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Hand Trauma & Infection MCQs

Practice Set 4 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 61

Topic: Hand Trauma & Infection

A 19-year-old college student presents with a 24-hour history of localized erythema, mild swelling, and tenderness along the lateral nail fold of his right ring finger after aggressively picking a hangnail. There is no visible pustule or fluctuance. He denies fever or chills. What is the most appropriate initial management for this patient?

. A. Immediate incision and drainage of the lateral nail fold
. B. Urgent referral for MRI to assess for deep space infection
. C. Warm soaks, elevation, and oral antibiotics targeting Staphylococcus aureus
. D. Complete nail avulsion to prevent subungual abscess formation
. E. Observation only, as it is likely to resolve spontaneously

Correct Answer & Explanation

. C. Warm soaks, elevation, and oral antibiotics targeting Staphylococcus aureus

Explanation

Correct Answer: CThis patient presents with early cellulitis without evidence of abscess formation (no fluctuance or visible pustule) and no signs of systemic involvement. In such mild, early presentations of acute paronychia, non-operative management is indicated. This includes warm soaks (to promote drainage and reduce inflammation), elevation (to reduce swelling), and empiric oral antibiotics, typically targeting common skin flora likeStaphylococcus aureus(e.g., cephalexin or clindamycin).Incorrect Options:A. Immediate incision and drainage of the lateral nail fold:I&D is indicated for abscess formation. Performing an I&D on pure cellulitis is unnecessary and potentially harmful, creating an open wound without pus to drain.B. Urgent referral for MRI to assess for deep space infection:MRI is a high-level imaging study reserved for complex or chronic cases with suspicion of deeper infection. It is not indicated for early, uncomplicated cellulitis.D. Complete nail avulsion to prevent subungual abscess formation:Nail avulsion is a surgical procedure for subungual abscesses or severe nail dystrophy. It is an overly aggressive and inappropriate intervention for early cellulitis.E. Observation only, as it is likely to resolve spontaneously:While some very mild cases might resolve, given the bacterial etiology and potential for progression, active management with warm soaks and antibiotics is prudent to prevent abscess formation or spread of infection.

Question 62

Topic: Hand Trauma & Infection

A 50-year-old patient underwent incision and drainage for a severe, neglected acute paronychia that had tracked proximally and distally, requiring partial nail avulsion and extensive debridement. Six months post-operatively, the patient complains of persistent pain and significant deformity of the new nail plate, which is thickened, discolored, and ridged. This complication is most likely due to iatrogenic injury to which of the following structures during the initial surgery?

. A. Proper digital artery
. B. Dorsal digital nerve
. C. Flexor digitorum profundus tendon
. D. Nail matrix (germinal matrix)
. E. Hyponychium

Correct Answer & Explanation

. D. Nail matrix (germinal matrix)

Explanation

Correct Answer: DThe nail matrix, specifically the germinal matrix, is responsible for producing 90% of the nail plate. Injury to the nail matrix during surgical intervention (e.g., aggressive debridement, improper incisions, or trauma during nail avulsion) can lead to permanent onychodystrophy, characterized by a deformed, thickened, discolored, or ridged nail plate. The description of the new nail plate's appearance directly points to damage to the nail-producing unit.Incorrect Options:A. Proper digital artery:Injury to the proper digital artery would lead to vascular compromise, potentially resulting in tissue necrosis or delayed healing, but not directly to nail plate deformity in this manner.B. Dorsal digital nerve:Injury to the dorsal digital nerve would result in sensory deficits (paresthesia, dysesthesia) in the nail unit area, not directly in nail plate deformity.C. Flexor digitorum profundus tendon:Injury to the flexor digitorum profundus tendon would result in loss of active DIP joint flexion and potential tendon rupture or adhesion, not nail plate deformity.E. Hyponychium:The hyponychium is the skin beneath the free edge of the nail. While important for sealing, its injury would not typically cause the described severe nail plate dystrophy, which originates from the matrix.

Question 63

Topic: Hand Trauma & Infection

A 45-year-old mechanic presents with an acutely swollen and painful index finger 3 days after a puncture wound. Which of the following is NOT one of Kanavel's four cardinal signs of pyogenic flexor tenosynovitis?

. Erythema extending to the palm
. Fusiform swelling of the entire digit
. Pain with passive extension of the digit
. Tenderness along the course of the flexor tendon sheath
. Digit held in a flexed resting posture

Correct Answer & Explanation

. Erythema extending to the palm

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are fusiform swelling, resting flexed posture, tenderness along the flexor sheath, and severe pain with passive extension. Erythema extending to the palm is not a cardinal sign, though cellulitis may be present concurrently.

