Book 2

2010 Self-Assessment
Examination
Preferred Responses, Discussions and References
2010 Self-Assessment Examination
Overview
This examination is offered as a convenient
self-education exercise by the American
Society for Surgery of the Hand and
is available to the medical profession,
especially those health care professionals
focusing on the care of the hand and upper
extremity. Designed to assist the physician
in reviewing basic principles of hand care,
the exam also helps to keep the physician
abreast of new developments and concepts
within the specialty.
The examination covers diagnostic and
therapeutic problems, both surgical and
non-operative, basic science knowledge,
and fundamental principles of hand surgery.
The interpretation of the illustrative material
(clinical photographs and radiographs) is an
integral part of this examination.
The 2010 examination consists of the
Question Book (Book 1) containing 200
questions, an answer sheet, evaluation,
and the Discussion Book (Book 2) with
preferred responses, discussion, and
literature references.
The American Society for Surgery of
the Hand guarantees anonymity of
examination results. Remember to record
your examination number, as the scoring
will be by the number and not by name.
Please keep a copy of your answer sheet
for your record; originals cannot be
returned. It is recommended that answers
sheets be mailed via overnight or second-
day delivery so that the receipt of the score
sheets can be verified.
Objectives
• Detect and differentiate injury
mechanisms, pathologies and applied
anatomy associated with upper extremity
conditions treated by hand surgeons.
• Differentiate and apply the range of non-
operative and surgical treatment options
to deal with upper extremity problems that
present to a hand surgeon’s practice.
• Develop informed, evidenced-based,
guided clinical decision practice
options in the treatment of upper
extremity disorders.
• Evaluate, by self-assessment, basic
cognitive abilities and clinical skills
needed by hand surgeons to successfully
complete the maintenance of certification.
Timelines
June 11, 2010
Answer sheets due back to the ASSH Office.
July 30, 2010
Individual scores, Book 2, containing preferred
responses, discussions, and references, and
an evaluation mailed to participants.
Please note: late submissions received
at the central office after June 11, 2010,
cannot be scored and will not be eligible
for CME credit.
Accreditation
The American Society for Surgery of the Hand
is accredited by the Accreditation Council
for Continuing Medical Education to provide
continuing medical education for physicians.
Self-Assessment in MOC™
Credits earned by completing this Self-
Assessment Examination can be applied to
the scored and recorded self-assessment
requirements as mandated by the ABOS
Maintenance of Certification (MOC™)
process and will count toward the CME
credit requirement as well.
2010 Self-Assessment Examination | 1
 Credit Hours
The ASSH designates this educational activity for a maximum
of 20.00 AMA PRA Category 1 Credits™. Physicians should
only claim credit commensurate with the extent of their
participation in the activity.
Answer sheets must be received by ASSH Central Office by
June 11, 2010, to be eligible for Category 1 CME credit.
Disclosures
• Kyle D. Bickel, MD, FACS – Ownership interests in Pacific
Heights Surgery Center, LLC
• David T. Netscher, MD – Deputy Editor of the Journal of
Hand Surgery (published by Elsevier)
• Jay F. Pomerance, MD – Paid Consultant for Wyeth
Pharmaceuticals and for Gerson Lehrman LLC
• David B. Siegel, MD – Ownership interests in Tucson

2010 Self-Assessment Surgery Center, LLC

• Andrew L. Terrono, MD – Ownership interests in Boston
Examination Committee Outpatient Surgical Services
◆ John M. Bednar, MD
Committee Chair
Kyle Bickel, MD, FACS Disclaimer
◆ Louis W. Catalano, MD The material presented in this continuing medical education
◆ Jonathan Cheng, MD program is being made available by the American Society
◆ Fred G. Corley, MD for Surgery of the Hand for educational purposes only. This
◆ Seth D. Dodds, MD material is not intended to represent the only, or necessarily
◆ Scott G. Edwards, MD the best, methods or procedures appropriate for the medical
◆ Harry A. Hoyen, MD situation discussed. Rather, this educational material is
intended to present an approach, view, statement, or opinion
◆ Richard S. Idler, MD
of the authors or presenters, which may be helpful, or of
◆ Howard M. Matsuba, MD
interest, to other practitioners.
◆ Kimberly K. Mezera, MD
David T. Netscher, MD The examinees agree to participate in this medical education
◆ Jerome W. Oakey, MD program sponsored by ASSH with full knowledge and
◆ Zubin J. Panthaki, MD awareness that they waive any claim that they may have
◆ Miguel A. Pirela-Cruz, MD against ASSH for reliance on any information presented in
Jay F. Pomerance, MD this examination.
◆ Gregory Rafijah, MD
◆ Lance A. Rettig, MD
◆ Marco Rizzo, MD Confidentiality
◆ Devesh Sharma, MD The Self-Assessment Exam is the sole property of the
◆ Russell A. Shatford, MD, MPH, MSEd American Society for Surgery of the Hand (ASSH) and
David B. Siegel, MD scores are confidential. Individual results will only be shared
Andrew L. Terrono, MD with the test-taker. Each participant is assigned a number
◆ Eric P. Thorson, MD and no names are used in the scoring process to further
◆ Raymond Wittstadt, MD ensure confidentiality.
◆ Montri D. Wongworawat, MD
◆ David S. Zelouf, MD
◆ Ephraim M. Zinberg, MD
◆ Bridget Treccia
ASSH Staff Liaison

◆ Nothing of value
The authors preceded by a ◆ have indicated that they have
not received anything of value in the form of: research or
institutional support, stock or stock options, equipment or
services, paid travel, royalties or as a consultant or employee
of a commercial company or institution related directly or
indirectly to the subject of the program.

2 | American Society for Surgery of the Hand

1. A 56 year-old man presented with an enlarging,
minimally tender, diffuse mass on the flexor surface
of his right palm. He had suffered a laceration
while cleaning his boat 9 months earlier, which
he allowed to heal secondarily. Hand examination
revealed thickening of the subcutaneous tissues on
the flexor surface of the palm, minimal tenderness,
no erythema or increased temperature, and limited
digital flexion. Surgical exploration was undertaken,
with findings depicted in Figure 1. In addition to
thorough debridement of the involved structures,
appropriate treatment consists of:
A. Continuous sterile saline irrigation via an indwelling
catheter for 72 hours
B. Postoperative external beam radiation
C. Postoperative brachytherapy radiation
D. Antibiotic therapy with trimethoprim-sulfamethoxazole
and rifampin for 6-12 months
E. Oral prednisone and rheumatology consultation
Preferred Response: D
Discussion: Atypical mycobacterial infections of the hand and
upper extremity present as indolent, progressive soft-tissue
infections, most often involving the flexor tenosynovium.
The average time to accurate diagnosis and treatment is a
year or more after inoculation. The original injury occurred
on a boat which suggests, and final cultures confirmed,
that this infection was caused by Mycobacterium marinum.
These infections can affect both immunocompetent
and immunocompromised patients. Confirmation of the
infectious agent is often delayed, as cultures grow slowly,
and can take several weeks after surgical debridement.
Effective treatment, therefore, requires an understanding of
the pathophysiology and a high index of suspicion, leading
to thorough debridement of infectious material and initiation
of appropriate antimicrobial therapy in a timely fashion.
References:
1. Kozin SH, Bishop AT. Atypical mycobacterium infections of the
upper extremity. J Hand Surg 1994;19A:480-7.
2. Bhatty MA, Turner DPJ, Chamberlain ST. Mycobacterium
marinum hand infection: Case reports and review of the
literature. Br J Plas Surg 2000;53:161-5.
Figure 1
2. A 22 year-old man presents with a painful, swollen,
stiff ring finger proximal interphalangeal joint (PIP)
5 days after an axial loading injury. Total active
range of motion measures 25-50°. Radiographs are
shown in Figures 1 and 2. Stable closed reduction
could not be maintained with a dorsal block splint.
Appropriate treatment of this injury consists of:
A. Closed reduction and K-wire fixation of fracture fragment
B. Open reduction and excision of fracture fragment
C. Closed reduction and dynamic external fixation
D. Open reduction, internal fixation of fracture fragment
E. PIP joint implant arthroplasty
Preferred Response: C
Discussion: PIP joint fracture-dislocations are relatively common
injuries resulting from axial loading on the PIP joint, with
disruption of the volar plate insertion on the middle phalanx and
resultant dorsal instability. Appropriate treatment requires
restoration of a stable volar buttress of the middle phalangeal
base to restore articular stability. In this case, the volar fragment
is quite small and is not amenable to internal fixation. Excision of
the volar fragment will worsen the instability. Use of a dynamic
external fixator, which provides distal traction and ligamentotaxis,
provides restoration of a concentric arc of rotation around
the proximal phalangeal head and reduction of the fracture
fragment (Figures 3 & 4). This device also allows for immediate
range of motion to prevent excessive stiffness during healing.
References:
1. Ruland RT, Hogan CJ, Cannon DL, Slade JF. Use of dynamic
distraction external fixation for unstable fracture-dislocations of
the proximal interphalangeal joint. J Hand Surg 2008;33A:19-25.
2. Ellis SJ, Cheng R, Prokopis P, Chetboun A, Wolfe S, et
al. Treatment of proximal interphalangeal dorsal fracture-
dislocation injuries with dynamic external fixation: A pins and
rubber band system. J Hand Surg 2007;32A:1242-50.
Figure 1 Figure 2
Figure 3 Figure 4
2010 Self-Assessment Examination | 3
 3. A 35 year-old man suffered a deep glass laceration
to the medial forearm and presented 6 weeks after
the injury with absence of ulnar nerve sensation and
loss of ulnar intrinsic function in the hand. Findings
of wound exploration are shown in Figure 1. Resection
to healthy axons on either side of the injury
produced a nerve gap of 5cm, despite transposition.
Appropriate management of the injury involves:
A. Primary repair of the nerve ends with the elbow and
wrist in full flexion to reduce tension
B. Sural nerve grafting across the gap
C. Repair with a synthetic nerve conduit
D. Tagging of the nerve ends for later repair or grafting
Figure 1
E. No repair of the nerve and tendon transfers to restore
intrinsic function
Preferred Response: B
Discussion: Several options are now available for repair
of nerve lacerations in the upper extremity. Primary repair
is optimal when excessive tension can be avoided. In this
case, the need for maximal flexion of the elbow and wrist
to achieve primary repair is suboptimal. Nerve conduits
have been shown in some series to be as effective as
autologous nerve grafting in short nerve defects of up to
2-3 cm. The 5 cm nerve defect in this case exceeds the gap
limitations of nerve conduits, and autologous nerve grafting
is indicated (Figure 2). Tagging and delayed repair is not
indicated in this case, as the injury is clean and should not
evolve substantially over time, and the proximal location of Figure 2
the defect requires early repair to minimize functional motor
loss in the extremity. Tendon transfers may be necessary to
augment any loss of intrinsic function that may occur from 4. A 17 year-old male football player presents with
the proximal injury, but early repair should still be performed a swollen, tender ring finger and inability to flex
to restore sensory function to the hand and proximal the distal interphalangeal joint (DIP) joint of his
extrinsic motor function. dominant hand. The injury occurred from a missed
References: tackle 5 weeks earlier. Physical examination reveals
1. Lohmeyer JA, Siemers F, Machens H-G, Mailander P. The tenderness over the middle phalanx. He can actively
clinical use of artificial nerve conduits for digital nerve repair: flex the PIP joint without pain. Radiographs are
a prospective cohort study and literature review. J Reconstr normal. Appropriate management of the injury is:
Microsurg 2009;25:55-61.
2. Battiston B, Geuna S, Ferrero M, Tos P. Nerve repair by A. Reinsertion of the avulsed FDP tendon into the
means of tubulization: literature review and personal clinical distal phalanx
experience comparing biological and synthetic conduits for B. Primary tendon grafting and pulley reconstruction
sensory nerve repair. Microsurgery 2005;25:258-267.
C. Two-stage FDP tendon reconstruction with silicone
rod insertion and delayed grafting
D. Conversion to a one-tendon finger
E. Fusion of the DIP joint in slight flexion
Preferred Response: A
Discussion: Avulsion of the FDP tendon from the distal
phalanx most often involves the ring finger in athletes.
Leddy and Packer described 3 types of injuries: Type I
involves retraction of the tendon into the palm; Type II
involves retraction to the level of the PIP joint; Type III
involves little or no proximal retraction. Type I injuries,

4 | American Society for Surgery of the Hand

with an empty digital flexor sheath, require early exploration
and repair, generally within 10 days to prevent shortening
and scarring of the proximal musculotendinous unit.
Radiographs may or may not show associated avulsion
fractures. McCallister, et al. showed that radiographic
findings may be misleading, and they recommended early
exploration and repair within 10 days for all FDP avulsions.
True Type III injuries (Figure 1) can be successfully
repaired for up to six weeks after injury. Primary or
secondary tendon grafting is useful in delayed treatment of
longstanding avulsion injuries with proximal contraction and
scarring of the musculotendinous unit. Fusion of the DIP
joint is an option when no useful proximal motor remains
and the DIP joint hyperextends.
References:
1. Leddy JP, Packer JW. Avulsion of the profundus tendon
insertion in athletes. J Hand Surg 1977;2:66-69.
2. McCallister WV, Ambrose HC, Katolik LI, Trumble TE.
Comparison of pullout button versus suture anchor for zone I
flexor tendon repair. J Hand Surg 2006;31A:246-251.
Discussion: The use of laminar matrix or dermal substitute
can be helpful in providing coverage for these wounds. They
can allow for tendon gliding in the absence of a paratenon.
Upon ensuring adherence to the wound, the dermal
template can be skin grafted. They are resistant to wound
contracture and can therefore be appropriately covered with
a split thickness skin graft.
Because of the absence of paratenon, the use of a split
thickness or full thickness skin graft alone will likely lead to
tendon adhesions and subsequent stiffness. Split-thickness
grafts also undergo more secondary contraction during
healing than full-thickness grafts, minimizing the resultant
surface area of the wounds. The remaining answers are not
necessary for coverage of a dermal template in this case.
Once an adequate vascular wound bed with subcutaneous
granulation tissue over joint and tendon structures has been
restored, free grafts are appropriate wound coverage. If
exposure of relatively avascular structures remains, transfer
of vascular tissue with either local pedicled or distant
microvascular flaps is necessary for adequate wound
coverage. Split-thickness skin grafts are more suitable for
relatively large surface areas, and they revascularize more
easily than full-thickness grafts.
References:
1. Carothers JT, Brigman BE, Lawson RD, Rizzo M. Stacking of a
dermal regeneration template for reconstruction of a soft-tissue
defect after tumor excision from the palm of the hand: A case
report. J Hand Surg 2005;30A:1322-1326.
2. Wolter TP, Noah EM, Pallua N. The use of Integra® in an upper
extremity avulsion injury. Br J Plast Surg 2005;58:416-418.

Question 4, Figure 1

5. A 50 year-old woman involved in an auto rollover

accident experienced avulsion injuries of the dorsal
soft tissues of the index thru small fingers (Figure 1).
After initial debridement and application of a dermal
substitute for 2 weeks, the extensor tendons are Figure 1
covered with healthy granulation tissue and no
joint structures are exposed (Figure 2). Appropriate
wound coverage at this stage consists of:
A. Split-thickness skin grafts
B. Full-thickness skin grafts
C. Dorsal metacarpal island flaps
D. Abdominal flap
E. Free fasciocutaneous flap
Preferred Response: A
Figure 2

2010 Self-Assessment Examination | 5

 6. A 7 year-old boy suffered an amputation of the upper
extremity at the level of the elbow (Figure 1). The
amputation is a high-energy avulsion. The patient
is stabilized quickly and transported to the hospital
within 2 hours of the injury. The appropriate treatment
after debridement is:
A. Bone shortening and primary closure of the stump
B. Bone shortening and split-thickness skin grafting
C. No bone shortening and free microvascular latissimus
flap coverage of the proximal stump
D. Bone shortening and replantation of the distal extremity
E. Bone shortening and upper extremity transplantation
Preferred Response: D
Discussion: Replantation of proximal upper extremity
amputations in high-energy avulsion injuries is generally
contraindicated in adults. The zone of injury is wide, with a
high risk of ischemic failure after replantation, and functional
restoration of the distal part is usually poor. Replantation
criteria in children, however, are more liberal and functional
results are generally superior to adults when replantation
is successful. When technically feasible and medically
not contraindicated by comorbidities, replantation of even
proximal injuries is therefore recommended in children.
References:
1. Kim JYS, Brown RJ, Jones NF. Pediatric upper extremity
replantation. Clin Plast Surg 2005;32:1-7.
2. Buncke GM, Buntic RF, Romeo O. Pediatric mutilating hand
injuries. Hand Clin 2003;19:121-131.
Figure 1
6 | American Society for Surgery of the Hand
7. A patient presents one week after injury with a painful
right wrist after a fall onto his outstretched hand while
snowboarding. Radiographs on the day of injury
were normal. Examination reveals tenderness in the
anatomic snuffbox and with loaded wrist extension.
There is mild dorsal wrist swelling. Repeat plain
radiographs are again normal. A scaphoid fracture
is suspected based on the clinical presentation. The
best imaging study to demonstrate an abnormality
providing support for the clinical diagnosis is:
A. Tomographic radiographs
B. Ultrasound
C. Bone scan
D. CT scan
E. MRI
Preferred Response: E
Discussion: Non-displaced scaphoid fractures may
present with clinical symptoms and findings but normal
radiographs. Confirmatory imaging studies are, therefore,
helpful in appropriate treatment and avoiding under-treatment
of fractures. Of the commonly-used imaging studies, MRI has
been shown to have the highest sensitivity, specificity, and
accuracy, at 98%, 99%, and 96% respectively, with very high
positive and negative predictive values (Figure 1). CT scanning
has been shown to have similar sensitivity, specificity, and
accuracy, but with lower predictive values. CT and tomography
also require substantial exposure to radiation, which is avoided
with MRI. Bone scan and ultrasound both have been shown
to have low specificity and positive predictive values,
making their use less reliable.
References:
1. Ring D, Lozano-Calderon S. Imaging for suspected scaphoid
fracture. J Hand Surg 2008;33A:954-957.
2. Bhat M, McCarthy M, Davis TR, Oni JA, Dawson S. MRI and
plain radiography in the assessment of displaced fractures
of the waist of the carpal scaphoid. J Bone Joint Surg
2004;86B:705-713.
Figure 1
8. The use of 500mg daily of vitamin C has been shown
in two recent randomized clinical trials to reduce the
incidence of what complication?
A. Postoperative hematoma
B. Complex regional pain syndrome after distal
radius fractures
C. Non-union after operative treatment of scaphoid fractures
D. Synovitis and tendon rupture after internal fixation of
radius fractures
E. Postoperative wound infection after internal fixation of
radius fractures
Preferred Response: B
Discussion: Two randomized, placebo-controlled clinical
trials have shown a reduced incidence of complex regional
pain syndrome in patients with distal radius fractures treated
with oral vitamin C. The effect appeared to be dose-related,
with optimal effect reaching a plateau at 500mg per day,
and with no statistically-significant benefit shown at 200mg
per day. This is now a current recommendation in the AAOS
guideline on the treatment of distal radius fractures.
References:
1. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can
vitamin C prevent complex regional pain syndrome in patients
with wrist fractures? (A randomized, controlled, multicenter
dose-response study). J Bone Joint Surg 2007;89A:1424-1431.
2. Shah AS, Verma MK, Jebsen PJL. Use of oral vitamin C after
fractures of the distal radius. J Hand Surg 2009;34A:1736-1738.
3. American Academy of Orthopaedic Surgeons: Clinical Practice
Guidelines. Guideline on Treatment of Distal Radius Fractures.
2009, AAOS.org.
9. A wrist fusion is planned in a cerebral palsy patient
with spastic flexion deformities of the wrist and
good hand function. Digital flexor tightness can be
improved by what concomitant procedure?
A. Profundus to superficialis transfers
B. Radial shortening osteotomy
C. Proximal row carpectomy
D. Superficialis to EDC transfers
E. Superficialis tenotomy
Preferred Response: C
Discussion: Wrist fusion has been used successfully to
treat severe flexion deformity of the wrist in patients with
cerebral palsy. Proximal row carpectomy concomitant
with wrist arthrodesis aids in positioning of the wrist
and correcting severe flexion. By changing the relative
length of the digital musculotendinous units, proximal
row carpectomy also aids in rebalancing severe flexion
tightness in the digital flexors. FCU and FCR tenotomies
are commonly performed with wrist fusion to assist in
releasing the tight wrist in spastic wrist deformities, but they
do not alter the digital tightness. Superficialis to profundus
tendon transfers are useful adjuncts to relieve digital flexion
tightness in patient’s with poor hand function but not
profundus to superficialis transfers, superficialis to EDC
transfers, or superficialis tenotomy.
References:
1. Van Heest AE, Strothman D. Wrist arthrodesis in cerebral palsy.
J Hand Surg 2009;34A:1216-1224.
2. Pomerance JF, Keenan ME. Correction of severe spastic
flexion contractures in the nonfunctional hand. J Hand Surg
1996;21A:828-833.
3. Rayan GM, Young BT. Arthrodesis of the spastic wrist. J Hand
Surg 1998;24A:944-952.
2010 Self-Assessment Examination | 7
 10. A 56 year-old man presents with a one-year history
of progressive ulnar-sided wrist pain. A coronal
MRI of his wrist is shown in Figure 1. He underwent
arthroscopic exploration which demonstrated
lunatotriquetral ligament insufficiency, a large
central triangular fibrocartilage tear, and lunate
chondromalacia (Figure 2). In addition to debridement
of the TFC lesion and the chondromalacia, what
treatment is most appropriate?
A. Ulnar shortening osteotomy
B. Lunotriquetral fusion
Figure 1
C. Hemiresection interposition arthroplasty
D. Proximal row carpectomy
E. Vascularized bone grafting of the lunate
Preferred Response: A
Discussion: The patient in this case has ulnocarpal
impaction syndrome. The MRI changes demonstrate edema
in the lunate. While similar changes can be seen with
Kienbock’s Disease, the eccentric location of the changes
in the lunate is more suggestive of impaction. In addition,
the MRI demonstrates positive ulnar variance. Both an ulnar Figure 2
shortening osteotomy and arthroscopic wafer resection
can be successful in alleviating the impaction. However,
the ulnar shortening may be more appropriate in cases
of L-T instability or hypermobility, as it has been shown 11. Which factor is associated with a poor level of
experimentally to increase ulnotriquetral and ulnolunate patient satisfaction after carpal tunnel release?
strains effectively helping to stabilize and reduce motion A. Diabetes mellitus
between carpal bones. Ulnar shortening osteotomy,
B. Thyroid disorders
however, has a higher incidence of complications related
to non-union and hardware problems than arthroscopic C. Symptom duration
ulnar shortening. Lunotriquetral fusion and proximal row D. Symptom severity
carpectomy do not unload the ulnar wrist and are not useful E. Age > 70 years
in treating ulnar impaction. Hemiresection interposition
arthroplasty is used for a painfully arthritic distal radioulnar Preferred Response: D
joint. Vascularized bone grafting of the lunate is a Discussion: Symptom severity has been shown to
treatment option for pre-collapse Kienbock’s disease and negatively impact the degree of symptom relief after
inappropriate in this case. surgery for carpal tunnel syndrome. Diabetes mellitus,
References: thyroid disease, duration, and advanced age have not been
1. Sachar K. Ulnar-sided wrist pain: Evaluation and treatment of shown to negatively impact symptom relief after carpal
triangular fibrocartilage complex tears. Ulnocarpal impaction tunnel release, although they may all be implicated in the
syndrome, and lunotriquetral ligament tears. J Hand Surg development of carpal tunnel symptoms.
2008;33A:1669-79.
References:
2. Gupta R, Bingenheimer E, Fornalski S, McGarry MH, Osterman
AL. The effect of ulnar shortening on lunate and triquetrum 1. Mallick A, Clarke M, Kershaw CJ. Comparing the outcome of a
motion – a cadaveric study. Clin Biomech 2005;20:839-45. carpal tunnel decompression at 2 weeks and 6 months. J Hand
Surg 2007;32A:1154-8.
3. Constantine KJ, Tomaino MM, Herndon JH, Sotereanos DG.
Comparison of ulnar shortening osteotomy and the wafer 2. Leit ME, Weiser RW, Tomaino MM. Patient-reported outcome
resection procedure as a treatment for ulnar impaction after carpal tunnel release for advanced disease: a prospective
syndrome. J Hand Surg 2000;25A:55-60. and longitudinal assessment in patients older than age 70.
J Hand Surg 2004;29A:379-83.
3. Thomsen NOB, Cederlund R, Rosen I, Bjork J, Dahlin LB.
Clinical outcomes of surgical release among diabetic patients
with carpal tunnel syndrome: prospective follow-up with
matched controls. J Hand Surg 2009;34A:1177-87.

8 | American Society for Surgery of the Hand

12. An 18 year-old high school pitcher has developed
medial-sided elbow pain while throwing his fastball.
MRI reveals a medial (ulnar) collateral ligament
strain without a tear. What muscle group(s) function
as dynamic stabilizers for this injury:
A. Flexor carpi ulnaris
B. Flexor digitorum profundus
C. Biceps and brachialis
D. Triceps
E. Supinator
Preferred Response: A
Disscussion: The flexor-pronator mass dynamically
stabilizes the elbow against valgus torque, therefore
protecting the medial (ulnar) collateral ligament. A well-done
cadaveric study by Park & Ahmad revealed that the FCU is
the primary stabilizer and the FDS a secondary stabilizer
against valgus stress.
References:
1. Park MC, Ahmad CS. Dynamic contributions of the flexor-
pronator mass to elbow valgus stability. J Bone Joint Surg Am
2004 Oct;86A(10):2268-74.
2. Maloney MD, Mohr KJ, El Attrache NS. Elbow injuries
in the throwing athlete. Difficult diagnoses and surgical
complications. Clin Sports Med 1999 Oct;18(4):795-809.
13. When using a 6-hole locking plate to treat a
comminuted radial shaft fracture in a patient with
severe osteoporosis, what screw configuration will
reduce the risk of peri-implant fracture and give the
strongest construct:
A. All locking screws
B. All nonlocking screws
C. Only 2 locked screws furthest from the fracture
D. Alternating locked and unlocked screws
E. A nonlocked screw at each end of the plate
Preferred Response: E
Discussion: A recent biomechanical study published
by Bottlang et al in JBJS highlighted a few important
biomechanical points regarding locking plates. By
substituting the locked end screw with a conventional
end screw, binding strength was increased by 40%. In
addition, stress concentration at the end of the plate was
reduced when a conventional end screw was used, thereby
lessening the risk of a fracture at the end of the plate.
References:
1. Bottlang M, Doornink J, Byrd GD, Fitzpatrick DC, Madey SM.
A nonlocking end screw can decrease fracture risk caused by
locked plating in the osteoporotic diaphysis. J Bone Joint Surg
Am 2009;91:620-7.
2. Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ.
Biomechanics of locked plates and screws. J Orthop Trauma
2004;18:488-93.
14. Estrogen is a critical hormone in bone physiology
because it:
A. Stimulates osteoclast activity
B. Suppresses osteoclast activity
C. Stimulates osteoblast activity
D. Suppresses osteoblast activity
E. Stimulates vitamin D activity
Preferred Response: B
Discussion: Estrogen is an important mediator of bone
resorption because it suppresses osteoclast activity in both
men and women. After menopause, the decrease in estrogen
leads to a rapid loss of bone mineral density in women.
Testosterone helps osteoblasts form bone. Vitamin D assists
with calcium absorption in the gut and decreases calcium
excretion. Sunlight converts Vitamin D to its active form.
References:
1. Dell RM, Greene D, Anderson D, Williams K. Osteoporosis
disease management: What every orthopaedic surgeon should
know. J Bone Joint Surg Am 2009;91 Suppl 6:79-86.
2. Ahlberg HG, Johnell O, Turner CH, Rannevik G, Karlsson MK.
Bone loss and bone size after menopause. N Engl J Med
2003;349:327-34.
15. The scaphoid shift test, as described by Watson,
requires:
A. Ulnar-directed pressure on the scaphoid
B. Volarly-directed pressure on the scaphoid proximal pole
C. Volarly-directed pressure on the lunate
D. Dorsally-directed pressure on the lunate
E. Dorsally-directed pressure on the scaphoid distal pole
Preferred Response: E
Discussion: The scaphoid shift test is used to diagnose
scapholunate instability. The test starts with the wrist in
ulnar deviation. A dorsally directed force is applied to
the scaphoid distal pole and then the wrist is moved into
radial deviation. This maneuver dislocates or subluxes the
scaphoid dorsally over the dorsal ridge of the distal radius.
If scapholunate dissociation is present, a painful “clunk” will
occur when pressure is released and the scaphoid reduces.
Comparison to the contralateral side is important. A bilateral
non painful “clunk” is a negative test. The “clunk” must be
painful for the test to be considered positive.
References:
1. Watson HK, Ashmead D IV, Makhlouf MV. Examination of the
scaphoid. J Hand Surg 1988;13A:657-60.
2. Easterling KJ, Wolfe SW. Scaphoid shift in the uninjured wrist.
J Hand Surg 1994;19A:604-606.
2010 Self-Assessment Examination | 9
 16. A 22 year-old male injures the ulnar aspect of his
thumb MP joint in a fall while skiing. Surgery should
be recommended if:
A. The MP joint is lax in extension, but stable in 30° flexion
B. The MP joint is lax in 30° flexion, but stable in extension
C. A tender mass is palpable proximal to the MP joint
D. The MP joint is lax in hyperextension, but an
endpoint exists
E. A nondisplaced proximal phalangeal fracture is present
Preferred Response: C
volar shear fractures that the lunate facet be reduced and
well fixed (or well buttressed).
References:
1. Harness NG, Jupiter JB, Orbay, JL, Raskin KB, Fernandez DL. Loss
of fixation of the volar lunate facet fragment in fractures of the
distal part of the radius. J Bone Joint Surg 2004;86A:1900-1908.
2. Rozental TD and Blazar PE. Functional Outcome and
Complications after Volar Plating for Dorsally Displaced, Unstable
Fractures of the Distal Radius. J Hand Surg 2006;31A:359-365.
3. McKay SD, MacDermid JC, Roth JH, Richards RS. Assessment
of complications of distal radius fractures and development of a
complication checklist. J Hand Surg 2001;26A:916-922.

Discussion: Skiers thumb, or rupture of the ulnar collateral

ligament of the thumb MP joint, is a common injury. The
indication for surgery is instability of the MP joint (greater
than 35° angulation or greater than 20° difference from the
uninjured side) without an endpoint during valgus stress
testing in extension and 30° flexion. Testing the MP joint in
extension evaluates the integrity of the accessory collateral
ligament/volar plate while testing the MP joint in 30° flexion
tests the proper collateral ligament. The joint must be
unstable in both extension and flexion to warrant surgery.
A Stener’s lesion is created by retraction of the collateral
ligament proximal to the adductor aponeurosis. If palpable,
the ligament is completely torn and retracted, necessitating PA film day of injury Lateral film day PA film 2 days post op
surgery. In the study by Heyman et al, a Stener’s lesion was of injury
present in 87% of surgical cases. A fracture of the ulnar
proximal base of the proximal phalanx may be present in
these injuries. However, surgery is indicated only if the joint
is unstable regardless of the non-displaced fracture.
References:
1. Heyman P, Gelberman RH, Duncan K, Hipp JA. Injuries of the
ulnar collateral ligament of the thumb metacarpophalangeal
joint. Clin Orthop 1993;292:165-171.
2. Malik AK, Morris T, Chou D, Sorene E, Taylor E. Clinical testing
of ulnar collateral ligament injuries of the thumb. J Hand Surg
2009 June;34B(3):363-6.

17. Recurrent volar subluxation, as seen in the figures,
can occur after ORIF of a volar Barton (shear)
fracture of the distal radius if:
A. Volar tilt is not restored
B. Radial height (inclination) is not restored
C. Radial length is not restored
D. The scaphoid facet is not reduced/fixed
E. The lunate facet is not reduced/fixed
Preferred Response: E
Discussion: Harness et al in JBJS presented a series of 7
cases of repeat carpal displacement following ORIF of a
volar shear fracture of the distal radius (as demonstrated
in the figure). The cause is inadequate fixation and/or re-
displacement of the lunate facet allowing the carpus to
displace volarly. It is critical when performing ORIF of these
Lateral film 2 days PA film 14 days post op Lateral Film 14 days
post op post op
18. An 80 year-old woman falls at home and injures her
neck. Afterwards, she has profound upper extremity
weakness, numbness, and mild lower extremity
weakness. Her expectations for recovery should be:
A. No recovery in the upper or lower extremities
B. Full recovery in both upper and lower extremities
C. Fair recovery of both upper and lower extremities
D. Full recovery in the upper extremities, but no recovery
in the lower extremities
E. Full recovery in the upper extremities, with only fair
recovery in the lower extremities
Preferred Response: C

