2009 Self-Assessment Examination

Preferred Responses, Discussions and References – Book 2

 2009 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 2009 examination consists of the Question Book (Book 1) containing 150
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.

Copyright© 2009
Timelines
June 12, 2009
American Society for Answer sheets due back to the ASSH Office.
Surgery of the Hand
6300 North River Road July 31, 2009
Suite 600 Individual scores, Book 2, containing preferred responses, discussions, and
Rosemont, IL 60018-4256 references, and an evaluation mailed to participants.
(847) 384-8300
Please note: late submissions received at the central office after June 12, 2009,
Fax: (847) 384-1435
cannot be scored and will not be eligible for CME credit.
www.assh.org

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.

2009 Self-Assessment Examination | 1

 Credit Hours Disclosures
The ASSH designates this educational activity for a maximum • Seth D. Dodds, MD
of 20.00 AMA PRA Category 1 Credits™. Physicians should Integra: speaking and educational honoraria
only claim credit commensurate with the extent of their • Jay F. Pomerance, MD
participation in the activity. Consultant for Wyeth Pharmaceuticals, and
Answer sheets must be received by ASSH Central Office by Gerson Lehrman Group, LLP
June 12, 2009, to be eligible for Category 1 CME credit. • Lance A. Rettig, MD
Biomet Instructor/Faculty for surgeon cadaver courses
2009 Self-Assessment • David C. Ring, MD
Consultant for Small Bone Innovations, Wright Medical, Smith
Examination Committee and Nephew, Acumed, and Tornier. Research/Institutional
◆ John M. Bednar, MD support from Small Bone Innovations, Wright Medical, Smith
Committee Chair and Nephew, Acumed, Tornier (all unrestricted gifts). Research/
Institutional support from Joint Active Systems, American
◆ O. Alton Barron, MD
Foundation for Surgery of the Hand, Orthopaedic Trauma
◆ Kyle D. Bickel, MD, FACS
Association, and Stryker (grants to specific research). Royalties
◆ Louis W. Catalano, III, MD
from Hand Innovations. Honoraria/paid travel from Small Bone
◆ Fred G. Corley, MD
Innovations, Wright Medical, Smith and Nephew, Acumed,
Seth D. Dodds, MD
Tornier AC International, AO North America, Depuy, and several
◆ Scott G. Edwards, MD
universities. Ownership interests with Mimedex and Illuminoss.
◆ Harris Gellman, MD
◆ Harry A. Hoyen, MD • Russell Shatford, MD, MPH, MSEd
◆ Richard S. Idler, MD Owns stock in Minnesota Mining and Manufacturing (3M)
◆ Howard M. Matsuba, MD • Andrew L. Terrono, MD
◆ Kimberly K. Mezera, MD Part owner of Boston Out Patient Surgical Suites
◆ David T. Netscher, MD
◆ Miguel A. Pirela-Cruz, MD
Jay F. Pomerance, MD Disclaimer
◆ Ghazi M. Rayan, MD The material presented in this continuing medical education
Lance A. Rettig, MD program is being made available by the American Society
David C. Ring, MD for Surgery of the Hand for educational purposes only. This
◆ Marco Rizzo, MD material is not intended to represent the only, or necessarily
Russell Shatford, MD, MPH, MSEd the best, methods or procedures appropriate for the medical
◆ David J. Slutsky, MD situation discussed. Rather, this educational material is
◆ Curtis M. Steyers, MD intended to present an approach, view, statement, or opinion of
Andrew L. Terrono, MD the authors or presenters, which may be helpful, or of interest,
◆ Eric P. Thorson, MD to other practitioners.
◆ Montri D. Wongworawat, MD
The examinees agree to participate in this medical education
◆ David S. Zelouf, MD
program sponsored by ASSH with full knowledge and
◆ Bridget Treccia
awareness that they waive any claim that they may have
ASSH Staff Liaison
against ASSH for reliance on any information presented in
this examination.
◆ Nothing of value
The authors preceded by a ◆ have indicated that they have Confidentiality
not received anything of value in the form of: research or
The Self-Assessment Exam is the sole property of the
institutional support, stock or stock options, equipment or
American Society for Surgery of the Hand (ASSH) and
services, paid travel, royalties or as a consultant or employee
scores are confidential. Individual results will only be shared
of a commercial company or institution related directly or
with the test-taker. Each participant is assigned a number
indirectly to the subject of the program.
and no names are used in the scoring process to further
ensure confidentiality.

2 | American Society for Surgery of the Hand

1. A 17 year-old healthy woman presents with a
three-year history of a progressive swan-neck
deformity that developed following a dorsal
laceration to the DIP of the long finger (open
mallet finger). Initial treatment was simple
skin closure. At times, the PIP joint will lock in
hyperextension. There is full passive motion of the
finger. The most reliable surgical treatment is:
A. Distal intrinsic release
B. SORL (Oblique retinacular ligament) reconstruction
C. Crossed intrinsic transfer
D. Interosseous slide
E. Lumbrical release
Preferred Response: B
Discussion: This is a secondary swan-neck deformity
following terminal extensor tendon disruption with
extensor forces now concentrated at the PIP joint.
The patient is young, non-rheumatoid, and has PIP
joint hyperextension with intermittent locking. The
best treatment for this is an SORL reconstruction,
which serves as a passive tether passing dorsal to
the DIP joint and volar to the PIP joint. Active PIP joint
extension thereby extends the DIP joint while PIP joint
hyperextension is prevented by the volar tether. A distal
intrinsic release is appropriate for post-traumatic intrinsic
contracture with isolated limited PIP flexion and a positive
intrinsic tightness test. A crossed intrinsic transfer is
used when there is ulnar drift of the digits and notable
contracture of the ulnar intrinsics. The ulnar intrinsics are
released and transferred radially. The interosseous slide is
used in cases of spastic contracture of the interosseous
muscles.
References:
1. Smith R. Intrinsic Contracture. In: Green DP, ed. Operative Hand
Surgery. 4th ed. New York: Churchill Livingstone, 1999.
2. Thompson JS, et al. The spiral oblique retinacular ligament.
SORL. J Hand Surg 1978; 3:482-487.
2. The clinical photos are those of a 48 year-old
construction worker who presented with
complaints of arm swelling and burning pain
following a direct blow to his forearm, which
occurred three months ago. He has not had
any diagnostic workup. The most appropriate
diagnosis is:
A. Complex regional pain syndrome
B. Vascular thoracic outlet syndrome
C. Factitious edema
D. Subclavian vein thrombosis
E. Chronic compartment syndrome
Preferred Response: C
Discussion: The patient is exhibiting a clear case of
factitious edema that he was effectively masking by
always wearing a long-sleeved shirt to hide the stigmata
of a proximal humeral tourniquet he was using to
create the distal edema. While psychological testing is
appropriate, in-patient treatment is not indicated as the
next step. Direct confrontation of the patient with the
truth is necessary, and no further medical diagnostic
workup or limb-specific treatment is necessary.
References:
1. Taskaynatan MA, et al. Factitious disorders encountered in
patients with the diagnosis of RSD. Clin Rheumatol 2005;
24(5):521-6.
2. Louis DS, Lamp MK, Greene TL. The upper extremity and
psychiatric illness. J Hand Surg 1985; 10:687-693. (This paper
reviews a large series of patients (33) who presented with a
variety of recognizable problems consistent with factitious illness.
The follow-up averaged 4½ years. At the time this was written,
self-causation was suspected but not established as it is now.)
Question 2, Figure 1
Question 2, Figure 2
2009 Self-Assessment Examination | 3
 3. A 20 year-old college baseball player presents
with a two-month history of non-dominant hand
pain, especially noticeable when batting. He was
not aware of any discrete trauma to his hand. He
primarily complains of 2 months of non-dominant
ulnar-sided hand pain with paresthesias in the ring
and small fingers. The radiological study most
likely to identify the problem is:
A. Chest radiograph
B. Elbow MRI
C. Scaphoid view of the wrist
D. Upper limb angiography
E. Wrist CT
Preferred Response: E
Discussion: Hook of the hamate fractures are most
commonly seen in golfers, baseball players, and racquet
sport athletes. While a carpal tunnel view may detect
many hamate fractures, those at the base of the hamate
are easily missed. A CT scan will readily detect the
fractures. A chest x-ray should be ordered when a patient
has ulnar nerve symptoms in the hand, shoulder pain
and a history of smoking to detect a pancoast tumor. An
elbow MRI might detect some ulnar nerve pathology, but
the clinical presentation would likely be more specific for
cubital tunnel syndrome. A clenched fist PA view is useful
in diagnosing scapholunate ligament disruption.
4. The patient in the photo is manifesting a clinical
deformity secondary to an isolated peripheral
nerve injury. This nerve is derived from which
cervical root(s)?
A. C2
B. C3-C4
C. C5-C7
D. C8
E. T1
Preferred Response: C
Discussion: The patient in the photo has dramatic
winging of the inferior scapula secondary to long thoracic
nerve palsy. The long thoracic nerve derives from the
ventral rami of C5-C7. After conservative treatment failed,
the patient underwent split pectoralis transfer to the
inferior scapular angle.
References:
1. Aval SM, et al. Neurovascular injuries to the athlete’s shoulder:
Part I. JAAOS 2007; 15(4):249-256.
2. Wiater JM, Flatow EL. Long thoracic nerve injury. Clin Orthop
1999; 368:17-27.

References:
1. Hirano K, Inoue G. Classification and treatment of hamate
fractures. J Hand Surg 2005; 10(2-3):151-7.

2. Jacobson JA, et al. Golf and racquet sports injuries. Semin

Musculoskelet Radiol 2005; 9(4):346-59.

Question 4, Figure 1

4 | American Society for Surgery of the Hand

5. A 40 year-old healthy woman presents with
a history of sharp pain and cold sensitivity
beneath the nail plate of her dominant long finger.
There are no visible lesions or abnormalities, but
tenderness is reproducible with pressure on the
nail plate. MRI of the finger is shown in Figure 1,
and a lesion is found at surgery, as shown in
Figure 2. The most probable diagnosis is:
A. Ganglion cyst
B. Epidermal inclusion cyst
C. Glomus tumor
D. Neurofibroma
E. Giant cell tumor of tendon sheath
Question 5, Figure 1
Preferred Response: C

Discussion: Glomus tumors are benign hamartomatous

lesions most frequently seen in the subungual soft
tissues. The majority of patients have no visible signs
of a tumor and are diagnosed based on symptoms,
physical findings, and MRI. Exquisite tenderness to
localized pressure is the hallmark of physical examination
and is often coupled with very localized cold sensitivity.
T2 weighted MRI often reveals intense signal activity in
the area of tenderness, confirming the lesion. Findings
at surgery are most commonly those of a solitary solid
soft tissue mass in the subungual adventitia beneath
the sterile matrix with multiple vascular lumina. Ganglion
cysts most often occur adjacent to joint capsule or
tendon sheaths and are fluid filled, rather than solid.
Epidermal inclusion cysts are limited to the immediate Question 5, Figure 2
subcutaneous tissues and are not found beneath the nail
plate. Neurofibromas are rarely tender and not located in the
subungual soft tissues, but are located in neuroectodermal
tissues. Giant cell tumors typically present adjacent
to tendinous structures and appear as heterogeneous
multiloculated solid soft tissue masses on MRI.

References:
1. McDermott EM, Weiss A-PC. Glomus tumors. J Hand Surg 2006;
31A:1397-1400.

2. Bhaskaranand K, Navadgi BC. Glomus tumor of the hand.

J Hand Surg 2002; 27B:229-231.

2009 Self-Assessment Examination | 5

 6. A healthy 30 year-old woman presents with
a painful index finger. Ulceration at the tip
has developed over several weeks. She has
severe cold sensitivity in the fingertip, which
has not responded to oral analgesics. Her
clinical appearance is shown in Figure 1, and
an arteriogram of the hand is shown in Figure 2.
The most appropriate treatment at this time is:
A. Surgical sympathectomy of the common digital and
proper digital arteries
B. Extremity warming, niacin, and a calcium-channel
blocker
C. Amputation and primary closure at the level of the
DIP joint Question 6, Figure 2
D. Oral antibiotics and close observation
E. Excision of the lesion and a thenar flap
7. A malunited fracture-dislocation of the PIP joint
Preferred Response: A is shown in Figure 1. The most appropriate donor
graft to restore congruous PIP joint alignment is:
Discussion: Raynaud’s disease occurs most often in
young women and can progress to digital ulceration A. A toe PIP joint transfer
and gangrenous necrosis. This patient presented with B. The contralateral PIP joint
ulceration and tissue loss, as depicted in Figure 1. Medical
C. Distal radius graft
management alone is unlikely to result in sufficient
improvement to prevent further tissue loss and gangrenous D. Dorsal hemi-hamate graft
changes at this late stage. Several reports have shown E. Iliac crest bone graft
that surgical sympathectomy improved local circulation
and allowed for ulcer healing in most cases after failure of Preferred Response: D
conservative measures, preventing amputation. Long- Discussion: PIP joint fracture-dislocations are highly
term results, however, have been equivocal, especially in complex and unstable injuries. Adequate reconstruction
patients with underlying collagen-vascular disease. requires reconstitution of a smooth and properly-
References: configured articular surface and reconstruction of a
stable volar buttress to correct dorsal subluxation. When
1. McCall TE, Petersen DP, Wong LB. The use of digital artery
sympathectomy as a salvage procedure for severe ischemia more than 50% of the articular surface is involved in
of raynaud’s disease and phenomenon. J Hand Surg 1999; the fracture, grafting techniques have been found to
24A:173-177. be superior to volar plate arthroplasty. Autologous toe
2. Wilgis EFS. Evaluation and treatment of chronic digital ischemia. PIP joint grafts have been used with some success, but
Ann Surg 1981; 193:693-698. the donor-site morbidity is considerable. Contralateral
PIP joint grafts also have unacceptable donor-site
considerations. Distal radius cortico-cancellous grafting
does not restore the proper alignment or smooth
articular cartilage necessary for PIP joint resurfacing.
An autologous hemi-hamate graft from the dorsal
articular surface of the 4th and 5th CMC joints has been
used with great success in several series. When properly-
fashioned and rigidly-fixed, it restores near-anatomic
configuration of the middle phalangeal base and provides
a stable volar buttress to correct dorsal subluxation of the
joint with mimimal donor-site morbidity.

Question 6, Figure 1

6 | American Society for Surgery of the Hand

References:
1. Capo JT, Hastings H II, Choung E, Kinchelow T, Rossy W,
Steinberg B. Hemicondylar hamate replacement arthroplasty
for proximal interphalangeal joint fracture dislocations: An
assessment of graft suitability. J Hand Surg 2008; 33A:733-739.
2. Williams RMM, Kiefhaber TR, Sommerkamp TG, Stern PJ.
Treatment of unstable dorsal proximal interphalangeal fracture/
dislocations using a hemi-hamate autograft. J Hand Surg 2003;
28A:856-865.
Question 7, Figure 1
Question 7, Figure 2
Question 7, Figure 3
8. Treatment to correct the malunion shown in
Figure 1 is likely to:
A. Produce no improvement in patient outcome
B. Improve arc of motion and decrease symptoms
C. Improve motion but not symptoms
D. Improve symptoms but not motion
E. Improve appearance of the wrist with no impact
on symptoms
Preferred Response: B
Discussion: Dorsal angulation of distal radius fractures is
a common deformity which alters the normal kinematics
of wrist motion. Increased wrist extension and decreased
flexion can lead to adaptive midcarpal instability and
increasing symptoms over time. Surgical correction of
dorsal angulation has been shown to improve both the
arc of motion and symptoms due to midcarpal instability.
References:
1. Taleisnik J, Watson HK. Midcarpal instability caused by malunited
fractures of the distal radius. J Hand Surg 1984; 9A:350-357.
2. Lichtman DM, Schneider JR, Swafford AR, Mack GR. Ulnar
midcarpal instability – clinical and laboratory analysis. J Hand
Surg 1981; 6:515-523.
3. Batra S, Gupta A. The effect of fracture-related factors on the
functional outcome at 1 year in distal radius fractures. Injury
2002; 33:499-502.
4. Grewal R, MacDermid JC. The risk of adverse outcomes in extra-
articular distal radius fractures is increased with malalignment in
patients of all ages but mitigated in older patients. J Hand Surg
2007; 32A:962-970.
Question 8, Figure 1
2009 Self-Assessment Examination | 7
 9. A 65 year-old woman presents with inability to
extend the ring and small finger MCP joints of
her left hand. Radiographs are shown in Figure 1.
Appropriate treatment is:
A. Extension splinting of the ring and small fingers
B. Two-stage tendon grafting of the ring and small
finger extensor tendons
C. Total wrist fusion
D. Primary tendon repairs of the ring and small finger
extensor tendons
E. Resection of the distal ulna and tendon reconstruction
Preferred Response: E C. Wrist extensor to digital flexor transfer, wrist fusion,
Discussion: Rheumatoid arthritis often affects the wrist
causing tenosynovitis of the extensor tendons, disruption
of the radioulnar ligaments, and distal radioulnar
joint capsule. Instability and erosion of the distal ulna
contribute to rupture of the extensor digitorum communis
and extensor digiti minimi tendons. Successful treatment
involves correction of the distal ulnar prominence with a
Darrach resection and tendon transfer to restore digital
extension. Primary and secondary tendon repairs are
not feasible with rheumatoid tendon ruptures due to
inflammatory destruction of the tendon substance and
retraction of the proximal tendon ends.
References:
1. Klemens T. Treatment of the wrist in rheumatoid arthritis.
J Hand Surg 2008; 33A:113-123.
2. Nalebuff E. Surgical treatment of tendon rupture in the
rheumatoid hand. Surg Clin North Am 1969; 49:811-822.
3. Ishikawa H, Hanyu T, Tajima T. Rheumatoid wrists treated with
synovectomy of the extensor tendons and the wrist joint combined
with a Darrach procedure. J Hand Surg 1992; 17A:1109-1117.
Question 9, Figure 1
8 | American Society for Surgery of the Hand
10. A 13 year-old boy suffered multiple gunshot wounds
to his wrist and hand. He presents 1 year after injury
with a wrist flexion contracture and loss of active
digital flexion in all fingers. Clinical exam and
electrodiagnostic studies demonstrate absent
median nerve function distal to the wrist. The bony
skeleton is intact. Appropriate treatment is:
A. Scar debridement, skin grafting, and carpal
tunnel release
B. Scar debridement, flexor tenolysis, neuroma
resection and segmental grafting to the median
nerve defect, with z-plasty closure of skin
and carpal tunnel release
D. Scar and flexor muscle debridement, free
microvascular active muscle and nerve transfer to
the flexor compartment, with skin grafting
E. Amputation and myoelectric prosthesis to the wrist
and hand
Preferred Response: B
Discussion: Traumatic ischemic contractures of the
upper extremity are classified by etiology and severity.
Type I injuries result from injury to vascular structures
proximal to the affected fascial compartment with distal
ischemic contracture. Type II injuries result from direct
trauma to tissues including muscles, nerves, and vessels.
Both groups are further classified as mild, moderate, and
severe depending on the extent of local tissue and nerve
involvement. The present case (Figure 1) is an example of
a Type II – Moderate contracture with contracture of the
deep and superficial flexor muscles and the median nerve
resulting from direct injury.
Appropriate treatment requires exploration and
determination of the degree of necrosis and fibrosis of
the involved tissues. In this case, (Figure 2) debridement
of cutaneous and fascial scar, tenolysis of the flexor
tendons, resection of the neuroma of the median nerve
with segmental nerve grafting, and z-plasty of the skin
were performed. This allowed return of active digital
flexion, protective sensation of the median nerve, and
release of the flexion contracture, without the need for
free tissue transfer and with preservation of the intact
musculotendinous units.
References:
1. Gulgonen A. Compartment Syndrome. In: Green DP, Hotchkiss
RN, Pederson WC, Wolfe SW (eds): Green’s Operative Hand
Surgery. 5th ed. Philadelphia: Churchill Livingston/Elsevier, 2005:
1996-2006.
2. Holden CEA. The pathology and prevention of Volkmann’s
ischemic contracture. J Bone Joint Surg 1979; 61B:296-300.
3. Tsuge K. Treatment of established Volkmann’s contracture.
J Bone Joint Surg 1975; 57A:925-929.
Question 10, Figure 1
Question 10, Figure 2
11. A patient presents with symptoms of severe cold
intolerance and joint stiffness progressing over
1 to 2 years’ duration. Physical findings include
digital pallor, sclerodactyly, multiple distal fingertip
ulcerations, severe PIP and DIP joint stiffness, and
telangectasias. Likely laboratory findings are:
A. Positive rheumatoid factor and negative ANA
B. Positive rheumatoid factor and positive ANA with a
speckled pattern
C. Negative rheumatoid factor and positive ANA with a
homogenous pattern
D. Positive rheumatoid factor and positive ANA with a
nucleolar pattern
E. Negative rheumatoid factor and negative ANA
Preferred Response: D
Discussion: The clinical scenario presented is one
of scleroderma involving the hands, with Raynaud’s
phenomenon, ulceration, sclerodactyly, contractures, and
telangectasias. Common laboratory findings in diffuse
scleroderma include a positive ANA test with a nucleolar
pattern in 60-90% of patients and a positive rheumatoid
factor in 15-30%. Further ANA subtype testing can
differentiate between limited and diffuse scleroderma,
which is more likely to produce severe hand involvement.
The homogenous pattern of ANA fluorescence is most
commonly associated with systemic lupus erythematosus.
The speckled pattern is most often seen in mixed
connective tissue disease and Sjogren’s syndrome, but
can be seen in other connective tissue diseases as well.
References:
1. Serup J, Staun-Olsen P. Antinuclear antibodies and anti-DNA
antibodies in scleroderma. Allergy 1986; 41:452-456.
2. Jolly M, Smaron M, Utset TO, Ellman M. Are isolated antinuclear
antibodies a marker of scleroderma? J Clin Rheumatol 2003;
9:291-295.
2009 Self-Assessment Examination | 9
 12. The fracture of the thumb proximal phalanx seen
in Figure 1 is best treated by:
A. Reduction and casting
B. Reduction and pin fixation
C. Open reduction and pin fixation
D. Open reduction and rigid internal fixation
E. Open reduction, internal fixation, and bone grafting
Preferred Response: E D. Elbow extension/forearm supination/
Discussion: This is a pathologic fracture at the site of
an enchondroma of the proximal phalanx. The tumor
has replaced the medullary bone in the majority of the
phalanx and thinned the cortex, weakening the bone and
precipitating the fracture. Stable extra-articular pathologic
fractures of the phalanges are best treated with
immobilization alone, until fracture healing restores some
stability to the bone followed by excavation and grafting
of the tumor. This fracture is an articular fracture of the
MCP joint with substantial displacement. Open reduction
of the articular surface is necessary to minimize the risk
of traumatic arthritis. The best treatment is therefore
open reduction, internal fixation, and curettage with bone
grafting of the phalanx.
References:
1. Todai P, Hoglund M, Lugnegard H. Is the treatment of
enchondroma of the hand by simple curettage a rewarding
method? J Hand Surg 1990; 15B:331-334.
2. Wulle C. On the treatment of enchondroma. J Hand Surg 1990;
15B:320-330.
Question 12, Figure 1
10 | American Society for Surgery of the Hand
13. Surgical treatment of stroke patients often involves
the release of which of the following contractures?
A. Elbow flexion/forearm supination/
wrist and finger extension
B. Elbow flexion/forearm supination/
wrist and finger flexion
C. Elbow flexion/forearm pronation/
wrist and finger flexion
wrist and finger extension
E. Elbow extension/forearm pronation/
wrist and finger flexion
Preferred Response: C
Discussion: 80-90% of patients survive their cerebral
vascular accidents, frequently resulting in significant
disability. Spontaneous neurologic recovery can occur
for up to six months following the stroke. After this time,
surgery is performed to release spastic muscles and joint
contractures, as well as use tendon transfers to position
the involved extremity in a more functional position.
Common joint contractures include shoulder adduction,
elbow flexion, forearm pronation, wrist and finger flexion,
intrinsic muscle spasticity, and thumb-in-palm deformity.
References:
1. Tafti MA, Cramer SC, Gupta R. Orthopaedic management of the
upper extremity of stroke patients. J Am Acad Orthop Surg 2008;
16(8):462-470.
2. Pomerance JF, Keenan MA: Correction of severe spastic flexion
contractures in the nonfunctional hand. The J Hand Surg 1996;
21:828-833.
14. A 30 year-old recreational boxer injured his right
hand throwing a “really hard punch” two days
ago. Physical examination revealed tenderness
and moderate ballotable fullness over the dorsal
aspect of the long finger MP joint with EDC
tendon subluxation during MP joint flexion.
Active MP joint ROM was 20º to 90º. Radiographs
revealed no fractures. Treatment should consist of
the following:
A. Observation
B. Aspiration of the fluid
C. Dynamic MP joint extension splinting for six weeks
D. Operative treatment with repair of the MP joint
dorsal capsule
E. Operative treatment with repair of the sagittal band
Preferred Response: E
Discussion: This clinical scenario describes a boxer
with a dorsal MP joint capsular tear (the ballotable
fullness over the MP joint) and a sagittal band rupture
(EDC tendon subluxation with MP joint flexion). In this
scenario, repair of the sagittal band is recommended.
Controversy exists about the need for concomitant repair
of the dorsal capsular tear as over-tightening the dorsal
capsule may limit post-operative MP joint flexion. Acute
sagittal band ruptures without dorsal capsular tears in
lower-demand patients have been successfully treated
with customized splinting.
References:
1. Hame SL, Melone CP Jr. Boxer’s knuckle in the professional
athlete. Am J Sports Med 2000 Nov-Dec; 28(6):879-82.
2. Catalano LW, Gupta S, Ragland R, Glickel SZ, Johnson C, Barron
OA. Closed treatment of non-rheumatoid extensor dislocations at
the metacarpophalangeal joint. J Hand Surg 2006; 31A:242-245.
15. Application of silicone gel sheeting to a scar:
A. Will eliminate the scar hypertrophy
B. Is more effective than steroid injections
C. Is more effective when coated with Vitamin E
D. Is more effective than non-silicon gel sheeting
E. Provides no cosmetic benefit
Preferred Response: E
Discussion: A recent Cochrane Review explored the
benefits of silicon gel sheeting in the treatment of
hypertrophic scars and keloids. Thirteen studies were
included. The authors concluded that silicone sheeting
reduced the incidence of hypertrophic scarring in people
prone to scarring and improved scar elasticity, but could
find no cosmetic benefit in postoperative scarring.
The authors did emphasize that all studies were highly
susceptible to bias and most were of poor quality.
References:
1. O’Brien L, Pandit A. Silicon gel sheeting for preventing and
treating hypertrophic and keloid scars. Cochrane Database Syst
Review 2006: Jan.
2. Tan E, Chua SH, Lim JTE. Topical silicone gel sheet versus
intralesional injections of triamcinolone acetonide in the
treatment of keloids – a patient-controlled comparative clinical
trial. Journal of Dermatological Treatment 1999; 10(4):251-4.
16. The long-term results of intra-articular distal
radius fractures treated operatively demonstrate:
A. Frequent, disabling pain
B. Significant grip strength weakness
C. High levels of patient function and satisfaction
D. No evidence of radiocarpal joint space narrowing
E. Poor wrist motion producing functional limitations
Preferred Response: C
Discussion: Intra-articular distal radius fractures are
one of the most common injuries that a hand surgeon
evaluates. Since the fracture involves the radiocarpal
and/or the distal radio-ulnar joints, obvious concern
exists about the development of premature wrist arthritis.
A recent study by Goldfarb et al provides data that
the surgeon can communicate to the patient to allay
patient fears. At a mean of 15-year follow-up, 14/16
patients functioned at a high level and the average
Musculoskeletal Functional Assessment score was 10
(a normal score). Strength and range of motion were
unchanged from the 7-year follow-up study. Despite the
high level of patient function, radiographic evidence of
wrist arthrosis was noted in 13/16 wrists.
References:
1. Goldfarb CA, Rudzki JR, Catalano LW III, Hughes M, Borrelli J Jr.
Fifteen-Year outcomes of displaced intra-articular fractures of the
distal radius. J Hand Surg 2006; 31A:633-639.
2. Catalano LW III, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA,
Borrelli J Jr. Displaced intra-articular fractures of the distal aspect
the radius. J Bone Joint Surg 1997; 79A:1290-1302.
2009 Self-Assessment Examination | 11
 17. Which flap is most appropriate to treat the soft
tissue defect shown in Figure 1?
A. Kite flap
B. Axial flag flap
C. Digital artery island flap
D. Fillet flap
E. Reversed cross finger flap

Preferred Response: C

Discussion: This skin defect required some type of flap

coverage due to exposed flexor tendon. The digital artery
island flap (Figure 2) is raised based upon the radial or Question 17, Figure 1
ulnar digital artery/veins of the long or ring fingers (the
index and small fingers have small radial and ulnar digital
arteries, respectively, so harvesting a digital artery in
these digits can lead to cold intolerance). The flap is
dissected proximally and can be rotated to cover defects
along the length of the involved or adjacent digit (Figure
3). The Kite flap is a proximally-based flap based on
the first dorsal metacarpal artery and is raised from the
distal-radial portion of the index finger metacarpal. It is
used for thumb MP/IP joint skin defects. The axial flag
flap is based upon a dorsal digital artery of any digit
and is elevated from the dorsal aspect of the donor digit
proximal phalanx. It can be rotated to cover adjacent
finger dorsal or volar MP joint skin defects. A fillet flap
Question 17, Figure 2
obtains skin from a severely damaged finger and involves
removing the bone and tendons from the injured digit
leaving vascularized skin for coverage. The reverse cross
finger flap is used to cover defects on the dorsum of digits.
It involves harvesting a flap of subcutaneous tissue at the
middle phalanx from an adjacent finger and rotating the
flap to cover the defect. A full-thickness skin graft is then
used to cover the flap of subcutaneous tissue.

