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Section 4
Chapter
18
Hand and Upper Limb/Children’s Orthopaedics
Hand I Structured SBA
Emma Reay
HAND I STRUCTURED SBA QUESTIONS
1. A 75-year-old man with dementia is admitted
after being found on the floor by his carer, who
last saw him 12 hours ago. He has a swollen left
upper limb and hand. His hand looks tense and
is tender to palpation over his thenar and
hypothenar eminences. On examination, he
winces when his fingers are passively flexed.
Pulses are present but you are unable to assess
sensation due to cognitive imp airment. He has
had high-dose opioid analgesia in the ED.
What is the most appropriate next step in the
management?
A. Admit for observation and reassessment of
clinical signs after 4 hours
B. Elevate arm and prescribe further opioid
analgesia
C. Perform urgent fasciotomies of the hand
D. Request creatine kinase levels
E. Request urgent hand compartment pressure
monitoring
2. A 53-year-old right-handed patient sustained a
small puncture wound to the palmar surface of
her right index finger 10 days ago. Yesterday, she
began to develop pain and swelling of the digit,
which is worsening despite oral antibiotics from
her GP.
Which clinical signs would suggest she requires
emergency surgical treatment?
A. Erythema, extended finger position, flexor
surface tenderness, pain on passive extension
B. Erythema, flexed finger position, tenderness
of palm at base of digit, pain on passive
extension
C. Fusiform swelling, flexor surface tenderness,
fixed proximal interphalangeal joint on passive flexion and extension
D. Fusiform swelling, flexor surface tenderness,
pain on passive extension and semi flexed
position
E. Swelling into the palm, loss of normal palmar
concavity, tenderness over proximal palmar
crease
3. A 48-year-old right-handed patient underwent a
washout for flexor sheath infection this afternoon. She does not have any known medication
allergies.
While waiting for microbiological analysis of
the intraoperative samples, what is the most
appropriate antibiotic management for this
patient?
A. Benzylpenicillin and flucloxacillin
B. Cefuroxime
C. Co-amoxiclav
D. Flucloxacillin
E. Flucloxacillin and metronidazole
4. A 26-year-old male patient has fallen from his
motorbike at 50 mph and is transferred to the
ED in your hospital. He is conscious and complaining only of pain in his left hand and wrist.
His X-rays show a trans-scaphoid perilunate dislocation. He is also complaining of altered sensation of his thumb and index finger.
What is the most appropriate initial management plan for this patient?
A. MUA and carpal tunnel decompression on
next available list
B. MUA and fixation of scaphoid on next avail-
able operating list
C. MUA, fixation of scaphoid and carpal tunnel
decompression on next available operating
list
D. MUA in the ED
E. MUA on next available operating list
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Emma Reay
5. A 35-ye ar-old joiner presents with increasing
pain and swelling of his right dominant hand
after sustaining a puncture wound over the
palmar aspect of his thumb MCPJ crease. On
examination, he has restricted range of movement of his index and little fingers and has
exquisite tenderness over the distal wrist crease
where the hypothenar and thenar eminences
meet.
Between which anatomical structures is the
most likely pathology in this case?
A. Flexor digitorum profundus tendons and
pronator quadratus
B. Flexor digitorum superficialis tendons and
pronator quadratus
C. Flexor pollicis longus and flexor digiti
minimi
D. Pronator quadratus and wrist capsule
E. Transverse carpal ligament and median nerve
6. A 60-year-old patient presents with inter mittent
radial-sided altered sensation in their dominant
hand occurring predominantly at night and
when driving. Phalen’ s test is grossly positive,
and there is no evidence of motor weakness or
wasting.
Which would be the mo st likely findings on
nerve conduction testing?
A. Decreased median nerve conduction velocity
compared with the ipsilateral ulnar nerve
B. Fibrillation potentials and positive sharp
waves on needle EMG
C. Normal study
D. Peak latency delay of median nerve sensory
nerve action potential (SNAP)
E. Unrecordable SNAP
7. Parents of a child who has a deformity of her
right forearm present to your outpatient clinic
wanting an explanation for her upper limb
abnormality. On examination, you find an
absent thumb and a flexed small index finger
on the right hand with a radia lly deviated wrist
and prominent ulnar head.
Which is the mo st likely explanation from the
options below?