10 | American Society for Surgery of the Hand

Discussion: Central cord syndrome is the most common
incomplete spinal cord injury and is becoming more
common as the age of the population increases. With a
hyperextension injury to the cervical spine in a patient
with preexisting cervical spondylosis (most commonly
elderly patients), the spinal cord is compressed anteriorly
by osteophytes and posteriorly by hypertrophied
ligaments. The central grey matter is most affected by the
compression resulting in significantly greater loss of motor
function in the upper compared to the lower extremities.
Also, variable upper extremity sensory loss occurs. Only fair
recovery can be expected in central cord syndrome.
References:
1. Marar BC. The pattern of neurological damage as an aid to the
diagnosis of the mechanism in cervical-spine injuries. J Bone
Joint Surg 1974;56A:1648-1654.
2. Maroon JC, et al. Central cord syndrome. Clin Neurosurg
1991;37:612-621.
3. McKinley W, Santos K, Meade M, Brooke K. Incidence and
outcomes of spinal cord injury clinical syndromes. J Spinal
Cord Med 2007;30(3):215-224.
19. A 49 year-old male presents with gradually
worsening weakness in both hands over the past
3 months. Physical examination reveals mild
atrophy of the interosseous and thenar musculature
bilaterally. Tongue fasciculations were noted as well.
His most likely diagnosis is:
A. Guillain-Barré Syndrome
B. Charcot Marie Tooth Syndrome
C. Multiple Sclerosis
D. Myasthenia Gravis
E. Amyotrophic Lateral Sclerosis (ALS)
Preferred Response: E
Discussion: ALS is a progressive degenerative disorder
caused by loss of brain stem and spinal motor neurons.
As a result, painless weakness and atrophy results with
minimal or no sensory loss. The first symptoms of ALS
include weakness in the upper and lower extremities,
dysphagia, dysarthria, and head drop. Tongue
fasciculations are nearly pathognomonic of ALS.
Guillain-Barré Syndrome is an ascending motor paralysis
that starts in the lower extremites and can ascend to reach
the upper extremities and the diaphragm. Charcot Marie
Tooth Syndrome is a demyelinating neuropathy that mainly
involves the lower extremities, but can result in intrinsic
wasting of the hands. Multiple Sclerosis is a demyelinating
disease that produces muscle weakness, ataxia, sensory
changes, visual problems, dysarthria and unstable moods.
Myasthenia Gravis is an autoimmune disorder in which
antibodies block the acetylcholine receptors of the post
synaptic neuromuscular junction. Muscles become weak
and easily fatigue. The muscles about the eye and mouth
are particularly susceptible.
References:
1. Shoesmith CL, Strong MJ. Amyotrophic lateral sclerosis.
Can Fam Physician 2006;52:1563-1569.
2. Ross MA, Miller RG, Berchert L, Parry G, Barohn RJ, Armon
C, et al. Toward earlier diagnosis of amyotrophic lateral
sclerosis: revised criteria. rhCNTF ALS Study Group. Neurology
1998;50(3):768-72.
20. A 45 year-old male cut his right hand while fishing
three months ago. Since the injury, he has noted
an enlarging painful wound. Examination revealed
a tender, indurated ulcer with an erythematous
base, but no fluctuance at the site of his laceration.
Intraoperative cultures are negative at five days.
Initial antibiotic treatment is:
A. Penicillin
B. Clarithromycin (Biaxin)
C. Vancomycin
D. Gentamycin
E. Amoxicillin + Clavulinic Acid (Augmentin)
Preferred Response: B
Discussion: Mycobacteria marinum infections result from
injuries sustained while exposed to water (e.g. cleaning
a fish tank). The resultant infection is indolent and often
results in chronic nodules or ulcers. Lymphangitis,
tenosynovitis, and osteomyelitis may also occur. The
organism does not grow well in temperatures above
32°C, so the laboratory must ensure proper incubation
temperatures in order to obtain growth after a biopsy.
Surgical debridement may be necessary, especially for
more severe, or deeper, infections. Although multiple
drug therapy is recommended for more severe infections,
the superficial ulcer in this patient can be managed with
single drug therapy. The most effective antibiotics against
mycobateria marinum include clarithromycin, sulfonamides,
rifampin, ethambutol, and trimethopriam sulfamethoxazole.
References:
1. Harris DM, Keating MR. Mycobacterium marinum: Current
recommended pharmacologic therapy. J Hand Surg
2009;34A:1734-35.
2. Lewis F, Marsh B, von Reyn C. Fish tank exposure and
cutaneous infections due to Mycobacterium marinum:
tuberculin skin testing, treatment, and prevention. Clin Infect
Dis 2003;37:390-397.
2010 Self-Assessment Examination | 11
 21. A 35 year-old technician at an industrial aerospace
plant presents 2 hours after an industrial
fluoroscopy accident. He has sustained an
estimated 200 Gy of radiation to the left hand and
forearm. There is erythema and pain in the exposed
areas. What is the most likely clinical outcome for
this patient in the absence of treatment?
A. Swelling followed by resolution of erythema
B. Mild blistering and reepithelialization
C. Extensive scarring and ulceration
D. Necrosis of the entire hand and forearm
E. Pseudomonas soft tissue infection
Preferred Response: C
Discussion: Low energy injuries (0.5-10 Gy) are
characterized by transient erythema, pruritis, and epilation
(hair loss), which present after 1-3 weeks.
Moderate energy injuries (10-20 Gy) result in transient
early erythema which returns after 1-2 weeks, with typical
desquamation and impaired motion from swelling. These
injuries recover with time and local wound care.
Radiation injuries in the modern era show a preponderance
of upper extremity involvement, high energy exposure, and
tissue and digit loss, due to the industrial use of fluoroscopy
and electron accelerators and the proliferation of nuclear
reactors. Recommendations, based on experience with
case series and animal studies, are for early excision and
coverage of high energy wounds on the lower end of the
energy spectrum (>20Gy). High energy wounds show initial
clinical signs of erythema and pain within 30 minutes, with
evolution to extensive scarring and ulceration based on
energy and depth of penetration over a period of weeks
to months. Commonly, isolated digit necrosis requires
ray amputation. Many reports indicate Pseudomonas
involvement prior to amputation, but it is not clear whether
necrosis or soft tissue infection occurred first.
Referneces:
1. Chambers JA, Long JN. Radiation injury and the hand surgeon.
J Hand Surg 2008;33A:601-611.
2. Krizek T, Ariyan S. Severe acute radiation injuries of the hands:
report of two cases. Plast Reconstr Surg 1973;51:14-22.
3. Milanov NO, Shilov BL, Tjulenev AV. Surgical treatment of
radiation injuries of the hand. Plast Reconstr Surg 1993;92:294.
12 | American Society for Surgery of the Hand
22. A 53 year-old butcher suffered a 3cm transverse
knife laceration to the radial border of the wrist
2 years ago. He has numbness of the dorsal first
webspace, significant pain, and hypersensitivity just
proximal to the laceration. There is a Tinel’s sign
at this location. His neuropathic pain is most likely
attributed to which of the following reactions to
external stimuli:
A. Synaptic impulse conduction
B. Ephaptic impulse conduction
C. Fast axonal transport
D. Slow axonal transport
E. Retrograde axonal transport
Preferred Response: B
Discussion: This patient has a painful neuroma of the
superficial radial nerve, which is characterized by numbness
in the first webspace, Tinel’s over the neuroma, and pain and
hypersensitivity at the neuroma. Pain and hypersensitivity
results from spontaneous nerve impulses from the nerve
fibers within the neuroma and ephaptic conduction,
(“cross-talk”) which allows magnification of normal and
spontaneous nerve impulses by inducing aberrant nerve
impulses within uninvolved adjacent nerve fibers.
Synaptic conduction of nerve action potentials is normal
transmission which occurs between the axons and
dendrites of first, second, and third order sensory neurons
at nerve synapses. An action potential is generated at a
peripheral sensory receptor in response to a stimulus, and
is transmitted along a sensory nerve fiber back to the first
order sensory neurons in the dorsal root ganglion. Synaptic
conduction allows transmission of this impulse to the
second order sensory neuron in the spinal cord. There is
normally no peripheral transmission between nerve fibers in
the absence of a synapse.
Fast and retrograde axonal transport represents physiologic
processes within the peripheral nerve, which are not
particularly contributory to neuropathic pain.
Although the radial nerve is anatomically more susceptible
to neuropathic pain than other distal cutaneous nerves,
compression neuropathy superimposed upon a
traumatic neuroma is not likely to be the primary cause
of neuropathic pain.
References:
1. Mackinnon SE. Evaluation and treatment of the painful
neuroma. Tech Hand Up Extrem Surg 1997;1:195-212.
2. Dellon AL, Mackinnon SE. Susceptibility of the superficial
sensory branch of the radial nerve to form painful neuromas.
J Hand Surg 1984;9B:42-45.
23. A healthy 52 year-old has a radial arterial line placed
prior to undergoing pituitary adenoma resection.
Following surgery, he is noted to have severe
ischemia of the thumb and index finger. There is
a palpable ulnar pulse and a palpable radial pulse
proximal to the arterial cannulation site. There
is no radial pulse or Doppler signal distal to the
cannulation site. What is the next step?
A. Angiography
B. Heparinization
C. Catheter-directed thrombolysis
D. Exploration and thrombectomy
E. Excision and vein grafting
Preferred Response: E
Discussion: This clinical scenario clearly points to a
cannulation-induced injury and thrombosis of the radial
artery distal to the cannulation site. The radial artery most
likely remains patent proximal to the cannulation site, due to
an intact arterial branch providing alternative outflow from
the artery. The thumb and index finger are ischemic despite
intact ulnar artery inflow due to an incomplete palmar arch.
Unless an inflow problem proximal to the site of cannulation
is suspected, angiography is unnecessary and time
consuming, which adds to morbidity.
Heparinization is unlikely to result in recannulation of the
thrombosed artery, if at all, with sufficient speed to prevent
infarction of the affected digits. Thrombolysis with TPA
is contraindicated due to the intracranial procedure. This
thrombotic event is most likely the result of intimal injury
caused by the physical act of cannulation, and is best
treated with resection and vein grafting. Thrombectomy is
possible, but would not address the underlying intravascular
injury and would require heparinization, which is also
contraindicated after an intracranial procedure.
References:
1. Koman LA, Ruch DS, Smith BP, Smith TL. Vascular disorders:
Cannulation injuries. In: Green DP, Hotchkiss RN, Pederson
WC, Wolfe SW, eds. Green’s Operative Hand Surgery. 5th ed.
Philadelphia: Churchill Livingstone/Elsevier, 2005;64:2289-2290.
2. McCollum CH, Mavor E. Brachial artery injury after cardiac
catheterization. J Vasc Surg 1986;4:355-359.
24. Which combination of imaging device and hand
position provides the greatest decrease in radiation
dose to the patient?
A. Mini C-arm, near image intensifier
B. Mini C-arm, near x-ray tube
C. Standard C-arm, behind image intensifier
D. Standard C-arm, on magnification mode
E. Standard C-arm, near x-ray tube
Preferred Response: A
Discussion: The mini C-arm offers significant advantages
in terms of 5-10 fold lower radiation exposure and horizontal
positioning, which allows the surgeon to stand behind
the image intensifier in the location best shielded from
radiation scatter.
As the intensity of radiation exposure follows the “inverse
square law” and varies proportionately to 1/r2, with
r=distance from the radiation source, the surgeon must
consciously position the patient’s hand as far from the
x-ray tube and as close to the image intensifier as possible.
This position is facilitated by rotating a standard C-arm
inverted with the tube up, and placing the image intensifier
down for use as a working platform. With a mini C-arm,
this position is achieved by placing the mini C-arm in a
horizontal position with the image intensifier toward the
surgeon as indicated above.
Finally, there is some advantage to using the magnification
function. As the beam is collimated, scatter is decreased,
and therefore the surgeon and other operating personnel
are exposed to less radiation.
Refernces:
1. Athwal GS, Bueno RA Jr, Wolfe SW. Radiation exposure in
hand surgery: mini versus standard C-arm. J Hand Surg
2005;30A:1310-1316.
2. Giordano BD, Baumhauer JF, Morgan TL, Rechtine GR 2nd.
Patient and surgeon radiation exposure: Comparison of
standard and mini-C-arm fluoroscopy. J Bone Joint Surg
2009;91A:297-304.
3. Tremains MR, Georgiadis GM, Dennis MJ. Radiation exposure
with use of the inverted-C-arm technique in upper-extremity
surgery. J Bone Joint Surg 2001;83A:674-678.
2010 Self-Assessment Examination | 13
 25. A 42 year-old manual laborer presents with numbness
and tingling in the median distribution of both
hands. He is confused about his options regarding
endoscopic versus open carpal tunnel release. Which
of the following short term advantages of endoscopic
release is supported by Level I evidence?
A. Decreased neuropraxia
B. Faster return to work
C. Greater relief of numbness
D. Less scar tenderness
E. Higher pinch and grip strength
Preferred Response: D
Discussion: Endoscopic carpal tunnel release has become
an accepted modality for treatment of carpal tunnel
syndrome. However, open carpal tunnel release remains
a mainstay in many hand surgery practices. The general
consensus is that long term results are comparable among
the two.
A systematic review of randomized controlled trials (Level
I evidence) by Thoma et al. in 2004, concluded that short-
term (6-12 weeks postoperative) scar tenderness and grip/
pinch strength were improved when comparing endoscopic
vs. open release. This study incorporated trials between
1992 and 2000. Thoma showed increased neuropraxia
in endoscopic release, which is a known drawback of
the endoscopic treatment; return to work was equivocal
between the two treatments. Subsequent Level I studies
by Ferdinand and MacLean showed no difference in
pinch/grip strength between treatments; MacDermid
et al. demonstrated no difference in sensory threshold,
suggesting no difference in neuropraxia; Atroshi et al.
showed no difference in symptomatic relief.
The heterogeneity of these Level I reports suggests the
importance of variability in patient selection, surgical
technique, and assessment measures in comparing open
vs. endoscopic carpal tunnel release.
References:
1. Thoma A, Veltri K, Haines T, Duku E. A meta-analysis of
randomized controlled trials comparing endoscopic and
open carpal tunnel decompression. Plast Reconstr Surg
2004;114:1137.
2. Ferdinand RD, MacLean JGB. Endoscopic versus open carpal
tunnel release in bilateral carpal tunnel syndrome. J Bone Joint
Surg 2002;84B:375-379.
3. MacDermid JC, Richards RS, Roth JH, Ross DC, King GJW.
Endoscopic versus open carpal tunnel release: A randomized
trial. J Hand Surg 2003;28A:475-480.
4. Atroshi I, Hofer M, Larsson GU, Ornstein E, Johnsson R,
Ranstam J. Open compared with 2-portal endoscopic carpal
tunnel release: A 5-year follow-up of a randomized controlled
trial. J Hand Surg 2009;34A:266-272.
5. Trumble TE, Diao E, Abrams RA, Gilbert-Anderson MM. Single-
portal endoscopic carpal tunnel release compared with open
release: A prospective, randomized trial. J Bone Joint Surg
2002;84A:1107-1115.
14 | American Society for Surgery of the Hand
26. Which muscle is most likely to be involved in a mild
Volkmann’s ischemic contracture of the forearm?
A. Flexor pollicis longus (FPL)
B. Flexor carpi ulnaris (FCU)
C. Palmaris longus (PL)
D. Flexor digitorum superficialis (FDS)
E. Pronator teres (PT)
Preferred Response: A
Discussion: Volkmann’s ischemic contracture of the forearm
results from an untreated or prolonged ischemia from an
acute compartment syndrome. The necrotic muscle is
replaced with fibrotic scar tissue, resulting in contractures.
Ulnar and/or median nerve injury may be irreversible.
The most vulnerable muscles have the deeper muscle
bellies and include the flexor pollicis longus and the flexor
digitorum profundus. In milder ischemic contractures,
only portions of these two muscles may be involved. The
superficial muscles in the volar forearm (e.g. FCR/FCU/
PT/PL/FDS) are damaged only with more severe and/or
prolonged compartment syndromes.
References:
1. Stevanovic M, Sharpe F. Management of established
Volkmann’s contracture of the forearm in children. Hand Clin
2006;22:99-111.
2. Tsuge K. Treatment of established Volkmann’s contracture.
J Bone Joint Surg 1975;57A:925-929.
27. Which of the following is associated with decreased
success of use of the isolated 1,2 intercompartmental
vascularized bone graft for scaphoid nonunion?
A. VISI deformity
B. Incomplete palmar arch
C. Avascular necrosis
D. Prior fixation
E. Humpback deformity
Preferred Response: E
Discussion: The 1,2 intercompartmental supraretinacular
artery (1,2 ICSRA) pedicled vascularized dorsal radius
bone graft has been developed extensively for treatment
of scaphoid nonunions and proximal pole avascular
necrosis (AVN). Success rates are 67-100% when using this
technique. The blood supply of this flap is based on a distal
branch of the radial artery at the wrist. Despite an abnormal
Allen’s test, this flap may be performed as long as the radial
artery has a palpable pulse. Prior fixation or surgery is not a
contraindication to its use.
In a retrospective review of 48 cases of scaphoid nonunion
and AVN treated with 1,2 ICSRA vascularized graft, 9 of 14
failures were attributed to humpback deformity, indicating
advanced carpal collapse. In the setting of humpback
deformity, a free vascularized bone graft from the medial
femoral condyle may be a more appropriate treatment.
References:
1. Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and
complications of 1,2 intercompartmental supraretinacular artery
pedicled vascularized bone grafting of scaphoid nonunions.
J Hand Surg 2006;31A:387-396.
2. Larson AN, Bishop AT, Shin AY. Dorsal distal radius
vascularized pedicled bone grafts for scaphoid nonunions.
Tech Hand Up Extrem Surg 2006;10:212-223.
3. Jones DB Jr, Burger H, Bishop AT, Shin AY. Treatment of
scaphoid waist nonunions with an avascular proximal pole and
carpal collapse. A comparison of two vascularized bone grafts.
J Bone Joint Surg 2008;90A:2616-2625.
28. A 3 year-old presents 6 months after sustaining a
window glass midpalm laceration over the index
metacarpal, which was closed at an urgent care center.
On exam, all joints are supple and a palmaris longus
tendon is present. DIP joint active flexion is absent,
and PIP joint active flexion is intact. Exploration reveals
a zone 3 FDP laceration with a 2cm gap between the
tendon stumps and an intact FDS tendon. What is
the best reconstructive option for finger flexion?
A. FDP excision
B. FDP primary repair
C. FDP reconstruction with interpositional palmaris
tendon graft
D. FDP excision, silicone rod placement
E. FDP 2-stage reconstruction with FDS tendon graft,
silicone rod placement
The Paneva-Holevich technique of two-stage tendon
reconstruction (which uses the FDS tendon as a graft that
is sutured to the proximal FDP stump at the same time
as silicone rod placement) provides an advantage of one
less tendon repair site at the second-stage reconstruction,
when compared with a free palmaris longus graft. However,
the Paneva-Holevich technique would require sacrificing
the intact FDS tendon for use as a graft to reconstruct the
lacerated FDP tendon.
The recommended postoperative regimen for tendon
repairs in younger children (generally less than 10 years of
age) is complete immobilization for four weeks. Recent work
suggests that early motion is possible in this group, but
immobilization remains the preferred regimen.
References:
1. Taras JS, Kaufmann RA. Flexor tendon injury: Flexor tendon
reconstruction. In: Green DP, Hotchkiss RN, Pederson WC,
Wolfe SW, eds. Green’s Operative Hand Surgery. 5th ed.
Philadelphia: Churchill Livingstone/Elsevier, 2005;7:254-272.
2. Stark HH, Anderson DR, Boyes JH, et al. Bridge grafts of flexor
tendons. Orthop Trans 1983;7:44.
3. Valenti P, Gilbert A. Two-stage flexor tendon grafting in
children. Hand Clin 2000;16:573-578.
4. O’Connell SJ, Moore MM, Strickland JW, Frazier GT, Dell PC.
Results of zone I and zone II flexor tendon repairs in children.
J Hand Surg 1994;19A:48-52.
5. Moehrlen U, Mazzone L, Bieli C, Weber DM. Early mobilization
after flexor tendon repair in children. Eur J Pediatr Surg
2009;19:83-86.

Preferred Response: C
Discussion: In children, many advocate for waiting until
after age 7 to reconstruct tendon injuries with delayed
presentation; specifically, in Zone 2 injuries requiring
2-stage silicone rod reconstruction, due to inability to
comply with early motion protocols. However, the tendon
injury in this case can be localized to zone 3, or midpalmar,
which is outside of the flexor tendon sheath. A tendon
defect outside of the sheath is suitable for single-stage
tendon graft repair without the use of a silicone rod, due to
decreased concern for tendon adhesions. Primary end-to- Figure 1 Figure 2
end tendon repair is not possible due to significant retraction
of the tendon stumps and degeneration of the tendon ends,
requiring freshening by sharp transection. Excising the FDP
tendon is not necessary and would create the potential
for scarring within the flexor sheath, which would impair
existing FDS excursion.

2010 Self-Assessment Examination | 15

 29. A 55 year-old man presents with triggering of the
right ring finger. On further questioning, he has a
2-year history of morning stiffness of both hands,
which gradually improves with use. Examination
shows diffuse volar swelling of the ring finger with
palpable crepitant triggering, and nonpainful boggy
enlargement of the wrists bilaterally and MCP joints
of all fingers. Radiographs show bony erosion and
destruction of the wrist and MCP joints. What is the
appropriate treatment for the ring finger?
A. Intravenous vancomycin
B. Oral clarithromycin/ethambutol
C. Closed catheter irrigation
D. Open tenosynovectomy
E. Release of the A1 pulley
Preferred Response: D
Discussion: This patient meets clinical criteria for a
diagnosis of rheumatoid arthritis based on the presence of
morning stiffness, symmetric joint involvement, involvement
of 3 hand joints, MCP and wrist involvement, and erosive
arthritis on x-rays.
The triggering represents true tenosynovitis, in contrast
to the tendovaginitis present in the idiopathic trigger
digit. Infectious etiologies such as suppurative flexor
tenosynovitis or mycobacterium marinum infection are
unlikely, given the chronicity and polyarticular involvement.
Recommended first treatment is open tenosynovectomy of
the flexor tendon within the sheath, with possible stepwise
progression to ulnar superficialis slip excision and reductive
flexor tenoplasty as needed to address associated
enlargement of the flexor tendons.
Release of the A1 pulley is not recommended in rheumatoid
arthritis patients due to the potential for worsening deformity.
References:
1. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF,
Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS, et al.
The American Rheumatism Association 1987 revised criteria
for the classification of rheumatoid arthritis. Arthritis Rheum
1988;31:315-24.
2. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and
complications. J Hand Surg 2006;31:135-146.
3. Ferlic DC, Clayton MC. Flexor tenosynovectomy in the
rheumatoid finger. J Hand Surg 1978;3:364-367.
A. Proximal prominence of the pretendinous cord with
skin pitting
B. Lack of skin adherence between palmar crease and
palmodigital crease
C. Absent proximal interphalangeal joint flexion contracture
D. Impaired metacarpophalangeal joint passive and
active extension
E. Normal fingertip two point discrimination and
monofilament exam
Preferred Response: B
Discussion: This untreated Dupuytren’s contracture fails
the Hueston “tabletop test”, which some use as a criterion
for surgical correction. The ring finger displays a typical
early Dupuytren’s presentation with pretendinous cord and
adjacent dermal pitting, restriction of MP joint extension,
and minimal PIP joint involvement.
Short and Watson have indicated that the palmar skin
and soft tissues between the distal palmar crease and
the palmodigital crease should be examined closely prior
to surgical treatment. The presence of dense adhesion
between the dermis and the pretendinous cord/central cord
structure in this location precludes the presence of spiral
cords. Thus, when the skin is completely adherent to the
longitudinal cords along this segment, the neurovascular
bundles are not pathologically displaced to the superficial
and midaxial position that renders them susceptible to
iatrogenic injury. This has implications for minimizing
iatrogenic nerve injury in open treatment, which is the
traditional option, and percutaneous release, which is ideal
for the primary (early) palmar disease present in this finger.
References:
1. Short WH, Watson HK. Prediction of the spiral nerve in
Dupuytren’s contracture. J Hand Surg 1982;7A:84-86.
2. Foucher G, Medina J, Malizos K. Percutaneous needle
fasciotomy in Dupuytren’s disease. Tech Hand Up Extrem Surg
2001;5:161-164.

30. A 64 year-old man presents with the deformity shown

in Figures 1 and 2. He is not able to flatten the palm
against a table. Which of the following physical
findings suggests that the digital neurovascular
bundles are displaced to a vulnerable superficial
position near the midaxis of the ring finger?

Figure 1 Figure 2

16 | American Society for Surgery of the Hand

31. A 46 year-old woman presents with extension Preferred Response: D
contracture of the ring and small finger MCP joints
Discussion: Congenital clasped thumb is a rare disorder
after ulnar nerve injury. She comes for surgical
where a child’s thumb displays a flexed posture at the MCP
release of the contractures. The joints are ranged
joint. This is most often caused by an abnormal extensor
following excision of the dorsal MCP joint capsule
mechanism. A hypoplastic extensor pollicis brevis tendon is
and incision of the dorsal 50% of the collateral
commonly encountered.
ligaments. During passive range of motion, full flexion
is obtained. However, when moved into extension Congenital clasped thumb was described Weckesser
there is noted to be a “jump” in the motion of the joint and Heiple in 1968 and classified into four groups. Group
prior to reaching full extension. What is the next step? one includes the cases most commonly encountered.
Conservative therapy can be successful here. Late or
A. Volar plate release
secondary changes in the intrinsic muscles and soft tissues
B. Flexor tenolysis can complicate surgical procedures. The principal defect
C. Collateral ligament reconstruction involves the extensor pollicis brevis muscle and tendon.
D. Collateral ligament release Group two includes cases in which the thumb is clasped in
the palm and the thumb extensors are weak or absent. There
E. Wound closure
are significant flexion contractures of the other digits. This is
Preferred Response: D thought to be the result of mild-to-moderate arthrogryposis.
Group three has diffuse alterations in all structures of the
Discussion: The primary goal of restoring full MCP flexion
thumb, including hypoplasia of the extensors, flexors, and
has been obtained. The “jump” noted when moving to
thenar muscles, as well as the osseous components. Group
extension indicates residual tightness of the collateral
four includes all cases, which do not fall into these other
ligaments. The collateral ligaments are snapping over the
three categories. There may be duplication of the digits and
condyles of the metacarpal head when passing from full
the extensor tendon may be abnormally distributed.
flexion to full extension, due to inadequate ligament length
and extensibility. The next step is to release the collateral Inability to extend the thumb, following splinting, can be
ligaments further by dividing the insertions to the metacarpal addressed with a tendon transfer. The flexor digitorum
head. If the problem persists, the accessory collaterals sublimus of the ring and long finger is transferred to the
should be taken down as well. This problem must be thumb extensor mechanism.
corrected because active MCP flexion may be significantly
Fixed deformities with web-space contracture may need
impaired by the physical restriction of ligament excursion.
MP joint release, flexor pollicis longus lengthening, or flexor
Volar plate release is not necessary in extension sheath release.
contractures, but intraarticular adhesions of the volar
Flexion deformities of the IP joint of the thumb are more
synovial pouch may need to be gently released. Flexor
commonly seen with congenital trigger thumb. They are
tenolysis may be necessary in these cases, but tendon
often associated with postural hyperextension of the MP
adhesions generally do not cause triggering.
joint. Inability to extend the MP joint of the thumb is rarely
References: seen in a patient with congenital trigger thumb.
1. Shin AY, Amadio PC. Stiff finger joints. In: Green DP, Hotchkiss
References:
RN, Pederson WC, Wolfe SW, eds. Green’s Operative Hand
Surgery. 5th ed. Philadelphia: Churchill Livingstone/Elsevier, 1. Lipskeir E, Weizenbluth M. Surgical treatment of the clasp
2005;11:417-438. thumb. J Hand Surg 1989;128:72-79.
2. Young VL, Weeks CR, Weeks PM. The surgical management of 2. Weckesser EC, Reed JR, Heiple KG. Congential clasp thumb.
stiff joints in the hand. Plast Reconstr Surg 1978;62:835-841. (Congential flexion-adduction deformity of the thumb) J Bone
Joint Surg 1968;50A:1417-1436.
3. Upton J. Congenital anomalies of the hand and forearm. In:
32. An 8-month-old child is seen with the thumb McCarthy JG, May JW, Littler JW. Plastic Surgery: The Hand
Part 2. Philadelphia: WB Saunders, 1990:5213-3398.
deformity in Figure 1. The MCP joint is flexed, but
supple, and easily passively extended. The child
cannot actively extend the MCP or the IP joint of the
thumb. There are no other abnormalities seen in this
child. In considering surgery for this deformity, what
common abnormality is found?
A. Thickening in the flexor pollicis longus tendon
B. Stenotic A1 pulley of the thumb
C. Absence of the flexor pollicis longus
D. Hypoplastic extensor pollicis brevis
E. Absence of the brachioradialis Figure 1

2010 Self-Assessment Examination | 17

 33. The abnormality evident in the nail bed of the patient
seen in Figure 1 is associated with which of the
following disorders?
A. Sarcoidosis
B. Psoriasis
C. Bronchogenic carcinoma
D. Cirrhosis
E. Arsenic toxicity
Preferred Response: D
Discussion: In 1954, Terry was the first to describe opacities of
the nail in patients with cirrhosis. The proximal nail is affected,
is opaque, and obscures the lunula. The discoloration
usually stops 1-2 millimeters from the distal edge of the
nail. The anomaly involves all nails uniformly. Arsenic toxicity
manifests with formation of arsenic keratosis. They are a
keratotic papule or plaque usually on the lateral nail fold. They
are found in patients with large amounts of arsenic ingestion.
Patients with bronchogenic carcinoma have clubbing of the
nails with loss of the normal depression at the base of the nail.
Patients with hepatitis may have palmar erythema and spider
angiomata. The palmar erythema is usually most prominent on
the thenar and hypothenar eminences. Sarcoidosis does not
cause nail change. Psoriasis is associated with nail pitting.
References:
1. Terry, RB. White nails in hepatic cirrhosis. Lancet 1955;4:757.
2. Bradburn H, Chase R, Fessel J. The Hand in Systemic Disease.
J Bone Joint Surg 1962;44A:1395-1411.
Figure 1
34. A patient presents to clinic complaining of
numbness and burning pain in both hands. The
patient is currently being treated with vincristine for
acute leukemia. Chemotherapy induced peripheral
neuropathy is most closely related to:
A. Cumulative dose
B. Patients gender
C. Avoidance of drug-dense dosing
D. Stage of cancer
E. Use of a single agent chemotherapy
Preferred Response: A
18 | American Society for Surgery of the Hand
Discussion: The mechanism of development of the
chemotherapy-induced peripheral neuropathy (CIPN) is
unknown. A painful sensory neuropathy may develop with
cisplatin, oxaliplatin, carboplatin. A mixed sensorimotor
neuropathy, with or without involvement of the autonomic
nervous system, is more common with vincristine, taxol,
and suramin. Neurotoxicity is believed to most likely
depend on the total cumulative dose and the type of drug
used. Patients with diabetes mellitus, alcohol or inherited
neuropathy are more susceptible to development of
chemotherapy-induced peripheral neuropathy. Gender of
the patient has no known connection to development of the
neuropathy. Use of dose-dense chemotherapy regimens, as
well as use of multimodal chemotherapy regiment, has been
found to increase the incidence of CIPN. Stage of cancer,
location of cancer, as well as the type of cancer, has no
known relation to the development of CIPN.
References:
1. Quanstoff S, Hartung P. Chemotherapy-induced peripheral
neuropathy. J of Neurology 2002;249:9-17.
2. Malik B, Stillman M. Chemotherapy-induced peripheral
neuropathy. Cr Neurology and Neuroscience Report
2008;8:56-65.
35. A cross finger flap is used to cover the pulp defect
of the ring finger. The flap is raised from the dorsum
of the middle phalanx of the long finger. If impaired
vascularity is encountered, which of the following
will aid in improving flap vascularity?
A. Incising Cleland’s ligament
B. Pinning the PIP joint of the ring finger in 60° of flexion
C. Pinning the PIP joint of the long finger in 60° of flexion
D. Incising the paratenon over the extensor tendon
E. Excising the paratenon over the extensor tendon
Preferred Response: A
Discussion: The cross finger flap is a random flap raised
from the dorsum of the finger at the proximal or middle
phalanx level. It is based on the subdermal plexus of
vessels supplied by both the dorsal digital arteries and the
proper digital arteries.
The main indication for the flap is the volar pulp wound, with
extensive soft tissue loss.
Contraindications include multiple injuries to the hand,
Berger’s and Raynaud’s disease, and Dupuytren’s
contracture.
In the case above, to improve vascularity and lengthen
the flap, one can divide Cleland’s ligament to allow more
mobility. The paratenon over the extensor tendon must be
preserved to allow skin graft coverage. PIP pin fixation in
patients over 50 can result in significant stiffness of the
PIP joint.
References:
1. Thomson HG, Sorokolit WT. The cross-finger flap in children: a
follow up study. Plast Reconstr Surg 1967;39(5):482-487.
2. Barclay TL. The late results of finger-tip injuries. Br J Plast Surg
1955;8:38-42.
3. Porter RW. Functional assessment of transplanted skin in volar
defects of the digits. J Bone Joint Surg 1968;50A:955-963.
4. Friedrich JB, Katolik LI, Vedder NB. Soft tissue reconstruction
of the hand. J Hand Surg 2009;34A:1148-1155.
36. Patients with pre-existing lymphedema secondary
to axillary node dissection that undergo a hand
surgical procedure have an increased rate of:
A. Infection
B. Complex regional pain syndrome
C. Prolonged stiffness
D. Delayed wound healing
E. Blood loss
Preferred Response: D
Discussion: Elective hand surgery in post-mastectomy
lymphedema can be tolerated, but a delay in wound healing
has been noted in the literature. To limit post-operative
lymphedema, sterile technique and judicious use of the
tourniquet are recommended.
The rates of infection, regional pain syndrome, blood loss
and stiffness were comparable with surgery done in normal
limbs. Only a slightly prolonged healing time separated the
post axillary node dissection group from the normal.
References:
1. Smith WK, Giddins GEB. Lymphedema and hand surgery.
J Hand Surg 1999;24A:138.
2. Gharbaoui IS, Netscher DT, Thornby J, Kessler FB. Safety of
upper extremity surgery after prior treatment for ipsilateral
breast cancer: results of an American Society for Surgery of the
Hand membership survey and literature review. J Am Soc Surg
Hand 2005;5:232–38.
37. Attempts at closed reduction of the small finger
metacarpophalangeal joint seen in Figures 1 and
2 have proven unsuccessful. A volar approach is
made to the MP joint to facilitate reduction. Which
of the following structures must be divided to
successfully reduce the dislocation?
A. Volar plate
B. Sagittal band
C. Lumbrical muscle
D. A1 Pulley
E. Superficial transverse metacarpal ligament
Preferred Response: D
Discussion: The photographs show a dorsal dislocation of
the metacarpophalangeal joint of the small finger. In reducible
dorsal dislocations of the MP joint, the proximal phalanx
is perched in a hyperextended position on the metacarpal
head with flexion of the proximal phalangeal joint. When a
dorsal metacarpophalangeal joint dislocation is complex,
the proximal phalanx lies dorsal to the metacarpal shaft in
a bayonet position. The border digits, index and small, are
more commonly injured. Dimpling in the skin of the proximal
palmer crease is pathognomonic for a dorsal dislocation.
Closed reduction is often attempted, and simple distraction
is usually unsuccessful. This can convert a reducible
dislocation into an irreducible one. The closed reduction
maneuver for dorsal dislocations flexes the wrist and
proximal phalangeal joint of the injured digit to relax the
flexor tendons. Then, a palmarly directed force is applied
to the base of the proximal phalanx in an attempt to slide
the proximal phalanx and its attached volar plate over the
metacarpal head into a reduced position.
Open reductions are either done through a dorsal or volar
approach. The volar approach endangers the radial digital
neurovascular bundle when the index MP joint is dislocated,
and the ulnar digital neurovascular bundle when the small
finger is dislocated. These neurovascular bundles are
placed in a precarious position by the dislocation. Through
a zig zag or chevron approach, the metacarpal head is
exposed and the A1 pulley is divided longitudinally. This
loosens the noose formed by the flexor tendon ulnarly and
the lumbrical tendon radially. The lumbrical lies radial to the
metacarpal head. Releasing the pulley relieves the tension
on this noose and allows one to hyperextend the joint and
removes the volar plate, facilitating reduction.
The hand is usually splinted in a dorsal splint for 2-3 weeks,
allowing active flexion within the range of stability.
References:
1. Green DP, Terry GC. Complex dislocation of the
metacarpophalangeal joint: Correlative pathological anatomy.
J Bone Joint Surg 1973;55A:1480-1486.
2. Dihn P, et al. Metacarpophalangeal joint dislocation. J Am Acad
Orthop Surg 2009;17(5):318-324.
3. Baldwin LW, Miller DL, Lockhart LD, Evans EB.
Metacarpalphalangeal dislocations of the fingers. A comparison
of the pathological anatomy of the index and little finger. J Bone
Joint Surg 1967;49A:1587-1590.
Figure 1 Figure 2
2010 Self-Assessment Examination | 19
 38. Which of the following anatomic structures is not References:
involved in the spiral cord in Dupuytren’s disease? 1. Terkonda SP, Perdikis G. Non-melanotic skin tumors of the
upper extremity. Hand Clin 2004;20:293-301.
A. Pretendinous band
2. Zabar RIS, Cottel WI. Skin Tumors 1: non-melanoma skin
B. Spiral band tumors. Sel Read Plast Surg 2000;9:2-19.
C. Cleland’s ligaments
D. Grayson’s ligament
E. Lateral digital sheath
Preferred Response: C
Discussion: The spiral cord seen in PIP joint contractures in
Dupuytren’s disease has four origins:
1. Pretendinous band
2. Spiral band
3. Lateral digital sheath
4. Grayson’s ligament
Cleland’s ligament is not involved in the makeup of the spiral
cord. The cord in the palm usually affects the ring and small
finger and is superficial to the neurovascular bundle. Distal
to the metacarpophalangeal joint, it passes deep to the
bundle. It runs lateral to the neurovascular bundle, involving
the lateral digital sheath; then, when Grayson’s ligament is
involved, the cord is again superficial to the bundle.
References:
1. Umlas ME, Bischoff RJ, Gelberman RH. Predictors of
neurovascular displacement in hands with Dupuytren’s
contracture. J Hand Surg 1994;19B:664-666. Figure 1
2. McFarlane R. The anatomy of Dupuytren’s disease. In: Hueston
JT, Tubiana R, eds. Dupuytren’s Disease. 2nd ed. New York:
Churchill Livingstone, 1985:54-71.
40. What associated joint deformity typically occurs
with PIP flexion contractures in patients with
psoriatic arthritis?
39. A 75 year-old rancher presents with a rapidly growing
lesion on the dorsum of his dominant hand seen in A. Boutonniere deformity
Figure 1. It is nonpainful and has been present for one B. Swan neck deformity
month. Which of the following is the correct diagnosis?
C. DIP flexion contracture
A. Squamous cell carcinoma D. MCP extension contracture
B. Basal cell carcinoma E. MCP flexion contracture
C. Keratoacanthoma
Preferred Response: D
D. Pyogenic granuloma
Discussion: The PIP flexion contracture that characteristically
E. Seborrheic keratosis
occurs with psoriatic arthritis is often accompanied by an
Preferred Response: C MCP joint extension contracture. However, the DIP joint does
not typically settle into a posture of hyperextension, as in
Discussion: Keratoacanthomas are rapidly growing skin tumors
a Boutonniere deformity. The MCP extension contractures
that are typically seen on sun-exposed skin. They pathologically
are in contrast to the more typical MCP flexion contractures
resemble squamous cell carcinoma. Keratoacanthoma is
seen in Rheumatoid arthritis.
characterized by rapid growth over a few weeks to months,
followed by spontaneous resolution over 4-6 months in most References:
cases. Squamous cell carcinoma has a more insidious history 1. Feldon, Terrono, Nalebuff, Millender. Rheumatoid Arthritis.
and rarely causes pain. Basal cell carcinomas are the most In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds.
common form of skin cancer. They are slow-growing with skin Green’s Operative Hand Surgery. 5th ed. Philadelphia: Churchill
Livingstone/Elsevier, 2005:2053.
atrophy, and pink-to-red skin discoloration. Ultimately, they
2. Rose JH, Belsky MR. Psoriatic arthritis in the hand. Hand Clin
ulcerate with elevated pearly borders. Seborrheic keratosis are
1989;5:137-144.
noncancerous (benign), wart-like growths on the surface of the
skin. A biopsy is necessary prior to definitive surgical treatment.

20 | American Society for Surgery of the Hand

41. The diagnosis of acute gout is best confirmed by:
A. A nucleated cell count above 50,000 on joint aspiration
B. The presence of chondrocalcinosis on plain radiographs
C. Elevated sedimentation rate
D. Elevated blood uric acid
E. Negative birefringence of crystals in joint fluid aspirate
Preferred Response: E
Discussion: Negative birefringence of urate crystals found
on joint aspiration is a clinically accurate way to confirm the
diagnosis of gout. The presence of negatively birefringent
urate crystals does not preclude concurrent infection or
other inflammatory arthropathy (such as rheumatoid arthritis).
Gout will often present with a slight fever, leucocytosis,
elevated ESR and CRP. Blood uric acid level cannot be relied
on to confirm or exclude gout. A synovial fluid analysis or
tissue specimen should be examined under polarized light
microscopy for the presence of urate crystals, which should
be negatively birefringent (yellow when aligned parallel to
axis of the red compensator inserted between the polarizer
and the analyzer within the microscope).
References:
1. Snaith ML. ABC of Rheumatology: Gout, Hyperuricemia, and
Crystal Arthritis. Br Med J 1995;310:521-524.
2. Kann SE, Jacquemin J, Stern PJ. Simulators of hand infections.
AAOS Instr Course Lect 1997;46:69-82.
Discussion: Patients with long-standing nerve injury (two
years from injury) are better served by tendon transfers for
radial nerve palsy than nerve repair, as motor-end plate
damage tends to occur 9-12 months after the injury. This
patient already has atrophy of his nondominant forearm
and would be well served with tendon transfers to restore
hand position for activities of daily living. Pronator teres to
ECRB, FCR to EDC, and palmaris longus to EPL tendon
transfers accomplish acceptable hand position for activities
of daily living.
If intervention is performed prior to nine months after injury,
Mackinnon’s group has recently described nerve transfers
from selected expendable branches of the median or ulnar
nerve to the posterior interosseous nerve and ECRB or
ECRL for restoration of long extensor function.
References:
1. Bishop J, Ring D. Management of radial nerve palsy associated
with humeral shaft fracture: a decision analysis model. J Hand
Surg 2009;34A:991-6.
2. Bumbasirević M, Lesić A, Bumbasirević V, Cobeljić G,
Milosević I, Atkinson HD. The management of humeral shaft
fractures with associated radial nerve palsy: a review of 117
cases. Arch Orthop Trauma Surg 2010;4:519-22.
3. Mackinnon SE, Roque B, Tung TH. Median to radial nerve
transfer for treatment of radial nerve palsy. Case report.
J Neurosurg 2007;107:666-71.
4. Lowe JB 3rd, Tung TR, Mackinnon SE. New surgical option for
radial nerve paralysis. Plast Reconstr Surg 2002;110:836-43.

