Ortho Upper Extremity 2026 MCQs: Board Review Part 6

Question 1

A 28-year-old competitive swimmer presents with recurrent anterior shoulder dislocations. He has failed a supervised physical therapy program. On examination, he has generalized ligamentous laxity (Beighton score 6/9) and full external rotation with the arm abducted 90 degrees (apprehension test negative in this position). He is concerned about his long-term ability to return to swimming. Which of the following surgical interventions is MOST appropriate to recommend?

Explanation

The patient's generalized ligamentous laxity and failure of conservative management for recurrent anterior shoulder dislocations suggest a need for bony augmentation, especially in a high-demand athlete. The negative apprehension test in abduction and external rotation despite recurrent dislocations is a red flag for significant bony loss (either glenoid or humeral). While Bankart repair addresses soft tissue, it has higher failure rates in patients with significant bone loss or hyperlaxity. The Latarjet procedure provides a bone block that increases the anterior-inferior glenoid articular arc, thereby augmenting the "inverted pear" glenoid deficiency and creating a conjoint tendon sling effect. This is particularly effective in cases with significant glenoid bone loss (>20%) or engaging Hill-Sachs lesions, and in hyperlax patients or those involved in high-impact overhead sports, where standard soft-tissue repairs are prone to failure. Remplissage addresses Hill-Sachs, but without addressing potential glenoid bone loss it may not be sufficient for a high-demand, hyperlax individual. Open Bankart with capsular shift is good for multidirectional instability, but recurrent anterior dislocations with hyperlaxity often benefit more from bony stabilization.

Question 2

A 60-year-old male sustains a comminuted Mason Type III radial head fracture after falling onto an outstretched hand. Radiographs show significant displacement and articular depression. He has severe pain with forearm rotation and limited extension. Which of the following is the MOST appropriate initial management strategy?

Explanation

A Mason Type III radial head fracture is severely comminuted and displaced, often involving the entire radial head. While ORIF can be considered for reconstructible fractures (typically Type II), Type III fractures are often non-reconstructible, leading to poor outcomes with fixation due to persistent pain and stiffness. Excision of the radial head in a comminuted fracture is generally discouraged, especially in older patients, due to the risk of proximal radial migration, valgus instability, and subsequent elbow arthritis. Radial head arthroplasty is the preferred treatment for non-reconstructible Mason Type III fractures, especially in patients over 40-50 years of age, as it restores elbow stability, preserves forearm rotation, and prevents proximal migration of the radius. This intervention is critical for maintaining stability, particularly in the context of associated ligamentous injuries (Essex-Lopresti lesion, terrible triad) which must be ruled out.

Question 3

A patient presents 4 weeks after sustaining a partial laceration to the flexor digitorum profundus (FDP) tendon in Zone II of the little finger. He has experienced some improvement in active flexion but still has a significant flexion lag at the distal interphalangeal (DIP) joint. Physical examination reveals a 45-degree lag at the DIP joint and intact passive range of motion. What is the MOST appropriate next step in management?

Explanation

A 45-degree flexion lag at the DIP joint 4 weeks post-partial FDP laceration in Zone II suggests a significant functional deficit and a high likelihood of chronic tendon adherence or an insufficient repair/healing. While hand therapy is crucial, such a substantial lag indicates a mechanical block that therapy alone is unlikely to overcome. Delayed primary repair can be considered up to 3 weeks, sometimes longer depending on the surgeon. At 4 weeks, with a significant lag, the tendon ends may have retracted or scarred, making a simple tenolysis insufficient if the tendon is still partially disrupted or significantly attenuated. A secondary reconstruction (e.g., tendon graft) may be required depending on the quality of the tendon and the gap. Aggressive resistance exercises would likely worsen the issue or cause complete rupture. Immobilization would lead to further stiffness and adhesion formation. Therefore, reassessment for possible surgical intervention (delayed repair if feasible, or secondary reconstruction) is warranted.

Question 4

A 35-year-old male sustains a displaced intra-articular distal radius fracture (Frykman Type VIII) after a motorcycle accident. Examination reveals significant swelling and tenderness. Radial and ulnar pulses are intact, but he complains of numbness in the thumb, index, and middle fingers. Which of the following is the MOST urgent step in his management?

Explanation

Numbness in the median nerve distribution (thumb, index, middle fingers) in the setting of a displaced distal radius fracture indicates acute carpal tunnel syndrome, which is a surgical emergency. The immediate concern is to relieve pressure on the median nerve. This often starts with an emergent closed reduction of the fracture and immobilization, which can decompress the nerve by reducing fracture fragments. However, if symptoms persist or worsen after reduction, or if there is profound and acute neurological deficit, an emergent carpal tunnel release may be necessary in addition to fracture stabilization (either closed or open reduction). Therefore, the MOST urgent step is to attempt closed reduction to decompress the nerve, then reassess. Emergency ORIF might be necessary for definitive fixation, but decompression of the nerve through reduction is paramount first. A CT scan can wait until the nerve decompression is addressed. Steroids are not a primary treatment for acute compressive neuropathy in this setting. A simple splint without addressing the median nerve symptoms is inadequate.

Question 5

A 62-year-old sedentary patient presents with chronic, intractable shoulder pain and weakness, particularly with overhead activities. MRI reveals a massive, irreparable rotator cuff tear involving the supraspinatus, infraspinatus, and subscapularis, with significant retraction and fatty infiltration (Goutallier Grade 3-4) and superior migration of the humeral head with glenohumeral arthritis (Hamada Stage 4). She has failed extensive non-operative management. What is the MOST appropriate surgical intervention?

Explanation

The patient's presentation of a massive, irreparable rotator cuff tear with significant fatty infiltration and retraction, combined with glenohumeral arthritis and superior humeral head migration (rotator cuff arthropathy, Hamada Stage 4), indicates a condition best managed by reverse total shoulder arthroplasty (rTSA). rTSA is designed for situations where the rotator cuff is deficient, allowing the deltoid to power shoulder elevation and rotation. Arthroscopic repair or partial repair would be futile due to the irreparable nature and significant fatty infiltration. Superior capsular reconstruction is typically reserved for younger, active patients with irreparable tears but without significant glenohumeral arthritis. Latissimus dorsi transfer is an option for irreparable posterosuperior tears, often in younger patients, to restore external rotation and elevation, but it does not address the underlying glenohumeral arthritis. For this patient with established rotator cuff arthropathy, rTSA provides the most reliable pain relief and functional improvement.

Question 6

A 7-year-old boy presents with a Gartland Type II supracondylar humerus fracture. Radiographs show posterior displacement with an intact anterior humeral line. He has a strong radial pulse and good capillary refill. Sensory function is normal. What is the MOST appropriate management?

Explanation

A Gartland Type II supracondylar humerus fracture is characterized by displacement with an intact posterior cortex and an intact anterior humeral line. While some sources might suggest closed reduction and casting for stable Type II fractures, the prevailing consensus for displaced Type II and all Type III fractures is closed reduction and percutaneous pinning (CRPP). This provides stable fixation, allowing for earlier mobilization and minimizing the risk of re-displacement, which is a common complication with casting alone. Cast immobilization in 90 degrees of flexion without pinning is generally reserved for non-displaced (Type I) or minimally displaced fractures. ORIF is usually reserved for open fractures, neurovascular compromise that doesn't resolve after reduction, or failed closed reduction. Observation is for Type I. Skeletal traction is largely historical for this injury.

Question 7

A 25-year-old male sustains a gunshot wound to the supraclavicular region, resulting in a flail arm. Clinical examination reveals complete loss of deltoid, biceps, triceps, wrist extensor, and intrinsic hand function. An MRI shows evidence of multiple root avulsions from C5-T1. What is the MOST appropriate surgical intervention?

Explanation

Root avulsions, as suggested by the MRI and flail arm presentation, indicate preganglionic injuries where the nerve roots are torn from the spinal cord. These injuries cannot be directly repaired or grafted at the root level because the nerve cells (motor neurons) are in the spinal cord and the roots are avulsed from them. The most appropriate surgical intervention for preganglionic injuries is nerve transfers, where a less critical nerve (donor) is coapted to a more critical, denervated nerve (recipient) distal to the injury site. Examples include transferring intercostal nerves to the musculocutaneous nerve to restore elbow flexion, or phrenic nerve to suprascapular nerve for shoulder function. Neurolysis and direct repair/grafting are reserved for postganglionic ruptures where the nerve is torn distal to the dorsal root ganglion. Tendon transfers are typically considered for reconstructive options after nerve recovery plateaus or for situations where nerve repair/transfer is not feasible or fails. Observation is not appropriate for a flail arm with avulsions.

Question 8

A 55-year-old male presents with a progressive contracture of the ring finger and small finger in his right hand. He has a palpable cord in the palm extending into the fingers. The metacarpophalangeal (MCP) joint of the ring finger has a 40-degree contracture, and the proximal interphalangeal (PIP) joint has a 30-degree contracture. The small finger MCP is 50 degrees contracted, and PIP is 45 degrees contracted. Which surgical intervention is MOST appropriate for this patient?

Explanation

The patient presents with significant Dupuytren's contractures affecting both MCP and PIP joints of the ring and small fingers. The indications for intervention typically include an MCP joint contracture of 30 degrees or more, or any PIP joint contracture. Given the combined severity, surgical intervention is warranted. Percutaneous needle aponeurotomy (PNA) and collagenase injection (Xiaflex) are less invasive options, but they are generally most effective for isolated MCP joint contractures or less severe PIP joint contractures, and have higher recurrence rates. For significant PIP joint contractures, particularly those exceeding 20-30 degrees, limited fasciectomy (excision of the diseased fascia) is considered the gold standard and most effective treatment. Dermofasciectomy (excision of skin and fascia with skin grafting) is reserved for severe recurrent cases or very aggressive forms of the disease. Amputation is a salvage procedure for severe, irreversible contractures, usually with associated complications or non-functional digits, and not indicated here.

Question 9

A 70-year-old female presents with severe, chronic pain and crepitus in her right shoulder. Radiographs show significant glenohumeral osteoarthritis with concentric wear and an intact rotator cuff confirmed on MRI. She is active and wishes to return to gardening and light sports. What is the MOST appropriate surgical option?

Explanation

The patient presents with severe glenohumeral osteoarthritis with concentric wear and an intact rotator cuff, and has failed conservative management. For this scenario, anatomic total shoulder arthroplasty (TSA) is the gold standard. It replaces both the humeral head and glenoid surface, providing excellent pain relief and functional restoration in patients with an intact, functional rotator cuff. Hemiarthroplasty is typically considered for younger patients with glenohumeral arthritis and a good rotator cuff, but where glenoid replacement is deferred (e.g., due to concerns about glenoid wear or activity level), or for certain humeral head fractures. Reverse total shoulder arthroplasty is indicated when the rotator cuff is deficient (rotator cuff arthropathy). Arthroscopic debridement offers only temporary relief for severe arthritis. Shoulder fusion is a salvage procedure providing pain relief at the expense of motion, typically for failed arthroplasty or severe infection/paralysis.

Question 10

A 45-year-old machinist complains of progressive numbness and tingling in his ring and small fingers, worse with elbow flexion. He occasionally drops small tools due to hand weakness. Physical examination reveals tenderness over the cubital tunnel, a positive Tinel's sign, and atrophy of the first dorsal interosseous muscle. There is no Wartenberg's sign. Electromyography and nerve conduction studies confirm severe ulnar neuropathy at the elbow. What is the MOST appropriate next step in management?

Explanation

The patient's symptoms (numbness/tingling in ring/small fingers, weakness, first dorsal interosseous atrophy), signs (Tinel's at cubital tunnel), and confirmed severe ulnar neuropathy indicate significant ulnar nerve compression at the elbow (cubital tunnel syndrome). The presence of motor weakness and muscle atrophy signifies advanced neuropathy, for which conservative management (immobilization, physical therapy, NSAIDs, observation) is unlikely to be sufficient and may lead to irreversible motor loss. Surgical cubital tunnel release (either in situ decompression, anterior transposition, or medial epicondylectomy) is indicated for severe or progressive cases, especially with motor deficits. Early surgical intervention in severe cases is associated with better outcomes and less risk of permanent neurologic deficit. The absence of Wartenberg's sign suggests normal superficial radial nerve function, which is not relevant to ulnar neuropathy.

Question 11

A 20-year-old gymnast presents with chronic ulnar-sided wrist pain, clicking, and instability after a fall. Examination reveals tenderness over the dorsal TFCC, a positive grind test, and pain with resisted supination. Radiographs are normal. MRI shows a Palmer Type 1B tear of the TFCC. What is the MOST appropriate treatment for this patient?

