Orthopedic With Answer Upper L Review | Dr Hutaif Gener -...

Question 1

A 24-year-old male presents after a high-speed motorcycle accident with a flail right arm. On examination, he has ptosis, miosis, and anhidrosis on the right side of his face. Which of the following MRI findings is most consistent with this clinical presentation?

Explanation

Horner's syndrome (ptosis, miosis, anhidrosis) in the setting of a brachial plexus injury is pathognomonic for a preganglionic root avulsion of C8 and T1, as the sympathetic chain is disrupted proximal to the dorsal root ganglion.

Question 2

A 22-year-old collegiate rugby player sustains a recurrent anterior shoulder dislocation. A 3D CT scan reveals 25% anterior glenoid bone loss. Which of the following surgical procedures is most appropriate to minimize recurrence?

Explanation

In the setting of significant anterior glenoid bone loss (>20-25%), soft tissue stabilization alone (Bankart repair) has unacceptably high failure rates. A bone-block procedure, such as the Latarjet (coracoid transfer), is indicated to restore the glenoid articular arc and provide a sling effect via the conjoint tendon.

Question 3

A 35-year-old cyclist falls onto his shoulder and sustains a closed, displaced midshaft clavicle fracture. Which of the following represents an absolute indication for immediate operative fixation?

Explanation

Absolute indications for operative fixation of clavicle fractures include open fractures, impending skin necrosis (severe tenting with ischemia), associated vascular injury, and symptomatic nonunion. Shortening > 2 cm, severe comminution, and 100% displacement are strong but relative indications.

Question 4

A 45-year-old male weightlifter presents with vague posterior shoulder pain and isolated weakness in external rotation. An MRI demonstrates an isolated paralabral cyst in the spinoglenoid notch. Which muscle is most likely to show denervation changes on EMG?

Explanation

A cyst at the spinoglenoid notch compresses the suprascapular nerve after it has already given off motor branches to the supraspinatus, leading to isolated denervation and weakness of the infraspinatus. Entrapment further proximally at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 5

In the evaluation of a displaced proximal humerus fracture, which of the following radiographic factors is most predictive of subsequent humeral head ischemia (avascular necrosis)?

Explanation

According to Hertel's criteria, the best predictors of humeral head ischemia are a short metaphyseal head extension (calcar length attached to the articular surface) of < 8 mm, a disrupted medial hinge, and an anatomic basicervical fracture line.

Question 6

A 28-year-old female sustains a closed midshaft humerus fracture. Her initial neurovascular examination in the emergency department is entirely intact. Following a closed reduction and application of a coaptation splint, she develops a complete wrist drop and inability to extend her MCP joints. What is the most appropriate next step in management?

Explanation

A secondary radial nerve palsy (one that develops after a closed reduction attempt) is a well-accepted absolute indication for surgical exploration of the nerve and internal fixation of the fracture, as the nerve may have become entrapped in the fracture site during manipulation.

Question 7

When surgically managing a 'terrible triad' injury of the elbow, which of the following represents the most accepted standard sequence of repair to restore elbow stability?

Explanation

The standard surgical algorithm for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) proceeds from deep to superficial: first addressing the coronoid, then repairing or replacing the radial head, and finally repairing the lateral collateral ligament (LCL) complex. The MCL is typically only repaired if the elbow remains persistently unstable after these lateral and anterior structures are restored.

Question 8

A 34-year-old female falls onto an outstretched hand and sustains a capitellum fracture. Radiographs and CT show a coronal shear fracture that involves the capitellum and extends medially to include the majority of the trochlea. According to the Bryan-Morrey classification (incorporating the McKee modification), what type of fracture is this?

Explanation

The McKee modification of the Bryan-Morrey classification adds Type IV, which describes a coronal shear fracture involving the capitellum that extends medially to include most or all of the trochlea, often referred to as a capitellotrochlear fracture.

Question 9

A 65-year-old female sustains an undisplaced distal radius fracture and is treated non-operatively in a cast. Six weeks later, she complains of a sudden, painless inability to actively extend her thumb at the interphalangeal joint. What is the primary pathomechanism of this complication?

Explanation

Extensor pollicis longus (EPL) rupture is a classic complication of undisplaced or minimally displaced distal radius fractures. It typically occurs 4-8 weeks post-injury due to a combination of mechanical attrition over Lister's tubercle and ischemia within the intact third dorsal compartment, secondary to hematoma and localized swelling.

Question 10

A 40-year-old man presents with chronic wrist pain and is diagnosed with a Scaphoid Nonunion Advanced Collapse (SNAC). Radiographs show arthritis strictly limited to the radioscaphoid joint, with preservation of the midcarpal joint. Which stage of SNAC wrist does this represent, and what is the most appropriate surgical treatment?

Explanation

SNAC Stage I involves arthritis isolated to the radioscaphoid articulation (specifically between the radial styloid and the distal scaphoid fragment). Treatment for Stage I is typically a radial styloidectomy combined with bone grafting and fixation of the scaphoid nonunion. Progression to involve the scaphocapitate joint marks Stage II, requiring salvage procedures like PRC or four-corner fusion.

Question 11

A 28-year-old carpenter with persistent dorsal wrist pain is diagnosed with Kienböck's disease (Lichtman Stage II). Radiographs demonstrate ulnar negative variance of 3 mm. Which surgical intervention is the most appropriate initial management?

Explanation

In early-stage Kienböck's disease (Lichtman Stage II or IIIa) with ulnar negative variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. This mechanically unloads the lunate to halt disease progression. Capitate shortening or radial wedge osteotomies are preferred when variance is neutral or positive.

Question 12

A 32-year-old tennis player presents with ulnar-sided wrist pain. An MRI arthrogram reveals a tear of the triangular fibrocartilage complex (TFCC) at its ulnar peripheral attachment without bony avulsion. According to the Palmer classification, what is this tear type, and is it generally amenable to direct primary repair?

Explanation

Palmer 1B tears are traumatic tears of the peripheral ulnar attachment of the TFCC. Because this peripheral zone receives adequate vascular supply, these tears have excellent healing potential and are highly amenable to direct surgical repair. In contrast, 1A tears are central and avascular, requiring debridement.

Question 13

During an open carpal tunnel release, the surgeon notes a highly branched recurrent motor branch of the median nerve that directly pierces the transverse carpal ligament. According to the Lanz classification of median nerve variations, which anatomic group does this represent?

