Hand 2013

Question 1

1. A 33-year-old womand has left index fingertip pain that is severely exasturbated by reacing movements. An intense T2 signal under the nailbed is visible on the MRI scan seen in Figure 1. What is the besttreatment option?
2. Tumor excision
3. Sympathetic digital block
4. Oral calcium channel blockers
5. Tuft amputation with nail ablation
6. Activty modification and glove wear􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀤􀁆􀁗􀁌􀁙􀁌􀁗􀁜􀀃􀁐􀁒􀁇􀁌􀂿􀁆􀁄􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁊􀁏􀁒􀁙􀁈􀀃􀁚􀁈􀁄􀁕

Answer 1

1. Tumor excision

RECOMMENDED READINGS

Nazerani S, Motamedi MH, Keramati MR. Diagnosis and management of glomus tumors of the hand. Tech Hand Up Extrem Surg. 2010 Mar;14(1):8-13. PubMed PMID: 20216046.

Question 2

15. A 24-year-old man with weakness and atrophy of the thumb for 12 months has very slight numbness on the radial side of his thumb that is constant and not progresing. He ahs no other hand or finger numbness. His 2-point static sensory examination is unremarkable in all digits and there is marked atrophy of the thenar muscles. His carpal tunnel provocative tests are negative. He has no symptoms on the opposite hand and otherwise is in excellent health. Which next step will most likely reveal the diagnosis?
16. An MRI scan
17. Muscle biopsy
18. Carpal tunnel diagnostic injection
19. Electrodiagnostic testing
20. Carpal tunnel view radiograph

Answer 2

1. An MRI scan

RECOMMENDED READINGS

Shimizu A, Ikeda M, Kobayashi Y, Saito I, Oka Y. Carpal tunnel syndrome caused by a ganglion in the carpal tunnel with an atypical type of palsy: a case report. Hand Surg. 2011;16(3):339-41. PubMed PMID: 22072471.

Chen CH, Wu T, Sun JS, Lin WH, Chen CY. Unusual causes of carpal tunnel syndrome: space occupying lesions. J Hand Surg Eur Vol. 2012 Jan;37(1):14-9. Epub 2011 Aug 8. PubMed PMID: 21825010. Mauermann ML, Amrami KK, Kuntz NL, Spinner RJ, Dyck PJ, Bosch EP, Engelstad J, Felmlee JP, Dyck

PJ. Longitudinal study of intraneural perineurioma–a benign, focal hypertrophic neuropathy of youth. Brain. 2009 Aug;132(Pt 8):2265-76. Epub 2009 Jun 30. PubMed PMID: 19567701.

Question 3

28. Figures 28a and 28b are the pre-and postreduction radiographs of a finger. The rehabilitation protocol is
29. buddy tape and active motion.
30. static splint in full extension.
31. static splint in 45 degrees of flexion at the proximal interphalangeal joint extension
32. static spling in the metacarpophalangeal joint flexion at the proximal interphalangeal joint extension.
33. extension block splint in 90 degrees of flexion at the proximal interphalangeal joint

Answer 3

1. buddy tape and active motion.

RECOMMENDED READINGS

Merrel G, Slade JF. Dislocations and ligament injuries in the digits. In: Wolfe SW, Hotchkiss RN, PedersonWC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2011:291-295.

Morgan WJ, Slowman LS. Acute hand and wrist injuries in athletes: evaluation and management. J Am Acad Orthop Surg. 2001 Nov-Dec;9(6):389-400. Review. PubMed PMID: 11730330.

Question 4

37.

A 27-year-old jackhammer operator has a 4-month history of hand coldness and severe ischemia that spares his thumb and index fingers. Systemic illness have been ruled out. Doppler workup reveals anerysmal changes, and digital subtraction arteriogram confirms the finding. Intervention should consist of

1. excision and vein graft.
2. surgical thrombectomy.
3. systemic anticoagulation.
4. intravascular fibrinolysis􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀁌􀁑􀁗􀁕􀁄􀁙􀁄􀁖􀁆􀁘􀁏􀁄􀁕􀀃􀂿􀁅􀁕􀁌􀁑􀁒􀁏􀁜􀁖􀁌􀁖􀀑
5. interventional embolectomy.

