Hand Surgery — MCQs

Hand Surgery Indian Medical PG Practice Questions and MCQs

Question 31: Which of the following is NOT a characteristic feature of carpal tunnel syndrome?

A. Pregnancy is the most common cause. (Correct Answer)
B. It is more common in women.
C. The median nerve is compressed.
D. Symptoms commonly occur at night.

Explanation: **Explanation:** **Carpal Tunnel Syndrome (CTS)** is the most common entrapment neuropathy, caused by the compression of the **median nerve** as it passes through the fibro-osseous carpal tunnel at the wrist. **Why Option A is the correct answer (The False Statement):** While pregnancy is a well-known physiological cause of CTS due to fluid retention and edema, it is **not the most common cause**. The most common cause of CTS is **idiopathic** (unknown origin). When an underlying pathology is present, it is often associated with repetitive stress, obesity, or systemic conditions like Diabetes Mellitus and Rheumatoid Arthritis. **Analysis of Incorrect Options:** * **Option B:** CTS is significantly **more common in women** (ratio approx. 3:1), likely due to smaller anatomical carpal tunnel dimensions. * **Option C:** The **median nerve** is the only nerve passing through the tunnel (along with nine tendons); its compression leads to the classic symptoms. * **Option D:** **Nocturnal symptoms** are a hallmark of CTS. Patients often wake up with numbness or pain, frequently relieved by shaking their hands (**"Flick sign"**). This occurs due to venous stasis and natural wrist flexion during sleep. **High-Yield Clinical Pearls for NEET-PG:** * **Sensory Loss:** Occurs over the lateral 3.5 fingers. Note: The **palmar cutaneous branch** of the median nerve arises proximal to the tunnel, so sensation over the **thenar eminence is preserved**. * **Motor Loss:** Weakness and atrophy of thenar muscles (LOAF: Lateral two lumbricals, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis). * **Provocative Tests:** Phalen’s test (most sensitive) and Tinel’s sign. * **Gold Standard Diagnosis:** Nerve Conduction Velocity (NCV) studies showing delayed conduction across the wrist.

Question 32: Bennett's fracture is a fracture-dislocation of the base of which metacarpal?

A. 3rd
B. 4th
C. 1st (Correct Answer)
D. 2nd

Explanation: **Explanation:** **Bennett’s fracture** is a classic high-yield topic in Orthopaedics. It is defined as an **intra-articular fracture-dislocation** at the base of the **1st metacarpal** (the thumb). **Why Option C is Correct:** The injury occurs due to axial loading along the longitudinal axis of the thumb while the metacarpal is in slight flexion. The fracture pattern involves a small triangular fragment of the 1st metacarpal base remaining attached to the **trapezium** via the anterior oblique ligament. Crucially, the rest of the metacarpal shaft is displaced **proximally, dorsally, and radially** by the pull of the **Abductor Pollicis Longus (APL)** muscle. This instability makes it a fracture-dislocation rather than a simple fracture. **Why Other Options are Incorrect:** * **Options A, B, and D:** Fractures at the base of the 2nd, 3rd, or 4th metacarpals are rare and do not carry the eponym "Bennett’s." These metacarpals are more rigidly fixed at the carpo-metacarpal joints and lack the unique mobility and muscular pull (APL) that characterizes the 1st metacarpal injury. **Clinical Pearls for NEET-PG:** * **Rolando Fracture:** A comminuted (T or Y shaped) intra-articular fracture at the base of the 1st metacarpal. It has a worse prognosis than Bennett’s. * **Gamekeeper’s/Skier’s Thumb:** Injury to the Ulnar Collateral Ligament (UCL) of the 1st MCP joint. * **Management:** Bennett’s fracture is inherently unstable; therefore, it usually requires **Closed Reduction and Internal Fixation (CRIF)** with K-wires or Open Reduction (ORIF).

