Hand Surgery Practice Questions

Q: A patient experienced a fall onto an outstretched hand, and an X-ray revealed a fracture of the base of the first metacarpal with accompanying subluxation at the carpometacarpal (CMC) joint. Define this type of fracture.

A. Bennett’s fracture. ***Bennett’s fracture***- This is a characteristic **intra-articular fracture** at the base of the **first metacarpal**, which extends into the carpometacarpal (CMC) joint.- The main metacarpal shaft is typically pulled proximally and radially by the **Abductor Pollicis Longus** tendon, leading to the obligatory **subluxation** described.*Scaphoid fracture*- This injury involves one of the **carpal bones** (the scaphoid) in the wrist, not the metacarpal bases or MCP/CMC joints.- Although commonly caused by a fall onto an outstretched hand (FOOSH), its primary presentation is tenderness in the **anatomical snuffbox**.*Reverse Colle’s fracture*- This fracture, also known as **Smith’s fracture**, affects the **distal radius** in the forearm.- It is defined by the **volar** (palmar) displacement of the distal radial fragment, opposite to the displacement seen in a typical Colle's fracture.*Colle’s fracture*- This common FOOSH injury affects the **distal radius** bones in the forearm, not the hand joints.- It is defined by the characteristic **dorsal** (posterior) displacement of the distal radial fragment, often creating a 'dinner fork' deformity.

Q: Which nerve will be involved in the following finding at rest?

Ulnar. ***Ulnar*** - The image displays a classic **Ulnar Claw Hand**, a deformity that occurs at rest due to ulnar nerve palsy. It specifically affects the 4th and 5th digits. - This is caused by paralysis of the medial two **lumbricals** (3rd and 4th) and the **interossei** muscles, leading to unopposed extension at the metacarpophalangeal (MCP) joints and flexion at the interphalangeal (IP) joints of the ring and little fingers. *Median* - A **median nerve** injury typically results in an **“Ape Hand”** deformity (thenar atrophy) or a **“Hand of Benediction”** when the patient tries to make a fist, affecting the 1st, 2nd, and 3rd digits. - It does not cause the clawing of the 4th and 5th digits seen in the image. *Musculocutaneous* - The **musculocutaneous nerve** innervates the muscles of the anterior compartment of the arm, such as the **biceps brachii** and **brachialis**. - Injury to this nerve would lead to weakness in elbow flexion and supination, not a deformity of the hand. *None* - The deformity shown is a well-known clinical sign directly linked to a specific peripheral nerve injury. - As the presentation is characteristic of an ulnar nerve palsy, this option is incorrect.

Q: A teenager presents to the emergency department with wrist pain after falling off his skateboard. He has snuff-box tenderness. Which bone is likely fractured?

Scaphoid. ***Scaphoid*** - **Snuff-box tenderness** is the classic and most reliable clinical sign indicating a scaphoid fracture, usually sustained after a **fall onto an outstretched hand (FOOSH)**, common in young adults and teenagers. - The **scaphoid** is the most frequently fractured carpal bone (approx. 60%) and requires careful immobilization and follow-up due to the high risk of **avascular necrosis** from its retrograde blood supply. ***Trapezoid*** - Fractures of the trapezoid are extremely rare (less than 1% of carpal fractures) because of its stable position wedged between the **second metacarpal** and other carpals. - Tenderness for an isolated trapezoid fracture would be localized to the dorsal aspect of the wrist, more centrally, not specifically within the anatomical snuff box which is bounded by the **extensor tendons** of the thumb. ***Capitate*** - The capitate is the largest carpal bone, located in the center of the wrist, articulating with the **third metacarpal**; it is the second most commonly fractured carpal bone after the scaphoid. - Tenderness would be localized more centrally over the dorsal wrist, proximal to the third metacarpal base, and is not associated with classic **snuff-box tenderness**. ***Trapezium*** - The trapezium carpal bone articulates primarily with the **first metacarpal (thumb)**, forming the highly mobile carpometacarpal joint. - A fracture typically results in tenderness localized to the base of the thumb or the **thenar eminence**, rather than the radial dorsal wrist corresponding to the anatomical snuff box.

Q: A labourer falls on an outstretched hand and complains of pain in the anatomical snuff box. Which of the following is the most appropriate next step?

Thumb spica cast and follow-up after 10-14 days. ***Thumb spica cast and follow-up after 10-14 days*** - The combination of a **fall on an outstretched hand (FOOSH)** and pain in the **anatomical snuff box** is highly suggestive of a **scaphoid fracture**, even if initial X-rays are negative. - The most appropriate initial management is immobilization with a **thumb spica cast** (to prevent non-union) and re-evaluation with a repeat X-ray or advanced imaging in **10–14 days**, as the fracture line often becomes visible after bone resorption. ***NSAIDs and discharge*** - Discharging the patient with only NSAIDs is inappropriate as it risks missing a potentially serious injury like an occult scaphoid fracture, which can lead to complications such as **non-union** and **avascular necrosis (AVN)**. - Scaphoid fractures are the most common carpal fracture and require prompt immobilization due to their precarious blood supply. ***MRI of the wrist*** - While MRI is the **most sensitive and specific** imaging modality for diagnosing an occult scaphoid fracture, it is often not the first line of management in resource-limited or non-critical settings due to cost and availability. - Immobilization and delayed X-ray is the standard, cost-effective initial approach, reserving MRI for cases where early definitive diagnosis is surgically important or when repeat X-rays are inconclusive. ***CT scan of the wrist*** - CT scans are excellent for evaluating **complex fractures**, **comminution**, and defining fragment displacement, but they are less sensitive than MRI or bone scan for detecting acute, undisplaced, occult fractures. - CT is typically used pre-operatively to better plan fixation or distinguish between acute and chronic non-union, rather than as the immediate next step for presumed occult scaphoid injury.