Answer 4

1. excision and vein graft.

RECOMMENDED READINGS

Yuen JC, Wright E, Johnson LA, Culp WC. Hypothenar hammer syndrome: an update with algorithms for diagnosis and treatment. Ann Plast Surg. 2011 Oct;67(4):429-38. Review. PubMed PMID: 21372671.

Lifchez SD, Higgins JP. Long-term results of surgical treatment for hypothenar hammer syndrome. Plast Reconstr Surg. 2009 Jul;124(1):210-6. PubMed PMID: 19568083.

Nitecki S, Anekstein Y, Karram T, Peer A, Bass A. Hypothenar hammer syndrome: apropos of six cases and review of the literature. Vascular. 2008 Sep-Oct;16(5):279-82. PubMed PMID: 19238870.

Question 5

48. A mechanic sustained a high-pressure injection of cleaning solvent into the tip of his index finger 2 hours ago. The finger has good capillary refill and his 2-point descrimination is 7mm. Initial treatment should include
49. a corticosteroid injection.
50. elevation and observation.
51. elective surgical treatment within 7 days.
52. oral clindamycin for 10 days.
53. emergent surgical debridement.

Answer 5

5. emergent surgical debridement.

RECOMMENDED READINGS

Tan V, Katolik LI. Hand and wrist trauma. In; Flynn JM, ed. Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:351-362.

Stevanovic MV, Sharpe F. Acute infections. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2011:81.

Question 6

58. An otherwise healthy 42-year-old woman is scheduled for carpal tunnel release. The physician should adhere to routine sterility protocols
59. without local or systemic antibiotics.
60. and irrigate with cefazolin solution.
61. and irrigate with bacitracin solution.
62. and administer cefazolin within 1 hour before incision.
63. and administer cefazolin within 1 hour before incision and continue dosing up to 23 hours after surgery.

Answer 6

1. without local or systemic antibiotics.

RECOMMENDED READINGS

Tosti R, Fowler J, Dwyer J, Maltenfort M, Thoder JJ, Ilyas AM. Is antibiotic prophylaxis necessary in elective soft tissue hand surgery? Orthopedics. 2012 Jun 1;35(6):e829-33. doi: 10.3928/01477447- 20120525-20. PubMed PMID: 22691653.

Bykowski MR, Sivak WN, Cray J, Buterbaugh G, Imbriglia JE, Lee WP. Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8,850 cases. J Hand Surg Am. 2011 Nov;36(11):1741-7. Epub 2011 Oct 5. PubMed PMID: 21975095.

Harness NG, Inacio MC, Pfeil FF, Paxton LW. Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis. J Hand Surg Am. 2010 Feb;35(2):189-96. PubMed PMID: 20141890.

Rizvi M, Bille B, Holtom P, Schnall SB. The role of prophylactic antibiotics in elective hand surgery. J Hand Surg Am. 2008 Mar;33(3):413-20. Review. PubMed PMID: 18343301.

Question 7

65. Figures 65a and 65b are the magnetic resonance arthrogram and wrist arthroscopic photograph of a 25-year-old man who has wrist pain during extension and ulnar rotation. Treatment should consist of
66. synovectomy.
67. ulnar shortening osteotomy.
68. diagnostic arthroscopy only.
69. triangular fibrocartilage complex tear debridement
70. triangular fibrocartilage complex repair dorsal ligament􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀁗􀁕􀁌􀁄􀁑􀁊􀁘􀁏􀁄􀁕􀀃􀂿􀁅􀁕􀁒􀁆􀁄􀁕􀁗􀁌􀁏􀁄􀁊􀁈􀀃􀁆􀁒􀁐􀁓􀁏􀁈􀁛􀀃􀁗􀁈􀁄􀁕􀀃􀁇􀁈􀁅􀁕􀁌􀁇􀁈􀁐􀁈􀁑􀁗􀀑

􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁗􀁕􀁌􀁄􀁑􀁊􀁘􀁏􀁄􀁕􀀃􀂿􀁅􀁕􀁒􀁆􀁄􀁕􀁗􀁌􀁏􀁄􀁊􀁈􀀃􀁆􀁒􀁐􀁓􀁏􀁈􀁛􀀃􀁕􀁈􀁓􀁄􀁌􀁕􀀃􀁇􀁒􀁕􀁖􀁄􀁏􀀃􀁏􀁌􀁊􀁄􀁐􀁈􀁑􀁗􀀑

Answer 7

4. triangular fibrocartilage complex tear debridement

RECOMMENDED READINGS

Faber KJ, Iordache S, Grewal R. Magnetic resonance imaging for ulnar wrist pain. J Hand Surg Am. 2010 Feb;35(2):303-7. Review. PubMed PMID: 20141901.

Chen NC, Osterman AL, Culp RW, Chung KC. Wrist arthroscopy. In: Chung KC, Murray PM, eds. Hand Surgery Update 5. Rosemont, IL: American Society for Surgery of the Hand; 2012:159-170.

Question 8

75. The least gliding resistence for a flexor tendon laceration a the thumb palmar-digital crease as shown in figure 75 can be achieved with
76. a 6-strand repair.
77. a division and repair.
78. debridement of the partial laceration.
79. no debridement, motion therapy only.
80. multiple-strand core repair with epitendinous repair.

Answer 8

3. debridement of the partial laceration.

Question 9

78. A 42-year-old woman has the injury shown in Figures 78a and 78b. The decision to treat the ulnar styloid surgically is based upon which finding?
79. Patient age
80. Displacement of the radius fracture
81. Displacement of the ulnar styloid fracture
82. Position of the ulnar styloid after open reduction and internal fixation of the radius
83. Stability of the distal radioulnar joint after open and internal fixation of the radius􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀳􀁒􀁖􀁌􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁘􀁏􀁑􀁄􀁕􀀃􀁖􀁗􀁜􀁏􀁒􀁌􀁇􀀃􀁄􀁉􀁗􀁈􀁕􀀃􀁒􀁓􀁈􀁑􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁌􀁑􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁕􀁄􀁇􀁌􀁘􀁖

Answer 9

5. Stability of the distal radioulnar joint after open and internal fixation of the radius􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀳􀁒􀁖􀁌􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁘􀁏􀁑􀁄􀁕􀀃􀁖􀁗􀁜􀁏􀁒􀁌􀁇􀀃􀁄􀁉􀁗􀁈􀁕􀀃􀁒􀁓􀁈􀁑􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁌􀁑􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁕􀁄􀁇􀁌􀁘􀁖

RECOMMENDED READINGS

Kim JK, Yun YH, Kim DJ, Yun GU. Comparison of united and nonunited fractures of the ulnar styloid following volar-plate fixation of distal radius fractures. Injury. 2011 Apr;42(4):371-5. Epub 2010 Oct 20.PubMed PMID: 20961540.

Sammer DM, Shah HM, Shauver MJ, Chung KC. The effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures. J Hand Surg Am. 2009 Nov;34(9):1595- 602. PubMed PMID: 19896004.

Question 10

95. The deformity caused by long-term arthritis of the first carpometacarpal joint of the hand often leads to a secondary hyperextension arthrosis of which joint
96. Midcarpal
97. Radiocarpal
98. Scaphotrapezotrapezoidal
99. Thumb interphalangeal
100. Thumb metacarpophalangeal

Answer 10

5. Thumb metacarpophalangeal

Question 11

103. Figure 103 is the clinical photograph of a 62-year-old man with numbness and weakness that has been progressing for 10 years. What is the most appropriate treatment to improve thumb function?
104. Functional splinting
105. Neurotization of the thenar muscles
106. Hypothenar muscle transfer to thumb intrinsic
107. Arthrodesis of the thumb carpometacarpal joint in abduction
108. Transfer of the extensor indicis proprius around the ulnar wrist

Answer 11

5. Transfer of the extensor indicis proprius around the ulnar wrist

RECOMMENDED READINGS

Burkhalter W, Christensen RC, Brown P. Extensor indicis proprius opponensplasty. J Bone Joint Surg Am. 1973 Jun;55(4):725-32. PubMed PMID: 4283744.

