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7. The most common malignant tumor of the brain is:
A. Ependymoma.
B. Astrocytoma.
C. Ganglioglioma.
D. Teratoma.
CHAPTER 42
Neurosurgery
Answer: B
Astrocytoma is the most common primary central nervous
system (CNS) neoplasm. The term glioma often is used
to refer to astrocytomas specifically, excluding other glial
tumors. Astrocytomas are graded from I to IV. Grades I and II
are referred to as low-grade astrocytoma or low-grade
glioma, grade III as anaplastic astrocytoma, and grade IV
as glioblastoma multiforme (GBM). Prognosis varies significantly between grades I/II, III, and IV, but not between
I and II. Median survival is 8 years after diagnosis with a lowgrade tumor, 2 to 3 years with an anaplastic astrocytoma, and
roughly 1 year with a GBM. GBMs account for almost twothirds of all astrocytomas, anaplastic astrocytomas account
for two-thirds of the rest, and low-grade astrocytomas the
remainder. Figure 42-3 demonstrates the typical appearance
of a GBM. (See Schwartz 10th ed., p. 1855.)
A
FIG. 42-3. A. Postcontrast T1-weighted axial magnetic resonance imaging demonstrating a ring-enhancing lesion in the anteromedial
right temporal lobe with central necrosis (dark area) consistent with glioblastoma multiforme. B. T2-weighted axial magnetic resonance
imaging with extensive bright signal signifying peritumoral edema seen with glioblastoma multiformes.
8. Medical management of traumatic brain injury with an
associated subdural hematoma requires which steps to
minimize secondary injury including:
A. High-dose methylprednisolone to reduce 6-month
mortality, especially in severe traumatic brain injury.
B. Antiseizure and peptic ulcer prophylaxis as well as
blood glucose, vital sign, and temperature monitoring.
C. Permissive hypotension to reduce intracranial hema-
toma growth.
D. Prophylactic administration of platelets for patients
with intracranial hemorrhage and exposure to aspirin.
B
Answer: B
Several medical steps may be taken to minimize secondary
injury and the systemic consequences of head injury. Patients
with a documented closed head injury and evidence of intracranial hemorrhage or a depressed skull fracture should
receive a 1 g Keppra loading dose, followed by 1 week of therapeutic maintenance Keppra, typically 500 mg twice a day.
Antiseizure prophylaxis has been shown to decrease the incidence of early posttraumatic seizures. There is no evidence
to support long-term use of prophylactic antiepileptic agents.
Blood glucose levels should be closely monitored by free
blood sugar checks and controlled with sliding scale insulin.
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Fevers also should be evaluated and controlled with antipyretics, as well as source-directed therapy when possible. Hyperglycemia and hyperthermia are toxic to injured neurons and
contribute to secondary injury. Head-injured patients have
an increased prevalence of peptic ulceration and gastrointestinal (GI) bleeding. Peptic ulcers occurring in patients with
head injury or high increased intracranial pressure (ICP)
are referred to as Cushing ulcers. Ulcer prophylaxis should
be used. Compression stockings or athrombic pumps should
be used when the patient cannot be mobilized rapidly for prophylaxis of deep venous thrombosis. (See Schwartz 11th ed.,
p. 1839.)
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CHAPTER 42
9. The most common level of cervical radiculopathy from
cervical disc herniation is:
A. C4–C5.
B. C5–C6.
C. C6–C7.
D. C7–T1.
Answer: C
The cervical nerve roots exit the central canal above the
pedicle of the same-numbered vertebra and at the level of the
higher adjacent intervertebral disc. For example, the C6 nerve
root passes above the C6 pedicle at the level of the C5–C6
discs. The cervical nerve roots may be compressed acutely by
disc herniation, or chronically by hypertrophic degenerative
changes of the discs, facets, and ligaments. Table 42-2 summarizes the effects of various disc herniations. Most patients
with acute disc herniations will improve without surgery.
