Hand Surgery — MCQs
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Which nerve injury is elicited by the 'pen test'?
A 35-year-old right-handed construction worker presents with complaints of nocturnal numbness and pain involving the right hand. Symptoms wake him and are then relieved by shaking his hand. There is some atrophy of the thenar eminence. Tinel sign is positive. What is the best advice for this patient?
Trigger finger is commonly associated with which of the following conditions?
Kanavel's sign is seen in?
What test is being performed?
A 35-year-old construction worker presents with complaints of nocturnal paresthesias of the thumb, index, and middle fingers. There is some atrophy of the thenar eminence. Tinel's sign is positive. What is the most likely diagnosis?
Which of the following statements are true about Dupuytren's contracture?
A 69-year-old man presents with numbness in the middle three digits of his right hand and difficulty grasping objects. He has a history of 50 years as a carpenter and has atrophy of the thenar eminence. What is the most likely cause of his hand problems?
Froment's sign is due to injury of which nerve?
Dupuytren's contracture is associated with which of the following conditions?
Hand Surgery Indian Medical PG Practice Questions and MCQs
Question 51: Which nerve injury is elicited by the 'pen test'?
- A. Median nerve (Correct Answer)
- B. Ulnar nerve
- C. Radial nerve
- D. Axillary nerve
Explanation: The **Pen Test** is a clinical examination used to assess the motor function of the **Median nerve**, specifically the integrity of the **Abductor Pollicis Brevis (APB)** muscle. ### Why Median Nerve is Correct: The APB is one of the thenar muscles exclusively supplied by the recurrent branch of the Median nerve. Its primary action is **palmar abduction** (moving the thumb perpendicular to the plane of the palm). * **Procedure:** The patient’s hand is placed flat on a table (supinated). A pen is held horizontally above the thumb, and the patient is asked to lift the thumb to touch the pen. * **Positive Result:** In Median nerve palsy (especially in Carpal Tunnel Syndrome), the patient cannot touch the pen due to paralysis of the APB. ### Why Other Options are Wrong: * **Ulnar Nerve:** Tested via **Froment’s Sign** (Adductor Pollicis) or the **Card Test** (Palmar Interossei). Ulnar injury leads to "Claw Hand." * **Radial Nerve:** Tested by checking for **Wrist Drop** or **Finger Extension** at the MCP joints. The characteristic test is the ability to extend the wrist and thumb against resistance. * **Axillary Nerve:** Supplies the Deltoid; tested by assessing shoulder abduction and sensation over the "Regimental Badge" area. ### High-Yield Clinical Pearls: * **Ape Thumb Deformity:** Seen in chronic Median nerve injury due to thenar atrophy and loss of thumb opposition. * **Pointing Index (Benediction Gesture):** Occurs in high Median nerve palsy when the patient attempts to make a fist. * **Ochsner’s Clasping Test:** Another test for Median nerve (specifically FDP of index finger); when clasping hands, the index finger remains extended.
Question 52: A 35-year-old right-handed construction worker presents with complaints of nocturnal numbness and pain involving the right hand. Symptoms wake him and are then relieved by shaking his hand. There is some atrophy of the thenar eminence. Tinel sign is positive. What is the best advice for this patient?
- A. Always ensure he has a firm grip on his equipment while working on the construction site as this may relieve pressure on the median nerve.
- B. Apply ice to his wrist each evening after performing his usual work.
- C. Wear a wrist splint at night as initial therapy prior to considering surgery. (Correct Answer)
- D. Refer the patient to physical therapy for exercises to alleviate the pain.
