerve injuries in pediatric supracondylar humerus fractures. Anterior interosseous nerve palsy ranks highest, with ulnar nerve palsy highest with flexion type injuries. Medial pinning leads to risk of iatrogenic ulnar nerve injury.
Figures A and B are AP and lateral elbow radiographs showing a Gartland type III supracondylar humerus fracture.
Incorrect Answers:

Question 29

A 47-year-old woman has a right bunion that has been symptomatic despite modifications in shoe wear. She requests surgical correction. An AP radiograph is shown in Figure 37. Treatment should consist of

Explanation

DISCUSSION: Because the radiograph reveals an intermetatarsal angle of greater than 15 degrees and an incongruent metatarsophalangeal joint, the treatment of choice is a proximal first metatarsal osteotomy with distal soft-tissue realignment. A distal chevron procedure would not correct this degree of deformity. A Keller procedure is reserved for a less active elderly individual. Arthrodesis is appropriate for a patient with advanced arthritis of the metatarsophalangeal joint. The double osteotomy is reserved for the congruent metatarsophalangeal joint with hallux valgus.
REFERENCES: Coughlin MJ, Carlson RE: Treatment of hallux valgus with an increased distal metatarsal articular angle: Evaluation of double and triple first ray osteotomies. Foot Ankle Int 1999;20:762-770.
Coughlin MJ: Hallux valgus. Instr Course Lect 1997;46:357-391.

Question 30

Figure 61 is the radiograph of a 42-year-old man who falls from a roof and sustains a right calcaneus fracture. His hindfoot is moderately swollen without skin wrinkling and the skin is intact and viable. Neurologic examination findings are normal and the dorsalis pedis pulse is strong and palpable. What is the best treatment plan at this time?

Explanation

DISCUSSION
This patient has a displaced tuberosity of the calcaneus. A high rate of posterior skin breakdown is associated with these fracture types. The skin should be checked within 10 to 14 days when these fractures occur. The skin is swollen and not acutely at risk, so an immediate ORIF via an extensile lateral approach is not warranted. Immobilizing the ankle in a plantar-flexed position can take some tension off the posterior skin with this fracture type but should
not be definitive treatment. Splinting with repeat examination in 1 to 2 days is the preferred response because of the short follow-up for a repeat skin check. If the skin is at risk when a fracture of this type occurs, the ankle can be immobilized in plantar flexion to relieve tension on the skin. Immediate repair with either open or percutaneous techniques may be necessary if the skin remains at risk.
RECOMMENDED READINGS
Gardner MJ, Nork SE, Barei DP, Kramer PA, Sangeorzan BJ, Benirschke SK. Secondary soft tissue compromise in tongue-type calcaneus fractures. J Orthop Trauma. 2008 Aug;22(7):439-45. PubMed PMID: 18670282.View Abstract at PubMed
Schwartz AK, Brage ME, Laughlin RT, Stephen D. Foot injuries. In: Baumgartner MR, Tornetta P III, eds. Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:453-468.

Question 31

In a patient with a C5-6 herniation, the most likely sensory deficit will be in the

Explanation

DISCUSSION: A C5-6 herniation compresses the C6 root, which innervates the radial forearm, thumb, and index finger. The lateral shoulder is innervated by C5. The dorsal forearm and the middle finger typically are innervated by C7. The ulnar forearm, ring finger, and little finger are innervated by C8. There is no specific nerve associated with the volar forearm and palm.
REFERENCE: Hoppenfeld S: Evaluation of nerve root lesions involving the upper extremity, in Orthopaedic Neurology. Philadelphia, PA, JB Lippincott, 1977, pp 7-23.

Question 32

Which of the following statements best describes the location of the nerve that is at risk in a direct posterior approach to the Achilles tendon?

Explanation

DISCUSSION: The sural nerve lies lateral to the Achilles tendon at the level of the foot but follows an oblique course proximally to lie directly over the tendon as it heads to the popliteal fossa. It is at risk with any proximal dissection from a direct posterior approach and in particular with procedures done at the musculotendinous junction. The nerve crosses over the lateral border of the Achilles tendon at an average of 9.8 cm above its insertion.
REFERENCES: Webb J, Moorjani N, Radford M: Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int 2000;21:475-477.
Fletcher MD, Warren PJ: Sural nerve injury associated with neglected tendo Achilles ruptures. Br J Sports Med 2001;35:131-132.

Question 33

5cm from the carpometacarpal joint. The attached deep transverse intermetacarpal ligaments are sacrificed. To prevent scissoring of the remaining digits and small objects falling through the gap between index and ring fingers, which of the following procedures should be performed?

Explanation

A 65-year-old man fell and injured his right wrist. Radiographs taken in the emergency room are seen in Figure A. He was treated as a sprain and no further follow-up was planned. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of

Anterior and posterior interosseous neurectomy
Scaphotrapezialtrapezoidal (STT) fusion
Complete wrist arthrodesis
Proximal row carpectomy
Four-corner fusion with scaphoidectomy
Four-corner fusion with scaphoidectomy is indicated for Stage III SLAC wrist.
Surgical treatment of SLAC wrist is stage dependent. Stage I disease (scaphoid-radial styloid arthritis) is treated with AIN/PIN neurectomy. This procedure can also be done in addition to other bony procedures for Stages II-III disease. Stage II (scaphoid-entire scaphoid facet) is treated with PRC or scaphoid excision with 4-corner fusion (4CF). Stage III (capitolunate arthritis with proximal migration of the capitate into the scapholunate interval) is treated with either scaphoidectomy with 4CF or total wrist fusion.
Some other conditions exist: If capitolunate arthritis exists, PRC is contraindicated and 4CF is performed. If radiolunate arthritis exists, both PRC and 4CF are contraindicated and total wrist fusion is performed. If both radiolunate and capitolunate surfaces are preserved, then either PRC or a 4CF may be performed.
Cohen et al. compare PRC with 4-corner fusion plus scaphoid excision. PRC is technically easier, but leads to shortening of the carpus with weakness and incongruity exists between the capitate and lunate fossa of the distal radius. Scaphoid excision and four-corner fusion maintains carpal height and preserves the radiolunate relationship, but is more technically demanding, there is risk of nonunion, and it requires longer postop immobilization. Pain relief is more reliable following 4-corner fusion.
Figure A shows scapholunate ligament disruption. Figure B shows late stage SLAC wrist. There is capitolunate arthritis but no radiolunate arthritis.
Illustration A shows an example of PRC. Illustration B shows an example of 4CF and scaphoidectomy.
Incorrect Answers

Which of the following statements is true regarding zone II flexor tendon injuries?
At this level, FDS and FDP are located within separate tendon sheaths
FDS repair has not been shown to improve outcomes
Improved gliding is seen with repair of 1 slip of FDS compared to repairing both slips
Repairing FDS does not affect post-operative digit strength
FDP repair has not been shown to improve outcomes
In zone II flexor tendon injuries, repairing only one slip of FDS has been shown to improve gliding when compared to repair of both slips.
Zone II flexor tendon injuries have notoriously had poor outcomes secondary to high rates of adhesion formation at the pulleys. However, new advances in post-operative rehabilitation have significantly improved outcomes to the point where it is no longer considered "no man's land." Management of the FDS has been a source of controversy. In the past, the FDS was occasionally excised to theoretically make more room for the FDP. This has now been largely abandoned and the FDS is repaired whenever possible. Whether or not to repair both slips of FDS remains controversial, with in vitro data suggesting that gliding resistance is improved if only one slip is repaired.
Zhao et al. review the effect of partial vs. complete FDS excision following repair of FDP for zone II flexor tendon injuries. Preserving the whole FDS resulted in a significantly larger increase in gliding resistance after FDP repair than did full or partial FDS removal, which were not significantly different from each other.
Illustration A shows the zones of flexor tendon injury. Note that zone II injuries occur between the FDS insertion and the distal palmar crease. Illustration B shows the anatomy of the flexor tendons in detail. Video V shows a technique for repair of zone II injuries.
Incorrect Answers:

A 6-year-old girl sustains transverse amputations through her long and ring fingertips after getting her hand caught in a lawn mower. She presents to the emergency room 30 minutes after the injury with the amputated tissue which was placed on ice in a waterproof bag. On physical exam the amputation levels are found to be 6 millimeters distal to the lunula. The wounds are noted to be fairly
contaminated with no evidence of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the most appropriate management at this time?
Emergent replantation of the amputated parts
Revision amputation through the distal interphalangeal joint
Thorough irrigation and debridement followed by elective Moberg advancement flaps
Thorough irrigation and debridement followed by elective Z-plasty reconstruction
Thorough irrigation and debridement, soft dressing application, and followup within 1 week
Distal fingertip amputations can be successfully managed with local wound care and healing by secondary intention if no bone is exposed and the soft tissue defects are minimal. This is especially true in the pediatric population.
Distal fingertip amputations are common injuries seen in the emergency department. If bone is not exposed, the wounds can be successfully treated with local wound care and dressing changes, followed by soaks in a hydrogen-peroxide solution after 7-10 days. Some controversy exists in the pediatric population if the soft tissue loss is > 1 cm, with options for management including a V-Y advancement flap or conservative management with dressing changes.
Quell et al. review the results of 82 patients with fingertip amputations treated conservatively; 31 of the digits were treated with primary closure with or without shortening of bone and 54 digits were treated with semiocclusive dressings. No complications were observed, and all healed fingertips were well padded and painless.
Tupper et al. review sixteen patients with twenty fingertip injuries who underwent V-Y plasty for transverse fingertip amputations. Sensitivity was 73% of normal, with eight patients reporting hypersensitivity. Contrary to popular belief, they believe normal sensation following a V-Y plasty is not a reasonable expectation.
Illustration A shows the three levels of fingertip amputations. Zone I is distal to the phalanx; Zone II is distal to the lunula; and Zone III is proximal to the lunula.
Incorrect Answers:

Which of following malformations is most commonly associated with Poland's syndrome?

Figure E CORRECT ANSWER: 4
Figure D demonstrates symbrachydactyly which is most commonly associated with Poland's syndrome.
Poland's syndrome is a rare birth defect characterized by underdevelopment or absence of the chest muscle in conjunction with ipsilateral symbrachydactyly. Poland syndrome most often affects the right side of the body, and occurs more often in males than in females.
Ireland et al. reviewed 43 consecutive cases of Poland's syndrome, and reviewed the relevant literature up to that point. The authors state that the clinical features are variable but always include congenital aplasia and syndactyly, and the right side is affected more than the left. They also note that although the hand remains hypoplastic and functional capacity is limited by the inherent skeletal anomalies, surgical treatment improves functional capacity and cosmetic appearance in the majority of patients.
Van Heest summarizes normal formation and growth of the upper limb as a basis for understanding malformation, with the goal of providing a basic understanding of the evaluation necessary for appropriate counseling and referrals for treatment of the child with hand and upper extremity congenital deformities.
Incorrect Answers:
A 55-year-old male laborer comes in with a chief complaint of clumsiness with his right hand for the past 3 months including difficulty using a hammer while at work. He has had no injury to the right upper extremity. On physical examination, he has persistent small finger abduction/extension with finger extension and active adduction. An EMG is performed and demonstrates ulnar nerve conduction velocities of 31 m/sec (normal >52m/sec). The patient symptoms are most accurately described as:
Axonotmesis with ischemia origin
Axonotmesis with myelin disruption
Neurapraxia with ischemia origin
Neurapraxia with endoneurium disruption
Neurotmesis CORRECT ANSWER: 3
The history and clinical presentation are consistent with ulnar entrapment neuropathy at the level of the cubital tunnel. This would be classified as a neuropraxia with ischemia origin.
Compression injuries to the peripheral nerves are often the result of microvascular dysfunction as the nerves traverse a high to low pressure gradient. Peripheral nerve injury can be classified as neuropraxia, axonotmesis, and neurotmesis. Compressive neuropathies are typically neuropraxias, with local myelin damage but not compromise of the major components of the nerve. In axonotmesis, there is Wallerian degeneration and myelin loss distal to the site of injury. The most severe type is that of neurotmesis. Neurotmesis is composed of a spectrum of injury in which the endoneurium is always disrupted (perineurium or epineurium may be intact). The worst form of neurotmesis is that of nerve transection.
Elhassan et al. review the pathophysiology of cubital tunnel syndrome. They report nerve dysfunction results from ischemic changes secondary to compression. Compressive effects on the nerves can last greater than 24 hours, even after the source of compression has been removed.
Rempel et al. review the pathophysiology of peripheral nerve compression syndromes. The authors indicate that deforming pressures to nerves are often the result of stenotic soft tissue canal boundaries. This leads to interference with local microvasculature of the nerve itself.
Illustration A demonstrates the Wartenberg sign, where the patient has persistent small finger abduction/extension resulting from weakness of the 3rd palmar interosseous/small finger lumbrical.
Illustration B reveals clawing which results from overpowering of the intrinsic muscles by the extrinsic muscles; a tenodesis effect results in flexion of the PIP/DIP joints. This is more severe in ulnar nerve compression at Guyon’s canal. Illustration C shows the Froment sign, where the FPL attempts to compensate for a deficient pinch, because of weakness of the adductor pollicis. Illustration D demonstrates atrophy of the 1st dorsal webspace from chronic compressive changes. Illustration E demonstrates atrophy of the thenar compartment which is consistent with carpal tunnel syndrome.
Incorrect Answers:

Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap?

Figure E CORRECT ANSWER: 3
Figure C shows a dorsal thumb laceration with exposed tendon that would be most appropriately treated with a first dorsal metacarpal artery (FDMA) flap.
The first dorsal metacarpal artery is a branch of the radial artery that supplies the dorsal hand skin from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the thumb and index to the proximal interphalangeal joint. The flap is raised distal to proximal as an island flap containing the FDMA, branches of the radial nerve, fascia of the underlying interosseous muscle of the first web space, and skin overlying the MP joint and proximal phalanx of the finger. It is an excellent option for large soft tissue defects on either side of the thumb. In this case, skin grafting is contraindicated because of exposed tendon without paratenon.
Sherif et al. detail the anatomy of the first dorsal metacarpal artery. They found three consistent branches, including the radial, ulnar, and intermediate branch. In part II of their study, they review the results of 23 patients where the FDMA flap was used as a fasciocutaneous or fascial flap for the coverage of soft tissue hand defects.
Illustration A shows a FDMA flap being raised for coverage of a thumb defect. Incorrect Answers:
bone can be allowed to heal through secondary intention.

Figure A is a radiograph of a 35-year-old women who sustained an isolated left wrist injury after a fall onto an outstretched hand. She has been complaining of left dorsal wrist pain since the fall. Examination reveals a positive Watson's scaphoid shift test. What ligamentous structure is an important secondary stabilizer to prevent dorsal intercalated segment instability (DISI) deformity in this patient?

Transverse carpal ligament
Dorsal intercarpal ligaments
Triangular fibrocartilage complex
Dorsal lunotriquetral ligament
Volar lunotriquetral ligament
The integrity of the dorsal intercarpal ligaments is important in preventing dorsal intercalated segment instability (DISI) deformity and persistent scapholunate instability.
Scapholunate instability is the most common carpal instability. The primary stabilizing structure of the scaphoid and lunate bones is the scapholunate ligament, which is commonly injured with a fall on an outstretched hand.
Secondary stabilizers of the scaphoid and lunate include the dorsal intercarpal ligaments and the dorsal radiocarpal ligaments. Failure to recognize injury of these structures can cause persistent dorsal intercalated segment instability (DISI). This can predispose patients to a SLAC wrist and early wrist osteoarthritis.
Mitsuyasu et al. examined the role of dorsal intercarpal ligaments (DIC) in scapholunate instability. They showed that the DIC had an important role in stabilizing the scaphoid and lunate bones with static and dynamic movements. The authors of this study suggest that the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction with surgical management of scapholunate ligament tears.
Viegas et al. showed that the dorsal intercarpal and the dorsal radiocarpal ligaments form a lateral V configuration over the dorsal wrist. This configuration acts as an indirect dorsal stabilizing effect on the scaphoid
throughout the range of motion of the wrist. Their integrity acts to ensure normal wrist kinematics.
Figure A shows an AP and lateral radiograph of the left hand. There is significant gapping between the scaphoid and lunate articulation. This is indicative of a complete scapholunate dissociation, however both wrists should be imaged as this deformity may exist without injury. Illustration A shows the anatomy of the dorsal intercarpal and the dorsal radiocarpal ligaments.
Incorrect Answers:

A 50-year-old patient presents with stiffness in her hand. A clinical photo is shown in Figure A. During surgical exposure, the neurovascular bundle is identified and dissected. What is the clinically most important pathologic structure to identify and what is its location relative to the neurovascular bundle in the digit?

Spiral cord which is central and superficial to the neurovascular bundle
Central cord which is midline and superficial to the neurovascular bundle
Retrovascular cord which is central and superficial to the neurovascular bundle
Spiral cord which is lateral and deep to the neurovascular bundle
Central cord which is lateral and deep to the neurovascular bundle
Based on clinical findings, the patient has evidence of Dupuytren’s contracture affecting her ring finger. Relative to the neurovascular bundle, the spiral cord will lie lateral and deep.
Dupuytren’s disease is a benign hand condition characterized by pathologic nodules and cords of existing fascial bands. The most clinically relevant structure in Dupuytren's disease, is the spiral cord. The spiral cord is the result of pathology of 4 structures: the middle layer of the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. The spiral cord is found predominantly at the palmodigital transition. The spiral cord displaces the neurovascular bundle centrally and superficially.
Benson et al. review the etiology, pathophysiology and treatment options for Dupuytren’s contracture. They highlight that while the pretendinous band is located volar and central to the neurovascular bundle in the palm, the spiral band and lateral digital sheath cause the neurovascular bundle to be displaced superficially and volarly as they become pathologically affected.
Black et al. review the pathoanatomy, diagnosis and management of Dupuytren's disease. They note that the spiral cord lies superficial to the neurovascular bundle proximal to the MCP joint. Distal to the MCP joint it passes deep to the bundle. At that location, the spiral cord lies lateral to the
neurovascular bundle as the lateral digital sheet becomes involved
Figure A demonstrates the cord formation that is characteristic of the pathologic Dupuytren’s condition. It is the central cord that causes contracture of the MCP, whereas the retrovascular and spiral cords cause contractures of the DIP and PIP respectively. Illustration A shows the relationship of spiral cord formation in Dupuytren's disease relative to the normal anatomy of the palmar fascia. The structures implicated in the formation of the spiral cord are the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament, more dorsally located, is spared in Dupuytren's disease. The neurovascular bundle is displaced superficially and towards the midline, as the pathological cord spirals around. Illustration B shows the presence of other affected structures, including the natatory ligament and the central band. The central band is an extension of the pretendinous cord and attaches to the base of the middle phalanx. It may insert onto the tendon sheath of the flexor tendon at this level. Formation of natatory cords cause webspace contractures. Formation of central cords lead to flexion contractures of the PIP. Illustration V is a video that provides an educational overview of Dupuytren's.
Incorrect Answers:

An infant is brought to your office for evaluation of his hands. Clinical photos are shown in Figures A and B. The clinical features are most consistent with a genetic mutation in which of the following:

Sonic Hedgehog (SHH)
FGFR2
FGFR3
PMP22
COL1A1 CORRECT ANSWER: 2
Based on the clinical features seen in the figures provided, the most likely syndrome is that of Apert syndrome, which is consistent with a mutation in FGFR2.
Apert syndrome is an autosomal dominant condition that gives rise to facial dysmorphism and complex syndactyly of the hands. The craniosynostosis that develops causes flattening of the skull and facial features.
Goldberg et al review congenital hand conditions and the malformations associated with them. They indicate that not only does identification allow for natural history to be better elucidated, but also timing of surgical intervention can be better gauged.
Figures A and B demonstrate clinical features consistent with Apert Syndrome. The “rosebud” hand is a complex syndactyly that affects the index, middle and ring fingers most commonly. Hypertelorism is exemplified with increased distance between the eyes; additionally, acrocephaly is noted with forehead broadening and skull flattening.
Incorrect Answers
1: Mutation in sonic hedgehog gene (SHH) is associated with a longitudinal deficiency of the radius. This is seen in conditions like TAR, Holt-Oram and VACTERL syndromes.
3: Mutation in FGFR3 leads to achondroplasia
4: Mutation in PMP22 gives rise to Charcot Marie Tooth syndrome 5: Mutation in COL1A leads to osteogenesis imperfecta
A 45-year-old patient presents with recurrence of radial sided wrist pain after undergoing a first dorsal compartment release about 3 months ago. The surgery was completed by one of your partners; operative reports indicate that the sheath was incised on the dorsal edge. On physical exam she is found to have normal appearing skin, a negative Tinel’s sign, and a positive Finklestein test. What is the most likely cause of the recurrence of her symptoms?
Development of neuroma
Complex regional pain syndrome
Failure to decompress the EPB sub-sheath
Failure to decompress the EPL sub-sheath
Failure to decompress the APB sub-sheath
Based on the history and clinical findings this patient has de Quervain’s tenosynovitis. The recurrence of her symptoms can be attributed to a failure to recognize and decompress the EPB sub-sheath.
De Quervain’s tenosynovitis is a stenosing inflammatory condition of the first dorsal compartment of the wrist (APL/EPB). Surgical release of the compartment is indicated after conservative measures have failed. At the time of the operation, the incision is made on the dorsal side of the sheath to prevent volar subluxation of the tendons. Failure to identify and release a distinct EPB sub-sheath or a separate fibro-osseous compartment of the APL can lead to a recurrence of symptoms.
Alegado et al. report a case of a patient with dysesthesias in the superficial radial nerve distribution 3 months after undergoing first dorsal compartment release for de Quervain’s tenosynovitis. They found a persistent fibrous remnant of the dorsal aspect of the sheath causing elevation of the superficial radial nerve. They recommend sheath excision or incision of the sheath at its dorsal attachment to avoid this complication.
Ashurst et al. report a case of a patient presenting with bilateral de Quervain’s tenosynovitis secondary to excessive text messaging. Conservative measures
afforded the patient complete symptomatic recovery. They recommend limitation of texting, in conjunction with other standard treatments, to treat text messaging- associated de Quervain’s tenosynovitis
Ilyas et al. review the etiology, diagnosis and management of De Quervain’s tenosynovitis. Non-surgical management is largely successful and includes splinting and cortisone injections. In refractory cases, surgical release of the first dorsal compartment is completed. They recommend meticulous care of the radial sensory nerve and identification of all separate sub-sheaths.
Illustration A shows an operative photo in a patient with multiple APL slips and an EPB that is hidden within a sub-sheath. Video V gives a brief overview of de Quervain’s tenosynovitis.
Incorrect Answers

A 28-year-old NFL running back complains of continued hand pain three days following an injury sustained while being tackled. He was splinted on the field. He has tenderness over the long finger metacarpal head, with subluxation of the extensor tendon into the intermetacarpal area during active metacarpophalangeal joint flexion. A representative MRI is shown in Figure A. What is the next best step in management of this patient?

Observation alone
Continued splinting in flexion
Continued splinting in extension
Open repair of the disrupted junctura tendinae
Open repair of the disrupted sagittal band
Based on the history and physical exam findings this patient has sustained a traumatic rupture of the sagittal band. In this professional athlete, the next best step would be to perform an open repair of the sagittal band. This will allow for earlier aggressive rehabilitation and a quicker return to sport.
Sagittal band ruptures may be traumatic (as in this case) or attritional in nature (as in rheumatoid arthritis). A direct blow to the MCP leads to forced flexion of the digit and subsequent stretching/rupture of the affected structure. On physical exam the tendons are most unstable with the wrist flexed; MCP flexion will lead to dislocation of the tendon into the intermetacarpal gutter.
Acute injuries may be treated with extension bracing for 4-6 weeks, but in professional athletes, direct open repair of the sagittal band is indicated.
Catalano et al. review sagittal band injuries treated with a thermally molded
plastic splint that held the MCP in ~25-35 degrees of hyperextension. Patients were evaluated over 14 months; out of 11 sagittal band injuries, splinting was successful in eight of them. They recommend initial nonsurgical management with custom splinting.
Hame et al. review the results of the management of sagittal band injuries in the professional athlete. The lesion commonly found was the disruption of the extensor mechanism with predictable sagittal band tears. In their series, all patients regained full range of motion and returned to their respective sports. They recommend surgical intervention in elite athletes in the form of extensor tendon centralization and sagittal band repair.
Figure A shows a T1 weighted axial cut of the affected hand; subluxation of the tendon (arrow) can be identified with disruption of the sagittal band (arrowhead).
The video provided briefly reviews injury to the sagittal band. Incorrect Answers
Compressive injury to the posterior interosseous nerve will lead to EMG fibrillations in which of the following muscles?
Extensor Carpi Radialis Longus/Extensor Carpi Radialis Brevis/Brachoradialis
Extensor Carpi Radialis Longus/Supinator/Abductor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Longus
Brachoradialis/Supinator/Extensor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Brevis
Based on the choices above, fibrillations will be seen in the extensor pollicis longus, supinator and abductor pollicis longus muscles.
The radial nerve splits into the superficial radial branch and the posterior interosseous nerve (PIN) at the anterior aspect of the radiocapitellar joint, just proximal to the supinator muscle. The PIN innervates the EDC, EDM, ECU,
EPB, EPL, EIP, APL and sometimes the ECRB. Compressive neuropathy of the PIN leads to motor dysfunction, namely weakness with wrist and finger extension.
Lubhan et al. review uncommon compression neuropathies affecting the upper extremity. They indicate that PIN syndrome may be caused by rheumatoid arthritis and compressive ganglion cysts. Depending on which nerve branch is affected, partial lesions may develop. They recommend use of conservative measures (rest, activity modification and splinting) first. Decompressive procedures may be indicated in symptoms lasting greater than 3 months.
Illustration A shows the course of posterior interosseous nerve from proximal to distal along the course of the supinator. This proximal edge of the supinator (Arcade of Froshe), the fibrous edge of the ECRB and the leash of Henry are three main points of compression of the PIN.
Incorrect Answers

Figure A shows a traumatic laceration of the distal forearm with a 5cm segmental median nerve defect. Which of the following repair or reconstruction techniques would allow for the best recovery of motor function?

Autogenous venous nerve conduit
Collegen synthetic nerve conduit
Biodegradable polyglycolic acid
Processed nerve allograft
Nerve autograft CORRECT ANSWER: 5
Figure A shows a traumatic laceration with 5cm of median nerve defect. The use of nerve autograft for this size defect has been shown to have the best recovery of motor function.
The optimal surgical treatment of nerve laceration is direct tension-free repair. In segmental nerve defects this approach cannot be achieved. The use of interposed autologous nerve grafting remains the gold standard of repair in this setting. The use of alternative techniques, such as processed allografts and synthetic conduits, have not shown to have equivalent recovery of motor function as compared to nerve autograft.
Giusti et al. used a rat model to examine techniques of peripheral nerve repair. They showed that nerve autograft resulted in better motor recovery than did the use of processed allograft or a collagen conduit.
Deal et al. discussed tubular interposition substitutes, or nerve conduits, as an alternative to nerve autograft in segmental nerve defect. Nerve conduits can include autogenous nerve conduits (venous or arterial) and synthetic nerve conduits (collagen, PGA, or caprolactone). In general, there is an upper limit of 3-cm when using nerve conduit.
Figure A is an image of the volar forearm. There is a traumatic laceration to
the anterior compartment tendons as well as the median nerve.
Incorrect Answers:
A 45-year-old man presents with a three-month history of unilateral symptoms in his right wrist and hand. He first noticed a palpable nodule over the volar aspect of his wrist about three months ago. The nodule would become painful after weekends of heavy drinking at which time he noticed tingling sensation in his index and middle fingers. He notes that ibuprofen has helped improve the pain in the past. On clinical examination, he has a palpable, nontender, solid nodule over the volar aspect of his wrist. He has no motor or sensory deficits and negative carpal tunnel provocative tests. An axial CT and MRI image are provided in figures A and B. What would be the most appropriate next step in the management of his symptoms?

Fine needle aspiration
Chemotherapy
Night splints
Establish a tissue diagnosis and referral to a rheumatologist
Surgical excision CORRECT ANSWER: 4
The clinical presentation is consistent with carpal tunnel syndrome caused by an atypical space occupying lesion - in his case, gout. The most appropriate next step in the management of his symptoms would be establishing a tissue diagnosis and referral to a rheumatologist where medical therapy, such as prophylaxis with colchicine, could be initiated.
Carpal tunnel syndrome is the most common compressive neuropathy, affecting up to 10% of the general population. Risk factors include female sex,
advanced age, obesity, and repetitive motion activities. Typically, patients will develop symptoms of median nerve compression including thenar muscle atrophy, numbness in the radial 3.5 digits, night pain, and positive Tinel's and Phalen tests. First line management is non-operative, including NSAIDs, night splints, and activitiy modification. Carpal tunnel release surgery is indicated for those who have failed conservative management.
Chen et al. described 23 unusual cases of CTS in which space-occupying lesions were responsible for the symptoms and signs of median nerve compression. In patients with an atypical presentation, such as male gender, non-middle-aged, or unilateral involvement, space-occupying lesions such as gout, synovial sarcoma, lipoma, and ganglions should be investigated as a cause.
Fitzgerald et al. discussed gout affecting the hand and wrist. The medical treatment of gout includes NSAIDs such as indomethacin or ibuprofen for acute flares, and colchicine and allopurinol for chronic prophylaxis.
Figures A and B represent axial CT and MRI images showing calcification and gouty tophi deposition in the carpal tunnel floor.
Incorrect Answers:
Which statement most accurately describes the physiology of peripheral nerve regeneration following an axonotmesic lesion?
The proximal nerve segment undergoes Wallerian degeneration
Axon growth occurs from the distal segment to proximal segment
Neurotrophic factors direct phagocytic activity
Proximal axon budding allows for antegrade (or distal) axon migration
Axoplasm and myelin are degraded distally predominantly by Schwann cells for the first 12 months following injury
Axonomesis is a disruption of the nerve axon following injury. Repair/regeneration of the nerve occurs via proximal budding, followed by antegrade (or distal) axon migration.
The peripheral nerve regeneration process begins with the distal segment undergoing Wallerian degeneration (axoplasm and myelin are degraded distally by phagocytes). Existing Schwann cells proliferate and line-up along the basement membrane. Proximal budding occurs after a one-month delay. This is followed by sprouting axons that migrate in an antegrade fashion to connect to the distal tube. Repair of the nerve can take months, and often have poor outcomes.
Lee et al. reviewed peripheral never injury and repair. They commented that Wallerian degeneration (i.e., breakdown of the axon distal to the site of injury) is initiated 48 to 96 hours after transection. The Schwann cells then align themselves longitudinally, creating columns of cells called Büngner bands. At the tip of the regenerating axon is the growth cone.
Illustration A shows a chart of peripheral nerve injury. The two main classification systems are Seddon and Sunderland. Video V is a lecture discussing peripheral nerve injury and management.
Incorrect Answers:

A 28-year-old male injures his hand while playing basketball and presents to the emergency room. Closed reduction is performed and is stable. Post-reduction rehabilitation is discussed with the patient.
Which of the following radiographs demonstrates an injury that would be treated best by dorsal extension block splinting?