Explanation

The Lanz classification describes variations of the recurrent motor branch. Group 1 is the normal extraligamentous course (recurrent branch loops around the distal edge). Group 2 is a subligamentous course. Group 3 is the transligamentous variant, where the motor branch pierces the flexor retinaculum, placing it at high risk during carpal tunnel release.

Question 14

In the digital flexor tendon sheath, which of the following annular pulleys are biomechanically the most critical to prevent tendon bowstringing and must be preserved or reconstructed during flexor tendon surgery?

Explanation

The A2 pulley (located over the proximal half of the proximal phalanx) and the A4 pulley (located over the middle third of the middle phalanx) are the most critical biomechanical components of the flexor pulley system. Sacrificing them leads to significant bowstringing of the flexor tendons and a severe loss of active interphalangeal joint motion.

Question 15

A patient presents to the emergency department with a swollen, acutely painful index finger after a puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of pyogenic flexor tenosynovitis?

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are: 1) fusiform (sausage-like) swelling, 2) tenderness along the flexor sheath, 3) posture of the digit in slight flexion, and 4) severe pain on PASSIVE (not active) extension. Active motion is generally painful, but exquisite pain on passive extension is the hallmark sign.

Question 16

A 60-year-old female with advanced Eaton Stage III basal joint arthritis of the thumb undergoes a ligament reconstruction and tendon interposition (LRTI) arthroplasty. Which tendon is most commonly harvested and utilized for the reconstruction phase in this specific procedure?

Explanation

In the Burton-Pellegrini LRTI procedure, the flexor carpi radialis (FCR) tendon is most commonly harvested (either completely or a distally-based slip) to reconstruct the anterior oblique ligament (beak ligament) and provide a biologic interpositional spacer in the void left by the trapeziectomy.

Question 17

A skier presents with a traumatic abduction injury to the thumb metacarpophalangeal (MCP) joint. MRI confirms a complete rupture of the ulnar collateral ligament (UCL) with a Stener lesion. Which anatomic structure is interposed between the torn UCL ends in a Stener lesion?

Explanation

A Stener lesion occurs when the completely avulsed distal end of the ulnar collateral ligament of the thumb MCP joint displaces superficial to the adductor pollicis aponeurosis. This interposition mechanically blocks the UCL from returning to its anatomic insertion, preventing healing and establishing an absolute indication for surgical repair.

Question 18

During surgical fasciectomy for Dupuytren's contracture, the surgeon dissects out the spiral cord. The spiral cord characteristically displaces the neurovascular bundle in which direction, placing it at increased risk of iatrogenic injury?

Explanation

The spiral cord in Dupuytren's disease forms via the coalescence of the pretendinous band, spiral nerve, lateral digital sheet, and Grayson's ligament. As it pathologically contracts, it spirals around the neurovascular bundle, displacing the bundle centrally towards the midline, superficially towards the skin, and proximally, placing it at high risk during excision.

Question 19

A patient is evaluated in the clinic for an inability to make an 'OK' sign with the thumb and index finger. Neurological examination reveals normal sensation throughout the entire hand and digits. Which of the following muscles is primarily affected by this specific nerve palsy?

Explanation

Anterior interosseous nerve (AIN) syndrome is a pure motor neuropathy that affects the flexor pollicis longus (FPL), flexor digitorum profundus (FDP) to the index and middle fingers, and the pronator quadratus. Weakness of the FPL and FDP prevents terminal IP joint flexion of the thumb and index finger, destroying the 'OK' sign. Sensation is spared because the AIN carries no cutaneous sensory fibers.

Question 20

A 6-year-old boy falls off monkey bars and sustains a Bado Type I Monteggia fracture equivalent. What is the defining radiographic feature of a classical Bado Type I lesion?

Explanation

The Bado classification describes Monteggia fracture-dislocations (ulnar shaft fracture with radial head dislocation). Type I, the most common type, is characterized by an anterior dislocation of the radial head and anterior angulation of the ulnar shaft fracture. Type II is posterior, Type III is lateral, and Type IV involves fractures of both the radius and ulna with an associated radial head dislocation.

Question 21

A 25-year-old motorcyclist presents with a flail upper limb after a high-speed collision. Physical examination reveals complete motor and sensory loss of the right upper extremity, ptosis, miosis, and anhidrosis on the right side of the face. A histamine test produces a flare response in the anesthetic C5-T1 dermatomes. What is the most likely anatomic level of this nerve injury?

Explanation

The presence of Horner's syndrome (ptosis, miosis, anhidrosis) and an intact histamine flare test in an anesthetic area indicates a preganglionic root avulsion injury. The intact flare test demonstrates that the sensory cell bodies in the dorsal root ganglion and their distal axons are intact, meaning the lesion is proximal to the DRG (preganglionic).

Question 22

A 35-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). On initial evaluation in the ER, he is noted to have a dense radial nerve palsy. He is placed in a coaptation splint. At his 2-week follow-up, the radial nerve palsy persists, and radiographs show acceptable fracture alignment. What is the most appropriate management regarding the nerve palsy?

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture (including Holstein-Lewis) is initially managed with observation. Spontaneous recovery occurs in over 90% of cases. Immediate exploration is generally not indicated for closed fractures unless the palsy occurs secondary to a closed reduction maneuver. EMG/NCS is typically delayed until 6-12 weeks if no clinical improvement is seen.

Question 23

A 45-year-old manual laborer presents with chronic progressive wrist pain. Radiographs demonstrate a scaphoid nonunion with radioscaphoid arthritis, but the capitolunate and radiolunate joints are preserved. According to the SNAC (Scaphoid Nonunion Advanced Collapse) classification, what is the optimal surgical treatment?

Explanation

SNAC stage II involves radioscaphoid arthritis with preserved radiolunate and capitolunate joints. Since the capitate is intact and unaffected by arthritis, a four-corner fusion with scaphoid excision is an excellent option to preserve motion while addressing the arthritic radioscaphoid joint. PRC is relatively contraindicated if capitate arthritis is present (SNAC III), though it can be used in some Stage II cases; four-corner fusion is the classic standard answer for preserving the radiolunate articulation.

Question 24

A 65-year-old female sustains a distal radius fracture. Closed reduction is performed. Which of the following radiographic parameters falls OUTSIDE the acceptable criteria for non-operative management of a distal radius fracture in an active patient?

