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7. Hand and Wrist MCQs

Practice Set 101 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 2001

Topic: 7. Hand and Wrist

A 55-year-old female undergoes volar locked plating for a comminuted intra-articular distal radius fracture.

Six months postoperatively, she suddenly loses the ability to actively flex the interphalangeal joint of her thumb. What is the most likely pathophysiologic cause of this complication?

. Attritional rupture of the flexor pollicis longus (FPL) tendon due to prominent hardware distal to the watershed line
. Attritional rupture of the extensor pollicis longus (EPL) tendon due to dorsally prominent screws
. Delayed median nerve palsy due to carpal tunnel syndrome
. Postoperative adhesions tethering the flexor digitorum profundus (FDP) tendons
. Late-onset anterior interosseous nerve (AIN) palsy secondary to scar tissue formation

Correct Answer & Explanation

. Attritional rupture of the flexor pollicis longus (FPL) tendon due to prominent hardware distal to the watershed line

Explanation

The inability to actively flex the thumb IP joint several months after volar plating of the distal radius is most commonly due to attritional rupture of the flexor pollicis longus (FPL) tendon. This typically occurs when the volar plate is placed too distally, crossing the 'watershed line' of the distal radius, leading to mechanical friction between the plate edge and the FPL tendon during wrist motion.

Question 2002

Topic: Nerve & Tendon

A 6-year-old girl falls from monkey bars and sustains a widely displaced extension-type supracondylar fracture of the distal humerus.

On physical examination prior to reduction, she is unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger, resulting in an inability to make an 'A-OK' sign. Which nerve is most likely injured?

. Radial nerve
. Ulnar nerve
. Anterior interosseous nerve (AIN)
. Posterior interosseous nerve (PIN)
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve (AIN)

Explanation

The anterior interosseous nerve (AIN), a motor branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. It innervates the flexor pollicis longus (FPL) and the flexor digitorum profundus (FDP) to the index and middle fingers. Injury results in the inability to flex the IP joint of the thumb and DIP joint of the index finger, preventing the patient from making an 'OK' sign.

Question 2003

Topic: 7. Hand and Wrist

A 24-year-old carpenter sustains a volar laceration to the index finger at the level of the proximal phalanx, resulting in a Zone II flexor tendon injury. During primary repair, the surgeon carefully preserves the flexor tendon sheath pulleys. Which two pulleys are most biomechanically critical to prevent bowstringing of the flexor tendons?

. A1 and A3
. A1 and A5
. A2 and A3
. A2 and A4
. A3 and C1

Correct Answer & Explanation

. A2 and A4

Explanation

In the flexor tendon pulley system of the fingers, there are 5 annular (A) and 3 cruciform (C) pulleys. The A2 pulley (located over the proximal phalanx) and the A4 pulley (located over the middle phalanx) are the major mechanical pulleys. Preservation or reconstruction of the A2 and A4 pulleys is absolutely critical to prevent bowstringing of the flexor tendons, which would cause significant loss of mechanical advantage and active range of motion.

Question 2004

Topic: 7. Hand and Wrist

A 24-year-old man sustains a proximal pole scaphoid fracture after a fall on an outstretched hand. He is counseled regarding the high risk of nonunion and avascular necrosis associated with this specific fracture pattern. Which of the following accurately describes the primary blood supply to the proximal pole of the scaphoid?

. Retrograde blood flow from the dorsal carpal branch of the radial artery
. Antegrade blood flow from the superficial palmar arch
. Direct branches from the anterior interosseous artery
. Retrograde blood flow from the ulnar artery via the deep palmar arch
. Antegrade blood flow from the volar carpal branch of the radial artery

Correct Answer & Explanation

. Retrograde blood flow from the dorsal carpal branch of the radial artery

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters the bone distally and provides retrograde blood flow to the proximal pole. This retrograde supply makes proximal pole fractures particularly vulnerable to avascular necrosis and nonunion.

Question 2005

Topic: 7. Hand and Wrist

A 30-year-old carpenter sustains a laceration to his dominant index finger, resulting in a Zone II injury of both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP). Postoperatively, the hand therapist initiates an early active motion rehabilitation protocol. The primary rationale for utilizing early active motion over prolonged immobilization in this specific scenario is to:

. Increase the tensile strength of the tendon faster than immobilization
. Promote primary tendon healing without a cellular phase
. Prevent the formation of restrictive peritendinous adhesions while minimizing the risk of rupture
. Allow early return to heavy manual labor within 3 weeks
. Prevent contracture of the lumbrical muscles

Correct Answer & Explanation

. Prevent the formation of restrictive peritendinous adhesions while minimizing the risk of rupture

Explanation

Early active or passive motion protocols following flexor tendon repair in Zone II are critical to facilitate intrinsic tendon healing and promote tendon glide. This movement helps prevent the formation of restrictive peritendinous adhesions (which limit excursion) while providing enough controlled stress to stimulate healing without rupturing the repair.

