Hand Surgery Practice Questions

Q: Which action is affected in Bennet's fracture of the thumb?

Opposition of thumb. **Explanation:** **Bennett’s fracture** is an intra-articular fracture-subluxation at the base of the first metacarpal. The fracture line separates a small, triangular volar-ulnar fragment (which remains attached to the trapezium via the anterior oblique ligament) from the rest of the metacarpal shaft. **Why Opposition is affected (Correct Answer):** The stability of the **Carpometacarpal (CMC) joint** is crucial for the complex movement of **opposition**, which allows the thumb to touch the tips of other fingers. In Bennett’s fracture, the pull of the *Abductor Pollicis Longus (APL)* muscle displaces the metacarpal shaft proximally, radially, and dorsally. This disruption of the joint surface and the resulting instability directly impairs the circumduction and rotational components required for opposition. **Why other options are incorrect:** * **Flexion/Adduction:** These actions are primarily mediated by the *Flexor Pollicis Brevis* and *Adductor Pollicis*, which may still function, though they contribute to the deformity by pulling the distal fragment into the palm. * **Abduction:** While the *APL* is involved in the deformity, the primary functional loss described in clinical orthopaedics for this intra-articular injury is the loss of the "pulp-to-pulp" opposition mechanism. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Indirect longitudinal stress along the axis of the thumb (e.g., punching with a closed fist). * **Deforming Forces:** The small fragment is held by the **Anterior Oblique Ligament**; the shaft is displaced by the **APL** (Abductor Pollicis Longus). * **Rolando Fracture:** A comminuted T- or Y-shaped intra-articular fracture at the base of the first metacarpal (worse prognosis than Bennett's). * **Treatment:** Most cases require **Closed Reduction and Internal Fixation (CRIF)** with K-wires or Open Reduction (ORIF) because it is an unstable intra-articular fracture.

Q: Which of the following is seen in Boutonniere's deformity?

Flexion contracture of PIP and extension of DIP. **Explanation:** **Boutonniere’s deformity** (also known as Buttonhole deformity) is a characteristic finger deformity resulting from the **rupture or avulsion of the central slip** of the extensor tendon from its insertion at the base of the middle phalanx. **1. Why Option C is Correct:** When the central slip is damaged, the lateral bands of the extensor mechanism slide volarly (towards the palm) past the axis of the Proximal Interphalangeal (PIP) joint. These lateral bands then act as flexors of the PIP joint rather than extensors. Simultaneously, the tension on the lateral bands increases at their distal insertion, causing compensatory **hyperextension of the Distal Interphalangeal (DIP) joint**. Thus, the classic presentation is **PIP flexion and DIP extension.** **2. Why Incorrect Options are Wrong:** * **Option A & B:** These describe uniform positions (both joints extended or both flexed), which do not account for the reciprocal mechanical imbalance caused by the displaced lateral bands. * **Option D:** This describes **Swan-neck deformity** (PIP hyperextension and DIP flexion), which is the clinical opposite of Boutonniere’s deformity and is often caused by volar plate laxity or rheumatoid arthritis. **3. Clinical Pearls for NEET-PG:** * **Etiology:** Most commonly seen in Rheumatoid Arthritis or trauma (e.g., a jammed finger). * **Elson’s Test:** The gold standard clinical test to diagnose early central slip injury before the deformity becomes fixed. * **Management:** Initial treatment is usually non-operative, involving splinting the PIP joint in full extension for 6–8 weeks while allowing active DIP motion. * **Mnemonic:** **B**outonniere = **B**ent (PIP) and **U**p (DIP).

Q: The term Bennett's fracture is used to describe which of the following?