Figure E CORRECT ANSWER: 2
Dorsal extension-block splinting is the treatment of choice for dorsal proximal interphalangeal joint (PIPJ) fracture dislocations that are stable following reduction and have less than 40% articular surface fracture involvement.
Dorsal PIPJ dislocations are a common injury, often resulting from jamming or hyperextending the finger. In the absence of an associated fracture or presence of a small volar plate avulsion, dorsal PIPJ dislocations are often
treated with closed reduction and buddy-taping to the adjacent digit. Injuries that are unstable following reduction or those associated with an intra-articular fracture of the middle phalanx are stabilized with a dorsal extension-block splint to maintain reduction. It is important to initiate early range of motion exercises within the constraints of the splint to minimize scar formation and subsequent PIPJ contracture.
Elfar et al. reviewed fracture-dislocations of the PIPJ. Dorsal PIPJ fracture-dislocations can be categorized as avulsion or impaction shear injuries.
Avulsion fractures result from hyperextension of the PIPJ, tensioning the volar plate (VP) with eventual VP rupture or avulsion of the volar lip of the middle phalanx. Axial load applied to the digit in PIPJ flexion drives the head of the proximal phalanx across the middle phalangeal base, resulting in a shear fracture or comminuted impaction fracture of the middle phalanx, depending on the amount of energy imparted and the bone quality.
Morgan et al. reviewed hand injuries in athletes. Dorsal PIPJ dislocations without associated fracture that are stable following successful reduction are treated by buddy taping the injured digit to the non-injured digit adjacent to the compromised collateral ligament. Buddy taping with active motion should be continued for 6 weeks. Unstable injuries and those with an intra-articular fracture of the middle phalanx should be treated with dorsal extension-block splinting with incremental extension of the splint on a weekly basis for 4 weeks, followed by buddy-taping for 3 months during sports activities.
Figure A shows a simple dorsal PIPJ dislocation. Figure B shows a dorsal PIPJ fracture dislocation. Figure C shows a simple volar PIPJ dislocation. Figure D shows a volar PIPJ fracture dislocation. Figure E shows a dorsal avulsion fracture at the base of the distal phalanx (bony mallet injury). Illustration A depicts an dorsal extension-block splint that blocks extension of the digit past a set point while allowing full active flexion of the digit. Illustration B is a lateral radiograph of a digit showing a small minimally displaced volar plate avulsion fracture at the PIPJ with minimal intra-articular involvement (as compared to Figure B). This injury may be managed with buddy taping and active range of motion as tolerated.
Incorrect Responses:
extension for 6-8 weeks to limit flexion of the digit and therefore fracture displacement.

A 35-year-old mixed martial arts fighter and recreational cocaine user presents with symptoms concerning for hypothenar hammer syndrome (HHS). Significant ischemia is found on physical exam. Arteriography is shown in Figure A. What is the most appropriate next step in treatment?

Conservative treatment with cocaine abstinence
Conservative treatment with activity modifications and medical management with calcium channel blockers
Therapeutic endovascular fibrinolysis
Excision of involved segment and reconstruction with or without a vein graft
Medical management with coumadin for 6 months
Figure A shows a bilobed aneurysm overlying the ulnar artery with normal appearing distal vasculature. Hypothenar hammer syndrome (HHS) can be associated with an aneurysm and is most appropriately treated with resection of the involved segment and either reconstruction with a primary anastomosis or vein graft.
HHS syndrome consists of two separate entities, thrombosis and aneurysm. In the setting of thrombosis without aneurysm, conservative management is preferred. If the thrombosis is acute (<2 weeks), endovascular fibrinolysis has shown good results. In patients with an HHS and an aneurysm, surgery is required for resection to prevent distal embolization and remove the often painful aneurysmal mass.
Yuen et al. review HHS. In patients with HHS and aneurysms, resection of the involved segment of the ulnar artery prevents distal embolic events, eliminates the painful mass, relieves ulnar nerve compression, and removes the thrombus which initiated the reflex vasospasm and closed off the collateral
vessels in the region.
Lifchez et al. review the long-term outcomes of 11 patients with HHS treated with ulnar artery reconstruction. 2 of the patients underwent excision and direct ulnar artery repair, and the rest underwent reconstruction with a vein graft. All patients had a mean improvement in digital brachial index, decrease in pain and dysesthesia symptoms, and decrease in cold intolerance compared with preoperatively.
Nitecki et al. review a case series of 6 patients with HHS. They state that the treatment of thrombosis should be largely conservative, but thrombolytic treatment could be considered if the event happened <2 weeks prior to presentation.
Illustration A shows an excised ulnar artery aneurysm in a patient with HHS. Note the typical "corkscrew" appearance of the distal segment.
Incorrect Answers:

A 36-year-male was using a high-pressure paint gun when he suffered the injury shown in Figure A. Which of the following variables would have the worst impact on his prognosis?

Delay in surgical treatment
Injected solvent was grease
Injected solvent was water-based paint
An entry wound of greater than 3 cm
Injected solvent was at room temperature
The clinical presentation is consistent for a high-pressure injection injury. Delays in surgical treatment are associated with serious sequelae.
High-pressure injection injuries are characterized by extensive soft tissue damage associated with a benign high-pressure entry wound. They should be treated with irrigation & debridement, foreign body removal and broad-spectrum antibiotics. There is a higher rates of amputation when surgery is delayed.
Bekler et al. looked at the results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up. Ten of the injuries required formal operative debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation. They concluded that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation.
Rosenwaser et al. report wide débridement of all involved tissues, decompression of tissue compartments, exploration and incision of tendon sheaths, removal of injected material, and saline irrigation are critical in the management of high-pressure injection injuries to the hand. They emphasize
delayed surgery has been associated with increased incidence of morbidity and amputation.
Figure A shows a typical high-pressure injection injury. Notice the benign looking entry wound.
Incorrect Answers:
A healthy 50-year-old secretary is about to undergo an open carpal tunnel release. Which of the following peri-operative steps will have the greatest influence on minimizing the risk of a surgical site infection in this patient?
Administration of cefazolin within 1 hour before incision
Administration of cefazolin within 1 hour before incision followed by 5 days of cephalexin post-op
Cleanse with bacitracin solution immediately before skin incision
Standard sterilization and prepping
Administration of one dose of cephalexin within 1 hour before incision
The patient is undergoing a clean, elective hand surgery. Prophylactic antibiotics, systemic or local, are not indicated for these procedures.
Carpal tunnel syndrome is the most common compressive neuropathy. Individuals who fail medical management (night splints, NSAIDs, activity modification) are candidates for carpal tunnel release surgery (CTS). The surgery may be performed open or endoscopically. The reported incidence of post-operative infections following CTS varies between studies from 0% to 8%.
Whittaker et al. performed a prospective, randomized, double-blinded, placebo
controlled trial investigating the use of antibiotic prophylaxis in clean, incised hand injuries. They found no significant difference in infection rates between patients who received IV flucloxacillin, IV followed by oral flucloxacillin, and an oral placebo (13% vs. 4% vs. 15%, p=0.19). They did not support the use of routine antibiotic prophylaxis prior to clean hand surgery.
Bykowski et al. retrospectively reviewed 8,850 outpatient elective hand surgeries and found no significant difference in the rate of surgical site infection, including patients with diabetes or history of smoking. They concluded that antibiotics should not be routinely administered prior to clean, elective hand surgeries.
Harness et al. found no statistical difference in the incidence of surgical site infection following CTS without prophylactic antibiotic compared with patients who received prophylactic antibiotics (0.7% vs. 0.4%, p=0.354). They did not recommend routine antibiotic prophylaxis.
Illustration A reviews the anatomic components of the carpal tunnel. Incorrect Answers:
infection in clean, elective hand surgery. Surgeons should consider the potential risks of antibiotics prior to administration, including Clostridium difficile colitis, antibiotic allergies, bacterial resistance, and so on.

A 30-year-old male laborer sustained a right wrist injury 9 months ago. He continues to have symptoms of recurrent ulnar-sided wrist pain that impairs his ability to work. An MRI is performed and
shows a triangular fibrocartilage complex (TFCC) injury. Which of the following is an indication to combine a Wafer procedure with arthroscopic TFCC debridement?
Ulnar styloid fracture
Radial styloid fracture
2 mm of positive ulnar variance and ulnocarpal impingment
2 mm of negative ulnar variance and radiocarpal joint arthritis
Scapholunate ligament injury
A Wafer procedure is indicated for positive ulnar variance and symptomatic ulnocarpal impingement associated with degenerative TFCC tears.
Ulnar impaction syndrome and triangular fibrocartilage complex (TFCC) injuries are relatively common causes of ulnar-sided wrist pain. Positive ulnar variance causes increased contact pressures between the lunate and the ulnar head. The Wafer procedure removes 2-4 mm of distal ulnar head to reduce ulnar variance to neutral or negative. This is thought to reduce ulnar impaction and decrease pain.
Faber et al. examined the role of MRI in wrist injuries. They showed that the sensitivity and specificity to detect TFCC tears using MRI is approximately 80%. They conclude that there is no supporting evidence for routine MRI's for patients with non-specific ulnar-sided wrist pain.
Illustration A is a coronal view MRI (without arthrogram) of the right wrist that shows a TFCC tear (blue arrow) with positive ulnar variance. Illustration B shows a series of images showing a TFCC tear on MRI and intra-operatively.
Incorrect Answers:

A 27-year-old male sustains the injury shown in Figure A. He is taken to the operating room and the lesion is repaired primarily. Two months later, he feels a "pop" while using his hand and is no longer able to flex the distal phalanx of the involved digit. He is taken to the operating room for surgical exploration where 1.8 cm of scar tissue between the tendon ends is identified. The tendon sheath is found to be intact and allows smooth passage of a pediatric urethral catheter. What is the next step in management?

Resection of scar and primary repair of tendon ends.
Resection of scar and adjacent 1cm of tendon, placement of Hunter rod for staged reconstruction.
Debulking of scar, partial excision of 25% of the A2 and A4 pulleys.
Resection of scar, harvest of ipsilateral palmaris longus tendon for tendon reconstruction.
Resection of scar and proximal tendon, tendon transfer from adjacent digit.
This patient sustained an FDP laceration that was treated initially with primary repair. He subsequently re-ruptured the tendon 2 months later. With scar >1 cm, tendon grafting is indicated and primary tendon grafting with palmaris longus is commonly performed as it is the most accessible tendon in the operative field.
Flexor tendon lacerations commonly result from volar lacerations. Concomitant neurovascular injury is common. Partial lacerations <60% of tendon width are treated with debridement and early range of motion. With partial lacerations, the least amount of gliding resistance can be obtained with debridement alone. Lacerations >60% of tendon width are treated with flexor tendon repair and controlled mobilization. Failed primary repair and chronic untreated injuries are indications for flexor tendon reconstruction and intensive postoperative rehabilitation.
Lilly et al. reviewed complications after flexor tendon injuries. Common complications include adhesions, joint contracture, tendon rupture, triggering, pulley failure and bowstringing, quadrigia, swan-neck deformity and lumbrical plus deformity.
Figure A shows a zone II laceration of the left index finger FDP.
Incorrect Answers:
A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of motion of her thumb is seen in Figure B. What is the most likely cause of her deformity?

Type II hypoplastic thumb
Median nerve neuropathy
Lupus thumb deformity
Extensor tendon rupture
Osteoarthritis of the trapeziometacarpal joint
The patient has 1st carpometacarpal (CMC) arthritis.
With 1st CMC arthritis, the patient avoids painful thumb abduction and an adduction deformity gradually develops, with 1st webspace contracture. With progressive 1st CMC stiffness, the thumb metacarpophalangeal joint (MCP) develops hyperextension deformity to compensate for the loss of motion, leading to a secondary "Z" deformity.
Rozental et al. reviewed hand and wrist reconstruction. They believe that arthrosis arises from loss of the anterior oblique ("beak") ligament.
Compensatory MCP hyperextension should be treated with MCP capsulodesis or arthrodesis.
Van Heest et al. reviewed thumb CMC arthritis. Treatment for Eaton stage I/II arthritis is open/arthroscopic debridement, volar ligament reconstruction (with APL or FCR tendons), or metacarpal extension osteotomy. For stage III/IV arthritis, treatment options include implant arthroplasty or resection arthroplasty +/- LRTI (with APL, FCR or palmaris longus), and fusion (young patients).
Figure A shows adduction contracture of the 1st webspace, with hyperextension deformity of the 1st MCP joint. Figure B illustrates decreased thumb abduction because of adduction contracture with decreased palmar abduction (normal, 45deg) and decreased radial abduction (normal, 60deg). Illustration A is a radiograph showing thumb CMC arthritis with Z deformity. Illustration B shows lupus thumb deformity ("hitchhiker thumb"). Illustration C shows hand changes in inflammatory arthritis.
Incorrect Answers:

A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures A through C. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition?

Ring flexor digitorum superficialis transfer to the abductor pollicis brevis
Extensor indicis proprius transfer to the abductor pollicis brevis
Neurotization of thenar muscles
Camitz palmaris longus transfer to the abductor pollicis brevis
Thumb carpometacarpal joint arthrodesis
This patient has a high median nerve neuropathy because of a supracondylar spur and ligament of Struthers. Reconstruction is best performed with extensor indicis proprius (EIP) transfer to the abductor pollicis brevis (APB).
In low median nerve palsy, the primary concern is restoration of thumb opposition. In high median nerve palsy, thumb opposition and IP flexion, and index and middle finger flexion have to be addressed. The four common opposition transfers include (1) ring or long FDS, (2) EIP, (3) Camitz palmaris longus (PL), or the Huber abductor digiti minimi (ADM).
Anderson et al. reviewed EIP transfer vs FDS transfer. They found a higher percentage of excellent results in the EIP group. In their series, complications included index finger extensor lag (EIP transfer if the extensor expansion was not repaired) and limited donor finger extension because of lateral band damage or adhesions between the remaining FDS tendon and flexor sheath (FDS transfer).
Cawrse et al. modified the Huber ADM opponens transfer by releasing the proximal end to prevent compression of the ulnar nerve in Guyon's canal by the rotated ADM belly. They found that this technique successfully restored
opposition and thenar bulk.
Figure A shows thenar wasting. Figures B and C show a supracondylar spur. The ligament of Struthers attaches from this spur to the medial epicondyle, under which median nerve and brachial artery pass. Illustration A shows EIP transfer. Illustration B shows FDS transfer. Illustration C shows Camitz PL transfer. Illustration D shows Huber ADM transfer.
Incorrect Answers:

A 2-year-old child is referred by her pediatrician for fixed flexion deformity of the left thumb. She has been wearing a splint for the last 6 months. She has ventricular septal defect and left renal agenesis. The interphalangeal joint does not extend past 40 degrees of flexion as seen in Figures A and B. There is no triggering. There is a firm, nontender nodule overlying the metacarpophalangeal joint as outlined in blue in Figure C. What is the diagnosis and most appropriate treatment?

Thumb camptodactyly. Therapy including passive stretching exercises.
Congenital clapsed thumb. Percutaneous release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley and resection of the tendon nodule.
Blauth Type I hypoplastic thumb. Open release of the A1 pulley and volar plate, and resection of the tendon nodule.
This child has pediatric trigger thumb (PTT). The potential for spontaneous resolution beyond the age of 2 years is limited. Surgical release of the A1
pulley is indicated.
Pediatric trigger thumb presents as fixed flexion at the interphalangeal joint (IPJ) rather than triggering. It is likely to be acquired (rather than congenital). It is associated with the presence of Notta's nodule, a thickening of the FPL tendon and overlying tendon sheath. Treatment involves A1 pulley release.
The role of non-surgical management (splinting/stretching) remains unclear. The duration of non-surgical treatment is long (up to 30 months) and compliance can be difficult.
Shah et al. reviewed pediatric trigger thumb. The condition is associated with MCP hyperextension. The authors note no advantage to percutaneous release as general anesthetic is required anyway.
Marek et al. performed a retrospective review and survey response review of surgery for pediatric trigger thumb. They found that age at the time of surgery influences residual flexion contracture and rate of recovery. They found surgery to be safe and effective, and recommend: (1) surgery for a 2-year-old child with a locked thumb for 6 months, (2) observation for a child <1 year if the thumb is triggering (not locked), and (3) a 6-month observation period if observation is advocated.
Figures A and B show a fixed flexion deformity of the thumb and an attempt at thumb extension. Figure C shows the outlined Notta nodule.
Incorrect Answers:
A 48-year-old hairdresser presents with pain and swelling of his ring finger for 4 days. On examination, there is generalized tenderness along the entire digit. Passive extension of the digit triggers
excruciating pain. The clinical appearance of the digit is shown in Figure A. What is the most appropriate next step in management?

Acyclovir
Intravenous antibiotics, splinting and elevation
Closed tendon sheath irrigation from the level of the A1 pulley (proximal) to the distal interphalangeal joint (distal)
Continuous closed tendon sheath irrigation from the wrist (proximal) to the distal interphalangeal joint (distal)
Open irrigation and debridement
This patient has advanced pyogenic flexor tenosynovitis (PFT) with visible ischemia/necrosis. Open irrigation and debridement is necessary.
Pyogenic flexor tenosynovitis is usually caused by a puncture wound (although it may infrequently arise from hematogenous spread). The most common organism is Staphylococcus aureus. Kanavel signs help differentiate this disease from herpetic whitlow, septic arthritis, gout/pseudogout, and other hand infections such as paronychia, felons, cellulitis, and deep space infections.
Draeger et al. reviewed the treatment of pyogenic flexor tenosynovitis (PFT). They recommend open irrigation and debridement for advanced PFT and atypical or chronic tenosynovial infections where tenosynovectomy may be
indicated. Both midaxial and volar zigzag incisions can be used.
Pang et al. reviewed factors affecting the prognosis of PFT. Of the 4 Kanavel signs, they found that fusiform swelling was most often present (97% of patients), followed by pain on passive extension (72%), semiflexed digit posture (69%), and tenderness along the flexor tendon sheath (64%).
Figure A shows advanced PFT demonstrating subcutaneous purulence and local ischemia in addition to fusiform digital swelling. Illustration A shows the Nevasier technique of closed tendon sheath irrigation. Illustration B shows the setup for continuous tendon sheath irrigation using nested catheters.
Illustration C shows the incision for open irrigation and debridement.
Incorrect Answers:

Madelung's deformity of the distal radius is caused by which of the following?
Premature fusion of the distal radial ulnar joint
Physeal growth mismatch between the distal radius and ulna
Nutritional deficiency affecting the physeal zone of provisional calcification
Impaired growth of the volar and ulnar aspect of the distal radial physis
Unrecognized trauma CORRECT ANSWER: 4
Madelung's deformity is that of excessive ulnar/palmar angulation of the distal radius caused by impaired growth of the volar and ulnar aspect of the distal radial physis. It may be caused by either a bony lesion in the palmar/ulnar corner of the distal radial physis or an abnormal radial-carpal ligament (Vicker's ligament). The other answers do not cause Madelung's deformity.
Leri-Weill dyschondrosteosis is a rare genetic disorder caused by mutation in the SHOX gene that causes mesomelic dwarfism with associated Madelung's defomity of the forearm.
Illustration A is a radiographic example of Madelung's deformity.

A 17-year-old boy presents with pain in his right elbow for 2 years and limitation in elbow motion bilaterally. He denies any pain or discomfort in his left elbow. He reports no history of trauma to either elbow. He has had two courses of physical therapy, but has noted no noticeable improvement in pain or motion. Examination demonstrates no elbow tenderness on palpation, and there are no neurological deficits. Manual reduction is unsuccessful. The range of motion of both elbows is shown in Figure A. Radiographs of left and right elbow are shown in Figure B and C respectively. What is the most appropriate treatment plan for the right and left elbow?

Bilateral open reduction and application of a hinged external fixator to both elbows
Radial head resection of the right elbow and non-operative management of the left elbow.
Bilateral radial head arthroplasty
Physical therapy and splinting to both elbows
Radial head resection and interposition arthroplasty for the right elbow and radial head resection alone for the left elbow
This patient has bilateral congenital radial head dislocation (CRHD). The right side is symptomatic with significant loss of motion. The left is asymptomatic with minimal loss of active motion. Therefore the most appropriate treatment is radial head resection of the right elbow and non-operative management of the left elbow.
It is important to differentiate CRHD from traumatic dislocation. Clinical features of CRHD include bilateral involvement, presence at birth, other congenital anomalies, familial occurrence, irreducible by closed methods, and
lack of a history of trauma. Radiological features include dome-shaped radial head and hypoplastic capitellum, relatively short ulna or long radius, deficient trochlea, prominent medial epicondyle, grooving of the distal radius, and anterior curvature of the posterior outline of the ulna.
Bengard et al. reviewed 10 surgically treated and 6 nonsurgically treated CRHD patients. They found no change in flexion-extension and carrying angle postoperatively, but forearm rotation was improved. Surgically treated patients had significant improvement in elbow pain. Ultimately, >25% of patients had wrist pain postop and this must be weighed in the decision process of treatment. They recommend radial head excision as an effective intervention in selected patients with significant elbow pain.
Figure A is a table showing moderately diminished ROM of the right elbow, and minimally reduced ROM of the left elbow. Figures B and C both show posterior dislocation of the radial head (a line along the long axis of the radius should intersect the capitellum in all views).
Incorrect Answers:
Which of the following muscles provide the primary deforming forces to Bennett and Rolando fractures (base of the 1st metacarpal fractures)?
Pronator quadratus
Flexor pollicis longus
Extensor pollicis longus
Adductor pollicis longus and abductor pollicis
Abductor pollicis longus and adductor pollicis
The primary deforming forces in Bennett and Rolando fractures are the Abductor pollicis longus and adductor pollicis.
In a Bennet's or Rolando fracture-dislocation the volar-ulnar fracture fragment is held reduced by the anterior oblique ligament while strong deforming forces pull the remaining metacarpal shaft proximally and dorsally, angulate the shaft ulnarly and supinate the shaft. Most important in these deforming forces are the abductor pollicis longus (APL) inserting on the base of the metacarpal which pulls the metacarpal shaft proximally and dorsally and the adductor pollicis (AP) which inserts on the ulnar base of the proximal phalanx and angulates the metacarpal shaft ulnarly and supinates the shaft. Less important is the extensor pollicis longus (EPL) which inserts on the base of the distal phalanx and also adds to the ulnar angulation of the distal fragment.
Soyer reviews the diagnosis, pathoanatomy, and treatment for fractures at the base of the 1st metacarpal. Understanding the biomechanics, anatomical deforming forces, and the exact fracture pattern aids the treating surgeon in determining the most appropriate method of fixation. The most essential factor for obtaining a good functional result is anatomic restoration of the articular surface.
Elgafy et al. examined the terminal anatomy of the posterior interosseous nerve in their cadaver study - identifing six terminal branches and describing methods to avoid injury. They describe how treating surgeons can maximize function and recovery after base of the 1st metacarpal fractures by understanding these nervous branches and specific fracture pattern treatment to avoid iatrogenic injury to the PIN.

A 28-year-old man sustained a complete laceration of the flexor digitorum profundus of his index finger while cutting a watermelon 3 days ago. A clinical photograph is shown in Figure A. The surgeon plans to repair the tendon using a 4-strand core suture technique. Which method of tendon repair will give him the best results in terms of load to failure and gliding resistance?

Repair with core suture purchase 5mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 10mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 5mm from the cut edge. Circumferential
simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential Silfverskiold epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge, coupled with circumferential simple running epitendinous suture will give him the best load to failure and gliding resistance.
The strength of tendon repairs depend on the number of strands crossing the repair site. Ideally, repairs should have 4-6 strands to allow for early active motion. A running epitendinous suture is recommended to improve tendon gliding and repair strength.
Gulihar et al. compared 3 different epitendinous suture techniques. They found that compared with an intact tendon, gliding resistance increased 100% with the Halsted repair, 80% with the Silfverskiold repair and 60% with a running suture. They thus recommend a simple running suture when an epitendinous suture is needed.
Lee et al. compared core suture purchase at 3, 5, 7 and 10mm from the cut edge. The 10mm-repair group had the highest 2-mm gap force and ultimate failure load. They recommend 10-mm suture purchase for optimal performance and to allow early active motion.
Figure A shows a laceration to the volar aspect of the index finger in flexor zone II. Illustration A shows a core suture purchase distance from the cut edge (represented by "X", where 10mm is the ideal distance). Illustration B shows 3 different epitendinous suture techniques (A, simple running; B, Silfverskiold; C, Halsted).
Incorrect Answers:

A 28-year-old professional baseball player injures his middle finger sliding into the catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A radiograph is provided in figure A. All of the following are true EXCEPT:

Anatomic reconstruction of the articular surface is prognostic of clinical function
Proximal interphalangeal joint subluxation precludes a normal gliding flexion arc
Hinging at the fracture site must be avoided
Early motion should be initiated in postoperative therapy
Early degenerative arthritis can be expected if the joint is not adequately reduced.
The radiograph demonstrates a dorsal fracture dislocation of the proximal interphalangeal joint of the middle finger. Kiefhaber and Stern review the presentation, evaluation, and treatment of PIP fractures. Congruent reduction of the joint to allow the middle phalanx to glide around the proximal phalangeal head is paramount to prevent joint subluxation and instability.
Anatomic reconstruction of the articular surface is desirable but not necessary for successful clinical outcome.
A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A. He undergoes a procedure to restore the soft tissue envelope. Which treatment option is contraindicated because of increased risk of interphalangeal joint stiffness?

Moberg volar advancement flap
Foucher first dorsal metacarpal artery flap
Littler neurovascular island flap
Free great toe pulp transfer
Holevich first dorsal metacarpal artery flap
This patient has a large thumb pulp defect measuring 3.5 cm in length, extending proximal to the interphalangeal joint (IPJ) crease. Inset of a Moberg flap large enough to cover the defect would necessitate IPJ flexion >45 degrees, increasing the risk of IPJ stiffness.
Thumb pulp defects may be resurfaced by different means, depending on size. The Moberg flap is suited for medium (1.8-3 cm) defects. For defects >1.5 cm, there is increased risk of wound dehiscence, parrot beak nail deformity, and decreased soft tissue padding. Modifications such as V-Y flaps, bilateral Z-plasties, Burrow triangles, 2 lateral triangular flaps at the proximal edge of the flap, or advancement of an island flap with skin grafting of the secondary defect (O’Brien modification), are recommended.
Baumeister et al. reviewed the functional outcome of Moberg flaps. These flaps do not cause marked impairment of active ROM and any reduction in the AROM of the IP joint is because of a loss of hyperextension.
Horta et al. reviewed the use of multiple flaps (Moberg, radial innervated cross-finger, Venkataswami-Subramanian, Foucher, Tezcan, and Littler). They recommended the Foucher flap because of good sensibility, single-stage surgery, and no need for cortical reintegration (unlike the Littler flap)
Figure A shows a large thumb pulp defect. Illustration A shows the options for resurfacing thumb pulp defects of different sizes. Illustration B is a diagram of these options. Illustrations C and D depict the Holevich dorsal metacarpal artery flap (with overlying skin strip). Illustrations E and F depict the Foucher dorsal metacarpal artery flap (islanded).
Incorrect Answers:

Percutaneous screw fixation for non-displaced scaphoid waist fractures has been shown to have which of the following differences compared to closed treatment?
Increased direct and indirect cost
Slower return to work
Higher union rates
Reduced time to fracture union
Improved motion and grip strength after 2 years
Fixation of non-displaced scaphoid fractures with a percutaneous screw has resulted in a shorter time to union (6-7 weeks versus 10-12 weeks) and faster return to work or sports.
Arora et al found the indirect cost reduction by a quicker return to work was shown to offset the direct costs of surgical intervention.The operatively treated group had a better mean DASH-score than the conservative group. Fracture
union was seen in the screw fixation group at a mean of 43 days and in the cast immobilization group at a mean of 74 days.
Bond et al found in active military personnel there was faster healing but no difference in ultimate union rates or final grip strength or range of motion between percutanous screw fixation and non-operative groups. The average time to fracture union in the screw fixation group was seven weeks compared with twelve weeks in the cast immobilization group. There was no significant difference in the range of motion of the wrist or in grip strength at the two-year follow-up evaluation.
Constriction ring syndrome, also known as amniotic band syndrome, is a congenital disorder associated with which paediatric foot condition?
Equinovalgus foot
Clubfoot (Congenital talipes equinovarus)
Tarsal coalition
Congenital vertical talus
Polydactyly CORRECT ANSWER: 2
Constriction ring syndrome is a congenital disorder that is most commonly associated with clubfeet (congenital talipes equinovarus). The reported incidence of clubfeet with concomitant constriction bands ranges from 12-56%.
Constriction ring syndrome is a collection of congenital malformations that occur as a result of intrauterine rings or bands that constrict fetal tissue. The etiology of constrictive ring syndrome remains elusive, though Streeter postulated in 1930 that a germline developmental abnormality is responsible for the development of amniotic constriction bands, hence one of the synomonous terms used to describe the disorder, Streeter’s dysplasia. Normal anatomy is found proximal to the band. Distally, a constrictive band can cause compression of lymphatic and neurovascular structures and result in lymphedema, altered circulation and neuropathy. In severe cases congenital amputation can occur. In terms of other orthopaedic conditions, constrictive ring syndrome is associated with clubfeet, acrosyndactyly and pseudoarthrosis. With respect to clubfeet, surgical treatment is commonly required, which consists of z-plasty releases of the constricted bands, in addition to surgical correction of the clubfoot deformity.
Gomez reviewed 35 children with clubfeet associated with constriction ring syndrome. In this cohort there was a poor response to casting, as 77% of the children required surgical corrections. Z-plasty releases of the deep bands were performed before the clubfoot correction.
Allington et al. examined the outcome of treatment of clubfeet distal to a lower extremity band in 18 patients (21 feet). Sixteen children (88.9%) underwent surgical treatment after manipulation and serial casting were unsuccessful.
Mild initial foot deformities and constriction bands located in the distal aspect of the lower leg were associated with the best outcomes.
Incorrect Answers:
You are consulted on a newborn male inpatient who presents with the clinical sign shown in Figure A. All of the following are commonly associated with this syndrome EXCEPT?

