Dupuytren's Disease — MCQs
A person is not able to extend his metacarpophalangeal joint. Injury to which of the following nerve result in this?
Rupture of extensor pollicis longus tendon occurs in all of the following except -
In congenital dystrophic variety of epidermolysis bullosa, mutation is seen in the gene coding for:
All are management of PDPH except-
A 65-year-old alcoholic suffering from diabetes has a flexion deformity of the right little finger over the metacarpophalangeal joint of around 15 degrees. The ideal management would be:
Which of the following is not used in the management of post-dural headache?
Which of the following statements about Dupuytren's contracture is false?
Which of the following statements about Peyronie's disease is false?
The given nature of injury will lead to the development of:
Hyperextension of the Proximal Interphalangeal (PIP) joint and flexion of the Distal Interphalangeal (DIP) joint is seen in which deformity?
Dupuytren's Disease Indian Medical PG Practice Questions and MCQs
Question 1: A person is not able to extend his metacarpophalangeal joint. Injury to which of the following nerve result in this?
- A. Posterior Interosseous nerve injury (Correct Answer)
- B. Radial nerve injury
- C. Ulnar nerve injury
- D. Median nerve injury
Explanation: Posterior Interosseous Nerve (PIN) injury - The Posterior Interosseous Nerve is the deep motor branch of the radial nerve that specifically innervates the extensor muscles of the fingers and thumb - These muscles include: Extensor Digitorum, Extensor Indicis, Extensor Digiti Minimi, Extensor Pollicis Longus and Brevis [1] - PIN injury causes inability to extend the MCP joints and interphalangeal joints of the fingers [1] - Wrist extension is preserved because the Extensor Carpi Radialis Longus (ECRL) and often ECRB are innervated by the radial nerve proper before it gives off the PIN [1] - This results in a characteristic finger drop without wrist drop Radial nerve injury - A high radial nerve injury (proximal, above the elbow) would cause both wrist drop AND finger extension loss - However, radial nerve injury at the spiral groove (most common site) typically spares the PIN or affects it less severely - The question asks specifically about isolated inability to extend MCP joints, which is the hallmark of PIN injury, not general radial nerve injury - Radial nerve proper gives branches to triceps, brachioradialis, and ECRL before dividing into PIN and superficial branch Ulnar nerve injury - The ulnar nerve innervates intrinsic hand muscles (interossei, lumbricals to digits 4-5, hypothenar muscles, adductor pollicis) [1] - Ulnar nerve injury causes claw hand deformity with MCP hyperextension (not loss of extension) and IP joint flexion - This is the opposite of what is described in the question Median nerve injury - The median nerve innervates the thenar muscles, lateral two lumbricals, and forearm flexors [1] - Median nerve injury causes ape hand deformity with loss of thumb opposition and flexion - It does not affect MCP joint extension, which is an extensor function
Question 2: Rupture of extensor pollicis longus tendon occurs in all of the following except -
- A. De Quervain's disease (Correct Answer)
- B. Rheumatoid arthritis
- C. Drummers
- D. Colles' fracture
Explanation: ***De Quervain's disease*** - This condition involves **tenosynovitis** of the **extensor pollicis brevis** and **abductor pollicis longus** tendons, not a rupture of the extensor pollicis longus. - The pathology is an inflammation and thickening of the tendon sheaths, distinct from a tendon tear. *Rheumatoid arthritis* - **Chronic inflammation** in rheumatoid arthritis can lead to weakening and eventual rupture of tendons, including the **extensor pollicis longus**, often due to synovitis eroding the tendon. - The condition creates an environment where tendons are vulnerable to **attrition** and damage, making rupture a recognized complication. *Drummers* - Repetitive, high-force movements involved in drumming can cause significant **stress** and microscopic damage to tendons, including the **extensor pollicis longus**. - Over time, this cumulative trauma can lead to inflammation, degeneration, and eventual **rupture** due to overuse. *Colles' fracture* - A **Colles' fracture** of the distal radius can cause a delayed rupture of the **extensor pollicis longus (EPL)** tendon. - This occurs due to attrition of the tendon as it rubs over the **roughened fracture site** or due to *avascular necrosis* of the tendon as it passes through a narrow osteofibrous tunnel.
