Abos Day 30 1-4 A & B

Front 1

The physical exam finding demonstrated on the patient's right hand in the video (Figure V) is found with neuropathy of which of the following nerves?

Back 1

Froment's sign on the patient's right hand,
- interphalangeal (IP) flexion during attempted key pinch,

Froment's sign is performed by having the patient pinch a piece of paper with the thumb IP joint extended against resistance (pulling paper away). If should be done with both hands side by side so compare them to each other.

Front 2

Cubital tunnel syndrome is caused by compression of the ulnar nerve between what two structures as it passes posterior to the medial epicondyle? (Horse)

Back 2

Osborne's ligament and the MCL

1 The ulnar nerve passes POSTERIOR to the medial epicondyle and medial to the olecranon,
2 enters the cubital tunnel.
3 The roof of the cubital tunnel is primarily made up of Osborne's ligament,
4 the floor consists of the medial collateral ligament.

These soft tissue structures can cause narrowing of the tunnel, especially with elbow flexion, leading to ulnar nerve compression and cubital tunnel syndrome.

Front 3

1-17 clockwise starting at 12:00
nerves are ? (traffic light)
muscles are? (beer)
tendon (antenna)
arteries? (elevator)
veins? (traffic light)
bones? (traffic light)

Back 3

1 ECRL 2 Brachioradialis 3 Radial nerve
4 Biceps 5 Cephalic vein 6 Brachialis
7. Brachial artery and veins 8 Median nerve
9 Pronator teres 10 Basilic vein 11 Common flexor tendon
12 Ulnar nerve 13 Superficial ulnar collateral artery
14 Trochlea 15 Capitellum 16 Olcranon
17 Anconeus

Front 4

All of the following are possible sites of compression for the ulnar nerve EXCEPT: (cubital tunnel-cup)

Back 4

ligament of Struthers

There are sites of potential ulnar nerve entrapment around the elbow:
1arcade of Struthers, 2 medial intermuscular septum, 3 medial epicondyle- osteophytes ,
4 cubital tunnel reticulum roof-Osborne’s ligament
5 the floor of cubital tunnel-the MCL
6 aponeurosis of the two heads of the FCU (arcuate ligament)
7 deep flexor pronator aponeurosis.

Front 5

50-year-old man complains of numbness and tingling along his right small finger. Physical exam is notable for the finding demonstrated in Figure A. Elbow flexion reproduces the numbness and tingling. Physical therapy and splinting have failed to relieve the symptoms. Which of the following is the most appropriate surgical intervention to alleviate the symptoms while minimizing complications?

Back 5

simple ulnar nerve decompression at the cubital tunnel
The patient's clinical presentation and physical exam are consistent with cubital tunnel syndrome. The clinical photograph demonstrates Froment's sign; compensatory IP hyperflexion of FPL (AIN) to compensate for the loss of adductor pollicis (ulna nerve) during key pinch. Simple decompression of the ulnar nerve is less invasive and achieves clinical outcomes equivalent to decompression with transposition.

Front 6

) In valgus extension overload of the elbow, which letter in Figure A corresponds to the typical location of osteophytes formation?

Back 6

The mechanism is thought to be valgus stress on the elbow during acceleration, especially with insufficiency of the medial ulnar collateral ligament. Over time, the continuous impaction of the posterior-medial olecranon in the olecranon fossa can lead to chondromalacia and osteophyte formation. D

Front 7

Back 7

Repetitive stress of pitching leads to excessive shear forces in and pathology in posteromedial elbow including

shear forces on medial aspect of olecranon tip and olecranon fossa
lateral radio-capitellar compression
posterior extension overload
medial tension at MCL

Epidemiology

competitive baseball pitchers

Pathophysiology

chondrolysis
osteophyte formation (posteromedial humerus and olecranon)
loose bodies
MCL can become attenuated with repetitive strain

Associated conditions

cubital tunnel syndrome
concurrent cubital tunnel syndrome in ~25% of cases

Front 8

Back 8

Symptoms
pain in posteromedial elbow with full extension of elbow
pain typically occurs in deceleration phase of pitch (sometimes during acceleration phase)
Physical exam
tender to palpation over posteromedial olecranon
crepitus
pain with forced elbow extension

Front 9

Which of the following patients would benefit most from a glenohumeral arthrodesis?

