Exam Corner

Hand

Prepared by Asif Parkar & Mohamed Sukeik 

 

Questions

  1. Juncturae tendinum in the hand:

    1. ​links the tendon slips of the flexor digitorum profundus and may mask proximal tendon laceration

    2. links the tendon slips of flexor digitorum superficialis and may mask proximal tendon laceration

    3. links the tendon slips of extensor digitorum communis and may mask proximal tendon laceration

    4. assists with hook grip

    5. assists with pincer grip

  2. Which of the following statements is false about the sagittal band?

    1. ​has a role in metacarpophalangeal extension

    2. attaches to the volar plate

    3. centralises the extensor mechanism

    4. ring finger is most commonly involved when an injury occurs

    5. dislocation resulting from rupture of the band is also known as Boxer’s knuckle

  3. Flexor digitorum profundus tendon splits Flexor digitorum superficialis at the Campers chiasma which is located at the level of the:

    1. ​carpometacarpal joint

    2. palm

    3. metacarpophalangeal joint

    4. proximal phalanx

    5. distal phalanx

  4. ​The carpal tunnel contains FPL, FDS and FDP and their arrangement is:     

    1. long and ring FDS tendons are volar to index and small FDS

    2. long and ring FDS tendons are dorsal to index and small FDS

    3. long and ring FDP tendons are volar to index and small FDP

    4. long and ring FDP tendons are dorsal to index and small FDP

    5. they are all located at the same level

  5. Which of the following statements is false?

    1. ​EPL tendon rupture may occur as a complication of closed reduction of distal radius fractures

    2. vascular insufficiency has no association with EPL rupture

    3. EPL tendon is the most common extensor tendon injured due to prominent screws used in distal radius fracture fixation

    4. FPL tendon is the most common flexor tendon ruptured after volar locking plate of distal radius fractures

    5. EPL tendon is the most common extensor tendon injured due to drill bit penetration during distal radius fracture fixation

  6. For scaphoid non union vascular bone graft is most commonly harvested from:

    1. ​dorsal distal radius based on 1,2 intercompartmental supraretinacular artery

    2. dorsal distal radius based on 2,3 intercompartmental supraretinacular artery

    3. dorsal distal radius based on 3,4 intercompartmental supraretinacular artery

    4. volar distal radius based on 1,2 intercompartmental supraretinacular artery

    5. volar distal radius based on 2,3 intercompartmental supraretinacular artery

  7. Which of the following is not associated with carpal instability?

    1. ​Carpal Instability Dissociative

    2. Carpal Instability Associative

    3. Carpal Instability Non-Dissociative

    4. Carpal Instability Complex

    5. Carpal Instability Adaptive

  8. Which of the following does not form part of Mayfield’s description of perilunate disruption?    

    1. scapholunate disruption

    2. lunocapitate disruption

    3. scaphocapitate disruption

    4. lunotriquetral disruption

    5. volar lunate dislocation

  9. Approximately what percentage of Perilunate dislocations get missed at the emergency department?

    1. ​10%

    2. 25%

    3. 50%

    4. 65%

    5. 80%

  10. Which of the following statements is false about ulnar collateral ligament of the thumb?

    1. ​acute injury is called Skier’s thumb

    2. chronic injury is called Gamekeeper’s thumb

    3. instability in 30 degree flexion indicates proper ulnar collateral injury

    4. instability in neutral indicates injury to accessory ulnar collateral ligament

    5. in less than 50% of cases, a complete injury is accompanied by a Stener lesion

  11. Elson test is used to assess:

    1. ​sagittal band rupture

    2. flexor digitorum superficialis rupture

    3. central slip rupture

    4. ulnar collateral ligament rupture

    5. flexor digitorum profundus rupture

  12. Which of the following statements is not true for flexor tendon repair?

    1. ​strength of repair is proportional to number of suture strands across the repair site

    2. high calibre material should be used

    3. a locking loop configuration decreases gap formation

    4. repair of flexor tendon sheath strengthens flexor tendon repair

    5. epitendinous repair decreases gap size and increases strength

  13. Which of the following is not associated with Trigger finger?

    1. ​diabetes

    2. female gender

    3. middle finger is most commonly involved

    4. inflammatory arthropathy

    5. repetitive grasping activities

  14. Commonest cause of carpal tunnel syndrome in children is:

    1. ​diabetes

    2. juvenile Rheumatoid arthritis

    3. mucopolysaccharidosis

    4. thyroid disease

    5. obesity

  15. Kaplan line is used as a reference to identify the:

    1. ​median nerve

    2. palmar cutaneous branch of median nerve

    3. recurrent motor branch of median nerve

    4. anterior interosseous nerve

    5. ulnar nerve

  16. Which of the following is not part of Kanavel’s description of flexor tendon sheath infection?

    1. ​redness along the course of the flexor tendon

    2. flexion attitude of the digit

    3. fusiform swelling of the digit

    4. tenderness along the flexor tendon sheath

    5. pain with passive extension of the digit

  17. Which of the following is not a recognised site of ulnar nerve entrapment?

    1. ​arcade of Struthers

    2. ligament of Struthers

    3. medial intermuscular septum

    4. Osborne ligament

    5. aponeurosis of flexor carpi ulnaris

  18. All of the following is relevant to surgical repair of a nerve except?

    1. ​the repair should be free of tension

    2. the repair must be within clean, well-vascularised wound bed

    3. neurolysis results in loss of nerve length

    4. repair should be done within 14 days

    5. repair techniques include epineurial, individual and group fascicular

  19. ​All of the following are principles of tendon transfer except?

