Hand 2016 Flashcards
15. Figures 15a and 15b are the radiographs of a 62-year-old right-hand-dominant woman who has right wrist pain. Thirty years ago she underwent scapholunate ligament repair. She never fully regained wrist motion or strength and reports that her pain and stiffness have progressed substantially during the last 5 years. An examination reveals decreased wrist flexion and extension and tenderness along the radiocarpal joint. She attempted bracing and corticosteroid injections without experiencing lasting symptom relief. Which surgical treatment will most likely provide pain relief and preserve motion?
- Complete radiocarpal arthrodesis
- Scaphoid excision and 4-corner arthrodesis
- Scaphoid distal pole excision
- Scaphoid excision and radial styloidectomy
- Proximal row carpectomy
- Scaphoid excision and 4-corner arthrodesis
RECOMMENDED READINGS
Tomaino MM, Miller RJ, Cole I, Burton RI. Scapholunate advanced collapse wrist: proximal row carpectomy or limited wrist arthrodesis with scaphoid excision? J Hand Surg Am. 1994 Jan;19(1):134-42. PubMed PMID: 8169358.
Strauch RJ. Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis–update on evaluation and treatment. J Hand Surg Am. 2011 Apr;36(4):729-35. doi: 10.1016/j.jhsa.2011.01.018. Review. PubMed PMID: 21463735.
28. Figure 28 is the ultrasound of a 23-year-old patient who has had a volar radial 1.5-cm tender and painful wrist mass for 6 months. The additional workup prior to surgery should consist of
- serum and urine protein electrophoresis.
- a chest CT scan.
- positron emission tomography.
- MRI with intravenous contrast.
- age-appropriate presurgical laboratory studies.
- age-appropriate presurgical laboratory studies.
RECOMMENDED READINGS
Amrami KK, Bishop AT, Berger RA: Radiology Corner: Imaging Soft-Tissue Tumors of the Hand and Wrist: Case Presentation and Discussion, Journal of the American Society for Surgery of the Hand, 2005;Volume 5(Issue 4):186-192. http://www.jhandsurg.org/article/S1531-0914(05)00149-X/abstract
Mayerson JL, Scharschmidt TJ, Lewis VO, Morris CD. Diagnosis and Management of Soft-tissue Masses. J Am Acad Orthop Surg. 2014 Nov;22(11):742-50. doi: 10.5435/JAAOS-22-11-742. PubMed PMID: 25344599.
39. Figure 39 is the right hand of a 65-year-old man with a history of hypertension and rheumatoid arthritis. He is taking immunosuppressive disease-modifying antirheumatic drugs (DMARDs) and is seen in the emergency department with rapid progression of erythema from his right thumb to his right arm during the last 12 hours. He is confused, lethargic, and has these vital signs: blood pressure 92/40, respiratory rate 45, temperature 39.7°C, pulse 135, and oxygen saturation 90% on 4 liters of oxygen by face mask. An examination of his right upper extremity reveals black bulla extending from the metacarpophalangeal down to the tip and no capillary refill at the pulp. Immediate treatment should consist of
- intravenous (IV) antibiotics and admission to a medical intensive care unit.
- emergent radical debridement including thumb amputation.
- emergent revascularization of the thumb with a vein graft.
- urgent irrigation of the thumb flexor tendon sheath.
- urgent debridement of the felon through a midlateral incision.
- emergent radical debridement including thumb amputation.
RECOMMENDED READINGS
Gonzalez MH, Kay T, Weinzweig N, Brown A, Pulvirenti J. Necrotizing fasciitis of the upper extremity. J Hand Surg Am. 1996 Jul;21(4):689-92. PubMed PMID: 8842969.
Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul;32(7):1535-41. PubMed PMID: 15241098.
48. A 16-year-old high school football player injured his ring finger during a game 5 days before his clinic visit. He reports pain and swelling at the proximal interphalangeal (PIP) joint and difficulty moving his finger. Which examination finding is most suggestive of a central slip disruption?
- With the PIP joint flexed to 90 degrees, attempted extension against resistance results in distal interphalangeal (DIP) hyperextension
- With the PIP joint flexed to 90 degrees, the patient cannot actively extend the DIP joint against resistance
- With the PIP joint in extension, the patient cannot actively extend the DIP joint against resistance
- The finger rests in a boutonniere posture that cannot be passively corrected
- The finger rests in a swan-neck posture that cannot be passively corrected
- With the PIP joint flexed to 90 degrees, attempted extension against resistance results in distal (Elson’s Test).
