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7. Hand and Wrist MCQs

Practice Set 104 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 2061

Topic: 7. Hand and Wrist

A 30-year-old carpenter suffers a laceration to the volar aspect of his index finger at the level of the proximal phalanx (Zone II). He undergoes surgical repair with a 4-strand core suture and an epitendinous repair. What is the most critical biomechanical benefit of adding a peripheral epitendinous suture?

. It increases the ultimate tensile strength of the repair by 10-20%
. It significantly increases the gap resistance and smooths the tendon surface
. It allows for immediate passive range of motion without a splint
. It prevents postoperative tendon adhesions to the A2 pulley
. It improves intrinsic blood supply to the tendon via the vincula

Correct Answer & Explanation

. It significantly increases the gap resistance and smooths the tendon surface

Explanation

An epitendinous suture increases the overall strength of a flexor tendon repair by up to 50%, but its most critical biomechanical contributions are increasing resistance to gap formation and smoothing the repair site to improve gliding.

Question 2062

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion advanced collapse (SNAC) pattern with radioscaphoid and midcarpal arthritis, but preservation of the radiolunate articulation. Which of the following is the most appropriate surgical intervention?
. Total wrist arthrodesis
. Scaphoid excision and four-corner fusion
. Proximal row carpectomy (PRC)
. Radial styloidectomy
. Vascularized bone grafting of the scaphoid

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

In a Stage II or III SNAC wrist with midcarpal and radioscaphoid arthritis but a preserved radiolunate joint, a four-corner fusion with scaphoid excision is indicated. Proximal row carpectomy (PRC) is contraindicated if there is significant capitate pole arthritis, which typically occurs in later stages.

Question 2063

Topic: 7. Hand and Wrist

A 45-year-old patient develops severe pain, swelling, skin discoloration, and allodynia in her left hand and wrist three weeks after a distal radius fracture. Radiographs show no hardware issues or signs of infection. Nerve conduction studies are normal. Based on the clinical presentation, Complex Regional Pain Syndrome (CRPS) Type I is suspected.

What is the MOST appropriate initial management strategy?

. Brachial plexus block and corticosteroids
. Intensive physical therapy focusing on desensitization and active range of motion
. Opioid analgesics and immobilization
. Surgical exploration to rule out nerve compression
. Sympathectomy

Correct Answer & Explanation

. Intensive physical therapy focusing on desensitization and active range of motion

Explanation

Early diagnosis and aggressive multidisciplinary management are crucial for CRPS. The cornerstone of initial management for CRPS Type I is intensive physical and occupational therapy focused on desensitization, active range of motion, and functional restoration. This helps prevent stiffness and contractures, and retrains the nervous system. While medications (e.g., gabapentinoids, NSAIDs) and regional blocks (e.g., stellate ganglion blocks, option A) can be used as adjuncts for pain control, they are not the primary or sole treatment. Opioids and immobilization (option C) are generally avoided as they can worsen the condition. Surgical exploration (option D) is not indicated without specific signs of nerve compression. Sympathectomy (option E) is a more invasive option reserved for refractory cases.

Question 2064

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic dorsal wrist pain. Radiographs reveal advanced radiocarpal arthritis sparing the radiolunate joint, but with proximal migration of the capitate and capitolunate arthritis. He is diagnosed with Scapholunate Advanced Collapse (SLAC) Stage III. What is the most appropriate surgical treatment?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Radial styloidectomy
. Scapholunate ligament reconstruction using a tendon graft

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

SLAC Stage III involves arthritic changes of the capitolunate joint. Proximal row carpectomy is contraindicated because the arthritic capitate head would articulate with the lunate fossa, leading to rapid failure. Scaphoid excision with four-corner fusion is the treatment of choice.

Question 2065

Topic: Wrist & Carpus

A 55-year-old female presents with a sudden inability to actively flex the interphalangeal joint of her right thumb, 8 months after undergoing open reduction and internal fixation of a distal radius fracture with a volar locking plate.

