H&W - RC Q's

Question 1

RC 2016 - Compression sites for ulnar nerve

Answer 1

“<div>Arcade of Struthers<br></br></div><div>Medial IM Septum (reccurent ulnar neuropathy)</div><div>Cubital Tunnel-Medial Epicondyle/osboure lig</div><div>FCU heads</div><div>FDS arch/aponeurosis</div><div>Anconeus epitrochlearis</div><div>Guyon’s canal</div>”

Question 2

<div>RC 2018 - Which of the following is associated with ulnocarpal impaction</div>

<div>a.Kienbocks</div>

<div>b.VISI</div>

<div>c.DISI</div>

<div>d.ECU subluxation</div>

Answer 2

B. VISI also assx with LT tears<div>theory:<b>Ulnocarpal impaction into lunate leads to LT attenuation and then VISI deformity</b></div><div><div><ul> <li>A - Keinbochs is ulnar negative (remember a tx is radial SHORTENING or Ulnar lengthening)</li> <li>B - VISI treatment can include TFCC ulnar shortening osteotomy</li> <li>C - DISI usually radial sided pain</li> <li>D - ECU subluxes usually with ulnar deviation, dunno how ulnar impaction relates to this though</li></ul></div><div><br></br></div></div>

Question 3

RC 2018 - 12 y.o. Female with bilateral 5th digit camptodactyly of 25 degrees. What is most appropriate treatment? <ol> <li>Skin grafting</li> <li>PIP volar capsulotomy</li> <li>Tendon transfer</li> <li>Splinting</li></ol>

Answer 3

D.<div>camptodactyly is from PIP flexion - tight lumbrical or hypoplastic fds</div><div><br></br></div><div>start with splinting.</div><div>tx: fds tenotomy, or arthrodesis</div>

Question 4

<div>RC 2017 - What are 8 associations with the etiology of Dupuytren’s disease</div>

Answer 4

<div>JAAOS 2011 Dupuytren’s Disease: An evolving understanding of an age-old disease</div>

<ul> <li>Classic: Male, age<50, smoking, EtOH, DM</li> <li>Family Hx (AD)</li> <li>Northern European descent</li> <li>Smoking hx</li> <li>Plantar fibromatosis, peyronies disease</li> <li>EtOH abuse</li> <li>Diabetes</li> <li>Epileptic medication</li> <li>Manual labour</li> </ul>

<div></div>

<div>Less solid answers:</div>

<ul> <li>Adhesive capsulitis</li> <li>Vibration exposure</li></ul>

<div><br></br></div>

Question 5

“<div>RC 2018, 2012 - All associated with Dupuytren’s contracture EXCEPT</div> <ol> <li>Spiral cord</li> <li>Cleland’s</li> <li>Grayson’s</li> <li>pre-tendinous</li></ol>”

Answer 5

“2. cleland not affected. cleland stays cool<div><br></br></div><div>grayson = volar = affected because its palmar fascia!</div><div>cleland = dorsal = not affected<br></br><div><div><br></br></div><div><img></img><br></br></div></div></div>”

Question 6

“RC 2008 - Which cord causes of decreased abduction in Dupuytren’s <ol> <li>Natatory cord</li> <li>Spiral Cord</li> <li>Pretendinous cord</li> <li>Lateral Band</li></ol>”

Answer 6

“1.<div><ul> <li>Natatory contracture leads to adduction of the fingers</li> <li>Spiral bands distort neurovascular anatomy</li> <li>Central cord = pretendinous cord –> MCP and PIP contracture</li> <li>Lateral Cord = contracture of lateral digital sheath</li> <ul> <li>Does not contribute to severe deformities</li> </ul></ul><div><img></img><br></br></div><div><br></br></div></div>”

Question 7

RC 2015 - What is true about Dupuytren’s disease? <div> a. Skin graft acts as a barrier to recurrence</div> <div> b. Needle aponeurotomy is more successful for PIP than for MCP contractures</div> <div> c. Failure to correct contracture with fasciectomy is an indication for open PIP joint release</div> <div> d. Radical fasciectomy is associated with increased complications</div>

Answer 7

D

Question 8

RC 2017 - What of the following is true for Dupuytren’s<ol> <li>Open palm technique has more complications</li> <li>Limited fasciectomy improves PIP contracture more than MCP</li> <li>Percutaneous release is better for MCP than PIP</li></ol>

Answer 8

A<div><br></br></div><div>Indications for surgical treatment</div><div>> 30deg MCP contracture</div><div>ANY PIP contracture (usually more than 15deg)<br></br></div><div><br></br></div><div><div>The MCP joint is notably more forgiving than the PIP joint in Dupuytren disease, both in surgical and nonsurgical management. MCP joints are much more likely than PIP joints to achieve full intraoperative correction and to remain this way 6 months postoperatively</div></div>

Question 9

RC 2011 - All of the following are true of Dupytrens, except? <ol> <li>affects males more commonly </li> <li>affects the 4 & 5th digits more commonly</li> <li>it is associated with penile disease</li> <li>It affects DIP joints more than MCP joints</li></ol>

Answer 9

D.<div><br></br></div><div><div>Dupuytren disease is a benign fibroproliferative disorder of unclear etiology. It typically begins as a nodule in the palmar fascia and progresses insidiously to form diseased cords and finally digital flexion contractures, <b>beginning at the MCP joint and progressing distally.</b></div><div><br></br></div><div><ul> <li>Family Hx (AD)</li> <li>Northern European descent</li> <li>Smoking hx</li> <li>Plantar fibromatosis, peyronies disease</li> <li>EtOH abuse</li> <li>Diabetes</li> <li>Epileptic medication</li> <li>Manual labour</li></ul></div><div><br></br></div><div><br></br></div></div>

Question 10

“RC 2009 - Fasciectomy of palm (with skin you cant close) in Dupuytren’s, tx?<ol> <li>STSG</li> <li>Delayed primary closure</li> <li>Allow to heal by secondary intention and start ROM</li></ol>”

Answer 10

C.<div><br></br></div><div><div>Would need a full thickness skin graft for the palm, STSG would just contract</div><div><br></br></div><div><br></br></div></div>

Question 11

<div>RC 2018, 2012 - Jersey finger with retraction to the palm. What is not true</div>

<ol> <li>Ring finger most frequent</li> <li>This is the most common type of FDP injury</li> <li>Good results can be achieved if fixed within 4-6 weeks</li> <li>Often delayed diagnosis</li></ol>

Answer 11

“C. zone 1 injury (distal to FDS insertion) but also type 1 (Retraction to palm) so all blood supply gone - must repair early.<div><br></br></div><div><ul> <li>JAAOS 2011 - Avulsion Injuries of the Flexor Digitorum Profundus Tendon</li> <ul> <li>Zone I flexor tendon injury</li> <li>Ring finger most commonly affected</li> <ul> <li>Most tethered motion, bipennate lumbricals, weakest insertion point</li> <li>5mm more prominent than other digits therefore exposed to greater average force during pull-away</li> </ul> <li>Retraction into palm = Type I injury w/ disruption to vincular vascular supply</li> <li>Patients with retraction to the palm should be treated within 7-10 days</li> </ul> </ul> <div></div> <div> <div>Type</div> <div>Description</div> <div>Treatment</div> <div>Type I</div> <div>FDP tendon retracted to palm. Leads to disruption of the vascular supply</div> <div><br></br></div> <div></div> <div>Prompt surgical treatment within 7 to 10 days</div> <div>Type II</div> <div>FDP retracts to level of PIP joint</div> <div>Attempt to repair within several weeks for opitmal outcome</div> <div>Type III</div> <div>Large avulsion fracture limits retraction to the level of the DIP joint</div> <div>Attempt to repair within several weeks for opitmal outcome</div> <div>Type IV</div> <div>Osseous fragment and simultaneous avulsion of the tendon from the fracture fragment (““Double avulsion” with subsequent retraction of the tendon usually into palm)</div> <div>If tendon separated from fracture fragment, first fix fracture via ORIF then reattach tendon as for Type I/II injuries</div> <div>Type V</div> <div>Ruptured tendon with bone avulsion with bony comminution of the remaining distal phalanx (Va, extraarticular; Vb, intra-articular)</div> <div></div> </div></div><div><br></br></div>”

Question 12

RC 2016 - When placing a suture anchor for repair of a jersey finger, in what position is pullout reduced? <ol> <li>Distal to proximal </li> <li>Proximal to distal </li> <li>Perpendicular to phalanx </li> <li>Skirting subchondral bone</li></ol>

Answer 12

“A.<div><br></br></div><div>jersey finger with a stump <1cm needs transosseous repair or suture anchors.<br></br><div><ul> <li>Pilot holes are typically drilled at a 45° angle from distal‐volar to proximal‐dorsal, in accordance with the deadman angle theory of suture anchors, to increase the resistance to pullout of the implant.</li> </ul> <div></div> <div><img></img></div></div></div>”

Question 13

<div>RC 2008 - Which of the following is the strongest for tendon repair</div>

<ul> <li>A. Pulvertaft </li> <li>B. Kessler</li> <li>C. Bunnell</li> <li>D. Interrupted</li></ul>

Answer 13

“D.<div><ul> <li>Repair strength is dependent on the number of core sutures</li> <ul> <li>Bunell and Kessler are 2 strand, if interrupted had 4 core, then would be stronger</li> </ul> <li>Modified Bunnell > Kessler</li> <li>Pulvertaft is a tendon weave for tendon transfers</li><li>epitendon sutures improve strength 10-50% as well</li> </ul> <div><img></img></div></div>”

Question 14

<div>RC 2009 - How do you treat quadrigia?</div>

<ul> <li>A. Release flexor</li> <li>B. Release extensor</li> <li>C. Do muscle lengthenings in forearm in CP</li> <li>D. Release gluteus medius (not kidding, something in the hip)</li></ul>

Answer 14

A.<div><ul> <li>Quadrigia = active flexion lag in fingers adjacent to a previously injured or repaired FDP tendon</li> <li>Caused by functional shortening of the repaired tendon</li> <li>>1cm of FDP advancement associated w/ quadrigia</li> <li>More common in the fingers that have a common FDP muscle belly = long, ring, little fingers</li> <li>Most commonly seen after Zone I injury (jersey finger)</li></ul></div>

