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Hand Trauma & Infection MCQs

Practice Set 6 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 101

Topic: Hand Trauma & Infection

In the evaluation of a patient with suspected pyogenic flexor tenosynovitis, which of Kanavel's four cardinal signs is generally considered the most sensitive and presents earliest in the course of the infection?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Tenderness along the entire course of the flexor tendon sheath
. Severe pain with passive extension of the digit
. Erythema confined to the volar aspect of the finger

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Kanavel's signs for suppurative flexor tenosynovitis include: 1) flexed resting posture, 2) fusiform (sausage) swelling, 3) tenderness along the flexor sheath, and 4) pain with passive extension. Pain with passive extension is typically the earliest, most sensitive, and most clinically significant sign to manifest.

Question 102

Topic: Hand Trauma & Infection

In the evaluation of a patient with suspected pyogenic flexor tenosynovitis, which of Kanavel's four classic signs is generally considered the earliest and most sensitive indicator of the condition?

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

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Kanavel's four signs of pyogenic flexor tenosynovitis are: 1) fusiform swelling (sausage digit), 2) flexed resting posture, 3) tenderness along the flexor tendon sheath, and 4) excruciating pain with passive extension. Pain with passive extension is widely recognized as the earliest and most sensitive clinical sign of a flexor sheath infection.

Question 103

Topic: Hand Trauma & Infection

A 30-year-old mechanic presents with a swollen, painful index finger 3 days after a minor puncture wound to the volar aspect of his hand. You suspect pyogenic flexor tenosynovitis. Which of Kanavel's four cardinal signs is generally considered the most sensitive and often the earliest finding in this condition?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Tenderness isolated to the volar pulp
. Pain with passive extension of the digit
. Erythema extending along the flexor sheath

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are: 1) Fusiform swelling of the digit, 2) Flexed resting posture, 3) Tenderness along the entire course of the flexor tendon sheath, and 4) Pain with passive extension. Pain with passive extension is considered the most sensitive and earliest sign of infectious flexor tenosynovitis.

Question 104

Topic: Hand Trauma & Infection

A 32-year-old mechanic presents with an infected index finger after a puncture wound. You suspect pyogenic flexor tenosynovitis. Which of the following is NOT one of Kanavel's four cardinal signs of flexor tenosynovitis?

. Flexed resting posture of the digit
. Fusiform (sausage-like) swelling of the digit
. Severe pain with active flexion of the digit
. Tenderness along the course of the flexor tendon sheath
. Pain with passive extension of the digit

Correct Answer & Explanation

. Severe pain with active flexion of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: 1) Flexed resting posture of the digit, 2) Fusiform swelling of the digit, 3) Tenderness along the flexor tendon sheath, and 4) Pain with passive extension of the digit (often the earliest and most sensitive sign). Pain with active flexion is not considered one of the specific cardinal signs.

Question 105

Topic: Hand Trauma & Infection
A 42-year-old man presents with a painful, swollen right index finger 3 days after a puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of purulent flexor tenosynovitis?
. Fusiform swelling of the entire digit
. Pain on active extension of the digit
. Flexed resting posture of the digit
. Exquisite tenderness along the flexor tendon sheath
. Pain on passive extension of the digit

Correct Answer & Explanation

. Pain on active extension of the digit

Explanation

Kanavel's four cardinal signs of purulent flexor tenosynovitis are: 1) fusiform (sausage) swelling of the digit, 2) flexed resting posture, 3) exquisite tenderness along the course of the flexor tendon sheath, and 4) pain with PASSIVE extension. Pain on active extension is not a classical sign.

Question 106

Topic: Hand Trauma & Infection

A 21-year-old skier falls while holding a ski pole, sustaining an acute thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) tear. Ultrasound reveals a Stener lesion. Which anatomical structure interposes between the torn ends of the UCL, preventing conservative healing?

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

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the torn distal end of the UCL displaces superficial to the adductor pollicis aponeurosis. This interposition prevents the ligament ends from healing naturally, necessitating surgical repair.

Question 107

Topic: Hand Trauma & Infection

A 35-year-old man presents with a puncture wound on the volar aspect of his index finger. Examination reveals a finger held in slight flexion, fusiform swelling, tenderness along the flexor tendon sheath, and severe pain with passive extension. What is the most appropriate next step in management?

