Abos Day #53 A 1-3 Daily Mastery Plan

Front 1

54yo M c/o slowly enlarg mass -> dorsum L wrist x 3 yrs. He denies any sign sx. PE: 1 cm palpable mass. MRI, Fig A. A bx of this lesion show? 1-Synovial cells w/ mucin accumulation; 2-Prolifertg histiocytes modrt cellularity & frequt multinucleated giant cells

Back 1

3-Polymorphonuclear neutrophils; 4-Spindle cells arranged in intersecting bundles; 5-Lipocytes, spindle cells, & scattered atypical giant cells:::Histo-gangln cyst -> mucin filled synovial cyst. MC mass found on hand/wrist. Dorsal ganglns MC scapholunate lig.Ans1

Front 2

10yo B c/o painless mass->dorsal aspect of his wrist x 3 wks. T1 & T2 Fig B & C, PE, the mass transilluminates & Allen test reveals patent radial & ulnar A. What is the next step in management? 1-Referral ortho-oncologist;

Back 2

2-Surgical excision w/ wide margins; 3- Observtn; 4-Autologus bn marrw aspirt inj 5-Inj N-Butyl-Cyanoacrylate:::Dx=ganglion cyst,"", MRI (+) well-marginated, homogenous signal intensity mass, Allen's test evalt radial & ulnar A collateral blood flow is especially important on volar aspect adjacent radial A.Ans3

Front 3

algorithm for imaging occult scaphoid fractures?
how long cast for?

Back 3

1-AP and lateral; scaphoid view-30 deg wrist extension, 20 degr ulnar dev; 45° pronation view; 2-thumb spica cast then repeat in 14-21 Dz; 3-@ 72 hr bn scan; 4-w/in 24 hrs; 5-1mm cuts CT progression of nonunion or union after surgery: distal-waist =3 mths
mid-waist = 4 mths; prox1/3= 5 mths

Front 4

what is the indication of dorsal approach and volar approach to scaphoid fx? adv of each

Back 4

dorsal approach indicated: proximal pole fx
care taken to preserve the blood supply when entering the dorsal ridge by limiting exposure to the proximal 1/2 scaphoid; percut has higher risk of unrecognized screw penetration of subchondral bone
volar approach indicated: in waist, distl pole fx, fx w/ humpback flexion deformities; allows exposure of the entire scaphoid;

Front 5

22yo M snowboarder falls on outstretched hand & presents Fig A. Which techniques is MOST important in optimizing biomech fixation? 1-longr screw->central axis scaphoid; 2-largr diameter screw ->central axis scaphoid; 3-longr screw->dorsal axis of the scaphoid

Back 5

4-largr diameter screw -> dorsal axis of the scaphoid
5. largr diameter screw->volar axis of the scaphoid::: centrally placed screw= 43% stiffness > eccentrically. recomm: central placement, cannulated screw, longer screw w/ 2mm of bone coverage provided >stability.Ans1

Front 6

open dorsal apprch for antegrade screw fixation->nondisplaced scaphoid waist fx differs in which of the following ways compared to a percut dorsal approach? 1-Dec'd risk prox pole AVN; 2-Inc'd risk of PIN inj 3-Dec'd risk inj -> APL tendn

Back 6

4-Inc'd risk of injury to the EPL tendn; 5-Dec'd risk screw prominence above subchondral bn::: Scaphoid screw fixation below the subchondral bone; this is best judged by direct visualization. perc approach scaphoid screw "was prominent (above the subchondral bone).Ans5

Front 7

Which of the followg is True about force transmission based on wrist position? 1-neutrl wrist positn dec force -> lunate fossa; 2-extnd wrist positn inc force -> lunate fossa; 3-neutrl wrist positn inc force ->scaphoid fossa;

Back 7

4-extend wrist positn inc force -> scaphoid fossa
5-wrist positn has no effect force transmission::: scaphoid fossa force <neutral & >extension. lunate fossa > neutral & < extension. therfore scaphoid fx & intra-articular distl rads fx 2^ fall -> extend wrist.Ans4

Front 8

Percut screw fixtn -> non-displcd scaphoid waist fx has been shown to have which of the following differences compared to closed tx? 1-Inc direct & indirect cost; 2-Slower RTW; 3-Higher union rts; 4-Redcd time-> fx union

Back 8

5-Improved motion & grip strength p/ 2 yrs::: Fixation ND scaphoid fx w/ percut screw =shorter time union (6-7 wks vs 10-12 wks) & fastr RTW/RTSports. in active military persnnl= fastr healg but NO difference in ultimate union, final grip strngth, ROM b/w percut screw fixation & non-op.Ans4

Front 9

30yo F c/o 5 mths wrist pn p/ fall onto wrist. in Fig A. If untreated, all of the following degenerative changes may be observed EXCEPT? 1-radial styloid osteophyte;
2-radioscaphoid DJD; 3-midcarpal DJD; 4-pancarpal DJD
5-radiolunate DJD

Back 9

scaphoid non-union -> Scaphoid Nonunion Advanced Collapse (SNAC wrist) & progressive DJD. hx of DJD changes 1st @ radioscaphoid area then progresses to pancarpal arthritis. NOT radiolunate DJD.Ans5

Front 10

20yo skateboarder fell 6 months ago c/o radial-sided wrist pain. xray fig A. What is tx? 1-SAC thumb spica;
2-LAC thumb spica; 3-wrist scopy to eval intercarpal ligs; 4-ORIF w/ autologous bn graft; 5-wrist arthrodesis

Back 10

standard tx of scaphoid nonunions isORIF w/BG ; non-operative tx is not appropriate. Proximal row carpectomy & wrist fusion = salvage reserved for advancd scaphoid nonunion, collapse & wrist DJD.Ans4

Front 11

27yo professional cowboy is thrown from a bull durg rodeo & lands on hand. No deformty& hand is n/v intact. Pain (+) palpation anatomic snuffbox. x-ray Fig A. He wants to return to competv ridg tomorrow. Which is the best next step in mangnt?

Back 11

1-Cock-up wrist splint & immediate RTSport as tolerated; 2-Steroid inj snuffbox, taping wrist & RTSport; 3-Wrist MRI; 4-Percut screw fixan ND fx; 5-Scapholunate lig repair & perc pin fixation::: cast w/ repeat xrays 2-3 wks or MRI.Ans3

Front 12

35yo F c/o wrist pain p/ fall onto outstretched hand. PE, (+) focal tendrnss wrist snuffbox. x-ray & CT Fig A & B. What is tx of injury? 1-Rest, ice, elevation; 2-Removable splint for comfort; 3-Thumb spica cast; 4-ORIF; 5-Vasclrzd Bn Grftg:::

Back 12

ORIF for any fx w/ screw fixation if = 1-displcd > 1mm; 2-w/ a radiolunate angle>15 deg; 3-intrascaphoid angle >35 deg; 4- (+) perilunate disloctn; 5- prox pole fx. if minimally displcd fx= percutaneous or mini-open fixation & preservation of extrinsic lig.Ans4

Front 13

28yo M fell while ice skatg 6 mths ago & has had ulnar-sided wrist pain ever since. The lateral xray & CT fig A & B. What is tx? 1-scapholunate lig repair; 2-excis hook hamate; 3-excis pisiform; 4-ORIF hamate; 5-ORIF pisiform :::

Back 13

dx=comminuted pisiform fx, pisiformectomy is a reliable way to relieve this pain & doesn’t impair wrist func. "no signif differences in grip strength, wrist movement, static strength, dynamic power" when compared to the unaffected wrist.Ans3