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Hand Trauma & Infection MCQs

Practice Set 1 of 10

This practice set contains high-yield board review questions covering key concepts in Hand Trauma & Infection. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1

Topic: Hand Trauma & Infection

A 35-year-old carpenter sustains a puncture wound to his right index finger. Two days later, he presents with severe throbbing pain. Which of the following Kanavel signs is typically the earliest clinical indicator of acute infectious flexor tenosynovitis?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Severe pain with passive extension of the digit
. Tenderness along the entire course of the flexor tendon sheath
. Erythema extending proximal to the palmar crease

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Pain out of proportion with passive extension of the involved digit is generally considered the earliest and most sensitive of Kanavel's four classic signs for infectious flexor tenosynovitis. Prompt recognition is critical to prevent tendon necrosis.

Question 2

Topic: Hand Trauma & Infection

A 28-year-old carpenter sustains a puncture wound to the volar aspect of his index finger. Three days later, he presents to the emergency department with a swollen, exquisitely painful finger. Which of the following is NOT one of Kanavel's four cardinal signs of flexor tenosynovitis?

. Flexed resting posture of the digit
. Fusiform swelling of the digit
. Tenderness along the course of the flexor tendon sheath
. Pain with active flexion of the digit
. Pain with passive extension of the digit

Correct Answer & Explanation

. Pain with active flexion of the digit

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are: flexed resting posture, fusiform (sausage) swelling, exquisite tenderness along the flexor tendon sheath, and severe pain with passive extension. Pain with active flexion is not a defining cardinal sign.

Question 3

Topic: Hand Trauma & Infection

A 35-year-old construction worker presents with a swollen, painful index finger after a minor puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of flexor tendon sheath infection?

. Pain on passive extension of the digit
. Fusiform swelling of the digit
. Flexed resting posture of the digit
. Erythema extending proximal to the wrist crease
. Tenderness along the course of the flexor tendon sheath

Correct Answer & Explanation

. Erythema extending proximal to the wrist crease

Explanation

Kanavel's four signs of suppurative flexor tenosynovitis are fusiform swelling, flexed posture, tenderness along the tendon sheath, and severe pain on passive extension. Erythema extending proximal to the wrist is not a specific Kanavel sign.

Question 4

Topic: Hand Trauma & Infection

A rupture of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal (MCP) joint primarily leads to instability when which of the following forces is applied?

. Valgus stress
. Varus stress
. Axial compression
. Palmar translation
. Hyperextension

Correct Answer & Explanation

. Valgus stress

Explanation

The UCL of the thumb prevents excessive abduction at the MCP joint. Therefore, injury to this structure (commonly known as Gamekeeper's or Skier's thumb) results in instability and laxity when a valgus stress is applied.

Question 5

Topic: Hand Trauma & Infection

A 35-year-old carpenter sustains a puncture wound to his index finger. He presents 48 hours later with severe pain and swelling. Which of the following Kanavel signs is generally considered the most reliable and earliest indicator of acute suppurative flexor tenosynovitis?

. Erythema extending to the proximal palm
. Pain with active flexion of the digit
. Pain with passive extension of the digit
. Fusiform swelling of the entire hand
. Fixed extension posture of the involved digit

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis include flexed resting posture, fusiform swelling, tenderness along the flexor tendon sheath, and pain with passive extension. Exquisite pain with passive extension is typically the earliest and most sensitive clinical indicator of this surgical emergency.

Question 6

Topic: Hand Trauma & Infection

A patient presents with a swollen, painful index finger. Which of the following is NOT one of Kanavel's four cardinal signs of acute suppurative flexor tenosynovitis?

. Fusiform swelling of the entire digit
. Exquisite tenderness along the course of the flexor tendon sheath
. Severe pain with passive extension of the digit
. Erythema extending proximal to the wrist crease
. Flexed resting posture of the digit

Correct Answer & Explanation

. Erythema extending proximal to the wrist crease

Explanation

Kanavel's signs include fusiform swelling, tenderness along the sheath, pain on passive extension, and a flexed resting posture. Erythema extending proximal to the wrist is not a cardinal sign and may suggest a more widespread cellulitis or proximal spread.

Question 7

Topic: Hand Trauma & Infection

Which of the following is NOT one of Kanavel's cardinal signs for flexor tenosynovitis?

. Fusiform swelling of the digit
. Tenderness along the flexor tendon sheath
. Pain with active extension of the digit
. Digit held in a flexed posture
. Pain with passive extension of the digit

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs are: flexed posture of the digit, fusiform swelling, tenderness along the flexor sheath, and severe pain with passive (not active) extension. Pain with active motion is less specific.

Question 8

Topic: Hand Trauma & Infection

A patient is diagnosed with an acute complete rupture of the ulnar collateral ligament (UCL) of the thumb (Skier's thumb). A Stener lesion is suspected, which mandates surgical intervention. A Stener lesion occurs when the torn UCL displaces superficial to the:

. Abductor pollicis brevis aponeurosis
. Adductor pollicis aponeurosis
. Extensor pollicis longus tendon
. Flexor pollicis brevis muscle belly
. First dorsal interosseous fascia

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the distally avulsed thumb ulnar collateral ligament (UCL) flips back and is trapped superficial to the adductor pollicis aponeurosis. This prevents healing and is a definitive indication for surgical repair.

