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7. Hand and Wrist MCQs

Practice Set 13 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 241

Topic: 7. Hand and Wrist
Which of the following nerves provides principal innervation to the central dorsal portion of the wrist?
. Anterior interosseous nerve (AIN)
. Posterior interosseous nerve (PIN)
. Dorsal branch of the ulnar nerve
. Lateral antebrachial cutaneous nerve

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The PIN is found on the deep radial wall of the fourth dorsal compartment, 1.2 cm ulnar to Lister's tubercle. As the PIN approaches the radiocarpal joint, it is covered in fascia and gives one branch to the radioscaphoid joint and three to four terminal branches to the intercarpal joints. The PIN is the principal innervation to the central dorsal portion of the wrist. The AIN innervates the radial volar lip of the distal radius. The dorsal branch of the ulnar nerve contributes to innervation of the triangular fibrocartilage complex. The lateral antebrachial cutaneous nerve innervates the thumb carpometacarpal joint and the scaphotrapezotrapezoid joint.

Question 242

Topic: 7. Hand and Wrist

What is the area of innervation of the anterior interosseous nerve (AIN):

. Radial volar lip of the distal radius
. Triangular fibrocartilage complex (TFC C )
. Dorsal radiocarpal joint
. Thumb carpometacarpal joint

Correct Answer & Explanation

. Radial volar lip of the distal radius

Explanation

The AIN is a branch of the median nerve. Its muscular innervations include the flexor pollicis longus, the radial half of the flexor digitorum profundus, and the pronator quadratus. The AIN terminates as a sensory branch to the volar radial surface of the distal radius. The TFC C is innervated by components of the ulnar nerve. The dorsal radiocarpal joint is innervated by the posterior interosseous nerve. The thumb carpometacarpal is innervated by the sensory branch of the radial nerve and the lateral antebrachial cutaneous nerve.

Question 243

Topic: 7. Hand and Wrist

When performing complete wrist denervation as described by Wilhem, what pain pathology did not have predictable results:

. Scaphoid nonunion
. Osteonecrosis of the scaphoid
. Primary radiocarpal arthritis
. Ulnar carpal arthritis

Correct Answer & Explanation

. Scaphoid nonunion

Explanation

In 1983, Ekerot and colleagues reported his results in 48 patients. They used the technique described by Wilhelm but only denervated the radial side of the wrist for patients with scaphoid or lunate pathology. However, the entire wrist was denervated in patients with global degenerative wrist disease or wrist pain with an unknown etiology. Pain relief occurred in only 56% of the patients. They noted the best results occurred in patients with scaphoid nonunion, osteonecrosis of the lunate, and primary radiocarpal arthritis.

Question 244

Topic: 7. Hand and Wrist

What two nerves are resected through a single dorsal incision for wrist denervation:

. Superficial branch of the radial nerve and posterior interosseous nerve (PIN)
. PIN and the dorsal cutaneous branch of the ulnar nerve
. PIN and anterior interosseous nerve (AIN)
. Superficial branch of the radial nerve and dorsal cutaneous branch of the ulnar nerve

Correct Answer & Explanation

. PIN and anterior interosseous nerve (AIN)

Explanation

Kupfer and colleagues presented a podium presentation of a single-incision approach to the resection of the PIN and AIN for denervation of the radial side of the wrist. Weinstein and Berger published their results in 2002 with a similar technique. They described a 2-cm long dorsal incision that was 3 to 5 cm proximal to the ulnar head. They then resected a 2-cm segment of the PIN and AIN. In their group of 20 patients, 85% were satisfied with their procedure after an average follow-up of 2.5 years. If failure were to occur, it occurred within the first year.

Question 245

Topic: 7. Hand and Wrist

What muscle is at risk for denervation when a single dorsal incision is used to denervate the radial side of the wrist:

. Flexor pollicis longus
. Extensor indicis
. Flexor digitorum profundus
. Pronator quadratus

Correct Answer & Explanation

. Pronator quadratus

Explanation

The single dorsal incision approach to wrist denervation involves resection of the posterior interosseous nerve (PIN) and the anterior interosseous nerve (AIN). Distally, the PIN is purely sensory and does not give off motor branches in the vicinity of the wrist joint. The terminal portion of the AIN has both motor and sensory components. A majority of this is motor, and it innervates the pronator quadratus right up to the radiocarpal articulation. Resection of the AIN close to the radiocarpal joint has a high probability of denervating the pronator quadratus. The extensor indicis is usually the last motor branch of the PIN, but this terminal portion of this branch is more than 5 cm proximal from the distal radioulnar joint. The flexor pollicis longus is innervated by the AIN, but motor branches to this muscle are more proximal than branches to the pronator quadratus. The flexor digitorum profundus muscle is innervated by the AIN and ulnar nerve. However, the motor branches are more proximal than the incision for dorsal innervation. C orrect Answer: Pronator quadratus

Question 246

Topic: 7. Hand and Wrist

A 62-year-old man presents with weakness in finger extension in his right hand. He has had the weakness for 1 month but denies any significant traumatic event. The patient maintains an active lifestyle, including golf and tennis. He denies pain or numbness in his hand and is otherwise neurologically intact. Which of the following is the most likely diagnosis:

. Thoracic outlet syndrome
. Posterior interosseous nerve palsy
. Ulnar nerve palsy
. C arpal tunnel syndrome
. Radial nerve palsy

Correct Answer & Explanation

. Posterior interosseous nerve palsy

Explanation

Posterior interosseous nerve palsy is described as painless finger drop. This syndrome is commonly associated with trauma to the lateral elbow.

