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7. Hand and Wrist MCQs

Practice Set 111 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 2201

Topic: Hand Trauma & Infection

A 30-year-old mechanic sustains a puncture wound to the volar aspect of his index finger and presents 48 hours later with suspected pyogenic flexor tenosynovitis. Which of the following physical examination findings is clinically considered the earliest and most sensitive of Kanavel's signs?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Tenderness localized symmetrically along the flexor tendon sheath
. Excruciating pain with passive extension of the digit
. Erythema extending proximal to the palmar crease

Correct Answer & Explanation

. Excruciating pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: 1) flexed resting posture, 2) fusiform (sausage-like) swelling, 3) tenderness along the flexor tendon sheath, and 4) disproportionate pain with passive extension. Pain with passive extension is historically and clinically considered the earliest and most sensitive sign.

Question 2202

Topic: 7. Hand and Wrist

A 45-year-old manual laborer presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with localized osteoarthritis strictly confined to the radial styloid and the distal pole of the scaphoid. The midcarpal joint is completely spared. What is the most appropriate surgical intervention?

. Proximal row carpectomy
. Four-corner arthrodesis
. Radial styloidectomy and scaphoid open reduction internal fixation with bone grafting
. Scaphoid excision and capitolunate arthrodesis
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial styloidectomy and scaphoid open reduction internal fixation with bone grafting

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage 1, characterized by arthritis limited to the radial styloid. The recommended treatment for Stage 1 is radial styloidectomy combined with scaphoid nonunion takedown, bone grafting, and internal fixation. Stages 2 and 3 involve more extensive carpal arthritis, requiring salvage procedures like proximal row carpectomy or four-corner fusion.

Question 2203

Topic: 7. Hand and Wrist

A patient presents with neglected pyogenic flexor tenosynovitis of the thumb. The infection is noted to have spread proximally and now directly involves the flexor sheath of the small finger, creating a 'horseshoe abscess.' This proximal communication occurs via which of the following anatomic structures?

. Space of Parona
. Midpalmar space
. Thenar space
. Guyon's canal
. Carpal tunnel

Correct Answer & Explanation

. Space of Parona

Explanation

The flexor tendon sheath of the thumb (radial bursa) and the flexor tendon sheath of the small finger (ulnar bursa) communicate proximally in the distal forearm through the Space of Parona. This potential space is located between the pronator quadratus fascia and the deep flexor tendons, allowing an infection to spread from the thumb to the small finger, resulting in a classic horseshoe abscess.

Question 2204

Topic: 7. Hand and Wrist

A 25-year-old male sustains a nondisplaced fracture of the scaphoid waist. He is warned about the risk of avascular necrosis (AVN) of the proximal pole due to its precarious retrograde blood supply. The primary blood supply to the proximal pole of the scaphoid is derived from which of the following vessels?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The primary blood supply to the scaphoid (supplying 70-80% of the bone, including the proximal pole) comes from the dorsal carpal branch of the radial artery. These vessels enter the scaphoid via a dorsal ridge at or distal to the waist and provide retrograde flow to the proximal pole, explaining the high rate of AVN in proximal pole and waist fractures.

Question 2205

Topic: 7. Hand and Wrist
In the natural progression of Scaphoid Nonunion Advanced Collapse (SNAC), which of the following carpal articulations is typically spared from degenerative changes due to its congruent spherical geometry and preserved kinematics?
. Radioscaphoid joint
. Capitolunate joint
. Scaphocapitate joint
. Radiolunate joint
. Scaphotrapezial joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

The radiolunate joint is characteristically spared in both SLAC (Scapholunate Advanced Collapse) and SNAC (Scaphoid Nonunion Advanced Collapse) wrists. The spherical geometry of the lunate and its congruent lunate fossa on the distal radius preserve contact area and mechanics, preventing early cartilage wear despite carpal collapse. SNAC staging typically progresses from the radial styloid-scaphoid joint (Stage I), to the scaphocapitate joint (Stage II), and finally the capitolunate joint (Stage III).

Question 2206

Topic: 7. Hand and Wrist

A 45-year-old carpenter presents with an isolated, chronic low median nerve palsy after a laceration at the wrist 2 years ago. He has severe thenar atrophy and inability to oppose the thumb. Which of the following tendon transfers is historically described to restore opposition by transferring the flexor digitorum superficialis (FDS) of the ring finger looped around the FCU to the APB insertion?

