Hand Surgery Practice Questions

Q: Which nerve injury is elicited by the 'pen test'?

Median nerve. The **Pen Test** is a clinical examination used to assess the motor function of the **Median nerve**, specifically the integrity of the **Abductor Pollicis Brevis (APB)** muscle. ### Why Median Nerve is Correct: The APB is one of the thenar muscles exclusively supplied by the recurrent branch of the Median nerve. Its primary action is **palmar abduction** (moving the thumb perpendicular to the plane of the palm). * **Procedure:** The patient’s hand is placed flat on a table (supinated). A pen is held horizontally above the thumb, and the patient is asked to lift the thumb to touch the pen. * **Positive Result:** In Median nerve palsy (especially in Carpal Tunnel Syndrome), the patient cannot touch the pen due to paralysis of the APB. ### Why Other Options are Wrong: * **Ulnar Nerve:** Tested via **Froment’s Sign** (Adductor Pollicis) or the **Card Test** (Palmar Interossei). Ulnar injury leads to "Claw Hand." * **Radial Nerve:** Tested by checking for **Wrist Drop** or **Finger Extension** at the MCP joints. The characteristic test is the ability to extend the wrist and thumb against resistance. * **Axillary Nerve:** Supplies the Deltoid; tested by assessing shoulder abduction and sensation over the "Regimental Badge" area. ### High-Yield Clinical Pearls: * **Ape Thumb Deformity:** Seen in chronic Median nerve injury due to thenar atrophy and loss of thumb opposition. * **Pointing Index (Benediction Gesture):** Occurs in high Median nerve palsy when the patient attempts to make a fist. * **Ochsner’s Clasping Test:** Another test for Median nerve (specifically FDP of index finger); when clasping hands, the index finger remains extended.

Q: Cubital tunnel syndrome involves which nerve?

Ulnar nerve. **Explanation:** **Cubital Tunnel Syndrome** is the second most common compression neuropathy of the upper limb (after Carpal Tunnel Syndrome). It occurs due to the compression or entrapment of the **Ulnar nerve** as it passes through the cubital tunnel at the elbow. The tunnel is bordered medially by the medial epicondyle and laterally by the olecranon, with the roof formed by **Osborne’s ligament** (arcuate ligament). * **Why Ulnar Nerve is Correct:** The ulnar nerve is most vulnerable at the elbow because it lies superficially in the retrocondylar groove. Chronic pressure, repetitive flexion, or valgus deformity (Tardy Ulnar Palsy) leads to paresthesia in the small finger and the ulnar half of the ring finger, along with weakness of the intrinsic muscles of the hand. **Analysis of Incorrect Options:** * **Radial Nerve:** Compression typically occurs in the spiral groove (Saturday Night Palsy) or at the arcade of Frohse (Posterior Interosseous Nerve syndrome), leading to wrist drop or finger extension weakness. * **Median Nerve:** Most commonly compressed at the wrist (Carpal Tunnel Syndrome) or between the two heads of the pronator teres (Pronator Syndrome). * **Axillary Nerve:** Usually injured during anterior shoulder dislocations or fractures of the surgical neck of the humerus, affecting the deltoid muscle. **Clinical Pearls for NEET-PG:** * **Tardy Ulnar Palsy:** Delayed ulnar nerve palsy occurring years after a lateral condyle fracture of the humerus due to resultant **cubitus valgus** deformity. * **Froment’s Sign:** Positive in ulnar nerve palsy due to weakness of the Adductor Pollicis (compensated by Flexor Pollicis Longus). * **Wartenberg’s Sign:** Persistent abduction of the small finger due to weak palmar interossei.

Q: Trigger finger is commonly associated with which of the following conditions?

Trauma. **Explanation:** **Trigger Finger (Stenosing Tenosynovitis)** occurs due to a size mismatch between the flexor tendon and the **A1 pulley** (most common site). This leads to a mechanical "snapping" or "locking" of the finger during flexion and extension. **Why Trauma is the Correct Answer:** Repetitive **micro-trauma** or chronic irritation to the palm (often from occupational overuse or tools) is the primary etiology. This trauma causes inflammation and hypertrophy of the A1 pulley and the formation of a nodule on the flexor tendon. While systemic conditions like Diabetes Mellitus are strongly associated, localized mechanical trauma is a classic precipitating factor in clinical practice and standard textbook descriptions for this condition. **Analysis of Incorrect Options:** * **A. Rheumatoid Arthritis:** While RA can cause tenosynovitis, it more typically leads to "triggering" due to rheumatoid nodules within the tendon or diffuse synovial thickening, rather than the classic isolated A1 pulley stenosis seen in primary trigger finger. * **C. Osteosarcoma:** This is a malignant bone-forming tumor. It does not involve the flexor tendon sheath or cause mechanical triggering of the digits. * **D. Osteoarthritis:** OA primarily affects the articular cartilage of joints (like the DIP or CMC joints). It does not involve the stenosing tenosynovitis of the flexor pulleys. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** A1 Pulley at the level of the MCP joint. * **Most commonly involved digit:** Ring finger (followed by the thumb). * **Associated Conditions:** Diabetes Mellitus (most common systemic association), Hypothyroidism, and Amyloidosis. * **Clinical Sign:** A palpable nodule that moves with the tendon; the finger "locks" in flexion. * **Management:** Conservative (NSAIDs/Splinting), Steroid injection (first-line medical), or **Surgical release of the A1 pulley** (definitive).

