Correct Answer & Explanation
. iliac crest bone grafting
Explanation
Index metacarpal transposition is indicated to reduce the space left between the index and ring finger. In this case, the middle ray is amputated because of malignancy.With amputation of the middle or ring metacarpals, small objects fall through the gap and the adjacent fingers scissor. For single central ray defects, techniques to reduce the gap include transposition of the index finger (for middle ray amputation), small finger (for ring ray amputation), complete removal of the metacarpal (without leaving a proximal metacarpal base stump) to allow the bases of index and ring metacarpals to migrate together and reconstruction of the deep transverse metacarpal ligament. The technique of index transposition may vary depending on the osteotomy (straight vs step-cut) and fixation (K wires vs plate) as seen in the illustrations below.Muramatsu et al. describe bony transposition for reconstruction after ray amputation for malignancy. The advantage is immediate closure of the space. The disadvantages include prolonged postoperative immobilization until union, malrotation (leading to scissoring), mal-tension of tendon (because of different metacarpal heights), and delayed or nonunion.Lyall et al. advocate total middle ray amputation. They believe that leaving the metacarpal base behind leads to difficulty in aligning the adjacent rays as the index and ring must angulate over the bony obstruction to close the distal gap, leading to scissoring. They believe that index transposition leaves an abnormally wide 1st web space and a remnant 2nd metacarpal stump that can protrude dorsally.Figure A is an AP radiograph of the right hand showing a destructive lesion of the proximal phalanx of the middle finger abutting the metacarpophalageal joint. Figure B is a STIR coronal MRI image showing the tumor mass extending into surround soft tissue. Illustration A is a diagram showing index transposition for middle ray amputation using a straight osteotomy and crossed K-wires. Illustration B is a diagram showing index transposition using a step-cut osteotomy and multiple K-wire fixation to the adjacent metacarpals. Illustration C is a diagram showing index transposition using a straight osteotomy and plate fixation. Illustration D is a diagram showing an alternative technique of suturing deep transverse metacarpal ligaments together to close the gap.Incorrect AnswersA 65-year-old man fell and injured his right wrist. Radiographs taken in the emergency room are seen in Figure A. He was treated as a sprain and no further follow-up was planned. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists ofAnterior and posterior interosseous neurectomyScaphotrapezialtrapezoidal (STT) fusionComplete wrist arthrodesisProximal row carpectomyFour-corner fusion with scaphoidectomyFour-corner fusion with scaphoidectomy is indicated for Stage III SLAC wrist.Surgical treatment of SLAC wrist is stage dependent. Stage I disease (scaphoid-radial styloid arthritis) is treated with AIN/PIN neurectomy. This procedure can also be done in addition to other bony procedures for Stages II-III disease. Stage II (scaphoid-entire scaphoid facet) is treated with PRC or scaphoid excision with 4-corner fusion (4CF). Stage III (capitolunate arthritis with proximal migration of the capitate into the scapholunate interval) is treated with either scaphoidectomy with 4CF or total wrist fusion.Some other conditions exist: If capitolunate arthritis exists, PRC is contraindicated and 4CF is performed. If radiolunate arthritis exists, both PRC and 4CF are contraindicated and total wrist fusion is performed. If both radiolunate and capitolunate surfaces are preserved, then either PRC or a 4CF may be performed.Cohen et al. compare PRC with 4-corner fusion plus scaphoid excision. PRC is technically easier, but leads to shortening of the carpus with weakness and incongruity exists between the capitate and lunate fossa of the distal radius. Scaphoid excision and four-corner fusion maintains carpal height and preserves the radiolunate relationship, but is more technically demanding, there is risk of nonunion, and it requires longer postop immobilization. Pain relief is more reliable following 4-corner fusion.Figure A shows scapholunate ligament disruption. Figure B shows late stage SLAC wrist. There is capitolunate arthritis but no radiolunate arthritis.Illustration A shows an example of PRC. Illustration B shows an example of 4CF and scaphoidectomy.Incorrect AnswersWhich of the following statements is true regarding zone II flexor tendon injuries?At this level, FDS and FDP are located within separate tendon sheathsFDS repair has not been shown to improve outcomesImproved gliding is seen with repair of 1 slip of FDS compared to repairing both slipsRepairing FDS does not affect post-operative digit strengthFDP repair has not been shown to improve outcomesIn zone II flexor tendon injuries, repairing only one slip of FDS has been shown to improve gliding when compared to repair of both slips.Zone II flexor tendon injuries have notoriously had poor outcomes secondary to high rates of adhesion formation at the pulleys. However, new advances in post-operative rehabilitation have significantly improved outcomes to the point where it is no longer considered "no man's land." Management of the FDS has been a source of controversy. In the past, the FDS was occasionally excised to theoretically make more room for the FDP. This has now been largely abandoned and the FDS is repaired whenever possible. Whether or not to repair both slips of FDS remains controversial, with in vitro data suggesting that gliding resistance is improved if only one slip is repaired.Zhao et al. review the effect of partial vs. complete FDS excision following repair of FDP for zone II flexor tendon injuries. Preserving the whole FDS resulted in a significantly larger increase in gliding resistance after FDP repair than did full or partial FDS removal, which were not significantly different from each other.Illustration A shows the zones of flexor tendon injury. Note that zone II injuries occur between the FDS insertion and the distal palmar crease. Illustration B shows the anatomy of the flexor tendons in detail. Video V shows a technique for repair of zone II injuries.Incorrect Answers:A 6-year-old girl sustains transverse amputations through her long and ring fingertips after getting her hand caught in a lawn mower. She presents to the emergency room 30 minutes after the injury with the amputated tissue which was placed on ice in a waterproof bag. On physical exam the amputation levels are found to be 6 millimeters distal to the lunula. The wounds are noted to be fairlycontaminated with no evidence of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the most appropriate management at this time?Emergent replantation of the amputated partsRevision amputation through the distal interphalangeal jointThorough irrigation and debridement followed by elective Moberg advancement flapsThorough irrigation and debridement followed by elective Z-plasty reconstructionThorough irrigation and debridement, soft dressing application, and followup within 1 weekDistal fingertip amputations can be successfully managed with local wound care and healing by secondary intention if no bone is exposed and the soft tissue defects are minimal. This is especially true in the pediatric population.Distal fingertip amputations are common injuries seen in the emergency department. If bone is not exposed, the wounds can be successfully treated with local wound care and dressing changes, followed by soaks in a hydrogen-peroxide solution after 7-10 days. Some controversy exists in the pediatric population if the soft tissue loss is > 1 cm, with options for management including a V-Y advancement flap or conservative management with dressing changes.Quell et al. review the results of 82 patients with fingertip amputations treated conservatively; 31 of the digits were treated with primary closure with or without shortening of bone and 54 digits were treated with semiocclusive dressings. No complications were observed, and all healed fingertips were well padded and painless.Tupper et al. review sixteen patients with twenty fingertip injuries who underwent V-Y plasty for transverse fingertip amputations. Sensitivity was 73% of normal, with eight patients reporting hypersensitivity. Contrary to popular belief, they believe normal sensation following a V-Y plasty is not a reasonable expectation.Illustration A shows the three levels of fingertip amputations. Zone I is distal to the phalanx; Zone II is distal to the lunula; and Zone III is proximal to the lunula.Incorrect Answers:Which of following malformations is most commonly associated with Poland's