ORTHOPEDIC MCQS ONLINE QUESTION BANK H1E

ORTHOPEDIC MCQS ONLINE QUESTION BANK H1E

1411. (1764) Q4-2162:

All of the following are characteristic of hemangiomas except:

 

1) 70% of hemangiomas are visible by 4 weeks of age

3) Hemangiomas are three times more common in woman than men

2) 70% of hemangiomas regress by 7 years of age

5) None of the above

4) All cavernous hemangiomas regress by 12 years of age

 

Cavernous hemangiomas are noninvoluting hemangiomas and require surgical excision.Correct Answer: All cavernous hemangiomas regress by 12 years of age

 

 

1412. (1765) Q4-2163:

Pseudoaneurysms differ from true aneurysms in that:

 

1) Pseudoaneurysms are expansile.

3) Pseudoaneurysms have a fibrous wall.

2) Pseudoaneurysms occur secondary to trauma.

4) Pseudoaneurysms frequently occur in the ulnar artery.

 

Pseudoaneurysms occur secondary to penetrating trauma and have a fibrous wall, compared to true aneurysms that have all the elements of an arterial wall.Correct Answer: Pseudoaneurysms have a fibrous wall.

 

 

1413. (1766) Q4-2164:

Neurofibromas are characterized by all of the following except:

 

1) Café-au-lait spots

3) Dumbbell tumors

2) Axillary freckles

5) Characteristic oval avascular tumor in continuity with nerve trunk

4) Ease of surgical excision

 

Neurofibromas are benign tumors of neural origin that are transmitted as an autosomal dominant trait with variable penetrance. Neurofibromas are associated with cutaneous manifestations like cafe-au-lait spots and axillary freckles. They may be dumbbell shaped and can be identified with magnetic resonance imaging, which is especially helpful for deeper multiple lesions. They are infiltrative, making excision with preservation of peripheral nerve function difficult thus requiring bridge grafting for significant motor or sensory funtional requirements.Correct Answer: Ease of surgical excision

 

 

1414. (1767) Q4-2165:

Recklinghausenâs disease is associated with all of the following except:

 

1) Diffuse neurofibromatosis

3) High potential for malignant degeneration

2) Schwannoma

5) None of the above

4) Plexiform growth

 

Diffuse neurofibromatosis is a separate clinical presentation and is not associated with Recklinghausenâs disease.Correct Answer: Diffuse neurofibromatosis

 

 

1415. (1768) Q4-2166:

Schwannomas are differentiated from neurofibromas by all of the following except:

 

1) Ease of excision

3) Absence of fascicles

2) Eccentric location on the nerve

5) None of the above

4) Presence of schwann cells

 

Schwann cells contribute to schwannoma and neurofibroma.Correct Answer: Presence of schwann cells

 

1416. (1769) Q4-2167:

All of the following are true for infantile digital fibroma except:

 

1) 80% of infantile digital fibroma cases appear by 1 year of age

3) Intracytoplasmic inclusion bodies are present

2) Infantile digital fibroma is exclusive to fingers and toes

5) Recurrent disease never implies malignant transformation

4) Wide local excision is curative

 

Eighty percent of infantile digital fibromata appear before a child's first birthday. They are exclusive to the fingers and toes and are usually painless. Infantile digital fibromata are often small and the same color as the skin. On histological examination, intracytoplasmic inclusion bodies are present. Although benign, the fibromata are locally aggressive. They do not metastaaize, but recurrences after wide local excision are common. Surgery is indicated when deformity or contracture is imminent.Correct Answer: Wide local excision is curative

 

 

1417. (1770) Q4-2168:

Felon complications include all of the following except:

 

1) Phalangeal osteomyelitis

3) Collar button abscess

2) Suppurative flexor tenosynovitis

5) Nailbed deformity

4) Distal interphalangeal joint septic arthritis

 

Felons that are chronic or neglected may penetrate adjacent structures such as the distal phalanx, nailbed, or distal interphalangeal joint. They can also contribute to the formation of a pyogenic flexor tenosynovitis. Collar button abscesses are localized to web space. They typically arise from direct inoculation, not from distant felons.Correct Answer: Collar button abscess

 

 

1418. (1771) Q4-2169:

Which of the following is not a classic Kanavel sign of flexor tenosynovitis:

 

1) Pain on passive extension

3) Tenderness of flexor sheath

2) Flexion attitude of the finger

5) Fusiform swelling of the entire finger

4) Anesthesia of the fingertip

 

The cardinal signs of flexor tenosynovitis described by Kanavel include pain on passive extension, flexion attitude of the finger, tenderness of flexor sheath, and swollen finger.Correct Answer: Anesthesia of the fingertip

 

 

1419. (1772) Q4-2170:

Septic flexor tenosynovitis may involve all of the following areas except the:

 

1) Radial bursa

3) Paronaâs space

2) Thenar space

5) Ulnar bursa

4) Snuffbox

 

The radial and ulnar bursae are extensions of the tendon sheaths of the flexor pollicis longus and the flexor digitorum profundus of the small fingers. They can easily be involved in a case of pyogenic flexor tenosynovitis. Although not direct extensions of the flexor sheaths, the thenar space and Parona's space are adjacent to the flexor sheaths and can be involved in suppurative conditions. The snuffbox, however, does not have any contributions from the flexor system and is not usually involved in cases of pyogenic flexor tenosynovitis.Correct Answer: Snuffbox

 

Regarding the management of web space abscess, which of the following statements is not true:

 

1) Transverse incisions should be used.

3) Drains are often used following evacuation.

2) Wounds may be left open.

5) Thorough debridement of the dead muscle is required.

4) Early motion must be encouraged.

 

Transverse incisions can lead to contractures that limit finger abduction. Leaving wounds open allow for continued drainage. If preferred, closed suction drains can be used after closure of the wound. All devitalized tissue must be debrided and all signs of infection removed and irrigated copiously. Early motion is encouraged to prevent stiffness.Correct Answer: Transverse incisions should be used.

 

 

1421. (1774) Q4-2172:

Meleneyâs infection is a:

 

1) Spreading ulcer rimmed with gangrenous skin

3) Dry gangrene with superimposed infection

2) Patchy gangrenous involvement of the hand

5) Creates a sinus fistula to the midcarpal space

4) Multiple infective ulcer of the forearm

 

Found in necrotizing fasciitis, Meleneyâs infection is a spreading ulcer rimmed with gangrenous skin. The affected area must be debrided immediately. Cultures are taken at the time of surgery to tailor antibiotic coverage. Amputation is not unusual to control the spread of the gangrenous infection.Correct Answer: Spreading ulcer rimmed with gangrenous skin

 

 

1422. (1775) Q4-2173:

Meleneyâs infection is caused by:

 

1) Streptococcus viridans

3) Microaerophyllic non-hemolytic streptococci

2) Aerobic hemolytic staphylococci

5) Staphylococcus aureus

4) B & C

 

Aerobic hemolytic staphylococci and microaerophyllic non-hemolytic streptococci synergistically act to produce Meleneyâs infection. Meleney's infection is a gangrenous infection that often results after a small injury. The infection is characterized by significant, rapid swelling with gangrenous changes.Correct Answer: B & C

 

 

1423. (1776) Q4-2174:

The most common pathogen for osteomyelitis of phalanges is:

 

1) Staphylococcus aureus

3) Haemophilus influenzae

2) Streptococci

5) Pasturella multocida

4) Mix of gram-negative and gram-positive organisms

 

Staphylococcus aureus is the most common pathogen that causes osteomyelitis in the hand. Most cases of osteomyelitis in the hand are due to direct extension. Other pathogens can be found if there is a contaminated injury that penetrates directly into the bone. H. infuenza , mixed pathogens, and Pasturella multocida are less likely causes of osteomyelitis and are often caused by direct inoculation injuries or bites.Correct Answer: Staphylococcus aureus

 

The most common pathogen causing septic arthritis in the hand is:

 

1) Staphylococcus aureus

3) Haemophilus influenzae

2) Streptococci

5) Atypical mycobacterium

4) Mix of gram-negative and gram-positive organisms

 

Staphylococcus aureus is the most common pathogen that causes septic arthritis in the hand. The second most common pathogen is streptococcus species infections, which are often the result of trauma. Treatment includes incision and drainage with copius irrigation.Correct Answer: Staphylococcus aureus

 

 

1425. (1778) Q4-2176:

"Collar button" abscess refers to:

 

1) Web space infection

3) Extension of infection from mid-palmar space to Paronaâs space in the forearm

2) Finger pulp infection

5) Septic joint with dorsal and palmar extension

4) Eponychial infection

 

Collar button abscess is an infection of web space and is usually a result of penetrating trauma. Treatment of such abscesses requires incision and drainage through dorsal and palmar incisions. Care must be taken to avoid the neurovascular bundles. Finger pulp infections are known as felon. Infections involving Parona's space is typically involved in a horseshoe abscess.

Eponychial infections are limited to the nail fold. Collar button abscesses do not include joint involvement.Correct Answer: Web space infection

 

 

1426. (1779) Q4-2177:

A 35-year-old woman is bitten on her left index finger by a snake in her backyard. Management of snake bites includes all of the following except:

 

1) Keeping the patient emotionally and physically still

3) Identifying the snake

2) Applying a tourniquet

5) Call immediately for help

4) Injecting antivenin locally based on recommended guidelines

 

There are different snake bite protocols depending on the species of snake. However, common steps in all snake bite protocols include keeping the patient emotionally and physically still, calling for help immediately, applying a moderately tight tourniquet proximally to prevent further spread of venom, and capture or identification of the snake. Local injection of the antivenin in the fingers or toes is contraindicated.Correct Answer: Injecting antivenin locally based on recommended guidelines

 

 

1427. (1780) Q4-2178:

Cardinal signs of evenomation include all of the following except:

 

1) Fang marks

3) Pain

2) Cyanosis

5) Ascending lymphangitis

4) Swelling

 

The cardinal signs of evenomation appear between 10 minutes and 4 hours after a person is bitten. The signs include fang marks, pain, swelling, and local necrosis. Cyanosis is not considered a cardinal sign of evenomation.Correct Answer: Cyanosis

 

All of the following nerves are involved in infection with Mycobacterium leprae except the:

 

1) Ulnar nerve at the elbow

3) Supraorbital nerve

2) Median nerve in the carpal tunnel

5) Spinal accessory nerve

4) Vagus nerve

 

Mycobacterium leprae causes skin, nerve, and tendon sheath infections. M leprae commonly affects the hands because it has a predilection for cool parts of the body. M leprae causes neuropathy, which frequently involves the ulnar nerve at the elbow and the median nerve at the wrist. The resulting limb deformities require various surgical procedures. Cranial nerves and autonomic nerves are not affected.Correct Answer: Vagus nerve

 

 

1429. (1782) Q4-2180:

A 24-year-old white man presents to the emergency department. He was bitten on his fist while fighting with another man. You notice teeth marks on the dorsum of the metacarpophalangeal (MCP) joint of the right middle finger. The bite does not appear to be deep because the joint is not exposed, and you can see the extensor tendon, which seems intact. The patient has active extension at the MCP joint. The wound is red and swollen, but there is no tenderness or redness on the volar aspect of the MCP joint. The patient has some limitation in range of motion. He is afebrile. Radiographs reveal air in the joint but no joint dislocation or fracture, and there is no neurovascular deficit. All of the following are appropriate steps in the management of this patient except:

 

1) Injection of tetanus toxoid

3) Exploration for air in the joint

2) Closure of the wound

5) Splinting

4) Admitting the patient for observation and intravenous antibiotics

 

Human bite wounds on the hand are typically found over the MP joint. The mechanism of injury is a clenched-fist blow to the mouth. Oral flora enters the wound, which often communicates with the joint. Eikenella corrodens is frequently cultured from human bite wounds, but the most common pathogen is staphylococcus aureus. Appropriate treatment includes the administration of tetanus toxoid, exploration if there is air in the joint or frank infection, observation, intravenous antibiotics, arm elevation, and splinting. All bites over joints should be assumed to penetrate and require formal incision and drainage.Correct Answer: Closure of the wound

 

 

 

1430. (1783) Q4-2181:

A 24-year-old man presents to the emergency department. He was bitten on his fist while fighting with another man. You notice teeth marks on the dorsum of the metacarpophalangeal (MCP) joint of the right middle finger. The bite does not appear to be deep because the joint is not exposed, and you can see the extensor tendon, which seems intact. The patient has active extension at the MCP joint. The wound is red and swollen, but there is no tenderness or redness on the volar aspect of the MCP joint. The patient has some limitation in range of motion. He is afebrile. Radiographs reveal soft tissue involvement but no joint dislocation or fracture, and there is no neurovascular deficit. An important step in assessment of human bites is:

 

1) Evaluation for tendon injury in clenched-fist position

3) Ultrasound to rule out septic arthritis

2) Bone scan to rule out osteomyelitis

5) None of the above

4) Monitoring finger girth to document progress

 

Evaluation for tendon injury in a clenched-fist position is essential because tendons slide proximally in the open-hand position. Involvement of tendon or joint usually necessitates surgical debridement.Correct Answer: Evaluation for tendon injury in clenched-fist position

 

A 24-year-old white man presents to the emergency department. He was bitten on his fist while fighting with another man. You notice teeth marks on the dorsum of the metacarpophalangeal (MCP) joint of the right middle finger. The bite does not appear to be deep because the joint is not exposed, and you can see the extensor tendon, which seems intact. The patient has active extension at the MCP joint. The wound is red and swollen, but there is no tenderness or redness on the volar aspect of the MCP joint. The patient has some limitation in range of motion. He is afebrile. Radiographs reveal soft tissue involvement but no joint dislocation or fracture, and there is no neurovascular deficit. After cultures are taken, the next important step in treatment is:

 

1) Debridement in the emergency department and suture

3) Admit and administer IV antibiotics

2) Single dose intravenous (IV) antibiotics and discharge on oral antibiotics with follow-up instructions

5) None of the above

4) Patient work up for human immunodeficiency virus

 

A patient with a human bite must be admitted for IV antibiotics and observation. If left untreated, human bites are commonly infected by a mixed flora of organisms. Therefore, they must be treated diligently.Correct Answer: Admit and administer IV antibiotics

 

 

1432. (1785) Q4-2183:

A 24-year-old white man presents to the emergency department. He was bitten on his fist while fighting with another man. You notice teeth marks on the dorsum of the metacarpophalangeal (MCP) joint of the right middle finger. The bite does not appear to be deep because the joint is not exposed, and you can see the extensor tendon, which seems intact. The patient has active extension at the MCP joint. The wound is red and swollen, but there is no tenderness or redness on the volar aspect of the MCP joint. The patient has some limitation in range of motion. He is afebrile. Radiographs reveal soft tissue involvement but no joint dislocation or fracture, and there is no neurovascular deficit. The most appropriate antibiotic treatment includes:

 

1) Imipenam and ciprofloxacin

3) Amoxicillin and ciprofloxacin

2) Cefotaxime and ciprofloxacin

5) Bactrim and rifampin

4) Amoxicillin and flocloxacillin

 

Imipenam and ciprofloxacin provide treatment for gram-negative and gram-positive organisms.Correct Answer: Imipenam and ciprofloxacin

 

 

1433. (1786) Q4-2184:

Which of the following organisms is most likely found in a cat bite:

 

1) Eikenella corrodens

3) Micrococcus

2) Pasteurella multocida

5) None of the above

4) Borrelia recurrentis

 

Pasteurella multocida is the most common organism found in animal bites.Correct Answer: Pasteurella multocida

 

 

1434. (1787) Q4-2185:

Which of the following is the atypical mycobacterium that infects a penetrating wound sustained in an aquatic environment:

 

1) Mycobacterium avium

3) Mycobacterium aquaticum

2) Mycobacterium marinum

5) Mycobacterium chelorei

4) Mycobacterium tuberculosis hominis

 

Tuberculosis is the most common chronic infection found in the hand. Mycobacterium marinum is the atypical mycobacterium that can infect a wound sustained in a marine environment, freshwater lake, or tropical fish tanks. It is also called swimming pool granuloma or fish tank granuloma.Correct Answer: Mycobacterium marinum

 

Which of the following is not true for infections caused by Mycobacterium marinum:

 

1) Noncaseating granuloma is present.

3) Lowenstein-Jensen media can be used for cultures.

2) Minocycline is the preferred treatment.

5) It is also referred to as fish tank granuloma.

4) Painful swelling of digit, palm, or wrist is present with redness, warmth, and tenderness.

 

Tuberculous infections are chronic infections and do not produce acute signs of inflammation. Therefore, pain and tenderness are present in these infections but warmth and redness are absent. Abscesses produced in tuberculous infections are termed "cold abcesses."Correct Answer: Painful swelling of digit, palm, or wrist is present with redness, warmth, and tenderness.

 

 

1436. (1967) Q4-2379:

Which of the following fascial structures does not contribute to the formation of the spiral cord:

 

1) Pretendinous band

3) Graysonâs ligament

2) Lateral digital sheet

5) Spiral band

4) Clelandâs ligament

 

The pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament are all parts of the normal fascia that contribute to the formation of the spiral cord. Cleland's ligament is not involved at all in the disease process.Correct Answer: Clelandâs ligament

 

 

1437. (1968) Q4-2380:

Which of the following structures contribute to the formation of the spiral cord:

 

1) Pretendinous band, Graysonâs ligament, and Clelandâs ligament

3) Pretendinous band, Landsmeer ligament, and Graysonâs ligament

2) Pretendinous band, lateral digital sheet, and Graysonâs ligam

5) Cleland's ligament and Grayson's ligament

4) Pretendinous band, Landsmeer ligament, and natatory ligament

 

The spiral cord is formed from the pretendinous band, spiral band, Grayson's ligament, and lateral digital sheet. Cleland's ligament is not affected in Dupuytren's contracture. Remember that bands and ligaments give rise to cords, which are the diseased state.Correct Answer: Pretendinous band, lateral digital sheet, and Graysonâs ligam

 

 

1438. (1969) Q4-2381:

Surgical release in Dupuytrenâs disease is indicated in which of the following:

 

1) A 15 metacarpophalangeal (MP) joint contracture and a 15 proximal interphalangeal (PIP) joint contracture

3) Palpable spiral cord involving ring and small fingers

2) A 15 MP joint contracture and a 0 PIP joint contracture

5) Palpable spiral cord involving ring and small fingers in both of the hands

4) Palpable spiral cord involving ring and small fingers with multiple skin pits

 

The indication for surgery in Dupuytrenâs disease is MP joint contracture larger than 30 and any degree of PIP joint deformity. The other answers are incorrect because they are subjective descriptions and do not necessarily indicate joint involvement.Correct Answer: A 15 metacarpophalangeal (MP) joint contracture and a 15 proximal interphalangeal (PIP) joint contracture

 

Skin pits in Dupuytrenâs disease are caused by:

 

1) Vertical septae of Legueu and Juvara

3) Longitudinal fibers of palmar aponeurosis inserting into the skin

2) Vertical fibers of palmar aponeurosis anchoring to the skin

5) Contractures of the natatory ligaments

4) Longitudinal pretendinous bands

 

The longitudinal fibers forming layer 1 of the palmar aponeurosis insert into the dermis and, when contracted, give rise to skin pits. The pretendinous bands give rise to the central cord. Contractures of the natatory ligament give rise to the natatory cord. Vertical fibers and septae do not give rise to pits.Correct Answer: Longitudinal fibers of palmar aponeurosis inserting into the skin

 

 

1440. (1971) Q4-2383:

An otherwise healthy man has Dupuytrenâs disease, which involves his small finger with 40 proximal interphalangeal joint involvement. The preferred surgery in this patient is:

 

1) Partial fasciectomy

3) Arthroplasty

2) Arthrodesis

5) Fasciotomy with skin grafting

4) Osteotomy

 

A partial fasciectomy is the preferred surgery in this situation. It is recommended that involved fascial cords be resected rather than performing prophylactic fasciectomies. Care must be taken to preserve the neurovascular bundles. Arthrodesis, arthroplasty, and osteotomies are salvage procedures meant for recurrent disease. Fasciotomy has been recommended for elderly patients who cannot tolerate a long operation.Correct Answer: Partial fasciectomy

 

 

1441. (1972) Q4-2384:

Marjolinâs ulcers are risk factors for which of the following tumors:

 

1) Squamous cell carcinoma

3) Melanoma

2) Basal cell carcinoma

5) Osteosarcoma

4) Synovial sarcoma

 

Marjolinâs ulcers are malignant degenerations in chronic skin ulcers, sinuses, and burn scars and are risk factors for squamous cell carcinoma. Any patient with chronic, nonhealing ulcers should undergo biopsy for malignant degeneration. Basal cell carcinoma, malignant melanoma, synovial sarcoma, and osteosarcoma are not commonly associated with Marjolin's ulcer.Correct Answer: Squamous cell carcinoma

 

 

1442. (1973) Q4-2385:

Which of the following tumors rarely metastasizes:

 

1) Malignant melanoma

3) Clear cell carcinoma

2) Synovial sarcoma

5) Squamous cell carcinoma

4) Dermatofibrosarcoma protuberans

 

Dermatofibrosarcoma protuberans presents as a variably colored, slow-growing nodule involving the subcutaneous tissue. This tumor has a low incidence of metastasis; however, the recurrence rate is high even with wide local excision.Correct Answer: Dermatofibrosarcoma protuberans

 

 

 

1) Sweat gland tumors

3) Melanoma

2) Squamous cell carcinoma

5) Merkel's cell carcinoma

4) Basal cell carcinoma

 

Basal cell carcinomas rarely metastasize. Malignant sweat gland tumors, malignant melanoma, and Merkel's cell carcinoma are aggressive. Treatment usually includes regional lymphadenectomy. Squamous cell carcinoma is one of the most common hand malignancies and has the capacity to metastasize via the lymphatics.Correct Answer: Basal cell carcinoma

 

 

1444. (1975) Q4-2387:

Which of the following is not a characteristic of an acrolentiginous melanoma:

 

1) Involves palm and nail bed

3) Presents in older patients

2) Delays in diagnosis are common

5) Develops rapidly

4) Does not commonly metastasize

 

Acrolentiginous melanomas are usually flat, pigmented lesions. These melanomas often occur in older patients, affecting the palm and nail bed. At the time of presentation, acrolentiginous melanomas are frequently metastasized.Correct Answer: Does not commonly metastasize

 

 

1445. (1976) Q4-2388:

Nevi at greatest risk for malignant degeneration are:

 

1) Giant congenital hair variety

3) Junctional nevi

2) Blue nevi

5) Nevus sebaceous

4) Compound nevi

 

Giant congenital hairy nevi, dysplastic nevi, senile lentigo, and congenital melanocytic nevi have significant risk for malignant degeneration.