Question 33: Carpal tunnel syndrome is associated with all of the following conditions, EXCEPT:

A. Acromegaly
B. Post-menopausal females (Correct Answer)
C. Myxedema
D. Pregnancy

Explanation: **Explanation:** Carpal Tunnel Syndrome (CTS) is a compressive neuropathy of the median nerve as it passes through the carpal tunnel. The underlying pathophysiology involves any condition that increases the volume of the tunnel contents or decreases the tunnel's capacity. **Why "Post-menopausal females" is the correct answer:** While CTS is more common in females due to smaller anatomical dimensions of the carpal tunnel, it is specifically associated with **pregnancy** and **oral contraceptive use** (due to fluid retention). There is no direct hormonal or physiological link between the post-menopausal state itself and the development of CTS. In fact, if a female develops CTS during menopause, it is usually attributed to age-related degenerative changes or other comorbidities rather than the menopausal state itself. **Analysis of Incorrect Options:** * **Acromegaly:** Excess growth hormone causes soft tissue hypertrophy and bony overgrowth, leading to significant narrowing of the carpal tunnel. * **Myxedema (Hypothyroidism):** This leads to the deposition of mucopolysaccharides (glycosaminoglycans) within the synovial sheath, increasing pressure on the median nerve. * **Pregnancy:** Hormonal changes lead to generalized edema and fluid retention, which increases the interstitial pressure within the carpal tunnel. It often resolves postpartum. **NEET-PG High-Yield Pearls:** * **Most common cause:** Idiopathic. * **Most common systemic cause:** Diabetes Mellitus. * **Clinical Tests:** Phalen’s test (most sensitive) and Tinel’s sign. * **Gold Standard Diagnosis:** Nerve Conduction Velocity (NCV) studies (shows increased latency). * **First muscle to atrophy:** Abductor Pollicis Brevis (APB). * **Other associations:** Rheumatoid Arthritis (synovitis), Amyloidosis (especially in chronic dialysis patients), and Colles’ fracture (malunion).

Question 34: Felon/Whitlow is defined as infection of which space?

A. Midpalmar space infection
B. Terminal pulp space infection (Correct Answer)
C. Infection of the ulnar bursa
D. Infection of the radial bursa

Explanation: ### Explanation **Correct Answer: B. Terminal pulp space infection** A **Felon** (also known as a Whitlow) is an acute, painful abscess involving the **terminal pulp space** of the finger. The pulp space is a closed compartment located on the palmar aspect of the distal phalanx. It is anatomically unique because it contains numerous **vertical fibrous septa** that run from the skin to the periosteum. When infection occurs (usually due to *Staphylococcus aureus* following a minor prick), the resulting inflammatory edema causes a rapid rise in pressure within these non-compliant compartments. This high pressure can lead to: 1. **Ischemic Necrosis:** Compression of the digital artery branches. 2. **Osteomyelitis:** If untreated, the infection can spread to the distal phalanx (sequestrum of the diaphysis). --- ### Analysis of Incorrect Options: * **A. Midpalmar space infection:** This involves the deep fascial space of the palm (bounded by the midpalmar septum and hypothenar muscles). It typically presents with loss of the normal palmar concavity and "ballooning" of the hand. * **C & D. Infection of the Ulnar/Radial Bursa:** These are types of **Suppurative Tenosynovitis**. The radial bursa surrounds the Flexor Pollicis Longus, while the ulnar bursa surrounds the flexor tendons of the little finger. Infection here presents with **Kanavel’s Signs**. --- ### High-Yield Clinical Pearls for NEET-PG: * **Treatment:** Early **Incision and Drainage** (I&D) is mandatory. The incision should be longitudinal (unilateral) to avoid damaging the digital nerves and to break the fibrous septa. * **Complication:** The most common complication of a neglected Felon is **Osteomyelitis of the distal phalanx**. * **Anatomy Note:** The epiphysis of the distal phalanx is usually spared in children because its blood supply arises proximal to the pulp space. * **Differential:** Do not confuse a bacterial Felon with **Herpetic Whitlow** (caused by HSV). Herpetic Whitlow is characterized by vesicles and is treated conservatively; incision is contraindicated.

