Plastic and Reconstructive Surgery Practice Questions

Q: A patient with ulnar nerve compression at the elbow (cubital tunnel syndrome) presents with early clawing of the ring and little fingers, numbness, and progressive weakness of hand intrinsic muscles. What is the most appropriate surgical intervention to prevent further deterioration of hand function?

Ulnar nerve transposition; prevents further deterioration. ***Ulnar nerve transposition*** - This procedure involves surgically relocating the ulnar nerve from its position behind the medial epicondyle to a new, less constricted position (anterior to the medial epicondyle), relieving compression at the **cubital tunnel** - By decompressing the nerve, it can **prevent further deterioration** of ulnar nerve function and may allow recovery of the **intrinsic hand muscles** (lumbricals, interossei), thus halting progression of the **claw hand deformity** - This is the definitive treatment for **cubital tunnel syndrome** with progressive neurological deficits - Note: For established, fixed claw deformity, **tendon transfer procedures** (like Zancolli lasso or modified Stiles-Bunnell) would be needed *Carpal tunnel release* - This procedure addresses compression of the **median nerve** at the wrist, causing symptoms like tingling and numbness in the thumb, index, middle, and radial half of the ring finger - Classic presentation includes nocturnal paresthesias, thenar atrophy, and weak thumb opposition - Would not address **ulnar nerve compression at the elbow** or ulnar-innervated muscle weakness *Median nerve repair* - This is performed for traumatic injuries causing **complete median nerve transection** and aims to restore motor function (pronation, wrist/finger flexion, thumb opposition) and sensation - Not appropriate for **ulnar nerve compression neuropathy**, which requires decompression, not repair *Radial nerve decompression* - This procedure targets compression of the **radial nerve** (commonly at the spiral groove or radial tunnel), which typically presents with **wrist drop** and weakness of finger/thumb extension - Sensory changes occur over the dorsal first web space - Not relevant for **ulnar nerve pathology at the elbow** causing intrinsic hand muscle weakness

Q: A 35-year-old female with carpal tunnel syndrome undergoes surgical release. Which structure is incised during the procedure?

Flexor retinaculum. ***Flexor retinaculum*** - The **flexor retinaculum** (also known as the **transverse carpal ligament**) forms the roof of the carpal tunnel. - Incising this ligament during surgery relieves pressure on the **median nerve**, which is entrapped in carpal tunnel syndrome. *Extensor retinaculum* - The **extensor retinaculum** is located on the dorsal aspect of the wrist and holds the extensor tendons in place. - It is not involved in carpal tunnel syndrome, which affects structures on the palmar side. *Palmar aponeurosis* - The **palmar aponeurosis** is a thick fibrous fascia in the palm of the hand, superficial to the carpal tunnel. - While it can be involved in conditions like Dupuytren's contracture, it does not form the boundaries of the carpal tunnel directly. *Ulnar bursa* - The **ulnar bursa** is a synovial sheath that encloses the flexor digitorum superficialis and profundus tendons within the carpal tunnel. - It lies within the carpal tunnel but incising it would not relieve the primary compression on the median nerve.

Q: Which type of skin graft is most appropriate for covering large full-thickness burn wounds?

Split-thickness graft. ***Split-thickness graft (Correct)*** - This type only includes the **epidermis** and a portion of the **dermis**, allowing for a large surface area to be harvested from a donor site. - Its ability to **engraft reliably** on various wound beds and cover large defects makes it ideal for extensive burn injuries. - Donor sites can **re-epithelialize** and be harvested again if needed for very extensive burns. *Full-thickness graft (Incorrect)* - Comprises the **entire epidermis and dermis**, offering better cosmetic results and durability but requiring a highly vascularized bed. - Harvesting sites are limited, and it is generally reserved for smaller, less contaminated wounds where cosmetic outcomes are critical. - **Not suitable for large burns** due to donor site limitations and need for excellent wound bed. *Composite graft (Incorrect)* - Consists of multiple tissue types (e.g., skin, cartilage, fat), used for reconstructive purposes in specific areas like the nose or ear. - It is not suitable for covering large, irregular burn wounds due to its bulk and specific tissue requirements. *Cultured epithelial autograft (Incorrect)* - Involves growing a patient's own epidermal cells in a lab, which can cover very large areas when donor sites are scarce. - While useful for extensive burns with limited donor sites, it is **fragile**, takes weeks to prepare, and is prone to contraction and scarring. - Not the **most appropriate initial choice** for immediate large wound coverage compared to split-thickness grafts.

