168/189 Day A & B (4/25 & 4/26) Mastery Training Program

Front 1

1-etiologies of elbow cause DJD? MC?#2MC
2-Most important primary stabilizer of elbow? name the (3) 1^ stabilizers of the elbow? name the 2^ stabilizers of elbow?
3-what structure stabilizes to both valgus and distraction forces? unilateral arthrodesis vs bilateral arthrodesis Optimal position?
4-MC location for osteophytes in elbow, MC co-morbidity in pt w/ elbow DJD and ligamentous incompetence
5-patients with severely limited preoperative motion (extension > 60 degrees and flexion of < 100 degrees are at risk for?
6-Outerbridge-Kashiwagi procedure aka indications
7name the 2 types of TEA? what are the indications of UTEA & CTEA

Back 1

1-MC-RA, #2 MC=post-traumatic arthritis, 1^ arthritis, hx of OCD, MUCL insufficiency
2-anterior oblique fibers of ant band MCL;, LCL, coronoid;
2^ stabiliz=radial head, lateral capsule, aconeus, LCL
3-anterior oblique fibers of ant band MCL;
uni-flex-90, valgus-7
4-PM olecranon fossa; RA
b/l-elb-110 & 65
5-ulner nerve dysfunction
6-olecranon fossa debridement, younger patients with decreased ROM
7-UTEA=competent elbow ligaments and adequate bone stock
CTEA=incompetent elbow ligaments

Front 2

A 66 year old woman has chronic elbow pain and loss of function. She has severe morning stiffness and takes several medications for this. Exam reveals a flexion arc from 35-100 degrees with markedly limited rotation. What is the most appropriate definitive treatment?
1. Total elbow arthroplasty
2. Radial head replacement
3. Radial head excision
4. Corticosteroid injection
5. Elbow arthroscopic debridement and removal of loose bodies

Back 2

Total elbow arthroplasty is the most established definitive surgical treatment for severe rheumatoid arthritis. This patient has pain and loss of function with radiographs that show degenerative changes consistent with rheumatoid arthritis. This would be classified as a Larson grade C with bony architectural changes on its way to joint destruction (Grade D). This is the original indication for total elbow arthroplasty. Ans1

Front 3

middle aged laborer c/o progressive pain, loss of terminal extension, & PE=loss of elbow ROM, ulnar neuropathy.

1.1-KIF(key image finding & R/O (3))? -->Dx
1.2 3 sxf w/ the Dx
1.3 3 pef w/ the dx?
1.4 other imaging
2-(indications--->Tx
2.1 if mild to moderate sx then
2.2 if mild dz w/ bone spurs, mechanical block to motion, pts w/ >90 deg of motion THEN?
2.3 if young high demand pts THEN?
2.4 if younger pts w/ decreased ROM
2.5 if older patients >65 years with severe elbow arthritis
2.6 if complex distal humerus fracture in elderly with poor bone stock w/ RA (with incompetent elbow ligaments)
3-Complication if patients with severely limited preoperative motion (extension > 60 degrees and flexion of < 100 degrees are at risk for then tx?

Back 3

1.1 Ap/Lat elbow:r/o (1)elbow joint space narrowing, (3)osteophytes @ coronoid process/fossa & olecranon tip / posteromedial olecranon fossa, (3)loose bodies
1.2sxf=progressive pain; loss of terminal extension;
painful locking of elbow
1.3PEF=loss of elbow ROM, ligamentous incompetence especially in RA, ulnar neuropathy present =50%
1.4CT-r/o define osteophytes & loose bodies
2.1-NSAIDS, cortisone injections, resting splints, and activity modification
2.2-arthroscopic debridement & capsular release
2.3-ulnohumeral distraction interposition arthroplasty, autogenous tensor fascia lata
achilles tendon allograft
2.4-olecranon fossa debridement (Outerbridge-Kashiwagi procedure)
2.5 unconstrained TEA
2.6 constrained TEA
3-ulnar nerve dysfunction tx=ulnar nerve decompression

Front 4

2-(indications--->Tx 2.1-NSAIDS, cortisone injections, resting splints, and activity modification 2.2-arthroscopic debridement & capsular release 2.3-ulnohumeral distraction interposition arthroplasty, autogenous tensor fascia lata achilles tendon allograft 2.4-olecranon fossa debridement (Outerbridge-Kashiwagi procedure) 2.5 unconstrained TEA 2.6 constrained TEA

Back 4

2-(indications--->Tx 2.1 if mild to moderate sx then2.2 if mild dz w/ bone spurs, mechanical block to motion, pts w/ >90 deg of motion THEN?2.3 if young high demand pts THEN?2.4 if younger pts w/ decreased ROM2.5 if older patients >65 years with severe elbow arthritis2.6 if complex distal humerus fracture in elderly with poor bone stock w/ RA (with incompetent elbow ligaments)

Front 5

1-Attenuation or rupture of the ulnar collateral ligament of the elbow leading to ? MC population affected, uncommon in ? if little leagues elbow, MC cause?2-if little leaguers elbow then sx seen? if baseball pitcher then sx seen? what phase of throwing is the valgus load the highest?3-if excessive olecranon resection places___at risk? techniques to improve poor throwing mechanics (3)? associated conditions w/Medial UCL Injury & Valgus Instability (3)?4-MCL aka, name the 3 components of MCL? which is strongest and most significant stabilizer to valgus stress?which is tight in flexion ?5-which is demonstrates the greatest change in tension from flexion to extension?which is no contribution to stability?which is tight in extension? which inserts on sublime tubercle?6-describe & significance of milking maneuver? 7-gravity stress of the elbow (+) if? what is "T-sign in MR-arthrogram of elbow?

