Hand Surgery — MCQs
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Hyperextension of the Proximal Interphalangeal (PIP) joint and flexion of the Distal Interphalangeal (DIP) joint is seen in which deformity?
Stenosing tenosynovitis of the flexor tendon sheath is also known as:
Which of the following is not a recognized treatment for carpal tunnel syndrome?
Which of the following is a feature of Carpal tunnel syndrome?
Which of the following structures is involved in Dupuytren's contracture?
The Card test or Book test is used to assess injury of which nerve?
What is the definition of a swan-neck deformity?
Finkelstein's test is used for which condition?
Which tendon is typically used for flexor tendon injury reconstruction in the hand, originating from the forearm to the finger?
Pollicization can be best described as:
Hand Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Hyperextension of the Proximal Interphalangeal (PIP) joint and flexion of the Distal Interphalangeal (DIP) joint is seen in which deformity?
- A. Swan neck deformity (Correct Answer)
- B. Mallet finger deformity
- C. Lumbricals paralysis
- D. Boutonniere's deformity
Explanation: ### Explanation **Swan Neck Deformity** is characterized by the classic combination of **hyperextension at the PIP joint** and **flexion at the DIP joint**. This occurs due to an imbalance in the extensor mechanism, often triggered by a volar plate rupture or dorsal displacement of the lateral bands. The resulting tension pulls the PIP joint into hyperextension, while the compensatory pull of the Flexor Digitorum Profundus (FDP) causes the DIP joint to flex. #### Analysis of Options: * **B. Mallet Finger:** This involves an injury to the extensor tendon at its insertion on the distal phalanx, resulting in **isolated flexion of the DIP joint** (inability to extend the tip of the finger). * **C. Lumbricals Paralysis:** Lumbricals normally flex the MCP joints and extend the IP joints. Their paralysis leads to the **"Claw Hand"** deformity (hyperextension of MCP and flexion of IP joints). * **D. Boutonniere’s Deformity:** This is the exact opposite of Swan Neck. It involves **flexion of the PIP joint** and **hyperextension of the DIP joint**, caused by a rupture of the central slip of the extensor tendon. #### NEET-PG High-Yield Pearls: * **Swan Neck Deformity** is most commonly associated with **Rheumatoid Arthritis** (due to synovitis) and Ehlers-Danlos syndrome. * **Boutonniere Deformity** is also seen in Rheumatoid Arthritis but is classically associated with direct trauma to the dorsum of the PIP joint. * **Mnemonic:** **"B"** comes before **"S"**; **B**outonniere starts with **flexion** (at PIP), **S**wan neck starts with **extension** (at PIP).
Question 2: Stenosing tenosynovitis of the flexor tendon sheath is also known as:
- A. Trigger finger (Correct Answer)
- B. Tennis elbow
- C. Carpal tunnel syndrome
- D. Dupuytren's contracture
Explanation: **Explanation:** **1. Why Trigger Finger is Correct:** **Stenosing tenosynovitis** of the flexor tendons is the pathological basis of **Trigger Finger**. It occurs due to inflammation and thickening of the flexor tendon sheath (usually at the level of the **A1 pulley**). This creates a size mismatch where the tendon nodule struggles to glide through the narrowed pulley, causing the finger to "lock" or "catch" in flexion. When the patient forcefully extends the finger, it snaps open like a trigger being released. **2. Why the Other Options are Incorrect:** * **Tennis Elbow (Lateral Epicondylitis):** This is an overuse injury involving the common extensor origin (specifically the *Extensor Carpi Radialis Brevis*) at the lateral epicondyle of the humerus, not the flexor tendons. * **Carpal Tunnel Syndrome:** This is a compressive neuropathy of the **median nerve** as it passes through the carpal tunnel. While it involves the same anatomical region, it is not a primary stenosing tenosynovitis of the tendons. * **Dupuytren's Contracture:** This is a progressive fibrosis and thickening of the **palmar fascia**, leading to permanent flexion contractures (most commonly affecting the ring and little fingers). It does not involve the tendon sheath itself. **Clinical Pearls for NEET-PG:** * **Most common site:** The **A1 pulley** (located over the metacarpal head). * **Associated conditions:** Frequently seen in patients with **Diabetes Mellitus** and Rheumatoid Arthritis. * **Treatment:** Initial management includes NSAIDs and corticosteroid injections. Definitive surgical management involves the **surgical release of the A1 pulley**. * **Differential Diagnosis:** Do not confuse this with *De Quervain’s Tenosynovitis*, which is stenosing tenosynovitis of the **1st dorsal compartment** (APL and EPB tendons).