Explanation

Acceptable radiographic parameters for non-operative management of distal radius fractures typically include: radial height >9 mm, radial inclination >15 degrees, intra-articular step-off <2 mm, and sagittal tilt between 15 degrees volar and neutral (0 degrees). A dorsal tilt of 15 degrees is unacceptable and is associated with poor outcomes and altered carpal biomechanics, typically indicating a need for operative intervention.

Question 25

A 72-year-old female presents with chronic shoulder pseudoparalysis and severe pain. Radiographs show superior migration of the humeral head with articulation against the acromion, and acetabularization of the coracoacromial arch (Hamada Stage 3). An MRI confirms a massive, irreparable rotator cuff tear. What is the most appropriate surgical intervention?

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for rotator cuff tear arthropathy with pseudoparalysis in older patients. It relies on the deltoid muscle to elevate the arm by medializing and distalizing the center of rotation, which increases the deltoid's moment arm. Anatomic TSA is contraindicated due to the deficient rotator cuff leading to early eccentric glenoid failure (the 'rocking horse' phenomenon).

Question 26

A 40-year-old male sustains a 'terrible triad' injury of the elbow after a fall on an outstretched hand. During surgical reconstruction, what is the classically recommended sequence of repair to restore elbow stability?

Explanation

The classic surgical sequence for a terrible triad injury of the elbow (coronoid fracture, radial head fracture, LCL tear) is to repair from deep to superficial: the coronoid fracture is addressed first, followed by the radial head (fixation or arthroplasty), and finally the lateral collateral ligament (LCL) complex. MCL repair or external fixation is reserved for persistent instability after these steps.

Question 27

A 45-year-old bodybuilder undergoes repair of a retracted distal biceps tendon rupture using a two-incision technique. Postoperatively, the patient reports an inability to extend the fingers and thumb, though wrist extension is preserved with radial deviation. Which nerve was most likely injured, and what is the mechanism in this surgical approach?

Explanation

The two-incision technique for distal biceps repair carries a specific risk of injuring the Posterior Interosseous Nerve (PIN) during the posterior approach if the supinator muscle is not split properly or if the forearm is not fully pronated (which draws the PIN away from the surgical field). PIN palsy presents with loss of finger and thumb extension, while ECRL (innervated by the radial nerve proper) preserves radially-deviated wrist extension.

Question 28

A 60-year-old postmenopausal woman presents with base of thumb pain. Radiographs demonstrate Eaton-Littler Stage III trapeziometacarpal joint arthritis with a >30-degree hyperextension deformity of the metacarpophalangeal (MCP) joint. In addition to a ligament reconstruction and tendon interposition (LRTI), what concomitant procedure is highly recommended?

Explanation

In the surgical management of advanced thumb CMC arthritis, addressing a concomitant MCP hyperextension deformity of >30 degrees is critical. Failure to correct this (via volar capsulodesis, EPB transfer, or MCP arthrodesis) leads to poor pinch strength and recurrent thumb metacarpal base subsidence after trapeziectomy/LRTI due to the persistent zigzag longitudinal collapse deformity.

Question 29

A 32-year-old male presents with dorsal wrist pain. Imaging confirms Kienbock's disease with lunate sclerosis, fragmentation, and carpal height collapse. The radioscaphoid angle is 65 degrees, but the articular surfaces of the scaphoid and capitate are preserved. He has negative ulnar variance. Which of the following is the most appropriate surgical treatment?

Explanation

This patient has Lichtman Stage IIIB Kienbock's disease, defined by lunate fragmentation, carpal collapse, and fixed scaphoid rotation (radioscaphoid angle > 60 degrees), without secondary arthritis. Joint leveling procedures (radial shortening) are generally contraindicated once fixed carpal collapse has occurred. Proximal row carpectomy (PRC) or STT/SC fusion are appropriate salvage procedures. PRC provides reliable pain relief and motion for Stage IIIB when the proximal capitate is preserved.

Question 30

A 28-year-old female overhead athlete complains of arm fatigue, numbness in the ulnar digits, and vague shoulder pain when pitching. Provocative testing is positive when her shoulder is abducted and externally rotated, causing a loss of the radial pulse. EMG/NCS is normal. Which anatomic structure is the most common site of compression in this specific variant of the syndrome?

Explanation

The clinical presentation and positive hyperabduction test (Wright's maneuver) are indicative of Thoracic Outlet Syndrome compression in the subcoracoid space (beneath the pectoralis minor tendon). This variant is often called pectoralis minor syndrome or hyperabduction syndrome. Adson's test evaluates the interscalene triangle, while the costoclavicular maneuver evaluates the costoclavicular space.

Question 31

A 22-year-old male rugby player presents with recurrent anterior shoulder dislocations. CT imaging with 3D reconstruction reveals a 25% anterior glenoid bone loss. What is the most appropriate surgical management to prevent further recurrences in this high-demand contact athlete?

Explanation

In patients with recurrent anterior shoulder instability and significant glenoid bone loss (>20-25%), especially high-demand contact athletes, isolated soft tissue stabilization (Bankart repair) has unacceptably high failure rates. The Latarjet procedure (coracoid process transfer) is the gold standard, restoring the glenoid bone track and providing a 'sling effect' from the conjoint tendon.

Question 32

Following a primary repair of a lacerated flexor digitorum profundus (FDP) and superficialis (FDS) in Zone II of the index finger, a patient begins a controlled mobilization protocol. Which of the following biomechanical principles best supports early active motion protocols compared to prolonged immobilization?

Explanation

Early motion (whether active or passive) applies controlled mechanical stress to the repaired tendon, which stimulates intrinsic healing (via tenocyte proliferation and parallel collagen orientation). This process reduces restrictive peritendinous adhesions and ultimately increases the ultimate tensile strength of the repair compared to static immobilization.

Question 33

During an open carpal tunnel release, the surgeon identifies a nerve branch originating from the median nerve immediately distal to the transverse carpal ligament, which recurrently hooks back over the ligament to innervate the thenar musculature. This anatomical variant is classified according to Poisel. Which variant is this?

Explanation

According to Poisel's classification of the recurrent motor branch of the median nerve: Extraligamentous (most common, ~50%) branches distal to the transverse carpal ligament (TCL) and turns back to the thenar muscles. Subligamentous (~30%) branches within the carpal tunnel and runs under the TCL before turning up. Transligamentous (~20%) branches within the tunnel and pierces directly through the TCL.

