Hand Surgery Practice Questions

Q: After a brawl, a young male presented with inability to extend his distal interphalangeal joint. An X-ray was taken and was shown to be normal. What should be the next step in managing the patient?

Splint. ***Splint*** - The patient presents with **inability to extend the distal interphalangeal joint** after an injury, with a **normal X-ray**. This clinical picture is highly suggestive of a **mallet finger**. - **Splinting** the distal interphalangeal joint in **extension** for 6-8 weeks is the primary non-surgical treatment for mallet finger, aiming to allow the ruptured extensor tendon to heal. *Wax bath* - A **wax bath** is a form of thermotherapy used to relieve pain and stiffness in joints by applying heat. - While it can be helpful for chronic conditions like **arthritis**, it is not an appropriate initial treatment for an acute **tendon injury** like mallet finger, as it does not promote healing of the extensor mechanism. *Ignore* - **Ignoring** the symptoms would lead to a failure to treat the injury, potentially resulting in a **chronic extensor lag deformity** (mallet finger deformity). - Untreated, this condition can cause persistent functional impairment and cosmetic deformity of the affected finger. *Surgery* - **Surgery** is typically reserved for specific cases of mallet finger, such as those with a **large avulsion fracture** of the dorsal base of the distal phalanx (where the fragment involves more than 30-50% of the articular surface), or if non-surgical treatment fails. - Since the **X-ray was normal** in this case, indicating no significant bony avulsion, and it's an acute presentation, surgery is not the appropriate first-line management.

Q: DeQuervain's disease classically affects the:

Extensor pollicis brevis and abductor pollicis longus. ***Extensor pollicis brevis and abductor pollicis longus*** - **DeQuervain's tenosynovitis** is an inflammation of the tendons and their synovial sheaths that pass through the first dorsal compartment of the wrist. - This compartment specifically houses the **extensor pollicis brevis (EPB)** and **abductor pollicis longus (APL)** tendons. *Abductor pollicis longus and brevis* - While the **abductor pollicis longus (APL)** is affected, the "abductor pollicis brevis" is an intrinsic hand muscle, not typically involved in DeQuervain's tenosynovitis, which affects wrist tendons. - The **abductor pollicis brevis** is innervated by the median nerve and acts at the carpometacarpal and metacarpophalangeal joints of the thumb, distal to the wrist compartment. *Extensor carpi radialis and extensor pollicis longus* - The **extensor carpi radialis (longus and brevis)** tendons are located in the second dorsal compartment of the wrist, lateral to the first compartment but are not primarily affected in DeQuervain's. - The **extensor pollicis longus (EPL)** tendon is located in the third dorsal compartment and is responsible for thumb interphalangeal joint extension, not the primary site of DeQuervain's inflammation. *Flexor pollicis longus and brevis* - The **flexor pollicis longus (FPL)** and **flexor pollicis brevis (FPB)** are involved in thumb flexion and are located on the palmar side of the wrist and hand. - DeQuervain's tenosynovitis is a condition affecting the dorsal (extensor side) compartment of the wrist, so these flexor tendons are not involved.

Q: A 22-year-old male medical student was seen in the emergency department with a complaint of pain in his hand. He confessed that he had hit a vending machine in the hospital when he did not receive his soft drink after inserting money twice. The medial side of the dorsum of the hand was quite swollen, and one of his knuckles could not be seen when he "made a fist." The physician made a diagnosis of a "boxer's fracture." What was the nature of the impatient student's injury?

Fracture of the neck of the fifth metacarpal. ***Fracture of the neck of the fifth metacarpal*** - A **boxer's fracture** specifically refers to a fracture of the neck of the fifth metacarpal bone. - This injury commonly occurs when punching a hard object, leading to swelling and loss of the knuckle prominence. *Colles' fracture of the radius* - A **Colles' fracture** involves the distal radius, typically caused by a fall on an outstretched hand, resulting in a "dinner fork" deformity. - It does not involve the metacarpals or knuckles. *Fracture of the styloid process of the ulna* - This fracture often accompanies a **Colles' fracture** of the radius but can also occur in isolation. - It's a fracture of the distal end of the ulna and does not cause the loss of a knuckle. *Smith's fracture of the radius* - A **Smith's fracture** is a fracture of the distal radius with volar displacement, often called a "reverse Colles' fracture." - It is caused by a fall on the back of the hand or a direct blow to the forearm and does not affect the metacarpals or knuckles.