Question 3: Which of the following is not a recognized treatment for carpal tunnel syndrome?
- A. Nerve stimulation therapy. (Correct Answer)
- B. Steroid injection.
- C. One-portal endoscopic surgical release.
- D. Two-portal endoscopic surgical release.
Explanation: **Explanation:** **Carpal Tunnel Syndrome (CTS)** is the most common entrapment neuropathy, caused by compression of the **median nerve** as it passes through the carpal tunnel. **Why Option A is correct:** **Nerve stimulation therapy** (such as TENS or electrical muscle stimulation) is **not** a recognized or evidence-based treatment for CTS. In fact, applying electrical stimulation to an already compressed and ischemic nerve can potentially exacerbate symptoms or delay definitive treatment. Management focuses on relieving pressure, not stimulating the nerve. **Why the other options are incorrect:** * **Steroid Injections (Option B):** These are a mainstay of conservative management. Local corticosteroid injections reduce inflammation and edema of the synovial sheaths, providing significant symptomatic relief in mild to moderate cases. * **Endoscopic Surgical Release (Options C & D):** When conservative management fails, surgical decompression by dividing the **transverse carpal ligament** is indicated. This can be performed via an open technique or endoscopically. * **One-portal (Agee technique):** Uses a single proximal incision at the wrist crease. * **Two-portal (Chow technique):** Uses both a proximal wrist incision and a distal palmar incision. Both are recognized surgical standards. **High-Yield Clinical Pearls for NEET-PG:** * **Contents of Carpal Tunnel:** Median nerve + 9 tendons (4 FDS, 4 FDP, 1 FPL). * **First-line treatment:** Night splinting in neutral position and NSAIDs. * **Gold Standard Diagnosis:** Nerve Conduction Study (NCS) showing increased distal latency and decreased conduction velocity. * **Phalen’s Test & Tinel’s Sign:** Classic clinical provocative tests. * **Ape Thumb Deformity:** Occurs in late stages due to thenar muscle atrophy (Opponens pollicis).
Question 4: Which of the following is a feature of Carpal tunnel syndrome?
- A. Compression of the ulnar nerve
- B. Compression of the median nerve under the flexor retinaculum (Correct Answer)
- C. Anesthesia over the thenar eminence
- D. Atrophy of the hypothenar muscles
Explanation: **Explanation:** **Carpal Tunnel Syndrome (CTS)** is the most common entrapment neuropathy, caused by the **compression of the median nerve** as it passes through the carpal tunnel beneath the **flexor retinaculum** (transverse carpal ligament). 1. **Why the correct answer is right:** The carpal tunnel is a fibro-osseous space containing nine tendons and the median nerve. Any condition that increases pressure within this tunnel (e.g., hypothyroidism, pregnancy, RA, or repetitive trauma) leads to ischemia of the median nerve, resulting in paresthesia and pain in its distribution. 2. **Why the other options are wrong:** * **Option A:** Compression of the ulnar nerve occurs at the **Guyon’s canal** or the cubital tunnel, not the carpal tunnel. * **Option C:** Sensory loss occurs in the lateral 3.5 fingers. However, the **thenar eminence is spared** because its nerve supply (the palmar cutaneous branch of the median nerve) arises proximal to the flexor retinaculum and passes superficial to it. * **Option D:** The median nerve supplies the thenar muscles (O-A-F: Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis). Therefore, chronic CTS leads to **thenar atrophy**, whereas hypothenar atrophy is a feature of ulnar nerve palsy. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Tests:** Phalen’s test (wrist flexion), Tinel’s sign (percussion over the retinaculum), and Durkan’s test (most sensitive). * **First muscle to show wasting:** Abductor Pollicis Brevis (APB). * **Management:** Conservative (Splints, NSAIDs, Steroids) or Surgical (Division of the flexor retinaculum). * **Associated Conditions:** Diabetes Mellitus, Acromegaly, and Amyloidosis.