Nonsteroidal anti-inflammatory drugs (NSAIDs) or cervical
traction may help alleviate symptoms. Patients whose symptoms do not resolve or who have significant weakness should
undergo decompressive surgery. The two main options for
nerve root decompression are anterior cervical discectomy
and fusion (ACDF) and posterior cervical foraminotomy
(keyhole foraminotomy). ACDF allows more direct access
to and removal of the pathology (anterior to the nerve root).
However, the procedure requires fusion because discectomy
causes a collapse of the interbody space and instability will
likely occur. Figure 42-4 demonstrates a C6–C7 ACDF with
the typical interposed graft and plating system. Keyhole
foraminotomy allows for decompression without requiring
fusion, but it is less effective for removing centrally located
canal pathology. (See Schwartz 11th ed., p. 1862.)
Neurosurgery
TABLE 42-2 Cervical disc herniations and symptoms by level
Level Frequency (%) Root Injured Reflex Weakness Numbness
C4–C5 2 C5 — Deltoid Shoulder
C5–C6 19 C6 Biceps Biceps brachii Thumb
C6–C7 69 C7 Triceps Wrist extensors (wrist drop) Second and third digits
C7–T1 10 C8 — Hand intrinsics Fourth and fifth digits
Adapted with permission from Greenberg MS. Handbook of Neurosurgery, 7th ed. New York, NY: Thieme; 2010.
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CHAPTER 42
Neurosurgery
BA
FIG. 42-4. A. Anteroposterior cervical spine X-ray showing the position of an anterior cervical plate used for stabilization after
C6–C7 discectomy. Patient presented with right triceps weakness and dysesthesias in the right fifth digit. Magnetic resonance imaging
revealed a right paracentral C6–C7 herniated disc compressing the exiting C7 nerve root. B. Lateral cervical spine X-ray of the same
patient clearly demonstrates the position of the plate and screws. The allograft bone spacer placed in the drilled-out disc space is
also apparent.
10. Urinary retention, saddle anesthesia, and progressing leg
weakness are:
A. Most often secondary to compression of the thoracic
spine secondary to massive disc herniation into the
cauda equina.
B. A surgical emergency and diagnosis should be made
clinically without evaluation of or confirmation by
preoperative imaging.
C. Due to compression of the lumbar nerve roots, which
require urgent intervention to preserve sphincter
function and ambulation.
D. A diagnosis of exclusion following failure to respond
to systemic steroid treatment (steroid challenge).
Answer: C
Cauda equina syndrome is due to compression of the cauda
equina and may result from massive disc herniation, epidural
hematoma (EDH), epidural abscess, tumor, or subluxation
from trauma. Patients with cauda equina compression often
present with urinary retention, saddle anesthesia, or progressing leg weakness. Saddle anesthesia is numbness in the
perineum, genitals, buttocks, and upper inner thighs. Patients
with suspected cauda equina syndrome should undergo
immediate magnetic resonance imaging (MRI) of the lumbar spine to evaluate for a surgical lesion. Mass lesions should
be removed urgently via laminectomy to preserve sphincter
function and ambulation. (See Schwartz 11th ed., p. 1865.)
CHAPTER 43
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Orthopedic Surgery
1. Long bone fractures can be described as any of the
following recognized types EXCEPT:
A. Convoluted.
B. Transverse.
C. Oblique.
D. Spiral.
2. Goals of fracture reduction include all of the following
EXCEPT:
A. Restore length.
B. Restore marrow integrity.
C. Restore rotation.
D. Restore angulation.
3. Which of the following is TRUE concerning compartment syndromes?
A. It is due to decreased intracompartmental pressure.
B. It is typified by hyperesthesia.
C. It can be assessed by needles placed into affected
compartment.
D. Pain is relieved by passive muscle stretching.
Answer: A
Musculoskeletal injuries resulting from trauma include
fractures of bones, damage to joints, and injuries to soft tissues. Long bone fractures can be described as transverse,
oblique, spiral, segmental, or comminuted. (See Schwartz
11th ed., p. 1881.)
Answer: B
Reduction is performed with axial traction and reversal of the
mechanism of injury in order to restore length, rotation, and
angulation. (See Schwartz 11th ed., p. 1881.)
