Hand
Hand
Hand
274) Which of the following flexor tendon annular pulleys originate from palmar plates
overlying joints?
1. A1, A3, A5
2. A2, A4
3. A1, A2, A4
4. A1, A2, A3
5. A2, A4, A5
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The pulley system governs the moment arm, excursion and joint rotation produced by the flexor
tendons. The A2 and A4 pulleys are the most biomechanically important to these functions. A2 and A4 arise from the
periosteum of the proximal half of the proximal phalanx, and the midportion of the middle phalanx, respectively. A1,
A3 and A5 are joint pulleys arising from the palmar plates of the MP, PIP, and DIP joints respectively. C1, C2, and C3
are thin, condensable, cruciate sections of the flexor sheath which permit the annular pulleys to approximate each
other during flexion.
2) (OBQ11.99) Which of the following dorsal wrist compartments is incorrectly paired with its
contents?
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The dorsum of the wrist is subdivided into six compartments. The PIN is the only nerve found in the
dorsal compartments. It is consistently found on the base of the fourth compartment. Anatomic structures within each
compartment are:
Iwamoto et al performed a cadaveric study of the six compartments and septa. They determined that the 1/2
compartment had the thickest radial surface while the 3/4 septa was the thinnest. The fifth dorsal compartment had
the lowest resistance to failure.
Palmer et al also performed a cadaveric study on the extensor retinaculum. They concluded that the retinaculum
provides a check rein to bowstringing and should be repaired during surgery.
Grutter et al injected the PIN and AIN in fresh-frozen cadavers. In the first group, the AIN and PIN were injected via a
single injection 1cm ulnar and 3cm proximal to Lister's tubercle. For group 2 (PIN alone), the injection site was 1cm
ulnar to the proximal aspect of Lister's tubercle. Their technique led to accurate delivery of anesthetic to the PIN and
AIN in 100% of the cadavers.
3) (OBQ07.33) In the majority of patients, the deep palmar arch has a main contribution from what
vessel which travels between the two heads of the first dorsal interosseous muscle?
5. Ulnar artery
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: The deep palmar arch (deep volar arch) is an arterial network found in the palm. In the majority of
patients it is formed mainly from the terminal part of the radial artery, with the ulnar artery contributing via its deep
palmar branch. This is in contrast to the superficial palmar arch, which is formed predominantly by the ulnar artery
with some contribution by the superficial palmar branch of the radial artery. The deep palmar arch lies upon the
bases of the metacarpal bones and on the interossei of the hand, being covered by the oblique head of the adductor
pollicis muscle, the flexor tendons of the fingers, and the lumbricals of the hand. At the wrist the radial artery passes
between the radial collateral ligament and the first dorsal compartment after which it dives between the heads of the
first dorsal interossei where it anastomoses with the deep palmar branch from the ulnar artery, completing the deep
volar arch.
4) (OBQ04.86) Which of following most appropriately details the anatomic orientation of the digital
nerve and artery in the finger?
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The digital nerve is palmar to the artery in the finger. A helpful way of remembering this orientation is
that sensation is performed with the pads (nerve is palmar) of your fingers and you test for cap refill at the fingernail
(artery is dorsal).
5)(SBQ11.1) A 40-year-old male sheet metal worker sustained a crush injury to his hand. His hand
was treated in a short arm splint after closed reduction and percutaneous pinning of multiple
metacarpal fractures. The patient’s fractures healed uneventfully however, he presented six months
later with the deformity shown in Figure A. What pathoanatomic process is responsible for his
deformity?
FIGURES: A
1. Volar plate laxity and tethering of the lateral bands at the proximal interphalangeal joints
2. FDP laceration distal to the origin of the lumbricals
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The clinical presenatation is consistent with a claw hand deformity characterized by MCP
hyperextension and IP joint flexion.
Imbalance between strong extrinsics and deficient intrinsics is the pathoanatomic process of a claw hand, also called
intrinsic minus hand deformity. Intrinsic minus hand posture can result from a variety of causes including ulnar or
median nerve palsy, Volkmann’s ischemic contracture, leprosy, hereditary motor-sensory neuropathy, failure to splint
a crush-injured hand using intrinsic plus posture, or compartment syndrome of the hand, as was the case in this
clinical vignette.
Ouellette et al performed a retrospective review of nineteen patients managed with fasciotomy for compartment
syndrome of the hand. They found that the most consistent clinical finding in making the diagnosis of compartment
syndrome was a tense, swollen hand in an intrinsic minus position.
Dellaero et al, in their review of compartment syndrome of the hand, discuss the etiology, diagnosis, and treatment of
acute hand compartment syndrome. They emphasize that the main goal in the management of ischemic contracture
is restoration of function; however the return of normal limb functionality is an unlikely result.
Figure A is a clinical photograph showing a classic claw hand deformity. Notice the MCP hyperextension and IP joint
flexion.
Incorrect Answers:
1. Answer choice 1 describes the pathoanatomy of swan neck deformity leading to hyperextension of the PIP joint
and DIP flexion.
2. Answer choice 2 describes the mechanism for lumbrical plus deformity characterized by paradoxical extension of
the IP joints while attempting to flex the digits.
3. Answer choice 3 describes the mechanism for a quadrigia effect characterized by an active flexion lag in multiple
digits adjacent to an FDP injury.
4. Answer choice 4 describes the pathoanatomy of an intrinsic plus hand characterized by MCP flexion and IP joint
extension.
6) (OBQ04.33) Extrinsic imbalance from splinting a crushed hand with metacarpophalangeal joint
extension causes what characteristic hand deformity?
5. Swan-neck deformity
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Failure to splint the hand in an intrinsic positive position leads to increased extrinsic finger flexor
tension, leading the DIP and PIP joints to have an increasing flexion position. Illustration A and B show a clinical
image and illustration of intrinsic minus hand.
von Schroeder et al present a Level 5 review of hand crush injuries. They conclude that early diagnosis and
treatment is critical, but the functional outcome is often poor with associated Volkmann's contracture.
7) (OBQ09.80) Chronic injury to what anatomic structure can lead to a boutonneire deformity of the
finger?
2. sagittal band
3. volar plate
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Rupture of the central slip of the extensor tendon and subsequent subluxation of the lateral bands
leads to a boutonneire deformity, which is characterized by PIP flexion and DIP extension. Central slip injuries can be
caused by a laceration or traumatic avulsion. In the listed reference, Imatami et al treated a series of central slip
injuries associated with attachment fractures successfully with ORIF. As stated by Tuttle et al, rupture of the terminal
extensor tendon leads to a mallet finger. Sagittal band injury can lead to subluxation of the extensor tendon at the
level of the MCP joint. Chronic volar plate injuries can lead to swan neck deformities. Avulsion of the FDP insertion
leads to a jersey finger. Illustrations A and B are a clinical photograph and anatomic diagram of a boutonneire
deformity.
8) (OBQ04.71) A 54-year-old female presents with a hand deformity. A surgical procedure is being
considered that relocates the lateral bands dorsally to counteract the pathophysiology of the
deformity. Which of the following deformities does this patient most likely have?
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: Boutonniere deformity is characterized with the PIP in flexion and the DIP in hyperextension as shown
in Illustration A. It is caused by central slip rupture or attenuation (secondary to capsular distention, e.g., rheumatoid
arthritis), laceration, or traumatic disruption. Volar subluxation of the lateral bands due to incompetence or disruption
of the triangular ligaments leads to increased deformity as the lateral bands become flexors of the PIP. Relocation of
the lateral bands to their original dorsal position to counteract the pathophysiology of the deformity is an option for
patients that have an approximately 40 degree active flexion contracture but full passive extension.
9)(OBQ12.2) A 42-year-old sustains a left finger injury while attempting to catch a baseball for his
son. He presents with left, long finger pain and an inability to extend his middle finger at the distal
interphalangeal joint. A radiograph after closed reduction and splinting is shown in Figure A. What
is the best course of treatment?
FIGURES: A
1. Reduction and pinning
4. Observation
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The radiograph depicts a bony mallet injury with volar subluxation of the distal phalanx after splinting
of the DIP joint in extension, which is an indication for reduction and pinning.
A mallet deformity is caused by disruption of the terminal extensor tendon distal to DIP joint. Occasionally, a bony
avulsion of the distal phalanx is noted on radiographs. "Bony" mallet fingers will rarely require surgical fixation. It is
important to attempt to splint a bony mallet injury and get a new radiograph prior to making the decision for operative
treatment. Indications for surgical management of this condition include volar subluxation of the distal phalanx even
after DIP splinting.
Notably, Stern et al. found the higher long term complication rate with surgical treatment of mallet injuries. He also
noted 15 degrees of more DIP flexion at follow-up in the splinting group compared to the surgical group.
Pegoli et al. describe an extension block technique for treatment of this injury with good results. Their indications for
surgery included the presence of a large bone fragment, and palmar subluxation or the loss of joint congruity of the
distal interphalangeal joint.
Theivendran et al. review the surgical treatment of DIP joint fractures and state that 30% articular involvement is an
indication for operative treatment.
Figure A shows a lateral radiograph with a large bony avulsion fragment, involvement of the articular surface, and
volar subluxation of the distal phalanx.
Incorrect Answers:
Answer 2,3,4: This patient meets the indications for ORIF and nonoperative modalities would not be appropriate.
Answer 5: A DIP fusion in a young patient would not be appropriate.
10) (OBQ06.52) A 22-year-old rugby player presents with a mass at the base of his ring finger 5 months
after sustaining an injury while making a tackle. Physical examination demonstrates a lack of active
distal interphalangeal joint flexion, but full passive range of motion of all joints of the ring finger.
Radiographs are normal. What is the most appropriate treatment to regain normal finger function?
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: This patient has a chronic jersey finger (flexor digitorum profundis avulsion). With the chronicity of the
injury, it would be more amenable to grafting rather than direct repair given retraction of the FDP tendon that occurs
with time that makes direct repair impossible. According to Green’s text, active silicone tendon rod implants have not
proven to be effective. A 2-stage tendon grafting is the treatment of choice in cases of neglected or chronic (>3mo)
tendon injuries or when previous surgery has failed. Two-stage flexor tendon grafting involves implanting a silicone
rod (flexible silicone–Dacron-reinforced gliding implant) in the first stage and a free tendon graft (usually palmaris
longus or plantaris) through the pseudosheath formed around the silicone in the second stage as intitially described
by Hunter and Salisbury in 1971. In single-stage flexor tendon grafting, the tendon graft notoriously adheres to the
surrounding fibro-osseous tunnel significantly limiting range of motion, but in 2-staged tendon grafting the
pseudosheath that is formed around the silicone implant in the first stage greatly reduces the formation of post-
operative adhessions to the tendon graft in the second stage.
Amadio et al showed at 6 month follow-up of staged flexor tendon reconstruction, patients expressed 54% good to
excellent results, but 16% of patients required tenolysis following the second stage of the procedure. LaSalle et al
followed 43 flexor tendon 2 stage reconstructions by comparing passive ROM after stage 1 to postop active ROM
after stage 2. They reported 16% excellent results, 23% good, 26% fair, and 35% poor. They stated that tenolysis
following the second stage improved results on the patients reporting poor outcomes. A distal interphalangeal fusion
would be reserved for failed reconstruction or a patient that does not desire/will not be compliant with likely lengthy
postoperative therapy needed for a staged tendon grafting.
11) (OBQ05.246) A 16-year-old football player sustains an injury to his ring finger after making a tackle.
A clinical photograph is shown in Figure A. What is the most likely diagnosis?
FIGURES: A
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The photograph demonstrates the inability to flex the ring finger DIP. Based on the mechanism and
clinical findings this injury represents a "rugby jersey finger", which is an avulsion of the flexor digitorum profundus
(FDP) tendon.
Tuttle et al reviewed these injuries and concluded treatment for an acute injury is FDP tendon reinsertion. For chronic
injuries, a 2-staged tendon grafting is required.
12) (OBQ07.34) A butcher sustains a traumatic amputation of the ring finger through the distal
interphalangeal joint. He is brought to the operating room where the flexor digitorum tendon is
retrieved and advanced to the distal stump. Three months after surgery the patient notes that when
he makes a fist, only his ring finger tip reaches the palm. What is this patient's clinical problem?
1. mallet finger
3. boutonniere deformity
5. quadrigia syndrome
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Quadrigia syndrome occurs when a flexor digitorum profundus (FDP) tendon is shortened and
advanced. Malerich et al found the tolerable degree of FDP advancement was 1 cm. The common muscle belly of
the FDP prevents the tendons to the other fingers from reaching full excursion. Treatment is release of the shortened
tendon. Lumbrical plus occurs when the FDP tendon retracts and causes paradoxical interphalangeal extension
when trying to flex. Mallet finger is an injury to the terminal extensor tendon. Boutonniere deformity occurs from
central slip injury and results in PIP flexion and DIP extension. Swan-neck deformity consists of hyperextension at
the PIP joint with flexion at the DIP joint typically caused by volar plate attenuation.
13) (OBQ04.97) A 35-year-old butcher inadvertently lacerates his ring finger FDP tendon at the level of
the DIP joint which is subsequently repaired. Following the operation he notes the inability to fully
flex his long and small fingers at the DIP joints with attempted fist clenching as well as a weak grip.
Which of the following intraoperative maneuvers was likely responsible for this?
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The clinical presentation is most consistent with the quadrigia effect which is caused by
overtensioning of the FDP tendon during surgical repair. The FDP tendons share a common muscle belly and have
many interconnections. Overtensioning one tendon has a reciprocal effect on the length-tension curve of the
remaining three muscle-tendon units, weakening grip strength in these digits.
Malerich et al performed a cadaveric study looking at FDP advancement on hand function. They determined
advancement >1cm can lead to an imbalance of muscle function in the profundus system.
In another cadaver study, Kaufmann et al studied maximal grip strength and point of contact in the extrinsic system.
They determined that FDP grip strength was optimized when the FDP point of contact was at the DIP. Thus moving
the FDP insertion point distal or advancing a lacerated FDP tendon leads to a decrease in grip strength.
14) (OBQ08.61) What is a potential complication of an amputation at the level of the distal
interphalangeal joint?
3. Boutonniere deformity
5. Quadrigia effect
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: A lumbrical plus finger is descibed as paradoxical extension of the IP joints while attempting to flex
the fingers.
The review article by Parkes describes how the lumbricals originate from the FDP. When the FDP is lacerated or
amputated, FDP contraction leads to pull on the lumbricals. This leads to shortening of the lateral bands and
paraodoxical PIP and DIP extension. (Illustrations A-C). There are several causes of lumbrical plus finger including
(1) FDP laceration or rupture distal to the lumbrical origin, (2) amputation of the DIP distal to central slip insertion,
and (3) excessively long flexor tendon graft. Treatment consists of tenotomy of the lateral band which releases the
lumbrical.
Quadrigia may occur when the profundus is advanced of greater than 1 cm in repair. The FDP tendons share a
common muscle belly, and distal advancement of one tendon will effect the flexion strength of the adjacent digits.
15) (OBQ11.265) A 44-year-old male factory worker presents with a 7-month history of pain and
paresthesias involving the palmar aspect of the right thumb, index finger, long finger, and the radial
half of the ring finger. He has a history of anemia and obstructive sleep apnea. Percussion over the
volar wrist crease produces electric sensation distally in the hand and wrist flexion with the elbow
in extension produces thumb paresthesias within 18 seconds. Figure A demonstrates a radiograph
of the right hand. A sensory nerve conduction velocity test shows a distal sensory latency of 5.7
ms. Which of the following is the most appropriate next step in management.
FIGURES: A
3. Wrist splinting
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: The patients history, examination, and nerve conduction velocity tests (normal distal sensory latency
is <3.5 ms) are consistent with carpal tunnel syndrome. There is Level 1 and 2 evidence supporting local steroid
injection or splinting for the nonoperative treatment of carpal tunnel syndrome. Phonophoresis, Vitamin B6
(pyridoxine), heat therapy, bumetanide, and physical therapy are not considered the most appropriate options for
carpal tunnel syndrome management.
The AAOS clinical guidelines for carpal tunnel syndrome consist of 9 clinical recommendations supported with a
grading of the recommendation and levels of evidence for the literature contributing to the recommendation.
The use of neutral wrist splints for carpal tunnel syndrome is most useful for improving night-time symptoms.
However wrist splinting is most functional at 30 degrees of extension, and the neutral splints can be functionally
limiting when used during productive daytime hours.
16) (OBQ08.34) All of the following are contents of the carpal tunnel EXCEPT:
5. Median nerve
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The only neurovascular structure that runs in the carpal tunnel is the median nerve. Flexor carpi
radialis is (FCR) is not a tendon within the carpal tunnel. In summary, the carpal tunnel contains the median nerve,
FPL and 4 tendons each of the FDP and FDS. Of note, with respect to the FDS tendons, the 3rd and 4th FDS
tendons are volar to the 2nd and 5th FDS tendons.
17) (OBQ07.55) All of the following can be found on the Electromyography (EMG) portion of an
electrodiagnostic study during the evaluation of a patient with carpal tunnel syndrome EXCEPT:
1. Fibrillations at rest
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: EMG's detect the electrical potential generated by muscle cells when these cells are electrically
activated. They give information about the muscle motor unit and can display the presence of fibrillations, sharp
waves, motor recruitment, and insertional activity of the muscle. The nerve conduction (NCV) portion of the
electrodiagnostic study measures the speed at which the nerve impulse travels down the axon. Large, myelinated
nerve fibers conduct impulses the fastest and thus only these fibers are evaluated in the nerve conduction portion of
the electrodiagnostic study. Distal latencies and conduction velocities are measured with NCV's. General parameters
for NCV diagnosis of carpal tunnel syndrome include a distal motor latency of >4.5 msec, a distal sensory latency of
>3.5msec, or a conduction velocity of < 52 m/sec. The article by Brumback et al and Gooch et al is a review of
electrodiagnostic studies for compression neuropathies.
18) (OBQ06.242) A 50-year-old woman is diagnosed with carpal tunnel syndrome. She is prescribed a
cock-up wrist splint at 30 degrees of extension to wear at night. This splint has what effect on the
carpal tunnel?
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: This question is based on the fact that carpal tunnel canal pressure varies with wrist position. Use of
neutral wrist splints for carpal tunnel syndrome is most useful for improving noctural symptoms. The reason for this is
the functional position of the wrist is approximately 30 degrees of extension, and the neutral splints can be
functionally limiting when used during productive daytime hours.
The reference by Gerritsen et al is a randomized controlled study of splinting versus surgery for carpal tunnel. They
found a 80% success rate for surgery at final follow-up versus 54% for splinting at 3 months, which increased to 90%
at 18 months for surgery and 75% for splinting.
The reference by Omer is a review of carpal tunnel, and it covers the diagnosis, treatment, and follow-up care of
these patients. They note the need for careful diagnosis to avoid unnecessary or inappropriate surgery.
Weiss et al showed that carpal tunnel pressures are elevated when the wrist is in extension, and are lowest at near
neutral. If one couples this with the inherent tunnel pressure increase from the disease itself, its easy to see that
extension splinting is a double hit and can lead to increased symptoms.
19) (OBQ05.55) All of the following are predictive findings for correctly diagnosing carpal tunnel
syndrome EXCEPT:
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: All of the listed physical exam findings, except for loss of small digit adduction (Wartenberg sign), has
been found to be predictive for diagnosing carpal tunnel syndrome.
Szabo et al in a Level 3 study used a regression model to analyze the most predictive factors for correctly diagnosing
carpal tunnel syndrome (CTS). Their analysis found that with an abnormal hand diagram, abnormal sensibility by
Semmes-Weinstein testing in wrist-neutral position, a positive Durkan's test, and night pain, the probability that carpal
tunnel syndrome will be correctly diagnosed is 0.86. They found the tests with the highest sensitivity were Durkan's
compression test (89%), Semmes-Weinstein testing after Phalen's maneuver (83%), and hand diagram scores
(76%). Night pain was a sensitive symptom predictor (96%). The most specific tests were the hand diagram (76%)
and Tinel's sign (71%). The authors concluded that the addition of electrodiagnostic tests did not increase the
diagnostic power of the combination of these 4 clinical tests, and proceeding with surgical release is appropriate even
if the EMG is normal.
Wartenberg sign is persistent abduction and extension of the small digit when a patient is asked to adduct the digits
and is seen in cubital tunnel syndrome, but not carpal tunnel syndrome.
20) (OBQ04.210) Approximately what percentage of pre-operative grip strength would be expected 3
months after carpal tunnel release?
1. 10%
2. 25%
3. 50%
4. 100%
5. 150%
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Gellman et al quantified grip and pinch strength post-operatively after carpal tunnel release. They
found grip strength was 28% of preoperative level at 3 weeks; 73% by 6 weeks, returned to the preoperative level by
3 months, and 116% at 6 months. Pinch strength was 74% of preoperative level at 3 weeks, 96% at 6 weeks, 108%
at 3 months, and 126% at 6 months.
21) (OBQ07.64) A 34-year-old seamstress was diagnosed with Parsonage-Turner brachial neuritis in the
right upper extremity 1 month ago. She has weak forearm pronation with the elbow in the flexed
position. She denies any current sensory changes. A clinical image of her hands attempting to
make a clenched fist are shown in Figure A. Which of the following most likely represents her
diagnosis and treatment?