Bronchopulmonary dysplasia
Cardiac defects
Cleft palate
Encephalocele
Rigid talipes equinovarus

Question 34

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

Explanation

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

Question 35

A 12 month old infant has congenital complete absence of the tibia. Examination reveals that the femur in the abnormal limb is 3 cm short, with a normal ipsilateral hip. The patient has an intact fibula, an equinovarus foot with four rays, and moderate popliteal skin webbing. Management should consist of

Explanation

Congenital longitudinal deficiency of the tibia (tibial hemimelia) is a rare anomaly. It is characterized by leg length inequality, malrotation of the extremity, and an equinovarus position of the foot. Currently, the primary treatment option is disarticulation at the knee. Centralization of the fibula has been performed in the past with poor long term results, which have required reoperations leading to amputations. The Syme amputation and prosthetic fitting of the present deformity has led to poor results.

Question 36

A 15-year-old girl who competes in gymnastics has immediate pain and giving way of the left elbow after falling from the uneven parallel bars and landing on her outstretched arms. Examination reveals swelling and tenderness about the elbow, especially over the medial side. Measurement of elbow motion shows 0° to 125° of flexion, and valgus stress at the elbow is painful. AP, lateral, and stress radiographs are shown in Figures 9a through 9c. Management should consist of

Explanation

DISCUSSION: While many low-demand patients with injuries to the ulnar collateral ligament can be treated nonsurgically, Jobe and associates described two situations in which ulnar collateral ligament reconstruction is indicated: (1) an acute complete rupture in a competitive athlete who uses the upper extremities extensively and who wishes to remain active; and (2) chronic pain or instability that does not improve after at least 3 months of nonsurgical management. Rarely is direct surgical repair of the ligament possible or able to withstand the valgus stresses applied to the elbow. Most authors recommend surgical reconstruction of the ulnar collateral ligament using a palmaris longus, plantaris, or fourth toe extensor tendon from the fourth autograft.
REFERENCES: Andrews JR, Jelsma RD, Joyce ME, et al: Open surgical procedures for injuries to the elbow in throwers. Oper Tech Sports Med 1994;4:109-133.
Jobe FW, Kvitne RS: Elbow instability in the athlete. Instr Course Lect 1991;40:17-23.
Smith GR, Altchek DW, Pagnani MJ, Keeley JR: A muscle-splitting approach to the ulnar collateral ligament of the elbow: Neuroanatomy and operative technique. Am J Sports Med 1996;24:575-580.

Question 37

Which factor has the most negative influence on the success of knee osteochondral allograft transplantation?

Explanation

DISCUSSION
The images illustrate a large unstable osteochondral lesion of the medial femoral condyle. Radiographs and MR images clearly show deep subchondral bone involvement. The appropriate choice of surgery is OCA transplantation, which is indicated for primary treatment of large cartilage lesions, osteochondral lesions, and salvage procedure from failed prior cartilage surgery. Correction of mechanical axis malalignment, ligamentous insufficiency, and meniscal deficiency should also be addressed. ACI alone or an arthroscopic microfracture procedure would not address the bone defect, leaving an uneven articular surface. Although an osteotomy may be a viable choice, a distal femoral varus osteotomy would increase the contact pressure in the medial compartment and worsen the situation.
The histologic anatomy of articular cartilage is well described. The superficial layer or lamina splendens contains a small amount of proteoglycan with collagen fibrils arranged parallel to the articular surface. In contrast, the deep zone contains the largest-diameter
collagen fibrils, oriented perpendicular to the joint surface, and the highest concentration of proteoglycans.

Video 54 this video is uploaded at
CLINICAL SITUATION FOR QUESTIONS 51 THROUGH 54
Figures 51a and 51b are the radiographs of an 18-year-old football linebacker who was involved in a tackle and fell onto an outstretched left arm. He had immediate pain and deformity of his left elbow.

Question 38

A 17-year-old high school long distance runner is seeking advice before running a marathon for the first time. What advice should be given regarding his fluid, carbohydrate, and electrolyte intake around the time of the race?

Explanation

DISCUSSION: The goal of fluid replenishment should be to replace the sweat that has been lost. Sweat is mostly water, with a small concentration of salts and other electrolytes. Absorption is enhanced by solutions of low osmolality. Scientific research has also shown that adding carbohydrates to the drink improves athletic performance. Carbohydrates such as glucose and maltodextrins (glucose polymers) stimulate fluid absorption by the intestines. Fructose slows intestinal absorption of fluids. Drinks that are high in fructose, such as orange juice, can lead to gastrointestinal distress and osmotic diarrhea.
REFERENCES: Kirkendall D: Fluids and electrolytes, in The U.S. Soccer Sports Medicine Book. Baltimore, MD, Williams and Wilkins, 1996.
Gisolfi CV, Duchman SM: Guidelines for optimal replacement beverages for different athletic events. Med Sci Sports Exerc 1992;24:679-687.

Question 39

At the first postoperative visit after mini-open carpal tunnel release, a patient reports hand weakness. Poor index finger interphalangeal joint extension and metacarpophalangeal joint flexion are present. This finding is most consistent with

Explanation

EXPLANATION:
Complications after carpal tunnel release are relatively uncommon. The clinical picture described above is most consistent with lumbrical muscle weakness secondary to neuropraxia of the proper palmar digital nerve to the index finger supplying motor innervation to that muscle. The recurrent motor branch of the median nerve innervates the thenar musculature and would not present as index finger weakness. A new onset of trigger finger may result from a loss of the pulley effect of the transverse carpal ligament, postoperative tendon inflammation, or previously unrecognized flexor tendon triggering. Flexor digitorum profundus to the index finger lies deep within the carpal tunnel, making its injury unlikely. If it were injured, the result would not be weakness of interphalangeal joint extension.

Question 40

At the time of revision total knee arthroplasty, the surgeon is trialing the knee and finds that it extends fully and is stable in flexion with a 23-mm trial spacer; however, the patella is impinging on the polyethylene spacer. No augments were used on the femur or the tibia because the components fit well without them. What is the most appropriate action at this time?

Explanation

DISCUSSION: The surgeon in this case is faced with a common scenario at the time of revision total knee arthroplasty and the tendency is to elevate the joint line. Elevation of the joint line is associated with deleterious effects including anterior knee pain, restricted knee flexion, and instability. The error that has been made is resting the femoral component on the bone that is left behind after removal of the prior component; this typically leads to a femoral component that is too small (leading to an enlarged flexion gap) and proximal to where it should be (enlarging the extension gap). Although the flexion and extension gaps are equivalent, joint line elevation has occurred. To correct this problem, the femoral component size should be increased or offset posteriorly (to decrease the size of the flexion gap) and distal femoral augments should be used to decrease the size of the extension gap and restore the joint line to the appropriate level.
REFERENCES: Laskin RS: Joint line position restoration during revision total knee replacement. Clin Orthop Relat Res 2002;404:169-171.
Yoshii I, Whiteside LA, White SE, et al: Influence of prosthetic joint line position on knee kinematics and patellar position. J Arthroplasty 1991;6:169-177.
Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction
Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 123-145. Question 100
A 68-year-old woman is undergoing a cementless medial/lateral tapered femoral placement during a total hip arthroplasty and the surgeon notices a small crack forming in the anteromedial femoral neck with final implant insertion. The most appropriate management should include which of the following?
Placement of a cerclage cable around the femoral neck above the lesser trochanter
Removal of the implant, placement of a cable around the femoral neck above the lesser trochanter, and reinsertion of the implant
Removal of the press-fit implant and cementing of the same femoral stem
Final seating of the cementless femoral component without additional measures
Removal of the cementless femoral component and placement of a revision modular taper- fluted femoral stem
DISCUSSION: The recognized treatment of the proximal periprosthetic fracture is first to identify its extent and then to optimize the correction. Removing the implant seems logical to accomplish the identification. Several studies indicate that proximal cerclage wiring is adequate to create a “barrel hoop” stability of the proxima l femur. The postoperative management may also include protected weight bearing and periodic radiographs.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475503.
Warren PJ, Thompson P, Fletcher MD: Transfemoral implantation of the Wagner SL stem: The abolition of
subsidence and enhancement of osteotomy union rate using Dall-Miles cables. Arch Orthop Trauma Surg 2002;122:557-560.
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Question 41

A year-old woman is referred for evaluation of a painful knee replacement. She underwent total knee arthroplasty (TKA) more than 1 year ago without perioperative complications but has had consistent pain since the surgery. The patient’s preoperative radiographs and postoperative radiographs are shown in Figures below. Examination reveals medial laxity during valgus stress testing and range of motion of 0° to 70°. Her erythrocyte sedimentation rate and C-reactive protein level are normal. What is the best next step?

Explanation

DISCUSSION:
The radiographs show substantial valgus malalignment of the femoral component, with lateral mechanical axis deviation. Clinically, by examination she displays instability and stiffness as a result. Revision knee replacement is appropriate and should consist of total revision to stemmed femoral and tibial components with a varus-valgus constrained insert, given the likely attenuation of the medial collateral ligament. Open debridement with ligament balancing and polyethylene exchange do not address the underlying cause and are inappropriate. Distal femoral osteotomy is not useful in the setting of previous total knee replacement.
Nonsurgical treatment with an unloader brace would be ineffective in correcting the alignment.

Question 42

A 22-year-old college football player reports shortness of breath and dyspnea after a tackle. Examination reveals tachypnea, tachycardia, the trachea is shifted to the right, and there are decreased breath sounds on the left lung fields. The first line of treatment on the field should be

Explanation

DISCUSSION: The patient has a tension pneumothorax. This is a life-threatening emergency where air is trapped between the pleura and the lung, which prevents expansion of the lung. This causes hypoxia and cardiopulmonary compromise. The first line of treatment is to place a needle into the second intercostal space in the midclavicular line. The athlete should then be transported to the emergency department for chest tube placement. The athlete cannot return to play, and resuscitation is not necessary because he has not gone into cardiopulmonary arrest.
REFERENCES: Amaral JF: Thoracoabdominal injuries in the athlete. Clin Sports Med 1997;16:739-753.
Perron AD: Chest pain in athletes. Clin Sports Med 2003;22:37-50.

Question 43

Which of following is pathognomonic of intervertebral disk degeneration? Review Topic

Explanation

Degradation of
large proteoglycan molecules in
the nucleus pulposus is
pathognomonic
of intervertebral disk
(IVD) degeneration.
Degeneration of the intervertebral disk (IVD) is a major pathological process implicated in low back pain and is often considered a prerequisite for intervertebral disc herniation. While the pathophysiologic causes of IVD degeneration at the molecular level are not fully known, there are many physical and molecular changes that are known to contribute to the disease process. The most significant is loss of large proteoglycan molecules and decreased water content.
An et al. showed that large proteoglycans (PGs), such as aggrecan and versican, decrease in patients with intervertebral disk (IVD) degeneration.
Kepler et al. reviewed IVD degeneration. They report that degeneration leads to changes in the expression of matrix proteins, cytokines, and proteinases. They suggest treatment with gene therapy, such as Growth and Differentiation Factor-5 (GDF-5), may help to promote the healing of degenerated intervertebral disks.
Illustration A shows a cadaveric image of normal disk anatomy (left) and IVD degeneration (right)
Incorrect Answers:

Question 44

A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient’s family reports that he is a Jehovah’s Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient’s blood pressure becomes unstable. What is the most appropriate action?

Explanation

DISCUSSION: Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open would is not recommended nor would there likely be enough from an open tibial fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.
REFERENCES: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.
Jehovah’s Witnessess Official Web Site: Medical Care and Blood, 2008, http://www.watchtower.org/e/medical_care_and_blood.htm

Question 45

Analysis of which of the following proteins is used to establish the diagnosis of Becker muscular dystrophy?

Explanation

Becker muscular dystrophy is an X-linked inherited disorder present in approximately 1 in 30,000 live male births. The responsible gene is located on the xp21 region of the X chromosome including sixty-five exons that encode for the protein dystrophin. Duchenne muscular dystrophy is also related to a mutation of the dystrophin gene. Muscle biopsies for dystrophin have been extremely successful for identifying these dystrophies and distinguishing them from other clinically similar autosomal recessive myopathies. (Ref: Shapiro, Hoffman) Question 18 -
A 25-year-old woman with spastic diplegia has a painful progressive bunion deformity that has failed to respond to nonsurgical treatment. Examination reveals tenderness and erythema over the bunion prominence; however, the hallux metatarsophalangeal joint has full range of motion. A standing AP radiograph shows a hallux valgus angle of 30 degrees and a 1-2 intermetatarsal angle of 13 degrees. Treatment should now consist of
arthrodesis of the hallux metatarsophalangeal joint.
arthrodesis of the first tarsometatarsal joint.
excision of the medial eminence and medial capsular reefing of the metatarsophalangeal joint.
osteotomy of the distal first metatarsal.
proximal metatarsal osteotomy with distal soft-tissue realignment.
Treatment of hallux valgus in a patient with cerebral palsy is largely dependent on the degree of spasticity and the pattern of gait. The only way to adequately eliminate spastic deforming forces is with an arthrodesis of the MTP joint. Any other procedure will most likely lead to a high incidence of either hallux varus or recurrent hallux valgus.
The optimal arthrodesis angle is 25-30 degrees, and the metatarsal inclination angle should be 25-30 degrees also. Sagittal plane position should be checked intraoperatively and the proximal phalanx should clear the table by 5-10mm with simulated WB

Question 46

The attachments of the transverse carpal ligament include which of the following structures?

Explanation

DISCUSSION: The transverse carpal ligament is the volar boundary of the carpal tunnel. It attaches to the scaphoid and trapezium radially and the pisiform and the hook of the hamate ulnarly. The ulna and trapezoid do not receive attachments of the transverse carpal ligament.
REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 471-472.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 168-170.

Question 47

A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season. Management should consist of

Explanation

DISCUSSION: The union rate for minimally displaced midthird scaphoid fractures is quite high with cast immobilization while allowing a return to sports. Inadequate immobilization results in a much higher nonunion rate. Early fixation and rehabilitation have been proposed for sports or positions that are not amenable to cast immobilization. While immobilization of a nondisplaced fracture results in an acceptably high union rate, there is no advantage to fixation in conjunction with immobilization in the course of healing. With adequate immobilization and protection, play restrictions until healing has occurred are unnecessary.
REFERENCES: Rettig AC, Kollias SC: Internal fixation of acute stable scaphoid fractures in the athlete. Am J Sports Med 1996;24:182-186.
Rettig AC, Weidenbener EJ, Gloyeske R: Alternative management in midthird scaphoid fractures in the athlete. Am J Sports Med 1994;22:711-714.
Riester JN, Baker BE, Mosher JF, Lowe D: A review of scaphoid fracture healing in competitive athletes. Am J Sports Med 1985;13:159-161.

Question 48

Figures 23a and 23b show the radiograph and clinical photograph of a patient who reports a reduced ability to flex the interphalangeal joint of her great toe after undergoing a Chevron-Akin bunionectomy. What is the most likely cause?

Explanation

DISCUSSION: The flexor hallucis longus tendon is at risk during a Chevron-Akin osteotomy because of its close relationship to the base of the proximal phalanx. The radiograph reveals a reduced ability to flex the interphalangeal joint secondary to the flexor hallucis longus laceration. The other complications are not supported by the radiograph.
REFERENCES: Tollison ME, Baxter DE: Combination chevron plus Akin osteotomy for hallux valgus: Should age be a limiting factor? Foot Ankle Int 1997;18:477-481.
Scaduto AA, Cracchiolo A III: Lacerations and ruptures of the flexor or extensor hallucis longus tendons. Foot Ankle Clin 2000;5:725-736.

Question 49

A 12-year-old boy with a family history of neurofibromatosis has anterolateral bowing of the left tibia. He has no pain and is ambulatory. Radiographs show a narrowed medullary canal but intact cortices. Treatment should consist of which of the following?

Explanation

DISCUSSION: Anterolateral bowing of the tibia is associated with confirmed neurofibromatosis in approximately 50% of patients. Although the risk of fracture with the development of pseudarthrosis exists, the initial treatment consists of bracing through maturity.
REFERENCES: Vander Have KL, Hensinger RN, Caird M, et al: Congenital pseudarthrosis of the tibia.
J Am Acad Orthop Surg 2008;16:228-236.
Vitale MG, Guha A, Skaggs DL: Orthopaedic manifestations of neurofibromatosis in children: An update. Clin Orthop Relat Res 2002;401:107-118.

Question 50

maximize physical capacity and 4) obtain local control of the disease. Other trivia from the references include: After the lung and liver the skeletal system is the third most common site of metastasis. The spine is the most common site of skeletal metastasis. 60% of all skeletal lesions and 36% are asymptomatic. Breast, prostate, lung and renal carcinoma comprise 80% of the carcinomatous skeletal metastasis. 70% metastasis occur in the thoracic and thoracolumbar regions. 21% had involvement of the lumbar and sacral regions. 8% involved the cervical and cervicothoracic regions together. As many as 90% of patients who die of cancer may have Spinal metastasis at autopsy, and only half of patients who die from cancer will have symptoms from spinal mets. Fewer than 10% with spinal mets are treated surgically. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont IL., American academy of orthopaedic surgeons, 2002, pp 723-736. back to this question next question 03 What is the most frequently encountered complication following juvenile hallux valgus correction?

Explanation

Postoperative complications have been frequently reported following juvenile hallux valgus corrections. Recurrence following surgery is probably the most frequently reported complication and is likely due to the high rate of congruency associated with a juvenile hallux valgus deformity.

OKU Foot and Ankle 2 Rosemont IL., American academy of orthopaedic surgeons, pp135-150.
back to this question next question

Question 51

A 12-year-old gymnast has had elbow pain for 4 weeks. She denies any specific trauma to the elbow. Examination reveals lateral pain and no instability on testing. Range of motion is as follows: 15 degrees, loss of elbow extension, normal flexion, and normal pronation and supination. Radiographs reveal a 3- x 7-mm radiolucency of the capitellum. A T1-weighted MRI scan reveals a single solitary lesion, and T2-weighted images show no signal around the lesion. There are no intra-articular loose bodies. Appropriate management should include which of the following? Review Topic

Explanation

This is a typical presentation for an osteochondral lesion of the capitellum. This patient is young and has, by definition, a stable lesion and has excellent potential to heal this lesion with nonsurgical management. However, the patient should stop her activities (gymnastics) to prevent further damage and the possible development of an unstable lesion that might then necessitate surgery. Surgical procedures are generally not necessary for the treatment of these lesions.

Question 52

Histologically, synovial chondromatosis is characterized by

Explanation

DISCUSSION: Histologically, there is metaplastic cartilage arising from the synovium. These lobules of zonates hyaline cartilage are of variable size, are embedded within edematous synovium, and protrude into the joint. The lobules calcify and ossify, leading to the characteristic radiographic appearance. Inflammatory synovitis is not characteristic of synovial chondromatosis. The fluid is clear and serosanguin, not blood tinged.
REFERENCES: Milgram JM: Synovial osteochondromatosis: A histopathological study of thirty cases. J Bone Joint Surg Am 1977;l59:792-801.
Murphy FP, Dahlin DC, Sullivan CR: Articular synovial chondromatosis. J Bone Joint Surg Am 1962;44:77.

Question 53

Rickets can be best characterized by which of the following radiographic changes in children?

Explanation

Rickets is a condition of inadequate mineralization of osteoid and cartilage at the growing ends of bone in children. It is associated with a nutritional deficiency in children that affects open physes, as opposed to osteomalacia which is a deficiency in people with closed growth plates. There are classic radiographic findings and disorders that mimic rickets. Classic findings are widened physes related to widening of the physis from accumulation of nonmineralized osteoid and cartilage, irregular metaphyses, and loss of definition of the zone of provisional calcification. The changes are seen predominantly in the bones with greatest growth (tibia, distal femur, distal radius) and rarely seen in slower growing bones such as the tubular bones in the hand. Widening of the anterior ribs, the rachitic rosary, may be seen. Hyperparathyroidism with accumulation of fibrous tissue in the metaphyses can produce lucencies that may appear similar to the nonmineralized osteoid of rickets. Hyperparathyroidism has erosion around the edge of the growth plate. There are punched out lesions and resorption subperiosteally. Rounded epiphyses and marked separation of the epiphysis and metaphysis are the classic differentiation of Jansen syndrome, a dominantly inherited metaphyseal chondrodysplasia. Sclerotic metaphyseal ends are similar to rickets, but with maturation, the spaces fill with irregular calcification classic to Jansen syndrome. Sclerotic of the vertebra, or "rugger jersey" spine, is typical of renal osteodystrophy.

Question 54

Figures 1 through 3 show the radiographs obtained from a 40-year-old woman who injured her right index finger in a bicycle collision. Failure to restore sagittal plane alignment would likely result in

Explanation

EXPLANATION:
The radiographs reveal an extra-articular proximal phalanx fracture of the index finger. The fracture is comminuted with dorsal angulation of the distal fragment. The question specifically asks about the restoration of sagittal alignment. The fracture is comminuted with dorsal angulation of the distal fragment. The other options are incorrect, because overlapping of the digits occurs with rotational malalignment, the development of arthritis may occur with intra-articular fractures, and hyperextension would not occur with this type of deformity.

Question 55

A 78-year-old woman underwent total hip arthroplasty 15 years ago. She reports a recent history of increasing thigh pain prior to a fall and is now unable to ambulate. Radiographs are shown in Figures 87a and 87b. What is the best treatment for this condition?

Explanation

DISCUSSION: Severe periprosthetic fractures after total hip arthroplasty with a loose implant and progressive bone loss are difficult problems for orthopaedic surgeons, with a high complication rate. Recent literature favors the use of long fluted tapered stems that have a long distal taper that may optimally engage the remaining femoral shaft isthmus. Plating options are problematic because the ability to use screws with the plate is limited by the intramedullary stem. Although not the only solution to this problem (such as allograft-prosthetic composites, impaction grafting, tumor prostheses), long distally fixed stems circumvent this problem by enhancing fracture healing and create a long-term prosthetic solution in these most difficult cases.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475503.
Kwong LM, Miller AJ, Lubinus P: A modular distal fixation option for proximal bone loss in revision total hip
arthroplasty: A 2- to 6-year follow-up study. J Arthroplasty 2003;18:94-97.

Question 56

An otherwise healthy 75-year-old man has a painful mass in the popliteal fossa of his right knee. A lateral radiograph of the knee, a CT scan of the distal femur, and a histopathologic specimen are shown in Figures 13a through 13c. Management should consist of

Explanation

DISCUSSION: The patient has a parosteal osteosarcoma of the distal femur. The findings of mild knee pain, radiographic evidence of a radiodense mass involving the parosseous space or surface of the distal femur, and histologic findings of a spindle cell lesion forming immature osteoid with little to no necrosis most likely suggest a parosteal osteosarcoma. The treatment of choice is surgical resection.
REFERENCES: Okada K, Frassica FJ, Sim FH, Beabout JW, Bond JR, Unni KK: Parosteal osteosarcoma: A clinicopathological study. J Bone Joint Surg Am 1994;76:366-378.
Campanacci M: Bone and Soft Tissue Tumors. New York, NY, Springer-Verlag, 1990, pp 433-454.

Question 57

-A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test. What phase of the throwing cycle most likely will reproduce his symptoms?

Explanation

Question 58

A healthy 65-year-old woman undergoes anatomic total shoulder arthroplasty to address osteoarthritis (OA). The surgery is uncomplicated. What is the most common indication for future revision?

Explanation

The most common reason for revision surgery following unconstrained shoulder arthroplasty for glenohumeral OA is loosening of an implant. In most studies that distinguish glenoid from humeral loosening, it appears the glenoid is the problem. Comprehensive systematic reviews have found that radiographic glenoid loosening can comprise nearly 30% to 40% of all complications following shoulder arthroplasty for non-
inflammatory arthritis. Infections, periprosthetic fractures, and rotator cuff tears are uncommon. In the population-based study by Matsen and associates, 10% of the revisions were performed for loosening versus
7% for infection and 7% for rotator cuff tearing.

Question 59

A researcher is working on Medication A, a drug FDA-approved for the treatment of osteoporosis in men and women. It is an anti-resorptive agent that inhibits the formation, function and survival of osteoclasts. It does not bind to calcium hydroxyapatite. At 1-year after the initial dose, tissue levels are non-detectable. It can be used in the presence of cancer metastases to bone. What is Medication A? Review Topic

Explanation

Denosumab is FDA-approved for the treatment of osteoporosis in men and women. It inhibits the formation, function and survival of osteoclasts (OC). It does not bind to calcium hydroxyapatite. At 1-year after the initial dose, tissue levels are non-detectable.
Denosumab is a human monoclonal antibody against RANKL. By binding RANKL, it prevents interaction of RANKL with RANK (on OC and osteoclast precursors, OCP), and inhibits OC-mediated bone resorption, and the formation, function and survival of OC. In contrast, bisphosphonates bind to calcium hydroxyapatite in bone, and decrease resorption by decreasing function and survival (but not formation) of OC.
Vaananen et al. reviewed the cell biology of OC. During bone resorption, 3 membrane domains appear: ruffled border, sealing zone and functional secretory domain. The resorption cycle starts with migration, bone attachment, polarization (formation of membrane domains), dissolution of hydroxyapatite, degradation of organic matrix, removal of degradation products from resorption lacuna, and apoptosis of the OC or return to the non-resorbing stage.
Boyce et al. reviewed the regulation of osteoclasts and their functions. OCPs are held in bone marrow by chemokines e.g. stroma-derived factor-1 (SDF1) and attracted to blood by sphingosine-1 phosphate (S1P) (increased in synovial fluid of patients with RA). All aspects of osteoclast formation and functions are regulated by M-CSF and RANKL. More recent studies indicate that osteoclasts and their precursors regulate immune responses and osteoblast formation and functions by means of direct cell-cell contact through ligands and receptors, such as ephrins and Ephs, and semaphorins and plexins, and through expression of clastokines.
Warriner and Saag reviewed the diagnosis and treatment of osteoporosis. They defined osteoporosis as T-score of = -2.5 or a history of fragility fracture. Incident hip and vertebral fractures increase future risk of these fractures (hazard ratio 7.3 and 3.5, respectively).
Cummings et al. compared subcutaneous denosumab (60mg every 6mths) vs placebo in prevention of fractures in 7868 osteoporotic (T-score -2.5 to -4.0) postmenopausal women. They found that denosumab reduced risk of vertebral fracture by 68% (risk ratio, 0.32), hip fracture by 40% (hazard ratio 0.6), nonvertebral fracture by 20% (hazard ratio 0.8). There was no increased risk of cancer, infection, delayed fracture healing, cardiovascular disease, osteonecrosis of the jaw or adverse reactions. They concluded that it was useful for reduction of fractures in osteoporotic women.
The video shows the action of denosumab (prolia). Illustration A shows the different osteoclast zones.
Incorrect Answers:

Question 60

A 7-year-old girl who sustained a type III posteromedial extension supracondylar fracture underwent a closed reduction at the time of injury. Figure 27a shows the position of the fracture fragments prior to percutaneous medial and lateral pin fixation. Following surgery, healing was uneventful and the patient regained a full painless range of motion. Fifteen months after the injury, she now reports loss of elbow motion and moderate pain with activity. A current AP radiograph is shown in Figure 27b. What is the most likely cause of her symptoms?

Explanation

DISCUSSION: The patient sustained a very distal supracondylar fracture of the humerus. Fractures in this area can disrupt the blood vessels supplying the lateral ossification center of the trochlea. With disturbance of the blood supply in this area, local osteonecrosis occurs and disrupts the support for the overlying articular surface, producing joint incongruity and localized degenerative arthritis.
REFERENCES: Haraldsson S: The interosseous vasculature of the distal end of the humerus with special reference to the capitellum. Acta Orthop Scand 1957;27:81-93.
Morrissy RT, Wilkins KE: Deformities following distal humeral fracture in childhood. J Bone Joint Surg Am 1984;66:557-562.

Question 61

A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Explanation

Neurogenic shock is defined as vascular hypotension with bradycardia as a result of spinal injury. The first few minutes after spinal cord injury are associated with hypertension and tachycardia, with a subsequent drop in pressure and pulse rate.

