Hand

Question 1

Treatment for Stage I SLAC wrist?

Answer 1

AIN/PIN neurectomy. Characterized by scaphoid-radial styloid arthritis.

Question 2

Treatment for stage II SLAC wrist?

Answer 2

PRC or scaphoid excision with four corner fusion. Characterized by arthritis of the entire scaphoid facet.

Question 3

Treatment for stage III SLAC wrist?

Answer 3

Scaphoidectomy with four corner fusion or wrist arthrodesis. Characterized by capitolunate arthritis with proximal migration of the capitate into the scapholunate interval.

Question 4

Which ligaments are important in preventing dorsal intercalated segment instability?

Answer 4

dorsal intercarpal ligaments are important for preventing DISI.

Question 5

What is the best imaging test to stage Keinbock’s disease?

Answer 5

CT scan.

Question 6

What are the advantages of wide-awake tendon repairs?

Answer 6

1. Ability to evaluate repairs to make sure they glide through pulleys. Can release all of A4 and vent half of A2 if needed. 2. Demonstrate that the sheath has not been inadvertently caught. 3. Confidently initiate early active motion if the patient can make a full fist during surgery.

Question 7

How do you know if you have a true AP view of the forearm?

Answer 7

The bicipital tuberosity and radial stylid should be 180 degrees apart on the AP view.

Lateral view should have ulnar styloid and coronoid 180 degrees apart.

Question 8

Which forearm compartment is most commonly affected with compartment syndrome?

Answer 8

Volar

Mobile wad is rarely involved. (Brachioradialis, ECRL, and ECRB.)

Question 9

What are the compartments of the hand?

Answer 9

10 in total

Thenar, hypothenar, adductor pollicis, dorsal interosseous (4), and volar interosseous (3).

Question 10

Another way of describing an intrinsic minus hand?

Answer 10

Claw hand.

Question 11

What is the treatment for Volkamn’s Ischemic contracture of the hand that affects both wrist and finger flexors?

Answer 11

This is Moderate per Tsuge classification

Tx is excision of necrotic tissue, median and ulnar neurolysis, BR to FPL and EXRL to FDP tendon transfers, distal slide of viable flexors.

Question 12

What is thought to lead to neonatal compartment syndrome?

Answer 12

Both extrinsic (mechanical compression) and intrinsic (hypercoagulable state such as polycythemia).

Idiopathic most common cause

All patients present with some sort of skin lesion at birth (bullae, erythema, ulcerative, eschar, or fingertip gangrene.)

Lack of spontaneous limb movement.

Often missed. Compartment pressures should not be measured, not reliable.

Question 13

Differential for neonatal compartment syndrome?

Very late complication?

Answer 13

Cellulitis

Vascular injuries associated with brachial plexus lesions

Necrotiing fasciitis

Physeal distortion requiring limb lengthening and angular correction.

Question 14

What disease can be treated with periarterial sympathectomy after medical management has failed.

Answer 14

Raynauds, may add arterial reconstruction.

Controversial use in thromboangiitis ovliterans (Buerger’s Disease)

Question 15

What is the most common site of compression of the PIN nerve?

Answer 15

arcade of Frohse.

Thick tendinous edge of the supinator.

Question 16

What can the lacertus fibrosis casue compression of?

Answer 16

median nerve.

Broad aponeurosis of the biceps brachii.lab

Question 17

First line chemoprophylaxtic treatment in patients undergoing leech therapy?

Answer 17

Ciprofloxacin (A fluoroquinolone).

Question 18

What is injured if an individual is unable to actively extend their MCP joint but is able to maintian it extened after passive extension?

Answer 18

sagittal band injury.

Question 19

What is retracted laterally and what is retracted medially in volar henry approach?

Answer 19

radial nerve is deep to brachioradialis and is retracted Laterally

Supinator, FCR, radial artery and PIN is retracted medially

Question 20

Tendon transfer for wrist drop?

Answer 20

pronator teres to ECRB

Question 21

Tendon transfer for loss of finger extension seen after obstetric brachial plexopathies?

Answer 21

FCR or FCU to EDC 2-5

Question 22

Tendon transfer for thumb abduction after obstetric brachial plexopathy?

Answer 22

EIP to abductor pollicis brevis.

Question 23

Answer 23

When the Lunotriquetral ligament is disrupted the scaphoid’s influence on lunate position is unchecked and the lunate gradually flexes with the scaphoid.

This leads to volar intercalated semental instability (VISI)

Normal is on average 47 degrees.

Visi is the < 30 degrees

Volar aspect of lunotriquetral ligment stronger. Dorsal side of SL ligament stronger.

Question 24

What is the most likely cause for persistent DRUJ incongruity after anatomic reduction and fixation of a Gaeleazzi fracture?

Answer 24

Interposed extensor carpi ulnaris tendon.

Question 25

What are the wrist arthroscopy portals?

Answer 25

Question 26

After a peripheral nerve injury function is lost distally in what order?

Answer 26

Motor function

proprioception

light touch sensation

temperature

pain

sympathetic activity

Returns in reverse order.

Question 27

What are the areas of compression of radial tunnel syndrome?

Answer 27

Arcade of Froshe, distal edge of the supinator, fibrous bands of superficial to the radiocapitellar joint.

Treated with activity modification, exhaustive physical therapy, and night bracing for at least a year.

Question 28

What tendons are involved in Intersection syndrome?

Answer 28

Second extensor compartment.

ECRB and ECRL

Question 29

What hand injuries are dorsal extenion block splinting the treatment of choice?

Answer 29

Fracture dislocation of the PIPJ that are stable following reduction and have less than 40% articular surface fracture involvement.

Question 30

Can you repair a flexor tendon with 75% laceration with epitendinous suture alone?

Answer 30

Yes

Same rates of gap fomration whether you use a core suture in addition or not based on Haddad et al.

Somewhat controversial

Question 31

How do you decide on volar vs dorsal approach for a scaphoid fracture?

Answer 31

Volar: Distal pole and waist fractures especially if there is a humpback deformity.

Dorsal: Proximal pole fratures.

Question 32

What is the recommended treatment for a symptomatic non-union of the pisiform?

Answer 32

Pisiformectomy.

Question 33

What is an Elson Test?

Answer 33

With the PIP joint in 90 degrees of flexion over a table ask the patient to extend the finger against resistance.

If central slip is intact. DIP will remain supple

IF central slip is distrupted DIP will be rigid

Question 34

What is a rugby jersey finger?

Answer 34

Avulsion of the flexor digitorum profundus tendon.

Question 35

What is different about irrigation of flexor tenosynovitis in the thumb and small finger?

Answer 35

In the thumb the irrigation must go to the level just distal to the carpal tunnel.

In the small finger if the ulnar bursa is onvolved a second catheter is palced from the A1 pulley to the wrist.

The other digits catheter is placed from the DIP to just proximal to the A1 pulley.

Question 36

What is more common a dorsal or volar CMC dislocation?

What ligament is torn?

Answer 36

Dorsal dislcoation

Dorsoradial ligament.

Mechanism is axial loading with a flexed MC joint.

Question 37

What structure blocks the reduction of the ulnar collateral ligament in a Stener lesion?

Answer 37

adductor pollicis aponeurosis.

Innervated by the ulnar nerve.

Question 38

What is the position of the finger when there is a contracture of the oblique or transverse band of the retinacular ligament?

Answer 38

Will lead to PIP flexion and DIP extension or a Boutonniere Deformity.

Question 39

What deformity wi;; upi see attenuation of the transverse bands or oblique bands of the Retinacular ligament?

Answer 39

Swan neck deformity.

Question 40

Contracture of the triangular ligament leads to what deormity?

Answer 40

Swan neck deformity.

Question 41

WHat annular ligaments are biomechanically most important and prevent bow stringing?

Answer 41

A2 and A4.

Question 42

What structures overlie the MP, PIP, and DIP joints and originate from the palmar plate?

Answer 42

A1, A3, and A5 respectively.

Question 43

Describe the pulley system of the thumb.

Answer 43

Oblique pully is most important pulley in the thumb. Facilitates full excursion of FPL and prevents bowstringing.

Annular pulleys A1, Av, and A2

Question 44

Which Flexor pulley is most important to reconstruct in the digits?

How should it be reconstructed?

Answer 44

A2 pulley.

Use 3 loops(strongest construct) around bone. Can be palmaris, plantaris, FDS, or flexor tendon allograft.

Need to excise all scar dorsalto tendon so that tendon sits right against bone.

Pass deep to extensor mechanism. In A4 pulley reconstruction pass superfiial to extensors and only two loops are needed.

Question 45

What population most commonly has closed flexor pulley ruptures?

Answer 45

Rock climbers.

Question 46

What should be done for a mass that is firm, round, and does not move with finger motion at the bass of the middle finger?

Answer 46

Needle aspiration.

This is most likely a A2 retinacular cyst.

Question 47

For bowstringing in the thumb to occur what pulleys must be disrupted?

Answer 47

Oblique and A1.

Bowstringing will not occur if only one is disrupted.

Question 48

What is normal and fuctional motion in the wrist for

Flexion

Extension

Radial Deviation

Ulnar Deviation

Answer 48

65 normal 10 functional

55 normal 35 functional

15 normal 10 functional. 90% is midcarpal motion.

35 normal 15 functional

Question 49

What percent of load is typically borne through the radius and the ulna in the wrist?

Answer 49

80% Radial

20% Ulnar

Question 50

What is the Space of Poirier?

Answer 50

Central weak area of the wrist in the floor of the carpal tunnel at the level of the proximal capitate.

Between the volar radioscaphocapitate ligament and volar long radiolunate ligament.

Area of weakness small with flexion and larger with extension.

In perilunate dislocations this space allws the distal carpal row to separate fom the lunate and in lunate dislocation the lunate escapes to this space.

Question 51

What ligament should be preserved and why when dling a proximal row carpectomy?

Answer 51

Radioscaphocapitate

Primary stabilizer of the wrist and prevents ulnar drift.

Question 52

What ligament is abnormal in Madelung’s deformity?

Answer 52

Long radiolunate

Also called radiolunotriquetral or volar radiolunate ligament.

Question 53

What ligaments have the uln prefix and what ligaments have the rad prefix?

Answer 53

The ulnocarpal ligaments are volar

ulnotriquetral, ulnolunate, and ulnocapitate

The dorsal radiocarpal ligaments are dorsal

Radiotriquetral, radiolunate, radioscaphoid and dorsal intercarpal

All are extrinsic ligaments.

Question 54

What is the primary stabilizer of the scapholunate joint?

Answer 54

Scapholunate ligament

3 components

Dorsal: thickest and strongest. Prevents translation

Volar: prevents rotation

Proximal: adds nothing.

Question 55

What determines nerve conduction velocity (NCV)?

Answer 55

Myelin thickness

Internode distance

Temperature

Age: Newborns are 50% of adult values, 1 year olds are 75% of adult values. Not until 5 years old are values 100% of adult values.

NCV =Distance divided by latency.

Question 56

What is a standard stimulus for a nerve conduction velocity test?

Answer 56

.1 to .2ms square wave.

Question 57

What is more specific of demyelination. Increased latencyies or decreased conduction velocites?

Answer 57

Increased latencies.

Distal sensory latency of > 3.2ms are abnormal for CTS

Motor latency > 4.3ms are abnormal for CTS

Velocity of < 52m/sec is abnormal.

Question 58

What is significant about amplitude, duration, and late responses with regard to nerve conduction velocity test?

Answer 58

Amplitude provides estimate of number of functioning axons and muscles

Duration reflects range of conduction velocities and synchrony of contraction of muscle fibers. If there are axons with different CVs this signifies acute demyelination and duration will be greater.

Late responses such as F-wave amplitude and H-reflex evaluate proximal nerve lesions hear the spinal cord

Question 59

What are the different types of activity on electromyography?

Answer 59

Insertional acivity

Contraction activity

Spontaneous activity: This includes normal spontaneous activity and abnormal spontaneous activity.

Question 60

What are examples of normal spontaneous activity on electromyography?

Answer 60

End plate potentials

End plate spikes

Question 61

What is insertional activity on an EMG?

Answer 61

shows state of muscle and innervation nerve as needle is inserted.

Normal muscle should have baseline electrical activity.

Reduced insertional activity occurs after prolonged denervation. Muscle undergoes fibrosis.

Abnormal insertional activity (>300-500ms) shows early denervation: Ex polymyositis, myotonic disorders, and myopathies

Question 62

What are abnormal spontaneous activites on EMG?

Answer 62

Indicates some nerve/muscle damage.

Sharp waves

Fibrillations

Fasciculations

Complex repetitive discharges

Myokimic discharges

Question 63

What are fibrillations on EMG?

Answer 63

Spontaneous action potentials from single muscle fibers caused by oscillations in resting membrane potential of denervated fibers.

Seen 3-5 wks after nerve lesion begins and stays until it resolves or muscle becomes fibrotic.

Can also be seen in muscle disorgers such as muscular dystrophy

Question 64

What are fasciculations on EMG?

Answer 64

Spontaneous discharge of a group of muscle fibers.

Found in ALS, progressive SMA, and anterior horn degenerative diseases such as polio or syrongomeyelia.

Seen as undulating bag of worms on physical exam.

Question 65

For the image below describe for each what you would find in regards to insertional activity, spontaneous activity, minimal activity, and interference.

Answer 65

Question 66

What are the indications for surgery of a phalanx fracture?

Answer 66

>2mm of shortening, > 10 degrees angulation, open fractures, displaced intra-articular fractures.

For every 1mm of shortening the PIPJ will develop a 12 degree extensor lag.

Question 67

What is Froment’s sign?

Answer 67

Obligatory thumb and index finer IPJ flexion to compensate for weakness of the adductor pollicis.

Seen in compressive neuropathies of the ulnar nerve.

Question 68

True or false a cyst in Guyon’s canal may cause motor, sensory, or mixed motor-sensory ulnar nerve symptoms?

Answer 68

True. This is becuase there are three zones.

Zone 1 proximal to bifurcation of the nerve -> both motor and sensory

Zone 2 surrounds the deep motor branch and will cause isolated motor symptoms

Zone 3 is further distal surroudning the superficial sensory branch and compression will only cause volar sensory symptoms.

