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7. Hand and Wrist MCQs

Practice Set 131 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 2601

Topic: 7. Hand and Wrist

A 28-year-old gymnast presents with chronic dorsal wrist pain and a positive Watson scaphoid shift test. Suspecting a scapholunate ligament tear, the surgeon discusses potential repair. Which anatomical region of the scapholunate interosseous ligament (SLIL) is the thickest and most critical for preventing pathologic diastasis?

. Volar
. Dorsal
. Proximal membranous
. Radial
. Ulnar

Correct Answer & Explanation

. Dorsal

Explanation

The scapholunate interosseous ligament is C-shaped and consists of three components. The dorsal portion is the thickest, strongest, and most critical for maintaining the mechanical stability of the scapholunate articulation.

Question 2602

Topic: Hand Trauma & Infection

A 21-year-old skier falls while holding a ski pole, sustaining an acute thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) tear. Ultrasound reveals a Stener lesion. Which anatomical structure interposes between the torn ends of the UCL, preventing conservative healing?

. Adductor pollicis aponeurosis
. Abductor pollicis brevis tendon
. Flexor pollicis brevis muscle belly
. Extensor pollicis longus tendon
. First dorsal interosseous aponeurosis

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the torn distal end of the UCL displaces superficial to the adductor pollicis aponeurosis. This interposition prevents the ligament ends from healing naturally, necessitating surgical repair.

Question 2603

Topic: Hand Trauma & Infection

A 35-year-old man presents with a puncture wound on the volar aspect of his index finger. Examination reveals a finger held in slight flexion, fusiform swelling, tenderness along the flexor tendon sheath, and severe pain with passive extension. What is the most appropriate next step in management?

. Intravenous antibiotics and splinting
. Corticosteroid injection into the flexor sheath
. MRI of the hand with contrast
. Surgical incision, drainage, and intravenous antibiotics
. Oral antibiotics and outpatient follow-up

Correct Answer & Explanation

. Surgical incision, drainage, and intravenous antibiotics

Explanation

The patient exhibits Kanavel's four cardinal signs, highly indicative of purulent flexor tenosynovitis. This is an orthopedic emergency requiring immediate surgical incision, drainage, and broad-spectrum intravenous antibiotics to prevent tendon necrosis.

Question 2604

Topic: 7. Hand and Wrist
A 25-year-old man falls onto his outstretched hand and presents with severe volar wrist pain and median nerve paresthesias. A lateral radiograph of the wrist demonstrates the "spilled teacup" sign. What is the most likely diagnosis?
. Scaphoid waist fracture
. Dorsal perilunate dislocation
. Volar lunate dislocation
. Colles fracture
. Lunate avascular necrosis (Kienböck disease)

Correct Answer & Explanation

. Volar lunate dislocation

Explanation

The "spilled teacup" sign on a lateral radiograph indicates a lunate dislocation, which almost exclusively displaces volarly into the carpal tunnel. This often causes acute median neuropathy due to direct compression.

Question 2605

Topic: Nerve & Tendon

A 45-year-old man presents with chronic lateral elbow pain. He reports deep, aching pain in the proximal forearm that worsens with repetitive pronation and supination. Examination reveals maximal tenderness approximately 4 cm distal to the lateral epicondyle and pain elicited by resisted middle finger extension. What is the most likely diagnosis?

. Lateral epicondylitis
. Radial tunnel syndrome
. Cubital tunnel syndrome
. Posterolateral rotatory instability
. Pronator syndrome

Correct Answer & Explanation

. Radial tunnel syndrome

Explanation

Radial tunnel syndrome is characterized by deep aching pain in the lateral proximal forearm, with point tenderness distal to the lateral epicondyle. Pain with resisted middle finger extension (provoking the extensor carpi radialis brevis) is a classic clinical test differentiating it from lateral epicondylitis.

