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Hand I Structured SBA
Odd numbers are allocated to joints (I = DIPJ; III
= PIPJ; V = MCPJ; VII = Wrist) and even
numbers represent the remaining structures (II
= middle phalanx; IV = proximal phalanx; VI =
dorsum of hand; VIII = forearm).
50. Answer A. Elbow replacement
With rheumatoid arthritis, the surgical sequence
in most cases is to start with the most proximal
joint that is affected and work distally. If the
patient is unable to place her hand in space
because she has a painful, stiff elbow, replacing
her finger MCPJs will not improve her overall
function, although it will help with pain.
Replacing or fusing her wrist joint will correct
the wrist deformity, which will in turn enable
later finger MCPJ replacements to have the maximum functional benefit.
51. Answer C. Flexor digitorum superficialis
muscle has two heads
The flexor pollicis longus takes its origin from
the midradial shaft, not the ulnar shaft; the flexor
digitorum profundus is supplied by the anterior
interosseous nerve and the ulnar nerve. The
flexor digitorum superficialis splits into four
tendons with the index and little finger tendons
running deep to the middle and ring finger
tendons. The pronator quadratus is supplied by
the anterior interosseous nerve.
52. Answer A. Chondrocalcinosis
This patient has psoriatic arthritis, which occurs
in 10–30% of patients who suffer from psoriasis.
The majority of these patients will have arthritis
affecting their hands and a minority will develop
arthritis mutilans (around 5%). Arthritis mutilans is a severe form of arthritis that affects both
patients with rheumatoid arthritis and those with
psoriatic arthritis. Severe forms cause bone loss
and telescoping of the digits, with a classic ‘pencil
in cup’ appearance of the joints.
Chondrocalcinosis is not usually associated
with arthritis mutilans.
53. Answer C. Pasteurella
Pasteurella spp. are the most common pathogen
found in both cat and dog bite wounds. All of the
other bacteria are also found in cat bites but less
frequently than Pasteurella.
54. Answer C. Martin –Gruber anastomosis
AMartin–Gruber anastomosis is an anatomical
variant that connects the ulnar and median nerves
in the forearm. All of the other conditions listed
can cause neurological symptoms. The examination findings in this case suggest a lesion at the
elbow is unlikely, Phalen’s test is positive, suggesting definite median nerve compression atthe wrist,
ruling out a peripheral neuropathy. Diabetes is
associated with carpal tunnel syndrome,as is hypothyroidism, but specific ulnar nerve symptoms
present only in the hand point to a Martin–
Gruber anastomosis as the most likely scenario.
55. Answer D. Pisiform
The carpus ossifies in a reliable sequence starting
with the capitate and ending with the pisiform.
The sequence is as follows:
Capitate, hamate, distal radius, triquetrum,
lunate, scaphoid, trapezium, trapezoid, pisiform,
distal ulna.
The carpal radiographs can be used to assess
the difference between chronological age and
physiological age in children with developmental
delay.
56. Answer B. De Quervain’s tenosynovitis
De Quervain’s tenosynovitis is a tendon entrapment syndrome affecting the first dorsal extensor
compartment. It presents as pain and tenderness
over the radial aspect of the wrist joint proximal
to the anatomical snuffbox. Intersection syndrome occurs over the second compartment
tendons and the pain is usually more proximal.
57. Answer A. Observation
The clinical picture is one of trigger thumb. The
nodule in the palm is a Notta’s nodule, which is a
thickening of the flexor tendon. The management is controversial. In young children under
the age of 5, there is some evidence that there
may still be spontaneous resolution of the trigger
thumb even after years of observation. The literature supports either non-operative or operative management.
58. Answer D. Percutaneous fixation with headless
compression screw
There is no conclusive evidence that fixation
gives a better long-term outcome or a quicker
401
Emma Reay
return to work. However, in this case the patient
needs to get back to sporting activities as soon as
possible. Following successful percutaneous fixation, a cast may not be required, and mobilisation can begin almost immediately. The patient
needs to be counselled as to the risks of surgery
vs cast and advised that healing may still take the
same length of time.
59. Answer A. 1%
Chronic regional pain syndrome presents as a
spectrum of symptoms and signs, but the most
defining feature is debilitating pain. There are
two types of the disorder: Type 1 has no associated nerve injury and type 2 is associated with
nerve injury. The most commonly used diagnostic criteria are the Budapest criteria. In a large
population study from the Netherlands in 2004,
the overall general population incidence was
defined at 26.2 per 100,000 with the highest
incidence occurring in women (3:1 ratio)
between the ages of 60 and 70 years and post
fracture. A study looking specifically at conservatively managed distal radial fractures described
an incidence of 1%.