42. A 45 year-old patient presents with the radiograph

shown in Figure 1 and a chief complaint of
weakness after sustaining a non-dominant humeral
shaft fracture. He states that he has not felt the back
of his hand, extended his fingers, or extended his
wrist since his initial injury 2 years ago. On exam, he
has extrinsic atrophy and no radial nerve function
distal to the triceps. What surgical plan is most
appropriate to offer him?
A. External neurolysis of the radial nerve and collagen
conduit treatment
B. Radial nerve grafting at the level of the fracture
C. FCR and palmaris nerve branches to posterior
interosseous nerve transfer
D. FCU to ECRB, FDS IV to EDC, and abductor digiti
minimi opponens tendon transfers Figure 1
E. Pronator teres to ECRB, FCR to EDC, and palmaris
longus to EPL tendon transfers
Preferred Response: E

2010 Self-Assessment Examination | 21

 43. Interfascicular nerve repair has been shown to: While documented hand strength and function may improve
with growth in a child with this chronic neuromuscular
A. Poorly reapproximate nerve fascicle orientation
disorder, the ever-present weakness from motor axon loss
B. Decrease tension at the repair site can be demonstrated in patients with CMT type 1A using
C. Increase scarring at the repair site straightforward dynamometry. In addition, grip strength has
D. Preserve perineural blood flow been correlated with CMAP amplitude.
E. Be significantly superior to epineural repair References:
1. Burns J, Bray P, Cross LA, North KN, Ryan MM, Ouvrier RA.
Preferred Response: C
Hand involvement in children with Charcot-Marie-Tooth disease
Discussion: Levinthal et al. compared different types of type 1A. Neuromuscul Disord 2008;18(12):970-3.
nerve repair in dogs and found increased scarring and 2. Videler AJ, van Dijk JP, Beelen A, de Visser M, Nollet F,
decreased axonal ratio (presence of axons compared to van Schaik IN. Motor axon loss is associated with hand
dysfunction in Charcot-Marie-Tooth disease 1a. Neurology
connective tissue) in the interfascicular repair group with 2008;71(16):1254-60.
no significant improvement in axonal recovery, compared
to epineural repair. There was improved axonal recovery
in the perineural, fascicular repair group. Cabaud et al
45. A spiral cord in Dupuytren’s contracture will
and Kline et al found no significant differences in recovery
displace the neurovascular bundle:
results, comparing fascicular versus epineural repairs
in cats and monkeys, respectively. No clinical study has A. Distally, dorsally, and away from the midline
effectively demonstrated the superiority of one type of B. Proximally, volarly, and towards the midline
nerve coaptation (fascicular, interfascicular, epineural) over
C. Distally, volarly, and towards the midline
another in a controlled trial in humans.
D. Proximally, dorsally, and away from the midline
References:
E. Distally, volarly, and away from the midline
1. Levinthal R, Brown WJ, Rand RW. Comparison of fascicular,
interfascicular and epineural suture techniques in the repair of Preferred Response: B
simple nerve lacerations. J Neurosurg 1977;47(5):744-50.
2. Lundborg G. A 25-year perspective of peripheral nerve surgery: Discussion: One of the more troublesome anatomic
evolving neuroscientific concepts and clinical significance. variants of Dupuytren’s contracture is the spiral cord. The
J Hand Surg 2000;25A(3):391-414. spiral cord will extend from the palm away from the midline,
3. Kline DG, Hudson AR, Bratton BR. Experimental study of pushing the bundle toward the midline (Figure 1). The spiral
fascicular nerve repair with and without epineural closure. cord will also extend deep to the neurovascular bundle,
J Neurosurg 1981;54(4):513-20. pushing it volarly or superficially. Lastly, the spiral cord will
4. Orgel MG. Epineural versus perineural repair of peripheral cause a flexion contracture of the finger, pushing the bundle
nerves. Clin Plast Surg 1984;11(1):101-4.
more proximally.
5. Cabaud HE, Rodkey WG, McCarroll HR Jr, Mutz SB, Niebauer
JJ. Epineural and perineural fascicular nerve repairs: a critical References:
comparison. J Hand Surg 1976;1A(2):131-7. 1. McGrouther. Dupuytren’s Contracture. In: Green DP, Hotchkiss
RN, Pederson WC, Wolfe SW, eds. Green’s Operative Hand
Surgery. 5th ed. Philadelphia: Churchill Livingstone/Elsevier,
2005:2053.
44. Children with Charcot-Marie-Tooth disease most
2. McFarlane RM. Patterns of the diseased fascia in the fingers of
frequently present with:
Dupuytren’s contracture. Plast Reconstr Surg 1974;54:31-44.
A. Intrinsic hand weakness and poor manual dexterity
B. PIP joint extension contractures
C. Intrinsic spasticity
D. Extrinsic spasticity
E. Characteristic nail changes and collagen related
joint laxity
Preferred Response: A
Discussion: Charcot-Marie-Tooth disease is a
demyelinating neuropathy with progressive muscle
weakness and atrophy. While the foot and the leg are most
characteristically affected, many patients (children and
adults) describe hand weakness and difficulty with manual
dexterity. Intrinsic muscle atrophy is the typical etiology.
Figure 1

22 | American Society for Surgery of the Hand

46. A 62 year-old man fell four days ago. The post- 47. The best treatment of the injury shown in Figure 1 is:
reduction x-ray is shown. The best treatment for
A. Casting in 30º flexion
the injury is:
B. Casting in 90º flexion
A. Open reduction internal fixation
C. Tension banding
B. Closed reduction percutaneous pinning
D. Plating
C. Static splint
E. Excision
D. Dorsal blocking splint
Preferred Response: D
E. Extension block pinning
Discussion: Displaced olecranon fractures require internal
Preferred Response: A
fixation. Simple, stable fractures may be considered for
Discussion: Joint alignment and stability has been shown tension-banding techniques. Unstable fractures must
to be more important in determining overall outcome with be fixed with more rigid constructs, such as plating.
these fractures than joint congruity. Proximal fracture Comminuted fractures are examples of unstable fractures.
dislocations involving the volar base of the middle phalanx Although the fracture pattern in the radiograph is relatively
may be treated with dorsal block splinting if the joint can simple, the obliquity passes distal to the center of the
reduce with flexion. The radiograph illustrates a failed semilunar (or trochlear) notch and is considered unstable
reduction attempt as the joint is hinging open (“wedge and unsuitable for tension banding techniques.
sign”), rather than becoming concentric. In these cases,
References:
nonoperative treatment is not an option. Operative
1. Villanueva P, Osorio F, Commessatti M, Sanchez-Sotelo J.
intervention in the form of ORIF is the most appropriate
Tension-band wiring for olecranon fractures: analysis of risk
answer. If repair is not possible because the fragments are factors for failure. J Shoulder Elbow Surg 2006;15(3):351-356.
too comminuted, hinged external fixation or reconstruction 2. Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr. Displaced
with hamate autograft is reasonable. olecranon fractures in adults. Biomechanical analysis of fixation
methods. Clin Orthop Relat Res 1987;(224):210-214.
References:
3. Veillette C, Steinmann S. Olecranon Fractures. Orthop Clin
1. Shibata T, O’Flanagan SJ, Ip FK, Chow SP. Articular fractures of North Am 2008;39(2):229-236.
the digits: A prospective study. J Hand Surg 1993;18B:225-229.
2. Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ. Pilon
fractures of the proximal interphalangeal joint. J Hand Surg
1991;16A:844-850.
3. Dobyns JH, McElfresh EC. Extension block splinting. Hand Clin
1994;10(2):229-37.

Figure 1

Figure 1

2010 Self-Assessment Examination | 23

 48. A 38 year-old male presents with a contracture of
the elbow following radial head ORIF one year prior.
Radiographs are shown in Figures 1 and 2. An elbow
contracture release was performed. After excising
the anterior capsule, extension improved from 70º to
40º. The next most appropriate step is:
A. Wound closure and static progressive splinting
B. Posterior debridement
C. Fenestration of distal humerus
D. Release one or both collateral ligaments
E. Removal of hardware
Preferred Response: B
Discussion: Functional range of motion for the elbow is
between 30º and 120º, so it would be preferable not to
accept the degree of extension following anterior capsule
alone. Deepening the olecranon fossa or partial olecranon
excision should be considered after releasing the anterior
tether. An Outerbridge-Kashiwagi (OK) procedure involves
creating a fenestration between the olecranon and
coronoid fossa and is indicated for arthritic conditions
involving significant bony abutment. The radiographs do
not depict osteophytes significant enough to warrant the
OK procedure. OK is indicated if insufficient extension is
obtained with posterior debridement. Releasing collateral
ligaments should be a last resort, and is usually reserved for
cases involving heterotopic bone.
References:
1. Martin BD, Johansen JA, Edwards SG. Complications related to
simple dislocations of the elbow. Hand Clin 2008;24(1):9-25.
2. Kraushaar BS, Nirschl RP, Cox W. A modified lateral approach
for release of posttraumatic elbow flexion contracture.
J Shoulder Elbow Surg 1999;8(5):476-80.
3. Morrey BF, Askew LJ, Chao EY. A biomechanical study
of normal functional elbow motion. J Bone Joint Surg
1981;63A:872-7.
4. Forster MC, Clark DI, Lunn PG. Elbow osteoarthritis: prognostic
indicators in ulnohumeral debridement—the Outerbridge-
Kashiwagi procedure. J Shoulder Elbow Surg 2001;10(6):557-60.
Figure 1 Figure 2
24 | American Society for Surgery of the Hand
49. When performing tendon transfers for complete
radial nerve palsy, in the absence of a palmaris
longus, which procedure is the most appropriate?
A. Extensor pollicis longus tenodesis
B. Flexor capri ulnaris to extensor pollicis longus
C. Brachioradialis to extensor pollicis longus
D. Flexor digitorum superficialis to extensor pollicis longus
E. Interphalangeal arthrodesis
Preferred Response: D
Discussion: In the absence of palmaris longus, several
alternatives have been described. Incorporating EPL into
the FCU to EDC transfer greatly diminishes the abduction
component of the transfer’s effect on the thumb. The
brachioradialis would not be functional with radial nerve
palsy, but is a reasonable transfer if the palsy was isolated
to the posterior interosseous nerve. Extensor pollicis longus
tenodesis may be possible, but is not as effective as a FDS
III or IV transfer.
References:
1. Bevin AG. Early tendon transfer for radial nerve transection.
Hand 1976;8:134-136.
2. Goldner JL, Kelley JM. Radial nerve injuries. South Med J
1958;51:873-883.
3. Tsuge K, Adachi N. Tendon transfer for extensor palsy of
forearm. Hiroshima J Med Sci 1969;18:219-232.
50. One advantage a four-flap Z-plasty has over
a simple 60° Z-plasty for a thumb index web
contracture is:
A. A greater increase in length
B. A lower rate of contracture recurrence
C. A smoother contour
D. Preservation of sensation
E. No skin graft is required
Preferred Response: C
Discussion: A simple 60° Z-plasty has been reported to
give the greatest increase in length and depth of webspace.
A four flap Z-plasty has an advantage of providing a
smoother contour than the 60° Z-plasty. Preservation of
sensation or rates of recurrence are not different between
the flaps. Neither flap requires skin grafting.
References:
1. Woolf RM, Broadbent TR. The four-flap Z-plasty. Plast Reconstr
Surg 1972;49(1):48-51.
2. Westreich M, Shulman Y. Simple method for 60-degree
Z-plasty. Ann Plast Surg 1981;6(1):24-5.
51. The arteriogram shown in the figure below is most
consistent with:
A. Buerger’s disease
B. Lupus
C. Hypothenar hammer syndrome
D. Cardiac emboli
E. Polyarteritis nodosa
Preferred Response: A
Discussion: The arteriogram demonstrates diffuse
narrowing of the vessels, particularly the digital ones. This
arteriogram is most consistent with Buerger’s disease, also
called thromboangiitis obliterans. Characteristics consistent
with Buerger’s disease include (1) small and medium vessel
involvement, (2) segmental occlusive disease, (3) distal
disease greater than proximal, (4) collateralization bypassing
occlusive segments, and (5) normal proximal (e.g., brachial)
vessels. Thrombectomy and vascular reconstruction may
be indicated in select cases of Berger’s disease; however,
the diffuse nature of these lesions preclude these options
in most patients with this disease. Buerger’s disease is
often difficult to differentiate from scleroderma and collagen
vascular disease. The presence of lymphocytic and
polymorphonuclear leukocytes within the vessel walls would
suggest Buerger’s disease. Polyarteritis shows arteries that
are dilated or constricted by blood vessel information.
References:
1. Lambeth JT, Yong NK. Arteriographic findings in
thromboangiitis obliterans. Roentgenology 1970;109:553-561.
2. Papa MZ, Adar R. A critical look at thromboangiitis obliterans
(Buerger’s disease). Vasc Surg 1992;5:1-18.
3. Buerger L. Thromboangiitis obliterans: A study of the vascular
lesions leading to presenile spontaneous gangrene. Am J Med
Sci 1980;136:567-580.
Figure 1
52. The expected outcome of amputation for a
nonfunctional finger in a patient with a history of the
complex regional pain syndrome (CRPS) is:
A. Symptom-free hand
B. Likely use a prosthetic digit
C. Low likelihood of CRPS recurrence
D. Persistent pain
E. Wound dehiscence
Preferred Response: D
Discussion: Patients with CRPS may undergo amputation
for several reasons, including a chance to ease intractable
pain, cease recurrent infection, or regain function. Results
of amputation in these patients have been less then
gratifying. Although patients report some improvement
in their symptoms, the vast majority of patients have
persistence of some pain at their stump site. Because of
this pain, compliance with prostheses is rare. Psychosocial
abnormalities that are present prior to amputation persist
despite amputation. CRPS has not been associated with
increases of wound dehiscence.
References:
1. Dielissen PW, Claassen ATPM, Veldman PHJM, Goris RJA.
Amputation for reflex sympathetic dystrophy. J Bone Joint Surg
1995;77B:270-273.
2. Szeinberg-Arazi D, Heim M, Nadvorna H, et al. A functional and
psychosocial assessment of patients with post-Sudeck atrophy
amputation. Arch Phys Med Rehabil 1993;74:416-418.
2010 Self-Assessment Examination | 25
 53. A 13 year-old boy presents in a long arm cast
6 weeks after closed reduction of a distal one-
third fracture of the radius and ulna. X-rays show
callus formation at the fractures with an angular
alignment 12° apex volar. On palpation along the
forearm, there is no tenderness. Grip in the affected
limb is diminished, but without forearm pain.
Recommended initial treatment is:
A. Revision closed reduction and casting for 6 weeks
B. Continued long arm casting with the forearm in
pronation for 3 weeks
C. Immediate open osteotomy and internal fixation
D. Munster cast immobilization with the forearm in
neutral for 3 weeks
E. Immediate range of motion with reassessment in
3 weeks
Preferred Response: E
Discussion: Cadaveric studies by Matthews, Kaufer, et al,
have shown that angular deformities involving midshaft
fractures of the forearm begin to impact forearm rotation
with deformities of 10° and become functionally important
beyond 20°. Tarr et al, felt significant loss of forearm rotation
began with midshaft fractures angulated as little at 15°, but
found that fractures of the distal third of the forearm sustained
similar losses in pronation, and less in supination compared
to midshaft fracture angulation. On the basis of clinical and
radiographic examination, the fractures are healed; therefore,
additional immobilization would not be appropriate. Given that
the present fracture alignment will most likely affect pronation
(which can be compensated for by shoulder abduction), the
appropriate treatment would be to initiate immediate range
of motion and strengthening and to reassess the functional
impact of the deformity, as opposed to proceeding with
immediate corrective osteotomy and internal fixation.
References:
1. Matthews SL, Kaufer H, et al. The affect on supination/
pronation of angular malalignment of the fracture of both bones
of the forearm. J Bone Joint Surg 1982;64A:14-17.
2. Tarr RR, Garfield AL, Sarmiento A. The affects of angular and
rotational deformities of both bones of the forearm. J Bone
Joint Surg 1984;66A:65-70.
3. Ring D. Forearm fractures and reconstruction. In: Trumble
TE, Budoff JE, eds. Hand Surgery Update IV. Rosemont, IL:
American Society for Surgery of the Hand, 2007.
26 | American Society for Surgery of the Hand
54. When harvesting a vascularized proximal fibular
physeal graft, the transfer must be based on
which artery:
A. Anterior tibialis
B. Posterior tibialis
C. Popliteal
D. Deep femoral
E. Peroneal
Preferred Response: A
Discussion: While the typical diaphyseal vascularized
fibular transfer is based on the peroneal vascular system,
work by Innocenti et al has shown that the nutrient vascular
supply to the proximal fibular apophysis is derived from
the anterior tibialis artery. This requires an anterolateral
approach to the proximal fibula.
References:
1. Innocenti M, Delcroix L, et al. Vascularized proximal fibular
apophyseal transfer for distal radial reconstruction. J Bone
Joint Surg 2004;86A:1504-1511.
2. Ghert M, Coulter John N, Manfrini M. Use of free vascularized
fibular grafts in skeletal reconstruction for bone tumors in
children. J Am Acad Orthop Surg 2007;15:577-587.
55. A 23 year-old female presents to the emergency
room with vomiting and increasingly severe pain
in her right hand. Forty-eight hours earlier, she
had popped a small pimple over the dorsal third
web of the right hand with a pin. She has fusiform
swelling of her right hand to the midforearm with
scattered serous blistering about the distal forearm.
There are hemorrhagic blisters of the dorsal third
webspace and extending into the middle and ring
fingers, which are swollen and cyanotic. The patient
demonstrates significant discomfort with attempts
at active and passive range of motion of her fingers.
Recommended treatment is:
A. Admission for IV hydration and antibiotics
B. Right upper extremity arteriogram to evaluate the
vascular status of the extremity
C. Compartment pressures and possible forearm
fasciotomies
D. Transfer for hyperbaric oxygen treatment
E. Immediate surgical debridement of the right hand
and forearm
Preferred Response: E
Discussion: The patient’s history and presenting clinical
findings are consistent with a patient with a necrotizing
fasciitis. Necrotizing fasciitis is a rapidly progressive
soft tissue infection, which is frequently life-threatening.
Necrotizing fasciitis is sometimes mistakenly diagnosed as
cellulitis. The distinguishing features of necrotizing fasciitis
are a rapid, progressive, high fever, significant swelling with exact role of surgical intervention in the treatment of distal
blister formation, without the erythema and induration biceps tendinosis is not known, literature does support
seen with cellulitis. While admission for IV hydration and good results for surgical treatment of this condition when it
antibiotics is appropriate, the only treatment shown to change is recalcitrant to conservative measures and the passage of
the prognosis of necrotizing fasciitis is immediate surgical time.
debridement and removal of necrotic tissue. A consistent
References:
finding with necrotizing fasciitis is pain out of proportion to the
1. Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures:
appearance of the infection. The destruction of subcutaneous
Epicondylitis, biceps and triceps rupture. J Hand Surg
tissues, including vascular structures, can create symptoms 2009;34A:566-576.
of vascular compromise and ischemia. As this destruction 2. Hobbs MC, Koch J, Bamberger HB. Distal biceps tendinosis:
is extrafascial, there is no compromise of the major arterial Evidence based review. J Hand Surg 2009;34A:1124-1126.
structures perfusing the extremity nor are there issues with
increased compartmental pressures.
References: 57. The amount of key pinch strength in a patient with a
1. Vellapianta JM, Ljunquist K, et al. Necrotizing fasciitis. J Am C6 level tetraplegia needed to improve activities of
ACAD Orthop Surg 2009;17:174-84. daily living is:
2. Sunderland IR, Friedrich JB. Predictors of mortality and limb
A. 2 kilograms
loss in necrotizing soft tissue infections of the upper extremity.
J Hand Surg 2009;34A:1900-1901. B. 5 kilograms
3. Sarani, et al. Necrotizing fascitis: Current concepts and review. C. 7 kilograms
J Am Coll Surg 2009;208(2):279-288.
D. 10 kilograms
E. 12 kilograms
56. A 45 year-old male who is an avid weightlifter presents Preferred Response: A
with a 6-month history of right anterior elbow pain. His
Discussion: Achieving 2-kilogram pinch strength has
pain has not improved with cessation of weight lifting.
been shown to enhance the performance of many
He has an MRI demonstrating diffuse tendinosis of the
activities of daily living. Hamou et al recently conducted a
distal biceps insertion. Recommended treatment is:
systematic review of the literature to evaluate the results
A. Six weeks of immobilization in a long arm cast of restoration of pinch and elbow extension in people with
B. Surgical debridement and reattachment of distal tetraplegia. Average restoration of pinch strength using the
biceps tendon brachioradialis transfer was 2 kilograms, whereas pinch
strength restored using a tenodesis procedure was 1 kilogram.
C. A series of two steroid injections to the biceps sheath
three weeks apart References:
D. Referral to physical therapy for iontophoresis 1. Smabyn, Johanson ME, et al. Identification of Key Pinch Forces
Required to Complete Functional Tasks. J Rehabil Res Dev
E. Percutaneous biceps tenotomy 2004;41:215-224.
Preferred Response: B 2. Hamou C, Shah NR, et al. Pinch and elbow extension
restoration in people with tetraplegia: A systematic review of
Discussion: A recent review of the literature on distal the literature. J Hand Surg 2009;34A:692-699.
biceps tendinosis by Hobbs, Koch, and Bamberger
reported that not only is the natural history of this condition
poorly understood, but there are few studies that have
investigated the results of conservative management. All
studies cited in the review demonstrated poor results with
conservative care, and most patients undergoing surgery
showed good results. Given the similarities between distal
biceps tendinosis and other enthesopathy, it is reasonable
to consider initial conservative treatment in the form of
avoidance of provocative activities and the passage of
time to see if symptoms abate. There is no evidence
in the literature to support the role of immobilization or
iontophoresis for treatment of this condition. Studies of
steroid injections for similar conditions, such as elbow
epicondylitis, show they do not change the natural history
of the disease. While a percutaneous biceps tenotomy
might alleviate the pain, this is not a recognized treatment,
nor would it be accepted by an avid weightlifter. While the

2010 Self-Assessment Examination | 27

 58. A 35 year-old female presents with a 6-week history
of bilateral wrist pain and dorsal hand swelling.
Clinical examination indicates 4th dorsal compartment
tenosynovitis. Laboratory studies include an
elevated erythrocyte sedimentation rate and positive
rheumatoid factor. The treatment that will have the
greatest impact on the patient’s long term outcome is:
A. Wrist splints and nonsteroidal anti-inflammatory drugs
B. Steroid injection 4th dorsal compartment
C. Surgical tenosynovectomy
D. Referral to a rheumatologist within 6 weeks
E. Observation for 6 months
Preferred Response: D
Discussion: Wrist splinting, nonsteroidal anti-inflammatory
medication, and steroid injections are all conservative
measures for tenosynovitis. In this case, however, the
clinical picture and laboratory findings are specific for
rheumatoid arthritis. Randomized controlled clinical studies
have shown that initiating disease-modifying antirheumatic
drugs within 3 months of diagnosis leads to a significant
decrease in the morbidity of rheumatoid arthritis. The
newest generation of biological response modifiers, such as
anti-TNF alpha drugs or recombinant IL-1 antagonist, used
in combination with methotrexate is particularly effective
in modifying the inflammatory response and destruction
seen with rheumatoid arthritis. With the advances in the
pharmacological modification of rheumatoid arthritis,
early surgical intervention would be inappropriate. While
observation for six months prior to considering surgery is
reasonable, the initiation of medical management early in
the disease will have the most significant impact on long-
term prognosis.
References:
1. Doan T, Massarotti E. Rheumatoid arthritis: An overview of new
and emerging therapies. J Clin Pharm 2005;45(7):751-762.
2. Little KJ, Stern PK. Rheumatoid arthritis reconstruction.
In: Trumble TE, Budoff JE, eds. Hand Surgery Update IV.
Rosemont, IL: American Society for Surgery of the Hand, 2007.
59. The reason a flexor digitorum superficialis tendon is
a superior graft over a palmaris longus tendon for a
staged flexor tendon reconstruction is:
A. The flexor digitorum superficialis graft is longer
B. The flexor digitorum superficialis graft has a
wider diameter
C. The palmaris longus is sometimes absent
D. An extrasynovial graft has greater strength and
gliding capacity
E. An intrasynovial graft heals intrinsically with
preservation of the gliding surface
Preferred Response: E
28 | American Society for Surgery of the Hand
Discussion: The expendability and length of the palmaris
longus has historically made this the tendon donor of choice
for stage flexor reconstruction. The palmaris longus is an
example of extrasynovial tendon, while the flexor digitorum
superficialis is an intrasynovial tendon. Experimental studies
have shown that these two types of tendons, when used as
grafts, heal by different methods. The extrasynovial tendon
serves as a scaffold and must be repopulated by tenocytes.
An intrasynovial graft heals intrinsically, maintaining the
viability of the tenocyte. As such, it possesses greater
strength during the healing process. The intrasynovial graft
also has a gliding surface that it retains. Such a surface is
not found with an extrasynovial graft.
References:
1. Seiler JG, Chu CR, et al. The Marshall R. Ruist Young
Investigator Award. Autogenous flexor tendon grafts. Biologic
mechanisms for incorporation. Clin Orthop 1997;(345):239-247.
2. Nishida J, Amadio PC, et al. Excursion properties of tendon
graft sources: Interaction between tendon and A2 pulley.
J Hand Surg 1998;23A:274-284.
60. On performing an anterior approach to a ruptured
distal biceps tendon, an arterial structure is noted
passing obliquely within the wound toward the
brachioradialis muscle. To facilitate exposure
division of this arterial structure is desirable. The
arterial structure to be ligated and divided is:
A. Radial
B. Recurrent radial
C. Radial collateral
D. Anterior interosseous
E. Recurrent branch of the posterior interosseous
Preferred Response: B
Discussion: In the absence of vascular anomalies, the
brachial artery divides into the radial and ulnar arteries,
just distal to the elbow joint. The first branch of the radial
artery is the radial recurrent artery, which passes radially
and proximally from the radial artery, just distal to the
biceps tendon. The radial collateral artery is a branch of the
profunda brachii, and eventually, an anastomosis with the
radial recurrent artery. The interosseous artery is a proximal
branch of the ulnar artery and will divide into anterior
and posterior interosseous branches. The interosseous
recurrent artery usually arises from the posterior
interosseous branch.
References:
1. Morrey BF. Anatomy of the elbow joint. In: Morrey BF, ed. The
elbow and its disorders. Philadelphia: WB Saunders Company,
1985:24-27.
2. Henry AK. Extensile exposure. 2nd ed. Edinburgh: Churchill
Livingstone, 1973: 94-100.
61. A 23 year-old male presents six months after a
motorcycle accident with a closed left brachial
plexus injury. The patient has intact sensation and
motor function below the elbow and diffuse muscle
atrophy about the shoulder. He is able to abduct
30° with 3/5 strength. He can flex his elbow with
3+/5 motor strength. He has recently undergone
an EMG of his left upper extremity showing the
following findings:
Emg Summary Table
Insertional Positive
Fibrillation
Activity Sharp Waves
Deltoid +1 +1 +3
Biceps 1- None +2
Triceps Normal None None
Supraspinatus Normal None +1
The patient would like to enhance his strength of
shoulder abduction. For treatment, you recommend:
A. Spinal accessory nerve transfer to the
suprascapular nerve
B. Intercostal nerve transfer to the musculocutaneous nerve
C. Radial nerve branch to the long head of the triceps
transfer to the axillary nerve
D. Latissimus dorsi transfer to the rotator cuff
E. C5-C6 sural nerve grafting to the upper trunk of the
brachial plexus
Preferred Response: C
Discussion: The EMG shows denervation primarily in
the deltoid and biceps. There is evidence of injury to the
supraspinatus; however, this appears to have recovered,
and is providing abduction and external rotation to the left
shoulder. Given the supraspinatus muscle is functioning
both clinically and electrodiagnostically, there would be
no reason to perform a transfer of the spinal accessory
nerve to the suprascapular nerve. For this same reason, it
would not be appropriate to perform a latissimus transfer
to the rotator cuff. While there are several methods
of reinnervating the biceps, such as intercostal nerve
transfer to the musculocutaneous, this would not aid in
strengthening shoulder abduction. However, it would help
with strengthening elbow flexion and forearm supination. This
could also be accomplished by a partial ulnar nerve transfer
to the musculocutaneous. To restore strength of abduction
of the shoulder, it is necessary to reinnervate the deltoid.
Perhaps the closest intact functioning nerve branch would
be the radial nerve branch to the long head of the triceps.
References:
1. Leechavengvongs S, Witoonchart K, Uerpairojkit C,
Thuvasethakul P. Nerve transfer to deltoid muscle using the
nerve to the long head of the triceps, part II: a report of 7
cases. J Hand Surg 2003;28A:633-8.
2. Bertelli JA, Ghizoni MF. Nerve transfer in C5 and C6 avulsions.
J Hand Surg 2004;29A:131-139.
62. The most appropriate treatment for the injury shown
in Figure 1 is:
A. Immobilization of the PIP joint in 60° of flexion for
3 weeks
B. Early active range of motion in a dorsal blocking splint
set at 30°
C. A dynamic distraction external fixator
D. Volar plate arthroplasty
E. Hemi hamate graft (osteochondral autograft)
Recruitment Preferred Response: C
Pattern
Absent Discussion: Pilon fractures of the articular base of the middle
Discrete phalanx are, by definition, comminuted and not amenable
Normal
to internal fixation. Immobilization of these injuries typically
results in considerable loss of motion. Due to the comminution
Normal
of the articular surface, there is no stable articular base that
can be positioned against the articular surface of the head
of the proximal phalanx for early active motion. Dorsal block
splinting is most appropriate for volar rim fractures involving
less than 30% of the joint surface. While an Eaton volar plate
arthroplasty and a hemi hamate graft can be used in articular
based fractures of the middle phalanx of increasing severity,
both rely on a portion of the dorsal cortex of the articular
face to have remained intact. This is not the case in a pilon
fracture. Several studies have documented the effectiveness of
dynamic distraction external fixation (Figure 2) in the treatment
of pilon fractures and have shown it to be the most effective
means of preserving range of motion in these fractures.
References:
1. Stern PJ, Roman RJ, et al. Pilon fractures of the proximal
interphalangeal joint. J Hand Surg 1991;16A(5):844-850.
2. Calfee RP, Sommer Kamp, TG. Fracture dislocations about the
finger joints. J Hand Surg 2009;34A:1140-1147.
3. Rutland RT, Hogan CJ, et al. Use of dynamic distraction
external fixation for unstable fracture dislocations of the
proximal interphalangeal joint. J Hand Surg 2008;33A:19-25.
Figure 1
Figure 2
2010 Self-Assessment Examination | 29
 63. The first step in skin graft survival is:
A. Adherence
B. Imbibition
C. Inosculation
D. Primary contracture
E. Secondary contracture
Preferred Response: A
Discussion: Adherence occurs in the first 8 hours after
skin graft placement. It is followed by imbibition during
the initial 48 hours when nutrient transfer occurs through
diffusion from the surrounding tissues. Inosculation occurs
next when vascular networks from the underlying bed and
the graft make connections. Capillary ingrowth results
in revascularization of the graft. Primary contracture of
the skin graft occurs following harvesting and before
graft placement. Secondary contracture is a late wound-
healing property.
References:
1. Smith M, Munster A, Spence R. Burns of the hand and upper
limb—a review. Burns 1998;24:493-505.
2. Sood, ed. Achauer and Sood’s Burn Surgery: Reconstruction
and Rehabilitation, 2006.
64. The most common site of metastasis for a malignant
fibrous histiocytoma of the upper extremity is:
A. Brain
B. Lung
C. Liver
D. Dermal satellites
E. Regional lymph nodes
Preferred Response: B
Discussion: Malignant fibrous histiocytoma is among the
most common soft tissue sarcomas in adults presenting in
the sixth to eighth decade. Although common in the upper
extremity, hand involvement is less common. Following
adequate wide excision and radiation therapy, recurrence
rates range from 10-30%. The metastatic rate is 35%
with the lung most commonly involved. Survival rates are
dependent on grade. Lymph node metastasis is uncommon.
References:
1. Gustafson P, Amer M. Soft tissue sarcoma of the upper
extremity: descriptive data and outcome in a population based
series of 108 adult patients. J Hand Surg 1999;24A:668-674.
2. McPhee M, McGrath BE, Zhong P, et al. Soft tissue sarcoma of
the hand. J Hand Surg 1999;24A:1001-1007.
30 | American Society for Surgery of the Hand
65. A patient with rheumatoid arthritis has a type II swan
neck deformity where the PIP joint has full flexion,
but flexion is limited with the MP joint in extension.
Silastic MP arthroplasties are planned. What
procedure should also be performed?
A. DIP fusion
B. Spiral oblique retinacular ligament reconstruction
C. PIP joint fusion
D. Lateral band mobilization
E. Intrinsic release
Preferred Response: E
Discussion: Type II swan neck deformity develops from MP
joint synovitis and subluxation. Sagittal band attenuation
weakens the extensor force and intrinsic contracture
results. Procedures that limit PIP hyperextension are not
sufficient. An intrinsic release, possibly combined with MP
arthroplasties, must be performed also.
Lateral band mobilization is indicated when passive PIP
motion is limited by a contracted extensor mechanism (type
III swan neck).
References:
1. Keifhaber TR, Strickland JW. Soft tissue reconstruction for
rheumatoid swan neck and boutonniere deformities: long term
results. J Hand Surg 1993;18A:984-989.
2. Rizio L, Belsky MR. Finger deformities in rheumatoid arthritis.
Hand Clin 1996;12:531-540.
66. A patient with chronic upper extremity ischemia has
Raynaud’s phenomenon, ulcers, pain and gangrene.
Initial treatment should include avoidance of cold and:
A. Intra-arterial reserpine
B. Topical nitroglycerine
C. Digital sympathectomy
D. Avoidance of nicotine products
E. Calcium channel blockers
Preferred Response: D
Discussion: In patients with chronic ischemia of the upper
extremity, initial treatment includes avoidance of cold
exposure and cessation of nicotine products. Morecraft
used an ultrasonic Doppler velocimeter to show smoking
caused increased vascular resistance and decrease in
volumetric blood flow and tissue perfusion.
References:
1. Jones NF. Acute and chronic ischemia of the hand:
Pathophysiology, treatment and prognosis. J Hand Surg
1991;16A:1074-1083.
2. Morecraft R, Blair WF, Brown TD, et al. Acute effects of
smoking on digital artery blood flow in humans. J Hand Surg
1994;19A:1-7.
67. Fitting for myoelectrically controlled, electrically-
powered artificial hands for a child with bilateral
transverse deficiencies at the upper forearm level is
best done at what age?
A. 1 month old
B. 4 months old
C. 18 months old
D. 3 years old
E. 12 years old
Preferred Response: D
Discussion: For transverse deficiencies at the upper
forearm level, early prosthetic fitting begins at age 4 to 6
months with a simple nonfunctional forearm and hand. A
body-powered split hook is introduced at 15 to 18 months.
Myoelectrically controlled artificial hands are best fitted at 2
to 3 years of age.
References:
1. Lamb DW, Law HT. Upper Limb Deficiencies in Children:
Prosthetic, Orthotic, and Surgical Management. Boston: Little
Brown, 1987.
2. Sorbye R. Myoelectric hand prostheses in children. Int J
Rehabil Res 1977;1:15.
68. Medical grade leeches were used to relieve venous
congestion following a distal digital replantation.
A subsequent wound infection is likely due to
which organism?
A. Staphylococcus aureus
B. Methicillin resistant Staphylococcus aureus
C. Pseudomonas aeruginosa
D. Aeromonas hydrophila
E. Mycobacterium marinum
Preferred Response: D
Discussion: Medical grade leeches are used when venous
congestion threatens survival of a replanted part. Infection
can occur with Aeromonas hydrophila, a gram negative
anaerobic rod. This bacterium is endosymbiotic with the
leech. It inhibits growth of other bacteria and produces
enzymes essential for the breakdown of red blood cells
and hemoglobin. Treatment usually involves debridement
and appropriate antibiotics, which include trimethoprim-
sulfamethoxazole, ciprofloxacin, and second generation
cephalosporin. Prophylactic antibiotics are recommended
when using leeches.
References:
1. Brody GA, Maloney WJ, Henz VR. Digit replantation applying
the leech Hirudo medicinalis. Clin Orthop 1989;245:133-137.
2. Lowen RM, Rodgers CM, Ketch ll, et al. Aeromonas hydrophila
infection complicating digital replantation and revascularization.
J Hand Surg 1989;14A:714-718.
69. A college rower develops pain and swelling 4
centimeters proximal to the wrist joint. This is
tenosynovitis of which dorsal compartment?
A. First
B. Second
C. Third
D. Fourth
E. Fifth
Preferred Response: B
Discussion: Frequently seen in athletes in sports such as
rowing and weight lifting, intersection syndrome presents
with pain, swelling, and crepitus 4 cm proximal to the
wrist joint. Muscle bellies and tendons of the first dorsal
compartment cross the tendons of the second dorsal
compartment. Grundberg and Reagan demonstrated
intersection syndrome to be tenosynovitis of the
second dorsal compartment. Initial treatment is usually
nonoperative, with most patients improving and remaining
asymptomatic without surgery.
References:
1. Grundberg AB, Reagan DS. Pathologic anatomy of the forearm:
Intersection syndrome. J Hand Surg 1985;10A:299-302.
2. Wood MB, Dobyns JH. Sports related extraarticular wrist
syndromes. Clin Orthop 1986;202:93-102.
70. At 14-year follow up, what percentage of silastic
metacarpophalangeal joint replacement implants
remain without fracture?
A. 15
B. 35
C. 55
D. 75
E. 95
Preferred Response: B
Discussion: Goldfarb evaluated 36 patients at 14 years
and found fractures occurred in all, except 37% of MP
silastic implants. Of these patients without fracture, another
22% had severely deformed implants. Trail retrospectively
reviewed 1336 implants in 381 patients and found 34%
remained without fracture at 17 years. Crossed intrinsic
transfers improved implant survival to 90% at 15 years.
References:
1. Goldfarb CA, Stern PJ. Metacarpophalangeal joint arthroplasty
in rheumatoid arthritis: a long-term assessment. J Bone Joint
Surg 2003;85:1869-1878.
2. Trail IA, Martin JA. Seventeen year survivorship analysis of
silastic metacarpophalangeal joint replacement. J Bone Joint
Surg 2004;86B:1002-1006.
2010 Self-Assessment Examination | 31
 71. The infant whose hands are shown in Figures 1 and 2
is expected to have a mutation in which gene?
A. FGF receptor 2 (FGFR2)
B. Homeobox D13 (HOXD13)
C. Holt-Oram syndrome 1 (HOS1)
D. Human zinc factor protein gene 3 (GLI3)
E. Brachyury T-box 5 (TBX5)
Preferred Response: A
Discussion: This is an Apert child. All Apert children
display one of two point mutations in the gene encoding Figure 1
FGF receptor 2 (FGFR2). These two-point mutations are
Ser252Trp and Pro253Arg. Patients with Apert syndrome
have inversely proportional deformity with respect to
cranial and hand involvement. The Ser252Trp mutation is
associated with the “good hands, bad head” phenotype,
and the Pro253Arg mutation is associated with the “bad
hands, good head” phenotype. Apert syndrome has
autosomal dominant inheritance.
HOXD13 is associated with central polysyndactyly, HOS1
with Holt-Oram syndrome, GLI3 with Greig syndrome, and
TBX5 with hand-heart syndrome. These four conditions are
also inherited in an autosomal dominant manner.
Hand-heart syndrome includes that group of patients
with radial-sided skeletal abnormalities and cardiac
abnormalities (similar to Holt-Oram syndrome), but Figure 2
who also have cardiac conduction anomalies. Greig (or
cephalopolysyndactyly) syndrome has craniofacial and
limb abnormalities, including postaxial polydactyly. GLI3 72. Mechanical shear stress with negative pressure
regulates sonic hedgehog (SHH) and is important in wound therapy (V.A.C.) stimulates granulation
determining digit number and digit identity. tissue. This has been shown to result from increased
References: expression of extracellular regulated kinase (ERK)
1. Borud LJ, Upton J. Embryology of the upper limb. In: Mathes which causes:
SJ, Hentz VR, eds. Plastic Surgery. 2nd ed. Philadelphia: A. Intracellular production of collagen
Saunders/Elsevier, 2006;8:20-21.
2. Muragai Y, Mundlos S, Upton J, Olsen BR. Altered growth in B. Increased cellular mitosis
branching patterns in synpolydactyly caused by mutations in C. Increased cross-linking between collagen fibers
HOXD13. Science 1996;272-548.
D. Stimulation of phagocytosis by macrophages
3. Kalff-Suske M, Wild A, Topp J, et al. Point mutations
throughout the GLI3 gene cause Greig cephalopolysyndactyly E. Production of integrins
syndrome. Human Mole Genet 1999;8:1769.
Preferred Response: B
4. Bonnet D, Laplet A, Legeai-Mallet L, et al. A gene for Holt-
Oram syndrome mapped to the distal long arm of chromosome Discussion: Fibroblasts are deformed and stretched by
12. Nat Genet 1994;6:405. negative pressure wound therapy, in the same way as occurs
5. Basson C, Solomon SD, Weissman B, et al. Genetic heterogeneity with tissue expansion and distraction osteogenesis. Kinases
of heart-hand syndrome. Circulation 1995;91:1326. are responsible for phosphorylation. Stretching fibroblasts
6. Li QY, Newbury-Ecob RA, Jerrett JA, et al. Holt-Oram results in increase in expression of extracellular regulated
syndrome is caused by mutations in TBX5, a member of the
kinase (ERK) and Jun N-terminal protein kinase (JNK), which
Brachyury (T) gene family. Nat Genet 1997;15:21.
in turn are associated with cell division. There is an increase
in the mitotic rate of the stretched cells. Applied mechanical
shear stresses activate the vascular endothelial cell growth
factor (VEGF) pathway. ERK and JNK are activated in the
VEGF pathway. These applied mechanical forces deform
tissues, which result in deformation of cells; then, this is
followed by stimulation of growth factor pathways, resulting
in increased mitosis and production of new tissue.

