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7. Hand and Wrist MCQs

Practice Set 106 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 2101

Topic: 7. Hand and Wrist

Which of the following conditions is most likely to be successfully treated with only a single corticosteroid injection?

. Severe carpal tunnel syndrome with thenar atrophy
. Chronic Dupuytren's contracture with a fixed flexion deformity
. Trigger finger in its early stages
. Acute septic arthritis of the wrist
. Complete UCL tear of the thumb MCP joint

Correct Answer & Explanation

. Trigger finger in its early stages

Explanation

Trigger finger (stenosing tenosynovitis) in its early stages, particularly with a palpable nodule and catching, often responds well to a single corticosteroid injection into the tendon sheath. Success rates are generally high (up to 60-90%). Severe CTS with thenar atrophy requires surgical decompression. Dupuytren's contracture cannot be cured by injection once fixed. Septic arthritis requires surgical drainage and antibiotics. A complete UCL tear (especially with a Stener lesion) requires surgical repair.

Question 2102

Topic: 7. Hand and Wrist

Which anatomical landmark is used to differentiate a high median nerve lesion from a low (wrist level) median nerve lesion?

. Sensory loss in the thenar eminence
. Wasting of the hypothenar muscles
. Ability to flex the DIP joint of the index finger
. Presence of a positive Tinel's sign at the wrist
. Weakness of the adductor pollicis

Correct Answer & Explanation

. Sensory loss in the thenar eminence

Explanation

The thenar eminence receives its sensory innervation from the palmar cutaneous branch of the median nerve, which typically arises proximal to the transverse carpal ligament and passes superficial to it. Therefore, a high median nerve lesion (e.g., at the elbow or forearm) will result in sensory loss over the thenar eminence, while a low lesion (carpal tunnel syndrome) typically spares thenar eminence sensation. The other options are either not specific for distinguishing high vs. low lesions or relate to different nerve pathologies (e.g., hypothenar wasting and adductor pollicis weakness are ulnar nerve signs).

Question 2103

Topic: 7. Hand and Wrist

The presence of a 'positive grind test' in the thumb is indicative of pathology in which joint?

. Thumb Metacarpophalangeal (MCP) joint
. Thumb Interphalangeal (IP) joint
. First Carpometacarpal (CMC) joint
. Radiocarpal joint
. Scaphotrapeziotrapezoid (STT) joint

Correct Answer & Explanation

. First Carpometacarpal (CMC) joint

Explanation

A positive grind test (axial compression and rotation of the first metacarpal on the trapezium, eliciting pain and crepitus) is a hallmark sign of osteoarthritis of the first carpometacarpal (CMC) joint of the thumb. This is a very common degenerative condition. The other joints are distinct and would have different provocative tests.

Question 2104

Topic: Wrist & Carpus

A 25-year-old weightlifter presents with ulnar-sided wrist pain, worse with gripping and pronation/supination. Examination reveals tenderness over the distal ulna and a positive 'fovea sign' (tenderness in the depression between the ulnar styloid and flexor carpi ulnaris tendon). Which of the following is the most likely diagnosis?

. Pisotriquetral arthritis
. Ulnar collateral ligament sprain
. Triangular Fibrocartilage Complex (TFCC) tear
. Extensor Carpi Ulnaris (ECU) subluxation
. Lunotriquetral instability

Correct Answer & Explanation

. Triangular Fibrocartilage Complex (TFCC) tear

Explanation

The clinical presentation, particularly the ulnar-sided wrist pain exacerbated by gripping and pronation/supination, and a positive fovea sign, are highly indicative of a Triangular Fibrocartilage Complex (TFCC) tear. The TFCC is a primary stabilizer of the DRUJ and the ulnar carpus. Pisotriquetral arthritis causes pain more volar and distal. Ulnar collateral ligament sprains are less common in the wrist itself. ECU subluxation often presents with snapping. Lunotriquetral instability also causes ulnar-sided pain, but the fovea sign is more specific to TFCC.

Question 2105

Topic: 7. Hand and Wrist

Which of the following statements about the lumbrical muscles of the hand is true?

. All lumbricals are innervated by the ulnar nerve.
. They originate from the carpal bones.
. They flex the MCP joints and extend the PIP and DIP joints.
. They are extrinsic muscles of the hand.
. They are primarily responsible for finger abduction.

Correct Answer & Explanation

. They flex the MCP joints and extend the PIP and DIP joints.

Explanation

The lumbricals are unique intrinsic muscles that originate from the flexor digitorum profundus tendons and insert into the extensor hood mechanism. Their primary action is to flex the metacarpophalangeal (MCP) joints and extend the proximal and distal interphalangeal (PIP and DIP) joints. The lateral two lumbricals are innervated by the median nerve, and the medial two by the ulnar nerve (not all by ulnar). They are intrinsic muscles, not extrinsic. Finger abduction is primarily by the dorsal interossei.

Question 2106

Topic: Nerve & Tendon

Which intrinsic muscle of the thumb is innervated by both the median and ulnar nerves in a variable proportion?

