FREE Orthopedics MCQS 2022 1551-1600

1551. (2404) Q4-2863:

Slide 1

A 1-year-old boy was born full-term and pregnancy was uneventful. However, the parents noticed deformity of the patientâs forearm, which progressed with growth. The parents consulted a pediatric orthopaedic surgeon 4 months prior and were advised to observe the growth. Multiple investigations in the form of two-dimensional echogram, abdomen ultrasonography, radiographs of the spine, and complete blood work did not reveal any abnormalities. No genetic or syndromic abnormality was reported. A radiograph taken 4 months prior is shown.

1) Postaxial longitudinal deficiency

3) Ulnar agenesis

2) Preaxial longitudinal deficiency

5) C left hand

4) Radial club hand

The ulnar deficiency is longitudinal and the ulna is considered a postaxial bone. Ulnar agenesis means absence while radial club hand is a pre-axial longitudinal deficiency and cleft hand is a central deficiency.

 

■Correct Answer:Postaxial longitudinal deficiency

1552. (2689) Q4-3182:

A 45-year-old man presents with marked lateral elbow pain. He says that the pain has been present for 3 weeks. He has no history of recent trauma. He is an avid tennis player, and he feels increased pain after playing tennis and when doing wrist extension exercises in the gym. His pain is maximally reproduced with resisted middle finger extension and with forearm supination with the elbow extended. Electromyography would confirm the diagnosis as:

1) Radial head fracture

3) Lateral ulnar collateral ligament tear

2) Lateral condyle fracture

5) Radial tunnel syndrome

4) Lateral epicondylitis

The clinical picture is similar to that of lateral epicondylitis. However, the maximal tenderness is slightly more distal, just beyond the radial head. Diagnosis may be confirmed using provocative maneuvers (resisted middle finger extension or forearm supination with the elbow extended) or with electromyography.

■Correct Answer:Radial tunnel syndrome

1553. (2690) Q4-3183:

A 45-year-old man presents with marked lateral elbow pain. He says that the pain has been present for 3 weeks. He has no history of recent trauma. He is an avid tennis player, and he feels increased pain after playing tennis and when doing wrist extension exercises in the gym. His pain is maximally reproduced with resisted middle finger extension and with forearm supination with the elbow extended. Which of the following is the appropriate initial treatment:

1) Open reduction and internal fixation

3) Posterior interosseous nerve decompression

2) Arthroscopic ligament repair

5) Anti-inflammatory medication and a program of muscle strengthening

4) Release of the extensor carpi radialis brevis origin off the lateral epicondyle

Ninety to 95% of all patients with tennis elbow respond to nonoperative treatment, which should always be tried first. Treatment begins with a period of rest, ice, and nonsteroidal anti-inflammatory medications.

■Correct Answer:Anti-inflammatory medication and a program of muscle strengthening

1554. (2691) Q4-3184:

Lateral epicondylitis is associated with a tear in the fibers of which muscle:

1) Extensor carpi radialis brevis (EC RB)

3) Brachioradialis

2) Extensor carpi radialis longus (EC RL)

5) Anconeus

4) Supinator

C urrent consensus is that tennis elbow is associated with a strain or microtear of the EC RB origin, which lies beneath the

EC RL.

■Correct Answer:Extensor carpi radialis brevis (EC RB)

1555. (2692) Q4-3185:

The gold standard for diagnosis of lateral epicondylitis is considered:

1) History and physical examination

3) Electromyography

2) Plain radiographs

5) Radionuclear bone scan

4) Magnetic resonance imaging

The clinical diagnosis of lateral epicondylitis is supported by specific provocative tests. The gold standard for diagnosis is the history and physical examination. Tenderness on examination is localized to the lateral epicondyle, which can radiate into the forearm; the area of maximum tenderness is approximately 2 mm to 5 mm distal and anterior to the midpoint of the lateral epicondyle. There is usually a history of overuse or of a repetitive activity. The pain is aggravated, with the elbow extended, by resisted wrist and finger extension or with passive finger and wrist flexion.

