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7. Hand and Wrist MCQs

Practice Set 15 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 281

Topic: 7. Hand and Wrist

The oblique retinacular ligament connects with what two structures:

. Flexor tendon to lateral extensor tendon
. Flexor tendon to central slip
. Flexor tendon sheath to lateral extensor tendon
. Flexor tendon sheath to central slip
. Flexor tendon sheath to head of middle phalanx

Correct Answer & Explanation

. Flexor tendon sheath to lateral extensor tendon

Explanation

Landsmeer (oblique retinacular ligament) runs from the flexor tendon sheath of the proximal phalanx to the lateral extensor tendon as they insert onto the base of the proximal phalanx. A stay or retaining ligament maintains centralization of the extensor tendons.

Question 282

Topic: 7. Hand and Wrist
A patient presents with hand weakness. On examination, she has no sensory deficit, decreased strength with pronation, and her elbow is at 90° of flexion and pulp-to-pulp contact on key pinch. The most likely diagnosis is:
. Carpal tunnel syndrome
. Anterior interosseous nerve syndrome
. Posterior interosseous nerve syndrome
. Cubital tunnel syndrome
. Martin-Gruber connection

Correct Answer & Explanation

. Anterior interosseous nerve syndrome

Explanation

Anterior interosseous nerve syndrome is due to compression of the anterior interosseous nerve (AIN) in the forearm by lacertus fibrosus, flexor digitorum superficialis, or pronator teres. The AIN innervates the pronator quadratus, flexor digitorum profundus (FDP) to the index finger, and the flexor pollicis longus (FPL). Anatomy variation exists where the AIN may innervate part of the flexor digitorum superficialis. In this patient, she has decreased pronation at 90° flexion, which relaxes the humeral attachment of the pronator from the pronator quadratus weakness. She also has pulp-to-pulp contact due to weakness of the FPL and FDP to the index finger.

Question 283

Topic: 7. Hand and Wrist

What is the order of joint destruction in a patient with scapholunate disassociation:

. Radial styloid, proximal radioscaphoid, radiolunate, midcarpal
. Radial styloid, proximal radioscaphoid, radiolunate
. Proximal radioscaphoid, midcarpal, radiolunate
. Proximal radioscaphoid, radial styloid, midcarpal, radiolunate
. Radial styloid, proximal radioscaphoid, midcarpal

Correct Answer & Explanation

. Radial styloid, proximal radioscaphoid, midcarpal

Explanation

Patients with scapholunate disassociation can develop a scapholunate advanced collapsed wrist. The progression is from the radial styloid to proximal radioscaphoid, to midcarpal (capitolunate). The lunate is extended and unloaded due to its concentric design, which results in preservation of the radiolunate.

Question 284

Topic: 7. Hand and Wrist
Which of the following is not characteristic of Dupuytren's disease:
. Autosomal dominant trait
. Irish and Scottish descent
. Higher prevalence in men
. Ring and small finger involvement first
. Predictable progression of disease

Correct Answer & Explanation

. Predictable progression of disease

Explanation

Dupuytren's disease is characteristically unpredictable in its clinical progression. It may spontaneously resolve or progress quickly to advanced disease.

Question 285

Topic: 7. Hand and Wrist
Operative indications for Dupuytren's contracture include:
. Metacarpophalangeal joint contraction of more than 25° to 30°
. Proximal interphalangeal joint contracture of 30° or more
. Palpable cords in the palm
. Decreased light touch sensation to affected digits
. Painful palmar nodule

Correct Answer & Explanation

. Proximal interphalangeal joint contracture of 30° or more

Explanation

As a general guideline, the "table test" is used as an indication for operative intervention. If the patient cannot lay his/her hand flat onto a table, the disease has usually progressed to the point where surgery is required. A metacarpophalangeal joint contracture of 30° to 40° or a proximal interphalangeal joint contracture of 30° or more is an indication for surgery.

Question 286

Topic: Wrist & Carpus

Injuries to the central articular disk portion of the triangular fibrocartilage complex are related to all of the following except:

. Age
. Positive ulnar variance
. Ulnocarpal impingement
. Scaphoid nonunion
. Avulsion injuries from the dorsal ligamentous attachments

Correct Answer & Explanation

. Positive ulnar variance

Explanation

Scaphoid nonunion is not related to central triangular fibrocartilage complex injuries. A positive ulnar variance is most strongly associated with triangular fibrocartilage complex central disk injuries.