. Abductor Pollicis Brevis
. Flexor Pollicis Brevis
. Opponens Pollicis
. Adductor Pollicis
. Extensor Pollicis Brevis

Correct Answer & Explanation

. Flexor Pollicis Brevis

Explanation

The Flexor Pollicis Brevis (FPB) muscle of the thumb thenar eminence is classically described as having dual innervation. Its superficial head is typically innervated by the median nerve, while its deep head often receives innervation from the ulnar nerve. This dual supply is responsible for variations in clinical findings in median or ulnar nerve palsies. APB and Opponens Pollicis are primarily median. Adductor Pollicis is solely ulnar. EPB is radial (extrinsic).

Question 2107

Topic: 7. Hand and Wrist

A 30-year-old office worker presents with pain over the ulnar side of his wrist, exacerbated by gripping and lifting, particularly with the wrist in ulnar deviation. There is tenderness over the base of the 5th metacarpal and pisiform. What is the most likely diagnosis?

. TFCC tear
. Hamate fracture
. Pisotriquetral osteoarthritis
. Extensor carpi ulnaris tendinopathy
. Lunotriquetral ligament tear

Correct Answer & Explanation

. Pisotriquetral osteoarthritis

Explanation

Pain and tenderness localized to the base of the 5th metacarpal and pisiform, exacerbated by gripping and ulnar deviation, are classic signs of pisotriquetral osteoarthritis. This degenerative condition affects the articulation between the pisiform and triquetrum. While TFCC tears, hamate fractures, ECU tendinopathy, and LT ligament tears can cause ulnar-sided pain, the precise localization to the pisiform region points most strongly to pisotriquetral pathology.

Question 2108

Topic: Hand Trauma & Infection

In a traumatic complete rupture of the ulnar collateral ligament of the thumb MCP joint without a bony avulsion, what is the most important anatomical factor that dictates the need for surgical repair?

. Degree of instability on stress testing (greater than 30 degrees)
. Patient's age and activity level
. Presence of a Stener lesion
. Involvement of the radial collateral ligament
. Size of associated subungual hematoma

Correct Answer & Explanation

. Presence of a Stener lesion

Explanation

The presence of a Stener lesion is the most important anatomical factor dictating surgical repair for a complete UCL tear of the thumb. A Stener lesion occurs when the adductor aponeurosis displaces superficially and interposes between the torn ends of the UCL, preventing healing. Stress testing helps diagnose a complete tear, but the Stener lesion is the specific anatomical barrier to non-operative healing. Without surgical intervention, the joint will remain unstable. Other factors are important but secondary to the Stener lesion.

Question 2109

Topic: 7. Hand and Wrist

A 50-year-old male presents with chronic wrist pain. Radiographs reveal Scapholunate Advanced Collapse (SLAC). Which of the following carpal articulations is classically preserved and typically remains free of degenerative changes in the end stages of this condition?

. Radioscaphoid joint
. Capitolunate joint
. Radiolunate joint
. Scaphotrapezial joint
. Capitohamate joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In a SLAC wrist, the radiolunate articulation is classically spared because the lunate remains concentrically congruent with the spherical lunate fossa of the radius. Degenerative changes predictably progress from the radial styloid to the scaphoid fossa, and ultimately to the capitolunate joint.

Question 2110

Topic: 7. Hand and Wrist
A 38-year-old female presents with dorsal wrist pain. MRI confirms avascular necrosis of the lunate (Kienböck's disease). Radiographs demonstrate ulnar negative variance of 3mm and a structurally intact lunate with no carpal collapse (Lichtman Stage II). What is the most appropriate surgical management?
. Proximal row carpectomy
. Radial shortening osteotomy
. Total wrist arthrodesis
. Scaphoid excision and four-corner fusion
. Ulnar lengthening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

Radial shortening osteotomy is the procedure of choice for early-stage Kienböck's disease (Lichtman I-IIIa) in patients with ulnar negative variance. It biomechanically unloads the radiolunate joint, which helps revascularize the lunate and halts progressive carpal collapse.

Question 2111

Topic: 7. Hand and Wrist

A 24-year-old male presents with a scaphoid proximal pole fracture non-union. Which of the following best describes the predominant arterial supply to the proximal pole of the scaphoid?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering distally

Explanation

The scaphoid receives 70-80% of its blood supply from branches of the radial artery entering via the dorsal ridge distally and flowing retrograde. This retrograde blood supply puts the proximal pole at high risk for avascular necrosis following fractures.

Question 2112

Topic: 7. Hand and Wrist

During a zone 2 flexor tendon repair, preservation of which pulleys is considered most critical to prevent bowstringing and maintain finger biomechanics?

. A1 and A3
. A2 and A4
. A3 and A5
. C1 and C2
. A1 and A5

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 (located at the proximal phalanx) and A4 (located at the middle phalanx) pulleys are the most critical biomechanically. Disruption leads to bowstringing, loss of excursion, and decreased flexion power.

Question 2113

Topic: 7. Hand and Wrist

In Dupuytren's contracture, the spiral cord is responsible for proximal interphalangeal (PIP) joint contracture. It typically displaces the neurovascular bundle in which direction?

