Hand 2015

Question 1

8. A 76-year-old woman underwent a left below-elbow amputation. Prior to the amputation, she had a stroke that caused a paretic, painful, clenched hand. Her hand became severely infected, necessitating amputation. She continues to have phantom pain, perceiving that her amputated hand is clenched. What is the best therapy modality at this time?
9. Iontophoresis
10. Contrast baths
11. Mirror therapy
12. Low-level laser therapy
13. Electrical stimulation

Answer 1

3. Mirror therapy

RECOMMENDED READINGS

Hartzell TL, Rubinstein R, Herman M. Therapeutic modalities–an updated review for the hand surgeon. J Hand Surg Am. 2012 Mar;37(3):597-621. doi: 10.1016/j.jhsa.2011.12.042. Epub 2012 Feb 2. Review. PubMed PMID: 22305724.

Rostami HR, Arefi A, Tabatabaei S. Effect of mirror therapy on hand function in patients with hand orthopaedic injuries: a randomized controlled trial. Disabil Rehabil. 2013 Sep;35(19):1647-51. doi: 10.3109/09638288.2012.751132. Epub 2013 Jan 22. PubMed PMID: 23336124.

Moseley GL. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain. 2004 Mar;108(1-2):192-8. PubMed PMID: 15109523.

Question 2

15. A 40-year-old woman has a closed oblique ring finger metacarpal fracture. There is no rotational deformity. Radiographs reveal a 10-degree apex-dorsal angulation and 2 mm of shortening. What is the expected outcome for fracture healing in this position?
16. Nonunion
17. Normal function
18. Extensor tendonitis
19. Flexion deformity of the metacarpophalangeal (MCP) joint
20. Flexion deformity of the proximal interphalangeal (PIP) joint

Answer 2

2. Normal function

RECOMMENDED READINGS

Strauch RJ, Rosenwasser MP, Lunt JG. Metacarpal shaft fractures: the effect of shortening on the extensor tendon mechanism. J Hand Surg Am. 1998 May;23(3):519-23. PubMed PMID: 9620194.

Al-Qattan MM. Outcome of conservative management of spiral/long oblique fractures of the metacarpal shaft of the fingers using a palmar wrist splint and immediate mobilisation of the fingers. J Hand Surg Eur Vol. 2008 Dec;33(6):723-7. doi: 10.1177/1753193408093559. Epub 2008 Jul 28. PubMed PMID: 18662959.

Question 3

28. Figure 28 shows an injury sustained by a 60-year-old man 4 weeks ago. Since that time he has had substantial pain and catching of his finger during attempts at range of motion. What is the most appropriate treatment at this point?
29. Tendon debridement
30. Release of the A2 pulley
31. Tendon repair with core sutures
32. Tendon repair with epitendinous sutures
33. Wound closure without tendon repair or debridement

Answer 3

4. Tendon repair with epitendinous sutures

RECOMMENDED READINGS

Haddad R, Scherman P, Peltz T, Nicklin S, Walsh WR. A biomechanical assessment of repair versus nonrepair of sheep flexor tendons lacerated to 75 percent. J Hand Surg Am. 2010 Apr;35(4):546-51. doi: 10.1016/j.jhsa.2009.12.039. Epub 2010 Mar 2. PubMed PMID: 20189731.

Mostofi A, Palmer J, Akelman E. Flexor tendon injury. In: Chung KC, ed. Hand Surgery Update V. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2012:181-192.

Question 4

39. Figure 39 is the clinical photograph of a 2-year-boy who has bilateral camptodactyly of 25 degrees at each of his ring finger proximal interphalangeal joints. No other abnormalities are present, and his parents report developmental milestones have all been reached on time. The boy’s father is concerned that the contractures will negatively influence his ability to engage in sports. What is the best next step?
40. Observation
41. Volar plate release
42. Proximal phalanx extension osteotomies
43. A progressive stretching and splinting program
44. Rerouting a slip of the flexor digitorum superficialis to the extensor central slip

Answer 4

4. A progressive stretching and splinting program

RECOMMENDED READINGS

Goldfarb CA. Congenital hand anomalies: a review of the literature, 2009-2012. J Hand Surg Am. 2013 Sep;38(9):1854-9. doi: 10.1016/j.jhsa.2013.03.023. Epub 2013 May 14. Review. PubMed PMID: 23683863.

Rhee SH, Oh WS, Lee HJ, Roh YH, Lee JO, Baek GH. Effect of passive stretching on simple camptodactyly in children younger than three years of age. J Hand Surg Am. 2010 Nov;35(11):1768-73. doi: 10.1016/j.jhsa.2010.07.032. PubMed PMID: 21050962.