Question 62

A 26-year-old man has had hand pain and progressive swelling in the knuckle for the past several months. He denies any trauma to the hand. The ring finger metacarpophalangeal joint is tender, and there is loss of motion in the digit. Figure 32a shows the radiograph and Figures 32b through 32d show the T 1 -weighted, T 2 -weighted, and gadolinium MRI scans, respectively. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph reveals a subchondral lesion in the metacarpophalangeal joint that is lytic and expansile. The MRI scans show a mass that is moderate in intensity on the

T₂-weighted image and has some gadolinium uptake. There are no cystic components in this lesion. The subchondral location and expansile nature are highly suggestive of giant cell tumor of bone. A lesion with this appearance might also represent an aneurysmal bone cyst, given the amount of expansion present.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 113-118.
Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 63

A 38-year-old marathon runner has had Achilles tendon pain for the past 2 months. Examination reveals that the tendon is thickened and tender proximal to the calcaneal insertion. The tendon sheath is not thickened or tender. The pathophysiology of the tendon is best described as

Explanation

DISCUSSION: Atraumatic Achilles tendon disease can be differentiated into Achilles tendinosis and peritendinitis. Thickening and tenderness of the Achilles tendon are present in both, but thickening and tenderness of the tendon sheath indicates peritendinitis. Histologic examination of Achilles tendinosis reveals an absence of acute and chronic inflammatory cells. Radiologists often diagnose partial tendon rupture by MRI and there may be microscopic longitudinal tears present, but there is no mechanical compromise as would be implied by a partial rupture. The thickening typically occurs in the portion of the tendon with the poorest blood supply, and biochemical analysis detects high levels of lactate and other products of anaerobic glycolysis.
REFERENCES: Astrom M, Rausing A: Chronic Achilles tendinopathy: A survey of surgical and histopathologic findings. Clin Orthop 1995;316:151-164.
Ohberg L, Lorentzon R, Alfredson H: Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: An ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc 2001;9:233-238.
Alfredson H, Bjur D, Thorsen K, et al: High intratendinous lactate levels in painful chronic Achilles tendinosis: An investigation using microdialysis technique. J Orthop Res

2002;20:934-938.

Question 64

What is the goal of surgical treatment in this scenario?

Explanation

DISCUSSION
This patient has a metastatic neuroendocrine tumor. Surgical treatment should prioritize palliation of her symptoms. She has high-grade spinal cord compression without neurologic signs or symptoms. Steroids are beneficial for patients with high-grade spinal cord compression caused by tumors, and these drugs should be administered in the acute setting. This patient was appropriately initially treated with conventional radiation. However, she is not a candidate for further radiation because of spinal cord tolerance limits and insufficient clearance between the tumor and spinal cord. Consequently, stereotactic radiation is not an option.
The goal of surgical treatment of this tumor should be palliation of her symptoms rather than cure. A costotransversectomy approach offers the advantage of ventral and dorsal spinal cord access, which is necessary in this case. A sternotomy or transthoracic approach would offer ventral access, but dorsal access would be less than optimal.
RECOMMENDED READINGS
Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: evaluation and management. J Am Acad Orthop Surg. 2011 Jan;19(1):37-48. Review. PubMed PMID: 21205766.View Abstract at PubMed
Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol. 2010 Oct;7(10):590-8. doi: 10.1038/nrclinonc.2010.137. Epub 2010 Aug

Question 65

The radiograph shown in Figure 27 shows measurement of what angle?

Explanation

DISCUSSION: The relationship between the distal articular surface of the first metatarsal head and the long axis of the first metatarsal is called the distal metatarsal articular angle. This angle has been validated by Richardson and associates to measure and determine the congruence of the first metatarsophalangeal joint. This angle is critical in determining the appropriate surgical procedure to perform on a patient with a bunion deformity because a congruent joint requires a procedure to maintain congruence of the articular surfaces following osteotomy. Therefore, a chevron becomes a biplanar chevron, and a Lapidus procedure adds a second osteotomy of the distal metatarsal to tilt the metatarsal head into a congruent location.
REFERENCES: Coughlin MJ: Juvenile hallux valgus: Etiology and treatment. Foot Ankle Int 1995;16:682-697.
Steel MW III, Johnson KA, DeWitz MA, et al: Radiographic measurements of the normal foot. Foot Ankle 1980;1:151-158.
Richardson EG, Graves SC, McClure JT, et al: First metatarsal head-shaft angle: A method of determination. Foot Ankle 1993;14:181-185.

Question 66

A 21-year-old soccer player reports pain and is unable to straighten his knee following an acute injury during a game. He is unable to continue to play. An MRI scan is shown in Figure 3. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has a locked knee that cannot be fully extended. This is most likely the result of the mechanical block of a bucket-handle tear that has flipped into the notch. Also, the pain may be so severe that the muscle spasm prevents the knee from straightening out. When the patient is anesthetized, the muscle spasm relaxes and the meniscus can be reduced out of the notch. Arthroscopy is the treatment of choice. A meniscal repair is usually possible in large bucket-handle tears because the meniscus is torn in the red-red zone where most of the vascular supply is located. If the handle portion is badly frayed or damaged, a partial meniscectomy should be performed. The classic finding on MRI is a “double PCL sign.” This is due to the flipped portion of the meniscus in the notch.
REFERENCES: Critchley IJ, Bracey DJ: The acutely locked knee: Is manipulation worthwhile? Injury 1985;16:281-283.
Bansal P, Deehan DJ, Gregory RJ: Diagnosing the acutely locked knee. Injury 2002;33:495-498.

Question 67

Initial postoperative management after repair of an acute rotator cuff tear includes

Explanation

DISCUSSION: In the immediate postoperative period following repair of an acute rotator cuff tear, passive forward elevation and external rotation should be performed within the safe zone determined at surgery. Early active range of motion (prior to tendon healing), internal rotation behind the back, and resistive exercises increase the risk of rupture of the repair.
REFERENCES: Iannotti JP: Full-thickness rotator cuff tear: Factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95.
Bigliani LU, Cordasco FA, McIlveen ST, et al: Operative repair of massive rotator cuff tears: Long-term result. J Shoulder Elbow Surg 1992;1:120-130.

Question 68

Which structure is indicated by the arrow in Figure 33?

Explanation

DISCUSSION
The posterior position of the sciatic nerve in relation to the acetabulum and the lateral peroneal division makes the peroneal division of the sciatic nerve the portion of the nerve that is most likely to be injured in a posterior traumatic hip dislocation, accounting for up to 10% of concomitant nerve injuries with posterior hip dislocation. The corona mortis is an anatomic variant that results in vascular anastomosis between the obturator and either the external iliac or inferior epigastric arteries. This variant occurs in approximately 80% of patients and varies in its position, being located 4 cm to 9 cm lateral to the symphysis pubis. The obturator vascular bundle is situated in the fat medial to the obturator internus muscle and must be mobilized to access the quadrilateral plate. Dissection may be carried out both above and below this vascular leash. The Kocher-Langenbeck approach is indicated for fractures involving the posterior wall and/or posterior column of the acetabulum and for both column fractures that require direct posterior visualization. This approach is not indicated for direct reduction of the anterior wall or column when direct visualization is required anteriorly. The L5 nerve root is located on the anterior sacrum and is indicated by the arrow.
The position of this neural structure must be considered whether the surgeon is stabilizing 31 the sacroiliac (SI) joint with percutaneous iliosacral screws or with anterior SI plating through the lateral window of the ilioinguinal approach.
RECOMMENDED READINGS
Cornwall R, Radomisli TE. Nerve injury in traumatic dislocation of the hip. Clin Orthop Relat Res. 2000 Aug;(377):84-91. Review. PubMed PMID: 10943188. View Abstract at PubMed
Darmanis S, Lewis A, Mansoor A, Bircher M. Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum. Clin Anat. 2007 May;20(4):433-9. PubMed PMID: 16944498. View Abstract at PubMed
Archdeacon MT, Kazemi N, Guy P, Sagi HC. The modified Stoppa approach for acetabular fracture. J Am Acad Orthop Surg. 2011 Mar;19(3):170-5. PubMed PMID: 21368098. View Abstract at PubMed
Rommens P. The Kocher-Langenbeck approach for the treatment of acetabular fractures. Operat Orthop Traumatol 2004; 16:59-74.
Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 2. Contemporary indications and techniques for definitive surgical management. J Am Acad Orthop Surg. 2013 Aug;21(8):458-68. doi: 10.5435/JAAOS-21-08-458. Review. PubMed PMID: 23908252.View Abstract at PubMed

Question 69

Acral metastases are most commonly seen in what type of carcinoma?

Explanation

DISCUSSION: Metastatic lesions to bone are usually located in the axial and proximal appendicular skeleton. Metastases below the elbow and knee are rare, but when they do occur they are most commonly from lung carcinoma.
REFERENCES: Hayden RJ, Sullivan LG, Jebson PJ: The hand in metastatic disease and acral manifestations of paraneoplastic syndromes. Hand Clin 2004;20:335-343.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 313.

Question 70

..First-line treatment recommendations include

Explanation

RESPONSES FOR QUESTIONS 47 THROUGH 52
Ultrasound
MRI scan of the thigh
Chest CT scan and whole-body bone scan
Positron emission tomography (PET) scan
Presurgical radiation therapy
Marginal resection
Radical resection and postsurgical radiation
Transverse incision centered over the mass
Incision centered over the mass in line with long axis of limb
Sentinel node biopsy
Core needle biopsy
For each soft-tissue mass clinical scenario or question below, match the most appropriate next evaluation or treatment step listed above.

Question 71

A 55-year-old woman who underwent a left total hip arthroplasty 8 months ago using a modified Hardinger approach reports a persistent painless limp. Examination reveals that when she is not using a cane, she lurches to the left during weight bearing on the left lower extremity. An AP radiograph is shown in Figure 29. Which of the following hip muscle groups should be strengthened to improve the gait abnormality?

Explanation

DISCUSSION: The modified Hardinger approach includes a partial anterior trochanteric osteotomy creating a trochanteric wafer (as seen on the radiograph) that is displaced anterior and medial in continuity with the gluteus medius and vastus lateralis. Failure of abductor reattachment, migration of the trochanter, nonunion of the osteotomy site, and excessive splitting of the gluteus medius muscle causing injury to the inferior branch of the superior gluteal nerve can result in weakness of the abductor mechanism. Abductor strength should be evaluated with the patient lying on the opposite side and elevating the affected limb. Although slight weakness may manifest itself as a limp only after prolonged muscular activity, significant weakness results in a constant limp without associated discomfort.
REFERENCES: Morrey BF (ed): Joint Replacement Arthroplasty. New York, NY, Churchill Livingstone, 1991, pp 512-526.
Kasser JR (ed): Orthopedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 389-426.

Question 72

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 73

The brachialis muscle is innervated by what two nerves?

Explanation

DISCUSSION: The brachialis is innervated by two nerves: medially, the musculocutaneous nerve; laterally, the radial nerve. The muscle is split longitudinally to approach the humerus anteriorly.
REFERENCES: Henry AK: The distal part of the humerus and front of the forearm, in Henry AK (ed): Extensile Exposure, ed 2. Edinburgh, UK, Churchill Livingstone, 1973, pp 90-115.
King A, Johnston GH: A modification of Henry’s anterior approach to the humerus. J Shoulder Elbow Surg 1998;7:210-212.

Question 74

Failure of posterolateral corner repair or reconstruction of the knee may be associated with which of the following? Review Topic

Explanation

Failure to reconstruct a torn anterior cruciate ligament or posterior cruciate ligament at the time of posterolateral corner (PLC) repair or reconstruction dramatically increases the likelihood of PLC failure. Uncorrected varus malalignment places extensive tension on a PLC reconstruction and is a well recognized cause of failure. Valgus malalignment and medial collateral ligament reconstruction are not recognized means of failure.

Question 75

Which of the following is considered a potential advantage in prophylaxis for the prevention of deep venous thrombosis associated with the use of low-molecular weight heparin (LMWH) as compared with fixed-dose unfractionated heparin?

Explanation

DISCUSSION: One possible reason for improved efficacy of LMWHs is the relative improved bioavailability compared with that of unfractionated heparin. This is, in part, the result of a more predictable dose response and a longer half-life. There is no alteration of venous flow, and the rate of bleeding complications is the same or slightly higher than that of other prophylactic agents.
REFERENCES: Colwell CW Jr, Spiro TE, Trowbridge AA: Use of enoxaparin, a low-molecular weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: A clinical trial comparing efficacy and safety. J Bone Joint Surg Am 1994;76:3-14.
Bara L, Billaud E, Kher A, Samama M: Increased anti-Xa bioavailability for a low-molecular weight heparin (PK 10169) compared with unfractionated heparin. Semin Thromb and Hemost 1985;11:316-317.
Paiement GD: Prevention and treatment of venous thromboembolic disease complications in primary hip arthroplasty patients, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 331-335.

Question 76

A 27-year-old man has had pain in the right index finger for the past 9 months. The pain is completely relieved with ibuprofen. An AP radiograph and CT scan are shown in Figures 80a and 80b. What is the most likely diagnosis?

Explanation

DISCUSSION: Osteoid osteoma is a round or oval, well-circumscribed lesion with a

radiolucent nidus. A small area of calcification may be present within the center of the nidus. The radiolucent nidus is surrounded by a thick rim of sclerotic bone. These diagnostic

features are frequently better seen on CT. An increase in cyclooxygenase activity has been demonstrated within osteoid osteomas, which may explain why aspirin and other nonsteroidal anti-inflammatory drugs classically relieve the pain associated with these lesions.
REFERENCES: Kneisl JS, Simon MA: Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg Am 1992;74:179-185.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 121-130.

Question 77

What nerve is most at risk during placement of the anterolateral portal in elbow arthroscopy?

Explanation

DISCUSSION: The radial nerve is only 4 mm from the anterolateral portal, while the median nerve is 11 mm away from the anteromedial portal. The ulnar nerve is only at risk on the medial side of the elbow. Anterior and posterior interosseous nerves are more distal within the forearm and are not in danger during portal placement.
REFERENCES: O’Driscoll SW, Morrey BF: Elbow arthroscopy, in Morrey BF (ed): The Elbow. Philadelphia, PA, Lippincott, Williams and Wilkins, 1994, pp 21-34.
Field LD, Altchek DW, Warren RF, O’Brien SJ, Skyhar MJ, Wickiewicz TL: Arthroscopic anatomy of the lateral elbow: A comparison of three portals. Arthroscopy 1994;10:602-607.

Question 78

A 12-year-old boy sustains open comminuted midshaft tibial and fibular fractures while playing indoor soccer. The wound is grossly clean and measures 7 cm with some periosteal stripping. Antibiotics and tetanus toxoid are administered immediately in the emergency department. Following irrigation and debridement of the wound in the operating room, treatment should include

Explanation

DISCUSSION: Open fractures in children have similar rates of short-term complications such as compartment syndrome, vascular injury, and nerve injury when compared to adult fractures. Primary wound closure should be used for Gustillo and Anderson type 1 or uncomplicated type 2 fractures after surgical debridement. Skeletal stabilization may consist of external fixation, flexible nails, or casting with or without supplementary pin fixation. For an open comminuted midshaft fracture, external fixation is the treatment of choice. Reamed intramedullary nailing is contraindicated in children with an open physis. Plate fixation has a high complication rate in severe open fractures.
REFERENCES: Jones BG, Duncan RD: Open tibial fractures in children under 13 years of age-10 years experience. Injury 2003;34:776-780.
Bartlett CS III, Weiner LS, Yang EC: Treatment of type II and type III open tibia fractures in children. J Orthop Trauma 1997;11:357-362.
Robertson P, Karol LA, Rab GT: Open fractures of the tibia and femur in children. J Pediatr Orthop 1996;16:621-626.
Cullen MC, Roy DR, Crawford AH, et al: Open fracture of the tibia in children. J Bone Joint Surg Am 1996;78:1039-1047.

Question 79

A 70-year-old former baseball catcher reports long-standing pain in the ring and little fingers. A gradient-echo MRI scan is shown in Figure 26. What is the most likely diagnosis?

Explanation

DISCUSSION: The gradient-echo MRI scan highlights the ulnar and radial arteries,

as indicated by the arrow. This technique suppresses the signal of the surrounding fat

and causes the stationary surrounding tissues to become intermediate in signal intensity.

The flowing blood is then easily identified with a bright signal because it does not absorb the radiofrequency pulse. Based on the findings, the diagnosis is an ulnar artery aneurysm, most likely caused by years of repetitive trauma as the result of catching baseballs. Neurolemmoma and giant cell tumor of the tendon sheath would be intermediately enhanced on this image sequence, and the continuity with the ulnar artery, demonstrated here, would not be expected. Lipomas are not enhanced using the gradient-echo technique. The chronic nature of the patient’s symptoms is not indicative of a hematoma, and the hematoma would be dark on this imaging sequence since it is stationary tissue.
REFERENCES: Koman LA, Ruch DS, Patterson Smith B, et al: Vascular disorders, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, vol 2, pp 2254-2302.
Holder LE, Merine DS, Yang A: Nuclear medicine, contrast angiography, and magnetic resonance imaging for evaluating vascular problems in the Hand: Vasospastic disorders. Hand Clin 1993;9:95-113.

Question 80

A 72-year-old man has had persistent pain after undergoing a hemiarthroplasty 18 months ago. Radiographs are shown in Figures 50a and 50b. What is the most likely cause of his problem?

Explanation

DISCUSSION: The radiographs demonstrate a rapid erosion of the bipolar component into the acetabulum. Although acetabular erosion is more common with unipolar hip arthroplasties, it can occur with bipolar components. Haidukewych and associates noted a very low erosion rate but none in the first 2 years. The second finding on the radiographs is the linear radiolucency progressing from the joint toward the end of the stem at the cement-bone interface suggesting chronic infection or diffuse loosening. The persistent pain since implantation also suggests chronic infection. High activity levels and osteoporosis do not lead to acetabular erosion in the first 2 years after hemiarthroplasty. While the cement technique is suboptimal, loosening and erosion should not be expected from this alone. An oversized bipolar head would extrude and not erode.
REFERENCES: Haidukewych GJ, Israel TA, Berry DJ: Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res 2002;403:118-126.
Lestrange NR: Bipolar hemiarthroplasty for 496 hip fractures. Clin Orthop Relat Res 1990;251:7-19.
Callaghan JJ, Dennis DA, Paprosky WG, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, p 158.

Question 81

The most common neurologic injury following an anterior cervical diskectomy and fusion (ACDF) is injury to which of the following structures? Review Topic

Explanation

The most common neurologic injury in ACDF is injury to the recurrent laryngeal nerve. It is most vulnerable on the right because it crosses from lateral to midline more cephalad in the incision after it passes under the subclavian artery; conversely, on the left the course is more caudal because it passes under the aortic arch, a more caudal structure. The superior laryngeal nerve runs along with the superior thyroid artery in the upper cervical spine, putting it at risk during surgical procedures on the upper cervical spine which are less commonly performed. A C5 root palsy more commonly occurs as a result of multilevel posterior decompressive procedures, possibly because of its short transverse take-off from the cord. The sympathetic chain lies on top of the longus colli and can be injured if retractors are not placed under the longus colli muscle.

Question 82

-The main blood supply to the capital femoral epiphysis in a 10-year-old child is supplied from the

Explanation

Question 83

The use of radiation therapy is most effective in metastatic bone disease from which of the following tumors?

Explanation

DISCUSSION: Both myeloma and lymphoma are more responsive to radiation therapy. The other types of tumors are relatively more resistant to radiation. Doses of 25 to 50 Gy (2,500 to 5,000 cGy) are usually sufficient for myeloma and lymphoma, while carcinomas frequently require a higher dosage. Large cell lymphoma of bone is usually of B-cell origin and is treated with chemotherapy and radiation therapy.
REFERENCES: Simon MA, Springfield DS, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 683.
Riley LH III, Frassica DA, Kostuik JP, Frassica FJ: Metastatic disease to the spine: Diagnosis and treatment. Instr Course Lect 2000;49:471-477.

Question 84

A 24-year-old baseball pitcher reports pain over the posterior aspect of his shoulder that occurs only during throwing. He notes that the discomfort is greatest during the late cocking and early acceleration phases. Examination reveals localized tenderness with palpation over the external rotators and posterior glenoid. Radiographs are shown in Figures 38a through 38c. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show a posterior glenoid osteophyte, often termed a “thrower’s exostosis.” These exostoses are best visualized on the Stryker notch view and may be missed on other more standard radiographic views of the shoulder. CT and MRI scans may be used, but usually add little information to the radiographic findings. Arthroscopic examination of patients with this condition commonly reveals undersurface tearing of the rotator cuff and posterior labrum. Treatment of this condition remains somewhat controversial, with avocation of both nonsurgical and surgical techniques.
REFERENCES: Meister K, Andrews JR, Batts J, Wilk K, Baumgarten T, Baumgartner T: Symptomatic thrower’s exostosis: Arthroscopic evaluation and treatment. Am J Sports Med 1999;27:133-136.
Ferrari JD, Ferrari DA, Coumas J, Pappas AM: Posterior ossification of the shoulder: The Bennett lesion. Etiology, diagnosis, and treatment. Am J Sports Med 1994;22:171-176.
Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posteriorsuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1992;1:238-245.

Question 85

Wear particles of ultra-high molecular weight polyethylene that are generated by total hip implants are predominantly of what diameter?

Explanation

DISCUSSION: Multiple studies have shown that the size of an ultra-high molecular weight polyethylene particle generated by total hip implants is typically less than 1 micron. This finding is significant in that particles of that size are readily phagocytized by macrophages.
REFERENCES: Campbell P, Ma S, Yeom B, McKellop H, Schmalzried TP, Amstutz HC: Isolation of predominantly submicron-sized UHMWPE wear particles from periprosthetic tissues. J Biomed Mater Res 1995;29:127-131.
Shanbhag AS, Jacobs JJ, Glant TT, Gilbert JL, Black J, Galante JO: Composition and morphology of wear debris in failed uncemented total hip replacement. J Bone Joint Surg Br 1994;76:60-67.
Maloney WJ, Smith RL, Schmalzried TP, Chiba J, Huene D, Rubash H: Isolation and characterization of wear particles generated in patients who have had failure of a hip arthroplasty without cement. J Bone Joint Surg Am 1995;77:1301-1310.

Question 86

Exostoses in which of the following anatomic locations is the most likely to undergo malignant transformation in a patient with multiple hereditary exostosis (MHE)?

Explanation

DISCUSSION: Although osteochondromas can occur in almost every bone in patients with MHE, proximally located lesions are more likely to undergo malignant transformation. Annual radiographs of the shoulder girdles and pelvis are indicated in patients with MHE. Any enlarging osteochondromas are a concern as possible malignancies.
REFERENCES: Peterson HA: Multiple hereditary osteochondromata. Clin Orthop 1989;239:222.
McCornack EB: The surgical management of hereditary multiple exostosis. Orthop Rev 1981;10:57.

Question 87

-Radiographs are shown in Figures 89a through 89c. What is the most likely diagnosis?

Explanation

Question 88

A 33-year-old female sustains the injury shown in Figure A as the result of a fall off a chair, and subsequently undergoes operative stabilization of her injury. Which of the following is most correlated with positive outcomes when treating this injury?

Explanation

Long-term outcomes after an ankle syndesmotic injury are most correlated with an anatomic reduction of the ankle syndesmosis. Formal open reduction of the syndesmosis has been shown to improve outcomes by improving the reduction quality.
While the importance of anatomic reduction of a syndesmotic injury is clear, controversy exists regarding the ideal method of fixation. No significant differences are reproducibly reported in regards to number of syndesmotic screws, size, or number of cortices. There is emerging data supporting the use of suture button fixation.
Wikeroy et al. reviewed 48 patients at a mean of 8.4 years, and they found that patients with a difference in the syndesmotic width between the operated and the nonoperated ankle of 1.5 mm or more showed inferior results. Posterior malleolar fragments and obese patients also had worse outcomes.
Schepers et al. published a review on the suture button device comparisons to traditional screw fixation, reviewing 6 biomechanical studies and 34 clinical studies. They found that the suture button systems have similar outcomes to screw fixation, but insufficient long-term and high-quality evidence prevented a strong conclusion. Implant removal in the suture button groups averaged 10%, while screw removal averaged 52%.
Sagi et al. reviewed 107 patients with ankle fractures and associated syndesmotic
injuries requiring surgery. They found that 39% were malreduced, but open reduction of the syndesmotic injury cut the malreduction rate by 2/3. They also reported that at a minimum of 2 years follow-up, patients with malreduced syndesmotic injuries demonstrated worse functional outcome scores.
Figure A shows an ankle fracture with obvious syndesmotic injury/widening. Incorrect answers:
1-4: These choices are not correlated with excellent outcomes with treatment of a
syndesmotic injury.

Question 89

Which of the following forms of nonsurgical management is considered best for acute low back pain without radiculopathy?

Explanation

DISCUSSION: Temporary bed rest (less than 4 days) with gradual resumption of activities can be efficacious. Epidural steroid injections may be indicated for acute low back pain with radiculopathy. Acupuncture, facet joint injections, or ligamentous (sclerosant) injections are not indicated.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, Appendix A15.
Helfgott SM: Sensible approach to low back pain. Bull Rheum Dis 2001;3:50.

Question 90

A patient reports persistent anterior shoulder pain following a forceful external rotation injury to the shoulder. An MRI scan is shown in Figure 4. The patient remains symptomatic despite 3 months of nonsurgical management. Treatment should now consist of

Explanation

DISCUSSION: The MRI scan reveals a subscapularis tear with a biceps that is out of the groove. Treatment in this patient is most predictable if the subscapularis is repaired. The biceps should either be tenodesed or tenotomized since it is unstable. Recentering of the biceps has been found to be unpredictable. Treatment of these lesions has been shown to have better results if the biceps is either released or tenodesed. This prevents recurrent biceps symptoms that can be source of surgical failure.
REFERENCES: Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10.
Deutsch A, Altcheck DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Walch G, Nove-Josserand L, Boileau P, et al: Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 1998;7:100-108.

Question 91

The images reveal T2-weighted MRI sequences with edema isolated to the infraspinatus. In the absence of a tear in the infraspinatus tendon, the edema is most likely due to compression of the suprascapular nerve in the spinoglenoid notch. As this pathology persists, progressive muscle atrophy and fatty infiltration can result. Compression of the suprascapular nerve in the suprascapular notch would have resulted in edema and weakness in both the supra- and infraspinatus muscles. Compression is commonly caused by cysts from the joint secondary to labral tears. A rotator cuff tear of the infraspinatus is not identified on these images, and there is no history of trauma provided. There is no evidence of an anteroinferior labral tear, nor would this be expected to result in external rotation weakness or MRI abnormality of the infraspinatus. Quadrilateral space syndrome results in compression of the axillary nerve, which supplies the teres minor. Correcr answer : C 40- A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?

Explanation

Figure 1 is the radiograph of a 12-year-old baseball player who has posterolateral elbow pain with throwing. The area of interest is designated by the black arrow. His range of motion and strength are full. No previous treatment has been provided. What is the most appropriate initial treatment?
A. Elbow arthroscopy with debridement
B. Immobilization and rest for 6 weeks
C. Corticosteroid injection
D. Open osteochondral autograft transfer
Osteochondritis dissecans of the capitellum is a painful condition that affects immature athletes who undergo repetitive compression of the radiocapitellar joint. Management is based primarily on the integrity of the articular cartilage surface and the stability of the lesion. Nonsurgical treatment is typically selected for patients
with early-grade, stable lesions, and it involves activity modification with cessation of sports participation. The duration of activity modification is dictated by symptoms, with 3 to 6 weeks of rest followed by return to sport in 3 to 6 months commonly used as a guideline. Strengthening and stretching exercises are commonly incorporated after the pain has subsided. Surgical intervention or corticosteroid injection would not be first-line treatment.
42- Figures 1 and 2 are the radiographs of a 69-year-old man with a history of treated prostate cancer and hemodialysis-dependent end- stage renal disease who presents to the emergency department with progressively worsening right shoulder pain and stiffness. Laboratory tests reveal a white blood cell count of 17,000, erythrocyte sedimentation rate, 75, and CRP, 10.1. He has a draining sinus located along the anterior shoulder. What is the best next step?

Question 92

What bilateral surgical intervention is considered inappropriate based on the findings shown in the radiograph in Figure 52?

Explanation

DISCUSSION: The radiograph reveals osteonecrosis of both femoral heads with reasonably maintained joint surfaces. There may be some slight flattening of the femoral heads. Hip arthrodesis is difficult to perform because of the necrotic bone. Its use in patients with osteonecrotic hips is limited because of the 80% bilaterality; therefore, it is not an acceptable alternative. All the other options are acceptable interventions.
REFERENCES: Mont MA, Jones LC, Sotereanos DG, et al: Understanding and treating osteonecrosis of the femoral head. Instr Course Lect 2000;49:169-185.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 93

Figure 10 is the radiograph of a 44-year-old man with a long-standing history of severe hip pain and a limp. Which clinical scenario most likely could occur when performing total hip arthroplasty on this patient?

Explanation

CLINICAL SITUATION FOR QUESTIONS 11 THROUGH 13
Figures 11a and 11b are the radiographs of a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, she has failed nonsurgical treatment including weight loss, activity modifications, and intra-articular injections. Her infection workup reveals laboratory findings within defined limits.

Question 94

The radiograph seen in Figure 67 reveals an ankle fracture in a 65-year-old woman who slipped on the ice. She has a history of diabetes mellitus for the past 7 years and reports that she maintains fair control of her diabetes; her last HgbA1c was 8%. The patient is a community ambulatory who lives independently. Examination reveals she has absent sensation with the 5.07 monofilament. When determining management, the physician must consider which of the following?

Explanation

Increased immobilization and delayed weight bearing are indicated in the neuropathic population after treating an ankle fracture. Patients with diabetes mellitus and peripheral neuropathy have higher complication rates following ankle fractures treated surgically or nonsurgically. The elevated HgbA1c and neuropathy both predict a higher complication rate with this fracture. Outcomes after nonsurgical management of this fracture are poorer than after surgical treatment. Early bone grafting is not recommended in closed fractures, but the use of supplemental internal fixation is recommended because of the high risk of nonunion. More substantial constructs with supplemental fixation, locking fixation, fixation through the calcaneus and talus into the tibia, or external fixation are necessary. Primary arthrodesis is not recommended in this fracture pattern or in a relatively active patient.