What technical error during the initial surgery most likely caused this complication?

. Placement of screws past the dorsal cortex
. Positioning the plate distal to the watershed line
. Failure to repair the pronator quadratus
. Over-reduction of the volar tilt
. Injury to the anterior interosseous nerve during the surgical approach

Correct Answer & Explanation

. Positioning the plate distal to the watershed line

Explanation

Attritional rupture of the flexor pollicis longus (FPL) tendon is a classic complication of volar plating for distal radius fractures. It is most commonly caused by positioning the plate too distally, allowing prominent hardware beyond the watershed line to cause friction and eventual tendon failure.

Question 2066

Topic: Nerve & Tendon

A 55-year-old female presents with chronic numbness and tingling in the ring and little fingers of her right hand, worse with prolonged elbow flexion. On examination, she has a positive Tinel's sign at the cubital tunnel and mild weakness of intrinsic hand muscles. What is the MOST appropriate initial management?

. Cubital tunnel release surgery
. Anterior ulnar nerve transposition
. Night splinting with the elbow in extension and activity modification
. Corticosteroid injection into the cubital tunnel
. Observation and reassurance

Correct Answer & Explanation

. Night splinting with the elbow in extension and activity modification

Explanation

The patient's symptoms are classic for cubital tunnel syndrome (ulnar nerve entrapment at the elbow). Initial management should always be conservative, focusing on activity modification (avoiding prolonged elbow flexion) and night splinting with the elbow in extension to relieve tension on the ulnar nerve. Surgical intervention (cubital tunnel release or anterior transposition) is reserved for cases that fail extensive conservative management, or for severe, progressive neurological deficits. Corticosteroid injections around nerves are generally not recommended due to potential nerve damage. Observation alone is insufficient given the progressive neurological symptoms.

Question 2067

Topic: Nerve & Tendon

A 25-year-old male presents with a persistent feeling of arm 'heaviness' and fatigue, swelling, and discoloration of his right upper extremity, particularly after overhead activities. He also reports numbness in his ring and little fingers. A venous Doppler confirms subclavian vein thrombosis. What is the MOST likely underlying condition?

. Cervical radiculopathy
. Cubital tunnel syndrome
. Thoracic Outlet Syndrome (TOS) - Venous Type (Paget-Schroetter)
. Brachial plexus injury
. Pancoast tumor

Correct Answer & Explanation

. Thoracic Outlet Syndrome (TOS) - Venous Type (Paget-Schroetter)

Explanation

The combination of arm heaviness, fatigue, swelling, discoloration, and subclavian vein thrombosis (Paget-Schroetter syndrome) in a young, active individual (often related to repetitive overhead activity) is highly characteristic of Venous Thoracic Outlet Syndrome (TOS). This results from compression of the subclavian vein in the costoclavicular space. Cervical radiculopathy causes nerve symptoms but not venous thrombosis. Cubital tunnel syndrome affects the ulnar nerve at the elbow. Brachial plexus injury can cause neurological deficits but typically not venous thrombosis. A Pancoast tumor is a malignancy in the lung apex causing TOS, but typically arterial or neurological, and less common in a young patient.

Question 2068

Topic: Nerve & Tendon

A 42-year-old female requires open reduction and internal fixation of a Dubberley Type 2B coronal shear fracture of the capitellum extending into the trochlea. An extensile lateral approach (Kocher interval) is utilized. Distal extension of this exposure places which of the following neurologic structures at greatest risk?

. Ulnar nerve
. Median nerve
. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The extensile lateral approach utilizes the Kocher or Kaplan interval. Distal extension of this exposure risks injury to the posterior interosseous nerve (PIN) as it courses within the supinator muscle. Supination of the forearm helps move the PIN further anteriorly and away from the surgical field.

Question 2069

Topic: Nerve & Tendon

A 35-year-old carpenter presents with gradual onset of pain at the base of his thumb, worse with gripping and pinching. Examination reveals tenderness over the radial styloid and pain elicited by passively flexing the thumb into the palm and then ulnarly deviating the wrist. Which of the following conditions is most likely?

