Hand Surgery — MCQs

A 57-year-old woman presents with numbness and tingling in her right thumb, index, and long finger for the past four weeks. She reports waking up in the middle of the night with these symptoms, requiring her to shake her hands to alleviate them. She denies similar symptoms in her other hand or legs and has no neck or upper arm pain. Physical examination reveals that her symptoms are reproduced by Tinel testing and exacerbated by wrist hyperflexion. Decreased sensation is noted over the palmar aspects of the thumb, index, and middle fingers, with no apparent motor weakness. What is the most likely diagnosis?

Q45Easy

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

Q46Easy

What is the most common cause of trigger finger?

Q47Easy

Carpal tunnel syndrome is caused by all of the following conditions EXCEPT?

Q48Easy

A patient is unable to actively extend the terminal phalange, although the distal interphalangeal joint can be extended passively. What is this condition known as?

Q49Easy

De Quervain's tenosynovitis involves which tendon(s)?

Q50Medium

A 40-year-old diabetic man presents with an inability to bend his ring finger and small nodules on the palm. Which of the following would NOT be part of your management for this patient?

Hand Surgery Indian Medical PG Practice Questions and MCQs

Question 41: Carpal tunnel syndrome is due to compression of which nerve?

A. Median nerve (Correct Answer)
B. Anterior interosseous nerve
C. Radial nerve
D. Ulnar nerve

Explanation: **Explanation:** **Carpal Tunnel Syndrome (CTS)** is the most common entrapment neuropathy of the upper limb. It occurs due to the compression of the **Median nerve** as it passes through the carpal tunnel, a narrow osteofibrous canal bounded by the carpal bones (floor) and the flexor retinaculum (roof). **Why the Correct Answer is Right:** The carpal tunnel contains ten structures: the Median nerve and nine tendons (4 Flexor Digitorum Superficialis, 4 Flexor Digitorum Profundus, and 1 Flexor Pollicis Longus). Any condition that increases pressure within this space (e.g., synovitis, pregnancy, hypothyroidism, or trauma) compresses the Median nerve, leading to paresthesia in its sensory distribution (lateral 3.5 fingers) and weakness of the thenar muscles. **Why Other Options are Wrong:** * **Anterior Interosseous Nerve (AIN):** This is a pure motor branch of the median nerve. Compression (AIN syndrome) causes weakness of the "OK" sign (FPL and FDP to index finger) but involves no sensory loss and does not occur in the carpal tunnel. * **Radial Nerve:** This nerve passes posteriorly to the humerus and through the radial tunnel in the forearm. Compression typically leads to wrist drop or sensory loss on the dorsum of the hand. * **Ulnar Nerve:** This nerve passes through **Guyon’s canal**, not the carpal tunnel. Compression here causes sensory loss in the medial 1.5 fingers and clawing. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Tests:** Phalen’s test (most sensitive), Durkan’s test (most specific), and Tinel’s sign. * **Muscle Sparing:** The **Palmar Cutaneous Branch** of the median nerve passes *superficial* to the flexor retinaculum; therefore, sensation over the thenar eminence is **spared** in CTS. * **First-line Treatment:** Night splinting in neutral position; definitive treatment is surgical release of the flexor retinaculum.

Question 42: Phalen's test is used in the diagnosis of which condition?

