Hand Surgery Practice Questions

Q: A 20-year-old girl presents to the OPD with complaints of a progressively increasing swelling on the dorsum of the left wrist. The swelling is cystic and nontender on examination and becomes more prominent on plantar flexion of the wrist. The swelling is 2 cm × 1 cm in size. What is the likely diagnosis in this case?

Ganglion cyst. ***Ganglion cyst*** - A **ganglion cyst** is the most common mass of the hand and wrist. It presents as a **smooth, firm, mobile cystic mass** that transilluminates. - It classically appears on the **dorsum of the wrist** and often becomes more prominent with wrist flexion (or plantar flexion of the wrist, as stated in the question, though dorsiflexion/flexion are more common terms for the wrist). *Dermoid cyst* - **Dermoid cysts** are congenital and result from entrapment of ectodermal and mesodermal elements. They are typically found in areas of **embryonic fusion lines** (e.g., face, scalp). - While they can be cystic, they are usually **immobile** and do not typically fluctuate in prominence with wrist movement. *Sebaceous cyst* - Also known as an **epidermoid cyst** (when arising from epidermis) or a **pilar cyst** (when arising from hair follicle), these are typically filled with keratin and sebum. - They tend to occur in areas with **hair follicles** (e.g., scalp, trunk, face) and often have a visible central punctum; they are less common on the dorsum of the wrist. *Epidermoid cyst* - **Epidermoid cysts** are subepidermal nodules formed by the cystic enclosure of epidermal cells. They are typically firm and mobile. - While they can occur anywhere, they are less characteristic of the dorsum of the wrist, and their prominence is generally **not affected by wrist movement**.

Q: Which one of the following bones is affected in Keinbock's disease?

Lunate bone. ***Lunate bone*** - Kienbock's disease is an **avascular necrosis** of the **lunate bone** in the wrist, leading to its collapse and fragmentation over time. - This condition is often associated with repetitive trauma, negative ulnar variance, and altered blood supply to the lunate. *Capitellum of the humerus* - Avascular necrosis of the capitellum is known as **Panner's disease**, which is distinct from Kienbock's disease. - Panner's disease primarily affects children and adolescents, often due to repetitive throwing or overhead activities. *Metatarsal* - Avascular necrosis of the metatarsal heads is seen in conditions like **Freiberg's disease**, which typically affects the second metatarsal. - This condition presents with forefoot pain and differs significantly in location and affected bone from Kienbock's disease. *Navicular bone* - Avascular necrosis of the tarsal navicular bone is referred to as **Kohler's disease**, predominantly appearing in young children. - This condition affects the foot and is not related to the wrist pathologies seen in Kienbock's disease.

Q: Patient had an injury to thumb causing thumb abduction. Which of the following can happen?

Game keepers thumb. ***Gamekeeper's thumb*** - A **Gamekeeper's thumb**, or **skier's thumb**, is an injury to the **ulnar collateral ligament (UCL)** of the thumb's metacarpophalangeal (MCP) joint. - This injury commonly occurs due to a **forceful abduction** and hyperextension of the thumb. *Kaplan lesion* - A **Kaplan lesion** refers to an avulsion fracture of the radial styloid process, usually associated with scaphoid fractures. - This lesion is typically related to wrist injuries, not primarily thumb abduction. *Bennett fracture* - A **Bennett fracture** is an intra-articular fracture at the base of the first metacarpal bone. - It usually results from an axial load applied to a partially flexed thumb, rather than pure abduction. *Mallet finger* - A **mallet finger** is an injury to the **extensor tendon** of the finger, causing the fingertip to remain in a flexed position. - This injury typically affects the distal interphalangeal (DIP) joint of any finger and is not directly related to thumb abduction.

