Orthopedic O Upper Extremity Review | Dr Hutaif General -...

Question 1

A 28-year-old semi-professional baseball pitcher presents with recurrent anterior glenohumeral instability despite dedicated rehabilitation. He has suffered 5 dislocations in the past 18 months. An axial CT scan reveals a glenoid bone loss of approximately 28% and an engaging Hill-Sachs lesion. The image provided shows a representative axial CT view of a shoulder with bone loss.

What is the most appropriate surgical management for this patient?

Explanation

The Latarjet procedure is indicated for recurrent anterior glenohumeral instability in patients with significant glenoid bone loss (typically >20-25%) or an engaging Hill-Sachs lesion, especially in high-demand athletes. This procedure addresses both the glenoid bone defect and the humeral head defect, providing a robust bony block to prevent recurrence. Arthroscopic or open Bankart repairs alone are insufficient for significant bone loss. Remplissage addresses the Hill-Sachs but doesn't restore glenoid bone. Thermal capsulorrhaphy is rarely used due to high failure rates and concerns for chondrolysis.

Question 2

An 82-year-old female with severe osteopenia falls from a standing height, sustaining a 4-part valgus-impacted proximal humerus fracture, as shown in the image below. She has limited pre-injury shoulder function due to long-standing rotator cuff arthropathy and a low demand lifestyle.

What is the most appropriate surgical treatment option for this patient?

Explanation

For elderly patients with complex 3- or 4-part proximal humerus fractures, especially in the setting of osteopenia and pre-existing rotator cuff dysfunction or rotator cuff arthropathy, reverse total shoulder arthroplasty (RTSA) has shown superior functional outcomes and lower reoperation rates compared to ORIF or hemiarthroplasty. ORIF has high failure rates in osteopenic bone, and hemiarthroplasty relies on a functional rotator cuff for optimal results, which is often compromised in this demographic. Non-operative management would likely lead to poor functional recovery in a displaced 4-part fracture.

Question 3

A 45-year-old male sustains a fall onto an outstretched hand, resulting in a complex elbow injury. Radiographs, similar to the one provided, confirm a posterior elbow dislocation, a Mason Type III radial head fracture, and a Regan-Morrey Type II coronoid fracture.

Which of the following represents the most appropriate sequence and combination of surgical interventions for this 'terrible triad' injury?

Explanation

The 'terrible triad' injury involves an elbow dislocation, radial head fracture, and coronoid fracture. Surgical management aims to restore stability and congruity. The preferred approach involves: 1) ORIF of the coronoid fracture (essential for elbow stability), 2) radial head replacement for Mason Type III fractures (ORIF if simple and reconstructible, but replacement is common for comminuted injuries), 3) repair of the lateral collateral ligament (LCL) complex (the primary varus and posterolateral stabilizer), and 4) repair of the medial collateral ligament (MCL) if significant instability persists after the initial repairs. Radial head excision alone can lead to valgus instability and wrist pain. Arthrodesis is a salvage procedure, not primary treatment. Closed reduction and casting alone are insufficient for such complex unstable injuries.

Question 4

A 45-year-old right-hand dominant construction worker presents with chronic wrist pain, weakness, and limited range of motion 6 months after sustaining a distal radius fracture that was treated non-operatively. Radiographs, as depicted, demonstrate a healed distal radius malunion with 25 degrees of dorsal tilt, 8 mm of radial shortening, and a positive ulnar variance.

Given his symptoms and radiographic findings, what is the most appropriate surgical management?

Explanation

The patient's symptoms are indicative of a symptomatic distal radius malunion with significant dorsal tilt and radial shortening. The most appropriate surgical management to restore anatomy and improve function is a corrective osteotomy of the distal radius. This typically involves opening the osteotomy dorsally or volarly, correcting the angulation and shortening, and securing it with a locking volar plate. Bone graft (autograft or allograft) is often used to fill the osteotomy gap and promote healing. Ulnar shortening osteotomy only addresses ulnar variance and does not correct radial shortening or dorsal tilt. Wrist arthrodesis is a salvage procedure for severe arthritis or instability, not a primary correction for malunion. Darrach procedure addresses distal radioulnar joint (DRUJ) impingement but not the primary deformity. Continued conservative management is unlikely to improve symptoms.

Question 5

A 30-year-old male presents with chronic right wrist pain and limited motion following a fall two years prior. Initial radiographs were negative, but subsequent imaging, including the provided X-ray, shows a scaphoid waist nonunion with evidence of proximal pole sclerosis and cystic changes, consistent with avascular necrosis (AVN). There is no signs of capitolunate or radioscaphoid arthritis.

What is the most appropriate surgical intervention for this patient?