Explanation: ### **Explanation** **Diagnosis: Carpal Tunnel Syndrome (CTS)** The patient presents with the classic triad of **Carpal Tunnel Syndrome**: nocturnal paresthesia, relief by shaking the hand (**"Flick sign"**), and thenar atrophy (indicating chronic compression of the **Median Nerve** within the carpal tunnel). **1. Why Option C is Correct:** Conservative management is the first-line treatment for mild-to-moderate CTS. **Nocturnal wrist splinting in a neutral position** is the most effective initial intervention. It prevents wrist flexion during sleep, which minimizes intracarpal pressure and prevents further ischemia of the median nerve. While thenar atrophy suggests advanced disease where surgery (Carpal Tunnel Release) is often eventually required, clinical guidelines dictate a trial of splinting and activity modification before invasive procedures. **2. Why the Other Options are Incorrect:** * **Option A:** A firm grip increases the pressure within the carpal tunnel and exacerbates nerve compression. Patients are advised to avoid repetitive gripping and vibrating tools. * **Option B:** While ice may provide temporary symptomatic relief for inflammation, it does not address the mechanical compression or the nocturnal nature of the symptoms. * **Option D:** Physical therapy (nerve gliding exercises) may be an adjunct, but it is not the primary "best advice" compared to the proven efficacy of neutral splinting. **3. NEET-PG High-Yield Pearls:** * **Most common nerve entrapped:** Median Nerve. * **Boundaries:** Carpal bones (floor) and Flexor Retinaculum/Transverse Carpal Ligament (roof). * **Clinical Tests:** **Phalen’s test** (most sensitive), **Tinel’s sign** (percussion over the nerve), and **Durkan’s compression test** (most specific). * **Sensory Sparing:** The **palmar cutaneous branch** of the median nerve passes superficial to the flexor retinaculum; therefore, sensation over the thenar eminence itself is usually preserved. * **Gold Standard Diagnosis:** Nerve Conduction Studies (NCS) showing increased latency and decreased conduction velocity.
Question 53: Trigger finger is commonly associated with which of the following conditions?
- A. Rheumatoid arthritis
- B. Trauma (Correct Answer)
- C. Osteosarcoma
- D. Osteoarthritis
Explanation: **Explanation:** **Trigger Finger (Stenosing Tenosynovitis)** occurs due to a size mismatch between the flexor tendon and the **A1 pulley** (most common site). This leads to a mechanical "snapping" or "locking" of the finger during flexion and extension. **Why Trauma is the Correct Answer:** Repetitive **micro-trauma** or chronic irritation to the palm (often from occupational overuse or tools) is the primary etiology. This trauma causes inflammation and hypertrophy of the A1 pulley and the formation of a nodule on the flexor tendon. While systemic conditions like Diabetes Mellitus are strongly associated, localized mechanical trauma is a classic precipitating factor in clinical practice and standard textbook descriptions for this condition. **Analysis of Incorrect Options:** * **A. Rheumatoid Arthritis:** While RA can cause tenosynovitis, it more typically leads to "triggering" due to rheumatoid nodules within the tendon or diffuse synovial thickening, rather than the classic isolated A1 pulley stenosis seen in primary trigger finger. * **C. Osteosarcoma:** This is a malignant bone-forming tumor. It does not involve the flexor tendon sheath or cause mechanical triggering of the digits. * **D. Osteoarthritis:** OA primarily affects the articular cartilage of joints (like the DIP or CMC joints). It does not involve the stenosing tenosynovitis of the flexor pulleys. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** A1 Pulley at the level of the MCP joint. * **Most commonly involved digit:** Ring finger (followed by the thumb). * **Associated Conditions:** Diabetes Mellitus (most common systemic association), Hypothyroidism, and Amyloidosis. * **Clinical Sign:** A palpable nodule that moves with the tendon; the finger "locks" in flexion. * **Management:** Conservative (NSAIDs/Splinting), Steroid injection (first-line medical), or **Surgical release of the A1 pulley** (definitive).
Question 54: Kanavel's sign is seen in?
- A. Tenosynovitis (Correct Answer)
- B. Trigger finger
- C. Dupuytrens contracture
- D. Carpal tunnel syndrome
Explanation: **Explanation:** **Kanavel’s Signs** are a clinical quartet used to diagnose **Acute Flexor Tenosynovitis**, a surgical emergency involving infection of the synovial sheath surrounding the flexor tendons. The correct answer is **Tenosynovitis** because these signs specifically indicate increased pressure and inflammation within the confined space of the tendon sheath. The four cardinal Kanavel’s signs are: 1. **F**lexed posture of the finger at rest. 2. **U**niform (fusiform) swelling of the entire digit (Sausage digit). 3. **T**enderness along the course of the tendon sheath (Percussion tenderness). 4. **P**ain on passive extension of the finger (the earliest and most sensitive sign). **Why other options are incorrect:** * **Trigger Finger (Stenosing Tenosynovitis):** Characterized by "locking" or "snapping" of the finger due to a nodule at the A1 pulley; it lacks the diffuse swelling and exquisite pain on passive extension seen in Kanavel’s signs. * **Dupuytren’s Contracture:** A chronic fibroproliferative disorder of the palmar fascia leading to permanent flexion contractures (usually the ring and little finger). It is painless and does not involve the tendon sheath. * **Carpal Tunnel Syndrome:** A compressive neuropathy of the median nerve. It presents with paresthesia and wasting of the thenar eminence, not signs of acute infection. **Clinical Pearls for NEET-PG:** * **Most sensitive sign:** Pain on passive extension is usually the first sign to appear. * **Common Organism:** *Staphylococcus aureus* is the most common causative agent. * **Horseshoe Abscess:** Infection in the thumb (radial bursa) and little finger (ulnar bursa) can communicate in the palm, forming a "horseshoe" shaped infection. * **Treatment:** Early cases may respond to IV antibiotics, but advanced cases require urgent surgical incision and drainage (washout).
