Hand 2014

Question 1

8. A patient has weakness with shoulder abduction and elbow flexion after a motorcycle collision. During an evaluation with electromyography and nerve conduction studies, what is the significant of a normal signal in the rhomboid muscle?
9. Predicts recovery of the biceps
10. Predicts recovery of the deltoid
11. Identified brachial plexus injury
12. Identifies injury􀀃 􀀖􀀑􀀃􀀃􀀃􀀬􀁇􀁈􀁑􀁗􀁌􀂿􀁈􀁖􀀃􀁄􀀃􀁅􀁕􀁄􀁆􀁋􀁌􀁄􀁏􀀃􀁓􀁏􀁈􀁛􀁘􀁖􀀃􀁌􀁑􀁍􀁘􀁕􀁜to the cervical spine
13. Identifies a cervical root avulsion from the spinal cord.

􀀃 􀀗􀀑􀀃􀀃􀀃􀀬􀁇􀁈􀁑􀁗􀁌􀂿􀁈􀁖􀀃􀁄􀁑􀀃􀁌􀁑􀁍􀁘􀁕􀁜􀀃􀁗􀁒􀀃􀁗􀁋􀁈􀀃􀁆􀁈􀁕􀁙􀁌􀁆􀁄􀁏􀀃􀁖􀁓􀁌􀁑􀁄􀁏􀀃􀁆􀁒􀁕􀁇

􀀃 􀀘􀀑􀀃􀀃􀀃􀀬􀁇􀁈􀁑􀁗􀁌􀂿􀁈􀁖􀀃􀁄􀀃􀁆􀁈􀁕􀁙􀁌􀁆􀁄􀁏􀀃􀁕􀁒􀁒􀁗􀀃􀁄􀁙􀁘􀁏􀁖􀁌􀁒􀁑􀀃􀁉􀁕􀁒􀁐􀀃􀁗􀁋􀁈􀀃􀁖􀁓􀁌􀁑􀁄􀁏􀀃􀁆􀁒􀁕􀁇

Answer 1

3. Identified brachial plexus injury

RECOMMENDED READINGS

Tubbs RS, Tyler-Kabara EC, Aikens AC, Martin JP, Weed LL, Salter EG, Oakes WJ. Surgical anatomy of the dorsal scapular nerve. J Neurosurg. 2005 May;102(5):910-1. PubMed PMID: 15926718.

Balakrishnan G, Kadadi BK. Clinical examination versus routine and paraspinal electromyographic studies in predicting the site of lesion in brachial plexus injury. J Hand Surg Am. 2004 Jan;29(1):140-3. PubMed PMID: 14751117.

Question 2

15. A 30-year-old man sustained a C5-C6 nerve root avulsion 3 months ago as a result of a motor vehicle collision. What is the most appropriate treatment option?
16. Explore the brachial plexus and repair avulsed nerve roots
17. Transfer tendon of the posterior deltoid to the central tendon of the biceps
18. Transfer the intercostal nerves to the posterior cord of the brachial plexus
19. Recommend surgical reconstruction if the elbow flexion does not return within 6 months. 􀀃 􀀗􀀑􀀃􀀃􀀃􀀵􀁈􀁆􀁒􀁐􀁐􀁈􀁑􀁇􀀃􀁖􀁘􀁕􀁊􀁌􀁆􀁄􀁏􀀃􀁕􀁈􀁆􀁒􀁑􀁖􀁗􀁕􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁌􀁉􀀃􀁈􀁏􀁅􀁒􀁚􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀃􀁇􀁒􀁈􀁖􀀃􀁑􀁒􀁗􀀃􀁕􀁈􀁗􀁘􀁕􀁑􀀃􀁚􀁌􀁗􀁋􀁌􀁑􀀃􀀙􀀃􀁐􀁒􀁑􀁗􀁋􀁖
20. Transfer fascicles of the ulnar nerve to the motor nerve of the biceps and fascicles of the median nerve to the motor nerve of the brachialis

Answer 2

5. Transfer fascicles of the ulnar nerve to the motor nerve of the biceps and fascicles of the median nerve to the motor nerve of the brachialis

RECOMMENDED READINGS

Teboul F, Kakkar R, Ameur N, Beaulieu JY, Oberlin C. Transfer of fascicles from the ulnar nerve to the nerve to the biceps in the treatment of upper brachial plexus palsy. J Bone Joint Surg Am. 2004 Jul;86-A(7):1485-90. PubMed PMID: 15252097.