Question 5

48. A 23-year-old man cut the dorsal and ulnar aspects of his long finger on a table saw. The dorsal and ulnar skin over the middle phalanx is missing, with a 2-cm x 2-cm area of loss. There is a 50% loss of the extensor tendon (ulnar), and the remaining tendon has no tenosynovium. The physician should recommend irrigation and debridement and
49. wet-to-dry dressing and early motion.
50. tendon repair, and thenar flap coverage.
51. full-thickness skin graft.
52. reversed cross-finger flap from the ring finger.
53. cross-finger flap coverage from the ring finger.

Answer 5

4. reversed cross-finger flap from the ring finger.

RECOMMENDED READINGS

Atasoy E. Reversed cross-finger subcutaneous flap. J Hand Surg Am. 1982 Sep;7(5):481-3. PubMed PMID: 7130658.

Kappel DA, Burech JG. The cross-finger flap. An established reconstructive procedure. Hand Clin. 1985 Nov;1(4):677-83. PubMed PMID: 3831054.

Question 6

58. A 25-year-old snowboarder has a contaminated open tibial fracture. He was down for several hours before being rescued and transported. He also sustained a cold injury to his fingers, which are blue and have multiple hemorrhagic blisters. What is the most appropriate timing for aggressive finger debridement/ amputation?
59. Prior to definitive fixation of the tibial fracture
60. Prior to irrigation and debridement (I & D) of the tibial fracture
61. During I & D of the tibial fracture
62. During definitive fixation of the tibia
63. No set time; delay until necrotic tissue demarcation

Answer 6

5. No set time; delay until necrotic tissue demarcation

RECOMMENDED READINGS

Golant A, Nord RM, Paksima N, Posner MA. Cold exposure injuries to the extremities. J Am Acad Orthop Surg. 2008 Dec;16(12):704-15. Review. PubMed PMID:19056919.

Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 2nd ed. Philadelphia, PA: Churchill Livingstone Elsevier; 2011:2114-2116.

Question 7

65. Which examination finding points toward a brachial plexus injury rather than root avulsion?
66. Winging of the scapula
67. Intact rhomboid function
68. A biceps with 0/5 strength
69. An ipsilateral clavicle fracture
70. Decreased radial artery pulse

Answer 7

2. Intact rhomboid function

RECOMMENDED READINGS

Caporrino FA, Moreira L, Moraes VY, Belloti JC, Gomes dos Santos JB, Faloppa F. Brachial plexus injuries: diagnosis performance and reliability of everyday tools. Hand Surg. 2014;19(1):7-11. doi: 10.1142/S0218810414500026. PubMed PMID: 24641734.

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.

Question 8

75. A 72-year-old woman with diabetes mellitus has right hand numbness. Provocative test findings are consistent with carpal tunnel syndrome, and electrodiagnostic study (EDS) findings show prolonged median motor and sensory distal latencies with low-amplitude thenar compound muscle action potential. Poor prognosis is most associated with which factor?
76. Diabetes
77. Older age
78. Female gender
79. Right-hand involvement
80. Severity of EDS findings

Answer 8

5. Severity of EDS findings

RECOMMENDED READINGS

Kronlage SC, Menendez ME. The benefit of carpal tunnel release in patients with electrophysiologically moderate and severe disease. J Hand Surg Am. 2015 Mar;40(3):438-444.e1. doi: 10.1016/j. jhsa.2014.12.012. PubMed PMID: 25708432.

Bland JD. Carpal tunnel syndrome. BMJ. 2007 Aug 18;335(7615):343-6. Review. PubMed PMID: 17703044.

Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve. 2001 Jul;24(7):935-40. PubMed PMID: 11410921.

Tomaino MM, Weiser RW. Carpal tunnel release for advanced disease in patients 70 years and older: does outcome from the patient’s perspective justify surgery? J Hand Surg Br. 2001 Oct;26(5):481-3. PubMed PMID: 11560433.

Stevens JC. AAEM minimonograph #26: the electrodiagnosis of carpal tunnel syndrome. American Association of Electrodiagnostic Medicine. Muscle Nerve. 1997 Dec;20(12):1477-86. Review. PubMed PMID: 9390659.