A. It is caused by an abnormality of the apical
ectodermal ridge
B. It is caused by an abnormal Hox gene
C. The condition occurs sporadically with no
known cause
D. This is an autosomal-dominant condition
E. This is an X-linked genetic condition
8. A patient returns from an ice-climbing trip with
acute pain in the right forearm and wrist. He
describes the forearm as feeling tired and heavy.
On examination, you find an inability to pinch
items between the thumb and index finger.
Which of the following is most likely?
A. Nerve conduction studies will show sensory
nerve conduction slowing
B. The patient will need a routine cervical MRI
scan and referral to a neurosurgeon
C. The symptoms are due to nerve compression
by the tendinous edge of pronator teres
D. The symptoms have an inflammatory cause
analogous to Parsonage–Turner syndrome
E. Urgent ultrasound and MRI of the forearm
should be requested
9. You are about to perform revision surgery on the
little finger of a patient with a benign fibroproliferative disorder of the palmar fascia.
Which of the following tests gives the most
useful preoperative information?
A. Allen’s test
B. Phalen’s test
C. Pincer grip test
D. Tinel’s test
E. Watson’
10. A 53-year-old right-handed patient sustained a
small puncture wound to the palmar surface of
her right index finger 10 days ago. Yesterday, she
began to develop pain and swelling of the digit,
which is worsening despite oral anti biotics from
her GP. On examining her finger, you find she
has fusiform swelling, flexor surface tenderness,
pain on passive extension and slight flexed position of the digit.
What is the most appropriate management?
A. Elevation, intravenous antibiotics and
reassessment
B. Open flexor sheath washout
C. Closed flexor sheath washout
D. Urgent ultrasound scan of the flexor sheath
E. X-ray to rule out foreign body
s test
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Hand I Structured SBA
11. A 27-year-old male patient presents to the hand
clinic complaining of pain over the dorsoradial
aspect of his left wrist. The pain is worse on
loading his wrist in extension, and he complains
of restricted range of extension of the wrist. He
remembers falling onto his wrist 6 months ago
while playing football. He had an X-ray and was
informed he had no bony injury. On examination, he has point tenderness over the dorsum
of his wrist between the second and third extensor compartments.
What is the most appropriate management
plan for this patient?
A. CT scan
B. MRI scan
C. X-ray and CT scan
D. X-ray and gadolinium-enhanced MRI scan
E. X-ray and MRI arthrogram
12. A 46-year-old rock climber presents to the hand
clinic 3 months after injuring her right dominant
ring finger while climbing. She describes a pop
and pain while taking her whole weight through
that digit. She developed immediate swelling. She
is now left with a strange appearance of her
finger when she bends the PIPJ – she says the
tendon ‘seems to be pulling away from the
finger’.
Which structures are most likely to have been
damaged?
A. A3 and A5 pulle ys
B. A1 and A2 pulleys
C. Volar plate of PIPJ
D. Collateral ligaments of PIPJ
E. A2 and A3 pulleys
13. A 55-year-old mechanic presents to the outpa-
tient department complaining of a tender lump
in his palm at the base of his ring finger without
functional impairment. On examination, you
observe a nodule and a thickened longitudinal
band of tissue extending from the ring finger
proximal compa rtment to the proximal palmar
crease, causing a 15° flexion contracture at the
MCPJ. Tabletop test is negative and there is no
PIPJ contracture.
What would you advise?
A. Collagenase injection
B. Nodule excision
C. Percutaneous fasciotomy
D. Segmental fasciectomy
E. Watchful waiting
14. A 72-year-old woman has a displaced and com-
minuted distal radius fracture, which you have
been asked to manage with a volar locking plate.
You choose to approach the distal radius
through the bed of flexor carpi radialis tendon.
Which anatomical structure is most commonly
damaged during this procedure?
A. Extensor pollicis longus
B. Palmar cutaneous branch of the median
nerve
C. Radial artery
D. Median nerve
E. Superficial branch of the radial nerve
15. A 56-year-old woman presents with a 6-month
history of difficulty extending her ring and
middle fingers of both hands after flexing into
her palms. She needs to use her opposite hand to
straighten the digits, and this is associated with
pain in her palm at the base of the digits.
Which one of the following medical conditions
is commonly associated with this pathology?
A. Carpal tunnel syndrome
B. Diabetes
C. Hypothyroidism
D. Psoriasis
E. Scleroderma
16. A 22-year-old semi-professional football player
falls heavily onto his outstretched right hand
during a tackle. He complains of a pop in his
wrist, followed by pain and swelling of his wrist.
