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7. Hand and Wrist MCQs

Practice Set 113 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 2241

Topic: Nerve & Tendon

During a complex trigger finger release in a 55-year-old diabetic patient, the surgeon inadvertently excises the entire A2 pulley of the ring finger. What is the most likely biomechanical consequence of this isolated injury?

. Decreased excursion of the flexor digitorum profundus (FDP)
. Increased work of flexion and bowstringing
. Inability to initiate distal interphalangeal joint flexion
. Swan neck deformity
. Boutonniere deformity

Correct Answer & Explanation

. Increased work of flexion and bowstringing

Explanation

The A2 and A4 pulleys are the most critical mechanically for maintaining the flexor tendons close to the bone. Loss of the A2 pulley leads to volar displacement of the flexor tendons (bowstringing). While bowstringing increases the moment arm (torque) at the joint, it significantly decreases the mechanical efficiency of the tendon, leading to an increased work of flexion and requiring increased tendon excursion to achieve the same arc of motion.

Question 2242

Topic: 7. Hand and Wrist

A 32-year-old male fell on an outstretched hand and complains of chronic wrist pain. Radiographs demonstrate a scapholunate angle of 75 degrees and a radiolunate angle of 20 degrees with the lunate extended. These findings are most consistent with which of the following patterns?

. Dorsal Intercalated Segment Instability (DISI)
. Volar Intercalated Segment Instability (VISI)
. Perilunate dislocation
. Midcarpal instability
. Scaphoid nonunion advanced collapse (SNAC)

Correct Answer & Explanation

. Dorsal Intercalated Segment Instability (DISI)

Explanation

A scapholunate angle > 60 degrees (normal is 30-60) and a radiolunate angle > 15 degrees with the lunate extended (dorsiflexed) are the radiographic hallmarks of Dorsal Intercalated Segment Instability (DISI). This is most commonly caused by a complete tear of the scapholunate interosseous ligament. In Volar Intercalated Segment Instability (VISI), the lunate is abnormally volarflexed.

Question 2243

Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with progressively worsening dorsal wrist pain. Radiographs reveal sclerosis of the lunate without architectural collapse. MRI confirms avascular necrosis of the entire lunate. Radiographs also demonstrate an ulnar variance of -3mm. What is the most appropriate surgical intervention?
. Proximal row carpectomy
. Lunate excision and tendon anchovy interposition
. Radial shortening osteotomy
. Capitate-hamate limited intercarpal fusion
. Four-corner arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Lichtman Stage II Kienböck's disease (sclerosis without collapse) with ulnar negative variance. In early-stage disease before significant carpal collapse or secondary osteoarthritis occurs, a joint-leveling procedure such as a radial shortening osteotomy is indicated to mechanically unload the lunate and potentially allow revascularization.

Question 2244

Topic: Nerve & Tendon
A patient presents with profound intrinsic muscle weakness in the right hand. Neurological examination reveals marked atrophy of the first dorsal interosseous and hypothenar muscles. However, sensation is completely preserved over both the volar and dorsal aspects of the small finger and the ulnar half of the ring finger. The compressive pathology is most likely located in which anatomical region?
. Guyon's canal Zone I
. Guyon's canal Zone II
. Guyon's canal Zone III
. The cubital tunnel
. The arcade of Struthers

Correct Answer & Explanation

. Guyon's canal Zone II

Explanation

Guyon's canal is divided into three zones. Zone I contains the mixed ulnar nerve proximal to its bifurcation. Compression here causes mixed motor and sensory deficits. Zone II surrounds the deep motor branch only; compression here results in isolated motor weakness of the ulnar-innervated intrinsic muscles with spared sensation. Zone III surrounds the superficial sensory branch; compression here causes isolated volar sensory deficits. The dorsal sensory branch leaves the main nerve proximal to Guyon's canal, so its sensation is spared in all Guyon's canal lesions.

