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7. Hand and Wrist MCQs

Practice Set 108 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 2141

Topic: Nerve & Tendon

A 55-year-old male presents with a neglected mallet finger deformity (flexion deformity of the DIP joint) that occurred 6 months ago. He complains of pain and difficulty with fine motor tasks. Which of the following is the most appropriate management?

. Continued splinting for another 6 weeks.
. DIP joint fusion.
. Surgical reconstruction of the extensor tendon.
. PIP joint manipulation and casting.
. Steroid injection into the DIP joint.

Correct Answer & Explanation

. Surgical reconstruction of the extensor tendon.

Explanation

A neglected mallet finger (extensor tendon rupture at the DIP joint) of 6 months duration, causing pain and functional deficit, is unlikely to resolve with continued splinting. Surgical reconstruction of the extensor tendon is the most appropriate management in such cases, often involving tendon repair or grafting, potentially with K-wire stabilization. This aims to restore active extension at the DIP joint. DIP joint fusion is a salvage procedure for severe arthritis or failed reconstructions, sacrificing motion. PIP joint manipulation is not relevant to a DIP joint injury. Steroid injections are not indicated for tendon ruptures.

Question 2142

Topic: 7. Hand and Wrist

A 25-year-old male presents with a painful, swollen wrist after punching a wall. Radiographs show a fracture of the neck of the fifth metacarpal, with 40 degrees of volar angulation. Which of the following is the most appropriate management?

. Closed reduction and immobilization in a short arm cast.
. Open reduction and internal fixation (ORIF) with plate and screws.
. Closed reduction and immobilization in a ulnar gutter splint with the MCP joint flexed to 90 degrees.
. Percutaneous K-wire fixation.
. Excision of the metacarpal head.

Correct Answer & Explanation

. Closed reduction and immobilization in a ulnar gutter splint with the MCP joint flexed to 90 degrees.

Explanation

A fracture of the neck of the fifth metacarpal (Boxer's fracture) with 40 degrees of volar angulation typically requires reduction to prevent rotational deformity and functional impairment. Closed reduction, often by applying axial pressure and flexion to the digit, followed by immobilization in an ulnar gutter splint with the metacarpophalangeal (MCP) joint flexed to 90 degrees (which uses the collateral ligaments to stabilize the fracture), is the standard of care. Acceptable angulation is generally up to 30-40 degrees for the 5th metacarpal. A short arm cast without proper MCP joint positioning is inadequate. ORIF or K-wire fixation is reserved for irreducible fractures, severe angulation (>40-50 degrees), or rotational deformity. Excision of the metacarpal head is a salvage procedure.

Question 2143

Topic: 7. Hand and Wrist

A 45-year-old male sustains a traumatic amputation of the thumb at the metacarpophalangeal (MCP) joint level. He is otherwise stable, and the amputated part is viable. What is the most appropriate management plan?

. Primary closure of the stump and rehabilitation.
. Delayed stump revision after 48 hours.
. Replantation of the thumb.
. Toe-to-hand transfer as a primary procedure.
. Skin grafting of the stump.

Correct Answer & Explanation

. Replantation of the thumb.

Explanation

Thumb amputation, even at the MCP joint level, is a critical injury due to the thumb's immense functional importance (accounting for approximately 50% of hand function). Therefore, replantation of a viable thumb is generally the preferred management whenever technically feasible, regardless of the level of amputation. Primary closure, delayed revision, or skin grafting are considered only if replantation is not possible or contraindicated. Toe-to-hand transfer is a reconstructive option for failed replantation or unavailable parts, not a primary procedure for an acutely viable amputated thumb.

Question 2144

Topic: 7. Hand and Wrist

A 22-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid waist nonunion with a humpback deformity and dorsal intercalated segment instability (DISI). No arthritic changes are present. Which of the following is the most appropriate surgical treatment?

. Volar wedge bone grafting and internal fixation
. Dorsal approach with vascularized bone graft
. Proximal row carpectomy
. Four-corner arthrodesis
. Percutaneous screw fixation without grafting

Correct Answer & Explanation

. Volar wedge bone grafting and internal fixation

Explanation

A scaphoid nonunion with a humpback deformity (volar flexion of the scaphoid) and DISI requires correction of the deformity to restore carpal kinematics. A volar wedge graft with internal fixation achieves structural deformity correction and restores length.