32 | American Society for Surgery of the Hand

References:
1. Morykwas MJ, Simpson J, Punger K, et al. Vacuum-assisted
closure: state of basic research and physiologic foundation.
Plast Reconstr Surg 2006;117:121.
2. Chen KD, Li YS, Kim M, et al. Mechanotransduction in
response to shear stress: Roles of receptor tyrosine kinases,
integrins, and Shc. J Biol Chem 1999;274:183-193.
73. Which of the following dorsal retinacular distal radius
pedicle bone grafts has the longest vascular pedicle?
A. 1,2 intercompartmental supraretinacular artery
(1,2 ICSRA)
B. 2,3 intercompartmental supraretinacular artery
(2,3 ICSRA)
C. 3rd extensor compartmental (EC) branch of 2,3 ICSRA
D. 2nd extensor compartmental (EC) branch of 1,2 ICSRA
E. 4th extensor compartmental (EC) branch of the 5thECA
Preferred Response: E
Discussion: Unlike the other three dorsal vessels
(1,2ICSRA, 2,3ICSRA, 4thECA), the 5thECA seldom
provides direct nutrient branches to the radius. However, it
is often used as a retrograde flow conduit to the 4thECA.
This retrograde flow comes from the dorsal intercarpal arch.
It provides the longest vascular pedicle of all the described
dorsal distal radius bone grafts and can easily reach up to
the metacarpals (Figures A and B).
74. The abnormality depicted in Figures 1 and 2
occurred during embryogenesis between weeks:
A. 1 and 2
B. 3 and 4
C. 5 and 7
D. 8 and 10
E. 11 and 13
Preferred Response: C
Discussion: Embryogenesis of the upper extremity begins
at 4 weeks and is complete by 8 weeks after fertilization.
At 5 weeks, the hand segment is present in the form
of a paddle with no separation of the digits. The apical
ectodermal ridge regulates separation of the digits, creating
longitudinal separation of the digits via apoptosis during
weeks 6 and 7.
References:
1. Kozin SH. Syndactyly. J Am Soc Surg Hand 2001;1:1-13.
2. Tonkin MA. Failure of differentiation part I: Syndactyly. Hand
Clin 2009;25:171-193.

Figure 1

Figure: A) Graft based on 1,2 ICSRA and its branch to the 2nd extensor
compartment. B) Graft based on the 4th ECA with retrograde flow through
the 5th ECA from the dorsal intercarpal arch. (From Shin AJ, Bishop AT. J
Am Soc Surg Hand 2002; 2:186).

References:
1. Shin AY, Bishop AT. Vascularized bone grafts from the distal
radius for disorders of the carpus. J Am Soc Surg Hand
2002;2:181. Figure 2
2. Sheetz KK, Bishop AT, Berger RA. The arterial blood supply
of the distal radius and its potential use in vascularized bone
grafts. J Hand Surg 1995;20A:902.

2010 Self-Assessment Examination | 33

 75. What is the predominant collagen type in a
granulating wound of three weeks duration?
A. I
B. II
C. III
D. IV
E. V
Preferred Response: A
Discussion: In the first 4-5 days, the predominant collagen
type is collagen type III. The collagen in uninjured skin
is 80-90% type I and 10-20% type III. The appearance
of collagen type III in fresh wounds coincides with the
presence of fibronectin. In granulation tissue, type III
collagen comprises 30% and in the mature scar is down
to 10%. Collagen I, except in the earliest phases of wound
healing, is the predominant collagen in a granulating wound.
References:
1. Witte M, Barbul A. General principles of wound healing. Surg
Clin North Am 1997;77:509.
2. Broughton G, Janis J, Attinger CE. The basic science of wound
healing. Plast Reconstr Surg 2006;117:12.
76. A 45 year-old male patient complains of persistent
deep wrist pain. The plain wrist radiographs were
normal. Computed tomography of the wrist showed
the lesion seen in Figure 1. Which of the following is
the best way to localize the lesion intraoperatively?
A. Technetium bone scan
B. Administration of tetracycline
C. Intravenous methylene blue
D. Fluorescein dye
E. Intraoperative ultrasonography
Preferred Response: B
Discussion: This is a classic example of an osteoid
osteoma with a relatively radiolucent “nidus” in a sclerotic
area. Plain radiographs may not show the lesion. Computed
tomography may be valuable to show the tumor. They will
nearly always be “hot” on technetium bone scan.
While radio-frequency ablation has been the suggestion for
treatment, especially for osteoid osteomas involving larger
bones and joints, en bloc excision of the nidus and some
surrounding sclerotic bone is necessary to ensure complete
resection and pain relief.
Exact nidus localization has been determined preoperatively
by placement of a needle under CT guidance. The
fluorescent localization by preoperative administration of
oral tetracycline for bone labeling and use of a Woods UV
lamp intraoperatively enables localization. Radioisotope
labeling has also been successfully used. One can also
34 | American Society for Surgery of the Hand
obtain intraoperative specimen radiography or send a
specimen for a CT scan to show the nidus.
Ultrasound localization has been used for certain
soft tissue tumors and lymph nodes, but not for small
intraosseous lesions.
References:
1. DeSmet L. Osteoid osteoma of the wrist and hand. J Am Soc
Surg Hand 2001;1:267.
2. Swee R, McLeod R, Beabout J. Osteoid osteoma, detection,
diagnosis, and localization. Radiology 1979;130:117.
3. Bednar M, Weiland A, Light T. Osteoid osteoma. Hand Clin
1995;11:211.
Figure 1
77. A 36 year-old healthy female patient, with no known
drug allergies, is to undergo a 2.5 hour elective
soft tissue surgery for release of thumb adduction
contracture and flap reconstruction. Based on the
best evidence-based medical practice, which of the
following is the first line prophylactic antibiotic choice?
A. Methicillin
B. Clindamycin
C. Cefazolin
D. Vancomycin
E. Penicillin
Preferred Response: C
Discussion: Prophylactic antibiotics reduce the rate of
postoperative infection after clean orthopedic procedures
lasting longer than 2 hours without prosthetic implantation.
Complex reconstructive and microvascular procedures have
a decreased incidence of infection with preoperative antibiotic
use. One of the absolute indications for the administration of
prophylactic antibiotics in hand surgery includes clean elective
procedures > 2 hours duration. To minimize the risk of surgical
site infection, the selected prophylactic antibiotic should cover
the most common infecting pathogens, but need not cover all
potential contaminating organisms. For class I/clean surgeries,
the CDC recommends Cefazolin as the first line agent for
antimicrobial prophylaxis and recommends against routine
use of Vancomycin.
References:
1. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for
prevention of surgical site infection, 1999. Hospital Infection
Control Practices Advisory Committee. Infect Control Hosp
Epidemiol 1999;20:250.
2. Annlan PS, Andenaes K, Samdal F, et al. A prospective,
double-blind, placebo-controlled trial of a single dose of
Azithromycin on postoperative wound infections in plastic
surgery. Plast Reconstr Surg 1995;96:1378.
3. Hoffman RD, Adams BD. The role of antibiotics in the
management of elective and post-traumatic hand surgery.
Hand Clin 1998;14:657.
4. Rizbi N, Bille B, Holtom P, et al. The role of prophylactic
antibiotics in elective hand surgery. J Hand Surg 2008;33A:413.
5. Verma MK, Shah AS, Jebson PJ. Cephalosporins in hand
surgery. J Hand Surg 2009;34A:755.
6. Elward AM, McAndrews JM, Young DL. Methicillin-sensitive and
Methicillin-resistant Staphylococcus aureus: Preventing surgical site
infections following plastic surgery. Aesth Surg J 2009;29:232.
78. A 26 year-old man has the injury shown in the
x-ray. In order to have minimum long-term
postoperative pain and the best possible function,
the recommended treatment should include:
A. Open reduction and plate fixation
B. Open or closed reduction and metacarpal fixation
C. Closed reduction by thumb pronation and thumb
spica cast application
D. Excision of the fragment and reconstruction of the
volar beak ligament
E. Arthroscopically assisted reduction of the fracture
Preferred Response: B
Discussion: This is a Bennett fracture-dislocation. From
available literature, the following treatment guidelines are
important: 1) reduction of the thumb metacarpal at the
CMC joint must be maintained by surgical fixation, whether
using open or percutaneous techniques; 2) fracture reduction
techniques should include thumb pronation to aid in anatomic
reduction of the metacarpal to the ulnar fragment; 3) resort to
open reduction when greater than 2 mm (some recommend
> than 1 mm) step-off, despite closed reduction attempt.
The metacarpal shaft subluxes in a dorsal, proximal, and radial
direction, due to the unbalanced pull of APL, EPL, EPB, and
adductor pollicis. The small volar-ulnar fragment is stable and
does not necessarily require fixation. Proper fracture reduction
requires axial traction, palmar abduction, and pronation,
while applying external pressure over the metacarpal base.
Generally, there are reports of poor outcomes with casting
alone, as this is an unstable fracture pattern.
All methods of fixation (intermetacarpal, to the trapezium, or
to the volar-ulnar fragment) have been shown to be effective.
Clinical studies document improved outcomes with anatomic
reduction and maintenance of minimal articular step-off.
Arthroscopic assistance has not yet been shown to result in
a better outcome than radiographic evaluation.
References:
1. Kjaer-Petersen K, Langhof O, Andersen K. Bennett’s fracture.
J Hand Surg 1990;15B:58.
2. Oosterbos CJ, deBoer HH. Nonoperative treatment of Bennett’s
fracture: A 13-year follow-up. J Orthop Trauma 1995;9:23.
3. Carlsen BT, Moran SL. Thumb trauma: Bennnett fractures,
Rolando fractures, and ulnar collateral ligament injuries:
Current concepts. J Hand Surg 2009;34A:945.
4. Timmenga EJ, Blokhius TJ, Mas M, et al. Long-term evaluation
of Bennett’s fracture. A comparison of open and closed
reduction. J Hand Surg 1994;19B:373.
Figure 1
79. Which of the following nerves provides innervation
to the gracilis muscle?
A. Genitofemoral
B. Obturator
C. Saphenous
D. Sciatic
E. Femoral
Preferred Response: B
Discussion: Innervation is through the obturator nerve. The
genitofemoral nerve supplies the cremaster muscle. The
saphenous nerve is the largest branch of the femoral nerve.
It supplies branches to the rectus femoris, vastus lateralis,
and vastus medialis muscles. The sciatic nerve supplies
the hamstring muscles before dividing into the tibial and
peroneal nerves. The femoral nerve supplies the pectineus
and sartorius muscles.
References:
1. Kay SBJ, Lees VC. Free tissue transfer in children. In: Gupta
A, Kay SBJ, Scheker LR, eds. The Growing Hand: Diagnosis
and Management of the Upper Extremity in Children. London:
Mosby, 2000:982-983.
2. Mathes SJ, Nahai F. Transplantation of muscle and
musculocutaneous flaps. In: Mathes SJ, Nahai F, eds. Clinical
Applications for Muscle and Musculocutaneous Flaps.
St. Louis: Mosby, 1982:663-667.
2010 Self-Assessment Examination | 35
 80. A 67 year-old male patient has spastic hemiplegia Discussion: The patient illustrated has a clinodactyly with
following a stroke. He has a clenched fist a trapezoidal, as opposed to a triangular, middle phalanx.
deformity. A superficialis-to-profundus (STP) Physiolysis is a procedure that involves resection of the
tendon transfer is recommended, rather than finger physeal bracket with interposition of a fat pad. The best
flexor fractional lengthening, based on which of the results are seen in children that are younger than six
following observations? years old, with greater deformity and a trapezoidal middle
phalanx. Lumbrical division, distraction lengthening,
A. Absence of volitional movement
and tendon transfer are not procedures for clinodactyly.
B. Skin maceration in the flexion creases Because of the risk of further shortening of the phalanx and
C. Demonstrable dynamic extrinsic finger flexion function extensive dissection required with osteotomy, physiolysis
D. PIP joints flex while the DIP joints remain extended is a better option for this young patient with a trapezoidal
distal phalanx.
E. Inability to passively extend the fingers
References:
Preferred Response: A
1. Ty JM, James MA. Failure of differentiation: Part II
Discussion: Muscles that contribute to the clenched fist (Arthrogryposis, camptodactyly, clinodactyly, Madelung
deformity in stroke victim patients include FDS and FDP. If deformity, trigger finger and trigger thumb). Hand Clin
2009;25:195-213.
PIP joints flex while DIP joints remain extended, spasticity
of FDS (rather than FDP) may be suspected. FDS muscles 2. Caoutte-Laberge L, Laberge C, Egerszegi EP. Physiolysis
for correction of clinodactyly in children. J Hand Surg
often exhibit a marked degree of spasticity, whereas FDP 2002;27A:659-665.
muscles may be normal or minimally spastic.
When the overriding problem is in the FDS, or when
volitional control is demonstrated in the extrinsic finger
flexor muscles (by having the patient grasp on a finger
placed in the palm, or by dynamic EMG), fractional
lengthening is indicated. Inability to accomplish passive
finger extension and skin maceration does not differentiate
which of the procedures is best. In a hand with skin
maceration and malodor from a clenched fist, in which
no volitional movement is detected, more significant
lengthening of flexor tendons is required and STP tendon
transfer is performed.
References:
1. Braun RM, Vise GT. Sublimus-to-profundus tendon transfers
in the hemiplegic upper extremity. J Bone Joint Surg Figure 1
1973;55A:873.
2. Hisey MS, Keenan MAE. Orthopedic management of upper
extremity dysfunction following stroke or brain injury. In: Green
DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand
Surgery. 4th ed. New York: Churchill Livingstone, 1999:315-318.

81. A three year-old patient with otherwise normal

growth and development presents with his parents
for evaluation of his small fingers. There is no
antecedent trauma and the deformity seen in
Figures 1 and 2 is present bilaterally. The most
appropriate treatment is:
A. Tendon transfer
B. Physiolysis Figure 2
C. Distraction lengthening
D. Surgical division of abnormal lumbrical
E. Observation
Preferred Response: B

36 | American Society for Surgery of the Hand

82. What is the theoretical length gain when performing References:
a 60º Z-plasty? 1. DiDonna ML, Kiefhaber TR, Stern PJ. Proximal row
carpectomy: Study with a minimum of ten years of follow-up.
A. 15% J Bone Joint Surg 2004;86A:2359-65.
B. 25% 2. Jebson PJ, Hayes EP, Engber WD. Proximal row carpectomy:
C. 50% a minimum 10-year follow-up study. J Hand Surg
2003;28A:561-569.
D. 75%
E. 95%
Preferred Response: D
Discussion: Z-plasties are commonly used for scar
contractures and can be fashioned at many angles. There
is commonly a balance between maximizing length and
ease of transposition. Flaps cut at 30º, 45º, and 60º yield
theoretical increases of length of 25%, 50%, and 75%
respectively.
References:
1. Smith P. Lister’s The Hand. 4th ed. London: Harcourt, 2002: 157.
2. Pederson WC, Hotchkiss RN, Wolfe SW. Skin Flaps. In: Green
DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green’s
Operative Hand Surgery. 5th ed. Philadelphia: Churchill
Livingstone/Elsevier, 2005:1654-1655.

83. A 48 year-old male has failed conservative treatment

of the pathology seen on the radiograph of his right
wrist. He asks about surgical treatment of his wrist.
When discussing a proximal row carpectomy, the
patient is advised that studies with ten-year follow-
up indicate the following outcome:
A. Patients typically do not return to the same occupation
B. Long-term range of motion will be more than 80% of
the uninjured side
C. There is a low rate of patient satisfaction with the
surgical outcome
D. Development of radiographic arthritis does occur and
correlates with symptoms
E. Grip strength following the procedure increases to
80% of the uninjured side
Preferred Response: E
Discussion: Multiple studies have assessed the durability
of proximal row carpectomy results. At ten-year follow-
up, the motion is approximately 60% of the uninjured side
and strength is 80%, compared with the uninjured side,
not corrected for hand dominance. Patients are typically
pleased with the results and return to previous occupations.
Radiocapitate degenerative changes have been reported
(almost universally in some studies), but do not typically
correspond with symptoms.
Figure 1
84. Compared with the radial forearm flap, an
advantage of the ulnar artery forearm flap is:
A. A donor site that can often be closed primarily
B. A lower incidence of neurologic compromise
C. A more hirsute donor site
D. No sacrifice of a major artery
E. Ability to cover defects about the elbow as well as
the hand
Preferred Response: A
Discussion: Both the radial and ulnar artery forearm flaps
can be based proximally and distally. Both require the
sacrifice of the radial and ulnar arteries, respectively. The
ulnar artery runs in close proximity to the ulnar nerve, and
therefore, has a higher incidence of nerve injury—often
transient. The donor site for the ulnar artery forearm flap
can often be closed primarily in older individuals and bears
less hair than the radial forearm flap.
Reference:
1. Guimberteau JC, Goin JL, Panconi B, Schuhmacher B. The
reverse ulnar artery forearm island flap in hand surgery: 54
cases. Plast Reconstr Surg 1988;81:925-32.
2. Glasson DW, Lovie MJ. The ulnar island flap in hand and
forearm reconstruction. Br J Plast Surg 1988;41:349-53.

2010 Self-Assessment Examination | 37

 85. After performing the procedure depicted, there is an Discussion: Gout is an inflammatory arthritis that is caused
ischemic event noted in the forearm. What is the most by crystallized monosodium urate (MSU) in or around the
likely muscle group to sustain permanent damage? joints. Arthroscopic findings of gout include diffuse synovitis
with crystalline deposits, often in the intercarpal ligaments.
A. Deep finger flexors
The crystals dissolve in formalin and therefore should be
B. Superficial finger flexors biopsied and sent in alcohol. Steroid can also be seen as
C. Finger extensors intraarticular crystals and therefore biopsy for diagnosis of
D. Pronator Teres gout is important.
E. Wrist flexors References:
1. Fitzgerald BT, Setty A, Mudgal CS. Gout affecting the hand and
Preferred Response: A
wrist. JAAOS 2007;15:625-635.
Discussion: FDP and FPL are the most vulnerable muscle 2. Wilczynski MC, Gelberman RH, Adams A, Goldfarb CA.
group in ischemic contracture. In the mildest form, these Arthroscopic findings in gout of the wrist. J Hand Surg
muscles are the only affected, with the ring and middle 2009;34A:244-250.
being affected first. FDS, Pronator teres and wrist flexors
are all involved with more severe or prolonged ischemia.
Only in the most severe cases are the extensors affected.
Reference:
1. Stevanovic M, Sharpe F. Management of established
Volkmann’s contracture of the forearm in children. Hand Clin
2006;22:99-111.
2. Hovius SE, Ultee J. Volkmann’s ischemic contracture.
Prevention and treatment. Hand Clin 2000;16:647-57.

Figure 1

87. What is the mechanism of action of bone

morphogenic protein (BMP) in the treatment of a
fracture nonunion?
A. Increase the cross linking of collagen in callus
B. Modulate the activity of mesenchymal stem cells
C. Provide a structural scaffolding for new bone formation
D. Decrease bone resorption via osteoclast apoptosis
E. Inhibit formation of type II collagen
Preferred Response: B
Discussion: BMP’s are proteins that are members of the
Figure 1 Figure 2 larger family of proteins called TGF-beta [transforming
growth factors] that act specifically on bone. While the
precise mechanism of induction of bone by BMP’s is under
investigation, it has been determined that these proteins act
86. A 57 year-old male with wrist pain undergoes wrist by modulating the activity of mesenchymal stem cells. They
arthroscopy at an outpatient center. Arthroscopic are not believed to increase the cross linking of collagen
findings are shown in Figure 1. In order to confirm or decrease the production of type II collagen, which is
the diagnosis, the optimal solution the synovial extruded in the matrix by chondrocytes early in bone
biopsy specimen should be sent in is: healing. Apoptosis, or programmed cell death, is an action
A. Sterile water of certain BMP’s in adipogenic and myogenic cell lines, not
osteoclasts. BMP’s had no structural properties and are
B. Saline
often added to structural materials in clinical applications.
C. Formalin
References:
D. Hydrogen peroxide
1. Einhorn TA, Lee CA. Bone regeneration: New findings and
E. Alcohol potential clinical applications. JAAOS 2001;9:157-165
Preferred Response: E 2. Geissler WB. Bone graft substitutes in the upper extremity.
Hand Clin 2006;22:329-339.

38 | American Society for Surgery of the Hand

88. The preferred study design for determining the
reliability of a new test is:
A. Randomized controlled trial
B. Retrospective cohort trial
C. Prospective cohort trial
D. Case-control study
E. Expert opinion
Preferred Response: C
Discussion: A randomized, controlled trial controls the
timing and the amount of intervention. A prospective cohort
study looks at individuals with a positive test, and then
applies a gold standard; while a retrospective study looks
back at individuals with a positive gold standard for a history
of prior positive test. In a case-control study, patients with a
disease are compared against controls without the disease Figure 1
for presence of a positive test. Expert opinion is weak
evidence compared with the other options available.
References: 90. A 38 year-old factory worker sustained a laceration
1. Spindler KP, Kuhn JE, Dunn W, Matthews CE, Harrell FE Jr, from a piece of sheet metal resulting in numbness
Dittus RS. Reading and reviewing the orthopaedic literature: a
in the following distribution image. This most likely
systematic, evidence-based medicine approach. J Am Acad
Orthop Surg 2005;13:220-9. represents a laceration of which nerve:
2. Bryant DM, Willits K, Hanson BP. Principles of designing a A. Ulnar
cohort study in orthopaedics. J Bone Joint Surg Am 2009;91
Suppl 3:10-4. B. Lateral Antebrachial Cutaneous
C. Medial Antebrachial Cutaneous
D. Superficial Radial
89. What is the preferred treatment for the lesions E. Posterior Interosseous
seen below?
Preferred Response: D
A. Observation
Discussion: The area of numbness closely corresponds to
B. Prednisone
the superficial sensory branch of the radial nerve. This nerve
C. Radiation emerges from beneath the brachioradialis approximately 9
D. Amputation cm proximal to the radial styloid. The cutaneous innervation
E. Chemotherapy of the lateral antebrachial cutaneous nerve is more proximal.

Preferred Response: A References:

1. Netter FH. Atlas of Human Anatomy, Summit, NJ: CIBA-GEIGY,
Discussion: The radiographs demonstrate several fairly 1991: 151.
symmetric foci of sclerotic lesions centered in the bones 2. Green D. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW,
without cortical disruption or periosteal reaction. These eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia:
do not extend beyond the margins of the bone and are Churchill Livingstone/Elsevier, 2005:1033-141.
consistent with the findings of multiple benign bone islands,
osteopoikilosis. Differential diagnosis includes osteoblastic
metastases, principally prostate in men and breast in
women. Multiple myeloma rarely results in sclerotic lesions.
Osteopoikilosis is a benign and nonprogressive disorder of
uncertain etiology and any concern for metastatic disease
can be addressed with the use of a bone scan which will
not demonstrate increased uptake in osteopoikilosis.
References:
1. McLennan M. Radiology Rounds: Osteopoikilosis Can Fam
Physician 1999;45:2318-20.
2. Greenspan A. Bone island (enostosis): current concept—
a review. Skeletal Radiol Feb 1995;24(2):111-5.
Figure 1

2010 Self-Assessment Examination | 39

 91. A 43 year-old woman presents to the emergency
room with a distal radius fracture after a fall on her
outstretched hand. She has a past medical history
significant for Crohn’s disease and is on long-term
corticosteroids. Open reduction and internal fixation
of her distal radius fracture is indicated. Which
vitamin can help reverse the detrimental effect of
corticosteroids on wound healing?
A. A
B. C
C. D
D. E
E. K
Preferred Response: A
Discussion: Glucocorticoids (corticosteroids) cause dehiscence
of surgical incisions, increased risk of wound infection, and
delayed healing of open wounds. They produce these effects
by interfering with inflammation, fibroblast proliferation, collagen
synthesis and degradation, deposition of connective tissue
ground substances, angiogenesis, wound contraction, and re-
epithelialization. These actions are mediated by the antagonism
of various growth factors and cytokines. Vitamin A restores
the inflammatory response and promotes epithelialization
and the synthesis of collagen and ground substances.
However, vitamin A does not reverse the detrimental effects
of glucocorticoids on wound contraction and infection. Oral
ingestion of 25,000 I.U. per day or topical application of 200,000
I.U. ointments every 8 hours is effective in most cases.
Vitamin C – ascorbic acid, is an essential cofactor in the
synthesis of collagen, and as such, is critically important for
wound healing. It does not, however, reverse the detrimental
effects of corticosteroids. Vitamin D is critical to bone
healing, mineral homeostasis and bone integrity, but also
for numerous physiologic functions including regulation
of growth and differentiation in a broad variety of normal
and malignant tissues. Vitamin E has been used to control
various problems in wound overhealing and large doses
of Vitamin E can inhibit healing. The mechanism of this
action appears to have something to do with its membrane
stabilizing properties. Vitamin E may improve wound healing
in the setting of irradiated wounds, but not in the setting
of long-term corticosteroids. Vitamin K is useful in the
coagulation cascade and affects bleeding, and clotting. It
may also play some role in bone loss and bone turnover but
the effect is not related to corticosteroids.
References:
1. Anstead GM. Steroids, retinoids, and wound healing. Adv
Wound Care 1998;11(6):277-85.
2. Reichrath J, Lehmann B, Carlberg C, Varani J, Zouboulis CC.
Vitamins as hormones. Horm Metab Res 2007;39(2):71-84.
3. Cheung AM, Tile L, Lee Y, Tomlinson G, Hawker G, Scher
J, Hu H, Vieth R, Thompson L, Jamal S, Josse R. Vitamin K
supplementation in postmenopausal women with osteopenia
(ECKO trial): a randomized controlled trial. PLoS Med 2008 Oct
14;5(10):e196. Erratum in: PLoS Med 2008 Dec;5(12):e247.
40 | American Society for Surgery of the Hand
92. A 58 year-old laborer presents with a tumor on
the dorsum of the hand. He is referred by the
dermatologist who has done a biopsy which yields
the diagnosis of invasive squamous cell carcinoma.
The lesion is 2 centimeters in diameter and lies in
a bed of sun-damaged skin. A specialist trained
in Moh’s micrographic surgery is not available
to participate in this patient’s care. Which of the
following treatments is most appropriate?
A. Cryosurgery with liquid nitrogen
B. Photodynamic therapy
C. Radiation therapy
D. Surgical excision
E. Topical 5-fluorouracil application
Preferred Response: D
Discussion: The key to successful use of cryosurgery for
squamous cell carcinoma is appropriate tumor selection,
with the fewest recurrences occurring with original lesions
that are small (<=1 cm), well-defined, well-differentiated, and
either in situ or only superficially invasive on biopsy. This
lesion, as presented, is too advanced to treat in this manner.
The proper treatment for this lesion is surgical excision
with an adequate margin. Current practice is based on the
pivotal study from Brodland and Zitelli, which demonstrated
that 6 mm margins are required for high risk squamous
cell carcinoma (in this study, high-risk lesions were defined
as those with size >=2 cm, poor differentiation, invasion
into subcutaneous fat, or location on high-risk areas
including the hands) to achieve 95% clearance. Using these
guidelines for margins, the 5-year cure rate of primary
squamous cell carcinoma is 92%.
Photodynamic therapy is frequently used to treat actinic
keratoses. Photodynamic therapy involves the application
of a topical photosensitizer with subsequent exposure of
the lesion to visible light, resulting in damage to neoplastic
cells. Based on current evidence, photodynamic therapy is
recommended only for squamous cell carcinoma in situ or
in nonsurgical candidates. It would not be appropriate in
this case of an invasive squamous cell cancer.
Radiation therapy is an important alternative to surgical
treatment of squamous cell carcinoma, especially for older
patients, patients with multiple comorbidities, and for treatment
of large lesions that are not amenable to surgical excision.
The 5-year cure rate for primary squamous cell carcinoma is
approximately 90%. Radiation therapy lacks margin control,
has a prolonged course of treatment, and increases the risk
of future squamous cell carcinoma within the radiation field.
Several studies have shown success in treating squamous
cell carcinoma in situ with topical 5-fluorouracil however, it
is currently only Food and Drug Administration–approved to
treat actinic keratosis and superficial basal cell carcinoma.
Moh’s micrographic surgery is an appropriate option when
available to the patient.
References:
1. Hepper DM, Hepper CT, Anadkat M. Treatment options for
squamous cell carcinoma of the dorsal hand including Mohs
micrographic surgery. J Hand Surg 2009;34A:1337-9.
2. Lane JE, Kent DE. Surgical margins in the treatment of
nonmelanoma skin cancer and mohs micrographic surgery.
Curr Sur 2005;62(5):518-26.
93. A 35 year-old professional boxer complains of pain
and fullness over the 2nd and 3rd carpometacarpal
joints of the right hand. X-rays demonstrate chronic
CMC subluxation of these joints with traumatic
carpal bossing. The recommended treatment is:
A. Arthrodesis of the affected joints
B. Extensor tendon realignment
C. Interposition arthroplasty
D. Wedge excision of the carpal boss
E. Wrist splint
Preferred Response: A
Discussion: Traumatic carpal bossing is a disabling
and crippling injury in professional boxing if not treated
appropriately. Arthrodesis of the destabilized carpometacarpal
joints has been the preferred method of treatment. Precisely-
executed operative treatment of both injuries has resulted
in a favorable outcome, as in the vast majority of cases
the boxers have experienced relief of pain, restoration of
function, and an unrestricted return to competition.
Wedge excision is for carpal bossing without subluxation.
It would not be appropriate in this patient since there is
subluxation and would likely lead to significant instability
leading to further pain and instability. The central rigid
pillar of the hand is made up of the index and middle
metacarpals, which are firmly joined through their irregularly
shaped carpometacarpal articulations and intermetacarpal
ligaments to the relatively immobile distal carpal row.
Extensor tendon realignment can be useful in cases of
tendon attrition from synovitis, such as in a case of an
os styloideum, but in this setting there is no mention of
tendinopathy or synovitis. Interposition arthroplasty is not
described for this condition and likely would not be strong
enough in a boxer to allow function.
References:
1. Melone CP Jr, Polatsch DB, Beldner S. Disabling hand injuries
in boxing: boxer’s knuckle and traumatic carpal boss. Clin
Sports Med 2009;28(4):609-621.
2. Citteur JME, Ritt MJPF, Bos KE. Disabling hand injuries in
boxing: boxer’s knuckle and traumatic carpal boss.
J Hand Surg 1998;23B:76-78.
3. Flatt AE. The care of minor hand injuries, 3rd ed. St. Louis: C V
Mosby Company, 1972: 3.
4. Joseph RB, Linscheid RL, Dobyns JH, Bryan RS. Chronic sprains
of the carpometacarpal joints. J Hand Surg 1981;6:172-180.
94. A 23 year-old woman presents with clinical findings
of DeQuervain’s tenosynovitis in her right wrist. She
recently delivered her first child and is currently
breast-feeding. She is asking about treatment
options; both surgical and non-surgical. The option
with the best chance of improving her symptoms at
this time is:
A. Cortisone injection
B. Iontophoresis
C. Occupational therapy
D. Splinting
E. Cold laser therapy
Preferred Response: A
Discussion: DeQuervain’s tenosynovitis, which involves
the abductor pollicis longus and extensor pollicis brevis
tendons, is much more common in women than men.
Housewives and persons involved in manual occupations
using the hands and wrists account for most cases in
previous series. In one series, six of 24 female patients
(25%) were pregnant or postpartum at the time of onset.
In five of the six, activities of infant care aggravated
symptoms. Both pregnancy, per se, and mechanical factors
appear to play a role in causing this condition.
DeQuervain’s disease of pregnancy and lactation is usually
self-limited and responds well to nonsurgical treatment.
In one study, one group had a cortisone injection into the
tendon sheath and the other group used thumb spica
splints. All 9 patients with injections had complete pain relief
with only one late recurrence. None of the patients with
splints had complete pain relief; however, at the end of the
lactation period, 8 had spontaneous resolution of symptoms
and 1 received a cortisone injection.
References:
1. Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment
measures for de Quervain’s disease of pregnancy and lactation.
J Hand Surg 2002;27A:322-4.
2. Peters-Veluthamaningal C, van der Windt DA, Winters JC,
Meyboom-de Jong B. Corticosteroid injection for de Quervain’s
tenosynovitis. Cochrane Database Syst Rev 2009
Jul 8;(3):CD005616. Review.
3. Peters-Veluthamaningal C, Winters JC, Groenier KH,
Meyboom-DeJong B. Randomised controlled trial of local
corticosteroid injections for de Quervain’s tenosynovitis in
general practice. BMC Musculoskelet Disord 2009;10:131.
4. Schned ES. DeQuervain’s tenosynovitis in pregnant and
postpartum women. Obstet Gynecol 1986;68(3):411-4.
2010 Self-Assessment Examination | 41
 95. A 65 year-old woman with rheumatoid arthritis
presents on referral from her rheumatologist because
she has lost the ability to extend the fingers of her right
hand. On clinical examination, she has full passive
metacarpophalangeal motion with intact tenodesis.
What is the most likely cause of her disability?
A. Atlanto-axial subluxation
B. Cubital tunnel syndrome
C. Extensor tendon attritional ruptures
D. Intrinsic tightness
E. Posterior interosseous nerve entrapment
Preferred Response: E
Discussion: Posterior interosseous nerve (PIN) entrapment
is a rare complication of rheumatoid arthritis (RA)
which, together with extensor tendon rupture and
metacarpophangeal joint dislocation, should be considered
in the differential diagnosis of inability to extend the fingers.
The inability to extend the thumb in PIN entrapment is a
useful distinguishing clue on physical examination, and
nerve conduction studies confirm the diagnosis. Elbow
joint synovitis and compression of the PIN at the arcade
of Frohse are the main reasons for PIN entrapment in RA.
Intraarticular steroid injections and surgical intervention
resolve symptoms of PIN entrapment in RA.
Atlanto-axial subluxation of the cervical spine can occur with
RA and is a life-threatening condition. It does not present as
an isolated peripheral nerve injury. Cubital tunnel syndrome
causes ulnar nerve weakness, and would not result in
inability to extend the fingers. The extensor tendons are likely
not ruptured in this case because the caput ulnae is mild and
the tenodesis effect is intact, suggesting that the fingers can
be passively extended if the wrist is flexed.
References:
1. Fernandez AM, Tiku ML. Posterior interosseous nerve
entrapment in rheumatoid arthritis. Semin Arthritis Rheum 1994
Aug;24(1):57-60.
2. White SH, Goodfellow JW, Mowat A. Posterior interosseous
nerve palsy in rheumatoid arthritis. J Bone Joint Surg
1988;70B:468-71.
3. Westkaemper JG, Varitimidis SE, Sotereanos DG. Posterior
interosseous nerve palsy in a patient with rheumatoid synovitis
of the elbow: a case report and review of the literature. J Hand
Surg 1999;24A:727-31.
96. Which of the following would be an appropriate use
of a Venous-Flow-Through-Flap?
A. Composite defects of bone, tendon and skin
B. Closure of a large skin cancer defect
C. Resurfacing a dorsal hand wound in a radiated bed
D. Closure of a small wound during a finger replant
E. Coverage of a palmar degloving injury
Preferred Response: D
42 | American Society for Surgery of the Hand
Discussion: A Venous-Flow-Through-Flap (VFTF) is a
novel technique of microsurgical free tissue transfer that
is appropriate for use in certain cases requiring soft-tissue
coverage. VFTF are unusual, but are gaining acceptance in
certain kinds of hand and finger wounds. The ideal site for
coverage with a VFTF is a long narrow defect needing thin soft
tissue. VFTF typically get congested in the first week, and then
decongest over the following two weeks as they revascularize
from the wound bed. VFTF cannot reliably transfer composite
tissue such as bone and tendon or cover a wide defect such
as an entire palm. Because they do not bring in as good
vascularization to the wound bed as a classical flap, they are
not indicated in radiated or potentially infected wound beds.
A small defect such as the 2 cm2 defect needing coverage
during a finger replant is the ideal candidate for this flap.
References:
1. Brooks, D. Invited Discussion: Arterialized venous free flaps.
J Reconstr Microsurg 2002 Oct;18(7):575-7.
2. De Lorenzi F, van der Hulst RR, den Dunnen WF, Vranckx JJ,
Vandenhof B, Francois C, Boeckx WD. Arterialized venous free
flaps for soft-tissue reconstruction of digits: a 40-case series.
J Reconstr Microsurg 2002;18(7):569-74.
3. Titley OG, Chester DL, Park AJ. A-a type, arterialized, venous,
flow-through, free flap for simultaneous digital revascularization
and soft tissue reconstruction-revisited. Ann Plast Surg
2004;53(2):185-91.
4. Rose EH. Small flap coverage of hand and digit defects. Clin
Plast Surg 1989;16(3):427-42.
97. Which of the following studies provides early indication
of eventual demarcation in severe frostbite injuries?
A. Angiography
B. Doppler laser
C. Technetium 99 bone scan
D. Thermography
E. Ultrasound
Preferred Response: C
Discussion: Several diagnostic tests have been used to
help predict the severity and prognosis of the frostbite
injury including plain radiographs, infrared thermography,
angiography, double and triple phase bone scanning, laser
Doppler studies, digital plethysmography and magnetic
resonance imaging/magnetic resonance angiography
(MRI/MRA). The most promising studies have used three
phase bone scanning and MRI/MRA. Bone scanning (using
99
technetium) has now become the standard study used
within the first few days after injury. This technique assesses
tissue viability in an effort to allow early debridement of soft
tissue and early coverage of ischemic bony structures.
Scintigraphic methods using technetium 99m pertechnetate
seem to be the most successful to delineate eventual
amputation necessity and level. The results of one study
show that an initial bone scan (as early as day 3) has excellent
specificity in evaluating the severity of frostbite injury.
There was a direct correlation between the demarcation
zone of uptake in the phalanges and the eventual level of
amputation (positive predictive value, 0.84). A second scan on
approximately day 7 was even more sensitive and informative.
A strong correlation existed between positive uptake and
eventual healing (negative predictive value, 0.99). This study
showed that 99mTc bone scanning in the first few days after
frostbite injury indicates the level of amputation in severe
frostbite in more than 84% of cases.
References:
1. Cauchy E, Marsigny B, Allamel G, Verhellen R, Chetaille E. The
value of technetium 99 scintigraphy in the prognosis of amputation
in severe frostbite injuries of the extremities: A retrospective study
of 92 severe frostbite injuries. J Hand Surg 2000;25A:969-78.
2. Imray C, Grieve A, Dhillon S. Caudwell Xtreme Everest Research
Group. Cold damage to the extremities: frostbite and non-
freezing cold injuries. Postgrad Med J 2009;85(1007):481-8.
98. Which outcome instrument is best for evaluating
patient disorders that involve multiple joints of the
upper limb?
A. Brigham and Women’s carpal tunnel questionnaire
B. DASH score (disability of arm, shoulder and hand
questionnaire)
C. Gartland and Werley score
D. PRWE score (patient-rated wrist evaluation
questionnaire)
E. SPADI (shoulder pain and disability index)
Preferred Response: B
Discussion: The choice of a proper validated instrument is
critical when trying to formulate and conduct an outcomes
study. The PRWE score is the most responsive instrument
for evaluating the outcome in patients with distal radius
fractures. SPADI is useful for shoulder dysfunction, while the
DASH score is the best instrument for evaluating patients
with disorders involving multiple joints of the upper limb. The
Brigham and Women’s score is a disease-specific outcome
instrument for carpal tunnel syndrome; it has been validated
and demonstrated to show good responsiveness and reliability
in evaluating outcome in patients with carpal tunnel release.
The Gartland and Werley score, although the most commonly
described instrument in the literature for evaluating outcome
after wrist surgery, has not been validated so to date.
The Disabilities of the Arm, Shoulder and Hand (DASH)
outcome measure was developed to evaluate disability
and symptoms in single or multiple disorders of the upper
limb at one point or at many points in time. DASH has
demonstrated reliability, validity, and responsiveness in
a group of diverse patients and compares favorably with
results obtained with joint-specific measures.
References:
1. Changulani M, Okonkwo U, Keswani T, Kalairajah Y. Outcome
evaluation measures for wrist and hand: which one to choose?
Int Orthop 2008 Feb;32(1):1-6. Epub 2007 May 30. Review.
2. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V,
Bombardier C. Measuring the whole or the parts? Validity,
reliability, and responsiveness of the Disabilities of the Arm,
Shoulder and Hand outcome measure in different regions of the
upper extremity. J Hand Ther 2001;14(2):128-46.
3. Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm,
shoulder and hand (DASH) outcome questionnaire: longitudinal
construct validity and measuring self-rated health change after
surgery. BMC Musculoskelet Disord 2003 Jun 16;4:11.
99. Which of the following factors related to open distal
radius fractures has the strongest correlation with
the risk of post-op infection?
A. Degree of contamination
B. Gustillo classification
C. Time to initial debridement
D. Systemic illness
E. Method of fixation
Preferred Response: A
Discussion: Of all the above possible factors relating to
risk of post-operative infection, the strongest correlation
is with significant contamination. Contamination type
is usually categorized by the CDC classification: clean,
clean-contaminated, contaminated and dirty/infected.
Significant contamination corresponds to contaminated and
dirty/infected wounds and is found to have the strongest
correlation with risk of post-op infection.
The Gustillo and Anderson fracture classification has been
found to have some correlation with open fracture infection
rates, but this is not as strong a correlation in the distal
radius as it is in long bones of the lower extremity.
Recent studies by Glueck et al. and Swanson et al. have
shown that contamination is a much stronger correlate to
risk of post-operative infection.
The timing of the initial debridement, as long as it was within
the first 24 hours of injury, does not significantly affect
infection rate. In contrast to this, there is some evidence
to suggest that performing multiple serial debridements
in significantly comtaminated wounds is of benefit in
preventing post-op infection.
The presence of systemic illness, such as diabetes mellitus,
and the type of fracture fixation, seems to have a modest
correlation to post-op infections in distal radius fracutres,
but the findings are generally not statistically significant.
References:
1. Glueck DA, Charoglu CP, Lawton JN. Factors associated with
infection following open distal radius fractures. Hand (NY)
2009;4:330-334.
2. Swanson TV, Szabo RM, Anderson DD. Open hand fractures:
prognosis and classification. J Hand Surg 1991;16A:101-107.
3. Rozental TD, Beredjiklian PK, Steinberg DR, Bozentka DJ. Open
fractures of the distal radius. J Hand Surg 2002;27A:77-85.
2010 Self-Assessment Examination | 43
 100. The hand finding most commonly associated with References:
the condition depicted in Figure 1 is: 1. Kay SPJ. Hypoplastic and absent digits. In: Green DP, Hotchkiss
RN, Pedersen WC, eds. Green’s Operative Hand Surgery. 4th
A. Normal hand ed. Philadelphia: Churchill Livingstone, 1999:368-369.
B. Hypoplastic hand 2. Flatt AE. The Care of Congenital Hand Anomalies. 2nd ed.
C. Radial club hand St Louis: Quality Medical Publishers, 1994: 337-365.
3. Al-Qattan MM. Classification of hand anomalies in Poland’s
D. Brachysyndactyly syndrome. Br J Plast Surg 2001 Mar;54(2):132-6. Review.
E. Transverse deficiency proximal to the MCP joints