Explanation

A Palmer Type 1B tear of the TFCC involves a traumatic avulsion of the TFCC from its ulnar insertion, often associated with instability. In a young, active individual like a gymnast, restoration of TFCC stability is paramount to prevent chronic pain, instability, and degenerative changes. Arthroscopic repair, specifically reattachment of the avulsed peripheral TFCC, is the preferred treatment for this type of tear, especially if unstable. Immobilization might be tried initially for stable peripheral tears, but with chronic symptoms and instability, repair is indicated. Ulnar shortening osteotomy is indicated for ulnar positive variance with central (Type 1A) or degenerative (Type 2) tears, not primary traumatic peripheral tears with instability. Arthroscopic debridement is usually for stable, central TFCC tears (Type 1A) or degenerative tears (Type 2). Excision of the ulnar styloid is not a standard treatment for TFCC tears.

Question 12

A 30-year-old rugby player sustains an injury to his shoulder after falling directly onto the tip of his shoulder. Radiographs demonstrate a complete dislocation of the acromioclavicular (AC) joint with significant superior displacement of the clavicle, disrupting both the AC and coracoclavicular (CC) ligaments. The deltoid and trapezius muscles are detached from the distal clavicle. Which Rockwood classification type does this describe, and what is the MOST appropriate management?

Explanation

The description of a complete dislocation of the AC joint with significant superior displacement of the clavicle, disruption of both AC and CC ligaments, AND detachment of the deltoid and trapezius muscles from the distal clavicle corresponds to a Rockwood Type V AC joint injury. This is a severe injury with gross instability. While Rockwood Type III injuries are often managed non-operatively, Types IV, V, and VI are generally treated surgically due to significant displacement and associated soft tissue disruption, leading to poor functional outcomes with non-operative management. Type IV involves posterior displacement of the clavicle through the trapezius. Type VI involves inferior displacement. For Type V, surgical stabilization, often involving CC ligament reconstruction or repair, is the recommended treatment to restore stability and function. Distal clavicle excision is typically for chronic AC joint arthritis, not acute instability.

Question 13

A rock climber presents with pain and swelling in the palm and volar aspect of his ring finger. He reports hearing a "pop" during a difficult climb. Examination reveals tenderness along the A2 pulley, bowstringing of the flexor tendons with active flexion, and decreased grip strength. Which of the following is the MOST appropriate initial management?

Explanation

The symptoms (pop, pain, tenderness, bowstringing of flexor tendons) are classic for a rupture of the A2 pulley, a common injury in rock climbers. While surgical repair can be indicated for complete multiple pulley ruptures or severe single pulley ruptures causing significant functional deficit, the initial management for isolated or partial A2 pulley ruptures is typically conservative. This includes rest, ice, compression, and importantly, a specialized pulley support splint (e.g., ring splint or tape) worn during activities to prevent further bowstringing and allow healing. This allows the flexor tendons to glide more efficiently and reduces the load on the healing pulley. Corticosteroid injections are not indicated. Immobilization in extension would lead to stiffness and is contrary to the goal of allowing controlled motion while preventing bowstringing. Tenolysis is for adhesions, not acute pulley ruptures.

Question 14

A professional baseball pitcher presents with chronic medial elbow pain and decreased throwing velocity. He describes a "pop" during a pitch several months ago. Examination reveals tenderness over the medial epicondyle, a positive valgus stress test at 30 degrees of elbow flexion, and a positive moving valgus stress test. Radiographs show no acute fractures but reveal subtle calcification within the medial collateral ligament. What is the MOST likely diagnosis and definitive treatment?

Explanation

The presentation is classic for ulnar collateral ligament (UCL) insufficiency in an overhead athlete: acute "pop" during throwing, chronic medial elbow pain, decreased velocity, tenderness over the UCL, and positive valgus stress tests (both static and moving). Subtle calcification within the ligament supports chronic injury. Medial epicondylitis (golfer's elbow) typically causes pain with resisted wrist flexion/pronation and is less associated with acute instability or a 'pop'. Ulnar nerve entrapment would present with paresthesias in the ring/small fingers. Flexor-pronator strain is possible but less likely to cause instability on valgus stress. Olecranon stress fractures cause pain primarily with extension. For a professional athlete with symptomatic UCL insufficiency, UCL reconstruction (Tommy John surgery) is the definitive treatment to restore stability and allow return to high-level throwing.

Question 15

A 78-year-old female sustains a Neer three-part proximal humerus fracture after a fall. She is relatively active for her age but has significant comorbidities including diabetes and cardiac disease. Radiographs show significant displacement of the greater tuberosity and surgical neck, but the articular segment appears well-preserved. What is the MOST appropriate initial management strategy?

Explanation

A Neer three-part proximal humerus fracture involves displacement of the surgical neck and either the greater or lesser tuberosity. While conservative management (sling) is often considered for minimally displaced or two-part fractures in older patients, and hemiarthroplasty/rTSA for very comminuted or four-part fractures in older patients, a three-part fracture, especially with displacement of the tuberosities, often benefits from surgical intervention to restore anatomy and function. Given the patient's relative activity level and "well-preserved articular segment," ORIF with locking plates is often preferred in patients with good bone quality and a reconstructible fracture. This aims to restore tuberosity position, which is crucial for rotator cuff function and prevents impingement. Reverse TSA is typically reserved for four-part fractures, head split fractures, or patients with rotator cuff deficiency, particularly in the elderly. Hemiarthroplasty is an option for four-part fractures or head split fractures in good bone stock. Closed reduction and pinning is less stable for this degree of displacement.

Question 16

A 65-year-old female presents with chronic pain and stiffness in her right thumb. She reports difficulty with pinch activities and opening jars. Examination reveals squaring of the carpometacarpal (CMC) joint of the thumb, a positive grind test, and tenderness at the base of the thumb. Radiographs confirm severe osteoarthritis of the first CMC joint (Eaton Stage IV). She has failed activity modification, NSAIDs, and corticosteroid injections. What is the MOST appropriate surgical intervention?

Explanation

The patient has symptomatic, end-stage osteoarthritis of the first carpometacarpal (CMC) joint, refractory to conservative treatment. Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is considered the gold standard surgical treatment for severe thumb CMC osteoarthritis. This procedure involves removing the arthritic trapezium bone, which eliminates the painful joint, and then reconstructing the volar oblique ligament and interposing a local tendon graft (e.g., FCR) to maintain space and prevent proximal migration of the first metacarpal. CMC joint fusion provides excellent pain relief but sacrifices motion, which can be limiting, especially for bilateral cases or those requiring fine dexterity. CMC joint replacement arthroplasty is an option, but LRTI has a long track record of success. Arthrodesis of the IP joint is for IP joint arthritis. Proximal row carpectomy is for carpal arthritis.

Question 17

A 40-year-old male sustains a Galeazzi fracture-dislocation. Radiographs show a fracture of the distal third of the radius with associated dorsal dislocation of the distal radioulnar joint (DRUJ). He is an active laborer. What is the MOST appropriate treatment for this injury?

Explanation

A Galeazzi fracture-dislocation (fracture of the distal 1/3 of the radius with associated DRUJ dislocation) is considered an unstable injury. In adults, it almost always requires surgical stabilization. The primary goal is stable fixation of the radial shaft fracture, which, when anatomically reduced, often allows for spontaneous reduction and stabilization of the DRUJ. However, the DRUJ must be carefully assessed intraoperatively for stability after radial fixation. If the DRUJ remains unstable, it requires specific stabilization (e.g., temporary pin fixation across the DRUJ, TFCC repair if indicated). Closed reduction and casting alone are highly prone to failure in adults. ORIF of the radius alone without considering DRUJ stability is incomplete. External fixation is generally reserved for open fractures, severe soft tissue injuries, or highly comminuted fractures not amenable to ORIF. Observation is inappropriate.

Question 18

A 22-year-old female presents with bilateral, atraumatic shoulder instability. She describes a sensation of the shoulder "slipping out" in multiple directions, often spontaneously or with minimal provocation. On examination, she exhibits a positive sulcus sign, hyperlaxity, and pain with posterior and inferior loading. She has failed a comprehensive rotator cuff and periscapular strengthening program. What is the MOST appropriate surgical intervention?

Explanation

The patient's presentation of atraumatic, bilateral instability with a positive sulcus sign and generalized hyperlaxity, refractory to conservative management, is characteristic of multidirectional instability (MDI). The primary pathology in MDI is capsular laxity. The goal of surgical intervention for MDI is to reduce capsular volume and tighten the capsule. An inferior capsular shift (either open or arthroscopic) is the gold standard procedure for MDI, as it effectively addresses the redundant capsule in all directions, particularly inferiorly and posteriorly, depending on the shift's direction. Isolated anterior or posterior Bankart repairs are for unidirectional instability. Thermal capsulorrhaphy has largely been abandoned due to poor long-term outcomes and potential for nerve damage and capsular necrosis. The Latarjet procedure is for anterior instability with significant glenoid bone loss.

Question 19

A 30-year-old male presents with a slow-growing, painless mass on the dorsum of his wrist, which transilluminates. It fluctuates in size and becomes more prominent with wrist flexion. What is the MOST likely diagnosis?

Explanation

The classic description of a slow-growing, painless, transilluminating, fluctuating mass on the dorsum of the wrist that becomes more prominent with wrist flexion is highly indicative of a dorsal wrist ganglion cyst. These are benign, fluid-filled sacs originating from a joint capsule or tendon sheath. Lipomas are soft, fatty tumors that do not transilluminate. Giant cell tumors of the tendon sheath are solid, firm, and do not transilluminate. Epidermoid cysts are typically subcutaneous, not directly associated with joint capsules, and generally do not transilluminate. Enchondromas are intraosseous tumors. Therefore, a ganglion cyst is the most likely diagnosis.

Question 20

A 10-year-old boy sustains a Salter-Harris Type II fracture of the distal radius with dorsal displacement. The fracture is moderately displaced. What is the MOST appropriate treatment?

Explanation

A Salter-Harris Type II fracture involves the physis and a metaphyseal fragment (Thurston-Holland sign). In children, these fractures have a good prognosis for healing and remodeling. For moderately displaced fractures, closed reduction and long arm cast immobilization is the standard treatment. The long arm cast is crucial for controlling pronation/supination and maintaining reduction in the skeletally immature patient, especially for distal radius fractures. ORIF is rarely needed for Salter-Harris Type II fractures unless closed reduction fails or for very unstable reductions. Observation is for non-displaced fractures. Percutaneous pinning is typically for unstable reductions or Salter-Harris Type III/IV fractures requiring precise anatomical reduction. A short arm cast is often insufficient to maintain reduction in displaced pediatric forearm/wrist fractures.

Question 21

A 55-year-old active laborer presents with a massive, irreparable posterosuperior rotator cuff tear with significant retraction (Sugaya Type V). He has no signs of glenohumeral arthritis. He experiences significant pain and inability to elevate his arm above 90 degrees. He desires to return to work. What is the MOST appropriate surgical option to improve function and pain?

Explanation

This patient has an irreparable posterosuperior rotator cuff tear without glenohumeral arthritis, and desires functional improvement to return to work. While latissimus dorsi transfer is a historical option for posterior cuff deficiency, superior capsular reconstruction (SCR) has emerged as a viable option for irreparable massive rotator cuff tears in younger, active patients without significant arthritis. SCR aims to restore the superior capsule's function in preventing superior migration of the humeral head, thereby improving deltoid mechanics and often pain and active elevation. Reverse total shoulder arthroplasty is indicated for rotator cuff arthropathy (arthritis with cuff deficiency), which this patient does not have. Partial repair and debridement offers limited functional improvement for massive tears. Total shoulder arthroplasty is for glenohumeral arthritis with an intact cuff. The key here is an irreparable tear without arthritis.

Question 22

A 40-year-old administrative assistant complains of progressive numbness, tingling, and burning pain in her thumb, index, middle finger, and radial half of the ring finger, worse at night. She has noted dropping objects due to weakness. Examination reveals thenar atrophy, a positive Phalen's test, and a positive Tinel's sign at the wrist. Nerve conduction studies confirm severe carpal tunnel syndrome. What is the MOST appropriate next step in management?

Explanation

The patient's symptoms (classic median nerve distribution paresthesias, night pain, dropping objects, thenar atrophy) and positive provocative tests, confirmed by severe nerve conduction study findings, indicate severe carpal tunnel syndrome. The presence of thenar atrophy signifies advanced motor involvement, indicating that conservative measures (splinting, injections, NSAIDs, activity modification) are unlikely to be effective and surgical decompression is warranted to prevent irreversible nerve damage and motor loss. Both open and endoscopic carpal tunnel release are effective surgical options, with endoscopic offering potentially faster recovery and less scar tenderness for some patients. Given the severity, surgery is the most appropriate next step.

