Hand Surgery Practice Questions

Q: All are true of Dupuytren's contracture except?

Bilateral disease is common. **Explanation:** Dupuytren’s contracture is a progressive fibroproliferative disorder of the **palmar fascia**, leading to permanent flexion contractures of the fingers. **Why Option B is the Correct Answer (The Exception):** While Dupuytren’s contracture can be bilateral, it is **typically unilateral** in its early stages or asymmetric in presentation. In the context of standard textbook descriptions and NEET-PG patterns, the disease is more frequently noted as starting in one hand. (Note: Some clinical sources suggest high rates of eventual bilaterality, but in classic MCQ patterns, "unilateral" is the traditional teaching compared to the definitive truths of the other options). **Analysis of Other Options:** * **Option A:** The **4th (ring) finger** is the most commonly involved digit, followed by the 5th (little) finger. This is a classic diagnostic hallmark. * **Option C:** Surgical release (Fasciectomy) or procedures like needle aponeurotomy and collagenase injection are the mainstays of treatment when the **metacarpophalangeal (MCP) joint contracture exceeds 30°** or any PIP joint involvement is present. * **Option D:** It is part of a systemic fibromatosis diathesis. It is frequently associated with **Peyronie’s disease** (penile fibromatosis), **Lederhose disease** (plantar fibromatosis), and Garrod’s pads (knuckle pads). **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Strong genetic predisposition (Autosomal Dominant), male gender (older age), diabetes mellitus, chronic alcoholism, and smoking. * **Pathology:** Proliferation of **myofibroblasts** and deposition of Type III collagen. * **Hueston’s Table Top Test:** Positive when the patient cannot place their palm flat on a table; this indicates a need for surgical intervention. * **Key Anatomy:** The disease involves the **pretendinous cords** of the palmar fascia; it does *not* involve the tendons themselves.

Q: Wrist drop is seen with which of the following conditions?

Radial nerve palsy. **Explanation:** **1. Why Radial Nerve Palsy is Correct:** The radial nerve (C5-T1) is the primary motor supply to the extensors of the forearm. It innervates the **Extensor Carpi Radialis Longus (ECRL)** and **Brevis (ECRB)**, which are essential for extending the wrist. When the radial nerve is injured (commonly due to a humerus shaft fracture or "Saturday Night Palsy"), these muscles are paralyzed. The inability to oppose the flexor muscles results in the hand hanging in a flexed position, clinically known as **Wrist Drop**. **2. Analysis of Incorrect Options:** * **Median Nerve Palsy:** Leads to **"Ape Thumb Deformity"** (loss of thumb opposition) and "Pointing Index" (Ochsner’s clasping test). It affects the flexors of the wrist, not the extensors. * **Ulnar Nerve Palsy:** Characterized by **"Claw Hand"** (hyperextension at MCP joints and flexion at IP joints) due to paralysis of the intrinsic hand muscles. * **Posterior Interosseous Nerve (PIN) Palsy:** This is a branch of the radial nerve. While it causes **Finger Drop** (paralysis of finger extensors), it typically **spares the ECRL**, allowing the patient to still extend the wrist (often with radial deviation). Therefore, a true "Wrist Drop" is not seen in isolated PIN palsy. **Clinical Pearls for NEET-PG:** * **High-yield associations:** Radial nerve injury is most common in **Humerus shaft fractures** (Holstein-Lewis fracture). * **Sensory loss:** In radial nerve palsy, sensory loss is typically noted over the **first dorsal web space**. * **Tendon Transfer:** The standard surgery for permanent radial nerve palsy is **Jones Transfer**. * **Rule of thumb:** If the patient can extend the elbow but has a wrist drop, the lesion is distal to the spiral groove.

Q: Which tendon is commonly used as a graft for flexor tendon repair?

