Multiple Choice Questions

Hands

Test your knowledge , learn more and get ready for your orthopaedic exam

 30. A 38-year-old man caught his index finger in a volleyball net. He noted an angular deformity of the finger that was reduced when a teammate pulled on his finger. Three weeks later, he now reports trouble extending his finger. A clinical photograph is shown in Figure . What anatomic structure is most likely injured?

A) Spiral oblique retinacular ligament 2 Sagittal bands
B) Sagittal
C) Volar plate
D) Central slip of the extensor tendon
E) Terminal extensor tendon

Correct Answer: D

The clinical photograph shows a classic boutonniere deformity. It is likely that the patient sustained a volar dislocation of the proximal interphalangeal joint, with a concomitant rupture of the central slip insertion of the extensor tendon.

Author: Firas Arnaout

 29. A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition?

A) Ring flexor digitorum superficialis transfer to the abductor pollicis brevis
B) Extensor indicis proprius transfer to the abductor pollicis brevis
C) Neurotization of thenar muscles
D) Camitz palmaris longus transfer to the abductor pollicis brevis
E) Thumb carpometacarpal joint arthrodesis

Correct Answer: B

This patient has a high median nerve neuropathy because of a supracondylar spur and ligament of Struthers. Reconstruction is best performed with extensor indicis proprius (EIP) transfer to the abductor pollicis brevis (APB).

Author: Firas Arnaout

 28. A 48-year-old hairdresser presents with pain and swelling of his ring finger for 4 days. On examination, there is generalized tenderness along the entire digit. Passive extension of the digit triggers excruciating pain. The clinical appearance of the digit is shown in Figure . What is the most appropriate next step in management?

A) Acyclovir
B) Intravenous antibiotics, splinting and elevation
C) Closed tendon sheath irrigation from the level of the A1 pulley (proximal) to the distal interphalangeal joint (distal)
D) Continuous closed tendon sheath irrigation from the wrist (proximal) to the distal interphalangeal joint (distal)
E) Open irrigation and debridement

Correct Answer: E

 Pyogenic flexor tenosynovitis is usually caused by a puncture wound (although it may infrequently arise from hematogenous spread). The most common organism is Staphylococcus aureus. Kanavel signs help differentiate this disease from herpetic whitlow, septic arthritis, paronychia, felons,gout/pseudogout, and cellulitis,andother hand infections such as deep space infections.

Author: Firas Arnaout

 27. Figures show the radiographs of a 62-year-old man with severe radially sided wrist pain. Management has consisted of wrist splinting, nonsteroidal anti-inflammatory drugs, and activity modification, but he continues to have pain and reports difficulty sleeping. What is the most appropriate treatment for this patient?

 

A) Arthroscopic debridement
B) Open reduction and internal fixation
C) Scaphoid nonvascularized bone graft and screw fixation
D) Scaphoid vascularized bone graft and screw fixation
E) Scaphoid excision and 4-corner fusion

Correct Answer: E

Scaphoidectomy and 4-bone fusion is the most appropriate management based on the choices available. The patient has arthritic changes of SNAC (scaphoid nonunion advanced collapse) wrist, stage III. Stage I is at the radial styloid, stage II is at the radioscaphoid joint, and stage III is at the midcarpal joint. Arthroscopic debridement is not appropriate in patients with arthrosis. Attempting to achieve scaphoid union is only appropriate if there is no arthrosis or the changes are classified as stage I where radial styloidectomy can be performed.

Author: Firas Arnaout

 26. A 46-year-old man sustains an injury to his left index finger while cleaning his paint gun with paint thinner. Examination reveals a small puncture wound at the pulp. The finger is swollen. What is the next most appropriate step in management?

A) Elevation and observation
B) Surgical debridement and lavage
C) Infiltration with corticosteroids
D) Infiltration with a neutralizing agent
E) Administration of antibiotics

Correct Answer: B

High-pressure injection injuries are associated with a high risk of amputation. The risk of amputation is highest with organic solvents. The presence of infection and the use of steroids do not impact the amputation rate. Amputation risk is lower if surgical debridement is performed within 6 hours. Elevation and observation would delay necessary care. Neutralizing agents may be used in specific situations, such as hydrofluoric acid exposure or chemotherapeutic agent extravasation, but in high pressure paint thinner injection, the best outcome is achieved through early surgical lavage.

Author: Firas Arnaout

 25. In obtaining informed consent for a percutaneous trigger finger release of the thumb, what structure is discussed as being most vulnerable to injury?