He attends the ED, and a wrist X-ray is performed. At X-ray, the distance between the
lunate and scaphoid appears increased.
Which of the following statements best
describes the anatomical structure damaged
following this injury?
A. Forty per cent of distal radialfractures will have
an associated scapholunate ligament injury
B. Of the three parts of the scapholunate liga-
ment, the anterior section is biomechanically
strongest
C. The blood supply enters the scapholunate
ligament through the arcuate ligament
383
Emma Reay
D. The normal scapholunate angle is between
80° and 110°
E. The scapholunate ligament is less biomecha-
nically important than the lunotriquetral
ligament
17. A 15-year-old girl complains of an inability to
actively flex the tip of her right middle finger
after grabbing an opponent’s collar during a judo
bout yesterday. She is taken to theatre and found
to have a type I injury of her flexor tendon.
What is most likely to be damaged?
A. A5 pulley
B. Both vinculae to flexor digitorum profundus
C. Flexor digitorum superficialis tendon
D. Vinculum brevis to flexor digitorum
profundus
E. Vinculum longus to flexor digitorum
profundus
18. You take a telephone referral from an urgent care
centre about a patient who has injured themselves with a knife while removing the stone
from an avocado. They have a laceration in their
palm at the level of the distal palm ar crease and
are unable to actively flex their index and middle
fingers.
How would you describe this injury?
A. Zone I flexor tendon injury
B. Zone II flexor tendon injury
C. Zone III flexor tendon injury
D. Zone IV flexor tendon injury
E. Zone V flexor tendon injury
19. A patient is assessed in the hand clinic following
an injury where they fell onto their outstretched
hand 3 months ago while skiing. X-rays show a
scapholunate angle of 80°.
Which anatomical structure is most likely to be
damaged?
A. Lunotriquetral ligament
B. Scapholunate ligament
C. Dorsal wrist capsule
D. Radioscapholunate ligament
E. Ligament of Testut
20. A window cleaner falls from the top of his ladder
onto an outstretched left wrist. He attends the
ED with a deformed and grossly swollen wrist.
X-rays show no evidence of a distal radial fracture, but Gilula’s lines within the carpus are
broken and there is an associated scaphoid
fracture.
Which of the following most accurately classifies this injury pattern?
A. Carpal instability complex
B. Carpal instability dissociative
C. Carpal instability non-dissociative
D. DISI deformity
E. VISI deformity
21. A patient presents with a laceration over the
ulnar border of her forearm and complains of
paraesthesia running from the level of the laceration down the ulnar border of her forearm into
her little and ring fingers. At exploration, the
ulnar nerve is found to be lacerated completely.
How would you classify this injury using the
Sunderland Classification system for nerve
injury?
A. First degree
B. Second degree
C. Third degree
D. Fourth degree
E. Fifth degree
22. An elderly patient caught the tip of his right
middle finger in a circular saw as he was cutting
wood. He presents to the ED with a 1cm defect in
the skin of the tip of his pulp with no bone
exposed. His X-rays show no associated bony
injury.
What is the most appropriate management for
this patient?
A. Atasoy flap
B. Primary closure
C. Terminalisation to the distal interphalangeal
joint level
D. Toilet, dressings and wound review 1 week
E. Venkataswami flap
23. A medical student observes you suturing an
incised skin wound and asks you what is
involved in the stages of wound healing.
Which of the following most accurately
describes the cellular sequence of healing of
the wound?
A. Coagulation, fibronectin, collagen, granulocytes
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Hand I Structured SBA
B. Fibroblasts, coagulation, macrophages, cross-
linked collagen
C. Granulocytes, macrophages, fibroblasts, col-
lagen, cross-linked extracellular matrix
D. Macrophages, granulocytes, collagen,
fibroblasts
E. Neutrophils, extracellular matrix cross-
linking, granulocytes, macrophages
24. A 76-year-old female patient sustained a closed
distal radius fracture, which was treated conservatively in a cast for 4 weeks. She presents to her
GP complaining of an inability to use her thumb
properly and with a reduced range of movement
of her thumb. Her GP refers her back to the
fracture clinic for review.
Which of the following thumb movements is
most likely to be impaired in this patient?
A. Abduction
B. Adduction
C. Flexion
D. Opposition
E. Retropulsion
25. A 26-year-old falls and injures her right hand.
There is no bony injury identified on X-ray, but
she is noted to have a lytic lesion at the base of
her middle finger proximal phalanx. The lesion
demonstrates geographic bone destruction, bony
expansion and cortical thinning. The lesion is
asymptomatic.