Question 64

Topic: Hand Trauma & Infection

A 35-year-old woman presents to the emergency department with a painful, swollen right index finger 3 days after a puncture wound to the volar crease. On examination, the finger is held in slight flexion, there is fusiform swelling, and tenderness is exquisite along the volar aspect of the digit. Which of the following is considered the earliest and most sensitive clinical sign for this patient's suspected diagnosis?

. Fusiform swelling of the entire digit
. Resting posture of the digit in slight flexion
. Tenderness along the course of the flexor tendon sheath
. Severe pain with passive extension of the digit
. Erythema tracking proximally into the palm

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

The patient has purulent flexor tenosynovitis, characterized by Kanavel's four cardinal signs. Pain with passive extension is considered the earliest and most sensitive clinical sign.

Question 65

Topic: Hand Trauma & Infection

A 24-year-old male sustains a laceration over the dorsal aspect of his right 3rd metacarpophalangeal joint after striking another individual in the mouth. He presents 48 hours later with profound erythema, swelling, and purulent drainage. Which of the following organisms is the most characteristic pathogen in this specific injury mechanism and requires targeted antibiotic coverage?

. Pasteurella multocida
. Eikenella corrodens
. Staphylococcus aureus
. Streptococcus pyogenes
. Mycobacterium marinum

Correct Answer & Explanation

. Eikenella corrodens

Explanation

A 'fight bite' (human bite wound) over the MCP joint is classically associated with Eikenella corrodens, a Gram-negative facultative anaerobe. Initial empiric treatment requires antibiotics such as amoxicillin-clavulanate that cover this pathogen along with common skin flora.

Question 66

Topic: Hand Trauma & Infection

A 40-year-old carpenter undergoes incision and drainage of a felon on his right index finger. The surgeon utilizes a longitudinal volar incision. If the incision is mistakenly extended too far proximally past the distal interphalangeal (DIP) joint flexion crease, which of the following complications is most likely to occur?

. Necrosis of the eponychial fold
. Laceration of the terminal branches of the digital nerve
. Introduction of infection into the flexor tendon sheath
. Vascular compromise of the fingertip
. Violation of the germinal matrix

Correct Answer & Explanation

. Introduction of infection into the flexor tendon sheath

Explanation

Extending a volar incision for a felon too far proximally risks violating the distal extent of the flexor tendon sheath. This iatrogenic error can introduce the superficial infection into the sheath, causing purulent flexor tenosynovitis.

Question 67

Topic: Hand Trauma & Infection

A 35-year-old construction worker sustains a 'fight bite' over the dorsal aspect of his right 3rd metacarpophalangeal (MCP) joint. He presents 48 hours later with significant erythema, swelling, and purulent drainage. Which of the following organisms is a fastidious Gram-negative rod uniquely associated with this specific injury mechanism, and what is the optimal empiric oral antibiotic therapy?

. Pasteurella multocida; Amoxicillin-clavulanate
. Eikenella corrodens; Amoxicillin-clavulanate
. Staphylococcus aureus; Cephalexin
. Capnocytophaga canimorsus; Clindamycin
. Streptococcus pyogenes; Penicillin V

Correct Answer & Explanation

. Eikenella corrodens; Amoxicillin-clavulanate

Explanation

Eikenella corrodens is a fastidious Gram-negative rod uniquely associated with human bite wounds ('fight bites'). Amoxicillin-clavulanate is the empiric oral antibiotic of choice because Eikenella is characteristically resistant to first-generation cephalosporins and clindamycin.

Question 68

Topic: Hand Trauma & Infection

Which of the following clinical signs is considered the most sensitive and earliest indicator of acute pyogenic flexor tenosynovitis?

. Fusiform swelling of the entire digit
. Slightly flexed resting posture of the digit
. Tenderness along the course of the flexor tendon sheath
. Pain with passive extension of the digit
. Erythema extending to the palmar crease

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Of the four Kanavel signs, pain with passive extension is considered the earliest and most sensitive clinical indicator of acute pyogenic flexor tenosynovitis. It typically presents before the full development of fusiform swelling and resting flexion.