FIGURES: A
1. Anterior interosseous nerve syndrome treated with observation
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: This patient presents with anterior interosseous nerve (AIN) syndrome and is often seen in
conjunction with brachial neuritis (Parsonage-Turner Syndrome).
AIN sydrome leads to motor palsies of the flexor pollicis longus and the two radial profundus tendons leading to the
clincal image shown in Figure A. The pronator quadratus is also involved and can be tested with the elbow held in a
flexed position to neutralize the humeral head of the pronator teres muscle. No sensory changes occur and
Electromyographic (EMG) and nerveconduction (NCV)studies are often helpful in establishing the diagnosis. Anterior
interosseous nerve syndrome usually resolves with time, particularly if the lesion is secondary to neuritis. Observation
for 3 to 6 months with splinting at 90 degrees is favored before surgical treatment.
22) (OBQ08.21) A 35-year-old female office worker reports 6 months of deep aching on her lateral
dominant elbow which worsens with repetitive movements. The pain is located 4cm distal to the
lateral epicondyle. She also complains of night pain. What is the most likely diagnosis?
1. Lateral epicondylitis
4. Erb's palsy
5. Multiple sclerosis
PREFERRED RESPONSE ▼ 2
CORRECT
23) DISCUSSION: As discussed by Dang et al in their review article on compression neuropathies of the upper
extremity, the clinical diagnosis of radial tunnel syndrome (RTS) must be distinguished from that of lateral
epicondylitis by the location of tenderness on physical exam. In lateral epicondylitis, the focal point of
tenderness is on the lateral epicondyle at the insertion of the ECRB. In contrast, the characteristic pain of
RTS is located 3-4 cm distal to the lateral epicondyle in the area of the mobile wad and radial tunnel.
The symptoms of radial nerve compression vary depending on the level of compression: motor and
sensory (high radial nerve palsy), motor (posterior interosseous nerve palsy), sensory (superficial radial
nerve palsy) or pain (radial tunnel syndrome). The radial nerve arises from the posterior cord of the
brachial plexus (C5-8 roots), descends anterior to the subscapularis, teres major, and latissimus dorsi
muscles, and continues lateral and posterior to travel in the spiral groove of the proximal humerus. The
radial nerve then passes beneath the lateral head of the triceps to pierce the lateral intermuscular septum
as it courses from the posterior to the anterior compartment. As it continues in the cubital fossa, the radial
nerve emits muscular branches to the brachialis, brachioradialis and extensor carpi radialis longus. The
nerve then divides into the motor posterior interosseous nerve (PIN) and sensory radial nerve (SRN) and at
the level of the radiohumeral joint the PIN enters the radial tunnel.
(OBQ11.128) The physical exam finding demonstrated on the patient's right hand in the video
(Figure V) is found with neuropathy of which of the following nerves?
FIGURES: V
1. Musculocutaneous nerve
3. Radial nerve
4. Ulnar nerve
5. Median nerve
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The video demonstrates Froment's sign on the patient's right hand, which is characterized by
interphalangeal (IP) flexion during attempted key pinch, and is found in patients with ulnar neuropathy. Therefore it
can be found with ulnar nerve compression in the cubital tunnel (Cubital Tunnel Syndrome) or in Guyon's Canal
(Ulnar Tunnel Syndrome).
Froment's sign is performed by having the patient pinch a piece of paper with the thumb IP joint extended against
resistance (pulling paper away). If should be done with both hands side by side so compare them to each other.
In a hand with a ulnar neuropathy, adductor pollicis (ulnar n.) is deficient, and can not flex the MCP joint to give pinch
strength with an extended IP joint. The thumb compensates by recruiting the FPL (median n.) to flex the IP joint to
give pinch strength. The result is, in a positive Froment's sign, the IP joint will flex (buckle) to try to give increased
strength to the pinch.
24) (OBQ10.84) Cubital tunnel syndrome is caused by compression of the ulnar nerve between what
two structures as it passes posterior to the medial epicondyle?
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The ulnar nerve passes posterior to the medial epicondyle and medial to the olecranon, then enters
the cubital tunnel. The roof of the cubital tunnel is primarily made up of Osborne's ligament, and the floor consists of
the medial collateral ligament. These soft tissue structures can cause narrowing of the tunnel, especially with elbow
flexion, leading to ulnar nerve compression and cubital tunnel syndrome. This is shown in Illustration A. The Arcade
of Struthers is a band of deep fascia that attaches to the intramuscular septum and covers the ulnar nerve 8cm
proximal to the medial epicondyle. The intramuscular septum is continuous from the medial epicondyle to the
coracobrachialis muscle. The ulnar nerve travels through the two heads of the FCU distal to the cubital tunnel. These
anatomic landmarks are shown in Illustration B. Morrey evaluated 26 patients with post-traumatic contracture of the
elbow who were treated with either operative release alone, or operative release and distraction arthroplasty. Twenty-
four (96%) of the patients had improved elbow function and two had persistent ulnar neuritis treated with nerve
transposition. Cheung et al discuss the various surgical approaches to the elbow and the indications for each.
25) (OBQ09.1) All of the following are possible sites of compression for the ulnar nerve EXCEPT:
1. arcade of Struthers
2. ligament of Struthers
5. Osborne's ligament
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: There are five sites of potential ulnar nerve entrapment around the elbow: arcade of Struthers, medial
intermuscular septum, medial epicondyle, cubital tunnel, and deep flexor pronator aponeurosis.
The ulnar nerve emerges from the medial intermuscular septum, under the arcade of Struthers, and lies on the
medial head of the triceps. At the level of the elbow, the ulnar nerve continues distally toward the posterior aspect of
the condylar groove, passing between the medial epicondyle and olecranon to enter the cubital tunnel. The roof is
formed by the arcuate (Osborne’s) ligament. This ligament blends distally with the antebrachial fascia superficial to
the aponeurosis and connects the ulnar and humeral heads of the FCU. The ligament of Struthers is a fibrous band
extending from the supracondylar process of the humerus to the medial epicondyle which can cause compression of
the median nerve.
Elhassan et al discuss the pathogenesis, evaluation, and treatment of entrapment neuropathy of the ulnar nerve.
26) (OBQ09.24) A 50-year-old man complains of numbness and tingling along his right small finger.
Physical exam is notable for the finding demonstrated in Figure A. Elbow flexion reproduces the
numbness and tingling. Physical therapy and splinting have failed to relieve the symptoms. Which
of the following is the most appropriate surgical intervention to alleviate the symptoms while
minimizing complications? Topic
FIGURES: A
2. Ulnar nerve decompression at the cubital tunnel with anterior submuscular transposition
3. Ulnar nerve decompression at the cubital tunnel with anterior subcutaneous transposition
CORRECT
DISCUSSION: The patient's clinical presentation and physical exam are consistent with cubital tunnel syndrome. The
clinical photograph demonstrates Froment's sign; compensatory IP hyperflexion of FPL (AIN) to compensate for the
loss of adductor pollicis (ulna nerve) during key pinch. Simple decompression of the ulnar nerve is less invasive and
achieves clinical outcomes equivalent to decompression with transposition.
Zlowodzki et al conducted a meta-analysis evaluating anterior transposition and simple decompression of the ulnar
nerve. No difference in motor nerve-conduction velocities or clinical outcome scores was found.
Bartels performed a prospective randomized trial (included in the Zlowodski meta-analysis) on 152 patients
comparing simple decompression to transposition. No difference in clinical results at 1 year were reported, but a
significantly higher complication rate in occurred in the transposition group (31%) compared to simple decompression
(9.6%).
Nabhan et al performed a level 1 study randomizing 66 patients to simple decompression or subcutaneous ulnar
nerve transposition. No differences were found with respect to clinical outcome or nerve conduction velocities.
27) (OBQ10.132) A 72-year-old female complains of progressive weakness with grasp and key pinch in
her left hand. Physical exam of the hand is significant for decreased sensation on the volar aspect
of the fourth and fifth digits. Dorsal sensation throughout the hand is normal. A clinical photo
displaying bilateral key pinch is shown in Figure A. What is the most likely cause of compression?
FIGURES: A
3. Osborne's ligament
5. Anconeus epitrochlearis
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Compression of the ulnar nerve within Guyon's canal, termed ulnar tunnel syndrome, is most
commonly caused by a ganglion cyst. A lack of dorsal ulnar sensory deficit helps differentiate entrapment here from
at the elbow because the dorsal ulnar cutaneous nerve branches proximal to Guyon's canal. The clinical photo
demonstrates Froment's sign where the FPL is used to substitute for the weakened adductor pollicis resulting in
flexion of the thumb at the interphalangeal joint, and MCP joint hyperextension. The AIN can be compressed by the
accssory head of the FPL (Gantzer's muscle) which results in loss of FPL, index FDP and PQ motor function and no
sensory deficits. Ulnar nerve compression at Osborne's ligament, the two heads of the FCU, or by the anconeus
epitrochlearis will classically result in volar and dorsal ulnar sensory loss of the affected hand.
28) (OBQ08.21) A 35-year-old female office worker reports 6 months of deep aching on her lateral
dominant elbow which worsens with repetitive movements. The pain is located 4cm distal to the
lateral epicondyle. She also complains of night pain. What is the most likely diagnosis?
1. Lateral epicondylitis
4. Erb's palsy
5. Multiple sclerosis
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: As discussed by Dang et al in their review article on compression neuropathies of the upper extremity,
the clinical diagnosis of radial tunnel syndrome (RTS) must be distinguished from that of lateral epicondylitis by the
location of tenderness on physical exam. In lateral epicondylitis, the focal point of tenderness is on the lateral
epicondyle at the insertion of the ECRB. In contrast, the characteristic pain of RTS is located 3-4 cm distal to the
lateral epicondyle in the area of the mobile wad and radial tunnel.
The symptoms of radial nerve compression vary depending on the level of compression: motor and sensory (high
radial nerve palsy), motor (posterior interosseous nerve palsy), sensory (superficial radial nerve palsy) or pain (radial
tunnel syndrome). The radial nerve arises from the posterior cord of the brachial plexus (C5-8 roots), descends
anterior to the subscapularis, teres major, and latissimus dorsi muscles, and continues lateral and posterior to travel
in the spiral groove of the proximal humerus. The radial nerve then passes beneath the lateral head of the triceps to
pierce the lateral intermuscular septum as it courses from the posterior to the anterior compartment. As it continues in
the cubital fossa, the radial nerve emits muscular branches to the brachialis, brachioradialis and extensor carpi
radialis longus. The nerve then divides into the motor posterior interosseous nerve (PIN) and sensory radial nerve
(SRN) and at the level of the radiohumeral joint the PIN enters the radial tunnel.
29) (OBQ08.9) A 31-year-old mother of a 2-month-old infant complains of radial sided wrist pain.
Corticosteroid injections should be directed into what anatomic area?
2. Carpal tunnel
4. A1 pulley of thumb
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: There is an association between the postpartum state and de Quervain’s tenosynovitis. De Quervain’s
is a pathologic process of the 1st dorsal (extensor) compartment which contains the extensor pollicis brevis and
abductor pollicis longus tendons. The best choice is #3 because of the very common and known association of
postpartum state and de Quervain’s as well as the potential for resolution with appropriately placed steroid injection.
Answer #1 refers to basal joint arthritis which is typically seen in older patients. Answer #2 refers to carpal tunnel
syndrome, which would present with paresthesias in the median nerve distribution. Answer #4 refers to a trigger
thumb. Answer #5 alludes to intersection syndrome which is generally more proximal to the wrist and results from
inflammation at crossing point of 1st dorsal compartment (APL and EPB) and 2nd dorsal compartment (ECRL,
ECRB). To review, the wrist extensor compartments (from radial to ulnar) are: 1) APL & EPB; 2) ECRL & ECRB
(common radial wrist extensors); 3) EPL; 4) EIP & EDC; 5) EDM; 6) ECU.
30) (OBQ11.56) A 2-year-old child has a flexion deformity of the interphalangeal joint of his thumb as
seen in Figure A. Surgical correction of this deformity places what structure most at risk as it
crosses the surgical field?
FIGURES: A
3. Oblique pulley
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The patient in the scenario has a trigger thumb. Surgical correction of this condition requires the
release of the A1 pulley. The A1 pulley is seen at the red arrow in Illustration A. During the dissection, the radial
digital nerve crosses the operative field and is at risk. It must be identified and protected.
Bae described the etiology, natural history and surgical indications in treatment of pediatric trigger thumbs. Currently,
the literature does not advocate for or against surgical management. He concluded that further long-term research
will help guide evidence-based treatment.
Baek at al described the natural history of pediatric trigger thumbs. They concluded that trigger thumbs in children will
resolve without treatment in >60% of patients. In patients who do not have full resolution, the flexion deformity can be
expected to gradually improve with time.
31) (OBQ10.113) When surgically treating a trigger finger in a child, what structure may need to be
released in addition to the A-1 pulley?
2. A-4 pulley
3. Lumbrical origin
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: Unlike adults, release of the A-1 pulley in a pediatric trigger finger alone may not resolve triggering
symptoms. Trigger finger in the child may be associated with a more proximal decussation of the FDS tendon,
nodules in either the FDS or FDP tendon, a thickened A-2 pulley, or a tight A-3 pulley. Cardon et al looked at 16
pediatric pts with 18 trigger fingers and found that 6 fingers continued to trigger after A-1 pulley release. The sublimis
decussation and A-3 pulley were found to be the most common cause of this persistent triggering. Bae et al looked at
23 pediatric trigger fingers and found that triggering was noted to occur at the level of the FDS tendon decussation in
half the cases. The conclusion was made that all pediatric trigger fingers should be treated with A-1 pulley release
and resection of a single FDS tendon slip. Illustration A shows normal decussation of the FDS tendon near the level
of the A2 pulley. The FDS decussation may be found to be more proximal in pediatric trigger fingers, necessitating
release.
32) (OBQ05.164) A 64-year-old diabetic female presents with sudden catching and locking of her ring
finger when trying to extend it. Attempts at finger extension are painful, and she notes tenderness
in her distal palm. A clinical photo is shown in Figure A. Which of the following structures are
implicated in the pathogenesis of this condition?
FIGURES: A
1. Extensor digitorum tendon
2. Grayson's ligament
4. A1 pulley
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The scenario listed above points to a diagnosis of trigger finger. In this condition, the disparity in size
between the flexor tendon and the surrounding retinacular pulley system, most commonly at the level of the first
annular (A1) pulley, results in difficulty flexing or extending the finger and the “triggering” phenomenon.
Metacarpophalangeal locking should be included in the differential, where the collateral ligament or volar plate
tethers on a prominent metacarpal head or osteophyte. The referenced text notes that a series of two corticosteroid
injections should be given before surgery is considered for A1 pulley release. Mention is also made of the possibility
of diabetics being more resistant to injections. Illustration A shows the pathogenesis of this disorder.
33) (OBQ06.92) A 20-year-old man has pain, swelling, and popping over his index metacarpophalangeal
joint after striking a wall a 3 days ago. Radiographs are normal, but physical exam reveals a
palpable defect over the dorsum of the joint with clenching of the fist, and this defect is resolved
with extension of the metacarpophalangeal joint. What is the next most appropriate step in
treatment?
3. Metacarpophalangeal synovectomy
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: “Boxer’s knuckle” refers to injury to the extensor hood mechanism that results following resisted
extension ("flicking") of the finger or direct trauma to the MP joint, usually involving the radial sagittal band of the
middle or ring finger. Often, both the sagittal band and the dorsal capsule are torn. The hallmark of the physical
examination is pain over the MCP with a palpable defect in the dorsal capsule, and it is important to examine for EDC
subluxation with MP flexion. Sagittal band injuries seen within 3 weeks of injury may be treated nonoperatively with
an MP joint flexion blocking splint. Patients presenting later than 2 to 3 weeks after the injury or patients who failed a
trial of splinting are candidates for surgical repair.
Hame et al reviewed 27 patients who were treated for Boxer’s Knuckle. The authors concluded that in cases in which
conservative treatment has failed, these injuries should be treated with sagittal band repair with centralization of the
extensor tendon without repair of the capsule. In the acute period however (less than 3 weeks), as is the scenario for
this patient, conservative management with extension splinting should be attempted first.
Araki et al peformed a study of 16 cases of rupture of the extensor hood initially treated conservatively with splinting.
While 8/16 responded successfully to nonoperative management, the remaining 8 did not improve with conservative
treatment and were eventually treated with surgical repair and closure of the joint capsule when injured.
34) (OBQ10.170) A 24-year-old male cuts his left middle finger with a knife while chopping vegetables.
Physical exam reveals a zone 2 flexor tendon laceration. He undergoes a 2-strand core suture
repair with epitendinous suture. This particular repair is strong enough for each of the following
rehabilitation protocols EXCEPT:
1. Kleinert protocol
2. Duran protocol
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Early active range of motion protocols are thought to decrease adhesions but risk rerupture or gap
formation.
Strickland et al notes that the generation of muscle forces to either assist digit flexion or perform “place and hold”
exercises require at least a 4-strand core suture with epitendinous repair. This patient only had a 2-strand repair.
The Kleinert and Duran protocols are both forms of low force and low tendon excursion programs, that include
passive digit flexion range of motion. Kleinert includes a dorsal block splint with the wrist in 45° of flexion and elastic
bands secured to the patient’s nails and a more proximal attachment point. Once the interphalangeal joints are
actively fully extended, recoil of the elastic bands flexes them down passively. The Duran protocol utilizes the other
hand to passively flex the affected DIP and PIP joints and a higher amount of patient compliance is needed.
Synergistic motion regimens allow passive digit flexion combined with active wrist extension, followed by active digit
extension coupled with active wrist flexion to produce low forces and high tendon excursions at the involved digit.
35) (OBQ09.97) You are seeing a 26-year-old man after he was involved in a knife fight. He has pain
when flexing and extending his index finger. You explore a 2cm wound in zone 2 and find his flexor
tendons to the index are 50% lacerated. What is the preferred method of treatment?
1. Trim the frayed tendon edges and begin early range of motion
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The management of partially lacerated flexor tendon injuries is controversial.
Bishop et al. developed a nonweightbearing canine model for testing partial tendon lacerations and found early
motion improved tendon excursion/stiffness resulting in more normal morphology.
McGeorge and Stillwell compared the results of repair with non-repair in humans for zone 2 injuries and concluded
that tendons lacerated by 60% or less should not be repaired.
36) (OBQ08.165) The median nerve lies immediately ulnar to which of the following structures at the
level of the distal radioulnar joint?
3. Radial artery
5. Pronator teres
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The median nerve sits immediately ulnar to the flexor carpi radialis (FCR). This anatomic relationship
is demonstrated by the fact that a median nerve injury is most likely to be associated with a deep laceration of flexor
carpi radialis (FCR) at the level of the wrist. Additionally, the risk associated in dissecting between the flexor carpi
radialis and palmaris longus is injury to palmar cutaneous branch of the median nerve.
37) (OBQ08.227) Flexor tendons of the fingers within Zone 2 receive their primary nutritional supply
from:
1. Vinculae
2. Phalangeal periosteum
3. Musculotendon junction
4. Tendon insertion
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The vascularity of tendon varies depending on the type of tendon (e.g. with or without a sheath) and
the location. Sheathed tendons (e.g. flexor tendons of the hand) have a dual blood supply via both vascular perfusion
but also have regions that are relatively avascular where they receive nutrition through synovial diffusion. This is the
case in zone 2 of the digital flexor tendons where the primary nutritional supply is from synovial diffusion through the
parietal paratenon which allows for passive nutrient delivery to the flexor tendon within the sheath. The digital flexor
tendons also receive minor direct arterial perfusion in zone 2 through the vinicular system, osseous bony insertions,
reflected vessels from the tendon sheath and longitudinal vessels from the palm, but this is not the major blood
supply.
Tendons not enclosed by a sheath receive their blood supply directly from vessels entering from the tendon surface
or from the tendon-to-bone insertion.
38) (OBQ06.274) A 32-year-old male sustains a 100% tear of his flexor tendon in the Zone 2 region after
cutting his finger with a knife. You plan a one-stage repair of the flexor tendon. Which of the
following variables has the greatest effect on increasing the strength of the tendon repair?
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: The single most effective intervention for increasing strength of a flexor tendon repair is to increase
the number of core sutures crossing the repair site.
Hatanaka and Manske found that locking loops were better than grasping loops, and that a higher core suture
diameter led to an increase in strength. It is well known that adding an epitendinous suture increases the repair up to
10-50% in strength depending on the depth of the suture. There is no evidence that fixing the flexor sheath after
repair increases the strength of the repair nor does it lead to improved outcome. Postoperative active range of motion
would increase excursion thus decreasing the number of potential adhesions. Active range of motion of a repaired
tendon can facilitate intrinsic over extrinsic tendon healing and increase tendon tensile strength, but the magnitude of
this effect is secondary to the number of sutures crossing the repair site.
39) (OBQ05.21) A 34-year-old man sustains a finger flexor tendon laceration and undergoes operative
repair. Which of the following statements best describes the tendon motion rehabilitation protocol
as depicted in Figures A where the splint holds the wrist at 45 degrees of flexion?
