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7. Hand and Wrist MCQs

Practice Set 11 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 201

Topic: 7. Hand and Wrist

During flexor tendon repair in Zone II of the hand, meticulous management of the tendon sheath and pulley system is essential. Which two pulleys are biomechanically most critical to preserve in order to prevent bowstringing of the flexor tendons?

. A1 and A3
. A2 and A4
. A1 and A5
. A3 and A5
. A2 and A3

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 and A4 pulleys are the major mechanical contributors to the flexor tendon pulley system. Their preservation is essential to prevent flexor tendon bowstringing and subsequent loss of active digital flexion.

Question 202

Topic: 7. Hand and Wrist

A 24-year-old male sustains a displaced fracture of the proximal pole of the scaphoid. This injury is at high risk for avascular necrosis due to the retrograde blood supply primarily derived from which vessel?

. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Deep palmar arch
. Superficial palmar arch
. Ulnar artery

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The major blood supply to the scaphoid enters distally via the dorsal carpal branch of the radial artery and flows retrograde to the proximal pole. Proximal pole fractures often disrupt this supply, leading to avascular necrosis.

Question 203

Topic: Wrist & Carpus

Six weeks after non-operative management of a non-displaced distal radius fracture, a 60-year-old female presents with a sudden inability to actively extend the interphalangeal joint of her thumb. What is the most appropriate surgical treatment?

. Primary end-to-end repair of the ruptured tendon
. Tendon transfer using the extensor indicis proprius (EIP)
. Tendon transfer using the palmaris longus (PL)
. Tendon graft using the plantaris tendon
. Tenodesis of the distal stump to the first dorsal compartment

Correct Answer & Explanation

. Tendon transfer using the extensor indicis proprius (EIP)

Explanation

Extensor pollicis longus (EPL) rupture is a known complication of non-displaced distal radius fractures due to attrition and localized ischemia. Primary repair is usually impossible due to tendon retraction and fraying, making EIP to EPL transfer the treatment of choice.

Question 204

Topic: 7. Hand and Wrist

A 22-year-old male sustains a fracture of the proximal pole of the scaphoid. The high risk of avascular necrosis (AVN) in this specific fracture pattern is primarily due to the retrograde blood supply originating from which of the following vessels?

. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Superficial palmar arch
. Deep palmar arch
. Anterior interosseous artery

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The major blood supply to the scaphoid enters the dorsal ridge distally via the dorsal carpal branch of the radial artery. It flows in a retrograde fashion to supply the proximal pole, predisposing proximal pole fractures to ischemia and AVN.

Question 205

Topic: 7. Hand and Wrist

During a physical examination of a 68-year-old male with progressive clumsiness in his hands, the examiner flicks the distal phalanx of the patient's middle finger, causing sudden flexion of the thumb and index finger. This physical sign indicates pathology in which of the following locations?

. Upper motor neuron lesion above the C5 or C6 level
. Lower motor neuron lesion at the C8-T1 level
. Peripheral entrapment of the median nerve at the carpal tunnel
. Cerebellar vermis degeneration
. Brachial plexus traction injury

Correct Answer & Explanation

. Upper motor neuron lesion above the C5 or C6 level

Explanation

The described maneuver elicits a positive Hoffmann sign, which is indicative of an upper motor neuron lesion, such as cervical spondylotic myelopathy. It typically points to spinal cord compression above the C5 or C6 level.

Question 206

Topic: 7. Hand and Wrist

A 30-year-old male basketball player presents with an acute, closed mallet finger of the right ring finger without volar subluxation of the distal phalanx. What is the most appropriate initial management?

. Observation and early active range of motion
. Primary surgical tendon repair utilizing a mini-anchor
. Splinting of both the PIP and DIP joints in extension for 6 weeks
. Immediate closed reduction and percutaneous pinning across the DIP joint
. Continuous extension splinting of the DIP joint alone for 6 to 8 weeks

Correct Answer & Explanation

. Continuous extension splinting of the DIP joint alone for 6 to 8 weeks

Explanation

The gold standard treatment for an acute, closed mallet finger injury without joint subluxation is strict, continuous extension splinting of the distal interphalangeal (DIP) joint for 6 to 8 weeks. The PIP joint is left free to move.

Question 207

Topic: 7. Hand and Wrist

A 28-year-old man falls on an outstretched hand and sustains a displaced proximal pole scaphoid fracture. Given the retrograde blood supply to the scaphoid, which surgical approach and fixation method is generally preferred for isolated proximal pole fractures?

