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7. Hand and Wrist MCQs

Practice Set 112 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 2221

Topic: 7. Hand and Wrist

A patient presents with intrinsic muscle wasting of the hand, numbness in the small finger, and a positive Froment's sign. Which muscle is compensating for the weakened adductor pollicis during the Froment's sign maneuver?

. Abductor pollicis brevis
. Flexor pollicis longus
. Flexor pollicis brevis (superficial head)
. First dorsal interosseous
. Extensor pollicis longus

Correct Answer & Explanation

. Flexor pollicis longus

Explanation

Froment's sign occurs when the patient attempts to pinch a piece of paper between the thumb and index finger. Weakness of the adductor pollicis (ulnar nerve) causes the patient to hyperflex the thumb interphalangeal joint using the flexor pollicis longus (innervated by the anterior interosseous nerve/median nerve) to compensate.

Question 2222

Topic: Wrist & Carpus
The natural history of an untreated scaphoid nonunion progresses predictably to Scaphoid Nonunion Advanced Collapse (SNAC). Which specific joint articulation is initially spared in the early stages (SNAC Stage I and II) but eventually becomes involved in SNAC Stage III?
. Radioscaphoid joint
. Capitolunate joint
. Scaphotrapezial joint
. Radioscaphocapitate joint
. Distal radioulnar joint

Correct Answer & Explanation

. Capitolunate joint

Explanation

SNAC wrist progresses in a predictable pattern. Stage I involves the radial styloid-scaphoid articulation. Stage II involves the entire radioscaphoid articulation. Stage III progresses to involve the midcarpal joint, specifically the capitolunate joint. The radiolunate joint is characteristically spared in both SLAC and SNAC wrists due to the spherical articulation and the protective short radiolunate ligament.

Question 2223

Topic: Nerve & Tendon

A patient with rheumatoid arthritis presents with a swan neck deformity of the ring finger. What is the primary pathophysiological event that typically initiates this specific deformity in the rheumatoid hand?

. Rupture of the extensor tendon central slip
. Volar plate laxity or attenuation at the PIP joint
. Subluxation of the lateral bands volar to the PIP joint axis
. Intrinsic muscle tightness and MCP joint subluxation
. Rupture of the flexor digitorum profundus (FDP) tendon

Correct Answer & Explanation

. Volar plate laxity or attenuation at the PIP joint

Explanation

In rheumatoid arthritis, the swan neck deformity typically initiates with synovitis at the proximal interphalangeal (PIP) joint, leading to stretching and attenuation of the volar plate. This causes PIP joint hyperextension, followed secondarily by dorsal subluxation of the lateral bands and compensatory flexion at the DIP joint. Central slip rupture causes a boutonniere deformity.

Question 2224

Topic: 7. Hand and Wrist
In the classification of flexor tendon injuries of the hand, which zone is historically referred to as 'no man's land' due to the high risk of adhesion formation and historically poor surgical outcomes?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II extends from the proximal edge of the A1 pulley (distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) at the middle phalanx. It is called 'no man's land' because both the FDS and flexor digitorum profundus (FDP) tendons run tightly together in the fibro-osseous sheath, making repair challenging and prone to severe adhesion formation.

Question 2225

Topic: 7. Hand and Wrist

A 25-year-old man presents with chronic wrist pain and is diagnosed with a proximal pole scaphoid nonunion. MRI confirms avascular necrosis (AVN) of the proximal pole. Radiographs show no evidence of radiocarpal or midcarpal arthritis (SNAC 0). Which of the following is the most appropriate surgical treatment?

. Non-vascularized corticocancellous iliac crest bone graft
. 1,2-Intercompartmental supraretinacular artery (ICSRA) pedicled graft
. Free vascularized medial femoral condyle (MFC) bone graft
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion

Correct Answer & Explanation

. Free vascularized medial femoral condyle (MFC) bone graft

Explanation

In the presence of a scaphoid nonunion with proximal pole AVN and no established arthritis, a vascularized bone graft is indicated. The free vascularized medial femoral condyle (MFC) graft provides structural support and robust blood supply, demonstrating significantly higher union rates than the pedicled 1,2-ICSRA graft, which often relies on unreliable retrograde flow. Salvage procedures (PRC or four-corner fusion) are premature in the absence of SNAC changes.