FIGURES: A
1. Low force and low excursion
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The rehabilitation protocol depicted in Figure A is the Kleinert protocol which is categorized as a low
force and low excursion rehabiliation. This uses a dorsal blocking splint with the wrist in 45° of flexion and elastic
bands secured to the patient’s nails and a more proximal point on the splint. Once the interphalangeal (IP) joints are
actively fully extended, recoil of the elastic bands flexes them down passively. The Duran protocol (Illustration A) is
similar but the wrist is in 20° of flexion and relies on the patient to alternately passively extend the DIP and PIP joints
with the other joints of the finger flexed. Early active motion protocols that include "place and hold" finger exercises
are considered moderate force and potentially high excursion protocols.
The review article by Lilly and Messer reports that synergistic motion protocols are low force and high tendon
excursion and are the best at minimizing peritendonous adhesions. In this splint, passive digit flexion is combined
with active wrist extension, followed by active digit extension coupled with active wrist flexion
40) (OBQ05.103) A 4 year-old boy sustains a flexor tendon laceration in Zone 2 of his 4th digit when he
attempts to grab a knife. Optimal surgical management and postoperative rehabilitation consists
of:
3. 4 strand core suture technique and gentle active flexion and extension exercises with wrist in
extension
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Ordinarily, adult flexor tendon repair postoperative rehab protocols call for early light active digital
flexion with wrist in extension as long as the tendon has been repaired with a 4 or 6 strand core suture technique and
strong epitendinous suture. However, this method cannot succeed without the cooperation of an intelligent,
motivated, scrupulous patient. Children or the mentally disabled are often lacking some of these prerequisites.
Therefore, a flexor tendon repair in a child should be treated like a flexor tendon repair with interposed graft in an
adult. Immobilization for a minimum of 3 – 4 weeks with a posterior molded plaster splint or cast from the tips of the
fingers to just above the elbow. Wrist is flexed 35 degrees, MCPs flexed 60 – 70 degrees and IP joints relaxed in
extension. Active motion can be started after the cast is removed at 4 weeks.
41) (OBQ04.10) A 23-year-old presents with a knife laceration in the flexor zone 2 of the hand.
Examination of the wound is performed and a laceration of the flexor tendon one-half the width of
the tendon is identified. There is no triggering present as the patient's finger is passively extended
and flexed fully. The most appropriate treatment is:
3. Tendon repair with 2 strand repair and early protected range of motion
4. Tendon repair with 2 strand repair with splint immobilization for 2 weeks
5. Tendon repair with 4 strand repair and early active range of motion
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: Nonsurgical treatment with early protected range of motion is indicated for flexor tendon lacerations
one-half the width of the tendon. The article by Al-Qattan recommends that partial flexor tendon lacerations should be
fixed if the laceration is greater than 60%. Furthermore, the patient should be witnessed under digital block that they
have full extension and flexion without triggering which would be another indication to operate. Rehabilitation consists
of early ROM, wrist and MP flexed in dorsal splint, PIP and DIP extended, Passive digital flexion with wrist flexed,
and wait until eight weeks postop to begin strengthening. This concept was also tested in question 9 of the 2007
OITE with the cited reference by McGeorge and Stillwell comparing the results of repair with non-repair in humans for
zone 2 injuries and concluded that tendons lacerated by 60% or less should not be repaired.
42) (OBQ07.235) A collegiate rower complains of dorsal wrist pain for 6 weeks refractory to NSAIDs and
bracing. Maximal tenderness is palpated on the dorsoradial forearm approximately 5 cm proximal
to the wrist. Pain is exacerbated with resisted wrist extension. Radiographs are unremarkable. A
steroid injection should be directed into the compartment containing which of the following
structures?
3. EPL tendon
5. Brachoradialis tendon
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: The clinical scenario is consistent with intersection syndrome, a inflammatory response to overuse at
the site of the second dorsal compartment crossing under the first dorsal compartment approximately 5 cm proximal
to the wrist. An anatomical depiction is provided in illustration A. Injections of the second dorsal compartment, which
includes ECRL and ECRB, may relieve symptoms and quell inflammation. Intersection must be differentiated from
DeQuervain's syndrome, which is tenosynovitis of the first dorsal compartment. Injections of the first dorsal
compartment, which includes APL and EPB, are part of the treatment algorithm for Dequervain's. Wood et al
summarizes the evaluation and treatment of sports-related wrist injuries. Grundberg et al demonstrates the
pathologic abnormality of intersection syndrome is stenosing tenosynovitis of the second compartment explaining the
rationale behind steroid injections into the sheath.
43) (OBQ09.36) A 22-year-old male snowboarder falls on an outstretched hand and presents with the
radiograph shown in Figure A. Which of the following techniques is MOST important in optimizing
biomechanical fixation?
FIGURES: A
2. Using a larger diameter screw placed in the central axis of the scaphoid
4. Using a larger diameter screw placed in the dorsal axis of the scaphoid
5. Using a larger diameter screw placed in the volar axis of the scaphoid
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: Several studies have shown a longer screw placed in the central axis of the scaphoid optimizes
biomechanical fixation of scaphoid waist fractures. The first reference by McCallister et al is a cadaveric,
biomechanical study that demonstrated a centrally placed screw had 43% more stiffness than an eccentrically placed
screw. They recommend using surgical techniques that optimize central placement and screw length, such as using
a cannulated screw. The study by Dodds et al supported these findings and added that a longer screw with 2mm of
bone coverage provided greater stability than a shorter screw. A more centrally placed screw is generally longer and
has more length of screw on each side of the fracture than does a peripherally placed screw due to the anatomic
dimensions of the scaphoid. Many studies have discussed the amount of compression generated by various internal
fixation screws (e.g headless vs. headed, variable pitch, partially vs. fully threaded, cannulated vs. noncannulated),
but it is believed that rigidity of fixation is probably the most important factor in promoting healing of scaphoid
fractures.
44) (OBQ09.56) An open dorsal approach for antegrade screw fixation of a nondisplaced scaphoid
waist fracture differs in which of the following ways compared to a percutaneous dorsal approach?
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Scaphoid screw fixation should be just below the subchondral bone; this is best judged by direct
visualization.
Adamany et al in an anatomic study using fluoroscopy to insert a scaphoid screw via a percutaneous approach found
that the scaphoid screw "was prominent (above the subchondral bone) in 2 of 12 specimens and flush with or buried
in the remaining 10 specimens." As a result, they recommend using a limited dorsal incision to verify full seating of
the screw. In addition, they found the percutaneous approach was within 2.2-3.1 mm of the PIN, EDC, and EIP.
Thus, all of these structures are at increased risk of injury in a percutaneous approach. The APL tendon is not in the
surgical field. Illustration A shows the AIN(arrowhead) is deep in relation to pronator quadratus. Sensory remnant of
posterior interosseous nerve (straight thick arrow) is adjacent to interosseous membrane. White arrow is median
nerve. Shaded open arrow is ulnar nerve, and long thin arrow is superficial radial nerve.
Tumilty et al inserted a Herbert screw through a dorsal approach in 12 cadaveric wrists. They then imaged them with
AP/Lateral xrays, and 360 degree fluoroscopic views. The wrists were then dissected to evaluated for subchondral
penetration, and plain x-ray films were accurate in 5 of 6 specimens. Fluoroscopy was accurate in all 6. They
concluded that fluoroscopy during placement of the Herbert screw may decrease the rate of subchondral penetration.
45) (OBQ09.234) Which of the following statements is true about force transmission based on wrist
position?
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Majima et al tested force transmission through the wrist in different positions in a cadaveric model.
They found that force through the scaphoid fossa is less in neutral and more in extension, while the force through the
lunate fossa is more in neutral and less in extension. The authors hypothesize that this may explain scaphoid
fractures and intra-articular distal radius fractures as the result of a fall onto an extended wrist.
46) (OBQ08.111) Percutaneous screw fixation for non-displaced scaphoid waist fractures has been
shown to have which of the following differences compared to closed treatment?
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Fixation of non-displaced scaphoid fractures with a percutaneous screw has resulted in a shorter time
to union (6-7 weeks verses 10-12 weeks) and faster return to work or sports.
Arora et al found the indirect cost reduction by a quicker return to work was shown to offset the direct costs of
surgical intervention.
Bond et al found in active military personnel there was faster healing but no difference in ultimate union rates or final
grip strength or range of motion between percutanous screw fixation and non-operative groups.
47) (OBQ07.78) A 30-year-old female reports 5 months of wrist pain after a fall onto her wrist. A
radiograph is shown in Figure A. If untreated, all of the following degenerative changes may be
observed EXCEPT?
FIGURES: A
1. radial styloid osteophyte
2. radioscaphoid arthritis
3. midcarpal arthritis
4. pancarpal arthritis
5. radiolunate arthritis
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Radiographs show a scaphoid non-union which can lead to Scaphoid Nonunion Advanced Collapse
(SNAC wrist) and progressive arthritis. The natural history of degenerative changes first occurs at the radioscaphoid
area and progresses to pancarpal arthritis. All of the answers above are features of a SNAC wrist except radiolunate
arthritis.
In the cited reference by Schuind et al, they found that professional heavy work, age of the nonunion of over 5 years,
associated radial styloidectomy, and duration of postoperative immobilization were associated with a significantly
decreased likelihood of healing of the scaphoid nonunion with operative treatment.
The study by Soejima et al found that distal scaphoid resection produces a satisfactory clinical outcome and should
be considered one of the surgical options for patients with long-standing scaphoid nonunion with either radioscaphoid
or intercarpal degenerative arthritis.
48) (OBQ07.127) A 20-year-old skateboarder fell 6 months ago and has had radial-sided wrist pain
since. His radiograph upon presentation to your office is shown in figure A. What is the most
appropriate treatment at this time?
FIGURES: A
1. short arm thumb spica cast
5. wrist arthrodesis
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: This patient has a scaphoid waist fracture nonunion. Several studies indicate that scaphoid nonunions
left untreated have a determined course of collapse and progressive arthritis (scaphoid nonunion advanced collapse -
SNAC). Per Markiewitz et al, the standard treatment of scaphoid nonunions is open reduction internal fixation with
bone graft; non-operative treatment is not appropriate. Proximal row carpectomy and wrist fusion are salvage
procedures reserved for patient that has an advanced scaphoid nonunion, collapse and wrist arthritis.
49) (OBQ06.16) A 27-year-old professional cowboy is thrown from a bull during the rodeo and lands on
his hand. No deformity is identified and the hand is completely neurovascularly intact. Pain is
present upon palpation of the anatomic snuffbox. A radiograph is provided in Figure A. The
cowboy wants to return to competitive riding tomorrow. Which of the following is the best next step
in management?
FIGURES: A
1. Cock-up wrist splint and immediate return to sport as tolerated by pain
2. Steroid injection of the snuffbox, taping of the wrist and return to sport
3. Wrist MRI
5. Scapholunate
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: Tenderness with palpation of the anatomic snuffbox should raise suspicion of a scaphoid fracture.
The radiograph does not show any findings, but scaphoid fractures are often not initially visualized on plain
radiographs. Appropriate treatment for any patient with snuffbox tenderness entails cast immobilization with repeat
radiographs at 2-3 weeks or advanced imaging with MRI to evaluate for a fracture that is not identified with plain
radiographs. The MRI that correlates with this patient's radiograph is provided in Illustration A and demonstrates a
nondisplaced scaphoid fracture. Gaebler et al performed an MRI study of 32 consecutive patients who were clinically
suspicious for a scaphoid fracture, but no fracture could be indentified on wrist radiographs. The MRI was 100%
sensitive and specific in diagnosing scaphoid fracture. Treatment for this patient following the MRI would be
debatable. Cast immobilization would be appropriate, but screw fixation may allow earlier return to sport. A
percutaneous compression screw would be an appropriate technique for this scaphoid fracture.
50) (OBQ05.130) A 35-year-old woman reports wrist pain after a fall onto an outstretched hand. On
exam, she has focal tenderness over the wrist snuffbox. A radiograph and CT image are shown in
Figures A and B. What is the proper treatment of her injury?
FIGURES: A B
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The radiograph and CT scan show a displaced scaphoid waist fracture. Optimal treatment is ORIF
with screw fixation.
The usual mechanism of injury to the scaphoid is axial load across a hyperextended wrist. Pain with resisted
pronation, snuffbox tenderness and scaphoid tuberosity tenderness should all raise suspicion for a scaphoid fracture.
AP and lateral X-rays, as well as PA view with the hand in ulnar deviation and an oblique 45 degree view with the
hand in pronation can help to identify the fracture. Bone scan, CT and MRI can also be used to make the diagnosis if
radiographs are indeterminate. ORIF is recommended for any fracture displaced more than 1mm, with a radiolunate
angle greater than 15 degrees, with intrascaphoid angle greater than 35 degrees, associated with perilunate
dislocation or with a proximal pole fracture. Optimal treatment is ORIF with screw fixation. For minimally displaced
fractures, percutaneous or mini-open fixation allows minimal dissection and preservation of extrinsic ligaments.
Incorrect Answers:
Answer 1,2,3: Nonoperative management is not indicated in displaced scaphoid fractures
Answer 5: Vascularized bone grafting is reserved for cases of scaphoid nonunion.
51) (SBQ07.40) A 44-year-old man presents with ulnar-sided right wrist pain and mild constant tingling
in the fourth and fifth digits after injuring his wrist while playing golf. Although pain and function
have improved with conservative treatment 6 months following the injury, he still reports difficulty
with his golf game. Which of the following should initially be obtained in this patient to aide in the
diagnosis?
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: This patients clinical presentation is most consistent with a chronic hook of the hamate fracture, which
should initially be evaluated with a carpal tunnel view radiograph. Hook of the hamate fractures typically are
associated with pain localized to the hypothenar eminence, and chronic cases can be associated with neuropathy of
the ulnar nerve. Excision of the hook through the fracture site usually yields satisfactory results in the presence of
chronic injuries.
Parker et al treated five patients with six hook of the hamate fractures over an eight year period. All patients
ultimately underwent hook resection and returned to their previous level of activity in 6 to 8 weeks after surgery
without loss of function. Based on their case series, they concluded that the entire hook should be resected to the
base of the hamate as the primary form of treatment in hook of the hamate fractures.
Illustration A: Patient positioning for carpal tunnel radiograph-wrist is extended 70 degrees, and beam is angled 25-
30 deg to the long axis of the hand(arrow).
Illustration B: Carpal tunnel view radiograph demonstrates a fracture at the base of the hook of the hamate(black
arrow) and normal pisotriquetral joint space.
Incorrect Answers:
1-Bone scans are not typically indicated in the diganostic setting of acute or chronic hook of the hamate fractures.
2-Imaging should be obtained to rule out bony injury prior to obtaining an EMG study.
4-CT scans can used to confirm the diagnosis of a hook of the hamate fracture after obtaining a carpal tunnel view
radiograph.
5-Contrast enhanged MRA of the wrist is typically used to diagnose hypothenar hammer syndrome or other vascular
abnormalities.
52) (OBQ11.130) A 24-year-old racquetball player presents after accidentally striking his racket against
the wall during a match two months ago. He is tender to palpation over the hypothenar mass, and
his pain is aggrevated by grasping. A radiograph and CT scan of his wrist are shown in Figures A
and B. Which of the following treatment methods has been definitively shown in the literature to
have a favorable outcome, and a high chance to return to pre-injury activities in patients with this
injury?
FIGURES: A B
1. Activity restriction and continued monitoring
5. Surgical excision
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The patients history and imaging are consistent with a subacute hook of the hamate fracture. This is
demonstrated by the carpal tunnel view radiograph in Figure A, and confirmed by the CT scan of the wrist in Figure
B. CT scan of the wrist is usually indicated to definitively diagnose these fractures. Current literature supports the
most favorable results and ability to return to pre-injury activities with excision of the fracture fragment. There is little
available literature reporting the results of open reduction and internal fixation of these fractures.
Rettig et al review traumatic wrist injuries in athletes. With regards to treatment of hook of the hamate fractures, they
state that ORIF and excision are the two viable treatment options in athletes. Of these, the literature supports
fragment excision, which has an average return to sport time of 7-10 weeks.
Welling et al determined which wrist fractures are not diagnosed with initial radiography, using CT as a gold standard
and identified specific fracture patterns. In their series, they found that only 40% of hamate fractures were diagnosed
on plain radiography, suggesting that CT should be considered after a negative radiographic finding if clinically
warranted.
53) (OBQ08.23) A professional baseball player develops acute hand pain after fouling off a pitch. He is
tender over the hypothenar eminence and has paresthesias in the ring and small fingers. Which
radiographic view is most likely to reveal the pathology?
1. PA wrist
3. Lateral wrist
4. Carpal tunnel
5. Scaphoid
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Plain radiographs usually do not reveal the fracture; carpal tunnel and supinated oblique views should
be obtained. Diagnosis is confirmed by CT scan and bone scan.
Fractures of the body of the hamate may occur from trauma and may occur in combination with fractures of the base
of the fourth and fifth metacarpals. Fractures of the hook of the hamate are more common in athletes. The incidence
of hook of the hamate fractures is 2% to 4% of all carpal fractures. The mechanism of injury is thought to be caused
by abutment of the hook on an object or by a shearing force applied by the flexor tendon of the small and ring fingers.
The injury usually occurs in athletes who participate in baseball, golf, and racquet sports because of the position of
the implement in the hand.
Rettig reviewed hand injuries in athletes. He noted that hamate hook fractures occur in a watershed area that may
explain the high incidence of nonunion post fractures. Hook of the hamate fracture must be suspected in athletes
participating in racquet sports, golf, or baseball who are seen with ulnar wrist pain. Examination reveals tenderness
over the hook of the hamate, which lies on a line between the pisiform and second metacarpal head. Treatment of
hook of the hamate fractures in athletes varies from casting to open reduction and internal fixation to excision.
Bishop and Beckenbaugh reported 21 cases of this fracture: 17 were treated by excision, 3 underwent ORIF, and 1
had casting. Although two of three fractures that were treated with ORIF healed, many authors recommend excision,
which has an average return to sport of 6 to 10 weeks.
54) (OBQ04.21) A 24-year-old professional baseball outfielder reports persistent pain in the hypothenar
region when batting for the past year. His CT scan is shown in Figure A. What is the recommended
treatment?
FIGURES: A
1. pisiform excision
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: The history is typical of a hook of the hamate fracture, which is confirmed on the CT image. A carpal
tunnel view radiograph of this injury is shown in Illustration A. It commonly occurs in baseball players and golfers.
Physical exam findings include point tenderness at the hamate, ulnar nerve paresthesias (hemorrhage within
Guyon's canal), and pain with axial load of ring and little fingers. For cases seen late, with few exceptions, the
recommended treatment has been excision of the hook fragment. Marchessault provides a review of diagnoses and
treatment for carpal fractures. They discuss the treatment of these injuries, indicating that acute, nondisplaced
fractures may be placed in a cast, and excised if nonunion develops. The authors go on to say that certain
investigators recommend excision of asymptomatic nonunions to minimize the risk for flexor tendon rupture.
55) (OBQ07.102) A 28-year-old man fell while ice skating 6 months ago and has had ulnar-sided wrist
pain ever since. The patient's lateral radiograph of the wrist is shown in figure A and a CT scan is
shown in Figure B. What is the most appropriate treatment?
FIGURES: A B
1. scapholunate ligament repair
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: The radiograph and CT scan demonstrate a comminuted pisiform fracture. Incongruity and/or arthritis
at the pisotriquetrial joint can cause ulnar-sided wrist pain. Studies show a pisiformectomy is a reliable way to relieve
this pain and doesn’t impair wrist function. Lam et al in a study of 20 patients who underwent pisiformectomy for
pisotriquetral joint dysfunction reported 15 with complete relief and 5 with mild discomfort at a mean follow-up of 65
months. They reported "no significant differences in grip strength and wrist movement, static strength and dynamic
power" when compared to the unaffected wrist.
56) (OBQ08.91) Which of the following muscles provide the primary deforming forces to Bennett and
Rolando fractures (base of the 1st metacarpal fractures)?
1. Pronator quadratus
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The primary deforming forces in Bennett and Rolando fractures are the Abductor pollicis longus and
adductor pollicis.
In a Bennet's or Rolando fracture-dislocation the volar-ulnar fracture fragment is held reduced by the anterior oblique
ligament while strong deforming forces pull the remaining metacarpal shaft proximally and dorsally, angulate the
shaft ulnarly and supinate the shaft. Most important in these deforming forces are the abductor pollicis longus (APL)
inserting on the base of the metacarpal which pulls the metacarpal shaft proximally and dorsally and the adductor
pollicis (AP) which inserts on the ulnar base of the proximal phalanx and angulates the metacarpal shaft ulnarly and
supinates the shaft. Less important is the extensor pollicis longus (EPL) which inserts on the base of the distal
phalanx and also adds to the ulnar angulation of the distal fragment.
Soyer reviews the diagnosis, pathoanatomy, and treatment for fractures at the base of the 1st metacarpal.
Understanding the biomechanics, anatomical deforming forces, and the exact fracture pattern aids the treating
surgeon in determining the most appropriate method of fixation. The most essential factor for obtaining a good
functional result is anatomic restoration of the articular surface.