Nevus sebaceous is present at birth in the head and neck region and has a 10% incidence of malignant transformation. Blue nevi, junctional nevi, and compound nevi have lower risks for transformation.Correct Answer: Giant congenital hair variety

 

 

 

1446. (1977) Q4-2389:

All of the following are risk factors for malignant melanoma except:

 

1) Sunlight

3) Copper-based tanning lotions

2) Genetic predisposition

5) Immunosuppressive state

4) Atypical nevi

 

Sun exposure is the most important risk factor for melanoma. Family history, atypical nevi, and an immunosuppressive state increases an individual's risk for developing melanoma. It is unknown if tanning lotions cause malignant melanomas.Correct Answer: Copper-based tanning lotions

 

 

 

1) Soft tissue sarcomas frequently metastasize to bone.

3) Soft tissue sarcomas present as a painful mass in the hand.

2) Patients with soft tissue sarcomas of the hand have worse prognosis than patients with similar tumors in other extremities.

5) Soft tissue sarcomas can be "shelled out".

4) Overall prognosis is better with radical resection than wide excision.

 

Soft tissue sarcomas in the hand present as painless lesions, do not metastasize to bone, and although local control is better with radical resection, there is no improvement in overall survival when compared to wide excision. Soft tissue sarcomas should not be "shelled out."Correct Answer: Patients with soft tissue sarcomas of the hand have worse prognosis than patients with similar tumors in other extremities.

 

 

1448. (1979) Q4-2391:

Which of the following tumor metastasizes to lungs:

 

1) Squamous cell carcinoma

3) Soft tissue sarcoma

2) Basal cell carcinoma

5) Actinic keratosis

4) Schwannoma

 

Squamous cell carcinoma and basal cell carcinoma do not commonly metastasize to the lungs. Actinic keratoses are premalignant lesions that progress into squamous cell carcinomas. Schwannomas are common benign nerve tumors.Correct Answer: Soft tissue sarcoma

 

 

1449. (1980) Q4-2393:

Which of the following is not a characteristic of synovial sarcomas:

 

1) Synovial sarcomas are poorly differentiated masses located close to joints, tendon, or bursa.

3) Lymphatic spread is common.

2) Spindle and epithelial-type cells with monophasic or biphasic cells are present on histology.

5) High grade malignant soft tissue sarcoma

4) Wide or radical excision with radiation or chemotherapy prevents metastases.

 

Synovial sarcomas are high grade malignant soft tissue sarcomas, in which metastases can occur years after surgery. Long term followup is necessary. They arise close to joints, tendons or bursa and lymphatic spred is common. Histology reveals spindle and epithelial type cells with menophasic or biphasic pattern. Treatment includes wide resection and radiation, chemotherapy is not usually used.Correct Answer: Wide or radical excision with radiation or chemotherapy prevents metastases.

 

 

1450. (1981) Q4-2394:

Characteristic histological features of malignant schwannoma are best described as:

 

1) Fusiform cells with neoplastic schwann cells and nerve fascicles

3) Round or fusiform cells with clear cytoplasm and nerve fascicles

2) Spindle and epithelial-type cell mix with monphasic or biphasic cells

5) None of the above

4) Pleomorphic spindle histiocytes and giant cells in a storiform pattern

 

The histological features of malignant schwannoma have characteristic fusiform cells with neoplastic schwann cells and nerve fascicles.Correct Answer: Fusiform cells with neoplastic schwann cells and nerve fascicles

 

 

 

1) Megalodactyly

3) Gigantism

2) Overgrowth

5) Macrodactylia fibrolipomatosis

4) Symbrachydactyly

 

Symbrachydactyly is a term that encompasses all variations of shortened digits. Symbrachydactyly may be associated with syndactylies, but it is not a term used in reference to macrodactyly.Correct Answer: Symbrachydactyly

 

 

1452. (2164) Q4-2590:

Most cases of macrodactyly are:

 

1) Bilateral and affect men more often than women

3) Unilateral and affect men more often than women

2) Bilateral and affect women more often than men

5) Bilateral with equal frequency in both men and women

4) Unilateral and affect women more often than men

 

The majority of patients (90%) present with unilateral macrodactyly, and men are more often affected than women. Macrodactyly is most frequently found in the index finger, followed by the long finger, thumb, ring, and little fingers. Typically, two digits are affected â most commonly the thumb and index or the index and long.Correct Answer: Unilateral and affect men more often than women

 

 

1453. (2165) Q4-2591:

Which digit is most commonly affected by macrodactyly:

 

1) Thumb

3) MIddle

2) Index

5) Small

1. Ring

    

   The index finger is most frequently affected, although multiple digital enlargement is actually more commonly seen.Correct Answer: Index

    

    

   1454. (2166) Q4-2592:

   Syndactyly is present in what percentage of patients with macrodactyly:

    

   1) 10%

   3) 30%

   2) 20%

2. 50%

4) 40%

 

The majority of patients (90%) present with unilateral macrodactyly, and men are more often affected than women. Macrodactyly is most frequently found in the index finger, followed by the long finger, thumb, ring, and little fingers. Typically, two digits are affected â most commonly the thumb and index or the index and long. Syndactyly may be present in 10% of patients with macrodactyly.Correct Answer: 10%

 

 

 

1. Birth advancing macrodactyly (BAM)

3) Progressive macrodactyly

2) Static macrodactyly

5) Complex macrodactyly

4) Simple macrodactyly

 

Barsky described macrodactyly as either static or progressive. Static macrodactyly is present at birth, and the affected digit grows larger as the child develops. In the progressive type of macrodactyly, growth begins soon after birth. This form of the disorder is more common than static macrodactyly.Correct Answer: Static macrodactyly

 

 

1456. (2168) Q4-2594:

The most accepted theory for the cause of macrodactyly is:

 

1) Idiopathic

3) Vascular

2) Neural

5) Congenital

4) Humoral

 

Some surgeons believe that macrodactyly is a variant of neurofibromatosis. Although macrodactyly is not an inherited anomaly, there are syndromes that may be associated with enlarged digits such as Proteus syndrome. Although numerous causes have been suggested, the most accepted theory was described by Inglis in 1950. He theorized that the abnormal nerves exert influence on the local tissues to stimulate growth.Correct Answer: Neural

 

 

1457. (2169) Q4-2595:

Syndromes that may be associated with macrodactyly include:

 

1) Proteus syndrome

3) Madelungâs deformity

2) Freeman-Sheldon syndrome

5) Poland syndrome

4) Holt-Oram syndrome

 

Some surgeons believe that macrodactyly is a variant of neurofibromatosis. Although macrodactyly is not an inherited anomaly, there are syndromes that may be associated with enlarged digits such as Proteus syndrome. Theoretical causes for macrodactyly include a neural cause, a vascular cause, as well as a humoral mechanism. The most accepted theory is that abnormal nerves exert some influence on the local tissues to stimulate growth.Correct Answer: Proteus syndrome

 

 

1458. (2170) Q4-2596:

Macrodactyly affects:

 

1) Only bones

3) Bones, fat, and nerves

2) Bones and fat

5) Bones, fat, nerves, blood vessels, and tendons

4) Bones, fat, nerves, and blood vessels

 

Although this is controversial, the majority of surgeons believe that macrodactyly affects bones, fat, and nerves.Correct Answer: Bones, fat, and nerves

 

enlarged ring and small fingers. There is full range of motion without instability. After examination of the patient, you recommend:

 

1) Scheduling the patient for immediate surgery

3) Performing surgery within 1 week of diagnosis

2) Telling the parents to return when the child develops functional abnormalities

5) Performing additional testing

4) Scheduling surgery to coincide with the patient beginning school

 

The child is not ready for surgery. Although surgery may coincide with the patient beginning school, this does not always occur. At this time, additional examination and testing are recommended.Correct Answer: Performing additional testing

 

 

1460. (2172) Q4-2598:

A 2-year-old child is brought to your office for evaluation of a "big hand." Upon examination, you notice that the child has mildly enlarged ring and small fingers. There is full range of motion without instability. The childâs parents inform you that they would like you to amputate the affected digits as soon as possible. You should:

 

1) Begin radiation therapy to arrest the growth of the affected digits

3) Send the patient to another hand surgeon

2) Proceed with amputation because you have the parentsâ consent

5) Schedule the patient for a debulking procedure

4) Explain the typical course of macrodactyly and order additional testing

 

Although amputation may be necessary in some patients with macrodactyly, it is too early in the course of this case to begin entertaining such a drastic measure. A debulking procedure is not recommended for a 2-year-old child. Radiation therapy is not an option in uncomplicated cases of macrodactyly. The surgeon must educate the parents about the disease process and order additional testing.Correct Answer: Explain the typical course of macrodactyly and order additional testing

 

 

1461. (2173) Q4-2599:

You discover that a patient who you have been treating for macrodactyly has been followed by the Proteus Syndrome Foundation. Exhaustive work-up has been completed and radiographs of the hand reveal:

 

1) Multiple enchondromas in the affected fingers

3) Enlarged bones in length and width

2) Enlarged bones in length only

5) Normal appearing bones

4) Enlarged bones in width only

 

In patients with macrodactyly, surgeons do not typically find enchondromas, especially not multiple enchondromas in the affected fingers. Enlargement of the bones is found in all dimensions â not only in the length and width. If the bones appear normal on radiograph, then they are not affected by macrodactyly.Correct Answer: Enlarged bones in length and width

 

 

1462. (2174) Q4-2600:

A 2-year-old child is brought to your office for evaluation of a "big hand." Upon examination, you notice that the child has mildly enlarged ring and small fingers. There is full range of motion without instability. After examination of the patient, you discuss the diagnosis of macrodactyly with the parents. The parents feel assured after your discussion of the disease process and your review of the radiographs. You should next see the patient:

 

1) Never

3) When functional abnormalities develop

2) In 1 year

5) When the patient is old enough to consent for surgery

4) When the enlargement of the digits has ceased

 

Patients with macrodactyly should be followed up yearly. Although the parents may be difficult, this is not a reason to stop seeing a patient. The other answers choices are incorrect because treatment would be too late.Correct Answer: In 1 year

 

 

 

1) Nerve injury

3) Decreased sensation

2) Bony malunion

5) Infection

4) Joint laxity

 

Complications of macrodactyly surgery include poor healing of flaps secondary to devascularization or undue tension, nerve injury or decreased sensation, infection, stiffness, bony nonunion or malunion, and failure of the epiphysiodesis.Correct Answer: Joint laxity

 

 

1464. (2176) Q4-2602:

Epiphysiodesis for macrodactyly should be performed at the following location:

 

1) Proximal phalanx only

3) Proximal phalanx, middle phalanx, and distal phalanx

2) Proximal phalanx and middle phalanx

5) Proximal phalanx and distal phalanx

4) Middle phalanx only

 

Treatment by epiphysiodesis for macrodactyly is ineffective if only single phalanges are treated. Therefore, treatment of the proximal phalanx, distal phalanx, or the middle phalanx alone is incorrect. The author prefers to perform epiphysiodesis only on the proximal and distal phalanges. The middle phalanx is not treated to preserve motion at the proximal interphalangeal joint.Correct Answer: Proximal phalanx and distal phalanx

 

 

1465. (2187) Q4-2614:

When ruptured, which portion of the scapholunate ligament leads to scaphoid-lunate diastasis:

 

1) Distal

3) Intermediate

2) Proximal

5) Volar

4) Dorsal

 

The dorsal section of the scapholunate ligament is the strongest portion, requiring 300 N of load for failure. The volar (150 N) and intermediate portions (25 N to 50 N) contribute less to overall stability.Correct Answer: Dorsal

 

 

1466. (2188) Q4-2615:

Which of the following radiographic views is not routinely used to diagnose scapholunate injury:

 

1) Semisupination oblique view

3) Lateral view

2) Clenched fist view

5) Oblique view

4) Anteroposterior (AP) view

 

The semisupination oblique view is used to visualize the pisiform and pisotriquetral joint. The PA oblique and lateral views are the primary films used to diagnose scapholunate instability. The clenched fist view is used as a provocative view to bring out dynamic instability.Correct Answer: Semisupination oblique view

 

 

 

1) Open repair with bone sutures

3) Closed reduction and long arm cast

2) Proximal row carpectomy

5) Open repair with suture anchors

4) Arthroscopically assisted reduction and pinning

 

Proximal row carpectomy is a salvage procedure for chronic instability with focal radioscaphoid arthritis. Open repair with sutures through bone tunnels, open repair with suture anchors, and arthroscopically assisted reduction and pinning have been used successfully in acute cases.Correct Answer: Proximal row carpectomy

 

 

1468. (2190) Q4-2617:

Which of the following is considered indicative of a scaphoid-lunate ligament tear on posteroanterior radiograph:

 

1) Terry Thomas sign

3) Spilled tea cup sign

2) Volar intercalated segmental instability (VISI) pattern

5) Dorsal intercalated segment instability (DISI) pattern

4) Watson-Jones scaphoid shift

 

The VISI, DISI, and spilled tea cup signs are seen on lateral radiographs, whereas the Watson-Jones scaphoid shift test is a clinical sign. The classic pattern after scaphoid-lunate ligament injury is a DISI pattern as the lunate extends and the scaphoid flexes. The spilled tea cup sign is present in perilunate dislocations.Correct Answer: Terry Thomas sign

 

 

1469. (2191) Q4-2618:

The Terry Thomas sign, which is considered indicative of scaphoid-lunate ligament rupture, is best described as:

 

1) Scapholunate diastases larger than 3 mm

3) Reduction and exaggeration of scapholunate diastases on radial and ulnar deviation motion studies

2) Scapholunate angle more than 30º to 60º on lateral radiographs

5) Scaphoid flexion with lunate extension

4) Exaggeration and reduction of scaphoid-lunate diastases on radial and ulnar deviation radiographs, respectively

 

The Terry Thomas sign refers to scapholunate diastases that may be apparent on posteroanterior radiographs of the wrist and is indicative of rupture if the diastases are larger than 3 mm. It is named after the famous comedian who had a gap between his front teeth.Correct Answer: Scapholunate diastases larger than 3 mm

 

 

1470. (2192) Q4-2619:

The most important requirement for a diagnostic magnetic resonance image (MRI) study in cases of scaphoid-lunate ligament injury is:

 

1) 2 mm thin slices

3) Gallium-enhanced scan

2) Tangential cuts

5) MRI in neutral, radial, and ulnar deviation

4) Dedicated wrist coil

 

MRI is not considered the technique of choice for the evaluation of the scaphoid-lunate ligament. Standard MRI coils are not adequate for the evaluation of the ligaments of the wrist. To maximize the yield from a wrist MRI, high-field strength and high-resolution images must be obtained using dedicated wrist coils. Only with such dedicated coils can detailed information be derived regarding the continuity of the scapoid-lunate ligament. Physical examination and wrist arthroscopy remain the gold standards for the evaluation of a torn scaphoid-lunate ligament.Correct Answer: Dedicated wrist coil

 

 

 

1) Herbert screw (reduction association of the scapholunate)

3) Scaphoid-lunate ligament reconstruction using bone-ligament-bone autograft

2) Scaphotrapeziotrapezoid (STT) fusion

5) Repair with capsulodesis

4) Allograft ligament

 

In cases of subacute scaphoid-lunate ligament injury without arthrosis, it is acceptable to attempt reconstruction with bone anchors, allograft ligament repair, capsulodesis, bone-ligament-bone autograft, and the RASL procedure with a Herbert screw. In the presence of localized arthritis, one might consider one of the limited wrist fusions such as scaphotrapeziotrapezoid fusion.Correct Answer: Scaphotrapeziotrapezoid (STT) fusion

 

 

1472. (2317) Q4-2770:

Mallet finger injuries refer to:

 

1) Fractures of the bony tuft

3) Lack of conjoined tendon continuity at the distal interphalangeal (DIP) joint

2) Flexor tendon injuries

5) Intrinsic tightness

4) Fractures of the middle phalanx

 

Mallet finger injuries may be associated with fractures of the bony tuft, fractures of the middle phalanx, flexor tendon injuries, and intrinsic tightness. However, mallet injuries refer to lack of continuity at the DIP joint.Correct Answer: Lack of conjoined tendon continuity at the distal interphalangeal (DIP) joint

 

 

1473. (2318) Q4-2772:

In mallet finger injuries, the distal phalanx posture is:

 

1) Hyperextended

3) Neutral

2) Flexed

5) Ulnarly deviated

4) Radially deviated

 

The characteristic deformity is âdroopingâ at the distal interphalangeal (DIP) joint. The DIP is flexed. It is not hyperextended, neutral, or deviated.Correct Answer: Flexed

 

 

1474. (2319) Q4-2773:

Mallet finger injuries are typically:

 

1) Secondary to hyperextension injuries

3) Secondary to torsion injuries

2) Secondary to forced flexion injuries

5) Asymptomatic

4) Secondary to fingertip amputations

 

Mallet finger usually results from a blow to the tip of the extended finger. This forces distal phalanx flexion and disruption of the extensor mechanism at the distal interphalangeal joint. Open injuries to the extensor mechanism can also cause mallet finger.Correct Answer: Secondary to forced flexion injuries

 

 

 

1) Cast immobilization of the affected digit in extension

3) Early active motion of the affected joint

2) Dorsal block splint of the affected digit

5) Splinting of the affected DIP joint in extension

4) Splinting of the affected distal interphalangeal joint (DIP) joint in flexion

 

Cast immobilization is excessive and will cause undue stiffness in the affected finger. Dorsal blocking splints, splinting in flexion, and early active motion are contraindicated in these injuries. Only the affected joint should be splinted in extension.Correct Answer: Splinting of the affected DIP joint in extension

 

 

1476. (2321) Q4-2775:

Type I mallet finger injuries must be immobilized constantly for a minimum of:

 

1) 4 weeks

3) 6 weeks

2) 5 weeks

5) 8 weeks

4) 7 weeks

 

Eight weeks of immobilization is preferred. If the finger is immobilized for a shorter period of time, the clock is reset and immobilization is started again.Correct Answer: 8 weeks

 

 

1477. (2323) Q4-2777:

The most common mallet finger injuries are:

 

1) Type I

3) Type III

2) Type II

5) Type V

4) Type IV

 

Type I mallet injuries are by far the most common mallet injuries. There is no such classification as a type V injury.Correct Answer: Type I

 

 

1478. (2324) Q4-2778:

On physical examination, a mallet finger assumes a:

 

1) Resting flexed posture with active and passive extension

3) Resting flexed posture without active extension

2) Resting flexed posture without passive extension

5) Resting flexed posture with active extension

4) Resting flexed posture without active or passive extension

 

The distal phalanx assumes a resting flexed posture. The patient is not able to actively extend the fingertip, but it can be passively extended.Correct Answer: Resting flexed posture without active extension

 

 

1479. (2325) Q4-2779:

The following mallet finger injuries always require tendon repair:

 

1) Type I and type II

3) Type III and type IV

2) Type II and type III

5) Type I and type IV

4) Type IV and type V

 

Type II and III injuries have absolute requirements for tendon repair as there is a laceration or loss of tendon substance.Correct Answer: Type II and type III

 

1480. (2326) Q4-2780:

After placing a type I mallet finger in a splint at the initial visit, next follow-up should be:

 

1) The following day

3) In 2 weeks

2) In 1 week

5) At the end of the 8-week regimen

4) In 1 month

 

After placement of the splint, the patient should follow-up in the next week to make sure the finger is still maintained in full extension. Loosening of the splint will occur as swelling decreases.Correct Answer: In 1 week

 

 

1481. (2335) Q4-2792:

The most common bone tumor of the upper extremity is:

 

1) Enchondroma

3) Osteochondroma

2) Osteoblastoma

5) Chondromyxoid tumor

4) Giant cell tumor

 

Osteochondromas are the most common primary benign bony tumors.Correct Answer: Osteochondroma

 

 

1482. (2336) Q4-2793:

The most common benign bone tumor of the hand is:

 

1) Enchondroma

3) Osteochondroma

2) Osteoblastoma

5) Chondromyxoid tumor

4) Giant cell tumor

 

Unlike the entire upper extremity, enchondromas are the most common tumors of the hand.Correct Answer: Enchondroma

 

 

1483. (2337) Q4-2794:

Osteochondromas are benign but can have a malignant transformation in which of the following cases:

 

1) Diaphyseal achalasia

3) Osteochondromatosis malignant transformans

2) Ollierâs disease

5) Mafucci's syndrome

4) Osteochondroma larger than 5 cm

 

Diaphyseal achalasia, also known as multiple hereditary exostoses, has a risk of malignant degeneration in up to 25% patients. Ollierâs disease and Mafucciâs syndrome are associated with enchondromas. There is no lesion called an osteochondromatosis malignant transformans.Correct Answer: Diaphyseal achalasia

 

 

1484. (2338) Q4-2795:

The risk of malignant transformation in patients with multiple hereditary exostoses is:

 

1) 0%

3) 1% to 2%

2) Less than 1%

5) 0.5% to 25%

4) Greater than 5%

 

The rate of malignant transformation in patients with multiple hereditary exostoses is variable and is generally reported between 0.5% to 25%.Correct Answer: 0.5% to 25%

 

1485. (2339) Q4-2796:

Recurrence of osteochondroma is likely if:

 

1) The cartilage cap is incompletely excised

3) The bony stalk is incompletely excised

2) The overlying bursa is incompletely excised

5) Its connection with the medullary canal is not obliterated

4) The tumor is incompletely excised

 

The cartilaginous portion of an osteochondroma is the neoplastic part; its complete excision is essential to avoid recurrences.Correct Answer: The cartilage cap is incompletely excised

 

 

1486. (2340) Q4-2797:

Malignant transformation of osteochondroma commonly occurs to:

 

1) High-grade osteosarcoma

3) Low-grade chondrosarcoma

2) High-grade chondrosarcoma

5) Parosteal osteosarcoma

4) Low-grade osteosarcoma

 

Osteochondroma is a cartilaginous tumor and malignant transformation is to a low-grade chondrosarcoma.Correct Answer: Low-grade chondrosarcoma

 

 

1487. (2341) Q4-2798:

All of the following suggest a possibility of malignant transformation in multiple hereditary exostoses except:

 

1) Recent onset of pain

3) Cartilaginous cap thickness greater than 3 cm

2) Growth after skeletal maturity

5) Calcific stippling in the cap on radiograph

4) Soft tissue extension

 

Stippling on radiographs in the cap is due to calcification and is a common characteristic of cartilaginous tumors.Correct Answer: Calcific stippling in the cap on radiograph

 

 

1488. (2342) Q4-2799:

Enchondromas are commonly involved in which of the following sites:

 

1) Metacarpals

3) Radius

2) Carpus

5) Clavicle

4) Ulna

 

Metacarpals and phalanges are the most common areas of hand involvement, and the hand is involved in 40% to 65% of cases. Enchondromas are also the most common primary benign bone tumor of the hand (90% cases).Correct Answer: Metacarpals

 

 

1489. (2343) Q4-2800:

The most common forearm deformity in patients with hereditary multiple osteochondromatosis is:

 

1) Ulnar shortening

3) Radial head dislocation

2) Radial shortening

5) Translocation of carpus

4) Madelungâs deformity

 

Ulnar involvement and shortening frequently occurs in patients with hereditary multiples osteochondromatosis because the distal ulnar growth plate is smaller than that of the radius, consequently its length is affected more. The ulnar shortening causes radial bowing or radial head dislocation.Correct Answer: Ulnar shortening

 

 

 

 

 

Slide 1

A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.