Back 5

1-NO MUCL= valgs instability; -MC-MLP & LLPe; -MC tension overload of the med structures-> physeal widening2 LLP-medial elbow pain w/ dec throwing effectiveness & distanceMLP-decreased throwing performance, loss of velocity, loss of control (accuracy), late cocking & early acceleration phase of throwingvalgus=accelrtn phase also late cocking3- MCL at riskbetter mech=trunk-scapular kinesis, forearm pronation, dynamic flexor-pronator stabilizationMedial UCL Injury & Valgus Instability=traction-related ulnar neuritis, olecranon (PM) impingement, elbow DJD4-MCL=UCL(3)mcl=ant oblique, post oblique, transverse ligstongest=ant oblique MCLflex Tght=post oblq bnd5-greatest change=post oblique Bno contirb=transvere ligextn tight=ant bandsublime tub=ant band6-milk=create a valgus stress by pulling on pt's thumb w/forearm supin & elbow flex @ 90 deg; (+)=subjective appreh, instability, pain @ MCL origin7-med jnt-line openg >3 mmT=contrast extravasation

Front 6

All of the following protect the elbow from valgus loads during the throwing cycle EXCEPT? 1. Flexor-pronator muscle contraction2. Reduced fastball velocity3. Increased glenohumeral internal rotation torque4. Forearm pronation5. Scapular protraction/retraction

Back 6

During a thrower's kinetic chain, increased shoulder internal rotation torque contributes to increased valgus elbow loads. Marshall et al described the importance of proximal to distal control of the upper extremity in producing angular and racket velocity and theorized that longitudinal rotations should be considered during injury prevention programs. Davis et al demonstrated that correct pitching mechanics offered the most efficient throwing velocity for a given shoulder internal rotation torque and elbow valgus load. Thus scapular dynamic control, correct pitching mechanics, pronation of the forearm with dynamic flexor-pronator muscle contraction protects the elbow from valgus loads. Ans3

Front 7

A 22-year-old collegiate pitcher sustains a medial collateral ligament (MCL) rupture of his throwing elbow requiring surgical reconstruction. Anatomic restoration of the MCL is desired to maximize function. Which of the following best describes the kinematics of the native MCL? 1. Anterior bundle becomes tight in flexion and lax in extension 2. The posterior bundle demonstrates the greatest change in tension from flexion to extension 3. Posterior bundle becomes lax in flexion and tight in extension 4. Posterior bundle is isometric 5. The posterior bundle is isometric, but the anterior is not

Back 7

The MCL (also known as the medial ulnar collateral) is an important dynamic stabilizer of the medial elbow that can become attenuated and rupture in throwing athletes leading to pain, valgus instability, and loss of throwing velocity. Morrey et al dissected 10 cadaver elbows to pinpoint the origin and insertion of both the medial and lateral stabilizing ligaments of the elbow. Most pertinent to this question, the anterior bundle of the MCL was found to be isometric throughout the flexion/extension arc of motion. The posterior bundle of the MCL became elongated with elbow flexion. It demonstrated the greatest change in length from extension to flexion of all the elbow ligaments. Ans2

Front 8

MLP c/o acutely injuries may result in a "pop" and then sudden drop in velocity, decreased throwing performance w/ loss of velocity, loss of control (accuracy) & pain PE=medial tenderness at or near MCL origin & moving valgus stress test is (+) 1-KIF(key image finding) -->Dx 1.1other KIF? 1.2 KIF xray 1.3 SxF (5)= 1.4 PeF (3 palp & provocative test 3) 2-(indication) Tx & Rehab/Time 2.1-first line treatment in most cases & Rehab 2.2-high-level throwers that want to continue competitive sports & Rehab 2.3 what autograft being used? describe reconstruction tech (4)?

Back 8

1-MR-arthrogram diagnostic->full-thickness & partial undersurface tears, r/o capsular "T-sign" w/ contrast extravasation; dx=Medial UCL Inj w/Attenuation/rupture ->UCL elbow leading -valgus instab1.1-Dynamic US=can eval laxity w/valgus stress dynamically1.2-xray=PM osteophyte (due to valgus extensn overload) & gravity stress=med jnt-line openg >3 1.3sx=loss of velocity, loss of control (accuracy), med/post elbow pain during late cocking & accelrtn phases of throwing, many throwers have PM pain due to valgus extension overload felt during the deceltion phase, ulnar nerve sx1.4-med tenderness @/or near MCL origin, evaluate integrity of the flex-prontr mass, eval cubital tunnel sx; prov T=valgus stress test, milking maneuver, moving valgus stress test2.1-rest & PT; 6 wks rest-> throwing2.2-MCL ant band lig recon (Tommy John Surgery) early active wrist, elbow, shoulder ROM2.3-palmaris longus, gracilis-modified Jobe tech, docking tech, hybrid interfere, Cortical suspnsry fix

Front 9

1-95% of the native MCL technique for reconstruction?1.1 post op PT=?2-Complication (5)

Back 9

1-humeral docking with interference screw fixation of the ulnar side showed strength of 95% of the native MCL1.2-avoid valgus stress until 4 months post-opreturn to competitive throwing at 9-12 mths post-op2-Ulnar nerve injury, Medial antebrachial cutaneous (MABC) nerve injury, nerve is present at distal aspect of the incision, Fx of ulna or medial epicondyle, Elbow stiffness, Inability to regain preinjury level throwing ability

Front 10

2.1-rest & PT; 6 wks rest-> throwing2.2-MCL ant band lig recon (Tommy John Surgery) early active wrist, elbow, shoulder ROM2.3-palmaris longus, gracilis-modified Jobe tech, docking tech, hybrid interfere, Cortical suspnsry fix2.4-humeral docking with interference screw fixation of the ulnar side showed strength of ___of the native MCL

Back 10

2.1-first line treatment in most cases & Rehab2.2-high-level throwers that want to continue competitive sports & Rehab2.3 what autograft being used? describe reconstruction tech (4)?2.4 1-95% of the native MCL technique for reconstruction

Front 11

1-definition of monteggia fx, mn 2-associated injuries w/monteggia fx? 3-MC in children and young adult class of monteggia fx? MC classification of adult monteggia fx? ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. Which direction is the radial head most likely dislocated? MC type/direction if radial head is irreducibly? MC type w/PIN neurathy 4-MC neuropathy w/montaggia fx? PEF (3) how to Tx? 5-ORIF of ulna interval between prox & distally? why monteggia fxs in children are often treated non-op w/ CR? 6-MCC of failure to align ulna? 7-MC reason for lack of reduction of radial head after ORIF of ulna? Tx?