60. Answer D. PIP joint silastic replacement
In this case, the patient wants to maintain range
of movement. The symptoms and signs are such
that an injection is only a very short-term solution. The time for watchful waiting has passed
and operative intervention is now the best option
to improve pain. Joint replacement is the only
option that will allow preservation of range of
movement. The laxity of the radial collateral
ligament is important in planning which type of
prosthesis you will choose. The silastic implant is
a hinged implant that will compensate for the
loss of the radial collateral ligament. The pyrocarbon implant does not lend any stability to the
joint and would be likely to fail in this scenario.
61. Answer C. Renal ultrasound, echocardiogram
and full blood count
The clinical photograph above shows a patient
with a radial longitudinal deficiency which is one
of a spectrum of limb differences which occur
when the radial forearm and hand anatomy fails
to develop normally. This patient has a thumb
but has a deficient radius which produces the
radial deformity and the prominence of the ulnar
at the wrist. The condition is associated with
several potentially life-threatening conditions
including Holt Oram syndrome and Fanconi
anaemia as well as cardiac and gastrointestinal
abnormalities hence the urgent need for renal
ultrasound, echocardiogram and full blood
count. It is also important to start treatment for
the forearm deformity with initiation of splintage
and stretching exercises but these start after the
child has had other more life-threatening conditions ruled out. Genetic testing is not likely to be
helpful as the aetiology of radial longitudinal
deficiency rem ains unknown. Surgical correction
may be warranted in older children with the aim
of realigning the carpus onto the radial shaft but
in newborns, splintage is the preferred initial
management. A full skeletal survey will not be
necessary but it will be useful to perform plain
radiography of the affected limb to plan further
management of the deformity.
Maschke SD, Seitz W, Lawton J. Radial lon-
gitudinal deficiency. J Am Acad Orthop Surg.
2007;15:41–52.
62. Answer B. Nail Bed
The clinical radiograph of the above skeletally
immature patient shows a deformity of the physis of the distal phalanx of the right middle finger
which represents a Salter Harris 2 fracture. This
is a classic presentation of a Seymour fracture
which is a variation of a mallet injury and occurs
in children. With the history of a crush injury
and the above radiographic appearance an associated nail bed injury must be assumed until
proven otherwise. The nail bed becomes approximated within the physis preventing either
normal bony healing or nail regrowth or both.
The nail plate is not involved in the fracture
neither is the terminal extensor tendon (true
mallet injury) or the triangular ligament which
is part of the extensor hood found just proximal
to the terminal extensor tendon.
63. Answer B. 3rd and 4th extensor compartment
splitting approach
The clinical radiograph above shows a perilunate
dislocation of the wrist. The ‘workhorse’
approach to the wrist for carpal trauma is a
dorsal approach through the interval between
402
Hand I Structured SBA
the 3rd and 4th extensor tendons. This approach
allows for direct visualisation of the scapholunate
ligament and the lunotriquetral ligament both of
which will be damaged following the above
injury. A volar approach through the carpal
tunnel may be needed in the acute setting if the
lunate is irreducible but will not allow adequate
visualisation of the dorsal structures allowing
repair. Neither a radial or an ulnar approach
would allow enough access to repair the scapholunate and lunotriquetral ligaments or
adequately hold the lunate reduced. An approach
through the 2nd and 3rd compartments would
also only provide limited exposure to the lunate.
64. Answer A. Excise the scaphotrapezoidal joint
Pantrapezial osteoarthritis is one of the most
frequent presentations to the hand clinic.
Trapeziectomy remains the gold standard management for relief of pain caused by thumb carpometacarpal joint osteoarthritis in combination
with STTJ osteoarthritis. The most common
cause of persistent pain following trapeziectomy
is residual scaphotrapezoidal joint (STJ) osteoarthritis. STJ involvement can be assessed intraoperatively and an excision arthroplasty can be
performed at the time of trapeziectomy. The
thumb metacarpal may subside causing impingement on the scaphoid but this is less common
than persistent STJ pain. A tendon interposition
at the time of trapeziectomy has not been shown
to improve post-operative pain, neither has
hyperextension of the thumb MCPJ (the reason
you would perform an MCPJ stabilisation). The
approach used to excise the trapezium has also
not been proven to significantly affect the incidence of post trapeziectomy pain.
Rhee PC, Shin AY. Complications of trape-
ziectomy with or without suspension arthroplasty. J Hand Surg Am. 2014;39:781–783.
65. Answer A. Marginal excision is curative
Glomus tumours are rare benign tumours of the
glomus body, often occurring in the subungual
region. The condition is typically seen in patients
between the ages of 20 and 40 who present with a
painful subungual mass with bluish discolouration.
Diagnosis is made with a biopsy showing a welldefined lesion lacking cellular atypia or mitotic
activity with the presence of small round cells with
dark nuclei. Treatment is usually marginal excision.