Question 12

115. A 50-year-old man sustained a clavicle fracture after a motorcycle collision. He has no sensation or motor function in the biceps, triceps; however, he has very weak thenar and finger flexion and extension. Which finding would suggest a postganglionic as opposed to a preganglionic injury?
116. Preservation of C8, T1 function
117. Preserved sensory nerve action potential
118. Pseudomeningocele on CT myelogram
119. Ptosis and miosis on the same side as the injury
120. The cervical paraspinal muscle is normal on electromyography

Answer 12

5. The cervical paraspinal muscle is normal on electromyography

RECOMMENDED READINGS

Moran SL, Steinmann SP, Shin AY. Adult brachial plexus injuries: mechanism, patterns of injury, and physical diagnosis. Hand Clin. 2005 Feb;21(1):13-24. Review. PubMed PMID: 15668062.

Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg. 2005 Oct;13(6):382-96. Review. PubMed PMID: 16224111.

Question 13

133. Figures 133a and 133b are the clinical photographs of a 34-year-old woman with increasing pain in her index finger for 3 days. The pain is worse with passive extension. Appropriate treatment shoudl consist of
134. observation.
135. hand therapy.
136. oral antibiotics.
137. intravenous antibiotics.
138. irrigation and debridement of the flexor tendon sheath􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁌􀁕􀁕􀁌􀁊􀁄􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁇􀁈􀁅􀁕􀁌􀁇􀁈􀁐􀁈􀁑􀁗􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁗􀁈􀁑􀁇􀁒􀁑􀀃􀁖􀁋􀁈􀁄􀁗􀁋􀀑

Answer 13

5. irrigation and debridement of the flexor tendon sheath􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁌􀁕􀁕􀁌􀁊􀁄􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁇􀁈􀁅􀁕􀁌􀁇􀁈􀁐􀁈􀁑􀁗􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁗􀁈􀁑􀁇􀁒􀁑􀀃􀁖􀁋􀁈􀁄􀁗􀁋􀀑

RECOMMENDED READINGS

Capo JT. Infections. In: Chung KC, Murray PM, eds. Hand Surgery Update 5. Rosemont, IL: AmericanSociety for Surgery of the Hand; 2012:394-399.

Draeger RW, Bynum DK Jr. Flexor tendon sheath infections of the hand. J Am Acad Orthop Surg. 2012 Jun;20(6):373-82. Review. PubMed PMID: 22661567.

Question 14

140. A 38-year-old woman had a distal radius fracture treated with a short-arm cast 3 months ago. The fracture healed in good alignment. Figure 140 shows her attempt to extend her thumb. What is the best treatment option?
141. Static splinting
142. Dynamic splinting
143. Transfer of the extensor pollicis brevis
144. Transfer of the extensor indicis proprius
145. Arthrodesis of the interphalangeal joint

Answer 14

4. Transfer of the extensor indicis proprius

RECOMMENDED READINGS

Roth KM, Blazar PE, Earp BE, Han R, Leung A. Incidence of extensor pollicis longus tendon rupture after nondisplaced distal radius fractures. J Hand Surg Am. 2012 May;37(5):942-7. Epub 2012 Mar 29. PubMed PMID: 22463927.

Question 15

213. Figures 213a and 213b are the clinical photograph and biopsy specimen of a 65-year-old man with a lesion under his thumbnail that was biopsied by a dermatologist. Appropriate treatment should consist of
214. observation.
215. local excision.
216. marginal excision.
217. thumb ray resection.
218. amputation at the interphalangeal joint.

Answer 15

5. amputation at the interphalangeal joint.

RECOMMENDED READINGS

Haase SC, Chung KC. Skin tumors. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2011:2131-2133.

Plate AM, Steiner G, Posner MA. Malignant tumors of the hand and wrist. J Am Acad Orthop Surg. 2006 Nov;14(12):680-92. PubMed PMID: 17077340.

