Reconstructive Hand Surgery — MCQs
Which of the following structures is fixed first during reimplantation of an amputated digit -
A 30-year-old pregnant woman presents with tingling pain and numbness at the tips of her thumb, index finger, and middle finger following trauma. On examination, when the doctor presses between the wrist joints for 30 seconds, the patient develops increased pain at the tips of the middle, index finger, and thumb. What is the diagnosis?
Cock-up splint is used in the treatment of
What is the age of tendon transfer in post polio residual paralysis
In hand injury, the first structure to be repaired should be?
Ulnar nerve injury results in:
An elderly man gets a burn injury to his hands. Over several weeks, the burned skin heals without the need for skin grafting. The most critical factor responsible for the rapid healing in this case is:
What is the MOST characteristic feature of low ulnar nerve palsy? a) Claw hand b) Sensory loss of medial four digits c) Weakness of grip d) Inability to abduct the thumb
Radial Nerve injury of this type recovers with conservative management
Allen's test is used in cardiac surgery for:
Reconstructive Hand Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following structures is fixed first during reimplantation of an amputated digit -
- A. Bone (Correct Answer)
- B. Vein
- C. Nerve
- D. Artery
Explanation: ***Bone*** - **Bone fixation** is the crucial first step to stabilize the digit, providing a stable framework for subsequent soft tissue repair. - This **restores skeletal integrity** and allows for proper alignment, reducing tension on delicate vascular and nervous structures. *Vein* - **Vein repair** is typically performed after arterial repair to ensure adequate outflow and prevent congestion, but after bone fixation. - While critical for successful reimplantation, venous repair without prior bone stability is difficult and prone to compromise. *Nerve* - **Nerve repair** is generally performed later in the sequence, after bone and vascular repairs have been completed. - The focus is on restoring blood flow first to ensure tissue viability before addressing nerve continuity for sensation and motor function. *Artery* - **Arterial reconstruction** is paramount for revascularization and tissue viability, but it follows initial bone stabilization. - Attempting to connect arteries without a stable skeletal foundation would make the repair challenging and increase the risk of avulsion or damage.
Question 2: A 30-year-old pregnant woman presents with tingling pain and numbness at the tips of her thumb, index finger, and middle finger following trauma. On examination, when the doctor presses between the wrist joints for 30 seconds, the patient develops increased pain at the tips of the middle, index finger, and thumb. What is the diagnosis?
- A. Pronator syndrome
- B. Carpal tunnel syndrome (Correct Answer)
- C. Tarsal tunnel syndrome
- D. Cubital tunnel syndrome
Explanation: **_Carpal tunnel syndrome_** * The symptoms of tingling, pain, and numbness in the thumb, index, and middle fingers are classic for **median nerve compression**, which occurs in the carpal tunnel [1]. * The positive **Phalen's sign** (phalen's test), indicated by increased pain with wrist flexion, also known as pressing between the wrist joints, further supports this diagnosis. * *Pronator syndrome* * Pronator syndrome involves compression of the **median nerve** by the pronator teres muscle, typically causing pain in the proximal forearm and less distinct finger numbness. * While it affects the median nerve, the pain distribution and positive maneuver described are more characteristic of **carpal tunnel syndrome** [1]. * *Tarsal tunnel syndrome* * **Tarsal tunnel syndrome** involves compression of the **posterior tibial nerve** in the ankle, leading to symptoms in the foot and toes, not the hand. * The location of symptoms (thumb, index, and middle fingers) rules out this diagnosis. * *Cubital tunnel syndrome* * **Cubital tunnel syndrome** results from compression of the **ulnar nerve** at the elbow, causing tingling and numbness in the ring and pinky fingers. * The affected fingers (thumb, index, and middle) are innervated by the median nerve, differentiating it from cubital tunnel syndrome.
Question 3: Cock-up splint is used in the treatment of
- A. Radial nerve palsy (Correct Answer)
- B. Ulnar nerve palsy
- C. Median nerve palsy
- D. Posterior interosseous nerve palsy
Explanation: ***Radial nerve palsy*** - A **cock-up splint** is specifically designed to provide **wrist extension**, which is lost in radial nerve palsy due to paralysis of the extensors. - This splint helps in maintaining an optimal position for **hand function** and preventing overstretching of denervated muscles. *Ulnar nerve palsy* - Ulnar nerve palsy typically causes a **claw hand deformity** due to hyperextension at the MCP joints of the 4th and 5th digits. - Treatment often involves splints that prevent MCP joint hyperextension, such as an **anti-claw splint**, not a cock-up splint. *Median nerve palsy* - Median nerve palsy results in conditions like **ape hand deformity** (loss of thumb opposition) and **carpal tunnel syndrome**. - Splints for median nerve palsy focus on maintaining thumb opposition or wrist neutrality, such as a **thumb spica splint** or **wrist splint**, respectively. *Posterior interosseous nerve palsy* - Posterior interosseous nerve palsy (PIN) is a purely motor palsy affecting wrist and finger extensors, similar to radial nerve palsy but sparing the brachioradialis and extensor carpi radialis longus. - While it affects extensors, the term "cock-up splint" is more commonly and broadly associated with the complete presentation of **radial nerve palsy** affecting all extensors.
