IS Hand / LE 2013

A 60-year-old woman is evaluated in the emergency department after she fell on her outstretched hand while playing tennis. Examination shows tenderness in the dorsal and volar aspects of the wrist. Which of the following bones was most likely fractured in this patient? A. Capitate neck B. Distal radius C. Lunate body D. Scaphoid wrist E. Triquetral ridge

B. Distal radius fractures usually occur in adults older than 40 years and are more common in women than in men due to the higher incidence of osteoporosis in women. The most common mechanism is a fall on an outstretched hand. After distal radius fracture, the next most common fracture of the wrist is scaphoid, followed by triquetrum, trapezium, and lunate.

A 32-year-old woman comes to the emergency department after she sustained an isolated sharp transverse laceration of the flexor digitorum profundus tendon of the index finger of the left hand at the proximal interphalangeal joint flexion crease with a kitchen knife. A four-strand core suture is planned for repair. The ideal purchase length is which of the following distances from the cut tendon end? A. 5 mm B. 10 mm C. 15 mm D. 20 mm

B. For both two-strand and four-strand locking core repair methods, the length of core suture purchase significantly influences both resistance to gapping and also ultimate strength to breaking. The optimal length of purchase is between 0.7 and 1.0 cm. Increased length of purchase from 0.7 to 1.2 cm does not increase the repair strength. Purchase length of 0.4 or less greatly reduces repair strength.

Which of the following is the earliest one might expect to find electromyographic changes after suspected median nerve damage during carpal tunnel release? A. 1 Week B. 3 Weeks C. 5 Weeks D. 7 Weeks

B. Patients with nerve injuries can be evaluated by nerve conduction velocities and electromyography (EMG). Abnormal conduction velocities are associated with decreased amplitude, decreased velocity, and increased latency. Sensory nerve latency above 3.5 ms and/or motor nerve latency above 4.5 ms are considered abnormal. Muscle changes assessed by EMG are typically altered later (2 to 3 weeks after injury) in the clinical course and consist of the presence of fibrillation potentials and decreased motor unit potential recruitment. Though the sensitivity of these studies may be somewhat low, at around 66% when using conduction velocity and latency, the specificity has been reproducibly near 95%.

Which of the following is the most likely cause of congenital constriction band syndrome of the lower extremity? A. Defect in the zone of polarizing activity B. Deletion of the gene responsible for the apical ectodermal ridge C. Early amnion rupture D. Exposure to retinoic acid E. Use of thalidomide during pregnancy

C. Early amnion rupture with subsequent entanglement of fetal parts (mostly limbs and appendages) by amniotic strands is the primary theory of pathogenesis. A wide spectrum of clinical deformities is encountered and range from simple ring constrictions to major visceral defects. Lower extremity limb malformations are extremely common and consist of asymmetric digital ring constrictions, distal atrophy, congenital intrauterine amputations, acrosyndactyly, lymphedema, and clubfoot. Amniotic band syndrome is not a rare anomaly, as first described more than 150 years ago, and appears to be rising. Once believed to have an incidence of 1:100,000, recent literature supports the incidence today as 1:1200 to 1:5000 births. No distinct sex predilection has been determined. Nearly 60% of the cases documented have some sort of abnormal gestation history. Prenatal risk factors associated with amniotic band syndrome include prematurity (less than 37 weeks), low birth weight (less than 2500 g), maternal illness during pregnancy, maternal drug exposure, and maternal hemorrhage. Attempted abortion in the first trimester is also a highly associated finding. Family history seldom shows any direct inheritance pattern since the syndrome occurs in no particular association with known genetic or chromosomal disorders. The zone of polarizing activity signals the developing limb bud towards anterior/posterior polarity and does not result in truncation. Proximodistal limb growth is the result of the apical ectodermal ridge. Deletion of the gene responsible for the apical ectodermal ridge will result in shortening of the limb but not in congenital constriction band syndrome. Experiments in which the apical ectodermal ridge has been removed show truncated limb growth. Scientific evidence supports that the pattern of limb anomalies in the offspring of mothers exposed to exogenous retinoids, such as retinoic acid, causes interference with apical ectodermal ridge function, resulting in similar deformities. Thalidomide results in various limb deformities, including phocomelia, dysmelia, amelia, and bone hypoplasticity, with as little as a single dose of thalidomide during gestation. It does not, however, result in constriction bands. It is postulated that thalidomide-associated malformations are the result of the drug's interference with vasculogensis.

A 62-year-old man comes to the office 1 week after he sustained an avulsion injury to the soft tissue of the dorsal aspect of the left thumb while firing his crossbow. Moist dressing changes have not resulted in granulation tissue over the tendon. A photograph is shown (dorsal thumb defect with denuded tendon). Which of the following is the most appropriate definitive treatment of the defect? A. Alginate dressing changes B. Cross-finger flap transfer C. First dorsal metacarpal artery flap transfer D. Full-thickness skin grafting E. Split-thickness skin grafting

C. In this patient with exposed tendon denuded of tenosynovium (as evidenced by the photo and failure to granulate) flap coverage with the first dorsal metacarpal artery flap, or "kite" flap, will provide closure of the wound with similar skin to what has been lost with minimal morbidity. Apart from reaching the thumb dorsal surface, this flap has been successfully used to resurface palmar wounds of the thumb. Photographs of the flap are shown.

A 34-year-old woman is scheduled to undergo bilateral prophylactic mastectomy because of a strong family history of breast cancer. Reconstruction with free flaps from the upper inner thigh is planned. Which of the following is the pedicle to these flaps? A. Ascending branch of the lateral femoral circumflex artery B. Descending branch of the lateral femoral circumflex artery C. Medial femoral circumflex artery D. Superficial circumflex iliac artery E. Superficial femoral artery

C. The transverse upper gracilis (TUG) flap is a free flap that can be used in breast reconstruction. It is particularly useful in cases where the abdominal donor site is not available or not desired. The flap incorporates the skin and subcutaneous tissues of the upper inner thigh, in the region of the medial thigh lift. The TUG flap is based on the gracilis vessels and perforators from the descending branch of the medial femoral circumflex artery, which forms the dominant pedicle. This arises from the profunda femoris artery. Modifications of this flap have been proposed to increase the volume available for free tissue transfer. The ascending branch of the lateral femoral circumflex artery provides blood supply to the tensor fascia lata flap. The descending branch of the lateral femoral circumflex artery forms the pedicle for the anterolateral thigh flap. The superficial circumflex iliac artery forms the pedicle for the groin flap. Branches from the superficial femoral artery provide minor pedicles to the distal portion of the gracilis muscle, but are less important and distal to the area of the TUG flap.

A 25-year-old construction worker has a 4-cm-diameter posterior calcaneal ulcer with exposed bone on removal of a short-leg cast applied 6 weeks ago for an ankle fracture. Coverage with a lateral calcaneal artery flap is planned. The lateral calcaneal artery is usually the terminal branch of which of the following arteries? A. Anterior tibial B. Dorsalis pedis C. Lateral malleolar D. Peroneal

D. Anatomic dissections by Drs. Grabb and Argenta found that the lateral calcaneal artery is usually the terminal branch of the peroneal artery but occasionally may arise from the posterior tibial artery. The branches of the peroneal include the nutrient artery which supplies the fibula, the perforating branch which gives branches to the tarsus, the communicating branch and the lateral calcaneal.

A 46-year-old automobile mechanic comes to the office because of a 3-week history of localized pain in the fingers of the dominant right hand. He does not smoke cigarettes. He says the pain occurs intermittently and that he has no symptoms anywhere else in the body. Examination shows scattered, punctate, dark petechiae at the tips of the ring and little fingers. Rubor progressing from the distal interphalangeal joints to the tips of the ring and little fingers is noted. An additional bounding pulse is palpable in the proximal ulnar palm. Radial and ulnar pulses at the wrist are normal. Digital Allen tests show decreased flow at the ring and little fingers and the ulnar aspect of the long finger. Plain x-ray studies show no abnormalities. A photograph is shown. Which of the following is the most likely diagnosis? A. Buerger disease B. Congenital vasospastic disease C. Distal embolization from the heart D. Hypothenar hammer syndrome E. Raynaud disease

D. This is a classic presentation for the patient who develops an ulnar artery aneurysm at Guyon canal. The aneurysm typically is the source of small emboli that tend to affect vessels at the ulnar aspect of the hand and fingers. The emboli cause decreased flow, cold sensitivity, ischemic pain and rubor in the small and ring fingers most commonly. This problem occurs most often in men in their 40s, who suffer repetitive blunt trauma to the hand. Some use their hand as a hammer at work. Other forms of blunt trauma have been linked to this problem, including certain sports and weight lifting. The treatment options include oral medications for vasodilation, cessation of the offending physical activity, smoking cessation if present, sympathectomy, thrombolytics, and either exclusion of the aneurysm and ulnar artery ligation in the palm, or aneurysm excision and vascular reconstruction. Raynaud disease is not the best answer because this presentation with embolic disease localized to the ulnar fingers and the palpable pulse/mass (aneurysm) in the hand are not consistent with Raynaud disease. Patients with Raynaud disease typically present complaining of cold sensitivity, periods of finger blanching, followed by diffuse return of flow to the fingers and pain. Raynaud disease is a diffuse sympathetic problem, not a local aneurysmal problem. Congenital vasospastic disease is not the best answer because the patient in this vignette has no symptoms prior to 3 weeks ago. A congenital vasospastic problem would have presented before, and would be unlikely to be so localized. Distal embolization from the heart is wrong for similar reasons: emboli from the heart would be very unlikely to present unilaterally, in two fingers, adjacent to one another. There would very likely be other symptoms and sites of embolization. Buerger disease is not the best answer for a few reasons. The patient in this vignette is a nonsmoker. Thromboangiitis obliterans (TAO), or Buerger disease, is an inflammatory arteritis seen in smokers. It improves or stops progressing with smoking cessation. Buerger disease does not typically present with such isolated symptoms, and can involve the lower extremities as well.

