Hand And Upper Extremity Surgery

A 29-year-old right-handed man sustains a clean knife laceration across the volar aspect of the index finger at the proximal phalanx. He cannot flex either the proximal or distal interphalangeal joint, and sensation is reduced along the radial side of the fingertip. Capillary refill is normal. What is the most appropriate management?

A 34-year-old woman presents after cutting the dorsum of her middle finger over the proximal interphalangeal joint. She can extend the metacarpophalangeal joint but cannot actively extend the proximal interphalangeal joint. The wound is clean and recent. What structure is most likely injured?

A 41-year-old carpenter presents after a puncture wound to the volar index finger 2 days earlier. The finger is held in slight flexion, is diffusely swollen, and is very painful with passive extension. There is tenderness along the flexor tendon sheath. What is the most appropriate next step?

A 26-year-old man sustains a closed injury while catching a ball. The distal interphalangeal joint of the ring finger rests in flexion, and he cannot actively extend it. Radiographs show no large fracture fragment or joint subluxation. What is the most appropriate treatment?

A 32-year-old rugby player presents with pain after his flexed ring finger was forcibly extended while grabbing another player’s jersey. He cannot actively flex the distal interphalangeal joint, and there is tenderness along the volar distal phalanx. What is the most appropriate management?

A 38-year-old mechanic presents with numbness of the thumb, index, and middle fingers that is worse at night. Symptoms are reproduced by wrist flexion, and thenar strength is mildly reduced. There is no neck pain or trauma. What is the most likely diagnosis?

A 47-year-old woman presents with numbness of the little finger and ulnar half of the ring finger, worsened by prolonged elbow flexion. Examination shows weak finger abduction and a positive Tinel sign behind the medial epicondyle. What is the most likely diagnosis?

A 25-year-old man sustains a transverse fingertip amputation of the index finger distal to the distal interphalangeal joint. Bone is exposed, the amputated part is severely crushed and unavailable for replantation, and preservation of finger length is important for his occupation. What is the most appropriate reconstruction?

A 36-year-old man presents after punching a wall. Radiographs show a closed fifth metacarpal neck fracture with acceptable rotation and moderate angulation. The skin is intact, and neurovascular examination is normal. What is the most appropriate initial management?

A 44-year-old man presents after a circular-saw injury to the thumb. The thumb is completely amputated through the proximal phalanx, the amputated part is relatively clean, and warm ischemia time is short. The patient is otherwise stable. What is the most appropriate management?

A 28-year-old carpenter presents after a table-saw injury to the distal index finger. The nail plate is partially avulsed, the nail bed is visibly lacerated, and radiographs show a nondisplaced distal phalanx fracture. The fingertip is well perfused. What is the most appropriate management?

A 35-year-old man presents after a crush injury to the hand. He has severe escalating pain despite analgesia, a tense swollen palm, pain with passive finger extension, and increasing sensory disturbance. Radial and ulnar pulses remain palpable. What is the most appropriate next step?

A 24-year-old man sustains a closed hyperextension injury of the proximal interphalangeal joint. After reduction, radiographs show a volar lip fracture involving approximately 45% of the middle-phalanx articular surface, and the joint subluxates dorsally whenever extension is attempted. What is the most appropriate management?

A 31-year-old woman sustains a sharp laceration over the dorsum of the index metacarpophalangeal joint. The extensor tendon drifts into the ulnar gutter during flexion, and she cannot initiate finger extension from a flexed position, although she can maintain extension once the finger is passively straightened. What structure is most likely injured?

A 46-year-old man presents after a glass laceration at the volar wrist. He has loss of sensation in the little finger and ulnar half of the ring finger, weak finger abduction, and inability to flex the distal interphalangeal joint of the little finger. The hand remains perfused. What is the most appropriate management?

A 29-year-old woman presents with a displaced intra-articular fracture at the base of the thumb metacarpal. Radiographs show a small volar-ulnar fragment remaining aligned with the trapezium while the metacarpal shaft is displaced proximally and dorsally. What is the most appropriate management?

A 40-year-old man presents after a fall with dorsal wrist pain and a painful clicking sensation. Radiographs demonstrate widening between the scaphoid and lunate, and stress views increase the gap. What is the most likely diagnosis?

A 52-year-old woman presents with progressive flexion contracture of the ring and little fingers. Examination shows a palpable cord in the palm, skin pitting, and inability to place the hand flat on a table. Sensation is normal, and there is no triggering. What is the most likely diagnosis?

A 33-year-old man presents with a painful swollen hand after a puncture wound in the first web space. The thumb and index finger are held apart, and there is marked tenderness and fullness on both the palmar and dorsal aspects of the web. What is the most appropriate management?

A 27-year-old man sustains a complete sharp amputation of the thumb through the distal metacarpal and a severe crush amputation of the little finger. The thumb part is well preserved, but the little finger is extensively contaminated and fragmented. What is the most appropriate reconstructive priority?

A 34-year-old tennis player presents with persistent ulnar-sided wrist pain after a twisting injury. Examination shows tenderness in the fovea between the ulnar styloid and flexor carpi ulnaris tendon, pain with forearm rotation, and clicking during ulnar deviation. Distal radioulnar joint stability is preserved, and radiographs show no fracture. What is the most likely diagnosis?

A 27-year-old cyclist presents with numbness of the little finger and ulnar half of the ring finger after a long-distance race. Examination shows weak finger abduction, but sensation over the dorsal ulnar aspect of the hand is preserved. Symptoms are reproduced by pressure over the volar ulnar wrist. What is the most likely site of compression?

A 45-year-old construction worker presents with hypothenar pain and weak grip after repeatedly using a hammer. Routine wrist radiographs are normal, but examination shows tenderness over the hook of the hamate and pain when the ring and little fingers flex against resistance. What is the most appropriate next diagnostic step?

A 58-year-old woman presents 6 weeks after a distal radius fracture treated in a cast. She suddenly loses the ability to extend the thumb interphalangeal joint without new trauma. Sensation is normal, and there is no significant pain. What is the most likely diagnosis?