Question 5: Which of the following structures is involved in Dupuytren's contracture?
- A. Thickening of the palmar fascia (Correct Answer)
- B. Thickening of the dorsal fascia
- C. Contracture of the flexor tendons
- D. Post burns contracture
Explanation: ### Explanation **Dupuytren’s Contracture** is a benign fibroproliferative disorder of the **palmar fascia**. The core pathology involves the transformation of normal fibroblasts into **myofibroblasts**, which produce excessive Type III collagen. This leads to the formation of nodules and cords that eventually shorten, causing fixed flexion deformities of the fingers (most commonly the ring and little fingers). #### Analysis of Options: * **A. Thickening of the palmar fascia (Correct):** The disease specifically targets the palmar aponeurosis and its digital extensions. The pathological shortening of these fascial bands pulls the MCP and PIP joints into flexion. * **B. Thickening of the dorsal fascia:** Dupuytren’s is localized to the volar (palmar) aspect of the hand. While Garrod’s pads (knuckle pads) can occur on the dorsum of the PIP joints in these patients, the primary contracture is palmar. * **C. Contracture of the flexor tendons:** This is a common distractor. In Dupuytren’s, the **tendons themselves are normal** and move freely within their sheaths; the restriction is entirely due to the overlying fascial cords. * **D. Post-burns contracture:** This is a secondary scarring process involving the skin and dermis, whereas Dupuytren’s is an idiopathic, often hereditary, primary fascial disease. #### High-Yield Clinical Pearls for NEET-PG: * **Risk Factors:** Strong association with **Diabetes Mellitus**, chronic alcoholism, smoking, epilepsy (anticonvulsant use), and Northern European ancestry (Viking disease). * **Clinical Sign:** **Hueston’s Table Top Test** — positive when the patient cannot flatten their palm against a flat surface. * **Anatomy:** The **Spiral Cord** (formed by the spiral band, lateral digital sheet, and Grayson’s ligament) is responsible for displacing the neurovascular bundle toward the midline, increasing the risk of iatrogenic injury during surgery. * **Treatment:** Indicated when the MCP joint contracture is >30° or any PIP joint contracture is present. Options include Fasciectomy or Collagenase (*Clostridium histolyticum*) injections.
Question 6: The Card test or Book test is used to assess injury of which nerve?
- A. Radial nerve
- B. Ulnar nerve (Correct Answer)
- C. Median nerve
- D. Tibial nerve
Explanation: The **Card test** (and its variant, the **Book test**) is a classic clinical assessment for **Ulnar nerve** palsy. ### Why Ulnar Nerve is Correct The test specifically evaluates the strength of the **Palmar Interossei** muscles. These muscles are responsible for **adducting** the fingers (bringing them together). * **Mechanism:** The examiner places a card or book between the patient’s extended fingers and asks them to hold it tightly while the examiner tries to pull it away. * **Clinical Sign:** If the ulnar nerve is injured, the palmar interossei are paralyzed, and the patient cannot maintain a strong grip on the card, causing it to be easily pulled out. ### Why Other Options are Incorrect * **Radial Nerve:** Primarily supplies the extensors of the wrist and fingers. Injury leads to **Wrist Drop**. * **Median Nerve:** Supplies the muscles of the thenar eminence (LOAF muscles). Injury is tested via the **Pen test** (Abductor Pollicis Brevis) or by checking for "Ape Thumb" deformity. * **Tibial Nerve:** A nerve of the lower limb; injury results in loss of plantar flexion and intrinsic foot muscle function, unrelated to hand tests. ### High-Yield Clinical Pearls for NEET-PG * **Froment’s Sign:** Often confused with the Card test, this also tests the ulnar nerve (Adductor Pollicis). When asked to hold a piece of paper between the thumb and index finger, the patient flexes the thumb's IP joint (using the Median-innervated Flexor Pollicis Longus) to compensate for weak adduction. * **Wartenberg’s Sign:** Inability to adduct the little finger due to ulnar nerve palsy. * **Egawa’s Test:** Tests the **Dorsal Interossei** (abduction) by asking the patient to sidestep the middle finger. * **Mnemonic:** **PAD** (Palmar Adduct) and **DAB** (Dorsal Abduct).
Question 7: What is the definition of a swan-neck deformity?