Question 35: Which of the following conditions does NOT produce carpal tunnel syndrome?

A. Colles' fracture
B. Acromegaly
C. Addison's disease (Correct Answer)
D. Hypothyroidism

Explanation: **Explanation:** Carpal Tunnel Syndrome (CTS) is a compressive neuropathy of the **median nerve** as it passes through the carpal tunnel. Any condition that decreases the volume of the tunnel or increases the volume of its contents can lead to CTS. **1. Why Addison’s Disease is the Correct Answer:** Addison’s disease (primary adrenocortical insufficiency) is characterized by a deficiency of cortisol and aldosterone, leading to weight loss and dehydration. It does **not** cause fluid retention or soft tissue hypertrophy. In contrast, **Cushing’s syndrome** (excess glucocorticoids) can lead to CTS due to increased fat deposition and fluid retention. **2. Why the other options are incorrect:** * **Colles’ Fracture:** This is a common bony cause. Malunion or acute edema/hematoma following a distal radius fracture alters the anatomy of the carpal tunnel, leading to direct pressure on the median nerve. * **Acromegaly:** Excess growth hormone causes **soft tissue hypertrophy** and bony overgrowth of the carpal bones, significantly narrowing the tunnel space. * **Hypothyroidism:** This is a classic metabolic cause. It leads to the deposition of **mucopolysaccharides** (myxedema) and fluid within the synovial sheaths, increasing pressure on the nerve. **Clinical Pearls for NEET-PG:** * **Most common cause:** Idiopathic. * **Most common associated systemic disease:** Diabetes Mellitus. * **Pregnancy:** A high-yield cause due to generalized edema (usually resolves post-partum). * **Clinical Tests:** Phalen’s test (most sensitive) and Tinel’s sign. * **Gold Standard Diagnosis:** Nerve Conduction Velocity (NCV) studies showing delayed conduction across the wrist.

Question 36: Carpal tunnel syndrome is associated with all of the following conditions except:

A. Dupuytren's contracture (Correct Answer)
B. Myxedema
C. Idiopathic causes
D. Rheumatoid arthritis

Explanation: **Explanation:** Carpal Tunnel Syndrome (CTS) is a compressive neuropathy of the **median nerve** as it passes through the carpal tunnel. The pathophysiology involves any condition that increases the volume of the tunnel contents or decreases the capacity of the canal. **Why Dupuytren's Contracture is the correct answer:** Dupuytren’s contracture is a fibroproliferative disorder of the **palmar fascia**, leading to thickening and shortening of the palmar aponeurosis and permanent flexion of the fingers. While it occurs in the hand, it is a superficial pathology and does not involve the carpal tunnel or increase pressure on the median nerve. Therefore, there is no direct causal link between Dupuytren’s and CTS. **Analysis of other options:** * **Myxedema (Hypothyroidism):** This is a classic systemic cause. It leads to the accumulation of glycosaminoglycans (mucopolysaccharides) in the connective tissues, causing fluid retention and swelling within the carpal tunnel. * **Idiopathic:** This is actually the **most common cause** of CTS. In many patients, no specific underlying systemic or local pathology is identified. * **Rheumatoid Arthritis:** This is the most common inflammatory cause. Synovitis of the flexor tendons (tenosynovitis) increases the volume of the tunnel contents, leading to secondary median nerve compression. **NEET-PG High-Yield Pearls:** * **Most common nerve compressed** in the upper limb: Median nerve. * **Clinical Tests:** Phalen’s test (most sensitive) and Tinel’s sign. * **Gold Standard Diagnosis:** Nerve Conduction Velocity (NCV) studies. * **Other common associations:** Pregnancy (fluid retention), Diabetes Mellitus, Acromegaly, and Amyloidosis (especially in dialysis patients). * **First muscle to atrophy:** Abductor Pollicis Brevis (APB).