Question 9

Topic: Hand Trauma & Infection

Felon complications include all of the following except:

. Phalangeal osteomyelitis
. Suppurative flexor tenosynovitis
. C ollar button abscess
. Distal interphalangeal joint septic arthritis
. Nailbed deformity

Correct Answer & Explanation

. Phalangeal osteomyelitis

Explanation

Felons that are chronic or neglected may penetrate adjacent structures such as the distal phalanx, nailbed, or distal interphalangeal joint. They can also contribute to the formation of a pyogenic flexor tenosynovitis. C ollar button abscesses are localized to web space. They typically arise from direct inoculation, not from distant felons.

Question 10

Topic: Hand Trauma & Infection

Which of the following is not a classic Kanavel sign of flexor tenosynovitis:

. Pain on passive extension
. Flexion attitude of the finger
. Tenderness of flexor sheath
. Anesthesia of the fingertip
. Fusiform swelling of the entire finger

Correct Answer & Explanation

. Anesthesia of the fingertip

Explanation

The cardinal signs of flexor tenosynovitis described by Kanavel include pain on passive extension, flexion attitude of the finger, tenderness of flexor sheath, and swollen finger.

Question 11

Topic: Hand Trauma & Infection
Septic flexor tenosynovitis may involve all of the following areas except the:
. Radial bursa
. Thenar space
. Parona's space
. Snuffbox
. Ulnar bursa

Correct Answer & Explanation

. Snuffbox

Explanation

The radial and ulnar bursae are extensions of the tendon sheaths of the flexor pollicis longus and the flexor digitorum profundus of the small fingers. They can easily be involved in a case of pyogenic flexor tenosynovitis. Although not direct extensions of the flexor sheaths, the thenar space and Parona's space are adjacent to the flexor sheaths and can be involved in suppurative conditions. The snuffbox, however, does not have any contributions from the flexor system and is not usually involved in cases of pyogenic flexor tenosynovitis.

Question 12

Topic: Hand Trauma & Infection
"Collar button" abscess refers to:
. Web space infection
. Finger pulp infection
. Extension of infection from mid-palmar space to Parona's space in the forearm
. Eponychial infection
. Septic joint with dorsal and palmar extension

Correct Answer & Explanation

. Web space infection

Explanation

Collar button abscess is an infection of the web space and is usually a result of penetrating trauma. Treatment of such abscesses requires incision and drainage through dorsal and palmar incisions. Care must be taken to avoid the neurovascular bundles. Finger pulp infections are known as a felon. Infections involving Parona's space are typically involved in a horseshoe abscess. Eponychial infections are limited to the nail fold. Collar button abscesses do not include joint involvement.

Question 13

Topic: Hand Trauma & Infection

A 32-year-old carpenter sustains a small puncture wound to his left index finger. Two days later, he presents with uniform swelling of the digit, flexed resting posture, and excruciating pain with passive extension.

Which of the following is the fourth Kanavel sign typically seen in this condition?

. Erythema extending to the palm
. Tenderness along the course of the flexor tendon sheath
. Palpable crepitus along the volar digit
. Loss of two-point discrimination
. Purulent drainage from the puncture site

Correct Answer & Explanation

. Tenderness along the course of the flexor tendon sheath

Explanation

The four classic Kanavel signs of acute suppurative flexor tenosynovitis are fusiform swelling, flexed resting posture, pain with passive extension, and tenderness along the flexor tendon sheath. Erythema, crepitus, and purulence are not considered part of the four classic signs.

Question 14

Topic: Hand Trauma & Infection

A 25-year-old male presents with a painful, swollen, and red index finger following a fight bite 36 hours ago. The wound is over the MCP joint. During surgical exploration, the extensor digitorum communis tendon is found to be partially lacerated. What is the most appropriate management for the partially lacerated tendon in this acutely infected field?

. A. Primary repair of the tendon with non-absorbable sutures.
. B. Thorough irrigation and debridement of the tendon ends, and leave unrepaired for delayed secondary repair.
. C. Excise the lacerated portion of the tendon to prevent further spread of infection.
. D. Cover the tendon with a local fascial flap for protection.
. E. Administer high-dose corticosteroids to reduce inflammation.

Correct Answer & Explanation

. B. Thorough irrigation and debridement of the tendon ends, and leave unrepaired for delayed secondary repair.

Explanation

Correct Answer: BIn an acutely infected wound, primary repair of a partially or completely lacerated tendon is generally contraindicated due to the high risk of infection of the repair site, leading to tendon necrosis, rupture, and adhesion formation. The most appropriate management is thorough irrigation and debridement of the tendon ends and surrounding tissue, followed by leaving the tendon unrepaired. Definitive repair, if necessary, should be delayed until the infection is completely resolved and the wound is clean. Excising the tendon (C) would result in significant functional deficit. Covering with a flap (D) is premature and risky in an infected field. Corticosteroids (E) are contraindicated in active infection.