■Correct Answer:History and physical examination

1556. (4055) Q4-3186:

The amount of time that nonoperative management should be followed for lateral epicondylitis is closest to:

1) 1 day

3) 1 month

2) 1 week

5) 6 months or longer

4) 3 months

Ninety to 95% of all patients with tennis elbow respond to nonoperative treatment, and it remains the mainstay for treatment of lateral epicondylitis. Operative treatment may be indicated for debilitating pain in patients without other pathologic causes of pain for whom nonoperative treatment has failed after a reasonable length of time. This time period is usually a minimum of 6 to 12 months.

■Correct Answer:6 months or longer

1557. (2693) Q4-3187:

Extracorporeal shock wave therapy                  in the treatment of lateral epicondylitis in high-quality trials.

1) Is ineffective

3) Has not been tested

2) Is beneficial

5) Improves function

4) Improves short-term pain

C urrent studies have found no benefit of extracorporeal shock wave therapy in the treatment of lateral epicondylitis.C orrect

Answer: Is ineffective

1558. (2768) Q4-3266:

All of the following medications are indicated in the early treatment of frostbite injury except:

1) Ibuprofen

3) Antibiotic prophylaxis

2) Tetanus booster

5) Intravenous beta blocker

4) Narcotic pain medications

Peripheral beta-blockade has minimal effect on peripheral vasculature and is not typically used in patients with frostbite injury. Ibuprofen, tetanus booster, antibiotic prophylaxis, and appropriate pain medication are routinely used in the treatment of frostbite injuries.

■Correct Answer:Intravenous beta blocker

1559. (2769) Q4-3267:

Orthopedic sequelae of frostbite injury include all of the following except:

1) Joint contractures

3) Decreased risk of future frostbite injury

2) Localized osteoporosis

5) C old intolerance

4) Punched-out subchondral bony lesions

People who have had previous frostbite injuries are at increased risk of thermal injury, whether cold or heat related. Joint contractures, localized osteoporosis, punched-out subchondral bony lesions, and cold intolerance are often present after frostbite injury.

■Correct Answer:Decreased risk of future frostbite injury

1560. (2770) Q4-3268:

Initial treatment of an acute frostbite injury should include:

1) Rapid rewarming in circulating 34° C to 36° C water

3) Rapid rewarming in steam

2) Rapid rewarming in circulating 40° C to 42° C water

5) Slow rewarming in room air

4) Slow rewarming with intermittent 50° C to 55° C water

Rapid rewarming in a 40° C to 42° C circulating water bath is the most effective early treatment of frostbite injury. Slow or fast rewarming in other temperatures and/or rewarming in air is not indicated.

■Correct Answer:Rapid rewarming in circulating 40° C to 42° C water

1561. (2771) Q4-3269:

Air temperature below          presents a pronounced risk of frostbite injury.

1) 32° C

3) 0° C

2) 10° C

5) â25° C

4) â10°C

Frostbite will generally not occur above â10° C , but the risk is significantly increased when the air temperature is below â25° C .

■Correct Answer:â25° C

1562. (2772) Q4-3270:

Superficial frostbite injuries result in:

1) Minimal tissue loss

3) Firm tissue

2) Significant tissue loss

5) Hemorrhagic blisters

4) Amputation

Superficial frostbite typically involves minimal tissue loss. Patients have pliable skin with sensation. Deep frostbite typically results in significant soft tissue loss with firm anesthetic tissue that forms hemorrhagic blisters.

■Correct Answer:Minimal tissue loss

1563. (2773) Q4-3271:

All of the following except             increase the risk of frostbite injury.

1) Altitude higher than 17,000 feet

3) Increased humidity

2) History of smoking

5) Peripheral vascular disease

4) Prolonged exposure

High altitudes, prolonged exposure, and anything that would cause peripheral vasoconstriction increase the risk of frostbite injury. Humidity does not play a significant role in the development of frostbite injury.