Question 95

An 18-year-old patient sustains a comminuted left femoral fracture starting 6.5cm distal to the lesser trochanter. He undergoes antegrade femoral nailing in the supine position on a radiolucent table. Upon completion of proximal and distal interlocking, both patellae are positioned facing the ceiling and a lateral radiographs confirms that the posterior condyles of both limbs are aligned. On AP imaging of both femora, it is noted that the lesser trochanter of the left (injured) side is larger than the right (uninjured) side. Assuming symmetrical anteversion, the left femur has been nailed Review Topic

Explanation

Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels I hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:

Question 96

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

Explanation

DISCUSSION: Two recent studies by Pollak and associates and Marsh and associates have focused on function after high-energy tibial plafond fractures. Findings are unfavorable even when anatomic reduction is performed in the best centers and patients are provided excellent rehabilitation. Function improves up to 2 years after injury, but even basic walking skills remain adversely affected. Virtually all patients have long-term adverse general health effects compared to their gender and age-matched peers. Posttraumatic degenerative arthritis is present in most ankles. Patients should be told early about the long-term prognosis, and early vocational/psychological counseling should be given. Despite these adverse outcomes, only a minority of patients require fusion or arthroplasty.
REFERENCES: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.
Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: How do these ankles function over time? J Bone Joint Surg Am 2003;85:287-295.

Question 97

A 23-year-old woman has had a 3-year history of snapping and pain in her left hip. She notes that the snapping started while marathon training and is only problematic about 15 minutes into a run. Examination is consistent with a negative Stinchfield, negative logroll, negative flexion abduction/external rotation test (FABER) of the hip; however, she has a positive Ober test as she has difficulty adducting her hip across the midline in the lateral decubitus position. Management consisting of nonsteroidal anti-inflammatory drugs and stretching has failed to improve her snapping. What is the most reliable surgical treatment? Review Topic

Explanation

The patient has external-type snapping hip (coxa saltans). It is not uncommon for patients to have a very long duration of symptoms that limit running or other sporting activities, and commonly affects the downward leg (usually the left leg when running on the left side of the road). The snapping causes a profound bursitis at the greater trochanter, and occasionally corticosteroid injections may be helpful. Her physical examination does not suggest an intra-articular process, and is not consistent with an internal-type snapping hip, usually caused by the iliopsoas tendon as it moves over the iliopectineal eminence. Stretching is the mainstay of treatment, as testing with a positive Ober signifies a tight iliotibial band as the thigh has difficulty crossing the midline with adduction. Various iliotibial band lengthening procedures have been described, including a Z-plasty near the proximal origin of the iliotibial band. Release at Gerdy's tubercle has not been described.

Question 98

A 42-year-old patient has had painful inferior subluxation of the glenohumeral joint following a recent cerebrovascular accident (CVA). Figure 34 shows the AP radiograph of the shoulder. Management should consist of

Explanation

DISCUSSION: Following a CVA and with the resumption of upright posture, downward subluxation of the glenohumeral joint may occur. Although usually painless, some patients may report pain secondary to stretching of the brachial plexus. This is the result of flaccid paralysis of the deltoid muscle, and it will persist until some motor tone or spasticity returns to the shoulder girdle musculature. Early sling support and range-of-motion exercises to prevent contracture will provide the best relief. Surgical procedures are not indicated.
REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.
McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient. Instr Course Lect 1975;24:45-55.

Question 99

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 100

Figure 1 is the MRI scan of a 19-year-old man who has an acute anterior shoulder dislocation. The bony fragment occupies 10% of the glenoid articular surface. What is the most appropriate treatment? Review Topic

Explanation

The MRI scan shows a bony Bankart lesion involving less than 20% of the glenoid joint surface. A recent series reported high success rates after arthroscopic treatment when the defect is incorporated into the repair. Anterior bony deficiencies occupying more than 25% to 30% of the glenoid joint surface treated with soft-tissue repair only are associated with high recurrence rates. In these patients, an open or arthroscopic coracoid transfer or structural iliac crest graft should be considered. Open reduction and internal fixation has been reported for treatment of large acute glenoid rim fractures but is not recommended for recurrent anterior shoulder instability in the setting of a 10% glenoid rim fracture.

Full Question & Answer Text (for Search Engines)

Question 1:

Arthrodesis of which of the following joints has the greatest cumulative effect on midfoot/hindfoot motion?

Options:

Talonavicular
Naviculocuneiform
Subtalar
Cuboid-fifth metatarsal
Calcaneocuboid

Correct Answer: Talonavicular

Explanation:

DISCUSSION: Arthrodesis of the talonavicular joint eliminates almost all hindfoot motion. Arthrodesis of the subtalar joint eliminates 74% of talonavicular motion and 44% of calcaneocuboid motion. Arthrodesis of the calcaneocuboid joint eliminates 33% of talonavicular motion and 8% of subtalar motion. Arthrodesis of the naviculocuneiform or cuboid-fifth metatarsal joint has limited effect on hindfoot motion.
REFERENCES: Astion DJ, Deland JT, Otis JC, et al: Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am 1997;79:241-246.
Savory KM, Wülker N, Stukenborg C, et al: Biomechanics of the hindfoot joints in response to degenerative hindfoot arthrodeses. Clin Biomech 1998;13:62-70.

Question 2:

Contraindications to cervical laminectomy as a treatment for cervical spondylotic myelopathy include which of the following findings?

Options:

Multilevel disease with spinal cord compression
Anterior spinal cord compression
Posterior spinal cord compression
Cervical kyphosis
Ossification of the posterior longitudinal ligament

Correct Answer: Cervical kyphosis

Explanation:

Question 3:

Options:

Fracture of the ulnar component
Disengagement of the axle of the prosthesis
Failure of the triceps mechanism repair
Periprosthetic fracture of the humerus
Periprosthetic fracture of the ulna

Correct Answer: Failure of the triceps mechanism repair

Explanation:

Question 4:

Placing the starting point for an antegrade femoral nail too anterior to the axis of the medullary canal can lead to what intraoperative complication?

Options:

Nail incarceration
Loss of locking screw trajectory into the lesser trochanter
Creation of a procurvatum deformity
Iatrogenic fracture of the proximal fragment
Decrease in hoop stresses

Correct Answer: Nail incarceration

Explanation:

Question 5:

Options:

Septic arthritis
Early onset osteoarthritis
ACL graft re-rupture
Cyclops lesion formation
Femoral and tibial tunnel osteolysis

Correct Answer: ACL graft re-rupture

Explanation:

Question 6:

With respect to the structure identified by the arrow in Figure 22b, the meniscofemoral 25 ligaments are

Options:

uniformly present, and are positioned posterior to the injured ligament.
uniformly present, with one positioned anterior and the other positioned posterior to the injured ligament.
variably present, and are positioned posterior to the injured ligament.
variably present, with one positioned anterior and the other positioned posterior to the injured ligament.

Correct Answer: variably present, with one positioned anterior and the other positioned posterior to the injured ligament.

Explanation:

DISCUSSION
The stress radiographs demonstrate posterior instability of the right knee in flexion. The MR images demonstrate injury to both the anterior and posterior cruciate ligament (PCL), with the stump identified with the arrow on the MR image (Figure 22b). The PCL has 2 functional bands. The anterolateral bundle originates from the roof of the intercondylar notch. It runs in a posterolateral direction onto the tibial crest between the posterior attachment of the medial and lateral menisci. During a double-bundled posterior ligament reconstruction, the
anterolateral bundle is tensioned with the knee in a position of mid flexion. The posteromedial bundle has a variable pattern of tension both in extension and in high flexion. Tensioning of the posteromedial bundle in extension may contribute to resistance against knee hyperextension.
The meniscofemoral ligaments are variably present. Although 93% of knees have been reported to have at least 1 meniscofemoral ligament present, both ligaments are simultaneously present in approximately 50% of knees. The ligament of Humphrey (anterior meniscofemoral ligament) and ligament of Wrisberg (posterior meniscofemoral ligament) are delineated by their anatomic relationship to the posterior cruciate.
RECOMMENDED READINGS
Amis AA, Bull AM, Gupte CM, Hijazi I, Race A, Robinson JR. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):271-81. Epub 2003 Sep 5. Review. PubMed PMID: 12961064.
View Abstract at PubMed
Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):257-63. Epub 2005 Oct 14. Review. PubMed PMID: 16228178.
View Abstract at PubMed
.
26

Question 7:

Options:

Peroneal spastic flatfoot
Flexible flatfoot with a short Achilles tendon
Calcaneonavicular coalition
Talocalcaneal coalition
Posterior tibial tendon dysfunction

Correct Answer: Talocalcaneal coalition

Explanation:

Question 8:

Options:

Revision to a long stem prosthesis with impaction grafting
Revision to a long stem prosthesis, bypassing the defect
Proximal femoral allograft reconstruction
Cable plate fixation with cortical strut graft augmentation
Cable fixation alone

Correct Answer: Cable plate fixation with cortical strut graft augmentation

Explanation:

Question 9:

..The best initial treatment would entail

Options:

physical therapy and nonsteroidal anti-inflammatory medications.
open biopsy of the lesion for permanent section.
manipulation under anesthesia.
shoulder arthroscopy. DISCUSSION.. Calcific tendinitis of the shoulder is a deposition of calcium carbonate apatite crystals into the structure of the rotator cuff tendon. The crystalline form appears to progress throughout the clinical disease process, demonstrating increasing matured stoichiometric apatite deposition during the resorptive phase. MRI can be difficult to interpret because the signal of the calcific lesion is frequently similar to that seen in normal supraspinatus tendon. Plain radiographs remain the gold standard for diagnosis. Ultrasound can be a useful ancillary study to determine the location and size of the lesion. Primary management of calcific tendinitis starts with nonsurgical treatment including physiotherapy and injections, if indicated. Mixed results have been reported with extracorporeal shock wave therapy. Surgical removal with repair of the tendon in larger lesions remains the definitive treatment when nonsurgical modalities fail. Subacromial decompression may improve pain relief in patients who require surgery; however, patients with decompression may take longer to fully recover.

Correct Answer: physical therapy and nonsteroidal anti-inflammatory medications.

Question 10:

Elbow distraction interposition arthroplasty may be most appropriate treatment for which of the following patient profiles? Review Topic

Options:

year-old woman with destructive juvenile rheumatoid arthritis
year-old male laborer with posttraumatic arthritis of the elbow
year-old woman with distal humerus osteonecrosis and collapse
year-old man with painful primary elbow osteoarthritis
year-old sedentary woman with end-stage rheumatoid arthritis

Correct Answer: year-old male laborer with posttraumatic arthritis of the elbow

Explanation:

Question 11:

Options:

intralesional curettage.
wrist disarticulation.
amputation.
chemotherapy.
radiation therapy.

Correct Answer: amputation.

Explanation:

Question 12:

Figure 16 shows an axial MRI scan through the knee joint. What structure is identified by the arrow?

Options:

Anterior cruciate ligament
Posterior cruciate ligament
Ligament of Wrisberg
Ligamentum mucosum
Popliteus tendon

Correct Answer: Anterior cruciate ligament

Explanation:

Question 13:

Options:

Ganglion cyst
Abscess
Hematoma
Giant cell tumor of tendon sheath
Synovial sarcoma

Correct Answer: Giant cell tumor of tendon sheath

Explanation:

DISCUSSION: Giant cell tumor of the tendon sheath is the most common solid soft-tissue mass in the hand. These tumors are slow-growing and may be present for months or years before coming to medical attention. Patients usually report mechanical difficulties because of the size or position of the tumor. The gross appearance is that of a lobulated mass that may be multicolored; typically yellow, brown, red, and gray. Histologically the lesion consists of multinucleated giant cells, polygonal mononuclear cells, and histiocytes that may contain abundant hemosiderin or lipid.
REFERENCES: Walsh EF, Mechrefe A, Akelman E, et al: Giant cell tumor of tendon sheath. Am J Orthop 2005;34;116-121.
Weiss SW, Goldblum JR (eds): Enzinger and Weiss’s Soft Tissue Tumors, ed 4. St Louis, MO, Mosby, 2001, pp 1038-1047.

Question 14:

Which component position is associated with poor patellar tracking during total knee arthroplasty (TKA)?

Options:

Lateral placement of the femoral component
Medial placement of the patellar component
Internal rotation of the tibial component
Varus alignment of the proximal tibia

Correct Answer: Internal rotation of the tibial component

Explanation:

DISCUSSION
Internal malrotation of the femoral or tibial component is associated with lateral tracking of the patella in TKA. Lateral placement of the femoral component and medial placement of the patella component can aid in preventing lateral tracking of the patella. Varus alignment of the proximal tibia has not been associated with patella maltracking.
RESPONSES FOR QUESTIONS 106 THROUGH 109
Immobilization/nonsurgical management
Irrigation and debridement
stage reimplantation total knee arthroplasty (TKA)
Increased constraint/polyethylene exchange
Revision of the femoral component only
Revision of the tibial component only
Revision of both components
Revision of the patellar component
Select the treatment listed above that most appropriately addresses each scenario described below.

Question 15:

Options:

Posterior band of the medial collateral ligament
Anterior band of the medial collateral ligament
Radial collateral ligament
Lateral ulnar collateral ligament The patient is showing signs of posterolateral rotatory instability after elbow dislocation. The lateral ulnar collateral ligament is responsible for stabilizing the elbow against this type of instability. The posterior and anterior bands of the medial collateral ligament are primarily resistors of valgus load, with the anterior band being the most significant contributor. The radial collateral ligament does not control the posterolateral rotatory instability described.

Correct Answer: Lateral ulnar collateral ligament The patient is showing signs of posterolateral rotatory instability after elbow dislocation. The lateral ulnar collateral ligament is responsible for stabilizing the elbow against this type of instability. The posterior and anterior bands of the medial collateral ligament are primarily resistors of valgus load, with the anterior band being the most significant contributor. The radial collateral ligament does not control the posterolateral rotatory instability described.

Explanation:

Question 16:

Options:

Profundus femoris
Middle genicular
Medial sural
Inferior medial genicular

Correct Answer: Medial sural

Explanation:

Question 17:

Options:

Technetium Tc 99m triple phase bone scan 1- Technetium Tc 99m triple phase bone scan
Admit for elevation, observation, and IV antibiotics
Total contact casting, no weight bearing, and weekly cast changes until erythema and swelling is decreased
Immediate stabilization of the talus and midfoot with internal fixation and postoperative splinting, no weight bearing, and total contact casting
Total contact casting, weight bearing as tolerated, with weekly cast changes

Correct Answer: Total contact casting, no weight bearing, and weekly cast changes until erythema and swelling is decreased

Explanation:

DISCUSSION: Whereas it is difficult to distinguish between cellulitis, septic joint, osteomyelitis, and early Eichenholtz stage 1 Charcot, the presence of a fracture in the absence of ulcerations with a normal WBC count and serum glucose strongly indicates that the described symptoms are due to an early Charcot process alone. A technetium Tc 99m scan alone would not be helpful; however, the addition of a sulfur colloid marrow scan or indium In 111 scan may be more specific to rule out infection, though it is not warranted here. Total contact casting with non-weight-bearing or limited weight bearing during Eichenholtz stage 1 when the foot is warm, erythematous, and swollen is advised to help prevent deformity. Alternatively, stabilization with pneumatic bracing may also be considered. While some authors have proposed early fixation or arthrodesis for Eichenholtz stage 1, the gold standard is still total contact casting with no to limited weight bearing until the swelling resolves and evidence of consolidation is seen on radiographs.
REFERENCES: Trepman E, Nihal A, Pinzur MS: Current topics review: Charcot neuropathy of the foot and ankle. Foot Ankle Int 2005;26:46-63.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 123-134.
Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950.

Question 18:

Options:

Manipulation under anesthesia
Left total knee arthroplasty (TKA)
Stem cell injection
Unicompartmental knee arthroplasty in the lateral compartment The patient has a valgus deformity and has developed stiffness in both flexion and extension. Given the progressive loss of motion, progression to TKA is indicated. Manipulation under anesthesia would not be efficacious to prevent the progressive loss of motion without correcting the underlying mechanical issues. The patient has global pain; and therefore, unicompartmental knee arthroplasty is not ideal. Stem cell injection in this setting has not been proven.

Correct Answer: Left total knee arthroplasty (TKA)

Explanation:

Question 19:

Options:

IDET has been proven to seal annular tears in the annulus fibrosis.
IDET restores segmental stability by shrinking collagen fibrils in the disk.
IDET has demonstrated no significant benefit over placebo in controlled trials.
IDET is an unsafe procedure with significant risk of permanent complications.
IDET has demonstrated poor clinical results in all reported series to date.

Correct Answer: IDET has demonstrated no significant benefit over placebo in controlled trials.

Explanation:

DISCUSSION: Intradiskal electrothermal therapy (IDET) initial clinical results were reported in 2000. The early case series were quite encouraging with reported therapeutic success rates of 60% to 80%. Early enthusiasm was high as IDET provided a nonsurgical treatment option for an otherwise complex and difficult clinical entity, chronic diskogenic low back pain. The actual mechanism of action was not well understood, and while the theoretic explanation made good sense, it did not hold up under laboratory testing. Soon clinical results from the field did not meet the high expectations set by the developers of the technique. Since those early case studies, a few level I evidence studies have been conducted, one by Freeman and associates and one by Pauza and associates. These randomized, placebo-controlled trials demonstrated no significant benefit of IDET over the placebo.
REFERENCES: Freeman BJ, Fraser RD, Cain CM, et al: A randomized, double-blind, controlled trial: Intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine 2005;30:2369-2377.
Pauza KJ, Howell S, Dreyfuss P, et al: A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 2004;4:27-35.
Wetzel FT, McNally TA: Treatment of chronic discogenic low back pain with intradiskal electrothermal therapy. J Am Acad Orthop Surg 2003;11:6-11.

Question 20:

Options:

anteroposterior axis.
tibial intramedullary axis.
posterior condylar axis.
femoral intramedullary axis.

Correct Answer: anteroposterior axis.

Explanation:

Question 21:

Options:

Hip arthroscopy
Corticosteroid injection
Percutaneous adductor tenotomy
Bone scan
Rheumatology consultation

Correct Answer: Corticosteroid injection

Explanation:

Question 22:

Options:

Cemented left total hip arthroplasty (THA)
Cementless left THA with a proximally porous coated femoral stem
Hybrid left THA
Cementless left THA with a diaphyseal engaging conical femoral stem

Correct Answer: Hybrid left THA

Explanation:

Question 23:

Options:

High hip center
Anatomic hip center with trochanteric osteotomy and progressive femoral shortening
Anatomic hip center with subtrochanteric shortening osteotomy
Iliofemoral lengthening followed by an anatomic hip center

Correct Answer: Anatomic hip center with subtrochanteric shortening osteotomy

Explanation:

Question 24:

A patient with rheumatoid arthritis with both ankle and subtalar involvement was treated as shown in Figures 11a and 11b. What complication is unique to this type of fixation?

Options:

Late rotatory deformity
Limb-length discrepancy
Talar osteonecrosis
Tibial stress fracture
Hardware failure

Correct Answer: Tibial stress fracture

Explanation:

DISCUSSION: The interlocking screws at the proximal end of the rod can act as a stress riser and lead to fracture. Postoperative pain at this level should prompt inclusion of this diagnosis in the differential. Removing the screws following bone union can decrease the chances of this occurring. A short rod that avoids the diaphyseal area may also be beneficial. Rotatory deformity is controlled by the perpendicularly oriented distal transfixion screws. Talar osteonecrosis would be unusual since the dissection can be minimized with an intramedullary rod. Any type of hardware can fail if the construct does not lead to a solid arthrodesis.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 236-237.
Thordarson DB, Chang D: Stress fractures and tibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail. Foot Ankle Int 1999;20:497-500.
Hammett R, Hepple S, Forster B, et al: Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail: The results of 52 procedures. Foot Ankle Int 2005;26:810-815.

Question 25:

03 Which of the following findings is the best indication for the use of temporary external fixation of a femoral shaft fracture?

Options:

Type IIIA open fracture
back to this question next question
Hemodynamic instability
Segmental fracture
Distal one third fracture
Ipsilateral tibial shaft fracture 33.03

Correct Answer: back to this question next question

Explanation:

These days, femoral shaft fractures at Tulane / Charity are commonly encountered by orthopaedic residents on the night-float team.
Despite the presence of a well-rested 4th year surgeon, definitive orthopaedic fixation is not always the correct answer for each trauma patient.
Tulane defines “Orthopaedic Tunnel Vision” as a condition commonly associated with a young MD at the Bulldog without a proper
wing-man, trying to make advances on the wrong patron due to his relatively easy 80-hour work week schedule and a few too many refined hops.
Skeletal Trauma (p. 1967) describes “Orthopaedic Tunnel Vision” as looking at the orthopaedic injury without considering the
patient’s injury in general. Femoral shaft fractures are typically high energy injuries which often do not occur in isolation. In these fractures, it is particularly important to not have tunnel vision.
Indications for temporary bridging external fixation includes hemodynamic instability
(ans. 2), acidosis, hypothermjia, hypoxemia, coagulopathy, sepsis or severely contaminated soft tissues that cannot be adequately debrided. Definitive fixation is performed after the general surgical and medical issues have resolved.
The other answer choices, including the type IIIA open fracture are not contraindications to definitive fixation in themselves (typically IM nailing—antegrade or retrograde).

Question 26:

Options:

Perform an immediate wake-up test
Continue with the surgery and reassess in 5 minutes
Administer intravenous methylprednisolone
Ensure that mean arterial blood pressure is 80 or higher

Correct Answer: Ensure that mean arterial blood pressure is 80 or higher

Explanation:

DISCUSSION
The use of intraoperative neuromonitoring is expanding, especially in the setting of deformity surgery. Changes in monitoring are concerning for the possibility of a neurologic injury; however, several other factors can alter signals. These include hypotension, changes in anesthesia depth and medications, the use of paralytic agents, and technical issues such as leads falling out or becoming disconnected. If a change in neuromonitoring signals is noted, these factors should be checked first to rule out false-positive findings. If this does not correct the problem, the wound should be explored to ensure there is no compression on the neural elements. Finally, if the deformity has been corrected, some of the correction can be released in an attempt to improve the signals. A wake-up test is difficult to perform and does not provide specific information regarding the location of the problem or how to correct it. Steroids may be used depending on surgeon preference, but should not be used until neurologic injury is ruled out. Any neuromonitoring changes always necessitate immediate investigation.
RECOMMENDED READINGS
Ziewacz JE, Berven SH, Mummaneni VP, Tu TH, Akinbo OC, Lyon R, Mummaneni PV. The design, development, and implementation of a checklist for intraoperative neuromonitoring changes. Neurosurg Focus. 2012 Nov;33(5):E11. doi: 10.3171/2012.9.FOCUS12263. PubMed PMID: 23116091.
View
Abstract at PubMed
Malhotra NR, Shaffrey CI. Intraoperative electrophysiological monitoring in spine surgery. Spine (Phila Pa 1976). 2010 Dec 1;35(25):2167-79. doi: 10.1097/BRS.0b013e3181f6f0d0.
Review. PubMed PMID: 21102290.
View Abstract at PubMed

Question 27:

Options:

reconstruction of the medial collateral ligament.
a short period of rest followed by a gradual return to activity.
physical therapy and dynamic extension splinting.
arthroscopic removal of the loose body.
a corticosteroid injection.

Correct Answer: arthroscopic removal of the loose body.

Explanation:

Question 28:

Options:

Place a medial pin to further stabilize the fracture
Remove all of the pins and displace the fracture
Obtain an emergent CT angiogram to assess arterial flow
Explore the artery
Splint the arm in extension as the fracture is now stabilized

Correct Answer: Explore the artery

Explanation:

Question 29:

Options:

distal chevron bunionectomy.
osteotomy of the proximal first metatarsal with distal soft-tissue realignment.
a Keller bunionectomy.
arthrodesis of the first metatarsophalangeal joint.
double osteotomy of the first metatarsal with distal soft-tissue realignment.

Correct Answer: osteotomy of the proximal first metatarsal with distal soft-tissue realignment.

Explanation:

Question 30:

Options:

- Immediate open reduction and internal fixation (ORIF) via an extensile lateral approach
- Casting in a plantar-flexed position for 6 weeks
- Splinting with follow-up in 10 to 14 days to check for resolution of swelling
- Splinting with a repeat examination in 1 to 2 days

Correct Answer: - Splinting with a repeat examination in 1 to 2 days

Explanation:

DISCUSSION
This patient has a displaced tuberosity of the calcaneus. A high rate of posterior skin breakdown is associated with these fracture types. The skin should be checked within 10 to 14 days when these fractures occur. The skin is swollen and not acutely at risk, so an immediate ORIF via an extensile lateral approach is not warranted. Immobilizing the ankle in a plantar-flexed position can take some tension off the posterior skin with this fracture type but should
not be definitive treatment. Splinting with repeat examination in 1 to 2 days is the preferred response because of the short follow-up for a repeat skin check. If the skin is at risk when a fracture of this type occurs, the ankle can be immobilized in plantar flexion to relieve tension on the skin. Immediate repair with either open or percutaneous techniques may be necessary if the skin remains at risk.
RECOMMENDED READINGS
Gardner MJ, Nork SE, Barei DP, Kramer PA, Sangeorzan BJ, Benirschke SK. Secondary soft tissue compromise in tongue-type calcaneus fractures. J Orthop Trauma. 2008 Aug;22(7):439-45. PubMed PMID: 18670282.
View Abstract at PubMed
Schwartz AK, Brage ME, Laughlin RT, Stephen D. Foot injuries. In: Baumgartner MR, Tornetta P III, eds. Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:453-468.

Question 31:

In a patient with a C5-6 herniation, the most likely sensory deficit will be in the

Options:

lateral shoulder.
radial forearm, thumb, and index finger.
dorsal forearm and middle finger.
ulnar forearm, ring finger, and little finger.
volar forearm and palm.

Correct Answer: radial forearm, thumb, and index finger.

Explanation:

Question 32:

Which of the following statements best describes the location of the nerve that is at risk in a direct posterior approach to the Achilles tendon?

Options:

The tibial nerve crosses the Achilles tendon 10 cm above its insertion.
The sural nerve crosses the Achilles tendon 5 cm above its insertion.
The sural nerve crosses the Achilles tendon 10 cm above its insertion.
The superficial peroneal nerve crosses the Achilles tendon 5 cm above its insertion.
The superficial peroneal nerve crosses the Achilles tendon 10 cm above its insertion.

Correct Answer: The sural nerve crosses the Achilles tendon 10 cm above its insertion.

