Free Orthopedics Review | Dr Hutaif General Orthopedics -...

Question 1

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could

grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.

Diagnosis of the condition is:

Explanation

The involved muscles have C 5, C 6 root innervations. Positive Tinelâs sign, functioning rhomboids and serratus anterior, and the absence of Hornerâs syndrome rule out a preganglionic lesion. The EMG finding confirms the clinical finding. Subclinical involvement of any other muscle is not shown. Neuropraxia usually recovers in 6 weeks and EMG shows fibrillation, which is inconsistent with neuropraxia. Brachial plexus neuritis, Parsonage-Turner syndrome, has an acute presentation following a painful episode involving the whole arm. There is significant history of a fall in this case.

Question 2

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could

grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.

The level of lesion is:

Explanation

The involved muscles have C 5, C 6 root innervations. Positive Tinelâs sign, functioning rhomboids and serratus anterior, and the absence of Hornerâs syndrome rule out a preganglionic lesion. The EMG finding confirms the clinical finding. Subclinical involvement of any other muscle is not shown. Neuropraxia usually recovers in 6 weeks and EMG shows fibrillation, which is inconsistent with neuropraxia. Brachial plexus neuritis, Parsonage-Turner syndrome, has an acute presentation following a painful episode involving the whole arm. There is significant history of a fall in this case.

Question 3

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could

grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.

The least helpful test in further management of this patient is:

Explanation

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

Question 4

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could

grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.

The plan of management in this patient 5 months postinjury with no clinical improvement should be:

Explanation

Neurotization is appropriate in preganglionic lesions. If at 6 months a patient shows no evidence of recovery, it is time for plexus exploration. Further observation will not change the picture. Tendon transfers are reconstructive procedures, which are done at a later stage.

Question 5

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could

grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3 cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.

The most important indication for early exploration in this patient is:

Explanation

An important indication for early exploration is the recovery of a distally supplied muscle, EC RLâC 6, in the absence of a proximally supplied muscle, bicepsâC 5. Trick movements are adaptive movements employed by the patient by recruiting other muscles, for example, the use of flexor-pronator as elbow flexors in this patient. Bony deformity is a late sequelae and biceps recovery at 3 months is important in obstetric brachial palsy.

Question 6

A 15-year-old boy presented with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle eight weeks prior. He landed on the right shoulder and twisted his neck. Radiographs of the skull, chest, cervical and thoracic spine, and shoulder were normal. There was no loss of consciousness, chest pain, or breathing difficulties. The patient was observed in the hospital until stable and referred for follow-up in the hand clinic at 4 weeks. An electromyelogram (EMG) was scheduled. C linical examination revealed weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature was preserved and he could

grasp, release, and pinch. Sensations were decreased along the distribution of the axillary nerve. There was 3-cm wasting of his arm and 2 cm of the forearm. Tinelâs sign is positive around the clavicle. Hornerâs signs are absent and his arm lies against the body. The EMG report showed fibrillation potentials in the weak muscles. The patient can now flex his elbow. When asked to demonstrate, he flexes his wrist and pronates his forearm to swing his elbow into flexion.

The most important function that needs to be restored in this patient is:

Explanation

Elbow flexion is central to management of brachial plexus management because it serves the most important function of feeding.

Question 7

An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of

5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.

Diagnosis of this condition is:

Explanation

This is a case of obstetric brachial plexus injury involving the C 8, T1 roots (Klumpkeâs palsy). Erbâs palsy involves upper roots only. C ombined nerve injuries can present in a similar fashion, however low ulnar and median nerve lesions will not have weakness of the flexor digitorum profundus and flexor digitorum sublimis.

History of a large baby, shoulder dystocia, and clavicle fracture point to difficult labor. The most common type of brachial plexus injury related to birth is Erbâs palsy, which is usually associated with a breech presentation. Isolated Klumpkeâs palsy is quite rare and the involvement of C 8 and T1 usually occurs as part of global plexus injury.

Question 8

An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of

5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.

The level of the lesion in this patient is:

Explanation

It is difficult to clinically differentiate between a pre- and postganglionic lesion of C 8, T1 in a child. Absence of Hornerâs syndrome and hemi-diaphragmatic palsy in this case indicates that this is not a preganglionic lesion. The ability of the patient to hold his

head suggests that the paravertebral muscles are functional, as is true in postganglionic lesions.

Question 9

An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of

5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.