Explanation

For scaphoid nonunion with avascular necrosis (AVN) of the proximal pole, especially without significant secondary arthritis, a vascularized bone graft combined with internal fixation (typically a headless compression screw) is the preferred treatment. The vascularized graft helps revascularize the avascular proximal pole, improving healing rates compared to non-vascularized grafts when AVN is present. Percutaneous fixation alone is for acute, undisplaced fractures. Non-vascularized grafts are used for nonunions without AVN. PRC and wrist arthrodesis are salvage procedures for cases with significant arthritis (SLAC wrist) or failed reconstruction, which are not yet present in this scenario.

Question 6

A 68-year-old male presents with chronic severe right shoulder pain and significant weakness, limiting his active abduction to 60 degrees. MRI imaging, similar to the one shown, confirms a massive, irreparable posterosuperior rotator cuff tear with significant superior migration of the humeral head and Goutallier Grade 3 fatty infiltration of the infraspinatus.

Given these findings and his age, what is the most appropriate surgical intervention?

Explanation

For an elderly patient with a massive, irreparable rotator cuff tear, significant superior humeral head migration (rotator cuff arthropathy), fatty infiltration of the rotator cuff muscles, and poor active elevation, reverse total shoulder arthroplasty (RTSA) is the gold standard. RTSA bypasses the need for a functional rotator cuff by medializing the center of rotation and tensioning the deltoid, leading to predictable pain relief and improved active elevation. Debridement and biceps tenodesis are palliative and unlikely to restore function. SCR is typically considered in younger, active patients with irreparable tears but without significant glenohumeral arthritis or superior migration. Partial repair or augmentation may be attempted in younger patients with less severe muscle atrophy and without significant cuff tear arthropathy. Latissimus dorsi transfer is an option for irreparable posterosuperior tears, particularly in younger, active patients without advanced arthropathy.

Question 7

A 55-year-old diabetic patient presents with a 6-month history of progressive right cubital tunnel syndrome. Clinical examination reveals severe intrinsic muscle atrophy in the hand (guttering between metacarpals), complete sensory loss in the ulnar nerve distribution, and a positive Froment's sign. Nerve conduction studies (NCS) and electromyography (EMG) confirm severe ulnar neuropathy at the elbow with evidence of axonal loss and denervation changes in the intrinsic muscles. What is the most appropriate surgical approach for this patient?

Explanation

In cases of severe cubital tunnel syndrome with advanced symptoms like intrinsic muscle atrophy, significant sensory loss, and severe axonal loss on NCS/EMG, a more robust decompression and protection of the ulnar nerve is generally recommended. Submuscular anterior transposition offers the most comprehensive decompression and places the nerve in a protective environment away from repetitive stretch and compression at the epicondyle. While in-situ decompression or medial epicondylectomy can be effective for milder to moderate cases, severe neuropathy warrants a more definitive solution to optimize recovery and prevent further deterioration. Conservative management is ineffective for severe, progressive cases.

Question 8

A 50-year-old concert pianist presents with severe, debilitating pain and progressive instability at the base of her right thumb, significantly impacting her ability to play. Radiographs, as shown, confirm Eaton-Littler Stage IV carpometacarpal (CMC) joint arthritis with subluxation and severe joint space narrowing. Conservative management, including injections and splinting, has failed. Maintaining excellent pinch strength and range of motion is paramount for her profession.

Which surgical intervention is most appropriate for this patient?

Explanation

For advanced thumb CMC arthritis (Eaton-Littler Stage IV) in a demanding patient like a concert pianist where motion and strength are critical, ligament reconstruction and tendon interposition (LRTI) arthroplasty is generally considered the gold standard. This procedure involves excision of the trapezium (trapeziectomy) to remove the arthritic joint, followed by reconstruction of the basal thumb ligaments and interposition of a rolled-up portion of the flexor carpi radialis (FCR) tendon. This technique aims to maintain a pain-free, stable, and mobile joint. Arthrodesis provides stability but sacrifices motion, which is unacceptable for a pianist. Trapezial excision alone may lead to shortening and instability. Silicone arthroplasty has fallen out of favor due to potential complications like synovitis and loosening. Osteotomy is typically for early-stage arthritis or deformities.

Question 9

A 35-year-old patient sustains a clean laceration to the palmar aspect of the ring finger at the level of the proximal phalanx (Zone II), resulting in complete transection of both the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons. Primary repair is performed within 6 hours. Which of the following post-operative rehabilitation protocols is generally considered most appropriate and evidence-based for optimizing outcomes in this injury?

Explanation

For flexor tendon repairs, particularly in Zone II, early controlled motion protocols have demonstrated superior outcomes compared to prolonged immobilization. Among these, early active protected motion protocols (such as modified Duran, modified Washington, or similar techniques) are increasingly favored. These protocols involve carefully prescribed active flexion and extension exercises within a protective splint, which helps to minimize adhesion formation, promote tendon gliding, and reduce joint stiffness, without increasing the risk of rupture compared to early passive protocols, assuming good patient compliance and a strong repair. Early passive protected motion (e.g., modified Kleinert) is also acceptable and widely used but may not achieve the same gliding potential as active protocols. Complete immobilization leads to significant stiffness and adhesions. Immediate unrestricted motion would place the repair at high risk of rupture.