Question 2145

Topic: 7. Hand and Wrist

Avascular necrosis is a well-known complication of scaphoid proximal pole fractures. Which of the following best describes the predominant arterial supply to the scaphoid that dictates this risk?

. Volar branches from the ulnar artery entering proximally
. Dorsal carpal branch of the radial artery entering distally and flowing retrograde
. Superficial palmar arch branches entering directly into the proximal pole
. Anterior interosseous artery branches entering through the scapholunate ligament
. Direct intra-articular branches from the radiocarpal joint capsule

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering distally and flowing retrograde

Explanation

The scaphoid is primarily supplied (70-80%) by the dorsal carpal branch of the radial artery, which enters at the distal pole and flows in a retrograde fashion. Fractures at the waist or proximal pole therefore disrupt the blood supply to the proximal fragment.

Question 2146

Topic: 7. Hand and Wrist
A 55-year-old man presents with chronic wrist pain. Radiographs show a scaphoid nonunion with degenerative changes involving the entire radioscaphoid joint and the capitolunate joint. The radiolunate articulation is completely spared. What is the most appropriate surgical management for this stage of Scaphoid Nonunion Advanced Collapse (SNAC)?
. Radial styloidectomy
. Proximal row carpectomy
. Four-corner fusion with scaphoid excision
. Total wrist arthrodesis
. Vascularized bone grafting of the scaphoid

Correct Answer & Explanation

. Four-corner fusion with scaphoid excision

Explanation

This represents Stage III SNAC wrist, involving the radioscaphoid and capitolunate joints but sparing the radiolunate joint. Four-corner fusion with scaphoid excision is indicated. Proximal row carpectomy is contraindicated here due to existing capitolunate arthritis.

Question 2147

Topic: 7. Hand and Wrist

In the digital flexor sheath of the hand, Camper's chiasm refers to the bifurcation and decussation of which of the following tendons?

. Flexor digitorum profundus
. Flexor pollicis longus
. Flexor digitorum superficialis
. Extensor digitorum communis
. Lumbricals

Correct Answer & Explanation

. Flexor digitorum superficialis

Explanation

Camper's chiasm is the bifurcation of the FDS tendon, allowing the FDP tendon to pass through and insert on the distal phalanx. This anatomical crossover occurs at the level of the proximal phalanx.

Question 2148

Topic: 7. Hand and Wrist

A patient presents with numbness in the radial 3.5 digits. Which physical examination finding would reliably differentiate Pronator Syndrome from Carpal Tunnel Syndrome?

. Positive Tinel's sign at the wrist
. Phalen's test positivity
. Weakness of the abductor pollicis brevis
. Atrophy of the thenar muscles
. Decreased sensation over the thenar eminence

Correct Answer & Explanation

. Decreased sensation over the thenar eminence

Explanation

The palmar cutaneous branch of the median nerve arises proximal to the carpal tunnel and supplies sensation to the thenar eminence. Thus, thenar sensation is preserved in carpal tunnel syndrome but decreased in proximal compression like pronator syndrome.

Question 2149

Topic: Nerve & Tendon

During a Zone II flexor tendon repair, which of the following technical factors is most important for minimizing tendon gliding resistance and allowing for early active mobilization?

. Addition of a running epitendinous suture
. Increasing the number of core suture strands from 2 to 6
. Using a thicker caliber core suture (e.g., 3-0 instead of 4-0)
. Complete venting of the A2 pulley
. Immobilization for 3 weeks prior to movement

Correct Answer & Explanation

. Addition of a running epitendinous suture

Explanation

The addition of a running epitendinous suture significantly decreases gliding resistance by smoothing the repair site. It also increases the overall tensile strength of the repair by up to 30%.

Question 2150

Topic: 7. Hand and Wrist

A 22-year-old falls onto an outstretched hand with tenderness in the anatomical snuffbox. Initial radiographs are entirely normal. If imaging is to be performed at 24 hours to definitively rule out a fracture, which modality is the most sensitive?