Question 69

What is the pathophysiologic pathway of tendon healing in flexor tendon lacerations?

Answer 69

Two Intrinsic and extrinsic

Intrinsic: produced by tenocytes within the tendon.

Extrinsic: stimulated by surrounding synovial fluid and inflammatory cells. Implicated in the formation of scarring and adhesions.

Question 70

What are the phases of tendon healing.

Answer 70

Question 71

What are flexor tendon zones?

What is the treatment based on each zone?

Answer 71

Question 72

How does Flexor tendon injuries and their management in the thumb differ from those in the digit?

Answer 72

Early motion protocols do not improve long-term results

There is a higher re-rupture rate

Question 73

What management is recommended for a flexor tendon laceration through 55% of the tenond?

What can this management be associated with?

Answer 73

wound care and early range of motion.

Gap formation or triggering.

Question 74

What treatment is recommended for a chronic FPL rupture?

Answer 74

FDS4 transfer to thumb

Question 75

What is ideal timing for a primary flexor tenon repair?

Answer 75

within 2 weeks but can be done up to 3 weeks out.

Question 76

Answer the following questions about flexor tendon repair:

True or false locking-loops decrease gap formation?

True or false ideal suture purchase is 5mm from cut edge?

Core sutures placed where are stronger?

Answer 76

True

False, 10mm is ideal.

Dorsally

Question 77

What is non-operative Rehab for a flexor tendon with a %50 laceration?

Answer 77

Early ROM

Wrist and MP flexed in dorsal splint.

PIP and DIP extended

Passive digital flexion with wrist flexed.

Wait until 8 weeks post injury to begin strengthening.

Question 78

For a FDS repair should one or two slips be repaired?

Answer 78

Repair of one slip is sufficiect in zone 2 injuries because of the improvement in gliding.

Question 79

What are some of the ways tendon repairs fail?

Answer 79

Tendon repairs are weakest between postoperative day 6 and 12.

Repair usually fails at suture knots.

Repair site gaps> 3mm are associated with an increased risk of repari failure

Question 80

What is the dosing for tumescent local anesthesia for tendon repairs?

Answer 80

Used in wide awake tedon repairs. No tourniquet, no sedation.

epinephrine 1:100,000(can use 1:400,000 to 1:1000) and 7mg/kg lidocaine

If using 50-100cc dilute by half. If using 100-200 dilute down to .25% lidocaine.

2ml in proximal and middle phalanges, 1ml distal phalanx, and 10-15ml in palm

Question 81

What are the requirement for a flexor tendon reconstruction?

Answer 81

Supple skin

Sensate digit

Adequate vascularity

Full passive range of motion of adjacent joints.

Question 82

How often is a tenolysis required after a flexor tendon reconstruction?

Answer 82

50%

Question 83

How long after placement of a silastic rod do you return for tendon reconstruction?

Answer 83

3-4 months

Question 84

What method of tendon reconstruction is this?

What are the advantage and disadvantages?

Answer 84

Paneva-Holevich. Other method is Hunter-Salisbury.

Advantages: Graft size(FDS) is knonw at time or silicone rod selection. FDS graft is intrasynovial so fewer adhesions. Relies on only 1 tenorrhapy site to heal at a time.

Disadvantage: Graft tensioning is at the distla end during stage II.

Question 85

When should a Tenolysis be perfomed?

Answer 85

At least after 3 months but preferably 4-6 months when soft tissue has stabilized and full passive motion of all joints is present.

Must be followed with extensive therapy.

Question 86

Describe the Duran protocol for tendon repari rehab?

Answer 86

Early passive motion protocol

Low Force

Low Excursion

Active finger extension with patient-assisted passive finger flexion and static splint.

Question 87

Describe the Kleinert protocol for post-op tendon repair rehab.

Answer 87

Early passive motion protocol

Low Force

Low Excursion

Active finger extension with dynamic splint-assisted passive finger flexion.

Question 88

Describe the Mayo synergistic splint for post-op tendon repair rehab.

Answer 88

Early passive motion protocol

Low Force

High Excursion

Adds active wrist motion wich increases flexor tendon excursion the most.

Question 89

Describe early active motion postoperative rehab protocol for flexor tendon repairs.

Answer 89

Moderate force and potentially high excursion

Dorsla blocking splint limiting wrist extension

Perform place and hold exercises with digits.

Question 90

What is the quadriga effect?

Answer 90

Question 91

What is the rerupture rate of flexor tendon repairs?

What is the recommended treatment?

Answer 91

15-25%

If <1cm of scar is present, resect the scar and perform primary repair.

If >1cm of scar is present perform tendon graft. If sheath is intact and allows passage of a pediatric urethral catheter or vascular dilator perform primary tendon grafting. Otherwise perfrom staged grafting.

Question 92

What is a lumbrical plus finger?

Answer 92

Paradoxical extension of the IP joints while attempting to flex the fingers.

Question 93

What finger is most commonly involved in a Jersey finger injury?

Answer 93

Ring finger 75% of cases

5mm more prominent during grip in 90% of patients.

Question 94

How should a jersey finger be repaired?

What is the risk of advancement > 1cm?

What postoperative rehab should be used?

Answer 94

See image

DIP flexion contracture or quadrigia

Duran or Kleinert. Both early passive motion protocols.

Question 95

What digit and what zone is most commonly involved in a extensor tendon injury?

Answer 95

Long finger

Zone VI- Disruption over the metacarpal. Nerve and vessel injury is likely.

Question 96

What are the zones of extensor tendon injuries?

Answer 96

Question 97

When is immobilization with early protected motion appropriate for a extensor tendon injury?

Answer 97

Lacerations <50% of tendon in all zones if patient can extend digit against resistance.

Question 98

What treatement is recommended for a closed central slip injury?

Answer 98

PIP extension splinting

Full time for six weeks. Part-time for 4-6 weeks.

Maintain DIP flexion.

Question 99

What treatment is recommended for a closed sagittal band rupture?

Answer 99

Full-time splinting for 4-6 weeks.

Question 100

What treatment is recommended for a mallet finger injury with a congruent and supple joint that occured 14 weeks ago?

Answer 100

Same as acute mallet finger and non-displaced bony mallet.

full time splinting 6 wks.

Then part time splinting for 4-6 wks.

Maintain PIP motion and avoid hyperextension which may cause skin necrosis.

Question 101

How would you treat an acute bony mallet finger with P3 volar subluxation?

Answer 101

Closed reduction and percutaneous pinnin through DIP joint. OR

Extension block pinning. OR

ORIF if it involves >50% of the articular surfrace.

Question 102

True or false incisions for extensor tendon repeairs can cross the joints?

Answer 102

Yes this is true unlike the palmar side.

Question 103

When should early active short-arc motion(SAM) be used in extensor tendon injuries?

Answer 103

After central slip repair.

Advantages over static immobilization: Increaes total arc of motion, decreases duration of therapy, increases DIP motion, and creates 4mm of tendon excursion and prevents adhesions.

Question 104

What is the pupose of a yoke splint?

What are its advantages over static immobilization and dynamic splinting?

Answer 104

Positions the involved MCP joint in hyperextension relative to adjacent digits.

Used after zone 4-7 extensor tedon repairs

Increased early active ROM, Decreases strain on tendon and prevents adhesions, eary for patient compliance, and earlier return to work.

Question 105

What zones and patient populations are adhesions more common in extensor tendon injuries?

Answer 105

Zone IV and Zone VII

Older patients.

Question 106

When do extensor tendon ruptures occur after repair, to whom, and how often?

Answer 106

Most requently during first 7-10 days post-op

Those undergoing aggressive therapy or non-compliant patients.

5%

Question 107

What is the recommended treatment for a 10 week old non-bony mallet finger injury?

Answer 107

Extension splinting of DIP joint for 6-8 weeks for 24 hours daily in injuries < 12 weeks old.

Volar splinting, avoid hyperextension.

Begin progressive flexion exercises at 6 weeks.

Question 108

What are the absolute and relative indications for CRPP vs ORIF of a mallet finger injury?

Answer 108

Absolute: volar subluxation of the distal phalanx

Relative: >50% of articular surface involved

>2mm articular gap

Question 109

Why does a swan neck deformity occur after mallet finger injury?

What is the treatment?

Answer 109

Attenuation of volar plate and transverse retinacular ligament at PIP joint -> Dorsal subluxation of lateral bands -> PIP hyperextension -> contracture of triangular ligament which maintains deformity.

Lateral band tenodesis, FDS tenodesis, Fowler central slip tenotomy for deformities <35 degree extensor lag.

Minimal swan neck deformities may correct with treatment of the DIP patholgoy alone.

Question 110

What is a non-traumatic cause of sagittal band rupture?

Answer 110

Rheumatoid arthritis

traumatic form is known as “boxer’s knuckle”

Middle finger most commonly involved

9:1 radial to ulnar sagittal band involvement.

Question 111

What is the primary stabilizer of the extensor tendon at the MCP joint?

What is the secondary stabilizer?

Answer 111

Sagittal Band- resists ulnar deviation during flexion and prevents bowstringing during hyperextension

Juncturae tendinum

Question 112

What is pseudo-triggering in the hand?

Answer 112

snapping that takes place from subluxation and relocation of the extensor tendon in a sagittal band injury.

Need to recognize in order to avoid unnecessary trigger release surgery.

Question 113

When do you do a Kettlekamp procedure for a sagittal band injury and when do you do a realignement procedure?

Answer 113

Kettlekamp = Direct repair: Used for chronic injuries (more than one week) where primary repair is possible. Athletes for quicker rehab and return to sport.

Realignment is a extensor centralization procedure. Used when it is a chronic injury where primary repair is not possible.

Question 114

What is defined as an acute injury that can undergo extension splinting or yoke splint for 4-6 weeks regarding sagittal band injuies?

Answer 114

Within one week.

Question 115

What is the Rehabilitation protocol for a safittal band repair?

Answer 115

0-4 wks resting splint MPs and IPs at 0 degrees

2 wks begin motion splint with MPs at 0 degrees, IPs free, do this for most of the day.

4-8 wks AROM with progressive strengtheing at 8 weeks.

Question 116

What area is the most commonly fractured in adult scaphoid?

Children?

Answer 116

Waist 65% of the time. Distal third least common

Distal pole is most common due to ossification sequence.

Question 117

What is the rate of AVN with a proximal 5th scaphoid fracture

Proximal 3rd?

Answer 117

100%

33%

Question 118

How do you obtain a scaphoid view radiograph?

Answer 118

30 degree wrist extension with 20 degrees of ulnar deviation.

Question 119

What is the most sensitive test to identify a scaphid fracture within 24 hours of injury?

Answer 119

MRI. This modality also provides an assessment of vascular status of bone. Proximal pole AVN best determined on T1 sequences.

Bone scan can be effective at 72 hours.

Question 120

Is there a consensus for long arm spica vs short arm spica casting for scaphoid fractures?

Answer 120

No

Question 121

When can athletes return to play after a scaphoid fracture?

Answer 121

Not until imaging shows a healed fracture.

Pulsed electromagnetic field studies have shown to be beneficial in cases of delayed union.

Question 122

What duration of casting is recomended for the following scaphoid fractures:

Distal waist

Mid waist

Proximal third

Answer 122

3 months

4 months

5 months

fxs with <1mm of displacement have union rate of 90%

Question 123

What is really the only difference between non-displaced scaphoid waist fractures treated with screw vs non-op?

Answer 123

Time to union

screw 6-7 weeks

Non-op 12 weeks

Question 124

When is ORIF or perc screw fixation of a scaphoid indicated?

Answer 124

Proximal pole fractures

displacement >1mm

15 degree humpback deformity

Radiolunate angle > 15 degrees (DISI)

Intrascaphoid angle of > 35 degrees

Associated with perilunate dislocation

Comminuted fractures

unstable vertical or oblique fractures

Question 125

What approach is recommended in scaphoid waist and distal pole fractures?

How about Humpback deformity?

Answer 125

Volar approach

Use interval bewteen the FCR and the radial artery

Allows exposure of the entire scaphoid

Question 126

What mechanism can lead to a lunate dislocation?

What is the pathoanatomy sequence of events?

Answer 126

When wrist is extended and ulnarly deviated.

Scapholunate ligament disrupted -> disruption of capitolunate articulation -> disruption of lunotriquetral articulation -> failure of dorsal radiocarpal ligament -> lunate rotates and dislocates usually into carpal tunnel.

Question 127

What is the “piece-of-pie” sign on a wrist radiograph?

Answer 127

Triangular appearance of lunate.

Due to palmar rotation from dorsal force of carpus.

Question 128

What further treatment is recommended for a perilunate dislocation that is succesfully reduced, has no median nerve symptoms?

Answer 128

Splinting should be followed by open reduction, ligament repair, fixation, +/- carpal tunnel release.

All acute injuries <8 weeks old.

Question 129

What treatment is recommended for chronic lunate or perilunate dislocations?

Answer 129

Proximal row carpectoomy if not severe degenerative changes. If severe degenerative changes then total wrist arthrodesis.

Chronic injuries are not uncommon as initial diagnosis is missed up to 25% of the time.

Question 130

What is transient ischemia of the lunate?

Answer 130

radiodense appearance of the lunate on radiograph reported in up to 12.5% of lunate dislocations.

Identified 1-4 months post lunate or perilunate dislocation.

Benign and self-limiting, treat with observation.

Do not confuse with Kienbocks

Question 131

what population are hook of hamate fracture most often seen in?

Answer 131

Golf, baseball, and hockey players.

Typically caused by a direct blow such as grounding a golf club or checking a baseball bat.

Bewar of a bipartate hamate, which will have smooth cortical surfaces.

Question 132

How do you peform the hook of hamate pull test?

Answer 132

Hand held in ulnar deviation as patient flexes DIP joints of the ulnar 2 digits. The flexor tendons act as a deforming force on the fracture site. Positive test elicits pain.

Question 133

What is the first line of treatment for a pisiform fracture?

Answer 133

short arm cast with 30 degrees of wrist flexion and ulnar deviation for 6-8 weeks.

Outcome is good.

Question 134

What treatment is recommended or severly displaced and symptomatic fractures or painful non-unions of the pisiform?

Answer 134

Pisiformectomy

Studies show is a reliable way to relieve this pain and does not impair wrist function.

