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7. Hand and Wrist MCQs

Practice Set 117 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 2321

Topic: 7. Hand and Wrist
A 28-year-old carpenter sustains a laceration over the volar aspect of the proximal phalanx of the index finger, dividing both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. This injury corresponds to which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically known as 'No Man's Land') extends from the distal palmar crease (level of the A1 pulley) to the FDS insertion on the middle phalanx. It contains both FDS and FDP tendons coursing together within the narrow fibro-osseous sheath. Injuries here are notorious for adhesion formation. Zone I is distal to the FDS insertion. Zone III is the palm (lumbrical origin), Zone IV is the carpal tunnel, and Zone V is proximal to the carpal tunnel.

Question 2322

Topic: Nerve & Tendon

A 40-year-old female undergoes an open carpal tunnel release. Postoperatively, her nocturnal paresthesias resolve, but she reports an inability to oppose her thumb to her little finger. Which structure was most likely iatrogenically injured during the procedure?

. Palmar cutaneous branch of the median nerve
. Recurrent motor branch of the median nerve
. Deep branch of the ulnar nerve
. Superficial branch of the radial nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Recurrent motor branch of the median nerve

Explanation

The recurrent motor branch of the median nerve supplies the thenar intrinsic muscles (opponens pollicis, abductor pollicis brevis, and the superficial head of the flexor pollicis brevis), which are responsible for thumb opposition. Its iatrogenic injury is a classic and devastating complication if the dissection strays too far radially during a carpal tunnel release.

Question 2323

Topic: 7. Hand and Wrist

Evaluating a post-reduction radiograph for a distal radius fracture, the surgeon measures the radial inclination to determine if criteria for acceptable alignment are met. What is the normal anatomic range for radial inclination on a PA radiograph of the wrist?

. 0 to 5 degrees
. 5 to 10 degrees
. 11 to 15 degrees
. 21 to 25 degrees
. 30 to 35 degrees

Correct Answer & Explanation

. 21 to 25 degrees

Explanation

Normal radiographic parameters of the distal radius are crucial for evaluating fracture reduction. They include: Radial inclination of 21-25 degrees (average 22 degrees), Radial height of 10-13 mm (average 11 mm), and Volar tilt of 10-12 degrees (average 11 degrees). Loss of these parameters alters load transmission across the radiocarpal and distal radioulnar joints.

Question 2324

Topic: 7. Hand and Wrist
A 30-year-old carpenter sustains a laceration over the volar aspect of the proximal phalanx of the index finger, dividing both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. This injury corresponds to which flexor tendon zone?
. 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 FDS on the middle phalanx. It contains both FDS and FDP tendons tightly enclosed within the fibro-osseous flexor sheath. Due to the high risk of adhesions and traditionally poor surgical outcomes, Bunnell historically termed this area 'no man's land'.

Question 2325

Topic: Nerve & Tendon

A 65-year-old male complains of deteriorating handwriting and clumsiness in his hands. Neurological examination reveals a positive Hoffman's sign and the inability to rapidly adduct and abduct his ulnar digits, causing the small finger to rest in an abducted position. This specific spontaneous abduction of the small finger is known as:

. Wartenberg's sign
. Froment's sign
. Finger escape sign
. Lhermitte's sign
. Tinel's sign

Correct Answer & Explanation

. Finger escape sign

Explanation

The 'finger escape sign' is a clinical finding in cervical spondylotic myelopathy (part of the 'myelopathy hand'). The patient is unable to hold the ulnar digits adducted and extended, causing them to drift into abduction and flexion. While Wartenberg's sign also involves abduction of the small finger, it is classically due to ulnar nerve palsy (loss of third palmar interosseous muscle with unopposed EDQ).

Question 2326

Topic: 7. Hand and Wrist

The recurrent motor branch of the median nerve innervates the thenar muscles. According to anatomical studies, this branch most commonly arises from the median nerve at which location relative to the transverse carpal ligament (TCL)?

