Hand Surgery Basics — MCQs
After a brawl, a young male presented with inability to extend his distal interphalangeal joint. An X-ray was taken and was shown to be normal. What should be the next step in managing the patient?
The commonly injured carpal bone next to the scaphoid is:
A 56-year-old female presents with nocturnal pain in the right thumb, index, and middle fingers for the past 3 months. All of the following provocative tests can be performed except:
Kanavel's sign is seen in:
A 54-year-old female marathon runner presents with pain in her right wrist that resulted from a fall onto her outstretched hand. Radiographic studies indicate an anterior dislocation of a carpal bone. Which of the following bones is most likely dislocated?
Longitudinal incision with Z-plasty closure is used in which of the following?
What is the most common complication associated with carpal tunnel release surgery?
Following radical surgery for the carcinoma of breast, reconstruction of the breast can be performed by using the following procedures except
A nasal surgery was carried out with the incision shown in the image. What was the procedure likely carried out?
A Young Male complained of intermittent pain, swelling and discharge at the base of spine. He also had episodes of fever and repeated abscesses that had burst spontaneously. By occupation, he is a jeep driver. Physical examination showed pilonidal sinus. Which flap-based procedure is used for pilonidal sinus surgery?
Hand Surgery Basics Indian Medical PG Practice Questions and MCQs
Question 1: After a brawl, a young male presented with inability to extend his distal interphalangeal joint. An X-ray was taken and was shown to be normal. What should be the next step in managing the patient?
- A. Splint (Correct Answer)
- B. Wax bath
- C. Ignore
- D. Surgery
Explanation: ***Splint*** - The patient presents with **inability to extend the distal interphalangeal joint** after an injury, with a **normal X-ray**. This clinical picture is highly suggestive of a **mallet finger**. - **Splinting** the distal interphalangeal joint in **extension** for 6-8 weeks is the primary non-surgical treatment for mallet finger, aiming to allow the ruptured extensor tendon to heal. *Wax bath* - A **wax bath** is a form of thermotherapy used to relieve pain and stiffness in joints by applying heat. - While it can be helpful for chronic conditions like **arthritis**, it is not an appropriate initial treatment for an acute **tendon injury** like mallet finger, as it does not promote healing of the extensor mechanism. *Ignore* - **Ignoring** the symptoms would lead to a failure to treat the injury, potentially resulting in a **chronic extensor lag deformity** (mallet finger deformity). - Untreated, this condition can cause persistent functional impairment and cosmetic deformity of the affected finger. *Surgery* - **Surgery** is typically reserved for specific cases of mallet finger, such as those with a **large avulsion fracture** of the dorsal base of the distal phalanx (where the fragment involves more than 30-50% of the articular surface), or if non-surgical treatment fails. - Since the **X-ray was normal** in this case, indicating no significant bony avulsion, and it's an acute presentation, surgery is not the appropriate first-line management.
Question 2: The commonly injured carpal bone next to the scaphoid is:
- A. Trapezoid
- B. Capitate
- C. Triquetrum (Correct Answer)
- D. Lunate
Explanation: ***Triquetrum*** - The **scaphoid** is the most commonly fractured carpal bone [1]. After the scaphoid, the **triquetrum** is the next most frequently injured carpal bone. - Injuries to the triquetrum often occur due to **hyperextension of the wrist** with ulnar deviation, typically resulting from falls onto an outstretched hand (FOOSH). *Trapezoid* - The trapezoid is a carpal bone in the **distal row** of the wrist, located medial to the trapezium and lateral to the capitate. - While it can be injured, it is **much less commonly fractured** than the scaphoid or triquetrum due to its protected position and strong ligamentous attachments. *Capitate* - The capitate is the **largest carpal bone** and the central bone in the distal row of the carpus. - Fractures of the capitate are **relatively rare**, often occurring in conjunction with other carpal injuries or dislocations, and are less frequent than triquetral fractures. *Lunate* - The lunate bone is located in the **proximal row** of carpal bones, articulating with the radius and contributing to wrist stability. - While the lunate is crucial in wrist mechanics, it is more commonly associated with **dislocations** or **Kienböck's disease** (avascular necrosis) rather than simple fractures, and is not the next most common fracture after the scaphoid.