A 36-year-old man sustains a sharp laceration to the radial side of the distal forearm. He cannot extend the metacarpophalangeal joints of the fingers or extend the thumb, but wrist extension is preserved with radial deviation. Sensation is normal. Which nerve is most likely injured?

A 49-year-old man presents with progressive wrist pain, reduced grip strength, and limited motion without a recent injury. Radiographs show sclerosis and early collapse of the lunate. What is the most likely diagnosis?

A 63-year-old woman presents with numbness in the thumb, index, and middle fingers, thenar wasting, and inability to oppose the thumb effectively. Nerve-conduction studies demonstrate severe median neuropathy at the wrist with denervation. What is the most appropriate treatment?

A 30-year-old man sustains a laceration to the volar aspect of the middle finger in flexor zone II. Both flexor tendons are repaired primarily. Which postoperative strategy offers the best balance between tendon healing and prevention of adhesions?

A 54-year-old woman presents with a gradually enlarging, painless, firm mass along the volar surface of the index finger near the distal interphalangeal joint. The mass moves minimally with the tendon and radiographs show a soft-tissue lesion without bone destruction. What is the most likely diagnosis?

A 26-year-old man sustains a sharp complete laceration of both digital nerves of the thumb at the proximal phalanx. The wound is clean, the ends can be approximated without tension, and circulation is intact. What is the most appropriate nerve-repair strategy?

A 52-year-old woman presents after a displaced distal radius fracture. She has severe wrist deformity, numbness in the thumb, index, and middle fingers, and increasing pain despite elevation. Finger perfusion is intact. What is the most appropriate next step?

A 25-year-old woman sustains a hyperextension injury of the proximal interphalangeal joint. Radiographs show a small volar plate avulsion fragment involving less than 20% of the articular surface. After reduction, the joint is congruent and stable except in terminal extension. What is the most appropriate treatment?

An 11-year-old boy presents after his fingertip was caught in a door. The distal phalanx is flexed, the nail plate lies superficial to the proximal nail fold, and radiographs show a displaced physeal fracture of the distal phalanx. What is the most appropriate management?

A 39-year-old mechanic presents 3 hours after accidental injection of industrial paint into the index finger from a high-pressure gun. The puncture wound is small, but the finger is increasingly swollen, pale, and painful. What is the most appropriate next step?

A 48-year-old man presents with a displaced spiral fracture of the ring-finger metacarpal shaft. When he makes a fist, the ring finger crosses beneath the middle finger. What is the most appropriate management?

A 33-year-old man sustains a closed midshaft humeral fracture. After the injury, he cannot extend the wrist or fingers and has reduced sensation over the dorsal first web space. The limb is perfused, and there is no open wound. What is the most appropriate initial management?

A 62-year-old woman presents with pain at the base of the thumb that worsens with pinch and opening jars. Examination shows tenderness and crepitus at the thumb carpometacarpal joint, and a grind test reproduces the pain. Radiographs show early joint-space narrowing without major subluxation. What is the most appropriate initial treatment?

A 29-year-old woman presents with a painless dorsal wrist mass that becomes more prominent with wrist flexion. The lesion is fluctuant, transilluminates, and causes mild discomfort during push-ups. Neurological examination is normal. What is the most likely diagnosis?

A 44-year-old man presents 5 months after zone II flexor tendon repair of the middle finger. Passive joint motion is nearly full, but active flexion remains markedly limited despite a completed supervised therapy program. Ultrasound shows intact tendons with restricted gliding. What is the most appropriate definitive treatment?

A 36-year-old man presents with a painful subungual hematoma involving most of the thumbnail after a crush injury. The nail folds are intact, the nail plate is firmly adherent, and radiographs show no displaced fracture. What is the most appropriate management?

A 36-year-old man sustains a deep glass laceration across the volar distal forearm. The hand is pale and cool, capillary refill is markedly delayed, and Doppler examination shows no flow in either the radial or ulnar artery distal to the wound. Flexor tendon and median nerve injuries are also suspected. What is the most appropriate next step?

A 24-year-old basketball player sustains a closed injury to the dorsal proximal interphalangeal joint. He has swelling and tenderness over the middle phalanx base, weak active proximal interphalangeal extension, and a positive Elson test. Radiographs show no displaced fracture. What is the most appropriate treatment?

A 47-year-old man develops difficulty using a key and pinching small objects after a forearm injury. He cannot form a normal circle between the thumb and index finger and instead produces a flattened pinch. Sensation in the hand is normal. Which nerve is most likely affected?

A 39-year-old woman reports several years of severe focal pain beneath the thumbnail. The pain is triggered by cold exposure and direct pressure. Examination shows a small bluish subungual spot, and radiographs show no bone destruction. What is the most likely diagnosis?

A 61-year-old woman presents with a translucent cystic lesion over the dorsal distal interphalangeal joint of the index finger. The lesion intermittently drains clear gelatinous material and has caused a longitudinal nail groove. Radiographs show distal interphalangeal osteoarthritis with a dorsal osteophyte. What is the most likely diagnosis?

A 29-year-old man presents 8 months after an untreated scaphoid waist fracture. He has persistent radial wrist pain, reduced grip strength, and computed tomography demonstrates a displaced nonunion with humpback deformity. Magnetic resonance imaging suggests reduced vascularity of the proximal fragment. What is the most appropriate reconstructive treatment?

A 40-year-old man falls from a height and sustains a comminuted radial head fracture. He also reports wrist pain, and examination shows distal radioulnar joint tenderness and instability. Radiographs suggest proximal migration of the radius. What is the most appropriate management principle?

A 46-year-old man feels a sudden pop in the front of the elbow while lifting a heavy object. He develops bruising, a proximally retracted muscle contour, and marked weakness of forearm supination. The distal biceps tendon cannot be palpated with the hook test. What is the most appropriate treatment for this active patient?

A 55-year-old man presents 3 days after a puncture wound over the metacarpophalangeal joint. The joint is swollen, erythematous, and held slightly flexed. Both active and passive motion cause severe pain, and aspiration yields purulent fluid. What is the most appropriate management?