syndrome?Figure ECORRECT ANSWER: 4Figure D demonstrates symbrachydactyly which is most commonly associated with Poland's syndrome.Poland's syndrome is a rare birth defect characterized by underdevelopment or absence of the chest muscle in conjunction with ipsilateral symbrachydactyly. Poland syndrome most often affects the right side of the body, and occurs more often in males than in females.Ireland et al. reviewed 43 consecutive cases of Poland's syndrome, and reviewed the relevant literature up to that point. The authors state that the clinical features are variable but always include congenital aplasia and syndactyly, and the right side is affected more than the left. They also note that although the hand remains hypoplastic and functional capacity is limited by the inherent skeletal anomalies, surgical treatment improves functional capacity and cosmetic appearance in the majority of patients.Van Heest summarizes normal formation and growth of the upper limb as a basis for understanding malformation, with the goal of providing a basic understanding of the evaluation necessary for appropriate counseling and referrals for treatment of the child with hand and upper extremity congenital deformities.Incorrect Answers:A 55-year-old male laborer comes in with a chief complaint of clumsiness with his right hand for the past 3 months including difficulty using a hammer while at work. He has had no injury to the right upper extremity. On physical examination, he has persistent small finger abduction/extension with finger extension and active adduction. An EMG is performed and demonstrates ulnar nerve conduction velocities of 31 m/sec (normal >52m/sec). The patient symptoms are most accurately described as:Axonotmesis with ischemia originAxonotmesis with myelin disruptionNeurapraxia with ischemia originNeurapraxia with endoneurium disruptionNeurotmesisCORRECT ANSWER: 3The history and clinical presentation are consistent with ulnar entrapment neuropathy at the level of the cubital tunnel. This would be classified as a neuropraxia with ischemia origin.Compression injuries to the peripheral nerves are often the result of microvascular dysfunction as the nerves traverse a high to low pressure gradient. Peripheral nerve injury can be classified as neuropraxia, axonotmesis, and neurotmesis. Compressive neuropathies are typically neuropraxias, with local myelin damage but not compromise of the major components of the nerve. In axonotmesis, there is Wallerian degeneration and myelin loss distal to the site of injury. The most severe type is that of neurotmesis. Neurotmesis is composed of a spectrum of injury in which the endoneurium is always disrupted (perineurium or epineurium may be intact). The worst form of neurotmesis is that of nerve transection.Elhassan et al. review the pathophysiology of cubital tunnel syndrome. They report nerve dysfunction results from ischemic changes secondary to compression. Compressive effects on the nerves can last greater than 24 hours, even after the source of compression has been removed.Rempel et al. review the pathophysiology of peripheral nerve compression syndromes. The authors indicate that deforming pressures to nerves are often the result of stenotic soft tissue canal boundaries. This leads to interference with local microvasculature of the nerve itself.Illustration A demonstrates the Wartenberg sign, where the patient has persistent small finger abduction/extension resulting from weakness of the 3rd palmar interosseous/small finger lumbrical.Illustration B reveals clawing which results from overpowering of the intrinsic muscles by the extrinsic muscles; a tenodesis effect results in flexion of the PIP/DIP joints. This is more severe in ulnar nerve compression at Guyonโs canal. Illustration C shows the Froment sign, where the FPL attempts to compensate for a deficient pinch, because of weakness of the adductor pollicis. Illustration D demonstrates atrophy of the 1st dorsal webspace from chronic compressive changes. Illustration E demonstrates atrophy of the thenar compartment which is consistent with carpal tunnel syndrome.Incorrect Answers:Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap?Figure ECORRECT ANSWER: 3Figure C shows a dorsal thumb laceration with exposed tendon that would be most appropriately treated with a first dorsal metacarpal artery (FDMA) flap.The first dorsal metacarpal artery is a branch of the radial artery that supplies the dorsal hand skin from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the thumb and index to the proximal interphalangeal joint. The flap is raised distal to proximal as an island flap containing the FDMA, branches of the radial nerve, fascia of the underlying interosseous muscle of the first web space, and skin overlying the MP joint and proximal phalanx of the finger. It is an excellent option for large soft tissue defects on either side of the thumb. In this case, skin grafting is contraindicated because of exposed tendon without paratenon.Sherif et al. detail the anatomy of the first dorsal metacarpal artery. They found three consistent branches, including the radial, ulnar, and intermediate branch. In part II of their study, they review the results of 23 patients where the FDMA flap was used as a fasciocutaneous or fascial flap for the coverage of soft tissue hand defects.Illustration A shows a FDMA flap being raised for coverage of a thumb defect. Incorrect Answers:bone can be allowed to heal through secondary intention.Figure A is a radiograph of a 35-year-old women who sustained an isolated left wrist injury after a fall onto an outstretched hand. She has been complaining of left dorsal wrist pain since the fall. Examination reveals a positive Watson's scaphoid shift test. What ligamentous structure is an important secondary stabilizer to prevent dorsal intercalated segment instability (DISI) deformity in this patient?Transverse carpal ligamentDorsal intercarpal ligamentsTriangular fibrocartilage complexDorsal lunotriquetral ligamentVolar lunotriquetral ligamentThe integrity of the dorsal intercarpal ligaments is important in preventing dorsal intercalated segment instability (DISI) deformity and persistent scapholunate instability.Scapholunate instability is the most common carpal instability. The primary stabilizing structure of the scaphoid and lunate bones is the scapholunate ligament, which is commonly injured with a fall on an outstretched hand.Secondary stabilizers of the scaphoid and lunate include the dorsal intercarpal ligaments and the dorsal radiocarpal ligaments. Failure to recognize injury of these structures can cause persistent dorsal intercalated segment instability (DISI). This can predispose patients to a SLAC wrist and early wrist osteoarthritis.Mitsuyasu et al. examined the role of dorsal intercarpal ligaments (DIC) in scapholunate instability. They showed that the DIC had an important role in stabilizing the scaphoid and lunate bones with static and dynamic movements. The authors of this study suggest that the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction with surgical management of scapholunate ligament tears.Viegas et al. showed that the dorsal intercarpal and the dorsal radiocarpal ligaments form a lateral V configuration over the dorsal wrist. This configuration acts as an indirect dorsal stabilizing effect on the scaphoidthroughout the range of motion of the wrist. Their integrity acts to ensure normal wrist kinematics.Figure A shows an AP and lateral radiograph of the left hand. There is significant gapping between the scaphoid and lunate articulation. This is indicative of a complete scapholunate dissociation, however both wrists should be imaged as this deformity may exist without injury. Illustration A shows the anatomy of the dorsal intercarpal and the dorsal radiocarpal ligaments.Incorrect Answers:A 50-year-old patient presents with stiffness in her hand. A clinical photo is shown in Figure A. During surgical exposure, the neurovascular bundle is identified and dissected. What is the clinically most important pathologic structure to identify and what is its location relative to the neurovascular bundle in the digit?Spiral cord which is central and superficial to the neurovascular bundleCentral cord which is midline and superficial to the neurovascular bundleRetrovascular cord which is central and superficial to the neurovascular bundleSpiral cord which is lateral and deep to the neurovascular bundleCentral cord which is lateral and deep to the neurovascular bundleBased on clinical findings, the patient has evidence of Dupuytrenโs contracture affecting her ring finger. Relative to the neurovascular bundle, the spiral cord will lie lateral and deep.Dupuytrenโs disease is a benign hand condition characterized by pathologic nodules and cords