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7. Hand and Wrist MCQs

Practice Set 107 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 2121

Topic: 7. Hand and Wrist
A 55-year-old male presents with advanced SLAC (scapholunate advanced collapse) wrist. Radiographs reveal degenerative changes at the radioscaphoid and capitolunate joints, while the radiolunate joint is entirely preserved. According to the SLAC staging system, which stage does this represent and what is the most appropriate definitive surgical management?
. Stage I; Scaphoid excision and four-corner fusion
. Stage II; Proximal row carpectomy
. Stage III; Scaphoid excision and four-corner fusion
. Stage II; Total wrist arthrodesis
. Stage III; Radial styloidectomy

Correct Answer & Explanation

. Stage III; Scaphoid excision and four-corner fusion

Explanation

Stage III SLAC wrist involves arthritic changes at the radioscaphoid and capitolunate joints with a preserved radiolunate joint. Scaphoid excision with four-corner fusion or proximal row carpectomy are standard treatments for Stage III, provided the capitate head is preserved for PRC.

Question 2122

Topic: 7. Hand and Wrist

During a flexor tendon repair in Zone II of the hand, maintaining the integrity of the pulley system is critical to prevent bowstringing of the tendon. Which two pulleys are the most mechanically essential and should be preserved or reconstructed?

. A1 and A3
. A2 and A4
. A3 and A5
. A1 and A5
. C1 and C3

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 and A4 pulleys arise from the proximal and middle phalanges, respectively, and are mechanically the most important for preventing bowstringing. Their preservation or reconstruction is vital during Zone II flexor tendon repairs.

Question 2123

Topic: Wrist & Carpus

A 42-year-old female sustained a nondisplaced distal radius fracture treated conservatively in a cast. Six weeks later, she suddenly loses the ability to actively extend her thumb interphalangeal joint. What is the preferred surgical management for this complication?

. Primary end-to-end tendon repair
. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) transfer
. Palmaris longus (PL) to extensor pollicis longus (EPL) transfer
. Flexor carpi radialis (FCR) to extensor pollicis longus (EPL) transfer
. Tenodesis of the EPL to the extensor carpi radialis brevis (ECRB)

Correct Answer & Explanation

. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) transfer

Explanation

This patient has an EPL rupture due to ischemic attrition at the watershed area or friction over a bony spike following a distal radius fracture. Primary repair is usually impossible due to tendon retraction and degeneration, making an EIP to EPL tendon transfer the gold standard treatment.

Question 2124

Topic: Wrist & Carpus
According to Mayfield's progressive perilunate instability classification, which of the following represents the correct sequential sequence of ligamentous failure ending in a lunate dislocation?
. Scapholunate -> Lunotriquetral -> Capitolunate -> Volar radiolunate
. Lunotriquetral -> Capitolunate -> Scapholunate -> Dorsal radiolunate
. Scapholunate -> Capitolunate -> Lunotriquetral -> Dorsal radiocarpal
. Scapholunate -> Capitolunate -> Lunotriquetral -> Volar radiocarpal
. Capitolunate -> Scapholunate -> Lunotriquetral -> Volar radiolunate

Correct Answer & Explanation

. Scapholunate -> Capitolunate -> Lunotriquetral -> Volar radiocarpal

Explanation

Mayfield's stages of perilunate instability occur in a distinct sequence: Stage I (Scapholunate), Stage II (Capitolunate), Stage III (Lunotriquetral), and Stage IV (Lunate dislocation, failing the dorsal radiocarpal ligaments and displacing volarly).

Question 2125

Topic: Nerve & Tendon

A 30-year-old cyclist presents with weakness in thumb adduction, finger abduction, and finger adduction. Sensation over the entire hand, including the small finger, is completely normal. Where is the most likely site of nerve compression?

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

Correct Answer & Explanation

. Guyon's canal Zone 2

Explanation

Guyon's canal Zone 2 contains only the deep motor branch of the ulnar nerve. Compression here causes isolated weakness of ulnar-innervated intrinsic muscles with perfectly spared sensation.