Question 15

RC 2016 - Which of the following is true regarding Zone II flexor tendon injuries? <ol> <li>Early ROM protocols reduces fibrous scar formation </li> <li>Repair both slips of FDS for improved gliding and PIP ROM </li> <li>? </li> <li>?</li></ol>

Answer 15

A. dont be dumb

Question 16

<div>RC 2018, 2012 -All of the following are acceptable for treating a bony mallet fracture, EXCEPT:</div>

<div>a.Dorsal block pinning</div>

<div>b.Splint the DIP in neutral</div>

<div>c.Pin the DIP joint</div>

<div>d.Excise the fracture fragment and advance the extensor tendon</div>

Answer 16

“D.<div><ul> <li>Splint in neutral (exact wording) – yes; extension splinting of DIP x 6-8wks, avoiding hyperextension</li> <li>Pin DIP – yes, “simple pin” fixation; if volar subluxation of the distal phalanx after splinting of the DIP jt in extension</li> <li>Dorsal-block pinning - yes</li><li><img></img><br></br></li> <li>Excision bony fragment and advance extensor tendon - no need to ever excise bone as can cause you to overtighten extensor tendon and destabilize joint</li></ul><div>Chronic: swan neck. tx: spiral retinacular lig reconstruction, central slip tenotomy, arthrodesis</div></div>”

Question 17

RC 2010 - What does not cause swan neck? <ol> <li>Mallet finger</li> <li>Volar subluxation of the proximal phalanx</li> <li>FDP rupture</li> <li>Tight intrinsics</li></ol>

Answer 17

“C. FDS rupture does - not FDP<div><img></img><br></br></div><div><ul> <li>Extrinsic:</li> <ul> <li>Disruption of terminal tendon (Mallet)</li> <li>Wrist or MP flexion contracture</li> </ul> <li>Intrinsic:</li> <ul> <li>Chronic MP volar subluxation</li> <li>Intrinsic contracture</li> <li>Tendon Adhesion</li> </ul> <li>Articular:</li> <ul> <li>Volar plate/capsule injury (hyperextension)</li> <li>Disruption of FDS</li> </ul></ul></div>”

Question 18

<div>RC 2017, 2011 - Treatment of swan neck. All true except? </div>

<ol> <li>crossed intrinsic tendon transfer</li> <li>oblique retinacular repair</li> <li>DIP fusion</li> <li>FDS partial tenodesis</li></ol>

Answer 18

“A.<div><br></br></div><div><ul> <li>Orthobullets (simplified approach because I can’t care to learn the details)</li> <ul> <li>volar plate advancement and PIP balancing withcentral slip tenotomy</li> <ul> <li>address volar plate laxity withvolar plate advancement</li> <li>correct PIP joint muscles imbalances with either</li> <ul> <li>FDS tenodesisindicated with FDS rupture</li> <li>spiral oblique retinacular ligament reconstruction</li> <li>central slip tenotomy (Fowler)</li> </ul> <li>DIP fusion</li> </ul> </ul></ul></div>”

Question 19

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

Answer 19

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

Question 20

<div>RC 2016, 2011 - List 3 causes of swan neck from synovitis in rheumatoid arthritis</div>

Answer 20

“<ul> <li><img></img><br></br></li><li>Extrinsic:</li> <ul> <li>Disruption of terminal tendon (Mallet)</li> <li>Wrist or MP flexion contracture</li> </ul> <li>Intrinsic:</li> <ul> <li>Chronic MP volar subluxation</li> <li>Intrinsic contracture</li> <li>Tendon Adhesion</li> </ul> <li>Articular:</li> <ul> <li>Volar plate/capsule injury (hyperextension)</li> <li>Disruption of FDS</li> </ul></ul>”

Question 21

<div>RC 2016, What is true regarding a boutonniere deformity?</div>

<ol> <li>Can be associated with MCP, PIP and DIP pathology</li> <li>Can be corrected with a fusion of the DIP joint</li> <li>Can be corrected with a tenotomy of the lateral bands</li> <li>Caused by dorsal subluxation of the lateral cords</li></ol>

Answer 21

“C. dorsalization/centralization of lateral bands is reconstructive option<div><br></br></div><div>a- no mcp pathology</div><div>b- can fuse pip but not dip</div><div>d- VOLAR subluxation of lateral bands</div><div><br></br></div><div><img></img></div><div><div> <div> <div><img></img></div> </div></div><div><br></br></div><div><br></br></div></div>”

Question 22

<div>RC 2014 - EPL rupture, which motion is affected:</div>

<ol> <li>IP extension and thumb abduction</li> <li>IP extension only</li> <li>Thumb abduction</li> <li>IP extension and adduction</li></ol>

Answer 22

B.

Question 23

RC 2012 - Extensor tendon subluxation at MCP, what is injured? <ol> <li>Central slip</li> <li>Sagittal Band</li> <li>Lateral Band</li> <li>Oblique retinacular ligament</li></ol>

Answer 23

“B<div><ul> <li>JAAOS 2015 - Sagittal Band Rupture</li> <ul> <li>EDC tendon crosses MP joint and is stabilized by the dorsal extensor hood</li> <li>Sagittal bands runs perpendicular to EDC and prevent subluxation of tendons</li> <li>Proximal radial portion is most important</li> </ul><li><img></img><br></br></li> </ul> <div></div></div>”

Question 24

<div>RC 2018, 2012 All are associated with swan-neck deformity in RA patient EXCEPT?</div>

<ul> <li>A. Patient unable to passively extend MCP</li> <li>B. Positive Bunnell </li> <li>C. Chronic Mallet finger </li> <li>D. MCP collaterals demonstrating increased laxity/instability when flexed to 90 degrees</li></ul>

Answer 24

“<div>ANSWER: D </div> <ul> <li>JAAOS 2006 - The Rheumatoid Wrist</li> <ul> <li>Cases of Swan Neck Deformity</li> <ul> <li>Extensor tendon rupture</li> <li>Volar MCP subluxation (A = unable to passively extend MCP)</li> <li>Intrinsic muscle tightness (B = Positive Bunnell)</li> <li>Volar plate subluxation</li> <li>Mallet finger/terminal tendon rupture (C)</li> </ul> </ul> </ul> <ul> <li>Bunnell test</li> <ul> <li>Differentiates between extrinsic and intrinsic tightness</li> <li>Test of the ability to flex the PIP joint with the MCP in flexion and extension</li> <li>Inability to flex the PIP with the MCP in extension = positive test = intrinsic tightness</li> </ul> <li><img></img></li></ul>”

Question 25

RC 2015, 2014 - What is the best indication for fixation of a 5th metacarpal fracture?

1. 20 degree apex dorsal angulation
2. short oblique minimally displaced
3. shortening 5mm
4. malrotation 5mm

Answer 25

D.

Intra-articular base/head fractures are generally reduced and pinned

• Acceptable alignment parameters (Dhaliwal)
• NO Malrotation (RC EXAM)
•  

  Shaft (Deg)

  Neck (deg)

  Shaft shortening (mm)

  D2

  10

  20

  3-5

  D3

  20

  30

  3-5

  D4

  30

  40

  3-5

  D5

  40

  50

  3-5

Question 26

RC 2011 - Which of the following are true in regards to metacarpal shaft fractures?

1. dorsal angulation is due to intrinsics and extensor tendons
2. treat short oblique with cast immobilization
3. transverse fractures reduced with longitudinal traction and fluoro
4. ORIF for displaced, malrotated, and shortened shaft by 2.5mm 

Answer 26

"D.

• A is wrong because it’s an apex dorsal deformity caused by the intrinsics pulling on the proximal fragment and the extrinsic FLEXOR muscles acting on the distal fragment

• B is wrong b/c it is difficult to control rotational deformities (common in short oblique #s) with casting alone. They usually need surgery.
• C is wrong because flexion of the MCP joints, not traction, allows reduction - Jahss maneuver
• 
  

• Acceptable alignment parameters (Dhaliwal)
• NO Malrotation (RC EXAM)
•  

  Shaft (Deg)

  Neck (deg)

  Shaft shortening (mm)

  D2

  10

  20

  3-5

  D3

  20

  30

  3-5

  D4

  30

  40

  3-5

  D5

  40

  50

  3-5

"

Question 27

RC 2008 - Oblique metacarpal fracture treated with interfrag screws

1. Length of fracture should be 2x cortical diameter
2. Screws should be 90o to the metacarpal
3. Screws should be 90o to the fracture

 

 

Answer 27

A. (if shorter, would either do plate or pins)

• Screws:
• Fracture length must be 2x metacarpal diameter (RC EXAM)
• Screw hole must be at least 2 screw diameters from fracture margin
• Minimum of 2 screws
• One perpendicular to fracture, on perpendicular to shaft

Question 28

RC 2016, 2014 - What is the treatment for a dorsal PIP fracture/dislocation with 50% volar bone loss from base of middle phalynx?

1. Hemi-hamate resurfacing
2. Dorsal block splinting
3. Dorsal block pinning
4. Buddy taping

Answer 28

"A. ideally orif would be first choice.

-tx: reduce and determine if stable

-if stable: buddy tape

-if unstable: OR

• Options for acute unstable injuries
• Closed reduction and trans-articular or extension block pinning
• Closed reduction and percutaneous pinning of volar fracture fragment
• ORIF
• Dynamic distraction and external fixation
• Volar plate arthroplasty
• DJ: Hemi-hamate is more used as a late reconstruction procedure. There is one case series that describes using the hemihamate acutely:

• Eaton Type III (fracture dislocation)
• If <40% of articular surface involved, will be stable once reduced
• If >40% of the palmar articular segment involved, ligamentous support will not be sufficient to hold reduction

"

Question 29

RC 2015 - Young male with dorsal PIP fracture/dislocation involving 25% of the articular surface. What is the most important factor for good outcome?

1. Anatomic articular reduction
2. Hand therapy
3. Congruent reduction of the dislocation
4. ORIF

Answer 29

"C.

