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7. Hand and Wrist MCQs

Practice Set 102 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 2021

Topic: 7. Hand and Wrist

A 65-year-old female complains of progressive clumsiness in her hands, difficulty buttoning her shirts, and a feeling of unsteadiness when walking.

Physical examination reveals hyperreflexia and a positive Hoffmann sign. How is the Hoffmann sign elicited on physical examination?

. Scraping the lateral plantar aspect of the foot
. Tapping the volar carpal tunnel
. Flicking the distal phalanx of the middle finger
. Tapping the distal biceps tendon
. Rapid, alternating supination and pronation of the forearm

Correct Answer & Explanation

. Flicking the distal phalanx of the middle finger

Explanation

The Hoffmann sign is an indicator of upper motor neuron dysfunction, commonly seen in cervical spondylotic myelopathy. It is elicited by stabilizing the patient's middle finger and rapidly flicking the distal phalanx downwards (volarward). A positive sign is the reflex flexion of the interphalangeal joint of the thumb and/or index finger. Scraping the plantar foot elicits the Babinski reflex. Tapping the carpal tunnel elicits a Tinel sign.

Question 2022

Topic: Nerve & Tendon
A 25-year-old male rugby player attempts to tackle an opponent by grabbing his jersey. He feels a sudden pop in his right ring finger and presents unable to actively flex the distal interphalangeal (DIP) joint. Radiographs demonstrate a large bony avulsion fragment located volar to the proximal interphalangeal (PIP) joint, failing to retract completely into the palm. According to the Leddy-Packer classification, what type of flexor digitorum profundus (FDP) avulsion injury is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

The Leddy-Packer classification categorizes FDP avulsion injuries (Jersey finger). Type I: The tendon retracts all the way into the palm; blood supply is severely compromised, requiring repair within 7-10 days. Type II: The tendon retracts to the level of the PIP joint, caught by the intact vincula; there may be a small fleck of bone. Type III: A large bony avulsion fragment that catches at the A4 pulley, preventing further retraction. The scenario describes a fragment at the PIP joint, which is characteristic of Type II, where it is held by the vincula longum.

Question 2023

Topic: 7. Hand and Wrist
A 28-year-old carpenter sustains a laceration to his volar index finger at the level of the proximal phalanx, transecting both the FDS and FDP tendons. This injury corresponds to which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically called 'no man's land') extends from the A1 pulley (distal palmar crease) to the FDS insertion (mid-middle phalanx). Lacerations here commonly involve both FDS and FDP and have a high risk of adhesion formation due to the tightly constrained fibro-osseous sheath.

Question 2024

Topic: Nerve & Tendon

De Quervain's tenosynovitis involves inflammation of the first dorsal compartment of the wrist. Which tendons are located within this compartment?

. Extensor pollicis longus and extensor pollicis brevis
. Abductor pollicis longus and extensor pollicis brevis
. Abductor pollicis longus and abductor pollicis brevis
. Extensor carpi radialis longus and brevis
. Extensor digitorum communis and extensor indicis proprius

Correct Answer & Explanation

. Abductor pollicis longus and extensor pollicis brevis

Explanation

The first dorsal compartment contains the Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB). The Extensor Pollicis Longus (EPL) is in the third compartment and routes around Lister's tubercle. De Quervain's is classically diagnosed with a positive Finkelstein's or Eichhoff's test.

Question 2025

Topic: 7. Hand and Wrist

A 25-year-old male manual laborer complains of persistent dorsal, central wrist pain. Radiographs show sclerosis of the lunate with preservation of its height and architecture. Ulnar variance is determined to be negative 2 mm. What is the most appropriate surgical intervention to halt disease progression?

. Proximal row carpectomy
. Scaphoid-trapezium-trapezoid (STT) arthrodesis
. Radial shortening osteotomy
. Total wrist arthrodesis
. Lunate excision and silastic arthroplasty

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Kienbock's disease (avascular necrosis of the lunate), Lichtman Stage II (sclerosis without collapse), in the setting of negative ulnar variance. A joint leveling procedure, such as a radial shortening osteotomy or ulnar lengthening, is the treatment of choice. This mechanically unloads the radiolunate joint, theoretically promoting revascularization of the lunate and halting disease progression before carpal collapse occurs.