Elgafy et al. examined the terminal anatomy of the posterior interosseous nerve in their cadaver study - identifing six
terminal branches and describing methods to avoid injury. They describe how treating surgeons can maximize
function and recovery after base of the 1st metacarpal fractures by understanding these nervous branches and
specific fracture pattern treatment to avoid iatrogenic injury to the PIN.
57) (OBQ11.18) A 25-year-old female is involved in a motorcycle collision and presents with the injuries
seen in Figures A through D. What is the best option for definitive management of the injuries seen
in Figure D?
FIGURES: A B C D
3. External fixation
4. Immediate therapy
5. Removable splint
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The patient presents with mutliple injuries including a subtalar dislocation (Figure A), femoral shaft
fracture (Figure B), tibia shaft fracture (Figure C) and multiple metacarpal shaft fractures (Figure D). Multiple
metacarpal shaft fractures are best managed with open reduction and internal fixation as non-operative management
is associated with loss of motion, asynchronous grasp and decreased grip strength.
Souer and Mudgal retrospectively reviewed their experience treating patients with multiple metacarpal fractures
utilizing hand-specific implants. They argue that rigid internal fixation of multiple metacarpal fractures allows for early
mobilisation and tendon excursion, and found excellent results in 18 of 19 patients with a 230 degree total arc of
motion.
Kawamura and Chung review fixation options for treating unstable oblique phalangeal and metacarpal fractures.
They found low complication rates regarding tendon adhesion and stiffness with published studies examing dorsal
plating of oblique metacarpal fractures as the extensor tendons are less adherent to bone at the level of the
metacarpal.
Incorrect Answers:
Answer 2. Closed reduction and casting would lead to stiffness due to immobilization
Answer 3. External fixation would bind the extensor mechanism and would not allow for early motion
Answer 4. Immediate therapy, although beneficial, would be difficult to accomplish without rigid fixation
Answer 5. Removeable splinting would not facilitate early motion and and would likely lead to loss of metacarpal
length and deformity as the stabilizing effect of the adjacent metacarpals is lost with multiple fractures
58) (OBQ11.63) A 39-year-old male sustained an index finger injury 6 months ago and has failed eight
weeks of splinting. A radiograph taken at the time of injury is shown in Figure A, and a current
radiograph is shown in Figure B. Which of the following is true regarding open reduction and screw
fixation of this injury?
FIGURES: A B
4. Open reduction via an approach through the nail bed leads to significant post-operative nail
deformity
5. Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-
operatively
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: Open reduction and internal fixation of distal phalanx fracture non-unions frequently requires the post-
operative removal of the fixation implant after complete fracture healing.
Chim et al followed 14 patients with non-union of fractures of the shaft of the distal phalanx who were treated with
open reduction and screw fixation. The implants required removal in 13/14 patients, and the mean post-operative
range of motion of the DIP joints was 56 degrees. No immobilization was required postoperatively, and bone grafting
was only necessary in two patients with severely comminuted fractures. Finally, the authors recommended
approaching the fracture through the nailbed for the best exposure, and found no postoperative nail growth
complications. Postoperative infections were not common in their series.
Mejis et al describe two patients with non-unions of the thumb distal phalanx treated with a single compression screw
using a minimally invasive approach. Both patients healed their fractures using this technique.
59) (OBQ09.194) What is the most frequently encountered form of osseous injury associated with
dorsal proximal interphalangeal joint(PIP) fracture-dislocations?
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: Middle phalanx palmar lip fractures are the most frequently encountered form of osseous injury
associated with dorsal PIP joint fracture-dislocations. Pure PIP joint hyperextension often disrupts the palmar plate
either at its distal insertion or by creating a tension fracture at the palmar lip of the middle phalanx.
The review article by Kiefhaber and Stern detail that the restoration of the middle phalangeal base to glide around the
proximal phalangeal head during the flexion arc is the primary goal. Hinging (instead of articular gliding) at the
fracture site must be avoided by eliminating joint subluxation and then re-establish joint stability to prevent recurrent
subluxation. Early motion of the PIP and anatomic restoration of the fractured joint surface is a desirable but is
secondary compared to reduction of the middle phalanx on the condyles of the proximal phalanx.
60) (OBQ08.100) A 28-year-old professional baseball player injures his middle finger sliding into the
catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A
radiograph is provided in figure A. All of the following are true EXCEPT:
FIGURES: A
5. Early degenerative arthritis can be expected if the joint is not adequately reduced.
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The radiograph demonstrates a dorsal fracture dislocation of the proximal interphalangeal joint of the
middle finger. Kiefhaber and Stern review the presentation, evaluation, and treatment of PIP fractures. Congruent
reduction of the joint to allow the middle phalangeal to glide around the proximal phalangeal head is paramount to
prevent joint subluxation and instability. Anatomic reconstruction of the articular surface is desirable but not
necessary for successful clinical outcome.
61) (OBQ07.24) A 20-year-old football player presents with a one week history of right index finger pain
which started after his hand got caught in a face mask during a tackle. Physical exam shows
swelling of the digit with no breaks in the skin, and no active flexion. AP, lateral, and oblique
radiographs are provided in Figures A, B, and C respectively. Which of the following structures
most often prevents closed reduction of this injury?
FIGURES: A B C
1. Volar plate
2. Collateral ligaments
3. FDP tendon
4. Central slip
5. Dorsal capsule
PREFERRED RESPONSE ▼ 1
DISCUSSION: Figures A, B, and C demonstrate a dorsal dislocation of the DIP joint without associated fracture.
Abouzahr et al conducted a case report and literature review on irreducible dorsal DIP dislocations. The authors
found that the most common block to reduction with a closed injury is an interposed volar plate, which is avulsed from
its origin on the middle phalanx. They recommened open reduction and extraction of the volar plate if one is unable
to achieve concentric stable reduction after two attempts. Furthermore, the authors determined that in open injuries,
the FDP tendon is primarily responsible for irreducibility. The collateral ligaments are less likely to be involved in this
case because there is little coronal deformity present. The dorsal capsule is typically not a block to reduction, and the
central slip is disrupted (but does not block reduction) in volar PIP joint dislocations.
62) (OBQ07.218) A 27-year-old man falls on his hand at work. He notices an immediate deformity of his
ring finger. Radiographs are provided in Figure A. Which of the following is the most appropriate
initial treatment?
FIGURES: A
1. Closed reduction, buddy taping, and early motion to prevent stiffness
3. Open reduction and repair of the central slip of the extensor tendon
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: The radiograph demonstrates a volar PIP dislocation. The central slip of the extensor tendon is
frequently ruptured and will lead to a boutonneire deformity if left untreated. The PIP must be immobilized in
extension to allow the extensor mechanism to heal. Immobilization in extension should be maintained for 6 weeks to
allow soft tissue healing. Open reduction and repair of the central slip would be the appropriate treatment for a
developing boutonneire deformity that presents in a subacute or chronic time basis. Illustrations A and B demonstrate
a schematic and clinical photo of central slip disruption and secondary deformity with PIP flexion and DIP
hyperextension (Boutonniere Deformity). Posner et al reviewed 7 patients with chronic palmar dislocations of the PIP
joint who were treated with open reduction and reconstruction of the extensor mechanism. All patients acheived
satisfactory range of motion and the authors concluded that this technique is preferable to arthrodesis. Peimer et al
reviewed 15 patients with palmar dislocations of the PIP joint. Twelve of the fifteen were evaluated on a delayed
basis (average 11 weeks following injury) and underwent open reduction and surgical repair of the extensor tendon.
Three of the fifteen were seen earlier following injury and were treated with closed reduction and pinning. All fifteen
patients acheived satisfactory clinical outcomes although finger range of motion was not fully recovered in any case.
63) (OBQ06.120) A collegiate baseball player injures his left small finger sliding into third base. He
complains of pain and swelling. The finger is ecchymotic, swollen throughout, and painful with
attempted range of motion of the PIP joint. No sensory or vascular deficits are present. A
radiograph is provided in Figure A. Which of the following interventions will provide the best
outcome?
FIGURES: A
1. Buddy taping the small finger to the ring finger
2. Immobilization of the MCP in flexion and the PIP and DIP in extension with a custom splint
3. External fixation
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The radiograph shows an oblique fracture of the distal proximal phalanx that extends into the joint
with an articular step off. Open reduction internal fixation will correct the deformity, expedite finger rehabilitation, and
prevent early degenerative arthritis. Closed treatment without fixation will not reliably hold the fracture reduced while
the bone heals. Arthrodesis is unnecessary in this young, active patient.
64) (OBQ12.49) A 34-year-old male sustains the closed finger injury shown in Figure A one week ago.
He undergoes closed reduction and pinning shown in Figure B to correct alignment. Which of the
following is responsible for the apex volar fracture deformity noted on the preoperative
radiographs?
FIGURES: A B
1. Pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal
phalanx
4. Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the
lateral bands
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The clinical presentation is consistent with a transverse proximal phalanx fracture. These fracture
have an apex palmar angulated deformity under the pull of the central slip on the distal fragment and the interossei
insertions at the base of the proximal phalanx.
If proximal phalanx fractures are allowed to heal with the apex palmar deformity, an extensor lag will result. Therefore
CRPP or ORIF is indicated in transverse fractures with > 10° angulation. To correct this deformity prior to surgical
fixation, the PIP joint should be flexed, which allows the extensor mechanism as a whole to function as a tension
band to help reduce the fracture. This is referred to as intrinsic plus splinting. Collateral ligament, capsule, and
intrinsic muscle attachments render transverse fractures in the proximal 6 to 9 mm of the P1 base more stable than
fractures located distally.
Henry provides a review of fractures of the proximal phalanx and metacarpals. He states that most transverse or
short oblique P1 fractures without comminution are best stabilized by two 0.045-inch K-wires placed longitudinally
through the fully flexed MCP joint. A single wire alone risks rotational malunion, but some fracture patterns may
provide inherent rotational stability that would allow use of one wire for angular control.
Figure A shows a transverse fracture of the proximal phalanx with apex volar angulation. Figure B shows two K-wires
placed transarticular through the MCP joint in a flexed (intrinsic plus) posture to correct the deformity and stabilize the
fracture.
Incorrect Answers:
Answer 2: Intrinsic muscle fibrosis and contracture is usually associated with chronic crush injuries and significant
soft tissue damage.
Answer 3: This is describing a swan neck deformity.
Answer 4: This is describing a Boutonnierre deformity.
Answer 5: Flexor tendon disruption is not likely in this closed injury pattern.
65) (OBQ10.213) Creation of a Stener lesion, as found in Gamekeeper's thumb, requires combined tears
of the proper and accessory ulnar collateral ligaments in order for the ligament to be displaced by
the adductor aponeurosis. Which of the following most accurately describes the role these ulnar
collateral ligaments (PCL/ACL) play in thumb MCP joint stability?
1. PCL is primary restraint to radial deviation with MCPJ in flexion, ACL provides restraint to radial
deviation with MCPJ in extension
2. PCL is primary restraint to radial deviation with MCPJ in extension, ACL provides restraint to radial
deviation with MCPJ in extension
3. ACL is primary restraint to ulnar deviation with MCPJ in flexion, PCL provides restraint to ulnar
deviation with MCPJ in extension
4. ACL is primary restraint to radial deviation with MCPJ in flexion, PCL provides restraint to radial
deviation with MCPJ in extension
5. PCL is primary restraint to ulnar deviation with MCPJ in flexion, ACL provides restraint to radial
deviation with MCPJ in extension
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The proper ulnar collateral ligament(PCL) runs from the metacarpal head to the volar aspect of
proximal phalanx and resists ulnar stress with the thumb MCPJ in flexion. The accessory ulnar collateral
ligament(ACL) lies palmar to the proper ligament, and insets inserts onto the volar plate. The volar plate and ACL
function as the principle restraints to ulnar stress with the thumb MCPJ in extension.
The function of the ulnar collateral ligaments is shown in Illustration A.(Please note the distal phalanx of the thumb
has been removed in Illustration A.) A Stener lesion is described by displacement of the distal end of the completely
ruptured UCL such that it comes to lie superficial and proximal to the adductor aponeurosis. This is shown in
Illustration B.
Thrikannad and Wolff report a case of distal pull-off of the ulnar collateral ligament (UCL) of the thumb MCPJ with
two fracture fragments. They identify the need to look for a second fragment of bone in these injuries, where an
apparently undisplaced fracture is noted at the base of the proximal phalanx. They suggest that this second fragment
probably indicates the location of the distal end of the UCL and may identify a Stener lesion. A radiographic example
from their paper is shown in Illustration C.
Newland, in his review article on Gamekeeper's Thumb, states that criteria for judging what constitutes a complete
tear vary from 15 deg to 45 deg difference with respect to the opposite side. He goes on to state, however, that many
authors choose an absolute value of >35 degrees of joint laxity compared to the contralateral side when judging a
tear to be complete or incomplete. When an acute tear is identified, surgical repair is recommended.
66) (SBQ07.38) A 32-year-old professional baseball player presents with wrist pain after a fall on his
outstretched wrist 10 days ago. He initially thought it was a sprain, but presents due to continued
pain worsened by push-ups. His physical exam shows dorsal wrist tenderness and is positive for
the provocative test shown in Figure V. Standard PA radiograph of the wrist is normal. Which of the
following radiographic views shown in Figures A to E would be most helpful in establishing the
diagnosis?
FIGURES: V A B C D E
1. A
2. B
3. C
4. D
5. E
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The clinical description and video of the patient's physical exam are consistent with an acute scapho-
lunate ligament tear. The video shown in the question stem demonstrates the Watson test. When positive, the patient
will feel dorsal wrist pain and/or a "clunk" when the wrist is brought from extension/ulnar deviation to radial deviation.
If plain radiographs are normal, a PA clenched fist radiograph as seen in Figure A should be performed.
In patients with a acute scapho-lunate ligament tear, initial radiographs may not show the characteristic "Terry
Thomas" sign, or widening of the SL gap > 3mm. When making a clenched fist, the capitate is drawn proximally,
stressing the SL ligament. This is an easy view to obtain during the initial patient visit and should strongly be
considered if this diagnosis is suspected.
Walsh et al review the various aspects of scapholunate ligament injuries. While they agree imaging is helpful in
establishing the diagnosis, they emphasize that wrist arthroscopy is the gold standard in the diagnosis of SL injuries.
Illustration A shows demonstrates a clenched fist view with obvious widening of the scapho-lunate gap.
Incorrect Answers
Answer 2: Shows a lateral radiograph in 30 degrees of supination. It is excellent for assessment of pisotriquetral
arthrosis.
Answer 3: Shows a PA of the wrist in radial deviation. This view will actually close the SL gap.
Answer 4: Shows a a carpal tunnel view, used for assessment of hook of hamate fractures.
Answer 5: Shows a a stardard PA wrist in neutral aligment.
67) (OBQ11.52) A 22-year-old gymnast with known ligamentous laxity has been treated in the hand
therapy clinic for 6 months for left wrist pain and discomfort. Radiographs of her left wrist are seen
in Figures A and B. Which of the following physical exam findings would be most diagnostic for
midcarpal instability?
FIGURES: A B
3. Pain and a clunk on ulnar to radial deviation of the wrist while pressure is held on the scaphoid
4. Pain in the lunate with volar directed pressure on the dorsum of hand
5. Pain and a clunk with axial and palmarly directed forces as the wrist is moved from neutral to ulnar
deviation
PREFERRED RESPONSE ▼ 5
DISCUSSION: The clinical situation is consistent with midcarpal instability. The most common finding on physical
examination is a clunk as the wrist is moved from a neutral position and forearm pronation to ulnar deviation with an
axial and palmarly directed load. Carpal instability is complex condition marked by abnormal kinematics in the
carpus. Carpal instability dissociative (CID) is marked by intrinsic ligamentous disruption. Carpal instability non-
dissociative (CIND) is marked by extrinsic ligamentous disruption between carpal rows or between the proximal row
and distal radius. Included in CIND is midcarpal instability (MCI) and radiocarpal instability. Radiographs typically
show a mild VISI deformity or no abnormalities as in Figures A and B. Videofluorscopy is diagnostic as the proximal
row assumes a volar, flexed position, then snaps into extension the wrist is moved into ulnar deviation.
Lichman et al provided an overview and historical perspective of carpal instability. Carpal instability is divided into
dissociative and non-dissociative. They concluded that there are several causes and patterns of carpal instability
leading to carpal subluxation. An in-depth understanding is required for proper treatment.
Apergis et al described 14 cases of midcarpal instability treated with ligamentous reefing of the midcarpal joint and or
the radiolunate joint. They reported excellent results in eight cases, good in five cases, and fair in one case.
Incorrect answers:
Answer 1: A positive Finkelstein's maneuver is radial-sided pain with a clinched thumb and ulnar deviation of the wrist
Answer 2: A positive Fovea sign is found with pain on palpation distal to the ulnar styloid
Answer 3: Watson's scaphoid shift is pain and a clunk on ulnar to radial deviation of the wrist while pressure is held
on the scaphoid tubercle.
Answer 4: Describes pain in the lunate as in Keinbock's.
68) (OBQ09.227) A 35-year-old professional football player complains of severe wrist pain after making
a tackle. He reports paresthesias in his thumb and index finger. AP and lateral radiographs of the
wrist are shown in figures A and B respectively. What is the most appropriate next step in
management?
FIGURES: A B
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: This patient is presenting with a perilunate dislocation with carpal tunnel symptoms. The most
important next step in treatment is reduction of the dislocation. Kozin et al note that these injuries can be overlooked
and have variable propagation patterns through the carpus/carpal ligaments. This patient has a radial styloid fracture
due to avulsion of the radiocarpal ligaments. Melone et al note that these injuries were historically treated with closed
reduction and pinning, but more recently the trend is for open reduction and fixation, for optimal anatomic restoration.
69) (OBQ05.267) In a patient with -2.5mm of ulnar variance, which of the following statements best
describes the distribution of compressive load across the wrist?
1. Approximately 50% of the wrist load is accepted by distal radius and 50% is accepted by the distal
ulna
2. Approximately 80% of the wrist load is accepted by the distal radius and 20% is accepted by the
distal ulna
3. Approximately 80% of the wrist load is accepted by the distal ulna and 20% is accepted by the distal
radius
4. Approximately 95% of the wrist load is accepted by the distal radius and 5% is accepted by the distal
ulna
5. Approximately 60% of the wrist load is accepted by the distal radius and 40% is accepted by the
distal ulna
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Ulnar variance describes the cranio-caudal position of the distal ulna in relation to the distal radius at
the wrist. In neutral ulnar variance, 80% of the compressive load across the wrist is accepted by the distal radius, and
20% is accepted by the distal ulna. With -2.5mm of ulnar variance (negative ulnar variance), approximately 5% of the
wrist load is accepted by the distal ulna. With +2.5mm of ulnar variance (positive ulnar variance), approximately 40%
of the wrist load is accepted by the distal ulna. As discussed in the biomechanical study by Palmer and Werner, the
loading characteristics of the wrist are dependent on the radio/ulnar variance. Specifically, a 2.5 mm increase in ulnar
variance increases load accepted by ulno-carpal joint from 18% to 42%; a 2.5 mm decrease in the ulno-carpal
variance will decrease the load accepted by the ulno-carpal joint to 4.3%. Friedman and Palmer review the clinical
diagnosis, pathophysiology, and treatment of ulnar impaction syndrome.
70) (OBQ05.273) Which of the following structures is an anatomical component of the triangular
fibrocartilage complex?
4. Radioscaphocapitate ligament
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: Palmer et al studied the anatomy and function of the triangular fibrocartilage complex (TFCC) through
anatomical dissections and biomechanical testing. The TFCC was found to be composed of the sheath of the
extensor carpi ulnaris (ECU), an articular disc, the dorsal and volar radioulnar ligaments, the meniscus homologue,
and the ulnar collateral ligament. Biomechanically, they determined that the TFCC functions as a cushion at the
ulnocarpal interface, and is a major stabilizer of the DRUJ. Nakamura et al histologically examined the origins and
insertions of the TFCC in fresh-frozen cadaver wrists. They found that the floor of the ECU sheath originated from the
dorsal side of the fovea of the ulna, through an arrangement of Sharpey's fibers. Illustration A shows the anatomy of
the TFCC.
71) (SBQ07.3) A 19-year-old football player suffers a fall onto a pronated, extended wrist. He has pain
with resisted ulnar deviation and is tender to palpation just distal to the ulnar styloid. He has no
tenderness over the extensor carpi ulnaris (ECU) tendon. Current radiographs are shown in in
Figures A and B and and MRI of the wrist is shown in FIgure C. Which of the following is the most
likely diagnosis?
FIGURES: A B C
5. Perilunate dislocation
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Fall from standing onto an extended and pronated wrist is a risk factor for injuries to the soft tissues of
the wrist. The structures at risk include the triangular fibrocartilaginous complex (TFCC), the lunotriquetral ligament,
ulnolunate ligament, hook of hamate, ulnar styloid, and the extensor carpi ulnaris (ECU) tendon sheath. Pain with
resisted ulnar deviation and ulnar catching are all concerning for injury to the TFCC. MRI is useful for diagnosing
TFCC tears ( Illustration A shows another example).
