Hand and Wrist (2008-2019)

Question 1

1. Extensor tendon subluxation at MCP, what is injured?

A. Central slip
B. Sagittal Band
C. Lateral Band
D. Oblique retinacular ligament

Answer 1

ANSWER: B

• 2012
• JAAOS 2015 - Sagittal Band Rupture
  
  • EDC tendon crosses MP joint and is stabilized by the dorsal extensor hood
  • Sagittal bands runs perpendicular to EDC and prevent subluxation of tendons
  • Proximal radial portion is most important

Question 2

2. What is true regarding a boutonniere deformity?

A. Can be associated with MCP, PIP and DIP pathology
B. Can be corrected with a fusion of the PIP joint
C. Can be corrected with a tenotomy of the lateral bands
D. Caused by dorsal subluxation of the lateral cords

Answer 2

ANSWER: B

• No description of DIP fusion for Boutoniere deformity
• Tenotomy of lateral bands described BUT accompanied with tenodesis to dorsal aspect OR release from transverse retinacular ligament
• JAAOS 2015 – Boutonniere Deformity
  
  • Disruption of the central slip and triangular ligament
  • Causes conjoint lateral bands to sublux volarly
  • Lateral bands then migrate proximally and tension the terminal tendon –> hyperextension at DIP

Question 3

3. Treatment of swan neck. All true except?

A. crossed intrinsic tendon transfer
B. oblique retinacular repair
C. DIP fusion
D. FDS partial tenodesis

Answer 3

ANSWER:A

• 2011
• JAAOS - Operative Correction of Swan Neck and Boutonniere
  
  • FDS tenodesis
  • Oblique retinacular ligament reconstruction
  • DIP Fusion

Question 4

4. What does not cause swan neck?

A. Mallet finger
B. Volar subluxation of the proximal phalanx
C. FDP rupture
D. Tight intrinsics

Answer 4

ANSWER: C (< — which does NOT cause it)

• 2010

Also, should be volar subluxation of middle phalanx

Question 5

5. Jersey finger with retraction to the palm. What is not true
6. Ring finger most frequent
7. This is the most common type of FDP injury
8. Good results can be achieved if fixed within 4-6 weeks
9. Often delayed diagnosis

 

Answer 5

ANSWER: B and C

• 2012
• JAAOS 2011 - Avulsion Injuries of the Flexor Digitorum Profundus Tendon
  
  • Ring finger most commonly affected
    
    • Most tethered motion, bipennate lumbricals, weakest insertion point
  • Patients with retraction to the palm should be treated within 10 days
• In type I injuries, the tendon retracts into the palm, the long and short vincula are both ruptured, leading to compromised tendon nutrition. These injuries have a worse prognosis if not diagnosed and treated within 7–10 days as the tendon contracts and becomes less viable. Type II injury is the most common type. The tendon retracts to the level of the PIPJ
• These injuries may be dismissed as minor sprains, however, and depending on the sport, some athletes may be capable of “playing through” the injury at a competitive level. It is not uncommon for competitive athletes to present in delayed fashion or once the season has ended.
• Type 2 most common - FDP retracted to PIPJ

Question 6

6. When placing a suture anchor for repair of a jersey finger, in what position is pullout reduced?
7. Distal to proximal
8. Proximal to distal
9. Perpendicular to phalanx
10. Skirting subchondral bone

Answer 6

ANSWER: A

2016

Source: JAAS 2011 Avulsion injuries of the FDP tendon

Pilot holes are typically drilled at a 45° angle from distal‐volar to proximal‐dorsal, in accordance with the deadman angle theory of suture anchors, to increase the resistance to pullout of the implant.

Question 7

7.Mallet finger. All are appropriate treatments except:

1. Splint in neutral position
2. Pin the DIP joint
3. Dorsal blocking pin

Answer 7

ANSWER: A

2016

JAAOS – Mallet Finger

Management:

Digit immobilized in full extension

Extension block pinning

Question 8

8. Which of the following is true regarding Zone II flexor tendon injuries?
9. Early ROM protocols reduces fibrous scar formation
10. Repair both slips of FDS for improved gliding and PIP ROM

Answer 8

ANSWER: A

2016

Question 9

9. Which pulley would you release in adult trigger finger
10. A1
11. A2
12. A3
13. A4

Answer 9

ANSWER: A

2013

JAAOS 2001 - Trigger Finger

Release of A1 pulley

Question 10

10. What is true regarding trigger finger:
11. Same outcomes with rheumatoid and normal trigger finger release
12. 20% complication rate with surgical treatment
13. Proximal edge of A2 pulley is pathologic
14. Cannot perform percutaneous release of the thumb

Answer 10

ANSWER: D

2015

• Giugale JM (Orthop Clin N Am 2015) Trigger Finger Adult and pediatric treatment strategies
• The complication rate of open A1 pulley release ranges from 7-43%
• Trigger finger release of the thumb is at particular risk of nerve injury because the digital nerve coruses over the A1 pulley
• “although percutaneous techqnique has been show effective and safe for the thumb, many advocates avoid performing the procedure on the thumb because of the digital nerve course”
• Bruijvzeel H (JHS 2012) Adverse Events of Open A1 Pulley Release for Idiopathic Triger Finger
• If we were to categorize scar tenderness, scar thickness, slight flexion contracture, and dissatisfaction as adverse events, we would have an overall event rate of 21%
• JHS 2006 - Trigger Digits: Principles, Management and Complications
• Secondary
• Carpal tunnel - look for endocrine and metabolic disorder; also associated with idiopathic
• Amyloidosis = A1 pulley release + complete tenosynovectomy (preserve all other pulleys)
• RA = do not take the A1 pulley! = preserve them all & just do tenosynovectomy - increases risk of ulnar drift*
• DM = respond less to cortisone (<50%) and surgery

Question 11

11. What is true about trigger finger?
12. Triggering is often from underlying disease
13. Triggering is often caused by RA synovitis
14. Triggering more common in young labourer
15. De quervain’s more common than triggering

Answer 11

ANSWER: B

2007, 2009

• Summary of Old Evidence:
• Incidence: Triggering 2-3% lifetime risk, de Quervain’s 2.8 per 1000 person-years
• Triggering associated with RA, diabetes, gout, carpal tunnel, de Quervain’s, Dupuytren’s, HTN
• Answer: B RA does commonly cause triggering and people with RA have worse outcomes
• A: False although there are many risk factors for trigger finger, it is most common in normal people
• D: De Quervain’s – inflammation of first dorsal compartment (APL, EPB). Second most common hand/wrist tenosynovitis after trigger finger, but only 1/20th as common.
• C: False more common in older crowd. The most common form of trigger finger is the primary type, which is found predominantly in otherwise healthy middle-aged women with a frequency two to six times that seen in men.
• Trigger finger – nodule in FDS catches at A1 pulley. Lifetime risk 2-3%, more common in women than men (about 4:1), age 55-60, dominant hand, and in rheumatoids and diabetics (up to 10%). No evidence for link between trigger finger and occupation. Ring finger most common.
• Primary stenosing tenosynovitis is usually idiopathic and occurs more frequently in middle-aged women than in men, but can be seen even in infancy. Secondary stenosing tenosynovitis of the digits can occur in patients with rheumatoid arthritis, diabetes mellitus, gout, and other disease entities that cause connective tissue disorders. As many as 85% of triggering fingers and thumbs can be treated successfully with corticosteroid injections and nonsteroidal anti-inflammatory drugs. Surgical release is generally indicated when nonoperative treatment fails. trigger finger common and multi-focal in pts with RA

Question 12

12. All of the following are principles of tendon transfer EXCEPT?
13. Straight line of pull is more efficient
14. Wrist fusion will help with tenodesis
15. Wait to perform transfers until soft tissue is in equilibrium
16. Must not use a tendon that would compromise function

Answer 12

ANSWER: B

2014

• Tendon transfers for radial, median, and ulnar nerve palsy. JAAOS. 2013
• Principles of tendon transfer:
• Donor tendon must be expendable and have intact innervation
• Donor muscle strength much be greater or equal to 4/5 (strength loss of one grade following transfer)
• Sufficient excursion of donor tendon to restore recipient function
• Direction of pull (vector) of donor should be in-line with recipient and only cross one joint (ideally)
• Transfer one tendon to fix one function

Stable, pliable, un-scarred soft tissue bed for transfer

Full passive ROM of joints

Donor tendon should be in-phase with recipient  

Question 13

13. All are true regarding tight hand extrinsics EXCEPT?
14. The extensor tendon is scarred down to the metacarpal
15. There is a block to passive MCP flexion
16. MCP flexion causes PIP extension
17. PIP Flexion causes MCP extension

Answer 13

ANSWER: B (Jess, read the question! EXTRINSICS!)

2009, 2014

• Claw Hand/Intrinsic Minus
• Wheeless:
  
  • Extrinsic tendon tightness usually results from scarring and adhesions of the extensor tendons over the metacarpals
  • Will be more PIP flexion with MP in extension
  • If PIP joints flexed, MPs will extend
• Miller’s
  
  • INTRINSIC TIGHTNESS = LIMITED PIP FLEX WITH MCP EXT
  • EXTRINSIC TIGHTNESS = LIMITED PIP FLEX WITH MCP FLEX

Question 14

14. Which of the following is the strongest for tendon repair
15. Pulvertaft
16. Kessler
17. Bunnell
18. Interrupted

Answer 14

ANSWER: D

2008

• Repair strength is dependent on the number of core sutures
• Bunell and Kessler are 2 strand, if interrupted had 4 core, then would be stronger
• Modified Bunnell > Kessler
• Pulvertaft is a tendon weave for tendon transfers

Question 15

15. How do you treat quadrigia?
16. Release flexor
17. Release extensor
18. Do muscle lengthenings in forearm in CP
19. Release gluteus medius (not kidding, something in the hip)

Answer 15

ANSWER: A

2009

Question 16

16. 50 yr old female with 2 week history of inability to extend 4th and 5th fingers. List 3 common causes in a Rheumatoid patient. (2010, 2011, 2013)

Answer 16

JAAOS 2006 - The Rheumatoid Wrist

• Attritional extensor tendon rupture (Vaughan-Jackson Syndrome)
• Sagittal band attenuation rupture
• MCP dislocations (volar, joint erosions and volar plate attentuation)
• PIN palsy at RC joint
• Cervical radiculopathy

CAMPS

Question 17

17. List 3 causes of swan neck from synovitis in rheumatoid arthritis (2011, 2016)

Answer 17

JAAOS 1999 - Swan Neck and Boutonniere in Rheumatoid

RA Pathologies:

• Attenuation of volar plate, collaterals, FDS insertion –> PIP hyperextension
• Intrinsic contractures (MCP flexion and volar subluxation)
• DIP synovitis/Mallet Finger –> attenuation of terminal extensor mechanism
• Transverse ligament attenuation with lateral band subluxation (dorsal subluxation)
• Fixed contracture of dorsal PIP structures
• Volar MCP Subluxation

Question 18

18. All are associated with swan-neck deformity in RA patient EXCEPT?
19. Patient unable to passively extend MCP
20. Positive Bunnell
21. Chronic Mallet finger
22. MCP collaterals demonstrating increased laxity when flexed to 90 degrees

Answer 18

ANSWER: D

2012

JAAOS 2006 - The Rheumatoid Wrist

• Cases of Swan Neck Deformity
  
  • Extensor tendon rupture
  • Volar MCP subluxation
  • Intrinsic muscle tightness
  • Volar plate subluxation
  • Mallet finger/terminal tendon rupture

Question 19

19. What is true about Boutonierre deformity in RA:
20. Not associated with MCP and DIP pathology
21. Can be corrected with tenotomy over DIP
22. An arthrodesis is contraindicated with a stiff PIP joint
23. Caused by dorsal subluxation of the lateral cords

Answer 19

ANSWER: B

2015

• Terminal ext tendon tenotomy (Fowler tenotomy) - tenotomy of the extensor tendon is performed distal to the triangular ligament but proximal to the DIP joint (and proximal to the ORL insertion, in order to allow the ORL to maitain some DIP extension)

JAAOS 2015 - Boutonniere and Swan Neck Deformity

• Caused by VOLAR subluxation of lateral cords
• Treatment options (only if PIP motion full)
  
  • Terminal tendon tenotomy
  • Tendon rebalancing
  • Staged reconstruction

Question 20

20. Mannerfelt lesion is progressive erosion and rupture of what tendon?
21. EDC
22. EPL
23. FPL
24. ECU

Answer 20

ANSWER: C

2008, 2012

JAAOS 2006 - The Rheumatoid Wrist

Mannerfelt Lesion = distal scaphoid penetrates volar wrist capsule and causes attritional wear of the FPL

Question 21

21. A 47yo female with longstanding rheumatoid arthritis presents to your clinic with an inability to extend her 4th and 5th digits. On exam you note an ulnar prominence. She has pain with supination/pronation but not with flexion/extension. What is the best treatment?
22. Splint (unsure if tenosynovectomy and tendon transfers included)
23. Tendon transfers, tenosynovectomy and sauve-kapanji
24. Tendon transfers, tenosynovectomy and distal ulnar resection
25. Tendon transfers, tenosynovectomy and wrist fusion

Answer 21

ANSWER B

2008, 2014

• At CORF, people were split 50:50 between Darrach and Sauve-Kapandje on this one. We went with B because the patient is >45 years. The true stem would really have to be convincing for an active, high-functioning, RA patient.
• JAAOS 2006 - We currently favor this procedure in most active patients with RA and have found it to be reliable, with a low complication rate. Distal ulnar stump instability, impingement, and extensor tendon rupture may occur after this procedure, but they are not as commonly reported as they are with the Darrach procedure.