Question 2245

Topic: Wrist & Carpus
A 55-year-old male presents with advanced Scapholunate Advanced Collapse (SLAC) wrist arthritis. Radiographs show arthritic changes involving the radioscaphoid and capitolunate joints, with preservation of the radiolunate joint. What is the most appropriate surgical treatment?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Scapholunate ligament reconstruction
. Radial styloidectomy
. Distal radius core decompression

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

In Stage III SLAC wrist, arthritic changes involve the radioscaphoid and capitolunate joints. Because the capitate head is arthritic, a proximal row carpectomy (PRC) is contraindicated, as the arthritic capitate would articulate with the lunate fossa, leading to persistent pain and failure. Scaphoid excision and four-corner fusion is the treatment of choice. The radiolunate joint is characteristically spared in SLAC and SNAC arthritis, making radiolunate-preserving procedures like four-corner fusion ideal.

Question 2246

Topic: 7. Hand and Wrist
A 25-year-old carpenter sustains a laceration over the volar aspect of the proximal phalanx of the index finger, resulting in loss of PIP and DIP flexion. This injury corresponds to which flexor tendon zone, traditionally known as 'no man's land'?
. 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 to the insertion of the Flexor Digitorum Superficialis (FDS) on the middle phalanx. It contains both FDS and FDP tendons in a tight fibro-osseous sheath and was historically termed 'no man's land' due to the high rate of adhesions and poor functional outcomes following repair.

Question 2247

Topic: Nerve & Tendon

A 50-year-old woman complains of numbness in her ring and small fingers, and weakness in her hand. Examination shows a positive Froment's sign when she is asked to hold a piece of paper between her thumb and index finger. Which muscle is compensating to produce the positive Froment's sign?

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

Correct Answer & Explanation

. Adductor pollicis

Explanation

Froment's sign occurs in ulnar nerve palsy. The paralyzed adductor pollicis (ulnar nerve) is compensated for by the flexor pollicis longus (innervated by the Anterior Interosseous Nerve branch of the median nerve), causing hyperflexion of the thumb interphalangeal joint during pinch.

Question 2248

Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with chronic dorsal wrist pain and decreased grip strength. Radiographs reveal sclerosis and fragmentation of the lunate, with a negative ulnar variance of 3mm. Which procedure is most appropriate to unload the lunate in this early-stage patient?
. Proximal row carpectomy
. Ulnar shortening osteotomy
. Radial shortening osteotomy
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has early-stage Kienböck's disease (avascular necrosis of the lunate) associated with ulnar minus variance. Joint-leveling procedures, such as a radial shortening osteotomy or ulnar lengthening, decrease the compressive forces across the radiolunate joint and are indicated in early stages prior to carpal collapse.

Question 2249

Topic: 7. Hand and Wrist

A 55-year-old woman undergoes volar locking plate fixation for a volarly displaced, intra-articular distal radius fracture. Eight weeks postoperatively, she suddenly loses the ability to actively flex the interphalangeal joint of her thumb. Which structure was most likely injured?

. Flexor digitorum superficialis to the index finger
. Flexor pollicis brevis
. Flexor pollicis longus
. Median nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Flexor pollicis longus

Explanation

Flexor pollicis longus (FPL) tendon rupture is a well-documented complication of volar plating of the distal radius. It typically occurs due to attritional wear when the plate is placed too distally (anterior to the watershed line), causing the FPL tendon to rub against the prominent distal edge of the plate.

Question 2250

Topic: 7. Hand and Wrist

During surgical fasciectomy for Dupuytren's contracture, the neurovascular bundle is at risk of iatrogenic injury. Which pathological fascial cord is classically responsible for displacing the neurovascular bundle toward the midline, placing it directly in harm's way?

. Pretendinous cord
. Spiral cord
. Central cord
. Lateral cord
. Natatory cord

Correct Answer & Explanation

. Spiral cord

Explanation

The spiral cord is formed by the amalgamation of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. As it contracts, it pulls the neurovascular bundle proximally, centrally (toward the midline), and superficial to the cord itself, putting the bundle at high risk of transection during dissection.

