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7. Hand and Wrist MCQs

Practice Set 12 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 221

Topic: 7. Hand and Wrist

If a metacarpal shaft fracture shortens 4 mm, what will the theoretical amount of extensor lag be at the metacarpophalangeal joint:

. 0°
. 5°
. 7°
. 14°
. 20°

Correct Answer & Explanation

. 14°

Explanation

For each 2 mm of shortening, a 7° extensor lag exists. Thus, with 4 mm of shortening, there will be a 14° extensor lag at the metacarpophalangeal joint.

Question 222

Topic: 7. Hand and Wrist

In a short oblique metacarpal shaft fracture without comminution or bone loss, what is usual amount of maximal shortening that will occur:

. 1 mm
. 3 mm
. 5 mm
. 7 mm
. 9 mm

Correct Answer & Explanation

. 5 mm

Explanation

In a cadaveric study, shortening beyond 5 mm was prevented by the tethering effect of the transverse metacarpal ligaments and adjacent metacarpals.

Question 223

Topic: 7. Hand and Wrist

Which of the following statements is true regarding metacarpophalangeal joint anatomy:

. The collateral ligaments are lax in flexion.
. The joint volume is highest in flexion.
. Joint stability is maximal in flexion.
. The metacarpal head is spherical.
. The collateral ligaments originate volar to the axis of flexion.

Correct Answer & Explanation

. Joint stability is maximal in flexion.

Explanation

The collateral ligaments are lax in extension and tight in flexion. The joint volume is highest in extension. The metacarpal head is cam-shaped. The collateral ligaments originate dorsal to the axis of flexion. Due to the tightening of the collateral ligaments over the cam-shaped metacarpal head in flexion, joint stability is maximized.

Question 224

Topic: 7. Hand and Wrist
A 25-year-old, right-hand-dominant male truck driver presents to the emergency department. The tip of his left ring finger was amputated in a bicycle accident 2 weeks prior. The amputated piece was "sewn back on" in the emergency department immediately after the accident, but "turned black" over the next week. There is no evidence of infection. He states that the appearance of his finger is embarrassing, and he would like it taken care of as soon as possible. Which of the following procedures is the most appropriate?
. Local debridement, allow to heal by secondary intention
. Atasoy-Kleinert V-Y advancement flap closure
. Kutler V-Y advancement flap closure
. Moberg flap closure
. Split-thickness hypothenar skin graft

Correct Answer & Explanation

. Atasoy-Kleinert V-Y advancement flap closure

Explanation

The Atasoy-Kleinert V-Y advancement flap is the best option for transversely oriented fingertip amputations/defects and also for defects with more dorsal than volar tissue loss. The apex of the V is positioned at, or just distal, to the distal interphalangeal joint crease on the volar side of the digit. After incising the V marking, the flap is advanced distally to cover the defect, and the incisions are closed in a Y pattern. Local, or chemical, debridement and allowing the resulting defect to heal by secondary intention are a viable option, but the patient stated that he would prefer an aggressive treatment protocol because the appearance of his fingertip is so embarrassing. The Kutler (lateral) V-Y advancement flap is typically used to cover tip defects that demonstrate more volar than dorsal tissue loss. The procedure involves creating V-Y advancement flaps laterally on either side of the affected digit and advancing them toward each other in the midline thereby covering the defect. The Moberg flap is typically used for reconstruction of thumb amputations. This procedure involves the creation of a volar tissue flap that includes the neurovascular bundles on either side of the digit. Its use is cautioned in very distal amputations because excess stretch on the vascular pedicles may lead to necrosis at the tip of the flap. Its use is also cautioned in the fingers because of the difference in orientation of the blood supply compared to the thumb. A full-thickness, rather than a split-thickness, skin graft is a viable option to manage this patient. Skin grafts for hand reconstruction should be harvested with the "like replaces like" principle in mind, especially when reconstructing the volar skin. Volar hand skin is much thicker and of unique quality when compared with the rest of the body, and therefore, the most appropriate place to harvest a skin graft is the volar surface of the hand.

