Hand Surgery Practice Questions

Q: Which of the following is NOT a symptom of carpal tunnel syndrome?

Ulnar nerve dysfunction. ***Ulnar nerve dysfunction*** - Carpal tunnel syndrome specifically involves compression of the **median nerve**, not the ulnar nerve. - Symptoms related to the median nerve include numbness and tingling in the **thumb, index, middle, and radial half of the ring finger**, along with **thenar muscle wasting**. *Tinel sign* - The **Tinel sign** is a common physical examination finding in carpal tunnel syndrome, elicited by tapping over the **median nerve** at the wrist. - A positive sign involves tingling or electric shock-like sensations in the **median nerve distribution**. *Phalen's sign* - **Phalen's sign** is another classic physical maneuver used to diagnose carpal tunnel syndrome, where exaggerated wrist flexion for 60 seconds reproduces symptoms. - This maneuver increases pressure within the **carpal tunnel**, exacerbating median nerve compression. *Pain & paraesthesia of wrist* - **Pain and paraesthesia (numbness and tingling)** in the wrist and hand are hallmark symptoms of carpal tunnel syndrome. - These symptoms are often worse at night or with repetitive hand movements, reflecting **median nerve irritation**.

Q: What is the primary use of a knuckle bender splint?

Ulnar nerve palsy. ***Ulnar nerve palsy*** - A knuckle bender splint is primarily used to counteract the characteristic **claw hand deformity** seen in ulnar nerve palsy [1] by maintaining the **metacarpophalangeal (MCP) joints** in flexion. - This splint helps improve function by preventing hyperextension of the MCP joints, which commonly occurs due to the unopposed action of the extensor muscles when the ulnar nerve is compromised. *Radial nerve palsy* - Radial nerve palsy typically results in **wrist drop** and an inability to extend the wrist and fingers, which is managed with wrist extension splints, not knuckle benders. - The primary goal of splinting in radial nerve palsy is to support the wrist in extension to facilitate grasping and carrying objects. *Median nerve palsy* - Median nerve palsy causes problems with thumb opposition and sensation in the first three and a half digits, often leading to an **ape hand deformity**. - Splints for median nerve palsy focus on maintaining the thumb in opposition, such as a **thumb spica splint**, which differs from a knuckle bender. *Axillary nerve palsy* - Axillary nerve palsy primarily affects the **deltoid muscle**, leading to weakness in shoulder abduction and external rotation. - Splinting for axillary nerve palsy typically involves shoulder immobilizers or abduction splints, which address shoulder joint positioning rather than hand function.

Q: What is the most common complication associated with carpal tunnel release surgery?

Finger stiffness. ***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.

Q: A 54-year-old female marathon runner presents with pain in her right wrist that resulted from a fall onto her outstretched hand. Radiographic studies indicate an anterior dislocation of a carpal bone. Which of the following bones is most likely dislocated?

Lunate. ***Lunate*** - The **lunate bone** is the most commonly dislocated carpal bone, especially with a fall onto an **outstretched hand**. - Its central position in the proximal carpal row and its articulation with the radius make it vulnerable to **anterior dislocation** with forced dorsiflexion. *Capitate* - The **capitate** is the largest carpal bone but is more stable due to its central position and strong ligamentous attachments. - Isolated dislocation of the capitate is **rare** and usually accompanies other carpal injuries. *Trapezoid* - The **trapezoid** is a small, irregularly shaped carpal bone in the distal row, which is very stable. - Its strong articulations with the trapezium, capitate, and second metacarpal make its dislocation **extremely uncommon**. *Triquetrum* - The **triquetrum** is the second most commonly fractured carpal bone but is less prone to dislocation than the lunate. - While it can dislocate, it typically occurs with **ulnar impaction** or other complex carpal instabilities rather than an isolated anterior dislocation from a fall onto an outstretched hand.

Q: A cricketer holds a catch and then presents with pain at the base of the right thumb; he should be examined to specifically rule out damage to which of the following structures?

Ulnar collateral ligament. ***Ulnar collateral ligament*** - A cricketer catching a ball can experience a sudden **valgus stress** at the thumb's metacarpophalangeal (MCP) joint, leading to a tear of the **ulnar collateral ligament (UCL)**. - This injury is commonly known as **"gamekeeper's thumb"** or "skier's thumb" and is characterized by pain, swelling, and instability at the base of the thumb on the ulnar side. *Extensor pollicis brevis* - This muscle is primarily involved in **extending the thumb** at the metacarpophalangeal joint. - Injury to the extensor pollicis brevis would more likely cause pain with active extension of the thumb rather than from a forceful catch mechanism. *Abductor pollicis longus* - The abductor pollicis longus is responsible for **abducting and extending the thumb** at the carpometacarpal joint. - While overuse can lead to conditions like de Quervain's tenosynovitis, acute injury from a catch is less common compared to UCL rupture. *Volar plate* - The volar plate is a fibrous structure on the palmar aspect of a joint that prevents **hyperextension**. - While it can be injured by hyperextension, its location and primary function make it less likely to be the primary structure damaged by the type of forceful valgus stress experienced during a catch, compared to the UCL.

