2014 Hand and Wrist

Question 1

When performing surgical excision of the lesion shown in the MRI scan in Figure 1, what nerve is most likely at risk?

1. Deep branch of the ulnar nerve
2. Anterior interosseous branch of the median nerve
3. Recurrent branch of the median nerve
4. Recurrent branch of the ulnar nerve
5. Palmar cutaneous branch of the ulnar nerve

Answer 1

PREFERRED RESPONSE: 3

DISCUSSION: The MRI scan shows a large mass (lipoma) in the thenar muscles of the palm. The recurrent motor branch of the median nerve innervates the thenar muscles. The anterior interosseous nerve (AIN) in the proximal forearm innervates the flexor pollicis longus, pronator quadratus, and flexor digitorum pollicis to the index and frequently the middle finger. The terminal branch of the AIN innervates only the wrist capsule. The palmar cutaneous branch of the ulnar nerve is a sensory structure to the hypothenar area. There is no commonly described recurrent branch of the ulnar nerve.

REFERENCE: Kozin SH: The anatomy of the recurrent branch of the median nerve. J Hand Surg Am 1998;23:852-858.

Question 2

A 21-year-old man sustains multiple gunshot wounds to his right upper extremity. He cannot extend his digits or his thumb but can extend and radially deviate his wrist. An injury to the radial nerve or one of its branches has most likely occurred at which of the following locations?

1. Spiral groove of the humerus
2. Midshaft of the radius
3. Radial neck
4. Anatomic neck of the humerus
5. Surgical neck of the humerus

Answer 2

PREFERRED RESPONSE: 3

DISCUSSION: In this patient, the radial nerve is most likely injured at the level of the radial neck. The radial nerve emerges from the posterior cord of the brachial plexus and travels along the spiral groove of the humerus. At the level of the lateral humeral condyle, the radial nerve branches into the posterior interosseous nerve after giving off two cutaneous branches, the superficial radial and the posterior cutaneous. The posterior interosseous nerve travels through the supinator muscle and winds around the radial neck. At this level, the posterior interosseous nerve is vulnerable to injury, particularly following fracture or penetrating trauma.

Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1. Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 53.

Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 428-429.

Question 3

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

1. Scaphoid and the ulna
2. Trapezium and the hook of the hamate
3. Trapezium and the triquetrum
4. Trapezoid and the hook of the hamate
5. Trapezoid and the pisiform

Answer 3

PREFERRED RESPONSE: 2

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.

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 4

A patient undergoes the procedure shown in Figure 2. An important part of this procedure is preservation of what wrist ligament?

1. Radioscaphocapitate
2. Scapholunate interosseous
3. Ulnotriquetral
4. Volar radioulnar
5. Deep proximal capitohamate

Answer 4

PREFERRED RESPONSE: 1

DISCUSSION: Proximal row carpectomy is a salvage wrist procedure that yields a surprisingly stable construct. This has been attributed to two factors: (1) the congruency of the head of the capitate in the lunate fossa (this articulation is less congruent than the native lunate/lunate fossa relationship, but surprisingly stable), and (2) preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.

REFERENCE: Jebson PJ, Engber WD: Proximal row carpectomy. Tech Hand Up Extrem Surg 1999;3:32-36.

Question 5

A 37-year-old patient with type I diabetes mellitus has a flexor tenosynovitis of the thumb flexor tendon sheath following a kitchen knife puncture wound to the volar aspect of the thumb. Left unattended, this infection will likely first spread proximally, creating an abscess in which of the following spaces of the palm?

1. Central space
2. Hypothenar space
3. Carpal tunnel
4. Posterior adductor space
5. Thenar space

Answer 5

PREFERRED RESPONSE: 5

DISCUSSION: Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.

Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 478-479.

Lee D, Ferlic R, Neviaser R: Hand infections, in Berger R, Weiss AP, eds: Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 1784-1785.

Question 6

New painful paresthesias near the site of the incision after an ulnar nerve transposition is the result of injury to what nerve?

1. Medial antebrachial cutaneous
2. Lateral antebrachial cutaneous
3. Posterior antebrachial cutaneous
4. Medial brachial cutaneous
5. Dorsal antebrachial cutaneous

Answer 6

PREFERRED RESPONSE: 1

DISCUSSION: Branches of the medial antebrachial cutaneous nerve can often be identified during routine ulnar nerve surgery crossing the medial aspect of the elbow. It should be preserved to avoid development of painful paresthesias.

REFERENCE: Dellon AL, Mackinnon SE: Injury to the medial antebrachial cutaneous nerve during cubital tunnel surgery. J Hand Surg Br 1985;10:33-36.

Question 7

Which of the following best describes the relationship of the median nerve to the flexor carpi radialis tendon just proximal to the carpal canal?

1. Median nerve is volar and ulnar
2. Median nerve is radial and volar
3. Median nerve is dorsal and ulnar
4. Median nerve is dorsal and radial
5. Median nerve is volar and radial

Answer 7

PREFERRED RESPONSE: 3

DISCUSSION: The median nerve has an intimate association with the palmaris longus and the flexor carpi radialis at the proximal aspect of the carpal canal. The median nerve lies just ulnar and dorsal to the flexor carpi radialis tendon.

Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 118-131.

Henry A: Extensile Exposure, ed 3. Edinburgh, UK, Churchill Livingstone, 1995, pp 100-107.

Question 8

Which of the following muscles has dual innervation?

1. Pronator teres
2. Flexor digitorum superficialis
3. Coracobrachialis
4. Latissimus dorsi
5. Brachialis

Answer 8

PREFERRED RESPONSE: 5

DISCUSSION: The brachialis muscle typically receives dual innervation. The major portion is innervated by the musculocutaneous nerve. Its inferolateral portion is innervated by the radial nerve. The other muscles listed have single innervation. The anterior approach to the humerus, which requires splitting of the brachialis, capitalizes on this dual innervation.