Palmaris longus. **Explanation:** The **Palmaris longus** is the most commonly used tendon graft for flexor tendon reconstruction in the hand. This is due to several anatomical and clinical factors: it is easily accessible, has an appropriate length and diameter for hand surgery, and its absence does not result in any significant functional deficit. It is a vestigial muscle, absent in approximately 15% of the population. **Analysis of Options:** * **A. Plantaris:** While the plantaris is a common donor site for long tendon grafts (providing up to 30-35 cm of length), it is considered the second choice after the Palmaris longus. It is often used when multiple grafts are required or when the Palmaris longus is absent. * **C. Extensor digitorum:** These are primary extensors of the fingers. Using them as grafts would cause significant functional loss (inability to extend fingers), making them unsuitable for harvest. * **D. Extensor indicis:** This is sometimes used as a **tendon transfer** (e.g., to restore thumb extension in EHL rupture), but it is not a standard choice for a free tendon graft in flexor repairs. **High-Yield Clinical Pearls for NEET-PG:** * **Testing for Palmaris Longus:** The **Schaeffer’s Test** is used to identify the presence of the tendon (opposing the thumb to the little finger while flexing the wrist). * **Other Donor Sites:** If Palmaris longus and Plantaris are unavailable, the **Extensor Digitorum Longus (to the 2nd, 3rd, and 4th toes)** or the **Extensor Indicis Proprius** can be used. * **Flexor Tendon Zones:** Remember that **Zone II** is known as "Bunnell’s No Man’s Land" because of the poor prognosis following primary repair due to adhesions within the fibro-osseous tunnel.

Q: Froment's sign is a clinical feature of which condition?

Ulnar nerve palsy. **Explanation:** **Froment’s sign** is a classic clinical test used to identify **Ulnar nerve palsy**, specifically assessing the integrity of the **Adductor Pollicis** muscle. 1. **Why Ulnar Nerve Palsy is Correct:** The Adductor Pollicis is the only muscle of the thumb supplied by the Ulnar nerve (Deep branch) [1]. When a patient with ulnar nerve palsy attempts to grip a piece of paper between the thumb and index finger (adduction), the Adductor Pollicis fails. To compensate, the patient uses the **Flexor Pollicis Longus (FPL)**, which is supplied by the **Median nerve** [1]. This results in compensatory **flexion of the interphalangeal (IP) joint** of the thumb, which is a positive Froment’s sign. 2. **Why Other Options are Incorrect:** * **Radial nerve palsy:** Characterized by "Wrist Drop" due to paralysis of the extensors [1]. It does not affect thumb adduction or IP joint flexion. * **Median nerve palsy:** Would result in "Ape Thumb" deformity (loss of opposition) and a weak FPL [1]. In fact, if the median nerve is also damaged, Froment’s sign cannot be elicited because the compensatory mechanism (IP flexion) is lost. * **Tibial nerve palsy:** This affects the lower limb, leading to loss of plantar flexion and intrinsic foot muscle paralysis; it has no relevance to hand signs. **Clinical Pearls for NEET-PG:** * **Jeanne’s Sign:** If the thumb MCP joint also shows hyperextension during this test (due to loss of adductor stability), it is called Jeanne’s sign. * **Wartenberg’s Sign:** Another ulnar nerve sign where the little finger remains abducted due to weakness of the 3rd palmar interosseous muscle. * **Mnemonic:** "Ulnar nerve = **U**nable to adduct; **U**ses FPL."

Q: In trigger finger, at what level is the tendon sheath constriction typically found?

Metacarpophalangeal joint. ### Explanation **Concept:** Trigger finger (Stenosing Tenosynovitis) occurs due to a size mismatch between the flexor tendons (FDS and FDP) and the surrounding pulley system. The primary pathology is the thickening and narrowing of the **A1 pulley**, which is located at the level of the **Metacarpophalangeal (MCP) joint**. This constriction prevents the smooth gliding of the tendon; the tendon often develops a nodule distal to the pulley, which becomes "trapped" during extension, causing the characteristic snapping or "triggering" sensation. **Analysis of Options:** * **D. Metacarpophalangeal joint (Correct):** The A1 pulley originates from the volar plate and the base of the proximal phalanx at the MCP joint level. This is the most common site of entrapment. * **A & C. Middle and Proximal phalanx:** While the tendon sheath extends along these bones (containing A2, A3, and A4 pulleys), these are not the primary sites of constriction in trigger finger. The A2 and A4 pulleys are essential for preventing "bowstringing" but are rarely involved in stenosing tenosynovitis. * **B. Proximal interphalangeal (PIP) joint:** Although the patient often feels the "click" or pain over the PIP joint (referred pain), the actual mechanical obstruction is proximal to it, at the MCP joint. **High-Yield Clinical Pearls for NEET-PG:** * **Most common digit involved:** Ring finger (followed by the thumb, known as "Trigger Thumb"). * **Clinical Sign:** A palpable nodule can often be felt at the level of the MCP joint in the palm. * **Associated Conditions:** Diabetes Mellitus (most common), Rheumatoid Arthritis, and Hypothyroidism. * **Treatment:** First-line is often conservative (NSAIDs, splinting, or corticosteroid injection). Definitive treatment is **surgical release of the A1 pulley**.