 

The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.

 

You order a radiograph of the patientâs forearm. The anteroposterior radiograph is shown (Slide). The next step is to order a:

 

1) Skeletal radiograph survey

3) Magnetic resonance imaging (MRI) with wrist arthrogram

2) Magnetic resonance imaging (MRI)

5) Computed tomography (CT) scan

4) Genetic evaluation

 

The next step is to order a skeletal survey to rule out involvement of other areas.Correct Answer: Skeletal radiograph survey

 

 

Slide 1 Slide 2 Slide 3

A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.

 

The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.

 

An immediate appointment for magnetic resonance imagine (MRI) and computed tomography (CT) scan are not available, and a genetic evaluation has been carried out previously. As you await the report from the geneticist office, you decide to get a skeletal radiograph series on the patient. The radiograph of the opposite forearm (Slide 1) and right leg are shown (Slide 2).

 

You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 3). Your suspected diagnosis is:

 

1) Diaphyseal achalasia

3) Multiple enchondromatosis

2) Madelungâs deformity

5) Infection

4) Multiple epiphyseal dysplasia

 

Diaphyseal achalasia, also called multiple hereditary exostoses, classically presents in a young individual with multiple sites of involvement. The more involved the disease, the more likely hand involvement becomes. Forearm involvement is also common. The radius is bowed due to the shortened ulna. The risk of radial head dislocation is higher if the radius does not bow. While infection or traumatic injury could have produced early physeal arrest as seen in the first radiograph, presence of lesions elsewhere indicates multiple hereditary exostoses and should be investigated with skeletal surveys. Multiple epiphyseal dysplasia is not a possible diagnosis as only the ulna is involved in the first radiograph and radius alone in the left forearm. No enchondromas are present.Correct Answer: Diaphyseal achalasia

 

 

 

Slide 1 Slide 2 Slide 3

A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.

 

The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.

 

You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).

The genetic pattern seen in patients with this type of presentation is:

 

1) Autosomal recessive

3) Sex-linked recessive

2) Autosomal dominant

5) Sporadic

4) Sex-linked dominant

 

Multiple hereditary exostoses is inherited in an autosomal-dominant manner with 90% penetrance.Correct Answer: Autosomal dominant

 

 

Slide 1 Slide 2 Slide 3

A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.

 

The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.

 

You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).

Which of the following areas is unlikely to be involved:

 

1) Phalanges

3) Clavicle

2) Pelvis

5) Talus

1. Femur

    

   The clavicle is a membranous bone, and osteochondromas do not arise in membranous bones.Correct Answer: Clavicle

    

    

   Slide 1 Slide 2 Slide 3

   A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.

    

   The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.

    

   You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).

   The chance of hand involvement in this child is:

    

   1) 0%

   3) 25%

   2) 10%

2. Undetermined

4) Greater than 25%

 

The hand is involved in 30% to 80% of cases.Correct Answer: Greater than 25%

 

 

Slide 1 Slide 2 Slide 3

A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.

 

The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.

 

You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).

The most likely complication in this child is:

 

1) Malignant degeneration

3) Posterior interosseous neuropathy (PIN) palsy

2) Carpal translocation

5) Elbow dislocation

4) Peroneal nerve palsy

 

Ulnar carpal translocation occurs due to the steep radial articular angulation that occurs due to the tethering effect of a shortened ulna and is already apparent in early stages in the first radiograph. While peroneal palsy is possible due to a proximal fibula lesion, it is less common. Malignant transformation occurs, risk varies with families.Correct Answer: Carpal translocation

 

 

Slide 1 Slide 2 Slide 3

A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.

 

The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.

 

You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).

The difference between Madelungâs deformity and this boyâs condition is:

 

1) The ulna is shorter

3) There is radial head dislocation

2) The radius is shorter

5) It is not congenital

4) There is bilateral involvement

 

The ulna is elongated or dorsally subluxed in Madelung's deformity.Correct Answer: The ulna is shorter

 

 

Slide 1 Slide 2 Slide 3

A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.

 

The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.

 

You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).

All of the following are acceptable options, either alone or in combination, for management of this childâs condition, except:

 

1) Excision of osteochondromas

3) Hemiphyseal stapling

2) Ulnar lengthening

5) Observation

4) Radial osteotomy

 

Although hemiphyseal stapling is an acceptable option to correct radial articular angulation, in this boy the distal radial physis is already fused as is seen in the first radiograph.Correct Answer: Hemiphyseal stapling

 

 

Slide 1 Slide 2 Slide 3

A 12-year-old boy is brought to the clinic by his concerned parents. The boyâs forearm is bowed, and his parents are confused as to the possible diagnosis and treatment options. You notice that the right forearm of the child is bowed ulnarwards and is shorter compared to the left forearm. The pronosupination is markedly decreased on the right side but is also limited on the left side. The patient has a good grip, pinch, and grasp. He is neurologically intact as well.

 

The parents say that they first noticed the deformity around 6 or 7 years ago, and the mother informs you that she had noticed a hard bump on the forearm. She has recently noticed another bump on his right leg. The child does not complain of pain and is using both of his hands quite well. The parents were informed by a previous physician that the child has Madelungâs deformity and are concerned that the disease is now involving other areas of his body.

 

You order a radiograph of the forearm. The anteroposterior radiograph is shown (Slide 1). The childâs skeletal radiograph survey is also presented (Slide 2 and Slide 3).

Which of the following is not true regarding the possibility of malignant degeneration in this child:

 

1) There is a risk of up to 25%

3) Most common secondary malignancy is chondrosarcoma

2) Bone scan can differentiate

5) Malignant change occurs in adulthood

4) Risk of malignancy varies between families

 

Bone scan cannot differentiate between an active lesion and a malignant transformation.Correct Answer: Bone scan can differentiate

 

 

1499. (2352) Q4-2810:

Hornerâs syndrome includes all of the following except:

 

1) Miosis

3) Enophthalmosis

2) Anhidrosis

5) Diplopia

4) Exophthalmosis

 

Hornerâs syndrome is caused by disruption of sympathetic innervation and is characterized by enophthalmosis, not exophthalmosis. Other symptoms include anhidrosis, miosis, and ptosis.

Correct Answer: Exophthalmosis

 

 

1500. (2353) Q4-2811:

Axonotmesis involves injury to the:

 

1) Epineurium

3) Perineurium

2) Endoneurium

5) Vasonervorum

4) Axon

 

Axontmesis, as described in Seddonâs classification, implies injury to the axon and myelin sheath. Neurontmesis involves injury to all three layers.

Correct Answer: Axon

 

 

1501. (2354) Q4-2812:

All of the following may be seen with preganglionic lesion except:

 

1) Hornerâs syndrome

3) Positive histamine test

2) Hemidiaphragmatic palsy

5) Root avulsion sleeve on myelogram

4) Tinelâs sign

 

 

Tinelâs sign is seen with postganglionic lesions. Correct Answer: Tinelâs sign

 

1502. (2355) Q4-2813:

Weakness is not seen with root avulsion in the:

 

1) Rhomboids

3) Supraspinatus

2) Serratus anterior

5) Infraspinatus

4) Trapezius

 

The trapezius is innervated by spinal accessory nerve and thus will not be involved in a brachial plexus lesion. In the case of a preganglionic lesion, all muscles innervated by the nerve roots will be affected.

Correct Answer: Trapezius

 

 

1503. (2356) Q4-2814:

In obstetric brachial plexus injury, an indicator of plexus recovery at 3 months is the return of the:

 

1) Biceps muscle

3) Brachioradialis muscle

2) Triceps muscle

5) Teres major muscle

4) Latissimus muscle

 

 

Biceps recovery at 3 months is the single most important indicator of recovery in obstetric plexus palsy. Correct Answer: Biceps muscle

 

 

1) Brachial plexus neuropraxia

3) Brachial plexus neuritis

2) Erbâs palsy

5) Klumpkeâs Palsy

4) C 5, C 6 disk herniations

 

The involved muscles have C 5, C 6 root innervations. Positive Tinelâs sign, functioning rhomboids and serratus anterior, and the absence of Hornerâs syndrome rule out a preganglionic lesion. The EMG finding confirms the clinical finding. Subclinical involvement of any other muscle is not shown. Neuropraxia usually recovers in 6 weeks and EMG shows fibrillation, which is inconsistent with neuropraxia. Brachial plexus neuritis, Parsonage-Turner syndrome, has an acute presentation following a painful episode involving the whole arm. There is significant history of a fall in this case.

 

Correct Answer: Erbâs palsy

 

 

1505. (2358) Q4-2816:

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. Clinical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.

 

The level of lesion is:

 

1) Postganglionic C 5, C 6

3) Posterior cord injury

2) Preganglionic C 5, C 6

5) Spinal accessory paralysis

4) Middle trunk

 

The involved muscles have C 5, C 6 root innervations. Positive Tinelâs sign, functioning rhomboids and serratus anterior, and the absence of Hornerâs syndrome rule out a preganglionic lesion. The EMG finding confirms the clinical finding. Subclinical involvement of any other muscle is not shown. Neuropraxia usually recovers in 6 weeks and EMG shows fibrillation, which is inconsistent with neuropraxia. Brachial plexus neuritis, Parsonage-Turner syndrome, has an acute presentation following a painful episode involving the whole arm. There is significant history of a fall in this case.

 

Correct Answer: Postganglionic C 5, C 6

 

 

 

1) Magnetic resonance imaging (MRI)

3) Repeat electromyelogram (EMG) after 4 weeks

2) Computed tomography (CT) scan of the neck

5) Careful neurological examination

4) Somatosensory evoked potential (SSEP)

 

Computed tomography scan of the cervical spine will not show the pseudomeningoceles nor provide any information on brachial plexus. Computed tomography may be needed in case of a suspected neck injury but does not form part of a brachial plexus work up.

 

Correct Answer: Computed tomography (CT) scan of the neck

 

 

1507. (2360) Q4-2818:

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. Clinical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.

 

The plan of management in this patient 5 months postinjury with no clinical improvement should be:

 

1) Neurotization

3) Continued observation

2) Exploration and nerve grafting

5) Shoulder arthrodesis

4) Tendon transfers

 

Neurotization is appropriate in preganglionic lesions. If at 6 months a patient shows no evidence of recovery, it is time for plexus exploration. Further observation will not change the picture. Tendon transfers are reconstructive procedures, which are done at a later stage.

 

Correct Answer: Exploration and nerve grafting

 

 

 

1) Absence of biceps function at 3 months

3) Presence of trick movements

2) Absence of biceps function with return of extensor carpi radialis longus (ECRL) power at 4 months

5) Weakness of the supraspinatus

4) Subluxation of humeral head on radiographs

 

An important indication for early exploration is the recovery of a distally supplied muscle, ECRLâC 6, in the absence of a proximally supplied muscle, bicepsâC 5. Trick movements are adaptive movements employed by the patient by recruiting other muscles, for example, the use of flexor-pronator as elbow flexors in this patient. Bony deformity is a late sequelae and biceps recovery at 3 months is important in obstetric brachial palsy.

 

Correct Answer: Absence of biceps function with return of extensor carpi radialis longus (ECRL) power at 4 months

 

 

1509. (2362) Q4-2820:

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle eight weeks prior. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. Clinical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.

 

The most important function that needs to be restored in this patient is:

 

1) Shoulder abduction

3) Elbow flexion

2) Shoulder elevation

5) Elbow extension

4) Wrist extension

 

 

Elbow flexion is central to management of brachial plexus management because it serves the most important function of feeding. Correct Answer: Elbow flexion

 

 

1) Erbâs palsy

3) Cerebrovascular accident

2) Klumpkeâs palsy

5) Syringomyelia

4) Ulnar and median combined nerve injury

 

This is a case of obstetric brachial plexus injury involving the C 8, T1 roots (Klumpkeâs palsy). Erbâs palsy involves upper roots only. Combined nerve injuries can present in a similar fashion, however low ulnar and median nerve lesions will not have weakness of the flexor digitorum profundus and flexor digitorum sublimis.

 

History of a large baby, shoulder dystocia, and clavicle fracture point to difficult labor. The most common type of brachial plexus injury related to birth is Erbâs palsy, which is usually associated with a breech presentation. Isolated Klumpkeâs palsy is quite rare and the involvement of C 8 and T1 usually occurs as part of global plexus injury.

 

Correct Answer: Klumpkeâs palsy

 

 

1511. (2364) Q4-2822:

An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of 5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.

 

The level of the lesion in this patient is:

 

1) Preganglionic lesion

3) Lateral cord

2) Postganglionic lesion

5) Upper trunk

4) Posterior cord

 

It is difficult to clinically differentiate between a pre- and postganglionic lesion of C 8, T1 in a child. Absence of Hornerâs syndrome and hemi-diaphragmatic palsy in this case indicates that this is not a preganglionic lesion. The ability of the patient to hold his head suggests that the paravertebral muscles are functional, as is true in postganglionic lesions.

 

Correct Answer: Postganglionic lesion

 

 

 

1) Neurotization

3) Tendon transfers

2) Exploration and nerve grafting

5) Vascularized nerve grafting

4) Neurolysis

 

Neurotization is done for preganglionic lesions and has not been shown to produce successful results for lower root involvement. At 18 months, exploration and nerve grafting must be carried out. Neurolysis is reserved for cases in which recovery is partial or plateaus. Tendon transfers in children less than 3 years old do not work as well. Younger children do not cooperate well in rehabilitation. It is also difficult to decide upon the functioning motors for transfer.

 

Correct Answer: Exploration and nerve grafting

 

 

1513. (2366) Q4-2825:

An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of 5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.

 

Reconstructive surgery includes all of the following except:

 

1) Thumb opposition

3) Thumb adduction

2) Widening of first web space

5) Thumb capsulodesis

4) Thumb metaphalangeal (MP) fusion

 

This patient has developed contractures of first web space, which will not respond to passive stretching. Fusion of the MP joint is unneccesary, as tendon transfers will provide lateral and tip pinch as well as opposition.

Correct Answer: Thumb metaphalangeal (MP) fusion

 

 

 

1) Volar proximal interphalangeal (PIP) joint dislocation and swan-neck deformity

3) Volar PIP joint dislocation and boutonniere deformity

2) Dorsal PIP joint dislocation and swan-neck deformity

5) Dorsal PIP joint dislocation and mallet finger deformity

4) Dorsal PIP joint dislocation and boutonniere deformity

 

Three types of PIP joint dislocations are identified: volar, dorsal, and central depression. Volar PIP joint dislocations result in avulsion of the dorsal fragment of the base of the middle phalanx, which represents the central tendonâs attachment. If displacement persists, than a boutonniere deformity may result. Volar avulsion fractures of the PIP joint are often due to a hyperextension injury at the attachment of the volar plate.Correct Answer: Volar PIP joint dislocation and boutonniere deformity

 

 

1515. (2368) Q4-2827:

At what degree of flexion is ulnar collateral ligament injury tested:

 

1) 0º of metacarpophalangeal (MCP) joint flexion

3) 60º of MCP joint flexion

2) 30º of MCP joint flexion

5) 120º of MCP joint flexion

4) 90º of MCP joint flexion

 

At 30º of MCP joint flexion, the ulnar collateral ligament is isolated from the volar plate.Correct Answer: 30º of MCP joint flexion

 

 

1516. (2369) Q4-2828:

Which of the following structures are found within the first dorsal compartment:

 

1) Abductor pollicis longus and extensor indicis

3) Abductor pollicis longus and extensor pollicis brevis

2) Abductor pollicis longus and extensor pollicis longus

5) Extensor carpi radialis longus and extensor pollicis brevis

4) Abductor pollicis brevis and extensor pollicis longus

 

The first dorsal compartment encompasses the abductor pollicis longus and extensor pollicis brevis. Multiple slips of abductor pollicus brevis may be present, which is important in de Quervainâs release.Correct Answer: Abductor pollicis longus and extensor pollicis brevis

 

 

1517. (2370) Q4-2829:

A 28-year-old man fell off his bike and sustained a fall onto his outstretched hand. He experiences thumb and index finger numbness. Attempts at reduction of his grade I open extra-articular distal radius fracture are unsuccessful. The next appropriate step of management is:

 

1) Incision and drainage, splint in functional position, and bone grafting

3) Incision and drainage, open reduction with internal fixation

2) Incision and drainage, carpal tunnel release, and splint in functional position

5) Incision and drainage, open reduction with internal fixation, carpal tunnel release, and bone grafting

4) Incision and drainage, open reduction with internal fixation, and carpal tunnel release

 

A patient with this injury represents a high-energy fracture in a high demand individual. The patient will require incision and drainage of his open wound, open reduction with internal fixation, and carpal tunnel release. Bone grafting would not be appropriate in a patient with open fracture.Correct Answer: Incision and drainage, open reduction with internal fixation, and carpal tunnel release

 

 

 

1) Thrombocytopenia absent radii

3) Holt-Oram syndrome

2) Fanconi anemia

5) Cardiac anomalies

4) Larsen syndrome

 

Patients with thrombocytopenia absent radii, Fanconi anemia, Holt-Oram syndrome, and cardiac anomolies all are associated with radial deficiency. Larsen syndrome is associated with multiple, larger joint dislocation.Correct Answer: Larsen syndrome

 

 

1519. (2372) Q4-2831:

Which of the following is the most common carpal coalition in the hand:

 

1) Lunotriquetral

3) Capitohamate

2) Scapholunate

5) Capitolunate

4) Radioscaphoid

 

Lunotriquetral coalition has a 1.6% prevalence in the general population. The second most common coalition is the capitohamate. Incomplete coalition is treated by arthrodesis of the lunotriquetral joint.Correct Answer: Lunotriquetral

 

 

1520. (2373) Q4-2832:

A 6-year-old boy presents with a Salter-Harris II distal radius fracture 3 weeks after injury. He is nontender and neurologically intact. On radiographs, he has a 35º dorsal angulation. The appropriate course of treatment is:

 

1) Observe, cast, follow until healed

3) Close reduction and casting

2) Observe, cast, follow with serial radiographs for at least 2 years

5) Open reduction

4) Close reduction and pins

 

For a patient with delayed presentation of a distal radius fracture, appropriate management includes casting and observation for at least 2 years to assess physeal damage and remodeling. The patient may require osteotomy if remodeling does not occur.Correct Answer: Observe, cast, follow with serial radiographs for at least 2 years

 

 

1521. (2374) Q4-2833:

The oblique retinacular ligament connects with what two structures:

 

1) Flexor tendon to lateral extensor tendon

3) Flexor tendon sheath to lateral extensor tendon

2) Flexor tendon to central slip

5) Flexor tendon sheath to head of middle phalanx

4) Flexor tendon sheath to central slip

 

Landsmeer (oblique retinacular ligament) runs from the flexor tendon sheath of the proximal phalanx to the lateral extensor tendon as they insert onto the base of the proximal phalanx. A stay or retaining ligament maintains centralization of the extensor tendons.Correct Answer: Flexor tendon sheath to lateral extensor tendon

 

her elbow is at 90º of flexion and pulp-to-pulp contact on key pinch. The most likely diagnosis is:

 

1) Carpal tunnel syndrome

3) Posterior interosseous nerve syndrome

2) Anterior interosseous nerve syndrome

5) Martin-Gruber connection

4) Cubital tunnel syndrome

 

Anterior interosseous nerve syndrome is due to compression of the anterior interosseous nerve (AIN) in the forearm by lacterus fibrosis, flexor digitorum superficialis, or pronator teres. The AIN innervates the pronator quadratus, flexor digitorum profundus (FDP) to the index finger and the flexor pollicis longus (FPL). Anatomy variation exists where the AIN may innervate part of the flexor digitorum superficialis. In this patient, she has decreased pronation at 90º flexion, which relaxes the humeral attachment of the pronator from the pronator quadrus weakness. She also has pulp-to-pulp contract due to weakness of the FPL and FDP to the index finger.Correct Answer: Anterior interosseous nerve syndrome

 

 

 

1523. (2376) Q4-2835:

Indications for operative treatment in an acute elbow dislocation include:

 

1) Instability to valgus stress

3) Radial head fracture involving 30% of the radial head

2) Recurrent dislocation with extension past 50º

5) Ulnar nerve parathesias

4) Osteochondral lesions

 

Recurrent dislocations with extension past 50° represent a significant injury to the elbow and require a stabilization period. Instability to valgus stress represents injury to the anterior band of the medial collateral ligament of the elbow and will heal with protected motion. The majority of radial head fractures (Mason type I and II) that are less than 30º of the radial head and less than 30º angulation heal with good functional results. Most dislocations will have osteochondral lesions. Ulnar nerve parathesias can be associated with dislocations but is not an indication for operative fixation.Correct Answer: Recurrent dislocation with extension past 50º

 

 

1524. (2377) Q4-2836:

When performing open reduction and internal fixation of radial neck fractures, the plate should be placed:

 

1) In the "nonarticular safe-zone" comprising 120º of the 360º radial head circumference

3) Forearm in supination with plate anterior

2) Forearm in pronation with plate posterior

5) Forearm in neutral with plate anterior

4) Forearm in supination with plate posterior

 

The "nonarticular safe-zone" comprising only 90º of the radial head circumference is achieved by placing the plate posterior with the arm in supination.Correct Answer: Forearm in supination with plate posterior

 

 

1525. (2378) Q4-2837:

Heterotopic ossification after elbow dislocations is not associated with which of the following:

 

1) Delay surgical intervention

3) Aggressive passive range of motion after dislocation

2) Closed head injury

5) Concomitant proximal humeral fracture

4) Extensive surgical dissection

 

Heterotopic ossification is commonly associated with delay of surgical intervention, closed head injury, aggressive passive range of motion after dislocation, and extensive surgical dissection. Radiographic evidence of heterotopic ossification is present in 75% of patients with elbow dislocations but only 5% of these are clinically significant.Correct Answer: Concomitant proximal humeral fracture

 

What is the order of joint destruction in a patient with scapholunate disassociation:

 

1) Radial styloid, proximal radioscaphoid, radiolunate, midcarpal

3) Proximal radioscaphoid, midcarpal, radiolunate

2) Radial styloid, proximal radioscaphoid, radiolunate

5) Radial styloid, proximal radioscaphoid, midcarpal

4) Proximal radioscaphoid, radial styloid, midcarpal, radiolunate

 

Patients with scapholunate disassociation can develop a scapholunate advanced collapsed wrist. The progression is from the radial styloid to proximal radioscaphoid, to midcarpal (capitolunate). The lunate is extended and unloaded due to its concentric design, which results in preservation of the radiolunate.Correct Answer: Radial styloid, proximal radioscaphoid, midcarpal

 

 

1527. (2380) Q4-2839:

Which of the following is not characteristic of Dupuytrenâs disease:

 

1) Autosomal dominant trait

3) Higher prevalence in men

2) Irish and Scottish decent

5) Predictable progression of disease

4) Ring and small finger involvement first

 

Dupuytrenâs disease is characteristically unpredictable in its clinical progression. It may spontaneously resolve or quickly progress to advanced disease.Correct Answer: Predictable progression of disease

 

 

1528. (2381) Q4-2840:

Operative indications for Dupuytrenâs contracture include:

 

1) Metacarpophalangeal joint contraction of more than 25º to 30º

3) Palpable cords in the palm

2) Proximal interphalangeal joint contracture of 30º or more

5) Painful palmar nodule

4) Decreased light touch sensation to affected digits

 

As a general guideline the "table test" is used as an indication for operative intervention. If the patient cannot lay his/her hand flat onto a table, the disease has usually progressed to the point where surgery is required. A metacarpophalangeal joint contracture of 30º to 40º or a proximal interphalangeal joint contracture of 30º or more is an indication for surgery.Correct Answer: Proximal interphalangeal joint contracture of 30º or more

 

 

1529. (2382) Q4-2841:

Favorable indications for attempted replantation include:

 

1) Amputation of the thumb

3) Crush injuries to the distal forearm

2) Warm ischemia time of less than 16 hours

5) Sharp amputation proximal to the elbow

4) Cold ischemia time of less than 20 hours

 

Favorable indications for replantation include thumb amputations because of the functional importance of the thumb. Warm ischemias less than 8 hours or cold ischemia time less than 16 hours are more favorable for replantation.Correct Answer: Amputation of the thumb

 

Injuries to the central articular disk portion of the triangular fibrocartilage complex are related to all of the following except:

 

1) Age

3) Ulnocarpal impingement

2) Positive ulnar variance

5) Avulsion injuries from the dorsal ligamentous attachments

4) Scaphoid nonunion

 

Scaphoid nonunion is not related to central triangular fibrocartilage complex injuries. A positive ulnar variance is most strongly associated with triangular fibrocartilage complex central disk injuries.Correct Answer: Scaphoid nonunion

 

 

1531. (2384) Q4-2843:

A patient reports that he felt a pop and immediate pain over the MP joint of his finger. Examination reveals tenderness on the dorsum of the joint and subluxation of the extensor tendon. Which of the following is the most common defect:

 

1) Central slip

3) Triangular ligament

2) Lateral bands

5) Extensor tendon

4) Sagittal fibers

 

Tears of the sagittal fibers of the dorsal aponeurosis result in subluxation of the extensor tendon. This usually occurs on the long finger with subluxation to the ulnar side. Treatment for acute injuries requires immobilization of the metacarpophalangeal joint in extension for 6 weeks. Treatment for chronic injuries includes repair of the torn radial sagittal fibers.Correct Answer: Sagittal fibers

 

 

1532. (2385) Q4-2844:

All of the following transfers may be used to improve function in a patient who has had radial nerve paralysis longer than 6 months, except:

 

1) Pronator to extensor carpi radialis brevis

3) Flexor digitorum superficialis of the ring finger to digital extensors

2) Flexor carpi radialis extensors

5) Flexor palmaris longus to extensor pollicis longus

4) Flexor digitorum superficialis of the ring finger to brachioradialis

 

Radial nerve paralysis is a common injury, and many patients recover after repair. Tendon transfers should be delayed until sufficient time for reinnervation has passed. Pronator to extensor carpi radialis brevis can be performed at time of nerve repair to provide wrist extension and grasp during period of nerve recovery. Transfers for radial nerve palsy need to address wrist extension, thumb extension, and finger extenstion. All of the above transfer would provide these functions except a transfer to the brachioradialis.Correct Answer: Flexor digitorum superficialis of the ring finger to brachioradialis

 

 

Slide 1

A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). Your diagnosis is:

 

1) Ulnar club hand

3) Postaxial longitudinal deficiency

2) Preaxial longitudinal deficiency

5) Hypoplastic hand syndrome

4) Thumb aplasia

 

This is a classic appearance of a radial club hand, which is often referred to as preaxial longitudinal deficiency. Ulnar club hand and postaxial longitudinal deficiency are synonymous.Correct Answer: Preaxial longitudinal deficiency

 

 

1534. (2387) Q4-2846:

 

 

 

Slide 1

A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). The patient has an elbow flexion contracture of 70° and desires lengthening. Which of the following statements is not true regarding lengthening:

 

1) Nerve palsies may occur during lengthening.

3) Lengthening usually equalizes limb length.

2) Lengthening must be done gradually.

5) Lengthening leads to recurrence of the deformity.

4) Lengthening helps improve function by extending the reach.

 

In most cases of radial club hand, excluding a hypoplastic radius, full correction cannot be achieved.Correct Answer: Lengthening usually equalizes limb length.

 

 

Slide 1

A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). The potential complications of lengthening are discussed, and the patient is advised against it. However, the elbow flexion contracture is corrected by gradual distraction. One year postoperatively, the patient has attained a 30° correction of the flexion deformity, which remains mobile. Now, he desires that his wrist deformity be corrected. The procedure of choice is:

 

1) Arthrodesis

3) Centralization

2) Radialization

5) Tendon transfers

4) Proximal row carpectomy

 

Wrist arthrodesis is the best solution for this patient and his recurrent deformity because it provides a stable platform for grasp.Correct Answer: Arthrodesis

 

 

1536. (2389) Q4-2848:

 

 

 

Slide 1

A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). Although the patient has a thumb, it is in an abnormal position. Any attempt to make his thumb more functional will be influenced by:

 

1) Index finger camptodactyly

3) Stiff fingers

2) Presence of a side-to-side finger grip

5) Radial bowing

4) Recurrence of radial club hand

 

The pattern of usage of the hand is established in the brain by 2 to 3 years of age. Although pollicization has been performed in adolescents, patients continue to prefer a scissor pinch. At 24 years of age, this pattern will be well established. The patient can be coaxed to use his thumb, but it will not be involuntary and automatic.Correct Answer: Presence of a side-to-side finger grip

 

 

Slide 1

A radial club hand is the result of an insult during which phase of the gestation period:

 

1) Weeks 1 to 4

3) Weeks 8 to 12

2) Weeks 4 to 7

5) Anytime during gestation

4) Weeks 12 to 16

 

A radial club hand is the result of an insult during weeks 4 to 7 of gestation.Correct Answer: Weeks 4 to 7

 

 

1538. (2391) Q4-2850:

A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; platelet 254 254×103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes 40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.

 

Diagnosis is:

 

1) Vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies (VATER)

3) Thrombocytopenia absent radii (TAR) syndrome

2) Abnormalities of vertebrae, anus, cardiovascular tree, trachea, esophagus, renal system, and limb buds (VACTERL)

5) Fanconiâs anemia

4) Holt-Oram syndrome

 

The patient has a radial club hand with a cardiac defect. Because the spine radiograph is normal, the diagnosis cannot be VATER or VACTERL anomaly as both involve vertebrae. Blood work up is normal, making this diagnosis Holt-Oram syndrome.Correct Answer: Holt-Oram syndrome

 

 

1539. (2392) Q4-2851:

The principal abnormality associated with Holt-Oram syndrome is:

 

1) Platelet deficiency

3) Pancytopenia

2) Cardiac defects

5) Vertebral defects

4) Malignancy

 

Holt-Oram syndrome is associated with cardiac defects. The most common defect is aldosterone secretion.Correct Answer: Cardiac defects

 

The hereditary pattern for Holt-Oram syndrome is:

 

1) Autosomal recessive

3) Sex-linked recessive

2) Autosomal dominant

5) Sporadic

4) Sex-linked dominant

 

Holt-Oram syndrome is inherited in an autosomal dominant manner.Correct Answer: Autosomal dominant

 

 

1541. (2394) Q4-2853:

A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; 254×103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes 40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.

 

The next step in the management of the radial club hand is:

 

1) Stretching

3) Radialization

2) Soft-tissue distraction

5) Pollicization

4) Centralization

 

For the first 6 to 9 months, parents and therapists perform passive stretching. Serial casting and splinting may also be used. Sometimes, preoperative soft-tissue distraction is performed, usually before a wrist stabilization procedure.Correct Answer: Stretching

 

 

1542. (2395) Q4-2854:

A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; platelet 254×103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes 40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.

 

Centralization will be performed on the patient. All of the following statements are true about centralization except:

 

1) It is necessary to make a notch in the carpus when performing centralization.

3) Preoperative soft tissue distraction can be useful.

2) The forearm must be aligned with the second metacarpal.

5) Ulnocarpal fusion is a known outcome.

4) Transfer of tendons from the radial to ulnar side provides additional stability.

 

In a centralization procedure, the forearm is aligned with the third metacarpal, not the second.Correct Answer: The forearm must be aligned with the second metacarpal.

 

A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; 254Ã103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes 40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.

 

When the patient is 10 years old, he is not satisfied with the length of his forearm and wishes to lengthen it. Which of the following is not a satisfactory recommendation:

 

1) Acute lengthening with bone graft

3) Hybrid frame and distraction using the Ilizarov method

2) Circular ring fixator and gradual distraction

5) Lengthening

4) External frame and distraction using De Bastianiâs principles

 

Acute lengthening is done for small defects and, if performed in this patient, may result in severe neurovascular compromise.Correct Answer: Acute lengthening with bone graft

 

 

1544. (2397) Q4-2856:

Which of the following conditions is present in patients with radial club hand but not in patients with ulnar club hand:

 

1) Thumb hypoplasia

3) Short forearm

2) Thumb aplasia

5) Bowing of the forearm

4) Renal malformations

 

Ulnar club hand differs from radial club hand in that cardiopulmonary, hematopoeitic, gastrointestinal, and genitourinary anomalies are uncommon.

Correct Answer: Renal malformations

 

 

1545. (2398) Q4-2857:

All of the following developmental anomalies are associated with ulnar club hand except:

 

1) Atrial septal defects

3) Fibular agenesis

2) Proximal focal femoral deficiencies

5) Radial ray defects

4) Mental retardation

 

 

Atrial septal defects are developmental abnormalities present in patients with radial club hand or Holt-Oram syndrome. Correct Answer: Atrial septal defects

Which of the following syndromes is associated with ulnar club hand:

 

1) Vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies (VATER)

3) Holt-Oram syndrome

2) Abnormalities of vertebrae, anus, cardiovascular tree, trachea, esophagus, renal system, and limb buds (VACTERL)

5) Femur-fibular-ulnar syndrome

4) Thrombocytopenia absent radii (TAR) syndrome

 

VATER, VACTERL, Holt-Oram syndrome, and TAR syndrome are associated with radial club hand. Femur-fibular-ulnar syndrome is characterized by proximal femoral focal deficiency, fibular agenesis, and ulnar ray defects.

Correct Answer: Femur-fibular-ulnar syndrome

 

 

1547. (2400) Q4-2859:

Which of the following areas is not involved in ulnar club hand:

 

1) Thumb

3) Shoulder

2) Elbow

5) Vertebra

4) Femur

 

 

Vertebrae are usually not involved in ulnar club hand. Correct Answer: Vertebra

 

1548. (2401) Q4-2860:

All of the following are true statements regarding elbow involvement in ulnar club hand except:

 

1) Fifty percent of patients have radial head dislocation.

3) Elbow instability worsens with the severity on involvement.

2) Nearly 50% of aplasia patients have radiohumeral synostosis.

5) The elbow is usually normal in all hypoplastic patients.

4) The anlage causes radial head dislocation or subluxation.

 

Elbow instability does not correspond with severity of involvement. Fifty percent of patients with total aplasia have radiohumeral synostosis, which provides adequate stability.

Correct Answer: Elbow instability worsens with the severity on involvement.

 

 

1549. (2402) Q4-2861:

All of the following statements are true regarding the carpal bones in patients with ulnar club hand except:

 

1) Involvement of carpus is severe in type III.

3) Carpal coalition is present in approximately 25% of patients.

2) The pisiform is the most common missing carpus.

5) The extent of ulnar deformity does not correlate with deformities in the hand.

4) Making a notch in the carpus provides stability at the wrist joint.

 

A notch is often created in centralization procedures for radial club hand. Wrist stabilization procedures are not performed for ulnar club hand.

Correct Answer: Making a notch in the carpus provides stability at the wrist joint.

 

All of the following anomalies are present in patients with ulnar club hand except:

 

1) Phocomelia

3) Humeral aplasia

2) Transverse arrest

5) Vertebral dysplasia

4) Humeral hypoplasia

 

 

Vertebral anomalies are not common in patients with ulnar club hand. Correct Answer: Vertebral dysplasia

 

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) Cleft 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

 

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 (ECRB)

3) Brachioradialis

2) Extensor carpi radialis longus (ECRL)

5) Anconeus

4) Supinator

 

Current consensus is that tennis elbow is associated with a strain or microtear of the ECRB origin, which lies beneath the ECRL.Correct Answer: Extensor carpi radialis brevis (ECRB)

 

 

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

 

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

 

Current studies have found no benefit of extracorporeal shock wave therapy in the treatment of lateral epicondylitis.Correct 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) Cold 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

 

 

 

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

 

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)

 

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 (TFCC)

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 TFCC 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

1. 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

    

    

   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) Carpal 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

    

   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

      1. Posterior interosseous nerve palsy

2. Radial nerve palsy

1. Carpal 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: Carpal 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:

   Carpal 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

    

    

    

   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

    

   Clostridial 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

    

   Compared 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

    

    

    

   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 Classification of Interosseous Ligament Injury1 1 Grade Findings

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

   2. Incongruence of the scapholunate interval seen from the midcarpal joint

   3. Complete separation of scaphoid and lunate visualized from both spaces; a 1-mm probe can be passed between the two bones

   4. 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) Corticosteroid injection into the midcarpal space

   4) Splinting and flexor carpi ulnaris training

    

   Conservative 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

    

    

    

   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:

   Complete 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 / MCP

   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 MCP 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

       

       

      1. Increasing capsular extensibility

   3. Increasing pain threshold

      1. Decreasing scar

2. Increasing ligament stretch ability

1. 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 EXCEPT:

       

      1. Carpal tunnel syndrome

   3. Shoulder/rotator cuff tendinitis

      1. Wrist arthritis

2. Medial epicondylitis

1. Lateral epicondylitis

 

 

Iontophoresis is effective in soft tissue conditions such as rotator cuff bursitis and lateral epicondylitis. Correct Answer: Wrist arthritis

 

 

1. Endoneurium

3) Perineurium

2) Hyponeurium

5) Epineurium

4) Mesoneurium

 

The structures surrounding the axons and Schwann cells include the endoneurium, perineurium, and epineurium. The mesoneurium is an adventitial layer in addition.

Correct Answer: Hyponeurium

 

 

1602. (3873) Q4-7656:

The Seddon grades of nerve injury include all of the following EXCEPT:

 

1) Neuropraxia

3) Neurotmesis

2) Axonotmesis

1. Schwann cell disruption

    

   Neuropraxic injuries are stretch injuries to the nerve. Axonotmetic injury involves a more severe injury with loss of continuity of axons, and connective tissue elements remain intact. Neurotmesis is a complete nerve discontinuity. Schwann cell disruption occurs in neurotmesis but is not among the grades of Seddon nerve injury.

    

   Correct Answer: Schwann cell disruption

    

    

   1603. (3874) Q4-7657:

   Younger age is associated with worse outcomes with nerve repair.

    

   1. True

   2. False

       

       

      Younger age is associated with improved functional outcome after nerve repair, particularly regarding sensory recovery. Correct Answer: False

       

      1604. (3875) Q4-7658:

      Optimum conditions for nerve healing after direct repair include:

       

      1. Gapping at suture repair site

   3. Early motion of extremity

      1. Tension-free repair

2. lacing sutures through the endoneurium to increase repair strength

1. Preservation of all tissue whether devitalized or viable

    

   Tension-free repair is the optimal technique to improve the potential for nerve recovery. Gapping, failure to splint to prevent tension on the nerve with motion, and failure to excise scarred or devitalized nerve tissue are impairments to successful nerve repairs. Suture repairs through the deep nerve segments can damage the axons. Sutures should be placed through the epineurium or, in a grouped fascicular repair, through the perineurium around the fascicles.

    

   Correct Answer: Tension-free repair

    

    

    

   1. True

   2. False

       

       

      Missile wounds can cause a blast stretch injury to peripheral nerves and may recover with observation. Correct Answer: True

       

      1606. (3887) Q4-7766:

      The anatomic location of the pathologic lesion of lateral epicondylitis is the:

       

      1. Extensor carpi radialis longus (ECRL)

   3. Extensor digitorum longus (EDL)

      1. Extensor carpi radialis brevis (ECRB)

2. Annular ligament

1. Extensor digitorum communis (EDC)

 

While the ECRL and EDL can sometimes be involved, the primary location of most cases of tennis elbow show characteristic changes at the origin of the ECRB.

Correct Answer: Extensor carpi radialis brevis (ECRB)

 

 

1607. (3888) Q4-7767:

Which of the following injectable substances have shown benefit in the treatment of lateral epicondylitis:

 

1. Corticosteroids

3) Botulinum toxin

2) Autologous blood

5) All of the above

4) None of the above

 

All of these substances have been shown to have efficacy in the treatment of tennis elbow. However, placebo saline injections have also been proven to add some benefit compared to no treatment.

Correct Answer: All of the above

 

 

1608. (4068) Q4-7768:

The nerve most at risk during arthroscopic debridement of lateral epicondylitis is the:

 

1) Ulnar nerve

3) Anterior interosseous nerve

2) Median nerve

5) Musculocutaneous nerve

4) Posterior interosseous nerve

 

While the ulnar nerve is most at risk during elbow arthroscopy in general, debridement of the lateral capsule posterior to the midpoint of the radiocapitellar joint places the posterior interosseous branch of the radial nerve at risk.

Correct Answer: Posterior interosseous nerve

 

all of the following, except:

 

1) Synovial plica

3) Synovitis

2) Loose body

5) Chondral lesion

4) Medial epicondylitis

 

While all of the other answers are intra-articular lesions that have been reported in elbow arthroscopies, medial epicondylitis is an extra-articular condition and must be addressed in an open fashion given the proximity of the ulnar nerve.

Correct Answer: Medial epicondylitis

 

 

1610. (3890) Q4-7770:

Arthroscopic resection/debridement posterior to the midline of the radio-capitellar joint can result in damage to      ligament, resulting in        instability.

 

1) Lateral collateral; valgus

3) Ulnar collateral; posterolateral rotatory

2) Ulnar collateral; valgus

5) Lateral collateral; posterolateral rotatory

4) Annular; posterolateral rotatory

 

Resection posterior to the midpoint of the radiocapitellar joint can result in damage to the lateral collateral ligament and subsequent development of posterolateral rotator instability.

Correct Answer: Lateral collateral; posterolateral rotatory

 

 

1611. (3911) Q4-7791:

The muscle that flexes the interphalangeal joint of the thumb is innervated by which roots of the brachial plexus:

 

1) C 5, C 6

3) C 6, C 7, C 8

2) C 5, C 6, C 7

5) C 7, C 8, T1

4) C 5, C 6, C 7, C 8, T1

 

The interphalangeal joint of the thumb is flexed secondary to actions of the flexor pollicis longus (FPL). The FPL is innervated by the anterior interosseous nerve, which is the longest branch of the median nerve. The median nerve is formed by the lateral (roots C 5, C 6, and C 7) and medial (roots C 8 and T1) cords of the brachial plexus.

 

Correct Answer: C 5, C 6, C 7, C 8, T1

 

 

1612. (3912) Q4-7792:

The anterior interosseous nerve (AIN) originates from the median nerve at what distance from the medial epicondyle:

 

1) 6 cm distal

3) 6 cm proximal

2) 10 cm proximal

5) At the medial epicondyle

4) 10 cm distal

 

The AIN, the largest branch of the median nerve, originates 5 cm to 8 cm distal to the medial epicondyle from the posteroradial aspect of the median nerve just distal to the proximal border of the superficial head of the pronator teres.

Correct Answer: 6 cm distal

 

A 30-year-old right-hand dominant woman presents to the emergency department with a 6-week history of difficulty writing and pain after playing tennis. She also reports a recent inability to abduct and adduct her fingers. What is the mechanism of her symptoms:

 

1) Writerâs cramp or focal dystonia

3) Martin-Gruber interconnection

2) Riche-Cannieu anastamosis

5) Carpal tunnel syndrome

4) Ulnar neuropathy

 

Approximately 17% of the population has a Martin-Gruber interconnection, and 50% of these patients may show additional denervation of normally ulnar nerve-innervated intrinsic muscles. The Martin-Gruber anomaly is a motor neural connection between the anterior interosseous nerve and ulnar nerves that is located adjacent to the ulnar artery in the proximal forearm.

 

 

 

 

Correct Answer: Martin-Gruber interconnection 1614. (3914) Q4-7794:

 

What is the innervation of the indicated muscle in the image (Slide):

 

1) Median nerve

3) Radial nerve

2) Anterior interosseous nerve

5) Posterior interosseous nerve

4) Ulnar nerve

 

The arrow in the photograph (Slide) is pointing to the pronator teres â one of the most common sites for compression of the anterior interosseous nerve. The pronator teres is innervated by the median nerve.

Correct Answer: Median nerve

 

 

1615. (3915) Q4-7795:

Sites of potential compression of the median nerve include all of the following except:

 

1) Pronator teres

3) Pisohamate ligament

2) Transverse carpal ligament

5) Mass in carpal canal (e.g., lipoma)

4) Supracondylar process

 

Around the elbow, the median nerve may be compressed by the pronator teres (causing either anterior interosseous nerve syndrome or pronator syndrome) or the ligament of Struthers originating from a supracondylar process (causing pronator syndrome). In the wrist, the median nerve may be compressed by the transverse carpal ligament or a mass within the carpal canal. The ulnar nerve, not the median nerve, can be compressed by the pisohamate ligament.

 

Correct Answer: Pisohamate ligament

 

What position of the wrist most commonly produces scaphoid fractures:

 

1) Wrist flexion and radial deviation

3) Wrist flexion and ulnar deviation

2) Wrist extension and radial deviation

5) Clenched fist and wrist flexion

4) Wrist extension and ulnar deviation

 

Frykman performed biomechanical studies to evaluate the wrist position in falls that produce scaphoid fractures. The results showed that wrist extension greater than 90° and radial deviation consistently resulted in fracture of the scaphoid.

Correct Answer: Wrist extension and radial deviation

 

 

1617. (3939) Q4-8127:

Which of the following blood vessels supplies the majority of the scaphoid:

 

1) Superficial palmar branch of the radial artery (volar)

3) Dorsal carpal branch of the radial artery (dorsal)

2) Radial artery

5) 3,4 intracompartmental supra-retinacular artery (3,4-ICSRA)

4) Ulnar artery

 

Gelberman and Menon used injection studies to demonstrate that the majority of scaphoid blood flow stems from branches of the radial artery entering the scaphoid at the distal pole. Of these, the branch entering the dorsal ridge supplies 70% to 80% of the intraosseous vascularity of the scaphoid bone. The proximal pole is completely dependent on the intraosseous blood supply and is vulnerable to avascular necrosis when fracture disrupts this vascular source.