Question 287

Topic: 7. Hand and Wrist

A 24-year-old man presents with a short forearm and a hand deformity. The patient is otherwise healthy with no other congenital defects. The clinical appearance of his forearm is shown (Slide). The potential complications of lengthening are discussed, and the patient is advised against it. However, the elbow flexion contracture is corrected by gradual distraction. One year postoperatively, the patient has attained a 30° correction of the flexion deformity, which remains mobile. Now, he desires that his wrist deformity be corrected. The procedure of choice is:

. Arthrodesis
. Radialization
. C entralization
. Proximal row carpectomy
. Tendon transfers

Correct Answer & Explanation

. Arthrodesis

Explanation

Wrist arthrodesis is the best solution for this patient and his recurrent deformity because it provides a stable platform for grasp.C orrect Answer: Arthrodesis

Question 288

Topic: 7. Hand and Wrist
A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000/µL; platelet 254×10^3/µL; neutrophils 50%; Hb 14.2 g/dL; lymphocytes 40%; Hct 45%; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal. Centralization will be performed on the patient. All of the following statements are true about centralization except:
. It is necessary to make a notch in the carpus when performing centralization.
. The forearm must be aligned with the second metacarpal.
. Preoperative soft tissue distraction can be useful.
. Transfer of tendons from the radial to ulnar side provides additional stability.
. Ulnocarpal fusion is a known outcome.

Correct Answer & Explanation

. The forearm must be aligned with the second metacarpal.

Explanation

In a centralization procedure, the forearm is aligned with the third metacarpal, not the second.

Question 289

Topic: 7. Hand and Wrist
All of the following statements are true regarding the carpal bones in patients with ulnar club hand except:
. Involvement of carpus is severe in type III.
. The pisiform is the most common missing carpus.
. Carpal coalition is present in approximately 25% of patients.
. Making a notch in the carpus provides stability at the wrist joint.
. The extent of ulnar deformity does not correlate with deformities in the hand.

Correct Answer & Explanation

. Making a notch in the carpus provides stability at the wrist joint.

Explanation

A notch is often created in centralization procedures for radial club hand. Wrist stabilization procedures are not performed for ulnar club hand.

Question 290

Topic: 7. Hand and Wrist

All of the following anomalies are present in patients with ulnar club hand except:

. Phocomelia
. Transverse arrest
. Humeral aplasia
. Humeral hypoplasia
. Vertebral dysplasia

Correct Answer & Explanation

. Vertebral dysplasia

Explanation

Vertebral anomalies are not common in patients with ulnar club hand.

Question 291

Topic: 7. Hand and Wrist

A patient presents with inability to actively flex the distal interphalangeal joint of the index finger and the interphalangeal joint of the thumb. To differentiate Anterior Interosseous Nerve (AIN) syndrome from flexor tendon rupture, which finding is pathognomonic for AIN syndrome?

. Positive Tinel's at the carpal tunnel
. Inability to make an "OK" sign but intact tenodesis effect
. Loss of sensation over the index finger tip
. Atrophy of the hypothenar eminence
. Pain with passive stretch of the digits

Correct Answer & Explanation

. Inability to make an "OK" sign but intact tenodesis effect

Explanation

AIN syndrome causes weakness of the FPL, FDP to the index/long fingers, and pronator quadratus. The tenodesis effect remains intact because the tendon is continuous, unlike in a flexor tendon rupture.

Question 292

Topic: Nerve & Tendon

A 25-year-old male presents with a complete C5-C6 root avulsion following a motorcycle accident 3 months ago. Clinical examination demonstrates absent elbow flexion and shoulder abduction, with preserved hand function. What is the most appropriate nerve transfer to restore active elbow flexion in this patient?

. Spinal accessory nerve to suprascapular nerve transfer
. Ulnar nerve fascicle to the biceps motor branch (Oberlin transfer)
. Intercostal nerves to the musculocutaneous nerve
. Phrenic nerve to the axillary nerve
. Medial pectoral nerve to the musculocutaneous nerve

Correct Answer & Explanation

. Ulnar nerve fascicle to the biceps motor branch (Oberlin transfer)

Explanation

The Oberlin transfer involves transferring a fascicle of the ulnar nerve (and often the median nerve in a double transfer) to the motor branches of the biceps and brachialis. It is highly effective for restoring elbow flexion in upper trunk (C5-C6) avulsion injuries because the ulnar nerve (C8-T1) remains intact.

Question 293

Topic: 7. Hand and Wrist

A 22-year-old man presents with wrist pain after a fall on an outstretched hand. Radiographs confirm a displaced fracture of the proximal pole of the scaphoid. The high risk of avascular necrosis and nonunion in this region is primarily due to the blood supply originating from branches of the:

. Radial artery entering distally and flowing proximally
. Ulnar artery entering proximally and flowing distally
. Anterior interosseous artery entering the scaphoid waist
. Deep palmar arch entering the volar tubercle
. Dorsal carpal arch entering the proximal pole directly

Correct Answer & Explanation

. Radial artery entering distally and flowing proximally

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters the distal pole and flows in a retrograde fashion to the proximal pole. Fractures at the waist or proximal pole disrupt this delicate supply, predisposing to avascular necrosis.

Question 294

Topic: 7. Hand and Wrist

A 55-year-old woman presents with advanced, neglected carpal tunnel syndrome, exhibiting severe thenar atrophy. Which specific intrinsic hand muscle is most classically atrophied and visible in this condition?