A 43-year-old man presents one year after revision amputation of the index fingertip. He has severe electric-shock pain when the radial side of the stump is touched, and a small focal tender mass is palpable beneath the scar. The skin is intact, and there is no infection. What is the most likely diagnosis and appropriate treatment?

A 29-year-old rock climber develops sudden pain over the volar aspect of the ring finger while gripping a small hold. He later notices bowstringing of the flexor tendon during resisted finger flexion, with preserved active flexion at both interphalangeal joints. Radiographs show no fracture. What is the most likely diagnosis?

A 35-year-old woman develops dorsoradial distal forearm pain after several weeks of repetitive rowing. Examination shows crepitus and tenderness several centimeters proximal to the wrist joint where the first dorsal compartment tendons cross the second compartment tendons. Finkelstein testing causes only minimal discomfort. What is the most likely diagnosis?

A 31-year-old tennis player reports painful snapping along the ulnar side of the wrist after a forceful forearm rotation injury. Examination shows the extensor carpi ulnaris tendon subluxating over the ulnar head during supination, and the distal radioulnar joint is stable. What is the most likely diagnosis?

A 40-year-old mechanic presents with hypothenar pain, cold sensitivity, and episodic discoloration of the ring and little fingers after years of using the palm as a hammer. Allen testing suggests reduced ulnar artery flow, and Doppler imaging shows an ulnar artery aneurysm with distal embolization. What is the most likely diagnosis?

A 26-year-old man sustains a sharp laceration of the radial artery at the wrist. The ulnar artery and palmar arch provide a warm, well-perfused hand with normal capillary refill. There is no associated nerve or tendon injury, and the wound is contaminated. What is the most appropriate vascular management?

A 48-year-old woman presents with chronic ulnar-sided wrist pain after a fall. Examination reveals a painful clunk during radial-to-ulnar deviation, and imaging suggests instability between the lunate and triquetrum without scapholunate widening. What is the most likely diagnosis?

A 37-year-old man presents after a distal radius fracture that healed with significant shortening and dorsal angulation. He now has painful prominence of the distal ulna, reduced forearm rotation, and instability of the distal radioulnar joint. What is the most appropriate management principle?

A 43-year-old man presents 10 months after a proximal radial nerve injury. There is no meaningful motor recovery despite serial examinations and electrodiagnostic testing. He has preserved passive wrist and finger motion but persistent wrist drop and inability to extend the fingers and thumb. What is the most appropriate reconstructive option?

A 30-year-old woman presents with redness, swelling, and tenderness along the lateral nail fold of the index finger after a manicure. A small fluctuant collection is visible, but there is no pulp-space tenderness or proximal spread. What is the most appropriate treatment?

A 34-year-old man sustains a complete single-level amputation of the little finger through the middle phalanx from a severe crush-avulsion mechanism. The amputated part is badly damaged, the remaining digits are normal, and the patient is a manual laborer. What is the most appropriate management?

A 32-year-old chef sustains a sharp laceration across the volar aspect of the middle finger in flexor zone II. He retains active flexion, but the finger catches painfully during movement. Operative exploration shows a partial flexor digitorum profundus laceration involving approximately 70% of the tendon width. What is the most appropriate management?

A 29-year-old man falls from a bicycle and sustains a comminuted intra-articular fracture at the base of the thumb metacarpal. Radiographs show multiple fragments with displacement and carpometacarpal joint incongruity. What is the most appropriate management?

A 38-year-old man sustains a displaced radial shaft fracture after a fall. Radiographs also show dislocation of the distal radioulnar joint. The skin is intact, and the hand is perfused. What is the most appropriate treatment?

A 27-year-old woman sustains a clean transverse laceration over the dorsum of the hand. She cannot actively extend the ring finger at the metacarpophalangeal joint, and exploration confirms complete division of the extensor tendon in zone VI. What is the most appropriate management?

A 44-year-old woman presents 14 months after a proximal median nerve injury that was repaired. Sensation has partially recovered, but thenar muscle function has not returned. She cannot oppose the thumb, passive thumb motion is full, and the joints are supple. What is the most appropriate reconstructive option?

A 55-year-old woman develops severe burning pain, swelling, temperature asymmetry, and marked hypersensitivity of the hand 6 weeks after a distal radius fracture. Radiographs show no new displacement, and there is no infection or nerve transection. What is the most appropriate management?

A 24-year-old man sustains an isolated dorsal dislocation of the thumb carpometacarpal joint. Closed reduction restores alignment, but the joint redislocates with gentle stress testing. No major fracture is present. What is the most appropriate management?

A 40-year-old man presents 8 months after revision amputation of the index fingertip. The nail has grown over the end of the shortened distal phalanx, producing a painful curved hook that catches on clothing. What is the most appropriate definitive treatment?

A 37-year-old man develops severe forearm pain and finger paresthesia several hours after a displaced forearm fracture is placed in a circumferential cast. The fingers are swollen, pain increases with passive extension, and the compartments feel tense. What is the most appropriate immediate management?

A 9-year-old child presents after a displaced supracondylar humerus fracture. The hand is pale and cool with absent radial pulse and delayed capillary refill. What is the most appropriate next step?

A 34-year-old man presents 3 months after an untreated closed central slip injury of the middle finger. The proximal interphalangeal joint rests in 45 degrees of flexion, the distal interphalangeal joint is hyperextended, and the deformity remains passively correctable. What is the most appropriate initial management?

A 46-year-old woman with rheumatoid arthritis develops hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint of the index finger. The deformity is flexible, and radiographs show preserved joint surfaces. What is the most likely deformity?

A 27-year-old man sustains a laceration across the volar proximal phalanx of the index finger. After repair, the finger is warm, but sensation remains absent on the radial side of the fingertip. Two-point discrimination is greater than 15 mm on that side and normal on the ulnar side. What structure was most likely injured?

A 39-year-old man presents 6 weeks after a metacarpal fracture treated elsewhere. The fracture is united, but the middle finger crosses over the index finger during flexion. Passive joint motion is full, and there is no tendon injury. What is the most appropriate definitive management?

