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Hand Trauma & Infection MCQs

Practice Set 2 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 21

Topic: Hand Trauma & Infection

A 30-year-old mechanic presents with severe, throbbing pain in the volar pulp of his right thumb. Examination reveals a tense, erythematous, and exquisitely tender thumb pulp. If an incision and drainage is required, which approach is considered safest to avoid neurovascular injury and painful scarring?

. Volar longitudinal incision
. High mid-lateral incision
. Bilateral longitudinal incisions
. Fish-mouth (circumferential) incision
. Transverse volar incision crossing the distal interphalangeal crease

Correct Answer & Explanation

. Volar longitudinal incision

Explanation

A volar longitudinal incision over the site of maximum fluctuance is generally preferred for a felon, as it avoids crossing the flexion creases and minimizes damage to the digital nerves. "Fish-mouth" incisions are historically discouraged due to high risks of painful scarring and neurovascular injury.

Question 22

Topic: Hand Trauma & Infection

Regarding the microbiology of human bite infections, particularly 'fight bites,' which of the following statements is most accurate?

. A. Infections are predominantly monomicrobial, typically caused by Staphylococcus aureus.
. B. Eikenella corrodens is a rare isolate, usually found only in severely immunocompromised patients.
. C. Polymicrobial infections involving both aerobic and anaerobic bacteria are characteristic.
. D. Fungal pathogens are the most common cause of delayed presentation infections.
. E. Viral coinfection, such as Herpes simplex, is a frequent finding and requires specific antiviral therapy.

Correct Answer & Explanation

. C. Polymicrobial infections involving both aerobic and anaerobic bacteria are characteristic.

Explanation

Correct Answer: CThe correct answer is C because human bite infections, including 'fight bites,' are characteristically polymicrobial, involving a complex mixture of aerobic and anaerobic bacteria from the oral flora. Common aerobes include Staphylococcus aureus (which can be MRSA), Streptococcus species, and Corynebacterium. Key anaerobes include Bacteroides, Fusobacterium, and Peptostreptococcus. Eikenella corrodens, a fastidious Gram-negative rod, is a hallmark pathogen of human bite wounds and is found in over 25% of infections, even in immunocompetent individuals. Monomicrobial S. aureus (A) is inaccurate. Eikenella is not rare (B). Fungal (D) and viral (E) infections are uncommon in the acute setting of a fight bite.

Question 23

Topic: Hand Trauma & Infection

A patient with an untreated fight bite develops progressive swelling and severe pain out of proportion over the palmar aspect of the affected finger, extending to the proximal palm. Which of the following physical signs indicates a pyogenic flexor tenosynovitis?

. Pain with active flexion only
. Tenderness isolated to the metacarpal head
. Pain with passive extension of the digit
. Erythema confined to the dorsal web space
. A palpable thrill over the flexor tendon

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Pain with passive extension is one of Kanavel's four cardinal signs of pyogenic flexor tenosynovitis. The others are fusiform swelling, flexed resting posture, and tenderness along the flexor tendon sheath.

Question 24

Topic: Hand Trauma & Infection

A 25-year-old male sustains a "fight bite" over the 3rd metacarpophalangeal (MCP) joint. He presents 12 hours post-injury with early signs of infection. If surgical washout is not immediately indicated for joint penetration, what is the most appropriate empiric oral antibiotic therapy?

. Cephalexin
. Clindamycin
. Amoxicillin-clavulanate
. Ciprofloxacin
. Doxycycline

Correct Answer & Explanation

. Amoxicillin-clavulanate

Explanation

Amoxicillin-clavulanate provides excellent coverage for Eikenella corrodens, Staphylococcus, and Streptococcus species typical of human bites. Eikenella is classically resistant to first-generation cephalosporins and clindamycin.

Question 25

Topic: Hand Trauma & Infection

A patient presents with a swollen, painful index finger 3 days after a minor puncture wound. Of Kanavel's four cardinal signs of flexor tenosynovitis, which is typically considered the earliest and most sensitive finding?