■Correct Answer:Increased humidity

1564. (2774) Q4-3272:

Treatment for frostbite injury includes:

1) Limiting active motion of the frostbitten area

3) Stopping the rewarming process when there is pain secondary to reperfusion

2) Elevating the frostbitten extremity to reduce edema

5) Massaging the frostbitten area thoroughly to increase perfusion

4) Using dry heat

Treatment of frostbite includes rapid rewarming (even when reperfusion pain occurs), early active motion, elevation, and avoidance of dry heat that can dessicate tissues. Massaging the frostbitten area is not recommended because it may induce additional trauma via shearing forces.

■Correct Answer:Elevating the frostbitten extremity to reduce edema

1565. (2947) Q4-3450:

Arthritis of the wrist is estimated to effect what percentage of the U.S. population:

1) Less than 1%

3) 5%

2) 3%

5) More than 15%

4) 10%

Arthritis of the wrist is estimated to affect 5.3% of the U.S. population, based on radiographic assessments of 4,000 wrists.1  After having rheumatoid arthritis (RA) for 10 years, 90% of patients experience arthritis in their wrist joints.2

 

■Correct Answer:5%

1566. (2948) Q4-3451:

The accessory ulnar collateral ligament inserts on the:

1) Proper ulnar collateral ligament

3) Proximal phalanx

2) Lateral bands

5) Flexor sheath

4) Volar plate

The accessory ulnar collateral ligament inserts into the volar plate, whereas the proper collateral inserts into the base of the proximal phalanx.

■Correct Answer:Volar plate

1567. (3113) Q4-3623:

Which of the following nerves is not a primary articular nerve of the wrist:

1) Posterior interosseous nerve (PIN)

3) Palmar cutaneous branch of the median nerve

2) Lateral antebrachial cutaneous nerve

4) Articular branches from the median nerve

Fukumoto and colleagues have used Wykeâs definition to explain primary and accessory innervation of the wrist. Primary articular nerves consist of small nerves that pass to each joint as independent branches of adjacent peripheral nerves. There are three primary articular nerves: the PIN, the lateral antebrachial cutaneous nerve, and the articular branches from the ulnar nerve. Accessory nerves originate from small, twig branches of intramuscular or cutaneous nerves that innervate the skin around the wrist joint. The accessory articular nerves have been identified as the anterior interosseous nerve (AIN), the palmar cutaneous branch of the median nerve, the deep and dorsal branches of the ulnar nerve, and the superficial branch of the radial nerve to the first intercarpal space.

■Correct Answer:Palmar cutaneous branch of the median nerve

1568. (3114) Q4-3624:

Which of the following nerves provides principal innervation to the central dorsal portion of the wrist:

1) Anterior interosseous nerve (AIN)

3) Dorsal branch of the ulnar nerve

2) Posterior interosseous nerve (PIN)

4) Lateral antebrachial cutaneous nerve

The PIN is found on the deep radial wall of the fourth dorsal compartment, 1.2 cm ulnar to Listerâs tubercle. As the PIN approaches the radiocarpal joint, it is covered in fascia and gives one branch to the radioscaphoid joint and three to four terminal branches to the intercarpal joints. The PIN is the principal innervation to the central dorsal portion of the wrist. The AIN innervates the radial volar lip of the distal radius. The dorsal branch of the ulnar nerve contributes to innervation of the triangular fibrocartilage complex. The lateral antebrachial cutaneous nerve innervates the thumb carpometacarpal joint and the scapho- trapezotrapezoid joint.

■Correct Answer:Posterior interosseous nerve (PIN)

1569. (3115) Q4-3625:

What is the area of innervation of the anterior interosseous nerve (AIN):

1) Radial volar lip of the distal radius

3) Dorsal radiocarpal joint

2) Triangular fibrocartilage complex (TFC C )

4) Thumb carpometacarpal joint

The AIN is a branch of the median nerve. Its muscular innervations include the flexor pollicis longus, the radial half of the flexor digitorum profundus, and the pronator quadratus. The AIN terminates as a sensory branch to the volar radial surface of the distal radius. The TFC C is innervated by components of the ulnar nerve. The dorsal radiocarpal joint is innervated by the posterior interosseous nerve. The thumb carpometacarpal is innervated by the sensory branch of the radial nerve and the lateral antebrachial cutaneous nerve.