Q: A 56-year-old female presents with nocturnal pain in the right thumb, index, and middle fingers for the past 3 months. All of the following provocative tests can be performed except:

Finkelstein's test. ***Finkelstein's test*** - **Finkelstein's test** is used to diagnose **De Quervain's tenosynovitis**, which involves inflammation of the tendons on the thumb side of the wrist. - The patient's symptoms (nocturnal pain in the thumb, index, and middle fingers) are classic for **carpal tunnel syndrome (CTS)**, not De Quervain's. *Phalen's test* - **Phalen's test** is a provocative test for **carpal tunnel syndrome (CTS)**, where the patient forcefully flexes their wrists for 60 seconds. - A positive result, indicated by numbness or tingling in the median nerve distribution, supports a diagnosis of CTS. *Tourniquet test* - While not as commonly used as Phalen's or Tinel's, the **tourniquet test** (or **pressure test**) can provoke symptoms of **carpal tunnel syndrome (CTS)** by applying pressure to the median nerve. - It involves applying a blood pressure cuff to compress the wrist above the carpal tunnel, which can elicit median nerve symptoms. *Tinel sign* - The **Tinel sign** is a classic test for **carpal tunnel syndrome (CTS)**, performed by tapping directly over the median nerve at the wrist. - A positive sign is indicated by tingling or shock-like sensations radiating into the thumb, index, and middle fingers.

Q: A 45-year-old man visits the outpatient clinic after a digit of his left hand was injured when a door was slammed on his hand. A superficial cut on his middle finger has been sutured, but functional deficits are observed in the finger: The proximal interphalangeal joint is pulled into constant flexion, whereas the distal interphalangeal joint is held in a position of hyperextension. What is the most likely diagnosis?

Boutonniere deformity. ***Boutonniere deformity*** - This deformity is characterized by **flexion of the proximal interphalangeal (PIP) joint** and **hyperextension of the distal interphalangeal (DIP) joint**, a classic presentation resulting from damage to the central slip of the extensor tendon. - The injury to the finger from the door slam likely caused trauma to the **extensor mechanism**, leading to this specific joint posture. *Mallet finger* - This condition involves an inability to **extend the distal interphalangeal (DIP) joint**, resulting in a constant flexed posture of the DIP joint. - It usually occurs due to a rupture or avulsion of the **extensor tendon at its insertion on the distal phalanx**, which is different from the described PIP flexion and DIP hyperextension. *Dupuytren's contracture* - This involves a progressive **fibrosis of the palmar fascia**, leading to fixed flexion deformities primarily in the metacarpophalangeal (MCP) and PIP joints. - It most commonly affects the **ring and little fingers** and is generally an idiopathic or inherited condition, not typically caused by acute trauma like a door slam. *Swan-neck deformity* - This deformity presents with **hyperextension of the PIP joint** and **flexion of the DIP joint**, which is the inverse of the described clinical picture. - It is often seen in conditions like **rheumatoid arthritis** or following trauma that disrupts the flexor tendons.

Q: Scaphoid fracture at waist with retrograde blood supply. Which segment is most susceptible to avascular necrosis?

Proximal. ***Proximal*** - The **scaphoid's blood supply** enters primarily through its distal pole and then flows proximally; a fracture at the **waist** disrupts blood flow to the **proximal segment**. - Without adequate blood supply, the **proximal fragment** is highly susceptible to **avascular necrosis**. *Middle* - A fracture at the **waist** *is* a fracture in the middle third of the scaphoid. The question asks which *segment* of the scaphoid is most susceptible following such a fracture. - While the fracture is in the middle, the **proximal segment** is the piece of bone that loses its blood supply due to the **retrograde blood flow**. *Distal* - The **distal segment** of the scaphoid receives its blood supply directly from branches that enter the distal pole, meaning blood flow to this part is usually preserved even with a waist fracture. - Therefore, the **distal segment** is less likely to suffer from **avascular necrosis** compared to the proximal segment. *Scaphoid tubercle* - The **scaphoid tubercle** is part of the distal pole and receives its own robust blood supply. - A fracture at the **waist** generally does not compromise the blood supply to the **scaphoid tubercle**.