Q: Kanavel's sign is seen in?

Tenosynovitis. **Explanation:** **Kanavel’s Signs** are a clinical quartet used to diagnose **Acute Flexor Tenosynovitis**, a surgical emergency involving infection of the synovial sheath surrounding the flexor tendons. The correct answer is **Tenosynovitis** because these signs specifically indicate increased pressure and inflammation within the confined space of the tendon sheath. The four cardinal Kanavel’s signs are: 1. **F**lexed posture of the finger at rest. 2. **U**niform (fusiform) swelling of the entire digit (Sausage digit). 3. **T**enderness along the course of the tendon sheath (Percussion tenderness). 4. **P**ain on passive extension of the finger (the earliest and most sensitive sign). **Why other options are incorrect:** * **Trigger Finger (Stenosing Tenosynovitis):** Characterized by "locking" or "snapping" of the finger due to a nodule at the A1 pulley; it lacks the diffuse swelling and exquisite pain on passive extension seen in Kanavel’s signs. * **Dupuytren’s Contracture:** A chronic fibroproliferative disorder of the palmar fascia leading to permanent flexion contractures (usually the ring and little finger). It is painless and does not involve the tendon sheath. * **Carpal Tunnel Syndrome:** A compressive neuropathy of the median nerve. It presents with paresthesia and wasting of the thenar eminence, not signs of acute infection. **Clinical Pearls for NEET-PG:** * **Most sensitive sign:** Pain on passive extension is usually the first sign to appear. * **Common Organism:** *Staphylococcus aureus* is the most common causative agent. * **Horseshoe Abscess:** Infection in the thumb (radial bursa) and little finger (ulnar bursa) can communicate in the palm, forming a "horseshoe" shaped infection. * **Treatment:** Early cases may respond to IV antibiotics, but advanced cases require urgent surgical incision and drainage (washout).

Q: What test is being performed?

Finkelstein test. ***Finkelstein test*** - The **Finkelstein test** is performed by having the patient tuck their **thumb into their fist** and then **ulnarly deviating** the wrist, causing pain over the **radial styloid process**. - This test is **positive for De Quervain's tenosynovitis**, which involves inflammation of the **abductor pollicis longus** and **extensor pollicis brevis** tendons. *Tinel sign* - **Tinel sign** involves **tapping over a nerve** (commonly the median nerve at the wrist or ulnar nerve at the elbow) to elicit **tingling or paresthesias**. - This test is used to diagnose **carpal tunnel syndrome** or **cubital tunnel syndrome**, not tendon pathology. *Froment sign* - **Froment sign** tests for **ulnar nerve palsy** by having the patient pinch paper between thumb and index finger, observing for **flexion of the thumb IP joint**. - This compensatory mechanism occurs due to weakness of the **adductor pollicis muscle**, which is innervated by the ulnar nerve. *Jeanne's sign* - **Jeanne's sign** also indicates **ulnar nerve palsy** and is observed as **hyperextension of the thumb MCP joint** during pinch grip. - This occurs due to **intrinsic muscle weakness**, specifically involving the **first dorsal interosseous** and **adductor pollicis** muscles.

Q: The test performed below shows involvement of which of the following nerve?

Median nerve. ***Median nerve*** - The test shown is the **pen test** or **grip test**, which assesses **median nerve function** by testing the ability to grip objects between thumb and fingers. - **Median nerve palsy** causes weakness in **thumb opposition** and **flexion of index and middle fingers**, making it difficult to hold objects firmly. *Ulnar nerve* - **Ulnar nerve palsy** is tested using **Froment's sign** or the **paper test**, where patients compensate for weak thumb adduction by flexing the thumb IP joint. - Ulnar nerve dysfunction primarily affects **hypothenar muscles** and causes **claw hand deformity** in the 4th and 5th fingers. *Radial nerve* - **Radial nerve palsy** is assessed by testing **wrist extension** and **finger extension** at the MCP joints, not grip strength. - Classic presentation includes **wrist drop** with inability to extend the wrist against gravity and weakness in **thumb extension**. *Axillary nerve* - **Axillary nerve palsy** is tested by assessing **deltoid muscle function** and **shoulder abduction**, not hand grip. - Loss of **sensation over the deltoid region** (regimental badge area) and inability to **abduct the arm** beyond 15 degrees are characteristic findings.