Question 69

Topic: Hand Trauma & Infection

A 30-year-old carpenter presents with a severe felon of the left index finger requiring incision and drainage. To minimize the risk of painful scarring and sensory loss on the primary pinch surfaces, what is the recommended location for a mid-axial longitudinal incision?

. The radial aspect of the index finger
. The ulnar aspect of the index finger
. The exact midline of the volar pad
. A transverse incision just distal to the DIP flexion crease
. A 'fish-mouth' incision extending around the entire fingertip

Correct Answer & Explanation

. The ulnar aspect of the index finger

Explanation

For felons, a mid-axial incision should avoid the primary pinch surfaces. The pinch surfaces are the ulnar side of the thumb, and the radial sides of the index, long, and ring fingers. Therefore, the ulnar aspect of the index finger is the correct approach.

Question 70

Topic: Hand Trauma & Infection

A 30-year-old nurse presents with painful, grouped vesicles on an erythematous base near the eponychium of her right index finger. She describes a burning and tingling prodrome before the vesicles appeared. A Tzanck smear is positive for multinucleated giant cells. Which of the following treatments is strictly contraindicated?

. Dry sterile dressing application
. Oral acyclovir therapy
. Incision and drainage
. Topical bacitracin ointment
. Observation alone

Correct Answer & Explanation

. Incision and drainage

Explanation

The patient has Herpetic Whitlow, caused by HSV. Incision and drainage is strictly contraindicated as it can lead to viral dissemination, bacterial superinfection, and failure to heal. Treatment is largely symptomatic with dry dressings; antivirals may be used if started early or in immunocompromised hosts.

Question 71

Topic: Hand Trauma & Infection

A 45-year-old diabetic male develops pyogenic flexor tenosynovitis in his left thumb following a minor penetrating injury. If left untreated, the infection is most likely to spread to the flexor sheath of the small finger to form a 'horseshoe abscess' through which of the following anatomic structures?

. Space of Poirier
. Parona's space
. Midpalmar space
. Thenar space
. Quadrangular space

Correct Answer & Explanation

. Parona's space

Explanation

Infections in the radial bursa (thumb flexor sheath) can communicate with the ulnar bursa (small finger flexor sheath) via Parona's space in approximately 80% of patients. Parona's space is a potential space located in the distal volar forearm between the pronator quadratus and the flexor digitorum profundus tendons.

Question 72

Topic: Hand Trauma & Infection

A 22-year-old male presents with a 3-mm puncture wound over his right 3rd metacarpophalangeal (MCP) joint after striking another person in the mouth. He exhibits pain with passive motion and localized swelling. Radiographs show no fracture. In addition to surgical irrigation and debridement, empiric antibiotic therapy MUST cover which of the following organisms characteristic of this injury?

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

Correct Answer & Explanation

. Eikenella corrodens

Explanation

This patient sustained a 'clenched fist injury' (fight bite), which inoculates the joint with human oral flora. Empiric antibiotics, such as amoxicillin-clavulanate, must specifically cover Eikenella corrodens, a gram-negative rod common in these infections.

Question 73

Topic: Hand Trauma & Infection

A 45-year-old diabetic patient presents with a swollen, painful index finger. Which of the following is NOT one of Kanavel's cardinal signs for pyogenic flexor tenosynovitis?

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

Correct Answer & Explanation

. Erythema extending proximally to the wrist crease

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are fusiform swelling, flexed resting posture, tenderness over the flexor sheath, and severe pain on passive extension. Erythema extending to the wrist is not a cardinal sign and may indicate a superficial cellulitis or ascending lymphangitis.

Question 74

Topic: Hand Trauma & Infection

A 36-year-old nurse has had redness, pain, and small vesicles on the pulp of her middle finger for the past 3 days. Management should consist of

. observation.
. marsupialization of the nail fold.
. application of copper sulfate.
. application of calcium gluconate.
. incision and drainage of the pulp.

Correct Answer & Explanation

. observation.

Explanation

DISCUSSION: Small vesicles on the fingers of a health care worker suggest a herpetic infection, and the management of choice is observation.  Incision and drainage may result in a bacterial infection.  Marsupialization is used in the treatment of a chronic paronychia.  Calcium gluconate is used for hydrofluoric acid burns, and copper sulfate is used for white phosphorus burns.REFERENCES: Fowler JR: Viral Infections.  Hand Clin 1989;5:613-627.Jebsen PL: Infections of the fingertip: Paronychias and felons.  Hand Clin 1998;14:547-555.