    1. ​donor must have good excursion

    2. one transfer to perform one function

    3. line of pull should be straight

    4. synergistic transfers are difficult to rehabilitate

    5. one grade of motor strength is lost after transfer

  20. Which of the following normal fascial structures does not become involved in Dupuytren disease?

    1. ​Pretendinous band

    2. Natatory band

    3. Spiral band

    4. Grayson ligament

    5. Cleland ligament

  

            

Answers

  1. c - links the tendon slips of extensor digitorum communis and masks proximal laceration
    Explanation - Juncturae tendinum is the interconnection that links extensor tendons mainly extensor digitorum communis and sometimes extensor digiti minimi. It helps in coordination and force distribution however this interconnection may mask proximal tendon laceration.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 517

  2. d - ring finger is most commonly involved
    Explanation - Sagittal band rupture is also known as Boxer’s knuckle and most commonly involves the middle finger (about 48% of cases) and the ring finger is the least commonly involved (about 7%). It is one of the differential causes for dropped finger as it aids extension at MCP level.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 517

  3. d - proximal phalanx
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 517

  4. a - long and ring FDS tendons are volar to the index and small FDS
    Explanation - Carpal tunnel contains the median nerve and nine flexor tendon slips. FPL is the most radially located and it has four slips of each FDS and FDP. Long and ring FDS tendons are volar to index and small FDS.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 518

  5. b - vascular insufficiency has no association with EPL rupture
    Explanation - EPL tendon injury typically presents with painless acute loss of thumb extension and is commonly seen as a late complication of closed reduction of distal radius fractures. Rupture of this tendon after minimally displaced fractures suggests ischaemic aetiology rather than attritional rupture over an osseous spike.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 523

  6. a - dorsal distal radius based on 1,2 intercompartmental supraretinacular artery
    Explanation - It is also called 1,2, ICSRA.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 525

  7. b - carpal instability associative
    Explanation - Carpal instability patterns are based on the rows of carpal bones (proximal, distal and mixed). Carpal instability adaptive is the long-term adaptive change leading to instability (e.g. malunited distal radius fracture). There is no such terminology as carpal instability associative.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 526

  8. c - scaphocapitate disruption
    Explanation - Mayfield described four stages proceeding in counter clockwise direction which are scapholunate disruption, lunocapitate disruption, lunotriquetral disruption and volar lunate dislocation.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 528

  9. b - 25%
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 528

  10. e - in less than 50% of cases, a complete injury is accompanied by a Stener lesion.
    Explanation - In over 85% of cases, a complete injury is accompanied by Stener lesion. In a Stener lesion, the adductor pollicis aponeurosis is interposed between the avulsed UCL and its insertion at the base of proximal phalanx.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 530

  11. c - central slip rupture
    Explanation - Elson test is performed by flexing patient’s PIP joint to 90 degrees at the edge of a table while the patient extends the PIP joint against resistance. If the central slip is intact, lateral bands are not recruited and hence DIPJ feels floppy but when the central slip is ruptured, lateral bands are recruited and DIPJ feels stiff.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 533

  12. d - repair of flexor tendon sheath strengthens flexor tendon repair
    Explanation - Repair of flexor tendon sheath has no effect on flexor tendon repair.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 535

  13. c - middle finger is most common
    Explanation - Ring finger is most common in adults.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 537

  14. c - Mucopolysaccharidosis
    Explanation - Mucopolysaccharidosis is the commonest cause of carpal tunnel syndrome in children.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 550

  15. c - recurrent motor branch of median nerve
    Explanation - Kaplan line is drawn along the ulnar border of the abducted thumb. Intersection of this line and a line drawn longitudinally in the web space of index and middle finger represents the location for recurrent motor branch of median nerve.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 550

  16. a - redness along the course of flexor tendon
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 570

  17. b - ligament of Struthers
    Explanation - Ligament of Struthers is an entrapment site for the median nerve whereas the arcade of Struthers is a site for ulnar nerve compression.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 553

  18. c - neurolysis results in loss of nerve length
    Explanation - Nerve length may be gained by neurolysis or transposition.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 557

  19. d - synergistic transfer are easier to rehabilitate
    Explanation - Other principles are that the donor should be expandable, minimal donor site morbidity and the tendon is to be transferred across a supple joint. Also patient should have rehabilitation potential and limb should be sensate.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 559

  20. e - Cleland ligament
    Explanation - Cleland ligament does not become involved in Dupuytren disease. All other fascial bands including the retrovascular band as well become involved in Dupuytren disease.
    Reference - Review of Orthopaedics - Miller, Sixth edition p - 565