7. Hand and Wrist MCQs

A resident is planning the placement of olive wires for an opening wedge osteotomy to correct a distal femoral varus deformity. To ensure proper placement and prevent convex migration, the attending surgeon asks the resident to recall the 'Rule of Thumbs.' Which of the following best describes the application of this rule?

A 58-year-old female presents with a 3-month history of progressive swelling, tenderness, and intermittent purulent discharge from the proximal and lateral nail folds of her right index finger. She works as a dishwasher and reports frequent hand immersion in water. On examination, the nail folds are boggy and erythematous, with significant cuticle loss and mild nail plate discoloration. There is no acute fluctuance, but the symptoms have been refractory to multiple courses of oral antibiotics prescribed by her primary care physician. Which of the following is the most likely etiology and the primary predisposing factor for this patient's condition?

A 32-year-old carpenter presents with an acute, painful, fluctuant swelling along the lateral nail fold of his left thumb, consistent with an acute paronychia with abscess formation. During incision and drainage, the surgeon makes a longitudinal incision parallel to the nail plate. Which of the following anatomical structures is most vulnerable to iatrogenic injury if the incision is made too deep or extends too far dorsally?

A 28-year-old healthcare worker presents with a painful, erythematous, and swollen right index fingertip. On examination, there are multiple clear vesicles clustered around the nail fold, some with a 'dewdrop on a rose petal' appearance. The patient reports a tingling sensation preceding the onset of the lesions. There is no fluctuance. Based on the clinical presentation, which of the following is the most appropriate initial management?

A 40-year-old diabetic patient presents with a severe acute paronychia involving both lateral nail folds and tracking proximally beneath the eponychium, forming a 'horseshoe' abscess. The surgeon plans for incision and drainage. Which of the following surgical techniques is most appropriate to drain the proximal subungual space while minimizing the risk of permanent nail matrix damage?

A 22-year-old male presents to the emergency department 3 days after sustaining a minor cut to his right middle finger, which has since become progressively painful, swollen, and erythematous. He now reports exquisite pain on passive extension of the digit, uniform swelling of the entire finger, and holds the finger in a semi-flexed posture. On palpation, there is tenderness along the flexor sheath. What is the most likely complication of his initial injury?

A 65-year-old male with a history of hypertension and coronary artery disease requires incision and drainage for a subungual abscess of his right ring finger. The surgeon plans to use a digital block for anesthesia. Which of the following local anesthetic agents and additives is most appropriate for this procedure?

A 35-year-old patient presents with an acute paronychia of the left index finger. The infection appears to have originated from a hangnail that disrupted the protective seal around the nail. Which specific anatomical structure, when compromised, most commonly serves as the initial portal of entry for bacteria in acute paronychia?

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 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 75-year-old female presents with a 6-month history of progressive pain and swelling in her left wrist and multiple finger joints. She reports numbness and tingling in her thumb, index, and middle fingers, worse at night. Her medical history includes well-controlled diabetes, hypertension, and chronic kidney disease (Stage 3). Physical examination reveals diffuse swelling and tenderness over the wrist and MCP joints, with palpable firm, non-tender nodules on the dorsal aspect of the PIP joints. Phalen's and Tinel's signs are positive at the wrist. Plain radiographs show preserved joint spaces but demonstrate several 'punched-out' erosions with sclerotic margins in the carpal bones and adjacent to the PIP joints. Given the patient's age and presentation, which of the following is the MOST likely atypical feature of gout in this elderly patient?

A 68-year-old male with a long history of uncontrolled gout presents with increasing pain and functional limitation in his right hand. He has multiple large, firm, subcutaneous nodules over his MCP and PIP joints. He reports difficulty with fine motor tasks and occasional skin breakdown over one of the nodules. His rheumatologist has optimized his urate-lowering therapy (ULT), and his serum uric acid (SUA) has been stable at 4.8 mg/dL for the past 6 months. Physical examination confirms significant mass effect from the tophi, limiting joint range of motion. There is a small, non-healing ulceration over a large tophus on the dorsal aspect of his index finger. Which of the following is the MOST appropriate indication for surgical intervention in this patient?

A 55-year-old male presents with chronic pain and swelling in his right hand. He has a history of recurrent gout flares, but has been non-adherent to his urate-lowering therapy (ULT). Plain radiographs of his hand are obtained. Based on the information provided in the teaching case, which of the following radiographic findings is MOST characteristic of chronic tophaceous gout?

A 60-year-old male presents with chronic hand pain and progressive numbness in the distribution of the median nerve. He has a long history of gout, with multiple tophi palpable around his wrist. His rheumatologist has confirmed stable urate levels. Surgical decompression of the median nerve and excision of compressive tophi are planned. During pre-operative planning, the surgeon considers various imaging modalities to precisely map the extent of crystal deposition and its relationship to neurovascular structures. Which advanced imaging modality is specifically highlighted in the teaching case for its ability to identify and quantify monosodium urate (MSU) crystal deposits based on their unique attenuation properties?

A 72-year-old male undergoes surgical excision of a large tophus from his right wrist, which was causing significant mass effect and median nerve compression. The procedure involved meticulous dissection and removal of the chalky white tophaceous material, followed by carpal tunnel release. Post-operatively, the patient is started on low-dose colchicine prophylaxis. Despite this, on post-operative day 3, he develops acute onset of severe pain, swelling, and erythema localized to the surgical site, with no signs of infection. His temperature is normal. Which of the following is the MOST likely complication and its primary management strategy?

A 65-year-old male with a history of chronic tophaceous gout in his hands is undergoing pre-operative evaluation for excision of a large, ulcerated tophus on his dominant index finger. He has multiple comorbidities, including renal impairment (eGFR 40 mL/min/1.73m²) and hypertension. During the pre-operative workup, the orthopedic surgeon reviews the patient's laboratory results. Which of the following lab findings is MOST critical to assess for long-term management and to minimize the risk of post-operative complications related to gout?

A 48-year-old male presents with a 3-month history of progressive swelling and pain in his right index finger, accompanied by a 'catching' sensation during flexion. He has a history of gout, but has been inconsistent with his medication. Physical examination reveals a palpable nodule at the A1 pulley of the index finger, with tenderness and triggering. An ultrasound confirms a tophaceous deposit within the flexor tendon sheath. Given this presentation, which anatomical structure is MOST likely affected by the tophus, leading to the described symptoms?

A 32-year-old male sustains a high-energy crush injury to his right hand. Initial radiographs are obtained upon presentation to the emergency department.

Based on the provided PA radiograph and the clinical description, which of the following statements accurately describes the fracture characteristics of the 5th metacarpal?

Considering the patient's clinical presentation, radiographic findings (including the initial PA radiograph shown in the previous question), and the high-energy mechanism, which of the following is the MOST compelling indication for operative intervention (ORIF) for this patient's multiple metacarpal fractures?

Following initial radiographs, a Computed Tomography (CT) scan of the right hand was performed. Given the high-energy mechanism, suspicion of open fractures, and multiple comminuted fractures, the CT scan was indicated. Which of the following pieces of information was the CT scan LEAST likely to provide that was crucial for surgical planning in this specific case?