Question 135

What are the two mechanisms of TFCC injury?

Answer 135

Type 1: tramatuic injury. Most common is a fall on extended wrist with forearm pronation. Can also be from a traction injury to ulnar side of wrist.

Type 2: Degenerative injury. Associated with positive ulnar variance and assocaiated ulnocarpal impaction.

Question 136

What imaging techniques are useful for identifying a TFCC tear?

Answer 136

Radiographs- Usually negative but may see some pathology on a PA zero rotation or dyanmic pronated view -> ulnar variance

Arthorgraphy- Can see dye extravasation

MRI- Has replaced arthrography

Arthroscopy- Most accurate diagnosis

Question 137

What is your differential for Ulnar Sided Wrist Pain?

Answer 137

Question 138

What is imporant about distinguishing greath than 2mm or less than 2mm ulnar postivie variance in TFCC degenerative conditions?

Answer 138

> 2mm need diaphyseal shortening

<2mm you can use a wafer procedure

Question 139

What is the recommended treatment for acute (<3months) TFCC injuries?

What are the outcomes?

Answer 139

Arthroscopic debridement for type 1A and arthroscopic repair for all other.

patients should expect to regain 80% of motion and grip strength.

Question 140

What are general indications for operative treatment of metacarpal fractures?

Answer 140

Open and intra-articular fxs

Rotational malalignment of the digit

Multiple metacarpal shaft fractures

Anything outside of acceptable criteria for non-operative treatment.

Instability at a border digit.

Question 141

Acceptable indications for non-operative treatment of metacarpal fractures?

Answer 141

Question 142

What metacarpal head fractures should be treated operatively?

Answer 142

Almost all.

No degree of articular displacement acceptable.

In cases of severely comminute fractures consider external fixation or MCP arthroplaty.

Question 143

Which direction and by which mechanism are MCP joints most often dislocated?

Answer 143

Dorsally

Caused by a fall onto hyperextended MCP joint.

Index finger is most commonly involved.

Avulsion of the volar plate from metacarpal neck

Question 144

What is a kaplan injury with regards to the hand?

Answer 144

Metacarpal head buttonholes into palm

Volar plate is interposed between base of proximal phalanx and metacarpal head

Most common in the index finger.

Question 145

In addition to volar plate what structures can block reduction of a MCP dislocation?

Answer 145

Notaotry ligamenets distally

Superficial transverse metacarpal ligament proximally.

This is an example of a complext dislocation that should be reduced open.

Question 146

What type of immobilization should be used after MCP dislocations?

Answer 146

Dorsal blocking spling in 30 degrees of flexion.

Early ROM after 2 weeks.

Question 147

What deformity is most commonly expected in a proximal phalanx fracture?

Answer 147

Apex Volar

Proximal fragment pulled into flexion by interossei

Distal fragment pulled into extension by central slip

Question 148

What are the accpetable limits for non-operative treatment of a middle or proximal phalanx fracture?

Answer 148

<10 degrees of angulation

<2mm shortening

No rotational Deformity

non-displaced intraarticular fractures.

Question 149

Indications for operative treatment of a distal phalanx fracture?

Answer 149

Displaced or irreducible shaft fractures

Dorsal base fractures with >25% articular involvement

Displaced volar base fractures with large fragment and involvement of FDP.

Non-unions

Question 150

How do you assess the competency of collateral ligaments in a PIP dislocation?

Answer 150

Lateral stress with the joint in 30 degrees of flexion.

Grade 1- pain with no laxity

Grade 2- laxity with firm endpoint and stable arc of motion

Grade 3- gross instability with no endpoint

competency of secondary stabilizers (bony anatomy, accessory collateral ligaments, volar plate) are assessed when the joint is stressed in extension.

Question 151

What is the v-sign with regards to phalanx dislocation?

Answer 151

dorsal widening of the joint seen on a lateral radiograph.

Indicates subtel subluxation

Question 152

Dorsal dislocations of the PIP joint lead to what deformity?

Answer 152

Swan neck deformity.

Question 153

Volar dislocations of the PIP joint can lead to what kind of deformity?

Answer 153

Boutonniere deformity

Question 154

How should a volar PIP dislocation be immobilized after reduction and for how long?

Answer 154

Extension splinting for 6-8 weeks.

Question 155

How should a dorsal PIP dislocation that is unstable after reduction be treated?

Answer 155

Extension block splinting fo 6 weeks.

Question 156

In failed closed reductions of the following PIP joints what is the most likely structure preventing reduction:

Closed dorsal dislocation?

Open dorsal dislocation?

Lateral dislocations?

Rotatory Volar?

Answer 156

Volar plate interposition

Dislocated FDP tendon

Lateral band interposition

Proximal phalangeal condyle buttonholes bewtween central slip and lateral band.

Question 157

What fracture is most commonly seen with dorsal PIP fracture dislocation?

Answer 157

volar lip fractures

Hyperextension leads to failure of the volar plate resulting in rupture or avulsion of the middle phalangeal volar lip

Question 158

What fracture is most common with volar PIPJ fracture-dislocations?

Answer 158

Middle phalangeal dorsal lip

Hyperflexion leads to failure of the central slip resulting in rupture or avulsion of the middle phalangeal dorsal lip.

Question 159

How do you determine whether to reat a PIPJ fracture dislocation closed with splinting vs operative treatment?

Answer 159

<40% involved can treat with extension block or extension splinting.

If >40% and unstable then CRPP vs ORIF.

Question 160

What structures need to be resected or reflected in order for adequate exposure of the volar plate?

Answer 160

Proximal portion of C2 pulley

Entire A3 pulley

Distal C1 pulley

Question 161

When might you use dynamic distraction external fixation of a PIPJ injury?

Answer 161

Highly comminuted pilon fracture-dislocations.

Question 162

When might you consider volar plate arthroplasty after a DIPJ injury?

Answer 162

When >40% of the joint is involved and the joint is unstable.

Question 163

Why is there an inbalance creats the deformity in a seymour fracture of the distal phalanx?

Answer 163

Imbalance occurs fue to different insertion sites of the flexor and extensor tendons.

Extensor tendon inserts into the eipiphysis of the distal phalanx.

Flexor tendon inserts ino metaphysis of the distal phalanx.

Question 164

How do you differentiate a pediatric mallet finger from a Seymour fracture?

Answer 164

Mallet finger fracture line enters DIPJ

Seymour fracutre line traverses physis and does not enter DIPJ

Question 165

How do you get a true AP and Lateral of the thumb?

Answer 165

True AP or Robert’s View: arm in full pronation with forsum of thumb on cassette

Ture lateral of thumb: Hand pronated 30 degrees and bean angled 15 degrees distally

Question 166

What sign on radiograph is indicative of a Rolando Fracture?

Answer 166

The Y-sign.

Represents a split of the 1st metacarpal base into volar and dorsal fragments.

Question 167

What fractures of the thumb might you consider distraction and external fixation?

How do you set up the construct?

Answer 167

Fractures with major soft tissue injury.

Severly comminuted or fractures with impacted articular fragments

Fractures with fragments too small for ORIF

Two 3mm pins are placed in the dorsoradial aspect of the distal shaft of the metacarpal

Tmow 3mm pins are placed in the dorsoradial aspect of the radius

Pins may be placed into the second metacarpal shaft to control deforming forces.

Question 168

What base of thumb fractures can be treated with closed reduction and thumb spica casting?

Answer 168

Extra-articular fractures with <30 degrees of angulation following closed reduction.

Bennett fractures with <1mm displacement

Reduction is achieved with longitudinal traction, palmar abduction, and pronation.

Question 169

What two ligaments are most important for stability ot the thumb CMC joint?

Answer 169

There are 16 total ligaments that stabilize the TMC joint.

4 key ligaments: Anterior oblique ligaments (remains attached to volar fragment in Bennett/Rolando fracture), Posterior oblique ligament, Intermetacarpal ligament, and dorsoradial ligament.

Two most important are anterior oblique ligament and dorsoradial ligament(If all other ligaments but this one are cut the CMC still remains reduced.

Question 170

What is the recommended treatment for a thumb CMC dislocation that is unstable after reduction?

Answer 170

Closed reduction and temporary pinning.

This should be followed by dorsal capsuloligamentous complex with tendon autograft + temporary pinning.

Better abduction and pinch strength than closed reduction and pinning

Question 171

How do you decide when to treat a thumb collateral injury non-operatively vs operatively?

Answer 171

<20 degrees of side to side variation of varus/valgus instability -> non-op

>20 degrees of side to side instability or > 35 degrees of opening -> operative repair.

Chronic injuries need to be reconstructed with tendon graft, MCP fusion, or adductor advancement.

Question 172

What percent of felon infections have no hisotry of penetrating injury?

Answer 172

50%

May result from bacterial contamination of the fat pad through the eccrine sweat glands.

Question 173

Who might you expect to get a felon infection with the caustive organism Eikenella corrodens?

Answer 173

Diabetic patients who bite their nails.

Question 174

What can happen if a felon infection is left untreated?

Answer 174

Can lead to a “compartment syndrome of the fingertip” but instead of the skin failing it leads to sequestration (osteomyelitis) of the diaphysis of the distal phalanx

Pyogenic arthritis of the DIP joint

Flexor tenosynovitis from proximal extension

Felon infection will not extend proximal to DIP flexion crease unless one of the above has occured.

Question 175

Which has a higher risk of infection Dog or Cat bites?

Answer 175

Cat bites. Small sharp teeth cause puncture wounds that seal immediately. Penetrate tendons and joints.

Dog bites are more likely to cause structural damage.

Question 176

What is the most common pathogen in dog and cat bites?

Answer 176

Pasteurella, but most infections are polymicrobial.

Need to inform lab about potential for pasteurella.

Cultures require appropriate growth media and take 1 wk to grow.

Question 177

What is the difference between the sterile matrix and germinal matrix of the nailbed?

Answer 177

Sterile- tissue deep to the nail but distal to the lunula. Adheres to the nail.

Germinal- Proximal to sterile matrix. Responsible for most of nail development.

Question 178

What is an alternative to suture repair that has a quikcer repair time with comparable cosmetic and functional results?

Answer 178

Dermabond (2-octylcyanoacrylate)

Question 179

What happens when nail matrix is advanced without adequate bony support?

Answer 179

Hook nail.

Need to remove nail and trim matrix to level of bone.

Question 180

Are there any indications for non-operative care of high-pressure injection injury?

Answer 180

Limited, but yes. Air or water.

Treat with tetanus prophylaxis, parenteral antibiotics, limb elevation, monitoring for compartment syndrome, and early mobilization.

Question 181

What is prognosis after a high pressure injection injury most dependent on?

Answer 181

1 Time from injury to treatment. Higher rates of amputation when surgery is delayed greater than 10 hours after injury.

Composition of material. Organic solvents (paint, paint thinner, diesel fuel, jet fuel, oil) cause more soft tissue necrosis (up to 50% amputation rate). Grease, latex, chloroflourocarbon, and water based paints are less destructive.

Force of injection.

Volume injected.

Question 182

What are risk factors for frostbite?

Answer 182

Alcohol abuse

Mental Illness

Peripheral vascular disease

Peripheral neuropathy

Malnutrition

Chronic Illness

Tobacco use and smoking- reduces nitric oxide (vasodilator) and potentiates thrombosis.

Race- African descent more likley because they do not haveas good of the cold induced vasodilation as Caucasians.

Question 183

At what core body temperature is a person considered to be hypothermic?

Answer 183

<35 degrees

Mild 35-32

Moderate 32-28

Severe < 28 degrees

Question 184

What is the classification for frostbite?

Answer 184

1st degree- cnetral whitish area with surrounding erythema

2nd degree- clear/cloudy blisters within 24h

3rd degree- hemorrhagic blisters/ hard black eschars

4th degree- tissue necrosis

Question 185

What imaging can be used to evaluate the severity of the soft-tissue damage from frostbite?

Answer 185

Serial bone scans

1st scan at 2 days after intial injury: Absence of uptake has poor prognosis but may not indicate necrosis.

2nd scan at 5 days after initial injury: Normal blood/bone pool = treat expectantly. Diminished blood/bone pool = observation, with potential early debridement. Absent blodd/bone pool = early debridement or amputation.

Question 186

What is a way you can radiographically tell if a volar distal radius plate is distal to the watershed line?

Answer 186

Soongs line.

Plum line made from the most volar edge of the distal radius proximally.

If a plate is too volar then the patient should be followed for any pain with thumb flexion. If this is present after 3 months the plate should be removed.

Question 187

What is the etiology of Kienbock disease?

Answer 187

Multifactorial

Includes: ulnar negative variance, decreased radial inlcination, vascular congestion from high interosseous pressure, and medical conditions including scloeroderma, sickle cell anemia, SLE, and corticosteroid use.

Question 188

What fingertip injuries can be treated by I&D and healing by secondary intention?

Answer 188

Adults with no bone or tendon exposed and < 2cm of skin loss.

Children are treated the same as above but also can be treated this way even when some bone is exposed.

Do not want to rongeur back bone if it compromises support to the nail.

Question 189

Why are split thickness skin grafts not used in the hand?

Answer 189

Because they are:

Contractile

Tender

Less Durable

Question 190

What should be done on a revision fingertip amputation if flexor or extensor tendon insertions cannot be preserved?

Answer 190

Disarticulate the DIP joint.

Question 191

What flaps should be performed for the following regions?

Answer 191

Question 192

What is the most common cause of finger flap failure?

Answer 192

Inadequate aterial flow and inadequare venous outlfow.

Question 193

What are the cutoffs for ischemia time in amputations proximal to the carpus?

Distal to carpus?

Answer 193

Warm < 6 hours

Cold < 12 hours

Warm < 12 hours

Cold < 24 hours

Question 194

What is the general operative sequence of replantation?

Answer 194

1. Vascular shunt first for proximal replants with large msucle mass to minimize warm ischemia time.
2. Bone fixation +/- shortening after irrigation and debridement
3. Extensor tendon repair
4. Artery repair unless ischemia time is >3 hours then do this after bone.
5. Venous anastomoses
6. Flexor tendon repair
7. Nerve repair
8. Skin +/- fsciotomy

Question 195

What is the finger order for replants in multiply amputated digits?