of existing fascial bands. The most clinically relevant structure in Dupuytren's disease, is the spiral cord. The spiral cord is the result of pathology of 4 structures: the middle layer of the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. The spiral cord is found predominantly at the palmodigital transition. The spiral cord displaces the neurovascular bundle centrally and superficially.Benson et al. review the etiology, pathophysiology and treatment options for Dupuytrenโs contracture. They highlight that while the pretendinous band is located volar and central to the neurovascular bundle in the palm, the spiral band and lateral digital sheath cause the neurovascular bundle to be displaced superficially and volarly as they become pathologically affected.Black et al. review the pathoanatomy, diagnosis and management of Dupuytren's disease. They note that the spiral cord lies superficial to the neurovascular bundle proximal to the MCP joint. Distal to the MCP joint it passes deep to the bundle. At that location, the spiral cord lies lateral to theneurovascular bundle as the lateral digital sheet becomes involvedFigure A demonstrates the cord formation that is characteristic of the pathologic Dupuytrenโs condition. It is the central cord that causes contracture of the MCP, whereas the retrovascular and spiral cords cause contractures of the DIP and PIP respectively. Illustration A shows the relationship of spiral cord formation in Dupuytren's disease relative to the normal anatomy of the palmar fascia. The structures implicated in the formation of the spiral cord are the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament, more dorsally located, is spared in Dupuytren's disease. The neurovascular bundle is displaced superficially and towards the midline, as the pathological cord spirals around. Illustration B shows the presence of other affected structures, including the natatory ligament and the central band. The central band is an extension of the pretendinous cord and attaches to the base of the middle phalanx. It may insert onto the tendon sheath of the flexor tendon at this level. Formation of natatory cords cause webspace contractures. Formation of central cords lead to flexion contractures of the PIP. Illustration V is a video that provides an educational overview of Dupuytren's.Incorrect Answers:An infant is brought to your office for evaluation of his hands. Clinical photos are shown in Figures A and B. The clinical features are most consistent with a genetic mutation in which of the following:Sonic Hedgehog (SHH)FGFR2FGFR3PMP22COL1A1CORRECT ANSWER: 2Based on the clinical features seen in the figures provided, the most likely syndrome is that of Apert syndrome, which is consistent with a mutation in FGFR2.Apert syndrome is an autosomal dominant condition that gives rise to facial dysmorphism and complex syndactyly of the hands. The craniosynostosis that develops causes flattening of the skull and facial features.Goldberg et al review congenital hand conditions and the malformations associated with them. They indicate that not only does identification allow for natural history to be better elucidated, but also timing of surgical intervention can be better gauged.Figures A and B demonstrate clinical features consistent with Apert Syndrome. The โrosebudโ hand is a complex syndactyly that affects the index, middle and ring fingers most commonly. Hypertelorism is exemplified with increased distance between the eyes; additionally, acrocephaly is noted with forehead broadening and skull flattening.Incorrect Answers1: Mutation in sonic hedgehog gene (SHH) is associated with a longitudinal deficiency of the radius. This is seen in conditions like TAR, Holt-Oram and VACTERL syndromes.3: Mutation in FGFR3 leads to achondroplasia4: Mutation in PMP22 gives rise to Charcot Marie Tooth syndrome 5: Mutation in COL1A leads to osteogenesis imperfectaA 45-year-old patient presents with recurrence of radial sided wrist pain after undergoing a first dorsal compartment release about 3 months ago. The surgery was completed by one of your partners; operative reports indicate that the sheath was incised on the dorsal edge. On physical exam she is found to have normal appearing skin, a negative Tinelโs sign, and a positive Finklestein test. What is the most likely cause of the recurrence of her symptoms?Development of neuromaComplex regional pain syndromeFailure to decompress the EPB sub-sheathFailure to decompress the EPL sub-sheathFailure to decompress the APB sub-sheathBased on the history and clinical findings this patient has de Quervainโs tenosynovitis. The recurrence of her symptoms can be attributed to a failure to recognize and decompress the EPB sub-sheath.De Quervainโs tenosynovitis is a stenosing inflammatory condition of the first dorsal compartment of the wrist (APL/EPB). Surgical release of the compartment is indicated after conservative measures have failed. At the time of the operation, the incision is made on the dorsal side of the sheath to prevent volar subluxation of the tendons. Failure to identify and release a distinct EPB sub-sheath or a separate fibro-osseous compartment of the APL can lead to a recurrence of symptoms.Alegado et al. report a case of a patient with dysesthesias in the superficial radial nerve distribution 3 months after undergoing first dorsal compartment release for de Quervainโs tenosynovitis. They found a persistent fibrous remnant of the dorsal aspect of the sheath causing elevation of the superficial radial nerve. They recommend sheath excision or incision of the sheath at its dorsal attachment to avoid this complication.Ashurst et al. report a case of a patient presenting with bilateral de Quervainโs tenosynovitis secondary to excessive text messaging. Conservative measuresafforded the patient complete symptomatic recovery. They recommend limitation of texting, in conjunction with other standard treatments, to treat text messaging- associated de Quervainโs tenosynovitisIlyas et al. review the etiology, diagnosis and management of De Quervainโs tenosynovitis. Non-surgical management is largely successful and includes splinting and cortisone injections. In refractory cases, surgical release of the first dorsal compartment is completed. They recommend meticulous care of the radial sensory nerve and identification of all separate sub-sheaths.Illustration A shows an operative photo in a patient with multiple APL slips and an EPB that is hidden within a sub-sheath. Video V gives a brief overview of de Quervainโs tenosynovitis.Incorrect AnswersA 28-year-old NFL running back complains of continued hand pain three days following an injury sustained while being tackled. He was splinted on the field. He has tenderness over the long finger metacarpal head, with subluxation of the extensor tendon into the intermetacarpal area during active metacarpophalangeal joint flexion. A representative MRI is shown in Figure A. What is the next best step in management of this patient?Observation aloneContinued splinting in flexionContinued splinting in extensionOpen repair of the disrupted junctura tendinaeOpen repair of the disrupted sagittal bandBased on the history and physical exam findings this patient has sustained a traumatic rupture of the sagittal band. In this professional athlete, the next best step would be to perform an open repair of the sagittal band. This will allow for earlier aggressive rehabilitation and a quicker return to sport.Sagittal band ruptures may be traumatic (as in this case) or attritional in nature (as in rheumatoid arthritis). A direct blow to the MCP leads to forced flexion of the digit and subsequent stretching/rupture of the affected structure. On physical exam the tendons are most unstable with the wrist flexed; MCP flexion will lead to dislocation of the tendon into the intermetacarpal gutter.Acute injuries may be treated with extension bracing for 4-6 weeks, but in professional athletes, direct open repair of the sagittal band is indicated.Catalano et al. review sagittal band injuries treated with a thermally moldedplastic splint that held the MCP in ~25-35 degrees of hyperextension. Patients were evaluated over 14 months; out of 11 sagittal band injuries, splinting was successful in eight of them. They recommend initial nonsurgical management with custom splinting.Hame et al. review the results of the management of sagittal band injuries in the professional athlete. The lesion commonly found was the disruption of the extensor mechanism with predictable sagittal band tears. In their series, all patients regained full range of motion and returned to their respective sports. They recommend surgical intervention in elite athletes in the form of extensor tendon centralization and sagittal band repair.Figure A shows