Hand Surgery Practice Questions

Q: What is this condition known as?

Felon. ***Felon*** - A **fingertip pulp space infection** characterized by **tense swelling** and severe pain in the **digital pulp**. - Requires urgent **incision and drainage** to prevent complications like **osteomyelitis** of the distal phalanx. *Preiser's disease* - **Avascular necrosis (AVN) of the scaphoid bone** in the wrist, not related to fingertip infections. - Presents with **wrist pain** and **limited range of motion**, typically following trauma or repetitive stress. *Kienbock's disease* - **Avascular necrosis (AVN) of the lunate bone** in the wrist, unrelated to soft tissue infections. - Characterized by **progressive wrist pain** and **collapse of the lunate**, often seen on X-rays. *Kaplan's lesion* - A **tear of the ulnar collateral ligament** at the thumb MCP joint (gamekeeper's thumb). - Involves **ligamentous injury** rather than infection, presenting with thumb **instability** and pain.

Q: Carpal tunnel syndrome is associated with all of the following except:

Hyperparathyroidism. **Explanation:** Carpal Tunnel Syndrome (CTS) is a compressive neuropathy of the median nerve within the carpal tunnel. The pathophysiology involves any condition that reduces the volume of the tunnel or increases the volume of its contents (tenosynovium, tendons, or nerve). **Why Hyperparathyroidism is the correct answer:** While several endocrine disorders are linked to CTS, **Hyperparathyroidism** is not classically associated with the condition. In contrast, **Hypothyroidism** is a well-known cause due to the deposition of mucopolysaccharides (myxedema) within the carpal canal, leading to increased pressure. **Analysis of other options:** * **Rheumatoid Arthritis:** This is a common cause of CTS. Chronic inflammation leads to **proliferative tenosynovitis** of the flexor tendons, which increases pressure within the rigid fibro-osseous tunnel. * **Wrist Osteoarthritis:** Degenerative changes, including the formation of **osteophytes** or joint space narrowing, can alter the anatomy of the carpal floor, effectively reducing the space available for the median nerve. * **Acromegaly:** Excess Growth Hormone causes **soft tissue hypertrophy** and bony overgrowth, which significantly narrows the carpal tunnel. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Idiopathic. * **Most common associated endocrine cause:** Diabetes Mellitus and Hypothyroidism. * **Pregnancy:** CTS is common in the third trimester due to fluid retention (edema). * **Clinical Tests:** Phalen’s test (most sensitive) and Durkan’s compression test (most specific). * **Gold Standard Diagnosis:** Nerve Conduction Velocity (NCV) studies showing increased latency.

Q: Carpal tunnel syndrome is caused by all of the following conditions EXCEPT?

Addison's disease. **Explanation:** Carpal Tunnel Syndrome (CTS) is a compressive neuropathy of the **median nerve** as it passes through the fibro-osseous carpal tunnel. It occurs when the space within the tunnel decreases or the volume of its contents increases. **Why Addison’s Disease is the Correct Answer:** Addison’s disease (primary adrenocortical insufficiency) is characterized by a deficiency of cortisol and aldosterone. It typically leads to weight loss and dehydration, which does not cause fluid retention or soft tissue hypertrophy. In contrast, **Cushing’s syndrome** (excess cortisol) and **Acromegaly** are associated with CTS due to increased fat deposition and soft tissue overgrowth, respectively. **Analysis of Incorrect Options:** * **Amyloidosis:** Deposition of amyloid proteins (especially $\beta_2$-microglobulin in dialysis patients) within the flexor retinaculum or synovium directly compresses the median nerve. * **Hypothyroidism:** Causes the accumulation of **glycosaminoglycans** (myxedematous tissue) and fluid in the carpal tunnel, leading to increased pressure. * **Diabetes Mellitus:** Hyperglycemia leads to the glycation of collagen, making the transverse carpal ligament stiffer and thicker. Diabetics also have a lower threshold for nerve compression (double crush syndrome). **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Idiopathic. * **Most common associated systemic condition:** Obesity; followed by Pregnancy (due to edema). * **Clinical Tests:** Phalen’s test (most sensitive), Tinel’s sign, and Durkan’s compression test (most specific). * **Gold Standard Diagnosis:** Nerve Conduction Velocity (NCV) studies showing increased latency. * **Anatomy:** The median nerve lies superficial to the flexor tendons; the **Flexor Pollicis Longus** is the most radial structure in the tunnel.

Q: A patient presented with a history of fall on an outstretched hand. There is pain and swelling over the radial aspect of the wrist without any obvious deformity. The radial styloid process is at a lower level than the ulnar styloid process. Tenderness can be elicited in the anatomical snuff box. Which of the following is the most likely diagnosis?

