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7. Hand and Wrist MCQs

Practice Set 100 of 266

This practice set contains high-yield board review questions covering key concepts in 7. Hand and Wrist. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1981

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with progressive wrist pain. Radiographs reveal sclerosis and collapse of the lunate without a fixed scaphoid ring sign or carpal instability (Lichtman Stage IIIA Kienböck's disease). Measurement of the radioulnar relationship demonstrates 3 mm of ulnar negative variance. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy
. Radial shortening osteotomy
. Total wrist arthrodesis
. Lunate excision and silastic replacement
. Scaphoid-trapezium-trapezoid (STT) fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Lichtman Stage IIIA Kienböck's disease, there is lunate collapse but carpal height and alignment (scaphoid) are maintained. For a patient with Stage IIIA disease and ulnar negative variance, a joint-leveling procedure such as a radial shortening osteotomy is the most appropriate and biomechanically sound intervention, as it decreases load transmission through the radiolunate fossa. Proximal row carpectomy or STT fusion are typically reserved for more advanced stages (IIIB or IV).

Question 1982

Topic: 7. Hand and Wrist

In the surgical repair of flexor tendon lacerations within Zone II of the hand, maintaining initial tensile strength is critical to permit early active motion protocols. The initial tensile strength of a flexor tendon repair is most directly proportional to which of the following factors?

. The caliber of the epitendinous suture
. The number of core suture strands crossing the repair site
. The location of the knot (internal vs. external)
. The preservation of the A3 and A5 pulleys
. The strict adherence to a passive-only rehabilitation protocol

Correct Answer & Explanation

. The number of core suture strands crossing the repair site

Explanation

The initial strength of a flexor tendon repair is directly proportional to the number of core suture strands crossing the repair site. A 4-strand or 6-strand repair provides significantly more tensile strength than a classic 2-strand repair (e.g., modified Kessler), which is necessary to safely support early active motion protocols. While epitendinous sutures reduce gapping and add some strength, the core strands are the primary structural determinant.

Question 1983

Topic: 7. Hand and Wrist

A 45-year-old woman complains of pain, tingling, and numbness over the dorsal radial aspect of her hand, which is exacerbated by wearing tight jewelry. She has a strongly positive Tinel's sign over the radial aspect of her mid-to-distal forearm. What nerve is most likely compressed, and between which two muscles does it typically emerge from the deep fascia?

. Superficial radial nerve, between brachioradialis and extensor carpi radialis longus
. Posterior interosseous nerve, between supinator and extensor digitorum communis
. Superficial radial nerve, between flexor carpi radialis and brachioradialis
. Posterior interosseous nerve, between brachioradialis and extensor carpi radialis brevis
. Lateral antebrachial cutaneous nerve, between biceps and brachialis

Correct Answer & Explanation

. Superficial radial nerve, between brachioradialis and extensor carpi radialis longus

Explanation

Wartenberg's syndrome is a compressive neuropathy of the superficial sensory branch of the radial nerve. The nerve typically emerges from the deep fascia in the distal third of the forearm between the brachioradialis and the extensor carpi radialis longus (ECRL) tendons. Tight items around the wrist, such as watches or bracelets, often exacerbate the symptoms.

Question 1984

Topic: 7. Hand and Wrist
A 30-year-old jackhammer operator presents with worsening dorsal wrist pain and weakened grip strength. Advanced imaging and radiographs reveal sclerosis and early fragmentation of the lunate bone. However, measurements confirm the overall carpal height is maintained, and there is no fixed palmar rotation of the scaphoid. What Lichtman stage of Kienböck's disease does this represent?
. Stage I
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IV

Correct Answer & Explanation

. Stage IIIA

Explanation

Lichtman Classification of Kienböck's disease: Stage I shows a normal radiograph but abnormal MRI. Stage II shows lunate sclerosis without collapse. Stage IIIA shows lunate collapse and fragmentation, but normal carpal height and normal scaphoid alignment. Stage IIIB shows lunate collapse with decreased carpal height and fixed palmar rotation of the scaphoid. Stage IV involves generalized secondary radiocarpal or midcarpal osteoarthritis.