REFERENCE: Mahakkanukrauh P, Somsarp V: Dual innervation of the brachialis muscle. Clin Anat 2002;15:206-209.

Question 9

A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure 3. Based on the image findings, what is the most likely diagnosis?

1. Preiser disease
2. Scaphoid nonunion and osteonecrosis
3. Kienbock disease
4. Intraosseous ganglion
5. Scapholunate dissociation

Answer 9

PREFERRED RESPONSE: 2

DISCUSSION: The coronal MRI scan of the wrist shows the scaphoid. There is a subtle fracture line with a step-off at the radial surface consistent with a nonunion. The signal intensity is markedly different between the two fragments of the scaphoid. This strongly suggests osteonecrosis. Preiser disease is osteonecrosis typically involving most or all of the scaphoid. Kienbock disease involves the lunate. Intraosseous ganglia are easily diagnosed on MRI but typically have a fluid-filled area surrounded by denser bone in the periphery. Scapholunate dissociation can be seen on MRI as an injury to the scapholunate ligament and widening of the scapholunate interval, neither of which is seen on this image.

REFERENCE: Perlik PC, Guilford WB: Magnetic resonance imaging to assess vascularity of scaphoid nonunions. J Hand Surg Am 1991;16:479-484.

Question 10

Which of the following tendons is found in the same dorsal compartment of the wrist as the posterior interosseous nerve?

1. Extensor digiti minimi
2. Extensor carpi radialis brevis
3. Extensor pollicis longus
4. Extensor indicis proprius
5. Abductor pollicis longus

Answer 10

PREFERRED RESPONSE: 4

DISCUSSION: The terminal branch of the posterior interosseous nerve is contained in the fourth dorsal compartment. The contents of the various dorsal wrist compartments are as follows:

First Compartment: Abductor pollicis longus, extensor pollis brevis

Second Compartment: Extensor carpi radialis brevis, extensor carpi radialis longus

Third Compartment: Extensor pollicis longus

Fourth Compartment: Extensor digitorum communis, extensor indicus proprius, posterior interosseous nerve

Fifth Compartment: Extensor digiti minimi

Sixth Compartment: Extensor carpi ulnaris

The extensor indicis proprius is also contained in the fourth dorsal compartment. The extensor digiti minimi is located in the fifth dorsal compartment. The extensor carpi radialis brevis is located in the second dorsal compartment. The extensor pollicis longus is located in the third dorsal compartment, and the abductor pollicis longus is located in the first dorsal compartment.

Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 150-151.

Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1 Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 60.

Question 11

Which of the following describes the correct proximal to distal progression of the annular and cruciform pulleys of the digits?

1. A1, C1, A2, C2, A3, A4, C3
2. A1, A2, A3, C1, C2, C3, A4
3. A1, C1, C2, A2, A3, A4, C3
4. A1, A2, C1, A3, C2, A4, C3
5. A1, A2, A3, A4, C1, C2, C3

Answer 11

PREFERRED RESPONSE: 4

DISCUSSION: The correct progression of the annular and cruciform pulley in the digits is A1, A2, C1, A3, C2, A4, C3. The two cruciform pulleys are collapsible elements adjacent to the more rigid annular pulleys of the flexor tendon sheath. This arrangement enables unrestricted flexion of the proximal interphalangeal joint.

Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 176-186.

Strickland J: Flexor tendon-acute injuries, in Green D, Hotchkiss R, Pederson W, eds: Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 1853-1855.

Question 12

In Dupuytren disease, the retrovascular cord typically displaces the radial proper digital nerve of the ring finger in what direction?

1. Palmarly and radially
2. Dorsally and ulnarly
3. Palmarly and ulnarly
4. Dorsally and radially
5. Directly dorsal

Answer 12

PREFERRED RESPONSE: 3

DISCUSSION: Retrovascular cords are common in Dupuytren disease and commonly require surgical treatment. Nerve injury during surgery to treat Dupuytren disease is an infrequent complication that occurs partly because the digital nerves can be displaced from their normal anatomic relationships by retrovascular cords. The nerves are displaced superficially, toward the center of the digit (palmarly and ulnarly). This displacement is typically seen at the level of the metacarpophalangeal joint.

REFERENCE: Rayan GM: Palmar fascial complex anatomy and pathology in Dupuytren’s disease. Hand Clin 1999;15:73-86.

Question 13

Ganglion cysts about the wrist most commonly arise from what structure?

1. First carpometacarpal joint
2. Second carpometacarpal joint
3. Scapholunate interosseous ligament
4. Radioscaphocapitate ligament
5. Capitohamate interosseous ligament

Answer 13

PREFERRED RESPONSE: 3

DISCUSSION: Ganglion cysts are the most common mass or mass-like lesions seen in the hand and wrist. They arise in a variety of locations, including synovial joints or tendon sheaths. The most common location is the dorsal/radial wrist arising from the dorsal scapholunate interosseous ligament.

REFERENCE: Thornburg LE: Ganglions of the hand and wrist. J Am Acad Orthop Surg 1999;7:231-238.

Question 14

Spontaneous entrapment of the posterior interosseous nerve most commonly occurs in which of the following locations?

1. Lateral intermuscular septum
2. Extensor carpi radialis brevis
3. Arcade of Frohse
4. Midsubstance of the supinator
5. Leash of Henry

Answer 14

PREFERRED RESPONSE: 3

DISCUSSION: The extensor carpi radialis brevis, supinator muscle, arcade of Frohse, and leash of Henry are potential sites of compression for the posterior interosseous nerve. The most common location of spontaneous entrapment is the arcade of Frohse. The lateral intermuscular septum is a site of compression for the radial nerve.

REFERENCE: Spinner RJ, Spinner M: Nerve entrapment syndromes, in Morrey BF: The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 839-862.

Question 15

What ligament is the primary stabilizer of the wrist following a proximal row carpectomy?