Should you digit by digit or sturcture by structure?

Answer 195

Thumb, Long, Ring, Small, Index.

Structure by structure is more efficint.

Question 196

Primary indications for for replantation after trauma?

Relative indications?

Answer 196

Thumb at any level, multiple digits, through the palm, wrist level or proximal, almost everything in children.

Individual digit distal to FDS (Zone 1), ring avulsion, through or above elbow.

Question 197

Primary and relative contraindications to replantation?

Answer 197

Primary: Severe vascular disorder, mangled limb or crush injury, segmental amputation, and prolonged ischemia time with large muscle content (>6 hours warm).

Relative: Single digit proximal to FDS (Zone II), medically unstable patient, disabling psychiatric illness, tissue contamination, and prolonged ischemia time with no mu muscle content (>12 hours warm)

Question 198

What environment and dietrary factors are important after a replant?

Answer 198

Keep patient in warm room >80F.

Avoid caffeine, chocolate, and nicotine

Question 199

How can the replant be monitored?

Answer 199

Skin temperature most reliable- concerning changes include a > 2 degree drop in skin temp in less than one hour or a temperature below 30 degrees Celsius

Pulse oximetry- <94% indicates potential vascular compromise

Question 200

How do you manage arterial insufficiency after a replant?

Answer 200

Release any constricting bandages

Place extremity in dependent position

Consider heparinization

Consider Stellate ganglion blockage

Early surgical exploration if previous measures are unsuccessful.

Thrombosis secondary to vasospasm is most common cause of early replant failure

Question 201

How do you manage venous congestion after a replant?

Answer 201

elevate extremity.

Leech application- Rleases Hirudin (powerful anticoagulant). Need prophylaxis with ciprofloxacin.

Use Heparin soaked pledgets if leeches not available.

Question 202

What anticoagualtion is recommended after replatation?

Answer 202

At least one of the following aspirin, dipyridamile, low-molecular weight dextram, or Heparin.

Ensure adequate hydration as well.

Question 203

What are the complications of a replant besides replant failure?

Answer 203

Stiffness- replanted digits have 50% of total motion. Tenolysis is the most common secondary surgery.

Myonecrosis is larger replants -> Myoglobinuria that can lead to renal failure and be fatal

Reperfusion injury- mechanism thought to be related to ischemia-induced hypoxanthine conversion to xanthine.

Infection

Cold Intolerance

Question 204

What medication or therapy can be used to decrease reperfusion injury from xanthine after a replant?

Answer 204

Allopurinol which decreases xanthine production.

Question 205

What is a Wartenberg Sign?

Answer 205

persisten small finger abduction/extension from weakness of the 3rd palmar interosseous/small finger lumbrical.

Question 206

What are the three nerve fiber types based on diameter, myelination, and speed?

Give an example of each.

Answer 206

Question 207

What is the seddon classification of peripheral nerve injuries?

Answer 207

Question 208

What happends to motor action potentials with peripheral nerve injuries?

Answer 208

Motor action potentials decrease in amplitude.

Question 209

What is the optimal time for nerve repair in the case of a GSW to the humerus with a comminuted fracture and radial nerve transection?

Would it be different for a serverely comminuted and open fracture with radial nerve transection?

Answer 209

Optimal time for repair is within 1-3 weeks from injury in order to allow time for the zone of injury to declare itself.

Would be the same in both instances above.

Question 210

What is the difference between epineural repair and fasicular repair?

When is fasicular repair indicated?

What is the difference in outcomes?

Answer 210

Repair the epineurium to approximate ends but no individual fasicles within the epineurium.

In a fasicular repair the perineurium and individual fasicles are approximated and repaired.

Indicated for median nerve in the distal third of forearm, ulnar nerve in distal third of forearm, and sciatic nerve in thigh.

No improvement in outcomes demonstrated wiht fascicular repairs.

Question 211

When should a collagen conduit be used vs autologous nerve grafting?

What are the outcomes between the two?

Answer 211

Collagen conduit defects ideally <2cm but can be used up to 3cm

Autograft for anything >3cm

Up to 5cm outcomes are the same.

> 5cm defects autograft better recovery.

Question 212

What is the blood supply for a lateral arm flap?

Answer 212

posterior radial collateral artery

Branch of profunda brachii

Question 213

how many grades will motor strength decrease after transfer?

Answer 213

Will decrease on grade after transfer.

Should transfer motor grade 5.

Question 214

What is Smiths 3-5-7 rule with regard to tendon transfers?

Answer 214

3cm excursion- wrist flexors, wrist extensors

5cm excursion- EDC, FPL, and EPL

7cm excursion FDS, FDP

Question 215

What are the basic principles of tendon transfer?

Answer 215

Donor must be expendalble and of similar excursion and power

One tendon tranfer performs one function

Synergistic transfers rehabilitate more easily

It is optimal to have a traight line of pull

One grade of motor strength is lost following transfer.

Question 216

What is the most prognostic factor regarding tendond transfers?

Answer 216

Age

worse outcomes after age 30

Location is second, the more distal the better.

Question 217

What are surgical priorities regarding upper extremity function when considering tendon transfers?

Answer 217

1. Elbow flexion (musculocutaneous n.)
2. Shoulder stabilization (suprascapular n.)
3. Brachiothoracic pinch (pectoral n.)
4. Sensation C6-C7 (lateral cord)
5. Wrist extension and finger flexion (lateral and posterior cords)

Question 218

How do you determine if an individaul has a high or low radial nerve palsy?

Answer 218

High= In addition to PIN syndrome will also have loss of function in tricpes, brachioradialis, and ECRL.

Low = PIN syndrome

Question 219

How do you differentiate a low from a high median nerve palsy?

Answer 219

Depends whether the lesion is proximal or distal to origin of AIN

Low- loss of thumb opposition (APB function)

High- Loss of thumb opposition plus loss of thumb, index, and middle finger flexion.

Question 220

What is the difference between low and high ulnar nerve palsies?

Answer 220

Low: Loss of power pinch, wartenberg sign, and clawing (results form imbalance between intrinsic and extrinsisc muscles)

High: Primary distinguishing deficit is loss of ring and small finger FDP funcion. Clawing is less pronounced because flexors are not functioning.

Question 221

What is the general rehab recommended for tendon transfers?

Answer 221

Protect in a splint for 3-4 weeks then begin ROM.

Maintain the splint whne not working on ROM until 6 weeks.

Synergistic transfers are easier to rehabilitate.

Question 222

For the goal function to regain, name the donor tendon and the recipient tendon?

Also what is the palsy that is leading to the dysfunction?

Answer 222

Question 223

What are risk factors for carpal tunnel syndrome?

Answer 223

Female sex, obseity, pregnancy, hypothyroidism, rheumatoid arthritis, advanced age, chronic renal failure, smoking, alcoholism, repetitive motion activities, mucopolysaccharidosis, and mucolipidosis.

Question 224

What is a cause of carpal tunnel syndrome other than repeititive motion activities and trauma?

Answer 224

Space occupying lesions.

gout is an example.

Question 225

What is the most specific test for carpal tunnel syndrome?

Answer 225

Self administered hand diagram (76%0

Question 226

What is Durkan’s test

Answer 226

Pressing thumbs over the carpal tunnel and holding pressure for 30 seconds.

Onset of pain or paresthesias in the median nerve distribution is positive.

Most sensitive test to diagnose carpal tunnel syndrome

Question 227

What is the most sensitive sensory test for detecting early carapl tunnel syndrome?

Answer 227

Semmes-Weinstein testing

Question 228

What dital sensory latency and motor latency is found on NCV tests for carpal tunnel syndrome?

Answer 228

distal sensory latency of > 3.5ms

motor latency of > 45ms

Conducion velocity is less specific than latencies- velocity of < 52m/sec is abnormal.

Question 229

In what patients with carpal tunnel syndrome should you use night splints?

Answer 229

Only useful in patients with nocturnal symptoms.

Question 230

what are the outcomes after a steroid injection for carpal tunnel syndrome?

Answer 230

80% have transient improvement of symptoms.

Of these 20% remain symptom free at one year.

Failure to improve after an injection is a poor prognostic factor and surgery is less effective for these patients.

Question 231

What are the outcoms after carpal tunnel release?

Answer 231

Rate of continued symptoms at 1+ year is 2% in moderate and 20% in severe CTS.

Grip strength is expected to return to 100% preoperative levels by 12 weeks post-op.

pinch strength returns in 6 weeks.

Question 232

What are the outcomes afet revision CTR for incomplete release?

Answer 232

25% will have complete relief after revision CTR

50% some relieft

25% will have no relief

Question 233

Is there any advanatge of an endoscopic carpal tunnel release?

Answer 233

Long term results same as open CTR

only advantage is accelerated rehabilitation

Most common complication is an incomplete division of transverse carpal ligament.

Question 234

When is a lengthening repair of transverse carpal ligament indicated after an open carpal tunnel release?

Answer 234

When a flexor tendon repair is performed at the same time.

Allows wrist immobilization in flexion postoperatively.

Question 235

What cutaneous sensory changes would you expect from compressive neuropathy of the AIN?

Answer 235

None

motor deficits only

Question 236

What are the potential sites of entrapment of the AIN?

Which one is most common?

Answer 236

Most common- tendinous edge of deep head of pronator teres

FDS arcade

edge of lacertus fibrosus

accessory head of FPL (Gantzer’s muscle)

accessory muscle from FDS to FDP

aberrant muscles (FCRB, palmaris profundus)

thrombosed radial or ulnar artery

Question 237

What is a Martin-Gruber anastamoses?

Answer 237

anomalous anatomy in 15% of people where the axons of AIN may corss over and connect to ulnar nerve and innervate other muscle groups.

If an individual has one of these and an AIN palsy they will also present with intrisic weakness

Question 238

If someone has signs of bilateral AIN palsies what should you be concerned for?

Answer 238

Viral brachial neuritis.

Motor loss is preceded by intense shoulder pain and viral prodrome.

Question 239

How do you best ilicit a weak pronator quadratus in a AIN compression neuropathy?

Answer 239

resisted pronation with the elbow maximally flexed.

Question 240

What is the recommended treatment for AIN compressive neuropathy?

Answer 240

observation with elbow splinting in 90 degrees of flexion for 8-12 weeks

Majority improve

Only case where this is not first line of treatment is clear space occupying mass

Question 241

What structures should be released in decompression surgery for AIN compressive neuropathy?

Answer 241

release superficial arch of FDS

laacertus fibrosus

Detach superficial head of pronator teres

Question 242

When should you consider surgical decompression of AIN compressive neuropathy?

Answer 242

clear space occupying lesion

failure of 2-3 months of nonoperative treatment

75% success rate

Question 243

What is pronator syndrome?

In what pateint population is it more commonly seen?

Answer 243

Compressive neuropathy of the median nerve at the elbow.

Women, 5th decade of life, and more associated in those with well-developed forearm muscles

Question 244

What are the five potential sites of entrapment in pronator syndrome?

Answer 244

1. Supracondylar process- residual osseous structure on distal humerus present in 1% of population
2. ligament of Struthers- travels from tip of supracondylar process to medial epicondyle. Do not confuse with arcade of Struthers which is stire of ulnar compression neuropathy in cubital tunnel syndrome.

3. Bicipital aponeurosis (a.k.a. lacertus fibrosus)

4. Between ulnar and humeral heads of pronator teres

5. FDS aponeurotic arch

Question 245

What orther condition is associated with pronator syndrome?

Answer 245

Medial epicondylitis.

Question 246

What characteristics differentiate pronator syndrome from carpal tunnel syndrome?

Answer 246

Aching pain over proximal volar forearm.

Sensory disturbances over the distribution of palmar cutaneous branch of the median nerve (palm of hand) which arises 4 to 5 cm proximal to carpal tunnel.

Lack of night symptoms

Question 247

What treatment is recommended for pronator syndrome?

Answer 247

rest, splinting, and NSAIDs for 3-6 months

When non-operative management fails for 3-6 months then surgical decompression of the median nerve at all 5 possible sites of compression. 80% have relief with this.

Question 248

What is the most common site of compression of the ulnar nerve?

Answer 248

Between the two heads of FCU/aponeurosis.

Question 249

What are the three most common sites of compression of the ulnar nerve?

Answer 249

two heads of FCU/aponeurosis

within arcade of Struthers (hiatus in medial intemuscular septum)

Between Osborne’s ligament and MCL

Less common sites of compression: medial head of triceps, medial intermuscular septum, medial epicondyle, fascial bands within FCU, anconeus epitrochlearis (anomalous muscle from the medial olecranon to the medial epicondyle, and aponeurosis of FDS proximal edge.

Question 250

There are many tests of intrinsic weakness in ulnar neuropathy, but what is a test for extrinsic weakness?

Answer 250

Pollock’s test: Weakness of the two ulnar FDPs

Question 251

What is Jeanne sign that can be found in ulnar neuropathy?

How about Masse sign?

Answer 251

Compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch.

Palmar arch flattening and loss of ulnar hand elevation secondary to weakn opponens digiti quinti and decreased small finger MCP flexion.

Question 252

What will you see on physical exam in a patient with severe ulnar neuropathy?

Answer 252

Interosseous and first web space atrophy

Ring and small finger clawing

Weakened grasp and pinch

Froments sign

Wartenberg sign

Question 253

How often is NSAIDs, activity modification, and nighttime elbow extension splinting succesful for cubital tunnel syndrome?

Answer 253

50%

Question 254

What are the outcomes for in situ ulnar nerver decompression if no denervation has occurred?

Answer 254

80-90%

poor prognosis correlates most with instrinsic muscle atrophy

generally transposition has been show to have equivacal results with greater complication rates.

Question 255

What are the indications for an anterior transposition after ulnar nerve decompression?

Answer 255

Failed in situ release

throwing athletes

Patient with poor ulnar nerve bed from tumor, osteophyte, or heterotopic bone.

Nerve that is unstable after in situ release.

Question 256

If an individual is having persistent posteromedial elbow pain after a ulnar nerve decompression but distal symptoms have mostly improved what is likely the cause?

Answer 256

iatrogenic injury to a branch of the medial antebrachial cutaneous nerve leading to neuroma formation.

Question 257

What is the most common cause of ulnar tunnel syndrome?