Q: In carpal tunnel syndrome evaluation, the Semmes-Weinstein monofilament test is primarily used to assess which nerve's sensory function?

Median Nerve. ***Median Nerve*** - The **Semmes-Weinstein monofilament test** is a quantitative sensory test used to assess **pressure threshold detection**, which is crucial for diagnosing and monitoring **carpal tunnel syndrome** [2]. - **Carpal tunnel syndrome** is caused by compression of the **median nerve** as it passes through the carpal tunnel, leading to sensory deficits in the **thumb, index, middle, and radial half of the ring finger** [1]. *Ulnar Nerve* - The **ulnar nerve** provides sensation to the **little finger and the ulnar half of the ring finger**, as well as motor innervation to most intrinsic hand muscles [1]. - While it can be assessed with monofilaments, its involvement is characteristic of **cubital tunnel syndrome** or other ulnar neuropathies, not carpal tunnel syndrome. *Radial Nerve* - The **radial nerve** primarily provides sensation to the **dorsal aspect of the hand**, particularly the thumb, index, and middle fingers, but not the palmar aspect affected in carpal tunnel syndrome [1]. - Its sensory distribution is distinct from the median nerve and is typically assessed in cases of **radial nerve palsy** or injury. *Posterior Interosseus Nerve* - The **posterior interosseus nerve** is a **purely motor branch** of the deep radial nerve and has no sensory function. - Compression or injury to this nerve would result in **motor weakness** (e.g., wrist drop), not sensory deficits measured by monofilaments.

Q: One of the common fractures that occur during boxing by hitting with a closed fist is:

Bennett's fracture dislocation. ***Bennett's fracture dislocation*** - This is an **intra-articular fracture** of the base of the **first metacarpal**, extending into the carpometacarpal (CMC) joint. - It is frequently caused by axial compression with the thumb in a flexed and adducted position, a common injury mechanism in **punching a hard object** during boxing. *Monteggia fracture dislocation* - This injury involves a fracture of the **proximal ulna** coupled with an **anterior dislocation of the radial head**. - It is typically caused by a direct blow to the forearm or a fall on an outstretched hand with a hyperpronated forearm, not a direct punch. *Galeazzi fracture dislocation* - This involves a fracture of the **distal radius** with an associated **dislocation of the distal radioulnar joint (DRUJ)**. - It results from a fall on an outstretched hand with a hyperpronated forearm, which is not consistent with a boxing injury. *Smith's fracture* - Also known as a **reverse Colles' fracture**, this is a fracture of the **distal radius** with **volar displacement of the distal fragment**. - It typically results from a fall on a flexed wrist or a direct blow to the back of the wrist, not a punching injury.

Q: Which carpal bone fracture causes median nerve involvement?

Scaphoid. ***Scaphoid*** - A fracture or dislocation of the **scaphoid bone** can lead to swelling and hematoma formation within the **carpal tunnel**, compressing the median nerve. - While less direct than lunate dislocations, **scaphoid fractures** can cause median nerve symptoms due to indirect pressure or callus formation. *Lunate* - A **dislocation of the lunate bone** (especially anterior displacement) is a hallmark cause of **acute carpal tunnel syndrome**, directly compressing the median nerve. - Unlike a fracture, the lunate's displacement itself physically reduces the space within the carpal tunnel, trapping the median nerve. *Trapezium* - Fractures of the **trapezium** are usually associated with injury to the **thumb carpometacarpal (CMC) joint** and do not typically cause median nerve involvement. - The trapezium is located more radially, outside the direct pathway of the median nerve in the carpal tunnel. *Trapezoid* - Fractures of the **trapezoid bone** are rare and typically stable, with little propensity to cause **median nerve compression**. - The trapezoid's anatomical position is deep within the wrist and away from the median nerve's primary pathway.

Q: For tendon transfer, the most common tendon used is

Palmaris longus tendon. ***Palmaris longus tendon*** - The **palmaris longus tendon** is the **most commonly used donor tendon** for tendon transfers due to multiple advantages: - **Dispensability**: Absent in 10-15% of the population without causing functional deficit, making it expendable - **Ideal dimensions**: Adequate length (12-15 cm) and appropriate diameter for various reconstructive procedures - **Easy access**: Superficial location with straightforward surgical harvest - **Minimal donor site morbidity**: Its removal causes virtually no functional impairment - Commonly used for tendon grafts in hand surgery, wrist reconstruction, and even ligament repairs (e.g., UCL reconstruction in elbow) *Achilles tendon* - The **Achilles tendon** is a large, critical tendon for ankle plantarflexion and is **not used as a donor** for tendon transfers due to its essential function - It is the strongest tendon in the body and its harvest would cause severe functional disability - May be involved in major reconstructive procedures of the ankle and foot, but not as a donor graft *Flexor carpi ulnaris tendon* - The **flexor carpi ulnaris tendon** is sometimes used for specific wrist transfers (e.g., in cerebral palsy or radial nerve palsy), but it is **not the most common donor tendon** overall - It plays an important role in wrist flexion and ulnar deviation, making its harvest potentially more impactful than the palmaris longus - More commonly used as a recipient rather than donor in transfer procedures *Tibialis posterior tendon* - The **tibialis posterior tendon** is commonly used as a **transfer** (not harvest) for specific conditions like foot drop or posterior tibial tendon dysfunction - It is an important stabilizer of the medial longitudinal arch and inversion of the foot - For general tendon grafting across various anatomical sites, it is not as frequently used as the palmaris longus