1. Dorsal radiocarpal
2. Dorsal intercarpal
3. Radioscaphocapitate
4. Ulnocapitate
5. Ulnotriquetral

Answer 15

PREFERRED RESPONSE: 3

DISCUSSION: The radioscaphocapitate ligament is the primary stabilizer between the radius and capitate, preventing ulnar translocation of the carpus. Its oblique orientation prevents the carpus from drifting ulnarly. This stout ligament must be protected when excising the scaphoid.

Stern PJ, Agabegi SS, Kiefhaber TR, et al: Proximal row carpectomy. J Bone Joint Surg Am 2005;87:166-174.

Wyrick JD: Proximal row carpectomy and intercarpal arthrodesis for the management of wrist arthritis. J Am Acad Orthop Surg 2003;11:227-281.

Question 16

The condition shown in Figures 4A and 4B is most likely the result of

1. infection.
2. uric acid deposition.
3. trauma.
4. a virus.
5. severe cold exposure.

Answer 16

PREFERRED RESPONSE: 2

DISCUSSION: The clinical photograph and radiograph show gout, which is the result of urate deposition in the joint and soft tissues. Radiographs frequently reveal periarticular erosions. The crystals are intracellular and negatively birefringent under the polarized microscope. Treatment for acute flares include colchicine, indomethacin, and corticosteroids (including injections). Medications such as allopurinol help prevent recurrent flares. Tophi such as that seen in this patient are often confused with and associated with infection.

Wortmann RL, Kelley WM: Crystal-induced inflammation: Gout and hyperuricemia, in Harris ED, Budd RC, Firestein GS, et al, eds: Kelley’s Textbook of Rheumatology, ed 7. New York, NY, Elsevier Science, 2005, pp 1402-1429.

Trumble TE, ed: Hand Surgery Update: Hand, Elbow, & Shoulder, ed 3. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 433-457.

Louis DS, Jebson PJ: Mimickers of hand infections. Hand Clin 1998;14:519-529.

Question 17

A patient reports hyperesthesia over the base of the thenar eminence following volar locked plating of a distal radius fracture. A standard volar approach of Henry was used. What is the most likely cause of the hyperesthesia?

1. Complex regional pain syndrome
2. Wartenberg syndrome
3. Carpal tunnel syndrome
4. Palmar cutaneous nerve injury
5. C7 radiculopathy

Answer 17

PREFERRED RESPONSE: 4

DISCUSSION: The palmar cutaneous branch of the median nerve separates from the median nerve approximately 4 to 6 cm proximal to the wrist crease and travels between the median nerve and the flexor carpi radialis tendon. It supplies the skin of the thenar region. This nerve is at risk for injury with retraction of the digital flexor tendons in plating the distal radius. Wartenberg syndrome is compression of the superficial radial nerve, which innervates the dorsum of the thumb and the first dorsal web space. Carpal tunnel syndrome causes dysesthesias of the thumb, index, and/or middle fingers. C7 radiculopathy affects the index and middle fingers.

Jupiter JB, Fernandez DL, Toh CL, et al: Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1996;78:1817-1828.

Hoppenfield S, deBoer P, eds: Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, JB Lippincott, 1994, pp 156-176.

Question 18

A patient sustained a sharp laceration to the base of his left, nondominant thumb 4 months ago. Examination reveals no active flexion but full passive motion of the interphalangeal joint. What is the best treatment option?

1. Interphalangeal joint fusion
2. Intercalary tendon graft
3. Silicone rod placement
4. Primary flexor pollicis longus repair
5. Flexor digitorum superficialis transfer

Answer 18

PREFERRED RESPONSE: 5

DISCUSSION: The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation.

Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.

Posner MA: Flexor superficialis tendon transfers to the thumb: An alternative to the free tendon graft for treatment of chronic injuries within the digital sheath. J Hand Surg Am 1983;8:876-881.

Question 19

A 17-year-old boy reports medial-sided elbow pain and diminished grip strength while throwing a javelin. He has decreased sensation in the little and ring fingers of his throwing hand only while throwing. The sensory deficits resolve at rest. Examination of the elbow reveals no instability and full motion. He has a positive Tinel sign over the cubital tunnel and a positive elbow flexion test. Radiographs are normal. What is the most appropriate next step in management?

1. Anterior ulnar nerve transposition
2. Cortisone injection
3. Nighttime elbow extension splinting
4. Medial collateral ligament reconstruction
5. Ulnar nerve decompression in situ

Answer 19

PREFERRED RESPONSE: 3

DISCUSSION: The patient’s symptoms and examination findings are consistent with ulnar neuritis/cubital tunnel syndrome, most probably exacerbated by javelin throwing. The first step includes rest and extension splinting. Surgical intervention should only be considered after failure of nonsurgical management.

Posner MA: Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-317.

Omer GE, Spinner M, Van Beek AL, eds: Management of Peripheral Nerve Problems, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 65-69.

Question 20

What are the most likely symptoms and examination findings related to the mass in zone 2 of Guyon canal seen in Figure 5?

1. Numbness and tingling in the little finger and the ulnar side of the ring finger
2. Weakness and atrophy of the first dorsal interosseous
3. Hypothenar muscle atrophy
4. Dorsal ulnar hand numbness and tingling
5. Weakness of the interossei of the hand and numbness and tingling of the little finger and the ulnar side of the ring finger

Answer 20

PREFERRED RESPONSE: 2

DISCUSSION: The lesion lies in zone II of the ulnar tunnel. In that zone the deep motor branch of the ulnar nerve is susceptible to compression. Distal to the hook of the hamate, the motor branch of the ulnar nerve dives deep to innervate the interossei as it begins to move from an ulnar to radial direction. Because of its course, it has little or no give in response to a mass effect from the floor of Guyon canal. Ganglions are the most common cause of ulnar nerve entrapment in the wrist. Lesions in zone I can affect both sensory and motor aspects of the ulnar nerve as well as the motor innervation of the hypothenar muscles. Lesions at the elbow or mid to proximal forearm are associated with dorsal hand numbness and tingling.

