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OITE > 2015 Hand > Flashcards

2015 Hand Flashcards

1
Q

Question 8
A 76-year-old woman underwent a left below-elbow amputation. Prior to the amputation, she had a stroke that caused a paretic, painful, clenched hand. Her hand became severely infected, necessitating amputation. She continues to have phantom pain, perceiving that her amputated hand is clenched. What is the best therapy modality at this time?

  1. Iontophoresis
  2. Contrast baths
  3. Mirror therapy
  4. Low-level laser therapy
  5. Electrical stimulation
A
  1. Mirror therapy

Mirror therapy is used for patients with phantom limb pain or pain from a paralyzed extremity, or patients with pain syndromes such as chronic regional pain syndrome. The patient places the normal limb in 1 side of a box. The amputated limb is rested into the other side. A mirror reflects the normal limb so that it appears to the patient that there is a normal hand in place of the missing limb (Fig. 8). When the good hand moves, the artificial visual feedback suggests to the patient that she is moving the missing or paralyzed limb.

Hand orthopaedic injuries can result in disabilities in activities of daily living. Mirror therapy (MT) provides perception of two healthy limbs through reflection of the healthy limb as the injured limb.

RECOMMENDED READINGS
Hartzell TL, Rubinstein R, Herman M. Therapeutic modalities–an updated review for the hand surgeon. J Hand Surg Am. 2012 Mar;37(3):597-621. doi: 10.1016/j.jhsa.2011.12.042. Epub 2012 Feb 2. Review. PubMed PMID: 22305724.
Rostami HR, Are A, Tabatabaei S. E ect of mirror therapy on hand function in patients with hand orthopaedic injuries: a randomized controlled trial. Disabil Rehabil. 2013 Sep;35(19):1647-51. doi: 10.3109/09638288.2012.751132. Epub 2013 Jan 22. PubMed PMID: 23336124.
Moseley GL. Graded motor imagery is e ective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain. 2004 Mar;108(1-2):192-8. PubMed PMID: 15109523

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2
Q

Question 15
A 40-year-old woman has a closed oblique ring nger metacarpal fracture. There is no rotational deformity. Radiographs reveal a 10-degree apex-dorsal angulation and 2 mm of shortening. What is the expected outcome for fracture healing in this position?

  1. Nonunion
  2. Normal function
  3. Extensor tendonitis
  4. Flexion deformity of the metacarpophalangeal (MCP) joint
  5. Flexion deformity of the proximal interphalangeal (PIP) joint
A
  1. Normal function

Study 1 below showed an average of 7 degrees of extensor lag at the MCP joint produced for every 2 mm of metacarpal shortening. The capacity of the MCP joint for active hyperextension may compensate for the extensor lag produced by metacarpal shortening in the clinical setting.

RECOMMENDED READINGS
Strauch RJ, Rosenwasser MP, Lunt JG. Metacarpal shaft fractures: the effect of shortening on the extensor tendon mechanism. J Hand Surg Am. 1998 May;23(3):519-23. PubMed PMID: 9620194.

Al-Qattan MM. Outcome of conservative management of spiral/long oblique fractures of the metacarpal shaft of the fingers using a palmar wrist splint and immediate mobilisation of the ngers. J Hand Surg Eur Vol. 2008 Dec;33(6):723-7. doi: 10.1177/1753193408093559. Epub 2008 Jul 28. PubMed PMID: 18662959.

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3
Q

Question 28
Figure 28 shows an injury sustained by a 60-year-old man 4 weeks ago. Since that time he has had substantial pain and catching of his nger during attempts at range of motion. What is the most appropriate treatment at this point? (figure showed a 75% partial thickness tear of 3rd FDP tendon, hooked underneath by Metz)

  1. Tendon debridement
  2. Release of the A2 pulley
  3. Tendon repair with core sutures
  4. Tendon repair with epitendinous sutures
  5. Wound closure without tendon repair or debridement
A
  1. Tendon repair with epitendinous sutures

First study below assessed the degree of gap formation with and without repair when the 75% lacerated tendon is subjected to cyclic loading. Repair with only a peripheral suture was compared to that using a core and peripheral repair technique.