Question 3

28. A 22-year-old man injured the dorsal aspect of his long finger with a grinder wheel. The defect over the middle phalanx is 1.5 x 1 cm with the bone exposed and no periosteum. Which procedure will providesoft-tissue coverage of the defect?
29. Axial flap􀀃 􀀔􀀑􀀃􀀃􀀃􀀤􀁛􀁌􀁄􀁏􀀃􀃀􀁄􀁓
30. Full-thickness skin graft
31. Split-thickness skin graft
32. Cross-finger flap from the index finger
33. Cross-finger flap from the ring finger􀀃 􀀗􀀑􀀃􀀃􀀃􀀦􀁕􀁒􀁖􀁖􀀐􀂿􀁑􀁊􀁈􀁕􀀃􀃀􀁄􀁓􀀃􀁉􀁕􀁒􀁐􀀃􀁗􀁋􀁈􀀃􀁌􀁑􀁇􀁈􀁛􀀃􀂿􀁑􀁊􀁈􀁕

􀀃 􀀘􀀑􀀃􀀃􀀃􀀵􀁈􀁙􀁈􀁕􀁖􀁈􀀃􀁆􀁕􀁒􀁖􀁖􀀐􀂿􀁑􀁊􀁈􀁕􀀃􀃀􀁄􀁓􀀃􀁉􀁕􀁒􀁐􀀃􀁗􀁋􀁈􀀃􀁕􀁌􀁑􀁊􀀃􀂿􀁑􀁊􀁈􀁕

Answer 3

5. Reverse cross-finger flap from the ring finger.

Question 4

39. A 2-year-old has a 1-year history of atraumatic stiffness of her middle finger. Her mother observes frequent locking of the finger into flexion. This condition is most successfully treated with
40. nighttime static splinting into extension
41. surgical release of the first annular (A-1) pulley.
42. excision of 1 slip of teh sublimus flexor digitorum superficialis tendon.
43. corticosteroid injection of the flexor tendon sheath
44. observation with expected spontaneous resolution

Answer 4

3. excision of 1 slip of the sublimus flexor digitorum superficialis tendon.

RECOMMENDED READINGS

Moon WN, Suh SW, Kim IC. Trigger digits in children. J Hand Surg Br. 2001 Feb;26(1):11-2. PubMed PMID: 11162006.

􀀦􀁄􀁕􀁇􀁒􀁑􀀃􀀯􀀭􀀏􀀃􀀨􀁝􀁄􀁎􀁌􀀃􀀰􀀏􀀃􀀦􀁄􀁕􀁗􀁈􀁕􀀃􀀳􀀵􀀑􀀃􀀷􀁕􀁌􀁊􀁊􀁈􀁕􀀃􀂿􀁑􀁊􀁈􀁕􀀃􀁌􀁑􀀃􀁆􀁋􀁌􀁏􀁇􀁕􀁈􀁑􀀑􀀃􀀭􀀃􀀫􀁄􀁑􀁇􀀃􀀶􀁘􀁕􀁊􀀃􀀤􀁐􀀑􀀃􀀔􀀜􀀜􀀜􀀃􀀱􀁒􀁙􀀞􀀕􀀗􀀋􀀙􀀌􀀝􀀔􀀔􀀘􀀙􀀐􀀙􀀔􀀑􀀃

Question 5

65. Following hand tendon suture (repair or transfer), which method of intrasurgical inspection provides the

best understanding of translation, gliding, and tension?