Kuschner SH, Gelberman RH, Jennings C: Ulnar nerve compression at the wrist. J Hand Surg Am 1988;13:577-580.

Posner MA: Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-317.

Question 21

Examination of a hand with compartment syndrome is most likely to reveal which of the following?

1. Clenched fist
2. Intrinsic minus posturing
3. Pain with passive stretch
4. Compression of the superficial arch
5. Pallor

Answer 21

PREFERRED RESPONSE: 2

DISCUSSION: In a study of 19 patients with compartment syndrome of the hand, all had tense swollen hands with elevated compartment pressures. Most patients were neurologically compromised, so pain with passive stretch may be difficult to elicit. Arterial inflow is present in the arch and thus pallor is not present. The typical posture of the hand is not clenched, rather it is an intrinsic minus posture of metacarpophalangeal joint extension and flexion of the proximal and distal interphalangeal joints.

Oullette EA, Kelly R: Compartment syndromes of the hand. J Bone Joint Surg Am 1996;78:1515-1522.

Dellaero DT, Levin LS: Compartment syndrome of the hand: Etiology, diagnosis, and treatment. Am J Orthop 1996;25:404-408.

Question 22

A 32-year-old woman sustained an elbow dislocation, and management consisted of early range of motion. Examination at the 3-month follow-up appointment reveals that she has regained elbow motion but has a weak pinch. A clinical photograph is shown in Figure 6. What is the most likely diagnosis?

1. Flexor pollicis longus rupture
2. Median nerve palsy
3. Ulnar nerve palsy
4. Anterior interosseous nerve palsy
5. Posterior interosseous nerve palsy

Answer 22

PREFERRED RESPONSE: 4

DISCUSSION: The photograph shows the characteristic attitude of the hand when an anterior interosseous nerve palsy is present. The patient is unable to flex the interphalangeal joint to the joint of the thumb. Anterior interosseous nerve palsies are often misdiagnosed as tendon ruptures.

Schantz K, Reigels-Nielsen P: The anterior interosseous nerve syndrome. J Hand Surg Br 1992;17:510-512.

Seror P: Anterior interosseous nerve lesions: Clinical and electrophysiological features. J Bone Joint Surg Br 1996;78:238-241.

Question 23

A 17-year-old boy reports wrist pain after being tackled while playing football. Radiographs are shown in Figures 7A through 7C. What is the recommended intervention?

1. Pedicled vascularized bone graft
2. Long arm thumb spica cast
3. Percutaneous screw fixation
4. Corticocancellous bone grafting via a volar approach (Matti-Russe)
5. Open reduction and differential pitch screw placement via a dorsal approach

Answer 23

PREFERRED RESPONSE: 5

DISCUSSION: The patient has an acute fracture of the proximal pole. A 100% healing rate has been reported for open reduction and internal fixation of proximal pole fractures via a dorsal approach. This allows for direct viewing of the fracture line, facilitates reduction, and bone grafting can be done through the same incision if necessary. A vascularized or corticocancellous graft is reserved for nonunions. Proximal fractures are very slow to heal with a cast, if they heal at all. As a small fragment, percutaneous fixation is very difficult and has been reported for waist fractures.

Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.

Raskin KB, Parisi D, Baker J, et al: Dorsal open repair of proximal pole scaphoid fractures. Hand Clin 2001;17:601-610.

Question 24

A 27-year-old woman reports the acute atraumatic onset of burning pain in her right shoulder followed a week later by substantial weakness and the inability to abduct her shoulder. One week prior to this incident she had recovered from a flu-like syndrome. Examination reveals full passive motion of the shoulder and the inability to actively raise the arm. Sensation in the right upper extremity is normal. Cervical spine examination is normal. Radiographs of the shoulder and cervical spine are normal. What is the most likely diagnosis?

1. Calcific tendinitis
2. Poliomyelitis
3. Diskogenic cervical spine disease
4. Impingement
5. Brachial neuritis

Answer 24

PREFERRED RESPONSE: 5

DISCUSSION: The patient has symptoms and examination findings of acute brachial neuritis, which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely.

Turner JW, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis). Lancet 1957;2:209-212. Omer GE, Spinner M, Van Beek AL, eds: Management of Peripheral Nerve Problems, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 101-104.

Question 25

A 30-year-old man has pain in the left arm after a motor vehicle accident. His neurovascular examination is intact, and radiographs are shown in Figures 8A and 8B. What is the best course of management?

1. Closed reduction and cast immobilization for 4 weeks, followed by therapy directed at regaining motion
2. Open reduction and internal fixation of the olecranon fracture, functional bracing of the humeral fracture, and therapy directed at regaining motion initiated at 2 weeks after surgery
3. Open reduction and internal fixation of the olecranon and humeral fractures, followed by therapy directed at regaining motion
4. Open reduction and internal fixation of the olecranon and humeral fractures, and splint immobilization for 4 weeks followed by therapy directed at regaining motion
5. Open reduction and internal fixation of the olecranon fracture, functional bracing of the humeral fracture, and therapy directed at regaining motion initiated at 4 weeks after surgery

Answer 25

PREFERRED RESPONSE: 3

DISCUSSION: The floating elbow is best managed with early open reduction and internal fixation of the humeral and forearm fractures, followed by early range of motion. These fractures predispose the elbow to stiffness, and early range of motion is recommended.

Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.

Yokoyama K, Itoman M, Kobayashi A, et al: Functional outcomes of “floating elbow” injuries in adult patients. J Orthop Trauma 1998;12:284-290.