Preferred Response: B
Discussion: Poland’s syndrome is absence of the sternal
head of the pectoralis major muscle. The syndrome is
classified according to the degree of involvement of the
hand and rays. The classic presentation, although not the most
common, is a Type III with the associated brachysyndactyly,
which is occasionally found. The most common finding is a
hypoplastic hand. Treatment is dependent on the degree of
hypoplasia of the hand and digits.

Classification of Hand Anomalies in Poland’s Syndrome

TYPE CLASSIFICATION FINDINGS Figure 1
I Normal hand Isolated pectoral anomaly
II Form fruste deformity Hypoplastic hand
III The “classic” Brachysyndactyly with five
deformity potentially functional rays:
A. Mild to moderate
B. Severe
IV Some functional rays A. A  radial club hand with
still present floating or absent thumb
B. Adactyly of the index
C. Adactyly of the index and
long fingers
D. A  dactyly of the central
rays creating a cleft hand
E. Adactyly of the ulnar rays
V All digits are
functionless or absent
VI Transverse deficiency
proximal to the
metacarpophalangeal
joints
VII Phocomelia-like
deficiency

44 | American Society for Surgery of the Hand

101. Which of the following treatment options is not
effective in arresting the longitudinal overgrowth in
the 9-month-old child with the condition depicted in
Figures 1 and 2?
A. Epiphysiodesis
B. Epiphysectomy
C. Digital neurectomy
D. Digital shortening
E. Debulking
Preferred Response: C
Discussion: A retrospective review was performed for 23
patients who were surgically treated for macrodactyly of
the hand. Although the authors found it difficult to compare
treatment regimens, epiphysiodesis/epiphysectomy was
quite effective in the prevention of longitudinal overgrowth
of the digits, but resection of the hypertrophic nerves
(digital neurectomy) was unsuccessful in preventing
finger overgrowth. Amputation of the involved digits
sometimes has to be considered as a measure to control
the size. Middle phalangectomy was successful in one
case with a good aesthetic and functional result. Further
clinical evaluation is obviously required before middle
phalangectomy can be recommended for macrodactyly.
References:
1. Ishida O, Ikuta Y. Long-term results of surgical treatment
for macrodactyly of the hand. Plast Reconstr Surg
1998;102(5):1586-90.
2. Tan O, et al. Middle phalangectomy: a functional and
aesthetic cure for macrodactyly. Scand J Plast Reconstr Surg
2006;40(6):362-5.
Figure 1
Figure 2
102. The scaphoid cortical ring (SCR) sign is abnormal if
present with the wrist in neutral (flexion/extension)
and what degree of radial or ulnar deviation:
A. 10° or greater of radial deviation
B. 5 to 9° of radial deviation
C. 13° or greater of ulnar deviation
D. 10° or less of ulnar deviation
E. Neutral radial / ulnar deviation
Preferred Response: C
Discussion: There is some confusion surrounding the
clinical significance of the SCR sign. The SCR sign however,
is normally observed when the wrist moves into radial
deviation from ulnar deviation. It is due to the vertical
posture of the scaphoid as the two poles are superimposed
on each other on the PA view. The functional status of
the scapholunate (S-L) ligament has a direct bearing on
the presence of this sign. A substantial portion of the
ligament needs to be torn for the sign to be present. It is,
however, sometimes difficult to determine if the presence
of this radiologic sign is abnormal. Moreover, when the
S-L ligament is completely torn, the scaphoid assumes a
more vertical posture. Partial S-L ligament injuries are still
a perplexing clinical problem. Therefore, other clinical and
radiographic parameters should be used when evaluating
a patient with a suspected S-L ligament injury. A study
was carried out with the wrist in neutral flexion-extension
to determine when the SCR sign should be considered
abnormal. The radiometacarpal angle was used to
determine the radioulnar position of the wrist. This study
used the normal wrists of patients to determine when
the SCR sign was absolutely not present based on two
standard deviations from the mean of the wrists evaluated.
Using this rationale, they concluded that if the SCR sign is
observed in 13° of ulnar deviation or greater, it should be
considered abnormal.
References:
1. Pirela-Cruz MA, Hilton ME, Faillace J. Frequency and
characteristics of the scaphoid cortical ring sign. Surg Radiol
Anat 2003;25(5-6):451-4.
2. Abe Y, Doi K, Hattori Y. The clinical significance of the scaphoid
cortical ring sign: a study of normal wrist X-rays. J Hand Surg
2008;33B:126-9.
3. Cautilli GP, Wehbé MA. Scapho-lunate distance and cortical
ring sign. J Hand Surg 1991;16A:501-3.
2010 Self-Assessment Examination | 45
 103. A 25 year-old male presents with chronic elbow pain
a year after undergoing a radial head implant for
a comminuted fracture. Intra-operative findings of
the radiocapitellar joint are noted in Figure 1. The
primary technical reason for this unsatisfactory
outcome is:
A. Implant particulate wear debris
B. Implant loosening
C. Occult infection
D. Joint “over-stuffing”
E. Metallosis
Preferred Response: D
Discussion: The surgical treatment for a comminuted
displaced radial head fracture in a young patient is a
difficult problem. Preservation of the radial head should be
considered initially. In cases where ORIF is not possible,
insertion of a radial head implant should be performed.
The most common primary reason for an unsatisfactory
outcome is “over-stuffing” of the radiocapitellar joint
manifested by the wear on the capitellum. Other reasons
for failure include implant malposition that can lead to an
eccentric wear pattern. Metallosis is a rare cause of implant
failure and was not noted in this patient.
References:
1. Ring D, King G. Radial head arthroplasty with a modular metal
spacer to treat acute traumatic elbow instability. Surgical
technique. J Bone Joint Surg Am 2008 Mar;90 Suppl 2 Pt 1:63-73.
2. Stuffmann E, Baratz ME. Radial head implant arthroplasty.
J Hand Surg 2009;34A:745-54.
Figure 1
46 | American Society for Surgery of the Hand
104. In the patient shown in Figure 1, the minimum
recommended time (months) before proceeding to
the second stage reconstruction is:
A. 2
B. 3
C. 6
D. 9
E. 12
Preferred Response: B
Discussion: Scarring of the flexor tendon after repair is
the prime reason for reduced range of motion of the finger
and failure. To minimize the problems associated with
scarring, staged flexor tendon reconstruction is performed
by-passing zone II. A silicone implant (Hunter rod) can
help to make the reconstruction successful by creating a
pseudosheath which lays down a more receptive bed for
the tendon graft. As a general rule, it requires approximately
three months for an adequate tendon pseudosheath.
The second flexor tendon reconstructive stage should be
performed after at least three months, when the scar is soft,
mature and the patient has good passive range of motion.
References:
1. Freilich AM, Chhabra AB. Secondary flexor tendon
reconstruction, a review. J Hand Surg 2007;32A:1436-42.
2. Vucekovich K, Gloria G, Fiala K. Rehabilitation after flexor
tendon repair, reconstruction and tenolysis. Hand Clin
2005;21:257-265.
3. Strickland JW. Delayed treatment of flexor tendon injuries
including grafting. Hand Clin 2005;21:219-43.
Figure 1
105. A 19 year-old male with a 4-week history of a
nondominant elbow dislocation was referred by another
physician after surgical treatment for an elbow injury.
See Figures 1, 2, and 3. The recommended treatment is:
A. Therapy
B. Resection arthroplasty
C. Arthrodesis
D. Open reduction
E. Closed reduction
Preferred Response: D Figure 3

Discussion: This young man and the treating physician have

a complicated problem to address. It is likely that this patient
had an ipsilateral olecranon fracture and an ulnohumeral
dislocation. The treatment provided was likely an ORIF of the
olecranon fracture and a closed reduction of the dislocation.
Despite this treatment, instability of the elbow persists. In a
study by Ruch and Triepel, patients with elbow instability
six weeks or less were treated with open reduction, hinged
elbow fixation and early ROM had a reasonable outcome.
In this study, formal repair or reconstruction of the collateral
ligaments was not performed.
References:
1. Tashjian RZ, Katarincic JA. Complex elbow instability. J Am
Acad Orthop Surg 2006;14(5):278-86.
2. Ring D, Jupiter JB. Compass hinge fixator for acute and chronic
instability of the elbow. Oper Orthop Traumatol 2005;17(2):143-57.
3. Ruch DS, Triepel CR. Hinged elbow fixation for recurrent
instability following fracture dislocation. Injury 2001 Dec;32
Suppl 4:SD70-8.
106. When elevating the flap in Figure 1, which structure
may tether the pedicle?
A. Tensor fascia
B. Femoral quadratus
C. Inguinal ligament
D. Sartorius muscle
E. Abdominal aponeurosis
Preferred Response: D
Discussion: Axially-patterned flaps based on single arteries
have a high success rate. The groin flap is an axial pattern flap
of the cutaneous variety based on the superficial circumflex
iliac artery (SCIA). It provides excellent tissue coverage for
the extensor surface of the hand, does not require a split
thickness skin graft, and is easily tubed to a pedicle. The
SCIA may be tethered by the sartorius muscle in certain
positions. Therefore, careful elevation of the flap is required
to ensure that flow into the groin flap is not compromised.
References:
1. Smith PJ, Foley B, McGregor IA, Jackson IT. The anatomical
basis of the groin flap. Plast Reconstr Surg 1972;49:41-47.
2. Taylor GI. Blood supply of the abdomen revisited, with
emphasis on the superficial inferior epigastric artery:
discussion. Plast Reconstr Surg 1984;74:667-670.

Figure 1

Figure 2 Figure 1

2010 Self-Assessment Examination | 47

 107. The flexion contracture of the distal interphalangeal pollicis. Andre-Thomas sign is when the patient attempts to
joint seen in Dupuytren’s disease can be attributed tenodese the extrinsic extensor tendons with wrist flexion,
to the: in an attempt to prevent digit clawing. This maneuver
actually increases the claw deformity.
A. Natatory cord
B. Pretendinous cord References:
1. Omer GE Jr. Ulnar nerve palsy. In: Green DP, ed. Operative hand
C. Retrovascular cord of Thomaine
surgery. New York: Churchill Livingstone, 1988:1535-1554.
D. Distal commissural cord 2. Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar
E. Vertical cord of Legueu and Juvara nerve. J Am Acad Orthop Surg 2007;15(11):672-81.
3. Kozin SH, Porter S, Clark P, Thoder JJ. The contribution of
Preferred Response: C the intrinsic muscles to grip and pinch strength. J Hand Surg
1999;24A:64-72.
Discussion: The retrovascular fibers of Thomaine are
located dorsal to the neurovascular bundle and thought
to extend to all three phalanges. Although these fibers do
not make up a well developed ligament, they extend distal
to the DIP joint. When diseased, they form a retrovascular
cord-like structure that contributes to DIP joint flexion
deformity. Other digital cords, however, can cause DIP
contracture. The pretendinous cord is involved in MP joint
contracture. The natatory cord causes digital web space
contracture. The distal commissural cord results in thumb
Figure 1
index web space contracture and is an indication of a more
extensive disease process. The vertical cord is the diseased
septum of Legueu and Juvara in the palm that may contribute
to stenosing tenosynovitis in Dupuytren’s disease. 109. A 65 year-old woman presents with a painful round
mass in her palm which she has noticed about 6
References:
weeks ago. Since the time she noticed the mass,
1. McGrouther DA. Dupuytren’s contracture. In: Green DP, she has developed a cord and “tightness” when
Hotchkiss RN, Pedersen WC, eds. Green’s Operative Hand
Surgery. 5th ed. Philadelphia: Churchill Livingstone/Elsevier, she attempts to extend the index and middle
2005:159-185. fingers. There is no history of penetrating trauma or
2. Rayan GM. Palmar facial complex anatomy and pathology in neurologic complaints. She recently has had a PAP
Dupuytren’s disease. Hand Clin 1999;15:73-86. smear after going to her gynecologist for new onset
vaginal bleeding. Her regular x-rays are normal. A
clinical picture of her hand, MRI and gross biopsy
108. The clinical sign depicted in the patient’s left hand specimen are shown (Figures 1-3). Her diagnosis is:
shown in Figure 1 is: A. Ganglion cyst
A. Froment’s sign B. Malignant fibrous hystiocytoma (MFH)
B. Wartenberg’s sign C. Palmar Fasciitis
C. Masse’s sign D. Hemangioma
D. Jeanne’s sign E. Dupuytren’s contracture
E. Andre-Thomas sign
Preferred Response: C
Preferred Response: A
Discussion: Palmar fasciitis and polyarthritis syndrome
Discussion: Figure 1 depicts Froment’s sign, also known as
(PFPAS) is an uncommon paraneoplastic syndrome
Bunnell’s “O” sign. This occurs due to loss of distal thumb
associated with several malignant neoplasms. Murray
tip stability from paralysis of the adductor pollicis and the
and coauthors recently published a series of patients with
flexor pollicis brevis. Wartenberg’s sign is an inability to
this syndrome associated with ovarian cancer. A literature
adduct the extended small finger due to loss of the third
review revealed 10 other cases of this syndrome associated
palmar interossei, which opposes the action of the extensor
with gynecologic cancer. Improvement of the palmar
digiti minimi. Masse’s sign is flattening of the palmar arch
fasciitis and associated arthritis can occur with successful
and loss of ability to elevate the ulnar portion of the hand,
treatment of the carcinoma. A gynecologic examination is
due to paralysis of the opponens digit quinti and decreased
recommended in any woman presenting with the sudden
range of flexion of the small finger metacarpophalangeal
onset of unexplained hand pain, palmar inflammatory
joint. Jeanne’s sign is hyperextension of the thumb MP joint
fasciitis, palmar fibromatosis, and digital contractures.
with gross grip or key pinch due to loss of the adductor

48 | American Society for Surgery of the Hand

References
1. Martorell EA, Murray PM, Peterson JJ, Menke DM, Calamia
KT. Palmar fasciitis and arthritis syndrome associated with
metastatic ovarian carcinoma: A Report of four cases. J Hand
Surg 2004;29A:654-660.
2. Leslie BM. Palmar fasciitis and polyarthritis associated with a
malignant neoplasm: a paraneoplastic syndrome. Orthopedics
1992;15:1436-1439.
Question 109, Figure 1 Question 109, Figure 2
Question 109, Figure 3
110. The fracture depicted in Figure 1 can be treated with a
number of methods, including dynamic external fixation.
In all of the methods, using this fixation modality, the
central concept to achieving a satisfactory result is:
A. Getting an anatomic reduction with traction
B. Maintaining a concentric reduction of the joint
C. Bone grafting any visible defects on x-rays
D. Keeping the device on for at least 6 weeks
E. Stable fixation of fracture fragments
Preferred Response: B
Discussion: The x-rays depict a pilon fracture of the PIP
joint. One of the more useful methods of treatment of this
injury is use of dynamic traction. There are a number of
variations of this technique, including commercially-available
devices. Central to all techniques is the ability to achieve
and maintain a concentric reduction with the device. Bone
grafting is not essential, or routinely used. Anatomic
reductions, while ideal, may not always be possible. Not
having a perfect reduction does not prevent an acceptable
result. There is not a designated time frame the device must
be left on for it to achieve the desired result.
References:
1. Badia A, Riano F, Ravikoff J, Khouri R, Gonzalez-Hernandez
E, Orbay JL. Dynamic intradigital external fixation for proximal
interphalangeal joint fracture dislocations. J Hand Surg
2005;30A:154-160.
2. Ellis SJ, Cheng R, Prokopis P, Chetboun A, Wolfe SW,
Athanasian EA, Weiland AJ. Treatment of proximal
interphalangeal dorsal fracture-dislocation injuries with
dynamic external fixation: A pins and rubber band system.
J Hand Surg 2007;32A:1242-1250.
Figure 1
111. Figure 1 represents the x-rays of the right hand of a
patient brought to the Emergency room after being
struck by a car while riding his motorcycle. The
imaging technique which best defines the injury is:
A. Standard x-rays
B. 30° pronated oblique films
C. 30° supinated oblique films
D. CT scan
E. MRI scan
Preferred Response: D
Discussion: This is an example of a carpometacarpal
(CMC) dislocation (small, ring, long, and index). Veigas has
investigated the pathomechanics of digital CMC fractures
and dislocations and has found them to be a complex
injury best imaged by CT scan. While x-rays can often
reveal considerable information, small fractures and other
information important to treatment can often be missed. The
injuries occur from a combination of axial load and shear and
are common in patients involved in high-force injuries.
References:
1. Yosida R, Shah M, Veigas SF, Patterson R, Buford M. Anatomy
and pathomechanics of ring and small finger carpometacarpal
joint injuries. J Hand Surg 2003;28A:1035-1043.
2. Nakamura K, Veigas SF, Patterson R. The ligament and skeletal
anatomy of the second through fifth carpometacarpal joints and
adjacent structures. J Hand Surg 2001;26A:1016-1029.
Figure 1
2010 Self-Assessment Examination | 49
 112. A patient falls off a scaffold onto his right wrist. There
is pain, swelling, limited range of motion but no open
wounds or neurologic deficit on exam. Figure 1 is a
radiograph of the injured wrist. Closed reduction is
attempted in the ER, but not successful. After open
reduction is achieved in the operating room, the
carpal injury should be treated with:
A. Fusion of the midcarpal joint
B. Ligament repair of the midcarpal joint with
internal fixation
C. External fixation of the wrist with no ligament repair
D. Proximal row carpectomy
E. Cast immobilization
Preferred Response: B
Dicussion: The x-rays reveal a divergent carpal dislocation
with dislocation of the midcarpal joint. Divergent carpal
dislocations typically result from high force injuries and
involve axial load and torsion applied to the carpus.
While there are no large series of these injuries in the
literature, all studies to date advocate open reduction and
ligament repair supplemented by internal fixation. Cast
immobilization is insufficient to stabilize these injuries and
acute fusions are not indicated. A proximal row carpectomy
in this situation would not be indicated. External fixation
without ligament repair has not been reported as a method
of stabilization for this injury pattern.
References:
1. Herzberg G. Perilunate and axial carpal dislocations and
fracture-dislocations. J Hand Surg 2008;33A:1159-1168.
2. Garcia-Elias M, Dobyns J, Cooney WP III, Linscheid RL.
Traumatic axial dislocations of the carpus. J Hand Surg
1989;14A:446-457.
Figure 1
50 | American Society for Surgery of the Hand
113. For the flap depicted in Figure 1, the modification
that will minimize the donor defect is:
A. Vein graft the artery defect at the donor site
B. Use a full thickness skin graft at the donor site
C. Leave the fascia at the donor site
D. Use a split thickness skin graft at the donor site
E. Use a wound VAC for donor site closure
Preferred Response: C
Dicussion: The radial forearm flap is one of the workhorse
flaps for upper extremity reconstruction. Its main drawback
is the donor site defect, which can sometimes be
problematic. Use of a full thickness vs. split thickness graft
has not been shown to solve the problem of sometimes
poor-take of the graft at the donor site. As long as the
palmar arch is complete and there is a patent ulnar artery,
reconstructing the radial artery is not necessary. Raising
the flap in a suprafascial plane has shown to be a significant
improvement in the donor site by various authors. Wound
VAC closure of the donor site would not be indicated.
References:
1. Lutz BS, Wei FC, Sophia CN. Donor site morbidity after
suprafascial elevation of the radial forearm flap: a prospective
study in 95 consecutive cases. Plas Recon Surg 1999;
103:132-137.
2. Bardsley AE, Soutar DS, Elliot D, Batchelor AD. Reducing
morbidity on the forearm flap donor site. Plas Recon Surg
1990;86:284-287.
Figure 1
114. The parents of a 12 year-old child are concerned
about the appearance of the right thumb nail shown
in Figure 1. There is no history of trauma. The child
does not report any pain, functional loss and other
than the nail appearance, the physical exam is
normal and no other digits are affected. X-rays are
normal. The next step in management would be:
A. Observation and re-evaluation in 6 months
B. MRI scan
C. IP joint disarticulation
D. Nail bed excision and full thickness skin graft
E. Biopsy
Preferred Response: E
Dicussion: With the lesion shown, one would need to
rule out a melanoma, which is very rare in children. It
is important to get a definitive diagnosis in this patient;
therefore, a biopsy would be the best choice. An MRI
scan would not give definitive information and observation
alone would be inadequate. The lesion is most likely a
melanonychia striata and proceeding with ablative surgery
would not be the best option.
References:
1. Molina D, Sanchez JL. Pigmented longitudinal bands of the nail.
A clinicopathologic study. Am J Dermatopathol 1995;17(6):539-41.
2. Buka R, Friedman KA, Phelps RG, Silver L, Calero F, Rudikoff
D. Childhood longitudinal melanonychia: case reports and
review of the literature. Mt Sinai J Med 2001;68(4-5):331-5.
3. Quinn MI, Thompson JE, Crotty K, McCarthy WH. Subungual
Melanomas of the Hand. J Hand Surg 1996;21A:506-511.
Figure 1
115. A 55 year-old right hand dominant woman with
advanced bilateral rheumatoid wrist arthritis wishes to
proceed with bilateral staged wrist surgery, after she
has been unable to obtain relief with oral medication,
splinting and injections. On examination, there do not
appear to be any tendon ruptures of the wrist and finger
tendons. There is no active synovitis. She has minimal
pain with forearm rotation. The radial carpal joint is
tender. Wrist motion reproduces her symptoms. Her
neurologic examination is normal. There is minimal joint
involvement and symptoms in the shoulder and elbow.
PA x-rays of the right and left wrist are shown in Figures
1 and 2. She would like to preserve some motion
so she can play Guitar Hero with her grandchildren.
The surgical plan supported by the current literature
which is consistent with her wishes would be:
A. Right silicone arthroplasty and left wrist fusion
B. Right wrist fusion and left proximal row carpectomy
C. Right total wrist arthroplasty and left wrist fusion
D. Right wrist fusion and left silicone arthroplasty
E. Right proximal row carpectomy and left wrist fusion
Preferred Response: C
Dicussion: Rheumatoid arthritis can be a crippling disease
which presently does not have a cure. When patients have
disease progression (despite non-operative measures) and
they desire pain-relief and functional improvement, then
surgery is indicated. While wrist fusions have been the “gold
standard” for end-stage rheumatoid wrist disease, the present
generation of wrist replacements appears to have addressed
a number of problems, such as component loosening and
instability (as reported by Adams). Considering the present
literature and patient wishes, the plan of a wrist fusion on
the non-dominant side with arthroplasty on the dominant
side would be appropriate. A proximal row carpectomy and
silicone wrist replacement would be contraindicated.
References:
1. Herzberg G. Management of bilateral advanced rheumatoid
wrist destruction. J Hand Surg 2008;33A:1192-1196.
2. Divelbiss BJ, Sollerman C, Adams BA. Early results of the
universal total wrist arthroplasty in rheumatoid arthritis. J Hand
Surg 2002;27A:195-204.
Figure 1 Figure 2
2010 Self-Assessment Examination | 51
 116. A 45 year-old right hand dominant man presents
with a burn contracture of his first web space after
contacting a steam pipe at home. There is 1-2 cm.
ulceration in the mid-web and this is the same hand
which had an open TFC repair one year ago. Pre-
operative angiography shows an incomplete palmar
arch. He wants a single-stage reconstruction. An
appropriate procedure would be:
A. Radial forearm flap
B. Dorsal ulnar artery flap (Becker flap)
C. Double opposing Z-plasty (jumping man flap)
D. 1st dorsal metacarpal artery flap
E. Posterior interosseous flap
Preferred Response: B
Discussion: In the scenario presented, a thumb web
space contracture with unstable skin, a local flap such as
a z-plasty would not give reliable coverage or restore web
span. With an incomplete arch, a radial forearm flap may
cause loss of vascularity to all or part of the hand. A 1st
dorsal metacarpal artery flap does not provide enough
tissue to resurface the web. A posterior interosseous flap
would be a reasonable choice, but with prior surgery at
the ulnar wrist, the vascular connection needed for pedicle
transfer may not be present. This leaves the dorsal ulnar
artery flap as the only viable choice. It is useful to have in
the armamentarium for this problem (Figure 1-3).
References:
1. Page R, Chang J. Reconstruction of hand soft-tissue defects:
alternatives to the radial forearm fasciocutaneous flap. J Hand
Surg 2006;31A:847-56.
2. Antonopoulos D, Kang NV, Debono R. Our experience with
the use of the dorsal ulnar artery flap in hand and wrist tissue
cover. J Hand Surg 1997;22B:739-44.
Figure 1
Figure 2
52 | American Society for Surgery of the Hand
Figure 3
117. The cell type associated with the development of a
Dupuytren’s contracture is:
A. Myofibroblast
B. Fibroblast
C. Osteoblast
D. Dermoblast
E. Pluripotential stem cell
Preferred Response: A
Discussion: The Myofibroblast is the cell line which has
been identified as the cell type in a Dupuytren’s contracture.
References:
1. McFarlane RM. The current status of Dupuytren’s disease.
J Hand Surg 1983;8:703-708.
2. Hueston JT. Dupuytren’s contracture. In: Flynn JE, ed. Hand
surgery. Baltimore: Williams & Wilkins, 1982:797-823.
118. A 37 year-old man has been transferred to you in a
posterior splint, one week after undergoing open
reduction and internal fixation of a right elbow
fracture dislocation sustained while break dancing.
The operative report documents anatomic repair of
a 50% vertical height coronoid fracture and a radial
head fracture. The current x-rays show a concentric
reduction. The lateral ulnar collateral ligament (LCL)
was firmly repaired, but the surgeon did not repair the
medial collateral ligament (MCL). Under anesthesia,
the elbow was reported to be stable in an arc of
20° short of full extension to 140° flexion. The most
appropriate program now is:
A. No therapy at present. Continue splinting for 6 weeks
B. No therapy at present. Continue splinting for 12 weeks
C. Return to OR to repair the medial ligaments
D. Begin motion now with the elbow in an arc of -20 to
140 with the forearm pronated
E. Begin motion now with the elbow in an arc of -20 to
140 with the forearm supinated
Preferred Response: E
Discussion: The patient has undergone repair for a “terrible
triad” injury to his elbow. By definition and the clinical
scenario presented, the medial collateral ligament has
been torn. Dr. Forthman has shown these injuries can be
managed with early motion, without repairing the medial
collateral ligament. Fracture fixation and lateral collateral
ligament repair allows early motion to commence. Dr.
Matthew and co-authors have reported early motion can
be used in MCL- and LCL-deficient elbows. If the MCL is
deficient and the LCL has been repaired firmly, keeping the
forearm supinated assists in elbow stabilization. In an LCL-
deficient elbow with MCL repair or continuity, the forearm
should be pronated to aid in stability. Since the LCL has
been repaired, shoulder abduction should be avoided to
keep stress off the ligament repair.
References:
1. Forthman C, Henket M, Ring D. Elbow dislocation with
intra-articular fracture: The results of operative treatment
without repair of the medial collateral ligament. J Hand Surg
2007;32A:1200-1209.
2. Matthew P, Athwal G, King GJW. Terrible triad injury of the
elbow: Current Concepts. JAAOS 2009;17:137-151.
119. A 45 year-old part-time cashier is scheduled to
undergo a right carpal tunnel release. Her pre-
operative nerve conduction studies reveal sensory
latencies just above normal values with normal
motor studies and a normal EMG. She has had
difficulties with co-workers and has been on anti-
depressant medication for over one year. She rates
her pain as a 10 on a 10 point pain scale. Based on
current literature, what is her expected outcome?
References:
1. Lozano Calderon S, Paiva A, Ring D. Patient satisfaction after
open carpal tunnel release correlates with depression. J Hand
Surg 2008;33A:303-307.
2. Pomerance J. Return to work in the setting of upper extremity
illness. J Hand Surg 2009;34A:137-141.
120. A 16 year-old male sustains a closed elbow injury
following a dirt bike accident. Radiographs and CT
scan of the elbow are obtained (Figures 1 and 2). What
is the recommended treatment for this isolated injury?
A. Closed reduction and pinning
B. Cast immobilization
C. Closed reduction and percutaneous screw fixation
D. Application of hinged brace with early range of motion
E. Open reduction and internal fixation
Preferred Response: E
Discussion: The patient has sustained a fracture of the
lateral column with intra-articular extension. Imaging studies
confirm intra-articular displacement. In order to achieve
anatomic reduction of the joint, an open approach is
required. Moderate comminution of the fracture including the
lateral epicondyle is present, requiring plate stabilization.
References:
1. Rizzo M, Nunley JA. Fractures of the elbow’s lateral column
radial head and capitellum. Hand Clin 2002;18(1):21-42.
2. Henley MB, Bone LB, Parker B. Operative management of
intra-articular fractures of the distal humerus. J Orthop Trauma
1987;1:24.

