Hand Surgery Practice Questions

Q: One of the common fractures that occur during boxing by hitting with a closed fist is:

Bennett's fracture dislocation. ***Bennett's fracture dislocation*** - This is an **intra-articular fracture** of the base of the **first metacarpal**, extending into the carpometacarpal (CMC) joint. - It is frequently caused by axial compression with the thumb in a flexed and adducted position, a common injury mechanism in **punching a hard object** during boxing. *Monteggia fracture dislocation* - This injury involves a fracture of the **proximal ulna** coupled with an **anterior dislocation of the radial head**. - It is typically caused by a direct blow to the forearm or a fall on an outstretched hand with a hyperpronated forearm, not a direct punch. *Galeazzi fracture dislocation* - This involves a fracture of the **distal radius** with an associated **dislocation of the distal radioulnar joint (DRUJ)**. - It results from a fall on an outstretched hand with a hyperpronated forearm, which is not consistent with a boxing injury. *Smith's fracture* - Also known as a **reverse Colles' fracture**, this is a fracture of the **distal radius** with **volar displacement of the distal fragment**. - It typically results from a fall on a flexed wrist or a direct blow to the back of the wrist, not a punching injury.

Q: Which carpal bone fracture causes median nerve involvement?

Scaphoid. ***Scaphoid*** - A fracture or dislocation of the **scaphoid bone** can lead to swelling and hematoma formation within the **carpal tunnel**, compressing the median nerve. - While less direct than lunate dislocations, **scaphoid fractures** can cause median nerve symptoms due to indirect pressure or callus formation. *Lunate* - A **dislocation of the lunate bone** (especially anterior displacement) is a hallmark cause of **acute carpal tunnel syndrome**, directly compressing the median nerve. - Unlike a fracture, the lunate's displacement itself physically reduces the space within the carpal tunnel, trapping the median nerve. *Trapezium* - Fractures of the **trapezium** are usually associated with injury to the **thumb carpometacarpal (CMC) joint** and do not typically cause median nerve involvement. - The trapezium is located more radially, outside the direct pathway of the median nerve in the carpal tunnel. *Trapezoid* - Fractures of the **trapezoid bone** are rare and typically stable, with little propensity to cause **median nerve compression**. - The trapezoid's anatomical position is deep within the wrist and away from the median nerve's primary pathway.

Q: For tendon transfer, the most common tendon used is

Palmaris longus tendon. ***Palmaris longus tendon*** - The **palmaris longus tendon** is the **most commonly used donor tendon** for tendon transfers due to multiple advantages: - **Dispensability**: Absent in 10-15% of the population without causing functional deficit, making it expendable - **Ideal dimensions**: Adequate length (12-15 cm) and appropriate diameter for various reconstructive procedures - **Easy access**: Superficial location with straightforward surgical harvest - **Minimal donor site morbidity**: Its removal causes virtually no functional impairment - Commonly used for tendon grafts in hand surgery, wrist reconstruction, and even ligament repairs (e.g., UCL reconstruction in elbow) *Achilles tendon* - The **Achilles tendon** is a large, critical tendon for ankle plantarflexion and is **not used as a donor** for tendon transfers due to its essential function - It is the strongest tendon in the body and its harvest would cause severe functional disability - May be involved in major reconstructive procedures of the ankle and foot, but not as a donor graft *Flexor carpi ulnaris tendon* - The **flexor carpi ulnaris tendon** is sometimes used for specific wrist transfers (e.g., in cerebral palsy or radial nerve palsy), but it is **not the most common donor tendon** overall - It plays an important role in wrist flexion and ulnar deviation, making its harvest potentially more impactful than the palmaris longus - More commonly used as a recipient rather than donor in transfer procedures *Tibialis posterior tendon* - The **tibialis posterior tendon** is commonly used as a **transfer** (not harvest) for specific conditions like foot drop or posterior tibial tendon dysfunction - It is an important stabilizer of the medial longitudinal arch and inversion of the foot - For general tendon grafting across various anatomical sites, it is not as frequently used as the palmaris longus

Q: A 30-year-old man involved in a fisticuff, injured his middle finger and noticed slight flexion of the distal interphalangeal (DIP) joint. X-rays were normal. The most appropriate management at this stage is:

Splint the finger in hyperextension. ***Splint the finger in hyperextension*** - The description of slight flexion of the **distal interphalangeal (DIP) joint** with normal X-rays after an injury suggests a **mallet finger**. This occurs due to rupture of the terminal extensor tendon, allowing unopposed flexion of the DIP joint. - The standard conservative treatment for **mallet finger** is continuous splinting of the DIP joint in slight **hyperextension** for 6 to 8 weeks, leaving the proximal interphalangeal (PIP) joint free. *Ignore* - Ignoring the injury is inappropriate as **mallet finger** will lead to a **permanent deformity** (extensor lag) and functional impairment if left untreated. - Early intervention with proper splinting provides a high success rate for tendon healing and restoration of function. *Surgical repair of the flexor tendon* - Surgical repair is indicated when the injury involves a **complex fracture**, severe subluxation, or chronic untreated cases of mallet finger that have failed conservative management. - The injury here affects the **extensor tendon**, not the flexor tendon, thus flexor tendon repair would be incorrect. *Buddy strapping* - **Buddy strapping** involves taping the injured finger to an adjacent healthy finger. This technique is primarily used for **phalangeal fractures** or dislocations to provide support and restrict movement. - For **mallet finger**, it would not adequately immobilize the DIP joint in hyperextension, which is crucial for healing the ruptured extensor tendon.