A) Radial digital sensory nerve to the index finger
B) Radial digital sensory nerve to the thumb
C) Median motor branch to the thenar muscles
D) Volar plate of the thumb metacarpophalangeal joint
E) Ulnar digital sensory nerve to the thumb

Correct Answer: B

Percutaneous release of the A1 pulley for trigger finger release has become increasingly popular. This procedure in the index, middle, and ring fingers can be carried out with little risk to adjacent neurovascular structures. However, percutaneous release in the thumb and little finger is controversial due to the close proximity of the digital nerves to the A1 pulley being released. It is generally recommended that percutaneous trigger release in the thumb and little finger be avoided. A cadaveric study by Bain and associates showed that the average distance of the digital nerves in the thumb from the pulley release point was 2.9 mm. The radial digital nerve was within 2 mm of the release point in 5 of 10 hands studied. Thus the margin of error is very small. The site of potential crossing of the digital nerves to the little finger was variable, increasing the risk of injury as well.

Author: Firas Arnaout

 24. Ganglion cysts about the wrist most commonly arise from what structure?

A) First carpometacarpal joint
B) Second carpometacarpal joint
C) Scapholunate interosseous ligament
D) Radioscaphocapitate ligament
E) Capitohamate interosseous ligament

Correct Answer: C

Ganglion cysts are the most common mass or mass-like lesions seen in the hand and wrist. They arise in a variety of locations, including synovial joints or tendon sheaths. The most common location is the dorsal/radial wrist arising from the dorsal scapholunate interosseous ligament.

Author: Firas Arnaout

 23. A patient sustained a sharp laceration to the base of his left, nondominant thumb 4 months ago. Examination reveals no active flexion but full passive motion of the interphalangeal joint. What is the best treatment option?

A) Interphalangeal joint fusion
B) Intercalary tendon graft
C) Silicone rod placement
D) Primary flexor pollicis longus repair
E) Flexor digitorum superficialis transfer

Correct Answer: E

The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation.

Author: Firas Arnaout

 22. When evaluating a patient with suspected purulent flexor tenosynovitis in the thumb, the distal forearm and little finger are found to be swollen as well. The most likely anatomic explanation is the existence of a potential space in which of the following?

A) Through the carpal tunnel
B) Across the midpalmar space
C) Communicating with the subcutaneous tissue
D)Superficial to the distal antebrachial fascia
E) Between the fascia of the pronator quadratus and flexor digitorum profundus conjoined tendon sheaths

Correct Answer: E

Pyogenic flexor tenosynovitis is an infection within the flexor tendon sheath that can involve the fingers or thumb. The tendon sheaths begin at the metacarpal neck level and extend to the distal interphalangeal joint. In the little finger and the thumb, the sheaths usually communicate with the ulnar and radial bursae, respectively. The potential space of communication, Parona's space, lies between the fascia of the pronator quadratus muscle and flexor digitorum profundus conjoined tendon sheaths. Infection tracking through this space presents as a horseshoe abscess.

Author: Firas Arnaout

 21. In the rheumatoid hand with an intact extensor tendon mechanism, replacement of the metacarpophalangeal joints might be considered if there is?

A) Gross joint destruction
B) Palmar and proximal dislocation of the base of the phalanx
C) Marked ulnar drift combined with (A) and (B)
D) All of these
E) None of these

Correct Answer: D

All of these
The indications for surgery in the rheumatoid patient
are listed below in order of importance:
a) Impending tendon rupture or severe nerve
compression
b) Relief of pain
c) Improvement in function
d) Cosmesis
MP joint arthroplasty will relieve pain effectively and
will correct ulnar deviation as long as the carpus
is not too radially deviated. If it is, the wrist should
be reconstructed first and stabilised employing a
radioulnate fusion. Howerver, this should not be
carried out, if the wrist is pain-free.

Author: Firas Arnaout

 20. Which of the following muscles is not located in the thenar group of muscles?

A) Abductor pollicis brevis
B) Opponens pollicis
C) Opponens digiti minimi
D) Flexor pollicis brevis
E) Adductor pollicis

Correct Answer: C

Opponens digiti minimi
Opponens digiti minimi is located in the hypothenar
group of muscles.1 The intrinsic muscles of the
hand are in four compartments – Thenar, adductor,
hypothenar and central:
Thenar compartment – abductor pollicis brevis, flexor
pollicis brevis and opponens pollicis
Adductor compartment – adductor pollicis
Hypothenar compartment – abductor digiti minimi,
flexor digiti minimi, opponens digiti minimi
Central compartment – the lumbricals and interossei
between the metacarpals

Author: Firas Arnaout

 19. Patient is seen post op after their wrist arthroscopy and is concerned about a firm lump just proximal to one of their portal sites .