Answer 257

Ganglion cyst.

Cause in 80% of nontraumatic cases.

Question 258

What will be seen in cubital tunnel but not ulnar tunnel syndrome?

Answer 258

Cubital tunnel demonstrates:

less clawing

sensory deficit to dorsum of the hand

motor deficit to ulnar-innervated extrinsic muscles

Tinel sign at the elbow

positive elbow flexion test

Question 259

Local surgical decompression of guyon’s canal includes?

Answer 259

Explore and release all three zones of Guyon’s canal.

Release of hypothenar muscle origin

Decompression of any ganglion cysts

Resection of the hook of the hamate

Vascular treatment of ulnar artery thrombosis

Question 260

Tendon transfer to correct claw fingers seen in severe ulnar tunnel syndrome might include?

Answer 260

possible grafts include ECRL, ECRB, and palmaris longus

Tendons must pass volar to transverse metacarpal ligament in order to flex the proximal phalanx.

Attach with either a two or four-tailed graft to the A2 pulley of the ring and small fingers.

Question 261

How would you restore pinch strength lost because of severe ulnar tunnel syndrome?

Answer 261

Smith transfer using ECRB or FDS of ring finger

Question 262

How do you restore adduction of the small finger in severe ulnar neuropathy?

Answer 262

Transfer ulnar insertion of EDM to A1 pulley or radial collateral ligament of the small finger.

Question 263

What are possible causes of PIN syndrome?

Answer 263

Microtrauma- repetitive pronosupination movements

Trauma

Space filling lesions

Inflammation

Iatrogenic

Question 264

What are five potential sites of compression of the PIN?

Answer 264

Fibrous tissue anterior to the radiocapitellar joint- between the brachialis and brachioradialis

Leash of Henry- recurrent radial vessels that fan out across the PIN at the level of the radial neck.

Extensor carpi radialis brevis edge

Arcade of Frohse- proximal edge of the superficial portion of the supinator

Supinator muscle edge

Question 265

What will you notice with wrist extension in a patient with PIN compression syndrome?

Answer 265

The wrist will extend with radial deviation due to intact ECRL (radial n.) and be weak or unable to extend in ulnar deviation due to absent ECU (PIN).

Question 266

When may a lidocaine or corticosteroid injection be indicated for PIN compression syndrome?

Answer 266

When sympomts have been refractory to rest, activity modification, NSAIDs, stretching/splinting, and a compressive mass such as lipoma or ganglion has been ruled out.

Isolated tenderness distal to lateral epicondyle.

Single injection 3-4cm dital to lateral epicondyle at site of compression.

Question 267

What is the most common location of spontaneous entrapment of the PIN?

Answer 267

Arcade of Frohse.

Question 268

How do you differentiate radial tunnel syndrome from PIN compression syndrome?

Answer 268

Radial tunnel syndrome is pain only.

No motor or sensory dysfunction.

EMG/NCS is not useful.

Same sites of compression though.

Question 269

What is the classic symptom of radial tunnel syndrome?

What provocative test will be positive on physical exam?

Answer 269

Deep aching pain in dorsoradial proximal forearm. Extends from lateral elbow to wrist.

Maximum tenderness is 3-5cm distal to lateral condyle

Resisted long finger extension test, resisted supination test, and passive pronation with wrist flexion.

Can perform a radial tunnel injection test which is diagnostic if injection leads to a PIN palsy and relieves pain.

Question 270

What will you see on MRI of a patient with radial cubital tunnel syndrome?

Answer 270

denervation edema/atrophy within the supinator/extensor

May show thickened edge of ECRB with prominent radial recurrent vessels (leash of Henry), and swelling of PIN.

Can also identify other causes of entrapment such as tumors, ganglia, radiocapitellar synovitis, bicipital bursitis, radial head fractures, or dislocations.

Question 271

Why is an EMG/NCV not useul in radial tunnel syndrome?

Answer 271

PIN carries unmyelinated Group IV fibers (C-fibers, nociception) and small myelinated Group IIA afferent fibers (temperature). It is the pressure on these fibers that produces pain.

The large myelinated fibers of PIN remain normal producing normal EMG/NCV

Question 272

How long do you recommend non-operative treatment for radial tunnel syndrome before operative intervention?

Answer 272

one year of activity modification, temporary splinting and NSAIDs.

can try a corticosteroid injection. Both diagnostic and therapeutic. 70% improvement at 6 weeks. 60% pain free at 2 years.

Question 273

What are the outcomes of radial tunnel release?

Answer 273

Not great. Reports vary 50-90 good to excellent results.

Delayed maximal recovery of up to 9-18 months.

Lower success rate in the following groups: concomitant multiple entrapment neuropathies (60%), concomitant lateral epicondylitis (40%), and workers compensation patients (30%).

Question 274

What is Wartenberg’s Syndrome?

Answer 274

Compressive neuropathy of the superficial sensory radial nerve

Question 275

what is cheiralgia paresthetica?

Answer 275

Compressive neuropathy of the superficial sensory radial nerve.

Another name for Wartenberg’s Syndrome.

Question 276

Is Wartengerg’s syndrome more common in women or men?

Answer 276

women 4:1

Question 277

What is the pathoanatomy of wartenberg’s syndrome?

Answer 277

Superficial radial sensory nerve is compressed by scissoring action of brachioradialis and ECRL tendons during forearm pronation.

Also by fascial at its exit site in the subcutaneous plane.

Associated with De Quervain’s disease in 20-50% of cases.

Spontatneous resolution of symptoms is common.

Question 278

What are the symptoms and physical exam findings of Wartenberg’s Syndrome?

Answer 278

ill-defined pain over dorsoradial hand (does not like to wear watch)

paresthesias over dorsoradial hand

numbness, no motor weakness.

Symptoms aggravated by motions involving repetitive wrist flexion and ulnar deviation.

Tinel’s sign over superficial radial nerve is most common exam finding.

Finkelstein test increases symptoms in 96% of patients because of traction on the nerve.

Question 279

What should be included in your differential for Wartenberg’s Syndrome and how can you tell them apart?

Answer 279

De Quervain’s tenosynovitis: pain is not aggravated by wrist pronation.

Lateral antebrachial cutaneous nerve neuritis. Need to make sure tinel is over respective nerve as they can be confused.

Intersection syndrome: symptom exacerbated and a wet leather crepitus on repeated flexion/extension. Also will have dorsoradial forearm swelling.

Question 280

When do you consider surgical decompression for wartenberg’s syndrome?

Answer 280

After 6 months of failed non-operative intervention.

Longitudinal incision volar to Tinel’s sign

Release of fascia between brachioradialis and ECRL.

Question 281

How do you differentiate mild, moderate, and severe capral tunnel syndrome?

Answer 281

Severity is delineated by EMG

Mild: purely sensory

Moderate: prolonged sensory and motor latencies

Severe: Muscle denervation

Question 282

What is a volar cross finger flap used for?

Answer 282

Uncommon, but can be used to close distal thumb amputations.

Question 283

What are some causes of claw hand?

Answer 283

Also known as intrisic minus hand.

Ulnar nerve palsy

Median nerve palsy

Charcot-Marie-Tooth disease

Compartment syndrome of the hand

Failure to splint the hand in an intrinsic-plus posture following a crush injury.

Rare cause is leprosy (Hansens disease)

Question 284

What is the position of the joints in a claw hand?

Answer 284

MCP hyperextension.

PIP and DIP flexion

Remember the EDC is not a significatn extensor of the PIP joint

Question 285

What will happen in a instrinsic minus hand if the MCP joints are brought out of hyperextension?

Answer 285

The flexion deformity of the DIP and PIP will correct.

Question 286

What causes an intrinsic plus hand?

Answer 286

Muscle imblaance between spastic intrinsics(interosseoi and lumbricals) and weak extrinsics (FDS, FDP, EDC)

Can be casued by trauma, neurologic pathology, and rheumatoid arthritis.

Rheumatoid- MCP joint dislocations and ulnar deviation lead to spastic intrinsics.

Question 287

What is Bunnell’s test?

Answer 287

Intrinsic tightness test

differentiates intrinsic tightness and estrinsic tightness

Positive when PIP flexion is less with MCP extension than with MCP flexion.

Question 288

What treatment is recommended for intrinsic plus hand?

Answer 288

passive stretching in mild cases

If that doesn’t work and the deformity is less severe then proximal muscle slide done by subperiosteal elevation of interossei which lengthens muscle-tendon unit.

Severe deformity that involves both MCP and IP joints. Dysfunctional intrinsic muscles that are fibrotic. Then perform resection of intrinsic tendon distal to the transverse fibers responsible for MCP joint flexion.

Question 289

What is the pathoanatomic sequence of a boutonniere deformity?

Answer 289

Rupture of central slip- cases the extrinsic extension mechanism from EDC to be lost -> prevents extension at the PIP joint.

Attenuation of triangular ligament- causes intrinsic muscles of the hand (lumbricals) to act as flexors at the PIP joint. Lumbricals also extend the DIP joint without an opposing or balancing force.

Palmar migration of collateral bnads and lateral bands- The lumbricals’ pull becomes unopposed, pulling through the base of the distal phalanx and volar to the PIP. Causes PIP flexion and DIP extension.

Question 290

When might you consider lateral band relocation vs terminal tendon tenotomy vs tendon reconstruction?

Answer 290

Chronic boutonniere deformity after flexible range of motion it obtained with therapy or surgical release.

terminal tendon tenotomy, never central slip tenotomy.

Secondary tendon reconstruction and triangular ligament reconstruction.

Question 291

What is the primary lesion in a Swan neck deformity?

Answer 291

lax volar plate that allows hyperextension of PIP.

Can be caused by rheumatoid arthritis, trauma, and generalized ligament laxity.

Question 292

What is the secondary lesion is a swan neck deformity?

Answer 292

imbalance of forces on the PIP joint. PIP extension force that is greater than the PIP flexion force.

Causes of this include:

Mallet injury- transfer of DIP extension force to PIP extension force

FDS rupture- leads to unopposed PIP extension combined with loss of integrity of the volar plate

Intrinsic contracture- tethering of the lateral (collateral) bands by the transverse retinacular ligaments as a result of PIP hyperextension. If the collateral bands are tethered excursion is restricted and the extension force is not transmitted to the terminal tendon, and is instead transmitted to the PIP joint.

MCP joint volar subluxation- caused by rheumatoid arthritis

Question 293

What is the treatment of a swan neck deformity?

Answer 293

Non-operative is a double ring splint

Operative: volar plate advancement and PIP balancing with central slip tenotomy (Fowler tenotomy which is done distally). only done for a progressive deformity.

Question 294

What flexor tendons in the hand share a common muscle belly?

Answer 294

FDP of long, ring, and little.

This is why excursion of the combined tendons is equal to the shortes tendon. Improper shortening of a tendon during repair results in inability to fully felx adjacent fingers.

Quadriga effect. Most injuries involve Zone I.

Usually only observation is recommended. If symptoms are severe (weak grip) and severly affecting function then can release FDP of the injured digit.

Question 295

What is a lumbrical plus finger?

Answer 295

Paradoxical extension of the IP joints while attempting to flex the fingers. Lumbricals originate from FDP so when it is lacerated contracation of FDP pulls on lumbrical with pulls on lateral bands leading to the IP extension.

Most common in the middle finger (2nd lumbrical)

Doesnt occur in index finger because of independent muscle belly.

FDP disruption distal to the origin of the lumbrical is most common.

Can also occur form DIP amputation, amputation through middle phalanx or too long tendon graft.

do NOT suture flexor-extensor mechanism over bone.

Question 296

What is the treatment for a lumbrical plus finger?

Answer 296

tenodesis of FDP to terminal tendon or reinsertion to distal phalanx.

Lumbrical release if FDP is retracted or unable to be fixed. Not done in acute setting. Release at the level of the flexor sheath in the palm

Lumbrical release is contraindicated in ulnar nerve palsies. The ulnar nerve also controls the interosseous muscles so will have two hits to IP joint extension.

Question 297

What conditions are associated with stenosing tenosynovitis?

Answer 297

Trigger finger can be associated with: Diabetes Mellitus, Rheumatoid Arthritis, and Amyloidosis.

Question 298

What is different about a pediatric trigger finger release and an adult trigger finger release?

Answer 298

In a pediatric trigger finger you usually release 1 slip (usually ulnar slip) of FDS along with the A1 pulley.

May also need to release all of FDS and A3 pulley as revision if the digit is still triggering.

In the pediatric population trigger thumbs are 10x more likely.

Question 299

What is a Notta’s nodule?

Answer 299

palpable nodule proxiaml to the A1 pulley found in pediatric tigger fingers.

Question 300

What is another name for Flexor digitorum superficialis?

Answer 300

Sublimus tendons

Question 301

What is the inheritance pattern of Dupuytren’s disease?

Answer 301

Autosomal dominant.

Variable penetrance

Question 302

In what patient population is Dupuytren’s Disease more common?

Answer 302

Male to female 2:1

Northern European descent. Rare in Africa or China.

5-7 decade of life. Presents earlier in men and is more severe.

Associated with HIV, alcoholism, diabetes, and antiseizure medication.

Question 303

What is the dominant cell type in Dupuytren’s Disease?

What collagen predominates?

Answer 303

Myofibroblast- different from fibroblast as the myofibroblast has intracellular actin filaments.

Type III collagen predominates

Question 304

What are ectopic manifestations of dupuytren’s disease?

Answer 304

Ledderhose disease (plantar fascia) 10-30%

Peyronie’s disease (dartos fascia of penis) 2-8%

Garrod disease (knuckle pads) 40-50%

Question 305

What contractures are caused by the following pathologic structures in Dupuytren’s disease:

Pretendinous cord

Natatory ligament

Spiral cord

Lateral cord

Retrovascular cord

Central cord-

Answer 305

Pretendinous cord- MCP contracture

Natatory ligament- web space contracture

Spiral cord- MCP and PIP contracture

Lateral cord- PIP or DIP flexion contracture

Retrovascular cord- DIP hyperextension contracture.

Central cord- forms palmar nodules and pits between distal palmar crease and palmar digital crease.

Question 306

What is the most important cord in Dupuytre’s disease pathology?

What are its components?

Answer 306

Spiral cord. Cause of PIP contracture. typically inserts distally into the lateral digital sheet then into Grayson’s ligament.