Fracture-dislocation of the trapezometacarpal joint. **Explanation:** **Bennett’s fracture** is an intra-articular fracture-dislocation occurring at the **base of the first metacarpal**. The correct answer is **D** because the base of the first metacarpal articulates with the trapezium to form the **trapezometacarpal (TMC) joint**. **Mechanism and Anatomy:** The fracture occurs when a small volar-ulnar fragment remains attached to the strong **anterior oblique ligament**, while the rest of the metacarpal shaft is displaced proximally, radially, and posteriorly by the pull of the **Abductor Pollicis Longus (APL)** muscle. This results in the characteristic "fracture-dislocation." **Analysis of Incorrect Options:** * **Option A & B:** Bennett’s fracture specifically involves the base of the metacarpal (TMC joint), not the metacarpophalangeal (MCP) or interphalangeal (IP) joints. * **Option C:** An anterior (volar) marginal fracture of the distal radius is known as a **Volar Barton’s fracture**, not Bennett’s. **High-Yield Clinical Pearls for NEET-PG:** * **Rolando Fracture:** A comminuted, T- or Y-shaped intra-articular fracture at the base of the first metacarpal (worse prognosis than Bennett's). * **Gamekeeper’s Thumb:** An injury to the Ulnar Collateral Ligament (UCL) of the thumb MCP joint. * **Management:** Bennett’s fracture is inherently unstable due to muscle pull (APL); therefore, it usually requires **Closed Reduction and Internal Fixation (CRIF)** with K-wires or Open Reduction (ORIF). * **Radiology:** Best visualized on a "Robert’s view" (AP view of the thumb).

Q: Which of the following is the most appropriate diagnosis for a patient presenting with wrist pain and stiffness, especially after repetitive stress, with a characteristic "humpback" deformity?

Osteochondrosis of the navicular. **Explanation:** The correct answer is **Osteochondrosis of the navicular** (also known as **Preiser’s disease**). 1. **Why it is correct:** Osteochondrosis refers to a group of disorders that affect the growing skeleton, involving idiopathic avascular necrosis (AVN) of a bone. When it affects the carpal navicular (scaphoid), it is termed Preiser’s disease. It typically presents in adults with progressive wrist pain, stiffness, and weakness, often exacerbated by repetitive stress or trauma. The **"humpback" deformity** is a classic radiological and clinical finding caused by the collapse of the scaphoid into flexion, leading to a prominent dorsal angulation at the fracture or necrosis site. 2. **Why the other options are incorrect:** * **A. Osteochondrosis of the lunate:** This is known as **Kienböck’s disease**. While it causes wrist pain and stiffness, it does not typically produce a "humpback" deformity; rather, it leads to lunate collapse and proximal migration of the capitate. * **C. Tuberculosis of the scaphoid:** While TB can affect small bones (carpal tunnel syndrome or dactylitis), it usually presents with systemic symptoms (fever, weight loss), "cold abscesses," and "rice bodies" in the synovium, rather than a specific humpback structural deformity. * **D. Syphilitic dactylitis:** This involves painless, spindle-shaped swelling of the phalanges (usually in infants) due to periostitis, not the carpal bones. **High-Yield Clinical Pearls for NEET-PG:** * **Preiser’s Disease:** AVN of the Scaphoid (Navicular). * **Kienböck’s Disease:** AVN of the Lunate. * **Humpback Deformity:** Specifically refers to the **dorsal angulation** of the scaphoid following a non-union or collapse. * **Terry Thomas Sign:** Widening of the scapholunate interval (>3mm), indicating ligamentous injury.

Q: Which nerve palsy is diagnosed using this test?

Median nerve. ***Median nerve*** - The **OK sign test** or **pinch grip test** specifically diagnoses **anterior interosseous nerve (AIN)** palsy, a branch of the median nerve, by testing the ability to form a circular "O" with thumb and index finger. - Inability to perform this test indicates weakness of **flexor pollicis longus (FPL)** and **flexor digitorum profundus (FDP)** of the index finger, resulting in a **flat pulp-to-pulp pinch** instead of tip-to-tip pinch. *Radial nerve* - Radial nerve palsy is diagnosed by **wrist drop test** and inability to extend the wrist and fingers at the **metacarpophalangeal joints**. - The **OK sign test** does not assess radial nerve function as it primarily involves **wrist and finger extension**, not flexion. *Ulnar nerve* - Ulnar nerve palsy is diagnosed using **Froment's sign** (compensatory thumb flexion during paper grip) and **Wartenberg's sign** (abducted little finger). - The OK sign test does not evaluate **ulnar nerve** function as it doesn't test the **adductor pollicis** or **interosseous muscles** innervated by the ulnar nerve. *Axillary nerve* - Axillary nerve palsy is diagnosed by testing **deltoid muscle** weakness and **sensory loss** over the **badge area** of the shoulder. - The **OK sign test** involves fine motor control of fingers and thumb, which is unrelated to **axillary nerve** function that primarily controls shoulder abduction.

Q: A middle-aged female presents with pain and tenderness at the base of the thumb, with a history of chronic wrist overuse. A specific maneuver, involving making a fist with the thumb inside and then bending the wrist towards the little finger, elicits pain. Which two tendons are primarily involved in this condition?

Abductor pollicis longus and Extensor pollicis brevis. ### Explanation The clinical presentation describes **De Quervain’s Tenosynovitis**, a common stenosing tenosynovitis affecting the **first dorsal compartment** of the wrist. The maneuver described is the **Finkelstein test**, which is pathognomonic for this condition. #### 1. Why Option C is Correct The first dorsal compartment of the extensor retinaculum contains two specific tendons: the **Abductor Pollicis Longus (APL)** and the **Extensor Pollicis Brevis (EPB)**. Chronic overuse (repetitive gripping or ulnar deviation) leads to thickening of the synovial sheath and narrowing of the fibro-osseous tunnel, causing pain during thumb and wrist movement. #### 2. Why Other Options are Wrong * **Option A & B:** The **Abductor Pollicis Brevis (APB)** is an intrinsic muscle of the hand (thenar eminence) and does not pass through the extensor compartments of the wrist. * **Option D:** The **Extensor Pollicis Longus (EPL)** passes through the **third dorsal compartment** and loops around Lister’s tubercle. It forms the ulnar border of the anatomical snuffbox, whereas De Quervain’s involves the radial border. #### 3. High-Yield Clinical Pearls for NEET-PG * **Demographics:** Most common in middle-aged females and "new mothers" (due to repetitive lifting of the infant). * **Anatomical Snuffbox:** The APL and EPB form the **radial (lateral) border**, while the EPL forms the **ulnar (medial) border**. * **Eichhoff’s Test:** Often confused with Finkelstein’s; it is the specific maneuver where the patient deviates the wrist while clutching the thumb. * **Management:** Conservative (NSAIDs, thumb spica splint, steroid injections). Surgical release of the first compartment is indicated if conservative measures fail. Watch out for a **septated first compartment** (a common cause of surgical failure).

Q: Which of the following statements is NOT TRUE regarding Dupuytren's contracture?

Typically affects the index finger first. **Explanation:** **Dupuytren’s contracture** is a progressive fibroproliferative disorder of the palmar fascia, characterized by the formation of nodules and cords that lead to fixed flexion deformities of the fingers. **Why Option B is the Correct Answer (The False Statement):** In Dupuytren’s contracture, the **ring finger** is most commonly affected first, followed by the little finger. The index finger and thumb are rarely involved. Therefore, the statement that it typically affects the index finger first is incorrect. **Analysis of Other Options:** * **Option A:** It is frequently associated with other fibromatoses, including **Peyronie’s disease** (penile fibromatosis) and **Ledderhose disease** (plantar fibromatosis). This triad is often seen in patients with a strong genetic predisposition. * **Option C:** While primarily a palmar condition, the disease process involves myofibroblast proliferation leading to nodule formation. When it involves the feet (Ledderhose disease), it causes thickening of the **plantar fascia**. * **Option D:** While the primary treatments are fasciectomy or collagenase injection, **amputation** (specifically of the little finger) may be indicated in severe, recurrent cases where function cannot be restored or the finger is severely contracted and interfering with daily activities. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Male gender (M:F = 10:1), age >50, smoking, alcohol use, diabetes mellitus, and epilepsy (anticonvulsant use). * **Pathology:** Proliferation of **Type III collagen** (replacing Type I). * **Hueston’s Table Top Test:** Positive when the patient cannot flatten their palm against a table; indicates a need for surgical intervention. * **Treatment:** Indicated when the MCP joint contracture is >30° or any PIP joint contracture is present.

Q: Claw hand is seen in all conditions except?

