Hand and Wrist (2008-2019) Flashcards

Question

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

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

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"

Answer 8

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"

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

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.

Answer 18

ANSWER: B 2012 Green's Hand Surgery Cleland's ligament (dorsal to NV bundle), not a component of Dypuytren's

Answer 19

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

Answer 20

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

Answer 21

ANSWER: D 2011

Answer 22

ANSWER: C 2009 Would need a full thickness skin graft for the palm, STSG just contract

Answer 23

ANSWER: B 2010 Scleroderma - CREST syndrome Calcinosis, Raynaud Phenomenom, Esophageal Dysmotility, Sclerodactyly, Telangiectasia Pitting nails --\> psoriasis, alopecia areata, eczema

Answer 24

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

Answer 25

ANSWER: B 2012 * Green DP (JHS 2015) Proximal Row Carpectomy * Radiocarpal arthritis * SLAC/SNAC * Advanced Kienbock disease * Articular incongruency of radius in lunate fossa

Answer 26

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)

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

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

Answer 35

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

Answer 36

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

Answer 37

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."

Answer 38

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

Answer 39

ANSWER: B 2008 Presence of sesamoid in the joint indicates volar plate is in the joint

Answer 40

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!)

Answer 41

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 

Answer 42

ANSWER: B 2011 Intact radiolunate ligaments and RSL ligament (Ligament of Testut)

Answer 43

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

Answer 44

ANSWER: D 2011 A is definitely true, B and C are synonymous

Answer 45

ANSWER: A 2010 Scaphoid non-union with a DISI deformity --\> needs structural bone grafting

Answer 46

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%).

Answer 47

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

Answer 48

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

Answer 49

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

Answer 50

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

Answer 51

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

Answer 52

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

Answer 53

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

Answer 54

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

Answer 55

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

Answer 56

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

Answer 57

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

Answer 58

(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

Answer 59

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)

Answer 60

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

Answer 61

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

Answer 62

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)

Answer 63

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

Answer 64

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.

Answer 65

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

Answer 66

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

Answer 67

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.

Answer 68

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

Answer 69

ANSWER: C 2008 Charles - should be BR to FPL and FDS4/5 to FDP 2/3

Answer 70

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

Answer 71

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

Answer 72

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)

Answer 73

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! 

Answer 74

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

Answer 75

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

Answer 76

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"

Answer 77

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  

Answer 78

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.

Answer 79

ANSWER: D 2009 See old answer --\> proximal edge of supinator most common site, McKinnon paper

Answer 80

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

Answer 81

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

Answer 82

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.

Answer 83

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.

Answer 84

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

Answer 85

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

Answer 86

Answer: B (2017)

Answer 87

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

Answer 88

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]. 

Answer 89

Answer: D (2017) – King confirmed. Lose pronation with distal fracture.

Answer 90

Answer: B (2017) A – Not unless there is a significant humpback deformity. B – Yes C – No, not acute D - No

Answer 91

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

Answer 92

Answer: B (2017) – anterior oblique.

Answer 93

Answer: C – should be \>35 degrees

Answer 94

Answer: B (2017)

Answer 95

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

Answer 96

Answer: B (2017) A – false – ulnar lengthening or radial shortening for negative ulnar variance B - True (Joint levelling procedure only) C - False D - false

Answer 97

Answer: C (2017)

Answer 98

Answer B (2017)

Answer 99

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;

Answer 100

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

Answer 101

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

Answer 102

ANSWER: B 2018

Answer 103

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

Answer 104

ANSWER: A 2018

Answer 105

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)"

Answer 106

ANSWER: D 2018 Best GS = – extension and ulnar deviation

Answer 107

ANSWER: D 2018 A- shortening B - – priesser is for scaphoid C– radial shortening

Answer 108

ANSWER: B 2018 Fresh water – cipro/levo or ceftazidime (aeromonas) Salt water – doxycycline (vibrio) Clarithromycin for M. Marinum

Answer 109

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.

Answer 110

ANSWER: B 2018

Answer 111

ANSWER: B 2018

Answer 112

Answer: C (2017) A - true B - true C - False D - True