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7. Hand and Wrist MCQs

Practice Set 134 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 2661

Topic: 7. Hand and Wrist
A 29-year-old construction worker complains of progressive dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate without carpal collapse. Measurements demonstrate 3 mm of negative ulnar variance. What is the most appropriate surgical treatment?
. Proximal row carpectomy
. Total wrist arthrodesis
. Lunate excision and silastic replacement
. Radial shortening osteotomy
. Ulnar shortening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Lichtman Stage II/IIIA Kienböck's disease with negative ulnar variance. A joint-leveling procedure, typically a radial shortening osteotomy, unloads the lunate and can successfully halt disease progression and relieve pain.

Question 2662

Topic: 7. Hand and Wrist

A 62-year-old woman presents with debilitating pain at the base of her right thumb. Examination shows a positive grind test. Radiographs demonstrate severe joint space narrowing and osteophytes at the trapeziometacarpal joint, but the scaphotrapezial joint is spared. Following failed conservative management, what is the gold standard surgical treatment?

. Trapeziometacarpal arthrodesis
. Trapeziectomy with or without ligament reconstruction and tendon interposition (LRTI)
. Silicone replacement arthroplasty
. Metacarpal extension osteotomy
. Volar capsulodesis

Correct Answer & Explanation

. Trapeziectomy with or without ligament reconstruction and tendon interposition (LRTI)

Explanation

Trapeziectomy with or without LRTI is the gold standard surgical treatment for advanced thumb carpometacarpal (CMC) arthritis. Outcomes between simple trapeziectomy and trapeziectomy with LRTI are highly comparable in long-term studies.

Question 2663

Topic: 7. Hand and Wrist

A 26-year-old male falls from a height and presents with a markedly swollen and painful wrist. The lateral radiograph demonstrates the "spilled teacup" sign with the lunate displaced volarly. During physical examination, which nerve distribution should be most meticulously evaluated?

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

Correct Answer & Explanation

. Median nerve

Explanation

A volar lunate dislocation (indicated by the "spilled teacup" sign on a lateral radiograph) occupies space within the carpal tunnel. This often causes acute compression of the median nerve, leading to acute carpal tunnel syndrome.

Question 2664

Topic: Wrist & Carpus
A 45-year-old male presents with chronic wrist pain and a history of a scaphoid fracture 15 years ago. Radiographs demonstrate advanced radioscaphoid arthritis and scaphocapitate arthritis, but the radiolunate joint is completely spared (SNAC Stage III). What is the most appropriate definitive surgical intervention?
. Proximal row carpectomy
. Total wrist arthrodesis
. Four-corner arthrodesis with scaphoid excision
. Radiolunate arthrodesis
. Darrach procedure

Correct Answer & Explanation

. Four-corner arthrodesis with scaphoid excision

Explanation

In Scaphoid Nonunion Advanced Collapse (SNAC) Stage III, there is arthritic involvement of both the radioscaphoid and midcarpal (scaphocapitate) joints. Proximal row carpectomy is contraindicated when the capitate is arthritic, making four-corner arthrodesis the procedure of choice.

Question 2665

Topic: 7. Hand and Wrist

A 28-year-old carpenter lacerates the volar surface of his index finger over the middle phalanx (Zone II). A primary flexor tendon repair is planned. To safely implement an early active motion protocol postoperatively, what is the minimum recommended number of core strands across the repair site?

. 2 strands
. 4 strands
. 6 strands
. 8 strands
. 10 strands

Correct Answer & Explanation

. 4 strands

Explanation

Early active motion protocols after flexor tendon repairs require a biomechanically robust construct to prevent gap formation or rupture. A minimum of a 4-strand core repair, often augmented with an epitendinous suture, is recommended to safely withstand the forces of active digital flexion.

Question 2666

Topic: 7. Hand and Wrist

A 26-year-old male falls from a ladder onto an outstretched hand. An AP radiograph of the wrist reveals a "piece of pie" sign, while the lateral radiograph demonstrates a "spilled teacup" sign. Which nerve is most commonly acutely injured in this specific clinical setting?

. Ulnar nerve
. Anterior interosseous nerve
. Superficial radial nerve
. Median nerve
. Deep motor branch of the ulnar nerve

Correct Answer & Explanation

. Median nerve

Explanation

The "piece of pie" and "spilled teacup" radiographic signs indicate a lunate dislocation. As the lunate is displaced volarly into the carpal tunnel, it frequently compresses the median nerve, leading to acute acute carpal tunnel syndrome requiring urgent reduction.

Question 2667

Topic: 7. Hand and Wrist

During a regional fasciectomy for severe Dupuytren's disease, the surgeon carefully dissects a spiral cord to avoid neurovascular injury. How does the spiral cord typically displace the digital neurovascular bundle?

