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Education & Research
Weekly AAHSk Q&A 16
Criteria for the diagnosis of symptomatic neuroma include:
Ref: Arnold DMJ, Wilkens SC, Coert JH, et al.Diagnostic Criteria for Symptomatic Neuroma. Ann Plast Surg. 2019; 82: 420-427.
Weekly AAHSk Q&A 15
The most impactful motor deficit resulting from an isolated, high median nerve injury is most commonly:
Ref: Soldado F, Bertelli JA, Ghizoni MF. High Median Nerve Injury: Motor and Sensory Transfers to Restore Function. Hand Clin. 2016; 32: 209-217.
Weekly AAHSk Q&A 14
One cluster of perforators emerging from the radial artery is found in close proximity to the radial styloid, and a second cluster is found at the following distance from the radial styloid to the lateral epicondyle?
Ref: Saint-Cyr M, Mujadzic M, Wong C, et al. The Radial Artery Pedicle Perforator Flap: Vascular Analysis and Clinical Implications. Plast. Reconstr. Surg. 2010; 125: 1469-1478.
Weekly AAHSk Q&A 13
Which of the following is an established (proven) benefit of supercharge nerve transfers?
Ref: Isaacs, J., et al., 2005. Reverse end-to-side neurotization. J Reconstr Microsurg. 21, 43-8; discussion 49-50.
Isaacs, J., et al., 2017. Does partial muscle reinnervation preserve future re-innervation potential? Muscle Nerve.
Isaacs, J.E., et al., 2008. Reverse end-to-side neurotization in a regenerating nerve. J Reconstr Microsurg. 24, 489-96.
Kale, S.S., et al., 2011. Reverse end-to-side nerve transfer: from animal model to clinical use. J Hand Surg Am. 36, 1631-1639 e2.
Weekly AAHSk Q&A 12
A patient presents with intermittent paresthesia in their little finger and ulnar half of their ring finger. There is no history of trauma. A nerve conduction study supports a diagnosis of cubital tunnel syndrome. In advising the patient on the risks/benefits of a mini-open or endoscopic in situ release verses a subcutaneous transposition, they can be informed that:
Ref: Flores, L. P. (2010). 'Endoscopically assisted release of the ulnar nerve for cubital tunnel syndrome.' Acta Neurochir (Wien) 152(4): 619-625.
Oertel, J., D. Keiner and M. R. Gaab (2010). 'Endoscopic decompression of the ulnar nerve at the elbow.' Neurosurgery 66(4): 817-824; discussion 824.
Kang, H. J., I. H. Koh, Y. M. Chun, W. T. Oh, K. H. Chung and Y. R. Choi (2015). 'Ulnar nerve stability-based surgery for cubital tunnel syndrome via a small incision: a comparison with classic anterior nerve transposition.' J Orthop Surg Res 10: 121.
Weekly AAHSk Q&A 11
When the wrist sustains an axial load, the scaphoid is forced into flexion. What are the most likely ligament constraints that prevent excess flexion?
Answer: B The dorsal scapholunate and dorsal scaphotriquetral ligaments both serve as helical antipronation ligaments that prevent flexion and pronation of the scaphoid.
Ref: Garcia-Elias M, Puig de la Bellacasa I, Schouten C. Carpal Ligaments: A Functional Classification. Hand Clin 33 (2017) 511-520.
Weekly AAHSk Q&A 10
What percentage of patients with cubital tunnel syndrome who obtain relief of symptoms from surgery show no signs of ulnar neuropathy on preoperative electrodiagnostic studies?
Answer: C Hand (N Y). 2021 Mar;16(2):170-173.doi: 10.1177/1558944719840750. Epub 2019 Apr 4.
Nerve Conduction Studies in Surgical Cubital Tunnel Syndrome Patients
Daniel J Shubert1, Joseph Prud'homme1, Shafic Sraj1
Weekly AAHSk Q&A 9
A patient is undergoing an index radial collateral ligament reconstruct of the index finger MP joint. If the surgeon desires to anatomically replicate the ligament origin and insertion, the proper location for each would be:
Answer: C The index RCL originates from the dorsal 1/3 of the metacarpal head (10mm from the articular surface) and inserts on the volar ¼ of the proximal phalangeal base (4mm distal to the articular surface
Ref: Dy CJ, Tucker SM, Kok PL, Hearns KA, Carlson MG. Anatomy of the radial collateral ligament of the index metacarpophalangeal joint. J Hand Surg Am. 2013 Jan;38(1):124-8.
Weekly AAHSk Q&A 8
A 3 month-old child presents with a brachial plexus birth injury. His parents state that he was initially unable to move his right upper extremity at all but has regained some elbow flexion and finger flexion. However these are still weak and he has not moved his shoulder at all. What is the most appropriate treatment?
Answer: C Recovery of elbow flexion by 3 months of age is prognostic of infants making a full recovery and regaining shoulder function. Surgical intervention is typically performed in the absence of recovery of elbow flexion.