Reference:
1. Rose EH. Local arterialized island flap coverage of difficult hand
defects preserving donor digit sensibility. Plast Reconstr Surg
1983; 72:848-857.

Question 17, Figure 3

12 | American Society for Surgery of the Hand

18. Proper treatment of extravasation of
Vincristine includes:
A. Application of ice packs
B. Local injection of dimethyl sulfoxide (DMSO)
C. Hot compresses and local injection of hyaluronidase
D. I.V. administration of sodium thiosulfate
E. Subcutaneous injection of sodium thiosulfate
Preferred Response: C
Discussion: Unfortunately, extravasation of cancer
chemotherapeutic agents is a frequently-encountered
clinical scenario that can potentially cause permanent
local injury. Initial treatment regardless of the type of
agent involves immediately stopping the infusion and
splinting/elevation of the involved extremity. Although
it is unreasonable to memorize all of the specific
antidotes for each agent, some basic principles should
be committed to memory. Heat is applied for vinca
alkaloid (e.g., vincristine) extravasation to produce
vasodilation and increase blood flow to the area. Ice
packs are used for anthracycline (e.g., doxorubicin)
extravasation. Use of heat for anthracycline and ice for
vinca alkaloid extravasation may result in harmful effects.
Additional treatment of vinca alkaloid extravasation
includes injection of hyaluronidase around the site
of extravasation. DMSO injections are used to treat
anthracycline extravasation. Sodium thiosulfate is
injected locally for extravasation of alkylating agents such
as cisplatin or nitrogen mustard.
References:
1. Schrijvers DL. Extravasation: a dreaded complication of
chemotherapy. Annals of Onc. 2003; 14 (supplement 3):iii26-iii30.
2. Ener RA, Meglathery S, and Styler M. Extravasation of systemic
hemato-oncological therapies. Annals of Onc. 2004; 15:858-862.
19. The most effective treatment of onychomycosis
caused by Candida infections is:
A. Terbinafine
B. Itraconazole
C. Mechanical removal of the nail plate alone
D. Griseofulvin
E. Amphotericin B
Preferred Response: B
Discussion: Onychomycosis is a common clinical
condition and can substantially negatively impact a
patient’s quality of life. Onychomycosis is caused by
dermatophytes, yeasts, and non-dermatophyte molds.
Yeasts (e.g., Candida) are most common in the fingernail
and represent up to 33% of fingernail onychomycosis.
Multiple trials have demonstrated that terbinafine is
the most effective treatment for infections caused by
dermatophytes. However, for Candida infections, a
recent randomized trial revealed a 92% cure rate with
itraconazole versus a 40% cure rate with terbinafine.
These studies highlight the importance of culturing
the nailplate and/or debrided tissue prior to starting
the drug treatment. Debridement of the nailplate in
addition to terbinafine has been shown to result in
higher cure rates that terbinafine alone in the treatment
of onychomycosis.
References:
1. Mishra M, Panda P, Tripathy S, Sengupta A, Mishra K. An open
randomized comparative study of oral itraconazole pulse and
terbinafine pulse in the treatment of onychomycosis. Indian J
dermatol verereol Leprol. 2005; 71:262-266.
2. Nunley KS, Cornelius L. Current management of onychomycosis.
J Hand Surg 2008; 33A:1222-1214.
20. Women undergoing elective hand surgery
following an ipsilateral axillary node dissection
should be informed that:
A. There is a higher risk of postoperative infection
B. New lymphedema will likely occur
C. Delayed wound healing is probable
D. Surgery can be performed without
additional complications
E. A sympathetically mediated pain syndrome is
more likely
Preferred Response: D
Discussion: Breast cancer survivors are frequently told to
have no interventions on the ipsilateral side of the axillary
node dissection. This poses a major problem when the
patient requires surgery on the affected side. Two studies
have clearly demonstrated that there is no additional risk
of infection, delayed wound healing, development of a
pain syndrome or new lymphedema after elective surgery
on an extremity having undergone a prior ipsilateral
axillary node dissection.
References:
1. Hershko DD and Stahl S. Safety of elective hand surgery
following axillary node dissection for breast cancer. Breast J.
2007; 13(3):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(2):132-137.
2009 Self-Assessment Examination | 13
 21. Acrosyndactyly (Figure 1), or fusion of the terminal
portion of two or more digits with proximal sinuses
between the digits, is seen in:
A. Constriction band syndrome
B. Poland’s syndrome
C. Cleft hand
D. Simple, incomplete syndactyly
E. Simple, complete syndactyly
Preferred Response: A
Discussion: Acrosyndactyly is a typical feature of
Constriction Band Syndrome (Streeter’s dysplasia). This
disorder occurs when amniotic bands wrap around the
digits producing simple and/or complex syndactyly,
digital shortening, and potentially, acute vascular
compromise of the digit. Acrosyndactyly arises from
normal developing fingertips being fused together by
the amniotic bands while the proximal aspect of the web
space remains patent, resulting in the interdigital cleft.
Reference:
Flatt AE. The Care of Congenital Hand Anomalies. St. Louis: Quality
Medical Publishing, 1994:276-291.
Question 21, Figure 1
14 | American Society for Surgery of the Hand
22. A study in which patients are recalled and
compared on the basis of two different types
of treatment (e.g., pinning versus ORIF of distal
radius fractures) is called a:
A. Randomized controlled study
B. Non-randomized, non-blinded controlled study
C. Retrospective comparative study
D. Case-control study
E. Case series
Preferred Response: C
Discussion: As a result of the recent emphasis on
evidence base medicine, all surgeons should be familiar
with the different types of therapeutic studies that
generate five different levels of evidence. Level I evidence
consists of high-quality, randomized, controlled trials with
statistical significance and narrow confidence intervals.
Studies that generate Level II evidence are lesser-quality
controlled trails and prospective comparative studies.
Level III evidence is generated by case-control and
retrospective comparison studies. A case control study is
a study in which patients are enrolled on the basis of an
outcome (cases) and compared to patients who did not
have that outcome (controls). A retrospective comparative
study is defined as a study that was started after the first
patient was enrolled and compares patients treated by
two different techniques at the same institution. Level IV
evidence arises from case series and Level V evidence
consists of expert opinion.
Reference:
Phillips B, Bell C, Sackett D, Badenech B, Straus S, Haynes B,
Dawes M. Oxford Centre for Evidence-Based Medicine Levels of
Evidence. May 2001.
23. The patient seen in Figures 1, 2 and 3 has a
long‑standing ulnar nerve injury above the elbow
and is being evaluated for correction of his claw
finger deformity. What is the most appropriate
tendon transfer?
A. ECRL dorsal to the intermetacarpal ligament
B. FDS of the ring finger dorsal to the
intermetacarpal ligament
C. FDS of the ring finger volar to the
intermetacarpal ligament
D. EIP volar to the intermetacarpal ligament
E. EIP dorsal to the intermetacarpal ligament
Preferred Response: D
Discussion: The cause of clawing from an ulnar nerve
palsy (MP joint hyperextension and PIP joint flexion) is a
loss of intrinsic muscle function. The force of the extrinsic
extensor is dissipated at the MP joint so all operations for
clawing are designed to prevent MP joint hyperextension.
Figure 3 demonstrates a Fowler’s test in which you test
active PIP extension while preventing MP hyperextension.
If you can get full PIP extension with Fowler’s test, there
is a good prognosis for any operation for ulnar clawing.
Although all of the above responses are recognized
transfers for claw finger deformity, the appropriate transfer
in this patient with this history is a transfer of the extensor
indicis proprius volar to the inter-metacarpal ligament.
A volar capsulorraphy in a person with good extensor
tendons available to his MP joints will usually stretch out
after time. If the flexor digitorum sublimis tendon of the ring
finger is used, there is no other tendon to flex the finger.
One of the basic tenants of tendon transfer is to transfer
the tendon volar to the axis of the metacarpophalangeal
joint and this is accomplished by transferring the tendon
volar to the intermetacarpal ligament.
References:
1. Anderson, GA. Ulnar nerve palsy. In: Green DP, Hotchkiss R,
Pederson W, Wolfe S eds. Operative Hand Surgery. 5th ed.
Philadelphia, Churchill Livingston, 2005:1168-1183.
2. Hastings, Hill II, Davidson S(RN). Tendon transfers for ulnar nerve
palsy. Hand Clin 1988; 4(2):167-178.
Question 23, Figure 1
Question 23, Figure 2
Question 23, Figure 3
24. Surgical correction of a PIP joint contracture in a
patient with a long standing Dupuytren’s disease
results in a passive correction at the time of
surgery to 15º from a 95º fixed flexion contracture.
Postoperatively, the patient is unable to extend the
PIP joint actively. What is the most likely cause?
A. Failure to adequately release the deforming cords
B. Failure to adequately release the volar plate
C. Shortening of the flexor digitorum profundus
and superficialis
D. Contracture and adhesions of the collateral and
accessory collateral ligaments
E. Attenuation of the extensor mechanism
Preferred Response: E
Discussion: Although all of these responses can
contribute to flexion contracture of the PIP joint in
Dupuytren’s disease, attenuation of the extensor
mechanism after long-standing PIP joint flexion
contracture is a common cause of an inability to actively
extend the joint postoperatively. Intraoperatively, passive
extension was obtained to 15° after releasing the
appropriate structures. The patient, after surgical release,
could not actively extend the PIP joint, secondary to
attenuation of the central slip of the extensor tendon.
In long-standing Dupuytren’s contracture and PIP
joint flexion contracture, the central slip is commonly
stretched and attenuated over the PIP joint. If this is
not recognized, active extension of the PIP joint is not
restored despite release of the offending structures.
References:
1. Andrew JG. Contracture of the proximal interphalangeal joint in
Dupuytren’s disease. J Hand Surg 1991; 16B:446.
2. Crowley B, Hawkin MA. The proximal interphalangeal joint in
Dupuytren’s disease. Hand Clin 1999; 15(1):137-148.
2009 Self-Assessment Examination | 15
 25. Cryotherapy for the treatment of injury has been References:
shown to: 1. Lister GD. The theory of the transposition flap and its practical
application in the hand. Clin Plast Surg 1981; 8:115-127.
A. Prevent local hemorrhage
2. Lister GD. Local flaps in the hand. Hand Clin 1985; 1(4):621-647.
B. Prevent edema
C. Reduce tenderness and hematoma
D. Decrease pain
E. Increase muscle spasm

Preferred Response: D

Discussion: Cold affects inflammatory responses

following soft tissue injury by reducing enzymatic
function and decreasing metabolism. It produces
vasoconstriction, which may alter the extension of a
hematoma but does not prevent local hemorrhage after
an injury. Edema is not prevented by cold application.
Muscle spasm is reduced by cold application through
its effect on the muscle spindle. Cold relieves pain Question 26, Figure 1 Question 26, Figure 2

through its effect on the pain fibers. Pain relief from

cold is caused by blocking the sensory transmission of
the pain impulses caused by slowing or elimination of
nerve conduction. Tenderness or soreness in the muscle
caused by palpation is not affected by cold.

References:
1. Matsen FA, Questad K, Matsen AL, et al. The effect of local
cooling on post-fracture swelling. Clin Orthop Relat Res 1975;
109:201.

2. Meeusen R, Lievens P. The use of cryotherapy in sports injuries.

Sports Med 1986; 3:398-414.

Question 26, Figure 3 Question 26, Figure 4

26. A 60 year-old patient with a soft tissue defect has
a rotation flap for coverage, as seen in Figures 1-5.
The survival of the skin graft placed on the defect
created by the rotation flap is dependent on:
A. Preservation of a vascular bed
B. The size of the defect that accepts the graft
C. Blood supply to the flap itself
D. The length of the flap
E. The width of the flap

Preferred Response: A

Discussion: The figures depict a transposition flap on the

dorsum of the hand involving the extensor tendons. The Question 26, Figure 5
survival of the flap depends upon the blood supply which,
in turn, is dependent on the anatomy, the length, width and
breadth of the flap and the tension under which it is sutured.

Preservation of the paratenon over the extensor tendon is

crucial in allowing the skin graft to survive and mature.

16 | American Society for Surgery of the Hand

27. A 40 year-old woman with breast cancer
complains of chronic fatigue, pain in multiple
joints and muscles, and a rash over her hand with
painful MCP and PIP joints. Her laboratory studies
show a markedly elevated SGOT, CPK and SGPT.
The image of her hand is seen in Figure 1. What is
the most likely diagnosis?
A. Rheumatoid arthritis
B. Scleroderma
C. Systemic lupus erythematosus
D. Dermatomyositis
E. Polymyositis
Preferred Response: D
Discussion: Dermatomyositis has a characteristic rash
over the eyelids and the dorsum of the hand. It is also
often associated with malignancy, particularly abdominal
sarcomas, lymphomas and breast cancer. Elevated
muscle enzymes, fatigue and weakness are characteristic
of dermatomyositis.
Gottron’s papules are symmetric, lacy, pink to violaceous
raised or macular areas found on the dorsum of the
MP and the PIP joints, the elbow, patella and the
medial malleoli. Periungual telangiectasias and capillary
changes are also seen about the hand, particularly
along the dorsum of the hand. The characteristic rash of
dermatomyositis is described as being a violaceous rash
present around the eyes.
28. A 49 year-old man has a diagnosis of acute
gouty arthropathy in his wrist. This is his first
symptomatology. In addition to splinting and ice
packs, the most appropriate initial drug treatment
is which of the following?
A. Oral colchicine
B. Intravenous colchicine
C. Non-steroidal anti-inflammatory drugs
D. Corticosteroids orally
E. Intraarticular corticosteroids
Preferred Response: C
Discussion: Under most circumstances, the primary
treatment for acute gouty arthritis is a non-steroidal
anti-inflammatory drug or a cox-2 inhibitor. Oral or
intraarticular glucocorticoids are the second choice.
Colchicine, either orally or intravenously, is the third
choice because of the significant toxicity associated
with colchicine. Gastrointestinal side effects, renal
dysfunctions, and bone marrow suppressions all occur
with colchicine administration.
References:
1. Wortmann RL. Gout and hyperuricemia. Current Opinion in
Rheum 2002; 14:281-286.
2. Roberts W, Liang MH, Stern SH. Colchicine in acute gout. JAMA
1987; 257:1920-1921.

References:
1. Callen J. Dermatomyositis. Lancet 2000; 255:53-57.

2. Euwer RL, Sontheimer RD, Braverman IM. Dermatomyositis

and polymyositis. In: Demis DJ, ed. Clin Dermatol. 1st ed.
Philadelphia: JB Lippincott, 1994:1-14.

Question 27, Figure 1

2009 Self-Assessment Examination | 17
 29. A 35 year-old man sustains the injury seen in
Figures 1 and 2. Which wrist ligament remains
intact in this injury?
A. Scapholunate
B. Lunotriquetral
C. Dorsoradial carpal
D. Short radiolunate
E. Long radiolunate

Preferred Response: D

Discussion: In the progression of perilunate instability,

in stage 1, the scapholunate ligaments fail—usually from Question 29, Figure 2
the palmar aspect to the dorsal aspect. In stage 2, there
becomes a progressive lunocapitate disassociation as
the distal row of carpal bones follow the capitate dorsally,
allowing the lunate to open the space of Poirier. 30. The rate at which an action potential is conducted
along an axon is increased with the presence of:
In stage 3, the lunotriquetral ligament is torn or an
A. Nodes of Ranvier
avulsion fracture of the triquetrum occurs. Also in stage
3, with a complete rupture of the lunotriquetral ligament, B. Local anesthetic
the ulnar expansions of the long radiolunate ligament C. Decreased axon diameter
usually tear, leaving the short radiolunate ligament and D. Nerve compression
the ulnolunate ligament as the lunate’s only stabilizing
E. Increased age of the patient
forces as it continues to rotate volarly.
Preferred Response: A
References:
1. Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds. Discussion: The presence of myelin, Nodes of Ranvier,
Green’s Operative Hand Surgery. 5th ed. Philadelphia: Churchill and larger axon diameter, all increase the rate of a nerve’s
Livingston/Elsevier, 2005: ch.14.
action potential. Nerve conduction slows with increased
2. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: age. Local anesthetics, such as lidocaine and marcaine,
pathomechanics and progressive perilunar instability. J Hand cause a nerve conduction block which causes slowing or
Surg 1980; 5A:2226-41.
interruption of nerve conduction.

References:
1. Bodine SC, Lieber RL. Peripheral nerve physiology, anatomy,
and pathology. In: Orthopaedic Basic Science, Buckwalter
JA, Einhorn TA, Simon SR, ed. 2000, American Academic of
Orthopaedic Surgeons. p. 617-682.

2. Ramamurthy S, Anderson D. Anesthesia. In: Green DP, Hotchkiss

RN, Pederson WC, Wolfe SW, eds. Green’s Operative Hand
Surgery. 5th ed. Philadelphia: Churchill Livingston/Elsevier,
2005:25-30.

Question 29, Figure 1

18 | American Society for Surgery of the Hand

31. Considering the physiology of bone healing, Discussion: Similar to SLAC wrist arthritis, SNAC wrist
scaphoid fractures heal by: arthritis can be staged:
A. Primary bone healing Stage I – degeneration of the radial styloid and radial
B. Secondary bone healing aspect of the scaphoid
C. Callus formation Stage II – degeneration progresses to the level of the
D. Internal fixation scaphoid fracture and involves the scaphocapitate joint
E. Enchondral ossification Stage III – degeneration of the capitolunate joint
Preferred Response: A Stage IV – pan-carpal arthrosis
Discussion: Scaphoid fractures do not make callus (nor Scaphoid nonunion, in this case, has led to flexion of
do they heal by secondary bone healing). They heal by the distal scaphoid and radioscaphoid arthritis with
primary bone healing with bridging trabeculae. degeneration of the scaphoid facet of the radius and the
References: scaphocapitate joint. In Stage II, degeneration attempts
to achieve healing at the scaphoid will not treat the
1. Singh HP, Forward D, Davis TRC, Dawson JS, Oni JA, Dowing
ND. Partial Union of acute scaphoid fractures. J Hand Surg 2005; arthritis of the scaphocapitate joint and radial styloid.
30B:5:440–445. Scaphoid excision with fusion of the capitate and lunate
or four-corner fusion can provide reliable pain relief for
2. Dias JJ. Definition of union after acute fracture and surgery
for fracture nonunion of the scaphoid. J Hand Surg 2001; radioscaphoid arthritis secondary to scaphoid nonunion.
26B:321–325.
References:
1. Enna M, Hoepfner P, Weiss AP. Scaphoid excision with four-
corner fusion. Hand Clin 2005; 21(4):531-538.
32. What is the most reasonable surgical treatment for
this 38 year-old laborer with radial wrist pain? 2. Cohen MS, Kozin SH. Degenerative arthritis of the wrist:
proximal row carpectomy versus scaphoid excision and
A. Arthroscopic debridement four-corner arthrodesis. J Hand Surg 2001; 26A(1):94-104.
B. Vascularized bone grafting of the scaphoid with 3. Siegel JM, Ruby LK. A critical look at intercarpal arthrodesis:
internal fixation review of the literature. J Hand Surg 1996; 21A(4):717-723.
C. Scaphoid excision with capitolunate fusion
D. Total wrist fusion
E. Total wrist arthroplasty

Preferred Response: C

Question 32, Figure 1 Question 32, Figure 2

2009 Self-Assessment Examination | 19

 33. What will optimize midcarpal motion in a patient
with a radioscapholunate fusion?
A. Fusion with headless screws
B. Excision of the distal pole of the scaphoid
C. Excision of the entire triquetrum
D. Midcarpal interposition arthroplasty
E. Release of the radioscaphocapitate ligament
Preferred Response: B
Discussion: Radioscapholunate fusion without excision
of the distal scaphoid creates a bridge between the
radius and the distal carpal row through the stout
ligaments of the STT joint. Without excision of the
distal pole of the scaphoid, the distal row is “locked” to
the proximal row which has been fused to the radius.
STT forces are high as flexion and radial deviation are
prevented. There is risk of scaphoid fracture due to these
high forces as well. Excision of the distal portion of the
scaphoid (30%) “unlocks” the proximal and distal carpal
rows, leading to improved mobility and less degeneration
of the STT joint.
Weiss and Rodner, in a literature review paper, have
noted when the distal pole of the scaphoid is excised in
a radiocarpal fusion, the expected flexion/extension arc
of the wrist is 50-66% of the opposite side. These results
have also been shown by Garcia-Elias and others.
References:
1. Garcia-Elias M, Lluch A, Ferreres A, Papini-Zorli I, Rahimtoola
ZO. Treatment of radiocarpal degenerative osteoarthritis by
radioscapholunate arthrodesis and distal scaphoidectomy.
J Hand Surg 2005; 30A(1):8-15.
2. Nagy L, Büchler U. Long-term results of radioscapholunate
fusion following fractures of the distal radius. J Hand Surg 1997;
22B(6):705-10.
3. Weiss KM, Rodner CE. Osteoarthritis of the wrist. J Hand Surg
2007; 32A:725-746.
34. What is the most effective means of preventing
a thumb web space contracture during the initial
management of a mutilated hand?
A. Thumb spica splint to maintain the web space
B. CMC fusion
C. External fixation to maintain the web space
D. Web space wound closure
E. Early motion
Preferred Response: C
20 | American Society for Surgery of the Hand
Discussion: External fixation with two pins in the thumb
metacarpal and two pins in the index metacarpal
provides rigid stability to allow the soft tissues of the first
web space to heal while minimizing contracture.
References:
1. Acartürk TO, Ashok K, Lee WP. The use of external skeletal
fixation to facilitate the surgical release of wrist flexion and thumb
web space contractures. J Hand Surg 2006; 31A(10):1619-1625.
2. Littler JW. The prevention and the correction of adduction
contracture of the thumb. Clin Orthop Relat Res 1959; 13:182-192.
35. When comparing treatment results after
incision and drainage of suppurative flexor
tenosynovitis, the use of postoperative continuous
catheter irrigation:
A. Demonstrates improved healing times and
functional recovery
B. Is not significantly different from intraoperative
irrigation alone
C. Demonstrates significantly prolonged healing times
D. Is significantly more effective in treating
MRSA infections
E. Diminishes the need for postoperative antibiotics
Preferred Response: B
Discussion: Lille et al. demonstrated, in a retrospective
review of 20 patients treated without postoperative
irrigation versus 55 patients with postoperative
continuous irrigation, no significant differences between
these two groups with respect to length of hospital stay,
complication rates, or postoperative range of motion.
While this study is level IV evidence, it does not show a
significant benefit of postoperative continuous irrigation.
References:
1. Lille S, Hayakawa T, Neumeister MW, et al. Continuous
postoperative catheter irrigation is not necessary for the
treatment of suppurative flexor tenosynovitis. J Hand Surg 2000;
25B(3):304-307.
2. Carter SJ, Burman SD. Treatment of digital tenosynovitis by
irrigation with peroxide and oxytetracycline. Review of nine
cases. Annals of Surgery 1996; 163:645-650.
36. Diagnosis of the infection pictured in Figures 1
and 2 in a 52 year-old nurse is confirmed by which
laboratory test?
A. Lowenstein-Jensen agar
B. Tzanck smear
C. Rapid Plasma Reagin (RPR)
D. Ziehl Neelsen prep with fluorescent stain
E. Fungal culture
Preferred Response: B
Discussion: These clinical pictures demonstrate a
herpetic whitlow infection which is common in health care
professionals. Optimal management in this case is to first
confirm the diagnosis by unroofing a vesicle and obtaining
a viral swab for Tzanck smear (viral cultures or PCR assay
are also possibilities). While superinfection with bacteria
may occur in cases of herpetic whitlow, these images do
not show signs of significant bacterial infection. Supportive
care for herpetic whitlow infections may include anti-virals
such as acyclovir, if the lesions are particularly painful.
References:
1. Adams RA, Botte MJ. Hand infections: treatment
recommendations for specific types. J Am Acad Orthop Surg
1996; 4:219-230.
2. Smith P. Lister’s The Hand: Diagnosis and Treatment, 4th ed.
London: Churchill Livingstone, 2002:319.
Question 36, Figure 1
Question 36, Figure 2
37. The most common complication after surgical
treatment of infectious flexor tenosynovitis is:
A. Digital stiffness
B. Nerve injury
C. Wound dehiscence
D. Tendon rupture
E. Recurrent infection
Preferred Response: A
Discussion: Lille et al. demonstrated a 19% digital
stiffness rate in 62 patients followed after flexor
tenosynovitis incision and drainage. Recurrent infection
occurred in 8% of patients.
References:
1. Lille S, Hayakawa T, Neumeister MW, et al. Continuous
postoperative catheter irrigation is not necessary for the
treatment of suppurative flexor tenosynovitis. J Hand Surg 2000;
25B(3):304-307.
2. Pollen AG. Acute infection of tendon sheaths. The Hand 1974;
6:21-25.
38. Prospective randomized trials assessing the value
of extracorporeal shock wave therapy (ESWT) for
lateral epicondylitis have shown significant:
A. Improvement in functional outcomes after ESWT
compared to a steroid injection
B. Improvement in function over six months not
significantly different from placebo
C. Improvement in function over six months with better
functional outcomes than placebo
D. Improvement in pain over six months with better
pain scores than placebo
E. Worsening in pain and function compared to placebo
Preferred Response: B
Discussion: Cochrane review and prospective,
randomized, controlled trials on the use of extracorporeal
shock wave therapy for lateral epicondylitis demonstrate
no significant difference over placebo.
References:
1. Staples MP, Forbes A, Ptasznik R, Gordon J, Buchbinder R.
A randomized controlled trial of extracorporeal shock wave
therapy for lateral epicondylitis (tennis elbow). J Rheumatol. 2008
Oct; 35(10):2038-46. Epub 2008 Sep 15.
2. Buchbinder R, Green SE, Youd JM, Assendelft WJ, Barnsley L,
Smidt N. Shock wave therapy for lateral elbow pain. Cochrane
Database Syst Rev. 2005 Oct 19;(4):CD003524. Update of:
Cochrane Database Syst Rev. 2002;(1):CD003524.
2009 Self-Assessment Examination | 21
 39. An experienced, senior hand surgeon publishes
her results on a new fixation technique for ulnar
shortening osteotomies in 10 patients, including
functional outcomes measured by objective and
subjective data, as well as pre and postoperative
DASH scores. This type of study is an example of
what level of evidence?
A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V
Discussion: Wounds, measuring less than 1 square cm,
affecting the volar aspect of the finger or the fingertip
itself, have a remarkable ability to heal with dressing
changes. This axiom is especially true in cases of wound
contamination after there has been a formal debridement
of all nonviable soft tissue.
References:
1. Vedder NB, Hanel DP. The Mangled Upper Extremity. In: Green
DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green’s
Operative Hand Surgery. 5th ed. Philadelphia: Churchill
Livingston/Elsevier, 2005:1587.
2. Smith P. Lister’s The Hand: Diagnosis and Treatment, 4th ed.
London: Churchill Livingstone, 2002:113-114.