An otherwise healthy 58-year-old man comes to the office because of numbness of all fingers of the left hand. He says he first noticed symptoms after a cross-country drive 6 weeks ago. On physical examination, the thumb, index, and long fingers show sensitivity to the 2.83 Semmes-Weinstein monofilament. The ring and little fingers show sensitivity to the 3.22 monofilament. The little finger is held in an abducted position. Abductor pollicis brevis muscle strength is normal. First dorsal interosseous muscle strength is diminished. Which of the following anatomical structures is the most likely cause of these findings? A. Arcade of Frohse B. Lacertus fibrosus C. Ligament of Struthers D. Osborne ligament E. Transverse carpal ligament

D. This scenario depicts a patient with ulnar nerve compression. Often patients who present with compression neuropathies give a history of numbness of all fingers; however, careful physical examination will show sensory abnormalities only in the anatomical location of the compression. The patient has weakness of the ulnar nerve innervated intrinsic muscles, the first dorsal interosseous muscle, but retains strength in the abductor pollicis brevis muscle. The diagnosis of ulnar nerve compression is suggested. The most common sight of ulnar nerve compression is at the elbow. The anatomical causes of all the nerve compression at the elbow are the arcade of Struthers, the medial intramuscular septum, the bony cubital tunnel, Osborne ligament, an anconeus epitrochlearis muscle, and the origin of the flexor carpi ulnaris muscle. The ligament of Struthers, lacertus fibrosus and the transverse carpal ligament are anatomical sites of compression of the median nerve. The arcade of Frohse is a site of compression of the radial nerve.

A 48-year-old man is evaluated for reconstruction after resection of a tumor of the distal radius. Physical examination shows a 10-cm defect of the metaphysis and shaft. Which of the following is the most appropriate source of bone for reconstruction? A. Contralateral fibula B. Contralateral radius C. Humeral shaft D. Medial femoral condyle E. Osteodistraction of the ipsilateral radius

A. The preferred source of bone for such a long piece of bone reconstruction is the fibula microsurgical vascularized transfer. Another viable option, which was not listed, could be the iliac crest. Other sources listed would not yield as much bone stock, nor would they offer sufficient bicortical bone to yield a stable reconstruction with rigid fixation, such as: -Contralateral radius (presumably with the radial vascular supply) -Humeral shaft (presumably with the posterior radial collateral vessels) -Medial femoral condyle (based on descending genicular vessels) Thus, they would not be the preferred source, although they could all be transferred microsurgically. Osteodistraction would not be the first line of treatment for this defect because of the length of bone transport necessary.

A 48-year-old woman comes to the office because of burning pain and stiffness in the right hand 6 weeks after treatment of a distal radius fracture. She says she has had difficulty sleeping and that she has discomfort despite taking narcotics. Physical examination shows a shiny appearance of the right hand, decreased range of motion of the fingers, and hypersensitivity to light touch. X-ray studies show good alignment of the fracture. Which of the following tests is the most appropriate to evaluate this patient's condition? A. Bone scan B. CT scan C. Digital subtraction angiography D. Lymphoscintigraphy E. Ultrasonography

A. This patient exhibits symptoms of complex regional pain syndrome (CRPS). The persistence of physiological changes after surgery or injury can lead to debilitating consequences. This condition is characterized by persistent pain, cold intolerance, autonomic dysfunction, and trophic changes. Patients may show swelling, stiffness, difficulty sleeping, and persistent pain out of proportion to the normal postoperative course that may be relieved incompletely by narcotics. CRPS is a clinical diagnosis without a single definitive test, and is divided into two types: type I, which occurs without identifiable nerve involvement (also known as reflex sympathetic dystrophy); and type II, which has identifiable nerve involvement (causalgia). It is more common in people who smoke and in women. Pain in CRPS can be either sympathetically mediated or sympathetically independent. The diagnosis of CRPS involves history, physical examination, and diagnostic testing. Although no specific test is pathognomonic, triple-phase bone scans are helpful in adding credence to the diagnosis. First- and second-phase bone scans may show asymmetric flow and autonomic dysfunction, while the third phase demonstrates increased periarticular uptake in multiple joints of the affected extremity. A variety of treatment modalities have been employed in addressing CRPS. These range from therapy modalities such as range of motion, stress loading, and desensitization to pharmacologic interventions with anticonvulsants or antidepressants. Stellate ganglion blocks or autonomic nerve blocks may be helpful in sympathetically mediated pain, and nerve stimulation (either transcutaneous or at the spinal cord level) can also be employed. Often, multiple modalities are used concurrently and in sequence. Peripheral nerve decompression may be helpful in resolving symptoms related to CRPS type II.

A 25-year-old man is scheduled to undergo muscle transfer with the gracilis muscle to restore finger flexion. To optimize function, the muscle should be inset under which of the following? A. Less tension than it was in the leg B. The same tension as it was in the leg C. More tension than it was in the leg D. No tension

B. Functional muscle transfers are a way to restore motion that has been lost. The gracilis muscle is a common option for this kind of transfer. To optimize the outcome, the muscle should be inset at the same tension it was under in the leg. The physiologic basis for this technique is that muscle fibers function best at a particular length/tension relationship. Muscles are typically under ideal tension in their donor position. When transferred, a muscle can be placed under too much or too little tension. If a muscle is overstretched, there is little overlap of the actin and myosin units, and the contractile force is weak. If the muscle is under too little tension, the actin and myosin units aren't able to achieve maximal contraction. Insetting a muscle under no tension produces the same result as insetting it under less tension.

A 35-year-old man is transferred to the emergency department via helicopter 7 hours after he sustained a table saw injury to the left hand. The patient smokes one pack of cigarettes daily. Physical examination shows amputation of the thumb and partial amputation of the index finger. No other injuries are noted. An x-ray and a photograph study are shown. Which of the following is the most appropriate management? A. Replantation of the thumb and index finger segment B. Revision amputation of the index finger and replantation of the thumb C. Revision amputation of the thumb and index finger D. Revision amputation of the thumb and microvascular "on-top plasty" of the index finger E. Revision amputation of the thumb and pollicization of the index finger

B. In patients with traumatic amputations of the thumb, optimal reconstruction is provided by replantation. Vein grafts from the princeps pollicis artery, in the anatomical snuff box, are often required because of the difficult positioning. Vein grafts can be harvested from the foot or the forearm. For injuries at the metacarpophalangeal joint level, no reconstruction method approximates that of the replanted thumb. All efforts should be utilized in order to salvage the amputated thumb. In contrast, for index finger amputations, any surgery which would not provide normal or near normal function often only serves to hamper hand function. A traumatic injury which involved the index finger metacarpophalangeal (MCP) joint would require arthrodesis. A fused MCP joint would only get in the way and detract from function. Option (A) replantation of the thumb and index segment is not correct because of the decreased function which would be observed after a replantation of a poorly functioning index finger. Option (B) is the correct answer. Option (C) is incorrect and since it involved the amputation of both the thumb and index finger. Option (D) "on-top plasty" is a procedure which involves a non-vascularized bone graft covered with a local pedicle flap; this would not provide optimal function. Option (E), which is pollicization of the thumb to index finger, would be suboptimal. Pollicization would only be an option if the thumb were deemed unreplantable.