. Repeat plain radiographs with scaphoid views
. High-resolution Ultrasound
. Computed Tomography (CT)
. Magnetic Resonance Imaging (MRI)
. Technetium-99m bone scintigraphy

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI)

Explanation

MRI is the most sensitive and specific modality for detecting occult scaphoid fractures within the first 24 to 48 hours. It can effectively visualize trabecular bone marrow edema and microscopic fracture lines missed by CT and early radiographs.

Question 2151

Topic: Nerve & Tendon

A 70-year-old male is being evaluated for cervical spondylotic myelopathy. Which of the following physical examination findings is an upper motor neuron sign highly specific to cervical cord compression?

. Absent brachioradialis reflex
. Positive Tinel's sign at the cubital tunnel
. Inverted brachioradialis reflex
. Weakness in intrinsic hand muscle abduction
. Decreased sensation in the C6 dermatome

Correct Answer & Explanation

. Inverted brachioradialis reflex

Explanation

An inverted brachioradialis reflex (spontaneous finger flexion upon striking the brachioradialis tendon) is a classic upper motor neuron sign. It indicates cord compression at the C5-C6 level with simultaneous lower motor neuron loss at C6 and upper motor neuron hyperreflexia below that level.

Question 2152

Topic: 7. Hand and Wrist
A 30-year-old carpenter sustains a volar laceration to the index finger at the level of the proximal interphalangeal joint crease, resulting in isolated loss of active distal interphalangeal joint flexion. Which anatomical zone of the flexor tendon is injured?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone I

Explanation

Zone I extends from the insertion of the flexor digitorum superficialis (FDS) to the insertion of the flexor digitorum profundus (FDP) at the distal phalanx base. An injury here results in an isolated loss of FDP function, preventing active DIP joint flexion.

Question 2153

Topic: 7. Hand and Wrist

A 45-year-old typist presents with numbness and tingling in her thumb, index, and long fingers. Examination reveals a positive Tinel's sign at the wrist and weakness in thumb abduction. Which electrodiagnostic finding most specifically confirms compression at the carpal tunnel?

. Fibrillation potentials in the flexor pollicis longus
. Prolonged distal sensory latency of the median nerve across the wrist
. Decreased conduction velocity of the ulnar nerve at the elbow
. Prolonged F-wave latencies in the ulnar nerve
. Denervation potentials in the abductor digiti minimi

Correct Answer & Explanation

. Prolonged distal sensory latency of the median nerve across the wrist

Explanation

Prolonged median nerve distal sensory and motor latencies across the carpal tunnel are hallmark electrodiagnostic findings of Carpal Tunnel Syndrome. The flexor pollicis longus is innervated proximal to the carpal tunnel and would not show abnormalities in isolated CTS.

Question 2154

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with arthritic changes involving the radioscaphoid and midcarpal joints, while the radiolunate joint is spared. This corresponds to a Stage III SNAC wrist. Which of the following is the most appropriate surgical treatment?
. Scaphoid open reduction and internal fixation with bone grafting
. Radial styloidectomy
. Proximal row carpectomy
. Scaphoid excision and four-corner arthrodesis
. Total wrist arthrodesis

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

Stage III SNAC wrist involves arthritis of the radioscaphoid and midcarpal (capitolunate) joints. Proximal row carpectomy is contraindicated due to capitate articular compromise, making scaphoid excision and four-corner fusion the preferred motion-preserving option.

Question 2155

Topic: 7. Hand and Wrist

The vulnerability of the scaphoid proximal pole to avascular necrosis following fracture is primarily dictated by its blood supply. Which of the following vessels provides the dominant intraosseous blood supply to the scaphoid?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The dorsal carpal branch of the radial artery supplies 70-80% of the scaphoid, entering at the distal ridge and flowing retrogradely to the proximal pole. This retrograde flow is responsible for the high rate of AVN in proximal fractures.