. Volar approach with a headless compression screw
. Dorsal approach with a headless compression screw
. Volar approach with K-wires
. Cast immobilization for 12 weeks
. Proximal row carpectomy

Correct Answer & Explanation

. Dorsal approach with a headless compression screw

Explanation

A dorsal approach is preferred for proximal pole scaphoid fractures because it provides direct access to the proximal fragment, avoids injury to the volar radiocarpal ligaments, and allows for central screw placement in the small proximal pole.

Question 208

Topic: Nerve & Tendon

The muscle that flexes the interphalangeal joint of the thumb is innervated by which roots of the brachial plexus:

. C 5, C 6
. C 5, C 6, C 7
. C 6, C 7, C 8
. C 5, C 6, C 7, C 8, T1
. C 7, C 8, T1

Correct Answer & Explanation

. C 5, C 6, C 7, C 8, T1

Explanation

The interphalangeal joint of the thumb is flexed secondary to actions of the flexor pollicis longus (FPL). The FPL is innervated by the anterior interosseous nerve, which is the longest branch of the median nerve. The median nerve is formed by the lateral (roots C 5, C 6, and C 7) and medial (roots C 8 and T1) cords of the brachial plexus.

Question 209

Topic: Nerve & Tendon

The anterior interosseous nerve (AIN) originates from the median nerve at what distance from the medial epicondyle:

. 6 cm distal
. 10 cm proximal
. 6 cm proximal
. 10 cm distal
. At the medial epicondyle

Correct Answer & Explanation

. 6 cm distal

Explanation

The AIN, the largest branch of the median nerve, originates 5 cm to 8 cm distal to the medial epicondyle from the posteroradial aspect of the median nerve just distal to the proximal border of the superficial head of the pronator teres.

Question 210

Topic: 7. Hand and Wrist

man presents to the emergency department with a 6-week history of difficulty writing and pain after playing tennis. She also reports a recent inability to abduct and adduct her fingers. What is the mechanism of her symptoms:

. Writers cramp or focal dystonia
. Riche-Cannieu anastamosis
. Martin-Gruber interconnection
. Ulnar neuropathy
. Carpal tunnel syndrome

Correct Answer & Explanation

. Martin-Gruber interconnection

Explanation

Approximately 17% of the population has a Martin-Gruber interconnection, and 50% of these patients may show additional denervation of normally ulnar nerve-innervated intrinsic muscles. The Martin-Gruber anomaly is a motor neural connection between the anterior interosseous nerve and ulnar nerves that is located adjacent to the ulnar artery in the proximal forearm.

Question 211

Topic: Nerve & Tendon
What is the innervation of the indicated muscle in the image (Slide)?
. Median nerve
. Anterior interosseous nerve
. Radial nerve
. Ulnar nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The arrow in the photograph (Slide) is pointing to the pronator teres - one of the most common sites for compression of the anterior interosseous nerve. The pronator teres is innervated by the median nerve.

Question 212

Topic: 7. Hand and Wrist

Sites of potential compression of the median nerve include all of the following except:

. Pronator teres
. Transverse carpal ligament
. Pisohamate ligament
. Supracondylar process
. Mass in carpal canal (e.g., lipoma)

Correct Answer & Explanation

. Pisohamate ligament

Explanation

Around the elbow, the median nerve may be compressed by the pronator teres (causing either anterior interosseous nerve syndrome or pronator syndrome) or the ligament of Struthers originating from a supracondylar process (causing pronator syndrome). In the wrist, the median nerve may be compressed by the transverse carpal ligament or a mass within the carpal canal. The ulnar nerve, not the median nerve, can be compressed by the pisohamate ligament.

Question 213

Topic: 7. Hand and Wrist
What position of the wrist most commonly produces scaphoid fractures?
. Wrist flexion and radial deviation
. Wrist extension and radial deviation
. Wrist flexion and ulnar deviation
. Wrist extension and ulnar deviation
. Clenched fist and wrist flexion

Correct Answer & Explanation

. Wrist extension and radial deviation

Explanation

Frykman performed biomechanical studies to evaluate the wrist position in falls that produce scaphoid fractures. The results showed that wrist extension greater than 90° and radial deviation consistently resulted in fracture of the scaphoid.