 Management of the distal radioulnar joint in rheumatoid arthritis. Hand Clinics. 2005.

• Vaughn-Jackson syndrome = progressive rupture of extensor tendons from ulnar to radial in RA patients (EDM is first and most commonly affected); multi-factorial process caused by synovial proliferation and degeneration + devascularization + rubbing on bony prominences
• Direct repair of tendons in the setting of RA is generally not possible due to retraction, shortening and fibrosis of the muscle unit, and destruction of remaining tendon due to invasion of synovium. Tendon transfer is necessary but is performed in conjunction with other DRUJ procedures. End-to-side and EIP transfers are most common
• DRUJ osseous procedures are indicated when there is derangement of the articular surface, instability, pain, or limitation in motion…
• Distal ulnar resection…
• Complete resection (Darrach) is indicated in elderly patients with no radiocarpal instability; risk of radioulnar impaction (10%) and ulnar translocation of carpus (up to 40%)
• Hemi-resection (+/- interposition) requires intact TFCC (which is almost never the case in RA)
• Fusion with proximal ulnar pseudoarthrosis (Sauve-Kapanji) is indicated in younger (<45 yrs) and active patients with no radiocarpal instability; risk of ulnar translocation of carpus (but less than with Darrach) and non-union; considered treatment of choice in patients with RA
• Arthroplasty is still relatively new with limited long term follow-up

JAAOS 2006 - Rheumatoid Wrist

• DRUJ involvement presents with dorsal wrist prominence, extensor tendon synovitis/rupture, DRUJ arthritis pain
• Darrach Procedure:
  
  • Reliable treatment option in older or less active RA patients
  • Patients with severe erosion of the distal ulnar head
  • Fails with pain from radioulnar impingement or unstable stump
  • Minimized with careful soft tissue procedures (ECU tenodesis)
• Sauve-Kapandji Fusion:
  
  • Preserves ulnocarpal support, resection of 10-15 mm of distal ulnar and fusion of ulnar head to radius
  • Preferred in active patients
  • Complications –> stump instability, impingement, extensor tendon rupture

Mod Rheumatol 2003 - Comparison of the Sauve-Kapandji procedure and the Darrach procedure for the treatment of rheumatoid wrists

• Sauve-Kapandji superior for reducing ulnar carpal migration and grip strength
• No difference in pain outcomes

Question 22

22. Which of the following is not correct regarding trigger finger in rheumatoid arthritis?
23. Type I involves focal Tendinopathy
24. Type II involves nodularity in distal palm
25. Type III involves nodularity adjacent to the A2 pulley
26. Type IV involves diffuse disease

Answer 22

ANSWER: A

2008

• Types of triggering:
• Type 1-Similar to non-rheumatoid stenosing tenosynovitis (first annular pulley)
• Type 1 is similar to nonrheumatoid stenosing tenosynovitis, in which the tendons catch at the first annular pulley during flexion secondary to small, localized hyperproliferation of the synovium
• Type 2 - Nodules form in distal palm, fingers lock in flexion
• Type 3 - Nodules on FDP near second annular pulley, fingers lock in extension
• Type 4- Generalized tenosynovitis within fibro osseous canal
• • 1 = A1 pulley synovitis
• 2 = A1 pulley nodule
• 3 = A2 pulley nodule
• 4 = generalized synovitis

From Oral Scenario – Classification (Green’s)

• 1)Grade 1:
• -Pain, history of catching, catching not demonstrable on exam…. Subjective catching
• 2)Grade 2:
• -Demonstrable catching, but pt can actively extend digit…… objective catching…active extension
• 3)Grade 3:
• -Demonstrable catching, requiring passive extension (or pt unable to actively flex)….objective catching… no active extension.
• 4)Grade 4:
• -Fixed flexion contracture of PIP joint….. fixed contracture

Question 23

23. Delayed healing of an ulnar collateral ligament of 1st MCP lesion results from interposition of what structure?
24. Adductor fascia
25. Abductor Pollicis
26. Interossei
27. Capsule

Answer 23

ANSWER: A

2013

JAOOS 2011 - Collateral Ligament of Thumb MCP

Stener lesion:

Distal end of UCL displaced proximal to adductor aponeurosis and blocked from reapproximation

Question 24

24. List the 4 stages of avascular necrosis of the lunate (2014)

Answer 24

Green’s Operative Hand Surgery

Litchman Classification:

1. No changes on imaging XR (only MR)
2. Sclerosis of lunate, may have fracture lines
3. Lunate Collapse, no scaphoid rotation
   
   1. 3B - Scaphoid rotation and DISI collapse
4. Degenerated Inter-carpal Joints

Question 25

25. List 5 stabilizers of the DRUJ (2010, 2014)

Answer 25

• TFCC
• Pronator quadratus
• ECU
• Interosseous membrane
• Bony congruency

Question 26

26. 65yo lady with ulnar sided wrist pain, unable to play tennis. What are 3 differential diagnoses? (2010, 2011, 2013, 2015)

Answer 26

Shin AY (JBJS ICL 2005) Ulnar sided wrist pain: diagnosis and treatment

• TFCC tear
• Ulnar impaction syndrome
• ECU tendonitis
• EDM tendonitis
• FCU tendonitis
• DRUJ instability/arthrosis
• LT instability
• PT arthritis
• Ulnar nerve compression
• Hypothenar hammer syndrome

Question 27

27. List four indications for a hemi-resection interpositional arthroplasty of the distal radioulnar joint of the wrist? (2011)

Answer 27

• Royal College Examples
• Rheumatoid arthritis in elderly patient
• OA DRUJ
• Ulnocarpal impaction syndrome
• Painful instability of DRUJ
• Rotational contractures of DRUJ

Question 28

28. Darrach procedure for arthritis. All of the following EXCEPT.
29. Better for OA than RA
30. Distal stump instability can be a complication
31. Associated with ulnar drift
32. Effective for DRUJ pain relief

Answer 28

ANSWER: A

2013

Some argument that all options are correct – Darrach not great in RA because of risk of ulnar drift

JAAOS 2012 - Arthritis of the DRUJ

Distal ulnar resection

Preferred option for low-demand patients with DRUJ arthrosis and non-reconstructable joint

Question 29

29. What is true about TFCC?
30. 18% of carpal load in ulnar neutral variance
31. have increased load with supination
32. increased load with ???
33. something about ligaments that was not true

Answer 29

ANSWER: A 

2014

The distal radioulnar joint: problems and solution. JAAOS. 1995.

• 18% of total compressive load across the wrist is transmitted through the ulnocarpal articulation à small changes in ulnar variance alter this force distribution (2.5mm increase in ulnar variance increases ulnocarpal load by 42%)
• Forearm PRONATION increases ulnar variance thereby increasing load through ulnocarpal articulation

Question 30

30. In regards to DRUJ, all are true except:
31. Bony articulation between sigmoid notch and ulna head provides 20% stability to DRUJ
32. ECU and volar ulnar carpal ligament are secondary stabilizers to DRUJ
33. Distal portion of interosseous membranes provides stabilization to dorsal dislocation
34. Palmar radial/ulnar ligament is primary stabilizer of palmar translation of radius on ulna

Answer 30

ANSWER: B

2011

JAAOS 2008 - Management of Acute TFCC Injury (Literally word for word)

• 20% of stability at DRUJ is provided through contact between ulnar head and sigmoid notch
• Dorsal translation primarily constrained by dorsal RU ligament
• Pronation has greatest translation if dorsal ligaments sectioned, vice versa with supination
• Distal portion of the interosseous membrane has been demonstrated to play a role in constraining dorsal radius translation and dislocation at the DRUJ
• The ECU subsheath and volar ulnocarpal ligaments do not appear to contribute significantly to DRUJ stability

Charles:

• TFCC is primary stabilizer and (ECU sheath and ulnocarpal lig origins are part of TFCC)
• ECU sheath, not ECU itself, ulnocarpal lig origins (not lig)
• Palmar DRUL resists palmar translation - Refer to Jay and Priya comments

B – primary stabilizers – Jay and Priya

D - Jacalyn and Kyla

Question 31

31. TFCC tear debridement, which of the following is a poor predictor of outcome?
32. Young age
33. Ulnar negative
34. Decreased pre-op ROM
35. Good pre-op ROM

Answer 31

ANSWER: C

2008

Ridiculous, C/D are contrary

JAAOS 2008 - Management of Acute TFCC Injury

Regarding arthroscopic repair of the TFCC

“significant correlations were noted between worsened outcomes and advancing age as well as post-operative ulnar positive variance”

Question 32

32. Matt Furey has painful ECU subluxation. Where does he get painful pop on exam?
33. supination
34. pronation
35. flexion
36. ulnar deviation

Answer 32

ANSWER: A

2011

JAAOS - Four common sports injuries of the hand and wrist

• Avoid the “ice cream scooping” position of supination, wrist flexion and ulnar deviation, which allows tendon subluxation

Orthobullets:

• Extension and supination of the wrist elicit a painful snap
• Reduces with pronation

Green’s Hand Surgery (p557)

• “patient can typically reproduce the pain or snapping by combined supination and ulnar deviation against resistance”

Question 33

33. Golfer with gradually increasing ulnar sided wrist pain. Recently has also been getting tingling in the 4th and 5th fingers. What is the best test?
34. Nerve conduction studies
35. MRI of Wrist
36. CT of carpus
37. AP and Lateral xray of wrist

Answer 33

C

2009, 2013

JAAOS 2001 - Acute hand and wrist injuries in athletes

• Hook of hamate fractures are endemic in sports such as golf, baseball and hockey
• Hook makes up one of the borders of guyons canal –> dyethesthesias of ulnar nerve from fracture or fibrous tissue encroaching on canal
• CT is most reliable test to identify a fracture

Question 34

34. What is an expected xray finding of LT dissociation:
35. Flexed scaphoid
36. No cortical ring sign
37. Lunotriquetral gap
38. Scapholunate angle of 45deg

Answer 34

ANSWER: A

2009, 2012, 2013, 2015

JAAOSs 2000 - Lunotriquetral Instability: Diagnosis and Treatment

• No gap between lunate and triquetrum
• Disruption of Guilila’s Line
• SL angle <30o
• Capitolunate angle >15o, zig-zag deformity
• Negative LT angle
• Cortical ring sign
• Shortened scaphoid

Question 35

35. All of the following are true regarding DISI deformity EXCEPT?
36. Scapholunate ligament disruption
37. Lunate extends
38. Scaphoid supinates
39. Incongruent radiolunate joint

Answer 35

ANSWER: D

-Supinates later, and Type 4 is controvertial, RL stays congruent (Charles changed from C)

2008, 2014

• Current status of scapholunate ligament injuries. JAAOS. 2002.
• DISI = dorsal intercalated segment instability; radiographic finding defined by increased radiolunate angle (>15deg dorsal); typically associated with scapholunate ligament disruption, scaphoid fracture/malunion, or distal radius malunion; associated with characteristic pattern of wrist arthrosis (SLAC/SNAC)
• Scaphoid flexes due to its attachments to trapezium, trapezoid, and capitate
• Triquetrum extends and pulls lunate into extension
• Radiolunate joint remains congruent until… end-stage SLAC (type IV) 
• • The thinner volar component contributes to rotational stability. SLD may progress to rotatory subluxation of the scaphoid when the ligaments secured to both ends of the scaphoid have failed, causing the scaphoid to collapse into flexion and pronation

Question 36

36. All are true about SLAC wrist except?
37. 4 corner fusion is preferential b/c it transfers load to the TFCC and distal ulna
38. triquetrum is dorsiflexed
39. scaphoid is flexed
40. Type I has severe involvement of the radial styloid

Answer 36

ANSWER: A

2011

• B and C are correct biomechanically due to de-tethering of proximal row
• Skie M (Hand 2007) Scaphoid Excision with Four-Corner Fusion
• Non-significant increase in load on the TFCC and scaphoid excision and four corner fusion

Question 37

37. Triscaph wrist fusion. All true except:
38. Lost 50% ROM
39. Rarely followed by another surgery
40. 90% contralateral side strength retained
41. Styloidectomy is essential part of procedure