Components: pretendinous band, spiral band, lateral digital sheet, and Grayson’s ligament.

Question 307

What happends to the neurovascular bundle in dupuytren’s disease?

What structure causes this?

Answer 307

Displaced centrally and superficially placing it at risk during surgical resection.

Spiral cord travels under the neurovascular bundle causing this.

Best predictors of displacement are PIP joint flexion contracture(77%) and interdigital soft tissue mass (71%)

Question 308

What is Xiaflex in regards to Dupuytren’s Disease?

Answer 308

Clostridium histolyticum collagenase. Has low activity against type IV collagen explaining the low neurovascular complication rate.

Inject .25ml for MCP an .20ml for PIP followed by stretch manipulation within 24-48 hours.

Causes lysis and rupture of cords.

Better for MCP than PIP.

Question 309

When is surgical resection/fasciectomy indicated for Dupuytren’s Disease?

Answer 309

MCP flexion contractures > 30 degrees

PIP flexion contractures

Painful nodules are not an indication for surgery.

Revision cases may need a skin graft. Recurrence is uncommon beneath a graft.

Question 310

What difference is there between fasciectomy and total fasciectomy and full thickness skin grafting?

Answer 310

None no difference in ROM, recurrence, or patient satisfaction.

Question 311

What is Dupuytren’s diathesis?

Answer 311

Age<50, white mend, bilateral hands involved, family history, and ectopic disease.

these patients need more aggressive follow-up and treatment.

Question 312

What is the recurrence rates of Dupuytren’s disease?

Answer 312

30% at 1-2 yrs

15% at 3-5 yrs

10% at 5-10 yrs

<10% after 10 yrs

Question 313

What is the most common surgical complication after Dupuytren’s release?

Answer 313

Hematoma formation that can lead to flap necrosis.

Question 314

Describe the following complications that can occure after surgical treatment of Dupuytren’s disease and how you can prevent them?

Flare reaction

Neurovascular injury

Digital ischemia

Answer 314

Flare reaction- pain syndrome characterized by diffuse swelling, hyperesthesia, redness, and stiffness. Minimize by not splinting immediately postop instead apply at first follow-up. Treat with cervical sympathetic blockage or A1 pulley release.

Neurovascular injury- Centrally and superficially displaced neurovascular bundle. Have higher suspicion with PIP contractures. identify entire bundle and all cords prior to excision.

Digital ischemia- long standing joint contractures where vessels have lost elasticity. Minimize by not splinting immediatley post-op. Tx by warming digit, allowing joint to relax. topical lidocaine and papaverine.

Question 315

In dupuytren’s disease PIP joints develop contractures of what secondray structures that require more comprehensive surgical release?

Answer 315

Volar plate.

Accessory collateral ligaments.

Flexor sheaths.

Question 316

What is De Quervain’s tenosynovitis?

Answer 316

A stenosing tenosynovial inflammation of the 1st dorsal compartment wich includes:

Abductor pollicis longus (APL)

Extensor pollicis brevis (EPB)

Most common in 30-50 women in the dominant wrist.

Question 317

True or False De Quervain’s is an inflammatory process?

Answer 317

False

thickening and swelling of the extensor tetinaculum that causes increased friction. Thought to be related to accumulation of mucopolysaccharides.

Question 318

Risk factors for De Quervain’s

Answer 318

Overuse: golfers and racquet sports

post-traumatic

Post-partum.

Question 319

What are two provocative tests for De Quervain’s?

Answer 319

Finklestein maneuver- quicly grasp the patient’s thumb and abducting the hand ulnarward. Pain over the radial styloid tip is positive.

Eichhoff maneuver- Patient clenches thumb in fist and then ulnarly deviates wrist. Pain is postivie especially if it is relieved by extension of the thumb

Question 320

What is firstline treatment for De Quervain’s?

What if this fails?

Answer 320

rest, NSAIDs, and thumb spica splint.

corticosteroid injection. No benefit of splinting after this.

Question 321

When do you consider surgical release of De Quervains?

Answer 321

First dorsal compartment release after 6 months of failed non-operative treatment in a patient with severe symptoms.

Protect the radial sensory nerve.

transverse incision with release over dorsal side of 1st compartment to prevent volar subluxation of the tendon.

APL usually has at least 2 tendon slips and its own fibro-osseous compartments. EPB with its own sheath as well. Need to release them all.

Question 322

What leads to intersection syndrome?

Answer 322

Repetitive wrist extension that leads to inflammation at corssing point of 1st dorsal commpartment and 2nd dorsal compartment.

Question 323

Where do you expect to find tenderness with intersection syndrome?

Answer 323

5cm proximal to wrist joint dorsoradial.

Question 324

What test can be obtained to confirm diagnosis of intersection syndrome when diagnosis is unclear?

Answer 324

MRI

Will sho peritendinous edema surroudning the 1st and 2nd extensor compartments.

Question 325

What treatment should be considered for intersection syndrome.

Answer 325

Almost always resolves with rest and wrist splinting.

Can perform an injection withc should be administered into 2nd dorsal compartment.

Surgical release only in recalcitrant cases that have failed all of the above. Release 2nd dorsal compartment 6cm proximal to radial styloid.

Question 326

What soft tissue injuries are associated with distal radius fractures and what is their incidence?

Answer 326

TFCC injury 40%

Scapholunate ligament injury 30%

Lunotriquetral ligament injury 15%

Question 327

After a distal radius fracture what are associated with poorer outcomes?

What correlates with succesful outcomes?

Answer 327

POOR: Worker’s comp, low socioeconomic status, low education levels, and low bone density.

SUCCESFUL: articular reduction, restoration of anatomic relationships and early ROM.

Question 328

What percent of axial load is the distal radius responsible for?

Answer 328

80%

Question 329

Describe the following distal radius fracture eponyms:

Die-punch

Bartons

Chauffer

Colles

Smith

Answer 329

Question 330

What are the normal and acceptable changes for radiographic criteria of distal radius fractures?

Answer 330

Question 331

According to AAOS clinical practice guidelines for distal radius fractures what received moderate strength recommendations?

Answer 331

1. Surgical fixation for fractures that had a post-reduction radial shortening > 3mm, dorsla tilt > 10 degrees, and intra-articular step off > 2mm.
2. Rigid immobilization for non-operative treatment
3. Use of a true lateral to assess the DRUJ
4. Beginning early ROM of the wrist are stable fixation.
5. Vitamin C to help mitigate intractable pain.

Question 332

What factors have been associated with re-displacement after closed reduction of distal radius fractures?

Answer 332

1. Initial displacement
2. The age of the patient
3. Extent of metaphyseal comminution.

Question 333

What is the Cotton-Loder Position?

Answer 333

Immobilization of wrist in extreme flexion and ulnar deviation which leads to increased risk of carpal tunnel syndrome.

Question 334

Regarding articular margin distal radius fractures, what is the critical corner?

Answer 334

Volar ulnar corner

Supports the volar lunate facet with its strong radiolunate ligament attachements.

May require fragment-specific fixation to prevent early postoperative failure.

Question 335

What rehabilitation should be prescribed after a simple adult distal radius fracture treating in a cast?

Answer 335

Home exercises

No benefit has been shown with formal physical therapy.

Question 336

What is most predictive of instability in distal radius fractures?

What is second?

Answer 336

Radial shortening.

Dorsal comminution

Question 337

What are LaFontaines predictors of instability for distal radius fractures?

Answer 337

Patients with three or more of the following have a high chance of loss of reduction:

Dorsal angulation > 20 degrees

Dorsal comminution > 50%, palmar comminution, intraarticular comminution

Initial displacement > 1cm

Initail radial shortening > 5mm

Associated ulnar fracture

Severe osteoporosis

Question 338

In a distal radius fracture what cannot be restored with an external fixator alone?

Answer 338

Volar tilt

Requires CRPP or plating as an adjunct.

Question 339

What radiographic or fluoroscopic view is needed to truly assess whether screws from are a volar plate are intra-articular?

What view can be used to check dorsal screw penetration?

Answer 339

23 degree elevated latera view.

Skyline view.

Question 340

Is there any added benefit to arthroscopically assissted reduction of distal radius fractures?

Answer 340

Studies have shown improved results.

Question 341

What neurologic issue is associated with DRUJ injuries?

Answer 341

Ulnar nerve neuropathy.

While not neurologic can also see ECU or EDM entrapment with DRUJ injury.

Question 342

What kind of distal radius fracture is most associated with EPL rupture?

Answer 342

non-displaced distal radius fractures

Extensor mechanism is thought to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition or a local area of ischemia in the tendon.

Question 343

What malunion after distal radius fracture is associated with the greatest loss of wrist funtion?

How is it treated?

Answer 343

Radial shortening malunion.

Treated with ulnar shortening.

Question 344

What percent of young adults will develop symptomatic arthrosis if left with an articular step-off of 2mm or more?

Answer 344

90%

Question 345

What can be done to decrease the incidence of RSD/CRPS after distal radius fracture?

Answer 345

Vitamin C supplementation.

500mg for 50 days.

Question 346

Place in order the incidence of osteoarthritis for the following joints:

DIP

Thumb CMC

PIP

MCP

Answer 346

DIP > Thumb CMC > PIP > MCP

Question 347

What are risk factors for thumb CMC arthritis?

Answer 347

female gender

Ehler-Danlos syndrome

Increased BMI

Question 348

Attenuation of what ligament is thought to lead to basilar thumb arthritis?

Answer 348

Anterior oblique ligament (Beak ligament)

Originates from the palmar tubercle of the trapeium and inserts on the articular margin of the ulnar metacarpal base.

Question 349

What deformity that is a sequlae of CMC arthritis may you see in the hand?

Answer 349

Zig-zag or “Z” deformity.

MCP joint hyperextension to compensate for less motion in the CMC joint, which initially occrus due to the patient avoiding painful motion and later because of joint stiffness.

Exacerbated during pinching.

Question 350

What is an indication for a CMC arthrodesis?

When is it contraindicated?

Answer 350

CMC arthritis stage II-III in young male heavy laborers.

Contraindicated in patients with scaphotapeiotrapezoidal (STT) arthritis.

Question 351

What surgical procedure can be done in addition to a trapeziectomy and ligament reconstruction for a patient with stage IV disease?

Answer 351

Excision of the proximal third of trapezoid is ideal for patients with concomitant scaphotrapezoid arthritis.

Question 352

What two tendons are most commonly used for trapeziectomy with suture suspension?

Answer 352

suture suspension with APL to FCR.

Can also use ECRL and PL around FCR.

Question 353

What is a surgical option for early (Stage I and II) thumb CMC arthritis and MCP hyperextension > 10 degrees.

Answer 353

CMC arthroscopic debridement is an option but a better choice would be a 1st metacarpal osteotomy.

Dorsal closing wedge osteotomy is performed.

redirects force to the more uninvolved portion of the 1st CMC joint.

Question 354

What amount of subsidence can you expect after LRTI for basilar thumb arthritis?

Answer 354

25% with no changes in outcome.

Question 355

What is the difference between LRTI and suspensionplasty for basilar thumb arthritis?

Answer 355

Suspensionplasty is when a partial slip of a tenond is woven through another tendon to stabilize the joint without drill holes. Most commonly FCR woven through APL.

LRTI can be performed with different tendons but involves drill holes through the metacarpals.

Question 356

What is the treatment for the following degrees of MCP hyperextension in basilar thumb arthrits?

8 degrees

15 degrees

30 degrees

45 degrees

Answer 356

< 10 degrees no surgical interveniont. NSAIDs and bracing.

10-20 degrees percutaneous pinnin of MCP in 25-35 degrees of flexion for 4 weeks +/- a EPB tendon transfer.

20-40 degrees volar capsulodesis or sesamoidesis

>40 degrees MCP fusion.

Question 357

Describe the Eaton and Littler Classification of Basilar Thumb Arthrits.

Answer 357

Question 358

What is a Heberden’s nodule associated with?

Answer 358

DIP osteoarthrits, caused by osteophytes.

Question 359

What are bouchard nodes associated with?

Answer 359

PIP joint arthritis.

Question 360

What is likely the underlying problem for a patient with nail splitting/ridging, defomrity, and loss of gloss with no history of trauma?

Answer 360

DIP osteoarthritis.

Can be caused by mucous cysts that are due to the underlying arthritis.

Question 361

What is the cause of articular cartilage and adjacent bone destruction in the DIP and PIP joints with synovial changes that are not systemic?

Answer 361

Erosive arthritis.

Intermitten inflammartory episodes.

Key is not systemic.

Pateints are relatively asymptomatic, condition is self limiting.

Question 362

What percent of mucous cysts will spontaneously resolve?

What treatment is recommended for those that do not?

Answer 362

20-60%

mucous cyst excision and osteophyte excision (this is the most critical part as cysts will recur unless this is done)

Question 363

Treatment for DIP arthritis?

Answer 363

1st Line: observation and NSAIDs

2nd Line: for debilitating pain and deformity. Fusion ->

Fusion with headless scre has highest fusion rate (nonunion 10%)

2nd and 3rd digit fused in extenion

4th and 5th digit fused in 10-20 degrees of flexion.

Question 364

What DIP and PIP joints an undergo silicone arthroplasty?

Answer 364

NO DIP

PIP long and ring finger, but they must have:

Good bone stock

No angulation or deformity.

Volar approach has better ROM and lower revision rates compared to dorsal approach.

Question 365

Operative treatment for PIP arthritis other than silicone arthroplasty?

Answer 365

For contractures with minimal joint involvement perform collateral ligament excision, volar plate release, and osteophyte excision.

FUSION: headless screws

Recreate normal cascade of fingers and flexion angles.

Index 30 degrees, Long 35 degrees, Ring 40 degrees, and small 45 degrees.

Question 366

In what position should the arm be to measure ulnar variance?

Answer 366

Shoulder abducted 90 degrees

Elbow flexed 90 degrees

Forearm neutral

Hand aligned with forearm axis

Question 367

What forearm radius;ulnar variance might you expect in patients who competed in gymnastics as children?

Answer 367

positive ulnar variance as distal radial growth plate can be injured leading to premature closure.

Question 368

What conditions are associated with postive ulnar variance?

negative ulnar variance?