Question 247

Topic: Nerve & Tendon

Posterior interosseous nerve palsy affects finger extension at the metacarpophalangeal and interphalangeal joints.

. True
. False Only the metacarpophalangeal joints are involved in posterior interosseous nerve palsy, as the muscles of the interphalangeal joints are innervated by the ulnar and median nerves.

Correct Answer & Explanation

. True

Explanation

Question 248

Topic: 7. Hand and Wrist

A 53-year-old woman presents with bilateral hand numbness and tingling. Her right hand is more affected than her left. The numbness wakes her up at night and is relieved when she shakes her hand. In addition, the patient has had increasing difficulty with fine motor tasks, such as shirt buttoning, over the past 2 to 3 months. Upon close inspection, muscle atrophy is present at the base of her thumbs. Which of the following is the most likely diagnosis:

. Thoracic outlet syndrome
. Posterior interosseous nerve palsy
. Ulnar nerve palsy
. Carpal tunnel syndrome
. Radial nerve palsy

Correct Answer & Explanation

. Carpal tunnel syndrome

Explanation

This patient displays the classic signs and symptoms of bilateral carpal tunnel syndrome, which involves median nerve entrapment at the base of the palm. This entrapment leads to numbness and dysesthesias that are worse at night and upon exertion. Pain is typically relieved by shaking the hand. Furthermore, the median nerve innervates several muscles of the hands, and entrapment may lead to muscle atrophy.

Question 249

Topic: Nerve & Tendon
All of the following muscles are innervated by the median nerve except:
. The ulnar two lumbricals (lumbricals III and IV)
. Opponens pollicis
. Abductor pollicis brevis
. Flexor pollicis brevis
. Flexor digitorum profundus to the middle finger

Correct Answer & Explanation

. The ulnar two lumbricals (lumbricals III and IV)

Explanation

Lumbricals 1 and 2 are innervated by the median nerve, in addition to the opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis. The ulnar two lumbricals are innervated by the ulnar nerve.

Question 250

Topic: 7. Hand and Wrist

All of the following are true regarding the transverse carpal ligament except:

. The transverse carpal ligament attaches medially to the pisiform and hook of hamate.
. The transverse carpal ligament attaches laterally to the scaphoid and trapezium.
. The palmaris longus tendon lies superficially to the transverse carpal ligament.
. All of the above are true
. None of the above are true

Correct Answer & Explanation

. All of the above are true

Explanation

All of the above statements are true regarding the transverse carpal ligament.

Question 251

Topic: 7. Hand and Wrist

All of the following structures pass through the carpal tunnel except:

. Motor branch of the median nerve
. Tendon of the flexor pollicis longus
. Palmar cutaneous branch of median nerve
. Tendon of the flexor digitorum profundus
. Tendon of the flexor digitorum sublimes

Correct Answer & Explanation

. Palmar cutaneous branch of median nerve

Explanation

The palmar cutaneous branch of the median nerve originates proximally to the carpal tunnel and travels superficial to the tunnel.

Question 252

Topic: 7. Hand and Wrist
Dupuytren's contracture characteristically involves which part of the hand?
. Ulnar side of the hand
. Thumb
. Radial side of the hand
. Extensor tendons
. Web space between the first and second metacarpals

Correct Answer & Explanation

. Ulnar side of the hand

Explanation

Dupuytren's contracture most frequently involves the ring and small fingers. Although Dupuytren's cords at the thumb have been described, they are rare.

Question 253

Topic: 7. Hand and Wrist
Dupuytren's cord tissue is characterized by what change from normal:
. An increase in type II collagen
. A decrease in type III collagen
. An increase of type III collagen
. Abnormal collagen crosslinks
. Increased hyaluronidase

Correct Answer & Explanation

. An increase of type III collagen

Explanation

Compared to normal palmar fascia, the fibrous bands in Dupuytren's disease have an increased ratio of type III to type I collagen, and an overall increase in the amount of type III collagen.