Question 26

A patient who underwent open reduction and internal fixation of an olecranon fracture 2 months ago now reports painless limitation of motion. Examination reveals a well-healed incision and a flexion-extension arc from 40° to 80°. The patient has been performing home exercises. Radiographs are shown in Figures 9A and 9B. What is the most appropriate treatment?

1. Continued observation and home therapy
2. Radiation therapy, followed by aggressive range-of-motion exercises
3. Formal physical therapy and static progressive splinting
4. Revision open reduction and internal fixation and capsular release
5. Manipulation under anesthesia

Answer 26

PREFERRED RESPONSE: 3

DISCUSSION: The radiographs do not show an articular malunion. Treatment is directed at the soft-tissue contracture and should begin with formal physical therapy and static progressive splinting. Radiation therapy is effective in the perioperative period and is indicated when ectopic bone formation is a concern.

Morrey BF: The posttraumatic stiff elbow. Clin Orthop Relat Res 2005;431:26-35.

King GJ, Faber KJ: Posttraumatic elbow stiffness. Orthop Clin North Am 2000;31:129-143.

Question 27

A 17-year-old boy who plays high school football reports wrist pain 5 months after the conclusion of the football season. A radiograph and MRI scan are shown in Figures 10A and 10B. What is the recommended intervention?

1. Pedicled vascularized bone graft
2. Long arm thumb spica cast
3. Percutaneous screw fixation
4. Corticocancellous bone grating via a volar approach (Matti-Russe)
5. Open reduction and differential pitch screw placement via a dorsal approach

Answer 27

PREFERRED RESPONSE: 1

DISCUSSION: The patient has a nonunion of the proximal pole of the scaphoid. Acutely, this condition can be repaired with a screw alone, but as a nonunion the proximal pole has very poor healing potential. Vascularized bone grafts have been successful for these challenging nonunions, particularly in adolescents. A cast can be used for nondisplaced acute waist fractures, and corticocancellous grafts can be used for nonunions of the waist.

Waters PM, Stewart SL: Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg Am 2002;84:915-920.

Steinmann SP, Bishop AT, Berger RA: Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am 2002;27:391-401.

Question 28

A 34-year-old man underwent open reduction and internal fixation of a closed both-bones forearm fracture 11 months ago. The radiographs shown in Figures 11A and 11B reveal a 3-mm gap and loose screws. What is the best treatment option?

1. Vascularized fibular graft
2. Locked intramedullary rodding
3. Tricortical iliac crest grafting and compression plating
4. Cancellous autograft and plating
5. Bone morphogenetic protein-7

Answer 28

PREFERRED RESPONSE: 4

DISCUSSION: In an atrophic nonunion with a good soft-tissue envelope, adequate plating with cancellous bone graft can be used to span defects of up to 6 cm. Cortical graft from the fibula or iliac crest is not necessary. Bone morphogenetic protein-7 is a bone graft substitute and should not be used alone in this patient because the hardware is loose.

REFERENCE: Ring D, Allende C, Jafarnia K, et al: Ununited diaphyseal forearm fractures with segmental defects: Plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am 2004;86:2440-2445.

Question 29

In surgically treating hand and finger infections in patients with diabetes mellitus, what factor is associated with higher amputation rates?

2. Insulin dependence
3. Gram-positive organisms
4. Renal failure
5. Retinopathy
6. Peripheral neuropathy

Answer 29

PREFERRED RESPONSE: 3

DISCUSSION: Patients with diabetes mellitus are prone to infection, and surgical treatment of their infections frequently requires multiple procedures. The triad of poor wound healing, chronic neuropathy, and vascular disease contributes to the increased infection rate. Studies have demonstrated increased amputation rates in patients with diabetes mellitus who have renal failure or deep polymicrobial or gram-negative infections.

Gonzalez MH, Bochar S, Novotny J, et al: Upper extremity infections in patients with diabetes mellitus. J Hand Surg Am 1999;24:682-686. Trumble TE, ed: Hand Surgery Update: Hand, Elbow, & Shoulder, ed 3. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 433-457.

Kour AK, Looi KP, Phone MH, et al: Hand infections in patients with diabetes. Clin Orthop Relat Res 1996;331:238-244.

Question 30

What is the primary indication for performing a total wrist arthroplasty in a patient with painful rheumatoid arthritis?

1. Ipsilateral total elbow arthroplasty
2. Contralateral wrist arthrodesis
3. Type III degenerative changes of the wrist
4. Age older than 55 years
5. Less than 30° of wrist flexion/extension

Answer 30

PREFERRED RESPONSE: 2

DISCUSSION: The most conservative indications for a total wrist arthroplasty are to spare motion on one side and to improve activities of daily living. Component loosening, dislocation, and wound problems are frequent. Suitable patients can be of various ages, and have various degrees of wrist motion and radiographic stages of arthritis. Ipsilateral total elbow arthroplasty, type III degenerative changes of the wrist, age older than 55 years, and limited range of motion are neither primary indications nor contraindications to a total wrist arthroplasty.

Divelbiss BJ, Sollerman C, Adams BD: Early results of the universal total wrist arthroplasty in rheumatoid arthritis. J Hand Surg Am 2002;27:195-204.

Vicar AJ, Burton RI: Surgical management of rheumatoid wrist-fusion or arthroplasty. J Hand Surg Am 1986;11:790-797.

Carlson JR, Simmons BP: Total wrist arthroplasty. J Am Acad Orthop Surg 1998;6:308-315.

Question 31

What is the most common bacteria cultured from dog and cat bites to the upper extremity?

1. Pasteurella
2. Streptococcus
3. Staphylococcus
4. Bacterioides
5. Moraxella

Answer 31

PREFERRED RESPONSE: 1

DISCUSSION: To define bacteria responsible for dog and cat bite infections, a prospective study yielded a median of five bacterial isolates per culture. Pasteurella is most common from both dog bites (50%) and cat bites (75%). Pasteurellacanis was the most frequent pathogen of dog bites, and Pasteurellamultocida was the most common isolate of cat bites. Other common aerobes included streptococci,staphylococci, Moraxella, and Neisseria.