. Intravenous antibiotics and splinting
. Corticosteroid injection into the flexor sheath
. MRI of the hand with contrast
. Surgical incision, drainage, and intravenous antibiotics
. Oral antibiotics and outpatient follow-up

Correct Answer & Explanation

. Surgical incision, drainage, and intravenous antibiotics

Explanation

The patient exhibits Kanavel's four cardinal signs, highly indicative of purulent flexor tenosynovitis. This is an orthopedic emergency requiring immediate surgical incision, drainage, and broad-spectrum intravenous antibiotics to prevent tendon necrosis.

Question 108

Topic: Hand Trauma & Infection
A 35-year-old carpenter presents with a swollen, painful index finger 2 days after a puncture wound. Examination reveals severe pain with passive extension, flexed resting posture, and tenderness along the flexor sheath. He is taken to the OR, where the flexor tendon appears frankly necrotic. What is the most appropriate intraoperative step?
. Closed tendon sheath irrigation with continuous saline
. Primary tendon repair and skin closure
. Extensive debridement of the necrotic tendon and placement of a silicone tendon spacer
. Intravenous antibiotics and re-evaluation in 48 hours
. Amputation of the digit at the metacarpophalangeal joint

Correct Answer & Explanation

. Extensive debridement of the necrotic tendon and placement of a silicone tendon spacer

Explanation

In cases of severe pyogenic flexor tenosynovitis with gross tendon necrosis (Michon stage III), the necrotic tendon must be excised to eradicate the infection. Placement of a silicone tendon spacer preserves the retinacular system to facilitate a staged flexor tendon reconstruction once the infection resolves.

Question 109

Topic: Hand Trauma & Infection

A 28-year-old carpenter presents with acute finger pain, swelling, and a flexed posture of the index finger 48 hours after a penetrating injury. Which of the following is NOT one of Kanavel's cardinal signs of acute suppurative flexor tenosynovitis?

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

Correct Answer & Explanation

. Erythema extending proximal to the metacarpophalangeal joint

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are fusiform swelling, flexed resting posture, tenderness along the flexor sheath, and pain on passive extension. Erythema extending proximally is not one of these specific signs, though it may indicate tracking cellulitis.

Question 110

Topic: Hand Trauma & Infection

A gardener presents with an acutely painful, swollen, and red index finger. He describes a puncture wound from a thorn 3 days prior. The finger is held in slight flexion, and any attempt at passive extension causes severe pain. There is tenderness along the entire course of the flexor tendon sheath. What is the MOST likely diagnosis?

. Cellulitis
. Felon
. Paronychia
. Septic arthritis
. Suppurative flexor tenosynovitis (SFT)

Correct Answer & Explanation

. Cellulitis

Explanation

The patient's presentation precisely describes Kanavel's Four Cardinal Signs of Suppurative Flexor Tenosynovitis (SFT): 1) Uniform swelling of the digit, 2) Flexed posture of the digit, 3) Exquisite tenderness along the course of the flexor tendon sheath, and 4) Severe pain on passive extension. SFT is a surgical emergency requiring urgent incision and drainage to prevent tendon necrosis and irreversible stiffness. Cellulitis is a diffuse infection without the specific tendon sheath involvement. A felon is a pulp space infection. Paronychia is a nail fold infection. Septic arthritis affects the joint, not primarily the tendon sheath, although it can coexist.

Question 111

Topic: Hand Trauma & Infection

A 28-year-old skier falls, landing on his outstretched thumb. He presents with pain and swelling at the ulnar aspect of the thumb metacarpophalangeal (MCP) joint. Examination reveals significant instability (greater than 30-35 degrees of valgus laxity compared to the contralateral side) with a positive stress test, even with the MCP joint in 30 degrees of flexion. Palpation reveals a soft tissue mass at the ulnar base of the thumb. What is the MOST likely diagnosis and treatment?

. Thumb MCP joint sprain; Thumb spica splint
. Gamekeeper's thumb with a Stener lesion; Surgical repair of the UCL
. Thumb carpometacarpal (CMC) joint dislocation; Closed reduction
. Thumb extensor tendon rupture; Extensor tendon repair
. Thumb collateral ligament calcification; NSAIDs and rest

Correct Answer & Explanation

. Thumb MCP joint sprain; Thumb spica splint

Explanation

The patient's history (skiing fall, valgus stress to thumb), examination findings (pain, swelling, significant valgus laxity at the MCP joint, soft tissue mass consistent with a displaced UCL), and mechanism are classic for a Gamekeeper's thumb (acute rupture of the ulnar collateral ligament, UCL) with a Stener lesion. A Stener lesion occurs when the avulsed distal end of the UCL displaces superficial to the adductor aponeurosis, preventing healing with conservative treatment. Surgical repair of the UCL is indicated for Stener lesions or acute complete ruptures with significant instability to restore stability and function. Conservative management with splinting is only appropriate for partial tears or stable complete tears without a Stener lesion. CMC joint dislocation is at the base of the thumb. Extensor tendon rupture would involve active extension loss. Collateral ligament calcification is chronic.

