Hand Oite 2015

Front 1

76yo woman has to have below elbow amputation for a clenched infected hand. After the amputation she still feels like her hand is clenched. What therapy is best to decrease phantom limb pain?

Back 1

Mirror therapy. From patient's perspective, there well limb has assumed the role of the paretic limb. This has been shown to improve function in stroke patients more than formal OT.

Front 2

For metacarpal fractures, what amount of shortening is problematic?

Back 2

Shortening > 4 mm may result in extension lag due to bone shortening and loss of tension on the extensor mechanism.

Front 3

For the partial laceration pictured here that occurred 4 weeks ago but continues to have catching and pain, how do you treat?

Back 3

Treat partial tendon lacerations with epitendinous sutures as core sutures do not add strength to partial lacerations. If < 60% of tendon, debridement alone may be appropriate.

Front 4

In this 2 year old patient with camptodactyly of the ring and small fingers, parents concerned about ability to play sport. How do you treat?

Back 4

Treat with progressive stretching and splinting program as this can decrease contracture in patients < 3 years old.

Front 5

For a 2cmx2cm DORSAL finger skin defect, what is the preferred coverage?

Back 5

Reversed cross-finger flap from the adjacent digit.

Front 6

In the setting of cold injury with blue, hemorrhagic blisters, in what time period should they be debrided? Circulation is intact.

Back 6

No set time, allow the tissues to declare themselves, until necrotic tissue demarcation. Escharotomy only if it is constricting the tissue and/or causing compartment syndrome.

Front 7

Upper brachial plexus injuries distal to the nerve root will leave which muscles intact?

Back 7

Rhomboids and levator scapula which are innervated by the dorsal scapular nerve, which is the first branch off of the C5 nerve root. The second and third branches slightly more distal are the suprascapular nerve (infra and supraspintus) and lateral pectoral nerve (pec major and pec minor) which get contributions from C5 and C6.

Front 8

What pre operative diagnostic finding is most predictive of prognosis after carpal tunnel release?

Back 8

Severity of EMG findings.

Moderate disease = abnormal median sensory distal latency and prolonged median motor distal latency.

Severe disease = prolonged median motor and sensory distal latencies with absent or mixed sensory nerve action potential or low amplitude/absent thenar muscle action potential.

Front 9

Which method of flexor tendon repair that necessitates excursion through the A2 pulley allows for the most thorough assessment of tendon gliding?

Back 9

Regardless of repair technique, doing it under local anesthesia gives the best assessment of tendon gliding because it allows active range of motion.

Front 10

18 year old boy 6 months out from surgery who has persistent pain over the snuff box. What imaging study should you use to work this up?

Back 10

Get a CT scan along the scaphoid axis to assess for scaphoid nonunion. Traditional axial cuts may skip through the fracture nonunion site and miss the defect.

Front 11

34 year old smoker as acute onset of right hand ischemia. Blood pressure is 188/90, hand is cool and pale but able to move fingers with some discomfort. No history of trauma. Unable to palpate raidal or ulnar pulses but able to doppler. What is the next step?

Back 11

Get an angiogram to identify location of thrombus.

Front 12

For closed reduction of an apex-volar angulated distal radius fracture, traction plus which maneuver will give the best fracture reduction?

Back 12

Traction plus volar translation of the lunate.

Front 13

When viewing the extrinsic volar ligaments through the 3 - 4 portal, what is the order of the ligaments from radial to ulnar?

Back 13

Radioscaphocapitate, long radiolunate, short radiolunate.

The scapholunate and the lunotriquetral ligaments are intrinsic ligaments.

Front 14

Describe the difference between the wrist extrinsic and wrist intrinsic ligaments.

Back 14

Extrinsic ligaments bridge from radius to carpals or carpals to metacarpals.

Intrinsic ligaments originate and insert on the carpal bones. Most important intrinsics are the scapholunate and lunotriquetral.

Front 15

In a thumb MCP ulnar collateral ligament injury, MRI reveals a displaced distal avulsion of the ligament off the base of the proximal phalanx. During repair, which structure blocks reduction of the ligament?

Back 15

This is describing a stenner lesion which is avulsion off the base of the first metacarpal and this avulsion gets displaced above the adductor aponeurosis. The adductor aponeurosis blocks reduction of the ligament.

Front 16

25 year old man with acute proximal third scaphoid fracture. How do you treat?

Back 16

This should be addressed with ORIF through a dorsal approach which allows visualization of the proximal fragment, reduction and central placement of a screw.

Front 17

50 year old man sustained a dorsal dislocation of his thumb CMC joint without fracture. He self reduced it. Which CMC capsuloligamentous complex prevents dorsal dislocation of the CMC joint?

Back 17

The dorsal radial ligament is the primary restrainst against dorsal dislocation. This can be treated with reduction and pinning and repair of the dorsal ligaments.

Front 18

After a palmar fasciectomy for Dupuytren contracture of palm and ring finger, how many narcotic pills should you give for post op pain?

Back 18

Small joint sugeries or soft tissue procedure such as carpal tunnel release and dupuytrens release can get 10 pills. Patients who had bony hand procedures averaged 14 pills and those that had soft tissue procedure used 9 pills. Small soft tissue procedures such as trigger finger release, do not need narcotics. Typical hand procedures should not exceed 40 tablets.

Front 19

While performing trapeziectomy, you accidentally detach the entire distal attachment of the flexor carpi radialis tendon. What do you do next?

Back 19

Usually, for an LRTI, you use FCR for the suspension arthroplasty. If you have 50% of the FCR tendon available, you should still use it. However, if it is completely gone, you should use extensor carpi radialis longus (ECRL) after passing it through a drill hole in the base of the index metacarpal.