. Carpal Tunnel Syndrome
. Intersection Syndrome
. De Quervain's Tenosynovitis
. Thumb CMC Osteoarthritis
. Wartenberg's Syndrome

Correct Answer & Explanation

. De Quervain's Tenosynovitis

Explanation

The clinical presentation describes De Quervain's Tenosynovitis, an inflammatory condition affecting the abductor pollicis longus and extensor pollicis brevis tendons within the first dorsal compartment. The Finkelstein's test (flexing the thumb into the palm and then ulnarly deviating the wrist) specifically elicits pain in this condition. Carpal Tunnel Syndrome involves median nerve compression. Intersection Syndrome involves inflammation where the first and second dorsal compartment tendons cross. Thumb CMC OA pain is typically at the joint, with positive grind test. Wartenberg's Syndrome is superficial radial nerve irritation.

Question 2070

Topic: Hand Trauma & Infection

A 28-year-old rugby player sustains a hyperextension injury to his thumb during a tackle. Examination reveals significant swelling and tenderness over the ulnar aspect of the thumb metacarpophalangeal (MCP) joint, with instability on valgus stress testing at 30 degrees of flexion. What is the most appropriate initial management?

. Buddy taping to index finger
. Thumb spica cast immobilization for 4-6 weeks
. Surgical repair of the ulnar collateral ligament
. Steroid injection into the MCP joint
. Referral for MRI to confirm Stener lesion

Correct Answer & Explanation

. Surgical repair of the ulnar collateral ligament

Explanation

The patient's presentation strongly suggests a complete rupture of the ulnar collateral ligament (UCL) of the thumb MCP joint, commonly known as 'Skier's Thumb' or 'Gamekeeper's Thumb'. Instability at 30 degrees of flexion is indicative of a complete tear. A Stener lesion, where the adductor aponeurosis interposes between the torn UCL and its insertion, preventing healing, is common and necessitates surgical repair. While MRI can confirm a Stener lesion, significant instability on stress testing warrants surgical repair as initial management due to the high likelihood of a Stener lesion or complete tear requiring fixation. Non-operative management is typically reserved for partial tears or stable injuries.

Question 2071

Topic: Nerve & Tendon

A 60-year-old diabetic patient presents with a history of his ring finger catching and locking in flexion, especially in the morning. He describes needing to manually extend it with a 'pop'. Physical examination confirms a palpable nodule at the base of the ring finger on the palmar aspect, consistent with tenosynovitis of which tendon?

. Flexor Digitorum Superficialis
. Flexor Digitorum Profundus
. Extensor Digitorum Communis
. Flexor Pollicis Longus
. Palmaris Longus

Correct Answer & Explanation

. Flexor Digitorum Superficialis

Explanation

This classic presentation describes 'trigger finger' (stenosing tenosynovitis), which most commonly affects the flexor digitorum superficialis (FDS) and/or profundus (FDP) tendons at the A1 pulley level. The locking and palpable nodule are characteristic findings. While both FDS and FDP are involved, the FDS is often the primary culprit due to its more superficial location and larger bulk at this level. The FPL can be involved in trigger thumb. Extensor tendons are on the dorsum, and the Palmaris Longus has no role in finger flexion.

Question 2072

Topic: Hand Trauma & Infection

A 40-year-old construction worker presents with acute onset of severe pain, swelling, and redness over the palmar aspect of his index finger DIP joint, following a minor puncture wound. He is febrile. Examination reveals a tense, exquisitely tender, fusiform swelling of the entire finger with marked pain on passive extension. What is the most appropriate immediate management?

