Hand Surgery and Brachial Plexus Reconstruction MCQs

Orthopedics · 50 free questions with answers & explanations.

1. A 30-year-old motorcyclist sustains a high-energy brachial plexus injury. Clinical assessment reveals complete loss of shoulder abduction (deltoid), elbow flexion (biceps), and wrist/finger extension. MRI shows pseudomeningoceles at C5, C6, C7 levels. The finding of pseudomeningoceles signifies which type of injury that is irreparable by direct nerve repair?
2. A patient has an isolated closed zone II flexor tendon injury of the middle finger (between distal palmar crease and PIP joint flexion crease). Primary repair is planned. Which tendon repair technique involving a 4-strand or 6-strand core suture and a circumferential epitendinous suture is now preferred to allow early active motion postoperatively?
3. A 40-year-old woman presents with numbness of the thumb, index, and middle fingers that worsens at night, relieved by shaking the hand (Flick sign positive). Tinel's sign is positive at the wrist. Electrodiagnostic studies confirm carpal tunnel syndrome. She failed 3 months of splinting and a steroid injection. The next appropriate management is:
4. Which nerve transfer (neurotization) is most commonly performed to restore elbow flexion in a patient with upper trunk brachial plexus avulsion (C5-C6) when both roots are avulsed?
5. A 28-year-old motorcyclist sustains a brachial plexus injury. Clinical examination shows total anesthesia of the entire upper limb with a Horner's syndrome on the ipsilateral side. The most accurate diagnosis and its significance are:
6. In flexor tendon injuries of the hand, Zone II (the 'critical zone' or 'no man's land') extends from:
7. A 35-year-old carpenter presents with inability to abduct the thumb and weakness of pinch grip. Nerve conduction studies confirm a thenar branch lesion of the median nerve at the wrist. The motor branch supplying the thenar muscles arises from the median nerve in its most common anatomical variant at:
8. In a replantation of a completely amputated ring finger at the zone II level, the optimal order of structure repair to maximise survival is:
9. A patient sustains complete avulsion of C5–C6 nerve roots in a motorcycle accident causing upper trunk brachial plexus palsy. The most commonly used donor nerve for neurotization of the musculocutaneous nerve to restore elbow flexion is:
10. In Zone II flexor tendon injury of the hand (no man's land), the recommended primary repair technique involves:
11. A patient with rheumatoid arthritis develops ulnar drift and volar subluxation of the metacarpophalangeal joints of the fingers. The underlying pathomechanism is:
12. Kienbock's disease (lunate avascular necrosis) in a patient with negative ulnar variance (ulna shorter than radius) and Stage II disease (sclerosis, no collapse) is best managed by:
13. A 28-year-old motorcyclist sustains a complete brachial plexus injury. At exploration, roots C5 and C6 are found to be avulsed from the spinal cord (preganglionic injury), while C7 is in continuity. The most reliable electrodiagnostic finding distinguishing preganglionic from postganglionic injury at C5 is:
14. A 32-year-old man with global brachial plexus palsy (C5–T1 avulsion) undergoes nerve transfer surgery. The intercostal nerves (T3–T5) are used as donors for reinnervating biceps via musculocutaneous nerve to restore elbow flexion. Which additional nerve transfer is classically described to restore shoulder abduction in this scenario?
15. A 45-year-old woman with rheumatoid arthritis develops boutonnière deformity of the index finger. The primary pathological event leading to this deformity is:
16. A 55-year-old man with diabetes presents with a 4-month history of progressive inability to extend his ring finger at the MCP joint while all other fingers extend normally. Passive extension is full. The correct diagnosis is:
17. A motorcyclist sustains a high-velocity injury and presents with a flail, anaesthetic upper limb. EMG shows absent motor and sensory action potentials in C5–T1 distribution. MRI shows pseudomeningocele formation at C6–C7 and C8–T1 levels. What does the pseudomeningocele indicate and how does it affect prognosis?
18. In total brachial plexus avulsion (C5–T1), which nerve is most commonly used as an extraplexal donor for neurotisation to restore elbow flexion?
19. A 35-year-old carpenter presents with a volar laceration at the wrist involving the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons in zone II. Regarding primary tendon repair in this zone, which statement is correct?
20. A patient presents with inability to flex the DIP joint of the ring finger after a forced extension injury while gripping a rugby jersey. No bony avulsion is seen on X-ray. What is the most likely diagnosis and preferred treatment?
21. A 22-year-old motorcyclist sustains a high-velocity road traffic accident. On examination, he has a flail arm with absent sensation from C5 to T1 dermatomes. Horner's syndrome is present. CT myelogram shows pseudomeningoceles at C7 and C8 levels. The type of brachial plexus injury is:
22. A patient with complete C5–C6 avulsion brachial plexus injury undergoes intercostal nerve transfer to the musculocutaneous nerve to restore elbow flexion. The earliest clinical evidence of reinnervation should appear approximately:
23. A carpenter presents with numbness of the thumb, index finger, and long finger for 6 months, worse at night and with prolonged gripping. Phalen's test is positive at 30 seconds. Nerve conduction velocity study shows prolonged median nerve distal motor latency of 5.2 ms (normal <4.5 ms) across the carpal tunnel. First-line treatment is:
24. A 35-year-old woman presents with a trigger finger (stenosing tenosynovitis) of the right ring finger that has failed two corticosteroid injections. The pathological site of tendon catching is at:
25. The extensor mechanism of the finger is most vulnerable to rupture at which zone following closed trauma to the distal phalanx?
