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Hand Trauma & Infection MCQs

Practice Set 7 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 121

Topic: Hand Trauma & Infection

When performing surgical debridement for a fight bite, what is the most important principle regarding wound closure?

. A. Primary closure is always preferred to minimize scarring.
. B. Delayed primary closure or leaving the wound open is generally recommended.
. C. Only absorbable sutures should be used for wound closure.
. D. Skin grafts are often required for adequate closure.
. E. Vacuum-assisted closure (VAC) therapy should be applied to all wounds.

Correct Answer & Explanation

. B. Delayed primary closure or leaving the wound open is generally recommended.

Explanation

For human bite wounds, especially those that have penetrated deeply or are already infected, delayed primary closure or leaving the wound open to heal by secondary intention is generally recommended. This allows for continuous drainage, reduces the risk of trapping infection, and permits close monitoring. Primary closure (A) significantly increases the risk of abscess formation and subsequent complications. Absorbable sutures (C) or skin grafts (D) are not universally indicated for the initial closure. VAC therapy (E) can be useful for complex wounds or those with significant tissue loss, but it's not a universal initial closure strategy.

Question 122

Topic: Hand Trauma & Infection

What is the recommended approach for initial wound care of a superficial, clean human bite wound (not a fight bite) that is less than 6 hours old and shows no signs of deep penetration?

. A. Primary closure with sutures and no antibiotics.
. B. Thorough irrigation, debridement, and leave the wound open; prophylactic oral antibiotics.
. C. Apply topical antiseptic and cover with a sterile bandage.
. D. Immediately admit for IV antibiotics and surgical consultation.
. E. Refer to plastics for cosmetic closure.

Correct Answer & Explanation

. B. Thorough irrigation, debridement, and leave the wound open; prophylactic oral antibiotics.

Explanation

Even superficial human bite wounds are considered contaminated and carry a risk of infection. The standard of care is thorough irrigation and debridement of any devitalized tissue. For superficial wounds without deep penetration and less than 6-12 hours old, the wound is typically left open to drain or managed with delayed primary closure. Prophylactic oral antibiotics (e.g., amoxicillin-clavulanate) are generally recommended for all human bite wounds. Primary closure (A) is contraindicated due to infection risk. Topical antiseptics alone (C) are insufficient. Admission and surgical consultation (D) are usually not necessary for truly superficial, non-fight bite wounds. Cosmetic closure (E) is secondary to infection control.

Question 123

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 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

In an acutely infected wound, primary repair of a partially 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. Corticosteroids (E) are contraindicated in active infection.

Question 124

Topic: Hand Trauma & Infection

Which of the following statements regarding extensor tendon injuries associated with fight bites is correct?

. A. Complete lacerations of extensor tendons should always be primarily repaired, even in an infected field.
. B. Extensor tendons are less susceptible to infection than flexor tendons due to better vascularity.
. C. Post-operative rehabilitation for extensor tendon repairs should avoid any joint motion for at least 6 weeks.
. D. Small, partial extensor tendon lacerations in an infected wound are best debrided and left open for delayed repair if needed.
. E. Extensor tendon injuries associated with fight bites rarely lead to functional deficits.

Correct Answer & Explanation

. D. Small, partial extensor tendon lacerations in an infected wound are best debrided and left open for delayed repair if needed.

Explanation

In an infected wound, small, partial extensor tendon lacerations are best managed by thorough debridement and leaving them open. Primary repair of any tendon in an infected field carries a very high risk of infection, adhesion, and rupture of the repair. Extensor tendons (A) are very susceptible to infection. While extensor tendons may be slightly less prone to catastrophic adhesion than flexor tendons, they can still become significantly affected. Extensor tendons can be significantly impacted by infection (B), and can lead to major functional deficits (E). Post-operative rehabilitation (C) is typically initiated early, often with controlled motion, not complete immobilization for 6 weeks, though specific protocols vary.

Question 125

Topic: Hand Trauma & Infection

After surgical debridement of a fight bite over the MCP joint, the wound is left open. The patient asks why it isn't being stitched closed. What is the best explanation?

