Microsurgery in Hand Surgery — MCQs
Which of the following structures is fixed first during reimplantation of an amputated digit -
Abbreviated laparotomy done for:
Longitudinal incision with Z-plasty closure is used in which of the following?
In hand injury, the first structure to be repaired should be?
Median nerve injury at the wrist is commonly tested by.
Radial Nerve injury of this type recovers with conservative management
What is the most common complication associated with carpal tunnel release surgery?
Allen's test is used in cardiac surgery for:
Avascular necrosis (AVN) is commonly associated with which type of femoral neck fracture?
Hyperextension of the Proximal Interphalangeal (PIP) joint and flexion of the Distal Interphalangeal (DIP) joint is seen in which deformity?
Microsurgery in Hand Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following structures is fixed first during reimplantation of an amputated digit -
- A. Bone (Correct Answer)
- B. Vein
- C. Nerve
- D. Artery
Explanation: ***Bone*** - **Bone fixation** is the crucial first step to stabilize the digit, providing a stable framework for subsequent soft tissue repair. - This **restores skeletal integrity** and allows for proper alignment, reducing tension on delicate vascular and nervous structures. *Vein* - **Vein repair** is typically performed after arterial repair to ensure adequate outflow and prevent congestion, but after bone fixation. - While critical for successful reimplantation, venous repair without prior bone stability is difficult and prone to compromise. *Nerve* - **Nerve repair** is generally performed later in the sequence, after bone and vascular repairs have been completed. - The focus is on restoring blood flow first to ensure tissue viability before addressing nerve continuity for sensation and motor function. *Artery* - **Arterial reconstruction** is paramount for revascularization and tissue viability, but it follows initial bone stabilization. - Attempting to connect arteries without a stable skeletal foundation would make the repair challenging and increase the risk of avulsion or damage.
Question 2: Abbreviated laparotomy done for:
- A. Hemodynamically stable patients with minor trauma
- B. Damage control in hemodynamically unstable trauma patients (Correct Answer)
- C. Elective abdominal surgeries
- D. Early wound healing promotion
Explanation: ***Damage control in hemodynamically unstable trauma patients*** - **Abbreviated laparotomy** is a key component of **damage control surgery**, primarily indicated for hemodynamically unstable trauma patients. - The goal is to rapidly control life-threatening issues like hemorrhage and contamination, then temporarily close the abdomen for physiologic stabilization before definitive repair. *Hemodynamically stable patients with minor trauma* - These patients typically do not require prompt surgical intervention; their injuries can often be managed non-operatively or with standard surgical techniques. - An abbreviated laparotomy is an aggressive approach reserved for severe, life-threatening scenarios, not minor trauma in stable patients. *Elective abdominal surgeries* - Elective surgeries are planned procedures performed on stable patients with no immediate life-threatening conditions. - They allow for complete surgical repair in a single setting, which is the opposite of the staged approach of an abbreviated laparotomy. *Early wound healing promotion* - The focus of an abbreviated laparotomy is on resuscitation and source control, not primarily on wound healing. - The initial closure is temporary, often leaving the wound open, which is not conducive to early, primary wound healing.
Question 3: Longitudinal incision with Z-plasty closure is used in which of the following?
- A. Hand surgery (Correct Answer)
- B. Thyroid surgery
- C. Breast reconstruction surgery
- D. Hernia repair surgery
Explanation: ***Hand surgery*** - **Z-plasty** is frequently employed in hand surgery to **lengthen constricted scars** or to **reorient tension lines**, especially across joints or creases. - This technique helps to improve **range of motion** and prevent contractures that can severely impair hand function following injury or surgery. *Breast reconstruction surgery* - While various flap techniques are used in breast reconstruction, the primary incision or closure does not typically involve a **longitudinal incision with Z-plasty**. - Procedures often focus on re-shaping and volume replacement using **tissue flaps** or implants, or linear scar realignment for aesthetic purposes. *Thyroid surgery* - Thyroidectomy typically involves a **transverse incision** in the neck (a **Kocher collar incision**) to minimize visible scarring and follow natural skin folds. - **Z-plasty** is not a standard technique for closing the primary incision in thyroid surgery. *Hernia repair surgery* - Hernia repair usually involves a **linear or curvilinear incision** in the groin or abdominal wall, followed by direct closure or mesh placement. - The goal is strong tissue repair, and **Z-plasty** is not used as a closure method for the primary incision in hernia repair.