Answer: C
Compartment syndrome is an orthopedic emergency caused
by significant swelling within a compartment of an injured
extremity that jeopardizes blood flow to the limb. Increased
pressure within the compartment compromises perfusion to
muscles and can cause ischemia or necrosis. Patients complain of pain and numbness, and passive stretch of muscles
within the compartment causes severe pain. While the diagnosis is based on clinical examination, pressures can be measured with needles placed into the compartment, which is
necessary in unconscious patients who may not show these
typical exam findings. (See Schwartz 11th ed., p. 1883.)
4. Each of the following is associated with pelvic fracture
EXCEPT:
A. Prompt operative intervention for pubic rami
fractures.
B. Life-threatening hemorrhage.
C. Associated genitourinary (GU) injury.
D. Displacement associated with two or more fractures
in the pelvic ring.
Answer: A
Pelvic fractures are indicative of high-energy trauma and are
associated with head, chest, abdominal, and urogenital injuries. Hemorrhage from pelvic trauma can be life-threatening
and patients can present with hemodynamic instability requiring significant fluid resuscitation and blood transfusions. The
bleeding that occurs is often due to injury of the venous plexus
in the posterior pelvis, though it can also be due to a large vessel injury such as a gluteal artery. Other associated injuries
are bladder and urethral injuries that manifest with bleeding from the urethral meatus or blood in the bladder catheter, and need to be assessed with a retrograde urethrogram.
The pelvis is a ring structure made up of the sacrum and the
two innominate bones that are held together by strong ligaments. Because it is a ring, displacement can only occur if the
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ring is disrupted in two places. Displaced sacral fractures and
iliac wing fractures are treated with screws or plates, while
pubic rami fractures can usually be managed nonoperatively.
(See Schwartz 11th ed., pp. 1887–1888.)
5. Chronic unremitting back pain suggests all of the following possibilities EXCEPT:
A. Infection.
CHAPTER 43
Orthopedic Surgery
B. Malignancy (primary).
C. Spinal cord infarction.
D. Metastatic disease.
6. Concerning long bone fractures, which of the following
is TRUE?
A. These are classified into four categories (Gustillo-
Anderson classification).
B. Treatment of these fractures consists of immediate
antibiotics, irrigation, debridement.
C. External fixation needed for clean and contaminated
wound.
D. Distal tibial wounds can be covered by local muscle
flaps.
7. Which of the following is FALSE concerning humeral
shaft fractures?
A. Radial nerve injuries are primarily neuropraxias.
B. Management is primarily nonsurgical.
C. Gentle motion exercises are begun at 8 weeks.
D. Radial nerve injury healing is monitored by
electromyography (EMG).
Answer: C
Back pain occurs in the majority of adults but is usually selflimited, resolving in 1 to 2 weeks. Chronic unremitting back
pain suggests the possibility of infection, malignancy, or metastatic disease. (See Schwartz 11th ed., p. 1904.)
Answer: B
An open fracture occurs when the bone breaks through the
skin. These injuries are classified into three types according to the Gustillo-Anderson classification. These injuries
require immediate administration of antibiotics and irrigation and debridement of the wound. When the wound is
contaminated, an external fixator is initially used. Early coverage of the wound is important to avoid infection. Usually
a large wound in the proximal or middle third of the tibia
can be covered using local muscle flaps, while the distal third
of the tibia will require a free flap. (See Schwartz 11th ed.,
pp. 1881–1883.)
Answer: C
The majority of humeral shaft fractures can heal with nonsurgical management if they are within an acceptable degree
of angulation. The radial nerve spirals around the humeral
shaft and is at risk for injury. Most radial nerve injuries are
neurapraxias, or stretching of the nerve, and function typically returns within 3 to 4 months. Gentle motion exercises
are begun within 1 to 2 weeks. The patient should have
an EMG to monitor recovery of the nerve. (See Schwartz
11th ed., pp. 1884–1885.)
8. Concerning knee dislocations, which of the following
statements is FALSE?