Question 254

Topic: 7. Hand and Wrist
The radiographic abnormality seen on the lateral radiograph characteristic of scapholunate instability is:
. Dorsal intercalated segment instability (DISI)
. Volar intercalated segment instability (VISI)
. Terry Thomas sign
. Ring pole sign
. Abnormal Gilula's arcs

Correct Answer & Explanation

. Dorsal intercalated segment instability (DISI)

Explanation

On a lateral view of the wrist, when the lunate slips into a statically dorsiflexed position greater than 10°, the condition is defined as dorsal intercalated segmental instability (DISI). DISI deformity is also present when the scapholunate angle is greater than 60 degrees (45+/- 15 degrees is normal). The VISI deformity seen on the lateral radiograph is characteristic of lunotriquetral dissociation. The other signs are seen on the anteroposterior projection.

Question 255

Topic: 7. Hand and Wrist
A 40-year-old woman with radial sided wrist pain for the last 2 years presents to the clinic. Plain radiographs are normal. Because of continued discomfort despite conservative therapies and occasional 'clicking' of the wrist, she is taken to the operating room for diagnostic arthroscopy. At the time, fraying of the membranous portion of the scapholunate (SL) ligament is seen, with mild incongruity from the midcarpal joint. The surgeon is unable to pass a 1-mm probe through the defect. This is most consistent with:
. Geissler Grade I SL tear
. Geissler Grade II SL tear
. Geissler Grade III tear
. Geissler Grade IV tear
. Scapholunate advanced collapse (SLAC) wrist

Correct Answer & Explanation

. Geissler Grade III tear

Explanation

Arthroscopy has become the gold standard for the diagnosis of ligamentous injuries to the wrist. A classification scheme has been proposed by Geissler and colleagues. Grade I is attenuation or hemorrhage, Grade II is fraying/tearing of the membranous portion without probe passage, Grade III is probe passage, and Grade IV is gross instability.

Question 256

Topic: 7. Hand and Wrist
Complete bifurcation of two distal phalanges articulating with a wide epiphysis of a single proximal phalanx is classified as:
. Wassel II / IP
. Wassel III / IP
. Wassel IV / MCP
. Wassel IV / IP
. Wassel I / Distal

Correct Answer & Explanation

. Wassel II / IP

Explanation

Wassel II (also categorized as IP in the universal classification system) occurs when the duplication begins at the interphalangeal joint of the thumb, resulting in complete bifurcation of two distal phalanges that articulate proximally with a single proximal phalanx.

Question 257

Topic: Nerve & Tendon

The nerve most at risk during arthroscopic debridement of lateral epicondylitis is the:

. Ulnar nerve
. Median nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

While the ulnar nerve is most at risk during elbow arthroscopy in general, debridement of the lateral capsule posterior to the midpoint of the radiocapitellar joint places the posterior interosseous branch of the radial nerve at risk.

Question 258

Topic: Nerve & Tendon

A patient is undergoing in situ decompression for cubital tunnel syndrome. Which of the following structures forms the roof of the cubital tunnel and must be released?

. Medial collateral ligament
. Osborne's ligament (cubital tunnel retinaculum)
. Struthers' ligament
. Lacertus fibrosus
. Arcade of Frohse

Correct Answer & Explanation

. Osborne's ligament (cubital tunnel retinaculum)

Explanation

The roof of the cubital tunnel is formed by Osborne's ligament (the cubital tunnel retinaculum) and the aponeurosis of the two heads of the flexor carpi ulnaris. Struthers' ligament is a potential site of median nerve compression proximal to the elbow.

Question 259

Topic: Wrist & Carpus

A 28-year-old male sustains a Galeazzi fracture. Following rigid plate fixation of the radial shaft, the distal radioulnar joint (DRUJ) is noted to be highly unstable in supination but stable in pronation. What is the most appropriate next step in management?

. Immobilization in a long arm cast in supination
. Immobilization in a long arm cast in neutral
. Percutaneous pinning of the DRUJ in supination
. Percutaneous pinning of the DRUJ in pronation
. Open reduction of the DRUJ with ulnar styloid excision

Correct Answer & Explanation

. Immobilization in a long arm cast in supination

Explanation

If the DRUJ remains unstable after rigid anatomical fixation of the radius in a Galeazzi fracture, it should be pinned in the position of maximum stability. If it is unstable in supination (and stable in pronation), pinning the DRUJ in the stable position or supination depending on reducibility is required to allow ligamentous healing.

Question 260

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with Lichtman Stage IIIB Kienböck's disease (lunate collapse, fixed scaphoid rotation, no extensive arthritic changes). Radiographs reveal an ulnar minus variance of 3 mm. Which of the following is the most appropriate surgical treatment?
. Radial shortening osteotomy
. Proximal row carpectomy
. Total wrist arthrodesis
. Lunate excision and silicone replacement
. Four-corner arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early to mid-stage Kienböck's disease (up to Stage IIIB) in a patient with ulnar negative variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated to offload the lunate. Proximal row carpectomy or arthrodesis is reserved for later stages with secondary degenerative changes.

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