• JAAOS 2013 - Fracture dislocation of the proximal IP joint
• Quality of reduction not shown to correlate with post-traumatic arthritis
• As long as there isn't hinging motion or unstable joint

"

Question 30

RC 2017, 2014, 2008 - Regarding a volar PIP dislocation, what is the block to reduction?

1. Oblique retinacular ligament
2. Transverse retinacular ligament
3. Lateral band
4. Collateral ligament

 

Answer 30

C.lateral band.

1. Lateral band is separated from central slip and in the joint, joint reduces once lateral band is fixed
2. All volar PIP dislocations tear central slip and one lateral band and volar plate

• Volar PIP dislocations result in injury to central slip and at least one collateral ligament
• Middle phalanx displaces volarly on proximal phalanx, and condyles of proximal phalanx can get caught between central slip and lateral bands
• Often require open reduction due to entrapped soft tissues
• Treatment is much slower than dorsal dislocations à require immobilization in extension to allow for central slip to heal
• Fracture dislocations that are unstable in full extension require surgical fixation (pinning vs ORIF) à best approach for reduction/fixation is dorsal through torn central slip

Question 31

RC 2011 - Primary stabilizer of PIP joint?

1. volar plate
2. collateral ligament
3. extrinsic tendons
4. intrinsic tendons

Answer 31

B.

• The volar plate resists joint hyperextension, while the collateral ligaments are the primary restraints to motion in the coronal plane
• At terminal extension, the volar plate and the accessory collateral ligaments assume a larger role.
• In flexion, the proper collateral ligament is tightened over the flare of the condyle and becomes the primary stabilizer against lateral displacement.
• Both the volar plate and at least one collateral ligament must be injured for dislocation of the PIP joint to occur

Question 32

RC 2016 - Which of these is best indicated for replantation?

1. 2 hrs warm ischemia time through distal thumb
2. 2 hrs warm ischemia time through the wrist
3. 2 hrs warm ischemia time through the middle phalanx
4. 7 hrs warm ischemia time through the distal forearm

Answer 32

B.

a-not complete loss of thumb

c-middle phalanx = zone 2 = contraindications

d-7 hrs warm ischemia too long

• Indications:
• Loss of a thumb
• Multiple digit amputation
• Amputations at or proximal to the palm
• Pediatric finger amputations at any level
• Single digit amputation in flexor tendon zone 1
• Contra-indications:
• Single digit amputations through zone II
• Severe crush
• Mangling
• Heavy contamination
• Segmental injuries
• Prolonged warm ischemia time
• 
  
• 
  
• Warm ischemia time should not exceed 12 hours for digits and 6 hours for amputated parts with substantial muscle
• Cold ischemia time 24 hours for digits and 10-12 hours for limbs

Question 33

"

RC 2018, 2014, 2008 - What ligament holds the articular fragment in place in a Bennet's fracture?

1. anterior oblique
2. posterior oblique
3. radial
4. Collateral

"

Answer 33

"A. tx: reduce then pin

1. Bennett fracture = avulsion of beak ligament from base of 1st MC; unstable due to pull of adductor pollicis and abductor pollicis longus resulting in supination and dorsoradial displacement of 1st MC
2. Beak ligament (aka. Palmar oblique ligament, anterior oblique ligament) runs from trapezium to ulnar/volar aspect of 1st MC

REDUCTION (MCQ)

traction, extension, PROnation, ABduction

"

Question 34

RC 2014, 2009 - X-ray of volar bartons with carpus dislocation volarly and 1st CMC dislocation. Tx?

1. ORIF scaphoid
2. closed reduction and casting
3. ORIF distal radius, CRPP 1st CMC
4. closed reduction and percutaneous pinning of scaphoid and 1st CMC

 

Answer 34

C.

Question 35

RC 2013 - Delayed healing of an ulnar collateral ligament of 1st MCP lesion results from interposition of what structure?

• A. Adductor fascia
• B. Abductor Pollicis
• C. Interossei
• D. Capsule

Answer 35

"A. adductor aponeurosis

• Note: grade 1/2 = nonop, grade 3 = op
• Grade 1 - sprain with no instability
• Grade 2 - incomplete tear with asymmetric joint laxity
• Grade 3 - complete tear with joint instability
• Test in 0 and 30o
• 0deg tests accessory UCL and 30deg tests UCL proper
• Instability = radial deviation >30-35o
• Or > 10-15o compared to other side
• However high proportion of people have this normally

"

Question 36

RC 2008 - 12 yr-old girl with a dislocated thumb MCP joint.  You are told that you can feel the metacarpal head through the palmar skin.  The X-ray shows a dislocation with no obvious fracture.  The sesamoids are not obvious but may be in the joint (Ottawa/MUN thought was in joint).  What is the treatment?

A. Thumb spica

B. Open reduction

C. Volar plate advancement arthroplasty

C. Immobilization with late ligament repair

Answer 36

B.

Wheeless – MCP dislocation, index > thumb > small > others, widened joint space results from interposition of volar plate or interposed sesamoid within joint (in children older than 10 yrs), presence of sesamoid in joint space indicates presence of volar plate with in joint, volar plate generally tears with this injury with complete disruption, wide joint space indicates complex DL (volar plate, sesamoids in joint), proximal volar plate disruption has sesamoids follow it into joint, distal volar plate disruption does not, OR indicated when irreducible, radial/ulnar instability of > 40 deg post reduction (collateral ligament tears), sesamoid #s

Management- if reducible is usually dorsal.  If irreducible – volar

Treat in thumb spica

Question 37

RC ORAL - DDX for RA pt unable to extend fingers

Answer 37

• Extensor tendon rupture
• Extensor tendon subluxation (usually ulnarly from sagittal band rupture)
• MCP dislocation (proximal  phalanx volar)
• Joint contracture after any of above
• PIN compression at elbow (rare)
• Cervical spine destruction with radiculopathy/myelopathy

Question 38

RC 2017 - Treatment of swan neck.  All true except?

1. crossed intrinsic tendon transfer
2. oblique retinacular repair
3. DIP fusion
4. FDS partial tenodesis

Answer 38

A.

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

Question 39

RC 2012, 2008 - Mannerfelt lesion is progressive erosion and rupture of what tendon?

• A. EDC
• B. EPL
• C. FPL
• D. ECU

Answer 39

C.

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

Tx: FDS4 to FPL

Question 40

RC 2014, 2008 - A 47yo female with longstanding rheumatoid arthritis presents to your clinic with an inability to extend her 4th and 5th digits. On exam you note an ulnar prominence. She has pain with supination/pronation but not with flexion/extension.  What is the best treatment?

• A. Splint (unsure if tenosynovectomy and tendon transfers included)
• B. Tendon transfers, tenosynovectomy and sauve-kapanji
• C. Tendon transfers, tenosynovectomy and distal ulnar resection
• D. Tendon transfers, tenosynovectomy and wrist fusion

Answer 40

"B

• Jer: Given she's relatively young, I would pick B - Sauve-Kapanji over C

• At CORF, people were split 50:50 between Darrach and Sauve-Kapandje on this one.  We went with B because the patient is >45years.  The true stem would really have to be convincing for an active, high-functioning, RA patient.
• CORF 2017 - Ruby Grewal says do Darrach, then leaves prior to any questions…was in combination with a wrist fusion though

"

Question 41

RC 2008 - Which of the following is not correct regarding trigger finger in rheumatoid arthritis?

• A. Type I involves focal Tendinopathy
• B. Type II involves nodularity in distal palm
• C. Type III involves nodularity adjacent to the A2 pulley
• D. Type IV involves diffuse nodularity throughout the tendon

Answer 41

A.

Four types of trigger finger occur in RA.

• Type 1 = is similar to nonrheumatoid stenosing tenosynovitis, in which the tendons catch at the first annular pulley during flexion secondary to small, localized hyperproliferation of the synovium.
• Type 2 = the nodules form in the distal palm and cause the finger to lock in flexion
• Type 3 = nodules on the flexor digitorum profundus (FDP) tendon near the second annular pulley (over the proximal phalanx) lock the finger in extension.
• Type 4 trigger finger results from generalized tenosynovitis within the fibroosseous canal. Active motion is more restricted than passive motion, and contracture and stiffness result.

Question 42

RC 2015, 2014, 2013... DDx for 65yo lady with ulnar sided wrist pain, unable to play tennis.

Answer 42

"

• Osseous
• Non-union/malunion after fractures
• Malunion of radius leading to intra-articular problems or ulnar +
• Non-union of hamate
• Non-union of pisiform
• Non-union of triquetrum
• Non-union 5th MC
• Non-union ulnar styloid
• Degenerative processes
• Pisotriquetral joint
• Midcarpal articulation
• 5th CMC joint
• DRUJ --> Arthritis/Instability
• Ulnar impaction
• Ligamentous
• TFCC tears
• Intrinsic tears (lunotriquetral/capitohamate)
• Extrinsic tears (ulnolunate, triquetrocapitate, triquetrohamate)
• Tendinous
• ECU tendinopathy/subluxation
• FCU tendinopathy
• EDM tendinopathy
• Vascular
• Ulnar artery thrombosis/aneurysm
• hemangiomas
• Neurologic
• Ulnar nerve entrapment at Guyon's canal
• Dorsal sensory ulnar nerve branch neuritis
• CRPS
• Neoplastic
• Osteoid osteomas
• Chondroblastomas
• Aneurysmal bone cysts

"

Question 43

RC 2013, 2009 - Golfer with gradually increasing ulnar sided wrist pain. Recently has also been getting tingling in the 4th and 5th fingers.  What is the best test?

• A. Nerve conduction studies
• B. MRI of Wrist
• C. CT of carpus
• D. AP and Lateral xray of wrist

Answer 43

C

• JAAOS 2001 - Acute hand and wrist injuries in athletes
• Hook of hamate fractures are endemic in sports such as golf, baseball and hockey
• Hook makes up one of the borders of guyons canal --> dyethesthesias of ulnar nerve from fracture or fibrous tissue encroaching on canal
• CT is most reliable test to identify a fracture

Question 44

RC 2011 - Matt Furey has painful ECU subluxation.  Where does he get painful pop on exam?