Q: Identify the test being performed.

Book test. ***Book test*** - The image depicts a technique used to assess the strength of **interossei muscles**. The examiner attempts to separate the patient's fingers while the patient tries to keep them adducted. This is characteristic of the **Book test**. - A positive test (inability to resist abduction) suggests weakness of the **interossei muscles**, often seen in conditions affecting the **ulnar nerve**. *Egawa test* - The **Egawa test** specifically assesses the function of the **dorsal interossei** of the middle finger. - It involves the patient flexing their middle finger while trying to maintain it in a straight line, resisting abduction or adduction. *Card test* - The **Card test** involves holding a piece of paper or a **card** between the fingers (usually between the thumb and index finger, or between adjacent fingers). - It is used to assess the strength of the **adductor pollicis** (if between thumb and index) or **interossei** (if between adjacent fingers), with a positive test (inability to hold the card) indicating muscle weakness, often due to **ulnar nerve palsy**. *Dugas' test* - **Dugas' test** is used to check for **shoulder dislocation**. - The patient is asked to place the hand of the affected arm on the opposite shoulder and attempt to abduct the elbow to the chest wall. Inability to do so indicates a **shoulder dislocation**.

Q: The test is performed for palsy of:

Ulnar nerve. *Ulnar Nerve* - The image shows the **Froment's sign**, which tests for the weakness of the adductor pollicis muscle, innervated by the **ulnar nerve**. - In a positive Froment's sign, the patient compensates for adductor weakness by intensely flexing the **flexor pollicis longus** (innervated by the median nerve) to hold a piece of paper, leading to interphalangeal joint flexion of the thumb.

Q: What is Incorrect about the test being performed?

Tests flexor digitorum superficialis. ***Tests flexor digitorum superficialis*** - This is the **incorrect statement** - the Ochsner Clasp test actually tests the **flexor digitorum profundus (FDP)**, not the flexor digitorum superficialis. - The **FDS is innervated by the median nerve** and remains unaffected in ulnar nerve injuries, while the test specifically evaluates **ulnar nerve function** through FDP assessment. *Ochsner clasp test* - This is the **correct name** for the test being performed, where the patient is asked to clasp their hands together. - It demonstrates **Ochsner's sign**, which is pathognomonic of **high ulnar nerve palsy** affecting the FDP muscles. *Performed in ulnar nerve injury* - The Ochsner clasp test is indeed performed to evaluate **ulnar nerve injury**, specifically **high ulnar nerve lesions** at or above the elbow. - It reveals weakness of the **FDP to the ring and little fingers**, which are the only FDP muscles innervated by the ulnar nerve. *Tests flexor digitorum profundus* - The test specifically evaluates the **flexor digitorum profundus (FDP)** muscles of the ring and little fingers, which are innervated by the **deep branch of the ulnar nerve**. - A positive test shows inability to fully flex the **distal interphalangeal (DIP) joints** of the affected fingers during the clasping motion.

Q: The deformity shown below can be due to involvement of: (AIIMS May 2016)

Ulnar nerve. ***Ulnar nerve*** - The image displays a characteristic **claw hand deformity**, especially prominent in the ring and little fingers, where the metacarpophalangeal (MCP) joints are hyperextended, and the interphalangeal (IP) joints are flexed. - This deformity results from **paralysis of the ulnar innervated intrinsic hand muscles** (interossei and medial two lumbricals), leading to an imbalance between extrinsic and intrinsic muscles. *Median nerve* - **Median nerve injury** typically causes features like "ape hand" (loss of thenar eminence and inability to abduct/oppose thumb) or "hand of benediction" (inability to flex the index and middle fingers). - These deformities primarily affect the radial side of the hand and the thumb, which is not primarily seen in the image. *Radial nerve* - **Radial nerve injury** proximally results in "wrist drop" and inability to extend the wrist and fingers. - This involves paralysis of the extensors of the wrist and digits, which is different from the flexion deformity seen in the image. *Musculocutaneous nerve* - The **musculocutaneous nerve** primarily innervates muscles in the anterior compartment of the arm (biceps brachii, brachialis, coracobrachialis) and provides sensation to the lateral forearm. - Its injury affects elbow flexion and forearm sensation, and does not cause a "claw hand" deformity.