A. Anterior and posterior cruciate ligaments are torn.
B. Common peroneal nerve is prone to injury.
C. Immediate reduction is critical.
D. Normal arterial pulses preclude need for further vas-
cular assessment.
9. Concerning shoulder dislocations, which of the following statements is FALSE?
A. Association with impingement syndromes.
B. Therapy with prolonged immobilization.
C. Open stabilization procedures are the “gold stan-
dard” of treatment for majority of injuries associated
with shoulder dislocation.
D. Humeral head fractures common.
Answer: D
When the knee dislocates, the anterior cruciate ligament
and posterior cruciate ligament are torn. The neurovascular
examination is extremely important, focusing on the common peroneal nerve and the vascular status of the extremity,
followed by immediate reduction of the knee and subsequent
neurovascular examination. If the pulses are normal, the
ankle brachial index (ABI) should be measured. If the ABI
is >0.5, the patient should be monitored with serial examination. If the ABI is less than 0.9, then a CT scan or an arterial duplex ultrasound should be performed. (See Schwartz
11th ed., p. 1890.)
Answer: C
Prolonged immobilization is not recommended because this
will often lead to substantial stiffness in the shoulder and does
not appreciably decrease the redislocation rate. Arthroscopic
stabilization procedures have been the gold standard treatment for the majority of injuries related to shoulder dislocations. Posterior dislocations of the shoulder are rare and could
be missed. This dislocation can occur due to electric shock or
seizures. Radiographs are generally obtained to evaluate for
concomitant body injuries, such as fractures of the humeral
head. After minor trauma or repetitive injury, patients may
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experience pain and discomfort, which can be due to irritation of the tissues in the subacromial space. In many cases,
such shoulder impingement syndromes are caused by simple bursitis or tendonitis and the long head of the biceps or
supraspinatus tendon. Occasionally, impingement syndromes
can progress to tears of the supraspinatus tendon, which can
be confirmed by magnetic resonance imaging (MRI) or ultrasound. (See Schwartz 11th ed., pp. 1895–1897.)
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CHAPTER 43
10. Management of arthritis includes which of the following?
A. Injection
B. Osteoplasty
C. Arthroclasty
D. Arthrotomy
Answer: A
Measures to treat arthritis include weight loss, rest, physical therapy, nonsteroidal antiinflammatory drugs (NSAIDs),
bracing, and assistive devices such as cane or walker. Joint
injections are commonly performed into the knee and
shoulder. Common injections include corticosteroids and
hyaluronic acid gels. Corticosteroid injections can decrease
inflammation within the joint. These injections are usually
administered in combination with a local anesthetic, such as
lidocaine, in order to provide more immediate relief for both
diagnostic and therapeutic purposes. (See Schwartz 11th ed.,
pp. 1905–1907.)
Orthopedic Surgery
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CHAPTER 44
Ulnar
EIP/EDC
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Surgery of the Hand and Wrist
1. The median, radial, and ulnar nerves serve the forearm,
wrist, and hand. Which of the following statements about
these nerves are TRUE?
A. Median nerve receives fibers from C5–T1 and travels
through the carpal tunnel.
B. The radial nerve receives fibers from C5–T1 and
innervates the intrinsic muscles of the hand.
C. The ulnar nerve receives fibers from C5–T1 and
innervates the extrinsic muscles of the hand.
D. The ulnar nerve with the median nerve travel through
the carpal tunnel.
APL
EPB
FPL
Answer: A
Three principal nerves serve the forearm, wrist, and hand: the
median, radial, and ulnar nerves. The most critical of these from
a sensory standpoint is the median nerve. The median nerve
begins as a terminal branch of the medial and lateral cords of
the brachial plexus. It receives fibers from C5–T1. The ulnar
nerve is a terminal branch of the medial cord of the brachial
plexus. It receives innervation from C8 and T1 roots. The radial
nerve is the larger of two terminal branches of the posterior
cord of the brachial plexus. It receives fibers from C5–T1 nerve
roots. It innervates all of the extensor muscles of the forearm
and wrist. See also Fig. 44-1. (See Schwartz 11th ed., p. 1930.)