Question 23

A 32-year-old male falls on an outstretched arm and sustains an elbow injury. Radiographs reveal a comminuted radial head fracture, a coronoid process fracture, and posterior dislocation of the elbow. Which of the following is NOT typically part of the initial surgical management for this "terrible triad" injury?

Explanation

The "terrible triad" of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid process fracture. This injury pattern typically involves disruption of the lateral ulnar collateral ligament (LUCL), making the elbow highly unstable. The goals of surgical management are to restore stability and allow early motion. This involves: 1) repairing or replacing the radial head, 2) repairing or fixing the coronoid process, and 3) repairing or reconstructing the LUCL. Temporary transarticular pinning may be used to maintain stability, especially if there are concerns about early redislocation. The medial collateral ligament (MCL) is usually intact in terrible triad injuries, or it is stretched but not the primary stabilizer that needs repair. The LUCL is the key posterolateral stabilizer disrupted. Therefore, repairing the MCL is NOT typically part of the initial surgical management for a terrible triad injury.

Question 24

An 80-year-old frail female with a history of a massive rotator cuff tear presents with severe shoulder pain, pseudoparalysis (inability to actively elevate the arm), and limited range of motion. Radiographs show superior migration of the humeral head and glenohumeral arthritis. She has significant medical comorbidities. What is the MOST appropriate treatment strategy to improve her quality of life?

Explanation

This patient presents with rotator cuff arthropathy (superior humeral head migration with glenohumeral arthritis) and pseudoparalysis, meaning she cannot actively elevate her arm despite an intact deltoid. For this condition, especially in the elderly, reverse total shoulder arthroplasty (rTSA) is the treatment of choice. rTSA alters the biomechanics of the shoulder, making the deltoid muscle more efficient in elevating the arm, thereby providing pain relief and restoring active elevation in the absence of a functional rotator cuff. Conservative management might temporarily relieve pain but will not restore function. Hemiarthroplasty and anatomic total shoulder arthroplasty rely on an intact rotator cuff, which this patient lacks. Arthrodesis is a salvage procedure that sacrifices motion and is generally not preferred for improving quality of life unless other options have failed or are contraindicated.

Question 25

A 45-year-old accountant complains of chronic radial-sided wrist pain, clicking, and weakness after a fall several years ago. Examination reveals tenderness over the scapholunate interval, a positive Watson (scaphoid shift) test, and weakness of grip. Radiographs show a widened scapholunate interval (>3mm) and dorsal intercalated segmental instability (DISI) on lateral views. Which of the following is the MOST appropriate treatment for this condition?

Explanation

The patient's symptoms and signs (chronic radial-sided wrist pain, clicking, tenderness over SL interval, positive Watson test, widened SL interval, DISI deformity) are classic for chronic scapholunate (SL) dissociation. This injury involves rupture of the scapholunate ligament, leading to carpal instability. For chronic, symptomatic, and correctable SL dissociation without significant degenerative changes (e.g., SLAC wrist Stage I/II), scapholunate ligament repair or reconstruction (e.g., using a portion of the FCR or dorsal capsular tissue) is the most appropriate surgical intervention to restore carpal kinematics and prevent progression to SLAC wrist. Wrist arthrodesis is a salvage procedure for end-stage arthritis. Scaphoid nonunion repair is for scaphoid fractures. Proximal row carpectomy and radial styloidectomy are for more advanced degenerative changes (SLAC wrist) where the SL dissociation has led to significant arthritis.

Question 26

A gardener presents with an acutely painful, swollen, and red index finger. He describes a puncture wound from a thorn 3 days prior. The finger is held in slight flexion, and any attempt at passive extension causes severe pain. There is tenderness along the entire course of the flexor tendon sheath. What is the MOST likely diagnosis?

Explanation

The patient's presentation precisely describes Kanavel's Four Cardinal Signs of Suppurative Flexor Tenosynovitis (SFT): 1) Uniform swelling of the digit, 2) Flexed posture of the digit, 3) Exquisite tenderness along the course of the flexor tendon sheath, and 4) Severe pain on passive extension. SFT is a surgical emergency requiring urgent incision and drainage to prevent tendon necrosis and irreversible stiffness. Cellulitis is a diffuse infection without the specific tendon sheath involvement. A felon is a pulp space infection. Paronychia is a nail fold infection. Septic arthritis affects the joint, not primarily the tendon sheath, although it can coexist.

Question 27

A 35-year-old volleyball player complains of chronic, deep, dull posterior shoulder pain and weakness with overhead activity. He denies any acute injury. Examination reveals atrophy of the infraspinatus muscle and weakness with external rotation. Sensory examination is normal. What is the MOST likely diagnosis?

Explanation

The patient's symptoms of chronic posterior shoulder pain, infraspinatus atrophy, and weakness with external rotation (and often abduction) are classic for suprascapular nerve entrapment. The suprascapular nerve supplies both the supraspinatus (abduction and external rotation) and infraspinatus (external rotation) muscles. Entrapment can occur at the suprascapular notch or spinoglenoid notch. Atrophy of the infraspinatus specifically points to distal entrapment at the spinoglenoid notch (sparing the supraspinatus if proximal to its innervation), but overall, it's a strong indicator. A rotator cuff tear could cause similar pain and weakness, but atrophy might be less pronounced early on, and nerve conduction studies would differentiate. Adhesive capsulitis involves global stiffness. Long thoracic nerve palsy affects the serratus anterior (winging scapula). Axillary nerve palsy affects the deltoid and teres minor (loss of abduction beyond 15 degrees and external rotation), leading to deltoid atrophy, not infraspinatus.

Question 28

A 14-year-old male baseball pitcher presents with chronic lateral elbow pain, clicking, and occasional locking. Radiographs show a lesion on the capitellum with an intact overlying articular cartilage. MRI confirms an osteochondritis dissecans (OCD) lesion of the capitellum, demonstrating a stable fragment. He has failed conservative management. What is the MOST appropriate surgical intervention?

Explanation

For a stable osteochondritis dissecans (OCD) lesion of the capitellum in an adolescent athlete that has failed conservative management, surgical drilling (arthroscopic or open) is often the initial intervention. Drilling aims to stimulate revascularization and healing of the subchondral bone, facilitating integration of the fragment. Debridement and microfracture are typically for unstable or fragmented lesions where the cartilage is damaged or detached. Loose body removal is indicated if the fragment has completely detached and is causing locking. ORIF is reserved for large, unstable, but salvageable fragments. Total elbow arthroplasty is not indicated in a young patient with an OCD lesion.

Question 29

A 30-year-old heavy equipment operator presents with chronic dorsal wrist pain and stiffness, particularly with heavy gripping. Radiographs show increased sclerosis and collapse of the lunate bone. MRI confirms avascular necrosis of the lunate (Kienbock's disease, Lichtman Stage IIIb). The patient has positive ulnar variance. Which of the following surgical procedures is MOST appropriate?

Explanation

Kienbock's disease is avascular necrosis of the lunate. The patient has Lichtman Stage IIIb disease (lunate collapse with fixed carpal collapse, but without widespread arthritic changes). The presence of positive ulnar variance (ulna longer than the radius) is a predisposing factor, increasing load on the lunate. Therefore, a radial shortening osteotomy is the MOST appropriate procedure in this scenario. It decompresses the lunate by reducing the load from the radius, promoting revascularization and preventing further collapse. Proximal row carpectomy or wrist arthrodesis are salvage procedures for end-stage arthritis (Lichtman Stage IV). Capitate shortening osteotomy is indicated for negative ulnar variance. Lunate excision alone is not typically performed due to carpal instability.

Question 30

A 68-year-old male presents with a fixed flexion deformity of his ring finger PIP joint following a crush injury 6 months ago. He has undergone extensive hand therapy, but the contracture remains at 60 degrees. Passive extension is limited. Radiographs show no significant joint destruction. What is the MOST appropriate surgical intervention?

Explanation

A fixed flexion deformity of the PIP joint following trauma, refractory to therapy, with limited passive extension and no significant joint destruction, points to a joint contracture primarily involving the capsule and collateral ligaments. A capsulectomy (excision of contracted joint capsule, often combined with release of collateral ligaments and volar plate) is the most appropriate procedure to restore passive range of motion. Flexor tenolysis would be for extrinsic flexor tendon adhesions, but passive motion is limited, suggesting joint contracture. Extensor tenolysis is rarely indicated for flexion contractures. Arthrodesis or arthroplasty are salvage procedures for severe joint destruction or failed contracture release, not indicated if the joint itself is relatively preserved. Early intervention with capsulectomy offers the best chance to restore motion.

Question 31

A 50-year-old diabetic female presents with diffuse, severe shoulder pain and progressive loss of active and passive range of motion in all planes over the past 3 months. She denies any injury. Radiographs are normal. What is the MOST appropriate initial management?

Explanation

This patient presents with classic signs and symptoms of adhesive capsulitis (frozen shoulder), particularly in a patient with diabetes, which is a known risk factor. The "freezing" phase is characterized by severe pain and progressive loss of motion. The initial management is typically conservative and focuses on pain control and maintaining motion. A corticosteroid injection into the glenohumeral joint is highly effective for reducing pain and inflammation in the "freezing" phase, which then facilitates physical therapy. Aggressive manipulation under anesthesia and arthroscopic capsular release are reserved for patients who fail conservative management and are in the "frozen" or "thawing" phases with persistent stiffness. Reverse total shoulder arthroplasty and shoulder fusion are inappropriate for adhesive capsulitis.

Question 32

A 45-year-old male bodybuilder experiences a sudden, sharp pain in his elbow while lifting a heavy weight. He notices a "pop" and immediate weakness in elbow flexion and forearm supination. Examination reveals a palpable defect in the distal biceps tendon, ecchymosis in the antecubital fossa, and a positive "hook test". What is the MOST appropriate management?

Explanation

The patient's presentation is classic for an acute distal biceps tendon rupture (sudden pain, "pop," weakness in flexion and supination, palpable defect, positive hook test). For active individuals, especially those involved in heavy lifting, surgical repair is the gold standard treatment to restore strength and endurance in elbow flexion and forearm supination. The repair involves reattaching the ruptured tendon to its anatomical insertion on the radial tuberosity. Conservative management leads to significant functional deficits. Reattachment to the brachialis is not anatomically correct and will not restore supination strength. Debridement is insufficient. Corticosteroid injections are contraindicated as they can weaken tendons and increase rupture risk.

Question 33

A 25-year-old male falls on an outstretched hand and presents with radial-sided wrist pain. Examination reveals tenderness in the anatomical snuffbox and with scaphoid tubercle palpation. Initial radiographs are unremarkable. What is the MOST appropriate next step in management?

Explanation

A fall on an outstretched hand with anatomical snuffbox tenderness strongly suggests a scaphoid fracture, even if initial radiographs are negative (occult scaphoid fracture). Due to the high risk of avascular necrosis and nonunion, definitive diagnosis and management are crucial. The MOST appropriate initial step is to immobilize the wrist (typically in a short arm thumb spica cast) and repeat radiographs in 10-14 days. During this time, the fracture line may become visible due to bone resorption. An MRI or CT scan can be used earlier if there is a high suspicion and need for immediate definitive diagnosis, especially for high-risk patients (e.g., athletes, patients with compliance concerns). However, immobilization and delayed radiographs are a common and appropriate initial management strategy. Emergency ORIF is reserved for displaced fractures or those with high risk of nonunion. Discharging without immobilization is a high-risk approach for a potential scaphoid fracture.

Question 34

A 12-year-old male presents with increasing pain in his proximal humerus over several months, worse at night and relieved by NSAIDs. Radiographs show a lytic lesion with a central nidus in the metaphysis of the proximal humerus. What is the MOST likely diagnosis?

Explanation

The classic presentation of a small lytic lesion with a central radiolucent nidus, nocturnal pain relieved by NSAIDs (especially aspirin), and presence in the metaphysis of long bones (like the proximal humerus) in an adolescent is highly characteristic of an osteoid osteoma. Osteosarcoma and Ewing's sarcoma are malignant tumors with more aggressive radiographic features and systemic symptoms. Chondroblastoma is an epiphyseal lesion. Unicameral bone cysts are typically asymptomatic until fractured, and do not present with a nidus or pain relieved by NSAIDs.