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

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Pain with passive extension of the digit is generally considered the earliest and most sensitive sign of infectious pyogenic flexor tenosynovitis. It effectively stretches the inflamed tendon sheath, eliciting immediate, disproportionate pain.

Question 26

Topic: Hand Trauma & Infection
A patient with a human bite wound over the third metacarpophalangeal joint grows a fastidious Gram-negative rod that forms 'pit' colonies on agar. Which of the following antibiotics is this organism predictably resistant to?
. Amoxicillin-clavulanate
. Ampicillin
. Clindamycin
. Cefoxitin
. Trimethoprim-sulfamethoxazole

Correct Answer & Explanation

. Amoxicillin-clavulanate

Explanation

Eikenella corrodens is a common pathogen in human 'fight bite' injuries. It is classically susceptible to penicillin and amoxicillin but notoriously resistant to clindamycin and first-generation cephalosporins.

Question 27

Topic: Hand Trauma & Infection

A 35-year-old male presents with a severely infected third metacarpophalangeal (MCP) joint four days after a bar altercation where he punched another patron in the mouth. Intraoperative cultures grow Eikenella corrodens. Which of the following best describes the antibiotic susceptibility and microbiological profile of this organism?

. It is an anaerobic Gram-positive bacillus highly susceptible to clindamycin.
. It is a fastidious Gram-negative rod typically resistant to first-generation cephalosporins but susceptible to amoxicillin-clavulanate.
. It is a coagulase-negative staphylococcus requiring treatment with intravenous vancomycin.
. It is an aerobic Gram-negative coccus that is universally susceptible to simple penicillin but resistant to fluoroquinolones.
. It is a spore-forming rod that requires hyperbaric oxygen therapy and high-dose penicillin.

Correct Answer & Explanation

. It is a fastidious Gram-negative rod typically resistant to first-generation cephalosporins but susceptible to amoxicillin-clavulanate.

Explanation

Eikenella corrodens is a fastidious Gram-negative bacillus frequently isolated from clenched-fist 'fight bite' injuries. It is classically resistant to first-generation cephalosporins and clindamycin, but demonstrates excellent susceptibility to amoxicillin-clavulanate and penicillin.

Question 28

Topic: Hand Trauma & Infection

A patient presents with a swollen, erythematous index finger 3 days after a puncture wound. Which of Kanavel's cardinal signs of flexor tenosynovitis is generally considered the most sensitive and earliest finding?

. Fusiform swelling of the digit
. Pain with passive extension of the digit
. Flexed resting posture of the digit
. Tenderness along the flexor tendon sheath
. Erythema tracking up the forearm

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Pain with passive extension of the digit is typically the earliest and most sensitive of Kanavel's four cardinal signs for purulent flexor tenosynovitis.

Question 29

Topic: Hand Trauma & Infection

A 28-year-old woman injured her thumb while skiing, resulting in a "Gamekeeper's thumb" (ulnar collateral ligament tear). Physical exam reveals an endpoint on valgus stress in extension, but no endpoint with 30 degrees of flexion, and a palpable mass at the ulnar base of the thumb MCP. What anatomical structure is blocking healing of the ligament, necessitating surgical repair?

. Extensor pollicis longus tendon
. Adductor pollicis aponeurosis
. Abductor pollicis brevis tendon
. Flexor pollicis brevis tendon
. Volar plate

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the torn ends of the ulnar collateral ligament of the thumb are separated by the adductor pollicis aponeurosis. This interposition prevents primary healing and is an absolute indication for surgical repair.

Question 30

Topic: Hand Trauma & Infection

A 45-year-old diabetic female presents with a 2-day history of right index finger pain and swelling. Which of the following is NOT one of Kanavel's four cardinal signs of flexor tenosynovitis?