Question 34

A 21-year-old collegiate baseball pitcher presents with medial elbow pain that occurs during the late cocking and early acceleration phases of pitching. On examination, he has pain with the milking maneuver and a positive moving valgus stress test. MRI confirms a full-thickness midsubstance tear of the anterior bundle of the ulnar collateral ligament (UCL). If surgical reconstruction is chosen, which structure is considered the primary isometric restraint to valgus stress at the elbow?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress. It is divided into anterior and posterior bands. The anterior band is taut in extension and up to approximately 90 degrees of flexion, functioning as the primary isometric restraint to valgus stress. The posterior band becomes taut in deeper flexion (>90 degrees).

Question 35

A 28-year-old gymnast presents with ulnar-sided wrist pain, clicking, and a feeling of instability. Physical examination demonstrates severe pain with ulnar deviation and axial loading (TFCC compression test). MRI arthrogram shows a tear of the triangular fibrocartilage complex (TFCC) at its ulnar attachment, specifically involving the fovea at the base of the ulnar styloid. According to the Palmer classification, what type of tear is this, and what is its healing potential?

Explanation

Palmer 1B tears are traumatic avulsions of the TFCC from its ulnar insertion (fovea or base of ulnar styloid). Because the peripheral 10-20% of the TFCC is highly vascularized (supplied by ulnar artery branches), 1B tears have excellent healing potential and are amenable to surgical repair. Palmer 1A (central articular disc) tears are avascular and typically treated with debridement.

Question 36

A 19-year-old male is brought to the trauma bay after a motorcycle accident. He has massive swelling over the shoulder girdle and a pulseless, flail upper extremity. Radiographs show lateral displacement of the scapula with a widened acromioclavicular joint and a displaced clavicle fracture. What is the most reliable early predictor of mortality or need for forequarter amputation in this specific condition?

Explanation

Scapulothoracic dissociation involves a complete disruption of the scapulothoracic articulation. The mortality and morbidity (including amputation risk) are primarily driven by catastrophic hemorrhage from a completely ruptured subclavian or axillary artery. Emergent vascular control is life-saving, and combined severe vascular and complete neural injuries often ultimately lead to amputation.

Question 37

In surgical decompression of the ulnar nerve for cubital tunnel syndrome, which structure forms the roof of the cubital tunnel and represents a common site of primary compression?

Explanation

The cubital tunnel is bordered anteriorly by the medial epicondyle, laterally by the olecranon, and its floor is the MCL. The roof is formed by Osborne's ligament (the arcuate ligament or fascia), which connects the two heads of the flexor carpi ulnaris (FCU). This is a primary site of compression for the ulnar nerve at the elbow.

Question 38

A 13-year-old male baseball pitcher complains of progressive right shoulder pain during the deceleration phase of throwing. Radiographs demonstrate widening and lateral fragmentation of the proximal humeral physis. What is the most appropriate initial management?

Explanation

Little Leaguer's shoulder is an epiphysiolysis of the proximal humerus caused by repetitive rotational stress. It is a classic overuse injury in skeletally immature throwers. The mainstay of treatment is absolute cessation of throwing (usually for 3 months) until symptoms resolve and radiographic healing is noted, followed by physical therapy and a gradual return-to-throwing program.

Question 39

A 6-year-old child presents after falling off the monkey bars. Radiographs demonstrate a fracture of the proximal third of the ulna with an anterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this, and what is the typical initial treatment in this age group?

Explanation

A fracture of the proximal ulna with anterior dislocation of the radial head is a Bado Type I Monteggia fracture-dislocation (the most common type). In pediatric patients, unlike adults, these are almost universally treated successfully with closed reduction of the ulnar fracture and radial head (typically by supinating the forearm and flexing the elbow) followed by cast immobilization.

Question 40

A 60-year-old female sustains a closed fracture of the mid-diaphysis of the humerus. Which of the following is an ABSOLUTE indication for immediate open reduction and internal fixation rather than conservative management with a functional brace?

Explanation

Absolute indications for ORIF of a humeral shaft fracture include: open fracture, associated vascular injury requiring repair, compartment syndrome, floating elbow, massive brachial plexus injury, and bilateral humeral shaft fractures (to allow the patient to assist with transfers and self-care). Primary radial nerve palsy with a closed fracture, up to 3cm shortening, and a transverse pattern can often be managed non-operatively.

Question 41

A 62-year-old male presents with a massive, irreparable posterosuperior rotator cuff tear with preserved subscapularis function. He has significant external rotation weakness and a positive hornblower's sign. He is not a candidate for reverse total shoulder arthroplasty due to medical comorbidities, but is medically optimized for soft tissue surgery. Which tendon transfer is most appropriate to restore external rotation?

Explanation

Lower trapezius transfer is increasingly preferred for massive irreparable posterosuperior rotator cuff tears to restore external rotation. It has a more favorable line of pull matching the infraspinatus compared to the latissimus dorsi, which requires a significant change in vector. Latissimus dorsi transfers historically have mixed outcomes and lower trapezius transfer with graft augmentation (e.g., Achilles tendon) has shown superior biomechanics for external rotation restoration in modern literature.

Question 42

During surgical management of a 'terrible triad' injury of the elbow, what is the recommended sequence of reconstruction to restore concentric stability?

Explanation

The standard surgical sequence for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) typically works from deep to superficial: 1) Coronoid fixation (restores anterior buttress), 2) Radial head fixation or replacement (restores lateral column), 3) LCL complex repair (restores posterolateral rotatory stability). MCL repair is generally only performed if the elbow remains grossly unstable in extension after the first three steps are completed.

Question 43

A 45-year-old manual laborer presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion advanced collapse (SNAC) wrist with degenerative changes isolated to the radioscaphoid joint. The capitolunate and radiolunate joints are well-preserved. According to the SNAC classification, what is the stage and most appropriate surgical treatment?

Explanation

SNAC Stage I involves arthritis isolated to the radial styloid-scaphoid articulation. Stage II involves the entire radioscaphoid fossa. Stage III involves periscaphoid and capitolunate arthritis. The radiolunate joint is typically spared. If changes involve the entire radioscaphoid joint but spare the midcarpal (capitolunate) joint, it is Stage II. Appropriate treatments include proximal row carpectomy (PRC) or scaphoid excision + 4-corner fusion. Stage I treatment is often radial styloidectomy + scaphoid bone grafting.