. Extraligamentous (distal to the TCL)
. Subligamentous (beneath the TCL)
. Transligamentous (piercing the TCL)
. Pre-ligamentous (proximal to the TCL)
. Ulnar to the hook of the hamate

Correct Answer & Explanation

. Extraligamentous (distal to the TCL)

Explanation

The most common branching pattern of the recurrent motor branch of the median nerve is extraligamentous (approx 50-90% depending on the study), branching distal to the TCL and recurring back to innervate the thenar musculature. Subligamentous and transligamentous variations occur and are critical to recognize during carpal tunnel release to avoid iatrogenic injury.

Question 2327

Topic: 7. Hand and Wrist

A 60-year-old woman returns to the clinic 6 months after open reduction and internal fixation of a distal radius fracture with a volar locking plate. She suddenly lost the ability to actively flex the interphalangeal joint of her thumb. Which of the following is the most likely cause?

. Undiagnosed median nerve laceration during the initial trauma
. Attritional rupture of the flexor pollicis longus (FPL) tendon
. Avulsion of the FPL insertion from the distal phalanx
. Hardware failure with loss of reduction and impingement
. Flexor tenosynovitis secondary to latent infection

Correct Answer & Explanation

. Attritional rupture of the flexor pollicis longus (FPL) tendon

Explanation

Placement of a volar locking plate distal to the watershed line of the radius increases the risk of the flexor tendons rubbing against the prominent distal edge of the plate. The Flexor Pollicis Longus (FPL) tendon is most intimately associated with this region and is highly susceptible to attritional rupture, a classic late complication of volar plating.

Question 2328

Topic: 7. Hand and Wrist
A 45-year-old man presents with chronic wrist pain. Radiographs reveal a scaphoid non-union with advanced collapse (SNAC). There is arthritic involvement of the radioscaphoid and capitolunate joints. Which of the following joints is classically spared in this condition, making the patient a suitable candidate for a four-corner fusion?
. Radiolunate
. Radioscaphoid
. Capitolunate
. Scaphotrapezial
. Distal radioulnar

Correct Answer & Explanation

. Radiolunate

Explanation

In both SNAC (scaphoid nonunion advanced collapse) and SLAC (scapholunate advanced collapse) wrists, the radiolunate joint is classically spared from osteoarthritis. This is due to the concentric, spherical articulation of the lunate fossa and the lunate, which maintains congruence and avoids abnormal shear forces even when carpal kinematics are altered. This sparing allows for motion-preserving salvage procedures such as proximal row carpectomy (if the capitate head is intact) or four-corner fusion.

Question 2329

Topic: 7. Hand and Wrist

A patient presents with an inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger, failing to make an 'OK' sign. Sensation over the hand is completely normal. Which of the following muscles is most likely ALSO affected by this nerve palsy?

. Flexor carpi radialis
. Pronator teres
. Pronator quadratus
. Abductor pollicis brevis
. First dorsal interosseous

Correct Answer & Explanation

. Pronator quadratus

Explanation

The clinical presentation is classic for Anterior Interosseous Nerve (AIN) syndrome. The AIN is a purely motor branch of the median nerve that innervates the flexor pollicis longus (FPL), the radial half of the flexor digitorum profundus (FDP to index and middle fingers), and the pronator quadratus. Sensation is spared. Loss of FPL and index FDP prevents the 'OK' sign.

Question 2330

Topic: 7. Hand and Wrist
A 45-year-old male presents with chronic, progressive wrist pain. Radiographs demonstrate a scaphoid nonunion with advanced arthritic changes at the radioscaphoid and capitolunate joints. The radiolunate joint is spared. Which of the following is the most appropriate surgical treatment?
. Radial styloidectomy
. Proximal row carpectomy
. Four-corner fusion
. Total wrist arthrodesis
. Scaphoid excision and triquetrum-hamate fusion

Correct Answer & Explanation

. Four-corner fusion

Explanation

The patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III, which involves arthritis of the radioscaphoid and capitolunate joints with a preserved radiolunate joint. Proximal row carpectomy (PRC) is contraindicated because the capitate head is arthritic (it would articulate with the lunate fossa). Four-corner fusion (capitate, hamate, lunate, triquetrum) with scaphoid excision is the standard bone-preserving salvage procedure for SNAC III.

Question 2331

Topic: Wrist & Carpus

A 65-year-old female undergoes open reduction and internal fixation of a distal radius fracture using a volar locking plate. Six months postoperatively, she suddenly loses the ability to actively extend her thumb interphalangeal joint. What is the most likely cause?