Q: No man's land in palm corresponds to -

Zone II. ***Zone II*** - **Zone II** of the flexor tendons, extending from the distal palmar crease to the mid portion of the middle phalanx, is known as "no man's land" due to the historical difficulty in achieving good outcomes after tendon repair. - This zone houses both the **flexor digitorum superficialis** and **flexor digitorum profundus** tendons within a single fibro-osseous sheath, making repairs complex and prone to adhesions. *Zone I* - **Zone I** extends from the insertion of the **flexor digitorum profundus** (distal to the middle phalanx) to the midportion of the middle phalanx [1]. - Injuries in this zone typically involve only the **profundus tendon**, allowing for more straightforward repair due to lack of the superficialis tendon. *Zone IV* - **Zone IV** constitutes the carpal tunnel, where nine flexor tendons and the median nerve pass through a confined space. - While injuries here can be severe due to potential nerve involvement, they are not typically referred to as "no man's land" in the context of tendon repair due to better outcomes historically compared to Zone II. *Zone III* - **Zone III** extends from the distal end of the carpal tunnel to the beginning of the A1 pulley (distal palmar crease). - This zone is predominantly in the palm and offers more space for tendon repair, leading to better outcomes than Zone II, as the tendons diverge here and are not yet constrained within a common sheath.

Q: A 65-year-old alcoholic suffering from diabetes has a flexion deformity of the right little finger over the metacarpophalangeal joint of around 15 degrees. The ideal management would be:

Observation. ***Observation*** - A 15-degree flexion deformity of the **metacarpophalangeal (MCP) joint** is considered mild and does not significantly impair hand function, making observation the appropriate initial management. - The goal of intervention in **Dupuytren's contracture** is to improve hand function, and surgical or medical treatment is typically reserved for deformities of **30 degrees or more** at the MCP joint or any **proximal interphalangeal (PIP) joint contracture**. *Complete fasciectomy* - This procedure involves the **excision of all diseased palmar fascia**, including tissue not directly involved in the contracture. - Due to its **aggressiveness** and higher rates of complications and recurrence, complete fasciectomy is generally **not recommended** for Dupuytren's contracture. *Partial (selective) fasciectomy* - This involves the **excision of only the diseased and contracted fascia**, aiming to release the finger contracture. - While an effective treatment for advanced Dupuytren's contracture, it is **overtreatment** for a mild, 15-degree MCP joint deformity, which typically does not require surgical intervention. *Percutaneous fasciotomy* - This minimally invasive procedure involves **dividing the contracted cords** using a needle, typically performed in an outpatient setting. - It's mainly suitable for **isolated cord contractures** at the MCP joint without extensive fascial involvement and for patients who prefer less invasive options, but similar to fasciectomy, it is reserved for more significant contractures to improve function.

Q: Which of the following is the most frequent tumor of the bone in the hand:

Enchondroma. ***Enchondroma*** - **Enchondromas** are the **most frequent benign tumors** of the bone in the hand, commonly arising from persistent hyaline cartilage rests within the medullary cavity. - They are typically discovered incidentally on radiographs and can present with pain if there's a **pathologic fracture**. *Hemangioma* - **Hemangiomas** are benign vascular tumors more commonly found in the **skull and vertebrae**, and less frequently in the hands. - While they can occur in bone, they are not the most common bone tumor in the hand. *Ganglion cyst of the bone* - An **intraosseous ganglion cyst** is a benign cystic lesion within the bone, typically communicating with a joint or tendon sheath. - While they can occur in the wrist and hand, they are less common than enchondromas as primary bone lesions within the digits. *Synovioma* - **Synovioma** (more accurately called **synovial sarcoma**) is a rare, malignant soft tissue tumor that typically arises near joints, bursae, or tendon sheaths, not primarily within the bone itself. - It is a highly aggressive tumor and not a frequent benign bone tumor of the hand.