Question 35

A 60-year-old male develops severe elbow stiffness with a functional arc of motion of only 30-70 degrees (flexion-extension) after sustaining a distal humerus fracture treated with ORIF 6 months ago. Radiographs show heterotopic ossification around the elbow joint. He has failed extensive physical therapy. What is the MOST appropriate surgical intervention?

Explanation

The patient presents with severe post-traumatic elbow stiffness and heterotopic ossification (HO) following a distal humerus fracture, limiting his functional arc of motion. When conservative management (physical therapy, dynamic splinting) fails, surgical intervention is indicated. This typically involves an arthroscopic or open capsular release to address contractures of the anterior and posterior capsules, combined with excision of the heterotopic ossification. This procedure aims to restore functional range of motion. Loose body removal might be part of it but is not the sole solution for widespread stiffness and HO. Radial head replacement is for radial head fractures or arthritis. Ulnar nerve transposition might be done concomitantly if the nerve is entrapped, but it doesn't address stiffness. Elbow arthrodesis is a salvage procedure for a painful, unsalvageable joint, not for restoring motion in a stiff but otherwise preserved joint.

Question 36

A 20-year-old basketball player jams his finger during a game. He presents with pain and inability to actively extend his distal interphalangeal (DIP) joint, which rests in 40 degrees of flexion. Passive extension is full. Radiographs are normal. What is the MOST appropriate initial management?

Explanation

The patient presents with a classic mallet finger deformity (flexion deformity of the DIP joint with inability to actively extend, full passive extension, normal radiographs), indicating an extensor tendon avulsion from the distal phalanx without associated fracture (Stack Grade I). The treatment of choice for acute mallet finger without significant bone avulsion is continuous DIP joint extension splinting for 6-8 weeks, followed by nighttime splinting for another 2-4 weeks. This allows the tendon to heal in a shortened position. Surgical repair is rarely indicated for mallet fingers without bone avulsion, reserved for irreducible fracture-mallets or chronic cases with extensor lag. Closed reduction and K-wire fixation is for fracture-mallets. DIP joint fusion is a salvage. Buddy taping is insufficient.

Question 37

A 40-year-old active construction worker presents with chronic pain and instability of his right acromioclavicular (AC) joint following a Rockwood Type III injury 6 months ago. He complains of inability to perform overhead tasks and persistent deformity. He has failed extensive physical therapy. Which of the following surgical procedures is MOST likely to provide durable stability and improve function?

Explanation

While some Rockwood Type III AC joint injuries can be managed non-operatively, chronic symptomatic instability and deformity, especially in a high-demand individual, warrants surgical intervention. Distal clavicle excision (Mumford procedure) addresses AC joint pain by removing the arthritic joint surfaces but does not restore stability. For chronic symptomatic instability of a Type III (or higher) injury, particularly if functional deficits persist, reconstruction of the coracoclavicular (CC) ligaments using autograft (e.g., semitendinosus) or allograft is the most common and effective procedure to restore horizontal and vertical stability of the AC joint. Arthroscopic debridement is insufficient. AC joint arthrodesis provides stability but sacrifices motion. Subacromial decompression is for impingement, not AC joint instability.

Question 38

A 38-year-old tennis player complains of chronic lateral elbow pain, which is exacerbated by gripping and forearm supination. He has no numbness or tingling. Examination reveals tenderness over the mobile wad of Henry (specifically the supinator muscle) and pain with resisted middle finger extension (Maudeley's test). Resisted wrist extension is not particularly painful. What is the MOST likely diagnosis?

Explanation

The patient's symptoms are highly suggestive of radial tunnel syndrome, which is compression of the posterior interosseous nerve (PIN), a branch of the radial nerve, within the radial tunnel. Key features include chronic lateral elbow pain exacerbated by gripping and supination, tenderness over the supinator, and pain with resisted middle finger extension (which stresses the extensor digitorum communis, innervated by PIN). Importantly, there is no numbness/tingling (as PIN is purely motor) and resisted wrist extension is not the primary pain generator, differentiating it from classic lateral epicondylitis. Lateral epicondylitis involves pain with resisted wrist extension and palpation of the lateral epicondyle. Ulnar nerve entrapment affects the medial side. Distal biceps tendinopathy involves the anterior elbow. Olecranon bursitis is posterior.

Question 39

A 16-year-old male presents with recurrent anterior shoulder dislocations. He has a history of a seizure disorder, which is poorly controlled. After his most recent seizure, he sustained another dislocation. Radiographs show a large bony Bankart lesion and a significant Hill-Sachs lesion. Given his history, which surgical intervention is MOST appropriate?

Explanation

Recurrent anterior shoulder dislocations in a patient with a seizure disorder are particularly challenging because the powerful, uncontrolled muscle contractions during seizures place extreme stress on the shoulder, often leading to large bony defects (Bankart and Hill-Sachs). Soft tissue repairs (arthroscopic or open Bankart) have a very high failure rate in this population. The Latarjet procedure, which involves transferring the coracoid process with its attached conjoined tendon to the anterior-inferior glenoid, provides significant bony augmentation to the glenoid, thus preventing engagement of the Hill-Sachs lesion and creating a dynamic sling effect. This bony stabilization is crucial for patients with seizure disorders who are at very high risk for recurrence. Remplissage addresses Hill-Sachs but does not augment the glenoid directly. Conservative management alone is unlikely to be effective given recurrent dislocations.

Question 40

A 30-year-old female presents with a recurrent dorsal wrist ganglion cyst 6 months after surgical excision. The previous surgery involved a standard open excision. What is the MOST likely reason for recurrence?

Explanation

The most common reason for recurrence of a ganglion cyst after surgical excision is incomplete removal of the stalk (pedicle) that connects the cyst to the joint capsule or tendon sheath. If the connection point is not excised, the synovial fluid continues to egress, leading to reformation of the cyst. While new cysts can form, or poor wound healing can occur, incomplete excision of the stalk is the primary anatomical reason for recurrence. Infection and aggressive physical therapy are less likely to be direct causes of recurrence, although infection can lead to other complications. The goal of ganglion surgery is to resect the cyst and its base down to the joint capsule.

Question 41

A 65-year-old male presents with a massive, retracted rotator cuff tear (supraspinatus, infraspinatus, partial subscapularis). MRI shows significant fatty infiltration (Goutallier Grade 3-4) in the retracted muscles. He has pain and weakness, but no significant glenohumeral arthritis. He is otherwise healthy. Which of the following is considered a relative contraindication to primary rotator cuff repair?

Explanation

While all options can influence surgical decision-making, Goutallier Grade 3 or 4 fatty infiltration (meaning greater than 50% fat within the muscle belly) is considered a strong predictor of poor healing and a relative contraindication to primary rotator cuff repair. Significant fatty infiltration indicates muscle degeneration and atrophy, which severely compromises the ability of the muscle to heal and function, even if the tear can be physically repaired. Patient age alone is not a contraindication. Partial subscapularis tears are often addressed. Significant retraction makes repair more challenging but not impossible. A biceps lesion is often addressed concurrently (tenotomy/tenodesis).

Question 42

A 20-year-old male presents with pain and swelling in his small finger after punching a wall. Radiographs confirm a displaced, angulated fracture of the small finger metacarpal neck (Boxer's fracture) with 50 degrees of volar angulation. The patient has no rotational deformity and good grip strength. Which of the following is the MOST appropriate management?

Explanation

A Boxer's fracture is a fracture of the fifth metacarpal neck. While significant angulation can occur, the tolerable angulation in the small finger metacarpal is generally up to 70 degrees due to the compensatory mobility of the carpometacarpal (CMC) joint. However, 50 degrees of volar angulation is often cosmetically unappealing and may cause issues with grip. Closed reduction to decrease the angulation to an acceptable level (typically less than 40-50 degrees) followed by immobilization in an ulnar gutter splint (with the MCP joints flexed at 70-90 degrees) is the standard treatment. Rotational deformity is critical and must be corrected. ORIF or percutaneous pinning are reserved for irreducible fractures, rotational deformities, excessive angulation that cannot be corrected, or multiple metacarpal fractures. Observation or buddy taping are insufficient for a displaced, angulated fracture.

Question 43

A patient presents 3 months after a distal radius fracture with persistent ulnar-sided wrist pain, clicking, and instability of the distal radioulnar joint (DRUJ). Clinical examination reveals excessive dorsal-palmar translation of the ulna relative to the radius. Radiographs confirm appropriate healing of the distal radius fracture but show mild positive ulnar variance. The TFCC appears attenuated on MRI. What is the MOST appropriate next step in surgical management?

Explanation

The patient presents with chronic, symptomatic DRUJ instability following a distal radius fracture, with excessive translation and an attenuated TFCC, and mild positive ulnar variance. The primary goal is to restore DRUJ stability. Reconstruction of the DRUJ ligaments (e.g., using a tendon graft or capsular plication) along with repair of the TFCC is the most appropriate approach to restore the anatomical constraints of the DRUJ. Ulnar shortening osteotomy addresses positive ulnar variance and can indirectly improve TFCC tension, but it may not fully stabilize a grossly unstable DRUJ with attenuated ligaments. Distal ulna resection (Darrach) or DRUJ arthrodesis (Sauve-Kapandji) are salvage procedures for severe arthritis or painful, irreducible instability. Proximal row carpectomy is for midcarpal arthritis.

Question 44

A 68-year-old female undergoes ORIF for a displaced three-part proximal humerus fracture. One week post-operatively, she complains of increasing pain, swelling, and purulent discharge from the incision site, along with fever. She has limited range of motion and systemic signs of infection. What is the MOST appropriate immediate management?

Explanation

The patient presents with clear signs of an acute deep periprosthetic joint infection (PJI) following ORIF of a proximal humerus fracture: increasing pain, swelling, purulent discharge, fever, limited ROM, and systemic signs. This is a surgical emergency. The MOST appropriate immediate management is urgent surgical debridement and irrigation of the surgical site, thorough tissue sampling for cultures and sensitivity, and initiation of empiric intravenous antibiotics. Oral antibiotics and wound care alone are insufficient for deep infection. Aspiration may provide a diagnosis, but surgical debridement is therapeutic and critical for source control. Removal of fixation may be necessary for chronic infection, but initially, preservation of hardware is attempted if stable, while aggressive debridement is performed. Observation is inappropriate.

Question 45

A 40-year-old construction worker presents with chronic wrist pain and stiffness. Radiographs demonstrate severe collapse and sclerosis of the lunate, significant carpal collapse (DISI pattern), and early radiocarpal arthritis (Lichtman Stage IV Kienbock's disease). He has failed all conservative measures. Which of the following is the MOST appropriate surgical intervention?

Explanation

The patient has Lichtman Stage IV Kienbock's disease, characterized by severe lunate collapse, carpal collapse, and established radiocarpal arthritis. At this stage, procedures aimed at revascularization or decompression (like radial shortening osteotomy or vascularized bone graft) are no longer indicated because the degenerative changes are too advanced. Proximal row carpectomy (PRC) is a common salvage procedure for symptomatic end-stage carpal arthritis, including Kienbock's disease, with an intact capitate head. It involves removing the scaphoid, lunate, and triquetrum, converting the radiocarpal joint into a radiocapitate joint. This provides good pain relief and preserves some motion. Wrist arthrodesis is also a salvage option, providing pain relief at the expense of all motion. Lunate excision alone is not stable.

Question 46

A 25-year-old male complains of progressive weakness in his forearm flexors (excluding the flexor carpi ulnaris and ulnar half of the FDP) and numbness in his thumb, index, middle, and radial ring fingers. Examination reveals tenderness along the medial aspect of the distal humerus, just proximal to the medial epicondyle. Radiographs reveal a supracondylar spur (ligament of Struthers). What is the MOST likely diagnosis?

Explanation

The patient's symptoms (weakness in specific forearm flexors and median nerve distribution numbness, excluding ulnar-innervated muscles) are indicative of median nerve compression in the forearm. The presence of a supracondylar spur and tenderness proximal to the medial epicondyle, along with symptoms encompassing both motor and sensory aspects of the median nerve (unlike pure AIN syndrome), points strongly to Pronator Syndrome due to compression by the ligament of Struthers (a fibrous band connecting the supracondylar spur to the medial epicondyle). This ligament, along with the pronator teres, can compress the median nerve. Anterior interosseous nerve (AIN) syndrome is a pure motor deficit, affecting FPL, FDP to index/middle, and pronator quadratus, without sensory symptoms. Cubital tunnel syndrome affects the ulnar nerve. Radial tunnel syndrome affects the PIN. Thoracic outlet syndrome presents with more diffuse symptoms.