3. Louis DS, Palmer AK, Burney RE. Open treatment of digital tip
Preferred Response: D
injuries. JAMA 1980; 244(7):697-698.
Discussion: Level of evidence has been classified for the
purpose of scientific publication:

Level I evidence – large, randomized, clinical trials with

clear results or meta-analyses of randomized trials

Level II evidence – randomized trials, uncertain results

and high quality prospective cohort

Level III evidence – case-control studies

Level IV evidence – case series with no controls

Level V evidence – expert opinion, physiology or

bench research
Question 40, Figure 1
References:
1. Szabo RM. Show me the evidence. J Hand Surg 2008; 33A:150–156.

2. MacDermid JC. An introduction to evidence-based practice for 41. As the forearm rotates from supination to
hand therapists. J Hand Ther 2004; 17:105–117. pronation, load-bearing on the articular surface of
the sigmoid notch of the distal radius:
A. Remains in the central third
40. Optimal wound management for this through
B. Moves distal to proximal along the dorsal 50%
and through gun shot wound (Figure 1) without
neurovascular, tendon, or bone injury after C. Moves from dorsal to volar in the central third
debridement includes: D. Moves from proximal volar to distal dorsal
A. Split thickness skin graft E. Moves from distal dorsal to proximal volar
B. Full thickness skin graft Preferred Response: D
C. Primary closure
D. Cross finger flap
E. Dressing changes

Preferred Response: E

22 | American Society for Surgery of the Hand

Discussion: Anatomic studies have demonstrated that
the radius of curvature of the sigmoid notch is greater
than that of the ulnar head. This leaves the sigmoid notch
a degree of freedom to translate moving the contact point
from a volar position in supination to a more dorsal contact
point in pronation. In addition, as the radius rotates around
the ulna from supination to pronation, there is a relative
shortening of the radius with respect to the ulna.
This moves the contact surface from proximally in
supination to distally in pronation. The combination of
these two translational forces moves the contact point from
proximal volar in supination to distal dorsal in pronation.
Discussion: CMT is a type of inherited peripheral nerve
disease. While onset is usually in the first or second decade,
it may occur later in life. Its initial clinical presentation
is variable but frequently patients have problems with
tripping and falling. On electrodiagnostic testing, patients
will typically have changes in both motor and sensory
conduction velocities, although clinically sensory symptoms
are unusual. Significant slowing of all motor nerves in
all extremities will be found with muscle denervation
affecting the more distal motors. The pathology in
CMT relates to defects in the production of myelin with
progressive axonal degeneration and muscle denervation.

References: ALS or amyotrophic lateral sclerosis is a neuro-

1. Af Ekenstam F, Hagert CG. Anatomic studies on the geometry degenerative disease affecting the motor neurons. With
and stability of the distal radioulnar joint. Scand J Plast Reconstr loss of the lower motor neurons in the anterior horn of
Surg 1985; 19:17-25. the spinal cord, there is muscle denervation and atrophy.
2. Palmer AK, Werner FW. Biomechanics of the distal radioulnar ALS does not produce a significant slowing in nerve
joint. Clin Orthop Relat Res 1984; 187:26-25. conduction velocity. Cubital tunnel syndrome would
3. Af Ekenstam FW, Palmer AK, Glisson RR. Load on the radius not result in denervation of radial or median innervated
and ulna in different positions of the wrist and forearm: a cadaver muscles. A C8 radiculopathy would not account for the
study. Acta Orthop Scand 1984; 55:363-365. increases in sensory latency, the changes in the flexor
carpi radialis, or the history of frequent tripping. Carpal
tunnel syndrome would not account for the ulnar nerve or
42. A 35 year-old male presents with bilateral arm radial nerve electrodiagnostic abnormalities.
weakness. An EMG/nerve conduction study of
References:
his more symptomatic right upper extremity is
performed and reveals the following results. 1. Chance PF, Bird TD. In: Kasper DL, Braunwald E, et al. Ed
Harrison’s Principals of Internal Medicine. New York: McGraw-
What is the most likely diagnosis?
Hill, 2005:2510-2513.
NCV Normal
2. Wood VE, et al. Treatment of upper limb in charcot-marie-tooth
Right median motor NCV 25 meters/sec >49 meters/sec disease. J Hand Surg 1995; 20B:511-8.
Right median palmar 2.4 ms <2.2 ms
sensory latency
Right ulnar motor NCV 31 m/sec >49 m/sec
Right ulnar palmar 2.4 ms <2.2 ms
sensory latency

EMG Insertional Activity Fibrillations Motor Unit Action

Normal or Increased 0 to 4+ Potentials
(R)EIP Increased 2+ Large, complex
(R)APB Increased 3+ Large, complex,
fast-firing
(R)FDI Increased 3+ Large, complex
(R)FCR Slightly increased 1+ Some normal, some large
(R) Triceps Normal None Normal
(R) Biceps Normal None Normal
(R) Deltoid Normal None Normal

A. ALS (motor neuron disease)

B. Cubital tunnel syndrome
C. C8 radiculopathy
D. Charcot-Marie-Tooth polyneuropathy
E. Carpal tunnel syndrome

Preferred Response: D
2009 Self-Assessment Examination | 23
 43. A 60 year-old homeless man is brought to the
emergency room after spending the night outside in
sub-zero weather. On examination, all of his fingers
are white, cold, and without capillary refill. For
treatment, you recommend immediate rewarming
of his hands in water 104º Fahrenheit, pain
medication, tetanus prophylaxis, antibiotics, and
ibuprofen. The role of ibuprofen is to:
A. Supplement pain management
B. Decrease red cell sludging caused by vasoconstriction
C. Limit platelet adhesiveness and thrombosis
D. Decrease sympathetically mediated vasospasm
E. Decrease the toxicity of the arachidonic acid cascade
Preferred Response: E
Discussion: Frostbite injury has been divided into the
phases of cooling, freezing, and rewarming. Cell death in
the cooling phase occurs as a result of vasoconstriction.
With vasoconstriction, there is sludging of blood and
thrombosis. The resultant ischemia triggers chemical and
cellular mediated inflammation. The chemical mediators
include prostaglandins, bradykinins, thromboxane,
and histamine. During the freezing phase, cell death
results from cellular dehydration as water freezes in the
interstitial space creating an ionic gradient intracellular
dehydration. When ice forms within the cell membrane,
there is a loss of membrane integrity and cell death.
The interstitial ice crystals melt, and the inflammatory
response is reactivated. The result is a toxic local
environment, which results in additional tissue loss.
Attempts have been made to limit tissue thrombosis with
heparin and dextran, but studies are inconclusive in their
ability to preserve tissue. Thrombolytic agents, such as
streptokinase and urokinase have been shown to be of
some benefit. It remains unclear as to whether or not
regional blocks and hyperbaric oxygen can limit tissue
loss in the rewarming phase. Clinical studies have shown
improved tissue survival in all degrees of frostbite with
the use of ibuprofen to inhibit the inflammatory effects of
the arachidonic acid cascade.
References:
1. Heggers JP, Robson MC, et al. Experimental and clinical
observations on frostbite. Ann Emerg 1987; 16(9):1056-62.
2. Su CW, Lohman R, Gottlieb LJ. Frostbite of the upper extremity.
Hand Clin 2000; 16(2):235-47.
3. Bruen KJ, Ballard JR, et al. Reduction of the incidence of
amputation and frostbite injury with thrombolytic therapy. Arch
Surg 2007; 142(6):546-51.
24 | American Society for Surgery of the Hand
44. When discussing with a patient the significance
of a 2 mm articular incongruity three months
after treatment of an intraarticular fracture of
the distal radius by another physician, the patient
is advised:
A. An immediate intraarticular osteotomy is necessary
B. Within five to seven years, a wrist fusion will
be required
C. While radiographic changes of joint degeneration
are likely, they may not be progressive and pain will
not correlate with these changes
D. There will be no further x-ray changes and normal
motion and grip strength can be anticipated
E. Radiographic changes of joint degeneration will be
progressive and pain will correlate with the severity
of these changes
Preferred Response: C
Discussion: A correlation between intraarticular
incongruity following distal radius fractures and the
radiographic findings of post-traumatic arthritis were
documented by Knirk and Jupiter in 1986. Subsequent
studies have shown a correlation between the amount
of incongruity and the development of radiographic
changes of post-traumatic osteoarthritis. There is also a
correlation with a decrease in motion and a decrease in
grip strength with intraarticular fractures in comparison
to the uninjured extremity. These studies have also
shown that while radiographic changes consistent
with post-traumatic arthritis may develop, they may
not be progressive and the severity of changes graded
according to the system of Knirk and Jupiter do not
correlate with pain. In this setting with a healed fracture,
there is presently no evidence to support the need for
an intraarticular osteotomy to address this incongruity
nor is there evidence that this will progress to require
a wrist fusion.
References:
1. Knirk JL, Jupiter JB. Intraarticular fractures of the distal end of
the radius in young adults. J Bone Joint Surg 1986; 68A:647-59.
2. Catalano WL III, Kohl JR, Gelberman RH et al. Displaced
intraarticular fractures of the distal aspect of the radius: long-
term results in young adults after open reduction and internal
fixation. J Bone Joint Surg 1997; 79A:1290-302.
3. Forward DP, Davis TRC, Sithole JS. Do young patients with
malunited fractures of the distal radius inevitably develop
symptomatic post-traumatic arthritis? J Bone Joint Surg 2008;
90B(5):629-637.
45. Eight weeks after closed reduction and 46. The most important factor inherent to the skin
percutaneous pinning of carpometacarpal graft itself in regard to contracture is the:
dislocations of the index through small fingers,
A. Skin graft donor site
a patient demonstrates active and passive MP
extension of only 45º. The patient has complete B. Total percentage of dermis within the graft
finger flexion and good grip strength. An intrinsic C. Absolute thickness of the graft
tightness test is positive for all digits. The initial D. Technique used in harvest of the graft
treatment for this patient should be:
E. Age of the patient
A. A1 pulley releases
Preferred Response: B
B. Static progressive MP extension splinting
C. Botox injections of the interosseous muscles Discussion: In both experimental and clinical settings,
full-thickness skin grafts have been shown to produce
D. Lateral band excision
less contracture than split-thickness skin grafts. When
E. Volar MP capsulectomies looking at factors inherent to the skin graft, it is the
percentage of the dermis grafted, not the absolute
Preferred Response: B
thickness of the graft that determines the amount of
Discussion: Following a high energy injury involving contracture (i.e., the greater the percentage of the
dislocation of multiple CMC joints, one would expect dermis included in the graft at any given donor site the
the possibility of injury to the interosseous muscles. less the degree of contracture). Other factors shown
The presence of MP flexion contractures and a positive to decrease contracture are early grafting, positioning
intrinsic tightness test would be consistent with myostatic devices, and pressure application to the graft during the
contracture of the interosseous muscles, either due remodeling phase.
to direct trauma or ischemia from a compartment
References:
syndrome or devascularization. While surgical release
of the intrinsics or an intrinsic slide might be required in 1. Corps BUM: The effect of graft thickness, donor site, and graft
bed on graft shrinkage in the hooded rat. BR J Plast Surg 1969;
the future, the initial treatment would be to attempt to
22:125.
aggressively stretch out the myostatic contracture. This
would best be accomplished using a static progressive 2. Nedelec B, Gharary A, et al. Control of wound contraction, basic
and clinical features. In Tredget EE, Ed. Thermal Injuries. Hand
MP extension splint.
Clin 2000; 16(2):289-302.
Trauma of this nature would not be expected to produce
stenosing tenosynovitis of the flexor sheaths. As these
are myostatic contractures and not spastic contractures,
Botox has no role in the treatment. Lateral band excision
would only address the effects of the intrinsic tightness
at the PIP level but would not result in improvement of
active and passive MP extension as the intrinsics would
maintain their attachments to the base of the proximal
phalanx. Unless there was direct trauma to the palmar
aspects of the MP joints, volar capsular scarring would
not be anticipated in this injury and releasing the volar
aspect of the MP joint would have no impact on the
myostatic contracture of this injury.

Reference:
Peimer,CA. Intrinsic Muscle Dysfunction and Contractures.
In: Peimer, CA ed: Surgery of the Hand and Upper Extremity.
New York: McGraw-Hill, 1996:1559-82.

2009 Self-Assessment Examination | 25

 47. A 35 year-old male laborer presents with a three-
month history of activity-related, ulnar-sided wrist
pain. He has no prior history of injury to the wrist.
An MRI of the wrist is obtained (Figure 1). The
patient’s diagnosis is most consistent with:
A. Ulnocarpal impaction syndrome
B. Kienböck’s disease
C. Pseudogout
D. Multiple enchondromas
E. Multi-focal giant cell tumors
Preferred Response: A
Discussion: The MRI is remarkable for edema in both
the head of the ulna and ulnar aspect of the lunate
accompanied by cystic changes within the medullary bone.
The patient has radiographic findings of an ulnar positive
variance and symptoms induced with manual labor. These
findings are most consistent with an ulnocarpal impaction
syndrome. The MRI images do not fit the diagnosis of
Kienböck’s disease as the pathology is located ulnarly
within the lunate as opposed to radially or throughout the
body of the lunate. While Kienböck’s disease can occur
in an ulnar positive variance, it is less frequent, and one
would not expect corresponding changes in the head of
the ulna. There is an absence of inflammatory synovitis
and other cystic changes in the wrist to be consistent with
pseudogout or chondrocalcinosis. Multi-centric giant cell
tumors would be extremely unusual. Multiple enchondromas
would also be unlikely and not associated with surrounding
edematous changes in the adjacent marrow.
References:
1. Escobedo EB, Bergman G, Hunter JC. MR imaging of ulnar
impaction. Skeletal Radiol 1993; 24:85-90.
2. Tomaino MM, Elfar J. Ulnar impaction syndrome. Hand Clin 2005;
21:567-575.
3. Zanetti M, Saupe N, Nagy L. Role of MR imaging in chronic wrist
pain. Eur Radiol 2007; 17:927-938.
4. Imaeda T, Nakamura R, Shionoya K, Makino N. Ulnar impaction
syndrome: MR imaging findings. Radiology 1996; 201:495-500.
Question 47, Figure 1
26 | American Society for Surgery of the Hand
48. Six months following muscle debridement and flexor
compartment release for a Volkmann’s contracture
of moderate severity, a patient can now actively
extend the wrist and fingers simultaneously to a
neutral position. While all fingers can be passively
flexed into the palm, active flexion lacks 3 cm from
the fingertips to the palm. The patient complains
of poor grip strength. Which of the following will
best increase active flexion and grip strength?
A. A flexor pronator slide
B. An intense three-month strengthening program
C. Superficialis to profundus tendon transfer
D. A free gracilis muscle transfer
E. An ECRL to profundus tendon transfer
Preferred Response: E
Discussion: In a Volkmann’s contracture of moderate
severity, the extensor compartment is typically spared. An
ECRL to profundus transfer would restore digital flexion and
add strength to the patient’s grip. A flexor pronator slide
would add no additional muscle power to flexion and might
further impair the patient’s ability to flex the fingers into the
palm. A superficialis to profundus tendon transfer would
sacrifice the existing strength imparted to grip by the
superficialis muscles and further lengthen the profundus
tendons, which would impair active digital flexion. Additional
therapy might strengthen grip through the superficialis
muscles but would not likely improve total digital flexion.
A free gracilis muscle transfer could be considered
but would be less predictable and unnecessary in an
extremity where an appropriate muscle transfer exists.
Reference:
Botte MJ. Compartment Syndromes and Ischemic Contractures.
In: Berger RA, Weiss APC, eds. Hand Surgery. Philadelphia:
Lippincott Williams & Wilkins, 2004:1555-1613.
49. A study is planned to evaluate the overall clinical
outcome of patients with rheumatoid arthritis who
undergo wrist fusion. Which instrument would be the
most appropriate patient-reported questionnaire?
A. 36-Item Short-Form Health Survey (SF-36)
B. Australian/Canadian Osteoarthritis Hand Index
(AUSCAN)
C. Disabilities of the Arm and Shoulder (DASH)
Questionnaire
D. O’Connor’s Decision Regret Scale (DRS)
E. Michigan Hand Outcomes Questionnaire (MHQ)
Preferred Response: E
Discussion: Patient–reported questionnaires can be
broad, general health questionnaires, region-specific, or
disease-specific. The SF-36 is too general to be applied
specifically to track the outcomes of hand surgery. The
AUSCAN is a disease-specific questionnaire for arthritis.
The O’Conner’s Decision Regret Scale measures patient
satisfaction with the decisions made, but does not
necessarily measure functional outcome. Both DASH
and MHQ are region-specific questionnaires that have
been validated, have good internal consistency, and are
responsive to treatment changes. However, the MHQ is
the benchmark for rheumatoid arthritis because it collects
not only functional data, but also information regarding
aesthetics, symptoms, and satisfaction.
References:
1. Alderman AK, Chung KC. Measuring outcomes in hand surgery.
Clin Plast Surg 2008; 35:239-250.
2. Chung KC, Kowalski CP, Myra Kim H, et al. Patient outcomes
following Swanson silastic metacarpophalangeal joint
arthroplasty in the rheumatoid hand: a systematic overview.
J Rheumatol 2000; 27:1395-1402.
50. In the time course of wound healing, which cells
predominate during the inflammatory phase:
A. Macrophages
B. Lymphocytes
C. Fibroblasts
D. Endothelial Cells
E. Keratinocytes
Preferred Response: A
Discussion: In the time course of different cells appearing
in the wound during the healing process, macrophages
and neutrophils predominate during inflammation,
lymphocytes peak later and fibroblasts predominate
during the proliferative phase. Keratinocytes and
endothelial cells appear late in wound healing with
epithelialization and angiogenesis respectively.
References:
1. Witte M, Barbul A. General principles of wound healing. Surg Clin
North Am 1997; 77:509-528.
2. Broughton G, Janis JE, Attinger CE. The basic science of wound
healing. Plast Reconstr Surg 2006; 117(7Suppl):12S-34S.
51. Six hours after undergoing a total elbow
arthroplasty, a 62 year-old female rheumatoid
patient develops a desquamating rash, high
fever, and hypotension. Blood tests show an
elevated BUN and creatinine, as well as elevated
liver function tests. She has to be transferred
to the intensive care unit. The surgical wound
is not tender and has no drainage or erythema.
Perioperative prophylactic antibiotics had
been given. The test most likely to prove your
suspected diagnosis is:
A. Positive blood culture for Staphylococcus aureus
B. Positive stool test for Clostridium difficile toxin
C. Radiograph of elbow shows gas shadows in the
soft tissues
D. CAT scan of the chest shows pulmonary embolus
E. Positive blood test for Staphylococcus aureus toxin 1
Preferred Response: E
Discussion: This patient has toxic shock syndrome which
is a toxemia rather than a septicemia. The wound is often
benign appearing. Necrotizing fasciitis might have gas
in the soft tissues, but air in the soft tissue would not be
surprising after total joint replacement. The extremity is
often very tender with necrotizing fasciitis and would be
expected to have some local signs to include erythema
and edema. Most surgical cases of toxic shock syndrome
are associated with S. aureus toxin 1 (TSST-1) and its
presence is confirmed in patient serum by a reverse
passive latex agglutination test.
The patient must be transferred to the ICU for monitoring,
the wound is debrided, and implants or drains must be
removed. The antibiotic of choice is clindamycin which is
bacteriostatic and inhibits TSST-1 production.
References:
1. Netscher DT, Lee-Valkov P. Infections of the hand. In: Mathes SJ,
Hentz VR eds. Plastic Surgery 2nd ed. Philadelphia: Saunders/
Elsevier, 2006:759-790.
2. Grayson MJ, Saldina MJ. Toxic shock syndrome complicating
surgery of the hand. J Hand Surg 1987; 12:1082-1084.
3. Esperson F, Baek L, Kjaelgard P, et al. Detection of staphyloccal
toxic shock syndrome toxin-1 by a latex agglutination kit. Scand
J Infect Dis 1988; 20:449-450.
2009 Self-Assessment Examination | 27
 52. A 60 year-old healthy construction worker presents
with a lesion (Figure 1) on the dorsum of his hand.
It has enlarged over several months, is not fixed
deeply, and now measures 2.5 cm in diameter.
Incisional biopsy revealed it to be a squamous cell
carcinoma of Broders grade II differentiation. The
preferred treatment option for this lesion is:
A. Mohs micrographic surgical excision
B. Cryotherapy
C. Surgical excision with 6 mm margins
D. Radiation therapy
E. Curettage and electrodesiccation
Preferred Response: C
Discussion: Cryotherapy and curettage are
recommended only for very small and low-risk
squamous cancers. Mohs micrographic surgery would be
unnecessary for this tumor. While this tumor is probably
too large to be appropriately treated by cryotherapy
or curettage and electrodesiccation, it is nonetheless
relatively low-risk by its location, histologic differentiation
and size (T1 lesion). Squamous carcinomas greater than
2 cm are twice as likely to recur locally and three times
as likely to metastasize than are tumors less than 2 cm
in diameter (9.2% versus 1.4%). Recommended margins
of excision are 4 mm for low-risk tumors and 6 mm (plus
underlying fat) for high-risk tumors.
While radiation therapy is very effective for treatment
of smaller squamous carcinomas, it requires multiple
treatments, and may produce progressive changes
including atrophy, fibrosis, telangiectasis, and even frank
ulcerations in the treated areas.
References:
1. Rudolph R, Zelac DE. Squamous cell carcinoma of the skin. Plast
Reconstr Surg 2004; 114:82e-94e.
2. Brodland DG, Zitelli JA. Surgical margins for excision of primary
cutaneous squamous cell carcinoma. J Am Acad Dermatol 1992;
27:241-248.
Question 52, Figure 1
28 | American Society for Surgery of the Hand
53. A 40 year-old mechanic had sudden onset of
pain in his dominant right hand middle finger.
The middle finger is cyanotic and the nail bed has
splinter hemorrhages. Allen testing shows delayed
flow through the ulnar artery with perfusion of
the finger tips after 10 seconds. The specific
diagnostic test that may give pathognomonic
evidence for this condition is:
A. Nail fold vital capillaroscopy
B. Arteriography
C. Digital pulse-volume recordings
D. Segmental digital pressures
E. Color duplex imaging
Preferred Response: B
Discussion: This patient has hypothenar hammer
syndrome with stenosis in the ulnar artery and distal
embolization to the finger. Nail fold capillaroscopy may be
helpful in diagnosis of small vessel disease, but not in this
condition. Segmental digital pressures and PVR tracings
may be helpful in evaluation of arterial flow and in making
some therapeutic decisions. Color duplex imaging may
diagnose stenotic lesions and vessel wall aneurysms.
However, the “corkscrew” sign on arteriography is
pathognomonic for hypothenar hammer syndrome and
is due to alternating stenosis and dilatation of the ulnar
artery. Distal embolic occlusion will also be diagnosed by
arteriography.
References:
1. Hammond DC, Matloub HS, Yousif NJ, Sanger JR. The
corkscrew sign in hypothenar hammer syndrome. J Hand Surg
1993; 18B:767-769.
2. McClinton MA, Wilgis EFS. Ischemic conditions of the hand. In:
Mathes SJ, Hentz VR eds. Plastic Surgery 2nd ed. Philadelphia:
Saunders/Elsevier, 2006:791-822.
54. A young quadriplegic patient (whose hand is References:
shown in Figures 1 and 2) has already undergone 1. Hentz VR, McAdams TR. Restoration of upper extremity
surgical restoration of elbow extension and now function in tetraplegia. In: Hentz VR ed. Plastic Surgery 2nd ed.
desires improvement in hand function. He is able Philadelphia: Saunders/Elsevier, 2006; Vol. 8: 507-541.
to extend the wrist (but with radial deviation) 2. Hentz VR. Surgical strategy: matching the patient with the
and can pronate the forearm, each function with procedure. Hand Clin 2002; 18:503-518.
strength of grade 4. He has grade 3 strength of
finger and thumb extension, and only a flicker of
finger flexion. The best potential muscles available
for transfer are:
A. Brachioradialis, extensor carpi radialis longus,
pronator teres
B. Brachioradialis, extensor carpi radialis brevis
C. Pronator teres, extensor indicis proprius
D. Brachioradialis, extensor carpi radialis brevis,
pronator teres
E. Extensor carpi radialis longus, pronator teres,
extensor indicis proprius

Preferred Response: A
Question 54, Figure 1
Discussion: In order to answer this question correctly,
one has to determine the cervical level of injury. From
upper cervical to lower cervical, in succession, the
following muscles would become innervated – deltoid,
biceps, brachioradialis, ECRL, ECRB, pronator teres,
FCR, finger extensors, thumb extensors.