. Huber transfer
. Burkhalter transfer
. Bunnell transfer
. EIP to APB transfer
. Camitz transfer

Correct Answer & Explanation

. Bunnell transfer

Explanation

The Bunnell transfer utilizes the flexor digitorum superficialis (FDS) of the ring finger, using a pulley created at the level of the pisiform (often using a loop of the FCU), to provide the correct vector to restore thumb opposition. The Huber transfer uses the abductor digiti minimi (ADM) and is favored in congenital hypoplasia. The Burkhalter transfer uses the extensor indicis proprius (EIP). The Camitz transfer utilizes the palmaris longus extended by palmar fascia and provides excellent palmar abduction but poorer opposition, often used in severe carpal tunnel syndrome.

Question 2207

Topic: 7. Hand and Wrist

The primary blood supply to the proximal pole of the scaphoid is derived from which of the following vessels?

. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery entering via the dorsal ridge
. Superficial palmar arch
. Anterior interosseous artery
. Ulnar artery via the deep palmar arch

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering via the dorsal ridge

Explanation

The scaphoid receives 70-80% of its blood supply (including the entire proximal pole) via retrograde flow from the dorsal carpal branch of the radial artery, which enters at the dorsal ridge. The volar carpal branch supplies the distal 20-30%.

Question 2208

Topic: 7. Hand and Wrist

A 35-year-old male falls on an outstretched hand and sustains a volar shear fracture of the distal radius with radiocarpal subluxation. Which of the following carpal ligaments remains attached to the displaced volar lunate facet fragment, maintaining its connection to the lunate?

. Dorsal radiocarpal ligament
. Radioscaphocapitate ligament
. Short radiolunate ligament
. Long radiolunate ligament
. Ulnolunate ligament

Correct Answer & Explanation

. Short radiolunate ligament

Explanation

The short radiolunate ligament originates from the volar lunate facet of the distal radius and inserts onto the lunate. In volar shear fractures (e.g., Volar Barton's), the lunate follows the volar lunate facet fragment due to the strong attachment of the short radiolunate ligament.

Question 2209

Topic: 7. Hand and Wrist
A 42-year-old manual laborer presents with progressive wrist pain. Radiographs reveal a scaphoid nonunion with advanced collapse (SNAC). There is radioscaphoid and capitolunate arthritis, but the radiolunate joint is entirely spared. Which of the following is the most appropriate surgical treatment?
. Scaphoid excision and four-corner fusion
. Proximal row carpectomy
. Total wrist arthroplasty
. Radioscapholunate fusion
. Distal radius corrective osteotomy

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

This patient has Stage II/III SNAC wrist. Because there is capitolunate arthritis, a proximal row carpectomy (PRC) is contraindicated as PRC requires a preserved proximal capitate and lunate fossa. The best option is scaphoid excision and four-corner fusion (capitate, hamate, lunate, triquetrum), which relies on the spared radiolunate joint to maintain wrist motion.

Question 2210

Topic: 7. Hand and Wrist
A 30-year-old female presents with progressive dorsal wrist pain. Radiographs reveal ulnar negative variance with sclerosis and mild fragmentation of the lunate, but no carpal collapse or arthritis (Lichtman Stage IIIa Kienböck's disease). Which of the following is the most appropriate surgical intervention?
. Proximal row carpectomy
. Ulnar shortening osteotomy
. Total wrist arthroplasty
. Radial shortening osteotomy
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early-stage Kienböck's disease (Stage I, II, IIIa) with ulnar negative variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. This unloads the radiolunate joint and alters the biomechanical forces across the carpus. Ulnar shortening osteotomy would worsen ulnar negative variance.

Question 2211

Topic: Nerve & Tendon

A 25-year-old rugby player presents with an inability to actively flex the distal interphalangeal (DIP) joint of his ring finger after grabbing an opponent's jersey. Radiographs are normal. Examination reveals a mass in the palm. According to the Leddy and Packer classification, this is a Type 1 injury. What is the recommended timeline for surgical repair?