■Correct Answer:Radial volar lip of the distal radius

1570. (3116) Q4-3626:

When performing complete wrist denervation as described by Wilhem, what pain pathology did not have predictable results:

1) Scaphoid nonunion

3) Primary radiocarpal arthritis

2) Osteonecrosis of the scaphoid

4) Ulnar carpal arthritis

In 1983, Ekerot and colleagues reported his results in 48 patients. They used the technique described by Wilhelm but only denervated the radial side of the wrist for patients with scaphoid or lunate pathology. However, the entire wrist was denervated in patients with global degenerative wrist disease or wrist pain with an unknown etiology. Pain relief occurred in only 56% of the patients. They noted the best results occurred in patients with scaphoid nonunion, osteonecrosis of the lunate, and primary radiocarpal arthritis.

■Correct Answer:Ulnar carpal arthritis

1571. (3117) Q4-3627:

What two nerves are resected through a single dorsal incision for wrist denervation:

1) Superficial branch of the radial nerve and posterior interosseous nerve (PIN)

3) PIN and anterior interosseous nerve (AIN)

2) PIN and the dorsal cutaneous branch of the ulnar nerve

4) Superficial branch of the radial nerve and dorsal cutaneous branch of the ulnar nerve

Kupfer and colleagues presented a podium presentation of a single-incision approach to the resection of the PIN and AIN for denervation of the radial side of the wrist. Weinstein and Berger published their results in 2002 with a similar technique. They described a 2-cm long dorsal incision that was 3 to 5 cm proximal to the ulnar head. They then resected a 2-cm segment of the PIN and AIN. In their group of 20 patients, 85% were satisfied with their procedure after an average follow-up of 2.5 years. If failure were to occur, it occurred within the first year.

■Correct Answer:PIN and anterior interosseous nerve (AIN)

1572. (3118) Q4-3628:

What muscle is at risk for denervation when a single dorsal incision is used to denervate the radial side of the wrist:

1) Flexor pollicis longus

3) Flexor digitorum profundus

2) Extensor indicis

4) Pronator quadratus

The single dorsal incision approach to wrist denervation involves resection of the posterior interosseous nerve (PIN) and the anterior interosseous nerve (AIN). Distally, the PIN is purely sensory and does not give off motor branches in the vicinity of the wrist joint. The terminal portion of the AIN has both motor and sensory components. A majority of this is motor, and it innervates the pronator quadratus right up to the radiocarpal articulation. Resection of the AIN close to the radiocarpal joint has a high probability of denervating the pronator quadratus. The extensor indicis is usually the last motor branch of the PIN, but this terminal portion of this branch is more than 5 cm proximal from the distal radioulnar joint. The flexor pollicis longus is innervated by the AIN, but motor branches to this muscle are more proximal than branches to the pronator quadratus. The flexor digitorum profundus muscle is innervated by the AIN and ulnar nerve. However, the motor branches are more proximal than the incision for dorsal innervation.

■Correct Answer:Pronator quadratus

1573. (3176) Q4-3995:

A 62-year-old man presents with weakness in finger extension in his right hand. He has had the weakness for 1 month but denies any significant traumatic event. The patient maintains an active lifestyle, including golf and tennis. He denies pain or numbness in his hand and is otherwise neurologically intact. Which of the following is the most likely diagnosis:

1) Thoracic outlet syndrome

3) Ulnar nerve palsy

2) Posterior interosseous nerve palsy

5) Radial nerve palsy

4) C arpal tunnel syndrome

Posterior interosseous nerve palsy is described as painless finger drop. This syndrome is commonly associated with trauma to the lateral elbow.