If this patient is able to actively pronate the forearm,

then by inference brachoradialis and both ECRL and
ECRB will have good function (being at higher spinal
levels). The patient radially deviates the wrist in extension
because ECU is not functioning. Since this patient
would be expected to have excellent biceps function,
brachioradialis can be used for tendon transfer. Any
muscle with at least grade 4 strength can be used in Question 54, Figure 2
transfer which will be downgraded by one (resulting in
useful function of at least grade 3 against gravity). Any
muscles of grade 3 strength or less will be unsuitable
for transfer.

ECRL and ECRB are available for transfer and one would
favor leaving the central wrist extensor and so ECRL
would be preferred. A strong wrist extensor (ECRB) must
then be left intact.

While there will be no active forearm pronation remaining

once pronator teres is transferred, it nonetheless can be
used as the patient will incorporate gravity to substitute
for forearm pronation.

2009 Self-Assessment Examination | 29

 55. Early protected dynamic splinting following hand
replantation at the transmetacarpal level is best
accomplished by a functional brace that maintains
the following wrist and MP joint positions:
A. Wrist in neutral, MP joints in extension
B. Wrist in 30° extension, MP joints in extension
C. Wrist in 30° extension, MP joints in flexion
D. Wrist in 30° flexion, MP joints in flexion
E. Wrist in neutral, MP joints in flexion
Preferred Response: E
Discussion: Splinting after replantation of transmetacarpal
hand amputations must prevent intrinsic minus hand
deformity and yet maintain extrinsic extensor and flexor
tendon function. The splint must mimic intrinsic functions.
The distal intrinsic tendons become adherent in their
canals in a shortened position when the MP joints are
maintained flexed. The dynamic craning outrigger splint
attempts to maintain the visco-elastic properties of the
extensor mechanism to enable extension of the DIP and
PIP joints through the extensor tendons, when no intrinsic
function is present.
Wrist in neutral (or at most 15° extension) enables both
extrinsic flexor and extensor repairs to be protected.
References:
1. Scheker LR, Netscher, DT, et al. Functional results of dynamic
splinting after transmetacarpal, wrist and distal forearm
replantation. J Hand Surg 1995; 20B:584-590.
2. Scheker LR, Hodges A. Brace and rehabilitation after replantation
and revascularization. Hand Clin 2001; 17:473-480.
30 | American Society for Surgery of the Hand
56. A 60 year-old female with a 10-year history of
rheumatoid arthritis has a hyperextension deformity
of her dominant thumb IP joint (Figure 1). She
cannot actively flex that joint. The joint is passively
mobile and her x-ray is shown (Figure 2). The most
suitable surgical treatment is:
A. Thumb IP joint fusion
B. Middle finger FDS transfer to the thumb
C. Distal stump FPL tenodesis of the distal phalanx
D. Primary FPL repair
E. Palmaris longus transfer to the thumb
Preferred Response: B
Discussion: In the presence of a normal IP joint,
arthrodesis would not be the best treatment. Tenodesis at
the IP joint will not restore active flexion.
Tendon grafts can sometimes be used for the so-called
Mannerfelt lesion secondary to FPL attrition rupture at the
level of the carpal scaphoid bone. However, if the distal
FPL cannot reach into the wrist incision, then a tendon
transfer is preferred. The Palmaris longus will have
difficulty reaching its distal target.
The superficial flexor of the middle finger is the preferred
motor because it is longer and avoids compromise of grip
function of the ring and small fingers. It is detached in
the distal palm and is anchored to the volar aspect of the
thumb distal phalanx deep to the terminal stump of FPL.
References:
1. Feldon P, Terrono AL, Nalebuff EA, Millender LH. Rheumatoid
arthritis and other connective tissue diseases. In: Green P, Hotchkiss
RN, Pederson WC, eds. Green’s Operative Hand Surgery 4th ed.
Philadelphia: Churchill Livingston, 1999:1680-1682.
2. Mannerfelt LG, Norman O. Attrition ruptures of flexor tendons in
rheumatoid arthritis caused by bony spurs in the carpal tunnel. A
clinical and radiological study. J Bone Joint Surg 1969; 51B:270-277.
 Discussion: Evaluation of segmental arterial pressures
is the single most valuable test for the patient who has
upper extremity ischemia. A digital/brachial index of 0.7
or less indicates compromised circulation. Resection
of an occluded ulnar arterial segment produces a
sympathectomy effect as described by Leriche.
Reconstruction is necessary if the digital/brachial index is
less than 0.7. If the patient were to have been a diabetic,
then arterial pressure indices may be inaccurate.

While cold stress testing may be indicative of an

Question 56, Figure 1 exaggerated sympathetic response, the most significant
preoperative evaluation that indicates collateral flow is
adequate and that arterial segment resection without
reconstruction can be done is the adequacy of collateral
flow as determined by digital/brachial index.

The arteriographic “corkscrew” sign is pathognomonic of

hypothenar hammer syndrome. Arteriography is a “static”
evaluation and gives little dynamic information regarding
blood flow. Vital capillaroscopy may indicate small vessel
disease. Laser Doppler perfusion indicates diminished
digital blood flow, but does not really help in treatment
decisions in this case.

References:
1. Chloros GD, Smerlis NN, Zhongyu L, Smith TL, Smith BP,
Koman LA. Non-invasive evaluation of upper extremity vascular
Question 56, Figure 2 perfusion. J Hand Surg 2008; 33A:591-600.

2. McClinton MA, Wilgis EFS. Ischemic conditions of the hand. In:

Mathes SJ, Hentz VR eds. Plastic Surgery 2nd ed. Philadelphia:
57. A 46 year-old non-diabetic male laborer presents Saunders/Elsevier, 2006: Ch. 194: 791-822.
with a 3-week history of constant pain in the ulnar 3. Zimmerman NB, Zimmerman ST, McClinton MA, et al. Long-term
three digits of his dominant right hand. All fingers recovery following surgical treatment for ulnar artery occlusion.
are cyanotic and the little finger has an ulcer at the J Hand Surg 1994; 19A:17-21.
tip (Figure 1). The Allen test shows no arterial flow
through the ulnar artery. Which preoperative study
will guide surgical treatment:
A. Digital plethysmography and digital/brachial index
B. Fingertip temperature re-warming following cold
stress testing
C. Forearm and hand arteriography
D. Vital nailfold capillaroscopy
E. Laser Doppler fingertip fluxmetry

Preferred Response: A

Question 57, Figure 1

2009 Self-Assessment Examination | 31

 58. Biomechanical analysis has shown that the digital
pulley reconstruction technique which produces
the maximum strength is:
A.
B.
C.
D.
E.
Preferred Response: B
Discussion: In an initial two-part study, the Karev method
was strong and provided the best effectiveness. The
single loop tendon graft at A2 and A4 originally described
by Bunnell was modified by Strickland as an interweave
of the two ends. This gave a strength equal to that of the
Karev repair, but not as effective. The weakest repairs
were the Lister extensor retinaculum and Weilby tendon
weave into the rim of residual pulley.
32 | American Society for Surgery of the Hand
While no reconstruction restores normal tendon excursion/
joint motion relationship, the three loop reconstruction at
A2 and A4 pulleys restored a more normal relationship
than the belt-loop reconstruction. Data on strength and
stiffness by the Mayo clinic study, suggest that the triple
loop pulley reconstruction may be sufficient even to allow
early protected active finger motion.
References:
1. Widstrom CJ, Johnson G, Doyle JR, Manske PR, Inhofe P. A
mechanical study of six digital pulley reconstruction techniques:
part I. Mechanical effectiveness. J Hand Surg 1989; 14A:821-825.
2. Widstrom CJ, Doyle JR, Johnson G, Manske PR, McGee R. A
mechanical study of six digital pulley reconstruction techniques:
part II. Strength of individual reconstructions. J Hand Surg 1989;
14A:826-829.
3. Lin T, Amadio PC, An KN, Cooney WP, Chao EYS. Biomechanical
analysis of finger flexor pulley reconstruction. J Hand Surg 1989;
14B:278-282.
59. Which group of patients with a congenital first
web space contracture is associated with the
highest rate of complication when treated with a
dorsal transposition flap from the index finger?
A. Radial polydactyly
B. Symbrachydactyly
C. Radial club hand
D. Arthrogryposis
E. Cleft hand
Preferred Response: B
Discussion: Friedman and Wood had published an
extensive series on the use of dorsal transposition
flaps for various etiologies of thumb-index web
space contractures. There was a 100% complication
rate when this procedure was used in patients with
symbrachydactyly. There is insufficient flap length and
the contracture too severe to be adequately treated
with a dorsal transposition flap. Other investigators
have also commented on the severe web contracture in
symbrachydactyly which often needs a staged approach.
References:
1. Coombs CJ, Mutimer KL. Tissue expansion for the treatment
of complete syndactyly of the first web. J Hand Surg 1994;
19A:968-972.
2. Friedman R, Wood VE. The dorsal transposition flap for
congenital contractures of the first web space: a 20-year
experience. J Hand Surg 1997; 22A:664-670.
60. Which molecule has shown promise in inhibiting
lipid peroxidation in limbs subjected to ischemia
reperfusion, such as when a tourniquet is used on
the upper arm in hand surgery?
A. Dexmedetomidine
B. Uric acid
C. Lactate dehydrogenase
D. Cyclo-oxygenase
E. Aspirin
Preferred Response: A
Discussion: Prolonging ischemia time may allow
longer tourniquet times during complex procedures or
allow replantation of severed digits or limbs previously
thought to be non-replantable. Efforts have been made
at the molecular level to accomplish this. Yagmurdur
and associates have shown dexmedetomidine to
inhibit lipid peroxidation which leads to injury due to
ischemia. Dexmedetomidine significantly attenuated
plasma hypoxanthine production in the ischemia and
plasma malondialdehyde production in the reperfusion
periods. Blood creatine phosphokinase and uric acid
levels were significantly lower in the dexmedetomidine
group compared with those in the control group after
reperfusion. The other molecules listed do not assist in
lowering lipid peroxidation.
References:
1. Yagmurdur H, Ozcan N, Dokumaci F, Kamer K, Yilmaz F,
Basar H. Dexmedetomidine reduces the ischemia-reperfusion
injury markers during upper extremity surgery with tourniquet.
J Hand Surg 2008; 33A:941-947.
2. Concannon MJ, Kester CG, Welsh CF, Puckett CL. Patterns of
free-radical production after tourniquet ischemia: implications for
the hand surgeon. Plast Reconstr Surg 1992; 89:846–852.
61. A consistent early radiographic finding of gout
arthropathy in the hand/wrist is:
A. Symmetric cartilage space narrowing
B. Peri-articular erosions
C. Osteosclerosis
D. Osteolysis of the tufts of the distal phalanges
E. Calcification of the articular disc of the TFCC
Preferred Response: B
Discussion: One of the earliest findings of gout is per-
articular erosions. Osteopenia and osteosclerosis are not
typical in gout. Osteolysis of the distal phalanges does
not occur in gout. Calcification of the articular disc of the
TFCC occurs in pseudo gout. Cartilage space narrowing
occurs late, not early, in gout.
References:
1. Straub LR, Smith JW, Carpenter GK Jr., Dietz GH. The surgery of
gout in the upper extremity. J Bone Joint Surg 1961; 43A:731-752.
2. Moore JR, Weiland AJ. Gouty tenosynovitis of the hand. J Hand
Surg 1985; 10A:291-295.
Question 61, Figure 1
62. A 72 year-old man with a longstanding history of
gout on 75 mg Indocin/day presents with a non-
painful mobile mass over the volar aspect of the
small finger proximal phalanx. He reports limited
flexion of the DIP joint for the past 2 weeks. X-rays
are normal, other than age-related degenerative
change. The most effective treatment would be:
A. Kenalog injection directly at the level of the finger mass
B. Increasing the dose of Indocin to 150 mg daily for
the next 10 days
C. Stopping the Indocin and changing to Allopurinol
D. Debridement of the flexor tendons
E. Repair of the FDP tendon using a bridge graft
Preferred Response: D
Discussion: The flexor tendon sheath was originally
thought to protect the flexor tendons from uric acid
crystal deposition. This is not true. In gout, flexor tendons
can become involved with uric acid being directly
deposited into the substance of the flexor tendons. Early
on they present with painless mobile masses in the digits
which can limit motion. If this goes unchecked, rupture
can occur which requires debridement and repair using a
bridge graft or tendon transfer.
References:
1. Weniger FG, Davison SP, Risin M, Salyapongse AN, Manders EK.
Gouty flexor tenosynovitis of the digits: report of three cases.
J Hand Surg 2003; 28(4):669-672.
2. Wurapa RK, Zelouf DS. Flexor tendon rupture caused by gout:
a case report. J Hand Surg 2002; 27(4):591-593.
2009 Self-Assessment Examination | 33
 63. The single presenting clinical finding in newborn References:
compartment syndrome of the forearm not present 1. Foucher G, Braun JB. A new island flap transfer from the dorsum
in adult forearm compartment syndrome is: of the index to the thumb. Plast Reconstr Surg 1979; 63:344-379.

A. No pain on passive finger extension 2. Earley MJ. The arterial supply of the thumb, first web and index
finger and its surgical application. J Hand Surg 1986; 11B:163-174.
B. Soft compartments on palpation
C. Sentinel skin lesion
D. Cyanosis of the involved extremity
E. There are no differences

Preferred Response: C

Discussion: Ragland had presented the over 20 years

experience of newborn forearm compartment syndrome
from the Texas Scottish Rite Children’s Hospital in
Dallas, Texas. They found 24 cases of newborn forearm
compartment syndrome—much more common than
previously expected. All of the cases presented with a
sentinal skin lesion on the involved forearm. It ranged
from a lesion resembling a bruise, to circumferential
lesions. The smaller the lesion is, the less tissue damage.
Question 64, Figure 1
References:
1. Caouette-Laberge L, Bartoluzzi P, Egerszegi EP, Marton D.
Neonatal Volkmann’s ischemic contracture of the forearm: a 65. In addition to nail deformity, the other primary
report of five cases. Plast Reconstr Surg 1992; 90:621-628.
problem in reconstructed thumbs after radial
2. Ragland R III, Moukoko D, Ezaki M, Carter PR, Mills J. Forearm polydactyly is:
compartment syndrome in the newborn: report of 24 cases.
J Hand Surg 2005; 30A:997-1003. A. Inadequate length
B. Rotational deformity
C. Joint angulation
64. The artery to the flap shown in Figure 1 is a branch
of the: D. Poor sensation
E. Poor motion
A. Radial artery
B. Dorsal Carpal Arch Preferred Response: C
C. Princeps Pollicis artery Discussion: Goldfarb has shown most thumbs after radial
D. Deep palmar arch polydactyly reconstruction have satisfactory length and
E. Digital artery girth. Dobyns noted this as well. The main problems
appear to be interphalangeal joint angulation which was
Preferred Response: A similar to reduced nail width in Goldfarb’s study.

Discussion: The flap shown in Figure 1 is a first dorsal References:

metacarpal artery flap commonly used for thumb
resurfacing. Earley first described the arterial anatomy of
the first web area and Foucher initially described the first
metacarpal artery flap which is sometimes called a “kite”
flap. The first dorsal metacarpal artery is a branch off the
radial artery.
1. Goldfarb CA, Patterson JM, Maender A, Manske PR. Thumb size
and appearance following reconstruction of radial polydactyly.
J Hand Surg 2008; 33A:1348-1353.
2. Dobyns JH, Lipscomb PR, Cooney WP. Management of thumb
duplcation. Clin Orthop Relat Res 1986; 195:26-44.

34 | American Society for Surgery of the Hand

66. What is the diagnosis of the infant seen in Figure 1?
A. Congenital radioulnar synostosis
B. Ulnar dimelia
C. Arthrogryposis multiplex congenita
D. Aperts syndrome
E. Congenital contractural arachnodactyly of the elbow
Preferred Response: C
Discussion: Elbow extension contracture is a common
presentation in arthrogryposis multiplex congenita. The
presence of wrist and digital flexion contractures as
seen in this child is a common finding in this condition.
Congenital contractural arachnodactyly of the elbow or
Beals syndrome is associated with flexion rather than
extension contracture of the elbow. Congenital radioulnar
synostosis is not usually associated with elbow extension
contracture. Ulnar dimelia is hand duplication and Apert’s
syndrome is associated with syndactyly.
References:
1. Viljoen D. Congenital contractural arachnodactyly (Beals
syndrome). J Med Genet 1994 Aug; 31(8):640-3.
2. Mennen U. Surgical aspects of neuromuscular disorders of
the upper extremity. In: Gupta A, Kay S, Schecker L, eds. The
growing hand. Philadelphia: Mosby/Elsevier, 2000:443-446.
Question 66, Figure 1
67. Subungual squamous cell carcinoma is most
commonly associated with:
A. Onychomycosis
B. Chronic psoriatic nail disease
C. Subungual exostosis
D. Human papilloma virus
E. Acute subungual paronychial infection
Preferred Response: D
Discussion: Theunis et al studied three patients with
subungual squamous cell carcinoma and found a
relationship between these patients’ diseases and
human papillomavirus particularly HPV-16. Porembski
et al reported a patient with subungual squamous cell
carcinoma arising in more than one digit and who also
had positive immunostaining for human papillomavirus.
The patient worked for a wastewater utility company for
22 years and placed his hands in stagnant wastewater
daily. Saccone et al reported on subungual malignant
degeneration following chronic perionychial infection.
Acute paronychial infection is not associated with
malignant degeneration. All other conditions listed have
no relationship to subungual carcinoma.
References:
1. Theunis A, Andre J, Noel JC. Evaluation of the role of genital
human papillomavirus in the pathogenesis of subungual
squamous cell carcinoma. Dermatology, 1999; 198:206–208.
2. Porembski M. and. Rayan G. M subungual carcinoma in multiple
digits. J Hand Surg 2007; 32B(5):547–549.
3. Saccone PG, Rayan GM. Subungual malignant degeneration
following chronic perionychial infection. Orthopaedic Review
1993; 22:623-26.
2009 Self-Assessment Examination | 35
 68. The effect of reversed interposition vein graft
for ulnar artery thrombosis (UAT) on cold stress
expected outcomes is:
A. Response worse than preoperative
B. Response less than normal controls
69. A 17 year-old high school football player presents
two days after a hyperdorsiflexion injury to the
wrist (Figure 1). The most appropriate treatment
for this patient is:
A. Short arm thumb spica cast application

C. No improvement B. Short arm thumb spica cast application with

bone stimulation
D. Response similar to normal controls
C. Open reduction and screw fixation
E. Response better than normal controls
D. Long arm cast application
Preferred Response: D E. Application of a muenster cast
Discussion: Chloros et al reported the outcomes of 12 Preferred Response: C
patients (13 hands) at 2 years’ minimum follow-up after
using reversed interpositional vein grafts for the treatment Discussion: Non-displaced proximal pole fractures of
of symptomatic patients with UAT. Patients were evaluated the scaphoid are considered unstable because of the
before surgery and at final follow-up using the following tenuous blood supply. These fractures have a propensity
instruments: (1) cold sensitivity severity scale, (2) visual for nonunion and require prolonged immobilization when
analog pain scale, (3) symptom and function scale, and (4) treated non-operatively. Open reduction and screw
Wake Forest University symptom scale (pain, numbness, stabilization of the proximal pole fragment is the best
and cold intolerance). Digital microvascular perfusion treatment.
testing (laser Doppler perfusion imaging and isolated
References:
cold stress testing) was also performed, and compared
with normal controls. All patients were evaluated for graft 1. Rettig ME, Raskin KB. Retrograde compression screw fixation
of acute proximal pole scaphoid fractures. J Hand Surg 1999;
patency as determined by Allen’s testing and/or Doppler
24A(6):1206-10.
ultrasound. Ten of the 13 grafts were patent at final follow-
up (77% patency rate). In all the patients with patent 2. Gelberman RH, Panagis JS, Taliesnik J, Baumgartner M. The
arterial anatomy of the human carpus. Part I: the extraosseous
grafts, the symptom scale, visual analog pain scale, the
vascularity. J Hand Surg 1983; 8:367-375.
cold sensitivity severity scale, and the isolated cold stress
testing responses were significantly improved at final
follow-up. Isolated cold stress testing responses were
not different from those of normal controls. The changes
in the function scale, Wake Forest University scale, and
laser Doppler perfusion imaging were not significant. The
authors concluded that successful arterial reconstruction
in symptomatic posttraumatic UAT decreases symptoms,
improves function and microvascular physiology, and
has a positive effect on the health-related quality of life.
Dethmers and Houpt treated 27 cases of hypothenar
hammer syndrome with revascularizations. At follow-up,
color-coded Duplex sonography revealed 13 grafts to be
patent, five occluded, one partially thrombosed, seven
grafts with aneurysmal dilatations and one coiled graft.
The Duplex outcomes of the revascularizations, however,
did not correspond well with the clinical outcomes. Question 69, Figure 1

References:
1. Chloros GD, Lucas RM, Li Z, Holden MB, Koman LA.
Post-traumatic ulnar artery thrombosis: outcome of arterial
reconstruction using reverse interpositional vein grafting at 2
years minimum follow-up. J Hand Surg 2008; 33A(6):932-40.

2. Dethmers RS, Houpt P. Surgical management of hypothenar and

thenar hammer syndromes: a retrospective study of 31 instances
in 28 patients. J Hand Surg 2005; 30B(4):419-23.

36 | American Society for Surgery of the Hand

70. A 52 year-old golfer presents with a two-month
history of pain along the ulnar aspect of the palm,
which is exacerbated by grip and grasp activities.
A CT scan of the injured hand is seen in Figure 1.
The most appropriate treatment for this patient is:
A. Long arm cast application
B. Open reduction and internal fixation of the fracture
C. Ulnar gutter short arm cast immobilization
D. Fracture fragment excision
E. Short arm splint with activity modification
71. The anterolateral thigh flap is based upon which of
the following pedicles:
A. Medial femoral circumflex artery
B. Ascending branch of the lateral femoral
circumflex artery
C. Descending branch of the posterior femoral
circumflex artery
D. Inferior epigastric artery
E. Descending branch of the lateral femoral
circumflex artery

Preferred Response: D Preferred Response: E

Discussion: Fractures of the hook of the hamate may Discussion: The pedicle for the anterolateral thigh flap is
occur secondary to repetitive trauma in stick-handling the descending branch of the lateral femoral circumflex
sports. Acute (<3 weeks) non-displaced fractures may artery. The flap is well suited for large defects of the
be treated with cast immobilization. In cases of nonunion upper extremity. Conversion to a sensate flap is possible
or delayed diagnosis excision or ORIF are possible with the lateral femoral cutaneous nerve.
treatment options. ORIF has a nonunion rate approaching
Reference:
30%, including complications such as flexor tendon
Saint-Cyr M, Gupta A. Microsurgical reconstruction of the upper
rupture.
extremity: state of the art. Hand Clin 2007; 23(1):41-42.
References:
1. Stark HH, Jobe FW, Boyes JH, Ashworth CR. Fracture of the
hook of the hamate in athletes. J Bone Joint Surg 1977;
59A:575-582.

2. Scheufler O, Andresen R, Radmer S, Erdmann D, Exner K,

Germann G. Hook of hamate fractures: critical evaluation of
different therapeutic procedures. Plast Reconstr Surg 2005;
115:488-497.

