ABOS Surgery of the Hand common mistakes
ABOS Surgery of the Hand · Understand the traps and how to avoid them.
For a displaced intra-articular distal radius fracture in a young patient, the candidate accepts closed reduction and casting without documenting articular step-off, carpal malalignment, or DRUJ instability.
Pattern recognition that 'distal radius fractures are usually casted' overrides articular congruity and instability criteria.
What to do instead
Use a checklist for articular step/gap, radial inclination, volar tilt, carpal alignment, and DRUJ; obtain CT when intra-articular detail is unclear and indicate surgery for persistent step-off or instability.
For a Bennett fracture, the candidate accepts closed reduction and thumb spica casting despite persistent articular step-off or subluxation on fluoroscopy.
Underestimating the deforming pull of the abductor pollicis longus and the need for stable articular reduction.
What to do instead
Confirm articular reduction with fluoroscopy or CT; use percutaneous pinning or open reduction and internal fixation when reduction is not anatomic or is unstable.
In a flexor tendon laceration, the candidate tests only composite finger flexion and misses an isolated flexor digitorum profundus injury.
The flexor digitorum superficialis can produce apparent composite flexion and mask a profundus laceration.
What to do instead
Test flexor digitorum profundus and superficialis individually with adjacent digits held in extension; document each tendon and check both wrists.
The candidate schedules syndactyly release in a newborn before six months of age without first distinguishing simple from complex syndactyly or obtaining imaging for bony synostosis.
Urgency to 'fix early' replaces assessment of web space anatomy, bony fusion, and growth timing.
What to do instead
Examine the web and obtain radiographs when bony fusion is suspected; plan simple border syndactyly around 6–12 months and central/complex cases with individualized timing and staging.
The candidate recommends pollicization for a type IIIA hypoplastic thumb or performs tendon transfer alone for a type IIIB thumb.
Blauth classification is applied by thumb size alone without assessing carpometacarpal joint stability and first web space.
What to do instead
Classify by carpometacarpal joint presence/stability and web adequacy; reconstruct type IIIA and pollicize type IIIB/IV when the carpometacarpal joint is unstable or absent.
The candidate treats thumb carpometacarpal arthritis with trapeziectomy but ignores fixed metacarpophalangeal hyperextension and scaphotrapeziotrapezoid arthritis.
Focusing on the most obvious carpometacarpal joint fails to assess the whole thumb ray and compensatory deformity.
What to do instead
Examine metacarpophalangeal hyperextension and scaphotrapeziotrapezoid tenderness; add metacarpophalangeal pinning/arthrodesis or address scaphotrapeziotrapezoid disease when present.
The candidate offers surgery for a painful palmar Dupuytren nodule without a measurable contracture or functional deficit.
Equating a palpable nodule with operative indication rather than documenting joint contracture and functional impact.
What to do instead
Record tabletop test, metacarpophalangeal and proximal interphalangeal angles, and functional limitation; observe stable nodules without contracture.
The candidate diagnoses carpal tunnel syndrome and proceeds to release based on nocturnal numbness alone in a patient with diabetes, without median nerve testing or excluding polyneuropathy and cervical radiculopathy.
Anchoring on the common diagnosis and failing to localize the nerve or consider systemic causes.
What to do instead
Examine median innervation, thenar atrophy, Tinel/Phalen, and two-point discrimination; obtain electrodiagnostics or ultrasound and screen for polyneuropathy/radiculopathy when atypical.
The candidate places a local random flap or skin graft over exposed tendon or joint before adequate debridement of a contaminated hand wound.
Closure is prioritized over wound bed preparation and durable coverage.
What to do instead
Perform serial debridement and cultures, then select coverage by defect location, size, and vascularity; use flaps for exposed tendon/joint without paratenon or periosteum.
The candidate treats flexor tenosynovitis with oral antibiotics and splinting instead of urgent surgical drainage.
Underestimating a closed-space infection and relying on mild early symptoms rather than Kanavel signs.
What to do instead
Recognize Kanavel signs, start intravenous antibiotics, and proceed to operating room irrigation and debridement; do not delay for oral therapy.