a T1 weighted axial cut of the affected hand; subluxation of the tendon (arrow) can be identified with disruption of the sagittal band (arrowhead).The video provided briefly reviews injury to the sagittal band. Incorrect AnswersCompressive injury to the posterior interosseous nerve will lead to EMG fibrillations in which of the following muscles?Extensor Carpi Radialis Longus/Extensor Carpi Radialis Brevis/BrachoradialisExtensor Carpi Radialis Longus/Supinator/Abductor Pollicis LongusExtensor Pollicis Longus/Supinator/Abductor Pollicis LongusBrachoradialis/Supinator/Extensor Pollicis LongusExtensor Pollicis Longus/Supinator/Abductor Pollicis BrevisBased on the choices above, fibrillations will be seen in the extensor pollicis longus, supinator and abductor pollicis longus muscles.The radial nerve splits into the superficial radial branch and the posterior interosseous nerve (PIN) at the anterior aspect of the radiocapitellar joint, just proximal to the supinator muscle. The PIN innervates the EDC, EDM, ECU,EPB, EPL, EIP, APL and sometimes the ECRB. Compressive neuropathy of the PIN leads to motor dysfunction, namely weakness with wrist and finger extension.Lubhan et al. review uncommon compression neuropathies affecting the upper extremity. They indicate that PIN syndrome may be caused by rheumatoid arthritis and compressive ganglion cysts. Depending on which nerve branch is affected, partial lesions may develop. They recommend use of conservative measures (rest, activity modification and splinting) first. Decompressive procedures may be indicated in symptoms lasting greater than 3 months.Illustration A shows the course of posterior interosseous nerve from proximal to distal along the course of the supinator. This proximal edge of the supinator (Arcade of Froshe), the fibrous edge of the ECRB and the leash of Henry are three main points of compression of the PIN.Incorrect AnswersFigure A shows a traumatic laceration of the distal forearm with a 5cm segmental median nerve defect. Which of the following repair or reconstruction techniques would allow for the best recovery of motor function?Autogenous venous nerve conduitCollegen synthetic nerve conduitBiodegradable polyglycolic acidProcessed nerve allograftNerve autograftCORRECT ANSWER: 5Figure A shows a traumatic laceration with 5cm of median nerve defect. The use of nerve autograft for this size defect has been shown to have the best recovery of motor function.The optimal surgical treatment of nerve laceration is direct tension-free repair. In segmental nerve defects this approach cannot be achieved. The use of interposed autologous nerve grafting remains the gold standard of repair in this setting. The use of alternative techniques, such as processed allografts and synthetic conduits, have not shown to have equivalent recovery of motor function as compared to nerve autograft.Giusti et al. used a rat model to examine techniques of peripheral nerve repair. They showed that nerve autograft resulted in better motor recovery than did the use of processed allograft or a collagen conduit.Deal et al. discussed tubular interposition substitutes, or nerve conduits, as an alternative to nerve autograft in segmental nerve defect. Nerve conduits can include autogenous nerve conduits (venous or arterial) and synthetic nerve conduits (collagen, PGA, or caprolactone). In general, there is an upper limit of 3-cm when using nerve conduit.Figure A is an image of the volar forearm. There is a traumatic laceration tothe anterior compartment tendons as well as the median nerve.Incorrect Answers:A 45-year-old man presents with a three-month history of unilateral symptoms in his right wrist and hand. He first noticed a palpable nodule over the volar aspect of his wrist about three months ago. The nodule would become painful after weekends of heavy drinking at which time he noticed tingling sensation in his index and middle fingers. He notes that ibuprofen has helped improve the pain in the past. On clinical examination, he has a palpable, nontender, solid nodule over the volar aspect of his wrist. He has no motor or sensory deficits and negative carpal tunnel provocative tests. An axial CT and MRI image are provided in figures A and B. What would be the most appropriate next step in the management of his symptoms?Fine needle aspirationChemotherapyNight splintsEstablish a tissue diagnosis and referral to a rheumatologistSurgical excisionCORRECT ANSWER: 4The clinical presentation is consistent with carpal tunnel syndrome caused by an atypical space occupying lesion - in his case, gout. The most appropriate next step in the management of his symptoms would be establishing a tissue diagnosis and referral to a rheumatologist where medical therapy, such as prophylaxis with colchicine, could be initiated.Carpal tunnel syndrome is the most common compressive neuropathy, affecting up to 10% of the general population. Risk factors include female sex,advanced age, obesity, and repetitive motion activities. Typically, patients will develop symptoms of median nerve compression including thenar muscle atrophy, numbness in the radial 3.5 digits, night pain, and positive Tinel's and Phalen tests. First line management is non-operative, including NSAIDs, night splints, and activitiy modification. Carpal tunnel release surgery is indicated for those who have failed conservative management.Chen et al. described 23 unusual cases of CTS in which space-occupying lesions were responsible for the symptoms and signs of median nerve compression. In patients with an atypical presentation, such as male gender, non-middle-aged, or unilateral involvement, space-occupying lesions such as gout, synovial sarcoma, lipoma, and ganglions should be investigated as a cause.Fitzgerald et al. discussed gout affecting the hand and wrist. The medical treatment of gout includes NSAIDs such as indomethacin or ibuprofen for acute flares, and colchicine and allopurinol for chronic prophylaxis.Figures A and B represent axial CT and MRI images showing calcification and gouty tophi deposition in the carpal tunnel floor.Incorrect Answers:Which statement most accurately describes the physiology of peripheral nerve regeneration following an axonotmesic lesion?The proximal nerve segment undergoes Wallerian degenerationAxon growth occurs from the distal segment to proximal segmentNeurotrophic factors direct phagocytic activityProximal axon budding allows for antegrade (or distal) axon migrationAxoplasm and myelin are degraded distally predominantly by Schwann cells for the first 12 months following injuryAxonomesis is a disruption of the nerve axon following injury. Repair/regeneration of the nerve occurs via proximal budding, followed by antegrade (or distal) axon migration.The peripheral nerve regeneration process begins with the distal segment undergoing Wallerian degeneration (axoplasm and myelin are degraded distally by phagocytes). Existing Schwann cells proliferate and line-up along the basement membrane. Proximal budding occurs after a one-month delay. This is followed by sprouting axons that migrate in an antegrade fashion to connect to the distal tube. Repair of the nerve can take months, and often have poor outcomes.Lee et al. reviewed peripheral never injury and repair. They commented that Wallerian degeneration (i.e., breakdown of the axon distal to the site of injury) is initiated 48 to 96 hours after transection. The Schwann cells then align themselves longitudinally, creating columns of cells called Bรผngner bands. At the tip of the regenerating axon is the growth cone.Illustration A shows a chart of peripheral nerve injury. The two main classification systems are Seddon and Sunderland. Video V is a lecture discussing peripheral nerve injury and management.Incorrect Answers:A 28-year-old male injures his hand while playing basketball and presents to the emergency room. Closed reduction is performed and is stable. Post-reduction rehabilitation is discussed with the patient.Which of the following radiographs demonstrates an injury that would be treated best by dorsal extension block splinting?Figure ECORRECT ANSWER: 2Dorsal extension-block splinting is the treatment of choice for dorsal proximal interphalangeal joint (PIPJ) fracture dislocations that are stable following reduction and have less than 40% articular surface fracture involvement.Dorsal PIPJ dislocations are a common injury, often resulting from jamming or hyperextending the finger. In the absence of an associated fracture or presence of a small volar plate avulsion, dorsal PIPJ dislocations are oftentreated with closed reduction and buddy-taping to the adjacent digit. Injuries that are unstable following reduction or those associated with an intra-articular fracture of the middle phalanx are stabilized with a dorsal