Answer 368

ulnar abutement syndrome, Scapho-Lunate dissociation, TFCC tears, arhtoris, and lunotriquetral ligament tears.

Kienbock’s disease and Ulnar impingement syndrome where ulna impinges on the radius proximal to the sigmoid notch.

Question 369

Name some congenital, traumatic, and iatrogenic caused of ulnar variance?

Answer 369

CONGENITAL: Madelung (positive UV) and Reverse Madelung deformity (Negative UV)

TRAUMATIC: Distal radius/ulna fracture, SH injuries, DRUJ injuries.

IATROGENIC: Joint leveling procedures and radial head resection.

Question 370

What happens to ulnar variance during pronation, supination, and grip?

Answer 370

Positive ulnar variance with pronation and grip.

Negative ulnar variance with supination.

Question 371

How is ulnar variance determined?

Answer 371

Radiographically

1 line tangential to the articular surface of the ulna and perpendicular to its shaft.

1 line tangential to the lunate fossa of the radius and perpendicular to its shaft.

Measure the difference between those 2 lines (normal is 0mm)

Question 372

What physical exam tests can be performed to test for ulnarcarpal abutment syndrome?

Answer 372

Ballottement test- dorsla and plamar displacement with pain of the ulnar with the wrist in ulnar deviation.

Nakamura’s ulnar stress test- ulnar deviation of pronated wrist while axially loading, flexing, and extending wrist. Positive test produces pain.

Fovea test- used to evaluate for TFCC tear or ulnotriquetral ligament tear. Performed by palpation of the ulnar wrist between the syloid and FCU tendon. The above conditions can lead to positive ulnar variance that can lead to ulnarcarpal abutement syndrome.

Question 373

What is a Sauve-Kapandji procedure?

Answer 373

fusion of DRUJ and creation of a ulnar pseudoarthrosis proximal to the fusion site through which rotation can still occur.

Good option for manual laborers?

Question 374

What operative treatment is recommended for the majority of ulnar positive variance causing carpalulnar abutement syndrome?

Answer 374

Ulnar shortening osteotomy.

+/- TFCC reconstruction.

contraindication is DRUJ degenerative changes. In this case may consider ulnar hemiresection arthroplasty.

Question 375

What patient population is Kienbock’s disease seen in most?

Answer 375

20-40 year old males.

Question 376

What are the biomechanical and anatomic risk factors for Kienbock’s disease?

Answer 376

Ulnar negative variance- leads to increased radial-lunate contact stress

Decreased radial inclination

Repetitive trauma

Geometry of lunate

Vascular supply to lunate. I pattern supply postulated to the highest risk for AVN.

Question 377

What is the Lichtman Classification for Kienbocks?

What is the generally recommended treatment?

Answer 377

Question 378

For what patient might you recommend a temporary scaphotrapeziotrapexoidal pinning?

Answer 378

Adolescent with radiographic evidence of Kienbock’s and progressive wrist pain.

Question 379

What procedure should be done after a vascularized bone graft procedure for Kienbock’s disease?

Answer 379

temporary pinning of the STT joint, SC joint, or external fixation to unload the lunate.

Question 380

What is the major blood supply to the scaphoid?

Minor blood supply?

Answer 380

Dorsal carpal branch of radial artery. Enters saphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80% of scaphoid via retrograde blood flow.

Superficial palmar arch. Branch of volar radial artery. Enters distal tubercle and supplies distal 20% of scaphoid.

Question 381

What symptoms and physical exam findings will be found in a patient with a SNAC wrist?

Answer 381

reduced grip and pinch strength.

Stiffness with extension and radial deviation.

Tenderness of radioscaphoid articulation.

Question 382

What are the treatment recommendation for each of the following radiographic stages of SNAC wrist?

Answer 382

Nonoperative treatment recommended for only medically frail and very low functioning.

Stage 1: radial styloidectomy plus scapholunate reduction and stabilization

Stage II and III: Proximal row corpectomy (disadvantage reduction of wrist motion and grip strength). Four corner fusion (retains 60% of wrist motion and 80% of grip strength), and wrist arthrodesis (loss of wrist motion).

Question 383

What does chronic scapholunate deficiency lead to?

Answer 383

Dorsal intercalated segmental instability (DISI)

The scapholunate dissociation causes the scaphoid to flex palmar and the lunate to dorsiflex.

If left untreated the DISI deformity can progress into a SLAC wrist.

Question 384

DISI is from?

VISI is from?

Answer 384

Scapholunate ligament injury

Lunotriquetral ligament injury

Question 385

Which component of the scapholunate ligament provides the greatest constraint to translation between the scaphoid and lunate bones?

Answer 385

Scapholunate ligaments has dorsal, proximal, and volar components

Dorsal component is thicker and provides more constraint.

Question 386

What is another cause of anatomic snuffbox pain other than scaphoid fracture?

Answer 386

SL ligament injury.

Can also have pain in the dorsal scapholunate internal.

Patients complain of increased pain with loading across the wrist such as a push-up position.

Question 387

How do you perform a Watson shift test and what is it used for?

Answer 387

Used to diagnose DISI

place volar pressure with the thumb over distal pole and index finger over proximal pole distally and then take patients wrist from ulnar deviation (Scaphoid extension) to radial deviation (scaphoid flexion) The thumb is then removed which will lead to subluxation of the the scaphoid producing a painful clunk.

Question 388

What radiographs are useful when evaluating a scapholunate injury and DISI?

Answer 388

AP radiograph and clenched fist radiograph. Clenched fist accentuates the SL gap. > 3mm is considered positive. Other radiograph descriptions from this view are cortical ring sign, humpback deformity, and scaphoid shortening.

Lateral radiograph. Measure the SL angle which should be less than 70 degrees. Inscreased in DISI.

Question 389

What is considered the gold standard for diagnosing as scapholunate ligament tear?

Answer 389

Arthroscopy.

MRI has low sensitivity for tears. Need experienced radiologist.

Arthrography can be used as a screening tool but does not give information on size of tear and should still be confirmed with arthroscopy.

Question 390

When is rest, immobilization, and NSAIDs appropriate treatment for SLIL ligament tears?

Answer 390

Acute nondisplaced (SLIL is scapholunate interosseous ligament) tears.

Chronic asymptomatic tears.

Question 391

When is a SL ligament injury treated with a wrist fusion and not reconstruction or repair?

What technique would you use for the wrist fusion?

Answer 391

Chronic, rigid, and unreducible DISI deformity.

DISI with severe DJD.

STT (scaphotrapezialtrapezoidal) fusion, SCL (scapholunocapitate fusion) and scapholunate fusion alone. However this last option as the highest non-union rate.

Question 392

What is a standard post-op protocol for a scapholunate ligament repair?

Answer 392

K-wires in place for 8-10 weeks. Then work on ROM.

No heavy labor for 4-6 months.

Question 393

What is a SLAC wrist?

Answer 393

scaphoid lunate advanced collapse.

Describes the specific pattern of degenerative arthritis of radiocarpal and midcarpal joints.

DISI defromity that leads to adnormal distribution of forces. Initially affects the radiocaphoid joint and progresses to capitolunate joint.

Question 394

What are the Watson stages of a SLAC wrist?

Answer 394

Question 395

What joint is characteristically spared in a SLAC wrist?

Answer 395

Radiolunate

Unlike other forms of wrist arthritis because there remains a concentric articulation between the lunate and the spheroid lunate fossa of the distal radius.

Some new controversial literature describes a Stage IV SLAC wrist that they believe has pancarpal arthrits and involves the radiolunate joint.

Question 396

True or false a Watson scaphoid shift test will not be present in advanced SLAC wrists with arthritic changes?

Answer 396

True, the arthritic changes stabilize the scaphoid.

Question 397

What treatment is recommended for the following SLAC wrist stages?

STAGE I

STAGE II

STAGE III

Answer 397

STAGE I: radial styloidectomy and scaphoid stabilization, PIN and AIN denervation.

STAGE II: Proximal row carpectomy (contraindicated if there is an incompetent radioscaphocapitate ligament or caputolunate arthritis). Scaphoid excision and four corner fusion

STAGE III: Scaphoid excision and four corner fusion. Wrist fusion. Wrist fusion give best apin relief and good grip strength at the cost of wrist motion. Should be done if any form of pancarpal arthritis.

Question 398

What is nondissociative carpal instability?

What is characteristic on physical exam?

Answer 398

Instability between rows

Can be either radiocarpal(high energy trauma) or midcarpal(No history of trauma).

Rupture of extrinsic ligaments.

Generalized ligamentous laxity.

Irritating clunk when wrist is moved ulnarly from flexion to extension with an axial load.

Question 399

What treatment is there for nondissociative carpal instability?

Answer 399

First line treatment is immobilization with splinting.

Ulnar translation associated with syloid fractures should be treated with immediate open repair, reduction, and pinning because late repair and reconstruction both have poor long term results

Midcarpal instabiliyt is best treated with midcarpal joint fusion after failed non-operative treatment.

Question 400

What is the most common form of wrist arthritis based on location?

Second?

Answer 400

SLAC wrist

STT arthrosis

Question 401

What is Praiser’s disease?

Answer 401

AVN of the scaphoid without a traumatic cause.

Question 402

How do you best obtain a radiograph of the pisotriquetral joint?

Answer 402

Lateral in 30 degrees of supination.

Question 403

Describe the pathoanatomy of the wrist in Rheumatoid arthritis?

Answer 403

Wrist becomes supinated, palmarly dislocated, radially deviated, and ulnarly translocated.

Early disruption of the DRUJ leads to dorsal subluxation of ulna (Caput-ulna).

Question 404

Radial Clubhand deficiency is associated with what conditions?

Answer 404

TAR(Thrombocytopenia with absent radius)

Fanconi’s anemia

Holt-Oram syndrome

VACTERL Syndrome

VATER Syndrome

Question 405

How is TAR different than other conditions with absent radius?

Answer 405

The thumb is present in TAR unlike other cases of radial deficiency where it is typically absent.

Question 406

If the following condition is found what other tests schould be ordered to screen for associated conditions?

Answer 406

Radial Club Hand

Should order a CBC, renal ultrasound, and echocardiogram.

Question 407

In what case is observation and no hand centralization recommended for a radial clubhand?

Answer 407

Observation is indicated if there is absent elbow motion or biceps deficiency.

Hand deformity allows for extra reach to mouth in presence of a stiff elbow.

Question 408

What are the indications and conraindications for a hand centralization procedure in radial club hand?

Answer 408

INDICATIONS: Good elbow motion and biceps function intact. Done at 6-12 months of age. Followed by tendon transfers.

CONTRAINDICATIONS: Older patient with good function. Patients with elbow extension contracture who rely on radial deviation. Proximate terminal condition.

TECHNIQUE: Involves resection of varying amount of carpus, shortening of ECU, and, if needed, an angular osteotomy of the ulna. Be sure to spare ulnar distal physis. If thumb deformity then do both procedures at 18 months of age instead of 6-12.

Question 409

What are the ways in which you can differentiate a congenital radial head dislocation form a traumatic dislocation.

Question 410

A congenital radial head dislocation is almost always in what direction?

Answer 410

Posterior dislocation.

Patients often asymptomatic.

Question 411

What treatment is recommended for a congenital radial head dislocation?

Answer 411

Initially observation.

Operative: Radial head resection. Usually done in adulthood if the patient has:

Significant pain, restricted motion, and cosmetic concerncs of the elbow.

Reduces pain and may improve some elbow ROM.

Question 412

What is a Madelung’s Deformity?

Answer 412

Congenital dyschondrosis of the distal radial physis that leads to partial deficiency of growth of distal radial physis (ulnar volar physis).

Leads to excessive radial inclination, volar tilt, and ulnar carpal impaction.

Occurs predominantly in adolescent females.

Common in gymnasts.

Question 413

What is Vicker’s Ligament?

Answer 413

Fibrous band running from the distla radius to the lunate on the volar surface of the wrist (radio-lunate legament).

Thought to be maybe be involved in Madelung deformity.

Question 414

What is the inheritance pattern of Madelung Defromity?

What condition is it associated with?

Answer 414

Autosomal dominant

Leri-Weill dyschondrosteosis:

Rare genetic disorder caused by mutation in the SHOX (short-statute homeobox-containing gene) gene.

Causes mesomelic (short stature) dwarfism

Question 415

What treatment is recommended for Madelung deformity?

Answer 415

Asymptomatic observe.

Restrict activity with repetitive wrist impaction and weight bearing activity until pain decreases.

Operative: Release of Vicker’s ligament is controversial. Usually recommend Radial corrective osteotomy +/- distal ulnar shortening osteotomy if there is wrist pain, decreased ROM, and functional limitation.

Question 416

What conditions are associated with Congenital Radial Ulnar Synostosis?

Answer 416

Is associated with one of these 30% of the time.

Apert syndrome (acrocephalosyndactyly)

Carpenter’s syndrome (acropolysyndactyly)

Arthrogryposis

Mandibulofacial dysostosis

Klinefelter’s syndrome (XXY) and other sex chromosome abnormalities

Question 417

What are the rates of recurrent synostosis after excision without soft tissue interposition in congenitla radial ulnar synostosis?

Answer 417

100%

Studes have reported 0% recurrence with vascularized fascio-fat graft.

, slight gain in motion, and generally unsatisfactory results in most studies with the use of a fat graft or even vascularized fat grafts.

Question 418

What is another surgical option besides synostosis excision in congenital radial ulnar synostosis?

Answer 418

FOREARM DEROTATIONAL OSTEOTOMY:

Done to place the forearm in a more functional position if they are fixed in > 60 degrees of pronation.

Perform between 3-6 years of age.

Can make correction or do over time. Lowest rate of neurovascular complications when done with a circular fixator.

Fix dominant forearm in 0-15 degrees pronation and nondominatn forearm in neutral.

Question 419

Poland syndrome is characterized by?

Answer 419

Unilateral chest wall hypoplasia- due to absence of sternocostal head of pectoralis major.

Hypoplasia of the hand and forearm

Symbrachydactyly and shortening of middle fingers- ansence of shortening of the middle phalanx

Question 420

What will you likely see on a chest CT of someone with Poland Syndrome?