. Fusiform swelling of the entire digit
. Severe pain with passive extension of the digit
. Erythema extending proximal to the wrist crease
. Tenderness along the course of the flexor tendon sheath
. The digit held in a flexed resting posture

Correct Answer & Explanation

. Erythema extending proximal to the wrist crease

Explanation

Kanavel's four signs include fusiform swelling, pain on passive extension, flexed resting posture, and tenderness along the flexor sheath. Erythema extending proximal to the wrist is not a cardinal sign, though it may indicate tracking infection.

Question 31

Topic: Hand Trauma & Infection

A patient presents with a thumb injury after a skiing accident. Examination reveals gross instability with valgus stress at the thumb MCP joint. An MRI confirms a complete rupture of the ulnar collateral ligament (UCL) with the torn edge displaced superficial to an aponeurosis. Which structure prevents anatomic healing in this Stener lesion?

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

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the completely torn distal end of the UCL displaces superficial to the adductor pollicis aponeurosis. This aponeurosis interposes between the torn ligament and its insertion, preventing conservative healing and necessitating surgical repair.

Question 32

Topic: Hand Trauma & Infection

A 28-year-old skier presents with a painful, swollen thumb after falling on an outstretched hand with the pole in his palm. MRI confirms a complete rupture of the ulnar collateral ligament (UCL) of the thumb MCP joint with a Stener lesion. What anatomical structure is interposed in a Stener lesion?

. Abductor pollicis brevis tendon
. Extensor pollicis longus tendon
. Adductor pollicis aponeurosis
. Flexor pollicis brevis aponeurosis
. Volar plate

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the torn proximal end of the ulnar collateral ligament displaces superficial to the adductor pollicis aponeurosis. This interposition prevents spontaneous healing and necessitates surgical repair.

Question 33

Topic: Hand Trauma & Infection

A 42-year-old diabetic patient presents with a swollen, acutely painful index finger. Which of the following is considered the most reliable, earliest, and most sensitive Kanavel sign for diagnosing purulent flexor tenosynovitis?

. A flexed resting posture of the digit
. Fusiform swelling of the entire digit
. Tenderness strictly along the flexor tendon sheath
. Severe pain with passive extension of the digit
. Erythema extending onto the volar pad

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

While all four Kanavel signs indicate purulent flexor tenosynovitis, pain with passive extension is recognized as the earliest and most sensitive sign. The inflammation of the sheath causes exquisite pain when the tendon is stretched by passive finger extension.

Question 34

Topic: Hand Trauma & Infection

A 42-year-old carpenter presents with a swollen, painful index finger 3 days after sustaining a puncture wound. Examination reveals a fusiform swollen digit that is held in slight flexion. What is considered the earliest and most sensitive Kanavel sign for pyogenic flexor tenosynovitis?

. Fusiform swelling of the digit
. Tenderness along the flexor tendon sheath
. Pain with passive extension of the digit
. Flexed resting posture of the digit
. Erythema extending to the palm

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Pain with passive extension is considered the earliest and most sensitive of the four Kanavel signs for pyogenic flexor tenosynovitis. The other signs include fusiform swelling, flexed resting posture, and tenderness along the tendon sheath.

Question 35

Topic: Hand Trauma & Infection

A 42-year-old carpenter sustains a puncture wound to his index finger. Two days later, he presents with the finger held in slight flexion, symmetric fusiform swelling of the digit, tenderness along the entire flexor tendon sheath, and severe pain with passive extension. Which of the following is the most appropriate immediate management?

. Splinting, oral antibiotics, and follow-up in 48 hours
. Intravenous antibiotics and close observation for 24 hours before considering surgery
. Emergent open irrigation and debridement of the flexor tendon sheath
. Local corticosteroid injection and early active motion
. Amputation of the affected digit

Correct Answer & Explanation

. Emergent open irrigation and debridement of the flexor tendon sheath

Explanation

The patient exhibits all four of Kanavel's cardinal signs of acute pyogenic flexor tenosynovitis. This is a surgical emergency requiring immediate irrigation and debridement of the flexor tendon sheath to prevent tendon necrosis and loss of digit function.