 

Correct Answer: Dorsal carpal branch of the radial artery (dorsal)

 

 

1618. (3940) Q4-8128:

During a posterior (dorsal) approach to percutaneous screw fixation for a scaphoid fracture, many structures are close to the guidewire insertion location and are at risk for injury. Which of the following structures is the closest to the guidewire insertion location according to a recent cadaveric study:

 

1) Posterior interosseous nerve

3) Extensor indicis proprius

2) Extensor digitorum communis to the index

5) Extensor digitorum communis to the index and posterior interosseous nerve

4) Extensor carpi radialis brevis

 

Adamany and colleagues performed a cadaveric study to evaluate the dorsal structures at risk with truly percutaneous headless screw placement for scaphoid fractures. They noted that the posterior interosseous nerve and the extensor digitorum communis to the index finger were an average of 2.2 mm from the guidewire and therefore at greatest risk from this approach.

 

Correct Answer: Extensor digitorum communis to the index and posterior interosseous nerve

 

Which of the following is a concerning risk factor for a dorsal open approach to the scaphoid:

 

1) Damage to tenous blood supply of the scaphoid

3) Damage to scapho-trapezial-trapezoid joint during the approach

2) Difficulty of central screw placement

5) njury to the higher rate of infection

4) Damage to the lunatotriquetral (LT) ligament

 

The dorsal approach is advantageous in obtaining central screw placement. The scapho-trapezial-trapezoid joint is at risk during a volar approach, not a dorsal approach, and infection has not been shown to occur more frequently in one approach over the other. The LT ligament is not seen in either approach. The risk of the open dorsal approach is compromise of the main blood supply to the scaphoid, entering through the dorsal ridge.

 

Correct Answer: Damage to tenous blood supply of the scaphoid

 

 

1620. (3942) Q4-8130:

A volar approach to the scaphoid is ideal in which of the following fractures:

 

1) Proximal pole fractures

3) Comminuted scaphoid fractures

2) Distal pole fractures

5) Scaphoid fracture with associated scapholunate ligament tear

4) Avascular necrosis of the scaphoid proximal pole

 

The volar approach to the scaphoid is optimal in distal pole fractures because it allows direct visualization of the fracture line and exact reduction and fixation. A volar approach is not recommended for fractures or avascular necrosis of the proximal pole, where dorsal screw placement is best. Scapholunate ligament tears are generally repaired from a dorsal approach because the ligament is stoutest dorsally.

 

Correct Answer: Distal pole fractures

 

 

1621. (3944) Q4-8195:

Which finger is most commonly involved in a flexor digitorum profundus (FDP) avulsion injury:

 

1) Index

3) Ring

2) Middle

5) Thumb

4) Small

 

An FDP avulsion is caused by forceful extension of the distal interphalangeal (DIP) joint, occurring at the same time as a maximum contraction of the FDP tendon. Jersey finger is often seen in athletes, especially football or rugby players, who commonly get their fingers caught in an opposing playerâs jersey, thus the name. In most cases, this injury affects the ring finger.Correct Answer: Ring

 

 

1622. (3945) Q4-8196:

Which type of flexor digitorum profundus (FDP) avulsion is considered the most severe:

 

1) Type I

3) Type III

2) Type II

5) Type V

4) Type IV

 

Type I is the most threatening scenario because the FDP tendon retracts into the palm, and vincular and diffusional blood supply is lost. The sheath may be noncompliant after a few days and may not allow passage of the FDP tendon through the sheath in an attempt to repair the stump to its insertion. Additionally, proximal muscle contracture prevents tendon stump advancement.Correct Answer: Type I

 

When performing pollicization to correct a hypoplastic thumb, the surgeon should rotate the index finger:

 

1) 120º

3) 150º

2) 135º

5) 180º

4) 165º

 

After the index finger is rotated 150º, the index finger will be in the ideal location as it mimics the position of where the thumb would have naturally been. This position allows for the greatest amount of grip and pinch strength possible.Correct Answer: 150º

 

 

1624. (3947) Q4-8198:

For which types of thumb hypoplasia is pollicization the best option:

 

1) Type I

3) Type IIIA

2) Type II

5) Type I, type II, and type IIIA

4) Type IIIB

 

Reconstruction is possible and is therefore the best option for thumb hypoplasia in patients with type I, type II, and type IIIA. These three types of hypoplasia can be corrected because the thumb still has most of the bones and muscles intact. Corrective surgery is necessary to correct weak muscles or a tight web space between the thumb and index finger. When a type IIIB exists, reconstruction is not possible and pollicization must be performed.Correct Answer: Type I, type II, and type IIIA

 

 

1625. (3948) Q4-8199:

What is the most critical step in pollicization to create a normal-looking thumb:

 

1) Creating skin incisions with skin flaps that will allow a natural first web space

3) Shortening of the index finger metacarpal

2) Shortening of tendons

5) All of the above

4) Creating a hyperextended joint when stabilizing the metacarpophalangeal joint to the carpus

 

It is necessary to create a hand with a natural first web space, shorter tendons that allow for natural movement, a shorter metacarpal that ensures the finger will not grow to an unnatural length, and a hyperextended joint to create the most natural-looking hand possible.Correct Answer: All of the above

 

 

1626. (3949) Q4-8200:

All of the following may be present in a child with type IIIA hypoplasia except:

 

1) Metacarpophalangeal (MP) joint laxity

3) Lack of extensor pollicis longus

2) Web space contracture

5) Thenar muscle atrophy

4) Unstable carpometacarpal (CMC) joint

 

Type IIIA hypoplasia includes web space narrowing, thenar atrophy, MP joint laxity, and extrinsic tendon abnormalities. Type IIIA is distinguished from a type IIIB by the fact that a stable CMC joint exists. Because a stable CMC joint exists, a reconstruction is the treatment of choice. When the CMC joint is unstable, as in type IIIB hypoplasia, a pollicization is necessary to restore thumb stability.Correct Answer: Unstable carpometacarpal (CMC) joint

 

The main 3-4 viewing portal for wrist arthroscopy lies in between which two tendons:

 

1) Extensor pollicis longus (EPL) and extensor carpi radialis brevis (ECRB)

3) Abductor pollicis longus (APL) and extensor carpi radialis longus (ECRL)

2) Extensor digitorum communis (EDC) and extensor digiti minimi (EDM)

5) Extensor pollicis brevis (EPB) and APL

4) EPL and EDC

 

The 3-4 portal is the main viewing portal and is located between the third and fourth compartment. This portal is bordered by the extensor digitorum communis (EDC) to the index finger, and the extensor pollicis longus (EPL) can be palpated in the âsoft spotâ 1 cm distal to Listers tubercle. This portal is usually the first portal to be made during wrist arthroscopy.Correct Answer: EPL and EDC

 

 

1628. (3951) Q4-8202:

Which of the following ligaments acts as a neurovascular conduit:

 

1. Long radiolunate

   3) Radioscapholunate

   2) Radioscaphocapitate

   5) Ulnotriquetral

   1. Short radiolunate

       

      The radioscapholunate ligament, otherwise known as the ligament of Testut, lacks structural intergrity and acts as a neurovascular conduit. This ligament is visible on the volar side of the wrist from the 3-4 portal in between the long radiolunate and short radiolunate ligaments.Correct Answer: Radioscapholunate

       

       

      1629. (3952) Q4-8203:

      Complications after wrist arthroscopy occur in what percentage of patients:

       

      1) 5%

      3) 15%

      2) 10%

   2. 25%

   4) 20%

    

   The complication rate after routine wrist arthroscopy is between 2% and 5%.Correct Answer: 5%

    

    

   1630. (3953) Q4-8204:

   Complications after wrist arthroscopy occur in what percentage of patients:

    

   1) 5%

   3) 15%

2. 10%

   5) 25%

   4) 20%

    

   The complication rate after routine wrist arthroscopy is between 2% and 5%.Correct Answer: 5%

    

   The fracture fragment in Bennettâs fracture is located in which of the following areas of the hand:

    

   1. Radiopalmar trapezium

3. Ulnopalmar trapezium

1. Dorsal thumb metacarpal base

5) Radiopalmer lunate

4) Ulnopalmar thumb metacarpal base

 

As an axial load is placed on the thumb tip, it drives the thumb metacarpal (MC) base in a dorsal-radial direction. As the thumb MC base moves dorsoradially, a fracture is created in the volar, ulnar quadrant of the thumb MC base. Gedda and Moberg describe this as a ligament fracture avulsion. The volar, ulnar quadrant piece usually remains stationary, perhaps migrating a small amount distal the thumb metacarpal base moves dorsoradially, creating a fracture in the volar, ulnar quadrant of the trapezium.Correct Answer: Ulnopalmar thumb metacarpal base

 

 

1632. (3955) Q4-8206:

Which of the following two main soft tissue forces are disrupted by Bennettâs fracture subluxation:

 

1) Volar beak (anterior oblique) ligament and extensor pollicis longus

3) Posterior oblique ligament and abductor pollicis brevis

2) Volar beak (anterior oblique) ligament and abductor pollicis longus

5) Dorsal radial ligament and abductor pollicis brevis

4) Dorsal radial ligament and flexor pollicis brevis

 

The volar, ulnar quadrant piece usually remains stationary due to the volar beak ligament. The thumb metacarpal base tends to sublux dorsoradially due to unopposed pull of the abductor pollicis longus and adductor pollicis. The intact volar beak ligament is usually the counterforce the to these two muscles in the static situation. The extensor pollis longus, flexor pollicis brevis, and abductor pollis longus do not have significant involvement in the Bennettâs fracture subluxation. Although the dorsal radial ligament is important for carpometacarpal stability, it is not the ligament attached to the fractures fragment.Correct Answer: Volar beak (anterior oblique) ligament and abductor pollicis longus

 

 

1633. (3956) Q4-8207:

The greatest amount of step-off that is well-tolerated in a Bennettâs fracture is:

 

1) 0 mm

3) 2 mm to 3 mm

2) 1 mm to 2 mm

5) 4 mm to 5 mm

4) 3 mm to 4 mm

 

Studies by Livesley, Kjaer-Petersen, and others have shown that patients with fractures with more than a 1-mm step-off after reduction were more likely to develop arthritis at the thumb carpometacarpal joint. Although some studies have not shown functional outcome correlating with the presence of arthritis, Oosterbos and De Boer found that all their patients with fair and poor overall results had nonanatomic reductions. Although a cadaveric study by Cullen has shown that a 2-mm step-off may be acceptable, this contrasts with the clinical evidence currently available.Correct Answer: 1 mm to 2 mm

 

 

1634. (3957) Q4-8208:

When fracture step-off is greater than the accepted limits, which of the following complications is the most common:

 

1) Arthritis

3) Decreased range of motion

2) Pain

5) All of the above

4) Decreased pinch strength

 

Studies by Livesley, Kjaer-Petersen, and others have shown that patients with fractures with more than a 1-mm step-off after reduction were more likely to develop arthritis at the thumb carpometacarpal joint. Pain, decreased range of motion, and decreased pinch strength also correlated with these poor outcomes.Correct Answer: All of the above

 

Clinically, what is the upper limit of acceptable fracture angulation for a fifth metacarpal neck fracture:

 

1) 20°

3) 50°

2) 40°

5) 80°

4) 70°

 

Although this is controversial, conservatively treated patients with angulations less than 70° fared well in two prospective studies. Fourteen percent of patients will have a cosmetic deformity, but operatively treated patients exhibited extensor lag and increased rehabilitation times.Correct Answer: 70°

 

 

1636. (3959) Q4-8210:

In cadaveric models, when does the biomechanics of fifth finger flexion consistently change in relationship to metacarpal neck fracture angulation:

 

1) 10°

3) 50°

2) 30°

5) 80°

4) 70°

 

Thirty degrees of angulation is the maximum deformity for acceptable fifth finger grip strength. Ali et al showed that fracture angulation of 30° results in a significant decrease in the distance between the origin and the insertion of the flexor digiti minimi (FDM). This shortening creates more âslackâ in the FDM muscle and more excursion is wasted as muscle shortening prior to the initiation of metacarpophalangeal (MP) flexion.Correct Answer: 30°

 

 

1637. (3960) Q4-8211:

Up to how much angulation can be tolerated in the small finger metacarpal shaft fracture:

 

1) 0° to 10°

3) 21° to 30°

2) 11° to 20°

5) 41° to 50°

4) 31° to 40°

 

The small finger carpometacarpal joint is mobile, which allows the small finger metacarpal to tolerate deformity better than the fixed index and middle finger rays. Thus, 41° to 50° of angulation can be accommodated by the mobile carpometacarpal joint.Correct Answer: 41° to 50°

 

 

1638. (3961) Q4-8212:

If a metacarpal shaft fracture shortens 4 mm, what will the theoretical amount of extensor lag be at the metacarpophalangeal joint:

 

1) 0°

3) 7°

2) 5°

5) 20°

4) 14°

 

For each 2 mm of shortening, a 7° extensor lag exists. Thus, with 4 mm of shortening, there will be a 14° extensor lag at the metacarpophalangeal joint.Correct Answer: 14°

 

In a short oblique metacarpal shaft fracture without comminution or bone loss, what is usual amount of maximal shortening that will occur:

 

1) 1 mm

3) 5 mm

2) 3 mm

5) 9 mm

4) 7 mm

 

In a cadaveric study, shortening beyond 5 mm was prevented by the tethering effect of the transverse metacarpal ligaments and adjacent metacarpals.Correct Answer: 5 mm

 

 

1640. (3962) Q4-8214:

Which of the following statements is true regarding metacarpophalangeal joint anatomy:

 

1) The collateral ligaments are lax in flexion.

3) Joint stability is maximal in flexion.

2) The joint volume is highest in flexion.

5) The collateral ligaments originate volar to the axis of flexion.

4) The metacarpal head is spherical.

 

The collateral ligaments are lax in extension and tight in flexion. The joint volume is highest in extension. The metacarpal head is cam-shaped. The collateral ligaments originate dorsal to the axis of flexion. Due to the tightening of the collateral ligaments over the cam-shaped metacarpal head in flexion, joint stability is maximized.Correct Answer: Joint stability is maximal in flexion.

 

 

1641. (3963) Q4-8215:

Which of the following fracture patterns and mechanisms is incorrectly paired:

 

1) Transverse fracture-direct blow

3) Comminuted fractures with a butterfly fragment-axial compression and bending

2) Transverse fracture-axial load on an extended metacarpophalangeal joint

5) Oblique-torsion and axial load

4) Spiral fracture-torsion

 

Biomechanically and clinically, fracture patterns are often associated with certain types of force. Transverse fractures occur with a direct blow, comminuted fractures occur with axial compression and bending, spiral fractures occur in torsion, and oblique fractures occur with torsion and axial load.Correct Answer: Transverse fracture-axial load on an extended metacarpophalangeal joint

 

 

1642. (3964) Q4-8216:

Giant cell tumor of tendon sheath commonly occurs in which of the following age groups:

 

1) Infants (age 0-1 year)

3) Age 10-20 years

2) Age 1-10 years

5) Age 60-70 years

4) Age 30-40 years

 

Giant cell tumor of tendon sheath is most commonly found in patients in the fourth through sixth decades; therefore, age 30-40 years is the most appropriate answer choice.Correct Answer: Age 30-40 years

 

Which of the following clinical features is common in giant cell tumor of tendon sheath:

 

1) Transillumination

3) Fluctuates in size

2) Erythematous

5) Painless

4) Presents with rapid change in size

 

Giant cell tumor of tendon sheath is painless. Giant cell tumor of tendon sheath does not transilluminate, as ganglion cyst does. No overlying skin color changes occur. Giant cell tumor of tendon sheath only increases in size and does not fluctuate like a ganglion cyst; it does not present with a rapid increase in size.Correct Answer: Painless

 

 

1644. (3966) Q4-8218:

After plain radiographs of giant cell tumor of tendon sheath are obtained, the following imaging study should be obtained:

 

1) Computed tomography scan

3) Magnetic resonance image

2) Ultrasound

5) Bone scan

4) Angiogram

 

Magnetic resonance imaging provides anatomic detail of the soft tissue mass, helps generate a differential diagnosis, and determines if the mass is unifocal or multifocal and where it originates. Giant cell tumor of tendon sheath is a soft-tissue tumor. Computed tomography is best for bone-based tumors. Ultrasound helps localize lesions but does not provide anatomic detail to help determine the type of mass. Although angiograms are useful for vascular tumors such as renal cell carcinoma or arteriovenous malformations, they are not necessary in the evaluation of a soft tissue mass in the hand with features suggestive of giant cell tumor of tendon sheath. A bone scan is useful when malignant bone tumors are suspected rather than benign soft tissue masses.Correct Answer: Magnetic resonance image

 

 

 

1645. (3967) Q4-8219:

Which of the following cell types is not typically found in giant cell tumors of tendon sheath:

 

1) Multinucleated giant cells

3) Monocytes

2) Histiocytes

5) Fibroblasts

4) Polymorphonuclear lymphocytes

 

Multinucleated giant cells, histiocytes, monocytes, and fibroblasts are commonly found in pathologic giant cell tumor of tendon sheath specimens. Polymorphonuclear lymphocytes are typically associated with bacterial infections.Correct Answer: Polymorphonuclear lymphocytes

 

 

 

 

 

A 25-year-old, right-hand-dominant male truck driver presents to the emergency department (Slide 1, Slide 2). The tip of his left ring finger was amputated in a bicycle accident 2 weeks prior. The amputated piece was âsewn back onâ in the emergency department immediately after the accident, but âturned blackâ over the next week. There is no evidence of infection. He states that the appearance of his finger is embarrassing, and he would like it taken care of as soon as possible. Which of the following procedures is the most appropriate:

 

1) Local debridement, allow to heal by secondary intention

3) Kutler V-Y advancement flap closure

2) Atasoy-Kleinert V-Y advancement flap closure

5) Split-thickness hypothenar skin graft

4) Moberg flap closure

 

The Atasoy-Kleinert V-Y advancement flap is the best option for transversely oriented fingertip amputations/defects and also for defects with more dorsal than volar tissue loss. The apex of the V is positioned at, or just distal, to the distal interphalangeal joint crease on the volar side of the digit. After incising the V marking, the flap is advanced distally to cover the defect, and the incisions are closed in a Y pattern.

 

Local, or chemical, debridement and allowing the resulting defect to heal by secondary intention are a viable option, but the patient stated that he would prefer an aggressive treatment protocol because the appearance of his fingertip is so embarrassing.

The Kutler (lateral) V-Y advancement flap is typically used to cover tip defects that demonstrate more volar than dorsal tissue loss. The procedure involves creating V-Y advancement flaps laterally on either side of the affected digit and advancing them toward each other in the midline thereby covering the defect.

 

The Moberg flap is typically used for reconstruction of thumb amputations. This procedure involves the creation of volar tissue flap that includes the neurovascular bundles on either side of the digit. Its use is cautioned in very distal amputations because excess stretch on the vascular pedicles may lead to necrosis at the tip of the flap. Its use is also cautioned in the fingers because of the difference in orientation of the blood supply compared to the thumb.

 

A full-thickness, rather than a split-thickness, skin graft is a viable option to manage this patient. Skin grafts for hand reconstruction should be harvested with the âlike replaces likeâ principle in mind, especially when reconstructing the volar skin. Volar hand skin is much thicker and of unique quality when compared with the rest of the body, and therefore, the most appropriate place to harvest a skin graft is the volar surface of the hand.

 

Correct Answer: Atasoy-Kleinert V-Y advancement flap closure

 

A 52-year-old, right-hand-dominant watchmaker arrives at the emergency department 30 minutes after the volar soft tissue of his right thumb and index finger was avulsed while using a bandsaw. Physical examination shows 2 cm 3 2 cm wounds involving the distal phalanx of each affected digit. No exposed tendon or bone is present, and no involvement of the joints is noted. The patient requests a treatment option that will retain the most sensation so he can effectively continue in his occupation. Which of the following options is the most appropriate management of this patientâs wounds:

 

1) Coverage with cross-finger flaps

3) Split-thickness skin grafting

2) Healing by secondary intention

5) Radial free forearm flap

4) Full-thickness skin grafting

 

Local flaps such as cross finger flaps are good options but require at least two surgeries (inset then division) and can often result in stiffness secondary to the requisite period of immobilization. In addition, local flaps have lesser return of sensibility than the other techniques listed.

 

Return of tactile sensibility is excellent after healing by secondary intention, but dressing changes for wounds that measure 2 cm 3 2 cm would take months to completely heal.

Skin grafting is the next available option with acceptable sensory return. It can be performed during local anesthesia, requires only one operation, and allows for early motion thereby avoiding stiffness. Studies have shown that full-thickness skin grafts recover sensation better than split-thickness skin grafts.

 

A radial forearm flap will be excessively bulky, has unacceptable donor site morbidity in this situation, and results in inadequate sensory recovery.

Correct Answer: Full-thickness skin grafting

 

 

1648. (3970) Q4-8222:

Which of the following is not considered a part of the triangular fibrocartilage complex:

 

1) Ulnolunate ligament

3) Dorsal radioulnar ligament

2) Palmar radioulnar ligament

5) Ulnotriquetral ligament

4) Radiolunate ligament

 

The triangular fibrocartilage complex is made up of the dorsal and palmar radioulnar ligaments, the meniscal homologue, the articular disk, the ulnolunate, and the ulnotriquetral ligaments. The radiolunate ligament is not part of the complex.Correct Answer: Radiolunate ligament

 

 

1649. (3971) Q4-8223:

Which of the following arterial branches does not supply the peripheral 25% of the triangular fibrocartilage complex:

 

1) Dorsal branch of the anterior interosseous artery

3) Dorsal branch of the radial artery

2) Palmar branch of the anterior interosseous artery

5) Palmar branch of the ulnar artery

4) Dorsal branch of the ulnar artery

 

The triangular fibrocartilage complex is supplied by both branches of the anterior interosseous artery and the ulnar artery; it is not supplied by the dorsal branch of the radial artery.Correct Answer: Dorsal branch of the radial artery

 

Which of the following statements is true:

 

1) In a wrist with neutral ulnar variance, 20% of the axial load is transmitted across the ulna.

3) In a wrist with 2.5 mm ulnar negative variance, 60% of the axial load is transmitted across the ulna.

2) In a wrist with 2.5 mm ulnar negative variance, 20% of the axial load is transmitted across the ulna.

5) In a wrist with 2.5 ulnar positive variance, 20% of the axial load is transmitted across the ulna.

4) In a wrist with 2.5 mm ulnar positive variance, 600% of the axial load is transmitted across the ulna.

 

Cadaveric studies have been performed to determine the amount of load across the wrist with various relationships between the radius and ulna lengths. In wrists with neutral ulnar variance (in which the radius and ulna are equal in length), 20% of the load is transmitted across the ulna and 80% is transmitted across the radius. In wrists with negative ulnar variance (in which the ulnar is shorter than the radius), more load is transmitted across the radius and less is transmitted across the ulna. The opposite is true with positive ulnar variance (the ulna is longer than the radius).Correct Answer: In a wrist with neutral ulnar variance, 20% of the axial load is transmitted across the ulna.