Appropriate surgical management in this case is:

Explanation

Neurotization is done for preganglionic lesions and has not been shown to produce successful results for lower root involvement. At 18 months, exploration and nerve grafting must be carried out. Neurolysis is reserved for cases in which recovery is partial or plateaus. Tendon transfers in children less than 3 years old do not work as well. Younger children do not cooperate well in rehabilitation. It is also difficult to decide upon the functioning motors for transfer.

Question 10

An 18-month-old boy presents with a clawing deformity of the right hand. He was born full term after a difficult delivery complicated by shoulder dystocia. He weighed 9.5 lbs at birth. The patient had a brief episode of apnea with an APGAR score of

5 at birth and needed resuscitation and admission to the neonatal intensive care unit. A tender bump was noted on the patientâs right clavicle, which was diagnosed as clavicle fracture. A week later, the patient could not flex the fingers of his right hand. The neonatologist informed the parents that the fracture was managed conservatively and the absence of finger flexion was due to fracture and would recover. However, recovery can be prolonged and may take up to two years. The patient has grown and his immunization is complete. His right hand has extension at all the metacarpal joints of the fingers while the proximal interphalangeal and distal interphalangeal joints are flexed. The thumb is in an adducted position, and it is difficult to passively bring the thumb to full abduction. There is obvious wasting of the hand and forearm. The patient moves the arm well with no abnormalities noticed at the shoulder, elbow, and wrist. Radiograph of the chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Hornerâs syndrome and the grasp reflex is absent.

Reconstructive surgery includes all of the following except:

Explanation

This patient has developed contractures of first web space, which will not respond to passive stretching. Fusion of the MP joint is unneccesary, as tendon transfers will provide lateral and tip pinch as well as opposition.

Question 11

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

Explanation

Three types of PIP joint dislocations are identified: volar, dorsal, and central depression. Volar PIP joint dislocations result in avulsion of the dorsal fragment of the base of the middle phalanx, which represents the central tendonâs attachment. If displacement persists, than a boutonniere deformity may result. Volar avulsion fractures of the PIP joint are often due to a hyperextension injury at the attachment of the volar plate.

Question 12

At what degree of flexion is ulnar collateral ligament injury tested:

Explanation

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

Question 13

Which of the following structures are found within the first dorsal compartment:

Explanation

The first dorsal compartment encompasses the abductor pollicis longus and extensor pollicis brevis. Multiple slips of abductor pollicus brevis may be present, which is important in de Quervainâs release.

Question 14

A 28-year-old man fell off his bike and sustained a fall onto his outstretched hand. He experiences thumb and index finger numbness. Attempts at reduction of his grade I open extra-articular distal radius fracture are unsuccessful. The next appropriate step of management is:

Explanation

A patient with this injury represents a high-energy fracture in a high demand individual. The patient will require incision and drainage of his open wound, open reduction with internal fixation, and carpal tunnel release. Bone grafting would not be appropriate in a patient with open fracture.

Question 15

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

Explanation

Patients with thrombocytopenia absent radii, Fanconi anemia, Holt-Oram syndrome, and cardiac anomolies all are associated with radial deficiency. Larsen syndrome is associated with multiple, larger joint dislocation.

Question 16

Which of the following is the most common carpal coalition in the hand:

Explanation

Lunotriquetral coalition has a 1.6% prevalence in the general population. The second most common coalition is the capitohamate. Incomplete coalition is treated by arthrodesis of the lunotriquetral joint.

Question 17

A 6-year-old boy presents with a Salter-Harris II distal radius fracture 3 weeks after injury. He is nontender and neurologically intact. On radiographs, he has a 35Âº dorsal angulation. The appropriate course of treatment is:

Explanation

For a patient with delayed presentation of a distal radius fracture, appropriate management includes casting and observation for at least 2 years to assess physeal damage and remodeling. The patient may require osteotomy if remodeling does not occur.

Question 18

The oblique retinacular ligament connects with what two structures:

Explanation

Landsmeer (oblique retinacular ligament) runs from the flexor tendon sheath of the proximal phalanx to the lateral extensor tendon as they insert onto the base of the proximal phalanx. A stay or retaining ligament maintains centralization of the extensor tendons.

Question 19

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

Explanation

Anterior interosseous nerve syndrome is due to compression of the anterior interosseous nerve (AIN) in the forearm by lacterus fibrosis, flexor digitorum superficialis, or pronator teres. The AIN innervates the pronator quadratus, flexor digitorum profundus (FDP) to the index finger and the flexor pollicis longus (FPL). Anatomy variation exists where the AIN may innervate part of the flexor digitorum superficialis. In this patient, she has decreased pronation at 90Âº flexion, which relaxes the humeral attachment of the pronator from the pronator quadrus weakness. She also has pulp-to-pulp contract due to weakness of the FPL and FDP to the index finger.