Radial A
S
ECRL/ECRB
FCR
Median N
TCL
3
4
2
5
5
4
3
2
H
C
AN
ECU
P
EPL
FIG. 44-1. Cross-section of the wrist at the midcarpal level. The relative geography
of the neurologic and tendinous structures can be seen. The transverse carpal
ligament (TCL) is the roof of the carpal tunnel, passing volar to the median nerve
and long flexor tendons. The TCL is also the floor of the ulnar tunnel, or Guyon’s
canal, passing dorsal to the ulnar artery and nerve. The wrist and digital extensor
tendons are also seen, distal to their compartments on the distal radius and
ulna. Bones: C = capitate; H = hamate; P = pisiform; S = scaphoid. Tendons (flexor
digitorum superficialis is volar to flexor digitorum profundus within the carpal
tunnel): 2 = index finger; 3 = middle finger; 4 = ring finger; 5 = small finger. A =
artery; APL = abductor pollicis longus; ECRB = extensor carpi radialis brevis; ECRL =
extensor carpi radialis longus; ECU = extensor carpi ulnaris; EDC = extensor
digitorum communis; EDQ = extensor digiti quinti; EIP = extensor indices proprius;
EPB = extensor pollicis brevis; EPL = extensor pollicis longus; FCR = flexor carpi
radialis; FPL = flexor pollicis longus; N = nerve.
EDQ
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2. For vascular injuries to the hand requiring tourniquet,
the maximum time the tourniquet should be applied to
prevent tissue necrosis is:
A. 1 hour.
B. 2 hours.
C. 3 hours.
D. 4 hours.
CHAPTER 44
3. Anesthetic agents with epinephrine should not be used in:
A. The fingertip.
B. The hand.
Surgery of the Hand and Wrist
C. The wrist.
D. The forearm.
Answer: B
Initial treatment for an actively bleeding wound should be
direct local pressure for no less than 10 continuous minutes.
If this is unsuccessful, an upper extremity tourniquet inflated
to 100 mmHg above the systolic pressure should be used. One
should keep this tourniquet time to <2 hours to avoid tissue
necrosis. Once bleeding is controlled well enough to evaluate
the wound, it may be cautiously explored to evaluate for bleeding points. One must be very cautious if attempting to ligate
these to ensure that adjacent structures such as nerves are not
included in the ligature. (See Schwartz 11th ed., p. 1936.)
Answer: A
A commonly held axiom is that epinephrine is unacceptable to be used in the hand. Several recent large series have
dispelled this myth. Epinephrine should not be used in the
fingertip and not in concentrations higher than 1:100,000
(ie, what is present in commercially available local anesthetic
with epinephrine). Beyond that, its use is acceptable and may
be useful in an emergency room (ER) where tourniquet control may not be available. Also, because most ER procedures
are done under pure local anesthesia, many patients will not
tolerate the discomfort of the tourniquet beyond 30 minutes.
Epinephrine will provide hemostasis and also prolong the
effect of the local anesthetic. (See Schwartz 11th ed., p. 1936.)
4. Proper handling of an amputated digit or limb includes
which of the following?
A. Place dry in a waterproof bag.
B. Immerse in an antiseptic solution.
C. Prep and wrapped in moistened gauze.
D. Place on dry ice.
5. Contraindications to reimplantation include:
A. Multiple digit amputations.
B. Amputations in children.
C. Amputation of the thumb.
D. Injury to a single digit distal to the proximal inter-
phalangeal (PIP) joint.
Answer: C
In preparation for replantation, the amputated part and proximal stump should be appropriately treated. The amputated
part should be wrapped in moistened gauze and placed in a
sealed plastic bag. This bag should then be placed in an ice
water bath. Do not use dry ice, and do not allow the part to
contact ice directly; frostbite can occur in the amputated part,
which will decrease its chance of survival after replantation.
Bleeding should be controlled in the proximal stump by as
minimal a means necessary, and the stump should be dressed
with a nonadherent gauze and bulky dressing. (See Schwartz
11th ed., p. 1938.)