Fracture scaphoid. ### Explanation **1. Why Scaphoid Fracture is Correct:** The scaphoid is the most commonly fractured carpal bone, typically resulting from a **fall on an outstretched hand (FOOSH)**. The hallmark clinical finding is **tenderness in the anatomical snuffbox**. A crucial detail in this question is that the **radial styloid remains at a lower level than the ulnar styloid**. This indicates that the normal anatomy of the distal radius is intact, effectively ruling out a distal radius fracture (like Colles') where the radial styloid would shift proximally. **2. Why Other Options are Incorrect:** * **Colles' Fracture:** While also caused by FOOSH, it presents with a classic "dinner fork deformity" and a change in the styloid relationship (the radial styloid moves up to the level of or above the ulnar styloid). * **Fracture Pisiform:** The pisiform is located on the **ulnar (medial) aspect** of the wrist. Tenderness would be localized to the hypothenar area, not the radial anatomical snuffbox. * **Wrist Osteoarthritis:** This is a chronic degenerative condition. While it causes pain, it does not typically present with acute post-traumatic swelling and localized snuffbox tenderness following a fall. **3. High-Yield NEET-PG Pearls:** * **Blood Supply:** The scaphoid has a retrograde blood supply (distal to proximal). Fractures at the **proximal pole** have the highest risk of **Avascular Necrosis (AVN)** and non-union. * **Radiology:** Scaphoid fractures may not appear on initial X-rays. If clinical suspicion is high despite normal X-rays, the wrist should be immobilized in a **thumb spica cast** and re-imaged after 10–14 days. * **View of Choice:** Scaphoid view (PA view with the wrist in ulnar deviation).

Q: A boxer's fracture is a fracture through which part of the bone?

5th metacarpal neck. **Explanation:** A **Boxer’s fracture** is a fracture of the **neck of the 5th metacarpal**. It typically occurs when a person strikes a hard object with a clenched fist. The force is transmitted axially through the metacarpal, leading to a fracture at its weakest point—the distal neck. This often results in volar (palmar) angulation of the metacarpal head due to the pull of the interosseous muscles. **Analysis of Options:** * **Option B (Correct):** The 5th metacarpal neck is the classic site. It is frequently seen in inexperienced "fighters" who punch with the ulnar side of the hand rather than the 2nd and 3rd metacarpals. * **Option A:** A fracture at the **5th metacarpal base** is often associated with a "Reverse Bennett’s fracture-dislocation," which is unstable due to the pull of the Extensor Carpi Ulnaris (ECU) tendon. * **Option C:** A fracture at the **5th metatarsal base** (foot) is known as a **Jones fracture** (at the metaphyseal-diaphyseal junction) or a **Pseudo-Jones fracture** (avulsion of the styloid process). * **Option D:** The 5th metatarsal neck is not a common eponym-associated fracture site. **Clinical Pearls for NEET-PG:** 1. **Acceptable Angulation:** The 5th metacarpal allows for more compensatory angulation (up to 40-50 degrees) than the 2nd or 3rd metacarpals because of the mobility of the CMC joint. 2. **Management:** Most are treated closed with an **Ulnar Gutter Splint**. 3. **Physical Exam:** Look for the "loss of the 5th knuckle" and check for rotational deformity (fingers should point toward the scaphoid tubercle when flexed).

Q: Which splint is used for the condition shown below?

Knuckle bender splint. ***Knuckle bender splint*** - Specifically designed to correct **claw hand deformity** caused by **ulnar nerve palsy** by preventing hyperextension at the MCP joints and allowing proper finger flexion. - Works biomechanically by blocking **MCP hyperextension** while preserving **PIP and DIP flexion**, restoring functional grip patterns. *Gutter splint* - Used primarily for **metacarpal fractures** or **finger fractures**, providing immobilization along the lateral or medial aspect of the hand. - Does not address the **MCP hyperextension** problem seen in claw hand deformity, making it inappropriate for this condition. *Mallet splint* - Designed specifically for **mallet finger injury** (extensor tendon rupture at DIP joint), keeping the DIP joint in extension. - Targets only the **DIP joint** and would not correct the **MCP hyperextension** characteristic of claw hand deformity. *Cock-up splint* - Used for **wrist drop** or **radial nerve palsy**, positioning the wrist in extension to improve hand function. - Addresses **wrist positioning** rather than finger MCP joint mechanics, making it unsuitable for ulnar nerve claw hand correction.

Q: Which test is demonstrated in the image?

Pointing index. ***Pointing index*** - Tests for **anterior interosseous nerve (AIN) palsy** by assessing the ability to flex the **index finger DIP joint** during the "OK" sign gesture. - When AIN is damaged, the patient cannot flex the index DIP, resulting in a **pointing appearance** of the index finger instead of forming a proper circle. *Card Test* - Used to assess **ulnar nerve function** by testing the ability to hold a card between fingers using **palmar interossei muscles**. - Does not involve testing **DIP joint flexion** or the anterior interosseous nerve pathway. *Froment's Sign* - Tests for **ulnar nerve palsy** by evaluating **adductor pollicis weakness** when pinching paper between thumb and index finger. - Patient compensates by using **flexor pollicis longus** (median nerve), causing thumb **IP joint flexion**, not index finger pointing. *Pen Test* - Assesses **ulnar nerve function** by testing the ability to hold a pen using **intrinsic hand muscles**. - Does not evaluate **AIN function** or involve the specific DIP flexion deficit seen in pointing index test.