Question 10

A 28-year-old male presents to the emergency department 4 hours after a crush injury to his right forearm. He complains of excruciating pain in his forearm, disproportionate to the injury, which is markedly exacerbated by passive extension of his fingers. His forearm is tense and swollen, but radial and ulnar pulses are palpable, and capillary refill is brisk. Sensory examination is normal. What is the most appropriate immediate next step in management?

Explanation

This patient's presentation with severe pain disproportionate to the injury, a tense forearm, and pain with passive stretching of muscles (a classic hallmark sign) are highly suggestive of acute forearm compartment syndrome. Although pulses may still be palpable and sensation initially intact, these are late signs of compartment syndrome. Compartment syndrome is a clinical diagnosis and a surgical emergency. Delay in treatment can lead to irreversible muscle necrosis, nerve damage, and limb dysfunction. Urgent fasciotomy is the definitive treatment to decompress the compartments. NSAIDs, elevation, ice, and imaging studies (like MRI) cause critical delays and are inappropriate in this acute setting. Discharging the patient would be a severe medical error.

Question 11

A 35-year-old male sustains a midshaft clavicle fracture. Which of the following radiographic or clinical findings is the most significant predictor of nonunion with nonoperative management?

Explanation

The most significant risk factors for nonunion in midshaft clavicle fractures include 100% displacement, shortening greater than 2 cm, and comminution. Advanced age and female gender are also associated risk factors.

Question 12

An 80-year-old female with severe rheumatoid arthritis sustains a comminuted intra-articular distal humerus fracture (AO/OTA 13-C3). Radiographs show profound osteopenia. What is the most appropriate surgical management?

Explanation

Total elbow arthroplasty (TEA) is the treatment of choice for elderly patients with complex, comminuted distal humerus fractures and poor bone quality, particularly in the setting of pre-existing rheumatoid arthritis. It allows for early mobilization and predictable pain relief compared to ORIF in osteoporotic bone.

Question 13

A 45-year-old heavy laborer presents with an irreparable massive rotator cuff tear involving the supraspinatus and infraspinatus. The subscapularis and teres minor are intact, and he lacks active external rotation. Which of the following is the most appropriate surgical option?

Explanation

Latissimus dorsi transfer is indicated for younger, active patients with irreparable posterosuperior cuff tears (supraspinatus and infraspinatus) and an intact subscapularis. Pectoralis major transfers are reserved for subscapularis tears, while reverse TSA is generally for older, lower-demand patients or those with arthropathy.

Question 14

A 25-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). Upon initial presentation in the emergency department, he has weak wrist extension and numbness in the first dorsal web space. What is the most appropriate next step in management?

Explanation

A primary radial nerve palsy in the setting of a closed humeral shaft fracture should initially be managed expectantly with a coaptation splint and observation. Surgical exploration is indicated for open fractures, associated vascular injuries, or if the palsy develops after a closed reduction attempt.

Question 15

A 22-year-old male presents with radial-sided wrist pain after a fall. Imaging reveals a displaced fracture of the proximal pole of the scaphoid. Why is this specific fracture pattern at a high risk for avascular necrosis (AVN)?

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters at the distal pole and flows retrograde to the proximal pole. Fractures at the proximal pole disrupt this delicate blood supply, leading to a high rate of avascular necrosis.

Question 16

Following a primary repair of a Zone II flexor tendon injury in the index finger, a patient undergoes an early active mobilization protocol. What is the primary biomechanical advantage of this rehabilitation strategy compared to static immobilization?

Explanation

Early mobilization after flexor tendon repair promotes intrinsic healing within the tendon itself and limits extrinsic healing or adhesions to surrounding tissues. This results in improved tendon gliding and better clinical range of motion without significantly compromising repair strength.

Question 17

A 45-year-old male presents with acute anterior elbow pain and a palpable defect after feeling a 'pop' while lifting a heavy couch. The Hook test is positive. If the surgeon elects to perform a single-incision anterior approach for anatomic repair, which of the following nerves is at highest risk of iatrogenic injury?

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. The posterior interosseous nerve is at higher risk with a two-incision approach.

Question 18

A 22-year-old cyclist sustains a closed midshaft clavicle fracture with 2.5 cm of shortening.

The patient asks about the expected outcome if he chooses non-operative management. Which of the following is the most likely functional deficit associated with non-operative treatment of significantly shortened midshaft clavicle fractures?

Explanation

Midshaft clavicle fractures with shortening greater than 2 cm treated non-operatively are associated with decreased shoulder strength, rapid fatigability, and a higher risk of symptomatic nonunion.