Question 70, Figure 1

2009 Self-Assessment Examination | 37

 72. A 62 year-old female with Dupuytren’s contracture
underwent a palmar fasciectomy of the ring
and small finger. One week after surgery, she
was doing well with near full composite flexion,
minimal discomfort, and minimal swelling. Two
weeks after surgery, she presents with a two-day
history of increasing pain, stiffness, and swelling
(Figure 1). What is the most appropriate step
in treatment?
A. Narcotic administration and immobilization
B. Stellate ganglion block
C. Oral antibiotics with serial examinations
D. Medrol dose pack with light range of motion exercises
E. Hospital admission with IV antibiotics
Preferred Response: D
Discussion: The patient demonstrates signs and
symptoms consistent with a “flare reaction” following
subtotal palmar fasciectomy. This recognized
complication is often noted 2-3 weeks postoperative
with a sudden decline in function and increase in pain.
The clinical picture reveals no obvious signs of infection.
These reactions, when diagnosed early, usually respond
to anti-inflammatory medication and occupational
therapy focusing on motion exercises.
References:
1. Prosser R, Conolly WB. Complications following surgical treatment
for Dupuytren’s contracture. J Hand Ther 1996; 9(4):344-8.
2. Bulstrode NW, Jenec B, Smith PJ. The complications of Dupuytren’s
contracture surgery. J Hand Surg 2005; 30A(5):1021-5.
Question 72, Figure 1
38 | American Society for Surgery of the Hand
73. In Dupuytren’s disease, the diseased fascia
contains collagen of primarily type:
A. I
B. II
C. III
D. IV
E. VI
Preferred Response: C
Discussion: Normal palmar tissue consists of primarily
type I collagen. Type IV and VI collagen may be seen in
small amounts during the early stages of Dupuytren’s
diseases. However, Type III is the most common collagen
within the diseased fascia.
Reference:
Glimcher MJ, Peabody HM. Collagen organization. In: McFarlane
RM, McGrouther DA, Flint MH eds. Dupuytren’s Disease: Biology
and Treatment. New York: Churchill Livingstone, 1990:72-85.
74. A patient returns three months after undergoing
free vascularized fibular grafting for a humeral
segmental defect with complaints of leg pain at
the donor site. The distal fibula was resected 4 cm
above the ankle joint. The most likely etiology of
the patient’s leg pain is:
A. Sural nerve entrapment
B. Valgus instability of the ankle
C. Tibial stress fracture
D. Saphenous nerve entrapment
E. Peroneal tendonitis
Preferred Response: B
Discussion: Tibial stress fracture and peroneal tendon
weakness are recognized complications of donor site
morbidity after vascularized fibular harvest. To minimize
the risk of valgus instability of the ankle, the fibula should
be harvested at a minimum of 7-8 cm proximal to the
ankle joint. In this case, the distal osteotomy site is in
close proximity to the mortise resulting in instability.
References:
1. Vail TP, Urbaniak JR. Donor-site morbidity with use of
vascularized autogenous fibular grafts. J Bone Joint Surg 1996;
78A:204-211.
2. Bishop AT. Vascularized Bone Grafting. In: Green DP, Hotchkiss
RN, Pederson WC, eds. Green’s Operative Hand Surgery. 4th ed.
Philadelphia: Churchill Livingston, 1999:1224-1226.
75. A college student presents 4 weeks after
sustaining an injury to the ring finger of the
dominant hand while playing flag football.
Ultrasound assessment of the digit reveals that
the distal stump of the flexor tendon is located
at the level of the PIP joint. Inspection of the
DIP joint demonstrates mild hyperextension.
The recommended treatment is:
A. DIP joint arthrodesis
B. Direct repair of the flexor digitorum profundus
C. Single stage tendon graft reconstruction
D. Two stage flexor tendon reconstruction
E. Non-operative management
Preferred Response: B
Discussion: With Type II FDP avulsions (retraction at the
level of PIPJ – Figure 1), direct repair (Figure 2) is usually
possible up to 6 weeks post-injury. In Type I injuries (more
proximal retraction into the palm), reconstructive options
may be required if diagnosis is delayed.
References:
1. Leddy JP, Packer JW. Avulsion of the profundus insertion in
athletes. J Hand Surg 1977; 2A:66-68.
2. Stamos BD, Leddy JP. Closed flexor tendon disruption in
athletes. Hand Clin 2000; 16:359-365.
Question 75, Figure 1
Question 75, Figure 2
76. A 54 year-old obese female presents 5 weeks
after undergoing radial head replacement for a
comminuted radial head fracture/dislocation of
the elbow with a new radiograph (Figure 1). What
treatment is recommended?
A. Open reduction with cast immobilization
B. Open reduction with lateral collateral ligament repair
or reconstruction
C. Closed reduction
D. Open reduction with radial head implant exchange,
lateral collateral ligament repair/reconstruction with
or without hinged elbow external fixator application
E. Open reduction with removal of the radial head implant
and lateral collateral ligament repair or reconstruction
Preferred Response: D
Discussion: The patient has recurrent instability of the
elbow despite radial head implant arthroplasty. In this
particular case the radial head implant is oversized.
Anatomic studies have identified that the articular surface
of the radial head is positioned an average of 0.9mm
proximal to the lateral edge of the coronoid articular
surface. In addition to re-sizing the implant, reconstruction
or repair of the lateral collateral ligament is required to
stabilize the elbow. If the elbow is still unstable hinged
external fixator application may be indicated. In cases of
chronic elbow dislocation, external fixator application is
often required. Removal of the prosthesis is not a viable
option as it would further destabilize the elbow.
References:
1. Doornberg JN. Reference points for radial head prosthesis size.
J Hand Surg 2006; 31A:53-57.
2. Morrey BF, Tanaka S, An KN. Valgus instability of the elbow. A
definition of primary and secondary restraints. Clin Orthop Relat
Res 1991; 265:187-195.
3. Jupiter JB, Ring D. Treatment of unreduced elbow dislocations
with hinged external fixation. J Bone Joint Surg Am 2002;
84(9):1630-5.
Question 76, Figure 1
2009 Self-Assessment Examination | 39
 77. A patient with long-standing rheumatoid arthritis
presents with a swan-neck deformity of the
index finger and complains of painful snapping
with attempted flexion of the digit. Examination
demonstrates that the deformity is passively
correctable. Radiographs of the involved digit
reveal minimal arthrosis. What is the most
appropriate treatment:
A. Mobilization and rerouting of the lateral bands deep
to the A3 pulley
B. Proximal interphalangeal joint capsulodesis
C. Proximal interphalangeal joint arthrodesis
D. Extensor tendon tenolysis with dorsal transfer of the
lateral bands
E. Proximal interphalangeal joint capsulectomy
Preferred Response: A
Discussion: In surgical correction of flexible swan-neck
deformities, the lateral band is positioned palmar to
the axis of rotation of the PIP joint. The procedure is a
motion sparing operation which maintains the PIP joint
in a resting posture of approximately 35° of flexion.
Arthrodesis of the PIP joint may be indicated in cases of
rigid deformity or significant arthritic deterioration of the
joint. Attenuation and synovitis of the palmar restraints of
the PIP joint in patients with rheumatoid arthritis would
preclude a capulodesis procedure.
References:
1. Gainor BJ, Hummel GL. Correction of rheumatoid swan-neck
deformity by lateral band mobilization. J Hand Surg 1985;
10A:370-376.
2. Tonkin MA, Hughes J, Smith KL. Lateral band translocation for
swan-neck deformity. J Hand Surg 1992; 17A:260-267.
40 | American Society for Surgery of the Hand
78. Which of the following best describes the
recommended guidelines for an HIV positive
hand surgeon who would like to continue the
practice of medicine:
A. The hand surgeon should avoid all contact
with patients
B. The hand surgeon should be able to return to all
of the usual and customary duties as an operating
hand surgeon
C. If the patient is informed about the HIV positive
status and consents to treatment, then the
physician should be able to engage in all duties as
an operating hand surgeon
D. A physician that is HIV positive should not engage
in any activity that creates an identified risk of
transmission of the disease
E. If the physician is seropositive and demonstrates
no active signs of HIV disease, then the physician
should be able to return to all the usual and
customary duties as an operating hand surgeon
Preferred Response: D
Discussion: A physician who is HIV positive must
recognize activities that place the patient at risk. It is
recommended that the physician consult with colleagues
to determine which activities the physician can engage in
without creating risk to patients.
References:
1. Code of Medical Ethics, Current Opinions with Annotations,
American Medical Association, 1997.
2. Health Care Workers Infected With the Human Immunodeficiency
Virus. The Next Steps. JAMA 1992; 268(5):601.
79. The histology of giant cell tumor of tendon sheath
is most similar to which of the following:
A. Atypical mycobacterial infection
B. Rheumatoid arthritis
C. Pigmented villonodular synovitis
D. Synovial cell sarcoma
E. Malignant fibrous histiocytoma
Preferred Response: C
Discussion: Histological and immunohistochemical
analysis support a common synovial cell origin for both
GCTS and PVNS.
Reference:
O’Connell JX, Fanburg JC, Rosenberg AE. Giant cell tumor of tendon
sheath and pigmented villonodular synovitis: immunophenotype
suggests a synovial cell origin. Hum Pathol 1995 Jul; 26(4):429-30.
80. An 80 year-old man presents complaining of 81. The parascapular flap is based on which artery:
severe wrist pain that makes it difficult to sleep.
A. The descending branch of the circumflex
He has used a wrist splint for years, but it is no scapular artery
longer adequate. He has a 25º arc of wrist motion.
His radiographs are shown in Figure 1. What do B. The transverse branch of the circumflex
scapular artery
you recommend?
C. The angular branch of the thoracodorsal artery
A. Scaphoid excision
D. The serratus anterior branch of the
B. Arthrodesis of the lunate and capitate
thoracodorsal artery
C. Scaphoid excision and arthrodesis of the lunate
E. The vertical branch of the thoracodorsal artery
and capitate
D. Total wrist arthrodesis Preferred Response: A
E. Proximal row carpectomy Discussion: There are several flaps based upon the
circulation around the scapula. Each is based off of a
Preferred Response: D
specific vessel.
Discussion: Since the primary goal is pain relief, there
Reference:
is very little remaining motion, and motion-sparing
procedures typically lose additional motion, total wrist Gilbert A, Teot L. The free scapuar flap. Plast Reconstr Surg 1982;
69(4):601-4.
arthrodesis is the best option for this patient. Wrist
arthrodesis has a high fusion rate when using plates.
Patients experience improved pain relief and function.

References:
1. Weiss KE, Rodner CM. Osteoarthritis of the wrist. J Hand Surg
2007; 32A(5):725-46.

2. Hastings H II, Weiss AP, Quenzer D, Wiedeman GP, Hanington

KR, Strickland JW. Arthrodesis of the wrist for post-traumatic
disorders. J Bone Joint Surg 1996; 78A(6):897-902.

Question 80, Figure 1

2009 Self-Assessment Examination | 41

 82. The injury shown in the figures is at greatest 83. Which of the following scaphoid fractures requires
risk for: operative treatment?
A. Nonunion A. Non-displaced distal pole
B. Growth arrest B. Displaced tubercle fracture
C. Infection C. Non-displaced waist fracture
D. Tendon detachment D. Displaced waist fracture
E. Instability E. Non-displaced proximal pole fracture

Preferred Response: C Preferred Response: D

Discussion: The nail and nail plate often avulse from
under the eponychial fold (Figures 3 and 4) with these
injuries, making them open fractures. The colonized
germinal matrix can then become interposed in the
physis (Figure 5) and may become infected.
Discussion: Scaphoid fractures account for 60% of all carpal
fractures. Avascular necrosis is reported in 13 to 50% of
scaphoid fractures with a higher incidence in proximal pole
fractures. Nonunion occurs in up to 12% of patients in an
untreated fracture and 10% of operatively treated fractures.

References: Internal fixation is indicated for displaced waist and displaced

1. Waters PM. Operative carpal and hand injuries in children.
J Bone Joint Surg 2007; 89A(9):2064-74.
2. Al-Qattan MM. Extra-articular transverse fractures of the base of
the distal phalanx (Seymour’s fracture) in children and adults.
J Hand Surg 2001; 26B(3):201-6.
proximal pole fractures due to their high risk of nonunion
and AVN. Displacement of more then 1 mm is defined as an
unstable scaphoid fracture. The most important consideration
during internal fixation with a headless screw is placement of
the screw in the center of the scaphoid. Central placement of
the screw produces union rates approximating 95%.

Nondisplaced scaphoid fractures can be treated by

immobilization for 8 to 12 weeks with a thumb spica cast.
There is no consensus on elbow immobilization in a long arm
cast. The healing rate of nondisplaced waist fractures treated
with cast immobilization is 88 to 95% if treated within 3
weeks of injury. Prospective randomized studies of operative
treatment of acute nondisplaced or minimally displaced
fractures of the scaphoid have failed to demonstrate a clear
benefit of early fixation compared to cast immobilization.
Long term outcomes do not differ between internal fixation
Question 82, Figure 1 Question 82, Figure 4
and cast immobilization. Economic analysis has shown
internal fixation to be better from a social perspective due to
earlier return to work. Fixation of nondisplaced fractures is
therefore not required as it is in displaced waist fractures but
is determined based on patient and surgeon preference after
presenting the available literature evidence to the patient.

Question 82, Figure 2 Displaced tubercle fractures are not associated with
nonunion, AVN or carpal collapse and do not require fixation.

References:
1. 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(5):705-13.
Question 82, Figure 5
2. Szabo RM, Manske D. Displaced fractures of the scaphoid.
Clin Orthop Relat Res 1988; (230):30-8.

3. Kawamura K, Chung KC. Treatment of scaphoid fractures and

nonunions. J Hand Surg 2008; 33A(6):987-997.

Question 82, Figure 3

42 | American Society for Surgery of the Hand

84. Uncontrolled studies claim that radiation
therapy and corticosteroid injection can slow
the progression of Dupuytren’s disease. Which
of the following makes uncontrolled studies of
Dupuytren’s disease difficult to interpret?
A. Regression to the mean
B. The placebo effect
C. The nocebo effect
D. The Hawthorne effect
E. The natural history of untreated disease
Preferred Response: E
Discussion: When the natural history of a disease is variable,
uncertain, or incompletely defined, nothing can be said about
the efficacy of treatment (particularly prophylaxis) without
a control group. All diseases are variably symptomatic and
a lessening of symptoms may just be a transition from a
peak or waxing of symptoms towards the average level
of symptoms. The placebo effect takes place when a patient
experiences improvement because they believe that they
should. The nocebo effect takes place when a patient
has a bad experience due to negative expectations. The
Hawthorne effect takes place when the result is changed
by the change in the environment, such as the artificial
study conditions and observations.
85. The unpredictable long-term outcome of Bennett’s
fracture of the thumb metacarpal is felt to be due
in part to unrecognized:
A. Articular impaction
B. Volar ligament injury
C. Trapezial injury
D. Trapezoid injury
E. Nonunion
Preferred Response: A
Discussion: Most Bennett’s fractures have a good short
and long-term outcome. Arthrosis and pain have been
ascribed to more extensive articular injury, which is
often underappreciated.
References:
1. Oosterbos CJ, de Boer HH. Nonoperative treatment of Bennett’s
fracture: a 13-year follow-up. J Orthop Trauma 1995; 9(1):23-7.
2. Thurston AJ, Dempsey SM. Bennett’s fracture: a medium to long-
term review. Aust N Z J Surg 1993; 63(2):120-3.
3. Buchler U, McCollam SM, Oppikofer C. Comminuted fractures
of the basilar joint of the thumb: combined treatment by external
fixation, limited internal fixation, and bone grafting. J Hand Surg
1991; 16A(3):556-60.

References:
1. Harrington A. The Placebo Effect: An Interdisiplinary Exploration.
First Harvard University Press, 1999.

2. Moerman DE. Meaning, Medicine and the “Placebo Effect”.

Cambridge University Press, 2002.

2009 Self-Assessment Examination | 43

 86. What is the name of the structure (**) shown in
Figure 1?
A. Grayson’s Ligament
B. Retrovascular Cord
C. Cleland’s Ligament
D. Spiral Cord
E. Pre-tendinous Cord
Preferred Response: D
Discussion: This patient has Dupuytren’s Disease and
the structure shown is the spiral cord. The spiral cord
forms from the pre-tendonis band, spiral band, Grayson’s
ligament and the lateral digital sheet. Spiral cords are
often in the proximity of the neurovascular structures
and can often displace them. The retrovascular cord
is implicated in causing DIP contractures. Cleland’s
ligament is typically spared in Dupuytren’s Disease.
References:
1. McGrouther DA. Dupuytren’s contracture. In: Green DP,
Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green’s Operative
Hand Surgery. 5th ed. Philadelphia: Churchill Livingston/Elsevier,
2005:159-185.
2. MacFarlane RM. Patterns of diseased fascia in the fingers in
Dupuytren’s contracture. Plast Reconstr Surg 1974; 54:31-44.
Question 86, Figure 1
87. When pinching between the thumb and index finger
with 5 kg load, what is the estimated joint contact
force acting on the trapeziometacarpal joint?
A. 1 kg
B. 5 kg
C. 10 kg
D. 20 kg
E. 60 kg
Preferred Response: E
44 | American Society for Surgery of the Hand
Discussion: Joint forces across the base of the thumb
can be significantly higher than forces with simple
pinch activities. At the IP joint, joint contact forces can
be 4 times the force generated at the tip. The MP joint
will exhibit 6 times the tip strength. However, at 12-13
times the tip strength, the CMC joint will experience the
greatest joint contact forces. Other investigators have
estimated that, depending on posture, between 6 and
24 fold increased in load at the CMC joint compared to
the applied force. This increased load is a major factor
contributing to the incidence of arthritis at this joint.
References:
1. Cooney WP III, Chao EY. Biomechanical analysis of static forces
in the thumb during hand function. J Bone Joint Surg 1977;
59:27-36.
2. Imaeda T, An KN, Cooney WP III. Functional anatomy and
biomechanics of the thumb. Hand Clin 1992; 8:9-15.
3. Giurintano DJ, Hollister AM, Buford WL, Thompson DE, Myers
LM. A virtual five-link model of the thumb. Med Eng Phys 1995;
17:297-303.
88. Closed reduction of the fracture shown in Figure 1 is
best achieved by longitudinal traction, downward
pressure at the apex of the fracture, extension of
the distal fragment and thumb:
A. Pronation
B. Adduction
C. Radial abduction
D. Palmar abduction
E. Supination
Preferred Response: A
Discussion: The deforming forces on extra-articular base
of the thumb fractures result in apex dorsal angulation
of the metacarpal. Proximally, the abductor pollicis
longus exerts an extension force on the proximal fracture
fragment. The thumb adductor, flexor pollicis brevis and
abductor pollicis brevis cause the distal fragment to be
flexed and supinated. Up to 30° of angulation is generally
pretty well tolerated due to the compensatory motion
of the CMC joint. These fractures are often amenable to
closed reduction or percutaneous fixation. The deformity
includes a supination force and gentle pronation of the
distal fragment (in addition to extension) will achieve a
more anatomic reduction.
References:
1. Burton RI, Eaton RG. Common hand injuries in the athlete.
Orthop Clin North Am 1973; 4:809-838.
2. Soyer AD. Fractures of the base of the first metacarpal: current
treatment options. J Am Acad Orthop Surg 1999; 7:403-412.
3. Stern, PJ. Fractures of the metacarpal and phalanges. In:
Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds.
Green’s Operative Hand Surgery. 5th ed. Philadelphia: Churchill
Livingston/Elsevier, 2005:277-341.
be performed. If the DRUJ is unstable and there is an
ulnar styloid fracture, reduction and fixation of the ulnar
styloid (Figure 3) usually affords stability. An irreducible
DRUJ suggests either interposition ECU, EDQ or EDC,
buttonhole of the ulna through the DRUJ capsule or
periosteal or bony interposition. Another cause of
irreducible DRUJ is malreduction of the radius such
as inappropriate restoration of the radial bow. In these
cases, the interposed structure needs to be removed and
stabilization achieved (if necessary).

References:
1. Giannoulis FS, Sotereanos DG. Galeazzi fractures and
dislocation. Hand Clin 2007; 21:153-163.

2. Hughston JC. Fractures of the distal radial shaft: Mistakes in

management. J Bone Joint Surg 1957; 39:249-64.

Question 88, Figure 1

89. Following open reduction and internal fixation of

the radius in the fracture shown in Figures 1 and 2,
the patient has instability of the distal radioulnar
joint. What is the recommended treatment?
Question 89, Figure 1 Question 89, Figure 2
A. Immobilization with the forearm in full supination
for 6 weeks
B. Open radioulnar joint ligament repair
C. Open reduction and fixation of the ulnar styloid
D. Immobilization with the forearm in full pronation
for 6 weeks
E. Exploration and removal of interposed extensor
carpi ulnaris tendon

Preferred Response: C

Discussion: Some of the most common complications Question 89, Figure 3

following operative treatment of Galeazzi fracture
treatment involve the distal radioulnar joint. The energy
of these injuries typically goes through the DRUJ. Thus
it is extremely important that the stability of this joint
be assessed following fixation of the radius fracture. If
the DRUJ is stable, the forearm can be immobilized in
supination to allow for healing of the stabilizing volar
and dorsal ligaments. If the DRUJ is unstable and
there is no ulnar styloid fracture pinning of the radius
and ulna in a reduced position with TFC repair can

2009 Self-Assessment Examination | 45

 90. The patient shown in Figure 1 has acute onset of
pain and swelling of the index finger. Diagnosis
has been confirmed to be due to uric acid deposition
disease. What would be the most appropriate next
step in improving this patient’s pain?
A. Surgical exploration and debridement
B. Distal interphalangeal arthrodesis
C. Administration of allopurinol
D. Aspiration and drainage with an 18 gauge needle
E. Diet modification including avoidance of seafood
and red meat
Preferred Response: D
Discussion: Patients with distal interphalangeal joint
gouty tophi can often present with significant pain and
swelling. The diagnosis is often confused with infection,
which must be ruled out. Confounding things further the
two conditions may coexist. In patients with significant
swelling and skin changes, surgical treatment can be
problematic and carry an increased risk of delayed
wound healing. Aspiration with a large bore needle
through an area of uninvolved skin is a relatively safe
alternative to facilitate decompression of the tophus
while avoiding the complications of surgery. DIP joint
arthrodesis may be helpful in cases where there is
persistent pain and arthritis following subsidence of the
flare. Allopurinol and diet modification can be considered
in the long-term to minimize recurrence of flares, but
would be of little use in the acute setting.
References:
1. Mudgal CS. Management of tophaceous gout of the distal
interphalangeal joint. J Hand Surg 2006; 31B:101-103.
2. Fitzgerald BT, Setty A, Mudgal CS. Gout affecting the hand and
wrist. J Am Acad Orthop Surg 2007; 15:625-35.
Question 90, Figure 1
46 | American Society for Surgery of the Hand
91. What is the most likely diagnosis for the bone changes
seen on x-ray of the patient shown in Figure 1?
A. Infection
B. Mafucci’s Syndrome
C. Osteoporosis
D. Particulate induced osteolysis
E. Vitamin D deficiency
Preferred Response: D
Discussion: The patient shown in the figure has an
advanced case of silicone induced osteolysis resulting
from the silicone metacarpophalangeal joint arthroplasties
seven years previously. Incidences of osteolysis following
silicone implant arthroplasty have been reported to be
greater than 50% at average 5.7 year follow-up. Most
of these tend to affect the cortices of the phalanges
and metacarpals. An association between osteolysis
and implant fractures has been observed. Patients with
severe osteolysis have an increased risk of metacarpal
and phalangeal fractures.
References:
1. Parkkila TJ, et al. Grading of radiographic osteolytic changes
after silastic metacarpophalangeal arthroplasty and a prospective
trial of osteolysis following use of Swanson and Sutter
prostheses. J Hand Surg 2005; 30B:382-7.
2. Parkkila T, et al. Osteolysis after Sutter metacarpophalangeal
arthroplasty: a prospective study of 282 implants followed up
for 5.7 years. Scand J Plast Reconstr Surg Hand Surg 2006;
40:297-301.
Question 91, Figure 1
92. The best surgical treatment option for the lesion
shown in Figure 1 is:
A. Primary repair of the tendon
B. Tendon grafting with a palmaris longus tendon graft
C. Staged tendon reconstruction using silicone rods
D. Arthrodesis of the thumb interphalangeal joint
E. FPL tenodesis
Preferred Response: B
Discussion: The lesion shown in Figure 1 is a flexor
pollicis longus (FPL) rupture or Mannerfelt Lesion. This
injury is often due to arthritis and osteophytes at the
scaphotrapeziotrapezoid (STT) joint. The FPL glides
superficial to this joint and is vulnerable to attritional
changes secondary to the arthritis. Because of the
attritional nature of these injuries, primary repair is usually
not feasible. Reconstruction with tendon graft, or tendon
transfer (mainly the FDS of the ring or long finger) are
typically the best treatment options.
References:
1. Mannerfelt L, Norman O. Attrition ruptures of flexor tendons in
rheumatoid arthritis caused by bony spurs in the carpal tunnel.
A clinical and radiological study. J Bone Joint Surg 1969;
51B(2):270-7.
2. Ertel AN, et al. Flexor tendon ruptures in patients with rheumatoid
arthritis. J Hand Surg 1988; 13A(6):860-6.
Question 92, Figure 1
93. A 33 year-old female presents to the emergency
room with a 13 cm ecchymotic lesion with small
superficial open wounds over the volar aspect
of her forearm and wrist. She recalls a brown
recluse spider bite 3-4 days prior. She states that
the wound has just developed over the past 24
hours, but the area of ecchymosis has not grown.
Her vital signs and lab work are normal and she
complains of mild discomfort. The next step in
management should be:
A. Administration of Dapsone
B. Immediate wide surgical debridement
C. Topical corticosteroids
D. Administration of anti-venom
E. Clean wounds and apply sterile dressings
Preferred Response: E
Discussion: Brown recluse spider bites are most common
in the south and the midwestern parts of the United
States. The bites can result in painful, necrotic and
slow-healing wounds. One study examining outcomes
of recluse spider bites in the upper extremity noted a
20% incidence of functional complications. DeLozier
et al noted that patients who underwent early surgical
debridement had more complications than those who
were more conservatively treated. Another report
suggested no benefit with dapsone, corticosteroids,
nitroglycerin or high dose Vitamin C. In fact, dapsone
and steroids were associated with slower healing rates
and dapsone increased the possibility of scarring.
Predictors of more rapid healing include: lower severity
level, less erythema & necrosis at presentation, the
absence of diabetes, younger age and earlier medical
attention. While systemic complications can occur,
they are rare. Wright et al reported only two cases (of
111) with systemic complications: one patient with mild
hemolytic anemia and another with mild coagulopathy.
Most caregivers recommend conservative wound care in
the immediate setting. Delayed surgical management of
persistent or infected wounds is preferred.
References:
1. DeLozier JB, Reaves L, King LE, Rees RS. Brown recluse spider
bites of the upper extremity. South Med J 1988; 81:181-4.
2. Wright SW, Wrenn KD, Murray L, Seger D. Clinical presentation
and outcome of brown recluse spider bite. Ann Emerg Med 1997;
30:28-32.
3. Mold JW, Thompson DM. Management of brown recluse spider
bites in primary care. J Am Board Fam Pract 2004; 17:347-52.
2009 Self-Assessment Examination | 47
 94. The free lateral arm flap is perfused by the:
A. Brachial artery
B. Ulna artery
C. Posterior radial collateral artery
D. Radial recurrent artery
E. Posterior interosseous artery
Preferred Response: C
Discussion: The lateral arm is perfused by the posterior
radial collateral artery (PRCA), one of the terminal
branches of the profunda brachii. It has a large fascial
component located anterior and posterior to the lateral
intermuscular septum, which itself lies between the
triceps posteriorly and the brachialis and brachioradialis
muscles anteriorly. The PRCA consistently divides into
two terminal branches—an anterior and a posterior
division. The anterior division is the nutrient vessel of
the flap. It can be used as a composite osteocutaneous
flap for immediate thumb reconstruction with or without
vascularized tendon. No major artery is sacrificed by
using this flap and the vascularity of the upper extremity
is unaffected.
Reference:
Katsaros J, Tan E, Zoltie N. The use of the lateral arm flap in upper
limb surgery. J Hand Surg 1991; 16A:598-604.
95. In throwing athletes, the late cocking phase of the
overhand throw has the greatest risk for injury to:
A. The anterior bundle of the medial collateral ligament
B. The posterior bundle of the medial collateral ligament
C. The anterior bundle of the lateral collateral ligament
D. The common flexor-pronator mass
E. The arcuate ligament overlying the epicondylar groove
Preferred Response: A
Discussion: Medial collateral ligament injuries occur
almost exclusively in overhand-throwing athletes. The late
cocking phase of the overhand throw places a marked
valgus moment across the medial elbow. This repetitive
force reaches the tensile limits of the medial collateral
ligament, subjecting it to microtraumatic injury and
attenuation. The anterior bundle of the medial collateral
ligament has been identified as the primary restraint to
valgus load and is the focus of reconstruction. Diagnosis
of medial collateral ligament injuries should be suspected
in any overhand throwing athlete with a history of medial-
48 | American Society for Surgery of the Hand
sided elbow pain, decreased control, and reduced
throwing velocity. Injury to the medial collateral ligament
can be confirmed by physical examination (moving valgus
stress test) and appropriate imaging studies (computed
tomography arthrogram and magnetic resonance imaging).
References:
1. Lynch, J et al. Medial collateral ligament injury in the overhand
throwing athlete. J Hand Surg 2008; 33A:430–437.
2. Cain EL Jr, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in
throwing athletes: a current concepts review. Am J Sports Med
2003 Jul-Aug; 31(4):621-35.
96. A mother seeks consultation regarding her 5 year-
old son who has a unilateral congenital forearm
amputation. She desires information for her child
regarding long-term prosthetic use. Your best
advice is:
A. A myoelectic hand will be the best choice
B. The child will never use a prosthetic hand
C. The child will be most likely to use a passive
cosmetic hand
D. Bimanual function will be close to normal if a
prosthesis is fitted immediately
E. He will not use a body powered device if he is fitted
with a myoelectric hand first
Preferred Response: C
Discussion: Seventy-six children with unilateral below-
elbow amputation were fitted in random sequence with a
myoelectric (MYO) and a body-powered (BP) prosthetic
hand of identical size, shape, and glove color. Subjects
ranged from six to 17 years, nine months and included
67 children with congenital limb deficiency and nine who
sustained traumatic amputation. After training, each child
wore each hand for three months. On the form board test
requiring only prosthetic use, subjects took 13.7% longer
with the MYO and committed more errors with the MYO,
specifically in dropping objects and delaying their grasp
and release. Object displacement, the most common
error, occurred nearly as often with BP as MYO. MYO
was minimally faster on a test of ten practical activities
designed for bimanual prehension. Card playing was
39.8% faster with BP, whereas donning socks, cutting
paper, and bandage application were 27.8%, 12.5%, and
10.9% faster with MYO. Performance with both hands
was rated as decidedly poorer than normal quality. No
major clinically important differences were found in the
comparison of performance.
Thirty-four unilateral below-elbow amputees from
the Shriners Hospitals for Children/Twin Cities were
retrospectively analyzed in long-term follow-up. All
of these patients were provided with a variety of
prosthetic options, including a “passive” cosmetic upper
extremity device. Most of the patients were also fitted
with conventional prostheses using a body-powered
voluntary closing terminal device (97%) as well as
myoelectric prostheses (82%). The average follow-up
was 14 years, with many of the patients being followed
up throughout their entire childhood. All patients
were sent questionnaires, and the authors carried
out patient interviews and chart review. Final analysis
indicated that 15 patients (44%) selected a simple
cosmetic “passive hand” as their prosthesis of choice.
In long-term follow-up, 14 patients (41%) continued
as multiple users. Fourteen patients (41%) selected
the conventional prosthesis using a voluntary closing
terminal device as the prosthesis of choice. Only five
patients (15%) selected the myoelectric device as their
primary prosthesis. The authors conclude that successful
unilateral pediatric amputees may choose multiple
prostheses on the basis of function and that frequently
the most functional prosthesis selected in the long term is
the simplest in design.
References:
1. Edelstein JE, Berger N. Performance comparison among children
fitted with myoelectric and body-powered hands. Arch Phys Med
Rehabil 1993; 74(4):376-80.
2. Crandall RC, Tomhave W. Pediatric unilateral below-elbow
amputees: retrospective analysis of 34 patients given multiple
prosthetic options. J Pediatr Orthop 2002; 22(3):380-3.
97. During exploration of the ulna nerve (“U”) at the
elbow for ulna nerve compression, a structure was
encountered. What is the structure marked “**”?
A. Arcade of Struthers
B. Gantzer’s muscle
C. Ligament of Struthers
D. Anconeus epitrochlearis muscle
E. Triceps muscle
Preferred Response: D
Discussion: The anconeus epitrochlearis muscle is
an anomalous muscle that arises from medial border
of olecranon and adjacent triceps and inserts into the
medial epicondyle. It may be found in about 10% of
patients undergoing cubital tunnel release. It may cause
ulnar neuritis.
References:
1. Hirasawa Y, Sawamura H, Sakakida K. Entrapment neuropathy
due to bilateral epitrochleoanconeus muscles: a case report.
J Hand Surg 1979; 4:181-184.
2. Dahners LE, Wood FM. Anconeus epitrochlearis, a rare cause
of cubital tunnel syndrome: a case report. J Hand Surg 1984;
9A:579-580.
3. Masear VR, Hill JJ and Cohen SM. Ulnar compression
neuropathy secondary to the anconeus epitrochlearis muscle.
J Hand Surg 1988; 13A:720-724.
Question 97, Figure 1
2009 Self-Assessment Examination | 49
 98. A patient with the ulna styloid fracture in Figure 1 99. When using the EIP for a tendon transfer, the EIP
is more likely to have DRUJ instability than a can be most reliably identified by:
patient with an ulna styloid fracture at the tip
A. Its position relative to the EDC tendon at the index
because which of the following structures is more MP joint
likely to be disrupted?
B. Having the most distal muscle belly
A. The dorsal radioulnar ligaments
C. Its size relative to the EDC tendon
B. The volar radioulnar ligaments
D. Presence of tendon interconnections
C. The ligamentum subcruentum
E. Its shape relative to the EDC tendon
D. The ECU subsheath
Preferred Response: B
E. The meniscus homologue
Discussion: The EIP tendon is an excellent transfer
Preferred Response: C
for a ruptured EPL. The index finger will reliably retain
Discussion: When the ulna styloid fracture is at the base independent extension. The EIP is usually ulnar to the
as shown in Figure 1 the deep portion of the TFCC is EDC, but not always (Figure 1). The EIP muscle belly
disrupted. This will lead to more instability than just a is reliably the most distal muscle (72/72). In this study,
fracture at the tip1. The volar and dorsal radius-ulna ligament it was never dorsal but could be volar. It may have
and the meniscus and ECU may be injured with either injury. interconnections. The EIP may also have more than one
Although technically not a ligament, the term “Ligamentum tendon slip (Figure 2).
subcruentum” has come to represent the deep fibers of
Reference:
the TFC (inserting into the fovea – Figure 2) and is now
used commonly by many investigators as interchangeable Gonzalez MH, Weinzweig M, Kay T, Grindel S. Anatomy of the
extensor tendons to the index finger. J Hand Surg 1996;
with the term “deep TFC radio ulna ligaments”2.
21A:988-991.
References:
1. Haugstvedt R, Berger RA, Berglund LJ, Neale PG, Sabick MB.
An analysis of the constraint properties of the distal radioulnar
ligament attachments to the ulna. J Hand Surg 2002; 27(1):61-67.