- A. Flexion of the metacarpophalangeal joint and extension at the interphalangeal joint.
- B. Extension at the proximal interphalangeal joint and flexion at the distal interphalangeal joint. (Correct Answer)
- C. Flexion at the proximal interphalangeal joint and extension at the distal interphalangeal joint.
- D. Extension at the metacarpophalangeal joint and flexion at the interphalangeal joint.
Explanation: **Explanation:** The **Swan-neck deformity** is a characteristic finger deformity characterized by **hyperextension of the Proximal Interphalangeal (PIP) joint** and **flexion of the Distal Interphalangeal (DIP) joint**. It occurs due to an imbalance in the extensor mechanism, often triggered by a lax volar plate or overpull of the extrinsic extensor muscles, commonly seen in Rheumatoid Arthritis. **Analysis of Options:** * **Option B (Correct):** Accurately describes the PIP extension and DIP flexion. The "swan-neck" appearance is created by the arched PIP joint resembling the bird's neck. * **Option C (Incorrect):** This describes a **Boutonnière deformity** (PIP flexion and DIP hyperextension), which is caused by a rupture of the central slip of the extensor tendon. * **Options A & D (Incorrect):** These describe various positions of the Metacarpophalangeal (MCP) joints, which are not the primary diagnostic criteria for defining a swan-neck deformity. **High-Yield NEET-PG Pearls:** 1. **Etiology:** Most commonly associated with **Rheumatoid Arthritis** (synovitis leads to volar plate laxity) or untreated **Mallet finger** (leads to secondary PIP hyperextension). 2. **Boutonnière vs. Swan-neck:** These are "opposites." Remember: **B**outonnière = **B**ent (flexed) PIP. 3. **Bunnell-Littler Test:** Used to differentiate if PIP restriction is due to intrinsic muscle tightness or capsular contracture. 4. **Treatment:** Mild cases use Silver Ring splints; severe cases may require volar plate reconstruction or dermodesis.
Question 8: Finkelstein's test is used for which condition?
- A. Congenital Dislocation of Hip (CDH)
- B. DeQuervain's tenosynovitis (Correct Answer)
- C. Trigger finger
- D. Lateral epicondylitis (Tennis elbow)
Explanation: **Explanation:** **De Quervain’s Tenosynovitis** is a stenosing tenosynovitis of the **first dorsal compartment** of the wrist. This compartment contains the tendons of the **Abductor Pollicis Longus (APL)** and **Extensor Pollicis Brevis (EPB)**. Finkelstein’s test is the pathognomonic clinical maneuver used to diagnose this condition. * **Mechanism of the Test:** The patient places their thumb into the palm, closes their fingers over it (making a fist), and then the wrist is passively deviated towards the ulnar side. A positive result is indicated by sharp, excruciating pain over the radial styloid process, caused by the stretching of the inflamed APL and EPB tendons through the narrowed fibro-osseous tunnel. **Analysis of Incorrect Options:** * **Congenital Dislocation of Hip (CDH/DDH):** Diagnosed using **Barlow’s** (dislocating the hip) and **Ortolani’s** (reducing the hip) maneuvers. * **Trigger Finger:** Characterized by "locking" or "snapping" of the finger due to a nodule in the flexor tendon catching on the **A1 pulley**. It is diagnosed clinically by palpating a nodule that moves with the tendon. * **Lateral Epicondylitis (Tennis Elbow):** Diagnosed using **Cozen’s test** or **Mill’s maneuver**, which involve resisted wrist extension or passive wrist flexion. **High-Yield Clinical Pearls for NEET-PG:** * **Anatomy:** Remember the mnemonic "Apples (APL) and Peanut Butter (EPB)" for the first compartment contents. * **Demographics:** Most common in middle-aged women and "new mothers" (due to repetitive lifting of infants). * **Eichhoff’s Test:** Often confused with Finkelstein’s; Eichhoff’s is the version where the patient actively makes a fist, while the classic Finkelstein’s involves the examiner pulling the thumb distally. * **Treatment:** Initial management is conservative (NSAIDs, thumb spica splint); refractory cases require corticosteroid injection or surgical release of the first dorsal compartment.
Question 9: Which tendon is typically used for flexor tendon injury reconstruction in the hand, originating from the forearm to the finger?