A 33-year-old woman presents after a crush injury to the fingertip. The distal phalanx is exposed, but the defect is small, transverse, and located distal to the nail lunula. There is sufficient mobile volar pulp, and preserving sensibility is important. What is the most appropriate reconstruction?

A 42-year-old man has a volar-oblique fingertip amputation of the index finger with exposed distal phalanx and insufficient local pulp for advancement. The adjacent middle finger is uninjured, and replantation is not possible. What is the most appropriate reconstructive option?

A 58-year-old man presents with progressive numbness of the little finger, intrinsic muscle wasting, and clawing of the ring and little fingers. When he attempts key pinch, the thumb interphalangeal joint flexes excessively. What does this positive Froment sign indicate?

A 36-year-old woman presents with pain and paresthesia over the dorsoradial hand after wearing a tight wristwatch. Symptoms worsen with forearm pronation and wrist ulnar deviation. Motor examination is normal, and Tinel testing over the superficial radial nerve is positive. What is the most likely diagnosis?

A 49-year-old man presents after a fall with a displaced intra-articular distal radius fracture. Computed tomography shows a volar marginal fragment with radiocarpal subluxation. Closed reduction cannot maintain alignment. What is the most appropriate management?

A 44-year-old man undergoes microsurgical replantation of an amputated thumb. Six hours later, the thumb becomes swollen, blue, and warm with brisk dark bleeding on pinprick, while arterial Doppler flow remains present. What is the most appropriate next step?

A 29-year-old factory worker presents after his ring finger was caught by a rotating machine and forcibly pulled from a metal ring. The skin is circumferentially degloved from the proximal phalanx, capillary refill is absent, and Doppler examination shows no distal digital arterial signal. Radiographs show no fracture, and both flexor tendons remain intact. What is the most appropriate next step?

A 37-year-old man sustains a high-energy axial load to the middle finger. Computed tomography shows a comminuted intra-articular fracture of the base of the middle phalanx with central depression, involvement of both the dorsal and volar articular margins, and proximal interphalangeal joint subluxation. What is the most appropriate management?

A 46-year-old man presents 6 months after a crush injury to the hand. The metacarpophalangeal joints can be flexed fully when the proximal interphalangeal joints are flexed, but proximal interphalangeal flexion becomes markedly restricted when the metacarpophalangeal joints are held in extension. Passive joint surfaces are otherwise supple. What is the most likely cause of the limitation?

A 35-year-old woman presents 7 months after dorsal hand trauma and extensor tendon repair. Passive metacarpophalangeal and interphalangeal motion is full, but active extension of the middle and ring fingers remains markedly limited despite supervised therapy. Ultrasound confirms tendon continuity with restricted gliding beneath a mature dorsal scar. What is the most appropriate definitive treatment?

A 2-year-old child has severe unilateral thumb hypoplasia. The thumb is markedly shortened and unstable, the first web space is narrow, the thenar muscles are absent, and imaging shows no functional thumb carpometacarpal joint. What is the most appropriate reconstructive procedure?

A 3-year-old child has a persistent flexion contracture of the thumb interphalangeal joint with a palpable nodule at the volar metacarpophalangeal region. Passive extension is limited, and observation over the previous year has not improved the deformity. What is the most appropriate treatment?

A 19-year-old man presents 10 months after a missed forearm compartment syndrome. He has a moderate Volkmann ischemic contracture with wrist flexion, finger flexion, and limited active extension. Finger extension improves when the wrist is flexed, passive joints remain mobile, and electromyography shows some functioning flexor muscle units. What is the most appropriate reconstructive principle?

A 43-year-old assembly-line worker reports aching pain in the proximal volar forearm and paresthesia in the thumb, index, and middle fingers. Symptoms worsen with repetitive pronation. Sensation over the thenar eminence is reduced, nocturnal symptoms are minimal, and Tinel testing at the carpal tunnel is negative. What is the most likely diagnosis?

A 66-year-old woman with rheumatoid arthritis develops progressive inability to extend the little finger followed by the ring finger. Examination shows caput ulnae deformity and dorsal prominence of the distal ulna. Passive finger motion is full, but the corresponding extensor tendons are not functioning. What is the most appropriate operative management?

A 51-year-old man has chronic ulnar-sided wrist pain aggravated by gripping and ulnar deviation. Radiographs demonstrate 4 mm of positive ulnar variance, and arthroscopy shows degenerative central triangular fibrocartilage wear with chondral damage of the lunate and ulnar head. The distal radioulnar joint is stable. What is the most appropriate definitive treatment?

A 42-year-old man presents 4 days after a puncture wound to the palm near the base of the thumb. He has deep palmar swelling, marked tenderness over the thenar eminence, pain with thumb motion, and loss of the normal concavity of the first web space. The flexor tendon sheath signs are absent in the fingers. What is the most appropriate management?

A 58-year-old man has progressive numbness of the little and ring fingers, intrinsic muscle wasting, weak pinch, and reduced two-point discrimination. Nerve-conduction studies show severe ulnar neuropathy across the elbow with axonal loss. Symptoms have persisted despite activity modification and nighttime elbow-extension splinting. What is the most appropriate treatment?

A 26-year-old man sustains a displaced unicondylar fracture of the proximal phalanx head of the index finger. The fragment is rotated, the proximal interphalangeal joint surface is incongruent, and closed reduction is unstable. What is the most appropriate management?

A 35-year-old woman develops a mature first-web-space contracture after a crush injury and skin grafting. Thumb abduction is markedly restricted, but the carpometacarpal joint remains supple and the scar band is narrow without exposed tendon or bone. What is the most appropriate reconstruction?

A 30-year-old woman presents after minor trauma with pain and swelling of the ring finger. Radiographs show a central expansile lytic lesion in the middle phalanx with cortical thinning and a nondisplaced pathological fracture. There are no aggressive periosteal changes or soft-tissue mass. What is the most likely diagnosis and appropriate management?