■Correct Answer:Posterior interosseous nerve palsy

1574. (3177) Q4-3996:

Which of the following are characteristic signs of PIN palsy:

1) Weakness in finger extension

3) Elbow tenderness

2) Pain in dorsum of hand

5) Weakness in finger extension, elbow tenderness, and pain in dorsum of hand

4) Weakness in finger extension, and elbow tenderness

Painless finger drop is characteristic of posterior interosseous nerve palsy. This syndrome may also involve elbow tenderness in the absence of other clinical findings. Pain in the dorsum of the hand is not associated with this condition because the posterior interosseous nerve contains no sensory component.

■Correct Answer:Weakness in finger extension, and elbow tenderness

1575. (3178) Q4-3997:

What is the most common site of posterior interosseous nerve entrapment:

1) The arcade of Frohse

3) The first cervical rib

2) The flexor retinaculum

5) Ligament of Struthers

4) In the spiral groove of the humerus

The most common site of posterior interosseous nerve entrapment is at the arcade of Frohse, which is a fibrotendinous ring found within the fibers of the supinator muscle as the posterior interosseous nerve originates from the radial nerve.

■Correct Answer:The arcade of Frohse

1576. (3179) Q4-3998:

Which of the following muscles is innervated by the posterior interosseous nerve:

1) Extensor carpi ulnaris

3) Extensor pollicis brevis and longus

2) Extensor digiti minimi

5) All of the above

4) Abductor pollicis longus

The posterior interosseous nerve innervates a number of muscles involved primarily in finger extension, including the extensor carpi ulnaris, extensor digitorum, extensor digiti minimi, extensor pollicis brevis and longus, abductor pollicis longus, and extensor indices.

■Correct Answer:All of the above

1577. (3180) Q4-3999:

Posterior interosseous nerve palsy affects finger extension at the metacarpophalangeal and interphalangeal joints.

1) True

2) False

Only the metacarpophalangeal joints are involved in posterior interosseous nerve palsy, as the muscles of the interphalangeal joints are innervated by the ulnar and median nerves.

■Correct Answer:False

1578. (3181) Q4-4000:

A 53-year-old woman presents with bilateral hand numbness and tingling. Her right hand is more affected than her left. The numbness wakes her up at night and is relieved when she shakes her hand. In addition, the patient has had increasing difficulty with fine motor tasks, such as shirt buttoning, over the past 2 to 3 months. Upon close inspection, muscle atrophy is present at the base of her thumbs. Which of the following is the most likely diagnosis:

1) Thoracic outlet syndrome

3) Ulnar nerve palsy

2) Posterior interosseous nerve palsy

5) Radial nerve palsy

4) C arpal tunnel syndrome

This patient displays the classic signs and symptoms of bilateral carpal tunnel syndrome, which involves median nerve entrapment at the base of the palm. This entrapment leads to numbness and dysesthesias that are worse at night and upon exertion. Pain is typically relieved by shaking the hand. Furthermore, the median nerve innervates several muscles of the hands, and entrapment may lead to muscle atrophy.

■Correct Answer:C arpal tunnel syndrome

1579. (3182) Q4-4001:

All of the following muscles are innervated by the median nerve except:

1) The ulnar two lumbricals (lumbricals III and IV)

3) Abductor pollicis brevis

2) Opponens pollicis

5) Flexor digitorum profundus to the middle finger

4) Flexor pollicis brevis

Lumbricals 1 and 2 are innervated by the median nerve, in addition to the opponens pollicis brevis, abductor pollicis brevis, and flexor pollicis brevis.

■Correct Answer:The ulnar two lumbricals (lumbricals III and IV)

1580. (3183) Q4-4002:

C arpal tunnel syndrome is typically due to median nerve entrapment at the:

1) Arcade of Frohse

3) First cervical rib

2) Flexor retinaculum

5) Ligament of Struthers

4) Spiral groove of the humerus

The carpal tunnel is made by the flexor retinaculum, also known as the transverse carpal ligament.