Question 225

Topic: 7. Hand and Wrist
A 52-year-old, right-hand-dominant watchmaker arrives at the emergency department 30 minutes after the volar soft tissue of his right thumb and index finger was avulsed while using a bandsaw. Physical examination shows 2 cm x 2 cm wounds involving the distal phalanx of each affected digit. No exposed tendon or bone is present, and no involvement of the joints is noted. The patient requests a treatment option that will retain the most sensation so he can effectively continue in his occupation. Which of the following options is the most appropriate management of this patient's wounds?
. Coverage with cross-finger flaps
. Healing by secondary intention
. Split-thickness skin grafting
. Full-thickness skin grafting
. Radial free forearm flap

Correct Answer & Explanation

. Full-thickness skin grafting

Explanation

Local flaps such as cross-finger flaps are good options but require at least two surgeries (inset then division) and can often result in stiffness secondary to the requisite period of immobilization. In addition, local flaps have lesser return of sensibility than the other techniques listed. Return of tactile sensibility is excellent after healing by secondary intention, but dressing changes for wounds that measure 2 cm x 2 cm would take months to completely heal. Skin grafting is the next available option with acceptable sensory return. It can be performed during local anesthesia, requires only one operation, and allows for early motion thereby avoiding stiffness. Studies have shown that full-thickness skin grafts recover sensation better than split-thickness skin grafts. A radial forearm flap will be excessively bulky, has unacceptable donor site morbidity in this situation, and results in inadequate sensory recovery.

Question 226

Topic: 7. Hand and Wrist

Which of the following statements is true:

. In a wrist with neutral ulnar variance, 20% of the axial load is transmitted across the ulna.
. In a wrist with 2.5 mm ulnar negative variance, 20% of the axial load is transmitted across the ulna.
. In a wrist with 2.5 mm ulnar negative variance, 60% of the axial load is transmitted across the ulna.
. In a wrist with 2.5 mm ulnar positive variance, 600% of the axial load is transmitted across the ulna.
. In a wrist with 2.5 ulnar positive variance, 20% of the axial load is transmitted across the ulna.

Correct Answer & Explanation

. In a wrist with neutral ulnar variance, 20% of the axial load is transmitted across the ulna.

Explanation

Cadaveric studies have been performed to determine the amount of load across the wrist with various relationships between the radius and ulna lengths. In wrists with neutral ulnar variance (in which the radius and ulna are equal in length), 20% of the load is transmitted across the ulna and 80% is transmitted across the radius. In wrists with negative ulnar variance (in which the ulnar is shorter than the radius), more load is transmitted across the radius and less is transmitted across the ulna. The opposite is true with positive ulnar variance (the ulna is longer than the radius).C orrect Answer: In a wrist with neutral ulnar variance, 20% of the axial load is transmitted across the ulna.

Question 227

Topic: 7. Hand and Wrist

Indications for replantation include:

. A crush injury in a patient who smokes
. A sharp amputation of the thumb in a 15-year-old patient
. An ischemia time of 24 hours
. The use of an amputated part that was immersed in warm water for transport
. A single digit amputation proximal to the flexor digitorum superficialis (FDS) insertion

Correct Answer & Explanation

. A sharp amputation of the thumb in a 15-year-old patient

Explanation

A sharp amputation, particularly of the thumb, is the best indication for replantation. C rushed digits, prolonged ischemia time, poor condition of the severed part, and single digit loss proximal to the FDS insertion on the middle phalanx are relative contraindications to replantation.

Question 228

Topic: 7. Hand and Wrist

An amputation through the wrist is an indication for attempted replantation.