58. The examination finding shown in Video 58 is consistent with which defect?
- Trigger finger
- Flexor digitorum profundus (FDP) incompetence
- Flexor digitorum sublimis (FDS) incompetence
- Extensor digitorum communis (EDC) incompetence
- Extensor digiti quinti (EDQ) incompetence
- Flexor digitorum profundus (FDP) incompetence
65. Figure 65a is the clinical photograph of a 64-year-old man who crashed while riding his motorcycle. An examination reveals his long-finger metacarpophalangeal (MP) joint is stuck in extension. He cannot passively or actively flex at the MP joint. A hand radiograph is seen in Figure 65b. Which interposed structure is preventing reduction?
- Flexor tendons
- Lateral band
- Extensor hood
- Lumbrical
- Volar plate
- Volar Plate
75. A router injury leaves a skin and soft-tissue defect over the volar middle phalanx of the long finger for a 32-year-old healthy man. There is a 2.2-cm x 1.2-cm area of exposed flexor tendon without tenosynovium. What is the best option for defect coverage?
- Full-thickness skin graft
- Split-thickness skin graft
- First dorsal metacarpal artery flap
- Moberg advancement flap
- Cross-finger flap
- Cross Finger Flap
88. A 70-year-old woman reports decreased thumb strength and intermittent numbness in her index and long fingers for 1 month. She also has radiographic thumb carpometacarpal (CMC) arthritis and 4/5 thenar muscle strength without atrophy. Nerve conduction studies and electromyography (EMG) reveal fibrillations within the abductor pollicis brevis and median nerve sensory latency of 3.6 ms (< 3.5 ms is normal). What is the best next step?
- Carpal tunnel release
- Carpal tunnel and Guyon’s canal release
- Cervical spine MRI and neurologic evaluation
- Corticosteroid injection in the thumb CMC joint
- Wrist neutral splint with corticosteroid injection in the carpal tunnel
- Carpal tunnel release
96.
A 54-year-old laborer has a 6-month history of lateral elbow pain. An elbow examination reveals full range of motion, tenderness over the lateral epicondyle, and pain with resisted wrist extension with the elbow in extension. Elbow radiograph findings are normal. You perform a steroid injection and the patient’s symptoms are decreased 6 weeks later. One year after receiving the injection, this patient—when compared to a patient who did not have a steroid injection—is likely to
- have no difference in elbow pain.
- no longer have elbow pain.
- need surgery.
- experience tendon rupture.
- change occupations.
- No difference in elbow pain
RECOMMENDED READINGS
Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013 Feb 6;309(5):461-9. doi: 10.1001/jama.2013.129. PubMed PMID: 23385272.
Dong W, Goost H, Lin XB, Burger C, Paul C, Wang ZL, Kong FL, Welle K, Jiang ZC, Kabir K. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med. 2016 Aug;50(15):900-8. doi: 10.1136/bjsports-2014-094387. Epub 2015 Sep 21. PubMed PMID: 26392595.
103. Figures 103a through 103d are the radiographs, sagittal-cut CT scan, and coronal T1 MR image of a 16-year-old boy who has wrist stiffness and pain after sustaining an injury 2 years ago. There is no bleeding from the proximal pole during surgery. Which procedure will most likely result in restoration of alignment and healing?
- 1,2 intercompartmental supraretinacular artery (ICSRA) graft
- Free-vascularized medial femoral condyle graft
- Iliac crest corticocancellous graft
- 4+5 extensor compartmental artery (ECA) vascularized bone graft
- Cancellous distal radius autograft
- Free-vascularized medial femoral condyle graft.
RECOMMENDED READINGS
Moon ES, Dy CJ, Derman P, Vance MC, Carlson MG. Management of nonunion following surgical management of scaphoid fractures: current concepts. J Am Acad Orthop Surg. 2013 Sep;21(9):548-57. doi: 10.5435/JAAOS-21-09-548. Review. PubMed PMID: 23996986.
Jones DB Jr, Bürger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint Surg Am. 2008 Dec;90(12):2616-25. doi: 10.2106/JBJS.G.01503. PubMed PMID: 19047706.
133. A 47-year-old woman has finger pain in all digits of her left hand. She denies a history of trauma or a connective tissue disorder. Cold exposure causes color changes in her fingers and exacerbates her pain. An examination reveals 2+ radial and ulnar pulses. The thumb, index, and long fingers display sluggish capillary refill, and small ulcers appear on her fingertips. There is no erythema or drainage from the ulcers. Which treatment will most likely decrease her pain and improve finger perfusion?
- Stellate ganglion block
- Botulinum toxin A injections
- Digital amputation
- Oral gabapentin
- Oral methotrexate
- Botulinum toxin A injection
RECOMMENDED READINGS
Iorio ML, Masden DL, Higgins JP. Botulinum toxin A treatment of Raynaud’s phenomenon: a review. Semin Arthritis Rheum. 2012 Feb;41(4):599-603. doi: 10.1016/j.semarthrit.2011.07.006. Epub 2011 Aug 24. Review. PubMed PMID: 21868066.
