Hand

Question 1

What is a subungual haematoma?

How can this be treated?

Answer 1

Bleed under the nail, causing pain. The nail will eventually fall off but it will grow back.

Leave it alone if the patient can tolerate it or it can be ablated

Question 2

How are fractures of the 3rd, 4th and 5th metacarpals treated?

Why do fractures of the 3rd and 4th metacarpals have such good stability?

Answer 2

Conservatively

They have strong intermetacarpal ligaments proximally and distally

Question 3

Fractures at the base of the thumb are common.

Are these intra or extra articular?

Why should they always be fixed?

Answer 3

Intra articular

Any displacement can predispose to OA

Question 4

Where are boxer’s fracture found?

Which direction will cause more displacement- proximal or distal?

How should these be treated?

How much angulation is accepted without disrupting hand function?

Answer 4

5th metacarpal

Proximal

Strap the digit to its adjacent one and allow early mobilisation

45 degrees

Question 5

With punching injuries, a ‘fight bite’ can occur. Where can this cause damage?

What can it lead to?

How is it treated?

Answer 5

MCP joint and the extensor tendon

Infection with oral bacteria causing septic arthritis

Always explored and washed out in surgery

Question 6

What is mallet finger?

What causes it?

Answer 6

Avulsion of the extensor tendon from its insertion into the distal phalanx

Forced flexion of the extended DIP (often from a ball at sport)

Question 7

What can be seen on examination of mallet finger?

Answer 7

Pain, drooped DIP, inability to extend the DIP, tenderness/bruising

Question 8

How is mallet finger managed?

Answer 8

Splint for 6 weeks to hold the DIP extended

Fixation if there is a displaced avulsion fracture

Question 9

How should you treat a PIP joint dislocation?

What can happen if these have a delayed presentation?

Answer 9

Pull it to reduce it and give it a buddy strap

May be impossible to reduce and need fusion

Question 10

What is a Bennett’s fracture?

Answer 10

A fracture/dislocation at the thumb CMC joint

Question 11

Where does the flexor digitorum profundis tendon run to?

How do you test its function?

Answer 11

Distal phalanx

Hold the PIP straight and try to bend the DIP

Question 12

Where does the flexor digitorum superficialis run to?

How do you test its function?

Answer 12

Middle phalanx

Hold the other fingers straight and try to bend the affected finger. There should be bending at the PIP but not the DIP.

Question 13

Once a repair for extensor tendon damage has been done, what is the next step in management and why?

Answer 13

Splint in extension for 6 weeks because any flexion in this time may cause failure of repair

Question 14

What is Eschar?

Answer 14

Leathery, inelastic skin which contracts following burns

Question 15

Penetrating volar hand injuries risk damage to which structures?

Penetrating dorsal hand injuries risk damage to which structures?

Answer 15

Flexor tendons, digital nerves and digital arteries

Extensor tendons

Question 16

How do you treat a damaged flexor tendon?

Answer 16

Splintage in a flexed position often with elastic traction to allow early extension to prevent stiffness

Question 17

How are phalangeal fractures usually treated?

If these are displaced or angulated, what is the management?

If they are unstable or intra-articular, what is the management?

Answer 17

Neighbour strapping or splintage

Manipulation under anaesthetic

K-wiring or small screws

Question 18

What is usually the mechanism of injury for a scaphoid fracture?

What are some clinical signs that this might present with?

Answer 18

FOOSH

Tenderness in the anatomical snuffbox and pain on compressing the thumb metacarpal

Question 19

What x-ray views are taken if there is suspected scaphoid fracture?

If scaphoid fractures do not show on initial x-rays, when will they be seen?

Answer 19

4 (AP, lateral and 2 oblique)

2 weeks later once the bones ends have been resorbed in fracture healing

Question 20

If a scaphoid fracture is suspected but there is no radiographic evidence, what is this known as?

What is the management for this?

Answer 20

Clinical scaphoid fracture

The wrist is splinted and further assessment +/- further x-rays are arranged for around 2 weeks later

Question 21

How are undisplaced scaphoid fractures usualy treated?

Answer 21

Plaster cast for 6-12 weeks

Question 22

What are the 2 main problems that are fairly common with scaphoid fractures and why?

Answer 22

AVN of the proximal pole: its blood supply comes distally from a branch of the radial artery

Non-union: due to synovial fluid inhibiting fracture healing

Question 23

How should displcaed scaphoid fractures be treated?

Answer 23

Compression screw sunk into the bone to avoid non-union

Question 24

What imaging test is most useful to assess whether or not union has occured in a scaphoid fracture?

How are non-unions treated?

Answer 24

CT

Screw fixation and bone grafting

Question 25

If patients are symptomatic of AVN following a scaphoid fracture, what is often the only treatment?

Answer 25

Partial or total wrist fusion

Question 26

What type of injury is needed to cause a lunate dislocation?

What direction does the lunate mostly dislocate in?

What is the classic radiograph sign of this?

What nerve can be compressed?

How is this treated?

Answer 26

High energy

Volarly

Split cup sign

Medial nerve

Emergency closed or open reduction with pinning

Question 27

What causes scapho-lunate dissociation?

What is seen on x-ray in this injury?

If left untreated, what can this cause?

How is it treated?

Answer 27

Rupture of the scapho-lumate ligament

Increased gap between these two bones

Osteoarthritis

Closed reduction and k-wiring (maybe ligament repair also)

Question 28

What is peri-lunate dislocation?

What type of injury is needed to cause this?

What test will demonstrate this?

What associated injury may be present?

What nerve can be injured?

Answer 28

Dislocation of one of the carpal bones around the lunate

High energy- hyperdorsiflexion

X-ray

Scaphoid or other carpal bone fracture

Median

Question 29

What is the treatment for a peri-lunate dislocation?

Answer 29

Closed reduction and percutaneous pinning