Question 9

88. Which method of flexor tendon repair that necessitates excursion through the A2 pulley allows for the most thorough assessment of tendon gliding?
89. 4-strand repair with 6-0 epitendinous suture with Bier block anesthesia
90. 4-strand repair with 6-0 epitendinous suture under local anesthesia only
91. 6-strand repair with regional anesthesia
92. 8-strand repair with regional anesthesia
93. Repair of the flexor tendon with incision of the remaining A2 pulley

Answer 9

2. 4-strand repair with 6-0 epitendinous suture under local anesthesia only

RECOMMENDED READINGS

Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014 Feb;30(1):1-6. doi: 110.1016/j.hcl.2013.08.015. Epub 2013 Nov 9. Review. PubMed PMID: 24286736.

Lalonde DH, Martin AL. Wide-awake flexor tendon repair and early tendon mobilization in zones 1 and 2. Hand Clin. 2013 May;29(2):207-13. doi: 10.1016/j.hcl.2013.02.009. Epub 2013 Mar 15. Review. PubMed PMID: 23660056.

Question 10

96. Figures 96a and 96b are the radiographs of an 18-year-old man who had surgery 6 months ago at an outside institution. He is being referred now because he has persistent pain. He is tender over the scaphoid at the snuffbox. What is the most appropriate next imaging step in his pain workup?
97. Bone scan
98. MR imaging with contrast
99. MR imaging without contrast
100. CT scan along the scaphoid axis
101. Axial-cut CT scans with reformats

Answer 10

4. CT scan along the scaphoid axis

RECOMMENDED READINGS

Ring D, Jupiter JB, Herndon JH. Acute fractures of the scaphoid. J Am Acad Orthop Surg. 2000 Jul- Aug;8(4):225-31. Review. PubMed PMID: 10951111.

Lutsky K, Matzon JL. Persistent fracture line after scaphoid fracture fixation. J Hand Surg Am. 2014 Nov;39(11):2294-6. doi: 10.1016/j.jhsa.2014.08.030. Epub 2014 Oct 3. PubMed PMID: 25282721.

Yin ZG, Zhang JB, Gong KT. Cost-Effectiveness of Diagnostic Strategies for Suspected Scaphoid Fractures. J Orthop Trauma. 2015 Aug;29(8):e245-52. doi: 10.1097/BOT.0000000000000316. PubMed PMID: 25756914.

Yin ZG, Zhang JB, Kan SL, Wang XG. Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis. Clin Orthop Relat Res. 2010 Mar;468(3):723-34. doi: 10.1007/s11999-009-1081-6. Epub 2009 Sep 15. Review. PubMed PMID: 19756904.

Question 11

103. (Item Deleted)

Which muscle or tendon function is most likely disrupted by the finding in the MR image shown in

Figure 103?

1. First dorsal interosseous
2. Flexor pollicis longus (FPL)
3. Long-finger flexor digitorum profundus (FDP)
4. Small-finger FDP
5. Extensor pollicis longus (EPL)

Answer 11

4. Small-finger FDP

RECOMMENDED READINGS

Yamazaki H, Kato H, Nakatsuchi Y, Murakami N, Hata Y. Closed rupture of the flexor tendons of the little finger secondary to non-union of fractures of the hook of the hamate. J Hand Surg Br. 2006 Jun;31(3):337- 41. Epub 2006 Mar 30. PubMed PMID: 16580104.

Klausmeyer MA, Mudgal CS. Hook of hamate fractures. J Hand Surg Am. 2013 Dec;38(12):2457-60; quiz 2460. doi: 10.1016/j.jhsa.2013.06.004. Epub 2013 Jul 26. Review. PubMed PMID: 23891177.

Question 12

133. A 34-year-old smoker has acute (less than 6 hours) onset of right hand ischemia. His blood pressure is 188/90 mm Hg. His hand is cool and pale; however, he can move his fingers with some discomfort. There is no swelling and no history of trauma. Radial and ulnar pulses are not palpable, but they are present by Doppler examination. What is the best next step?
134. Angiogram
135. Ulnar artery thrombectomy
136. Magnetic resonance angiogram (MRA)
137. Transthoracic echocardiogram
138. Measurement of compartment pressures

Answer 12

1. Angiogram

RECOMMENDED READINGS

Rapp JH, Reilly LM, Goldstone J, Krupski WC, Ehrenfeld WK, Stoney RJ. Ischemia of the upper extremity: significance of proximal arterial disease. Am J Surg. 1986 Jul;152(1):122-6. PubMed PMID: 3728805.