Question 20

Indications for operative treatment in an acute elbow dislocation include:

Explanation

Recurrent dislocations with extension past 50Â° represent a significant injury to the elbow and require a stabilization period. Instability to valgus stress represents injury to the anterior band of the medial collateral ligament of the elbow and will heal with protected motion. The majority of radial head fractures (Mason type I and II) that are less than 30Âº of the radial head and less than 30Âº angulation heal with good functional results. Most dislocations will have osteochondral lesions. Ulnar nerve parathesias can be associated with dislocations but is not an indication for operative fixation.

Question 21

When performing open reduction and internal fixation of radial neck fractures, the plate should be placed:

Explanation

The "nonarticular safe-zone" comprising only 90Âº of the radial head circumference is achieved by placing the plate posterior with the arm in supination.

Question 22

Heterotopic ossification after elbow dislocations is not associated with which of the following:

Explanation

Heterotopic ossification is commonly associated with delay of surgical intervention, closed head injury, aggressive passive range of motion after dislocation, and extensive surgical dissection. Radiographic evidence of heterotopic ossification is present in 75% of patients with elbow dislocations but only 5% of these are clinically significant.

Question 23

What is the order of joint destruction in a patient with scapholunate disassociation:

Explanation

Patients with scapholunate disassociation can develop a scapholunate advanced collapsed wrist. The progression is from the radial styloid to proximal radioscaphoid, to midcarpal (capitolunate). The lunate is extended and unloaded due to its concentric design, which results in preservation of the radiolunate.

Question 24

Which of the following is not characteristic of Dupuytrenâs disease:

Explanation

Dupuytrenâs disease is characteristically unpredictable in its clinical progression. It may spontaneously resolve or quickly progress to advanced disease.

Question 25

Operative indications for Dupuytrenâs contracture include:

Explanation

As a general guideline the "table test" is used as an indication for operative intervention. If the patient cannot lay his/her hand flat onto a table, the disease has usually progressed to the point where surgery is required. A metacarpophalangeal joint contracture of 30Âº to 40Âº or a proximal interphalangeal joint contracture of 30Âº or more is an indication for surgery.

Question 26

Favorable indications for attempted replantation include:

Explanation

Favorable indications for replantation include thumb amputations because of the functional importance of the thumb. Warm ischemias less than 8 hours or cold ischemia time less than 16 hours are more favorable for replantation.

Question 27

Injuries to the central articular disk portion of the triangular fibrocartilage complex are related to all of the following except:

Explanation

Scaphoid nonunion is not related to central triangular fibrocartilage complex injuries. A positive ulnar variance is most strongly associated with triangular fibrocartilage complex central disk injuries.

Question 28

A patient reports that he felt a pop and immediate pain over the MP joint of his finger. Examination reveals tenderness on the dorsum of the joint and subluxation of the extensor tendon. Which of the following is the most common defect:

Explanation

Tears of the sagittal fibers of the dorsal aponeurosis result in subluxation of the extensor tendon. This usually occurs on the long finger with subluxation to the ulnar side. Treatment for acute injuries requires immobilization of the metacarpophalangeal joint in extension for 6 weeks. Treatment for chronic injuries includes repair of the torn radial sagittal fibers.

Question 29

All of the following transfers may be used to improve function in a patient who has had radial nerve paralysis longer than 6 months, except:

Explanation

Radial nerve paralysis is a common injury, and many patients recover after repair. Tendon transfers should be delayed until sufficient time for reinnervation has passed. Pronator to extensor carpi radialis brevis can be performed at time of nerve repair to provide wrist extension and grasp during period of nerve recovery. Transfers for radial nerve palsy need to address wrist extension, thumb extension, and finger extenstion. All of the above transfer would provide these functions except a transfer to the brachioradialis.

Question 30

A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (). Your diagnosis is:

Explanation

This is a classic appearance of a radial club hand, which is often referred to as preaxial longitudinal deficiency. Ulnar club hand and postaxial longitudinal deficiency are synonymous.

Question 31

A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other

congenital defects. The clinical appearance of his forearm is shown (). The patient has an elbow flexion contracture of 70Â°

and desires lengthening. Which of the following statements is not true regarding lengthening:

Explanation

In most cases of radial club hand, excluding a hypoplastic radius, full correction cannot be achieved.