A full-term male newborn is evaluated because of Blauth Type IV (pouce flottant) thumb hypoplasia. Physical examination shows no other abnormalities. A pollicization procedure is planned. At which of the following ages is it most appropriate to perform this procedure? A. 1 Month B. 1 Year C. 5 Years D. 10 Years E. 15 Years

B. Pollicization for thumb hypoplasia Types IIIB and IV, and for aplasia, has been successful when performed when the patient is between 3 months and 3 years of age. Most surgeons will prefer to do pollicization procedures when the patient is between 6 and 12 months of age because there is a more natural integration and adaptation process in using the pollicized digit as a thumb while the child becomes more involved with manual activities. Nevertheless, the outcome also depends on the quality of the anatomical structures of the pollicized digit. Technically, the procedure can be done at any time; however, at less than 3 months of age, the child's cardiopulmonary maturation may be incomplete. Also, the child becomes aware of the thumb after the age of 3 months, so performing the procedure earlier than this age only raises the degree of technical difficulty because of the minute size of structures and potential circulatory issues, without any further advantage. The older the child is at the time of the procedure, the more difficult it becomes to change the patterns of pinch and prehension that have already begun in the first 3 years of life. Fine coordination is achieved at 3 years of age. Reorganization of cortical representation of the index finger as a thumb is a slower and incomplete process in older children or adults. Exposure of the new configuration of the hand to the process of neuromuscular growth of the child is a key consideration.

Which of the following is the most common sequela of using the Moberg volar skin advancement flap for closure of thumb defects? A. Difficulty retraining sensory function B. Extension deficit of the interphalangeal joint C. Hook-nail deformity D. Necrosis of the flap E. Skin necrosis of the dorsal thumb

B. The Moberg volar advancement flap is a useful and rugged flap for thumb tip coverage of open wounds up to a maximum of 2 cm. The principal advantage of the flap is that it provides like tissue with near-normal sensitivity. In one series of Moberg flaps, when patients with associated bony amputations were excluded, 6 of 11 patients were found to have extension deficits at the interphalangeal joint with a resultant reduction in active range of motion of at least 20 degrees. Unlike other flaps used for thumb coverage, like the Littler neurovascular island flap, sensory retraining is not necessary with the Moberg flap. Dorsal thumb skin necrosis is not a likely complication of the Moberg flap when used for thumb coverage, as the thumb has an independent and hardy dorsal circulation. This is in contradistinction to the other digits, where a volar advancement flap would likely result in dorsal skin necrosis because of inadequate dorsal circulation. Hook-nail deformity can occur after distal fingertip injuries with tissue loss; this would not likely be related to use of a Moberg flap, but instead to loss of support of the distal nail bed. Because the thumb neurovascular bundles are included in the volar tissue advancement of the Moberg flap, volar flap necrosis is an unlikely complication given the robust circulation of the flap.

The apical portion at which the distal nail loses its natural adherence and transitions to the white color indicated by the arrow in diagrammatic longitudinal section of the fingertip shown (just below end of nail plate) is called which of the following? A. Eponychium B. Hyponychium C. Lunula D. Perionychium E. Sterile matrix

B. The hyponychium is the junction of the nail bed (sterile matrix) and fingertip skin beneath the distal free margin of the nail. It consists of a keratinous plug and contains large numbers of polymorphonuclear leukocytes and lymphocytes. It is the first barrier of defense, preventing microorganisms from invading the subungual region. The perionychium extends along the lateral borders of the nail. The eponychium is the distal part of the nail fold where it attaches to the surface of the nail. The lunula is the white arc just distal to the eponychium and marks the distal end of the germinal matrix of the nail bed. It is caused by nail cell nuclei in the germinal matrix as they stream distally and upwards, creating a difference in light reflection between this area and the more distal pink sterile matrix. The nail overlying the sterile matrix, on the other hand, is pink since the nuclei within the nail cells have disintegrated. The nail beyond the point of the lunula is thus clear and the blood vessels of the nail bed show through, giving that part of the nail a pink color.

A 30-year-old man is scheduled to undergo great toe-to-thumb transfer 7 months after traumatic amputation of the dominant thumb. During dissection of the toe, the first dorsal metatarsal artery is most likely to be found branching from which of the following vessels? A. Deep plantar B. Dorsalis pedis C. Plantar arterial arch D. Posterior tibial E. Proper digital

B. The origin and course of the first dorsal metatarsal artery (FDMA) are key to dissecting the first or second toe and the variety of available toe flaps. This anatomy is quite variable. In two thirds of cases, this artery emanates from the dorsalis pedis artery as its distal continuation. This course can then be superficial, within, or deep to the interosseous muscle. However, in one third of patients, the metatarsal artery may arise from the deep plantar artery that communicates with the plantar arch or actually from the plantar arch itself, in which case the FDMA may be vestigial. In the latter two situations, the metatarsal artery passes plantar to the deep transverse metatarsal ligament. The proper digital arteries are the distal continuations of the FDMA. The posterior tibial artery runs longitudinally in a superficial plane to the forefoot on the plantar surface. It is the larger lateral plantar artery that travels deeply to become the plantar arterial arch.

A female newborn is evaluated in the neonatal intensive care unit because of severe congenital constriction band syndrome of the left lower extremity. Examination shows cyanosis and severe swelling of the distal affected extremity. The constriction is located at the distal thigh and is very deep, extending down to the anterior distal femur. A Doppler popliteal pulse is audible. Plantar stimulation shows no sensory pain withdrawal reflex. Which of the following is the most appropriate immediate treatment? A. Application of medicinal leeches to the foot B. Constriction excision and Z-plasties C. Leg elevation and edema wrapping D. Limb amputation E. Microsurgical repair of popliteal artery and vein and of the sciatic nerve

B. The patient described has type IIIB constriction (amniotic) band syndrome. Constriction banding affects 1:1,200 live births. Severity of the banding is classified as follows: Type I (mild) - Shallow indentation of skin and soft tissue without distal lymphedema; Type II (moderate) - Distal lymphedema, acrosyndactyly, and even discontinuous neurovascular or musculotendinous structures, but without vascular compromise; Type III (severe) - Progressive lymphaticovenous or arterial compromise; Type IV - Intrauterine amputation. Weinzweig introduced the concept of a dynamic, or type IIIB, subtype in which there is evolving vascular compromise and in which "limb rescue" can be performed with emergency surgery despite a severe band. The dynamic progressive swelling and cyanosis and certain ischemic necrosis can be reversed by surgery. However, there are consequences, and these are neurologic deficits and long-term leg-length discrepancies that may even require leg-lengthening procedures or appropriately timed opposite extremity epiphysiodesis. Early release of such a severe constriction band does not result in long-term neurologic improvement. Early excision of the involved nerve segment may be required, accompanied by nerve grafting.

A 40-year-old, right-hand-dominant man comes to the office because of minimal sensation in the tips of the digits of the right hand and severe pain in the volar aspect of the right wrist. He sustained lacerations of the median and ulnar nerves, radial and ulnar arteries, and all volar flexor tendons 11 months ago when he punched a window. Each of the structures was repaired primarily within hours of injury. On examination, the hand is well perfused. Percussion over median nerve produces severe, painful paresthesia, which radiate distally. Sharp touch sensation is minimally present at the tips of the thumb, index, and long fingers and the radial side of the ring finger; light touch sensation is absent. Which of the following is the most appropriate next step in treatment? A. Administration of tacrolimus B. Excision repair with a sural graft C. Neurolysis and conduit wrap D. Reassessment in 3 months E.Transfer of the extensor indicis proprius

B. The patient has a neuroma of the median nerve after laceration and repair. At 11 months out from injury, he would be expected to have improving light touch at the fingertips. The combination of this and the severe pain with percussion of the volar wrist indicates that very few axons have crossed the repair site. Observing the patient for additional time is unlikely to yield improved recovery. At surgical exploration, the patient had a large neuroma at the repair site. A photograph is shown. Tacrolimus is an immune modulating agent commonly used in solid organ transplants. It has been investigated in animals and clinical trials in humans and shown some effectiveness in improving nerve regeneration across the repair. It is not currently used in humans outside of clinical trials. Also, in all trials of tacrolimus use, the medication was started at the time of repair, not 11 months later. Nerve conduits have been used to repair short-gap nerve injuries. Although there are reports of successful nerve regeneration of gaps greater than the original indication of 1.5 cm, a gap of 6 cm is well beyond the limits of what a conduit can bridge. Transfer of the extensor indicis proprius tendon would restore thumb opposition and use a tendon not involved in the original injury. However, this would not address the patient's principal complaint of pain and lack of sensation.

A 16-year-old girl is brought for evaluation because she has been unable to extend her left ring finger since the tip of her finger was struck by a basketball during a game 3 hours ago. On physical examination, she is unable to straighten the distal interphalangeal (DIP) joint. An extensor lag of 35 degrees is noted. X-ray study shows no fracture or dislocation. Which of the following is the most appropriate management? A. Arthrodesis of the DIP joint B. Continuous extension splinting of the distal phalanx C. Exploration and suture of the torn tendon D. Open repair with reinsertion of the tendon into bone E. Splinting of the proximal interphalangeal (PIP) joint in extension with the DIP free

B. The patient has sustained a mallet injury to the left ring finger. There is tearing of the terminal extensor tendon from its insertion at the base of the distal phalanx, resulting in inability to extend the finger at the DIP joint. On occasion, these injuries may be associated with an avulsion fracture from the dorsal aspect of the distal phalanx. The majority of closed mallet injuries (Type I) in Zone I of the extensor tendon can be treated by continuous extension splinting for 6 to 8 weeks. It is important that the finger not be allowed to flex at the DIP joint during this time period to avoid disruption of healing. Arthrodesis of the DIP joint is reserved for cases of DIP joint arthritis and would not be necessary in this patient. Exploration and suture of the tendon can be performed, but results are no better than closed treatment due to the difficulty of obtaining adequate repair of the thin tendinous substance at this level. Additionally, the patient will still require prolonged immobilization of the DIP joint after open repair. Exploration and suture of the tendon is used to treat Type II (open) mallet injuries. Open repair with reinsertion of tendon into bone is performed in flexor digitorum profundus avulsion injuries. Splinting of the PIP joint in extension with the DIP joint free is used to treat Zone III extensor tendon injuries (central slip avulsion injuries).