Answer: D
After replantation was first reported, replantation was
attempted for nearly all amputations. Over the ensuing
decades, more stringent guidelines have been established
regarding what should be replanted. Indications for replantation include amputations of the thumb, multiple digit
amputations, and amputations in children. Relative contraindications to replantation include crush injuries, injuries
to a single digit distal to the PIP joint, and patients who are
unable to tolerate a long surgical procedure. As with all guidelines, one should evaluate the particular needs of the injured
patient. (See Schwartz 11th ed., p. 1938.)
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6. Which of the following is incorrect about high-pressure
injection injuries?
A. They occur most commonly in the nondominant
hand at the base of the digit.
B. They should be treated with elevation and antibiotics,
with high rates of recovery.
C. They require exploration within 6 hours of injury.
D. Half of these injuries are associated with digit loss.
7. Which of the following statements about carpal tunnel
syndrome is FALSE?
A. Carpal tunnel syndrome involved the compression of
radial nerve under the flexor retinaculum.
B. There is an association with exposure to force and
repetition activities, and force and posture.
C. Syndrome is associated with thenar wasting and loss
of thumb strength.
D. Treatment consists of splinting of the wrist at 20° to
be worn during sleep, steroid injection, and carpal
tunnel release.
Answer: B
High-pressure devices are commonly used for cleaning and
applications of liquids such as lubricants and paint. Most
commonly, the inexperienced worker accidentally discharges
the device into his nondominant hand at the base of the
digit. Severity of injury depends on the amount and type of
liquid injected; hydrophobic compounds cause greater damage. These injuries are typically quite innocuous to inspection. They are, however, digit-threatening emergencies. The
patient should be informed of the severity of the injury, and
exploration is ideally performed within 6 hours of injury. Up
to 50% of such injuries result in loss of the digit, but early recognition and treatment are associated with increased chance
of digit survival. Early frank discussion with the patient and
initiation of appropriate treatment produce the best results
and medicolegal protection. (See Schwartz 11th ed., p. 1939.)
Answer: A
The most common location of upper extremity nerve compression is the median nerve at the carpal tunnel, called carpal tunnel syndrome (CTS). The carpal tunnel is bordered by
the scaphoid bone radially, the lunate and capitate bones dorsally, and the hook of the hamate bone ulnarly (see Fig. 44-1).
The transverse carpal ligament, also called the flexor retinaculum, is its superficial border. The flexor pollicis longus
(FPL), four flexor digitorum superficialis (FDS), and four
flexor digitorum profundus (FDP) tendons pass through the
carpal tunnel along with the median nerve. Of these 10 structures, the median nerve is relatively superficial and radial to
the other nine. There is strong evidence of a positive association between exposure to a combination of risk factors
(eg, force and repetition, force and posture) and CTS. There
is disagreement among hand surgeons regarding whether
occurrence of CTS in a patient who does repetitive activities
at work represents a work-related injury.
Physical examination should begin with inspection. Look
for evidence of wasting of the thenar muscles. Tinel sign
should be tested over the median nerve from the volar wrist
flexion crease to the proximal palm, although this test has
significant interexaminer variability. Applying pressure over
the carpal tunnel while flexing the wrist has been shown in
one series to have the highest sensitivity when compared to
Phalen and Tinel signs. Strength of the thumb in opposition
should also be tested.
Early treatment of CTS consists of conservative management. The patient is given a splint to keep the wrist at 20°
extension worn at nighttime. Many patients can have years
of symptom relief with this management. As a treatment and
diagnostic modality, corticosteroid injection of the carpal
tunnel is often employed. Mixing local anesthetic into the
solution provides the benefit of early symptom relief (corticosteroids often take 3–7 days to provide noticeable benefit),
and report of postinjection anesthesia in the median nerve
distribution confirms the injection went into the correct location. Multiple authors have shown a strong correlation to relief
of symptoms with corticosteroid injection and good response
to carpal tunnel release. (See Schwartz 11th ed., p. 1944.)
CHAPTER 44
Surgery of the Hand and Wrist
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