. Dorsal and peripheral
. Volar and midline
. Dorsal and midline
. Volar and peripheral
. It does not displace the bundle

Correct Answer & Explanation

. Volar and midline

Explanation

The spiral cord displaces the neurovascular bundle volarly (superficially) and centrally (towards the midline). This abnormal anatomy places the nerve at high risk of transection during fasciectomy.

Question 2114

Topic: Wrist & Carpus
According to Mayfield's progressive perilunar instability, what is the final stage (Stage IV) of the sequence?
. Scapholunate dissociation
. Lunotriquetral disruption
. Dorsal perilunate dislocation
. Volar lunate dislocation
. Capitate fracture

Correct Answer & Explanation

. Volar lunate dislocation

Explanation

Mayfield's stages describe a predictable pattern of ligamentous injury around the lunate. Stage I is scapholunate dissociation, Stage II includes capitate dislocation, Stage III is perilunate dislocation, and Stage IV is a volar lunate dislocation.

Question 2115

Topic: 7. Hand and Wrist

In the natural history of Scapholunate Advanced Collapse (SLAC), which articulation is typically spared from degenerative arthritic changes?

. Radioscaphoid joint
. Lunocapitate joint
. Radiolunate joint
. Scaphocapitate joint
. Scaphotrapezial joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In SLAC wrist, the radiolunate joint is typically spared from osteoarthritis due to its concentric, spherical articulation which maintains normal contact stresses despite carpal collapse. This preservation allows for radiolunate-sparing salvage procedures like a four-corner fusion.

Question 2116

Topic: Hand Trauma & Infection

A patient presents with a swollen, painful index finger. Which of the following is NOT one of Kanavel's four cardinal signs of infectious flexor tenosynovitis?

. Fusiform swelling of the digit
. Finger held in slight extension
. Tenderness along the flexor tendon sheath
. Pain on passive extension of the digit
. Flexed posture of the digit

Correct Answer & Explanation

. Finger held in slight extension

Explanation

Kanavel's signs include a flexed posture of the digit (not extension), fusiform swelling, tenderness along the tendon sheath, and severe pain with passive extension. These signs mandate urgent surgical decompression and washout.

Question 2117

Topic: 7. Hand and Wrist
A 32-year-old manual laborer is diagnosed with Kienbock's disease. Radiographs show lunate sclerosis, fragmentation, and carpal collapse, with fixed scaphoid rotation but no osteoarthritis. According to the Lichtman classification, what stage is this?
. Stage I
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IV

Correct Answer & Explanation

. Stage IIIA

Explanation

Lichtman Stage IIIA involves lunate collapse without fixed scaphoid rotation or carpal height loss. Stage IIIB features lunate collapse with fixed scaphoid flexion and loss of carpal height, while Stage IV adds radiocarpal or midcarpal arthritis.

Question 2118

Topic: Wrist & Carpus

A 45-year-old female treated non-operatively for a minimally displaced distal radius fracture presents 6 weeks later with a sudden inability to actively extend her thumb interphalangeal joint. What is the most appropriate management?

. Primary repair of the extensor pollicis longus (EPL) tendon
. Tendon transfer using the extensor indicis proprius (EIP)
. Tenolysis of the first dorsal compartment
. Tendon transfer using the extensor carpi radialis longus (ECRL)
. Tendon graft using palmaris longus

Correct Answer & Explanation

. Tendon transfer using the extensor indicis proprius (EIP)

Explanation

EPL rupture is a known complication of nondisplaced or minimally displaced distal radius fractures due to attrition and ischemia. Because the tendon ends are typically frayed and retracted, EIP to EPL transfer is the preferred surgical treatment.

Question 2119

Topic: 7. Hand and Wrist

In a Bennett's fracture, what muscle is primarily responsible for the proximal and dorsal displacement of the first metacarpal shaft?

. Adductor pollicis
. Abductor pollicis longus (APL)
. Extensor pollicis brevis (EPB)
. Flexor pollicis longus (FPL)
. First dorsal interosseous

Correct Answer & Explanation

. Abductor pollicis longus (APL)

Explanation

The volar ulnar beak fragment remains tethered to the trapezium by the anterior oblique ligament. The metacarpal shaft is pulled proximally and dorsally by the Abductor Pollicis Longus (APL), with adductor pollicis contributing to the adduction deformity.

Question 2120

Topic: Nerve & Tendon

A cyclist presents with numbness in the volar aspect of the small finger and ulnar half of the ring finger, along with intrinsic muscle weakness. Sensation on the dorsoulnar aspect of the hand is preserved. Where is the most likely site of ulnar nerve compression?

. Cubital tunnel
. Arcade of Struthers
. Guyon's canal (Zone 1)
. Guyon's canal (Zone 2)
. Guyon's canal (Zone 3)

Correct Answer & Explanation

. Guyon's canal (Zone 1)

Explanation

Compression in Guyon's canal spares the dorsal ulnar cutaneous nerve, which branches off proximally to the wrist. Zone 1 compression causes mixed motor and sensory deficits, whereas Zone 2 is purely motor and Zone 3 is purely sensory.

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