Hand Surgery — MCQs

A middle-aged female presents with pain and tenderness at the base of the thumb, with a history of chronic wrist overuse. A specific maneuver, involving making a fist with the thumb inside and then bending the wrist towards the little finger, elicits pain. Which two tendons are primarily involved in this condition?

Q18Medium

Which of the following statements is NOT TRUE regarding Dupuytren's contracture?

Q19Medium

A 66-year-old diabetic lady complains of pain in the palm of her right hand at the base of her ring finger, which is held in flexion. Extension is painful, produces an audible click, and often requires the assistance of the other hand. What is the first-line treatment for this condition?

Q20Easy

What does Tinel's test assess?

Hand Surgery Indian Medical PG Practice Questions and MCQs

Question 11: Mallet finger is a common traumatic lesion resulting in flexion deformity of the distal interphalangeal joint. What is the basic pathology of this condition?

A. Avulsion fracture of the middle phalanx
B. Rupture of collateral slips of the extensor expansion (Correct Answer)
C. Rupture of the central slip of the extensor expansion
D. Dislocation of the distal interphalangeal joint

Explanation: **Explanation:** **Mallet Finger** (also known as Baseball finger) is a common injury caused by sudden forced flexion of an extended finger, typically when a ball hits the fingertip. **1. Why the Correct Answer is Right:** The extensor mechanism of the finger divides into a **central slip** (inserting on the middle phalanx) and two **lateral/collateral slips** (lateral bands). These lateral slips converge to form a single terminal tendon that inserts into the base of the **distal phalanx**. Mallet finger occurs due to the disruption of this terminal extensor mechanism—either through a pure tendon rupture or an avulsion fracture at the dorsal base of the distal phalanx. This loss of extensor continuity allows the Flexor Digitorum Profundus (FDP) to act unopposed, resulting in a characteristic flexion deformity at the Distal Interphalangeal (DIP) joint. **2. Why the Other Options are Wrong:** * **Option A:** An avulsion fracture in Mallet finger involves the **distal phalanx**, not the middle phalanx. * **Option C:** Rupture of the **central slip** leads to a **Boutonnière deformity**, characterized by PIP joint flexion and DIP joint hyperextension. * **Option D:** While trauma can cause DIP dislocation, Mallet finger specifically refers to the extensor mechanism disruption, not a loss of joint congruity. **3. Clinical Pearls for NEET-PG:** * **Clinical Feature:** Patient cannot actively extend the DIP joint but passive extension is possible. * **Management:** Most cases are treated conservatively with a **Mallet splint** (holding the DIP in continuous extension/slight hyperextension) for 6–8 weeks. * **Boutonnière Deformity:** Remember the "Central Slip" rule for PIP joint pathology to distinguish it from Mallet finger.

Question 12: Which of the following is seen in Boutonniere's deformity?

A. Extension of PIP and DIP
B. Flexion of PIP and DIP
C. Flexion contracture of PIP and extension of DIP (Correct Answer)
D. Flexion of DIP and extension of PIP

Explanation: **Explanation:** **Boutonniere’s deformity** (also known as Buttonhole deformity) is a characteristic finger deformity resulting from the **rupture or avulsion of the central slip** of the extensor tendon from its insertion at the base of the middle phalanx. **1. Why Option C is Correct:** When the central slip is damaged, the lateral bands of the extensor mechanism slide volarly (towards the palm) past the axis of the Proximal Interphalangeal (PIP) joint. These lateral bands then act as flexors of the PIP joint rather than extensors. Simultaneously, the tension on the lateral bands increases at their distal insertion, causing compensatory **hyperextension of the Distal Interphalangeal (DIP) joint**. Thus, the classic presentation is **PIP flexion and DIP extension.** **2. Why Incorrect Options are Wrong:** * **Option A & B:** These describe uniform positions (both joints extended or both flexed), which do not account for the reciprocal mechanical imbalance caused by the displaced lateral bands. * **Option D:** This describes **Swan-neck deformity** (PIP hyperextension and DIP flexion), which is the clinical opposite of Boutonniere’s deformity and is often caused by volar plate laxity or rheumatoid arthritis. **3. Clinical Pearls for NEET-PG:** * **Etiology:** Most commonly seen in Rheumatoid Arthritis or trauma (e.g., a jammed finger). * **Elson’s Test:** The gold standard clinical test to diagnose early central slip injury before the deformity becomes fixed. * **Management:** Initial treatment is usually non-operative, involving splinting the PIP joint in full extension for 6–8 weeks while allowing active DIP motion. * **Mnemonic:** **B**outonniere = **B**ent (PIP) and **U**p (DIP).