Q: Finkelstein's test is done for diagnosis of:

De quervain's tenosynovitis. ***De Quervain's tenosynovitis*** - **Finkelstein's test** is the classic physical examination maneuver used to diagnose **De Quervain's tenosynovitis**. - The test involves pain elicited when the patient makes a **fist with the thumb tucked inside** the other fingers, and then ulnar deviates the wrist. *Trigger finger (stenosing tenosynovitis)* - While it is also a tenosynovitis, **trigger finger** affects the flexor tendons of the digits and is characterized by painful clicking or locking. - Diagnosis is clinical, based on observing the **finger catching or locking** during attempted extension. *Acute compartment syndrome* - This is a limb-threatening condition involving increased pressure within a muscle compartment, often due to trauma. - Diagnosis is based on **clinical signs** (pain out of proportion, pallor, paresthesia, pulselessness, paralysis) and **intracompartmental pressure measurements**. *Carpal tunnel syndrome* - This condition results from compression of the **median nerve** within the carpal tunnel, causing numbness, tingling, and weakness in the hand. - Diagnostic tests include **Tinel's sign** (tapping over the median nerve) and **Phalen's maneuver** (wrist flexion), not Finkelstein's test.

Q: Scaphoid fracture which area has maximum chances of AVN/Non-union/Malunion:-

Proximal 1/3. ***Proximal 1/3*** - The **proximal pole of the scaphoid** has a precarious blood supply, primarily from retrograde extraosseous vessels entering distally. A fracture in this region can compromise this supply, leading to **avascular necrosis (AVN)**. - Due to the limited blood flow to the proximal fragment, healing is often impaired, increasing the risk of **non-union** and **malunion**. *Distal 1/3* - Fractures in the **distal 1/3 (distal pole)** of the scaphoid typically have a better prognosis. - This area has a more robust blood supply, reducing the risk of AVN and promoting faster healing. *Scaphoid Tubercle fracture* - Fractures of the **scaphoid tubercle** are usually considered stable and intra-articular, with a good blood supply. - These fractures generally heal well with conservative treatment and have a very low incidence of AVN or non-union. *Middle 1/3* - Fractures in the **middle 1/3 (waist)** of the scaphoid are the most common but still pose a significant risk of non-union. - While the risk of AVN is lower than for proximal pole fractures, it is still higher than for distal fractures, due to the critical vascular supply to both fragments.

Q: A 45-year-old woman presents with burning pain and numbness in the wrist and hand. Tinel's sign is positive. What is the most likely diagnosis?

Carpal tunnel syndrome. ***Carpal tunnel syndrome*** - **Burning pain**, **numbness** in the hand, and a **positive Tinel's sign** at the wrist are classic symptoms of median nerve compression within the carpal tunnel [1]. - The median nerve supplies sensation to the thumb, index, middle, and radial half of the ring finger, which is where symptoms are typically experienced [1]. *Radial nerve palsy* - This condition affects the **radial nerve**, causing **wrist drop** and sensory loss over the posterior forearm and dorsum of the hand [1]. - It does not typically present with burning pain or numbness in the distribution described. *Cubital tunnel syndrome* - Involves compression of the **ulnar nerve** at the elbow, leading to numbness and tingling in the **little finger** and ulnar half of the ring finger [1]. - While it can cause burning pain, the anatomical distribution of symptoms is distinct from the patient's presentation. *Thoracic outlet syndrome* - Results from compression of neurovascular structures in the **thoracic outlet**, causing varied symptoms such as pain, numbness, and weakness in the arm and hand [2]. - A positive Tinel's sign at the wrist is not a characteristic finding, and the symptom distribution is often broader or less specific to a single nerve.