Answer 37

ANSWER: A

2008

Watson (JHS Br 1999) One thousand intercarpal arthrodeses

• 798 STT fusions
• 96% union
• 75% ROM, 80% grip strength of contra-lateral side
• “radial styloidectomy was added to the procedure in 1987 to alleviate frequent symptomatic styloid impingement”

Kienbocks

• 80 patients in the series
• 60% ROM, 92% grip strength

Green’s Hand Surgery:

• 20% non-union rate
• Up to 52% complication rates in some series
• 50-70% ROM –> 80% at 1 year

Decision Making for Partial Carpal Fusions

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658677/pdf/jws01103.pdf
• The triscaphe joint is the shared joint between the scaphoid, trapezium and trapezoid bones in the wrist. This joint is also referred to by its much longer name, the scaphotrapeziotrapezoid (STT) joint.
• The main indications for STT fusion are isolated STT arthritis, rotary subluxation of the scaphoid, and Kienböck disease

Question 38

38.  List stages of Kienbock’s (2010, 2014)

Answer 38

Litchtman Classification:

1. Normal radiographs, abnormal MRI/bone scan
2. Lunate Sclerosis
3. Lunate Collapse
4. Carpal arthritis changes

Question 39

39. Two motion sparing techniques to manage a stage II SLAC wrist (2012)

Answer 39

• JAAOS 2003 - Proximal Row Carpectomy and Intercarpal Arthrodesis for the Management of Wrist Arthritis
• PRC
• Four-corner arthrodesis with scaphoid excision

Question 40

40. Which of the following is true regarding the wrist?
41. Lunate intraosseous pressures change with flexion and extension of the wrist
42. A capitate lengthening osteotomy is a good option for early Kienbock
43. A radial lengthening osteotomy is a good option for early Kienbock
44. Preiser disease of the triquetrum is usually self-limited

Answer 40

ANSWER: A

2012

Schiltenwolf M (JHS 1996) Further investigations of the intraosseous pressure characteristics in necrotic lunates

• Both in extension and in flexion, the intra-osseous pressures of all bones exceeded those in neutral position; this corresponded to the increase in pressure during venous stasis

Green’s Hand Surgery

• Joint leveling procedures:
  
  • Radial SHORTENING osteotomy
  • Ulnar lengthening osteotomy
  • Capitate shortening osteotomy +/- capitohamate fusion
• Vascularized bone graft
• STT fusion/SC fusion/PRC
• Presier disease is osteonecrosis of the scaphoid

Question 41

41. Which of the following is not normal for distal radius
    a. Ulnar variance -1mm
    b. Ulnar variance +1mm
    c. volar tilt 11 degrees
    d. radial inclination of 18 degrees

Answer 41

ANSWER: D

2015

• Schuind FA (JBJS 1992) A normal database of PA roetgenographic measurements of the wrist
• Mean ulnar variance -0.9mm (-4 to 2mm)
• Carpal height ratio 53% (46-61%)
• Radial inclination 24o (19-29)
• JAAOS 1997 - Surgical correction of the malunited distal radius
• The normal radial tilt is approximately 11 degrees.
• The average radial inclination is 22 degrees.

Question 42

42. All associated with Dupuytren’s contracture EXCEPT
43. Spiral cord
44. Cleland’s
45. Grayson’s
46. pre-tendinous

Answer 42

ANSWER: B

2012

Green’s Hand Surgery

Cleland’s ligament (dorsal to NV bundle), not a component of Dypuytren’s

Question 43

43. Which cord causes decreased abduction in Dupuytren’s?
44. Natatory cord
45. Spiral cord
46. Pretendinous cord
47. Lateral Band

Answer 43

ANSWER: A

2008

Green’s Hand Surgery:

• Natatory contracture leads to adduction of the fingers
• Spiral bands distort neurovascular anatomy
• Central cord = pretendinous cord –> MCP and PIP contracture
• Lateral Cord = contracture of lateral digital sheath
  
  • Does not contribute to severe deformities

Question 44

44. What is true about Dupuytren’s disease?
45. Skin graft acts as a barrier to recurrence
46. Needle aponeurotomy is more successful for PIP than for MCP contractures
47. Failure to correct contracture with fasciectomy is an indication for open PIP joint release
48. Radical fasciectomy is associated with increased complications

Answer 44

ANSWER: D

2015

Green’s Hand Surgery/JAAOS 2011/1998

• Percutaneous fasciotomy is more effective for MP contracture than PIP contracture
• Dermatofasciectomy –> proponents argue that skin is involved in process and must be removed
• Radical fasciectomy was originally performed out of the philosophy that resection of all palmar fascia would eliminate the chance for recurrence. However, recurrence rates remained high and the procedure has been abandoned for its unacceptably high rate of wound complications.
• Arthrolysis/capsuloligamentous release (controversial)

Weinzweig N (Plast Recon Surg 1996) - no difference in retrospective cohort study

Beyermann K (JHS Br 2004) - no difference in ROM

Question 45

45. All of the following are true of Dupytrens, except?
46. affects males more commonly
47. affects the 4 & 5th digits more commonly
48. it is associated with penile disease
49. It affects DIP joints more than MCP joints

Answer 45

ANSWER: D

2011

Question 46

46. Fasciectomy of palm in Dupuytren’s
47. STSG
48. Delayed primary closure
49. Allow to heal by secondary intention and start ROM

Answer 46

ANSWER: C

2009

Would need a full thickness skin graft for the palm, STSG just contract

Question 47

47. Patient has cold intolerance, ulcer on pulp of finger and blanching over dorsum of hand. What is not associated with this condition?
48. Calcinosis
49. Pitting Nails
50. Telangectasias
51. Arthralgia

Answer 47

ANSWER: B

2010

Scleroderma - CREST syndrome

Calcinosis, Raynaud Phenomenom, Esophageal Dysmotility, Sclerodactyly, Telangiectasia

Pitting nails –> psoriasis, alopecia areata, eczema

Question 48

48. List the dorsoradial and dorsoulnar wrist arthroscopy portals?

Answer 48

JAAOS 2012 - Advances is wrist arthroscopy

• 1-2 - dorsum of snuffbox, radial to EPL tendon (uncommon)
• 3-4 – between EPL and EDC – established first, main viewing portal
• 4-5 – between EDC and EDM – main instrumentation, visualized TFCC
• 6R – Radial side of ECU – instrumentation of ulnar sided structure
• 6U – Radial side of ECU
• Radial Midcarpal – Radial side of 3rd MC – visualize STT, SL and distal pole scaphoid
• Ulnar Midcarpal – 1 cm distal to 4-5 – visualize distal lunate, LT, TH
• STT - midshaft axis of index MC joint, just ulnar to EPL
• TH - just ulnar to ECU tendon at level of TH joint

Question 49

49. What is an indication for PRC
50. Septic Arthritis
51. End Stage Kienbock’s
52. Unrepairable TFCC
53. Ulnocarpal impaction

Answer 49

ANSWER: B

2012

• Green DP (JHS 2015) Proximal Row Carpectomy
• Radiocarpal arthritis
• SLAC/SNAC
• Advanced Kienbock disease
• Articular incongruency of radius in lunate fossa

Question 50

50. What is the main blood supply to the scaphoid?
51. Recurrent radial artery
52. Superficial radial artery
53. Dorsal carpal branch and superficial palmar arch
54. Ulnar Artery

Answer 50

ANSWER: C

2014

• Management of scaphoid non-unions. JAAOS. 2003.
• “The proximal half of the scaphoid is covered almost completely with articular surface with few, if any, perforating vessels. Thus, the vascularity of the scaphoid is based primarily on retrograde blood flow. Vessels entering the scaphoid through the dorsal ridge supply blood to 70% to 80% of the bone, and vessels that enter it through the volar branches of the artery supply the remaining 20% to 30%.”  
• Radial artery à branches into superficial branch (forms palmar arch) and dorsal carpal branch (gives off dorsal scaphoid branch which is main blood supply to scaphoid)

Question 51

51. All are true regarding Madelung’s, except?
52. Result of abnormality in dorsoulnar aspect of distal radial physis
53. Volar subluxation of the carpus
54. Often ulnar positive variance
55. Associated with Ollier’s

Answer 51

ANSWER: A

2013, 2014, 2016

• JAAOS 2013 – Madelung Deformity/Lovel and Winters Madelung Deformity
• Vicker’s Ligament – volar ulnar ligament
• Associated Syndromes  Turners, Leri-Weil Dysosteochondrosis, MHE, Ollier, Achondroplasia, MED, Hurler’s
• Features:
• Early presentation shows slight positive ulnar variance
• Loss of volar ulnar aspect of radial lunate fossa
• Carpus subluxes volarly
• McCarroll (JHS 2010)
• Ulnar tilt
• Lunate subsidence
• Lunate fossa angle
• Palmar carpal displacement

Question 52

52. Where can a glomus tumor be most commonly found
53. Pulp
54. Hyponychia
55. Distal phalanx
56. Nail Bed

Answer 52

ANSWER: D

2010

OKU9

• Glomus tumor is bridging of the terminal ends of the artery and vein
• Usually female in 20-40s, pain out of proportion
• Hypersensitive to temperature changes
• 75% hand, subungal most common
• Clinically have bluish tinge
• Can create a pressure erosion on underlying bone and deform cortex

Question 53

53. How do you diagnose a glomus tumor
54. MRI
55. XR
56. CT
57. US

Answer 53

ANSWER: A

2008

• JAAOS 2002 - Vascular problems of the upper extremity
• Normal glomus is an AVM in retinacular layer of dermis
• Often in fingertip beneath the nail
• Paroxysmal pain, pin point tenderness and cold sensitivity (50%)
• MRI can identify lesions as small as 5mm
• Treat with excision

Question 54

54. Glomus tumor: all except
55. Deep blue color
56. x-ray normal
57. Pin point pain
58. Situated under the nail bed

Answer 54

ANSWER: B

2009

AAOS Core Review (p.555)

• Benign tumor of the normal glomus body in subungual region
• Rare
• Patients 20-40 years, males = females
• Characteristic triad: paroxysmal pain, cold insensitivity, localized tenderness
• 10% have multiple lesions
• Plain radiographs not helpful, can show scalloped defect
• MRI best for diagnosis

Question 55

55. Give the 4 stages of perilunate instability. (2010,2011, 2013)

Answer 55

JAAOS 1998 Perilunate Injuries: Diagnosis and Treatment

The 4 stages of peri-lunate instability refers to the Mayfield Classification.

• Stage 1: disruption of the scapholunate ligamentous complex
• Stage 2: force propagates through space of Poirier and disrupts the lunocapitate connection
• Stage 3: lunotriquetral connection is disrupted and carpus separates from the lunate, usually dorsally
• Stage 4: the lunate dislocates from its radial fossa with the volar extrinsic ligaments intact, flipping volarly into the carpal tunnel. The rest of the carpus realigns with the radius

Question 56

56. List 5 reasons for fixation of an acute scaphoid fracture (2012, 2013, 2015, 2016)

Answer 56

JAAOS 2007 “Percutaneous fixation of scaphoid fractures.”

• Decision to forego conservative (cast) treatment of a scaphoid fracture is based on assessment of stability. The Mayo classification categorizes fractures as follows:
• Stable
  
  • Displacement <1mm
  • Normal intercarpal alignment
  • Distal pole fractures or waist fractures
• Unstable
  
  • Displacement >1mm
  • Lateral intrascaphoid angle >35 degrees
  • Bone loss or comminution
  • Perilunate fracture dislocation
  • DISI alignment (radiolunate angle > 15o)
  • Proximal pole fracture
  • Could also make an argument for patient desire for shorter duration of cast immobilization to be an indication.
  • Open Fracture

Question 57

57. What is true about dorsal barton fracture with dorsal subluxation of carpus?
58. Treat with closed reduction and casting
59. Volar radiocarpal ligaments not injured
60. Usually need volar and dorsal approach
61. Teardrop angle (TDA) will be ?increased/decreased due to volar impaction

Answer 57

ANSWER: C

2014, 2016

AAOS 2008 – Radiocarpal fracture dislocations

• Radiocarpal injuries must be differentiated from marginal or rim fractures of the distal radius
• Barton fractures
  
  • Barton fractures are compression injuries in which the articular surface of the fractured distal radius remains in contact with the proximal carpal row holding the intact radiocarpal ligaments
• Treatment principles:
  
  • Concentric reductions of radiocarpal joint
  • Identification and treatment of intercarpal injuries
  • Stable repair of osseo-ligamentous avulsions
  • Although closed reduction and cast immobilization have been reported to yield satisfactory results….we consider these injuries to be complex and unstable and routinely warrant surgical reduction and fixation

Lozano-Calderon/Doornberg/Ring (JBJS 2006) Fractures of the dorsal articular margin of the distal part of the radius with dorsal radiocarpal subluxation

• Dorsal Barton = subluxation of the distal radius consequent to a fracture through the articular surface of the carpal extremity of the radius, the fragment, usually is quite small and is broken from the dorsal end of the radius
• Case series of 19 operative patients
• 11 had dorsal alone, 7 combined, 1 volar alone
• “In conclusion, fractures of the dorsal margin of the articular surface of the distal part of the radius associated with dorsal radiocarpal subluxation or dislocation should be carefully evaluated for the presence of volar ligament injury or volar avulsion fracture, central articular impaction, and impaction of the majority of the articular surface as a large volar fragment. A combined dorsal and volar exposure is often necessary for these injuries because the central articular impaction and the dorsal marginal shearing fracture may be best treated through a dorsal exposure in internal fixation and the volar ligament injuries or avulsion fracture require a volar exposure and fixation. Despite the relative complexity of these injuries, satisfactory wrist function can be achieved in most patients.”

