Hand Surgery Practice Questions

Q: The commonly injured carpal bone next to the scaphoid is:

Triquetrum. ***Triquetrum*** - The **scaphoid** is the most commonly fractured carpal bone [1]. After the scaphoid, the **triquetrum** is the next most frequently injured carpal bone. - Injuries to the triquetrum often occur due to **hyperextension of the wrist** with ulnar deviation, typically resulting from falls onto an outstretched hand (FOOSH). *Trapezoid* - The trapezoid is a carpal bone in the **distal row** of the wrist, located medial to the trapezium and lateral to the capitate. - While it can be injured, it is **much less commonly fractured** than the scaphoid or triquetrum due to its protected position and strong ligamentous attachments. *Capitate* - The capitate is the **largest carpal bone** and the central bone in the distal row of the carpus. - Fractures of the capitate are **relatively rare**, often occurring in conjunction with other carpal injuries or dislocations, and are less frequent than triquetral fractures. *Lunate* - The lunate bone is located in the **proximal row** of carpal bones, articulating with the radius and contributing to wrist stability. - While the lunate is crucial in wrist mechanics, it is more commonly associated with **dislocations** or **Kienböck's disease** (avascular necrosis) rather than simple fractures, and is not the next most common fracture after the scaphoid.

Q: Dupuytren's contracture occurs in which of the following conditions? a) Diabetes Mellitus b) Alcohol c) Epilepsy d) Rheumatoid Arthritis e) Chronic Pulmonary disease

ABCE. ***ABCE*** - **Dupuytren's contracture** is commonly associated with several medical conditions, including **diabetes mellitus**, **alcoholism**, **epilepsy** (especially with phenobarbital use), and **chronic pulmonary disease**. - These conditions are known risk factors that contribute to the development of fibrous tissue proliferation in the palmar fascia. *BCDE* - This option correctly identifies **alcohol**, **epilepsy**, and **chronic pulmonary disease** as risk factors, but incorrectly omits **diabetes mellitus**, which is a significant association. - **Rheumatoid arthritis** is generally not considered a primary risk factor for Dupuytren's contracture. *ABCD* - This option includes **diabetes mellitus**, **alcohol**, and **epilepsy**, all known associations. However, it incorrectly includes **rheumatoid arthritis** and omits **chronic pulmonary disease**. - **Rheumatoid arthritis** is a distinct condition with different pathological mechanisms, not typically linked to Dupuytren's. *ABDE* - This option includes **diabetes mellitus**, **alcohol**, and **chronic pulmonary disease** but incorrectly includes **rheumatoid arthritis** and omits **epilepsy**. - **Epilepsy**, particularly with certain medications, is a well-established risk factor for Dupuytren's contracture. *ACDE* - This option includes **diabetes mellitus**, **epilepsy**, and **chronic pulmonary disease** but incorrectly includes **rheumatoid arthritis** and omits **alcohol**. - **Alcoholism** is a strong and frequently cited risk factor for the development of his condition due to its effects on connective tissue.

Q: Which bone is most commonly fractured in the arrow marked area?

Scaphoid. ***Scaphoid*** - This image highlights the **anatomical snuffbox**, which is the classic location for tenderness following a **scaphoid fracture**. - The **scaphoid** is the most common carpal bone to fracture, often resulting from a fall on an **outstretched hand**. *Triquetral* - **Triquetral fractures** are less common than scaphoid fractures and typically result from direct trauma or hyperextension of the wrist. - Pain and tenderness would generally be felt more dorsally and ulnarly, rather than in the anatomical snuffbox. *Lunate* - **Lunate fractures** are relatively rare and often associated with high-energy trauma or chronic wrist instability. - Tenderness over the lunate would be more centrally located on the dorsal aspect of the wrist. *Trapezoid* - The **trapezoid bone** is well-protected by other carpal bones and is one of the least commonly fractured carpal bones. - A fracture would typically present with pain over the base of the index finger and dorsal wrist, distinct from the snuffbox.

