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7. Hand and Wrist MCQs

Practice Set 133 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 2641

Topic: 7. Hand and Wrist

Six weeks after closed reduction and casting of a nondisplaced distal radius fracture, a 65-year-old woman presents with the sudden inability to actively extend her thumb interphalangeal joint. What is the most appropriate surgical management?

. Primary end-to-end repair of the ruptured tendon
. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer
. Palmaris longus interposition tendon graft
. A1 pulley release
. Extensor carpi radialis longus to EPL transfer

Correct Answer & Explanation

. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer

Explanation

Extensor pollicis longus (EPL) tendon rupture is a known complication of nondisplaced distal radius fractures due to ischemia or attrition in the third dorsal compartment. Because the tendon ends are typically retracted and degenerated, EIP to EPL transfer is the preferred and most reliable treatment.

Question 2642

Topic: 7. Hand and Wrist

A 42-year-old woman undergoing hemodialysis for end-stage renal disease presents with severe, bilateral carpal tunnel syndrome that has failed conservative management. During open carpal tunnel release, thick, brownish tenosynovial tissue is noted. What is the most likely composition of this tissue?

. Monosodium urate crystals
. Calcium pyrophosphate dihydrate
. Beta-2-microglobulin amyloid
. Rheumatoid pannus
. Granulomatous mycobacterial inflammation

Correct Answer & Explanation

. Beta-2-microglobulin amyloid

Explanation

Dialysis-related amyloidosis is caused by the accumulation of Beta-2-microglobulin, which is not adequately cleared by standard hemodialysis membranes. It frequently deposits in the osteoarticular system, commonly causing severe carpal tunnel syndrome and destructive arthropathy.

Question 2643

Topic: 7. Hand and Wrist

The spiral cord in Dupuytren's disease causes central and superficial displacement of the digital neurovascular bundle, placing it at high risk during fasciectomy. Which of the following normal anatomical structures is NOT a component 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 is formed by the pathologic contracture of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. Cleland's ligament is located dorsal to the neurovascular bundle and is typically spared in Dupuytren's disease.

Question 2644

Topic: 7. Hand and Wrist
A 30-year-old manual laborer presents with dorsal wrist pain. Radiographs show sclerosis and fragmentation of the lunate, with a negative ulnar variance of 3 mm. There is no radiocarpal arthritis. What is the most appropriate initial surgical intervention?
. Radial shortening osteotomy
. Proximal row carpectomy
. Lunate excision and silastic replacement
. Scaphoid-trapezium-trapezoid (STT) fusion
. Ulnar lengthening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early-stage Kienböck's disease (Stage II or IIIA) associated with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. This decreases the mechanical load transmitted across the radiolunate joint, potentially allowing for revascularization of the lunate.

Question 2645

Topic: 7. Hand and Wrist
A 35-year-old carpenter has central dorsal wrist pain. Radiographs reveal sclerosis and a coronal fracture of the lunate, without carpal collapse (Lichtman Stage IIIa). Ulnar variance is neutral. What is the most appropriate joint-leveling procedure to unload the lunate?
. Proximal row carpectomy
. Lunate excision and capitate advancement
. Radial shortening osteotomy
. Ulnar lengthening osteotomy
. Four-corner fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

For Kienböck disease stage I-IIIa with neutral or negative ulnar variance, a joint-leveling procedure like radial shortening osteotomy is indicated. It decreases the mechanical load on the lunate to prevent progressive collapse.

Question 2646

Topic: 7. Hand and Wrist

A 28-year-old male sustained a wrist hyperextension injury 3 weeks ago. Radiographs demonstrate a scapholunate interval of 4mm and a 'signet ring' sign of the scaphoid. What is the most appropriate surgical intervention?