Green’s Hand Surgery:

• Also agrees with the dual approaches

Question 58

58. X-ray of volar bartons with carpus dislocation volarly and 1st CMC dislocation. Tx?
59. ORIF scaphoid
60. closed reduction and casting
61. ORIF distal radius, CRPP 1st CMC
62. closed reduction and percutaneous pinning of scaphoid and 1st CMC

Answer 58

ANSWER: C (although there appears to be something missing/forgotten about this question as there is no mention of scaphoid fracture in the stem yet there are multiple answer options for scaphoid fixation…)

2009, 2014

Traumatic thumb CMC joint dislocations. J Hand Surg, 2008

CMC dislocation of the thumb associated with ipsilateral fracture of the distal radius. JOT, 1997

• Thumb CMC (TM joint) dislocations are exceedingly rare!
• TM joint is inherently unstable due to biconcave surface, and relies on soft tissues for stability - beak ligament (aka. palmar/volar/anterior oblique), dorsal radial ligament, intermetacarpal ligament
• In opposition, MC internally rotates tightening dorsal radial ligament and beak ligament is compressed into recess of trapezium. Articular congruence of TM joint required for stability and function
• Dislocations occur due to axial load on adducted thumb - causes MC to dislocate dorsally on trapezium
• Treatment: significant controversy still exists (and difficult to conduct good studies due to rarity of condition)
• Poor evidence –> options spica cast, CRPP, ligament reconstruction
• Unable to maintain closed reduction = CRPP vs open reduction + ligament reconstruction (one RCT with small number of patients showed that 50% of patients treated with pinning alone required later ligament reconstruction – Simonian PT, J Hand Surg, 1996;21A:802)
• Unable to obtain closed reduction = open reduction + ligament reconstruction

Only one study addresses a CMC dislocation with a distal radius fracture! (Milankov M, JOT. 1997;11(4):311.)

• Case report of one patient with distal radius fracture (pattern not specified) and associated first CMC dislocation - treated with closed reduction and casting of radius + closed reduction and pinning of first-second MC. Patient had persistent CMC subluxation on 2yr f/u but refused treatment

Question 59

59. What is the best indication for performing a distal radius osteotomy?
60. 1 mm intra-articular step
61. 2mm radial shortening
62. Less than 10 degrees radial inclination on PA view
63. 5 degrees of dorsal tilt

Answer 59

ANSWER: C (old answer, stupid question)

none of these are strong! March Jess now thinks C. Fall Jess thought D because the paper talks a ton about dorsal tilt

2008, 2014

Bhandari - Evidence Based Orthopedics

Patients under the age of 65 years of age are more likely to have pain or stiffness or diminished grip strength with dorsal angulation 10o or more, radial inclination 15o or less, or ulnar positive variance of 3mm or more

“the following radiographic features warrant consideration of osteotomy: dorsal angulation > 20o, displaced fractures with carpal malalignment (>15o dorsal angulation of lunate), incongruity of the DRUJ, greater than 5mm ulnar positive variance, or unacceptable cosmetic deformity”

Early presentation of simple intra-articular malunion with >2mm incongruity can be treated with osteotomy

Question 60

60. After a distal radius fracture, a patient sustains a rupture of the EPL. What deficit will they have?
61. Thumb IP extension only
62. Thumb IP extension and pronation
63. Thumb IP extension and abduction
64. Thumb IP extension and adduction

Answer 60

ANSWER: A

2014

• Principles of hand surgery and therapy. Trumble, 2010.
• Abduction = extensor pollicis brevis; abductor pollicis brevis and longus contribute to palmar abduction
• Adduction = adductor pollicis
• IP extension = only extensor pollicis longus; only tendon to hyperextend

Question 61

61. Wrist 6 months post-ORIF. Patient returns unable to extend thumb DIP. What is the NEXT best step?
62. Tendon transfer EIP to EPL
63. Tendon transfer FDS to EPL
64. Nerve conduction studies
65. Thumb IP Joint Fusion

Answer 61

ANSWER: A

2016

• Hand Clinics 2010 “Soft tissue complications in distal radius fractures”
• Most common time period after a distal radius fracture for EPL rupture is 8 weeks after injury.
• “If rupture does occur, primary repair is not possible given the frayed tendon ends.
• Thumb extension can be restored by transferring the extensor indicis proprius tendon to the EPL tendon or reconstructing the tendon with an intercalary tendon graft.”

Question 62

62. 25 M Galeazzi facture. Radius underwent ORIF. DRUJ is reducible but unstable dorsally in pronation. Very tip of ulnar styloid is fractured. Appropriate treatment?
63. PIN and place in pronation
64. Arthroscopically or open fix TFCC
65. Fix styloid with tension band
66. Cast above elbow in supination x 6 wks

Answer 62

ANSWER: D… Charles says cast only if reducible and stable. If reducible and unstable, fix styloid (check stability after), if to small of a fragment then pin it and cast in supination. Suh says D

2008, 2011

JAAOS - Galeazzi Fractures

No mention of casting in adults without pinning when reducible and unstable

Question 63

63. 12 yr-old girl with a dislocated thumb MCP joint. You are told that you can feel the metacarpal head through the palmar skin. The X-ray shows a dislocation with no obvious fracture. The sesamoids are not obvious but may be in the joint (Ottawa/MUN thought was in joint). What is the treatment?
64. Thumb spica
65. Open reduction
66. Volar plate advancement arthroplasty
67. Immobilization with late ligament repair

Answer 63

ANSWER: B

2008

Presence of sesamoid in the joint indicates volar plate is in the joint

Question 64

64. An elderly lady comes to clinic, one year following a distal radius fracture. She complains of ulnar sided wrist pain. What is the best option for treatment at this point? (assuming it is healed in mal union?)
65. Observe and have continued follow-up
66. Resects the ulnar styloid
67. Resects the distal 2 cm of the ulna
68. Place her in a pronated wrist splint

Answer 64

ANSWER: A

2008

Lots of evidence in old answer which is loosely related but not directly getting at question, too irritated with the distal radius questions to look it up now

Current logic:

Maximize non-operative treatment…but if she wants an OR then why do a procedure which may fail (i.e. the styloid) when this is a low demand patient….just chop it out.

Shit question: if radius malunion then osteotomy and correct malunion, don’t chop of the ulna.

Answer: A

®JAAOS, DR Malunion, 2007 – non operative tx first, as there are no clear indications to operate, then discuss issues and patients needs, proper addressing of radial side or ulnar side, most definitely in younger, high demand patients, osteotomy > BG > fixation > druj > unlar procedure, darrach in elderly low demand (this is the old answer from most previous years)

Brinker p. 284 – non union usually involves dorsal tilt, loss radial length, leading to ulnocarpal impingement, DRUJ incongruity, mid carpal instability, pain, weakness, < ROM, corrective sx involves radial open wedge and BG

Jupiter, JBJS, 1996 – early or late DR mal union sx both acceptable, but tech easier earlier

Young et al, J Hand Sx – non op tx in elderly low demand and unfit for OR satisfactory

Wheeless – Darrach (1 – 2 cm) bone resection ulna for DR # non union in elderly

Jupiter & Fernadez, Comp Following DR #, JBJS, 2001 – elderly darrach still has place in ulnar pain tx, as loss of grip strength and function is well tolerated (done when? 5 months? 1 year? Phack!)

Question 65

65. What is the NOT associated with a lesser arc injury?
66. Scapholunate ligament tear
67. Luno-capitate ligament tear
68. Dorsal radiocarpal ligament injury
69. Volar radiolunate ligament tear

Answer 65

ANSWER: D

2013

JAAOS 1998 - Perilunate Injuries

Lesser arc injuries are the ligamentous pattern of a perilunate dislocation. The volar radiolunate ligaments are not disrupted (why lunate tips forward). Greater arc injuries are associated fractures 

Question 66

66. Why is lunate AVN rare with a dislocation?
67. multiple vessel supply
68. volar blood supply
69. intact SL ligament
70. intact dorsal capsule attachment

Answer 66

ANSWER: B

2011

Intact radiolunate ligaments and RSL ligament (Ligament of Testut)

Question 67

67. What is true regarding scaphoid waist fractures?
68. 90% of non-displaced fractures heal in a cast in 8 weeks
69. There is good evidence to support inclusion of the thumb in the cast
70. Surgery does not lead to faster return to work
71. Surgery decreases non-union rate

Answer 67

ANSWER: A (changed from D)

2015, 2016

NEW ANSWER:

-Suh/Grewal 2016 paper : The union rate was 99.4% (1 nonunion/172 subjects). The mean time to union was approximately 7.5 weeks (53 ± 37 days)

• A less likely….many not healed at 8 weeks
• McGill Stem –> specifies non-displaced fracture in stem
• Surgery decreases non-union
• Majority will heal after 8 weeks of immobilization
• Good evidence to include thumb in cast
• Patients will return to work faster with surgery
• Buijze GA (Journal Hand Surgery 2014) Cast Immobilization With and Without Immobilization of the Thumb for Nondisplaced and Minimally Displaced Scaphoid Waist Fractures: A Multicenter RCT (CAST Trial Collaboration)
• Null hypothesis = no difference in percentage of the fracture line at 10 weeks post treatment of BEC with or without thumb inclusion
• 62pts in US and Netherlands with CT or MRI confirmed scaphoid f#s (included 7 distal pole fractures due to an error in enrollment, but they included them anyway)
• More healing in NO THUMB group than thumb group at 10 weeks (85% fracture healed vs 70%), overall union rate 98%
• Only failure was idiot who used crutches after dropping out and getting ORIF
• No difference wrist motion, grip strength Mayo Modified Wrist Score, DASH, or pain rating between groups
• Journal of Hand Surgery 2016 - A systematic review and meta-analysis examining the differences between nonsurgical management and percutaneous fixation of minimally and non-displaced scaphoid fractures
• Although the RTW in group 2 (operative) has a wide range between 1 and 8 weeks, almost all studies showed a faster RTW using percutaneous fixation (compared to 8-15 weeks in non-op).
• Reported average time to union in group 2 (operative) ranged between 6 and 10 weeks compared with 10 and 12 weeks in group 1 (non-operative).
• The majority of studies have shown a comparable rate of union between nonsurgical management and surgical intervention for undisplaced scaphoid waist fractures
• Buijze GA (JBJS 2010) Surgical Compared with Conservative Treatment for Acute Nondisplaced or Minimally Displaced Scaphoid Fractures: A review and meta-analysis
• Heterogenous results that favors surgical treatment in terms of satisfaction, grip strength, time to union and time off work
• No difference in pain, ROM, rate of nonunion and malunion, cost of treatments
• Complications higher if surgical group
• 2016 Open Orthop J - Is casting for non-displaced simple scaphoid waist fracture effective? A CT based assessment of union
• In total, 98 patients healed in ≤6 weeks (57%) and there were only 20 patients who took >12 weeks to heal (11.7%) (but only 126/172 were healed by 8 weeks, which is 73%)
• Note: they counted 50% union on CT as healed
• Bhandari - Evidence Based Orthopedics
• Faster return to work only in laborers
• Opinion is divided on whether undisplaced fractures heal faster with ORIF or casting

Question 68

68. Scaphoid waist fracture. All are true for risk of non-union except?
69. delayed intervention
70. carpal instability
71. SL tear
72. ulnar negative variance

Answer 68

ANSWER: D

2011

A is definitely true, B and C are synonymous

Question 69

69. 25 yo with 3 month old scaphoid non-union with SL angle 70 degrees. What is most appropriate treatment? 
70. ORIF with ICBG and compression screw
71. ORIF with ICBG and pins
72. Cast
73. ORIF with pin

Answer 69

ANSWER: A

2010

Scaphoid non-union with a DISI deformity –> needs structural bone grafting

Question 70

70. Which patient needs surgery for scaphoid non-union?
71. Proximal pole scaphoid
72. 25 year old male, asymptomatic
73. Not united at 6 weeks in a cast
74. CT evidence of progressive healing

Answer 70

ANSWER: B (A)

2008

IDK about the proximal pole

Lindstrom G (JHS Br 1992) Natural history of scaphoid non-union, with special reference to asymptomatic cases

100% incidence of progressive radiocarpal osteoarthritis at 37 years following scaphoid non-union

Freedom of pain is not a reliable prognosticator, all patients with non-union are likely to benefit from surgical treatment of the surgical pseudoarthrosis

Ruby LK (JBJS 1985) Natural history of scaphoid non-union

In the thirty-two patients who had been injured five years or more earlier, arthritis developed in thirty-one (97%).