. A. 'Closing the wound would be too painful for you.'
. B. 'Leaving it open allows for drainage and prevents trapping infection inside.'
. C. 'We are waiting for the plastic surgeon to close it cosmetically later.'
. D. 'It's a small wound, so sutures aren't necessary.'
. E. 'We need to see if it develops osteomyelitis before closing it.'

Correct Answer & Explanation

. B. 'Leaving it open allows for drainage and prevents trapping infection inside.'

Explanation

The most appropriate explanation for leaving a fight bite wound open after surgical debridement is that it allows for continuous drainage of any remaining bacteria or inflammatory exudates, thereby preventing the trapping of infection within the wound and reducing the risk of abscess formation or deeper spread. This approach prioritizes infection control over immediate cosmesis. Pain (A) is not the primary reason. While plastics may be involved later, infection control is paramount (C). Even small deep wounds are dangerous (D). Waiting to see osteomyelitis (E) before closing is an outcome, not a reason for initial wound management.

Question 126

Topic: Hand Trauma & Infection

Which of the following scenarios in a fight bite patient would warrant a consultation with an infectious disease specialist?

. A. Routine wound requiring standard empiric antibiotics.
. B. Patient with no significant comorbidities and uncomplicated course.
. C. Failure to respond to initial appropriate empiric antibiotics, or unusual/resistant organisms identified.
. D. Superficial wound treated with oral antibiotics only.
. E. Patient requesting specific antibiotic recommendations.

Correct Answer & Explanation

. C. Failure to respond to initial appropriate empiric antibiotics, or unusual/resistant organisms identified.

Explanation

Consultation with an infectious disease specialist is warranted when a patient fails to respond to initial appropriate empiric antibiotic therapy, or if unusual or resistant organisms are identified in cultures. This suggests a need for specialized expertise in pathogen identification, antibiotic selection, and complex infection management. Routine cases (A, B, D) are typically managed by the orthopedic or emergency department team. Patient requests (E) do not, by themselves, warrant a subspecialty consult.

Question 127

Topic: Hand Trauma & Infection

For a patient with a confirmed Eikenella corrodens infection in a fight bite wound, which antibiotic is generally considered effective?

. A. Metronidazole
. B. Clindamycin
. C. Cefazolin
. D. Penicillin G
. E. Gentamicin

Correct Answer & Explanation

. D. Penicillin G

Explanation

Eikenella corrodens is typically sensitive to penicillin and ampicillin, as well as second and third-generation cephalosporins, tetracyclines, and fluoroquinolones. Metronidazole (A) has poor activity against Eikenella. Clindamycin (B) has variable activity against Eikenella and should not be relied upon as a sole agent. Cefazolin (C), a first-generation cephalosporin, generally covers Eikenella. Gentamicin (E) is an aminoglycoside which has limited activity against Eikenella and generally requires combination therapy. Penicillin G (D) is a good choice for confirmed Eikenella infection.

Question 128

Topic: Hand Trauma & Infection

Which of the following describes the potential impact of a 'fight bite' injury on the psychological well-being of the patient?

. A. Patients are typically unaffected psychologically, focusing only on physical recovery.
. B. There may be feelings of guilt, shame, anxiety, or post-traumatic stress, particularly given the circumstances of injury.
. C. Patients often develop a heightened sense of self-esteem due to surviving the altercation.
. D. The injury primarily affects memory and cognitive function.
. E. Long-term psychological effects are rare and insignificant.

Correct Answer & Explanation

. B. There may be feelings of guilt, shame, anxiety, or post-traumatic stress, particularly given the circumstances of injury.

Explanation

Fight bite injuries often occur in the context of altercations, violence, and sometimes substance abuse. Patients may experience significant psychological distress, including feelings of guilt, shame, anxiety, or even post-traumatic stress disorder (PTSD). The injury can be a source of social stigma and may affect personal relationships and employment. Therefore, considering the psychological impact and offering appropriate support or referral is an important aspect of holistic patient care. Patients are not typically unaffected (A), nor do they usually experience heightened self-esteem (C). Cognitive function (D) is not primarily affected. Psychological effects can be significant and long-lasting (E).