A. De quervain tenosynovitis
B. Carpal tunnel syndrome (Correct Answer)
C. Trigger finger
D. Ulnar nerve injury

Explanation: **Explanation:** **Phalen’s test** is a provocative clinical maneuver used to diagnose **Carpal Tunnel Syndrome (CTS)**, which is the compression of the median nerve as it passes through the carpal tunnel at the wrist. **Why the correct answer is right:** In Phalen’s test, the patient is asked to hold their wrists in complete, forced flexion (pushing the dorsal surfaces of the hands together) for 60 seconds. This position increases the pressure within the carpal tunnel and further compresses the median nerve. A positive test is indicated by the reproduction of symptoms—numbness, tingling, or paresthesia—in the median nerve distribution (thumb, index, middle, and radial half of the ring finger). **Why the incorrect options are wrong:** * **De Quervain Tenosynovitis:** Diagnosed using **Finkelstein’s test** (ulnar deviation of the wrist with the thumb tucked into the palm). It involves the 1st dorsal compartment (APL and EPB tendons). * **Trigger Finger:** A clinical diagnosis based on "locking" or "snapping" of the finger during extension due to a nodule in the flexor tendon at the A1 pulley. * **Ulnar Nerve Injury:** Associated with tests like **Froment’s sign** (adductor pollicis weakness) or Wartenberg’s sign, not wrist flexion maneuvers. **High-Yield Clinical Pearls for NEET-PG:** * **Reverse Phalen’s Test:** Performed by holding the wrists in forced extension ("prayer position"); also used for CTS. * **Tinel’s Sign:** Percussion over the flexor retinaculum that elicits electric-like shocks in the median nerve distribution. * **Durkan’s Test:** (Manual Compression Test) Pressing the thumb over the carpal tunnel for 30 seconds; it is considered the **most sensitive** clinical test for CTS. * **Gold Standard Investigation:** Nerve Conduction Velocity (NCV) studies.

Question 43: What is this condition known as?

A. Preiser's disease
B. Kienbock's disease
C. Felon (Correct Answer)
D. Kaplan's lesion

Explanation: ***Felon*** - A **fingertip pulp space infection** characterized by **tense swelling** and severe pain in the **digital pulp**. - Requires urgent **incision and drainage** to prevent complications like **osteomyelitis** of the distal phalanx. *Preiser's disease* - **Avascular necrosis (AVN) of the scaphoid bone** in the wrist, not related to fingertip infections. - Presents with **wrist pain** and **limited range of motion**, typically following trauma or repetitive stress. *Kienbock's disease* - **Avascular necrosis (AVN) of the lunate bone** in the wrist, unrelated to soft tissue infections. - Characterized by **progressive wrist pain** and **collapse of the lunate**, often seen on X-rays. *Kaplan's lesion* - A **tear of the ulnar collateral ligament** at the thumb MCP joint (gamekeeper's thumb). - Involves **ligamentous injury** rather than infection, presenting with thumb **instability** and pain.

Question 44: A 57-year-old woman presents with numbness and tingling in her right thumb, index, and long finger for the past four weeks. She reports waking up in the middle of the night with these symptoms, requiring her to shake her hands to alleviate them. She denies similar symptoms in her other hand or legs and has no neck or upper arm pain. Physical examination reveals that her symptoms are reproduced by Tinel testing and exacerbated by wrist hyperflexion. Decreased sensation is noted over the palmar aspects of the thumb, index, and middle fingers, with no apparent motor weakness. What is the most likely diagnosis?

A. C5 cervical nerve root compression
B. Carpal tunnel syndrome (Correct Answer)
C. Cubital tunnel syndrome
D. Radial tunnel syndrome

Explanation: ### Explanation **Correct Answer: B. Carpal tunnel syndrome (CTS)** The clinical presentation is classic for **Carpal tunnel syndrome**, the most common entrapment neuropathy. It results from compression of the **median nerve** as it passes through the fibro-osseous carpal tunnel. * **Sensory Distribution:** The median nerve provides sensation to the palmar aspect of the thumb, index, middle, and radial half of the ring finger. * **Nocturnal Symptoms:** Patients typically report "night cries"—waking up with numbness—and the **"Flick sign"** (shaking the hand for relief). * **Provocative Tests:** The diagnosis is supported by **Phalen’s test** (wrist hyperflexion) and **Tinel’s sign** (percussion over the flexor retinaculum), both of which reproduce paresthesia in the median nerve distribution. --- ### Why the other options are incorrect: * **A. C5 cervical nerve root compression:** This typically presents with neck pain radiating to the shoulder and lateral arm, with weakness in shoulder abduction (deltoid) and elbow flexion (biceps). It does not cause isolated hand numbness. * **C. Cubital tunnel syndrome:** This involves compression of the **ulnar nerve** at the elbow. It causes numbness in the small finger and the ulnar half of the ring finger, not the thumb or index finger. * **D. Radial tunnel syndrome:** This is primarily a motor/pain syndrome involving the posterior interosseous nerve. It presents with lateral elbow pain (mimicking tennis elbow) and does not cause sensory loss in the palmar fingers. --- ### NEET-PG High-Yield Pearls: 1. **Most common cause:** Idiopathic; however, associated with Pregnancy, Hypothyroidism, Diabetes, and Rheumatoid Arthritis. 2. **Early sign:** Sensory loss in the median distribution. **Late sign:** Thenar atrophy (Ape-thumb deformity). 3. **Sensation over the thenar eminence:** This is usually **spared** in CTS because the **palmar cutaneous branch** of the median nerve arises proximal to the carpal tunnel. 4. **Gold Standard Investigation:** Nerve Conduction Velocity (NCV) studies (showing increased latency). 5. **First-line treatment:** Wrist splinting in neutral position (especially at night) and NSAIDs.