Question 71

71. Reduction maneuver for a Bennet fracture does NOT include
72. Traction
73. Adduction
74. Extension
75. Pronation

Answer 71

ANSWER: B

2013

JAAOS 1999 - Thumb Metacarpal Fractures

Reduction maneuver includes:

Longitudinal traction

Abduction with dorsoradial pressure on apex

Pronation of distal fragment

Thumb extension

Question 72

72. What ligament holds the articular fragment in place in a Bennet’s fracture?
73. anterior oblique
74. posterior oblique
75. radial
76. Collateral

Answer 72

ANSWER: A

2008, 2014

Principles of hand surgery and therapy. Trumble, 2010.

 JAAOS 1999

Bennett fracture = avulsion of beak ligament from base of 1st MC; unstable due to pull of adductor pollicis and abductor pollicis longus resulting in supination and dorsoradial displacement of 1st MC

Beak ligament (aka. Palmar oblique ligament, anterior oblique ligament) runs from trapezium to ulnar/volar aspect of 1st MC

Question 73

73. What is the treatment for a dorsal PIP fracture/dislocation with 50% volar bone loss from base of middle phalynx?
74. Hemi-hamate resurfacing
75. Dorsal block splinting
76. Dorsal block pinning
77. Buddy taping

Answer 73

ANSWER: A

2014, 2016

JAAOS 2013 – Fracture dislocation of the PIP

Management:

Stable dislocation can be treated with buddy taping

Need to be stable in <30o of flexion

Closed reduction and trans-articular or extension block pinning

Closed reduction and percutaneous pinning

Question 74

74. Young male with dorsal PIP fracture/dislocation involving 25% of the articular surface. What is the most important factor for good outcome?
75. Anatomic articular reduction
76. Hand therapy
77. Congruent reduction of the dislocation
78. ORIF

Answer 74

ANSWER: C

2015

JAAOS 2013 - Fracture dislocation of the proximal IP joint

Quality of reduction not shown to correlate with post-traumatic arthritis

As long as there isn’t hinging motion or unstable joint

Question 75

75. Regarding a volar PIP dislocation, what is the block to reduction?
76. Oblique retinacular ligament
77. Transverse retinacular ligament
78. Lateral band
79. Collateral ligament

Answer 75

ANSWER: C

2008, 2014

• Principles of hand surgery and therapy. Trumble, 2010.
• Irreducible palmar dislocation of the proximal interphalangeal joint. J Hand Surg. 1990
• Rare injuries
• Mechanism is typically forced flexion à axial load often leads to fracture-dislocation
• Volar PIP dislocations result in injury to central slip and at least one collateral ligament
• Middle phalanx displaces volarly on proximal phalanx, and condyles of proximal phalanx can get caught between central slip and lateral bands
• Often require open reduction due to entrapped soft tissues
• Treatment is much slower than dorsal dislocations à require immobilization in extension to allow for central slip to heal
• Fracture dislocations that are unstable in full extension require surgical fixation (pinning vs ORIF) à best approach for reduction/fixation is dorsal through torn central slip
• Chir Main 2009 - Irreducible volar dislocation of the proximal interphalangeal finger joint
• Lateral band is separated from central slip and in the joint, joint reduces once lateral band is fixed
• All volar PIP dislocations tear central slip and one lateral band and volar plate

Question 76

76. What is the best indication for fixation of a 5th metacarpal fracture?
77. 20 degree apex dorsal angulation
78. short oblique minimally displaced
79. shortening 5mm
80. malrotation 5mm

Answer 76

ANSWER: D 

• 2014, 2015 ( slight variations)
• Principles of hand surgery and therapy. Trumble, 2010.
• Operative treatment of metacarpal and phalangeal shaft fractures. JAAOS. 2000.
• Fifth MC fractures are very common à “boxer’s injury”
• Intra-articular base/head fractures are generally reduced and pinned
• Increased displacement acceptable more distal (ie. neck) than proximal (ie. base)
• Unacceptable displacement of ring and small MC:
• Any amount of rotation
• Shortening >5mm
• Angulation >10-15deg (shaft) or 40-70deg (neck)
• Unacceptable displacement of index and middle MC:
• Any amount of rotation
• Shortening >5mm
• Angulation >5deg (shaft) or 20-30deg (neck)
• Green’s Surgery:
• Angulation of metacarpal shaft fractures
• 30o in D5, 20o D4, 10o D2-3
• 2-5mm shortening
• No rotation

Question 77

77. Which of the following are true in regards to metacarpal shaft fractures?
78. dorsal angulation is due to intrinsics and extensor tendons
79. treat short oblique with cast immobilization- unstable so cant treat in cast usually
80. transverse fractures reduced with longitudinal traction and fluoro
81. ORIF for displaced, malrotated, and shortened shaft by 2.5mm

Answer 77

ANSWER: D

2011

Green’s Hand Surgery

Metacarpal shaft fractures displace apex dorsal (volar angulation) due to interossei

Oblique fractures displace into rotation –> fix

Any malrotation is unacceptable

Question 78

78. Oblique metacarpal fracture treated with interfrag screws
79. Length of fracture should be 2x cortical diameter
80. Screws should be 90o to the metacarpal
81. Screws should be 90o to the fracture

Answer 78

ANSWER: A

2008

JAAOS 2000 - Metacarpal and Phalangeal Fractures

Inter-fragmentary screw fixation alone is adequate if the length of the fracture exceeds twice the diameter of the bone

Interfragmentary screw configuration should include one screw perpendicular to the fracture and one screw perpendicular to the shaft to resist shear stress at the fracture site

Question 79

79. Primary stabilizer of PIP joint?
80. volar plate
81. collateral ligament
82. extrinsic tendons
83. intrinsic tendons

Answer 79

ANSWER: A (and B)

2011

Netter’s Orthopedics:

Proper collateral is the primary stabilizer of PIP

Tight in flexion, loose in extension

Sagars: volar plate and collaterals are main restraints to PIP

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5891829/pdf/nihms951164.pdf

The true and accessory collateral ligaments (ACLs) embrace the radial and ulnar walls of the box and prevent lateral deviation. Along the base, the volar plate functions to limit hyperextension of the joint.11 In addition to the three primary stabilizers, the joint is further supported by the central slip, the lateral bands, and the flexor tendons, collectively referred to as secondary stabilizers

Question 80

80. Which of these is best indicated for replantation?
81. 2 hrs warm ischemia time through distal thumb
82. 2 hrs warm ischemia time through the wrist
83. 2 hrs warm ischemia time through the middle phalanx
84. 7 hrs warm ischemia time through the distal forearm

Answer 80

ANSWER: B

2016

• JAAOS 2015 – Replantation of the Upper Extremity
• JAAOS 1998 Amputations of the Fingers and Hand: indications for Replantation
• Indications:
• Loss of a thumb
• Multiple digit amputation
• Amputations at or proximal to the palm
• Pediatric finger amputations at any level
• Single digit amputation in flexor tendon zone 2
• Contra-indications:
• Single digit amputations through zone II
• Severe crush
• Mangling
• Heavy contamination
• Segmental injuries
• Prolonged warm ischemia time
• Warm ischemia time should not exceed 12 hours for digits and 6 hours for amputated parts with substantial muscle
• Cold ischemia time 24 hours for digits and 10-12 hours for limbs

Question 81

81. List 5 regions of entrapment for the ulnar nerve (2016)

Answer 81

JAAOS 2007 - Entrapment Neuropathy of the Ulnar Nerve

• Medial intermuscular septum
• Arcade of Struthers
• Medial head of triceps
• Cubital Tunnel
• Medial epicondyle
• Osbourne Ligament
• Fascia of the FCU
• Aponeurosis of the proximal edge of the FDS
• Anconeus epitrochlearis
• Anomalous muscle
• Guyon’s Canal

Question 82

82. 3 sites of compression in radial tunnel syndrome (2010)

Answer 82

(1998 JAAOS Uncommon Nerve Compression Syndromes of the Upper Extremity)

• Fibrous margin of the ECRB
• “fibrous bands at level of the radiocapitellar joint”
• Radial recurrent artery (Leash of Henry)
• Arcade of Frohse (entrance to supinator)
• Fibrous band at distal margin of supinator

Question 83

83. 4 Successful non-operative modalities for carpal tunnel (2012)

Answer 83

AAOS Clinical Practice Guidelines from 2016 for CTS

• Brace/splint (strong)
• Steroid (methylprednisolone) injection (strong)
• Ketoprophen phonophoresis (moderate evidence for pain reduction)
• Oral steroids (moderate evidence for)
• Therapeutic ultrasound (limited evidence)
• Laser therapy (limited evidence)
• Note: Moderate evidence supports NO BENEFIT for other oral medications including NSAIDs, gabapentin, etc)

Question 84

84. List 4 sites of compression of the PIN (2011)

Answer 84

JAAOS 1998 - Uncommon Nerve Compression Syndromes of the Upper Extremity

Elbow synovitis by TA

• Benign tumors/ganglions
• Supinator muscle
• Arcade of Frohse
• Netter’s Orthopedic Anatomy:
• Leash of Henry
• ECRB
• Arcade of Frohse
• Distal edge of supinator

Question 85

85. List 4 sites of compression of the AIN around the elbow and forearm (2014)

Answer 85

JAAOS 2013 - Pronator Syndrome and Anterior Interosseous Nerve Syndrome

• “all points of compression from proximal to distal should be identified and released, including:
  
  • Overlying lacertus fibrosis
  • Humeral head of PT
  • Proximal fascial margin of the FDS arch
  • Gantzer muscle (accessory head of FPL)

GFPL

Pronator Syndrome:

• Proximal median nerve dysfunction that may result from compression of the nerve at:
  
  • Ligament of Struthers
  • Supracondylar Process
  • Bicipital aponeurosis
  • Gantzer muscle

Question 86

86. List 6 principles of tendon transfers. (2010, 2013)

Answer 86

JAAOS - Tendon Transfers for Radial, Median and Ulnar Nerve Palsy

• Tendon Transfer Principles:
• Minimize functional loss of donor tendon
• Strength of donor muscle must be normal and under voluntary control
• Strength of tendon will decrease by one grade of motor power
• Must have sufficient excursion
• Wrist Ex/Flex –> 33mm
• Finger extension –> 50mm
• Finger flexion –> 70mm
• • 20-30mm with wrist motion
• Vector of pull in line, ideally only cross one joint
• One tendon, one function
• Stable soft tissue bed that allows gliding
• Full passive range of joints
• Preferentially use in phase tendons (synergistic functions)

Question 87

87. 50 yr Secretary had carpal tunnel release 6 months ago and still has hand/wrist pain. OE has tinels on scar on radial side of wrist at the wrist crease. 5 mm 2 pd. Thumb power normal. What is the problem?
88. Partial transverse carpal ligament release
89. Damage to the Recurrent motor branch
90. Incomplete carpal tunnel release
91. Damage to the palmar cutaneous branch

Answer 87

ANSWER: D

2012

Tung THH (Plast Reconstr Surg 2001) Secondary Carpal Tunnel Surgery

Injury to the palmar cutaneous nerve or one of its branches is most frequently the problem. A more radially placed incision is more likely to cross the distribution of the palmar cutaneous branch, with subsequent injury and neuroma formation

Question 88

88. What is the most common complication following carpal tunnel release?
    a. Pillar pain
    b. Recurrance/incomplete
    c. Infection 20%
    d. Injury to the palmar cutaneous branch

Answer 88

ANSWER: A

2015

• Tung THH (Plast Reconstr Surg 2001) Secondary Carpal Tunnel Surgery
• Persistence of pre-operative complaints is the most common complication of carpal tunnel release with an incidence of 7-20%
• Persistence occurs for three reasons:
• Transverse carpal ligament is incompletely released
• Continued compression more proximally by inadequate release of distal antebrachial fascia
• Compression of nerve more proximally (wrong diagnosis)
• JAAOS 2007 Carpal Tunnel Syndrome
• Complications have been reported with all techniques of carpal tunnel release surgery, including but not limited to injuries to the motor branch and palmar cutaneous branches of the median nerve, hypertrophic scar formation, pillar pain, laceration of the superficial palmar arterial arch, incomplete release of the TCL, tendon adhesions, infection, wound hematoma, finger stiffness, and recurrence.77 The most common complication with open carpal tunnel release surgery is pillar pain, followed by laceration of the palmar cutaneous branch of the median nerve. Pillar pain occurs in approximately 25% of surgical cases, with symptom resolution reported in most patients by 3 months.78 Incomplete release of the TCL with persistent or recurrent CTS symptoms is the most frequent complication attributed to endoscopic carpal tunnel release surgery.