. Within 7 to 10 days
. Within 24 hours
. Within 3 to 4 weeks
. After 6 weeks to allow inflammation to subside
. Staged tendon reconstruction is required immediately

Correct Answer & Explanation

. Within 7 to 10 days

Explanation

A Leddy and Packer Type 1 jersey finger involves avulsion of the FDP tendon with retraction all the way into the palm. This completely disrupts the vincula, compromising the blood supply to the tendon. Early surgical repair (within 7-10 days) is required before the tendon undergoes myostatic contracture and necrosis, making primary repair impossible.

Question 2212

Topic: 7. Hand and Wrist

The risk of avascular necrosis (AVN) in a scaphoid fracture is highly dependent on the anatomic location of the fracture line. What is the primary arterial supply to the proximal pole of the scaphoid?

. Volar branches of the radial artery entering at the distal tubercle
. Dorsal carpal branch of the radial artery entering via the dorsal ridge
. Direct branches from the ulnar artery
. Intraosseous vessels crossing from the lunate via the scapholunate ligament
. Anterior interosseous artery branches

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering via the dorsal ridge

Explanation

The blood supply to the scaphoid is largely retrograde. The dorsal carpal branch of the radial artery enters the dorsal ridge in the distal third and supplies 70-80% of the proximal bone via retrograde intraosseous flow, making proximal pole fractures highly susceptible to AVN.

Question 2213

Topic: Nerve & Tendon

A 6-year-old boy presents with a displaced lateral condyle fracture of the humerus. Which of the following describes the most likely long-term complication if this fracture goes on to nonunion?

. Cubitus varus and tardy radial nerve palsy
. Cubitus valgus and tardy ulnar nerve palsy
. Cubitus valgus and median nerve palsy
. Cubitus varus and tardy ulnar nerve palsy
. Premature physeal closure with limb length discrepancy

Correct Answer & Explanation

. Cubitus valgus and tardy ulnar nerve palsy

Explanation

Nonunion of a lateral condyle humerus fracture often leads to progressive cubitus valgus deformity. Over time, the stretching of the ulnar nerve behind the medial epicondyle can cause a tardy ulnar nerve palsy. Cubitus varus is classically associated with supracondylar humerus malunions.

Question 2214

Topic: 7. Hand and Wrist

The blood supply to the scaphoid primarily enters the bone distally and travels proximally, which predisposes proximal pole fractures to avascular necrosis. Which artery is the primary source of this retrograde blood supply?

. Palmar carpal branch of the ulnar 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 scaphoid receives 70-80% of its blood supply from branches of the radial artery (specifically the dorsal carpal branch), which enter the bone at the dorsal ridge near the scaphoid waist and supply the proximal pole in a retrograde fashion. The remaining 20-30% enters via the volar superficial palmar arch branch, supplying the distal pole.

Question 2215

Topic: Wrist & Carpus

A 45-year-old manual laborer presents with progressive wrist pain. Radiographs reveal a scaphoid nonunion with localized arthritis at the radial styloid-scaphoid articulation. The radioscaphoid joint is narrowed, but the midcarpal joint and the radiolunate articulation are completely preserved (SNAC Stage 1). Which of the following is the most appropriate surgical intervention?

. Proximal row carpectomy
. Four-corner arthrodesis
. Radial styloidectomy with scaphoid nonunion takedown and bone grafting
. Total wrist arthrodesis
. Scaphoid excision and capitolunate arthrodesis

Correct Answer & Explanation

. Radial styloidectomy with scaphoid nonunion takedown and bone grafting

Explanation

Scaphoid nonunion advanced collapse (SNAC) Stage 1 is characterized by arthritis limited to the radial styloid. For Stage 1 SNAC, an organ-preserving procedure is indicated, specifically radial styloidectomy combined with open reduction, internal fixation, and bone grafting of the scaphoid. Salvage procedures like proximal row carpectomy (PRC) or four-corner fusion are indicated for SNAC Stage 2 (scaphocapitate arthritis) and Stage 3 (periscaphoid arthritis).

Question 2216

Topic: 7. Hand and Wrist

A 28-year-old carpenter sustains a laceration over the volar aspect of the proximal phalanx of his index finger, severing both the FDS and FDP tendons. This anatomical area is designated as Zone II. Why was this specific zone historically referred to by Bunnell as 'no man's land'?