Back 11

1-prox 1/3 fx ulna & radial head dislocation/instability -GRIMUS-G-Galeatzi R-Radius I-Infer/distal, M-Montaggia, U-Ulna Sup/proximal2-olecranon fx-dislocation, radial head fx, coronoid fx, LCL injury, terrible triad of elbow3-child/yng adt=Fx of the prox or middle 1/3 of the ulna apex ant w/ ant dislcation of the radial head typ 1, -adt mont=post disloation w/prox ulna fx, typ 2-ulna w/apex anter=radial head dislocation ant-Type III (unla fx metaph & radial head lat)bc/ of interpos annular lig-MCC PIN=Typ III 4-PIN neuropathy= radial deviation of hand w/wrist ext, weakness of thumb extweakness of MCP exttx=obser x 2-3 mths, spontaneously resolves in most cases, if no improv EMG 3-4 mths 5-prox=FCU & aconeus distally=FCU & ECU; if the ulna fx is transverse & stable but pinning if fx is obliqu & unstble6-chronic dislocations of radial head7-MC radialhead block=annular ligament block found bt/radiohumeral joint; tx=ulnar osteotomy & Opn Rdcn of the radial head

Front 12

A 12-year-old male sustains an ulnar fracture with an associated posterior-lateral radial head dislocation. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. What is the most likely finding? 1. Lateral ulnar collateral ligament disruption2. Anterior band of the medial collateral disruption3. Posterior band of the medial collateral ligament disruption4. Annular ligament interposition5. Anconeus muscle interposition

Back 12

In pediatric Monteggia fractures the annular ligament is commonly interposed in the radiocapitellar joint. The most common injury pattern is an extension type 1 with anterior radial head dislocation and apex anterior ulnar shaft fracture. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna. These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable. Type III is the one most commonly associated with irreducibility of the radial head because of interposition of the annular ligament. The incidence of posterior interosseous nerve injury is high with this lesion. The nerve deficit usually completely resolves rapidly and spontaneously. Ans4

Front 13

A 45-year-old male falls off his motorcycle and injures his arm. AP and lateral radiographs reveal an ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. Which direction is the radial head most likely dislocated? 1. Lateral2. Posterior3. Posterolateral4. Anterior5. Anteromedial

Back 13

A Monteggia fracture with apex anterior ulnar shaft fracture is associated with an anterior radial head dislocation (See Illustration A). Bado initially described and classified these injuries. The most common injury pattern is an extension type 1 with anterior radial head dislocation and apex anterior ulnar shaft fracture. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna. These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable as illustrated by Fowles' case series, but may also require pinning if the fracture is oblique and unstable.Ans4

Front 14

45-year-old male falls out of moving car, c/o pain and swelling at elbow joint, PE=loss of ROM at elbow & instability @ elbow, skin integrity intact, NV intact w/out _____? 1.NV intact r/o _____? 1.1-KIF(key image finding) -->Dx & classification name & describe 1.2 other KIF r/o?(3) 2-(indications->) Tx 2.1 child w/Fx of the prox/middle 1/3 ulna w/ant dislocation radial head then Tx->? 2.2 child w/Fx of the metaphysis ulna w/lat dislocation radial head then Tx->? 2.3 child w/Fx of the prox/middle 1/3 ulna w/post dislocation radial head then Tx->? 2.4 Monteggia fractures in adults 2.5 failure to reduce radial head with ORIF of ulnar shaft only 2.6 approach to tx of radial head & ulna 2.7Fractures of both the radius and ulna at the same level with an anterior dislocation of the radial head 2.8 Ulnar communition with ulnar shortening w/ radial head dislocation 3-Complication (2) how to tx malunion?

Back 14

1-r/o PIN=ext-> wrist (nl w/out radial deviation of hand]); ext->thumb; ext->MCP1.1-AP/Lat of elbow, wrist, & forearm->dx monteggia fx; class bado 1-4, 1-ant 2- post, 3-ulna metaph & lat 4-both bone + dislocation any direction1.2 CT-R/O coronoid, olecranon radial head2.1LAC in supination2.2LAC in supination2.3 LAC in pronation2.4 ORIF ulna2.5 ORIF ulna OR of radial head2.6 radius=posterolateral (Kocher) approach & ulna= b/t FCU & anconeus-prox: FCU & ECU-dist2.7 flexible IM nailing / ORIF ulna w/reduction of radial head2.8 ORIF ulna3 PIN neurapathy & malunion of radial head dislocation-ulnar osteotomy

Front 15

2.1LAC in supination2.2LAC in supination2.3 LAC in pronation2.4 ORIF ulna2.5 ORIF ulna OR of radial head2.6 radius=posterolateral (Kocher) approach & ulna= b/t FCU & anconeus-prox: FCU & ECU-dist2.7 flexible IM nailing / ORIF ulna w/reduction of radial head2.8 ORIF ulna3 PIN neurapathy & malunion of radial head dislocation-ulnar osteotomy

Back 15

2.1 child w/Fx of the prox/middle 1/3 ulna w/ant dislocation radial head then Tx->?2.2 child w/Fx of the metaphysis ulna w/lat dislocation radial head then Tx->?2.3 child w/Fx of the prox/middle 1/3 ulna w/post dislocation radial head then Tx->?2.4 Monteggia fractures in adults2.5 failure to reduce radial head with ORIF of ulnar shaft only2.6 approach to tx of radial head & ulna2.7Fractures of both the radius and ulna at the same level with an anterior dislocation of the radial head 2.8 Ulnar communition with ulnar shortening w/ radial head dislocation3-Complication (2) how to tx malunion

Front 16

1 define galeazzi fx, when is DRUJ most stable? 2-most important factor in seeing DRUJ injury? 3-MC position to maintain reduction of Galleazzi fx? 4-MCC irreducible DRUJ? 5- Most important structure for DRUJ stability? 6- what are the DRUJ ligaments

Back 16

1-galeazzi=distal radial shaft with disruption of the distal radioulnar joint (DRUJ) GRIMUS-joint is most stable at the extremes of rotation2-true lat=direction of displacement3-supination4-ECU most common interposed tendon5-triangular fibrocartilage complex (TFCC) is a critical component to DRUJ stability6-Dorsal radioulnar ligaments