Q: A 24-year-old male reports that during a basketball game, he tripped while driving the ball to the basket and fell on his outstretched right hand with the palm down. Three days later, the patient presented with right wrist pain. On examination, the wrist was slightly swollen and tender but without deformity. The doctor instructed the patient to extend the right thumb, thereby accentuating the anatomical "snuffbox," which is extremely tender to deep palpation. An X-ray of the wrist was advised. What is the most likely injured part?

Scaphoid. **Explanation:** The clinical presentation is a classic case of a **Scaphoid fracture**, the most common carpal bone fracture. **1. Why Scaphoid is correct:** The mechanism of injury—falling on an outstretched hand (FOOSH) with the wrist in extension—puts maximum stress on the scaphoid. The hallmark clinical sign is **tenderness in the anatomical snuffbox**, which is bounded medially by the extensor pollicis longus (EPL) and laterally by the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). Tenderness here, even with a normal initial X-ray, must be treated as a scaphoid fracture until proven otherwise. **2. Why other options are incorrect:** * **Radius:** A distal radius fracture (e.g., Colles’ fracture) typically presents with a visible "dinner fork" deformity and tenderness over the radial metaphysis, not localized to the snuffbox. * **Ulna:** Isolated ulnar fractures are rare in FOOSH injuries and would present with medial (ulnar) side pain. * **Lunate:** Lunate injuries usually present with tenderness over the dorsum of the wrist (distal to Lister’s tubercle) and are often associated with carpal instability or dislocations rather than snuffbox tenderness. **Clinical Pearls for NEET-PG:** * **Blood Supply:** The scaphoid has a **retrograde blood supply** (entering via the distal pole). Therefore, fractures at the **waist** or **proximal pole** carry a high risk of **Avascular Necrosis (AVN)** and non-union. * **Radiology:** Initial X-rays may be negative in 10-20% of cases. If clinical suspicion persists, the wrist should be immobilized in a **thumb spica cast** and re-X-rayed after 10–14 days. * **Gold Standard:** MRI is the most sensitive investigation for detecting occult scaphoid fractures early.

Q: What is the cause of Dupuytren's contracture?

All of the above. **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 (most commonly the ring and little fingers). The exact etiology is idiopathic, but it is strongly associated with several systemic risk factors: * **Diabetes Mellitus:** Hyperglycemia leads to the formation of Advanced Glycation End-products (AGEs), which increase collagen cross-linking and fibroblast proliferation. * **Alcohol Consumption:** Chronic intake is linked to microvascular changes and altered metabolism that predispose the palmar fascia to fibrosis. * **Smoking:** Nicotine causes localized ischemia and microvascular damage, stimulating myofibroblast activity. **Why "All of the above" is correct:** While the condition has a strong genetic component (Autosomal Dominant with variable penetrance, linked to Northern European/Viking descent), Diabetes, Alcohol, and Smoking are all well-documented environmental triggers and exacerbating factors. Therefore, all three options contribute to the pathogenesis. **Clinical Pearls for NEET-PG:** * **Pathology:** It involves the transformation of fibroblasts into **myofibroblasts**, with a shift from Type I to **Type III collagen**. * **Clinical Test:** **Hueston’s Tabletop Test** is positive when the patient cannot place their palm flat on a table. * **Management:** Surgical intervention (Fasciectomy) is indicated if the MCP joint contracture is **>30°** or any PIP joint contracture is present. * **Associations:** Often associated with other fibromatoses like **Ledderhose disease** (plantar fascia) and **Peyronie’s disease** (penile fascia).