Question 55: What test is being performed?
- A. Finkelstein test (Correct Answer)
- B. Tinel sign
- C. Froment sign
- D. Jeanne's sign
Explanation: ***Finkelstein test*** - The **Finkelstein test** is performed by having the patient tuck their **thumb into their fist** and then **ulnarly deviating** the wrist, causing pain over the **radial styloid process**. - This test is **positive for De Quervain's tenosynovitis**, which involves inflammation of the **abductor pollicis longus** and **extensor pollicis brevis** tendons. *Tinel sign* - **Tinel sign** involves **tapping over a nerve** (commonly the median nerve at the wrist or ulnar nerve at the elbow) to elicit **tingling or paresthesias**. - This test is used to diagnose **carpal tunnel syndrome** or **cubital tunnel syndrome**, not tendon pathology. *Froment sign* - **Froment sign** tests for **ulnar nerve palsy** by having the patient pinch paper between thumb and index finger, observing for **flexion of the thumb IP joint**. - This compensatory mechanism occurs due to weakness of the **adductor pollicis muscle**, which is innervated by the ulnar nerve. *Jeanne's sign* - **Jeanne's sign** also indicates **ulnar nerve palsy** and is observed as **hyperextension of the thumb MCP joint** during pinch grip. - This occurs due to **intrinsic muscle weakness**, specifically involving the **first dorsal interosseous** and **adductor pollicis** muscles.
Question 56: A 35-year-old construction worker presents with complaints of nocturnal paresthesias of the thumb, index, and middle fingers. There is some atrophy of the thenar eminence. Tinel's sign is positive. What is the most likely diagnosis?
- A. Carpal tunnel syndrome (Correct Answer)
- B. De Quervain's tenosynovitis
- C. Amyotrophic lateral sclerosis
- D. Rheumatoid arthritis of the wrist joint
Explanation: **Explanation:** The clinical presentation is a classic case of **Carpal Tunnel Syndrome (CTS)**, the most common entrapment neuropathy. It occurs due to compression of the **median nerve** as it passes through the carpal tunnel under the flexor retinaculum. 1. **Why Option A is Correct:** * **Distribution:** The median nerve provides sensation to the thumb, index, middle, and radial half of the ring finger. * **Nocturnal Paresthesia:** This is a hallmark symptom, often due to wrist flexion during sleep increasing canal pressure. * **Thenar Atrophy:** The median nerve supplies the **LOAF** muscles (Lateral two lumbricals, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis). Chronic compression leads to wasting of the thenar eminence. * **Tinel’s Sign:** Percussion over the flexor retinaculum produces paresthesia in the median nerve distribution. 2. **Why Other Options are Incorrect:** * **B. De Quervain’s Tenosynovitis:** Involves the 1st dorsal compartment (APL and EPB tendons). It presents with radial-sided wrist pain, not paresthesia, and is diagnosed via **Finkelstein’s test**. * **C. Amyotrophic Lateral Sclerosis (ALS):** A motor neuron disease causing progressive weakness and atrophy. While it causes hand wasting, it **never** presents with sensory symptoms (paresthesia). * **D. Rheumatoid Arthritis:** While RA can *cause* CTS due to synovitis, the specific neurological findings and positive Tinel’s sign point directly to the entrapment syndrome itself as the primary diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Phalen’s Test:** Most sensitive provocative test (forced wrist flexion for 60 seconds). * **Gold Standard Diagnosis:** Nerve Conduction Velocity (NCV) studies (shows increased latency). * **First-line Treatment:** Wrist splinting in neutral position (especially at night). * **Surgical Landmark:** The incision for carpal tunnel release is made on the ulnar side of the thenar crease to avoid injuring the **recurrent branch of the median nerve**.
Question 57: Which of the following statements are true about Dupuytren's contracture?
