100+ Free ABPS Surgery of the Hand Practice Questions

Fractures (Phalangeal, Metacarpal, Scaphoid, Distal Radius)

Phalangeal (P1/P2/P3, mallet bony, jersey FDP avulsion — Leddy-Packer), metacarpal (boxer's — 5th MC neck, Bennett — base 1st MC intra-articular subluxation by APL, Rolando T/Y intra-articular), scaphoid (waist 70%, retrograde flow from dorsal carpal branch of radial artery — proximal pole AVN; Russe/Matti-Russe bone graft, Herbert screw), distal radius (Colles dorsal, Smith volar, Barton intra-articular dislocation, chauffeur's, Frykman, AO/OTA, volar locking plate), perilunate dislocations (Mayfield I-IV; lunate dislocation = Mayfield IV), Galeazzi (radial shaft + DRUJ), Monteggia (ulnar shaft + radial head).

Tendon Injuries (Flexor & Extensor)

Flexor zones I-V (Verdan; zone II 'no man's land' = A1 to FDS insertion, modified Kessler core + epitendinous, 4-6 strand stronger, Kleinert dynamic vs Duran passive vs early active rehabilitation; pulley reconstruction — A2 and A4 most critical), jersey finger (FDP avulsion — Leddy-Packer I-III), trigger finger (A1 pulley release; risk of bowstringing), extensor zones I-VIII (mallet zone I — splint DIP extension 6-8 wk, Doyle classification; central slip rupture zone III — boutonniere, Elson test; sagittal band rupture — boxer's knuckle), swan-neck deformity, EPL rupture (drummer boy palsy after distal radius fracture — Lister tubercle attrition; EIP transfer).

Hand & Upper Extremity Anatomy

Intrinsic muscles (lumbricals — MCP flex/IP extend; interossei — DAB/PAD), extensor mechanism (sagittal bands, central slip, lateral bands, terminal tendon, ORL, juncturae tendinum), pulley system (A1-A5, C1-C3; A2 over P1, A4 over P2 most critical), Guyon canal (zone 1 mixed, zone 2 motor only — deep branch, zone 3 sensory only — superficial branch), carpal tunnel (transverse carpal ligament; recurrent motor branch of median; palmar cutaneous branch outside tunnel), median/ulnar/radial motor and sensory distributions, vascular anatomy (Allen test, superficial vs deep palmar arch).

Nerve Compression Syndromes

Carpal tunnel syndrome (median nerve at wrist — Phalen, Tinel, Durkan compression test most sensitive/specific; EMG/NCS — distal motor latency >4.5 ms; open vs endoscopic release; thenar atrophy late finding), cubital tunnel (ulnar nerve at elbow — McGowan I-III, Froment sign, Wartenberg sign; in situ decompression vs medial epicondylectomy vs subcutaneous/intramuscular/submuscular transposition), Guyon canal (ulnar at wrist — hook of hamate fracture, ganglion), pronator syndrome (median in proximal forearm — between heads of pronator teres), AIN palsy (Kiloh-Nevin — loss of OK pinch, FPL/FDP-2/PQ), PIN syndrome (Arcade of Frohse), radial tunnel syndrome, Wartenberg syndrome (superficial radial — handcuff).

Peripheral Nerve Injury & Brachial Plexus

Seddon (neurapraxia — Sunderland I, axonotmesis II-IV, neurotmesis V) and Sunderland I-V (epi/peri/endoneurium intact); Wallerian degeneration; regeneration ~1 mm/day; nerve repair (epineurial, group fascicular; tension-free; autograft sural/MABC/LABC; allograft Avance; PGA/collagen conduit for short gaps <3 cm sensory). Nerve transfers — Oberlin (ulnar fascicle to musculocutaneous biceps motor branch for C5-C6), spinal accessory to suprascapular for shoulder, double fascicular (median + ulnar to musculocutaneous), AIN to ulnar motor for high ulnar palsy. Brachial plexus (preganglionic — Horner, pseudomeningocele, denervation of paraspinals; postganglionic — distal stump available for grafting), Erb (C5-C6 — waiter's tip), Klumpke (C8-T1 — claw, Horner).

Microsurgery, Replantation & Vascular

Replantation indications (thumb at any level, multiple digits, any digit in child, sharp single-digit distal to FDS insertion — zone I, hand/wrist/forearm). Relative contraindications: single digit zone II in adult, severe crush/avulsion, prolonged ischemia (digit cold ~12 hr / warm ~6 hr; major limb cold ~6 hr / warm ~3-4 hr), self-mutilation, mentally unstable. Order of repair: bone → extensor → flexor → artery → nerve → vein → skin (BEFANS). Monitoring (color, capillary refill <2 sec, temperature, implantable Doppler). Leech for venous congestion (ciprofloxacin or Bactrim prophylaxis for Aeromonas hydrophila). Heparin/ASA, no benefit dextran (HUVEN trial concerns). Hypothenar hammer syndrome (ulnar artery thrombosis at hook of hamate), Raynaud (primary vs secondary), Buerger thromboangiitis obliterans.