Question 2606

Topic: Nerve & Tendon
A 20-year-old rugby player felt a pop in his ring finger while grabbing an opponent's jersey. He is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs show a small bony avulsion fragment located at the level of the proximal interphalangeal (PIP) joint. According to the Leddy-Packer classification, what type of injury is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

In Leddy-Packer Type II "Jersey finger" injuries, the avulsed FDP tendon retracts to the level of the PIP joint, held up by the intact vinculum longum. Type I retracts to the palm, and Type III features a large bony fragment trapped at the A4 pulley.

Question 2607

Topic: 7. Hand and Wrist
A 30-year-old man presents with chronic central dorsal wrist pain. Radiographs demonstrate ulnar minus variance and sclerosis of the lunate without architectural collapse (Lichtman Stage II). Which of the following is the most appropriate joint-leveling procedure for this patient?
. Proximal row carpectomy
. Total wrist arthrodesis
. Radial shortening osteotomy
. Ulnar lengthening osteotomy
. Lunate excision with tendon interposition

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Kienböck disease with ulnar negative variance and no carpal collapse (Lichtman Stage I, II, or IIIa), joint leveling reduces compressive loads on the lunate. Radial shortening osteotomy is preferred over ulnar lengthening due to lower nonunion rates.

Question 2608

Topic: 7. Hand and Wrist

A 35-year-old woman complains of volar forearm pain and numbness in the thumb, index, and long fingers. Which of the following physical examination findings best differentiates Pronator Syndrome from Carpal Tunnel Syndrome?

. Positive Phalen test
. Wasting of the abductor pollicis brevis
. Decreased sensation over the thenar eminence
. Nocturnal awakening due to pain
. Positive Tinel sign at the wrist crease

Correct Answer & Explanation

. Decreased sensation over the thenar eminence

Explanation

The palmar cutaneous branch of the median nerve arises proximal to the carpal tunnel and supplies sensation to the thenar eminence. Consequently, thenar sensation is typically decreased in Pronator Syndrome but spared in Carpal Tunnel Syndrome.

Question 2609

Topic: 7. Hand and Wrist

A 60-year-old woman with severe basilar thumb arthritis undergoes a ligament reconstruction and tendon interposition (LRTI) procedure. What is the most common radiographic complication associated with this surgery?

. Flexor carpi radialis (FCR) tendon rupture
. Scaphoid fracture
. Subsidence of the first metacarpal
. Complex regional pain syndrome
. Nonunion of the base of the metacarpal

Correct Answer & Explanation

. Subsidence of the first metacarpal

Explanation

Subsidence (proximal migration) of the first metacarpal is the most common radiographic complication following an LRTI procedure. Despite this radiographic finding, clinical outcomes and pain relief generally remain satisfactory.

Question 2610

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic wrist pain. Radiographs demonstrate a scaphoid nonunion with radioscaphoid and capitolunate arthritis, but the radiolunate joint is well preserved. What is the most appropriate surgical treatment?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Scaphoid open reduction and internal fixation with vascularized bone graft
. Radial styloidectomy alone

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has a SNAC stage III wrist, defined by arthritis of the radioscaphoid and capitolunate joints with a spared radiolunate joint. Scaphoid excision and four-corner fusion is the treatment of choice, as proximal row carpectomy is contraindicated when capitate head arthritis is present.

Question 2611

Topic: 7. Hand and Wrist

A Martin-Gruber anastomosis involves a connection from the median to the ulnar nerve in the forearm. How does this anatomic variant classically affect electromyography/nerve conduction studies (EMG/NCS) of the ulnar-innervated intrinsic hand muscles?

. Ulnar motor amplitude is higher with wrist stimulation compared to elbow stimulation
. Ulnar motor amplitude is higher with elbow stimulation compared to wrist stimulation
. Sensory nerve action potentials are increased at the elbow
. Median nerve motor amplitude is higher at the wrist than at the elbow
. F-waves are completely absent in the median nerve

Correct Answer & Explanation

. Ulnar motor amplitude is higher with wrist stimulation compared to elbow stimulation

Explanation

In a Martin-Gruber anastomosis, motor fibers cross from the median to the ulnar nerve in the forearm. Therefore, ulnar nerve stimulation at the wrist activates more motor axons (including the crossed fibers) than stimulation at the elbow, resulting in a higher compound muscle action potential (CMAP) amplitude at the wrist.