- A. Associated with Peyronie's disease.
- B. First affects the index finger.
- C. Nodule formation and thickening of the palmar fascia. (Correct Answer)
- D. Amputation may be required.
Explanation: **Explanation:** **Dupuytren’s contracture** is a benign proliferative disorder of the palmar fascia characterized by the formation of nodules and cords, leading to progressive flexion deformities of the fingers. **1. Why Option C is Correct:** The pathophysiology involves the transformation of fibroblasts into **myofibroblasts**, which produce excessive Type III collagen. This leads to the characteristic **nodule formation and thickening of the palmar fascia**. These nodules eventually mature into longitudinal cords that contract, pulling the fingers into permanent flexion. **2. Analysis of Other Options:** * **Option A (Associated with Peyronie’s disease):** While this statement is clinically **true** (Dupuytren’s is part of a "fibromatosis" spectrum including Peyronie’s and Ledderhose disease), it is not the *defining* pathological feature described in the primary answer choice. In many MCQ formats, the most direct pathological description is preferred. * **Option B (First affects the index finger):** This is **incorrect**. It most commonly affects the **ring finger**, followed by the little finger. The index and thumb are rarely involved. * **Option D (Amputation may be required):** While salvage amputation is a theoretical last resort for severe, recurrent cases in elderly patients, it is not a standard or diagnostic feature of the disease. **Clinical Pearls for NEET-PG:** * **Risk Factors:** Strong genetic component (Autosomal Dominant with variable penetrance), smoking, alcohol, diabetes, and epilepsy (anticonvulsant use). * **Hueston’s Table Top Test:** Positive when the patient cannot flatten their palm against a table; indicates a need for surgical intervention. * **Management:** * Non-surgical: Collagenase Clostridium Histolyticum (Xiaflex) injections. * Surgical: Fasciectomy (Partial/Total) is the gold standard. * **Key Anatomy:** The disease involves the **Pretendinous cords** (MCP joint contracture) and **Spiral cords** (PIP joint contracture). Note that the spiral cord can displace the neurovascular bundle medially.
Question 58: A 69-year-old man presents with numbness in the middle three digits of his right hand and difficulty grasping objects. He has a history of 50 years as a carpenter and has atrophy of the thenar eminence. What is the most likely cause of his hand problems?
- A. Compression of the median nerve in the carpal tunnel (Correct Answer)
- B. Compression of the ulnar nerve at the medial epicondyle by osteophytes
- C. Compression of the brachial plexus by hypertrophy of the triceps muscle
- D. Osteoarthritis of the cervical spine
Explanation: This patient presents with classic features of **Carpal Tunnel Syndrome (CTS)**, the most common entrapment neuropathy. ### **Explanation of the Correct Answer** The **median nerve** passes through the carpal tunnel along with nine tendons. Chronic repetitive stress (common in carpenters) leads to inflammation and increased pressure within the tunnel. * **Sensory Loss:** The median nerve provides sensation to the palmar aspect of the **lateral 3.5 digits** (thumb, index, middle, and radial half of the ring finger). * **Motor Loss:** It supplies the **thenar muscles** (LOAF: Lateral two lumbricals, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis). Long-standing compression leads to **thenar atrophy**, causing difficulty with grip and opposition. ### **Why Other Options are Incorrect** * **Option B:** Ulnar nerve compression (Cubital Tunnel Syndrome) causes numbness in the **medial 1.5 digits** (little and ulnar half of ring finger) and atrophy of the **hypothenar eminence** and interossei (Claw hand). * **Option C:** The brachial plexus is typically compressed by the scalene muscles or a cervical rib (Thoracic Outlet Syndrome), not the triceps. It would present with more diffuse symptoms involving the whole arm or C8-T1 distribution. * **Option D:** Cervical spondylosis (C6-C7 radiculopathy) can mimic CTS, but it usually presents with neck pain, radiation (radiculopathy), and weakness in proximal muscles (like triceps or wrist extensors) rather than isolated thenar atrophy. ### **High-Yield Clinical Pearls for NEET-PG** * **Phalen’s Test & Tinel’s Sign:** Key provocative tests for CTS diagnosis. * **Sensory Sparing:** The **palmar cutaneous branch** of the median nerve branches *before* the carpal tunnel; thus, sensation over the central palm is usually **spared** in CTS. * **Gold Standard Investigation:** Nerve Conduction Velocity (NCV) studies showing increased latency. * **First-line Treatment:** Wrist splinting in neutral position (especially at night) and NSAIDs. Surgical release of the **flexor retinaculum** is indicated for thenar atrophy.