Question 3: A 56-year-old female presents with nocturnal pain in the right thumb, index, and middle fingers for the past 3 months. All of the following provocative tests can be performed except:
- A. Phalen's test
- B. Tourniquet test
- C. Finkelstein's test (Correct Answer)
- D. Tinel sign
Explanation: ***Finkelstein's test*** - **Finkelstein's test** is used to diagnose **De Quervain's tenosynovitis**, which involves inflammation of the tendons on the thumb side of the wrist. - The patient's symptoms (nocturnal pain in the thumb, index, and middle fingers) are classic for **carpal tunnel syndrome (CTS)**, not De Quervain's. *Phalen's test* - **Phalen's test** is a provocative test for **carpal tunnel syndrome (CTS)**, where the patient forcefully flexes their wrists for 60 seconds. - A positive result, indicated by numbness or tingling in the median nerve distribution, supports a diagnosis of CTS. *Tourniquet test* - While not as commonly used as Phalen's or Tinel's, the **tourniquet test** (or **pressure test**) can provoke symptoms of **carpal tunnel syndrome (CTS)** by applying pressure to the median nerve. - It involves applying a blood pressure cuff to compress the wrist above the carpal tunnel, which can elicit median nerve symptoms. *Tinel sign* - The **Tinel sign** is a classic test for **carpal tunnel syndrome (CTS)**, performed by tapping directly over the median nerve at the wrist. - A positive sign is indicated by tingling or shock-like sensations radiating into the thumb, index, and middle fingers.
Question 4: Kanavel's sign is seen in:
- A. Mid palmar space abscess
- B. Flexor tendon sheath infectious inflammation in the hand (Correct Answer)
- C. Web space involvement
- D. Ulnar bursa
Explanation: ***Flexor tendon sheath infectious inflammation in the hand*** - **Kanavel's signs** are a set of four clinical findings highly indicative of **flexor tenosynovitis** (infection of the flexor tendon sheath) in the hand. - These signs include **uniform swelling of the affected digit**, **flexed posturing of the affected digit**, **exquisite tenderness along the course of the flexor tendon sheath**, and **pain with passive extension of the affected digit**. *Mid palmar space abscess* - A **mid palmar space abscess** is a localized collection of pus in the central compartment of the hand and typically presents with **diffuse palmar swelling** and **tenderness**, not the specific findings of Kanavel's signs limited to a single digit. - While it can cause significant pain and restricted movement, it does not involve the flexor tendon sheath of a single digit in a way that elicits all four Kanavel's signs. *Ulnar bursa* - Inflammation/infection of the **ulnar bursa** (the common flexor sheath) can involve multiple digits, particularly the small finger and thumb if it communicates with the radial bursa, but the presentation is usually a more **diffuse swelling** of the palm and digits, not the isolated, characteristic signs of Kanavel's affecting a single digit. - Pain and swelling may be more generalized across the palm, and Kanavel's signs are specific to a single, infected flexor tendon sheath. *Web space involvement* - **Web space infections** occur in the loose connective tissue between the metacarpal heads in the interdigital spaces, presenting as **swelling** and **tenderness localized to the web space**. - This condition does not directly involve the flexor tendon sheath of a digit and therefore does not produce the specific clinical signs described by Kanavel.
Question 5: A 54-year-old female marathon runner presents with pain in her right wrist that resulted from a fall onto her outstretched hand. Radiographic studies indicate an anterior dislocation of a carpal bone. Which of the following bones is most likely dislocated?
- A. Capitate
- B. Lunate (Correct Answer)
- C. Trapezoid
- D. Triquetrum
Explanation: ***Lunate*** - The **lunate bone** is the most commonly dislocated carpal bone, especially with a fall onto an **outstretched hand**. - Its central position in the proximal carpal row and its articulation with the radius make it vulnerable to **anterior dislocation** with forced dorsiflexion. *Capitate* - The **capitate** is the largest carpal bone but is more stable due to its central position and strong ligamentous attachments. - Isolated dislocation of the capitate is **rare** and usually accompanies other carpal injuries. *Trapezoid* - The **trapezoid** is a small, irregularly shaped carpal bone in the distal row, which is very stable. - Its strong articulations with the trapezium, capitate, and second metacarpal make its dislocation **extremely uncommon**. *Triquetrum* - The **triquetrum** is the second most commonly fractured carpal bone but is less prone to dislocation than the lunate. - While it can dislocate, it typically occurs with **ulnar impaction** or other complex carpal instabilities rather than an isolated anterior dislocation from a fall onto an outstretched hand.