A 2-year-old child sustains a clean complete amputation of the distal fingertip without exposed proximal phalanx. Microsurgical replantation is not technically feasible because the vessels are extremely small. The amputated part is available and minimally crushed. What is the most appropriate management?

A 31-year-old man punches a solid object and develops swelling over the ulnar side of the hand. Computed tomography shows fracture-dislocations at the fourth and fifth carpometacarpal joints with dorsal displacement of both metacarpal bases. Closed reduction is achieved but immediately redislocates. What is the most appropriate management?

A 28-year-old woman sustains a clean digital nerve laceration of the index finger. After debridement, there is a 12-mm gap between healthy nerve ends with the finger in a neutral position. Direct repair would create tension, and the wound is clean. What is the most appropriate reconstruction?

A 40-year-old golfer presents with loss of active distal interphalangeal flexion of the ring finger and ulnar-sided wrist pain. Imaging demonstrates a chronic nonunion of the hook of the hamate with attritional rupture of the ring-finger flexor digitorum profundus tendon. What is the most appropriate management?

A 54-year-old woman undergoes open carpal tunnel release. Immediately after surgery, she cannot oppose or palmarly abduct the thumb, although median-distribution sensation has improved. Preoperative thenar strength was normal. What is the most appropriate next step?

A 28-year-old man falls onto an outstretched hand and presents with a prominent painful ulnar head, loss of forearm rotation, and the hand fixed in pronation. Radiographs show an isolated dorsal dislocation of the distal ulna relative to the radius without fracture. The hand is neurovascularly intact. What is the most appropriate initial management?

A 24-year-old athlete presents after a fall with a scaphoid waist fracture. Computed tomography demonstrates 2 mm of displacement, dorsal angulation, and early humpback deformity. There is no established arthritis or avascular necrosis. What is the most appropriate management?

A 31-year-old man presents 12 days after a forceful wrist hyperextension injury. He has dorsal wrist pain, a widened scapholunate interval on stress radiographs, and arthroscopy confirms a complete scapholunate ligament tear. The carpus is reducible, and no arthritis is present. What is the most appropriate definitive treatment?

A 35-year-old man undergoes primary repair of both flexor tendons in zone II of the index finger. Ten days later, he falls while the protective splint is removed and immediately loses active flexion of both interphalangeal joints. Ultrasound confirms rupture at the repair site, and the wound remains clean. What is the most appropriate next step?

A 40-year-old woman sustains a sharp transverse laceration over the dorsal wrist. Operative exploration shows complete division of the extensor digitorum tendons within zone VII and disruption of the extensor retinaculum. What is the most appropriate reconstructive principle?

A 38-year-old man presents after flexor tendon reconstruction of the middle finger. During attempted finger flexion, the metacarpophalangeal joint flexes, but the proximal and distal interphalangeal joints paradoxically extend. Passive motion is full, and the reconstructed flexor tendon is intact. What is the most likely diagnosis?

A 42-year-old man undergoes flexor digitorum profundus repair of the ring finger. After rehabilitation, the repair is intact, but active flexion of the middle, ring, and little fingers is limited when he attempts a composite fist. Passive motion is full, and isolated tendon testing shows that the repaired ring-finger profundus is excessively shortened. What is the most likely cause?

A 14-month-old child has thumb duplication with two partially developed thumbs arising from a shared metacarpophalangeal joint. The radial thumb is smaller, while the ulnar thumb has better alignment and active motion. What is the most appropriate reconstructive approach?

A 9-month-old infant has severe radial longitudinal deficiency with marked radial deviation of the wrist, a shortened forearm, and a stiff narrow first web space. The hand remains passively correctable toward neutral after gentle stretching. What is the most appropriate initial management?

A 27-year-old man has complete traumatic loss of the thumb through the proximal metacarpal. Replantation was not possible, the index finger is intact and functionally important, and the patient requests restoration of opposition and sensate pinch. What is the most appropriate definitive reconstruction?

A 31-year-old chef sustains a clean transverse laceration on the volar aspect of the index finger distal to the flexor digitorum superficialis insertion. He can flex the proximal interphalangeal joint but cannot actively flex the distal interphalangeal joint. Sensation and perfusion are intact, and exploration confirms complete division of the flexor digitorum profundus tendon with a repairable distal stump. What is the most appropriate management?

A 27-year-old man sustains a sharp open laceration across the dorsal distal interphalangeal joint of the middle finger. He cannot actively extend the distal interphalangeal joint, and the terminal extensor tendon is visibly divided. Radiographs show no joint subluxation or major articular fracture. The wound contains superficial contamination but no tissue loss. What is the most appropriate treatment?

A 35-year-old office worker sustains a clean transverse amputation of the middle-finger tip distal to the nail bed. The defect measures 7 mm, there is no exposed bone or tendon, capillary refill in the remaining fingertip is normal, and the patient wishes to avoid surgery. What is the most appropriate management?

A 29-year-old mechanic has a 2-cm volar pulp defect of the index finger after a crush injury. The distal phalanx is exposed, the defect is too large for a tension-free V-Y advancement flap, and the adjacent fingers are intact. Durable padded coverage is required, and temporary immobilization of the injured finger is acceptable. What is the most appropriate reconstruction?

A 43-year-old warehouse worker reports aching pain over the proximal dorsolateral forearm approximately 4 cm distal to the lateral epicondyle. Pain is reproduced by resisted middle-finger extension and resisted forearm supination. Finger extension strength is normal, and there is no sensory loss. What is the most likely diagnosis?

A 64-year-old woman has severe thumb carpometacarpal joint pain that limits pinch, opening containers, and writing. Radiographs show advanced trapeziometacarpal osteoarthritis with joint-space loss and subluxation. Splinting, medication, activity modification, and corticosteroid injection have failed. The metacarpophalangeal joint is stable. What is the most appropriate definitive treatment?

A 38-year-old man presents 8 months after a missed scapholunate ligament injury. He has dorsal wrist pain, reduced grip strength, and dynamic scapholunate widening. Under anesthesia, the scaphoid and lunate can be reduced to normal alignment, and imaging shows no radiocarpal or midcarpal arthritis. The native ligament is no longer repairable. What is the most appropriate reconstructive principle?