What is the most appropriate management
plan for this patient?
A. CT scan
B. MRI scan and review
C. Reassurance and discharge
D. Reassurance and observation with serial
radiographs
E. Screening blood tests and chest X-ray
26. You have just repaired a zone II flexor tendon
injury involving both flexor digitorum superficialis and flexor digitorum profundus. You are
now filling in the hand therapy request form
after applying a dorsal splint.
Which of the following post-operative rehabilitation regimens is most appropriate?
A. Early combined passive and active motion at
days 3–5
B. Early full range active flexion
C. Early passive motion at days 3–5
D. Place and hold at 1 week
E. Splint 7 days, then combined passive and
active motion
27. A patient sustained a proximal humeral fracture
that was treated with plating while she was on
holiday in Egypt. Six months later, she now presents with an inability to extend her wrist, fingers
or thumb. Nerve conduction tests have alre ady
been organised by her GP and show no evidence
of function of the affected nerve. She has read on
the Internet about tendon transfers.
Which of the following tendon transfers would
be most app ropriate in this patient?
A. Brachioradialis to flexor pollicis longus
B. Flexor digitorum superficialis to adductor
pollicis
C. Latissimus dorsi to triceps
D. Pronator teres to extensor carpi radialis
brevis
E. Pronator teres to extensor carpi radialis
longus
28. A 36-year-old rugby player sustained a forced
abduction injury to his right dominant thumb
during a match. He attends hand trauma clinic
24 hours later with a bruised and swollen right
thumb, he is tender over the ulnar border of the
MCPJ with a palpable lump over the ulnar side of
the joint. On examining the joint, there is no
firm end point to radial deviation in either full
extension or 20° of flexion.
Which of the following most accurately
describes the most likely anatomical injury?
A. Avulsion of ulnar collateral ligament from
distal insertion
B. Midsubstance ulnar collateral ligament injury
C. Stener lesion
D. Ulnar collateral ligament and volar plate
injury
E.
Volar plate injury
29. You are asked to assess a motorcyclist who was
involved in a serious RTA 2 weeks ago. He has
open fractures to both lower limbs which have
been nailed. He complains of weakness in his left
upper limb. When you examine him, he has
385
Emma Reay
weakness of flexion and extension of his wrist
and fingers including his thumb. He is also
unable to actively pull his arm into his side
against r esistance. He cannot cross his fingers
when asked.
Which is the most likely level of brachial plexus
injury based on the above clinical examination?
A. C5, C6
B. C5, C6, C7
C. C7
D. C7, C8, T1
E. C8, T1
30. A patient presents with a pattern of upper limb
injury suggestive of brachial plexus damage. You
notice that he is unable to fully open his eye on
the ipsilateral side.
At what level within the brachial plexus is this
lesion?
A. Root level
B. Trunk level
C. Division level
D. Cord level
E. Nerve level
31. You are asked to assess a pedal cyclist who fell off
his bicycle 2 weeks ago. At that time, he was
diagnosed with a lower brachial plexus injury
resulting in weakness of his left upper limb. He
has now returned to clinic with pain on active
and passive movement of his shoulder.
What is the most appropriate next step for this
patient?
A. Angiogram left arm
B. CT myelogram
C. MRI cervical spine
D. Nerve conduction testing
E. Shoulder and chest X-rays
32. A 55-year-old male patient presents to your outpa-
tient clinic complaining of pain, swelling and
restricted range of movement of his right dominant wrist. The painoccasionallyoccurs at night and
it is affecting his ability to do his job. He remembers an injury to his wrist as a young man. X-rays
show osteoarthritic change in the radioscaphoid
articulation and the capitoscaphoid articulations.
What is the most appropriate next course of
management?
A. CT scan
B. Four corner fusion
C. Proximal row carpectomy
D. Steroid injection and CT scan
E. Total wrist fusion
33. A 27-year-old cleaner presents to the hand clinic
with an inability to actively extend the distal
interphalangeal joint (DIPJ) of her right middle
finger after changi ng a bed. On examination, she
has mild swelling and bruising over the dorsum
of the DIPJ and an extensor lag of 30°. X-rays
show no bony injury.
What is the most appropriate management
plan in this patient?