Question 19

A 28-year-old elite volleyball player complains of vague posterior shoulder pain. On examination, he has full active abduction but marked weakness in external rotation. MRI reveals a paralabral cyst at the spinoglenoid notch. Which muscle(s) will show denervation changes on EMG?

Explanation

The suprascapular nerve innervates the supraspinatus before passing through the spinoglenoid notch. Compression at the spinoglenoid notch only affects the infraspinatus, leading to isolated external rotation weakness.

Question 20

A 35-year-old male presents to the ER after a generalized seizure. His arm is locked in internal rotation and he cannot passively externally rotate past 0 degrees. An AP radiograph shows a symmetric, rounded humeral head ('lightbulb sign').

CT imaging is obtained. What specific osseous defect is most likely to be present on the humeral head?

Explanation

Posterior shoulder dislocations are classically associated with a 'Reverse Hill-Sachs' lesion, which is an impaction fracture on the anteromedial aspect of the humeral head caused by the posterior glenoid rim.

Question 21

A 21-year-old male falls on an outstretched hand and presents with anatomic snuffbox tenderness. Imaging confirms an acute, displaced fracture of the proximal pole of the scaphoid.

What is the most appropriate surgical approach for this specific fracture pattern, and why?

Explanation

Proximal pole scaphoid fractures are best approached dorsally to allow for accurate screw trajectory (perpendicular to the fracture) while preserving the tenuous retrograde blood supply entering distally.

Question 22

A 30-year-old carpenter presents with progressive, activity-related dorsal wrist pain. Radiographs reveal sclerosis, fragmentation, and collapse of the lunate (Kienböck's disease stage IIIA), with an ulnar variance of -3 mm. What is the most appropriate primary surgical intervention?

Explanation

In Kienböck's disease with ulnar negative variance and an intact lunate cartilage shell without secondary osteoarthritis (Stage IIIA), a joint-leveling procedure such as a radial shortening osteotomy is indicated to offload the lunate.

Question 23

A 65-year-old osteoporotic female presents with a distal radius fracture featuring a displaced volar intra-articular fragment (Volar Barton's fracture).

If this fracture is treated with a dorsal spanning plate instead of a volar buttress plate, what is the most likely mechanism of failure?

Explanation

A Volar Barton's fracture is a shear fracture. It must be neutralized with a volar buttress plate; treating it from the dorsal side alone is biomechanically insufficient to resist the volar shear forces.

Question 24

A 28-year-old male falls from a roof. His lateral wrist radiograph demonstrates a 'spilled teacup' sign, with the capitate displaced dorsally to the lunate.

Which peripheral nerve is at the highest acute risk of compression in this clinical scenario?

Explanation

This describes a perilunate/lunate dislocation. The volarly displaced lunate severely compromises the carpal tunnel, placing the median nerve at acute risk for compression and necessitating emergent reduction.

Question 25

A 55-year-old female presents with bilateral base of thumb pain, positive grind tests, and radiographic evidence of severe trapeziometacarpal joint space narrowing, osteophytes, and subchondral sclerosis (Eaton-Littler Stage III). Conservative management has failed. What is the gold standard surgical treatment?

Explanation

For advanced thumb CMC osteoarthritis (Eaton Stage III) failing conservative treatment, trapeziectomy with or without Ligament Reconstruction and Tendon Interposition (LRTI) is the standard surgical option.

Question 26

A 32-year-old mechanic presents with an infected index finger after a puncture wound. Which of the following is NOT one of Kanavel's cardinal signs for acute pyogenic flexor tenosynovitis?

Explanation

Kanavel's signs include: flexed posture, fusiform swelling, tenderness over the flexor sheath, and pain with passive extension. Erythema tracking proximally indicates lymphangitis, not tenosynovitis.

Question 27

A 30-year-old male sustains a closed spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). On presentation, he exhibits a complete radial nerve palsy. What is the most appropriate initial management?

Explanation

Primary radial nerve palsies with closed humeral shaft fractures typically recover spontaneously (neurapraxia). Initial management is non-operative with functional bracing and clinical observation for 3-4 months.

Question 28

A 21-year-old collegiate baseball pitcher reports medial elbow pain during the late cocking and early acceleration phases of throwing. MRI confirms a full-thickness tear of the anterior bundle of the ulnar collateral ligament (UCL). To correctly reconstruct this ligament, where must the ulnar tunnel be primarily centered?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow, and it inserts distally on the sublime tubercle of the proximal ulna.

Question 29

A 45-year-old heavy laborer presents with deep shoulder pain and mechanical catching. MRI arthrogram reveals a Type II SLAP tear. Given his age and occupational demands, current literature suggests which surgical intervention provides the most reliable return to work and pain relief?

Explanation

Recent literature demonstrates that patients over the age of 40, especially laborers, have higher complication rates and stiffness with SLAP repairs. Biceps tenodesis provides superior, reliable outcomes in this demographic.