Question 13: Which of the following is the most appropriate diagnosis for a patient presenting with wrist pain and stiffness, especially after repetitive stress, with a characteristic "humpback" deformity?

A. Osteochondrosis of the lunate
B. Osteochondrosis of the navicular (Correct Answer)
C. Tuberculosis of the scaphoid
D. Syphilitic dactylitis

Explanation: **Explanation:** The correct answer is **Osteochondrosis of the navicular** (also known as **Preiser’s disease**). 1. **Why it is correct:** Osteochondrosis refers to a group of disorders that affect the growing skeleton, involving idiopathic avascular necrosis (AVN) of a bone. When it affects the carpal navicular (scaphoid), it is termed Preiser’s disease. It typically presents in adults with progressive wrist pain, stiffness, and weakness, often exacerbated by repetitive stress or trauma. The **"humpback" deformity** is a classic radiological and clinical finding caused by the collapse of the scaphoid into flexion, leading to a prominent dorsal angulation at the fracture or necrosis site. 2. **Why the other options are incorrect:** * **A. Osteochondrosis of the lunate:** This is known as **Kienböck’s disease**. While it causes wrist pain and stiffness, it does not typically produce a "humpback" deformity; rather, it leads to lunate collapse and proximal migration of the capitate. * **C. Tuberculosis of the scaphoid:** While TB can affect small bones (carpal tunnel syndrome or dactylitis), it usually presents with systemic symptoms (fever, weight loss), "cold abscesses," and "rice bodies" in the synovium, rather than a specific humpback structural deformity. * **D. Syphilitic dactylitis:** This involves painless, spindle-shaped swelling of the phalanges (usually in infants) due to periostitis, not the carpal bones. **High-Yield Clinical Pearls for NEET-PG:** * **Preiser’s Disease:** AVN of the Scaphoid (Navicular). * **Kienböck’s Disease:** AVN of the Lunate. * **Humpback Deformity:** Specifically refers to the **dorsal angulation** of the scaphoid following a non-union or collapse. * **Terry Thomas Sign:** Widening of the scapholunate interval (>3mm), indicating ligamentous injury.

Question 14: Felon means infection of which anatomical space?

A. Epinychium
B. Terminal pulp space (Correct Answer)
C. Deep palmar space
D. Subcuticular space

Explanation: **Explanation:** A **Felon** is a closed-space infection of the **terminal pulp space** of the fingertip. This space is anatomically unique because it is divided into multiple small, non-compliant compartments by tough **fibrous septa** that run from the periosteum of the distal phalanx to the skin. 1. **Why Terminal Pulp Space is correct:** When infection occurs here, the inflammatory edema causes a rapid rise in pressure within these tight compartments. This leads to intense, throbbing pain and can compress the local blood supply, potentially causing **ischemic necrosis** of the distal phalanx (osteomyelitis). 2. **Why other options are incorrect:** * **Epinychium:** Infection here is called **Paronychia**. It involves the soft tissue fold around the nail plate. * **Deep palmar space:** These include the thenar and mid-palmar spaces. Infections here present with generalized hand swelling and loss of the palmar concavity, rather than localized fingertip pain. * **Subcuticular space:** This refers to infections just beneath the epidermis (e.g., a blister or "collar-stud" abscess), which do not involve the deep fibrous compartments characteristic of a felon. **Clinical Pearls for NEET-PG:** * **Treatment:** Incision and drainage (I&D) are mandatory. The incision should be made where the tenderness is maximal, typically avoiding the "pinching" surface of the finger. * **Complication:** If untreated, a felon can lead to **sequestration** of the distal phalanx (diaphysis) because the pressure exceeds the capillary perfusion pressure of the bone. * **Anatomy:** Note that the **flexor tendon sheath** does not extend into the terminal pulp space; therefore, a felon rarely leads to tenosynovitis unless the injury is deep and proximal.