Front 17

12 yo c/o wrist and forearm pain and limitation of wrist motion, PE=pain with movement of palpation of the wrist & DRUJ instability w/ local tenderness NV intact 1.1-KIF(key image finding) -->Dx 2-indication-> Tx 2.1 in younger pts Galeazzi 2.2 in adolescents Galeazzi, irreducible DRUJ due to interposed tendon or periosteum 2.3 DRUJ subluxation is caused by a radial malunion 2.4 chronic DRUJ instability

Back 17

1 AP/Lat wrist=signs of DRUJ injury, ulnar styloid fxwidening of joint on AP view, dorsal or volar displacement on lateral view, radial shortening (≥5mm), true lateral determining the direction of displacement AP- displaced distal radial shaft fx-Dx Galeazzi fx2.1 CR w/ LAC in supination 2.2 ORIF w+/- DRUJ pinning2.3 ORIF, soft tissue reconstruction of DRUJ and TFCC, corrective osteotomy2.4 ORIF, soft tissue reconstruction of DRUJ and TFCC, corrective osteotomy

Front 18

2.1 CR w/ LAC in supination 2.2 ORIF w+/- DRUJ pinning2.3 ORIF, soft tissue reconstruction of DRUJ and TFCC, corrective osteotomy2.4 ORIF, soft tissue reconstruction of DRUJ and TFCC, corrective osteotomy

Back 18

2.1 in younger pts Galeazzi2.2 in adolescents Galeazzi, irreducible DRUJ due to interposed tendon or periosteum2.3 DRUJ subluxation is caused by a radial malunion2.4 chronic DRUJ instability

Front 19

A 30-year-old female presents with the injury shown in Figure A after falling on her outstretched arm. During operative treatment of the fracture, anatomic reduction of the radius is achieved. However, the surgeon is unable to reduce the distal radioulnar joint. What structure is most likely impeding the reduction? 1. Median nerve 2. Flexor carpi radialis 3. Pronator quadratus 4. Extensor carpi ulnaris 5. Flexor carpi ulnaris

Back 19

In this injury, an inability to reduce the distal radioulnar joint in a closed fashion is most commonly secondary to interposition of the extensor carpi ulnaris tendon. Early recognition of the dislocation of the ulna and ECU into the DRUJ and their significance may avoid poor results. Ans4

Front 20

A 42-year-old female sustains the injury shown in Figure A. What other anatomic structure is most commonly injured with this fracture? 1. Volar long radiolunate ligament2. Radioscaphocapitate ligament3. Dorsal radioulnar ligaments4. Ligament of Testut and Kuentz5. Scapholunate ligament

Back 20

This is termed a Galeazzi fracture. This patient's AP radiograph is shown in illustration A, revealing an obvious DRUJ dislocation. Treatment of this unstable injury is operative, consisting of open reduction and internal fixation with a plate and screw construct, followed by intraoperative assessment of DRUJ alignment. Ans3

Front 21

A 33-year-old man sustains blunt trauma to his forearm and presents with the injury seen in Fig A and B. Definitive management of this injury involves the following: 1. Perform closed reduction of the radius, then immobilize the forearm in a long arm cast in supination. 2. Perform open reduction and internal fixation of the radius, then assess the proximal radioulnar joint for instability, and percutaneously fix the proximal radioulnar joint if instability persists. 3. Perform open reduction and internal fixation of the radius, then assess the distal radioulnar joint for instability, and reconstruct the distal radioulnar joint with a looped palmaris longus autograft if instability persists. 4. Perform closed reduction of the radius, then assess the distal radioulnar joint for instability, and perform internal fixation of the radius if instability persists. 5. Perform open reduction and internal fixation of the radius, then

Back 21

Galeazzi fracture-dislocations are fractures of necessity and must be managed surgically. The first step involves surgical fixation of the radial fracture. Next, the distal radioulnar joint (DRUJ) needs to be assessed for stability by looking for gross motion of the distal ulna in forearm supination. If DRUJ instability persists, this needs to be addressed with temporary percutaneous pin fixation with one or two 1.2- or 1.6mm K-wires placed transversely proximal to the sigmoid notch. This is followed by immobilization in above-elbow plaster casts in forearm supination for 6 weeks postop. Anatomic reduction and rigid fixation of the radius alone does not guarantee DRUJ stability. Ans5

Front 22

1-when you flex a muscle what does the origin and insertion do?2-MC location of partial distal biceps tendon tear to occur? -MC location of partial distal biceps tendon tear to occur w/ tug-o-war?3-MC MoI of Distal Biceps Avulsion? assoc condition4-hook test, popeye deformity?5-effect of distal biceps tendon tear? what position protects the PIN nerve?6-MCC of Distal Biceps repair w 2 incicion technique? PEF7-MCC superficial dissection when repairing a distal biceps rupture through a single incision anterior approach

Back 22

1-when one flex a muscle the insertion moves towards the origin. 2-primarily on the radial side of the tuberosity footprint; intersubstance muscles transection3-eccentric overload with elbow at 90° of flexion; lead to sx of median nerve compression 4-partial tear or no tear (strain) the examiner will be able to get their finger under the tendon near the insertion.ie no tear of biceps tendon, bicepts tear PE=muscle bulges5-loss ->40-50% supination, ~30% flex,15% grip strength, supinate forearm expose tuberosity and protect PIN6-lateral antebrachial cutaneous nerve, Numbness to lateral aspect of volar forearm7-lateral antebrachial cutaneous nerve (LABCN)

Front 23

A 28-year-old male sustains a distal biceps rupture while lifting a heavy table and elects to undergo surgical repair using a two-incision technique. What is the most likely neurologic deficit to occur as a complication of this surgical approach? 1. Intrinsic hand weakness 2. Numbness of the volar radial three and a half digits 3. Wrist extension weakness 4. Numbness to lateral aspect of volar forearm 5. Inability to flex thumb and index interphalangeal joints