. Scaphoid excision and four-corner fusion
. Proximal row carpectomy
. Open reduction, scapholunate ligament repair, and dorsal capsulodesis
. Arthroscopic debridement of the scapholunate ligament
. Closed reduction and cast immobilization for 12 weeks

Correct Answer & Explanation

. Open reduction, scapholunate ligament repair, and dorsal capsulodesis

Explanation

Acute or subacute (< 4 weeks) scapholunate dissociation with a reparable ligament is best treated with direct open repair of the dorsal scapholunate ligament, typically augmented with a dorsal capsulodesis or pinning to protect the repair.

Question 2647

Topic: Nerve & Tendon

A 50-year-old male with severe cubital tunnel syndrome presents with intrinsic muscle atrophy and clawing of the small and ring fingers. He previously underwent a simple in-situ ulnar nerve release 2 years ago, with initial relief followed by recurrence. What is the most appropriate next surgical step?

. Revision in-situ ulnar nerve release
. Medial epicondylectomy
. Submuscular ulnar nerve transposition
. Ulnar nerve wrapping with a vein conduit
. Fasciotomy of the flexor-pronator mass

Correct Answer & Explanation

. Submuscular ulnar nerve transposition

Explanation

For recurrent cubital tunnel syndrome after a failed in-situ release, or in severe cases with deformity/atrophy, anterior transposition (submuscular or subfascial) is recommended to place the nerve in a pristine, well-vascularized bed away from the scar tissue.

Question 2648

Topic: 7. Hand and Wrist

A 40-year-old manual laborer presents with Stage II SLAC (Scapholunate Advanced Collapse) wrist. Radiographs show osteoarthritis at the radioscaphoid joint, but the radiolunate and midcarpal joints are spared. If he desires a motion-preserving salvage procedure, which of the following is acceptable?

. Total wrist arthrodesis
. Proximal row carpectomy
. Scaphoid excision and capitolunate arthrodesis
. Radial styloidectomy alone
. Darrach procedure

Correct Answer & Explanation

. Proximal row carpectomy

Explanation

Proximal row carpectomy (PRC) is a motion-preserving option for SLAC stage II, provided the capitate head and lunate fossa cartilage are intact. It offers comparable outcomes to four-corner fusion with slightly better range of motion.

Question 2649

Topic: 7. Hand and Wrist
A 55-year-old man presents with chronic wrist pain and weakness. Radiographs demonstrate scapholunate advanced collapse (SLAC) stage III, defined by capitatolunate arthritis with a preserved radiolunate joint. Which of the following is the most appropriate surgical management?
. Proximal row carpectomy (PRC)
. Four-corner arthrodesis with scaphoid excision
. Scaphotrapeziotrapezoid (STT) arthrodesis
. Total wrist arthroplasty
. Radial styloidectomy

Correct Answer & Explanation

. Four-corner arthrodesis with scaphoid excision

Explanation

SLAC stage III involves the capitatolunate joint. Proximal row carpectomy is contraindicated because it relies on a preserved proximal capitate articular surface. Four-corner fusion with scaphoid excision is the standard of care for SLAC stage III.

Question 2650

Topic: Nerve & Tendon

A 42-year-old bodybuilder feels a 'pop' in his anterior elbow while doing heavy biceps curls. MRI confirms a complete distal biceps tendon rupture. If a single anterior incision technique is chosen for the repair, which nerve is at the highest risk of iatrogenic injury?

. Posterior interosseous nerve (PIN)
. Median nerve
. Ulnar nerve
. Lateral antebrachial cutaneous nerve (LABC)
. Superficial radial nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABC)

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single anterior incision approach for distal biceps repair. The PIN is at higher risk during a two-incision technique.

Question 2651

Topic: Wrist & Carpus

A 28-year-old gymnast presents with chronic ulnar-sided wrist pain. Examination reveals a positive foveal sign. MRI arthrogram demonstrates a peripheral tear of the triangular fibrocartilage complex (TFCC) with an avulsion from the fovea of the ulna. This corresponds to which Palmer classification, and what is the preferred treatment?