1. Tenodesis examination
2. Active motion during surgery
3. Passive extension of the wrist and digit
4. Nerve stimulation to general finger motion
5. Observation for kinking of the tendon during passive flexion and extension. 􀀃 􀀗􀀑􀀃􀀃􀀃􀀱􀁈􀁕􀁙􀁈􀀃􀁖􀁗􀁌􀁐􀁘􀁏􀁄􀁗􀁌􀁒􀁑􀀃􀁗􀁒􀀃􀁊􀁈􀁑􀁈􀁕􀁄􀁗􀁈􀀃􀂿􀁑􀁊􀁈􀁕􀀃􀁐􀁒􀁗􀁌􀁒􀁑

􀀃 􀀘􀀑􀀃􀀃􀀃􀀲􀁅􀁖􀁈􀁕􀁙􀁄􀁗􀁌􀁒􀁑􀀃􀁉􀁒􀁕􀀃􀁎􀁌􀁑􀁎􀁌􀁑􀁊􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁗􀁈􀁑􀁇􀁒􀁑􀀃􀁇􀁘􀁕􀁌􀁑􀁊􀀃􀁓􀁄􀁖􀁖􀁌􀁙􀁈􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁈􀁛􀁗􀁈􀁑􀁖􀁌􀁒􀁑

Answer 5

2. Active motion during surgery

RECOMMENDED READINGS

Lalonde D. How the wide awake approach is changing hand surgery and hand therapy: inaugural AAHS sponsored lecture at the ASHT meeting, San Diego, 2012. J Hand Ther. 2013 Apr-Jun;26(2):175-8. doi: 10.1016/j.jht.2012.12.002. Epub 2013 Jan 5. PubMed PMID: 23294825.

Question 6

75. A 52-year-old mechanic has painful, cold ring and small fingers and ulcerations at the tip of his small finger. An ulnar artery aneurysm is identified on arteriogram. He has a digital-branchial index result of 0.5. Which treatment most likely will reduce his symptoms?
76. Ulnar artery ligation
77. Ulnar artery reconstruction
78. Release of the Guyon’s canal
79. Thrombolysis of the ulnar artery
80. Radial artery to the ulnar artery bypass graft

Answer 6

2. Ulnar artery reconstruction

RECOMMENDED READINGS

Chloros GD, Lucas RM, Li Z, Holden MB, Koman LA. Post-traumatic ulnar artery thrombosis: outcome of arterial reconstruction using reverse interpositional vein grafting at 2 years minimum follow-up. J Hand Surg Am. 2008 Jul-Aug;33(6):932-40. Cdoi: 10.1016/j.jhsa.2008.02.011. PubMed PMID: 18656768.

McClinton MA. Reconstruction for ulnar artery aneurysm at the wrist. J Hand Surg Am. 2011 Feb;36(2):328-32. doi: 10.1016/j.jhsa.2010.11.021. Review. PubMed PMID: 21276898.

Question 7

96. Contracture of the web space in Dupuytren’s disease is attributed to involvement of which structure?
97. Spiral band
98. Natatory ligament
99. Grayson’s ligament
100. Pretendinous bands
101. Septa of Legueu and Juvara

Answer 7

2. Natatory ligament

RECOMMENDED READINGS

Strickland JW, Leibovic SJ. Anatomy and pathogenesis of the digital cords and nodules. Hand Clin. 1991 Nov;7(4):645-57; discussion 659-60. Review. PubMed PMID: 1769987.