extension-block splint to maintain reduction. It is important to initiate early range of motion exercises within the constraints of the splint to minimize scar formation and subsequent PIPJ contracture.Elfar et al. reviewed fracture-dislocations of the PIPJ. Dorsal PIPJ fracture-dislocations can be categorized as avulsion or impaction shear injuries.Avulsion fractures result from hyperextension of the PIPJ, tensioning the volar plate (VP) with eventual VP rupture or avulsion of the volar lip of the middle phalanx. Axial load applied to the digit in PIPJ flexion drives the head of the proximal phalanx across the middle phalangeal base, resulting in a shear fracture or comminuted impaction fracture of the middle phalanx, depending on the amount of energy imparted and the bone quality.Morgan et al. reviewed hand injuries in athletes. Dorsal PIPJ dislocations without associated fracture that are stable following successful reduction are treated by buddy taping the injured digit to the non-injured digit adjacent to the compromised collateral ligament. Buddy taping with active motion should be continued for 6 weeks. Unstable injuries and those with an intra-articular fracture of the middle phalanx should be treated with dorsal extension-block splinting with incremental extension of the splint on a weekly basis for 4 weeks, followed by buddy-taping for 3 months during sports activities.Figure A shows a simple dorsal PIPJ dislocation. Figure B shows a dorsal PIPJ fracture dislocation. Figure C shows a simple volar PIPJ dislocation. Figure D shows a volar PIPJ fracture dislocation. Figure E shows a dorsal avulsion fracture at the base of the distal phalanx (bony mallet injury). Illustration A depicts an dorsal extension-block splint that blocks extension of the digit past a set point while allowing full active flexion of the digit. Illustration B is a lateral radiograph of a digit showing a small minimally displaced volar plate avulsion fracture at the PIPJ with minimal intra-articular involvement (as compared to Figure B). This injury may be managed with buddy taping and active range of motion as tolerated.Incorrect Responses:extension for 6-8 weeks to limit flexion of the digit and therefore fracture displacement.A 35-year-old mixed martial arts fighter and recreational cocaine user presents with symptoms concerning for hypothenar hammer syndrome (HHS). Significant ischemia is found on physical exam. Arteriography is shown in Figure A. What is the most appropriate next step in treatment?Conservative treatment with cocaine abstinenceConservative treatment with activity modifications and medical management with calcium channel blockersTherapeutic endovascular fibrinolysisExcision of involved segment and reconstruction with or without a vein graftMedical management with coumadin for 6 monthsFigure A shows a bilobed aneurysm overlying the ulnar artery with normal appearing distal vasculature. Hypothenar hammer syndrome (HHS) can be associated with an aneurysm and is most appropriately treated with resection of the involved segment and either reconstruction with a primary anastomosis or vein graft.HHS syndrome consists of two separate entities, thrombosis and aneurysm. In the setting of thrombosis without aneurysm, conservative management is preferred. If the thrombosis is acute (<2 weeks), endovascular fibrinolysis has shown good results. In patients with an HHS and an aneurysm, surgery is required for resection to prevent distal embolization and remove the often painful aneurysmal mass.Yuen et al. review HHS. In patients with HHS and aneurysms, resection of the involved segment of the ulnar artery prevents distal embolic events, eliminates the painful mass, relieves ulnar nerve compression, and removes the thrombus which initiated the reflex vasospasm and closed off the collateralvessels in the region.Lifchez et al. review the long-term outcomes of 11 patients with HHS treated with ulnar artery reconstruction. 2 of the patients underwent excision and direct ulnar artery repair, and the rest underwent reconstruction with a vein graft. All patients had a mean improvement in digital brachial index, decrease in pain and dysesthesia symptoms, and decrease in cold intolerance compared with preoperatively.Nitecki et al. review a case series of 6 patients with HHS. They state that the treatment of thrombosis should be largely conservative, but thrombolytic treatment could be considered if the event happened <2 weeks prior to presentation.Illustration A shows an excised ulnar artery aneurysm in a patient with HHS. Note the typical "corkscrew" appearance of the distal segment.Incorrect Answers:A 36-year-male was using a high-pressure paint gun when he suffered the injury shown in Figure A. Which of the following variables would have the worst impact on his prognosis?Delay in surgical treatmentInjected solvent was greaseInjected solvent was water-based paintAn entry wound of greater than 3 cmInjected solvent was at room temperatureThe clinical presentation is consistent for a high-pressure injection injury. Delays in surgical treatment are associated with serious sequelae.High-pressure injection injuries are characterized by extensive soft tissue damage associated with a benign high-pressure entry wound. They should be treated with irrigation & debridement, foreign body removal and broad-spectrum antibiotics. There is a higher rates of amputation when surgery is delayed.Bekler et al. looked at the results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up. Ten of the injuries required formal operative debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation. They concluded that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation.Rosenwaser et al. report wide dรฉbridement of all involved tissues, decompression of tissue compartments, exploration and incision of tendon sheaths, removal of injected material, and saline irrigation are critical in the management of high-pressure injection injuries to the hand. They emphasizedelayed surgery has been associated with increased incidence of morbidity and amputation.Figure A shows a typical high-pressure injection injury. Notice the benign looking entry wound.Incorrect Answers:A healthy 50-year-old secretary is about to undergo an open carpal tunnel release. Which of the following peri-operative steps will have the greatest influence on minimizing the risk of a surgical site infection in this patient?Administration of cefazolin within 1 hour before incisionAdministration of cefazolin within 1 hour before incision followed by 5 days of cephalexin post-opCleanse with bacitracin solution immediately before skin incisionStandard sterilization and preppingAdministration of one dose of cephalexin within 1 hour before incisionThe patient is undergoing a clean, elective hand surgery. Prophylactic antibiotics, systemic or local, are not indicated for these procedures.Carpal tunnel syndrome is the most common compressive neuropathy. Individuals who fail medical management (night splints, NSAIDs, activity modification) are candidates for carpal tunnel release surgery (CTS). The surgery may be performed open or endoscopically. The reported incidence of post-operative infections following CTS varies between studies from 0% to 8%.Whittaker et al. performed a prospective, randomized, double-blinded, placebocontrolled trial investigating the use of antibiotic prophylaxis in clean, incised hand injuries. They found no significant difference in infection rates between patients who received IV flucloxacillin, IV followed by oral flucloxacillin, and an oral placebo (13% vs. 4% vs. 15%, p=0.19). They did not support the use of routine antibiotic prophylaxis prior to clean hand surgery.Bykowski et al. retrospectively reviewed 8,850 outpatient elective hand surgeries and found no significant difference in the rate of surgical site infection, including patients with diabetes or history of smoking. They concluded that antibiotics should not be routinely administered prior to clean, elective hand surgeries.Harness et al. found no statistical difference in the incidence of surgical site infection following CTS without prophylactic antibiotic compared with patients who received prophylactic antibiotics (0.7% vs. 0.4%, p=0.354). They did not recommend routine antibiotic prophylaxis.Illustration A reviews the anatomic components of the carpal tunnel. Incorrect Answers:infection in clean, elective hand surgery. Surgeons should consider the potential risks of antibiotics prior to administration, including Clostridium difficile colitis, antibiotic allergies, bacterial resistance, and so on.A 30-year-old male laborer sustained a right wrist injury 9 months ago. He continues to have symptoms of recurrent ulnar-sided wrist pain that impairs his ability to work. An MRI is