. Extensor digitorum communis attrition
. Extensor pollicis longus rupture due to dorsal screw prominence
. Flexor pollicis longus rupture from the volar plate
. Abductor pollicis longus adherence
. Posterior interosseous nerve palsy

Correct Answer & Explanation

. Extensor pollicis longus rupture due to dorsal screw prominence

Explanation

Loss of active thumb IP extension is the hallmark of Extensor Pollicis Longus (EPL) rupture. When a volar locking plate is used, screws that are too long and penetrate the dorsal cortex (especially near Lister's tubercle) can cause attrition and secondary rupture of the EPL tendon.

Question 2332

Topic: 7. Hand and Wrist

In Dupuytren's disease, the spiral cord can cause proximal interphalangeal (PIP) joint contracture and central displacement of the neurovascular bundle, putting it at risk during surgery. Which of the following normal fascial structures does NOT contribute to the formation of the spiral cord?

. Pretendinous band
. Spiral band
. Lateral digital sheet
. Grayson's ligament
. Cleland's ligament

Correct Answer & Explanation

. Cleland's ligament

Explanation

The spiral cord in Dupuytren's contracture is composed of the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament is dorsal to the neurovascular bundle and is characteristically spared (not involved) in Dupuytren's disease.

Question 2333

Topic: Wrist & Carpus
Scaphoid Nonunion Advanced Collapse (SNAC) wrist follows a predictable pattern of progressive articular degeneration. Stage III of the SNAC wrist natural history is characterized by degenerative changes specifically involving which of the following articulations?
. Radioscaphoid articulation only
. Scaphocapitate joint
. Capitolunate joint
. Radiolunate joint
. Distal radioulnar joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

SNAC wrist progression occurs as follows: Stage I involves the radial styloid and distal scaphoid fragment. Stage II progresses to involve the radioscaphoid joint and the scaphocapitate joint. Stage III involves the capitolunate joint as the capitate subluxates dorsally. Notably, the radiolunate joint is typically spared in both SNAC and SLAC (Scapholunate Advanced Collapse) patterns due to the congruent nature of the spherical lunate facet.

Question 2334

Topic: 7. Hand and Wrist
During primary repair of a flexor tendon laceration in the hand, the surgeon identifies the 'Camper's chiasm'. This anatomical landmark, where the flexor digitorum superficialis (FDS) bifurcates to allow the flexor digitorum profundus (FDP) to pass dorsally to volarly, is located in which of the flexor tendon zones?
. Zone I
. Zone III
. Zone II
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Camper's chiasm is located in flexor tendon Zone II (historically termed 'no man's land'). In this zone, the FDS tendon splits (bifurcates) to form a chiasm, allowing the FDP tendon to pass through it to become superficial and insert on the base of the distal phalanx. Zone II extends from the proximal aspect of the A1 pulley to the insertion of the FDS on the middle phalanx.

Question 2335

Topic: 7. Hand and Wrist

A 28-year-old carpenter sustains a laceration to the volar aspect of his index finger at the level of the proximal phalanx, resulting in a Zone II flexor tendon injury. To ensure optimal healing following surgical repair, the surgeon must be mindful of the tendon's intrinsic blood supply. The primary vascular supply to the flexor digitorum profundus (FDP) within this fibrous digital sheath is derived from:

. Direct musculotendinous perforators
. The vincula longa and brevia
. Metacarpal nutrient arteries
. Digital artery branches directly entering the volar plate
. The common digital artery bifurcation

Correct Answer & Explanation

. The vincula longa and brevia

Explanation

In Zone II (the 'no man\'s land'), the flexor tendons are enclosed within a synovial sheath. They rely on two mechanisms for nutrition: synovial fluid diffusion (imbibition) and direct blood supply. The direct vascular supply enters the dorsal aspect of the tendons via the vincula longa and vincula brevia, which are tiny vascular folds carrying vessels from the digital arteries.

Question 2336

Topic: 7. Hand and Wrist

A 45-year-old data analyst presents with an inability to make an 'OK' sign with her right hand. Instead of forming a circle with her thumb and index finger, her distal interphalangeal (DIP) joints remain in extension, resulting in a flat-pinch posture. Sensory examination of the hand is completely normal. Compression of the affected nerve is most commonly caused by which of the following structures?