 

 

 

1651. (3973) Q4-8225:

Which of the following parameters is not a determinant of the Palmer classification of triangular fibrocartilaginous complex injuries:

 

1) Location of the lesion

3) Presence of lunatotriquetral ligament injury

2) Presence of ulnar head chondromalacia

5) Presence of ulnocarpal arthritis

4) Size of the lesion

 

The Palmer classification divides triangular fibrocartilage complex lesions into traumatic and degenerative. Traumatic subclassifications are based on the location of the ligament tear. In the degenerative tear, subclassifications are based on the degree of injury to the triangular fibrocartilage complex and associated chondral and ligamentous injury. Thus, the size of the lesion is not a parameter in the Palmer classification.Correct Answer: Size of the lesion

 

 

1652. (3974) Q4-8226:

What are the components of a Galeazzi fracture-dislocation:

 

1) Triangular fibrocartilage complex (TFCC) tear, interosseous membrane tear, and radial shaft fracture

3) Interosseous membrane tear and radial shaft fracture

2) Ulnar shaft fracture, interosseous membrane tear, and TFCC tear

5) Wrist radial collateral ligament tear, dorsal intercarpal ligament tear, and ulnar shaft fracture

4) TFCC tear and radial shaft fracture

 

Only one in vitro study examined the soft tissue constraints of the Galeazzi fracture-dislocation pattern. Moore and colleagues performed a radial osteotomy at the pronator teres insertion of nine cadaveric forearms and then sectioned the TFCC and the interosseous membrane in alternating orders. They found that all three structures (TFCC, interosseous membrane, and radial shaft) must be injured to create a radial shortening of more than 10 mm in relationship to the distal ulna.Correct Answer: Triangular fibrocartilage complex (TFCC) tear, interosseous membrane tear, and radial shaft fracture

 

 

1653. (3975) Q4-8227:

Who are the most common athletes to get medial epicondylitis of the elbow:

 

1) Tennis players

3) Swimmers

2) Golfers

5) Basketball players

4) Gymnasts

 

Although medial epicondylitis is called golferâs elbow, tennis players are more likely to have this condition. Medial epicondylitis can occur in any sport such as baseball pitching, javelin throwing, swimming, and gymnastics in which athletes place a significant valgus flexion force on their elbow.Correct Answer: Tennis players

 

 

 

1) A crush injury in a patient who smokes

3) An ischemia time of 24 hours

2) A sharp amputation of the thumb in a 15-year-old patient

5) A single digit amputation proximal to the flexor digitorum superficialis (FDS) insertion

4) The use of an amputated part that was immersed in warm water for transport

 

A sharp amputation, particularly of the thumb, is the best indication for replantation. Crushed digits, prolonged ischemia time, poor condition of the severed part, and single digit loss proximal to the FDS insertion on the middle phalanx are relative contraindications to replantation.

 

Correct Answer: A sharp amputation of the thumb in a 15-year-old patient

 

 

1655. (3993) Q4-8245:

An amputation through the wrist is an indication for attempted replantation.

 

1. True

2. False

    

   An amputation through the wrist, palm, or forearm is an indication for attempted replantation. The caliber of the vessels and other structures provides a favorable environment for reconstruction.

   Correct Answer: True

    

    

   1656. (3994) Q4-8246:

   Care of an amputated part prior to replantation includes:

    

   1. Painting the amputated part with povidone-iodine

3. Placing the amputated part in a warm saline bath

1. Immersing the amputated part in water

5) Putting the amputated part next to the patientâs body to keep it warm

4) Wrapping the amputated part with saline-soaked gauze and placing it in a plastic bag on ice

 

The appropriate care of an amputated part includes wrapping it in saline-dampened gauze and placing it on ice in a watertight bag. These actions preserve the tissues and slow cellular death until replantation is attempted. The part should not be immersed, painted with povidone-iodine, or kept next to the body.

 

Correct Answer: Wrapping the amputated part with saline-soaked gauze and placing it in a plastic bag on ice

 

 

1657. (3995) Q4-8247:

Replants are monitored by:

 

1) Color

3) Doppler probes

2) Turgor

5) All of the above

4) Temperature measurements

 

Monitoring of replanted parts postoperatively is accomplished by clinical checks of color or turgor to indicate blood flow. Additional objective monitoring is performed by using Doppler probes to check flow or by measuring temperature differences between the replanted part as compared to other digits.

 

Correct Answer: All of the above

 

Complications post-replantation include:

 

1) Cold intolerance

3) Excessive laxity of the digit

2) Stiffness

5) All of the above

4) A and B only

 

Complications after replantation include cold intolerance, which may improve over time, and stiffness of the replanted digit, which is generally due to immobility, tendon adhesions, and joint contracture.

Correct Answer: A and B only

 

 

1659. (4003) Q4-8255:

Placing some tension on a flexor tendon repair increases the ultimate tensile strength of the repair.

 

1. True

2. False

    

   Tension on the repair site of a flexor tendon laceration has been shown experimentally to increase the tensile strength of the repair.

   Correct Answer: True

    

    

   1660. (4004) Q4-8256:

   Flexor tendon nutrition is derived from:

    

   1. The vincula

3. Synovial diffusion

   1. The pulleys

   5) A and C only

   4) All of the above

    

   Flexor tendon nutrition in the uninjured state is derived via the vincula, which contain blood vessels for nutrition. Injured tendons obtain nutrition via diffusion of synovial fluid. The pulley system does not contribute to flexor tendon nutrition.

   Correct Answer: A and C only

    

    

   1661. (4005) Q4-8257:

   Immobilization as a postoperative therapy for flexor tendon repair is recommended for:

    

   1) Lacerations that involve both the flexor digitorum superficialis tendon and the flexor digitorum profundus tendon

   3) Children

   2) 2-strand tendon repairs

   5) Flexor tendon laceration in the thumb

   4) Associated pulley rupture

    

   As children have difficulties in following the detailed flexor tendon rehabilitation program that is recommended for adults after flexor tendon repair, it is advisable to completely immobilize them to protect the repair and avoid inadvertent rupture.

   Correct Answer: Children

    

   Optimization of early active motion protocols for flexor tendon rehabilitation includes:

    

   1) Multi-strand repair

   3) Using passive flexion of the finger to gain flexibility

   2) Splinting the digit in extension

   5) Ultrasound as an adjunct

   4) Therapist hyperextension of the finger

    

   The use of 6- and 8-strand repair techniques allow the flexor tendon repair to withstand the force applied by early active motion protocols. The addition of epitendinous tendon repair also strengthens the repair.

   Correct Answer: Multi-strand repair

    

    

   1663. (4007) Q4-8259:

   The splint for early active motion flexor tendon rehabilitation protocols includes:

    

   1) A wrist flexion piece

   3) A yoke over the affected finger

   2) A dynamic extension outrigger

   5) None of the above

   4) A hinge at the wrist to allow a tenodesis effect

    

   A hinge at the wrist, which provides a tenodesis effect, allows the patient to passively extend the wrist and flex the fingers in preparation for gentle muscle contraction of the fingers.

   Correct Answer: A hinge at the wrist to allow a tenodesis effect

    

    

   1664. (4010) Q4-8262:

   A 13-year-old boy tears his anterior cruciate ligament (ACL) while playing flag football. What is the preferred graft material for his ACL reconstruction:

    

   1) Bone-patellar tendon-bone autograft

   3) Four-strand hamstring tendon autograft

   2) Quadriceps tendon autograft

   5) Achilles tendon allograft

   4) Four-strand hamstring tendon allograft

    

   Due to the patients age, autograft is the preferred option. Also, due to the patientâs age, his growth plates are open and the surgeon is prohibited from using a graft with a bone construct due to the possible damage to the growth plate.

   Correct Answer: Four-strand hamstring tendon autograft

    

    

   1665. (4021) Q4-8274:

   What deformity can develop in a mistreated volar PIP joint dislocation?

    

   1) Swan neck deformity

   3) Boutonniere deformity

   2) Extensor lag

   5) Hyperextension deformity

   1. Flexion contracture

       

      With volar PIP joint dislocations, there is almost always a disruption of the central slip of the extensor tendon. Because the central slip is involved, the PIP joint will hold a flexed position, and the lateral bands will fall volar to the axis of rotation of the PIP joint. The lateral bands will then exacerbate the flexion at the PIP joint, and due to their pull on the terminal tendon at the insertion on the distal phalanx, the DIP joint will hyperextend. This results in a boutonniere deformity.Correct Answer: Boutonniere deformity

       

      What percentage of the articular surface must be involved in a dorsal PIP joint fracture dislocation for disruption of the collateral ligaments to occur?

       

      1) 20%

      3) 60%

      2) 40%

   2. 100%

4. 80%

 

The percentage of articular surface involved differentiates a stable dorsal PIP joint fracture dislocation from an unstable one. It is believed that when the involved fracture fragment is less than 40% of the articular surface, the insertion site of the collateral ligaments is not disrupted and the joint is stable. If more than 40% of the articular surface is fractured, then the insertion of the collateral ligaments is involved and the joint will subsequently be unstable.Correct Answer: 40%

 

 

1667. (4023) Q4-8276:

Which structures are disrupted in a lateral PIP joint dislocation?

 

1. Volar plate by itself

3) Volar plate, both collateral ligaments and central slip

2) Volar plate and both collateral ligaments

5) Volar plate and lateral bands

4) Volar plate and one collateral ligament

 

When a lateral PIP joint dislocation occurs, failure probably begins with disruption of the collateral ligament either from its origin on the head of the proximal phalanx or its insertion on the base of the middle phalanx. The injury then proceeds through the accessory collateral ligaments and terminates with disruption of the insertion of the volar plate on the middle phalangeal base.Correct Answer: Volar plate and one collateral ligament

 

 

1668. (4024) Q4-8277:

A 22-year old right-hand dominant male college student consumes a large amount of alcohol and falls asleep for eleven hours with his right arm over a chair. When he awakens, he is unable to feel the dorsum of his hand and cannot extend his elbow, wrist, or the metacarpalphalangeal joints of his affected arm. Initial management should consist of

 

1) Upper Extremity Angiography

3) Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

2) Observation

5) Emergent Nerve Exploration, with repair if necessary

4) Electromyography

 

Saturday night palsy is the term used for external compression of the radial nerve, and commonly occurs following the clinical scenario described above. The accepted treatment is observation, as Sunderland et al, described complete relief in all seven patients with Saturday night palsy after a period of observation without any adjunctive treatments. Although NSAIDs can be used if pain is a symptom or there is significant edema, these are not necessarily needed. Electromyography may be indicated if there is no improvement in symptoms after a three to six month period of observation. Emergent nerve exploration is indicated only for open fractures with a known radial nerve injury. There is no role for angiography in treatment of Saturday night palsy.Correct Answer: Observation

 

 

Flumazenil can be administered to reverse the effects of which of the following drugs:

 

1) Propofol

3) Midazolam

2) Fentanyl

5) Methohexital

4) Ketamine

 

Midazolam is a benzodiazepine. Flumazenil is the only commercially available benzodiazepine antagonist. The recommended dose is 0.01 mg/kg every minute until reversed to a maximum dose of 1 mg.

Fentanyl is an opioid and is reversible with naloxone. Flumazenil is a benzodiazepine antagonist and has no effects on the effects of opioids.

 

Propofol, ketamine, and methohexital have no known antagonists. Correct Answer: Midazolam

 

1670. (187) Q5-294:

A 7-year-old boy fell off the jungle gym and landed on his outstretched right arm sustaining a forearm fracture in both bones. The fracture requires reduction. He was given a combination of fentanyl and midazolam for sedation. At his current level of sedation, he is protecting his own airway. His oxygen saturation has dropped slightly to 92% but is stable. He does not display any awareness or discomfort when the fracture is being manipulated. How would you define his current level of sedation:

 

1) Analgesia

3) Deep sedation

2) Conscious sedation

5) Dissociative amnesia

4) General anesthesia

 

Deep sedation is the level where most fracture reductions are performed. Patients who are deeply sedated do not respond to verbal or noxious stimuli; they may display both a decreased ability to protect their airway and decreased respiratory drive.

Analgesia is defined as affecting the sensation of pain, however, there is no change in overall awareness.

Conscious sedation is defined as a lessening of awareness, with maintenance of protective reflexes. Patients will respond appropriately to commands and awaken to verbal stimuli. Patients do not respond to commands or noxious stimuli.

With general anesthesia, patients will not respond to verbal or noxious stimuli. Additionally, they lose all of their respiratory drive and ability to protect their airway.

Correct Answer: Deep sedation

 

A 14-year-old girl with a history of multiple food allergies and severe asthma was involved in a motor vehicle accident and sustained an isolated right femur fracture. Which of the following medications is the best choice to control her pain:

 

1) Ketamine

3) Methohexital

2) Morphine

5) Midazolam

4) Meperidine

 

The goal in this patient is to provide safe, effective, and long-acting analgesia. Meperidine is recommended in this circumstance. It is an opioid that provides intermediate and long-term analgesia. Additionally, it does not cause the associated histamine release and bronchospasm that can occur in patients with asthma and atopia.

 

Ketamine would provide short-term analgesia, but would also alter the level of consciousness.

Morphine is well known for precipitating bronchospasm in patients with atopia and asthma. Therefore, it would not be the best choice in the scenario presented.

Methohexital (a barbiturate) and midazolam (a benzodiazepine) both cause decreased awareness and have no analgesic properties.

Correct Answer: Meperidine

 

 

1672. (189) Q5-296:

Which of the following choices is the best for sedating an otherwise healthy child for a fracture reduction:

 

1) Morphine, diazepam

3) Fentanyl, diazepam

2) Meperidine, midazolam

5) Fentanyl, midazolam

4) Demerol, phenergan, and thorazine

 

The combination of fentanyl and midazolam is the closest we have to an ideal drug combination for conscious sedation. Both drugs have commercially available antagonists. Fentanyl and midazolam are both quick-onset and short-duration drugs. When using these two drugs together, there is a significant risk of respiratory depression. It is important to monitor patients closely.

 

Correct Answer: Fentanyl, midazolam

 

A 3-year-old child presents with an obvious right lower extremity abnormality. The left lower extremity has normal alignment and joint function. The right lower extremity displays a severely short thigh with a flexed hip. The right foot and leg are also abnormal. Radiographs reveal a right proximal femur with no femoral head or neck, as well as acetabular dysplasia. There is also fibular hemimelia and two missing lateral rays of the foot. The parents want treatment to preserve the function of the normal leg. The most appropriate treatment is:

 

1) Observation

3) Van Nes rotation-plasty

2) Right Syme's amputation with knee fusion and prosthetic fitting

5) Equinus prosthesis

4) Femoral lengthening

 

According to the Aitken classification, the patient has a type C proximal femoral focal deficiency (PFFD). In addition to a severe leg length discrepancy, a dysfunctional foot and ankle are also present. The patient would be best suited with an operative procedure to allow the development of ambulatory skills. The Syme's amputation with knee fusion is the standard procedure for severe PFFD and allows the patient to become proficient in the use of a prosthesis at an early age.

 

 

In a child this young, a rotation-plasty may not be the best option due to a propensity to de-rotate and the weakness of the underdeveloped right ankle.

 

For severe PFFD with unstable or dysplastic joints, lengthening is not the best option. If the leg length discrepancy were predicted to be <20 cm and a hip joint were present, then lengthening would be a better choice.

 

If the child had a mild leg length discrepancy and was a candidate for lengthening, then an equinus prosthesis would be a reasonable choice until appropriate age for lengthening.

Correct Answer: Right Syme's amputation with knee fusion and prosthetic fitting

 

 

1674. (191) Q5-298:

The most common associated abnormality with proximal femoral focal deficiency (PFFD) is:

 

1) Tibial hemimelia

3) Absent radius

2) Fibular hemimelia

5) Cardiac defects

4) Congenital scoliosis

 

Up to 45% of proximal femoral focal deficiency (PFFD) cases have coexisting fibular hemimelia.

 

Tibial hemimelia may also have associated abnormalities of the distal femoral physis leading to a varus knee, but PFFD is more common.

 

 

Absent radius is typically associated with thrombocytopenia agenesis radius (TAR) syndrome. Congenital scoliosis and cardiac defects are not commonly reported with PFFD.

Correct Answer: Fibular hemimelia

 

 

1675. (192) Q5-299:

Osteogenesis imperfecta (OI) is caused by defects in:

 

1) Calcitonin

3) Type II collagen

2) Type I collagen

5) Osteoclasts

4) Type X collagen

 

Both quantitative and qualitative defects in type I collagen lead to the various types of osteogenesis imperfecta (OI). Several hundred different collagen I mutations have been found in patients with OI. The less severe forms of OI are caused by mutations in which the defective gene product is not incorporated into collagen, so that formation of cells using the unimpaired strands can continue.Correct Answer: Type I collagen

 

 

Genetic transmission of osteogenesis imperfecta (OI) is best described as:

 

1) Autosomal dominant

3) Sex-linked dominant

2) Autosomal recessive

5) Not genetically transmitted

4) Autosomal dominant and autosomal recessive

 

Depending on the particular mutation involved, osteogenesis imperfecta can be either autosomal dominant or autosomal recessive. Osteogenesis imperfecta occurs because of a defect in type I collagen. The genes for type I collagen are found on chromosomes 7 and 17, and are therefore not sex-linked.

 

Correct Answer: Autosomal dominant and autosomal recessive

 

 

1677. (194) Q5-301:

Which type of osteogenesis imperfecta (OI) is most likely to be confused with child abuse:

 

1) Type I

3) Type III

2) Type II

5) Type I and Type II

4) Type IV

 

Osteogenesis imperfecta (OI) type IV can be mild, with normal sclera, normal teeth, and variable levels of hearing impairment. Such cases can be easily mistaken for child abuse.

 

While mild forms of OI type I do exist, the presence of blue sclera in all patients throughout life, and a high percentage of hearing impairment and dentinogenesis imperfecta help to rule out a diagnosis of child abuse.

 

Child abuse is not a consideration in OI type II because it is an extremely severe form of the disease and results in perinatal death.

 

 

OI type III is a severe progressively deforming form. Over one half of patients have fractures and deformities at birth. Short stature, kyphoscoliosis, and triangular faces help to distinguish OI type III from child abuse.

Correct Answer: Type IV

 

 

1678. (195) Q5-302:

The most common neurologic complications of osteogenesis imperfecta (OI) is:

 

1) Intracranial hemorrhage

3) Brainstem compression

2) Subdural hematoma

5) Herniated nucleus pulposes

4) Mental retardation

 

Basilar impression with brainstem compression is a neurologic sequela of the deforming types of osteogenesis imperfecta (OI). It can be identified by noting that the tip of the dens projects 7 mm or more above McGregor's line on plain film.Correct Answer: Brainstem compression

 

 

Criteria for diagnosis of neurofibromatosis 1 (NF1) include all the signs below except:

 

1) Café-au-lait spots

3) Axillary or inguinal freckling

2) Lisch nodules

5) A distinctive osseous lesion

4) Neurologic deficit

 

While neurologic deficit may be associated with some of the spinal deformities in neurofibromatosis 1 (NF1), it does not constitute one of the diagnostic criteria.

The diagnostic criteria for NF1 were established by The Consensus Development Conference on Neurofibromatosis at the National Institutes of Health in 1987:

 

 

Six or more café-au-lait spots, at least 15 mm in diameter in adults and 5 mm in children. Two or more neurofibromas of any type or one plexiform neurofibroma.

 

 

Freckling in the axillae or inguinal regions (Crowe sign). Two or more iris hamartomas (Lisch nodules).

 

 

A distinctive osseous lesion, such as sphenoid dysplasia or thinning of long bone cortex, with or without pseudarthrosis. A first-degree relative with NF1 by the above criteria.

Correct Answer: Neurologic deficit

 

 

1680. (197) Q5-304:

The most common osseous abnormality in neurofibromatosis 1 (NF1) is:

 

1) Congenital tibial dysplasia

3) Valgus deformity of the ankle

2) Scoliosis

5) Dysplasia of posterior cranial fossa

4) Macrodactyly

 

Of the many orthopedic manifestations of neurofibromatosis 1 (NF1), including kyphoscoliosis, lordoscoliosis, spondylolisthesis, congenital tibial dysplasia, segmental hypertrophy, cystic bone lesions, and subperiostial bone proliferation, scoliosis is the most common.

 

Correct Answer: Scoliosis

 

 

1681. (198) Q5-305:

The origin of "dumbbell lesions" found in radiographs of patients with neurofibromatosis 1 (NF1) is:

 

1) Flattening of the intervertebral disk with enlargement on the lateral borders

3) Neurofibromas or meningoceles that protrude through spinal foramina

2) Thinning of the midshaft of the tibia giving this bone the appearance of a dumbbell

5) Two closely spaced cysts within a bone

4) Subperiostial bone proliferation

 

Intraspinal lesions, such as neurofibromas and meningoceles, that protrude through the neural foramina give the radiologic appearance of a "dumbbell lesion."

 

 

 

Flattening of the intervertebral disk with enlargement of the lateral borders is not a feature of neurofibromatosis 1 (NF1). Tibial dysplasia seen in patients with NF1 lead to anterolateral bowing and does not give the appearance of a dumbbell. While subperiostial bone proliferation is seen in NF1, it does not give the appearance of a dumbbell.

 

Bone cysts are a recognized complication of NF1, but are not the origin of the dumbbell lesions seen on radiographs.

Correct Answer: Neurofibromas or meningoceles that protrude through spinal foramina

 

Which of the following treatments is contraindicated as treatment for kyphoscoliosis in neurofibromatosis 1 (NF1):

 

1) Laminectomy over the apex of the kyphosis

3) Bracing

2) Halo traction

5) Posterior spinal fusion

4) Anterior spinal fusion

 

Laminectomy is contraindicated because the cord is usually compressed anteriorly and resection removes bone necessary for fusion.Correct Answer: Laminectomy over the apex of the kyphosis

 

 

 

1683. (200) Q5-307:

A 1-year-old girl presents with a right lower extremity abnormality. Her parents report that she has been attempting to stand, but she has not yet walked. Clinically, she has a stiff, flexed, varus right knee with an obvious leg length discrepancy. Her ankle is also in a varus position. She does not spontaneously flex or extend the knee from its flexed position. Radiographs show that she has complete tibial hemimelia. The best choice of treatment at this time for the condition is:

 

1) Observation

3) Limb lengthening

2) Syme amputation

5) Brown procedure

4) Knee disarticulation

 

Knee disarticulation eliminates the malformed knee and ankle, allows the use of a prosthesis at an early age to promote ambulation development, and has good long-term results.

 

 

Observation is a poor option due to the severity of the deformity and the need for treatment to develop ambulation. Syme's amputation does not address the deformity of the knee.

 

In general, joint malformation or instability precludes lengthening procedures.

