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Surgical Semiology Dr. Ly Kang

1. Type or classification of nail injury

Subungual hematoma

Lacerations

Avulsion

Nail absence

Cornified nail bed

2. Treatment of subungual hematoma

Split thickness graft

Tetanus and antibiotic prophylaxis

Drainage of hematoma by perforation (Trephination)

Nail removal, D&I, nail bed repair

Nail bed repair

3. Tuft fracture is

Fracture of the base of the thumb

An injury to the end of your finger that causes it to bend inwards towards your palm

Tibial tuberosity fracture

Nail injury in combination with finger tip fracture.

A break in the neck of the 5th metacarpal bone in the hand

4. Split nail cause by

By advancement of the matrix to obtain coverage without adequate bony support

Scarring of the matrix following injury to nail bed

Nail separates from its nail bed

Epidermal keratinocytes undergo cornification

Vitamin deficiency

5. A 7-year-old boy sustains a ring finger injury after falling from his bike. The fingernail has been torn transversely beneath the eponychium and the surgeon has removed the nail as shown in Figure A. Radiographs are shown in Figure B. What is the next best step in management?

Irrigation and debridement with alumafoam placement and immobilization

Irrigation and debridement followed by percutaneous pinning and immobilization

Irrigation and debridement followed by reduction, nail bed repair and immobilization

Betadine soaks at home three times daily with intermittent alumafoam splint placement and immobilization

Alumafoam splint placement and immobilization

6. Repair of a nailbed injury with 2-octylcyanoacrylate (Dermabond) provides what distinct advantage over standard suture repair?

Better ultimate cosmesis

Better functional outcome

Faster procedure

Less pain at follow up

Lower infection rate

7. Eponychium is

Is the clear, firm and translucent portion made of keratin

Is the crescent shaped whitish area of the nail bed

Skin fold at the proximal end of the nail

Is under the free edge of the nail plate

Is continuation of the matrix and the nail plate rests on

8. Hyponychium is

Is the clear, firm and translucent portion made of keratin

Is the crescent shaped whitish area of the nail bed

Skin fold at the proximal end of the nail

Is continuation of the matrix and the nail plate rests on

Is under the free edge of the nail plate

9. Paronychia is

Is the clear, firm and translucent portion made of keratin

Is an infection of the skin that surrounds a toenail or fingernail.

Is skin fold at the proximal end of the nail

Is continuation of the matrix and the nail plate rests on

Is under the free edge of the nail plate

10. A job or occupation that may increase the risk of chronic paronychia includes

Heating maintenance

Dishwashers

Roofing

Carpenter

Taxi driver

11. Which of the following might indicate paronychia in a client?

A thin black line around the nail bed

Extremely thick, hard, yellow nails

Red, inflamed, swollen skin around the nails

None of the above

Nail plate has separated from the nail bed

12. Which of the following is a common treatment for paronychia?

A blood transfusion

Topical, oral antibiotics and surgery

Ice pack therapy

Meditation and yoga

All the above

13. Swan-neck deformity is

PIP joint hyperextension with concurrent DIP joint flexion

Hyperextension of MCP joints and flexion of PIP and DIP joints

Hyperflexion on DIP joint

Abnormal thickening of the tissue just beneath the skin of the hand

All form of hand deformity

14. Swan-neck cause by

MCP extension forces that is greater than the MCP flexion force

DIP extension forces that is greater than DIP flexion force

PIP extension forces that is greater than the PIP flexion force

Infection travels in the synovial sheath that surrounds the flexor Tendon

Nodules appear before contractile cords

15. Nalebuff Classification Type I is

Type I – PIP joint is flexible in all positions of the MCP joint

Type I – PIP joint flexion is limited in certain positions of the MCP joint

Type I – PIP joint flexion is limited irrespective of the position of the MCP joint

Type I – PIP joints are stiff and have a poor radiographic appearance

16. Nalebuff Classification Type III is

Type III – PIP joint is flexible in all positions of the MCP joint

Type III – PIP joint flexion is limited irrespective of the position of the MCP joint