Question 30

A 25-year-old rugby player sustains a Type V acromioclavicular (AC) joint separation, characterized by >100% superior displacement of the clavicle into the trapezius fascia. What is the most widely accepted surgical approach for this severe injury?

Explanation

Type IV, V, and VI AC separations are indications for operative management due to severe displacement and soft tissue disruption. This requires robust reconstruction of the coracoclavicular (CC) ligaments.

Question 31

A 30-year-old powerlifter feels a tearing sensation in his anterior chest while performing a heavy bench press. Examination reveals loss of the anterior axillary fold. When evaluating a pectoralis major rupture, where does the failure most commonly occur?

Explanation

Pectoralis major ruptures almost exclusively occur in the sternal head, most commonly at its tendinous insertion on the lateral lip of the bicipital groove of the humerus.

Question 32

A 25-year-old military recruit presents with aching shoulder pain and notable medial prominence of his right scapula (medial winging) when asked to perform a wall push-up. Which nerve is most likely injured?

Explanation

Medial scapular winging is caused by serratus anterior paralysis due to long thoracic nerve palsy. Lateral winging is associated with trapezius dysfunction from spinal accessory nerve injury.

Question 33

A 35-year-old skier falls while holding his pole, sustaining a hyperabduction injury to the thumb. Clinical examination reveals gross laxity of the metacarpophalangeal (MCP) joint to valgus stress. A Stener lesion is suspected. What anatomical structure prevents spontaneous healing of the torn ulnar collateral ligament (UCL) in this lesion?

Explanation

A Stener lesion occurs when the torn UCL displaces superficial to the adductor pollicis aponeurosis. The aponeurosis physically blocks the ligament from returning to its insertion site, mandating surgical repair.

Question 34

A 24-year-old male is trapped under heavy machinery, resulting in a severe crush injury to his forearm. On examination, he has extreme pain with passive extension of his fingers. In acute compartment syndrome of the volar forearm, which muscle is most susceptible to irreversible ischemia and subsequent Volkmann's contracture?

Explanation

The deep compartment of the volar forearm is the most severely affected in ischemic contracture. The flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) are the most profoundly involved muscles.

Question 35

A 20-year-old rugby player presents with the inability to actively flex the DIP joint of his ring finger after grabbing an opponent's jersey. Radiographs show a small bony avulsion fragment localized at the level of the PIP joint. What is the correct classification and recommended timeline for repair?

Explanation

This is a Leddy-Packer Type II 'Jersey Finger' (avulsion retracts to the PIP level, held by the intact vinculum longum). Blood supply is preserved enough to allow repair up to 3-4 weeks post-injury.

Question 36

A patient presents with a 'terrible triad' of the elbow, which includes a posterior dislocation, radial head fracture, and coronoid fracture. When performing surgical reconstruction for this injury complex, what is the standard, biomechanically validated sequence of fixation?

Explanation

The standard surgical algorithm for the terrible triad works deep to superficial and anterior to posterior: fix the coronoid first, replace or fix the radial head second, and finally repair the LCL complex.

Question 37

A 42-year-old male bodybuilder feels a 'pop' in his antecubital fossa while performing heavy deadlifts. Clinical examination reveals a positive hook test. If a single-incision anterior surgical approach is chosen for repair, which structure is at the greatest risk of iatrogenic injury?

Explanation

The lateral antebrachial cutaneous (LABC) nerve is the most commonly injured structure during a single-incision anterior approach for distal biceps repair. In contrast, the posterior interosseous nerve (PIN) is at higher risk during a two-incision approach if retractors are improperly placed.

Question 38

Reverse total shoulder arthroplasty (RTSA) is indicated for a 72-year-old with pseudoparalysis secondary to a massive irreparable rotator cuff tear. How does RTSA alter the shoulder biomechanics to allow the deltoid to initiate abduction?

Explanation

RTSA medializes and distalizes the center of rotation of the glenohumeral joint. This increases the lever arm of the deltoid and recruits more deltoid fibers, allowing it to initiate and power abduction in a cuff-deficient shoulder.

Question 39

A 35-year-old male sustains a distal third spiral humeral shaft fracture (Holstein-Lewis). Upon arrival at the emergency department, he is unable to extend his wrist or fingers. Closed reduction and splinting are performed, but post-reduction examination shows no change in his neurologic status. What is the most appropriate next step in management?

Explanation

Primary radial nerve palsy associated with a closed humeral shaft fracture is typically managed with observation, as 70-90% will spontaneously recover. Surgical exploration is indicated for open fractures, secondary nerve palsies (loss of function after reduction), or failure to improve clinically or on EMG by 3 to 4 months.

Question 40

A 60-year-old female undergoes volar locking plate fixation for a displaced distal radius fracture. Six months postoperatively, she presents with an inability to actively flex the interphalangeal joint of her thumb. What is the most likely cause?