Question 2026

Topic: 7. Hand and Wrist

A 30-year-old carpenter sustains a volar laceration over the proximal phalanx of his index finger, severing both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons (Zone II). Following primary surgical repair, the hand therapist initiates a rehabilitation protocol that uses a dorsal blocking splint, allowing for active extension and utilizing rubber band traction attached to the fingernail to achieve passive flexion. Which protocol is being utilized?

. Kleinert protocol
. Duran protocol
. Early active motion protocol
. Immobilization protocol
. Strickland protocol

Correct Answer & Explanation

. Kleinert protocol

Explanation

The Kleinert protocol is a dynamic splinting program used after flexor tendon repair. It involves a dorsal blocking splint (which prevents passive extension past a certain angle) combined with rubber bands attached to the patient's fingernails and anchored volarly. This allows the patient to perform active extension against the resistance of the rubber band, while the band passively pulls the finger back into flexion, protecting the repair.

Question 2027

Topic: 7. Hand and Wrist
A 40-year-old manual laborer presents with central dorsal wrist pain. Radiographs show sclerosis and early collapse of the lunate, without fixed scaphoid rotation or pan-carpal arthritis. Ulnar variance is -3 mm. According to the Lichtman classification, this represents Stage IIIa Kienbock's disease. Which of the following is the most appropriate surgical intervention?
. Proximal row carpectomy (PRC)
. Total wrist arthrodesis
. Radial shortening osteotomy
. Scaphoid-trapezium-trapezoid (STT) fusion
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Kienbock's disease, ulnar negative variance increases sheer stress on the lunate. For Stage II and Stage IIIa (lunate collapse but preserved carpal height and normal scaphoid alignment), joint leveling procedures like a radial shortening osteotomy are indicated to offload the lunate. Salvage procedures like PRC or intercarpal fusions are reserved for later stages (IIIb or IV).

Question 2028

Topic: Wrist & Carpus
A 45-year-old man presents with chronic wrist pain and a history of a scaphoid fracture 10 years ago. Radiographs demonstrate a scaphoid nonunion. There is radioscaphoid arthritis and narrowing of the scaphocapitate joint, but the lunocapitate and radiolunate joints are completely preserved. According to the Scaphoid Nonunion Advanced Collapse (SNAC) classification, what is the stage of his arthritis?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage II

Explanation

SNAC arthritis staging progresses predictably based on altered kinematics. Stage I involves arthritis localized to the radial styloid and the distal scaphoid fragment. Stage II progresses to involve the scaphocapitate joint. Stage III involves the lunocapitate joint. The radiolunate joint is uniquely spared in both SLAC and SNAC wrists due to the spherical congruency of the lunate fossa.

Question 2029

Topic: 7. Hand and Wrist

A 25-year-old carpenter lacerates his index finger volar surface at the level of the proximal phalanx base (Zone II). Both the FDS and FDP are lacerated.

What is the optimal timing and treatment?

. Primary repair within 24 hours using a 2-strand core suture
. Primary repair within 1-2 weeks using a 4-strand or 6-strand core suture
. Delayed primary repair at 4 weeks
. Tendon graft at 6 weeks
. Two-stage tendon reconstruction

Correct Answer & Explanation

. Primary repair within 1-2 weeks using a 4-strand or 6-strand core suture

Explanation

Zone II flexor tendon injuries are best treated with primary repair, ideally within the first 1-2 weeks. Multi-strand core sutures (4 or 6 strands) provide sufficient strength to allow for early active motion protocols, which improve outcomes.

Question 2030

Topic: Nerve & Tendon

A 45-year-old typist complains of numbness and tingling in the small and ring fingers of her right hand. Examination reveals a positive Tinel's sign at the elbow and weakness of the dorsal interossei. The flexor carpi ulnaris (FCU) strength is normal. Where is the most likely site of compression?

. Between the two heads of the FCU (Cubital tunnel)
. Guyon's canal
. Ligament of Struthers
. Arcade of Frohse
. Pronator teres syndrome

Correct Answer & Explanation

. Between the two heads of the FCU (Cubital tunnel)

Explanation

The symptoms indicate ulnar nerve compression. While FCU strength is often preserved due to its proximal innervation (branches sometimes arise proximal to the compression), compression typically occurs at the cubital tunnel (Osborne's ligament/between the heads of FCU). Guyon's canal compression would not cause Tinel's at the elbow.