Question 37: All are true of Dupuytren's contracture except?

A. Usually, the 4th finger is involved
B. Bilateral disease is common (Correct Answer)
C. Surgical release is useful
D. May be associated with Peyronie disease

Explanation: **Explanation:** Dupuytren’s contracture is a progressive fibroproliferative disorder of the **palmar fascia**, leading to permanent flexion contractures of the fingers. **Why Option B is the Correct Answer (The Exception):** While Dupuytren’s contracture can be bilateral, it is **typically unilateral** in its early stages or asymmetric in presentation. In the context of standard textbook descriptions and NEET-PG patterns, the disease is more frequently noted as starting in one hand. (Note: Some clinical sources suggest high rates of eventual bilaterality, but in classic MCQ patterns, "unilateral" is the traditional teaching compared to the definitive truths of the other options). **Analysis of Other Options:** * **Option A:** The **4th (ring) finger** is the most commonly involved digit, followed by the 5th (little) finger. This is a classic diagnostic hallmark. * **Option C:** Surgical release (Fasciectomy) or procedures like needle aponeurotomy and collagenase injection are the mainstays of treatment when the **metacarpophalangeal (MCP) joint contracture exceeds 30°** or any PIP joint involvement is present. * **Option D:** It is part of a systemic fibromatosis diathesis. It is frequently associated with **Peyronie’s disease** (penile fibromatosis), **Lederhose disease** (plantar fibromatosis), and Garrod’s pads (knuckle pads). **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Strong genetic predisposition (Autosomal Dominant), male gender (older age), diabetes mellitus, chronic alcoholism, and smoking. * **Pathology:** Proliferation of **myofibroblasts** and deposition of Type III collagen. * **Hueston’s Table Top Test:** Positive when the patient cannot place their palm flat on a table; this indicates a need for surgical intervention. * **Key Anatomy:** The disease involves the **pretendinous cords** of the palmar fascia; it does *not* involve the tendons themselves.

Question 38: Which tendon is commonly used as a graft for flexor tendon repair?

A. Plantaris
B. Palmaris longus (Correct Answer)
C. Extensor digitorum
D. Extensor indicis

Explanation: **Explanation:** The **Palmaris longus** is the most commonly used tendon graft for flexor tendon reconstruction in the hand. This is due to several anatomical and clinical factors: it is easily accessible, has an appropriate length and diameter for hand surgery, and its absence does not result in any significant functional deficit. It is a vestigial muscle, absent in approximately 15% of the population. **Analysis of Options:** * **A. Plantaris:** While the plantaris is a common donor site for long tendon grafts (providing up to 30-35 cm of length), it is considered the second choice after the Palmaris longus. It is often used when multiple grafts are required or when the Palmaris longus is absent. * **C. Extensor digitorum:** These are primary extensors of the fingers. Using them as grafts would cause significant functional loss (inability to extend fingers), making them unsuitable for harvest. * **D. Extensor indicis:** This is sometimes used as a **tendon transfer** (e.g., to restore thumb extension in EHL rupture), but it is not a standard choice for a free tendon graft in flexor repairs. **High-Yield Clinical Pearls for NEET-PG:** * **Testing for Palmaris Longus:** The **Schaeffer’s Test** is used to identify the presence of the tendon (opposing the thumb to the little finger while flexing the wrist). * **Other Donor Sites:** If Palmaris longus and Plantaris are unavailable, the **Extensor Digitorum Longus (to the 2nd, 3rd, and 4th toes)** or the **Extensor Indicis Proprius** can be used. * **Flexor Tendon Zones:** Remember that **Zone II** is known as "Bunnell’s No Man’s Land" because of the poor prognosis following primary repair due to adhesions within the fibro-osseous tunnel.

Question 39: In trigger finger, at what level is the tendon sheath constriction typically found?