Papapetropoulos et al in their review article discuss the evaluation and arthroscopic treatment of TFCC injuries.
Specifically they discuss that most tears in athletes are acute and amenable to repair by repair of the dorsal tear to
the ECU tendon sheath.
Cohen in his review of injuries in athletes discusses scapholunate ligament, lunotriquetral ligament, and midcarpal
injuries. Of note he divides scapholunate and lunotriquetral ligament injuries into dissociative lesions (abnormal
motion within proximal carpal bones) vs. midcarpal lesions which are generally considered nondissociative (abnormal
motion between proximal and distal carpal bones).
Rettig in his review of sports injuries of the extremities discusses the Palmer classification of TFCC tears. Specifically
he notes that central tears are more associated with repetitive activities in patients with positive ulnar variance.
Incorrect Answers:
Answer 1: The patient is not tender in the region of the ECU tendon sheath.
Answer 3: The carpal tunnel view radiograph shows no hook of hamate fracture.
Answer 4 and 5: Wrist radiographs shows no scapholunate widening or perilunate dislocation. Physical exam in this
case is more consistent with a TFCC injury.
72) (OBQ09.229) A 32-year-old carpenter has a 6 month history of ulnar wrist pain that is worsened
opening a jar, squeezing a wet towel, typing, or changing a gearshift. Radiograph and MRI images
are detailed in Figures A through C. All of the following concerning ulnar shortening osteotomy are
true EXCEPT:
FIGURES: A B C
1. Care should be taken to avoid the dorsal sensory branch of the ulnar nerve
3. Placement of the plate to the dorsal surface of the ulna can cause tendinitis of the extensor carpi
ulnaris
4. Concomitant arthroscopy is indicated for patients who are seen to have cystic changes of the carpus
on radiographs
5. Degenerative cystic changes of the ulnar carpal bones resolve after the ulnar shortening osteotomy
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Ulnocarpal impaction syndrome results from abutment of the ulnar head into the proximal ulnar aspect
of the lunate. It is worsened by activities that have wrist rotation and ulnar deviation. A positive ulnar variance with or
without cystic changes of the carpus is often seen on plain radiographs. In the absence of structural abnormalities,
such as a Madelung deformity or DRUJ arthrosis, the most commonly performed procedure is an ulnar shortening
osteotomy. Coexisting central TFCC tears are common and can be addressed by arthroscopic or open débridement.
The Level 4 study by Baek et al describes 31 patients that had improved Gartland and Werley scores following ulnar
shortening osteotomy. They also noted that all patients with degenerative cystic changes had resolution of the cysts
at 1-2 year followup and they include a detailed outline of their surgical technique. The Level 4 study by Chun et al
showed very good outcomes with minimal complications and no ulnar nonunions.
73) (OBQ05.46) A 42-year-old construction worker presents with pain in his right wrist. A current
radiograph of the wrist is shown in Figure A. He reports that rotating activities, such as turning a
screw driver, are bothersome and the pain is preventing him from working. A current MRI reveals a
TFCC tear, and nonsurgical treatment has failed to provide relief. Treatment should now consist of:
FIGURES: A
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The clinical presentation is consistent with DRUJ arthritis in a heavy laborer. Of the options listed,
ulnar hemiresection arthroplasty with concurrent TFCC reconstruction would be the most appropriate treatment.
While there are multiple treatment options, the ulnar hemiresection arthroplasty with concurrent TFCC reconstruction
is considered most appropriate in heavy laborers, as it would likely resolve the pain and enable them to return to
work sooner. The TFCC should be intact when performing an ulnar hemiresection arthroplasty to prevent distal ulna
instability with forearm rotation. One could also consider performing a Suave-Kapandji procedure laborers. This
procedure creates a distal radioulnar fusion and an ulnar pseudarthrosis proximal to the fusion site through which
rotation can occur. The advantage is that the ulnocarpal joint is not sacrificed, and a stable wrist is created.
Scheker et al reported on the outcome of ulnar shortening performed on 32 wrists with early osteoarthritis of the
DRUJ. The postoperative wrist ratings were 7/32 excellent, 11/32 good, 9/32 fair, 5/32 poor, with plate irritation being
the most frequent postoperative complication.
Figure A is a radiograph showing significant DRUJ arthritis. Illustration A shows ulnar hemiresection arthroplasty.
Illustration B shows a Darrach procedure. Illustration C shows a Suave-Kapandji procedure. Illustration D is a
treatment schematic of TFCC reconstruction.
Incorrect Answers:
Answer 1: There is no obvious ulnar styloid non-union.
Answer 2: As mentioned in Miller's review text, the Darrach procedure is typically reserved for low-demand, elderly
patients and may lead to painful proximal ulna stump instability.
Answer 3: Complete ulnar head resection is not indicated.
Answer 5: TFCC reconstruction will not improve or treat the DRUJ arthritic changes.
74) (OBQ04.266) An ulnar shortening osteotomy would be MOST indicated for which of the following
patients presenting with longstanding ulnar sided wrist pain refractory to conservative measures?
1. 34-year-old female with an ulnar neutral wrist and distal radioulnar joint incongruity
2. 34-year-old female with an ulnar positive wrist and distal radioulnar joint incongruity
3. 34-year-old female with an ulnar negative wrist and distal radioulnar joint incongruity
4. 78-year-old female with ulnar positive wrist and distal radioulnar joint arthritis
5. 78-year-old female with ulnar negative wrist and distal radioulnar joint arthritis
PREFERRED RESPONSE ▼ 2
DISCUSSION: Ulnar shortening osteotomy is the best procedure for young adults with longstanding ulnar sided wrist
pain due to ulnar positive variance and associated distal radioulnar joint (DRUJ) incongruity. Ulnar positive variance
causes an "ulnar impaction syndrome" as the distal ulnar styloid can cause damage to the triangular fibrocartilage
complex (TFCC), and ulnocarpal joint (illustration A.)
Advantages of an ulnar shortening osteotomy include preservation of ulnar dome articular cartilage and DRUJ joint,
and also tightens the TFCC and ulnocarpal ligaments as the distal ulna is translated and fixed proximally after the
osteotomy.
It is also important to note that ulnar shortening in the setting of preoperative DRUJ incongruity may simultaneously
decrease ulnocarpal abutment and improve congruity at the distal radioulnar articulation. One specific instance in
which to avoid an ulnar shortening in an ulnar positive wrist with DRUJ incongruity is a joint with a reverse oblique
inclination in the coronal plane. This may create abnormally high radioulnar contact and may lead to joint
degeneration
75) (OBQ11.112) Figures A through E depict various conditions affecting the pediatric hand and wrist.
For which of the depicted conditions is temporary scaphotrapeziotrapezoidal pinning most
indicated?
FIGURES: A B C D E
1. A
2. B
3. C
4. D
5. E
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Temporary scaphotrapeziotrapezoidal (STT) pinning is indicated for treatment of Kienbocks disease
in adolescents as shown in Figure D. The radiograph shows increased density and slight lunate collapse. The result
is a decrease in radiolunate contact stress while increasing the load on the radioscaphoid articulation. STT pinning is
not indicated in any of the conditions explained below.
Ando et al retrospectively reviewed the results of six adolescents treated with temporary scaphotrapezoidal (ST)
pinning. All patients had an increase in wrist flexion/extension arc, strength, and lunate intensity on MRI from their
preoperative baseline.
Shigematsu et al published a case study on a single 11-year-old patient with wrist pain at rest and with use who was
treated with temporary scaphotrapeziotrapedoidal (STT) pinning and cast immobilization for 8 weeks. Both wrist ROM
and grip strength improved. Lunate revascularization was also seen on subsequent MRI.
Incorrect Answers:
Answer 1,2,3: Radial clubhand, scaphoid fracture, and hypoplastic thumb are not treated with temporary
scaphotrapeziotrapezoidal pinning.
Answer 5: Gymnast’s wrist is a distal radius physeal injury due to repetitive axial loading. Plain films will show
physeal widening and hazy irregularity. The condition is not treated with temporary scaphotrapeziotrapezoidal
pinning.
76) (OBQ11.144) A 39-year-old male presents with longstanding right wrist pain. He has failed
conservative measures including prolonged immobilization. His radiographs and MRI are seen in
figures A and B. Which of the following options is an accepted treatment option?
FIGURES: A B
2. TFCC repair
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: The patient in the clinical scenario has Kienbock's disease. Treatment options include a joint leveling
procedure, or radius core decompression, which is thought to incite a local vascular healing response in the lunate.
Sherman et al did a biomechanical study reviewing distal radius core decompression for Kienbock's disease.
Although the procedure has good clinical outcomes for this disease process, their findings did not show any
biomechanical explanation for these good outcomes.
Illarramendi et al reviewed results of curettage of the distal radius and ulna metaphyseal bone through small cortical
windows for the treatment of Kienbock's disease. They concluded that the decompression procedure had good
results without any complications. Most patients had improvement in pain and were able to return to work.
Incorrect Answers:
Answer 1: Kienbock's disease is commonly associated with ulnar negative variance which is thought to lead to
increased forces on the lunate leading to this disease. Therefore a ulnar shortening osteotomy would not be
appropriate.
Answer 2,4,5: Are not treatment options for this disease process.
77) (OBQ10.61) A 32-year-old carpenter complains of progressively worsening wrist pain for 2 months
duration. He denies any recent history of trauma to the wrist or hand. A MRI is provided in figure A.
Which of the following surgical interventions is thought to be effective for this condition by inciting
a local vascular healing response.
FIGURES: A
1. Wrist fusion
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: This clinical scenario and imaging studies are consistent with Kienbock's disease, avascular necrosis
of the lunate, in the pre-collapse stage. Core decompression of the distal radius is an accepted treatment for
Kienbock's disease. The procedure creates a local vascular healing response facilitating vascular recovery prior to
collapse and degeneration of the lunate. Other acceptable interventions include revascularization with a pedicled
graft and joint leveling procedures such as a radial shortening osteotomy. The radial shortening osteotomy is ideal for
patients with negative ulnar variance who experience greater loads through the radiolunate fossa. Proximal row
carpectomy and wrist fusion would be options for the collapsed and degenerative lunate. Ulnar shortening osteotomy
and schapholunate ligament reconstruction are incorrect as they do not address the pathology of Kienbock's.
Sherman et al performed a cadaveric study demonstrating minimal change in the distribution of force between the
radiocarpal fossa and ulnocarpal fossa following core decompression of the distal radius.
78) (OBQ10.74) A 30-year-old female undergoes arthroscopy for a chronically painful right wrist that
failed to improve with 4 months of immobilization and NSAIDS. Her clinical examination revealed
point tenderness dorsally over the lunate but no tenderness elsewhere in the wrist. A picture from
the procedure is shown in Figure A where 'R' identifies the distal radius, 'L' the lunate, and '*'
represents a chondral flap. The articular surface of the lunate is stable to probing. A radiograph
and MRI image of the patients wrist are shown in Figures B and C respectively. What is the most
appropriate next step in treatment?
FIGURES: A B C
1. Continue Immobilization and NSAIDS
4. Scaphotrapeziotrapezoid fusion
5. Wrist fusion
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: The patients clinical presentation and radiographs are consistent with Stage 2 Kienbock's disease in
the setting of negative ulnar variance. Radial shortening osteotomy is the most appropriate treatment option listed for
Stage 2 disease which is defined as lunate sclerosis without significant collapse. Shortening osteotomy can alter
DRUJ contact pressures leading to remodeling, especially in the presence of a Tolat Type II DRUJ, such as that
shown in the radiographs. However, this remodeling has been shown to occur without the development of arthritis,
and therefore is not a contraindication to this procedure.
This patients radiographs shows some slight sclerosis of the lunate and negative ulnar variance, and the MRI shows
diffuse edema and early osteonecrosis of the lunate. The arthroscopic image shows a cartilage flap with a stable
base left on the lunate. Based on these images, the patient has Stage 2 disease and should be treated with a joint
leveling procedure; or radial shortening osteotomy in this case.
Sltusky et al provide a review article which focuses on the methodology behind a normal arthroscopic wrist
examination and discusses some of the more standard arthroscopic procedures along with the expected outcomes.
Bain et al review the arthroscopic staging of Kienbock's disease, and state that this techinique is a valuable
assessment tool which allows for not only classification of Kienbock's disease, but also may guide treatment.
Schuind et al. provide a review of the pathogenesis of Kienbock's. They conclude that the natural history of the
condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the
degree of carpal collapse. They also state that there is no strong evidence to support any particular form of
treatment.
Illustration B shows a table which outlines the general treatment options for each stage of Kienbock's Disease.
Incorrect Answers:
Answer 1: Immobilization and NSAIDS is indicated in Stage I disease or as a first line of treatment for Stage 2, which
this patient has failed.
Answer 3: Proximal row carpectomy is indicated in Stage 3B.
Answer 4: STT Fusion is indicated in Stage 3B.
Answer 5: Wrist fusion is indicated in Stage 4.
80) (OBQ11.246) A 68-year-old female office assistant reports left thumb pain that has progressively
worsened over the past 2 years. She is left hand dominant and reports difficulty with opening jars
and holding a coffee cup. On examination of the left hand she has a positive thumb
carpometacarpal grind test and has a fixed deformity at the thumb metacarpalphalangeal joint.
Figure A demonstrates the left hand grasping an object and Figure B shows a radiograph of the left
thumb. What is the most appropriate next step in treatment?
FIGURES: A B
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: The patients history, examination, and images are consistent with thumb CMC (basilar) joint arthritis
with associated MCP joint arthritis. At the MCP joint there is hyperextension of the thumb metacarpophalangeal
(MCP) joint and adduction involving the first web space of the hand (Z deformity). Arthrodesis of the MCP joint is the
treatment of choice when thumb MCP hyperextension exceeds 40°, the deformity is not passively correctable, or
advanced degenerative changes are noted to affect the articulation.
The review article by Armbruster and Tan state that when MCP joint hyperextension is:
0° to 10°= Surgical intervention is not necessary when MCP hyperextension is less than 10°.
10° to 20°= Percutaneous pinning of the MCP joint in 25° to 35° of flexion for 3-4 weeks may be performed
independently or as an adjunct to EPB transfer.
20° to 40°= Capsulodesis of the volar aspect of the MCP joint is recommened to provide a check rein for
hyperextension and Sesamoidesis has also been investigated as an adjunctive procedure.
Cooney et al performed a Level 4 review of their CMC arthroplasty patients and found 15 patients with 17 revision
arthroplasties in the treatment of mechanical pain related to instability or bone impingement. The revisions included
soft-tissue interposition alone or soft-tissue interposition with ligament reconstruction and found that this provided
satisfactory patient outcomes in more than 75% of the cases.
Illustration A depicts the forces accounting for the observed adduction and hyperextension deformities. The
arrowhead indicates the direction of subluxation of the base of the thumb metacarpal (due to incompetent volar beak
ligament). The arrow represents the force vector of the EPB potentiating the MCP hyperextension deformity
81) (OBQ09.122) A 60-year-old man has chronic pain at the base of this thumb and weakness on
attempted thumb pinch. A radiograph is shown in Figure A. Which injection would likely reduce his
pain and increase his function?
FIGURES: A
1. Saline
2. Steroid
3. Hylan
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The patient has basal joint arthritis of the thumb and randomized controlled trials have failed to
demonstrate an advantage of steroid or hylan over saline, so the answer is 4. A study by Heyworth demonstrated
that all three injections were similarly effective for approximately 3 months at reducing pain and increasing thumb
function over baseline levels. Stahl found that steroid and hylan were equally effective, but did not control with saline.
Hylan derivatives have been extensively studied in the knee and Henderson found no advantage of hyaluronan over
saline for knee arthritis during a 5 week treatment course.
82) (OBQ07.92) A 64-year-old female presents with pain in the base of her thumb and a positive grind
test. A radiograph is shown in Figure A. Which of the following surgical steps is the most crucial in
surgical treatment of this condition to achieve a successful clinical outcome?
FIGURES: A
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: This patient is presenting with signs/symptoms consistent with 1st CMC arthritis. The most important
step in a 1st CMC arthroplasty for basilar thumb arthritis is excision of trapezium.
The various surgical options that have been discussed in the literature include excision of the trapezium, excision of
the trapezium with interposition arthroplasty and suspensory ligament reconstruction, and excision with interposition
arthroplasty only.
Davis et al showed that the outcome of three common CMC arthroplasty procedures were similiar as long as
trapeziectomy was included.
83) (OBQ10.258) A 38-year-old woman complains of a painful finger mass of 4 months duration. A
photograph of the mass is provided in Figure A. The decision is made to proceed with surgical
excision. Which of the following is an advantage of surgical excision with joint debridement as
opposed to aspiration?
FIGURES: A
1. Reduced rate of infection of the DIP joint
5. Reduced risk of metastasis from seeding the mass into the joint
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Figure A demonstrates a mucous cyst. This benign mass originates from the DIP joint, and is
secondary to arthritis. It may be treated with aspiration or surgical excision. However, recurrence occurs frequently
with aspiration. Debridement of any osteophytes from the DIP joint is crucial to preventing recurrence with surgical
excision. Rizzo et al retrospectively evaluated the results of 154 mucous cysts treated with either aspiration or
surgery. Aspiration resulted in a 40% recurrence rate. There were zero recurrences with surgical excision and joint
debridement.
84) (OBQ10.110) Which of the following patients with Dupuytren's contracture would benefit the most
from dermatofasciectomy and full-thickness skin grafting opposed to traditional fasciectomy?
1. 70-year-old sedentary male with small finger involvement isolated to the MCP joint
2. 50-year-old male systems analyst with ring and small finger involvement limited to the MCP joints
3. 65-year-old female golfer with ring and small finger involvement including MCP and PIP joints
4. 40-year-old female stenographer with middle, ring, and small finger involvement including MCP and
PIP joints with 50 and 55 degree contractures of ring and small finger MCP joints, respectively
5. None of the above as no difference in outcome has been demonstrated between the two
procedures
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Dermatofasciectomy and full-thickness grafting has not demonstrated superior finger range of motion,
recurrence rate, or patient satisfaction in comparison with traditional fasciectomy.
The main reference from Ullah et al conducted a prospective randomized study of 84 Dupuytren's cases treated with
fasciectomy alone or dermatofasciectomy with full-thickness skin grafting. The question was whether the overlying
skin needed to be excised. No difference in clinical outcome or recurrence rate was discovered.
Roy et al reviewed 79 cases of advanced Dupuytren's treated with radical fasciectomy (but preservation of the
overlying skin) and then adding full-thickness skin grafting to the open areas once the fingers were extended. They
found their results of fasciectomy to be similar to those published for dermofasciectomy.
85) (OBQ04.133) All of the following have been implicated in the pathogenesis of Duputryen's
contracture EXCEPT?
3. Myofibroblasts
5. CBFA-1
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Of the answers listed, only CBFA-1 has NO known role in the pathogenesis of Duputryen's
contracture.
Dupuytren contracture, a disease of the palmar fascia, results in the thickening and shortening of fibrous bands in the
hands and fingers. The offending cells are thought to be myofibroblasts and fibroblasts. Growth factors such as basic
fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), and transforming growth factor-beta (TGF-beta)
may signal the overproduction of the myofibroblasts and/or myofibroblastic activity of the fibroblasts. In addition, high
levels of TGF-Beta may hinder apoptosis of the active myofibroblasts, unlike normal tissue healing.
McGrouther discusses how the pathophysiology of Dupuytren's is related to the anatomy of the palmar ligaments.
The article discusses the proposed etiology of Dupuytren's with a loss of normal motion between palmar fascial
ligaments causes stress concentrations which stimulate fibrous tissue deposition and contracture.
Baird et al performed a tissue analysis of 12 patients with Dupuytren's contracture compared to 12 control patients.
They found that Dupuytren's expressed a higher percentage of peptide regulatory factors including interleukin-1
alpha, interleukin-1 beta, transforming growth factor beta, and basic fibroblast growth factor.
86) (OBQ04.267) What is the name of the pathologic structure, identified by the white arrow in Figure A,
that displaces the digital neurovascular bundle and places it at risk during during surgical
treatment of Dupuytren's disease?
FIGURES: A
1. Pretendinous cord
2. Pretendinous band
3. Spiral cord
4. Spiral band
5. Natatory cord
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: The spiral cord, shown by the white arrow in Figure A, can displace the neurvascular bundle (blue
arrow) and places it at risk during surgical resection. Dupuytren's contracture is a rare and progressive condition
characterized by contractures of the fascia of the hand as seen in Illustration A. The fascial components involved in
the disease include the pretendinous bands, spiral bands, natatory bands, lateral digital sheets, and Grayson's
ligament. The offending cell is the myofibroblast which causes the normal structures to become fibrosed. Once these
normal bands become pathologically involved in the disease process, they are termed cords. An easy way to
remember this is that bands are normal, and cords are abnormal. The spiral cord travels dorsal to the NVB and
displaces it volarly, placing it at risk during surgical resection. Example is shown in Illustrations B. Of note, Cleland's
ligament is not involved in this disease process.
87) (OBQ06.1) A 32-year-old male sustains a type IIIb open proximal third tibia fracture. Four days after
intramedullary nailing of the tibia, the wound is clean and ready for coverage with a medial
gastrocnemius rotational flap. What is the dominant arterial blood supply to this flap?