■Correct Answer:Flexor retinaculum

1581. (3184) Q4-4003:

All of the following are true regarding the transverse carpal ligament except:

1) The transverse carpal ligament attaches medially to the pisiform and hook of hamate.

3) The palmaris longus tendon lies superficially to the transverse carpal ligament.

2) The transverse carpal ligament attaches laterally to the scaphoid and trapezium.

5) None of the above are true

4) All of the above are true

All of the above statements are true regarding the transverse carpal ligament.

■Correct Answer:All of the above are true

1582. (3185) Q4-4004:

All of the following structures pass through the carpal tunnel except:

1) Motor branch of the median nerve

3) Palmar cutaneous branch of median nerve

2) Tendon of the flexor pollicis longus

5) Tendon of the flexor digitorum sublimes

4) Tendon of the flexor digitorum profundus

The palmar cutaneous branch of the median nerve originates proximally to the carpal tunnel and travels superficial to the tunnel.

■Correct Answer:Palmar cutaneous branch of median nerve

1583. (3628) Q4-6515:

Dupuytrenâs contracture characteristically involves which part of the hand:

1) Ulnar side of the hand

3) Radial side of the hand

2) Thumb

5) Web space between the first and second metacarpals

4) Extensor tendons

Dupuytrenâs contracture most frequently involves the ring and small fingers. Although Dupuytrenâs cords at the thumb have been described, they are rare.

■Correct Answer:Ulnar side of the hand

1584. (3629) Q4-6516:

Which of the following cells are involved in Dupuytrenâs contracture:

1) Giant cells

3) Fibrocytes

2) Polymorphonuclear cells

5) Myocytes

4) Myofibroblasts

Gabbiani and Majno noted the abnormal appearance of fibroblasts found in patients with Dupuytrenâs contracture. They used the term myofibroblasts to describe these cells because they showed characteristics of fibrous and muscular tissue.

■Correct Answer:Myofibroblasts

1585. (3630) Q4-6517:

All of the following are contributory risk factors to the development of Dupuytrenâs contracture except:

1) Diabetes mellitus

3) Tobacco use

2) Hypertension

5) Human immunodeficiency virus (HIV)

4) Alcohol abuse

No association exists between high blood pressure and Dupuytrenâs disease, but all of the other listed conditions have been associated with Dupuytrenâs contracture. HIV has recently been described as a risk factor; patients with Dupuytrenâs contracture have been in advanced stages of HIV.

■Correct Answer:Hypertension

1586. (3631) Q4-6518:

The use of clostridial collagenase for Dupuytrenâs contracture is performed by:

1) Injecting collagenase into the affected joint

3) Performing a subcutaneous wheal injection of collagenase

2) Injecting collagenase into the Dupuytrenâs cord

5) Applying collagenase to the Dupuytrenâs cords during surgery

4) Using a patch of collagenase on the skin

C lostridial collagenase works by breaking the collagen connections. The Dupuytrenâs cord is ruptured manually; surgery is not necessary.

■Correct Answer:Injecting collagenase into the Dupuytrenâs cord

1587. (3632) Q4-6519:

Dupuytrenâs cord tissue is characterized by what change from normal:

1) An increase in type II collagen

3) An increase of type III collagen

2) A decrease in type III collagen

5) Increased hyaluronidase

4) Abnormal collagen crosslinks

C ompared to normal palmar fascia, the fibrous bands in Dupuytrenâs disease have an increased ratio of type III to type I

collagen, and an overall increase in the amount of type III collagen.

■Correct Answer:An increase of type III collagen

1588. (3633) Q4-6520:

The strongest portion of the scapholunate interosseous ligament (SLIL) is the:

1) Proximal

3) Volar

2) Distal

5) Dorsal intercarpal

4) Dorsal

The SLIL is a c-shaped structure, which is thickest dorsally. The dorsal fibers have an average thickness of 3 mm and are composed of transversely oriented fibers, which afford the greatest resistance to translation between the scaphoid and the lunate, preventing the characteristic radiographic separation and flexion deformity of the scaphoid.