. Palmer 1A; Debridement
. Palmer 1B; Open or arthroscopic repair
. Palmer 1C; Ulnar shortening osteotomy
. Palmer 1D; Proximal row carpectomy
. Palmer 2C; Darrach procedure

Correct Answer & Explanation

. Palmer 1B; Open or arthroscopic repair

Explanation

A peripheral tear of the TFCC involving the foveal attachment is classified as Palmer 1B. Because the peripheral TFCC has excellent blood supply, these tears are highly amenable to open or arthroscopic surgical repair.

Question 2652

Topic: 7. Hand and Wrist

During the surgical management of a distal radius fracture with a volar locking plate, the surgeon ensures the plate is placed proximal to the watershed line. This anatomic guideline is primarily utilized to prevent which of the following complications?

. Median nerve compression
. Extensor pollicis longus (EPL) tendon rupture
. Flexor pollicis longus (FPL) tendon rupture
. Volar carpal subluxation
. Radiocarpal joint penetration

Correct Answer & Explanation

. Flexor pollicis longus (FPL) tendon rupture

Explanation

The watershed line is a critical anatomic landmark on the volar distal radius. Placing a volar plate distal to this line significantly increases the risk of flexor tendon irritation and subsequent rupture, most commonly the flexor pollicis longus (FPL).

Question 2653

Topic: 7. Hand and Wrist

A 30-year-old male sustains a Bennett fracture. Radiographs show a fracture at the base of the thumb metacarpal where the volar ulnar intra-articular fragment retains its anatomic position. The metacarpal shaft is displaced proximally, dorsally, and radially. Which muscle is the primary deforming force responsible for this characteristic shaft displacement?

. Adductor pollicis
. Abductor pollicis longus (APL)
. Extensor pollicis longus (EPL)
. Flexor pollicis longus (FPL)
. Opponens pollicis

Correct Answer & Explanation

. Abductor pollicis longus (APL)

Explanation

In a Bennett fracture, the anterior oblique ligament anchors the small volar ulnar fragment in place. The main shaft of the metacarpal is pulled proximally, dorsally, and radially primarily by the abductor pollicis longus (APL) tendon.

Question 2654

Topic: Nerve & Tendon

A patient with a severe ulnar nerve transection at the level of the elbow initially presents with weakness of intrinsic hand muscles but minimal clawing of the ring and small fingers. Three months following nerve repair at the elbow, pronounced clawing of these digits develops. This phenomenon is known as:

. Froment's sign
. Wartenberg's sign
. Ulnar paradox
. Martin-Gruber anastomosis effect
. Tinel's sign

Correct Answer & Explanation

. Ulnar paradox

Explanation

The Ulnar paradox occurs in high ulnar nerve lesions where the flexor digitorum profundus (FDP) to the ring and small fingers is paralyzed, preventing prominent clawing. As the nerve regenerates and reinnervates the FDP, active flexion returns and clawing becomes pronounced.

Question 2655

Topic: 7. Hand and Wrist
A 40-year-old patient with Kienböck's disease is evaluated radiographically. Images reveal lunate sclerosis and fragmentation, fixed scaphoid rotation, and established osteoarthritis in the capitolunate joint. According to the Lichtman classification, this is Stage IV Kienböck's. Which of the following procedures is contraindicated in this setting?
. Proximal row carpectomy (PRC)
. Scaphocapitate fusion
. Total wrist arthrodesis
. Radial shortening osteotomy
. Denervation of the wrist

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

Radial shortening osteotomy (a joint-leveling procedure) relies on preserving carpal kinematics and is contraindicated in Stage IV Kienböck's disease, where there is extensive carpal collapse and secondary osteoarthritis. Salvage procedures like PRC or wrist fusion are indicated instead.