Question 44

In evaluating a patient with a severe closed traction injury to the brachial plexus, which of the following electrodiagnostic or clinical findings is MOST indicative of a preganglionic nerve root avulsion rather than a postganglionic lesion?

Explanation

In a preganglionic root avulsion, the dorsal root ganglion (DRG) remains intact and attached to the peripheral nerve. Therefore, the peripheral sensory axons do not undergo Wallerian degeneration, and SNAPs remain normal or preserved, even though the patient has no sensation in that dermatome (because the connection to the spinal cord is severed). In postganglionic injuries, the lesion is distal to the DRG, leading to Wallerian degeneration and absent SNAPs.

Question 45

Which of the following anatomic variations of the recurrent motor branch of the median nerve is most common, according to the Lanz classification?

Explanation

According to the Lanz classification of the recurrent motor branch of the median nerve, the extraligamentous type (branching distal to the transverse carpal ligament and curving back to innervate the thenar muscles) is the most common, occurring in approximately 46-90% of individuals depending on the study. Transligamentous and subligamentous variations are less common but critical to recognize to avoid iatrogenic injury during carpal tunnel release.

Question 46

A 28-year-old gymnast presents with ulnar-sided wrist pain. MRI arthrogram reveals a tear of the triangular fibrocartilage complex (TFCC) at its ulnar attachment to the fovea, with distal radioulnar joint (DRUJ) instability. According to the Palmer classification, what type of tear is this, and what is its healing potential?

Explanation

Palmer Class 1 refers to traumatic TFCC tears. Palmer 1B is a peripheral tear involving the ulnar attachment (fovea or base of ulnar styloid). Because the peripheral 10-25% of the TFCC is well-vascularized by branches of the ulnar artery, these tears have good healing potential and are typically treated with surgical repair. Palmer 1A (central articular disc tears) are avascular and generally require debridement rather than repair.

Question 47

During a single-incision anterior approach for distal biceps tendon repair, the forearm is held in full supination while passing sutures and reattaching the tendon to the radial tuberosity. Which nerve is at greatest risk of injury if retractors are placed too deeply on the lateral aspect of the proximal radius?

Explanation

The posterior interosseous nerve (PIN) wraps around the radial neck within the supinator muscle. Retractors placed blindly or deeply on the lateral side of the radius can compress or stretch the PIN. Keeping the forearm in supination moves the PIN further laterally and posteriorly, protecting it during the anterior approach, but deep radial retractor placement still poses the greatest risk to this structure.

Question 48

A 32-year-old male presents with dorsal wrist pain. Radiographs demonstrate sclerosis of the lunate with coronal fracture lines, but the carpal height is maintained. The distal radius has negative ulnar variance. Which of the following is the most appropriate surgical treatment?

Explanation

The patient has Kienbock's disease (avascular necrosis of the lunate). The presence of coronal fracture lines with maintained carpal height corresponds to Lichtman Stage IIIa. In the presence of ulnar minus variance, a joint-leveling procedure such as a radial shortening osteotomy is the gold standard, as it unloads the lunate and can halt progression. Proximal row carpectomy or intercarpal fusions are reserved for Stage IIIb (carpal collapse) or Stage IV (radiocarpal arthritis).

Question 49

A 24-year-old male sustains a closed, spiral fracture of the distal third of the humerus (Holstein-Lewis fracture). Upon initial examination in the emergency department, he is noted to have a complete radial nerve palsy. What is the most appropriate initial management of the radial nerve injury?

Explanation

The vast majority of radial nerve palsies associated with closed humeral shaft fractures (even Holstein-Lewis types) are neuropraxias that will spontaneously recover. The standard of care is conservative management of the fracture (e.g., functional brace or coaptation splint) and observation of the nerve. Indications for immediate exploration include open fractures, vascular injury, or a nerve palsy that develops after a closed reduction.

Question 50

A 35-year-old carpenter amputates his left index fingertip. The injury is a volar oblique amputation with exposed distal phalanx bone. Which of the following local flaps is most appropriate to provide durable coverage and preserve length for this specific injury pattern?

Explanation

A volar oblique amputation of the fingertip results in more loss of the volar pad than the dorsal nail matrix. A cross-finger flap is ideal for volar oblique injuries because it provides glabrous, durable skin coverage from the dorsum of an adjacent finger. A V-Y advancement flap (Atasoy) is best for dorsal oblique or transverse amputations. A Moberg flap is strictly for the thumb.

Question 51

In the design and biomechanics of a reverse total shoulder arthroplasty (rTSA), moving the center of rotation medially and distally compared to the native shoulder achieves which of the following mechanical advantages?

Explanation

The fundamental biomechanical principle of the Grammont reverse total shoulder arthroplasty is medializing and distalizing the center of rotation. This lengthens the deltoid (increasing its tension) and increases the deltoid moment arm, allowing it to act as the primary elevator of the shoulder in the absence of a functioning rotator cuff. It recruits more of the anterior and posterior deltoid fibers to assist the middle deltoid in abduction and elevation.

Question 52

When evaluating a patient for cubital tunnel syndrome, the examiner asks the patient to hold a piece of paper tightly between the thumb and index finger while the examiner pulls it away. The patient compensates by flexing the interphalangeal (IP) joint of the thumb. What is this sign called and what muscle weakness does it indicate?

Explanation

Froment's sign occurs when a patient pinches a piece of paper between the thumb and index finger. If the adductor pollicis (innervated by the ulnar nerve) is weak, the patient compensates by firing the flexor pollicis longus (innervated by the anterior interosseous nerve/median nerve), leading to hyperflexion of the thumb IP joint.

Question 53

A 29-year-old chef sustains a laceration to the volar aspect of his right long finger at the level of the proximal phalanx, resulting in an inability to flex both the PIP and DIP joints. The injury is classified as being in which flexor tendon zone, and what is the primary reason this zone was historically called 'no man's land'?

Explanation

The laceration is at the level of the proximal phalanx, corresponding to Zone II (from the A1 pulley to the FDS insertion). This area was historically termed 'no man's land' by Bunnell because both the flexor digitorum superficialis (FDS) and profundus (FDP) run closely together within the narrow fibro-osseous tendon sheath. Primary repair in this zone historically had poor outcomes due to dense adhesions between the tendons and the sheath.

Question 54

Which of the following is NOT one of the four classic Kanavel signs indicating pyogenic flexor tenosynovitis?