Question 32

A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (). The potential complications of lengthening are discussed, and the patient is advised against it. However, the elbow flexion contracture is corrected by gradual distraction. One year postoperatively, the patient has attained a 30Â° correction of the flexion deformity, which remains mobile. Now, he desires that his wrist deformity be corrected. The procedure of choice is:

Explanation

Wrist arthrodesis is the best solution for this patient and his recurrent deformity because it provides a stable platform for grasp.

Question 33

A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (). Although the patient has a thumb, it is in an abnormal position. Any attempt to make his thumb more functional will be influenced by:

Explanation

The pattern of usage of the hand is established in the brain by 2 to 3 years of age. Although pollicization has been performed in adolescents, patients continue to prefer a scissor pinch. At 24 years of age, this pattern will be well established. The patient can be coaxed to use his thumb, but it will not be involuntary and automatic.

Question 34

A radial club hand is the result of an insult during which phase of the gestation period:

Explanation

A radial club hand is the result of an insult during weeks 4 to 7 of gestation.

Question 35

A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; platelet 254 254×103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes

40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.

Diagnosis is:

Explanation

The patient has a radial club hand with a cardiac defect. Because the spine radiograph is normal, the diagnosis cannot be VATER or VAC TERL anomaly as both involve vertebrae. Blood work up is normal, making this diagnosis Holt-Oram syndrome.

Question 36

The principal abnormality associated with Holt-Oram syndrome is:

Explanation

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

Question 37

The hereditary pattern for Holt-Oram syndrome is:

Explanation

Holt-Oram syndrome is inherited in an autosomal dominant manner.

Question 38

A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; 254×103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes 40%; Hct

45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.

The next step in the management of the radial club hand is:

Explanation

For the first 6 to 9 months, parents and therapists perform passive stretching. Serial casting and splinting may also be used. Sometimes, preoperative soft-tissue distraction is performed, usually before a wrist stabilization procedure.

Question 39

A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; platelet 254×103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes

40%; Hct 45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.

C entralization will be performed on the patient. All of the following statements are true about centralization except:

Explanation

In a centralization procedure, the forearm is aligned with the third metacarpal, not the second.

Question 40

A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000 mcu/L; 254Ã103 mcu/L; neutophils 50%; Hb 14.2 mg/dL; lymphocytes 40%; Hct

45; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal.

When the patient is 10 years old, he is not satisfied with the length of his forearm and wishes to lengthen it. Which of the following is not a satisfactory recommendation:

Explanation

Acute lengthening is done for small defects and, if performed in this patient, may result in severe neurovascular compromise.

Question 41

Which of the following conditions is present in patients with radial club hand but not in patients with ulnar club hand:

Explanation

Ulnar club hand differs from radial club hand in that cardiopulmonary, hematopoeitic, gastrointestinal, and genitourinary anomalies are uncommon.

Question 42

All of the following developmental anomalies are associated with ulnar club hand except:

Explanation

Atrial septal defects are developmental abnormalities present in patients with radial club hand or Holt-Oram syndrome.

Question 43

Which of the following syndromes is associated with ulnar club hand:

Explanation

VATER, VAC TERL, Holt-Oram syndrome, and TAR syndrome are associated with radial club hand. Femur-fibular-ulnar syndrome is characterized by proximal femoral focal deficiency, fibular agenesis, and ulnar ray defects.

Question 44

Which of the following areas is not involved in ulnar club hand:

Explanation

Vertebrae are usually not involved in ulnar club hand.

Question 45

All of the following are true statements regarding elbow involvement in ulnar club hand except:

Explanation

Elbow instability does not correspond with severity of involvement. Fifty percent of patients with total aplasia have radiohumeral synostosis, which provides adequate stability.

Question 46

All of the following statements are true regarding the carpal bones in patients with ulnar club hand except:

Explanation

A notch is often created in centralization procedures for radial club hand. Wrist stabilization procedures are not performed for ulnar club hand.

Question 47

All of the following anomalies are present in patients with ulnar club hand except:

Explanation

Vertebral anomalies are not common in patients with ulnar club hand.

Question 48

A 28-year-old male presents with severe left leg pain following a closed tibial shaft fracture sustained in a motor vehicle collision. The pain is not relieved by intravenous opioids. On examination, the leg is tense and swollen. Pulses are palpable and capillary refill is less than 2 seconds. Which of the following is the most reliable early clinical indicator of the suspected diagnosis?

Explanation

Pain out of proportion to the injury and exacerbated by passive stretch of the involved muscles is the most reliable early clinical sign of acute compartment syndrome. Pulselessness, pallor, and paralysis are late, often irreversible signs.