McFarlane RM. The anatomy of Dupuytren’s disease. Bull Hosp Jt Dis Orthop Inst. 1984 Fall;44(2):318- 37. PubMed PMID: 6099177

Question 8

103. What is a relative contraindication to replantation in the hand?
104. Presence of an arterial “ribbon sign”
105. Amputation of a single nonborder digit
106. Cold ischemia time of 12 hours in an amputated digit
107. Multiple digit amputations in the nondominant hand
108. Amputation of a digit distal to the flexor digitorum sublimus tendon􀀃 􀀘􀀑􀀃􀀃􀀃􀀤􀁐􀁓􀁘􀁗􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁄􀀃􀁇􀁌􀁊􀁌􀁗􀀃􀁇􀁌􀁖􀁗􀁄􀁏􀀃􀁗􀁒􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁇􀁌􀁊􀁌􀁗􀁒􀁕􀁘􀁐􀀃􀁖􀁘􀁅􀁏􀁌􀁐􀁘􀁖􀀃􀁗􀁈􀁑􀁇􀁒􀁑

Answer 8

1. Presence of an arterial “ribbon sign”

Ribbon Sign- tortuousity of digital arteries

RECOMMENDED READINGS

Friedrich JB, Poppler LH, Mack CD, Rivara FP, Levin LS, Klein MB. Epidemiology of upper extremity replantation surgery in the United States. J Hand Surg Am. 2011 Nov;36(11):1835-40. doi: 10.1016/j. jhsa.2011.08.002. Epub 2011 Oct 5. PubMed PMID: 21975098.

Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg Br. 2001 Dec;26(6):572-81. Review. PubMed PMID: 11884116.

Question 9

113. Which clinical feature is most likely associated with the radiograph shown in Figure 133?
114. Skin thickening and hardening
115. Sacroiliac joint pain and stiffness
116. Activity-related pain relieved by rest
117. Erythematous plaques and pruritic scaling
118. Pain and swelling precipitated by excessive alcohol use

Answer 9

4. Erythematous plaques and pruritic scaling

RECOMMENDED READINGS

Rose JH, Belsky MR. Psoriatic arthritis in the hand. Hand Clin. 1989 May;5(2):137-44. Review. PubMed PMID: 2661570.

Day MS, Nam D, Goodman S, Su EP, Figgie M. Psoriatic arthritis. J Am Acad Orthop Surg. 2012 Jan;20(1):28-37. doi: 10.5435/JAAOS-20-01-028. Review. PubMed PMID: 22207516.

Question 10

140. A 40-year-old woman has no active thumb flexion afer 2 attempts at repair of her zone II flexor pollics longus laceration during the last 4 months. Extension is also limited with her wrist and thumb extended, but there is improved interphalangeal extension with the metacarpophalangeal joint flex. She would like to maintain motion. Ultrasound examination reveals a discontinuous tendon. During exploration there is a moderate scar, the oblique pulley is intact, and the ends of the flexor pollics longus are separated by 3cm What is the best next treatment step?
141. Thumb interphalangeal joint arthrodesis
142. Single-stanged flexor pollicis longus reconstruction of the flexor pollicis longus
143. Silastic tendon implant with staged reconstruction of the flexor pollcis longus
144. Tendolysis, partial oblique pulley resection, and primary flexor pollicis longus repair
145. Transfer of the flexor digitorum sublimis from the ring finger to the distal flexor pollicis longus

Answer 10

3. Silastic tendon implant with staged reconstruction of the flexor pollcis longus

RECOMMENDED READINGS

Kutsumi K, Amadio PC, Zobitz ME, An KG. Gliding resistance of the flexor pollicis longus 􀀮􀁘􀁗􀁖􀁘􀁐􀁌􀀃􀀮􀀏􀀃􀀤􀁐􀁄􀁇􀁌􀁒􀀃􀀳􀀦􀀏􀀃􀀽􀁋􀁄􀁒􀀃􀀦􀀏􀀃􀀽􀁒􀁅􀁌􀁗􀁝􀀃􀀰􀀨􀀏􀀃􀀤􀁑􀀃􀀮􀀱􀀑􀀃􀀪􀁏􀁌􀁇􀁌􀁑􀁊􀀃􀁕􀁈􀁖􀁌􀁖􀁗􀁄􀁑􀁆􀁈􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁓􀁒􀁏􀁏􀁌􀁆􀁌􀁖􀀃􀁏􀁒􀁑􀁊􀁘􀁖􀀃tendon after repair: does partial excision of the oblique pulley affect gliding resistance? Plast Reconstr Surg. 2006 Nov;118(6):1423-8; discussion 1429-30. PubMed PMID: 17051113.