Question 45: Carpal tunnel syndrome is associated with all of the following except:

A. Hyperparathyroidism (Correct Answer)
B. Rheumatoid arthritis
C. Wrist osteoarthritis
D. Acromegaly

Explanation: **Explanation:** Carpal Tunnel Syndrome (CTS) is a compressive neuropathy of the median nerve within the carpal tunnel. The pathophysiology involves any condition that reduces the volume of the tunnel or increases the volume of its contents (tenosynovium, tendons, or nerve). **Why Hyperparathyroidism is the correct answer:** While several endocrine disorders are linked to CTS, **Hyperparathyroidism** is not classically associated with the condition. In contrast, **Hypothyroidism** is a well-known cause due to the deposition of mucopolysaccharides (myxedema) within the carpal canal, leading to increased pressure. **Analysis of other options:** * **Rheumatoid Arthritis:** This is a common cause of CTS. Chronic inflammation leads to **proliferative tenosynovitis** of the flexor tendons, which increases pressure within the rigid fibro-osseous tunnel. * **Wrist Osteoarthritis:** Degenerative changes, including the formation of **osteophytes** or joint space narrowing, can alter the anatomy of the carpal floor, effectively reducing the space available for the median nerve. * **Acromegaly:** Excess Growth Hormone causes **soft tissue hypertrophy** and bony overgrowth, which significantly narrows the carpal tunnel. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Idiopathic. * **Most common associated endocrine cause:** Diabetes Mellitus and Hypothyroidism. * **Pregnancy:** CTS is common in the third trimester due to fluid retention (edema). * **Clinical Tests:** Phalen’s test (most sensitive) and Durkan’s compression test (most specific). * **Gold Standard Diagnosis:** Nerve Conduction Velocity (NCV) studies showing increased latency.

Question 46: What is the most common cause of trigger finger?

A. Trauma (Correct Answer)
B. Alcohol
C. Smoking
D. Drug abuse

Explanation: **Explanation:** **Trigger Finger (Stenosing Tenosynovitis)** occurs due to a size mismatch between the flexor tendon and its surrounding pulley system, most commonly at the **A1 pulley**. **1. Why Trauma is correct:** The primary etiology of trigger finger is **repetitive micro-trauma** or overuse. Chronic irritation leads to inflammation and hypertrophy of the A1 pulley and the formation of a nodule on the flexor tendon (usually the Flexor Digitorum Superficialis). This creates a mechanical obstruction where the tendon "catches" or "locks" during extension. While systemic conditions like Diabetes Mellitus and Rheumatoid Arthritis are significant risk factors, among the provided options, mechanical/repetitive trauma is the fundamental causative mechanism. **2. Why other options are incorrect:** * **Alcohol, Smoking, and Drug Abuse:** These are general lifestyle factors that do not have a direct, evidence-based causal link to the mechanical thickening of the A1 pulley or the development of stenosing tenosynovitis. While smoking can impair tendon healing, it is not a primary cause of trigger finger. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** The **A1 pulley** (located at the level of the MCP joint). * **Most common finger involved:** Ring finger, followed by the thumb (Trigger Thumb). * **Clinical Presentation:** Painful "snapping" or "locking" of the finger in flexion; a palpable nodule may be felt at the base of the finger. * **Associated Conditions:** Highly associated with **Diabetes Mellitus** (often multiple digits involved) and Rheumatoid Arthritis. * **Management:** First-line is activity modification and NSAIDs; second-line is **Corticosteroid injection** (most effective non-operative treatment). Surgical release of the A1 pulley is indicated for refractory cases.