A. Middle phalanx
B. Proximal interphalangeal joint
C. Proximal phalanx
D. Metacarpophalangeal joint (Correct Answer)

Explanation: ### Explanation **Concept:** Trigger finger (Stenosing Tenosynovitis) occurs due to a size mismatch between the flexor tendons (FDS and FDP) and the surrounding pulley system. The primary pathology is the thickening and narrowing of the **A1 pulley**, which is located at the level of the **Metacarpophalangeal (MCP) joint**. This constriction prevents the smooth gliding of the tendon; the tendon often develops a nodule distal to the pulley, which becomes "trapped" during extension, causing the characteristic snapping or "triggering" sensation. **Analysis of Options:** * **D. Metacarpophalangeal joint (Correct):** The A1 pulley originates from the volar plate and the base of the proximal phalanx at the MCP joint level. This is the most common site of entrapment. * **A & C. Middle and Proximal phalanx:** While the tendon sheath extends along these bones (containing A2, A3, and A4 pulleys), these are not the primary sites of constriction in trigger finger. The A2 and A4 pulleys are essential for preventing "bowstringing" but are rarely involved in stenosing tenosynovitis. * **B. Proximal interphalangeal (PIP) joint:** Although the patient often feels the "click" or pain over the PIP joint (referred pain), the actual mechanical obstruction is proximal to it, at the MCP joint. **High-Yield Clinical Pearls for NEET-PG:** * **Most common digit involved:** Ring finger (followed by the thumb, known as "Trigger Thumb"). * **Clinical Sign:** A palpable nodule can often be felt at the level of the MCP joint in the palm. * **Associated Conditions:** Diabetes Mellitus (most common), Rheumatoid Arthritis, and Hypothyroidism. * **Treatment:** First-line is often conservative (NSAIDs, splinting, or corticosteroid injection). Definitive treatment is **surgical release of the A1 pulley**.

Question 40: What is the cause of Dupuytren's contracture?

A. Diabetes Mellitus
B. Alcohol consumption
C. Smoking
D. All of the above (Correct Answer)

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 (most commonly the ring and little fingers). The exact etiology is idiopathic, but it is strongly associated with several systemic risk factors: * **Diabetes Mellitus:** Hyperglycemia leads to the formation of Advanced Glycation End-products (AGEs), which increase collagen cross-linking and fibroblast proliferation. * **Alcohol Consumption:** Chronic intake is linked to microvascular changes and altered metabolism that predispose the palmar fascia to fibrosis. * **Smoking:** Nicotine causes localized ischemia and microvascular damage, stimulating myofibroblast activity. **Why "All of the above" is correct:** While the condition has a strong genetic component (Autosomal Dominant with variable penetrance, linked to Northern European/Viking descent), Diabetes, Alcohol, and Smoking are all well-documented environmental triggers and exacerbating factors. Therefore, all three options contribute to the pathogenesis. **Clinical Pearls for NEET-PG:** * **Pathology:** It involves the transformation of fibroblasts into **myofibroblasts**, with a shift from Type I to **Type III collagen**. * **Clinical Test:** **Hueston’s Tabletop Test** is positive when the patient cannot place their palm flat on a table. * **Management:** Surgical intervention (Fasciectomy) is indicated if the MCP joint contracture is **>30°** or any PIP joint contracture is present. * **Associations:** Often associated with other fibromatoses like **Ledderhose disease** (plantar fascia) and **Peyronie’s disease** (penile fascia).

Practice by Chapter

Hand Anatomy and Biomechanics

Practice Questions

Hand Fractures and Dislocations

Practice Questions

Tendon Injuries

Practice Questions

Nerve Injuries in Hand

Practice Questions

Dupuytren's Disease

Practice Questions

Carpal Tunnel Syndrome

Practice Questions

Rheumatoid Hand

Practice Questions

Reconstructive Hand Surgery

Practice Questions

Tendon Transfers

Practice Questions

Congenital Hand Anomalies

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Hand Infections

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Microsurgery in Hand Surgery

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