Question 3: In congenital dystrophic variety of epidermolysis bullosa, mutation is seen in the gene coding for:
- A. Laminin 4
- B. Keratin 14
- C. Collagen type 7 (Correct Answer)
- D. Alpha 6 integrin
Explanation: ***Correct: Collagen type 7*** - **Dystrophic epidermolysis bullosa** is characterized by defects in **collagen type 7**, which forms anchoring fibrils that connect the epidermis to the underlying dermal tissue. - Mutations in the gene *COL7A1* lead to fragile skin that **blisters easily** in the **dermo-epidermal junction** below the lamina densa (sublamina densa level). - This distinguishes it from other EB subtypes by its **sub-basement membrane zone** blistering. *Incorrect: Laminin 4* - Mutations in **laminin 332** (formerly laminin 5), not laminin 4, are associated with **junctional epidermolysis bullosa**, a different subtype. - Junctional EB primarily affects the **lamina lucida** within the dermo-epidermal junction. *Incorrect: Keratin 14* - Mutations in **keratin 5** and **keratin 14** are responsible for **epidermolysis bullosa simplex**, which involves blistering within the **basal layer of the epidermis**. - In this form, blisters occur *intraepidermally* above the basement membrane zone. *Incorrect: Alpha 6 integrin* - Mutations in **alpha 6 beta 4 integrin** subunits are also associated with **junctional epidermolysis bullosa**, specifically affecting the assembly of **hemidesmosomes**. - These defects lead to blistering within the **lamina lucida**, similar to laminin 332 mutations.
Question 4: All are management of PDPH except-
- A. Stool softeners (Correct Answer)
- B. Analgesic + caffeine
- C. Intravenous / oral fluids
- D. Upright position
Explanation: ***Stool softeners*** - While **stool softeners** may be prescribed to prevent **straining** in patients experiencing PDPH, they do not directly treat the underlying cause or symptoms of PDPH. - The primary goal of PDPH management is to re-establish **CSF pressure** and relieve headache, which stool softeners do not achieve. *Analgesic + caffeine* - **Caffeine** is a common component of PDPH management as it causes **cerebral vasoconstriction**, which can help alleviate the headache. - **Analgesics** (e.g., NSAIDs, opioids) are used to manage the pain associated with PDPH. *Intravenous / oral fluids* - Increasing **fluid intake**, both oral and intravenous, helps to promote **CSF production** and potentially increase intracranial pressure, thereby alleviating PDPH symptoms. - This is a supportive measure for rehydration and to potentially restore **CSF volume**. *Upright position* - An **upright position** typically **worsens** PDPH symptoms because it increases the gravitational pull on the CSF, further lowering intracranial pressure. - Patients with PDPH are usually advised to maintain a **supine (flat)** position to minimize headache severity.
Question 5: A 65-year-old alcoholic suffering from diabetes has a flexion deformity of the right little finger over the metacarpophalangeal joint of around 15 degrees. The ideal management would be:
- A. Complete fasciectomy
- B. Partial (selective) fasciectomy
- C. Percutaneous fasciotomy
- D. Observation (Correct Answer)
Explanation: ***Observation*** - A 15-degree flexion deformity of the **metacarpophalangeal (MCP) joint** is considered mild and does not significantly impair hand function, making observation the appropriate initial management. - The goal of intervention in **Dupuytren's contracture** is to improve hand function, and surgical or medical treatment is typically reserved for deformities of **30 degrees or more** at the MCP joint or any **proximal interphalangeal (PIP) joint contracture**. *Complete fasciectomy* - This procedure involves the **excision of all diseased palmar fascia**, including tissue not directly involved in the contracture. - Due to its **aggressiveness** and higher rates of complications and recurrence, complete fasciectomy is generally **not recommended** for Dupuytren's contracture. *Partial (selective) fasciectomy* - This involves the **excision of only the diseased and contracted fascia**, aiming to release the finger contracture. - While an effective treatment for advanced Dupuytren's contracture, it is **overtreatment** for a mild, 15-degree MCP joint deformity, which typically does not require surgical intervention. *Percutaneous fasciotomy* - This minimally invasive procedure involves **dividing the contracted cords** using a needle, typically performed in an outpatient setting. - It's mainly suitable for **isolated cord contractures** at the MCP joint without extensive fascial involvement and for patients who prefer less invasive options, but similar to fasciectomy, it is reserved for more significant contractures to improve function.
Question 6: Which of the following is not used in the management of post-dural headache?