Question 75

Topic: Hand Trauma & Infection

A 35-year-old mechanic presents with an acutely swollen, painful ring finger 2 days after a puncture wound.

You suspect pyogenic flexor tenosynovitis. Which of the following physical examination findings is NOT one of Kanavel's four cardinal signs?

. The affected digit is held in a resting posture of slight flexion
. Uniform, fusiform swelling over the entire length of the digit
. Exquisite tenderness along the anatomical course of the flexor tendon sheath
. Severe pain elicited by active flexion of the digit against resistance
. Severe pain elicited by passive extension of the digit

Correct Answer & Explanation

. The affected digit is held in a resting posture of slight flexion

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are: 1) fusiform swelling of the digit, 2) finger held in resting slight flexion, 3) tenderness along the flexor tendon sheath, and 4) pain on passive extension. Pain with active flexion is not a Kanavel sign; patients generally refuse to actively move the digit.

Question 76

Topic: Hand Trauma & Infection
A 22-year-old male presents 3 days after striking an opponent in the mouth during a fistfight. He has a 1 cm laceration over the 3rd metacarpophalangeal joint with surrounding erythema and purulence. During formal surgical I&D, which of the following systemic antibiotic regimens is most appropriate to empirically cover the classic pathogen associated with this specific mechanism?
. Oral cephalexin
. Intravenous vancomycin
. Intravenous ampicillin-sulbactam
. Oral clindamycin
. Oral trimethoprim-sulfamethoxazole

Correct Answer & Explanation

. Intravenous ampicillin-sulbactam

Explanation

This is a 'fight bite' (clenched fist injury against human teeth). The classic associated pathogen is Eikenella corrodens, alongside other mixed flora. Ampicillin-sulbactam (IV) or amoxicillin-clavulanate (PO) are the empiric treatments of choice.

Question 77

Topic: Hand Trauma & Infection

A 35-year-old carpenter presents with a swollen, painful index finger 3 days after a puncture wound. The physician suspects acute pyogenic flexor tenosynovitis. According to Kanavel's cardinal signs, which of the following is typically the earliest and most sensitive clinical finding?

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

Correct Answer & Explanation

. Fusiform swelling of the entire digit

Explanation

Kanavel's four classic signs of acute pyogenic flexor tenosynovitis are: 1) flexed resting posture of the digit, 2) fusiform (sausage-like) swelling, 3) exquisite tenderness along the course of the flexor tendon sheath, and 4) severe pain elicited by passive extension. Pain with passive extension is typically the earliest, most reliable, and most sensitive clinical sign of infection within the tendon sheath.

Question 78

Topic: Hand Trauma & Infection

A 28-year-old carpenter presents with a swollen, painful index finger 3 days after a splinter injury. On examination, the finger is held in slight flexion. Which of Kanavel's four cardinal signs is considered the earliest and most sensitive indicator of pyogenic flexor tenosynovitis?

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

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Pain out of proportion with passive extension is classically described as the earliest and most sensitive of Kanavel's four signs for pyogenic flexor tenosynovitis.

Question 79

Topic: Hand Trauma & Infection

Among Kanavel's four cardinal signs of flexor tenosynovitis, which is generally considered the most reliable, earliest, and most sensitive indicator of the condition?

. Fusiform swelling of the digit
. Flexed resting posture of the digit
. Tenderness along the flexor tendon sheath
. Pain with passive extension of the digit
. Erythema tracking proximally into 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 Kanavel's signs for pyogenic flexor tenosynovitis. The other signs include fusiform swelling, flexed resting posture, and tenderness along the sheath.

Question 80

Topic: Hand Trauma & Infection

A 30-year-old male presents with a deep, purulent laceration over the third metacarpophalangeal joint after striking another individual in the mouth ('fight bite'). Which fastidious gram-negative rod is characteristically associated with human bite wounds and must be covered by the chosen empiric antibiotic regimen?

. Pasteurella multocida
. Eikenella corrodens
. Bartonella henselae
. Capnocytophaga canimorsus
. Mycobacterium marinum

Correct Answer & Explanation

. Eikenella corrodens

Explanation

Eikenella corrodens is a fastidious gram-negative facultative anaerobe that is part of normal human oral flora. It is a classic pathogen in clenched-fist injuries (fight bites) and human bite wounds. Empiric therapy typically involves amoxicillin-clavulanate. Pasteurella and Capnocytophaga are seen in dog/cat bites, Bartonella in cat scratch disease, and M. marinum in aquatic exposures.

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