. Dorsal and lateral
. Dorsal and central
. Volar and central
. Volar and lateral
. Proximal and lateral

Correct Answer & Explanation

. Volar and central

Explanation

In Dupuytren's contracture, the spiral cord originates from the pretendinous band, passing dorsal to the neurovascular bundle before spiraling volarly. This pathognomonic contracture displaces the neurovascular bundle volarly and centrally (toward the midline), placing it at severe risk during surgical release.

Question 2668

Topic: Wrist & Carpus

A 24-year-old gymnast complains of ulnar-sided wrist pain and clicking. Examination reveals severe distal radioulnar joint (DRUJ) instability in both supination and pronation. MRI confirms a foveal avulsion of the triangular fibrocartilage complex (TFCC). What is the primary biomechanical function of the foveal attachment of the TFCC?

. Stabilizes the ulnocarpal joint against axial load
. Prevents volar translation of the carpus
. Provides the primary restraint to DRUJ translation
. Acts as an articular cushion for the lunate
. Prevents dorsal intercalated segment instability (DISI)

Correct Answer & Explanation

. Provides the primary restraint to DRUJ translation

Explanation

The deep foveal attachment of the TFCC inserts into the base of the ulnar styloid and constitutes the primary stabilizing restraint to distal radioulnar joint (DRUJ) translation. Tears at this location (Type 1B) reliably result in DRUJ instability and often require open or arthroscopic repair.

Question 2669

Topic: 7. Hand and Wrist
A 45-year-old man presents with chronic wrist pain. Radiographs demonstrate advanced osteoarthritis of the radioscaphoid and capitolunate joints, while the radiolunate joint is spared. A scaphoid nonunion is also noted. Which of the following surgical interventions is most appropriate?
. Proximal row carpectomy
. Total wrist arthrodesis
. Scaphoid excision and four-corner fusion
. Scaphoid open reduction and internal fixation with bone grafting
. Radial styloidectomy

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has Stage III Scaphoid Nonunion Advanced Collapse (SNAC). Because the capitate is arthritic, a proximal row carpectomy is contraindicated. Scaphoid excision with four-corner fusion is the most appropriate motion-preserving procedure.

Question 2670

Topic: 7. Hand and Wrist

A 65-year-old woman undergoes volar locking plate fixation for a displaced distal radius fracture. Postoperative radiographs show the plate is placed distal to the watershed line. Which structure is at greatest risk of rupture?

. Extensor pollicis longus tendon
. Flexor pollicis longus tendon
. Flexor carpi radialis tendon
. Extensor carpi radialis brevis tendon
. Median nerve

Correct Answer & Explanation

. Flexor pollicis longus tendon

Explanation

Placing a volar plate distal to the watershed line of the distal radius places the flexor tendons, most notably the flexor pollicis longus (FPL), at high risk of irritation and subsequent spontaneous rupture. Extensor pollicis longus rupture is more classically associated with nonoperative treatment or dorsal screw prominence.

Question 2671

Topic: Nerve & Tendon
A 6-year-old child presents after a fall onto an outstretched arm. Radiographs demonstrate a fracture of the proximal third of the ulna with an anterior dislocation of the radial head. Based on this specific Bado classification pattern, which nerve is most commonly injured?
. Median nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Ulnar nerve
. Superficial branch of the radial nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

A proximal ulnar fracture with an anterior radial head dislocation is a Bado Type I Monteggia fracture-dislocation. The posterior interosseous nerve (PIN) is the most commonly injured nerve in Bado Type I and Type III injuries due to the displacement of the radial head.

Question 2672

Topic: 7. Hand and Wrist

A 21-year-old male sustains a proximal pole scaphoid fracture. The treating orthopedic surgeon advises the patient of a high risk of nonunion and avascular necrosis. This risk is primarily due to the retrograde nature of the scaphoid's blood supply. Which of the following vessels provides this dominant arterial supply to the proximal pole?

. Superficial palmar arch
. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Deep palmar arch
. Anterior interosseous artery

Correct Answer & Explanation

. Superficial palmar arch

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery. This vessel enters the scaphoid distally and flows in a retrograde fashion, leaving the proximal pole highly susceptible to avascular necrosis following a fracture.

Question 2673

Topic: Nerve & Tendon

A 40-year-old man undergoes a single-incision anterior approach repair of a distal biceps tendon rupture. What is the most commonly injured neurologic structure associated with this specific surgical approach?

. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Median nerve
. Ulnar nerve
. Radial nerve proper

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. Posterior interosseous nerve (PIN) injury is less frequent but more devastating.

Question 2674

Topic: Wrist & Carpus

A 55-year-old woman sustains a nondisplaced distal radius fracture treated in a short arm cast. Six weeks later, the cast is removed, and she is unable to actively extend her thumb interphalangeal joint. Tenodesis effect of the thumb is absent. What is the most likely etiology?