Question 6: Longitudinal incision with Z-plasty closure is used in which of the following?
- A. Hand surgery (Correct Answer)
- B. Thyroid surgery
- C. Breast reconstruction surgery
- D. Hernia repair surgery
Explanation: ***Hand surgery*** - **Z-plasty** is frequently employed in hand surgery to **lengthen constricted scars** or to **reorient tension lines**, especially across joints or creases. - This technique helps to improve **range of motion** and prevent contractures that can severely impair hand function following injury or surgery. *Breast reconstruction surgery* - While various flap techniques are used in breast reconstruction, the primary incision or closure does not typically involve a **longitudinal incision with Z-plasty**. - Procedures often focus on re-shaping and volume replacement using **tissue flaps** or implants, or linear scar realignment for aesthetic purposes. *Thyroid surgery* - Thyroidectomy typically involves a **transverse incision** in the neck (a **Kocher collar incision**) to minimize visible scarring and follow natural skin folds. - **Z-plasty** is not a standard technique for closing the primary incision in thyroid surgery. *Hernia repair surgery* - Hernia repair usually involves a **linear or curvilinear incision** in the groin or abdominal wall, followed by direct closure or mesh placement. - The goal is strong tissue repair, and **Z-plasty** is not used as a closure method for the primary incision in hernia repair.
Question 7: What is the most common complication associated with carpal tunnel release surgery?
- A. Malunion
- B. Avascular necrosis
- C. Finger stiffness (Correct Answer)
- D. Rupture of EPL tendon
Explanation: ***Finger stiffness*** - Among the options listed, **finger stiffness** is the most recognized complication of carpal tunnel release surgery. - **Post-operative pain, swelling, and scar tissue formation** can lead to reduced range of motion in the digits. - Patients may develop stiffness due to **immobilization**, **scar adhesions**, or apprehension in mobilizing the hand after surgery. - **Note:** In clinical practice, **pillar pain** (pain at the thenar and hypothenar eminences) is actually the most common complication (10-30% of cases), but it is not among the options provided. *Malunion* - **Malunion** refers to improper healing of a fractured bone. - Carpal tunnel release involves dividing the **transverse carpal ligament** (flexor retinaculum), which is a **soft tissue procedure**. - No bone is cut or fractured, so malunion is not relevant to this surgery. *Avascular necrosis* - **Avascular necrosis (AVN)** is bone death due to interrupted blood supply. - AVN affects bones with precarious blood supply (femoral head, scaphoid, lunate in Kienböck's disease). - Carpal tunnel release does not involve bone manipulation and **AVN is not a recognized complication** of this procedure. *Rupture of EPL tendon* - **Extensor Pollicis Longus (EPL) tendon rupture** is classically associated with **distal radius fractures** or inflammatory arthritis. - EPL runs through the **third dorsal compartment** and is anatomically distant from the carpal tunnel (volar wrist). - While median nerve injury is a rare but serious complication of carpal tunnel release, **EPL rupture is not associated** with this surgery.