Question 49

A 13-year-old obese male presents with a 3-week history of vague right groin and knee pain. He walks with an antalgic limp. On physical examination, as his right hip is passively flexed, it obligatorily falls into external rotation. Radiographs confirm the diagnosis. Which of the following is the gold standard initial management?

Explanation

The clinical presentation is classic for a slipped capital femoral epiphysis (SCFE). In situ pinning with a single cannulated screw placed in the center of the epiphysis is the gold standard to prevent further slippage.

Question 50

A 15-year-old girl presents with persistent distal thigh pain. Radiographs reveal a destructive, permeative lesion in the distal femoral metaphysis with a 'sunburst' periosteal reaction and elevation of the periosteum (Codman's triangle). Which of the following histological findings is required to confirm the most likely diagnosis?

Explanation

The clinical and radiographic findings strongly suggest osteosarcoma. The histologic hallmark required for the diagnosis of osteosarcoma is the production of osteoid matrix directly by malignant spindle cells.

Question 51

A 35-year-old male undergoes open reduction and internal fixation of a simple transverse radial shaft fracture using a dynamic compression plate to achieve absolute stability. By which mechanism will this fracture primarily heal?

Explanation

Rigid internal fixation that achieves absolute stability (e.g., dynamic compression plating) eliminates interfragmentary motion, leading to primary bone healing. This occurs directly via osteoclastic cutting cones and osteoblastic bone formation without a callus phase.

Question 52

A 45-year-old man with a known L4-L5 disc herniation presents to the emergency department with acute worsening of back pain, bilateral sciatica, and perineal numbness. Which of the following is the most sensitive early clinical indicator to suspect cauda equina syndrome?

Explanation

Urinary retention is the most sensitive early symptom of cauda equina syndrome. If a patient does not have urinary retention (often assessed by confirming a low post-void residual volume), the diagnosis of cauda equina syndrome is highly unlikely.

Question 53

In a patient undergoing a primary total hip arthroplasty with a highly cross-linked polyethylene liner and a cobalt-chrome femoral head, which type of wear mechanism is predominantly responsible for the generation of submicron particulate debris?

Explanation

Adhesive wear is the primary mechanism of normal articulation wear in metal-on-polyethylene bearings. This microscopic transfer of material generates submicron particles that can be phagocytosed by macrophages, initiating the osteolysis cascade.

Question 54

A 22-year-old soccer player continues to experience a positive pivot shift test following a primary anterior cruciate ligament (ACL) reconstruction, despite normal sagittal plane stability. What surgical technical error during tunnel placement most commonly accounts for this residual rotational instability?

Explanation

Placing the femoral tunnel high in the intercondylar notch (the 12 o'clock position) creates a vertically oriented graft. While this controls anterior-posterior translation, it fails to adequately restore rotational stability, leaving a positive pivot shift.

Question 55

A 30-year-old carpenter sustained a sharp laceration to his volar index finger, resulting in a Zone II flexor digitorum profundus rupture. During surgical repair, which technical factor contributes most significantly to the ultimate tensile strength of the tendon repair, allowing for safe early active mobilization?

Explanation

The tensile strength of a flexor tendon repair is directly proportional to the number of core suture strands crossing the coaptation site. A minimum of a 4-strand core repair is generally required to withstand the forces of early active motion protocols.

Question 56

A 35-year-old male arrives in hemorrhagic shock following a motorcycle crash. Primary survey reveals an unstable Anteroposterior Compression Type III (APC-III) pelvic ring injury. A pelvic binder is applied, and the FAST exam is negative. Despite 2 units of uncrossmatched blood, his blood pressure remains 70/40 mmHg. According to ATLS protocols, what is the next most appropriate intervention?

Explanation

In a hemodynamically unstable patient with a mechanically stabilized pelvic fracture and no other identified sources of bleeding (negative FAST), the bleeding is presumed to be retroperitoneal. Pre-peritoneal pelvic packing or angioembolization is indicated to control venous and arterial hemorrhage.

Question 57

A 24-year-old male falls onto an outstretched hand and sustains a displaced fracture through the proximal pole of the scaphoid. This specific fracture pattern has a high risk of nonunion and avascular necrosis because the primary blood supply enters the scaphoid at which location?

Explanation

The major blood supply to the scaphoid enters distally along the dorsal ridge via branches of the radial artery, perfusing the bone in a retrograde fashion. Fractures at the proximal pole disrupt this retrograde supply, leading to a high rate of avascular necrosis.

Question 58

A 55-year-old diabetic male presents with severe erythema, swelling, and pain out of proportion in his right calf. You are calculating a LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score to help guide your decision for operative debridement. Which of the following laboratory values is NOT a component of the LRINEC score?