A 40-year-old, right-hand-dominant man comes to the office because of a 2-mm pigmented lesion beneath the thumbnail of the left hand. He says that he first noticed the lesion within the last week. The patient recalls no trauma to the thumb. He has no other fingernails or toenails with similar streaking. Biopsy of a subungual lesion is most appropriate after which of the following periods of time has passed without change? A. 0 to 3 Weeks B. 4 to 6 Weeks C. 7 to 9 Weeks D. 10 to 12 Weeks E. 13 to 15 Weeks

B. The prognosis for a subungual melanoma is worse than that of cutaneous melanoma. Often, there is a delay in the diagnosis of subungual melanomas; in practice, it is better to be highly suspicious of any pigmented lesion beneath the nail and perform a biopsy. According to recent research, the 5-year survival rate for a patient with a subungual melanoma ranges from 28 to 30%. The 10-year survival rate drops to 0 to 13%. Clearly, this is a devastating disease, and over-vigilance regarding diagnosis is recommended. The current recommendation is to perform a biopsy of any subungual lesion after 4 to 6 weeks without significant change.

A 10-year-old girl is brought to the office 2 years after she sustained a crush injury to the nail bed of the long finger of the right hand. Her mother sought no treatment at the time of injury. She now says that the nail appears split in two with no growth of the middle third of the nail. Examination shows a midline deformity that involves both the sterile and germinal matrices. Which of the following is the most appropriate management? A. Excision of scar and primary closure of the nail bed B. Full-thickness grafting from the nail bed of the great toe C. Full-thickness grafting from the nail bed of the ring finger D. Split-thickness grafting from the nail bed of the great toe E. Split-thickness grafting from the nail bed of the ring finger

B. This patient has a split-nail deformity; the most appropriate management is full-thickness nail grafting from the toe. This deformity is caused by injury to the nail bed, leading to scarring of the bed. The nail plate does not grow in the scarred area, resulting in a split in the nail plate. The deformity described involves both the sterile and germinal matrices. Therefore, only a full-thickness nail will provide the sterile and germinal matrix components required for reconstruction. When a full-thickness nail bed graft is harvested, donor morbidity will always occur. Therefore, the donor site should be from the first or second toes or from spare parts in multidigit injuries. In patients who have a small scar affecting the sterile matrix only, appropriate management may include excision of the scar and reapproximation of the sterile matrix. This is usually not possible unless the affected area is quite narrow and there is no involvement of the germinal matrix. A split-thickness nail bed graft from either another finger nail bed or a toe will not provide the components needed for reconstruction of this defect. In addition, using another finger as a donor will result in an unsightly donor defect in the hand.

A 36-year-old man comes to the emergency department 8 hours after he sustained a sharp circumferential laceration of the proximal forearm. Most of the musculature is visibly transected. The distal forearm and hand are pale and insensate, and there are no discernible pulses distal to the laceration. X-ray study shows no bony injury. All structures are successfully repaired and hand perfusion is restored during a 6-hour procedure. Which of the following is the most appropriate next step in treatment? A. Administration of an anticoagulant B. Administration of thrombolytic agents C. Forearm and hand fasciotomies D. Splinting, and intravenous administration of antibiotics E. Tissue oximetry

C. Following a protracted course of tissue ischemia, reperfusion will lead to soft-tissue and muscle edema, and there is a very high risk of compartment syndrome. Routine prophylactic fasciotomy after arterial repair has been questioned. Nevertheless, an extended warm ischemia time of greater than 8 hours and a combined injury involving both major arteries and veins have been proposed as indications for this procedure. In this scenario, the patient has both of these risk factors for reperfusion compartment syndrome, and fasciotomy of the hand and forearm should be performed before leaving the operating room. Wound management, splinting, intravenous administration of antibiotics, and monitoring of hand perfusion are important postoperative modalities, but they are not as temporally relevant as fasciotomy. The use of thrombolytic agents is not indicated in this setting because the perfusion was restored and there is no reason in the vignette to suspect evolving thrombus formation. The routine use of anticoagulant after uncomplicated vessel repair is controversial.

A 35-year-old, right-hand-dominant man comes to the office because of passively correctable clawing of all four fingers of the right hand 1 year after he sustained a stab wound to the proximal right forearm that lacerated the ulnar nerve and artery, median nerve, flexor digitorum superficialis (FDS), flexor digitorum profundus, flexor carpi radialis (FCR), and flexor carpi ulnaris (FCU). Each of the injured structures was repaired primarily on the day of injury. A photograph is shown. Which of the following tendons is the most appropriate donor to address the clawing deformity? A. Abductor pollicis brevis B. Brachioradialis C. Extensor carpi radialis brevis D. FCR E. FDS-3 to the long finger

C. The flexor digitorum superficialis and flexor carpi radialis musculotendinous units were lacerated in the original injury. They would not be appropriate donor motors due to this. Brachioradialis transfer to the flexor pollicis longus transfer has been reported for patients with cervical spine injuries, but it is not used for transfers to restore intrinsic muscle function. The abductor pollicis brevis cannot be used to correct a claw deformity due to its small size and position in the thenar eminence; in addition, for this patient, its innervation was injured in the original trauma. Both the extensor carpi radialis longus and brevis have been described as a tendon transfer. Neither muscle has been affected by the initial injury. Whichever tendon is not harvested can power wrist extension along with the extensor carpi ulnaris. The tendon does need to be elongated with a graft.

A 25-year-old man is brought to the emergency department after he sustained a knife wound to the right lower extremity. Examination shows numbness of the lateral aspect of the leg and weakness in plantar flexion and eversion of the foot. Which of the following nerves was most likely injured in this patient? A. Femoral B. Obturator C. Peroneal D. Sural E. Tibial

C. The patient appears to demonstrate symptoms of a superficial peroneal nerve injury. The superficial peroneal nerve arises from the common peroneal nerve at the fibular neck. It supplies the lateral compartment of the leg, giving motor branches to peroneus longus and brevis, as well as sensory contribution to the lateral aspect of the leg. Injury to the superficial peroneal nerve results in anesthesia of the lateral aspect of the leg and weakness in eversion and plantar flexion of the foot. The deep peroneal nerve arises from the common peroneal nerve at the fibular neck. It travels in the anterior compartment of the leg and gives branches to the tibialis anterior, extensor hallucis longus, and extensor digitorum longus and brevis, as well as peroneus tertius. The sensory distribution is in the area of the first web space. Injury to the deep peroneal nerve causes weakness in dorsiflexion of the foot. The femoral nerve innervates muscles of the anterior thigh, including the quadriceps group, iliacus, and sartorius. Injury to the femoral nerve results in weakness of leg extension. The obturator nerve provides innervation to the medial thigh muscles (adductor group), including adductor brevis, longus, and magnus, as well as the gracilis and obturator externus. The cutaneous branch provides sensation of the medial thigh. Injury to the obturator nerve results in weakness in thigh adduction and sensory deficits in the medial thigh. The sural nerve travels on the posterior aspect of the leg between the lateral malleolus and calcaneus. It provides sensation to the lateral aspect of the foot and does not have a motor component. It is commonly sampled in nerve biopsy and used as a source of nerve graft. Injury or sacrifice of the sural nerve would result in numbness of the lateral foot. The tibial nerve is a branch of the sciatic nerve. It travels through the popliteal fossa and gives off branches to gastrocnemius, soleus, plantaris, and popliteus muscles. The tibial nerve travels in proximity to the posterior tibial artery. In the leg, it gives off branches to the flexor digitorum longus, tibialis posterior, and flexor hallucis longus. Distally in the foot, it branches to give rise to the medial and lateral plantar nerves, which provide sensation to the plantar surface of the foot. Injury to the tibial nerve results in deficits of plantar flexion, as well as anesthesia to the plantar surface of the foot.