. True
. False An amputation through the wrist, palm, or forearm is an indication for attempted replantation. The caliber of the vessels and other structures provides a favorable environment for reconstruction. C orrect Answer: True

Correct Answer & Explanation

. True

Explanation

Question 229

Topic: Nerve & Tendon
A 35-year-old carpenter presents with an inability to make an "OK" sign with his thumb and index finger. A diagnosis of anterior interosseous nerve (AIN) syndrome is suspected. Which of the following muscles will have normal function in this patient?
. Flexor pollicis longus
. Flexor digitorum profundus to the index finger
. Pronator quadratus
. Flexor carpi radialis
. Flexor digitorum profundus to the middle finger

Correct Answer & Explanation

. Flexor carpi radialis

Explanation

The AIN innervates the FPL, the FDP to the index and middle fingers, and the pronator quadratus. The flexor carpi radialis is innervated by the proper median nerve before the AIN branches off.

Question 230

Topic: Nerve & Tendon

During an in situ ulnar nerve decompression at the elbow, the surgeon releases the tissue spanning the two heads of the flexor carpi ulnaris (FCU). Which anatomical structure forms the primary roof of the cubital tunnel in this region?

. Ligament of Struthers
. Osborne's ligament
. Arcade of Struthers
. Lacertus fibrosus
. Arcade of Frohse

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (or Osborne's fascia) forms the roof of the cubital tunnel, bridging the olecranon and the medial epicondyle over the two heads of the FCU. The Arcade of Struthers is a potential compression site located approximately 8 cm proximal to the medial epicondyle.

Question 231

Topic: 7. Hand and Wrist

A 45-year-old typist complains of aching pain in the proximal forearm and numbness in the radial three and a half digits. Which physical examination finding most reliably distinguishes pronator syndrome from carpal tunnel syndrome?

. Positive Tinel's sign at the wrist
. Positive Phalen's test
. Decreased sensation over the thenar eminence
. Weakness of the abductor pollicis brevis
. Positive Finkelstein's test

Correct Answer & Explanation

. Decreased sensation over the thenar eminence

Explanation

The palmar cutaneous branch of the median nerve branches off proximal to the carpal tunnel, supplying sensation to the thenar eminence. Consequently, sensation over the thenar eminence is spared in carpal tunnel syndrome but affected in pronator syndrome.

Question 232

Topic: Nerve & Tendon

A 6-year-old child sustains a displaced extension-type supracondylar humerus fracture.

Based on typical displacement patterns, what is the most common neurological deficit associated with this specific injury?

. Radial nerve palsy
. Ulnar nerve palsy
. Anterior interosseous nerve palsy
. Median nerve proper palsy
. Musculocutaneous nerve palsy

Correct Answer & Explanation

. Anterior interosseous nerve palsy

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures, particularly those with posterolateral displacement. Flexion-type fractures place the ulnar nerve at higher risk.

Question 233

Topic: 7. Hand and Wrist

Flexor tendon injuries in 'Zone 2' of the hand are historically referred to as 'no man's land' due to the high risk of adhesion formation. What are the anatomical boundaries of Zone 2?

. FDS insertion to the FDP insertion
. A1 pulley to the FDS insertion
. Distal palmar crease to the FDP insertion
. Carpal tunnel to the A1 pulley
. Musculotendinous junction to the carpal tunnel

Correct Answer & Explanation

. A1 pulley to the FDS insertion

Explanation

Zone 2 of the flexor tendons begins at the proximal edge of the A1 pulley (distal palmar crease) and ends at the insertion of the Flexor Digitorum Superficialis (FDS) on the middle phalanx. In this zone, the FDP and FDS tendons lie closely together within the tight fibro-osseous sheath.

Question 234

Topic: 7. Hand and Wrist

A 22-year-old male sustains a scaphoid waist fracture. Which of the following best describes the predominant arterial supply to the scaphoid, explaining its propensity for proximal pole avascular necrosis?

. Volar carpal branch entering the proximal pole
. Dorsal carpal branch of the radial artery entering distally
. Superficial palmar arch entering the waist volarly
. Ulnar artery branches entering through the scapholunate ligament
. Anterior interosseous artery entering proximally

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering distally

Explanation

The scaphoid is predominantly supplied by the dorsal carpal branch of the radial artery, which enters at the distal pole and provides retrograde blood flow to the proximal pole. Fractures at the waist or proximal pole disrupt this retrograde supply, risking avascular necrosis.