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

Correct Answer & Explanation

. Abductor pollicis brevis

Explanation

The abductor pollicis brevis (APB) is innervated by the recurrent motor branch of the median nerve. Severe compression in the carpal tunnel leads to denervation and classic wasting of the APB, which constitutes the bulk of the superficial thenar eminence.

Question 295

Topic: 7. Hand and Wrist

A 25-year-old man suffered a C5-C6 root avulsion injury resulting in a permanent loss of elbow flexion. Hand and wrist functions remain entirely normal. A Steindler flexorplasty is planned to restore active elbow flexion. Which of the following anatomical structures is transferred during this procedure?

. Latissimus dorsi insertion
. Flexor-pronator mass
. Triceps brachii tendon
. Pectoralis major insertion
. Sternocleidomastoid muscle

Correct Answer & Explanation

. Flexor-pronator mass

Explanation

The Steindler flexorplasty involves surgically transferring the flexor-pronator muscle origin from the medial epicondyle proximally to the anterior aspect of the humerus. This effectively changes their moment arm, providing active elbow flexion in patients with preserved hand and wrist musculature.

Question 296

Topic: Nerve & Tendon

During the clinical and electrodiagnostic evaluation of a patient with a traumatic closed brachial plexus injury, which of the following findings is most strongly indicative of a preganglionic root avulsion rather than a postganglionic lesion?

. Presence of a strong Tinel's sign in the supraclavicular fossa
. Normal sensory nerve action potentials (SNAPs) in a clinically anesthetic dermatome
. Absent SNAPs with fully preserved motor function
. Fibrillation potentials in the biceps but not in the cervical paraspinal muscles
. Rapid improvement of neurological deficits with conservative management

Correct Answer & Explanation

. Normal sensory nerve action potentials (SNAPs) in a clinically anesthetic dermatome

Explanation

In a preganglionic root avulsion, the injury is proximal to the dorsal root ganglion (DRG). Because the DRG remains intact and connected to the peripheral nerve, sensory axons do not undergo Wallerian degeneration, resulting in normal SNAPs despite profound clinical anesthesia.

Question 297

Topic: 7. Hand and Wrist
Syndactyly is present in what percentage of patients with macrodactyly?
. 10%
. 20%
. 30%
. 40%
. 50%

Correct Answer & Explanation

. 10%

Explanation

The majority of patients (90%) present with unilateral macrodactyly, and men are more often affected than women. Macrodactyly is most frequently found in the index finger, followed by the long finger, thumb, ring, and little fingers. Typically, two digits are affected—most commonly the thumb and index or the index and long. Syndactyly may be present in 10% of patients with macrodactyly.

Question 298

Topic: 7. Hand and Wrist
You discover that a patient who you have been treating for macrodactyly has been followed by the Proteus Syndrome Foundation. Exhaustive work-up has been completed and radiographs of the hand reveal:
. Multiple enchondromas in the affected fingers
. Enlarged bones in length only
. Enlarged bones in length and width
. Enlarged bones in width only
. Normal appearing bones

Correct Answer & Explanation

. Enlarged bones in length and width

Explanation

In patients with macrodactyly, surgeons do not typically find enchondromas, especially not multiple enchondromas in the affected fingers. Enlargement of the bones is found in all dimensions—not only in the length and width. If the bones appear normal on radiograph, then they are not affected by macrodactyly.

Question 299

Topic: 7. Hand and Wrist

Epiphysiodesis for macrodactyly should be performed at the following location:

. Proximal phalanx only
. Proximal phalanx and middle phalanx
. Proximal phalanx, middle phalanx, and distal phalanx
. Middle phalanx only
. Proximal phalanx and distal phalanx

Correct Answer & Explanation

. Proximal phalanx and distal phalanx

Explanation

Treatment by epiphysiodesis for macrodactyly is ineffective if only single phalanges are treated. Therefore, treatment of the proximal phalanx, distal phalanx, or the middle phalanx alone is incorrect. The author prefers to perform epiphysiodesis only on the proximal and distal phalanges. The middle phalanx is not treated to preserve motion at the proximal interphalangeal joint.

Question 300

Topic: 7. Hand and Wrist
The Terry Thomas sign, which is considered indicative of scapholunate ligament rupture, is best described as:
. Scapholunate diastasis larger than 3 mm
. Scapholunate angle more than 30º to 60º on lateral radiographs
. Reduction and exaggeration of scapholunate diastasis on radial and ulnar deviation motion studies
. Exaggeration and reduction of scapholunate diastasis on radial and ulnar deviation radiographs, respectively
. Scaphoid flexion with lunate extension

Correct Answer & Explanation

. Scapholunate diastasis larger than 3 mm

Explanation

The Terry Thomas sign refers to scapholunate diastasis that may be apparent on posteroanterior radiographs of the wrist and is indicative of rupture if the diastasis is larger than 3 mm. It is named after the famous comedian who had a gap between his front teeth.

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