Question 4: What is the age of tendon transfer in post polio residual paralysis
- A. 1 year
- B. 2 years
- C. >5 years (Correct Answer)
- D. <6 months
Explanation: ***>5 years*** - Tendon transfer surgery is typically delayed until the child is **at least five years old** to ensure maximal spontaneous recovery has occurred and definitive muscle weakness patterns are established. - This age allows for better patient cooperation with **post-operative rehabilitation** and provides sufficient size for effective tendon grafting and fixation. *1 year* - This age is generally too early for tendon transfer, as it does not allow enough time for the **natural recovery process** from polio to conclude. - Performing surgery at this age risks unnecessary intervention if motor function might still spontaneously improve. *2 years* - While some recovery may have occurred, **two years** is still often considered premature for definitive tendon transfer in post-polio paralysis. - The child's growth and neuromuscular maturation are not yet complete, which could impact surgical outcomes and the ability to gauge permanent deficits. *<6 months* - This age is far too early for tendon transfer surgery in post-polio residual paralysis. - Infants require time for initial muscle recovery post-infection and for their skeletal and muscular systems to develop sufficiently for such a procedure.
Question 5: In hand injury, the first structure to be repaired should be?
- A. Skin
- B. Muscle
- C. Nerve
- D. Bone (Correct Answer)
Explanation: ***Bone*** - In hand injury, **skeletal stability** is paramount and is typically the first structure to be addressed to provide a stable foundation. - Repairing bone first allows for proper alignment and length restoration, which is crucial for the subsequent repair of soft tissues like tendons, nerves, and vessels. *Skin* - While skin closure is the final step in wound management, it should only be performed after deeper structures like bone, tendons, and nerves have been repaired. - Repairing the skin first would prevent access to underlying damaged structures and could lead to functional impairment. *Muscle* - Muscle repair is important for restoring function but should follow bone stabilization to ensure proper length and tension. - Unstable bone fragments can impede effective muscle repair and healing. *Nerve* - Nerve repair is critical for restoring sensation and motor function and should be done with meticulous attention to detail. - However, nerve repair typically follows bone stabilization and sometimes tendon repair, as a stable environment is necessary for successful nerve coaptation and healing.
Question 6: Ulnar nerve injury results in:
- A. Pointing index
- B. Ape thumb deformity
- C. Clawing of fingers (Correct Answer)
- D. Wrist drop
Explanation: ***Clawing of fingers*** - An ulnar nerve injury, particularly at the elbow, often leads to **paralysis of the interossei muscles** and the **medial two lumbricals**. [1] - This results in **hyperextension at the metacarpophalangeal joints** and **flexion at the interphalangeal joints** of the 4th and 5th fingers (and sometimes 3rd), creating the characteristic claw hand deformity. [1] *Pointing index* - **Pointing index**, also known as the **sign of benediction** or **preacher's hand**, occurs with **high median nerve lesions** affecting the lateral lumbricals and flexor digitorum superficialis. - The patient is unable to flex the index and middle fingers, especially when attempting to make a fist. *Ape thumb deformity* - **Ape thumb deformity** is caused by a **median nerve injury**, specifically affecting the **thenar muscles** (abductor pollicis brevis, opponens pollicis, and superficial head of flexor pollicis brevis). - This paralysis leads to the thumb being pulled laterally and into the same plane as the other fingers, losing its ability to oppose. *Wrist drop* - **Wrist drop** is a classic sign of **radial nerve injury**, which paralyzes the **extensor muscles of the wrist and fingers**. - This prevents the patient from extending their wrist and metacarpophalangeal joints.
Question 7: An elderly man gets a burn injury to his hands. Over several weeks, the burned skin heals without the need for skin grafting. The most critical factor responsible for the rapid healing in this case is:
- A. Remnant skin appendages (Correct Answer)
- B. Underlying connective tissues
- C. Minimal edema and erythema
- D. Granulation tissue
Explanation: ***Remnant skin appendages*** - The presence of **hair follicles** and **sweat glands** contributes to the healing process by providing a source of epithelial cells for regeneration [1]. - These **skin appendages** facilitate quicker re-epithelialization compared to areas without appendages [1]. *Underlying connective tissues* - While connective tissues support healing, they are not the primary factor in **rapid re-epithelialization** in this scenario. - Their role is more about structural integrity rather than direct promotion of skin regeneration. *Minimal edema and erythema* - These conditions indicate less inflammation, but they do not directly enhance the healing rate of the skin. - The absence of these symptoms is beneficial, yet healing still relies on **active cellular processes** rather than just inflammation levels. *Granulation tissue* - Granulation tissue is primarily involved in the healing of deeper wounds and is more critical during the **initial phases** of healing [2]. - Its presence is generally more associated with greater **tissue damage**, rather than contributing to quick healing when skin appendages are intact. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 104-105. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 105-106.
