123 Day A (12/20 A & B 12/21) Daily Mastery Plan

Front 1

Hx:67yo M has soft tissue defect on the palmar aspect of his R hand following a resection of mass Fig A &B. Which is most appropriate for achieving coverage of the defect? 1-Vacuum-assisted wound closure only; 2-Flap coverage with full-thickness skin coverage; 3-Wet-to-dry dressings only
4-split-thickness skin coverage only; 5-Flap coverage with meshed split-thickness skin coverage

Back 1

Soft tissue defects of the palm are most appropriately treated with flap w/ full-thickness grafts. A flap is tissue supported by blood vessels and moved from a donor site to a recipient site to cover a defect in tissue. full-thickness coverage was created from a posterior interosseous artery island flap The skin of the dorsal hand is similar to that of the rest of the body and thus may be adequately replaced by split-thickness skin grafts from the skin of most donor sites. In contrast, palmar hand skin differs from that of the dorsal hand in that it (1) lacks both hair and sebaceous glands and (2) has specialized encapsulated nerve endings (Meissner’s corpuscles and Vater-Pacini corpuscles) that confer enhanced sensation via mechanoreception. Full thickness skin grafts (FTSG) transfer all of the skin appendages and nerve endings except those sweat glands located in the subcutaneous tissue and some of the Vater -Pacini corpuscles of palmar and plantar skin.Ans2

Front 2

An open dorsal approach for antegrade screw fixation of a nondisplaced scaphoid waist fx differs in which of the following ways compared to a percutaneous dorsal approach? 1-Decreased risk of proximal pole AVN; 2-Increased risk of PIN injury
3-Decreased risk of injury to the APL tendon; 4- Increased risk of injury to the EPL tendon; 5- Decreased risk of screw prominence above subchondral bone

Back 2

Scaphoid screw fixation should be just below the subchondral bone; this is best judged by direct visualization. scaphoid screw via a percutaneous approach found that the scaphoid screw "was prominent (above the subchondral bone) in 2 of 12 specimens and flush with or buried in the remaining 10 specimens." As a result, they recommend using a limited dorsal incision to verify full seating of the screw. In addition, they found the percutaneous approach was within 2.2-3.1 mm of the PIN, EDC, and EIP. Thus, all of these structures are at increased risk of injury in a percutaneous approach.Ans5

Front 3

Hx:20yo skateboarder fell 6 mths ago and has had radial-sided wrist pain since. His xray upon presentation in fig A. What is the tx at this time? 1- short arm thumb spica cast; 2-long arm thumb spica cast; 3-wrist arthroscopy to evaluate intercarpal ligaments; 4-ORIF with autologous bone graft; 5-wrist arthrodesis

Back 3

pt has a scaphoid waist fx nonunion. scaphoid nonunions left untreated have a determined course of collapse and progressive arthritis (scaphoid nonunion advanced collapse - SNAC). the standard tx of scaphoid nonunions is ORIF w/ BG; non-op Tx is not appropriate. Proximal row carpectomy and wrist fusion are salvage procedures reserved for patient that has an advanced scaphoid nonunion, collapse and wrist arthritis.Ans4

Front 4

Hx;27yo professional cowboy is thrown from a bull during the rodeo and lands on his hand. No deformity is identified and the hand is completely neurovascularly intact. Pain is present upon palpation of the anatomic snuffbox. xray in Fig A. The cowboy wants to return to competitive riding tomorrow. Which of the following is the best next step in management? 1-Cock-up wrist splint & immediate return to sport as tolerated by pain
2-Steroid injection of the snuffbox, taping of the wrist and return to sport; 3-Wrist MRI; 4-Percutaneous screw fix of theND fx; 5-Scapholunate ligament repair and percutaneous pin fix

Back 4

Tenderness with palpation of the anatomic snuffbox should raise suspicion of a scaphoid fx. xray does NOT show any findings, but scaphoid fx are often not initially visualized on plain xrays. Appropriate tx for any pt w/snuffbox tenderness entails cast immobilization with repeat xrays @ 2-3 wks OR advanced imaging with MRI to evaluate for a fx that is not identified with plain xrays The MRI demonstrates a nondisplaced scaphoid fx. MRI study of 32 consecutive patients who were clinically suspicious for a scaphoid fx, but no fracture could be indentified on wrist xray. The MRI was 100% sensitive and specific in dx scaphoid tx, Tx for this pt p/ MRI would be debatable. Cast immobilization would be appropriate, but screw fixation may allow earlier return to sport A percutaneous compression screw would be an appropriate technique for this scaphoid fracture.Ans3

Front 5

A child is seen in the pedi orthopedic hand clinic for evaluation of a congenital deformity. in Fig A & B. What is the next best step in this child's evaluation to rule out an associated AR lethal condition? 1-Cardiac ultrasound and renal ultrasound; 2-Cardiac ultrasound, barium swallow and MRI; 3-LFTs, CBC & cardiac US; 4-Cardiac US, peripheral blood smear & MRI; 5-CBC, peripheral blood smear and chromosomal breakage analysis

Back 5

This is associated with a number of congenital anomalies including Fanconi’s Anemia (FA), thrombocytopenia absent radius (TAR), Holt-Oram syndrome, VACTERL syndrome, and VATER syndrome. Although all these congenital anomalies are important to recognize and treat, none is more life-threatening than FA. FA is an AR condition resulting in aplastic anemia and eventual death. The typical presentation is between 6-9 years of age. It is the most common inherited form of aplastic anemia. Genetic testing will reveal increased chromosomal breakage. A CBC will show decreased leukocytes, red blood cells and platelets. Of the choices above, it is the only one which requires bone marrow transplantation for survival.ANS5

Front 6

Hx:35yo butcher inadvertently lacerates his ring finger FDP tendon at the level of the DIP joint which is subsequently repaired. Following the operation he notes the inability to fully flex his long and small fingers at the DIP joints with attempted fist clenching as well as a weak grip. Which of the following intraop maneuvers was likely responsible for this? 1-FDP reconstruction with a long tendon graft; 2-FDS to FDP transfer at level of the A2 pulley
3-Inadequate repair of the C3, A4 and A5 pulleys
4-Distal advancement of lumbricals; 5-overtensioning of the FDP tendon

Back 6

The clinical presentation is most consistent w/the quadrigia effect which is caused by overtensioning of the FDP tendon during surgical repair. The FDP tendons share a common muscle belly and have many interconnections. Overtensioning one tendon has a reciprocal effect on the length-tension curve of the remaining three muscle-tendon units, weakening grip strength in these digits. advancement >1cm can lead to an imbalance of muscle function in the profundus system.Ans5