Question 15: Which structure is usually repaired first in a hand injury?

A. Bone (Correct Answer)
B. Tendon
C. Nerve
D. Artery

Explanation: In hand surgery, particularly in cases of complex trauma or replantation, the sequence of repair follows a specific surgical hierarchy to ensure stability and optimal outcomes. **Why Bone is Repaired First** The fundamental principle of hand reconstruction is **"Stability before Mobility."** The skeleton provides the structural framework for the hand. Rigid internal fixation of the bone (using K-wires, plates, or screws) is performed first because: 1. It provides a stable scaffold for the repair of soft tissue structures. 2. It prevents subsequent tension or disruption of delicate microvascular and nerve repairs that would occur if the bone were manipulated later. 3. It allows for accurate restoration of the limb's length. **Explanation of Incorrect Options** * **Tendon:** Tendons are repaired after bone fixation but usually before nerves and vessels. Repairing them too early without skeletal stability leads to gap formation or rupture during bone manipulation. * **Nerve:** Nerves are fragile and require a tension-free environment. They are repaired toward the end of the procedure to prevent accidental stretching during the orthopedic or vascular stages. * **Artery:** While restoring circulation is critical, vascular repair is typically performed after bone and tendon stabilization. If the artery is repaired before the bone, the subsequent manipulation required for fracture fixation can easily tear the delicate anastomosis. **NEET-PG High-Yield Pearls** * **Standard Sequence of Replantation:** Bone → Tendon → Artery → Nerve → Vein → Skin (Mnemonic: **B-T-A-N-V-S**). * **Exception:** If the warm ischemia time is nearing its limit, a temporary **vascular shunt** may be placed to restore perfusion before proceeding with bone fixation. * **Golden Rule:** Always stabilize the "chassis" (bone) before fixing the "cables" (tendons/nerves) and "pipes" (vessels).

Question 16: Ulnar paradox is seen in which of the following conditions?

A. High ulnar nerve lesion (Correct Answer)
B. Low ulnar nerve lesion
C. Triple nerve injuries
D. Combined ulnar and median nerve injuries

Explanation: **Explanation:** The **Ulnar Paradox** refers to the clinical observation that a **High Ulnar Nerve Lesion** (at or above the elbow) results in a **less severe** claw hand deformity than a low lesion, despite the injury being more proximal. **1. Why Option A is Correct:** In a **Low Ulnar Nerve Lesion** (at the wrist), the Medial 2 Lumbricals are paralyzed, but the **Flexor Digitorum Profundus (FDP)** to the ring and little fingers remains intact (as it is supplied by the nerve in the forearm). The unopposed action of the intact FDP causes marked flexion at the Interphalangeal (IP) joints, making the "clawing" very prominent. In a **High Ulnar Nerve Lesion**, the FDP is also paralyzed. Since there is no long flexor force to pull the fingers into flexion, the clawing appears **milder**. The "paradox" is that a higher (worse) injury results in a better-looking hand. **2. Why Other Options are Incorrect:** * **Option B:** Low ulnar nerve lesions produce the most severe clawing (Main en Griffe). * **Option C & D:** Triple nerve or combined injuries result in complex deformities (like a "Total Claw Hand"), but they do not demonstrate the specific biomechanical trade-off between the FDP and lumbricals that defines the ulnar paradox. **Clinical Pearls for NEET-PG:** * **Claw Hand Mechanism:** Hyperextension at MCP joints (unopposed Extensor Digitorum) + Flexion at IP joints (paralyzed Lumbricals). * **Froment’s Sign:** Tests for Adductor Pollicis palsy (Ulnar nerve); patient compensates by flexing the thumb IP joint using the Median nerve (FPL). * **Mnemonic:** "The higher the lesion, the lesser the claw."

