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7. Hand and Wrist MCQs

Practice Set 126 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 2501

Topic: 7. Hand and Wrist

During a limited fasciectomy for Dupuytren's contracture, a surgeon meticulously dissects the spiral cord. The spiral cord alters normal anatomy by displacing the neurovascular bundle in which direction?

. Proximal, superficial, and midline
. Distal, deep, and lateral
. Proximal, deep, and medial
. Distal, superficial, and midline
. Lateral, deep, and distal

Correct Answer & Explanation

. Proximal, superficial, and midline

Explanation

The spiral cord characteristically displaces the neurovascular bundle proximally, superficially, and centrally (towards the midline of the digit). This distorted anatomy places the digital nerve at extremely high risk of iatrogenic transection.

Question 2502

Topic: Wrist & Carpus

A 26-year-old motorcyclist falls onto an extended wrist. Lateral radiographs show a 'spilled teacup' sign with the lunate displaced volarly. The capitate is aligned with the radius. What is the correct diagnosis?

. Scaphoid fracture
. Perilunate dislocation
. Lunate dislocation
. Trans-scaphoid perilunate dislocation
. Volar Barton's fracture

Correct Answer & Explanation

. Lunate dislocation

Explanation

A volarly displaced and tipped lunate with the capitate maintaining its collinear alignment with the radius describes a lunate dislocation. In a perilunate dislocation, the lunate remains aligned with the radius while the rest of the carpus is dorsally dislocated.

Question 2503

Topic: Nerve & Tendon
A 24-year-old football player grabs an opponent's jersey and feels a pop in his ring finger. He cannot actively flex the DIP joint. Radiographs show a bony avulsion resting at the level of the PIP joint. What is the Leddy and Packer classification and optimal timing for surgery?
. Type I; surgery within 7 to 10 days
. Type II; surgery within 3 to 4 weeks
. Type III; surgery anytime
. Type IV; surgery within 7 to 10 days
. Type V; surgery within 24 hours

Correct Answer & Explanation

. Type II; surgery within 3 to 4 weeks

Explanation

A 'Jersey finger' where the tendon retracts to the PIP joint level (restrained by an intact vinculum longum) is a Leddy and Packer Type II injury. Surgical repair should ideally be performed within 3 to 4 weeks before definitive tendon retraction and fibrosis occur.

Question 2504

Topic: 7. Hand and Wrist
A 30-year-old manual laborer has progressive dorsal wrist pain. X-rays reveal Kienbock's disease with sclerosis and collapse of the lunate, proximal migration of the capitate, and early secondary arthritic changes. The ulna variance is negative. What is the Lichtman classification and corresponding management?
. Stage II; Radial shortening osteotomy
. Stage IIIA; Radial shortening osteotomy
. Stage IIIB; Proximal row carpectomy or partial wrist fusion
. Stage IV; Total wrist arthrodesis
. Stage I; Cast immobilization

Correct Answer & Explanation

. Stage IIIB; Proximal row carpectomy or partial wrist fusion

Explanation

Sclerosis and collapse of the lunate with fixed scaphoid rotation and capitate proximal migration indicates Lichtman Stage IIIB Kienbock's disease. Joint leveling procedures are ineffective at this stage; salvage procedures like proximal row carpectomy or STT fusion are required.

Question 2505

Topic: 7. Hand and Wrist
A 55-year-old manual laborer presents with chronic dorsal wrist pain. Radiographs demonstrate advanced narrowing of the capitolunate joint, with relative sparing of the radiolunate joint. This presentation is most consistent with which stage of Scapholunate Advanced Collapse (SLAC)?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage II

Explanation

SLAC wrist progresses in a predictable pattern: Stage I involves the radial styloid, Stage II involves the entire radioscaphoid facet, and Stage III progresses to the capitolunate joint while typically sparing the radiolunate articulation.

Question 2506

Topic: 7. Hand and Wrist

A 25-year-old male presents with a 9-month-old scaphoid waist fracture nonunion. MRI demonstrates no avascular necrosis of the proximal pole, and radiographs show no radiocarpal arthritis (SNAC wrist stage 0). What is the most appropriate surgical management?

. Four-corner fusion
. Proximal row carpectomy
. Non-vascularized bone graft with rigid screw fixation
. Vascularized bone graft from the distal radius
. Scaphoid excision and partial wrist fusion

Correct Answer & Explanation

. Non-vascularized bone graft with rigid screw fixation

Explanation

For scaphoid waist nonunions without avascular necrosis, non-vascularized bone grafting with rigid internal fixation yields high union rates and is the preferred initial treatment. Vascularized grafts are typically reserved for proximal pole nonunions or cases with confirmed AVN.

Question 2507

Topic: 7. Hand and Wrist

A 32-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis of the lunate without collapse, and negative ulnar variance (Lichtman Stage II Kienboeck disease). What is the most appropriate definitive surgical treatment?

. Proximal row carpectomy
. Joint leveling procedure (radial shortening osteotomy)
. Lunate excision and silicone implant replacement
. Total wrist arthrodesis
. Ulnar shortening osteotomy

Correct Answer & Explanation

. Joint leveling procedure (radial shortening osteotomy)

Explanation

In Lichtman Stage II Kienboeck disease with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy unloads the lunate and can halt disease progression. Salvage procedures like proximal row carpectomy are reserved for advanced collapse.