Question 89

89. What is the primary functional loss with a low median nerve palsy?
90. Thumb opposition
91. Key pinch
92. Thumb IP flexion
93. Index IP flexion

Answer 89

ANSWER: A

2014

• Thump opposition = low median
• Key Pinch = ulnar
• Thumb IP = AIN
• Index IP flexion = AIN
• Principles of Hand Surgery, Trumble
• Course of median nerve: medial and lateral cord of brachial plexus à runs with brachial artery in anteromedial upper arm à crosses elbow between biceps and pronator teres (two heads of pronator is spot of compression) à runs between FDS and FDP in forearm (compression) à AIN branches ~4cm distal to elbow and dives deep to travel on anterior interosseous membrane (first to be affected by compartment syndrome as well as injuries about proximal forearm and distal humerus) à palmar cutaneous branches proximal to wrist and lies ulnar to FCR and radial to palmaris longus (provides sensation to thenar eminence) à carpal tunnel (compression) à recurrent motor branch has variable course but usually branches off radial aspect at distal end of tunnel (motor to thenar muscles) à final branches are digital nerves to middle, ring, and small fingers (motor to lumbrical + palmar skin of radial 3½ digits)
• Thumb flexion = FPL à high median nerve
• Thumb opposition = opponens + abductor pollicis brevis à recurrent motor branch
• Key pinch = adductor pollicis + interossei à deep motor branch of ulnar nerve
• MCP flexion = FPB à two heads (superficial = median; deep = ulnar)
• Green’s Hand Surgery - Ch34 Median and Ulnar Nerves:
• “Median nerve injuries are classified as high or low, depending on whether the lesion is proximal or distal to the origin of the AIN in the proximal forearm.”
• ALTHOUGH. AAOS says its below the palmar cutaneous nerve
• JAAOS 2013 Tendon Transfers for Radial, Median and Ulnar Nerve Palsy
• Low median nerve palsy results in loss of thumb opposition, which is a composite motion involving pronation, flexion and palmar abduction at the trapeziometacarpal joint and flexion at the MCP joint
• Principal motor unit for thumb opposition is the APB muscle
• Because of the complex innervation –> patients may have opposition despite low median nerve palsy
• High median nerve palsy:
• Proximal to the elbow
• Loss of thumb opposition, flexion deficits of the DIP and PIP in the index and middle fingers, low of thumb IP flexion, decreased pronation

Question 90

90. Pt. Has weakness of FPL, FDP, and pronation, with no sensory weakness. Cause?
91. Median nerve
92. AIN
93. Pronator syndrome
94. C7

Answer 90

ANSWER: B

2011

JAAOS - Uncommon Nerve Compression Syndromes of the Upper Extremity

• AIN Syndrome:
• Motor deficits alone
• FDP (2,3), FPL and pronator
• Pronator Syndrome:
• Pain with resisted elbow flexion, pronation, FDS
• Compression of both median nerve and AIN

Question 91

91. What is true about electro-diagnostic studies and carpal tunnel syndrome?
92. EMG is most sensitive
93. motor latency is the least sensitive
94. sensory is the most sensitive
95. decreased conduction velocity in early disease

Answer 91

ANSWER: C

2011

Wheeless:

• Sensory latency is the most sensitive and earliest indicator of Carpal Tunnel
• JAAOS 2007 Carpal Tunnel Syndrome
• Threshold sensory tests are more sensitive than innervation density measurements in detecting early CTS
• This is referring to things like monofilament testing but I think the principle stands
• Miller’s
• Distal sensory latencies more than 3.5 ms or motor latencies more than 4.5 ms are abnormal.
• Decreased conduction velocity and peak amplitude are LESS SPECIFIC
• EMG may show insertional activity, postive sharp waves, fibrillation and APB fasciculations
• MORE severe findings on EMG are associated with worse treatment outcomes
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6426775/pdf/fneur-10-00149.pdf
• It has previously been established that sensory nerve conduction studies are the most sensitive electrodiagnostic tests to confirm the diagnosis of CTS. Motor nerve conduction studies are important in the documentation of motor fiber involvement in CTS. In more severe cases, sensory nerve action potentials (SNAP) may not be recordable (4). In this case, motor nerve conduction studies are the only electrophysiological means to confirm the clinically defined diagnosis of CTS
• In the electrophysiological confirmation of CTS, sensory nerve conduction tests and terminal latency index have a high sensitivity. If, however, sensory nerve action potentials cannot be recorded, all motor nerve conduction tests have a high sensitivity.
• The sensory nerve action potential becomes unrecordable as CTS becomes more severe while the distal motor latency is both insensitive to early CTS and also becomes unrecordable at the most severe extreme.

Question 92

92. What is the most sensitive test for carpal tunnel compression? 
93. vibratory
94. emg
95. Static 2 point
96. Moving 2 point

Answer 92

ANSWER: A

2010

I just did a ton of searching and can’t find the answer to this question, but I’ll go with this single sentence from the above mentioned JAAOS and accept the old answer of A

Sensory testing alternatives for CTS include innervation density measurements using static or moving 2‐point discrimination and threshold sensory measurements using Semmes‐Weinstein monofilaments or vibrometry. Threshold sensory tests are more sensitive than innervation density measurements in detecting early CTS

https://www.jospt.org/doi/pdf/10.2519/jospt.2019.0301

Question 93

93. ORIF of forearm and FPL and FDP 2/3 not working, options for tendon transfers
94. DIP fusions
95. Fuse both thumb and fingers
96. BR to FPL and FDP 4/5 to FDP 2/3
97. BR to FPL and fuse DIPs

Answer 93

ANSWER: C

2008

Charles - should be BR to FPL and FDS4/5 to FDP 2/3

Question 94

94. Several lacerations to ulnar aspect of distal forearm and hand. Pt has numbness to dorsum of ulnar aspect of hand. No volar numbness, no motor deficit. Where is the injury?
95. Guyon’s Canal Zone 1
96. Guyon’s Canal Zone 2
97. Guyon’s Canal Zone 3
98. Proximal to Guyon’s Canal

Answer 94

ANSWER: D

2014

• Reference is mainly Orthobullets (for zones of Guyon’s canal) and Netter’s anatomy
• Zones of Guyon’s canal:
• Zone 1 - from the proximal edge of the palmar carpal ligament to the bifurcation of the ulnar nerve; sensory and deep motor branches of the ulnar nerve susceptible to compression
• Zone 2 - from the bifurcation of the ulnar nerve just distal to the fibrous arch of the hypothenar muscles; deep motor branch of the ulnar nerve susceptible to compression
• Zone 3 - only the sensory branch of the ulnar nerve is susceptible to compression
• Numbness to dorsoulnar aspect of hand = injury superficial sensory branch of ulnar nerve which branches PROXIMAL to Guyon’s canal
•  
• Pfaeffle (Hand Clin 2007) - Ulnar Nerve Laceration and Repair
• High level ulnar nerve lesions encompass all injuries to the nerve proximal to the innervation of the FCU and FDP
• Present with absence of sensation in the small finger and ulnar half of the ring finger, loss of the intrinsic motors in the hand, and loss of motor function in the FDP to the small and ring fingers
• Weakness of the intrinsic musculature results in clawing of the small and
• ring fingers with MCP joint hyperextension and PIP flexion plus weakness of key pinch
• Low-level lesions:
• Similar sensory deficits, although the dorsal sensory branch might be spared and dorsoulnar hand sensation thus preserved
• FDP function intact, clawing is more pronounced because there are intact flexors
• Wrist flexion strength is maintained

Question 95

95. Patient with complete paralysis of intrinsics but no anaesthesia. Where is the lesion?
96. At formation of ulnar nerve
97. At the elbow
98. Proximal to pisiform
99. Between adductor and flexor digiti minimi

Answer 95

ANSWER: D

2015

JAAOS 2014 - Ulnar Nerve Entrapment at the Wrist

Deep motor branch typically arises from the dorsal and ulnar side of the nerve trunk and courses distally and radially to the hook of the hamate, innervating the FDM, ADM and ODM

Question 96

96. Which of the following is not a sign of cubital tunnel compression:
97. Claw hand
98. Positive Finklesteins
99. Positive Froment (or ?Wartenberg)
100. Positive tinels at elbow

Answer 96

ANSWER: B

2014

• Cubital tunnel syndrome. J Hand Surgery. 2010.
• Potential sites of ulnar nerve compression around elbow:
• Arcade of Struthers (aka. band of fascia from medial head of triceps to medial intermuscular septum)
• Anconeus epitrochlearis
• Medial intermuscular septum
• Medial epicondyle
• Cubital tunnel (roof is formed by ligament of Osbourne)
• FCU aponeurosis (between two heads)
• Claw hand = weakness of instrinsics and overpull of extrinsics à due to ulnar neuropathy anywhere along length of nerve
• Finkelstein’s = pain with grasping of thumb in palm and ulnar deviation of wrist à sign of DeQuervain’s tenosynovitis
• Froment’s = flexion of thumb IP when grasping paper between 1st and 2nd fingers à sign of intrinsic muscle weakness (specifically adductor pollicis) due to ulnar neuropathy
• Wartenberg’s sign = persistent abduction of D5 with attempted adduction due to weakness of interossei (3rd palmar interosseous)

Question 97

97. Pt with numbness to ulnar side of left forearm and ulnar aspect of digit 5. No motor findings. What is the most likely diagnosis?
98. C7-T1 left disc herniation
99. C6-7 left disc herniation
100. ulnar nerve compression at wrist
101. ulnar nerve compression at cubital tunnel

Answer 97

ANSWER: A

2012, 2014

• Cubital tunnel syndrome, J Hand Surg. 2010
• Netter’s anatomy
• Innervation to the ulnar aspect of the forearm is provided by the medial antebrachial cutaneous nerve purely sensory nerve derived from C8 and T1 nerve roots; branches directly from medial cord of brachial plexus
• Innervation to the ulnar aspect of D5 is primarily from the superficial sensory branch of the ulnar nerve (C8 and T1) –> branches in Guyon’s canal
• Innervation to the dorsal ulnar hand is from the dorsal cutaneous branch of the ulnar nerve (C8 and T1) - branches in distal 1/3 of forearm
• A) C7-T1 left disc herniation will compress the exiting nerve root (C8) and possibly the traversing nerve root as well (T1) –> sensory to both ulnar forearm and D5 numbness +/- motor to intrinsics and FCU
• B) C6-7 disc herniation will compress C7 –> sensory to middle finger + motor to triceps
• C) Ulnar nerve compression at wrist - sensory only to volar ulnar palm and 1.5 digits + motor to intrinsics
• D) Ulnar nerve compression in cubital tunnel - sensory to entire ulnar palm and 1.5 digits + motor to intrinsics and FCU; FOREARM PAIN IS COMMON, BUT GENERALLY NO NUMBNESS! 

Question 98

98. A young male patient has ulnar neuropathy from the cubital tunnel. What is true regarding ulnar nerve exploration and release?
99. Subcutaneous anterior transposition has better results.
100. There is no difference between no anterior transposition and sub-muscular transposition.
101. Submuscular anterior transposition has better results.
102. there are increased complications with sub-muscular anterior transposition

Answer 98

ANSWER: D (B old answer, now meta-analyses to show D true)

Anterior Subcutaneous Versus Submuscular Transposition of the Ulnar Nerve for Idiopathic Cubital Tunnel Syndrome: A Matched Retrospective Comparative Study J Hand Surg;

JAAOS 2015 Subcutaneous Versus Submuscular Anterior Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

2019 Apr;11(1):18-27. doi: 10.1055/s-0038-1670928. Epub 2018 Sep 27.

Ulnar Nerve In Situ Decompression versus Transposition for Idiopathic Cubital Tunnel Syndrome: An Updated Meta-Analysis

Conclusion There is no statistically significant difference in clinical outcomes or rate of revision surgery between SD versus UNT. However, there were significantly more complications with UNT. The current body of evidence regarding cubital tunnel syndrome lacks prospective, randomized, controlled trials, uniform reporting of indications, and standardized outcome scoring.