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: 1) Fusiform (sausage-like) swelling of the digit, 2) Flexed resting posture of the digit, 3) Tenderness to palpation along the course of the flexor tendon sheath, and 4) Severe pain elicited by passive extension of the digit (most sensitive sign). Erythema extending proximal to the MCP joint is not a classic Kanavel sign and may indicate a deeper space infection or diffuse cellulitis.

Question 55

A 6-year-old boy falls from monkey bars and sustains a Gartland Type III extension-type supracondylar humerus fracture. On arrival, his hand is pale, cool, and pulseless. After closed reduction and percutaneous pinning, the hand becomes pink and capillary refill is less than 2 seconds, but the radial pulse remains absent. What is the next most appropriate step in management?

Explanation

In the setting of a poorly perfused hand ('pulseless, pinkless') prior to reduction of a pediatric supracondylar humerus fracture, reduction and pinning should be performed urgently. If the hand becomes well-perfused (pink, warm, good capillary refill) after reduction, even if the radial pulse remains absent (a 'pulseless, pink' hand), the standard of care is close clinical observation. Immediate exploration is only indicated if the hand remains ischemic after anatomic reduction.

Question 56

A 34-year-old female presents with chronic numbness and tingling in the ulnar distribution of her right hand, accompanied by intrinsic muscle weakness. She has a positive Roos test and a positive Adson maneuver. A cervical radiograph reveals bilateral cervical ribs. Electromyography (EMG) shows decreased SNAP amplitude in the ulnar nerve and denervation in the abductor pollicis brevis. What is the most likely diagnosis?

Explanation

The clinical picture describes 'true neurogenic thoracic outlet syndrome' (tnTOS). It is rare but classically associated with a structural anomaly like a cervical rib causing compression of the lower trunk of the brachial plexus (C8-T1). It is characterized by objective findings: thenar atrophy (Gilliatt-Sumner hand), weakness in intrinsic muscles, and objective EMG/NCS changes. 'Disputed' or 'symptomatic' neurogenic TOS lacks objective EMG findings.

Question 57

A 7-year-old boy sustains a fall on an outstretched hand resulting in an isolated proximal ulna fracture with anterior bowing. Which associated injury MUST be carefully evaluated and ruled out on the initial radiographs?

Explanation

The injury described is a Monteggia fracture-dislocation (proximal/diaphyseal ulna fracture associated with a radial head dislocation). Bado classified these based on the direction of radial head dislocation, with anterior (Type I) being the most common. Any fracture of the ulna must prompt a careful evaluation of the radiocapitellar line on all views to ensure the radial head is concentrically reduced.

Question 58

A 42-year-old tennis player complains of persistent, severe lateral elbow pain that radiates down the dorsal forearm. The pain is not relieved by conservative measures for lateral epicondylitis. On examination, the point of maximum tenderness is located 4 cm distal to the lateral epicondyle over the mobile wad. Pain is exacerbated by resisted middle finger extension. What is the most likely site of anatomic compression in this condition?

Explanation

The clinical presentation is classic for Radial Tunnel Syndrome (RTS), a compressive neuropathy of the posterior interosseous nerve (PIN). It is distinguished from lateral epicondylitis by the location of maximal tenderness (distal to the lateral epicondyle in the muscle belly) and pain with resisted middle finger extension. The most common site of PIN compression in the radial tunnel is the proximal edge of the superficial layer of the supinator muscle, known as the arcade of Frohse.

Question 59

A 25-year-old elite overhead throwing athlete presents with deep shoulder pain and a 'dead arm' sensation. An MR arthrogram reveals a Type II SLAP tear. Non-operative management has failed. During arthroscopy, a significant 'peel-back' sign is noted. What is the classic gold standard surgical intervention for this specific patient population?

Explanation

A Type II SLAP tear involves detachment of the superior labrum and biceps anchor from the superior glenoid. The 'peel-back' sign is characteristic in throwing athletes. In a young, elite overhead throwing athlete, arthroscopic SLAP repair with suture anchors has historically been the gold standard to restore native throwing kinematics, whereas biceps tenodesis is often preferred in older or non-overhead athletes.

Question 60

A 30-year-old male sustains a distal third radial shaft fracture. Radiographs reveal widening of the distal radioulnar joint (DRUJ) on the PA view and dorsal displacement of the ulna on the lateral view. Following open reduction and internal fixation of the radius with a compression plate, the DRUJ remains grossly unstable in all positions of forearm rotation and irreducible. What is the most appropriate next step in management?

Explanation

The injury is a Galeazzi fracture-dislocation. After anatomic rigid fixation of the radial shaft, the DRUJ must be assessed. If the DRUJ is grossly unstable in all positions of forearm rotation or irreducible, it indicates severe disruption of the stabilizing structures with potential soft tissue interposition (e.g., ECU tendon or capsule). The most appropriate next step is open exploration of the DRUJ to remove interposed tissue and directly repair the TFCC.

Question 61

A 68-year-old female presents with chronic shoulder pain, profound weakness, and an inability to actively elevate her arm past 60 degrees. Radiographs reveal a massive rotator cuff tear with superior migration of the humeral head and acromiohumeral interval of 3 mm. She has no active external rotation. What is the most appropriate surgical management?

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for rotator cuff arthropathy with pseudoparalysis. Tendon transfers require an intact subscapularis and are contraindicated in the setting of glenohumeral arthritis.

Question 62

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), what is the most accepted sequence of reconstruction to restore stability?

Explanation

The standard protocol for a terrible triad injury works deep to superficial and medial to lateral: coronoid fixation first, followed by radial head repair or arthroplasty, and then LCL repair. The MCL is only addressed if the elbow remains grossly unstable after lateral sided repair.

Question 63

A 30-year-old carpenter undergoes a 4-strand Zone 2 flexor tendon repair. Postoperatively, the therapist initiates an early active motion protocol rather than a passive motion protocol. What is the primary biomechanical benefit of this approach?

Explanation

Early active motion protocols after multi-strand flexor tendon repairs significantly decrease adhesion formation and improve tendon excursion, thereby decreasing the work of flexion. A minimum of a 4-strand core repair is required to withstand the forces of active motion.

Question 64

A 45-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion advanced collapse (SNAC) wrist with degenerative changes extending into the capitolunate joint (Stage III). Which of the following carpal articulations is characteristically spared in this disease progression?

Explanation

In both SLAC and SNAC wrist patterns, the radiolunate articulation is characteristically spared because the spherical lunate remains congruent with the lunate fossa, lacking the shear forces seen in the radioscaphoid joint. This allows for salvage procedures like a proximal row carpectomy or four-corner fusion.