Question 36

Topic: Hand Trauma & Infection

A 30-year-old carpenter presents with a swollen, erythematous, and exquisitely tender index finger 3 days after sustaining a minor puncture wound. Which of the following Kanavel signs is considered the most sensitive and earliest indicator of pyogenic flexor tenosynovitis?

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

Correct Answer & Explanation

. Severe pain on passive extension of the digit

Explanation

Kanavel signs are used to diagnose pyogenic flexor tenosynovitis. Pain on passive extension of the affected digit is generally considered the most sensitive and earliest presenting clinical sign.

Question 37

Topic: Hand Trauma & Infection

A 35-year-old right-hand dominant male presents with acute right thumb pain and instability after a skiing accident. He fell while gripping a ski pole, which forced his thumb into violent abduction and hyperextension. He reported an immediate 'pop' and profound weakness in pinch grip. Which of the following statements best describes the biomechanical sequence of ligamentous failure in this classic injury pattern?

. A. The proper ulnar collateral ligament fails first in extension, followed by the accessory ulnar collateral ligament in flexion.
. B. The volar plate is the primary restraint in both extension and flexion, failing before the ulnar collateral ligament components.
. C. The accessory ulnar collateral ligament and volar plate bear initial stress in extension, with the proper ulnar collateral ligament failing as the joint is forced into flexion and abduction.
. D. The adductor pollicis aponeurosis ruptures first, leading to secondary failure of the ulnar collateral ligament.
. E. The radial collateral ligament is primarily affected due to the abduction force, with secondary involvement of the ulnar collateral ligament.

Correct Answer & Explanation

. C. The accessory ulnar collateral ligament and volar plate bear initial stress in extension, with the proper ulnar collateral ligament failing as the joint is forced into flexion and abduction.

Explanation

Correct Answer: CThe case explicitly states, 'When the metacarpophalangeal joint is in extension during the traumatic event, the accessory ulnar collateral ligament and volar plate bear the initial stress. However, as the joint is forced into flexion and abduction, the proper ulnar collateral ligament becomes the primary restraint and subsequently fails.' This accurately describes the sequential failure of the ulnar collateral ligament complex in a Skier's Thumb injury.Option A is incorrectbecause the proper UCL is the primary restraint in flexion, not extension, and the accessory UCL bears initial stress in extension.Option B is incorrectbecause while the volar plate contributes to stability in extension, it is not the primary restraint in both positions, nor does it typically fail before the entire UCL complex in this specific mechanism.Option D is incorrectbecause the adductor pollicis aponeurosis is a muscular aponeurosis, not a primary ligamentous restraint, and its interposition (Stener lesion) occurs after the UCL rupture, not as a primary failure leading to it.Option E is incorrectbecause a forced abduction injury primarily stresses the ulnar collateral ligament, not the radial collateral ligament, which resists varus forces.

Question 38

Topic: Hand Trauma & Infection

The case highlights the importance of specific techniques during valgus stress testing of the thumb metacarpophalangeal joint. Which of the following statements represents a critical 'pearl' for accurate assessment of ulnar collateral ligament integrity?

. A. Stress testing should always be performed in full extension first, as this is the most sensitive position for detecting UCL injury.
. B. Stress radiography is mandatory to objectively quantify laxity and should be performed before clinical stress testing.
. C. A local intra-articular anesthetic block is essential to overcome muscle guarding and allow for reliable assessment of laxity.
. D. Palpation for a Stener lesion should only be performed after stress testing to avoid causing discomfort.
. E. The interphalangeal joint should be immobilized during stress testing to prevent confounding motion.

Correct Answer & Explanation

. C. A local intra-articular anesthetic block is essential to overcome muscle guarding and allow for reliable assessment of laxity.