Q: A 42-year-old female presents with pain and swelling in the right wrist after a fall. An X-ray shows a fracture in the carpal bones. Which bone is most commonly fractured in such injuries?

Scaphoid. ***Scaphoid*** - The **scaphoid bone** is the most commonly fractured carpal bone, often due to a **fall on an outstretched hand (FOOSH)**, which transmits force directly to it. - Its **poor blood supply** makes it prone to **avascular necrosis** and delayed healing if not properly managed. *Lunate* - While the lunate can be injured, particularly in **Kienbock's disease** (avascular necrosis), it is less commonly fractured than the scaphoid in trauma. - Fractures of the lunate often result from high-energy trauma and are less frequent than scaphoid fractures. *Triquetrum* - The **triquetrum** is the **second most commonly fractured carpal bone**, usually due to impaction against the ulna or from avulsion injuries. - However, its fracture rate is still significantly lower than that of the scaphoid. *Pisiform* - Fractures of the **pisiform** are rare and typically result from **direct trauma** to the hypothenar eminence or avulsion injuries. - It is located anterior to the triquetrum and functions primarily as a sesamoid bone for the flexor carpi ulnaris tendon.

Q: A patient with ulnar nerve compression at the elbow (cubital tunnel syndrome) presents with early clawing of the ring and little fingers, numbness, and progressive weakness of hand intrinsic muscles. What is the most appropriate surgical intervention to prevent further deterioration of hand function?

Ulnar nerve transposition; prevents further deterioration. ***Ulnar nerve transposition*** - This procedure involves surgically relocating the ulnar nerve from its position behind the medial epicondyle to a new, less constricted position (anterior to the medial epicondyle), relieving compression at the **cubital tunnel** - By decompressing the nerve, it can **prevent further deterioration** of ulnar nerve function and may allow recovery of the **intrinsic hand muscles** (lumbricals, interossei), thus halting progression of the **claw hand deformity** - This is the definitive treatment for **cubital tunnel syndrome** with progressive neurological deficits - Note: For established, fixed claw deformity, **tendon transfer procedures** (like Zancolli lasso or modified Stiles-Bunnell) would be needed *Carpal tunnel release* - This procedure addresses compression of the **median nerve** at the wrist, causing symptoms like tingling and numbness in the thumb, index, middle, and radial half of the ring finger - Classic presentation includes nocturnal paresthesias, thenar atrophy, and weak thumb opposition - Would not address **ulnar nerve compression at the elbow** or ulnar-innervated muscle weakness *Median nerve repair* - This is performed for traumatic injuries causing **complete median nerve transection** and aims to restore motor function (pronation, wrist/finger flexion, thumb opposition) and sensation - Not appropriate for **ulnar nerve compression neuropathy**, which requires decompression, not repair *Radial nerve decompression* - This procedure targets compression of the **radial nerve** (commonly at the spiral groove or radial tunnel), which typically presents with **wrist drop** and weakness of finger/thumb extension - Sensory changes occur over the dorsal first web space - Not relevant for **ulnar nerve pathology at the elbow** causing intrinsic hand muscle weakness

Q: A 50-year-old office worker presents with numbness and tingling in the hand, which worsens at night. Tinel's sign is positive. Analyze the condition and select the best initial treatment option.