A. DIPJ splinting for 4 weeks in extension
B. DIPJ splinting for 6 weeks in extension,
followed by plain radiographs
C. Surgical repair
D. Percutaneous K-wire fixation
E. DIPJ splinting for 6 weeks in extension, then
2 weeks at night only
34. A 30-year-old builder presents with fractures to
the shafts of his 3rd, 4th and 5th metacarpals,
which are closed injuries. There is no rotational
deformity, although it is difficult to examine him
because of pain on flexion of his digits. The
fractures are oblique midshaft comminuted
fractures.
What is the most appropriate management
plan for this patient?
A. Buddy taping and mobilisation
B. Cast immobilisation
C. Moulded thermoplastic splinting
D. MUA and cast immobilisation
E. Operative fixation
35. After sustaining an axial load type injury to their
right ring finger, a 22-year-old factory worker
attends the hand trauma clinic with a painful
proximal interphalangeal joint (PIPJ), and Xrays show a comminuted intra-articular fracture
to the base of their middle phalanx and confirm a
dorsal triangle sign.
What is the most appropriate management for
this patient?
A. Dynamic external fixation
B. Open reduction and internal fixation
386
Hand I Structured SBA
C. Non-operative management with buddy
taping
D. Splinting in flexion
E. Static external fixation
36. A 76-year-old female patient complains of pain
over the radial side of her hand and around her
thumb with an inability to open her hand fully
and decreased grip strength because of pain. She
is unable to knit for more than 10 minutes. Xrays show grade IV changes at both the thumb
CMC joint and the STT joint.
Which other anatomical structure should be
examined during the consultation?
A. IPJ of the thumb
B. Median nerve
C. Radial artery
D. Superficial radial nerve
E. Ulnar nerve
37. A patient returns to clinic 6 months after carpal
tunnel decompression complaining that they
have not felt any improvement in their symptoms post-operatively. They are 89 years old and
had preoperative nerve conduction testing,
which showed severe compression of the median
nerve. They also have evidence of abductor pollicis brevis wasting.
Which is the most important prognostic indicator following carpal tunnel decompression?
A. Age
B. Comorbidities
C. Duration of symptoms
D. Presence of muscle wasting
E. Severity of compression on NCT
38. A 43-year-old sustained a twisting injury to her
wrist when picking up a heavy suitcase while on
holiday 2 weeks ago. She attends the hand trauma
clinic with a painful wrist, and on examination
she has tenderness over the fovea of her ulnar
head and her distal radioulnar joint appears lax.
Which anatomical structure provides most stability to the distal radioulnar joint?
A. Bony anatomy
B. Deep head of pronator quadratus
C. Extensor carpi ulnaris
D. Intraosseous membrane of forearm
E. Triangular fibrocartilage complex
39. A patient presents with functional problems in
her hand after repair of a flexor digitorum profundus avulsion injury of her left middle finger.
She describes being unable to fully flex her index
and ring fingers when she flexes her repaired
middle finger into her palm.
What is the anatomical basis for this
problem?
A. Adhesions within flexor sheath of repaired
middle finger
B. Damage to nerve supply to flexor digitorum
profundus
C. Rupture of flexor digitorum profundus
tendons to index and ring fingers
D. Shared muscle belly of all four flexor digi-
torum profundus tendons
E. Tethering of flexor digitorum profundus
tendons in forearm
40. A 45-year-old factory worker presents with a
long-standing history of a painful wrist that she
localises to the dorsum, worse on extension. Xrays show sclerosis of the lunate, and an MRI
organised by the musculoskeletal service shows
proximal lunate collapse.
What is the most appropriate management
option to discuss with the patient?
A. Immobilisation and rehabilitation
B. Lunate replacement
C. Proximal row carpectomy
D. Radial shortening
E. Vascularised bone graft to lunate
41. A 52-year-old manual worker presents to the ED
after amputating part of his little finger with a
circular saw. On examination, he has a jagged,
dirty wound at the level of the PIPJ. He hand s
you the amputated digit, which he recovered
from the scene. The amputated digit has no
evidence of vessels or nerves on inspection. Xrays show severe comminution of the middle and
distal phalanges of the amputate.
What advice are you going to give him when he
asks what can be done for his finger?