Explanation

The LRINEC score uses six laboratory parameters: C-reactive protein, white blood cell count, hemoglobin, serum sodium, serum creatinine, and serum glucose. Serum potassium is not a component of this predictive model.

Question 59

A researcher is studying the biomechanical properties of human hyaline articular cartilage. The tensile stiffness and structural framework of this tissue are primarily provided by which of the following macromolecular components?

Explanation

Type II collagen comprises 90-95% of the collagen in normal articular cartilage and is primarily responsible for its tensile strength. Proteoglycans like aggrecan provide compressive stiffness through osmotic tissue swelling.

Question 60

A 4-month-old female with developmental dysplasia of the hip (DDH) has been treated with a Pavlik harness for 4 weeks. Serial ultrasounds confirm that the hip remains dislocated despite verifiable compliance and proper harness application. What is the most appropriate next step in management?

Explanation

If a Pavlik harness fails to achieve reduction after 3 to 4 weeks, continuing it increases the risk of 'Pavlik harness disease' (erosion of the posterior acetabulum). The next appropriate non-operative step is transitioning to a rigid abduction orthosis.

Question 61

A 68-year-old female presents with persistent knee pain 14 months after a primary total knee arthroplasty (TKA). Radiographs show no obvious signs of component loosening. Which of the following is statistically the most common cause for revision TKA within the first 2 years after the index procedure?

Explanation

Periprosthetic joint infection is the most common reason for early revision (within the first 2 years) following total knee arthroplasty. Aseptic loosening and polyethylene wear are the most common causes for late revisions.

Question 62

A 35-year-old male sustains a closed spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). On initial presentation in the emergency department, his radial nerve motor and sensory exams are completely intact. After closed reduction and application of a coaptation splint, he is unable to extend his wrist or fingers. What is the most appropriate next step in management?

Explanation

A radial nerve palsy that newly develops or worsens immediately after a closed reduction of a humeral shaft fracture strongly suggests iatrogenic nerve entrapment within the fracture site. This is an absolute indication for immediate surgical exploration.

Question 63

A 70-year-old female presents with chronic, severe right shoulder pain and the inability to actively elevate her arm above 60 degrees. Passive range of motion is normal. Radiographs reveal superior migration of the humeral head with articulation against the acromion, and severe glenohumeral osteoarthritis. MRI confirms a massive, retracted, irreparable rotator cuff tear. What is the most reliable surgical treatment for restoring active elevation and relieving pain?

Explanation

This patient has classic rotator cuff tear arthropathy with pseudoparalysis. A reverse total shoulder arthroplasty alters the center of rotation, allowing the deltoid to effectively elevate the arm independent of the deficient rotator cuff.

Question 64

A 10-year-old boy presents with low-grade fever, weight loss, and mid-thigh pain. Radiographs of the femur show a large diaphyseal lesion with an 'onion-skin' periosteal reaction. Biopsy reveals sheets of small round blue cells. This malignancy is classically associated with which of the following chromosomal translocations?

Explanation

Ewing sarcoma typically presents in the diaphysis of long bones with an 'onion-skin' periosteal reaction and small round blue cells on histology. It is characterized by the t(11;22) translocation, producing the EWS-FLI1 fusion protein.

Question 65

A 42-year-old male sustains an acute Achilles tendon rupture while playing basketball. He is discussing operative versus non-operative treatment with his orthopedic surgeon. If a modern, accelerated functional rehabilitation protocol is utilized, what is the primary consensus finding regarding the outcomes of non-operative compared to operative management?

Explanation

Recent high-quality evidence shows that when acute Achilles tendon ruptures are treated with functional bracing and early weight-bearing protocols, the rerupture rates are comparable to operative repair, while avoiding surgical wound complications.

Question 66

A 25-year-old male sustains a Gustilo-Anderson Type IIIA open tibia fracture. According to established trauma principles, which of the following interventions has been proven to have the greatest impact on reducing the subsequent risk of deep infection?

Explanation

The early administration of systemic intravenous antibiotics (ideally within 1-3 hours of injury) is the single most important, evidence-based intervention for reducing the infection rate in open fractures.

Question 67

A 62-year-old female presents with deteriorating fine motor skills in her hands and recent gait instability. Physical examination reveals a positive Hoffmann sign bilaterally, hyperreflexia in the lower extremities, and an inverted brachioradialis reflex. Which of the following is the best imaging modality to confirm the suspected diagnosis?