Question 59: Froment's sign is due to injury of which nerve?
- A. Intercostobrachial nerve
- B. Radial nerve
- C. Ulnar nerve (Correct Answer)
- D. Median nerve
Explanation: **Explanation:** **Froment’s sign** is a classic clinical test used to identify **Ulnar nerve palsy**, specifically assessing the paralysis of the **Adductor Pollicis** muscle. **Why Ulnar Nerve is correct:** The Adductor Pollicis is the only muscle of the thumb innervated by the Ulnar nerve. Its primary function is to adduct the thumb against the index finger (e.g., when holding a piece of paper). When the ulnar nerve is injured, this muscle becomes paralyzed. To compensate and maintain a grip on the paper, the patient uses the **Flexor Pollicis Longus (FPL)**, which is innervated by the **Median nerve** (Anterior Interosseous branch). This results in compensatory **flexion of the thumb at the Interphalangeal (IP) joint**, which is the positive Froment’s sign. **Why other options are incorrect:** * **Intercostobrachial nerve:** A sensory nerve supplying the skin of the axilla and upper medial arm; it has no motor function in the hand. * **Radial nerve:** Supplies the extensors of the wrist and fingers. Injury leads to "Wrist Drop," not thumb adduction deficits. * **Median nerve:** Supplies the FPL and the thenar muscles. Injury would cause "Ape Thumb" deformity and an inability to flex the thumb IP joint, making a positive Froment's sign impossible. **Clinical Pearls for NEET-PG:** * **Jeanne’s Sign:** If the thumb MCP joint also shows hyperextension during the Froment’s test, it is called Jeanne’s sign (due to loss of stability from the adductor pollicis). * **Mannerfelt-Camitz Syndrome:** Another name for the compensatory FPL recruitment. * **Wartenberg’s Sign:** Inability to adduct the little finger (due to palmar interossei weakness), also seen in Ulnar nerve palsy. * **Ulnar Paradox:** A higher lesion (at the elbow) results in less clawing than a lower lesion (at the wrist).
Question 60: Dupuytren's contracture is associated with which of the following conditions?
- A. Peyronie's disease (Correct Answer)
- B. Hypospadias
- C. Epispadias
- D. Exotropia
Explanation: **Explanation:** **Dupuytren’s contracture** is a benign fibroproliferative disorder of the palmar fascia. It results in the formation of nodules and cords, leading to progressive, permanent flexion contractures of the fingers (most commonly the ring and little fingers). **1. Why Peyronie’s Disease is Correct:** Dupuytren’s contracture is part of a systemic fibromatosis diathesis. It is strongly associated with other ectopic fibromatoses, most notably **Peyronie’s disease** (fibromatosis of the tunica albuginea of the penis). Both conditions involve abnormal collagen deposition (Type III collagen replacing Type I) and myofibroblast proliferation. Other associated conditions include **Ledderhose disease** (plantar fibromatosis) and **Garrod’s pads** (knuckle pads over the PIP joints). **2. Why the Other Options are Incorrect:** * **Hypospadias & Epispadias:** These are congenital anatomical malformations of the male urethra (abnormal location of the urethral meatus). They are developmental defects, not fibrotic disorders, and have no association with palmar fascia pathology. * **Exotropia:** This is a form of strabismus (eye misalignment) where one or both eyes turn outward. It is a neuromuscular or refractive issue of the extraocular muscles, unrelated to systemic fibromatosis. **Clinical Pearls for NEET-PG:** * **Risk Factors:** Strong genetic predisposition (Autosomal Dominant with variable penetrance), male gender (older age), diabetes mellitus, chronic alcoholism, smoking, and epilepsy (associated with phenytoin use). * **Pathology:** Proliferation of **myofibroblasts** is the hallmark. * **Clinical Sign:** **Hueston’s Tabletop Test** is positive when the patient cannot flatten their palm against a flat surface. * **Management:** Surgical options include fasciectomy (gold standard) or needle aponeurotomy. Non-surgical treatment includes collagenase *Clostridium histolyticum* injections.
Practice by Chapter
Hand Anatomy and Biomechanics
Practice Questions
Hand Fractures and Dislocations
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Tendon Injuries
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Nerve Injuries in Hand
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Dupuytren's Disease
Practice Questions
Carpal Tunnel Syndrome
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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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