The average time to diagnosis remains at over 2
years and the most challenging aspect of the management of glomus tumours is the diagnosis, as not
all lesions have the characteristic bluish tinge.
Anatomic location
75% occur in hand.
50% are subungual.
50% have erosions of distal phalanx (primary
involvement of bone being very rare).
Fewer common locations: palm, wrist,
forearm, foot.
Anatomy
Glomus body: the glomus body is a
perivascular temperature regulating structure
frequently located at the tip of a digit or
beneath the nail.
Presentation
Symptoms (classic triad).
○ Paroxysmal pain.
○ Exquisite tenderness to touch.
○ Cold intolerance.
Clinical examination
Small bluish nodule.
Often difficult to see, especially in the
subungual location.
Nail ridging or discolouration is common.
Love test
○ Pressure to the area with a pinhead elicits
exquisite pain.
○ 100% sensitive, 78% accurate.
Hildreth test
○ Tourniquet inflation reduces pain/
tenderness and abolishes tenderness to the
Love test.
○ 92% sensitive, 91% specific.
Imaging
Radiographs
○ Glomus tumours can produce a pressure
erosion of the underlying bone and an
associated deformity of the bone cortex.
○ MRI
▪ Helpful to establish diagnosis.
▪ Presents as a low T1 signal and high
T2 signal.
403
Emma Reay
Histology
Well-defined lesion lacking cellular atypia or
mitotic activity.
○ Small round cells with dark nuclei.
○ Associated small vessels in a hyaline/
myxoid stroma.
Can show gland-like or nest structures,
separated by stromal elements.
Treatment
Operative
Marginal excision is curative.
○ Indications.
▪ Sympt oms affecting quality of life.
○ Outcomes
▪ Due to the benign nature of this
disease, recurrence is uncommon.
▪ Severa l cases of malignant glomus
tumours have been reported in the
literature.
Reconstruction of nail bed contour with
autologous fat graft
○ Indications.
▪ For large defects after resection.
66. Answer A. Proximal row carpectomy
This patient has lunate degeneration most likely
secondary to Kienböck’sdisease.Kienböck’sdis-
ease is a rare (7 per 100,000) and progressive
osteonecrosis of the lunate bone. The staging of
this condition is based on the combination of plain
imaging, MRI findings and arthroscopic examination. The modified Lichtman classification is
most commonly used and is outlined below.
Stage I – lunate maintains normal architecture
and density.
Stage II – characterised by an increase in lunate
density and diffuse sclerosis of the lunate.
Stage IIIa – the lunate is collapsed but its carpal
alignment and height remain unchanged.
Stage IIIb – in addition to lunate collapse,
scaphoid palmar flexion occurs.
Stage IIIc – complete coronal plane split.
Stage IV – lunate collapse and radiocarpal or
midcarpal degenerative arthritis.
This patient has stage 4 Kienböck’s disease.
There is loss of the lunate height and flexion of
the scaphoid (circle sign on PA) with proximal
migration of the capitate. There is also early
radio-scaphoid arthritis. In the presence of
lunate collapse and degenerative changes, the
management of Kienböck’s disease is a salvage
procedure. Given the patient’s current range of
movement, the decision of which salvage procedure to choose is based on whether or not the
patient wants to maintain their range of movement and what their occupation/hobbies are. A
proximal row carpectomy is a salvage procedure
which preserves wrist range of movement
whereas a radiocarpal fusion does not.
However, PRC does require that the capitate
head and the lunate fossa are not arthritic.
Given the age of the patient, the heavy job and
the fact that the capitate head is not arthritic on
the X-rays provided, the choice of PRC would be
the best option for this patient. Radiocarpal
fusion is also appropriate but less so given the
occupation and current good range of
movement.
The other options are for management of
earlier stage Kienböck’s disease.
Chojnowski K et al. Recent advances in
assessment and treatment in Kienböck’s disease.
J Clin Med. 2022;11:664.
67. Answer D. Natatory band
This patient has Dupuytren’s disease in the hand.
Dupuytren’s disease can affect all parts of the
palmar fascial complex. The following make up
the normal palmar fascial complex.
The palmar aponeurosis: originates at the
wrist close to the palmaris longus tendon. It
diverges from the wrist into:
Pretendinous bands, longitudinal strips that
course toward the fingers.
In a sagittal plane, it divides into: superficial
fibres which insert in to the dermis, intermediat edepth fibres (which bifurcate into two separate
strips; spiral bands and lateral digital sheet) and
deepest fibres which pass almost vertically and
dorsally (related to the metacarpal joint capsule
and tendon flexor sheath).
Two sets of transverse fibres in the palm;
superficial transverse palmar ligament and natatory ligament.