Back 23

A 28-year-old male sustains a distal biceps rupture while lifting a heavy table and elects to undergo surgical repair using a two-incision technique. What is the most likely neurologic deficit to occur as a complication of this surgical approach? Topic Review TopicQID: 35931. Intrinsic hand weakness2. Numbness of the volar radial three and a half digits3. Wrist extension weakness4. Numbness to lateral aspect of volar forearm5. Inability to flex thumb and index interphalangeal joints

Front 24

A 40-year-old male was moving his furniture several days ago when he developed anterior forearm pain. On physical exam he is tender just distal to the antecubital fossa. He has decreased strength on supination and elbow flexion when compared to the contralateral side. His MRI is shown in Figures A and B. His injury typically occurs in what portion of the tendon’s distal insertion? 1. Proximal2. Distal3. Central4. Radial5. Ulnar

Back 24

The clinical presentation and MRI are consistent with a partial tear of the distal biceps tendon. Figure A shows inflammation at the site of the biceps insertion on the bicipital tuberosity with some attached tendon fibers remaining. Figure B shows abnormally increased signal intensity and an increased diameter of the distal biceps tendon (arrow) compatible with a partial tear. Avulsive marrow edema is present within the bicipital tuberosity of the radius (arrowheads) and distension of the bicipitoradial bursa is present (short arrow). Partial tears of the distal biceps tendon are rare and may be frequently misdiagnosed. It typically occurs in active, middle-aged males, and only a small number have been reported in the literature.Ans4

Front 25

What is the most appropriate initial management of a suspected distal biceps rupture with a tendon that can be palpated but is painful during the hook test examination?1. Operative exploration of distal biceps tendon2. Immobilization for three weeks followed by repeat physical examination3. Early physical therapy with emphasis on ROM and strengthening4. CT scan5. MRI scan

Back 25

It is important to distinguish between complete and partial tears as it guides treatment decisions. Classic physical exam findings of complete tears include: antecubital pain and ecchymosis, non-palpable distal biceps tendon (abnormal hook test), proximal retraction of the biceps muscle, and weakness with supination and flexion. A partial tear often has a normal hook test but has pain with the examination. An MRI is most appropriate for confirmation of a partial distal biceps rupture, while an MRI is not always required for a complete tear if the exam is conclusive. Ans5

Front 26

males in their 50s c/o hears a pop w/heavy lifting & pain in antecubital fossa, PE=popeye deformity, hook test not present 1.1-KIF(key image finding) -->Dx &MoI 1.2 KPEF (3) 2-(indications->) Tx 2.1- older or sedentary patients who are willing to sacrifice function 2.2 young healthy patients who do not want to sacrifice function 2.3 partial tears that do not respond to nonop management 3-Complication 3.1 MCC surgical repair of tendon to tuberosity 3.2 CC of tx, how to dx & avoid 4 position post op?

Back 26

1-xray-nl KIF-MRI is important to distinguish bt/complete tear vs. partial tear; muscle substance vs. tendon tear; deg of retractiondx= Distal Biceps AvulsionMoI=eccentric overload with elbow at 90° of flexion 2-popeye defrmty-prox bicepts avulsion, "reverse" popeye=distal bicepts avulsion, hook test=partial tear or no tear (strain) able to get finger under the tendon near the insertion.2.1 PT knowing there is lose 40-50% supintn,~30% flex, 15% grip strength2.2 surgical repair of tendon to tuberosity Anterior one-incision technique or Two-incision technique (Boyd-Anderson)2.3 same-surgical repair of tendon to tuberosity3.1MCC=lateral antebrachial cutaneous nerve3.2CC synostosis,dx-loss of pronation/supination, avoid-exposing periosteum of ulna & dissection b/t radius & ulna; HO 4-immobilize in 110° of flexion and moderate supination

Front 27

2.1 PT knowing there is lose 40-50% supintn,~30% flex, 15% grip strength, which pts recieve this tx? 2.2 surgical repair of tendon to tuberosity Anterior one-incision technique or Two-incision technique (Boyd-Anderson) , which pts recieve this tx? 2.3 same-surgical repair of tendon to tuberosity, which pts recieve this tx? 3.1MCC=lateral antebrachial cutaneous nerve 3.2CC synostosis,dx-loss of pronation/supination, avoid-exposing periosteum of ulna & dissection b/t radius & ulna; HO 4-immobilize in 110° of flexion and moderate supination

Back 27

2.1- older or sedentary patients who are willing to sacrifice function2.2 young healthy patients who do not want to sacrifice function2.3 partial tears that do not respond to nonop management3-Complication 3.1 MCC surgical repair of tendon to tuberosity3.2 CC of tx, how to dx & avoid4 position post op?

Front 28

1-what is #1 & #2 MC neurpathy of UE2-MC sites of entrapment of median grt cubital tunnels syndrome?

Back 28

1-MC-CTS #2 C-cubital tunnel syndrome2-MC site-b/t Osborne's lig & MCL

Front 29

1. what is the diagnosis in an adult baseball pitcher
2. was a diagnosis and a skeletally immature baseball pitcher
3. where 3 associated conditions with this condition in an adult
4. what is the treatment surgical

Back 29

1. medial UCL injury causing valgus instability
2. Little League elbow
3. Traction related ELLNER neuritis, olecranon impingement – posterior medial, elbow arthritis
4. surgical treatment is MCL anterior band ligament reconstruction AKA, TOMMYJOHN surgery

Front 30

1. which component of the MCL of the elbow is the strongest and provides the most significant stabilizer to valgus stress
2. what physical exam provocation test is 100% sensitive and 75% specific for an MCL injury of the elbow
3. what x-ray finding his diagnostic of this elbow condition and which test is diagnostic

Back 30

1. the anterior oblique component of the MCL
2. moving valgus stress test applying valgus stress while the elbow is ranged through full locker motion in extension positive test is with apprehension instability or pain at the MCL origin between 70 and 120°
3. gravity stress test was thrown medial joint line opening greater than 3 mm
4. diagnostic tests is an MR arthrogram looking for the key side

Front 31

 All of the following protect the elbow from valgus loads during the throwing cycle EXCEPT? 