2. Kleinman WB. Stability of the distal radioulna joint: biomechanics,

pathophysiology, physical diagnosis, and restoration of function what
we have learned in 25 years. J Hand Surg 2007; 32(7):1086-1106.

Question 98, Figure 1

Question 98, Figure 2

Question 99, Figure 1. Relative position of the extensor tendons at
the index metacarpophalangeal joint: six variations.

50 | American Society for Surgery of the Hand

 101. Which opponensplasty requires creation of
a pulley?
A. Abductor digiti minimi
B. Adductor pollicis
C. Extensor indicis propius
D. Extensor carpi radialis longus
E. Flexor digitorum superficialis

Preferred Response: E

Discussion: The FDS and EIP are common choices for

opponensplasty. The FDS needs to have a pulley on the
ulna side of the wrist. The EIP uses the ulna side of the
forearm as a pulley and a pulley does not have to be
constructed. The EIP is relatively expendable and usually
independent index extensor function is maintained. It is
weaker than the FDS, but has adequate strength for this
positioning transfer. The disadvantages of an EIP transfer
Question 99, Figure 2. Accessory slip of extensor indicis proprius
include the need for multiple incisions, the transfer,
(EIP) tendon. Tendon running to long finger.
passes over the median nerve, and if there is scarring
over the ulna forearm adhesions may develop.

100. Surgical treatment of an extension contracture to References:

the MP joint requires:
A. Release of the check rein ligaments
B. Release of the volar plate
C. Checking the flexor tendon excursion
1. Smith RJ. Tendon transfer of the hand and forearm. Little Brown
Co., 1987:67-70.
2. Chhabra AB, Dorf ER. Tendon transfer surgery. In: Hand Surgery
Update IV. American Society for Surgery of the Hand, Rosemont:
2007:439-454.

D. Dorsal capsulotomy
E. Preservation of the collateral ligaments

Prerferred Response: D

Discussion: MP joint contractures are common and

usually in extension rather than flexion. There are no
checkrein ligaments to release and usually the volar
plate is not significantly involved. The flexor tendons
do not have to be checked if there is good PIP active
flexion since there are not the primary flexors of the
MP joint. The collateral ligaments almost always have
to be partially released and postoperative instability
is uncommon.

Reference:
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 Livingston/Elsevier, 2005:414.

2009 Self-Assessment Examination | 51

 102. A 28 year-old professional chef amputated the
tip of her dominant left ring finger. Examination
revealed an oblique amputation of soft tissue
involving the pulp distal to the DIP crease with
an intact nail plate and exposed bone (Figure 1).
Recommended treatment is:
A. Debridement and primary closure
B. Skin graft
C. A V-Y advancement flap
D. Volar advancement flap
E. Thenar flap
Preferred Response: E
Discussion: There are many options for care of fingertip
injuries. In this young woman with exposed distal phalanx,
loss of significant volar pulp and intact nail plate optimal
treatment would be to maintain length. A skin graft would
not be appropriate because of exposed bone. A V-Y
advancement flap is not appropriate because of the amount
of soft tissue loss. The volar advancement flap is best
for the thumb because of the excellent dorsal circulation. In
the finger, it has been unreliable and may be complicated
by dorsal skin loss. A cross finger flap from an adjacent
finger is an alternative, but not listed as an answer for
this question. A cross finger flap does require a skin
graft to cover the donor finger. The thenar flap offers
several advantages including palmar skin match, adequate
soft tissue, and an inconspicuous donor site. With the
H-modification, it can be closed primarily without a skin
graft. The flap is divided and inset at 2-3 weeks and range
of motion started. The complication of joint stiffness and
flexion contracture may be lessen with early motion,
therapy, and patient choice (young, without arthritis or preop
stiffness and women who may be more flexible than men).
References:
1. Watt AJ, Chang J. Fingertip Injuries and Amputations. In: Hand
Surgery Update IV. American Society for Surgery of the Hand,
Rosemont: 2007:505-507.
2. Melone CG, Beasley RW, Carstens JH. The thenar flap: an
analysis of its use in 150 cases. J Hand Surg 1982; 7:291-297.
Question 102, Figure 1
52 | American Society for Surgery of the Hand
103. A 38 year-old mountain climber has a frostbite
involving both hands. He is evacuated to
a mountain first aid station, but cannot be
transported by snowmobile to a permanent facility
for 12 hours. What treatment should wait until he
is in the permanent facility?
A. Core body temperature rewarming
B. Tetanus prophylaxis
C. Cold water baths
D. Rapid rewarming at 40-44° C
E. Oral antibiotic to prevent infection
Preferred Response: D
Discussion: Frostbite is one of the two major groups of
cold injuries. This is usually associated with prolonged
cold exposure, inadequate nutrition, fatigue and some
degree of panic. Early treatment includes restoration
of normal core temperatures, management of shock,
fractures and malnutrition. The frostbitten area must be
protected. Specific treatment of deep frostbite should
only be undertaken when adequate ongoing care without
re-exposure to cold is available. Rapid rewarming at
40-44° C is the most important step in salvage of tissue
and function, but should only be performed when the
involved part will not be exposed to the cold. Tetanus
prophylaxis is a part of the management of frostbite.
Antibiotics are only used for a confirmed infection.
Cold-water baths and rubbing snow on the injured part
are not part of the treatment for frostbite.
References:
1. Frostbite. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe
SW eds. Green’s Operative Hand Surgery 5th ed. Philadelphia:
Churchill Livingston/Elsevier, 2005:2186-2187.
2. Mills WJ Jr. Frostbite: a method of management including rapid
rewarming, Northwest Med 1966; 65:119-125.
104. The gracilis muscle can be used as a functioning
free muscle transfer. The innervation of the gracilis
muscle is by the:
A. Pudendal nerve
B. Femoral nerve
C. Obturator nerve
D. Tibial nerve
E. Peroneal nerve
Preferred Response: C
Discussion: The gracilis is the most suitable muscle
for functional muscle transfers. There is a single
motor nerve—a branch of the obturator nerve—that is
composed of two or three fascicles. The nerve enters the
muscle immediately proximal to the vascular pedicle and
lies under the adductor longus. With nerve stimulation,
the adult gracilis muscle will shorten more than 50% of its
extended length for a functional contraction of 12 to 15
cm. The fascicles of the motor nerve can be teased apart
and each fascicle separately stimulated. By using a nerve
stimulator with frequency and voltage control, it was
usually possible to separate the muscle into longitudinal,
separately functioning neuromuscular territories. 90% of
the time, a single fascicle will control the anterior 20%
to 50% of the muscle, and the remaining portion of the
muscle is controlled by the remaining fascicles. This
functional separation is quite useful when the muscle is
used to provide independent thumb and finger flexion.
Reference:
Manktelow RT, Anastakis DJ. Free Functioning Muscle Transfers.
In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW eds. Green’s
Operative Hand Surgery. 5th ed. Philadelphia: Churchill Livingston/
Elsevier, 2005:1757.
105. Selection bias in clinical trials is reduced by:
A. Randomization by the surgeon
B. Blind randomization
C. Randomization by day of the week
D. Similarity of comparison populations
E. Decreased population size
Preferred Response: D
Discussion: Selection bias may be introduced when
the populations under study are first assembled. It is
critically important to be sure that the two populations are
similar. When they are different, the researcher cannot be
certain that the difference in the effect of an intervention
is the result of the intervention or the result of different
characteristics of the two groups. To reduce the likelihood
of selection bias, prospective studies should have well-
defined entry criteria and recruitment processes. Clinical
trials are best performed by randomly assigning patients
to treatment groups. There are also pseudorandom
methods of assigning patients that may be subject to
bias (e.g., by surgeon, by the days of the week that
patients present to the clinic). Even randomized trials
may be at risk for a group assignment bias if clinicians
are able to predict the next group assignment in a
clinical trial. Another form of selection bias occurs as
a result of patient follow-up. However, if follow-up is
“nondifferential”—that is, not related to the exposure or
outcome of interest—then an important selection bias
might not be present.
Reference:
Spindler KP, Kuhn JE, Dunn W, Matthews CE, Harrell, Jr FE,
Dittus RS J. Reading and reviewing the orthopaedic literature: a
systematic, evidence-based medicine approach. Am Acad Ortho
Surg 2005; 13:220-229.
106. A 10 year-old female with cerebral palsy presents
with persistent wrist flexion posture. Physical
examination reveals mild wrist flexion and ulnar
deviation posturing, but with near full active range
of motion. Motion laboratory evaluation revealed
phasic firing of the flexor carpi ulnaris and
extensor carpi radialis brevis and longus. The next
most appropriate treatment is:
A. Observation only
B. Botulinum toxin injection to FCU
C. Lengthening of FCU
D. FCU to ECRB transfer
E. FCU to ECRB transfer with proximal row carpectomy
Preferred Response: B
Discussion: The wrist flexion contracture is mild, and the
patient has full range of motion. Observation alone would
not correct the problem, and lengthening or transfer of
the FCU is unnecessary when only a mild contracture
exists. While not yet approved by the FDA for this use,
the next step of botulinum toxin injection is appropriate to
minimize phasic firing of the FCU.
The FDA has not approved Botulinum toxin injection
for this clinical use.
References:
1. Yang TF, Fu CP, Kao NT, Chan RC, Chen SJ. Effect of botulinum
toxin type A on cerebral palsy with upper limb spasticity. Am J
Phys Med Rehabil 2003; 82(4):284-9.
2. Van Heest AE, Ramachandran V, Stout J, Wervey R, Garcia
L. Quantitative and qualitative functional evaluation of upper
extremity tendon transfers in spastic hemiplegia caused by
cerebral palsy. J Pediatr Orthop 2008; 28(6):679-83.
2009 Self-Assessment Examination | 53
 107. Dynamic splinting, when compared with passive
splinting, for zone VI extensor tendon repairs has
been shown to improve:
A. Short and long-term range of motion
B. Short-term but not long-term range of motion
C. Neither short-term nor long-term range of motion
References:
1. Egloff DV, Verdan C. Pollicization of the index finger for
reconstruction of the congenitally hypoplastic or absent thumb.
J Hand Surg 1983; 8A(6):839-48.
2. McDonald TJ, James MA, McCarroll HR Jr, Redlin H.
Reconstruction of the type IIIA hypoplastic thumb. Tech Hand Up
Extrem Surg 2008; 12(2):79-84.

D. The incidence of early tendon rupture

E. The incidence of late tendon rupture

Preferred Response: B

Discussion: While dynamic splinting may improve

short-term range of motion post-surgical repairs of
extensor tendons, studies have failed to demonstrate
better long-term outcome.

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(2):482-7. Question 108, Figure 1
2. Bulstrode NW, Burr N, Pratt AL, Grobbelaar AO. Extensor tendon
rehabilitation a prospective trial comparing three rehabilitation
regimes. J Hand Surg 2005; 30B(2):175-9.

108. In choosing the most appropriate reconstruction of

the problem shown in Figures 1 and 2, the surgical
treatment involves ligation of the:
A. Radial digital artery to the index finger
B. Ulnar digital artery to the index finger
C. Radial digital artery to the long finger
D. Ulnar digital artery to the long finger
E. Radial digital artery to the ring finger Question 108, Figure 2

Preferred Response: C

Discussion: In creating the index finger rotational flap,

the finger is tethered by the radial digital artery to the long
finger. Ligating this branch will allow the common digital
nerve to the second web to rotate with the index into the
thumb position.

54 | American Society for Surgery of the Hand

109. A 38 year-old female sustained a thermal burn to
her upper extremity (Figures 1 and 2). The hand
is vascular and sensate. Definitive management
for treatment of this injury leading to the best
outcome must include:
A. Dressing changes
B. Split thickness skin grafting
C. Full thickness skin grafting
D. Free vascularized flap coverage
E. Amputation
Preferred Response: D
Discussion: The deeply burned forearm in the figures
shown is best reconstructed with free flap coverage due
to exposed tendons and other deep structures that lack a
healthy vascular bed. Skin grafting will have poor viability
over such structures, and amputation is drastic when
there is a functional hand.
References:
1. Tredget EE. Management of the acutely burned upper extremity.
Hand Clin 2000; 16(2):187-203.
2. Takeuchi M, Nozaki M, Sasaki K, Nakazawa H, Sakurai H.
Microsurgical reconstruction of the thermally injured upper
extremity. Hand Clin 2000; 16(2):261-9.
Question 109, Figure 1
Question 109, Figure 2
110. A 35 year-old male presents to the emergency
department after sustaining a fingertip injury while
cleaning his paint gun. Examination (Figure 1)
reveals a 2 mm wound at the left long fingertip
and a swollen digit. The next management step
should be:
A. Elevation of the left hand and arm
B. Compartment pressure measurement in the finger
C. Needle aspiration
D. Limited incision to enlarge the puncture wound
E. Wide surgical debridement of the entire digit
Preferred Response: E
Discussion: The injury represents a high-pressure
injection. The wound will often appear innocuous.
Emergency open debridement 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(7):503-11.
2. Bekler H, Gokce A, Beyzadeoglu T, Parmaksizoglu F. The surgical
treatment and outcomes of high-pressure injection injuries of the
hand. J Hand Surg Eur Vol. 2007; 32(4):394-9.
Question 110, Figure 1
2009 Self-Assessment Examination | 55
 111. The diagnosis of extrinsic flexor tendon tightness
on physical examination is best demonstrated
with the wrist and digits in what position?
A. Wrist extension, MP extension
B. Wrist extension, MP flexion
C. Wrist flexion, MP extension
D. Wrist flexion, MP flexion
E. Wrist neutral, MP flexion
Preferred Response: A
Discussion: Extrinsic flexor tendon tightness most
commonly follows trauma to the extrinsic flexors, either
within the hand or forearm. A volar forearm mass or flexor
tenosynovitis may also result in extrinsic flexor tendon
tightness secondary to a mass effect. It is most often
noted following flexor tendon injury and subsequent
repair secondary to scarring and shortening of the
muscle/tendon unit. With the wrist and MP joints in full
extension, in the absence of digital contracture, the PIP
and DIP joints will be tight; and in some cases, it will
not be possible to fully extend the PIP and DIP joints.
With the wrist and MP joints in flexion, full PIP and DIP
extension should be possible.
References:
1. Curtis RM. Capsulectomy of the interphalangeal joints of the
fingers. J Bone Joint Surg 1954; 36A:1219-1232.
2. Lister G. The Hand: Diagnosis and Indications, 4th ed. Churchill
Livingstone, London, 2002.
56 | American Society for Surgery of the Hand
112. A 45 year-old right hand-dominant male presents
four months after a fall from a ladder complaining
of stiffness of his right ring finger. The patient
recalls immediate pain and a “tearing” sensation
prior to losing his grip. The patient reports a
progressive loss of digital extension, despite three
months of supervised hand therapy. Physical
examination demonstrates active PIP joint
motion from 60º to 100º. Plain radiographs are
normal. MRI is shown in Figure 1. Recommended
treatment is:
A. Profundus tendon repair
B. Staged flexor tendon reconstruction
C. PIP joint volar release
D. PIP joint volar release and extensor tenolysis
E. PIP joint volar release and pulley reconstruction
Preferred Response: E
Discussion: Originally described by Bollen in 67 British
rock climbers, closed ruptures of the digital flexor pulley
system often presents in a delayed fashion with PIP
joint flexion contractures. The mechanism of injury is
a rapidly applied extension force in the acutely flexed
digit, resulting in a closed rupture of the retinacular
sheath, rather than a flexor profundus avulsion. In the
setting of a significant PIP flexion contracture, one most
commonly finds a rupture of multiple pulleys, including
A2, A3 and A4. In such a case, significant flexor tendon
bowstringing results precluding successful non-operative
management. The proper treatment includes release of
the sheath scar and pulley reconstruction. Temporary PIP
joint pinning may also be required.
References:
1. Bollen SR. Soft tissue injury in extreme rock climbers. Br J Sports
Med 1988; 22:145-147.
2. Bowers WH, Kuzma GR, Bynum DK. Closed traumatic rupture of
finger flexor pulleys. J Hand Surg 1994; 19A:782-787.
Question 112, Figure 1
113. What is the most appropriate indication for the use
of a skin graft in Dupuytren’s disease?
A. 50° primary MP joint contracture
B. 50° primary PIP joint contracture
C. 50° recurrent MP contracture with isolated cord
D. 50° recurrent PIP contracture with isolated cord
E. 50° recurrent PIP contracture with diffuse
skin involvement
Preferred Response: E
Discussion: Skin grafts are especially useful in
Dupuytren’s patients with severe, diffuse disease and
in recurrences—particularly when multiple joints are
involved. Though rarely required in primary cases, if
the disease is infiltrative and diffuse, skin grafts can
be useful. Full thickness skin grafts are preferred,
providing more esthetic and durable skin coverage while
exhibiting less tendency to retract than partial thickness
grafts. Most authors have observed that recurrence is
uncommon beneath a graft, though a recent article by
Roush and Stern did not find that full thickness skin
grafting prevented recurrences. Grafts rarely do not
“take,” despite placing them directly over neurovascular
bundles and the flexor sheath.
References:
1. Hall PN, Fitzgerald A, Sterne GD, Logan AM. Skin replacement in
Dupuytren’s disease. J Hand Surg 1997; 22B:193-197.
2. Hueston JT. The control of recurrent Dupuytren’s contracture by
skin replacement. Br J Pl Surg 1969; 22:152-156.
3. McCash CR. The open palm technique in Dupuytren’s
contracture. Br J Pl Surg 1964; 17:271-280.
4. Roush TF, Stern PJ. Results following surgery for recurrent
Dupuytren’s disease. J Hand Surg 2000; 25A:291-296.
114. To best limit occupational radiation scatter to the
hand surgeon while using the mini C-arm, the
surgeon should:
A. Wear a lead apron at all times
B. Orient the unit horizontally and stay on the source
side of the C-arm during imaging
C. Increase the kVp and mA to improve the contrast of
a dark image
D. Increase the distance of the patient’s extremity from
the x-ray source
E. Not be concerned since radiation exposure is a
non-issue while using the mini C-arm
Preferred Response: D
Discussion: Occupational radiation exposure continues
to concern all of us who regularly utilize in-office and
intra-operative fluoroscopy. Until fairly recently, the
literature regarding the use of the mini C-arm has been
lacking. The potential risk of low dose radiation exposure
remains unclear, but it is clear that we should take steps
to minimize radiation exposure.
Scattered radiation is radiation that arises from interaction
between the radiation beam and the part being imaged, or
any other object that is struck by radiation. The amount of
scatter is dependent on the characteristics of the object
being imaged, the energy of the X-ray photons, and the dose
of radiation delivered. Radiation exposure decreases as the
square of the distance, so placing the patient’s extremity as
far from the X-ray source as possible will reduce the amount
of radiation available to interact with the patient’s extremity,
and therefore reduce the scattered radiation. Placing the
patient’s hand as far from the source as possible also
reduces the patient’s direct and scatter exposure. Keeping
the surgical team’s hands out of the beam, whenever
possible, greatly reduces direct radiation hand exposure.
Other measures to decrease surgeon exposure include
using the mini C-arm machine, along with adjustment in
contrast and brightness for a dark image, rather than an
increase in kVp and mA. In addition, one should consider
using the mini C-arm in a horizontal orientation allowing
one to stand behind the image intensifier, thus lessening
radiation exposure. The use of radioprotective devices such
as lead aprons, thyroid collars and protective eyewear
can lessen exposure to the torso, thyroid and eyes, but
does not lessen exposure to the surgeon’s hands, and
therefore, other measures should be considered.
Reference:
Athwal GS, Bueno RA, Wolfe SW. Radiation exposure in hand
surgery: mini versus standard C-arm. J Hand Surg 2005;
30:1310-1316.
2009 Self-Assessment Examination | 57
 115. A 6 year-old boy presents to the emergency room
following a fall from the monkey bars complaining
of severe elbow pain. Physical examination
reveals an isolated injury with a closed fracture of
the distal humerus, absent distal pulses, sluggish
capillary refill and definite coolness of the hand.
Radiographs demonstrate supracondylar distal
humerus fracture (Figure 1). The most appropriate
management includes:
A. Skeletal traction
B. Closed reduction percutaneous pin fixation
C. Open reduction internal fixation
D. Closed reduction percutaneous pin fixation and
forearm fasciotomies
E. Closed reduction percutaneous pin fixation with
intraoperative vascular reassessment

Preferred Response: E Question 115, Figure 1

Discussion: Limb ischemia in the setting of a markedly

displaced pediatric supracondylar fracture remains a true
orthopedic emergency. Loss of limb and/or loss of function
secondary to limb ischemia and associated compartment
syndrome can result from the associated vascular injury.
The currently recommended treatment in this case includes
emergent operative reduction and pin fixation (closed, if
possible), followed by an assessment of the distal pulses. If
the limb remains pulseless, most recommend intraoperative
angiography. This fairly simple and rapid procedure may
aid in the planning of the vascular procedure and may
prevent unnecessary exploration of the brachial artery in
cases of arterial spasm. If this is not feasible, a brachial
artery exploration is appropriate.
References:
1. Copley LA, Dormans JP, Davidson RS. Vascular injuries and their
sequelae in pediatric supracondylar humeral fractures: toward a
goal of prevention. J Pediatr Orthop 1996; 16:99-103.
2. Luria S, Sucar A, Eylon S, Pinchas-Mizrachi R, Berlatzky Y, Anner
H, Liebergall M, Porat S. Vascular complications of supracondylar
humeral fractures in children. J Pediatr Orthop 2007; 16B:133-143.
116. A 24 year-old male rugby player sustained
an unstable elbow dislocation with a Type 2
coronoid fracture. After anatomically stabilizing
the coronoid with a single screw and repairing
the lateral collateral ligament, intraoperative
evaluation demonstrates subluxation of the elbow
within 60º of extension. The most appropriate
treatment is:
A. Cast immobilize the elbow at 90° for four weeks
B. Repair the medial facet of the coronoid with
another screw
C. Steinmann pin fixation of the ulnohumeral joint for
six weeks
D. Repair the anterior capsule
E. Apply a hinged external fixator
Preferred Response: E
Discussion: The elbow remains unstable following
surgical intervention. While some surgeons may
immobilize the ulnohumeral joint for a brief time by
either casting or pinning, prolonged immobilization is not
desirable for the traumatic elbow. Repair of the anterior
capsule is unnecessary following coronoid fixation. The
chances of having significant medial facet involvement
with a Type 2 coronoid fracture is low. A hinged external
fixator will maintain a concentric joint, protect the ligament
repair, and allow for early motion. Another acceptable
treatment would be to repair or reconstruct the medial
collateral ligament, a choice not offered .