- A. Palmaris longus
- B. Plantaris (Correct Answer)
- C. Extensor digitorum communis
- D. Extensor digiti minimi
Explanation: ### Explanation In hand surgery, when a primary repair of a flexor tendon is not possible (due to extensive scarring or neglect), a **tendon graft** is required. **Why Plantaris is the Correct Answer:** The **Plantaris tendon** is considered the "gold standard" or the first choice for long tendon grafts in the hand. * **Length and Girth:** It provides a long, thin, and consistent cord-like structure (approx. 30-35 cm) that fits perfectly within the narrow fibro-osseous tunnels of the fingers. * **Vestigial Nature:** It is a vestigial muscle, meaning its removal causes no functional deficit in the lower limb. * **Anatomy:** It originates from the lateral supracondylar ridge of the femur and inserts into the calcaneus. However, it is absent in approximately 7–10% of the population. **Analysis of Incorrect Options:** * **Palmaris Longus (Option A):** While frequently used for shorter grafts (like pulley reconstruction), it is often too short for a full-length flexor reconstruction from the forearm to the fingertip. It is also absent in about 15% of people. * **Extensor Digitorum Communis (Option C):** These are primary functional tendons of the hand. Harvesting them would result in a significant loss of finger extension. * **Extensor Digiti Minimi (Option D):** This is a functional tendon for the little finger. While it can be used for tendon transfers, it is not a preferred source for free grafting due to its functional importance. **High-Yield Clinical Pearls for NEET-PG:** 1. **Order of Preference for Grafts:** Plantaris > Palmaris Longus > Extensor Digitorum Longus (toes) > Longus colli (rare). 2. **Donor Site Testing:** To check for the presence of Palmaris Longus, use **Schaeffer’s Test** (opposing thumb to little finger with wrist flexion). 3. **Bunnell’s Technique:** Often used for suturing these grafts. 4. **Zone II (No Man’s Land):** The most common site requiring complex reconstruction due to the risk of adhesions within the flexor sheath.
Question 10: Pollicization can be best described as:
- A. Toe to thumb transfer
- B. Thumb reconstruction (Correct Answer)
- C. Finger shoening
- D. Amputation of thumb
Explanation: **Explanation:** **Pollicization** is a surgical procedure where a functional finger (most commonly the **index finger**) is repositioned and reconstructed to function as a **thumb**. The goal is to restore the essential functions of the thumb, such as opposition, grasp, and pinch, in cases where the thumb is congenitally absent (e.g., radial club hand, hypoplasia) or lost due to trauma. Therefore, it is fundamentally a method of **thumb reconstruction**. **Analysis of Options:** * **Option A (Toe to thumb transfer):** While this is a method of thumb reconstruction, it is a microsurgical procedure involving a free tissue transfer from the foot. Pollicization specifically refers to using an existing digit from the same hand. * **Option C (Finger shortening):** This is a descriptive term for reducing the length of a digit, often part of a larger procedure, but it does not define pollicization. * **Option D (Amputation of thumb):** This is the removal of the thumb, which is the clinical problem that pollicization aims to solve, not the procedure itself. **High-Yield Clinical Pearls for NEET-PG:** * **Buck-Gramcko Technique:** The most widely used surgical technique for pollicization, particularly in congenital cases. * **Indications:** Blauth Grade IIIb, IV, and V thumb hypoplasia (where the CMC joint is unstable or absent). * **Key Step:** The index finger is transposed on its neurovascular bundle, and the metacarpophalangeal (MCP) joint of the index finger becomes the new carpometacarpal (CMC) joint of the reconstructed thumb. * **Nerve Supply:** The sensory and motor supply is preserved by meticulous dissection of the digital nerves and vessels.
Practice by Chapter
Hand Anatomy and Biomechanics
Practice Questions
Hand Fractures and Dislocations
Practice Questions
Tendon Injuries
Practice Questions
Nerve Injuries in Hand
Practice Questions
Dupuytren's Disease
Practice Questions
Carpal Tunnel Syndrome
Practice Questions
Rheumatoid Hand
Practice Questions
Reconstructive Hand Surgery
Practice Questions
Tendon Transfers
Practice Questions
Congenital Hand Anomalies
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Hand Infections
Practice Questions
Microsurgery in Hand Surgery
Practice Questions
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