Q: Which of the following is not a feature of De Quervain's tenosynovitis?

Autoimmune etiology. ***Autoimmune etiology*** - De Quervain's tenosynovitis is primarily an **overuse injury** or **repetitive strain injury** involving the tendons on the thumb side of the wrist, not an autoimmune disease. - It is often seen in individuals performing repetitive tasks involving wrist and thumb movements, or in new mothers due to lifting infants. *Pain at radial styloid process* - This is a very common and hallmark symptom of De Quervain's tenosynovitis, as the affected tendons (abductor pollicis longus and extensor pollicis brevis) pass over the **radial styloid process**. - Tenderness and pain in this specific area, especially with movement of the thumb, are key diagnostic findings. *Positive Finkelstein's test* - The **Finkelstein's test** is a classic provocative maneuver used to diagnose De Quervain's tenosynovitis, by causing sharp pain at the radial styloid. - This test involves making a fist with the thumb tucked inside, and then deviating the wrist towards the ulnar side, stretching the affected tendons. *Thickening of first dorsal compartment* - **Thickening** and inflammation of the synovial sheath surrounding the **abductor pollicis longus** and **extensor pollicis brevis** tendons within the first dorsal compartment are characteristic pathological features. - This thickening contributes to the symptoms of pain and restricted movement as the tendons rub against the sheath.

Q: Dupuytren's contracture can be caused by -

All of the options. ***All of the options*** - **Dupuytren's contracture** has been associated with several risk factors, including **alcoholism**, **diabetes mellitus**, and certain medications like **phenytoin (Eptoin)**. - The exact mechanism is not fully understood, but these conditions are thought to contribute to the **fibroproliferative process** in the palmar fascia. *Alcoholism* - **Chronic alcohol abuse** is a known risk factor and can exacerbate the fibrotic changes in the palmar fascia. - Alcoholism is linked to increased oxidative stress and altered collagen metabolism, which may contribute to the development of **Dupuytren's contracture**. *Diabetes* - Patients with **diabetes mellitus**, particularly those with poorly controlled glucose levels, have a higher incidence of Dupuytren's contracture. - Diabetic microvascular complications and **advanced glycation end products (AGEs)** are believed to play a role in the fibrotic process. *Eptoin* - **Phenytoin**, often marketed as Eptoin, is an anticonvulsant medication that has been implicated in the development of Dupuytren's contracture. - The mechanism is thought to involve alterations in **collagen metabolism** and fibroblast activity.

Q: Rupture of extensor pollicis longus tendon occurs in all of the following except -

De Quervain's disease. ***De Quervain's disease*** - This condition involves **tenosynovitis** of the **extensor pollicis brevis** and **abductor pollicis longus** tendons, not a rupture of the extensor pollicis longus. - The pathology is an inflammation and thickening of the tendon sheaths, distinct from a tendon tear. *Rheumatoid arthritis* - **Chronic inflammation** in rheumatoid arthritis can lead to weakening and eventual rupture of tendons, including the **extensor pollicis longus**, often due to synovitis eroding the tendon. - The condition creates an environment where tendons are vulnerable to **attrition** and damage, making rupture a recognized complication. *Drummers* - Repetitive, high-force movements involved in drumming can cause significant **stress** and microscopic damage to tendons, including the **extensor pollicis longus**. - Over time, this cumulative trauma can lead to inflammation, degeneration, and eventual **rupture** due to overuse. *Colles' fracture* - A **Colles' fracture** of the distal radius can cause a delayed rupture of the **extensor pollicis longus (EPL)** tendon. - This occurs due to attrition of the tendon as it rubs over the **roughened fracture site** or due to *avascular necrosis* of the tendon as it passes through a narrow osteofibrous tunnel.

Q: Tardy ulnar nerve palsy is seen in ?