Question 2006

Topic: 7. Hand and Wrist
A 32-year-old mechanic sustains a volar laceration to his middle finger at the level of the proximal phalanx, resulting in a loss of active flexion at both the proximal and distal interphalangeal joints. This injury is located within which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Verdan's flexor tendon zones classify the anatomical locations of flexor tendon injuries. Zone II (historically called 'no man's land' due to historically poor surgical outcomes) extends from the proximal aspect of the A1 pulley (distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. Lacerations here frequently involve both the FDS and flexor digitorum profundus (FDP) tendons within the tight fibro-osseous sheath.

Question 2007

Topic: Wrist & Carpus
Review the clinical image. What is the earliest radiographic change expected in the natural progression of Scaphoid Nonunion Advanced Collapse (SNAC) if left untreated?
. Radioscaphoid joint arthritis (radial styloid)
. Capitolunate joint arthritis
. Scaphotrapezial joint arthritis
. Radiolunate joint arthritis
. Ulnocarpal arthritis

Correct Answer & Explanation

. Radioscaphoid joint arthritis (radial styloid)

Explanation

Scaphoid Nonunion Advanced Collapse (SNAC) follows a predictable pattern of degenerative changes. Stage I involves arthritis isolated to the articulation between the scaphoid and the radial styloid. Stage II progresses to involve the entire radioscaphoid joint. Stage III involves the capitolunate joint. The radiolunate joint is characteristically spared because the lunate fossa cartilage remains concentric with the lunate.

Question 2008

Topic: Nerve & Tendon

During surgical decompression of the ulnar nerve at the elbow, an anatomical release is planned.

What is the most proximal potential site of ulnar nerve compression that must be evaluated?

. Arcade of Struthers
. Medial intermuscular septum
. Osborne's ligament
. Aponeurosis of the flexor carpi ulnaris
. Deep flexor pronator aponeurosis

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The potential sites of ulnar nerve compression around the elbow from proximal to distal include: the Arcade of Struthers (about 8 cm proximal to the medial epicondyle), the medial intermuscular septum, the medial epicondyle itself, Osborne's ligament (cubital tunnel), and the deep aponeurosis of the FCU.

Question 2009

Topic: 7. Hand and Wrist

A 24-year-old male falls on an outstretched hand and sustains a proximal pole scaphoid fracture.

This specific fracture location has a notoriously high rate of avascular necrosis and nonunion. Which vessel is the predominant source of blood supply to the proximal pole of the scaphoid?

. Superficial palmar arch
. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Anterior interosseous artery
. Deep palmar arch

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The primary blood supply to the scaphoid is retrograde. The dorsal carpal branch of the radial artery enters the dorsal ridge of the scaphoid at the waist and supplies the proximal 70-80% of the bone. A fracture through the proximal pole or waist often disrupts this retrograde flow, putting the proximal pole at high risk for avascular necrosis. The volar carpal branch supplies only the distal 20-30% of the bone.

Question 2010

Topic: 7. Hand and Wrist

A 55-year-old female with severe, long-standing carpal tunnel syndrome is scheduled for an open carpal tunnel release. To avoid iatrogenic injury, the surgeon must be aware of the anatomic variations of the recurrent motor branch of the median nerve. What is the most common anatomic relationship of the recurrent motor branch to the transverse carpal ligament?

. Extraligamentous with a recurrent course
. Subligamentous
. Transligamentous
. Preligamentous
. Ulnar to the hook of the hamate

Correct Answer & Explanation

. Extraligamentous with a recurrent course

Explanation

The extraligamentous origin with a recurrent course is the most common anatomic variation of the recurrent motor branch of the median nerve, occurring in approximately 46-90% of cases (historically cited around 50-80% in various studies). In this pattern, the branch arises distal to the transverse carpal ligament and loops back to innervate the thenar muscles. Subligamentous (arising within the tunnel) and transligamentous (piercing the ligament) are less common but put the nerve at higher risk of direct injury during ligament division if the surgeon strays too far radially.