Result: There is a large gap when an unrepaired 75% partial laceration is cyclically loaded. This gap is significantly reduced with a peripheral repair (i.e. epitendinous) whether or not a core suture is used.

RECOMMENDED READINGS
Haddad R, Scherman P, Peltz T, Nicklin S, Walsh WR. A biomechanical assessment of repair versus nonrepair of sheep exor tendons lacerated to 75 percent. J Hand Surg Am. 2010 Apr;35(4):546-51. doi: 10.1016/j.jhsa.2009.12.039. Epub 2010 Mar 2. PubMed PMID: 20189731.

Mosto A, Palmer J, Akelman E. Flexor tendon injury. In: Chung KC, ed. Hand Surgery Update V. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2012:181-192.

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4
Q

Question 39

Figure 39 is the clinical photograph of a 2-year-boy who has bilateral camptodactyly of 25 degrees at each of his ring nger proximal interphalangeal joints. No other abnormalities are present, and his parents report developmental milestones have all been reached on time. The boy’s father is concerned that the contractures will negatively in uence his ability to engage in sports. What is the best next step?

  1. Observation
  2. Volar plate release
  3. Proximal phalanx extension osteotomies
  4. A progressive stretching and splinting program
  5. Rerouting a slip of the exor digitorum super cialis to the extensor central slip
A
  1. A progressive stretching and splinting program

Camptodactyly is a nontraumatic, painless flexion contracture of the proximal interphalangeal joint which may progress if untreated, resulting in cosmetic and functional problems

Passive stretching can effectively improve flexion deformity in camptodactyly in infants and young children

RECOMMENDED READINGS
Goldfarb CA. Congenital hand anomalies: a review of the literature, 2009-2012. J Hand Surg Am. 2013 Sep;38(9):1854-9. doi: 10.1016/j.jhsa.2013.03.023. Epub 2013 May 14. Review. PubMed PMID: 23683863.

Rhee SH, Oh WS, Lee HJ, Roh YH, Lee JO, Baek GH. E ect of passive stretching on simple camptodactyly in children younger than three years of age. J Hand Surg Am. 2010 Nov;35(11):1768-73. doi: 10.1016/j.jhsa.2010.07.032. PubMed PMID: 21050962.

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5
Q

Question 48
A 23-year-old man cut the dorsal and ulnar aspects of his long nger on a table saw. The dorsal and ulnar skin over the middle phalanx is missing, with a 2-cm x 2-cm area of loss. There is a 50% loss of the extensor tendon (ulnar), and the remaining tendon has no tenosynovium. The physician should recommend irrigation and debridement and

  1. wet-to-dry dressing and early motion.
  2. tendon repair, and thenar ap coverage.
  3. full-thickness skin graft.
  4. reversed cross- finger flap from the ring finger.
  5. cross- finger flap coverage from the ring finger.
A
  1. reversed cross-finger flap from the ring finger.

The reverse cross finger flap is usually performed on patients with deep dorsal digital skin, nailbed, and extensor tendon injuries that cannot be repaired and grafted. These patients will require additional dorsal digital flaps from the adjacent fingers.

Preferred donor areas are the dorsal aspect of the middle and proximal phalanges of the adjacent fingers. Because of the thinness and lack of adequate subcu- taneous tissue at the dorsum of the distal IP and PIP joint areas, these regions are not satisfactory, and if possible they should be avoided.

——-Read Below for More Info—

Indications & Contra-indications
The reverse cross finger flap is indicated in these situations:
1. Reconstruction of an eponychial skinfold and coverage of an exposed extensor tendon near the IP joint
2. Reconstruction of large, full-thickness, sterile matrix nailbed defects with exposed distal phalanx
3. Coverage of a contused, repaired, or grafted extensor tendon denuded of paratenon
4. Boutonniere deformity with poor-quality skin over the proximal interphalangeal (PIP) joint after burn or avulsion injury
5. Full-thickness coverage of complete avulsion of the nailbed, germinal matrix, and surrounding skin of digits. In such an injury of the index finger, the alternative procedure is a cross thumb to index flap.3
6. As an elective case to correct a deformity of the digit and apply a reverse cross finger flap
There are no contraindications except extensive dorsal skin loss and injuries to the adjacent digits.