Back 9

A 30-year-old laborer with a paralysis of the deltoid and rotator cuff muscles
A glenohumeral arthrodesis would be most beneficial to a patient with a flail shoulder but intact elbow and hand function. This is especially important for a laborer. It will allow the patient to have a stable base upon which to be able to use the hand. The position of arthrodesis is described in the review topic, and the goal is to position the shoulder so that the hand can reach the patient's mouth for feeding and groin for hygiene.

Front 10

A 45-year-old man has paralysis of his deltoid and rotator cuff as the result of a motorcycle injury. His neurologic injury has not improved in the 5 years since the injury, but he does have some use of his hand and wrist. What is the most appropriate treatment?

Back 10

Shoulder arthrodesis
A young patient with a flail shoulder but functional use of his hand is a good candidate for glenohumeral arthrodesis. The shoulder needs to be fused in a position of function, with mid-abduction and enough forward flexion and internal rotation so that his hand can reach his mouth. A typical arthrodesis position would be roughly 40 degrees of abduction, 35 degrees of foward elevation, and 20 degrees of internal rotation.

Front 11

Fusion position

Back 11

goal is to have patient get his hand to his mouth to feed himself
think 30°-30°-30°
20°-30° of abduction
20°-30° of forward flexion
20°-30° of internal rotation

Front 12

Indications shoulder arthodesis (cup)

Back 12

1 stabilization of paralytic disorders
2 brachial plexus palsy
3 irreparable deltoid and rotator cuff deficiency with arthropathy
4 failed total shoulder arthroplasty salvage
5 reconstruction after tumor resection
6 painful ankylosis after chronic infection
7 recurrent shoulder instability which has failed previous repair attempts
8 paralytic disorders in infancy

Front 13

Contraindications shoulder arthodesis
(beer)

Back 13

1 ipsilateral elbow arthrodesis
2 lack of functional scapulothoracic motion
3 trapezius, levator scapulae, serratus anterior paralysis
4 Charcot arthropathy
5 elderly patients
6 progressive neurologic disease

Front 14

A 24-year-old male sustains the right elbow injury shown in Figures A and B. He promptly undergoes operative irrigation and debridement, reduction, vascular bypass of the brachial artery, and hinged elbow fixator placement for 6 weeks. Three years later he complains of clicking and locking with elbow extension and difficulty performing arm triceps dips while attempting exercise. Which of the following reconstruction procedures is MOST appropriate?

Back 14

Lateral ulnar collateral ligament reconstruction with palmaris tendon graft
This clinical pesentation is consistent with posterolateral rotatory instability of the elbow due to a previous open elbow dislocation. The most appropriate treatment is lateral ulnar collateral ligament reconstruction with palmaris tendon graft.

Front 15

Back 15

Mechanism

traumatic
most often discussed in the setting of posterolateral rotatory instability (PLRI)
combination of forearm supination, axial loading, valgus (posterolateral) stress, and elbow extension results in posterior subluxation of radial head and rotation of semilunar notch away from trochlea
iatrogenic injury
may occur from arthroscopic or open procedures involving lateral elbow
arthroscopic debridement should be kept anterior to equator of the radial head
chronic attenuation
secondary to chronic cubitus varus malunion also described

Front 16

A 26-year-old male wrestler suffers the elbow injury shown in Figure A. On physical exam he is neurologically intact and has a palpable radial pulse. He is treated with closed reduction in the emergency room. In order to optimize his clinical outcomes, his post reduction immobilization and rehabilitation should include all of the following EXCEPT?

Back 16

The patient should be splinted for 4 weeks, then begin physical therapy
Simple elbow dislocations are second only to the shoulder in rates of joint dislocation. Closed reduction with early rehabilitation has proven the most effective treatment for these injuries when the elbow is stable. Prolonged splinting of greater than 2 weeks after reduction can lead to chronic stiffness and poor outcomes.

Front 17

A 34-year-old male falls from a roof and sustains a right elbow dislocation that is closed reduced in the emergency room. An AP radiograph is shown in Figure A. This injury pattern is at highest risk for which of the following?