Question 1985

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic, progressive dorsal wrist pain and weakness. Radiographs demonstrate scapholunate advanced collapse (SLAC) stage II. Which of the following best describes the anatomical distribution of arthritis and an appropriate salvage procedure for this stage?
. Arthritis confined to the radioscaphoid joint; treatable with scaphoid excision and four-corner fusion.
. Arthritis involving the radioscaphoid and capitolunate joints; treatable with proximal row carpectomy (PRC).
. Arthritis involving the radiolunate joint; requiring total wrist arthrodesis.
. Arthritis confined to the radial styloid; treatable with isolated radial styloidectomy.
. Arthritis involving the pisotriquetral joint; treatable with isolated pisiform excision.

Correct Answer & Explanation

. Arthritis involving the radioscaphoid and capitolunate joints; treatable with proximal row carpectomy (PRC).

Explanation

SLAC Stage I involves the radial styloid and distal scaphoid. Stage II involves the entire radioscaphoid joint. Stage III involves the capitolunate joint. The radiolunate joint is typically spared in SLAC wrists. Proximal row carpectomy (PRC) or four-corner fusion with scaphoid excision are appropriate for Stage II, but PRC is contraindicated in Stage III due to capitolunate arthritis.

Question 1986

Topic: Nerve & Tendon



A 55-year-old female with long-standing type 2 diabetes presents with a painful, catching ring finger that locks in flexion. She is diagnosed with stenosing tenosynovitis (trigger finger). Which annular pulley is primarily implicated in the pathogenesis of this condition, and what is its anatomic relationship to the corresponding joint?

. A1 pulley; located at the level of the proximal interphalangeal (PIP) joint
. A2 pulley; located over the mid-portion of the proximal phalanx
. A1 pulley; located at the level of the metacarpophalangeal (MCP) joint
. C1 pulley; located immediately distal to the A1 pulley
. A3 pulley; located at the level of the PIP joint

Correct Answer & Explanation

. A1 pulley; located at the level of the metacarpophalangeal (MCP) joint

Explanation

Trigger finger is caused by a size mismatch between the flexor tendon (often with a reactive nodule) and the retinacular sheath, primarily at the A1 pulley. The A1 pulley is located palmar to the metacarpophalangeal (MCP) joint. The A2 pulley is over the proximal phalanx, and the A3 pulley is over the PIP joint.

Question 1987

Topic: 7. Hand and Wrist

A 45-year-old cyclist presents with numbness in his small and ring fingers, and weakness of finger abduction. Sensation to the dorsal ulnar aspect of the hand is preserved. At which zone of Guyon's canal is the compression most likely located, and what structures are involved?

. Zone 1; motor and sensory branches
. Zone 2; motor branch only
. Zone 3; sensory branch only
. Zone 1; motor branch only
. Cubital tunnel; motor and sensory branches

Correct Answer & Explanation

. Zone 1; motor and sensory branches

Explanation

Preservation of dorsal ulnar sensation indicates the compression is distal to the dorsal ulnar sensory branch (which arises proximal to the wrist), localizing the lesion to Guyon's canal. Guyon's canal is divided into three zones: Zone 1 is proximal to the bifurcation and contains both motor and sensory fibers; Zone 2 contains only the deep motor branch; Zone 3 contains only the superficial sensory branch. Mixed motor and sensory deficits localize to Zone 1.

Question 1988

Topic: Wrist & Carpus
A 45-year-old man presents with wrist pain 10 years after an untreated scaphoid fracture. Radiographs show arthritis involving the entire radioscaphoid joint, but the capitolunate joint is completely preserved. What stage of Scaphoid Nonunion Advanced Collapse (SNAC) is this, and what is a recommended salvage procedure?
. SNAC Stage I; Radial styloidectomy and scaphoid fixation
. SNAC Stage II; Proximal row carpectomy or four-corner fusion
. SNAC Stage III; Total wrist arthrodesis
. SNAC Stage I; Proximal row carpectomy
. SNAC Stage II; Total wrist arthroplasty

Correct Answer & Explanation

. SNAC Stage II; Proximal row carpectomy or four-corner fusion

Explanation

SNAC staging: Stage I involves the radial styloid and distal scaphoid. Stage II involves the entire radioscaphoid fossa. Stage III involves the capitolunate (midcarpal) joint. Because the entire radioscaphoid joint is arthritic but midcarpal is spared, this is Stage II. Proximal row carpectomy (PRC) or four-corner fusion are standard recommended treatments.