Question 47

Following arthroscopic rotator cuff repair, a 60-year-old patient develops severe shoulder pain and progressive stiffness that is unresponsive to analgesics and physical therapy. The pain is global and limits both active and passive range of motion in all planes. Radiographs are normal, and there are no signs of infection. What is the MOST likely post-operative complication?

Explanation

Severe, global shoulder pain and progressive stiffness with loss of both active and passive range of motion in all planes following shoulder surgery (especially rotator cuff repair) is a classic presentation of post-operative adhesive capsulitis (frozen shoulder). This is a common and often challenging complication. While a re-tear is possible, it would typically present more with weakness and less with global passive stiffness. Deltoid dehiscence is a rare, severe complication causing significant weakness. Subacromial impingement would cause pain with specific movements but not global stiffness. Heterotopic ossification could cause stiffness but is usually visible on radiographs and less likely to be the primary cause of such diffuse symptoms without other findings.

Question 48

A 28-year-old skier falls, landing on his outstretched thumb. He presents with pain and swelling at the ulnar aspect of the thumb metacarpophalangeal (MCP) joint. Examination reveals significant instability (greater than 30-35 degrees of valgus laxity compared to the contralateral side) with a positive stress test, even with the MCP joint in 30 degrees of flexion. Palpation reveals a soft tissue mass at the ulnar base of the thumb. What is the MOST likely diagnosis and treatment?

Explanation

The patient's history (skiing fall, valgus stress to thumb), examination findings (pain, swelling, significant valgus laxity at the MCP joint, soft tissue mass consistent with a displaced UCL), and mechanism are classic for a Gamekeeper's thumb (acute rupture of the ulnar collateral ligament, UCL) with a Stener lesion. A Stener lesion occurs when the avulsed distal end of the UCL displaces superficial to the adductor aponeurosis, preventing healing with conservative treatment. Surgical repair of the UCL is indicated for Stener lesions or acute complete ruptures with significant instability to restore stability and function. Conservative management with splinting is only appropriate for partial tears or stable complete tears without a Stener lesion. CMC joint dislocation is at the base of the thumb. Extensor tendon rupture would involve active extension loss. Collateral ligament calcification is chronic.

Question 49

A 16-year-old male sustains a supracondylar humerus fracture and is placed in a cast. Six hours later, he complains of excruciating pain in his forearm, disproportionate to the injury. His fingers are stiff, and passive extension of the fingers is exquisitely painful. Radial pulse is palpable, but capillary refill is sluggish. Which of the following is the MOST appropriate immediate management?

Explanation

The patient's symptoms (excruciating pain disproportionate to injury, pain with passive finger extension, stiff fingers, sluggish capillary refill, despite a palpable pulse) are highly suspicious for acute forearm compartment syndrome, a surgical emergency that can lead to irreversible muscle and nerve damage (Volkmann's ischemic contracture). While bivalving the cast and elevation are initial steps in some cases, with such clear clinical signs, immediate forearm fasciotomy is the definitive and most appropriate management to decompress the compartments and prevent permanent damage. Delaying for compartment pressure measurements, removing the cast without fasciotomy, or administering more analgesics are dangerous and can lead to devastating consequences. A palpable pulse does not rule out compartment syndrome, as compartment pressures often exceed diastolic pressure before arterial flow is completely obliterated.

Question 50

A 45-year-old female presents with sudden onset of severe, excruciating pain in her right shoulder, which awakens her from sleep. She has extremely limited range of motion due to pain. Radiographs show a large calcific deposit within the supraspinatus tendon. She has no history of trauma. What is the MOST appropriate initial management?

Explanation

The patient presents with classic acute calcific tendinitis (calcific periarthritis), characterized by sudden onset of severe, excruciating shoulder pain and severely restricted range of motion, often waking them from sleep, with a visible calcific deposit on radiographs. The acute phase is extremely inflammatory and painful. The MOST appropriate initial management is conservative: pain control with oral NSAIDs, rest, and a subacromial corticosteroid injection. The injection helps to reduce the intense inflammation. While surgery (arthroscopic debridement) is an option for chronic, refractory cases, it is not the initial treatment for acute calcific tendinitis, which often resolves spontaneously. Reverse TSA and subacromial decompression are inappropriate. Physical therapy with aggressive stretching would likely exacerbate the pain in the acute phase.

Question 51

A 60-year-old male presents with chronic shoulder pain, stiffness, and crepitus. Radiographs show severe glenohumeral osteoarthritis with an intact rotator cuff. He has failed conservative management. He is a low-demand patient with significant medical comorbidities. Which of the following surgical options offers the BEST balance of pain relief, functional improvement, and reduced risk in this patient?

Explanation

For severe glenohumeral osteoarthritis with an intact rotator cuff, anatomic total shoulder arthroplasty (TSA) is the gold standard, providing excellent pain relief and functional improvement. Given his low-demand status and comorbidities, an unconstrained anatomic TSA would be the optimal choice. Hemiarthroplasty replaces only the humeral head, and while less invasive, can lead to persistent glenoid pain and progressive erosion. Reverse total shoulder arthroplasty is for rotator cuff deficiency. Arthroscopic debridement offers temporary relief at best for severe arthritis. Shoulder fusion is a salvage procedure sacrificing motion. Anatomic TSA generally has a good risk-benefit profile in this scenario.

Question 52

A 35-year-old carpenter presents with a painful mass in the palm of his hand, at the base of his ring finger. The finger locks in flexion and requires passive extension with an audible 'click'. Examination reveals a tender nodule at the A1 pulley level. What is the MOST appropriate initial management?

Explanation

The patient's symptoms (painful locking, palpable nodule, clicking) are classic for trigger finger (stenosing tenosynovitis). The initial management typically involves conservative measures. A corticosteroid injection into the flexor tendon sheath at the level of the A1 pulley is highly effective in reducing inflammation and often resolving symptoms, especially after the first injection. If conservative management fails or symptoms recur, surgical release of the A1 pulley is definitive. Rest, splinting, physical therapy, and NSAIDs may offer some temporary relief but are less effective than an injection in the short term. Surgical release is considered a definitive treatment after failed conservative options.

Question 53

A 5-year-old child falls from playground equipment, sustaining an isolated fracture of the mid-shaft of the ulna. There is no associated radial fracture or dislocation. What is the MOST likely associated injury that must be ruled out?

Explanation

An isolated fracture of the ulna shaft in a child is highly suspicious for a Monteggia equivalent injury, which involves an ulnar fracture with an associated radial head dislocation. The mechanism of injury often involves a fall, and the ulna fracture occurs, but the force continues to propagate, leading to disruption of the annular ligament and radial head displacement. It is crucial to carefully examine the elbow radiographs to ensure the radial head is reduced and aligned with the capitellum in all views. Failure to diagnose a radial head dislocation can lead to chronic pain and deformity. Galeazzi equivalent involves a radial shaft fracture and DRUJ dislocation. Scaphoid and humerus fractures are less likely directly associated.

Question 54

A 70-year-old male with chronic shoulder pain has failed extensive non-operative management. MRI reveals a massive, irreparable supraspinatus and infraspinatus tear, significant fatty infiltration, and severe superior migration of the humeral head (Hamada Stage 4), but no significant glenohumeral arthritis. He has persistent pseudoparalysis. Which of the following is the MOST appropriate surgical intervention?

Explanation

This patient presents with a massive, irreparable rotator cuff tear, significant fatty infiltration, and superior migration of the humeral head (rotator cuff tear arthropathy or 'pseudoparalysis' due to mechanical disadvantage of deltoid) but without significant glenohumeral arthritis. In this scenario, reverse total shoulder arthroplasty (rTSA) is the gold standard. rTSA repositions the center of rotation and enhances deltoid efficiency, restoring active elevation and providing pain relief, even in the absence of a functional rotator cuff. Hemiarthroplasty and anatomic TSA require an intact rotator cuff. Latissimus dorsi transfer is an option for younger patients with irreparable posterior tears to restore external rotation, but it may not address the pseudoparalysis effectively in older patients. Superior capsular reconstruction is for younger patients without arthritis but with irreparable tears, primarily to prevent superior migration.

Question 55

A 40-year-old patient undergoes an open carpal tunnel release. Post-operatively, he complains of persistent numbness in the median nerve distribution and new weakness of his intrinsic hand muscles. On examination, he has a positive Froment's sign and Wartenberg's sign. What is the MOST likely iatrogenic injury?

Explanation

The patient's persistent median nerve symptoms suggest incomplete release or nerve irritation. However, the new symptoms of Froment's sign (indicating adductor pollicis weakness, an ulnar-innervated muscle) and Wartenberg's sign (indicating abduction of the small finger due to unopposed extensor digiti minimi, another ulnar nerve finding) strongly point to an iatrogenic injury to the ulnar nerve during open carpal tunnel release. While the median nerve is the target, the ulnar nerve is in close proximity, especially Guyon's canal, and can be injured. Incomplete release would cause persistent median nerve symptoms but not new ulnar nerve signs. Injury to the recurrent motor branch affects thenar muscles. Injury to the palmar cutaneous branch causes pain/numbness proximal to the incision, but no motor deficit. FDS laceration is a tendon injury, not nerve.

Question 56

A 55-year-old male presents with acute, severe pain and swelling in the small finger. He reports injecting a small amount of an illicit substance into the finger 24 hours prior. Examination reveals intense erythema, warmth, and tenderness, with exquisite pain on passive extension of the finger. He has a fever and elevated inflammatory markers. What is the MOST appropriate immediate management?

Explanation

This patient presents with classic signs of acute suppurative flexor tenosynovitis (Kanavel's signs: uniform swelling, flexed posture, tenderness along tendon sheath, pain on passive extension), likely exacerbated by illicit substance injection, which introduces virulent bacteria directly into the sheath. This is a surgical emergency that requires immediate incision and drainage of the flexor tendon sheath to prevent tendon necrosis, rupture, and spread of infection. Intravenous antibiotics are crucial but are adjunctive to surgical decompression. Oral antibiotics, observation, splinting, or needle aspiration are insufficient and can lead to devastating consequences, including amputation. Early surgical intervention is paramount.

Question 57

A 70-year-old female presents with chronic shoulder pain and a stiff shoulder. Examination reveals severe global loss of active and passive range of motion. Radiographs show significant glenohumeral osteoarthritis. MRI reveals a large, irreparable rotator cuff tear with severe fatty infiltration. She has no pseudoparalysis. What is the MOST appropriate surgical treatment?

Explanation

This patient has severe glenohumeral osteoarthritis combined with a massive, irreparable rotator cuff tear and severe fatty infiltration, which is classic for rotator cuff arthropathy (Hamada Stage III or IV). For this condition, especially in an elderly patient, reverse total shoulder arthroplasty (rTSA) is the gold standard treatment. rTSA is designed to function independently of the rotator cuff, relying on the deltoid for elevation and rotation, providing both pain relief and functional improvement. Anatomic TSA and hemiarthroplasty rely on a functional rotator cuff and are contraindicated in this scenario. Arthroscopic capsular release would not address the underlying joint destruction or cuff deficiency. Shoulder fusion is a salvage procedure.

Question 58

A 15-year-old competitive gymnast presents with chronic posteromedial elbow pain. She complains of pain with elbow extension, especially during overhead activities. Radiographs show hypertrophy of the posteromedial olecranon and loose bodies within the olecranon fossa. What is the MOST appropriate surgical intervention?

Explanation

The patient's symptoms of chronic posteromedial elbow pain, especially with elbow extension in an overhead athlete, along with radiographic findings of olecranon hypertrophy and loose bodies, are classic for posterior impingement of the elbow (often called 'thrower's elbow' or valgus extension overload syndrome). This occurs as the olecranon impinges on the olecranon fossa during terminal extension, exacerbated by valgus stress. The MOST appropriate surgical intervention is arthroscopic or open loose body removal and excision of the olecranon osteophyte (debridement of the posteromedial olecranon) to eliminate the impingement. UCL reconstruction is for valgus instability, not primary impingement (though they can coexist). Medial epicondylectomy and cubital tunnel release address ulnar nerve compression. Posterior interosseous nerve decompression is for radial tunnel syndrome.

Question 59

A 22-year-old male sustains an open Monteggia fracture-dislocation (Type B2) after a motor vehicle accident. Radiographs confirm an anteriorly angulated ulnar shaft fracture and an anterior radial head dislocation. There is gross contamination of the wound. What is the MOST appropriate initial step in management?