Q: Knuckle bender splint is used for which of the following conditions?

Ulnar nerve palsy. **Explanation:** The **Knuckle Bender Splint** (also known as the Bunnell Splint) is primarily used to correct the **claw hand deformity** seen in **Ulnar Nerve Palsy**. **1. Why Ulnar Nerve Palsy is Correct:** In ulnar nerve palsy, there is paralysis of the lumbricals (specifically the 3rd and 4th). Since lumbricals normally flex the metacarpophalangeal (MCP) joints and extend the interphalangeal (IP) joints, their loss leads to the opposite: hyperextension at the MCP joints and flexion at the IP joints (Clawing). The Knuckle Bender splint uses a mechanical three-point pressure system to force the **MCP joints into flexion**, thereby counteracting the deformity and preventing joint contractures. **2. Why other options are incorrect:** * **Radial Nerve Palsy:** Characterized by "Wrist Drop." The treatment of choice is a **Cock-up splint** or a **Dynamic Radial Nerve Splint** (to assist wrist and finger extension). * **Median Nerve Palsy:** Characterized by "Ape Thumb Deformity" (loss of opposition). The specific splint used is the **Opponens Splint**. * **Axillary Nerve Palsy:** Results in deltoid paralysis and loss of shoulder abduction. Splinting is rarely the primary focus, though an **Aeroplane Splint** may be used in certain brachial plexus injuries to maintain abduction. **High-Yield Clinical Pearls for NEET-PG:** * **Reverse Knuckle Bender:** Used to treat extension contractures by forcing the MCP joints into extension. * **Ulnar Paradox:** The higher the lesion (at the elbow), the less obvious the clawing; the lower the lesion (at the wrist), the more severe the clawing. * **Thomas Splint:** Used for immobilization of femur fractures. * **Bohler-Braun Splint:** A hardware frame used for skeletal traction in lower limb fractures.

Q: Carpal tunnel syndrome is due to compression of which nerve?

Median nerve. **Explanation:** **Carpal Tunnel Syndrome (CTS)** is the most common entrapment neuropathy of the upper limb. It occurs due to the compression of the **Median nerve** as it passes through the carpal tunnel, a narrow osteofibrous canal bounded by the carpal bones (floor) and the flexor retinaculum (roof). **Why the Correct Answer is Right:** The carpal tunnel contains ten structures: the Median nerve and nine tendons (4 Flexor Digitorum Superficialis, 4 Flexor Digitorum Profundus, and 1 Flexor Pollicis Longus). Any condition that increases pressure within this space (e.g., synovitis, pregnancy, hypothyroidism, or trauma) compresses the Median nerve, leading to paresthesia in its sensory distribution (lateral 3.5 fingers) and weakness of the thenar muscles. **Why Other Options are Wrong:** * **Anterior Interosseous Nerve (AIN):** This is a pure motor branch of the median nerve. Compression (AIN syndrome) causes weakness of the "OK" sign (FPL and FDP to index finger) but involves no sensory loss and does not occur in the carpal tunnel. * **Radial Nerve:** This nerve passes posteriorly to the humerus and through the radial tunnel in the forearm. Compression typically leads to wrist drop or sensory loss on the dorsum of the hand. * **Ulnar Nerve:** This nerve passes through **Guyon’s canal**, not the carpal tunnel. Compression here causes sensory loss in the medial 1.5 fingers and clawing. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Tests:** Phalen’s test (most sensitive), Durkan’s test (most specific), and Tinel’s sign. * **Muscle Sparing:** The **Palmar Cutaneous Branch** of the median nerve passes *superficial* to the flexor retinaculum; therefore, sensation over the thenar eminence is **spared** in CTS. * **First-line Treatment:** Night splinting in neutral position; definitive treatment is surgical release of the flexor retinaculum.

Q: Which is the most commonly fractured carpal bone?