A 55-year-old man is evaluated in the emergency department for foot salvage after he was involved in a motorcycle collision. Flow is restored after 6 hours from the time of injury. On examination, the foot is cold, and no plantar sensation is noted. The posterior tibial nerve is disrupted. A temporary external fixator is placed. A photograph and an x-ray study are shown. Which of the following is the most appropriate classification of this injury and recommendation for management? A. Gustilo type IIIB; amputation B. Gustilo type IIIB; reconstruction C. Gustilo type IIIC; amputation D. Gustilo type IIIC; reconstruction

C. The patient described has a Gustilo IIIC injury. Based on the best available data, he should undergo amputation. Ultimately, the choice to reconstruct versus amputate is a gestalt of the situation and the patient, as well as the capabilities of the hospital and the care team. In this case, the factors influencing the decision would be the warm ischemia time of 6 hours and severed posterior tibial nerve, as well as the extensive soft-tissue injury. Some of the newer data suggests that absence of plantar sensation is no longer criteria for amputation in and of itself. However, an anatomically disrupted nerve in an adult strongly favors amputation. In addition, there is evidence supporting the notion that limb salvage might involve less cost in the long term versus reconstruction.

A 49-year-old man comes to the office because he has been unable to extend the wrist, fingers, and thumb of his right hand since fracturing his humerus 16 months ago. He underwent open reduction and internal fixation at that time. The fracture healed well. There has been no change in function since the procedure. Physical examination shows the patient is unable to actively extend the wrist, fingers, and thumb. Tendon transfers are planned. Which of the following is the most appropriate muscle to transfer for restoration of finger extension? A. Brachioradialis B. Extensor carpi radialis longus C. Flexor carpi ulnaris D. Palmaris longus E. Pronator teres

C. The radial nerve can be injured as a result of humerus fracture and/or surgery as it crosses the spiral groove of the humerus. The resultant radial nerve palsy will cause inability to extend the wrist, fingers, and thumb. Reinnervation of the muscle ideally should be completed within 12 to 18 months following injury to allow for recovery. In this patient who has radial nerve palsy after humerus fracture, the time following injury has been too long, so nerve repairs or nerve transfers are not a viable option, and tendon transfer is the procedure of choice. Tendon transfer involves the use of a noncritical or expendable donor tendon to provide a missing function. The tendon to be transferred should have adequate strength and range of motion to provide the desired function. Ideally, the tendon used should have synergistic action and allow for tenodesis to facilitate reeducation. Transfer of the flexor carpi ulnaris to the extensor digitorum communis will provide extensor function of the fingers, as it has adequate power and excursion and takes advantage of the linkage between wrist flexion and finger extension. Other typical tendon transfers for finger extension in radial nerve palsy include the flexor carpi radialis and the flexor digitorum superficialis. The pronator teres has adequate power but less excursion. It is typically used to restore wrist extension rather than finger extension.

A 35-year-old man comes to the office for follow-up 3 years after he sustained a scaphoid fracture of the dominant right wrist that was treated in a cast until radiographically healed. Examination shows reduced wrist extension of 35 degrees, weakened grip strength, and dorsoradial wrist pain. Scaphoid malunion is suspected, and an oblique sagittal CT scan is obtained. Which of the following is the minimum intrascaphoid angle at which surgical intervention is required? A. 10 Degrees B. 25 Degrees C. 45 Degrees D. 65 Degrees E. 80 Degrees

C. Treatment of a scaphoid malunion or "humpback" nonunion deformity by means of an opening interposition wedge bone graft is indicated when the lateral intrascaphoid angle is greater than 45 degrees. The intrascaphoid angle is determined by drawing a line tangent to the dorsal cortex of the distal fragment and the palmar cortex of the proximal fragment. Normally, this angle is 30 to 40 degrees. Amadio and coworkers reported on 45 patients with 46 scaphoid fractures greater than 6 months after healing. There were good clinical outcomes in 83% of those with intrascaphoid angles less than 35 degrees, and posttraumatic arthritis in 22%. In contrast, in those with greater than 45 degrees of lateral intrascaphoid angulation, only 27% had good outcome, and 54% developed posttraumatic arthritis. Nakamura and colleagues performed volar wedge bone grafting on seven symptomatic patients with scaphoid malunion, and all improved their symptoms.

A 45-year-old man with a detailed history of alcohol abuse is referred for evaluation of pain in his left arm and forearm that began 1 week ago after a fall. Volkmann contracture is suspected. Which of the following is the most likely area to be initially affected? A. Extensor digitorum communis B. Flexor carpi radialis and palmaris longus C. Flexor digitorum profundus D. Supinator, brachioradialis, and extensor carpi radialis E. Volar wrist ligaments and capsule

C. Volkmann ischemic contracture can evolve from an untreated acute injury or fracture, blunt or sharp. In the scenario described, the patient appears to have passed out on his forearm, inebriated, possibly compounded by drug use. He presents in a delayed fashion with an early or partial Volkmann ischemic contracture. Essentially, this item tests the examinee's basic knowledge of which parts of the forearm musculature are most sensitive to internal pressure and ischemic injury. Useful classification systems that correlate well with clinical examination include the Tsuge and Holden classifications. The Tsuge classification basically describes a predictable injury pattern based on the relative susceptibility of different muscles in the forearm to ischemia and pressure. Essentially, the deeper compartments are the most susceptible. A mild Tsuge type affects the flexor digitorum profundus first. The moderate type involves the rest of the deep flexor compartment and begins to affect the superficial flexor compartment. Severe Tsuge type involves the complete deep and superficial flexor compartments, as well as the extensor compartment and mobile wad to varying degrees. Therefore, in this case, the correct response is the flexor digitorum profundus because it is the most sensitive muscle group to a Volkmann ischemic contracture generating insult. A complementary classification system is the Holden classification. The Holden Type 1 classification essentially describes contractures of varied severity caused by injuries proximal to the injured forearm muscles. Examples include a brachial artery thrombosis or a humeral fracture leading to vascular injury and a Volkmann ischemic contracture distal to the site of the initial injury. The Holden Type 2 classification describes direct injuries to the fascial compartment of varied severity, such as prolonged direct pressure, as in the scenario described. Other examples would be direct crush injuries or severe radial and ulnar fractures.

A 48-year-old man comes to the office because of drainage from the distal aspect of the wound 2 weeks after he underwent soft-tissue coverage with a free latissimus dorsi muscle flap for a degloving injury of the left lower extremity sustained in a motorcycle collision. Examination in the emergency department showed a Gustilo type IIIB tibia/fibula fracture and 6 cm of tibial loss. Debridement of the bone and stabilization with an external fixator were performed at the time of the injury. The patient underwent soft-tissue coverage 8 days after the injury. Examination today shows purulent drainage at the lower portion of the flap. Which of the following is the most likely cause of this complication? A. Age of patient B. Delay in soft-tissue coverage C. Distal flap necrosis D. Inadequate debridement

D. Posttraumatic reconstruction of the lower extremities with significant soft-tissue defects that expose bone, joints and tendons generally require free tissue transfer. The Gustilo-Anderson fracture classification system is widely used to describe the injury when associated with a long bone fracture. Gustilo type IIIB fractures are associated with periosteal stripping and exposure of bone with contamination. In 1986, Godina emphasized coverage of these soft-tissue defects within the first 72 hours of injury. Given the nature of these poly-trauma injuries, coverage of these wounds is not always possible in the given time frame. Staged debridement and negative pressure therapy have become common in the management of these injuries. Inadequate bone or soft-tissue debridement prior to reconstruction is a common cause of failure. The wound has to be free of all contaminants prior to reconstruction; thus, it is unlikely that an 8-day delay is the cause of breakdown. Distal flap necrosis would show more superficial breakdown and, in this case, is not the cause for a deep space infection. The patient's age does not have any bearing on this complication.

A 37-year-old man comes to the office because of wound breakdown 2 weeks after he sustained a calcaneal fracture. Orthopaedic stabilization was performed in the emergency department at the time of the injury. Examination today shows a 3 × 4-cm wound over the lateral calcaneus. Coverage with a propeller fasciocutaneous flap from the lateral leg is planned. Which of the following blood vessels supplies the perforators of this flap? A. Anterior tibial artery B. Lateral plantar artery C. Lateral sural artery D. Peroneal artery E. Posterior tibial artery

D. Propeller flaps are a useful method of lower extremity reconstruction. These flaps were initially popularized by Teo and have been utilized for a variety of defects in the lower leg and foot. The propeller flap is based on perforating blood vessels from the peroneal artery to reconstruct lateral defects and perforators from the posterior tibial artery to reconstruct defects on the medial aspect of the leg wound. The propeller flaps can often replace the need for a sural artery, neurocutaneous artery flap or a free tissue transfer. Laterally based plantar flaps may be used to cover small defects on the weight-bearing surface of the foot but are not reliable for larger or lateral defects. The posterior and anterior tibial arteries do not have perforator in the desired location for a distally based propeller flap. The lateral sural vessels are too proximal for heel coverage.