Question 2251

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with chronic, progressive wrist pain. Radiographs demonstrate advanced Kienbock's disease. According to the Lichtman classification, what specific radiographic finding distinguishes Stage IIIA from Stage IIIB?
. Lunate sclerosis without volume loss
. Fixed scaphoid rotary subluxation
. Lunate fragmentation without carpal collapse
. Presence of a coronal plane fracture of the lunate
. Capitate proximal migration without lunate fragmentation

Correct Answer & Explanation

. Fixed scaphoid rotary subluxation

Explanation

In the Lichtman classification of Kienbock's disease (avascular necrosis of the lunate), Stage III represents lunate collapse. It is subdivided into IIIA and IIIB. Stage IIIA exhibits lunate collapse but normal carpal alignment. Stage IIIB exhibits lunate collapse along with fixed scaphoid rotary subluxation (often indicated by a cortical ring sign) and a decrease in carpal height ratio, signifying carpal instability. Stage IV includes secondary radiocarpal or midcarpal arthritis.

Question 2252

Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with progressive dorsal wrist pain. Radiographs demonstrate sclerosis of the lunate, normal carpal height, and negative ulnar variance. MRI confirms osteonecrosis of the lunate without coronal fractures. According to the Lichtman classification, what is the most appropriate surgical intervention?
. Proximal row carpectomy
. Scaphoid-trapezium-trapezoid (STT) fusion
. Radial shortening osteotomy
. Total wrist arthrodesis
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Lichtman Stage II Kienböck's disease (lunate sclerosis, normal carpal height) and negative ulnar variance. A joint-leveling procedure, such as a radial shortening osteotomy, is the treatment of choice in patients with negative ulnar variance and early-stage disease (Stages I, II, and early IIIa) to biomechanically decompress the lunate.

Question 2253

Topic: Wrist & Carpus

A 55-year-old female undergoes volar locking plate fixation for a displaced distal radius fracture. Six months postoperatively, she presents with a sudden inability to actively flex the interphalangeal joint of her thumb. Which of the following plate placement errors most likely contributed to this specific complication?

. Placement of the plate proximal to the watershed line
. Placement of the plate distal to the watershed line
. Use of excessively long dorsal screws
. Failure to repair the pronator quadratus
. Inadequate reduction of the volar lunate facet

Correct Answer & Explanation

. Placement of the plate distal to the watershed line

Explanation

Flexor pollicis longus (FPL) tendon rupture is a known complication of volar plating of the distal radius. It is most commonly caused by placement of the plate too distally (distal to the 'watershed line'), leading to mechanical attrition of the tendon against the prominent distal edge of the plate during active thumb motion.

Question 2254

Topic: Nerve & Tendon
According to the modified Verdan classification of flexor tendon zones in the hand, which zone is historically referred to as 'no man's land' due to the high propensity for adhesion formation and 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 to the insertion of the flexor digitorum superficialis (FDS). Historically, it was termed 'no man's land' by Sterling Bunnell because both the FDS and FDP tendons run tightly together within the narrow fibro-osseous sheath, making primary repair technically demanding and highly prone to restrictive adhesions.

Question 2255

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic right wrist pain. Radiographs reveal severe joint space narrowing at the radioscaphoid and capitolunate joints. The radiolunate joint is completely preserved. Given this specific pattern of arthritis, which of the following surgical procedures is considered contraindicated?
. Four-corner fusion with scaphoid excision
. Proximal row carpectomy (PRC)
. Total wrist arthrodesis
. Wrist denervation
. Scaphoid excision and capitolunate arthrodesis

Correct Answer & Explanation

. Total wrist arthrodesis

Explanation

The radiographic findings describe Scapholunate Advanced Collapse (SLAC) Stage III, characterized by radioscaphoid and capitolunate arthritis with sparing of the radiolunate joint. Proximal row carpectomy (PRC) relies on a pristine capitate head to articulate with the lunate fossa of the radius. Because the capitate head is arthritic in Stage III SLAC, PRC is contraindicated. Four-corner fusion or total wrist arthrodesis are appropriate options.