NSAIDs and wrist splinting. ***NSAIDs and wrist splinting*** - This is the **first-line treatment** for mild to moderate carpal tunnel syndrome, aiming to reduce inflammation and stabilize the wrist. - **Nocturnal wrist splinting** helps maintain a neutral wrist position, preventing compression of the **median nerve** during sleep and alleviating night symptoms. *Surgical decompression* - This is typically reserved for **severe cases** or when conservative treatments have failed after a prolonged period. - It involves cutting the **transverse carpal ligament** to relieve pressure on the median nerve. *Steroid injections* - **Corticosteroid injections** can provide temporary relief by reducing inflammation and swelling around the **median nerve**. - They are often used when initial conservative measures are insufficient but surgery is not yet indicated, not as a primary first-line treatment. *Physical therapy* - **Physical therapy** may include nerve gliding exercises, stretching, and strengthening, but it is often used as an adjunct to splinting or in later stages. - It is generally not considered the sole initial treatment for symptom relief in **carpal tunnel syndrome**.

Question 1

Which among the following is TRUE regarding mallet finger?

Accepted Answer

Avulsion of extensor tendon at the base of the distal phalanx

Answer

Fracture of distal phalanx

Answer

Fracture of the proximal phalanx

Answer

Avulsion of tendon at the base of the middle phalanx

Question 2

After a brawl, a young male presented with inability to extend his distal interphalangeal joint. An X-ray was taken and was shown to be normal. What should be the next step in managing the patient?

Accepted Answer

Splint

Answer

Wax bath

Answer

Ignore

Answer

Surgery

Question 3

DeQuervain's disease classically affects the:

Accepted Answer

Extensor pollicis brevis and abductor pollicis longus

Answer

Abductor pollicis longus and brevis

Answer

Extensor carpi radialis and extensor pollicis longus

Answer

Flexor pollicis longus and brevis

Question 4

A 22-year-old male medical student was seen in the emergency department with a complaint of pain in his hand. He confessed that he had hit a vending machine in the hospital when he did not receive his soft drink after inserting money twice. The medial side of the dorsum of the hand was quite swollen, and one of his knuckles could not be seen when he "made a fist." The physician made a diagnosis of a "boxer's fracture." What was the nature of the impatient student's injury?

Accepted Answer

Fracture of the neck of the fifth metacarpal

Answer

Colles' fracture of the radius

Answer

Fracture of the styloid process of the ulna

Answer

Smith's fracture of the radius

Question 5

Finkelstein's test is done for diagnosis of:

Accepted Answer

De quervain's tenosynovitis

Answer

Trigger finger (stenosing tenosynovitis)

Answer

Acute compartment syndrome

Answer

Carpal tunnel syndrome

Question 6

Scaphoid fracture which area has maximum chances of AVN/Non-union/Malunion:-

Accepted Answer

Proximal 1/3

Answer

Distal 1/3

Answer

Scaphoid Tubercle fracture

Answer

Middle 1/3

Question 7

A 45-year-old woman presents with burning pain and numbness in the wrist and hand. Tinel's sign is positive. What is the most likely diagnosis?

Accepted Answer

Carpal tunnel syndrome

Answer

Radial nerve palsy

Answer

Cubital tunnel syndrome

Answer

Thoracic outlet syndrome

Question 8

A 42-year-old female presents with pain and swelling in the right wrist after a fall. An X-ray shows a fracture in the carpal bones. Which bone is most commonly fractured in such injuries?

Accepted Answer

Scaphoid

Answer

Lunate

Answer

Triquetrum

Answer

Pisiform

Question 9

A patient with ulnar nerve compression at the elbow (cubital tunnel syndrome) presents with early clawing of the ring and little fingers, numbness, and progressive weakness of hand intrinsic muscles. What is the most appropriate surgical intervention to prevent further deterioration of hand function?

Accepted Answer

Ulnar nerve transposition; prevents further deterioration

Answer

Carpal tunnel release; reduced pain

Answer

Median nerve repair; restored thumb opposition

Answer

Radial nerve decompression; enhanced wrist extension

Question 10

A 50-year-old office worker presents with numbness and tingling in the hand, which worsens at night. Tinel's sign is positive. Analyze the condition and select the best initial treatment option.

Accepted Answer

NSAIDs and wrist splinting

Answer

Surgical decompression

Answer

Steroid injections

Answer

Physical therapy

Hand Surgery — MCQs

Hand Surgery — MCQs

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