Question 47: Carpal tunnel syndrome is caused by all of the following conditions EXCEPT?

A. Amyloidosis
B. Hypothyroidism
C. Addison's disease (Correct Answer)
D. Diabetes mellitus

Explanation: **Explanation:** Carpal Tunnel Syndrome (CTS) is a compressive neuropathy of the **median nerve** as it passes through the fibro-osseous carpal tunnel. It occurs when the space within the tunnel decreases or the volume of its contents increases. **Why Addison’s Disease is the Correct Answer:** Addison’s disease (primary adrenocortical insufficiency) is characterized by a deficiency of cortisol and aldosterone. It typically leads to weight loss and dehydration, which does not cause fluid retention or soft tissue hypertrophy. In contrast, **Cushing’s syndrome** (excess cortisol) and **Acromegaly** are associated with CTS due to increased fat deposition and soft tissue overgrowth, respectively. **Analysis of Incorrect Options:** * **Amyloidosis:** Deposition of amyloid proteins (especially $\beta_2$-microglobulin in dialysis patients) within the flexor retinaculum or synovium directly compresses the median nerve. * **Hypothyroidism:** Causes the accumulation of **glycosaminoglycans** (myxedematous tissue) and fluid in the carpal tunnel, leading to increased pressure. * **Diabetes Mellitus:** Hyperglycemia leads to the glycation of collagen, making the transverse carpal ligament stiffer and thicker. Diabetics also have a lower threshold for nerve compression (double crush syndrome). **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Idiopathic. * **Most common associated systemic condition:** Obesity; followed by Pregnancy (due to edema). * **Clinical Tests:** Phalen’s test (most sensitive), Tinel’s sign, and Durkan’s compression test (most specific). * **Gold Standard Diagnosis:** Nerve Conduction Velocity (NCV) studies showing increased latency. * **Anatomy:** The median nerve lies superficial to the flexor tendons; the **Flexor Pollicis Longus** is the most radial structure in the tunnel.

Question 48: A patient is unable to actively extend the terminal phalange, although the distal interphalangeal joint can be extended passively. What is this condition known as?

A. Mallet finger (Correct Answer)
B. Trigger finger
C. Butter finger
D. Ring finger

Explanation: ### Explanation **Correct Option: A. Mallet Finger** Mallet finger (also known as "Baseball finger") is a deformity caused by the disruption of the **extensor digitorum tendon** at its insertion into the base of the distal phalanx. This can occur due to a sudden forceful flexion of the extended finger (e.g., being struck by a ball) or an avulsion fracture. * **Mechanism:** Because the terminal extensor mechanism is lost, the patient cannot actively extend the Distal Interphalangeal (DIP) joint. * **Clinical Feature:** The DIP joint remains in a flexed position at rest. However, since the joint itself is not fused or locked, it can be extended **passively** by the examiner. **Analysis of Incorrect Options:** * **B. Trigger Finger (Stenosing Tenosynovitis):** This involves inflammation of the flexor tendon sheath at the A1 pulley. It presents as "locking" or "catching" during finger extension/flexion, not a loss of terminal extension. * **C. Butter Finger:** This is a colloquial term for clumsiness and is not a recognized medical or orthopedic diagnosis. * **D. Ring Finger:** This is an anatomical name for the fourth digit and does not describe a pathological condition. **NEET-PG High-Yield Pearls:** * **Treatment:** Most cases are managed conservatively with a **Mallet splint** (holding the DIP joint in continuous slight hyperextension) for 6–8 weeks. * **Boutonnière Deformity:** Often confused with Mallet finger; it involves disruption of the **central slip** of the extensor tendon, leading to PIP flexion and DIP hyperextension. * **Jersey Finger:** The opposite of Mallet finger; it is an avulsion of the **Flexor Digitorum Profundus (FDP)**, where the patient cannot actively *flex* the DIP joint.

Question 49: De Quervain's tenosynovitis involves which tendon(s)?