Sarcoidosis. **Explanation:** The term **"Claw Hand"** refers to a clinical deformity characterized by hyperextension at the metacarpophalangeal (MCP) joints and flexion at the interphalangeal (IP) joints. This occurs due to an imbalance between the strong extrinsic extensors and the paralyzed intrinsic muscles (interossei and lumbricals). **Why Sarcoidosis is the Correct Answer:** Sarcoidosis is a multisystem granulomatous disease that primarily affects the lungs and lymph nodes. While it can cause neurosarcoidosis (mononeuritis multiplex), it is **not** a classic or recognized cause of a permanent claw hand deformity. The other options represent well-documented causes of either neurogenic or musculoskeletal clawing. **Analysis of Other Options:** * **Leprosy (Hansen’s Disease):** The most common cause of claw hand worldwide. It involves the **Ulnar nerve** (at the elbow or wrist) and/or the **Median nerve**, leading to intrinsic muscle paralysis. * **Scleroderma:** This systemic autoimmune disease causes progressive fibrosis and tightening of the skin (**Sclerodactyly**). The severe skin contractures pull the fingers into a fixed, claw-like position. * **Hurler’s Syndrome (MPS I):** A lysosomal storage disorder where the accumulation of glycosaminoglycans in the tendons and ligaments leads to joint stiffness and a characteristic **"claw-press" deformity**. **High-Yield Clinical Pearls for NEET-PG:** * **Ulnar Paradox:** The higher the lesion of the ulnar nerve (e.g., at the elbow), the *less* prominent the clawing, because the medial half of the Flexor Digitorum Profundus is also paralyzed. * **Klumpke’s Paralysis:** Injury to the **C8-T1** nerve roots (lower plexus) results in a total claw hand. * **Volkmann’s Ischemic Contracture:** Can also lead to a claw-like deformity due to ischemic fibrosis of the forearm flexors.

Q: A 66-year-old diabetic lady complains of pain in the palm of her right hand at the base of her ring finger, which is held in flexion. Extension is painful, produces an audible click, and often requires the assistance of the other hand. What is the first-line treatment for this condition?

Corticosteroid injection. **Diagnosis: Trigger Finger (Stenosing Tenosynovitis)** **Explanation:** The clinical presentation of a painful "clicking" sensation, a finger locked in flexion, and the requirement of passive assistance for extension is classic for **Trigger Finger**. This condition is caused by a size mismatch between the flexor tendon (often due to a nodule) and the **A1 pulley** at the metacarpophalangeal (MCP) joint. It is highly associated with **Diabetes Mellitus**. 1. **Why Corticosteroid Injection is Correct:** According to standard orthopedic guidelines (and high-yield for NEET-PG), **corticosteroid injection** into the tendon sheath is the **first-line treatment**. It reduces peritendinous inflammation and edema, resolving symptoms in up to 60-90% of non-diabetic patients. While diabetic patients may have higher recurrence rates, it remains the initial intervention before considering surgery. 2. **Why Other Options are Incorrect:** * **Splinting:** While an option for very mild/early cases, it has lower success rates than injections and is generally not the "first-line" choice in a patient already experiencing locking and painful clicks. * **Surgery (A1 Pulley Release):** This is the definitive treatment but is reserved for cases where conservative management (injections) has failed. * **Oral NSAIDs:** These may provide symptomatic pain relief but do not address the mechanical obstruction at the A1 pulley effectively. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ring finger (followed by thumb and middle finger). * **Pathology:** Fibrocartilaginous metaplasia of the **A1 pulley**. * **Diabetic Association:** Patients with DM often have multiple digits involved and are more resistant to corticosteroid treatment. * **Pediatric Trigger Thumb:** Unlike adults, this is usually congenital and often requires surgical release rather than injections.

Q: What does Tinel's test assess?