Question 2612

Topic: Hand Trauma & Infection
A 35-year-old carpenter presents with a swollen, painful index finger 2 days after a puncture wound. Examination reveals severe pain with passive extension, flexed resting posture, and tenderness along the flexor sheath. He is taken to the OR, where the flexor tendon appears frankly necrotic. What is the most appropriate intraoperative step?
. Closed tendon sheath irrigation with continuous saline
. Primary tendon repair and skin closure
. Extensive debridement of the necrotic tendon and placement of a silicone tendon spacer
. Intravenous antibiotics and re-evaluation in 48 hours
. Amputation of the digit at the metacarpophalangeal joint

Correct Answer & Explanation

. Extensive debridement of the necrotic tendon and placement of a silicone tendon spacer

Explanation

In cases of severe pyogenic flexor tenosynovitis with gross tendon necrosis (Michon stage III), the necrotic tendon must be excised to eradicate the infection. Placement of a silicone tendon spacer preserves the retinacular system to facilitate a staged flexor tendon reconstruction once the infection resolves.

Question 2613

Topic: 7. Hand and Wrist
A 32-year-old mechanic presents with dorsal wrist pain. Radiographs reveal sclerosis and early fragmentation of the lunate, with negative ulnar variance (Lichtman Stage IIIA). The carpal height ratio is maintained. What is the most appropriate surgical intervention?
. Proximal row carpectomy
. Radial shortening osteotomy
. Ulnar shortening osteotomy
. Lunate excision and capitohamate fusion
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

For Kienböck's disease Stage IIIA (lunate sclerosis and fragmentation without carpal collapse) in a patient with negative ulnar variance, joint-leveling procedures such as a radial shortening osteotomy are the treatment of choice to mechanically offload the lunate. Salvage procedures like proximal row carpectomy are reserved for later stages involving carpal collapse (Stage IIIB/IV).

Question 2614

Topic: 7. Hand and Wrist

A 28-year-old woman is unable to form a perfect "OK" sign with her thumb and index finger 4 weeks after a proximal forearm crush injury. She demonstrates a flat, pad-to-pad pinch. Sensation in her hand is completely normal. Which of the following muscles is most likely affected?

. Flexor digitorum superficialis
. Flexor pollicis longus
. Adductor pollicis
. First dorsal interosseous
. Abductor pollicis brevis

Correct Answer & Explanation

. Flexor pollicis longus

Explanation

The patient exhibits signs of Anterior Interosseous Nerve (AIN) syndrome, characterized by the inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. This is due to denervation of the flexor pollicis longus (FPL) and the flexor digitorum profundus (FDP) to the index finger.

Question 2615

Topic: Wrist & Carpus

A 62-year-old woman sustained a nondisplaced distal radius fracture treated nonoperatively in a cast. Two weeks after cast removal, she suddenly loses the ability to actively extend her thumb interphalangeal joint. What is the primary pathophysiology of this specific complication?

. Attritional rupture due to prominent volar hardware
. Ischemic necrosis of the tendon within the third extensor compartment
. Denervation of the extensor pollicis longus due to radial nerve traction
. Adhesions within the first dorsal compartment
. Unrecognized concomitant rupture at the time of the initial injury

Correct Answer & Explanation

. Ischemic necrosis of the tendon within the third extensor compartment

Explanation

Extensor pollicis longus (EPL) rupture is a known complication following nondisplaced distal radius fractures. Fracture hematoma and subsequent callus formation within the tight, unyielding third extensor compartment compromise the local microvascular supply, leading to ischemic necrosis and subsequent rupture of the EPL tendon.