Question 11

175. Figure 175 is the lateral radiograph of a 20-year-old man who fell from a roof and has an isolated injury to his wrist and forearm. His skin is intact. He has moderate pain and his neurovascular examination reveals a 10-mm 2-point discrimination in median nerve distribution. Which closed reduction should be performed in the emergency department?
176. Midcarpal joint dislocation
177. Radioulnar joint dislocation
178. Radiocarpal joint dislocation
179. Radiocarpal and midcarpal joint dislocations
180. Radiocarpal and distal radioulnar joint dislocations

Answer 11

5. Radiocarpal and distal radioulnar joint dislocations

RECOMMENDED READINGS

Ilyas AM, Mudgal CS. Radiocarpal fracture-dislocations. J Am Acad Orthop Surg. 2008 Nov;16(11):647- 55. Review. PubMed PMID: 18978287.

Mudgal CS, Psenica J, Jupiter JB. Radiocarpal fracture-dislocation. J Hand Surg Br. 1999 Feb;24(1):92-8. PubMed PMID: 10190615.

Question 12

228. Figure 228 is the clinical photograph of a 55-year-old man who cannot flatten his hand because of a contracture. The treatment options of collagenase injection and percutaneous needle fasciotomy have been discussed; these 2 procedures differ most in which aspect?
229. Cost
230. Recurrence rate
231. Correction obtained
232. Postprocedure pain
233. Need for hand therapy

Answer 12

1. Cost

RECOMMENDED READINGS

Black EM, Blazar PE. Dupuytren disease: an evolving understanding of an age-old disease. J Am Acad Orthop Surg. 2011 Dec;19(12):746-57. Review. PubMed PMID: 22134207.

Nydick JA, Olliff BW, Garcia MJ, Hess AV, Stone JD. A comparison of percutaneous needle fasciotomy and collagenase injection for dupuytren disease. J Hand Surg Am. 2013 Dec;38(12):2377-80. doi: 10.1016/j.jhsa.2013.08.096. Epub 2013 Sep 20. PubMed PMID: 24060510.

Question 13

256. A 65-year-old woman has had right hand numbness in her radial 3 fingers for 12 months. She previously experienced excellent pain relief for 6 weeks after receiving a carpal tunnel corticosteroid injection. Now the pain wakes her from sleep despite wrist brace wear. Examination reveals positive Tinel, flexion compression, and the Phalen test findings. What is the most appropriate next treatement step?
257. Splinting
258. Observation
259. Hand therapy
260. Repeat injection
261. Carpal tunnel release

Answer 13

5. Carpal tunnel release

RECOMMENDED READINGS

Graham B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2008 Dec;90(12):2587-93. PubMed PMID: 19047703.

Rozental TD, LaPorte DM. Hand and wrist reconstruction. In: Flynn JM, ed. Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:363-376.