Question 15

Topic: Hand Trauma & Infection

A 40-year-old carpenter presents with a swollen, painful index finger 3 days after a penetrating injury from a splinter. Which of the following is considered the most sensitive and earliest clinical sign of pyogenic flexor tenosynovitis?

. Fusiform swelling of the digit
. Flexed resting posture of the digit
. Tenderness along the flexor tendon sheath
. Pain with active flexion of the interphalangeal joints
. Pain with passive extension of the digit

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis include fusiform swelling, a flexed resting posture, tenderness along the tendon sheath, and pain with passive extension. Exquisite pain with passive extension is considered the earliest and most sensitive sign of the condition.

Question 16

Topic: Hand Trauma & Infection

A 32-year-old mechanic presents with severe pain and swelling in his dominant right index finger 3 days after a puncture wound. Which of the following is NOT one of Kanavel's classic cardinal signs of acute suppurative flexor tenosynovitis?

. Flexed resting posture of the digit
. Fusiform swelling of the entire digit
. Erythema tracking proximally up the forearm
. Tenderness along the course of the flexor tendon sheath
. Severe pain with passive extension of the digit

Correct Answer & Explanation

. Erythema tracking proximally up the forearm

Explanation

Kanavel's four cardinal signs are fusiform swelling, flexed resting posture, tenderness along the flexor sheath, and severe pain with passive extension. Erythema tracking up the forearm is a sign of lymphangitis, not a specific cardinal sign of flexor tenosynovitis.

Question 17

Topic: Hand Trauma & Infection

A 22-year-old male presents with a painful, swollen, and erythematous wound over his right third metacarpophalangeal (MCP) joint after striking another individual in the mouth. In addition to Staphylococcus and Streptococcus species, empirical antibiotic therapy must primarily cover which of the following organisms?

. Pasteurella multocida
. Eikenella corrodens
. Mycobacterium marinum
. Bartonella henselae
. Sporothrix schenckii

Correct Answer & Explanation

. Eikenella corrodens

Explanation

Human bites, or "fight bites," occurring over the MCP joint carry a high risk of deep space infection and septic arthritis. Eikenella corrodens is a fastidious Gram-negative rod uniquely associated with human oral flora, requiring treatment with amoxicillin-clavulanate or ampicillin-sulbactam.

Question 18

Topic: Hand Trauma & Infection

A patient presents with a painful, tense, erythematous volar pad of the distal thumb, diagnosed as a felon. The surgeon plans an incision and drainage. To minimize the risk of digital nerve injury, painful scarring, and functional impairment, which surgical incision is most currently recommended?

. A "fish-mouth" incision extending completely around the tip of the digit
. A central volar longitudinal incision that does not cross the distal interphalangeal (DIP) crease
. A transverse incision directly over the distal flexion crease
. A bilateral mid-axial incision meeting at the apex
. A dorsal transverse incision just proximal to the eponychium

Correct Answer & Explanation

. A central volar longitudinal incision that does not cross the distal interphalangeal (DIP) crease

Explanation

A volar longitudinal incision over the point of maximum fluctuance is currently the preferred approach for a felon, as it provides direct access to the septal compartments without jeopardizing digital nerves or causing tip necrosis. It must not cross the DIP flexion crease to prevent scar contracture.

Question 19

Topic: Hand Trauma & Infection

A 50-year-old bartender presents with bilateral swelling, induration, and loss of the cuticle around multiple fingernails, present for over 3 months. The condition is refractory to oral antibiotics. What is the most likely dominant pathogen responsible for this chronic paronychia?

. Staphylococcus aureus
. Candida albicans
. Streptococcus pyogenes
. Pseudomonas aeruginosa
. Herpes simplex virus

Correct Answer & Explanation

. Candida albicans

Explanation

While acute paronychia is usually bacterial (S. aureus), chronic paronychia is classically associated with prolonged moisture exposure and fungal infection, most commonly Candida albicans. Treatment involves keeping hands dry, topical antifungals/steroids, or surgical marsupialization if refractory.

Question 20

Topic: Hand Trauma & Infection

A 28-year-old male presents with a 1 cm laceration over the 3rd metacarpophalangeal joint. He admits to punching someone in the mouth 2 days ago. The joint is swollen and erythematous. What is the most likely associated responsible organism and the appropriate empiric outpatient oral antibiotic?

. Pasteurella multocida; Ciprofloxacin
. Eikenella corrodens; Amoxicillin-clavulanate
. Staphylococcus aureus; Cephalexin
. Pseudomonas aeruginosa; Cefepime
. Mycobacterium marinum; Clarithromycin

Correct Answer & Explanation

. Eikenella corrodens; Amoxicillin-clavulanate

Explanation

"Fight bites" over the MCP joint carry a high risk of septic arthritis and are classic for human oral flora, prominently Eikenella corrodens. Amoxicillin-clavulanate provides appropriate broad-spectrum empiric coverage for this organism alongside Staph and Strep.

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