Q: After how many days post skin grafting does revascularization and angiogenesis typically begin?

5. ***5*** - **Revascularization** and **angiogenesis** in a skin graft typically become well-established around **day 5** post-grafting. - While **inosculation** (direct anastomosis of vessels) may begin earlier around day 3-4, active **angiogenesis** (new vessel formation) is most prominent starting day 5. - This process involves the ingrowth of new blood vessels from the host bed into the graft, essential for its survival and integration. *4* - Day 4 marks the transition phase where **inosculation** is beginning and **plasmatic imbibition** is declining. - However, robust **angiogenesis** and active neovascularization are not yet fully established at this stage. - The graft is transitioning from passive diffusion to active vascular ingrowth. *6* - While revascularization is robust and well-established by day 6, the active initiation phase begins earlier around day 5. - Day 6 demonstrates a maturing vascular network, but the question asks about when the process typically begins. *7* - By day 7, the process of **revascularization** and **angiogenesis** is typically well-established and maturing. - The initial stages of capillary ingrowth and new vessel formation have already been completed by this point. - This represents the consolidation phase rather than the initiation phase.

Q: Which myocutaneous pedicle graft is most commonly used for pelvis surgeries?

Rectus abdominis muscle. ***Rectus abdominis muscle*** - The **rectus abdominis myocutaneous flap** is highly versatile due to its reliable vascular supply (superior and inferior epigastric arteries) and anatomical proximity, making it a common choice for pelvic reconstruction. - Its bulk and ability to carry a large skin paddle make it ideal for filling large defects in the **pelvic region**, such as after cancer resections. *External oblique muscle* - While it can be harvested, the **external oblique muscle** is less commonly used for large pelvic defects compared to the rectus abdominis due to its more complex vascular anatomy and limited bulk. - Harvesting this muscle can also lead to more significant deficits in **abdominal wall integrity** and function. *Internal oblique muscle* - The **internal oblique muscle**, although part of the abdominal wall, is generally thinner and has a less robust vascular pedicle compared to the rectus abdominis, making it less suitable for bulkier pelvic reconstructions. - Its primary role is in **abdominal wall support** and movement, and its harvest can compromise these functions. *Transversus abdominis muscle* - The **transversus abdominis muscle** is typically thinner and more intimately involved in core abdominal stability, making its use as a pedicled flap for large volume reconstruction in the pelvis less practical. - Its vascular supply is generally not as robust or as easily dissectible for long pedicles as the rectus abdominis, limiting its reach for **pelvic defects**.

Q: What is the ideal angle for Z-plasty?

60°. ***60°*** - An angle of **60°** is considered ideal for Z-plasty because it provides the best balance between **lengthening the scar** and maintaining **tissue viability**. - This angle typically results in a **75% gain in length** along the central limb of the Z-plasty, while ensuring the flaps have a broad enough base for adequate blood supply. *90°* - While a **90°** angle would provide the most lengthening (around 100%), it creates very **thin, narrow flap tips** that are highly susceptible to **ischemia and necrosis** due to compromised blood supply. - This angle is generally avoided in Z-plasty due to the high risk of **flap complications**. *45°* - A **45°** angle results in less lengthening (approximately 50% gain) compared to a 60° angle, which may not be sufficient for significant release of scar contractures. - While it offers excellent flap viability due to wider bases, the **suboptimal lengthening** makes it less efficient for many Z-plasty applications. *75°* - An angle of **75°** would yield greater lengthening than 60°, but it also compromises flap viability making the flap susceptible to **necrosis**. - The benefits of increased length are often outweighed by the increased **risk of complications** when using this angle.