Question 112

Topic: Hand Trauma & Infection

A 55-year-old male presents with acute, severe pain and swelling in the small finger. He reports injecting a small amount of an illicit substance into the finger 24 hours prior. Examination reveals intense erythema, warmth, and tenderness, with exquisite pain on passive extension of the finger. He has a fever and elevated inflammatory markers. What is the MOST appropriate immediate management?

. Oral antibiotics and wound care
. Intravenous antibiotics and observation
. Incision and drainage of the flexor tendon sheath
. Splinting and rest
. Needle aspiration of the infection

Correct Answer & Explanation

. Oral antibiotics and wound care

Explanation

This patient presents with classic signs of acute suppurative flexor tenosynovitis (Kanavel's signs: uniform swelling, flexed posture, tenderness along tendon sheath, pain on passive extension), likely exacerbated by illicit substance injection, which introduces virulent bacteria directly into the sheath. This is a surgical emergency that requires immediate incision and drainage of the flexor tendon sheath to prevent tendon necrosis, rupture, and spread of infection. Intravenous antibiotics are crucial but are adjunctive to surgical decompression. Oral antibiotics, observation, splinting, or needle aspiration are insufficient and can lead to devastating consequences, including amputation. Early surgical intervention is paramount.

Question 113

Topic: Hand Trauma & Infection

A 35-year-old mechanic presents to the emergency department complaining of a severely swollen, throbbing index finger 3 days after sustaining a minor puncture wound with a wire.

You suspect pyogenic flexor tenosynovitis. According to Kanavel's criteria, which of the following is considered the earliest and most sensitive clinical sign of this condition?

. Flexed resting posture of the digit
. Fusiform swelling of the entire 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

. Flexed resting posture of the digit

Explanation

Kanavel's four cardinal signs for pyogenic flexor tenosynovitis are: 1) fusiform swelling of the digit, 2) flexed resting posture, 3) tenderness along the flexor tendon sheath, and 4) disproportionate pain with passive extension. Among these, pain with passive extension of the digit is consistently recognized as the earliest and most sensitive clinical sign for diagnosing pyogenic flexor tenosynovitis.

Question 114

Topic: Hand Trauma & Infection

A 28-year-old skier presents with acute thumb pain and weakness of pinch after a fall with the thumb forcefully abducted. Clinical examination shows significant laxity of the thumb metacarpophalangeal (MCP) joint to valgus stress. MRI reveals a complete rupture of the ulnar collateral ligament (UCL), and the torn distal end of the ligament is displaced superficial to the adductor aponeurosis. What is the most appropriate management?

. Thumb spica cast for 6 weeks
. Figure-of-eight splint for 4 weeks
. Corticosteroid injection and physical therapy
. Surgical repair of the UCL
. MCP joint arthrodesis

Correct Answer & Explanation

. Thumb spica cast for 6 weeks

Explanation

The patient's MRI demonstrates a Stener lesion, which occurs when a completely avulsed ulnar collateral ligament (UCL) of the thumb MCP joint becomes displaced and trapped superficial to the adductor pollicis aponeurosis. This mechanical block prevents the torn ligament ends from apposing and healing. Therefore, conservative treatment is ineffective, and surgical repair is the definitive standard of care.

Question 115

Topic: Hand Trauma & Infection

A 28-year-old avid skier catches his thumb in a ski pole strap, sustaining a severe hyperabduction injury to the metacarpophalangeal (MCP) joint of the thumb. Physical examination reveals gross instability to valgus stress. Which of the following anatomical findings defines a Stener lesion, an absolute indication for operative repair?

. Interposition of the extensor pollicis brevis tendon between the torn UCL and its insertion
. Interposition of the adductor pollicis aponeurosis between the torn UCL and its insertion
. Interposition of the abductor pollicis longus tendon between the torn UCL and its insertion
. An avulsion fracture of the base of the proximal phalanx with greater than 2 mm of displacement
. Complete rupture of the radial collateral ligament associated with a UCL tear

Correct Answer & Explanation

. Interposition of the extensor pollicis brevis tendon between the torn UCL and its insertion

Explanation

A Stener lesion occurs when the ulnar collateral ligament (UCL) of the thumb MCP joint completely ruptures (usually from its distal insertion on the proximal phalanx) and the proximal stump of the torn ligament displaces superficial to the adductor pollicis aponeurosis. Consequently, the aponeurosis becomes interposed between the torn UCL and its anatomical insertion site. Because the ligament is physically blocked from reaching its insertion, natural healing is prevented, making a Stener lesion a definitive indication for surgical repair of the UCL (Gamekeeper's or Skier's thumb).