Question 65

When surgically addressing a chronic Type V acromioclavicular (AC) joint separation, what is the primary biomechanical advantage of an anatomic coracoclavicular (CC) ligament reconstruction over the traditional modified Weaver-Dunn procedure?

Explanation

Anatomic reconstruction utilizes free tendon grafts to recreate both the conoid and trapezoid ligaments. This restores superior anterior-posterior and superior-inferior stability significantly better than the Weaver-Dunn, which only transfers the coracoacromial (CA) ligament.

Question 66

A 26-year-old elite volleyball player presents with insidious onset, painless weakness of her hitting arm. Examination reveals isolated atrophy and weakness of the infraspinatus with normal supraspinatus strength. An MRI is most likely to show a cyst compressing the nerve at which location?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus muscle. Compression more proximally at the suprascapular notch would denervate both the supraspinatus and infraspinatus.

Question 67

A 35-year-old male sustains a closed, distal third spiral fracture of the humerus (Holstein-Lewis fracture). Neurological examination in the emergency department is normal. A closed reduction and splinting are performed. Post-reduction examination reveals a new-onset complete radial nerve palsy. What is the most appropriate next step in management?

Explanation

A new-onset secondary radial nerve palsy occurring immediately after closed reduction of a humeral shaft fracture is a strong indication for surgical exploration, as the nerve may be entrapped within the fracture fragments.

Question 68

A 42-year-old female sustains a complex coronal shear fracture of the capitellum that extends medially into the trochlea (Dubberley Type IV). Which surgical approach provides the most extensile visualization for anatomic reduction of the articular surface?

Explanation

The extended lateral approach provides excellent exposure of the anterior capitellum and trochlea by elevating the common extensor origin and anterior capsule. Olecranon osteotomies are typically reserved for distal humerus fractures involving both columns, not isolated anterior shear fractures.

Question 69

A 32-year-old male manual laborer is diagnosed with Stage II Kienbock's disease. Radiographs reveal sclerosis of the lunate without collapse, and an ulnar minus variance of 3 mm. What is the most appropriate surgical intervention to halt disease progression?

Explanation

In early-stage Kienbock's disease (Stages I, II, or IIIa) in a patient with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated to offload the radiolunate joint and promote revascularization.

Question 70

Dupuytren's contracture is characterized by the formation of nodules and cords in the palmar fascia. At the molecular and cellular level, this disease is primarily driven by the proliferation of which cell type and an abnormal shift in collagen production?

Explanation

The pathophysiology of Dupuytren's contracture involves the proliferation of myofibroblasts and a pathological increase in Type III collagen relative to Type I collagen, leading to tissue contraction.

Question 71

A 48-year-old heavy laborer presents with anterior shoulder pain and clicking. MRI arthrogram reveals a Type II SLAP tear. Conservative management has failed. To optimize his return to heavy labor and minimize postoperative stiffness, what is the best surgical procedure?

Explanation

In older patients or manual laborers with a Type II SLAP tear, primary biceps tenodesis provides more predictable pain relief, a faster return to work, and lower rates of postoperative stiffness compared to SLAP repair.

Question 72

During ulnar collateral ligament (UCL) reconstruction of the elbow in an overhead throwing athlete, the graft is tensioned to recreate the primary valgus stabilizer. Which specific portion of the UCL complex is the primary restraint to valgus stress at 90 degrees of elbow flexion?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress. Specifically, the anterior band of the anterior bundle is taut and acts as the primary stabilizer from 30 to 120 degrees of flexion.

Question 73

A 7-year-old boy falls from the monkey bars and sustains a diaphyseal fracture of the ulna with posterior angulation. Radiographs also demonstrate a posterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this?

Explanation

The Bado classification for Monteggia fractures categorizes injuries by the direction of radial head dislocation. Type II involves posterior dislocation of the radial head with posterior angulation of the ulnar fracture.

Question 74

A 60-year-old female undergoes a ligament reconstruction and tendon interposition (LRTI) procedure for Eaton Stage III trapeziometacarpal osteoarthritis. Which tendon is most commonly harvested as the autograft for this reconstruction to suspend the first metacarpal?

Explanation

The Flexor Carpi Radialis (FCR) tendon is the workhorse autograft used in the LRTI procedure. It is passed through a drill hole in the base of the first metacarpal to prevent proximal migration after trapeziectomy.

Question 75

Recent quantitative anatomical studies evaluating the vascularity of the proximal humerus have shifted the traditional paradigm regarding its blood supply. Which artery is now recognized as providing the dominant blood supply to the humeral head, placing it at significant risk in displaced 4-part fractures?

Explanation

While historically the anterior circumflex humeral artery (via the arcuate branch) was thought to be primary, recent studies show the posterior circumflex humeral artery provides approximately 64% of the blood supply to the humeral head.

Question 76

A 55-year-old male presents with a Stage II Scapholunate Advanced Collapse (SLAC) wrist, demonstrating arthritis at the radioscaphoid joint but sparing the midcarpal joint. Which of the following surgical options is considered INCORRECT as a definitive standalone treatment for his pathology?

Explanation

Radial styloidectomy alone is insufficient for Stage II SLAC wrist, as it only addresses the impingement at the styloid and ignores the advanced arthritic changes in the scaphoid fossa. PRC or 4-corner fusion are the treatments of choice.

Question 77

A patient with severe cubital tunnel syndrome undergoes surgical decompression. The surgeon traces the ulnar nerve proximally to distally. What is the most common site of ulnar nerve compression in this condition?

Explanation

The most common site of ulnar nerve compression at the elbow is between the two heads of the flexor carpi ulnaris (FCU), which are connected by the cubital tunnel retinaculum, also known as Osborne's ligament.

Question 78

An 18-year-old rugby player presents to the emergency department with dyspnea, dysphagia, and an apparent posterior sternoclavicular (SC) joint dislocation. When considering closed reduction versus surgical intervention, the surgeon must remember that the medial clavicular epiphysis typically fuses at what age?

Explanation

The medial epiphysis of the clavicle is the last physis to close in the human body, typically fusing between 22 and 25 years of age. Therefore, apparent SC dislocations in young adults under 25 are often Salter-Harris physeal fractures.