Explanation

The patient's clinical presentation (clumsy hands, gait instability, upper motor neuron signs) is classic for cervical spondylotic myelopathy. MRI of the cervical spine is the gold standard imaging modality to evaluate spinal cord compression and myelomalacia.

Question 68

A 68-year-old male presents with a painful right total hip arthroplasty 3 years after the index procedure. Inflammatory markers are elevated, and hip aspiration reveals a synovial fluid white blood cell count of 45,000 cells/uL with 90% polymorphonuclear leukocytes. What is the most appropriate definitive management?

Explanation

A chronic periprosthetic joint infection presenting years after the index procedure with high WBCs and PMNs is definitively treated with a two-stage exchange arthroplasty in North America. DAIR is reserved for acute postoperative or acute hematogenous infections with stable implants.

Question 69

A 14-year-old boy presents with progressive knee pain. Radiographs reveal a metaphyseal, permeative, bone-forming lesion in the distal femur with a 'sunburst' periosteal reaction. Biopsy confirms high-grade osteosarcoma. Which of the following is the most important prognostic factor for this patient's survival?

Explanation

The most important prognostic factor for patients with high-grade osteosarcoma is the histologic response to neoadjuvant chemotherapy, specifically the percentage of tumor necrosis. Greater than 90% necrosis indicates a good response and correlates with improved survival.

Question 70

A 5-year-old child falls from monkey bars and sustains a completely displaced (Gartland Type III) extension-type supracondylar humerus fracture. On examination, the radial pulse is absent, but the hand is warm, pink, and has capillary refill under 2 seconds. What is the most appropriate next step in management?

Explanation

In a 'pulseless, pink' hand associated with a supracondylar humerus fracture, the initial treatment is emergent closed reduction and percutaneous pinning. Often, the pulse returns once the fracture is reduced, and vascular exploration is not indicated unless the hand becomes cool and pale.

Question 71

During a physical examination of the knee, the pivot shift test is performed to assess anterior cruciate ligament (ACL) integrity. The test primarily evaluates the function of which ACL bundle, and in what position does the tibia typically subluxate?

Explanation

The pivot shift test primarily assesses the rotatory stability provided by the posterolateral (PL) bundle of the ACL. During the test, the tibia subluxates anteriorly when the knee is in extension and reduces with a clunk as the knee flexes past 20-30 degrees.

Question 72

During trial reduction of a posterior-stabilized total knee arthroplasty, the knee is found to be tight in flexion but stable and well-balanced in extension. Which of the following adjustments is most appropriate to achieve a balanced gap?

Explanation

A knee that is tight in flexion but balanced in extension has a tight flexion gap. Downsizing the femoral component (which removes more posterior condylar bone) or increasing the posterior tibial slope will specifically enlarge the flexion gap without affecting the extension gap.

Question 73

A 32-year-old man sustains a closed diaphyseal tibia fracture. He reports excruciating leg pain out of proportion to the injury. Which of the following parameters is the most reliable indicator for emergency fasciotomy?

Explanation

A delta pressure (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is the most reliable threshold for diagnosing acute compartment syndrome and indicating fasciotomy. Absolute pressures are less reliable due to systemic blood pressure variations.

Question 74

A 14-year-old boy is diagnosed with high-grade osteosarcoma of the distal femur. He undergoes neoadjuvant chemotherapy followed by limb-salvage resection. Which of the following is the most significant prognostic factor for his long-term survival?

Explanation

The percentage of tumor necrosis following neoadjuvant chemotherapy (histologic response) is the single most important prognostic factor for long-term survival in patients with high-grade osteosarcoma. A good response is typically defined as greater than 90% necrosis.

Question 75

A 5-year-old boy presents with a completely displaced, extension-type supracondylar humerus fracture. Upon examination, his hand is pink and warm, but the radial pulse is absent. After urgent closed reduction and percutaneous pinning, the hand remains pink and well-perfused, but the radial pulse remains absent. What is the most appropriate next step in management?

Explanation

For a pulseless but well-perfused (pink and warm) hand following reduction and pinning of a pediatric supracondylar fracture, the standard of care is close observation. Collateral circulation is usually sufficient, and vascular exploration is only indicated if the hand becomes cold and ischemic.

Question 76

A 22-year-old rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals 28% anterior glenoid bone loss. Which of the following surgical interventions is most appropriate to restore stability?

Explanation

In the setting of significant anterior glenoid bone loss (typically >20-25%) in a collision athlete, soft tissue stabilization alone (Bankart repair) has an unacceptably high failure rate. A bony augmentation procedure, such as the Latarjet procedure, is the gold standard.