Question 235

Topic: Wrist & Carpus

A 28-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate (Kienbock's disease). Which of the following radiographic anatomical variants is most highly associated with this condition?

. Positive ulnar variance
. Negative ulnar variance
. Type II lunate morphology
. Dorsal intercalated segment instability (DISI)
. Madelung deformity

Correct Answer & Explanation

. Negative ulnar variance

Explanation

Negative ulnar variance is strongly associated with Kienbock's disease. The shortened ulna relative to the radius leads to increased radiolunate contact stresses, precipitating lunate avascular necrosis.

Question 236

Topic: Nerve & Tendon

An 8-year-old child presents with an extension-type supracondylar humerus fracture as shown.

If the distal fragment demonstrates significant posteromedial displacement, which nerve is at the greatest risk of injury due to tethering across the fracture site?

. Ulnar nerve
. Radial nerve
. Median nerve
. Anterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

Posteromedial displacement of the distal fragment in an extension-type supracondylar fracture puts the radial nerve at greatest risk as the proximal fragment displaces anterolaterally. Conversely, posterolateral displacement predominantly endangers the median nerve and anterior interosseous nerve (AIN).

Question 237

Topic: Nerve & Tendon

During an electrodiagnostic evaluation for suspected cubital tunnel syndrome, a Martin-Gruber anastomosis is identified. This anatomical variant involves a neural connection between which two structures?

. From the median nerve to the ulnar nerve in the forearm
. From the ulnar nerve to the median nerve in the forearm
. From the superficial radial nerve to the ulnar nerve in the hand
. From the deep branch of the ulnar nerve to the median nerve in the palm
. From the median nerve to the musculocutaneous nerve in the arm

Correct Answer & Explanation

. From the median nerve to the ulnar nerve in the forearm

Explanation

The Martin-Gruber anastomosis is a motor crossover from the median nerve (often via the AIN) to the ulnar nerve in the forearm. It can confound nerve conduction studies by producing spuriously normal ulnar motor amplitudes.

Question 238

Topic: 7. Hand and Wrist

Arthritis of the wrist is estimated to effect what percentage of the U.S. population:

. Less than 1%
. 3%
. 5%
. 10%
. More than 15%

Correct Answer & Explanation

. 5%

Explanation

Arthritis of the wrist is estimated to affect 5.3% of the U.S. population, based on radiographic assessments of 4,000 wrists.1 After having rheumatoid arthritis (RA) for 10 years, 90% of patients experience arthritis in their wrist joints.2

Question 239

Topic: 7. Hand and Wrist

The accessory ulnar collateral ligament inserts on the:

. Proper ulnar collateral ligament
. Lateral bands
. Proximal phalanx
. Volar plate
. Flexor sheath

Correct Answer & Explanation

. Proximal phalanx

Explanation

The accessory ulnar collateral ligament inserts into the volar plate, whereas the proper collateral inserts into the base of the proximal phalanx.

Question 240

Topic: 7. Hand and Wrist
Which of the following nerves is not a primary articular nerve of the wrist?
. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve
. Palmar cutaneous branch of the median nerve
. Articular branches from the median nerve

Correct Answer & Explanation

. Palmar cutaneous branch of the median nerve

Explanation

Fukumoto and colleagues have used Wyke's definition to explain primary and accessory innervation of the wrist. Primary articular nerves consist of small nerves that pass to each joint as independent branches of adjacent peripheral nerves. There are three primary articular nerves: the PIN, the lateral antebrachial cutaneous nerve, and the articular branches from the ulnar nerve. Accessory nerves originate from small, twig branches of intramuscular or cutaneous nerves that innervate the skin around the wrist joint. The accessory articular nerves have been identified as the anterior interosseous nerve (AIN), the palmar cutaneous branch of the median nerve, the deep and dorsal branches of the ulnar nerve, and the superficial branch of the radial nerve to the first intercarpal space.

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