Question 2126

Topic: Wrist & Carpus
A 29-year-old male presents with dorsal wrist pain. X-rays reveal Lichtman Stage IIIA Kienbock's disease with a negative ulnar variance of 3 mm. What is the most appropriate joint-leveling procedure to unload the lunate?
. Proximal row carpectomy
. Ulnar lengthening osteotomy
. Radial shortening osteotomy
. Capitate shortening osteotomy
. Scaphoid excision and four-corner fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early stages of Kienbock's disease (Stages I-IIIA) with negative ulnar variance, joint-leveling procedures are indicated to unload the lunate. Radial shortening osteotomy is the gold standard as it is technically easier and has lower nonunion rates than ulnar lengthening.

Question 2127

Topic: Hand Trauma & Infection

A 34-year-old diabetic patient presents with a swollen, painful index finger 3 days after a minor puncture wound. Of the four classic Kanavel signs for suppurative flexor tenosynovitis, which is considered the earliest and most reliable indicator of infection?

. Fusiform swelling of the digit
. Flexed resting posture of the digit
. Tenderness along the course of the flexor tendon sheath
. Erythema tracking up the forearm
. Severe pain elicited by passive extension of the digit

Correct Answer & Explanation

. Severe pain elicited by passive extension of the digit

Explanation

Kanavel's four signs include fusiform swelling, flexed posture, tenderness over the sheath, and pain on passive extension. Pain on passive extension is classically considered the earliest, most sensitive, and most reliable sign of suppurative flexor tenosynovitis.

Question 2128

Topic: 7. Hand and Wrist
A 62-year-old female presents with severe pain at the base of the thumb. Radiographs demonstrate Eaton-Littler Stage IV basal joint arthritis. What radiographic finding distinguishes Stage IV from Stage III?
. Sclerosis of the trapezium
. Joint space narrowing at the trapeziometacarpal joint
. Presence of osteophytes larger than 2 mm
. Subluxation of the thumb metacarpal base
. Involvement of the scaphotrapezial-trapezoid (STT) joint

Correct Answer & Explanation

. Involvement of the scaphotrapezial-trapezoid (STT) joint

Explanation

Eaton-Littler staging evaluates thumb carpometacarpal arthritis. Stage III is defined by advanced CMC arthritis with large osteophytes (>2 mm), while Stage IV is defined by the additional arthritic involvement of the scaphotrapezial-trapezoid (STT) joint.

Question 2129

Topic: Nerve & Tendon

A 21-year-old rugby player sustained a "jersey finger" injury. Exploration reveals a Type I Leddy-Packer avulsion of the flexor digitorum profundus (FDP). What is the defining characteristic of this injury and its required timing for repair?

. Tendon retracted to the PIP joint; requires repair within 3 weeks
. Tendon retracted into the palm; requires repair within 7-10 days
. Bony avulsion caught at the A4 pulley; requires repair within 4 weeks
. Tendon retracted to the distal palmar crease; requires repair within 3 months
. Bony avulsion caught at the A2 pulley; delayed repair is acceptable

Correct Answer & Explanation

. Tendon retracted into the palm; requires repair within 7-10 days

Explanation

Type I jersey finger involves the FDP retracting all the way into the palm, which ruptures both the short and long vincula. Because the tendon loses its blood supply, it must be repaired early (within 7-10 days) before it undergoes irreversible necrosis and contracture.

Question 2130

Topic: Hand Trauma & Infection

A 28-year-old male presents with a "fight bite" over the third metacarpophalangeal joint after striking another person in the mouth. Which organism is uniquely associated with this specific injury mechanism, and what is the empiric antibiotic of choice?

. Pasteurella multocida; Ciprofloxacin
. Eikenella corrodens; Amoxicillin-clavulanate
. Staphylococcus aureus; Cephalexin
. Bartonella henselae; Azithromycin
. Capnocytophaga canimorsus; Clindamycin

Correct Answer & Explanation

. Eikenella corrodens; Amoxicillin-clavulanate

Explanation

Human bites ("fight bites") carry a high risk of deep infection. Eikenella corrodens is the classic organism uniquely associated with human oral flora. The empiric treatment of choice is surgical washout coupled with Amoxicillin-clavulanate (Augmentin).

Question 2131

Topic: 7. Hand and Wrist

A 45-year-old female presents with an inability to make an "OK" sign with her thumb and index finger. She has no sensory deficits. Examination reveals weakness in flexing the thumb interphalangeal joint and the index finger distal interphalangeal joint. What is the diagnosis?