Question 129

Topic: Hand Trauma & Infection

What is the recommended approach for debriding a necrotic extensor tendon in a fight bite wound?

. A. Extensive excision of all visible necrotic tendon up to healthy tissue.
. B. Gentle scraping of the tendon surface only.
. C. Application of enzymatic debridement agents.
. D. Leaving it in place to revascularize naturally.
. E. Repairing it immediately with a graft.

Correct Answer & Explanation

. A. Extensive excision of all visible necrotic tendon up to healthy tissue.

Explanation

When a tendon is necrotic in an infected field, extensive excision of all visible necrotic tendon up to healthy, bleeding tissue is crucial. Necrotic tissue serves as a nidus for infection and prevents healing. While this may result in a tendon defect, addressing the infection takes precedence. Gentle scraping (B) or enzymatic agents (C) are insufficient for significant necrosis in an infected field. Leaving it in place (D) will perpetuate the infection. Immediate repair with a graft (E) is contraindicated in an infected field due to high failure rates and risk of graft infection.

Question 130

Topic: Hand Trauma & Infection

A 35-year-old manual laborer presents to the emergency department with a swollen, painful index finger 3 days after sustaining a puncture wound. Which of the following is NOT one of Kanavel's cardinal signs for acute suppurative flexor tenosynovitis?

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

Correct Answer & Explanation

. Pain with active flexion of the digit.

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are: 1) fusiform (sausage-like) swelling of the digit, 2) flexed resting posture, 3) tenderness along the flexor tendon sheath, and 4) severe pain with passive extension. Pain with active flexion is not considered one of the four classic Kanavel signs, though the patient may have generalized pain with any movement.

Question 131

Topic: Hand Trauma & Infection

A 35-year-old manual laborer presents with a swollen, painful index finger three days after a puncture wound to the volar aspect of the digit. The physician evaluates for pyogenic flexor tenosynovitis. Which of Kanavel's four cardinal signs is generally considered the most reliable, earliest to appear, and last to resolve?

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

Correct Answer & Explanation

. Exquisite pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs for flexor tenosynovitis are fusiform (sausage-like) swelling, the digit resting in a flexed posture, tenderness along the flexor tendon sheath, and severe pain with passive extension. Pain on passive extension is widely regarded as the most sensitive and earliest sign to appear.

Question 132

Topic: Hand Trauma & Infection

A 40-year-old mechanic presents with severe pain and swelling in his right index finger after a puncture wound 2 days ago. You suspect flexor tenosynovitis. Which of Kanavel's four cardinal signs is considered the most specific, eliciting the earliest and most severe pain?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Exquisite pain with passive extension of the digit
. Tenderness along the course of the flexor tendon sheath
. Erythema tracking proximally into the palm

Correct Answer & Explanation

. Exquisite pain with passive extension of the digit

Explanation

Kanavel's signs indicate pyogenic flexor tenosynovitis. Pain with passive extension is considered the most sensitive, specific, and often the earliest sign of this infection, as it maximally stretches the inflamed tendon sheath.

Question 133

Topic: Hand Trauma & Infection

Kanavel's signs are classically used to clinical diagnose pyogenic flexor tenosynovitis of the hand. Which of the following is considered the earliest and most reliable of these signs?

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

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

The four Kanavel signs are: 1) flexed resting posture, 2) fusiform (sausage) swelling, 3) tenderness along the flexor tendon sheath, and 4) excruciating pain with passive extension. Pain with passive extension is historically considered the earliest and most reliable clinical hallmark of pyogenic flexor tenosynovitis.

Question 134

Topic: Hand Trauma & Infection

A 35-year-old skier injures his thumb after catching his pole in the snow. Physical examination reveals laxity of the thumb metacarpophalangeal (MCP) joint when stressed in radial deviation with the joint in 30 degrees of flexion. Which of the following anatomic structures prevents spontaneous healing of the injured ligament in a Stener lesion?

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

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the completely avulsed ulnar collateral ligament (UCL) of the thumb MCP joint becomes displaced superficial to the adductor pollicis aponeurosis. This aponeurosis becomes interposed between the ruptured ends of the UCL, preventing spontaneous healing and necessitating surgical repair.