4. Sural artery
5. Saphenous artery
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The dominant arterial blood supply to a medial gastrocnemius muscle flap is the sural artery.
Rotational gastrocnemius flaps are useful for coverage of the proximal third of the tibia and some wounds/defects
about the knee. Medial and lateral gastrocnemius arterial supply is from the medial and lateral sural arteries
respectively. Coverage of the middle third of the tibia requires use of a rotational soleus muscle flap, supplied by the
peroneal artery proximally and the posterior tibial artery distally. Coverage of the distal third of the tibia requires a
free muscle flap transfer, based on a specific vascular pedicle.
88) (OBQ05.3) The sural artery provides the vascular supply to which musculocutaneous flap?
1. soleus
2. gastrocnemius
3. latissimus dorsi
4. tibialis anterior
5. peroneus longus
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: The sural artery supplies the both heads of the gastrocnemius and is the pedicle for rotational flaps.
Eighty-five percent of the time there is a single vascular source.
89) (OBQ10.235) Which of the following hand injuries is most appropriately treated with a volar
advancement (Moberg) flap closure?
FIGURES: A B C D E
1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Figure D shows a volar thumb defect which can be best covered with a Moberg advancement volar
flap (if < 2 cm). FDMA (1st dorsal metacarpal artery) and neurovascular island flaps are typically used to cover larger
soft tissue defects of volar aspect of the thumb. FDMA (1st dorsal metacarpal artery) flaps can also be used for
dorsal thumb wounds as shown in Figure B. The cross-finger flap is a useful heterodigital flap for digital wounds with
primarily volar tissue loss (Figure A). Additionally, several articles have advocated secondary intention healing even if
bone is exposed as discussed in the 2009 OITE question #48. The thenar flap is useful for volar defects of the index
and middle fingers (Figure C). Figure E represents a ring avulsion injury and it is treated with vessel repair if there is
inadequate circulation and the bone, tendon, and nerve components are intact. Amputation of the digit is chosen if
there is inadequate circulation concomitant with bone, tendon, or nerve injury.
The referenced articles by Martin and Hynes are review articles discussing the treatment options available for digit
injuries. Illustration A shows the planned incisions for a moberg advancement flap on a volar thumb defect and
Illustration B shows the completed Moberg.
90) (OBQ09.48) A 6-year-old boy sustained a finger tip amputation shown in Figure A after grabbing a
broken glass out of the dishwasher. Your plan was to perform a bedside irrigation and debridement
of the finger after digit anesthetic block and apply antibiotic ointment with a sterile dressing. Upon
exploration of the wound you notice that distal phalanx is exposed. Your plan should change to
include which of the following treatments?
FIGURES: A
2. Thenar flap
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: In young children with a fingertip amputation, ointment and dressing changes is the most appropriate
treatment even if bone is exposed.
When deciding on a treatment, consideration of a "reconstruction ladder" is helpful in determining the least invasive
procedure to obtain the optimal outcome. The ladder includes primary closure, healing by secondary intention, split-
thickness skin grafts, full-thickness skin grafts, random pattern local flaps, axial pattern local flaps, island pattern local
flaps, distant random pattern flaps, distant axial pattern flaps, and free tissue transfer.
Lamon et al reviewed 25 patients, with an average age of 30 years old, with fingertip injuries treated with dressings
and warm soaks started 2 days after injury and noted no healing complications. Only one patient in this cohort had
bone exposed.
Soderberg et al performed a Level 3 study of 36 operative and 34 conservatively treated fingertip amputations with
bone exposure and found no benefit to surgery.
Farrell et al conducted a Level 4 review of 21 fingertip amputations with 6 having exposed bone and concluded that
they healed with excellent results in regards to contour, sensation, and finger length.
Illustration A shows a homodigital island flap. Illustration B shows a thenar flap. Illustration C shows a volar flap
advancement. Illustration D shows a volar flap advancement.
91) (OBQ09.65) You are taking care of an adult patient with significant scar contracture in her first web
space after a thermal burn. Which of the following techniques will allow you to lengthen her scar
approximately 75%?
1. Cross-finger flap
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: One of the most commonly used techniques for lengthening scar contracture in hand surgery is the Z-
plasty. When the two 60 degree triangular flaps are transposed and closed, the original direction of the scar is rotated
and the scar length is increased by approximately 75% Because of its history the 60 degree Z-plasty is the technique
to which other methods of contracture lengthening are compared.
Hove et al describe the technique, various applications, and different types of Z-plasty used today. Neither the cross-
finger flap nor island pedical flap are useful for this amount of scar release. Two flap Z-plasty with 25 degree limbs
does not offer enough lengthening. Split-thicknes skin grafts are not useful for either lengthening or the volar aspect
of the hand due to the significant contracture they experience.
92) (OBQ06.14) A 28-year-old factory worker has his ring finger caught in the machinery at work. A
photograph of the injury is shown in Figure A. Which of the following procedures will best supply
coverage of the wound?
FIGURES: A
1. Amputation through the proximal interphalangeal joint
2. Shortening of the distal phalanx, nail bed removal, and dorsal V-Y flap
3. Cross-finger flap
4. Groin flap
5. Thenar flap
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: The V-Y flap is useful for extending dorsal skin to cover a transverse or or dorsally angulated fingertip
injury. They are typically used for finger tip amputations which have more dorsal soft tissue loss than palmar loss.
Nail bed removal is important to prevent a subsequent hook nail deformity. There is too much exposed bone
remaining to simply cover with sterile dressings. Cross-finger flaps are useful for fingertip injuries with volar tissue
loss only. Thenar flaps are reserved for index and middle fingertip injuries and carry a risk of postoperative flexion
contractures. Fassler reviews the proper management of fingertip injuries including the different flap coverage
outlines discussed above.
93) (OBQ05.91) A 29-year-old intravenous drug user undergoes irrigation and debridement of a ring
finger abscess. After adequate eradication of the infection, he is left with the skin defect shown in
Figure A. What is the most appropriate treatment at this time?
FIGURES: A
3. Thenar flap
4. Moberg flap
5. Cross-finger flap
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Based on the location of the lesion, a cross-finger flap would be most appropriate.
Cross finger flaps are indicated in patients > 30 years of age when the lesion is a volar oblique finger tip lacerations
or a volar proximal finger lesions. The advantage is it leads to less stiffness.
Martin et al review the treatment options available for digit injuries. They report treatment of fingertip injuries is a
continuous focus of controversy among hand and orthopaedic surgeons. Different treatment options have been
described, depending on the affected segment and finger, type of lesion, gender and age of the patient, location,
size, and depth of the defect.
Fassler et al reviews the proper management of fingertip injuries discussing variables such as the severity of soft
tissue loss and whether bone is exposed.
Incorrect Answers:
Answer 1: Secondary intention healing of this wound is inappropriate due to size and exposed tendon.
Answer 2: V-Y advancement flaps are for dorsal injuries.
Answer 3: Thenar flaps are good for getting more bulk for distal fingertip injuries.
Answer 4: A Moberg flap is performed on the thumb. A cross-finger flap is a full-thickness flap useful for volar soft
tissue loss distal to PIP.
94) (OBQ05.134) You have decided to perform a thenar flap for coverage on a patient following a partial
fingertip amputation. What should you advise your patient is a likely risk of this type of coverage?
1. Flap failure
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Thenar flaps can be used for coverage of digital tip injuries in which there is exposed bone or
extensive loss of pulp. This flap can be used for the index, long and sometimes ring fingers; it is less commonly used
for the small finger, as this digit does not comfortably flex to the thenar eminence. Advantages of the technique
include the availability of more subcutaneous fat than with a cross finger flap, good color and texture match, and
primary closure of the donor site, avoiding an unsightly scar. Disadvantages include potential for joint stiffness and
permanent flexion contracture, as well as limited flap size and donor site tenderness. Any condition that predisposes
a patient to stiffness, including RA, Dupuytren’s contracture and advanced age with degenerative disease, are
contraindications for this flap.
95) (OBQ04.65) A 25-year-old left hand dominant musician sustains an injury to the left thumb shown
in Figure A. He is unable to extend the interphalangeal joint and has less than 2 second capillary
refill at the thumb. What is the most appropriate method to achieve soft tissue coverage after
extensor tendon repair or transfer?
FIGURES: A
1. Moberg advancement flap
3. Wet-to-dry dressings
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The clinical scenario is consistent with a dorsal thumb avulsion with missing extensor tendon and
exposed bone necessitating soft tissue coverage. The first dorsal metacarpal artery (Kite) flap is the most appropriate
flap for defects of the dorsal aspect of the thumb.
Fassler et al in a Level 5 review state that the first dorsal metacarpal artery (Kite) flap is appropriate for defects of the
dorsal aspect of thumb. The flap is performed in one stage with the skin over the dorsum of the proximal index finger
elevated with incisions on all four sides. An incision is extended proximally over the dorsum of the first web space,
and a pedicle containing the first dorsal metacarpal artery, the subcutaneous veins, and branches of the dorsal
sensory branch of the radial nerve is isolated. The skin island with the attached pedicle is transferred to the thumb
defect and sutured in place.
Illustration A shows the technical steps of the first dorsal metacarpal artery (Kite) flap. Illustration B shows the final
functional results of the first dorsal metacarpal artery (Kite) flap are shown in Illustration B.
Incorrect Answers:
Answer 1: Moberg advancement flaps are indicated for volar thumb defects.
Answer 2 & 3: Wet to dry dressings or vaccuum-assisted wound closure would be inappropriate in this situation.
Answer 5: V-Y advancement flaps are most appropriate for transverse or dorsal oblique fingertip amputations.
96) (OBQ12.15) A 30-year-old healthy female sustains a traumatic digit amputation while working at a
factory. Which of the following is a relative indication for digit replantation in this patient?
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The unique functional role of the thumb in opposition and pinch dictates that it be replanted whenever
possible in a healthy patient, regardless of the level of amputation. The remainder of the answer choices are relative
contraindications for digit replantation.
Boulas et al outline indications and contraindications for digit replantation after traumatic amputation.
Contraindications to replantation include multilevel or segmental injury, a single digit proximal to the FDS insertion, a
severe crush or mangling injury, extreme contamination, prior impaired function, concomitant life-threatening injury,
severe medical problems, anesthetic risk, and major psychiatric disorder.
Waikakul et al determined the influencing factors of the immediate and late outcome of replantation and
revascularization of amputated digits. They found that the type of injury was the most important factor influencing
immediate and late outcomes. They also determined that connecting the profundus tendon stump of the proximal part
to the superficialis tendon of the amputated part gave a better result than two tendon repair and repairing only the
profundus tendon.
Illustration A shows a clinical photo of an isolated amputation of the thumb proximal to the FPL insertion.
Incorrect Answers:
Answer 1: Replantation of a single digit proximal to the FDS insertion is associatedwith poor results related to the
loss of PIP joint motion due to flexor sheath adhesion formation.
Answer 2: Crush or mangling injury is associated with serious damage to tissues, which are at risk for infection,
problematic healing, and scarring, thereby contributing to a poor outcome.
Answer 3: Segmental injury to the index finger is a contraindication to replantation due to poor function post-
operatively.
Answer 5: Prolonged warm ischemia time, defined as more than 12 hours, is associated with replantation failure.
97) (OBQ11.166) A 25-year-old right-hand dominant construction worker suffers an industrial injury as
seen below. He is hemodynamically stable and his only injury is to the limb below. In terms of
replantation of the affected limb, which of the following is true?
FIGURES: A B C D
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The clinical scenario and images depict a through the palm amputation with the digits intact. The
injury is a clean amputation with minimal avulsion. Thus, anatomic replantation of the entire hand is indicated. Digit
transposition refers to using the salvageable digits and replanting them on the functionally important positions in the
hand. Transpositional replantation is not indicated in the above scenario and would be more appropriate for a
multidigit amputation as shown in Illustration A.
Soucacos et al reviewed their results of transpositional digital microsurgery in 34 patients. They found that
transposition of a digit to the most functional part of the hand lead to a 2-point discrimination of 10-14mm in
transposed digits and equivalent functionality of transposed digits with anatomically replanted digits.
Schwabegger et al presented a case series of 13 patients with multiple digit amputations. The primary goal of surgery
was function and secondly, cosmesis. They found the results of transpositional replantation similar to conventional
replantation.
1. multiple level amputation of the small finger at the proximal and distal interphalangeal joints
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: As outlined by Pederson, the contraindications to replantation are more relative than the indications,
but they include the following: Single-finger replantations at the level of zone II (from the A1 pulley to the distal
sublimis tendon insertion) are rarely indicated, with the notable exception of the thumb. Amputated parts that are
severely crushed and those with multiple level injuries have poor function even if they survive replantation. While ring
avulsion injuries with a vascular injury and no bone, tendon or nerve injury (Urbaniak type 2A ring avulsion injuries)
should be repaired, ring avulsion injuries with bone, tendon or nerve injury (Urbaniak type 2B) or with complete
degloving (Urbaniak type 3) have poor outcomes and Urbaniak and colleagues recommend amputation for such
injuries. Very distal amputations at the level of the nail bed are marginally indicated as there needs to be
approximately 4 mm of intact skin proximal to the nailfold for adequate veins to be present. Indications for
replantation that rule out the other 4 choices of this question include the following: Overall, thumb replantation
probably offers the best functional return. Even with poor motion and sensation, the thumb is useful to the patient as
a post for opposition. A replanted thumb offers the best reconstruction available, toe transfers notwithstanding.
Replantation beyond the level of the sublimis tendon insertion (zone I) usually results in good function. Multiple finger
amputations present reconstructive difficulties that may be difficult to correct without replantation of one or all of the
amputated digits. Any hand amputation from zone III (distally) to zone V (proximally) offers the chance of reasonable
function after replantation, usually superior to available prostheses. Although usually indicated, the replantation of
any hand or arm proximal to the level of the mid-forearm must be carefully considered.
99) (OBQ06.45) What is the most important factor influencing immediate and late outcome of digit
replantation?
1. Gender
2. Anastamosing the proximal profundus tendon stump to the superficialis tendon of the amputated
digit
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The Level 2 study by Waikakul et al is a cohort of 552 patients that underwent 1018 digit replantation.
Mechanism of injury was the most important factor influencing the survival rate with an odds ratio of 46.3.
Specifically, avulsion, degloving and extensive crushed amputation resulted in a low survival rate and poor functional
outcome. Cigarette smoking and male gender were associated with worse results but not to the degree of the
mechanism of injury. Utilization of composite skin and subcutaneous vein grafts as well as connecting the profundus
to the superficialis at the anastomoses correlated to better outcomes. After the operation, 329 of 946 survived digits
(34.7%) in 180 patients (35.4%) needed further reconstructive surgery to improve their function. Tenolysis was the
most common procedure followed by staged tendon grafting and capsulotomy.
The review article by Wang found that tendon procedures, specifically tenolysis, accounted for 47.2% secondary
surgeries following digit replantation.
2. Heparin
3. COX 2 inhibitor
4. Allopurinol
5. Leeches
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Allopurinol is a xanthine oxidase inhibitor and may have a beneficial role in replantation. Inhibition of
xanthine oxidase also decreases uric acid in patients with gout.
Waikakul et al. published a randomized control trial with a 2-year follow-up comparing thumb replantation with and
without adjunctive allopurinol. There were 60 patients in the trial group, and 38 patients in the control group. All were
young, healthy laborers who had sharp or locally crushed amputations of the thumb at the proximal phalanx with a
total ischemic time >10 hours. The standard management for thumb replantation was used in these patients, except
that 300mg allopurinol was given orally in the trial group on admission and a further 300mg for another 5 days. After
the operation, the trial group had a lower infection rate, and less postoperative pain and chronic swelling than the
control group. Recovery of sensation was also better in the trial group.
101) (OBQ06.265) Which of the following digit amputations may be considered a relative
contraindication for a replantation?
2. Mid forearm
4. Middle, ring, and small fingers through the middle phalanx shaft
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Waikakul et al. in a study of 1018 replantations found that type of injury was the most important factor
influencing immediate and late outcome. Extensively crushed injuries had the worst outcome, followed by degloving
and avulsion injuries. Sharp cut injuries fared the best. Regular cigarette smoking resulted in poor immediate survival
rate and prolonged ischemia had a significant influence in final functional outcome, but neither were as important as
mechanism of injury. Alcohol consumption was also a negative predictor. Favorable factors for replantation survival
were female gender, age under 13 years old, and nonsmokers. Regarding ischemia time, Miller recommends <12
hours of warm ischemia or <24 hours of cold ischemia for a digit to obtain optimal outcomes.
102) (OBQ05.239) A 34-year-old male undergoes a thumb replantation after an industrial meat slicer
accident. At 4 hours postoperatively there is a drop from 33 degrees celsius to 29 degrees celsius
and the pulse oximetry monitor on the thumb reads 87%. All of the following are treatment options
for the management of his arterial inflow insufficiency EXCEPT:
1. Administer IV heparin
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: Arterial thrombosis after digit replantation typically occurs within the first 12 hours postoperatively
whereas venous thrombosis/congestion occurs after the first 12 hours postoperatively. Leeches excrete Hirudin,
which is 100 times more potent than heparin, but are typically used for the treatment of venous
thrombosis/congestion and not arterial thrombosis. Miller's review states a drop in temperature >2 C in 1 hour or
temperature below 30 C indicates decreased digital perfusion. If arterial insufficiency develops: release constrictive
bandages, place the extremity in a dependent position, consider heparinization, consider stellate ganglion blockade,
or explore early if these maneuvers do not work.
103) (OBQ05.270) A 34-year-old male sustains amputations of the 4th and 5th fingers at the level of the
middle phalanx after cutting them with a butcher knife. Which of the following techniques would
most likely increase total surgical time during replantation?
5. Obtaining a thorough inventory of the digit structures that are deficient and the structures that are
available for reconstruction
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Surgical time in multiple digit replantation is increased by digit-by-digit repair techniques and
decreased by structure-by-structure repair techniques.
The Level 5 article by Morrison and McCombe reviews the indications and results of finger replantation. Results of
replantation from the DIP to PIP joint typically have good outcomes whereas replantations at the proximal
interphalangeal (PIP) joint to MCP joint have poor outcomes due to flexion contractures. The review article by Wang
cites that tenolysis and tendon procedures were needed in 47.2% of the published cases of digit replantation and is
the leading type of secondary operation.
The classic article by Waikakul et al reviewed 1018 digital replantations in 552 patients. They had a 92% rate of
successful outcome and found that type of injury was the most important factor influencing immediate and late
outcome.
104) (OBQ04.48) A 67-year-old male has soft tissue defect on the palmar aspect of his right hand
following a resection of mass as shown in Figures A and B. Which of the following is most
appropriate for achieving coverage of the defect?
FIGURES: A B
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Soft tissue defects of the palm are most appropriately treated with flap coverage followed with full-
thickness grafts. A flap is a unit of tissue supported by blood vessels and moved from a donor site to a recipient site
to cover a defect in tissue. This patient's full-thickness coverage was created from a posterior interosseous artery
island flap as shown in Illustrations A-C. The skin of the dorsal hand is similar to that of the rest of the body and thus
may be adequately replaced by split-thickness skin grafts from the skin of most donor sites. In contrast, palmar hand
skin differs from that of the dorsal hand in that it (1) lacks both hair and sebaceous glands and (2) has specialized
encapsulated nerve endings (Meissner’s corpuscles and Vater-Pacini corpuscles) that confer enhanced sensation via
mechanoreception. Full thickness skin grafts (FTSG) transfer all of the skin appendages and nerve endings except
those sweat glands located in the subcutaneous tissue and some of the Vater-Pacini corpuscles of palmar and
plantar skin. It is necessary to remove all fat and subcutaneous tissue from the undersurface of a full-thickness skin
graft, as this will otherwise act as a barrier preventing vascularization and graft survival.
105) (OBQ10.14) A 50-year-old woman sustains an open both bone forearm fracture seen in Figure A
and undergoes the treatment seen in Figure B. During surgery the posterior interosseous nerve
was transected and primary repair was attempted. One year following surgery the patient continues
to have no posterior interosseous nerve function. Which of the following treatments will best
restore function?
FIGURES: A B
1. Sural nerve grafting to the posterior interosseus nerve
2. Wrist fusion with transfer of the flexor carpi ulnaris to the finger extensors
3. Transfer of the flexor carpi radialis to extensor digitorum and the palmaris longus to the extensor
pollicis longus
4. Transfer of the pronator teres to the wrist extensors and the palmaris longus to the finger
extensors
5. Transfer of the flexor carpi ulnaris to the wrist extensors and the palmaris longus to the extensor
pollicis longus
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: Figures A and B show a pre and post-operative radiograph of a both bone forearm fracture. The
posterior interosseus nerve is at risk during surgical approaches to this fracture pattern and care should be taken.
Ropars et al retrospectively reviewed 15 patients who underwent treatment for radial nerve and PIN palsy. For PIN
palsy, they concluded the most beneficial transfers included transferring the flexor carpi radialis to the finger
extensors (to restore finger extension) and palmaris longus to the extensor pollicis longus (to restore extension of the
thumb). In contrast with a radial nerve palsy, with a PIN palsy the patient has adequate wrist extension due to intact
ECRL (providing radial wrist extension) supplied by the radial nerve proximal to the PIN.