A. It is unclear if her pain complaints and depression will

affect outcomes
B. Placing her on short term disability will resolve her
work issues
C. Her near normal nerve conduction study predicts
consistently good outcomes
D. Factors are present which may negatively affect
surgical outcome
E. While return to work may be delayed, her surgery
outcomes should be equal to other patients with
similar nerve conduction study findings Figure 1
Preferred Response: D
Discussion: The patient presents with multiple factors
which have been shown to negatively affect patient
outcomes and return to work. These would include pain
catastrophizing, depression, and poor coping mechanisms.
Depression and poor coping mechanisms have been shown
to predict patient dissatisfaction after open carpal tunnel
release. Similarly, these same factors, along with pain out of
proportion (pain catastrophizing) prolong return to work.
Figure 2

2010 Self-Assessment Examination | 53

 121. A patient undergoes arthroscopic elbow capsular
release for a post-traumatic contracture. Post-
operatively, the patient reports new onset of altered
sensation in the ring and small finger. Examination
of the operated extremity demonstrates weakness
of the ulnar innervated intrinsic muscles and absent
sensation in the small finger and ulnar aspect of the
ring finger. The nerve injury most likely occurred
during which portion of the procedure?
A. Arthroscopic anterior capsular release
B. Establishment of the proximal anteromedial portal
C. Establishment of the posterocentral portal
D. Arthroscopic release of the posterior band of the
medial collateral ligament
E. Osteophyte debridement of the posterior
lateral olecranon
Preferred Response: D
Discussion: In cases of severe elbow flexion contracture,
scarring of the ulnar nerve may take place between the
ulnar nerve and the posterior band of the medial collateral
ligament. Arthroscopic release of the posterior band places
the ulnar nerve at risk. The radial nerve is at greatest risk
during anterior capsular release. The ulnar nerve is in close
proximity to the posterocentral and proximal anteromedial
portals. However, nerve injury is avoidable with careful
portal placement.
References:
1. Evans PJ, Nandi S, Maschke S, Hoyen HA, Lawton JN. Prevention
and treatment of elbow stiffness. J Hand Surg 2009;34A:769-778.
2. O’Driscoll SW. Arthroscopic osteocapsular arthroplasty.
In: Yamaguchi K, King GJW, McKee MD, O’Driscoll SW, eds.
Advanced reconstruction elbow. Rosemont, IL: American
Academy of Orthopaedic Surgeons, 2007:59-68.
122. Which of the following study designs is consistent
with the highest level of evidence (Level I)?
A. Case Series without controls
B. Meta-analysis of randomized trials
C. Expert opinion
D. Prospective cohort series
E. Meta-analysis of case controlled studies
Preferred Response: B
Discussion: Five levels of quality of evidence have been created
to assess studies. The highest level of evidence (Level I) is
represented by large randomized clinical trials or meta-analysis
of randomized trials with low error risk. Level II evidence comes
from randomized trials with high error risk or prospective cohort.
Level III is represented from case-controlled studies. Level
IV is represented by case series without controls. Expert
opinion is consistent with level V evidence.
54 | American Society for Surgery of the Hand
References:
1. Szabo RM, MacDermid JC. Evidence-Based Practice. Hand
Clin 2009 Feb;25(1):1-14.
2. Hatala R, Keitz S, Wyer P, et al. Tips for learners of evidence-
based medicine: 4. Assess heterogeneity of primary studies in
systematic reviews and whether to combine their results. CMAJ
2005;172(5):661-5.
123. A 25 year-old male presents 6 weeks following
traumatic amputation to his dominant hand
(Figure 1). Radiographs of the involved hand are
demonstrated (Figure 2). Which of the following is
the best reconstructive option for the thumb?
A. Distraction lengthening
B. Radial forearm flap
C. Web Space deepening
D. Toe-to-thumb transfer
E. Osteoplastic thumb reconstruction
Preferred Response: D
Discussion: The patient has sustained an amputation
through the proximal portion of the thumb metacarpal.
Soft tissue loss at this level requires complete thumb
reconstruction. Pollicization is not possible in this case.
Microvascular reconstruction with great toe or second toe
transfer is the best option (Figure 3). In cases of amputation
through the middle third of the thumb: metacarpal
lengthening, web space deepening, dorsal rotational flap or
osteoplastic thumb reconstruction can be considered.
References:
1. Shin AY, Bishop AT, Berger RA. Microvascular reconstruction of
the traumatized thumb. Hand Clin 1999;15:347-371.
2. Chung KC, Wei FC. An outcome study of thumb reconstruction
using microvascular toe transfer. J Hand Surg 2000;25A:651-658.
Question 123, Figure 1

Question 123, Figure 2
Question 123, Figure 3
124. A 35 year-old patient sustained a traumatic brain
injury 20 months ago and presents with a clenched
fist. Dynamic EMG demonstrates volitional control
of the extrinsic flexors. There is no evidence of
skin maceration or wrist flexor contracture on
examination. What is the recommended treatment to
improve the patient’s hand function?
A. Superficialis-to-profundus tendon transfer
B. Fractional lengthening of the flexor digitorum
profundus tendons
C. Flexor pronator slide
D. Dynamic splinting
E. Phenol injection
Preferred Response: B
Discussion: Fractional lengthening of the long flexors is
the surgical treatment of choice, since volitional control
was identified on EMG. A more extensive lengthening with
superficialis-to-profundus transfer is indicated in the absence
of volitional motion and with severe skin breakdown of the
palm. Botulinum toxin may be used in the recovery phase to
modulate spasticity. Phenol causes permanent nerve injury
and is not indicated during the recovery phase.
References:
1. Braun RM, Vise GT. Sublimus-to-profundus tendon transfers in the
hemiplegic upper extremity. J Bone Joint Surg 1973;55A:873.
2. Hisey MS, Keenan ME. Orthopaedic management of upper
extremity dysfunction following stroke or brain injury. In: Green
DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative
Hand Surgery. 4th ed. Philadelphia: Churchill Livingstone,
1999:316-318.
125. A 45 year-old male sustained an eccentric load to
the arm two days ago. He presents with pain and
ecchymosis within the antecubital fossa of the elbow.
An MRI of the elbow was obtained (Figure 1). The
axial image demonstrates which of the following?
A. Brachialis strain
B. Normal appearance of the distal biceps tendon
C. Partial tearing of the distal biceps tendon
D. Complete tearing of the distal biceps tendon
E. Disruption of the lacertus fibrosis
Preferred Response: C
Discussion: MRI imaging for distal biceps tendon injuries
may be useful when clinical exam is equivocal. The axial
image of the radial tuberosity is the most helpful view to
define distal biceps pathology. Figure 1 demonstrates
increased fluid surrounding the distal biceps with partial
loss of the insertion. Studies have demonstrated high
sensitivity and specificity in the diagnosis of partial and
complete tears of the distal biceps utilizing MRI. Normal
appearance of the distal biceps insertion is shown in
Figure 2.
References:
1. Williams BD, Schweitzer ME, et al. Partial tears of the distal
biceps tendon: MR appearance and associated clinical
findings. Skeletal Radiol 2001;30(10):560-4.
2. Festa A, Mullieri PJ, Spitz DJ, Leslie BM. Effectiveness of
magnetic resonance imaging in detecting partial and complete
distal biceps tendon rupture. J Hand Surg 2010;35A:77-83.
Figure 1 Figure 2
2010 Self-Assessment Examination | 55
 126. Following operative repair of the distal biceps with
single incision endobutton fixation, the patient
reports painful numbness within the volar and
radial portion of the distal forearm. The most likely
explanation for the patient’s complaints is an injury
of which of the following nerves?
A. Superficial radial nerve
B. Posterior interosseous nerve
C. Anterior interosseous nerve
D. Lateral antebrachial cutaneous nerve
E. Palmar cutaneous branch median nerve
Preferred Response: D
Discussion: Performing a single incision endobutton
technique for a distal biceps repair places the lateral
antebrachial cutaneous nerve at risk during the approach. The
nerve should be identified with its superficial location exiting
between the brachialis and biceps tendon (Figure 1). Injury
may occur as result of laceration or secondary to excessive
retraction. Although the superficial radial nerve is at risk
with this procedure, the patient describes symptoms within
the distribution of the lateral antebrachial cutaneous nerve.
References:
1. Greenberg JA, Fernandez JJ, Wang T, Turner C. Endobutton-
assisted repair of distal biceps tendon ruptures. J Shoulder
Elbow Surg 2003;12(5):484-490.
2. Cohen MS. Complications of distal biceps tendon repairs.
Sports Med Arthrosc 2008;16(3):148-53.
Figure 1
56 | American Society for Surgery of the Hand
127. In a patient following ORIF of a both bones forearm
fracture, which factor is most associated with
refracture following hardware removal?
A. Transverse fracture of the radius
B. Hardware removal after one year
C. Use of 4.5 mm plates
D. Use of 3.5 mm plates
E. Use of locking plates and screws
Preferred Response: C
Discussion: Hardware removal following both bone
forearm fractures should be strongly discouraged. Mih
and colleagues reported an 11% refracture rate following
forearm hardware removal. The average time for refracture
was 6 months. In addition, hardware removal did not
predictably improve symptoms and there was a four
times higher complication rate in patients who underwent
hardware removal, compared to those that did not. Risk
factors for fracture following hardware removal include:
early plate removal (< 1yr), fractures with initial comminution,
and the use of 4.5mm plates.
References:
1. Mih AD, Cooney WP, Idler RS, et al. Long-term follow-up
of forearm bone diaphyseal plating. Clin Orthop Rel Res
1994;299:256-8.
2. Moss JP, Bynum DK. Diaphyseal fractures of the radius and
ulna in adults. Hand Clin 2007;23:143-51.
128. Figures 1-5 demonstrate a 45 year-old male who has
been diagnosed with a plasmacytoma. What is the
most appropriate treatment?
A. Curettage, open reduction and internal fixation,
bone grafting, and radiation
B. Curettage and bone grafting following fracture healing
C. Curettage, phenol and polymethylmethacrylate
D. Chemotherapy, above elbow amputation
E. Chemotherapy, radical wide excision
Preferred Response: A
Discussion: Plasmacytoma is a marrow plasma cell tumor
characterized by overproduction of an intact monoclonal
immunoglobulin, or free monoclonal kappa or lambda
chains. The lesion is expansile and has features of
malignancy. The appropriate treatment for the lesion is to
stabilize the fracture with bone grafting or PMMA. Following
fracture fixation and wound healing, these lesions can be
treated with radiation therapy. Lesions with no fracture
may be treated with radiation alone. Two thirds of solitary
plasmacytomas progress to multiple myeloma.
References:
1. Dimopoulos MA, Hamilos G. Solitary bone plasmacytoma
and extramedullary plasmacytoma. Curr Treat Options Oncol
2002;3:255-9.
2. Ellis PA, Colls BM. Solitary plasmacytoma of bone: Clinical
features, treatment and survival. Hematol Oncol 1992;10:207-11.
Question 128, Figure 1 Question 128, Figure 2
Question 128, Figure 3 Question 128, Figure 4
Question 128, Figure 5
129. Which of the following conditions or considerations
is associated with a higher risk of neurovascular
injury in patients undergoing elbow arthroscopy?
A. Obesity with a BMI greater than 40%
B. Tourniquet time of greater than 1 hour
C. History of prior surgery
D. Elbow joint contracture
E. Osteophytosis of the coronoid
Preferred Response: D
Discussion: In a large review of elbow arthroscopy
and its complications, Kelly et al noted that the factors
significantly associated with increased transient nerve
injury were rheumatoid arthritis, a joint contracture and the
performance of a capsulotomy. The authors also found
that a prolonged tourniquet time was noted in patients with
nerve complications, but it was not statistically significant.
A history of prior nerve transposition or surgery that
distorts the elbow anatomy is considered by many to be a
contraindication to elbow arthroscopy.
References:
1. Kelly EW, Morrey BF, O’Driscoll SW. Complications of elbow
arthroscopy. J Bone Joint Surg 2001;83A:25-34.
2. Dodson CC, Nho SJ, Williams RJ, Altchek DW. Elbow
arthroscopy. J Am Acad Orthop Surg 2008;16:574-85.
130. A 48 year-old male presents with acute pain in his
nondominant arm following forced elbow flexion.
Clinical exam demonstrates significant pain with
resisted supination, but no obvious deformity. His
elbow MRI is shown in Figures 1 and 2. What is the
most appropriate initial treatment?
A. Injection
B. Immobilization
C. Surgical debridement
D. Surgical release
E. Surgical repair
Preferred Response: B
Discussion: Figures 1 and 2 show a partial biceps tendon
rupture. While the definitive surgical treatment remains
debated and depends on the level of patient activity and
functional demands, most surgeons agree that a trial of
non-operative treatment is an excellent first choice in
management. Immobilization for 2-3 weeks has been shown
to be effective followed by protected range of motion.
References:
1. Bourne MH, Morrey BF. Partial ruptures of the distal biceps
tendon. Clin Orthop Rel Res 1991;271:143-8.
2. Durr HR, Stabler A, Pfahler M, et al. Partial rupture of the distal
biceps tendon. Clin Orthop Rel Res 2000;374:195-200.
3. Ramsey ML. Distal biceps tendon injuries: Diagnosis and
management. JAAOS 1999;7:199-207.
Figure 1 Figure 2
2010 Self-Assessment Examination | 57
 131. What characteristic differentiates an aneurysm from
a pseudoaneurysm?
A. The presence of a thrombus
B. Dilation of the vessel
C. The presence of a pulsatile mass
D. Association with acute or repetitive trauma
E. Weakening of the internal elastic lamina of the artery
Preferred Response: E
Discussion: Aneurysms may be classified into (1) true or (2) false
or pseudoaneurysms. False aneurysms are generally the result
of penetrating trauma, are eccentric, and tend to have a lumen
that is contiguous with the arterial lumen that has no endothelial
layer lining. True aneurysms are more symmetric and tend to
occur in response to a repetitive trauma that results in gradual
dilation of the vessel. They are associated with a weakening of
the internal elastic lamina of the artery. Both may present as a
dilated vessel, pulsatile mass and have an associated thrombus.
References:
1. Rush D, Koman A, et al. Other disorders of the upper extremity.
In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds.
Green’s Operative Hand Surgery. 5th ed. Philadelphia: Churchill
Livingstone/Elsevier, 2005:2300-2.
2. Koman LA, Urbaniak JR. Ulnar artery thrombosis. Hand Clin
1985;3:11-25.
133. What is the typical amount of lengthening that can
be obtained with this technique shown in Figure 1?
A. 10 mm
B. 20 mm
C. 30 mm
D. 40 mm
E. 50 mm
Preferred Response: C
Discussion: Metacarpal lengthening, with and without bone
grafting for partial thumb amputations, can help afford
improved length and function in patients. They are generally
indicated for amputations through the middle or proximal
one-third of the phalanx. The average amount of length that
can be afforded is approximately 30 mm.
References:
1. Finsen V, Russwurm H. Metacarpal lengthening after traumatic
amputation of the thumb. J Bone Joint Surg 1996;78B:133-6.
2. Zimmerman R, et al. Functional outcome with special attention
to the DASH questionnaire following callus distraction and
phalangization of the thumb after traumatic amputation in the
middle one-third. Arch Orthop Trauma Surg 2003;123:521-6.

132. Examples of osteoinductive bone graft

substitutes include:
A. Bone morphogenic protein-2
B. Hydroxyapatite
C. Collagen
D. Beta-tricalcium phosphate
E. Marine coral
Preferred Response: A
Discussion: Alternative options to bone autograft include
cadaveric allograft and bone graft substitutes. Bone graft
material may possess osteoconductive and/or osteoinductive
properties. Osteoconductive material is thought to provide Figure 1
a scaffold to support new bone formation in a process
of graft incorporation known as creeping substitution.
Osteoinductive material stimulates a biological response to
differentiate primitive mesenchymal cells into osteoblasts.
Bone morphogenic proteins are known osteogenic proteins.
Hydroxyapatite is a ceramic-containing calcium phosphate
and has no known osteoinductive properties. Collagen,
beta-tricalcium phosphate, and coralline substitutes are all
osteoconductive to varying degrees.
References:
1. Khan SN, Fraser JF, Sandhu HS, et al. Use of osteopromotive
growth factor demineralized bone matrix and ceramics to enhance
spinal fusions. J Am Acad Orthop Surg 2005;13:129-137.
2. Finkemeier CG. Bone-grafting and bone-graft substitutes.
J Bone Joint Surg 2002;84A:454-464. Figure 2

58 | American Society for Surgery of the Hand

134. Which of the following agents is used at the site of a
mechlorethamine chemotherapy extravasation?
A. Dexrazoxane administered intravenously at the site
away from the extravasation site
B. Dimethyl sulfoxide applied topically with a cotton
swab or gauze
C. Hyaluronidase injected either through the existing IV
or subcutaneously at the extravasation site
D. Sodium thiosulfate with sterile water injected at the
extravasation site
E. Glucocorticoid injection into the extravasation site
Preferred Response: D
Discussion: Chemotherapy extravasation can lead to a
significant amount of morbidity, depending on the agent
and the amount infiltrated. Antidotes for some common
chemotherapeutic agents include: (1) Sodium thiosulfate for
mechlorethamine infiltration (and optionally for cisplatin), (2)
Hyaluronidase injection for plant alkaloids (such as vincristine
and vinblastine), and (3) topical Dimethyl sulfoxide (DMSO)
and intravenous dexrazoxane for anthracyclines.
Vesicant Extravasation Antidotes and Treatment
Agent Antidote/Treatment
Mechlorethamine Sodium Thiosulfate
Anthacyclines Dimethyl sulfoxide (DMSO)
Dexrazoxane
Plant Alkaloids Hyaluronidase
References:
1. Schulmeister L. Extravasation management. Semin Oncol Nurs
2007;23:184-90.
2. Goolsby TV, Lombardo FA. Extravasation of chemotherapeutic
agents: Prevention and treatment. Semin Oncol 2006;33:139-43.
3. Dorr RT. Antidotes to vesicant chemotherapy extravasations.
Blood Rev 1990;4:41-60.
135. Postoperative therapy options following the repair
of a zone 6 extensor tendon laceration include
dynamic or static splinting. The literature comparing
the outcomes of dynamic versus static splinting
following the repair of a zone 6 extensor tendon
laceration reports that dynamic splinting yields:
A. A higher incidence of tendon re-ruptures
B. Better long-term (greater than one year) range-of-motion
C. Better short-term (8 weeks) strength
D. Better long-term (greater than one year) strength
E. Worse long-term (greater than one year) strength
Preferred Response: C
Discussion: Dynamic and static splinting were compared
in a prospective study for zone 5 and 6 extensor tendon
injuries by Mowlavi et al. The authors noted improved short-
term range-of-motion and strength in the group treated
with dynamic splinting. However, in the long-term, strength
and range-of-motion were not statistically significant.
Dynamic splinting does not appear to result in increased
complications for injuries in these zones.
References:
1. Mowlavi A, Burns M, Brown RE. Dynamic versus static splinting
of simple zone V and zone VI extensor tendon repairs:
A prospective, randomized, controlled study. Plast Reconstr
Surg 2005;115:482-7.
2. Chow JA, Dovelle S, Thomes LJ, Ho PK, Saldana J.
A comparison of results of extensor tendon repair followed by
early controlled mobilization versus static immobilization.
J Hand Surg 1989;14B:18-20.
136. The optimal treatment for a patient who has a remote
history of mallet finger now with a long finger swan
neck deformity with 45° hyperextension of the PIP
joint that is passively correctable but cannot be
overcome with active finger flexion is:
A. Arthrodesis of the PIP joint
B. Reconstruction of the oblique retinacular ligament
C. Superficialis hemitenodesis of the PIP joint
D. Percutaneous pinning of the DIP joint in flexion
E. Percutaneous pinning of the PIP and DIP joint in extension
Preferred Response: B
Discussion: The single procedure among the options that
addresses both the PIP and DIP joints is reconstruction
of the oblique retinacular ligament. It will help correct
the hyperextension deformity of the PIP and the flexion
deformity of the DIP joint. All of the other treatment options
are either incomplete or incorrect.
References:
1. Thompson JS, Littler JW, Upton J. The spiral oblique retinacular
ligament (SORL). J Hand Surg 1978;3:482-7.
2. Kleinman WB, Petersen DP. Oblique retinacular ligament
reconstruction for chronic mallet finger deformity. J Hand Surg
1984;9:399-404.
2010 Self-Assessment Examination | 59
 137. Which of the following hand conditions or
deformities is associated with systemic lupus
erythematosis (SLE)?
A. Ankylosis of the PIP joint
B. Boutonniere deformity of the PIP joint
C. Hyperlaxity of the finger joints
D. Thumb adduction contracture
E. Fixed subluxation and dislocation of the MP joints
Preferred Response: C
Discussion: Ligamentous laxity is the primary characteristic
of the fingers in patients with SLE. It often results in
hyperlaxity and incompetence of the fingers and MP joint
of the thumb. Generally speaking these patients are not
likely to ankylose and develop contractures. Swan-neck
deformity, rather than boutonniere deformities, are more
associated with SLE.
References:
1. Bleifeld CJ, Inglis AE. The hand in systemic lupus
erythematosis. J Bone Joint Surg 1974;56:1207-15.
2. Dray GJ. The hand in systemic lupus erythematosis. Hand Clin
1989;5:145-55.
138. The effect of physical training on the structure and
function of muscle tissue is?
A. Potential force of muscular contraction is directly
proportional to the increase in muscle cross sectional
area produced by training
B. The velocity of muscular contraction is inversely
proportional to the change in muscle fiber length
produced by training
C. Physical training results in the production of additional
muscle fibers which leads to increased force of
muscular contraction
D. Physical training produces a change in muscle fiber
type within a single muscle
E. The force of muscular contraction increases with
training as the velocity of contraction increases
Preferred Response: A
Discussion: The force of muscular contraction is directly
proportional to the cross sectional area and inversely
proportional to the velocity of contraction. Longer muscular
fibers are able to contract more rapidly than shorter ones.
Physical training results in hypertrophy of muscle fibers, but
not production of additional ones, and does not lead to a
change in fiber type within a given muscle.
Referrences:
1. Huard J, et al. Muscle injuries and repair: Current trends in
research. J Bone Joint Surg 2002;84A:822-832.
2. Mariet E. Essentials of human anatomy and physiology. 9th ed.
Addison Wesley Publishing, 2008: 312-320.
60 | American Society for Surgery of the Hand
139. The most likely anatomical explanation for a
posturally abducted small finger in a patient with a
neurotmetic injury to the ulnar nerve 2 cm proximal
to the medial humeral epicondyle is:
A. Loss of function of the fourth dorsal interosseous muscle
B. Preservation of flexor digitorum superficialis function
in the small finger
C. Unopposed pull of the abductor digiti minimi muscle
D. Preservation of radial nerve function
E. Intact function of the third palmar interosseous muscle
Preferred Response: D
Discussion: The abducted small finger in high (proximal)
ulnar nerve palsy (Wartenberg’s sign) occurs in
approximately 50% of patients with this injury. It is thought
to be caused by the preservation of function in the radially-
innervated extensor digiti minimi muscle, which may have
an attachment to the abductor tubercle of the proximal
phalanx of the small finger or an unbalanced ulnar slip
of the extensor digiti minimi tendon. The loss of the third
palmar interosseous and lumbrical to the small finger
allows unopposed abduction and extension to occur by the
extensor digiti minimi tendon. The abductor digiti minimi
muscle is denervated in ulnar nerve palsy. The fourth dorsal
interosseous, which is also denervated, is an abductor of
the ring finger.
References:
1. Gonzalez MH, et al. The extensor tendons to the little finger:
An anatomic study. J Hand Surg 1995;20A:844-847.
2. Chung MS, et al. Extensor indicis proprius transfer for the
abducted small finger. J Hand Surg 2008;33A:392-397.
140. A 35 year-old carpenter presents with wrist pain,
cold intolerance, ring and small finger numbness,
and tingling of insidious onset. Figures 1-3
demonstrate his arteriogram. His intraoperative photos
(pre and post-reverse vein grafting) are shown.
Which factor is associated with improved long-term
patency of the graft?
A. Symptoms less than 2 years in duration
B. Non-dominant extremity involvement
C. Male gender
D. The use of a lower extremity vein graft
E. Life-long use of Persantine
Preferred Response: D
Discussion: The patient shown has ulnar artery thrombosis
and underwent reverse saphenous vein grafting. Melhoff
and Wood demonstrated that factors associated with
improved prognosis regarding long-term patency of the
reconstruction included: the use of a lower extremity graft,
duration of symptoms for less than five months, obstruction
secondary to a single traumatic event, and cessation of
smoking. Most of these conditions involve males and
affect the dominant extremity. While the definitive surgical
treatment of ulnar artery thrombosis is somewhat debated,
successful arterial reconstruction has been shown to
improve function, symptoms, and patient related outcomes.
References:
1. Melhoff TL, Wood MB. Ulnar artery thrombosis and the role
of interposition vein grafting: Patency with microsurgical
technique. J Hand Surg 1991;16:174-8.
2. Chloros GD, et al. Post-traumatic ulnar artery thrombosis:
Outcome of arterial reconstruction using reverse interpositional
vein grafting at 2 years minimum follow-up. J Hand Surg
2008;33:932-40.
Question 140, Figure 1
Question 140, Figure 2
Question 140, Figure 3
141. A 24 year-old man was involved in a motorcycle
racing accident. He hit a brick embankment at
approximately 60 mph. His only musculoskeletal
injury is a fracture of the trapezial body. The
fracture is associated with subluxation of the thumb
metacarpal. There is no associated fracture of
the metacarpal. He is treated with open reduction
and pin fixation of the fracture-dislocation and
anatomical alignment is restored. The pins
are removed in 6 weeks and joint alignment is
maintained. Two years after the injury he is most
likely to complain of:
A. Loss of pinch strength
B. Pain
C. Difficulty writing
D. Decreased range of motion of his thumb
E. Inability to work
Preferred Response: B
Discussion: In the largest single series published about this
injury, the most common problem was residual pain. Many
patients also complained of loss of grip strength, however,
objective measures demonstrated no difference in grip or
pinch strength compared to the contralateral uninjured side.
Surprisingly, loss of pinch strength and functions requiring
pinch were rare subjective complaints. Thumb and wrist
range-of-motion were unaffected by the injury.
References:
1. McGuigan FX, Culp RW. Surgical treatment of intra-articular
fractures of the trapezium. J Hand Surg 2002;27A:697-703.
2. Colman M, Mass DP, Draganich LF. Effects of deep anterior
oblique and dorsoradial ligaments on trapeziometacarpal joint
stability. J Hand Surg 2007;32A:310-317.
2010 Self-Assessment Examination | 61
 142. A 50 year-old woman complains of swelling in her
dominant right long finger and pain in her small
finger. She relates no history of trauma. She has
had occasional low-grade fever, a dry cough
but no other constitutional symptoms. Physical
examination reveals flexor tenosynovitis without
erythema in the long finger. There is a raised,
erythematous nodule at the dorsal base of the
small finger. There are no other hand deformities.
Sensibility is intact. She also has several small,
raised tender nodules on her nose and cheeks.
A hand x-ray demonstrates a lytic, moth eaten
appearance of the proximal phalangeal base. No
fractures are seen. A biopsy of the nodule and
tenosynovium is performed revealing non-caseating
granulomas without acid-fast bacilli. There is no
endarteritis. Tissue cultures are negative. In addition
to chest x-ray and blood tests, the most appropriate
treatment for this patient is:
A. Place a PPD test to rule out miliary tuberculosis
B. Triple antibiotic therapy for tuberculosis
C. Antibiotic therapy for tertiary syphilis
D. Synovectomy, debridement of the bone lesion,
followed by antibiotic therapy for atypical
mycobacterial infection
E. Oral corticosteroid therapy
Preferred Response: E
Discussion: This patient presents with features typical for
sarcoidosis. It occurs in the United States approximately
ten times more frequently in women than men, and about
five times more commonly in African American women
than white women. The etiology is unknown. Bilateral hilar
lymphadenopathy is present in 90% and accounts for the
cough. Patients with sarcoidosis and miliary tuberculosis
are anergic, so a PPD will be negative in both. Absence of
acid fast bacilli suggests a mycobacterial infection is less
likely. Most patients with tertiary syphilis have neurological
abnormalities and biopsies demonstrate endarteritis.
Operative excision of the sarcoid tissue frequently results
in a recurrence, and oral corticosteroids are the hallmark
of treatment.
References:
1. Wang HT, Sunil TM, Kleinert HE. Multiple unusual complications
after extensive chronic sarcoid tenosynovitis of the hand: A
case report. J Hand Surg 2005;30A:610-614. Although this is a
case report, it is a good review of the literature and has a good
reference list.
2. Gonzalez del Pino J, et al. Sarcoidosis of the hand and wrist.
J Hand Surg 1997;22A:942-945.
62 | American Society for Surgery of the Hand
143. For the past six months, a retired 84 year-old
man has had pain in his dominant left hand and
wrist. He awakens several times every night with
pain and numbness in his thumb, index and long
fingers. He has no thumb pain. Night splints do not
help. Pressure over the carpal tunnel reproduces
his painful symptoms. Electrophysiologic studies
demonstrate sensory latency of 8.5msec and
motor latency of 6.5msec. Fibrillations are found in
the abductor pollicis brevis muscle. A hand x-ray
demonstrates stage III trapeziometacarpal joint
osteoarthritis. Recommended treatment for long-
term improvement of function is:
A. Continued conservative treatment
B. Carpal tunnel release
C. Trapezial resection arthroplasty
D. Trapezial resection arthroplasty combined with carpal
tunnel release
E. Opponensplasty
Preferred Response: B
Discussion: Carpal tunnel release surgery for severe
median nerve compression in elderly patients has been
demonstrated to be effective in relieving painful symptoms.
In a prospective clinical outcome study that examined
75 elderly patients with severe carpal tunnel syndrome,
there was statistically improved function in activities of
daily living, work performance, overall hand function, and
satisfaction with hand function. Sensory recovery is rarely
complete, and motor recovery is not expected. Painful
symptoms, especially nocturnal paresthesias, usually
improve and 90% of patients are satisfied with the outcome.
References:
1. Weber RA, Rude MJ. Clinical outcomes of carpal tunnel release
in patients 65 and older. J Hand Surg 2005;30A:75-80.
2. Leit ME, et al. Patient-reported outcome after carpal
tunnel release for advanced disease: a prospective and
longitudinal assessment in patients older than 70. J Hand Surg
2004;29A:379-383.
144. The most common problem related to transfer of
the posterior third of the deltoid to the triceps, in the
restoration of elbow extension in patients with a C5
functional level spinal cord injury is:
A. Rupture or stretching of the repair
B. Injury to the axillary nerve
C. Excursion provided by the deltoid is inadequate to
extend the elbow
D. Heterotopic ossification of the triceps
E. Ankle contracture after harvesting the tibialis
anterior tendon
Preferred Response: A
Discussion: The most common complication is stretching
or rupture of the repair. Post-operative immobilization of the
elbow in 10 degrees of flexion can help avoid this potential
problem. The 3 cm of deltoid excursion is adequate for
elbow extension, and the potential complication of deltoid
muscle denervation can be minimized by avoiding deep
muscle dissection within 5 cm of the lateral edge of the
acromion. Post-operative ankle contracture is best avoided
with casting for 4-6 weeks. Heterotopic ossification is a rare
complication.
References:
1. Hamou C, et al. Pinch and elbow extension restoration in
people with tetraplegia: a systematic review of the literature.
J Hand Surg 2009;34A:692-699.
2. Mulcahey MJ, et al. Prospective evaluation of biceps to triceps
and deltoid to triceps for elbow extension in tetraplegia. J Hand
Surg 2003;28A:964-971.
145. When treating a poorly-differentiated squamous cell
carcinoma of the dorsal hand in a 50 year-old male
laborer, the highest cure rates are achieved with
which treatment modality:
A. Surgical excision incorporating a 4 mm tumor
free margin
B. Surgical debulking (intralesional) followed by
cryosurgery with liquid nitrogen
C. Mohs micrographic surgery
D. Electrodessication and curettage
E. Photodynamic therapy
Preferred Response: C
Discussion: Although all of the answers have been used
for squamous cell carcinoma of the skin on the dorsum of
the hand, Mohs micrographic surgery has the highest cure
rate. It has the highest cure-rate for all non-melanoma skin
cancers. Surgical excision of aggressive lesions, defined
as poorly differentiated or greater than 2.5 cm, require
a 6 mm tumor free margin. The dorsum of the hand is
considered a high-risk lesion. Radiation therapy is indicated
as an adjuvant to surgery in cases of recurrent tumor, large
lesions (>2 cm), deep lesions (>4 mm), as well as those
with perineural invasion or regional nodal metastasis.
Consultation with a dermatologist should be considered in
all patients with squamous cell carcinoma.
References:
1. Hepper DM, et al. Treatment options for squamous cell
carcinoma of the dorsal hand including Mohs micrographic
surgery. J Hand Surg 2009;34A:1337-1339.
2. Scholtens REM, et al. Treatment of Recurrent Squamous Cell
Carcinoma of the Hand in Immunosuppressed Patients. J Hand
Surg 1995;20A:73-76.
2010 Self-Assessment Examination | 63
 146. A 36 year-old computer programmer injured his
dominant right wrist in a motorcycle accident. His
physical exam shows marked swelling in the wrist
with pain diffusely to palpation. The x-ray is shown in
Figure 1. The best treatment for this injury would be:
A. Closed reduction of radius and scaphoid and thumb
spica splint
B. Closed reduction percutaneous pin fixation of radius
fracture and thumb spica splint
C. Closed reduction of radius with external fixation and
thumb spica splint
D. Closed reduction of radius with percutaneous fixation
of scaphoid and long arm splint
Figure 1
E. Open reduction and internal fixation of all injuries
Preferred Response: E
Discussion: Combined distal radius and scaphoid injuries
are uncommon, generally high-energy injuries which occur
in patients between the 3rd and 5th decade. Several limited
series have reviewed treatment for these injuries. More
recent studies advocate internal fixation of both fractures in
order to initiate early rehabilitation. The distal radial fracture
is the prime determinant of outcome, and the radius fracture
treatment is the most important treatment consideration.
While closed treatment may be done in nondisplaced radial
fractures, displaced radial fractures are recommended for
Figure 2 Figure 3
internal fixation, with open or arthroscopic reduction. Screw
fixation of the scaphoid is recommended, considering bone
grafting if the scaphoid injury is comminuted or widely
displaced. Although there is concern about distraction 147. Figure 1 shows a mass found in a 38 year-old female
forces, either from reduction maneuvers or external with symptoms of carpal tunnel syndrome and nerve
fixation causing displacement and healing problems in conduction studies showing advanced median
the scaphoid, the literature is divided over whether this is nerve compression. The mass is a:
actually a clinical problem. A. Schwannoma
The ulnar styloid fracture was fixed to stabilize a distal radial B. Neurofibroma
ulnar joint, which was unstable after reduction and fixation C. Intraneural lipofibroma
of the radius. D. Giant Cell tumor
References: E. Synovial sarcoma
1. Rutgers M, Mudgal CS, Shin R. Combined fractures of the
distal radius and scaphoid. J Hand Surg 2008;33A:478-83. Preferred Response: C
2. Slade JF, Sudeep T, Safanda J. Combined fracture of scaphoid Discussion: Figure 1 shows an example of an intraneural
and distal radius fracture; a revised treatment rationale lipoma, or lipofibroma, of the median nerve. This sometimes
using percutaneous and arthroscopic techniques. Hand Clin
2005;21:427-41.
occurs with macrodactyly. The median nerve is most
commonly involved, although multiple other peripheral
3. Trumble TE, Benirschke SK, Vedder NB. Ipsilateral fractures of
the scaphoid and radius. J Hand Surg 1993;18A:8-14. nerves (including the ulnar nerve) have been reported.
Treatment is aimed primarily at decompression of the nerve
involved, although sometimes, debulking or resection is
indicated for neurologic deterioration.
References:
1. Camilleri IG, Milner RH. Intraneural lipofibroma of the median
nerve. J Hand Surg 1998;23B:120-22.
2. Houpt P, Storm van Leeuwen JB, van den Bergen HA.
Intraneural lipofibroma of the median nerve. J Hand Surg
1989;14A:706-9.