Congenital Hand Differences

Oberg-Manske-Tonkin (OMT) classification (replaces Swanson/IFSSH; malformations, deformations, dysplasias, syndromes). Polydactyly — Wassel I-VII for thumb duplication (Wassel IV most common — bifid proximal phalanx; reconstruction by Bilhaut-Cloquet, on-top plasty, ablation of less developed). Syndactyly (Flatt — simple/complex, complete/incomplete; Apert — complex acrosyndactyly). Symbrachydactyly. Radial longitudinal deficiency (Bayne I-IV; Blauth thumb hypoplasia I-V — type IIIB and beyond require pollicization of index). Ulnar deficiency (Bayne). Cleft hand. Constriction band syndrome (Streeter dysplasia — Z-plasty release). Camptodactyly, clinodactyly, trigger thumb (Notta nodule), arthrogryposis, Apert/Poland syndrome.

Rheumatoid & Arthritic Hand

Rheumatoid hand (MCP ulnar drift and volar subluxation, swan-neck, boutonniere; Vaughan-Jackson — sequential extensor tendon rupture from distal ulna 'caput ulnae'; Mannerfelt — FPL rupture from scaphoid; tenosynovitis; synovectomy; MCP arthroplasty Swanson silicone vs pyrocarbon). CMC arthritis of thumb (Eaton-Littler/Glickel I-IV; trapeziectomy ± LRTI — ligament reconstruction tendon interposition with FCR; suspensionplasty). SLAC wrist (scapholunate advanced collapse — chronic SL tear; SNAC — chronic scaphoid nonunion; stage I-IV; treatment by stage — radial styloidectomy early, PRC vs four-corner fusion stage II/III, total wrist fusion stage IV). Kienböck (lunate AVN — Lichtman I-IV; ulnar negative variance association; radial shortening, joint leveling, vascularized bone graft, PRC).

Wrist Ligaments, TFCC & Carpal Instability

Scapholunate ligament injury (DISI — dorsal intercalated segmental instability; SL gap >3 mm 'Terry Thomas sign,' SL angle >70 deg, scaphoid cortical ring sign; dorsal SL strongest and most important; treatment — repair vs capsulodesis vs ligament reconstruction). Lunotriquetral ligament (VISI — volar intercalated; ballottement test). TFCC (Palmer 1A central perforation — debridement; 1B ulnar avulsion — repair; 1C volar; 1D radial avulsion). Midcarpal instability. Ulnar variance and ulnar abutment syndrome (positive variance — ulnar shortening osteotomy or wafer procedure). DRUJ instability.

Dupuytren Contracture

Cords (pretendinous, central, spiral — displaces NV bundle volarly and centrally — danger during fasciectomy, lateral, natatory; pathologic cords from Grayson — volar, NOT Cleland — dorsal). Pits and nodules. Hueston tabletop test indication for treatment. MCP contracture corrects easily; PIP contracture harder (joint contracture, accessory collateral ligament shortening). Treatment — collagenase clostridium histolyticum (Xiaflex) injection then manipulation; percutaneous needle aponeurotomy (NA); limited fasciectomy (gold standard); dermofasciectomy with FTSG for recurrence. Dupuytren diathesis (Garrod knuckle pads, Ledderhose plantar fibromatosis, Peyronie penile, early/bilateral/family history; Northern European descent, male, alcohol, diabetes).

Hand Infections

Felon (volar pulp space — septated; longitudinal incision and drainage; risk of P3 osteomyelitis). Paronychia (most common hand infection — lateral/eponychial fold; S. aureus; Eikenella in human bite; chronic — Candida — antifungals + marsupialization). Herpetic whitlow (HSV — vesicles; DO NOT incise — self-limited; acyclovir). Flexor tenosynovitis (Kanavel signs — fusiform digit swelling, semiflexed posture, pain on passive extension, tenderness along sheath; surgical drainage; Pseudomonas in IV drug users). Deep space (thenar, midpalmar, hypothenar, Parona — communicates with horseshoe abscess). Human bite/clenched fist (Eikenella corrodens — Augmentin, NEVER close primarily). Animal bite (Pasteurella multocida — Augmentin). Necrotizing fasciitis (Group A Strep, polymicrobial).

Tumors of the Hand

Most common soft-tissue mass — ganglion cyst (60-70%; dorsal wrist from SL ligament most common location; volar wrist from radioscaphoid joint near radial artery; mucous cyst at DIP from osteoarthritis with Heberden node — excise with osteophyte). Most common solid soft-tissue tumor — giant cell tumor of tendon sheath (PVNS variant; volar surface digit; high recurrence — marginal excision). Most common bone tumor of hand — enchondroma (proximal phalanx, lytic with stippled calcification; pathologic fracture often presenting feature; curettage and bone graft; Ollier disease — multiple enchondromatosis; Maffucci — enchondromas + soft-tissue hemangiomas, malignancy risk). Glomus tumor (subungual; classic triad — pain, cold sensitivity, point tenderness; Love test, Hildreth test, MRI). Epidermoid inclusion cyst, schwannoma (Antoni A/B), neurofibroma.

Ethics, Safety & Scholarly

Informed consent, billing ethics, social media professionalism, WHO surgical safety checklist, never events (wrong site/wrong digit — universal protocol, time-out, sign your site), VTE risk (Caprini score) and prophylaxis, tourniquet pharmacology (safe inflation typically <120 min; reperfusion intervals if longer), wide-awake local anesthesia no tourniquet (WALANT — lidocaine 1% + epinephrine 1:100,000 + bicarbonate; allows intraoperative active testing for tendon/nerve transfers), biostatistics (sensitivity/specificity, PPV/NPV, NNT), evidence-based medicine, research design (RCT, cohort, case-control).