Question 2508

Topic: Nerve & Tendon

During a single anterior-incision repair of a distal biceps tendon rupture using an endobutton technique, the patient is at highest risk for iatrogenic injury to which of the following nerves?

. Median nerve
. Ulnar nerve
. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Superficial radial nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most frequently injured nerve during a single-anterior-incision distal biceps repair due to its superficial location and proximity to the cephalic vein. The PIN is more commonly at risk during a two-incision technique.

Question 2509

Topic: 7. Hand and Wrist

A hand surgeon is repairing a Zone II flexor tendon laceration. To optimize tensile strength for an early active motion protocol while minimizing tendon gliding resistance (work of flexion), what is the optimal suture construct?

. 2-strand core suture, no epitendinous suture
. 4-strand core suture, running epitendinous suture
. 6-strand core suture, running epitendinous suture
. 8-strand core suture, no epitendinous suture
. 2-strand core suture, running epitendinous suture

Correct Answer & Explanation

. 4-strand core suture, running epitendinous suture

Explanation

A 4-strand core suture combined with a running epitendinous suture provides an optimal balance of strength for early active motion while avoiding excessive bulk. Constructs with 6 or 8 strands can increase gliding resistance and risk tendon bunching.

Question 2510

Topic: 7. Hand and Wrist

A patient with severe, longstanding carpal tunnel syndrome undergoes a carpal tunnel release. Due to profound thenar atrophy, an opponensplasty using the flexor digitorum superficialis (FDS) of the ring finger is performed. To optimize the vector for thumb opposition, the transfer should be routed around which structure?

. Flexor carpi ulnaris (FCU)
. Flexor carpi radialis (FCR)
. Palmaris longus
. Extensor carpi ulnaris (ECU)
. Brachioradialis

Correct Answer & Explanation

. Flexor carpi ulnaris (FCU)

Explanation

The Burkhalter opponensplasty uses the FDS of the ring finger transferred to the abductor pollicis brevis. Routing it around the flexor carpi ulnaris (FCU) acts as a pulley to direct the vector of pull from the pisiform, which is optimal for restoring thumb opposition.

Question 2511

Topic: 7. Hand and Wrist

A 28-year-old female presents with persistent ulnar-sided wrist pain after a fall on an outstretched hand. MRI confirms a Palmer Class 1B tear of the triangular fibrocartilage complex (TFCC). After failing conservative management, what is the best surgical intervention?

. Ulnar shortening osteotomy
. Arthroscopic debridement of the central articular disc
. Arthroscopic or open repair of the TFCC to the fovea
. Darrach procedure
. Suave-Kapandji procedure

Correct Answer & Explanation

. Arthroscopic or open repair of the TFCC to the fovea

Explanation

A Palmer Class 1B tear is a peripheral avulsion of the TFCC from its ulnar attachment at the fovea. Because the peripheral TFCC is well-vascularized, it has excellent healing potential and is best treated with arthroscopic or open anatomic repair.

Question 2512

Topic: 7. Hand and Wrist

A 60-year-old man undergoes limited fasciectomy for severe Dupuytren's contracture involving the ring finger. During the dissection, the surgeon carefully traces the neurovascular bundle. Which specific cord is primarily responsible for contracture of the proximal interphalangeal (PIP) joint and typically displaces the digital nerve centrally and superficially?

. Pretendinous cord
. Spiral cord
. Natatory cord
. Lateral cord
. Retrovascular cord

Correct Answer & Explanation

. Spiral cord

Explanation

The spiral cord is formed by the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligaments. It is primarily responsible for PIP joint contracture and characteristically displaces the neurovascular bundle centrally, superficially, and proximally, increasing the risk of iatrogenic injury.

Question 2513

Topic: 7. Hand and Wrist
A 26-year-old man falls from a roof and presents with severe wrist pain. Lateral radiographs show a 'spilled teacup' sign, indicative of a volar lunate dislocation. According to the Mayfield classification of progressive perilunate instability, what is the correct sequence of ligamentous failure?
. Scapholunate -> Lunotriquetral -> Capitolunate -> Volar lunate dislocation
. Scapholunate -> Capitolunate -> Lunotriquetral -> Volar lunate dislocation
. Lunotriquetral -> Capitolunate -> Scapholunate -> Volar lunate dislocation
. Capitolunate -> Scapholunate -> Lunotriquetral -> Volar lunate dislocation
. Volar lunate dislocation -> Scapholunate -> Lunotriquetral -> Capitolunate

Correct Answer & Explanation

. Scapholunate -> Capitolunate -> Lunotriquetral -> Volar lunate dislocation

Explanation

The Mayfield progression of perilunate instability occurs in four sequential stages starting radially and progressing ulnarward: scapholunate (Stage I), capitolunate (Stage II), lunotriquetral (Stage III), and finally volar lunate dislocation (Stage IV).