Q: Most common tumor in the hand is

Enchondroma. ***Enchondroma*** - **Enchondromas** are the most common primary osseous tumors of the hand, frequently found in the small bones of the **phalanges** and **metacarpals**. - They are **benign cartilaginous tumors** and are often asymptomatic, discovered incidentally, although they can present with pain, swelling, or pathologic fractures. *Exostosis* - An **exostosis** (osteochondroma) is a bony outgrowth capped with cartilage, typically arising from the surface of long bones near growth plates. - While they can occur in the hand, they are less common than enchondromas and usually present as a palpable bony mass. *Giant cell tumour* - **Giant cell tumors (GCTs)** are aggressive but usually benign tumors that most commonly occur around the **knee** (distal femur and proximal tibia). - They are rare in the bones of the hand, accounting for only a small percentage of hand bone tumors. *Synovial sarcoma* - **Synovial sarcoma** is a malignant soft tissue tumor that can occur near joints, but it is **not a bone tumor**. - While it can arise in the extremities, including the hand, it is a tumor of the soft tissues rather than directly from the bone like an enchondroma.

Q: Froment's sign is positive in injury of which nerve?

Ulnar nerve. ***Ulnar nerve*** - **Froment's sign** assesses the weakness of the **adductor pollicis muscle**, which is innervated by the ulnar nerve [1]. - A positive sign is indicated when the patient compensates for this weakness by hyperflexing the interphalangeal joint of the thumb using the **flexor pollicis longus** (median nerve innervation), creating a *key pinch*. *Median nerve* - Injury to the median nerve would primarily affect the **thenar muscles** and sensation over the radial side of the palm, not primarily the adductor pollicis [1]. - While the flexor pollicis longus is innervated by the median nerve, its hyperflexion is a **compensatory action** in ulnar nerve palsy, not a direct sign of median nerve injury. *Radial nerve* - Radial nerve injury primarily causes **wrist drop** and impaired extension of the wrist and fingers [1]. - It does not directly affect the intrinsic hand muscles involved in Froment's sign [1]. *None of the options* - This option is incorrect because **Froment's sign** is a classic clinical test specifically associated with **ulnar nerve palsy**. [2]

Q: What is the primary deforming force on the proximal fragment in a Bennett's fracture?

APL. **APL** - In a **Bennett's fracture**, the **abductor pollicis longus (APL)** tendon inserts onto the **first metacarpal base** and exerts a strong pull that displaces the small, ulnar-sided proximal fragment. - This pull is largely responsible for the typical **subluxation** and **instability** seen in this fracture. *Adductor Pollicis* - The **adductor pollicis** muscle primarily adducts the thumb and acts on the **proximal phalanx**, not the base of the first metacarpal. - Its action tends to *pull the entire first metacarpal toward the palm*, rather than specifically displacing the small fracture fragment. *EPL* - The **extensor pollicis longus (EPL)** extends the interphalangeal joint and assists in extension of the metacarpophalangeal joint of the thumb, inserting on the **distal phalanx**. - It does not have a direct insertion or significant deforming force on the **proximal fragment of the first metacarpal base** in a Bennett's fracture. *EPB* - The **extensor pollicis brevis (EPB)** extends the metacarpophalangeal joint of the thumb, inserting on the **proximal phalanx**. - Similar to the EPL, it does not exert a primary deforming force on the **fracture fragment at the base of the first metacarpal**.

Question 1

One of the common fractures that occur during boxing by hitting with a closed fist is:

Accepted Answer

Bennett's fracture dislocation

Answer

Monteggia fracture dislocation

Answer

Galeazzi fracture dislocation

Answer

Smith's fracture

Question 2

Which carpal bone fracture causes median nerve involvement?

Accepted Answer

Scaphoid

Answer

Trapezium

Answer

Trapezoid

Answer

Lunate

Question 3

For tendon transfer, the most common tendon used is

Accepted Answer

Palmaris longus tendon

Answer

Achilles tendon

Answer

Flexor carpi ulnaris tendon

Answer

Tibialis posterior tendon

Question 4

A 30-year-old man involved in a fisticuff, injured his middle finger and noticed slight flexion of the distal interphalangeal (DIP) joint. X-rays were normal. The most appropriate management at this stage is:

Accepted Answer

Splint the finger in hyperextension

Answer

Ignore

Answer

Surgical repair of the flexor tendon

Answer

Buddy strapping

Question 5

Most common tumor in the hand is

Accepted Answer

Enchondroma

Answer

Exostosis

Answer

Giant cell tumour

Answer

Synovial sarcoma

Question 6

Froment's sign is positive in injury of which nerve?

Accepted Answer

Ulnar nerve

Answer

None of the options

Answer

Median nerve

Answer

Radial nerve

Question 7

What is the primary deforming force on the proximal fragment in a Bennett's fracture?

Accepted Answer

APL

Answer

EPL

Answer

EPB

Answer

Adductor Pollicis

Hand Surgery — MCQs

Hand Surgery — MCQs

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