Question 2256

Topic: 7. Hand and Wrist
A 52-year-old mechanic presents with chronic, progressive wrist pain. Radiographs demonstrate scapholunate advanced collapse (SLAC) with severe narrowing of the radioscaphoid and capitolunate joints, while the radiolunate joint is preserved. A proximal row carpectomy (PRC) is being considered. Which of the following radiographic findings in this patient is an absolute contraindication to performing a PRC?
. A scapholunate interval greater than 3 mm
. Severe radioscaphoid arthritis
. Capitolunate arthritis
. Preservation of the radiolunate joint
. Ulnar positive variance

Correct Answer & Explanation

. Capitolunate arthritis

Explanation

Proximal row carpectomy (PRC) relies on a healthy articulation between the lunate fossa of the distal radius and the proximal capitate. Capitolunate arthritis (which occurs in Stage III SLAC wrist) is a contraindication to PRC, as the new joint formed would be arthritic and painful. In such cases, a four-corner fusion with scaphoid excision is the preferred surgical option.

Question 2257

Topic: 7. Hand and Wrist

In the anatomic classification of flexor tendon injuries of the hand, Zone II (historically termed 'no man\'s land' due to poor surgical outcomes in the past) presents significant challenges for repair. What are the proximal and distal anatomic boundaries that define Zone II?

. From the transverse carpal ligament to the proximal edge of the A1 pulley
. From the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS)
. From the insertion of the FDS to the insertion of the flexor digitorum profundus (FDP)
. From the musculotendinous junction to the transverse carpal ligament
. From the A2 pulley to the A4 pulley

Correct Answer & Explanation

. From the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS)

Explanation

Zone II of the flexor tendon system begins at the proximal edge of the A1 pulley (at the level of the distal palmar crease) and extends distally to the insertion of the flexor digitorum superficialis (FDS) tendon on the middle phalanx. Both the FDS and FDP travel together within the narrow fibro-osseous sheath in this zone, making repairs prone to adhesions.

Question 2258

Topic: 7. Hand and Wrist

Which of the following flexor tendon pulleys is the most critical to preserve during hand surgery to prevent bowstringing of the flexor tendons in the digits?

. A1 and A3 pulleys
. A2 and A4 pulleys
. C1 and C2 pulleys
. A3 and A5 pulleys
. A1 and A5 pulleys

Correct Answer & Explanation

. A2 and A4 pulleys

Explanation

The A2 and A4 pulleys are the most biomechanically critical annular pulleys in the digits. They insert directly onto the periosteum of the proximal and middle phalanges, respectively. Loss of both of these pulleys will invariably lead to bowstringing, decreased tendon excursion, and a significant loss of active flexion at the interphalangeal joints.

Question 2259

Topic: Nerve & Tendon

During an in situ ulnar nerve decompression at the elbow, the surgeon must divide several structures to fully release the cubital tunnel. Which of the following structures forms the roof of the cubital tunnel?

. The medial intermuscular septum
. Osborne's ligament
. The Arcade of Struthers
. The deep flexor pronator aponeurosis
. The medial collateral ligament of the elbow

Correct Answer & Explanation

. Osborne's ligament

Explanation

The cubital tunnel is bounded by the medial epicondyle anteriorly, the olecranon laterally, and the elbow joint capsule and medial collateral ligament (MCL) as the floor. The roof is formed by Osborne's ligament (the cubital tunnel retinaculum), which spans from the medial epicondyle to the olecranon and blends with the fascia of the two heads of the flexor carpi ulnaris (FCU).

Question 2260

Topic: 7. Hand and Wrist

A 45-year-old male presents with right arm pain and weakness. Physical examination reveals weakness in right elbow extension and wrist flexion. He has diminished pinprick sensation over the dorsal aspect of the middle finger. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

The C7 nerve root provides motor innervation for elbow extension (triceps) and wrist flexion (flexor carpi radialis). The dermatomal sensory distribution of C7 includes the middle finger. C5 supplies shoulder abduction and elbow flexion; C6 supplies wrist extension and sensation to the thumb and index finger; C8 supplies finger flexors and sensation to the ulnar side of the hand.

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