Type III – PIP joint flexion is limited in certain positions of the MCP Joint

Type III – PIP joints are stiff and have a poor radiographic appearance

17. Treatment option for Type I of Swan-neck deformity without synovitis is

Silver ring splint to flex PIPJ

Intrinsic Release

Tenosynovectomy

Fusion or arthroplasty

Skin Release

18. Treatment option for Type IV of Swan-neck deformity is

Silver ring splint to flex PIPJ

Intrinsic Release

Tenosynovectomy

Fusion or arthroplasty

Skin Release

19. Intrinsic Minus Hand (Claw Hand) is

PIP joint hyperextension with concurrent DIP joint flexion

Hyperextension of MCP joints and flexion of PIP and DIP joints

Hyperflexion on DIP joint

Abnormal thickening of the tissue just beneath the skin of the hand

All form of hand deformity

20. Claw hand cause by

Compartment syndrome of the hand

Ulnar nerve palsy et median nerve palsy

PIP extension forces that is greater than the PIP flexion force

Infection travels in the synovial sheath that surrounds the flexor tendon

Nodules appear before contractile cords

21. Type of claw hand is

Partial or ulnar claw hand and Complete claw hand

Partial or radial claw hand and Complete claw hand

Partial or median claw hand and Complete claw hand

Sub claw hand and total claw hand

Mid claw hand and full claw hand

22. Partial or ulnar claw hand position will have

The 2nd and 3rd fingers hyperextended at the MCP joints and flexed at the PIP joints

The 3rd and 4th fingers hyperextended at the MCP joints and flexed at the PIP joints

The 4th and 5th fingers hyperextended at the MCP joints and flexed at the PIP joints

All fingers hyperextended at the MCP joints and flexed at the PIP joints

Paralysis of the hand

23. Surgical treatment of claw hand is

Joint fusion

Arthrolysis

Amputation

Incision and drainage

Repaire damaged nerve, ligament or muscle

24. A 40-year-old male sheet metal worker sustained a crush injury to his hand. His hand was treated in a short arm splint after closed reduction and percutaneous pinning of multiple metacarpal fractures. The patient’s fractures healed uneventfully however, he presented six months later with the deformity shown in Figure A. What pathoanatomic process is responsible for his deformity?

Volar plate laxity and tethering of the lateral bands at the proximal interphalangeal joints

FDP laceration distal to the origin of the lumbricals

Adhered FDP tendon of the middle finger

Imbalance between spastic intrinsics and weak extrinsics

Imbalance between strong extrinsics and deficient intrinsics

25. Extrinsic imbalance from splinting a crushed hand with metacarpophalangeal joint extension causes what characteristic hand deformity?

Distal interphalangeal joint extension

Ulnar subluxation of the metacarpophalangeal joints

Proximal interphalangeal joint extension

Proximal interphalangeal joint flexion

Swan-neck deformity

26. What is Pyogenic flexor tenosynovitis

Is an infection of the synovial sheath that surrounds the flexor tendon.

Is an arteriovenous anastomosis present in the reticular dermis and the subungual region

Is an infection of the skin that surrounds a toenail or fingernail.

Swelling of the tendons that run along the thumb side of the wrist and attach to the base of the thumb.

A condition affecting tendons that flex the fingers and thumb, typically resulting in a sensation of locking or catching when you bend

27. What are the 4 kanavel signs? (4 answers)

Flexed posturing of the involved digit

Tenderness to palpation over the tendon sheath

Hyperflexion DIP joint and hyperextension PIP joint

Marked pain with passive extension of the digit

Fusiform swelling of the digit

28. kanavel’s signs may be absent in (4 answers)

Recently administered antibiotics

Early manifestations of the condition

Immunocompromised state

After trauma on the affect finger

Chronic infections

29. De quervain tenosynovitis

An injury to the thin tendon that straightens the end joint of a finger or thumb.

A condition in which your fingers to bend in toward your wrist.

Pain occurs on palpation along the radial aspect of the wrist

A painless condition that causes one or more fingers to bend toward the palm of the hand.

Affecting tendons that flex the fingers and thumb, typically resulting in a sensation of locking or catching when you bend

30. A 48-year-old hairdresser presents with pain and swelling of his ring finger for 4 days. On examination, there is generalized tenderness along the entire digit. Passive extension of the digit triggers excruciating pain. The clinical appearance of the digit is shown in Figure A. What is the most appropriate next step in management?