Question 2011

Topic: Wrist & Carpus
A 45-year-old manual laborer presents with chronic, progressive right wrist pain. Radiographs demonstrate a nonunion of the scaphoid with advanced arthritic changes narrowing the radioscaphoid articulation as well as the scaphocapitate joint. The radiolunate joint is completely preserved. What is the correct classification and an appropriate surgical treatment for this condition?
. SNAC I; Radial styloidectomy
. SNAC II; Proximal row carpectomy
. SNAC III; Scaphoid excision and 4-corner fusion
. SNAC III; Total wrist arthrodesis
. SLAC II; Scapholunate ligament repair

Correct Answer & Explanation

. SNAC II; Proximal row carpectomy

Explanation

Scaphoid Nonunion Advanced Collapse (SNAC) progresses in a predictable pattern. SNAC I involves only the radial styloid and distal scaphoid pole. SNAC II involves the entire radioscaphoid joint and the scaphocapitate joint. SNAC III progresses to periscaphoid arthritis (including the capitolunate joint). The radiolunate joint is characteristically spared. A condition involving the radioscaphoid and scaphocapitate joints is SNAC II. Acceptable salvage procedures for SNAC II include proximal row carpectomy (PRC) or scaphoid excision with 4-corner fusion.

Question 2012

Topic: 7. Hand and Wrist

Following a primary repair of a Zone II flexor digitorum profundus (FDP) laceration, a hand surgeon opts for a specific postoperative rehabilitation protocol to prevent tendon adhesions. The protocol employs a dorsal blocking splint, and the patient actively extends the digit against the resistance of a rubber band attached to the fingernail, which then passively pulls the digit back into flexion. Which protocol does this describe?

. Duran protocol
. Kleinert protocol
. Early active motion protocol
. Modified Chow protocol
. Immobilization protocol

Correct Answer & Explanation

. Kleinert protocol

Explanation

The Kleinert protocol utilizes active extension and passive flexion via rubber band traction while the hand is in a dorsal block splint. The Duran protocol involves controlled passive extension and passive flexion exercises performed by the patient or therapist. Early active motion protocols (e.g., Belfast, Indiana) allow true active flexion and extension within strict limits, minimizing adhesions but requiring a stronger initial core suture construct (e.g., 4 or 6 strands).

Question 2013

Topic: 7. Hand and Wrist
A 24-year-old carpenter sustains a deep laceration to the volar aspect of his right index finger exactly at the level of the proximal interphalangeal (PIP) joint flexion crease. Examination shows absent active flexion at both the PIP and DIP joints. During surgical exploration, complete lacerations of the FDP and FDS tendons are identified. In which flexor tendon zone is this injury located?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (also known historically as 'no man's land') extends from the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. A laceration at the level of the PIP joint falls squarely within Zone II, where both the FDS and FDP tendons are enclosed within the tight fibro-osseous sheath.

Question 2014

Topic: 7. Hand and Wrist

A 45-year-old woman presents with severe numbness and tingling in her thumb, index, and middle fingers, confirming a diagnosis of severe carpal tunnel syndrome. She is scheduled for an open carpal tunnel release. Which of the following anatomical structures is NOT contained within the true carpal tunnel?

. Flexor pollicis longus tendon
. Median nerve
. Flexor carpi radialis tendon
. Flexor digitorum superficialis tendons
. Flexor digitorum profundus tendons

Correct Answer & Explanation

. Flexor carpi radialis tendon

Explanation

The carpal tunnel contains exactly 10 structures: the median nerve, 4 flexor digitorum superficialis (FDS) tendons, 4 flexor digitorum profundus (FDP) tendons, and the flexor pollicis longus (FPL) tendon. The flexor carpi radialis (FCR) tendon runs within its own separate fibro-osseous sheath within the fibers of the transverse carpal ligament, outside the main carpal tunnel.

Question 2015

Topic: 7. Hand and Wrist

A 22-year-old man falls onto an outstretched hand and presents with marked anatomic snuffbox tenderness. Initial radiographs are negative, but an MRI obtained 3 days later confirms a nondisplaced fracture traversing the proximal pole of the scaphoid. What is the primary anatomical reason this specific fracture pattern is highly predisposed to avascular necrosis and nonunion?

. The proximal pole is supplied exclusively by the volar carpal branch of the radial artery
. The primary blood supply enters the distal pole via the dorsal carpal branch of the radial artery and flows retrograde
. The proximal pole relies entirely on diffusion from synovial fluid without any direct intraosseous vessels
. The blood supply originates from the deep palmar arch, which is easily disrupted by capsular swelling
. The scaphoid relies entirely on the superficial palmar arch which enters through the scapholunate ligament

Correct Answer & Explanation

. The primary blood supply enters the distal pole via the dorsal carpal branch of the radial artery and flows retrograde

Explanation

The major blood supply to the scaphoid (providing 70-80% of its vascularity) comes from the dorsal carpal branch of the radial artery. These vessels enter the scaphoid along its dorsal ridge at the level of the waist and distal pole, and then perfuse the proximal pole in a retrograde fashion. A fracture at the waist or proximal pole interrupts this retrograde flow, putting the proximal fragment at extremely high risk for avascular necrosis.