Question 4: In hand injury, the first structure to be repaired should be?
- A. Skin
- B. Muscle
- C. Nerve
- D. Bone (Correct Answer)
Explanation: ***Bone*** - In hand injury, **skeletal stability** is paramount and is typically the first structure to be addressed to provide a stable foundation. - Repairing bone first allows for proper alignment and length restoration, which is crucial for the subsequent repair of soft tissues like tendons, nerves, and vessels. *Skin* - While skin closure is the final step in wound management, it should only be performed after deeper structures like bone, tendons, and nerves have been repaired. - Repairing the skin first would prevent access to underlying damaged structures and could lead to functional impairment. *Muscle* - Muscle repair is important for restoring function but should follow bone stabilization to ensure proper length and tension. - Unstable bone fragments can impede effective muscle repair and healing. *Nerve* - Nerve repair is critical for restoring sensation and motor function and should be done with meticulous attention to detail. - However, nerve repair typically follows bone stabilization and sometimes tendon repair, as a stable environment is necessary for successful nerve coaptation and healing.
Question 5: Median nerve injury at the wrist is commonly tested by.
- A. Contraction of abductor pollicis brevis (Correct Answer)
- B. Loss of sensation on palm
- C. Loss of sensation on ring finger
- D. Contraction of flexor pollicis brevis
Explanation: ***Contraction of abductor pollicis brevis*** - The **abductor pollicis brevis (APB)** is primarily innervated by the **median nerve**, and its motor function is often the **first to be affected** and is a reliable test for median nerve integrity at the wrist. - Testing the **abduction of the thumb** against resistance (often called the "OK" sign or simply checking for strength) directly assesses the function of the APB and therefore the median nerve. *Contraction of flexor pollicis brevis* - The **flexor pollicis brevis (FPB)** has a **dual innervation**; its superficial head is supplied by the median nerve, but its deep head is often supplied by the ulnar nerve. - This dual innervation makes its contraction an unreliable isolated test for median nerve injury, as ulnar nerve compensation might mask a median nerve deficit. *Loss of sensation on palm* - While the median nerve supplies sensation to the radial side of the palm, an injury at the wrist, specifically within the **carpal tunnel**, typically spares the palmar cutaneous branch. - The **palmar cutaneous branch** of the median nerve arises proximal to the carpal tunnel and provides sensation to the thenar eminence and central palm, so its sensation is often preserved even with significant carpal tunnel syndrome. *Loss of sensation on ring finger* - The **ring finger** receives sensory innervation from both the **median nerve** (radial half) and the **ulnar nerve** (ulnar half). - Therefore, isolated loss of sensation on the ring finger would not be a definitive test for median nerve injury alone, as it requires assessment of both nerve distributions.
Question 6: Radial Nerve injury of this type recovers with conservative management
- A. Crush injury
- B. Chemical injury
- C. Neurotmesis
- D. Neuropraxia (Correct Answer)
Explanation: ***Neuropraxia*** - **Neuropraxia** is a mild form of nerve injury involving demyelination without axonal disruption, allowing for complete recovery with conservative management. - The nerve's electrical conduction is temporarily blocked, but the **axon** and its supporting structures remain intact. *Crush injury* - Crush injuries often result in more severe nerve damage, ranging from **axonotmesis** to **neurotmesis**, generally requiring more than conservative management for recovery. - The extensive compression and potential tissue damage can lead to significant axonal disruption and scar tissue formation, impeding nerve regeneration. *Chemical injury* - Chemical injuries can cause varying degrees of nerve damage, often resulting in **axonopathy** or demyelination, which may or may not recover with conservative management. - The extent of damage is highly dependent on the type and concentration of the chemical, and the duration of exposure. *Neurotmesis* - **Neurotmesis** involves complete transection of the nerve, including the axon and surrounding connective tissue sheaths, making spontaneous recovery highly unlikely. - Surgical intervention, such as **nerve repair** or grafting, is typically required for any functional recovery.
Question 7: What is the most common complication associated with carpal tunnel release surgery?