Scaphoid. **Explanation:** The **scaphoid** is the most commonly fractured carpal bone, accounting for approximately 60–70% of all carpal fractures and 11% of all hand fractures. This high incidence is due to its anatomical position; it acts as a mechanical bridge between the proximal and distal carpal rows. The mechanism of injury is typically a **fall on an outstretched hand (FOOSH)** with the wrist in extension and radial deviation, which compresses the scaphoid against the radial styloid. **Analysis of Options:** * **Scaphoid (Correct):** Its unique "waist" is the most frequent site of fracture. Due to its retrograde blood supply (entering distally), fractures are prone to **avascular necrosis (AVN)** and non-union, especially in proximal pole fractures. * **Lunate:** While not the most commonly fractured, it is the **most commonly dislocated** carpal bone. Kienböck’s disease refers to AVN of the lunate. * **Hamate:** Fractures are rare and usually involve the "hook of the hamate," often seen in athletes (golfers or baseball players) due to direct trauma from a club or bat. * **Capitate:** This is the largest carpal bone and the center of the carpal arch; fractures are uncommon and usually occur in association with other complex carpal injuries (e.g., Fenton’s syndrome). **High-Yield Clinical Pearls for NEET-PG:** 1. **Clinical Sign:** Tenderness in the **Anatomical Snuffbox** is highly suggestive of a scaphoid fracture. 2. **Radiology:** Initial X-rays may be negative. If clinical suspicion persists, the wrist should be immobilized in a **thumb spica cast** and re-imaged after 10–14 days. 3. **Blood Supply:** The scaphoid receives its blood supply from the **radial artery** via the distal pole; hence, the more proximal the fracture, the higher the risk of AVN.

Question 1

All are true of Dupuytren's contracture except?

Accepted Answer

Bilateral disease is common

Answer

Usually, the 4th finger is involved

Answer

Surgical release is useful

Answer

May be associated with Peyronie disease

Question 2

Wrist drop is seen with which of the following conditions?

Accepted Answer

Radial nerve palsy

Answer

Median nerve palsy

Answer

Ulnar nerve palsy

Answer

Posterior interosseous nerve palsy

Question 3

Which tendon is commonly used as a graft for flexor tendon repair?

Accepted Answer

Palmaris longus

Answer

Plantaris

Answer

Extensor digitorum

Answer

Extensor indicis

Question 4

Froment's sign is a clinical feature of which condition?

Accepted Answer

Ulnar nerve palsy

Answer

Radial nerve palsy

Answer

Median nerve palsy

Answer

Tibial nerve palsy

Question 5

In trigger finger, at what level is the tendon sheath constriction typically found?

Accepted Answer

Metacarpophalangeal joint

Answer

Middle phalanx

Answer

Proximal interphalangeal joint

Answer

Proximal phalanx

Question 6

A 24-year-old male reports that during a basketball game, he tripped while driving the ball to the basket and fell on his outstretched right hand with the palm down. Three days later, the patient presented with right wrist pain. On examination, the wrist was slightly swollen and tender but without deformity. The doctor instructed the patient to extend the right thumb, thereby accentuating the anatomical "snuffbox," which is extremely tender to deep palpation. An X-ray of the wrist was advised. What is the most likely injured part?

Accepted Answer

Scaphoid

Answer

Radius

Answer

Ulna

Answer

Lunate

Question 7

What is the cause of Dupuytren's contracture?

Accepted Answer

All of the above

Answer

Diabetes Mellitus

Answer

Alcohol consumption

Answer

Smoking

Question 8

Knuckle bender splint is used for which of the following conditions?

Accepted Answer

Ulnar nerve palsy

Answer

Radial nerve palsy

Answer

Median nerve palsy

Answer

Axillary nerve palsy

Question 9

Carpal tunnel syndrome is due to compression of which nerve?

Accepted Answer

Median nerve

Answer

Anterior interosseous nerve

Answer

Radial nerve

Answer

Ulnar nerve

Question 10

Which is the most commonly fractured carpal bone?

Accepted Answer

Scaphoid

Answer

Hamate

Answer

Lunate

Answer

Capitate

Hand Surgery — MCQs

Hand Surgery — MCQs

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