Question 16

225. Figure 225 is the clinical photograph of a 26-year-old man who fell through a window and sustained a laceration to his thumb 5 days ago. He is unabel to flex his thumb. Treatment should include
226. palmaris longus tendon transfer.
227. reconstruction with a palmaris longus free tendon bridge graft.
228. direct repair of the flexor pollicis longus with core sutures only.
229. repair of the flexor pollicis longus with core and epidtendinious sutures
230. transfer of the flexor digitorum superficialis of the ring finger to the thumb􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀁇􀁌􀁕􀁈􀁆􀁗􀀃􀁕􀁈􀁓􀁄􀁌􀁕􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁓􀁒􀁏􀁏􀁌􀁆􀁌􀁖􀀃􀁏􀁒􀁑􀁊􀁘􀁖􀀃􀁚􀁌􀁗􀁋􀀃􀁆􀁒􀁕􀁈􀀃􀁖􀁘􀁗􀁘􀁕􀁈􀁖􀀃􀁒􀁑􀁏􀁜􀀑

􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀁕􀁈􀁓􀁄􀁌􀁕􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁓􀁒􀁏􀁏􀁌􀁆􀁌􀁖􀀃􀁏􀁒􀁑􀁊􀁘􀁖􀀃􀁚􀁌􀁗􀁋􀀃􀁆􀁒􀁕􀁈􀀃􀁄􀁑􀁇􀀃􀁈􀁓􀁌􀁗􀁈􀁑􀁇􀁌􀁑􀁒􀁘􀁖􀀃􀁖􀁘􀁗􀁘􀁕􀁈􀁖􀀑

􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁗􀁕􀁄􀁑􀁖􀁉􀁈􀁕􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁇􀁌􀁊􀁌􀁗􀁒􀁕􀁘􀁐􀀃􀁖􀁘􀁓􀁈􀁕􀂿􀁆􀁌􀁄􀁏􀁌􀁖􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁕􀁌􀁑􀁊􀀃􀂿􀁑􀁊􀁈􀁕􀀃􀁗􀁒􀀃􀁗􀁋􀁈􀀃􀁗􀁋􀁘􀁐􀁅􀀑

Question 17

230. Figures 230a through 230d are the pre- and postreduction radiographs of a 6-year-old boy who had a fracture of the radius and ulna shafts in the distal diaphyses. Successful reduction of the completely displaced fractures is achieved. To best maintain reduction while minimizing complications, treatment should include immobilization in a
231. removable splint.
232. sugar-tong splint.
233. short-arm cast.
234. long-arm cast.
235. long-arm thumb spica cast.

Answer 17

3. short-arm cast.

RECOMMENDED READINGS

Paneru SR, Rijal R, Shrestha BP, Nepal P, Khanal GP, Karn NK, Singh MP, Rai P. Randomized controlled trial comparing above- and below-elbow plaster casts for distal forearm fractures in children. J Child Orthop. 2010 Jun;4(3):233-7. Epub 2010 Mar 17. PubMed PMID: 21629372.

Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children. J Bone Joint Surg Am. 2006 Jan;88(1):9-17. PubMed PMID: 16391244.

Bohm ER, Bubbar V, Yong Hing K, Dzus A. Above and below-the-elbow plaster casts for distal forearm fractures in children. A randomized controlled trial. J Bone Joint Surg Am. 2006 Jan;88(1):1-8. PubMed PMID: 16391243.

Question 18

240. Figure 240 is the clinical photograph of a 33-year-old man who sustained a thumb pulp injury. There is 1-cm necrosis and tissue loss at the distal flap edge. What is the most appropriate treatment option?
241. Cross-finger flap
242. Volar advancement flap
243. Free microvascular pulp reconstruction
244. Free microvascular pulp reconstruction
245. Local wound care with wet-to-moist dressings

􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀯􀁒􀁆􀁄􀁏􀀃􀁕􀁒􀁗􀁄􀁗􀁌􀁒􀁑􀀃􀃀􀁄􀁓􀀃􀁉􀁕􀁒􀁐􀀃􀁗􀁋􀁈􀀃􀁇􀁒􀁕􀁖􀁄􀁏􀀃􀁐􀁈􀁗􀁄􀁆􀁄􀁕􀁓􀁄􀁏􀀃􀁙􀁈􀁖􀁖􀁈􀁏􀁖