Cubital Tunnel Syndrome

Journal of the American Academy of Orthopaedic Surgeons, 25(10), e215-e224 - October 2017

In practice, submuscular transposition is a highly effective procedure for patients with advanced disease.38 However, it increases surgical time and involves greater surgical morbidity. Surgical wound complications are more likely after transposition surgery than after in situ decompression. Several series have identified increased rates of deep infection (9% to 14% versus zero to 3%) and more frequent loss of sensation around the incision (19% versus 3%)30,37 after transposition, compared with in situ decompression

2010, 2013

• Difficult question given recent rapid swing of pendulum of evidence
• Old groups all agree that there are no difference in clinical outcomes and increased complications with transposition
• Liu CH (PLoS One 2015) Anterior subcutaneous versus sub-muscular transposition of the ulnar nerve for cubital tunnel syndrome: a systematic review and meta-analysis
• No difference
• Our meta-analysis suggested that no significant differences in the primary outcomes were observed between comparison groups, both in RCT (RR, 1.16; 95% CI 0.68–1.98; P = 0.60; I2 = 81%) and observational studies (RR, 1.01; 95% CI 0.95–1.08; P = 0.69; I2 = 0%). These findings were also consistent with all subgroup analyses for observational studies. In the secondary outcomes, the incidence of adverse events was significantly lower in subcutaneous group than in submuscular group
• Macadam SA (JHS 2008) Simple decompression versus anterior subcutaneous and Submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis
• No difference
• Bartels (Neurosurg 2005)
• 75 decompression vs 77 subcutaneous transposition
• No difference in clinical outcome
• More complication in transposition (31 vs 10%)
• • Overall, there is no evidence to suggest subcutaneous transposition is superior to in situ decompression, and that outcomes are likely comparable between the two techniques. Except in the case of a nerve subluxation on exam, which over time may cause chronic irritation which is relieved by transposition it may be preferable to perform in situ decompression as the de facto procedure in order to preserve the vascular supply which is disrupted by transposition, however many proponents of the procedure argue that the anastomoses between proximal and distal vascular supply to the nerve negates this point (47). The nerve is more exposed to potential trauma in its post-transposition location, with only the skin and small amount of subcutaneous tissue protecting it from external forces as compared to being protected by the bony structures of the elbow and several layers of overlying tissue in its native position.
• • Subcutaneous transposition has the advan-tages of being less invasive, less technically demanding, and allowing for early postoperative mobilization(26) when compared with intramuscular or submuscular transposition of the ulnar nerve; however, it places the nerve in a position vulnerable to repetitive trauma, par-ticularly in thin patients

Question 99

99. Which is not a possible cause of cubital tunnel syndrome
100. medial border of Brachialis
101. Arcade of Struthers
102. Intermuscular septum
103. Osbornes ligament

Answer 99

ANSWER: A

2013

• JAAOS 2007 - Entrapment Neuropathy of the Ulnar Nerve
• Medial intermuscular septum
• Arcade of Struthers
• Medial head of triceps (?)
• Cubital Tunnel
• Medial epicondyle
• Osbourne Ligament
• Fascia of the FCU
• Aponeurosis of the proximal edge of the FDS
• Anconeus epitrochlearis
• Anomalous muscle
• Guyon’s Canal

Question 100

100. What is the most common cause of recurrent compression of the ulnar nerve after decompression?
101. Arcade of struthers
102. Medial intermuscular septum
103. Osbourne’s ligament
104. FCU

Answer 100

ANSWER: B

2009

Filippi R (Minim Invasiv Neurosurg 2001) Recurrent cubital tunnel syndrome

• “The causes of continued or recurrent symptoms after initial surgery included dense perineural fibrosis of the nerve after subcutaneous transposition, adhesions of the nerve to the medial epicondyle and retention of the medial IM septum”
• JBJS Current Concept Reviews 2016 - Recurrent Cubital Tunnel Syndrome
• “multiple authors have reported that the unresected IM septum was the site of compression found during revision cubital tunnel surgery”

Question 101

101. Guy who does a lot of work with repetitive lifting and elbow flexion. Has weakness to digital extension and his wrist radially deviates with extension. Failed all non-op. What to decompress?
102. Intermuscular septum 5cm proximal to lateral epicondyle
103. Struther’s ligament
104. Lacertus fibrosis
105. Proximal supinator edge

Answer 101

ANSWER: D

• ECRB function maintained (intact extension with radial deviation)
• Struther’s Ligament and Lacertus compress median nerve
• Septum compresses above elbow, so would get ECRB too

 

JAAOS 1998 - Uncommon Nerve Compression Syndromes of the Upper Extremity

• Elbow synovitis by TA
• Benign tumors/ganglions
• Supinator muscle
• Arcade of Frohse
• Netter’s Orthopedic Anatomy:
• Leash of Henry
• ECRB
• Arcade of Frohse
• Distal edge of supinator

 

Question 102

102. What is true about a PIN palsy?
103. Most common neurological sequlae associated with Monteggia fracture
104. Associated with fibrous bands of FDS
105. Demands operative decompression
106. Weakened power grip

Answer 102

ANSWER: A

2011

Jessing P (Acta Orthop Scan 1975) Monteggia lesions and their complicating nerve damage

Posterior interosseous nerve neuropraxia following acute Monteggia injury patterns about the elbow has been described and is thought to be secondary to traction or direct trauma. The condition typically resolves following successful closed reduction of the radial head.

• Acute and tardy palsy of the PIN have been reported as the most frequent neurologic complications following these complex injuries about the elbow. Following the acute injury and anterior dislocation of the radial head, direct trauma and traction neuropraxia are implicated. However, several authors have reported that these acute neuropraxias resolve with observation following closed reduction of the radial head.

Question 103

103. Most common site of PIN compression?
104. Fibrous bands under BR
105. Recurrent leash of Henry
106. Ligament of Struthers
107. Fibrous bands at proximal edge of supinator

Answer 103

ANSWER: D

2009

See old answer –> proximal edge of supinator most common site, McKinnon paper

Question 104

104. What is not correct about EMG and nerve conduction studies?
105. Sensory latency is the earliest finding
106. axonal injury will show decreased amplitude on NCV
107. H-reflex can monitor for an asymmetric S1 root issue
108. EMG cannot discern between acute and chronic nerve injuries

Answer 104

ANSWER: D

2014

Source: JAAOS 2000 “Role of neurophysiologic evaluation in diagnosis.”

• Terrible article that almost killed me, but does say “the most useful application of the H wave is in detection of S1 radiculopathy.” Sensory latency is an extremely sensitive finding that can be effected even by environmental factors, such as the temperature of the room. By definition, axonal injury will show decreased amplitude on motor nerve conduction studies, but these would not be velocity studies. I think this is just a recall typo. EMG can discern between acute and chronic nerve injuries because changes occur over time. Fibrillations and positive sharp waves take a few weeks to show up.

Green’s Hand Surgery:

• Peripheral Nerve Compression:
• Early stages of compression are dynamic, therefore electrodiagnostic studies are normal
• May see fibrillations without slowing (rarely)
• External pressure causes demyelination
• Focal conduction slowing (increased LATENCY)
• Sensory affected before motor
• Axon Loss (late)
• SNAP AMPLITUDE decreased, then CMAP
• MUP recruitment decreases (motor weakness)
• Complete injury –> no conduction, marked fibrillation potentials, no MUPs

Question 105

105. All of the following result in loss of sensation except:
     a. Polio
     b. CMT
     c. Alcohol
     d. Diabetes

Answer 105

ANSWER: A

2015

Lovell and Winter:

• Poliomyelitis
• Fewer than 1% progress to paralytic variant (otherwise mainly GI)
• Invades oropharyngeal route before localizing in the anterior horn cells of the spinal cord and brain stem motor nuclei
• Incubates 6-20 days
• Except for motor areas, the white matter of the spinal cord and the cerebral cortex are uninvolved
• CMT:
• Demyelinating disorder characterized by peroneal weakness, absent deep reflexes, slow nerve conduction velocity
• Characterized by muscle weakness in the feet and hands, diminution of distal sensory capabilities, particularly light touch position and vibratory sensation
•  
• Campbells:
• Diabetic Neuropathy:
• When large sensory nerve fibers are affected, protective sensation can be loss. Small fiber afferent neuropathy can lead to increased pain generation.
• Motor neuropathy can cause foot deformities, such as claw toes, which can lead to bony prominences.
• When the sympathetic nervous system is affected, the skin becomes scaley and dry, eventually causing cracks in the skin through which bacteria can enter.
• Alcoholism:
• Peripheral neuropathy secondary to avitaminosis

Question 106

106. What nerve injury has a disrupted axon and intact endoneurium
107. Neurpraxia
108. Axonotmesis
109. Neurotmesis
110. Electrotmesis

Answer 106

ANSWER: B

2009, 2012 (variation)

• Journal of Hand Surgery 2007 “The role of neurodiagnostic studies in nerve injuries and other orthopedic disorders” and Journal of Hand Surgery 2010 “Treatment of acute peripheral nerve injuries.”
• This refers to the Seddon classification of nerve injuries. Type 1 is neuropraxia which involves myelin damage but no issue with axon or other structures. Type II is axonotmesis where the myelin and the axon are disrupted, but the remaining architecture “including the endoneural tubes” remain intact. Type III is neurotomesis there is complete destruction of neural architecture.

Question 107

107. Wallerian Degeneration. All of the following undergo it except?
108. Axonotmesis
109. Neuropraxia
110. Neuronotmesis
111. Electrotmesis

Answer 107

ANSWER: B

2009

the fuck is electrotmesis

Aside peripheral nerve injuries: 30 mmhg of pressure can cause paresthesias and 60mmhg can cause complete block of conduction. Distal segment undergoes Wallerian degeneration. Phagocytes eat the end. Factors that affect the success if recovery after repair: age = most important, level of injury (more distal = better), sharp better than crush, repair delay

Neurotmesis – complete loss of continuity is (relatively) rare, but injury is severe enough to involve axon, perineurium and endoneurium. EMG findings are the same as axonotmesis (fibrillations and sharp waves). Neuroma formation as a result of attempted healing if there is complete transection. Will not regeneration or heal unless repaired.

According to Seddon, neurapraxia is Class I, axonotmesis Class II, neurotmesis Class III.

Sunderland: First Degree = neurapraxia. Second = axonotmesis. Third – endoneurium damaged, epi/perineurium still intact. Recovery possible. Fourth – only epineurium remains intact. Surgery required. Fifth – complete transection/disruption of all layers.

Question 108

108. What order does neurologic function return after a peripheral nerve injury?
109. Pain, proprioception, temperature, light touch and motor
110. Pain, temperature, light touch, proprioception and motor
111. Pain, proprioception, temperature, motor and light tough
112. Motor, proprioception, temperature, light touch and pain

Answer 108

ANSWER: B

2010

Pain is first motor last:

• Pain
• Temperature
• Touch“PTTPM” PhysioTherapists Teach Patients Movement
• Proprioception
• Motor

AAOS Review:

• Function return in sensory nerve
• Pressure sense (light tough)
• Protective Pain
• Moving touch
• Moving two point discrimination
• Static two point
• Proprioception

JAAOS 2008 - Peripheral Nerve Injury and Repair

• After injury (short of transection), function fails sequentially in the following order: motor, proprioception, touch, temperature, pain, and sympathetic. Recovery occurs sequentially in the reverse order:
  
  • Sympathetic
  • Pain
  • Temperature
  • Touch
  • Proprioception
  • Motor

Question 109

109. Woman post CRPP distal radius #. Pain and dysaesthesia over thumb & 1st dorsal webspace. What is the most effective form of treatment?
110. Type I + stellate ganglion block
111. Type I + antidepressants & gabapentin
112. Type II + stellate ganglion block
113. Type II + antidepressants & gabapentin

Answer 109

ANSWER: D

2009

Type 1 – RSD (aka CRPS)

Type II - Causalgia, has obvious nerve injury (anatomic)

See my awful CRPS page I just made - no evidence for stellate ganglion block

Question 110

110. Low median nerve palsy loses what critical function?
111. Key pinch
112. Opposition
113. Thumb IP flexion
114. Index IP flexion

Answer 110

Answer: B (2017)

Question 111

111. Compared with casting, percutaneous screw fixation of NON displaced scaphoid fractures results in?
112. Better ROM at 2 years
113. No functional benefit
114. Faster radiographic union
115. Decrease in complications

Answer 111

Answer: C (2015, 2016, 2017)