404
Hand I Structured SBA
Bands are the normal palmar tissue; cords are
the abnormal palmar tissuein Dupuytren’sdisease.
Natatory cords originate from the natatory
ligaments and cause contractures of the second
through to the fourth webspace. Changing the
normal U-shaped web spaces into the classic Vshaped web in Dupuytren’s disease. These contractures result in finger adduction. The distal
natatory ligaments are found in the second to
fourth webspace and the palmar digital junction
acts to connect the adjacent web skin.
The pretendinous cord is formed from
pretendinous bands.
The spiral cord is made up of the
pretendinous band, spiral band, lateral digital
sheet and Grayson ligament; this often occurs
in the ring and little fingers and winds
around the neurovascular bundle.
The lateral cord is formed from the lateral
digital band and is rarely observed, except on
the ulnar aspect of the small finger.
The central cord is the extension of the
pretendinous cord in the palm; it is the most
common cause of proximal PIP contracture.
The natatory cord contributes to webspace
contractures and passes superficial to
neurovascular bundles.
A natatory ligament runs transversely across
each webspace distal to the MCP joint, giving
fibres that blend with each lateral digital sheet
and to the superficial aspect of the flexor
tendon sheath.
Leibovic SJ. Normal and pathologic anatomy of
Dupuytren disease. Hand Clin. 2018;34:315–329.
Rayan GM. Dupuytren disease: anatomy,
pathology, presentation, and treatment. JBone
Joint Surg Am. 2007;89:189–198.
68. Answer B. Normal pronation strength with the
elbows fully flexed
The anterior interosseous nerve innervates two
of the deep muscles of the forearm and contributes 50% to the innervation of another.
Flexor pollicis longus.
Pronator quadratus (PQ).
The radial (lateral) half of FDP (index and
middle fingers).
The AIN supplies PQ. PQ is tested with the
elbow fully flexed to defunction the pronator
teres.
The AIN has no sensory innervation.
Flexion of the IPJ of the thumb is controlled
by the flexor pollicis longus (FPL) supplied by
the AIN.
Natatory
ligament
Superficial transverse
palmar ligament
Pretendinous bands
Palmar aponeurosis
Figure 18.8 Natatory cords have transverse components and
therefore cause adduction of finger. Reproduced with permission
from Elsevier
405
Emma Reay
Flexion of the DIPJ of the middle finger is
controlled by flexor digitorum profundus (FDP)
supplied by the AIN.
69. Answer E. Toilet and dressing
A volar fingertip injury without exposed bone
involving 1cm or less of skin loss is best treated
with toilet and dressing. The aim of any fingertip
reconstruction is to maintain length, sensation
and function of the affected digit. Advice should
be given to the patient that the wound will take 6
weeks to heal and the contour and sensation of
the tip will recover. Primary closure is not appropriate as this would leave a more abnormal contour to the fingertip. If the injury involved/
exposed the bone of the distal phalanx, the
options of treatment are to perform an advancement flap such as an Atasoy flap which involves
mobilising more proximal skin over the defect in
a V-Y pattern or to terminalise the digit.
Terminalisation shortens the digit to allow for
primary skin closure. Pedicled flaps such as a
first dorsal metacarpal artery flap or a cross
finger flap are not required for this injury as
the size of the defect will allow for healing by
secondary intention and split skin grafting is not
performed for volar digital skin loss.
Whilst we realise that this SBA is similar to Q22
we have kept it in the chapter. The topic seems to
have been repeated in several different diets of
recent exams. More is more in this situation.
Golinvaux NS, Maslow JI, Hovis JP, Lee
DH. Fingertip injury and management. JBJS
Essent Surg Tech. 2019;9:e30.
70. Answer E. Watchful waiting
This patient has a classic history for Orf infectionwhichispassedtohumansfromsheep,
and in particular lambs. It is a viral infection
(Parapoxvirus) and often starts as a sm all flat
blue red circular lesion becoming bigger and
more blister-like and eventually weeping.
Systemic upset can be a feature of the infection and the digit can become very swollen
and painful with restricted range of
movement.
Orf is usually self-limiting and does not
require any treatment and will usually clear up
completely after 6 weeks.
71. Answer E. Partial fasciectomy
Dupuytren’s disease: Little finger PIPJ 60°
flexion contracture.
General: MCPJ >30° and/or PIPJ >20°
Treatment options:
• None: Mild, slowly
progressive or
patient refusal
• Needle fasciotomy: Pretendinous cord
(i.e. not just nodule)
• Fasciectomy: Healthy skin with
significant
contracture
• Dermofasciectomy: Poor skin, diathesis
(e.g. young),
revision
• Amputation: ‘Finger-in-palm’
disease, preference
(e.g. severe)
• PIPJ fusion: Coexisting severe
PIPJ OA, preference
(e.g. severe)
406
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
382
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
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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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