Question 135

Topic: Hand Trauma & Infection

A 42-year-old diabetic male presents with severe swelling, erythema, and pain in his right middle finger after a minor puncture wound. You suspect pyogenic flexor tenosynovitis.

According to Kanavel's criteria, which of the following signs is typically the earliest and most sensitive finding?

. Symmetric swelling of the entire digit (fusiform swelling)
. Exquisite tenderness along the course of the flexor tendon sheath
. A flexed resting posture of the digit
. Exquisite pain with passive extension of the digit
. Erythema tracking proximally into the palm

Correct Answer & Explanation

. Exquisite pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: (1) exquisite pain with passive extension, (2) symmetric (fusiform) swelling of the digit, (3) exquisite tenderness along the course of the flexor sheath, and (4) a flexed resting posture of the digit. Pain with passive extension is widely considered the earliest and most sensitive sign of the condition.

Question 136

Topic: Hand Trauma & Infection

A patient presents with a swollen, painful index finger 3 days after a minor puncture wound to the volar crease. Which of the following is NOT one of Kanavel's four cardinal signs of suppurative flexor tenosynovitis?

. Fusiform swelling of the entire digit
. Tenderness along the entire course of the flexor tendon sheath
. Severe pain on active flexion of the digit
. Digit held in a semi-flexed resting posture
. Severe pain on passive extension of the digit

Correct Answer & Explanation

. Severe pain on active flexion of the digit

Explanation

Kanavel's four cardinal signs are: 1) fusiform swelling (sausage digit), 2) digit held in slightly flexed posture, 3) tenderness along the flexor tendon sheath, and 4) severe pain with passive extension. Pain on passive extension stretches the inflamed sheath and is typically the earliest and most reliable sign. Active flexion pain is not a formal Kanavel sign.

Question 137

Topic: Hand Trauma & Infection

A 32-year-old carpenter sustains a puncture wound to his index finger and presents 48 hours later with swelling. Which of Kanavel's four cardinal signs is typically the earliest and most sensitive indicator of infectious flexor tenosynovitis?

. 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 extending to the palm

Correct Answer & Explanation

. Fusiform swelling of the digit

Explanation

Pain with passive extension of the affected digit is generally considered the earliest and most sensitive of Kanavel's cardinal signs for infectious flexor tenosynovitis. The other signs typically develop as the infection progresses.

Question 138

Topic: Hand Trauma & Infection

A patient presents with a swollen, erythematous, and painful index finger 3 days after a puncture wound. Which of the following is considered the most sensitive and earliest, albeit least specific, of Kanavel's signs for pyogenic flexor tenosynovitis?

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

Correct Answer & Explanation

. Flexed posture of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: 1) flexed posture of the digit, 2) fusiform swelling, 3) tenderness along the flexor sheath, and 4) pain with passive extension. Pain with passive extension is typically the earliest and most sensitive sign, although it may be the least specific.

Question 139

Topic: Hand Trauma & Infection

A 45-year-old diabetic patient presents with a pyogenic flexor tenosynovitis of his small finger following a puncture wound. Two days later, he develops massive swelling in the thumb and thenar eminence despite having no direct trauma to the thumb. What anatomical structure facilitates this specific spread of infection?

. Midpalmar space
. Thenar space
. Parona's space
. Superficial palmar arch
. Space of Poirier

Correct Answer & Explanation

. Midpalmar space

Explanation

The ulnar bursa (enveloping the small finger flexor tendons) and the radial bursa (enveloping the FPL tendon of the thumb) commonly communicate in the distal forearm via Parona's space (the potential space between the pronator quadratus and the deep flexor tendons). An infection spreading from the small finger to the thumb is known as a 'horseshoe abscess'.

Question 140

Topic: Hand Trauma & Infection

In an acute rupture of the ulnar collateral ligament of the thumb MCP joint (skier's thumb), what anatomical structure typically interposes between the torn ligament ends, preventing healing and necessitating surgical repair?

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

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the torn ulnar collateral ligament displaces superficial to the adductor pollicis aponeurosis. This prevents proper apposition of the ligament ends and is an indication for surgical repair.

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