Back 17

Varus posteromedial rotatory instability
Anteromedial coronoid facet fracture and LCL injury following an elbow dislocation is commonly associated with varus posteromedial rotatory instability. Varus and posteromedial rotation force on the forearm results in rupture of the LCL from its humeral origin. As the LCL ruptures, the medial coronoid process is fractured as it impacts against and under the medial trochlea. Fracture involvement of the sublime tubercle, where the MCL attaches, can lead to more instability. The lateral pivot shift test is similar to pushing oneself up from a seated position in a chair is an indication of valgus posterolateral rotatory instability. Ulnar neuropathy can be seen following this injury pattern but AIN and PIN nerve palsy do not commonly characterize this injury pattern.

Front 18

What is the most common mode of failure of the lateral ulnar collateral ligament associated with an elbow dislocation?

Back 18

ligament avulsion off the humeral origin
The lateral ulnar collateral ligament (LUCL) is often injured with elbow dislocations, and is most commonly injured at the proximal origin. McKee noted that in 62 consecutive operative elbow dislocations and fracture/dislocations, the LUCL was ruptured in all of the patients, proximally in 32, bony avulsion proximally in 5, midsubstance rupture in 18, ulnar detachment in 3, ulnar bony avulsion in only 1, and combined patterns in 3. Pugh et al established a standard protocol to treat elbow fracture dislocations (terrible triad) which includes coronoid repair, radial head repair/replacement, LUCL repair, and MCL and/or external fixation as needed.

Front 19

You are planning open reduction and internal fixation for a comminuted radial head fracture. To avoid impingement with the proximal ulna, you need to carefully place your fixation. What percent of the proximal radial head does not articulate with the proximal ulna? Topic

Back 19

25%
of the radial head (or a 90 degree arc) does not articulate with the ulna and is the "safe zone" for placement of fixation.

Front 20

Which component is most common to both simple and complex elbow dislocations?

Back 20

Elbow dislocations are classified as either simple (no associated fracture) or complex (associated fracture). The goal of treatment is a stable joint that tolerates early motion. The initial range of motion is the stable arc found on postreduction examination. Studies have demonstrated a better outcome when simple elbow dislocations are treated non-surgically rather than with surgical repair. Simple elbow dislocations usually have an excellent outcome (return of functional range of motion with normal strength). A loss of terminal extension is the most common sequelae.

Front 21

Optimal position
unilateral arthrodesis
bilateral arthrodesis
Functional ROM

Back 21

unilateral arthrodesis
90° of flexion
0-7° of valgus
bilateral arthrodesis
one elbow in 110 ° of flexion for feeding
one elbow in 65 ° of flexion for perineal hygiene
bilateral arthrodesis
Functional ROM
30° to 130 flexion
50° supination
50° pronation

Front 22

Back 22

Joint reaction force
large joint reaction forces due to short and inefficient lever arms around elbow (biceps inserts not far from center of rotation)
lead to degenerative changes of the elbow

Front 23

Static progressive turnbuckle splinting is most appropriate for which of the following patients?

Back 23

3 months after ORIF of a distal humerus fracture with a flexion arc of 45° to 100° with no further improvement with physical therapy

Static progressive splinting is useful treatment for certain patients with post-traumatic elbow stiffness. Generalized accepted indications are flexion contractures greater than 30 degrees, or flexion less than 130 degrees after a failed trial of physical therapy.

Gelinas et al treated 22 patients with an elbow contracture using a static progressive turnbuckle splint for a mean of 4.5 months. Eleven patients gained a 'functional arc of movement,' defined as at least 30 degrees to 130 degrees,

Front 24

Ulnar tunnel syndrome: compression in Guyon’s Canal vs Cubital Tunnel Syndrome difference sx
mcc ulnar tunnel syndrome?
causes of Ulnar tunnel syndrome? (star)

Back 24

compression in Guyon’s Canal
-no involvement of dorsal cutaneous nerve since it branches before canal
-no involvement of FDP of 4th & 5th and FCU
-ganglia most common cause (from triquetrohamate joint, 32-48%)
-causes:1 other mass, 2 trauma (Distal radius/ulna, hook of hamate), 3 muscle anomaly, 4 ulnar artery aneurysm 5 ganglia most common cause