1.  Flexor-pronator muscle contraction

2.  Reduced fastball velocity

3.  Increased glenohumeral internal rotation torque

4.  Forearm pronation

5.  Scapular protraction/retraction

Back 31

increased shoulder internal rotation torque contributes to increased valgus elbow loads. Marshall et al described the importance of proximal to distal control of the upper extremity in producing angular and racket velocity and theorized that longitudinal rotations should be considered during injury prevention programs. Davis et al demonstrated that correct pitching mechanics offered the most efficient throwing velocity for a given shoulder internal rotation torque and elbow valgus load. Thus scapular dynamic control, correct pitching mechanics, pronation of the forearm with dynamic flexor-pronator muscle contraction protects the elbow from valgus loads. ans3

Front 32

The greatest stress on the medial ulnar collateral ligament of the elbow occurs during which phase of throwing?

1.  Wind-up

2.  Early cocking

3.  Late cocking

4.  Ball release

5.  Follow through

Back 32

late cocking and early acceleration phase of the overhead throw causes the greatest amount of valgus stress to the elbow. During this phase, the forearm lags behind the upper arm and generates valgus stress while the elbow is primarily dependent on the anterior band of the UCL for stability. The windup phase is benign for the elbow. In early cocking, the rotator cuff and deltoid are active, not the elbow. Ball release is the culmination of cocking and acceleration, but the maximal joint forces have already occurred across the UCL due to the rapid combination of valgus and extension during late cocking and early acceleration. In deceleration, the elbow flexors are most active to prevent hyperextension. 
ans3

Front 33

1. patient heard a pop and has pain in the cubital fossa what is the diagnosis
2. what would one expect to see on physical exam
3. what is the treatment
4. if this is a partial tear was the most common location
5. If this injury occurred while  the person with involvement of the war wears knee injury
6. With the mechanism of injury

Back 33

1. distal biceps avulsion
2. Surgical repair to the tuberosity in a young healthy patient who does not want to sacrifice function and what other tests is helpful
3. reverse Popeye deformity test, MRI helpful to distinguish between partial incomplete midsubstance versus tendon.  Care the degree of retraction
4. Partial tear of the radial side of the tuberosity
5. Intrasubstance muscle transection
6. Eccentric overload

Front 34

patient undergoes an anterior one incision technique to repair the distal biceps tendon was the

1. most common complication
2. what is the most severe complication
3. common complication

Back 34

1. Most common complication lateral antebrachial cutaneous nerve injury
2. most severe is of radial nerve injury
3. Synostosis and heterotopic ossification

Front 35

A 44-year-old left-hand dominant carpenter has the onset of left elbow pain after trying to stop a heavy object from falling two days ago. Figure A shows a clinical image of the patient upon presentation. Physical exam shows full strength with wrist flexion, wrist extension and pronation, but notable weakness with supination of the forearm. Sensory exam shows no deficits in the forearm or hand. There is a negative milking maneuver test. Radiographs are shown in Figure B. What is the next most appropriate step in management?

1.  Sling use as needed for comfort and progressive physical therapy

2.  Allograft reconstruction of the distal biceps tendon

3.  Ulnar collateral ligament reconstruction

4.  Distal biceps tendon avulsion repair

5.  Brachioradialis and ECRB avulsion repair

Back 35

Distal biceps tendon avulsion repair is the most appropriate next step in management.Incorrect Answers:
Answers 1 & 2: Conservative management is not indicated in a healthy middle-aged patient with a distal biceps tear of the dominant arm.
Answer 3 & 5: UCL reconstruction or mobile wad tendon repair is not indicated in this patient. A positive milking maneuver would be consistent with a UCL injury. 

ans4

Front 36

 

A patient sustains a distal biceps brachii tendon rupture. If treated non-operatively, the greatest loss of strength would be seen with which activity? 

1.  Forearm supination

2.  Forearm pronation

3.  Elbow flexion

4.  Shoulder forward flexion

5.  Shoulder internal rotation

Back 36

While both elbow flexion and forearm supination strength are affected, there is a greater percentage loss of supination strength. Patients may complain of weakness and fatigue with rotational activities such as using a screwdriver. The primary elbow flexor is actually the brachialis, and therefore less weakness in flexion is reported. 

Patterson reviewed distal biceps ruptures and found nonsurgical treatments had 21–55% loss of supination strength and 8–36% loss of flexion strength. ans1

Front 37

what is the most common pediatric elbow fracture associated with an elbow dislocation

Back 37

medial epicondylar fracture

Front 38

1. what the dx
2. what the treatment
3. what the indication for surgery

Back 38

1. medial epicondylar fracture
2. Surgery open reduction internal fixation
3. > 5 mm displacement

Front 39

what muscles are involved in the common flexor the medial epicondyles injury

Back 39

mobile wad – pronator teres – flexor carpi radialis – palmaris longus, flexor digitorum superficialis and flexor carpi ulnaris

Front 40

 Which of the following muscles is involved in the avulsion injury that creates the fracture shown in Figure A?

1.  Pronator quadratus

2.  Pronator teres

3.  Extensor carpi radialis longus

4.  Brachioradialis

5.  Brachialis

Back 40

displaced medial epicondyle fracture, which results from extreme valgus loads or violent muscle contractions in overhead athletes during the throwing motion and commonly occur in adolescents as the medial epicondyle begins to fuse. The medial epicondyle is avulsed by forceful contraction of the common flexor wad, which includes the pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris. 
ans2

Front 41

was most common site for cubital tunnel syndrome

Back 41

between OSBORNE's ligament and MCL

Front 42

1. what sign is this
2. Describe what is in the picture
3. what nerve is affected that causes a sign

Back 42

1. FROMENT sign
2. Compensatory IP flexion of the FPL during key pinch which is a compensation 4 loss of MCP flexion of the adductor pollicis which is innervated by the ulnar nerve
3. Ulnar nerve injury seen with cubital tunnel

Front 43

1. what sign is this
2. Describe what is in the picture
3. what nerve is affected that causes a sign

Back 43

1. WARTENBERG sign
2. Persistent abduction and extension parent attempted abduction secondary to weak 3rd palmaris interosseous and 3rd finger lumbrical
3. Ulnar nerve injury seen with cubital tunnel