Question 77

A 45-year-old man is brought to the trauma bay after a motorcycle collision. He is hypotensive and tachycardic. Pelvic radiographs show an anteroposterior compression (APC) type III injury. Where should a pelvic binder be anatomically centered to most effectively reduce pelvic volume?

Explanation

A pelvic binder must be placed at the level of the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement over the iliac crests is incorrect and can paradoxically open the pelvis further in some fracture patterns.

Question 78

A 13-year-old obese boy presents with left thigh pain and a limp for 3 weeks. Examination reveals obligatory external rotation of the left hip with passive flexion. He is diagnosed with a slipped capital femoral epiphysis (SCFE). Which of the following is a strong indication for prophylactic pinning of the contralateral, asymptomatic hip?

Explanation

Prophylactic pinning of the contralateral hip in SCFE is highly recommended for patients with underlying endocrine disorders (such as hypothyroidism or renal osteodystrophy) due to the exceedingly high risk of bilateral involvement. Routine prophylactic pinning in idiopathic cases remains controversial.

Question 79

A 32-year-old woman presents with knee pain. Radiographs reveal an eccentric, lytic lesion in the proximal tibial epiphysis extending to the subchondral bone, with no sclerotic margin. Biopsy confirms mononuclear cells and multinucleated giant cells. What is the most appropriate primary surgical treatment?

Explanation

Giant cell tumors of bone are aggressive but benign lesions. The standard treatment is intralesional extended curettage (using a high-speed burr, phenol, or argon beam) followed by packing with PMMA bone cement, which provides immediate structural support and causes thermal necrosis of residual microscopic cells.

Question 80

A 28-year-old man sustains a displaced, vertically oriented (Pauwels type III) femoral neck fracture. He undergoes closed reduction and internal fixation with cannulated screws. Which of the following represents the highest risk complication associated with this specific fracture pattern?

Explanation

Pauwels type III fractures are highly vertical, generating significant shear forces rather than compressive forces across the fracture site. This mechanical disadvantage leads to a high rate of varus collapse, hardware failure, and nonunion compared to more horizontal fracture patterns.

Question 81

A 68-year-old woman underwent a posterior-stabilized total knee arthroplasty (TKA) 8 months ago. She now complains of a painful catching sensation and an audible "clunk" when her knee extends from 40 degrees of flexion. What is the most likely etiology of her symptoms?

Explanation

Patellar clunk syndrome is a known complication of posterior-stabilized TKA, characterized by a fibrotic nodule forming at the superior pole of the patella. As the knee extends, this nodule catches in the intercondylar box of the femoral component and pops out with an audible clunk.

Question 82

A 55-year-old diabetic male presents with severe, progressive back pain, low-grade fevers, and new-onset bilateral leg weakness. Inflammatory markers are significantly elevated. You suspect a spinal epidural abscess. What is the most common causative organism?

Explanation

Staphylococcus aureus is the most common organism responsible for spinal epidural abscesses, accounting for more than 50-60% of cases. Immediate MRI with gadolinium is the imaging modality of choice, followed by urgent surgical decompression if neurologic deficits are present.

Question 83

A 45-year-old carpenter complains of numbness in his ring and small fingers, and progressive hand weakness. Examination shows intrinsic muscle wasting, a positive Froment's sign, and a positive Tinel's sign at the elbow. Which of the following anatomical structures is the most common site of compression for this pathology?

Explanation

The patient has cubital tunnel syndrome (ulnar nerve compression at the elbow). The most common site of ulnar nerve entrapment in this region is the cubital tunnel retinaculum, also known as Osborne's ligament, which spans between the medial epicondyle and the olecranon.

Question 84

A 25-year-old man sustains a laceration to the volar aspect of his index finger in Zone II. He undergoes primary flexor tendon repair. To optimize tendon gliding and minimize adhesion formation postoperatively, which rehabilitation protocol is currently most favored?

Explanation

Early active extension with passive flexion (e.g., modified Kleinert or Duran protocols) is standard after Zone II flexor tendon repairs. It stimulates intrinsic tendon healing while minimizing restrictive peritendinous adhesions.

Question 85

A 30-year-old restrained driver presents after a head-on motor vehicle collision. He has a shortened, internally rotated, and adducted right lower extremity. Radiographs confirm a posterior hip dislocation. Which of the following neurologic structures is at highest risk of injury in this scenario?

Explanation

Posterীয় hip dislocations place the sciatic nerve at risk of stretch or compression. The peroneal division is more commonly and severely injured than the tibial division due to its lateral position and secure tethering at the sciatic notch and fibular head.

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