performed andshows a triangular fibrocartilage complex (TFCC) injury. Which of the following is an indication to combine a Wafer procedure with arthroscopic TFCC debridement?Ulnar styloid fractureRadial styloid fracture2 mm of positive ulnar variance and ulnocarpal impingment2 mm of negative ulnar variance and radiocarpal joint arthritisScapholunate ligament injuryA Wafer procedure is indicated for positive ulnar variance and symptomatic ulnocarpal impingement associated with degenerative TFCC tears.Ulnar impaction syndrome and triangular fibrocartilage complex (TFCC) injuries are relatively common causes of ulnar-sided wrist pain. Positive ulnar variance causes increased contact pressures between the lunate and the ulnar head. The Wafer procedure removes 2-4 mm of distal ulnar head to reduce ulnar variance to neutral or negative. This is thought to reduce ulnar impaction and decrease pain.Faber et al. examined the role of MRI in wrist injuries. They showed that the sensitivity and specificity to detect TFCC tears using MRI is approximately 80%. They conclude that there is no supporting evidence for routine MRI's for patients with non-specific ulnar-sided wrist pain.Illustration A is a coronal view MRI (without arthrogram) of the right wrist that shows a TFCC tear (blue arrow) with positive ulnar variance. Illustration B shows a series of images showing a TFCC tear on MRI and intra-operatively.Incorrect Answers:A 27-year-old male sustains the injury shown in Figure A. He is taken to the operating room and the lesion is repaired primarily. Two months later, he feels a "pop" while using his hand and is no longer able to flex the distal phalanx of the involved digit. He is taken to the operating room for surgical exploration where 1.8 cm of scar tissue between the tendon ends is identified. The tendon sheath is found to be intact and allows smooth passage of a pediatric urethral catheter. What is the next step in management?Resection of scar and primary repair of tendon ends.Resection of scar and adjacent 1cm of tendon, placement of Hunter rod for staged reconstruction.Debulking of scar, partial excision of 25% of the A2 and A4 pulleys.Resection of scar, harvest of ipsilateral palmaris longus tendon for tendon reconstruction.Resection of scar and proximal tendon, tendon transfer from adjacent digit.This patient sustained an FDP laceration that was treated initially with primary repair. He subsequently re-ruptured the tendon 2 months later. With scar >1 cm, tendon grafting is indicated and primary tendon grafting with palmaris longus is commonly performed as it is the most accessible tendon in the operative field.Flexor tendon lacerations commonly result from volar lacerations. Concomitant neurovascular injury is common. Partial lacerations <60% of tendon width are treated with debridement and early range of motion. With partial lacerations, the least amount of gliding resistance can be obtained with debridement alone. Lacerations >60% of tendon width are treated with flexor tendon repair and controlled mobilization. Failed primary repair and chronic untreated injuries are indications for flexor tendon reconstruction and intensive postoperative rehabilitation.Lilly et al. reviewed complications after flexor tendon injuries. Common complications include adhesions, joint contracture, tendon rupture, triggering, pulley failure and bowstringing, quadrigia, swan-neck deformity and lumbrical plus deformity.Figure A shows a zone II laceration of the left index finger FDP.Incorrect Answers:A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of motion of her thumb is seen in Figure B. What is the most likely cause of her deformity?Type II hypoplastic thumbMedian nerve neuropathyLupus thumb deformityExtensor tendon ruptureOsteoarthritis of the trapeziometacarpal jointThe patient has 1st carpometacarpal (CMC) arthritis.With 1st CMC arthritis, the patient avoids painful thumb abduction and an adduction deformity gradually develops, with 1st webspace contracture. With progressive 1st CMC stiffness, the thumb metacarpophalangeal joint (MCP) develops hyperextension deformity to compensate for the loss of motion, leading to a secondary "Z" deformity.Rozental et al. reviewed hand and wrist reconstruction. They believe that arthrosis arises from loss of the anterior oblique ("beak") ligament.Compensatory MCP hyperextension should be treated with MCP capsulodesis or arthrodesis.Van Heest et al. reviewed thumb CMC arthritis. Treatment for Eaton stage I/II arthritis is open/arthroscopic debridement, volar ligament reconstruction (with APL or FCR tendons), or metacarpal extension osteotomy. For stage III/IV arthritis, treatment options include implant arthroplasty or resection arthroplasty +/- LRTI (with APL, FCR or palmaris longus), and fusion (young patients).Figure A shows adduction contracture of the 1st webspace, with hyperextension deformity of the 1st MCP joint. Figure B illustrates decreased thumb abduction because of adduction contracture with decreased palmar abduction (normal, 45deg) and decreased radial abduction (normal, 60deg). Illustration A is a radiograph showing thumb CMC arthritis with Z deformity. Illustration B shows lupus thumb deformity ("hitchhiker thumb"). Illustration C shows hand changes in inflammatory arthritis.Incorrect Answers:A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures A through C. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition?Ring flexor digitorum superficialis transfer to the abductor pollicis brevisExtensor indicis proprius transfer to the abductor pollicis brevisNeurotization of thenar musclesCamitz palmaris longus transfer to the abductor pollicis brevisThumb carpometacarpal joint arthrodesisThis patient has a high median nerve neuropathy because of a supracondylar spur and ligament of Struthers. Reconstruction is best performed with extensor indicis proprius (EIP) transfer to the abductor pollicis brevis (APB).In low median nerve palsy, the primary concern is restoration of thumb opposition. In high median nerve palsy, thumb opposition and IP flexion, and index and middle finger flexion have to be addressed. The four common opposition transfers include (1) ring or long FDS, (2) EIP, (3) Camitz palmaris longus (PL), or the Huber abductor digiti minimi (ADM).Anderson et al. reviewed EIP transfer vs FDS transfer. They found a higher percentage of excellent results in the EIP group. In their series, complications included index finger extensor lag (EIP transfer if the extensor expansion was not repaired) and limited donor finger extension because of lateral band damage or adhesions between the remaining FDS tendon and flexor sheath (FDS transfer).Cawrse et al. modified the Huber ADM opponens transfer by releasing the proximal end to prevent compression of the ulnar nerve in Guyon's canal by the rotated ADM belly. They found that this technique successfully restoredopposition and thenar bulk.Figure A shows thenar wasting. Figures B and C show a supracondylar spur. The ligament of Struthers attaches from this spur to the medial epicondyle, under which median nerve and brachial artery pass. Illustration A shows EIP transfer. Illustration B shows FDS transfer. Illustration C shows Camitz PL transfer. Illustration D shows Huber ADM transfer.Incorrect Answers:A 2-year-old child is referred by her pediatrician for fixed flexion deformity of the left thumb. She has been wearing a splint for the last 6 months. She has ventricular septal defect and left renal agenesis. The interphalangeal joint does not extend past 40 degrees of flexion as seen in Figures A and B. There is no triggering. There is a firm, nontender nodule overlying the metacarpophalangeal joint as outlined in blue in Figure C. What is the diagnosis and most appropriate treatment?Thumb camptodactyly. Therapy including passive stretching exercises.Congenital clapsed thumb. Percutaneous release of the A1 pulley.Pediatric trigger thumb. Open release of the A1 pulley.Pediatric trigger thumb. Open release of the A1 pulley and resection of the tendon nodule.Blauth Type I hypoplastic thumb. Open release of the A1 pulley and volar plate, and resection of the tendon nodule.This child has pediatric trigger thumb (PTT). The potential for spontaneous resolution beyond the age of 2 years is limited. Surgical release of the A1pulley is indicated.Pediatric trigger thumb presents as fixed flexion at the interphalangeal joint (IPJ) rather than triggering. It is likely to be acquired (rather than congenital). It is associated with the presence of Notta's nodule, a thickening of the FPL tendon and overlying tendon sheath. Treatment involves A1 pulley release.The role of non-surgical management (splinting/stretching) remains unclear. The duration of non-surgical treatment is long (up to 30 months) and