Question 214

Topic: Wrist & Carpus

During a posterior (dorsal) approach to percutaneous screw fixation for a scaphoid fracture, many structures are close to the guidewire insertion location and are at risk for injury. Which of the following structures is the closest to the guidewire insertion location according to a recent cadaveric study:

. Posterior interosseous nerve
. Extensor digitorum communis to the index
. Extensor indicis proprius
. Extensor carpi radialis brevis
. Extensor digitorum communis to the index and posterior interosseous nerve

Correct Answer & Explanation

. Extensor digitorum communis to the index and posterior interosseous nerve

Explanation

Adamany and colleagues performed a cadaveric study to evaluate the dorsal structures at risk with truly percutaneous headless screw placement for scaphoid fractures. They noted that the posterior interosseous nerve and the extensor digitorum communis to the index finger were an average of 2.2 mm from the guidewire and therefore at greatest risk from this approach.

Question 215

Topic: Nerve & Tendon
Which finger is most commonly involved in a flexor digitorum profundus (FDP) avulsion injury?
. Index
. Middle
. Ring
. Small
. Thumb

Correct Answer & Explanation

. Ring

Explanation

An FDP avulsion is caused by forceful extension of the distal interphalangeal (DIP) joint, occurring at the same time as a maximum contraction of the FDP tendon. Jersey finger is often seen in athletes, especially football or rugby players, who commonly get their fingers caught in an opposing player's jersey, thus the name. In most cases, this injury affects the ring finger.

Question 216

Topic: 7. Hand and Wrist

What is the most critical step in pollicization to create a normal-looking thumb:

. Creating skin incisions with skin flaps that will allow a natural first web space
. Shortening of tendons
. Shortening of the index finger metacarpal
. Creating a hyperextended joint when stabilizing the metacarpophalangeal joint to the carpus
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

It is necessary to create a hand with a natural first web space, shorter tendons that allow for natural movement, a shorter metacarpal that ensures the finger will not grow to an unnatural length, and a hyperextended joint to create the most naturallooking hand possible.

Question 217

Topic: 7. Hand and Wrist
The fracture fragment in Bennett's fracture is located in which of the following areas of the hand?
. Radiopalmar trapezium
. Dorsal thumb metacarpal base
. Ulnopalmar trapezium
. Ulnopalmar thumb metacarpal base
. Radiopalmer lunate

Correct Answer & Explanation

. Ulnopalmar trapezium

Explanation

As an axial load is placed on the thumb tip, it drives the thumb metacarpal (MC) base in a dorsal-radial direction. As the thumb MC base moves dorsoradially, a fracture is created in the volar, ulnar quadrant of the thumb MC base. Gedda and Moberg describe this as a ligament fracture avulsion. The volar, ulnar quadrant piece usually remains stationary, perhaps migrating a small amount distal as the thumb metacarpal base moves dorsoradially, creating a fracture in the volar, ulnar quadrant of the trapezium.

Question 218

Topic: 7. Hand and Wrist

C linically, what is the upper limit of acceptable fracture angulation for a fifth metacarpal neck fracture:

. 20°
. 40°
. 50°
. 70°
. 80°

Correct Answer & Explanation

. 70°

Explanation

Although this is controversial, conservatively treated patients with angulations less than 70° fared well in two prospective studies. Fourteen percent of patients will have a cosmetic deformity, but operatively treated patients exhibited extensor lag and increased rehabilitation times.

Question 219

Topic: 7. Hand and Wrist

In cadaveric models, when does the biomechanics of fifth finger flexion consistently change in relationship to metacarpal neck fracture angulation:

. 10°
. 30°
. 50°
. 70°
. 80°

Correct Answer & Explanation

. 30°

Explanation

Thirty degrees of angulation is the maximum deformity for acceptable fifth finger grip strength. Ali et al showed that fracture angulation of 30° results in a significant decrease in the distance between the origin and the insertion of the flexor digiti minimi (FDM). This shortening creates more slack in the FDM muscle and more excursion is wasted as muscle shortening prior to the initiation of metacarpophalangeal (MP) flexion.C orrect Answer: 30°

Question 220

Topic: 7. Hand and Wrist

Up to how much angulation can be tolerated in the small finger metacarpal shaft fracture:

. 0° to 10°
. 11° to 20°
. 21° to 30°
. 31° to 40°
. 41° to 50°

Correct Answer & Explanation

. 41° to 50°

Explanation

The small finger carpometacarpal joint is mobile, which allows the small finger metacarpal to tolerate deformity better than the fixed index and middle finger rays. Thus, 41° to 50° of angulation can be accommodated by the mobile carpometacarpal joint.

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