■Correct Answer:Dorsal

1589. (4063) Q4-6521:

A 29-year-old man with a remote history of wrist trauma and chronic pain presents with a palpable clunk on radio-ulnar deviation of the wrist. The most sensitive technique for identifying a scapholunate injury is:

1) Plain radiographs

3) Dynamic cineradiography

2) Magnetic resonance image (MRI)

5) Arthroscopy

4) Bone scan

Magnetic resonance imaging is commonly used among patients with concern for ligamentous injuries of the wrist, particularly in the presence of an abnormal physical exam when plain radiographs are normal. However, the sensitivity of MRI has been shown to be less than 40% in comparison with arthroscopy. Arthroscopy has become the gold standard for the diagnosis of ligamentous injuries to the wrist. A classification scheme has been proposed based on both radiocarpal and midcarpal arthroscopic findings.

■Correct Answer:Arthroscopy

1590. (3634) Q4-6522:

The radiographic abnormality seen on the lateral radiograph characteristic of scapholunate instability is:

1) Dorsal intercalated segment instability (DISI)

3) Terry Thomas sign

2) Volar intercalated segment instability (VISI)

5) Abnormal Gilulaâs arcs

4) Ring pole sign

On a lateral view of the wrist, when the lunate slips into a statically dorsiflexed position greater than 10°, the condition is defined as dorsal intercalated segmental instability (DISI). DISI deformity is also present when the scapholunate angle is greater than 60 degrees (45+/- 15 degrees is normal). The VISI deformity is seen on the lateral radiograph is characteristic of lunotriquetral dissociation. The other signs are seen on the anteroposterior projection.

■Correct Answer:Dorsal intercalated segment instability (DISI)

1591. (3635) Q4-6523:

A 40-year-old woman with radial sided wrist pain for the last 2 years presents to the clinic. Plain radiographs are normal. Because of continued discomfort despite conservative therapies and occasional âclickingâ of the wrist, she is taken to the operating room for diagnostic arthroscopy. At the time, fraying of the membranous portion of the scapholunate (SL) ligament is seen, with mild incongruity from the midcarpal joint. The surgeon is unable to pass a 1-mm probe through the defect. This is most consistent with:

1) Geissler Grade I SL tear

3) Geissler Grade III tear

2) Geissler Grade II SL tear

5) Scapholunate advanced collapse (SLAC ) wrist

4) Geissler Grade IV tear

Arthroscopy has become the gold standard for the diagnosis of ligamentous injuries to the wrist. A classification scheme has been proposed by Geissler and colleagues, based on both radiocarpal and midcarpal arthroscopic findings (Table).

Table. Arthroscopic C lassification of Interosseous Ligament Injury1 1

Grade                  Findings

I                     Attenuation of the interosseous ligament with no radiocarpal or midcarpal step-off

II                    Incongruence of the scapholunate interval seen from the midcarpal joint

III                   C omplete separation of scaphoid and lunate visualized from both spaces;

a 1-mm probe can be passed between the two bones

IV                      Ability to pass 2.7-mm arthroscope between the scapholunate interval

 

■Correct Answer:Geissler Grade II SL tear

1592. (3636) Q4-6524:

A 33-year-old woman with a history of a traumatic fall onto her wrist and tenderness over the scapholunate (SL) interval presents to the clinic. Radiographs are normal, and magnetic resonance imaging reveals a partial tear of the SL ligament. The remaining wrist ligaments are normal. If conservative therapy is attempted, then it should consist of:

1) Short arm casting for 2 months

3) Splinting and flexor carpi radialis training

2) Activity modification and wrist extension stretching

5) C orticosteroid injection into the midcarpal space

4) Splinting and flexor carpi ulnaris training

C onservative management includes a period of splinting and activity modification, followed by proprioception training of the flexor carpi radialis to act as a dynamic scaphoid stabilizer.