Question 2616

Topic: 7. Hand and Wrist

A 24-year-old man falls on an outstretched hand and sustains a proximal pole scaphoid fracture. Which of the following best describes the blood supply to the proximal pole of the scaphoid and its clinical implication?

. It receives blood primarily from the volar carpal branch of the radial artery, making it low risk for AVN.
. It relies on intraosseous retrograde blood flow, increasing the risk of avascular necrosis and nonunion.
. It is supplied directly by the deep palmar arch, ensuring rapid healing with cast immobilization.
. It receives dual blood supply from the radial and ulnar arteries, minimizing nonunion rates.
. It is supplied by the dorsal carpal branch of the ulnar artery, requiring prolonged immobilization.

Correct Answer & Explanation

. It relies on intraosseous retrograde blood flow, increasing the risk of avascular necrosis and nonunion.

Explanation

The scaphoid's blood supply enters distally from the dorsal carpal branch of the radial artery and flows retrograde. Proximal pole fractures disrupt this intraosseous supply, leading to high rates of avascular necrosis and nonunion.

Question 2617

Topic: Wrist & Carpus

A 25-year-old man sustains a traumatic injury to his right forearm. Radiographs demonstrate a fracture of the distal third of the radial shaft with associated dorsal displacement of the distal ulna. Which of the following is the most appropriate definitive management?

. Closed reduction and long arm casting in supination
. Closed reduction and long arm casting in pronation
. Open reduction and internal fixation (ORIF) of the radius and pinning of the DRUJ if unstable
. ORIF of both the radius and the ulna
. External fixation of the radius with DRUJ pinning

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) of the radius and pinning of the DRUJ if unstable

Explanation

A Galeazzi fracture (distal third radius fracture with DRUJ disruption) is highly unstable and requires ORIF of the radius in adults. The DRUJ should then be assessed and, if unstable, stabilized via pinning or immobilization in supination.

Question 2618

Topic: 7. Hand and Wrist

A 32-year-old male presents with persistent wrist pain following a hyperextension injury 6 weeks ago. Radiographs show a widened scapholunate interval of 4 mm and a "cortical ring sign" of the scaphoid. What does the cortical ring sign indicate?

. Avascular necrosis of the scaphoid proximal pole
. Rotary subluxation and volar flexion of the scaphoid
. Dorsal intercalated segment instability (DISI) of the lunate
. Concomitant fracture of the scaphoid waist
. Perilunate dislocation

Correct Answer & Explanation

. Rotary subluxation and volar flexion of the scaphoid

Explanation

The cortical ring sign is seen on an AP radiograph in scapholunate dissociation. It represents the axially aligned scaphoid viewed end-on due to abnormal volar flexion and rotary subluxation of the scaphoid.

Question 2619

Topic: 7. Hand and Wrist

A 28-year-old man presents to the emergency department after a motorcycle accident. His wrist is grossly deformed, and he reports numbness in his thumb, index, and middle fingers. Radiographs reveal a volar dislocation of the lunate with the capitate lying dorsally. Which nerve is most commonly injured in this scenario?

. Ulnar nerve
. Radial nerve
. Median nerve
. Anterior interosseous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Median nerve

Explanation

Lunate and perilunate dislocations frequently cause acute carpal tunnel syndrome due to the displaced lunate compressing the median nerve within the carpal tunnel, requiring prompt reduction and possible carpal tunnel release.

Question 2620

Topic: 7. Hand and Wrist

A 28-year-old man presents with chronic wrist pain after an untreated injury 5 years ago. Radiographs shown in

demonstrate a scaphoid nonunion advanced collapse (SNAC). Which of the following articulations is typically preserved the longest in the natural history of a SNAC wrist?

. Radioscaphoid
. Capitolunate
. Scaphocapitate
. Radiolunate
. Scaphotrapezial

Correct Answer & Explanation

. Radiolunate

Explanation

In both SLAC and SNAC wrists, the radiolunate articulation is classically spared until late in the disease process due to the concentric shape of the fossa and the intact short radiolunate ligament.

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