Pellerin O, Delorme L, Bellmann L, Sapoval M. Clinical presentation and percutaneous endovascular management of acute left subclavian artery thrombosis: report of two cases. Diagn Interv Imaging. 2014 Jan;95(1):95-9. doi:10.1016/j.diii.2013.07.005. Epub 2013 Sep 4. PubMed PMID: 24012286.

Question 13

140. (Item Deleted)

Figure 140 is the T1-weighted MR image of a 24-year-old man who has a 6-month history of right wrist pain. He fell on an outstretched hand while skateboarding 18 months ago and had pain that resolved after several weeks. Radiographs of his right wrist demonstrate an established scaphoid nonunion at the waist with a humpback deformity and no signs of arthritis. What is the best next step?

1. Proximal row carpectomy
2. Scaphoid excision and 4-corner fusion
3. Vascularized dorsal distal radial pedicle graft and fixation
4. Vascularized medial femoral condyle graft and fixation
5. Open reduction and internal fixation with a cancellous bone graft

Answer 13

4. Vascularized medial femoral condyle graft and fixation

RECOMMENDED READINGS

Al-Jabri T, Mannan A, Giannoudis P. The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review. J Orthop Surg Res. 2014 Apr 1;9:21. doi: 10.1186/1749-799X-9-21. Review. PubMed PMID: 24690301; PubMed Central PMCID: PMC3976175.

Jones DB Jr, Bьrger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint Surg Am. 2008 Dec;90(12):2616-25. doi: 10.2106/JBJS.G.01503. PubMed PMID: 19047706.

Question 14

174. During closed reduction of an apex-volar angulated distal radius fracture, which maneuver, in addition to traction, likely will provide the best fracture reduction?
175. Pronation of the wrist
176. Ulnar deviation of the wrist
177. Volar translation of the lunate
178. Flexion of the lunocapitate joint
179. Extension of the radiocarpal joint

Answer 14

3. Volar translation of the lunate

RECOMMENDED READINGS

Agee JM. Distal radius fractures. Multiplanar ligamentotaxis. Hand Clin. 1993 Nov;9(4):577-85. Review. PubMed PMID: 8300728.

Agee JM, Szabo RM, Chidgey LK, King FC, Kerfoot C. Treatment of comminuted distal radius fractures: an approach based on pathomechanics. Orthopedics. 1994 Dec;17(12):1115-22. PubMed PMID: 7899154.

Question 15

228. When viewing the wrist joint arthroscopically from the 3-4 portal, what is the correct order of the volar extrinsic wrist ligaments from radial to ulnar?
229. Scapholunate, lunotriquetral, ulnotriquetral
230. Short radiolunate, long radiolunate, radioscaphocapitate
231. Radioscapholunate, radioscaphocapitate, long radiolunate
232. Radioscaphocapitate, long radiolunate, short radiolunate
233. Radial collateral, long radiolunate, short radiolunate

Answer 15

4. Radioscaphocapitate, long radiolunate, short radiolunate

RECOMMENDED READINGS

Bettinger PC, Cooney WP 3rd, Berger RA. Arthroscopic anatomy of the wrist. Orthop Clin North Am. 1995 Oct;26(4):707-19. PubMed PMID: 7566915.

Berger RA. Arthroscopic anatomy of the wrist and distal radioulnar joint. Hand Clin. 1999 Aug;15(3):393- 413, vii. Review. PubMed PMID: 10451815.

Berger RA. The anatomy of the ligaments of the wrist and distal radioulnar joints. Clin Orthop Relat Res. 2001 Feb;(383):32-40. Review. PubMed PMID: 11210966.

Question 16

246. A 32-year-old man has a thumb metacarpophalangeal joint (MCP) ulnar collateral ligament (UCL) injury. The joint is unstable, and an MR image reveals a displaced distal avulsion of the ligament off the base of the proximal phalanx. During repair, which structure(s) block(s) reduction of the ligament?
247. Adductor aponeurosis
248. Extensor pollicis longus tendon
249. Extensor pollicis brevis (EPB) tendon
250. Ulnar sesamoid bone
251. EPB and dorsal capsule

Answer 16

1. Adductor aponeurosis

RECOMMENDED READINGS

Stener B. Skeletal injuries associated with rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. A clinical and anatomical study. Acta Chir Scand. 1963 Jun;125:583-6. PubMed PMID: 13983826.

Bean CH, Tencer AF, Trumble TE. The effect of thumb metacarpophalangeal ulnar collateral ligament attachment site on joint range of motion: an in vitro study. J Hand Surg Am. 1999 Mar;24(2):283-7. PubMed PMID: 10194011.