Q: A lady having flexion at the proximal interphalangeal joint and hyperextension at the distal interphalangeal joint of the index finger is called:

Boutonniere deformity. ***Boutonniere deformity*** - This deformity is characterized by **flexion of the proximal interphalangeal (PIP) joint** and **hyperextension of the distal interphalangeal (DIP) joint**, often due to damage to the central slip of the extensor tendon. - It is commonly seen in conditions like **rheumatoid arthritis** or following trauma to the finger. *Z deformity* - This deformity typically affects the **thumb**, presenting as **hyperflexion of the metacarpophalangeal (MCP) joint** and **hyperextension of the interphalangeal (IP) joint**, giving a "Z" shape. - It primarily involves the thumb and not the PIP and DIP joints in the described manner. *Wind swept deformity* - This refers to a deformity in which the **knees are angled in opposite directions**, resembling how trees might bend in a strong wind, where one knee is in valgus and the other in varus. - This is a lower limb deformity and is not related to finger joint deformities. *Swan neck deformity* - This deformity is characterized by **hyperextension of the proximal interphalangeal (PIP) joint** and **flexion of the distal interphalangeal (DIP) joint**, which is the opposite of the given description. - It also commonly occurs in conditions like **rheumatoid arthritis** but presents with a distinct pattern of joint involvement.

Question 1

A 20-year-old girl presents to the OPD with complaints of a progressively increasing swelling on the dorsum of the left wrist. The swelling is cystic and nontender on examination and becomes more prominent on plantar flexion of the wrist. The swelling is 2 cm × 1 cm in size. What is the likely diagnosis in this case?

Accepted Answer

Ganglion cyst

Answer

Dermoid cyst

Answer

Sebaceous cyst

Answer

Epidermoid cyst

Question 2

Which one of the following bones is affected in Keinbock's disease?

Accepted Answer

Lunate bone

Answer

Capitellum of the humerus

Answer

Metatarsal

Answer

Navicular bone

Question 3

Patient had an injury to thumb causing thumb abduction. Which of the following can happen?

Accepted Answer

Game keepers thumb

Answer

Kaplan lesion

Answer

Mallet finger

Answer

Bennett fracture

Question 4

A 56-year-old female presents with nocturnal pain in the right thumb, index, and middle fingers for the past 3 months. All of the following provocative tests can be performed except:

Accepted Answer

Finkelstein's test

Answer

Phalen's test

Answer

Tourniquet test

Answer

Tinel sign

Question 5

A 45-year-old man visits the outpatient clinic after a digit of his left hand was injured when a door was slammed on his hand. A superficial cut on his middle finger has been sutured, but functional deficits are observed in the finger: The proximal interphalangeal joint is pulled into constant flexion, whereas the distal interphalangeal joint is held in a position of hyperextension. What is the most likely diagnosis?

Accepted Answer

Boutonniere deformity

Answer

Mallet finger

Answer

Dupuytren's contracture

Answer

Swan-neck deformity

Question 6

Scaphoid fracture at waist with retrograde blood supply. Which segment is most susceptible to avascular necrosis?

Accepted Answer

Proximal

Answer

Middle

Answer

Distal

Answer

Scaphoid tubercle

Question 7

No man's land in palm corresponds to -

Accepted Answer

Zone II

Answer

Zone I

Answer

Zone IV

Answer

Zone III

Question 8

A 65-year-old alcoholic suffering from diabetes has a flexion deformity of the right little finger over the metacarpophalangeal joint of around 15 degrees. The ideal management would be:

Accepted Answer

Observation

Answer

Complete fasciectomy

Answer

Partial (selective) fasciectomy

Answer

Percutaneous fasciotomy

Question 9

Which of the following is the most frequent tumor of the bone in the hand:

Accepted Answer

Enchondroma

Answer

Hemangioma

Answer

Ganglion cyst of the bone

Answer

Synovioma

Question 10

A lady having flexion at the proximal interphalangeal joint and hyperextension at the distal interphalangeal joint of the index finger is called:

Accepted Answer

Boutonniere deformity

Answer

Z deformity

Answer

Wind swept deformity

Answer

Swan neck deformity

Hand Surgery — MCQs

Hand Surgery — MCQs

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