58 | American Society for Surgery of the Hand

References:
1. Morrey BF, O’Driscoll SW. Complex elbow instability. In: Morrey
BF, ed. The Elbow and its Disorders. 3rd ed. Philadelphia: WB
Saunders; 2000:423.
2. McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ.
Standard surgical protocol to treat elbow dislocations with radial
head and coronoid fractures. Surgical technique. J Bone Joint
Surg 2005; 87A Suppl 1(Pt 1):22-32.
117. A 32 year-old male sustained an injury to his right
long finger playing flag football. X-ray revealed
a volar dislocation of the PIP joint. Following a
concentric closed reduction, the most appropriate
management is:
A. Immediate active motion
B. Guided passive motion
C. Extension block splinting
D. Static PIP extension splinting
E. Dynamic external fixation
Preferred Response: D
Discussion: The primary difference between volar
dislocations and volar rotary dislocations of the PIP
joint is that volar dislocations are often associated with
central slip avulsion injuries. In volar rotary dislocations,
the condyle of the proximal phalanx penetrates between
the central slip and lateral band, leaving both structures
intact. After reduction, the joint is usually stable and early
motion is allowed. Volar dislocations, however, cannot
be mobilized and the extensor tendon must be either
repaired or statically splinted. Extension block splinting
and dynamic external fixation are indicated for fracture/
dislocations of the PIP.
References:
1. Schernberg F, Elzein F, Gillier P, Gerard Y. Dislocations of the
proximal interphalangeal joints of the long fingers. Anatomo-
clinical study and therapeutic results. Ann Chir Main 1982;
1(1):18-28.
2. Vicar AJ. Proximal interphalangeal joint dislocations without
fractures: Hand Clin 1988 Feb; 4(1):5-13.
118. A 54 year-old male is taken to surgery for
post-traumatic contracture release of his elbow
twelve months after a simple dislocation.
Preoperatively, his range of motion was 45º of
extension and 90º of flexion. Preoperative
radiographs showed no development of heterotopic
bone formation or joint degeneration. In addition to
capsular release, which of the following would likely
improve the patient’s outcome?
A. Release of one or both collateral ligaments
B. Ulnar nerve decompression
C. Application of hinged external fixator
D. Fenestrate the distal humerus
E. Immobilize in full extension for two weeks
Preferred Response: B
Discussion: Long-standing contractures of the elbow
have repercussions on extra-articular structures, such
as tendons and nerves. Prolonged lack of excursion can
cause the ulnar nerve, for example, to become encased
in fibrosis. After contracture release, the motion of
the newly freed joint pulls on the tethered ulnar nerve,
which causes pain and paresthesias. Patients without
ulnar nerve symptoms prior to contracture release often
develop them postoperatively. The pain caused by
ulnar nerve tethering has been identified as a significant
hindrance for patients attempting to maintain motion after
contracture release. It is recommended to preemptively
decompress or transpose the ulnar nerve at the same
time as the contracture release, even if the release is
performed arthroscopically. In the absence of hetertopic
bone formation, the collateral ligaments should be
preserved, maintaining joint stability and negating the
need for a hinged external fixator. While deepening of the
coronoid and/or olecranon fossa may be helpful in some
cases, fenestrating the distal humerus is not indicated for
this patient. Immobilization following contracture release
is contraindicated.
References:
1. Martin BG, Johansen JA, Edwards SG. Complications related to
simple dislocations of the elbow. Hand Clin 2007; 24(1):9-25.
2. Lindenhovius AL, Jupiter JB. The posttraumatic stiff elbow: a
review of the literature. J Hand Surg 2007; 32A(10):1605-23.
2009 Self-Assessment Examination | 59
 119. A 37 year-old female substance abuser inadvertently
injected an undisclosed substance into her brachial
artery. She presents with painful digital motion and
swelling. Arteriogram reveals multiple occlusions of
the small vessels to the index, long, ring, and small
fingers. The most appropriate initial treatment is:
A. Heparin
B. Thrombolytic therapy
C. Digital fasciotomy
D. Superficial arch reconstruction
E Amputation
Preferred Response: B
Discussion: Embolic phenomena can lead to many
different injuries requiring different interventions. Once
the terminal small vessels become involved, vascular
reconstruction is not possible. Isolated involvement
requires supportive therapies such as anticoagulation,
vasodilation, and close observation. Diffuse involvement,
however, requires more aggressive intervention because
of the heightened risk of multiple amputations. In this
case, thrombolytic agents, such as urokinase, are
recommended. Although compartment syndrome is a
complication of embolic disease, there is no evidence of
a compartment syndrome here, in this particular case,
fasciotomies are not indicated.
References:
1. Koman LA, Ruch DS, Smith BP, Smith TL. Vascular Disorders.
In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW eds.
Green’s Operative Hand Surgery. 5th ed. Philadelphia: Churchill
Livingston/Elsevier, 2005:2290-2291.
2. Jones NF. Acute and chronic ischemia of the hand:
pathophysiology, treatment, and prognosis. J Hand Surg 1991;
16A(6):1074-83.
120. A 65 year-old male with a history of renal
insufficiency and an upper respiratory infection
presents with an acutely swollen, painful right wrist.
Aspiration of the wrist demonstrates a synovial
WBC count of 20,000 and negatively birefringent
crystals. The most appropriate treatment involves:
A. Surgical incision and drainage
B. Nonsteroidal anti-inflammatory medication
C. Colchicine
D. Steroid injection
E. Allopurinol
Preferred Response: D
60 | American Society for Surgery of the Hand
Discussion: This patient has gout, which can mimic
septic arthritis. The diagnosis often depends on joint
aspiration. Synovial aspirations with WBC counts of
greater than 80,000 are indicative of bacterial septic
arthritis, with the exception of gonococcal infections
which WBC counts may be around 50,000-70,000.
Typically, WBC counts less than 50,000 are indicative
of non-infectious etiologies, such as gout, RA, and
Reiter’s syndrome. Gout is commonly seen in the setting
of renal insufficiency and treatment options should be
modified because of this. Colchicine and nonsteroidal
anti-inflammatory medications are reasonable treatments
for acute gouty attacks, but are relatively contraindicated
for this patient because of his renal insufficiency. Steroid
injections can be very effective in relieving symptoms
caused by gouty arthritis.
References:
1. Freeland A, Senter B. Septic arthritis and osteomyelitis.
Hand Clin 1989; 5:533-552.
2. Werlen D, Gabay C, Vischer TL. Costeroid therapy for the
treatment of acute attacks of crystal-induced arthritis: an
effective alternative to nonsteroidal antiinflammatory drugs.
Rev Rhum Engl Ed. 1996; 63(4):248-54.
121. Which nerve provides sensory innervation to the
dorsal radiocarpal ligament?
A. Dorsal sensory branch of the radial
B. Posterior interosseous branch of the radial
C. Palmar cutaneous branch of the median
D. Dorsal sensory branch of the ulnar
E. Motor branch of the ulnar
Preferred Response: B
Discussion: A rich sensory innervation is provided by
the posterior interosseous nerve to the dorsal radiocarpal
ligament. These nerve endings are involved in the
proprioceptive and pain modulating function of the
dorsal capsule.
References:
1. Lin YT, Berger RA, Tomita K, et al. Nerve endings of the wrist
joint: a preliminary report of the dorsal radiocarpal ligament.
J Orthop Res 2006; 24:1225-1230.
2. Tolo ET, Shin AY. Fracture dislocations of the carpus. In: Trumble
TE, Budoff JE eds. Hand Surgery Update IV. American Society for
Surgery of the Hand, Rosemont: 2007:271-292.
122. Traumatic disruption of the radial collateral
ligament of the thumb MP joint is prone to a
pathologic sequence of joint instability with
progressive ulnar and volar subluxation. This is
due to the unopposed force of which muscle?
A. Abductor pollicis longus
B. Abductor pollicis brevis
C. Adductor pollicis
D. Extensor pollicis brevis
E. Opponens pollicis
Preferred Response: C
Discussion: The radial collateral ligament (RCL) is a
critical lateral stabilizer of the thumb MP joint. The
intrinsic anatomy of the RCL is not a mirror image of
the ulnar side. Disruption of the RCL, coupled with the
unopposed dynamic force of the adductor pollicis, leads
to the pathologic sequence of joint instability, ulnar and
volar subluxation and degenerative joint disease.
References:
1. Culp R, Ratner J. Acute thumb injuries. In: Trumble TE, Budoff JE
eds. Hand Surgery Update IV. American Society for Surgery of
the Hand, Rosemont: 2007:51-61.
2. Melone CP, Beldner S, et al. Thumb collateral ligament injuries:
an anatomic basis for treatment. Hand Clin 2000; 16:345-357.
123. In rheumatoid arthritis swan-neck deformity with
no intrinsic tightness, PIP joint imbalance leads to
tightening of which structure?
A. Volar capsule of the PIP joint
B. Lumbrical muscle
C. Flexor digitorum superficialis
D. Triangular ligament
E. Transverse retinacular ligament
Preferred Response: D
Discussion: Type I swan-neck deformity has full flexibility
of the PIP joint. As PIP hyperextension develops, the
lateral bands displace dorsally and the transverse
retinacular ligaments stretch. The dorsal triangular
ligament tightens while the volar capsule attenuates.
With less tension on the lateral bands, the DIP joint flexes
in a mallet deformity.
Type II swan-neck deformity develops when synovitis
of the MP joint attenuates the sagittal bands leading
to MP subluxation and intrinsic tightness. For Type II
deformities, intrinsic release must also be performed.
Type III and IV deformities both have limited PIP motion.
In Type III, motion is limited by the extensor mechanism,
collateral ligaments and contracted skin. Type IV has
severe intraarticular PIP joint destruction. Type III is
treated by lateral band mobilization, while Type IV is
treated by PIP fusion or arthroplasty.
References:
1. Dodds SD, Brugel-Sanchez, Swigert CR. Rheumatoid arthritis of
the hand: soft tissue reconstruction. In: Trumble TE, Budoff JE
eds. Hand Surgery Update IV. American Society for Surgery of
the Hand, Rosemont: 2007:673-685.
2. Kiefhaber TR, Strickland JW. Soft tissue reconstruction for
rheumatoid swan-neck and boutonnierre deformities: long-term
results. J Hand Surg 1993; 18A:984-989.
124. Following a severe crush injury to the hand, the
characteristic position assumed by the swollen
hand consists of:
A. MP joint flexion
B. PIP joint extension
C. DIP joint extension
D. Thumb adduction
E. Wrist extension
Preferred Response: D
Discussion: Edema results from any insult to the hand.
Accumulation of fluid or hematoma within the capsular
structures of the joint or within the synovial space will
impair joint function and subsequently promote joint
stiffness and contracture. The joints assume the positions
of maximum fluid capacity. This results in the intrinsic
minus hand, characterized by interphalangeal joint
flexion, metacarpophalangeal joint extension, thumb
adduction and wrist flexion. These changes can become
fixed resulting in joint contractures.
References:
1. Ghidella SD, Segalman KA, et al. Long-term results of surgical
management of proximal interphalangeal joint contracture.
J Hand Surg 2007; 27A:799-805.
2. Watson HK, Weinzweig J. Stiff joints. In: Green DP, Hotchkiss
RN, Pederson WC eds. Green’s Operative Hand Surgery 4th ed.
Philadelphia: Churchill Livingston, 1999:552-562.
2009 Self-Assessment Examination | 61
 125. The etiology of a swan-neck deformity in a
rheumatoid arthritis patient with a positive Bunnell
intrinsic tightness test and full active PIP flexion is:
A. DIP joint mallet deformity with arthritis
B. DIP joint mallet deformity without arthritis
C. PIP joint stiffness with lateral band contracture
D. PIP joint arthritis with joint destruction
E. MP joint synovitis and subluxation
Preferred Response: E
Discussion: Type II swan-neck deformity develops from
MP joint synovitis and subluxation. The sagittal bands
are attenuated, thereby weakening the extensor force.
Subsequent intrinsic contracture occurs. It is not enough to
perform procedures that simply limit PIP hyperextension. An
intrinsic release, either alone or combined with MP joint
arthroplasty, must be performed as well.
References:
1. Dodds SD, Brugel-Sanchez V, Swigert CR. Rheumatoid arthritis
of the hand: soft tissue reconstruction. In: Trumble TE, Budoff JE
eds. Hand Surgery Update IV. American Society for Surgery of
the Hand, Rosemont: 2007:673-685.
2. Kiefhaber TR, Strickland JW. Soft tissue reconstruction for
rheumatoid swan-neck and boutonnierre deformities: long-term
results. J Hand Surg 1993; 18A:984-989.
62 | American Society for Surgery of the Hand
126. Which artery serves as the pedicle of a latissimus
dorsi flap?
A. Circumflex scapular
B. Thoracodorsal
C. Lateral thoracic
D. Thoracoacromial
E. Posterior intercostal
Preferred Response: B
Discussion: The subscapular artery is a branch off the
axillary artery. It branches into the thoracodorsal artery
and the circumflex scapular artery. The thoracodorsal
artery supplies the latissimus dorsi muscle. The
circumflex scapular artery supplies the scapular flap. The
thoracodorsal artery also divides within the latissimus dorsi
muscle into an upper transverse (medial) branch and a
lower descending (lateral) branch. The latissimus dorsi
muscle flap can be pedicled on the posterior intercostal
arteries, but not for coverage on the upper extremity.
References:
1. Jones NF, Lister GD. Free skin and composite flaps. In: Green DP,
Hotchkiss RN, Pederson WC eds. Green’s Operative Hand Surgery.
4th ed. Philadelphia: Churchill Livingston, 1999:1159-1200.
2. Mathes SJ, Nahai F. Clinical atlas of muscle and myocutaneous
flaps. St. Louis: Mosby, 1979:369-391.
Question 126, Figure 1
This article was published in Green’s Operative Hand Surgery, 5th
edition, Volume 2, Pederson, W.C. and Lister, L., Skin Grafts and
Skin Flaps (Skin Flaps), Page 1690, Copyright Elsevier (2005).
127. Electrodiagnostic studies are performed in a
patient with carpal tunnel syndrome. Abnormal
antidromal peak sensory latency measured at
14 cm is greater than how many milliseconds?
A. 2
B. 2.5
C. 3
D. 3.5
E. 4
Preferred Response: D
Discussion: Nerve conduction studies are frequently used
electrodiagnostic tests for carpal tunnel syndrome. A sensory
specific recording is called a sensory nerve action potential
(SNAP). The nerve can be stimulated in an antidromic (from
proximal to distal) or orthodromic (from distal to proximal)
fashion. The speed of conduction is similar in either direction.
The distance (in millimeters) and time (in milliseconds) of
action potential travel between electrodes must be known in
order to measure the speed of conduction. Action potential
velocity (distance/time), latency (time between the stimulus
and the onset of the action potential), and amplitude are
typically recorded. The question involves antidromic sensory
nerve latency across a 14 cm measured segment. Values
above 3.5 milliseconds (ms) are considered abnormal.
Abnormal values of orthodromic sensory nerve latency
measured at a standard 8 cm distance across the wrist
are typically greater than 2.2 ms.
References:
1. Means KR, Segalman KA. Carpal tunnel syndrome. In: Trumble
TE, Budoff JE eds. Hand Surgery Update IV. American Society for
Surgery of the Hand, Rosemont: 2007:399-407.
2. Townshend DN, Taylor PK, Gwynne-Jones DP. The outcome of
carpal tunnel decompression in elderly patients. J Hand Surg
2005; 30A:500-505.
3. Slutsky DJ. Nerve conduction studies in hand surgery. J Hand
Surg 2003; 3(3):152-169.
128. A child is born with radial deficiency. Evaluation
for associated systemic conditions includes a
chromosomal challenge test for early diagnosis of:
A. Holt-Oram syndrome
B. TAR syndrome
C. VACTERL syndrome
D. Fanconi anemia
E. Hunter-Thompson syndrome
Preferred Response: D
Discussion: Holt-Oram, TAR, VACTERL and Fanconi
anemia are syndromes associated with radial deficiency.
All forms of radial deficiency warrant systemic evaluation
irrespective of the degree of expression. The appropriate
work-up usually necessitates referral to pediatric
subspecialists. Children with Fanconi anemia do not
have signs of bone marrow failure at birth. The majority
of children experience signs of aplastic anemia between
the ages of 3 and 12 years (median age of 7 years). A
chromosomal challenge test is currently available that
allows the detection of the disease prior to the onset of
bone marrow failure. Since bone marrow transplant is the
only cure for Fanconi anemia, this preliminary diagnosis is
crucial for the child and family.
References:
1. Kozin SH. Upper extremity congenital anomalies: current
concepts review. J Bone Joint Surg 2003; 85:1564-1575.
2. McCarroll HR. Congenital anomalies: a 25-year review. J Hand
Surg 2000; 25A:1007-1037.
2009 Self-Assessment Examination | 63
 129. The recommended treatment for improving severe
finger flexion contractures in a stroke patient with
palmar skin maceration is:
A. Occupational and/or physical therapy
B. Antispasticity medication
C. Flexor-pronator slide
D. Functional electrical stimulation
E. Superficialis to profundus tendon (STP) transfer
Preferred Response: E
Discussion: The superficialis to profundus (STP) procedure
is used primarily for addressing finger-in-palm deformities
to improve hygiene. It is not a good procedure for improving
motor function of the digits. It is not the procedure of
choice in patients with good hand/finger function.
References:
1. Hier DB, Mondlock J, Caplan LR. Recovery of behavioral
abnormalities after right hemisphere stroke. Neurology 1983;
33345-350.
2. Tafti MA, Cramer SC, Gupta R. Orthopaedic management of
upper extremity stroke patients. J Am Acad Orthop Surg 2008;
16:462-470.
130. A 35 year-old female presents with complaints of
dorsal wrist pain associated with finger flexion
two years after undergoing an ORIF of a distal
radius fracture. She was diagnosed with Complex
Regional Pain Syndrome (CRPS) after her surgery
and required extensive hand therapy to resolve
her symptoms. Radiographs reveal her fracture
to be well united with prominent hardware. Your
recommendation for this patient is:
A. No operation is indicated, due to her CRPS history
B. Proceed with removal of the hardware
C. Denervation procedure, leaving the hardware intact
D. Hardware removal and stellate ganglion block
E. Refer to a pain specialist for chronic pain management
Preferred Response: D
64 | American Society for Surgery of the Hand
Discussion: In a patient with a strong history of complex
regional pain syndrome (CRPS), generally, surgery should
be avoided due to the risk of triggering another episode
of CRPS.
Symptomatic prominent hardware should not be ignored.
A meta-analysis of the literature found a 7.8% incidence
of tendon rupture and tenosynovitis, and a 16% rate of
plate removal in 603 patients, 53% of whom were treated
with a volar plate.
If surgery is indicated in these individuals, the administration
of a perioperative stellate ganglion block has been found
to significantly reduce the recurrence of CRPS.
References:
1. Reuben SS, Rosenthal EA, Steinberg RB: Surgery on the affected
upper extremity of patients with a history of complex regional
pain syndrome: a retrospective study of 100 patients. J Hand
Surg 2000; 25A(6):1147-51.
2. Margaliot Z, et al. A meta-analysis of outcomes of external
fixation versus plate osteosynthesis for unstable distal radius
fractures. J Hand Surg 2005; 30A:1185-1199.
131. What is the most likely diagnosis of the lesion
seen in the 34 year-old female in Figures 1 and 2?
A. Synovial cell sarcoma
B. Giant cell tumor of bone
C. Osteosarcoma
D. Enchondroma
E. Metastatic lesion
Preferred Response: B
Discussion: Giant cell tumor (GCT) of bone affects
skeletally mature individuals, F > M, in the 20 to 50 age
group. This tumor is rare in children and patients older
than 60 years of age. GCT’s are locally very aggressive
and as a result can cause considerable destruction. They
are relatively common, accounting for 4% of all primary
bone tumors. Multifocal lesions are usually Brown tumors
of hyperparathyroidism. Brown tumors may be confused
with GCT’s. The histogenesis of GCT’s is unclear with
characteristics of macrophages and osteoclastic cells.
References:
1. O’Donnell RJ, Springfield DS, Motwani HK, et al. Recurrence of
giant cell tumors of the long bones after curettage and packing
with cement. J Bone Joint Surg 1994; 76A:1827.
2. Ferracini R, Masterson EL, Bell RS, Wunder JS. Distal ulnar
tumours. Results of management by en bloc resection in
nine patients and review of the literature. J Hand Surg 1998;
23B(4):517-21.
 Discussion: Drawing of a lateral radiograph of the wrist
showing the anatomic landmarks used in the triangulation
method. The normal DL:PL ratio is 0.5 to 1.0.

The distal landmark is located at the junction of the

dorsal and middle thirds of the (dorsopalmar) width of the
capitate at the level of the third carpometacarpal joint.

The scapholunate angle is the traditional method

used for assessing VISI and DISI deformities of the
wrist. Other angulatory measurements such as the
radiolunate, capitolunate, and rarely the lunotriquetral,
are sometimes used.

In a comparative study involving the various radiological

methods available, the triangulation method was found
to have the best inter/intraobserver correlation. In part, the
difficulty with many of these angulatory measurements is that
Question 131, Figure 1 there are large standard deviations with these values which
reduces their clinical specificity. Additionally, the angulatory
measurements are more susceptible to positional problems
compared to radiological ratios. The method is performed
by drawing a point between the dorsal and middle third of
the capitate at the level of the CMC joint on a true lateral
x-ray. Additionally, points on the dorsal and palmar poles
of the lunate are also drawn. Connecting the three dots
forms a triangle with a dorsal limb (DL) and a palmar limb
(PL). A DL:PL ratio greater than 1.0 indicates a DISI deformity
and a DL:PL ratio less than 0.5 is a VISI deformity. If there
is a borderline value, then the radiometacarpal (RM) angle
is measured and the value is checked on a “normagram”
to assess for carpal instability. Hence, the triangulation
ratio was found to have a better agreement among
examiners than the other radiographic methods.