A. Amputation at the level of the MCPJ
B. Ray amputation
C. Replantation
D. Terminalisation
E. Wound debridement and closure in the ED
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Emma Reay
42. A 52-year-old manual worker presents to the ED
after amputating part of his dominant thumb with
a circular saw. On examination, he has a jagged,
dirty wound at the level of the MCPJ. He hands
you the amputated digit which he recovered from
the scene. The amputated digit has no obvious
vessels or nerves on examination. X-rays show
severe comminution of the proximal and distal
phalanges of the amputated thumb.
What is the most appropriate management of
this patient?
A. Amputation at the level of the MCPJ
B. Ray amputation
C. Replantation
D. Terminalisation
E. Wound debridement and closure in the ED
43. A 45-year-old female patient presents with a
recent history of pain at the tip of her right
middle finger. She als o complains of hypersensitivity to cold stimulus at the tip of the finger. On
examination, a small mass lesion is palpated in
the tip and there is slight discolouration of the
nailbed.
What is the most likely diagnosis?
A. Glomus tumour
B. Malignant melanoma of the nailbed
C. Mucous cyst
D. Osteoid osteoma
E. Pulp abscess
44. A patient who is studying biology at university is
about to undergo carpal tunnel decompression.
They ask you to describe to them the anatomical
structures that can be encountered during the
operation.
Which of the following structures is most at
risk during a carpal tunnel decompression?
A. Deep palmar arch
B. Extra-ligamentous recurrent motor branch of
the median nerve
C. Flexor digitorum superficialis tendons
D. Palmar cutaneous branch of the median
nerve
E. Superficial recurrent motor branch of the
median nerve
little and ring fingers. He has guttering of the
small muscles of the hand and a mild flexible
claw deformity of his little and ring fingers.
Where is the most likely nerve pathology in his
case?
A. Arcade of Struthers
B. Cubital tunnel
C. Exit from flexor carpi ulnaris
D. Guyon’s canal
E. Midforearm
46. An elderly patient undergoes treatment for her
pantrapezial osteoarthritis with a trapeziectomy
through a dorsal approach.
Which anatomical structure is not at risk
through this approach?
A. ECRB tendon
B. EPB tendon
C. Flexor carpi radialis tendon
D. Radial artery
E. Superficial radial nerve branches
47. A patient presents to hand trauma clinic with
pain in his palm after using his palm to knock
down some tent pegs during a recent camping
trip. He has tenderness over his hypothenar eminence and weakness of abductor digiti minimi
and first dorsal interosseous muscle but no sensory loss.
What imaging would be most appropriate?
A. Angiography
B. MRI wrist
C. Nerve conduction testing
D. Ultrasound scan
E. X-ray
48. You have been asked to perform a diagnostic
wrist arthroscopy and are being quizzed about
the best port sites to use.
Which of the following portal sites is the best
for accessing the wrist?
A. 3–4
B. 4–5
C. 6R
D. 6U
E. Radial midcarpal
45. A 76-year-old male patient presents with weak-
ness in his left hand and altered sensation in the
388
49. A chef has sustained a laceration to the dorsum
of her right index finger at the MCPJ level.
Hand I Structured SBA
Which zone of extensor tendon injury is this?
A. Zone I
B. Zone III
C. Zone V
D. Zone VI
E. Zone VIII
50. A 55-year-old patient with severe rheumatoid
deformities in her hands, wrists and elbows has
asked for your advice regarding her surgical
options to improve her function. She has severe
pain in her right elbow and wrist and her right
hand MCP joints.
Which procedure should be performed first in
the sequence of management for her joint
pathology?
A. Elbow replacement
B. Finger MCP joint replacements
C. PIPJ fusions
D. Thumb MCP joint fusion
E. Wrist fusion
51. You are asked to describe the anatomy of the
forearm.
Which of the following descriptions most
accurately describes the forearm musculature?
A. Flexor pollicis longus muscle takes its origin
from the mid ulnar shaft
B. Flexor digitorum profundus muscle is sup-
plied in part by the radial nerve
C. Flexor digitorum superficialis muscle has two
heads
D. Flexor digitorum superficialis tendons to the
index and middle finger are deep to the ring
and little finger tendons
E. Pronator quadratus is supplied by the poster-
ior interosseous nerve
52. A patient presents with painful swollen deformed
distal interphalangeal joints (DIP joint) of both
of his hands with shortened digits. He has pitting
and onycholysis of his nails.
What finding would you not expect to see at Xray?