Question 116

Topic: Hand Trauma & Infection

A 30-year-old mechanic presents with a swollen, painful index finger 3 days after sustaining a minor puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of pyogenic flexor tenosynovitis?

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

Correct Answer & Explanation

. Fusiform swelling of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: 1) fusiform (sausage-like) swelling of the entire digit, 2) resting flexed posture of the digit, 3) exquisite tenderness along the course of the flexor tendon sheath, and 4) excruciating pain with passive extension of the digit. Erythema extending proximally to the wrist is not a cardinal sign and may instead indicate spreading cellulitis or a proximal space infection.

Question 117

Topic: Hand Trauma & Infection

A 28-year-old carpenter presents with a swollen, painful index finger 3 days after sustaining a puncture wound from a wood splinter. Examination reveals a finger held in slight flexion, fusiform swelling, and tenderness along the entire flexor tendon sheath. Which of the following signs is considered the most reliable and specific for diagnosing suppurative flexor tenosynovitis in its early stages?

. Erythema extending to the palmar crease
. Resting posture of the digit in rigid extension
. Fusiform swelling of the digit alone
. Severe pain with passive extension of the digit
. Localized fluctuance over the distal phalanx

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are 1) fusiform swelling of the digit, 2) resting posture of the digit in slight flexion, 3) tenderness along the flexor tendon sheath, and 4) excruciating pain with passive extension of the digit. Pain on passive extension is widely considered the most specific and earliest reliable clinical sign of suppurative flexor tenosynovitis.

Question 118

Topic: Hand Trauma & Infection

A 38-year-old diabetic male presents with a severely swollen, erythematous left thumb that he holds in a flexed posture. He reports severe pain with passive extension. Over the next 24 hours, he develops similar swelling, pain, and flexed posture in his little finger, while the index, middle, and ring fingers remain relatively asymptomatic. This classic spread of infection occurs through which of the following anatomical spaces?

. Midpalmar space
. Thenar space
. Space of Parona
. Deep subaponeurotic space
. Hypothenar space

Correct Answer & Explanation

. Space of Parona

Explanation

This clinical presentation describes a 'horseshoe abscess,' resulting from pyogenic flexor tenosynovitis. The radial bursa (which surrounds the flexor pollicis longus tendon sheath) and the ulnar bursa (which contains the flexor tendons of the little finger) communicate in the distal forearm via the Space of Parona in approximately 50-80% of individuals. This anatomical connection allows an infection to spread rapidly from the thumb to the little finger (or vice versa), sparing the central digits.

Question 119

Topic: Hand Trauma & Infection

In a complete rupture of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint, a Stener lesion prevents conservative healing. This lesion occurs when the torn UCL becomes displaced superficial to the aponeurosis of which muscle?

. Abductor pollicis brevis
. Flexor pollicis brevis
. Adductor pollicis
. First dorsal interosseous
. Opponens pollicis

Correct Answer & Explanation

. Adductor pollicis

Explanation

A Stener lesion occurs when the distal end of the completely ruptured ulnar collateral ligament of the thumb MCP joint displaces superficial to the adductor pollicis aponeurosis. This mechanical interposition prevents the ligament from healing back to its anatomic insertion, mandating surgical repair.

Question 120

Topic: Hand Trauma & Infection

During surgical debridement of a fight bite over the fifth MCP joint, a small, yellowish-white, firm structure is encountered within the wound. This is most likely a:

. A. Devitalized adipose tissue.
. B. Necrotic tendon fragment.
. C. Retained tooth fragment.
. D. Calcified synovial cyst.
. E. Foreign body granuloma.

Correct Answer & Explanation

. C. Retained tooth fragment.

Explanation

A small, yellowish-white, firm structure encountered in a fight bite wound is highly suggestive of a retained tooth fragment. These fragments are common in clenched-fist injuries and can act as a persistent nidus for infection, requiring meticulous removal. While devitalized adipose tissue (A) or necrotic tendon (B) can be found, they typically have a different appearance. Calcified synovial cysts (D) and foreign body granulomas (E) are typically chronic findings and less likely to be encountered as a primary foreign body during acute debridement.

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