A - no

B – no, faster return to work

C – yes but no impact on non-union in undisplaced waist fractures

D- no

• Percutaneous cannulated screw fixation of nondisplaced scaphoid fractures resulted in faster radiographic union and return to military duty compared with cast immobilization.
• • McGill Stem –> specifies non-displaced fracture in stem
• Surgery decreases non-union
• Majority will heal after 8 weeks of immobilization
• Good evidence to include thumb in cast
• Patients will return to work faster with surgery
• • Buijze GA (Journal Hand Surgery 2014) Cast Immobilization With and Without Immobilization of the Thumb for Nondisplaced and Minimally Displaced Scaphoid Waist Fractures: A Multicenter RCT (CAST Trial Collaboration)
• Null hypothesis = no difference in percentage of the fracture line at 10 weeks post treatment of BEC with or without thumb inclusion
• 62pts in US and Netherlands with CT or MRI confirmed scaphoid f#s (included 7 distal pole fractures due to an error in enrollment, but they included them anyway)
• More healing in NO THUMB group than thumb group at 10 weeks (85% fracture healed vs 70%), overall union rate 98%
• Only failure was idiot who used crutches after dropping out and getting ORIF
• No difference wrist motion, grip strength Mayo Modified Wrist Score, DASH, or pain rating between groups
• Journal of Hand Surgery 2016 - A systematic review and meta-analysis examining the differences between nonsurgical management and percutaneous fixation of minimally and non-displaced scaphoid fractures
• Although the RTW in group 2 (operative) has a wide range between 1 and 8 weeks, almost all studies showed a faster RTW using percutaneous fixation (compared to 8-15 weeks in non-op).
• Reported average time to union in group 2 (operative) ranged between 6 and 10 weeks compared with 10 and 12 weeks in group 1 (non-operative).
• The majority of studies have shown a comparable rate of union between nonsurgical management and surgical intervention for undisplaced scaphoid waist fractures
• Buijze GA (JBJS 2010) Surgical Compared with Conservative Treatment for Acute Nondisplaced or Minimally Displaced Scaphoid Fractures: A review and meta-analysis
• Heterogenous results that favors surgical treatment in terms of satisfaction, grip strength, time to union and time off work
• No difference in pain, ROM, rate of nonunion and malunion, cost of treatments
• Complications higher if surgical group
• 2016 Open Orthop J - Is casting for non-displaced simple scaphoid waist fracture effective? A CT based assessment of union
• In total, 98 patients healed in ≤6 weeks (57%) and there were only 20 patients who took >12 weeks to heal (11.7%) (but only 126/172 were healed by 8 weeks, which is 73%)
• Note: they counted 50% union on CT as healed
• Bhandari - Evidence Based Orthopedics
• Faster return to work only in laborers
• Opinion is divided on whether undisplaced fractures heal faster with ORIF or casting

Question 112

112.What is true about wrist tendinopathies

1. DeQuervain’s is associated with repetitive radio-ulnar deviation activities
2. EPL ruptures are almost exclusively due to displaced bony fragments
3. Trigger finger is caused by a pathologic A2 pulley
4. Vaughan-Jackson syndrome is caused by tendon irritation on Lister’s tubercle

Answer 112

Answer: A (2017)

A – True - Repetitive thumb movements, abduction & extension, combined with RD & UD movements

B – False – non displaced

C – false – tendon problem crossing the A1 pully

D – false, caput ulna syndrome

• Nondisplaced fracture of the distal radius is a well-established risk factor with an incidence of EPL rupture of 0.2–5 % [22]. Other predisposing factors that have been reported in the literature include chronic inflammatory conditions such as rheumatoid arthritis [2, 4, 8, 14, 20, 24], systemic or local steroid injections, and repetitive or excessive abnormal motion of the wrist [6, 16]. 

Question 113

113. Regarding loss of motion in rotational malunions in both bones forearm fractures, what is true?
114. Loss of pronation greatest in distal third #
115. Loss of supination greatest in distal third #
116. Loss of pronation greatest in middle third #
117. Loss of supination greatest in middle third #

Answer 113

Answer: D (2017) – King confirmed.

Lose pronation with distal fracture.

Question 114

114. What would be the most appropriate treatment for the following injury that occurred 5 months ago in a 26yo male longboarder. Shown proximal pole, undisplaced with sclerosis. Mild DISI.
115. Volar approach with iliac crest bone graft
116. Dorsal approach and screw fixation
117. PRC
118. Radial wedge osteotomy

Answer 114

Answer: B (2017)

A – Not unless there is a significant humpback deformity.

B – Yes

C – No, not acute

D - No

Question 115

115. Which of the following is an absolute reason to operate on a metacarpal fracture
116. Shortening of 5mm
117. Rotation of 5mm
118. Dorsal angulation of 30 degrees
119. Oblique fracture

Answer 115

Answer: B (2017). No rotation is acceptable.

Question 116

116. Which of the following ligament is pathologic in thumb CMC arthritis
117. Posterior oblique ligament
118. Anterior oblique ligament
119. Trapezial ligament
120. Ulnar collateral ligament

Answer 116

Answer: B (2017) – anterior oblique.

Question 117

117. The following parameters are indications for fixation of a scaphoid fracture except:
118. SL angle of 70
119. Radiolunate angle 35
120. Intrascaphoid angle 15 degrees
121. Displacement 1.5mm

Answer 117

Answer: C – should be >35 degrees

Question 118

118. The TFCC is composed of all of the following except
119. volar and dorsal radiocarpal ligaments
120. tendon sheath of EDM
121. tendon sheath of ECU
122. central articular disc

Answer 118

Answer: B (2017)

Question 119

119. All the following will be seen on radiographs of a DISI deformity except
120. SL widening
121. extended lunate
122. radiolunate incongruence – Late stage
123. Scaphoid supination

Answer 119

Answer: C vs D (2017) – Scaphoid pronates as it flexes in DISI deformity so D BUT later stage supinates. Refer to greens

Question 120

120. What is true with regards to Kienbock’s disease
121. Ulnar shortening osteotomy results in decreased lunate pressure
122. Radial shortening is contraindicated in ulnar neutral
123. Radial closing wedge osteotomy results in increased radial inclination
124. STT fusion doesn’t change motion

Answer 120

Answer: B (2017)

A – false – ulnar lengthening or radial shortening for negative ulnar variance

B - True (Joint levelling procedure only)

C - False

D - false

Question 121

121. All of the following are options to correct a swan neck deformity except?
122. DIPJ fusion
123. FDS tenodesis
124. Crossed intrinsic transfer
125. Oblique retinacular repair

Answer 121

Answer: C (2017)

Question 122

122. Guy punches another guy and sustains a deep cut on his hand. What is the best antibiotic regimen?
123. Cipro-clav
124. Amox-clav
125. Amox
126. Cefazolin

Answer 122

Answer B (2017)

Question 123

123. What blocks the closed reduction of a volar PIP dislocation?
124. Lateral band
125. Collateral ligament
126. Transverse retinacular ligament

Answer 123

Answer: A (2017) - lateral bands

• • Reduction:
•     - traction and manipulation of the middle phalanx is carried out while MP joint is held in flexion;
•            - MP joint is held in flexion prior to reduction inorder to relax the lateral bands;
•     - difficult reduction may be due to entrapment of lateral bands around the volar aspect of the proximal phalanx;

Question 124

124. A 12 year old has bilateral 45 degree camptodactyly. How is this best managed?
125. Splinting
126. Tendon transfers
127. Volar skin grafting
128. PIP volar plate release

Answer 124

ANSWER: A (old answer B)

2018

-camptodactyly = congenital digital flexion deformity that occurs in PIP joint (typically 5th digit)

***Discussed with Ross - surgical options are all terrible and would mostly always initially start with splinting*

• treatment <30degress – stretching and splinting
• >30 degrees 1st choice is FDS release + FDS to lateral band transfer
• >30 degrees severe deformity either osteotomy or arthrodesis

Question 125

125. All of the following contribute to swan neck deformity in rheumatoid arthritis EXCEPT
126. Inability to extend the MCP joint
127. Positive bunnel test for intrinsic tightness
128. Mallet deformity
129. The collateral ligaments are lax with MCP flexion

Answer 125

ANSWER: D

2018

• -hyperextention of PIP and flexion of DIP bc volar plate laxity and imbalance of muscles on PIP (extension force>flexion force)
• -MCP volar subluxaion, Mallet finger, FDS lacs, intrinsic contracture
• -tethering of the collateral ligaments with lead to deformity (NOT laxity)
• -bunnell text tests intrinsic tightness (see in RA and leads to MCP subluxation). Positive when PIP flexion is less with MCP extension than with flexion

Question 126

126. What is the most common cause of VISI?
127. Distal radius fracture
128. LT tear
129. Scaphoid non union
130. SL tear

Answer 126

ANSWER: B

2018

Question 127

127. What is associated with ulnocarpal impaction?
128. Keinbocks
129. ECU subluxation
130. LT tear (?VISI…can’t remember which of these two they had)
131. ? DISI

Answer 127

ANSWER: C

2018

• https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC4262812&blobtype=pdf
• ulnar impaction.4 The diagnosis relies heavily on clinical examination and secondary radiographic studies, and has been classified based on pathoanatomical change resulting from progressive deterioration of the TFCC, as well as degenerative changes within the dome of the ulnar head, lunate, triquetrum, and lunotriquetral ligament (LTIL)
• JAAOS 1995 on DRUJ and ulnar impaction - The finding of surface incongruities will influence treatment options. Diagnostic arthroscopy has been especially helpful, not only in examining the articular disk of the TFCC and the lunotriquetral ligament, but also in detecting chondromalacic changes in the lunate and ulnar head

Question 128

128. Something about how load is transmitted from the ulnar head across the TFCC, what is TRUE ?of the TFCC
129. 18% of the load is transmitted across the TFCC when the wrist is ulnar neutral
130. the load across TFCC is more in supination
131. Grip strength / clenched fist decreases the load
132. The load is less in pronation

Answer 128

ANSWER: A

2018

Question 129

129. What is true for undisplaced scaphoid waist fractures?
130. ORIF decreases non union
131. After 8 weeks of casting, >90% will be united
132. There is good evidence for thumb immobilization
133. Return to work is NOT faster with ORIF

Answer 129

ANSWER: B

2018

-Suh/Grewal 2016 paper: “The union rate was 99.4% (1 nonunion/172 subjects). The mean time to union was approximately 7.5 weeks (53 ± 37 days)”

Question 130

130. What is true regarding wrist arthrodesis?
131. Bilateral is a contraindication
132. The best grip strength occurs with neutral position
133. Infection is an indication to do it
134. Nail/Steinman pin is a reliable technique in rheumatoid patients

Answer 130

ANSWER: D

2018

Best GS = – extension and ulnar deviation

Question 131

131. Which of the following is true?
132. Keinbocks can be treated with capitate lengthening procedures
133. Pressier disease of the triquetrium usually is self limiting/spontaneously resolves
134. Radial lengthening in stage II keinbocks is expected to halt disease progression
135. Intraosseous pressure in the lunate changes with wrist position

Answer 131

ANSWER: D

2018

A- shortening

B - – priesser is for scaphoid

C– radial shortening

Question 132

132. Someone is waterskiing and falls (like an ass) and gets a forearm fracture that is open. They were skiing in freshwater. What do you give them in terms of antibiotics?
133. Cloxacillin
134. Ciprofloxacin
135. Doxycycline – doxy salty = salt water

Answer 132

ANSWER: B

2018

Fresh water – cipro/levo or ceftazidime (aeromonas)

Salt water – doxycycline (vibrio)

Clarithromycin for M. Marinum

Question 133

133. FDP rupture with retraction to the palm. All are true EXCEPT:
134. This most commonly happens in the ring finger
135. This is the most common type of this injury
136. Good results can be achieved if treated within 6 weeks
137. They are often missed / missed on initial presentation / misdiagnosed (something like that)

Answer 133

ANSWER: B and C

2018

• ring finger involved in 75% of cases
• during grip ring fingertip is 5 mm more prominent than other digits in ~90% of patients
• therefore ring finger exposed to greater average force than other fingers during pull-away
• The relative incidences of pure FDP tendon avulsions, and those sustained in association with distal phalanx osseous avulsion fracture, remain difficult to quantify; there are no large studies dedicated to the clinical spectrum of FDP tendon injury patterns. Based on our review of available case series limited by relatively small cohorts, Leddy and Packer1 type I, II, and III injuries are the most common. Types IV and V are seen with less frequency. Approximately 50% of FDP tendon avulsions are associated with an osseous fragment.
• C = Leads to disruption of vascular supply
• Prompt surgical treatment within 7 to 10 days
• • Jersey finger = avulsion of FDP from insertion at base of distal phalanx
• Ring finger most common – 75%
• Type II most common type – retraction to PIPJ
• Often delayed dx – sprain
• Type I
• FDP tendon retracted to the palm
• Vascular supply disrupted
• Prompt repair recommended – 7-10 days***
• These injuries have a worse prognosis if not diagnosed and treated within 7–10 days as the tendon contracts and becomes less viable.

Question 134

134. All of the following are acceptable treatments for a bony mallet fracture EXCEPT:
135. Dorsal block pinning
136. Splinting in neutral
137. Technically called “extension splinting”
138. Pin the DIP joint???
139. Excise the fragment and advance the extensor tendon

Answer 134

ANSWER: B

2018

Question 135

135. All of the following structures are involved in Dupuytren’s contracture EXCEPT?
136. Grayson’s ligament
137. Cleland’s Ligament
138. ?Natatory ligament

Answer 135

ANSWER: B

2018

Question 136

136. What is false about Dupuytren’s disease?
137. MCP joint contractures are more responsive to needle release than PIP joint contractures
138. PIP joint disease is more likely to recur following partial palmar fasciectomy than MCP joint disease
139. The neurovascular bundles of the digits are not at risk with open surgical treatment
140. Open palm technique is associated with increased complications

Answer 136

Answer: C (2017)

A - true

B - true

C - False

D - True