compliance can be difficult.Shah et al. reviewed pediatric trigger thumb. The condition is associated with MCP hyperextension. The authors note no advantage to percutaneous release as general anesthetic is required anyway.Marek et al. performed a retrospective review and survey response review of surgery for pediatric trigger thumb. They found that age at the time of surgery influences residual flexion contracture and rate of recovery. They found surgery to be safe and effective, and recommend: (1) surgery for a 2-year-old child with a locked thumb for 6 months, (2) observation for a child <1 year if the thumb is triggering (not locked), and (3) a 6-month observation period if observation is advocated.Figures A and B show a fixed flexion deformity of the thumb and an attempt at thumb extension. Figure C shows the outlined Notta nodule.Incorrect Answers:A 48-year-old hairdresser presents with pain and swelling of his ring finger for 4 days. On examination, there is generalized tenderness along the entire digit. Passive extension of the digit triggersexcruciating pain. The clinical appearance of the digit is shown in Figure A. What is the most appropriate next step in management?AcyclovirIntravenous antibiotics, splinting and elevationClosed tendon sheath irrigation from the level of the A1 pulley (proximal) to the distal interphalangeal joint (distal)Continuous closed tendon sheath irrigation from the wrist (proximal) to the distal interphalangeal joint (distal)Open irrigation and debridementThis patient has advanced pyogenic flexor tenosynovitis (PFT) with visible ischemia/necrosis. Open irrigation and debridement is necessary.Pyogenic flexor tenosynovitis is usually caused by a puncture wound (although it may infrequently arise from hematogenous spread). The most common organism is Staphylococcus aureus. Kanavel signs help differentiate this disease from herpetic whitlow, septic arthritis, gout/pseudogout, and other hand infections such as paronychia, felons, cellulitis, and deep space infections.Draeger et al. reviewed the treatment of pyogenic flexor tenosynovitis (PFT). They recommend open irrigation and debridement for advanced PFT and atypical or chronic tenosynovial infections where tenosynovectomy may beindicated. Both midaxial and volar zigzag incisions can be used.Pang et al. reviewed factors affecting the prognosis of PFT. Of the 4 Kanavel signs, they found that fusiform swelling was most often present (97% of patients), followed by pain on passive extension (72%), semiflexed digit posture (69%), and tenderness along the flexor tendon sheath (64%).Figure A shows advanced PFT demonstrating subcutaneous purulence and local ischemia in addition to fusiform digital swelling. Illustration A shows the Nevasier technique of closed tendon sheath irrigation. Illustration B shows the setup for continuous tendon sheath irrigation using nested catheters.Illustration C shows the incision for open irrigation and debridement.Incorrect Answers:Madelung's deformity of the distal radius is caused by which of the following?Premature fusion of the distal radial ulnar jointPhyseal growth mismatch between the distal radius and ulnaNutritional deficiency affecting the physeal zone of provisional calcificationImpaired growth of the volar and ulnar aspect of the distal radial physisUnrecognized traumaCORRECT ANSWER: 4Madelung's deformity is that of excessive ulnar/palmar angulation of the distal radius caused by impaired growth of the volar and ulnar aspect of the distal radial physis. It may be caused by either a bony lesion in the palmar/ulnar corner of the distal radial physis or an abnormal radial-carpal ligament (Vicker's ligament). The other answers do not cause Madelung's deformity.Leri-Weill dyschondrosteosis is a rare genetic disorder caused by mutation in the SHOX gene that causes mesomelic dwarfism with associated Madelung's defomity of the forearm.Illustration A is a radiographic example of Madelung's deformity.A 17-year-old boy presents with pain in his right elbow for 2 years and limitation in elbow motion bilaterally. He denies any pain or discomfort in his left elbow. He reports no history of trauma to either elbow. He has had two courses of physical therapy, but has noted no noticeable improvement in pain or motion. Examination demonstrates no elbow tenderness on palpation, and there are no neurological deficits. Manual reduction is unsuccessful. The range of motion of both elbows is shown in Figure A. Radiographs of left and right elbow are shown in Figure B and C respectively. What is the most appropriate treatment plan for the right and left elbow?Bilateral open reduction and application of a hinged external fixator to both elbowsRadial head resection of the right elbow and non-operative management of the left elbow.Bilateral radial head arthroplastyPhysical therapy and splinting to both elbowsRadial head resection and interposition arthroplasty for the right elbow and radial head resection alone for the left elbowThis patient has bilateral congenital radial head dislocation (CRHD). The right side is symptomatic with significant loss of motion. The left is asymptomatic with minimal loss of active motion. Therefore the most appropriate treatment is radial head resection of the right elbow and non-operative management of the left elbow.It is important to differentiate CRHD from traumatic dislocation. Clinical features of CRHD include bilateral involvement, presence at birth, other congenital anomalies, familial occurrence, irreducible by closed methods, andlack of a history of trauma. Radiological features include dome-shaped radial head and hypoplastic capitellum, relatively short ulna or long radius, deficient trochlea, prominent medial epicondyle, grooving of the distal radius, and anterior curvature of the posterior outline of the ulna.Bengard et al. reviewed 10 surgically treated and 6 nonsurgically treated CRHD patients. They found no change in flexion-extension and carrying angle postoperatively, but forearm rotation was improved. Surgically treated patients had significant improvement in elbow pain. Ultimately, >25% of patients had wrist pain postop and this must be weighed in the decision process of treatment. They recommend radial head excision as an effective intervention in selected patients with significant elbow pain.Figure A is a table showing moderately diminished ROM of the right elbow, and minimally reduced ROM of the left elbow. Figures B and C both show posterior dislocation of the radial head (a line along the long axis of the radius should intersect the capitellum in all views).Incorrect Answers:Which of the following muscles provide the primary deforming forces to Bennett and Rolando fractures (base of the 1st metacarpal fractures)?Pronator quadratusFlexor pollicis longusExtensor pollicis longusAdductor pollicis longus and abductor pollicisAbductor pollicis longus and adductor pollicisThe primary deforming forces in Bennett and Rolando fractures are the Abductor pollicis longus and adductor pollicis.In a Bennet's or Rolando fracture-dislocation the volar-ulnar fracture fragment is held reduced by the anterior oblique ligament while strong deforming forces pull the remaining metacarpal shaft proximally and dorsally, angulate the shaft ulnarly and supinate the shaft. Most important in these deforming forces are the abductor pollicis longus (APL) inserting on the base of the metacarpal which pulls the metacarpal shaft proximally and dorsally and the adductor pollicis (AP) which inserts on the ulnar base of the proximal phalanx and angulates the metacarpal shaft ulnarly and supinates the shaft. Less important is the extensor pollicis longus (EPL) which inserts on the base of the distal phalanx and also adds to the ulnar angulation of the distal fragment.Soyer reviews the diagnosis, pathoanatomy, and treatment for fractures at the base of the 1st metacarpal. Understanding the biomechanics, anatomical deforming forces, and the exact fracture pattern aids the treating surgeon in determining the most appropriate method of fixation. The most essential factor for obtaining a good functional result is anatomic restoration of the articular surface.Elgafy et al. examined the terminal anatomy of the posterior interosseous nerve in their cadaver study - identifing six terminal branches and describing methods to avoid injury. They describe how treating surgeons can maximize function and recovery after base of the 1st metacarpal fractures by understanding these nervous branches and specific fracture pattern treatment to avoid iatrogenic injury to the PIN.A 28-year-old man sustained a complete laceration of the flexor digitorum profundus of his index finger while cutting a watermelon 3 days ago. A clinical photograph is shown in Figure A. The surgeon plans to repair the tendon using a 4-strand core suture technique. Which method of tendon repair will give him the best results in terms of load to failure and gliding resistance?Repair with core suture purchase 5mm from the cut edge only. No epitendinous sutureRepair with core suture purchase 10mm from the cut edge only. No epitendinous sutureRepair with core suture purchase 5mm from the cut edge. Circumferentialsimple running epitendinous suture.Repair with core suture purchase 10mm from the cut edge. Circumferential Silfverskiold epitendinous suture.Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture.Repair with core suture purchase 10mm from the cut edge, coupled with circumferential simple running epitendinous suture will give him the best load to failure and gliding resistance.The strength of tendon repairs depend on the number of strands crossing the repair site. Ideally, repairs should have 4-6 strands to allow for early active motion. A running epitendinous suture is recommended to improve tendon gliding and repair strength.Gulihar et al. compared 3 different epitendinous suture techniques. They found that compared with an intact tendon, gliding resistance increased 100% with the Halsted repair, 80% with the Silfverskiold repair and 60% with a running suture. They thus recommend a simple running suture when an epitendinous suture is needed.Lee et al. compared core suture purchase at 3, 5, 7 and 10mm from the cut edge. The 10mm-repair group had the highest 2-mm gap force and ultimate failure load. They recommend 10-mm suture purchase for optimal performance and to allow early active motion.Figure A shows a laceration to the volar aspect of the index finger in flexor zone II. Illustration A shows a core suture purchase distance from the cut edge (represented by "X", where 10mm is the ideal distance). Illustration B shows 3 different epitendinous suture techniques (A, simple running; B, Silfverskiold; C, Halsted).Incorrect Answers:A 28-year-old professional baseball player injures his middle finger sliding into the catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A radiograph is provided in figure A. All of the following are true EXCEPT:Anatomic reconstruction of the articular surface is prognostic of clinical functionProximal interphalangeal joint subluxation precludes a normal gliding flexion arcHinging at the fracture site must be avoidedEarly motion should be initiated in postoperative therapyEarly degenerative arthritis can be expected if the joint is not adequately reduced.The radiograph demonstrates a dorsal fracture dislocation of the proximal interphalangeal joint of the middle finger. Kiefhaber and Stern review the presentation, evaluation, and treatment of PIP fractures. Congruent reduction of the joint to allow the middle phalanx to glide around the proximal phalangeal head is paramount to prevent joint subluxation and instability.Anatomic reconstruction of the articular surface is desirable but not necessary for successful clinical outcome.A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A. He undergoes a procedure to restore the soft tissue envelope. Which treatment option is contraindicated because of increased risk of interphalangeal joint stiffness?Moberg volar advancement flapFoucher first dorsal metacarpal artery flapLittler neurovascular island flapFree great toe pulp transferHolevich first dorsal metacarpal artery flapThis patient has a large thumb pulp defect measuring 3.5 cm in length, extending proximal to the interphalangeal joint (IPJ) crease. Inset of a Moberg flap large enough to cover the defect would necessitate IPJ flexion >45 degrees, increasing the risk of IPJ stiffness.Thumb pulp defects may be resurfaced by different means, depending on size. The Moberg flap is suited for medium (1.8-3 cm) defects. For defects >1.5 cm, there is increased risk of wound dehiscence, parrot beak nail deformity, and decreased soft tissue padding. Modifications such as V-Y flaps, bilateral Z-plasties, Burrow triangles, 2 lateral triangular flaps at the proximal edge of the flap, or advancement of an island flap with skin grafting of the secondary defect (OโBrien modification), are recommended.Baumeister et al. reviewed the functional outcome of Moberg flaps. These flaps do not cause marked impairment of active ROM and any reduction in the AROM of the IP joint is because of a loss of hyperextension.Horta et al. reviewed the use of multiple flaps (Moberg, radial innervated cross-finger, Venkataswami-Subramanian, Foucher, Tezcan, and Littler). They recommended the Foucher flap because of good sensibility, single-stage surgery, and no need for cortical reintegration (unlike the Littler flap)Figure A shows a large thumb pulp defect. Illustration A shows the options for resurfacing thumb pulp defects of different sizes. Illustration B is a diagram of these options. Illustrations C and D depict the Holevich dorsal metacarpal artery flap (with overlying skin strip). Illustrations E and F depict the Foucher dorsal metacarpal artery flap (islanded).Incorrect Answers:Percutaneous screw fixation for non-displaced scaphoid waist fractures has been shown to have which of the following differences compared to closed treatment?Increased direct and indirect costSlower return to workHigher union ratesReduced time to fracture unionImproved motion and grip strength after 2 yearsFixation of non-displaced scaphoid fractures with a percutaneous screw has resulted in a shorter time to union (6-7 weeks versus 10-12 weeks) and faster return to work or sports.Arora et al found the indirect cost reduction by a quicker return to work was shown to offset the direct costs of surgical intervention.The operatively treated group had a better mean DASH-score than the conservative group. Fractureunion was seen in the screw fixation group at a mean of 43 days and in the cast immobilization group at a mean of 74 days.Bond et al found in active military personnel there was faster healing but no difference in ultimate union rates or final grip strength or range of motion between percutanous screw fixation and non-operative groups. The average time to fracture union in the screw fixation group was seven weeks compared with twelve weeks in the cast immobilization group. There was no significant difference in the range of motion of the wrist or in grip strength at the two-year follow-up evaluation.Constriction ring syndrome, also known as amniotic band syndrome, is a congenital disorder associated with which paediatric foot condition?Equinovalgus footClubfoot (Congenital talipes equinovarus)Tarsal coalitionCongenital vertical talusPolydactylyCORRECT ANSWER: 2Constriction ring syndrome is a congenital disorder that is most commonly associated with clubfeet (congenital talipes equinovarus). The reported incidence of clubfeet with concomitant constriction bands ranges from 12-56%.Constriction ring syndrome is a collection of congenital malformations that occur as a result of intrauterine rings or bands that constrict fetal tissue. The etiology of constrictive ring syndrome remains elusive, though Streeter postulated in 1930 that a germline developmental abnormality is responsible for the development of amniotic constriction bands, hence one of the synomonous terms used to describe the disorder, Streeterโs dysplasia. Normal anatomy is found proximal to the band. Distally, a constrictive band can cause compression of lymphatic and neurovascular structures and result in lymphedema, altered circulation and neuropathy. In severe cases congenital amputation can occur. In terms of other orthopaedic conditions, constrictive ring syndrome is associated with clubfeet, acrosyndactyly and pseudoarthrosis. With respect to clubfeet, surgical treatment is commonly required, which consists of z-plasty releases of the constricted bands, in addition to surgical correction of the clubfoot deformity.Gomez reviewed 35 children with clubfeet associated with constriction ring syndrome. In this cohort there was a poor response to casting, as 77% of the children required surgical corrections. Z-plasty releases of the deep bands were performed before the clubfoot correction.Allington et al. examined the outcome of treatment of clubfeet distal to a lower extremity band in 18 patients (21 feet). Sixteen children (88.9%) underwent surgical treatment after manipulation and serial casting were unsuccessful.Mild initial foot deformities and constriction bands located in the distal aspect of the lower leg were associated with the best outcomes.Incorrect Answers:You are consulted on a newborn male inpatient who presents with the clinical sign shown in Figure A. All of the following are commonly associated with this syndrome EXCEPT?Bronchopulmonary dysplasiaCardiac defectsCleft palateEncephaloceleRigid talipes equinovarus