Ustün et al in their cadaveric studies were able to show that it is possible to perform posterior interosseous nerve
neurotization via the median nerve.
Hirachi et al reviewed the results of 17 traumatic PIN palsies that were treated either with nerve repair, tendon
transfers, or nonoperatively. They noted that associated muscle damage resulted in poorer results.
The muscles involved in the suggested transfer (FCR, ED, PL, EPL)
106) (OBQ12.46) The patient sustains the injury seen in Figure A from a gunshot injury. The physical
exam is notable for lack of sensation in his fourth and fifth digits as well as a positive Froment's
sign. Which of the following factors has not been shown to be a significant prognostic indicator of
functional recovery following nerve repair?
FIGURES: A
1. Duration to time of repair
2. Repair level
3. Length of repair
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The clinical scenario describes an ulnar nerve laceration. Studies have shown that the ulnar nerve
does not typically have good outcomes after nerve repair. (worse recovery than repairs of the tibial, radial, femoral,
and musculocutaneous nerves)
Nerve injuries from gunshot injuries (GSWs) can cause both a direct injury to the nerve as well as surrounding
structures (zone of injury). Many factors including age of patient, time to repair, repair level, and length of repair have
been shown to be important determinants in nerve recovery following repair. The type of nerve graft (sural,
saphenous, etc) used has not shown to be statistically significant in terms of functional recovery after nerve repair.
Secer et al.(J. Neurosurg) reviewed 2210 peripheral nerve lesions in 2106 patients which were injured by a GSW and
who were treated surgically. Of the peripheral nerves repaired surgically, the tibial, median, and femoral nerve
lesions showed the best recovery rate. The deep peroneal nerve, ulnar nerve, and brachial plexus lesions had the
worst recovery.
Secer et al.(Surg. Neur.) found that of 455 patients with 462 ulnar nerve lesions only a good outcome was noted in
15.06% of patients who underwent high-level repair, 29.60% of patients who underwent intermediate-level repair, and
49.68% of patients after low-level repair. The authors also noted that a better functional recovery was noted in
patients who were treated earlier.
Incorrect Answers
Answer 1: Earlier nerve repairs typically have better functional results.
Answer 2: The lower level of nerve repair (more distal), the better functional results.
Answer 3: Shorter length of the nerve repair typically leads to better functional results.
Answer 4: Pre and post operative physical rehabilitation after nerve repairs has been shown to have better results.
107) (OBQ09.268) You are seeing a 24-year-old male in the emergency room after he was involved in a
knife fight. He has severed the common digital nerve to the index finger on his dominant hand, with
an 8mm gap between nerve ends. In counselling him about repair, which of the following options is
as good as autologous nerve grafting?
1. Glycolide trimethylene carbonate conduit
2. Collagen conduit
3. Silicone sleeve
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Repair of segmental nerve loss in the hand using collagen conduits allows for nutrient exchange and
accessibility of neurotrophic factors to the axonal growth zone during regeneration. While the other listed answers
have been used, none has shown the efficacy of collagen conduits or autograft. Li et al. describe the repair of
peripheral nerves with a tubular collagen conduit and review supporting data from in vitro and in vivo primate studies
to this regard. Bertleff et al. describe the recovery of sensory nerve function after treatment of traumatic peripheral
nerve lesions with a biodegradable poly(DL-lactide-epsilon-caprolactone) neurolac nerve guide, compared to their
control of end-to-end repair, no autologous grafting. They show equal results between primary end-to-end repair and
their synthetic graft. Waitayawinyu et al. compared 2 synthetic polyglycolic acid conduits to autogenous nerve
grafting using histopathologic and neurophysiologic analyses in a segmental defect rat model. They found that
collagen conduits and autografts produced comparable results, which were significantly better than polyglycolic acid
conduits.
108) (OBQ04.257) Which of the following peripheral nerve structures functions to cushion the nerve
against external pressure?
1. Endoneurium
2. Fibronectin
3. N-cadherin
4. Epineurium
5. Perineurium
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The epineurium is a supportive sheath surrounding peripheral nerves that cushions fascicles against
external pressure. It is comprised of a loose meshwork of collagen and elastin fibers that are aligned parallel with the
nerve fibers.
Illustration A & B depicts the contents of a nerve including epineurium, perineurium, and endoneurium.
Incorrect Answers:
Answer 1: Endoneurium is a fibrous tissue that covers the axon, Schwann cell, and myelin of each nerve fiber.
Answer 2: Fibronectin and laminin are extracellular matrix glycoproteins that facilitate directional nerve fiber
branching.
Answer 3: N-cadherin is an adhesive membrane glycoproteins on neural ectoderm and facilitate growing axons.
Answer 4: Perineurium is a dense connective tissue which surrounds nerve fascicles. It provides high tensile
strength. The perineurium also limits diffusion within the intraneural environment and subsequently prevents injury
from edema.
109) (OBQ11.143) A child is seen in the pediatric orthopedic hand clinic for evaluation of a congenital
deformity. A clinical photograph and radiograph are seen in Figures A and B. What is the next best
step in this child's evaluation to rule out an associated autosomal-recessive lethal condition?
FIGURES: A B
1. Cardiac ultrasound and renal ultrasound
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The clinical and radiographic images depict a patient with radial club hand. This is associated with a
number of congenital anomalies including Fanconi’s Anemia (FA), thrombocytopenia absent radius (TAR), Holt-Oran
syndrome, VACTERL syndrome, and VATER syndrome. Although all these congenital anomalies are important to
recognize and treat, none is more life-threatening than FA. FA is an autosomal-recessive condition resulting in
aplastic anemia and eventual death. The typical presentation is between 6-9 years of age. It is the most common
inherited form of aplastic anemia. Genetic testing will reveal increased chromosomal breakage. A CBC will show
decreased leukocytes, red blood cells and platelets. Of the choices above, it is the only one which requires bone
marrow transplantation for survival.
DeKerviler et al reviewed many clinical and radiological features of FA. Congenital malformations affect multiple
systems including the radial aspect of the forearm as well as the urinary system. They recommended ultrasound and
imaging modalities for early detection of FA.
Alter described hematologic disorders manifest in the pediatric upper extremity. Pediatric orthopedic surgeons may
be the first to detect FA, Diamond-Blackfan anemia and TAR. As such, an understanding of the syndromes and
inheritance patterns may aid in early detection and aid in future genetic counseling.
110) (OBQ11.149) A 7-month-old boy has radial longitudinal deficiency. The initial work-up is negative
for any cardiac, hematopoetic or renal abnormalities. He has good active elbow flexion and no
other deformities. A clinical image and radiograph are seen in Figures A and B. Surgical
management should include which of the following?
FIGURES: A B
1. Definitive splinting and stretching
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The image and vignette are consistent with non-syndromic radial longitunidal deficiency (RLD). He
has a viable thumb with good active elbow flexion, therefore the treatment of choice is centralization and tendon
transfers to re-establish balance across the wrist. The goal of centralizing the carpus on the ulna is to improve reach
and to stabilize tendons and muscle balance across the wrist.
The decision for surgery is based on the range of motion of the elbow. In the case of a stiff elbow, a centralization
should not be performed as doing so would prohibit the patient from reaching his/her face for dentition and feeding.
RLD is commonly associated with Thrombocytopenia absent radius (TAR), Holt-Oram and Fanconi’s anemia.
Classification of RLD is based on the Bayne and Klug system and takes into account the amount of remaining radius
present:
Type I: short distal radius
Type II: short distal radius with residual growth plates
Type III: small proximal radius
Type IV: absent radius
Incorrect Answers:
Answer 1: For advanced cases (types III/IV), surgery is recommended
Answer 2: The patient in the scenario has a thumb so pollicization is not indicated
Answer 3: This is not a surgical option
Answer 4: MTPJ transfers have been explored but not free fibula
111) (OBQ08.19) A 2-year-old boy has the upper limb deformity seen in Figures A and B. All of the
following are associated with this condition EXCEPT?
FIGURES: A B
1. Fanconi's Anemia
2. Holt-Oram syndrome
3. VATER syndrome
4. VACTERL syndrome
5. Osteogenesis Imperfecta
PREFERRED RESPONSE ▼ 5
DISCUSSION: The clinical presentation is consistent with radial longitudinal deficiency, also known as "radial
clubhand", which is associated with all of the listed conditions except for osteogenesis imperfecta.
Maschke et al report "radial longitudinal deficiency encompasses a spectrum of upper limb dysplasias and
hypoplasias. The clinical presentation of the involved upper limb is often more obvious than the potentially life-
threatening associated systemic conditions. All children presenting with radial longitudinal deficiency, regardless of
severity, require a renal ultrasound, echocardiogram, and complete blood count to evaluate the potential for
associated systemic conditions; these include Fanconi’s anemia, the Holt-Oram syndrome, and the VATER (vertebral
anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, renal agenesis) syndrome or VACTERL
(vertebral anomalies, anal atresia, cardiac abnormalities, tracheoesophageal fistula, renal agenesis, and limb
defects) association."
112) (OBQ10.59) Which of the following skeletal dysplasias is caused by a sex linked mutation of the
short stature homeobox (SHOX) gene?
1. Cleidocranial dyplasia
2. Leri-Weil dyschondrosteosis
3. Pseudoachondroplasia
5. Achondroplasia
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Leri Weill dyschondrosteosis is a skeletal dysplasia characterized by short stature and bilateral
Madelung deformities of the wrist (Illustration A). The SHOX gene is located on the X and Y chromosomes and a
mutation on either of the sex chromosomes leads to the dysplasia (sex linked dominant). Madelung deformity is a
result of disruption of the volar ulnar physis of the distal radius (leading to radial inclination and a radiopalmar tilt).
Symptoms from the wrist deformity include ulnocarpal impaction, restricted forearm rotation, and median nerve
compression. Cleidocranial dyplasia is an autosomal dominant defect in CBFA-1, a transcription factor that activates
osteoblast differentiation. Pseudoachondroplasia is an autosomal dominant mutation in COMP on chromosome 19.
Ellis-van Creveld (EVC) syndrome is an autosomal recessive mutation in the EVC gene causing acromesomelic
shortening and postaxial polydactyly among other anomalies. Achondroplasia is an autosomal dominant mutation of
FGFR-3.
Illustrations: A
113) (OBQ08.90) Madelung's deformity of the distal radius is caused by which of the following?
4. Impaired growth of the volar and ulnar aspect of the distal radial physis
5. Unrecognized trauma
PREFERRED RESPONSE ▼ 4
DISCUSSION: Madelung's deformity is that of excessive ulnar/palmar angulation of the distal radius caused by
impaired growth of the volar and ulnar aspect of the distal radial physis. It may be caused by either a bony lesion in
the palmar/ulnar corner of the distal radial physis or an abnormal radial-carpal ligament (Vicker's ligament). The other
answers do not cause Madelung's deformity. Leri-Weill dyschondrosteosis is a rare genetic disorder caused by
mutation in the SHOX gene that causes mesomelic dwarfism with associated Madelung's defomity of the forearm.
114) (OBQ08.140) The parents of a 2-year-old girl are concerned that their daughter has difficulty
feeding herself from a bottle. They have noticed that she rotates her elbow in front of her body
when trying to bring the bottle to her mouth. Physical exam demonstrates 10 degrees of elbow
hyperextension and 160 degrees of flexion. The forearm does not actively or passively rotate. A
radiograph is provided in figure A. Which of the following would be an indication for a future
surgical intervention?
FIGURES: A
5. Bilateral involvement
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Radiograph demonstrates proximal radioulnar synostosis. This rare congenital deformity is most
frequently a pronation deformity, but is not frequently a functionally limiting deformity. Observation is the treatment of
choice in most cases. Surgical osteotomy and fusion is beneficial for bilateral involvement with the objective of
achieving one arm fixed in modest pronation and the other fixed in modest supination to facilitate competence in
activities of daily living and hygeine. Surgical excision and reconstruction has not demonstrated successful
outcomes.
115) (OBQ11.125) Figure A depicts a child with syndactyly. Following surgical treatment, the most
common complication involves which of the following?
FIGURES: A
1. Nail plate
2. Nail bed
3. Web commissure
PREFERRED RESPONSE ▼ 3
DISCUSSION: Web creep, the most common complication of this procedure, is the distal migration of the web
commissure seen in surgically corrected syndactyly patients. It is caused by abnormal scar tissue formation and
increasing growth of underlying osseous structures. Informing parents of this complication preoperatively is advised.
Deunk et al reviewed the long-term results of 27 patients treated with either STSG or FTSG at 21 years. The STSG
group had increased flexion and extension lags but decreased finger abduction and increased graft breakdown. The
FTSG had higher rates of web creep, hyperpigmentation and hair presence. The authors did not favor one technique
over the other.
Ricterman et al performed a radiographic analysis of web height in children. They were able to radiographically
determine a standard web height quantification system using anatomic landmarks. This technique serves as the
foundation for measuring web creep in syndactlyly.
1. Apert syndrome
2. Poland's syndrome
3. Holt-Oram syndrome
4. Carpenter syndrome
5. Tay-Sach's Disease
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Syndactyly is one of the most common congenital hand deformities with an incidence of 1 in 2000 live
births and is associated with Poland's syndrome (chest wall deformity with limb hypoplasia), Apert syndrome
(autosomal dominant inheritance with mental retardation, craniosynostosis), Holt-Oram syndrome (also known as
"heart-hand syndrome" with abnormalities of the heart and upper limbs), and Carpenter syndrome (acrocephaly,
peculiar facies). There is no association of syndactyly with Tay-Sach's disease.
Ireland and colleagues reviewed 43 consecutive cases of Poland's syndrome and found that clinical features were
variable but always included congenital aplasia and syndactyly which is usually incomplete and simple. It can involve
all fingers and not uncommonly the thumb as well.
Galland and Bora wrote a review on congenital disorders of the upper extremity, and describe that syndactyly may
occur as part of a syndrome including Poland's syndrome (chest wall anomalies and syndactyly) or Apert's syndrome
(severe syndactyly with craniosynostosis, mental retardation, ankylosed IP joints, flattened faces and hypotelorism).
There is no known increased incidence in Tay-Sach's disease, however.
117) (OBQ10.247) A 4-year-old child has flattened facial features, wide set eyes, and the hand deformity
pictured in Figure A. Which of the following is the most likely diagnosis?
FIGURES: A
1. Apert's syndrome
3. Cleidocranial dysplasia
4. Noonan syndrome
5. Achondroplasia
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: Apert's syndrome is a congenital disorder causing deformity of the skull, face, hands, and feet. It
affects 1/80,000 children. An autosomal dominant mode of inheritance exists, but the majority of new cases are
sporadic. Early fusion of the cranial and facial suture lines (craniofacial synostosis) results in a variety of skull and
facial deformities. The primary deformity of the hands and feet is severe syndactyly, often with fusion of the digits.
The index, middle, and ring fingers are affected most often. Cognitive function may be normal or moderately
disabled.
Rebelo et al reviews the hand deformities of 170 patients with Apert's syndrome and their clinical outcomes following
surgical treatment.
Al-Qattan et al review the complex syndactyly of the hand associated with Apert's syndrome and suggests a new
classification scheme.
Illustrations A-C are further examples of the face, hand, and foot deformities associated with Apert's syndrome
Illustrations: A B C
118) (OBQ07.142) Apert's syndrome is caused by a mutation in what gene?
5. Fibrillin
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: Apert's syndrome (acrocephalosyndactyly type 1) is characterized by anomalies of the cranium,
hands, and feet. Mutations in the FGFR2 gene cause Apert syndrome.
Anderson et al report that in Apert's syndrome there is widespread anomalies of the feet, with defects including both
predictable dysmorphic changes and progressive fusions of the skeletal components during skeletal maturity.
Incorrect Answers:
2: Achondroplasia is related to abnormalities in the FGFR3, not FGFR2.
3: SED congenita is caused by mutations in COL2A1 (type II collagen alpha 1 chain) on chromosome 12. These
result in abnormal type II collagen.
4:The X-linked form of SED tarda is caused by mutation in SEDL (SED late) gene.
5: Marfan syndrome is caused by defects in the fibrillin gene.
119) (OBQ10.151) Which of the following congenital hand deformities displayed in figures A-E is more
prevalent in patients of African-American ancestry?
FIGURES: A B C D E
1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E
PREFERRED RESPONSE ▼ 2
DISCUSSION: Image B is consistent for postaxial polydactyly, which is more prevalent in patients of African-
American ancestry.
The cohort study by Woolf found the incidence of postaxial polydactyly in African americans is 12.42 per 1,000
(1.2%) compared to the Caucasian incidence of 0.91 per 1,000 (0.09%). If postaxial polydactyly is found in a patient
of Caucasian ancestry then further workup for underlying syndromes (chondroectodermal dysplasia or Ellis-van
Creveld syndrome) is needed.
The article by Orioli is a case-control study that hypothesizes that a sex-linked recessive modifier gene occurs more
frequently in African americans and this gene then promotes the autosomal dominant polydactyly gene.
Incorrect Answers: Constriction band syndrome or amniotic band syndrome is a type of pseudosyndactyly (Figure A)
and is not the result of failure of differentiation during embryogenesis, but a result of injury by bands after the fingers
are formed. Preaxial polydactyly (Figure C) is more common in caucasians and is usually sporadic except for
triphalangism which is associated with Holt-Oram and Fanconi's Anemia. Syndactyly (Figure D) is defined as an
abnormal interconnection between adjacent digits and syndactyly variations are associated with Apert syndrome and
Poland syndrome. Macrodactyly (Figure E) represents overgrowth of all structures of the involved digit and is
associated with neurofibromatosis and Klippel-Trenaunay-Weber syndrome.
120) (OBQ09.54) The Bilhaut-Cloquet procedure for thumb duplication, where the central portions of
bone and nail are removed and the radial half of one thumb is combined with the ulnar half of the
other to create one thumb, is most appropriate in which Wassel Type shown in Figure A?
FIGURES: A
1. Type 2
2. Type 4
3. Type 5
4. Type 6
5. Type 7
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The Bilhaut-Cloquet procedure has been shown to be successful in Wassel Type 1, 2, and 3
deformities. Asymmetrical Type I or II duplications with distinct components may also be treated with ablation of the
smaller thumb with transfer of the collateral ligament and centralization of the extensor tendon. Types 3 and 4
duplications (Type 4= most common duplication) are often treated with selection of a dominant thumb and ablation of
the lesser counterpart after preservation and transfer of intrinics and collateral ligaments. The article by Ogino states
that the ablation of the radial thumb is most common and Miller's Review states radial thumb ablation is preferred.
Treatment of Types 5 and 6 duplication utilizes similar principles as Type 4 deformities, with the added complexity of
additional intrinsic reconstruction. Type 7 is a triphalangeal thumb and has variable treatment based on the
presentation, and reconstruction includes excision versus fusion of the extra phalanx. Baek el al conducted a Level 4
review of 7 patients with Type 3 and Type 4 duplication treated with an extra-articular modified Bilhaut-Cloquet and
found excellent IP joint range of motion, no nail deformities, and no episodes of growth arrest.
121) (OBQ09.146) Which of the following upper extremity congenital anomalies, represented in the
figures below, if found in an individual of Caucasian descent requires a work-up for
chondroectodermal dysplasia or Ellis-van Creveld syndrome?
FIGURES: A B C D E
1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Postaxial polydactyly is rare in Caucasian individuals and deserves further workup for underlying
syndromes. Postaxial polydactyly is ten times more common in African Americans and does not require further
workup. Constriction band syndrome or amniotic band syndrome is a type of pseudosyndatyly(Figure A) and is not
the result of failure of differentiation during embryogenesis, but a result of injury by bands after the fingers are
formed. Preaxial polydactyly (Figure C) is more common in caucasians and is usually sporadic except for
triphalangism which is associated with Holt-Oram and Fanconi's Anemia. Syndactyly (Figure D) is defined as an
abnormal interconnection between adjacent digits and syndactyly variations are associated with Apert syndrome and
Poland syndrome. Macrodactyly (Figure E) represents overgrowth of all structures of the involved digit and is
associated with neurofibromatosis and Klippel-Trenaunay-Weber syndrome. The referenced article by Kozin is an
excellent Current Concepts Review that summarizes upper limb embryogenesis and the most common anomalies.
122) (OBQ08.215) An 8-year-old boy's parents are concerned about the appearance of the child's middle
finger. The child denies pain and his digital neurovascular status is normal. A clinical photograph
and radiograph are provided in figures A and B. For children with this condition, which of the
following is the best intervention to achieve a finger that is proportional to the rest of the hand?
FIGURES: A B
1. Epiphysiodesis now
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Clinical photograph and radiographs demonstrate macrodactyly of the middle finger, a rare congenital
malformation enlarging all structures of the digit.
Ishida et al reviews 23 cases of surgically treated macrodactyly finding favorable results with
epiphysiodesis/epiphysiodectomy while resection of hypertrophic nerves was unsuccessful in preventing overgrowth.
The epiphysiodesis is performed once the finger reaches the length of the same sex parent, using their digit as a
template for final growth.
123) (OBQ11.8) Figure A depicts a child with a congenital abnormality. Which of the following is true
regarding this condition?