Question 2514

Topic: Nerve & Tendon

A 50-year-old female presents with severe ulnar neuropathy at the elbow. Intraoperative examination reveals that the ulnar nerve actively subluxates over the medial epicondyle during elbow flexion. What is the most appropriate surgical management?

. In situ decompression
. Medial epicondylectomy
. Anterior transposition of the ulnar nerve
. Endoscopic in situ decompression
. Isolated resection of the arcuate ligament of Osborne

Correct Answer & Explanation

. Anterior transposition of the ulnar nerve

Explanation

While in situ decompression is effective for most cases of cubital tunnel syndrome, a nerve that subluxates anteriorly with flexion requires anterior transposition. Leaving a subluxating nerve in situ will lead to continued dynamic friction and poor clinical outcomes.

Question 2515

Topic: 7. Hand and Wrist
A 38-year-old man presents with chronic wrist pain. Radiographs demonstrate a scaphoid nonunion with advanced collapse (SNAC). Imaging shows arthritic changes involving both the radioscaphoid and capitolunate joints, while the radiolunate joint is entirely spared. Which of the following is the most appropriate surgical intervention?
. Proximal row carpectomy
. Radial styloidectomy
. Four-corner arthrodesis with scaphoid excision
. Scaphotrapeziotrapezoid (STT) arthrodesis
. Scaphoid open reduction internal fixation with vascularized bone grafting

Correct Answer & Explanation

. Four-corner arthrodesis with scaphoid excision

Explanation

In Stage III SNAC wrists (radioscaphoid and capitolunate arthritis), four-corner arthrodesis with scaphoid excision is the preferred treatment. Proximal row carpectomy is contraindicated because the degenerate capitate head would articulate poorly with the lunate fossa, leading to persistent pain.

Question 2516

Topic: 7. Hand and Wrist

During a flexor tendon repair in Zone II of the hand, maintaining the integrity of the flexor tendon sheath is critical. Which of the following pulley combinations is considered most essential to prevent bowstringing of the flexor tendons?

. A1 and A3
. A2 and A4
. A3 and A5
. A1 and A5
. C1 and C3

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 and A4 pulleys arise directly from the periosteum of the proximal and middle phalanges, respectively, and are the most critical biomechanical pulleys. Loss of these specific pulleys leads to significant flexor tendon bowstringing, causing a loss of active flexion and grip strength.

Question 2517

Topic: Nerve & Tendon

During an open in-situ ulnar nerve decompression at the cubital tunnel, the skin incision is made just posterior to the medial epicondyle. To avoid painful neuroma formation, the surgeon must carefully identify and protect a sensory nerve branch that crosses the proximal forearm transversely. Which nerve is this?

. Lateral antebrachial cutaneous nerve
. Posterior antebrachial cutaneous nerve
. Medial antebrachial cutaneous nerve
. Superficial radial nerve
. Palmar cutaneous branch of the median nerve

Correct Answer & Explanation

. Medial antebrachial cutaneous nerve

Explanation

The posterior branch of the medial antebrachial cutaneous nerve (MABC) typically crosses the incision region transversely, just distal to the medial epicondyle. Injury to this nerve during superficial dissection can result in a painful postoperative neuroma.

Question 2518

Topic: 7. Hand and Wrist

To safely execute a standard open carpal tunnel release while minimizing the risk of injuring the palmar cutaneous branch of the median nerve, the surgeon should align the longitudinal incision with which anatomical landmark?

. The radial border of the flexor carpi radialis
. The ulnar border of the palmaris longus (or 3rd webspace)
. The radial border of the flexor carpi ulnaris
. Transversely across the distal wrist crease
. Over the hook of the hamate

Correct Answer & Explanation

. The ulnar border of the palmaris longus (or 3rd webspace)

Explanation

The palmar cutaneous branch of the median nerve arises approximately 5 cm proximal to the wrist crease and travels distally on the radial side of the palmaris longus. An incision along the ulnar border of the palmaris longus (or in line with the 3rd webspace) avoids this branch.

Question 2519

Topic: 7. Hand and Wrist

A patient exhibits an inability to actively extend the metacarpophalangeal joints of the fingers and thumb, but maintains normal wrist extension with radial deviation. Which of the following anatomic structures is the most common site of compression for the affected nerve?

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

Correct Answer & Explanation

. Arcade of Frohse

Explanation

The patient has posterior interosseous nerve (PIN) syndrome. The most common site of PIN entrapment is the Arcade of Frohse, which is the proximal fibrous edge of the superficial head of the supinator muscle.

Question 2520

Topic: 7. Hand and Wrist

Electrodiagnostic testing of a patient reveals an anomalous median-to-ulnar nerve communication in the forearm. This anomaly most commonly involves crossing motor fibers that eventually innervate which of the following muscles?

. Abductor pollicis brevis
. Flexor carpi ulnaris
. First dorsal interosseous
. Pronator quadratus
. Lumbricals to index and middle fingers

Correct Answer & Explanation

. First dorsal interosseous

Explanation

The Martin-Gruber anastomosis is a connection from the median to the ulnar nerve in the forearm. It predominantly carries motor fibers that innervate the intrinsic hand muscles, most commonly the first dorsal interosseous.

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