Explanation

Correct Answer: CThe case explicitly states under 'Clinical Pearls and Pitfalls': 'Local Anesthesia is Mandatory: Attempting to grade laxity in an acutely injured, unanesthetized thumb is highly unreliable due to involuntary muscle guarding by the adductor pollicis. A local intra-articular or digital block is essential for an accurate physical examination.' This is a crucial step for accurate diagnosis.Option A is incorrectbecause while testing in extension is part of the assessment, the '30-Degree Flexion Rule' is critical for isolating the proper UCL, which is often the primary injury. Testing only in extension may yield a false negative if the volar plate and accessory ligament are intact.Option B is incorrectbecause the case states, 'in the modern clinical setting, stress radiography is largely contraindicated when a Stener lesion is suspected clinically' due to the risk of iatrogenic Stener lesion formation or conversion of a partial to a complete tear.Option D is incorrectbecause the case advises, 'Palpation Precedes Stress: Always palpate the ulnar joint line for a Stener lesion before applying valgus stress. Forceful stress testing of a non-displaced complete tear can iatrogenically displace the ligament superficial to the aponeurosis, converting a potentially non-operative injury into an operative one.'Option E is incorrectbecause the interphalangeal joint's motion does not significantly confound MCP joint stress testing, and its immobilization is not a standard or critical step for this specific assessment.

Question 39

Topic: Hand Trauma & Infection

Given the patient's clinical presentation and MRI findings, which of the following is the most appropriate management strategy?

. A. Rigid immobilization in a thumb spica cast for 6 weeks, followed by gradual rehabilitation.
. B. Immediate referral for a second opinion to confirm the diagnosis before any intervention.
. C. Open surgical repair of the ulnar collateral ligament with suture anchor fixation.
. D. Percutaneous pinning of the metacarpophalangeal joint to stabilize the joint.
. E. Corticosteroid injection into the metacarpophalangeal joint to reduce pain and inflammation.

Correct Answer & Explanation

. C. Open surgical repair of the ulnar collateral ligament with suture anchor fixation.

Explanation

Correct Answer: CThe case clearly states, 'In this patient's case, the clinical examination demonstrating gross valgus instability lacking a firm endpoint, combined with the palpable mass and definitive MRI evidence of a Stener lesion, served as absolute indications for operative intervention.' The Stener lesion creates a mechanical barrier to healing, making non-operative management futile. Open surgical repair with suture anchor fixation is the standard of care for acute, complete UCL ruptures with a Stener lesion.Option A is incorrectbecause non-operative management is strictly reserved for partial tears or non-displaced bony avulsions, not for complete ruptures with a Stener lesion where spontaneous healing is impossible.Option B is incorrectbecause the diagnosis is highly probable clinically and definitively confirmed by MRI, making a second opinion for diagnosis unnecessary and delaying definitive treatment.Option D is incorrectbecause percutaneous pinning is typically used for fractures or dislocations requiring temporary stabilization, not for direct ligamentous repair in the presence of a Stener lesion which requires open reduction.Option E is incorrectbecause corticosteroid injections are contraindicated in acute ligamentous injuries, especially ruptures, as they can impair healing and increase the risk of further damage. They are also not a definitive treatment for mechanical instability.

Question 40

Topic: Hand Trauma & Infection

A 62-year-old farmer presents with chronic instability and pain in his right thumb MCP joint, sustained from an injury 10 years ago. He has a positive pinch grip test with significant weakness. Radiographs demonstrate severe joint space narrowing, subchondral sclerosis, and osteophyte formation at the MCP joint. What is the most appropriate surgical treatment?

. Primary repair of the UCL with a suture anchor
. Reconstruction of the UCL using a palmaris longus autograft
. Adductor advancement (Eaton-Littler technique)
. Metacarpophalangeal (MCP) joint arthrodesis
. Trapeziometacarpal joint arthroplasty

Correct Answer & Explanation

. Metacarpophalangeal (MCP) joint arthrodesis

Explanation

In cases of chronic UCL insufficiency (Gamekeeper's thumb) accompanied by significant osteoarthritis of the MCP joint, soft tissue reconstruction will fail to address the arthritic pain. MCP joint arthrodesis provides a stable, pain-free pinch.

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