64 | American Society for Surgery of the Hand


Question 147, Figure 1
148. A 63 year-old diabetic male with renal failure on dialysis
presents with complaints of increasingly severe pain in
the hand. He has had multiple digital amputations for
nonhealing ulcers. The hand appears cyanotic to the
midpalm. The best level for amputation would be:
A. Metacarpal
B. Distal third forearm
C. Mid forearm
D. Proximal third forearm
E. Elbow disarticulation
Preferred Response: B
Discussion: Because of the relative rarity of upper extremity
amputation, most hand surgeons do not gain a great deal
of experience with this problem. Preserving limb length
is generally the best approach when selecting an upper
extremity amputation level.
In the forearm, preserving length will preserve forearm
rotation. Longer forearm levels better distribute forces
across the limb during daily activities, and may help with
residual limb pain, which limits prosthesis use. Studies have
shown that persons with distal upper extremity amputation
wore their prostheses more days per month than those
with a proximal amputation; also, that appearance of the
prosthesis is comparable in importance to its function for
those with upper limb loss.
While wrist disarticulation retains more forearm rotation,
it creates problems due to extra limb length. This may
restrict the type of components which can be attached as a
terminal device. In most cases, use the “three finger widths
rule” to determine the level from the wrist joint crease for a
transradial amputation.
Elbow disarticulation gives better rotational control than
a more proximal transhumeral level, and it optimizes
suspension. However, elbow function, in terms of weight
bearing and force distribution are not as good as an intact
elbow joint, so forearm levels are preferred if possible.
References:
1. Supan TJ. Active functional prostheses. Hand Clin 2003;19:185-191.
2. Lake C, Dodson R. Progressive upper limb prosthetics.
Phys Med Rehabil Clin N Am 2006;17:49-72.
3. Raichle KA, Hanley MA, Molton I, Kadel NJ, Campbell K, Phelps
MA, Ehde D, Smith DG. Prosthesis use in persons with lower and
upper limb amputations. J Rehabil Res Dev 2008;45(7):961-72.
149. A 21 year-old female presents with a history of blunt
trauma to the proximal forearm, two years prior
to exam. Since the injury, she has been unable to
extend any of her digits. She extends the wrist with
5/5 strength. Her neurological exam is otherwise
normal. The best choice for tendon transfers to
restore function to her hand would be:
A. PT to EDC, PL to EPL
B. FCU to EDC, FDS IV to APL
C. FCR to EDC, PL to EPL
D. ECU to EDC, PL to EPL
E. ECRB to EDC, FDS IV to APL
Preferred Response: C
Discussion: The patient has an injury to the posterior
interosseous nerve (PIN), and has intact radial wrist
extensor function. The pronator teres is used to restore
wrist extension, in radial nerve palsy; but in this example,
the patient does not need this restored.
The FCU is often used to motor the digital extensors in radial
nerve palsy, and is the strongest motor with better excursion
than the FCR. In PIN palsy, the radial wrist extensors still
function so that using the ulnar-sided wrist flexor in transfer
weakens the ulnar side, and leads to radial deviation of the
wrist, especially with wrist extension. The ECU muscle is
denervated in PIN palsy, and is of no use for transfer.
Although the ECRB can be transferred to give finger extension,
it is not optimal, as the strength and excursion are less than
the EDC. The thumb extension can be restored by transfer of
the PL to the EPL. This involves less donor deficit than taking
a superficialis tendon from the ring or long finger, which some
authors feel should be avoided in patients such as computer
workers (who require maximal autonomy of finger flexor function).
The FCR to EDC and PL to EPL will avoid radial deviation in
wrist extension. The FCR can be transferred either around the
radial side of the wrist, or through the interosseous membrane.
The PL will motor the rerouted EPL. This is the preferred
transfer in PIN palsy. An option for patients with absent PL
can be the FCR, split to motor both the fingers and thumb.
References:
1. Ropars M, Deano T Piret P, Belot N, Langlais F. Long term
results of tendon transfers in radial and posterior interosseous
nerve paralysis. J Hand Surg 2006;31B(5):502-506.
2. Chidgey LK, Szabo RM. Radial nerve palsy. In: Chapman MW,
ed. Chapman’s Orthopaedic Surgery. 3rd ed. Philadelphia:
Lippincott Williams & Wilkins, 2001: 1633-45.
2010 Self-Assessment Examination | 65
 150. A 52 year-old female complains of scissoring of the
fingers following a proximal phalangeal fracture
5 months prior to presentation. Her deformity is
shown in the clinical photo. The maximum expected
correction a rotational osteotomy at the metacarpal
level can achieve is approximately how many degrees?
A. 10
B. 20
C. 30
D. 40
E. 50
Preferred Response: B
Discussion: The treatment of phalangeal malunions is
difficult and may be compromised by stiffness, particularly
around the PIP joint. Many surgeons prefer to treat purely
rotational malunion with osteotomy at the metacarpal level
to avoid tendon adhesion and PIP stiffness. If the nonunion
is less than 10 weeks old, osteotomy through the fracture
site will reestablish the anatomy, and may be the best choice.
For a longer duration malunion of the metacarpal or phalanx,
metacarpal derotation osteotomy (either transverse or step cut)
has been show to improve alignment with little risk of motion
loss or joint stiffness, and it has demonstrated reliable healing.
In cadaver studies, Gross and Gelberman have shown the
deep metacarpal ligament limits the maximal rotation of
the digit to 19° in the index, long and ring, and 30° in the
little finger.
References:
1. Jawa A, Zucchini M, Lauri G, Jupiter J. Modified step-cut
osteotomy for metacarpal and phalangeal rotational deformity.
J Hand Surg 2009;34A:335-40.
2. Freeland AE, Lindley SG. Malunions of the finger metacarpals
and phalanges. Hand Clin 2006;22:341-55.
3. Ring D. Malunion and nonunion of the metacarpals and
phalanges. J Bone Joint Surg 2005;87A:1380-88.
4. Gross MS, Gelberman RH. Metacarpal rotational osteotomy.
J Hand Surg 1985;10A:105-108.
Figure 1
66 | American Society for Surgery of the Hand
151. The 33 year-old contractor pictured in Figure 1 had
an amputation of the thumb tip. The most common
complication as a result of the treatment shown in
the photo is:
A. Loss of length
B. Flap failure
C. Cold intolerance
D. Unstable skin coverage
E. Joint stiffness
Preferred Response: E
Discussion: The photo shows a cross-finger flap from the
index proximal phalanx dorsum to the thumb tip. This is a
reliable flap with low-risk of flap failure (30 of 31 successful
in one report). The flap can resurface moderate size defects
with good quality soft tissue coverage, and limit the loss
of length. Although cold intolerance occurs, the more
common complication is related to loss of motion in the MP
and IP joints.
Other coverage options to maintain sensibility also have
limitations. Palmar advancement is effective with pulp
defects up to 1.5cm, but may limit IP motion. Radial and
neurovascular island flaps have problems with donor site
neuromas, and cortical misrepresentation. The authors
below showed good recovery of protective sensation with
simple cross finger flap, and concluded that in comparison
to other, more complex innervated flaps, that it remains
uncertain if a greater surgical effort consistently delivers a
superior surgical outcome.
References:
1. Woon CY, Lee JY, Teoh LC. Resurfacing hemipulp losses of
the thumb: the cross finger flap revisited: indications, technical
refinements, outcomes and long term neurosensory recovery.
Ann Plast Surg 2008;61(4):385-91.
2. Hynes DE. Neurovascular pedicle and advancement flaps for
palmar thumb defects. Hand Clin 1997;13(2):207-16.
Figure 1
152. The 11 year-old female in Figure 1 has a contracture
of her small finger, which arose from a laceration at
age 3, after getting it caught in an exercise machine.
The limitation of passive extension is 25° at the PIP
and 15° at the DIP. The best reconstructive choice to
correct this contracture would be:
A. Z-plasty
B. Split thickness skin graft
C. Full thickness skin graft
D. Kite flap
E. Cross finger flap
Preferred Response: A
Discussion: This mild contracture is best served by the simplest
level of the reconstructive ladder. Z-plasties are transposition
flaps which require no distant donor site, no prolonged
immobilization, and they heal reliably. They will provide up
to a 75 percent increase in length with 60° angles, which will
adequately restore full extension in this case (Figure 2).
Skin grafting after scar release, with either full or partial
thickness, would be a better choice for more advanced skin
contracture. A neurovascular rotation flap, such as a kite flap,
is primarily indicated if there is tissue loss in the thumb—where
sensibility is desired. A cross-finger flap would be used only for
contractures so extensive that correction would expose deeper
structures, such as tendons and nerves that need coverage.
References:
1. Lehman TP, Petersen SL, Rayan GM. Soft tissue coverage of
the hand. In: Trumble TE, Budoff JE, eds. Hand Surgery Update
IV. Rosemont, IL: American Society for Surgery of the Hand,
2007:593-617.
2. Trumble TE, Vedder NB. Tissue Transfer: pedicle and free
tissue flaps. In: Trumble TE, ed. Principles of Hand Surgery and
Therapy. 1st ed. Philadelphia: WB Saunders, 2001:499-528.
Figure 1
Figure 2
153. The injury shown in Figures 1 and 2, occurred while
bench pressing. There is no pain at the elbow.
Appropriate management of this closed fracture
should include ORIF of the radius. After ORIF of
the radius what other important aspect should be
assessed intraoperatively?
A. Wrist flexion and extension
B. Elbow varus and valgus stability
C. Elbow flexion and extension
D. Stability of DRUJ
E. ROM of DRUJ
Preferred Response: D
Discussion: The x-ray shows a comminuted fracture of the
radial shaft and a fracture at the base of the ulnar styloid.
Accurate restoration of radial length and stable fixation
is the essential first step in treatment. Once the radius is
fixed, intraoperative assessment of the stability of the DRUJ
is essential. If unstable, consideration should be given to
fixation of the ulnar styloid fracture. This can be done with
percutaneous K-wires, cannulated screws, or tension band
technique. If no fracture is present, then repair of the TFCC
should be considered if the DRUJ is unstable. ROM of
the wrist, elbow, and DRUJ should also be assessed, but
are unlikely to be abnormal in the absence of elbow pain.
Elbow stability should also be checked, but is unlikely to be
a problem.
References:
1. Rettig ME, Raskin KB. Galeazzi fracture-dislocation:
a new treatment-oriented classification. J Hand Surg
2001;26A:228-35.
2. Giannoulis FS, Sotereanos DG. Galeazzi fractures and
dislocations. Hand Clin 2007;23(2):153-63.
Figure 1 Figure 2
2010 Self-Assessment Examination | 67
 154. Surgical anterior approach to expose the fracture
in Figures 1 and 2 in question 153 should be between
what two structures?
A. FCR and Median nerve
B. Radial artery and Brachioradialis
C. Brachioradialis and ECRL
D. ECRL and APL
E. FPL and FCR
Preferred Response: B
Discussion: Anterior or volar approach to the distal half of
the radius is through a volar incision over the FCR tendon.
Deeper dissection is between the Brachioradialis and the
Radial artery. Dissection between the FCR and Median
nerve in the distal forearm places the median nerve and
palmar cutaneous branch at risk. Dissection between the
Brachioradialis and ECRL places the radial sensory nerve
at risk and is not an internervous plane. This is true for
the ECRL and APL interval as well. The FPL is deep to the
FCR and needs to be reflected ulnarly to expose the radial
shaft. The insertion of the Pronator Teres will also need to
be reflected ulnarly. Exposure more proximal in the forearm
requires dissection between the brachioradialis and FCR,
as well as release of the supinator muscle.
References:
1. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics.
2nd ed. Philadelphia: Lippincott Williams & Wilkins, 1994:
120-123.
2. Agur AMR, Lee MJ. Grant’s Atlas of Anatomy. 10th ed.
Philadelphia: Lippincott Williams & Wilkins, 1999: 476-479.
155. A 45 year-old presents 4 months after cast
treatment for a distal radius fracture complaining
of an inability to make a fist. Clinical exam reveals
40° of wrist flexion and extension. MP joint motion
reveals full extension but only a 20° arc of both
active and passive flexion. Wrist position has no
effect on MP motion. The PIP joints lack only a few
degrees of extension with 90° of active flexion. The
most likely cause of the MP joint contracture is?
A. Extrinsic extensor tendon tightness
B. Extrinsic flexor tendon tightness
C. Intrinsic muscle tightness
D. MP capsular tightness
E. Oblique retinacular ligament tightness
Preferred Response: D
Discussion: Contracture of joints can develop after many
different types of trauma and determining its cause can be
difficult. In this case, no direct trauma to the hand is noted;
but immobilization, post-traumatic swelling, or reluctant
ROM of the fingers has led to an MP joint contracture.
68 | American Society for Surgery of the Hand
Careful exam is helpful in determining the contributing
factors causing contracture. Equal active and passive
ROM of a joint suggests that capsular tightness is the main
cause. Relatively good PIP motion and MP motion that is
unchanged by wrist position suggests that extrinsic flexor
or extensor tendons are not a significant factor in this MP
motion loss although the limited wrist motion must be
taken into account. Oblique retinacular ligament tightness
would tend to cause DIP extension and a flexed PIP joint.
Tightness of this ligament is suspected when the DIP joint
can be flexed only with PIP joint flexion. With the limited MP
motion, the classic Bunnell intrinsic muscle tightness test
cannot be performed; thus, intrinsic tightness cannot be
entirely ruled out. However, the good PIP motion suggests
that intrinsic tightness is not a major cause.
References:
1. Shin AY, Amadio PC. Stiff finger joints. In: Green DP, Hotchkiss
RN, Pederson WC, Wolfe SW, eds. Green’s Operative Hand
Surgery. 5th ed. Philadelphia: Churchill Livingstone/Elsevier,
2005:424.
2. Field PL, Hueston JT. Articular cartilage loss in long-standing
immobilization of the interphalangeal joints. Br J Plast Surg
1970;23:186-191.
156. Cold intolerance following a finger amputation will:
A. Resolve with time
B. Occur in one third of the patients
C. Be less likely with flap coverage
D. Be less likely if the digit is replanted
E. Be unaffected by surgical treatment
Preferred Response: E
Discussion: Cold intolerance is a common sequela to
any digital amputation. Multiple studies have reported
incidences of 80 percent and higher. This problem is likely
more common in colder climates. Although the symptoms
may moderate with time, several studies looking at cold
intolerance from amputation or nerve injury do not show
such resolution.
There seems to be little difference in the incidence or
severity of cold intolerance, whether a digital amputation is
simply revised, or the digit is replanted. The cold intolerance
is felt to be the result of the initial trauma, rather than the
subsequent surgical treatment. The pathophysiology of cold
sensitivity is not well understood, and is usually ascribed
to the sympathetic nervous system. It does not seem to
correlate with vessel patency or flow at the capillary level.
References:
1. Lithel M, Backman C, Nystrom A. Cold intolerance is not
more common or disabling after digital replantation than after
other treatment of compound digital injuries. Ann Plast Surg
1998;40(3):256-9.
2. Nystrom A, Backman C, Bertheim U, Karlson L, Carlsson A.
Digital amputation, replantation and cold intolerance.
J Reconstr Microsurg 1991;7(3):175-8.
3. Klein-Welgel P, Pavelka M, Dabernig J, Rein P, Kronenberg
F, Fraedich G, Plza Katzer H. Macro and microcirculatory
assessment of cold sensitivity after traumatic finger amputation
and microsurgical replantation. Arch Orthop Trauma Surg
2007;127(5):355-60.
157. A 65 year-old female complains of achy pain in her
right thumb with most activities. She has sharp
pains daily when trying to pinch objects. She denies
numbness and tingling. Clinical exam reveals pain
with thumb grind test at the CMC joint and marked
laxity of the ulnar collateral ligament of the MP joint
with pain and hyperextension. There is no pain
with IP joint flexion. An x-ray is shown in Figure 1.
After discussing the treatment options the patient
requests trapezial excision and tendon interposition
arthroplasty. An adjunctive procedure that is
recommended to be performed at the same time is?
A. Open CTR
B. Thumb IP joint arthrodesis
C. Thumb MP joint arthrodesis
D. EPB tenotomy
E. Opponensplasty of thumb
Preferred Response: C
Discussion: Basilar joint arthritis of the thumb is a common
problem and the underlying pathology can be addressed
with a tendon interposition arthroplasty, CMC arthrodesis,
or other type of arthroplasty. The presence of chronic
MP joint ulnar collateral ligament laxity should also be
addressed at the same time. While repair or reconstruction
of the UCL can be considered, in this age group, a fusion
is more likely to provide stability and predictable pain
relief. While about 20% of patients with osteoarthritis of
the thumb CMC joint will have concurrent CTS, this patient
did not complain of numbness. Any flexed posture of the
thumb IP joint usually corrects if the MP and CMC joints
are corrected. Fusion of the IP joint is not usually needed
unless painful. EPB tenotomy or transfer to the metacarpal
has been proposed to help address MP hyperextension in
the absence of arthritis or pain. This will not help correct
ulnar MP laxity. Opponensplasty would only be needed in
the presence of neuropathy or other nerve compression
syndrome.
References:
1. Trumble TE, ed. Hand Surgery Update 3, Hand, Elbow, and
Shoulder. Rosemont, IL: American Society for Surgery of the
Hand, 2003: 510.
2. Tomaino MM, Pellegrini VD, Burton RI. Arthroplasty of the
basal joint of the thumb, long-term follow-up after ligament
reconstruction with tendon interposition. J Bone Joint Surg
1995;77A:346-355.
Figure 1
158. The spastic clenched fist deformity is commonly
seen in patients after a stroke involving the upper
extremity. This pattern is caused by?
A. Unmasking of the primitive grasp reflex
B. Ischemic contracture of the forearm flexor
compartment
C. Ischemic contracture of the hand intrinsic muscles
D. Lack of extension splinting during the acute stroke
E. Failure to maintain passive ROM during recovery
Preferred Response: A
Discussion: Distinct clinical syndromes occur following a
stroke depending on which area of the brain is involved.
Motor impairment and recovery follows a typical pattern.
Initial flaccid paralysis occurs, followed by gradual motor
recovery from proximal to distal, starting a few days after
the initial insult. This increasing muscle tone can lead to
eventual spasticity. The main cause of residual clenched
hand posture is due to the unmasking of the primitive grasp
reflex. Peripheral ischemia or compartment syndromes are
not common after a stroke, unless the affected individual
is alone and left in one position for a prolonged period of
time. While extension splinting is helpful during the flaccid
paralysis phase, the increasing spasticity that can develop
after severe strokes can make continued splinting difficult,
painful, or cause skin problems. Trying to maintain passive
motion as the spasticity increases can become a full time
pursuit and is difficult to continue.
References:
1. Keenan MAE. Upper extremity dysfunction after stroke or brain
injury. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW,
eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia:
Churchill Livingstone/Elsevier, 2005:1262.
2. Pomerance JF, Keenan MA. Correction of severe spastic
flexion contractures in the nonfunctional hand. J Hand Surg
1996;21A:828-833.
2010 Self-Assessment Examination | 69
 159. A 35 year-old mechanic presents complaining of
pain, limited motion, and swelling of his middle
finger after a puncture wound 3 days ago. Exam
reveals a flexed resting posture of the finger, pain
with passive stretching, and marked tenderness
along the flexor tendon sheath. Appropriate
management should be?
A. Outpatient management with oral antibiotics
B. Needle aspiration of flexor tendon sheath and
oral antibiotics
C. Inpatient management with intravenous antibiotics
D. Operative drainage
E. Continuous irrigation with tendon sheath catheter
Preferred Response: D
Discussion: Infection of the finger flexor tendon sheath
is usually a result of a direct puncture wound. However,
extension from a felon or other deep space infection is
possible. Diagnosis of pyogenic flexor tenosynovitis is made
clinically. The typical hallmarks of infection include pain
with passive extension, tender volar flexor tendon sheath,
fusiform finger swelling, and a flexed finger posture different
from adjacent fingers. A high index of suspicion maybe
needed in unusual infections or immunocompromised
hosts, where the typical signs may not be present. The
preferred treatment for infections that are treated within 3-5
days of onset is small proximal and distal incisions into the
tendon sheath with careful intra-operative irrigation. Care
should be taken to avoid tendon sheath distention possibly
causing finger ischemia. Lille has shown that placement
of a tendon sheath catheter for continuous irrigation is
unnecessary. Larger exposure and debridement of fibrotic
tenosynovium associated with chronic or unusual infections
maybe needed
References:
1. Trumble TE, ed. Hand Surgery Update 3, Hand, Elbow, and
Shoulder. Rosemont, IL: American Society for Surgery of the
Hand, 2003: 443.
2. Lille S, Hayakawa T, Neumeister MW, Brown RE, Zook EG,
Murray K. Continuous postoperative catheter irrigation is not
necessary for the treatment of suppurative flexor tenosynovitis.
J Hand Surg 2000;25B:304-307.
70 | American Society for Surgery of the Hand
160. The best adjunctive therapy agent to decrease
xanthine production is:
A. Heparin
B. Dextran
C. Allopurinol
D. Aspirin
E. T-PA
Preferred Response: C
Discussion: Establishment of blood flow after microvascular
anastomosis may lead to reperfusion injury. One
contributing factor may be due to ischemia-induced
hypoxanthine conversion to xanthine. Blockage of this
reaction has been shown to decrease post-operative pain,
swelling, and infection rate.
A well-performed randomized study by Waikakul
compared outcomes in replantations with and without the
perioperative addition of allopurinol. The allopurinol group
demonstrated a lower infection rate, less perioperative
pain, and less swelling. Nerve recovery may also have
improved. Reperfusion after ischemia results in the
activation of neutrophils which release cytotoxic oxidants.
These oxidants initiate a cascade of capillary permeability
and tissue damage with the reestablishment of blood flow.
This study suggests that the xanthine oxidase inhibitory
effects of allopurinol may decrease some of the damage
brought about by prolonged ischemia. The other adjunctive
pharmacologic agents have a role in replantation. Dextran,
with its volume enhancing effects is used routinely in many
replant centers. Aspirin is also used for its platelet inhibition.
Heparin and t-PA use is less common.
References:
1. Trumble TE, ed. Hand Surgery Update 3, Hand, Elbow, and
Shoulder. Rosemont, IL: American Society for Surgery of the
Hand, 2003: 475.
2. Waikakul S, et al. The role of allopurinol in replantation. J Hand
Surg 1999;24B(3):325-7.
3. Conrad MH, Adams WP. Pharmacologic optimization of
microsurgery in the new millennium. Plast Reconstr Surg
2001;108(7):2088-96.
161. In distal biceps repair, the advantage of 2-incision
versus 1-incision technique yields is:
A. Improved supination strength
B. Improved elbow motion
C. No clear advantage
D. Lower incidence of nerve injury
E. Lower risk of heterotopic ossification
Preferred Response: C
Discussion: The repair of distal biceps tendon ruptures has
undergone intensive recent study. Without repair, about
70% return of flexion strength and 50% return of supination
torque can be expected by one year after injury. This may
not be acceptable to young active workers that require
manual labor. The classic two-incision repair through bone
tunnels, described by Boyd and Anderson, was utilized
for years. This provided anatomic repair of the tendon, but
carried a significant risk of heterotopic ossification leading
to radio-ulnar synostosis. Recently, single-incision anterior
repairs have been performed using several repair methods.
Endo-Button repair seems to provide a superior repair that
allows early mobilization. Henry’s study has shown that,
while the one anterior incision does not place the tendon
repair in anatomic position, there is no clinically-significant
difference in supination torque and flexion force compared
to a two-incision technique.
References:
1. Morrison KD, Hunt TR. Comparing and contrasting methods
for tenodesis of the ruptured distal biceps tendon. Hand Clin
2002;18(1):169-78.
2. Greenberg JA. Endobutton repair of distal biceps tendon
ruptures. J Hand Surg 2009;34A:1541-8.
3. Henry J, et al. Biomechanical analysis of distal biceps tendon
repair methods. Am J Sports Med 2007;35(11):1950-4.
4. Greenberg JA, et al. Endobutton assisted repair of distal biceps
tendon ruptures. J Shoulder Elbow Surg 2003;12(5):484-90.
162. A 57 year-old female complains of worsening pain in
her non-dominant thumb. Pain is mostly with activity
limiting her ability to pinch and grasp objects. She
has some achiness at night, but denies morning
numbness, tingling, or nocturnal awakening. Clinical
exam reveals a positive thumb grind test and 60° of
MP hyperextension with 60° of MP flexion. X-rays
reveal pantrapezial arthritis. MP joint space is well
preserved. The preferred treatment is?
A. CMC and MP arthrodesis
B. CMC arthrodesis and MP volar capsulodesis
C. CMC implant arthroplasty and MP arthrodesis
D. CMC LRTI and MP volar capsulodesis
E. CMC and MP implant arthroplasties
Preferred Response: D
Discussion: This clinical picture is one of CMC basilar
joint arthritis and MP hyperextension without arthritis.
This problem requires treatment of both joints for long
term success. The CMC arthritis can be treated with
resection of the trapezium alone, tendon interposition,
ligament reconstruction and tendon interposition, implant
arthroplasty, or arthrodesis. Each procedure has their
advocates, but of the choices offered above, the LRTI is
the most appropriate. LRTI has been in widespread clinical
use since 1986 and has consistently provided pain relief
and preservation of motion. Implant arthroplasties of the
CMC joint have been associated with unacceptably high
complication rates. Arthrodesis does provide good pain
relief and stability, but the loss of motion and inability to
flatten out the hand can be problematic.
It is of equal importance to assess the MP joint, as this
is crucial to long term success of the LRTI or other CMC
procedures. MP hyperextension of greater than 20° or 30°
can result in continued collapse of the thumb with pinch
activities. Restoring MP stability with a volar capsulodesis
or arthrodesis is needed to provide the best outcomes. If
no arthritis is present, then capsulodesis or arthrodesis
can be performed. Patients with arthritic changes, pain,
or limited flexion arcs are treated with arthrodesis. Implant
arthroplasties of the thumb MP joint require intact collateral
ligaments and are unpredictable in outcome.
References:
1. Trumble TE, ed. Hand Surgery Update 3, Hand, Elbow, and
Shoulder. Rosemont, IL: American Society for Surgery of the
Hand, 2003: 510.
2. Trumble TE, Budoff JE, eds. Hand Surgery Update IV.
Rosemont, IL: American Society for Surgery of the Hand, 2007:
639-641.
3. Tomanio MM, Pellegrini VD, Burton RI. Arthroplasty of the
basal joint of the thumb, Long term follow-up after ligament
reconstruction with tendon interposition. J Bone Joint Surg
1995;77A:346-355.
163. Which of the following treatment modalities is
contraindicated in the treatment of snakebites?
A. Antibiotics
B. Tetanus prophylaxis
C. Systemic corticosteroids
D. Application of ice
E. Application of a “lymphatic” tourniquet
Preferred Response: D
Discussion: Treatment of poisonous snakebites continues
to evolve. While some treatment aspects remain
controversial, others are more universally accepted. The
use of a broad spectrum antibiotic and tetanus prophylaxis
is appropriate. The application of a lymphatic tourniquet
is helpful, but this should be applied loosely and moved
proximally as swelling advances. Steroid administration
is advocated by some authors, but has no benefit in
preventing tissue damage. It is universally accepted that
ice should not be used after snakebites. Cooling has been
shown to potentiate the necrotic effect of the snake venom.
References:
1. Deichmann WB, Radomski JL, Farrell JJ, et al. Acute toxicity
and treatment of intoxication due to Crotalus adamanteus
(rattlesnake venom). Am J Med Sci 1958;236:204-207.
2. Kerrigan KR. Bacteriology of snakebite abscess. Trop Doctor
1992;22:158-160.
3. Ya PM, Guzman T, Perry JF. Treatment of bites of North
American pit vipers. South Med J 1961;54:134-136.
2010 Self-Assessment Examination | 71
 164. A 55 year-old male sustains an essentially non-
displaced fracture of his distal radius. He was
placed in a cast and followed every two weeks.
X-rays remained unchanged as to fracture position.
Just before he is to return for his 6-week check, he
calls complaining of a sudden inability to extend
his thumb. He reports no new injury or pain.
Recommended treatment is:
A. Application of a thumb spica cast
B. Primary tendon repair
C. Thumb IP joint fusion
D. ORIF of fracture
E. EIP to EPL tendon transfer
Preferred Response: E
Discussion: Impacted and minimally-displaced fractures
of the distal radius are routinely treated in a cast or splint.
The EPL has a relative avascular area at the level of
Lister’s tubercle. Here, the tendon can undergo pressure
necrosis, due to increased pressure in the third extensor
compartment from post-fracture swelling or hematoma.
This can cause delayed rupture of the tendon, leading to
loss of thumb function. Operative exploration is indicated
to explore the EPL tendon. Treatment options include
primary repair, repair with a tendon graft, or tendon transfer.
Repair is often difficult (or impossible even) with tendon
transposition, due to the atrophic nature of the tendon
rupture. Repair with an intercalated tendon graft is possible,
but requires a donor tendon, and healing of two tendon
repair sites. EIP to EPL transfer is the preferred treatment.
While this procedure is not urgent, it should be performed
to prevent loss of thumb extension.
Application of a thumb spica cast will not help, as the
tendon ends are not in close proximity. Sudden onset of
radial nerve palsy is unlikely and would usually affect finger
extension as well. ORIF is contraindicated at this time,
unless fracture displacement has occurred.
References:
1. Trumble TE, ed. Hand Surgery Update 3, Hand, Elbow and
Shoulder. Rosemont, IL: American Society for Surgery of the
Hand, 2003: 544.
2. Bonatz E, Kramer TD, Masear VR. Rupture of the EPL tendon.
Am J Orthop 1996;25:118-122.
3. Skoff HD. Post fracture extensor pollicis longus tenosynovitis
and tendon rupture: a scientific study and personal series.
Am J Orthop 2003;32:245-247.
72 | American Society for Surgery of the Hand
165. A 34 year-old man presents 2 months after
penetrating injury to the hand. Examination suggests
radial digital nerve injury to his index finger. At
surgery, after trimming of the ends, the resulting gap
is 10 mm. The best reconstructive choice is:
A. Direct repair under tension after nerve mobilization
B. Direct repair by keeping the finger in full flexion
C. Nerve grafting with sural nerve donor
D. Nerve grafting with lateral antebrachial cutaneous
nerve donor
E. Spanning the gap with a conduit
Preferred Response: E
Discussion: Nerves should be repaired without tension.
When a significant gap is present, nerve grafting or conduit
reconstruction is required. Polyglycolic acid conduit
reconstruction produces results that are equivalent to
those of grafting in large gaps (greater than 8 mm) while
eliminating donor-site morbidity associated with harvest.
References:
1. Weber RA, Breidenbach WC, Brown RE, Jabaley ME, Mass DP.
A randomized prospective study of polyglycolic acid conduits
for digital nerve reconstruction in humans. Plast Reconstr Surg
2000;106:2036.
2. Mackinnon SE, Dellon AL. Clinical nerve reconstruction with
a bioabsorbable polyglycolic acid tube. Plast Reconstr Surg
1990;85:419.
166. A 32 year-old man presents with a small puncture
wound in the pulp of his left index finger which
occurred when the paint gun he was cleaning
with paint thinner misfired. The most appropriate
treatment is:
A. Administration of systemic steroids
B. Administration of antibiotics
C. Injection of a neutralizing agent
D. Local surgical debridement electively
E. Wide surgical debridement emergently
Preferred Response: E
Discussion: High-pressure injection injuries can result in
devastating sequelae, with an amputation rate of 30%. The
risk of amputation is highest with organic solvent (paint,
paint thinner, gasoline, oil, jet fuel) injection into the fingers.
Emergent surgical debridement within six hours reduces the
risk of amputation.
References:
1. Hogan CJ, Ruland RT. High-pressure injection injuries to the
upper extremity: a review of the literature. J Orthop Trauma
2006;20:503.
2. Gonzalez R, Kasdan ML. High pressure injection injuries of the
hand. Clin Occup Environ Med 2006;5:407.
167. Patients with which of the following causes of ischemia
will benefit most from periarterial sympathectomy?
A. Smoking
B. Embolic
C. Auto-immune
D. Post-traumatic Figure 3
E. Atherosclerosis
Preferred Response: C
Discussion: Periarterial sympathectomy can result in complete
healing in patients with autoimmune digital ischemia from
vasospasm (e.g. Raynaud’s disease, CREST syndrome).
However, this procedure has little benefit in patients with
Figure 1 Figure 4
chronic ischemia due to atherosclerotic disease.
References:
1. Hartzell TL, Makhni EC, Sampson C. Long-term results of
periarterial sympathectomy. J Hand Surg 2009;34A:1454.
2. el-Gammal TA, Blair WF. Digital periarterial sympathetectomy for
ischemic digital pain and ulcers. J Hand Surg 1991;16B:382.
Figure 2 Figure 5

168. A 34 year-old female presents with a wrist mass for

several years. Radiographs, CT images, and biopsy
pathology slides are shown. The best treatment
option is:
A. Intralesional curettage with bone autograft
B. Marginal resection with bone autograft
C. Wide resection and reconstruction with
matched allograft
D. Wide resection with free vascularized graft and
wrist fusion
E. Wide resection and prosthetic wrist reconstruction
Preferred Response: D
Discussion: Giant cell tumors of bone are generally
treated with intralesional curettage, if there is no significant
cortical break thru. With significant bone destruction, joint
reconstruction may be possible—using fibular head or
matched allograft if the tumor has not invaded the radial
carpal joint. In this case, with severe bone and joint space
destruction, the best option for a stable wrist is wide
resection including the proximal carpus and fusion with a
vascularized fibular graft.
References:
1. Kawamura K, Yajima H, Kobata Y, Murata K, Shigematsu K,
Maegawa N, Takakura Y. Wrist arthrodesis with vascularized
fibular grafting. J Reconstr Microsurg 2009;25:501.
2. Ono H, Yajima H, Mizumoto S, Miyauchi Y, Mii Y, Tamai S.
Vascularized fibular graft for reconstruction of the wrist after
excision of giant cell tumor. Plast Reconstr Surg 1997;99:1086.
169. A 6-month-old male presents with upper limb
deformities. Examination reveals radial deviation of
the hands with normal thumbs. Which laboratory
abnormality is expected?
A. Microcytic anemia
B. Iron deficient anemia
C. Hemolytic anemia
D. Thrombocytopenia
E. T-cell lymphopenia
Preferred Response: D
Discussion: Radial longitudinal defect can be associated
with a variety of disorders. However, the presence of normal
thumbs suggests TAR (thrombocytopenia with absent
radii) syndrome. TAR syndrome (autosomal recessive) is
characterized by hypomegakaryocytic thrombocytopenia
and bilateral radial aplasia.
References:
1. Bonsi L, Marchionni C, Alviano F, Lanzoni G, Franchina M,
Costa R, Grossi A, Bagnara GP. Thrombocytopenia with
absent radii (TAR) syndrome: from hemopoietic progenitor to
mesenchymal stromal cell disease. Exp Hematol 2009;37:1.
2. Ballmaier M, Schulze H, Strauss G, Cherkaoui K, Wittner N,
Lynen S, Wolters S, Bogenberger J, Welte K. Thrombopoietin
in patients with congenital thrombocytopenia and absent
radii: elevated serum levels, normal receptor expression, but
defective reactivity to thrombopoietin. Blood. 1997;90:612.

2010 Self-Assessment Examination | 73

 170. A 49 year-old female breast cancer survivor
presents for evaluation one year after axillary lymph
node dissection with painful numbness in her hand.
Physical examination reveals no lymphedema.
The clinical and electrodiagnostic findings indicate
median nerve compression at the ipsilateral
wrist. She has failed trials of splinting and steroid
injection. Appropriate treatment should include:
A. Continued splinting with advice against surgery
B. Repeat injection and splinting with advice against surgery
C. Carpal tunnel release, exsanguination, and
tourniquet use
D. Carpal tunnel release, tourniquet use, but no
exsanguination is allowed
E. Carpal tunnel release with prohibition on
exsanguination and tourniquet use
Preferred Response: C
Discussion: Patients with prior ipsilateral axillary
dissection can undergo elective upper extremity surgery
using the normal precautions of sterile technique and
anesthesia. If there is no pre-existing lymphedema, these
individuals should not be prohibited from blood pressure
measurements or elective surgery.
References:
1. Hershko DD, Stahl S. Safety of elective hand surgery following
axillary lymph node dissection for breast cancer. Breast J
2007;13:287-290.
2. Dawson WJ, Elenz DR, Winchester DP, Feldman JL. Elective
hand surgery in the breast cancer patient with prior ipsilateral
axillary dissection. Ann Surg Oncol 1995;2:132-137.
74 | American Society for Surgery of the Hand
171. A 62 year-old patient presents with the ring and small
finger deformity seen in Figure 1. He also has numbness
in the thumb, index, long, and half the ring finger. Carpal
tunnel compression test reproduces the symptoms.
Which is the most appropriate course of treatment?
A. Observation
B. Carpal tunnel release
C. Partial palmar fasciectomy
D. Staged carpal tunnel release and palmar
fasciectomies
E. Carpal tunnel release and palmar fasciectomies
in the same operation
Preferred Response: E
Discussion: While there are reports that carpal tunnel
release performed concomitantly with partial palmar
fasciectomy in Dupuytren’s patients can result in a flare
reaction and complex regional pain syndrome, comparative
studies have shown that simultaneous surgery is
recommended and does not increase the complication rate.
References:
1. Gonzalez F, Watson HK. Simultaneous carpal tunnel release
and Dupuytren’s fasciectomy. J Hand Surg 1991;16B:175.
2. Nissenbaum M, Kleinert HE. Treatment considerations in carpal
tunnel syndrome with coexistent Dupuytren’s disease. J Hand
Surg 1980;5A:544.
Figure 1
172. A 4-month-old female is referred by her pediatrician References:
for weakness in the left upper extremity that has been 1. Kjaer-Petersen K, Jurik AG, Petersen LK. Intra-articular fractures
present since birth. If present, which of the following at the base of the fifth metacarpal. A clinical and radiographical
findings would suggest a favorable outcome? study of 64 cases. J Hand Surg 1992;17B:144-147.
2. Yoshida R, Shah MA, Patterson RM, Buford WL, Knighten
A. Ptosis and anhydrosis J, Viegas SF. Anatomy and pathomechanics of ring and
B. Biceps contraction small finger carpometacarpal joint injuries. J Hand Surg
2003;28A:1035-1043.
C. Scapular winging
3. Bushnell BD, Draeger RW, Crosby CG, Bynum DK. Management
D. Meningoceles on MRI of intra-articular metacarpal base fractures of the second
through fifth metacarpals. J Hand Surg 2008;33:573-83.
E. Insertional activity on electromyography
Preferred Response: B
Discussion: Return of biceps function before six months is
an important prognosticating indicator for obstetric brachial
plexus palsies. The other findings listed indicate a pre-
ganglionic lesion, for which the prognosis is worse.
References:
1. Kirjavainen M, Remes V, Peltonen J, et al. The function of
the hand after operations for obstetric injuries to the brachial
plexus. J Bone Joint Surg 2008;90B:349-355.
2. Waters PM. Update on management of pediatric brachial
plexus palsy. J Pediatr Orthop 2005;25:116-126.

Figure 1 Figure 2
173. A 21 year-old right hand dominant man injures his
right hand in a martial arts competition three weeks
prior to presenting for treatment. Examination reveals
significant ulnar sided hand swelling and tenderness
at the base of the fifth metacarpal. Digital flexion is
nearly full with no malrotation. Figures 1 and 2 are
the plain radiographs and CT images are shown in
Figures 3 and 4. The most appropriate treatment is:
A. Cast immobilization
B. Hand therapy for edema control and range of
motion exercises
C. Application of an external fixator
D. Closed reduction percutaneous pin fixation Figure 3 Figure 4
E. Open reduction internal fixation
Preferred Response: E
Discussion: This fifth metacarpal base fracture is displaced,
comminuted, and impacted. It is also associated with dorsal
subluxation of the metacarpal on the hamate. The CT scan
confirms the impaction of a sizable portion of the articular
surface of the metacarpal base. In addition, the injury is
nearly three weeks old and is not likely to reduce by closed
means. Open reduction is therefore required. This technique
would enable a more accurate restoration of the articular
surface. If the patient had presented earlier, a closed
reduction percutaneous pinning may have been successful,
but may not have reduced the impacted articular segment.
The injury usually results from a longitudinally-directed
force along the axis of the fifth metacarpal.