Question 2156

Topic: 7. Hand and Wrist

Six months following volar locking plate fixation of a distal radius fracture, a patient reports a sudden inability to actively flex the interphalangeal joint of the thumb. Attritional rupture of the flexor pollicis longus (FPL) is suspected. Which surgical technical error is the most common cause of this complication?

. Placing the plate proximal to the watershed line
. Using screws that are too long dorsally
. Prominence of the plate at or distal to the watershed line
. Inadequate reduction of the dorsal cortex
. Failing to repair the pronator quadratus

Correct Answer & Explanation

. Prominence of the plate at or distal to the watershed line

Explanation

Attritional rupture of the FPL tendon is most commonly caused by placement of the volar plate at or distal to the watershed line. This prominence creates friction against the flexor tendons during wrist motion.

Question 2157

Topic: 7. Hand and Wrist
In the context of the FRCS (Tr & Orth) clinical viva, what is the primary purpose of presenting a 'short case'?
. To assess the candidate's ability to perform a complete head-to-toe physical examination.
. To evaluate the candidate's detailed knowledge of a specific rare orthopedic condition.
. To test the candidate's ability to identify key signs, formulate a differential diagnosis, and propose an investigation plan for a focused problem.
. To gauge the candidate's speed in making a definitive diagnosis without further investigation.
. To assess communication skills with patients, rather than clinical knowledge.

Correct Answer & Explanation

. To test the candidate's ability to identify key signs, formulate a differential diagnosis, and propose an investigation plan for a focused problem.

Explanation

The primary purpose of a 'short case' in the FRCS clinical viva is to assess the candidate's ability to perform a focused examination, identify key clinical signs, formulate a differential diagnosis, and propose an appropriate investigation and management plan for a specific orthopedic problem (e.g., a knee pathology, a hand deformity). It is not about a complete head-to-toe exam, nor about rare conditions, nor about speed over accuracy, nor solely communication skills (though they are assessed).

Question 2158

Topic: Nerve & Tendon

A candidate is asked about clinical tests for ulnar nerve compression (cubital tunnel syndrome). The examiner asks what muscle weakness produces a positive Froment's sign. Which muscle is primarily affected?

. Flexor pollicis longus
. Adductor pollicis
. Abductor pollicis brevis
. First dorsal interosseous
. Opponens pollicis

Correct Answer & Explanation

. Adductor pollicis

Explanation

A positive Froment's sign occurs due to weakness of the adductor pollicis (innervated by the ulnar nerve). The patient compensates by using the flexor pollicis longus (median nerve) to pinch, resulting in hyperflexion of the thumb interphalangeal joint.

Question 2159

Topic: 7. Hand and Wrist

A 25-year-old carpenter sustains a laceration to the volar aspect of his proximal phalanx (Zone II), cleanly severing both the FDS and FDP tendons. What is the optimal surgical repair construct to maximize tensile strength and minimize gap formation during early active rehabilitation?

. 2-strand core suture alone
. 2-strand core suture with an epitendinous repair
. 4-strand core suture with an epitendinous repair
. 6-strand core suture without epitendinous repair
. Bunnell pull-out suture

Correct Answer & Explanation

. 4-strand core suture with an epitendinous repair

Explanation

A 4-strand core suture supplemented by a running epitendinous suture provides sufficient tensile strength for early active motion protocols while minimizing tendon bulk. The epitendinous suture significantly reduces gap formation and improves the gliding characteristics.

Question 2160

Topic: Wrist & Carpus

An examiner questions you on diagnostic tests. A new clinical test for diagnosing scaphoid fractures has a high positive predictive value (PPV). Which of the following epidemiological factors will most directly cause the PPV of this test to increase?

. An increase in the sensitivity of the test
. An increase in the prevalence of scaphoid fractures in the population
. A decrease in the specificity of the test
. An increase in the number of false-positive results
. A decrease in the prevalence of scaphoid fractures in the population

Correct Answer & Explanation

. An increase in the prevalence of scaphoid fractures in the population

Explanation

Positive predictive value is highly dependent on the prevalence of the disease in the tested population. As disease prevalence increases, the likelihood that a positive test truly represents the disease (PPV) also increases, assuming sensitivity and specificity remain constant.

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