Carlson MG, Warner KK, Meyers KN, Hearns KA, Kok PL. Anatomy of the thumb metacarpophalangeal ulnar and radial collateral ligaments. J Hand Surg Am. 2012 Oct;37(10):2021-6. doi: 10.1016/j. jhsa.2012.06.024. Epub 2012 Aug 31. PubMed PMID: 22939823.

Question 17

256. A 25-year-old man has an acute scaphoid fracture in the proximal third of the scaphoid. It is displaced 1 mm. What is the recommended treatment for his fracture?
257. Long-arm cast with a thumb spica
258. Closed reduction and pin fixation with casting
259. Open reduction and internal fixation (ORIF) through a volar approach
260. ORIF with vascularized bone graft
261. ORIF through a dorsal approach

Answer 17

5. ORIF through a dorsal approach

RECOMMENDED READINGS

Rettig ME, Kozin SH, Cooney WP. Open reduction and internal fixation of acute displaced scaphoid waist fractures. J Hand Surg Am. 2001 Mar;26(2):271-6. PubMed PMID: 11279573.

Raskin KB, Parisi D, Baker J, Rettig ME. Dorsal open repair of proximal pole scaphoid fractures. Hand Clin. 2001 Nov;17(4):601-10, ix. PubMed PMID: 11775471.

Question 18

236. A 50-year-old man experienced a dorsal dislocation of his thumb carpometacarpal (CMC) joint without an associated fracture 1 week ago. He self-reduced his thumb. Radiographs reveal slight subluxation of the joint with minimal arthritis. Which region of the thumb CMC capsuloligamentous complex most likely prevents dorsal dislocation of the thumb CMC joint?
237. Dorsal radial
238. Intermetacarpal
239. Ulnar collateral
240. Volar oblique deep
241. Volar oblique superficial

Answer 18

1. Dorsal radial

RECOMMENDED READINGS

Strauch RJ, Behrman MJ, Rosenwasser MP. Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study. J Hand Surg Am. 1994 Jan;19(1):93-8. PubMed PMID: 8169374.

Bettinger PC, Berger RA. Functional ligamentous anatomy of the trapezium and trapeziometacarpal joint (gross and arthroscopic). Hand Clin. 2001 May;17(2):151-68, vii. Review. PubMed PMID: 11478038.

Question 19

267. After performing an uneventful partial palmar fasciectomy for Dupuytren contracture of the palm and ring finger, a general postsurgical pain medication prescription should include how many narcotic pills?
268. 0
269. 10
270. 20
271. 30
272. 40

Answer 19

2. 10

RECOMMENDED READINGS

Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012 Apr;37(4):645-50. doi: 10.1016/j.jhsa.2012.01.035. Epub 2012 Mar 10. PubMed PMID: 22410178.

Stanek JJ, Renslow MA, Kalliainen LK. The effect of an educational program on opioid prescription patterns in hand surgery: a quality improvement program. J Hand Surg Am. 2015 Feb;40(2):341-6. doi: 10.1016/j.jhsa.2014.10.054. Epub 2014 Dec 24. PubMed PMID: 25542435.

Question 20

271. A 42-year-old worker has failed nonsurgical treatment of painful thumb carpometacarpal (CMC) arthritis. The decision has been made to perform ligamentous reconstruction and tendon interposition arthroplasty. However, when the bony ridge of the trapezium is removed, the entire distal attachment of the flexor carpi radialis (FCR) tendon is inadvertently detached. What is the best next step?
272. Perform suspension arthroplasty with the extensor carpi radialis longus (ECRL)
273. Perform a suspension arthroplasty with the ring finger flexor digitorum superficialis
274. Perform a suspension arthroplasty with the palmaris longus tendon
275. Reattach the insertion of the FCR with suture anchors
276. Perform a CMC arthrodesis

Answer 20

1. Perform suspension arthroplasty with the extensor carpi radialis longus (ECRL)

RECOMMENDED READINGS

Jones DB Jr, Rhee PC, Shin AY, Kakar S. Salvage options for flexor carpi radialis tendon disruption during ligament reconstruction and tendon interposition or suspension arthroplasty of the trapeziometacarpal joint. J Hand Surg Am. 2013 Sep;38(9):1806-11. doi: 10.1016/j.jhsa.2013.06.014. Epub 2013 Aug 6. PubMed PMID: 23928018.

Conolly WB, Rath S. Revision procedures for complications of surgery for osteoarthritis of the carpometacarpal joint of the thumb. J Hand Surg Br. 1993 Aug;18(4):533-9. PubMed PMID: 8409675.