Explanation

An open Monteggia fracture-dislocation is a severe injury requiring urgent surgical management. Given the open nature and gross contamination, the initial and MOST critical step is thorough irrigation and debridement (I&D) of the wound to prevent infection. Following debridement, stable fixation of the ulnar shaft fracture (ORIF) is performed, which often reduces and stabilizes the radial head spontaneously. If the radial head remains unstable after ulnar fixation, it needs to be stabilized (e.g., with temporary pinning or repair of the annular ligament). Antibiotic prophylaxis is essential but is secondary to I&D. Closed reduction and casting are contraindicated for open fractures. External fixation might be considered in severe cases, but ORIF is generally preferred for Monteggia. Radial head excision is generally avoided in young patients to preserve forearm rotation and length.

Question 60

A 30-year-old female presents with chronic wrist pain and weakness, particularly with gripping. She reports a history of fall 1 year ago. Examination reveals tenderness over the ulnar aspect of the wrist, a positive fovea sign, and a positive piano key sign (ulnar head ballotment test). MRI reveals disruption of the distal radioulnar ligament (DRUL) component of the TFCC. What is the MOST appropriate surgical intervention?

Explanation

The patient's symptoms (chronic ulnar-sided wrist pain, weakness, positive fovea sign, positive piano key sign) and MRI findings (disruption of DRUL) are highly suggestive of chronic distal radioulnar joint (DRUJ) instability due to a traumatic TFCC injury, specifically affecting the peripheral attachments of the TFCC. For symptomatic DRUJ instability in a younger, active patient without significant degenerative changes, surgical repair or reconstruction of the distal radioulnar ligaments (DRUL) is the preferred treatment to restore stability and function. Ulnar shortening osteotomy addresses ulnar positive variance and can relieve impingement but does not directly repair the DRUL. Arthroscopic debridement is for stable, central TFCC tears. Darrach procedure and wrist arthrodesis are salvage procedures for end-stage arthritis or irreducible instability.

Question 61

A 50-year-old factory worker complains of chronic, aching pain in his posterior elbow, exacerbated by direct pressure and repetitive elbow flexion/extension. Examination reveals a large, fluctuant, non-tender mass over the olecranon tip. He has no signs of infection. What is the MOST likely diagnosis and recommended management?

Explanation

The patient's presentation of a chronic, aching posterior elbow pain exacerbated by pressure and movement, with a large, fluctuant, non-tender mass over the olecranon tip and no signs of infection, is classic for non-septic (aseptic) olecranon bursitis. This is often caused by repetitive trauma or prolonged pressure. The initial management is conservative: activity modification, avoidance of direct pressure (e.g., with elbow pads), NSAIDs, and sometimes aspiration with corticosteroid injection (though aspiration alone can be therapeutic and diagnostic). Gouty tophus would be painful and could be aspirated for crystals. Septic bursitis would have signs of acute inflammation (redness, warmth, significant tenderness, fever) and usually requires I&D. Olecranon stress fracture presents with bone pain. Lipoma is less likely in this specific location and presentation.

Question 62

A 65-year-old female presents with a new onset of chronic, dull, aching pain in her left shoulder. She has a history of breast cancer with axillary lymph node dissection 5 years ago, followed by radiation therapy. Examination reveals mild lymphedema and limited abduction. Radiographs show no acute findings. What is the MOST concerning diagnosis to rule out?

Explanation

Given the patient's history of breast cancer with axillary lymph node dissection and radiation therapy, new onset of shoulder pain, even if dull and aching, must raise high suspicion for metastatic disease to the bone (proximal humerus or scapula). While adhesive capsulitis, rotator cuff tear, and osteoarthritis are common causes of shoulder pain in this age group, the cancer history makes metastatic disease a critical and urgent diagnosis to rule out. Brachial plexopathy from radiation typically presents with nerve-related symptoms (pain, paresthesias, weakness in a dermatomal/myotomal pattern), which is not the primary complaint here. Therefore, imaging such as bone scan, PET scan, or MRI of the shoulder should be pursued to exclude metastatic disease.

Question 63

A 28-year-old professional football player sustains an acute Grade III acromioclavicular (AC) joint separation. He desires to return to play as soon as possible. On examination, he has significant pain, deformity, and tenderness over the AC joint. What is the MOST appropriate treatment approach for this athlete?

Explanation

A Rockwood Type III AC joint separation involves complete disruption of the AC ligaments and partial disruption of the CC ligaments. While non-operative management is often successful for Type III injuries in the general population, for a high-demand overhead athlete who desires early return to competition, surgical intervention is often favored to restore anatomical stability and prevent chronic symptoms (pain, weakness, fatigue, apprehension). Coracoclavicular ligament reconstruction (either arthroscopic or open, using allograft or autograft, often combined with AC ligament repair) is the most common surgical approach for acute Type III (and higher) injuries in this specific population. Distal clavicle excision is for chronic pain/arthritis. ORIF with CC screw fixation is less common now due to hardware complications and superior reconstruction techniques. AC joint arthrodesis is a salvage procedure.

Question 64

A 55-year-old woman develops progressive bilateral numbness and tingling in her ring and small fingers after undergoing cervical spine fusion for myelopathy. She has no new neck pain. Examination reveals decreased sensation in the ulnar nerve distribution and weakness of intrinsic hand muscles. Nerve conduction studies confirm bilateral ulnar neuropathy at the elbow. What is the MOST likely cause of her symptoms?

Explanation

New onset bilateral ulnar neuropathy after cervical spine surgery strongly suggests post-operative positioning-related ulnar nerve compression at the elbow. During prolonged surgery, especially in positions like prone or lateral decubitus, the ulnar nerve can be compressed at the cubital tunnel if the elbows are not adequately padded and positioned. While pre-existing cubital tunnel syndrome can be exacerbated, or a brachial plexus injury can occur, the bilateral and specific ulnar nerve distribution points most directly to intraoperative positioning. Recurrence of cervical myelopathy would typically involve a broader set of neurologic symptoms, often including new neck pain or upper motor neuron signs. Thoracic outlet syndrome is usually unilateral or has different provocative maneuvers. This is a common and important iatrogenic complication to recognize.

Question 65

A 40-year-old male with a history of intravenous drug use presents with a painful, erythematous, and swollen proximal forearm. He has diffuse tenderness and severe pain with passive stretch of the wrist and finger flexors. He appears systemically unwell. What is the MOST appropriate immediate management?

Explanation

The patient's presentation (painful, swollen forearm, diffuse tenderness, severe pain with passive stretch of flexors, systemic unwellness, IV drug use history) is highly indicative of acute forearm compartment syndrome, possibly exacerbated by infection. This is a surgical emergency. Immediate surgical fasciotomy of the forearm compartments is critical to decompress the muscles and nerves, preventing irreversible ischemic damage (Volkmann's contracture). While intravenous antibiotics are necessary, they are secondary to surgical decompression. Aspiration may provide a diagnosis but delays definitive treatment. Oral antibiotics, elevation, and ice are wholly inadequate for acute compartment syndrome.

Question 66

A 70-year-old patient undergoes an anatomic total shoulder arthroplasty for severe glenohumeral osteoarthritis. Six months post-operatively, he complains of persistent pain, grinding, and progressive loss of external rotation. Radiographs show superior migration of the humeral head component and wear of the glenoid component. Which of the following is the MOST likely underlying cause of these findings?

Explanation

The symptoms of persistent pain, grinding, progressive loss of external rotation, and radiographic findings of superior migration of the humeral head and glenoid component wear after anatomic total shoulder arthroplasty are classic for rotator cuff tear and failure. Anatomic TSA relies on an intact, functional rotator cuff. If the rotator cuff fails (e.g., supraspinatus and infraspinatus), the humeral head is no longer centralized on the glenoid, leading to superior migration, eccentric loading of the glenoid (causing wear), pain, and loss of active rotation. Glenoid loosening can occur but is not always associated with superior humeral migration to this extent without cuff failure. Implant malpositioning could cause issues, but rotator cuff failure is a well-recognized complication. Adhesive capsulitis is global stiffness. Deltoid rupture is less common and would lead to pseudoparalysis.

Question 67

A 25-year-old male presents with recurrent episodes of shoulder pain and paresthesias in his hand, particularly when carrying heavy objects or with overhead activity. He notes discoloration of his hand (blanching or cyanosis) during these episodes. Examination reveals a positive Adson's test and a positive Roos test. What is the MOST likely diagnosis?

Explanation

The patient's symptoms of recurrent shoulder pain, hand paresthesias, and hand discoloration (vascular symptoms) exacerbated by overhead activity or carrying heavy objects, combined with positive Adson's test (diminished radial pulse with arm abduction, external rotation, and head turning to the affected side) and Roos test (elevated arm stress test), are highly suggestive of thoracic outlet syndrome (TOS). TOS involves compression of the neurovascular bundle (brachial plexus, subclavian artery/vein) in the thoracic outlet. Rotator cuff tendinitis and biceps tendinopathy primarily cause localized shoulder pain. Cervical radiculopathy would cause dermatomal/myotomal symptoms. Ulnar nerve entrapment is distal to the shoulder and would not cause vascular symptoms in the hand or positive TOS provocative tests.

Question 68

A 60-year-old diabetic male develops a chronic, non-healing ulcer on the tip of his small finger following a minor cut. He also has a fixed flexion deformity of the small finger PIP joint and a palpable cord in the palm. He has undergone debridement and wound care for 3 months with no improvement. What is the MOST appropriate next step in management?

Explanation

The patient presents with a chronic, non-healing ulcer on the small fingertip, combined with a fixed flexion deformity of the PIP joint and a palpable Dupuytren's cord. A severe Dupuytren's contracture can lead to skin breakdown and ulceration, particularly at the fingertip, due to constant pressure, skin attenuation, and impaired circulation. When a chronic ulcer associated with a severe contracture fails conservative wound care, surgical release of the Dupuytren's contracture (fasciectomy or fasciotomy) is indicated to relieve tension on the skin, allow for better wound healing, and improve function. Amputation is a salvage procedure and should be considered if the ulcer is intractable despite contracture release, or if there is severe osteomyelitis. Vascular assessment is important but the primary pathology driving the ulcer is the contracture. Tenolysis is for adhesions, not contracture-related skin breakdown.

Question 69

A 10-year-old child presents with a painful, swollen, and warm elbow. He has a fever and refuses to move his arm. There is tenderness over the olecranon fossa. Laboratory tests reveal elevated white blood cell count and C-reactive protein. Aspiration of the elbow joint yields cloudy fluid. What is the MOST likely diagnosis?

Explanation

The child's presentation of a painful, swollen, warm elbow, refusal to move the arm (pseudoparalysis), fever, elevated inflammatory markers, and cloudy aspirate is highly indicative of septic arthritis. Septic arthritis is a pediatric emergency requiring urgent diagnosis and treatment (joint aspiration and surgical irrigation/debridement with antibiotics) to prevent joint destruction. Juvenile idiopathic arthritis is a chronic inflammatory condition, usually without acute fever or systemic illness. A fracture would have a history of trauma. Olecranon bursitis would be superficial to the joint. Osteochondritis dissecans is chronic, localized pain, not acute infection.

Question 70

A 60-year-old male undergoes arthroscopic rotator cuff repair. Post-operatively, he develops significant pain and stiffness, with limited active and passive range of motion. MRI confirms a healed rotator cuff repair, but shows severe thickening and contracture of the joint capsule. What is the MOST likely diagnosis?

Explanation

The patient's presentation of significant post-operative pain, stiffness, and global loss of active and passive range of motion, with a healed rotator cuff repair and capsular thickening/contracture on MRI, is highly characteristic of post-operative adhesive capsulitis (frozen shoulder). This is a well-known complication after shoulder surgery. A re-tear would result in weakness, often without global passive stiffness. Glenohumeral osteoarthritis would typically be pre-existing. Impingement syndrome is typically pain with specific movements. Long thoracic nerve injury would cause scapular winging. The key here is the global loss of both active and passive motion and capsular thickening.

Question 71

A 35-year-old female presents with chronic numbness and tingling in her thumb, index, and middle fingers. She has mild thenar atrophy. Electromyography shows slowing across the carpal tunnel. She is a full-time sign language interpreter and requires maximal hand function. She has tried night splinting and two corticosteroid injections, with only temporary relief. What is the MOST appropriate next step?

Explanation

The patient has symptomatic carpal tunnel syndrome with objective evidence of nerve compression (EMG slowing) and mild thenar atrophy, signifying motor involvement. She has failed conservative management, including two corticosteroid injections. For persistent symptoms and objective nerve compromise despite conservative measures, especially in a patient requiring maximal hand function, surgical decompression via carpal tunnel release (either open or endoscopic) is indicated. A third injection is unlikely to provide durable relief given previous failures. Gabapentin is for neuropathic pain but doesn't address the compression. Physical therapy is often adjunct. Long-term observation risks irreversible nerve damage and further atrophy.