References:
1. Pirela-Cruz MA, Hansen MF. Assessment of midcarpal deformity
of the wrist using the triangulation method. J Hand Surg 2003;
28A(6):938-42.
Question 131, Figure 2
2. Cho MS, Battista V, Dubin NH, et al. Assessment of four
midcarpal radiologic determinations. Surg Radiol Anat. 2006;
28(1):92-7. Epub 2005 Dec 9.
132. Which of the following carpal measurements
has the best inter and intra observer correlation
for determining VISI and DISI deformities of
the wrist?
A. Radiolunate angle
B. Scapholunate angle
C. Lunotriquetral angle
D. Triangulation ratio
E. Capitolunate angle

Preferred Response: D

Question 132, Figure 1

2009 Self-Assessment Examination | 65
 133. A 27 year-old male suffers a transverse laceration
to the volar wrist. He has no sensation in the finger
pads and no active finger flexion. At surgery, a
transected 3 mm diameter artery is encountered
within the carpal tunnel. This finding is associated
with what anomaly:
A. Duplication of the ulnar nerve
B. Failure of formation of the flexor pollicis longues
C. Heart defects, most commonly atrial septal defects
D. High bifurcation of the median nerve
E. A single nerve incorporating the function of both the
median and radial nerves
Preferred Response: D
Discussion: The presence of a persistent median artery
is associated with an increased incidence of a high
bifurcation of the median nerve, with the artery lying
between. In one ultrasound study, a persistent median
artery was found in 16% of wrists in asymptomatic
volunteers, and the persistent median artery was
associated with a high median nerve division or bifed
median nerve in 63%. Much lower prevalence has been
reported, including a 0.6% prevalence of a persistent
median artery in Korean surgical patients.
When exploring a volar wrist laceration, the finding of
either a smaller than expected median nerve, particularly
a very radial or very ulnar median nerve, or the presence
of a persistent median artery, may suggest that there may
be a second branch of the median nerve to repair.
References:
1. Gassner EM, Schocke M, Peer S, Schwabegger A, Jaschke W,
Bodner G. Persistent median artery in the carpal tunnel: color
Doppler ultrasonographic findings. J Ultrasound Med 2002 Apr;
21(4):455-61.
2. Ahn DS, Yoon ES, Koo SH, Park SH. A prospective study of the
anatomic variations of the median nerve in the carpal tunnel in
Asians. Ann Plast Surg 2000 Mar; 44(3):282-7.
66 | American Society for Surgery of the Hand
134. Which of the following best describes the primary
action of bone morphogenic protein 2 (BMP2) in
fracture healing?
A. Chemotactic effect on inflammatory cells,
stimulation of extracellular matrix synthesis,
angiogenesis, recruitment of endogenous fibrogenic
cells to the injury site, and bone resorption
B. Degradation of the cartilage and bone allowing
the invasion of blood vessels during endochondral
ossification and bone remodeling
C. Differentiation of undifferentiated mesenchymal
cells into chondrocytes and osteoblasts, and
osteoprogenitors into osteoblasts
D. Decreased osteoclast activity through up regulation
of receptor activator nuclear factor-kappaB ligand
(RANKL) mRNA in primary bone marrow stromal cells
E. Up regulation of noggin, gremlin, sclerostin, and
chordin mRNA
Preferred Response: C
Discussion: One of the main actions of BMP2 is that it
is believed to stimulate the proliferation and differentiation
of osteoblasts, increasing the number of osteoblasts
by helping undifferentiated mesenchymal cells become
chondrocytes and osteoblasts, and osteoprogenitors
into osteoblasts.
Cytokines (IL-1, IL-6, TNF-a) act through a chemotactic
effect on other inflammatory cells, stimulation of
extracellular matrix synthesis, angiogenesis, recruitment
of endogenous fibrogenic cells to the injury site, and
at later stages bone resorption. Metaloproteasis act
by degradation of the cartilage and bone allowing
the invasion of blood vessels during the final stages
of endochondral ossification and bone remodeling.
Parathryroid hormone upregulates receptor activator
nuclear factor-kappaB ligand (RANKL) mRNA, increasing
osteoclast activity. Noggin, gremlin, sclerostin, and
chordin are BMP antagonists.
References:
1. Dimitriou R, Tsiridis E, Giannoudis PV. Current concepts of molecular
aspects of bone healing. Injury. 2005 Dec; 36(12):1392-404.
2. Huang JC, Sakata T, Pfleger LL, Bencsik M, Halloran BP, Bikle
DD, Nissenson RA. PTH differentially regulates expression of
RANKL and OPG. J Bone Miner Res 2004; 19(2):235-44. Epub
2003 Dec 16.
135. Which of the following measures has the highest
level literature evidence for prophylaxing against
CRPS in elderly females with distal radius fractures?
A. Axillary block
B. Steroid/Bretylium Bier block
C. Pregabalin
D. Stellate ganglion blocks
E. Vitamin C
Preferred Response: E
Discussion: Although from the same author, two reports
of a randomized trial from the Netherlands showed a
deceased incidence of complex regional pain syndrome
in patients with distal radius fractures given Vitamin C.
In the most recent study, the prevalence of complex
regional pain syndrome was 2.4% (eight of 328) in the
Vitamin C group and 10.1% (10 of 99) in the placebo
group (p = 0.002). Patients who received at least 500 mg
per day for 50 days showed the lowest incidence. The
patients with CRPS were elderly females, and there was
an association between development of CRPS and early
cast complaints. The reduction of CPRS was also found
in a sequential cohort study in the French literature.
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(7):1424-31.
136. A 9 year-old female fell down stairs approximately
3 feet, injuring her right elbow 3 days ago and
presents with elbow pain. Radiographs are
shown (Figures 1 and 2). The most appropriate
management is:
A. Sling until comfort improves, then early mobilization
B. Immobilization in splint (then cast) for 4 weeks
C. Closed manipulation and immobilization for 4 weeks
D. Closed reduction and percutaneous pinning
E. Open reduction and internal fixation
Preferred Response: E
Discussion: The X-rays show a shear fracture of the
capitellum in a child, which is a relatively rare injury in
this age group, in contrast to a lateral condyle fracture.
Older literature, with limited follow up, older patients,
and limited fixation options, suggested excision of
the fragment as an option. Anatomic closed reduction
is unlikely to be achievable on a routine basis. Open
reduction and internal fixation restores the anatomy, and
allows primary bone healing.
Reference:
De Boeck H, Pouliart N. Fractures of the capitellum humeri in
adolescents. Int Orthop. 2000; 24(5):246.

2. Cazeneuve JF, Leborgne JM, Kermad K, Hassan Y. Vitamin C

and prevention of reflex sympathetic dystrophy following surgical
management of distal radius fractures. Acta Orthop Belg. 2002;
68(5):481-4.

3. Zollinger PE, Tuinebreijer WE, Kreis RW, Breederveld RS. Effect

of vitamin C on frequency of reflex sympathetic dystrophy in wrist
fractures: a randomised trial. Lancet 1999; 354:9159.

Question 136, Figure 1

Question 136, Figure 2

2009 Self-Assessment Examination | 67

 137. A 50 year-old previously healthy male presents
with bilateral upper extremity weakness.
Physical exam reveals wasting of both thenar
and hypothenar intrinsic muscles and tongue
fasciculations. The most likely diagnosis is:
A. Amyotrophic lateral sclerosis
B. Multiple nerve compression syndrome
C. Multiple sclerosis
D. Spinal cord tumor
E. Syrinx
Preferred Response: A
Discussion: Amyotrophic lateral sclerosis (ALS) is a
disorder of the anterior horn cells that leads to progressive
muscle weakness and atrophy. Sensory changes are
not seen or are minimal. Cranial motor nerves can be
involved, and can manifest the disease with visible
facilitations in the tongue (“bag of worms”), although
this is not pathognomonic for ALS. The combination of
muscle weakness and wasting in the distribution of more
than one peripheral nerve, sensory sparing, and visible
fasciculations of the tongue, suggest the possibility of ALS.
Reference:
Goetz TJ. Textbook of Clinical Neurology, 3rd ed. Philadelphia:
Saunders/ Elsevier, 2007.
138. Which of the following measures has the highest
level literature evidence for reducing acute
phantom limb pain?
A. Calcitonin
B. Clonazepam
C. Metoprolol
D. Pregabalin
E. Steroid/Bretylium Bier block
Preferred Response: A
Discussion: Although all of the medications above have
been suggested for neuropathic pain, the literature is
anecdotal for all of the options except calcitonin. A cross
over study by Jaeger and Maier showed a reduction of
the visual analog pain score in 21 patients with acute
phantom limb pain treated with Calcitonin. However, in a
recent randomized crossover trial by Eichenberger et al.,
no benefit was found for calcitonin for the treatment of
chronic phantom limb pain, leaving only the first trial and
anecdotal reports to support the use of calcitonin.
68 | American Society for Surgery of the Hand
References:
1. Jaeger H, Maier C. Calcitonin in phantom limb pain: a double-
blind study. Pain. 1992; 48(1):21-7.
2. Eichenberger U, Neff F, Sveticic G, Björgo S, Petersen-Felix S,
Arendt-Nielsen L, Curatolo M. Chronic phantom limb pain: the
effects of calcitonin, ketamine, and their combination on pain and
sensory thresholds. Anesth Analg. 2008; 106(4):1265-73.
139. Which of the following is the most common cause
of revision amputations in children?
A. Contractures
B. Deep venous thrombosis
C. Phantom limb pain
D. Bony overgrowth
E. Skin breakdown
Preferred Response: D
Discussion: Bony overgrowth requiring revision does
occur in children, particularly in younger children. Joint
disarticulations do not undergo overgrowth.
In the absence of other factors, joint contractures
in children rarely occur. Deep venous thrombosis is
extraordinarily rare in children. The incidence of phantom
limb pain in upper extremity amputations would be
expected to depend on both the criteria used to define
phantom limb pain, as well as the aggressiveness
which the symptoms are elicited, particularly from a
suggestible population. The incidence of phantom limb
pain after amputations has been reported to be high.
Ebrahimzadeh et al. studied young adults with upper
extremity amputations secondary to war injuries and
found phantom limb pain in 32% and phantom sensation
in 64%. Krane and Heller, in pediatric lower extremity
amputees, reported an incidence of phantom pain of
83-92%, with the symptoms documented in the formal
medical record in only 40% of those identified as having
phantom limb pain. Wilkins et al. included both lower
and upper extremity pediatric amputees, although more
of the amputations were upper extremity amputations.
They found that 3.7% had phantom limb pain in their
congenital group, but in children with amputations that
were not the result of congenital differences, 48.5%
had phantom limb pain. According to Thomas et al.,
phantom limb pain in pediatric amputations secondary
to burns was found in 0/4 upper limb amputations
secondary to thermal flame burns, but in 5/10 with upper
limb amputations secondary to electrical burns. But,
regardless of the frequency of phantom limb pain, revision
amputation is rarely performed for phantom limb pain.
References:
1. O’Neal ML, Bahner R, Ganey TM, Ogden JA. Osseous Overgrowth
After Amputation in Adolescents and Children. Journal of Pediatric
Orthopaedics 1996; 16(1):78-84.
2. Ebrahimzadeh MH, Fattahi AS, Nejad AB. Long-term follow-up of
Iranian veteran upper extremity amputees from the Iran-Iraq war
(1980-1988). J Trauma 2006; 61(4):886-8.
3. Krane EJ, Heller LB. The prevalence of phantom sensation and pain
in pediatric amputees. J Pain Symptom Manage 1995; 10:21–29.
4. Wilkins KL, McGrath PJ, Finley JA. Katz J. Phantom limb sensations
and phantom limb pain in child and adolescent amputees. Pain
1998; 78:7–12.
5. Thomas CR, Brazeal BA, Rosenberg L, Robert RS, Blakeney PE,
Meyer WJ. Phantom limb pain in pediatric burn survivors. Burns
2003; 29(2):139-142.
140. In considering the advantages and disadvantages
of transhumeral amputation versus elbow
disarticulation, a transhumeral amputation:
A. Facilitates suspension of the prosthetic limb
B. Allows use of standard internal hinge elbow joints
C. Improves rotational stability of the stump
D. Avoids limb length discrepancies and overgrowth
in children
E. Minimizes redundant tissue between prosthesis
and stump
Preferred Response: B
Discussion: An elbow disarticulation preserves the
condyles, which provide a flare on which to suspend
the prosthesis, as well as an improved rotational
moment arm, minimizing rotation of the stump within the
prosthetic socket. A trans-humeral amputation allows the
use of an internal elbow hinge that lies in the anatomic
position of the original elbow joint and matches brachial
length, avoiding a more bulky external hinge. An elbow
disarticulation avoids overgrowth in children, but has
limited tissue coverage, which has been anecdotally
reported in both upper and lower extremities to lead to
breakdown and subsequent revision surgery.
141. A 3 year-old male suffered a right index finger
crush in a car door one week ago and has a
swollen stiff proximal interphalangeal joint.
Radiographs are shown. The best option for
management is:
A. Immobilization
B. Closed reduction and immobilization
C. Closed reduction and pinning
D. Open reduction and pinning
E. Volar plate arthroplasty
Preferred Response: D
Discussion: This fracture-dislocation involves the middle
phalanx base epiphysis, with the epiphysis flipped within
the joint. Limited information regarding non-operative
treatment of this injury is available. In a case treated
non-operatively initially, and then treated with operative
excision of the epiphysis eight years later, subsequent
range of motion was limited. The rest of the reported
cases were all surgically-reduced, and sometimes,
supplemented with K-wires. The fractures were explored
from dorsal, except for one that was explored both
dorsally and volarly to achieve reduction.
References:
1. Hashizume H, Nishida K, Mizumoto D, Takagoshi H, Inoue H.
Dorsally displaced epiphyseal fracture of the phalangeal base.
J Hand Surg 1996; 21B(1):136-8.
2. Keene JS, Engber WD, Stromberg WB Jr. An irreducible
phalangeal epiphyseal fracture-dislocation. A case report.
Clin Orthop Relat Res 1984; (186):212-5.

References:
1. Jebson P, Louis D. Amputations. In: Green DP, Hotchkiss RN,
Pederson WC, Wolfe SW eds. Green’s Operative Hand Surgery, 5th
ed. Philadelphia: Churchill Livingston/Elsevier, 2005:1939-1983.

2. de Luccia N, Marino HL. Fitting of electronic elbow on an elbow

disarticulated patient by means of a new surgical technique. Prosthet
Orthot Int. 2000; 24(3):247-51. Question 141, Figure 1 Question 141, Figure 2
3. O’Neal ML, Bahner R, Ganey TM, Ogden JA. Osseous overgrowth
after amputation in adolescents and children. Journal of Pediatric
Orthopaedics 1996; 16(1):78-84.

2009 Self-Assessment Examination | 69

 142. A 70 year-old woman in Figure 1 presents with a
humeral nonunion, with the original fracture being
treated by open reduction and internal fixation
with a compression plate 2 years ago. At surgery
for repair of the nonunion, the plate is found to be
placed with the upside-down. Postoperatively, the
issue of the plate being placed with the upside-
down is most appropriately addressed with the
patient as follows:
A. Document the information of the plate placement
thoroughly in the dictated operative note, but do not
specifically volunteer that the plate was upside-down
unless asked Question 142, Figure 1
B. Inform the patient that an upside-down plate does
not function effectively as a compression plate and
that this was a major contributor to the nonunion 143. You are performing surgery for an injury that was
C. Recommend to the patient that they pursue reported to have occurred at work and is therefore
malpractice litigation against the previous surgeon being paid for by workers’ compensation.
Before going back to the operating room, the
D. Tell the patient that the plate was placed upside-down
anesthesiologist reports that the patient, after
E. Wait to make sure there are no complications from receiving preoperative sedation, said that the
your surgery and for the humerus to heal before injury actually occurred at home. You should:
bringing up the issue of whether plate placement
caused the nonunion A. Cancel the surgery
B. Carefully document the conversation with
Preferred Response: D
the anesthesiologist in the chart
Discussion: “It is a fundamental ethical requirement C. Inform the insurance company
that a physician should at all times deal honestly and D. Disregard what the patient said after
openly with patients. Patients have a right to know their receiving medication
past and present medical status and to be free of any
E. Question the patient further prior to beginning
mistaken beliefs concerning their conditions. Situations
the procedure
occasionally occur in which a patient suffers significant
medical complications that may have resulted from the Preferred Response: D
physician’s mistake or judgment. In these situations, the
physician is ethically required to inform the patient of all Discussion: There are multiple conflicting needs in this
the facts necessary to ensure understanding of what has scenario. The needs of the patient, the physician, the
occurred. Only through full disclosure is a patient able to payer, and society are not aligned. Even if the problem
make informed decisions regarding future medical care.” is evaluated from only the perspective of the physician,
there is still conflict between the differing factors, including
“Ethical responsibility includes informing patients of responsibility to the patient, responsibility to society, one’s
changes in their diagnoses resulting from retrospective own moral code, responsibilities toward co-workers, and
review of test results or any other information. This external reputation and one’s self-perception. However,
obligation holds even though the patient’s medical in this scenario, one factor has primacy. After sedation,
treatment or therapeutic options may not be altered by ethically and legally the patient is not considered
the new information.” competent. Therefore, as a general principle, anything said
after the patient receives sedation should be disregarded,
Reference:
unless the statement requires a medical response—such
AMA code of medical ethics, opinion 8.12.
as a patient complaining of shortness or breath and chest
pain. Additionally, as stated in the AMA code of ethics,
“A physician shall, while caring for a patient, regard
responsibility to the patient as paramount.”

Reference:
AMA code of ethics, VIII.

70 | American Society for Surgery of the Hand

144. During surgery, requested equipment that is needed
for the surgery is not available, but the equipment
is required to proceed with the case. Your assistant
goes to get the equipment, but the hospital
employee in the supply area is on break and refuses
to look for the equipment. Your assistant engages
in an argument with the employee using language
that violates hospital nondiscrimination policy. The
hospital employee reports the language used to
the hospital administration. Your most appropriate
response would be to:
A. Ignore the issue
B. Apologize to the administration for your assistant’s
behavior, inform the administration that the assistant
will be terminated, and institute sensitivity training
for all of your remaining employees
C. Have the head of the Human Resources Department
engage in conflict resolution between your assistant
and the hospital employee, allowing your assistant
to confront and resolve the underlying issues of
their prejudice
D. Apologize for your assistant’s lack of
professionalism, state that the assistant will
be disciplined, but also state clearly that the
professionalism of everyone involved needs
scrutiny, and that the system problems allowing this
issue to occur must be addressed
E. Demonstrate loyalty to your assistant and publicly
back his or her behavior, while privately counseling
your assistant about his or her behavior
Preferred Response: D
Discussion: Ignoring minor infractions that are self-
correcting is often a reasonable course. However,
this issue may not be self-correcting, and the
administration will see this issue as a major potential
liability. Ignoring what they perceive to be a critical
problem will reduce one’s credibility with the
administration, and reduce one’s overall effectiveness.
However, the response to the problem must be fair
and cannot focus on punishing only those lowest
in the hierarchy, or one will also lose credibility and
effectiveness with employees. Further, even though
the administration wants complete capitulation and will
in the short term reward throwing the assistant to the
wolves, in the long-term, even a hospital administrator
will see this action as pusillanimous and one will become
ultimately less effective with the administration as well
as employees. Answer D allows the problem with the
assistant to be addressed, allows the problem with
the hospital employee to be addressed, allows the
system problems that contributed to the confrontation
to be addressed, and reframes an adversarial conflict
regarding who is to blame into a cooperative approach
to a communal goal: improving patient care.
References:
1. Katz JD. Conflict and its resolution in the operating room. J Clin
Anesth. 2007; 19(2):152-8.
2. Fisher R, Ury W. Getting to yes: negotiating agreement without
giving in. New York: Penguin Books 1992.
2009 Self-Assessment Examination | 71
 145. A 57 year-old female has a six month history of
pain and mild swelling about the index MCP joint.
There is no history of trauma. The arc of motion
is 10º extension to 80º flexion. Her x-rays are
normal. Her laboratory studies, including a CBC,
sedimentation rate, ANA, and uric acid are all
within normal limits. Her MRI is shown in Figure 1
below. The most likely diagnosis would be:
A. Intraosseous lipoma
B. Intraosseous ganglion
C. Giant cell tumor
D. Avascular necrosis
E. Metastatic tumor
Preferred Response: D
Discussion: Dieterich’s disease, or avascular necrosis
of the metacarpal head, is an unusual finding which may
present in early stages with normal appearing x-rays.
This may be seen in patients with a history of trauma,
steroid use, or SLE, but can also be idiopathic. The
long finger metacarpal is most commonly involved, but
involvement of all metacarpals have been reported. The
MRI images will show hypointensity in the metacarpal
head on the T1 images, usually in the subarticular area,
and hyperintensity on the T2 images with marrow edema.
Other diagnostic possibilities, based on the MRI findings,
would include infection, which would be unlikely with
these laboratory studies.
146. The 44 year-old woman in Figure 1 complains of hand
pain and stiffness. What is the most likely diagnosis:
A. Giant cell tumor of tendon sheath
B. Ganglion cyst
C. Pseudogout
D. CREST syndrome
E. Psoriatic arthritis
Preferred Response: D
Discussion: The figures show multiple nodules of
cutaneous calcification in a patient with CREST
syndrome, a type of systemic sclerosis, also known
as scleroderma. The two clinical subsets, limited
cutaneous and diffuse cutaneous, are distinguished
by the extent of skin involvement, antibody profile and
pattern of organ involvement.
Common procedures include resection of calcifications,
first web space release, MP joint releases or MP
resection arthroplasty. The most common deformity is
advanced flexion deformity of the PIP joints. This has
been treated successfully in multiple series with PIP
fusion. PIP arthroplasty has been associated with poor
range of motion and wound healing problems, sometimes
requiring prosthesis removal.
References:
1. Bogoch ER, Gross DK. Surgery of the hand in patients with
systemic sclerosis. J Rheumatol. 2005; 32(4):642-48.

References: 2. Nalebuff EA. Surgery in patients with systemic sclerosis of the

hand. Clin Orthop Relat Res 1999; 366:91-97.
1. Thienpart E, Vandsande W, De Smet L. Dieterich’s Disease:
Avascular necrosis of the metacarpal head: a case report. Acta 3. Gilbart MK, Jolles BM, Lee P, Bogoch ER. Surgery of the hand in
Orthop Belgica 2001; 67(2):182-184. severe systemic sclerosis. J Hand Surg 2004; 29B; 6:599-603.
2. Barrueco J, Zapatero M, Lignereux Y, Regodon S.
Osteochondritis dissecans of the head of the second metacarpal
bone. J Hand Surg 1992; 17A:1079-81.

3. Karlakki SL, Bindra RR. Idiopathic avascular necrosis of the

metacarpal head. Clin Orthop. 2003; 406:103-108.

Question 146, Figure 1

Question 145, Figure 1

72 | American Society for Surgery of the Hand

 Discussion: This patient has a partial tear of the triceps.
It involves the long head, which arises from the scapula
and then joins the lateral head to form the superficial
muscular sleeve, which attaches onto the triceps tendon.
The medial (or deep) head of the triceps muscle arises
from the posterior humerus distal to the spiral groove.
The medial head sits deep to the triceps aponeurosis
which is created by the confluence of the more superficial
lateral and long heads. With partial tears, the insertion of
the aponeurosis on the olecranon may be intact.

The medial head inserts by a separate tendon near the

olecranon. Testing for weakness with the elbow flexed
more than 90° may help suggest a partial tear of the
medial head. Triceps tears can be confirmed by MRI.
Early surgical repair, preferably within three weeks, is the
recommended treatment of triceps tendon injuries.

References:
Question 146, Figure 2 1. Madsen M, Marx RG, Millett PJ, Rodeo SA, Sperling JW,
Warren RF. Surgical anatomy of the triceps brachi tendon:
anatomical study and clinical correlation. Am J Sports Med 2006;
34(11):1839-43.
147. A 22 year-old patient presents with pain in the
posterior arm after an injury 4 weeks prior. He 2. Van Reit RP, Morrey BF, Ho E, O’Driscoll SW. Surgical treatment of
distal triceps ruptures. J Bone Joint Surg 2003; 85A(10):1961-67.
was lifting weights and felt a pop in the arm.
He complains of persistent pain and weakness. 3. Kibuule LK, Fehringer EV. Distal triceps tendon rupture and
His exam shows swelling and tenderness in the repair in an otherwise healthy pediatric patient: a case report and
review of the literature. J Shld Elbow Surg 2007; 16:e1-e3.
muscular portion of the posterior arm, with a
palpable defect medially. He has weakness with
extension against resistance. His x-ray is normal,
and an MRI is shown in Figures 1 and 2. His injury
occurred in which head of the triceps:
A. Long
B. Lateral
C. Radial
Question 147, Figure 2
D. Deep
E. Medial

Preferred Response: A

Question 147, Figure 1

2009 Self-Assessment Examination | 73

 148. A 34 year-old police officer presents with
right wrist pain after a fall from a ladder.  His
neurovascular exam is intact. His x-rays are
shown in the Figures below. The best treatment
would consist of:
A. Closed reduction with long arm cast
B. Closed reduction with external fixation
C. Closed reduction with percutaneous pin fixation
D. Open reduction internal fixation
E. Open reduction with fragment excision

Preferred Response: D

Discussion: The radiographs show an intra-articular

coronal fracture involving the volar margin of the radius,
with displacement of the carpus due to loss of the
buttress support of the volar rim. Because this fracture
is inherently unstable, proper treatment requires open
reduction of the volar fragment to restore articular Question 148, Figure 1
congruity and proper support for the volar carpus.
Disruption of the volar ligaments, particularly the long and
short radiolunate ligaments, may be a component of the
fracture and require repair if found to be unstable after
fracture reduction and fixation.

References:
1. Ilyas AM, Mudgal CS. Radiocarpal fracture-dislocations. J Am
Acad Orthop Surg 2008; 16:647-55.

2. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL.
Loss of fixation of the volar lunate facet fragment in the fractures
of the distal part of the radius. J Bone and Joint Surg 2004;
86A(9):1900-08.

3. Chin KR, Jupiter JB. Wire loop fixation of volar displaced

osteochondral fractures of the distal radius. J Hand Surg 1999;
24A:525-33.

Question 148, Figure 2

74 | American Society for Surgery of the Hand

149. When comparing in-situ ulnar nerve
decompression versus anterior transposition in
the surgical treatment of cubital tunnel syndrome,
anterior transposition affords:
A. Improved sensory recovery
B. Decreased sensory recovery
C. Improved motor recovery
D. Decreased motor recovery
E. No difference in motor or sensory recovery
Preferred Response: E
Discussion: Several recent studies (therapeutic level I or
II) have looked at meta-analysis of randomized, controlled
trials to evaluate the efficacy of simple decompression
versus anterior transposition for the treatment of cubital
tunnel syndrome. Although one study noted a trend
toward improved clinical outcome with transposition of the
ulnar nerve, either subcutaneous or submuscular, none of
the randomized studies showed a statistically significant
difference between simple decompression and any type
of transposition. One investigator recommended simple
decompression in cases without deformity of the elbow as
it is a less invasive operative procedure.
References:
1. Macadam SA, Gandhi R, Bezuhly M, Lefaivre K. Simple
decompression versus anterior subcutaneous and submuscular
transposition of the ulnar nerve for cubital tunnel syndrome: a
meta-analysis. J Hand Surg 2008; 33A:1314-24.
2. Zlowoddzki M, Chan S, Bhandari M, Kallianen L, Schubert W.
Anterior transposition compared with simple decompression
for the treatment of cubital tunnel syndrome: a meta-analysis of
randomized controlled trials. J Bone Joint Surg 2007; 89:2591-8.
3. Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwendtfeger K,
Steudel WI. Simple decompression or subcutaneous anterior
transposition of the ulnar nerve for cubital tunnel syndrome.
J Hand Surg 2005; 30B(35):521-4.
150. Pathophysiologic changes resulting from
peripheral nerve compression include:
A. Wallerian degeneration
B. Increased endoneurial fluid pressure
C. Increased retrograde axonal transport
D. Schwann cell proliferation
E. Thickening of the myelin sheath
Preferred Response: B
Discussion: A compressed peripheral nerve undergoes
multiple changes. The severity is dependent on the
magnitude, duration and character of the compressive
trauma. Tissue pressures above 20 mm can limit
epineural blood flow, creating ischemic changes including
thickening of the walls of the plexus of microvessels.
Endoneurial fluid pressure is increased (rather than
decreased) and confined because of the diffusion barrier
in the perineural membrane. This increased endoneurial
pressure interferes with endoneurial microcirculation,
inhibiting blood flow to the fasicles.
Pressures of 30 mm will limit axonal transport—both
anterograde and retrograde. Pressures of 50 mm can
alter the structure of the myelin sheath. Other changes
include increased fibrosis in the perineural tissues, with
impaired nerve gliding. All of these changes will adversely
affect nerve function.
References:
1. Rempel D, Dahlin L, Lundborg G. Pathophysiology of nerve
compression syndromes: response of peripheral nerves to
loading. J Bone Joint Surg 1999; 81A(11):1600-10.
2. Lundborg G, Dahlin LB. Anatomy, function and physiology of
peripheral nerves and nerve compression. Hand Clin 1996;
12(6):185-92.
2009 Self-Assessment Examination | 75
 Notes

76 | American Society for Surgery of the Hand

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