Q: Identify the true statement regarding the clinical examination given in the image:

Wrist is held in forced flexion for 60 sec eliciting pain. ***Wrist is held in forced flexion for 60 sec eliciting pain*** - The image depicts **Phalen's test**, used to diagnose **carpal tunnel syndrome**. In this test, the patient's wrists are held in maximal sustained **flexion** for 30-60 seconds. - The reproduction of **tingling or pain** in the median nerve distribution (thumb, index, middle, and radial half of the ring finger) within this time frame indicates a positive test. *Wrist is held in forced extension for 60 sec* - Holding the wrist in **forced extension** for 60 seconds describes **reverse Phalen's test**, not the standard Phalen's test shown. - While reverse Phalen's test also assesses for **carpal tunnel syndrome**, it typically involves holding the wrists in **extension**. *Wrist is held in forced flexion for 45 sec eliciting pain* - While **flexion** is correct for Phalen's test, the standard duration is up to **60 seconds**, not specifically 45 seconds to determine a positive result. - Pain should be elicited within this timeframe, but the 45-second duration is not the most accurate statement regarding the full range of the test's timing. *Wrist is held in forced extension for 45 sec* - This option incorrectly states **forced extension** rather than flexion for Phalen's test, and the specific duration of 45 seconds is not universally cited as the definitive endpoint for a positive result. - **Forced extension** is part of the reverse Phalen's maneuver, not the test shown.

Q: The following test is done to elicit:

Tapping over the median nerve to elicit symptoms. ***Tapping over the median nerve to elicit symptoms*** - The image depicts the **Tinel's sign** test, where light tapping is performed over the median nerve at the wrist. - This maneuver is used to elicit neurological symptoms like **tingling, numbness, or pain** in the median nerve distribution, indicative of conditions such as **carpal tunnel syndrome**. *Circular friction of the flexors* - **Circular friction** is a massage technique typically applied to muscles or tendons, not directly over a nerve in this manner for diagnostic purposes. - It would be used for muscle relaxation or to address **adhesions**, not to diagnose nerve compression. *Effleurage of the extensors* - **Effleurage** is a light, gliding massage stroke used for relaxation and increasing circulation, typically applied to larger muscle groups. - It is not a diagnostic test for nerve entrapment and is generally performed on the **skin/superficial tissues**, not deep structures like nerves. *Petrissage of the extensor* - **Petrissage** involves kneading, lifting, and wringing of muscles, aiming to affect deeper tissues. - This technique is therapeutic in nature, used to increase **circulation** and **tissue flexibility**, not a diagnostic maneuver for nerve compression.

Question 1

A patient experienced a fall onto an outstretched hand, and an X-ray revealed a fracture of the base of the first metacarpal with accompanying subluxation at the carpometacarpal (CMC) joint. Define this type of fracture.

Accepted Answer

A. Bennett’s fracture

Answer

B. Scaphoid fracture

Answer

C. Reverse Colle’s fracture

Answer

D. Colle’s fracture

Question 2

Which nerve will be involved in the following finding at rest?

Accepted Answer

Ulnar

Answer

Median

Answer

Musculocutaneous

Answer

None

Question 3

A teenager presents to the emergency department with wrist pain after falling off his skateboard. He has snuff-box tenderness. Which bone is likely fractured?

Accepted Answer

Scaphoid

Answer

Trapezoid

Answer

Trapezium

Answer

Capitate

Question 4

A labourer falls on an outstretched hand and complains of pain in the anatomical snuff box. Which of the following is the most appropriate next step?

Accepted Answer

Thumb spica cast and follow-up after 10-14 days

Answer

NSAIDs and discharge

Answer

CT scan of the wrist

Answer

MRI of the wrist

Question 5

Identify the test being performed.

Accepted Answer

Book test

Answer

Egawa test

Answer

Card test

Answer

Dugas' test

Question 6

The test is performed for palsy of:

Accepted Answer

Ulnar nerve

Answer

Median nerve

Answer

Radial nerve

Answer

Axillary nerve

Question 7

What is Incorrect about the test being performed?

Accepted Answer

Tests flexor digitorum superficialis

Answer

Ochsner clasp test

Answer

Performed in ulnar nerve injury

Answer

Tests flexor digitorum profundus

Question 8

The deformity shown below can be due to involvement of: (AIIMS May 2016)

Accepted Answer

Ulnar nerve

Answer

Median nerve

Answer

Radial nerve

Answer

Musculocutaneous nerve

Question 9

Identify the true statement regarding the clinical examination given in the image:

Accepted Answer

Wrist is held in forced flexion for 60 sec eliciting pain

Answer

Wrist is held in forced extension for 60 sec

Answer

Wrist is held in forced flexion for 45 sec eliciting pain

Answer

Wrist is held in forced extension for 45 sec

Question 10

The following test is done to elicit:

Accepted Answer

Tapping over the median nerve to elicit symptoms

Answer

Circular friction of the flexors

Answer

Effleurage of the extensors

Answer

Petrissage of the extensor

Hand Surgery — MCQs

Hand Surgery — MCQs

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