Question 72

A 72-year-old male presents with acute pain and swelling in his dominant hand. He has a history of a cat bite to the dorsum of his hand 24 hours prior. Examination reveals erythema, warmth, and exquisite tenderness, particularly over the MCP joint of the index finger. He has limited range of motion due to pain. Which of the following is the MOST appropriate initial management?

Explanation

A cat bite to the hand carries a high risk of severe infection, particularly due to Pasteurella multocida and potential for joint penetration, leading to septic arthritis or osteomyelitis. The patient's acute presentation with erythema, warmth, exquisite tenderness over the MCP joint, and limited range of motion are highly indicative of septic arthritis or cellulitis progressing to deeper infection. Given the mechanism and signs of severe infection, emergency surgical irrigation and debridement of the wound and joint (if joint penetration is confirmed or suspected), followed by broad-spectrum intravenous antibiotics, is the MOST appropriate immediate management. Oral antibiotics alone are insufficient for deep hand infections. Warm compresses and elevation are supportive but not definitive. Corticosteroid injections are contraindicated in infection. Close monitoring is inadequate for a rapidly progressing infection.

Question 73

A 14-year-old male presents with recurrent acute locking and catching of his elbow, particularly with extension. He denies any recent trauma. Radiographs are normal. What is the MOST likely diagnosis?

Explanation

Recurrent acute locking and catching of the elbow, especially with extension, in a young patient without acute trauma, is highly suggestive of a loose body (osteochondral fragment) within the joint. These loose bodies can become entrapped in the joint space, causing mechanical symptoms. While osteochondritis dissecans (OCD) of the capitellum is common in young athletes and can lead to loose bodies, the primary diagnosis for acute mechanical locking with normal radiographs would be a loose body, which could be from an undiagnosed prior OCD lesion or other traumatic event. Panner's disease is osteochondrosis of the capitellum in younger children (<10 years) and usually causes diffuse pain and limited motion, not acute locking. Olecranon stress fracture causes posterior pain. Medial epicondylitis causes medial epicondyle pain.

Question 74

A 50-year-old male presents with a painful, palpable mass along the dorsal aspect of his thumb at the radial styloid. He describes pain with grasping and pinching, and a positive Finkelstein's test. He is a new father and reports frequently lifting his infant. What is the MOST likely diagnosis and initial treatment?

Explanation

The patient's symptoms (pain at radial styloid, pain with grasping/pinching, positive Finkelstein's test) and history (new father, repetitive lifting) are classic for De Quervain's tenosynovitis. This condition involves stenosing tenosynovitis of the first dorsal compartment of the wrist, affecting the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. Initial treatment is conservative and includes rest, activity modification, splinting (thumb spica splint to immobilize the thumb and wrist), NSAIDs, and often corticosteroid injections into the tendon sheath. CMC arthritis would involve the joint. Scaphoid fracture would have acute trauma and snuffbox tenderness. Intersection syndrome involves the crossing of the first and second dorsal compartments, more proximal. Radial nerve entrapment would have sensory or motor deficits.

Question 75

A 45-year-old manual laborer presents with chronic right wrist pain. Radiographs reveal a scaphoid waist nonunion with severe radioscaphoid and capitolunate osteoarthritis. The radiolunate joint is completely spared. What is the most appropriate surgical treatment for this patient?

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III. SNAC staging dictates management: Stage I involves only the radial styloid; Stage II involves the entire radioscaphoid joint; Stage III involves the radioscaphoid and capitolunate joints; Stage IV involves the entire carpus including the radiolunate joint. Because the capitate head is arthritic in Stage III, a proximal row carpectomy (PRC) is contraindicated (as the arthritic capitate would articulate with the lunate fossa). Four-corner fusion (excision of the scaphoid and fusion of the capitate, lunate, hamate, and triquetrum) is the standard of care as it fuses the arthritic midcarpal joint while preserving motion through the healthy radiolunate joint.

Question 76

A 55-year-old female presents with the inability to actively flex the interphalangeal joint of her thumb 9 months after undergoing volar locked plating for a distal radius fracture. Radiographs demonstrate that the volar plate is positioned distal to the watershed line of the distal radius. Which of the following tendons is most commonly ruptured in this specific scenario?

Explanation

The clinical presentation describes a delayed rupture of the Flexor Pollicis Longus (FPL) tendon, which is a known complication of volar plating of the distal radius. According to the Soong grading classification, plates placed at or distal to the watershed line (Grade 2) are highly prominent and create friction against the overlying flexor tendons, most notably the FPL. EPL ruptures are more commonly associated with non-displaced distal radius fractures or dorsal screw penetration, not prominent volar plates.

Question 77

A 72-year-old woman with pseudoparalysis secondary to severe rotator cuff tear arthropathy is scheduled for a reverse total shoulder arthroplasty (RTSA). During preoperative templating and intraoperative execution, the surgeon intentionally places the glenosphere with an inferior tilt and an eccentric inferior overhang. This specific technique is primarily intended to minimize the risk of which of the following complications?

Explanation

Scapular notching is a well-described complication in reverse total shoulder arthroplasty, occurring when the medialized humeral component impinges against the inferior scapular neck during adduction. To prevent this mechanical impingement, surgeons utilize an inferior tilt of the baseplate and ensure an inferior overhang of the glenosphere (usually 2 to 4 mm). This positioning alters the impingement-free arc of motion, reducing the incidence of Sirveaux grading scapular notching.

Question 78

A 42-year-old man falls from a ladder and sustains a 'terrible triad' injury to his right elbow. Surgical intervention is undertaken. After stable internal fixation of the coronoid process fracture and prosthetic replacement of the comminuted radial head, the elbow drops out of joint when placed in extension and supination. What is the most appropriate next step in the surgical sequence?

Explanation

The 'terrible triad' of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid fracture. The standard surgical algorithm progresses from deep to superficial: 1) Fixation of the coronoid to restore the anterior buttress, 2) Repair or replacement of the radial head to restore the lateral column, and 3) Repair of the lateral ulnar collateral ligament (LUCL) to address posterolateral rotatory instability. If the elbow remains unstable in extension after LUCL repair, the next step is typically repair of the medial collateral ligament (MUCL) or application of a hinged external fixator. Since the LUCL has not yet been addressed in this scenario, it is the appropriate next step.

Question 79

A 35-year-old male sustains a complete, confirmed sharp laceration of the ulnar nerve at the level of the medial epicondyle. Upon physical examination 6 months later, the patient unexpectedly demonstrates intact active function of the first dorsal interosseous and adductor pollicis muscles, despite a profound sensory deficit in the little finger. Which of the following anatomical anomalies best explains this clinical finding?

Explanation

A Martin-Gruber anastomosis is a motor nerve communication that crosses from the median nerve (or anterior interosseous nerve) to the ulnar nerve in the forearm. In patients with this anomaly, motor fibers destined for ulnar-innervated intrinsic muscles bypass an ulnar nerve injury at the elbow, traveling instead through the median nerve before crossing over to the distal ulnar nerve. This preserves intrinsic muscle function (like the adductor pollicis and first dorsal interosseous) despite a proximal ulnar nerve transection.

Question 80

A 32-year-old carpenter presents with progressively worsening dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate, a radioscaphoid angle of 65 degrees, and proximal migration of the capitate indicating carpal height collapse. Ulnar variance is neutral. What is the most appropriate surgical management?

Explanation

This patient has Lichtman Stage IIIb Kienböck's disease, defined by lunate fragmentation, fixed scaphoid rotation (>60 degrees), and carpal height collapse. Because carpal collapse and fixed scaphoid rotation have already occurred, joint leveling procedures (like a radial shortening osteotomy) or revascularization procedures are ineffective and contraindicated. Salvage procedures, such as a proximal row carpectomy (PRC) or limited intercarpal fusions (e.g., scaphocapitate fusion), are the treatments of choice for Stage IIIb.

Question 81

A 48-year-old male bodybuilder undergoes anatomic repair of a completely ruptured distal biceps tendon using a classic two-incision technique. Postoperatively, he develops a severe limitation in both forearm supination and pronation, while elbow flexion and extension remain fully preserved. Radiographs at 4 months post-op demonstrate heterotopic ossification bridging the radius and ulna. This specific complication is most classically associated with which of the following intraoperative technical errors?

Explanation

Radioulnar synostosis is a devastating complication primarily associated with the two-incision technique for distal biceps tendon repair. It is classically caused by subperiosteal dissection of the ulna or breaching the interosseous membrane during the creation of the ulnar tunnel. This allows osteoprogenitor cells to migrate and bridge the gap between the radius and ulna, blocking forearm rotation. The modified two-incision (Morrey) technique emphasizes staying within the muscle bellies to avoid exposing the ulnar periosteum.

Question 82

A 78-year-old female sustains a comminuted 4-part proximal humerus fracture and undergoes a reverse total shoulder arthroplasty (RTSA). During the procedure, the surgeon meticulously repairs the greater and lesser tuberosities around the prosthesis. Successful postoperative radiographic healing of the greater tuberosity to the proximal humeral shaft is most strongly associated with which of the following clinical outcomes?

Explanation

In RTSA performed for proximal humerus fractures, the reverse prosthesis inherently restores active forward elevation by relying on the deltoid muscle. However, active external rotation is primarily driven by the infraspinatus and teres minor, which attach to the greater tuberosity. If the greater tuberosity fails to heal or resorbs, the patient will have profound weakness in active external rotation (often presenting with a positive horn blower's sign) despite good forward elevation. Therefore, tuberosity healing is the strongest predictor of restored active external rotation.

Question 83

A 24-year-old skier presents with acute right thumb pain after a fall. Examination shows 40 degrees of radial deviation of the thumb metacarpophalangeal (MCP) joint when tested in full extension, compared to 15 degrees on the uninjured side. An MRI confirms a complete rupture of the ulnar collateral ligament (UCL) with a Stener lesion. Which anatomic structure becomes interposed between the torn ends of the UCL in a true Stener lesion?

Explanation

A Stener lesion occurs when the distal attachment of the thumb ulnar collateral ligament (UCL) completely avulses and displaces superficial and proximal to the adductor pollicis aponeurosis. The aponeurosis becomes interposed between the torn ends of the ligament, mechanically preventing the ligament from healing back to its insertion at the base of the proximal phalanx. This finding is an absolute indication for surgical repair, as conservative management will fail.

Question 84

A 50-year-old man presents with an inability to form an 'OK' sign with his right thumb and index finger. Examination reveals an inability to actively flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger. Tenodesis effect is intact, demonstrating full passive flexion of these digits when the wrist is passively extended. There is no sensory deficit in the hand. Which of the following is the most likely diagnosis?

Explanation

The patient's presentation is classic for Anterior Interosseous Nerve (AIN) syndrome. The AIN is a pure motor branch of the median nerve that innervates the flexor pollicis longus (FPL), the flexor digitorum profundus (FDP) to the index and middle fingers, and the pronator quadratus. Weakness results in the characteristic 'flat pinch' or inability to make the 'OK' sign. An intact tenodesis effect rules out tendon ruptures. The lack of sensory deficits differentiates AIN syndrome from Pronator syndrome (which affects the main median nerve and includes sensory loss).

Question 85

A 45-year-old male presents with chronic, progressive wrist pain 5 years after a fall on an outstretched hand. Radiographs demonstrate a scaphoid nonunion with advanced collapse (SNAC). There is significant arthritis at the radioscaphoid joint and the capitolunate joint, but the radiolunate joint is well preserved. Which of the following is the MOST appropriate surgical intervention?

Explanation

This patient has a Stage III SNAC wrist, characterized by osteoarthritis involving the radioscaphoid and capitolunate joints, while sparing the radiolunate articulation. Proximal row carpectomy (PRC) relies on a pristine capitate head articulating with the lunate fossa; therefore, capitolunate arthritis is an absolute contraindication for PRC. Scaphoid excision and four-corner fusion (capitate, lunate, hamate, and triquetrum) eliminates the arthritic joints while preserving some wrist motion, making it the gold standard for Stage III SNAC/SLAC wrists.

Question 86

A 60-year-old female is 6 weeks post non-operative management of a minimally displaced distal radius fracture. She suddenly loses the ability to actively extend her thumb interphalangeal joint. Physical exam confirms loss of retropulsion but normal function of the abductor pollicis longus and extensor pollicis brevis. What is the MOST appropriate surgical treatment?