Question 2226

Topic: Nerve & Tendon
A rugby player sustains a flexor digitorum profundus (FDP) avulsion of the ring finger (Jersey finger). Intraoperatively, the surgeon finds the tendon stump blocked at the level of the A4 pulley due to a large bony avulsion fragment. How is this injury classified according to the Leddy-Packer classification?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type III

Explanation

The Leddy-Packer classification for FDP avulsion: Type I involves retraction to the palm (loss of all blood supply, repair within 7-10 days). Type II involves retraction to the PIP joint level (caught at chiasm of Camper, blood supply intact via vincula longa). Type III involves a large bony avulsion that gets caught at the A4 pulley, preventing further proximal retraction.

Question 2227

Topic: 7. Hand and Wrist

A 25-year-old man presents with a symptomatic proximal pole scaphoid non-union and is scheduled for structural bone grafting. The high rate of osteonecrosis in the proximal pole is due to its precarious blood supply. The primary vascular supply to the proximal pole of the scaphoid is derived from which of the following?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The scaphoid is supplied primarily by the dorsal carpal branch of the radial artery. This vessel enters the scaphoid at the non-articular dorsal ridge and supplies the proximal 80% of the bone via retrograde flow. Fractures through the waist or proximal pole easily disrupt this retrograde supply, leading to a high rate of avascular necrosis and non-union.

Question 2228

Topic: Nerve & Tendon

A 35-year-old new mother presents with severe pain over the radial styloid. Finkelstein's test is markedly positive. After failing conservative management, she is scheduled for surgical release of the first dorsal compartment (De Quervain's tenosynovitis). Which of the following nerve branches is at the highest risk of iatrogenic injury during the superficial surgical dissection of this procedure?

. Palmar cutaneous branch of the median nerve
. Superficial branch of the radial nerve
. Dorsal cutaneous branch of the ulnar nerve
. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve

Correct Answer & Explanation

. Superficial branch of the radial nerve

Explanation

The superficial branch of the radial nerve (SBRN) runs in extremely close proximity to the first dorsal compartment. It typically crosses over the extensor retinaculum just superficial to the compartment. Iatrogenic injury to this nerve during De Quervain's release is a well-known complication that can lead to a highly debilitating and painful neuroma.

Question 2229

Topic: Wrist & Carpus
A patient with long-standing scaphoid nonunion presents with progressive wrist pain. Radiographs demonstrate early arthritic changes characteristic of Scaphoid Nonunion Advanced Collapse (SNAC). Which joint is typically the first to develop degenerative changes in the SNAC progression?
. Radioscaphoid joint (specifically the radial styloid and distal scaphoid)
. Capitolunate joint
. Scaphotrapeziotrapezoid (STT) joint
. Lunotriquetral joint
. Distal radioulnar joint (DRUJ)

Correct Answer & Explanation

. Radioscaphoid joint (specifically the radial styloid and distal scaphoid)

Explanation

In SNAC wrist, arthritis progresses in a predictable sequence. Stage I involves the radial styloid and the distal pole of the scaphoid (radioscaphoid joint). Stage II progresses to the entire radioscaphoid joint. Stage III involves the capitolunate joint. The radiolunate joint is characteristically spared due to a congruent spherical relationship.

Question 2230

Topic: 7. Hand and Wrist

In a Scaphoid Nonunion Advanced Collapse (SNAC) pattern of wrist arthritis, which of the following joints is characteristically spared from degenerative changes even in advanced stages?

. Radioscaphoid joint
. Capitolunate joint
. Radiolunate joint
. Scaphotrapezio-trapezoidal joint
. Capitohamate joint

Correct Answer & Explanation

. Capitolunate joint

Explanation

In SNAC wrist arthritis, the proximal pole of the scaphoid moves synchronously with the lunate, and the radiolunate articulation is characteristically spared. Degenerative changes progress from the radial styloid to the radioscaphoid, then the midcarpal (capitolunate) joint.

