Free Hand Surgery CAQ Practice Questions

Question 1

A 54-year-old electrician has disabling wrist pain despite splinting and injections. Chronic scapholunate dissociation has produced arthritis throughout the radioscaphoid joint and full-thickness cartilage loss at the proximal capitate. The radiolunate articulation is well preserved. He wants to retain useful wrist motion. Which operation offers an appropriate motion-preserving salvage for this cartilage pattern?

Accepted Answer

Scaphoid excision with four-corner arthrodesis

Answer

Conventional proximal row carpectomy alone

Answer

Total wrist arthrodesis with dorsal plate fixation

Answer

Scapholunate ligament reconstruction using a tendon graft

Question 2

In an observation unit, a hand surgeon is supervising an intravenous-antibiotic trial for very early flexor-sheath infection after an index-finger puncture. Initially, swelling and sheath tenderness are mild, and the patient is afebrile. The finger is splinted and elevated. During the next six hours, which finding should end the antibiotic-only trial and prompt operative sheath irrigation?

Accepted Answer

Passive-extension pain worsens and tenderness spreads proximally along the sheath

Answer

Ultrasound shows a small sheath effusion without a discrete abscess

Answer

The leukocyte count rises from 8,900 to 10,600/µL

Answer

C-reactive protein increases from 24 to 31 mg/L

Question 3

Nocturnal numbness repeatedly wakes a 46-year-old patient and affects the thumb, index, and middle fingers. Phalen and Tinel maneuvers reproduce these symptoms. Thenar strength and two-point discrimination are normal; there are no proximal symptoms or findings of another neuropathy. The CTS-6 score is 16.5. What does this assessment justify?

Accepted Answer

Establishing the diagnosis clinically without routine confirmatory electrodiagnostic testing

Answer

Using the score to identify motor axon loss and expedite surgical decompression

Answer

Favoring proximal median neuropathy because two-point discrimination remains normal in the fingers

Answer

Obtaining ultrasound confirmation before establishing the diagnosis without electrodiagnostic testing

Question 4

Seven months after zone II flexor tendon repair, a patient has active flexion of 85° at the MCP joint, 75° at the PIP joint, and 45° at the DIP joint. Active extension deficits are 0°, 15°, and 5°, respectively. Passive motion is full. Ultrasound shows continuity of both flexor tendons with restricted glide, the scars are supple, and progress has plateaued despite eight weeks of focused therapy. The patient can participate in postoperative rehabilitation. Which total active motion and surgical option fit these findings?

Accepted Answer

185°; flexor tenolysis

Answer

205°; flexor tenolysis

Answer

185°; PIP and DIP capsular release

Answer

225°; staged flexor tendon reconstruction

Question 5

Fluoroscopy after reduction of a dorsal PIP fracture-dislocation shows a volar-lip fragment involving 38% of the middle-phalanx articular surface. The joint remains concentrically reduced from 20° to 95° of flexion, without hinging, but begins to subluxate as it approaches full extension. The injury is closed, and tendon function is intact. Select the plan that protects reduction while limiting avoidable stiffness.

Accepted Answer

Extension-block splinting at 20° with protected motion and radiographic follow-up

Answer

Buddy taping with immediate unrestricted active extension

Answer

Open fixation of the volar-lip fragment before permitting protected motion

Answer

Rigid immobilization at 45° of flexion for four weeks before starting motion

Question 6

At her first follow-up after reduction of a closed distal radius fracture, a 79-year-old woman has 18° of dorsal tilt and 4 mm of radial shortening. Alignment has not changed in the cast, pain is improving, and the skin and median-nerve examination are normal. She performs light household activities, accepts a visible deformity, and prioritizes avoiding an operation over faster early recovery. Which recommendation best matches her priorities and the evidence for this population?

Accepted Answer

Continue cast treatment with clinical follow-up

Answer

Use a volar locking plate to improve long-term function

Answer

Perform percutaneous fixation to restore radial length

Answer

Apply a bridging external fixator to restore alignment

Question 7

Reconstruction is being planned for a 2-year-old with a hypoplastic thumb, a narrowed first web space, weak opposition, and MCP instability. The index finger has normal motion and sensibility. Which additional finding most strongly favors index pollicization rather than reconstruction of the existing thumb?

Accepted Answer

An unstable carpometacarpal joint with deficient first-metacarpal base support

Answer

A tight first web space that limits passive thumb abduction

Answer

Ulnar collateral insufficiency at an otherwise congruent thumb MCP joint

Answer

Marked thenar muscle hypoplasia with absent active palmar abduction

Question 8

Eight hours after index-finger replantation with arterial and venous repair, the digit becomes tense and purple. Capillary refill is nearly instantaneous, pinprick produces dark blood, and an arterial Doppler signal remains audible. Loosening the dressing and correcting hand position do not reverse the change. The patient is normotensive and can return to the operating room immediately. What is the appropriate salvage response?

Accepted Answer

Re-explore promptly for venous outflow obstruction

Answer

Treat presumed arterial spasm with warming and reassess after one hour

Answer

Start medicinal leeches and defer exploration while the arterial signal persists

Answer

Increase systemic anticoagulation and await a change in the arterial Doppler signal

Question 9

Over one month, a patient with rheumatoid arthritis first loses small-finger MCP extension and then ring-finger MCP extension. Both joints remain passively correctible. Ultrasound confirms extensor tendon discontinuity over a dorsally prominent, arthritic distal ulna. The remaining extensor tendons are intact. Which operative strategy addresses both the lost function and the risk of further rupture?

Accepted Answer

Tendon reconstruction combined with treatment of the distal-ulnar attritional source

Answer

Tendon reconstruction with immobilization until the transfers heal, leaving the distal ulna unchanged

Answer

Distal-ulnar surgery with synovectomy and therapy, leaving the ruptured tendons unreconstructed

Answer

MCP arthroplasty with extensor centralization, leaving the wrist-level tendon defects unchanged

Question 10

An adult treated in a cast for a nondisplaced scaphoid waist fracture still has focal tenderness at eight weeks. Dedicated radiographs show a persistent fracture line, but bridging is difficult to judge. He hopes to resume work that requires forceful gripping. Before changing protection or recommending fixation, which study best resolves the uncertainty about bony union?

Accepted Answer

CT with reconstructions aligned to the scaphoid's long axis

Answer

MRI with fluid-sensitive sequences to measure residual marrow edema

Answer

Repeat plain radiographs using additional oblique scaphoid views

Answer

Bone scintigraphy to quantify persistent osteoblastic activity at the waist

Free Hand Surgery CAQ Practice Questions

Domain 2: Arthritis (13-15%)

Question 1

Question 2

Domain 3: Infection (11-13%)

Question 3

Domain 4: Joint (10-12%)

Question 4

Domain 5: Microsurgery (6-8%)

Question 5

Domain 6: Nerve (12-14%)

Question 6

Domain 7: Osseous (9-11%)

Question 7

Question 8

Domain 8: Pediatrics (3-5%)

Question 9

Domain 10: Tendon (8-10%)

Question 10

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