Question 1989

Topic: Hand Trauma & Infection

The Stener lesion, which prevents non-operative healing of a complete ulnar collateral ligament (UCL) tear of the thumb, involves the interposition of which structure between the torn ends of the UCL?

. Abductor pollicis brevis aponeurosis
. Adductor pollicis aponeurosis
. Extensor pollicis longus tendon
. Flexor pollicis longus tendon
. Volar plate

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the distal attachment of the thumb ulnar collateral ligament (UCL) completely avulses and retracts proximally, becoming displaced superficial to the adductor pollicis aponeurosis. This aponeurosis interposes between the torn UCL ends, preventing native healing and necessitating surgical repair.

Question 1990

Topic: 7. Hand and Wrist

A 28-year-old sustains a laceration to the volar aspect of the digit in Zone II, requiring surgical exploration and flexor tendon repair.

To prevent tendon bowstringing and maximize biomechanical excursion efficiency, which two annular pulleys are the most critical to preserve or reconstruct?

. A1 and A3
. A2 and A4
. A3 and A5
. A1 and A5
. A2 and A3

Correct Answer & Explanation

. A2 and A4

Explanation

The flexor tendon sheath mechanism comprises five annular (A1-A5) and three cruciform (C1-C3) pulleys. The A2 and A4 pulleys are the major pulleys responsible for preventing bowstringing of the flexor tendons. The A2 pulley arises from the proximal phalanx, and the A4 arises from the middle phalanx. Biomechanical studies have shown that preserving or reconstructing A2 and A4 is critical to maintaining normal digital kinematics and work of flexion.

Question 1991

Topic: 7. Hand and Wrist

During a carpal tunnel release, the surgeon must be meticulously aware of the anatomical variations of the recurrent motor branch of the median nerve. According to the Lanz classification, what is the most common anatomical course of the recurrent motor branch?

. Extraligamentous with a recurrent course
. Subligamentous with a recurrent course
. Transligamentous through the transverse carpal ligament
. Ulnar branching from the main median nerve trunk
. Branching proximal to the carpal tunnel

Correct Answer & Explanation

. Extraligamentous with a recurrent course

Explanation

The Lanz classification describes the anatomical variations of the recurrent motor branch of the median nerve. The most common configuration (Lanz Group I, occurring in ~46-90% of individuals depending on the series) is an extraligamentous branch that arises from the radial side of the median nerve just distal to the transverse carpal ligament and then takes a recurrent course to innervate the thenar musculature. The transligamentous course is a well-known variation that places the nerve at high risk during transverse carpal ligament release.

Question 1992

Topic: Wrist & Carpus

A 60-year-old woman undergoes volar locked plating for a comminuted, dorsally angulated distal radius fracture. Six weeks postoperatively, she suddenly loses the ability to actively extend her thumb interphalangeal joint. Rupture of the extensor pollicis longus (EPL) tendon in this scenario is most directly associated with which iatrogenic factor?

. Plate placement distal to the volar watershed line
. Over-distraction of the radiocarpal joint during reduction
. Prominent screw tips penetrating the dorsal cortex
. Use of a tourniquet for greater than 120 minutes
. Failure to repair the pronator quadratus

Correct Answer & Explanation

. Prominent screw tips penetrating the dorsal cortex

Explanation

EPL tendon rupture after volar locked plating of a distal radius fracture is most commonly caused by attrition from prominent screw tips penetrating the dorsal cortex. The EPL runs in the 3rd dorsal compartment, closely apposed to the dorsal cortex of the distal radius, making it highly vulnerable to protruding dorsal screws. Conversely, rupture of the flexor pollicis longus (FPL) tendon on the volar side is associated with prominent hardware placed distal to the volar watershed line.