Q: Which of the following statements about keloids is true?

Local recurrence is common after excision.. ***Local recurrence is common after excision*** - Keloids are characterized by an overgrowth of **scar tissue** that extends beyond the original wound boundaries. - Due to their aggressive fibrous nature and growth factors, **surgical excision alone often leads to recurrence**, sometimes even larger than the original keloid [1]. *They undergo malignant transformation frequently* - Keloids are **benign fibrous growths** and do **not typically undergo malignant transformation**. - While they can be cosmetically distressing and cause symptoms like itching or pain, they are not a precursor to cancer. *They occur equally across all ethnic groups* - Keloids show a significant **predisposition in individuals with darker skin pigmentation**, including those of African, Asian, and Hispanic descent [1]. - This suggests a **genetic component** influencing their occurrence, which is not equally distributed across all ethnic groups [1]. *They remain confined to the original wound boundaries* - This statement describes **hypertrophic scars**, not keloids. - Keloids are specifically defined by their tendency to **grow beyond the margins** of the original injury, invading surrounding healthy skin [1].

Question 1

A patient with ulnar nerve compression at the elbow (cubital tunnel syndrome) presents with early clawing of the ring and little fingers, numbness, and progressive weakness of hand intrinsic muscles. What is the most appropriate surgical intervention to prevent further deterioration of hand function?

Accepted Answer

Ulnar nerve transposition; prevents further deterioration

Answer

Carpal tunnel release; reduced pain

Answer

Median nerve repair; restored thumb opposition

Answer

Radial nerve decompression; enhanced wrist extension

Question 2

A 35-year-old female with carpal tunnel syndrome undergoes surgical release. Which structure is incised during the procedure?

Accepted Answer

Flexor retinaculum

Answer

Extensor retinaculum

Answer

Palmar aponeurosis

Answer

Ulnar bursa

Question 3

Which type of skin graft is most appropriate for covering large full-thickness burn wounds?

Accepted Answer

Split-thickness graft

Answer

Full-thickness graft

Answer

Composite graft

Answer

Cultured epithelial autograft

Question 4

After how many days post skin grafting does revascularization and angiogenesis typically begin?

Accepted Answer

5

Answer

4

Answer

6

Answer

7

Question 5

Which of the following is true about breast reconstruction surgery?

Accepted Answer

Simplest reconstruction is done using silicone gel implant

Answer

Nipple reconstruction cannot be performed under local anesthesia

Answer

Radiotherapy in post op period does not influence the outcome after breast reconstruction

Answer

TRAM flap has less donor site morbidity than LD flap

Question 6

Which myocutaneous pedicle graft is most commonly used for pelvis surgeries?

Accepted Answer

Rectus abdominis muscle

Answer

External oblique muscle

Answer

Internal oblique muscle

Answer

Transversus abdominis muscle

Question 7

Which flap is commonly used in breast reconstruction?

Accepted Answer

DIEP based on deep inferior epigastric perforator vessels

Answer

Gluteal flap based on superior gluteal artery

Answer

Latissimus dorsi flap based on thoracodorsal artery

Answer

TRAM based on transverse rectus abdominis muscle

Question 8

Which of the following statements is NOT true regarding tenosynovitis of the finger?

Accepted Answer

Fingers are more likely to be held in an extended position due to pain and swelling.

Answer

With involvement of the little finger, the infection does not spread to the index finger.

Answer

Treatment is not always conservative and may require surgical intervention in severe cases.

Answer

Tenosynovitis of the little finger can spread to the thumb but not to the ring finger.

Question 9

What is the ideal angle for Z-plasty?

Accepted Answer

60°

Answer

90°

Answer

45°

Answer

75°

Question 10

Which of the following statements about keloids is true?

Accepted Answer

Local recurrence is common after excision.

Answer

They undergo malignant transformation frequently.

Answer

They occur equally across all ethnic groups.

Answer

They remain confined to the original wound boundaries.

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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