Explanation

Placement of a volar plate distal to the watershed line increases the risk of flexor tendon irritation and rupture. The Flexor Pollicis Longus (FPL) is the most commonly ruptured tendon due to its anatomical proximity to the prominent distal edge of the plate.

Question 41

A 40-year-old male presents with severe wrist and elbow pain after falling from a ladder. Radiographs reveal a comminuted, unsalvageable radial head fracture. Wrist examination demonstrates DRUJ instability. Which of the following is absolutely contraindicated?

Explanation

This patient has an Essex-Lopresti injury (radial head fracture, interosseous membrane tear, and DRUJ disruption). Radial head excision alone is contraindicated as it removes the primary restraint to proximal radial migration, leading to chronic wrist pain and ulnar impaction.

Question 42

A 22-year-old male presents with a nonunion of a proximal pole scaphoid fracture 8 months after the initial injury. MRI reveals avascular necrosis (AVN) of the proximal pole. What is the most appropriate surgical management?

Explanation

For a scaphoid nonunion with avascular necrosis of the proximal pole, a vascularized bone graft (such as the medial femoral condyle) is indicated to restore blood supply and promote healing. Non-vascularized grafts have a high failure rate in the presence of AVN.

Question 43

A 19-year-old male rugby player sustains a direct blow to the medial clavicle, resulting in a posterior sternoclavicular dislocation. He complains of mild dysphagia but has normal vital signs. What is the most appropriate initial management step?

Explanation

Posterior sternoclavicular dislocations can compress critical mediastinal structures (trachea, esophagus, great vessels). Closed reduction should be attempted in the operating room under general anesthesia with a cardiothoracic surgeon available in case of catastrophic vascular injury during reduction.

Question 44

During an in situ ulnar nerve decompression at the elbow, the surgeon must release multiple potential sites of compression. Which of the following is the most proximal site of potential ulnar nerve entrapment?

Explanation

The Arcade of Struthers is a fascial band located approximately 8 cm proximal to the medial epicondyle and represents the most proximal potential site for ulnar nerve entrapment at the elbow. Note that the Ligament of Struthers is associated with median nerve compression.

Question 45

A 32-year-old carpenter presents with chronic dorsal wrist pain. Radiographs demonstrate Kienbock's disease with sclerosis of the lunate, no lunate collapse, and ulnar minus variance. What is the most appropriate surgical treatment?

Explanation

In early Kienbock's disease (Lichtman Stage I or II) without lunate collapse and with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy unloads the lunate to halt disease progression.

Question 46

Which of the following is an absolute indication for open reduction and internal fixation of an acute midshaft clavicle fracture?

Explanation

Open fracture, skin tenting leading to necrosis, and neurovascular compromise are absolute indications for ORIF of a midshaft clavicle fracture. Shortening and displacement are relative indications based on an increased risk of nonunion or symptomatic malunion.

Question 47

A 25-year-old elite overhead throwing athlete undergoes arthroscopy for a symptomatic Type II SLAP tear that failed conservative management. What is the pathomechanical basis of this injury during the late cocking phase of throwing?

Explanation

The 'peel-back' mechanism occurs during the late cocking phase of throwing (maximum abduction and external rotation), placing a torsional force on the biceps anchor that dynamically peels the superior labrum off the glenoid rim.

Question 48

A 6-year-old child sustains a Bado Type I Monteggia fracture-dislocation. Closed reduction of the ulna fracture is achieved, but the radial head remains anteriorly dislocated. What is the most likely blocking structure preventing radial head reduction?

Explanation

In Monteggia fracture-dislocations, the annular ligament can become interposed or wrapped around the radial head, acting as a physical block to closed reduction of the radiocapitellar joint.

Question 49

A 50-year-old diabetic female presents with 'frozen shoulder'. She has significant limitation of passive external rotation with the arm at the side. Contracture of which of the following structures is primarily responsible for this specific physical exam finding?

Explanation

Contracture of the coracohumeral ligament within the rotator interval is the primary restrictor of passive external rotation when the arm is adducted at the patient's side.

Question 50

A 55-year-old female presents with base of thumb pain. Radiographs reveal Eaton-Littler Stage III basal joint arthritis. She is scheduled for a ligament reconstruction and tendon interposition (LRTI). Which tendon is most commonly harvested for this procedure?

Explanation

The flexor carpi radialis (FCR) is the most frequently harvested tendon for an LRTI procedure to stabilize the thumb metacarpal base after trapeziectomy, reconstructing the beak ligament.

Question 51

A 42-year-old female presents with chronic lateral elbow pain. She has point tenderness 4 cm distal to the lateral epicondyle. Pain is exacerbated by resisted extension of the middle finger with the elbow extended. What is the most likely site of nerve compression?

Explanation

The patient's presentation is consistent with radial tunnel syndrome. The most common site of compression of the posterior interosseous nerve (PIN) in radial tunnel syndrome is the Arcade of Frohse, the proximal fascial edge of the supinator muscle.