FIGURES: A
2. Risk factors include late gestation (>44 weeks) and high birth weight (>3500g)
3. Incomplete circumferential bands not directly interfering with lymphatic circulation should be
resected
5. Complete circumferential bands that interfere with lymphatic drainage can be treated with band
excision and z-plasty.
PREFERRED RESPONSE ▼ 5
DISCUSSION: The image and vignette describe a patient with constriction band syndrome (CBS). In the case of
lymphatic obstruction or vascular compromise, the treatment of CBS is band excision. There are many terms used to
describe this phenomenon. However, the etiology is the entanglement of fetal parts in the amniotic membrane.
Foulkes et al reviewed 71 cases of congenital constriction band syndrome (CCBS). They found the average patient
had three involved limbs, with a predilection for distal, central digits of the upper extremity. There was a strong
correlation with abnormal gestation and clubfoot. Treatment included distraction osteogenesis and free
osteocutaneous transfer.
Goldfarb et al reviewed amniotic constriction band syndrome (ABS), highlighting its association with annular
constriction of multiple extremities. They classified ABS into classic (disruptions and deformations) and non-classic
(malformations). ABS is due to disruptions (amputations, acrosyndactyly), deformations (oligohydraminos, scoliosis,
talipes equinovarus) and malformations (body-wall defects, cleft lip/palate). As there is moderate overlap between the
classic and nonclassic, additional research into the underlying cause is being investigated.
Green described a one-stage release of circumferential constriction bands in three patients. The advantages of this
technique are the decreased need for anesthesia and subsequent procedures as well as facilitating postoperative
care.
Kawakura et al reviewed the intrinsic and extrinsic theories of (CBS). The most common manifestations are distal
extremity involvement, intrauterine amputations and acrosyndactyly. Excision of bands and mobilization of
subcutaneous adipose tissue as described by Upton is seen in Illustration A.
Incorrect Answers:
Illustrations: A
124) (OBQ10.6) The parents of a newly adopted 3-year-old boy bring the child to the office for evaluation
of his thumb. A clinical photograph is provided in figure A. Which of the following is the most
important factor in determining thumb reconstruction versus ablation and pollicization?
FIGURES: A
1. Stability of the carpometacarpal joint
PREFERRED RESPONSE ▼ 1
CORRECT
DISCUSSION: The clinical photograph demonstrates a hypoplastic thumb. The incidence of thumb hypoplasia is 1 in
every 100,000 births and associated anomalies including radial aplasia, thrombocytopenia, and
renal/cardiovascular/CNS anomalies are frequent. Stability of the carpometacarpal joint is essential for success of
thumb reconstruction procedures. If CMC stability is deficient, then ablation and pollicization is preferred.
Light et al describe the evaluation and surgical technique involved in treating the hypoplastic thumb. They note that
severe thumb hypoplasia and aplasia are best treated by thumb ablation and pollicization of the index finger.
125) (OBQ05.256) What is the most important variable when determining treatment of a hypoplastic
thumb?
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Congenital thumb hypoplasia presents as a wide range of first ray deficiencies and frequently occur
as part of a larger systemic syndrome such as Holt-Oram, Fanconi’s, or Apert’s syndrome. To function correctly, the
thumb must be positioned so that it can oppose the adjacent medial fingers and grasp objects securely from an
antiposed (abducted, slightly extended, and pronated) position. Although normal motion is usually not required at the
MP or interphalangeal joints, thumb function is greatly dependent on preserving a full arc of circumduction at the
carpometacarpal (CMC) joint. The CMC joint must be sufficiently stable to provide resistance during grasp and pinch.
The Blauth's classification ranges from type I to V and Types IIIB to V are treated with pollicization. The key
difference between a Blauth IIIA and IIIB is the presence of carpometacarpal joint stability in Blauth IIIA.
126) (OBQ04.120) Using the Blauth classification of thumb hypoplasia, grade IIIA can be treated with
thumb reconstruction whereas grade IIIB is treated with thumb amputation & pollicization. What is
the key difference between these two grades?
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: To function correctly, the thumb must be positioned so that it can oppose the adjacent medial fingers
and grasp objects securely from an antiposed (abducted, slightly extended, and pronated) position. Although normal
motion is usually not required at the MP or interphalangeal joints, thumb function is greatly dependent on preserving
a full arc of circumduction at the carpometacarpal (CMC) joint. The CMC joint must be sufficiently stable to provide
resistance during grasp and pinch. The Blauth's classification ranges from type I to V and Types IIIB to V are treated
with pollicization. The key difference between a Blauth IIIA and IIIB is the presence of carpometacarpal joint stability
in Blauth IIIA.
127) (OBQ09.67) A 10-year-old boy presents with a painless mass on the dorsal aspect of his wrist that
has been present for 3 weeks. A clinical image is shown in Figure A. T1 and T2 magnetic resonance
images are shown in Figure B and C, respectively. On your exam, the mass transilluminates and
Allen test reveals patent radial and ulnar arteries. What is the most appropriate next step in
management?
FIGURES: A B C
3. Observation
5. Injection of N-Butyl-Cyanoacrylate
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: This child has a ganglion cyst on the dorsal aspect of his wrist. Imaging provided shows a well-
marginated, homogenous signal intensity mass consistent with a ganglion cyst. Physical examination findings of a
mass transilluminating corroborate the MRI findings of a ganglion cyst. Performing an Allen's test to evaluate radial
and ulnar artery collateral blood flow is especially important when evaluating ganglion cysts on the volar aspect of the
wrist as they are often adjacent to the radial artery. Wang et al peformed a Level 4 review of 14 children with hand
and wrist ganglion cysts and found that 79% of these cysts resolved spontaneously within 1 year. Autologus bone
marrow aspirate injection is a treatment option for unicameral bone cysts and N-Butyl-Cyanoacrylate injections have
been described for treatment of hemangiomas. Referral to an orthopaedic oncologist is not indicated.
128) (OBQ10.253) Level 1 evidence has shown vitamin C reduces the incidence of reflex sympathetic
dystrophy (RSD) or complex regional pain syndrome type I (CRPS) in patients with which of the
following?
5. Ankle fractures
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: Two different prospective, double-blind studies performed by the same institution have shown that
vitamin C administration is associated with a lower risk of RSD(i.e CRPS) after wrist fractures. Vitamin C is thought to
reduce lipid peroxidation, scavenge free hydroxyl radicals, protect the capillary endothelium, and inhibit vascular
permeability.
The first trial by Zollinger was published in Lancet and included 115 adults with 119 fractures treated with
conservative management. They found that RSD/CRPS occurred in four (7%) wrists in the vitamin C group (500mg
daily for 50 days) and 14 (22%) in the placebo group.
The second trial by Zollinger published in JBJS included 317 adult patients sustaining 328 distal radius fractures
treated conservatively. They had allocated treatment groups to 200mg, 500mg, or 1500mg vitamin C dosages for 50
days. RSD/CRPS occurrence was 4.2% in the 200mg group, 1.8% in the 500mg group, and 1.7% in the 1500mg
group and thus the 500mg dosage for 50 days was recommended at the conclusion of the study. Patients making
early cast-related complaints to their provider had a higher incidence of developing RSD/CRPS.
129) (OBQ07.202) Which of the following modalities has been shown to have a positive effect when
treating early stages of complex regional pain syndrome?
2. Plyometric exercises
3. Ultrasound therapy
4. Acupuncture
5. Gentle physiotherapy
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Complex regional pain syndrome type I (reflex sympathetic dystrophy) is defined as a disease that
develops after an initial noxious or painful event which causes the development of pain and dysfunction out of
proportion to the event. It sometimes cannot be linked to a specific physiologic process. Hyperesthesias, edema,
and/or blood flow changes are prevalent. Type II (synonym for causalgia) has a known identifiable nerve injury.
Hypotheses include increased sympathetic tone causes feedback loop, activation of nociceptors to neurons in spinal
cord, continued ischemia, re-activation of pain receptors, and possibly unregulated sensitivity of alpha adrenergic
receptors.
For treatment, early gentle physiotherapy is recommended for this condition. Aggressive passive range of motion is
contraindicated in the early phases because it will provoke pain and inflammation. The primary goal of therapy is to
decrease pain and prevent stiffness. Contrast baths can help desensitize and improve blood flow, and TENS
(transcutaneous electrical nerve stimulator) has been shown to have a positive outcome on CRPS type II only (those
with identifiable nerve lesions). Illustration A shows the basic pathology of this condition.
130) (OBQ06.29) A 52-year-old woman falls stepping off the escalator and sustains the wrist fracture
shown in Figures A and B. Post-reduction radiographs demonstrate 20 degrees of residual dorsal
angulation. The decision is made to proceed with open reduction internal fixation with a volar plate.
Which of the following adjuvant interventions has been shown to improve outcomes?
FIGURES: A B
3. Immobilization of the wrist in an extension splint or cast for 3 weeks following surgery
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: The radiographs demonstrate a distal radius fracture. Given the residual angulation, open reduction
internal fixation is necessary. Supplemental vitamin C has been shown in 2 separate level 1 studies to reduce the
incidence of reflex sympathetic dystrophy.
Cazanueve et al evaluated 195 patients who underwent open reduction internal fixation of a distal radius fracture.
The first 100 did not receive vitamin C postoperatively. The next 95 patients received oral vitamin C for 45 days
beginning the first day after surgery. The patients who received vitamin C had 5 times less incidence (2% vs. 10%) of
reflex sympathetic dystrophy.
131) (OBQ05.139) All of the following are clinical features of complex regional pain syndrome (reflex
sympathetic dystrophy) of the lower extremity EXCEPT:
1. Swelling
3. Allodynia
4. Crepitus
5. Hyperpathia
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: Complex regional pain syndrome is a complex clinical problem for the orthopaedic surgeon. In the
acute stage (<3 months), burning or aching pain that cannot be controlled by narcotics is the major feature. Swelling,
cool and shiny skin, allodynia and hyperpathia are also clinical features. Crepitus, however, is not a clinical feature.
Hogan et al provide a review of the evaluation and treatment of complex regional pain syndrome. They argue
"despite many divergent and often conflicting theories, the cause of the severe pain, alterations in regional blood
flow, and edema is unknown. Interventions that have proved successful for treating similar conditions in the arm and
hand frequently do not relieve pain similarly in the lower extremity. Common treatment regimens target individual
components of this symptom complex, namely, sympathetic or afferent nerve hyperactivity, vasomotor instability, or
regional osteoporosis. Despite widespread use of some of these treatments, few controlled clinical trials quantify their
effectiveness."
132) (OBQ05.230) A 58-year-old female complains of continued pain and swelling 6 months following
total knee arthroplasty. She describes a burning pain that radiates from the knee down the anterior
compartment of the leg. The pain arises sporadically and is associated with swelling, sweating, and
a purplish hue of the leg. Knee radiographs are provided in Figures A and B. Which of the following
is the best management?
FIGURES: A B
2. Alpha-adrenergic blockers, physical therapy, tactile discrimination training, and graded motor
imagery
4. Surgical debridement, pulsatile irrigation, tissue sampling for culture/biopsy, and polyethylene
exchange
5. Magnetic resonance arthrogram (MRA) with intra-articular contrast and diagnostic steroid injection
PREFERRED RESPONSE ▼ 2
CORRECT
DISCUSSION: The clinical scenario and radiographs are consistent with a patient who is experiencing complex
regional pain syndrome following total knee arthroplasty. Treatment is multi-modal including GABA agonists, alpha-
blockers, beta-blockers, physical therapy, occupational therapy, graded motor imagery, tactile discrimination
treatments, sypathectomy, local anesthetics, and even spinal cord stimulators. Mont et al reported limited success in
27 patients who had surgical exploration of radiographically normal knees following TKA with unexplained pain.
Outcomes were especially poor in patients who had acheived adequate range of motion and continued to have pain
prior to surgical exploration. Patients with decreased range of motion who acheived improvement in motion
postoperatively also demonstrated great relief of pain.
133) (OBQ05.269) A 38-year-old patient presents 6 months after intramedullary nailing of a distal third
tibia fracture with symptoms consistent with complex regional pain syndrome. During the early
stage of the disease he was treated with intermittent splinting, elevation and massage, contrast
baths, and transcutaneous electrical nerve stimulation. Despite these modalities, he continues to
have severe and debilitating systems. Which of the following treatment options is indicated as a
second line of treatment?
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Complex regional pain syndrome is a chronic progressive disease of unknown etiology characterized
by pain, swelling and skin changes. If nonoperative modalities fail, a surgical sympathectomy of the affected limb is
indicated.
The first line of treatment is physical therapy including intermittent splinting, elevation and massage, contrast baths,
and transcutaneous electrical nerve stimulation. Aggressive passive range-of-motion exercises should be avoided. If
nonoperative modalites fail and symptoms remain severe, a surgical sympathectomy of the affected limb is indicated.
Keys to successful treatment include early clinical suspicion and treatment. Late CRPS is highly refractory to
treatment and often results in permanent disability.
Two forms of Complex regional pain syndrome exist: 1) Reflex sympathetic dystrophy - which does not demonstrate
nerve lesions, and 2) Causalgia - which is associated with damage to peripheral nerves. Diagnostic criteria include:
Major criteria: intense and prolonged pain, swelling, stiffness, and discoloration (vasomotor disturbances).
Minor criteria: trophic changes, osseous demineralization, temperature changes, and palmar fibromatosis.
Tran et al present their systemic review of 41 RCTs of the research regarding treatment of CRPS. Their data suggest
that only bisphosphonates offer clear medicinal benefits in the treatment of CRPS. Evidence regarding a beneficial
effect of lumbar sympathetic blocks, gabapentin, and physical therapy is lacking. As such, these authors advocate for
further study thru well-designed RCTs to better evaluate appropriate and effective treatment strategies.
134) (OBQ04.43) A 34-year-old laborer has her left foot crushed in a piece of farming equipment as
shown in Figure A. All of the following are reasons for a poor outcome following a crush injury to
the foot EXCEPT:
FIGURES: A
1. Workers compensation injury
5. Ongoing litigation
PREFERRED RESPONSE ▼ 4
CORRECT
DISCUSSION: This patient has a mangled extremity. Rigid skeletal stabilization is recommended to enhance soft-
tissue healing.
Level 4 evidence from Myerson et al found that delayed soft-tissue coverage in mangled extremities correlated with
poor outcome. Poor results also occurred if treatment was not immediately initiated (immediate debridement shown
in Illustration A), if patients subsequently had neuritis or reflex sympathetic dystrophy, or if patients were involved in
ongoing workers' compensation and litigation. Neuroischemia following substantial soft-tissue injury likely plays a role
in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral
nerves or by intraneural or extraneural fibrosis. This trauma to the nerve may cause chronic neuritis, which then
triggers a sympathetically mediated reflex sympathetic dystrophy (complex regional pain syndrome).
135) (OBQ04.191) What is the most common radiographic finding in reflex sympathetic dystrophy (RSD)
or complex regional pain syndrome of the knee?
1. patella baja
2. patella alta
3. patella osteopenia
4. generalized osteopenia
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: Reflex Sympathetic Dystrophy (RSD) of the knee is different than that of the upper extremity. Pain out
of proportion to the initial injury is the hallmark symptom. Other features include vasomotor disturbances, delayed
functional recovery and various associated trophic changes. The JAAOS article by Cooper et al states that patellar
osteopenia "is the most common radiographic finding". However, they go on to state that the most reliable diagnostic
test is symptom relief after sympathetic blockade. The JBJS article by Cooper et al treated 14 patients with RSD of
the knee with epidural blocks for 4 days. Eleven patients had complete resolution of their symptoms, and pain that
was out of proportion to the severity of the injury was the most consistent finding. Katz et al reviewed 36 patients with
RSD primarily affecting the knee. They found that injuries or operation about the patellofemoral joint triggered its
onset in 64% of patients.
136) (OBQ11.83) A 46-year-old homeless IV drug abuser presents with the hand infection shown in
Figure A, which developed after sustaining a superficial laceration. Cultures are taken during
operative irrigation and debridement, and he is started on antibiotic therapy. Based on the patients
history, what is the most common pathogen in this setting?
FIGURES: A
2. Candida albicans
3. Escherichia coli
4. Eikenella corrodens
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: Figure A shows an abscess over the metacarpophalangeal joint of the thumb. Infections with these
characteristics in IV drug abusers are most commonly caused by MRSA, and can affect any portion of the hand.
Imahara et al retrospectively reviewed 159 hand infections treated in the operating room over an 11-year period. The
examined data included known risk factors for MRSA, including human immunodeficiency virus infection, diabetes
mellitus, intravenous drug use, incarceration, and homelessness. Intravenous drug use was the only independent risk
factor for CA-MRSA infections.
Boucher et al examined the trends in both nosocomial and community-associated MRSA infections and explored
recent studies of the mechanisms that allow S. aureus to become resistant to currently available drugs.
Incorrect Answers:
1-Herpes simplex virus can cause Herpetic whitlow, as shown in Illustration A, typically presents on the fingers health
care workers exposed to a carriers mouth. Usually, this infection appears as small ulcers or vesicles, and operative
debridement is contraindicated.
2-Candida albicans is a more rare hand infection typically associated with chronic paronychia, as shown in Illustration
B.
3-Escherichia coli is a less common cause of abscess formation in the hand.
4-Eikenella is usually associated with "fight-bite" infections on the dorsal aspect of the MCP joint, and does not
commonly occur after superficial lacerations. It can also rarely occur in IV drug users who clean their needles with
saliva, as Eikenlla is part of the normal oral flora. An example of a Eikenella infection is shown in Illustration C.
137) (OBQ06.231) All of the following are considered the cardinal signs of flexor tenosynovitis EXCEPT:
1. Tenderness along the flexor tendon sheath
PREFERRED RESPONSE ▼ 5
CORRECT
DISCUSSION: The hallmarks of pyogenic flexor tenosynovitis include 1) partially flexed resting posture of the
involved finger, 2) pain with passive extension, 3) fusiform swelling of the finger, 4) volar tenderness along the flexor
sheath (cardinal signs of Kanavel). Usually patients present after 24 or 48 hours of the onset of the symptoms. The
standard of care is “urgent surgical drainage” to avoid tendon scarring or necrosis with subsequent impairment of
finger function. According to Hand Surgery Update 3, open sheath irrigation has been replaced largely by closed
sheath irrigation. These authors cite a retrospective study that showed no statistical difference in resolution of
infection using open sheath irrigation or closed sheath irrigation, however, there was a trend towards more frequent
complications and reoperations in the open drainage group. This infection generally requires admission, surgical I&D,
followed by IV antibiotics and observation in-house.
Lille et al reviewed the records of 75 patients with pyogenic flexor tenosynovitis and found that there was no
difference in outcomes between those who received intraoperative irrigation only versus those receiving
intraoperative irrigation and continuous postoperative irrigation.
138) (OBQ11.74) A 7-year-old boy sustains a ring finger injury after falling from his bike. The fingernail
has been torn transversely beneath the eponychium and the surgeon has removed the nail as
shown in Figure A. Radiographs are shown in Figure B. What is the next best step in
management?
FIGURES: A B
1. Irrigation and debridement with alumafoam placement and immobilization
3. Irrigation and debridement followed by reduction, nail bed repair and immobilization
4. Betadine soaks at home three times daily with intermittent alumafoam splint placement and
immobilization
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: The clinical presentation is consistent with a physeal separation and a nail bed injury. This is also
called a Seymour fracture which is a juxta-epiphyseal fracture of the distal phalanx. Treatment of a nail bed avulsion
and physeal separation is irrigation and debridement, physeal reduction, nail bed repair and immobilization. The
primary goals are to achieve a stable, viable nail and good cosmetic results.
Inglefield at al retrospectively reviewed 19 children with 22 nail bed injuries. Early operative repair led to good to
excellent results in 91% of patients. They concluded that repair of the nail bed at the time of injury is superior to
secondary correction.
Fassler reviewed fingertip injuries, providing recommendations for treatment based on degree of soft tissue loss,
bone exposure, feasibility for flap coverage and the presence or absence of mitigating systemic conditions. He also
concluded that the outcome of nail bed injuries is dependent on the severity of injury to the germinal matrix.
Illustration A shows the makeup of the terminal phalanx. Illustration B shows nail bed repair with suture.
Illustrations: A B
139) (OBQ09.14) Repair of a nailbed injury with 2-octylcyanoacrylate (Dermabond) provides what
distinct advantage over standard suture repair?
3. Faster procedure
4. Less pain
PREFERRED RESPONSE ▼ 3
CORRECT
DISCUSSION: Octylcyanoacrylate (Dermabond) has been found to be a viable method in nailbed repair, and has the
advantage of being a faster procedure.
Strauss et al performed a level 1 randomized trial of 2-octylcyanoacrylate (Dermabond) versus suture repair of
nailbed injuries. They found the only significant difference was that 2-octylcyanoacrylate had a shorter procedure
time. All other indices were similar.
Richards et al provide a description of their technique using dermabond to secure the nail following a nailbed repair.
They found good results with no complications in their cohort of 22 patients, and recommend it as a technique.
Incorrect Answers
Answer 1,2,4,5: There is no difference in these outcomes when comparing 2-octylcyanoacrylate (Dermabond) versus
suture repair