Question 2231

Topic: 7. Hand and Wrist
A 30-year-old carpenter lacerates his volar index finger at the level of the proximal phalanx. Which flexor tendon zone is involved, and what is a defining characteristic of this zone?
. Zone I; contains only the FDP tendon
. Zone II; contains both FDS and FDP tendons within the fibro-osseous sheath
. Zone III; origin of the lumbrical muscles
. Zone IV; contents of the carpal tunnel
. Zone V; proximal to the carpal tunnel

Correct Answer & Explanation

. Zone II; contains both FDS and FDP tendons within the fibro-osseous sheath

Explanation

The laceration is at the proximal phalanx, which corresponds to Zone II ('no man's land'). This zone extends from the distal palmar crease to the middle of the middle phalanx. It is characterized by both the Flexor Digitorum Superficialis (FDS) and Flexor Digitorum Profundus (FDP) tendons running tightly together within the fibro-osseous tendon sheath.

Question 2232

Topic: Wrist & Carpus

When utilizing a volar locking plate for fixation of a distal radius fracture, placement of the plate at or distal to the watershed line significantly increases the risk of rupture of which tendon?

. Extensor pollicis longus
. Flexor carpi radialis
. Flexor pollicis longus
. Flexor digitorum profundus to the index finger
. Extensor carpi radialis longus

Correct Answer & Explanation

. Flexor pollicis longus

Explanation

The watershed line is a transverse anatomical ridge on the volar margin of the distal radius. Plate prominence at or distal to this line causes attritional wear on the flexor pollicis longus (FPL) tendon due to its immediate proximity as it courses over the distal radius, leading to a high risk of iatrogenic rupture.

Question 2233

Topic: Hand Trauma & Infection

A 32-year-old manual laborer presents with a swollen, painful index finger three days after a minor puncture wound. He exhibits Kanavel's four cardinal signs of flexor tenosynovitis. Which of these signs is considered the earliest and most sensitive indicator of this condition?

. Fusiform (sausage-like) swelling of the digit
. The finger held in a resting posture of slight flexion
. Severe pain with passive extension of the digit
. Tenderness along the anatomical course of the flexor tendon sheath
. Erythema tracking proximally up the volar forearm

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of purulent flexor tenosynovitis are: 1) fusiform swelling, 2) resting flexed posture, 3) tenderness along the flexor sheath, and 4) pain with passive extension. Clinical consensus defines pain with passive extension as the most sensitive and earliest clinical sign of tenosynovitis.

Question 2234

Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with chronic dorsal wrist pain. Radiographs demonstrate sclerosis of the lunate with coronal fracture lines, but no carpal collapse. Ulnar variance is negative 3 mm. According to the Lichtman classification, what is the most appropriate surgical treatment?
. Proximal row carpectomy
. Total wrist arthrodesis
. Joint-leveling procedure (radial shortening osteotomy)
. Lunate excision and scaphocapitate fusion
. Vascularized bone graft from the distal radius without offloading

Correct Answer & Explanation

. Joint-leveling procedure (radial shortening osteotomy)

Explanation

This patient has Lichtman Stage IIIa Kienbock's disease (lunate fragmentation/collapse but no fixed scaphoid rotation or loss of carpal height). In the presence of negative ulnar variance, a joint-leveling procedure (such as a radial shortening osteotomy) is the most reliable treatment to unload the lunate and halt disease progression.

Question 2235

Topic: Nerve & Tendon
A 22-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. Ultrasound confirms avulsion of the flexor digitorum profundus (FDP) tendon with retraction of the tendon end into the palm (Zone II). Based on the Leddy and Packer classification, what type of injury is this and what is the optimal surgical timeframe?
. Type I - requires repair within 7-10 days
. Type II - requires repair within 7-10 days
. Type I - can be safely repaired up to 6 weeks post-injury
. Type II - can be safely repaired up to 6 weeks post-injury
. Type III - requires immediate DIP arthrodesis

Correct Answer & Explanation

. Type I - requires repair within 7-10 days

Explanation

This is a classic 'Jersey finger' injury. According to the Leddy and Packer classification: Type I involves retraction of the FDP tendon into the palm, which ruptures both the vincula longa and brevia. The tendon loses its blood supply and must be repaired within 7 to 10 days before irreversible tendon retraction and necrosis occur. Type II retracts to the level of the PIP joint (held by the intact vinculum longum) and can be repaired later. Type III involves a large bony avulsion that catches at the A4 pulley.