. The ligament of Struthers
. The deep head of the pronator teres
. The arcade of Frohse
. The two heads of the flexor carpi ulnaris
. The bicipital aponeurosis (lacertus fibrosus)

Correct Answer & Explanation

. The deep head of the pronator teres

Explanation

The patient's presentation is classic for Anterior Interosseous Nerve (AIN) syndrome, characterized by weakness of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger, leading to an inability to make an 'OK' sign. Because the AIN is purely motor, sensation is normal. The most common site of AIN compression is the deep head of the pronator teres (or the tendinous edge of the FDS arcade).

Question 2337

Topic: 7. Hand and Wrist

A 24-year-old male falls on an outstretched hand and sustains a fracture of the proximal pole of the scaphoid. The high rate of avascular necrosis in this area is due to the retrograde nature of its vascular supply. Which artery provides the primary vascular supply to the proximal pole of the scaphoid?

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

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 distally at the dorsal ridge and running in a retrograde fashion to supply the proximal pole. The volar carpal branch supplies only the distal 20-30% of the bone. This retrograde intraosseous blood flow is responsible for the high risk of AVN following proximal pole fractures.

Question 2338

Topic: 7. Hand and Wrist
A 42-year-old manual laborer presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with radioscaphoid arthritis and capitolunate arthritis, but the radiolunate joint is preserved. This corresponds to a stage III Scaphoid Nonunion Advanced Collapse (SNAC). Which of the following is the most appropriate surgical treatment?
. Scaphoid excision and four-corner fusion
. Proximal row carpectomy (PRC)
. Radial styloidectomy and scaphoid ORIF
. Total wrist arthrodesis
. Scaphotrapezio-trapezoid (STT) fusion

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

In SNAC Stage III, arthritis involves both the radioscaphoid and capitolunate joints, while the radiolunate joint is typically spared. Because the head of the capitate is arthritic, a proximal row carpectomy (PRC) is contraindicated (PRC relies on a pristine capitate head articulating with the lunate fossa). Therefore, scaphoid excision and four-corner fusion (capitate, hamate, lunate, triquetrum) is the motion-preserving procedure of choice.

Question 2339

Topic: 7. Hand and Wrist
A 55-year-old manual laborer presents with chronic progressive wrist pain and limited range of motion. Radiographs demonstrate advanced degenerative changes involving the radioscaphoid joint and the capitolunate joint. The radiolunate joint is perfectly preserved. This radiographic pattern is best described as Stage III Scapholunate Advanced Collapse (SLAC). What is the most appropriate surgical treatment to relieve pain while preserving some wrist motion?
. Radial styloidectomy alone
. Proximal row carpectomy (PRC)
. Four-corner arthrodesis with scaphoid excision
. Total wrist arthrodesis
. Scaphoid excision and capitolunate arthrodesis

Correct Answer & Explanation

. Four-corner arthrodesis with scaphoid excision

Explanation

Stage III SLAC wrist involves arthritis of the radioscaphoid and capitolunate joints while sparing the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in Stage III SLAC because the capitate articular surface is compromised, which would lead to painful capitoradial articulation. The procedure of choice to maintain motion and relieve pain when the capitolunate joint is arthritic (Stage III SLAC) is a four-corner arthrodesis (capitate, hamate, lunate, triquetrum) with scaphoid excision, which relies on the preserved radiolunate joint.

Question 2340

Topic: Hand Trauma & Infection

A 30-year-old mechanic presents with a swollen, painful index finger 3 days after a minor puncture wound to the volar aspect of his hand. You suspect pyogenic flexor tenosynovitis. Which of Kanavel's four cardinal signs is generally considered the most sensitive and often the earliest finding in this condition?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Tenderness isolated to the volar pulp
. Pain with passive extension of the digit
. Erythema extending along the flexor sheath

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are: 1) Fusiform swelling of the digit, 2) Flexed resting posture, 3) Tenderness along the entire course of the flexor tendon sheath, and 4) Pain with passive extension. Pain with passive extension is considered the most sensitive and earliest sign of infectious flexor tenosynovitis.

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