Explanation:

Question 33:

Options:

iliac crest bone grafting
ring metacarpal transposition
second toe transfer
index metacarpal transposition
suture of deep transverse intermetacarpal ligaments

Correct Answer: iliac crest bone grafting

Explanation:

Index metacarpal transposition is indicated to reduce the space left between the index and ring finger. In this case, the middle ray is amputated because of malignancy.
With amputation of the middle or ring metacarpals, small objects fall through the gap and the adjacent fingers scissor. For single central ray defects, techniques to reduce the gap include transposition of the index finger (for middle ray amputation), small finger (for ring ray amputation), complete removal of the metacarpal (without leaving a proximal metacarpal base stump) to allow the bases of index and ring metacarpals to migrate together and reconstruction of the deep transverse metacarpal ligament. The technique of index transposition may vary depending on the osteotomy (straight vs step-cut) and fixation (K wires vs plate) as seen in the illustrations below.
Muramatsu et al. describe bony transposition for reconstruction after ray amputation for malignancy. The advantage is immediate closure of the space. The disadvantages include prolonged postoperative immobilization until union, malrotation (leading to scissoring), mal-tension of tendon (because of different metacarpal heights), and delayed or nonunion.
Lyall et al. advocate total middle ray amputation. They believe that leaving the metacarpal base behind leads to difficulty in aligning the adjacent rays as the index and ring must angulate over the bony obstruction to close the distal gap, leading to scissoring. They believe that index transposition leaves an abnormally wide 1st web space and a remnant 2nd metacarpal stump that can protrude dorsally.
Figure A is an AP radiograph of the right hand showing a destructive lesion of the proximal phalanx of the middle finger abutting the metacarpophalageal joint. Figure B is a STIR coronal MRI image showing the tumor mass extending into surround soft tissue. Illustration A is a diagram showing index transposition for middle ray amputation using a straight osteotomy and crossed K-wires. Illustration B is a diagram showing index transposition using a step-cut osteotomy and multiple K-wire fixation to the adjacent metacarpals. Illustration C is a diagram showing index transposition using a straight osteotomy and plate fixation. Illustration D is a diagram showing an alternative technique of suturing deep transverse metacarpal ligaments together to close the gap.
Incorrect Answers
A 65-year-old man fell and injured his right wrist. Radiographs taken in the emergency room are seen in Figure A. He was treated as a sprain and no further follow-up was planned. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of
Anterior and posterior interosseous neurectomy
Scaphotrapezialtrapezoidal (STT) fusion
Complete wrist arthrodesis
Proximal row carpectomy
Four-corner fusion with scaphoidectomy
Four-corner fusion with scaphoidectomy is indicated for Stage III SLAC wrist.
Surgical treatment of SLAC wrist is stage dependent. Stage I disease (scaphoid-radial styloid arthritis) is treated with AIN/PIN neurectomy. This procedure can also be done in addition to other bony procedures for Stages II-III disease. Stage II (scaphoid-entire scaphoid facet) is treated with PRC or scaphoid excision with 4-corner fusion (4CF). Stage III (capitolunate arthritis with proximal migration of the capitate into the scapholunate interval) is treated with either scaphoidectomy with 4CF or total wrist fusion.
Some other conditions exist: If capitolunate arthritis exists, PRC is contraindicated and 4CF is performed. If radiolunate arthritis exists, both PRC and 4CF are contraindicated and total wrist fusion is performed. If both radiolunate and capitolunate surfaces are preserved, then either PRC or a 4CF may be performed.
Cohen et al. compare PRC with 4-corner fusion plus scaphoid excision. PRC is technically easier, but leads to shortening of the carpus with weakness and incongruity exists between the capitate and lunate fossa of the distal radius. Scaphoid excision and four-corner fusion maintains carpal height and preserves the radiolunate relationship, but is more technically demanding, there is risk of nonunion, and it requires longer postop immobilization. Pain relief is more reliable following 4-corner fusion.
Figure A shows scapholunate ligament disruption. Figure B shows late stage SLAC wrist. There is capitolunate arthritis but no radiolunate arthritis.
Illustration A shows an example of PRC. Illustration B shows an example of 4CF and scaphoidectomy.
Incorrect Answers
Which of the following statements is true regarding zone II flexor tendon injuries?
At this level, FDS and FDP are located within separate tendon sheaths
FDS repair has not been shown to improve outcomes
Improved gliding is seen with repair of 1 slip of FDS compared to repairing both slips
Repairing FDS does not affect post-operative digit strength
FDP repair has not been shown to improve outcomes
In zone II flexor tendon injuries, repairing only one slip of FDS has been shown to improve gliding when compared to repair of both slips.
Zone II flexor tendon injuries have notoriously had poor outcomes secondary to high rates of adhesion formation at the pulleys. However, new advances in post-operative rehabilitation have significantly improved outcomes to the point where it is no longer considered "no man's land." Management of the FDS has been a source of controversy. In the past, the FDS was occasionally excised to theoretically make more room for the FDP. This has now been largely abandoned and the FDS is repaired whenever possible. Whether or not to repair both slips of FDS remains controversial, with in vitro data suggesting that gliding resistance is improved if only one slip is repaired.
Zhao et al. review the effect of partial vs. complete FDS excision following repair of FDP for zone II flexor tendon injuries. Preserving the whole FDS resulted in a significantly larger increase in gliding resistance after FDP repair than did full or partial FDS removal, which were not significantly different from each other.
Illustration A shows the zones of flexor tendon injury. Note that zone II injuries occur between the FDS insertion and the distal palmar crease. Illustration B shows the anatomy of the flexor tendons in detail. Video V shows a technique for repair of zone II injuries.
Incorrect Answers:
A 6-year-old girl sustains transverse amputations through her long and ring fingertips after getting her hand caught in a lawn mower. She presents to the emergency room 30 minutes after the injury with the amputated tissue which was placed on ice in a waterproof bag. On physical exam the amputation levels are found to be 6 millimeters distal to the lunula. The wounds are noted to be fairly
contaminated with no evidence of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the most appropriate management at this time?
Emergent replantation of the amputated parts
Revision amputation through the distal interphalangeal joint
Thorough irrigation and debridement followed by elective Moberg advancement flaps
Thorough irrigation and debridement followed by elective Z-plasty reconstruction
Thorough irrigation and debridement, soft dressing application, and followup within 1 week
Distal fingertip amputations can be successfully managed with local wound care and healing by secondary intention if no bone is exposed and the soft tissue defects are minimal. This is especially true in the pediatric population.
Distal fingertip amputations are common injuries seen in the emergency department. If bone is not exposed, the wounds can be successfully treated with local wound care and dressing changes, followed by soaks in a hydrogen-peroxide solution after 7-10 days. Some controversy exists in the pediatric population if the soft tissue loss is > 1 cm, with options for management including a V-Y advancement flap or conservative management with dressing changes.
Quell et al. review the results of 82 patients with fingertip amputations treated conservatively; 31 of the digits were treated with primary closure with or without shortening of bone and 54 digits were treated with semiocclusive dressings. No complications were observed, and all healed fingertips were well padded and painless.
Tupper et al. review sixteen patients with twenty fingertip injuries who underwent V-Y plasty for transverse fingertip amputations. Sensitivity was 73% of normal, with eight patients reporting hypersensitivity. Contrary to popular belief, they believe normal sensation following a V-Y plasty is not a reasonable expectation.
Illustration A shows the three levels of fingertip amputations. Zone I is distal to the phalanx; Zone II is distal to the lunula; and Zone III is proximal to the lunula.
Incorrect Answers:
Which of following malformations is most commonly associated with Poland's syndrome?
Figure E
CORRECT ANSWER: 4
Figure D demonstrates symbrachydactyly which is most commonly associated with Poland's syndrome.
Poland's syndrome is a rare birth defect characterized by underdevelopment or absence of the chest muscle in conjunction with ipsilateral symbrachydactyly. Poland syndrome most often affects the right side of the body, and occurs more often in males than in females.
Ireland et al. reviewed 43 consecutive cases of Poland's syndrome, and reviewed the relevant literature up to that point. The authors state that the clinical features are variable but always include congenital aplasia and syndactyly, and the right side is affected more than the left. They also note that although the hand remains hypoplastic and functional capacity is limited by the inherent skeletal anomalies, surgical treatment improves functional capacity and cosmetic appearance in the majority of patients.
Van Heest summarizes normal formation and growth of the upper limb as a basis for understanding malformation, with the goal of providing a basic understanding of the evaluation necessary for appropriate counseling and referrals for treatment of the child with hand and upper extremity congenital deformities.
Incorrect Answers:
A 55-year-old male laborer comes in with a chief complaint of clumsiness with his right hand for the past 3 months including difficulty using a hammer while at work. He has had no injury to the right upper extremity. On physical examination, he has persistent small finger abduction/extension with finger extension and active adduction. An EMG is performed and demonstrates ulnar nerve conduction velocities of 31 m/sec (normal >52m/sec). The patient symptoms are most accurately described as:
Axonotmesis with ischemia origin
Axonotmesis with myelin disruption
Neurapraxia with ischemia origin
Neurapraxia with endoneurium disruption
Neurotmesis
CORRECT ANSWER: 3
The history and clinical presentation are consistent with ulnar entrapment neuropathy at the level of the cubital tunnel. This would be classified as a neuropraxia with ischemia origin.
Compression injuries to the peripheral nerves are often the result of microvascular dysfunction as the nerves traverse a high to low pressure gradient. Peripheral nerve injury can be classified as neuropraxia, axonotmesis, and neurotmesis. Compressive neuropathies are typically neuropraxias, with local myelin damage but not compromise of the major components of the nerve. In axonotmesis, there is Wallerian degeneration and myelin loss distal to the site of injury. The most severe type is that of neurotmesis. Neurotmesis is composed of a spectrum of injury in which the endoneurium is always disrupted (perineurium or epineurium may be intact). The worst form of neurotmesis is that of nerve transection.
Elhassan et al. review the pathophysiology of cubital tunnel syndrome. They report nerve dysfunction results from ischemic changes secondary to compression. Compressive effects on the nerves can last greater than 24 hours, even after the source of compression has been removed.
Rempel et al. review the pathophysiology of peripheral nerve compression syndromes. The authors indicate that deforming pressures to nerves are often the result of stenotic soft tissue canal boundaries. This leads to interference with local microvasculature of the nerve itself.
Illustration A demonstrates the Wartenberg sign, where the patient has persistent small finger abduction/extension resulting from weakness of the 3rd palmar interosseous/small finger lumbrical.
Illustration B reveals clawing which results from overpowering of the intrinsic muscles by the extrinsic muscles; a tenodesis effect results in flexion of the PIP/DIP joints. This is more severe in ulnar nerve compression at Guyon’s canal. Illustration C shows the Froment sign, where the FPL attempts to compensate for a deficient pinch, because of weakness of the adductor pollicis. Illustration D demonstrates atrophy of the 1st dorsal webspace from chronic compressive changes. Illustration E demonstrates atrophy of the thenar compartment which is consistent with carpal tunnel syndrome.
Incorrect Answers:
Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap?
Figure E
CORRECT ANSWER: 3
Figure C shows a dorsal thumb laceration with exposed tendon that would be most appropriately treated with a first dorsal metacarpal artery (FDMA) flap.
The first dorsal metacarpal artery is a branch of the radial artery that supplies the dorsal hand skin from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the thumb and index to the proximal interphalangeal joint. The flap is raised distal to proximal as an island flap containing the FDMA, branches of the radial nerve, fascia of the underlying interosseous muscle of the first web space, and skin overlying the MP joint and proximal phalanx of the finger. It is an excellent option for large soft tissue defects on either side of the thumb. In this case, skin grafting is contraindicated because of exposed tendon without paratenon.
Sherif et al. detail the anatomy of the first dorsal metacarpal artery. They found three consistent branches, including the radial, ulnar, and intermediate branch. In part II of their study, they review the results of 23 patients where the FDMA flap was used as a fasciocutaneous or fascial flap for the coverage of soft tissue hand defects.
Illustration A shows a FDMA flap being raised for coverage of a thumb defect. Incorrect Answers:
bone can be allowed to heal through secondary intention.
Figure A is a radiograph of a 35-year-old women who sustained an isolated left wrist injury after a fall onto an outstretched hand. She has been complaining of left dorsal wrist pain since the fall. Examination reveals a positive Watson's scaphoid shift test. What ligamentous structure is an important secondary stabilizer to prevent dorsal intercalated segment instability (DISI) deformity in this patient?
Transverse carpal ligament
Dorsal intercarpal ligaments
Triangular fibrocartilage complex
Dorsal lunotriquetral ligament
Volar lunotriquetral ligament
The integrity of the dorsal intercarpal ligaments is important in preventing dorsal intercalated segment instability (DISI) deformity and persistent scapholunate instability.
Scapholunate instability is the most common carpal instability. The primary stabilizing structure of the scaphoid and lunate bones is the scapholunate ligament, which is commonly injured with a fall on an outstretched hand.
Secondary stabilizers of the scaphoid and lunate include the dorsal intercarpal ligaments and the dorsal radiocarpal ligaments. Failure to recognize injury of these structures can cause persistent dorsal intercalated segment instability (DISI). This can predispose patients to a SLAC wrist and early wrist osteoarthritis.
Mitsuyasu et al. examined the role of dorsal intercarpal ligaments (DIC) in scapholunate instability. They showed that the DIC had an important role in stabilizing the scaphoid and lunate bones with static and dynamic movements. The authors of this study suggest that the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction with surgical management of scapholunate ligament tears.
Viegas et al. showed that the dorsal intercarpal and the dorsal radiocarpal ligaments form a lateral V configuration over the dorsal wrist. This configuration acts as an indirect dorsal stabilizing effect on the scaphoid
throughout the range of motion of the wrist. Their integrity acts to ensure normal wrist kinematics.
Figure A shows an AP and lateral radiograph of the left hand. There is significant gapping between the scaphoid and lunate articulation. This is indicative of a complete scapholunate dissociation, however both wrists should be imaged as this deformity may exist without injury. Illustration A shows the anatomy of the dorsal intercarpal and the dorsal radiocarpal ligaments.
Incorrect Answers:
A 50-year-old patient presents with stiffness in her hand. A clinical photo is shown in Figure A. During surgical exposure, the neurovascular bundle is identified and dissected. What is the clinically most important pathologic structure to identify and what is its location relative to the neurovascular bundle in the digit?
Spiral cord which is central and superficial to the neurovascular bundle
Central cord which is midline and superficial to the neurovascular bundle
Retrovascular cord which is central and superficial to the neurovascular bundle
Spiral cord which is lateral and deep to the neurovascular bundle
Central cord which is lateral and deep to the neurovascular bundle
Based on clinical findings, the patient has evidence of Dupuytren’s contracture affecting her ring finger. Relative to the neurovascular bundle, the spiral cord will lie lateral and deep.
Dupuytren’s disease is a benign hand condition characterized by pathologic nodules and cords of existing fascial bands. The most clinically relevant structure in Dupuytren's disease, is the spiral cord. The spiral cord is the result of pathology of 4 structures: the middle layer of the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. The spiral cord is found predominantly at the palmodigital transition. The spiral cord displaces the neurovascular bundle centrally and superficially.
Benson et al. review the etiology, pathophysiology and treatment options for Dupuytren’s contracture. They highlight that while the pretendinous band is located volar and central to the neurovascular bundle in the palm, the spiral band and lateral digital sheath cause the neurovascular bundle to be displaced superficially and volarly as they become pathologically affected.
Black et al. review the pathoanatomy, diagnosis and management of Dupuytren's disease. They note that the spiral cord lies superficial to the neurovascular bundle proximal to the MCP joint. Distal to the MCP joint it passes deep to the bundle. At that location, the spiral cord lies lateral to the
neurovascular bundle as the lateral digital sheet becomes involved
Figure A demonstrates the cord formation that is characteristic of the pathologic Dupuytren’s condition. It is the central cord that causes contracture of the MCP, whereas the retrovascular and spiral cords cause contractures of the DIP and PIP respectively. Illustration A shows the relationship of spiral cord formation in Dupuytren's disease relative to the normal anatomy of the palmar fascia. The structures implicated in the formation of the spiral cord are the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament, more dorsally located, is spared in Dupuytren's disease. The neurovascular bundle is displaced superficially and towards the midline, as the pathological cord spirals around. Illustration B shows the presence of other affected structures, including the natatory ligament and the central band. The central band is an extension of the pretendinous cord and attaches to the base of the middle phalanx. It may insert onto the tendon sheath of the flexor tendon at this level. Formation of natatory cords cause webspace contractures. Formation of central cords lead to flexion contractures of the PIP. Illustration V is a video that provides an educational overview of Dupuytren's.
Incorrect Answers:
An infant is brought to your office for evaluation of his hands. Clinical photos are shown in Figures A and B. The clinical features are most consistent with a genetic mutation in which of the following:
Sonic Hedgehog (SHH)
FGFR2
FGFR3
PMP22
COL1A1
CORRECT ANSWER: 2
Based on the clinical features seen in the figures provided, the most likely syndrome is that of Apert syndrome, which is consistent with a mutation in FGFR2.
Apert syndrome is an autosomal dominant condition that gives rise to facial dysmorphism and complex syndactyly of the hands. The craniosynostosis that develops causes flattening of the skull and facial features.
Goldberg et al review congenital hand conditions and the malformations associated with them. They indicate that not only does identification allow for natural history to be better elucidated, but also timing of surgical intervention can be better gauged.
Figures A and B demonstrate clinical features consistent with Apert Syndrome. The “rosebud” hand is a complex syndactyly that affects the index, middle and ring fingers most commonly. Hypertelorism is exemplified with increased distance between the eyes; additionally, acrocephaly is noted with forehead broadening and skull flattening.
Incorrect Answers
1: Mutation in sonic hedgehog gene (SHH) is associated with a longitudinal deficiency of the radius. This is seen in conditions like TAR, Holt-Oram and VACTERL syndromes.
3: Mutation in FGFR3 leads to achondroplasia
4: Mutation in PMP22 gives rise to Charcot Marie Tooth syndrome 5: Mutation in COL1A leads to osteogenesis imperfecta
A 45-year-old patient presents with recurrence of radial sided wrist pain after undergoing a first dorsal compartment release about 3 months ago. The surgery was completed by one of your partners; operative reports indicate that the sheath was incised on the dorsal edge. On physical exam she is found to have normal appearing skin, a negative Tinel’s sign, and a positive Finklestein test. What is the most likely cause of the recurrence of her symptoms?
Development of neuroma
Complex regional pain syndrome
Failure to decompress the EPB sub-sheath
Failure to decompress the EPL sub-sheath
Failure to decompress the APB sub-sheath
Based on the history and clinical findings this patient has de Quervain’s tenosynovitis. The recurrence of her symptoms can be attributed to a failure to recognize and decompress the EPB sub-sheath.
De Quervain’s tenosynovitis is a stenosing inflammatory condition of the first dorsal compartment of the wrist (APL/EPB). Surgical release of the compartment is indicated after conservative measures have failed. At the time of the operation, the incision is made on the dorsal side of the sheath to prevent volar subluxation of the tendons. Failure to identify and release a distinct EPB sub-sheath or a separate fibro-osseous compartment of the APL can lead to a recurrence of symptoms.
Alegado et al. report a case of a patient with dysesthesias in the superficial radial nerve distribution 3 months after undergoing first dorsal compartment release for de Quervain’s tenosynovitis. They found a persistent fibrous remnant of the dorsal aspect of the sheath causing elevation of the superficial radial nerve. They recommend sheath excision or incision of the sheath at its dorsal attachment to avoid this complication.
Ashurst et al. report a case of a patient presenting with bilateral de Quervain’s tenosynovitis secondary to excessive text messaging. Conservative measures
afforded the patient complete symptomatic recovery. They recommend limitation of texting, in conjunction with other standard treatments, to treat text messaging- associated de Quervain’s tenosynovitis
Ilyas et al. review the etiology, diagnosis and management of De Quervain’s tenosynovitis. Non-surgical management is largely successful and includes splinting and cortisone injections. In refractory cases, surgical release of the first dorsal compartment is completed. They recommend meticulous care of the radial sensory nerve and identification of all separate sub-sheaths.
Illustration A shows an operative photo in a patient with multiple APL slips and an EPB that is hidden within a sub-sheath. Video V gives a brief overview of de Quervain’s tenosynovitis.
Incorrect Answers
A 28-year-old NFL running back complains of continued hand pain three days following an injury sustained while being tackled. He was splinted on the field. He has tenderness over the long finger metacarpal head, with subluxation of the extensor tendon into the intermetacarpal area during active metacarpophalangeal joint flexion. A representative MRI is shown in Figure A. What is the next best step in management of this patient?
Observation alone
Continued splinting in flexion
Continued splinting in extension
Open repair of the disrupted junctura tendinae
Open repair of the disrupted sagittal band
Based on the history and physical exam findings this patient has sustained a traumatic rupture of the sagittal band. In this professional athlete, the next best step would be to perform an open repair of the sagittal band. This will allow for earlier aggressive rehabilitation and a quicker return to sport.
Sagittal band ruptures may be traumatic (as in this case) or attritional in nature (as in rheumatoid arthritis). A direct blow to the MCP leads to forced flexion of the digit and subsequent stretching/rupture of the affected structure. On physical exam the tendons are most unstable with the wrist flexed; MCP flexion will lead to dislocation of the tendon into the intermetacarpal gutter.
Acute injuries may be treated with extension bracing for 4-6 weeks, but in professional athletes, direct open repair of the sagittal band is indicated.
Catalano et al. review sagittal band injuries treated with a thermally molded
plastic splint that held the MCP in ~25-35 degrees of hyperextension. Patients were evaluated over 14 months; out of 11 sagittal band injuries, splinting was successful in eight of them. They recommend initial nonsurgical management with custom splinting.
Hame et al. review the results of the management of sagittal band injuries in the professional athlete. The lesion commonly found was the disruption of the extensor mechanism with predictable sagittal band tears. In their series, all patients regained full range of motion and returned to their respective sports. They recommend surgical intervention in elite athletes in the form of extensor tendon centralization and sagittal band repair.
Figure A shows a T1 weighted axial cut of the affected hand; subluxation of the tendon (arrow) can be identified with disruption of the sagittal band (arrowhead).
The video provided briefly reviews injury to the sagittal band. Incorrect Answers
Compressive injury to the posterior interosseous nerve will lead to EMG fibrillations in which of the following muscles?
Extensor Carpi Radialis Longus/Extensor Carpi Radialis Brevis/Brachoradialis
Extensor Carpi Radialis Longus/Supinator/Abductor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Longus
Brachoradialis/Supinator/Extensor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Brevis
Based on the choices above, fibrillations will be seen in the extensor pollicis longus, supinator and abductor pollicis longus muscles.
The radial nerve splits into the superficial radial branch and the posterior interosseous nerve (PIN) at the anterior aspect of the radiocapitellar joint, just proximal to the supinator muscle. The PIN innervates the EDC, EDM, ECU,
EPB, EPL, EIP, APL and sometimes the ECRB. Compressive neuropathy of the PIN leads to motor dysfunction, namely weakness with wrist and finger extension.
Lubhan et al. review uncommon compression neuropathies affecting the upper extremity. They indicate that PIN syndrome may be caused by rheumatoid arthritis and compressive ganglion cysts. Depending on which nerve branch is affected, partial lesions may develop. They recommend use of conservative measures (rest, activity modification and splinting) first. Decompressive procedures may be indicated in symptoms lasting greater than 3 months.
Illustration A shows the course of posterior interosseous nerve from proximal to distal along the course of the supinator. This proximal edge of the supinator (Arcade of Froshe), the fibrous edge of the ECRB and the leash of Henry are three main points of compression of the PIN.
Incorrect Answers
Figure A shows a traumatic laceration of the distal forearm with a 5cm segmental median nerve defect. Which of the following repair or reconstruction techniques would allow for the best recovery of motor function?
Autogenous venous nerve conduit
Collegen synthetic nerve conduit
Biodegradable polyglycolic acid
Processed nerve allograft
Nerve autograft
CORRECT ANSWER: 5
Figure A shows a traumatic laceration with 5cm of median nerve defect. The use of nerve autograft for this size defect has been shown to have the best recovery of motor function.
The optimal surgical treatment of nerve laceration is direct tension-free repair. In segmental nerve defects this approach cannot be achieved. The use of interposed autologous nerve grafting remains the gold standard of repair in this setting. The use of alternative techniques, such as processed allografts and synthetic conduits, have not shown to have equivalent recovery of motor function as compared to nerve autograft.
Giusti et al. used a rat model to examine techniques of peripheral nerve repair. They showed that nerve autograft resulted in better motor recovery than did the use of processed allograft or a collagen conduit.
Deal et al. discussed tubular interposition substitutes, or nerve conduits, as an alternative to nerve autograft in segmental nerve defect. Nerve conduits can include autogenous nerve conduits (venous or arterial) and synthetic nerve conduits (collagen, PGA, or caprolactone). In general, there is an upper limit of 3-cm when using nerve conduit.
Figure A is an image of the volar forearm. There is a traumatic laceration to
the anterior compartment tendons as well as the median nerve.
Incorrect Answers:
A 45-year-old man presents with a three-month history of unilateral symptoms in his right wrist and hand. He first noticed a palpable nodule over the volar aspect of his wrist about three months ago. The nodule would become painful after weekends of heavy drinking at which time he noticed tingling sensation in his index and middle fingers. He notes that ibuprofen has helped improve the pain in the past. On clinical examination, he has a palpable, nontender, solid nodule over the volar aspect of his wrist. He has no motor or sensory deficits and negative carpal tunnel provocative tests. An axial CT and MRI image are provided in figures A and B. What would be the most appropriate next step in the management of his symptoms?
Fine needle aspiration
Chemotherapy
Night splints
Establish a tissue diagnosis and referral to a rheumatologist
Surgical excision
CORRECT ANSWER: 4
The clinical presentation is consistent with carpal tunnel syndrome caused by an atypical space occupying lesion - in his case, gout. The most appropriate next step in the management of his symptoms would be establishing a tissue diagnosis and referral to a rheumatologist where medical therapy, such as prophylaxis with colchicine, could be initiated.
Carpal tunnel syndrome is the most common compressive neuropathy, affecting up to 10% of the general population. Risk factors include female sex,
advanced age, obesity, and repetitive motion activities. Typically, patients will develop symptoms of median nerve compression including thenar muscle atrophy, numbness in the radial 3.5 digits, night pain, and positive Tinel's and Phalen tests. First line management is non-operative, including NSAIDs, night splints, and activitiy modification. Carpal tunnel release surgery is indicated for those who have failed conservative management.
Chen et al. described 23 unusual cases of CTS in which space-occupying lesions were responsible for the symptoms and signs of median nerve compression. In patients with an atypical presentation, such as male gender, non-middle-aged, or unilateral involvement, space-occupying lesions such as gout, synovial sarcoma, lipoma, and ganglions should be investigated as a cause.
Fitzgerald et al. discussed gout affecting the hand and wrist. The medical treatment of gout includes NSAIDs such as indomethacin or ibuprofen for acute flares, and colchicine and allopurinol for chronic prophylaxis.
Figures A and B represent axial CT and MRI images showing calcification and gouty tophi deposition in the carpal tunnel floor.
Incorrect Answers:
Which statement most accurately describes the physiology of peripheral nerve regeneration following an axonotmesic lesion?
The proximal nerve segment undergoes Wallerian degeneration
Axon growth occurs from the distal segment to proximal segment
Neurotrophic factors direct phagocytic activity
Proximal axon budding allows for antegrade (or distal) axon migration
Axoplasm and myelin are degraded distally predominantly by Schwann cells for the first 12 months following injury
Axonomesis is a disruption of the nerve axon following injury. Repair/regeneration of the nerve occurs via proximal budding, followed by antegrade (or distal) axon migration.
The peripheral nerve regeneration process begins with the distal segment undergoing Wallerian degeneration (axoplasm and myelin are degraded distally by phagocytes). Existing Schwann cells proliferate and line-up along the basement membrane. Proximal budding occurs after a one-month delay. This is followed by sprouting axons that migrate in an antegrade fashion to connect to the distal tube. Repair of the nerve can take months, and often have poor outcomes.
Lee et al. reviewed peripheral never injury and repair. They commented that Wallerian degeneration (i.e., breakdown of the axon distal to the site of injury) is initiated 48 to 96 hours after transection. The Schwann cells then align themselves longitudinally, creating columns of cells called Büngner bands. At the tip of the regenerating axon is the growth cone.
Illustration A shows a chart of peripheral nerve injury. The two main classification systems are Seddon and Sunderland. Video V is a lecture discussing peripheral nerve injury and management.
Incorrect Answers:
A 28-year-old male injures his hand while playing basketball and presents to the emergency room. Closed reduction is performed and is stable. Post-reduction rehabilitation is discussed with the patient.
Which of the following radiographs demonstrates an injury that would be treated best by dorsal extension block splinting?
Figure E
CORRECT ANSWER: 2
Dorsal extension-block splinting is the treatment of choice for dorsal proximal interphalangeal joint (PIPJ) fracture dislocations that are stable following reduction and have less than 40% articular surface fracture involvement.
Dorsal PIPJ dislocations are a common injury, often resulting from jamming or hyperextending the finger. In the absence of an associated fracture or presence of a small volar plate avulsion, dorsal PIPJ dislocations are often
treated with closed reduction and buddy-taping to the adjacent digit. Injuries that are unstable following reduction or those associated with an intra-articular fracture of the middle phalanx are stabilized with a dorsal extension-block splint to maintain reduction. It is important to initiate early range of motion exercises within the constraints of the splint to minimize scar formation and subsequent PIPJ contracture.
Elfar et al. reviewed fracture-dislocations of the PIPJ. Dorsal PIPJ fracture-dislocations can be categorized as avulsion or impaction shear injuries.
Avulsion fractures result from hyperextension of the PIPJ, tensioning the volar plate (VP) with eventual VP rupture or avulsion of the volar lip of the middle phalanx. Axial load applied to the digit in PIPJ flexion drives the head of the proximal phalanx across the middle phalangeal base, resulting in a shear fracture or comminuted impaction fracture of the middle phalanx, depending on the amount of energy imparted and the bone quality.
Morgan et al. reviewed hand injuries in athletes. Dorsal PIPJ dislocations without associated fracture that are stable following successful reduction are treated by buddy taping the injured digit to the non-injured digit adjacent to the compromised collateral ligament. Buddy taping with active motion should be continued for 6 weeks. Unstable injuries and those with an intra-articular fracture of the middle phalanx should be treated with dorsal extension-block splinting with incremental extension of the splint on a weekly basis for 4 weeks, followed by buddy-taping for 3 months during sports activities.
Figure A shows a simple dorsal PIPJ dislocation. Figure B shows a dorsal PIPJ fracture dislocation. Figure C shows a simple volar PIPJ dislocation. Figure D shows a volar PIPJ fracture dislocation. Figure E shows a dorsal avulsion fracture at the base of the distal phalanx (bony mallet injury). Illustration A depicts an dorsal extension-block splint that blocks extension of the digit past a set point while allowing full active flexion of the digit. Illustration B is a lateral radiograph of a digit showing a small minimally displaced volar plate avulsion fracture at the PIPJ with minimal intra-articular involvement (as compared to Figure B). This injury may be managed with buddy taping and active range of motion as tolerated.
Incorrect Responses:
extension for 6-8 weeks to limit flexion of the digit and therefore fracture displacement.
A 35-year-old mixed martial arts fighter and recreational cocaine user presents with symptoms concerning for hypothenar hammer syndrome (HHS). Significant ischemia is found on physical exam. Arteriography is shown in Figure A. What is the most appropriate next step in treatment?
Conservative treatment with cocaine abstinence
Conservative treatment with activity modifications and medical management with calcium channel blockers
Therapeutic endovascular fibrinolysis
Excision of involved segment and reconstruction with or without a vein graft
Medical management with coumadin for 6 months
Figure A shows a bilobed aneurysm overlying the ulnar artery with normal appearing distal vasculature. Hypothenar hammer syndrome (HHS) can be associated with an aneurysm and is most appropriately treated with resection of the involved segment and either reconstruction with a primary anastomosis or vein graft.
HHS syndrome consists of two separate entities, thrombosis and aneurysm. In the setting of thrombosis without aneurysm, conservative management is preferred. If the thrombosis is acute (<2 weeks), endovascular fibrinolysis has shown good results. In patients with an HHS and an aneurysm, surgery is required for resection to prevent distal embolization and remove the often painful aneurysmal mass.
Yuen et al. review HHS. In patients with HHS and aneurysms, resection of the involved segment of the ulnar artery prevents distal embolic events, eliminates the painful mass, relieves ulnar nerve compression, and removes the thrombus which initiated the reflex vasospasm and closed off the collateral
vessels in the region.
Lifchez et al. review the long-term outcomes of 11 patients with HHS treated with ulnar artery reconstruction. 2 of the patients underwent excision and direct ulnar artery repair, and the rest underwent reconstruction with a vein graft. All patients had a mean improvement in digital brachial index, decrease in pain and dysesthesia symptoms, and decrease in cold intolerance compared with preoperatively.
Nitecki et al. review a case series of 6 patients with HHS. They state that the treatment of thrombosis should be largely conservative, but thrombolytic treatment could be considered if the event happened <2 weeks prior to presentation.
Illustration A shows an excised ulnar artery aneurysm in a patient with HHS. Note the typical "corkscrew" appearance of the distal segment.
Incorrect Answers:
A 36-year-male was using a high-pressure paint gun when he suffered the injury shown in Figure A. Which of the following variables would have the worst impact on his prognosis?
Delay in surgical treatment
Injected solvent was grease
Injected solvent was water-based paint
An entry wound of greater than 3 cm
Injected solvent was at room temperature
The clinical presentation is consistent for a high-pressure injection injury. Delays in surgical treatment are associated with serious sequelae.
High-pressure injection injuries are characterized by extensive soft tissue damage associated with a benign high-pressure entry wound. They should be treated with irrigation & debridement, foreign body removal and broad-spectrum antibiotics. There is a higher rates of amputation when surgery is delayed.
Bekler et al. looked at the results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up. Ten of the injuries required formal operative debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation. They concluded that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation.
Rosenwaser et al. report wide débridement of all involved tissues, decompression of tissue compartments, exploration and incision of tendon sheaths, removal of injected material, and saline irrigation are critical in the management of high-pressure injection injuries to the hand. They emphasize
delayed surgery has been associated with increased incidence of morbidity and amputation.
Figure A shows a typical high-pressure injection injury. Notice the benign looking entry wound.
Incorrect Answers:
A healthy 50-year-old secretary is about to undergo an open carpal tunnel release. Which of the following peri-operative steps will have the greatest influence on minimizing the risk of a surgical site infection in this patient?
Administration of cefazolin within 1 hour before incision
Administration of cefazolin within 1 hour before incision followed by 5 days of cephalexin post-op
Cleanse with bacitracin solution immediately before skin incision
Standard sterilization and prepping
Administration of one dose of cephalexin within 1 hour before incision
The patient is undergoing a clean, elective hand surgery. Prophylactic antibiotics, systemic or local, are not indicated for these procedures.
Carpal tunnel syndrome is the most common compressive neuropathy. Individuals who fail medical management (night splints, NSAIDs, activity modification) are candidates for carpal tunnel release surgery (CTS). The surgery may be performed open or endoscopically. The reported incidence of post-operative infections following CTS varies between studies from 0% to 8%.
Whittaker et al. performed a prospective, randomized, double-blinded, placebo
controlled trial investigating the use of antibiotic prophylaxis in clean, incised hand injuries. They found no significant difference in infection rates between patients who received IV flucloxacillin, IV followed by oral flucloxacillin, and an oral placebo (13% vs. 4% vs. 15%, p=0.19). They did not support the use of routine antibiotic prophylaxis prior to clean hand surgery.
Bykowski et al. retrospectively reviewed 8,850 outpatient elective hand surgeries and found no significant difference in the rate of surgical site infection, including patients with diabetes or history of smoking. They concluded that antibiotics should not be routinely administered prior to clean, elective hand surgeries.
Harness et al. found no statistical difference in the incidence of surgical site infection following CTS without prophylactic antibiotic compared with patients who received prophylactic antibiotics (0.7% vs. 0.4%, p=0.354). They did not recommend routine antibiotic prophylaxis.
Illustration A reviews the anatomic components of the carpal tunnel. Incorrect Answers:
infection in clean, elective hand surgery. Surgeons should consider the potential risks of antibiotics prior to administration, including Clostridium difficile colitis, antibiotic allergies, bacterial resistance, and so on.
A 30-year-old male laborer sustained a right wrist injury 9 months ago. He continues to have symptoms of recurrent ulnar-sided wrist pain that impairs his ability to work. An MRI is performed and
shows a triangular fibrocartilage complex (TFCC) injury. Which of the following is an indication to combine a Wafer procedure with arthroscopic TFCC debridement?
Ulnar styloid fracture
Radial styloid fracture
2 mm of positive ulnar variance and ulnocarpal impingment
2 mm of negative ulnar variance and radiocarpal joint arthritis
Scapholunate ligament injury
A Wafer procedure is indicated for positive ulnar variance and symptomatic ulnocarpal impingement associated with degenerative TFCC tears.
Ulnar impaction syndrome and triangular fibrocartilage complex (TFCC) injuries are relatively common causes of ulnar-sided wrist pain. Positive ulnar variance causes increased contact pressures between the lunate and the ulnar head. The Wafer procedure removes 2-4 mm of distal ulnar head to reduce ulnar variance to neutral or negative. This is thought to reduce ulnar impaction and decrease pain.
Faber et al. examined the role of MRI in wrist injuries. They showed that the sensitivity and specificity to detect TFCC tears using MRI is approximately 80%. They conclude that there is no supporting evidence for routine MRI's for patients with non-specific ulnar-sided wrist pain.
Illustration A is a coronal view MRI (without arthrogram) of the right wrist that shows a TFCC tear (blue arrow) with positive ulnar variance. Illustration B shows a series of images showing a TFCC tear on MRI and intra-operatively.
Incorrect Answers:
A 27-year-old male sustains the injury shown in Figure A. He is taken to the operating room and the lesion is repaired primarily. Two months later, he feels a "pop" while using his hand and is no longer able to flex the distal phalanx of the involved digit. He is taken to the operating room for surgical exploration where 1.8 cm of scar tissue between the tendon ends is identified. The tendon sheath is found to be intact and allows smooth passage of a pediatric urethral catheter. What is the next step in management?
Resection of scar and primary repair of tendon ends.
Resection of scar and adjacent 1cm of tendon, placement of Hunter rod for staged reconstruction.
Debulking of scar, partial excision of 25% of the A2 and A4 pulleys.
Resection of scar, harvest of ipsilateral palmaris longus tendon for tendon reconstruction.
Resection of scar and proximal tendon, tendon transfer from adjacent digit.
This patient sustained an FDP laceration that was treated initially with primary repair. He subsequently re-ruptured the tendon 2 months later. With scar >1 cm, tendon grafting is indicated and primary tendon grafting with palmaris longus is commonly performed as it is the most accessible tendon in the operative field.
Flexor tendon lacerations commonly result from volar lacerations. Concomitant neurovascular injury is common. Partial lacerations <60% of tendon width are treated with debridement and early range of motion. With partial lacerations, the least amount of gliding resistance can be obtained with debridement alone. Lacerations >60% of tendon width are treated with flexor tendon repair and controlled mobilization. Failed primary repair and chronic untreated injuries are indications for flexor tendon reconstruction and intensive postoperative rehabilitation.
Lilly et al. reviewed complications after flexor tendon injuries. Common complications include adhesions, joint contracture, tendon rupture, triggering, pulley failure and bowstringing, quadrigia, swan-neck deformity and lumbrical plus deformity.
Figure A shows a zone II laceration of the left index finger FDP.
Incorrect Answers:
A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of motion of her thumb is seen in Figure B. What is the most likely cause of her deformity?
Type II hypoplastic thumb
Median nerve neuropathy
Lupus thumb deformity
Extensor tendon rupture
Osteoarthritis of the trapeziometacarpal joint
The patient has 1st carpometacarpal (CMC) arthritis.
With 1st CMC arthritis, the patient avoids painful thumb abduction and an adduction deformity gradually develops, with 1st webspace contracture. With progressive 1st CMC stiffness, the thumb metacarpophalangeal joint (MCP) develops hyperextension deformity to compensate for the loss of motion, leading to a secondary "Z" deformity.
Rozental et al. reviewed hand and wrist reconstruction. They believe that arthrosis arises from loss of the anterior oblique ("beak") ligament.
Compensatory MCP hyperextension should be treated with MCP capsulodesis or arthrodesis.
Van Heest et al. reviewed thumb CMC arthritis. Treatment for Eaton stage I/II arthritis is open/arthroscopic debridement, volar ligament reconstruction (with APL or FCR tendons), or metacarpal extension osteotomy. For stage III/IV arthritis, treatment options include implant arthroplasty or resection arthroplasty +/- LRTI (with APL, FCR or palmaris longus), and fusion (young patients).
Figure A shows adduction contracture of the 1st webspace, with hyperextension deformity of the 1st MCP joint. Figure B illustrates decreased thumb abduction because of adduction contracture with decreased palmar abduction (normal, 45deg) and decreased radial abduction (normal, 60deg). Illustration A is a radiograph showing thumb CMC arthritis with Z deformity. Illustration B shows lupus thumb deformity ("hitchhiker thumb"). Illustration C shows hand changes in inflammatory arthritis.
Incorrect Answers:
A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures A through C. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition?
Ring flexor digitorum superficialis transfer to the abductor pollicis brevis
Extensor indicis proprius transfer to the abductor pollicis brevis
Neurotization of thenar muscles
Camitz palmaris longus transfer to the abductor pollicis brevis
Thumb carpometacarpal joint arthrodesis
This patient has a high median nerve neuropathy because of a supracondylar spur and ligament of Struthers. Reconstruction is best performed with extensor indicis proprius (EIP) transfer to the abductor pollicis brevis (APB).
In low median nerve palsy, the primary concern is restoration of thumb opposition. In high median nerve palsy, thumb opposition and IP flexion, and index and middle finger flexion have to be addressed. The four common opposition transfers include (1) ring or long FDS, (2) EIP, (3) Camitz palmaris longus (PL), or the Huber abductor digiti minimi (ADM).
Anderson et al. reviewed EIP transfer vs FDS transfer. They found a higher percentage of excellent results in the EIP group. In their series, complications included index finger extensor lag (EIP transfer if the extensor expansion was not repaired) and limited donor finger extension because of lateral band damage or adhesions between the remaining FDS tendon and flexor sheath (FDS transfer).
Cawrse et al. modified the Huber ADM opponens transfer by releasing the proximal end to prevent compression of the ulnar nerve in Guyon's canal by the rotated ADM belly. They found that this technique successfully restored
opposition and thenar bulk.
Figure A shows thenar wasting. Figures B and C show a supracondylar spur. The ligament of Struthers attaches from this spur to the medial epicondyle, under which median nerve and brachial artery pass. Illustration A shows EIP transfer. Illustration B shows FDS transfer. Illustration C shows Camitz PL transfer. Illustration D shows Huber ADM transfer.
Incorrect Answers:
A 2-year-old child is referred by her pediatrician for fixed flexion deformity of the left thumb. She has been wearing a splint for the last 6 months. She has ventricular septal defect and left renal agenesis. The interphalangeal joint does not extend past 40 degrees of flexion as seen in Figures A and B. There is no triggering. There is a firm, nontender nodule overlying the metacarpophalangeal joint as outlined in blue in Figure C. What is the diagnosis and most appropriate treatment?
Thumb camptodactyly. Therapy including passive stretching exercises.
Congenital clapsed thumb. Percutaneous release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley and resection of the tendon nodule.
Blauth Type I hypoplastic thumb. Open release of the A1 pulley and volar plate, and resection of the tendon nodule.
This child has pediatric trigger thumb (PTT). The potential for spontaneous resolution beyond the age of 2 years is limited. Surgical release of the A1
pulley is indicated.
Pediatric trigger thumb presents as fixed flexion at the interphalangeal joint (IPJ) rather than triggering. It is likely to be acquired (rather than congenital). It is associated with the presence of Notta's nodule, a thickening of the FPL tendon and overlying tendon sheath. Treatment involves A1 pulley release.
The role of non-surgical management (splinting/stretching) remains unclear. The duration of non-surgical treatment is long (up to 30 months) and compliance can be difficult.
Shah et al. reviewed pediatric trigger thumb. The condition is associated with MCP hyperextension. The authors note no advantage to percutaneous release as general anesthetic is required anyway.
Marek et al. performed a retrospective review and survey response review of surgery for pediatric trigger thumb. They found that age at the time of surgery influences residual flexion contracture and rate of recovery. They found surgery to be safe and effective, and recommend: (1) surgery for a 2-year-old child with a locked thumb for 6 months, (2) observation for a child <1 year if the thumb is triggering (not locked), and (3) a 6-month observation period if observation is advocated.
Figures A and B show a fixed flexion deformity of the thumb and an attempt at thumb extension. Figure C shows the outlined Notta nodule.
Incorrect Answers:
A 48-year-old hairdresser presents with pain and swelling of his ring finger for 4 days. On examination, there is generalized tenderness along the entire digit. Passive extension of the digit triggers
excruciating pain. The clinical appearance of the digit is shown in Figure A. What is the most appropriate next step in management?
Acyclovir
Intravenous antibiotics, splinting and elevation
Closed tendon sheath irrigation from the level of the A1 pulley (proximal) to the distal interphalangeal joint (distal)
Continuous closed tendon sheath irrigation from the wrist (proximal) to the distal interphalangeal joint (distal)
Open irrigation and debridement
This patient has advanced pyogenic flexor tenosynovitis (PFT) with visible ischemia/necrosis. Open irrigation and debridement is necessary.
Pyogenic flexor tenosynovitis is usually caused by a puncture wound (although it may infrequently arise from hematogenous spread). The most common organism is Staphylococcus aureus. Kanavel signs help differentiate this disease from herpetic whitlow, septic arthritis, gout/pseudogout, and other hand infections such as paronychia, felons, cellulitis, and deep space infections.
Draeger et al. reviewed the treatment of pyogenic flexor tenosynovitis (PFT). They recommend open irrigation and debridement for advanced PFT and atypical or chronic tenosynovial infections where tenosynovectomy may be
indicated. Both midaxial and volar zigzag incisions can be used.
Pang et al. reviewed factors affecting the prognosis of PFT. Of the 4 Kanavel signs, they found that fusiform swelling was most often present (97% of patients), followed by pain on passive extension (72%), semiflexed digit posture (69%), and tenderness along the flexor tendon sheath (64%).
Figure A shows advanced PFT demonstrating subcutaneous purulence and local ischemia in addition to fusiform digital swelling. Illustration A shows the Nevasier technique of closed tendon sheath irrigation. Illustration B shows the setup for continuous tendon sheath irrigation using nested catheters.
Illustration C shows the incision for open irrigation and debridement.
Incorrect Answers:
Madelung's deformity of the distal radius is caused by which of the following?
Premature fusion of the distal radial ulnar joint
Physeal growth mismatch between the distal radius and ulna
Nutritional deficiency affecting the physeal zone of provisional calcification
Impaired growth of the volar and ulnar aspect of the distal radial physis
Unrecognized trauma
CORRECT ANSWER: 4
Madelung's deformity is that of excessive ulnar/palmar angulation of the distal radius caused by impaired growth of the volar and ulnar aspect of the distal radial physis. It may be caused by either a bony lesion in the palmar/ulnar corner of the distal radial physis or an abnormal radial-carpal ligament (Vicker's ligament). The other answers do not cause Madelung's deformity.
Leri-Weill dyschondrosteosis is a rare genetic disorder caused by mutation in the SHOX gene that causes mesomelic dwarfism with associated Madelung's defomity of the forearm.
Illustration A is a radiographic example of Madelung's deformity.
A 17-year-old boy presents with pain in his right elbow for 2 years and limitation in elbow motion bilaterally. He denies any pain or discomfort in his left elbow. He reports no history of trauma to either elbow. He has had two courses of physical therapy, but has noted no noticeable improvement in pain or motion. Examination demonstrates no elbow tenderness on palpation, and there are no neurological deficits. Manual reduction is unsuccessful. The range of motion of both elbows is shown in Figure A. Radiographs of left and right elbow are shown in Figure B and C respectively. What is the most appropriate treatment plan for the right and left elbow?
Bilateral open reduction and application of a hinged external fixator to both elbows
Radial head resection of the right elbow and non-operative management of the left elbow.
Bilateral radial head arthroplasty
Physical therapy and splinting to both elbows
Radial head resection and interposition arthroplasty for the right elbow and radial head resection alone for the left elbow
This patient has bilateral congenital radial head dislocation (CRHD). The right side is symptomatic with significant loss of motion. The left is asymptomatic with minimal loss of active motion. Therefore the most appropriate treatment is radial head resection of the right elbow and non-operative management of the left elbow.
It is important to differentiate CRHD from traumatic dislocation. Clinical features of CRHD include bilateral involvement, presence at birth, other congenital anomalies, familial occurrence, irreducible by closed methods, and
lack of a history of trauma. Radiological features include dome-shaped radial head and hypoplastic capitellum, relatively short ulna or long radius, deficient trochlea, prominent medial epicondyle, grooving of the distal radius, and anterior curvature of the posterior outline of the ulna.
Bengard et al. reviewed 10 surgically treated and 6 nonsurgically treated CRHD patients. They found no change in flexion-extension and carrying angle postoperatively, but forearm rotation was improved. Surgically treated patients had significant improvement in elbow pain. Ultimately, >25% of patients had wrist pain postop and this must be weighed in the decision process of treatment. They recommend radial head excision as an effective intervention in selected patients with significant elbow pain.
Figure A is a table showing moderately diminished ROM of the right elbow, and minimally reduced ROM of the left elbow. Figures B and C both show posterior dislocation of the radial head (a line along the long axis of the radius should intersect the capitellum in all views).
Incorrect Answers:
Which of the following muscles provide the primary deforming forces to Bennett and Rolando fractures (base of the 1st metacarpal fractures)?
Pronator quadratus
Flexor pollicis longus
Extensor pollicis longus
Adductor pollicis longus and abductor pollicis
Abductor pollicis longus and adductor pollicis
The primary deforming forces in Bennett and Rolando fractures are the Abductor pollicis longus and adductor pollicis.
In a Bennet's or Rolando fracture-dislocation the volar-ulnar fracture fragment is held reduced by the anterior oblique ligament while strong deforming forces pull the remaining metacarpal shaft proximally and dorsally, angulate the shaft ulnarly and supinate the shaft. Most important in these deforming forces are the abductor pollicis longus (APL) inserting on the base of the metacarpal which pulls the metacarpal shaft proximally and dorsally and the adductor pollicis (AP) which inserts on the ulnar base of the proximal phalanx and angulates the metacarpal shaft ulnarly and supinates the shaft. Less important is the extensor pollicis longus (EPL) which inserts on the base of the distal phalanx and also adds to the ulnar angulation of the distal fragment.
Soyer reviews the diagnosis, pathoanatomy, and treatment for fractures at the base of the 1st metacarpal. Understanding the biomechanics, anatomical deforming forces, and the exact fracture pattern aids the treating surgeon in determining the most appropriate method of fixation. The most essential factor for obtaining a good functional result is anatomic restoration of the articular surface.
Elgafy et al. examined the terminal anatomy of the posterior interosseous nerve in their cadaver study - identifing six terminal branches and describing methods to avoid injury. They describe how treating surgeons can maximize function and recovery after base of the 1st metacarpal fractures by understanding these nervous branches and specific fracture pattern treatment to avoid iatrogenic injury to the PIN.
A 28-year-old man sustained a complete laceration of the flexor digitorum profundus of his index finger while cutting a watermelon 3 days ago. A clinical photograph is shown in Figure A. The surgeon plans to repair the tendon using a 4-strand core suture technique. Which method of tendon repair will give him the best results in terms of load to failure and gliding resistance?
Repair with core suture purchase 5mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 10mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 5mm from the cut edge. Circumferential
simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential Silfverskiold epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge, coupled with circumferential simple running epitendinous suture will give him the best load to failure and gliding resistance.
The strength of tendon repairs depend on the number of strands crossing the repair site. Ideally, repairs should have 4-6 strands to allow for early active motion. A running epitendinous suture is recommended to improve tendon gliding and repair strength.
Gulihar et al. compared 3 different epitendinous suture techniques. They found that compared with an intact tendon, gliding resistance increased 100% with the Halsted repair, 80% with the Silfverskiold repair and 60% with a running suture. They thus recommend a simple running suture when an epitendinous suture is needed.
Lee et al. compared core suture purchase at 3, 5, 7 and 10mm from the cut edge. The 10mm-repair group had the highest 2-mm gap force and ultimate failure load. They recommend 10-mm suture purchase for optimal performance and to allow early active motion.
Figure A shows a laceration to the volar aspect of the index finger in flexor zone II. Illustration A shows a core suture purchase distance from the cut edge (represented by "X", where 10mm is the ideal distance). Illustration B shows 3 different epitendinous suture techniques (A, simple running; B, Silfverskiold; C, Halsted).
Incorrect Answers:
A 28-year-old professional baseball player injures his middle finger sliding into the catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A radiograph is provided in figure A. All of the following are true EXCEPT:
Anatomic reconstruction of the articular surface is prognostic of clinical function
Proximal interphalangeal joint subluxation precludes a normal gliding flexion arc
Hinging at the fracture site must be avoided
Early motion should be initiated in postoperative therapy
Early degenerative arthritis can be expected if the joint is not adequately reduced.
The radiograph demonstrates a dorsal fracture dislocation of the proximal interphalangeal joint of the middle finger. Kiefhaber and Stern review the presentation, evaluation, and treatment of PIP fractures. Congruent reduction of the joint to allow the middle phalanx to glide around the proximal phalangeal head is paramount to prevent joint subluxation and instability.
Anatomic reconstruction of the articular surface is desirable but not necessary for successful clinical outcome.
A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A. He undergoes a procedure to restore the soft tissue envelope. Which treatment option is contraindicated because of increased risk of interphalangeal joint stiffness?
Moberg volar advancement flap
Foucher first dorsal metacarpal artery flap
Littler neurovascular island flap
Free great toe pulp transfer
Holevich first dorsal metacarpal artery flap
This patient has a large thumb pulp defect measuring 3.5 cm in length, extending proximal to the interphalangeal joint (IPJ) crease. Inset of a Moberg flap large enough to cover the defect would necessitate IPJ flexion >45 degrees, increasing the risk of IPJ stiffness.
Thumb pulp defects may be resurfaced by different means, depending on size. The Moberg flap is suited for medium (1.8-3 cm) defects. For defects >1.5 cm, there is increased risk of wound dehiscence, parrot beak nail deformity, and decreased soft tissue padding. Modifications such as V-Y flaps, bilateral Z-plasties, Burrow triangles, 2 lateral triangular flaps at the proximal edge of the flap, or advancement of an island flap with skin grafting of the secondary defect (O’Brien modification), are recommended.
Baumeister et al. reviewed the functional outcome of Moberg flaps. These flaps do not cause marked impairment of active ROM and any reduction in the AROM of the IP joint is because of a loss of hyperextension.
Horta et al. reviewed the use of multiple flaps (Moberg, radial innervated cross-finger, Venkataswami-Subramanian, Foucher, Tezcan, and Littler). They recommended the Foucher flap because of good sensibility, single-stage surgery, and no need for cortical reintegration (unlike the Littler flap)
Figure A shows a large thumb pulp defect. Illustration A shows the options for resurfacing thumb pulp defects of different sizes. Illustration B is a diagram of these options. Illustrations C and D depict the Holevich dorsal metacarpal artery flap (with overlying skin strip). Illustrations E and F depict the Foucher dorsal metacarpal artery flap (islanded).
Incorrect Answers:
Percutaneous screw fixation for non-displaced scaphoid waist fractures has been shown to have which of the following differences compared to closed treatment?
Increased direct and indirect cost
Slower return to work
Higher union rates
Reduced time to fracture union
Improved motion and grip strength after 2 years
Fixation of non-displaced scaphoid fractures with a percutaneous screw has resulted in a shorter time to union (6-7 weeks versus 10-12 weeks) and faster return to work or sports.
Arora et al found the indirect cost reduction by a quicker return to work was shown to offset the direct costs of surgical intervention.The operatively treated group had a better mean DASH-score than the conservative group. Fracture
union was seen in the screw fixation group at a mean of 43 days and in the cast immobilization group at a mean of 74 days.
Bond et al found in active military personnel there was faster healing but no difference in ultimate union rates or final grip strength or range of motion between percutanous screw fixation and non-operative groups. The average time to fracture union in the screw fixation group was seven weeks compared with twelve weeks in the cast immobilization group. There was no significant difference in the range of motion of the wrist or in grip strength at the two-year follow-up evaluation.
Constriction ring syndrome, also known as amniotic band syndrome, is a congenital disorder associated with which paediatric foot condition?
Equinovalgus foot
Clubfoot (Congenital talipes equinovarus)
Tarsal coalition
Congenital vertical talus
Polydactyly
CORRECT ANSWER: 2
Constriction ring syndrome is a congenital disorder that is most commonly associated with clubfeet (congenital talipes equinovarus). The reported incidence of clubfeet with concomitant constriction bands ranges from 12-56%.
Constriction ring syndrome is a collection of congenital malformations that occur as a result of intrauterine rings or bands that constrict fetal tissue. The etiology of constrictive ring syndrome remains elusive, though Streeter postulated in 1930 that a germline developmental abnormality is responsible for the development of amniotic constriction bands, hence one of the synomonous terms used to describe the disorder, Streeter’s dysplasia. Normal anatomy is found proximal to the band. Distally, a constrictive band can cause compression of lymphatic and neurovascular structures and result in lymphedema, altered circulation and neuropathy. In severe cases congenital amputation can occur. In terms of other orthopaedic conditions, constrictive ring syndrome is associated with clubfeet, acrosyndactyly and pseudoarthrosis. With respect to clubfeet, surgical treatment is commonly required, which consists of z-plasty releases of the constricted bands, in addition to surgical correction of the clubfoot deformity.
Gomez reviewed 35 children with clubfeet associated with constriction ring syndrome. In this cohort there was a poor response to casting, as 77% of the children required surgical corrections. Z-plasty releases of the deep bands were performed before the clubfoot correction.
Allington et al. examined the outcome of treatment of clubfeet distal to a lower extremity band in 18 patients (21 feet). Sixteen children (88.9%) underwent surgical treatment after manipulation and serial casting were unsuccessful.
Mild initial foot deformities and constriction bands located in the distal aspect of the lower leg were associated with the best outcomes.
Incorrect Answers:
You are consulted on a newborn male inpatient who presents with the clinical sign shown in Figure A. All of the following are commonly associated with this syndrome EXCEPT?
Bronchopulmonary dysplasia
Cardiac defects
Cleft palate
Encephalocele
Rigid talipes equinovarus