REFERENCE: Talan DA, Citron DM, Abrahamian FM, et al: Bacteriologic analysis of infected dog and cat bites: Emergency Medicine Animal Bite Infection Study Group. N Engl J Med 1999;340:85-92.

Question 32

A previously healthy 65-year-old woman has a closed fracture of the right clavicle after falling down the basement stairs. Examination reveals good capillary refill in the digits of her right hand. Radial and ulnar pulses are 1+ at the right wrist compared with 2+ on the opposite side. In the arteriogram shown in Figure 12, the arrow is pointing to which of the following arteries?

1. Brachiocephalic
2. Innominate
3. Subclavian
4. Axillary
5. Circumflex scapular

Answer 32

PREFERRED RESPONSE: 4

DISCUSSION: The axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.

REFERENCE: Radke HM: Arterial circulation of the upper extremity, in Strandness DE Jr, ed: Collateral Circulation in Clinical Surgery. Philadelphia, PA, WB Saunders, 1969, pp 294-307.

Question 33

Which of the following structures may help maintain radial length after a radial head fracture?

1. Triangular fibrocartilage complex
2. Medial ulnar collateral ligament
3. Lateral ulnar collateral ligament
4. Annular ligament
5. Coronoid

Answer 33

PREFERRED RESPONSE: 1

DISCUSSION: Essex-Lopresti injuries affect axial stability of the forearm. Injury to the interosseous membrane or the triangular fibrocartilage complex can result in proximal migration of the radius.

Morrey BF, Chao EY, Hui FC: Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am 1979;61:63-68.

Coleman DA, Blair WF, Shurr D: Resection of the radial head for fracture of the radial head: Long-term follow-up of seventeen cases. J Bone Joint Surg Am 1987;69:385-392.

Question 34

Outcome measures should have established psychometric properties of reliability, validity, and responsiveness. Reliability refers to which of the following?

1. The amount of change in the score over time
2. Sensitivity of the measure in evaluating a problem
3. The ability of the instruments to actually measure what it intends to measure
4. The measure of change over the course of treatment
5. The reproducibility of the measurements either between repeated tests or between observers

Answer 34

PREFERRED RESPONSE: 5

DISCUSSION: The recent J Bone Joint Surg Am article by Kocher and associates defines the different psychometric properties that are used in outcome measures. Reliability is a measure of how reproducible a test is. This can be interobserver reliability (reliability between people), or intraobserver reliability (reliability for the same person doing the outcome measure at different occasions).

REFERENCE: Kocher MS, Horan MP, Briggs KK, et al: Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons subjective shoulder scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis. J Bone Joint Surg Am 2005;87:2006-2011.

Question 35

Figure 13 shows a coronal T2-weighted MRI scan. The arrow is pointing to what torn structure?

1. Brachialis tendon
2. Biceps tendon
3. Flexor/pronator origin
4. Medial collateral ligament (MCL)
5. Lateral collateral ligament (LCL)

Answer 35

PREFERRED RESPONSE: 5

DISCUSSION: The arrow is pointing to the LCL, and it is avulsed from the lateral humeral epicondyle. This is the most common site of injury for the LCL. The biceps and brachialis tendon insertions are not well visualized in this section. The MCL and flexor/pronator origins are intact.

Potter HG, Weiland AJ, Schatz JA, et al: Posterolateral rotatory instability of the elbow: Usefulness of MR imaging in diagnosis. Radiology 1997;204:185-189.

King JC, Spencer EE: Lateral ligamentous instability: Techniques of repair and reconstruction. Tech Orthop 2000;8:93-104.

Question 36

Which of the following findings is a contraindication to isolated percutaneous pinning of a distal radius fracture?

1. Dorsal comminution
2. Volar comminution
3. Radial comminution
4. Intra-articular fracture
5. Physeal fracture

Answer 36

PREFERRED RESPONSE: 2

DISCUSSION: Intrafocal pinning allows the Kirschner wires to be placed through a site of comminution and then drilled through intact cortex. Generally Kapandji intrafocal pinning is done for dorsal comminuted extra-articular dorsal bending fractures, but it also may be used to elevate and buttress radial comminution. Simple intra-articular fractures can also be treated with pinning alone. Intrafocal pinning works best as a dorsal or radial buttress to prevent shortening. When there is volar comminution, the fracture is prone to shortening and supplemental external fixation or plating is recommended.

Trumble TE, Wagner W, Hanel DP, et al: Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. J Hand Surg Am 1998;23:381-394.

Choi KY, Chan WS, Lam TP, et al: Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children: A report of 157 cases. J Bone Joint Surg Br 1995;77:797-801.

Weil WM, Trumble TE: Treatment of distal radius fractures with intrafocal (Kapandji) pinning and supplemental skeletal stabilization. Hand Clin 2005;21:317-328.

Question 37

A 55-year-old man sustained an elbow dislocation in a fall. Postreduction radiographs are shown in Figures 14A and 14B. What is the best course of management?

1. Closed reduction and casting for 4 weeks
2. Closed reduction and bracing with immediate range of motion
3. Open reduction, lateral collateral ligament repair, and open reduction and internal fixation or metallic replacement of the radial head
4. Open reduction, radial head Silastic arthroplasty, and lateral collateral ligament repair
5. Open reduction, lateral collateral ligament repair, and radial head excision

Answer 37

PREFERRED RESPONSE: 3

DISCUSSION: The radiographs show an elbow dislocation associated with a comminuted radial head fracture. In the setting of comminution and instability, factures of the radial head are best managed with an arthroplasty rather than open reduction and internal fixation. Resection of the radial head will worsen the instability and is not recommended. Silastic radial head replacements are contraindicated.

Hildebrand KA, Patterson SD, King GJ: Acute elbow dislocations: Simple and complex. Orthop Clin North Am 1999;30:63-79.