Question 1993

Topic: Nerve & Tendon

A 45-year-old man presents with numbness in his small and ring fingers and intrinsic muscle weakness. Physical examination reveals a 'claw' posture of the ring and small fingers. Which of the following clinical findings would best differentiate a high ulnar nerve compression (cubital tunnel syndrome) from a low ulnar nerve compression (Guyon's canal syndrome)?

. A positive Froment's sign
. Weakness of the dorsal interossei
. A positive Wartenberg's sign
. Less pronounced clawing of the ring and small fingers (ulnar paradox)
. Preservation of two-point discrimination on the volar tip of the small finger

Correct Answer & Explanation

. Less pronounced clawing of the ring and small fingers (ulnar paradox)

Explanation

The 'ulnar paradox' refers to the phenomenon where a higher ulnar nerve lesion (at the elbow) results in a less pronounced claw deformity compared to a lower lesion (at the wrist). This occurs because a high lesion paralyzes the ulnar-innervated half of the flexor digitorum profundus (FDP) to the ring and small fingers, reducing the flexion force at the DIP joints. In a low lesion, the FDP is intact and forcefully flexes the DIP joints against the paralyzed intrinsics, creating a severe claw. Additionally, loss of sensation over the dorsal ulnar aspect of the hand indicates a lesion proximal to the wrist, as the dorsal sensory branch of the ulnar nerve branches off proximal to Guyon's canal.

Question 1994

Topic: 7. Hand and Wrist
A 42-year-old construction worker presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with advanced radioscaphoid and capitolunate arthritis, but the radiolunate articulation is completely preserved. Which of the following surgical interventions is most appropriate for this stage of Scaphoid Nonunion Advanced Collapse (SNAC)?
. Proximal row carpectomy (PRC)
. Four-corner arthrodesis with scaphoid excision
. Total wrist arthrodesis
. Scaphoid open reduction and internal fixation with vascularized bone grafting
. Radial styloidectomy

Correct Answer & Explanation

. Four-corner arthrodesis with scaphoid excision

Explanation

This patient has Stage III SNAC wrist (involvement of the radioscaphoid and capitolunate joints). Because the radiolunate joint is preserved (a hallmark of SNAC and SLAC wrists due to the spherical congruency of the lunate fossa), a motion-preserving salvage procedure is indicated. However, Proximal Row Carpectomy (PRC) is contraindicated in Stage III disease because the capitate head is arthritic and would articulate directly with the lunate fossa. Therefore, four-corner arthrodesis with scaphoid excision is the most appropriate treatment.

Question 1995

Topic: Hand Trauma & Infection



In a complete rupture of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint (Skier's thumb), a Stener lesion prevents non-operative healing. This lesion occurs when the torn ends of the UCL are separated by the aponeurosis of which of the following muscles?

. Abductor pollicis brevis
. Adductor pollicis
. Flexor pollicis brevis
. Extensor pollicis longus
. First dorsal interosseous

Correct Answer & Explanation

. Adductor pollicis

Explanation

A Stener lesion occurs when the distal attachment of the ulnar collateral ligament (UCL) is avulsed from the proximal phalanx of the thumb and flips proximally and superficially to the adductor pollicis aponeurosis. The aponeurosis becomes interposed between the torn ends of the ligament, preventing anatomical healing and thus serving as an absolute indication for surgical repair.

Question 1996

Topic: 7. Hand and Wrist

A 35-year-old rock climber presents with a 'popping' sensation in his long finger after attempting a forceful crimp grip. He demonstrates pain over the volar proximal phalanx and clinically evident bowstringing of the flexor tendons on resisted flexion. Which two annular pulleys of the flexor tendon sheath are considered biomechanically essential to prevent bowstringing and must be preserved or reconstructed?