• A. supination 
• B. pronation
• C. flexion
• D. ulnar deviation

Answer 44

"A.

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

"

Question 45

RC 2008 - An elderly lady comes to clinic, one year following a distal radius fracture.  She complains of ulnar sided wrist pain.  What is the best option for treatment at this point? (assuming it is healed in mal union?)

A. Observe and have continued follow-up

  B. Resects the ulnar styloid

  C. Resects the distal 2 cm of the ulna 

     D. Place her in a pronated wrist splint

Answer 45

C.

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

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

Question 46

RC 2017, 2015, 2014 - All of the following are true regarding DISI deformity EXCEPT?

• A. Scapholunate ligament disruption
• B. Lunate extends
• C. Scaphoid supinates
• D. Incongruent radiolunate joint

Answer 46

"C. scaphoid pronates

SLIL is incompetent, the lunate tends to extend due to the pull of the triquetrum, which is now unopposed by the scaphoid’s tendency to flex. Thus, the scaphoid rotates into flexion and pronation while the lunate extends

"

Question 47

RC 2012 - Two motion sparing techniques to manage a stage II SLAC wrist

Answer 47

PRC

Scaphoidectomy and 4 corner fusion (Luno-capitate, Triquetro-hamate)

Question 48

RC 2011 - All are true about SLAC wrist except? 

• A. 4 corner fusion is preferential b/c it transfers load to the TFCC and distal ulna
• B. triquetrum is dorsiflexed
• C. scaphoid is flexed
• D. Type I has severe involvement of the radial styloid

Answer 48

A. there is a nonsignificant increase in load on the TFCC after scaphoid excision and four-corner fusion

BCD all true

Question 49

RC 2015, 2013, 2012 - What is an expected xray finding of LT dissociation:

• A. Flexed scaphoid
• B. No cortical ring sign
• C. Lunotriquetral gap
• D. Scapholunate angle of 45deg

Answer 49

"A.

b - cortical ring sign is present from flexed scaphoid

c - no LT gap

d - SL<30

tx: perc pin vs fusion

"

Question 50

RC 2010, 2014 - List 5 stabilizers of the DRUJ

Answer 50

• TFCC
• Pronator quadratus
• ECU tendon (subsheath or actual tendon?)
• Distal oblique band of the Interosseous membrane
• Bony congruency

Question 51

RC 2018, 2014 - In regards to distal ulna, what is true about the TFCC?

1. The force it transmits is reduced in an ulnar positive wrist (force increases on TFCC in ulnar + wrist)
2. The force it transmits is reduced in the presence of a dorsal distal radius malunion
3. 18% force is transmitted through ulna when ulna variance is neutral
4. The force it transmits is increased with forearm supination

Answer 51

C

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

Question 52

RC 2011 - In regards to DRUJ, all are true except:

A. Bony articulation between sigmoid notch and ulna head provides 20% stability to DRUJ

B. ECU and volar ulnar carpal ligament are secondary stabilizers to DRUJ

C. Distal portion of interosseous membranes provides stabilization to dorsal dislocation

D. Palmer radial/ulnar ligament is primary stabilizer of palmer translation of radius on ulna 

Answer 52

B

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

Question 53

RC 2008 - TFCC tear debridement, which of the following is a poor predictor of outcome?

• A. Young age
• B. Ulnar negative
• C. Decreased pre-op ROM
• D. Good pre-op ROM

Answer 53

"C

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

"

Question 54

RC 2011 - With respect to the relationship of radius and ulna, all are true EXCEPT:

1. TFCC allows 6mm of longitudinal translation with axial load
2. The fibers of the interosseous membrane are oriented from proximal on the radius to distal on the ulna
3. The most important part of the interosseous membrane is a narrow central band

Answer 54

"A

• The most representative component of the IOM is the central band
• Runs obliquely from the proximal radial shaft to the distal ulnar shaft

"

Question 55

RC 2011, 2017 List four indications for a hemi-resection interpositional arthroplasty of the distal radioulnar joint of the wrist?

Answer 55

"

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

"

Question 56

RC 2013 - Darrach procedure for arthritis.  All of the following EXCEPT.

• A. Better for OA than RA
• B. Distal stump instability can be a complication
• C. Associated with ulnar drift
• D. Effective for DRUJ pain relief

Answer 56

"

ANSWER: A - more reproducible for RA

This procedure is associated with several well-known postoperative complications, which include abutment of the distal radius on the ulnar stump, ulnar stump instability with or without attritional extensor tendon rupture and crepitance from rubbing on the ulnar stump, and ulnar translocation of the carpus. Because of these known complications, elderly patients and patients with low functional demands are better candidates for this procedure because repetitive and powerful forearm loading increase instability and abutment.

 

The procedure does not produce uniformly good results, especially in younger patients;

    - instability of the distal ulnar shaft;

    - painful subluxation of the ECU over the transected end of the ulna, which can lead to attritional rupture;

    - palmar subluxation or ulnar translation of the carpi;

    - radio-ulnar impingement (convergence);

"

Question 57

RC 2017 - Basilar thumb arthritis is related to deficiency of which structure?

1. anterior oblique ligament
2. posterior oblique ligament
3. radial Collateral Ligament
4. Flexor Carpi Radialis

Answer 57

A (historic)

Question 58

RC 2012 - Which of the following is true regarding the wrist?

• A. Lunate intraosseous pressures change with flexion and extension of the wrist
• B. A capitate lengthening osteotomy is a good option for early Kienbock
• C. A radial lengthening osteotomy is a good option for early Kienbock
• D. Preiser disease of the triquetrum is usually self-limited 

Answer 58

"A.

Interosseous pressure of lunate greater in wrist extension than neutral

capitate shortening

radial shortening/ulnar lengthening

preiser = avn of scaphoid

"

Question 59

"

RC 2012 - What is an indication for PRC

1. Septic Arthritis
2. End Stage Kienbock's
3. Unrepairable TFCC
4. Ulnocarpal impaction

"

Answer 59

B.

• Green DP (JHS 2015) Proximal Row Carpectomy
• Radiocarpal arthritis

1. SLAC/SNAC
2. Advanced Kienbock disease

1. Articular incongruency of radius in lunate fossa

Stage IV Kienbock’s disease = radiocarpal and/or midcarpal arthritis

TX = Total Wrist Fusion or PRC

Reference = Millers, Orthobullets

 

Symptomatic stage IV. With advanced degenerative arthritis, the available salvage options include wrist denervation, proximal row carpectomy if the articular surfaces of the capitate and radius are preserved, or total wrist fusion.

Question 60

RC 2014 - Litchman Classification 

Answer 60

"

"

Question 61

RC 2008 - Triscaph wrist fusion. All true except:

A.  Lost 50% ROM

B.  Rarely followed by another surgery

C.  90% contralateral side strength retained

D.  Styloidectomy is essential part of procedure

Answer 61

"A. only lose 25%, ie maintain 75%

• Watson (JHS Br 1999) One thousand intercarpal arthrodeses
• 798 STT fusions
• 96% union
• 75% ROM, 80% grip strength of contra-lateral side
• ""radial styloidectomy was added to the procedure in 1987 to alleviate frequent symptomatic styloid impingement""
• Kienbocks""
• 80 patients in the series
• 60% ROM, 92% grip strength
• Green's Hand Surgery:
• 20% non-union rate
• Up to 52% complication rates in some series
• 50-70% ROM --> 80% at 1 year

"

Question 62

RC 2013 - Which pulley would you release in adult trigger finger

1. A1
2. A2
3. A3
4. A4

Answer 62

"A."

Question 63

RC 2017, 2012 - What is true regarding trigger finger:

1. Same outcomes with rheumatoid and normal trigger finger release
2. 20% complication rate with surgical treatment
3. Proximal edge of A2 pulley is pathologic
4. Cannot perform percutaneous release of the thumb

Answer 63

"B. 

• If we were to categorize scar tenderness, scar thickness, slight flexion contracture, and dissatisfaction as adverse events, we would have an overall event rate of 21%

• Giugale JM (Orthop Clin N Am 2015) Trigger Finger Adult and pediatric treatment strategies
• The complication rate of open A1 pulley release ranges from 7-43%
• Trigger finger release of the thumb is at particular risk of nerve injury because the digital nerve coruses over the A1 pulley, but can still do it
• ""although percutaneous technique has been show effective and safe for the thumb, many advocates avoid performing the procedure on the thumb because of the digital nerve course""

 

JHS 2006 - Trigger Digits: Principles, Management and Complications

• Amyloidosis = A1 pulley release + complete tenosynovectomy (preserve all other pulleys)
• RA = do not take the A1 pulley! = preserve them all & just do tenosynovectomy - increases risk of ulnar drift*
• DM = respond less to cortisone (<50%) and surgery

"

Question 64

RC 2017 - Which of the following is true for trigger finger

A.  Pathology is in proximal aspect of A2

B.  You should not do percutaneous for the thumb

C.  Etiology of RA is same as idiopathic

Answer 64

b.

Question 65

RC 2009, 2007 - What is true about trigger finger?

1. Triggering is often from underlying disease
2. Triggering is often caused by RA synovitis
3. Triggering more common in young labourer
4. De quervain’s more common than triggering

Answer 65

"A. (group consensus, shitty Q)

• Summary of Old Evidence:
• Incidence: Triggering 2-3% lifetime risk, de Quervain's 2.8 per 1000 person-years
• Triggering associated with RA, diabetes, gout, carpal tunnel, de Quervain's, Dupuytren's, HTN

"

Question 66

RC 2018 -  What is the most common cause of VISI?

a.     Distal radius fracture

b.    LT tear

c.     Scaphoid non union

d.    SL tear

Answer 66

b.

Question 67

RC 2017, 2016, 2015 - List 5 reasons for fixation of an acute scaphoid fracture

Answer 67

1. Stable
1. Displacement <1mm
2. Normal intercarpal alignment
3. Distal pole fractures or waist fractures
2. Unstable
1. Displacement >1mm
2. Bone loss or comminution
3. Perilunate fracture dislocation
1. Proximal pole fracture
1. Alignment parameters
1. Lateral intrascaphoid angle >35 degrees
2. DISI alignment (radiolunate angle > 15o)
3. >15 deg scaphoid humpback deformity (orthobullets)
3. Relative
1. Labourer who wants a quicker return to work
4. Open Fracture

Question 68

RC 2014 - What is the main blood supply to the scaphoid?