- A. Malunion
- B. Avascular necrosis
- C. Finger stiffness (Correct Answer)
- D. Rupture of EPL tendon
Explanation: ***Finger stiffness*** - Among the options listed, **finger stiffness** is the most recognized complication of carpal tunnel release surgery. - **Post-operative pain, swelling, and scar tissue formation** can lead to reduced range of motion in the digits. - Patients may develop stiffness due to **immobilization**, **scar adhesions**, or apprehension in mobilizing the hand after surgery. - **Note:** In clinical practice, **pillar pain** (pain at the thenar and hypothenar eminences) is actually the most common complication (10-30% of cases), but it is not among the options provided. *Malunion* - **Malunion** refers to improper healing of a fractured bone. - Carpal tunnel release involves dividing the **transverse carpal ligament** (flexor retinaculum), which is a **soft tissue procedure**. - No bone is cut or fractured, so malunion is not relevant to this surgery. *Avascular necrosis* - **Avascular necrosis (AVN)** is bone death due to interrupted blood supply. - AVN affects bones with precarious blood supply (femoral head, scaphoid, lunate in Kienböck's disease). - Carpal tunnel release does not involve bone manipulation and **AVN is not a recognized complication** of this procedure. *Rupture of EPL tendon* - **Extensor Pollicis Longus (EPL) tendon rupture** is classically associated with **distal radius fractures** or inflammatory arthritis. - EPL runs through the **third dorsal compartment** and is anatomically distant from the carpal tunnel (volar wrist). - While median nerve injury is a rare but serious complication of carpal tunnel release, **EPL rupture is not associated** with this surgery.
Question 8: Allen's test is used in cardiac surgery for:
- A. To select finger prick for blood glucose estimation
- B. To check warmth of hands
- C. When radial artery harvest is planned (Correct Answer)
- D. For evaluation of AV fistula
Explanation: ***When radial artery harvest is planned*** - **Allen's test** is performed to assess the patency of the **ulnar artery** and ensure adequate collateral circulation to the hand before harvesting the radial artery. - A positive test (indicating good collateral flow) is crucial to prevent **hand ischemia** if the radial artery is removed. *To select finger prick for blood glucose estimation* - Finger prick sites for **blood glucose estimation** are chosen based on adequate capillary blood flow and patient comfort, not by Allen's test. - Allen's test is specifically for evaluating **arterial patency** and collateral circulation, which is irrelevant for routine fingersticks. *To check warmth of hands* - Checking the **warmth of hands** is a basic clinical assessment for peripheral perfusion but does not involve Allen's test. - Allen's test is a dynamic test of **vascular competence**, not a static thermal assessment. *For evaluation of AV fistula* - **AV fistula evaluation** involves assessing patency, thrill, and bruit, and is typically done using physical examination and Doppler ultrasound. - Allen's test is not used for this purpose, as it assesses **collateral arterial flow** to a digit, not the patency of an arteriovenous connection.
Question 9: Avascular necrosis (AVN) is commonly associated with which type of femoral neck fracture?
- A. Transcervical
- B. Basal
- C. Subcapital (Correct Answer)
- D. Intertrochanteric
Explanation: ***Subcapital*** - Subcapital fractures occur at the anatomical **neck of the femur**, just below the femoral head, and often disrupt the **blood supply** to the femoral head due to injury to the lateral epiphyseal arteries. - The high rate of **vascular disruption** in these fractures significantly increases the risk of avascular necrosis (AVN) a condition where bone tissue dies due to lack of blood supply. *Transcervical* - Transcervical fractures are located through the **middle part of the femoral neck**, between subcapital and basal fractures, and also carry a risk of AVN. - However, the risk of AVN is generally considered **lower than subcapital fractures** but higher than basal fractures, due to less consistent disruption of the retinacular vessels. *Basal* - Basal fractures occur at the **base of the femoral neck**, near the intertrochanteric line, and typically have a **better prognosis** regarding AVN. - The principal blood supply to the femoral head is usually **less compromised** in basal fractures compared to subcapital or transcervical fractures, as the fracture line is more distal to the weight-bearing femoral head. *Intertrochanteric* - Intertrochanteric fractures occur **outside the hip joint capsule**, in the region between the greater and lesser trochanters, and are considered **extracapsular**. - Due to their location being well away from the **femoral head's vascular supply**, these fractures have a very low risk of avascular necrosis and primarily raise concerns about stability and healing.
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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