Q: A patient is unable to actively extend the terminal phalange, although the distal interphalangeal joint can be extended passively. What is this condition known as?

Mallet finger. ### Explanation **Correct Option: A. Mallet Finger** Mallet finger (also known as "Baseball finger") is a deformity caused by the disruption of the **extensor digitorum tendon** at its insertion into the base of the distal phalanx. This can occur due to a sudden forceful flexion of the extended finger (e.g., being struck by a ball) or an avulsion fracture. * **Mechanism:** Because the terminal extensor mechanism is lost, the patient cannot actively extend the Distal Interphalangeal (DIP) joint. * **Clinical Feature:** The DIP joint remains in a flexed position at rest. However, since the joint itself is not fused or locked, it can be extended **passively** by the examiner. **Analysis of Incorrect Options:** * **B. Trigger Finger (Stenosing Tenosynovitis):** This involves inflammation of the flexor tendon sheath at the A1 pulley. It presents as "locking" or "catching" during finger extension/flexion, not a loss of terminal extension. * **C. Butter Finger:** This is a colloquial term for clumsiness and is not a recognized medical or orthopedic diagnosis. * **D. Ring Finger:** This is an anatomical name for the fourth digit and does not describe a pathological condition. **NEET-PG High-Yield Pearls:** * **Treatment:** Most cases are managed conservatively with a **Mallet splint** (holding the DIP joint in continuous slight hyperextension) for 6–8 weeks. * **Boutonnière Deformity:** Often confused with Mallet finger; it involves disruption of the **central slip** of the extensor tendon, leading to PIP flexion and DIP hyperextension. * **Jersey Finger:** The opposite of Mallet finger; it is an avulsion of the **Flexor Digitorum Profundus (FDP)**, where the patient cannot actively *flex* the DIP joint.

Question 1

What is this condition known as?

Accepted Answer

Felon

Answer

Preiser's disease

Answer

Kienbock's disease

Answer

Kaplan's lesion

Question 2

A 57-year-old woman presents with numbness and tingling in her right thumb, index, and long finger for the past four weeks. She reports waking up in the middle of the night with these symptoms, requiring her to shake her hands to alleviate them. She denies similar symptoms in her other hand or legs and has no neck or upper arm pain. Physical examination reveals that her symptoms are reproduced by Tinel testing and exacerbated by wrist hyperflexion. Decreased sensation is noted over the palmar aspects of the thumb, index, and middle fingers, with no apparent motor weakness. What is the most likely diagnosis?

Accepted Answer

Carpal tunnel syndrome

Answer

C5 cervical nerve root compression

Answer

Cubital tunnel syndrome

Answer

Radial tunnel syndrome

Question 3

Carpal tunnel syndrome is associated with all of the following except:

Accepted Answer

Hyperparathyroidism

Answer

Rheumatoid arthritis

Answer

Wrist osteoarthritis

Answer

Acromegaly

Question 4

Carpal tunnel syndrome is caused by all of the following conditions EXCEPT?

Accepted Answer

Addison's disease

Answer

Amyloidosis

Answer

Hypothyroidism

Answer

Diabetes mellitus

Question 5

A patient presented with a history of fall on an outstretched hand. There is pain and swelling over the radial aspect of the wrist without any obvious deformity. The radial styloid process is at a lower level than the ulnar styloid process. Tenderness can be elicited in the anatomical snuff box. Which of the following is the most likely diagnosis?

Accepted Answer

Fracture scaphoid

Answer

Fracture Colles'

Answer

Fracture pisiform

Answer

Wrist osteoarthritis

Question 6

A boxer's fracture is a fracture through which part of the bone?

Accepted Answer

5th metacarpal neck

Answer

5th metacarpal base

Answer

5th metatarsal base

Answer

5th metatarsal neck

Question 7

Which splint is used for the condition shown below?

Accepted Answer

Knuckle bender splint

Answer

Gutter splint

Answer

Mallet splint

Answer

Cock-up splint

Question 8

Which test is demonstrated in the image?

Accepted Answer

Pointing index

Answer

Card Test

Answer

Froment's Sign

Answer

Pen Test

Question 9

A patient is unable to actively extend the terminal phalange, although the distal interphalangeal joint can be extended passively. What is this condition known as?

Accepted Answer

Mallet finger

Answer

Trigger finger

Answer

Butter finger

Answer

Ring finger

Question 10

A 40-year-old diabetic man presents with an inability to bend his ring finger and small nodules on the palm. Which of the following would NOT be part of your management for this patient?

Accepted Answer

Subtotal fasciectomy when more than 15 degrees of flexion deformity is involved at the proximal interphalangeal (PIP) joint

Answer

Wait and watch

Answer

Subtotal fasciectomy when more than 30 degrees of flexion deformity is involved at the metacarpophalangeal (MCP) joint

Answer

Collagenase injection

Hand Surgery — MCQs

Hand Surgery — MCQs

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