26. A 28-year-old motorcyclist sustains a high-velocity injury. He presents with a flail upper limb with Horner's syndrome (ptosis, miosis, anhidrosis). Nerve conduction studies show absent sensory nerve action potentials (SNAPs) in the ulnar and median nerves. This pattern is most consistent with:
27. In total brachial plexus palsy following birth trauma, the Narakas classification type IV includes:
28. A 35-year-old woman presents with inability to flex the terminal phalanx of the thumb and index finger. She cannot form an 'OK sign.' MRI shows a ganglion cyst at the elbow compressing a nerve. Which nerve and which branch is involved?
29. A 45-year-old laborer presents with inability to extend the fingers but intact wrist extension, after a closed injury to the proximal forearm. The most likely structure injured is:
30. In Zone II flexor tendon injuries of the hand (no man's land), the preferred repair technique and postoperative regimen recommended for best outcomes is:
31. A 50-year-old diabetic presents with acute flexion of the ring finger DIP and PIP joints with inability to extend, plus a palpable tender nodule at the base of the finger and triggering on movement. The most appropriate first-line treatment is:
32. A 25-year-old motorcyclist sustains a high-velocity road accident. He has loss of shoulder abduction, elbow flexion, and wrist extension but intact hand intrinsics and finger flexion. This pattern is consistent with injury to which roots of the brachial plexus?
33. In brachial plexus reconstruction, the MOST favored nerve donor for restoring elbow flexion (reinnervating musculocutaneous nerve) via nerve transfer in a preganglionic C5–C6 avulsion is:
34. A patient with an isolated median nerve laceration at the wrist presents with inability to oppose the thumb and decreased sensation over the lateral 3½ fingers. Which intrinsic muscle is MOST critical for opposition and is denervated?
35. The 'intrinsic minus' hand (claw hand) deformity is characterized by hyperextension of the MCP joints and flexion of the IP joints. In a low ulnar nerve palsy, which fingers are MOST severely affected and why?
36. A 25-year-old motorcyclist sustains a high-velocity road traffic accident and presents with a flail right upper limb. MRI of the brachial plexus reveals pseudo-meningoceles at C5, C6, C7 levels. Electrodiagnostic study shows absent SNAP but preserved CMAP. These findings are consistent with:
37. In a 28-year-old with C5–C6 brachial plexus avulsion (global upper trunk loss), which donor nerve is used for intercostal nerve transfer to restore elbow flexion, and what is the expected recovery timeline?
38. A 35-year-old carpenter sustains a complete laceration of the flexor digitorum profundus (FDP) of the ring finger in Zone II ('no man's land'). Primary repair is performed with a core suture. Which suture technique achieves the highest tensile strength for Zone II FDP repair?
39. A 42-year-old typist presents with pain, numbness over the radial 3.5 fingers, and thenar wasting. Nerve conduction studies show prolonged distal motor latency of the median nerve at the wrist. Conservative treatment has failed. At surgery, the transverse carpal ligament is released. The roof of the carpal tunnel is formed by:
40. A 55-year-old diabetic man presents with progressive inability to extend the ring and little finger metacarpophalangeal joints, with flexion contractures at those joints but normal PIP and DIP extension. The pathology involves:
41. A 28-year-old motorcyclist sustains a high-velocity shoulder injury. Examination reveals complete flail upper limb. Horner's syndrome is present on the ipsilateral side. Electromyography shows preserved paraspinal muscle activity. The most likely injury is:
42. In obstetric brachial plexus palsy involving C5–C6 (Erb's palsy), the classical posture of the limb and the mechanism responsible are:
43. A 35-year-old presents with inability to oppose the thumb and sensory loss over the thenar eminence following a laceration at the wrist. Tinel's sign is positive at the wrist crease. The most appropriate surgical procedure is:
44. The intrinsic-plus position (the 'safe position') recommended for splinting the hand after burns or trauma is:
45. A patient with chronic rheumatoid arthritis develops progressive 'swan-neck' deformity of the finger. The primary anatomical disruption causing this deformity is:
46. A 28-year-old motorcyclist sustains a high-velocity injury. Examination shows absent shoulder abduction and elbow flexion with preserved forearm rotation and hand function. Horner's syndrome is present. MRI myelography demonstrates pseudomeningoceles at C5–C6. The nerve roots most likely avulsed from the spinal cord are:
47. To restore elbow flexion in a patient with C5–C6 brachial plexus avulsion (pre-ganglionic), the most reliable donor nerve for neurotization of the musculocutaneous nerve is:
48. A patient presents with inability to extend the fingers and thumb at the metacarpophalangeal joints after a humeral shaft fracture (Holstein-Lewis fracture). Wrist extension is partially preserved. The specific nerve injury pattern is:
49. A 35-year-old presents with a lacerating injury to the palm. Examination shows inability to flex the distal phalanx of the index finger and the interphalangeal joint of the thumb, with intact finger flexion at other joints. This indicates injury to:
50. In trigger finger (stenosing tenovaginitis), the anatomical site of pathological thickening causing triggering is: