Abstract
Hand I Structured SBA Questions
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 impairment. He has had high dose opioid analgesia in the ED.
What is the most appropriate next step in the management?
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 emergent surgical treatment?
Fusiform swelling, flexor surface tenderness, fixed proximal interphalangeal joint on passive flexion and extension
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?
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?
5. A 35-year-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?
6. A 60-year-old patient presents with intermittent 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 most likely findings on nerve conduction testing?
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 radially deviated wrist and prominent ulnar head.
Which is the most likely explanation from the options below?
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?
9. You are about to perform revision surgery on the little finger of a patient with a benign fibro-proliferative disorder of the palmar fascia.
Which of the following tests gives the most useful preoperative information?
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 antibiotics 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?
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?
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?
13. A 55-year-old mechanic presents to the outpatient 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 compartment 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?
14. A 72-year-old woman has a displaced and comminuted 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?
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?
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 describe the anatomical structure damaged following this injury?
Of the three parts of the scapholunate ligament, the anterior section is biomechanically strongest
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?
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 palmar crease and are unable to actively flex their index and middle fingers.
How would you describe this 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 degrees.
Which anatomical structure is most likely to be damaged?
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?
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?
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?
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?
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?
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?
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 postoperative rehabilitation regimens is most appropriate?
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 already 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 appropriate in this patient?
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 describe the most likely anatomical 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 weakness of flexion and extension of his wrist and fingers including this thumb. He is also unable to actively pull his arm into his side against resistance. He cannot cross his fingers when asked.
Which is the most likely level of brachial plexus injury based on the above clinical examination?
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?
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?
Related posts:
Chapter 6 – Knee II Structured SBA
Chapter 20 – Pathology I Structured SBA
Chapter 19 – Structure and Function of Connective Tissue Structured SBA
Chapter 5 – Knee Structured I SBA
Chapter 26 – Clinical Environment, Evidence Management and Quality Improvement Structured SBA
Chapter 15 – Hand II Structured SBA
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