- A. Hydration
- B. Epidural blood patch
- C. Propped up position (Correct Answer)
- D. Sumatriptan
Explanation: ***Propped up position*** - Maintaining a **propped-up position** can worsen a post-dural puncture headache (PDPH) because it increases the hydrostatic pressure gradient on the brain, exacerbating the intracranial hypotension. - PDPH is typically relieved by lying **supine** and worsened by sitting or standing, indicating that an upright position is contraindicated for symptom relief. *Sumatriptan* - **Sumatriptan**, a selective serotonin receptor agonist, can be used to treat post-dural puncture headache (PDPH) in some patients, particularly if the headache has migrainous features. - It works by causing **vasoconstriction** of intracranial blood vessels, which may help reduce cerebral blood flow and alleviate headache pain. *Hydration* - **Hydration**, specifically increasing fluid intake, is a common and often effective conservative measure for managing post-dural puncture headache (PDPH). - Adequate hydration can help increase **cerebrospinal fluid (CSF) volume** and pressure, thereby reducing the severity of the headache caused by CSF leakage. *Epidural blood patch* - An **epidural blood patch (EBP)** is considered the definitive treatment for severe or persistent post-dural puncture headache (PDPH) that does not respond to conservative measures. - It involves injecting a small amount of the patient's own blood into the epidural space, forming a clot that seals the dural puncture site and **stops CSF leakage**.
Question 7: Which of the following statements about Dupuytren's contracture is false?
- A. More common in male than female
- B. Alcoholic cirrhosis may predispose
- C. Autosomal recessive inheritance (Correct Answer)
- D. The ring finger is most commonly affected
Explanation: ***Autosomal recessive inheritance*** - This statement is false because Dupuytren's contracture is typically associated with an **autosomal dominant inheritance pattern**, not autosomal recessive. - While genetics play a role, the dominant inheritance means only one copy of the mutated gene is needed for the condition to manifest. *Alcoholic cirrhosis may predispose* - **Alcoholic cirrhosis** is a recognized risk factor for Dupuytren's contracture, particularly in severe cases. - Chronic alcohol use and liver disease can lead to changes in connective tissue, increasing susceptibility to fibrosis. *More common in male than female* - Dupuytren's contracture is indeed **more prevalent in males** than in females, with a higher incidence and often more severe presentation. - The male-to-female ratio can vary, but the male predominance is well-documented in epidemiological studies. *The ring finger is most commonly affected* - The **ring finger (fourth digit)** is the most frequently affected digit, followed by the little finger (fifth digit). - The contracture often involves the **metacarpophalangeal (MCP)** and **proximal interphalangeal (PIP)** joints of these fingers.
Question 8: Which of the following statements about Peyronie's disease is false?
- A. Surgical treatment is effective
- B. It does not show a self-limited course.
- C. Associated with fibrosis in the penis
- D. It is not associated with Dupuytren's contracture. (Correct Answer)
Explanation: ***It is not associated with Dupuytren's contracture.*** - Peyronie's disease is, in fact, associated with other fibrotic conditions, including **Dupuytren's contracture** (fibrosis of the palmar fascia) and **Ledderhose's disease** (plantar fibromatosis). - This association suggests a common underlying genetic predisposition to fibrous tissue overgrowth. *Associated with fibrosis in the penis* - Peyronie's disease is characterized by the formation of **fibrous plaques** within the **tunica albuginea** of the penis. - This fibrosis leads to abnormal penile curvature, pain, and erectile dysfunction. *It does not show a self-limited course.* - While some cases might stabilize, Peyronie's disease typically has a **progressive course** or remains stable but problematic, often requiring intervention. - It is rarely self-limiting and often leads to worsening penile curvature and sexual dysfunction over time if left untreated. *Surgical treatment is effective* - **Surgical interventions**, such as plication, grafting, or incision/excision of plaques, are effective for severe penile curvature and improving erectile function in Peyronie's disease. - Surgery is typically reserved for patients with stable disease and significant erectile dysfunction or curvature that prevents intercourse.
Question 9: The given nature of injury will lead to the development of:
- A. Jersey finger
- B. Mallet finger (Correct Answer)
- C. Jammed finger
- D. Boxer knuckle
Explanation: ***Mallet finger*** - The image shows a **rupture of the extensor tendon** at its insertion into the distal phalanx, or an avulsion fracture of the distal phalanx, causing an inability to extend the distal interphalangeal (DIP) joint. - This injury results in the characteristic **flexion deformity** of the DIP joint, known as mallet finger. *Jersey finger* - This injury involves the **rupture of the flexor digitorum profundus tendon** from its insertion at the base of the distal phalanx. - Patients cannot actively **flex their DIP joint**, unlike the extensor tendon injury shown. *Jammed finger* - This is a general term for an **axial load injury** to the finger, usually causing a sprain or mild fracture without a specific tendon rupture as depicted. - It typically results from impact on the fingertip, leading to **ligamentous injury** or joint capsule damage. *Boxer knuckle* - **Boxer's knuckle** refers to a sagital band rupture at the metacarpophalangeal (MCP) joint, affecting the central slip of the extensor tendon. - This injury primarily involves the **MCP joint** and not the DIP joint, as shown in the image.
Question 10: 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).
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