. Pronator syndrome
. Carpal tunnel syndrome
. Anterior interosseous nerve (AIN) syndrome
. Cubital tunnel syndrome
. Posterior interosseous nerve (PIN) syndrome

Correct Answer & Explanation

. Anterior interosseous nerve (AIN) syndrome

Explanation

AIN syndrome is a pure motor neuropathy affecting the flexor pollicis longus (FPL), the flexor digitorum profundus (FDP) to the index/middle fingers, and the pronator quadratus. This classically presents as an inability to form the "OK" sign, with entirely normal sensation.

Question 2132

Topic: 7. Hand and Wrist

A patient with long-standing rheumatoid arthritis presents with a sudden inability to flex their thumb interphalangeal joint. This is known as a Mannerfelt-Norman syndrome. What is the pathoanatomic cause of this specific tendon rupture?

. Dorsal subluxation of the ulnar head causing extensor tendon attrition
. Ischemic necrosis of the flexor pollicis longus within the carpal tunnel
. Attrition of the flexor pollicis longus over a volar scaphoid osteophyte
. Invasion of the tendon by hypertrophic tenosynovium
. Rupture of the extensor pollicis longus over Lister's tubercle

Correct Answer & Explanation

. Attrition of the flexor pollicis longus over a volar scaphoid osteophyte

Explanation

Mannerfelt-Norman syndrome refers to the spontaneous rupture of the flexor pollicis longus (FPL) tendon in rheumatoid patients. It is caused by attritional wear over a bony prominence, most commonly a volar osteophyte on the scaphoid.

Question 2133

Topic: 7. Hand and Wrist

When performing a carpal tunnel release, the surgeon must be mindful of the recurrent motor branch of the median nerve. Which anatomical variation of the recurrent motor branch is the most common?

. Transligamentous
. Subligamentous
. Extraligamentous
. Ulnar to the median nerve main trunk
. Piercing the flexor retinaculum directly over the hamate

Correct Answer & Explanation

. Extraligamentous

Explanation

The extraligamentous variation is the most common path of the recurrent motor branch of the median nerve, occurring in roughly 50% of people. It branches distal to the transverse carpal ligament and recurrently enters the thenar musculature.

Question 2134

Topic: 7. Hand and Wrist

In Dupuytren's disease, different fascial cords are responsible for specific joint contractures and anatomical displacements. Which cord is primarily responsible for proximal interphalangeal (PIP) joint contracture and causes central/volar displacement of the neurovascular bundle?

. Pretendinous cord
. Natatory cord
. Spiral cord
. Lateral cord
. Retrovascular cord

Correct Answer & Explanation

. Spiral cord

Explanation

The spiral cord contributes to PIP joint contracture and uniquely displaces the neurovascular bundle centrally and volarly, placing it at high risk of iatrogenic injury during surgical excision.

Question 2135

Topic: Wrist & Carpus

A 32-year-old male presents with a rigid, isolated volar dislocation of the distal radioulnar joint (DRUJ) following a hyperpronation injury. Attempted closed reduction is unsuccessful. What anatomical structure is most commonly responsible for blocking the closed reduction of a volar DRUJ dislocation?

. Extensor carpi ulnaris (ECU) tendon
. Pronator quadratus muscle
. Triangular fibrocartilage complex (TFCC)
. Ulnar nerve
. Flexor digitorum profundus (FDP) tendons

Correct Answer & Explanation

. Pronator quadratus muscle

Explanation

In a volar dislocation of the DRUJ, the ulnar head displaces volarly. The pronator quadratus is frequently the structure that entraps the ulnar head, acting as a soft tissue interposition that blocks closed reduction.

Question 2136

Topic: Wrist & Carpus
A 32-year-old male presents with chronic dorsal wrist pain and decreased grip strength. Radiographs demonstrate sclerosis and early collapse of the lunate, with a negative ulnar variance of 3 mm. There is no evidence of radiocarpal or midcarpal arthritis. Which of the following is the most appropriate surgical management?
. Proximal row carpectomy
. Radial shortening osteotomy
. Four-corner fusion
. Lunate excision and silastic replacement
. Ulnar lengthening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Stage IIIA Kienbock's disease with negative ulnar variance. A joint-leveling procedure, such as a radial shortening osteotomy, offloads the radiolunate joint and is the treatment of choice before the onset of degenerative arthritis.