1. Recurrent radial artery
2. Superficial radial artery
3. Dorsal carpal branch and superficial palmar arch
4. Ulnar Artery

Answer 68

"3.

• 70-80% through dorsal artery at dorsal ridge
• Dorsal carpal branch of radial artery
• Distal 25% from superficial palmar branch of radial artery

"

Question 69

RC 2011 - Scaphoid waist fracture.  All are true for risk of non-union except? 

1. delayed intervention
2. carpal instability
3. SL tear
4. ulnar negative variance

Answer 69

"D.

• Proximal Pole fractures
• Displacement > 1mm
• 18% non-union if disp >1mm on plain XR
• Humpback Deformity
• Delay in treatment > 4 weeks
• Height to length ratio > 0.65

"

Question 70

RC 2017 - 25 year old male has wrist injury 5 months ago and presents with persistent pain. Radiographs show an undisplaced proximal pole fracture, no deformity, no evidence of AVN. How do you want to manage this?

1. Non-operatively with spica cast
2. Physiotherapy and anti-inflammatories
3. ORIF with volar approach and ICBG
4. ORIF with dorsal approach

Answer 70

"D. 

indication for volar approach: waist with no AVN

Surgical management of established scaphoid nonunions is necessary given the strong likelihood of eventual development of radiocarpal arthrosis with a persistent nonunion

"

Question 71

RC 2010 - 25 yo with 3 month old scaphoid non-union with SL angle 70 degrees.  What is most appropriate treatment? 

1. ORIF with ICBG and compression screw
2. ORIF with ICBG and pins
3. Cast
4. ORIF with pin

Answer 71

"A.

• No humpback deformity --> Inlay bone graft (Russe)
• Humpback deformity --> interposition bone graft (Fisk)
• Osteonecrosis/proximal/revision--> vascularized bone graft
• Distal radius (1-2 intercompartmental supraretinacular artery)
• Distal femur (MFC; descending genicular artery pedicle (from the superficial femoral artery))
• If Stage 1 SNAC (ie early RS changes) --> can do styloidectomy as well

"

Question 72

RC 2018 - McGill/Calgary/Winnipeg: What is true regarding non-displaced scaphoid fractures?

1. Surgery decreases nonunion rates
2. 90% of these will heal after 8 weeks of immobilization
3. There is good evidence supporting immobilization of the thumb
4. Patients will not return to work faster with surgery 

Answer 72

"B

• FACTS: Undisplaced scaphoid waist
• Same union
• Faster time to union with OR
• Non-op - 90% at 8 weeks healed
• Faster RTW with surgery

Winnipeg: a

Mcgill: b

Jer: really no good answer to this question. Maybe B?

The 2015 recall had 'surgery results in faster time to union' which IS TRUE.

 

• Shen (PLOS One 2015) Comparison of Operative and Non-Operative Treatment of Acute Undisplaced or Minimally-Displaced Scaphoid Fractures: A Meta-Analysis of Randomized Controlled Trials
• 6 RCTs, 340 fractures.
• Operative treatment
• significantly better functional outcomes in the short term
• more rapid return to work
• prevents delayed union of the fractures, a finding supported by the results of analysis of the time to fracture union
• A number-needed-to-treat analysis revealed that more than 20 patients would have to undergo operative treatment to prevent one delayed union
• No significant differences for
• Nonunion
• Malunion
• OA

"

Question 73

RC 2013, 2011, 2010 - Give the 4 stages of perilunate instability

Answer 73

"

• Mayfield
• Stage 1 - SL complex disruption
• Force then propagates through Space of Poirier
• Stage 2 - lunocapitate disruption
• Stage 3 - lunotriquetral complex is violated (perilunate dislocation)
• Whole carpus separates from lunate (usually dislocates dorsally)
• Lunate remains articulating in lunate fossa of radius
• Stage 4 - lunate dislocates from radius volarly
• Rotates and flexes forward on strong intact palmar ligaments
• Carpus reduces back to radius
• Dorsal radiolunate tears; Volar radiolunate ligament remains intact (RC EXAM)

"

Question 74

RC 2013 - What is the NOT associated with a lesser arc injury?

1. Scapholunate ligament tear
2. Luno-capitate ligament tear
3. Dorsal radiocarpal ligament injury
4. Volar radiolunate ligament tear

Answer 74

"D.

volar stays intact, as does blood supply

• Lesser arc"" injury = purely ligamentous disruption
• ""Greater arc"" injury = osseous structures around lunate are fractures

"

Question 75

RC 2011 - Why is lunate AVN rare with a dislocation?

1. multiple vessel supply
2. volar blood supply
3. intact SL ligament
4. intact dorsal capsule attachment

Answer 75

B.

• Intact radiolunate ligaments and RSL ligament (Ligament of Testut)

•  palmar branch of radiocarpal arch (gives volar blood supply), but variability in blood supply (also get is from dorsal radioacarpal branch)
• The lunate can have multiple vessel supply, but this is not the reason it doesn’t get AVN – it doesn’t get AVN b/c the volar blood supply is maintained
• radiolunate ligament is intact during all stages of dislocation, which maintains blood supply. This ligament acts as the hinge around which the lunate rotates as it dislocates volarly

Question 76

RC 2009 - What nerve injury has a disrupted axon and intact endoneurium

1. Neuropraxia
2. Axonotmesis
3. Neurotmesis
4. Electrotmesis

Answer 76

B.

Seddon Type

Degree

Myelin Intact

Axon Intact

Endoneurim Intact

Wallerian Degen.

Reversible

Neurapraxia

1st

No

Yes

Yes

No

reversible

Axonotmesis

2nd

No

No

Yes

Yes

reversible

Neurotmesis

3rd

No

No

No

Yes

irreversible

Question 77

RC 2009 - Wallerian Degeneration. All of the following undergo it except?

1. Axonotmesis
2. Neuropraxia
3. Neuronotmesis
4. Electrotmesis

Answer 77

B.

Seddon Type

Degree

Myelin Intact

Axon Intact

Endoneurim Intact

Wallerian Degen.

Reversible

Neurapraxia

1st

No

Yes

Yes

No

reversible

Axonotmesis

2nd

No

No

Yes

Yes

reversible

Neurotmesis

3rd

No

No

No

Yes

irreversible

Question 78

RC 2010 - What order does neurologic function return after a peripheral nerve injury?

Answer 78

"

• JAAOS 2000 - Peripheral Nerve Injury and Repair - 'SPTTPM'

1. Sympathetic
2. Pain
3. Temperature
4. Touch
5. Proprioception
6. Motor

"

Question 79

RC 2014 - What is not correct about EMG and nerve conduction studies?

1. Sensory latency is the earliest finding
2. axonal injury will show decreased amplitude on NCV
3. H-reflex can monitor for an asymmetric S1 root issue
4. EMG cannot discern between acute and chronic nerve injuries

Answer 79

"D.

Source: JAAOS 2000 ""Role of neurophysiologic evaluation in diagnosis.""

""the most useful application of the H wave is in detection of S1 radiculopathy.""

Sensory latency is an extremely sensitive finding that can be effected even by environmental factors, such as the temperature of the room. 

By definition, axonal injury will show decreased amplitude on motor nerve conduction studies, but these would not be velocity studies. I think this is just a recall typo. EMG can discern between acute and chronic nerve injuries because changes occur over time. Fibrillations and positive sharp waves take a few weeks to show up.

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

"

Question 80

RC 2018 - Patient sustained an undisplaced distal radius fracture that was managed with no complication. Unable to extend thumb IP joint 2 months post injury, treatment involves?

1. EIP to EPL
2. Superficial Flexor of ring (FDS4) finger to EPL
3. IP fusion
4. ?

Answer 80

A

• nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the EPL tendon
• extensor mechanism is thought to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition or a local area of ischemia in the tendon
• treat with EIP to EPL transfer 

Question 81

RC 2018 - Describe the 3 anatomic variations of lunate vascularity and how each of them are characterized.

• Which variation is the highest risk for Kienbock’s disease?

Answer 81

""

Question 82

RC 2018 - Regarding wrist arthrodesis, what is true:

1. Bilateral arthrodesis is contraindicated
2. It is adequate to perform steinmann pin arthrodesis in RA
3. Wrist arthrodesis is indicated in acute infection
4. Neutral position of wrist arthrodesis gives the optimal grip strength 

Answer 82

JAAOS 2017

• However, for patients with painful, end-stage rheumatoid arthritis affecting the wrist, standard wrist arthrodesis techniques can provide excellent clinical outcomes. Kluge et al19 retrospectively reviewed a series of 104 wrists in 87 patients with rheumatoid arthritis at a mean followup of 87 months. Using a modified Clayton-Mannerfelt technique (steinman pin), the authors attained a 98% rate of fusion at a mean 10 weeks postoperatively, with two nonunions that required conversion to an AO wrist fusion plate

Question 83

RC 2012 - 4 Successful non-operative modalities for carpal tunnel

Answer 83

"

1. Brace/splint (strong) at 30 deg extension at night
2. Steroid (methylprednisolone) injection (strong)
3. Ketoprofen phonophoresis (moderate evidence for pain reduction) - ""NSAID with U/S""
4. Oral steroids (moderate evidence for)

 

1. Therapeutic ultrasound (limited evidence)
2. Laser therapy (limited evidence)
3. Note: Moderate evidence supports NO BENEFIT for other oral medications including NSAIDs, gabapentin, etc)

"

Question 84

RC 2012 - 50 yr Secretary had carpal tunnel release 6 months ago and still has hand/wrist pain. OE has tinels on scar on radial side of wrist at the wrist crease. 5 mm 2 pd. Thumb power normal. What is the problem?

1. Partial transverse carpal ligament release
2. Damage to the Recurrent motor branch
3. Incomplete carpal tunnel release
4. Damage to the palmar cutaneous branch

Answer 84

"D.