Neumeister MW, Webb KN, Romanelli M. Minimally invasive treatment of Raynaud phenomenon: the role of botulinum type A. Hand Clin. 2014 Feb;30(1):17-24. doi: 10.1016/j.hcl.2013.09.006. Review. PubMed PMID: 24286738.
140. A 32-year-old man sustained the thumb metacarpophalangeal (MP) joint ulnar collateral ligament (UCL) injury seen in Figure 140. During repair, which structure blocks reduction of the ligament?
- Extensor pollicis longus (EPL) tendon
- Extensor pollicis brevis (EPB) tendon
- EPB and dorsal capsule
- Ulnar sesamoid bone and adductor muscle
- Adductor aponeurosis
- Adductor aponeurosis
175. A 63-year-old woman is seen 3 weeks after sustaining a closed minimally displaced distal radius fracture. She has been in a short-arm cast and reports minimal pain but notes that she is having difficulty using her thumb. You suspect she may have an extensor pollicis longus (EPL) rupture. Which examination finding would confirm lack of EPL function?
- A positive Froment sign
- Thenar atrophy
- Inability to lift her thumb off of the examination table with her palm flat
- Inability to abduct her thumb from the palm with her palm flat on the table
- Tenderness over the third dorsal compartment
- Inability to lift her thumb off the examination table with her palm flat.
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. doi: 10.1016/j. jhsa.2012.02.006. Epub 2012 Mar 29. PubMed PMID: 22463927.
Kulshreshtha R, Patel S, Arya AP, Hall S, Compson JP. Variations of the extensor pollicis brevis tendon and its insertion: a study of 44 cadaveric hands. J Hand Surg Eur Vol. 2007 Oct;32(5):550-3. Epub 2007 Jun 12. PubMed PMID: 17950220.
228. While attempting to recreate the inclination of the distal radius during volar fixation of an intra-articular sagittal split fracture, use of intraoperative fluoroscopic imaging in the position shown in Figure 228 would be helpful in showing
- intra-articular screw penetration.
- alignment of the joint surface.
- alignment of the sigmoid notch.
- carpal alignment.
- dorsal screw penetration.
- Intra-articular screw penetration
RECOMMENDED READINGS
Tweet ML, Calfee RP, Stern PJ. Rotational fluoroscopy assists in detection of intra-articular screw penetration during volar plating of the distal radius. J Hand Surg Am. 2010 Apr;35(4):619-27. doi: 10.1016/j.jhsa.2009.12.033. Epub 2010 Mar 3. PubMed PMID: 20202762.
Patel A, Culbertson MD, Lahey P, Semenovski M, Choueka J. Improving accuracy and confidence in distal radius volar plate screw placement through supplemental radiography: examining specialty, education, and experience levels. Hand (N Y). 2013 Sep;8(3):308-14. doi: 10.1007/s11552-013-9528-3. PubMed PMID: 24426939.
232. A 50-year-old man with a history of tobacco use sustained a traumatic amputation of his dominant hand index finger through the proximal phalanx while using a table saw. He arrived at the emergency department 6 hours after the injury with the amputated digit wrapped in moist gauze in a plastic bag inside a cooler with ice. Replantation should not be performed because of
- prolonged ischemia time.
- a history of tobacco use.
- poor function of the replanted digit.
- the patient’s age.
- the table saw mechanism.
- Poor funciton of the replanted digit
RECOMMENDED READINGS
Urbaniak JR, Roth JH, Nunley JA, Goldner RD, Koman LA. The results of replantation after amputation of a single finger. J Bone Joint Surg Am. 1985 Apr;67(4):611-9. PubMed PMID: 3980507.
Boulas HJ. Amputations of the fingers and hand: indications for replantation. J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):100-5. PubMed PMID: 9682072.
256. Figures 256a through 256d are the wrist MR images of a 43-year-old right-hand-dominant bricklayer who reports gradually progressive left hand weakness for 4 months. He describes difficulty gripping objects, tying his shoes, and holding utensils. He denies any numbness, paresthesias, or a previous injury. An examination reveals intact sensation in a median, radial, and ulnar nerve distribution. He has atrophy of hand interossei and a positive Froment sign finding. He has no Tinel sign finding at the wrist or elbow and no exacerbation of symptoms with elbow hyperflexion. Electromyography shows signs of denervation in an ulnar nerve distribution distal to the wrist. What is the best next step?
- Cubital tunnel release
- Guyon’s canal release
- Hook-of-hamate excision
- Chest radiograph and positron emission tomography scan
- Excision of the ganglion cyst
- Excision of ganglion cyst.