Question 2137

Topic: 7. Hand and Wrist
A 55-year-old manual laborer presents with progressively worsening radial-sided wrist pain. Radiographs reveal narrowing of the radioscaphoid joint and capitolunate joint, but the radiolunate joint is preserved. Scapholunate dissociation is noted. What is the most appropriate definitive surgical intervention?
. Total wrist arthrodesis
. Radioscapholunate fusion
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Scaphoid open reduction and ligament reconstruction

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

This describes Stage III Scapholunate Advanced Collapse (SLAC) wrist, characterized by radioscaphoid and capitolunate arthritis with a preserved radiolunate joint. Proximal row carpectomy is contraindicated due to capitate involvement, making scaphoid excision and four-corner fusion the most appropriate treatment.

Question 2138

Topic: Wrist & Carpus

A 45-year-old female presents with sudden inability to actively extend the interphalangeal joint of her thumb. Six weeks prior, she sustained a nondisplaced distal radius fracture treated in a cast. What is the most reliable surgical option to restore thumb extension?

. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer
. Primary end-to-end repair of the EPL tendon
. Palmaris longus interposition graft
. Extensor carpi radialis longus (ECRL) to EPL transfer
. Abductor pollicis longus (APL) transfer to EPL

Correct Answer & Explanation

. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer

Explanation

Delayed EPL rupture after a nondisplaced distal radius fracture is due to vascular ischemia or mechanical attrition in Lister's tubercle. Primary repair is rarely possible due to tendon retraction and degeneration, making an EIP to EPL tendon transfer the gold standard treatment.

Question 2139

Topic: 7. Hand and Wrist

A 15-year-old competitive gymnast complains of chronic wrist pain, particularly with weight-bearing and hyperextension, following an injury sustained 6 months ago. Plain radiographs are normal. What is the most likely diagnosis and appropriate next investigation?

. Distal radius growth plate injury; repeat plain radiographs in 2 weeks.
. Scaphoid non-union; MRI of the wrist.
. Ganglion cyst; ultrasound of the wrist.
. Triangular fibrocartilage complex (TFCC) tear; MRI of the wrist with arthrogram.
. Carpal tunnel syndrome; nerve conduction studies.

Correct Answer & Explanation

. Triangular fibrocartilage complex (TFCC) tear; MRI of the wrist with arthrogram.

Explanation

Chronic wrist pain in a gymnast, especially with weight-bearing and hyperextension, with normal plain radiographs, is highly suggestive of a Triangular Fibrocartilage Complex (TFCC) tear. The TFCC is a critical stabilizer of the distal radioulnar joint and load distributor. MRI of the wrist, ideally with arthrogram, is the investigation of choice to visualize TFCC tears, which can be difficult to see on standard MRI due to their complex anatomy and small size. Distal radius growth plate injury is less likely given the 6-month duration and normal X-rays. Scaphoid non-union is a possibility, but typically leads to tenderness in the anatomical snuffbox and is often visible on delayed X-rays or standard MRI; however, TFCC is a better fit for gymnast symptoms. Ganglion cysts are usually palpable. Carpal tunnel syndrome causes nerve symptoms, not primarily mechanical pain with weight-bearing.

Question 2140

Topic: Wrist & Carpus

A 60-year-old female presents with acute pain and deformity in her wrist after a fall onto an outstretched hand. Radiographs show a Galeazzi fracture-dislocation (fracture of the distal radius with dislocation of the distal radioulnar joint). What is the preferred treatment for this injury in an adult?

. Closed reduction and long arm cast immobilization.
. External fixation.
. Open reduction and internal fixation (ORIF) of the radius and stabilization of the DRUJ.
. Percutaneous pinning of the radius.
. Distal radioulnar joint (DRUJ) fusion.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) of the radius and stabilization of the DRUJ.

Explanation

A Galeazzi fracture-dislocation in an adult is an inherently unstable injury and typically requires open reduction and internal fixation (ORIF) of the radial shaft fracture to restore its length and rotation. Once the radius is anatomically reduced and fixed, the distal radioulnar joint (DRUJ) usually reduces spontaneously. The DRUJ must then be assessed for stability, and if unstable, it may require temporary K-wire fixation across the DRUJ and/or repair of the TFCC. Closed reduction and casting are rarely successful in adults due to the instability of the DRUJ. External fixation is generally reserved for severe open injuries or as a temporary measure. Percutaneous pinning is inadequate for this fracture pattern. DRUJ fusion is a salvage procedure, not a primary treatment.

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