Question 8: What is the MOST characteristic feature of low ulnar nerve palsy? a) Claw hand b) Sensory loss of medial four digits c) Weakness of grip d) Inability to abduct the thumb
- A. Claw hand (Correct Answer)
- B. Sensory loss of lateral three digits
- C. Weakness of wrist flexion
- D. Inability to oppose the thumb
- E. Inability to extend at M.C.P. joint
Explanation: ***Claw hand*** - A **claw hand** (specifically an **ulnar claw**) is a classic sign of low ulnar nerve palsy, resulting from paralysis of the **interossei** and **medial two lumbricals**. - This leads to hyperextension at the **metacarpophalangeal (MCP) joints** and flexion at the **interphalangeal (IP) joints** of the 4th and 5th digits. *Sensory loss of lateral three digits* - Sensory loss in the **lateral three digits** (thumb, index, middle fingers) is characteristic of **median nerve palsy**, not ulnar nerve palsy. - The ulnar nerve supplies sensation to the **medial 1.5 digits** (half of the ring finger and the little finger). *Weakness of wrist flexion* - While the ulnar nerve contributes to wrist flexion via the **flexor carpi ulnaris**, significant weakness in overall wrist flexion alone is not its most characteristic distinguishing feature. - The median nerve and radial nerve also play crucial roles in wrist flexion and extension, respectively. *Inability to oppose the thumb* - The inability to **oppose the thumb** (touch the thumb to the tips of the other fingers) is a hallmark of **median nerve palsy**, specifically affecting the **opponens pollicis** muscle. - The ulnar nerve primarily affects adduction of the thumb via the **adductor pollicis**. *Inability to extend at M.C.P. joint* - The inability to extend at the **metacarpophalangeal (MCP) joint** is more characteristic of **radial nerve palsy**, which affects the **extensor muscles** of the fingers. - Ulnar nerve palsy causes increased extension at the MCP joints due to paralysis of the lumbricals and interossei.
Question 9: Radial Nerve injury of this type recovers with conservative management
- A. Crush injury
- B. Chemical injury
- C. Neurotmesis
- D. Neuropraxia (Correct Answer)
Explanation: ***Neuropraxia*** - **Neuropraxia** is a mild form of nerve injury involving demyelination without axonal disruption, allowing for complete recovery with conservative management. - The nerve's electrical conduction is temporarily blocked, but the **axon** and its supporting structures remain intact. *Crush injury* - Crush injuries often result in more severe nerve damage, ranging from **axonotmesis** to **neurotmesis**, generally requiring more than conservative management for recovery. - The extensive compression and potential tissue damage can lead to significant axonal disruption and scar tissue formation, impeding nerve regeneration. *Chemical injury* - Chemical injuries can cause varying degrees of nerve damage, often resulting in **axonopathy** or demyelination, which may or may not recover with conservative management. - The extent of damage is highly dependent on the type and concentration of the chemical, and the duration of exposure. *Neurotmesis* - **Neurotmesis** involves complete transection of the nerve, including the axon and surrounding connective tissue sheaths, making spontaneous recovery highly unlikely. - Surgical intervention, such as **nerve repair** or grafting, is typically required for any functional recovery.
Question 10: Allen's test is used in cardiac surgery for:
- A. To select finger prick for blood glucose estimation
- B. To check warmth of hands
- C. When radial artery harvest is planned (Correct Answer)
- D. For evaluation of AV fistula
Explanation: ***When radial artery harvest is planned*** - **Allen's test** is performed to assess the patency of the **ulnar artery** and ensure adequate collateral circulation to the hand before harvesting the radial artery. - A positive test (indicating good collateral flow) is crucial to prevent **hand ischemia** if the radial artery is removed. *To select finger prick for blood glucose estimation* - Finger prick sites for **blood glucose estimation** are chosen based on adequate capillary blood flow and patient comfort, not by Allen's test. - Allen's test is specifically for evaluating **arterial patency** and collateral circulation, which is irrelevant for routine fingersticks. *To check warmth of hands* - Checking the **warmth of hands** is a basic clinical assessment for peripheral perfusion but does not involve Allen's test. - Allen's test is a dynamic test of **vascular competence**, not a static thermal assessment. *For evaluation of AV fistula* - **AV fistula evaluation** involves assessing patency, thrill, and bruit, and is typically done using physical examination and Doppler ultrasound. - Allen's test is not used for this purpose, as it assesses **collateral arterial flow** to a digit, not the patency of an arteriovenous connection.
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