What injury should you check for?

A) Nerve injury
B) Ganglion
C) Loose Body
D) retropulsion of thumb fracture
E) Extending the little finger

Correct Answer: D

EPL can be commonly injured with placement of the portal between the 3rd and 4th extensor compartments. Ganglion typical is distal or over the portal site

Author: David Hughes

 

18. A patient presents to your clinic with both hands in this position. 

What medications might they be on?

A) none
B) Beta blocker’s
C) Simvastatin
D) Metformin
E) Hydrazine

Correct Answer: E

This is an intrinsic plus hand associated with neurological conditions such as Parkinson’s .

Hydrazine is a Monamine inhibitor used in the treatment of Parkinson’s.

Author: David Hughes

 

17. An amateur boxer presents to your clinic, she is worried as after her most recent match she cannot extend her finger.

If she straightens with her other hand she can hold it straight and it stays up

This is  because:

A) partial tendon tear
B) posterior interosseous nerve compression from the fight
C) complete tendon rupture
D) saggittal band rupture
E) MCP subluxation

Correct Answer: D

saggital band rupture, leading to extensor tendon subluxation ulnarily  leading inability to extend at the MCP joint, but once in full extension passively can hold it.

Author: David Hughes

 

16. The ulnar paradox relates to:

A) Cubital tunnel syndrome is rarely associated with carpal tunnel syndrome
B) A proximal compression of the nerve leads to a worse deformity
C) After cubital tunnel release the deformity gets worse before it gets better
D)Cubital tunnel syndrome is always bilateral
E) Double pinch syndrome has a far worse outcome

Correct Answer: C

Ffter surgery nerves recover proximal to distal so the proximal extrinsic muscles recover first, over powering the intrinsic muscle of the hand causing clawing of the ring and little finger.

Author: David Hughes

 

15. Nail bed injury in the adult might be associated with which of the following:

A) Seymour fracture
B) Tuft fracture
C) Fracture of middle phalanx
D)Proximal phalanx fracture
E) Avulsion of central slip

Correct Answer: B

Nailbed Injury is associated with tuft fracture in adults and Seymour fracture in children.

Author: S Kamat

 

14. A 19-year-old  volleyball player injured her right thumb during a game. 

A magnetic resonance image (MRI) through the metacarpophalangeal joint is shown . 

What is the diagnosis:

A) Extensor tendon disruption
B) Complete ulnar collateral ligment tear
C) Volar plate disruption
D) Incomplete ulnar collateral ligament tear
E) Ulnar collateral

ligament sprain

Correct Answer: B

The MRI reveals a complete disruption of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb.

Author: Rajesh Bahadur Lakhey.

 

13. When applying a POSI splint, which of the following is true?

A) The wrist should be extended 10-45 degrees
B) PIPJ flexed to 90 degrees
C) DIPJ flexed to 30 degrees
D) Thumb in maximum abduction
E) MCPJ full extension

Correct Answer: A

POSI = Position of safety of intrinsics

Author: Fouad Chaudery

 

12. Macrodactyly is associated with all of the following syndromes except:

A) Neurofibromatosis
B) Proteus syndrome
C) Klippel-Trenaunay syndrome
D) Marfan syndrome
E) Multiple enchondromatosis

Correct Answer: D

Macrodactyly is an increase in length and width of a digit or two adjacent digits. It may be associated with all of the above syndromes except for Marfan syndrome. 

Macrodactyly is also a common isolated condition.

Author: Fouad Chaudery

 

11. A 16-year-old male high school rugby player was making a tackle when he felt sudden pain in his right long finger. 

He has swelling and tenderness along the volar aspect of the injured digit. He is unable to actively flex the distal interphalangeal joint of the injured digit. 

Radiographs are negative for fracture. 

Recommended treatment should include:

A) Observation
B) Splinting of the distal interphalangeal joint in extension
C) Splinting of the distal interphalangeal joint in flexion
D) Immediate active range of motion exercises
E) Surgical repair

Correct Answer: E

Avulsion of the flexor digitorum profundus, or "jersey finger," is a common injury in contact sports. 

Appropriate treatment includes surgical repair.

Author: Fouad Chaudhry

 

10. During a wrist arthroscopy in a basketball player who has ulnar-sided wrist pain, the articular disk of the triangular fibrocartilage complex is observed. 