. Posterior interosseous nerve palsy
. Extensor pollicis longus rupture
. Flexor pollicis longus rupture
. Extensor indicis proprius rupture
. Anterior interosseous nerve palsy

Correct Answer & Explanation

. Posterior interosseous nerve palsy

Explanation

Extensor pollicis longus (EPL) tendon rupture is a well-known complication of nondisplaced distal radius fractures. It occurs due to a combination of mechanical attrition at Lister's tubercle and ischemia in a watershed vascular zone.

Question 2675

Topic: 7. Hand and Wrist
A 45-year-old man presents with chronic wrist pain. A radiograph confirms a scaphoid nonunion with radioscaphoid and capitolunate arthritis. The radiolunate joint is completely preserved. What is the most appropriate surgical treatment?
. Scaphoid ORIF with vascularized bone graft
. Proximal row carpectomy (PRC)
. Total wrist arthrodesis
. Scaphoid excision and four-corner fusion
. Radial styloidectomy

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

In SNAC Stage III arthritis (involving the capitolunate joint), a proximal row carpectomy is contraindicated because the capitate head is arthritic. Scaphoid excision with four-corner fusion preserves motion utilizing the intact radiolunate joint.

Question 2676

Topic: Nerve & Tendon

A 42-year-old man feels a pop in his anterior elbow while lifting a heavy object. An MRI confirms a complete avulsion of the distal biceps tendon. He elects to undergo surgical repair via a single-incision anterior approach. What is the most common neurologic complication associated with this specific surgical approach?

. Posterior interosseous nerve palsy
. Lateral antebrachial cutaneous nerve neuropraxia
. Median nerve transection
. Ulnar nerve subluxation
. Superficial radial nerve injury

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve neuropraxia

Explanation

The lateral antebrachial cutaneous nerve is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. The posterior interosseous nerve is more typically at risk during a two-incision approach.

Question 2677

Topic: 7. Hand and Wrist

A 35-year-old tennis player complains of ulnar-sided wrist pain. MRI confirms an isolated tear of the central, articular disk portion of the triangular fibrocartilage complex (TFCC). Which of the following statements best dictates the preferred surgical management of this specific lesion?

. The central portion is highly vascularized and should be repaired directly
. The central portion is avascular and responds best to arthroscopic debridement
. It requires an ulnar shortening osteotomy in all cases regardless of variance
. It should be treated with a vascularized bone graft from the radius
. It necessitates open repair using suture anchors to the fovea

Correct Answer & Explanation

. The central portion is avascular and responds best to arthroscopic debridement

Explanation

The central portion of the TFCC is avascular, meaning tears in this region have poor healing potential and are best treated with arthroscopic debridement. Conversely, peripheral tears are located in the vascular zone and can be primarily repaired.

Question 2678

Topic: Wrist & Carpus

A 33-year-old construction worker sustains a fracture of the distal third of the radial shaft with associated disruption of the distal radioulnar joint (DRUJ). After rigid open reduction and internal fixation of the radius, the DRUJ remains highly unstable. What is the most appropriate next step in management?

. Pinning the DRUJ in maximum supination
. Pinning the DRUJ in maximum pronation
. Casting the arm in neutral rotation without pinning
. Resection of the distal ulna (Darrach procedure)
. Immediate ulnar shortening osteotomy

Correct Answer & Explanation

. Pinning the DRUJ in maximum supination

Explanation

In a Galeazzi fracture, if the DRUJ remains unstable after rigid anatomical fixation of the radius, it should be pinned in the position of maximum stability. For most DRUJ instabilities, this position is full supination.

Question 2679

Topic: Nerve & Tendon

A 23-year-old professional baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft. Which nerve is most at risk for injury or entrapment during the harvesting of the graft at the volar wrist?

. Median nerve
. Ulnar nerve
. Anterior interosseous nerve
. Superficial radial nerve
. Deep branch of the ulnar nerve

Correct Answer & Explanation

. Median nerve

Explanation

The palmaris longus tendon lies in very close proximity to the median nerve at the wrist. Careful identification and precise harvesting techniques are critical to avoid iatrogenic median nerve injury during graft procurement.

Question 2680

Topic: 7. Hand and Wrist

A patient presents with weakness in thumb interphalangeal joint flexion and index finger distal interphalangeal joint flexion, but normal hand sensation. Entrapment of the involved nerve most commonly occurs at which of the following sites?

. Ligament of Struthers
. Bicipital aponeurosis (Lacertus fibrosus)
. Tendinous edge of the deep head of the pronator teres
. Arcade of Frohse
. Carpal tunnel

Correct Answer & Explanation

. Ligament of Struthers

Explanation

The anterior interosseous nerve (AIN) is most commonly compressed by the tendinous edge of the deep head of the pronator teres. It presents with purely motor deficits, clinically manifesting as an inability to make the 'OK' sign.

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