Acyclovir

Intravenous antibiotics, splinting and elevation

Closed tendon sheath irrigation from the level of the A1 pulley (proximal) to the distal interphalangeal joint (distal)

Continuous closed tendon sheath irrigation from the wrist (proximal) to the distal interphalangeal joint (distal)

Open irrigation and debridement

31. All of the following are considered the cardinal signs of flexor tenosynovitis EXCEPT

Tenderness along the flexor tendon sheath

Flexed resting posture of the finger

Fusiform swelling of the finger

Pain on passive extension of the finger

Pain on passive flexion of the finger

32. A 46-year-old homeless IV drug abuser presents with the hand infection shown in Figure A, which developed after sustaining a superficial laceration. Cultures are taken during operative irrigation and debridement, and he is started on antibiotic therapy. Based on the patients history, what is the most common pathogen in this setting?

Herpes simplex virus

Candida albicans

Escherichia coli

Eikenella corrodens

Methicillin-resistant staphylococcus aureus

33. A 42-year-old IV drug user presents to the ED with a 2-day history of severe pain and swelling in his right index finger. He states he cut it on a piece of metal and its condition has been worsening since. His inflammatory markers are significantly elevated. The clinical appearance of the finger is seen in Figure A. Which of the following is true of the most likely diagnosis?

Gram positive bacilli are most common causes of infection

Diagnosis is confirmed with MRI

Early IV antibiotic administration correlates most closely with good outcomes

Involvement of the index finger can lead to a horseshoe abscess

Two-incision irrigation and debridement is more effective than open irrigation and debridement

34. What is Dupuytren's Disease

Is an infection of the synovial sheath that surrounds the flexor tendon.

Is an arteriovenous anastomosis present in the reticular dermis and the subungual region

Is an infection of the skin that surrounds a toenail or fingernail.

Is a disease which causes the abnormal thickening of the tissue just beneath the skin of the hand.

A condition affecting tendons that flex the fingers and thumb, typically resulting in a sensation of locking or catching when you bend

35. Clinical presentation of Dupuytren's Disease

Hyperflexion DIP joint and hyperextension PIP joint

Hyperextended at the MCP joints and flexed at the PIP joints

Inability to extend at the DIP joint

The formation of lumps and pits within the palm

Paralysis of the hand

36. Heuston’s tabletop test

Pressure to the area with a pinhead elicits exquisite pain

Tourniquet inflation reduces pain/tenderness and abolishes tenderness

Ask patient to place palm flat on table look for MCP or PIP contracture

Patient seated. Instruct him to touch the opposite shoulder and bring the elbow to the chest wall

Pain occurs on palpation along the radial aspect of the wrist

37. All of the following have been implicated in the pathogenesis of Dupuytren's contracture EXCEPT?

Fibroblast growth factor (FGF)

Transforming growth factor- beta (TGF-beta)

Myofibroblasts

Platelet-derived growth factor (PDGF)

Core-binding factor alpha (CBFA-1)

38. What is the name of the pathologic structure, identified by the white arrow in Figure A, that displaces the digital neurovascular bundle and places it at risk during during surgical treatment of Dupuytren's disease?

Pretendinous cord

Pretendinous band

Spiral cord

Spiral band

Natatory cord

39. A 50-year-old patient presents with stiffness in her hand. A clinical photo is shown in Figure A. During surgical exposure, the neurovascular bundle is identified and dissected. What is the clinically most important pathologic structure to identify and what is its location relative to the neurovascular bundle in the digit?

Spiral cord which is central and superficial to the neurovascular bundle

Central cord which is midline and superficial to the neurovascular bundle

Retrovascular cord which is central and superficial to the neurovascular bundle

Spiral cord which is lateral and deep to the neurovascular bundle

Central cord which is lateral and deep to the neurovascular bundle

40. Which of the following patients with Dupuytren's contracture would benefit the most from dermatofasciectomy and full-thickness skin grafting opposed to traditional fasciectomy?