Q: A 30-year-old man involved in a fisticuff, injured his middle finger and noticed slight flexion of the distal interphalangeal (DIP) joint. X-rays were normal. The most appropriate management at this stage is:

Splint the finger in hyperextension. ***Splint the finger in hyperextension*** - The description of slight flexion of the **distal interphalangeal (DIP) joint** with normal X-rays after an injury suggests a **mallet finger**. This occurs due to rupture of the terminal extensor tendon, allowing unopposed flexion of the DIP joint. - The standard conservative treatment for **mallet finger** is continuous splinting of the DIP joint in slight **hyperextension** for 6 to 8 weeks, leaving the proximal interphalangeal (PIP) joint free. *Ignore* - Ignoring the injury is inappropriate as **mallet finger** will lead to a **permanent deformity** (extensor lag) and functional impairment if left untreated. - Early intervention with proper splinting provides a high success rate for tendon healing and restoration of function. *Surgical repair of the flexor tendon* - Surgical repair is indicated when the injury involves a **complex fracture**, severe subluxation, or chronic untreated cases of mallet finger that have failed conservative management. - The injury here affects the **extensor tendon**, not the flexor tendon, thus flexor tendon repair would be incorrect. *Buddy strapping* - **Buddy strapping** involves taping the injured finger to an adjacent healthy finger. This technique is primarily used for **phalangeal fractures** or dislocations to provide support and restrict movement. - For **mallet finger**, it would not adequately immobilize the DIP joint in hyperextension, which is crucial for healing the ruptured extensor tendon.

Question 1

Which of the following is NOT a symptom of carpal tunnel syndrome?

Accepted Answer

Ulnar nerve dysfunction

Answer

Phalen's sign

Answer

Pain & paraesthesia of wrist

Answer

Tinel sign

Question 2

What is the primary use of a knuckle bender splint?

Accepted Answer

Ulnar nerve palsy

Answer

Radial nerve palsy

Answer

Median nerve palsy

Answer

Axillary nerve palsy

Question 3

What is the most common complication associated with carpal tunnel release surgery?

Accepted Answer

Finger stiffness

Answer

Malunion

Answer

Avascular necrosis

Answer

Rupture of EPL tendon

Question 4

A 54-year-old female marathon runner presents with pain in her right wrist that resulted from a fall onto her outstretched hand. Radiographic studies indicate an anterior dislocation of a carpal bone. Which of the following bones is most likely dislocated?

Accepted Answer

Lunate

Answer

Capitate

Answer

Trapezoid

Answer

Triquetrum

Question 5

A cricketer holds a catch and then presents with pain at the base of the right thumb; he should be examined to specifically rule out damage to which of the following structures?

Accepted Answer

Ulnar collateral ligament

Answer

Extensor pollicis brevis

Answer

Abductor pollicis longus

Answer

Volar plate

Question 6

In carpal tunnel syndrome evaluation, the Semmes-Weinstein monofilament test is primarily used to assess which nerve's sensory function?

Accepted Answer

Median Nerve

Answer

Ulnar Nerve

Answer

Radial Nerve

Answer

Posterior Interosseus Nerve

Question 7

One of the common fractures that occur during boxing by hitting with a closed fist is:

Accepted Answer

Bennett's fracture dislocation

Answer

Monteggia fracture dislocation

Answer

Galeazzi fracture dislocation

Answer

Smith's fracture

Question 8

Which carpal bone fracture causes median nerve involvement?

Accepted Answer

Scaphoid

Answer

Trapezium

Answer

Trapezoid

Answer

Lunate

Question 9

For tendon transfer, the most common tendon used is

Accepted Answer

Palmaris longus tendon

Answer

Achilles tendon

Answer

Flexor carpi ulnaris tendon

Answer

Tibialis posterior tendon

Question 10

A 30-year-old man involved in a fisticuff, injured his middle finger and noticed slight flexion of the distal interphalangeal (DIP) joint. X-rays were normal. The most appropriate management at this stage is:

Accepted Answer

Splint the finger in hyperextension

Answer

Ignore

Answer

Surgical repair of the flexor tendon

Answer

Buddy strapping

Hand Surgery — MCQs

Hand Surgery — MCQs

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