 

The Brown procedure centralizes the fibula at the knee and includes a Syme's amputation for the abnormal ankle. However, a functioning quadriceps is a prerequisite and there is a high likelihood of flexion contracture postoperatively.

Correct Answer: Knee disarticulation

 

 

1684. (201) Q5-308:

All of the following are consistent with tibial hemimelia (TH) except:

 

1) Hypoplastic distal femur

3) Ankle varus

2) Absent extensor mechanism

5) Knee flexion contracture

4) Knee valgus

 

All of the answers are consistent with tibial hemimelia (TH) except for knee valgus. The knee is typically in varus due to a present fibula in TH. The foot is typically also in equinovarus, and the leg segment is shortened. Knee disarticulation is the best treatment for a complete TH.Correct Answer: Knee valgus

 

 

A newborn boy presents with an abnormal right lower extremity. The right ankle is at the same level as the midshaft of the right tibia. The foot is also abnormal, and appears to be in a position of equinus and valgus. Radiographs confirm the equinovalgus of the foot, as well as absence of two lateral rays. There is also an absence of the fibula and anterolateral bowing of the tibia.

Treatment of the lower extremity should consist of:

 

1) Trans-tibial amputation

3) Observation

2) Limb lengthening

5) Tibial osteotomy

4) Syme amputation

 

Currently, the Syme's amputation (or modifications thereof) is the standard treatment for type II fibular hemimelia (FH). The procedure is usually delayed until the child is pulling to stand so that the child can begin walking with a prosthesis. The procedure has reports of excellent long-term results.

 

 

Trans-tibial amputation in a young child is not a good option due to secondary overgrowth of the distal limb residual and need for multiple revision surgeries.

 

Limb lengthening may be an option for a child with a mild type I fibular hemimelia with minimal foot and ankle deformity, however, this is not an option for type II FH because of the severe abnormality of the foot and ankle.

 

Observation as a form of treatment for a child with a type II FH will be unsuccessful because eventually surgical intervention will be needed due to the leg length discrepancy and prosthetic fitting issues.

 

Tibial osteotomy may occasionally be required for the tibial bowing, however, the bowing usually resolves on its own. This procedure does not address the deformity of the foot and ankle.

Correct Answer: Syme amputation

 

 

1686. (203) Q5-310:

Fibular hemimelia (FH) can be associated with which of the following abnormalities:

 

1) Femoral shortening

3) Equinovalgus foot

2) Anterior cruciate ligament (ACL) deficiency

5) All of the above

4) Tarsal coalition

 

All of the stated abnormalities can be found with femoral hemimelia. It is estimated that 15% of cases have femoral deficiency. Commonly seen in the condition are tarsal coalition, anterior cruciate ligament deficiency, and an equinovalgus foot.Correct Answer: All of the above

 

 

 

1687. (204) Q5-311:

A 7-year-old boy presents with bilateral high arches. His parents report that they are having difficulty finding shoes that comfortably fit him. The patient denies any foot pain. The father had similar problems with his feet and was diagnosed with a "mild" neurologic condition. On exam, the child has bilateral pes cavus with a supple hindfoot. Treatment of the feet at this time should consist of:

 

1) Soft tissue procedures alone

3) Triple arthrodesis

2) Soft tissue procedures and calcaneal osteotomy

5) Observation

4) Bracing

 

The child has a supple deformity secondary to Charcot-Marie-Tooth disease that will progress if untreated. Soft tissue procedures, which may consist of claw toe correction, plantar release, and possibly tendon transfer, are recommended for children younger than 8 years old who have a supple hindfoot.

 

 

The calcaneal osteotomy is reserved for patients with a rigid hindfoot.

 

Triple arthrodesis is a salvage procedure reserved for a fixed, painful foot in older children.

 

Bracing and observation are not preferred options due to the progressive nature of the disease, and the lack of ability to apply corrective forces to the foot in cavus.

Correct Answer: Soft tissue procedures alone

 

A 17-year-old man with Charcot-Marie-Tooth disease (CMT) presents with pain in his right foot. He has had no treatment for the foot in the past. On exam, he is noted to have a rigid pes cavus with hindfoot varus, as well as some weakness in the anterior tibialis and peroneal muscles. Radiographs display the above deformity with degenerative changes in the subtalar joint.

Treatment of the foot should consist of:

 

1) Observation

3) Triple arthrodesis

2) Nonsteroidal anti-inflammatory drugs (NSAIDs)

5) Soft tissue release and calcaneal osteotomy

4) Soft tissue release and tendon transfers

 

The patient has a rigid, painful deformity with radiographic signs of arthritis. A triple arthrodesis is his best chance at a pain-free, plantigrade foot.

 

Observation will not solve his pain due to the deformity and degenerative changes in the foot.

 

Nonsteroidal anti-inflammatory drugs (NSAIDs) may help with his pain, however, the degeneration in the foot will continue to progress.

 

Because the patient has a rigid deformity, soft tissue procedures will not alleviate the pain.

Correct Answer: Triple arthrodesis

 

 

1689. (206) Q5-313:

Which ancillary test is not helpful in the diagnosis of Charcot-Marie-Tooth disease (CMT):

 

1) Electromyography (EMG)

3) Nerve biopsy

2) Nerve conduction velocity (NCV)

5) Muscle enzymes

4) Muscle biopsy

 

Charcot-Marie-Tooth disease (CMT) is a neuropathic process resulting in muscle atrophy, therefore, muscle enzyme studies will not be helpful.

 

Electromyography (EMG) will confirm the diagnosis by displaying increased amplitude and duration of signals, both of which are indicative of a neuropathic process.

 

Nerve conduction velocity (NCV) will also confirm the diagnosis by displaying decreased motor and sensory conduction velocities.

 

 

Nerve biopsy can be helpful by showing loss of myelinated fibers and fibrosis. Muscle biopsy will show diffuse atrophy, fibrosis, and adipose tissue within muscle.

Correct Answer: Muscle enzymes

 

 

1690. (207) Q5-314:

Which of the following is not a feature of the foot deformity in Charcot-Marie-Tooth disease (CMT):

 

1) Hindfoot valgus

3) Plantarflexed 1st metatarsal

2) Forefoot pronation

5) Interphalangeal (IP) joint flexion

4) Metatarsophalangeal (MTP) joint hyperextension

 

Hindfoot varus develops to counter forefoot pronation due to weakness of evertors with preservation of inverter muscle strength.

 

The first metatarsal plantarflexes relative to the other metatarsals, leading to pronation of the forefoot.

 

 

Plantarflexion of the first metatarsal occurs as part of the windlass mechanism as the intrinsics and plantar fascia contract. As the intrinsics weaken, the toe extensors pull the metatarsophalangeal (MTP) joint into hyperextension as part of the claw toe deformity.

 

When the MTP joint hyperextends, the strength of the long toe flexors pulls the interphalangeal joint into flexion contributing to the claw toe deformity.

Correct Answer: Hindfoot valgus

 

Which of the following etiologies is not thought to be associated with pseudarthrosis of the clavicle:

 

1) Prominent cervical ribs

3) Cleidocranial dysplasia

2) Failure of fusion of the medial and lateral clavicular ossification centers

5) Stress lesion from dominant arm

4) Pressure from the higher position of the right subclavian artery

 

Several theories have been proposed to explain the rare phenomenon of isolated pseudarthrosis of the clavicle. The most accepted theory is pressure from the higher riding right subclavian artery. Pseudarthrosis has also been described in patients with prominent cervical ribs. Finally, some believe that this condition is caused by failure of fusion of the medial and lateral ossification centers of the clavicle. Cleidocranial dysplasia may be associated with pseudarthrosis of the clavicle. There is no evidence that they are related to stress.Correct Answer: Stress lesion from dominant arm

 

 

 

1692. (369) Q5-493:

The most common presenting symptoms of congenital pseudarthrosis of the clavicle are:

 

1) Enlarging mass and history of pseudoparalysis at birth

3) Minimally painful or painless prominence with no history of trauma

2) Refusal to use arm, palpable defect, and pain

5) Weakness in the distribution of the upper trunk of the brachial plexus

4) Limitation of abduction to less than or equal to 90°

 

The most common presentation of pseudarthrosis of the clavicle is a painless mass in right the clavicle. There is no history of trauma, and the child uses the extremity normally, with minimal pain, and with no signs of instability.

 

 

There is no history of pseudoparalysis involved with congenital pseudarthrosis. Arm use is nearly normal, except for aching with activity.

 

There is minimal restriction of motion with the pseudarthrosis, which is one reason it is sometimes not diagnosed until later in childhood.

 

There has not been neurologic impairment with this condition.

Correct Answer: Minimally painful or painless prominence with no history of trauma

 

 

1693. (370) Q5-494:

Which of the following statements regarding congenital pseudarthrosis of the clavicle is not true:

 

1) Congenital pseudarthrosis of the clavicle occurs primarily on the right, rarely bilaterally, and when occurring on the left, congenital pseudarthrosis of the clavicle is usually associated with dextrocardia.

3) Congenital pseudarthrosis of the clavicle is thought to occur due to pressure on the clavicle from the subclavian artery or prominent cervical ribs.

2) Congenital pseudarthrosis of the clavicle is strongly associated with neurofibromatosis and patients often have other pseudarthroses, with the tibia being the most commonly affected site.

5) Impairment of the upper trunk of the brachial plexus rarely develops over time.

4) Treatment for congenital pseudarthrosis of the clavicle involves intercalary bone grafting, plate, and screws.

 

Pseudarthrosis of the clavicle occurs primarily on the right side. The right predominance has been attributed to pressure on the right clavicle from the subclavian artery and occasionally cervical ribs. Treatment is straightforward with intercalary bone grafting with plate and screws fixation. There is no association with neurofibromatosis and/or pseudarthrosis of the tibia.

 

 

Unlike pseudarthrosis of the tibia, congenital pseudarthrosis of the clavicle is rarely, if ever, associated with neurofibromatosis

 

Pressure from the subclavian artery or prominent cervical ribs have been used to explain the observation that the pseudarthrosis is almost always located on the right, and if bilateral, it is associated with bilateral cervical ribs

 

Bone graft with plate fixation is the usual treatment for these cases, although there have been reports of success in younger children from simply suturing the periosteum of the two ends together

 

Brachial plexus impairment rarely develops in the untreated pseudarthrosis.

Correct Answer: Impairment of the upper trunk of the brachial plexus rarely develops over time.

 

 

 

1) Elevated erythrocyte sedimentation rate (ESR), positive antinuclear antibody (ANA), negative rheumatoid factor (RF), and HLA-DR4

3) Elevated ESR, negative ANA, positive RF, and HLA-B27

2) Normal ESR, negative ANA, negative RF, and HLA-B27

5) Normal ESR, positive ANA, positive RF, and HLA-B27

4) Elevated ESR, negative ANA, negative RF, and positive HLA-B27

 

Diagnostic work-up for an inflammatory autoimmune condition should include an erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), rheumatoid factor (RF), haplotype, and Lyme titer. The laboratory results most consistent with ankylosing spondylitis are an elevated ESR at the time of an acute exacerbation, negative ANA and RF, and a haplotype of HLA-B27.Correct Answer: Elevated ESR, negative ANA, negative RF, and positive HLA-B27

 

 

 

1695. (376) Q5-500:

Which of the following clinical features distinguishes homocystinuria from Marfan syndrome:

 

1) Lens dislocation

3) Chest wall abnormalities

2) Scoliosis

5) Delayed intellectual development

4) Tall stature

 

Patients with Marfan syndrome do not typically have defects in intellectual functioning, while patients with homocystinuria typically do show signs of delayed intellectual development.

Patients with Marfan syndrome and homocystinuria both develop lens dislocations, scoliosis, chest wall abnormalities, and tall stature.Correct Answer: Delayed intellectual development

 

 

 

1696. (377) Q5-501:

Patients with homocystinuria undergoing lower extremity and spinal surgery must be warned of an increased risk of which complication:

 

1) Aortic root dissection

3) Venous thromboembolic disease

2) High output heart failure

5) Spontaneous pneumothorax

4) Prolonged ventilator dependence

 

Arterial and venous thromboembolic disease is common in patients with homocystinuria. Patients are at increased risk for this major complication when undergoing any surgical procedure.

 

Unlike patients with Marfan syndrome, patients with homocystinuria do not develop aortic root dilation, aneurysms, mitral valve prolapse with high output heart failure, or spontaneous pneumothoraces.

 

Underlying lung pathology is not a feature of homocystinuria, therefore, these patients are not at an increased risk for prolonged ventilatory support.

Correct Answer: Venous thromboembolic disease

 

 

 

1) Translocation of chromosome 11 and 22

3) Methionine deficiency

2) Accumulation of cerebrosides in the reticuloendothelial system

5) Pyridoxine deficiency

4) Deficiency of cystathionine b-synthase

 

The metabolic disturbance responsible for homocystinuria is a deficiency of cystathionine ß-synthase.

 

 

A translocation of chromosome 11 and 22 is a feature of some patients with Ewingâs tumor. Accumulation of cerebrosides in the reticuloendothelial system is found in Gaucherâs disease.

 

Methionine is present in excessive quantities in homocystinuria because it cannot be converted to cysteine due to the deficiency of cystathionine ß-synthase.

 

Pyridoxine deficiency is a secondary feature of the disorder, but it is not the primary cause.

Correct Answer: Deficiency of cystathionine b-synthase

 

 

1698. (435) Q5-573:

Which form of chronic inflammatory arthritis is more common in boys than in girls?

 

1) Polyarticular

3) Systemic onset

2) Pauciarticular

5) Monoarticular

4) Seronegative spondyloarthropaty

 

Overall, juvenile rheumatoid arthritis (JRA) is much more common in girls. In pauciarticular JRA, the ratio is 4:1 female. In polyarticular JTA, it is 3:1 female, and in systemic JRA the ratio is 1:1. Seronegative spondylarthropathy is more common in males.

 

The incidence of polyarticular JRA is 3 times higher in girls than in boys. The incidence of pauciarticular JRA occurs 4 times more often in girls than in boys. Girls and boys are equally affected by systemic onset JRA.Correct Answer: Seronegative spondyloarthropaty

 

 

 

1699. (436) Q5-574:

Which of the following subtypes of juvenile rheumatoid arthritis (JRA) results in the highest risk of developing iritis:

 

1) Systemic JRA

3) Polyarticular JRA

2) Pauciarticular JRA

5) Eye involvement is not a problem in JRA

4) All are at approximately equal risk

 

Patients with pauciarticular juvenile rheumatoid arthritis (JRA) have the highest risk of developing iritis, cataracts, and blindness. Polyarticular JRA has the second highest risk. Patients with systemic JRA rarely develop iritis. All newly diagnosed JRA patients should be acutely evaluated and closely followed by an ophthalmologist.

 

Systemic-onset JRA has the lowest risk of uveitis There is a distinct difference among the types of JRA in terms of risk of eye involvement. Eye involvement is one of the problems physicians should be alert for in order to make an early diagnosis and prevent cataracts and blindness.Correct Answer: Pauciarticular JRA

 

 

arthritis:

 

1) CBC, ANA, RF, ESR, CRP, ophthalmology consult

3) CBC, echocardiogram, ANA, RF, and CRP

2) RF, CRP, ANA, ESR, and CBC

5) RF and synovial fluid analysis

4) HLA-typing, ophthalmology consult, ANA, RF, and CBC

 

Juvenile rheumatoid arthritis (JRA) is primarily a clinical diagnosis; however, routine screening tests should be ordered as part of a routine work-up. All patients should have a CBC, RF, ANA, ESR, CRP, and ophthalmology consult to look for eye involvement. An echocardiogram is not necessary unless a pericardial rub or other cardiac symptoms are present. HLA associations have been made with the different sub-types of the disease; however, this test is not necessary or diagnostic.

 

 

The CBC helps to rule out hematologic malignancy and assess the patientâs general health.

 

The ANA looks at the possibility of systemic lupus erythematosus and, if positive at low titer, heralds an increased risk of uveitis.

 

A positive RF helps rule in JRA and makes the risk of later erosive disease more likely.

 

ESR and CRP are helpful for monitoring disease activity. Ophthalmology consultation will help to rule out or detect uveitis at an early stage.

 

 

HLA typing is not indicated in the typical patient with JRA; it may be useful in the older male with axial symptoms. Synovial fluid analysis yields inflammatory fluid in this condition, but no information specific for the diagnosis.

Correct Answer: CBC, ANA, RF, ESR, CRP, ophthalmology consult

 

 

1701. (438) Q5-576:

A 7-year-old child sustained a type 3 closed supracondylar fracture of the humerus 2 hours ago. Neurologic function is intact, but a pulse cannot be found by palpation or doppler. The hand is slightly cool. Your next step is to perform:

 

1) Arteriogram of the extremity.

3) An attempt at closed reduction of the fracture

2) Injection of lidocaine into the antecubital region

5) Vascular repair

4) Open reduction of the fracture

 

Closed reduction should be carefully attempted at first, and often a tethered artery will be freed. If no pulse returns, open exploration is indicated if the hand remains cool.

 

 

An arteriogram is rarely indicated because it is unlikely to yield additional information. Lidocaine may be instilled if there is spasm at the time of open reduction.

 

Open reduction of the fracture is indicated only if closed reduction fails, or if the fracture is open.

 

Vascular repair is not the first step; exploration and repair should be carried out only if the pulse does not return after an attempt at closed reduction.

Correct Answer: An attempt at closed reduction of the fracture

 

 

 

1) Radial nerve

3) Ulnar nerve

2) Median nerve

5) Posterior interosseous nerve

4) Anterior interosseous nerve

 

The anterior interosseous nerve is the most commonly injured nerve. The anterior interosseous nerve can be tested by asking the patient to make an "O" with the thumb and index fingers, and watching for active flexion of the distal interphalangeal joints.

 

The radial nerve is the second most commonly injured, after the anterior interosseous nerve.

 

The ulnar nerve is not the most commonly injured at time of fracture but is the most commonly injured at time of treatment.

 

The posterior interosseous nerve is rarely injured.

Correct Answer: Anterior interosseous nerve

 

 

1703. (440) Q5-578:

A 9-year-old child presents one year after a supracondylar humerus fracture is healed. The elbow is in 15° more varus than the other side. Which of the following statements to the family is true:

 

1) This is likely to be due to growth plate damage in the distal humerus.

3) The deformity is probably due to hyperemia and overgrowth of the capitellum.

2) This is likely to correct fully before the end of growth.

5) The varus will likely lead to an increased likelihood of degenerative joint disease.

4) The deformity is likely due to malposition of the fracture during healing.

 

Fracture malalignment is the most common cause of cubitus varus.

 

Physeal damage is rare after supracondylar fractures.

 

 

Angular malalignment corrects slowly and incompletely in the distal humerus, especially in the coronal plane. There is no reason for selective hyperemia of the capitellum in this fracture.

 

There is no evidence of predisposition to degenerative joint disease in cubitus varus.

Correct Answer: The deformity is likely due to malposition of the fracture during healing.

 

 

1704. (441) Q5-579:

In what region of the United States is Lyme disease most prevalent:

 

1) Hawaii

3) Northeastern United States

2) Alaska

5) Southern United States

4) Lower Midwestern United States

 

Lyme disease is most common in the northern United States, Wisconsin, and California; however, the disease can occur anywhere. Vector ticks identified in Europe transmit several variations of Lyme disease.

Hawaii, Alaska, the lower midwestern states, and southern states do not have an increased incidence of Lyme diseaseCorrect Answer: Northeastern United States

 

 

 

 

1) Elevated erythrocyte sedimentation rate (ESR)

3) Negative antinuclear antibody (ANA)

2) Elevated C-reactive protein (CRP)

5) Elevated antibody titer to Borrelia burgdorferi

4) Negative rheumatoid factor

 

The most specific laboratory finding is an elevated antibody titer to Borrelia burgdorferi. This test is commonly referred to as a Lyme titer.

All of the mentioned tests are generally seen in Lyme disease, however, elevated erythrocyte sedimentation rate, elevated C-reactive protein, negative antinuclear antibody, and negative rheumatoid factor are all nonspecific.Correct Answer: Elevated antibody titer to Borrelia burgdorferi

 

 

 

1706. (443) Q5-581:

Which of the following statements is true regarding Lyme disease:

 

1) Cardiac and neurologic symptoms are the most common manifestations of the disease.

3) The characteristic skin rash occurs late in the disease and can be permanently disfiguring.

2) Arthritic symptoms primarily affect large joints and a majority of patients are cured with antibiotic therapy.

5) Lyme disease is easy to diagnose and a majority of cases are picked up after a few weeks.

4) Arthritic symptoms often do not fully resolve with antibiotic treatment, with a majority of patients progressing on to a rheumatoid-like destructive arthritis.

 

Approximately 60% of patients develop arthritic symptoms that primarily affect large joints. The prognosis for most patients is good after treatment with antibiotics.

 

 

Cardiac and neurologic symptoms occur in a minority of patients, however, they can be the most serious symptoms. Erythema chronicum migrans is the characteristic skin rash. The rash tends to remit with antibiotic treatment and permanent disfigurement is not typically a problem.

 

Only 1%-2% of pediatric patients develop chronic arthritis.

 

Lyme disease may be difficult to diagnose because of the numerous possible presentations.

Correct Answer: Arthritic symptoms primarily affect large joints and a majority of patients are cured with antibiotic therapy.

 

 

1707. (444) Q5-582:

Lyme disease is caused by which of the following organisms or mechanisms:

 

1) Group A Streptococcus

3) Vibrio vulnificus

2) Borrelia burgdorferi

5) Autoimmune disorder of unknown etiology

4) Group B Streptococcus

 

Lyme disease was initially thought to be an idiopathic autoimmune disorder; however, in the 1970s, researchers at Yale University identified Borrelia burgdorferi as the cause of the disease. The disease is transmitted by a deer tick known as Ixodes ricinusi.

Group A streptococcal pharyngitis may be followed by rheumatic fever, but not Lyme disease.

Vibrio vulnificus is the organism responsible for severe soft tissue infections in patients who are exposed to fresh-water shellfish. Group B Streptococcus is a common etiologic agent for necrotizing fasciitis.Correct Answer: Borrelia burgdorferi

 

 

 

1) Skin disfiguration from migratory rash

3) Rheumatic valvular heart disease

2) Disabling arthritis in affected joints

5) Decreased lung capacity secondary to fibrosis

4) Need for long-term prophylaxis for the prevention of relapses

 

The most serious potential long-term sequela of rheumatic fever is rheumatic valvular heart disease.

 

Patients do not develop any permanent skin lesions or joint disability from the disease.

Some patients require long-term prophylaxis to prevent recurrences, however, this is an inconvenience and not a sequela. The lungs are not affected in the acute fever or subsequent relapses.