Question 52

Tension band wiring is an accepted treatment for simple transverse olecranon fractures. This fixation principle converts which type of force at the articular surface into compressive forces during active elbow flexion?

Explanation

The tension band principle relies on placing fixation (wires) on the tension side (dorsal cortex) of the bone. During active triceps contraction and elbow flexion, the tensile forces are converted into dynamic compressive forces at the articular surface.

Question 53

A 48-year-old female presents with numbness in her thumb, index, and middle fingers. Phalen's test is negative, but she has a positive Tinel's sign in the proximal forearm. She also reports pain in the proximal forearm with resisted forearm pronation. Which condition is most likely?

Explanation

Pronator teres syndrome is a proximal median nerve entrapment characterized by vague volar forearm pain and paresthesias in the median nerve distribution. It is differentiated from carpal tunnel syndrome by a negative Phalen's test and pain with resisted pronation.

Question 54

A 45-year-old weightlifter presents with a sudden 'pop' and ecchymosis in his right antecubital fossa. A reverse Popeye sign is noted. He undergoes a single-incision anterior approach for distal biceps tendon repair. Which of the following neurologic structures is at the highest risk of injury during this specific surgical approach?

Explanation

The lateral antebrachial cutaneous nerve is the most commonly injured structure during a single-incision anterior approach for distal biceps repair due to its superficial course laterally. The posterior interosseous nerve is more at risk during a two-incision approach.

Question 55

A 40-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with advanced radioscaphoid arthritis and narrowing of the capitolunate joint space, but preservation of the radiolunate articulation. Which of the following is the most appropriate surgical intervention?

Explanation

The clinical scenario describes a Stage III Scaphoid Nonunion Advanced Collapse (SNAC) wrist, featuring capitolunate arthritis. Proximal row carpectomy is contraindicated when capitate arthrosis is present, making four-corner fusion the treatment of choice.

Question 56

A 22-year-old collegiate baseball pitcher reports medial elbow pain during the late cocking and early acceleration phases of throwing. On examination, he has valgus laxity when the elbow is flexed between 30 and 120 degrees. Which specific anatomical structure is most likely compromised?

Explanation

The anterior bundle of the ulnar collateral ligament is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion, which is critical during the throwing motion.

Question 57

A 32-year-old male sustains a closed distal-third humeral shaft fracture (Holstein-Lewis type). On initial evaluation, his radial nerve function is completely intact. Following closed reduction and splint application, he is found to have an inability to extend his wrist and fingers. What is the most appropriate next step in management?

Explanation

A secondary radial nerve palsy that develops immediately after a closed reduction attempt of a humeral shaft fracture is an absolute indication for surgical exploration, as the nerve may be entrapped in the fracture site.

Question 58

A 25-year-old tennis player complains of shoulder weakness and a prominent shoulder blade following a viral illness. On physical examination, forward elevation of the arm against resistance demonstrates pronounced medial winging of the scapula. An injury to which of the following nerves is the most likely cause of this clinical presentation?

Explanation

Medial winging of the scapula is caused by serratus anterior paralysis, which is innervated by the long thoracic nerve. Lateral winging is typically associated with spinal accessory nerve palsies affecting the trapezius.

Question 59

A 65-year-old female presents with an inability to flex her thumb interphalangeal joint six months after undergoing volar plate fixation for a distal radius fracture. Radiographs indicate the plate is positioned distally, bridging the watershed line. Which of the following tendons is most likely ruptured?

Explanation

Placement of a volar plate distal to the watershed line of the distal radius increases the risk of flexor tendon irritation and rupture. The flexor pollicis longus (FPL) is the most frequently ruptured tendon in this scenario.

Question 60

A 58-year-old female with advanced base of thumb arthritis undergoes a ligament reconstruction and tendon interposition (LRTI) procedure using the flexor carpi radialis (FCR) tendon. Which primary stabilizing ligament of the first carpometacarpal joint is this procedure attempting to reconstruct?

Explanation

The LRTI procedure primarily aims to reconstruct the anterior oblique ligament (often called the beak ligament), which is the primary restraint to dorsal subluxation of the first carpometacarpal joint.

Question 61

A 34-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate, with an ulnar variance of minus 3 mm. Advanced imaging confirms stage IIIA Kienböck's disease without carpal collapse. Which of the following is the most appropriate surgical treatment?

Explanation

In Stage IIIA Kienböck's disease with ulnar negative variance, joint-leveling procedures (like radial shortening osteotomy) are indicated to mechanically offload the lunate and prevent progression to carpal collapse.

Question 62

In the evaluation of a displaced proximal humerus fracture, which of the following radiographic criteria is the most reliable predictor of subsequent avascular necrosis of the humeral head?