Question 34:

Options:

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

Correct Answer: Doxycycline and ceftazidime

Explanation:

Question 35:

- A 12 month old infant has congenital complete absence of the tibia. Examination reveals that the femur in the abnormal limb is 3 cm short, with a normal ipsilateral hip. The patient has an intact fibula, an equinovarus foot with four rays, and moderate popliteal skin webbing. Management should consist of

Options:

Syme’s amputation
Arthrodesis of the knee
Disarticulation of the knee
Centralization of the fibula
Prosthetic fitting to accommodate the present deformity

Correct Answer: Disarticulation of the knee

Explanation:

Question 36:

Options:

arthroscopic repair of the ulnar collateral ligament.
direct surgical repair of the ulnar collateral ligament.
reconstruction of the ulnar collateral ligament with a palmaris longus tendon autograft.
a hinged elbow brace to allow early protected range of motion.
immobilization of the elbow to allow healing of the ulnar collateral ligament.

Correct Answer: reconstruction of the ulnar collateral ligament with a palmaris longus tendon autograft.

Explanation:

Question 37:

Which factor has the most negative influence on the success of knee osteochondral allograft transplantation?

Options:

Mechanical axis malalignment
Blood-type matching of the host and donor
Sex of the donor
Failed previous cartilage procedure

Correct Answer: Mechanical axis malalignment

Explanation:

Question 38:

Options:

Restrict fluid intake 2 hours before the start of the race to avoid abdominal cramping.
Drink low osmolality (less than 10%) solutions before, during, and after the race.
Drink fruit juice, such as orange juice, instead of water to replenish essential carbohydrates.
Drink high osmolality (greater than 10%) solutions before and during the race and low osmolality solutions after the race.
Avoid the use of glucose polymers because they slow down gastric emptying and may lead to abdominal cramping.

Correct Answer: Drink low osmolality (less than 10%) solutions before, during, and after the race.

Explanation:

Question 39:

Options:

unrecognized injury to the recurrent motor branch.
neuropraxia of the proper palmar digital nerve.
new-onset stenosing flexor tenosynovitis.
injury to the flexor digitorum profundus to the index finger.

Correct Answer: neuropraxia of the proper palmar digital nerve.

Explanation:

EXPLANATION:
Complications after carpal tunnel release are relatively uncommon. The clinical picture described above is most consistent with lumbrical muscle weakness secondary to neuropraxia of the proper palmar digital nerve to the index finger supplying motor innervation to that muscle. The recurrent motor branch of the median nerve innervates the thenar musculature and would not present as index finger weakness. A new onset of trigger finger may result from a loss of the pulley effect of the transverse carpal ligament, postoperative tendon inflammation, or previously unrecognized flexor tendon triggering. Flexor digitorum profundus to the index finger lies deep within the carpal tunnel, making its injury unlikely. If
it were injured, the result would not be weakness of interphalangeal joint extension.

Question 40:

Options:

Proceed with implantation of the final components.
Perform a Z-lengthening of the patellar tendon.
Increase the size of the femoral component and use posterior femoral augments to decrease the size of the flexion gap.
Increase the size of the femoral component and use augments both distally and posteriorly to lower the joint line and decrease the size of the flexion gap.
Place distal femoral augments on the femoral component to lower the joint line.

Correct Answer: Perform a Z-lengthening of the patellar tendon.

Explanation:

Question 41:

Options:

Unloader brace
Distal femoral osteotomy
Open arthrofibrosis debridement with lateral ligament balancing and polyethylene exchange
Revision TKA of both the femoral and tibial components

Correct Answer: Revision TKA of both the femoral and tibial components

Explanation:

Question 42:

Options:

placement of a chest tube.
insertion of a large gauge needle into the second intercostal space.
cardiopulmonary resuscitation.
administration of adrenaline.
immediate transfer to the emergency department.

Correct Answer: insertion of a large gauge needle into the second intercostal space.