Question 79

A 45-year-old male falls from a height and sustains a terrible triad injury of the elbow. During surgical reconstruction, which of the following represents the most appropriate sequence of repair?

Explanation

The standard surgical protocol for a terrible triad injury follows a deep-to-superficial, inside-out approach. The coronoid is fixed first to restore anterior stability, followed by the radial head, and finally the lateral collateral ligament (LCL).

Question 80

A 30-year-old mechanic complains of chronic dorsal wrist pain. Radiographs demonstrate a scapholunate gap of 4 mm and a radiolunate angle of 20 degrees extended. What is the most likely secondary deformity?

Explanation

Scapholunate ligament disruption leads to dorsal intercalated segment instability (DISI). The lunate extends because the intact lunotriquetral ligament pulls it dorsally while the unsupported scaphoid flexes.

Question 81

Following a single-incision anterior approach for a distal biceps tendon repair, a patient demonstrates an inability to extend the fingers and thumb, but wrist extension is preserved with radial deviation. Which nerve was most likely injured?

Explanation

The PIN is at risk during the single-incision anterior approach to the distal biceps due to overly aggressive lateral retraction. Injury causes loss of finger and thumb extension, while radial wrist extension is preserved via the ECRL.

Question 82

A 28-year-old male sustains a closed spiral fracture of the distal third of the humeral shaft (Holstein-Lewis). He has a concomitant inability to extend his wrist and fingers upon presentation in the emergency department. What is the most appropriate initial management?

Explanation

A closed Holstein-Lewis fracture with a primary radial nerve palsy is generally treated non-operatively initially with functional bracing. The nerve recovers spontaneously in over 70% of cases, making early exploration unnecessary unless reduction cannot be maintained.

Question 83

A skier falls while holding a ski pole, sustaining a hyperabduction injury to the thumb. An MRI reveals an ulnar collateral ligament (UCL) tear with the torn end displaced superficial to the adductor pollicis aponeurosis. What is the most appropriate management?

Explanation

This describes a Stener lesion, where the adductor aponeurosis interposes between the torn UCL and its anatomic insertion. This interposition prevents spontaneous healing, making surgical repair the definitive indication.

Question 84

Which of the following anatomic boundaries defines Zone II in the classification of flexor tendon injuries of the hand?

Explanation

Zone II, historically known as "no man's land", extends from the A1 pulley (distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS). Both FDS and FDP tendons lie tightly within the fibro-osseous sheath in this zone.

Question 85

A 72-year-old female presents with pseudoparalysis of the shoulder and severe glenohumeral osteoarthritis. MRI shows massive, irreparable tears of the supraspinatus and infraspinatus. Which of the following is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty is the gold standard for rotator cuff tear arthropathy complicated by pseudoparalysis. It restores elevation by medializing and distalizing the center of rotation, relying on the deltoid muscle.

Question 86

A 35-year-old manual laborer presents with dorsal wrist pain and decreased grip strength. Radiographs show sclerosis and collapse of the lunate, with negative ulnar variance. Which of the following is the most appropriate joint-leveling procedure?

Explanation

In early-stage Kienböck's disease (avascular necrosis of the lunate) associated with negative ulnar variance, a radial shortening osteotomy unloads the lunate. This shifts mechanical forces appropriately to the radioulnar and ulnocarpal joints.

Question 87

A 40-year-old male experiences a seizure and subsequently complains of shoulder pain with a locked internally rotated arm. Radiographs reveal a "lightbulb" sign on the AP view. What is the most likely associated osseous defect?

Explanation

Seizures commonly cause posterior shoulder dislocations, recognized by the "lightbulb" sign due to internal rotation of the humeral head. This is frequently associated with an impaction fracture of the anteromedial humeral head, known as a reverse Hill-Sachs lesion.

Question 88

A 6-year-old child presents with a pulseless, pink hand following a displaced extension-type supracondylar humerus fracture. After closed reduction and percutaneous pinning, the hand remains pink but the radial pulse is absent. What is the next best step in management?

Explanation

A "pulseless but pink" (well-perfused) hand after stable reduction of a supracondylar fracture typically indicates adequate collateral circulation. The standard of care is close clinical observation rather than immediate vascular exploration.

Question 89

A 25-year-old male falls on an outstretched hand. Lateral wrist radiographs show the capitate displaced dorsally, while the lunate remains articulated with the distal radius. What is the diagnosis?

Explanation

In a perilunate dislocation, the lunate remains within the lunate fossa of the radius, but the capitate is dislocated dorsally. In a true lunate dislocation, the lunate is displaced volarly (spilled teacup sign) while the capitate aligns with the radius.

Question 90

When evaluating a lateral radiograph of a normal adult wrist, what is the average normal volar tilt of the distal radius articular surface?

Explanation

The normal anatomic volar tilt of the distal radius is approximately 11 to 12 degrees. Restoration of this volar tilt is an important radiographic parameter during the surgical fixation of distal radius fractures.

Question 91

A 7-year-old boy falls and sustains a Bado Type I Monteggia fracture-dislocation. Which of the following describes this specific injury pattern?

Explanation

A Bado Type I Monteggia fracture involves a fracture of the ulnar diaphysis with an anterior dislocation of the radial head. This is the most common Bado classification type seen in pediatric patients.

Question 92

A patient presents with weakness in making an "OK" sign with their thumb and index finger, but has absolutely no sensory deficits in the hand. Which of the following muscles is most likely affected?

Explanation

The anterior interosseous nerve (AIN) supplies the flexor pollicis longus, the flexor digitorum profundus to the index and long fingers, and the pronator quadratus. AIN neuropathy presents as a purely motor deficit, classically demonstrated by an inability to pinch.

Question 93

A 32-year-old competitive weightlifter feels a pop in his anterior chest during a heavy bench press. Examination reveals an asymmetric chest wall and weakness with internal rotation. Which portion of the pectoralis major is most commonly injured in this scenario?

Explanation

Pectoralis major ruptures most frequently occur at the humeral insertion or musculotendinous junction of the sternal head. This injury pattern is classic in weightlifters performing the bench press due to extreme eccentric loading.

Question 94

During surgical decompression for cubital tunnel syndrome, which of the following structures represents a potential site of ulnar nerve compression located approximately 8 cm proximal to the medial epicondyle?

Explanation

The Arcade of Struthers is a fascial band located about 8 cm proximal to the medial epicondyle that can compress the ulnar nerve. The Ligament of Struthers, by contrast, compresses the median nerve.

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