. Oral antibiotics and rest
. Splinting and elevation
. Incision and drainage with intravenous antibiotics
. Steroid injection into the DIP joint
. Observation for 24 hours

Correct Answer & Explanation

. Incision and drainage with intravenous antibiotics

Explanation

This is a classic presentation of suppurative flexor tenosynovitis (Kanavel's signs: fusiform swelling, uniform tenderness along tendon sheath, pain on passive extension, flexed posture). This is a surgical emergency. Delay in treatment can lead to tendon necrosis, adhesions, and permanent functional deficits. Immediate incision and drainage of the tendon sheath, along with intravenous antibiotics, are crucial. Oral antibiotics alone are insufficient for an established infection of this severity.

Question 2073

Topic: 7. Hand and Wrist

A 22-year-old college athlete presents after falling onto an outstretched hand, resulting in a dorsal dislocation of the lunate bone. Which of the following nerves is at highest risk of acute compression?

. Radial nerve
. Ulnar nerve
. Median nerve
. Anterior interosseous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Median nerve

Explanation

Dorsal lunate dislocation (often actually a perilunate dislocation with lunate volarly displaced, or a pure lunate dislocation where the lunate dislocates volarly into the carpal tunnel) places significant pressure on the median nerve as it passes through the carpal tunnel. The median nerve is highly susceptible to acute compression in these injuries due to its anatomical proximity to the carpus. Radial and ulnar nerves are less directly affected by isolated lunate dislocations. AIN and PIN are branches and are less commonly compressed acutely by this specific injury.

Question 2074

Topic: 7. Hand and Wrist

A patient undergoing carpal tunnel release complains of persistent numbness in the thumb, index, and middle fingers immediately post-operatively, despite successful surgical decompression. Which of the following is the most likely explanation?

. Incomplete release of the transverse carpal ligament
. Median nerve transection
. Pre-existing severe median nerve compression with Wallerian degeneration
. Superficial palmar arch injury
. Ulnar nerve injury

Correct Answer & Explanation

. Pre-existing severe median nerve compression with Wallerian degeneration

Explanation

Persistent numbness immediately post-operatively after a technically successful carpal tunnel release, especially in cases with long-standing or severe pre-operative compression, is most often due to the slow recovery of a severely compressed median nerve with Wallerian degeneration. Nerve recovery can take weeks to months, and some degree of residual numbness may persist. Incomplete release is possible but usually leads to continued typical CTS symptoms. Median nerve transection is a catastrophic, rare complication. Superficial palmar arch injury would cause vascular compromise. Ulnar nerve injury would affect different digits.

Question 2075

Topic: Wrist & Carpus

A 45-year-old female presents with a chronic, progressively worsening painful wrist, especially on the ulnar side. X-rays show positive ulnar variance and degenerative changes at the distal radioulnar joint (DRUJ) and ulnocarpal articulation. Which condition is most likely?

. Kienbock's disease
. Preiser's disease
. TFCC tear
. Ulnar Impaction Syndrome
. Scapholunate Advanced Collapse (SLAC)

Correct Answer & Explanation

. Ulnar Impaction Syndrome

Explanation

Ulnar impaction syndrome (also known as ulnar abutment syndrome) is caused by repetitive loading and degenerative changes between the ulnar head, TFCC, lunate, and triquetrum, often associated with positive ulnar variance. This results in ulnar-sided wrist pain. Kienbock's disease is avascular necrosis of the lunate. Preiser's disease is avascular necrosis of the scaphoid. A TFCC tear can cause ulnar pain but is often a component of ulnar impaction or can occur in isolation. SLAC wrist involves scapholunate ligament disruption and subsequent arthritis, typically radial-sided initially.

Question 2076

Topic: Wrist & Carpus

Which of the following ligaments is considered the most important stabilizer of the distal radioulnar joint (DRUJ)?

. Palmar radiocarpal ligament
. Dorsal radiocarpal ligament
. Ulnar collateral ligament of wrist
. Radial collateral ligament of wrist
. Triangular Fibrocartilage Complex (TFCC)

Correct Answer & Explanation

. Triangular Fibrocartilage Complex (TFCC)

Explanation

The Triangular Fibrocartilage Complex (TFCC) is the primary stabilizer of the DRUJ and the ulnar side of the wrist. It consists of the articular disc, dorsal and volar radioulnar ligaments, and the meniscal homologue. The radiocarpal and ulnar/radial collateral ligaments primarily stabilize the radiocarpal joint but have less direct influence on DRUJ stability.