Correct Answer: Rheumatic valvular heart disease

 

1709. (446) Q5-586:

Joint pain in rheumatic fever:

 

1) Affects 2 to 4 large joints over several months

3) Results in long-term disability with joint destruction

2) Responds to aspirin therapy

5) Is a major criterion for diagnosis

4) Is best treated with penicillin G

 

Joint pain is common in rheumatic fever. It is an intensely painful arthralgia that migrates from joint to joint within hours. The pain responds to aspirin therapy, as well as rest. Although oral penicillin G is used for treatment of the disease, it will not produce rapid resolution of the joint pain. In untreated cases, it can affect up to 16 joints. Most patients are left with no long-term sequelae or disability of the musculoskeletal system from rheumatic fever. Joint arthralgias are minor criteria for diagnosis.Correct Answer: Responds to aspirin therapy

 

 

 

1710. (447) Q5-587:

Patients with homocystinuria phenotypically resemble patients with:

 

1) Achondroplasia

3) Marfan syndrome

2) Larsen's syndrome

5) Noonan's syndrome

4) Gaucher's disease

 

Patients with homocystinuria may phenotypically resemble patients with Marfan syndrome. Patients with homocystinuria and Marfan syndrome are tall with long limbs, arachnodactyly, scoliosis, chest wall deformities, and lens dislocations.

 

 

Achondroplasia is characterized by short stature, frontal bossing, and rhizomelic shortening of the limbs. Larsen's syndrome is a disorder characterized by short stature and multiple joint dislocations.

 

Gaucher's disease is a lysosomal storage disease characterized by accumulation of cerebroside in cells of the reticuloendothelial system. As in patients with homocystinuria, patients with Gaucher's disease have osteoporosis, however, they do not develop any of the other phenotypic features seen in homocystinuria.

 

Noonan's syndrome effects boys and clinical features include short stature, a webbed neck, and cubitus valgus deformities.

Correct Answer: Marfan syndrome

 

 

 

1) Fibrillin

3) Fibroblast growth factor (FGF) receptor 3

2) Type I collagen

5) Hypoxanthine-guanine phosphoribosyl transferase

4) Dystrophin

 

Ehlers-Danlos syndrome (EDS) was once described as a single gene disorder affecting type I collagen, but it has since been discovered that EDS is a family of heterogeneous disorders with many described mutations. Type I collagen is defective in EDS type VII and collagen type III is defective in EDS type IV and VIII.

 

 

 

Fibrillin and fibroblast growth factor (FGF) receptor 3 are defective in Marfan syndrome and achondroplasia, respectively. Dystrophin is deficient in muscular dystrophy.

 

Hypoxanthine-guanine phosphoribosyl transferase is defective in Lesch-Nyhan syndrome.

Correct Answer: Type I collagen

 

 

1712. (449) Q5-590:

Which of the following features differentiates Marfan syndrome from Ehlers-Danlos syndrome (EDS):

 

1) Joint hypermobility

3) Lens dislocation

2) Scoliosis

5) Joint dislocations

4) Vascular problems

 

Patients with Ehlers-Danlos syndrome (EDS) and Marfan syndrome may have joint hypermobility, scoliosis, vascular problems, and recurrent joint instability. Patients with Marfan syndrome also develop lens dislocations, and while some patients with EDS exhibit eye problems, it is related to ocular globe fragility. Lens dislocation is not a feature of EDS.Correct Answer: Lens dislocation

 

 

 

1713. (450) Q5-591:

Which of the following statements concerning Ehlers-Danlos syndrome (EDS) is true:

 

1) EDS type III is the most severe form of the disease.

3) EDS type VII is characterized by dislocated hips and/or knees at birth.

2) EDS is primarily inherited as an autosomal dominant disorder.

5) Knowing the subtype of the disease does not affect the overall management of the patient.

4) Demonstrating joint hyperlaxity or voluntary dislocation in EDS patients does not damage the joint.

 

Ehlers-Danlos syndrome (EDS) types I, II, III, and VII are commonly seen by orthopedic surgeons. Type VII is characterized by congenital hip and knee dislocations.

 

 

EDS type III is the mildest form of the disease; the main symptom of this type is hyperlaxity. EDS may be inherited via any of the Mendelian patterns.

 

Children with EDS should be encouraged not to use their hyperlaxity as a âtrickâ because of potential long-term joint damage that may occur.

 

Knowing the subtype of the disease is often helpful in management and perioperative planning because than the surgeon may anticipate operative risks and potential complications.

Correct Answer: EDS type VII is characterized by dislocated hips and/or knees at birth.

 

 

 

1) EDS type I

3) EDS type III

2) EDS type II

5) EDS type VII

4) EDS type IV

 

Many of the mutations responsible for the differing subtypes of Ehlers-Danlos syndrome (EDS) have not been identified (EDS types I, II, and III). Lysyl hydroxylase deficiency has been identified as the cause of type IV. A mutation in type I collagen has been identified as the cause of EDS VII.Correct Answer: EDS type IV

 

 

 

1715. (452) Q5-593:

The most common type of chronic inflammatory arthritis in childhood is:

 

1) Pauciarticular juvenile rheumatoid arthritis

3) Systemic juvenile rheumatoid arthritis

2) Polyarticular juvenile rheumatoid arthritis

5) Reactive arthropathy

4) Seronegative spondyloarthropathy

 

Forty percent to 60% of children afflicted with juvenile rheumatoid arthritis (JRA) have the pauciarticular subtype. Polyarticular JRA is the second most common type occurring in 30%-40%. Systemic onset JRA is the least common form and occurs in approximately 20% of children. Seronegative spondyloarthropathy is more rare in patients <20 years old.

 

 

 

 

 

Polyarticular JRA comprises about 30%-40% of JRA. Systemic onset JRA is the least common form of JRA. Seronegative spondyolarthropathy is uncommon in childhood. Reactive arthropathy is not a chronic inflammation.

 

Correct Answer: Pauciarticular juvenile rheumatoid arthritis

 

 

1716. (453) Q5-594:

A 14-year-old left-handed boy suffers an avulsion of the medial epicondyle of the distal humerus when landing from a fall. The epicondyle is displaced 7 mm. His physical demands include swimming and lifting boxes. The recommended treatment for this injury is:

 

1) Open reduction and internal fixation

3) Percutaneous fixation in situ

2) Manipulation and percutaneous fixation

5) Excision of the fragment with reattachment of muscle to bone

4) Splint for 1 week

 

Unless the fragment is entrapped or significant valgus loading is anticipated, nonoperative treatment is indicated. Range of motion should be started within 1 week.

 

Open reduction is only indicated, if the epicondyle was entrapped in the joint, or if significant valgus loading was anticipated.

 

The results of nonoperative treatment are just as good as any invasive treatment.

 

Excision of the fragment is only indicated, if operative treatment is indicated, and the epicondyle is fragmented.

Correct Answer: Splint for 1 week

 

 

 

1) The medial humeral epicondyle is the first center to ossify in the distal humerus.

3) The medial humeral epicondyle is located anteromedially on the distal humerus.

2) The medial humeral epicondyle usually fuses to the distal humerus at age twelve.

5) The medial humeral epicondyle may ossify from several centers.

4) The medial humeral epicondyle is the origin of the wrist extensor muscles.

 

The medial epicondyle may have several ossification centers.

 

 

 

The medial epicondyle is the third center to ossify, beginning at age 4 to 6 years old. The medial epicondyle usually fuses near skeletal maturity, at approximately age 15. The medial epicondyle is located posteromedially.

 

The medial epicondyle is the origin of the flexor-pronator muscles.

Correct Answer: The medial humeral epicondyle may ossify from several centers.

 

 

1718. (455) Q5-596:

Which of the following statements is true regarding ankylosing spondylitis:

 

1) Radiographic changes present early.

3) It is a common inflammatory disorder affecting children < 8 years of age.

2) Characteristic features make it easy to diagnose.

5) Long-term prognosis is poor.

4) It is an inflammation of ligament insertions associated with HLA-B27.

 

Ankylosing spondylitis is an inflammatory enthesopathy that rarely affects children. Diagnosis is often difficult because the features may be similar to pauciarticular juvenile rheumatoid arthritis. It typically affects males >8 years of age. It is associated with haplotype HLA-B27. The long-term prognosis in these children is generally good.Correct Answer: It is an inflammation of ligament insertions associated with HLA-B27.

 

 

 

1719. (456) Q5-597:

A 4-year-old child injures his elbow and presents with swelling and limitation of voluntary movement. The radiographs show no obvious fracture, but it does show a Baumann angle of 71° and an elevation of the posterior fat pad. You tell the parents that this most likely represents:

 

1) A congenital anomaly with a valgus deformity of the elbow

3) A Salter I physeal separation

2) A medial epicondyle fracture

5) A variation of normal

4) An occult supracondylar fracture

 

Occult supracondylar fracture was the most common diagnosis assigned after careful study of a clinical series of elevated pediatric posterior fat pads.

 

 

The value for Baumann angle is normally 81° - 64°. Nothing in this description suggests a congenital anomaly. Medial epicondyle fractures are extremely rare before 9 years of age.

 

Although a Salter I physeal separation is a possibility, it is a rare injury.

 

With an elevation of the posterior fat pad, there is increasing recognition that a fracture exists.

Correct Answer: An occult supracondylar fracture

 

some overlap of the medial column and a gap on the lateral column of the distal humerus. Baumannâs angle measures 85Â

°-89º.The alignment on the lateral film shows no significant translation, but approximately 15° of increased extension. The recommended treatment is:

 

1) Accept this and treat in a long arm cast

3) Closed reduction with the elbow in extension to better monitor the angulation

2) Closed reduction with supination of the forearm and application of long arm cast

5) Open reduction and medial and lateral plate fixation

4) Closed reduction and percutaneous pin fixation

 

Closed reduction should allow regain of alignment and percutaneous pin fixation will allow it to be maintained.

 

 

The elbow is in 10°-15° of varus and this will be an objectionable appearance in the future. Supination will increase the varus.

 

 

Extension will exacerbate the deformity seen on the lateral and will cause further loss of contact of the fracture fragments. Medial and lateral plate fixation is needed in adolescents and adults with intercondylar fractures to allow early range of movement but is excessive treatment for this fracture in young children.

 

Correct Answer: Closed reduction and percutaneous pin fixation

 

 

1721. (465) Q5-641:

A 6-year-old girl presents with a fracture of the radial neck that is angulated 25° compared to the other side. No other abnormalities are seen. The recommended treatment is:

 

1) Sling and early range of motion

3) Reduction using a percutaneously placed K-wire with intraosseous fixation

2) Reduction using an intramedullary K-wire introduced from a retrograde approach (Metaizeau technique)

5) Open reduction and internal fixation

4) Open reduction without internal fixation

 

Fractures with angulation <30° have an excellent chance of remodeling, and can be left as they are with early range of motion. Reduction using an intramedullary K-wire introduced from a retrograde approach (Metaizeau technique) is indicated mainly for fractures angulated >30°.

 

 

Reduction using a percutaneously placed K-wire with intraosseous fixation, while effective, is not needed unless the fracture is angulated >30°.

 

Open reduction and internal fixation are indicated only if the fracture is angulated >50° and does not reduce by one of the manipulative techniques.

Correct Answer: Sling and early range of motion

 

 

1722. (466) Q5-642:

A 7-year-old boy falls and suffers a Salter type IV fracture of the proximal radius. The size of the displaced fragment is 40% of the radial head, and it is translated distally by 2 mm. The optimum treatment is:

 

1) Immobilization for 2 weeks with early range of motion

3) Percutaneous fixation in situ to prevent further displacement

2) Immobilization for 6 weeks with early range of motion

5) Open reduction, internal fixation

4) Excision of the radial head fragment

 

Because the displacement is likely to be >2 mm, open reduction may lessen the risk of problems with growth and mobility. This is suggested by clinical series.

 

The displacement is likely to be greater than the radiograph shows, and growth disturbance is likely. Range of motion at two weeks is too early.

 

Percutaneous fixation in situ would still carry a risk of growth disturbance, because the displacement is likely to be more than the plain radiographs show due to the largely cartilaginous nature of the radial head.

 

Excision of a fragment this large is likely to produce incongruity of the radio-capitellar joint.

Correct Answer: Open reduction, internal fixation

 

A 12-year-old boy sustains a Salter type II fracture of the proximal humerus during a fall. The fracture has an apex angulation of 40° anteriorly and laterally. The neurovascular examination is normal. The recommended treatment is:

 

1) Longitudinal traction in abduction followed by slowly bringing the arm into an abduction (airplane) splint

3) Open reduction and plate fixation

2) Closed reduction and percutaneous pin fixation

5) No formal reduction attempt, rather placement of the arm in a sling

4) Skeletal traction in abduction with an olecranon pin

 

Recommended treatment involves no formal reduction attempt, rather placement of the arm in a sling. This simple treatment is adequate for all patients with at least 2 years of growth remaining. This is due to the tendency to self-align, the remodeling potential, and the ability to tolerate some deformity in the region with no functional consequence.

 

 

The abduction splint is cumbersome. It is not necessary because simpler means are effective due to the young age and remodeling potential.

 

Closed reduction and pin fixation are not needed because adequate remodeling is expected. Any residual deformity is well tolerated in this region. The pins can sometimes cause significant soft tissue irritation in the bulky area of the shoulder.

 

 

Plate fixation is not feasible because of the open physis. It is also not necessary because simpler means are available. Skeletal traction is not needed because the humerus will align itself better with time in a dependent position.

Correct Answer: No formal reduction attempt, rather placement of the arm in a sling

 

 

1724. (468) Q5-644:

The most common cause of a pediatric pathologic fracture of the proximal humerus is:

 

1) Osteochondroma

3) Unicameral bone cyst

2) Osteogenic sarcoma

5) Fibrous cortical defect

4) Codman tumor (chondroblastoma)

 

The most common cause of a pathologic fracture of the proximal humerus is unicameral bone cyst. This fluid-filled cyst expands and weakens the humerus, often causing a fracture as its first evidence of existence.

 

Although the proximal humerus is one of the more common sites of their occurrence, osteochondromas do not significantly weaken the humerus.

 

 

Osteogenic sarcoma is a relatively rare bone tumor, and it does not weaken the bone until it is at an advanced stage. Codman tumor (chondroblastoma) is classically described in the proximal humerus, it is rare and typically epiphyseal in location, and does not appreciably weaken the bone.

 

Although fibrous cortical defects are common tumors, they rarely present in this way.

Correct Answer: Unicameral bone cyst

 

 

1725. (469) Q5-645:

A 6-year-old boy has a painful elbow, with swelling over the region of the olecranon. Radiographs reveal a thin sliver of bone that is displaced 4 mm from the proximal border of the olecranon. Treatment should consist of:

 

1) Closed treatment in a cast in 90° of flexion

3) Open excision of the osseous fragment

2) Closed treatment in a cast in extension

5) No immobilization; early range of motion

4) Open reduction and tension band fixation

 

Open reduction and tension band fixation is the best method to hold the proximal ulnar apophysis.

 

The patient has a âsleeveâ fracture that should be reduced because it is attached to the olecranon apophysis.

 

The osseous fragment is attached to the entire olecranon apophysis, which develops a secondary ossification center at age 9.

 

With early range of motion, further displacement and/or nonunion may develop.

Correct Answer: Open reduction and tension band fixation

 

Which of the following statements is true about the radiographic development of the proximal ulna:

 

1) A small sliver of a secondary ossification center is present at birth.

3) A secondary ossification center appears at 7 years of age.

2) A secondary ossification center appears at 5 years of age.

5) There is no secondary ossification center for this region.

4) A secondary ossification center appears at 9 years of age.

 

There is a secondary ossification center developing in children approximately 9 years of age. There is no ossification center in the proximal ulna until the child reaches 9 years old.Correct Answer: A secondary ossification center appears at 9 years of age.

 

 

 

1727. (471) Q5-647:

A 14-year-old boy sustains an intercondylar fracture of the distal humerus. There is a single fracture line into the joint between the capitellum and the trochlea. The medial column of the distal humerus is comminuted, but the lateral column is not. All fragments are highly displaced. Neurovascular status is normal. The recommended treatment is:

 

1) Olecranon pin traction overhead for 2 weeks and long arm cast

3) Closed reduction and pin fixation

2) Closed reduction and long arm cast

5) Open reduction and dual plate fixation through a posterior approach

4) Open reduction and dual plate fixation through an anterior incision

 

A posterior approach (Bryan-Morrey or olecranon osteotomy) will facilitate anatomic reduction and rigid fixation sufficient for early range of motion.

 

 

Prolonged traction and cast will result in an incomplete reduction and excessive stiffness. A cast alone will result in an incomplete reduction and excessive stiffness.

 

Rigid fixation with plates, rather than pins, is required to maintain reduction of these fractures and allow early range of motion.

 

An anterior approach will not allow adequate exposure of the distal humerus for articular fixation.

Correct Answer: Open reduction and dual plate fixation through a posterior approach

 

 

1728. (472) Q5-648:

In treating which of the following elbow fractures is it most important to begin early range of motion:

 

1) Salter I physeal fracture of distal humerus

3) Supracondylar fracture of distal humerus

2) Intercondylar (T-condylar) fracture of distal humerus

5) Lateral epicondyle fracture

4) Lateral condyle fracture

 

Intercondylar fractures have a significant risk of loss of motion because of the magnitude of injury, intra-articular extension, and older age of patient.

 

Salter I physeal fractures typically occur in young children. They usually pose no difficulty with regaining motion after 4 to 6 weeks of immobilization.

 

Supracondylar fractures usually are followed by regaining motion after healing despite immobilization of up to 6 weeks or more.

 

 

Patients with this fracture usually regain their motion after healing. Because this is a nonarticular fracture, loss of motion is not a high risk.

Correct Answer: Intercondylar (T-condylar) fracture of distal humerus

 

A previously healthy 3-year-old girl presents with 3 weeks of painful torticollis and facial asymmetry. A birth history reveals a normal vaginal delivery with no perinatal complications. The girl has no history of esophagitis or gastrointestinal problems. Her mother reports that approximately 1 month ago, the young girl had an upper respiratory tract infection that has since resolved. The most likely diagnosis is:

 

1) Muscular torticollis

3) Grisel syndrome

2) Os odontoideum

5) Pseudosubluxation of C 2 on C 3

4) Sandifer syndrome

 

Grisel syndrome is an abnormal rotation of the atlantoaxial joint that produces painful torticollis and often follows an upper respiratory tract infection.

 

Muscular torticollis is unlikely in this patient because this condition is usually attributed to a difficult delivery, breech presentation, or some type of in utero positioning problem. Furthermore, muscular torticollis usually presents itself within the first 4-6 weeks and has no association with respiratory infections.

 

Symptoms associated with os odontoideum consist of neck pain, paresthesia, transient paresis, or myelopathy. Patients with os odontoideum do not have torticollis.

 

Sandifer syndrome is a painful torticollis and the abnormal trunk rotation is associated with gastroesophageal reflux disease.

 

Pseudosubluxation does not produce painful torticollis.

Correct Answer: Grisel syndrome

 

 

1730. (507) Q5-706:

A computerized tomography (CT) scan of the neck reveals an atlantoaxial rotatory displacement with 6 mm of anterior translation. The most likely associated anatomic defect is:

 

1) Disruption of both the transverse ligament of C 1 and the alar ligaments

3) Disruption of the anterior and posterior longitudinal ligaments

2) Odontoid fracture

5) Ossiculum terminale

4) Disruption of the ligamentum flavum between C 1 and C 2

 

In order to have anterior displacement of C 1 on C 2 >5 mm, there must be disruption of both the transverse ligament of C 1 and the alar ligaments.

 

Odontoid fracture does not disrupt the articulation between the dens and the atlas, therefore, there would be no abnormal diastasis between the atlas and the dens.

 

The anterior and posterior longitudinal ligaments attach to the anterior and posterior aspects of the vertebral bodies respectively. Insufficiency does not affect the atlantoaxial articulation.

 

Disruption of the ligamentum flavum alone is not thought to result in translation of C 1 on C 2.

 

An ossiculum terminale is a persistent growth center at the tip of the odontoid, but is not indicative of any pathological condition.

Correct Answer: Disruption of both the transverse ligament of C 1 and the alar ligaments

 

A 14-year-old ice hockey player had a jersey pulled over his head in a brawl during a game. He finished the game without incident and denies any other traumatic event. The boy presents the following day with a stiff neck tilted to the right side and an inability to bring his head to a neutral position. On more careful physical examination, the boyâs head is tilted to the right 20°, rotated to the left 20°, and slightly flexed. Attempts at passive rotation to a neutral position produce pain. The exam is otherwise unremarkable. Computerized tomography scans show atlantoaxial rotatory displacement with no anterior displacement of C 1 on C 2. Treatment should include:

 

1) Urgent C 1 to C 2 fusion

3) Head halter traction and NSAIDs

2) Use of a soft collar, exercises, and nonsteroidal anti-inflammatory drugs (NSAIDs)

5) Occiput to C 2 fusion

4) Philadelphia collar, Minerva casting, and NSAIDs

 

A soft collar, exercises, and nonsteroidal anti-inflammatory drugs (NSAIDs) should be tried for 1 week if the diagnosis of atlantoaxial rotatory displacement is made within a week of its onset. The patientâs progress must be followed closely. If NSAIDs and a collar do not work after 1 week, the patient should be hospitalized and head halter traction should be administered along with muscle relaxants. If head halter traction successfully reduces the deformity, the patient should be placed in a Philadelphia collar with Minerva casting for 6 weeks. If the patient has no neurologic findings and no anterior displacement, the condition is likely to resolve with conservative measures alone. If surgery becomes necessary, the occiput should not be included in surgical treatment of atlantoaxial rotatory displacement.Correct Answer: Use of a soft collar, exercises, and nonsteroidal anti-inflammatory drugs (NSAIDs)

 

 

 

1732. (509) Q5-709:

Congenital pseudarthrosis of the clavicle occurs most commonly on which side:

 

1) Bilateral

3) Left

2) Right

5) The side with the proximal focal femoral dysplasia

4) The side more involved with fibrous dysplasia

 

Ninety percent of cases are noted on the right side. Ten percent of cases are bilateral and have been associated with bilateral cervical ribs. Only a few cases of left-sided pseudarthrosis have been described and have been associated with dextrocardia.

 

 

Only <5% of cases of congenital pseudarthrosis are on the left. Congenital pseudarthrosis is not related to fibrous dysplasia.

 

Congenital pseudarthrosis is not related to proximal focal femoral dysplasia.

Correct Answer: Right

 

 

1733. (510) Q5-710:

The most common structure to be injured in conjunction with an elbow dislocation is:

 

1) The ulnar nerve

3) The radial nerve

2) The median nerve

5) The biceps tendon

4) The brachial artery

 

With an injury rate of approximately 6%, the ulnar nerve is the most common injured structure in an elbow dislocation.

 

Median nerve injuries are rare with elbow dislocation. Such injuries may be due to nerve entrapment. If chronic, this may produce the Matev sign of a groove in the distal humerus.

 

 

The radial nerve and biceps tendon are not commonly injured with an elbow dislocation. The brachial artery is rarely injured with an elbow dislocation.

Correct Answer: The ulnar nerve