. Due to the completely avascular nature of the flexor tendons within this segment
. Because primary repair historically yielded poor results due to dense adhesions within the narrow fibro-osseous sheath
. Due to the lack of distinct anatomical landmarks making surgical exploration hazardous
. Because both the median and ulnar nerves arborize extensively in this exact location
. Due to the extremely high rate of purulent flexor tenosynovitis following any surgical intervention

Correct Answer & Explanation

. Because primary repair historically yielded poor results due to dense adhesions within the narrow fibro-osseous sheath

Explanation

Zone II of the hand extends from the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS). Historically, Sterling Bunnell termed this area 'no man's land' because primary repair of the flexor tendons within this tight fibro-osseous sheath resulted in dense adhesions and severely restricted motion. Modern microscopic techniques, better suture materials, and early active mobilization protocols have reversed this, making primary repair the standard of care.

Question 2217

Topic: 7. Hand and Wrist

A laceration of the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons in 'Zone II' is notoriously difficult to treat, historically termed 'no man's land'. What specific anatomical landmarks define the proximal and distal boundaries of flexor tendon Zone II?

. Proximal edge of the A1 pulley to the FDS insertion
. Distal edge of the carpal tunnel to the proximal edge of the A1 pulley
. FDS insertion to the FDP insertion at the distal phalanx
. Musculotendinous junction to the proximal edge of the carpal tunnel
. Proximal edge of the A2 pulley to the FDP insertion

Correct Answer & Explanation

. Distal edge of the carpal tunnel to the proximal edge of the A1 pulley

Explanation

Zone II of the flexor tendon system begins proximally at the level of the A1 pulley (distal palmar crease) and ends distally at the insertion of the FDS tendon on the middle phalanx. Both FDS and FDP tendons are tightly constrained within the fibro-osseous sheath here, making repairs highly prone to adhesion formation.

Question 2218

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with progressive wrist pain. Radiographs show lunate sclerosis and fragmentation, but normal carpal height. Ulnar variance is measured at minus 3 mm. According to the Lichtman classification, this is Stage IIIA Kienböck's disease. What is the most appropriate surgical treatment?
. Proximal row carpectomy
. Radial shortening osteotomy
. Capitate shortening osteotomy
. Total wrist arthrodesis
. Scaphoid excision and four-corner fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Lichtman Stage IIIA Kienböck's disease (lunate fragmentation without fixed carpal collapse), joint-leveling procedures are indicated if there is ulnar negative variance. A radial shortening osteotomy unloads the lunate and halts disease progression. Salvage procedures (PRC, 4-corner fusion) are reserved for Stage IIIB or IV.

Question 2219

Topic: Wrist & Carpus
A 45-year-old man presents with chronic wrist pain and a known scaphoid nonunion. Radiographs reveal narrowing of the radioscaphoid joint and capitolunate joint, but the radiolunate joint is spared. What is the SNAC stage and most appropriate surgical treatment?
. SNAC Stage I - Radial styloidectomy
. SNAC Stage II - Proximal row carpectomy
. SNAC Stage III - Four-corner arthrodesis
. SNAC Stage III - Scaphoid excision and capitolunate arthrodesis
. SNAC Stage IV - Total wrist arthrodesis

Correct Answer & Explanation

. SNAC Stage III - Four-corner arthrodesis

Explanation

SNAC Stage III involves arthritis of the radioscaphoid and midcarpal (capitolunate) joints, while the radiolunate joint is characteristically spared. Four-corner fusion (capitate, hamate, lunate, triquetrum) with scaphoid excision is the standard treatment when the capitate is involved, precluding a proximal row carpectomy.

Question 2220

Topic: 7. Hand and Wrist
A 32-year-old heavy laborer presents with chronic dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate with proximal migration of the capitate and a measured radioscaphoid angle of 65 degrees. He has ulnar neutral variance. What is the most appropriate surgical intervention?
. Radial shortening osteotomy
. Radial wedge osteotomy
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Vascularized bone graft from the distal radius

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has Lichtman Stage IIIB Kienböck's disease (fragmentation of lunate, carpal collapse with fixed scaphoid rotation >60 deg). In the presence of carpal collapse and neutral ulnar variance, salvage procedures such as proximal row carpectomy or scaphoid excision and four-corner fusion are indicated. Radial shortening is reserved for earlier stages with ulnar minus variance.

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