Q: Froment's sign is due to injury of which nerve?

Ulnar nerve. **Explanation:** **Froment’s sign** is a classic clinical test used to identify **Ulnar nerve palsy**, specifically assessing the paralysis of the **Adductor Pollicis** muscle. **Why Ulnar Nerve is correct:** The Adductor Pollicis is the only muscle of the thumb innervated by the Ulnar nerve. Its primary function is to adduct the thumb against the index finger (e.g., when holding a piece of paper). When the ulnar nerve is injured, this muscle becomes paralyzed. To compensate and maintain a grip on the paper, the patient uses the **Flexor Pollicis Longus (FPL)**, which is innervated by the **Median nerve** (Anterior Interosseous branch). This results in compensatory **flexion of the thumb at the Interphalangeal (IP) joint**, which is the positive Froment’s sign. **Why other options are incorrect:** * **Intercostobrachial nerve:** A sensory nerve supplying the skin of the axilla and upper medial arm; it has no motor function in the hand. * **Radial nerve:** Supplies the extensors of the wrist and fingers. Injury leads to "Wrist Drop," not thumb adduction deficits. * **Median nerve:** Supplies the FPL and the thenar muscles. Injury would cause "Ape Thumb" deformity and an inability to flex the thumb IP joint, making a positive Froment's sign impossible. **Clinical Pearls for NEET-PG:** * **Jeanne’s Sign:** If the thumb MCP joint also shows hyperextension during the Froment’s test, it is called Jeanne’s sign (due to loss of stability from the adductor pollicis). * **Mannerfelt-Camitz Syndrome:** Another name for the compensatory FPL recruitment. * **Wartenberg’s Sign:** Inability to adduct the little finger (due to palmar interossei weakness), also seen in Ulnar nerve palsy. * **Ulnar Paradox:** A higher lesion (at the elbow) results in less clawing than a lower lesion (at the wrist).

Question 1

Which nerve injury is elicited by the 'pen test'?

Accepted Answer

Median nerve

Answer

Ulnar nerve

Answer

Radial nerve

Answer

Axillary nerve

Question 2

A 35-year-old right-handed construction worker presents with complaints of nocturnal numbness and pain involving the right hand. Symptoms wake him and are then relieved by shaking his hand. There is some atrophy of the thenar eminence. Tinel sign is positive. What is the best advice for this patient?

Accepted Answer

Wear a wrist splint at night as initial therapy prior to considering surgery.

Answer

Always ensure he has a firm grip on his equipment while working on the construction site as this may relieve pressure on the median nerve.

Answer

Apply ice to his wrist each evening after performing his usual work.

Answer

Refer the patient to physical therapy for exercises to alleviate the pain.

Question 3

Cubital tunnel syndrome involves which nerve?

Accepted Answer

Ulnar nerve

Answer

Radial nerve

Answer

Median nerve

Answer

Axillary nerve

Question 4

Trigger finger is commonly associated with which of the following conditions?

Accepted Answer

Trauma

Answer

Rheumatoid arthritis

Answer

Osteosarcoma

Answer

Osteoarthritis

Question 5

Kanavel's sign is seen in?

Accepted Answer

Tenosynovitis

Answer

Trigger finger

Answer

Dupuytrens contracture

Answer

Carpal tunnel syndrome

Question 6

What test is being performed?

Accepted Answer

Finkelstein test

Answer

Tinel sign

Answer

Froment sign

Answer

Jeanne's sign

Question 7

A 35-year-old construction worker presents with complaints of nocturnal paresthesias of the thumb, index, and middle fingers. There is some atrophy of the thenar eminence. Tinel's sign is positive. What is the most likely diagnosis?

Accepted Answer

Carpal tunnel syndrome

Answer

De Quervain's tenosynovitis

Answer

Amyotrophic lateral sclerosis

Answer

Rheumatoid arthritis of the wrist joint

Question 8

The test performed below shows involvement of which of the following nerve?

Accepted Answer

Median nerve

Answer

Ulnar nerve

Answer

Radial nerve

Answer

Axillary nerve

Question 9

A 69-year-old man presents with numbness in the middle three digits of his right hand and difficulty grasping objects. He has a history of 50 years as a carpenter and has atrophy of the thenar eminence. What is the most likely cause of his hand problems?

Accepted Answer

Compression of the median nerve in the carpal tunnel

Answer

Compression of the ulnar nerve at the medial epicondyle by osteophytes

Answer

Compression of the brachial plexus by hypertrophy of the triceps muscle

Answer

Osteoarthritis of the cervical spine

Question 10

Froment's sign is due to injury of which nerve?

Accepted Answer

Ulnar nerve

Answer

Intercostobrachial nerve

Answer

Radial nerve

Answer

Median nerve

Hand Surgery — MCQs

Hand Surgery — MCQs

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