A 35-year-old handyman comes to the office for follow-up 12 days after he underwent repair of the flexor digitorum profundus and superficialis (FDP and FDS) tendons of the little finger of the nondominant hand because of a knife injury. Early active motion was initiated during occupational therapy with sudden loss of flexion of distal and proximal joints yesterday. Which of the following is the most appropriate treatment? A. Delay treatment for 10 weeks, then place a silicone rod B. Discontinue occupational therapy for 2 weeks, then resume with a Duran passive protocol C. Fuse the proximal and distal joints of the little finger D. Repair the FDS and FDP tendons E. Transfer the FDS tendon of the ring finger to the FDP of the little finger

D. Tendon rupture can occur early or late, up to 6 to 7 weeks, with days 7 to 10 being most common. Reoperation with repair of the previously repaired tendons will yield results similar to primary repair. Therefore, discontinuation of therapy and rod placement are incorrect. Repair should be undertaken before 2 weeks due to tendon shortening. Repair of both tendons will retain independent finger motion with greater power and decreased chance of proximal interphalangeal joint hyperextension. There will also be a better bed for FDP gliding. Therefore, flexor digitorum superficialis transfer is incorrect. Arthrodesis is reserved for failed treatment.

A 53-year-old man is brought to the emergency department after sustaining a laceration of the index flexor digitorum profundus, superficialis, and radial digital nerve of the nondominant left hand. He is scheduled to undergo urgent repair with single-cuff Bier block anesthesia. Which of the following would be the best reason to use an axillary block in this patient? A. Age B. Gender C. Occupation D. Surgical duration E. Urgency of surgery

D. The advantages of Bier block include reliability with low incidence of block failure, safety with rapid onset and recovery. The block is limited to tourniquet pain often occurring after 20 to 30 minutes and limits its use to shorter procedures on the upper extremities. Sudden cardiovascular collapse or seizures may occur if local anesthetic is released into the circulation too early. Disease processes in which a tourniquet is contraindicated include Raynaud disease, sickle cell disease, and severe hypertension. Uncooperative patients and young children are also contraindications. Short duration procedures, including carpal tunnel release, tendon contracture release, foreign body extraction, and trigger finger release, are examples of procedures where Bier blocks may be considered. Age, gender, occupation, and urgency of surgery are not contraindications to this procedure. Bier block anesthesia is a contraindication in the very young and very old, but not in a 53-year-old patient.

A 35-year-old man comes to the emergency department with a humerus fracture. On examination, he is unable to extend his wrist, fingers, and thumb. Which of the following nerves is most likely injured? A. Axillary B. Median C. Musculocutaneous D. Radial E. Ulnar

D. This patient has a radial nerve injury, which can occur with humerus fractures. The radial nerve innervates the wrist extensors, extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB); the thumb extensors, extensor pollicis longus (EPL) and extensor pollicis brevis (EPB); and the finger extensors, extensor digitorum communis (EDC). These radial nerve injuries are usually managed with a period of observation and therapy until a potential neurapraxia resolves. Early evidence of muscle reinnervation would be evident with improved function of the ECRL, followed by the ECRB, then the finger and thumb extensors. If the patient does not regain any function by 3 to 6 months, exploration and nerve repair or tendon transfers to restore lost function can be considered. The standard tendon transfers considered for radial nerve function loss include the pronator teres to the ECRB (wrist extension), flexor carpi ulnaris to the EDC (finger extension), and the palmaris longus to the EPL (for thumb extension). A median nerve deficit would result in loss of flexion of wrist, fingers, thumb, and loss of palmar sensation and not typical after humerus fractures. An ulnar nerve injury could present with loss of hand intrinsic function and loss of sensation of the small finger. The musculocutaneous nerve innervates the biceps and would result in loss of elbow flexion. The axillary nerve is not injured with humerus fractures.

A 32-year-old man comes to the emergency department after a motorcycle collision. Examination and x-ray studies show an isolated injury to the left wrist consistent with a perilunate dislocation. In perilunate dislocations, dislocation of which of the following is the initial injury that leads to lunate dislocation? A. Dorsal carpal ligaments B. Lunocapitate junction C. Lunotriquetral ligaments D. Scapholunate ligament E. Triangular fibrocartilage complex

D. Wagner and Mayfield conducted classic studies on carpal dynamics and anatomy to determine the progression of stresses across the wrist in severe hyperextension injuries. They determined that there is a reliable and predictable pattern to these injuries, which is described as Progressive Perilunate Instability (PLI). There are four stages of PLI, corresponding to the degree of stress applied in the injury. The mildest form is the isolated scapholunate dissociation: PLI stage 1. As the forces continue in an ulnar and distal direction, the distal row and scaphoid progress dorsally, and the capitate separates from the lunate: PLI stage 2. As the force continues in an ulnar direction, the lunotriquetral ligaments separate, and if the lunate is still in place, this is the full Midcarpal Dislocation: PLI stage 3. Finally, in the most severe cases, the dorsally dislocated capitate will dislodge the lunate and push it volarly, creating the true lunate dislocation: PLI stage 4.

A 35-year-old, right-hand-dominant man comes to the office 3 months after he completely severed both the flexor digitorum superficialis and profundus tendons in Zone II of the right long finger. He did not seek medical attention at the time of the injury. Physical examination shows inability to flex actively at the proximal interphalangeal (PIP) joint and distal interphalangeal (DIP) joint. He has passive range of motion. Which of the following is the most appropriate management? A. One-stage tendon grafting B. Primary repair C. Tendon transfer D. Two-stage tendon reconstruction E. Observation only

D. When patients present with zone II flexor injuries, it is optimal to repair both flexors within 10 days after the injury before the tendons retract excessively preventing primary approximation of the tendon ends. Late flexor injuries (after 2 weeks) in zones I, III, IV, and V can be managed with single-stage tendon grafting. However, when the injury is in zone II, the sheath has collapsed and tendon grafts cannot be easily pulled under intact pulleys, necessitating pulley reconstruction over a silicone rod in the first stage. Then, in a second stage, the tendon rod is replaced with the tendon graft pulled into the sheath in the proximal to distal direction after suturing the graft to the rod. The tendon is repaired first distally to bone, and then the appropriate tension is set on the proximal juncture repair of the graft to the motor tendon (usually the flexor digitorum superficialis to avoid quadriga and lumbrical plus posture). Two-stage tendon grafting in general is recommended for zone II flexor repairs that present late, require simultaneous critical pulley reconstruction (A2, A4), or if volar finger soft-tissue reconstruction is required. Tendon transfer options would not be long enough to span the defect out to the distal phalanx and the flexor digitorum profundus from other fingers should not be sacrificed. Further observation is certainly not warranted.

A 345-lb (156-kg), 5-ft 1-in (155-cm), 59-year-old woman comes to the office because of the condition of the lower extremities in the photograph shown (lymphedema). BMI is 65 kg/m2. She says she has tried "everything" and "nothing seems to work." She states that the left leg is worse than right. The condition first appeared over 20 years ago after she underwent surgery of the left leg. She was hospitalized 10 times for cellulitis/infection in the past 1 year. She refuses compression therapy because it has become too painful. Which of the following are the most likely diagnosis and most appropriate management? A. Primary lymphedema; medical management B. Primary lymphedema; surgical management C. Secondary lymphedema; medical management D. Secondary lymphedema; surgical management

D. The morbidly obese patient described suffers from severe secondary lymphedema. Assuming she doesn't have any contraindications to an operative procedure, she has failed medical management and should be offered surgery. Lower extremity lymphedema can be considered either primary or secondary. Primary lymphedema can be congenital, praecox, or tarda based on the age at presentation. Secondary lymphedema can be due to either lymphatic obstruction (due to cancer, infection, or radiation) or lymphatic interruption (due to groin surgery or lymph node excision). By far, the most common approach to lymphedema (either primary or secondary) is medical management. However, the most common indication for surgery is failure of medical management. There are a variety of surgical options. These include procedures to improve lymphatic flow and procedures to debulk the affected tissue.

A 30-year-old man is evaluated because he is unable to abduct or externally rotate his shoulder or flex his elbow 4 months after he was involved in a high-speed motor vehicle collision. Physical examination shows numbness of the lateral upper arm and forearm. Which of the following nerve transfers is most appropriate to restore external rotation of the shoulder? A. C7 ipsilateral root to anterior division of upper trunk B. Medial pectoral nerve to medial cord C. Phrenic nerve to long thoracic nerve D. Radial nerve to axillary nerve E. Spinal accessory nerve to suprascapular nerve

E. Examination findings indicate a C5-6 avulsion or very proximal upper trunk injury. External rotation of the shoulder is provided by the supraspinatus and infraspinatus muscles. Multiple techniques for harvest of the distal spinal accessory nerve to transfer to the suprascapular nerve have been described. This transfer would restore external rotation. Transfer of the radial nerve to the axillary nerve will provide deltoid and possibly teres major innervation. This will improve shoulder function overall but will not restore external rotation. The phrenic nerve is commonly used to provide donor motor axons, but the long thoracic nerve goes to the serratus anterior. Contralateral C7 transfer can be used to innervate the upper trunk. Ipsilateral C7 would not be used because the C5 and C6 roots were destroyed in the injury. Also, coaptation to the anterior division of the upper trunk would be distal to the origin of the suprascapular nerve. The medial pectoral nerve can also be used for donor motor axons. It is limited by its relatively short reach. Coaptation to the medial cord of the brachial plexus would innervate the ulnar nerve, which is not injured in this patient.

