FREE Orthopedics MCQS 2022 1501-1550

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

1504. (2357) Q4-2815:

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. C linical 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.

Diagnosis of the condition is:

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. C linical 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

1506. (2359) Q4-2817:

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. C linical 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 least helpful test in further management of this patient is:

1) Magnetic resonance imaging (MRI)

3) Repeat electromyelogram (EMG) after 4 weeks

2) C omputed tomography (C T) scan of the neck

5) C areful neurological examination

4) Somatosensory evoked potential (SSEP)

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

 

■Correct Answer:C omputed tomography (C T) 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. C linical 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) C ontinued 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

1508. (2361) Q4-2819:

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. C linical 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 indication for early exploration in this patient is:

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 (EC RL) 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, EC RLâC 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 (EC RL) 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. C linical 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

1510. (2363) Q4-2821:

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.

Diagnosis of this condition is:

1) Erbâs palsy

3) C erebrovascular 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. C ombined 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

1512. (2365) Q4-2823:

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.

Appropriate surgical management in this case is:

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

1514. (2367) Q4-2826:

Which mechanism and long-term deformity is most often associated with a dorsal avulsion fracture at the base of the middle phalanx:

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 (MC P) joint flexion

3) 60º of MC P joint flexion

2) 30º of MC P joint flexion

5) 120º of MC P joint flexion

4) 90º of MC P joint flexion

At 30º of MC P joint flexion, the ulnar collateral ligament is isolated from the volar plate.

■Correct Answer:30º of MC P 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

1518. (2371) Q4-2830:

Which of the following is not usually associated with radial deficiency:

1) Thrombocytopenia absent radii

3) Holt-Oram syndrome

2) Fanconi anemia

5) C ardiac 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) C apitohamate

2) Scapholunate

5) C apitolunate

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) C lose reduction and casting

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

5) Open reduction

4) C lose 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

1522. (2375) Q4-2834:

A patient presents with hand weakness. On examination, she has no sensory deficient, decreased strength with pronation, and her elbow is at 90º of flexion and pulp-to-pulp contact on key pinch. The most likely diagnosis is:

1) C arpal tunnel syndrome

3) Posterior interosseous nerve syndrome

2) Anterior interosseous nerve syndrome

5) Martin-Gruber connection

4) C ubital 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) C losed head injury

5) C oncomitant 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:C oncomitant proximal humeral fracture

1526. (2379) Q4-2838:

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) C rush injuries to the distal forearm

2) Warm ischemia time of less than 16 hours

5) Sharp amputation proximal to the elbow

4) C old 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

1530. (2383) Q4-2842:

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) C entral 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

1533. (2386) Q4-2845:

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.

1535. (2388) Q4-2847:

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) C entralization

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

1537. (2390) Q4-2849:

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 (VAC TERL)

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 VAC TERL 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) C ardiac defects

5) Vertebral defects

4) Malignancy

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

■Correct Answer:C ardiac defects

1540. (2393) Q4-2852:

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) C entralization

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.

C entralization 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.

1543. (2396) Q4-2855:

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) C ircular 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

1546. (2399) Q4-2858:

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 (VAC TERL)

5) Femur-fibular-ulnar syndrome

4) Thrombocytopenia absent radii (TAR) syndrome

VATER, VAC TERL, 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) C arpal 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.

1550. (2403) Q4-2862:

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