Ref: Al-Qattan MM, El-Sayed AA, Al-Zahrani AY, Al-Mutairi SA, Al-Harbi MS, Al-Mutairi AM, Al-Kahtani FS. Narakas classification of obstetric brachial plexus palsy revisited. J Hand Surg Eur Vol. 2009;34:788-791.
Weekly AAHSk Q&A 7
In the supraclavicular approach for exploration of the brachial plexus, what nerve can be identified on the anterior scalene muscle and should be protected during the exposure?
Answer: D The phrenic nerve is most prone to injury during the supraclavicular approach in exploration of brachial plexus birth injuries. It is most commonly injured by traction but can also be accidentally transected. Hence identification and protection of this nerve is vital.
Ref: Grossman JA, Price AE, Sadeghi P. Perioperative Complications Associated With Brachial Plexus Repair in Infants. J Hand Surg Br. 2003;28:274-275.
La Scala GC, Rice SB, Clarke HM. Complications of Microsurgical Reconstruction of Obstetrical Brachial Plexus Palsy. Plast Reconstr Surg. 2003;111: 1383-388.
Weekly AAHSk Q&A 6
What is the most common pattern of shoulder deformity in brachial plexus birth injury?
Answer: A Internal rotation contracture is the main concern in brachial plexus birth injury. Interventions such as botulinum toxin injection and surgery are focused on regaining external rotation, to provide a more functional upper extremity.
Ref: Grossman JA, DiTaranto P, Yaylali I, Alfonso I, Ramos LE, Price AE. Shoulder Function Following Late Neurolysis And Bypass Grafting For Upper Brachial Plexus Birth Injuries. J Hand Surg Br. 2004;29:356-358.
Hale HB, Bae DS, Waters PM. Current concepts in the management of brachial plexus birth palsy. J Hand Surg Am. 2010;35:322-331.
Weekly AAHSk Q&A 5
On average, roughly what percent of patients who previously underwent a hand surgical procedure recall any risks of the procedure having been reviewed with them?
Answer: C In a postoperative survey of 54 hand surgery patients, approximately one half of patients could not remember a single risk being reviewed with them.
Ref: Yu M, Von Schroeder HP. “Uninformed” Consent: Patient Recollection From Surgical Consent in Hand Surgery—A Quality Improvement Initiative. HAND 2021, Vol. 16(4) 528–534
Weekly AAHSk Q&A 4
When compared to withholding antibiotics preoperatively, the administration of IV pre operative antibiotics for elective, soft tissue hand procedures such as carpal tunnel syndrome has been shown to result in:
Answer: A In a prospective multicentered trial, preoperative antibiotic administration for soft tissue elective hand procedures did not result in a reduction of infection rates amongst 434 patients: 257 (no antibiotic), 177 (antibiotic).
Ref: Bäcker HC, Freibott CE, Wilbur D, Tang P, Barth R, Strauch RJ, Rosenwasser MP, Neviaser R. Prospective Analysis of Hand Infection Rates in Elective Soft Tissue Procedures of the Hand: The Role of Preoperative Antibiotics. HAND 2021, Vol. 16(1) 81–85.
Weekly AAHSk Q&A 3
In a multi-fragmentary distal radius fracture, inadequate stabilization of which fracture fragment can lead to volar radiocarpal instability?
Answer: C The volar rim or lunate facet fragment is an insertion site of the stout short radiolunate ligament. In addition, the volar rim fragment consists of two articular surfaces as the radiolunate and distal radio-ulnar articulation. Inadequate stabilization of the volar lunate facet fragment can lead to volar radiocarpal subluxation.
Ref: Harness NG, Jupiter JB, Orbay JL, RAskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am. 2004 Sep;86(9):1900-8.
Weekly AAHSk Q&A 2
Brachioradialis distal tenotomy without tendon repair, at the time of surgical management of an unstable distal radius fracture, results in what functional change?
Answer: D A biomechanical study in a cadaver model noted that tenotomy of the distal brachioradialis tendon up to 52 cm from the tip of the radial styloid resulted in a loss of elbow torque up of 14%. This biomechanical study concludes that release of the BR tendon up to 7 cm from the tip of the radial styloid results in elbow flexion torque above 80% of its original value.
Ref: Tirrell TF, Orrin FI, Bhola S, Hentzen ER, Abrams RA, and Lieber RL. Functional consequence of distal brachioradialis tendon release: A Biomechanical study. J Hand Surg 2013;38A:920-926.
Weekly AAHSk Q&A 1
For an acute scaphoid fracture stabilized with a single headless compression screw (HCS), what percentage of fracture union is necessary for the scaphoid-HCS construct to be at least as strong as the native scaphoid?
Answer: C In a biomechanical study utilizing a cadaver model of a midline waist scaphoid fracture, a centrally placed HCS within a scaphoid with a 50% osteotomy had a higher mean load to failure to cantilever bending then an intact scaphoid. This biomechanical study indicates that a scaphoid fracture with 50% union after single axial HCS fixation is stronger than the native scaphoid.
Ref: Guss MS, Mitgang JT, Sapienza A. Scaphoid healing required for unrestricted activity: a biomechanical cadaver model. J Hand Surg Am. 2018;43(2):134-138.
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