A 32-year-old man comes to the office because of a "mallet" deformity of the distal joint of the long finger of the dominant hand sustained 12 years ago while he was playing baseball. He has not sought medical treatment until now. On examination, which of the following deformities is most likely? A. Boutonnière B. Camptodactyly C. Clinodactyly D. Hook-nail E. Swan-neck

E. Flexion deformity of the distal joint seen in mallet finger will lead to secondary hyperextension of the proximal joint. This occurs in a zigzag fashion because of the imbalance of forces. If the terminal tendon is displaced proximally, the conjoined tendons will slide proximally and become extensors to the proximal joint. A boutonnière deformity is a flexion deformity of the proximal joint from disruption of the central slip. The lateral slips migrate volarly becoming an extensor to the distal joint which then hyperextends. Clinodactyly is a genetic condition in which there is a curvature of the fifth finger toward the fourth finger. A hook nail usually results from loss of nail bed support, usually after amputation. Camptodactyly is also a genetic condition in which there is a fixed flexion deformity of the proximal joint of the little finger.

A 55-year-old woman comes to the office because of a 2-year history of a painless mass within the thenar eminence. Physical examination shows a soft, mobile, nontender mass that does not transilluminate. Which of the following is the most likely diagnosis? A. Epidermal cyst B. Ganglion C. Giant cell tumor D. Glomus tumor E. Lipoma

E. Lipomas are one of the most common tumors of the body with 10 to 20% occurring in the hand and wrist. Lipomas are most frequently located in the thenar eminence followed by dorsal or volar sides of the digits. The female-to-male ratio is 2:1 and age range is third to sixth decade. Epidermal cysts have a 2:1 male-to-female ratio with a peak incidence at age 39. They are located in the distal phalanges, usually palmar index and long. Ganglions account for 50 to 70% of all benign hand tumors with a female-to-male ratio of 3:1. They usually occur in the second to fourth decade with locations being dorsal carpal, volar carpal, volar retinacular, and mucous cyst of the distal interphalangeal joints. Some superficial ganglions will transilluminate. Benign giant cell tumors of the tendon sheaths have no sex difference, occurring between the fourth and sixth decade and are located in the digits, mostly volar index and long. Glomus tumors account for only 1 to 5% of hand tumors. There is a 2:1 female-to-male ratio, usually occurring between ages 30 to 50, and the tumors are subungual 50% of the time.

A 60-year-old woman comes to the office because of a 15-year history of rheumatoid arthritis affecting both hands. She has intractable pain, wrist collapse with carpal supination, a severe ulnar deviation with volar subluxation deformity of the metacarpophalangeal (MCP) joints, and distal interphalangeal (DIP) joint flexion deformities. She says these conditions are greatly decreasing her strength when she attempts to grasp objects. Which of the following findings is a contraindication to immediate MCP joint arthroplasty in this patient? A. DIP joint flexion deformities B. Grasp weakness C. MCP joint subluxation D. Severe pain E. Wrist collapse

E. Patients with rheumatoid arthritis can have progressive deformity of their metacarpophalangeal (MCP) joints, ultimately resulting in loss of function. Classically, these patients present with ulnar drift and volar dislocation of these joints. When the pain in the MCP joint is severe along with weak grasp and poor appearance, implant arthroplasty may be performed to improve the functional range of motion, stability, and resistance to lateral and rotational forces. These patients can also present with concurrent deformity of the wrist and joints distal to the MCP joint. Reconstruction of the rheumatoid hand must proceed from proximal to distal joints. If there is significant deformity of the wrist that is not addressed, the patient may get recurrent ulnar deviation of the fingers after arthroplasty. In addition, preoperative wrist pain may limit hand function, even after successful treatment of the MCP joint with arthroplasty. Thus, the wrist should be addressed first prior to MCP joint arthroplasty.

A 20-year-old man comes to the office 2 months after "jamming" the long finger of the right hand in a rugby game. On examination, the patient has a boutonnière deformity. The distal interphalangeal (DIP) joint has 20 degrees of hyperextension and active flexion to 85 degrees. X-ray study shows no fracture. Which of the following is the most appropriate initial treatment? A. Open central slip repair B. Resection of the lateral bands and oblique retinacular ligament C. Resection of the lateral bands only D. Splinting of the proximal interphalangeal (PIP) and DIP joints in extension E. Splinting of the PIP in extension and active DIP flexion

E. The patient has a boutonnière deformity that is passively correctable. In most instances, this can be successfully managed with splinting of the PIP joint in extension while allowing active DIP flexion. Splinting of the PIP in extension helps restore central slip continuity; active DIP flexion with the PIP joint extended draws the tight, volarly displaced lateral bands into a more dorsal position while reducing DIP joint hyperextension. Holding the PIP and DIP joints both in extension will not correct the deformity. Open central slip repair is indicated if there is an open wound, but that is not the case in this scenario. Resection of the distal lateral bands only is a reasonable treatment for chronic deformity by relaxing the lateral bands. There is no role for resection of both lateral bands and oblique retinacular ligament in the management of this condition.

A 63-year-old right-hand-dominant woman with rheumatoid arthritis comes to the office because of a progressive deformity of the long finger of the left hand characterized by proximal interphalangeal (PIP) joint hyperextension and distal interphalangeal (DIP) joint flexion. Examination shows limited PIP joint flexion in all metacarpophalangeal (MCP) joint positions. Which of the following is the most appropriate management? A. DIP joint arthrodesis with a small-caliber cannulated screw B. Figure-of-eight splinting for 6 to 8 weeks C. PIP joint arthrodesis and MCP joint intrinsic release D. Transection of the terminal tendon E. Translocation of the lateral bands and dorsal PIP joint capsulectomy

E. Rheumatoid arthritis is a chronic, systemic inflammatory disorder that principally affects synovial joints. Finger deformities resulting from rheumatoid arthritis are often disabling and aesthetically unsatisfactory. The swan-neck deformity consists of PIP joint hyperextension and DIP joint flexion. Classification of swan-neck deformities is based on PIP joint mobility and radiographic changes. Nalebuff described four types: Type I Flexible PIP joint deformity, regardless of MCP joint position Type II Limited PIP joint flexion with the MCP extended because of intrinsic tightness Type III Limited PIP joint flexion in all MCP joint positions because of a fixed dorsal position of the lateral bands Type IV PIP joint destruction Management depends on the extent of the PIP joint deformity. Type I swan-neck deformities generally respond to figure-of-eight splinting. DIP arthrodesis can be considered for swan-neck deformity resulting from a mallet. Type II swan-neck deformities may be managed by a figure-of-eight splint or by an intrinsic release if the intrinsics are tight without MCP joint subluxation or degeneration. Type III swan-neck deformities are treated with translocation of the lateral bands, PIP joint capsulectomy and collateral ligament release. Type IV swan-neck deformities are treated with PIP joint arthrodesis or PIP joint silicone arthroplasty.

A 24-year-old, right-hand-dominant man comes to the office because of a 2-year history of a deformity of the ring finger of the left hand that has worsened progressively. History includes rheumatoid arthritis that is managed with multiple disease-modifying medications. A photograph and an x-ray study are shown (swan neck). Which of the following anatomical abnormalities is the most likely cause of this patient's ring finger deformity? A. Contraction of the oblique retinacular ligament B. Flexor digitorum profundus avulsion at the distal interphalangeal (DIP) joint C. Palmar subluxation of the metacarpophalangeal (MCP) joint D. Rupture of the central slip of the extensor mechanism E. Volar plate laxity of the proximal interphalangeal (PIP) joint

E. Swan-neck deformity can occur in the post-traumatic setting as well as in the rheumatoid arthritis population. The PIP joint hyperextends, and the DIP joint flexes. Unlike boutonnière deformity, which is always initiated by a rupture of the central slip of the extensor mechanism, the origin of a swan-neck deformity can be at the DIP, PIP, or MCP joint. Regardless of the initiating problem, a swan-neck deformity can only occur if there is laxity of the volar plate of the PIP joint to allow hyperextension. Flexor digitorum profundus avulsion would lead to inability to flex the DIP joint and would not cause hyperextension of the PIP joint. The oblique retinacular ligament can be used to repair a swan-neck deformity but is not causative of the pathology. Palmar subluxation of the MCP joint can lead to a swan-neck deformity in rheumatoid arthritis patients, but the photograph and x-ray study show this is not present in this patient. Rupture of the central slip of the extensor mechanism would lead to a boutonnière deformity.