■Correct Answer:Splinting and flexor carpi radialis training

1593. (3662) Q4-7439: C ongenital thumb duplication:

1) Should be treated after 2 years of age

3) Usually presents in association with other systemic abnormalities

2) Usually presents bilaterally

5) Occurs in approximately 1 out of every 5,000 births

4) Often presents with a hypoplastic radial thumb and a dominant-appearing ulnar thumb

Experts recommend treating congenital thumb duplication before the age of 6 months, when the potential for growth and remodeling is greatest. The condition usually presents unilaterally, lacking association with other systemic abnormalities, and usually presents with a hypoplastic radial duplicate and dominant ulnar duplicate.

■Correct Answer:Often presents with a hypoplastic radial thumb and a dominant-appearing ulnar thumb

1594. (3663) Q4-7440:

C omplete bifurcation of two distal phalanges articulating with a wide epiphysis of a single proximal phalanx is classified as:

1) Wassel II / IP

3) Wassel IV / MC P

2) Wassel III / IP

5) Wassel I/ Distal

4) Wassel IV / IP

Wassel II (also categorized as IP in the universal classification system) occurs when the duplication begins at the interphalangeal joint of the thumb, resulting in complete bifurcation of two distal phalanges that articulate proximally with a single proximal phalanx.

■Correct Answer:Wassel II / IP

1595. (3664) Q4-7441:

One of the more common complications of congenital thumb duplication reconstruction is:

1) Weakness of resulting digit

3) Ulnar deviation at metacarpophalangeal joint and radial deviation at interphalangeal joint

2) Paresthesias in resulting digit

5) Nail splitting

4) Nonhealing wound

A Z-deformity, with ulnar deviation at the MC P joint and radial deviation at the IP joint, is one of the most common complications after reconstruction. Weakness, paresthesias, and wound complications are uncommon possible complications.

■Correct Answer:Ulnar deviation at metacarpophalangeal joint and radial deviation at interphalangeal joint

1596. (3850) Q4-7633:

Ultrasound therapy delivers superficial heat to the tissue and has a penetration depth of 5 mm.

1) True

2) False

Ultrasound is considered a deep heat modality and does not heat the superficial tissues. 

■Correct Answer:False

1597. (3851) Q4-7634:

Thermal ultrasound is used for all of the following purposes EXC EPT:

1) Increasing capsular extensibility

3) Increasing pain threshold

2) Decreasing scar

5) Increasing ligament stretch ability

4) Reversing Dupuytrenâs contracture

Thermal uses of ultrasound include increasing pain threshold, decreasing scar, and improving extensibility of the ligaments and joint capsule. Ultrasound has not been shown to have an effect in Dupuytrenâs contracture.

 

■Correct Answer:Reversing Dupuytrenâs contracture

1598. (3852) Q4-7635: Phonopheresis is:

1) Delivery of heat to the tissues with a special oval-shaped attachment

3) Delivery of medicine through the skin using ultrasound

2) Aspiration of blood with concentration of platelets for re-injection

5) Delivery of substimulus auditory waves to the tissue

4) Using ultrasound in a rapid, deep massage-type application

Phonopheresis is delivery of medicine through the skin using ultrasound. Although there is some question as to whether the medications are more effectively absorbed or delivered with ultrasound use, this is a described modality.

 

■Correct Answer:Delivery of medicine through the skin using ultrasound

1599. (3853) Q4-7636:

Iontophoresis delivers medications such as analgesics or steroids through the skin using an electrical charge.

1) True

2) False

Iontophoresis uses a direct or galvanic current to âdriveâ medications transdermally and is used for scar management and pain control.

 

■Correct Answer:True

1600. (3854) Q4-7637:

Iontophoresis has been effectively used in all of the following EXC EPT:

1) C arpal tunnel syndrome

3) Shoulder/rotator cuff tendinitis

2) Wrist arthritis

5) Medial epicondylitis

4) Lateral epicondylitis

Iontophoresis is effective in soft tissue conditions such as rotator cuff bursitis and lateral epicondylitis. 

■Correct Answer:Wrist arthritis