Explanation

The Hertel criteria for predicting ischemia and avascular necrosis in proximal humerus fractures include a metaphyseal head extension (calcar length) of less than 8 mm and disruption of the medial hinge.

Question 63

A 25-year-old male presents with persistent wrist pain 18 months after a fall onto an outstretched hand. Radiographs and subsequent MRI reveal a scaphoid proximal pole nonunion with signs of avascular necrosis, but no evidence of radiocarpal arthritis. What is the most appropriate surgical management?

Explanation

Proximal pole scaphoid nonunions with avascular necrosis and no arthritis are best treated with a vascularized bone graft (e.g., 1,2 ICSRA or medial femoral condyle). Non-vascularized grafts have a high failure rate in the setting of AVN.

Question 64

During an anterior single-incision surgical repair of a distal biceps tendon rupture, the patient is at highest risk for injury to a specific peripheral nerve. Injury to this nerve typically results in which of the following clinical deficits?

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision distal biceps repair. Injury results in numbness over the lateral (radial) aspect of the forearm.

Question 65

A 32-year-old male sustains a closed, isolated, distal third spiral fracture of the humeral shaft (Holstein-Lewis fracture). On initial presentation, he is unable to actively extend his wrist or fingers. What is the most appropriate initial management?

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture is typically a neuropraxia and is managed observationally. If there is no clinical improvement by 6 weeks, baseline EMG/NCS should be obtained.

Question 66

A 28-year-old female undergoes open reduction and internal fixation of a displaced midshaft clavicle fracture. Postoperatively, she has normal motor function but complains of significant numbness over the anterior chest wall immediately inferior to the surgical incision. Injury to which nerve is the most likely cause?

Explanation

The supraclavicular nerve branches cross over the clavicle and are frequently sacrificed or injured during standard surgical approaches to the midshaft clavicle. This results in an expected area of numbness over the anterior chest wall.

Question 67

A 72-year-old male presents with severe shoulder pain and an inability to actively elevate his arm above 40 degrees. Deltoid function is intact. Radiographs reveal advanced glenohumeral arthritis with severe superior migration of the humeral head (acetabularization of the coracoacromial arch).

What is the most appropriate definitive management?

Explanation

The patient has classic rotator cuff arthropathy with pseudoparalysis. Reverse total shoulder arthroplasty (RTSA) is the treatment of choice as it alters the center of rotation, allowing the intact deltoid to initiate and maintain shoulder elevation.

Question 68

A 30-year-old male with a severe traumatic brain injury sustains an elbow dislocation. He subsequently develops severe heterotopic ossification (HO) bridging the radiocapitellar joint, causing a rigid block to forearm rotation. When is the optimal time for surgical excision of the HO?

Explanation

Modern guidelines suggest HO excision can be safely performed once it is radiographically mature (sharp margins, distinct trabecular pattern), typically around 4-6 months. A normal alkaline phosphatase level is no longer considered a strict prerequisite.

Question 69

Six weeks after completing conservative management in a cast for a non-displaced distal radius fracture, a 55-year-old female experiences a sudden, painless inability to extend her thumb interphalangeal joint. What is the most appropriate surgical treatment?

Explanation

Delayed rupture of the extensor pollicis longus (EPL) tendon is a known complication of non-displaced distal radius fractures. Because the tendon ends are typically attritional and retracted, primary repair is usually impossible, making an EIP to EPL tendon transfer the gold standard.

Question 70

A 45-year-old male presents with weakness in his intrinsic hand muscles and numbness in his small and ring fingers. Froment's sign is positive. Intraoperative exploration of the ulnar nerve at the elbow reveals compression by an anomalous muscle bridging the medial epicondyle and the olecranon. What is the name of this anatomical structure?

Explanation

The anconeus epitrochlearis is an anomalous muscle present in a small percentage of the population that can cause cubital tunnel syndrome. It replaces the Osborne ligament, forming a muscular roof over the ulnar nerve at the elbow.

Question 71

A 22-year-old overhead throwing athlete complains of deep shoulder pain during the late cocking phase of throwing. MR arthrography reveals a Type II Superior Labrum Anterior to Posterior (SLAP) tear. Which of the following best describes the specific anatomical pathology of a Type II SLAP lesion?

Explanation

A Type II SLAP tear involves detachment of the superior labrum and the biceps anchor from the superior glenoid tubercle. This results in superior labral instability, particularly during the peel-back mechanism in overhead sports.

Question 72

A 30-year-old male sustains a forced hyperabduction injury to his thumb metacarpophalangeal (MCP) joint while skiing. MRI confirms a complete tear of the ulnar collateral ligament (UCL) with the adductor aponeurosis interposed between the ruptured ligament and its anatomical insertion. What is this lesion called, and what is the indicated management?

Explanation

A Stener lesion occurs when the torn UCL displaces superficial to the adductor aponeurosis, preventing anatomical healing. It is an absolute indication for surgical repair.

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