A 7-year-old child presents after a door-crush injury to the little finger. Radiographs show a displaced phalangeal neck fracture with rotation of the distal fragment. Closed reduction is difficult to maintain, and the finger demonstrates visible angular deformity. What is the most appropriate management?

A 13-year-old girl has gradually progressive flexion contracture of both little-finger proximal interphalangeal joints. The deformities are painless, passively correctable, and do not interfere significantly with hand function. Radiographs show no articular destruction. What is the most appropriate initial management?

A 26-year-old man sustains a complete radial collateral ligament rupture of the index metacarpophalangeal joint after forced ulnar deviation. Examination shows marked radial-sided tenderness, no firm endpoint during stress testing, and instability that interferes with pinch. Radiographs show no major fracture. What is the most appropriate management?

A 34-year-old man sustains a high-energy forearm injury after a motorcycle collision. Radiographs show a displaced proximal ulnar shaft fracture with anterior dislocation of the radial head. The skin is intact, and the hand is neurovascularly intact. What is the most appropriate definitive management?

A 29-year-old factory worker sustains an open crush injury of the index finger. After debridement, there is segmental loss of the proximal phalanx, disruption of the extensor mechanism, and a dorsal skin defect with exposed bone. Both digital arteries remain patent, and the finger is potentially salvageable. What is the most appropriate reconstructive strategy?

A 46-year-old active man presents 4 months after an untreated distal biceps tendon rupture. He has marked weakness of supination, a retracted tendon that cannot be mobilized to the radial tuberosity without excessive tension, and preserved elbow motion. What is the most appropriate reconstruction?

A 52-year-old woman undergoes fixation of a proximal radius fracture. Immediately after surgery, she cannot extend the fingers or thumb at the metacarpophalangeal joints, although wrist extension is preserved with radial deviation. There is no sensory loss, and preoperative motor examination was normal. What is the most appropriate next step?

A 27-year-old woman sustains a crush-avulsion injury to the proximal nail fold of the thumb. The nail plate is displaced, the germinal matrix is lacerated, and the distal phalanx is stable. What is the most appropriate management?

A 4-month-old infant has a deep congenital constriction ring around the forearm with progressive distal edema, reduced hand perfusion, and increasing limitation of finger motion. What is the most appropriate management?

A 24-year-old man with C6-level tetraplegia has strong wrist extension but no useful finger flexion. The hand is supple, passive finger motion is full, and he wishes to regain grasp for daily activities. What is the most appropriate reconstructive option?

A 39-year-old man has chronic painful distal radioulnar joint instability after a traumatic triangular fibrocartilage complex injury. The native stabilizing tissue is irreparable, but the joint remains reducible and the articular surfaces are preserved. What is the most appropriate definitive treatment?

A 13-year-old child with spastic hemiplegia has a flexible thumb-in-palm deformity. The first web space is narrow, the adductor pollicis is tight, and the extensor pollicis longus and abductor pollicis longus are weak but functional. The joints remain passively correctable. What is the most appropriate reconstructive principle?

A 33-year-old man develops purulent drainage and increasing pain 9 days after zone II flexor tendon repair. Operative exploration shows an infected repair, necrotic tendon ends, and inflamed pulley tissue. What is the most appropriate management?

A 34-year-old man sustains a circular-saw injury to the dorsum of the hand. After debridement, there is a 6-cm soft-tissue defect with exposed second and third metacarpals, extensor tendon loss, and a clean wound bed. The metacarpal fractures have been stabilized. What is the most appropriate reconstructive plan?

A 28-year-old woman presents 3 months after repair of the flexor digitorum profundus tendon of the ring finger. She has full passive distal interphalangeal motion but only 10 degrees of active flexion. Ultrasonography confirms tendon continuity with dense adhesions. A further 3 months of supervised therapy produces no improvement. What is the most appropriate management?

A 45-year-old man presents after a sharp laceration at the volar base of the thumb. He cannot flex the thumb interphalangeal joint, and exploration demonstrates complete flexor pollicis longus division with minimal tissue loss. The tendon ends can be approximated without tension. What is the most appropriate treatment?

A 62-year-old woman presents with painful weakness of pinch and progressive numbness of the ring and little fingers. Examination shows intrinsic wasting, a positive Froment sign, and tenderness over Guyon canal. Sensation over the dorsal ulnar hand is preserved. Ultrasound demonstrates thrombosis and aneurysmal enlargement of the ulnar artery compressing the adjacent ulnar nerve. What is the most appropriate management?

A 40-year-old man presents 8 months after a distal radius fracture with painful limitation of forearm rotation. Computed tomography shows a malunited sigmoid notch with distal radioulnar joint incongruity, but the articular cartilage is not severely degenerated. What is the most appropriate reconstructive principle?

A 30-year-old man sustains a sharp laceration across the dorsal thumb metacarpophalangeal joint. He cannot actively extend the thumb interphalangeal joint, but passive motion is full. Exploration reveals complete extensor pollicis longus division with healthy tendon ends. What is the most appropriate management?

A 6-year-old child has complete syndactyly between the middle and ring fingers and partial syndactyly between the ring and little fingers. The digits are straight, and there is no urgent growth-related deformity. What is the safest operative strategy?

A 51-year-old manual laborer has painful post-traumatic arthritis limited to the distal interphalangeal joint of the index finger. The joint is unstable, motion is minimal and painful, and conservative treatment has failed. What is the most appropriate definitive treatment?

A 37-year-old man sustains a complete amputation of the middle finger through the proximal phalanx and a partial amputation of the ring finger with intact arterial inflow. The amputated middle finger is severely crushed, while the ring finger is potentially salvageable. What is the most appropriate reconstructive priority?

A 44-year-old man presents 18 months after a high median nerve injury. Sensation has partially returned, but thumb opposition remains absent. Passive thumb motion is full, the first web space is adequate, and the flexor digitorum superficialis of the ring finger is strong. What is the most appropriate reconstruction?