Question 2016

Topic: 7. Hand and Wrist



A 22-year-old presents with radial-sided wrist pain after a fall. A scaphoid waist fracture is diagnosed. The proximal pole of the scaphoid is at high risk for avascular necrosis due to its tenuous blood supply. Which of the following best describes the predominant arterial supply to the scaphoid?

. Palmar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Anterior interosseous artery
. Ulnar artery via the deep palmar arch
. Superficial palmar branch of the radial artery

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The scaphoid receives 70-80% of its blood supply from the dorsal carpal branch of the radial artery. These vessels enter the scaphoid via a dorsal ridge at the waist and distal pole, flowing in a retrograde fashion to supply the proximal pole. Because of this retrograde flow, fractures at the waist or proximal pole highly compromise the blood supply to the proximal fragment, leading to a high rate of avascular necrosis and nonunion.

Question 2017

Topic: 7. Hand and Wrist

In the surgical anatomy of the hand, Flexor Tendon Zone II (historically referred to as 'no man's land') is defined by specific anatomical landmarks. Which of the following best describes the boundaries of Zone II?

. From the carpal tunnel to the proximal edge of the A1 pulley
. From the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS)
. From the insertion of the FDS to the insertion of the flexor digitorum profundus (FDP)
. Proximal to the transverse carpal ligament
. Specifically within the camper's chiasm only

Correct Answer & Explanation

. From the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS)

Explanation

Flexor Tendon Zone II extends from the proximal edge of the A1 pulley (at the level of the metacarpal neck/distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. It is termed 'no man's land' because historically, primary repair of both the FDS and FDP in this tight fibro-osseous sheath yielded poor results due to adhesion formation.

Question 2018

Topic: Nerve & Tendon

A 28-year-old professional cyclist presents with intrinsic muscle weakness in his right hand but normal sensation over the volar and dorsal aspects of the small finger. He is diagnosed with ulnar nerve compression at Guyon's canal. This clinical presentation most likely correlates with compression at which specific zone of Guyon's canal?

. Zone 1
. Zone 2
. Zone 3
. Zone 4
. Zone 5

Correct Answer & Explanation

. Zone 2

Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the bifurcation; compression here causes mixed motor and sensory deficits. Zone 2 contains only the deep motor branch; compression here (often from a ganglion or hook of hamate fracture) causes isolated motor weakness of ulnar-innervated intrinsic muscles, with normal sensation. Zone 3 contains the superficial sensory branch; compression causes isolated sensory deficits.

Question 2019

Topic: 7. Hand and Wrist



Following a flexor tendon repair in Zone 2, a patient experiences bowstringing of the flexor tendons. During the surgical approach, the surgeon aggressively vented the pulley system. Which two annular pulleys are most critical to preserve to prevent bowstringing and loss of mechanical advantage in the finger?

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

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 and A4 pulleys are the most crucial biomechanical pulleys in the digital flexor sheath. The A2 pulley arises from the proximal phalanx, and the A4 pulley arises from the middle phalanx. Preserving or reconstructing these pulleys is essential to prevent bowstringing of the flexor tendons, which drastically reduces tendon excursion efficiency and grip strength.

Question 2020

Topic: 7. Hand and Wrist

A 55-year-old carpenter presents with a long history of dominant wrist pain. Radiographs demonstrate advanced scapholunate advanced collapse (SLAC).

The surgeon is deciding between a four-corner fusion and a proximal row carpectomy (PRC). Which of the following radiographic findings represents an absolute contraindication to performing a proximal row carpectomy?

. Radioscaphoid arthritis
. Radiolunate arthritis
. Capitolunate arthritis
. Scaphotrapezial arthritis
. Ulnocarpal abutment

Correct Answer & Explanation

. Capitolunate arthritis

Explanation

A proximal row carpectomy (PRC) involves excising the scaphoid, lunate, and triquetrum, allowing the capitate to articulate within the lunate fossa of the distal radius. Therefore, the articular surfaces of the proximal capitate head and the lunate fossa must be preserved. Capitolunate arthritis (which involves the capitate head) or damage to the lunate fossa are contraindications to PRC, and a four-corner fusion or total wrist arthrodesis should be considered instead.

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