It looks like she is about to wail away with the fulcrum in mid position near the instrument's hinge. This was for relatively minor offenses like passing an instrument to a resident rather than the attending surgeon, even though the resident was in the proper position to deal with the problem. Rules were rules-always provide the attending surgeon first.
The most brutal knuckle cracks were for any offense, real or imagined. that broke aseptic technique. Alice was an equal opportunity knuckle basher and residents were fodder for her cruel ministrations as well as nurses. She caught a young resident with his nostrils protruding over his mask and he received a double punishment, Cracked knuckles and a set of dental rolls plugging his nose. I think there might be an old post about that Aliceism somewhere amidst my foolishness.