A 56-year-old woman with rheumatoid arthritis presents with progressive ulnar deviation of the fingers at the metacarpophalangeal joints. The extensor tendons subluxate into the ulnar gutters during flexion, but the deformity remains passively correctable and radiographs show preserved joint surfaces. Medical control of the inflammatory disease has been optimized. What is the most appropriate reconstructive treatment?

A 42-year-old woman has persistent radial styloid pain from de Quervain tenosynovitis despite activity modification, thumb-spica splinting, and two accurately placed corticosteroid injections. Ultrasound demonstrates separate subcompartments for the abductor pollicis longus and extensor pollicis brevis tendons. What is the most appropriate definitive treatment?

A 34-year-old athlete presents with persistent ulnar-sided wrist pain after a twisting injury. Arthroscopy demonstrates a traumatic central triangular fibrocartilage complex perforation. The distal radioulnar joint is stable, the peripheral foveal attachment is intact, and radiographs show neutral ulnar variance without arthritis. What is the most appropriate treatment?

A 38-year-old manual worker has painful post-traumatic distal radioulnar joint arthritis with restricted pronation and supination. The triangular fibrocartilage complex is irreparable, but the radiocarpal joint is preserved and maintaining ulnar support of the carpus is important. Conservative treatment has failed. What is the most appropriate salvage procedure?

A 67-year-old woman has advanced thumb carpometacarpal osteoarthritis with severe pain and metacarpal subluxation. She also has a fixed 45-degree hyperextension deformity of the thumb metacarpophalangeal joint that does not correct with passive examination. Conservative treatment has failed. What is the most appropriate operative plan?

A 45-year-old woman presents with a slowly enlarging tender mass along the volar distal forearm. Percussion over the lesion produces tingling into the thumb and index finger. Magnetic resonance imaging demonstrates a well-circumscribed eccentric mass arising from the median nerve and displacing rather than diffusely infiltrating the fascicles. What is the most appropriate management?

A 40-year-old man presents 4 days after a puncture injury to the central palm. He has deep palmar pain, loss of the normal palmar concavity, swelling that is more prominent dorsally, and painful limitation of the middle and ring fingers. The thenar and hypothenar regions are relatively spared. What is the most appropriate management?

A 43-year-old man has an irreparable radial nerve injury in the proximal arm with no recovery 14 months after trauma. The wrist and finger joints are supple, pronator teres, flexor carpi radialis, and palmaris longus are strong, and passive thumb extension is full. What is the most appropriate tendon-transfer reconstruction?

A 6-year-old child has progressive macrodactyly of the index and middle fingers. The enlarged digits are becoming longer and broader than the remaining fingers, interfere with grasp, and show increasing angular deformity. Sensation and perfusion are intact. What is the most appropriate management principle?

A 69-year-old woman with low physical demands has severe bilateral rheumatoid wrist arthritis. One wrist has constant pain and marked loss of motion despite medication, splinting, and injections. Finger function is reasonably preserved, bone stock is adequate, and she strongly wishes to retain some wrist movement for personal care. What is the most appropriate surgical option?

A 27-year-old man sustains a sharp laceration directly over the dorsal proximal interphalangeal joint of the index finger. He cannot actively extend the proximal interphalangeal joint, and exploration demonstrates complete division of the central slip with an intact joint surface and viable lateral bands. The wound is clean and less than 6 hours old. What is the most appropriate management?

A 46-year-old woman presents 18 months after an untreated mallet injury. She has a fixed 45-degree distal interphalangeal extensor lag, painful distal interphalangeal osteoarthritis, and recurrent skin irritation over the dorsal joint. Splinting has failed, and the proximal interphalangeal joint remains well aligned. What is the most appropriate definitive treatment?

A 55-year-old woman continues to experience painful locking of the ring finger 3 months after surgical trigger-finger release. Examination reveals persistent catching at the level of the distal palmar crease, and ultrasonography shows incomplete division of the distal A1 pulley without flexor tendon rupture. What is the most appropriate next step?

A 33-year-old man sustains a deep transverse laceration across the central palm. The superficial palmar arch is divided, and the thumb, index, and middle fingers are pale with delayed capillary refill despite intact radial and ulnar arteries at the wrist. What is the most appropriate management?

A 29-year-old woman sustains a clean laceration of the ulnar digital nerve of the thumb. After debridement to healthy fascicles, a 28-mm gap remains with the thumb in a neutral position. Direct approximation would create significant tension, and protective thumb sensibility is important for her occupation. What is the most appropriate reconstruction?

A 41-year-old man has a 7-cm dorsal hand defect after debridement of an industrial injury. The extensor tendons and stable metacarpal fixation plates are exposed, local hand tissue is unavailable, and the ipsilateral posterior forearm skin is uninjured. What is the most appropriate reconstruction?

A 36-year-old man presents 9 months after a scaphoid waist fracture. Computed tomography shows a mobile nonunion with humpback deformity, and magnetic resonance imaging suggests avascular necrosis of the proximal fragment. The radiocarpal and midcarpal joints remain free of arthritis. What is the most appropriate treatment?

A 45-year-old man develops severe elbow stiffness 10 months after a fracture-dislocation. Flexion is limited to 70 degrees, extension lacks 50 degrees, and forearm rotation is restricted. Computed tomography demonstrates a mature heterotopic bone bridge around the elbow, and the patient also has ulnar-distribution paresthesia. What is the most appropriate definitive management?

A 52-year-old man presents with painful limitation of forearm rotation and ulnar-sided wrist impaction after a distal radius fracture healed with 12 degrees of dorsal tilt, radial shortening, and sigmoid-notch incongruity. The distal radioulnar joint cartilage is preserved. What is the most appropriate definitive treatment?

A 39-year-old woman undergoes excision of a recurrent soft-tissue tumor from the volar wrist. The final defect exposes the median nerve, several flexor tendons, and the radial artery over a length of 9 cm. Local tissues are scarred from previous surgery, and a thin pliable reconstruction is required to preserve tendon gliding. What is the most appropriate coverage?

A 28-year-old skier presents 5 days after forced radial deviation of the thumb metacarpophalangeal joint. Examination shows marked valgus instability in both flexion and extension with no firm endpoint. Ultrasound demonstrates complete ulnar collateral ligament rupture with the ligament displaced superficial to the adductor aponeurosis. What is the most appropriate management?

A 35-year-old man presents 8 months after flexor tendon repair of the ring finger. He has visible and palpable bowstringing during flexion, reduced active finger flexion, and preserved passive joint motion. Imaging confirms severe incompetence of the A2 pulley, while the repaired flexor tendons remain intact. What is the most appropriate definitive treatment?

A 31-year-old man presents after a high-energy wrist injury. Radiographs show the lunate displaced volarly and rotated out of the lunate fossa, while the remaining carpus is relatively aligned with the radius. He has numbness in the thumb, index, and middle fingers. What is the most appropriate management?

A 48-year-old man has a chronic low ulnar nerve palsy with clawing of the ring and little fingers. When the examiner prevents metacarpophalangeal hyperextension, the patient can fully extend both interphalangeal joints. Passive motion is full, and the deformity is flexible. What is the most appropriate reconstructive procedure?

A 36-year-old man presents one year after infection and failure of a zone II flexor tendon repair. The finger has full passive motion after therapy, but there is no active flexion. Exploration demonstrates severe sheath scarring, loss of the native flexor tendon, and inadequate pulleys for immediate grafting. What is the most appropriate reconstructive plan?

A 40-year-old man presents with a painful pulsatile mass along the radial side of the index finger 6 weeks after a glass laceration. Duplex ultrasonography demonstrates a pseudoaneurysm of the radial digital artery. The ulnar digital artery is patent, and the fingertip remains well perfused during temporary compression of the affected vessel. What is the most appropriate treatment?

A 52-year-old manual worker has a painful rigid middle finger after multiple failed reconstructions for a severe crush injury. The finger has minimal sensation, no useful active motion, and projects into the palm, interfering with grasp. The metacarpal and adjacent digits are healthy. What is the most appropriate definitive management?

A 45-year-old man presents 8 months after an untreated thumb metacarpophalangeal ulnar collateral ligament injury. He has painful valgus instability, weak key pinch, and a firm endpoint only after marked deviation. Radiographs show no significant arthritis, and the ligament remnants are attenuated and unsuitable for direct repair. What is the most appropriate treatment?

A 12-month-old child has complete simple syndactyly of the middle and ring fingers extending to the fingertips. The nails are separate, there is no bony fusion, and both digits have normal perfusion. What is the most appropriate reconstructive management?

A 24-year-old man presents 18 hours after punching another person in the mouth. He has a 1-cm laceration over the dorsal third metacarpophalangeal joint, increasing pain, swelling, and reduced joint motion. When the finger is flexed, the wound tracks into the joint and partially divides the extensor tendon. What is the most appropriate management?

A 57-year-old man with poorly controlled diabetes presents 18 hours after a minor puncture wound to the palm. He has rapidly progressive swelling extending into the forearm, severe pain beyond the visible erythema, hemorrhagic bullae, skin anesthesia, and systemic hypotension. Crepitus is absent, and radiographs show no gas. What is the most appropriate next management step?

A 31-year-old cabinetmaker loses most of the volar thumb pulp in a saw injury. After debridement, a 3-cm defect exposes the distal phalanx and flexor pollicis longus insertion. Thumb length is preserved, local advancement is insufficient, and durable sensate coverage is required for precision pinch. The dorsal index finger is uninjured. What is the most appropriate reconstruction?

A 48-year-old man has a 9-cm dorsal hand defect after debridement of an infected metacarpal fixation site. The infection is controlled, the hardware is stable and must remain, and multiple extensor tendons lack paratenon. Microsurgical free-tissue transfer is temporarily unavailable. Allen testing and angiography confirm a complete palmar arch with reliable ulnar arterial supply. What is the most appropriate coverage?

A 39-year-old woman has severe burning pain and an electric shock sensation over the dorsoradial hand 10 months after first dorsal compartment surgery. A small tender mass is present in the operative scar, and percussion reproduces symptoms into the thumb-index web space. Diagnostic local anesthetic injection provides temporary complete relief. Desensitization and medication have failed. What is the most appropriate operative treatment?

A 22-year-old woman has a compressible bluish mass involving the palm and thenar region that enlarges when the hand is dependent. Magnetic resonance imaging shows a multiloculated low-flow venous malformation infiltrating several tissue planes without arterial flow voids. She has recurrent pain and localized thrombosis but no motor deficit. What is the most appropriate initial interventional treatment?

A 43-year-old mechanic presents with progressive swelling and tenderness of the distal index finger years after a penetrating metal injury. Radiographs show a well-defined expansile lytic lesion in the distal phalanx with a thin sclerotic margin and no aggressive periosteal reaction. Magnetic resonance imaging shows a keratin-containing cystic lesion. What is the most appropriate treatment?

A 4-year-old child with an obstetric upper brachial plexus injury has recovered elbow flexion but maintains the shoulder in internal rotation. Passive external rotation is limited, and magnetic resonance imaging shows early posterior glenohumeral subluxation without advanced joint deformity. What is the most appropriate reconstructive strategy?

A 30-year-old man presents 20 months after a pan-brachial plexus injury. Shoulder stability has been reconstructed, but he has no active elbow flexion. Local elbow flexor muscles are irreversibly denervated, passive elbow motion is full, and no suitable regional tendon-transfer donor remains. What is the most appropriate functional reconstruction?

A 62-year-old woman has persistent median-distribution numbness and nocturnal pain from the day of an open carpal tunnel release performed 4 months earlier. She never experienced postoperative improvement. Ultrasound shows persistent compression at the distal edge of the transverse carpal ligament, and electrodiagnostic testing demonstrates ongoing median neuropathy. What is the most appropriate management?

A 25-year-old man accidentally injects concentrated epinephrine into the volar pulp of the index finger from an autoinjector. Thirty minutes later, the finger remains pale, cold, painful, and without capillary refill despite warming and removal of constrictive items. What is the most appropriate next treatment?