The primary blood supply to a free anterolateral thigh fasciocutaneous flap arises from vessels that perforate which of the following muscles? A. Gluteus maximus B. Rectus femoris C. Sartorius D. Tensor fascia lata E. Vastus lateralis

E. The anterolateral thigh (ALT) flap has proven to be one of the most versatile free tissue transfers in reconstructive surgery. Based on perforators from the descending branch of the lateral circumflex femoral artery that traverse the vastus lateralis (VL) (80%) or the septum between the rectus femoris and VL (18-20%), this flap can be fashioned as large as 10 cm wide by 25 cm long. Occasionally, no large perforator will be identified during dissection; in this circumstance, the flap may be carried on multiple perforators along with the vastus lateralis muscle. Branches of the lateral circumflex femoral artery also supply the sartorius (partial, as the supply is segmental), rectus femoris (descending branch), and tensor fascia lata (ascending branch). Vascular supply to the gluteus maximus arises from the superior and inferior gluteal arteries.

An otherwise healthy 47-year-old man is transferred to the hospital because of an infection of the leg. He sustained the initial injury in a fall 6 weeks ago that was treated with internal fixation. The infection is now under control, and the internal hardware has been removed. Examination shows a 9-cm bony defect of the lower extremity. Neurovascular status of the foot is normal. Angiography of both lower extremities shows no abnormalities. A photograph and x-ray study are shown. Which of the following considerations favors vascularized bone grafting in this patient? A. Length of time since the initial injury B. Mechanism of the injury C. Method of injury stabilization D. Patient age E. Size of the bony defect

E. The injury described is a Gustilo IIIB lower extremity wound complicated by infection. The sequence of reconstruction is often bony stabilization and debridement until bacterial balance. Bony deficits can be reconstructed in a variety of ways, including non-vascularized grafts, vascularized grafts (free of pedicle), and bone transport. Generally, for defects greater than 6 to 8 cm, vascularized bone grafting is indicated. Other indications for vascularized bone grafting are the presence of infection and prior failure of conventional (non-vascularized) grafting. Age of the patient is not a contraindication to reconstruction per se, as long as he or she is medically stable to undergo a prolonged operation. Gustilo Classification I: open fracture; clean; wound less than 1 cm II: open fracture; wound greater than 1 cm IIIA: open fracture; extensive soft-tissue injury but adequate tissue for coverage IIIB: open fracture; extensive soft-tissue injury but inadequate tissue for coverage IIIC: any of the above with a vascular (arterial) injury

A 25-year-old woman comes to the office with a 2-day history of difficulty moving the left thumb. Eight weeks ago, she sustained a nondisplaced distal radius fracture. She has been out of a cast for the past 2 weeks. On examination, thumb retropulsion is absent. Which of the following is the most appropriate definitive treatment? A. Fusion of the carpometacarpal (CMC) joint of the thumb B. Fusion of the interphalangeal (IP) joint of the thumb C. Transfer of the anterior interosseous nerve to the recurrent branch of the median nerve D. Transfer of the extensor indicis proprius (EIP) tendon to the abductor pollicis brevis tendon E. Transfer of the EIP tendon to the extensor pollicis longus tendon

E. The scenario depicts a classic case of extensor pollicis longus (EPL) tendon rupture following distal radius fracture. The reported incidence of EPL tendon rupture ranges from 0.2 to 3%. Ruptures can occur after internal or external fixation due to impingement of hardware on the tendon or due to ischemic changes in the tendon due to swelling of the tendon and the third dorsal compartment. Reconstruction of the EPL tendon can be accomplished either by tendon transplantation, typically the palmaris interposition between the proximal and distal healthy segments of the EPL tendon, or by transfer of the EIP to the distal segment of EPL tendon. When identified and treated before the EPL muscles retract and shorten, equivalent outcomes can be achieved. Later treatment necessitates tendon transfer. Fusion of the thumb IP joint may be useful in flexor pollicis longus ruptures that cannot be repaired, but this would not restore thumb retropulsion. Fusion of the CMC joint can alleviate pain from basal joint arthritis, but would result in further loss of motion of the thumb. Transfer of the EIP to the abductor pollicis brevis and transfer of the anterior interosseous nerve to the recurrent branch of the median nerve are techniques for restoring thumb palmar abduction/opposition and would not restore retropulsion/extension.

An active 73-year-old woman comes to the office because of Eaton Stage IV arthritis of the carpometacarpal joint of the dominant thumb (pantrapezial arthritis with carpometacarpal [CMC] joint subluxation). She says she has severe pain when she tries to grip something, such as open a door or twist off the top of a jar. Which of the following is the most predictable procedure to decrease pain and improve hand function in this patient? A. CMC fusion B. Metacarpal osteotomy C. Trapezial hemi-resection and tendon interposition D. Trapezial resection and silicone implantation E. Trapezial resection, ligament reconstruction, and tendon interposition

E. Thumb basilar joint arthritis is a common debilitating problem. The prevalence in postmenopausal women has been estimated at 33%, although many patients with radiographic evidence of arthritis remain asymptomatic. It more often occurs in the dominant hand. The extent of arthritis and joint deformity dictates the best treatment choice. The most widely used classification is that of Eaton and is based on radiographic findings. Stage I has normal joint contours but possible joint widening due to effusion. Although most patients respond to splinting, anti-inflammatory medications, trapezial hemi-resection, and metacarpal osteotomy have been advocated in very symptomatic patients. Stage II shows slight trapeziometacarpal (TM) joint narrowing and minimal sclerosis of the articular surface. The indications for operative treatment are more concrete, and surgical options are largely the same as Stage I, with the addition of CMC fusion as an option in a laborer. Stage III presents as TM joint narrowing with cystic or sclerotic changes in the articular surface. There is variable dorsal subluxation of the TM joint, and adduction contracture may occur. There can be early signs of scaphotrapezial (ST) joint arthritis. If the ST joint is in relatively good condition, some authors still advocate trapezial-sparing procedures such as hemi-resection. Nevertheless, most advocate trapeziectomy with or without ligament reconstruction/tendon interposition (LRTI). There is some evidence that ligament reconstruction preserves the joint space better than no reconstruction, but provides no better clinical outcome and has a higher complication rate. Trapeziectomy ± LRTI provides excellent pain relief and improved function, especially in lower demand patients. In Stage IV, the TM and ST joints are completely destroyed. In these patients, LRTI is the preferred treatment. Some authors report good early results in selected patients with implant arthroplasty; however, there is a moderately high rate (up to 40%) of instability, dislocation, and implant breakage. The use of silicone as a spacer has fallen into disuse due to the risk of chronic tissue inflammation and resultant bone resorption.

During harvest of a plantaris tendon graft, which of the following structures is at greatest risk for injury? A. Dorsalis pedis artery B. Extensor hallucis brevis muscle C. Medial plantar artery D. Sural nerve E. Tibial nerve

E. When multiple tendon grafts are needed or when it is necessary to harvest grafts long enough to reach from the forearm to the fingertip, lower extremity tendon graft harvest is necessary. The plantaris tendon is a good source of tendon graft and is present in about 80% of limbs. The graft is harvested through a vertical incision just anterior to the medial aspect of the Achilles tendon. Then the graft is followed proximally using either a tendon stripper or with further incisions. As such, dissection of the plantaris tendon begins behind the medial malleolus and close to the tibial nerve. The sural nerve lies about the lateral malleolus and thus is not likely to be inadvertently injured during plantaris harvest. The medial plantar artery is on the sole of the foot and would be distal to the field of dissection. The extensor hallucis brevis muscle is a small muscle that lies over the dorsum of the foot and thus, like the dorsalis pedis artery, would not be injured in the dissection.

A 24-year-old man comes to the office 3 months after closed reduction of a right knee dislocation. His knee is stable, but he still depends on an ankle/foot orthosis for ambulation. Physical examination shows decreased light-touch sensation along the dorsolateral aspect of the foot. Ankle eversion is absent. Sensation and motor function are otherwise intact. Nerve conduction testing is most likely to demonstrate a block in which of the following nerves? A. Common peroneal B. Lateral plantar C. Medial plantar D. Posterior tibial E. Superficial peroneal

E. Common peroneal nerve injuries involving motor function loss have been reported in up to 50% of knee dislocations. If isolated sensory disturbances are also included, the incidence of nerve injury approaches 75%. If no recovery is noted by 3 to 6 months following injury, then surgical treatment is warranted. Physical exam primarily determines the nerve to be explored, neurolysed, and possibly grafted, but nerve conduction studies can be useful pre- and intraoperatively. The common peroneal nerve divides into three branches at the knee, an articular branch that innervates the joint capsule and lateral collateral ligament of the knee, the superficial, and deep branches. The superficial branch innervates the muscles of the lateral compartment of the leg and provides sensation to the lateral calf and dorsal foot. The deep branch innervates the anterior compartment and provides sensation to the first web space of the foot. The scenario given above is most consistent with compromise of the superficial peroneal nerve. If dorsiflexion of the ankle and toe extension had also been lost, then common peroneal nerve injury would have been suggested. The posterior tibial nerve proper innervates the muscles of the posterior calf, mediating ankle plantar flexion and toe flexion. The medial and lateral plantar nerves are terminal branches of the posterior tibial nerve. They provide motor innervation to the deep plantar muscles of the foot and sensation to the plantar surface of the foot.