Question 8: Following radical surgery for the carcinoma of breast, reconstruction of the breast can be performed by using the following procedures except
- A. Silicone implants
- B. Transversus abdominis muscle flap (TRAM flap)
- C. Latissimus dorsi flap (LD flap)
- D. Deltopectoral flap (Correct Answer)
Explanation: ***Deltopectoral flap*** - The **deltopectoral flap**, also known as the Bakamjian flap, is primarily used for **head and neck reconstruction**, particularly for defects in the pharynx, esophagus, or oral cavity. - It involves tissue from the shoulder and chest wall, but its design and vascular supply make it unsuitable for **breast reconstruction** after radical mastectomy, which requires significantly more volume and different tissue characteristics. *Silicone implants* - **Silicone implants** are a common method for breast reconstruction, offering a less invasive option than flap procedures. - They are placed either beneath the pectoral muscle or subcutaneously to restore breast volume and shape. *Transversus abdominis muscle flap (TRAM flap)* - The **TRAM flap** is a widely used and versatile autologous tissue reconstruction method, utilizing tissue from the lower abdomen to create a new breast mound. - It can be either pedicled (retaining its original blood supply) or free (requiring microvascular anastomosis), providing a natural-feeling and long-lasting reconstruction. *Latissimus dorsi flap (LD flap)* - The **latissimus dorsi (LD) flap** involves transferring muscle, fat, and skin from the back to the chest to reconstruct the breast. - It is particularly useful for smaller breasts or when combined with an implant, and it can provide good aesthetic results with reliable blood supply.
Question 9: A nasal surgery was carried out with the incision shown in the image. What was the procedure likely carried out?
- A. Submucosal resection (SMR)
- B. FESS (Functional Endoscopic Sinus Surgery)
- C. Open rhinoplasty (Correct Answer)
- D. Caldwell-Luc's procedure
Explanation: ***Open rhinoplasty*** - The image displays a **transcolumellar incision** (typically inverted V or W-shaped), which is the hallmark approach for **open rhinoplasty**. - This incision allows for direct visualization of the underlying nasal cartilages and bones, enabling precise reshaping of the nose. *Submucosal resection (SMR)* - SMR is a procedure to correct a **deviated nasal septum** by removing cartilage or bone from beneath the mucoperichondrial flaps. - It involves an **intranasal incision**, usually along the septal mucosa, not an external transcolumellar incision. *FESS (Functional Endoscopic Sinus Surgery)* - FESS is a minimally invasive procedure used to treat **chronic sinusitis** and other sinus conditions. - It is performed entirely **endoscopically through the nostrils**, with no external incisions on the nasal columella. *Caldwell-Luc's procedure* - This procedure accesses the **maxillary sinus** through an incision in the upper gum beneath the lip. - It is used for drainage of the maxillary sinus or removal of foreign bodies/tumors, and does not involve an external nasal incision.
Question 10: A Young Male complained of intermittent pain, swelling and discharge at the base of spine. He also had episodes of fever and repeated abscesses that had burst spontaneously. By occupation, he is a jeep driver. Physical examination showed pilonidal sinus. Which flap-based procedure is used for pilonidal sinus surgery?
- A. Circular flap
- B. Rhomboid flap (Correct Answer)
- C. Rotational flap
- D. Free flap
Explanation: ***Rhomboid flap*** - The **Limberg flap** (also called rhomboid flap) is the most commonly used and well-established flap-based technique for **pilonidal sinus surgery** - It involves excising the sinus in a rhomboid shape and then rotating an adjacent flap of skin and subcutaneous tissue to cover the defect, leading to **faster healing and lower recurrence rates** - This technique effectively **obliterates the natal cleft**, which helps prevent future pilonidal disease by eliminating the deep sulcus where hair and debris can collect - The specific geometric design provides excellent tissue coverage with minimal tension *Circular flap* - Circular flaps are generally **not used for pilonidal sinus surgery** because they can lead to tension at the wound edges and do not effectively flatten the natal cleft - Simple excision with primary closure techniques are associated with **higher recurrence rates** (up to 40%) and wound complications compared to flap-based techniques *Rotational flap* - This is a **generic term** encompassing various flap designs that rotate tissue to cover defects - While the rhomboid flap is technically a type of rotational flap, this option is **too non-specific** as an answer - The question asks for the specific flap-based procedure used, making "Rhomboid flap" the more precise and appropriate answer - Other rotational techniques (Karydakis flap, V-Y advancement) have different geometries and applications *Free flap* - **Free flaps** involve microsurgical transfer of tissue from a distant site with its own vascular pedicle, requiring microvascular anastomosis - This is **overly complex and unnecessary** for pilonidal sinus reconstruction - Reserved for large, complex defects in highly specialized reconstructive cases, not for routine management of **pilonidal disease**
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