O’Driscoll SW, Jupiter JB, King GJ, et al: The unstable elbow. Instr Course Lect 2001;50:89-102.

Question 38

In a patient with rheumatoid arthritis of the wrist, which of the following extensor tendons is most at risk of rupture?

1. Extensor digiti quinti
2. Abductor pollicis longus
3. Extensor pollicis longus
4. Extensor carpi radialis brevis
5. Extensor carpi ulnaris

Answer 38

PREFERRED RESPONSE: 1

DISCUSSION: The tendon most prone to rupture in a patient with rheumatoid arthritis of the wrist is the extensor digiti quinti. It can be a silent injury because the extensor digitorum communis can provide extension to the fifth finger. The extensor digiti quinti is at high risk because it is overlying the ulnar head where it is prone to attritional rupture (Vaughan-Jackson syndrome).

Vaughan-Jackson OJ: Rupture of extensor tendons by attrition at the inferior radioulnar joint: A report of two cases. J Bone Joint Surg Br 1948;30:528-530.

Papp SR, Athwal GS, Pichora DR: The rheumatoid wrist. J Am Acad Orthop Surg 2006;14:65-77.

Question 39

What is the most appropriate surgical treatment for a stage III symptomatic scapholunate advanced collapsed (SLAC) wrist?

1. Radioscapholunate arthrodesis
2. Scaphotrapeziotrapezoid arthrodesis
3. Scaphocapitate arthrodesis
4. Proximal row carpectomy
5. Scaphoid excision and capitate-lunate-triquetrum-hamate arthrodesis

Answer 39

PREFERRED RESPONSE: 5

DISCUSSION: SLAC is the end result of chronic scapholunate instability. The arthritis follows a predictable pattern. Stage I disease involves cartilage loss between the waist of the scaphoid and the radial styloid. In stage II, the arthritis progresses to include the proximal pole of the scaphoid and the scaphoid fossa of the radius. Finally, stage III goes on to include arthritis of the capitolunate joint. The only treatment option that addresses all of the sites of arthritis is the scaphoid excision and four-corner fusion.

Ashmead DT IV, Watson HK, Damon C, et al: Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:741-750.

Sauerbier M, Trankle M, Linsner G, et al: Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): Operative technique and outcome assessment. J Hand Surg Br 2000;25:341-345.

Question 40

A 25-year-old man shot himself at the base of the right index finger while cleaning his handgun. Examination reveals that the finger is cool and cyanotic. A radiograph and clinical photograph are shown in Figures 15A and 15B. What is the recommended treatment?

1. Open reduction and internal fixation and arterial reconstruction
2. Crossed pinning with Kirschner wires
3. Open (guillotine) finger amputation
4. Index ray amputation
5. Application of an external fixator

Answer 40

PREFERRED RESPONSE: 4

DISCUSSION: The gunshot wound has caused injury to multiple systems: bone, vascular, skin, and tendon; therefore, the treatment of choice is amputation. An immediate ray amputation allows for a more rapid return to activities and less time off work.

Peimer CA, Wheeler DR, Barrett A, et al: Hand function following single ray amputation. J Hand Surg Am 1999;24:1245-1248.

Neumeister MW, Brown RE: Mutilating hand injuries: Principles and management. Hand Clin 2003;19:1-15.

Question 41

What are the two terminal branches of the lateral cord of the brachial plexus?

1. Musculocutaneous and median
2. Musculocutaneous and axillary
3. Median and axillary
4. Ulnar and median
5. Ulnar and medial pectoral

Answer 41

PREFERRED RESPONSE: 1

DISCUSSION: The lateral cord divides into the musculocutaneous and median nerves. The posterior cord terminates into the axillary and radial nerves. The medial cord divides into the ulnar and median nerves.

Hollinshead WH: Anatomy for Surgeons, ed 3. Philadelphia, PA, Harper and Row, 1982, pp 228-236. Shin AY, Spinner RJ, Steinmann SP, et al: Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg 2005;13:382-396.

Question 42

What is the most common complaint in patients with a developmental radial head dislocation?

1. Pain
2. Recurrent elbow subluxation
3. Limitation of extension
4. Cosmetic deformity
5. Locking

Answer 42

PREFERRED RESPONSE: 4

DISCUSSION: Developmental dislocation of the radial head most frequently presents as a painless mass over the posterior aspect of the elbow. Patients do not have feelings of elbow subluxation but may report pain or clicking. Limitation of motion is most frequently found in the pronation and supination arc rather than in flexion and extension.

Lloyd-Roberts GC, Bucknill TM: Anterior dislocation of the radial head in children-etiology: Natural history and management. J Bone Joint Surg Am 1977;58:402.

Hamilton W, Parks JC II: Isolated dislocation of the radial head without fracture of the ulna. Clin Orthop Relat Res 1973;97:94-96.

Question 43

A 35-year-old man sustained the closed injury shown in Figure 16 in his dominant extremity. Neurologic function is normal. Treatment should consist of

1. functional bracing.
2. a sling and swathe.
3. intramedullary nail fixation.
4. open reduction and internal fixation.
5. iliac crest bone graft.

Answer 43

PREFERRED RESPONSE: 1

DISCUSSION: Functional bracing has been demonstrated to have a very high rate of healing without any functional limitations in a large series of patients. Surgery is reserved for floating elbows, open injuries, neurovascular injuries, and those fractures that go on to nonunion.

Sarmiento A, Zagorski JB, Zych GA, et al: Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-486.

Dirschl DR: Shoulder trauma: Bone, in Koval KJ, ed: Orthopaedic Knowledge Update, ed 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 267.

Question 44

The radiograph shown in Figure 17 reveals that the plate on the second metacarpal is acting in what manner?

1. Compression
2. Tension band
3. Bridge
4. Buttress
5. Spring

Answer 44

PREFERRED RESPONSE: 3

DISCUSSION: There are four ways in which a plate acts: compression, tension band, bridge or spanning, and buttress. Because there is no cortical contact with the large span of comminution, this plate is acting as a bridge plate. A bridge plate is defined as one that is used as an extramedullary splint attached to the two main fragments, leaving the comminution untouched.

REFERENCE: Ruedi T, Murphy WM, eds: AO Principles of Fracture Management. New York, NY, Thieme, 2000, p 221.

Question 45

Figure 18 shows the radiograph of a 30-year-old man who sustained a closed comminuted fracture of the right clavicle. Examination reveals decreased sensation in the radial nerve distribution. Weakness is noted with shoulder abduction, internal rotation, and wrist extension. A displaced bone fragment is most likely pressing on what portion of the brachial plexus?

1. C5 and C6 spinal roots
2. Superior trunk
3. Anterior division of the inferior trunk
4. Posterior cord
5. Lateral and posterior cords

Answer 45

PREFERRED RESPONSE: 4

DISCUSSION: Clavicular fractures are occasionally complicated by injury to the brachial plexus. A displaced bone fragment pressing on the posterior cord proximal to the upper subscapularis nerve would account for these findings.

Jobe CM, Coen MJ: Gross anatomy of the shoulder, in Rockwood CA, Matsen FA, Wirth MA, et al, eds: The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 1078-1079.

Barbier O, Malghem J, Delaere O, et al: Injury to the brachial plexus by a fragment of bone after fracture of the clavicle. J Bone Joint Surg Br 1997;79:534-536.

Question 46

Which of the following is considered an important component in treating the lesion shown in Figure 19?

1. Excision of the skin in addition to the cyst
2. Resection of the nail plate
3. Excision of bony osteophytes from the distal interphalangeal (DIP) joint
4. Injection of corticosteroid into the DIP joint
5. Resection of part of the collateral ligament and extensor mechanism

Answer 46

PREFERRED RESPONSE: 3

DISCUSSION: Mucoid cysts are commonly associated with DIP joint arthritis. Two treatment options are commonly used: (1) aspiration/drainage and injection of corticosteroid and (2) surgical excision. When performing the surgery, excision of the bony osteophytes about the DIP joint is helpful in achieving a cure. There are no reports of significant benefit with nail removal or partial ligament or extensor tendon resection. Some authors have advocated skin excision and rotational flaps for wound coverage, but this is somewhat controversial.

Rizzo M, Beckenbaugh RD: Treatment of mucous cysts of the fingers: Review of 134 cases with minimum 2-year follow-up evaluation. J Hand Surg Am 2003;28:519-524.

Eaton RG, Dobranski AI, Littler JW: Marginal osteophyte excision in treatment of mucous cysts. J Bone Joint Surg Am 1973;55:570-574.

Question 47

A patient with rheumatoid arthritis has a rupture of the extensor digitorum communis to the fourth and fifth metacarpals. You are planning to perform an extensor indicis proprius (EIP) tendon transfer. What effect will this have on index finger extension?

1. No effect
2. Index finger weakness
3. Index metacarpophalangeal hyperextension
4. Index metacarpophalangeal hyperflexion
5. Index metacarpophalangeal ulnar deviation

Answer 47

PREFERRED RESPONSE: 1

DISCUSSION: EIP transfer results in no functional deficit. If the tendon is cut proximal to the sagittal band, there will be no extensor deficit.

Browne EX, Teague MA, Snyder CC: Prevention of extensor lag after indicis proprius transfer. J Hand Surg Am 1979;4:168-172.

Moore JR, Weiland AJ, Valdata L: Independent index extension after extensor indicis proprius transfer. J Hand Surg Am 1987;12:232-236.

Question 48

A 22-year-old man is tackled while playing college football and sustains a reducible first carpometacarpal dislocation. What is the recommended treatment?

1. Closed reduction and casting
2. Closed reduction and percutaneous pinning
3. First carpometacarpal arthrodesis
4. Dorsal capsulodesis
5. Ligament reconstruction using tendon autograft

Answer 48

PREFERRED RESPONSE: 5

DISCUSSION: When comparing closed reduction and pinning to ligament reconstruction, the reconstruction group had slightly better abduction and pinch strength. The volar oblique ligament usually tears off the first metacarpal in a subperiosteal fashion. In this young patient, motion-sparing procedures are preferred.

Simonian PT, Trumble TE: Traumatic dislocation of the thumb carpometacarpal joint: Early ligamentous reconstruction versus closed reduction and pinning. J Hand Surg Am 1996;21;802-806.

Strauch RJ, Behrman MJ, Rosenwasser MP: Acute dislocation of the carpometacarpal joint of the thumb: An anatomic and cadaver study. J Hand Surg Am 1994;19:93-98.

Question 49

What structure provides the most static stability for valgus restraint in the elbow?

1. Posterior band of the ulnar collateral ligament
2. Anterior band of the ulnar collateral ligament
3. Transverse band of the ulnar collateral ligament
4. Annular ligament
5. Flexor/pronator mass

Answer 49

PREFERRED RESPONSE: 2

DISCUSSION: The anterior band of the ulnar collateral ligament provides the greatest restraint to valgus stress in the elbow. The posterior band is taut in flexion and resists stress between 60° and full flexion. The annular ligament stabilizes the radial head. The flexor/pronator mass are important dynamic stabilizers of the medial elbow.

Ahmad CS, ElAttrache NS: Elbow valgus instability in the throwing athlete. J Am Acad Orthop Surg 2006;14:693-700.

Regan WD, Korinek SL, Morrey BF, et al: Biomechanical study of ligaments around the elbow joint. Clin Orthop Relat Res 1991;271:170-179.

Safran M, Ahmad CS, ElAttrache NS: Ulnar collateral ligament of the elbow. Arthroscopy 2005;21:1381-1395.