Cubitus valgus. ***Cubitus valgus*** - **Cubitus valgus** is an increased carrying angle at the elbow, often a result of a childhood elbow fracture (e.g., **supracondylar humerus fracture**). - This deformity causes chronic stretching and friction on the **ulnar nerve** as it passes behind the medial epicondyle, leading to delayed onset (tardy) neuropathy. *Cubitus varus* - **Cubitus varus** is a decreased carrying angle (gunstock deformity), which does not typically predispose to ulnar nerve compression or palsy. - While it is also often a sequela of elbow fractures, it alters the nerve's path differently. *Excision of elbow joint* - Excision of the elbow joint is a severe surgical procedure, usually performed for conditions like severe **arthritis** or **infection**. - While it could potentially damage the ulnar nerve intraoperatively or due to scarring, it is not a classic cause of "tardy" (delayed onset) ulnar nerve palsy in the same chronic mechanical way as cubitus valgus. *Fracture of olecranon process* - An **olecranon fracture** could cause acute injury to the ulnar nerve due to direct trauma or swelling. - However, it is not a common cause of *tardy* (delayed) ulnar nerve palsy unless it leads to significant deformity impacting the ulnar groove or chronic instability, which is less common than with cubitus valgus.

Q: The proximal fragment of scaphoid after fracture is predisposed for Avascular Necrosis because:

Retrograde blood flow to the proximal fragment. ***Retrograde blood flow to the proximal fragment*** - The **scaphoid** receives its blood supply predominantly from the **radial artery** via branches entering the distal pole and waist. - This anatomical arrangement means blood flows in a **retrograde direction** towards the proximal pole, making the proximal fragment vulnerable to **avascular necrosis** if its blood supply is interrupted by a fracture at the waist or proximal pole. *Difficulty in immobilizing the proximal fragment* - While immobilization can be challenging for some fractures, it is not the primary reason for **avascular necrosis** in scaphoid fractures. - The risk of **avascular necrosis** is more closely related to the anatomical **blood supply** rather than the effectiveness of immobilization. *Fracture configuration of the proximal fragment is usually comminuted* - **Comminuted fractures** of the scaphoid are less common in the proximal fragment compared to the waist or distal pole. - While comminution can complicate healing, the inherent **blood supply pattern** is the overriding factor for AVN in the proximal fragment, not the fracture pattern itself. *Proximal Fragment articulates with the radius* - The **proximal pole of the scaphoid** articulates with the radius as part of the radiocarpal joint. - This articulation is a normal anatomical feature and does not predispose the fragment to **avascular necrosis** following a fracture.

Q: Test for De-quervain's tenovaginitis -

Finkelstein test. ***Finkelstein test*** - The **Finkelstein test** is performed to diagnose **De Quervain's tenosynovitis**, which involves inflammation of the **abductor pollicis longus** and **extensor pollicis brevis** tendons. - The test involves making a fist with the thumb tucked inside the fingers, followed by **ulnar deviation** of the wrist. Pain along the **radial styloid** is a positive sign. *Phalen test* - The **Phalen test** is used to diagnose **carpal tunnel syndrome**, which is compression of the **median nerve**. - This test involves holding the wrists in maximal **flexion** for 30-60 seconds, which exacerbates median nerve symptoms like **numbness** and **tingling**. *Cozen test* - The **Cozen test** is used to diagnose **lateral epicondylitis**, also known as "tennis elbow." - It involves resisted **wrist extension** and **radial deviation** with the elbow extended, causing pain at the **lateral epicondyle**. *Kanavel's sign* - **Kanavel's signs** (pain on passive extension, uniform swelling, flexed posture of digit, tenderness along the tendon sheath) are clinical indicators for **flexor tenosynovitis** in the hand. - These signs suggest a severe infection of the **flexor tendon sheath**, requiring urgent surgical intervention.

Q: A 40-year old male after binge drinking slept on a chair. On the next day, he presented with weakness of the right arm and was not able to move his hand. Examination showed radial nerve palsy. What would be the management?