Question 2031

Topic: 7. Hand and Wrist
A 40-year-old laborer complains of chronic radial-sided wrist pain. Radiographs demonstrate advanced arthrosis of the radioscaphoid joint and capitolunate joint, with a preserved radiolunate articulation. Based on these findings, which of the following is the most appropriate surgical treatment?
. Scaphoid open reduction internal fixation with vascularized bone graft
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Radial styloidectomy and scaphoid fixation
. Total wrist arthrodesis

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The clinical scenario describes Scaphoid Nonunion Advanced Collapse (SNAC) Stage III, characterized by arthrosis extending to the capitolunate joint but sparing the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in the presence of capitolunate arthrosis because the capitate must articulate with the lunate fossa of the radius. Therefore, scaphoid excision and four-corner fusion is the most appropriate motion-preserving salvage procedure.

Question 2032

Topic: Nerve & Tendon

A 35-year-old female undergoes surgical release of the first dorsal extensor compartment for recalcitrant De Quervain's tenosynovitis.

To prevent incomplete relief of symptoms, the surgeon must specifically look for and release a separate subsheath that frequently houses which of the following tendons?

. Extensor pollicis longus
. Abductor pollicis longus
. Extensor pollicis brevis
. Extensor carpi radialis longus
. Extensor indicis proprius

Correct Answer & Explanation

. Extensor pollicis brevis

Explanation

De Quervain's tenosynovitis involves the first dorsal compartment, which contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. Anatomical variations are common, and in a significant percentage of patients (up to 40%), the EPB is located within its own distinct subsheath. Failure to identify and release this EPB subsheath is the most common cause of persistent symptoms following surgery.

Question 2033

Topic: 7. Hand and Wrist
A 42-year-old manual laborer presents with chronic radial-sided wrist pain 10 years after an untreated fall on an outstretched hand. Radiographs demonstrate a scaphoid nonunion advanced collapse (SNAC). Arthrosis is visible at both the radioscaphoid articulation and the capitolunate articulation, but the radiolunate joint is perfectly preserved (Stage III SNAC). Which of the following surgical procedures is strictly contraindicated in this patient?
. Proximal row carpectomy (PRC)
. Four-corner arthrodesis
. Total wrist arthrodesis
. Scaphoid excision and capitolunate fusion
. Denervation of the wrist

Correct Answer & Explanation

. Four-corner arthrodesis

Explanation

A Proximal Row Carpectomy (PRC) relies on a preserved, healthy articulation between the proximal pole of the capitate and the lunate fossa of the radius. In Stage III SNAC (or SLAC) wrist, capitolunate arthritis is present, meaning the capitate cartilage is compromised. Therefore, PRC is contraindicated. A four-corner fusion (which fuses the capitate, lunate, hamate, and triquetrum) is the preferred motion-preserving salvage procedure for Stage III disease.

Question 2034

Topic: Nerve & Tendon

A surgeon is performing a percutaneous trigger finger release of the index finger. The A1 pulley is being transected. If the cutting instrument strays too far radially during the release, which structure is at greatest risk of iatrogenic injury?

. Ulnar digital nerve of the index finger
. Radial digital nerve of the index finger
. Ulnar digital artery of the index finger
. Flexor digitorum superficialis tendon
. Proper palmar digital nerve to the thumb

Correct Answer & Explanation

. Radial digital nerve of the index finger

Explanation

During an A1 pulley release of the index finger, the radial digital nerve is at exceptional risk because it courses obliquely over the flexor sheath near the MP joint crease, crossing closer to the midline than in other digits. Similarly, the radial digital nerve of the thumb is at risk during thumb trigger release for the same anatomical reason.

Question 2035

Topic: 7. Hand and Wrist

A 38-year-old avid cyclist presents with a two-month history of numbness and tingling isolated to his right ring and small fingers. Physical examination reveals weakness in interossei abduction and adduction. Wrist flexion and extension strength are normal. Tinel's sign is positive over Guyon's canal at the wrist. Which of the following anatomic structures forms the floor of Guyon's canal?

. Volar carpal ligament
. Transverse carpal ligament (flexor retinaculum) and pisohamate ligament
. Pisiform and the hook of the hamate
. Palmar aponeurosis
. Extensor retinaculum

Correct Answer & Explanation

. Transverse carpal ligament (flexor retinaculum) and pisohamate ligament

Explanation

Guyon's canal (the ulnar tunnel) contains the ulnar nerve and artery. Its boundaries are critical for understanding compression syndromes (like 'cyclist's palsy'). The roof is formed by the volar carpal ligament (and palmaris brevis). The ulnar border is the pisiform, and the radial border is the hook of the hamate. The floor is formed by the transverse carpal ligament (flexor retinaculum) and the pisohamate ligament.