Percussion produces a tingling sensation.. **Explanation:** **Tinel’s sign** is a clinical test used to identify irritated or regenerating nerves. It is performed by lightly **percussing** over the course of a nerve. A positive result occurs when this percussion produces a **tingling sensation** (paresthesia) in the cutaneous distribution of that nerve. **Why the correct answer is right:** The underlying pathophysiology involves **mechanical hyper-excitability** of regenerating axonal sprouts or irritated nerve fibers. When the nerve is tapped, these sensitive fibers fire, sending signals to the brain that are interpreted as "pins and needles" or tingling in the nerve's territory. **Analysis of incorrect options:** * **A & B:** Loss of sensation and loss of two-point discrimination are signs of **nerve deficit** (anesthesia/hypesthesia). Tinel’s test is a provocative test for nerve *irritability* or *regeneration*, not a measure of sensory loss. * **D:** Tinel’s sign is classically associated with **Carpal Tunnel Syndrome (CTS)**, where percussion over the median nerve at the wrist crease reproduces symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Phalen’s Test:** The most sensitive provocative test for CTS (wrist flexion for 60 seconds). * **Regeneration Tracking:** In peripheral nerve injuries, a "distally progressing" Tinel’s sign is a positive prognostic indicator, suggesting that axons are regenerating (at a rate of approximately **1 mm/day**). * **Common Sites:** Median nerve (Carpal Tunnel), Ulnar nerve (Cubital Tunnel), and Common Peroneal nerve (at the fibular head).

Question 1

Which action is affected in Bennet's fracture of the thumb?

Accepted Answer

Opposition of thumb

Answer

Flexion of thumb

Answer

Abduction of thumb

Answer

Adduction of thumb

Question 2

Which of the following is seen in Boutonniere's deformity?

Accepted Answer

Flexion contracture of PIP and extension of DIP

Answer

Extension of PIP and DIP

Answer

Flexion of PIP and DIP

Answer

Flexion of DIP and extension of PIP

Question 3

The term Bennett's fracture is used to describe which of the following?

Accepted Answer

Fracture-dislocation of the trapezometacarpal joint

Answer

Fracture-dislocation of the metacarpophalangeal joint of the thumb

Answer

Interphalangeal fracture-dislocation of the thumb

Answer

Anterior marginal fracture of the distal end of the radius

Question 4

Which of the following is the most appropriate diagnosis for a patient presenting with wrist pain and stiffness, especially after repetitive stress, with a characteristic "humpback" deformity?

Accepted Answer

Osteochondrosis of the navicular

Answer

Osteochondrosis of the lunate

Answer

Tuberculosis of the scaphoid

Answer

Syphilitic dactylitis

Question 5

Which nerve palsy is diagnosed using this test?

Accepted Answer

Median nerve

Answer

Radial nerve

Answer

Ulnar nerve

Answer

Axillary nerve

Question 6

A middle-aged female presents with pain and tenderness at the base of the thumb, with a history of chronic wrist overuse. A specific maneuver, involving making a fist with the thumb inside and then bending the wrist towards the little finger, elicits pain. Which two tendons are primarily involved in this condition?

Accepted Answer

Abductor pollicis longus and Extensor pollicis brevis

Answer

Abductor pollicis brevis and Extensor pollicis brevis

Answer

Abductor pollicis brevis and Extensor pollicis longus

Answer

Abductor pollicis longus and Extensor pollicis longus

Question 7

Which of the following statements is NOT TRUE regarding Dupuytren's contracture?

Accepted Answer

Typically affects the index finger first

Answer

Associated with Peyronie's disease

Answer

Involves nodule formation and thickening of the plantar fascia

Answer

Amputation may be required in severe cases

Question 8

Claw hand is seen in all conditions except?

Accepted Answer

Sarcoidosis

Answer

Scleroderma

Answer

Leprosy

Answer

Hurler’s syndrome

Question 9

A 66-year-old diabetic lady complains of pain in the palm of her right hand at the base of her ring finger, which is held in flexion. Extension is painful, produces an audible click, and often requires the assistance of the other hand. What is the first-line treatment for this condition?

Accepted Answer

Corticosteroid injection

Answer

Splinting for 6 weeks

Answer

Surgery under local anesthesia

Answer

Oral NSAIDs

Question 10

What does Tinel's test assess?

Accepted Answer

Percussion produces a tingling sensation.

Answer

Loss of sensation.

Answer

Loss of two-point discrimination.

Answer

Is not associated with carpal tunnel syndrome.

Hand Surgery — MCQs

Hand Surgery — MCQs

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