Question 2077

Topic: Nerve & Tendon

A 65-year-old patient with rheumatoid arthritis develops a 'boutonniere deformity' in her middle finger. This deformity is characterized by which of the following?

. Hyperextension of the MCP joint and flexion of the PIP joint
. Flexion of the MCP joint and hyperextension of the PIP joint
. Flexion of the PIP joint and hyperextension of the DIP joint
. Hyperextension of the PIP joint and flexion of the DIP joint
. Flexion of the MCP, PIP, and DIP joints

Correct Answer & Explanation

. Hyperextension of the PIP joint and flexion of the DIP joint

Explanation

A boutonniere deformity is characterized by a fixed flexion deformity of the proximal interphalangeal (PIP) joint and compensatory hyperextension of the distal interphalangeal (DIP) joint. It results from disruption of the central slip of the extensor mechanism, allowing the lateral bands to migrate volarly and become PIP joint flexors.

Question 2078

Topic: 7. Hand and Wrist

A 10-year-old boy presents with a 'jersey finger' injury after his finger was caught in an opponent's jersey during a soccer match. This injury most commonly involves avulsion of which tendon?

. Flexor Digitorum Superficialis (FDS) of the ring finger
. Flexor Digitorum Profundus (FDP) of the ring finger
. Extensor Digitorum Communis (EDC) of the ring finger
. Flexor Pollicis Longus (FPL)
. Flexor Carpi Ulnaris (FCU)

Correct Answer & Explanation

. Flexor Digitorum Profundus (FDP) of the ring finger

Explanation

'Jersey finger' is an avulsion of the flexor digitorum profundus (FDP) tendon from its insertion on the distal phalanx. It most commonly affects the ring finger. The patient is unable to actively flex the DIP joint while the PIP joint is stabilized. Surgical repair is typically required.

Question 2079

Topic: Nerve & Tendon

Which of the following conditions is an indication for surgical decompression in Carpal Tunnel Syndrome?

. Mild symptoms responding to night splinting
. Intermittent paresthesias for less than 3 months
. Thenar muscle atrophy with objective motor weakness
. Positive Phalen's and Tinel's signs without nocturnal symptoms
. Sensory deficits confirmed by nerve conduction studies but without motor involvement

Correct Answer & Explanation

. Thenar muscle atrophy with objective motor weakness

Explanation

Thenar muscle atrophy with objective motor weakness (strength less than M4/5) is a strong indication for surgical decompression of the median nerve to prevent irreversible motor loss. Mild symptoms, intermittent paresthesias, or purely sensory deficits without motor involvement can often be managed conservatively initially. While nerve conduction studies confirming severe sensory deficits can indicate surgery, motor involvement is a more urgent indicator.

Question 2080

Topic: Nerve & Tendon

A 25-year-old presents with a 'mallet finger' injury after jamming his finger while playing basketball. This injury involves disruption of which anatomical structure?

. Central slip of the extensor tendon at the PIP joint
. Flexor digitorum profundus tendon insertion at the DIP joint
. Extensor digitorum communis tendon insertion at the DIP joint
. Ulnar collateral ligament of the thumb MCP joint
. Radial collateral ligament of the index finger PIP joint

Correct Answer & Explanation

. Extensor digitorum communis tendon insertion at the DIP joint

Explanation

A mallet finger results from disruption of the extensor digitorum communis (EDC) tendon insertion into the dorsal base of the distal phalanx (Zone 1 extensor injury), leading to an inability to actively extend the DIP joint. This can be a tendinous avulsion or an osseous avulsion. The central slip is involved in boutonniere deformity. FDP tendon avulsion is a 'jersey finger'. Ligament injuries are different pathologies.

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