. A1 and A3
. A2 and A4
. A1 and A5
. A3 and A5
. A2 and A3

Correct Answer & Explanation

. A2 and A4

Explanation

The flexor tendon sheath contains a series of annular (A) and cruciate (C) pulleys. The A2 pulley (located over the proximal phalanx) and the A4 pulley (located over the middle phalanx) are biomechanically the most critical for maintaining the flexor tendons closely apposed to the bone, thereby preventing bowstringing and maintaining the mechanical advantage (moment arm) of the flexor digitorum superficialis and profundus.Disruption of both results in clinically significant mechanical deficits.

Question 1997

Topic: 7. Hand and Wrist

A 40-year-old carpenter presents with weakness in his right hand. On examination, when asked to make an 'OK' sign with his thumb and index finger, the distal interphalangeal joint of the index finger and the interphalangeal joint of the thumb remain in extension, resulting in a 'flat' pinch. He has absolutely no sensory deficits in the forearm or hand. This clinical presentation represents a deficit in which of the following muscle-nerve pairings?

. Adductor pollicis; Ulnar nerve
. Flexor pollicis longus; Anterior interosseous nerve
. Flexor digitorum superficialis; Median nerve
. First dorsal interosseous; Ulnar nerve
. Extensor pollicis longus; Posterior interosseous nerve

Correct Answer & Explanation

. Flexor pollicis longus; Anterior interosseous nerve

Explanation

The patient has an abnormal 'OK' sign, indicating weakness or paralysis of the flexor pollicis longus (FPL) and the flexor digitorum profundus (FDP) to the index finger. These muscles, along with the pronator quadratus, are innervated by the Anterior Interosseous Nerve (AIN), a pure motor branch of the median nerve. AIN syndrome results in weakness of these muscles without any sensory loss.

Question 1998

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic right wrist pain. He reports a fall on an outstretched hand 10 years ago that was never treated. Radiographs reveal a scaphoid nonunion with advanced arthritic changes at the radioscaphoid joint, but the radiolunate joint is completely spared. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Radial styloidectomy
. Capitohamate fusion

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has Scaphoid Nonunion Advanced Collapse (SNAC) wrist. Stage II SNAC involves arthritis at the radioscaphoid joint, and Stage III involves the midcarpal joint, but both spare the radiolunate joint. Scaphoid excision and four-corner fusion (capitate, lunate, hamate, triquetrum) is the classic treatment. Proximal row carpectomy (PRC) is contraindicated if there is significant arthritis at the proximal capitate.

Question 1999

Topic: 7. Hand and Wrist

During surgical fasciectomy for severe Dupuytren's contracture, the surgeon must carefully identify and protect the neurovascular bundles. The pretendinous band of the palmar fascia becomes the pretendinous cord, causing MCP joint contracture. Which specific pathological cord is primarily responsible for contracture of the proximal interphalangeal (PIP) joint and central/superficial displacement of the neurovascular bundle?

. Pretendinous cord
. Central cord
. Spiral cord
. Lateral cord
. Natatory cord

Correct Answer & Explanation

. Spiral cord

Explanation

The spiral cord is formed from the coalescence of four structures: the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. As it contracts, it causes PIP joint flexion and crucially spirals around the neurovascular bundle, pulling it centrally, volarly (superficially), and proximally. This altered anatomy puts the digital nerve at extremely high risk of iatrogenic transection during surgery.

Question 2000

Topic: 7. Hand and Wrist

A 28-year-old carpenter sustains a volar laceration to his dominant index finger at the level of the proximal phalanx. He is unable to flex the proximal or distal interphalangeal joints. During surgical exploration, the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) are found to be completely transected in Zone II. What is the most appropriate management?

. Primary repair of the FDP only and excision of the FDS slips
. Primary repair of both FDP and FDS
. Primary repair of the FDS only and excision of the FDP
. Two-stage tendon reconstruction with a silicone rod
. Excision of the FDP and tenodesis of the distal phalanx

Correct Answer & Explanation

. Primary repair of both FDP and FDS

Explanation

In Zone II flexor tendon injuries, the standard of care is primary repair of both the FDP and FDS tendons. Repairing both tendons helps preserve the vincula (blood supply), maintains a smooth gliding surface, reduces the risk of postoperative bowstringing, and generally leads to superior functional outcomes compared to isolated FDP repair.

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