RECOMMENDED READINGS
Atasoy E. Reversed cross- nger subcutaneous ap. J Hand Surg Am. 1982 Sep;7(5):481-3. PubMed PMID: 7130658.

Kappel DA, Burech JG. The cross- nger ap. An established reconstructive procedure. Hand Clin. 1985 Nov;1(4):677-83. PubMed PMID: 3831054.

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6
Q

A 25-year-old snowboarder has a contaminated open tibial fracture. He was down for several hours before being rescued and transported. He also sustained a cold injury to his ngers, which are blue and have multiple hemorrhagic blisters. What is the most appropriate timing for aggressive nger debridement/ amputation?

  1. Prior to de nitive xation of the tibial fracture
  2. Prior to irrigation and debridement (I & D) of the tibial fracture
  3. During I & D of the tibial fracture
  4. During de nitive xation of the tibia
  5. No set time; delay until necrotic tissue demarcation
A
  1. No set time; delay until necrotic tissue demarcation
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7
Q

Which examination nding points toward a brachial plexus injury rather than root avulsion?

  1. Winging of the scapula
  2. Intact rhomboid function
  3. A biceps with 0/5 strength
  4. An ipsilateral clavicle fracture
  5. Decreased radial artery pulse
A
  1. Intact rhomboid function
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8
Q

A 72-year-old woman with diabetes mellitus has right hand numbness. Provocative test ndings are consistent with carpal tunnel syndrome, and electrodiagnostic study (EDS) ndings show prolonged median motor and sensory distal latencies with low-amplitude thenar compound muscle action potential. Poor prognosis is most associated with which factor?

  1. Diabetes
  2. Older age
  3. Female gender
  4. Right-hand involvement
  5. Severity of EDS findings
A
  1. Severity of EDS ndings
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9
Q

Question 88
Which method of exor tendon repair that necessitates excursion through the A2 pulley allows for the most thorough assessment of tendon gliding?

  1. 4-strand repair with 6-0 epitendinous suture with Bier block anesthesia
  2. 4-strand repair with 6-0 epitendinous suture under local anesthesia only
  3. 6-strand repair with regional anesthesia
  4. 8-strand repair with regional anesthesia
  5. Repair of the exor tendon with incision of the remaining A2 pulley
A
  1. 4-strand repair with 6-0 epitendinous suture under local anesthesia only
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10
Q

Figures 96a and 96b are the radiographs of an 18-year-old man who had surgery 6 months ago at an outside institution. He is being referred now because he has persistent pain. He is tender over the scaphoid at the snu box. What is the most appropriate next imaging step in his pain workup?

  1. Bone scan
  2. MR imaging with contrast
  3. MR imaging without contrast
  4. CT scan along the scaphoid axis
  5. Axial-cut CT scans with reformats
A
  1. CT scan along the scaphoid axis
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11
Q

Question 103 (Item Deleted)
Which muscle or tendon function is most likely disrupted by the nding in the MR image shown in Figure 103?
1. First dorsal interosseous
2. Flexor pollicis longus (FPL)
3. Long- nger exor digitorum profundus (FDP)
4. Small- nger FDP
5. Extensor pollicis longus (EPL)

A
  1. Small- finger FDP
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12
Q

Question 133
A 34-year-old smoker has acute (less than 6 hours) onset of right hand ischemia. His blood pressure is 188/90 mm Hg. His hand is cool and pale; however, he can move his ngers with some discomfort. There is no swelling and no history of trauma. Radial and ulnar pulses are not palpable, but they are present by Doppler examination. What is the best next step?

  1. Angiogram
  2. Ulnar artery thrombectomy
  3. Magnetic resonance angiogram (MRA)
  4. Transthoracic echocardiogram
  5. Measurement of compartment pressures
A
  1. Angiogram
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13
Q 
Question 140 (Item Deleted)
Figure 140 is the T1-weighted MR image of a 24-year-old man who has a 6-month history of right wrist pain. He fell on an outstretched hand while skateboarding 18 months ago and had pain that resolved after several weeks. Radiographs of his right wrist demonstrate an established scaphoid nonunion at the waist with a humpback deformity and no signs of arthritis. What is the best next step?
  1. Proximal row carpectomy
  2. Scaphoid excision and 4-corner fusion
  3. Vascularized dorsal distal radial pedicle graft and xation
  4. Vascularized medial femoral condyle graft and xation
  5. Open reduction and internal xation with a cancellous bone graft
A
  1. Vascularized medial femoral condyle graft and xation
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14
Q

Question 175
During closed reduction of an apex-volar angulated distal radius fracture, which maneuver, in addition to traction, likely will provide the best fracture reduction?

  1. Pronation of the wrist
  2. Ulnar deviation of the wrist
  3. Volar translation of the lunate
  4. Flexion of the lunocapitate joint
  5. Extension of the radiocarpal joint
A
  1. Volar translation of the lunate
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15
Q

Question 228
When viewing the wrist joint arthroscopically from the 3-4 portal, what is the correct order of the volar extrinsic wrist ligaments from radial to ulnar?

  1. Scapholunate, lunotriquetral, ulnotriquetral
  2. Short radiolunate, long radiolunate, radioscaphocapitate
  3. Radioscapholunate, radioscaphocapitate, long radiolunate
  4. Radioscaphocapitate, long radiolunate, short radiolunate
  5. Radial collateral, long radiolunate, short radiolunate
A
  1. Radioscaphocapitate, long radiolunate, short radiolunate
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16
Q

A 32-year-old man has a thumb metacarpophalangeal joint (MCP) ulnar collateral ligament (UCL) injury. The joint is unstable, and an MR image reveals a displaced distal avulsion of the ligament o the base of the proximal phalanx. During repair, which structure(s) block(s) reduction of the ligament?

  1. Adductor aponeurosis
  2. Extensor pollicis longus tendon
  3. Extensor pollicis brevis (EPB) tendon
  4. Ulnar sesamoid bone
  5. EPB and dorsal capsule
A
  1. Adductor aponeurosis
17
Q

Question 256
A 25-year-old man has an acute scaphoid fracture in the proximal third of the scaphoid. It is displaced 1 mm. What is the recommended treatment for his fracture?

  1. Long-arm cast with a thumb spica
  2. Closed reduction and pin xation with casting
  3. Open reduction and internal xation (ORIF) through a volar approach
  4. ORIF with vascularized bone graft
  5. ORIF through a dorsal approach
A
  1. ORIF through a dorsal approach
18
Q

A 50-year-old man experienced a dorsal dislocation of his thumb carpometacarpal (CMC) joint without an associated fracture 1 week ago. He self-reduced his thumb. Radiographs reveal slight subluxation of the joint with minimal arthritis. Which region of the thumb CMC capsuloligamentous complex most likely prevents dorsal dislocation of the thumb CMC joint?

  1. Dorsal radial
  2. Intermetacarpal
  3. Ulnar collateral
  4. Volar oblique deep
  5. Volar oblique superficial
A
  1. Dorsal radial
19
Q

Question 267
After performing an uneventful partial palmar fasciectomy for Dupuytren contracture of the palm and ring nger, a general postsurgical pain medication prescription should include how many narcotic pills?

  1. 0
  2. 10
  3. 20
  4. 30
  5. 40
A

Answer 2. 10

20
Q

A 42-year-old worker has failed nonsurgical treatment of painful thumb carpometacarpal (CMC) arthritis. The decision has been made to perform ligamentous reconstruction and tendon interposition arthroplasty. However, when the bony ridge of the trapezium is removed, the entire distal attachment of the exor carpi radialis (FCR) tendon is inadvertently detached. What is the best next step?

  1. Perform suspension arthroplasty with the extensor carpi radialis longus (ECRL)
  2. Perform a suspension arthroplasty with the ring nger exor digitorum super cialis
  3. Perform a suspension arthroplasty with the palmaris longus tendon
  4. Reattach the insertion of the FCR with suture anchors
  5. Perform a CMC arthrodesis
A
  1. Perform suspension arthroplasty with the extensor carpi radialis longus (ECRL)

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