Front 44

1. what sign is this
2. Describe what is in the picture
3. what nerve is affected that causes a sign

Back 44

1. JEANne sign
2. compensatory thumb MCP hyperextension and thumb abduction by the EPL  with key pinch
3. compensatory loss of IP extension of the thumb abduction by the abductor pollicis ulnar nerve out cubital tunnel

Front 45

1. what sign is this in the bottom picture
2. Describe what is in the picture
3. what nerve is affected that causes a sign

Back 45

1. masse's sign
2. which is flattening of the palmar archloss of theup: In digiti quinti decrease small finger MCP flexion
3. Ulnar nerve injury

Front 46

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

1.  Osborne's ligament and the MCL

2.  MCL and Arcade of Struthers

3.  Osborne's ligament and the intermuscular septum

4.  MCL and medial head of the triceps

5.  Ulnar and humeral heads of the flexor carpi ulnaris muscle

Back 46

The ulnar nerve passes posterior to the medial epicondyle and medial to the olecranon, then enters the cubital tunnel. The roof of the cubital tunnel is primarily made up of Osborne's ligament, and the floor consists of the medial collateral ligament. ans1
 

Front 47

was most common fracture and children less than 16 years of age

Back 47

form fractures

Front 48

was indication open reduction internal fixation of forearm fracture and a pediatric population

Back 48

Salter-Harris III and 4

Both bone forearm fracture greater than 30° angulation and he age

Front 49

An 11-year old boy presents to fracture clinic 1 week after sustaining a displaced metaphyseal distal radius fracture that was managed with closed reduction and cast application. While the initial post-reduction radiographs showed near anatomic alignment with a well molded cast, radiographs 1 week later show 22 degrees of apex volar angulation and dorsal re-displacement. What is the best management at this time? 

1.  Accept the deformity, cast change and follow-up in 3 weeks

2.  Closed reduction and cast application, follow-up in 1 week

3.  Closed reduction and percutaneous fixation

4.  Closed reduction and flexible intramedullary rod fixation

5.  Open reduction and internal fixation with a plate and screws

Back 49

fter failed initial treatment with closed reduction and casting, displaced distal radius/forearm fractures should be treated with repeat closed reduction. Percutaneous fixation can decrease the risk of re-displacement. Incorrect Answers:
Answer 1: The current amount of angulation is unacceptable for a child > 10 years.
Answer 2: The fracture has re-displaced once despite the first attempt at closed reduction in a well-molded cast. It is likely to re-displace and would benefit from fixation to stabilize the fracture.
Answer 4: The fracture is too distal to control the distal fragment with a flexible intramedullary rod.
Answer 5: Closed reduction will likely be sufficient to reduce the fracture. Open reduction should be reserved for cases where an adequate closed reduction cannot be achieved.ans3

Front 50

what is the treatment of pediatric forearm fracture that initially is acceptable returns to the office with loss of reduction was a  is treatment

Back 50

closed reduction percutaneous pinning

Front 51

1. the average past index the patient's who lost reduction was_____ compared to patient's who did not lose reduction of 0.7
2. how does one calculate cast index

 

 

Back 51

1. >.8
2. CI = A/B

 

Front 52

 Isolated pronation of the forearm will most likely achieve reduction of what type of fracture in a 7-year-old boy?

1.  Supination injury resulting in an apex-volar greenstick both bone forearm fracture

2.  Pronation injury resulting in an apex-dorsal greenstick both bone forearm fracture

3.  Supination injury resulting in an apex-dorsal greenstick both bone forearm fracture

4.  Complete both bone forearm fracture with bayonete apposition of both the radius and ulna

5.  Distal radius fracture with 25 degrees of apex-dorsal angulation

Back 52

 supination injuries with apex-volar angulation (Illustration A), which can be reduced with varying degrees of forearm pronation. As a rule of thumb, most pediatric both bone fractures can be temporarily reduced by pointing the palm in the direction of the deformity. Complete both bone forearm fractures with bayonette apposition require traction to aide in reduction, and malaligned distal radius fractures can be reduced with a combination of traction, angulation, and rotation of the palm in the direction of the angulation. supination injuries with apex-volar angulation (Illustration A), which can be reduced with varying degrees of forearm pronation. As a rule of thumb, most pediatric both bone fractures can be temporarily reduced by pointing the palm in the direction of the deformity. Complete both bone forearm fractures with bayonette apposition require traction to aide in reduction, and malaligned distal radius fractures can be reduced with a combination of traction, angulation, and rotation of the palm in the direction of the angulation.ans1

Front 53

with distal humerus fracture what is the goal regarding range of motion

Back 53

goal range of motion = 30 to 1:30 of flexion

Front 54

anconeus & the pronator teres attach where an elbow

Back 54

the pronator teres attaches at the medial epicondyle

And anconeus attaches the lateral epicondyle

Front 55

1. which ligament and the elbow was tight and pronation
2. what is this ligaments origin
3. What is his ligaments Insertion
4. what is his ligaments primary function

Back 55

1. MCL of the elbow
2. Originates on the distal medial epicondyles specifically the anterior bundle of MCL
3. Inserts on the sublime tubercle
4. Primary string to valgus stress of the elbow from 30° – 120°

Front 56

1. which ligamentum of the elbow is tight and pronation
2. what is his ligaments origin
3. What is this ligamentous insertion
4. What is this ligaments primary function

Back 56

1. LCL
2. Originates from the distal lateral epicondyle
3. Inserts in the Christi supinatorus
4. primary function this is stabilized against posterior lateral rotatory instability

Front 57

1. which nerve resides spiral groove 15 cm proximal to distal humeral articular surface
2. This nerve resides between the which 2 muscles proximal to the elbow
3. Where does it divide into the PIN and superficial radial nerve at what level

Back 57

1. radial nerve
2. Brachioradialis and brachialis muscle
3. At the level of the radial head it divides