Explanation:

Question 43:

Which of following is pathognomonic of intervertebral disk degeneration? Review Topic

Options:

Increased water content in the nucleus pulposus
Loss of Type X collagen in the nucleus pulposus
Decreased thickness of the inner annulus fibers
Degradation of large proteoglycans molecules in the nucleus pulposus
Annular tears and fissuring occurring most frequently in the central disc

Correct Answer: Loss of Type X collagen in the nucleus pulposus

Explanation:

Question 44:

Options:

Consult the ethics committee before giving blood.
Use cell saver blood.
Ask the patient’s family for consent to give blood.
Use plasma expanders.
Give the patient blood.

Correct Answer: Use plasma expanders.

Explanation:

DISCUSSION: Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open would is not recommended nor would there likely be enough from an open tibial fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.
REFERENCES: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.
Jehovah’s Witnessess Official Web Site: Medical Care and Blood, 2008, http://www.watchtower.org/e/medical_care_and_blood.htm

Question 45:

- Analysis of which of the following proteins is used to establish the diagnosis of Becker muscular dystrophy?

Options:

Myosin
Troponin
Tropomyosin
Fibrillin
Dystrophin

Correct Answer: Myosin

Explanation:

Becker muscular dystrophy is an X-linked inherited disorder present in approximately 1 in 30,000 live male births. The responsible gene is located on the xp21 region of the X chromosome including sixty-five exons that encode for the protein dystrophin. Duchenne muscular dystrophy is also related to a mutation of the dystrophin gene. Muscle biopsies for dystrophin have been extremely successful for identifying these dystrophies and distinguishing them from other clinically similar autosomal recessive myopathies. (Ref: Shapiro, Hoffman)
Question 18 -
A 25-year-old woman with spastic diplegia has a painful progressive bunion deformity that has failed to respond to nonsurgical treatment. Examination reveals tenderness and erythema over the bunion prominence; however, the hallux metatarsophalangeal joint has full range of motion. A standing AP radiograph shows a hallux valgus angle of 30 degrees and a 1-2 intermetatarsal angle of 13 degrees. Treatment should now consist of
arthrodesis of the hallux metatarsophalangeal joint.
arthrodesis of the first tarsometatarsal joint.
excision of the medial eminence and medial capsular reefing of the metatarsophalangeal joint.
osteotomy of the distal first metatarsal.
proximal metatarsal osteotomy with distal soft-tissue realignment.
Treatment of hallux valgus in a patient with cerebral palsy is largely dependent on the degree of spasticity and the pattern of gait. The only way to adequately eliminate spastic deforming forces is with an arthrodesis of the MTP joint. Any other procedure will most likely lead to a high incidence of either hallux varus or recurrent hallux valgus.
The optimal arthrodesis angle is 25-30 degrees, and the metatarsal inclination angle should be 25-30 degrees also. Sagittal plane position should be checked intraoperatively and the proximal phalanx should clear the table by 5-10mm with simulated WB

Question 46:

The attachments of the transverse carpal ligament include which of the following structures?

Options:

Scaphoid and the ulna
Trapezium and the hook of the hamate
Trapezium and the triquetrum
Trapezoid and the hook of the hamate
Trapezoid and the pisiform

Correct Answer: Trapezium and the hook of the hamate

Explanation:

DISCUSSION: The transverse carpal ligament is the volar boundary of the carpal tunnel. It attaches to the scaphoid and trapezium radially and the pisiform and the hook of the hamate ulnarly. The ulna and trapezoid do not receive attachments of the transverse carpal ligament.
REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 471-472.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 168-170.

Question 47:

A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season. Management should consist of

Options:

cast immobilization and a return to play as symptoms allow.
cast immobilization and a return to play when union is achieved.
open reduction and internal fixation, followed by early range of motion with a return to play when union is achieved.
open reduction and internal fixation, followed by a return to play with protective casting.
symptomatic treatment, with definitive treatment at the end of the season.

Correct Answer: cast immobilization and a return to play as symptoms allow.

Explanation:

Question 48:

Options:

Interphalangeal joint arthritis
Laceration of the flexor hallucis longus tendon
Sesamoid entrapment
Metatarsal malunion
Phalangeal malunion

Correct Answer: Laceration of the flexor hallucis longus tendon

Explanation:

Question 49:

Options:

Ankle-foot orthosis with anterior shell
Vascularized fibular graft
Intramedullary nailing of the left tibia
Amputation
Physical therapy

Correct Answer: Ankle-foot orthosis with anterior shell

Explanation:

Question 50:

Options:

Recurrence of the deformity
Hallux varus
back answer
Transfer metatarsalgia
Nonunion of the first metatarsal osteotomy
Osteonecrosis of the first metatarsal osteotomy 77.03

Correct Answer: Recurrence of the deformity

Explanation:

Coglin’s referenced paper is a study out of Idaho. 11 year retrospective study of 45 patients (60 feet). A multiprocedural approach was used to surgically correct the deformity. There were 6 recurrences of the deformities and eight
complications (6 cases of hallux varus, one case of wire breakage and one case of undercorrection.) So according to their reference this question has two correct answers.
Postoperative complications have been frequently reported following juvenile hallux valgus corrections. Recurrence following surgery is probably the most frequently reported complication and is likely due to the high rate of congruency associated with a
juvenile hallux valgus deformity.
OKU Foot and Ankle 2 Rosemont IL., American academy of orthopaedic surgeons, pp135-150.
back to this question next question

Question 51:

Options:

Arthroscopic debridement of the elbow
Open repair of the lesion
Open biopsy of the lesion
Continued participation in gymnastics until symptoms worsen
No participation in gymnastics until symptoms resolve and motion recovers

Correct Answer: No participation in gymnastics until symptoms resolve and motion recovers

Explanation:

Question 52:

Histologically, synovial chondromatosis is characterized by

Options:

exuberant synovitis (Pannus).
loose fragments of articular cartilage embedded in the synovium.
ossified cartilage nodules embedded in the synovium.
the presence of granulomas in the synovium.
hemosiderin deposition in the synovium.

Correct Answer: ossified cartilage nodules embedded in the synovium.

Explanation:

Question 53:

Rickets can be best characterized by which of the following radiographic changes in children?

Options:

Narrowed physes
Widening of the ribs anteriorly
Rounded epiphyses
Punched out metaphyseal defects with subperiosteal resorption
Sclerotic bands in the upper and lower margins of each vertebra

Correct Answer: Widening of the ribs anteriorly

Explanation:

Question 54:

Options:

overlapping of the digits.
index finger proximal interphalangeal (PIP) joint arthritis.
extensor lag at the PIP joint.
hyperextension at the PIP joint.

Correct Answer: extensor lag at the PIP joint.

Explanation:

Question 55:

Options:

Surgical traction for 6 weeks followed by application of a cast brace
Application of a femoral cable plate
Femoral revision with a cemented long stem prosthesis
Application of cerclage wired double allograft femoral struts
Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Correct Answer: Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Explanation:

Question 56:

Options:

observation.
radiation therapy.
radiation therapy and chemotherapy.
surgical resection.
surgical resection and chemotherapy.

Correct Answer: surgical resection.

Explanation:

Question 57:

Options:

Early cocking
Late cocking
Acceleration
Deceleration DISCUSSION --This patient is experiencing soreness over his medial (ulnar) collateral ligament. Valgus overload is likely to reproduce his symptoms and is most pronounced during the late cocking phase of the throwing cycle.In wind up, very little elbow torque is required. In early cocking, the arm is getting loaded and maximum valgus is not yet achieved at the elbow. In acceleration and deceleration, more force is generated at the level of the shoulder joint.

Correct Answer: Late cocking

Question 58:

A healthy 65-year-old woman undergoes anatomic total shoulder arthroplasty to address osteoarthritis (OA). The surgery is uncomplicated. What is the most common indication for future revision?

Options:

Deep infection
Periprosthetic fracture
Glenoid component loosening
Rotator cuff tear

Correct Answer: Glenoid component loosening

Explanation:

Question 59:

Options:

Denosumab
Alendronate
Abaloparatide
Teriparatide
Strontium ranelate

Correct Answer: Strontium ranelate

Explanation:

Question 60:

Options:

Latent osteomyelitis from the percutaneous pins
Muscle weakness because of a lack of postinjury rehabilitation
Tardy ulnar nerve paralysis from injury by the medial pin
Osteonecrosis of the trochlea, producing joint incongruity
A new acute process

Correct Answer: Osteonecrosis of the trochlea, producing joint incongruity

Explanation:

Question 61:

- A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Options:

Spinal shock
Neurogenic shock
Hypovolemic shock
Pulmonary embolism
Fat embolus syndrome

Correct Answer: Neurogenic shock

Explanation:

Question 62:

Options:

Infection
Giant cell tumor
Nonossifying fibroma
Enchondroma
Osteosarcoma

Correct Answer: Giant cell tumor

Explanation:

DISCUSSION: The radiograph reveals a subchondral lesion in the metacarpophalangeal joint that is lytic and expansile. The MRI scans show a mass that is moderate in intensity on the
T
2
-weighted image and has some gadolinium uptake. There are no cystic components in this lesion. The subchondral location and expansile nature are highly suggestive of giant cell tumor of bone. A lesion with this appearance might also represent an aneurysmal bone cyst, given the amount of expansion present.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 113-118.
Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 63:

Options:

acute inflammation.
chronic inflammation.
partial tendon rupture.
anaerobic degeneration.
impaired collagen cross-linking.

Correct Answer: anaerobic degeneration.

Explanation:

Question 64:

What is the goal of surgical treatment in this scenario?

Options:

To cure cancer
To prolong life
To relieve pain
To reverse neurologic symptoms

Correct Answer: To relieve pain

Explanation:

DISCUSSION
This patient has a metastatic neuroendocrine tumor. Surgical treatment should prioritize palliation of her symptoms. She has high-grade spinal cord compression without neurologic signs or symptoms. Steroids are beneficial for patients with high-grade spinal cord compression caused by tumors, and these drugs should be administered in the acute setting. This patient was appropriately initially treated with conventional radiation. However, she is not a candidate for further radiation because of spinal cord tolerance limits and insufficient clearance between the tumor and spinal cord. Consequently, stereotactic radiation is not an option.
The goal of surgical treatment of this tumor should be palliation of her symptoms rather than cure. A costotransversectomy approach offers the advantage of ventral and dorsal spinal cord access, which is necessary in this case. A sternotomy or transthoracic approach would offer ventral access, but dorsal access would be less than optimal.
RECOMMENDED READINGS
Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: evaluation and management. J Am Acad Orthop Surg. 2011 Jan;19(1):37-48. Review. PubMed PMID: 21205766.
View Abstract at PubMed
Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol. 2010 Oct;7(10):590-8. doi: 10.1038/nrclinonc.2010.137. Epub 2010 Aug

Question 65:

The radiograph shown in Figure 27 shows measurement of what angle?

Options:

Hallux valgus
Distal metatarsal articular
Intermetatarsal
Sesamoid divergence
Angle of joint congruence

Correct Answer: Distal metatarsal articular

Explanation:

Question 66:

Options:

No weight bearing
Cortisone injection
Physical therapy
Arthroscopic meniscectomy or repair
Anterior cruciate ligament reconstruction

Correct Answer: Arthroscopic meniscectomy or repair

Explanation:

Question 67:

Initial postoperative management after repair of an acute rotator cuff tear includes

Options:

active range of motion.
active abduction to prevent scarring.
passive forward elevation and external rotation within a safe zone determined at surgery.
eccentric strengthening exercises.
internal rotation behind the back.

Correct Answer: passive forward elevation and external rotation within a safe zone determined at surgery.

Explanation:

Question 68:

Which structure is indicated by the arrow in Figure 33?

Options:

Corona mortis
Tibial division, sciatic nerve
Sciatic nerve, peroneal division
Fifth lumbar nerve root
Kocher-Langenbeck approach
Stoppa approach
Obturator vessels
L4 nerve root

Correct Answer: Fifth lumbar nerve root

Explanation:

DISCUSSION
The posterior position of the sciatic nerve in relation to the acetabulum and the lateral peroneal division makes the peroneal division of the sciatic nerve the portion of the nerve that is most likely to be injured in a posterior traumatic hip dislocation, accounting for up to 10% of concomitant nerve injuries with posterior hip dislocation. The corona mortis is an anatomic variant that results in vascular anastomosis between the obturator and either the external iliac or inferior epigastric arteries. This variant occurs in approximately 80% of patients and varies in its position, being located 4 cm to 9 cm lateral to the symphysis pubis. The obturator vascular bundle is situated in the fat medial to the obturator internus muscle and must be mobilized to access the quadrilateral plate. Dissection may be carried out both above and below this vascular leash. The Kocher-Langenbeck approach is indicated for fractures involving the posterior wall and/or posterior column of the acetabulum and for both column fractures that require direct posterior visualization. This approach is not indicated for direct reduction of the anterior wall or column when direct visualization is required anteriorly. The L5 nerve root is located on the anterior sacrum and is indicated by the arrow.
The position of this neural structure must be considered whether the surgeon is stabilizing
31
the sacroiliac (SI) joint with percutaneous iliosacral screws or with anterior SI plating through the lateral window of the ilioinguinal approach.
RECOMMENDED READINGS
Cornwall R, Radomisli TE. Nerve injury in traumatic dislocation of the hip. Clin Orthop Relat Res. 2000 Aug;(377):84-91. Review. PubMed PMID: 10943188.
View
Abstract at PubMed
Darmanis S, Lewis A, Mansoor A, Bircher M. Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum. Clin Anat. 2007 May;20(4):433-9. PubMed PMID: 16944498.
View Abstract at PubMed
Archdeacon MT, Kazemi N, Guy P, Sagi HC. The modified Stoppa approach for acetabular fracture. J Am Acad Orthop Surg. 2011 Mar;19(3):170-5. PubMed PMID: 21368098.
View Abstract at PubMed
Rommens P. The Kocher-Langenbeck approach for the treatment of acetabular fractures. Operat Orthop Traumatol 2004; 16:59-74.
Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 2. Contemporary indications and techniques for definitive surgical management. J Am Acad Orthop Surg. 2013 Aug;21(8):458-68. doi: 10.5435/JAAOS-21-08-458. Review. PubMed PMID: 23908252.
View Abstract at PubMed

Question 69:

Acral metastases are most commonly seen in what type of carcinoma?

Options:

Renal cell
Lung
Thyroid
Breast
Ovarian

Correct Answer: Lung

Explanation:

DISCUSSION: Metastatic lesions to bone are usually located in the axial and proximal appendicular skeleton. Metastases below the elbow and knee are rare, but when they do occur they are most commonly from lung carcinoma.
REFERENCES: Hayden RJ, Sullivan LG, Jebson PJ: The hand in metastatic disease and acral manifestations of paraneoplastic syndromes. Hand Clin 2004;20:335-343.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 313.

Question 70:

..First-line treatment recommendations include

Options:

synovectomy.
arthrocentesis, compressive wrap, and rest.
en bloc resection.
intra-articular radioactive nucleotide injection. DISCUSSION… The MRI scans reveal classic findings of PVNS with low signal on proton density and T2 sequences and evidence of “blooming” on gradient echo sequences. A discrete mass suggestive of a sarcoma (which would typically appear dark on T1 and bright on T2, but heterogenous and enhancing) is not seen, and synovial sarcomas rarely arise in an intra-articular location. Cartilaginous nodules of synovial chondromatosis are not seen, and the abnormal synovial process indicates that this is more than just a posttraumatic hemarthrosis. Treatment is synovectomy; radiotherapy is reserved for select recurrent cases. Arthrocentesis would be used for a simple hemarthrosis, and resection used for a sarcoma.

Correct Answer: en bloc resection.

Explanation:

Question 71:

Options:

External rotators
Extensors
Abductors
Flexors
Adductors

Correct Answer: Abductors

Explanation:

Question 72:

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 73:

The brachialis muscle is innervated by what two nerves?

Options:

Radial and musculocutaneous
Lateral and medial brachial cutaneous
Axillary and medial and lateral pectoral
Radial and ulnar
Ulnar and musculocutaneous

Correct Answer: Radial and musculocutaneous

Explanation:

Question 74:

Failure of posterolateral corner repair or reconstruction of the knee may be associated with which of the following? Review Topic

Options:

Valgus malalignment
Varus malalignment
Anterior cruciate ligament reconstruction
Posterior cruciate ligament reconstruction
Medial collateral ligament reconstruction

Correct Answer: Varus malalignment

Explanation:

Question 75:

Options:

Reduction in free fibrinogen radicals
Reduction in bleeding complications
Increased venous flow
Improved bioavailability
Inhibition of factors V, VI, and IX

Correct Answer: Improved bioavailability

Explanation:

Question 76:

Options:

Brodie’s abscess
Hyperparathyroidism
Stress fracture
Enchondroma
Osteoid osteoma

Correct Answer: Osteoid osteoma

Explanation:

DISCUSSION: Osteoid osteoma is a round or oval, well-circumscribed lesion with a
radiolucent nidus. A small area of calcification may be present within the center of the nidus. The radiolucent nidus is surrounded by a thick rim of sclerotic bone. These diagnostic
features are frequently better seen on CT. An increase in cyclooxygenase activity has been demonstrated within osteoid osteomas, which may explain why aspirin and other nonsteroidal anti-inflammatory drugs classically relieve the pain associated with these lesions.
REFERENCES: Kneisl JS, Simon MA: Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg Am 1992;74:179-185.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 121-130.

Question 77:

What nerve is most at risk during placement of the anterolateral portal in elbow arthroscopy?

Options:

Median
Ulnar
Radial
Posterior interosseous
Anterior interosseous

Correct Answer: Radial

Explanation:

Question 78:

Options:

a long leg cast.
a reamed nail.
an unreamed nail.
an external fixator.
plates and screws.

Correct Answer: an external fixator.

Explanation:

Question 79:

A 70-year-old former baseball catcher reports long-standing pain in the ring and little fingers. A gradient-echo MRI scan is shown in Figure 26. What is the most likely diagnosis?

Options:

Giant cell tumor of the tendon sheath
Ulnar artery aneurysm
Lipoma
Hematoma
Neurolemmoma

Correct Answer: Ulnar artery aneurysm

Explanation:

DISCUSSION: The gradient-echo MRI scan highlights the ulnar and radial arteries,
as indicated by the arrow. This technique suppresses the signal of the surrounding fat
and causes the stationary surrounding tissues to become intermediate in signal intensity.
The flowing blood is then easily identified with a bright signal because it does not absorb the radiofrequency pulse. Based on the findings, the diagnosis is an ulnar artery aneurysm, most likely caused by years of repetitive trauma as the result of catching baseballs. Neurolemmoma and giant cell tumor of the tendon sheath would be intermediately enhanced on this image sequence, and the continuity with the ulnar artery, demonstrated here, would not be expected. Lipomas are not enhanced using the gradient-echo technique. The chronic nature of the patient’s symptoms is not indicative of a hematoma, and the hematoma would be dark on this imaging sequence since it is stationary tissue.
REFERENCES: Koman LA, Ruch DS, Patterson Smith B, et al: Vascular disorders, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, vol 2, pp 2254-2302.
Holder LE, Merine DS, Yang A: Nuclear medicine, contrast angiography, and magnetic resonance imaging for evaluating vascular problems in the Hand: Vasospastic disorders. Hand Clin 1993;9:95-113.

Question 80:

A 72-year-old man has had persistent pain after undergoing a hemiarthroplasty 18 months ago. Radiographs are shown in Figures 50a and 50b. What is the most likely cause of his problem?

Options:

Suboptimal cement technique
Excessive activity level
Oversized bipolar component
Infection
Osteoporosis

Correct Answer: Infection

Explanation:

DISCUSSION: The radiographs demonstrate a rapid erosion of the bipolar component into the acetabulum. Although acetabular erosion is more common with unipolar hip arthroplasties, it can occur with bipolar components. Haidukewych and associates noted a very low erosion rate but none in the first 2 years. The second finding on the radiographs is the linear radiolucency progressing from the joint toward the end of the stem at the cement-bone interface suggesting chronic infection or diffuse loosening. The persistent pain since implantation also suggests chronic infection. High activity levels and osteoporosis do not lead to acetabular erosion in the first 2 years after hemiarthroplasty. While the cement technique is suboptimal, loosening and erosion should not be expected from this alone. An oversized bipolar head would extrude and not erode.
REFERENCES: Haidukewych GJ, Israel TA, Berry DJ: Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res 2002;403:118-126.
Lestrange NR: Bipolar hemiarthroplasty for 496 hip fractures. Clin Orthop Relat Res 1990;251:7-19.
Callaghan JJ, Dennis DA, Paprosky WG, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, p 158.

Question 81:

The most common neurologic injury following an anterior cervical diskectomy and fusion (ACDF) is injury to which of the following structures? Review Topic

Options:

Recurrent laryngeal nerve
Superior laryngeal nerve
C5 root
Spinal cord
Sympathetic chain

Correct Answer: Recurrent laryngeal nerve

Explanation:

Question 82:

-The main blood supply to the capital femoral epiphysis in a 10-year-old child is supplied from the

Options:

artery of the ligamentum teres.
epiphyseal branch of the lateral femoral circumflex artery.
posterosuperior and posteroinferior retinacular branches of the lateral femoral circumflex artery.
posterosuperior and posteroinferior retinacular branches of the medial femoral circumflex artery. DISCUSSION-Before the age of 4 years, blood to the femoral head is supplied by the medial and lateral femoral circumflex arteries as well as the artery of the ligamentum teres. After the age of 4, the blood supply through the artery of the ligamentum teres diminishes. The lateral femoral circumflex system regresses,and its flow into the physis and epiphysis diminishes significantly so the medial femoral circumflex artery becomes the predominant blood supply to the metaphysis. The medial femoral circumflex artery provides the principal blood supply to the proximal femur via its posterosuperior and posteroinferior retinacular branches.

Correct Answer: posterosuperior and posteroinferior retinacular branches of the medial femoral circumflex artery. DISCUSSION-Before the age of 4 years, blood to the femoral head is supplied by the medial and lateral femoral circumflex arteries as well as the artery of the ligamentum teres. After the age of 4, the blood supply through the artery of the ligamentum teres diminishes. The lateral femoral circumflex system regresses,and its flow into the physis and epiphysis diminishes significantly so the medial femoral circumflex artery becomes the predominant blood supply to the metaphysis. The medial femoral circumflex artery provides the principal blood supply to the proximal femur via its posterosuperior and posteroinferior retinacular branches.

Question 83:

The use of radiation therapy is most effective in metastatic bone disease from which of the following tumors?

Options:

Renal cell carcinoma
Adenocarcinoma of the lung
Adenocarcinoma of the colon
Carcinoma of the cervix
Lymphoma

Correct Answer: Lymphoma

Explanation:

Question 84:

Options:

Fracture of the posterior glenoid
Triceps insertion avulsion
Calcific tendinitis
Posterior glenoid exostosis
Loose body

Correct Answer: Posterior glenoid exostosis

Explanation:

Question 85:

Wear particles of ultra-high molecular weight polyethylene that are generated by total hip implants are predominantly of what diameter?

Options:

Less than 1 micron
10 to 50 microns
100 to 200 microns
500 to 750 microns
Greater than 1,000 microns

Correct Answer: Less than 1 micron

Explanation:

Question 86:

Exostoses in which of the following anatomic locations is the most likely to undergo malignant transformation in a patient with multiple hereditary exostosis (MHE)?

Options:

Distal humerus
Distal radius
Distal femur
Lumbar spine
Scapula

Correct Answer: Scapula

Explanation:

Question 87:

-Radiographs are shown in Figures 89a through 89c. What is the most likely diagnosis?

Options:

Medial tibial plateau fracture
Chronic medial collateral ligament injury
Anterior cruciate ligament (ACL) rupture
Acute lateral collateral ligament rupture

Correct Answer: Anterior cruciate ligament (ACL) rupture

Question 88:

Options:

Immediate weightbearing
Subchondral debridement of any osteochondral defect
Repair of medial ligamentous structures
Casting or splinting in a neutral position postoperatively
Anatomic reduction of the syndesmosis

Correct Answer: Anatomic reduction of the syndesmosis

Explanation:

Question 89:

Which of the following forms of nonsurgical management is considered best for acute low back pain without radiculopathy?

Options:

Acupuncture
Epidural steroid injections
Facet joint injections
Sclerosant injections
Bed rest

Correct Answer: Bed rest

Explanation:

Question 90:

Options:

repair of the superior labrum.
isolated supraspinatus repair.
biceps recentering.
subscapularis repair and biceps tenodesis.
subscapularis repair and recentering of the biceps tendon.

Correct Answer: subscapularis repair and biceps tenodesis.

Explanation:

DISCUSSION: The MRI scan reveals a subscapularis tear with a biceps that is out of the groove. Treatment in this patient is most predictable if the subscapularis is repaired. The biceps should either be tenodesed or tenotomized since it is unstable. Recentering of the biceps has been found to be unpredictable. Treatment of these lesions has been shown to have better results if the biceps is either released or tenodesed. This prevents recurrent biceps symptoms that can be source of surgical failure.
REFERENCES: Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10.
Deutsch A, Altcheck DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Walch G, Nove-Josserand L, Boileau P, et al: Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 1998;7:100-108.

Question 91:

Options:

Inflammatory elbow arthritis
A presurgical flexion-extension elbow arc of approximately 50°
Retained distal humerus hardware on presurgical radiographs
Evidence of presurgical elbow instability End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion-extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability. Retained hardware from prior surgery was not deemed a contraindication.

Correct Answer: A presurgical flexion-extension elbow arc of approximately 50°

Explanation:

Question 92:

What bilateral surgical intervention is considered inappropriate based on the findings shown in the radiograph in Figure 52?

Options:

Vascularized fibular graft
Proximal femoral osteotomy
Core decompression
Hip arthrodesis
Femoral resurfacing

Correct Answer: Hip arthrodesis

Explanation:

DISCUSSION: The radiograph reveals osteonecrosis of both femoral heads with reasonably maintained joint surfaces. There may be some slight flattening of the femoral heads. Hip arthrodesis is difficult to perform because of the necrotic bone. Its use in patients with osteonecrotic hips is limited because of the 80% bilaterality; therefore, it is not an acceptable alternative. All the other options are acceptable interventions.
REFERENCES: Mont MA, Jones LC, Sotereanos DG, et al: Understanding and treating osteonecrosis of the femoral head. Instr Course Lect 2000;49:169-185.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 93:

Options:

Placing the hip center too inferior
Overmedializing the acetabular component
Overlengthening the extremity
Intrasurgical acetabular fracture

Correct Answer: Overlengthening the extremity

Explanation:

DISCUSSION
The radiograph reveals hip dysplasia. Patients with hip dysplasia and severe limb shortening are at high risk for sciatic nerve palsy from overlengthening. Overmedializing the acetabular component is not the preferred response because overlateralization is more of a concern if the cup is placed in the pseudoacetabulum instead of in the true acetabulum. Placing the hip center too inferior is not the preferred response because the concern in this scenario is placing the hip center too superior if the cup is placed in the pseudoacetabulum or if a large-diameter cup is used. Acetabular fractures are possible because of osteoporotic bone at the true hip center, but is less likely than overlengthening of the extremity.
CLINICAL SITUATION FOR QUESTIONS 11 THROUGH 13
Figures 11a and 11b are the radiographs of a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, she has failed nonsurgical treatment including weight loss, activity modifications, and intra-articular injections. Her infection workup reveals laboratory findings within defined limits.

Question 94:

Options:

Supplemental internal fixation
Primary ankle arthrodesis
Nonsurgical treatment to avoid infection
Early bone grafting because of poor bone quality
Early mobilization and weight bearing to minimize stiffness

Correct Answer: Supplemental internal fixation

Explanation:

Question 95:

Options:

with varus malalignment
with valgus malalignment
with external rotation malalignment
with internal rotation malalignment
with no malalignment

Correct Answer: with varus malalignment

Explanation:

When the lesser trochanter (LT) profile is larger than the uninjured side, the proximal fragment is externally rotated. This leads to an overall internal rotation (IR) malalignment of the distal fragment. Malalignment is described based on the distal fragment relative to the proximal fragment. For more proximal femoral fractures, the proximal fragment tends to be flexed and externally rotated due to the iliopsoas. Matching rotation requires external rotation of the distal fragment when the patient is supine on a fracture table.
Rotational malalignment is the most common complication of intramedullary nailing of a comminuted diaphyseal femoral fracture. The rotational profile of the lesser trochanter can be used to evaluate rotational alignment. The proximal femur is rotated until a neutral position is obtained as judged by the radiographic profile of the lesser trochanter. If the AP image shows a smaller lesser trochanter, there is IR of the LT. A larger LT indicates external rotation (ER) of the LT.
Jaarsma et al. describe CT imaging in determining rotational alignment. They note that the incidence of post-nailing malalignment > 10 ° is 40%, > 15 ° is 20-30%, and
> 20 ° is 16%. They also note that patients with ER deformities have more symptoms than those with IR deformities, and that small deformities <15 ° give rise to less complaints. This is because ER deformities lead to compensation with hip retroversion, which causes more symptoms than hip anteversion when compensating for IR deformities.
Incorrect Answers:
(SBQ12TR.37) A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?
Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels I hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:

Question 96:

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

Options:

Need for ankle fusion or arthroplasty
Return to normal function
Ankle stiffness without pain
Severe constant pain and inability to work
Adversely affected general health status and posttraumatic arthritis

Correct Answer: Adversely affected general health status and posttraumatic arthritis

Explanation:

Question 97:

Options:

Hip arthroscopy with labral debridement
Hip arthroscopy with femoral acetabular impingement lesion debridement
Release of the iliopsoas tendon
Z-plasty of the iliotibial band
Release of the iliotibial band at Gerdy's tubercle

Correct Answer: Z-plasty of the iliotibial band

Explanation:

Question 98:

Options:

closed reduction.
symptomatic sling support and range-of-motion exercises.
arthroscopic thermal capsulorrhaphy.
an open anterior-inferior capsular shift.
a Laterjet procedure.

Correct Answer: symptomatic sling support and range-of-motion exercises.

Explanation:

Question 99:

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.

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

Orthopedic MCQ Exam: Arthroplasty, Foot & Spine Board Review | Part 36

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 36

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index