A. Chondrocalcinosis
B. Interphalangeal ankylosis
C. Joint subluxation
D. ‘Pencil in cup’ appearance of joints
E. Resorption of bone
53. A patient presents to the ED after being bitten by
her cat 3 days ago. She has erythema and swelling
over the palmar surface of her hand and over the
thumb. She has multiple small, healing puncture
wounds. You take her to the operating theatre
and wash the wounds out. Intraoperative microbiology swabs are taken.
What is the most likely organism cultured from
the swabs?
A. Corynebacterium
B. Neisseria
C. Pasteurella
D.
E. Streptococcus
54. A 45-year-old patient presents with altered sen-
sation and tingling in the radial three digits of
her right dominant hand, which she says intermittently also affects the ulnar two digits particularly when she is driving. She is Phalen’s positive
at the wrist and provocation testing for cubital
tunnel syndrome is grossly negative.
What is the most likely explanation for her
symptoms?
A. Diabetes
B. Hypothyroidism
C. Martin–Gruber anastomosis
D. Peripheral neuropathy
E. Ulnar nerve entrapment at elbow
55. A 3-year-old patient comes into clinic after
having a set of scaphoid X-rays performed.
Their mother asks why there aren’
bones on the 3-year-old’s X-rays as there were
on her own scaphoid X-ray.
Which is the last carpal bone to ossify?
A. Capitate
B. Hamate
C. Lunate
D. Pisiform
E. Trapezium
56. A 53-year-old female patient with a history of
diabetes presents with pain over the radial border
of her right dominant wrist. On examination, she
has tender nodularity over her radial styloid and
pain on ulnar deviation of her wrist with her
thumb flexed.
What is the most likely diagnosis?
t as many
389
Emma Reay
A. Base of thumb arthritis
B. De Quervain’s tenosynovitis
C. Flexor carpi radialis tendonitis
D. Intersection syndrome
E. Superficial radial nerve neuroma
57. A 3-year-old child is brought to the hand clinic
after her parents noticed she was unable to fully
extend the IPJ of her left thumb. There has been
no history of injury and she is functioning normally. On exami nation, the IPJ of her left thumb
is fixed in 30° of flexion and you palpate a nodule
in her palm at the base of the digit. What management should you propose?
A. Observation
B. Observation and splinting
C. Thumb A1 pulley release
D. Ultrasound scan of flexor sheath
E. X-ray of thumb
58. A 21-year-old football player has been diagnosed
with an undisplaced scaphoid waist fracture. He
wants to get back to training as soon as possible
and asks for your advice regarding management.
What management option would you suggest?
A. Cast for 6 weeks and CT scan to assess union
B. Cast for 6 weeks and X-ray again
C. Open reduction and internal fixation with
headless compression screw
D. Percutaneous fixation with headless compres-
sion screw
E. Scaphoid plate
60. A 56-year-old female patient prese nts to the
hand clinic with a painful, swollen right ring
finger proximal interphalangeal joint (PIP joint).
The pain occurs at rest and at night, requiring
regular analgesia. On examination, she has an arc
of movement of 10–80°at the PIP joint, and her
radial collateral ligament is lax. She expresses a
wish to maintain as mu ch movement at the joint
as possible to allow her to continue her hobbies.
Radiographs show complete loss of joint space at
the PIPJ level.
What is the most appropriate management
option for this patient?
A. PIP joint fusion
B. PIP joint injection
C. PIP joint pyrocarbon replacement
D. PIP joint silastic replacement
E. Watchful waiting
61. A family is referred to your hand clinic by the
paediatric team. Their baby was born yesterday
with the upper limb difference illustrated in
Figure 18.1. This is their first child and they are
planning to have more children.
Figure 18.1
Clinical picture
hand (Photograph
courtesy of Shriners
Hospital for
Children,
Philadelphia, PA)
59. A 65-year-old patient presents to the fracture clinic
12 weeks after her cast was removed following
conservative treatment of her right distal radius
fracture. Check radiographs show a healing fracture that is well aligned. She is complaining of a
constant burning pain in her wrist. She describes
the skin over her wrist being very sensitive and
swollen. On examination, her wrist is swollen and
red and her skin appears thin and shiny.
What is the most likely incidence of the above
condition, following distal radius fracture?
A. 1%
B. 5%
C. 10%
D. 20%
E. 40%
390
Choose the most appropriate initial management plan from the option s below.
A. Consent for surgical correction
B. Genetic testing
C. Renal ultrasound, echocardiogram and full
blood count
D. Serial splintage and stretching
E. Skeletal survey
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