Front 58

 radial nerve innervation, mn

Back 58

Radial nerve, proximal to distal 
"Try A Big Brazilian Chocolate PECAN 
Chip Sundae, Double Dip Cherries And PeanutButter Please Included"
T-Triceps, A-Anconeus, B-Brachioradialis, B-Brachials Lateral 1/2, C-ext. Carpi radialis longus(ECRL), 
PECAN-PIN
C-ext. Carpi radialis brevis (ECRB), S-Supinator, 
D-ext. Digitorum comminunus (EDC), D-ext.Digiti minimi, ext.(EDM) C-extensor Carpi ulnaris (ECU), A- Abductor poll. longus (APL), P-ext. Poll. brevis (EPB), P- ext. Poll. longus (EPL), I- ext. Indicis proprius (EIP)

Front 59

1. describe 1 MILCH 2 classification for single column condyle fracture of the distal humerus
2. how does treatmentdear for between milch 1 milch 2

Back 59

MILCH 1 the lateral trochlear ridge is intact whereas milch 2 it is fractured to the lateral trochlear ridge

MILCH 1 nondisplaced can be treated with a cast fieldand a displaced fracture can be treated closed reduction percutaneous pinning

Milt to require open reduction internal fixation

 

Front 60

1. what position his arm casted with the MILCH 2 fracture of the medial condyle
2. what position the arm casted for MILCH 2 fracture of the lateral condyle was the
3. treatment of choice for by condylar fracture in elderly patient

Back 60

1. MILCH 1 medial condyle casted in pronation
2. MILCH 1lateral condyle casted in supination
3. Comminuted fracture total elbow arthroplasty

Front 61

what patient population has a highest survivorship after total elbow arthroplasty

Back 61

rheumatoid arthritis

Front 62

with the contraindication for total elbow arthroplasty 4

Back 62

1. active infection
2. Charcot joint
3. Poor neurologic control affected extremity
4. Active young patient less than 65

Front 63

What is the preferred treatment for a propionibacterium acnes infection that has been symptomatic for 6 months after total elbow arthroplasty with well-fixed components, good bone stock, and a healthy patient?

1.  Non-operative treatment with IV antibiotics for 6 weeks

2.  Arthroscopic irrigation and debridement

3.  Open irrigation and debridement with poly exchange

4.  Single stage revision arthroplasty

5.  Two stage revision arthroplasty

Back 63

Chronic propionibacterium acnes infections of elbow arthroplasty are best treated with two staged revision arthroplasty in healthy patients with adequate bone stock for reimplantation. The algorithm to treat infected total elbow arthroplasty depends on a number of factors including patient characteristics, bacteriology, duration of symptoms, and implant fixation/bone stock. ans5

Front 64

 A 6-year-old boy fell off the monkey bars 5 weeks ago and has had pain and decreased elbow motion since his fall. His radiographs are shown in figures A and B. What is the most appropriate treatment?

1.  Bracing and early range of motion

2.  Closed reduction of the radial head dislocation with casting in supination and flexion

3.  Open reduction internal fixation of medial epicondyle fracture

4.  Open reduction internal fixation of lateral condyle fracture

5.  Open reduction of radial head dislocation with casting in supination and flexion

Back 64

The radiographs show a dislocation of the radiocapitellar joint. This is going to require open reduction due to the chronicity of the injury. Treatment options include annular ligament repair, ulnar osteotomy, radial osteotomy or a combination of these procedures. Also, the annular, quadrate, oblique & interosseous ligaments tighten in supination, providing further stability to the proximal radioulnar joint and decreasing the risk of re-dislocation. ans5

Front 65

what is the clinical exam of a PIN neuropathy

Back 65

radial deviation of the hand and wrist

Weakness of thumb extension

Weakness of MCP extension

Front 66

what is the diagnosis and what is the treatment

Back 66

Monteggia fracture BADO type I anterior dislocation

treatment –cast supination interosseous membrane tight

Front 67

1. what is the  diagnosis
2. what is the  treatment

Back 67

Monteggia fracture BADO type 3 lateral dislocation

treatment –cast supination interosseous membrane tight

 

Front 68

1. with the diagnosis
2. With the treatment
3. what is unique about this adult fracture

Back 68

1. Monteggia fracture BADO type 2 posterior dislocation

2. treatment –cast pronation interosseous membrane loose

3. most common type of fracture in an adult

Front 69

A 45-year-old male falls off his motorcycle and injures his arm. AP and lateral radiographs reveal a proximal ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. Which direction is the radial head most likely dislocated?

 

1.  Lateral

2.  Posterior

3.  Posterolateral

4.  Anterior

5.  Anteromedial

Back 69

A Monteggia fracture with apex anterior ulnar shaft fracture is associated with an anterior radial head dislocation (See Illustration A). 
ans4

Front 70

was most common reason for inability to reduce a GALEAZZI fracture

Back 70

interpretation of the ECU tendon

Front 71

 A 30-year-old female presents with the injury shown in Figure A after falling on her outstretched arm. During operative treatment of the fracture, anatomic reduction of the radius is achieved. However, the surgeon is unable to reduce the distal radioulnar joint. What structure is most likely impeding the reduction?

1.  Median nerve

2.  Flexor carpi radialis

3.  Pronator quadratus

4.  Extensor carpi ulnaris

5.  Flexor carpi ulnaris

Back 71

to interposition of the extensor carpi ulnaris tendon. Early recognition of the dislocation of the ulna and ECU into the DRUJ and their significance may avoid poor results. 

The referenced study by Biyani et al reports a case in which both the extensor carpi ulnaris and extensor digiti minimi tendons were displaced on either side of the ulnar head. ans4

Front 72

A 66 year old woman has chronic elbow pain and loss of function. She has severe morning stiffness and takes several medications for this. Exam reveals a flexion arc from 35-100 degrees with markedly limited rotation. What is the most appropriate definitive treatment?  1.  Total elbow arthroplasty

2.  Radial head replacement

3.  Radial head excision

4.  Corticosteroid injection

5.  Elbow arthroscopic debridement and removal of loose bodies

Back 72

Total elbow arthroplasty is the most established definitive surgical treatment for severe rheumatoid arthritis. This patient has pain and loss of function with radiographs that show degenerative changes consistent with rheumatoid arthritis. This would be classified as a Larson grade C with bony architectural changes on its way to joint destruction (Grade D). This is the original indication for total elbow arthroplasty. ans1