A probe is inserted and the disk is free floating without tension, a negative “trampoline test”. 

Trampoline test is an arthroscopic evaluation of tension of triangular... | Download Scientific Diagram

What does this signify:

A) Flexor carpi ulnaris subluxation 
B) Distal radioulnar joint disruption 
C) Scapholunate instability 
D) Tear in either the central or peripheral portion of the TFCC 
E) Ulnar abutment syndrome 

Correct Answer: D

A probe should be used to test the integrity of the articular disc of the TFCC. This disk should be fairly taught, similar to a trampoline. 

When the articular disk is floppy and floating without tension, a tear in either the central or peripheral portion must be suspected.

Author: Fouad Chaudhry

 

9. A golfer sustained a hook of the hamate fracture . 

After 12 weeks of splinting and therapy, the hand is still symptomatic. 

RiT radiology: Hook of Hamate Fracture

What is the most appropriate management to allow return to competitive activity?

A) Continued observation
B) Open reduction and internal fi xation of the fracture
C) Excision of the hook of the hamate
D) Carpal tunnel release
E) Guyon canal release

Correct Answer: C

Excision of the fracture fragment typically leads to rapid return to function. 

Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. 

Nerve deficits are not typically noted in this injury. 

The motor branch of the ulnar nerve in Guyon canal must be protected during the surgical approach.

Author: Salam Al-Abayachi

 

8. What is the most appropriate indication for replantation in an otherwise healthy 35y old man?

A) Isolated transverse amputation of the thumb through the middle of the nail bed
B) Isolated transverse amputation of the index fi nger through the proximal phalanx
C) Isolated transverse amputation of the ring finger through the proximal phalanx
D) Isolated transverse amputation of the hand at the level of the wrist
E) Forearm amputation with a 10-hour warm ischemia time

Correct Answer: D

Vascular anastomoses are exceedingly difficult with amputations distal to the nail fold because the digital vessels bifurcate or trifurcate at this level, and little functional benefit is gained compared to other means of soft-tissue coverage. 

Single-digit amputations, other than the thumb, are a relative contraindication for replantation. 

Replantations at the level of the proximal phalanx lead to poor motion of the proximal interphalangeal joint. 

In a healthy, active adult, an amputation through the wrist is an appropriate situation to proceed with a replantation. 

A transverse forearm amputation is a good indication with a warm ischemia time of less than 6 hours.

Author: Salam Al-Abayachi

 

7.  A 59 years old man attended A&E with hand infection. Blood culture grow Eikonella Corrodens . 

Which injury is associated with this organism?

A) Human bites
B) Cat bites
C) Dog bites
D) Pyogenic flexor tenosynovitis
E) Paronychia

Best answer:  A

Staph aureus is the most common causing organism in all the above infections.However, Eikonella Corrodens is characteristic of human bites.

Hand infections are potentially serious. Treatment is with antibiotics and incision & drainage of any collection.

 

Pasteurella multocida is  common pathogen in cats and dogs scratches and bites.

 

 Ref: http://www.orthobullets.com/hand/6104/human-bite

 Author :Firas Arnaout

 

6. The following statements about Dupuytren’s contracture are true except that:

A) It is due to contraction of the palmar fascia which starts as an indurated nodule on the ulnar border of the hand.
B) The ring and little fingers are severely affected.
C) The deformity consists of flexion of the MCP and PIP joints with extension of the terminal joint.
D) The skin overlying the indurated fascia is often puckered and immobile.
E) The joint capsules and flexor tendons are not affected.

Correct Answer is : E

Dupuytren's contracture usually affects the ring and little finger. 

The contracture spreads to the joints of the finger, which can become permanently immobilized. 

Author : Firas Arnaout

 

5. During replantation of a digit; what is the sequence of repairing structures:

A) Bone; Extensor tendon; Flexor tendons; Arteries; Veins; Nerves
B) Nerves; Arteries; Bone; Veins; Extensor tendon; Flexor tendons
C) Arteries; Bone; Flexor tendons; Extensor tendon; Veins; Nerves
D) Bone; Arteries; Nerves; Veins; Flexor tendons; Extensor tendon
E) Bone; Extensor tendon; Flexor tendons; Arteries; Nerves; Veins

Best answer: E

 

BE a FAN of V (BEFANV)

Secured bone fixation should be done before starting any repair. 

Author: Ahmed Eltanboly

 

 

4. In Wassel classification of thumb polydactyly.