1. Tung THH (Plast Reconstr Surg 2001) Secondary Carpal Tunnel Surgery
1. Injury to the palmar cutaneous nerve or one of its branches is most frequently the problem. A more radially placed incision is more likely to cross the distribution of the palmar cutaneous branch, with subsequent injury and neuroma formation

 

2. ** RADIAL is key word – Palmer cutaneous branch = sensory innervation to radial palm, splits 5-7 cm proximal to wrist crease, travels b/t PL and FCR does not travel in CT, therefore assuming CTR was adequate, the original symptoms “still has hand/wrist pain” are secondary to palmer cutaneus branch. Also, if there was an incomplete release of the carpal tunnel, we would expect there to be a positive phalen test in addition to the positive tinnels, and persistent decrease in 2 point discrimination in the fingers (the palmar cutaneous branch does not supply any of the fingers).

 

"

Question 85

RC 2015 - What is the most common complication following carpal tunnel release?

      a.  Pillar pain

      b.  Recurrance/incomplete

      c.  Infection 20%

      d.  Injury to the palmar cutaneous branch

Answer 85

"A.

1. Tung THH (Plast Reconstr Surg 2001) Secondary Carpal Tunnel Surgery
1. Persistence of pre-operative complaints is the most common complication of carpal tunnel release with an incidence of 7-20%
2. Persistence occurs for three reasons:
1. Transverse carpal ligament is incompletely released
2. Continued compression more procimally by inadequate release of distal antebrachial fascia
3. Compression of nerve more proximally (wrong diagnosis)
2. JAAOS 2007 Carpal Tunnel Syndrome

Complications have been reported with all techniques of carpal tunnel release surgery, including but not limited to injuries to the motor branch and palmar cutaneous branches of the median nerve, hypertrophic scar formation, pillar pain, laceration of the superficial palmar arterial arch, incomplete release of the TCL, tendon adhesions, infection, wound hematoma, finger stiffness, and recurrence.77 The most common complication with open carpal tunnel release surgery is pillar pain  (pillar pain: may result from division of the terminal branches of the palmar cutaneous nerve and/or scar between the divided TCL and skin) followed by laceration of the palmar cutaneous branch of the median nerve.

Pillar pain occurs in approximately 25% of surgical cases, with symptom resolution reported in most patients by 3 months.78 Incomplete release of the TCL with persistent or recurrent CTS symptoms is the most frequent complication attributed to endoscopic carpal tunnel release surgery.

"

Question 86

RC 2011 - What is true about electro-diagnostic studies and carpal tunnel syndrome?

1. EMG is most sensitive
2. motor latency is the least sensitive
3. sensory is the most sensitive
4. decreased conduction velocity in early disease

Answer 86

C.

• Wheeless:

1. Sensory latency is the most sensitive and earliest indicator of Carpal Tunnel

JAAOS 2007 Carpal Tunnel Syndrome

1. Threshold sensory tests are more sensitive than innervation density measurements in detecting early CTS

1. This is referring to things like monofilament testing but I think the principle stands

Question 87

RC 2010 - What is the most sensitive test for carpal tunnel compression? 

1. Vibratory
2. EMG
3. Static 2 point
4. Moving 2 point

Answer 87

"

A. 

Jer: from Green's

• Vibration and cutaneous pressure thresholds will permit quantification of the early changes that occur with chronic nerve compression. Changes in sensory receptor innervation density will occur in the later stages of chronic nerve compression, and therefore two-point discrimination measures will become abnormal only in the more severe stages of nerve compression. 

"

Question 88

RC 2010 - Patient has cold intolerance, ulcer on pulp of finger and blanching over dorsum of hand. What is not associated with this condition?

1. Calcinosis
2. Pitting Nails
3. Telangectasias
4. Arthritis

Answer 88

B

Scleroderma - CREST syndrome = Calcinosis, Raynaud Phenomenom, Esophageal Dysmotility, Sclerodactyly (thickening of skin on hands and fingers), Telangiectasia

Question 89

RC 2017, 2-14 - What is the primary functional loss with a low median nerve palsy?

1. Thumb opposition
2. Key pinch
3. Thumb IP flexion
4. Index IP flexion

Answer 89

"A.

• Jer: LOW MEDIAN = DISTAL to AIN - ie really only recurrent motor branch = OAF muscles (OP, AbPB, FBPs)
• Key pinch is from ULNAR nerve: adductor pollicis and 1st lumbrical
• Froment sign (FPL (AIN) works for IP flexion during key pinch) is a sign of ulnar neuropathy

1. Thumb flexion = FPL à high median nerve
2. Thumb opposition = opponens + abductor pollicis brevis à recurrent motor branch
3. Key pinch = adductor pollicis + interossei à deep motor branch of ulnar nerve
4. MCP flexion = FPB à two heads (superficial = median; deep = ulnar)

"

Question 90

RC 2011 - Pt. Has weakness of FPL, FDP, and pronation, with no sensory weakness.  Cause?

1. Median nerve
2. AIN
3. Pronator syndrome
4. C7

Answer 90

"2. AIN is pure motor.

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

"

Question 91

RC 2014 - List 4 sites of compression of the AIN around the elbow and forearm

Answer 91

• Pronator syndrome = compression of median nerve b/w 2 heads of pronator teres
• MOTOR weakness and PAIN
• Pain due to compression of palmar cutaneous branch of median nerve also being involved
• Median nerve compression sites
• Ligament of Struthers
• Lacertus fibrosis
• Humeral head of Pronator teres

• AIN syndrome = compression of AIN
• AIN given off 4cm distal to medial epicondyle as median nerve dives deep to FDS
• WEAKNESS only (no cutaneous branches therefore no pain)
• Associated with Brachial neuritis (parsonage turner syndrome)

• AIN branches off after median nerve passes the superior edge of pronator teres. Additional compression sites:
• Deep head of PT
• Proximal margin of FDS arch
• Gantzer’s muscle (accessory head of FPL)
• Aberrant vessel

Question 92

RC 2008 - AIN after it branches off median nerve is likely to match up with which of the following

1. FCR
2. FCU
3. FDS
4. FDP

Answer 92

"d.

"

Question 93

RC 2009 - What doesn’t AIN innervate?

1. PQ
2. All of FDP
3. Volar joint capsule (DRUJ)
4. Volar joint capsule (carpals)

Answer 93

"B. Only D2/3

"

Question 94

RC 2011, 2010 - 3 sites of compression in radial tunnel syndrome 

Answer 94

"-supinator: leading edge (arcade of froshe) and distal edge

-ECRB

-RC joint / fibrous tissure

-RRA (leash of henry)

note that radial nerve branches at level of RC joint

"

Question 95

"

RC EXAM: Guy who does a lot of work with repetitive lifting and elbow flexion. Has weakness to digital extension and his wrist radially deviates with extension. Failed all non-op. What to decompress?

1. Intermuscular septum 5cm proximal to lateral epicondyle
2. Struther's ligament
3. Lacertus fibrosis
4. Proximal supinator edge

"

Answer 95

"D.

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

"

Question 96

RC 2009 - Dude with elbow pain and worse with supination and resisted finger extension, what do you do?

1. Decompress supinator
2. Decompress brachioradialis
3. Decompress at triceps
4. …

Answer 96

"A.

• Provocative maneuvers for radial tunnel:
• Resisted supination
• Pain with resisted middle finger extension
• Therefore decompress at supinator

"

Question 97

RC 2009 - Most common site of PIN compression?

1. Fibrous bands under BR
2. Recurrent leash of Henry
3. Ligament of Struthers
4. Fibrous bands at proximal edge of supinator

Answer 97

"

D.

"

Question 98

What is true about a PIN palsy?

1. Most common neurological sequlae associated with Monteggia fracture
2. Associated with fibrous bands of FDS
3. Demands operative decompression
4. Weakened power grip

Answer 98

a.

• Posterior interosseous nerve neuropraxia following acute Monteggia injury patterns about the elbow has been described and is thought to be secondary to traction or direct trauma. The condition typically resolves following successful closed reduction of the radial head.
• Acute and tardy palsy of the PIN have been reported as the most frequent neurologic complications following these complex injuries about the elbow. Following the acute injury and anterior dislocation of the radial head, direct trauma and traction neuropraxia are implicated. However, several authors have reported that these acute neuropraxias resolve with observation following closed reduction of the radial head.

Question 99

"

RC 2014 - Several lacerations to ulnar aspect of distal forearm and hand. Pt has numbness to dorsum of ulnar aspect of hand. No volar numbness, no motor deficit. Where is the injury?

1. Guyon's Canal Zone 1
2. Guyon's Canal Zone 2
3. Guyon's Canal Zone 3
4. Proximal to Guyon's Canal

 

"

Answer 99

"4. injury to dorsal cutaneous nerve.

• Zone 1 = sensory (volar fingers/palm) and deep motor branches of the ulnar nerve susceptible to compression
• Zone 2 = deep motor branch of the ulnar nerve susceptible to compression
• Zone 3 = only the sensory branch (volar fingers/palm) of the ulnar nerve
• Numbness to dorsoulnar aspect of hand = injury superficial sensory branch of ulnar nerve which branches PROXIMAL to Guyon’s canal
• 
  

"

Question 100

RC 2018, 2014 - Which of the following is not a sign of cubital tunnel compression:

1. Claw hand
2. Positive Finklesteins
3. Positive Froment (or ?Wartenberg)
4. Positive tinels at elbow

Answer 100

"

2.

• Claw hand = weakness of instrinsics and overpull of extrinsics = due to ulnar neuropathy anywhere along length of nerve
• Finkelstein’s = pain with grasping of thumb in palm and ulnar deviation of wrist = sign of DeQuervain’s tenosynovitis
• Froment’s = cannot do KEY PINCH - flexion of thumb IP when grasping paper between 1st and 2nd fingers = sign of intrinsic muscle weakness (specifically adductor pollicis) due to ulnar neuropathy
• Wartenberg’s sign = persistent abduction of D5 with attempted adduction due to weakness of interossei (3rd palmar interosseous)
• wartenberg syndrome = SRN entrapment between BR and ECRL

"

Question 101

RC 2015 - Patient with complete paralysis of intrinsics but no anaesthesia. Where is the lesion?

1. At formation of ulnar nerve
2. At the elbow
3. Proximal to pisiform
4. Between adductor and flexor digiti minimi

Answer 101

"D.

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

"

Question 102

RC 2014, 2011 - Pt with numbness to ulnar side of left forearm and ulnar aspect of digit 5. No motor findings. What is the most likely diagnosis?

1. C7-T1 left disc herniation
2. C6-7 left disc herniation
3. ulnar nerve compression at wrist
4. ulnar nerve compression at cubital tunnel 

Answer 102

A.

• A) C7-T1 left disc herniation will compress the exiting nerve root (C8) and possibly the traversing nerve root as well (T1) = sensory to both ulnar forearm and D5 numbness +/- motor to intrinsics and FCU
• B) C6-7 disc herniation will compress C7 = sensory to middle finger + motor to triceps
• C) Ulnar nerve compression at wrist = sensory only to volar ulnar palm and 1.5 digits + motor to intrinsics
• D) Ulnar nerve compression in cubital tunnel = sensory to entire ulnar palm and 1.5 digits + motor to intrinsics and FCU; FOREARM PAIN IS COMMON, BUT GENERALLY NO NUMBNESS! 

Question 103

RC 2013, 2010 - A young male patient has ulnar neuropathy from the cubital tunnel. What is true regarding ulnar nerve exploration and release?

1. Subcutaneous anterior transposition has better results.
2. There is no difference between no anterior transposition and sub-muscular transposition.
3. Submuscular anterior transposition has better results.
4. there are increased complications with sub-muscular anterior transposition

Answer 103

D, B (d preferred)

• Difficult question given recent rapid swing of pendulum of evidence
• Old groups all agree that there are no difference in clinical outcomes and increased complications with transposition

Liu CH (PLoS One 2015) Anterior subcutaneous versus sub-muscular transposition of the ulnar nerve for cubital tunnel syndrome: a systematic review and meta-analysis

• No difference

 

Macadam SA (JHS 2008) Simple decompression versus anterior subcutaneous and Submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis

• No difference

 

Bartels (Neurosurg 2005)

• 75 decompression vs 77 subcutaneous transposition
• No difference in clinical outcome
• More complication in transposition (31 vs 10%)

 

Gervasio (Neurosurg 2009)

• RCT found no differences b/w groups clinically or electrophysiologically

 

JAAOS 2017 Cubital tunnel syndrome: Current Concepts

• Clinical outcomes similar between the two treatments
• Transposition has higher rates of complications, specifically peri-incision numbness and deep infection

Question 104

RC 2013 - Which is not a possible cause of cubital tunnel syndrome

1. medial border of Brachialis
2. Arcade of Struthers
3. Intermuscular septum
4. Osbornes ligament

Answer 104

"A.

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

"

Question 105

RC 2009 - What is the most common cause of recurrent compression of the ulnar nerve after decompression?

1. Arcade of struthers
2. Medial intermuscular septum
3. Osbourne’s ligament
4. FCU

Answer 105

"B.

• Filippi R (Minim Invasiv Neurosurg 2001) Recurrent cubital tunnel syndrome
• ""The causes of continued or recurrent symptoms after initial surgery included dense perineural fibrosis of the nerve after subcutaneous transposition, adhesions of the nerve to the medial epicondyle and retention of the medial IM septum""
• JBJS Current Concept Reviews 2016 - Recurrent Cubital Tunnel Syndrome
• ""multiple authors have reported that the unresected IM septum was the site of compression found during revision cubital tunnel surgery""

"

Question 106

RC 2013 - What 2 muscles surround the radial nerve at the distal humerus as it pierces the intermuscular septum

Answer 106

"brachialis, BR

"

Question 107

RC 2009 - With regards to pulleys in the hand, what is false?

1. A1 has no useful function
2. C1 is distal to A2
3. C2 is distal to A4
4. A2 and A4 are the most important

Answer 107

"C.

"

Question 108

RC 2014 , 2009 - All are true regarding tight hand extrinsics EXCEPT?

• A. The extensor tendon is scarred down to the metacarpal
• B. There is a block to passive MCP flexion
• C. MCP flexion causes PIP extension
• D. PIP Flexion causes MCP extension

 

Answer 108

"B. can flex MCP

• Tight extrinsics = weak instrinsics = intrinsic minus hand = MCP hyperextension and PIP flexion
• B - there is NO block to MCP flexion. Provocative test is to flex MCP to see if DIP/PIP extend
• C. MCP flexion causes PIP extension = this means that if you bring the MCPs out of hyper-extension into a flexed position, the PIPs are able to extend
• Wheeless:
• Extrinsic tendon tightness usually results from scarring and adhesions of the extensor tendons over the metacarpals
• Will be more PIP flexion with MP in extension (just think intrinsic minus positive = claw hand)
• If PIP joints flexed, MPs will extend

"

Question 109

RC 2017 - Enchondroma in the hand.  All are true except

1. After curettage, it is controversial whether or not to put bone graft in
2. Transformation to Chondrosarcoma is rare
3. Pathologists accept more atypia in a hand enchondroma then elsewhere in the body
4. Recurrence after curettage is >10%

Answer 109

D.

• Recurrence is uncommon in solitary lesions, and malignant degeneration is exceedingly rare

• The generated void may be filled or left vacant to fill in naturally with hematoma. There is no consensus on an optimal management strategy, and the medical literature is replete with case series describing low complication rates with and without void augmentation
• Hand enchondromas are unique because they may exhibit hypercellularity and cytologic atypia consistent with malignant features in other skeletal locations but in the hand are benign

Question 110

RC 2010, 2009 - A 23 y.o. male has 4 month history of increasing pain in proximal phalanx of middle finger.  Not shown the x-ray, but told that there is a lytic lesion that the radiologist thinks is benign.  List 7 possible diagnoses

Answer 110

• JAAOS 2016 - Enchondroma of the Hand
• Infections and Tumor-like Conditions
• Pyogenic osteomyelitis
• Cystic tuberculosis
• Coccidiodomycosis
• ABC
• UBC
• Intra-osseous Epidermal Inclusion cyst
• Benign Tumor:
• Enchondroma
• GCT
• Chondroblastoma
• Malignant Tumor:
• Chondrosarcoma
• Ewing Sarcoma
• Lymphoma
• Osteogenic osteosarcoma
• Acrometastasis

Question 111

RC 2012, 2011 - 8 year old boy with proximal phalanx fracture. Shown well circumscribed lesion with stippled calcification. What to do?

1. Amputate (O’Neill style)
2. Open biopsy
3. Reduce and immobilize
4. CRPP

Answer 111

C

• JAAOS 2016 - Enchondroma of the Hand
• Traditionally, enchondroma-related pathologic fractures have been treated with 1-2 months of immobilizations to allow healing before curettage (adults)

Question 112

RC 2009 - Where can a glomus tumor be most commonly found

• A. Pulp
• B. Hyponychia
• C. Distal phalanx
• D. Nail Bed

Answer 112

"D.

"

Question 113

RC 2011 - How do you diagnose a glomus tumor

1. MRI
2. XR
3. CT
4. US

Answer 113

A.

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

Question 114

RC 2009 - Glomus tumor: all except

1. Deep blue color
2. x-ray normal
3. Pin point pain
4. Situated under the nail bed

Answer 114

"B.

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

"

Question 115

RC 2015, 2013, 2011 - Wrist Portals? 

Answer 115

"

• JAAOS 2012 - Advances is wrist arthroscopy
• 1-2 - dorsum of snuffbox, radial to EPL tendon (uncommon)
• 3-4 – between EPL and EDC – established first, main viewing portal
• 4-5 – between EDC and EDM – main instrumentation, visualized TFCC
• 6R – Radial side of ECU – instrumentation of ulnar sided structure
• 6U – Radial side of ECU
• Radial Midcarpal (just distal to 3-4)– Radial side of 3rd MC – visualize STT, SL and distal pole scaphoid
• Ulnar Midcarpal – 1 cm distal to 4-5 – visualize distal lunate, LT, TH
• STT - midshaft axis of index MC joint, just ulnar to EPL
• TH - just ulnar to ECU tendon at level of TH joint
• 
  

"

Question 116

RC 2016 - All are true regarding Madelung’s, except?

1. Result of abnormality in dorsoulnar aspect of distal radial physis
2. Volar subluxation of the carpus
3. Often ulnar positive variance
4. Associated with Ollier’s

Answer 116

A.

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

Question 117

RC ORAL - Tendon transfers in UE

Answer 117

Radial Nerve

Wrist Extension

PT to ECRB

 

Thumb Extension

PL to EPL

 

Finger Extension

FCR to EDC

Median Nerve

Thumb opposition

FDS4 to Abductor Pollicis

 

Thumb IP flexion

BR to EPL

 

Finger Flexion D2/D3

ECRL

Ulnar Nerve

Thumb adduction

ECRB

 

D2 abduction

ECRL

 

Reverse clawing

FDS to lateral bands of ulnar digits

Question 118

RC 2013, 2011 - Principles of tendon transfers?

Answer 118

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

Question 119

RC 2014 - All of the following are principles of tendon transfer EXCEPT?

1. Straight line of pull is more efficient
2. Wrist fusion will help with tenodesis
3. Wait to perform transfers until soft tissue is in equilibrium
4. Must not use a tendon that would compromise function

Answer 119

B. ANSWER: B

• 2014
• B: False --> Wrist flexion and extension can add 20 to 30 mm of excursion through a tenodesis effect  (JAAOS, 2015)
• Tendon transfers for radial, median, and ulnar nerve palsy. JAAOS. 2013

Question 120

RC 2008 - ORIF of forearm and FPL and FDP 2/3 not working, options for tendon transfers

1. DIP fusions
2. Fuse both thumb and fingers
3. BR to FPL and FDP 4/5 to FDP 2/3
4. BR to FPL and fuse DIPs

Answer 120

C.

• High median nerve palsy = unable to oppose thumb (recurrent median), flex thumb (AIN), flex index and middle finger (Median)
• Opponensplasty
• EIP to ABP
• FDS of ring finger to APB w/ Bunnell pully (split FCU to pisiform)
• PL to ABP
• Thumb IP flexion
• BR to FPL
• Index flexion
• Side-to-side tenodesis of FDP of ring and little finger to index and middle (ulnar needs to be working)

Question 121

RC 2016, 2014 - What is true about dorsal barton fracture with dorsal subluxation of carpus?

1. treat with closed reduction and casting
2. volar radiocarpal ligaments not injured
3. usually need volar and dorsal approach
4. Teardrop angle (TDA) will be ?increased/decreased due to volar impaction

Answer 121

C.

A combined dorsal and volar exposure is often necessary for these injuries because the central articular impaction and the dorsal marginal shearing fracture may be best treated through a dorsal exposure in internal fixation and the volar ligament injuries or avulsion fracture require a volar exposure and fixation.

Question 122

RC 2015 - Fight bite. What antibiotic?

1. Keflex
2. Amox-Clav
3. TMP/SMX
4. ? 

Answer 122

"

B

• JAAOS 2015 - Human and Other Mammalian Bite Injuries of the Hand
• Common Bacteria Isolated from Infected Bite Wounds:
• Aerobic - Step, Staph, Eikenella, Haemophilus, Enterobacteriacae, Gernella, Neisseria
• Anaerobic - Prevotella, Fusobacterum, Eubacterium, Veillonella, Peptostreoptococcus

"

Question 123

PIP dorsal fracture dislocation involving 25% of joint surface, how would you manage? (RC 2019)

a.     Dorsal block splint

b.     ORIF

c.     Immobilize in 60-90° of flexion

d.     Volar plate reconstruction

Answer 123

"

Answer: A

 

Ref: JAAOS 2013 – Fracture-dislocation of the Proximal Interphalangeal Joint

•  The amount of articular surface involvement can often be used to predict stability 

•  Stability of PIPJ fracture-dislocations is defined by the ability to maintain a well-aligned reduction.

•  Radial collateral more commonly ruptured than ulnar 

•  Failure usually at proximal insertion 

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

 

•  Hastings Classification 

•  Type I - <30% articular surface involved 

•  Stable 

•  Buddy tape x 6 weeks and active ROM while taped 

•  Buddy taping shown to be superior to static immobilization 

•  Type II - 30-50% articular surface involvement 

•  Tenuous 

•  Extension block splinting 

•  Have also described short course of splinting in 50-60^o flexion followed by sequential splinting with 10^o more extension each week (controversial) 

•  Type III - >50% articular involvement 

•  Unstable

•  If >30^o flexion required to make joint stable --> unstable 

•  Small dorsal blocking splint used 

•  If avulsion fracture of volar plate present, monitor for flexion contracture development 

•  Goals of management of fracture-dislocation of the PIPJ include obtaining and maintaining a reduced joint, reestablishing normal joint motion, allowing early ROM if possible without compromising stability and, when feasible, achieving an anatomic reduction of the articular surface.

•  Several investigators have shown that a small intra-articular step-off can be well tolerated in the setting of a well aligned, reduced joint with no hinging and early initiation of ROM to promote cartilage healing

•  A well aligned, reduced joint is essential for acceptable clinical outcome.

•   Injuries requiring > 30° of flexion to maintain stability should undergo surgical stabilization, while those that require < 30° of flexion should be managed nonsurgically.

"

Question 124

What is true about prospective lower extremity injury severity scores?

a.     High specificity but low sensitivity

b.     Highly specific

c.      

d.     There is minimal clinical utility to these scores

Answer 124

JBJS 2008. 90: 1738-43

•  Five LE rating scores: MESS, LSI, PSI, NISSSA, HFS-98 are not predictive of outcome and therefore cannot be used to determine limb salvage vs recon

•   Conclusion states that currently available injury severity scores are not predictive of functional recovery of patients who undergo successful limb salvage surgery

LEAP study

Helps with some prognostication but no good/useful score available

Question 125

What is true about Boutonierre deformity in RA? (RC 2019)

A. Not associated with MCP or DIP pathology

B. Can be corrected with tenotomy over proximal phalanx

C. An arthrodesis is contraindicated with a stiff PIP joint

D. Caused by dorsal subluxation of the lateral bands

Answer 125

Ans: A

Boutonniere deformity occurs with the lateral bands slip VOLARLY, transforming them into PIP joint flexors

- This results in contracted oblique retinacular ligaments, and eventually changes in the PIP joint volar plate and collateral ligaments. In addition, the DIP joint is pulled into hyperextension (ORL contraction)

- In RA, the cause is often PIP joint synovitis

- Many treatment options have been described, including:

1. Terminal tendon tenotomy (distal phalanx)

2. Central slip re-insertion or reconstruction using dorsal PIP capsule, a slip of FDS or lateral bands

Outcomes are unpredictable - loss of correction over time. Indications for soft tissue only boutonniere reconstruction are limited. 

Algorithm

1. If joint is preserved: dynamic PIP joint extension splint x 8 weeks, +/- terminal tendon tenotomy (if DIP flexion remains)

2. If joint is not preserved, PIP arthrodesis is performed

Question 126

PIP dorsal fracture dislocation involving 25% of joint surface, how would you manage?

1. Dorsal block splint
2. ORIF
3. Immobilize in 60-90° of flexion
4. Volar plate reconstruction

Answer 126

"

Answer: A

Ref: JAAOS 2013 – Fracture-dislocation of the Proximal Interphalangeal Joint 

• The amount of articular surface involvement can often be used to predict stability  
• Stability of PIPJ fracture-dislocations is defined by the ability to maintain a well-aligned reduction.

• Radial collateral more commonly ruptured than ulnar 
• Failure usually at proximal insertion 

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

• Hastings Classification 
• Type I - <30% articular surface involved 
• Stable 
• Buddy tape x 6 weeks and active ROM while taped 
• Buddy taping shown to be superior to static immobilization 
• Type II - 30-50% articular surface involvement 
• Tenuous 
• Extension block splinting 
• Have also described short course of splinting in 50-60o flexion followed by sequential splinting with 10o more extension each week (controversial) 
• Type III - >50% articular involvement 
• Unstable

• If >30o flexion required to make joint stable --> unstable 

• Small dorsal blocking splint used 
• If avulsion fracture of volar plate present, monitor for flexion contracture development 
  
  

• Goals of management of fracture-dislocation of the PIPJ include obtaining and maintaining a reduced joint, reestablishing normal joint motion, allowing early ROM if possible without compromising stability and, when feasible, achieving an anatomic reduction of the articular surface. 
• Several investigators have shown that a small intra-articular step-off can be well tolerated in the setting of a well aligned, reduced joint with no hinging and early initiation of ROM to promote cartilage healing

• A well aligned, reduced joint is essential for acceptable clinical outcome. 

• Injuries requiring > 30° of flexion to maintain stability should undergo surgical stabilization, while those that require < 30° of flexion should be managed nonsurgically.

   

"

Question 127

FDP avulsion to palm includes everything, except?

A. Most common in the ring finger

B. Good results can be expected with repair within 6 weeks

C. Represents the least common form of this injury

D. Often delayed diagnosis

Answer 127

"

Answer: B

Ref: Klifto et al. Flexor Tendon Injuries. JAAOS 2018 

“Jersey finger”

• Ring finger most commonly injured

Zones of Injury:

1. Distal to insertion of FDS

• Injury only to FDP 

1. FDS insertion to A1 pulley (""no man's land"") 
2. Carpal tunnel to A1 pulley 

• Origin of lumbricals from FDP tendon 

1. Carpal Tunnel 
2. Tendinous Portion of Forearm 

• Zone 1 injuries:

• 4 types of FDP avulsions: 
• Type 1:  
• Tendon has retracted into the palm with a rupture 
• Both vincula are disrupted, and the tendon has retracted proximal to the synovial sheath and is therefore devoid of nutrition.
• Tendon must be repaired within 7 days to avoid tendon contracture and necrosis.
• Worst prognosis of all zone I injuries
• Type 2: 
• Tendon retracted to the level of PIP joint 
• Blood supply intact so can be repaired even after a delay 
• The avulsion may be successfully repaired within 6 weeks of injury

• Most common

• Type 3: 
• Avulsion attached to large piece of bone which prevent the tendon from retracting past the distal edge of the A4 pulley. 
• Direct repair may be possible for up to 6 weeks. 
  
  

• Type IV and V injuries were not initially described in the Leddy and Packer classification but were added subsequently.
  
  

• Type 4: 
• Avulsion fracture, but the fracture and avulsion of the FDP tendon from the fracture fragment. FDP retracts to palm.
• When the tendon must be advanced for repair, advancing it >1 cm can cause a quadriga effect.

• Must be repaired urgently 

• Type 5 
• Characterized by a distal phalanx fracture along with bony avulsion of the FDP.

• Zone I injuries can be surgically corrected using different techniques.
• When the stump > 1 cm, a primary end-to-end tendon repair is possible.
• When the tendon stump is < 1 cm long, alternative techniques using pull-out buttons or suture anchors into the bone may be employed.
• No significant difference between technique

• Problems encountered with acute zone I repairs are: 
• Site gapping
• A gap formation of >3 mm decreases the strength of the repair and lead to ultimate failure.
• Unsatisfactory distal joint flexion
• DIP flexion contractures
• PIP joint contracture
• Decreased FDS glide

• Zone I injuries lasting > 6 weeks are considered chronic injuries.
• These injuries are difficult to manage because of tendon retraction and myonecrosis of the muscle belly. 
• When these injuries are reconstructed, loss of PIP motion is a common complication. Most often, patients have a functional PIP joint and may be treated nonsurgically; when they are symptomatic, patients are treated with a DIP arthrodesis.

Summary of Repair algorithm:

• Acute injuries (< 6 weeks)

• > 1cm stump = primary repair
• < 1cm stump = pullout button or anchor

• Chronic injuries (> 6 weeks)

• Non-op, if become symptomatic = DIP arthrodesis

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