2010 Self-Assessment Examination | 75

 174. A 21 year-old right hand dominant man presents
three months following an injury to his right ring
finger that occurred while he was playing football.
He reports persistent pain despite intermittent
splinting. Examination reveals DIP joint swelling
with active distal joint motion 15/55, with full range
of motion of the PIP and MP joints. Radiographs
are shown in Figures 1 and 2. The most appropriate
treatment at this time is:
A. Full time DIP static extension splinting for 6 weeks
B. Supervised hand therapy including modalities
C. Closed reduction percutaneous pin fixation
D. Open reduction internal fixation
E. DIP joint arthrodesis
Preferred Response: D
Discussion: The radiographs demonstrate dorsal
subluxation of the DIP joint without an obvious fracture or
arthrosis. The patient reports ongoing pain which is not
likely to respond to further immobilization, or hand therapy,
given the persistent subluxation. Given the length of time
since the injury, a closed reduction and pinning is not likely
to reduce the joint. An arthrodesis is not indicated at this
time, due to the patient’s age, apparent preservation of the
joint space, as well as his preserved range of motion. An
open reduction and internal fixation is most appropriate,
possibly in conjunction with a volar plate arthroplasty.
References:
1. Rettig ME, Dassa G, Raskin KB. Volar plate arthroplasty of the
distal interphalangeal joint. J Hand Surg 2001;26A:940-944.
2. Horiuchi Y, Itoh Y, Sasaki T, Tasaki K, Iijima K, Uchinishi K.
Dorsal dislocation of the DIP joint with fracture of the volar base
of the distal phalanx. J Hand Surg 1989;14B:177-182.
Figure 1 Figure 2
76 | American Society for Surgery of the Hand
175. After being outside for less than 24 hours, a 34
year-old mountaineer presents with severe frostbite
involving both hands. After rapid rewarming,
a technetium 99 bone scan is obtained that
demonstrates no digital blood flow to multiple digits
bilaterally. What intervention should now be utilized?
A. Daily dry dressing changes, elevation and warm soaks
B. Surgical debridement
C. High dose intravenous corticosteroid therapy
D. Intravenous tissue plasminogen activator therapy
E. Systemic antibiotic therapy
Preferred Response: D
Discussion: The management of acute severe frostbite
should consist of several measures: restoration of core
body temperature, rapid rewarming of the frozen extremity
using a 40-44° C whirlpool bath along with tetanus
prophylaxis, topical aloe vera Q6h, and oral ibufrofen
200mg QID. Following rewarming, a technetium 99 bone
scan should be obtained, and if no digital blood flow is
detected, intravenous TPA is recommended. Surface blebs
should be left intact and early surgical debridement is
contraindicated. An open dressing technique with topical
aloe is recommended and occlusive dressings should
be avoided. Antibiotics are not recommended unless a
secondary infection ensues.
References:
1. Bruen KJ, Ballard JR, Morris SE, Cochran A, Edelman LS,
Saffle JR. Reduction of the incidence of amputation in frostbite
injury with thrombolytic therapy. Arch Surg 2007;142:546-551.
2. Bruen KJ, Gowski WF. Treatment of digital frostbite: Current
concepts. J Hand Surg 2009;34A:553-554.
3. Murphy JV, Banwell PE, Roberts AH, McGrouther DA. Frostbite:
Pathogenesis and treatment. J Trauma 2000;48:171-178.
4. Twomey JA, Peltier GL, Zera RT. An open-label study to
evaluate the safety and efficacy of tissue plasminogen activator
in treatment of severe frostbite. J Trauma 2005;59:1350-1354.
176. A 51 year-old left hand dominant male laborer with
no history of injury presents with a progressive two
year history of left elbow pain and stiffness. Physical
examination reveals painful active and passive
range of motion from 50 to 100° of flexion, with
near full rotation. X-rays demonstrate significant
ulnohumeral arthritis with significant osteophyte
formation. The most appropriate management at
this point is:
A. Physical therapy with dynamic splinting
B. Resection arthroplasty
C. Interposition arthroplasty
D. Unlinked total elbow arthroplasty
E. Semiconstrained total elbow arthroplasty
Preferred Response: C
Discussion: This patient presents with primary
osteoarthritis of his dominant elbow. Given radiographs
that demonstrate significant osteoarthritis, along with his
markedly restricted active and passive range-of-motion,
physical therapy is not likely to improve his pain or his
range-of-motion for any significant period of time. Because
of his age and occupation, TEA is contraindicated. A
resection arthroplasty is rarely indicated, except in the
setting of uncontrollable infection with inadequate bone
stock. Two recent studies by Morrey and Stanley report
favorable long-term results of ulnohumeral arthroplasty
in this age group, with improved range of motion and
decreased pain.
References:
1. Artuna SA, Morrey BF, Adams RA. Ulnohumeral arthroplasty for
primary degenerative arthritis of the elbow: Long-term outcome
and complications. J Bone Joint Surg 2002;84A:2168-2173.
2. Larson AN, Morrey BF. Interposition arthroplasty with an
Achilles tendon allograft as a salvage procedure for the elbow.
J Bone Joint Surg 2008;90A:2714-2723.
3. Phillips NJ, Ali A, Stanley D. Treatment of primary degenerative
arthritis of the elbow by ulnohumeral arthroplasty: A long-term
follow-up. J Bone Joint Surg 2003;85B:347-350.
177. A 19 year-old right hand dominant woman who fell
15' out of a tree presents with right elbow pain and
swelling. Physical examination demonstrates significant
global right elbow swelling with active motion from
40 to 80° of flexion, pronation and supination 30/30.
X-rays are shown in Figures 1, 2 and 3. The most
appropriate management should consist of:
A. A sling and immediate range of motion exercises
B. Cast immobilization for four weeks followed by
supervised therapy
C. Radial head implant arthroplasty
D. Open reduction and internal fixation of the olecranon
E. Open treatment of the radial head fracture and
triceps repair
Preferred Response: E
Discussion: The radiographs demonstrate a displaced
radial head fracture and triceps avulsion fracture off of the
olecranon. Clearly surgery is indicated to repair the triceps
and radial head. Given the patient’s age, an ORIF of the
radial head is preferable to implant arthroplasty, if at all
possible. This injury combination, though rare, has been
reported by Levy et al. This individual underwent a triceps
repair and ORIF of the radial head with plate fixation utilizing
a posterior skin incision (Figures 4 and 5).
Reference:
1. Levy M, Fishel RE, Stern GM. Triceps tendon avulsion with
or without fracture of the radial head: A rare injury? J Trauma
1978;18:677-679.
Figure 1 Figure 2
Figure 3 Figure 4
Figure 5
2010 Self-Assessment Examination | 77
 178. A 58 year-old right hand dominant man with long
standing diabetes mellitus presents with a chief
complaint of right hand weakness for two years
and difficulty turning a key in a tight lock. Physical
examination demonstrates advanced intrinsic atrophy,
moderate clawing and a sensory deficit in the ulnar
nerve distribution. NCV/EMG study demonstrates
absent ulnar nerve function. The treatment most
likely to improve activities of daily living is:
A. Occupational therapy
B. Brand tendon transfer (ECRL to lateral bands)
C. ECRB adductorplasty
D. In situ ulnar nerve decompression
E. Submuscular ulnar nerve transposition
Preferred Response: C
Discussion: This patient presents with unimprovable ulnar
nerve dysfunction secondary to cubital tunnel syndrome in
the setting of long-standing diabetes mellitus. It is highly
unlikely that either occupational therapy or an ulnar nerve
decompression would be beneficial, given the advanced
atrophy noted. The Brand transfer does improve power
for gross grip, but does not address power pinch—this is
the patient’s chief complaint. Power pinch can be reliably
improved by using a radial wrist extensor lengthened by a
palmaris longus graft to the thumb adductor. If the thumb
MP joint is markedly unstable, an MP arthrodesis may be
required in addition to the transfer.
References:
1. Smith RJ. Extensor carpi radialis brevis tendon transfer
for thumb adduction–a study of power pinch. J Hand Surg
1983;8:4-15.
2. Mondelli M, Aretini A, Rossi. Ulnar neuropathy at the elbow in
diabetes. Am J Phys Med Rehabil 2009;88:278-85.
3. Hastings H, Davidson S. Tendon transfers for ulnar nerve palsy.
Evaluation of results and practical treatment considerations.
Hand Clin 1988;4:167-78.
179. The long term results of periarterial sympathectomy
for the treatment of digital vasospasm associated
with scleroderma compared with atherosclerotic
disease demonstrate:
A. Amputation is rarely necessary in both groups
B. Better results for scleroderma
C. Worse results for scleroderma
D. Complete permanent relief in both groups
E. Temporary relief only in atherosclerotic disease
Preferred Response: B
78 | American Society for Surgery of the Hand
Discussion: Digital vasospasm is seen in patients with
autoimmune diseases such as scleroderma, and in
patients with diffuse atherosclerosis. A recent study by
Hartzell et al, published in the Journal of Hand Surgery,
demonstrated that the results of sympathectomy are
considerably better in the autoimmune group. Despite
some relief in both groups, amputation was eventually
required in 26% of the autoimmune patients and 59% of
the atherosclerotic patients.
References:
1. Hartzell TL, Makhni EC, Sampson C. Long-term results of
periarterial sympathectomy. J Hand Surg 2009;34A:1454-60.
2. Ruch DS, Holden M, Smith BP, Smith TL, Koman LA.
Periarterial sympathectomy in scleroderma patients:
intermediate-term follow up. J Hand Surg 2002;27A:258-264.
180. A 35 year-old executive presents complaining of
painless elbow stiffness three months following a fall
resulting in a posterolateral elbow dislocation and a
nondisplaced radial head fracture. Initial treatment
consisted of a closed reduction and splinting for
one week, followed by supervised physical therapy.
Physical examination reveals elbow motion from
50-120° of flexion with near full forearm rotation.
X-rays demonstrate a concentric reduction,
preserved joint spaces and minimal heterotopic
ossification. Recommended treatment is:
A. Static progressive splinting
B. Elbow manipulation under anesthesia
C. Arthroscopic elbow release
D. Open release using a lateral approach
E. Open release and radial head implant arthroplasty
Preferred Response: A
Discussion: This patient presents with significant elbow
stiffness following an uncomplicated elbow dislocation
in association with a nondisplaced radial head fracture.
A manipulation of the elbow under anesthesia is rarely, if
ever, indicated. Though surgery may ultimately be required
in this case, static progressive splinting may obviate the
need for operative intervention. Static progressive splinting
can improve passive range of motion even in the setting
of “hard end-feel joints.” Conceptually, static progressive
splinting uses inelastic components to apply torque to a
joint, in order to statically position it as close to end range
as possible; thus, increasing passive range-of-motion.
References:
1. Doornberg JN, Ring D, Jupiter JB. Static progressive
splinting for posttraumatic elbow stiffness. J Orthop Trauma
2006;20(6):400-404.
2. Schultz-Johnson, K. Static progressive splinting. J Hand Ther
2002;15:163-178.
181. Which of the following is an example of an
appropriate relationship between the orthopaedic
surgeon consultant and industry?
A. Reimbursement for the physician and his spouse to
attend a product development meeting
B. Receiving a consultant fee for attending an
educational meeting
C. Receiving a consultant fee based on volume of
implants used
D. Receiving a consultant fee of $5000 for attending a full
day product development meeting
E. Receiving a yearly stipend of $50,000 and be listed as
a consultant
Preferred Response: D
Discussion: The relationship between physicians and
industry is currently under tremendous scrutiny by the
Department of Justice and the public in general. In 2003,
the Advanced Medical Technology Association (AdvaMed)
adopted a code of ethics on interactions with health care
professionals, which included sections on consulting
arrangements and gifts to physicians. The group outlined
clear parameters for appropriate interactions between
physicians and corporations that would result in the
avoidance of conflict of interest. Consulting arrangements
need bonafide, written agreements with specific services
outlined, providing compensation consistent with fair
market value for the service provided. The AAOS has similar
guidelines that outline appropriate rules of engagement.
It is appropriate for consultants to industry, that provide
genuine services, to receive reasonable compensation for
their services. These arrangements should be established in
writing and include documentation of an actual need for the
service, proof that the service was provided, and evidence
that physician reimbursement for services be equal to
fair market value. Inappropriate relationships include
receiving a consultant fee for simply attending a meeting,
and receiving remuneration for using a particular implant.
It is not appropriate for the physician to be reimbursed for
the added travel expenses of his or her spouse, and thus,
answer A is not correct. Answer E is not correct, since the
duties are not defined and likely exceed fair market value.
References:
1. Advanced Medical Technology Association. AdvaMed Code of
Ethics. Available at: http://www.advamed.org/MemberPortal/
About/code/codeofethics/htm.
2. AAOS. Opinions on ethics and professionalism. Available at:
http://www.aaos.org/about/papers/ethics/1204eth.asp.
3. Glickel SZ. The Ethics of Expediency. J Hand Surg
2009;34A:799-807.
182. A 25 year-old male presents having had a ring finger
proximal phalanx fracture 8 weeks ago after minor
trauma. The ring finger proximal phalanx base is
clinically enlarged, but non-tender. Radiographs
are shown. Based on available evidence, the
demonstrated advantage of routine bone grafting
(vs. curettage alone) the proximal phalanx is:
A. Decreased infections
B. Decreased postoperative fractures
C. Decreased tumor recurrences
D. Quicker return to activities of daily living
E. No advantage
Preferred Response: E
Discussion: Multiple studies suggest that a routine
enchondroma can be treated with curettage, without
cancellous autograft. No postoperative fractures were
identified in the series of hand enchondromas and a series
of foot enchondromas. Schaller and Baer compared 8
patients treated with bone graft, and 8 without, and were
unable to demonstrate radiographic differences in bone
density measured years later.
References:
1. Schaller P, Baer W. Operative treatment of enchondromas of
the hand: is cancellous bone grafting necessary? Scand J Plast
Reconstr Surg Hand Surg 2009;43(5):279-85.
2. Goto T, Kawano H, Yamamoto A, Yokokura S, Iijima T, Motoi
T, Nakamura K. Simple curettage without bone grafting for
enchondromas of the foot. Arch Orthop Trauma Surg 2004
Jun;124(5):301-5. Epub 2004 Mar 11.
3. Sekiya I, Matsui N, Otsuka T, Kobayashi M, Tsuchiya D.
The treatment of enchondromas in the hand by endoscopic
curettage without bone grafting. J Hand Surg 1997;22B:230-4.
4. Hasselgren G, Forssblad P, Törnvall A. Bone grafting
unnecessary in the treatment of enchondromas in the hand.
J Hand Surg 1991;16A:139-42.
Figure 1
2010 Self-Assessment Examination | 79
 183. The transverse retinacular ligament stabilzes the
extensor mechanism at the level of the:
A. DIP joint
B. PIP joint
C. MCP joint
D. Wrist
E. Proximal Phalanx
Preferred Response: B
Discussion: The extensor mechanism has several
supporting bands and ligaments. The triangular ligament
supports the conjoined lateral bands at the level of the DIP
joint. At the PIP joint, the transverse retinacular ligaments
are the important stabilizers of the extensor mechanism and
the sagittal bands support the extensor tendon at the level
of the MCP joint. The extensor tendons are also supported
by the junctura tendinae at the dorsal hand level, and the
extensor retinaculum supports the extensor tendon at
the wrist.
Reference:
1. Yu HL, Chase RA, Strauch B. Extensor Apparatus. In: Atlas of
Hand Anatomy and Clinical Implications. St Louis, Missouri:
2004:336-356.
184. A 27 year-old male sustains a soft tissue injury to
the medial arm, elbow, and forearm, including a
20 cm segmental defect in the ulnar nerve starting
at the mid-brachium. He has complete loss of
ulnar innervated intrinsic muscles. Which of the
following would be the best choice to restore some
intrinsic function?
A. Anterior interosseous nerve branch to pronator
quadratus transferred to ulnar motor nerve
B. Ulnar nerve reconstruction using bilateral sural
nerve grafts
C. FDS ring tendon transfer to A1 pulley
(Zancolli procedure)
D. FDP ring two-tailed split tendon transfer to ring and
small radial lateral band
E. Ulnar nerve motor branch end-to-side into median
nerve common digital nerve to 3rd web
Preferred Response: A
Discussion: Battiston and Lanzetta reported 6/7 patients
recovering M4 or M5 recovery after PQ branch to ulnar
motor branch. With this proximal an ulnar nerve injury, the
sural nerve grafts are unlikely to reinnervate the muscle
prior to the motor end plates degenerating, and this is
a long defect. FDS ring transfer would be a poor choice
given that the FDP to the ring and small have lost their
innervation in the trauma, leaving the ring finger without
80 | American Society for Surgery of the Hand
a flexor. Similarly, any transfer of the FDP ring would be a
static transfer only because of the loss of innervation. The
results of end-to-side nerve grafting, while some excellent
functional results have been reported, have not been
universally stellar. In this question, the common digital
nerve to 4th web would be expected to be a sensory nerve,
except for autonomic motor fibers, and would be expected
to be a poor motor donor.
References:
1. Battiston B, Lanzetta M. Reconstruction of high ulnar nerve
lesions by distal double median to ulnar nerve transfer. J Hand
Surg 1999;24A:1185-91.
2. Brown JM, Mackinnon SE. Nerve transfers in the forearm and
hand. Hand Clin 2008;24(4):319-40.
185. The dorsal sensory branch of the ulnar nerve is at
risk with exposures of the distal ulna. Which of the
following best describes its expected position? The
dorsal sensory branch of the ulnar nerve branches
from the ulnar nerve 8.3 centimeters:
A. Distal to the olecranon, passing dorsal to the FCU,
and dorsal to the ulnar styloid
B. Distal to the olecranon, passing dorsal to the FCU,
at the level of the ulnar styloid
C. Distal to the olecranon, passing volar to the FCU,
and volar to the ulnar styloid
D. Proximal to the pisiform, passing volar to the FCU,
and dorsal to the ulnar styloid
E. Proximal to the pisiform, passing dorsal to the FCU,
and volar to the ulnar styloid
Preferred Response: E
Discussion: The ulnar dorsal sensory nerve arises from the
ulnar nerve at approximately 1/4 of the ulnar length from the
distal end of the ulna, or 8.3 cm proximal to the pisiform. It
penetrates the fascia dorsal to the FCU to run superficial
to the FCU, passing volar to the ulnar styloid, then onto the
dorsal ulnar hand.
References:
1. Doyle JR, Botte, MJ. Surgical anatomy of the hand and upper
extremity. Philadelphia: Lippincott Williams & Wilkins, 2003:
206-7.
2. Mok D, Nikolis A, Harris PG. The cutaneous innervation of the
dorsal hand: Detailed anatomy with clinical implications.
J Hand Surg 2006;31A:565-574.
186. A one day-old baby exhibits signs of worsening
edema of the right arm associated with decreased
hand mobility. The child has an ulcerated skin lesion
on the dorsal forearm. Appropriate initial treatment
should include:
A. MR angiography followed by an endovascular procedure
B. Wet-to-dry dressings for the skin ulceration and
elevation of the extremity
C. Emergent surgical intervention and compartment releases
D. IV antibiotics and edema control modalities
E. Surgical debridement of the ulcer with plan for staged
skin graft
Preferred Response: C
Discussion: Forearm compartment syndrome in the
neonate is not as uncommon as previously thought. The
presence of a bullous or ulcerative lesion on the dorsal
forearm, wrist, and/or hand is the salient initial diagnostic
finding. Early treatment in the face of evolving compartment
syndrome may salvage an otherwise compromised limb.
Compartment pressure measurement in the neonate is
not routinely performed and no standards for acceptable
pressure gradients are available. Because the average
diastolic pressure in a term newborn is 40 mm Hg or less,
a very small increase in compartment pressure may impair
muscle function. The decision to intervene surgically with
compartment release is therefore primarily a clinical one.
Patterns of involvement can range from mild skin lesions
to a severe Volkmann’s with tissue loss. Predisposing
factors may include mechanical compression, amniotic
band constriction, malposition of the extremity, forceps
extraction, oligo/polyhydramnios, pre-eclampsia, excessive
maternal weight gain, and maternal use of neuroleptic and
anxiolytic agents.
While MR angiography may play a role in the overall
evaluation of this condition, initial emergent treatment should
not be delayed while obtaining this exam. Wound care,
antibiotics, and edema control techniques may also play
a secondary role in treatment but they are not considered
definitive treatment in an evolving compartment syndrome
and will not stop progressive damage from ischemia.
References:
1. Ragland R 3rd, Moukoko D. Forearm compartment syndrome
in the newborn: report of 24 cases. J Hand Surg
2005;30A:997-1003.
2. Caouette-Laberge L, Bortoluzzi P. Neonatal Volkmann’s
ischemic contracture of the forearm: a report of five cases.
Plast Recontr Surg 1992;90(4):621-8.
187. A 55 year-old male presents to your office complaining
of painful progressive stiffness of his fingers. He
recalls no trauma or recent overuse. He was referred
to you by his nephrologist. His only other medical
issue is failed back surgery, but a recent MRI with
gadolinium showed no surgically correctable lesion.
On exam, you note that the skin on the back of his
hands is thickened and hyperpigmented in some
areas. You should advise this patient that:
A. The condition is benign and self-limited with resolution
expected with 8-10 weeks
B. Surgical treatment with joint capsulotomies and
tenolysis is recommended
C. There is no curative medical treatment for this
condition and treatment is primarily symptomatic
D. Treatment after a biopsy would include parenteral
antibiotic therapy for 6 weeks
E. Symptoms are likely to be limited to the hand and
fingers with little chance of systemic involvement
Preferred Response: C
Discussion: Nephrogenic systemic fibrosis is a debilitating
fibrosing disorder that occurs in patients with underlying
kidney disease, following exposure to gadolinium contrast
agents. It is associated with fibrosis of skin and connective
tissue throughout the body. The skin hyperpigments,
thickens, becomes hard and rigid which severely restricts
motion of joints. Patients will often present to a hand
surgeon seeking help for the disabling contractures of
their hands and fingers. Systemic involvement is common
including lungs, heart, diaphragm, esophagus, and skeletal
muscle. There is no curative medical treatment at this
time, although imatinib mesylate shows some potential in
preliminary studies. Symptomatic treatment is focused on
intensive occupational therapy and pain control. Deaths
have been reported as a result of this condition.
References:
1. Kay J. Nephrogenic systemic fibrosis: a gadolinium-associated
fibrosing disorder in patients with renal dysfunction. Ann
Rheum Dis 2008 Dec; 67 Suppl 3: iii66-9.
2. Saxena SK, Sharma M. Nephrogenic systemic fibrosis: an
emerging entity. Int Urol Nephrol 2008;40(3):715-24.
3. Marckmann P, Skov L. Nephrogenic systemic fibrosis: clinical
picture and treatment. Radiol Clin North Am 2009;47(5):833-40.
.
2010 Self-Assessment Examination | 81
 188. A 35 year-old male construction worker sustained a nail
puncture wound to the ulnar side of his palm 4 days
ago. Examination reveals tenderness and swelling over
the hypothenar area of the palm and pain with thumb
range of motion. The diagnosis is most likely:
A. Thenar space infection
B. Horseshoe abscess
C. Retained foreign body
D. Partial FPL laceration
E. Mid-palmar space infection
Preferred Response: B
Discussion: The thenar space extends from the third
metacarpal to the thumb. A puncture wound in the
hypothenar area would be unlikely to involve this space
initially. An infection in the ulnar bursa can track to the
thenar bursa and cause a horseshoe abscess.
The examination doesn’t support a retained foreign body
or a tendon laceration given the mechanism and area of the
wound. The midpalmar space doesn’t communicate with
the ulnar bursa.
References:
1. Neviaser RJ. Acute Infections. In: Green DP, Hotchkiss RN,
Pederson WC, eds. Green’s Operative Hand Surgery. 4th ed.
Philadelphia: Chuchill Livingstone, 1999:1033-1047.
189. The following structures have been shown to
block reduction of a complex dislocation of the
metacarpal phalangeal joint of the thumb:
A. Flexor pollicis longus and opponens pollicis
B. Opponens pollicis and adductor pollicis
C. Flexor pollicis longus and adductor pollicis
D. Adductor pollicis and flexor pollicis brevis
E. Adductor pollicis and extensor pollicis longus
Preferred Response: D
Discussion: The volar plate most commonly interferes
with reduction of a complex thumb MCP dislocation. The
sesamoids can also block reduction in association with
incomplete tears of their attachments of the adductor
pollicis to the ulnar sesamoid and the flexor pollicis brevis to
the radial sesamoid. The attachments function as a tension
force that prevents reduction. Adduction of the metacarpal
reduces this tension.
References:
1. Stener B. Hyperextension injures to metacarpal phalangeal
joint of the thumb – rupture of ligaments, fracture of sesamoid
bones, rupture of flexor pollicis brevis, anatomical and clinical
study. ACTA Chir Scand 1963;125:275-83.
2. Dislocations and Ligamentous Injuries of the Digit. In: Green’s
Operative Hand Surgery. Online 5th ed. Part II-9.
82 | American Society for Surgery of the Hand
190. When performing a total wrist arthrodesis for
osteoarthritis, which of the following joints should
always be fused:
A. Scaphoid-capitate
B. Capitate-hamate
C. Triquetrum-hamate
D. Lunate-triquetrum
E. Trapezium-first metacarpal
Preferred Response: A
Discussion: Joints commonly included in a total wrist
arthrodesis are the radius-scaphoid, radius-lunate,
scaphoid-capitate, and lunate-capitate. Fusion of the
capitate and third metacarpal base is controversial.
Optional fusions depending on extent of disease include
the capitate-hamate, hamate-triquetrum, lunate-triquetrum,
scaphoid-trapezoid-trapezium, and the trapezoid-second
metacarpal base.
References:
1. Weiss A-PC, Hastings H II. Wrist arthrodesis for traumatic
conditions: a study of plate and local bone graft application.
J Hand Surg 1995;20A:50-56.
2. Osteoarthritis. In: Trumble TE, Budoff JE, eds. Hand Surgery
Update IV. Rosemont, IL: American Society for Surgery of the
Hand 2007;652.
191. Biological response modifying medications such
as Etanercept(Enbrel), Infliximab(Remicade),
and Adalimumab(Humira) used in the treatment
of rheumatoid arthritis work by the following
mechanism of action:
A. Blocking of tumor necrosis factor (TNF)
B. Binding of cell messenger protein IL-1
C. Blocking of T-cell activation
D. Antagonist of DNA synthesis
E. B-cell depletion
Preferred Response: A
Discussion: Glucocorticoids have long been at the core of
medical treatment for RA and are commonly associated
with the development of osteoporosis and diabetes. Other
first line treatments include anti-inflammatories. DMARDS
such as gold, MTX, sulfasalizine have served as a second
line of treatment, but their onset of action is much slower
than the newer treatments, and treatment is often required
for extended periods of time. Mechanisms of action include
blocking the inflammatory cascade and prostaglandins, as
well as DNA and RNA synthesis. Newer medication called
biological response modifying medications (BRM) include
Infliximab, Etanercept, Adalimumab, and Anakinra, among
others. These work by blocking enzymes in the immune
activation cascade, such as TNF, IL-1, B-cells and T-cells.
They have a much more targeted mechanism of action and
have been shown to have a powerful effect on arresting
disease progression.
References:
1. Doan T, Massarotti E. Rheumatoid Arthritis: An overview
of new and emerging therapies. J Clin Pharmacology 2005
Jul;45(7):751-62.
2. Rheumatoid Arthritis. In: Trumble TE, Budoff JE, eds. Hand
Surgery Update IV. Rosemont, IL: American Society for Surgery
of the Hand, 2007;83.
192. The expected course of the vessel on which the
ulnar artery distal perforator flap (Becker flap) is
based arises from the ulnar artery:
A. Dorsal to the ulnar nerve, then penetrates the fascia
dorsal to the ECU
B. Volar to the ulnar nerve, then penetrates the fascia
dorsal to the ECU
C. Volar to the ulnar nerve, then penetrates the fascia
volar to the FCU
D. Dorsal to the ulnar nerve, then penetrates the fascia
volar to the FCU
E. Volar to the ulnar nerve, then penetrates the fascia
dorsal to the FCU
Preferred Response: E
Discussion: The Becker flap pedicle is based on a
perforator of the ulnar artery that was originally described
as arising from the ulnar artery 2-5 cm proximal to the
pisiform, then passing volar to the ulnar nerve, then passing
dorsal to the FCU to penetrate the fascia and reach the
subcutaneous tissue. However, any significantly-sized
perforator of the ulnar or radial artery can probably be used
as the vascular supply for a pedicled regional forearm flap.
References:
1. Page R, Chang J. Reconstruction of hand soft-tissue defects:
alternatives to the radial forearm fasciocutaneous flap. J Hand
Surg 2006;31A:847-56.
2. Uygur F, Uygur M, Ulkür E, Sever C. Versatility of the reverse
dorsoulnar fasciocutaneous flap in coverage of hand defects:
clinical experience with 36 cases. J Hand Surg
2009;34A:1327-33.
193. A 55 year-old man sustains a fracture of his
dominant right distal radius and ulnar styloid
process. Pre-operative radiographs demonstrate
displacement of the radius with intra-articular and
extra-articular comminution. The ulnar fracture is
not comminuted, is through the base of the styloid
process and is displaced 3mm. After satisfactory
operative open reduction and internal fixation of the
radius, the distal radial ulnar joint is stable to stress
testing but the ulnar styloid remains displaced
2mm. Recommended treatment for the ulnar styloid
component of this injury is:
A. Excise the ulnar styloid fragment
B. No surgical treatment of the ulnar styloid fracture
C. Open reduction and internal fixation of the ulnar styloid
D. Excise the ulnar styloid fragment and suture the
triangular fibrocartilage to the ulna
E. Arthroscopic assisted reduction and percutaneous
fixation of the ulnar styloid
Preferred Response: B
Discussion: Potential complications of an untreated ulnar
styloid base fracture include painful nonunion and instability
of the distal radioulnar joint, resulting from loss of integrity
of the styloid attachment of the triangular fibrocartilage.
A recent study examined the effect of untreated styloid
fractures in patients undergoing internal fixation for an
associated distal radius fracture. The authors found no
difference in multiple outcome measures when compared to
a cohort of patients without styloid fractures. Prior studies
have examined the potential instability associated with an
ulnar styloid fracture and restoration of joint stability with
internal fixation of styloid base fractures. However, these
studies have not demonstrated conclusively that internal
fixation improves outcome after this complex injury.
References:
1. Greenberg J. Reconstruction of the distal ulna: instability,
impaction, impingement, and arthrosis. J Hand Surg
2009;34A:351-356.
2. Kleinman WB. Stability of the distal radioulnar joint:
biomechanics, pathophysiology, physical diagnosis, and
restoration of function. J Hand Surg 2007;32A:1086-1106.
3. Souer JS, Ring D, Matschke S, Audige L, Marent-Huber M,
Jupiter JB. Effect of an unrepaired fracture of the ulnar styloid
base on outcome after plate-and-screw fixation of a distal
radial fracture. J Bone Joint Surg 2009;91A:830-838.
2010 Self-Assessment Examination | 83
 194. The terrible triad injury to the elbow is a traumatic Discussion: The patient has suffered a severe traumatic
fracture dislocation that includes a radial head open radio-carpal dislocation. Initial care requires open
fracture and a coronoid fracture. The most reduction, radio-carpal ligament repair, and stable fixation
commonly observed fracture pattern of the coronoid of an anatomic reduction. Despite open treatment, a high
in the terrible triad injury is fracture of the: percentage of patients will have recurrent instability often
manifested by recurrent ulnar translocation of the carpus.
A. Base of the coronoid
Resection or recession of the distal ulna will exacerbate
B. Tip of the coronoid instability and ligament reconstruction is unpredictable
C. Medial facet of the coronoid with a high risk of recurrent joint subluxation. A bony
D. Lateral facet of the coronoid surgical procedure to stabilize the wrist will have the most
predictable outcome. Fusion may require total or partial
E. Coronoid comprising about 50% of the height
wrist arthrodesis. Radiolunate fusion has been reported
Preferred Response: B with success.
Discussion: The most commonly observed coronoid References:
fracture pattern associated with the terrible triad is a small 1. Ilyas AM, Mudgal CS. Radiocarpal fracture-dislocations. J Am
tip fracture. These fractures are often comminuted, less Acad Orthop Surg 2008 Nov;16(11):647-55.
than 2 mm in height and represent an anterior capsular 2. Freeland AE, Ferguson CA, McCraney WO. Palmar radiocarpal
avulsion. The fracture is frequently too small to accept dislocation resulting in ulnar radiocarpal translocation and
internal fixation and is often stabilized with a suture lasso multidirectional instability. Orthopedics 2006 Jul;29(7):604-8.
technique. The presence of a small coronoid tip fracture
in the presence of an otherwise radiographically “ benign”
x-ray is an indication of significant elbow ligament injury and
potential instability.
References:
1. Mathew PK, Athwal GS, King GJW. Terrible triad injury of the
elbow: Current concepts. J Am Acad Orthop Surg
2009;17:137-151.
2. Ring D. Fractures of the coronoid process of the ulna. J Hand
Surg Am 2006;31:1679-1689.
3. O’Driscoll SW, Jupiter JB, Cohen M, Ring D, McKee MD.
Difficult elbow fractures: pearls and pitfalls. Inst Course
Lectures 2003;52:113-134.

195. 19 year-old male suffers an acute open injury to Figure 1

his non-dominant wrist (Figure 1 and 2). He has an
emergent operation to repair his wrist injury (Figure 3).
Pins are removed at 8 weeks post-injury and he is
placed in a brace and started on rehabilitation. At 6
months post-injury, he complains of wrist pain with
most activities and is unable to return to work. His
most recent radiograph is seen in Figure 4. The next
step in the patients care would likely involve:
A. Observation
B. Arthrodesis
C. Ligament reconstruction with tendon graft Figure 2 Figure 3 Figure 4
D. Distal ulna resection
E. Ulnar shortening
Preferred Response: B

84 | American Society for Surgery of the Hand

196. A 68 year-old retired engineer and avid golfer
presents to your office with a chief complaint of
difficulty bending his left small finger for 6 weeks.
His PCP refers him after failing a cortisone injection.
The patient only has a vague complaint of pain and
some mild tingling in his small finger. He is healthy,
except for non-insulin dependent diabetes treated
with oral medication. A clinical photograph is seen
in Figure 1 along with his radiographs in Figures 2
and 3. A CT scan is seen in Figure 4. The next step
in the care of this patient should include:
A. A second cortisone injection Figure 1

B. Trigger finger release surgery

C. Open reduction of the fracture with internal fixation
D. Fracture fragment excision and flexor
tendon reconstruction
E. Neurodiagnostic testing to determine the level of
nerve compression
Preferred Response: D
Discussion: The patient presents with a chronic rupture
of his FDP tendon to the small finger, due to attritional
rupture from a hamate hook non-union. The hamate hook
fracture may have occurred weeks, and even years, before
the tendon rupture. Golfers and players of racquet sports
are predisposed to hamate hook fracture. Osteosynthesis
Figure 2 Figure 3
of hamate hook fractures can be considered in fresh
fractures in elite athletes, otherwise hamate hook excision
usually results in a good outcome. Hamate hook fractures
should typically be treated with excision when nonunion is
established. Patients presenting with tendon rupture usually
involves the FDP to the small finger and treatment requires
hamate hook excision and flexor tendon reconstruction.
References:
1. Hartford JM, Murphy JM. Flexor digitorum profundus rupture of
the small finger secondary to nonunion of the hook of hamate: Figure 4
A case report. J Hand Surg 1996;21A:621-623.
2. Yamakazi H, Kato H, et al. Closed rupture of the flexor tendons
of the little finger secondary to non-union of fractures of the
hook of the hamate. J Bone Joint Surg 2006;31B:337-341.

2010 Self-Assessment Examination | 85

 197. A 5 year-old boy with leukemia is in the hospital for
chemotherapy. The pediatric oncologist calls for a
hand surgery consult for a dark-colored lesion near an
IV site on the dorsum of the wrist (Figure 1). The child
has no complaint of pain and is afebrile. His recent
WBC is 850. A bedside scraping of the lesion showed
nonseptate nonbranching hyphae under microscopy.
The next appropriate step in management is:
A. Observation, continue chemotherapy
B. Topical antifungal agents on the lesion and correct
immunodeficiency
C. Systemic antifungal agent, correct immunodeficiency
and wide surgical excision
D. Apply splint and obtain radiographs to rule out
child abuse
E. Correct the immunodeficiency. There is no need for
surgery in this case
Preferred Response: C
Discussion: This immunodeficient child has developed
a case of mucormycosis. Mucormycosis occurs as an
opportunistic infection in immunocompromised hosts. The
infection often begins as a small blackish area near an IV
Site. If unrecognized, the infection can invade quickly and
deeply making eradication difficult. The treatment should
be aggressive and should include a wide surgical excision
of the lesion, systemic antifungal agents and correction of
immunodeficiency. Both fungal cultures and histopathology
should be studied at each debridement.
This child required 3 debridements, and the lesion resolved
after correction of the immunodeficiency. The wound
required a skin graft for closure.
References:
1. Jones NF, Shin EK, Eo S, Starzl TE. Succesful salvage of
mucormycosis infection of the forearm and osteomyelitis of the
ulna. Hand (NY) 2008 Dec;3(4):332-6.
2. Arnaiz-Garcia ME, et al. Cutaneous mucormycosis: report of
five cases and review of the literature. J Plast Reconstr Aesthet
Surg 2009;62:434-441.
3. Patel RP, Malaviya GN, Sugar AM. Chronic Infections. In:
Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds.
Green’s Operative Hand Surgery. 5th ed. Philadelphia: Churchill
Livingstone/Elsevier, 2005:113-14.
Figure 1
86 | American Society for Surgery of the Hand
198. A 28 year-old professional skateboarder injures his
wrist and presents one week after a fall in the skate
park. The patient was referred from the Emergency
Department with a diagnosis of scaphoid fracture.
His wrist radiographs are seen in Figures 1 and 2. His
neurovascular exam demonstrates normal median
and ulnar nerve function. Appropriate treatment for
this injury is:
A. Short arm thumb spica cast and application of a
bone stimulator
B. Closed reduction and application of a long arm thumb
spica cast
C. Closed reduction, percutaneous pinning, and long
arm cast
D. Percutaneous screw fixation of the scaphoid fracture
and short arm cast
E. Open treatment of the wrist injury and short arm cast
Preferred Response: E
Discussion: The patient presents with an unreduced
greater arc perilunate injury. The variant in this case is
a trans-scaphoid perilunate fracture dislocation of the
wrist. According to Herzberg, this injury is missed in about
25% of cases and delayed presentation may occur as
a result. Closed reduction should be performed in the
acute setting, if possible, to reduce tension on the median
nerve and realign the carpus. However, closed reduction
alone is not likely to produce a favorable result. Perilunate
injuries require stable fixation of an anatomic reduction to
obtain a good long term result. Anatomic reduction of the
midcarpal joint, lunotriquetral joint and scaphoid is unlikely
after closed reduction; therefore, anatomic open reduction
should be performed as soon as possible. Fixation of
the scaphoid alone would result in neglect of the luno-
triquetral dissociation and the probable development of
VISI deformity. Therefore, fixation of both the scaphoid
and lunotriquetral joint must be performed with an open
approach to obtain the best long term result.
References:
1. Redjal H, Rafijah G. Perilunate Inuries of the Wrist. In: Slutsky
DJ, Osterman AL, eds. Fracture and Injuries of the Distal
Radius and Carpus, The Cutting Edge. Philadelphia: Saunders,
2008:425-435.
2. Herzberg G, Comtet JJ, Amadio PC, et al. Perilunate
dislocations and fracture dislocations: a multicenter study.
J Hand Surg 1993;18A:768-779.
Figure 1 Figure 2
199. In the medicolegal arena, the statement “within a References:
reasonable degree of medical certainty” implies 1. Mathew PK, Athwal GS, King GJW. Terrible triad injury of the
medical probability greater than: elbow: Current concepts. J Am Acad Orthop Surg
2009;17:137-151.
A. 25% 2. Ring D. Fractures of the coronoid process of the ulna. J Hand
B. 50% Surg Am 2006;31:1679-1689.
C. 75% 3. O’Driscoll SW, Jupiter JB, Cohen M, Ring D, McKee MD.
Difficult elbow fractures: pearls and pitfalls. Inst Course
D. 90% Lectures 2003;52:113-134.
E. 98%
Preferred Response: B
Discussion: To be “legally sufficient,” the physician’s
opinion must be based upon a “reasonable degree of
medical certainty.” This statement implies greater than
50% likelihood. In the case of causation determination (for
example), in order for a condition to be accepted as “work
related,” the physician must opine that there is more than a
50% probability that the condition arose from the injury in
question. “Possibility” implies less than 50% likelihood.
Figure 1 Figure 2
References:
1. Brigham CR, Babitsky S. Independent medical evaluations
and impairment ratings. In Occ Med: State of the art reviews
1998;13(2):325-343.
2. Kreisler L. With a reasonable degree of medical certainty.
J Occup Med 1972;5:313-314.

200. A 30 year-old physician crashes his mountain Figure 3 Figure 4

bike and injures his elbow. He presents to your
office 2 days after injury. His diagnostic images
are presented in Figures 1-5. The recommended
treatment for this injury is:
A. Open treatment with buttress plate via posterior or
medial approach
B. Immobilization for 3 weeks followed by protected
mobilization
C. Immediate protected range of motion of the elbow
D. Open treatment of coronoid fracture with suture
Figure 5
lasso technique
E. Radial head replacement
Preferred Response: A
Discussion: The patient has a coronoid fracture of the
medial facet. O’Driscoll classified coronoid fractures into
three types: tip, medial facet, and fractures at the base of
the coronoid. Fractures of the medial facet of the coronoid
are deceptive injuries and are easy to overlook. However,
if untreated, these fractures result in varus posteromedial
instability and a varus aligned elbow. The result is the rapid
development of elbow joint arthritis. This fracture should be
treated with a buttress plate and possible bone graft via a
medial approach. A posterior skin incision could be utilized
to access both side of the elbow if necessary.

2010 Self-Assessment Examination | 87

 Notes

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