Answer 420

Absent pectoralis major

Question 421

What other chest deformities might you see in Poland syndrome beside hypoplasia or absence of the pectoralis?

Answer 421

Hypoplasia or absence of deltoid, serratus anterior, external oblique, and latissmus dorsi.

Sprengel’s deformity

Scoliosis

Dextrocardia

Absence or underdevelopment of the breast.

Question 422

What hand deformites can you see besides syndactyly in Poland syndrome?

Answer 422

Hypoplasia or absence of metacarpals or phalanges

Absence of extensor or flexor tendonds

Carpal coalition or hypoplasia

Radioulnar synostosis

Nail agenesis

Question 423

What is thought to be the etiolgoy of Poland syndrome?

Answer 423

Subclavian artery hypoplasia in utero

Question 424

What is Apert’s Syndrome characterized by?

Answer 424

Bilateral complex syndactyly

symphalangism- ankyloses of IP joints of fingers and toes

Premature fusion of cranial sutures (craniosynostosis) that leads to flattened skull and broad forehead (acrocephaly)

Glenoid hypoplasia

Radioulnar synostosis

Normal to moderately disabled cognitive function.

Question 425

What syndrome does a FGFr2 gene mutation lead to?

What is the most common mod of inhertiance?

Answer 425

Apert Syndrome- Dysmorphi face and complex syndactyly ( where the index, middle, and ring finger share a common nail).

Most new cases are sporadic but can be autosomal dominant.

Question 426

What is the operative treatment for complex syndactyly in a child with Apert syndrome?

Answer 426

Surgical release of border digits at 1 year of age

Digit reconstruction where central three digits are convered into two digits perfrom at 1.5 year.

Question 427

What is camptodactyly?

Answer 427

Congenital digital flexion deformity that usually occurs in the PIP joint of the small finger.

More commonly bilateral.

Question 428

What is the most common pathophysiologic cause of camptodactyly?

Answer 428

Abnormal lumbrical insertion/origin

Abnormal (adherent or hypoplastic) FDS insertion

This leads to a flexion deformity of the small finger PIP joint(usually normal MCP and DIP joints). Can be flexible or fixed. Worsens over time, especially growth spurts, if left untreated.

Question 429

What treatement is recommended for camptodactyly?

Answer 429

Nonoperative treatment for most. Best for PIP contractures < 30 degrees. Passive stretching and static splinting.

Operative for progressive deformity that leads to functional defromity. Must address all abnormal anatomy. Must be passively correctible. FDS tenotomy or FDS transfer to radial lateral band if full active PIP extension can be achieved with MCP flexion.

Osteotomy vs arthrodesis for severe fixed deformities.

Question 430

What is the most common congenital malformation of the limbs?

Answer 430

syndactyly

M > F

Most common long-ring finger

Autosomal dominant in pure cases but shows reduced penetrance and variable expression.

Question 431

What is acrosyndactyly?

Answer 431

The fingers have separated but a band of tissue around them caused them to refuse during development.

Question 432

What is the most common complication of digit release for syndactyly?

Answer 432

Web creep

Early- caused by necrosis of the tip of the dorsal quadrilateral flap and loss of the full thickness skin graft palced in the web.

Late- Caused by discrepant gorwth between scar/skin graft and surrounding tissue during the growth spurt.

Question 433

If multiple digits are to be released for syndactyly what technique should be used?

Answer 433

Perform procedure in two stage meaning release 1 side of a finger at a time to avoid compromising vasculature.

Question 434

What are the three kinds of polydactlyly?

Answer 434

Preaxial- thumb duplication

Postaxial- small finger duplication

Central

Question 435

What are the following with regards to Preaxial polydactyly:

Incidence?

Demographics?

Genetics?

Pollex Abductus?

Answer 435

I in 1,00-10,000. Duplicated Proxiaml phalanx is most common.

M>F, Caucasian > African Americans

usually unilateral and sporadic

Abnormal connection between EPL and FPL tendon seen in 20% that is suggested by abduction of affected digit + absence of IP joint crease.

Question 436

What operative treatment is recommended for preaxial polydactyly?

See Wassel Classification chart for Types

Answer 436

Goal is to construct thumb that is 80% of the size of contralateral thumb. Resect smaller thumb usually radial component. Preserve/reconstruct medial collateral structures in order to preserve pinch function. Reconstruction of all components typically done in one procedure.

Type I, II, or III use a combination procedure (Bilhaut-Cloquet). Removes central tissue and combines both digits into one.

Type III and IV. Preserve skeleton and anil of one component and agument with soft tissue from other lesser digit. Usally radial digit is the lesser digit ->ablation

Type V, VI, and VII. When one digit has superior proximal component and one digit has superior distal fragment. Segmental distal transfer (on-top plasty)

Question 437

With regards to Postaxial polydactyly, what is the:

Demographics?

Genetics?

Classification?

Answer 437

10x more common in African Americans.

Autosomal dominant in African Americans. Caucasians should have a genetic work-up to evaluate for chondroectodermal dysplasia or Ellis-van Creveld Syndrome.

Type A- well formed digit (cannot just amputate as some structed need to be preserved or reconstructed for the radial remaining digit).

Type B-rudimentary skin tag.

Question 438

What is the genetic inheritance of macrodactyly?

Answer 438

Nonhereditary. No known genetic correlation.

Very rare. 90% are unilateral. In order of decreasing frequency: Long finger, thumb, ring, and small

Question 439

What treatment is recommended for macrodactyly?

Answer 439

For single digit epiphysiodesis once digit reaches adult length of same sex parent.

Osteotomies and shortening procedures: thumb involvement, multiple digit involvement, or severe deformity.

Amputations for severe non-reconstructable digits.

Question 440

What is Streeter’s dysplasia?

What is the inheritance pattern?

Answer 440

Another name for AMniotic band syndrome where fibrous bands of ruptured amnion adhere to and entangle the normal developing structures of the fetus.

Occurs distal to the wrist 90% of the time.

Sporadic and not hereditary.

Question 441

What orthopaedic conditions are associated with amniotic band syndrome?

What nonorthopaedic conditions?

Answer 441

Clubfoot and syndactyly

Cleft palate, cleft lip, craniofacial defects, cardiac defects, and encephalocele.

Question 442

What is the pathophysiology of thumb hypoplasia?

What are the associated anomalies?

What anomaly is it most commonly associated with?

Answer 442

Exact cause during embryologic development is not known

Most commonly associated with partial or complete absence of the radius.

Greater than 80% will have associated anomalies that include: VACTERL, Holt-Oram, TAR, and Fanconi anemia.

Question 443

Treatment for thumb hypoplasia hinges on the presence and competency of what structure?

Answer 443

CMC joint.

If thumb CMC joint is intact then can stabilize MCP joint, release webspace and do an Opponensplasty.

If thumb CMC joint is deficient then thumb amputation and pollicization.

Question 444

What is causing triggering in a pediatric trigger thumb?

Answer 444

FPL tendon is thickened due to abnormal collagen degeneration and synovial proliferation caused diruption of normal tendon gliding of A1.

Acquired, not thought to be much of a genetic component.

Question 445

What is the treatment for a pediatric trigger thumb?

Answer 445

If the deformity is not fixed can recommend passive extension exercises and observation. 30-60% resolve by 2 years of age. <10% will resolve after 2 years old.

First line of treatment is usually intermittend extension, also not recommended with fixed deformity. Splint maintains IP joint hyperextension and prevent MCP joint hyperextension. 6-12 weeks duration. 50-60% resolution. High drop out rate from therapy.

A1 pulley release for fixed deformity beyond 12 months of age and for failed conservative treatment. 65-95% resolution in all age groups.

Question 446

What is a ganglion cyst filled with?

Answer 446

Mucin.

Most common hand mass (60-70%)

Question 447

What is the most common location for a ganglion cyst in the hand?

Where can they originate from in the hand that is not a joint?

Answer 447

SL articulation (70% of the time)

Volar retinacular from herniated tendon sheath fluid

Question 448

What will the histology of a ganglion cyst show?

Answer 448

Mucin-filled synovial cell lined sac.

Question 449

What treatment is recommended for children with gangion cysts?

Answer 449

Observation. 76% will resolve within 1 year in pediatric patients.

Question 450

what neurovascular injury is most common with ganglion cyst excision from the hand/wrist area?

Answer 450

Radial artery

Question 451

Which has a higher recurrence rate of surgical resection dorsal or volar ganglions?

Answer 451

Volar

Question 452

What is hypothenar hammer syndrome?

Answer 452

Post-traumatic digital ischemia from thrombosis of ulnar artery at Guyon’s canal.

Male: female ration is 9:1

Men in 40s-50s

Question 453

What is the mechanism that leads to hypothenar hammer syndrome?

Answer 453

Single or repetitive blunt impact on hypothenar eminence that leads to ulnar artery thrombosis or aneurysm.

Hook of hamate functions as an anvil.

Question 454

What is the relation of the ulnar artery to hook of the hamate?

Answer 454

Ulnar artery branches into 2 branches as it exits Guyon’s canal: Deep branch and superficial palmar arch in Guyon’s canal.

2cm of the artery is directly anterior to the hook of the hamate covered by palmaris brevis, subcu tissue and skin.

Question 455

How will a patient present with hypothenar hammer syndrome?

Answer 455

Pain over hypothenar eminence and ring finger. Cold sensitivity and paresthesias.

digits may have blanching, mottling, cyanosis, pallor, and gangrene.

Fingertip ulcerations or splinter hemorrhages over ulnar digits.

Question 456

What is first line test for hypothenar hammer syndrome?

What is mandatory for diagnosis?

Answer 456

Ultrasound. Measure digital brachial index <.7 necessitates reconstruction.

Angiogram, CT angiogram, or MR angiogram.

Question 457

What is treatment for a ulnar artery thrombosis without aneurysm < 2weeks?

> 2 weeks?

Answer 457

endovascular fibrinolysis.

If relatively asymptomatic and no threat for digital loss then can proceed with nonoperative treatment with lifestyle modifications (smoking cessation and avoiding recurrent trauma). 80% success.

Question 458

What treatement is recommended for ulnar artery aneurysm?

Answer 458

If digital brachial index <.7 and there is ischemia of the digits then excise involved segment and reconstruction. Can be done with or without a vein graft.

Leriche procedure is arterial ligation that can be done if digital brachial index >.7 and dominant radial artery.

Question 459

What are the two forms of Raynaud’s?

How do you differentiate the two?

Answer 459

RAYNAUDS PHENOMENON or RAYNAUDS SYNDROME:

RAYNAUD’S DISEASE: vasospastic disease with no known cause (idopathic).

both have periodic digital schemia due to vasoconstriction. Can be induced by cold temperature or sympathetic stimuli including pain or emotional stress.

Question 460

What non-operative management is recommended for Raynaud’s?

Answer 460

Medical management & lifestyle modifications: First line treatment. Modalities include: smoking cessation and avoidance of cold exposure is critical. thermal biofeedback techniques. Medications which include calcium channel blockers, ASA, intra-arterail reserpine, dipyridamole, pentoxifylline, and Sildenafil.

Botulinum toxin A injections: Indicated when medical management has failed, presence of ischemia and pain, ulcerations not a contraindication. Off label use but has been shown to improve digital perfusion.

Question 461

What conditions are associated with Raynaud’s phenomenon.

Answer 461

vasospastic disease with a known underlying cause. Most often connective tissue diseases such as scleroderma(80-90%), SLE (18-26%) Dermatomyositis (30%), RA (11%), Neurovascular compression (thoracic outlet syndrome), CREST syndrome.

Question 462

What are the possible operative interventions for Raynaud’s?

Answer 462

Digital sympathectomy- severe cases that fail conservative treatment (impending gangrene). Periarterial sympathectomy most common method where adventitia and sympathetic nerve fibers are removed. Not indicated in calcific arterial disease.

Microvascular reconstruction- ONly an option where occlusio of a small sement of one major artery wile other vessels are spared or have minimal involvement.

Question 463

What is Thromboangiitis Obliterans (Buerger’s disease)

Answer 463

Nonatherosclerotic segmental inflammaroty disease in the small and medium-sized vessles of the hands and feet.

Occurs predominantly in smokers.

Affects patients < 45 years old.

Prognosis depends most on smoking status. 94% who quit smoking avoid amputation. 43% chance of amputation within 8 years if smoking is continued.

Question 464

True or false In patients with Buergers disease smoking cessation is the oly treatment known to decrease the risk of future amputation.

Answer 464

True.

Daily aspirin and vasodilators are treatment options but not shown to decrease risk of amputation.

Question 465

What is the most common organsim isolated after culture is performed of a human bite?

Answer 465

It is most frequently polymicrobial.

Eikenella corrodens is isolated in about 1/3 of infections from human bites.

Question 466

True or false collagenase injection for Dupuytren’s has equivalent effect on attempted correction 1 or 7 days following injection?

Answer 466

True

Question 467

What may you see on radiographs of the hand of a patient with psoriatic arthritis?

Answer 467

pencil-in-cup deformity. Different than DJD by presence of centripetal erosions which caue joint space widening.

Small joint erosions or fusions (PIP, MCP, and wrist commonly involved)

Fluffy periostitis (caused by periosteal ossification)

Acroosteolysis (resorption of the distal phalanx tuft)

Flaid digits.

Question 468

Acceptable radiographic parameters to treat a distal radius fracutes in an active healthy patient <65 years old?

Answer 468

radial length within 5mm of the contralateral wrist

Dorsal tilt <10 degrees

Intraarticular step-off of less than 2mm

Less than 5 degrees loss of radial inclination

Question 469

What is the treatment for a patient with rheumatoid arthritis and fixed MCP deformities with ulnar drift?

Answer 469

MCP arhtorplasty is the procedure of choice for the digits with arthrodesis for the thumb.

Patients can expect an arc of motion of 40 to 60 degrees with improvement of finger extension and ulnar drift.

Question 470

What is the appearance order of ossification centers for carpal bones

Answer 470

Capitate 1-3 months

Hamate 2-4 months

Triquetrum 2-3 years

Lunate 2-4 years

Scaphoid 4-6 years

Trapezium 4-6 years

Trapezoid 4-6 years

Pisiform 8-12 years

Excluding the pisiform start at the capitate then move in a counterclockwise direction on the volar surface of the right carpus to remember the order.