Question 17: A middle-aged female presents with pain and tenderness at the base of the thumb, with a history of chronic wrist overuse. A specific maneuver, involving making a fist with the thumb inside and then bending the wrist towards the little finger, elicits pain. Which two tendons are primarily involved in this condition?

A. Abductor pollicis brevis and Extensor pollicis brevis
B. Abductor pollicis brevis and Extensor pollicis longus
C. Abductor pollicis longus and Extensor pollicis brevis (Correct Answer)
D. Abductor pollicis longus and Extensor pollicis longus

Explanation: ### Explanation The clinical presentation describes **De Quervain’s Tenosynovitis**, a common stenosing tenosynovitis affecting the **first dorsal compartment** of the wrist. The maneuver described is the **Finkelstein test**, which is pathognomonic for this condition. #### 1. Why Option C is Correct The first dorsal compartment of the extensor retinaculum contains two specific tendons: the **Abductor Pollicis Longus (APL)** and the **Extensor Pollicis Brevis (EPB)**. Chronic overuse (repetitive gripping or ulnar deviation) leads to thickening of the synovial sheath and narrowing of the fibro-osseous tunnel, causing pain during thumb and wrist movement. #### 2. Why Other Options are Wrong * **Option A & B:** The **Abductor Pollicis Brevis (APB)** is an intrinsic muscle of the hand (thenar eminence) and does not pass through the extensor compartments of the wrist. * **Option D:** The **Extensor Pollicis Longus (EPL)** passes through the **third dorsal compartment** and loops around Lister’s tubercle. It forms the ulnar border of the anatomical snuffbox, whereas De Quervain’s involves the radial border. #### 3. High-Yield Clinical Pearls for NEET-PG * **Demographics:** Most common in middle-aged females and "new mothers" (due to repetitive lifting of the infant). * **Anatomical Snuffbox:** The APL and EPB form the **radial (lateral) border**, while the EPL forms the **ulnar (medial) border**. * **Eichhoff’s Test:** Often confused with Finkelstein’s; it is the specific maneuver where the patient deviates the wrist while clutching the thumb. * **Management:** Conservative (NSAIDs, thumb spica splint, steroid injections). Surgical release of the first compartment is indicated if conservative measures fail. Watch out for a **septated first compartment** (a common cause of surgical failure).

Question 18: Which of the following statements is NOT TRUE regarding Dupuytren's contracture?

A. Associated with Peyronie's disease
B. Typically affects the index finger first (Correct Answer)
C. Involves nodule formation and thickening of the plantar fascia
D. Amputation may be required in severe cases

Explanation: **Explanation:** **Dupuytren’s contracture** is a progressive fibroproliferative disorder of the palmar fascia, characterized by the formation of nodules and cords that lead to fixed flexion deformities of the fingers. **Why Option B is the Correct Answer (The False Statement):** In Dupuytren’s contracture, the **ring finger** is most commonly affected first, followed by the little finger. The index finger and thumb are rarely involved. Therefore, the statement that it typically affects the index finger first is incorrect. **Analysis of Other Options:** * **Option A:** It is frequently associated with other fibromatoses, including **Peyronie’s disease** (penile fibromatosis) and **Ledderhose disease** (plantar fibromatosis). This triad is often seen in patients with a strong genetic predisposition. * **Option C:** While primarily a palmar condition, the disease process involves myofibroblast proliferation leading to nodule formation. When it involves the feet (Ledderhose disease), it causes thickening of the **plantar fascia**. * **Option D:** While the primary treatments are fasciectomy or collagenase injection, **amputation** (specifically of the little finger) may be indicated in severe, recurrent cases where function cannot be restored or the finger is severely contracted and interfering with daily activities. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Male gender (M:F = 10:1), age >50, smoking, alcohol use, diabetes mellitus, and epilepsy (anticonvulsant use). * **Pathology:** Proliferation of **Type III collagen** (replacing Type I). * **Hueston’s Table Top Test:** Positive when the patient cannot flatten their palm against a table; indicates a need for surgical intervention. * **Treatment:** Indicated when the MCP joint contracture is >30° or any PIP joint contracture is present.