A. Abductor pollicis longus
B. Extensor pollicis brevis
C. Both of the above (Correct Answer)
D. None of the above

Explanation: **Explanation:** De Quervain’s tenosynovitis is a stenosing tenosynovitis of the **first dorsal compartment** of the wrist. This compartment contains two specific tendons: the **Abductor Pollicis Longus (APL)** and the **Extensor Pollicis Brevis (EPB)**. The condition is caused by repetitive friction or overuse, leading to thickening of the extensor retinaculum and narrowing of the fibro-osseous tunnel, which results in pain over the radial styloid. * **Why Option C is correct:** Both APL and EPB pass through the same sheath in the first compartment. Inflammation typically affects both, making "Both of the above" the most accurate clinical description. * **Why Options A & B are incorrect:** While both tendons are involved, selecting only one would be incomplete. In NEET-PG, when both constituents of a compartment are listed, the combined option is the preferred answer. * **Why Option D is incorrect:** It contradicts the established anatomy of the condition. **High-Yield Clinical Pearls for NEET-PG:** * **Finkelstein’s Test:** The pathognomonic clinical test where the patient makes a fist with the thumb tucked inside the fingers and deviates the wrist toward the ulnar side. Sharp pain over the radial styloid indicates a positive result. * **Anatomy Tip:** Remember the mnemonic **"Apple (APL) and Peanut Butter (EPB)"** for the first compartment. * **Differential Diagnosis:** Must be distinguished from **Intersection Syndrome** (involving the 1st and 2nd compartments) and **Wartenberg’s Syndrome** (compression of the superficial radial nerve). * **Management:** Initial treatment is conservative (NSAIDs, thumb spica splint, steroid injections). Surgical release of the first dorsal compartment is reserved for refractory cases.

Question 50: A 40-year-old diabetic man presents with an inability to bend his ring finger and small nodules on the palm. Which of the following would NOT be part of your management for this patient?

A. Wait and watch
B. Subtotal fasciectomy when more than 15 degrees of flexion deformity is involved at the proximal interphalangeal (PIP) joint (Correct Answer)
C. Subtotal fasciectomy when more than 30 degrees of flexion deformity is involved at the metacarpophalangeal (MCP) joint
D. Collagenase injection

Explanation: ### Explanation The clinical presentation of a diabetic patient with palmar nodules and finger flexion deformity is classic for **Dupuytren’s Contracture**. This condition involves pathological thickening and shortening of the palmar fascia, leading to fixed flexion deformities. **Why Option B is the Correct Answer (The "Incorrect" Management):** Surgical intervention (like subtotal fasciectomy) is indicated based on specific severity thresholds. For the **Proximal Interphalangeal (PIP) joint**, surgery is indicated if there is **any** degree of contracture (often cited as >0°) because PIP joints develop irreversible changes and stiffness very quickly. Waiting for 15 degrees of deformity is inappropriate; early intervention is preferred for PIP involvement to prevent permanent loss of function. **Analysis of Other Options:** * **Option A (Wait and watch):** This is appropriate for early, non-progressive disease where there is no functional impairment and only nodules are present. * **Option C (Subtotal fasciectomy for >30° MCP joint):** This is a standard surgical indication. Unlike the PIP joint, the MCP joint can tolerate more deformity before surgery is mandatory; 30 degrees is the widely accepted threshold. * **Option D (Collagenase injection):** *Clostridium histolyticum* collagenase is a modern, FDA-approved enzymatic treatment used to "dissolve" the cords (enzymatic fasciotomy) as a non-surgical alternative. **High-Yield Clinical Pearls for NEET-PG:** * **Associations:** Strongly linked with **Diabetes Mellitus**, smoking, alcohol use, and epilepsy (phenytoin use). * **Pathology:** Proliferation of **myofibroblasts** and a shift from Type I to **Type III collagen**. * **Hueston’s Table Top Test:** Positive when the patient cannot flatten their palm against a table; this indicates a need for surgical consultation. * **Most Common Finger:** Ring finger (4th), followed by the little finger (5th).

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

Practice Questions

Hand Infections

Practice Questions

Microsurgery in Hand Surgery

Practice Questions

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