Question 14

263. A patient has sustained an extension injury with dorsal proximal interphalangeal joint dislocation. The joint appears congruent after reduction, but there is a 15% fracture of the volar tip of the base of the middle phalanx. The physician should recommend
264. open reduction and internal fixation.
265. no splint and immediate active and passive motion.
266. a dynamic external fixator with early active motion. 􀀃 􀀖􀀑􀀃􀀃􀀃􀁄􀀃􀁇􀁜􀁑􀁄􀁐􀁌􀁆􀀃􀁈􀁛􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁒􀁕􀀃􀁚􀁌􀁗􀁋􀀃􀁈􀁄􀁕􀁏􀁜􀀃􀁄􀁆􀁗􀁌􀁙􀁈􀀃􀁐􀁒􀁗􀁌􀁒􀁑􀀑
267. an extension block splint with active flexion and extension.􀀃 􀀗􀀑􀀃􀀃􀀃􀁄􀁑􀀃􀁈􀁛􀁗􀁈􀁑􀁖􀁌􀁒􀁑􀀃􀁅􀁏􀁒􀁆􀁎􀀃􀁖􀁓􀁏􀁌􀁑􀁗􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀁆􀁗􀁌􀁙􀁈􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁈􀁛􀁗􀁈􀁑􀁖􀁌􀁒􀁑􀀑
268. an intrinsic-plus position splint for 4 weeks (interphalangeal joints at 0-10 degrees).

Answer 14

4. an extension block splint with active flexion and extension.􀀃 􀀗􀀑􀀃􀀃􀀃􀁄􀁑􀀃􀁈􀁛􀁗􀁈􀁑􀁖􀁌􀁒􀁑􀀃􀁅􀁏􀁒􀁆􀁎􀀃􀁖􀁓􀁏􀁌􀁑􀁗􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀁆􀁗􀁌􀁙􀁈􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁈􀁛􀁗􀁈􀁑􀁖􀁌􀁒􀁑􀀑

RECOMMENDED READINGS

Gaine WJ, Beardsmore J, Fahmy N. Early active mobilization of volar plate avulsion fractures. Injury. 1998 Oct;29(8):589-91. PubMed PMID: 10209589.

McElfresh EC, Dobyns JH, O’Brien ET. Management of fracture-dislocation of the proximal interphalangeal joints by extension-block splinting. J Bone Joint Surg Am. 1972 Dec;54(8):1705-11. PubMed PMID: 4653646.

Question 15

267. Figure 267 is the clinical photograph of a 36-year-old woman who has experienced pain and swelling of her left middle finger; this condition has worsened during the last 3 days. She has recieved no treatment so far. What is the most appropriate next step?
268. Oral antibiotics and close follow up
269. Aspiration and culture of purulent material
270. Splint, elevation, and intravenous antibiotics
271. Urgent surgical drainage through a fish-mouthed incision. 􀀃 􀀗􀀑􀀃􀀃􀀃􀀸􀁕􀁊􀁈􀁑􀁗􀀃􀁖􀁘􀁕􀁊􀁌􀁆􀁄􀁏􀀃􀁇􀁕􀁄􀁌􀁑􀁄􀁊􀁈􀀃􀁗􀁋􀁕􀁒􀁘􀁊􀁋􀀃􀁄􀀃􀂿􀁖􀁋􀀐􀁐􀁒􀁘􀁗􀁋􀀃􀁌􀁑􀁆􀁌􀁖􀁌􀁒􀁑
272. Urgent surgical drainage through a midaxial incision

Answer 15

4. Urgent surgical drainage through a fish-mouthed incision.

RECOMMENDED READINGS

Capo JT. Infections. In: Chung KC, Murray PM, eds. Hand Surgery Update V. Rosemont, IL: AmericanSociety for Surgery of the Hand; 2012:391-399.

Question 16

271. A 32-year-old mechanic felt a pop in his thumb 4 months after undergoing an A1 pulley release. He has weakened pinch strength. Figure 271 is a clinical photograph of his thrumb iwth resisted flexion. The most appropriate treatment is to reconstruct the
272. Av pulley.
273. A1 pulley.
274. oblique pulley.
275. extensor tendon.
276. abductor pollicis brevis.

Answer 16

3. oblique pulley.

RECOMMENDED READINGS

Bayat A, Shaaban H, Giakas G, Lees VC. The pulley system of the thumb: anatomic and biomechanical study. J Hand Surg Am. 2002 Jul;27(4):628-35. PubMed PMID: 12132087.