Question 2656

Topic: Nerve & Tendon

A 50-year-old diabetic female presents with a locking thumb that is refractory to corticosteroid injections. During surgical release of the A1 pulley, the surgeon must be particularly careful to protect a nerve that courses obliquely over the flexor sheath near the metacarpophalangeal flexion crease. Which nerve is this?

. Ulnar digital nerve of the thumb
. Radial digital nerve of the thumb
. Recurrent motor branch of the median nerve
. Palmar cutaneous branch of the median nerve
. Superficial branch of the radial nerve

Correct Answer & Explanation

. Radial digital nerve of the thumb

Explanation

The radial digital nerve of the thumb is particularly vulnerable during A1 pulley release because it crosses obliquely from ulnar to radial directly over the flexor tendon sheath at the level of the MCP flexion crease.

Question 2657

Topic: 7. Hand and Wrist

A 32-year-old carpenter suffers a clean guillotine amputation of his index finger at the level of the proximal phalanx. Replantation is attempted. To maximize venous outflow and ensure the best survival rate of the replanted digit, what is the optimal ratio of veins to arteries that should be anastomosed?

. One vein for every two arteries
. One vein for every one artery
. Two veins for every one artery
. Three veins for every two arteries
. Vein repair is not necessary if the bone is shortened

Correct Answer & Explanation

. Two veins for every one artery

Explanation

During digital replantation, venous congestion is a primary cause of failure. The standard microsurgical principle is to attempt to repair two veins for every one artery anastomosed to ensure adequate venous outflow.

Question 2658

Topic: 7. Hand and Wrist

A 26-year-old chef sustains a deep laceration to the volar aspect of his index finger over the middle phalanx, cleanly transecting both the FDS and FDP tendons (Zone II). Primary repair is planned. According to biomechanical studies, the strength of the flexor tendon repair is most directly proportional to which of the following factors?

. The use of a running epitendinous suture
. The thickness of the suture material used
. The number of core suture strands crossing the repair site
. The decision to vent the A2 pulley
. The length of the core suture purchase

Correct Answer & Explanation

. The number of core suture strands crossing the repair site

Explanation

The ultimate tensile strength of a repaired flexor tendon is most directly proportional to the number of core suture strands crossing the repair site (e.g., a 4-strand or 6-strand repair is significantly stronger than a 2-strand repair).

Question 2659

Topic: 7. Hand and Wrist

A 35-year-old man presents with chronic wrist pain and stiffness 2 years after a fall. Imaging reveals a scaphoid nonunion with radioscaphoid arthritis and preservation of the midcarpal joint. The proximal pole of the capitate demonstrates no arthritic changes. Which of the following procedures is most appropriate?

. Total wrist arthrodesis
. Scaphoid excision and four-corner fusion
. Proximal row carpectomy (PRC)
. Radial styloidectomy
. Distal radioulnar joint arthroplasty

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

In Scaphoid Nonunion Advanced Collapse (SNAC) stage II with a preserved proximal capitate and lunate fossa, proximal row carpectomy (PRC) is highly effective. While four-corner fusion is an option, PRC is favored when capitate cartilage is pristine as it avoids nonunion risks and allows earlier rehabilitation.

Question 2660

Topic: Hand Trauma & Infection

A 28-year-old carpenter presents with acute finger pain, swelling, and a flexed posture of the index finger 48 hours after a penetrating injury. Which of the following is NOT one of Kanavel's cardinal signs of acute suppurative flexor tenosynovitis?

. Fusiform swelling of the entire digit
. Erythema extending proximal to the metacarpophalangeal joint
. Severe pain on passive extension of the digit
. Tenderness along the course of the flexor tendon sheath
. Flexed resting posture of the digit

Correct Answer & Explanation

. Erythema extending proximal to the metacarpophalangeal joint

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are fusiform swelling, flexed resting posture, tenderness along the flexor sheath, and pain on passive extension. Erythema extending proximally is not one of these specific signs, though it may indicate tracking cellulitis.

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