Question 19: A 66-year-old diabetic lady complains of pain in the palm of her right hand at the base of her ring finger, which is held in flexion. Extension is painful, produces an audible click, and often requires the assistance of the other hand. What is the first-line treatment for this condition?

A. Splinting for 6 weeks
B. Surgery under local anesthesia
C. Corticosteroid injection (Correct Answer)
D. Oral NSAIDs

Explanation: **Diagnosis: Trigger Finger (Stenosing Tenosynovitis)** **Explanation:** The clinical presentation of a painful "clicking" sensation, a finger locked in flexion, and the requirement of passive assistance for extension is classic for **Trigger Finger**. This condition is caused by a size mismatch between the flexor tendon (often due to a nodule) and the **A1 pulley** at the metacarpophalangeal (MCP) joint. It is highly associated with **Diabetes Mellitus**. 1. **Why Corticosteroid Injection is Correct:** According to standard orthopedic guidelines (and high-yield for NEET-PG), **corticosteroid injection** into the tendon sheath is the **first-line treatment**. It reduces peritendinous inflammation and edema, resolving symptoms in up to 60-90% of non-diabetic patients. While diabetic patients may have higher recurrence rates, it remains the initial intervention before considering surgery. 2. **Why Other Options are Incorrect:** * **Splinting:** While an option for very mild/early cases, it has lower success rates than injections and is generally not the "first-line" choice in a patient already experiencing locking and painful clicks. * **Surgery (A1 Pulley Release):** This is the definitive treatment but is reserved for cases where conservative management (injections) has failed. * **Oral NSAIDs:** These may provide symptomatic pain relief but do not address the mechanical obstruction at the A1 pulley effectively. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ring finger (followed by thumb and middle finger). * **Pathology:** Fibrocartilaginous metaplasia of the **A1 pulley**. * **Diabetic Association:** Patients with DM often have multiple digits involved and are more resistant to corticosteroid treatment. * **Pediatric Trigger Thumb:** Unlike adults, this is usually congenital and often requires surgical release rather than injections.

Question 20: What does Tinel's test assess?

A. Loss of sensation.
B. Loss of two-point discrimination.
C. Percussion produces a tingling sensation. (Correct Answer)
D. Is not associated with carpal tunnel syndrome.

Explanation: **Explanation:** **Tinel’s sign** is a clinical test used to identify irritated or regenerating nerves. It is performed by lightly **percussing** over the course of a nerve. A positive result occurs when this percussion produces a **tingling sensation** (paresthesia) in the cutaneous distribution of that nerve. **Why the correct answer is right:** The underlying pathophysiology involves **mechanical hyper-excitability** of regenerating axonal sprouts or irritated nerve fibers. When the nerve is tapped, these sensitive fibers fire, sending signals to the brain that are interpreted as "pins and needles" or tingling in the nerve's territory. **Analysis of incorrect options:** * **A & B:** Loss of sensation and loss of two-point discrimination are signs of **nerve deficit** (anesthesia/hypesthesia). Tinel’s test is a provocative test for nerve *irritability* or *regeneration*, not a measure of sensory loss. * **D:** Tinel’s sign is classically associated with **Carpal Tunnel Syndrome (CTS)**, where percussion over the median nerve at the wrist crease reproduces symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Phalen’s Test:** The most sensitive provocative test for CTS (wrist flexion for 60 seconds). * **Regeneration Tracking:** In peripheral nerve injuries, a "distally progressing" Tinel’s sign is a positive prognostic indicator, suggesting that axons are regenerating (at a rate of approximately **1 mm/day**). * **Common Sites:** Median nerve (Carpal Tunnel), Ulnar nerve (Cubital Tunnel), and Common Peroneal nerve (at the fibular head).

Practice by Chapter

Hand Anatomy and Biomechanics

Practice Questions

Hand Fractures and Dislocations

Practice Questions

Tendon Injuries

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Nerve Injuries in Hand

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Dupuytren's Disease

Practice Questions

Carpal Tunnel Syndrome

Practice Questions

Rheumatoid Hand

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Reconstructive Hand Surgery

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Tendon Transfers

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Congenital Hand Anomalies

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Hand Infections

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Microsurgery in Hand Surgery

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