Answer 18

2. Volar advancement flap

RECOMMENDED READINGS

Horta R, Barbosa R, Oliveira I, Amarante JM, Marques M, Cruz Reis J, Rebelo M. Neurosensible reconstruction of the thumb in an emergency situation: review of 107 cases. Tech Hand Up Extrem Surg. 2009 Jun;13(2):85-9. PubMed PMID: 19516133.

Question 19

256. An 84-year-old patient who has been hospitalized for pneumonia has developed isolated wrist pain and swelling with an effusion. The wrist is aspirated, the nucleated cell count is 75,000 cells/mm3, and urate crystal s are identified. What is the most important next treatment step?

􀁆􀁕􀁜􀁖􀁗􀁄􀁏􀁖􀀃􀁄􀁕􀁈􀀃􀁌􀁇􀁈􀁑􀁗􀁌􀂿􀁈􀁇􀀑􀀃􀀃􀀺􀁋􀁄􀁗􀀃􀁌􀁖􀀃􀁗􀁋􀁈􀀃􀁐􀁒􀁖􀁗􀀃􀁌􀁐􀁓􀁒􀁕􀁗􀁄􀁑􀁗􀀃􀁑􀁈􀁛􀁗􀀃􀁗􀁕􀁈􀁄􀁗􀁐􀁈􀁑􀁗􀀃􀁖􀁗􀁈􀁓􀀢1. Begin allopurinol.

2. Begin nonsteroidal anti-inflammatory drugs.􀀃 􀀕􀀑􀀃􀀃􀀃􀀃􀀥􀁈􀁊􀁌􀁑􀀃􀁑􀁒􀁑􀁖􀁗􀁈􀁕􀁒􀁌􀁇􀁄􀁏􀀃􀁄􀁑􀁗􀁌􀀐􀁌􀁑􀃀􀁄􀁐􀁐􀁄􀁗􀁒􀁕􀁜􀀃􀁇􀁕􀁘􀁊􀁖􀀑
3. Administer a corticosteroid wrist injection.
4. Obtain cultures and begin empiric antibiotics.
5. Obtain radiographs to evaluate for a wrist fracture.

Answer 19

4. Obtain cultures and begin empiric antibiotics.

RECOMMENDED READINGS

Shah K, Spear J, Nathanson LA, McCauley J, Edlow JA. Does the presence of crystal arthritis rule out septic arthritis? J Emerg Med. 2007 Jan;32(1):23-6. PubMed PMID: 17239729.

Schuind FA, Remmelink M, Pasteels JL. Co-existent gout and septic arthritis at the wrist: a case report. Hand Surg. 2003 Jul;8(1):107-9. PubMed PMID: 12923944.

Yu KH, Luo SF, Liou LB, Wu YJ, Tsai WP, Chen JY, Ho HH. Concomitant septic and gouty arthritis–an analysis of 30 cases. Rheumatology (Oxford). 2003 Sep;42(9):1062-6. Epub 2003 Apr 16. PubMed PMID: 12730521.

Question 20

269. Figures 269a and 269b are the MRI scans of a 60-year-old man who ahs pain and loss of elbow flexion strength. In addition to the distal biceps tendon injury, what is the most likely diagnosis?
270. Soft-tissue sarcoma
271. Intraneural ganglion cyst
272. Denervation of the biceps muscle
273. Benign peripheral nerve sheath tumor
274. Malignant peripheral nerve sheath tumor

Answer 20

4. Benign peripheral nerve sheath tumor

RECOMMENDED READINGS

Bhargava R, Parham DM, Lasater OE, Chari RS, Chen G, Fletcher BD. MR imaging differentiation of benign and malignant peripheral nerve sheath tumors: use of the target sign. Pediatr Radiol. 1997 Feb;27(2):124-9. PubMed PMID: 9028843.