Question 2036

Topic: 7. Hand and Wrist
A 42-year-old manual laborer presents with chronic progressive wrist pain and weakness. In the predictable progression of Scapholunate Advanced Collapse (SLAC), which articulation is characteristically spared due to its concentric spherical anatomy?
. Radioscaphoid
. Capitolunate
. Radiolunate
. Scaphocapitate
. Trapeziometacarpal

Correct Answer & Explanation

. Radiolunate

Explanation

In SLAC wrist, the radiolunate articulation is characteristically spared, even in late stages. This is due to the concentric, spherical shape of the radiolunate joint, which distributes forces evenly and avoids the abnormal shear forces that cause early degeneration in the radioscaphoid (Stage I/II) and capitolunate (Stage III) joints.

Question 2037

Topic: 7. Hand and Wrist
A 24-year-old carpenter sustains a volar laceration over the proximal phalanx of his index finger, severing both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. This injury corresponds to which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically called 'No Man's Land') extends from the A1 pulley (distal palmar crease) to the insertion of the FDS on the middle phalanx. Injuries here typically involve both the FDS and FDP tendons within the narrow fibro-osseous sheath, making surgical repair challenging due to a high risk of postoperative adhesions.

Question 2038

Topic: Nerve & Tendon
A 22-year-old rugby player grasps an opponent's jersey and forcefully extends his flexing ring finger, sustaining an avulsion of the flexor digitorum profundus (FDP) tendon. The avulsed tendon retracts proximally into the palm (Zone II/III). According to the Leddy and Packer classification, what type of injury is this, and what is the recommended timeframe for surgical repair?
. Type I; repair within 7-10 days
. Type II; repair within 3-4 weeks
. Type III; repair anytime within 3 months
. Type I; delayed reconstruction after 6 weeks
. Type IV; immediate primary arthrodesis of the DIP joint

Correct Answer & Explanation

. Type I; repair within 7-10 days

Explanation

This describes a Leddy and Packer Type I Jersey finger injury, where the FDP tendon retracts into the palm. This proximal retraction completely disrupts the vincula (the tendon's blood supply). To prevent tendon necrosis and irreversible myostatic contracture, early primary repair within 7-10 days is strictly recommended.

Question 2039

Topic: 7. Hand and Wrist
A 35-year-old carpenter suffers a laceration to the volar aspect of his index finger at the level of the proximal phalanx. He is unable to flex the distal interphalangeal joint. This injury is located in a flexor tendon zone historically referred to as 'no man's land' due to poor outcomes. Which zone is this?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Flexor tendon Zone II extends from the distal palmar crease (A1 pulley) to the insertion of the flexor digitorum superficialis (FDS) tendon on the middle phalanx. In this zone, both the FDS and flexor digitorum profundus (FDP) tendons run tightly together within the fibro-osseous digital sheath. Historically, it was called 'no man's land' by Bunnell because primary repairs in this area often failed due to adhesions between the tendons and the sheath. Advances in surgical technique and early active rehabilitation have significantly improved outcomes.

Question 2040

Topic: 7. Hand and Wrist

Which of the following is considered an important component in treating the lesion shown in Figure 56?

Orthopedic Surgery Board Review 2026 | High-Yield MCQs - Set 7 - Figure 91

. Excision of the skin in addition to the cyst
. Resection of the nail plate
. Excision of bony osteophytes from the distal interphalangeal (DIP) joint
. Injection of corticosteroid into the DIP joint
. Resection of part of the collateral ligament and extensor mechanism

Correct Answer & Explanation

. Excision of bony osteophytes from the distal interphalangeal (DIP) joint

Explanation

Mucoid cysts are commonly associated with DIP joint arthritis. Two treatment options are commonly used: (1) aspiration/drainage and injection of corticosteroid and (2) surgical excision. When performing the surgery, excision of the bony osteophytes about the DIP joint is helpful in achieving a cure. There are no reports of significant benefit with nail removal or partial ligament or extensor tendon resection. Some authors have advocated skin excision and rotational flaps for wound coverage, but this is somewhat controversial. Rizzo M, Beckenbaugh RD: Treatment of mucous cysts of the fingers: Review of 134 cases with minimum 2-year follow-up evaluation. J Hand Surg Am 2003;28:519-524.

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