Question 2236

Topic: 7. Hand and Wrist

Fractures of the scaphoid proximal pole have a notoriously high rate of nonunion and avascular necrosis due to the bone's retrograde blood supply. The primary arterial supply responsible for perfusing the proximal pole of the scaphoid originates from which of the following vessels?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The blood supply to the scaphoid is predominantly retrograde. The major blood supply enters the scaphoid via the dorsal ridge, which is perfused by the dorsal carpal branch of the radial artery. This dorsal supply accounts for roughly 70-80% of the bone's vascularity, specifically feeding the proximal pole in a retrograde fashion. The volar carpal branch supplies the distal 20-30% of the scaphoid (tubercle).

Question 2237

Topic: Hand Trauma & Infection

According to Kanavel's cardinal signs for pyogenic flexor tenosynovitis of the hand, which of the following is generally considered the earliest and most reliable clinical indicator?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Tenderness along the entire course of the flexor tendon sheath
. Exquisite pain with passive extension of the digit
. Erythema and warmth over the volar aspect of the affected finger

Correct Answer & Explanation

. Exquisite pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: 1) flexed resting posture of the digit, 2) uniform (fusiform) swelling, 3) tenderness along the flexor tendon sheath, and 4) exquisite pain with passive extension. Of these, severe pain with passive extension stretches the inflamed synovium and is considered the earliest, most sensitive, and most reliable sign of the condition.

Question 2238

Topic: 7. Hand and Wrist

A 65-year-old male presents with deteriorating hand dexterity and difficulty performing tandem gait. Physical examination reveals a positive Hoffmann sign. Magnetic resonance imaging demonstrates severe central canal stenosis at C5-C6. What is the precise pathophysiological mechanism indicating a positive Hoffmann sign?

. Lower motor neuron degeneration at the C6 level
. Upper motor neuron lesion originating above the C5 spinal level
. Dorsal column demyelination at the cervical level
. Peripheral entrapment neuropathy of the median nerve
. Isolated radicular compression of the C6 nerve root

Correct Answer & Explanation

. Upper motor neuron lesion originating above the C5 spinal level

Explanation

The Hoffmann sign (reflex finger flexion upon snapping the distal phalanx of the middle finger) is a reliable indicator of an upper motor neuron (UMN) lesion. It indicates pathology in the corticospinal tract above the spinal segment that supplies the hand, typically implying spinal cord compression or brain pathology proximal to the C5 level.

Question 2239

Topic: Hand Trauma & Infection

In the evaluation of a patient with suspected pyogenic flexor tenosynovitis, which of Kanavel's four cardinal signs is generally considered the most sensitive and presents earliest in the course of the infection?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Tenderness along the entire course of the flexor tendon sheath
. Severe pain with passive extension of the digit
. Erythema confined to the volar aspect of the finger

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Kanavel's signs for suppurative flexor tenosynovitis include: 1) flexed resting posture, 2) fusiform (sausage) swelling, 3) tenderness along the flexor sheath, and 4) pain with passive extension. Pain with passive extension is typically the earliest, most sensitive, and most clinically significant sign to manifest.

Question 2240

Topic: Wrist & Carpus

In the natural history of Scaphoid Nonunion Advanced Collapse (SNAC), degenerative arthritic changes progress through a predictable radiographic sequence. Which specific articulation is classically spared from this degenerative cascade due to its uniquely preserved concentric spherical kinematics?

. Radioscaphoid joint
. Capitolunate joint
. Scaphocapitate joint
. Radiolunate joint
. Triscaphe (STT) joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

The radiolunate articulation is classically spared in both Scapholunate Advanced Collapse (SLAC) and Scaphoid Nonunion Advanced Collapse (SNAC) wrists. This is because the lunate maintains a congruent, concentric, spherical relationship with the lunate fossa of the radius, even when it assumes an extended (DISI) posture, thereby avoiding abnormal cartilage loading and shear stresses.

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