Give a knuckle bender splint. ***Give a knuckle bender splint*** - This patient presents with features of **Saturday Night Palsy** (radial nerve compression from prolonged pressure), which is typically a **neurapraxia**. - Management for neurapraxia usually involves **conservative measures** like splinting to support the wrist and fingers, protecting the nerve, and allowing for spontaneous recovery, which typically occurs within weeks to months. *Neurolysis* - **Neurolysis** (surgical freeing of a nerve from scar tissue) is an invasive procedure generally reserved for cases of **nerve entrapment** or persistent compression that have failed conservative therapy or show signs of ongoing nerve damage. - Given the acute presentation and typical course of Saturday Night Palsy, it is too premature and often unnecessary for this type of injury, where spontaneous recovery is common. *Instant exploration* - **Instant surgical exploration** of the nerve is usually only indicated in cases of **acute, severe trauma** where nerve transection or severe crush injury is suspected, or when there are clear signs of progressive nerve dysfunction. - In Saturday Night Palsy, the injury is typically a **mild compression (neurapraxia)**, making immediate surgery unwarranted and potentially more harmful than beneficial. *Electromyography after 2 days and decide after results* - **Electromyography (EMG)** and **nerve conduction studies (NCS)** are valuable diagnostic tools but have limitations in the very acute phase of a nerve injury. - **EMG changes (denervation potentials)** typically take 2-3 weeks to develop after an injury, so performing it after only two days would likely yield normal results and not provide useful information for immediate management.

Question 1

The commonly injured carpal bone next to the scaphoid is:

Accepted Answer

Triquetrum

Answer

Trapezoid

Answer

Capitate

Answer

Lunate

Question 2

Dupuytren's contracture occurs in which of the following conditions? a) Diabetes Mellitus b) Alcohol c) Epilepsy d) Rheumatoid Arthritis e) Chronic Pulmonary disease

Accepted Answer

ABCE

Answer

BCDE

Answer

ABCD

Answer

ABDE

Answer

ACDE

Question 3

Which bone is most commonly fractured in the arrow marked area?

Accepted Answer

Scaphoid

Answer

Triquetral

Answer

Lunate

Answer

Trapezoid

Question 4

Which of the following is not a feature of De Quervain's tenosynovitis?

Accepted Answer

Autoimmune etiology

Answer

Pain at radial styloid process

Answer

Positive Finkelstein's test

Answer

Thickening of first dorsal compartment

Question 5

Dupuytren's contracture can be caused by -

Accepted Answer

All of the options

Answer

Alcoholism

Answer

Diabetes

Answer

Eptoin

Question 6

Rupture of extensor pollicis longus tendon occurs in all of the following except -

Accepted Answer

De Quervain's disease

Answer

Rheumatoid arthritis

Answer

Drummers

Answer

Colles' fracture

Question 7

Tardy ulnar nerve palsy is seen in ?

Accepted Answer

Cubitus valgus

Answer

Cubitus varus

Answer

Excision of elbow joint

Answer

Fracture of olecranon process

Question 8

The proximal fragment of scaphoid after fracture is predisposed for Avascular Necrosis because:

Accepted Answer

Retrograde blood flow to the proximal fragment

Answer

Difficulty in immobilizing the proximal fragment

Answer

Fracture configuration of the proximal fragment is usually comminuted

Answer

Proximal Fragment articulates with the radius

Question 9

Test for De-quervain's tenovaginitis -

Accepted Answer

Finkelstein test

Answer

Phalen test

Answer

Cozen test

Answer

Kanavel's sign

Question 10

A 40-year old male after binge drinking slept on a chair. On the next day, he presented with weakness of the right arm and was not able to move his hand. Examination showed radial nerve palsy. What would be the management?

Accepted Answer

Give a knuckle bender splint

Answer

Neurolysis

Answer

Instant exploration

Answer

Electromyography after 2 days and decide after results

Hand Surgery — MCQs

Hand Surgery — MCQs

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