70-year-old sedentary male with small finger involvement isolated to the MCP joint

50-year-old male systems analyst with ring and small finger involvement limited to the MCP joints

65-year-old female golfer with ring and small finger involvement including MCP and PIP joints

40-year-old female stenographer with middle, ring, and small finger involvement including MCP and PIP joints with 50 and 55 degree contractures of ring and small finger MCP joints, respectively

None of the above as no difference in outcome has been demonstrated between the two procedures

41. Zones 1 of Extensor Tendon Injuries

Disruption of tendon over middle phalanx or proximal phalanx of thumb

Disruption of terminal extensor tendon distal

Disruption over the metacarpal

Disruption at the wrist joint

Disruption at the distal forearm

42. Zones VII of Extensor Tendon Injuries

Disruption of tendon over middle phalanx or proximal phalanx of thumb

Disruption of terminal extensor tendon distal

Disruption over the metacarpal

Disruption at the wrist joint

Disruption at the distal forearm

43. Zones VI of Extensor Tendon Injuries

Disruption of tendon over middle phalanx or proximal phalanx of thumb

Disruption of terminal extensor tendon distal

Disruption over the metacarpal

Disruption at the wrist joint

Disruption at the distal forearm

44. Clinical presentation of Zones I of Extensor Tendon Injuries

DIP joint hyperextension

Inability to extend at the DIP joint

Flexed posturing of the involved digit

Tenderness to palpation over the tendon sheath

Abnormal thickening of the tissue just beneath the skin of the hand

45. For dermatome of extensor tendons injury, how many zones is divided?

4 zones

5 zones

6 zones

7 zones

8 zones

46. What is glomus ?

Is the clear, firm and translucent portion made of keratin

Is the crescent shaped whitish area of the nail bed

Is an arteriovenous anastomosis present in the reticular dermis and the subungual region

Hard skin overlapping the base and sides of the nail

The abnormal thickening of the tissue just beneath the skin of the hand

47. Glomus tumors is

Is the clear, firm and translucent portion made of keratin

Tumors of the glomus body, often occurring in the subungual region.

Infection of the skin that surrounds a toenail or fingernail.

Hard skin overlapping the base and sides of the nail

The abnormal thickening of the tissue just beneath the skin of the hand

48. How we do love test for glomus tumor

Pressure to the area with a pinhead elicits exquisite pain

Tourniquet inflation reduces pain/tenderness and abolishes tenderness

Ask patient to place palm flat on table look for MCP or PIP contracture

Patient seated. Instruct him to touch the opposite shoulder and bring the elbow to the chest wall

Pain occurs on palpation along the radial aspect of the wrist

49. How we do Hildreth test for glomus tumor

Pressure to the area with a pinhead elicits exquisite pain

Tourniquet inflation reduces pain/tenderness and abolishes tenderness

Ask patient to place palm flat on table look for MCP or PIP contracture

Crepitation and catching of the tendon when the finger is flexed

Pain occurs on palpation along the radial aspect of the wrist

50. Imagery of glomus tumor on finger show

Joint space narrowing, erosions, lower-than normal bone density and bone spurs

Decreased bone density can be appreciated by decreased cortical thickness and loss of bony trabeculae

A pressure erosion of the underlying bone and an associated deformity of the bone cortex

A sequestrum may be visible on plain radiographs as a focal sclerotic lesion with a lucent rim

They appear as well marginated, unilocular or multilocular lytic defects with a thin rim of sclerosis

51. A 20-year-old male presents with 3 months of pain and swelling in his ring finger. Clinical photo, radiograph, and histology slide are shown in Figures A through C. What is the most likely diagnosis?

Melanoma

Squamous cell carcinoma

Synovial sarcoma

Epithelioid sarcoma

Glomus tumor

52. A 43-year-old women presents with a long-standing history of pain at the tip of her right non-dominant middle finger. Pain is exacerbated by cold weather. She denies systemic symptoms or preceding trauma. She has seen a number of physicians but no formal diagnosis as been made. Physical examination reveals no distinct mass or color change. Pain is reproduced by palpating over the ulnar nail bed of her distal middle finger. Radiographs and routine laboratory results are within normal limits. MRI images are shown in Figures A-C. What is the most likely diagnosis?

Raynaud's phenomenon

Epidermal inclusion cyst

Osteomyelitis

Glomus tumor

Osteoid osteoma

53. Action of Flexor digitorum profundus