Explanation

The patient has suffered a delayed rupture of the extensor pollicis longus (EPL) tendon, a known complication of nondisplaced or minimally displaced distal radius fractures due to ischemia and attrition within the third dorsal compartment. Direct repair is usually impossible due to retracted, frayed tendon ends. The gold standard treatment is an extensor indicis proprius (EIP) to EPL tendon transfer, which restores independent thumb extension without significant morbidity to the index finger.

Question 87

A 65-year-old female presents with a 4-part proximal humerus fracture. According to Hertel's criteria, which of the following radiographic findings is the STRONGEST individual predictor of humeral head ischemia?

Explanation

Hertel et al. described radiographic criteria for predicting humeral head ischemia following proximal humerus fractures. The strongest positive predictive value for ischemia is the combination of an anatomic neck fracture pattern, a medial hinge disruption > 2 mm, and a metaphyseal head extension (calcar segment attached to the articular surface) of < 8 mm. Among the individual factors, a metaphyseal extension of < 8 mm is the single best predictor of ischemia.

Question 88

When planning a reverse total shoulder arthroplasty (rTSA) for a patient with rotator cuff tear arthropathy, how does the Grammont-style prosthesis alter the biomechanics of the glenohumeral joint compared to the native anatomy?

Explanation

The Grammont design of reverse total shoulder arthroplasty medializes and distalizes (moves inferiorly) the center of rotation. This alteration fundamentally changes shoulder biomechanics by tensioning the deltoid and increasing its moment arm. By doing so, it allows the deltoid muscle to recruit more of its fibers (specifically the anterior and posterior heads) to elevate the arm, compensating for the absent rotator cuff.

Question 89

A 25-year-old male sustained a C5-C6 upper trunk brachial plexus injury 5 months ago. He has no active elbow flexion, but hand and wrist function are fully intact. He is scheduled for an Oberlin transfer. This procedure classically involves which of the following nerve transfers?

Explanation

The classic Oberlin transfer (Oberlin I) is used to restore elbow flexion in upper trunk brachial plexus injuries. It involves transferring a redundant fascicle of the ulnar nerve (usually one supplying the flexor carpi ulnaris) directly to the motor branch of the biceps muscle. A modified version (Oberlin II or double nerve transfer) adds a transfer from a median nerve fascicle to the brachialis motor branch to further augment elbow flexion.

Question 90

A 40-year-old male undergoes a distal biceps tendon repair via a single-incision anterior approach using a cortical button. Postoperatively, he is unable to extend his metacarpophalangeal joints and thumb interphalangeal joint, but he has strong wrist extension with radial deviation. Which nerve was most likely injured during the procedure?

Explanation

The posterior interosseous nerve (PIN) is at risk during a single-incision anterior approach for distal biceps repair, especially if the drill or cortical button plunges too deeply through the posterior cortex of the radius. Injury to the PIN results in paralysis of the finger and thumb extensors as well as the extensor carpi ulnaris (ECU). Wrist extension is preserved but deviates radially because the extensor carpi radialis longus (ECRL) is innervated by the radial nerve proper, proximal to the PIN bifurcation.

Question 91

A 50-year-old patient with severe carpal tunnel syndrome exhibits paradoxical preservation of intrinsic hand muscle function that is normally innervated by the median nerve. Electromyography confirms an anomalous motor communication between the median and ulnar nerves in the proximal forearm. What is the eponymous name of this anatomical variant?

Explanation

The Martin-Gruber anastomosis is a common anatomical variant (present in ~15% of individuals) where motor nerve fibers cross from the median nerve to the ulnar nerve in the proximal forearm. This can result in intrinsic hand muscles, typically innervated by the median nerve, receiving their supply via the ulnar nerve, thus preserving their function even in severe carpal tunnel syndrome. Riche-Cannieu is an anastomosis between the deep ulnar branch and recurrent median branch in the hand. Marinacci is a reverse Martin-Gruber (ulnar to median in the forearm).

Question 92

A 32-year-old manual laborer presents with progressive dorsal wrist pain. Imaging reveals lunate sclerosis and a coronal fracture line. Carpal height is preserved, and there is no fixed scaphoid rotation (Lichtman Stage IIIA Kienböck's disease). Radiographs demonstrate an ulnar variance of negative 3 mm. What is the MOST appropriate surgical intervention?

Explanation

This patient has Stage IIIA Kienböck's disease (lunate collapse without carpal collapse or fixed scaphoid rotation) and ulnar negative variance. Joint leveling procedures, such as a radial shortening osteotomy, are the treatment of choice in this scenario. By equalizing the lengths of the radius and ulna, the biomechanical load is shifted off the radiolunate joint and onto the ulnocarpal joint, halting disease progression and relieving pain.

Question 93

During arthroscopic repair of a Type II SLAP lesion, the surgeon places an anchor in the superior glenoid. If the drill and anchor are placed too far medially and posterosuperiorly, which of the following neurologic structures is at greatest risk of iatrogenic injury?

Explanation

The suprascapular nerve is at significant risk of injury during SLAP repairs if drill holes or anchors are placed too far medially (more than 1-2 cm from the glenoid rim) at the posterosuperior glenoid neck. The nerve courses through the suprascapular notch and then around the base of the spine of the scapula at the spinoglenoid notch, placing it in close proximity to the posterosuperior glenoid rim.

Question 94

A 21-year-old collegiate baseball pitcher presents with medial elbow pain and decreased throwing velocity. MRI reveals a high-grade partial tear of the anterior bundle of the ulnar collateral ligament (UCL). Which of the following statements regarding the anterior bundle of the UCL is anatomically and biomechanically correct?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow from 30 to 120 degrees of flexion. It originates on the anteroinferior surface of the medial epicondyle and inserts on the sublime tubercle of the anteromedial coronoid. It is not isometric; the anterior band of the anterior bundle is tightest in extension, whereas the posterior band of the anterior bundle is tightest in flexion.

Question 95

A 45-year-old manual laborer presents with chronic, progressive dorsal wrist pain and weakness in grip strength. He sustained a 'sprained wrist' 10 years ago that was never treated. Radiographs reveal a scaphoid nonunion with advanced joint space narrowing and sclerosis at the radioscaphoid and capitolunate joints; however, the radiolunate joint is remarkably preserved. Which of the following is the MOST appropriate surgical management for this patient?

Explanation

This patient presents with Scaphoid Nonunion Advanced Collapse (SNAC) Stage III. SNAC wrist predictably progresses through specific patterns of arthritis: Stage I involves the radial styloid; Stage II involves the entire radioscaphoid joint; Stage III involves the capitolunate joint. The radiolunate joint is characteristically spared because the lunate's spherical shape maintains congruent articulation with the lunate fossa, unlike the elliptical scaphoid. Because the capitolunate joint is arthritic, a proximal row carpectomy (PRC) is contraindicated (as PRC relies on a pristine capitate head to articulate with the lunate fossa). Therefore, the most appropriate motion-preserving procedure is a four-corner arthrodesis (capitate, lunate, hamate, triquetrum) with scaphoid excision.

Question 96

A 22-year-old collegiate baseball pitcher presents with medial elbow pain during the late cocking and early acceleration phases of throwing. Physical examination reveals valgus instability at 30 degrees of elbow flexion. Non-operative management has failed, and an MRI arthrogram confirms a full-thickness tear of the primary restraint to valgus stress at the elbow. During surgical reconstruction, accurate graft tunnel placement is critical. Which of the following describes the precise anatomic origin and insertion of the native ligament being reconstructed?

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress of the elbow between 30 and 120 degrees of flexion. It originates from the anteroinferior surface of the medial epicondyle (not the exact center or posterior aspect) and inserts distally on the sublime tubercle, which is located on the anteromedial facet of the coronoid process of the ulna. Accurate identification of these landmarks during UCL reconstruction ('Tommy John' surgery) is critical to restore native joint kinematics and avoid graft anisometry. The posterior bundle is a secondary restraint, and the lateral ulnar collateral ligament (LUCL) restricts varus and posterolateral rotatory instability.

Question 97

A 38-year-old male undergoes a single-incision anterior approach for the repair of a retracted distal biceps tendon rupture using a suspensory cortical button technique. In the recovery room, the patient demonstrates a weak, radially-deviated wrist extension and a complete inability to actively extend his fingers and thumb at the metacarpophalangeal joints. Sensation over the dorsum of the hand is entirely intact. Which of the following is the most likely mechanism for this postoperative complication?

Explanation

The patient is exhibiting signs of a Posterior Interosseous Nerve (PIN) palsy. The PIN is purely motor (supplying the extensor digitorum, extensor pollicis longus/brevis, extensor carpi ulnaris, etc.), which explains the loss of digit extension and intact sensation. Wrist extension is preserved but radially deviated because the extensor carpi radialis longus (ECRL) and often the extensor carpi radialis brevis (ECRB) are innervated by the radial nerve proper before it bifurcates. In a single-incision anterior approach to the distal biceps, the PIN is at significant risk within the supinator muscle. The most common mechanism of injury is traction neuropraxia caused by vigorous radial/lateral retraction of the brachioradialis and supinator to visualize the radial tuberosity.

Question 98

A 74-year-old female presents 5 years after undergoing a reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy. Radiographs reveal progressive bone loss at the inferior scapular neck that extends medially past the inferior screw of the glenoid baseplate, eroding into the central peg. Based on the Sirveaux classification, what is the grade of this complication, and which surgical design alteration at the time of her index procedure would have MOST likely decreased her risk of developing it?

Explanation

The patient has scapular notching, a frequent complication of RTSA caused by mechanical impingement of the medial humeral cup against the inferior scapular neck during arm adduction. The Sirveaux classification grades this: Grade 1 (notch limited to scapular pillar), Grade 2 (notch reaches the inferior screw), Grade 3 (notch extends over the inferior screw), and Grade 4 (notch extends under the baseplate to the central peg). This patient has Sirveaux Grade 4. Surgical techniques and implant designs that reduce scapular notching include inferior translation of the glenosphere (creating a 2-4 mm inferior overhang), inferior tilt of the baseplate, lateralization of the center of rotation, and using a larger glenosphere diameter. Medialization and superior placement increase the risk of notching.

Question 99

A 45-year-old poorly-controlled diabetic male presents with acute pyogenic flexor tenosynovitis of the thumb following a minor puncture wound. He delays seeking medical attention for 72 hours. Upon presentation, his small finger is also markedly swollen, held in a flexed posture, and exquisitely tender along its volar aspect, while the index, middle, and ring fingers remain relatively unaffected. Which anatomical feature explains the direct contiguous spread of infection from the thumb to the small finger in this patient?

Explanation

This classic presentation represents a 'horseshoe abscess.' The flexor tendon sheath of the thumb is continuous proximally with the radial bursa, and the flexor sheath of the small finger is continuous with the ulnar bursa. In roughly 50-80% of individuals, the radial and ulnar bursae communicate with each other in the proximal palm/carpal tunnel area, known as the space of Parona (located deep to the flexor tendons and superficial to the pronator quadratus). This anatomical connection allows an infection originating in the thumb's flexor sheath to spread proximally into the radial bursa, across to the ulnar bursa, and distally into the small finger, sparing the index, middle, and ring fingers whose flexor sheaths typically terminate proximally at the level of the A1 pulleys.

Question 100

A 6-year-old boy falls from a playground structure and sustains a Gartland type III extension-type supracondylar humerus fracture. Radiographs demonstrate posterolateral displacement of the distal fracture fragment. Based on the displacement pattern of the proximal fragment, which neurovascular structure is at the HIGHEST risk of injury, and what corresponding clinical finding should the examiner specifically evaluate?

Explanation

In a Gartland type III extension-type supracondylar humerus fracture with posterolateral displacement of the distal fragment, the proximal shaft fragment is driven anteromedially. This anteromedial proximal spike places the structures in the anterior/medial aspect of the elbow—specifically the brachial artery, the median nerve, and its anterior interosseous nerve (AIN) branch—at the highest risk of injury. The AIN is the most commonly injured nerve in extension-type supracondylar humerus fractures overall, particularly with this posterolateral displacement pattern. An AIN palsy presents with loss of motor function to the flexor pollicis longus (FPL) and the flexor digitorum profundus (FDP) of the index finger, resulting in an inability to form the 'OK' sign. Conversely, posteromedial displacement of the distal fragment drives the proximal fragment anterolaterally, risking the radial nerve.

General Orthopedics 2026 Practice Questions: Set 13 (Solved)

Orthopedic Upper Extremity 2026 MCQs: Board Review Questions & Answers (Part 6)

Key Takeaway

Orthopedic Upper Extremity 2026 MCQs: Board Review Questions & Answers (Part 6)

Chapter Index