Hand Surgery Practice Questions

Q: Hyperextension of the Proximal Interphalangeal (PIP) joint and flexion of the Distal Interphalangeal (DIP) joint is seen in which deformity?

Swan neck deformity. ### 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).

Q: Stenosing tenosynovitis of the flexor tendon sheath is also known as:

Trigger finger. **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).

Q: Which of the following is not a recognized treatment for carpal tunnel syndrome?

Nerve stimulation therapy.. **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).

Q: Bennet's fracture involves which metacarpal bone?

1st metacarpal. **Explanation:** **Bennett’s fracture** is a specific injury defined as an **intra-articular fracture-dislocation** at the base of the **1st metacarpal** (the thumb). The fracture line separates a small, triangular volar-ulnar fragment, which remains attached to the strong anterior oblique ligament. Meanwhile, the rest of the metacarpal shaft is displaced proximally and radially by the pull of the **Abductor Pollicis Longus (APL)** muscle. This instability makes it a classic "fracture-dislocation." **Why other options are incorrect:** * **2nd and 3rd Metacarpals:** These bones are relatively fixed at the carpo-metacarpal joints and are not associated with Bennett’s or Rolando’s fractures. Fractures here are usually shaft or neck fractures. * **4th and 5th Metacarpals:** Fractures of the neck of the 5th (and sometimes 4th) metacarpal are known as **Boxer’s fractures**, typically caused by a direct blow with a clenched fist. **High-Yield Clinical Pearls for NEET-PG:** 1. **Rolando Fracture:** A comminuted (T or Y-shaped) intra-articular fracture at the base of the 1st metacarpal. It carries a worse prognosis than Bennett's. 2. **Mechanism:** Usually caused by axial loading along the longitudinal axis of the thumb (e.g., a punch or a fall). 3. **Treatment:** Because it is inherently unstable due to the pull of the APL, it often requires **Closed Reduction and Internal Fixation (CRIF)** with K-wires or Open Reduction (ORIF). 4. **Gamekeeper’s/Skier’s Thumb:** An injury to the **Ulnar Collateral Ligament (UCL)** of the 1st metacarpophalangeal (MCP) joint, not the metacarpal base.

Q: The Card test or Book test is used to assess injury of which nerve?

Ulnar nerve. 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).

Q: A 27-year-old gentleman presents with pain following an injury. What is the diagnosis shown in the X-ray?

Boxer's fracture. ***Boxer's fracture*** - Fracture of the **neck of the 5th metacarpal** with characteristic **volar angulation** typically seen after punching a hard object. - X-ray shows **loss of normal metacarpal head contour** and **dorsal cortical disruption** at the neck region. *Undisplaced fracture of the scaphoid* - Would show a **fracture line through the scaphoid waist** on X-ray, often requiring specialized views to visualize. - Clinical presentation includes **anatomical snuffbox tenderness** and pain with **thumb movement**, not metacarpal deformity. *Perilunate dislocation* - X-ray would demonstrate **disrupted relationship between lunate and capitate** with the lunate maintaining normal alignment with radius. - Presents with severe **wrist swelling** and **carpal malalignment** on lateral view, not isolated metacarpal fracture. *Chauffeur's fracture* - Shows **fracture of the radial styloid process** caused by forced **dorsiflexion and ulnar deviation** of the wrist. - X-ray reveals **avulsion fracture** at the **radial styloid**, typically associated with **scapholunate ligament injury**.

Question 1

Hyperextension of the Proximal Interphalangeal (PIP) joint and flexion of the Distal Interphalangeal (DIP) joint is seen in which deformity?

Accepted Answer

Swan neck deformity

Answer

Mallet finger deformity

Answer

Lumbricals paralysis

Answer

Boutonniere's deformity

Question 2

Stenosing tenosynovitis of the flexor tendon sheath is also known as:

Accepted Answer

Trigger finger

Answer

Tennis elbow

Answer

Carpal tunnel syndrome

Answer

Dupuytren's contracture

Question 3

Which of the following is not a recognized treatment for carpal tunnel syndrome?

Accepted Answer

Nerve stimulation therapy.

Answer

Steroid injection.

Answer

One-portal endoscopic surgical release.

Answer

Two-portal endoscopic surgical release.

Question 4

Which of the following is a feature of Carpal tunnel syndrome?

Accepted Answer

Compression of the median nerve under the flexor retinaculum

Answer

Compression of the ulnar nerve

Answer

Anesthesia over the thenar eminence

Answer

Atrophy of the hypothenar muscles

Question 5

Bennet's fracture involves which metacarpal bone?

Accepted Answer

1st metacarpal

Answer

2nd metacarpal

Answer

3rd metacarpal

Answer

4th metacarpal

Question 6

Which of the following structures is involved in Dupuytren's contracture?

Accepted Answer

Thickening of the palmar fascia

Answer

Thickening of the dorsal fascia

Answer

Contracture of the flexor tendons

Answer

Post burns contracture

Question 7

What is true about lunate dislocation?

Accepted Answer

The lunate dislocates anteriorly, while other carpal bones remain in place.

Answer

The lunate stays in place while other carpal bones dislocate posteriorly.

Answer

The ulnar nerve is most commonly involved.

Answer

None of the above.

Question 8

The Card test or Book test is used to assess injury of which nerve?

Accepted Answer

Ulnar nerve

Answer

Radial nerve

Answer

Median nerve

Answer

Tibial nerve

Question 9

What is the definition of a swan-neck deformity?

Accepted Answer

Extension at the proximal interphalangeal joint and flexion at the distal interphalangeal joint.

Answer

Flexion of the metacarpophalangeal joint and extension at the interphalangeal joint.

Answer

Flexion at the proximal interphalangeal joint and extension at the distal interphalangeal joint.

Answer

Extension at the metacarpophalangeal joint and flexion at the interphalangeal joint.

Question 10

A 27-year-old gentleman presents with pain following an injury. What is the diagnosis shown in the X-ray?

Accepted Answer

Boxer's fracture

Answer

Undisplaced fracture of the scaphoid

Answer

Perilunate dislocation

Answer

Chauffeur's fracture

Hand Surgery — MCQs

Hand Surgery — MCQs

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